Orthognathic Surgery

JEFFREY C. POSNICK, DMD, MD
ORTHOGNATHIC
SURGERY:
PRINCIPLES & PRACTICE

(Trang không có chữ)

JEFFREY C. POSNICK, DMD, MD
JEFFREY C. POSNICK, DMD, MD
Clinical Professor of Surgery and Pediatrics
Georgetown University
Washington, DC
Clinical Professor of Orthodontics
University of Maryland, School of Dentistry
Baltimore, Maryland
Adjunct Professor of Oral and Maxillofacial Surgery
Howard University College of Dentistry
Washington, DC
Director, Posnick Center for Facial Plastic Surgery
Chevy Chase, Maryland
ORTHOGNATHIC
SURGERY:
PRINCIPLES & PRACTICE

3251 Riverport Lane
St. Louis, Missouri 63043
ORTHOGNATHIC SURGERY: PRINCIPLES & PRACTICE
978-1-4557-2698-1
Copyright © 2014 by Jeffrey C. Posnick. Published by Saunders, an imprint of Elsevier Inc.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center
and the Copyright Licensing Agency, can be found at our website:
This book and the individual contributions contained in it are protected under copyright by the Publisher (other
than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such information or
methods they should be mindful of their own safety and the safety of others, including parties for whom they
have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration, and
contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of
their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient,
and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any
liability for any injury and/or damage to persons or property as a matter of products liability, negligence or
otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the
material herein.
Library of Congress Cataloging-in-Publication Data
Posnick, Jeffrey C., author.
  Orthognathic surgery : principles & practice / Jeffrey C. Posnick.
    p. ; cm.
  Includes bibliographical references and index.
  ISBN 978-1-4557-2698-1 (hbk. : alk. paper)
  I. Title.
  [DNLM:  1.  Orthognathic Surgical Procedures–methods.  2.  Malocclusion–surgery.  3.  Maxillofacial
Abnormalities–surgery.  4.  Orthognathic Surgery–methods. WU 600]
  RK501
  617.6′9–dc23
    2013024047
Unless otherwise indicated, medical illustrations throughout the work © by Elsevier Inc.
Printed in China
Last digit is the print number:  9  8  7  6  5  4  3  2  1 
Vice President and Publisher: Linda Duncan
Executive Content Strategist: Kathy Falk
Senior Content Development Specialist: Brian Loehr
Publishing Services Manager: Julie Eddy
Senior Project Manager: Celeste Clingan
Design Direction: Brian Salisbury

To my wife, best friend and Soul mate Patti, and our two sons,
Joshua and David who have grown into fine young men.
Jeffrey C. Posnick

vi
W
hen I was asked by Jeff Posnick to write a foreword
to his new book on orthognathic surgery I said yes,
without hesitation. I have known and respected Jeff since
he was an enthusiastic, curious, and very bright student at
the Harvard School of Dental Medicine, class of 1977.
These formative years as a student were instrumental in the
subsequent development of his interests and career in cra­
niofacial and orthognathic surgery. Jeff would attend the
Children’s Hospital Craniofacial Clinic on many a Friday
afternoon where he would observe Joseph Murray, John
Mulliken, and me interacting with complex craniofacial
patients, their families, our students and residents and the
rest of our team. From the beginning, I liked Jeff personally,
and I developed a relationship with him because he was very
attentive and asked many probing questions. He did this
not to show off (as Harvard students have been known to
do) but to satisfy his inherent curiosity and eagerness to
learn. To this day, Jeff will occasionally call to discuss a case
and ask for advice, not because he does not have his own
ideas or because he does not know what to do, but to check
with someone else to see if that person has something to
add. This is consistent with his desire to obtain the best
information to help each patient and to educate himself.
When you give Jeff advice, he always has probing follow-up
questions to test your knowledge and recommendations. I
have very much enjoyed these interactions over the years,
even when our opinions have differed. I also admire Jeff’s
persistent “sense of wonder” during his long career.*
Never having written a Foreword before, I considered
the role of the Foreword and Foreword writer. I was sur­
prised to find that most texts in surgical disciplines have a
Preface or an Introduction written by the author, telling
how the author became interested in the subject of the book
and describing how the book came about. The Preface or
Introduction may also contain a summary of the contents
of the book. The less common Foreword, on the other hand,
is a short introductory statement written by someone other
than the author. The writer of a Foreword may be an expert
in the field, an author of a similar book and may have a
relationship with the author. Presumably, good things will
be said about the book, and the author of the Foreword will
tell the reader why reading the book is worthwhile. In this
respect, the Foreword may be helpful to the publisher for
the purpose of marketing.
The more I began thinking about the task at hand, the
more onerous it seemed to become. There was no doubt in
Foreword
my mind that this book would be a major contribution to
the field, as was Jeff Posnick’s 2-volume book: Craniofacial
and Maxillofacial Surgery in Children and Adolescents, Phila­
delphia, WB Saunders, 2000. Dr. Paul Tessier wrote in his
Foreword to that book: “Thanks go to Dr. Posnick for his
overall work and to the publisher for accepting such an
abundance of images for printing. As we approach the year
2000 (which has no quantitative reality), this book is already
a landmark in craniofacial surgery.” M. Michael Cohen Jr.
wrote a second foreword calling it a “tour de force” and
noting that Jeff wrote 40 of 45 chapters, making it an
unusual single-authored book relative to the primary
subject. Well, Orthognathic Surgery: Principles and Practice
is equally a “landmark” and a “tour de force” and there is
no use in trying to say something clever about it. Anyone
who reads this book will find that it speaks for itself: “Res
ipsi loquitur.”
As with Craniofacial and Maxillofacial Surgery in Chil­
dren and Adolescents, Orthognathic Surgery: Principles and
Practice is a single-authored, 2-volume set and therefore has
a consistent format, writing style, and “personality” not
usually achieved in a multi-authored and edited textbook.
This makes it easier and more pleasant to read. The book is
divided into seven sections: Basic Principles and Concepts;
Planning, Surgical Technique, and Complications; Classic
Patterns and Presentations of Dentofacial Deformities; Fre­
quently Seen Malformations with Dentofacial Deformity;
Cleft Jaw Deformities; Post-Traumatic Dentofacial Defor­
mities; and Frequent Aesthetic Considerations in the Den­
tofacial Deformity Patient. Dr. Posnick wrote 39 of the 40
chapters. The first and only invited chapter is the wonder­
fully informative and entertaining contribution by Jeff’s
long-term friend and colleague, M. Michael Cohen Jr.: “The
New Perspectives on the Face.”
Jeff Posnick is meticulous and pays obsessive attention
to detail. Therefore, each chapter includes comprehensive
background material presented with a scholarly review of
the pertinent literature. The relevance of this background
to the overall treatment planning, execution, and outcome
of orthognathic surgery is revealed and all this is supported
by the incredible, well-documented, and beautifully illus­
trated material from Jeff’s personal experience and practice.
This presentation allows the reader to benefit from Jeff’s
thinking and his triumphs, challenges, and difficulties.
It is not the role of the Foreword writer to summarize
the book. However, I would like to describe the highlights
of just two chapters to support my laudatory comments
above. Chapter 2 is an account of the pioneers in ortho­
dontics, oral and maxillofacial surgery, plastic surgery, and
*Mulliken JB: A Sense of Wonder, Plast Reconstr Surg 110:1353-1359,
2002.

vii
Foreword
craniofacial surgery. Jeff Posnick painstakingly chronicles
the critical advances in these specialties that brought us to
our current state. The chapter reads like an exciting novel.
Not only is the history documented in referenced detail, but
also anecdotes of personal relationships between these great
leaders and personal communications regarding their think­
ing, ideas, triumphs, and tribulations are described. The
chapter ends by thanking the pioneers for their contribu­
tions and an appeal to future generations of surgeons to take
up the challenge of creating their own innovations.
Chapter 28 on hemifacial microsomia (HFM), a defor­
mity in which I am particularly interested, is another
example of the quality of this text. Jeff Posnick and I have
some disagreements in this area, particularly regarding the
natural progression of the deformity and timing of treat­
ment. We also disagree about the potential benefits of oper­
ative correction during growth, i.e., in the mixed dentition
stage. Nevertheless, this chapter is one of the most compre­
hensive treatises on the condition, what is known of the
etiopathogenesis and all the significant issues related to the
care of patients with this variable, and in my opinion, pro­
gressive facial asymmetry that you will find in one location.
He has reviewed the pertinent literature, and presented and
critically evaluated the available data. By doing this, he
implies the importance of understanding the natural history
of the deformity and the patterns of growth in the manage­
ment of these patients. Jeff Posnick is also correctly cautious
and skeptical about the use of distraction osteogenesis for
early correction. My experience is somewhat different.
However, Jeff presents the facts as he sees them, and the
conclusions are debatable but fair.
Much has been written on the subject of orthognathic
surgery from its history, basic biology and physiology of the
operations, descriptions of the techniques, peer-reviewed
outcome studies, to review articles and textbooks. The chal­
lenge in writing about a common subject is to bring new
insights and information to the readers; to say something
new or significant and not to simply say what has already
been said. Jeff Posnick meets this challenge in Orthognathic
Surgery: Principles and Practice. It is comprehensive, well
referenced, data supported, and scholarly. Also of note is
the amazing number of quality color illustrations, a credit
to Jeff and to the commitment of the publisher.
I started this project on a beautiful, early summer
weekend in Boston, thinking I would skim the chapters
quickly for a few hours to get a feel for the book. Not by
choice or plan, however, I spent the entire weekend reading
the book; I could not put it down. I suspect the readers will
have the same experience. This text should be required
reading for all surgeons interested in orthognathic surgery.
Leonard B. Kaban, DMD, MD
Walter C. Guralnick Professor and Chairman,
Department of Oral & Maxillofacial Surgery
Massachusetts General Hospital
Harvard School of Dental Medicine
Boston, Massachusetts

viii
Preface
The last comprehensive textbook on the subject—Surgi­
cal Correction of Dentofacial Deformities edited by Bell,
Proffit, and White (1980)—had a major impact on patient
care and remains a landmark in the field. Since then, other
published texts have been useful but not comprehensive.
After setting the outline for this project, my initial intention
was to have experts in the field make contributions. I soon
realized this was impractical if a consistent and comprehen­
sive level of cohesive knowledge on the subject was to be
compiled in a timely manner. In writing this single-authored
text (the exception being a chapter contribution by M.
Michael Cohen Jr.), I enlisted the help of clinicians from a
spectrum of specialties to read each chapter for accuracy,
adequacy of depth, and readability. This included critiques
from academicians, clinicians in practice, past surgical
fellows, and residents in training. They came from a spec­
trum of specialties, including oral and maxillofacial surgery,
orthodontics, periodontics, prosthedontics, speech pathol­
ogy, otolaryngology/head and neck surgery, plastic surgery,
anesthesiology, medical genetics, sleep medicine, radiology,
psychology and psychiatry, and pathology. I am grateful for
their suggestions, as each brought a different perspective
and individual criticism. By clarifying current knowledge
on the subject, I hope this text encourages quality care and
further advances in the field.
I would also like to thank my patients who have allowed
the use of their case studies as teaching instruments. The
presentation of clinical problems and real-life solutions
remains an invaluable way to convey this knowledge. Their
contributions will no doubt minimize treatment errors and
optimize results for future patients.
Jeffrey C. Posnick, DMD, MD
Director, Posnick Center for Facial Plastic Surgery
Chevy Chase, Maryland, USA
JPosnick@DrPosnick.com
T
he treatment of dentofacial deformities has come a long
way since 1897 when Vilray Blair, with Edward Angle’s
coaxing, completed bilateral body osteotomies under chlo­
roform anesthesia to setback a prognathic mandible and
establish an improved occlusion. The 70-minute operation
conducted at the Baptist Hospital in St. Louis, Missouri,
also included placement of a custom gutta-percha inter-
occlusal splint and application of intermaxillary fixation.
The field of orthognathic surgery advanced by small
increments over the next 6 decades until Hugo Obwegeser
executed what has now become the three classic orthogna­
thic procedures: Le Fort I (maxillary) osteotomy with
down-fracture and disimpaction; intraoral sagittal split
ramus osteotomies of the mandible; and the intraoral
oblique osteotomy of the chin. His published results in the
1950s and presentations throughout the 1960s dissemi­
nated this early work. The animal model research carried
out by William Bell confirmed the safety of these osteoto­
mies and set the stage for refinements in orthognathic pro­
cedures by practicing surgeons. During this same timeframe,
Hans Luhr boldly challenged standard thinking of osteot­
omy and fracture healing and stabilization techniques
with his concepts of rigid metal plate and screw fixation.
Simultaneously, Paul Tessier’s imaginative introduction of
craniofacial surgery energized thinking concerning the
reconstruction of all head and neck conditions.
Today, knowledge of how to safely improve the quality
of life for the individual with a dentofacial deformity is
extensive. The object is no longer limited to achieving short-
term improved occlusion. Currently, the triad of improved
quality of life by achieving long-term dental health,
enhanced facial aesthetics, and an open airway represent
standard thinking. There still remain limitations relating
to the uneven geographic distribution of experienced dedi­
cated clinicians and the financial barriers to the correction
of dentofacial deformities. However, the value of treatment
to improve lives is undisputed.

xi
Orthognathic Surgery Videos
Go to to view the videos
INTRA-NASAL PROCEDURES
Video 1: Septoplasty and reduction of the inferior
turbinates carried out through Le Fort I downfracture
Video 2: Septoplasty and reduction of the inferior
turbinates carried out through Le Fort I downfracture
Video 3: Recontouring of the nasal floor, pyriform rims
and anterior nasal spine region carried out during Le
Fort I osteotomy
Video 4: Recontouring of the nasal floor, pyriform rims
and anterior nasal spine region carried out during Le
Fort I osteotomy
AWAKE INTUBATION TECHNIQUES
Video 5: Awake fiberoptic naso-tracheal intubation in
patient with TMJ ankylosis
ORTHOGNATHIC PROCEDURES:
STEP-BY-STEP APPROACH
Patient 1
Video 6-1: Patient preparation and draping
Video 6-2: Sagittal split ramus osteotomies: incision
placement, dissection, and the cortical cuts
Video 6-3: Maxillary Le Fort I osteotomy
Video 6-4: Septoplasty and reduction of the inferior
turbinates
Video 6-5: Removal of impacted maxillary wisdom teeth
Video 6-6: Continuing the Le Fort I osteotomy: removal
of bony interferences, placement of the intermediate
splint, and securing intermaxillary fixation
Video 6-7: Achieving the desired vertical midface
dimension
Video 6-8: Placement of titanium plate and screw fixation
across Le Fort I osteotomy
Video 6-9: Recontouring of the nasal floor, pyriform rims
and anterior nasal spine region
Video 6-10: Release of IMF—confirming the correct
occlusion-removal of the intermediate splint-securing of
the final splint
Video 6-11: Osseous genioplasty
Video 6-12: Splitting of each sagittal ramus osteotomy
of the mandible and removal of impacted mandibular
wisdom teeth
Video 6-13: Securing of intermaxillary fixation through
the final splint
Video 6-14: Insertion of the transbuccal trocar, seating of
the proximal segment, removal of bony interferences,
and placement of bicortical screw fixation
Video 6-15: Release of intermaxillary fixation and
confirmation of correct occlusion
Video 6-16: Wound closure
Patient 2
Video 7-1: Patient preparation and draping
Video 7-2: Sagittal split ramus osteotomies: Incision
placement, dissection, and cortical cuts
Video 7-3: Maxillary Le Fort I osteotomy
Video 7-4: Septoplasty and reduction of the inferior
turbinates
Video 7-5: Continuing the Le Fort I osteotomy: removal
of bony interferences, placement of the intermediate
splint, and securing intermaxillary fixation
Video 7-6: Achieving the desired vertical midface
dimension
Video 7-7: Recontouring of the nasal floor, pyriform rims,
and anterior nasal spine region
Video 7-8: Placement of titanium plate and screw fixation
across the Le Fort I osteotomy
Video 7-9: Release of IMF-confirming the correct
occlusion-removal of the intermediate splint-securing of
the final splint
Video 7-10: Osseous genioplasty
Video 7-11: Splitting of each sagittal ramus osteotomy of
the mandible
Video 7-12: Securing of intermaxillary fixation through
the final splint
Video 7-13: Insertion of the transbuccal trocar, seating of
the proximal segment, removal of bony interferences,
and placement of bicortical screw fixation
Video 7-14: Release of intermaxillary fixation and
confirmation of the correct occlusion
Video 7-15: Wound closure
Video 7-16: Anterior neck rejuvenation
GRAFT HARVESTING
Video 8: Harvesting cancellous bone through the anterior
iliac crest
Video 9: Harvesting a corticocancellous block graft from
the anterior iliac crest
Video 10: Harvesting a rib cartilage graft

xii
Orthognathic Surgery Videos
OSSEOUS GENIOPLASTY
Video 11: Osseous genioplasty with horizontal
advancement
Video 12: Osseous genioplasty with horizontal
advancement
SELECTED PROCEDURES
Video 13: Anterior neck rejuvenation: cervical flap
elevation, fat removal, vertical platysma muscle plication
Video 14: Cleft orthognathic surgery for the BCLP
deformity
Video 15: Monobloc and facial bipartition osteotomies
for the reconstruction of craniosynostosis
syndromes

1

1
The New Perspectives on the Face+
M. MICHAEL COHEN JR.
SECTION 1  Basic Principles and Concepts
• What Constitutes a Face?
• Facial Perspectives and Stages in
the Life Cycle
• Evolutionary Considerations
• Craniofacial Growth and Development
• Dysmorphic Faces
• The Outer Limits in Facial Surgery
• Making Blind People See Again
• Prosopagnosia
• The New Psychiatric Genetics
• Artistic Perspective
What Constitutes a Face?
Structural Definitions
There are several ways to view faces. Figure 1-1 shows two
fish.14 If two eyes and a mouth define a face, then fish have
faces. They may have one or two nostrils, which are not
connected to the mouth. However, water entering the nos­
trils does bathe the olfactory mucosa. Fish lack an ear canal,
but the inner ear is present. Weber’s bones connect the swim
bladder to the inner ear, and sound is transmitted.10
Another definition requires evolutionary transformation
of the skull, in which a face is recognizable in mammals,
but not in fish, amphibians, or reptiles (Fig. 1-2). The jaw
is suspended from the braincase in reptiles. Mammals,
however, have three ear ossicles, a secondary palate separat­
ing the airway passage from the mouth, and vertical posi­
tioning of the dentary.35
Behavioral Definitions
All animals communicate with each other in various ways
by tactile, chemical, visual, and acoustical signaling. Insects
have heads, but do they have faces? Paper wasps (Polistes
+This chapter is dedicated to my Fellow Angela M. Castro, MD.
• Figure 1-1  Two fish faces. Copyright © Shutterstock.com.
dominulus) signal their status to each other by the number
of black splotches on their yellow faces (Fig. 1-3).41
Some define faces by the presence and use of facial
muscles, which do not exist in fish, amphibians, reptiles, or
birds. In contrast, mammals can suckle and later chew, sup­
ported by a muscular tongue and movable lips and cheeks
(Fig. 1-4). Often, the muscles in the ears can change posi­
tions to aid in hearing; a movable nose for smelling and
touching, and facial hair, the vibrissae, are associated with
musculature and serve as tactile organs.10
For some, a behavioral definition must include facial
expressions, which are found in various primates (Fig. 1-5),
including humans (Fig. 1-6).10
Symbolic Definitions
The term symbolism has been defined in many different
ways. Here, I define symbolic transformation as the ambi­
guous representation of two things by association or
resemblance. Two examples are shown in Figures 1-7
and 1-8.10
Facial Perspectives and Stages
in the Life Cycle
Box 1-1 summarizes all possible perspectives from which
the face can be described; Box 1-2 lists all the stages in the

2
SECTION 1  Basic Principles and Concepts
• Figure 1-2  Transformation of a mammalian-like reptile to a mammalian skull. Lateral and cross-
sectional views of the skulls. Based on Radinsky, 1987.
Orbit
Orbit
Temporalis muscle
Temporal opening
Zygomatic arch
Lower jaw
Pterygoid muscle
Reptile
Mammal
Temporalis muscle
Coronoid process
Zygomatic arch
Lower jaw
Pterygoid muscle
• Figure 1-3  Wasp faces signal their status to each other by the
number of black splotches on their yellow faces. The more blotches,
the higher the status. Copyright 2004 Elizabeth Tibbetts. Modified by
M. Michael Cohen Jr.
Low
status
High
status
Paper wasps (Polistes dominulus)
• Figure 1-4  Mammals can suckle and later chew, supported by a
muscular tongue and movable lips and cheeks.
• Figure 1-5  Rhesus monkey facial expressions. From left to right, a bared-teeth display, a scream, an open-mouth threat, and a
relaxed, open-mouth face (play face). From Parr and Heintz, 2009.

3
CHAPTER 1  The New Perspectives on the Face
•  BOX 1-1 
Perspectives on the Face
Evolutionary
Developmental
Anatomic
Genetic
Surgical
Psychological
Sociocultural
Artistic
•  BOX 1-2 
The Face in the Life Cycle
Intrauterine development
Birth
Infancy
Childhood
Adolescence
Adulthood
Old age
Death
• Figure 1-6  Human facial expressions. A, Happiness. B, Surprise. C, Anger. D, Disgust. Based on Cohen, 2006.
A
B
C
D
• Figure 1-7  Gossiping scallions. From Elffers, 1997.
• Figure 1-8  All Is Vanity. The mirror is also a skull. House of Art,
New York.
life cycle; and Box 1-3 lists the origin of some craniofacial
components. Figure 1-9 shows embryonic facial develop­
ment at approximately 42 to 44 days.25 Figure 1-10 shows
skull molding in a newborn. Figure 1-11 shows the face of
a small child, and Figure 1-12 shows a painting, The Stages
of Human Life, by Hans Baldung Grien. In this allegory, a
young woman, an old woman, and a dead woman are linked
by their hands and arms.4 The dead woman holds an hour­
glass timer, indicating that life is over.

4
SECTION 1  Basic Principles and Concepts
• Figure 1-9  Embryo of about 42 to 44 days. The developing face
has a frontal area with bulging cerebral hemispheres; a nasodorsal
center with nasoseptal and nasozygomatic portions; nasal pits
delineated by nasal ridges with premaxillary, medionasal, and latero­
nasal portions; maxillary primordia; interpremaxillary depression; a
premaxillary–maxillary junction; and a lower jaw. Courtesy of Jan E.
Jirásek, Prague.
• Figure 1-10  Molding of the head caused by compression during
passage through the birth canal. From Cohen, 2006.
•  BOX 1-3 
Origins of Some Craniofacial Components
Neural Crest Origin
Facial connective tissue
Facial bones
Nasal capsule
Frontal bone
Metopic suture
Sagittal suture
Temporal squama
Mesodermal Origin
Facial muscles
Endothelial lining of blood vessels
Chondrocranium
Parietal bones
Coronal suture
Lambdoid suture
Temporal bones (except squama)
Occipital bone (somites plus squama)
Evolutionary Considerations
Evolution of the Mammalian Brain
The evolution of the mammalian brain is based on the
development of the neocortex (Fig. 1-13), which also
resulted in a cranial shape that was different than that of
the dinosaurs. The coexistence of dinosaurs and mammals
and their competition during the Mesozoic era made mam­
malian neocortical development possible.5
Dinosaurs were large and had long life spans of about
100 years. In contrast, mammals were very small and had
short life spans, which allowed them to evolve into many
different species rapidly. Possibly, there were 50 generations
of mammals during one dinosaur generation.
Mammals were nocturnal and hunted at night. With the
development of the neocortex, mammals had an active life­
style as well as acute hearing and smelling, which made
insect prey easier to come by and made escape from preda­
tors easier as well. The end of the dinosaur era allowed
mammals to evolve larger body forms.
Molecular Components in Primate Brain
and Craniofacial Evolution
The gene Microcephalin (MCPH1) was first identified in its
mutant form in which it causes primary microcephaly, but
the normal gene was then adaptively found to be important
in regulating brain size, and it continues to evolve in
humans.18
Homozygous ASPM mutations also cause microcephaly.
The normal gene may regulate neural stem cell proliferation

5
CHAPTER 1  The New Perspectives on the Face
• Figure 1-11  Baby’s face with relatively large head, prominent eyes,
and a diminutive face. From Cohen, 2006.
• Figure 1-12  The Stages of Human Life (1530-1545), by Hans
Baldung Grien, oil on wood, 61 × 151 cm, Prado Museum, Madrid.
From Buendia, 1989. See text for details. Musceo del Prado, Madrid,
Spain. Photo credit: Bridgeman-Giraudon/Art Resource, NY.
• Figure 1-13  Stages in the evolution of the brain. A comparison of
the brain size of the fish, reptile, rabbit, and human. As the cerebral
cortex increases in size, the cranium becomes larger and more
rounded. Based on Campbell, 1970.
Fish
Reptile
Rabbit
Human
and/or differentiation, possibly by mediating spindle-cell
assembly during cell division.31
SIGLEC11, a gene involved in sialic acid biology, is
expressed in high concentration in microglial cells in the
human brain, but only occasionally in the cells of
chimpanzees.24
The Ret finger protein-like 1,2,3 (RFPL 1,2,3) genes on
chromosome 22 are evolutionary forces that play a role in
neocortical development.3
GTF2IRD1—a gene that, when mutated, causes cranio­
facial anomalies—has been shown in its normal form to be
a regulatory determinant of craniofacial development.39
Comparison of Different Skulls
Figure 1-14 shows the orientation of the foramen magnum
and the anterior cranial base in a rodent and a human. The
foramen magnum is posteriorly placed in the rodent and
vertically placed in the human. The anterior cranial floor
and the cribriform plate face forward in the rodent and are
vertically placed in the human.16 Figure 1-15 shows a dog’s

6
SECTION 1  Basic Principles and Concepts
• Figure 1-14  Orientation of the foramen magnum and the anterior
cranial base in a human and a rodent. The foramen magnum is verti­
cally placed in the human (A) and posteriorly placed in the rodent (C).
The anterior cranial floor and the cribriform plate face downward in the
human (B) and forward in the rodent (D). Based on Enlow, 1968.
Rodent
A
B
C
D
Anterior cranial fossa and cribriform plate
Foramen magnum
Human
skull compared to a Chevrolet Corvette in contrast to a
human skull compared to a camper, indicating an expanded,
upright forehead above the face.17
In Figure 1-16, expansion of the brain and a reduction
in human facial prominence results in a flat facial profile
compared with a smaller brain and a more protruding
gorilla face, resulting in a sloping facial angle.10 Figure 1-17
compares the growth pattern of a fetal chimp with that of
a human fetus. Both fetuses look similar. However, com­
pared with the adult chimp, the adult human more closely
resembles its own fetal pattern. Neoteny—a slowdown in
the growth rate with a delay in maturation—has occurred
in human evolution.23
Comparison of Homo sapiens, Homo
neanderthalensis, and Homo floresiensis
Evidence now shows that there are three separate species
of hominins. Figure 1-18 compares the skulls of Homo
neanderthalensis with Homo sapiens. The braincase of modern
humans is relatively shorter, and the forehead is rounder,
higher, and has a nearly vertical slope. Neanderthals have
large brow ridges, projecting midface, elongated skull,
occipital protuberance, a skull capacity 10% greater than
that of modern humans, and a distinctive bony labyrinth not
found in humans.27 DNA sequence comparisons show that
Neanderthals fall outside the variation of modern humans.
Molecular divergence provides a date of over 500,000 years.28
Figure 1-19 contrasts the phenotypes of the different
species of hominins. Homo neanderthalensis has an elon­
gated skull with a larger endocranial capacity than in
humans; a distinctive bony labyrinth not found in humans
(not shown); a robust skeleton with a barrel-shaped ribcage;
a long superior pubic ramus; long clavicles; thick, bowed
femoral shafts; large patellas; and large, round, terminal
phalanges (fingers). Homo floresiensis has a tiny skull with a
small endocranial capacity (380 cm3 to 430 cm3), a chinless
mandible, a diminutive body (~1 m in height), long arms
in relation to the legs (arms hang almost to the knees),
unusual shoulders, a wider pelvis than in humans, and large
feet (more than 7½ inches long and out of proportion with
the short lower limbs, flat feet, and a stubby great toe).10
The time spans of the three different species of hominins
are (1) Homo sapiens from 500,000 years ago to the present
time; (2) Homo neanderthalensis from 500,000 years ago
until 30,000 years ago; and (3) Homo floresiensis from
95,000 years ago until 12,000 years ago. Thus, from 95,000
to 30,000 years ago, three different species of hominins
occupied the earth at the same time.
Craniofacial Growth and Development
Comparative Skull Size with Age
In the newborn skull (Fig. 1-20), the cranium and the orbits
are relatively large, and the face is diminutive. In early child­
hood, the cranium and the orbits remain relatively large,
but the eruption of the primary dentition enlarges the facial
skeleton. In the adult skull, the facial skeleton is well-
developed with relatively less prominence of the orbits and
cranium. The ratio of the cranial volume to the facial
volume changes during growth, and these ratios appear in
Figure 1-20 under the skulls.10
Bone Modification with Age
Bone modification of the craniofacial skeleton occurs nor­
mally with age (summarized in Table 1-1). Table 1-2 lists
some examples of abnormal alterations in the craniofacial
skeleton with age.10
Alterations in the Face with Age
The changing proportions of head size to body size are
illustrated in Figure 1-21. From the 2-month-old embryo
to the 22-year-old adult, the relative head size decreases
significantly, but it is greatest in the fetus and the infant.
Figure 1-22 illustrates line drawings of the facial profile
showing alterations from 5 months of age to adulthood,
with striking changes in the nose and chin with age.10 The

7
CHAPTER 1  The New Perspectives on the Face
• Figure 1-15  Top, Lateral view of a dog skull compared to a Chevrolet Corvette; the face is anterior to the cranium. Bottom, Lateral view of a
human skull compared to a camper; the expanded forebrain results in an upright forehead above the face. From Enlow, 1990.
• Figure 1-16  Expansion of the brain and a reduction in the facial prominence of humans result in a
flat facial angle compared with the smaller brain and more protrusive face of the gorilla, resulting in a
sloping facial angle.
Human
Gorilla

8
SECTION 1  Basic Principles and Concepts
• Figure 1-17  Morphology of the chimpanzee and human skulls. Compared with the chimp,
the adult human skull resembles its fetal counterpart. Neoteny—a slowdown in the growth
rate with a delay in maturation—has occurred in human evolution. Based on Gould, 1977.
Adult
Fetus
Human
Chimpanzee
Fetus
Adult
• Figure 1-18  Lateral view of the skulls of Homo sapiens and Homo neanderthalensis. See text for
description.
Homo sapiens
Homo neanderthalensis
TABLE
1-1 
Normal Growth and Modification of the Craniofacial Skeleton with Age
Cartilaginous
Growth
Sutural Growth
Skeletal Mass
Bone Remodeling
Infancy and Childhood
Active
Passive
Increases
Deposition greater than resorption
Adulthood
Absent
Absent
Remains the same
Deposition equals resorption
Old Age
Absent
Absent
Decreases
Resorption greater than deposition

9
CHAPTER 1  The New Perspectives on the Face
• Figure 1-19  Comparison of A, Homo sapiens, B, Homo neanderthalensis, and C, Homo
floresiensis. See text for description. Based on the work of M. Michael Cohen Jr.
A Homo sapiens
B Homo neanderthalensis
C Homo floresiensis
• Figure 1-20  Alterations of the skull in the newborn, in childhood, and in adulthood. The ratios of the cranial volume
to the facial volume change during growth, and these ratios appear under the figure. For a description of skull altera­
tions with age, see text. From Cohen, 2006.
Ratio of cranial volume to facial volume
• Birth (8:1)
• 2 years (5:1)
• 6 years (3:1)
• 12 years (2.5:1)
• 18 years (2:1)
A
B
C

10
SECTION 1  Basic Principles and Concepts
• Figure 1-21  Diagram illustrating the changing proportions of head size and body size. From the 2-month-old embryo to the 22-year-old
adult, the relative head size decreases significantly, but it is greatest in the fetus and the infant. Based on Scammon, 1953.
2 Months
fetus
3 Months
fetus
Newborn
2 Years
5 Years
13 Years
22 Years
• Figure 1-22  Line drawing of the human profile illustrating alterations in form and proportion from 5 weeks prenatally
through the newborn period to the adult. Based on Scammon, 1953.
5 weeks
8 weeks
10 weeks
13 weeks
Newborn
Adult
lower jaw in the male Atlantic salmon is extraordinary.
There is rapid and pronounced growth during adult life
(Fig. 1-23), when the starving salmon migrate upriver for
spawning.42
Facial Asymmetry
Those psychologists who study faces and state that “beau­
tiful faces are symmetric” don’t know what they’re talking
about, because all normal faces are asymmetric. With
respect to the normal face, subtle degrees of asymmetry
become particularly evident when properly oriented frontal
photographs are divided along the median plane and
reprocessed, each side being paired with its mirror image
(Fig. 1-24).10
The Skull as a Community of Bones versus
the Skull as a Community of Joints
According to Pruzansky,34 the skull is a community of bones
separated by joints, but according to Moffett32 the skull is
a community of joints separated by bones. Which view is
correct? They are simply different contexts in which to view
the development of the skull.10

11
CHAPTER 1  The New Perspectives on the Face
• Figure 1-23  Rapid and pronounced growth of the lower jaw in a starving adult male salmon migrating upriver for
spawning. A, Normal adult male jaw. B, Extraordinary upriver growth of the lower jaw. From Witten et al, 2003.
A
B
• Figure 1-24  Demonstration of the facial asymmetry that is so typical
of everyone. From Cohen, 2006.
Normal face
(All normal faces
are asymmetric)
Frontal photographs
are reprocessed,
each side being paired
with its mirror image
Left side
reprocessed with
its mirror image
Right side
reprocessed with
its mirror image
• Figure 1-25  Midface deficiency secondary to hypoplasia of the
nasal capsule in achondroplasia. From Cohen, 2000.
Pruzansky34 stated the following:
“The skull is a community of bones and organ systems of
diverse phylogenetic origin and variable patterns of
development, altogether relating to several functions vital
to the life and well-being of the organism. If in the course
of development one member of this community is affected
adversely, inevitably other parts will suffer.”
Achondroplasia, caused by several FGFR3 gain-of-
function mutations (particularly Gly380 Arg9) illustrates
what Pruzansky34 meant (Fig. 1-25): if one member of
the community is affected, inevitably other parts will suffer.
In this case, the nasal capsule and cranial base, both car­
tilaginous in origin, have a secondary effect on membrane
bones, because all craniofacial bones articulate with one
another. Thus, in achondroplasia, the hypoplastic nasal
capsule and short anterior cranial fossa result in midface
deficiency.7,9,10
The skull may also be considered a community of joints
separated by bones. Types of joints, known as craniofacial
articulations, include synovial, cartilaginous, fibrous, and
dental.32 Table 1-3 summarizes craniofacial articulations
together with their physiologic and mechanical functions
and their remodeling responses.10

12
SECTION 1  Basic Principles and Concepts
TABLE
1-2 
Some Examples of Abnormal Alterations in the Craniofacial Skeleton with Age
Abnormal Skeletal Condition
Pathologic Process
Infancy and Childhood
Achondroplasia
Bony midface deficiency secondary to hypoplasia of
cartilaginous nasal capsule and cranial base
Craniosynostosis
Premature sutural fusion by bone deposition
Adulthood
Acromegaly
Bone deposition dramatically exceeds bone resorption
Hemifacial atrophy
Localized bone resorption exceeds bone deposition
Old Age
Paget disease of bone
Bone deposition exceeds bone resorption
Senile osteoporosis
Bone resorption exceeds bone deposition
Dysmorphic Faces
Four different types of faces are contrasted in Figure 1-26:
(1) the normal face; (2) Down syndrome with minor anom­
alies; (3) Crouzon syndrome; and (4) a bizarre prenatally
determined face. Three views of Williams syndrome are
illustrated in Figure 1-27. The combination of minor facial
anomalies—strabismus, anteverted nares, and thick lips—
are evident in all three patients. In contrast, the severe facial
anomalies associated with holoprosencephaly—cyclopia,
ethmocephaly, cebocephaly, and premaxillary agenesis—are
shown in Figure 1-28.6,8,10-12 A newborn with diprosopus—
a double face with two nostrils, four eyes, two noses, and
two mouths—is illustrated in Figure 1-29. The most bizarre
case of all is shown in Figure 1-30. This patient is missing
his lateral orbital walls, and he is able to pull his eyes apart
laterally without ripping his optic heads from the back of
his eyeballs. How he does this is mysterious, but I suspect
he started doing this very early in childhood and gradually
increased the distance over time.
The Outer Limits in Facial Surgery
The problems surrounding complete facial transplantation
are technical, psychological, and ethical. Earlier, facial trans­
plantation was rejected by many institutions, with the
exception of the Cleveland Clinic’s Institutional Review
Board, and I have discussed the concept of facial transplan­
tation and its associated problems elsewhere.10 Although it
was rejected earlier by the French National Ethics Advisory
Committee, the door was left open for a severely disfigured
woman bitten by a dog for which she received a lower facial
transplant. Since then, at least seven facial transplants have
been carried out. The result of a facial transplant after a
gunshot wound is shown in Figure 1-31.
Making Blind People See Again
The cornea covers the eye globe and a narrow zone between
the cornea and the conjunctiva known as the limbus (Fig.
1-32), which is a source of stem cells for corneal epithelium.
In recent years, new techniques that can restore vision in
certain types of blindness have come to the fore. In a surgi­
cal procedure called limbal cell transplantation, extraction of
stem cells from the healthy contralateral eye of a patient or
from a relative in the family is transplanted into a patient’s
eye with corneal degeneration, blindness, or some other
ocular disease. The stem cells then differentiate into corneal
epithelial cells and improve vision.19 The limbus itself can
be destroyed by chemical burns, by thermal burns, or by
infection, which results in corneal stem-cell deficiency.
However, it has been recently reported that a viable alterna­
tive source of cells for transplantation consists of limbal cells
maintained in culture.36 A biosynthetic cornea created from
human collagen has also been developed. It mimics the
protein’s scaffolding and can be used to trigger regeneration
of a patient’s own corneal cells.20
Age-related macular degeneration is a major cause of
blindness. Although there is no treatment for the avascular
type, the neovascular type results from an imbalance in
antiangiogenic and proangiogenic factors and can be treated.
Intravitreal injection of VEGF inhibitors results in signifi­
cant recovery of vision in 30% to 40% of patients.40
Leber congenital amaurosis is an inherited group of rod–
cone dystrophies resulting in congenital blindness. One
form caused by the RPE65 gene accounts for 16% of the
cases. Using rAAV as a vector for retinal gene therapy, a
cannula is passed through the front of the eye and across
the vitreous gel. Working copies of the gene are injected
into the back of the eye. Maguire and colleagues30 reported
improvement in visual acuity for all patients.
Several animal studies show great promise for future
treatment. The development of retinal cell transplants has
been studied in rabbits,38 and retinal repair by transplanta­
tion of photoreceptor precursors has been studied in mice.29
Prosopagnosia
The ability to identify human faces is remarkable. Although
the face ages with time, it is possible to instantly identify a
face of someone who has not been seen for 25 or 30 years.
An area in the brain that governs facial recognition is found

13
CHAPTER 1  The New Perspectives on the Face
• Figure 1-26  Four kinds of faces with different implications. A normal child’s face is shown.
Down syndrome involves many minor facial anomalies that are diagnostic. Crouzon syndrome is
severe but can be treated successfully with surgery. There is no effective treatment for the infant
with severe facial anomalies and hydrocephalus. Based on the work of M. Michael Cohen Jr.
Crouzon syndrome is by courtesy of Bonnie Padwa, Boston.
Normal face
Down syndrome
Crouzon syndrome
Severe prenatal anomaly
• Figure 1-27  Three patients with Williams syndrome of different ages. All have strabismus, anteverted
nares, and thick lips. From Cohen, 1997, 2002, 2006, and 2007, a and b.

• Figure 1-28  Faces associated with holoprosencephaly. From Cohen, 1997, 2002, 2006, and 2007, a and b.
Holoprosencephaly
Cyclopia
Ethmocephaly
Cebocephaly
Premaxillary agenesis
• Figure 1-29  Diprosopus. Courtesy of Gosla Reddy.
• Figure 1-30  Hypertelorism with absent lateral orbital walls. This
man is able to manipulate his eyes without ripping his optic heads from
the back of his eyeballs. I suspect that he learned to do this very
gradually. Courtesy of M-Reza Farahvash.
• Figure 1-31  A, Three frontal views by dates. 12/3/08:
A 45-year-old woman with a shotgun blast to the face.
She underwent a nearly total facial transplantation, includ­
ing a composite LeFort III midfacial skeleton, overlying
skin, soft tissue, nose, lower eyelids, upper lip, total infra­
orbital floor, both zygomas, both parotid glands, the ante­
rior maxilla with central maxillary incisors, the whole
alveolus, the anterior hard palate, and intraoral mucosa.
Note tracheostomy. 5/4/09: Second facial transplantation
with construction of the nose and lips. 8/23/10: Reduction
of facial fat and better facial appearance. B, Three profile
views with the same dates as in A. 5/4/09: Note better
projection of the nose. 8/23/10: Mandibular advancement
with normal lower facial appearance. Both the upper and
lower portions of the face are balanced. Courtesy of the
Cleveland Clinic.
12/3/08
5/4/09
8/23/10
A
B

15
CHAPTER 1  The New Perspectives on the Face
• Figure 1-32  Eye globe, horizontal plane. Note the limbus. Based
on Cohen, 2006.
Cornea
Limbus
Iris
Lens
Macula
Vitreous body
Retina
Optic nerve
Optic papilla
Aqueous
humor
Sclera
• Figure 1-33  Prosopagnosia. Note the area of the brain that governs
facial recognition found at the base of the temporal and occipital lobes
on both sides of the cerebral cortex. Based on Geschwind, 1979.
Frontal lobe
Temporal lobe
Occipital lobe
Facial recognition
area
TABLE
1-3 
Craniofacial Articulations
Type of
Articulation
Example
Physiological Function
Mechanical Function
Remodeling
Response
Synovial
Temporomandibular
joint
Jaw movement
Resists compression and
shear to some extent
Limited, avascular
Cartilaginous
Cranial base
synchondroses
Active growth
Resists compression
Limited, avascular
Fibrous
Cranial sutures
Allows passage through
narrow birth canal;
growth secondary to
brain enlargement
Respond to tension
Great, vascularized
Facial sutures
Mastication
Sutures remain patent
until old age; shock
absorbers for forces of
mastication
Great, vascularized
Periodontal fibers
Eruption of teeth; anchoring
support of teeth
Responds to tension,
compression, and
shear
Great, vascularized
Dental
Occlusal and
interproximal
articulations
Mastication and speech
Subject to compression
and shear
None, acellular
at the base of the cerebral cortex (Fig. 1-33). Any lesion that
destroys this area impairs the ability to identify faces but
has almost no other effects, although the dimming of vision
may occur in some affected individuals. The patient can
read, name objects, and match a full-face picture with a
profile picture of the same person. Only the ability to rec­
ognize specific faces is lost; this is a neurological condition
known as prosopagnosia. An affected man who cannot rec­
ognize his own wife can see her, but he can only recognize
who she is when he hears her speak.21 An epidemiologic
study has found a prevalence rate of prosopagnosia of
2.47%; of 17 cases, 14 subjects had at least one first-degree
relative with prosopagnosia.26
The New Psychiatric Genetics
The brain, as part of the craniofacial complex, is associated
with a number of psychiatric and neurodegenerative disor­
ders. In medical genetics, we used to delineate newly recog­
nized syndromes by describing them as single entities and
then finding a Mendelian pattern, a chromosomal anomaly,
or a teratogenic cause. After molecular genetics became
established, it became clear that the same disorder might

16
SECTION 1  Basic Principles and Concepts
References
1. Arneson DJ: Stories: Tweety and Sylvester,
Middleton, Conn, 1971, Xerox Education
Publications. Courtesy of Warner Bros.
2. Berenson B: Italian Painters of the Renaissance,
New York, 1976, Meridian.
3. Bonnefont J, Nikolaev SI, Perrier AL, Guo S,
Cartier L, Sorce S, Laforge T, Aubry L,
Khaitovich P, Peschanski M, Stylianos E,
Antonarakis E, Karl-Heinz K: Evolutionary
forces shape the human RFPL 1,2,3 genes
toward a role in neocortex development. Am J
Hum Genet 83:208–218, 2008.
4. Buendia JR: Basic Guide to the Prado, Madrid,
1989, Silex.
5. Campbell B: Human Evolution, Chicago,
1970, Aldine.
6. Cohen MM, Jr: The Child with Multiple Birth
Defects, ed 2, New York, 1997, Oxford
University Press.
7. Cohen MM, Jr, MacClean RE: Craniosynostosis:
Diagnosis, Evaluation, and Management, New
York, 2000, Oxford University Press.
8. Cohen MM, Jr: Perspectives on Craniofacial
Anomalies, Syndromes, and Other Disorders.
In Lin KY, Ogle RC, Jane JA, editors:
Craniofacial Surgery: Science and Surgical
Technique, Philadelphia, 2002, W.B. Saunders
Company, Chapter 1, pp. 3–38.
9. Cohen MM, Jr: FGFs/FGFRs and Associated
Disorders. In Epstein CJ, Erickson RP,
Wynshaw-Boris A, editors: Inborn Errors of
Development, 2004. New York, 2004,
Oxford University Press, Chapter 33,
pp 380–400.
10. Cohen MM, Jr: Perspectives on the Face, New
York, 2006, Oxford University Press.
11. Cohen MM, Jr: Craniofacial Disorders. In
Rimoin DL, Conner JM, Pyeritz RE, Korf
BR, editors: Emory and Rimoin’s Principles
and Practice of Medical Genetics, ed 5,
Philadelphia, 2007, Elsevier, Chapter 151,
pp 3303–3348.
• Figure 1-34  Left, Close-up of a Florentine Portrait of a Man with a Medal of Cosimo the Elder by Botticelli.
Right, Close-up of a Venetian Portrait of Jacopo Soranzo, by Tintoretto. For stylistic interpretation, see text.
A, From the Uffizi Gallery, Florence Inv 1890 no. 1,488; B, from Gallerie del’ Accademia, Venice. Image source:
Art Resource, NY.
A
B
have causative mutations in several different genes on dif­
ferent chromosomes. For example, Biedl-Bardet syndrome
can be caused by mutations in 14 different genes, all on
different chromosomes. Thus, we learned that what appeared
to be a single disorder was etiologically heterogeneous.
Because psychiatric thinking began by attributing behav­
ioral problems to earlier psychological events, it was the last
bastion to be stormed by molecular genetics. Behavioral
disorders are now being delineated at a molecular level, but,
like the early delineation of physical genetic disorders, prog­
ress in psychiatric genetics only accounts for a small percent­
age of cases at present. Disorders with molecular findings
include intellectual disability, schizophrenia, bipolar disor­
der, Alzheimer disease, autism, Parkinson disease, Hunting­
ton disease, and frontotemporal dementia.13
Artistic Perspective
Figure 1-34 compares two Renaissance paintings: a Floren­
tine Portrait of a Man with a Medal of Cosimo the Elder by
Botticelli and a Venetian Portrait of Jacopo Soranzo by
Tintoretto. The difference in painting style is striking. In
the Florentine painting, the outlines of the face are sharply
drawn with a three-dimensional sculptural quality together
with a sense of palpability. In contrast, in the Venetian
painting, the lines of the face are soft and less distinct but
with a sense of atmosphere surrounding the figure.2

17
CHAPTER 1  The New Perspectives on the Face
12. Cohen MM, Jr: Craniofacial Abnormalities.
In Potter’s Pathology of the Fetus, Infant, and
Child, ed 2, Philadelphia, 2007, Elsevier,
Chapter 20, pp 885–918.
13. Cohen MM, Jr: Mental retardation, psychiatric
disorders, neurodegenerative disorders, and
genetics. PowerPoint presentation dedicated to
my Fellow Angela M. Castro, MD. 2010.
14. Doubilet D: Fishface, New York, 2003,
Phaidon Press.
15. Elffers J: Play with Your Food, New York,
1997, Stewart, Tabori & Chang.
16. Enlow DH: The Human Face, New York,
1968, Harper & Row.
17. Enlow DH: Facial Growth, ed 3, Philadelphia,
1990, Saunders.
18. Evans PD, Gilbert SL, Mekel-Bobrov N,
Vallender EJ, Anderson JR, Vaez-Azizi LM,
Tishkoff SA, Hudson RR, Lahn BT:
Microcephalin, a gene regulating brain size,
continues to evolve adaptively in humans.
Science 309:1717–1720, 2005.
19. Ezhkova E, Fuchs E: An eye to treating
blindness. Nature 466:567–568, 2010.
20. Fagerholm P, Lagali NS, Merrett K, Jackson
WB, Munger R, Liu Y, Polarek JW, Söderqvist
M, Griffith M: A biosynthetic alternative to
human donor tissue for inducing corneal
regeneration: 24-month follow-up of a phase
1 clinical study. Sci Transl Med 2:46ra61,
2010.
21. Geschwind N: Specialization of the human
brain. In The Brain: A Scientific American
Book, San Francisco, 1979, W.H. Freeman
and Co., pp 108–117.
22. Gilbert CA: All Is Vanity. New York: House
of Art.
23. Gould SJ: Ontogeny and Phylogeny,
Cambridge, UK, 1977, Harvard University
Press.
24. Hayakawa T, Angata T, Lewis AL, Mikkelsen
TS, Varki, NM, Varki A: A human-specific
gene in microglia. Science 309:1693, 2005.
25. Jirásek JE: Atlas of Human Prenatal
Morphogenesis, Boston, 1983, Martinus
Nijhoff.
26. Kenerknecht I, Grueter T, Welling B, Wentzek
S, Horst J, Edwards S, Gueter M: First report
of prevalence of non-syndromic hereditary
prosopagnosia (HPA). Am J Med Genet
140A:1617–1622.27, 2006.
27. Klein RG: Whither the Neanderthals? Science
299:1525–1527, 2003.
28. Krings M, Capelli C, Tschentdcher F, Geisert
H, Meyer S, von Haeseler A, Grossschmidt K,
Possnert G, Paunovic M, Pääbo S: A view of
Neanderthal genetic diversity. Nat Genet
26:144–146, 2004.
29. MacLaren RE, Pearson RA, MacNeil A,
Douglas RH, Salt TE, Akimoto M, Swaroop
A, Sowden JC, Ali RR: Retinal repair by
transplantation of photoreceptor precursors.
Nature 444:203–207, 2006.
30. Maguire AM, Simonelli F, Pierce EA, Pugh
EN, Mingozzi F, Benicelli J, Banfi S, Marshall
KA, Tesa F, Surace EM: Safety and efficiency
of gene transfer for Leber congenital
amaurosis. New Engl J Med 358:2240–2248,
2008.
31. Mekel-Bobrov N, Gilbert SL, Evans PD,
Vallender EJ, Anderson JR, Hudson RR,
Tishkoff SA, Lahn BT: Ongoing adaptive
evolution of ASPM, a brain size determinant
in Homo sapiens. Science 309:1720, 2005.
32. Moffett BC, Jr: Syllabus for course in
fundamentals of skeletal biology related to
clinical dentistry, Unpublished manuscript,
1973. University of Washington.
33. Parr LA, Heintz M: Rhesus monkey
expressions. Anim Behav 77:1507–1513, 2009.
34. Pruzansky S: Clinical investigation of the
experiments of nature. ASHA Report 8:62–94,
1973.
35. Radinsky LB: The Evolution of Vertebrate Design,
Chicago, 1987, University of Chicago Press.
36. Rama P, Matuska S, Paganoni G, Spinelli A,
De Luca M, Pellegrini G: Limbal stem-cell
therapy and long-term corneal regeneration.
New Engl J Med 363:147–155, 2010.
37. Scammon R: Section 1 in Human Anatomy by
H. Morris, ed 11, Philadelphia, 1953, Blakiston.
38. Sharma RK: Developmental expression of
GABAA receptors in retinal transplants.
Ophthalmic Res 32:45–51, 2000.
39. Tassabehji M, Hammond P, Karmiloff-Smith
A, Thompson P, Thorgeirsson SS, Durkin
ME, Popescu NC, Hutton T, Read AP,
Macconochie M, Donnai D: GTF2IRD1 in
craniofacial development of humans and mice.
Science 310:1184–1187, 2005.
40. Thumann G: Nonviral gene therapy for
age-related macular degeneration. Expert Rev
Ophthalmol 6:81–93, 2011.
41. Tibbetts EA, Dale J: A socially enforced signal
of quality in a paper wasp. Nature 432:218–
222, 2004.
42. Witten PE, Hall BK: Seasonal changes in the
lower jaw skeleton in male Atlantic salmon
(Salmo salar L.): Remodeling and regression of
the kype after spawning. J Anat 203:435–450,
2003.

18

2
Pioneers and Milestones
• Pioneers in the Field of Orthodontics
• Early Pioneers in the Field of Orthognathic
Surgery
• Hugo L. Obwegeser: Development of the
Standard Orthognathic Procedures
• William H. Bell: Experimental Studies to
Confirm the Biologic Basis of the Standard
Orthognathic Procedures
• Hans G. Luhr: Development of Plate and Screw
Fixation for Craniomaxillofacial Surgery
• Paul Louis Tessier: Development of
Craniofacial Surgery
• Conclusions
arch expansion appliance (Fig. 2-2).202 It consisted of a
heavy maxillary labial arch wire to which the teeth were
ligated.202 The term orthodontia is said to have been coined
in 1841 by Lafoulon, and it appeared in the book about
malocclusion written by J.M. Alexis Schange.11,157,203
In 1858, perhaps the first formal article on orthodontics
published in a medical journal was written by Norman W.
Kingsley (Fig. 2-3). By the 1880s, Norman Kingsley’s Trea­
ties on Oral Deformities as a Branch of Mechanical Surgery
systematically described the current techniques of the day
for the repositioning of teeth (Fig. 2-4).109 Kingsley was
among the first to fully describe how extraoral forces (e.g.,
headgear) could be used to correct protruding maxillary
anterior teeth. His emphasis was primarily on the alignment
of the anterior maxillary teeth in an attempt to improve
facial appearance. To Kingsley, the extraction of teeth for
the purpose of uncrowding and to reduce the protraction
of the incisors was acceptable practice. Details of how the
upper and lower teeth articulated with each other (i.e.,
occlusion) were of secondary importance. He used a wide
variety of apparatus to reposition the anterior teeth, includ­
ing wires, bands, custom palatal plates, elastics, wedges,
linen twine, rubber tubing, leathers, gold bands, and vulca­
nite. Impressions of the teeth and dental models were used
during planning and for the precontouring of labial placed
wires. The use of an external apparatus placed over the top
of the head and then either secured to the chin or held with
bands secured to the maxillary incisors became part of his
everyday practice (Fig. 2-5).
Kingsley’s basic principles for the mechanical alignment
of the teeth can be summarized as follows:
• The positioning of the six maxillary anterior teeth with
regard to each other and in relationship to the lip is
essential for facial aesthetics.
• The contact of a certain number of maxillary and man­
dibular posterior teeth, at least on one side, is important
for the grinding and mastication of food.
Pioneers in the Field of Orthodontics
Background
Orthodontic appliances that are somewhat primitive but
surprisingly well-designed for their time have been found in
Ancient Greek written materials.8 Four Etruscan specimens
of young adult women dating back to 900 B.C. that specifi­
cally demonstrate appliances on the teeth have also been
recovered.23,208 The orthodontic type appliances are gold
bands around teeth that are adjacent to an edentulous gap.
The appliances appear to be for the purpose of managing the
space left by tooth loss earlier in life (Fig. 2-1).209 In addi­
tion, the Ancient Greek scholars Hippocrates and Aristotle
both have writings that discuss various ways to straighten
teeth and to treat various dental conditions.20,51 Knowledge
of dental extractions carried out for the purpose of mechani­
cally straightening the remaining teeth was also reported by
Leonardo da Vinci during the High Italian Renaissance.166
The bandolet or bandeau, which was created in 1723 by
Pierre Fauchard of France, was the first documented dental
in the Field of Orthodontics
and Orthognathic Surgery
JEFFREY C. POSNICK, DMD, MD

19
CHAPTER 2  Pioneers and Milestones in the Field of Orthodontics and Orthognathic Surgery
• Figure 2-3  Photograph of Norman W. Kingsley (1829-1913).
• Figure 2-4  Norman Kingsley’s text entitled A Treatise on Oral Defor­
mities as a Branch of Mechanical Surgery, which was published in
1880.
• Figure 2-2  Illustration of the “bandolet” bandeau, which was
created in 1723 by Pierre Fauchard of France. This was the first docu­
mented dental arch expansion appliance.
• Figure 2-1  A, A drawing of the anterior mandibular dentition in a mummy specimen from ancient Greece
(approximately 1000 B.C.) currently housed in the Archaeological Museum in Athens, Greece. A gold wire was
used to tie teeth together and to band others to support replacements. The use of human, animal, carved wood,
bone, or ivory for replacement teeth was practiced by the ancient Grecian society. B, A drawing of an ancient
Etruscan orthodontic appliance found on the maxilla of a mummy in a tomb (approximately 700 B.C.), which is
currently at the Civic Museum in Cornet, Italy. It demonstrates gold soldered rings and rivets to hold dental
replacements as a bridge. The specimen has two natural teeth, one riveted oxtooth and four spaces for others
A Ancient Grecian appliance
B Ancient Etruscan appliance
• All other teeth are potentially expendable, depending on
the effort required by the clinician for straightening and
the individual’s desire to maintain them.
• From both a mastication and an aesthetic perspective,
there is no particular need for the maintenance of all 32
teeth or to achieve a specific and detailed way of the
upper and lower teeth occluding with one another.
Dr. Kingsley also commented on facial aesthetics, stating
that “the eye soon tires of the stiffness and formality of
unbroken uniformity, and is only permanently pleased with
the beauty which comes from graceful variation.”109 He
acknowledged the occurrence of jaw deformities when he
said that “[a] lack of harmony between the maxilla and
mandible is occasionally seen. For instance, when the

20
SECTION 1  Basic Principles and Concepts
prosthodontic-trained dentist like Edward H. Angle to
develop a more holistic concept regarding the importance
of the occlusion of the natural dentition (Fig. 2-7).5-8
During his career, Angle taught prosthetics at the University
of Minnesota (Minneapolis, Minn), Northwestern Univer­
sity Dental School (Chicago, Ill), and the Missouri Dental
College (St. Louis, Mo). Dr. Angle’s interest in dental occlu­
sion and his ingenuity and dedication with regard to the
correction of malocclusion led to the development of the
specialty that we now call “orthodontics.”
Angle’s textbook, Treatment of Malocclusion of the Teeth,
was first published in 1887 (Fig. 2-8).6 It went into seven
much-revised editions, and it laid the foundation for the
modern specialty of orthodontics. The publication of Angle’s
classification of malocclusion during the 1890s was a key
step in the development of orthodontics (Fig. 2-9).42,43
• Figure 2-6  John Nutting Farrar’s two-volume illustrated text entitled
A Treatise on the Irregularities of the Teeth and Their Correction, which
was published in 1897.
• Figure 2-7  Photograph of Edward H. Angle (1855-1930).
mandible is very large and massive or unusually small in
comparison to the upper jaw. When present, this will inter­
fere with the harmony of the surrounding parts of the
face.”109
In 1897, J.N. Farrar published a two-volume illustrated
text entitled A Treatise on the Irregularities of the Teeth and
Their Corrections (Fig. 2-6).12 In that text, he also demon­
strates detailed orthodontic appliances, and he was among
the first to suggest the advantages of mild (rather than
heavy) force applied at intervals to effectively move the
teeth.10
Edward H. Angle
It was common practice through the later half of the 19th
century to extract the teeth in response to most dental
problems.9,60 Restorative dentistry was generally not the first
choice for the management of “toothaches.” Most adults at
that time (i.e., the 1880s) did not have a full complement
of teeth nor was there much stigmata associated with partial
edentulism.210 Details of how the teeth occluded with each
other seemed important only when establishing how upper
and lower dentures were to meet so as to prevent loosening
or mobility when wearing them and to improve chewing
ability. It was a natural extension of this thinking for a
• Figure 2-5  Headgear designed and used by Norman W. Kingsley.
According to Kingsley, “I sat to work to make an apparatus that would
pull the lower jaw back. As you can see from the photograph taken
at the time she was wearing the apparatus, it consists of two parts.
For the lower part, I made a brass plate to fit the chin, having arms
with hooked ends reaching to a point just below the point of the chin.
These arms were arranged in such a way that the distance between
them could be altered at will by simply pressing them apart or to
gather. The upper part consisted of a simple network going over the
head and having two hooks on each side, one hook being above and
the other below the ear. When the apparatus was completed and in
use, there were four ligatures of ordinary elastic rubber pulling in such
a way as to force the lower jaw almost directly backward.” From
Kingsley NW: A treatise on oral deformities as a branch of mechanical
surgery, London, 1880, H.K. Lewis, pp 137, Figure 68.

21
CHAPTER 2  Pioneers and Milestones in the Field of Orthodontics and Orthognathic Surgery
• Figure 2-9  Angle described three classes of malocclusion based
on the relationships of the first molars: Class I, Class II, and Class III.
Class I: Neutrocclusion
Class II: Distocclusion
Class III: Mesiocclusion
• Figure 2-8  Dr. Angle published a comprehensive text entitled A
Treatment of Malocclusion of the Teeth and Fractures of the Maxillae,
the first edition of which was published in 1887. It went into seven
revised editions, and it laid the foundation for the modern specialty of
orthodontics.
Angle introduced the first precise and simple definition of
the normal human occlusion of the natural dentition. He
postulated that a key aspect of how the teeth should fit
together was the positioning of the maxillary first molars.
He then went on to describe three classes of malocclusion
that were based on the occlusal relationships of the first
molars:
Class I: There is a normal relationship of the molars, but
the line of occlusion is incorrect as a result of malposed
teeth, rotations, or other causes.
Class II: The lower molar is distally positioned relative to
the upper molar, and the line of occlusion is not
specified.
Class III: The lower molar is mesially positioned relative to
the upper molar, and the line of occlusion is not
specified.
Angle’s classification actually has four classes:
• Normal occlusion (Class I, with a normal line of
occlusion)
• Class I malocclusion
• Class II malocclusion
• Class III malocclusion
Normal occlusion and Class I malocclusion share the
same molar relationship, but they differ with regard to the
arrangement of the other teeth relative to the line of
occlusion. The line of occlusion may or may not be correct
in Class II and Class III.
By the early 1900s, orthodontists no longer just aligned
irregular teeth in each arch.175,218 The practice had now
evolved into the treatment of malocclusion (i.e., how the
upper and lower teeth align with each other). Angle’s phi­
losophy was to achieve a specific relationship between the
upper and lower teeth for each patient. Since Angle’s pre­
cisely defined dental relationships also required a full com­
plement of teeth in each arch, the maintenance of an intact
dentition became an important component of orthodontic
treatment. Angle and his followers strongly opposed extrac­
tion for orthodontic purposes.69 In an attempt to achieve
the three-axis control of tooth movement, Angle introduced
the ribbon arch (Fig. 2-10).70 He then devised the edgewise
appliance to overcome the weaknesses of the ribbon arch
(Fig. 2-11). The Angle reoriented bracket slot was designed
to control the bodily movement of teeth and to limit
tipping.135 Angle also heavily relied on the use of intraoral

22
SECTION 1  Basic Principles and Concepts
the lateral halves of the mandible. This idea was discussed
by Dr. Angle with various surgeons and dentists and deter­
mined to be feasible. His proposal involved the following6:
• Careful photographs should first be taken of the patient.
• Two accurate models should be made of the lower dental
arch, and one should be made of the upper.
• One of the plaster models of the lower jaw should then
be sawed through and the sections removed.
• The positions and extent of the sections should be care­
fully experimented with until the three remaining sec­
tions of the model could be made to best harmonize with
the upper arch so that the teeth may be in best possible
occlusion with those of the upper jaw.
• The sections of the plaster model should then be cemented
or waxed together.
• Over this reconstructed model, a vulcanite or metal
splint should then be formed.
• With the use of careful comparisons and measurements
of the reconstructed model as compared with the
unchanged model, the exact size and form of both resec­
tions of bone to be removed can be determined so that
there need be no guessing as to the relationships of the
bone. In this way, complete apposition of the cut ends
can be made.
• Because there is a lingual inclination of the lower incisors
in all cases of mandibular prognathism, the sections of
bone to be removed must not be parallel on their sides
but instead more or less wedged or V-shaped to gain the
best positions for the occlusion of the incisors as well as
for the appearance of the chin.
• The degree of variation from the parallel of the lines of
bone resection must be determined by the conditions
that are present (i.e., patient variation).
• Because the operation must be skillfully performed, the
most rigid support should be given to the reconstructed
jaw. This technique (i.e., a cap splint over the teeth)
should give more rigid support than is possible with the
crude, unstable, and unmechanical plan of wiring the
ends of the bone together, which is so often employed
for the reduction of fractures.
According to Dr. Angle, “The question most often raised
by dentists in discussing the practicability of an operation
as outlined above was the uncertainty as to union of the
bones and as to impairment of vitality of the teeth in the
anterior segment [of the mandible].”36 However, Dr. Angle
helped with the overcoming of these concerns via two case
reports that were presented in his textbook, Treatment of
Malocclusion of the Teeth and Fractures of the Mandible:
Angle’s System6 (pp 173-184):
First Patient (Operation)
June 23, 1897, the author [Dr. Angle] assisted the late
Professor Henry H. Mudd in one of these operations
performed at St. Luke’s Hospital, St. Louis, upon Ms.
M.J. of Arkansas, a delicate girl, 13 years old. She had
likely suffered with generalized sepsis at 3 years of age
rubber bands and limited the use of extraoral appliances
(e.g., headgear) as much as possible.
Angle was among the first to state that jaw discrepancies
exist in some individuals and that these discrepancies will
prevent the achievement of a normal occlusion. He then
acknowledged the need for jaw-straightening surgery. In
Chapter 14: Operative Surgery of the sixth edition of
Angle’s textbook, he states that the use of appliances to
move teeth may be properly called conservative surgery to
distinguish it from more bold or aggressive operations
involving the use of cutting instruments, which were desig­
nated as operative surgery. He states the following: “While
such operations [mandibular osteotomies] should probably
be employed only as auxiliary to the conservative method,
they are doubtless destined to play an more important part
in the practice in the future.”6
Dr. Angle worried that no technique that relied solely on
tooth movement could establish the appropriate relation­
ships of the teeth or truly improve the facial lines in cases
involving the severe overdevelopment of the inferior maxilla
[mandible].6 He felt that these cases may be successfully
treated by removing a section of bone from each of the
lateral halves of the mandible. At the time, the removal of a
single complete section of the jaw had been reported for
cases involving such conditions as ankylosis, tumors, and
gunshot wounds, but Dr. Angle was unable to find informa­
tion about the removal of complete sections from each of
• Figure 2-11  The edgewise bracket attachment comes in a variety
of modifications. The original single bracket (left) has been widened for
molar teeth and for greater rotational control (center). The twin edge­
wise modification (right) is available in different widths, and it is used
most frequently because of its greater versatility, its reduced frictional
component, and its adaptability to various light-wire techniques.
• Figure 2-10  The ribbon arch appliance, which was introduced by
Angle in 1916. The vertical slot in the bracket accepts either round or
rectangular wire, which in turn is held in place by a locked pin.

23
CHAPTER 2  Pioneers and Milestones in the Field of Orthodontics and Orthognathic Surgery
the work of Thompson in “Functional Analysis of Occlu­
sion,” Wylie’s “Assessment of Anterior-Posterior Dysplasia,”
and the work of Margolis’ “Basic Facial Pattern and Its
Application in Clinical Orthodontics.”174 The use of cepha­
lometric radiography in clinical practice became widespread
with the mandible becoming fixed and firmly closed
[temporomandibular joint ankylosis]. The upper jaw was
normal in size and contained a full complement of teeth.
The lower jaw was deformed. The ramus of the jaw on
each side passed downward and backwards so that the
angle of the jaw came a little behind rather than in
front of the vertical line dropped from the lobe of the
ear. The arch of the lower jaw was broad and the
incisor teeth were impinging the surface of the palate.
The only point of entrance for food was the opening
under the arch of the hard palate above the incisor teeth
of the lower jaw.
To free the body of the jaw so that the mouth might be
opened, a triangular segment with the base downward
and the apex upward and forward was removed from the
angle of the jaw on each side. A complete section of the
bone was thus removed on each side to make false joints
at the junction of the ramus and the body of the
mandible. When the bone was separated, the tongue and
jaw dropped down, making respiration difficult. An
urgent tracheostomy was made. Wire ligatures were used
to establish IMF [intermaxillary fixation]. This pulled
the tongue and neck muscles superior and anterior, and
established a good airway. The ligatures were occasionally
removed in the ensuing weeks to allow movement of the
jaw and establish a hinge joint instead of osseous union
in the ramus regions of the mandible. Unfortunately, the
patient was lost to follow-up several weeks later without
permanent record of how things turned out.
Second Patient (Operation)
A double resection [of the mandible] for the purpose
of shortening a prognathic mandible was performed
successfully at the Baptist Hospital in St. Louis [Dr. Vilray
Blair was the surgeon, and the procedure was performed
on December 19, 1897]. Such an operation might at first
seem formidable, but there is no reason why, if skillfully
performed according to modern aseptic methods of surgery
and the plan is indicated, that clean smooth ends of the
bone should not unite at least as readily as they do in
the common cases of double [mandibular] fractures and
the result being nearly ideal.
Holly Broadbent
The introduction of the cephalometer by Holly Broadbent
in 1931 was another important milestone that placed ortho­
dontic research on a scientific foundation (Fig. 2-12).157
For the first time, it made possible the accurate study of the
facial bones in the growing child (Figures 2-13 and 2-14).
It became a valuable supplement to the orthodontist’s
plaster models and intraoral x-rays. The value of serial ceph­
alograms in clinical practice was quickly realized. Broad­
bent’s original work on the “face of the normal child” and
Brody’s classic research “on the growth pattern of the human
head from the third month to the eighth year of life” were
among the earliest contributions.163 These were followed by
the research of Down’s “Variations in Facial Relationships,”
• Figure 2-13  Broadbent was the first to develop the standardized
lateral “head plate.” The cephalometer is a device for holding the
patient’s head, the x-ray film, and the central ray of the x-ray machine
in proper relationship with one another. Ear-rod extensions are neces­
sary to adjust the head so that the profile is centered, regardless of
the size or shape of the head. The orbital pointer and the ear rods
adjust the patient’s head along the horizontal or Frankfort plane. An
adjustable chair is used, and the teeth are placed in “centric occlusion”
unless otherwise indicated. The cephalometer may be rotated so that
posterior and anterior radiographs as well as profile radiographs can
be taken. The central ray is directed through the ear rods, thereby
producing a circle on the x-ray film. From Broadbent BH Sr., Broadbent
BH Jr and Golden WH: Bolton Standards of Dentofacial Developmen­
tal Growth, St. Louis, C.V. Mosby, 1975.
• Figure 2-12  Photograph of Holly Broadbent (1894-1977). From
Broadbent BH Sr., Broadbent BH Jr and Golden WH: Bolton Stan­
dards of Dentofacial Developmental Growth, St. Louis, C.V. Mosby,
1975.

24
SECTION 1  Basic Principles and Concepts
• Figure 2-15  Photograph of Charles Tweed (1895-1970).
• Figure 2-16  Photograph of Raymond Begg (1889-1983). From
Wahl N: Orthodontics in 3 millennia. Chapter 6: More early 20th-century
appliances and the extraction controversy. Am J Orthod Dentofacial
Orthop 128:795–800, 2005.
• Figure 2-17  Photograph of Lawrence F. Andrews.
after World War II and made clear to all clinicians that
many of the Class II and Class III malocclusions being
treated actually resulted from abnormal skeletal relation­
ships rather than just malposed teeth.165 These radiographic
truths were hard to ignore and further inspired orthodon­
tists and surgeons to search for operative solutions.181
Charles Tweed and Raymond Begg
Another “orthodontic truth” was also soon to fall. A purest
“Angle” approach to maintaining and straightening all of
the teeth in all patients frequently proved untenable with
regard to the maintenance of the occlusion after the
appliances were removed.54,144,145 This non-extraction, arch-
expansion approach gave little consideration to long-term
periodontal health or to the individual’s overall facial aes­
thetics.161 The extraction of teeth (typically the bicuspids)
to achieve occlusal stability and periodontal health was rein­
troduced into American orthodontics during the 1930s by
Charles Tweed (Fig. 2-15) and simultaneously into the
United Kingdom (Australia) by Raymond Begg (Fig. 2-16)
(see Chapter 17 for in-depth discussion).47-49,59,204
Lawrence F. Andrews
Dr. Lawrence F. Andrews’ pioneer contributions to the field
of orthodontics and the treatment of dentofacial deformity
must also be mentioned (Fig. 2-17).2-4 After completing
orthodontics training at Ohio State University in 1958, he
entered private practice that was limited to orthodontics.
Early in his career, Dr. Andrews recognized clinical problems
that were yet unsolved and sought solutions. This sent him
• Figure 2-14  The cephalostat device, as described in Figure 2-13, is
shown with a patient who is positioned and ready for film exposure.
From Broadbent BH Sr., Broadbent BH Jr and Golden WH: Bolton
Standards of Dentofacial Developmental Growth, St. Louis, C.V. Mosby,
1975.

25
CHAPTER 2  Pioneers and Milestones in the Field of Orthodontics and Orthognathic Surgery
be in harmony (i.e., to have all elements in alignment) with
the overall face, the following must be present:
Element I: Proper arch shape and positioning of the maxil­
lary and mandibular teeth (roots) over the basal bone
Element II: Proper horizontal (sagittal) projection of the
maxilla
Element III: Proper width of the maxillary and mandibular
arches
Element IV: Proper vertical height of the maxilla
Element V: Proper prominence (shape) of the chin (i.e.,
pogonion prominence)
Element VI: Establishment of the Six Keys to Optimal
Occlusion
He studied each of these Six Elements and defined both
qualitatively and quantitatively how the orthodontist and
the surgeon can work together to achieve these objectives
for each patient.
William R. Proffit
By the mid 1970s, Dr. Proffit recognized the benefits of
a collaborative surgeon–orthodontist interaction for the
correction of dentofacial deformities.164 He and others
convincingly demonstrated to surgeons that rectangular
orthodontic arch wires in edgewise brackets were satisfac­
tory for surgical patients without the need for the intraop­
erative placement of Erich arch bars. This paved the way for
the routine preoperative orthodontic relief of dental com­
pensations, and it was followed by the placement of orth­
odontic “surgical wires and hooks” for intraoperative use.
After the initial surgical healing, a smooth transition to
orthodontic maintenance and detailing soon became the
standard of care. Dr. Proffit was also an early believer in
the importance of a collaborative effort to understand the
patient’s presenting dysfunction and dysmorphology and
then to develop a comprehensive treatment plan. The use
of a cephalometric analysis with prediction tracings fol­
lowed by dental model planning with splint construction
became the routine. Dr. Proffit and others also insisted on
analysis of the early results that were achieved. This was
followed by critical studies of the long-term outcomes after
various surgical approaches and orthodontic techniques
were employed. This analytic approach has been responsible
for much progress in the field over the past four decades.
According to Dr. William R. Proffit* (Fig. 2-18), ortho­
dontics in the 21st century differs from that of the previous
century in three fundamental ways162,163:
1. There is more emphasis on both facial and dental aesthetics
and less on the details of dental occlusion as an overriding
objective. This has much to do with the safe and reliable
orthognathic surgical techniques that are currently
on a search to better understand occlusion as well as devia­
tions from normal. Between 1960 and 1964, Dr. Andrews
began to gather data for analysis. One hundred and twenty
non-orthodontic normal (dental) models were acquired
with the cooperation of local dentists, orthodontists, and a
major university. The models selected for study were of teeth
that had never undergone orthodontic treatment; that were
straight and pleasing in appearance; that had a bite that
looked generally correct; and that, in Dr. Andrews’ judg­
ment, would not benefit from orthodontic treatment.
Dr. Andrews studied the crowns of this multisource
collection of models to ascertain which characteristics, if
any, would be found consistently in all of them. Angle’s
molar cusp groove concept was validated but found to be
incomplete. After meticulous evaluation, including com­
parison with “treated cases” from the nation’s most skilled
orthodontists (n = 1150), six consistent occlusal charac­
teristics were formulated by Dr. Andrews in general terms
and then explained in detail.2 The six fundamental qualities
or Six Keys of Optimal Occlusion were validated not solely
because all were present in each of the non-orthodontic
normal models (n = 120) but because the lack of even
one of the six was a defect that was predictive of an incom­
plete end result in the orthodontically treated models that
were studied (n = 1150).
The significant characteristics (i.e., the Six Keys of Optimal
Occlusion) described by Andrews that were found in all of
the non-orthodontic normal models were as follows:
Key I: Interarch (molar) relationship
Key II: Crown angulation
Key III: Crown inclination
Key IV: Rotations
Key V: Tight contacts
Key VI: Curve of Spee
In his published article, Dr. Andrews acknowledged that,
although each normal person is unique in his or her own
way, they nevertheless have much in common.2 The 120
non-orthodontic normal models studied differed with regard
to certain aspects, but all shared the Six Keys. Dr. Andrews
suggested that we use as our benchmark “nature’s best” and
that, in the absence of abnormalities outside of our control,
we limit compromise and strive for the ideal. He developed
the straight-wire appliance in 1970 for orthodontic use to
help accomplish these objectives. This preadjusted appliance
soon became the standard of the specialty.2-4
Dr. Andrews then went on to describe six fundamental
principles that are necessary to achieve both facial and
dental harmony: the Six Elements of Orofacial Harmony.
Both of these aspects—facial and dental harmony—are fre­
quently absent in the patient with dentofacial deformity.
Dr. Andrews was one of the first orthodontist to clarify the
importance of addressing both facial and dental harmony
from the beginning of treatment to achieve the best facial
form and head and neck function for each patient. Dr.
Andrews stated that, for the maxillomandibular complex to
*Please note that the author of this text has paraphrased Dr. Proffit’s
original work.

26
SECTION 1  Basic Principles and Concepts
of the mandible. The procedure was performed on a middle-
aged woman whose mandibular deformity was the result of
a severe burn scar contracture of the anterior neck and lip
from an injury that had occurred during her childhood (see
Fig. 2-19, B and C).
In 1887, Berger from Lyon, France, described bilateral
condylar neck osteotomies to set back the prognathic man­
dible.90 In 1895, Jaboulay also reported the bilateral oste­
otomy of the condylar neck (condylectomy) for the
correction of prognathism.100 This method continued to be
popular in France for the treatment of prognathism through
the 1950s.75
On December 19, 1897, Vilray Blair in St. Louis, Mo,
carried out a distinct modification of the original Hullihen
procedure for the treatment of mandibular prognathism
(see the “Second Patient (Operation)” case report by Dr.
Angle earlier in this chapter) (Fig. 2-20).38 The operation
was performed on a 22-year-old man with asymmetric man­
dibular prognathism. The young man had difficulty with
chewing and speech articulation, and he also was self-
conscious about his appearance; thus, he was enthusiastic
about proceeding with the recommended surgical plan. Dr.
Blair stated that the immediate surgical objective was to
carry out bilateral body osteotomies to shorten the horizon­
tal ramus [body of the mandible] and to change the man­
dibular angle [rotate the distal mandible counterclockwise],
thereby allowing for the closure of the open bite. Dr. Blair’s
preoperative concerns about the operation included the
following:
1. Could a portion of the mandible be cut out on each side
in a satisfactory way?
2. Would sacrifice of the inferior dental nerve cause detri­
mental injury to the distal mandible?
3. After healing had occurred, would the mandible con­
tinue to grow and cause a recurrence of the deformity?
Through cadaver dissections, Dr. Blair satisfied his
concerns regarding whether the mandible could be sec­
tioned and repositioned successfully. As a result of the
age of the patient (22 years), he had little concern regard­
ing further growth after surgery. He conferred with two
other surgeons (Dr. E.H. Gregory and Dr. P. Tupper),
both of whom concurred that the surgical plan seemed
reasonable. The patient was also under the care of Dr.
J.W. Whipple (orthodontist). Dr. Blair had discussed the
feasibility of a surgical solution for mandibular progna­
thism with Dr. Angle (the patient had also consulted
with Dr. Angle before surgery), and Dr. Angle “had advised
such an operation.”38
The surgery was carried out at the Missouri Baptist Sana­
torium. The surgery commenced with the patient under
chloroform anesthesia at 9:20 AM with the patient in the
recovery room by 10:30 AM. During the operation, the
patient’s head was hyperextended over the end of the operat­
ing room table. Skin incisions below the inferior border of
the mandible on each side provided exposure. The incisions
extended up into the mouth and involved cutting through
available and with the recognition that long-term stable
occlusion and periodontal health can best be achieved in
conjunction with harmonious jaw relationships. This
will require extractions when necessary to uncrowd and
achieve periodontal health; decompensating orthodontic
therapy to place teeth that are solidly in the alveolar
bone; and jaw-straightening surgery, when indicated.
2. Patients and families expect greater involvement in the
treatment planning process. Full disclosure requires the
orthodontist to consider and review ideal and compro­
mised treatment options. Providing a balanced and
objective assessment of each option’s effect on facial
aesthetics, dental stability, periodontal health, speech
articulation, and the upper airway is ideal. Consultation
with appropriate dental, surgical, and medical specialists
before instituting treatment has become the standard
of care.
3. Orthodontics is now offered not just to children, adolescents,
and young adults but also to older adults through an inter­
disciplinary approach. Consideration should be given to
facial aesthetics, occlusion, periodontal health, the upper
airway, speech articulation, and the long-term mainte­
nance of the dentition. There is increased emphasis on
coordinated treatment with other dentists, surgeons, and
medical specialists. Taking advantage of currently avail­
able sophisticated orthodontics and orthognathic surgery
to provide individuals of all ages with quality care should
now be considered routine.
Early Pioneers in the Field of
Orthognathic Surgery
Mandibular Setback for Prognathism
Simon Hullihen described a procedure for the correction
of mandibular dentoalveolar protrusion in the American
Journal of Dental Science in January 1849 (Fig. 2-19, A).18,98
Technically, this was a bilateral bicuspid region wedge ostec­
tomy to “set back” the anterior mandibular dentoalveolar
segment. The osteotomy did not violate the inferior border
• Figure 2-18  Photograph of William R. Proffit (1936-Present)

27
CHAPTER 2  Pioneers and Milestones in the Field of Orthodontics and Orthognathic Surgery
A
B
• Figure 2-19  A, Photograph of Simon Hullihen
(1810-1897). B, Illustration of anterior mandibular
dento-alveolar segmental osteotomy proposed
and C, carried out by Dr. Hullihen. A from Ambre­
cht EC: Hullihen, the oral surgeon. Int J Orthod
Oral Surg 23:377, 511, 598, 711, 1937. B and
C from Hullihen S: Case of elongation of the
under jaw and distortion of the face and neck,
caused by a burn, successfully treated. Am J
Dent Sci 9:157, 1849.
C
• Figure 2-20  Photograph of Vilray Blair (1871-1955).
the mucous membrane. A full-thickness osteotomy was to
be completed on the left side of the mandible between the
first and second bicuspids and on the right side between the
second bicuspid and the first molar. The osteotomy was
initiated with a “double-bladed saw” three quarters of the
way through on each side; the inferior border remained
intact.38 This allowed for the presence of a stable mandible
on each side before the cut was fully completed on either
side. A drill was used to place holes on either side of the
osteotomy site for eventual “cooper wire fixation”38 near
the inferior border on each side before cutting through the
inferior border on either side. After the completion of both
full-thickness osteotomies, soft gutta-percha was placed
over the mandibular dentition, and the upper and lower
teeth were firmly wired together through the gutta-percha.
This method of intermaxillary fixation immobilized the
distal mandible in its new position for the closure of the
open bite. Dr. Blair stated that “this method of fixation was
suggested to him by seeing Dr. Angle’s fracture bands.”38
The fracture band method of mandible fracture manage­
ment was commonly in use.

28
SECTION 1  Basic Principles and Concepts
Dr. Blair stated that, as the patient was emerging from
the anesthesia, the vomiting of mucus and blood occurred,
thereby necessitating the cutting of the intermaxillary fixa­
tion.38 After the vomiting subsided, rather than reapplying
intermaxillary fixation, a Barton bandage of plaster was used
to secure the mandible into occlusion with the maxilla.21
When the Barton bandage was removed several weeks later,
Dr. Blair felt that there was “bony union on the right side
and a very slight but perceptible motion on the left side
when the fragments were grasped.”38 Dr. Blair decided to
take the patient to the office of the treating dentist (ortho­
dontist), Dr. Whipple. He requested that Dr. Whipple place
two dental bands with a bar between them across the weak
left osteotomy site. This would afford the patient sufficient
support and allow him to go without the additional protec­
tion of a Barton bandage or intermaxillary fixation.” Unfor­
tunately, while he was tightening the bands across the left
and right osteotomy sites, Dr. Whipple “broke the union
of the provisional callus.”38 At this point, Dr. Whipple
applied properly adjusted bands to the teeth on the left side
of the mandible, and Dr. Blair reapplied a Barton plaster
external facial bandage.38 Dr. Whipple also placed crowns
on the mandibular teeth posterior to the osteotomy sites so
that the molars would occlude properly with the upper
teeth, and he filled some points on the teeth to improve the
occlusion of the incisors.38 Apparently, the combination of
the mandibular setback with the clockwise rotation resulted
in “a small [osteotomy] gap between the second bicuspid
and first molar on the right side” but “without a gap [previ­
ous edentulous space] in the left first bicuspid region.”38
Despite these difficulties, the osteotomies went on to heal
with a reasonable correction of the occlusion.38 Dr. Blair
stated that there was “almost a complete loss of cutaneous
sensation of the lower lip” but that the “sensation of the
tooth-pulp is good.”38
Interestingly, Dr. Whipple, the treating dentist and
orthodontist, published his version of the patient’s surgery,
convalescence, and ultimate result in Dental Cosmos in
1897.212 This was before the journal publication by Dr.
Blair, in which he gave a full account of the case from his
perspective.38 Although Dr. Whipple’s description of events
varied somewhat from what was eventually reported by Dr.
Blair, both concurred that the procedure had taken place
and that it was a success.
In his textbook, Dr. Blair cautions the surgeon that “the
lower jaw should be set back only far enough to be in
harmony with the rest of the face” and that the surgeon
should “leave it to the orthodontist to bring forward the
upper incisors if necessary.”40 He stated that “an orthodon­
tist should be involved in the planning of the patient’s
treatment from the beginning.”40 For some patients, Dr.
Blair notes that “it would be of considerable advantage to
have the upper jaw [orthodontically] expanded and the
upper incisors and canines brought forward before the lower
jaw is surgically set back.”40
A horizontal osteotomy through the ascending ramus,
on each side and above the occlusal plane, as a method of
“setting back” the prognathic mandible was first described
by Lane.117 During the early 1900s, Blair39 and Babcock19
also made use of the horizontal ramus osteotomy on each
side for the correction of prognathism.36
In 1912, Harsha reported bilateral wedge resections of
the mandible body near the angle regions to set the man­
dible back; this was similar to the procedure that Blair
described in 1897.89 Unfortunately, at least one of his
reported patients suffered the loss of (and the eventual need
to remove) the entire anterior part of the jaw. In 1945,
Moose143 may have been the first to describe a fully intraoral
technique to carry out horizontal ramus osteotomies for the
correction of mandibular prognathism. In 1950, G.V.
Barrow and Reed O. Dingman discussed the surgical man­
agement of mandibular prognathism.22 They described a
method to determine the exact amount and shape of man­
dibular bone to be resected on each side by using dental
models that involved the construction of splints and tem­
plates. Their described meticulous approach was similar to
that of Angle in the 1903 edition of his textbook.7 The
operation was reported by Dingman as having a two-stage
approach71,72; this was to separate the intraoral and extraoral
aspects to maintain control of the segments and to limit the
risk of infection. During the first stage, the teeth to be
extracted (i.e., the first molars) were removed with the use
of local anesthesia. As determined by the “preconstructed
template,” osteotomies for wedge resection were initiated
through the intraoral approach at the time of the extrac­
tions. Approximately 4 weeks later, the patient was anesthe­
tized in the operating room for the second stage. An incision
of the skin of the neck was made 2 cm below the inferior
border, and the lower aspect of the mandible was exposed
on each side. The previous intraoral vertical cuts on each
side were identified. With a power-driven bur or saw, the
two vertical cuts were continued through the inferior border.
Attempts to preserve the inferior alveolar nerve were made.
Stabilization across the osteotomy on each side site was with
24-gauge stainless-steel wires. The teeth were placed into
occlusion with the use of either orthodontic appliances or
Erich arch bars. In either case, to improve accuracy, the
mandibular dentition was secured into a prefabricated
acrylic wafer before intermaxillary fixation occurred.
In 1954, J.B. Caldwell and G.S. Letterman devised a
vertical osteotomy of the ascending ramus that involved the
decortication and perforation of the fragments and then the
splitting of the medial and lateral cortices of the ramus to
allow for setback of the mandible followed by direct wire
fixation.45,46 This innovative technique had the advantage of
providing at least a degree of overlapping of the bone for
more reliable and rapid healing.
All of these techniques for the management of mandibu­
lar prognathism79,87,91-93,96,138,167,211 eventually fell by the
wayside after the introduction by Hugo Obwegeser of what
we now refer to as the “intraoral sagittal splitting of the
mandibular ramus,” which is described later in this
chapter.149 The stabilization of the osteotomy segments is
now generally accomplished with titanium bicortical screws

29
CHAPTER 2  Pioneers and Milestones in the Field of Orthodontics and Orthognathic Surgery
forward the lower jaw to harmonious outline” with the
maxilla.40 Malocclusion in a patient with a jaw deformity
results from the “pressure and counter pressure of growth
and apposition.”40 Normal occlusion cannot be established
by jaw surgery alone. To reach certain objectives, the surgeon
“shall have knowledge of occlusion and of the scope and
limitations of orthodontic procedures.”40
Blair went on to say this: “We have to accept the upper
jaw position but the lower jaw is capable of almost any kind
of surgical adjustment. The complication of an ununited
fracture of the lower jaw is rare. The complication of necro­
sis or loss of teeth from surgically sectioning the ramus is
not reported in the world literature.”40 However, “osteot­
omy of the ramus of the mandible is a recognized procedure
for the treatment of temporomandibular joint ankylosis.”40
Esmarck, who was a prominent surgeon when Dr. Blair was
discussing this treatment, recommended the removal of a
whole section of the horizontal ramus to avoid a union (i.e.,
reankylosis) when creating a pseudoarthrosis for the treat­
ment of temporomandibular joint ankylosis. However, Blair
felt that surgeons did not need to concern themselves with
the possibility of necrosis or nonunion when “completing
an osteotomy through the inferior alveolar neurovascular
bundle.”40
Blair felt that the surgeon could correct mandibular ret­
rognathia by completing a ramus osteotomy on each side
and then “bringing the distal mandible forward to meet a
good occlusion with the maxillary arch.”40 Intermaxillary
fixation could then be achieved with stainless steel wires and
the use of soft cement in between the occluding teeth.40
Fixation across the osteotomy site was felt to be unnecessary.
The (horizontal) ramus osteotomy was made at or just above
the mandibular occlusal plane with the use of a Gigli saw
placed transcutaneously.39 The osteotomy was cut through
the inferior alveolar neurovascular bundle, which was not
felt to be important either to the circulation of the mandible
or as a cause of disability. The ramus osteotomies were later
made blindly and transorally with a Gigli saw.40
According to Dr. Blair, “the operation presented three
distinct problems: (1) the cutting of the bone [which is the
easiest of the three]; (2) the placing of the jaw into its new
position; and (3) holding it there [for the time required for
healing].”40 He used postoperative x-rays to show that the
fragments of the ramus remained in contact at the posterior
border of the osteotomy. “[A]s the distal mandible is brought
forward,” said Dr. Blair, “a gap is created anteriorly while
the fragments remain in contact at the posterior border. For
healing to occur, the bone gap must be filled with granula­
tions. The resulting bone scar tends to contract [relapse] for
months afterwards.”40 The maintenance of tight intermaxil­
lary fixation was felt to be essential to maintain the new
position. Blair used iron wire for its strength, lack of stretch,
and pliability; it could also be twisted, unless it was damaged
by sharp instruments.40 He also used quick-setting cement
between the occlusal surfaces of the molars to prevent the
placement of postoperative forces on the anterior teeth,
which could cause the patient significant pain.40
or with a titanium plate and screws in accordance with the
pioneering innovations of H. Luhr, who is also discussed in
a later section of this chapter.127
Mandibular Advancement for Retrognathism
An important early maxillofacial textbook publication was
Surgery and Diseases of the Mouth and Jaws by Vilray P. Blair
(Fig. 2-21).40 At the time of publication, Dr. Blair was a
Major in charge of the subsection of Plastic and Oral
Surgery, Section of Surgery of the Head Office of the
Surgeon General of the Army in Washington, DC.197 He
was also a professor of oral surgery at the Washington Uni­
versity Dental School and an associate in surgery at the
Washington University School of Medicine in St. Louis,
Mo. In his textbook, Chapter 21 deals with the treatment
of deformities and malrelations of the jaws.
Dr. Blair cautions that, before entering into jaw-
straightening surgery, the surgeon would be well advised to
do the following:
• To not undertake any cases without first having the
fullest confidence in his or her patient
• To remember that procedures undertaken for only “mod­
erate” deformity should not be taken lightly
• To remember that maximum restoration will also require
orthodontics
• To remember that the earlier a competent and genial
orthodontist is associated with the case, the better it will
be for both the surgeon and the patient
In the 21st century, these remain useful words of wisdom
for the surgeon to consider before entering into the treat­
ment of a patient with a jaw deformity.
According to Dr. Blair, for the treatment of mandibular
micrognathia, a surgical procedure may be used to “bring
• Figure 2-21  Vilray P. Blair published a text entitled Surgery and
Diseases of the Mouth and Jaws, the first edition of which was pub­
lished by the C.V. Mosby Company in 1912.

30
SECTION 1  Basic Principles and Concepts
Dr. Blair also used this same operation involving hori­
zontal ramus osteotomies for the treatment of ankylosis
associated with severe mandibular retrusion; this operation
was first carried out by Dr. Mudd with Dr. Angle assisting
in 1897. Dr. Blair also suggests addressing the residual chin
deformity by either “injecting paraffin into the chin or by
inserting a piece of cartilage or rib.”40
Most of the early reported attempts at horizontally
advancing the retrognathic mandible focused on the man­
dibular body. Dr. Blair specifically addressed the problem
of an anterior open bite by rotating the distal mandible
counterclockwise after body osteotomies and ostectomies.
He states that the “sectioning of the mandible on both sides
in front of the first molars [as long as the molars are in
occlusion] is the preferred procedure. The anterior mandible
can then be moved into good occlusion with the upper
teeth. In other cases, it is necessary to remove a V-shaped
section of the bone on each side with extraction of the tooth
[bicuspid]. The apex of the V-shaped ostectomy segment is
at the lower border of the mandible and usually a tooth is
extracted from the site of the section on each side. The bone
is cut using a Gigli saw or a cross-cut Fisher bur.”40
Dr. Blair goes on to state that “the deformity is in both
jaws but the operation is limited to the lower jaw. It is best
to restore the lower jaw to its proper form and then manage
the residual open bite by bringing down the upper incisors
with orthodontic appliances or by extending the upper
teeth with porcelain crowns. Fixation is achieved with a
prefabricated splint constructed on plaster dental models.
This will prevent pulling down of the distal segment by the
digastric and geniohyoid muscles.”40
A variety of techniques were carried out by pioneering
surgeons to address concerns regarding the maintenance of
contact between the fragments to achieve bony union; soft-
tissue coverage to limit infection; opposing muscle pull to
limit relapse; and adequate fixation. In 1928, a “step oste­
otomy” of the body of the mandible was proposed by Von
Eiselberg.201 Also in 1928, Gadd reported a stepped proce­
dure for the body of the mandible for the purpose of cor­
recting asymmetric mandibular deficiency.80 That same year,
Limberg completed L-shaped sliding osteotomies of the
mandibular body to improve bone-to-bone contact after
advancement.122,123 In 1931, Kostecka published his work
with the Blair-type transcutaneous horizontal ramus oste­
otomies with the use of a Gigli saw (Fig. 2-22).115 In 1936,
Kazanjian performed mandibular “step” osteotomies ante­
rior to the mental foramen with extension back into the
body of the mandible to allow for advancement and frag­
ment approximation (Fig. 2-23, A through D).68,103-108 The
constant problems encountered with all of these approaches
involved maintaining sufficient bone-to-bone contact and
achieving adequate fixation for a stable long-term result.
The problems were finally solved through the pioneering
work of Hugo Obwegeser (i.e., the intra-oral sagittal split­
ting of the ramus of the mandible) and Hans Luhr (i.e.,
plate and screw fixation across the osteotomy site), which
is described later in this chapter. In 1960, Caldwell described
vertical osteotomies of the ramus with interpositional iliac
• Figure 2-22  As originally depicted, methods for the correction
of mandibular deformities by the blind technique. A, The method
of Blair. From Blair VP: Surgery and diseases of the mouth and jaws,
ed 3, St. Louis, 1914, C.V. Mosby Company. B, The method of
Kostecka. From Kostecka F: Die chirurgische therapie der proggeni.
Zahnaertzliche Rundschau 40:669–687, 1931.
A
B
bone graft for the correction of micrognathia.45 A
C-osteotomy of the ramus was later described by Caldwell
and colleagues, in 1968.46 Although these osteotomies with
interpositional grafting are occasionally used for the man­
agement of mandibular retrognathism, the Obwegeser sag­
ittal split ramus osteotomy is generally preferred. Throughout
the 18th and 19th centuries, many surgeons saw the need
to mobilize the maxilla for better access either to remove an
epipharyngeal tumor or for the correction of maxillary
deformity.
Maxillary Osteotomies for Management of
Dentofacial Deformity
In 1868, David Williams Cheever of Boston published a
report of a Le Fort I osteotomy for the purpose of exposing
and removing a large nasopharyngeal polyp (Fig. 2-24).55,88
After completing the tumor resection, the maxilla was
placed back in its original location. Cheever stated, “so far
as I know, the operation including both superior maxillary
bones—is novel.”55 “Nothing but the posterior attachments
of the upper maxilla now prevented their depression and
hinging on the pterygoid processes. The upper jaw was
brought down so as to expose the tumor.”55 By the early
1900s, reports of series of patients undergoing maxillary
osteotomies for the purpose of tumor resection were detailed
in the literature.37
With reference to the treatment of dentofacial deformi­
ties, in 1921 in Berlin, Cohn-Stock was the first to report
an elective maxillary osteotomy to establish a preferred
occlusion.56,214 He used a two-stage approach (a precaution
against flap necrosis) when completing an anterior maxillary
osteotomy. Martin Wassmund, the founder of the “German
school” of maxillofacial surgery, is credited with developing
the one-stage anterior maxillary osteotomy.205-207 The Wass­
mund procedure was completed through limited palatal and
labial incisions with subperiosteal tunneling. The tunneling

31
CHAPTER 2  Pioneers and Milestones in the Field of Orthodontics and Orthognathic Surgery
incisions limited mobilization, but this was thought to be
necessary to maintain circulation. Karl Schuchardt is cred­
ited with developing the posterior maxillary segmental
osteotomy.171-173 This was completed with the use of broadly
elevated full-thickness palatal flaps and limited labial flaps.
In 1959, Köle described the combined simultaneous maxil­
lary and mandibular anterior segmental (alveolar) osteoto­
mies for the correction of bimaxillary protrusion and other
forms of open bite, deep bite, and posterior crossbite.111-114
He also pioneered the “corticotomy of maxillary and man­
dibular bones to facilitate the orthodontic movement of
either a single tooth or group of teeth.”114
Wassmund is credited with performing a first “total
maxillary osteotomy” for the correction of a dentofacial
deformity in 1927.205-207 This was in a patient with an open-
bite malocclusion. The maxillary osteotomy was completed
through tunneling incisions without full down-fracture.
Intermaxillary elastics were applied, with the gradual move­
ment of the maxilla into occlusion occurring over the course
of 2 weeks. In 1934, Axhausen was the first to mobilize and
• Figure 2-23  A, Dr. Varaztad H. Kazanjian leaving Buckingham Palace after his investiture as a Companion of St. Michael and St. George for
his services during World War I, March 15, 1919, B, View of the hospital showing Dr. Kazanjian’s three wards, circa 1916, C, Photograph of
the hospital ward within the makeshift (Harvard unit) barrack where trauma patients were under the care of Varaztad H. Kazanjian (1915-1919).
D, Photograph of Varaztad H. Kazanjian later in his career. A and B, From The Harvard Medical Library in the Francis A. Countway Library of
Medicine. C, From Deranian HM: The miracle man of the western front. Bull Hist Dent 32:85-95, 1984.
A
B
C
D
• Figure 2-24  Photograph of David Williams Cheever of Boston
(1831-1915). Courtesy Harvard University Portrait Collection.

32
SECTION 1  Basic Principles and Concepts
immediately reposition a malunited maxillary fracture by
Le Fort I osteotomy.15-17 Pioneering surgeons described and
continued to attempt maxilla osteotomies (anterior segmen­
tal, posterior segmental, and total maxillary) to improve
the occlusion in individuals with dentofacial deformi­
ties.44,50,57-59,61,116,119-121,126,141,158,160,169,180,183,212,213,219,220 Unfor­
tunately, circulation requirements of the maxillary segments
were poorly understood, mobilization was often incom­
plete, and available fixation options were limited.66,86,87,110
These problems severely hampered the results that were
possible for the patient with a jaw deformity.142,217
It was not until Hugo H. Obwegeser described the total
horizontal Le Fort I osteotomy with complete down-fracture
through a circumvestibular incision followed by full mobi­
lization that the maxillary deformity could be universally
addressed in all three planes, as described later in this
chapter (Fig. 2-25).153 Animal research carried out in
William H. Bell’s laboratory soon confirmed the vascular
integrity of each specific dentoalveolar–musculomucosal
mandibular and maxillary osteotomy-created flap that had
been clinically described and used by Obwegeser and other
European maxillofacial pioneers (Fig. 2-26).29 Experimental
confirmation of the adequacy of the circulation to each of
these flaps, when properly elevated, encouraged the rapid
dissemination of knowledge and the incorporation of
orthognathic procedures into maxillofacial clinical practice
throughout the world; this is discussed in more detail later
in this chapter.
Dr. Hans Luhr’s innovative ideas with regard to the
development and clinical use of plate and screw fixation in
maxillofacial surgery was the final piece of the puzzle, as
described later in this chapter (Fig. 2-27).127-134 Interest­
ingly, the third edition of Dr. Blair’s text, which was pub­
lished in 1912, illustrates the use of what he calls “silver
splints” for fixation across a mandibular osteotomy site (Fig.
• Figure 2-25  Photograph of Hugo L. Obwegeser (1920-present).
• Figure 2-26  Photograph of William H. Bell (1927-present).
• Figure 2-27  Photograph of Hans Luhr (1932-present).
*Please note that this section was reviewed for accuracy by Dr. Obwegeser.
2-28).40 He stated that the use of these fixation devices was
essential for healing. The “silver splints” look much like the
titanium mini-plates with screws that we use today. He
states that the “silver splints” were used on a patient for the
correction of mandibular prognathism.
Hugo L. Obwegeser: Development of
the Standard Orthognathic Procedures*
After completing his medical studies in mid 1945, Hugo
Obwegeser started his career as an unpaid visiting doctor in
a small hospital near his hometown. By doing so, he had

33
CHAPTER 2  Pioneers and Milestones in the Field of Orthodontics and Orthognathic Surgery
the opportunity to assist with surgery, including the treat­
ment of extremity fractures. He did not know at that point
in what direction his medical training would lead him. His
uncle, an orthopedic surgeon, gave him this advice: “What­
ever you want to become, a general medical practitioner in
a small town or a specialist in any field of medicine, you
will always need a fundamental knowledge of pathology and
pathophysiology.”156 Obwegeser listened to his uncle, and,
in October 1945, he accepted an unpaid position training
under Professor Chiari at the Rockitansky Institute of Path­
ological Anatomy at the University of Vienna. At first,
Obwegeser watched and listened, and he was occasionally
allowed to assist at the dissecting tables. After 1 year of
general surgery training and 2 years of pathology training,
he was offered a paid position to train in maxillofacial
surgery under Richard Trauner at Graz University. At Graz,
Obwegeser would also train in dentistry and sit for the
Austrian dental qualification examination (dentistry in
Austria was a subspecialty of general medicine). Obwegeser
trained and worked with R. Trauner for 6 years. He saw
professor Trauner both as a teacher and like a father.156
According to Obwegeser, Trauner “opened our eyes regard­
ing the scope of the specialty [maxillofacial surgery] and
stimulated us to see problems and find solutions for them.”156
The maxillofacial clinical practice at the Graz University
Hospital included primary clefts, head and neck cancer,
facial trauma, and the management of severe residual facial
war injuries.
During that time and with a scholarship from the British
Council, Trauner sent Obwegeser to Harold Gillies, the
founder of modern plastic and reconstructive surgery (Fig.
2-29).81-85 Obwegeser observed and worked with Gillies
from October 1951 to February 1952, primarily on the
reconstruction of war cases. From Dr. Gillies, Obwegeser
• Figure 2-28  A, Open bite of an extreme type in a young man showing how correction may be
made by with V-shaped excision. This would have the disadvantage of shortening the jaw consider­
ably, as shown in the reconstructed jaw, which is indicated by the dotted lines. B, A demonstration
of how an operation involving an S-shaped bone cut that lengthens the jawbone provides for the
better closure of the mouth. The silver splints at the site of the bone-cutter are absolutely necessary.
From Blair V: Surgery and diseases of the mouth and jaws, ed 3, St. Louis, 1917, C.V. Mosby
Company, pp 309, Figures 287 and 288.
• Figure 2-29  Photograph of Harold Gillies (1882-1960).
learned “how to plan the reconstruction of a facial defect
and how to handle soft tissues.”156 Trauner also sent Obwe­
geser to spend time with Edward Schmid at Marien-Hospital
in Stuttgart, where Obwegeser further advanced his knowl­
edge of the handling of soft tissues, the movement of flaps
to a new location, the management of cleft defects, and the
closure of fistulas.156 During his career, Obwegeser was also
influenced by Dr. Paul Louis Tessier (Fig. 2-30).184-196
Obwegeser states that, from Paul Tessier, he learned “the
principal technique for advancing the whole middle third
of the face and how to rotate the eye sockets into the
planned position.”156 Tessier used these new techniques to

34
SECTION 1  Basic Principles and Concepts
considered to be a series of unsatisfying procedures carried
out primarily for the correction of prognathism. The avail­
able mandibular procedures were limited variations of hori­
zontal ramus osteotomies. The basic techniques were those
described by Blair38-41 and Kostecka115:
“The Blair-Kostecka technique included: The ascending
ramus was cut on each side of the face [see Fig. 2-22].
The patient was placed in IMF [intermaxillary fixation]
(6 to 8 weeks). It was estimated that approximately
50% of patients experienced significant complications
including: partial or total relapse; residual malocclusion
(open bite); pseudoarthrosis; injury to the facial nerve;
injury to the inferior alveolar nerve; or parotid gland
fistula. It was assumed that a primary reason for
nonunion/malunion was the limited area of bone
to bone contact across the osteotomy site once the
distal mandible was placed in occlusion. This was
compounded by contraction of the temporalis muscle
of the non-fixed proximal segment causing further
dislocation and separation. This complication was
especially common when the procedure was used to
correct mandibular deficiency as the distal mandible
had to be advanced to achieve IMF [intermaxillary
fixation].”156
In 1952, Dr. Obwegeser retrospectively reviewed a con­
secutive series (n = 36) of Dr. Trauner’s mandibular osteoto­
mies that had been treated with the Blair-Kostecka
approach.76,198-200 Obwegeser found a 50% incidence of sig­
nificant complications. At his teacher’s request to look for
a better way to solve the mandibular deformity problem,
Dr. Obwegeser made a personal decision about two aspects.
First, he felt that the extraoral (cutaneous) approach left an
unpredictable quality of scar and added a risk of injury to
the inferior alveolar (sensory) nerve and the facial (motor)
nerve, so he chose to find an intraoral approach. Second,
he believed that the available techniques produced inade­
quate bone-to-bone contact to ensure stable bony healing.
A new approach would have to provide broad contacting
bone surfaces, even after anterior mandibular repositioning
from micrognathia.
Dr. Obwegeser studied the cadaver mandible and con­
cluded that “the ramus could be split along its sagittal
plane—with a broad bony surface area for healing.”156 He
had noticed a sagittal pattern on the radiographs of man­
dibular fractures that he had seen, and he wondered if such
a fracture could be purposely created by a surgeon. Obwe­
geser was certain that “the inner and outer cortex could be
cut at different levels and [then] the two corticotomies
[could be] reconnected along the sagittal plane.”156 He was
also convinced that the intraoral approach would not in
itself result in infection. He had treated mandibular frac­
tures via an intraoral approach by repositioning the frag­
ments and providing intermaxillary fixation within 24
hours of the injury, and he had found that this resulted in
minimal complications.156
correct posttraumatic or congenital anomalies of the upper
half of the face. Tessier’s “cranial approach to the orbits via
the anterior base of the skull has created the possibility of
producing a normal appearance and with that a normal life
for many patients”156; this is described later in this chapter.
In June 1966, Dr. Obwegeser broadly introduced his
orthognathic surgery techniques to North American sur­
geons when he presented a series of invited lectures and
demonstrations at a comprehensive conference sponsored
by the American Society of Oral Surgery at Walter Reed
Military Hospital in Washington, DC.156 At that time,
Obwegeser also described other new ideas with broad impli­
cations for the scope of oral and maxillofacial surgery,
including preprosthetic procedures, transoral approaches to
the reduction of mandibular fractures, and the simultaneous
resection and reconstruction of tumors of the mandible
with the use of a transoral approach.150-155
According to Obwegeser, “With fundamental basic
training in medicine and dentistry and through my teachers’
influence, I was able to produce new ideas and procedures,
assemble them in contrast to the then existing rules. The
influence of my teachers enabled me to become a teacher
myself. It enabled me from 1958 until 1987 to establish the
so-called Zurich-School of Maxillofacial Surgery.”156
The Transoral Sagittal Splitting of
the Mandibular Ramus
Trauner R, Obwegeser H: Zur operationstechnik bei der
progenia und anderen unterkieferanomalien.
Dtsch Zahn Mund Kieferhlkd 23:11–25, 1955
In 1947, Obwegeser started his training in maxillofacial
surgery under the direction of Richard Trauner from the
maxillofacial unit of the dental school at the University of
Graz in Austria. At that time, orthognathic surgery was
• Figure 2-30  Photograph of Paul Louis Tessier (1917-2008).

35
CHAPTER 2  Pioneers and Milestones in the Field of Orthodontics and Orthognathic Surgery
IMF. The recovery was uneventful.” The published result
shows a favorable occlusion and good facial contour198
(Fig. 2-32).
Obwegeser recognized that additional problems to be
overcome included the need for special instrumentation,
intraoral lighting, and improved anesthesia. He joined the
Department of Maxillofacial Surgery at the University Hos­
pital in 1954. In 1956, Dr. Hotz, an orthodontist, asked
Dr. Obwegeser to perform the “sagittal splitting procedure”
on one of his patients.156 This patient was a 14½-year-old
girl with a prognathic mandible who was partially maxillary
edentulous.156 On April 9, 1956, with the patient under
nasotracheal intubation, Dr. Obwegeser successfully com­
pleted the sagittal splitting of the ramus of the mandible on
each side. On one side, the lateral ramus broke off, but it
was secured back in place at the end of the procedure with
direct wires. The operation took 4 hours, and healing was
uneventful. According to the surgeons, “She had a wonder­
ful aesthetic and functional result—no external scars”150 By
the early 1960s, the sagittal splitting technique of the ramus
of the mandible became routine for Dr. Obwegeser, and
word soon spread worldwide.
Obwegeser mentions two important modifications to the
sagittal splitting of the ramus of the mandible that later
came about.151-153 The first modification was in “the place­
ment of the lateral corticotomy to increase the surface area
of the bony contact for improved union and to accommo­
date a wider range of advancement of the distal mandi­
ble.”156 The change was from a horizontal orientation of the
lateral corticotomy of the ramus to a vertical orientation of
the lateral corticotomy of the mandibular body. In 1957,
while an observer of Dr. Obwegeser in Zurich, Dr. Dal Pont
“conceived the idea of changing the lateral corticotomy
from horizontal in the ramus to vertical in the body.”156 Dal
Pont assisted Obwegeser with this goal, and it worked. In
Obwegeser then set out to sagittally split the ramus trans­
orally on a cadaver. He did his cadaver work at the Institute
of Anatomy in Graz, Austria (Fig. 2-31). Professor Trauner,
who was Obwegeser’s chief, then agreed to let Obwegeser
try the new technique (i.e., intraoral approach sagittal split
of the mandibular ramus) on a patient. Dr. Trauner would
carry out his preferred approach (reverse L-shaped osteot­
omy of the ramus through a combined extraoral and intra­
oral approach) on one side, and Obwegeser would be
allowed to try his technique on the other side. The procedure
was carried out on an edentulous 27-year-old woman who
presented with mandibular prognathism. A preoperatively
constructed acrylic splint was made for the final occlusion,
and the jaws would be wired together with the use of
intermaxillary fixation (IMF). The procedure was carried
out with the patient in a half-sitting position under local
anesthesia on February 17, 1953. Unfortunately, when
Obwegeser tried to execute his technique, the ramus “unex­
pectedly shattered instead of splitting.”156 The patient’s man­
dible was set back, the occlusion was secured with the acrylic
splint, and IMF was applied. Healing was satisfactory.
Two months later, a 24-year-old woman with mandibu­
lar prognathism and a nearly full dentition presented. Dr.
Trauner again agreed to allow Dr. Obwegeser to try his
technique. On April 22, 1953, with the patient in a half-
sitting position and under local anesthesia, Dr. Obwegeser
completed his osteotomy using long Lindemann burs, a
keyhole saw and a fissure bur to perforate the cortex, and
then a rose bur to connect the cortical perforations. An
osteotome was finally used to split the ramus. The coronoid
process fractured off, but, “with a gentile twisting maneuver,
the cortical plates fell apart and the ramus was sagittally
split.”198 On the other side, Dr. Trauner performed his
inverted L-shaped osteotomy through a combined oral
and extraoral approach. “This was followed by six weeks of
• Figure 2-31  Illustration demonstrating the first sagittal splitting of the rami. From Trauner R, Obwegeser
H: Zur operationstechnik bei der progenia und anderen unterkieferanomalien. Dtsch Zahn Mund Kieferhlkd
23:11–25, 1955.

36
SECTION 1  Basic Principles and Concepts
• Figure 2-32  The patient shown underwent the first successful transoral sagittal split of the ramus on the left side. This operation was com­
pleted by Obwegeser. A transcutaneous inverted L osteotomy on the right side was completed by Trauner on April 22, 1953. A, Left profile
views before surgery as well as 5 months and 22 years after the surgery. B, The patient’s occlusion before and after surgery is also shown.
C, The posteroanterior cephalometric radiograph shows the wire fixation on the inverted L side (the right side) and without wire fixation on the
sagittal split side (the left side). From Obwegeser HL: Orthognathic surgery and a tale of how three procedures came to be: a letter to the next
generations of surgeons. Clin Plastic Surg 34:335, 2007, Figure 4.
B
A
C

37
CHAPTER 2  Pioneers and Milestones in the Field of Orthodontics and Orthognathic Surgery
Early in his career, Dr. Obwegeser had the intention of
finding a reconstructive technique that would correct
microgenia through an intraoral approach, that would allow
for sufficient bone contact for reliable union, and that
would maintain the advancement without resorption or
relapse. After evaluating a woman with a retrusive chin and
normal occlusion and reviewing her lateral cephalometric
radiograph, Obwegeser realized that a favorable chin
contour could best be accomplished by sectioning the chin
transversely (i.e., below the roots of the teeth and the mental
foramen) and then advancing it. He used the same transoral
incision that he was familiar with from mandibular fracture
management. He used a Lindemann bur to make a hori­
zontal osteotomy below the roots of the teeth and the
mental foramen, and he then completed the osteotomy with
a chisel. He repositioned the distal chin horizontally forward
by 10 mm while maintaining the geniohyoid muscle
pedicle. He fixed the chin in its new position with circum-
mandibular threads around the chin and bicuspid regions.
The threads were primarily secured over a prefabricated
acrylic wafer that was placed on the occlusal surfaces of the
mandibular teeth to prevent “cheese wiring” through the
interproximal regions. Obwegeser published this successful
chin osteotomy outcome in 1957 (Fig. 2-33).150 Interest­
ingly, an earlier publication by Hofer reported the sliding
the inferior border of the chin forward.94,95 Although this
osteotomy was similar to the one reported by Obwegeser,
it was completed through an extraoral incision, and it was
performed on a cadaver rather than a living patient. Over
the decades, few useful clinical modifications of the original
chin osteotomy (i.e., the Obwegeser technique) have been
found in the literature. They include a double-step advance­
ment and the splitting of the osteotomy in the midline to
control width and angulation.150
1958, Dal Pont went back to his home base in Italy and
eventually published these results himself.62,63 However, Dal
Pont failed to mention that the patient described was Dr.
Obwegeser’s patient. A second modification was also sug­
gested by Dal Pont when he observed that, in some patients,
the split did not go back all the way to the posterior border
when the ramus was sectioned; satisfactory results neverthe­
less occurred.64 This second modification was also recom­
mended by Hunsuck and Epker when they “advocated that
the osteotomy of the lingual side should be incomplete,
extending just past the entrance of the neurovascular
bundle.”156 This would result in an incomplete fracture
along the medial aspect of the ramus.65,67,77,78,99,136
The Transoral Sliding Osseous Genioplasty
Trauner R, Obwegeser H: The surgical correction of
mandibular prognathism and retrognathia with
consideration of genioplasty. I. Surgical procedures to
correct mandibular prognathism and reshaping of the
chin. Oral Surg Oral Med Oral Pathol 10:677–689, 1957
Through the late 1950s, the correction of microgenia was
achieved through onlay techniques to augment the deficient
chin.13,14,102,140 The procedures were carried out through a
submental (skin) incision. Autogenous bone and cartilage
grafts (e.g., rib, hip) and a variety of alloplastic materials
(e.g., acrylic, Silastic, metal) were used to augment the
deficient chin. The onlay bone grafts resorbed over time.
The cartilage grafts healed in a capsule and were often
mobile and displaced, thereby causing asymmetry. The allo­
plastic materials, although easy to fabricate and place, had
a high complication rate that included infection, displace­
ment, the erosion of underlying bone, the resorption of the
dental roots, and an unfavorable appearance.
A
• Figure 2-33  The first transoral approach of an osseous genioplasty to correct a
chin deformity. A, Facial profile views before and after surgery.
Continued

38
SECTION 1  Basic Principles and Concepts
B
C
B, The transoral osseous genioplasty as illustrated in a 1957 article by Obwegeser. C, Lateral
cephalograms before and after surgery. From Obwegeser HL: Surgical procedures to correct mandibular prognathism
and reshaping of the chin. In Trauner R, Obwegeser H, editors: The surgical correction of the mandibular prognathism
and retrognathia with consideration of genioplasty. Oral Surg Oral Med Oral Pathol 10:677–689, 1957.
•  Figure 2-33, cont’d 
The Le Fort I (Type) Osteotomy
Obwegeser H: Der offene biss in chirurgischer sicht.
Schweiz Monatschr Zahnhlkd 74;668–687, 1964
Early on during his career, Dr. Obwegeser recognized the
necessity of developing a technique that would allow for the
reliable repositioning of the maxilla. He realized that, for
many jaw deformities, the occlusion could be restored with
a mandibular setback, but a flat appearance to the midface
and the stigma of the underlying con­dition would remain.
Obwegeser explained that, by the 1950s, he realized solving
this problem would require 1) safe surgical sectioning of the
maxilla; 2) the ability to three-dimensionally reposition the
maxilla in the operating room; 3) the ability to maintain

39
CHAPTER 2  Pioneers and Milestones in the Field of Orthodontics and Orthognathic Surgery
supply—limited successful outcomes.156 He was convinced
that the limited vertical vestibular mucosal incisions 1) pre­
vented the full mobilization of the maxilla; 2) prevented the
relaxed repositioning of the upper jaw in the operating
room; and 3) prevented the placement of fixation and bone
grafts, 4) thus further limiting the stability of the advance­
ment and resulting in eventual relapse.
Obwegeser was able to innovate by making a quantum
leap in the reconstructive possibilities of maxillary osteoto­
mies for the correction of jaw deformities. In 1964, he was
asked to treat an 18-year-old man who had been in a car
accident 6 weeks earlier. The young man had sustained a
fracture of the maxilla in two segments (palatal split), with
telescoping occurring into the nose and the maxillary sinus.
This resulted in a retropositioned maxilla with a severe
anterior open bite. Three maxillary incisors were lost, there
were multiple oronasal fistulas, and the vestibular mucosa
had been lacerated circumferentially. There was initial
healing of the soft tissues present, with scarring and mal­
union of the bones. To repair the deformity, Obwegeser
realized that limited vertical vestibular incisions, which were
part of his usual approach, were not feasible. He instead
elected to reopen the circumferential vestibular incisions,
also through the oronasal fistula opening (Fig. 2-34). He
then completed a Le Fort I osteotomy through the two
halves of the maxilla that had healed in malunion. This
required horizontal osteotomies above the teeth from the
canine fossa past the tuberosities and through the sinus on
each side. He used osteotomies and a fissure-type bur on a
rotary drill to complete the osteotomies. He raised the nasal
mucosa, detached the septum, cut through the lateral nasal
walls, and separated the pterygoid plates vertically. With
each step, he confirmed that the vascularity to the dento-
osseous–musculomucosal flap was not jeopardized. With
finger pressure, the maxilla was disimpacted via the down-
fracture technique. Obwegeser fully mobilized the maxilla
to move it forward. He recreated the palatal fracture (seg­
mentation) to independently reposition the two halves of
the maxilla. He realized that the descending palatine arteries
were no longer intact; while working through a circumves­
tibular incision, he was able to split the maxilla into two
segments and to maintain the circulation to each half. He
simultaneously closed the oronasal fistulas, fixed the maxil­
lary segments in place, and established the preferred
occlusion. By doing so, it was not necessary to complete
mandibular osteotomies to correct the occlusion.
Over the next several years, Obwegeser succeeded in
advancing the maxilla in cleft patients “without the need to
establish the occlusion with a mandibular setback as in years
past.”156 On April 14, 1968, he treated a patient with uni­
lateral cleft lip and palate and a severe maxillary deficiency.
Obwegeser advanced the lesser segment by 15 mm and the
greater segment by 13 mm. The Le Fort I osteotomy was
completed, and this was followed by down-fracture and
mobilization. He recognized that “mobilization—release of
scar tissue—and having both segments absolutely loose—
was the entire key to success.” He realized that he could
the upper jaw in the new position during healing, with
4) an acceptable complication rate and 5) a predictable
outcome.
Obwegeser knew that Langenbeck118 and Cheever55 were
able to section the maxilla horizontally above the roots of
the teeth through skin incisions of the cheek and lip for the
purpose of gaining access to the posterior pharynx and the
skull base. Wassmund reported that, in 1927, he had
“detached the maxilla as a Guerin-type fracture” (personal
communication) but without separating it from the ptery­
goid processes.205-207 He then used elastics (rather than a
complete mobilization of the maxilla) to close the anterior
open-bite malocclusion. Axhausen successfully completed
osteotomies and repositioned the upper jaw in posttrau­
matic and cleft patients.15-17 He used elastics to relocate
the maxilla after an osteotomy of the upper jaw, which
included separation from the pterygoid processes but
without complete intraoperative mobilization. In 1942,
Schuchardt reported about a posttraumatic midface defor­
mity caused by a war injury in which he completed a hori­
zontal osteotomy of the maxilla above the roots of the teeth
as a first procedure.171-173 Several weeks later, during a second
operation, he fractured the pterygoid processes. After
the second procedure, he used weight traction to horizon­
tally advance the maxilla. He stated that “this procedure
would have a large indication in cleft cases, but it would
probably never come into use.”171-173 In 1951 and 1952,
Obwegeser observed Sir Harold Gillies completing maxil­
lary osteotomies to correct cleft maxillary deformities in
numerous patients.156 Dr. Gillies “used horizontal vestibular
incisions to approach the maxilla,” “but he only rotated the
collapsed cleft segments with a Green-stick fracture at the
pterygoid-maxillary junction.”156 This is similar to what
Schmid reported in 1956 for the correction of posterior
crossbites.170 According to Obwegeser, neither Gillies nor
Schmid completed the horizontal maxillary osteotomies
with the purpose of advancing the maxilla.156 Gillies and
Rowe84 and Gillies85 did report that, in 1947, they had
completed an osteotomy of the maxilla and were able to
bring the upper jaw into the desired position in a patient
with a cleft palate, with Gillies reopening the alveolar/
palatal cleft and dividing the maxilla in two. This was fol­
lowed by immobilization that lasted for 12 weeks. Gillies
would secure the maxilla in its new location with the use of
cast cap splints over the teeth that then attached to a vertical
bar in front of the face and to a head cap. Gillies placed
cancellous bone grafts on the steps (gaps) in the canine fossa
regions and directly into the maxillary sinuses. Because of
Gillies’ reticence to advance the maxilla, the horizontal dis­
crepancy in the jaws had to be overcome by setting the
mandible back. Unfortunately, the patients retained their
“dish face” with, at best, a “flat appearance.”156
Throughout the 1950s, Obwegeser looked for solutions
to correct the midface deformity seen in cleft and posttrau­
matic patients.137,159 He believed that vertical vestibular
incisions—which were felt by most surgeons of the day
to be necessary to maintain the maxillary blood