Orthognathic Surgery

41
CHAPTER 2  Pioneers and Milestones in the Field of Orthodontics and Orthognathic Surgery
Sumpter Arnim encouraged Bell’s interest in studying the
circulation requirements of jaw osteotomies and offered
experimental rabbits for use. After visiting the laboratories
of orthopedic surgeons Drs. Rhinelander and Baraquay in
Cleveland, Ohio, Dr. Bell performed a preliminary pilot
study in rabbits to work out the details of microangio­
graphic and histologic laboratory techniques (personal
communication). This initial work gave support to these
techniques for studying the biologic basis for jaw osteoto­
mies. While at the University of Texas Dental Branch of the
Texas Medical Center in Houston, Tex, and with support
from U.S. Public Health Service grants, Dr. Bell carried out
the first of his many revascularization bone-healing studies
after completing maxillary and mandibular osteotomies
with the use of adult rhesus monkeys, mongrel dogs, and
baboons. In his first revascularization publication, Dr. Bell
states the following: “Despite numerous clinical successes
and occasional failures, the rationale for using various surgi­
cal techniques [for maxillary and mandibular osteotomies]
remains virtually empiric. Basic questions concerned with
the healing of the surgical wound produced by maxillary
osteotomies and the vessels necessary to maintain blood
supply to the bone segments and viability of the teeth have
not been investigated.”24 Nine further animal laboratory
studies would eventually be completed from 1969 to 1995,
and these would validate the circulatory integrity of all of
the basic osteotomies used in orthognathic surgery.25-35
In 1971, Dr. Bell was recruited by Dr. Robert Walker to
the University of Texas Southwestern Medical Center in
Dallas, Tex, to develop a research laboratory that focused
on the vascularity and wound healing associated with maxil­
lary and mandibular osteotomies (Fig. 2-35). This provided
the opportunity to continue animal studies and to apply the
knowledge gained in the laboratory to the solving of clinical
challenges. For the next 20 years, he worked with and
cephalometric radiograph to confirm what needed to be
done. With the maxilla and the mandible completely freed
up, he placed them into occlusion as a single unit. He then
repositioned the maxillomandibular complex “according to
[his] imagination.”156 When he was satisfied with the aes­
thetic result, he fixed the maxilla and then the mandible in
place with wires and bone grafts. He maintained the patient
in IMF for 6 weeks, after which he reported, “The occlusal
and facial aesthetic results were excellent!”154
Only minor modifications have been introduced to the
basic Obwegeser design of the maxillary Le Fort I osteotomy.
According to Dr. Obwegeser, “In time, internal fixation with
plates and screws became a reality. In 1968, Hans Luhr
published his [initial] work with plate and screw fixation.
It revolutionized internal fixation, limiting the need for
extended IMF and increased [the osteotomy] stability.”156
William H. Bell: Experimental Studies to
Confirm the Biologic Basis of the
Standard Orthognathic Procedures*
William H. Bell attended a Jesuit high school, college, and
dental school in St. Louis, Mo (Fig. 2-26), and he would
be forever affected and influenced by the Jesuit challenge to
“be men for others.” After completing dental school in
1954, he interned in oral surgery in New York City at the
Metropolitan City Hospital. He recalls that “in any given
week, [he] would literally see hundreds of patients who
[were] candidates for either orthognathic surgery or ortho­
dontics. Unfortunately, none of them received any treat­
ment.”156 In 1955, he served as resident in oral surgery at
the Jefferson Davis Hospital in Houston, Tex. Dr. Edward
C. Hinds was the program director, and, at the time, it was
considered one of the country’s finest programs in recon­
structive mandibular surgery. Hinds had refined and
clinically applied the extraoral vertical ramus osteotomy
technique for the correction of mandibular prognathism.
The program was also strong in the management of facial
trauma, particularly mandibular and midface fractures. In
1956, Dr. Bell was the first teaching fellow in oral surgery
at M.D. Anderson Hospital in Houston, Tex. His clinical
work was limited to extracting teeth and the treatment of
benign tumors and cysts of the jaws, but he had the oppor­
tunity to observe innovative head and neck cancer surgery.
According to Dr. Bell, “Dr. Hinds and the other American
oral surgeons in Houston were aware of descriptions of both
anterior and posterior maxillary osteotomies, but none were
performed for orthognathic problems at that time”(personal
communication). Bell envisioned the potential of maxillary
osteotomies for the correction of dentofacial and posttrau­
matic deformities. He searched the English literature avail­
able to him for relevant studies, but he found none that
supported the biologic foundation of these procedures. Dr.
• Figure 2-35  Photograph of Robert V. Walker (1924-2011). From
Fonseca RJ, Barber D, Powers MP, Frost DE: Oral and maxillofacial
trauma, ed 4, St. Louis, 2013, Saunders.
*Please note that this section was reviewed for accuracy by Dr. Bell.

42
SECTION 1  Basic Principles and Concepts
maxillary osteotomies (i.e., labial versus palatal pedicle)
were completed with the Wassmund technique, and the
animals were sacrificed at 1, 3, and 6 weeks after surgery.
Before sacrifice, the common carotid arteries were exposed,
cannulated, heparinized, and perfused with a suspension
of Micropaque injection medium. Each maxilla was then
dissected from the specimen, and radiographs were taken.
The 1-week specimens confirmed a “blood clot in the
center of the osteotomized fragments bounded by prolif­
erating young granulation tissue.”24 The 3-week specimens
“showed early callus formation between the bone fragments.
Considerable subperiosteal new bone formation was present
in some of the sections.”24 The 6-week specimens “showed
osseous union of the osteotomized bone fragments with
no evidence of necrosis.”24 According to Dr. Bell, “The
results indicated that no single blood vessel, such as the
incisive canal or greater palatine arteries, is essential to
maintenance of circulation to the anterior maxillary frag­
ment. Interosseous and soft tissue collateral circulation and
the freely anastomosing gingival, palatal, floor of the nose
and periodontal plexuses permit many variations of the
anterior maxillary osteotomy technique [labial versus palatal
pedicles] without detriment to the integrity of the blood
supply to the anterior maxillary segment”24 (Fig. 2-37).
Biologic Basis for the Anterior Mandibular
Segmental Osteotomy
Bell WH, Levy BM: Revascularization and bone healing
after anterior mandibular osteotomy. J Oral Surg
28:196–203, 1970
In 1970, Bell and Levy published an experimental animal
study to analyze the biologic basis for wound healing
and revascularization after anterior mandibular segmental
trained 27 oral and maxillofacial surgery residents in his
research laboratory at the University of Texas Southwestern
Medical School. He also conducted weekly dentofacial
deformity conferences for surgical residents, faculty, and
visitors from every corner of the world as well as for Dallas
community orthodontists and surgeons. Beginning in 1973
and continuing through 1985, Dr. Bell, Dr. Raymond
White, and Dr. William Proffit wrote and edited the text
Surgical Correction of Dentofacial Deformities (Fig. 2-36).
Volumes I and II of this text, which were published in 1980,
became the comprehensive clinical reference for the inter­
disciplinary art and science of the correction of dentofacial
deformities by surgeons and orthodontists. This work com­
bined an atlas of surgical and orthodontic procedures with
sound diagnostic and biologic guidelines for their applica­
tion. The outstanding supporting original artwork by Bill
Winn was remarkable for its clarity regarding the presenting
dysmorphic maxillofacial anatomy and for its demonstra­
tion of how surgical procedures can be used to solve clinical
problems.
Biologic Basis for the Maxillary Anterior
Segmental Osteotomy
Bell WH: Revascularization and bone healing after
anterior maxillary osteotomy: a study
using adult rhesus monkeys. J Oral Surg
27:249–255, 1969
An investigation was designed by Bell and colleagues to
delineate the biology of anterior maxillary osteotomy
wound healing. This was done by studying revasculariza­
tion and bone regeneration in monkeys with the use of
microangiographic and histologic techniques after com­
pleting an anterior maxillary osteotomy. Standard anterior
• Figure 2-36  A textbook entitled Surgical Correction of Dentofacial
Deformities, which was edited by W. Bell, W. Proffit, and R. White and
which was published by W.B. Saunders in 1980. This was the first
comprehensive textbook to cover the subject of orthognathic surgery.
• Figure 2-37  Microangiogram of a 1-mm transverse tissue slice from
the molar region of a control animal. Areas are indicated as follows:
palatal (Pa), maxillary sinus (MS), and nasal cavity (NC) blood vessels,
penetrating bone and anastomosing with intramedullary blood vessels
(I) and periodontal vascular plexus (Pe), turbinate (Tu), and nasal
septum (NS). Courtesy William Bell.
MS
NC
NS
Pe
Pa
Tu

43
CHAPTER 2  Pioneers and Milestones in the Field of Orthodontics and Orthognathic Surgery
(Fig. 2-39). In half of the posterior maxillary osteotomy
flaps, the greater palatine vessel was ligated. The microan­
giographic and histologic studies were completed. At 1 week
after surgery, the dento-alveolar segments remained freely
movable. By 3 weeks, mobility had greatly diminished.
After 6 weeks, the clinical union of the osteotomy segments
osteotomy in adult rhesus monkeys (n = 11). Half of the
experimental animals underwent a one-stage anterior man­
dibular segmental osteotomy that involved six teeth. The
procedure was performed through a circumgingival deglov­
ing labial flap. The lingual soft-tissue pedicle remained
attached to the osteotomized segment. Second bicuspids
were extracted, and the mandibular anterior segment was
set back. The second group underwent the same one-stage
anterior mandibular segmental osteotomy, but this was per­
formed through a labial vestibular incision with the main­
tenance of a gingival cuff around the labial aspect of the
teeth. The lingual soft-tissue pedicle also remained attached
to the osteotomized segment. The repositioned (set-back)
anterior mandibular segment was stabilized with a prefab­
ricated acrylic splint that was ligated to the teeth with
interdental wires. The animals were sacrificed at specific
postoperative intervals at weeks 1, 3, 6, and 24. Microan­
giograms and histologic slides were reviewed. The analysis
of the data demonstrated that intraosseous and intrapulpal
circulation to the anterior mandibular segments was main­
tained with the use of both of the surgical flap designs. The
dento-osseous–musculomucosal flaps healed by osseous
union within 6 weeks. In the control animals—in which
the complete degloving of the labial and lingual soft tissues
from the bone occurred—intraosseous necrosis, vascular
ischemia, and nonunion resulted (Fig. 2-38).
Biologic Basis for the Posterior Maxillary
Segmental Osteotomy
Bell WH, Levy BM: Revascularization and bone healing
after posterior maxillary osteotomy. J Oral Surg
29(5):313–320, 1971
An animal model investigation was designed by Bell
and Levy to clarify the biology of wound healing after pos­
terior maxillary osteotomies with the Schuchardt technique
• Figure 2-38  A, Photomicrograph of a section of the mandible of an animal 6 weeks after osteotomy. The osteotomy
site is replaced by cancellous bone. Hematoxylin-eosin stain. Original magnification ×10. B, Microangiogram demonstrating
the generalized distribution of injection medium throughout the anterior mandibular bone fragment 6 months after anterior
mandibular osteotomy. Reconstitution of normal vascular architecture. Sagittal section. Courtesy William Bell.
A
B
• Figure 2-39  Microangiogram of 1-mm transverse tissue slice taken
from the first molar region of an experimental animal 3 weeks after
posterior maxillary osteotomy. This image demonstrates the prolifera­
tion of endosteal (E) and periosteal (P) circulatory beds; the reattach­
ment of buccal and palatal mucoperiosteal flaps to underlying bone;
and the vascularization of pulp canal from periodontal vascular plexus
and accessory root canal (arc), buccal (B), and palatal (Pa) osteotomy
sites; the nasal cavity (NC); and the first molar tooth (T). Courtesy
William Bell.
NC
Pa
arc
T
E
E
P
B

44
SECTION 1  Basic Principles and Concepts
was seen. The individual teeth and the mobilized bone seg­
ments remained stable. There was minimal osteonecrosis
and only transient vascular ischemia, and osseous union
between most of the osteotomized segments occurred. No
difference was seen with or without the ligation of the pala­
tine vessels. The results of the experimental study suggested
that “clinically analogous single-stage posterior maxillary
osteotomies are biologically sound.”26
Revascularization and Bone Healing after
Maxillary Corticotomies
Bell WH, Levy BM: Revascularization and bone
healing after maxillary corticotomies. J Oral Surg
30:640–648, 1972
In 1972, Bell and colleagues published an experimental
animal study to analyze the biologic basis for revasculariza­
tion and bone healing after maxillary interdental corticoto­
mies with the use of the Köle technique (Fig. 2-40). Five
adult rhesus monkeys underwent Köle type procedures and
analysis. One-stage maxillary corticotomies were performed
bilaterally in the premolar and incisor regions in four
monkeys; one monkey served as a control. Corticotomies
were completed in each dento-osseous segment. These seg­
ments were then mobilized by a chisel between the corti­
cotomy sites, and the wounds were closed. The mobile
segments were stabilized with a preoperatively made acrylic
splint by ligating each tooth to the splint with interdental
wires. The experimental monkeys were sacrificed at 1, 7, 21,
and 63 days after surgery. Microangiographic and histologic
slides were reviewed. The procedures that were carried out
were found to have a destructive effect on the maxillary
incisors. The intraosseous and interpulpal circulation also
appeared to be imperiled.
• Figure 2-40  Illustration of blood supply to the anterior maxilla. The
vascular architecture—which consists of freely anastomosing gingival
plexus, palatal plexus, periodontal plexus, labial artery, intra-alveolar
vessels, apical vessels, and pulp vessels—permits anterior maxillary
osteotomies to be performed without compromising circulation to the
anterior maxilla and the teeth. Courtesy William Bell.
Biologic Basis for the Le Fort I
(Down-Fracture) Osteotomy
Bell WH, Fonseca RJ, Kenneky JW, Levy BM: Bone healing
and revascularization after total maxillary osteotomy.
J Oral Surg 33:253–260, 1975
In 1975, Bell and colleagues published an experimental
animal study that confirmed the biologic basis for bone
healing and revascularization after total maxillary (Le Fort
I) osteotomy carried out through a circumvestibular inci­
sion followed by down-fracture and disimpaction via the
Obwegeser technique. Twelve adult rhesus monkeys under­
went single-stage total maxillary osteotomy according to
Obwegeser’s protocol (Fig. 2-41). Two non-operated animals
served as controls. In seven animals, the greater palatine
arteries were preserved; in three animals, they were tran­
sected. The animals were sacrificed at the following inter­
vals: immediately; after 2 days; and 1, 2, 4, 6, and 12 weeks
after surgery. In all of the animals, the wounds healed
without signs of infection or dehiscence. Revascularization
and bone healing were studied with the use of microangio­
graphic and histologic techniques (Fig. 2-42). Within
1 week after surgery, there was increased filling of both the
endosteal and periosteal vascular beds. By 4 weeks, a callus
that was composed of fibrous connective tissue and young
bone was seen histologically. By 6 weeks, the callus con­
tained mature bone. The 12-week specimen showed com­
plete osseous bridging between fragments. Interestingly, the
ligation of both greater palatine arteries had only minimal
short-term effects on the perfusion of Micropaque through
the intraosseous, intrapulpal, or soft tissues.
Biologic Basis for the Vertical Oblique
Osteotomy of the Mandible
Bell WH, Kennedy JW, 3rd: Biological basis for vertical
ramus osteotomies—a study of bone healing and
revascularization in adult rhesus monkeys. J Oral Surg
34:215–225, 1976
In 1976, Bell and Kennedy completed a microangiographic
and histologic study of adult rhesus monkeys (n = 15) to
evaluate the biologic basis for the vertical ramus osteotomies
that were commonly in clinical use. Bone healing and revas­
cularization of the proximal condylar segment were studied
after pedicled and nonpedicled vertical ramus osteotomies
were completed. The animals were sacrificed at specific
postoperative intervals (1, 2, 3, 6, and 12 weeks), and
microangiograms and histologic slides were reviewed. Speci­
mens for which the proximal segment was not pedicled to
soft tissue showed intraosseous necrosis, vascular ischemia,
and delayed healing. Early osseous union, minimal osteo­
necrosis, and minimal vascular ischemia were found in
pedicled specimens. The study confirmed that the circula­
tion and viability of the proximal condylar segment was
maintained after standard vertical ramus osteotomy as long
as it was pedicled to the lateral pterygoid muscle and the
articular capsule.

45
CHAPTER 2  Pioneers and Milestones in the Field of Orthodontics and Orthognathic Surgery
• Figure 2-41  Clinically analogous pedicled down-fractured four-
segment Le Fort I osteotomy technique performed in rhesus monkey.
Courtesy William Bell.
• Figure 2-42  Microangiogram of the molar region of experimental
animal 2 days after surgery, revealing generalized distribution of the
injection medium in soft tissues, bone, and pulp canals of the molar
(T) as well as an avascular space (A) between superior surface of the
maxilla (M) and detached nasal mucosa (NM). Pa, Palate; NC, nasal
cavity. Courtesy William Bell.
NM
NC
A
A
Pa
M
with sagittal ramus split procedures (Fig. 2-43). Ten adult
rhesus monkeys were used. In each animal, on one side,
the procedure was completed with complete subperiosteal
stripping on the medial and lateral sides of the ramus
osteotomy segment. On the contralateral side, the maxi­
mizing of the soft-tissue attachments on the medial and
lateral side of the osteotomies was carried out. The animals
were sacrificed at specific postoperative intervals (immedi­
ately or at 1, 2, 3, 6, 12, or 24 weeks). Microangiograms
and histologic slides were reviewed at each time interval.
The results of the experimental study confirmed that the
Obwegeser technique of sagittal ramus osteotomy was bio­
logically sound. Intraosseous ischemia and osteonecrosis
were dramatically reduced when the mucoperiosteum and
the pterygomasseteric sling were maintained to the repo­
sitioned proximal segment.
Biologic Basis for a “One Tooth”
Dento-Osseous Segmental Osteotomy
Bell WH, Schendel SA, Finn RA: Revascularization after
surgical repositioning of one-tooth dento-osseous
segments. J Oral Surg 36:757–765, 1978
In 1978, Bell, Schendel, and Finn published an experimen­
tal animal study to analyze the biologic basis for wound
healing and revascularization after “one-tooth” dento-osse­
ous segmental osteotomies in six adult mongrel dogs. Half
of the experimental animals underwent a two-stage (single-
tooth dento-osseous segment) approach, whereas the other
group underwent a one-stage (single tooth dento-osseous
segment) approach. The animals were sacrificed at specific
postoperative intervals (3 days or 1, 3, 4, or 8 weeks).
Microangiograms and histologic slides were reviewed. The
data showed early transient vascular ischemia, minimal
osteonecrosis, and osseous union between most of the oste­
otomized segments. The study parameters showed that
necrosis occurred at a few of the interdental osteotomy sites.
The authors stated that the “excessive removal of interseptal
and interradicular bone may cause protracted bone healing
and have a destructive effect on the periodontium.”33 The
authors cautioned that the single-tooth dento-osseous seg­
ments were critically dependent on the preservation of
viable circulation through the soft-tissue attachments to the
underlying bone. This was by way of a freely anastomosing
vascular plexus of the gingiva, the palate, the periodontium,
and the dental pulp.
Biologic Basis for the Oblique Osteotomy
of the Chin
Storum KA, Bell WH, Nagura H: Microangiographic
and histologic evaluation of revascularization and
healing after genioplasty by osteotomy of the
inferior border of the mandible. J Oral Maxillofac Surg
48:210–216, 1988
In 1988, Storum, Bell, and Nagura completed micro­
angiographic and histologic studies in adult rhesus
Biologic Basis for the Sagittal Split Osteotomy
of the Mandible
Bell WH, Schendel SA: Biologic basis for modification
of the sagittal ramus split operation. J Oral Surg 35:
362–369, 1977
In 1977, Bell and Schendel published an experimental
animal study to analyze the biologic basis for vasculariza­
tion, revascularization, and bone healing in conjunction

46
SECTION 1  Basic Principles and Concepts
• Figure 2-43.   A, Microangiogram of a transverse section of vertical ramus 1 week after conventional sagittal
split ramus osteotomy technique showing decreased perfusion of Micropaque into the distal region of the
proximal segment (PS) and increased filling of the endosteal circulatory bed in the medial aspect of the distal
segment (DS). Ma, Masseter muscle; Mp, medial pterygoid muscle. Arrows indicate the osteotomy site.
B, Photomicrograph of the demarcated area of proximal segment showing detached periosteum
(P) and subjacent avascular bone with empty lacunae. C, Histologic appearance of osteotomy site in the verti­
cal ramus 6 weeks after modified sagittal split ramus osteotomy technique. There was some bridging of the
proximal and distal bone segments with mature fibrous connective tissue (CT) and focal areas of viable vas­
cularized osteophytic bone (O). D, Microangiogram of a 1-mm section through the ramus and condyle of a
conventional saggittal split ramus osteotomy specimen 6 months after surgery showing vascular architecture
similar to that seen in control animals. Courtesy William Bell.
CT
PS
A
B
DS
Ma
Mp
P
B
C
D

47
CHAPTER 2  Pioneers and Milestones in the Field of Orthodontics and Orthognathic Surgery
Hans G. Luhr: Development of
Plate and Screw Fixation for
Craniomaxillofacial Surgery*
Hans Luhr was born in Germany in 1932. Like so many
others during this time, his childhood years were disrupted
by World War II. He graduated from the University of
Bonn with a degree in medicine in 1958 at the age of 26,
and he went on to complete a degree in dentistry in 1960.
He worked as a ship’s physician, and he then completed his
postgraduate training and research in general pathology at
the University of Bonn. In 1961, after receiving a public
health scholarship award from the German Developing Aid
Program, he served as a dentist in charge of a mobile unit
that provided aid in the hinterland of Liberia in Western
Africa.
In 1963, Luhr began his training in maxillofacial surgery
under the direction of Professor Karl Schuchardt. At that
time, the Hamburg unit was considered the most presti­
gious in Germany. It was a regional maxillofacial trauma
center, and, because Schuchardt had pioneered segmental
osteotomies of the maxilla, there was much activity con­
cerning jaw deformities with malocclusion. Schuchardt had
also developed the acrylated arch bar, which was considered
the treatment of choice for most mandibular fractures as
well as for stabilization after elective mandibular osteoto­
mies. Until Obwegeser described the Le Fort I down-
fracture procedure with full mobilization, the Schuchardt
method of horizontal Le Fort I osteotomy without ptery­
goid–maxillary disjunction was the procedure of choice.
The incompletely mobilized maxilla was then managed by
a “roll extension” and the application of 1.5 kg of weight
via a sack of sand that was attached over the end of the
hospital bed (Fig. 2-45). Disimpaction was gradual and
monkeys. These studies indicated that an intra-oral pedicled
genioplasty involving an osteotomy of the inferior man­
dibular border maintained circulation and osseous viability
after the manipulation and repositioning of the chin
segment (Fig. 2-44). Circulation to the dental pulp was not
discernibly affected.182
Biologic Basis for the Le Fort I (Down-Fracture)
Osteotomy with Segmentation
Bell WH, You ZH, Finn RA, Fields RT: Wound healing after
multisegmental Le Fort I osteotomy and transection of
the descending palatine vessels. J Oral Maxillofac Surg
53:1425–1433, 1995
In 1995, Bell and colleagues completed a clinically analo­
gous four-segment LeFort I (down-fracture) osteotomy
through a circumvestibular incision via the Obwegeser tech­
nique in nine adult rhesus monkeys. The animals were
sacrificed after surgery on day 0, 3, 7, 14, or 28. Revascu­
larization and bone healing were studied by microangio­
graphic and histologic techniques. The findings indicated
that the palatal mucosa, the labial–buccal gingiva and
mucosa provide adequate nutrient pedicles for Le Fort I
down-fractured
segmental
osteotomies
accomplished
through a circumvestibular incision. It was documented
that segmentalization, the stretching of the vascular pedicles
(within physiologic limits), and the transection of the
descending palatine vessels have only transitory discernable
effects on revascularization and bone healing.
• Figure 2-44  Biologic foundation for the use of an advancement
osseous genioplasty with the maintenance of a soft-tissue pedicle. An
adult Macaca nemestrina monkey was used as the experimental
model. The genial segment was advanced 5 mm and fixed in the
planned position with interosseous wires. This is a microangiogram of
a 2.0-mm mid-sagittal tissue slice from an experimental animal that
was sacrificed 1 week after advancement genioplasty. The photomi­
crograph shows vascularized and vital bone in the center of the genial
segment. Proliferating osteoblasts (arrows) line viable trabecular bone,
and bony lacunae are filled with osteocytes. Hematoxylin-eosin stain,
×125. M, Medullary space; PV, small perfused blood vessel. Courtesy
William Bell.
PV
M
*Please note that this section was reviewed for accuracy by Dr. Luhr.
• Figure 2-45  Roll extension with the application of 1.5 kg of weight
on the side of the hospital bed. Disimpaction of the maxilla was gradual
and occurred over a period of 2 weeks. Courtesy Hans Luhr.

48
SECTION 1  Basic Principles and Concepts
this approach was later applied to elective jaw (orthogna­
thic) osteotomies (Fig. 2-47).1 These suspension wires were
occasionally supplemented by threaded Steinmann pins as
clinicians searched for improved ways of establishing stable
fixation. Long periods of IMF continued to be the work­
horse of immobilization in an attempt to achieve bony
union of the jaws. Prolonged periods of limited mouth
opening had negative effects on speech, breathing, chewing,
swallowing, hygiene, and temporomandibular joint mobil­
ity. As a resident in training, Dr. Luhr viewed these
maxillofacial challenges with fresh eyes. Appreciating the
limitations and hazards of these methods of immobilization
and with background knowledge of what was known at the
time about long bone fractures, he hypothesized that the
addition of compression across a mandibular fracture would
occurred over a 2-week period. When the preferred occlu­
sion was finally realized, the jaws were secured with IMF.
Although it was clear that interosseous wire fixation was
not rigid enough to counteract the masticatory muscle
forces, it and other methods of fixation (e.g., plaster head
cap with reinforced bar, palatal plate, cast cap splint, wire
suture) were all that was known for the treatment of man­
dibular fractures and elective osteotomy stabilization (Fig.
2-46). Extended periods of IMF were also applied in an
attempt to achieve healing. With these limited fixation and
immobilization methods, complications such as osteomyeli­
tis and nonunion frequently occurred, especially in the
mandible. Skeletal wire suspension via the “belt-and-sus­
penders approach” had been introduced by Milton Adams
in 1942 for the added stabilization of midface fractures, and
• Figure 2-46  Kazanjian published an example of his management of a complex facial injury that was sustained by a soldier during
World War I. The wound involved the soft tissues and skeletal structures of the face. Kazanjian used a combination of a plaster head
cap, a facial bar, a palatal plate, cast cap splints, wire sutures, and interosseous wires to establish bony healing and soft-tissue
maintenance. From Kazanjian VH, Converse EJ: The surgical treatment of facial injuries, Baltimore, 1949, The Williams and Wilkins
Company.
Before injury
Early after injury
After reconstruction
Plaster
headcap
Palatal
plate
Cast cap
splint
Wire
sutures
Interosseous
wires
Facial
bar

49
CHAPTER 2  Pioneers and Milestones in the Field of Orthodontics and Orthognathic Surgery
pressure created by a compression bone plate was at least
partially maintained during the healing period (i.e., approx­
imately 50% at 4 weeks). Further experiments by Luhr
determined that the use of compression increased the rate
of strength during fracture union as compared with fixation
techniques without the use of compression. Interestingly,
Luhr found that, with an actual fracture model, the histo­
logic pattern of primary bone healing differed significantly
from the descriptions by Schenk and Willenegger (i.e.,
Association for Osteosynthesis/Association for the Study of
Internal Fixation investigators), who used a “saw-cut” tibia
osteotomy dog model.129 During healing, these researchers
observed the primary penetration of the osteotomy line via
an ossification process that originated predominantly or
exclusively in the cells and vessels within the Haversian
canals. They termed this process intracanalicular osteogenesis,
and they also called it contact primary bone healing. In their
“saw-cut” tibia osteotomy dog model, the bone surfaces
were in direct apposition to one another as fusion occurred.
This was in contrast with “microgap healing,” which was
described by Luhr in the mandible fracture model (Fig.
2-48, A). Luhr’s experimental model more closely simulated
a real-life mandibular fracture. He found that the micro­
scopic reduction of the fracture did not occur, despite the
fact that the fracture appeared to the clinician to be grossly
reduced. Small gaps still existed between the opposing
bone spicular surfaces. Blood vessels and cells that origi­
nated in the endosteal cavity and in the periosteal side first
invaded the microgaps between the opposing spicular sur­
faces. Lamellar bone was then deposited on the partially
• Figure 2-47  An illustration of Adams suspension wires used to
stabilize a midface fracture. In the past, this was a common method
that was used in an attempt to immobilize a midface fracture.
• Figure 2-48  A, A schematic diagram of microgap healing at the microscopic level after the compression
osteosynthesis of an experimental mandibular fracture in a dog. Although the fracture looks reduced at the time
of surgery, microscopically, there were discrete areas of contact and separation between the fracture ends. The
regeneration of bone took place in the non-contacting areas. Blood vessels had grown in both from the endosteal
cavity and the periosteal side. Lamellar bone is deposited at the partially devitalized marginal fracture ends (C)
with empty lacunae. B, Primary lamellar bone is deposited on the partially devitalized fracture ends around the
blood vessels (cross-sectioned), which had grown in from the endosteal cavity and the periosteal side. This is a
microscopic slide from 4 weeks after the compression osteosynthesis of an experimental mandible fracture in a
dog. From Luhr HG: Callus symposion. Nova Acta Leopold 44:85–93, 1976.
D
B
A
A
A
A
A
A
A
A
A
C
A
B
B
B
A
B
provide the necessary interfragmentary stability and elimi­
nate the need for intermaxillary fixation. With research
interests in the biomechanics of bone healing and jaw frac­
ture management in particular, Luhr established an animal
laboratory to study these issues. His experimental dog
model involved a traumatically induced mandibular frac­
ture. The fracture model confirmed that interfragmentary

50
SECTION 1  Basic Principles and Concepts
devitalized bone within the small interfragmentary gaps,
and it soon filled up the microgaps and united the fracture
segments (Fig. 2-48, B). As soon as 4 weeks later, the frac­
ture was already clinically solid. The Haversian system con­
tributed only to the late remodeling of the whole fracture
zone, which could take several months. However, “gap
healing” was seen with regularity, and it is viewed as a form
of primary bone healing.
After confirming its success in experimental animals,
Luhr was the first to apply maxillofacial compression osteo­
synthesis in a human. He did this on an edentulous woman
who had sustained bilateral body fractures in an atrophic
mandible (Fig. 2-49).127 Within 6 months of this initial
success, Luhr used similar compression osteosynthesis tech­
niques on mandibular fractures in 16 additional patients,
all with good results. He immediately saw the value of “self-
tapping screws” in maxillofacial surgery. However, this went
against the grain of general orthopedic surgeons, who at the
time were beginning to use compression osteosynthesis for
long bone injuries. They preferred to “pretap” the bone
before the placement of fixation screws. Dr. Luhr chose
Vitallium as a material, because it was a corrosive-resistant
cobalt/chromium/molybdenum alloy with good strength.
The small plates that he designed for use in the mandible
were first modeled in wax, and they were then cast at a
private dental lab. He would grind eccentric holes into each
Vitallium fixation plate with the use of a diamond bur to
complete the required design (Fig. 2-50). When drilling
holes in the bone for the placement of self-tapping screws,
Dr. Luhr initially used a hand-drill technique, because low-
speed drills were not available in the operating room at that
time. In 1968, Luhr reported on his initial consecutive
series of mandibular fractures that involved the use of com­
pression plating.127 The Luhr Maxillofacial Fixation System
was then manufactured by Howmedica in 1969.133 Remark­
ably, all of the commercially available plate configurations
in this system were designed by Luhr himself. He first com­
pleted pencil drawings to scale, and these served as design
patterns for the manufacturer. This was true for all of the
plating systems that Luhr introduced over the following two
decades.
In January 1970, Dr. Luhr was presented with a patient
who had been operated on elsewhere to correct a develop­
mental jaw deformity that was characterized by mandibular
prognathism. A Dingman osteotomy technique with inter­
osseous wire fixation had been used, and this was followed
by 12 weeks of IMF. The result was osteomyelitis with
extraoral fistulas and nonunion on both sides (Fig. 2-51).
Dr. Luhr initially removed the involved tooth at each oste­
otomy site and achieved drainage to manage the infection.
He was able to stabilize each osteotomy site with the use of
a compression plate with screws. A lower jaw arch bar was
also left in place for 8 weeks to provide additional stability.
With the stable direct fixation described, the intermaxillary
fixation was immediately released, and healing was unevent­
ful. This was likely the first case of plate and screw fixation
used in orthognathic surgery. Although this case was not
officially published by Dr. Luhr at the time, word quickly
spread regarding this new technique of bone fixation for
elective maxillofacial osteotomies.
The advantages of plate and screw fixation for orthogna­
thic surgery soon caught on. Francois Michelet and col­
leagues from Bordeaux, France, published their results
involving mini-plate fixation of the Obwegeser sagittal split
osteotomy in 1971.139 Two years later, mini-plate stabiliza­
tion of elective maxillary osteotomies was also reported,
with clear illustrations demonstrating how it should be
done. Maxime Champy also described the use of mini-
plates and monocortical screws for the treatment of man­
dibular fractures as well as the use of mini-plates and screws
for elective Le Fort I osteotomies.52,53 Bernd Spiessl pre­
ferred the use of lag screw techniques to stabilize sagittal
split osteotomies.176-178 He and others soon realized that,
unless this technique was meticulously executed, the use of
lag screws at the sagittal split osteotomy site could easily
result in condyle dislocation with malocclusion as a result
of the torquing effects. For the majority of surgeons, the
philosophy of osteotomy fixation for sagittal splits soon
shifted to the concept of “bicortical” (non–lag screw)
technique in an attempt to avoid these complications.
The so-called “positional screw” technique described by
Lindorf124,125 and Niederdellmann146-148 gradually took
hold. The potential risk of condyle dislocation with the
application of mandibular osteotomy fixation during
orthognathic surgery was recognized by Luhr.132 To help
prevent this occurrence, he designed a temporomandibular
joint positioning device, which remains a viable alternative
to the freehand positioning approach that is most frequently
used today (see Chapter 15).
Publications describing the value of mini-plate and
screw fixation after Le Fort I osteotomy were initially
described by Michelet139 and then by Champy,52,53 Hörster,97
Steinhäuser,179 and Drommer and Luhr (1981).73,74 Dr.
Luhr reported on 17 cases of Le Fort I osteotomies using
mini-plate and screw fixation specifically to correct the max­
illary deformity in patients with cleft palates. During the
late 1970s, the advantage of Dr. Luhr’s L-shaped mini-plates
(specifically designed for the fixation of Le Fort I osteotomy
sites) became known. The L-shaped plates overcame the
difficulties of establishing fixation along the dense bicortical
vertical pillars (i.e., the piriform rim region and the maxil­
lary buttress) of the maxilla while also gaining maximum
horizontal fixation directly above the roots of the teeth on
the dentoalveolar side.
Dr. Luhr reported one of the first bimaxillary orthogna­
thic cases in which plate and screw fixation was used at all
locations without the need for intermaxillary fixation after
surgery. This was for a dental student who presented with
a dentofacial deformity during the early 1980s. The opera­
tion included a maxillary Le Fort I osteotomy with advance­
ment and bilateral sagittal split osteotomies of the mandible
with setback. It is believed that the first bimaxillary orthog­
nathic procedures that involved the use of rigid fixation in
the United States were completed in 1983 by Dr. Harvey

51
CHAPTER 2  Pioneers and Milestones in the Field of Orthodontics and Orthognathic Surgery
• Figure 2-49  The first-ever compression osteosynthesis in maxillofacial surgery, which was performed by Luhr in 1967. A, An intraoperative
view of the compression bone plates after the stabilization of bilateral body fractures of an edentulous mandible. B, A postoperative radiograph
showing the fixation plates and screws that secured the reduced fracture. C, An illustration of the plate and screws (in millimeters) as designed
by Luhr. Courtesy Hans Luhr.
October 30-1967
October 30-1967
A
B
3.75
DS
RS
RSL
RSL
DSL
DSL
2.75
10
28
C
6.3
4.0

52
SECTION 1  Basic Principles and Concepts
• Figure 2-50  Self-tapping screw with a cutting flute is shown (A), along with an example of the raw plates that were cast
for Dr. Luhr in Vitallium by a private dental lab (B). These plates were then refinished, and eccentric gliding holes were
placed by Dr. Luhr with the use of a drill with a diamond bur. Courtesy Hans Luhr.
A
B
• Figure 2-51  Osteomyelitis and nonunion resulted from a Dingman-technique osteotomy for the cor­
rection of mandibular prognathism, which included 12 weeks of intermaxillary fixation. A, A panorex
radiograph is shown. B, The involved teeth were removed and drainage was achieved to manage the
infection. Each of the osteotomy sites were stabilized with the use of a compression screw plate that was
designed and placed by Dr. Luhr. Intermaxillary fixation was immediately released, and the final result after
healing was uneventful. Courtesy Hans Luhr.
A
L
B
L

53
CHAPTER 2  Pioneers and Milestones in the Field of Orthodontics and Orthognathic Surgery
Rosen and Dr. Luhr (personal communication between Dr.
Rosen and Dr. Luhr). In July 1983, after observing Dr. Luhr
operating in Göttingen, Germany, Dr. Rosen was given a
fixation set and encouraged to make use of it back home.
In Philadelphia, Dr. Rosen completed bimaxillary surgery
in a teenage girl with a cleft jaw deformity. He used Luhr
plates and screws for the fixation of the Le Fort I and bilat­
eral ramus osteotomies in November 1983. I served as Dr.
Rosen’s first assistant, and I was impressed by the new tech­
nology. The following month (December 1983), while
serving as a visiting professor with Dr. Linton Whitaker at
the University of Pennsylvania, Dr. Luhr demonstrated his
techniques on a teenage girl with a long face mandibular
deficiency anterior open bite who required a Le Fort I oste­
otomy with vertical intrusion and horizontal advancement
as well as bilateral sagittal split osteotomies of the mandible
with advancement. Under Dr. Whitaker, as a craniofacial
surgery fellow, I was fortunate to have the opportunity to
assist Dr. Luhr during this surgery. To rapidly disseminate
the knowledge of Dr. Luhr’s innovations, Dr. Whitaker
organized a 1-day symposium at the University of Pennsyl­
vania entitled “Fixation Options in Cranio-Maxillofacial
Surgery.” This event was attended by the leading craniofacial
surgeons from throughout Canada, the United States, and
Mexico. Recognizing the value of Luhr’s application of plate
and screw fixation to patient care, within months, this
procedure became routine at their centers. Luhr’s tech­
niques were enthusiastically embraced by their residents
in training and by the surgeons within their respective
communities.
By the mid to late 1980s, the advantages of plate and
screw fixation for use in a spectrum of elective craniofacial
osteotomies, for fractures, and for tumor management was
becoming known throughout the world. It was clear to Dr.
Luhr that plates and screws of smaller dimension were
required to accomplish clinical objectives, especially in the
upper face. He designed the Luhr Micro-Fixation System,
which is the smallest bone fixation system in the world; it
includes screw diameters of as small as 0.8 mm and micro-
plates of various design to match (Fig. 2-52).133 The system’s
applicability to upper face clinical problems (e.g., cranial
vault, orbit, zygomas, nose) was immediately clear and
quickly adapted by craniofacial surgeons and neurosurgeons
throughout the world.
Until the 1980s, chin osteotomy via Obwegeser tech­
nique fixation was accomplished with interosseous wires or
circumsymphyseal wires. Some clinicians also used threaded
Steinmann pins. During the late 1980s, Dr. Luhr published
articles about a series of genioplasties in which he used plate
and screw fixation on a routine basis.134 There were few
complications, and the clinical success was remarkable (Fig.
2-53). Dr. Luhr found the plate and screw fixation tech­
niques for chin osteotomy stabilization to be especially
useful when vertical lengthening and interpositional graft­
ing were required. In 1988, Dr. Rosen also published a
successful series of osseous genioplasties involving vertical
lengthening with the use of Luhr (rigid) fixation.168
• Figure 2-52  The first microplates designed by Dr. Luhr. A typical
mini-plate from the time is shown in the upper right corner to demon­
strate the difference in size. From Luhr HG: Indication for use of a
microsystem for internal fixation in craniofacial surgery. J Craniofac
Surg 1:36, 1990, Figure 2.
As professor and head of the Department of Maxillofa­
cial Surgery at the University of Göttingen, Dr. Luhr con­
tinued primate laboratory research and provided care to
patients who had sustained facial trauma, who presented
with dentofacial deformities, and who arrived with a spec­
trum of head and neck tumors until he retired from clinical
practice in 2000. During this time, he published more than
200 scientific articles and book chapters. He continues to
serve as Professor Emeritus in Maxillofacial Surgery at the
University of Göttingen.
Throughout the 1960s and into the 1990s, Dr. Luhr
stimulated a generation of craniomaxillofacial surgeons to
embrace plate and screw fixation for trauma, elective oste­
otomies, and tumor management.127-134 Luhr’s initial ideas
and commercially available fixation system served as a
springboard for many of today’s craniomaxillofacial innova­
tions. Stable plate and screw fixation is one of the most
significant advances in craniomaxillofacial surgery to have
occurred during the 20th century. On the basis of his labo­
ratory research, technical innovations, and clinical contri­
butions, it is right to consider Dr. Luhr “the father of rigid
fixation.”
Paul Louis Tessier: Development of
Craniofacial Surgery101,215,216
Paul Tessier (1917-2008) was born into a family of wine
merchants in Héric on France’s Atlantic Coast (see Fig.
2-30). He was an only child, and he had no family back­
ground in medicine. It has been stated that his initial ambi­
tion was to join the Navy, but he was excluded from this
by early ill health. Because of his love for the outdoors, he
also considered a career in forestry. In 1936, at age 19, he
entered medical school. However, just halfway through his

54
SECTION 1  Basic Principles and Concepts
• Figure 2-53  The advantage of plate and screw fixa­
tion is demonstrated via a double-step genioplasty that
resulted in a 20-mm advancement. A, The two bony
segments were stabilized with the use of two segmented
mini-plates and screws. B, The steps were filled with
hydroxyapatite granules that were packed into Vicryl
sacks. C, Profile views of the patient before and after
surgery. Courtesy Hans Luhr.
A
B
C
studies, he became a prisoner of war in 1940. While he was
interred, he became critically ill with a typhoid infection,
but he eventually recovered. When he was released, he
finally receiving his Doctor of Medicine degree from the
Faculté de Médecine de Paris in 1943. When he came to
Paris in 1944 (because the U.S. 8th Air Force had destroyed
the hospital that he worked at in Nantes), Tessier worked
with Maurice Virenque, a maxillofacial surgeon, at Hôpital
Puteauz. After the war, the service moved to Foch, where
there were, in essence, two maxillofacial services: one with
Virenque and Tessier and one with Gustave Ginestet, an
officious martinet who held the rank of General in the
French Army. After Virenque died, Ginestet wrote Tessier
several letters forbidding him to perform any maxillofacial

55
CHAPTER 2  Pioneers and Milestones in the Field of Orthodontics and Orthognathic Surgery
• Figure 2-54  Gillies published the results of a Le Fort III osteotomy
that was completed in 1942 for an adult with Crouzon syndrome. From
Gillies H, Harrison SH: Operative correction by osteotomy of recessed
malar maxillary compound in case of oxycephaly. Br J Plast Surg
3:102, 1950.
Before operation
After operation
Before operation
After operation
surgery; his only function was to be running the burn
service. Tessier ignored Ginestet, but many of his methods
of interlocking bone fixation were the result of the fact that
Ginestet controlled the dental lab and forbade the techni­
cians to provide any help to Tessier. Jacques Dautrey, who
was Tessier’s friend but who was also on Ginestet’s service,
used to sneak in to help Tessier.
Between 1946 and 1950, Dr. Tessier made yearly visits
to England to observe Harold Gillies, Archibald McIndoe,
and others whose advances in plastic surgery in response to
severe military injuries were ongoing. Through his observa­
tions and his passion to find solutions to complex recon­
structive problems, Dr. Tessier began to find innovative
ways to perform osteotomies for the correction of congeni­
tal midface retrusion but without the problems that had
plagued the performance by his mentor Harold Gillies. By
the mid 1950s, Tessier had become the head of his depart­
ment in Paris. He was consulted in 1957 by a young man
with a facial deformity of “monstrous aspect” who was
found to have Crouzon syndrome.186 The patient’s facial
deformities included severe orbital dystopia/eye proptosis,
midface deficiency/malocclusion, and obstructed breathing.
Dr. Tessier was aware that Gillies had completed an elective
Le Fort III osteotomy on a young adult with Crouzon
syndrome who had a moderate degree of proptosis and
midface deficiency (Fig. 2-54). Dr. Gillies was reported to
be discouraged with the eventual outcome and had recom­
mended to others “never to do it.”82
Tessier was undeterred, and he set out to solve the
problem initially by performing an anatomic study of dry
skulls. For access to the anatomy laboratory, he traveled by
train in the evenings to his medical school in Nantes. After
his late-night cadaver dissections, he returned during the
early hours for the next Parisian working day. His painstak­
ing preparatory work paid off when he successfully advanced
his patient’s face by 25 mm and achieved stability with the
novel use of bone grafts (which Gillies had not used),
improved osteotomy design, incision placement, and immo­
bilization techniques, including use of an external fixation
apparatus (Fig. 2-55).
Dr. Tessier’s next advance was to devise a technique for
separating the orbits from the skull, thereby allowing for
the relocation of the orbits and eyeballs for the protection
of vision and improved aesthetics without damaging the
brain or the eyes in the process. Working with Gerard
Guiot, a neurosurgeon, Tessier took 3 more years to perfect
his technique, which included the making of the bony cuts
through the skull base by what soon became known as the
“Tessier intracranial approach” to the orbits and the midface.
The surgical procedures developed by Tessier were shown
to the world at a presentation that he made in Rome at the
International Plastic Surgery Meeting in 1967.187 The tech­
niques were so revolutionary that Tessier sought to establish
their validity before continuing further. In the most humble
and unique way, Tessier invited prominent surgeons from
around the world to observe him operating live so that he
could demonstrate these techniques before a distinguished
international group of his peers. He asked for their vote on
whether his demonstrated surgical techniques had a place
in the practice of surgery. The resounding positive responses
of his peers were clear evidence of their support and
approval. During the late 1960s and throughout the 1970s,
Dr. Tessier developed all of the basic procedures and essen­
tial techniques that are currently used to perform what has
come to be known as craniofacial surgery, including the
transcranial and subcranial correction of orbital dystopia
such as orbital hypertelorism; the correction of midface
deficiency or deformity among patients with conditions
such as Crouzon syndrome and Apert syndrome; the cor­
rection of facial deformities associated with such conditions
as Treacher Collins–Franceschetti syndrome; and the
description and correction of the spectrum of oro-ocular
clefts. The impact of Dr. Tessier’s work has affected every
surgical specialty that seeks solutions to head and neck
problems, including plastic surgery, otolaryngology/head
and neck surgery, ophthalmology, neurosurgery, trauma
surgery, and oral and maxillofacial surgery.
By the late 1960s, Paris become the birthplace of the new
specialty of craniofacial surgery, where visitors would flock
to observe Tessier’s techniques and approach to problem

56
SECTION 1  Basic Principles and Concepts
• Figure 2-55  Tessier reported early results with an intracranial Le Fort III osteotomy.
solving. Dr. Tessier began traveling to the United States and
England to demonstrate his procedures in cities such as
Philadelphia, Chicago, Kansas City, Houston, Boston,
Norfolk, and London.185 Dr. Tessier’s work became so far
reaching that, by the 1990s, virtually everyone performing
craniofacial procedures was either trained by Dr. Tessier
himself or by surgeons whom he had trained.
Dr. Tessier’s contributions cannot be overestimated.184-196
His basic innovations to safely separate the orbits and the
midface from the base of the skull with the use of an intra­
cranial approach satisfy the needs for exposure during
complex surgery and craniofacial reconstruction. His tech­
niques have revolutionized the treatment of birth defects of
the head and neck; tumors of the midface, orbit, and skull
base; severe facial deformities and asymmetries; craniofacial
trauma; and complex infections. In response to questions
about what inspired his unique approach to problem
solving, Tessier would quote Guiot’s response: “Pourquoi
pas?” This phrase—which is translated into English as
“Why not?”—became the motto of the International
Society of Craniofacial Surgery, founded in 1983, of which
Tessier was invited to be Honorary President.
Dr. Tessier understood the importance of interspecialty
collaboration, because “no one man could master all
techniques and be an island onto himself” (personal
communication). The recognition that individuals with
complex surgical problems and deformities of the head and
neck often require a team approach did not deter him. Tes­
sier’s painstaking preparatory work to achieve the best
results for each and every patient and his insistence on the
highest level of collaborative care was the mark of the man.
He did not settle for mediocrity, and he expected the same
commitment from others. This was true in all aspects of his
professional and personal life. Hard work, determination,
intelligence, focus, innovation, meticulous organization and
planning, and—above all—imagination were the character­
istics that Tessier demonstrated in his everyday life and that
he appreciated in others.
Conclusions
Modern practicing orthodontists and maxillofacial surgeons
have learned much from the pioneers in this field. We stand
on the shoulders of the giants who came before us. Thanks
to them, when evaluating an individual with a dentofacial
deformity, we are now able to safely and reliably offer effec­
tive treatment to achieve long-term occlusal stability, peri­
odontal health, an improved upper airway, and enhanced
facial aesthetics in most cases. Even so, further innovations
are expected from those who will come next.
References
1. Adams WM: Internal wiring fixation of
facial fractures. Surgery 12:4, 1942.
2. Andrews LF: The six keys to normal
occlusion. Am J Orthod 63:296–309, 1972.
3. Andrews WA: Andrews. Journal of
Orthodontics and Orofacial Harmony
1(1):1–56, 2000.
4. Andrews WA: Andrews. Journal of
Orthodontics and Orofacial Harmony
1(2):1–60, 2001.
5. Angle EH: Double resection of the lower
maxilla. Dent Cosmos 40(July-Dec): 1898.
6. Angle EH: Treatment of malocclusion of the
teeth and fractures of the mandible: Angle’s
system. Philadelphia, 1900, White Dental
Manufacturing.
7. Angle EH: Double resection for the
treatment of mandibular protrusion.
Dent Cosmos 45:268, 1903.
8. Angle JL: Greek teeth: ancient and modern.
Hum Biol 16:283–297, 1944.

57
CHAPTER 2  Pioneers and Milestones in the Field of Orthodontics and Orthognathic Surgery
9. Asbell MB: Bicentenary of a dental classic:
John Hunter’s natural history of the human
teeth. J Am Dent Assoc 84:1311–1334,
1972.
10. Asbell MB: A brief history of orthodontics.
Am J Orthod Dentofacial Orthop 98:
176–183, 1990.
11. Asbell MB: Simeon Hayden Guilford
(1841-1919). Am J Orthod Dentofacial
Orthop 113:367, 1998.
12. Asbell MB: John Nutting Farrar 1839-1913.
Am J Orthod Dentofacial Orthop 114:602,
1998.
13. Aufricht G: Combined nasal plastic and chin
plastic: correction of microgenia by
osteocartilaginous transplant from large
hump of nose. Am J Surg 25:292, 1934.
14. Aufricht G: Combined plastic surgery of the
nose and chin. Am J Oral Surg 95:231,
1958.
15. Axhausen G: Zur Behandlung veralteter
disloziert
geheilter oberkieferbruche. Dtsch Zahn Mund
Kieferheilkd 1:334, 1934.
16. Axhausen G: Ueber die korrigierende
osteotomie am oberkiefer. Dtsch Z Chir
248:515–522, 1936.
17. Axhausen G: Die operative orthopädie bei
den fehlbildungen der kiefer. Dtsch Zahn
Mund Kieferhlkd 6:582–600, 1939.
18. Aziz SR, Simon P: Hullihen and the origin
of orthognathic surgery. Oral Maxillofac Surg
62:1303–1307, 2004.
19. Babcock WW: Surgical treatment of certain
deformities of the jaw associated with
malocclusion of the teeth. JAMA 53:833,
1909.
20. Baker CR: Orthodontic profiles. Am J
Orthod 43:210–218, 1957.
21. Barton JR: Systemic bandage for fracture of
the lower jaw. Am Med Rec 2:153, 1819.
22. Barrow GV, Dingman RO: Orthodontic
considerations in the surgical management of
developmental deformities of the mandible.
Am J Orthod 36:121–124, 1950.
23. Begg PR: Stone age man’s dentition. Am J
Orthod 40:298–312, 373–383, 462–475,
517–531, 1954.
24. Bell WH: Revascularization and bone
healing after anterior maxillary osteotomy:
a study using adult rhesus monkeys.
J Oral Surg 27:249–255, 1969.
25. Bell WH, Levy BM: Revascularization and
bone healing after anterior mandibular
osteotomy. J Oral Surg 28:196–203, 1970.
26. Bell WH, Levy BM: Revascularization and
bone healing after posterior maxillary
osteotomy. J Oral Surg 29:313–320, 1971.
27. Bell WH: Correction of skeletal type of
anterior open bite.
J Oral Surg 29:706, 1971.
28. Bell WH, Levy BM: Revascularization and
bone healing after maxillary corticotomies.
J Oral Surg 30:640–648, 1972.
29. Bell WH, Fonseca RJ, Kenneky JW, Levy
BM: Bone healing and revascularization after
total maxillary osteotomy. J Oral Surg
33:253–260, 1975.
30. Bell WH: Le Fort I osteotomy for correction
of maxillary deformities. Oral Surg
33:412–426, 1975.
31. Bell WH, Kennedy JW: Biologic basis for
vertical ramus osteotomies—a study of bone
healing and revascularization in adult rhesus
monkeys. J Oral Surg 34:215–225, 1976.
32. Bell WH, Schendel SA: Biologic basis for
modification of the sagittal ramus split
operation. J Oral Surg 35:362–369, 1977.
33. Bell WH, Schendel SA, Finn RA:
Revascularization after surgical repositioning
of one-tooth dento-osseous segments.
J Oral Surg 36:757–765, 1978.
34. Bell WH, Mannai C, Luhr HG: Art and
science of the Le Fort I downfracture. Int J
Adult Orthod Orthognath Surg 3:23, 1988.
35. Bell WH, You ZH, Finn RA, Fields RT:
Wound healing after multisegmental Le Fort
I osteotomy and transection of the
descending palatine vessels. J Oral Maxillofac
Surg 53:1425–1433, 1995.
36. Biederman W: The strange story of the Angle
operation. Ann Dent 15:115, 1956.
37. Bier A, Braun A, Kummel H: Chirurgische
operationslehre. Band I. Leipzig, Germany,
1914, Barth.
38. Blair VP: Report of a case of double
resection for the correction of protrusion of
the mandible. Dent Cosmos 48:817–820,
1906.
39. Blair VP: Operations on the jaw-bone and
face. Surg Gynecol Obstet 4:67–78, 1907.
40. Blair VP: Surgery of the mouth and jaws.
St. Louis, 1914, Mosby.
41. Blair VP: Instances of operative correction of
malrelation of the jaws. Int J Orthod 1:395,
1915.
42. Brodie AG: Orthodontic history and what it
teaches. Angle Orthod 4:85–97, 1934.
43. Brodie AG: Orthodontic concepts prior to
the death of Edward H Angle. Angle Orthod
26:144–154, 1956.
44. Cadenat H, Aussenac R, Barthélémy I,
Combelles R: Le maxillaire supérieur, facteur
de prognathie inférieur. Rev Stomatol Chir
Maxillofac 72:527–530, 1971.
45. Caldwell JB, Letterman GS: Vertical
osteotomy in the mandibular rami for
correction of prognathism. J Oral Surg
12:185, 1954.
46. Caldwell JB, Hayward J, Lister R:
Correction of mandibular retrognathia by
vertical L-osteotomy: a new technique.
J Oral Surg 26:259, 1968.
47. Case CS: Principles of occlusion and
dentofacial relations. Dent Items Int 27:489,
1905.
48. Case CS: A practical treatise on the techniques
and principles of dental orthopedia and
prosthetic correction of cleft palate, ed 2,
Chicago, 1922.
49. Casto FM: A historical sketch of
orthodontia. Dent Cosmos 76:111–135,
1934.
50. Cernea, Grignon, Crépy, Benoist: Les
osteotomies totales de maxillaire superieurs.
Rev Stomatol 56:700–716, 1955.
51. Chadwick J, Mann W: The medical works of
Hippocrates. London, 1950, Blackwell
Scientific, pp 260–265.
52. Champy M, Lodde JP, Wilk A, Grasset D:
Plattenosteosynthesen bei
mittelgesichtsfrakturen und osteotomien.
Dtsch Z Mund-Kiefer-u Gesichts-Chir
2:26–36, 1978.
53. Champy M: Surgical treatment of midface
deformities. Head Neck Surg 2:451–465,
1980.
54. Chapman H: Orthodontics: Fifty years in
retrospect. Am J Orthod 41:421–442, 1955.
55. Cheever DW: Displacement of the upper
jaw. Med Surg Rep Boston City Hosp 1:156,
1870.
56. Conn-Stock G: Die chirurgische
immediate—gulierung der kiefer, speziell die
chirurgische behandlung der prognathie.
Vjscher Zahnhkd 37:320, 1921.
57. Converse JM, Shapiro H: Treatment of
developmental deformations of the jaws.
Plast Reconstr Surg 10:473–510, 1952.
58. Converse JM, Wood-Smith D: Horizontal
osteotomy of the mandible. Plast Reconstr
Surg 34:464, 1964.
59. Converse JM, Horwitz SL: The surgical
orthodontic approach to the treatment of
dentofacial deformities. Am J Orthod
55:217–243, 1969.
60. Cryer M: Typical and atypical occlusion of
teeth. Dent Cosmos 46:713, 1904.
61. Cupar I: Die chirurgische behandlung der
form und stellungs veranderungen des
oberkiefers. Ost Z Stomatol 51:565, 1954.
62. Dal Pont G: L’osteotomia retromolare per la
correzione della progenia. Minerva Chir
1:369–371, 1958.
63. Dal Pont G: L’osteotomia retromolare per la
correzione della progenia. Minerva Chir
14:1138–1141, 1959.
64. Dal Pont G: Retromolar osteotomy for the
correction of prognathism. J Oral Surg
Anaesth Hosp D Serv 19:42–47, 1961.
65. Delaire J: De l’interet des osteotomies
sagittales dans la correction des infragnathies
mandibulaires. Ann Chir Plast 15:104, 1970.
66. Delaire J, Verdon P, Lumineau J, et al:
Quelques resultats des tractions extra-orales
B appui fronto-mentonnier dans le
traitement orthopedique des malformations
maxillomandibulaires de classe III et des
sequelles osseuses des fentes labio-maxillaires.
Rev Stomatol (Paris) 73:633, 1972.
67. Delaire J: Sagittal splitting of the body of the
mandible (Mehnert’s technique) for
correction of open bite and deep over bite.
J Maxillofac Surg 5:93, 1977.
68. Deranian HM: The miracle man of the
Western Front; the story of Dr. Varaztad
Kazanjian. Bull Hist Dent 32:85–95, 1984.
69. Dewel BF: The Case-Dewey-Cryer extraction
debate. Am J Orthod 50:862–865, 1964.
70. Dewel BF: The ribbon arch: its influence in
the development of orthodontic appliances.
Angle Orthod 51:263–268, 1981.
71. Dingman RO: Surgical correction of
mandibular prognathism: an improved

58
SECTION 1  Basic Principles and Concepts
method. Am J Orthod Dentofacial Orthop
30:683, 1944.
72. Dingman RO, Harding RL: The treatment
of malunited fractures of the facial bones.
Plast Reconstr Surg 7:505–519, 1951.
73. Drommer R, Luhr HG: The stabilization of
osteotomized maxillary segments with Luhr
miniplates in secondary cleft surgery. J
Maxillofac Surg 9:166–169, 1981.
74. Drommer R: The history of the “Le Fort I
osteotomy,”.
J Maxillofac Surg 14:119–122, 1986.
75. Dufourmentel L: Le traitement chirurgical
du prognathisme. Presse Med 29:235, 1921.
76. Egyedi P, Obwegeser H: Zur operativen
zungenwerk-leinerung. Dtsch Zahn Mund
Kieferheilkd 41:16, 1964.
77. Epker BN: A modified anterior maxillary
osteotomy. J Maxillofac Surg 5:35, 1977.
78. Epker B: Modifications in the sagittal
osteotomy of the mandible. J Oral Surg
35:157–159, 1977.
79. Ernst F: Uber die chirurgische beseitigung
der prognathie des unterkiefers (progenie).
Zentralbl Chir 65:179, 1938.
80. Gadd P: Cited in Limber. J Am Dental Assoc
15:851, 1928.
81. Gillies HD: Plastic surgery of the face.
London, 1920, Oxford University Press.
82. Gillies HD, Harrison SH: Operative
correction by osteotomy of recessed malar
maxillary compound in case of oxycephaly.
Br J Plast Surg 3:123, 1950.
83. Gillies HD, Kristensen HK: Ox cartilage in
plastic surgery.
Br J Plast Surg 4:63, 1951.
84. Gillies HD, Rowe NL: L’ostéotomie du
maxillaire supérieur enoisagée essentiellement
dans le cas de bec-de-lièvre total. Rev
Stomatol 55:545–552, 1954.
85. Gillies HD, Millard DR, Jr: The principles
and art of plastic surgery. Boston, 1957,
Little, Brown.
86. Gilmer TL: Fractures of the inferior maxilla.
Ohio St J Dent Sci 2:14, 57, 112, 1882.
87. Gunning TB: The treatment of lower jaw by
interdental splints. NY Med J 3:433, 1866.
88. Halvorson EG, Mulliken JB: Cheever’s
double operation: the first Le Fort I
osteotomy. Plast Reconst Surg 121:
1375–1381, 2008.
89. Harsha, WM: Bilateral resection of the jaw
for prognathism. Surg Gynecol Obstet 15:51,
1912.
90. Hausamen JE: The scientific development of
maxillofacial surgery in the 20th century and
an outlook into the future.
J Craniomaxillofac Surg 29:2, 2001.
91. Herbert JM, Kent JN, Hinds EC: Correction
of prognathism by an intraoral vertical
subcondylar osteotomy. J Oral Surg 28:651,
1970.
92. Hinds EC: Correction of prognathism by
subcondylar osteotomy. J Oral Surg 16:209,
1958.
93. Hinds EC, Girotti WJ: Vertical subcondylar
osteotomy: a reappraisal. Oral Surg 24:164,
1967.
94. Hofer O: Die operative behandlung der
alveolare retraktion des unterkiefers und ihre
anwendungsmoglichkeit fur prognathie und
mikrogenie. Dtsch Zahn Mund Kieferheilkd
9:121–132, 1942.
95. Hofer O: Die osteoplastiche verlagerung des
unterkiefers nach von eiselberg bei
mikrogenie. Dtsch Zahn Mund Kieferheilkd
27:81, 1957.
96. Hogemann KE: Surgical orthopaedic
correction of mandibular protrusion. Acta
Chir Scand Suppl 159:26–28, 1951.
97. Hörster W: Experience with functionally
stable plate osteosynthesis after forward
displacement of the upper jaw.
J Maxillofac Surg 8:176–181, 1980.
98. 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.
99. Hunsuck EE: A modified intraoral sagittal
splitting technique for correction of
mandibular prognathism. J Oral Surg
26:250–253, 1968.
100. Jaboulay M, Berard L: Traitemente
chirurgical du prognathisme inferieur. Presse
Med 1898.
101. Jones BM: Paul Louis Tessier. J Plast Reconstr
Surg 122:1297–1299, 2008.
102. Joseph J: Verbesserung meiner
hangewangenplastik (melomioplastik). Dtsch
Med Wochenschr 54:567, 1928.
103. Kazanjian VH: Surgical correction of
deformities of the jaws and its relation to
orthodontia. Am J Orthod Oral Surg 22:259,
1936.
104. Kazanjian VH: Jaw reconstruction. Am J
Surg 3:249, 1939.
105. Kazanjian VH: The interrelation of dentistry
and surgery in the treatment of deformities
of the face and jaws. Am J Orthod Oral Surg
27:11, 1941.
106. Kazanjian VH, Converse EJ: The surgical
treatment of facial injuries. Baltimore, 1949,
The Williams and Wilkins Company.
107. Kazanjian VH: The treatment of mandibular
prognathism with special reference to
edentulous patients. J Oral Surg Oral Med
Oral Pathol 4:680–688, 1951.
108. Kazanjian VH: Remembrance of things past.
Plast Reconst Surg 35:(1)5–13, 1965.
109. Kingsley NW: A treatise on oral deformities
(as a branch of mechanical surgery). New
York, 1880, Appleton & Co.
110. Kirchner L: Die bedeutung der
gesichtsproportionen für die
wiederherstellungschirurgie. Fortschr Kiefer
Gesichtschir 7:5–14, 1961.
111. Köle H: Corticalisschwachung zur
unterstutzung bei der kieferorthopadischen
behandlung. Fortschr Kiefer Gesichtschir
4:208, 1958.
112. Köle H: Surgical operations on the alveolar
ridge to correct occlusal abnormalities. Oral
Surg Oral Med Oral Pathol 12:515–529, 1959.
113. Köle H: Results, experience and problems in
the operative treatment of anomalies with
reserve overbite. Oral Surg 18:427, 1965.
114. Köle H: Zur behandlung der
luxationsfracturen des unterkiefers. Zahnärztl
Rundsch 64:419–425, 1995.
115. Kostecka F: Die chirurgische therapie der
progenie. Zahnärztl Rundsch 16:670–688,
1931.
116. Kufner J: Four-year experience with major
maxillary osteotomy for retrusion. J Oral
Surg 29:549–553, 1971.
117. Lane WA: Cleft palate and hare lip.
London, 1905, London Medical Publishing
Co Ltd.
118. Langenbeck BV: Beitrage zur osteoplastik—
die osteoplastische resektion de oberkiefers.
In Goschen A, editor: Deutsche klinik,
Berlin, 1859, Reimer.
119. Le Fort R: Etude experimentale sur les
fractures de la machoire superieure. Rev Chir
Paris 23:214, 1901.
120. Le Fort R: Experimental study of fracture of
the upper jaw [reprint]. Plast Reconstr Surg
50:497, 1972.
121. Levignac J: Traitment d’un enforcement
consolide du tiers moyen de la face par
osteotomies et greffes. Rev Stomatol
50:551–556, 1958.
122. Limberg AA: Treatment of open bite by
means of plastic oblique osteotomy of the
ascending rami of the mandible. Dent
Cosmos 67:1191, 1925.
123. Limberg AA: New method of plastic
lengthening of the mandible in unilateral
micrognathism and asymmetry of the face.
J Am Dent Assoc 15:851, 1928.
124. Lindorf HH: Functionally stable tandem
screw fixation in sagittal ramus osteotomy:
surgical technique. Dtsch Z Mund Kiefer
Gesichtschir 8:367–373, 1984.
125. Lindorf HH: Sagittal ramus osteotomy with
tandem screw fixation: technique and results.
J Maxillofac Surg 14:311, 1986.
126. Loh FC: Surgical refinement of the anterior
maxillary subapical osteotomy. J Oral
Maxillofac Surg 51:332–334, 1993.
127. Luhr HG: Zur stabilen osteosynthese bei
unterkiefer-frakturen. Dtsch Zahnarztl Z
23:754, 1968.
128. Luhr HG: Die operative behandlung von
unterkieferfrakturen besonderer
berucksichtigung der
kompressionosteosynthese. Zentralbl Chir
94:819, 1969.
129. Luhr HG: The compression osteosynthesis of
mandibular fracture in dogs. A histologic
contribution to “primary bone healing.”
Eur Surg Res 1:3, 1969.
130. Luhr HG: Die kompressionsosteosynthese bei
unterkieferfrakturen. Munich, 1972, Hanser.
131. Luhr HG, Busch W, Maerker R:
Histologische untersuchungen zur frage de
primaren knochenheilung nach
kompressionosteosynthese. Fortschr Kiefer
Gesichtschir 19:13, 1975.
132. Luhr HG: Skelettverlagernde operationen
zur harmonisierung des gesichtsprofils—
probleme der stabilen fixation von
osteotomiesegmenten. In von Pfeifer G,
editor: Die esthetik von form und funktion in

59
CHAPTER 2  Pioneers and Milestones in the Field of Orthodontics and Orthognathic Surgery
der plastischen und wiederherstellungs—
chirurgie, Berlin, 1985, Springer-Verlag.
133. Luhr HG: A micro-system for
craniomaxillofacial surgery.
J Cranio Maxillofac Surg 16:312, 1988.
134. Luhr HG: In Fortschritte der kiefer und
gesichts-chirurgie. Stuttgart, 1994, Thieme
Verlag, pp 1–13.
135. Matasa CG, Graber TM: Angle, the
innovator, mechanical genius, and clinician.
Am J Orthod Dentofacial Orthop 117:
444–452, 2000.
136. Max D, Rotskoff K: A modified technique
for the sagittal split osteotomy. J Oral
Maxillofac Surg 51:1050, 1993.
137. McKinstry RE: Cleft palate dental care: a
historical perspective. Arlington, Va, 2000,
ABI Publications.
138. Mehnert H: Progenieoperation durch
sagittalstufenformige osteotomie in
horizontalen ast bei bezahntem unterkiefer.
Dtsch Zahn Mund Kieferheilkd 4:88, 1967.
139. Michelet FX, Deymes J, Dessus B:
Osteosynthesis with miniaturized screws and
plates in maxillofacial surgery. J Maxillofac
Surg 1:79, 1973.
140. Millard DR: Chin implants. Plast Reconstr
Surg 13:70, 1954.
141. Mohnac AM: Maxillary osteotomy in the
management of occlusal deformities. J Oral
Surg 24:305, 1966.
142. Moos KF: Origins of orthognathic surgery.
Dent Hist 37:5–18, 2000.
143. Moose SM: Correction of abnormal
mandibular protrusion by intraoral
operation. J Oral Surg 3:304–310,1945.
144. Muchnic HV: Spencer Roane Atkinson
(1886-1970). Am J Orthod 77:580–582,
1980.
145. Nance HN: The limitations of orthodontic
treatment. Am J Orthod 33:177–223,
1947.
146. Niederdellmann H, Schilli W: Zur platen
osteosynthese bei unterkieferfrakturen. Dtsch
Zahnarztl Z 28:638, 1973.
147. Niederdellmann H, Schilli W, Ewers R, et al:
Photoelastic behavior of osteosynthesis plates
with different arrangements of screw holes
for mandibular fractures. Int J Oral Surg
4:27, 1975.
148. Niederdellmann H, Shetty V: Solitary lag
screw osteosynthesis in the treatment of
fractures of the angle of the mandible: a
retrospective study. Plast Reconstr Surg 80:68,
1987.
149. Obwegeser HL: In Trauner R, Obwegeser H,
editors: Zur operationstechnik bei der
progenie und anderen unterkieferanomalien.
Dtsch Zahn- Mund- u Kieferheilk 23:1–26,
1955.
150. Obwegeser HL: The surgical correction of
mandibular prognathism and retrognathia
with consideration of genioplasty. Part 1.
Oral Surg 10:677, 1957.
151. Obwegeser HL. The indications for surgical
correction of mandibular deformity by the
sagittal splitting technique. Br J Oral Surg
1:157–171, 1964.
152. Obwegeser HL: Der offene biss in
chirurgischer sicht. Schweiz Monatschr
Zahnhlkd 74:668–687, 1964.
153. Obwegeser HL: Surgical correction of small
or retrodisplaced maxillae. Plast Reconstr Surg
53:351, 1969.
154. Obwegeser HL: Zur korrektur der dysostosis
otomandibularis. Schweiz Monatsschr
Zahnheilkd 80:331, 1970.
155. Obwegeser HL: Kieferchirurgische aufgaben
im bereich des mittelgesichtes. Arch
Otorhinolaryngol 207:229, 1974.
156. Obwegeser HL: Orthognathic surgery and a
tale of how three procedures came to be: a
letter to the next generations of surgeons.
Clin Plast Surg 34:331–355, 2007.
157. Paladin P, editor: Orthodontic history: braced
for a century, St. Louis, 2005, American
Association of Orthodontics.
158. Perko M: Maxillary sinus and surgical
movement of maxilla. Int J Oral Surg 1:177,
1972.
159. Perko M: The history of treatment of cleft
lip and palate. Prog Pediatr Surg 20:239–248,
1986.
160. Perthes G: Ueber frakturen und
luxationsfrakturen des kieferkopfchens und ihre
operative behandlung. Verh Dtsch Gesell Chir.
Berlin, 1924, Springer, pp 418–433.
161. Peterson HW: Some observations on the
progress of orthodontics during the past fifty
years. Am J Orthod 39:289–290, 1953.
162. Proffit WR, White RP, Sarver DM:
Contemporary treatment of dentofacial
deformity. St. Louis, 2003, Mosby.
163. Proffit WR, Fields HW, Sarver DM, editors:
Contemporary orthodontics, ed 4, St. Louis,
2007, Mosby/Elsevier.
164. Proffit WR, White RP, Jr: Development of
surgeon-orthodontist interaction in
orthognathic surgery. Semin Orthod
17:183–185, 2011.
165. Ricketts RM: Keystone triad: part 2. Am J
Orthod 50:728–750, 1964.
166. Ring ME: A thousand years of dental
implants: a definitive history, part 1.
Compend Contin Educ Dent 16:1060–1069,
1995.
167. Robinson M: Prognathism corrected by
vertical subcondylotomy. J Oral Surg 16:215,
1958.
168. Rosen HM: Surgical correction of the
vertically deficient chin. Plast Reconstr Surg
82:247, 1988.
169. Rowe NL, Killey HC: Fractures of the facial
skeleton, ed 2, Edinburgh and London, 1968,
Livingstone Ltd.
170. Schmid E: Zue wiederherstellung des
mittelgeisichtes nach entwicklungsstorungen
und defekten der knochernen unterbaues.
Fortschr Kiefer Gesichtschir II:240–243,
1956.
171. Schuchardt K: Ein beitrag zur chirurgischen
kieferorthopadie unter berucksichtigung ihrer
bedentung fur die behandlung angeborener
und erworbener kieferdeformitaten bei
soldaten. Dtsch Zahn Mund Kieferhlkd 9:73,
1942.
172. Schuchardt K: Die chirurgie als helferin der
kieferorthopadie. Fortschr Kieferorthop 15:9,
1954.
173. Schuchardt K: Formen des offenen bisses
und ihre operativen
behandlungsmoglechkeiten. In Schuchardt
K, editor: Fortschritt in kiefer und
gesichtschirurgie, Stuttgart, Germany, 1955,
Thieme.
174. Shankland WM: The American Association of
Orthodontists: the biography of a specialty
organization. St. Louis, 1971, The American
Association of Orthodontists.
175. Simon P: Fundamental principles of systematic
diagnosis of dental anomalies. Boston, 1926,
Stratford Co.
176. Spanier F: Prognathie-operationen. Z
Zahnarztl Orthop Munchen 24:76, 1932.
177. Spiessl B: Osteosynthese bei sagittaler
osteotomie nach Obwegeser/Dal Pont.
Fortschr Kiefer Gesichts Chir 18:145, 1974.
178. Spiessl B: The sagittal splitting osteotomy for
correction of mandibular prognathism. Clin
Plast Surg 9:496, 1982.
179. Steinhauser EW: Bone screws and plates in
orthognathic surgery. Int J Oral Surg 11:209,
1982.
180. Stoker NG, Epker BN: The posterior
maxillary osteotomy: a retrospective study of
treatment results. Int J Oral Surg 3:153,
1974.
181. Strang RH: Highlights of sixty-four years in
orthodontics. Angle Orthod 44:101–112,
1974.
182. Storum KA, Bell WH, Nagura H:
Microangiographic and histologic evaluation
of revascularization and healing after
genioplasty by osteotomy of the inferior
border of the mandible. J Oral Maxillofac
Surg 48:210–216, 1988
183. Stubtelny JD, Sakuda M: Open bite:
diagnosis and treatment. Am J Orthod
Dentofacial Orthop 50:337, 1964.
184. Tessier P, Guiot G, Rougerie J, et al:
[Cranio-naso-orbito-facial osteotomies.
Hypertelorism]. Ann Chir Plast 12:103–118,
1967.
185. Tessier P: Demonstration operations at
Hopital Foch. Paris (Suresnes) 1967.
186. Tessier P: Osteotomies totales de la face:
syndrome de Crouzon, syndrome d’Apert:
oxycephalies, scaphocephalies, turricephalies.
Ann Chir Plast 12:273–286, 1967.
187. Tessier P: Dysostosis cranio-faciales (syndromes
de Crouzon et d’Apert) osteotomies totales de la
face. Transactions of the Fourth International
Congress of Plastic and Reconstructive Surgery,
Rome, 1967/Amsterdam, 1969, Excerpta
Medica Foundation, pp 774–783.
188. Tessier P: Autogenous bone grafts taken
from the calvarium for facial and cranial
applications. Plast Reconstr Surg 48:224,
1971.
189. Tessier P: The definitive plastic surgical
treatment of the severe facial deformities
of craniofacial synostosis: Crouzon and
Apert diseases. Plast Reconstr Surg 48:419,
1971.

60
SECTION 1  Basic Principles and Concepts
190. Tessier P: Total osteotomy of the middle
third of the face for faciostenosis or for
sequelae of the Le Fort III fractures.
Plast Reconstr Surg 48:533, 1971.
191. Tessier P: Traitement des dysmorphies
faciales propres aux dysostoses craniofaciales
(DGF), maladies de Crouzon et d’Apert.
Neurochirurgie 17:295, 1971.
192. Tessier P: Recent improvement in the
treatment of facial and cranial deformities in
Crouzon disease and Apert syndrome. In
Symposium of plastic surgery of the orbital
region, St. Louis, 1976, CV Mosby Co,
pp 271.
193. Tessier P: Relationship of craniosynostosis to
craniofacial dysostosis and to faciosynostosis:
a study with therapeutic implications. Clin
Plast Surg 9:531, 1982.
194. Tessier P: Apert syndrome:
acrocephalosyndactyly, type I. In Caronni P,
editor: Craniofacial surgery, Boston, 1985,
Little, Brown.
195. Tessier P: Craniofacial surgery in syndromic
craniosynostosis: craniosynostosis, diagnosis,
evaluation and management. New York,
1986, Raven Press, pp 321.
196. Tessier P: The monobloc and frontofacial
advancement: do the pluses outweigh the
minuses? [discussion]. Plast Reconstr Surg
91:988, 1993.
197. The Division of Plastic and Reconstructive
Surgery, Department of Surgery, Washington
University School of Medicine: The legacy of
Vilray Blair. Available at
wustl.edu/Surgery_M.aspx?id=2990&menu_
id=284. Accessed December 27, 2012.
198. Trauner R, Obwegeser H: Zur
operationstechnik bei der progenie und
anderen unterkieferanomalien. Deutsche
Zahn-, Mund- und Kieferheilkunde 23:1–26,
1955.
199. 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.
200. Trauner R, Obwegeser H: The surgical
correction of mandibular prognathism and
retrognathia with consideration of
genioplasty. II. Operating methods for
microgenia and distoocclusion. Oral Surg
Oral Med Oral Pathol 10:787–792, 1957.
201. Von Eiselberg E: Cited in Limberg. J Am
Dental Assoc 15:851, 1928.
202. Wahl N: Orthodontics in 3 millennia.
Chapter 1: Antiquity to the mid-19th
century. Am J Orthod Dentofacial Orthop
127:255–259, 2005.
203. Wahl N: Orthodontics in 3 millennia.
Chapter 2: Entering the modern era. Am J
Orthod Dentofacial Orthop 127:510–515,
2005.
204. 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.
205. Wassmund M: Frakturen und luxationen des
gesichtsschadels. Berlin, 1927.
206. Wassmund M: Die totale mobilisation des
oberkiefers. Lehrbuch der praktischen chirurgie
des mundes und der kiefer. Leipzig, 1935,
Meusser, pp 282–284.
207. Wassmund M: Die korrektur der
mikrognathie. Lehrbuch der praktischen
chirurgie des mundes und der kiefer. Leipzig,
1939, Barth, pp 493–494.
208. Weinberger BW: Orthodontics: a historical
review of its origin and evolution, including an
extensive bibliography of orthodontic literature
up to the time of specialization. St. Louis,
1926, The CV Mosby Company.
209. Weinberger BW: Historical resume of the
evolution and growth of orthodontia. J Am
Dent Assoc 21:2001–2021, 1934.
210. Weinberger BW: Dr Edward Hartley Angle:
his influence on orthodontics. Am J Orthod
36:596–607, 1950.
211. Weinstein I: C-osteotomy for correction of
mandibular retrognathia: report of cases.
J Oral Surg 29:358, 1971.
212. Whipple JW: Double resection of the
inferior maxilla for protruding lower jaw.
Dent Cosmos 40:552–557, 1898.
213. Wikkeling OME, Tacoma J: Osteotomy of
the pterygomaxillary junction. Int J Oral
Surg 4:99, 1975.
214. Wolfe SA: Gunther Cohn-Stock, M.S.,
D.D.S., father of maxillary orthognathic
surgery. J Cranio Maxillofac Surg 17:
331–334, 1989.
215. Wolfe SA: Paul Tessier, creator of a new
surgical specialty, is recipient of Jacobson
innovations award. J Craniofacial Surg
12(1):98–99, 2001.
216. Wolfe SA: Paul Louis Tessier, MD, 1917 to
2008. J Plast Reconstr Surg 122:1294–1296,
2008.
217. Worms FW, Meskin CH, Isaacson RJ:
Open bite. Am J Orthod Dentofacial Orthop
59:589, 1971.
218. Wright CF: Status of orthodontic education
prior to 1930. Angle Orthod 17:92–96,
1947.
219. Wunderer S: Die prognathie-operation
mittels frontal gestieltem maxillofragment.
Oesterr Z Stomatol 59:98–102, 1962.
220. Wunderer S: Erfahrungen mit der operativen
behandlung hochgradiger prognathien.
Dtsch Zahn Mund Kieferheilkd 39:451,
1963.

61

3
Definition and Prevalence of
Dentofacial Deformities
JEFFREY C. POSNICK, DMD, MD
• Prevalence of Jaw Deformities and
Malocclusion
• Orthognathic Procedures Performed on
Hospitalized Patients in the United States
• Conclusions
and dentistry alone?” A cosmetic surgeon who evaluates the
same patient must ask himself or herself, “Will limited soft-
tissue or augmentation procedures alone be sufficient to
properly manage the presenting dysmorphology and to
address functional aspects?”
If the discrepancy in the size or position of the jaws as
they relate to each other and to the upper facial skeleton
results in significant facial disproportion and also negatively
affects certain head and neck functions (e.g., speech, swal­
lowing, chewing, lip closure and posture, breathing), then
it should not be ignored. It would be misguided to consider
orthodontics alone to alter the occlusion without fully
informing the patient and his or her family of the preferred
biologic approach to management (i.e., orthodontics and
jaw surgery). Likewise, it would be avoiding the obvious for
the cosmetic surgeon to recommend either soft-tissue aes­
thetic or skeletal contour procedures without discussion of
the presenting malocclusion, airway dysfunction, and
overall facial disproportion. The treatment recommended
to the patient and his or her family should not be limited
by the skill set of the initial consulting clinician.
Facial disproportion observed in a child may at times be
self-correcting. For example, apparent mandibular defi­
ciency that is present before the pubertal growth spurt may
normalize. In some cases, the maxilla or mandible may be
induced to grow a few millimeters, more or less, through
dentofacial orthopedics. However, major transformation of
the jaws with the use of growth-modification techniques
cannot be expected. Proffit has pointed out that, even with
the well-intended aim of dentofacial orthopedics to alter
jaw growth, as a result of anchorage requirements and bio­
logic realities coupled with the practical desire of the ortho­
dontist to “correct the occlusion,” the treatment generally
results in the displacement of the teeth in the direction of
correcting the occlusion rather than the jaw relationships.53
The term dental compensation for the skeletal discrepancy is
universally understood to explain this treatment approach.
Orthodontic-introduced dental compensation for the
occlusion will hinder the eventual skeletal (orthognathic)
correction if this is later required or requested.
The term dentofacial deformity refers to significant
deviations from normal proportions of the maxillo­
mandibular complex that also negatively affect the
relationship of the teeth within each arch and the rela­
tionship of the arches with one another (occlu­
sion).2,4,5,8,11,14,15,17,18,21,22,25,27,31,36,37,40,52,54
The
affected
individual will have varied degrees of compromise in head
and neck functions related to breathing, swallowing, speech
articulation, chewing, and lip closure/posture. Effects on
the temporomandibular joints, the periodontium, and the
teeth themselves may also occur.24,25,28,33,34,38,55 The present­
ing facial disproportion will, in general, have at least some
negative effects on psychosocial health.16,39,56,57
Racial variations with regard to the incidence of facial
dysmorphology and the resulting malocclusion are also
known to occur.59,64 Definitions of acceptable levels of devi­
ation from normal continue to be questioned by both clini­
cians and pa­tients.7,26,30,32,35,58,61,62 Over the years, the
National Center for Health Statistics has collected data and
the Research Council has held multidisciplinary confer­
ences to focus attention on these issues.6,12,19,20,29,41-51,53,63
Surgery to reposition the jaws (i.e., an orthognathic pro­
cedure) as part of an interdisciplinary approach is often
recommended to manage the related skeletal, dental, and
soft-tissue dysfunctions and concerns.3,13,23,60,66 Speech
therapy, dental work, orthodontics, and surgical procedures
alone are generally inadequate as isolated treatment
modalities.
A dental clinician who is asked to evaluate the affected
individual must ask himself or herself, “Are the problems
too severe to be most effectively managed with orthodontics

62
SECTION 1  Basic Principles and Concepts
negative effects on periodontal health (e.g., labial cortical
bone stripping), the airway (e.g., retroglossal obstruction),
and facial aesthetics (e.g., a weak profile).39,56,57 It also com­
promises the option of an orthognathic correction with the
need to first “undo” the dental compensations through
“redo” orthodontics (Fig. 3-1).
In the growing child who presents with a Class II maloc­
clusion pattern, an active treatment approach is often
offered by the orthodontist. This approach may attempt
Informed consent from the patient or his or her family
is strongly recommended before embarking on a compro­
mised treatment plan. For example, if a child is recognized
to have an underdeveloped mandible with a Class II maloc­
clusion and standard growth modification is attempted, it
may be difficult for the orthodontist to prevent at least some
retraction of the upper incisors and the forward displace­
ment of the lower teeth. This may result in an “improved”
occlusion, but it may also potentially involve long-term
• Figure 3-1  A 21-year-old woman with a primary mandibular deficiency growth pattern requested a surgical consultation
for a “weak chin.” During her early teenage years, she underwent unsuccessful growth modification in an attempt to stimulate
the forward projection of the mandible. This was followed by an orthodontic camouflage approach. The mandibular anterior
dentition was flared forward. The history was significant for restless sleeping and a degree of daytime fatigue, which are sug­
gestive of obstructive sleep apnea. Examination confirmed a retrognathic mandible with a Class II malocclusion. The mandibu­
lar incisors were crowded and procumbent. The family had hoped that a “chin implant” would be effective to manage the
aesthetic effects. A sleep study confirmed obstructive sleep apnea (respiratory disturbance index = 18/hour). An orthognathic
approach (Le Fort I, Sagittal splits, Osseous genioplasty) with redo orthodontic treatment including lower bicuspid extractions
was recommended as the preferred method to improve the airway, to achieve long-term dental health, and to enhance facial
aesthetics. A, Frontal facial and occlusal views. B, Profile facial view and lateral cephalometric radiograph.
A
Or
Or
Or
O ththththththth
r ogn
gn
gn
gn
gn
gn
g atatatatatatatatatatatathicicicic Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
r ; J.C.
C.
C.
C.
C.
C Pos
os
os
o nicicick
B
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O ththththththththththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gnatatatatatatatatatatatatatatatathicicicicicicicicicicicicicici Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
o nicicicicicicick

63
CHAPTER 3  Definition and Prevalence of Dentofacial Deformities
a limited degree of mandibular retrusion. In these cases,
the extraction of maxillary premolars with the retraction
of the incisors to a corrected inclination in combination
with the minimal forward displacement of the lower
teeth may result in both favorable occlusion and acceptable
facial aesthetics.
For the experienced surgeon and orthodontist, the accu­
rate diagnosis of a dentofacial deformity will usually be clear
after the initial examination and a review of standard
records. A favorable correction through the effective
to alter jaw growth and to correct the occlusion by means
of the following: (1) functional appliance use (e.g., Frankel,
Twinblocks) to stimulate sagittal growth of the mandible;
(2) the possible extraction of maxillary premolars with
orthodontic incisor retraction; (3) the use of headgear to
restrain maxillary sagittal growth; and (4) the orthodontic
forward displacement of the lower anterior teeth (Fig. 3-2).
With the use of this approach, favorable facial results will
be seen in only a very specific patient subgroup that includes
those patients with true maxillary dental protrusion and
• Figure 3-2  A 20-year-old man with a primary mandibular deficiency growth pattern requested a surgical consultation for
a “weak chin.” During his early teenage years, he underwent unsuccessful growth modification in an attempt to stimulate the
forward projection of the mandible. This was followed by an orthodontic camouflage approach that included maxillary first
bicuspid extractions to retract the anterior teeth. In addition, the mandibular anterior dentition was flared forward. His history
was significant for heavy snoring, restless sleeping, and a degree of daytime fatigue, all of which are suggestive of obstructive
sleep apnea. Examination confirmed a retrognathic mandible with a molar Class II deep bite malocclusion. The mandibular
incisors were crowded and procumbent. The family had hoped that a “chin implant” would be effective to manage the aes­
thetic effects. A sleep study was recommended. An orthognathic approach (Le Fort I, Sagittal splits, osseous genioplasty)
with redo orthodontic treatment was suggested as the preferred method to improve the airway, to achieve long-term dental
health, and to enhance facial aesthetics. A, Frontal facial and occlusal views. B, Profile facial view and lateral cephalometric
radiograph.
A
Orthth
r ogn
gn
gn
gn
g atathicic Su
Su
Su
Surg
r ery
ry
ry
ry; J.C.
C.
C Pos
os
os
os
os
o nicicici k
B
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orthththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gnatatatatatatatatatathicicicicicicicicici Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry; J.C.
C.
C Pos
os
os
os
o nicicick

64
SECTION 1  Basic Principles and Concepts
after growth completion). This data confirms that, in
some children, a late mandibular growth spurt not only
corrects the excess positive overjet but actually causes it to
become negative. Fortunately, in at least some of the chil­
dren with an excess overjet, “catch-up” mandibular growth
corrects the occlusion without overshooting the mark. The
NHANES III study also documents that significant reverse
overjet is more prevalent among blacks and Latino Ameri­
cans as compared with whites. This confirms the more
frequent dentofacial deformity growth pattern of maxillary
deficiency in combination with relative mandibular excess
that is seen among blacks and Latinos as compared with
whites.
According to the NHANES III study, only a third of the
members of the U.S. population have ideal (horizontal)
anteroposterior incisor relationships, and another third of
these individuals have a moderate overjet discrepancy (i.e.,
borderline jaw dysharmony). The remaining third have
either a severe positive overjet or a reverse overjet malocclu­
sion. It is reasonable to assume that a significant percentage
of this subgroup (i.e., those with a severe positive overjet
or a reverse overjet) have a jaw discrepancy that would
benefit from orthognathic surgery. In reality, many indi­
viduals in this subgroup will be treated with compromised
orthodontics (i.e., dental compensation) in an attempt
to neutralize the occlusion without the benefit of an
orthognathic correction. This will result in suboptimal facial
aesthetics and the potential for occlusal instability, long-
term periodontal sequela, and compromise of the upper
airway.
The Vertical Dimension
According to the NHANES III study, only half of the U.S.
population has an ideal vertical relationship of the incisors
(i.e., 0- to 2-mm overbite). In the others, a deep bite in
combination with mandibular deficiency or maxilloman­
dibular deficiency is more prevalent among whites, and an
open bite in combination with bimaxillary dental protru­
sion is more frequent among blacks. Interestingly, either a
severe deep bite (≥5 mm) or a marked open bite (≥2 mm)
was present in approximately 20% of children and 13% of
adults. The extreme values of open bite that were measured
in the study group likely represent either a long face growth
pattern (i.e., vertical maxillary excess or mandibular defi­
ciency; see Chapter 21) or bimaxillary dental protrusion
(see Chapter 24). Interestingly, significant anterior open
bite as part of a long face growth pattern is more prevalent
among white Americans. The extreme values of deep bite
in the studied individuals are likely to represent either a
short face growth pattern (i.e., maxillomandibular defi­
ciency; see Chapter 23) or a primary mandibular deficiency.
Significant degrees of vertical discrepancy (deep bite or
open bite) at the incisors ideally benefit from orthognathic
surgery. When dental compensating orthodontic treatment
is instituted rather than orthognathic correction, compro­
mised facial aesthetics, occlusal instability, and periodontal
sequela are more likely to occur.
ortho­dontic alignment of the teeth in combination with the
surgical repositioning of the jaw(s) will be the preferred
approach.
Prevalence of Jaw Deformities
and Malocclusion
U.S. Population Survey
As part of a large-scale evaluation of the health of the U.S.
population, a National Health and Nutrition Examination
Survey (NHANES III) was carried out between 1989 and
1994.53 Starting with a sampling of 14,000 individuals,
estimates of the incidence of malocclusion and its severity
were made. The sample of individuals was carefully selected
to provide weighted estimates for an approximate
150,000,000 people between the ages of 8 and 50 years who
were members of black, white, and Latino American racial
and ethnic groups. Those individuals outside of that age
range (i.e., those younger than 8 years and older than 50
years), Native Americans, those living on military reserva­
tions, and some other specific population groups were
excluded from this study. Data collected included the
following:
• The alignment of the incisor teeth
• The horizontal position of the incisors (i.e., overjet or
reverse overjet)
• The vertical overlap of the incisors (i.e., deep bite or
open bite)
• The presence of posterior crossbite
• The presence of maxillary midline diastema
The Horizontal/Sagittal Dimension
This study provides useful information about preadolescent
children (8 to 11 years old), adolescents (12 to 17 years old),
and adults (18 to 50 years old) with reference to how the
teeth fit together and, by inference, the prevalence of den­
tofacial deformities. When interpreting the data collected
for the NHANES III study, it is important to consider that
at least some degree of dental compensation for an existing
jaw deformity normally occurs during growth and is
expected to have been present at the time that the study
measurements were taken. Therefore, it is unlikely that
either the moderate or greater values of positive overjet or
the mild to moderate values of negative overjet measured in
the NHANES III study were found in individuals with
“normal” jaw relationships. It would be safe to assume that
any individual in the study with more than 7 mm of posi­
tive overjet has a jaw discrepancy that is characterized by
mandibular deficiency (see Chapter 19). In addition, those
with 2 mm or more of reverse overjet are assumed to have
elements of maxillary deficiency in combination with rela­
tive mandibular excess (see Chapter 20).
The NHANES III study documents that extreme posi­
tive overjet is more frequent among children and that
reverse overjet becomes more common among adults (i.e.,

65
CHAPTER 3  Definition and Prevalence of Dentofacial Deformities
• Severe contact point discrepancy (>4 mm)
• Less extensive hypodontia (e.g., one tooth per quad­
rant requiring preprosthetic orthodontics)
• Partially erupted teeth that are tipped and impacted
against adjacent teeth
• The presence of supernumerary teeth
Individuals with extremes in positive overjet, reverse
overjet, crossbite, and open bite as well as those with associ­
ated cleft lip and palate are considered to have Grade 4 and
5 conditions and judged to have problems that are severe
enough that definitive treatment is needed. By inference, it
is likely that a significant number of individuals with Grade
4 and 5 issues would ideally receive both orthodontics and
jaw-straightening surgery.
The second part of the authors’ overall assessment of
treatment priority was to record the aesthetic impairment
contributed by the malocclusion. The authors used the
Standard Continuum of Aesthetic Need (SCAN) index as
a rating scale.16 The SCAN scale was constructed with the
use of dental photographs from 1000 12-year-old children
that were collected as part of a large multidisciplinary
survey. Six non-dental judges rated these photographs on a
10-point visual analog scale. Both the aesthetic impairment
component and the dental health component were part of
the overall study.
The distribution of ratings for the Dental Health Indica­
tions Study conducted by Brook and Shaw were obtained
from examination subjects (n = 222) who, at minimum,
were felt to have a malocclusion to the extent that referral
to a regional orthodontic center for advice or treatment was
recommended.10 Each study patient was then examined,
and their available radiographs were reviewed by skilled
clinicians. Both components of the index (i.e., aesthetic and
dental) were applied, and the patients were also asked to
give their own rating according to the SCAN scale. Interest­
ingly, there was a high correlation (confirmed by intraex­
aminer and interexaminer error testing of the findings)
between both components (i.e., aesthetic and dental) of the
study.
The study results indicated that 19.2% of the subjects
(44 of 222) were considered to have Grade 5 conditions.
Interestingly, the distribution of ratings from Grades 1
through 5 that were obtained from the examination of
a matched, random, unselected group of schoolchildren
(n = 333) indicated that only 5.1% fell in the Grade 5
category. A Grade 5 score indicates severe malocclusion with
a high need for treatment to establish dental health. Most
of the traits listed as Grade 5 cannot be corrected with
orthodontics alone, and orthognathic surgery would likely
be recommended or at least considered. The Shaw study
indicates that, in the United Kingdom, more than 5% and
as high as 19% of children who have been referred to an
orthodontist for evaluation are likely to have a malocclusion
to the extent that orthodontics alone would not be the first
choice for full correction (i.e., there is a need for orthogna­
thic surgery).10
U.K. Population Survey
An Index of Treatment Need was developed by the Swedish
Dental Board to classify the severity of dental findings by
the worst presenting characteristic.33 This method tends to
downplay the specific alignment of individual teeth. It is a
classification system that looks more globally at facial pro­
portions and head and neck function than at isolated dental
details. For example, if you have a mild irregularity of the
incisors and only a mildly excessive overjet, you are judged
to have only a mild problem. In other words, the impact
on the individual is not judged to be more severe, because
there is a combination of two mild occlusal deviations from
normal. Alternatively, if you have a 10-mm overjet, even if
the teeth are aligned in each jaw, you are judged to have a
severe problem.
Brook and Shaw made modifications to the Swedish
classification and developed the Index of Treatment Need
for malocclusion to be used as a grading system of dental
health and functional indications for treatment.9,10 The first
part of their study was derived from the direct examination
of occlusion and dental alignment. They defined five grades
of treatment need, with Grade 1 representing little or no
need for treatment and Grade 5 representing great need for
treatment. The authors attempted to establish meaningful
values for cutoff points between grades for each occlusal
trait and to determine the quantifiable threat to the denti­
tion if no treatment is provided. Grades 4 and 5 have
characteristics that can result in a more severe impact on
both facial aesthetic and dental aspects. These characteristics
include the following:
Grade 5:
• Defects of cleft lip and palate*
• Overjet of more than 9 mm*
• Reverse overjet of more than 3.5 mm with reported
masticatory and speech difficulties*
• Extensive hypodontia*
• Impeded eruption of the permanent teeth
• Submerged primary teeth
Grade 4:
• Extreme lateral or anterior open bites (>4 mm)*
• Increased overjet (>6 mm but ≤9 mm)*
• Reverse overjet (>3.5 mm with no masticatory or
speech difficulties)*
• Reverse overjet of more than 1 mm with reported
masticatory or speech difficulties
• Posterior crossbite with no functional occlusal con­
tacts in one or both buccal segments
• Increased and complete overbite with gingival or
palatal trauma
• Anterior or posterior crossbites with more than 2 mm
of centric relation/centric occlusion discrepancy
*Occlusal traits consistently found in association with a dentofacial
deformity.

66
SECTION 1  Basic Principles and Concepts
procedures were for the correction of a syndromal form of
jaw deformity.
Ninety-six percent of patients were discharged routinely
without the need for a “home health care facility” or transfer
to either a long-term or acute-care facility. The mean length
of hospital stay was 2.95 days, and the mean hospital bill
generated costs of $47,348.00. This was assumed to include
all costs related to the hospital, operating room, and anes­
thesia, but it did not include the surgeons’ fees. The hospital
bill generated did not necessarily correlate with the amount
actually paid by either the third-party insurance company
or the self-paying patient. Data regarding the actual pay­
ments is not available. From the available data, the total
estimated hospitalization charges for orthognathic proce­
dures carried out in the United States during 2008 were
estimated to be $466.8 million (not including the surgeons’
fees). Surgeons in “teaching hospitals” performed 67.1% of
the procedures, and surgeons in “large-bed hospitals” per­
formed 70% of the procedures. Hospitals in urban areas
accounted for 97.4% of the hospital admissions.
It must be understood that the study by Venugoplan
and colleagues did not capture those orthognathic proce­
dures carried out either in an outpatient setting (i.e., not
requiring admission to hospital) or procedures that were
performed exclusively in a “surgicenter.” These parameters
were outside of the NIS database. It is estimated that as
many as another 20% of orthognathic procedures were
likely completed in these outpatient or surgicenter settings
during this time period, which could result in 2000 addi­
tional patients.
Conclusions
The term dentofacial deformity refers to significant devia­
tions from the normal proportions of the maxillomandibu­
lar complex that also negatively affect the relationship of the
teeth within each arch as well as the relationships of the
archs with one another (i.e., occlusion). The affected indi­
viduals will have varying degrees of compromise in their
head and neck functions related to breathing, swallowing,
speech, chewing, and lip closure and posture. A negative
impact of the maxillofacial dysmorphology on psychosocial
health is also to be expected. Studies confirm that, at a
minimum, 5% of both the U.S. and U.K. general popula­
tions will have dentofacial deformities that are associated
with severe malocclusion and that require orthognathic
surgery. It is likely that as high as 19% of individuals who
present for orthodontic assessment would ideally require
not just orthodontics but jaw-straightening procedures
as well.
Orthognathic Procedures Performed
on Hospitalized Patients
in the United States
Venugoplan and colleagues completed a study with the aim
of providing a nationally representative estimate of the
number and type of orthognathic procedures performed on
hospitalized patients in the United States.65 Their data was
obtained from the Nationwide Inpatient Sample (NIS)
database from 2008 and included all hospitalizations for
orthognathic procedures. The procedures were identified via
the procedure code listed in the International Classification
of Diseases, 9th Revision, Clinical Modification.1 The NIS
database is sponsored by the Agency for Healthcare Research
and Quality, a division of the Department of Health and
Human Services of the U.S. government. Ten thousand
three hundred and forty-five (10,345) hospitalizations for
orthognathic procedures were identified as occurring during
the 2008 calendar year. The average age of these patients
was 26.7 years, and female patients comprised 56.2% of all
those who were hospitalized for these procedures. Whites,
blacks, Hispanics, Asians, Pacific Islanders, and Native
Americans and other races constituted 71.9%, 4.9%,
12.6%, 5.6%, 0.4%, and 4.6% of the hospitalizations,
respectively. Private insurance plans were the primary payers
(77.3%). Government insurance plans (i.e., Medicare and
Medicaid) accounted for 13.4% of the patient mix, whereas
3.5% of patient paid privately (i.e., out of pocket), without
the benefit of medical insurance.
Le Fort I osteotomy without segmentation accounted for
15.3% of the procedures; 45.8% of the procedures were Le
Fort I with segmentation; and 31.7% of the procedures
were ramus osteotomies of the mandible (e.g., sagittal split
ramus osteotomies or vertical oblique osteotomies). It was
found that 53.3% of the patients underwent one jaw
surgery, whereas 36.8% likely underwent bimaxillary oste­
otomies. It would appear that only 9.2% of the patients
underwent combined upper jaw, lower jaw and chin proce­
dures. Only 0.7% underwent additional other simultaneous
procedures, including such possibility as septoplasty, infe­
rior turbinate reduction, neck liposuction, and the removal
of wisdom teeth.
The pattern of jaw deformity for which the patient
underwent orthognathic surgery could to a certain extent
be delineated. It would appear that 33.1% of the skeletal
patterns were Class III anomalies, whereas 23.8% involved
skeletal Class II anomalies. The vast majority of orthogna­
thic procedures were for the correction of routine dentofa­
cial deformities. Approximately 10% of the orthognathic
References
1. Agency for Healthcare Research and Quality:
NIS Database Documentation: The Nationwide
Inpatient Sample (NIS). Available at

nisdbdocumentation.jsp. Accessed November
29, 2012.
2. Allwright WC, Bundred WH: A survey of
handicapping dentofacial anomalies among
Chinese in Hong Kong. Int Dent J 14:505–
519, 1964.
3. American Association of Oral and
Maxillofacial Surgeons: Residency procedure

67
CHAPTER 3  Definition and Prevalence of Dentofacial Deformities
report, Chicago, 2007, American Association
of Oral and Maxillofacial Surgeons.
4. Angle EH: Classification of malocclusion.
Dent Cosmos 41:248–264, 1899.
5. Ast D-B, CMOS JP, Cons NC: The
prevalence and characteristics of malocclusion
among senior high school students in upstate
New York. Am J Orthod 51:437–445, 1965.
6. Baume LJ, Horowitz HS, Summers CJ, et al:
A method of examining occlusal traits
developed by the FDI commission on
classification and statistics for oral conditions
(COCSTOQ). Int Dent J 23:530–537, 1973.
7. Bjork A, Krebs AA, Solow B: A method for
epidemiological registration of malocclusion.
Acta Odontol Scand 22:27–41, 1964.
8. Bolton WA: Disharmony in tooth size and its
relation to the analysis and treatment of
malocclusion. Angle Orthod 28:113–130,
1958.
9. Brook PH: The development of an
orthodontic treatment priority index. MSc
thesis. University of Manchester, 1987.
10. Brook PH, Shaw WC: The development of an
index of orthodontic treatment priority. Eur J
Orthod 11:309–320, 1989.
11. Carlos JP: Evaluation of indices of
malocclusion. In Transactions of the Second
FDI Conference on Oral Epidemiology,
Epidemiological Assessment of Dentofacial
Anomalies 20(4):606–615, 1969.
12. Cirainger RM: The statistical basis for
international dental epidemiology. World
Health Organization Document No. PA/98.6
13. DeLuke DM: Orthognathic surgery: the state
of the art. N Y State Dent J 64:30, 1998.
14. Draker HL: Handicapping labio-lingual
deviations, a proposed index for public health
purposes. Am J Orthod 46:295–305, 1960.
15. Emrich RE, Brodie AG, Blayney JR:
Prevalence of class I, class II, and class III
malocclusions (Angle) in an urban population:
an epidemiological study. J Dent Res
44:947–953, 1965.
16. Evans MR, Shaw WC: Preliminary evaluation
of an illustrated scale for rating dental
attractiveness. Eur J Orthod 9:314–318, 1987.
17. Foster TD, Walpole Day AJ: A survey of
malocclusion and the need for orthodontic
treatment in a Shropshire school population.
Br J Orthod 3:73–78, 1973.
18. Gardiner JH: A survey of malocclusion and
some aetiological factors in 1000 Sheffield
school children. Dent Practit 6:187–201,
1956.
19. Grainger RM: Indexing handicapping
malocclusions. Working paper for meeting of
Expert Committee on Dental Health, Geneva,
1961, World Health Organization.
20. Grainger RM: Orthodontic treatment priority
index. Public Health Service Publication No.
1000, Series 2, No 25, Washington, DC,
1967, U.S. Government Printing Office.
21. Gravely JF, Johnson DB: Angle’s classification
of malocclusion: an assessment of reliability.
Br J Orthod 3:79–86, 1974.
22. Grewe JM, Cervenka J, Shapiro BL, et al:
Prevalence of malocclusion in Chippewa
Indian children. J Dent Res 47:302–305,
1968.
23. Hausamen JE: The scientific development of
maxillofacial surgery in the 20th century and
an outlook into the future. J Craniomaxillofac
Surg 29:2–21, 2001.
24. Haynes S: Discontinuation of orthodontic
treatment in the General Dental Service in
England and Wales 1972-1979. Br Dent J
152:127–129, 1982.
25. Helm S, Kreiborg S, Barlebo J, et al:
Estimates of orthodontic treatment need in
Danish schoolchildren. Community Dent Oral
Epidemiol 3:136–142, 1975.
26. Helm S: Intra-examiner reliability of
epidemiological registrations of malocclusion.
Acta Odontol Scand 35:161–165, 1977.
27. Horup N, Melsen B, Terp S: Relationship
between malocclusion and maintenance of
teeth. Community Dent Oral Epidemiol
15:74–78, 1987.
28. Jarvinen S: Traumatic injuries to upper
permanent incisors related to age and incisal
overjet. Acta Odontol Scand 37:335–338,
1979.
29. Kelley JE, Sanchez M, Van Kirk GE: An
assessment of the occlusion of teeth of children
6-11 years. U.S. Department of Health,
Education, and Welfare, Public Health Service
publication (HRA) No. 74-1612, Washington,
DC, 1973, National Center for Health
Statistics.
30. Kelley JE, Harvey CR: An assessment of the
occlusion of teeth of youths 12-17 years. U.S.
Department of Health, Education, and Welfare,
Public Health Service publication (HRA) No.
77-1644, Washington, DC, 1977, National
Center for Health Statistics.
31. Kelly JF, Helfrick JF, Smith DW, Jones BL:
A survey of oral and maxillofacial surgeons
concerning their knowledge, beliefs, attitudes,
and behavior relative to parameters of care.
J Oral Maxillofac Surg 50:50–58, 1992.
32. Lau D, Griffiths G, Shaw WC:
Reproducibility of an index for recording the
alignment of individual teeth. Br J Orthod
11:80–84, 1984.
33. Linder-Aronson S: Orthodontics in the
Swedish Public Dental Health System. Trans
Eur Orthod Soc 233–240, 1974.
34. Lundstrom A: Need for treatment in cases of
malocclusion. Trans Eur Orthod Soc
53:111–123, 1977.
35. Malmgren O: Studies on the need and
demand for orthodontic treatment. Swed Dent
J Suppl (6):1–121, 1980.
36. Massler M, Frankel JM: Prevalence of
malocclusion in children aged 14-18 years.
Am J Orthod 37:751–768, 1951.
37. Mills LF: Epidemiologic studies of occlusion:
IV. The prevalence of malocclusion in a
population of 1,455 school children. J Dent
Res 45:332–336, 1966.
38. Mohlin B, Thilander B: The importance of
the relationship between malocclusion and
mandibular dysfunction and some clinical
applications in adults. Eur J Orthod
16:192–204, 1984.
39. Montegi E, Hatch JP, Rugh JD, Yamaguchi
H: Health-related quality of life and
psychosocial function 5 years after
orthognathic surgery. Am J Orthod Dentofacial
Orthop 124:138–143, 2003.
40. Moyers RE, van der Linden FPGM, Riolo
ML, et al: Standards of human occlusal
development, Ann Arbor, MI, 1976, University
of Michigan Center for Human Growth and
Development, 1976.
41. National Center for Health Statistics: Volume
of dental visits, United States, July 1963-June
1964. Vital and Health Statistics. PHS Pub No
1000-Series 10-No 23. Public Health Service,
Washington, DC, 1965, U.S. Government
Printing Office.
42. National Center for Health Statistics: Decayed,
missing, and filled teeth in adults. Vital and
Health Statistics. PHS Pub No 1000-Series
11-No 23. Public Health Service, Washington,
DC, 1967, U.S. Government Printing Office.
43. National Center for Health Statistics: Plan,
operation and response results of a program of
children’s examinations. Vital and Health
Statistics. PHS Pub No 1000-Series l-No 5.
Public Health Service, Washington, DC, 1967,
U.S. Government Printing Office.
44. National Center for Health Statistics: The
orthodontic treatment priority index. Vital and
Health Statistics. PHS Pub No 1000-Series
2-No 25. Public Health Service, Washington,
DC, 1967, U.S. Government Printing Office.
45. National Center for Health Statistics: Plan
and operation of a health examination survey of
US youths 12-17 years of age. Vital and Health
Statistics. PHS Pub No 1000-Series l-No 8.
Public Health Service, Washington, DC, 1969,
U.S. Government Printing Office.
46. National Center for Health Statistics: Decayed,
missing, and filled teeth among children. Vital
and Health Statistics. Series 11-No 106.
DHEW Pub No (HSM) 72-1003. Health
Services and Mental Health Administration,
Washington, DC, 1971, U.S. Government
Printing Office.
47. National Center for Health Statistics: Dental
visits, volume and interval since last visit,
United States, 1969. Vital and Health Statistics.
Series 10-No 76. DHEW Pub No (HSM)
72-1066. Health Services and Mental Health
Administration, Washington, DC, 1972, U.S.
Government Printing Office.
48. National Center for Health Statistics: Plan
and initial program of the health examination
survey. Vital and Health Statistics. Series l-No 4.
DHEW Pub No (HRA) 74-1038. Health
Resources Administration, Washington, DC,
1973, U.S. Government Printing Office.
49. National Center for Health Statistics: An
assessment of the occlusion of the teeth of
children 6-11 years, United States. Vital and
Health Statistics. Series 1l-No 130. DHEW Pub
No (HRA) 74-1612. Health Resources
Administration, Washington, DC, 1973, U.S.
Government Printing Office.
50. National Center for Health Statistics: Decayed,
missing, and filled teeth among youths 12-17
years, United States. Vital and Health Statistics.

68
SECTION 1  Basic Principles and Concepts
Series 1l-No 144. DHEW Pub No (HRA)
75-1626. Health Resources Administration,
Washington, DC, 1974, U.S. Government
Printing Office.
51. National Center for Health Statistics: Vital
statistics of the United States, 1971, Vol. I,
Nationality. DHEW Pub No (HRA) 75-1113.
Health Resources Administration, Washington,
DC, 1975, U.S. Government Printing Office.
52. Newman GV: Prevalence of malocclusion in
children six to fourteen years of age and
treatment in preventable cases. J Am Dent
Assoc 52:566–575, 1965.
53. Proffit WR, Fields HW, Jr, Moray LJ:
Prevalence of malocclusion and orthodontic
treatment need in the United States: Estimates
from the NHANES III survey. Int J Adult
Orthod Orthognath Surg 13:97–106, 1998.
54. Salzmann JA: Handicapping malocclusion
assessment to establish treatment priority. Am
J Orthod 54:749–765, 1968.
55. Sandali T: Irregularities of the teeth and their
relation to the periodontal condition with
particular reference to the lower labial
segment. Trans Eur Orthod Soc 319–333,
1973.
56. Shaw WC, Addy M, Ray C: Dental and social
effects of malocclusion and effectiveness of
orthodontic treatment: a review. Community
Dent Oral Epidemiol 8:36–45, 1980.
57. Shaw WC, Addy M, Dummer PMH, et al:
Dental and social effects of malocclusion and
effectiveness of orthodontic treatment: a
strategy for investigation. Community Dent
Oral Epidemiol 14:60–64, 1986.
58. Singh IJ, Savara BS: Norms of size and annual
increments of seven anatomical measures of
maxillae in girls from 3 to 17 years of age.
Angle Orthod 36:312, 1968.
59. Siriwat PP, Jarabak JR: Malocclusion and
facial morphology: is there a relationship? An
epidemiologic study. Angle Orthod 55:127–
138, 1985.
60. Sullivan SM: Orthognathic surgery dilemma:
increasing access. J Oral Maxillofac Surg
69:813–816, 2011.
61. Summers CJ: The occlusal index: a system for
identifying and scoring occlusal disorders. Am
J Orthod 57:552–567, 1971.
62. The American Association of Orthodontists:
Study of the availability of orthodontists’
services. Am J Orthod 68(3):326–338,
1975.
63. U.S. National Health Survey: Dental care,
interval and frequency of visits, United
States, July 1957-June 1958. PHS Pub No
584-1314. Public Health Service, Washington,
DC, 1960, U.S. Government Printing
Office.
64. Van Kirk LE, Jr, Pennell EH: Assessment of
malocclusion in population groups. Am J Pub
Health 49(9):1157–1163, 1959.
65. Venugoplan SR, Nanda V, Turkistani K, et al:
Discharge patterns of orthognathic surgeries
in the United States. J Oral Maxillofac Surg
70:e77–e86, 2012
66. Zins JE, Bruno J, Moreira-Gonzalez A, et al:
Orthognathic surgery: is there a future? Plast
Reconstr Surg 116:1442–1450, 2005.

69

4
Hereditary, Developmental, and
Environmental Influences on the
Formation of Dentofacial Deformities
JEFFREY C. POSNICK, DMD, MD
• Development of the Head and Neck
• Syndromes and Anomalies that Include
Dentofacial Deformities
• Hereditary Tendencies in the Development of
Dentofacial Deformities
• Environmental and Neuromotor Effects on
Skeletal Growth
• Effects of Trauma on Skeletal Growth
• Effects of Tumors and Growths on
Skeletal Growth
• Conclusions
factors that influence facial skeletal growth and dental
development (e.g., the muscles of the neck, tongue, and
lips; breathing patterns) is important. Factors that are
known to alter facial growth and cause jaw discrepancy can
be subdivided to include the following: 1) known syn­
dromes and anomalies; 2) hereditary tendencies; 3) envi­
ronmental and neuromotor effects; 4) effects of trauma; and
5) effects of tumors or growths.
Development of the Head and Neck
Skull
The skull is formed from the lateral plate mesoderm (the
neck region), the paraxial mesoderm, and the neural crest
(Fig. 4-1). The bony skull is formed by one of two mecha­
nisms: intramembranous ossification or endochondral ossifica­
tion. Skull development is divided into two parts: the
viscerocranium and the neurocranium. The viscerocranium
forms the bones of the face, whereas the neurocranium
forms the bones of the cranial base and the cranial vault.
The neurocranium can be divided into the membranous
neurocranium and the cartilaginous neurocranium. The
anterior fontanel (bregma) has a wide range of expected
closure between 4 and 26 months of age. The posterior
fontanel (lambda) generally closes between 1 and 2 months
of age.
From the first pharyngeal pouch are formed the maxillary
process, the mandibular process, and the second pharyngeal
arch. Many bones are derived from the maxillary arch,
including the maxilla, the temporal bones, the zygoma, the
palatine bone, the lacrimal bone, the vomer, the nasal
bones, and the inferior nasal concha. The mandibular process
forms the mandible, the sphenomandibular ligament, the
malleus, and the incus. From the second pharyngeal arch are
The term dentofacial deformity is generally used to describe
a significant disproportion of the jaws in association with
malocclusion. It is estimated that, at a minimum, 5% of the
population will have a discrepancy that falls into the devel­
opmental dentofacial deformity category. Another 45% of
the population will fall into a much larger group of those
with malocclusion but without what is considered a
“notable” jaw discrepancy component.2,3,5,56,65,72 After jaw
growth is complete (i.e., 14 to 16 years of age in girls and
16 to 18 years of age in boys), the definitive reconstruction
of a dentofacial deformity can go forward.
Knowing the etiology of a patient’s jaw deformity can be
important to the fundamental understanding of how and
when to treat the problem. Knowledge of normal facial
growth and development as well as the effect of any associ­
ated malformations (e.g., hemifacial microsomia with cervi­
cal spine anomalies) is useful both to limit complications
during treatment and for family planning. Understanding
the natural history of a condition that involves environmen­
tal influences may provide an opportunity to prevent or at
least lessen the impact of the deformity. Knowledge of

70
SECTION 1  Basic Principles and Concepts
• Figure 4-1  Illustrations of the development of the skull. From © Elsevier Inc. All rights reserved.
Orbitosphenoid (orbital,
or lesser, wing of future
sphenoid bone) (vision)
Crista galli
Nasal capsule (olfaction)
Meckel’s cartilage
Styloid process
Hyoid cartilage
Thyroid cartilage
Cricoid cartilage
Interparietal
part of
occipital bone
Zygomatic
bone
Squamous part
of temporal bone
Chondrocranium
Membrane bones at 9 weeks
Frontal bone
Nasal bone
Lacrimal bone
Maxilla
Zygomatic bone
Mandible
Membrane bones at 12 weeks
Optic foramen
Pharyngeal arch
mesenchyme for
viscerocranium
Head mesenchyme
for neurocranium
Cartilage from
pharyngeal arches
for viscerocranium
and neck cartilages
Cartilage from somite
sclerotomes and neural
crest anteriorly for base
of neurocranium
Intramembranous
ossification (both
from neural crest)
Endochondral
ossification
Greater wing of future
sphenoid bone
Otic capsule (audition)
Incus
Malleus
Frontal bone
Nasal bone
Maxilla
Mandible
Site of future anterior
fonticulus (fontanelle)
Site of future coronal suture
Parietal bone
Interparietal part of occipital bone
Greater wing of sphenoid bone
Chondrocranium
Squamous part and zygomatic
process of temporal bone
Tympanic ring of temporal bone
Chondrocranium at 9 weeks
Cartilaginous
pharyngeal
arch skeleton

71
CHAPTER 4  Hereditary, Developmental, and Environmental Influences on the Formation of Dentofacial Deformities
Skull of Newborn
Lateral view
Sphenoidal fontanelle
Frontal bone
Squamous part
Supraorbital notch (foramen)
Ethmoid bone
Orbital plate
Lacrimal bone
Nasal bone
Maxilla
Zygomatic bone
Palatine bone
Pyramidal process
Anterior fontanelle
Coronal suture
Parietal bone
Tuber (eminence)
Squamous suture
Posterior fontanelle
Lambdoid suture
Occipital bone
Temporal bone
Squamous part
Petrosquamous fissure
Petrous part
(mastoid process absent)
Tympanic part (bony external
acoustic meatus absent)
Oval (vestibular) window
Round (cochlear) window
Styloid process
Mandibular fossa
Zygomatic process
Sphenoid
bone
Greater wing
Lateral plate of
pterygoid process
Hamulus of medial
plate of pterygoid
process
Superior view
Frontal bone
Parietal bone
Occipital bone
Mastoid fontanelle
Anterior fontanelle
Coronal suture
Sagittal suture
Lambdoid suture
Posterior fontanelle
• Figure 4-1, cont’d

72
SECTION 1  Basic Principles and Concepts
• Figure 4-2  Illustrations of the development of the face. From © Elsevier Inc. All rights reserved.
Lateral view at 6 to 7 weeks
Left eye
Nasolacrimal
groove
Maxillary
process
Opening of
left nasal sac
(future naris)
Cardiac
prominence
1st pharyngeal
groove
Nodules that will
merge to form
auricle of ear
2nd pharyngeal
arch
3rd and 4th
pharyngeal
arches in
cervical sinus
1st pharyngeal
arch
Oral opening
7.0 mm
Ventral view at 6 to 7 weeks
Opening of right nasal
sac (future naris)
Right eye
Maxillary
process
of 1st arch
1st pharyngeal
arch
1st pharyngeal
cleft (future
external acoustic
meatus)
2nd pharyngeal arch
Intermaxillary segment
Medial nasal
prominence
Lateral nasal
prominence
Nasolacrimal groove
Oral opening
Nodules that merge to
form auricle of ear
3rd and 4th pharyngeal
arches in cervical sinus
(sites of future laryngeal
cartilages)
Lateral view at 5 to 6 weeks
Left eye
Maxillary
process of
1st arch
Nasolacrimal
groove
Nasal pit
1st pharyngeal
arch
Cardiac
prominence
2nd pharyngeal
arch
Pharyngeal
arches 3 and 4
Ventral view at 5 to 6 weeks
Right
nasal
pit
Right
eye
Nasolacrimal
groove
Stomodeum
1st
pharyngeal
groove
Site of future
hyoid bone
Location
of otic vesicle
(future membranous
labyrinth of
inner ear)
1st
pharyngeal
groove
1st cervical
somite
(myotome
portion)
Arm bud
Frontonasal
process
Medial nasal
prominence
Lateral nasal
prominence
Maxillary
process of
1st arch
1st pharyngeal
arch (mandibular
part)
2nd pharyngeal
arch
3rd and 4th
pharyngeal
arches (sites
of future
laryngeal
cartilages)
4.0 mm
formed the styloid process, the stapes, the hyoid bone, and
the stylohyoid ligament.
Face
The face is formed mainly from the neural crest, which
makes three “swellings” that surround the stomodeum
(Fig. 4-2). The three swellings are the frontonasal promi­
nence, the maxillary prominence (from the first pharyngeal
arch), and the mandibular prominence (from the first
pharyngeal arch).
Lateral to the frontonasal prominence, there are two
areas of ectoderm that form the nasal placodes, which invagi­
nate in the center to form the nasal pits. The placodes that
invaginate create ridges of tissues on either side of the pits.
The ridges are called the lateral nasal prominence and the
medial nasal prominence. The fusion of the medial nasal
prominence at the midline results in the formation of the
intermaxillary segment.
Palate
The palate is formed by the primary palate (intermaxillary
segment) and the secondary palate (protrusions from the
lateral prominences) (Fig. 4-3). The intermaxillary segment
(primary palate) is the initial portion of the palate to
develop. It contains the central and lateral incisors. Swell­
ings of the maxillary prominence form shelves that project
medially but that are separated by the tongue. When the
tongue no longer occupies the space between the palatal
shelves, these processes fuse together to form the secondary
palate. The primary and secondary palatal tissues all meet
at the incisal foramen. The primary and secondary palates
and the nasal septum fuse to form the definitive palate.

73
CHAPTER 4  Hereditary, Developmental, and Environmental Influences on the Formation of Dentofacial Deformities
Lateral view at 7 to 8 weeks
Ventral view at 7 to 8 weeks
Lateral nasal process
Medial nasal process
Philtrum
Auricle of ear
10.0 mm
24.0 mm
Lateral view at 8 to 10 weeks
Auricle
of ear
Fused eyelids
Philtrum of
upper lip
Site of nasolacrimal groove (fusion of
lateral nasal and maxillary processes)
Site of fusion of medial nasal and maxillary
processes (site of cleft lip)
Auricle of ear
Philtrum of upper lip (fusion of
medial nasal processes)
• Figure 4-2, cont’d 
Syndromes and Anomalies that Include
Dentofacial Deformities
Many of the syndromes and anomalies that involve the
cranio-orbito-zygomatic (upper face) region also affect the
maxillomandibular (lower face) location.1,20,124 These condi­
tions may involve any of the tissue components, including
the skin, the muscles, the nerves, the fat, the vessels, the
bone, the teeth, the cartilage, and the associated viscera (i.e.,
brain, ears, eyes, salivary glands, sinuses). Known syndromes
and anomalies comprise only a small proportion of the
dentofacial deformity group (see Chapters 27 through
31).19 These conditions can be further subdivided according
to etiology or tissue of origin.
Deficiencies of Midline Tissue Structures
Holoprosencephalies involve variable deficiencies of midline
tissues. These structural deficiencies have been documented
to occur early during embryologic development.16,18,23,27
They may range from severe brain anomalies to simple
absence or hypoplasia of the corpus callosum. Severe facial
anomalies such as cyclopia, ethmocephaly, and cebocephaly
are always associated with severe holoprosencephaly, and
they are incompatible with life. This can also be true of
premaxillary agenesis; however, in some instances, patients
may survive for several months or even years. There are
reported cases of premaxillary agenesis with normal head
circumference and no brain abnormalities (i.e., without
holoprosencephaly), although these patients sometimes
have mild mental deficiencies. Syntelencephaly (the absence
or hypoplasia of the corpus callosum or absent or hypoplas­
tic olfactory tracts and bulbs) is compatible with life and
should thus be treated. Associated facial anomalies include
retinal colobomas, cleft lip, cleft palate, single maxillary
central incisor, and midface deficiencies. Holoprosenceph­
aly has multiple causes and includes many chromosomal
types, many monogenetic disorders, and at least three
teratogens.
Deficiencies and Anomalies of Neural
Crest Origin
Most of the tissues of the face, including the muscular and
skeletal components, are derived from the mesoderm. Inter­
estingly, throughout the rest of the body, these components
(i.e., muscle and skeleton) are derived from an ectodermal
origin.19 The facial mesodermal elements develop from the
neural crest and then migrate downward beside the neural
tube and laterally under the surface ectoderm. When the
neural crest cells have completed migration to their specific
location, then facial development is dominated by specific
growth centers, the formation of visceral structures (e.g.,
brain, eyes, sinuses), and the differentiation of the tissue
layers. Facial anomalies of neural crest origin are thought to
arise when the neuroepithelium has apoptosis (i.e., the
cells die).25 This results in less neuroepithelium to migrate
through into the facial locations and to ultimately

74
SECTION 1  Basic Principles and Concepts
Frontal (coronal) section at 7 to 8 weeks
Frontal (coronal) section at 8 to 10 weeks
Right olfactory bulb
Ocular muscles
Eyeball
Maxilla
Right lateral palatine process
of secondary palate
Enamel organs of deciduous
molar teeth
Muscles of facial expression
Sites of fusion of lateral
Palatine processes and
nasal septum
Meckel’s cartilage
Submandibular salivary gland
Hyoid cartilage
Thyroid cartilage
Septal cartilage
Superior concha and meatus
Ethmoid cartilage
Eyeball
Lens
Middle concha and meatus
Right nasal cavity
Inferior concha and meatus
Meckel’s cartilage
Submandibular salivary gland
Hyoid cartilage
Infrahyoid muscles
Ethmoid cartilage
Frontal bone
Septal cartilage
Eyelid
Nasal septum
Tongue
Muscles of facial expression
Mandible
Hypoglossal (XII) nerve
Platysma
Lumen of larynx
Esophagus
Frontal bone
Ocular muscles
Fused eyelids
Maxilla
Zygomatic bone
Oral cavity
Mandible
Tongue
Platysma
• Figure 4-3  Illustrations of the development of the palate. From © Elsevier Inc. All rights reserved.

75
CHAPTER 4  Hereditary, Developmental, and Environmental Influences on the Formation of Dentofacial Deformities
Roof of stomodeum (inferior view; 6 to 7 weeks)
Palate formation (inferior view; 7 to 8 weeks)
Roof of oral cavity (inferior view; 8 to 10 weeks)
Opening of right nasal sac
Right eye
Primitive or primary palate
(median palatine process)
Oronasal membrane (primitive
posterior naris or choana)
Roof of stomodeum
(base of skull)
Philtrum of upper lip (fusion
of medial nasal processes)
Primary palate (median
palatine process)
Definitive nasal septum
Mucosa covering base of skull
Broken lines border area
formed from medial nasal
processes and primary palate
Medial palatine process
(primary palate contribution
to definitive palate)
Lateral palatine process
(secondary palate
contribution to
definitive palate)
Arrow emerging from choana
(posterior naris of right nasal cavity)
Frontal area
Medial nasal process
Lateral nasal process
Nasolacrimal groove
Definitive nasal septum
Maxillary process of 1st arch
Lateral palatine process
(secondary palate)
Opening of Rathke’s pouch
Left naris
Site of fusion of medial nasal and
maxillary processes (cleft lip site)
Primitive posterior naris or choana
(former site of oronasal membrane)
Left lateral palatine process
Site of evagination of
Rathke’s pouch
Left naris
Upper lip
Gingiva (gum)
Palatine raphé (cleft palate site)
Palatoglossal arch
Palatopharyngeal arch
Uvula
• Figure 4-3, cont’d
differentiate. Current knowledge of Treacher Collins syn­
drome indicates that this is not a migration problem but
simply a lack of cells to migrate (Figs. 4-4 and 4-5).
Teratogens that are known to result in head and neck
(neural crest) congenital anomalies include cytomegalovi­
rus (microcephaly, hydrocephaly, microophthalmia); Dilan­
tin (cleft lip and palate); vitamin D excess (premature
suture closure); Valium (cleft lip and palate); Rubella virus
(microophthalmia, cataracts, deafness); and thalidomide
(variations of hemifacial microsomia and Treacher
Collins syndrome). Despite these known relationships,
teratogenic agents are not the most frequent causes of these
syndromes.1
The branchial arch syndromes are neural crest anomalies
that comprise an etiologically heterogeneous group of dis­
orders.14 They account for only a small percentage of the
patients who present to the surgeon or orthodontist in need
of jaw reconstruction. The best known of these are

76
SECTION 1  Basic Principles and Concepts
• Figure 4-4  An 11-year-old boy who
was born with Treacher Collins syndrome
has typical malformations of the soft
tissues and the skeletal structures within
the first and second branchial arches on
both sides. There is significant hypoplasia
of each zygomatic complex, the orbits,
and the maxillomandibular structures
(Kaban type II-A mandible). The soft
tissues of the adnexal region are deficient.
The external ears are malformed, but
all parts are present. The central part of
the face is fully formed. A, Frontal facial
and computed tomography scan views.
B, Profile facial and computed tomogra­
phy scan views. C, Oblique facial and
computed tomography scan views.
A
Or
Or
Or
Or
Or
Or
Or
O thththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatathicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
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77
CHAPTER 4  Hereditary, Developmental, and Environmental Influences on the Formation of Dentofacial Deformities
• Figure 4-5  This mother and daughter demonstrate the extent of variation of expression of Treacher
Collins syndrome within a family. The mother was not aware that she carried the Treacher Collins gene
until after the birth of her daughter. From Posnick JC: Treacher Collins syndrome: perspectives in
evaluation and treatment. J Oral Maxillofac Surg 55:1120–1133, 1997.
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hemifacial microsomia, its variant Goldenhar syndrome,
and Treacher Collins syndrome.14 Hemifacial microsomia
affects aural, zygomatic, and mandibular growth at a
minimum (Fig. 4-6). The disorder may be mild or severe,
and it is generally limited to one side of the face. However,
bilateral involvement, with more severe expression on one
side, is also known to occur. Goldenhar syndrome, which is
a variant of hemifacial microsomia, also includes epibulbar
dermoids and vertebral anomalies. Involvement is often
but not always limited to the face. There may be cardiac,
renal, skeletal, and central nervous system anomalies
(see Chapter 28). At a minimum, patients with Treacher
Collins syndrome demonstrate the physical findings
of bilateral zygomatic hypoplasia, down-slanting palpebral
fissures, malformed ears, and micrognathia (see Chapter
27). Inheritance occurs in an autosomal-dominant fashion,
and expressivity varies (see Figs. 4-4 and 4-5). The syn­
drome maps to 5q32-q33.1, and mutations in the TCOF1
gene are of the nonsense, insertion, deletion, or splice-
site types.14,30,139
Clefting of the Lip and Palate
The most prevalent congenital defect of dentofacial devel­
opment is clefting of the lip, the palate, or both (Figures 4-7
through 4-19). This condition occurs in approximately 1 in
1000 whites, 1 in 500 Asians, and 1 in 2000 blacks.27 The
etiology of clefts is often complex and multifactorial. Evi­
dence supports the view that genetic factors are associated
with orofacial clefting.37 In twins with cleft lips and palates,
concordance is far greater among monozygotic twins (40%)
as compared with dizygotic twins (4.2%). In twins with
isolated cleft palate, concordance is also higher among
monozygotic twins (35%) as compared with dizygotic twins
(7.8%).138 Nevertheless, orofacial clefting is heterogeneous
and variable, and it is likely determined by a number of
major genes, minor genes, environmental factors, and a
developmental threshold.37 Some syndromes associated
with clefting in which specific gene mutations have been
identified include van der Woude syndrome (IRF6), popli­
teal pterygium syndrome (IRF6), autosomal-recessive cleft
palate/ectodermal dysplasia (PVRL1), hypodontia/clefting
(MSX1), Hay-Wells syndrome (TP63), and cleft palate/
ankyloglossia (TBX22). These mutations explain only about
5% of clefting cases, with an additional 10% to 15% of
cases explained by variations involving the IRF6 gene.110
Although orofacial clefting is caused by a malformation, the
development of secondary deformities of the jaws after birth
is well known (see Chapters 32, 33, and 34). For the most
part, maxillary hypoplasia in patients with orofacial clefts is
felt to be the result of palate surgical interventions carried
out during infancy and early childhood and not from the
primary congenital anomaly. Although van der Woude and
Stickler are just 2 of more than 100 clefting syndromes, they
demonstrate the importance of having an awareness of asso­
ciated anomalies to assist with family counseling and to
achieve effective reconstruction.
Van der Woude Syndrome
In 1845, Demarquay was the first to report the occurrence
of congenital sinuses of the lower lip in combination with
cleft lip and palate; this condition became known as van der
Woude syndrome. This syndrome occurs in roughly 1% to
2% of patients with lip and palatal clefts. Van der Woude
syndrome has an autosomal-dominant inheritance pattern;
Text continued on p. 91

78
SECTION 1  Basic Principles and Concepts
• Figure 4-6  A 7-year-old boy born with hemifacial microsomia and unilateral cleft lip and palate (left side) has typical malformations of the soft
tissues and skeletal structures within the first and second branchial arches on the left side. There is an absence of the left zygomatic complex and
hypoplasia of the orbit, the anterior cranial vault, and the maxilla. The mandibular malformation is a Kaban type III. The soft tissues of the left
external ear, the ear canal adnexal structures, and the cheek region are markedly deficient. A, Frontal facial and computed tomography scan views.
B, Oblique facial and computed tomography scan views.
A
B
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79
CHAPTER 4  Hereditary, Developmental, and Environmental Influences on the Formation of Dentofacial Deformities
• Figure 4-7  Cleft lip and palate represents a spectrum of morphologic findings that are initially dependent on the
individual’s specific anomalies but that are then affected by surgical intervention during growth. A newborn with a
complete (left side) unilateral cleft lip and palate is shown.
• Figure 4-8  A Hispanic child was born with complete clefting of the left primary lip and palate. He was
adopted when he was approximately 1 year old, before repair. He then underwent single-stage primary
lip, nasal, and palate repair. He is shown before repair and then at the age of 2 years after single-stage
repair.
©Elsevier Inc.
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©Elsevier Inc.
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• Figure 4-9  A child was born with an incomplete cleft of the left lip that also involved the alveolar ridge back
to the incisal foramen. She is shown before primary lip and nasal reconstruction and then at the age of 5 years
before alveolar cleft grafting.
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80
SECTION 1  Basic Principles and Concepts
• Figure 4-10  A child was born with a complete (left side) unilateral cleft lip and palate. He is shown before and at intervals after primary lip and
palate repair. A, He is shown before primary lip and nasal reconstruction and B, at the age of 10 months, just before cleft palate repair. C, The
same child at the age of 3 years and D, at the age of 8 years just before mixed dentition bone grafting.
A
B
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C
D
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81
CHAPTER 4  Hereditary, Developmental, and Environmental Influences on the Formation of Dentofacial Deformities
A
B
©Elsevier Inc.
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©Elsevier Inc.
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©Elsevier Inc.
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©Elsevier Inc.
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C
• Figure 4-11  Three newborns with bilateral cleft lip and palate (BCLP) are shown. A, A newborn with complete BCLP. B, A newborn
with BCLP but with partial attachment of the lip and the nasal floor on the left side. C, A 3-month-old infant with complete BCLP is
shown. The premaxilla is attached to the septum of the nose; it is forwardly projecting without attachment to the lateral lip segments.
The wide separation of the palatal shelves is also demonstrated by the intraoral view. D and E, A series of computed tomography
scan views of the maxillofacial complex of the infant shown in C demonstrate the skeletal anatomy associated with BCLP.
D
E

82
SECTION 1  Basic Principles and Concepts
• Figure 4-12  A child born with complete bilateral cleft lip and palate. He is shown
before and then 7 years after primary lip and palate repair, just before mixed dentition
bone grafting.
©Elsevier Inc.
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©Elsevier Inc.
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• Figure 4-13  A child born with incomplete bilateral cleft lip and palate. He is shown before and then
8 years after primary lip and palate repair, just before mixed dentition bone grafting.
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O ththththththththththththtr ogn
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• Figure 4-14  A child born with a complete cleft of the right lip and palate and incomplete clefting of the left lip. He is shown
A, before and then B, at 2 and C, 8 years after primary lip and palate repair. The last photo was taken just before mixed dentition
bone grafting.
A
B
C
©Elsevier Inc.
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©Elsevier Inc.
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©Elsevier Inc.
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83
CHAPTER 4  Hereditary, Developmental, and Environmental Influences on the Formation of Dentofacial Deformities
• Figure 4-15  A, A child born with complete clefting of the secondary palate (i.e., incisal
foramen through the uvula) is shown. B, An adult born with a complete unilateral cleft
lip and palate is also shown. He underwent lip repair during childhood, but the cleft
palate was neglected. Note the severe septal deviation that obstructs the right nasal
valve.
A
B
• Figure 4-16  A teenage boy from Jamaica who was born with a bilateral cleft lip and a unilateral cleft of the
alveolar ridge and palate. He underwent rudimentary lip repair as a child. The unrepaired clefted alveolus and
palatal anatomy are shown. Note the normal growth parameters of the upper jaw when the palate is unrepaired.
With a lack of continuity of the alveolar ridge, there has been typical distorted growth of the maxilla.

84
SECTION 1  Basic Principles and Concepts
• Figure 4-17  A woman who was born with bilateral cleft lip and palate and pitting of the lower (central) lip. At the time of her
pregnancy, an ultrasound confirmed twins, one of which was suspected of having bilateral cleft lip and palate and the other of
having unilateral cleft lip and palate. This was documented at the time of delivery. A, A family with van der Woude syndrome,
including a mother with a repaired bilateral cleft lip and palate and newborn twins. B, Twin A with bilateral cleft lip and palate. C,
Twin B with unilateral cleft lip and palate.
A
B
C
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A
B
• Figure 4-18  A 16-year-old boy who was born with Stickler syndrome (type II collagen mutation). At the time of birth, Pierre Robin sequence
was appreciated. The patient underwent repair of the cleft palate before he was 1 year old. He had positive eye findings, and he required the
treatment of a retinal detachment during his teenage years. A small cataract is being followed. He arrived for the evaluation of a jaw deformity and
malocclusion characterized by maxillomandibular deficiency with anterior open-bite malocclusion. This was combined with chronic obstructive nasal
breathing and a long face growth pattern. Attempted growth modification and camouflage orthodontics earlier during life were ineffective. There
was generalized root deficiency throughout the maxillary and mandibular dentition, likely as a result of the collagenopathy. A, Frontal views in repose
before and after treatment. B, Frontal views with smile before and after treatment.
Continued

86
SECTION 1  Basic Principles and Concepts
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C
D
The patient agreed to an orthodontic and surgical approach. Further orthodontic (dental) decompensation was cautiously
carried out as a result of the compromised periodontal apparatus. The procedures included maxillary Le Fort I osteotomy (vertical intrusion, hori­
zontal advancement, counterclockwise rotation, and arch expansion); bilateral sagittal split ramus osteotomies (horizontal advancement and coun­
terclockwise rotation); osseous genioplasty (vertical shortening and horizontal advancement); and septoplasty, inferior turbinate reduction, and nasal
floor recontouring. C, Oblique facial views before and after treatment. D, Profile views before and after treatment.
• Figure 4-18, cont’d

87
CHAPTER 4  Hereditary, Developmental, and Environmental Influences on the Formation of Dentofacial Deformities
Prior to retreatment
After treatment
Pre surgery
E
E, Occlusal views before retreatment, with orthodontics in progress, and after treatment.
• Figure 4-18, cont’d 
Continued

88
SECTION 1  Basic Principles and Concepts
F
Maxillary counter-
clockwise rotation
Mandibular counter-
rotation
Arch expansion
G
• Figure 4-18, cont’d  F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs
before and after treatment.

89
CHAPTER 4  Hereditary, Developmental, and Environmental Influences on the Formation of Dentofacial Deformities
Prior to retreatment
After surgery
H
• Figure 4-18, cont’d  H, Panorex radiographs before and after treatment that demonstrate generalized
limited root formation. The right maxillary first molar was lost 5 years earlier as a result of limited roots.
The right maxillary first molar was lost 1½ years after surgery as a result of limited root support; the right
mandibular first molar will likely be lost to similar pathology. Periodontal evaluation and treatment are
ongoing. Future plans are for the placement of dental implants in the right posterior maxilla and
mandible.