Orthognathic Surgery

Orthognathic surgery has evolved over many years to correct both facial deformity and oral dysfunction. Facial beauty is difficult to define in precise terms because subtle differences between individuals can produce marked aesthetic contrasts. Furthermore, different racial forms of beauty are not comparable and so ethnic norms are required to correct the abnormality. Despite this skeletal abnormality is recognisable, measurable, and usually correctable by orthognathic surgery.

Orthognathic surgery started as “Orthodontic surgery’ as an aid to orthodontics, later graduated to orthognathic surgery as a remedial measure to orthodontic limitations.

Orthognathic surgery is mainly directed at the correction of basal bone defects. The aim is to attain aesthetic, psychological and functional rehabilitation of the patient. However  fine tooth movements for the optimum results are difficult to obtain with orthognathic surgery alone. Such finer adjustments can be achieved by orthodontics. Orthognathic surgery along with rhinoplasty and orthodontics can rehabilitate patients with facial deformities and oral dysfunction.

Historical events

Hullihen was the first person to correct jaw deformity surgically in 1849, when he corrected an anterior open bite by mandibular subapical osteotomy.          Orthognathic surgery of the maxilla was first described in 1859 by Von Langenbeck for the removal of nasopharyngeal polyps. Cheever 1867 reported a maxillary osteotomy for complete nasal obstruction secondary to epistaxis, he used a right hemimaxillary down fracture. Later many maxillary osteotomy techniques were described for the treatment of pathological process.

Blair in the early 1900’s was the first to classify  jaw deformity into five classes as : Mandibular prognathism, Mandibular retrognathism, Alveolar mandibular protrusion, Alveolar maxillary protrusion and open bite.

In 1901, Le Fort published his classic description of the natural planes of maxillary fracture. Cohn-stock 1921 described segmental osteotomy of maxilla which was modified by Wassmund (1926) by a labial approach. Cupar 1954, Kole 1959 and Wunderer 1963 reported a direct surgical access to these procedures which improved mobilisation and maintained blood supply. Wassmund (1927) described a total horizontal maxillary osteotomy to close a posterior open bite and this constitute earliest work of Le fort I surgery.  Axhausen (1934) performed the first total mobilisation of the maxilla.

Posterior segmentalization of the maxilla was first used by Schuchardt 1959 for correction of open bite. This had limited stability owing to its incomplete mobilisation. Kufner 1970 improved on this technique by completely mobilising the osteotomized segment prior to repositioning.

Paceno (1922) published some basic principles of roentgenographic cephalometry which was later modified and popularised by Broadbent and Holfrath (1935).  Down (1945) put forward some standard measurements which helped the diagnosis of deformities of midface. Burstone et al 1978 & 1980 gave an analysis for the assessment of dentofacial deformity using cephalometric radiographs ” The cephalometric analysis for Orthognathic surgery” (COGS).

Use of bone grafts in midface surgical advancement were reported by Rowe (1954), Cernea and associates (1955), Lerinac (1958).

Separation of the pterygomaxillary junction was first advocated by Schuchardt in 1942. Moore and Ward 1949 recommended horizontal transection of the pterygoid plates for advancement. This technique was associated with severe bleeding so Wilmar advocated the pterygomaxillary disjunction technique for Le fort I osteotomy.

A combined form of anterior and posterior subapical osteotomies “total subapical maxillary osteotomy” were reported by Paul 1969 for midface hypoplasia.. This technique was further described by West & Epker 1972, Hall & Roddy 1975, Wolford & Epker 1975, West and McNeil 1975 and Hall & West 1976.  Maloney (1982) reviewed this technique and described it as a good technique during his time. This technique is hardly in use now.

Hugo Obwegesser 1965 advocated complete mobilisation of maxilla so that maxilla could be repositioned without tension. This aided in stabilisation which was documented by Haller, Hogemann & Wilmar and Perko.

Hugo Obwegesser 1969 described a high quadrangular Le Fort I osteotomy for midface deficiency correction. This technique was later named as Quadrangular Le Fort I osteotomy by Keller & Sather 1989.

Converse & Colleagues in 1970 described an osteotomy at Le Fort II level but this had several biologic and anatomical flaws so this technique did not have appreciation later. Henderson & Jackson 1973 described a classic Le Fort II osteotomy for correction of midface deficiency.

Kufner 1971 described an osteotomy procedure for midface deficiency correction, which was named as quadrangular Le fort II osteotomy by Steinhäuser 1980. This technique was modified by Stoleinga & Brown in 1996 which prevents damage to infra orbital nerve.

Vascular supply of lower maxilla and alveolar portion was extensively studied by Bell and Levi (1971) and Bell et al (1979).  They concluded that the vitality of segment will not be affected if either palatal or buccal flaps were retained undisturbed.

Epker and Woodford 1980 gave a detailed down fracture technique for Le fort I maxillary osteotomy based on palatal flap.  They advocated the use of same for anterior  maxillary segment 0steotomy.

Sir Harold Gillies & Harrison 1950 performed Le Fort III osteotomy for midface deficiency.

Paul Tessier 1967 described various techniques for correction of orbito-craniofacial deformities.

The first use of bone plating was carried out by Soerensen in 1917 for fracture mandible. Bernd Spiessl 1974 was the first to use rigid fixation after sagittal split osteotomy. Use of rigid fixation to stabilise osteotomised segment was reported by Champy & associates 1976, Mischelet, Leyoness & Desus 1973, Dromer and Luhr 1981, Steinhäuser 1986 etc.  Miniaturised plates were used by Luhr 1981, Steinhäuser 1986 etc. Miniaturised plates by Luhr, 1989 solved the problem of excessive bulk of miniplates for use in midface.

The latest developments in orthognathic surgery is the use of adjutant plastic surgical procedures like blepharoplasty, rhinoplasty, rhitidectomy, liposuction , lip correction and the use of the principle of distraction osteogenesis for correction of jaw deformities.