May 1, 2000
by H.I. Holmes, DDS; P. Sectakof, DDS, Dip. Ortho; I. Pynn, DDS; B.
Surgical Orthodontics” or “Orthognathic Surgery” are old terms, which have adhered to the present time, which depict the techniques employed in the surgical correction of malocclusions, dental, skeletal, or combined in their origin. By far, most of these malocclusions are associated with what is generally termed “Dentofacial” deformities. These represent abnormalities of dental or jaw relationships arising from inherited skeletal growth patterns, additionally influenced by superimposed environmental influences. (Fig. 1) Traumatic insults to the facial skeleton with ensuing malunions, as well as ablative oncologic procedures, which have undergone subsequent, less than ideal reconstructive efforts constitute additional subgroups to which the principles of orthognathic surgery can be adopted. Far less common in their occurrence are the “Craniofacial” deformities, which constituting about 0.1% of the population, are malformation syndromes resulting from primary errors in morphogenesis during embryological development and for which many of the principles of orthognathic surgery are equally applicable. (Fig. 2)
Up until the last two to three decades, a majority of dentofacial deformities, especially if mild, were treated largely orthodontically. The focus was directed towards the dentition and occlusion, and to the manipulating of growth as best could be accomplished. Surgical procedures were relicated to the more severe deformities, or to individuals economically unable to obtain orthodontic intervention. Most surgical procedures prior to and during this time were also primarily directed at treating the deformity solely in the mandible, irrespective of the underlying skeletal abnormality. Additionally, little attention was afforded the management of vertical disharmonies of the facial skeleton. Orthodontists and surgeons often worked independent of each other, or the interaction if it occurred, was often poor, and misguided by a lack of understanding and appreciation of the limitations and capabilities of each other. Resultantly orthodontist improved occlusions, but failed to address the disharmonies of facial propositions, or at times made them worse. Conversely, surgeons improved, within the limits of the existing compensated dentition the facial disharmony and occlusion. Their effects were however also compromised resulting in residual occlusal problems and facial proposition, which were less than ideal or also worsened. (Fig 3)
The purpose of this paper is to review the historical developments in orthognathic surgery, which have led to its dramatic change in the last half-century, affording treatment results of a more ideal nature and to reflect on what the future may hold.
Although, arbitrarily defined, orthognathic surgery’s history can be broken down into several periods. These periods are certainly not exclusive to each other, and as the last three decades can attest, they were and are highly inter-related. These periods include, the technical, biological, rigid fixation, esthetic, digital and finally the collaborative periods. (Fig. 4)
TECHNICAL PERIOD: [LATE 1800s TO PRESENT]
As is often the case, “need” becomes the “mother” of invention. In orthognathic surgery, in the early and middle 1900s this was the rule rather than the exception. It was therefore, characterized by the development of surgical procedures to position the jaws or their particular segments to a position, which improved the bite and or esthetics of a patient. The techniques developed were founded, largely on a paucity of collaborative orthodontic intervention, a poor understanding of anatomy, vascularity and biological principles, but nevertheless set the stage for the development of many procedures still in use today. Evaluation of results, in terms of success, improved esthetics and occlusion, or complications often determined if a particular technique survived.
The surgical correction of mandibular prognathisim by an intra-oral anterior subapical osteotomy, as performed and reported by an American surgeon Dr. S.P. Hullihen in 1849, represented the first orthognathic procedure described. As described by Steinhauser the birth center of orthognathic surgery was indeed in America at this time and centered in St. Louis, Missouri.11 Here an orthodontist, Edmund Angle and general surgeon, Vilray Blair (had dental training) worked together in the development of the first described horizontal osteotomy of the mandibular, used to treat mandibular prognathisim. In a book entitled “Operations on the Jaw Bone and Face,” he described numerous methods to correct maxillofacial deformities. Unfortunately due to the intervening world wars, little attention was addressed to surgical orthodontics in America for almost 100 years, and in the post WWII period the cradle of modern orthognathic surgery was in central Europe. In the early to mid 1900s surgeons such as Pichler and Wassmund started centers of maxillofacial surgery in Vienna and Germany respectfully, and other than the fame attributed to them through the surgical procedures they invented, they were responsible for training subsequent surgeons such as Trauner, Kole, Obwegeser (Obwegeser established the Zurich center for Maxillofacial Surgery) and Schuchardt who, along with a few surgeons from Britain were largely responsible for most of the procedures employed up until the early 1970s, some of which continue to be used presently.11,2 At this time many North American surgeons, who had just recently learned the European techniques, reclaimed the dominance in orthognathic surgery and nurtured it into adulthood.
Up until the mid-1950s mandibular prognathisim, was treated most commonly, by the body ostectomy as originally described by Blair in 1896. In this procedure a segment of the mandible is removed, in either the bicuspid or molar area. The shape of the ostectomy varied from rectangular, to V shaped or trapezoidal, depending on the presence of open bites. Other early surgeons such as Erich and Trauner preferred the ostectomy to be distal to the last molar and in the form of a step, to provide greater bone contact and stability (Fig. 5). Digman (1948) best described the procedure as a two stage effort, the first being intra-orally and the second, extra -orally.6 It was not until 1951 that Burch performed it in one stage entirely intra-orally. Most often the soft tissue incision was a typical crevicular envelope flap, until Converse (1964) described a horizontal vestibular incision, which additionally could afford simultaneous exposure of the mandibular symphysis for the performance of midline osteotomies for width control, or genioplasties and anterior subapicals.6,2,3
The first ramus procedure to address prognathisim was the condylectomy (Jacbulay 1895) and surprisingly reports of its use can be found up until 1970, in spite of reported instability, limited capability for movement and high rate of complications.6 Blair (1907) and Babcock (1908) advocated a horizontal osteotomy of the ramus, just below the sigmoid notch. (Fig. 6) Known as the “St. Louis Operation,” it was also fraught with instability problems.11 In 1930 Kostecka employed his “blind sub condylar (Gigli Saw) procedure. (Fig.7) It however provided limited posterior displacement, problems with control of the condylar position and significant risk of facial nerve injury, and although used by some into the early 1970s it was largely replaced by what is now called the intra-oral subcondylar (Vertical Oblique) “IVO”. This procedure, originally described by Moose (1967) a later Witstanley (1968), was perfected in 1970 by the American Oral and Maxillofacial Surgeons, Drs. Herbert, Hinds and Kent subsequent to the technologic development of the oscillating saw (a right angle cutting saw).6 It survives in its modified form today, being aptly suited for small symmetric and asymmetric mandibular setbacks and for patients concerned about dysesthesia of the inferior alveolar nerve.
Alternatively, and prior to the development of the IVO and sagittal split osteotomies, the favored procedure was the extra-oral vertical obl
ique (subcondylar) “EVO,” simultaneously described by Hinds (USA) and Robinson (Br.) in 1955, which largely replaced a similar procedure described one year earlier by Caldwell and Letterman.6 It was and still is especially suited for large asymmetric setbacks. Concerns of scars and facial nerve paresis, although rare, nevertheless led a drive for the acceptance of the IVO and the sagittal split ramus osteotomies. The sagittal split procedure, although first described by Schuchardt, was popularized by Trauner and Obwegeser in 1957 in Europe and introduced into North America in the early and mid 1960s.6 (Fig. 8) The initial technique, which split the ramus all the way to the posterior boarder was at times technically difficult, and unpredictable. Subsequent modifications by Dalpont (1961) and Hunsuck (1968) increased its acceptability and it has largely replaced other ramus procedures, especially since the advent of rigid internal fixation (RIF), save for individuals unwilling to accept it’s high incidence of permanent nerve injury.2,3,6 (Fig. 9 A&B)
Indeed since the introduction of the sagittal split osteotomy, this procedure has largely replaced all other operations for mandibular advancement in the treatment of mandibular retrognathia or other class II malocclusion of skeletal origin, as well as mandibular setback. Historically every procedure, body, ramus (vertical or horizontal) or subapical described for prognathism has been adapted for retrognathia. Body procedures, mandibular subapicals, and most ramus procedures required the adjunctive need of bone grafts, extra-oral approaches or were innately, like the C osteotomy of Caldwell and Hayward (1968), technically difficult in their execution and this afford the sagittal split osteotomy the ability to acquire its dominate stature by the mid-1970s to 1980s as the optimum mandibular advancement technique.
Although maxillary osteotomies had been described in the late 1800s for the management of pathological problems, it was not until 1927 that Wassmund introduced a technique for moving the entire maxilla to correct a malocclusion.6 Most total maxillary procedures, more commonly called the Le Fort I osteotomies after the French surgeon Henry Le Fort, who described them in relationship to trauma, were performed in order to treat mal positioned maxillary fractures. Most surgeons performing them were hampered by a lack of knowledge of, or fear of, compromising the vascularity to the maxilla. Most surgeons were afraid to separate the tuberosity from the ptyergoid plates and immediately mobilize the maxilla. Therefore most early procedures were staged and relied on the application of externally applied traction forces to drag the maxilla into its final position. Indeed although the need for mobilization had been advocated, as early as 1934 by Axhausen, it was not until 1965-6 that Obwegeser via the typical vertical buccal excisions, severed the maxilla from all of its superior structures and the ptyergoid plates, mobilized it completely, and placed it immediately into its desired position.
To a large extent therefore, most maxillary surgery in the initial development period of orthognathic surgery was primarily subapical procedures, performed anteriorly to retract, intrude, or extrude the segment, often to close anterior open bites, or camouflage class II malocclusions. Posteriorly they were used to intrude, widen or narrow, thus facilitating open bite, and transverse discrepancy correction. Specific techniques were synonymous with their inventor. Anterior procedures included the Wassmund (1927), Wunderer (1963) and the two stage Cupur (1950). Those performed posteriorly were the two stage Schuchardt (1959) and Kufner (1970).
With the advent of the biological period significant advances in technical surgical procedures occurred as well as the beginning of the use of rigid internal fixation as a means of enhancing stability and patient acceptance. Towards the end of this century the rediscovery of a biological phenomena called “distraction osteogenesis”9 and its development and initial employment of in crainiofacial, as well as orthognathic surgery, mark the final technical milestones of last three decades.
BIOLOGICAL PERIOD [MID 1960 – PRESENT]:
Up until the mid 1960s and extending into the early 1970s orthognathic surgeons still depended on mandibular ramus and mandibular or maxillary subapical procedures, and now for some the sagittal split osteotomy was included in their repertoire. The Le Fort I osteotomy was used when definitely indicated by a few more daring surgeons when it was realized that there was truly a deficient maxilla responsible for the prognathism (psuedoprognathism). Beginning at this time however, largely pioneered by American surgeons, animal research exploring biological aspects of the present surgical procedures was undertaken, specifically in relationship to vascularity, osseous osteotomy healing, condylar segment control in relationship to stability and relapse, muscle adaptation, functional outcomes, and fixation techniques.2 Revolutionary with respect to maxillary surgery were Bell’s vascularity studies, which established that the total maxillary or the anterior or posterior subapical, could be performed through horizontal buccal vestibular incisions as a one stage procedure, even with the ligation of the greater palatine arteries. It was found that adequate vascularity via the palatal and remaining buccal soft tissues and their existing vascular plexuses was maintained to ensure adequate viability of the attached osseous segments, and subsequent soft and hard tissue healing, unless their remaining soft tissue attachments were inadvertently detached.2 This revelation led to the development by Bell (1975), of the “Down fracture” technique for the Le Forte I osteotomy, which was performed with a horizontal incision in the buccal vestibule, extending from one molar to the molar on the opposite side. This afforded the surgeon for the first time more significant visibility, making it easier to now intrude, advance or lower the maxilla. (Fig.10) Concomitantly it was realized that the previously described two stage subapical procedures of Cupur and Schuchardt were performable in one stage using a similar buccal incision approach. The combination of the anterior (Cupur) and posterior (Kufner) osteotomies was described by Bell and Epker in 1977 with minor modification.2 The procedure now known as the “segmental Le Forte I” allowed the orthognathic surgeon to now reposition the maxilla and or its segments in all three planes of space. (Fig. 11 A&B)
Similar investigations with respect to the various mandibular ramus and subapical procedures were also undertaken, which led to further modification in their technical execution, emphasizing the maintenance of muscle and soft tissue attachments to afford better condylar segment control, osseous healing with less chance of aseptic vascular necrosis and ultimately better stability and predictability of results. Additionally, although initially advocated by Obwegeser in 1970, simultaneous maxillary and mandibular procedures were now thought more appropriate and more safely carried out. Now nurtured in the bath of biological reality American surgeon perfected the existing techniques, and expanded their scope to higher midface components of the facial skeleton by performing Le Fort II and III osteotomies in their pure or modified forms.3 They continued in their biological approach to investigate more fully the relapse phenomena and ways by which the surgeon and orthodontist could deal with it. Significant with respect to this was the application of rigid internal fixation, which led us into yet another period in surgical orthodontics.
RIGID FIXATION [1970s – PRESENT]:
Prior to the mid-1980s the typical patient undergoing orthognathic surgery had osteotomy sites stabilized with transosseous wires, and was placed into intermaxillary immobilization (IMF), supplemented by indirect skeletal fixation ((ISF). (Fig. 12) The use of rigid internal fixation (RIF) for osteotomies was a direct extension of its use in
both orthopaedic and facial fracture repair, the principles for which had been founded by a Belgian orthopaedic surgeon, R. Danis in 1949. Michelet (1971) a French maxillofacial surgeon can be credited with the use of mini plates and screws to stabilize sagittal split osteotomies as well as maxillary osteotomies and fractures. Spiessl (1974) describes the use of fixation screws in a “lag” method for the mandibular sagittal osteotomy and in 1978 Souyris advocated the use of “positional screws.”13
An American surgeon Jeter popularized the use of smaller diameter (2.0mm) screws for the sagittal split placed transcutaneously in 1984, and other surgeons as well for the IVO and EVO ramus procedures. The trans oral approach later advocated by Turvey (1986) and Kempt (1987) now represents the common approach used clinically today. (Fig. 13) Numerous mechanical studies have attempted to define the significance, security wise, of such factors as screw size, number, pattern of placement, self tapped vs. tapped, positional vs. lag, trans buccal vs. trans oral or the number of plates and or screws necessary. The clinical reality of such studies suggested that two plates placed in parallel,3 screws placed widely separated in a linear pattern at the superior boarder, suffice with an initial period of light elastic IMF for one to two weeks to provide security a the osteotomy site during the initial period of post-surgical diminished jaw function and forces.
Although used earlier by European surgeons, the first reported use of RIF in a maxillary orthognathic procedure with plates was not until 1983 in North America and was performed by Frost who used metacarpal bone plates to fixate a maxillary osteotomy, which was found to be unstable after fixation with conventional wire osteosynthesis. The shapes of early fixation plates was however initially cumbersome and difficult to adapt and it was not until their shapes had been significantly altered that their use became commonplace in mid 1980s for maxillary procedures as well as for genioplasties. (Fig.14)
The use of RIF was predicated on its potential to afford sufficient stability at the osteotomy site so as to allow immediate mandibular mobility and also on there being more rapid osseous healing and in mandibular procedures, to avoid degenerative changes within the joints and associated peri-mandibular muscles and connective tissue that had been found associated with associated with IMF. Ultimately as an extrapolation from greater stability there was the expectation of less relapse. (Fig. 15) Regretfully, save for maxillary down grafting procedures to vertically lower the maxilla, this has not been substantiated unequivocally either in animal or clinical studies and it appears in most circumstances that in the long term IMF with ISF is as stable as RIF. It indeed appears, based on published as well as unpublished data, that there is perhaps an increased initial stability at the osteotomy site, but that this, in mandibular procedures may be distracted from by a delayed condylar remodeling process, which now becomes the primary center of the relapse process. At this site relapse occurs at later and for a longer period of time. In some circumstances clinicians have also observed abnormal condylar resorption, which has been responsible for significantly protracted relapse problems. (Fig. 16)
Additionally, problems of the condylar-fossa relationship cannot be eliminated by either fixation technique, and therefore both can result in relapse from condylar reseating as well as from the pathological resorption when the condyle is over compressed. Some clinicians are also concerned with the potential of iatrogenically induced condylar-meniscal mal relationships, yet studies in this area are equivocal. On an empirical bases, as well as published reports, there is considerable, as yet, variability in the results of RIF. As stated by Taylor (1993) “a mistake in the positioning of a fragment while using rigid fixation results in a rigidly fixed mistake.”13 That is, it is unforgiving. In contrast, passive inter-segment control in the mandible with the reliance on IMF and ISF afford some flexibility in the system especially in relationship to the condylar segment, which under muscular activity during IMF may become more harmoniously related back into a more normal condylar-fossa relationship. The normal range of mandibular movement with either fixation system returns without evidence of persistent degenerative changes occurs.
Overall it is probably to soon to be able to assess the true position RIF will have in orthognathic surgery. It is without a doubt beneficial in maxillary procedures. We may, however just be seeing the tip of the iceberg in respect to its application in the mandible. In light of this it would appear more commonly that the request for RIF is often patient or orthodontist driven, owing indeed to its increased acceptability in relationship to overall patient comfort, speech, nutritional, hygiene, and social acceptability concerns. (Fig.17)
Regardless, the economics of our health care system where RIF is concerned, which increases procedure costs up to $650, may in the long term force the issue of the use of such devices until a + cost vs. benefit correlation can be established. Concerns also exist with respect to stress shielding, loosening, migration translocation and interference in growth in growing individuals, palpability, temperature sensitivity, potential for infection, interference with diagnostic and therapeutic in radiation, and long term tissue reactions to the present metal fixation devices.1 In some European centers this has mandated their removal on a routine basis.
The need to remove such hardware is extremely low. However, although all the concerns regarding their long-term placement cannot be well substantiated, these concerns have given impetus for the development of absorbable fixation devices. Presently these are being fabricated from synthetic polymers, consisting of the homopolymers of glycotic (PLLA) and L-Latic acid (PLA) and more recently copolymers (PLLA/ PLA) or self-reinforced copolymers such as SR-PLA. Clinical use of these materials began in the early 1970s in the form of absorbable sutures such as Dexon and Vicryl. Their initial use as osseous fixation began in the USA, in orthopaedics in 1987. Within the last four years they have received clinical use in craniofacial and orthognathic surgical procedure. (Fig. 18)
DISTRACTION OSTEOGENESIS [1992 TO PRESENT]
Distraction osteogenesis (DO) in both craniofacial surgery and in orthognathic is one of the newest modalities of treatment over which a great deal of enthusiasm and research is now being generated.9 Although presently not a true period in orthognathic surgery, its future employment may or may not make it one. It, like RIF, was a direct product of a biologic principle used in orthopaedics. Interestingly, as is often the case, the wheel is very often re-invented and depending on the available manufacturing and engineering technology of the period the biology of yesterday is further defined, refined and adopted to the needs of the present. Such appears to be the case with distraction osteogenesis in respect to its use in the maxillofacial area. Bone lengthening by distraction for orthopaedics appears in the literature as early as 1905 by the American orthopaedic surgeon Corivabla and again later by Abbott (1927). Clinically it was a technique, which was silently utilized by Ilizarov in 1959 as a means of treating non-healing orthopaedic fractures or non-unions of Russian soldiers. It was, however not until Ilizarov’s reports in 1975 of its potential, and more specifically his elucidation of the biological principles involved which afford clinic success (1988-89), that the technique became a standard option to lengthen components of the axial skeleton.4,12
In reality, the potential use of distraction for mandibular lengthening had been delineated by Snyder (1972) in a canine animal model. Subsequently, Michicli and Meoti described mandibular lengthening in a canine model employing distraction fo
rces by a tooth born oral appliance. Similarly without their realization, early maxillofacial surgeons in Europe actually employed DO to reposition mal positioned LeFort I maxillary fractures. Early surgeons such as Wassmund (1927), Schuchdart, as well as other previously afraid of performing the LeFort I osteotomy routinely repositioned the maxilla as stated early, by traction forces, which gradually dragged it forward to its desired relationship. Oral and maxillofacial surgeon in conjunction with their orthodontics colleagues have routinely for the past 25 years employed the principles of DO in a technique which we describe as surgically assisted rapid palatal expansion (SARPE) used to treat maxillary transverse disharmonies in the non-growing individual.
It was, however, not until 1989 that this re-invented technique, based on further animal experiments, was employed clinically to lengthen a mandible by an American craniofacial surgeon McCarthy (1992).5 Cuerro is sited as being the first to widen the mandibular symphysis in 1990 with reports following in 1992. He used a distracter similar to that commonly employed for SARPE. Unfortunately, unreported and likely the first clinical mandibular expansion procedure was performed in London, ON, by a plastic surgeon B. Coclough and orthodontist R. Latham and one of the authors (Holmes) in 1973-4.
Since McCarthy’s report, numerous clinicians have employed DO to treat severe mandibular deficiencies of a syndromic nature or as the result of a iatrogenically induced growth disturbances secondary to an early acquired tempromandibular joint ankylosis. Likewise maxillary and mid face advancements have been achieved.9 Initial distraction appliances for the lower jaw were in the form of external pin fixed devices and unidirectional in the vector of displacement of the attached osseous segment. Most recently, owing to the cumbersome nature of these appliances, scars and their stigma, internal bone born multi-directional devices are being developed.9,4 Although some have acclaimed distraction osteogenesis as an entity, which will pre-empt the end of osteotomies as we know them, only the future will determine this.
ESTHETIC PERIOD [MID 1980 – PRESENT]
Orthognathic surgery has always been concerned with facial esthetics or, more appropriately stated, the establishment or maintenance of optimum facial balance. The most versatile esthetic yet functional procedure in the orthognathic surgeon’s repertoire has been the genioplasty as initially described in 1957 by Trauner and Obwegeser.2,6 It has been modified by numerous subsequent surgeons and affords one the ability to enlarge or reduce chin anterior-posteriorly, vertically lengthen or shorten, as well as widen, narrow, or level it in a fairly predicable manner that exceed procedures using alloplastic material. Significant advances in obtaining optimum facial balance were achieved with the advent of predictable maxillary surgical procedures, as well as higher level osteotomies at the Le Fort I level and those involving the nasal-maxillary complex and malar areas. (Fig. 19) Added to osteotomies in their armitarium is also the use of bone grafts and alloplastic substances for augmentation of such sites as the mandibular angles or body, malar, para nasal, infraorbital and frontal areas. In the 1980s, soft tissue the Oral & Maxillofacial Surgeon was performing procedures, such as lip reduction or augmentation, and open and closed liposuction of the cervical and submental areas. In the last decade, driven by economics and changes in training programs especially in America, rhinoplasty and other soft tissue esthetic surgical procedures are becoming commonplace.
[MID 1980 – PRESENT]
The digital era has affected all human endeavors including orthognathic surgery. The last 10 years have seen the development of computer-based treatment planning programs. Initially diagnostic, the surgeon or orthodontist could input a cephalometric tracing into a computer based software program by means of a digitizing tablet and have a variety of analysis automatically generated. Dramatically, with the development of scanners, digital cameras and more sophisticated programs and computer hardware, in addition to analysis, we are capable of manipulating teeth, jawbones or their segments, simulating orthodontic and surgical movements and obtaining immediate photo realistic images of the soft tissue changes. This has allowed quick treatment planning alternatives as well as sophisticated patient teaching aid. The entire patient record, including x-rays, photos, and now with the advent of surface laser scanning, 3-D manipulatable dental models and facial images can be digitized and kept in a computer. Based on computerized tomography developed in the late 1980s and now, magnetic resonance imaging, models of facial bones can be produced in 3-D, CNC (computer numeric controlled) milling machines (1987).8 With the advent of steriolithography and other laser technology, even more accurate 3-D models can be achieved, which can be used for pre-operative surgical simulation in orthognathic as well as trauma and reconstructive procedures. (Fig. 20)
[1970 – PRESENT]Orthognathic surgery is both an art and science demanding compulsive attention to detail both with respect to diagnostics and execution. Regardless, however; of the expertise that both the surgeon and orthodontist may possess, the inter-relationship of teeth, supporting alveolus and jaws cannot be divorced from one another if one expects to obtain results that really reflect present day expectation and result in a harmonious facial balance, a maximally functional occlusion and stability. To achieve this, collaboration with the orthodontist and surgeon as well as other members of the dental and medical profession in a professional, responsible manner is mandatory.5 The importance of this interaction was stated in Blair’s book previously alluded to, in which he admonished “treating skeletal deformities is really surgical work, both the earlier a competent, congenial orthodontist is associated with the case, the better it will be for both the surgeon and the patient.”11 Regretfully these early words by Blair were apparently quickly forgotten perhaps as a result of egos, biases, patient demands, and a lack of appreciation for each others’ capabilities as well as limitation. This quickly changed when the center of orthognathic surgery returned to the North American continent towards the end of the 1960s.It was also finally realized, that in spite of the advancements in surgical techniques brought about by the shrinking isolation of clinical and scientific information from one continent to another, and scientific biologically-based experimentation, that one could not obtain optimum uncompromised results without sincere collaborative interaction by all involved in the patient’s care. Finally, surgeons started working with orthodontists and in the 1970s numerous articles reflecting appropriate combined orthodontic and surgical care of the various dentofacial deformities appeared in the literature. These were followed by texts written conjointly by surgeons or orthodontist, the first of its kind being that by Epker and Fish.3 Conjoint meetings between major orthodontic and surgical groups in most countries became commonplace, as were continuing education programs that further served to foster the collaborative milieu and dissemination of knowledge. The result of such interaction has been the establishment of collaborative treatment care protocols, which allow for the optimum interprofessional relationship between the treating specialists and patient, culminating in optimum results. (Fig. 21)At the University of Toronto’s Faculty of Dentistry this collaborative spirit is fostered and actively taught through a Dentofacial Deformities Treatment Program, which has been established between the respective graduate departments, not only for providing treatment to patients, but more importantly to afford the establishment of a truly conjoint teaching program in su
rgical orthodontics. It represents one of the most unique teaching programs in North America. In this program both orthodontic and surgical students share a joint responsibility in a patient’s treatment planning and care from the onset. Conjointly they must formulate a treatment and subsequently take responsibility in its completion, in a manner not dissimilar to the one outlined by Fridrich, which is as typical a protocol as exists in the real practice world.5 Academically there is a conjoint program of lectures and seminars, which, over a two-year period and starting with patient assessment, covers every aspect of orthognatic surgery. Orthodontic students learn about the various surgical techniques in almost as much depth as their surgical confers. Surgical residents learn the most customary orthodontic principles involved in such procedures. The students jointly present most of the topics and both groups learn how and do, model surgery and splint fabrication. Orthodontic students attend the operating room sessions and the surgery residents attend specifically delegated clinics with their orthodontic confers where they screen new patients and see longterm retention cases together, as well as follow their current patients. Although, not without its growing pains, this program truly represents collaboration at its best, not only with respect to patient care but also with regards to interactive learning.23Dr. Holmes is Assistant Head, Dept. Oral & Maxillofacial Surgery, Coordinator, Undergraduate Education and Surgical Director, Dentofacial Treatment Program, Dept. Oral & Maxillofacial Surgery Faculty of Dentistry, University of Toronto.Bruce R. Pynn, MSc., DDS, FRCD(C) is currently staff oral surgeon at the Thunder Bay Regional Hospital, Thunder Bay, ON.Iain A. Nish, MSc., DDS, FRCD(C) is currently staff oral surgeon at the Hospital for Sick Children, Toronto, ON.Drs. Sectakof, Metaxas and Marko teach at the Faculty of Dentistry, University of Toronto.Oral Health welcomes this original article.References1.Alpert, B., Silicon, D., Removal of As symptomatic Bone Plate Used for Orthognathic Surgery and Facial Fractures. J. Oral and Maxillofacial Surgery, 54:5:618, 1996.2.Bell, W., Proffit, W., White, R. Surgical Corrections of Dentofacial Deformities. 1980: W.B.Saunders Co.3.Eeker, B., et, Fish, L. Dentofacial Deformities, Integrated Orthodontic and Surgical Correction. C.V. Mosby. St. Louis, 1986.4.Freidrich, R., Sailer, H., 7 years Clinical Experience with Mandibular Distraction in Children. J. Cranio-Maxillofacial Surgery. 26: 197-208, 1998.5.Fridrich. K.L., et al., Co-ordination of the Orthosurgical Program. J. Adult Orthod Orthognath Surg. Vol9 #3, 196-199, 1994.6.Hinds, E., Kent, J., Surgical Treatment of Developmental Jaw Deformities. C.V. Mosby Co. St. Louis, 1972.7.Kallel, I., et al.: Fixation of Mandibular Osteotomies Using Biodegradable Amorphous Self-Reinforced Polylactide or Metal Lag Screws, an experimental study. J. Cranio-Maxillofacial Surgery, 27:124-133, 1999.8.Kermer, C., et al.: Pre-operative Steriolithographic Model Planning for Primary Reconstruction in Craniofacial Surgery. J. Cranio and Maxillofacial Surgery 26:136, 1998.9.McCormick, S., Distraction Osteogenesis. Atlas of Oral and Maxillofacial Surgeon Clinics of North America. 7:1, March 1999.10.Robinson, E., Resorbable Fixation of LeFort I Osteotomies. J. Craniofacial Surg. 9: #3:210-214, 1998.11.Steinhuser, E.W., Historical Development of Orthognathic Surgery. J. Cranio-Maxillofacial Surgery 24:195-204 1996.12.Tavakoli, K., et al: The role of the latency period in mandibular osteodistraction. J. Cranio-Maxillofacial Surgery. 26:209-219, 199813.Taylor T.D., Complications of Osteotomies with Rigid Fixation, in Internal Rigid Fixation in Orthognathic Surgery. Atlas of Oral and Maxillofacial Surgery Clinics of North America, p 68, March 1993.