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The Biggest Movement: Orthognathic Surgery Undergoes Another Paradigm Shift

2008; Elsevier BV; Volume: 66; Issue: 3 Linguagem: Inglês

10.1016/j.joms.2008.01.001

1531-5053

Leon A. Assael,

History of Medical Practice

The only thing missing in the darkened room was demitasse cups, tapping against saucers. Instead, only Styrofoam squeaked to the Godfather’s words. He sat in the corner in his usual professorial tweed suit and sweater vest. But the comforting drone of the PowerPoint projector did not match the revolutionary but measured presentation of the Godfather. All leaned toward him to hear better as he uttered his startling words: “They won’t buy that stuff anymore.” “The old ways of doing business are over.” “We need to make new alliances.” “Others are waiting to seize our turf.” The experienced surgeons in the group could not be sure the young residents understood the importance of what they were hearing. William (Bill) Bell presented informally and genially on Friday rounds and took a leap so great it seemed to question all we once “knew” about orthognathic surgery. Here was the living icon, the Godfather of orthognathic surgery, explaining that the standard orthognathic operations of our practice were undergoing fundamental change and were in fact moribund. New technology, new economics, new alliances, even a new world sociologic view were all changing our ways. The health and beauty achieved today with orthognathic surgery is but a step along a complicated path toward comprehensive correction of skeletofacial deformities to be achieved in the future. Kuhn (1962) invented the term “paradigm shift” to describe an irrefutable scientific discovery that is the complete undoing of previously accepted knowledge. Once the shift is completed, all previous understanding of a clinical scientific topic is abandoned and is supplanted by new knowledge/new understanding. The first such occurrence in orthognathic surgery was the appearance of Hugo Obwegeser at Walter Reed Hospital in 1967. Orthognathic surgery to that point was nearly almost exclusively limited to the treatment of prognathism with extraoral vertical ramus osteotomies and body ostectomies. Obwegeser introduced a versatile osteotomy, the sagittal ramus osteotomy of the mandible that could address deformities in 3 dimensions. American surgeons were so energized by his work that several did fellowships with Obwegeser and returned with even broader understanding and skills. Importantly, mandibular deficiency and laterognathias could now be treated. The 1970s brought the development of intraoral vertical ramus osteotomies and segmental osteotomies. Remarkably, there was no discussion of vertical dysplasia until David Hall, Roger West, Bruce Epker, Larry Wolford, and William Bell, among others, almost simultaneously and independently developed operations to address vertical maxillary excess and deficiency. Like the inventions of the automobile and the airplane, great thinkers, working apart, nearly simultaneously identified a problem and their own solution to it. Weirdly, vertical dysplasias in maxillary growth essentially had to be discovered simultaneously with the operations to correct them. This was the final paradigm shift in understanding the 3-dimensional nature of skeletofacial deformities. Within a few years, centers that performed more than 90% of their osteotomies in the mandible were performing a majority in the maxilla. Finally, 2-jaw surgery to comprehensively address deformities became routine. To digest these remarkable advances, many important but less revolutionary changes followed. The most problematic aspects of this treatment now needed to be addressed including the extended recovery with maxillomandibular fixation orthognathic surgery patients sustained as well as subsequent dental and skeletal relapse that compromised initially favorable results. As each of these issues was addressed, new ones were identified and solved.•Presurgical orthodontics to eliminate dental compensation became more refined.•The development of rigid internal fixation techniques, immediate full function, and same day surgery shortened treatment cycles and improved stability of postsurgical position.•Distraction osteogenesis extended the potential for large movements and soft tissue adaptation.•As surgical understanding of the aging face improved and cosmetic techniques became more integrated, the importance of the projection of the soft tissue envelope became recognized. The role of maxillomandibular position in airway function and obstructive sleep apnea linked to this concern. Thus, more maxillomandibular advancement and greater vertical height to support aging soft tissue and airway became understood means of enhancing function and appearance. In spite of these remarkable achievements for the modern world, William Bell contends that orthognathic surgery currently remains too complicated, too invasive, too time-consuming, too expensive, and too unpredictable. Additionally, it is not consistently covered under health insurance plans. Technological, economic, and social advances will make the correction of skeletofacial deformities more widely achieved by greater numbers of people by simpler, less expensive, more predictable, less time-consuming, and more broadly available means. Here are some of the trends that will drive the next paradigm shift in orthognathic surgery.•Implant and miniplate supported orthodontics: The 2 to 3 mm universe of orthodontic movement has been expanded greatly to achieve stable 3-dimensional movements of far greater distances. Posterior maxillary intrusion to close open bite and maxillary protraction for midface deficiency are 2 examples of effective implant supported orthodontic care that can obviate the need for further surgery or result in a simplified surgical plan.•Computerized surgical assessment, planning and execution: Fully computerized 3-dimensional treatment planning, virtual dental casts, computer milled splints, navigation guided surgery, and robotic surgery are all on the verge of providing extreme accuracy and predictability for efficient morphologic correction of skeletofacial deformities.•Ambulatory/office-based orthognathic surgery: Eliminating the need for hospitalization with simplified surgical plans allows for markedly decreased costs and early recovery with an excellent patient safety record.•Maxillomandibular advancement as the preferred method for treatment of obstructive sleep apnea: Outcome studies now demonstrate that maxillomandibular advancement is the most reliable means of addressing sleep apnea for many patients. Refinements of this technique along with improvements in outcomes with various airway enhancement options are emerging.•Surgically facilitated orthodontic therapy: Interdental corticotomy/osteotomy, often with less traumatic cutting instruments such as the ultrasonic knife, has re-emerged as a means of shortening the duration of orthodontic care.•Globalization’s impact on elective surgery: The ability to diagnose and treat patients anywhere will drive competition in surgery as it has in manufacturing. Globalization is having a major impact on how skeletofacial deformities are diagnosed, worked up, and treated. As the Godfather summarized the state of the family business so eloquently, the room was stunned, but energized. One could imagine Michael Corleone would be sitting to his left. In a way he was, as Bryan Bell sat rapt, listening to his father’s words, and making plans for the coming paradigm shift.