Chapter 1 The Development of the Specialty

Chapter 1

The Development of the Specialty

Introduction

There is ample evidence that the Egyptians and later the Greeks dealt with fractures of the mandible and even dislocation of the jaw. Hippocrates (400 BC), in particular, is credited with describing a bandage to support the chin which would stabilize the mandible in cases of fracture. Several illustrations are proof of the fact that in many ancient civilizations in both Asia as well as Europe, teeth were “pulled.” Throughout the 16th to 18th century, artists in Europe made paintings of traveling barber-surgeons, or charlatans, pulling teeth in the open air (Ring, 1985). It is, however, safe to assume that these treatments were not widely available for the general public.

It is really hard to point towards the true beginning of the development of the specialty, because there are anecdotal reports of oral surgery in most countries of the world that go back to medieval times or even earlier. A detailed description of the development of the specialty in ancient times is presented by Hoffman-Axthelm (1995). With the Renaissance, however, a new era of medicine began which started with some important discoveries in anatomy, which, in large part, were carried out in Italy. Preceding the true development of our specialty, however, which really began in the second half of the 19th century, three surgeons paved the way for its emergence.

Artwork depicting a tooth puller. This painting was made during the 19th century in the Netherlands using a mirror picture from a copper etching made by F. Maggiotto. On loan from the Utrect University Museum, Medical-Dental collection, but in possession of the Dutch Dental Association. Reproduced with permission.

The Frenchman Ambroise Paré (1515–1590) is generally considered to be the father of modern surgery and the first to have published about oral surgery in a book called “A Treatise on Surgery.” As a military surgeon he became famous for the way he treated gunshot wounds. Contrary to the then current method of Ambroise Paré

using hot oil, he dressed the wounds with “an unguent of egg whites, oil of roses and turpentine.” This practice was widely copied after his publication, probably much to the relief of the wounded soldiers. He also described the treatment of mandibular fractures for which he recommended manual reposition and wiring to the neighboring teeth, supported by a bandage around the chin, similar to the description by Hippocrates. His book also presents illustrations of instruments to elevate teeth from their sockets. Another French surgeon, Pierre Fauchard (1678–1761), is considered to be the father of dentistry. He published the first comprehensive book on dentistry Pierre Fauchard in 1728, “Le chirurgien dentiste, ou, traité des dentes” (The Surgeon-Dentist or Treatise on the Teeth). This book became the authoritative text for a century to come and was translated into German, which meant that it spread over most of the European continent. He settled in Paris and devoted his entire career to dentistry. He covered the whole field of dentistry, including oral surgery, for instance, extractions, re-implantation of avulsed teeth and homologous tooth transplantations.

The third person who was instrumental to dentistry and oral surgery alike was a Scotsman, John Hunter (1728– 1793). Trained as a surgeon, he is seen as the founder of a scientific approach to the subject. He became interested in dentistry early in his career and wrote the classic, “Natural History of the Human Teeth” in 1771, in which he explained their structure, use, formation, growth and diseases. He introduced the nomenclature of teeth still used today and made observations John Hunter about caries, periodontal disease and inflammation around affected teeth. This book became a main reference for many practitioners in Europe as it was translated into German, Dutch, Italian and Latin.

Seminal discoveries Advances in surgery have generally been by a process of gradual evolution but by the end of the 18th and throughout the 19th centuries, several seminal discoveries were made which had a profound influence on medicine as a whole. Louis Pasteur (1822–1895) recognized the role of bacteria as the cause 1st Baron Joseph Lister of infection and Joseph Lister (1827–1912) developed the concept of antisepsis and applied these techniques to surgery through his carbolic spray.

The development of general anesthetic agents started with Horace Wells, who, in 1845, first carried out a painless dental extraction under nitrous oxide anesthesia at Massachusetts Horace Wells General Hospital. This work was followed by T.G. Morton (1846), using ether and, in Edinburgh, James Young Simpson, using chloroform, all of which changed treatments dramatically.

Carl Thiersch (1874) adapted the technique described by Louis Léopold Ollier (1872) and using the principles of Lister, introduced the split skin graft for reconstruction, which revolutionized this aspect of surgery. Additionally, Wilhelm Conrad Röntgen (1895), a physicist, demonstrated the use of x-rays in the diagnosis and management of fracture care. New interest in mouth surgery brings breakthrough As previously mentioned, the real breakthrough came in the second half of the 19th century when general surgeons with a special interest in surgery of the mouth and related structures began to practice oral and facial surgery. This happened particularly in the U.S.A. and in the Germanspeaking areas of Europe but also in many other countries, as appears from the various reports of the affiliated national

associations (see chapter 7).

This development came relatively late considering the development of surgery in general. This may be explained by the lack of knowledge about dentistry, which is of great importance when working in the orofacial area. It is, therefore, not surprising that the first pioneers are

to be found in the U.S.A. where dentistry had become an academic profession with the establishment in 1867 of Harvard Dental School, which was soon followed by several state universities. Before that time, however, there were already dental colleges where dentistry was taught, with Baltimore College of Dental Surgery, established in 1840, being the first.

James E. Garretson (1825–1895) is rightly considered by the American Association of Oral of Maxillofacial Surgeons (AAOMS) as the father of oral surgery. Garretson, a general surgeon with a formal dental degree, published in 1873 a book entitled: “A System of Oral Surgery: A Consideration of the Diseases and Surgery of the Mouth, Jaws and Associated Parts.” Almost 140 years later, one can only admire the vision this man must have had about the specialty considering the title of his book. He truly can be considered the father of oral and maxillofacial surgery worldwide, although colleagues in other parts of the globe had no knowledge of his work. Probably the first surgeon who exclusively limited his practice to OMF surgery was Simon Hullihen (1810–1857). He also was a general surgeon who later received an honorary dental degree from Baltimore College of Dental Surgery. Despite his lack of formal dental training, he performed a wide spectrum of surgical procedures in the oral and maxillofacial area and is particularly known for the first mandibular, subapical, segmental set-back osteotomy, which was carried out in 1849.

There were several American colleagues at this time who held medical and dental degrees and who were specialized in oral surgery but a man who really stood out is Truman W. Brophy (1848–1929). In 1883, he established the Chicago Dental College and became a professor in oral surgery at that institution. He gained a tremendous reputation, particularly for his skills in cleft surgery. His major contribution to the specialty, however, was his 1916 book, “Oral Surgery: A

Treatise on Diseases, Injuries and Malformations of the Mouth and Associated Parts.” It is also striking to note that in those days, Brophy, just like Garretson before him, had a wider vision of the specialty than just the mouth. One can only be deeply impressed by the quality of this two-volume book, which not only covered oral surgery in its widest sense, it also covered the treatment of fractures, tumors and congenital deformities. It is the color anatomy figures, in particular, of the mouth and related structures in color that impresses the reader today. He was also instrumental in establishing the first U.S.A. association of oral surgery in 1921. Originally, the membership consisted of surgeons with both medical and dental degrees but two years later, membership was opened up to include those with a single degree, either medical or dental. Some well-known names that are either linked to surgical procedures or instruments, such as Cryer, Ivy, Risdon, Waldron and Lyons, joined this association. It is of interest to note that this association became the American James E. Garretson Association of Plastic Surgery in 1941, after it had changed its name in 1933 to Oral and Plastic Surgery (Randall et al., 1996). From 1931 on, the membership of this association was only open to colleagues with a medical degree. Disciples of Brophy continued to advance the specialty and wrote another excellent comprehensive book, “Essentials of Oral Surgery” (Blair, Ivy & Brown), which first appeared in 1923, with updated reprints in 1936 and 1944. Specialty grows in Germany The early history of the specialty in Europe is largely defined Simon P. Hullihen by the activities of surgeons in the German-speaking countries, although there were also pioneers in other countries, such as France, England and elsewhere (see chapter 7). Similar to the specialty’s American beginnings, but somewhat later, it was general surgeons who began to develop an interest in the surgery of the mouth and face. What were probably the first books in the German language, which dealt with what is now called oral and maxillofacial surgery, stemmed from general surgeons and were published in 1907 by Perthes and in 1913 by Bruns, Garré and Küttner. The German involvement in the 1870–1871 Franco-Prussian War and World War I apparently initiated some original thinking on how to treat soldiers with facial wounds and fractures. The use of arch bars, fixed to bands around the molar teeth, provided anchorage for intermaxillary fixation. This was often supported by a bandage around the chin. The use of splints, made of vulcanite, both for dentate as well as edentulous patients, was already known to surgeons of this period.

Truman W. Brophy

It is particularly interesting to read what these surgeons did for those poor young men who were missing parts of their mandible due to gunshot wounds. Extraoral pin fixation and devices that gradually repositioned the stumps in the desired position were fabricated, using very ingenious techniques. It is also fascinating to read about the first attempts to graft defects of the jaws with autogenous bone from various donor sites, including the mandible, tibia and even metatarsal bones, in times when no antimicrobial treatment existed. These first attempts date back to the very beginning of the 20th century in the German-speaking area and were used especially to treat large defects as a result of war injuries during and after World War I (Bruhn et al. 1915, Misch & Rumpel, 1916, Klapp & Schröder, 1917).

Very much the same discussions took place in Germany as those held in the U.S.A. regarding the need for oral surgeons to possess a dental education. Texts on oral and maxillofacial surgery from this period were written by general surgeons with an interest in the field (Sontag & Rosenthal, 1930). It was Martin Wassmund (1892–1956), however, who was one of the strongest supporters of the double degree. As a dentist with a keen interest in oral surgery and very much an autodidactic, Wassmund later studied medicine and became the leading surgeon at Rudolf-Virchow Hospital in Berlin. It is only fair to say that he probably wrote the first comprehensive book on oral and maxillofacial surgery (1935, 1939) which contained surgical procedures that are still widely practiced today. His name, of course, is also linked to the subapical anterior maxillary set-back osteotomy. Georg Axhausen (1877–1960) also deserves special recognition. He was a general surgeon, departmental chair and professor at the University of Berlin in oral and maxillofacial surgery (Zahn-, Mund- und Kieferheilkunde), whose 1940 book presents some very impressive and still valid thoughts on free autogenous bone grafts and soft tissue transplantations. It also includes the description of a vestibuloplasty in the symphyseal area of the mandible, using a free skin graft.

If we regard the Huntarian period of English surgery, the years preceding this, comprising the 17th and 18th centuries, were marked by repeated wars in Europe. Military

surgeons wrote individual vivid accounts of severe facial injuries, particularly those resulting from gunshot injuries. Treatment consisted of suturing skin to mucosa and later, making good the anatomical defects with prosthetic shields made from silver. These meticulous descriptions are exemplified by those of Richard Wiseman, who, in the 17th century, was probably the most advanced thinker of the age. A naval surgeon, he wrote up some 600 cases which accurately described the signs and symptoms of bone fractures and the nature of jaw fractures from gunshot Richard Wiseman wounds and assaults. His writeups included shrewd observations of a middle third fracture in a child, including the posterior displacement. He went on to describe the digital reduction of this displacement and the problems associated with retaining it in a forward position. He was also the first person to emphasize the need for early removal of facial sutures to reduce the scar from the continuous suture itself. During this period, any surgery was carried out by general surgeons, but in the late 18th and early 19th centuries, there was an increased influence from dental surgery. These were individual contributions which each added significantly to the practice of the specialty although no single one was responsible for any major breakthrough. The consequence of this greater awareness of the dentition meant that the treatment of fractures of the jaws advanced Martin Wassmund side by side with improvements in prosthetic techniques and later, in orthodontic techniques, so that at last, someone attempted to effect a cure other than by simple ligation of adjacent teeth and the provision of a submental bandage. The first dental splint was probably made in 1780. Over the next 100 years it underwent significant modification to improve its ability to stabilize the jaw fragments. For instance, Naysmith, a dentist, working with Robert Liston, describes the use of a metal cap splint to prevent displacement of the jaw following resection for a tumor. With the exception of this case, the majority of reports were of extensive gunshot wounds and the subsequent Georg Axhausen replacement of missing parts by ingenious devices constructed of silver. Lessons then poured in from the American Civil War, which resulted in significant developments in the dental splint. The very nature of trench warfare and the increased power of munitions all tended to increase the severity of facial injuries in particular. The introduction of anti-gas gangrene serum, the copious irrigation of soft tissue wounds

with hypochlorite solution, and the introduction of the tube pedicle by Harold Gillies and at the same time, but independently, by Filatov in Russia, together with bone grafting, greatly facilitated the management of these injuries. Against this background, the U.K recognized the need for special centers within which this type of reparative surgery could be carried out. The first such center was at Queen Mary’s, Sidcup, where Major Harold Gillies, Captain Kelsey Fry and Captain Fraser worked together, aided by many noteworthy surgeons of the time including Kilner (U.K.), Blair, Ivy, Kazanjian and Curtis (U.S.A.), Valadier (France) and Pickerell (New Zealand), among many others.

Between the wars, iliac crest bone became firmly established as the site of choice for the reconstruction of jaw defects. An improved form of eyelet wiring was described by Ivy (1920) and Gillies, Kilner and Stone (1927) described the temporal approach to the zygomatic arch.

The British government at that time established a special task force charged with ensuring that in the event of further hostilities, the injured service men and women would be assured of far better care than ever before. From the maxillofacial point of view, Harold Gillies (later, Sir Harold Gillies) was charged with the task. It established the concept of a team of surgeons, dedicated to the management of facial injuries, who would work together in frontline hospitals, evacuate the injured after primary stabilization to rear positions, often to the U.K., when it was the most practical thing to do. The surgeons involved in these teams would be general surgeons, some of whom were already trained in reconstruction, and would be known as plastic surgeons, together with ENT and dental surgeons. It must be remembered that, at that time, the treatment of jaw fractures was largely by the use of cast silver cap splints, for which dental expertise was essential.

The development in France was slightly different and can only be understood when realizing that dentistry was not considered an academic profession until quite recently. Instead, a medical specialty called “Stomatologie” existed. Stomatologists would carry out dentistry but some specialized in maxillofacial surgery. There were, however, other specialists, such as general and plastic surgeons and ear, nose and throat surgeons who could attain a “competence” in maxillofacial surgery.

A French surgeon who contributed a lot to our understanding of maxillary fracture patterns was Rene Le Fort (1869–1951). His classic studies were carried out in 1901, when he was still a young doctor in the military (Pons et al., 1988). One of the most renowned surgeons of his time was Victor Veau (1869–1951), a general surgeon who published his seminal work on the treatment of cleft lip and palate in 1938. There were

Sir Harold Gillies several other French pioneers who contributed to the development of the specialty in France. Guillaume Dupuytren (1777–1875), for instance, was probably the first surgeon who described the typical signs and symptoms of a jaw cyst including crepitation of the thin overlying bone shell. He also called these lesions cysts but had no idea about their origin.

An excellent account of the early French contributions is presented by Dechaume and Huard (1977). One cannot escape the impression, however, that much published in German or English never penetrated into the French literature but that is also probably true the other way around. There is a French book on oral surgery that reflects the state of the art in France in the 1930s (Chompret, Dechaume & Richard, 1935). It is limited to pure oral procedures and is less comprehensive than the German or American books of the same period.

One of the factors that defined this early period, apart from the daring character that all of these pioneers must have had, was the fact that they were almost certainly unaware of what was going on in other countries, let alone in the transatlantic world, the one exception being Truman Brophy, who quotes Perthes (1907) in his book. For this reason, some operations or techniques were invented several times in different countries without the inventors knowing of each other. The reason for this was the limited number of journals available and the inability of most professionals to read each other’s language. Most medical and dental journals were also rather parochial as they had limited distribution. The event which changed this completely was World War II. Not only did this war profoundly change the profession due to the new developments caused by the need to take care of large numbers of wounded soldiers but soon afterwards, the world opened and English became the main language for scientific publications.

Rene Le Fort Guillaume Dupuytren

The specialty has benefited enormously from general advances in medicine and surgery that were made during the war. Probably the most important one relates to the discovery of Penicillin by Fleming in 1941. This enabled surgeons to begin exposing jaw bones more safely and to carry out procedures, including open reductions of fractures and osteotomies, in a predictable manner. This was certainly not common practice before and, for instance, Brophy warns in his book that, “this procedure, which should be the last resort, etc.” He was referring here to open reduction of some mandibular fractures and to applying a wire osteosynthesis. Also, inflammatory diseases caused by the teeth were no longer as life threatening as before, while specific infections, such as actinomycosis, could be adequately tackled.

The emergence of the journals

Another factor that contributed to the rapid spread of knowledge worldwide was the establishment of journals solely devoted to oral surgery. The AAOS began their journal in 1943, which appeared quarterly in the early years. It was later published every two months and became a monthly journal only in 1965. Although this journal was meant especially for the American colleagues, there were many subscribers from overseas but few contributions from abroad. The other American journal that appeared first in 1958, also quarterly, was called Oral Surgery, Oral Medicine and Oral Pathology. This journal, from the beginning, had a somewhat broader vision in that it aimed to attract international contributions and even had international editors. This probably had to do with the fact that its first

kurt H. tHoma

In the first issue of the “Triple O,” Thoma writes a remarkable and extensive editorial, introducing the new journal: “The material will include advances in clinical procedures as well as information about new developments in the basic sciences. The latter are fundamental, since they furnish the foundation needed for the thorough understanding of disease processes and the application of correct treatment, be it medicinal or surgical in nature. Let us not forget that the true art of medicine and surgery is based on a thorough concept of the basic medical sciences, which include anatomy, physiology, biochemistry, bacteriology, pathology and pharmodynamics and that the clinician depends on investigation and research for progress. Yet, truly, the clinic is the proving ground for discoveries made in laboratories.”

He then goes on to mention the names of various pioneers, such as Pasteur, Semmelweis, Lister, Morton and several others in medicine and surgery who applied basic ideas to the development of an important discovery. This introduction led to the following narrative. “Today, we definitely accept organized investigations as the most promising method for success in the revelation of new scientific facts. We no longer wait for a genius to appear, for a lucky discovery to come along. The great wonder of organized progress is made by an army of patient investigators, by groups working together with leadership from within. Discoveries in modern times are made by cooperation and by the cumulative effort and therefore, it is necessary for investigators to study the accumulated scientific knowledge which has increased in an amazing manner, as highly trained specialists added fact upon fact by the sweat of their brow.”

Thoma then describes the passing of knowledge in ancient times as it was based by word of mouth and often went lost, contrary to the present time. “It was the advent of the printing press which facilitated the distribution of knowledge and today man is to a great degree educated by published material. Periodicals are published constantly to keep the reader informed of the most recent accomplishments of his contemporaries,” he wrote. He then continues to promise the reader to provide the best original articles, including all aspects of the profession and “Quarterly Reviews of the Literature.” He had appointed corresponding editors in many countries to report on the development outside the U.S.A.; “because the world is small and there should be complete cooperation, especially in the medical and dental professions, for the benefit of all.”

The reader, almost 60 years later, could not agree more with these wise and highly relevant words. Apart from his phenomenal accomplishments and broad knowledge of the pathology and surgery of his time, this man had a vision that has proved to be right until today.

Kurt H. Thoma

Paul J.W. Stoelinga

editor, Kurt H. Thoma, who was born in Switzerland, was brought up speaking both German and French. American OMF surgeons were hitherto sporadically publishing in either dental or surgical journals.

The German-speaking countries had their Fortschritte der Mund,-Kiefer,- und Gesichtschirurgie from 1954, which was not so much a real journal and was certainly not peer reviewed but rather was an accumulation of the papers presented at their annual meeting, edited by one of their leading professors. Nevertheless, it contained some very useful information and gave the reader a sense of where the specialty was heading.

The British established their journal in 1963, which only appeared twice a year and later, in 1980, three times a year. The IAOMS published its first journal in 1972, followed by the European association in 1976. Both journals started out by appearing six times a year.

It is of interest to note that French stomatologists had their journal from 1899, called La Revue de la Stomatologie. This journal, however, did not exclusively publish on oral and maxillofacial surgery but also on common dental issues. The same was true for the Acta Stomatologica Belgica, which first appeared in 1902.

In order to gain an impression of the scope and armamentarium of the OMF surgeon in those days, it is quite revealing to read the journals of these years. There were a lot of case reports and experienced based papers written by authors who were leaders in the specialty. This is well illustrated when comparing the 12 issues of the American Journal of 1963 and 1964 with the four issues of the British Journal from 1963–1965 (see table below).

The British Journal in those years appeared only twice a year, the American Journal six times a year. The contents were quite comparable. Case reports, mainly pathology, made up about one third of the contents. Reviews and experience based articles filled about one third to one quarter, the remainder were technical notes and papers about anesthesia, the latter were only present in the American journal for obvious reasons. Of 225 published articles, altogether there were only 11 papers that could be classified as research and these were mainly clinical retrospective studies.

It is also of interest to note that in 1965, Fred Henny, the editor-in-chief of the Journal of Oral Surgery, wrote an editorial in a special issue of that journal which was completely devoted to research. He stressed the importance of research and, in fact, became very directive in indicating the areas that should be explored.

The subspecialties

Around 1960, it was possible to define nine specific areas of clinical practice. They will be discussed here in three time frames that are somewhat arbitrarily chosen, although some major trends mark the selected dates.

The period before 1960 is characterized by post-war recovery and the establishment of oral and maxillofacial surgery as a specialty in most western countries, as well as several others. In most countries, the development was still mainly orientated towards the national interests and based on historical customs, with very little awareness of what was happening in other countries. This changed in the period 1960–1990, largely as a result of the appearance of journals that were purely devoted to the specialty. They were read worldwide and caused a growing sense of international dependency on ideas brought forwards by various clinicians and researchers.

the emergence of the journals

Type of Article

Opinion Review Research Anesthesia

British Journal of Oral Surgery (1963–1965)

4 issues

8

20

New Technique 9 Case Report

Total

19

66

Journal of Oral Surgery (1963) 6 issues

4

15

5

14

9

35 82

Journal of Oral Surgery (1964) 6 issues

14 18

6

4

3

32

77

This was also the time that elective surgery began to emerge, including orthognathic and preprosthetic surgery. These two subspecialties would flourish in this period and expand the scope of OMF surgeons enormously. The period 1990–2010 brought many new technologies into the specialty and also a growing awareness that the treatments chosen needed to be valid and preferably evidence based. For this, several mechanisms became available but not the least of which was the “Parameters of Care: Clinical Practice Guidelines for Oral and Maxillofacial Surgeons,” as proposed by AAOMS and endorsed by the IAOMS and many affiliated, national associations.

In the following sections, the development of these specific areas will be described in the three periods mentioned. It was not the intention of the authors to describe a detailed or complete history of all aspects of the specialty but rather to present a bird’s eye view, with an emphasis on the reasons why and when we arrived at the present situation. When studying the literature of the past, the sheer number of articles on procedures that are no longer carried out and also the number of papers that are repetitive as they emphasize points previously made, is striking. We inevitably had to be selective to illustrate the points made. In some sections, strong beliefs and even conclusions were postulated by various authors which later had to be reversed. Some of these conclusions were wrong and had to be changed dramatically. In that sense, the history is quite revealing and worth studying as it may happen again.

It is also acknowledged that the development is described from the perspective of “westerners,” with an emphasis on English literature and, to a lesser degree, on German and French literature. When reading the contributions of the affiliated associations from different parts of the world, it appears that important developments also took place in the non-English, non-German and non-French speaking world. However, it was not possible to get access to written documents from these countries, let alone that it would have been necessary to translate them.

Apart from many articles on specific items, it was most instructive to read the textbooks as they appeared over the years. They are listed in a separate column at the end of this chapter since many are quoted through all nine sections.

researcH

Fred Henny wrote an introduction in the issue of the Journal of Oral Surgery of June 1965, which was completely devoted to research and contained the contributions of several speakers of a research summit, which had taken place at Henry Ford Hospital in Detroit in September of the previous year. This was an initiative of the American Board in conjunction with the leadership of AAOS at that time. He writes a lengthy introduction in which he stresses the importance of research as part of the training of residents. This column contains his main message and one cannot escape being impressed with the vision of this man who was the first president of this association. Everything he says would apply to the current situation and his warning is just as timely today as it was in 1965.

“Education and research are welded together in an unbreakable band and it is a basic truth that a high quality of training service in any of the health sciences cannot be developed or maintained without this combination,” he wrote. “Strength in a clinical science, such as oral surgery, is built like a Russian troika: three powerful forces all pulling equally together: clinical care, education and research. If one force gets out of balance, obviously the pace of progress must slacken and the overall result becomes less desirable.

“Although formal education provides the foundation for a capable specialty in the health sciences, it is research that keeps it moving forward at a vigorous pace. In the present day of rapidly expanding scientific technology, it is virtually impossible for a branch of health sciences to keep pace with others around it unless it is fed by a steady diet of imaginative, well-conceived and productive research. Oral surgery cannot be an exception to this principle and obviously it must conform or eventually be relegated to a minor professional position that could almost be considered a craft.”

He also outlines 11 areas where he foresees that research is very much needed so as to improve patient care. These include: growth and development, neoplasia, aging process, trauma, the painful temporomandibular joint, focal infection, neurological state, wound healing, anesthesia, vascular changes and speech. It would not be difficult to update this list so as to make it more applicable for the present time but how appropriate this message was in 1965 and how much did we benefit from research in all these areas.

Paul J.W. Stoelinga

Dentoalveolar surgery

Before 1960

Dentoalveolar surgery had been carried out in many countries for about 150 years before the 1960s on a more or less regular basis. Exodontia, in particular, was most often performed, using various forceps and elevators. It was John Tomes, however, a surgeon who practiced dentistry, who in 1841 proposed a logical design for forceps that would fit the contour of the cervices of the various teeth. Since that time, extraction forceps exist until today with few variations, something which is particularly notable when comparing European forceps with those commonly used in the U.S.A.

It is not surprising that in the two countries where oral surgery began, i.e. the United States and the German speaking area that the first written instructions appear. There are even monographs, solidly devoted to exodontia, which were published at the beginning of the 20th century (Mayrhofer, 1922, Winter, 1926, Berger, 1929 and Sicher, 1937). The latter emigrated to the U.S.A. and became widely known for his contributions to oral anatomy.

It is of interest to note that the techniques described entail the complete removal of all teeth and their roots, without any attempt to split them. This is even illustrated when removing deeply impacted third molars in the mandible. The removal of bone was largely done by chisel, although Adolf Berger recommended the use of a dental bur as an alternative, apparently against the then prevailing opinion, as he remarked: “The use of the bur is not regarded favorably by those who scoff at the dental engine as a surgical instrument. It will be found, however, that this method is satisfactory from the surgical and from the patient’s standpoint. Furthermore, it often has several advantages over the chisel technique. The bone can be cut accurately, quickly and safely; the tissue destruction is minimal; and the trauma and postoperative pains are mild.”

Berger was ahead of his time and would not have found much opposition today. It is needless to mention that large amounts of bone had to be removed to expose impacted teeth and to be able to remove them in one piece. This practice was still advocated by Wassmund (1935), although he used burs to remove the bone around impacted teeth.

Just before, during or shortly after the war, several textbooks on oral surgery appeared, again, mostly written by American and German-speaking authors. From most of these books, several new editions appeared with updates

on techniques or new developments, sometimes changing the titles slightly. (Archer, 1952, Pichler & Trauner, 1940, Mead, 1933, Thoma, 1948, and Rheinwald 1958). Some of them had updated editions until the 1970s. There is one French book written by Chopret, Dechaume and Richard (1935) that reflects the state of the art in France at that time. The chapters dealing with dentoalveolar surgery, however, hardly changed and most advocated the use of burs to remove the necessary bone and to split impacted teeth and remove them in pieces. This probably had to do with the development of drills that had evolved from simple engines, driven by foot pedals, Sir John Tomes to electrically powered machines. The burs also had evolved into various designs suitable for the removal of bone or to cut through the teeth in the desired fashion. The techniques described in these books have not changed much and probably served as a basis for many manuals published in many countries in different languages. There is one exception that needs further explanation. It concerns the “lingual split” technique as was previously practiced widely in the U.K. According to Ward (1956), this technique was introduced by Kelsey Fry but never written up until the publication of Terence Ward. The rationale for this technique is beautifully described by Killey and Kay (1965): “When a chisel is preferred for 3rd molar surgery, use should be made of the fact that the buccal bone is relatively thick by comparison with the thin shelf of lingual plate and that when the latter is split off, the main bony support to the tooth is eliminated and with it the resistance to effective delivery. It also reduces the size of the residual socket and, therefore, the blood clot.” This author (PS) learned this technique in 1971 in East Grinstead and has used it ever since in selected cases, particularly distally tilted molars, very much to his satisfaction. Apicectomies, with the intention of treating an apical cyst or granuloma and to save the tooth, also have a long history. According to Wassmund (1935), it was Partsch (1896) who introduced the principle of surgical endodontics, but Thoma (1948) refers to Farrar (1876). From the beginning, removal of approximately one-third of the root was recommended to include the apical inflammatory tissues along with the ”necrotic” cementum (Wassmund, 1935, Mead, 1940, Thoma, 1948, Archer, 1952), or even to resect to the deepest level of the bony defect so as to avoid any dead space behind the root (Rheinwald, 1958).

Sir William Kelsey Fry

To illustrate the way of thinking of that time, it is revealing to quote Thoma in 1948 “…consists of the apex of the tooth because it harbors bacteria in the dentinal canals and the lacunae of the cementum which are not accessible to ordinary methods of sterilization. The apex of tooth undergoes necrosis, but, unlike bone, it is not sequestrated although resorptive processes are frequently present.” What did he see that we presently are not aware of?

All mentioned authors describe only an orthograde filling technique, apart from Pichler & Trauner (1940) and Rheinwald (1958), who also described retrograde fillings using amalgam. Most authors were also rather hesitant to embark on multi-rooted teeth such as molars and bicuspids. They warn of perforation of the sinus membrane with possible sinusitis as a result, or damage to the inferior alveolar nerve. Louis Grossman (1965) described the operation in a step-by-step version with simultaneous root canal filling. It is obvious at this stage that knowledge of the detailed anatomy of the dental root canals was lacking, while also the advances made in conventional endodontic treatment had not yet become apparent. The theories on which the treatment was based, along with the subsequent recommendations, were all based on experience and assumptions rather than evidence, as we know it now.

A procedure that had certainly fascinated clinicians for a long time was tooth transplantation, be it autogenous or allogenic. It was already known, at this time, that allogenic transplantations did not result in long-lasting success. A very good description of autogenous tooth transplantation is found in the book of Georg Axhausen (1940), who describes the importance of maintaining the periodontal membrane and, thus, the need for atraumatic removal of the tooth used for re-implantation or transplantation. He had done animal experiments, without being specific about it, that showed replacement resorption occurring soon if the periodontal membrane is not preserved. He also showed some very good results in his book. This technique became very popular in the succeeding years.

There are, of course, other procedures that could be mentioned in this section but they will be dealt with in the specific sections, such as pathology and preprosthetic surgery. One exception has to be made; it concerns the handling of oro-antral perforations. In the second volume of Wassmund (1939), almost all methods used during this time to close an open antrum are beautifully presented with extreme detail, including excellent illustrations. There has been very little new published, in this respect, ever since. It also becomes very obvious when reading the American textbooks, that they had no knowledge about the things Wassmund had written about and vice versa and certainly not about this topic.

Painting by Kunmiyoshi Utagawa (1798–1861). Depicts tooth puller in left lower corner. On loan from the Utrecht University Museum, Medical-Dental collection, but in possession of the Dutch Dental Association. Reproduced with permission. 1960–1990 Exodontia had not developed further during this period, apart probably from some better drills to free retained roots or impacted teeth. All textbooks or monographs written in this period [Killey & Kay, (1980), Tetsch & Wagner, (1982), Laskin, (1985)], or adapted from earlier versions of published books and reprinted, show pretty much the same techniques. There was, however, more concern about the possible complications associated with removal of impacted mandibular third molars. This had largely to do with some follow-up studies that were done during this period. It became obvious that temporary or even permanent disturbance of sensitivity of the inferior alveolar and lingual nerve was a serious problem and occurred with a frequency of between 5–12 percent. The majority of cases, however, recovered spontaneously.

The issue of alveolitis was also addressed during this period, and with it came the discussion whether or not to use antimicrobial drugs as a prophylactic measure. The studies of Birn (1973), however, threw some light

on the etiology of alveolitis, pointing towards fibrinolysis as the causative factor rather than primary infection. In retrospect, it is surprising that there was no doubt about the recommendation of prophylactic removal of all impacted third molars, despite the absence of any evidence to support this notion, apart from personal anecdotal experience. The National Institute of Health in the U.S.A. even came out with a statement in 1979 saying: • All third molars are pathological. • They cause crowding over the years. • Removal at a young age causes fewer complications. At present, this would be called level V evidence, the lowest level possible, based on a consensus of “experts.” At that stage no information was available on any longitudinal study supporting the statements they made.

The practice of apicectomies was still carried out according to the principles as laid out by the authors of the mentioned texts but some nuance was introduced, probably because of the progress endodontics had made over the years. Gerstein, writing the chapter on apicoectomies in Laskin’s book (1985), writes: “It is usually not necessary to remove the portion of the root that lies within the bony lesion, except for access to the area of pathosis.” Most current practitioners would agree with this statement in the light of the current knowledge of minimal exposure of accessory canals. There is also no hesitation anymore in treating posterior teeth.

The biggest progress in this period was made in the area of tooth transplantations and re-implantations. Research in this field had resulted in fairly predictable outcomes, particularly when teeth were transplanted with wide open apical foramina. One of the pioneers in this field was Shullman, who also wrote a chapter in Laskin’s book (1985) about tooth re-implantation and transplantation, for a large part based on his own research. He emphasized the advantages of transplanting teeth at a young age, when the apical foramen is still wide open, so as to facilitate survival of pulp vasculature. He preferred auto-transplanted teeth to implants, because erupting transplanted teeth stimulate growth of the alveolar process, contrary to implants. He also wrote: “Survival depends on maintained viability of the periodontal ligament and cementum on the surface of the donor tooth.”

This is pretty much in line with what Axhausen had said some 45 years previously. Considering the many articles in various journals on this topic, this technique was enormously popular. The ultimate book on tooth transplantation and re-implantation is written by Andreasen (1991), another pioneer in this area. It provides the science behind the technique but also serves as a step-by-step atlas, demonstrating the procedures in detail. He also advocates transplantation of developing bicuspids into sockets of avulsed front teeth in growing children, as opposed to implants.

1990–2010 As stated before, dentoalveolar surgery did not change much during this period, apart from the improvement of instruments used and better imaging. Numerous manuals in various languages appeared but two classic books stand out, one from Sailer and Pajarola (1996) and the other from Andreasen, Kølsen, Petersen and Laskin (1997). In both texts, up-to-date information is provided about the currently used techniques, the preoperative preparation of patients and their aftercare.

In this period, the third molar issue came prominently into play, initiated by two thought-provoking articles (Mercier & Precious, 1992 and Shepherd, 1993). They questioned the routine prophylactic removal of asymptomatic third molars in the light of the morbidity associated with it and the cost effectiveness. This discussion prompted some research that in part is still going on but is notoriously difficult, because the necessary long-term, longitudinal studies are still not present. There are, however, some well-designed studies that, for the time being, are helpful in making up one’s mind.

Kugelberg et al. (1991–1993) from Norway did some excellent work on the healing capacity of the periodontium distal to the second molar and found that this was almost 100 percent when the patients were younger than 25 years. Beyond that age, the chances are that irreparable damage will occur, leading to loss of septal height distal to the remaining second molar, with subsequent problems. Ventä et al. (2004) found in a group of dental students that over a period of 18 years seemingly deeply impacted third molars in the mandible could still change their position and even erupt. Last, but not least, the assumption that third molars contribute to the crowding of the lower front teeth is seriously questioned by orthodontists as well as OMF surgeons, based on some rather convincing clinical research (Lindauer et al., 2007).

This would certainly be one reason less for contemplating prophylactic removal. The overriding argument, however, to question this policy is the fact that from several studies, it became apparent that only in some three percent is there serious pathology involved, including cysts and tumors, associated with impacted third molars (Eliason et al.,1989, Güven et al., 2000). It will probably take some time until this issue is settled, based on evidence rather than speculation or anecdotal information.

The AAOMS currently has a research project underway that should provide clinical and biological data to support effective third molar treatment (White, 2007). The Cochrane Group, however, has come out with a recommendation based on currently available information (Mettes et al., 2005): “Asymptomatic bony impactions and even third molars completely covered by soft tissues should not be removed, while only partially erupted wisdom teeth should be removed, preferably before the age of 25 years.” There is no doubt, however, that there is another side of the coin. Removal of third molars at a later age, because of inflammatory disease or otherwise, particularly when elderly people are involved, leads to more morbidity. (Kunkel, et al., 2007). The longitudinal study that is currently underway, sponsored by the AAOMS, should establish whether hard data exist to support established practice.

Another issue in which much progress has been made concerns the avoidance and the repair of damaged branches of the trigeminal nerve after mandibular third molar surgery. Excellent studies have appeared on the anatomical variation of the lingual nerve position, which enables the prudent surgeon to avoid its damage (Pogrel et al., 1995). Three dimensional imaging allows for exact assessment of the relationship between the inferior alveolar nerve and the roots of a third molar to avoid traumatic Soren Hillerup injury of this nerve. It is thanks to Hillerup and coworkers (2007, 2008), that objective criteria have been established upon which to base the seriousness of the damage and a protocol for micro-surgical repair with subsequent follow-up.

The development of endodontics has narrowed the indications for surgical endodontic treatment (apicoectomies) considerably. Modern techniques to find and open obliterated canals, or to remove metal posts in previously treated canals, have eliminated the need for surgery. In addition, the current practice of conventional endodontic treatment has improved the outcome of the treatment in such a way that there is less need for surgical solutions. Yet, there are still indications for surgical endodontic treatment and the techniques as described above are still valid.

Infectious diseases

Before 1960 Infectious disease must have been very prominent in the old days as there was no emphasis on oral hygiene and both periodontal and pulpal infections must have abounded. There are many illustrations made in the 17th and 18th centuries and even before that time, which show individuals suffering from a swollen cheek with a bandage around their heads. This probably was the main reason why general surgeons were called upon, since some of these conditions were life-threatening.

In the beginning of the 19th century, these surgeons had no idea what the cause was of the severe abscesses and indurations that they saw. This is well illustrated by the description of “an inflammation in the anterior part of the neck with an emphasis on the submandibular regions” by Friedrich von Ludwig in 1836. He describes that he favored a conservative approach, which in most cases would result in death. He also commented that in some cases, foul smelling, reddish-brown fluid escaped via the mouth. He had, however, no idea what the cause could be and suggested an “erysipelitic process probably related to a poor general condition or a weak nervous system.”

Contemporary surgeons such as Dupuytren in Paris, shared his approach (Hoffmann-Axthelm, 1995). It took some time before the link was made to the role of bacteria and the dentition.

A complete and accurate description of the often dramatic and rather quick development of a phlegmone of the floor of the mouth (Ludwig’s angina) is presented by Mickulicz and Kümmel in 1898. They recognized the delicate anatomical structure and the proximity to the throat as the main reason why the patients had difficulty swallowing and breathing. They also mentioned difficulty in inspecting the mouth because of trismus and the swollen tongue and realized that this condition had, of course, nothing to do with an inflammation of the throat. They also described the often fatal course of events, despite surgical intervention, such as incision and drainage and particularly emphasized that death might be a matter of days if the patient does not respond to the surgical treatment. Thoma, in 1948, added: “The clinical course might be mild but it may suddenly change and assume an alarming character. Deglutition is hindered, speech is difficult and saliva may run from the mouth since swallowing causes pain. There is a rapidly extending edema, which causes respiratory difficulties (angina). The larynx itself may be involved suddenly in the rapidly progressing edema and may become obstructed.” Today, one cannot think of a better description. It is only after the introduction of penicillin that the prognosis of this condition changed, as Thoma rightly noticed in 1948.

Friedrich von Ludwig

Textbooks in German and English from the first half of 20th century all mention the necessity of treating abscesses in and around the mouth by incision and drainage, recognizing that the cause of these inflammatory conditions in most instances were decayed teeth which, therefore, had to be extracted as well. The better knowledge of head and neck anatomy also led to the recognition of the stereotype appearance of deep space infections.

Osteomyelitis was another condition that gave rise to major concern in the days before antimicrobial agents were available. It was in particular, the acute form that worried the clinicians. One has to keep in mind that most of them had a general surgery background and were, therefore, inclined to compare the disease in the mandible with the often dramatic course of events in the long bones. Surgeons like Axhausen and Wassmund, but also others, were hesitant to go into the bone to remove sequestra, fearing uncontrollable spread of the inflammatory process.

A much feared complication was thrombophlebitis with hematologic spread to other bones, resulting in certain death. These considerations still played a role in the 1950s. For instance, Archer writes in the late 1950s and early 1960s that sequestrectomy should only be carried out “when the sequestra are freely movable.” There apparently was still this fear of manipulation in the infected bone with the idea in mind of metastatic spread despite “the use of massive doses of penicillin.”

Last but not least, specific infections were apparently a widespread problem. Tuberculosis, syphilis, gonorrhea and actinomycosis presented frequently in the orofacial area and also affected the jaw bones. The old German textbooks are full of case reports and describe drastic surgical approaches with often negative results. When reading, for instance, how clinicians struggled when treating patients with actinomycosis, one can only utter a sigh of relief that we live in a different era. Brophy (1918) quite flatly states “that spreading usually takes place in the soft part of the neck and even mediastinum and that there is no cure!” Wassmund (1935) mentions also that there is a high mortality rate associated with actinomycosis but recommends irradiation on top of rinsing with potassium-iodine. This therapy was followed by many German clinicians until the 1950s as they all quote Wassmund as the proponent of irradiation (Pichler & Trauner, 1948). Even in 1952, Hofer and Reichenbach still mention potassium-iodine rinsing in combination with irradiation, although they also mention the use of penicillin and aureomycin.

1960–1990 As mentioned previously, the introduction of antimicrobial agents changed the approach to infectious disease drastically although the principles of incision and drainage remained valid and the old adage “ubi pus ubi evacue” the mainstay of proper management of an abscess. Textbooks written in this period all deal with odontogenic infections and emphasize the elimination of the cause by either extraction of the causative teeth or proper endodontic treatment (Thoma, Archer, Laskin, etc.).

Another factor that played an important role in the improved management of infectious disease was the introduction of better imaging as compared to the hitherto used plain radiographs. The orthopantomogram, CT scan, MRI and scintigraphy all contributed to the diagnostic capacity of the clinician. Most important were also the advances made in microbiology, in that better determination of the bacteria involved was possible. This had major consequences because the antimicrobial therapy could be directed specifically to the microorganisms involved. This was particularly important for deep space infections in which anaerobic bacteria are often involved.

Recommendations for the treatment of osteomyelitis and particularly the acute form included much more aggressive procedures than in the preceding period, including decortications and removal of sequestra along with proper antimicrobial treatment (Topazian, Goldberg 1981, Laskin, 1985). It is somewhat remarkable that there are relatively few papers written in this period on the subject of acute osteomyelitis.

In the early 1970s, the first reports appear on a special entity that was called chronic sclerosing osteomyelitis. It was Jacobsson et al. (1978) who emphasized the use of scintigraphy in the diagnosis of this therapy resistant lesion. Further diagnostic improvement was reported in 1984, also by Jacobsson, while the adjunct diffuse was added to the description of the condition. It is of interest to note that surgeons applied the techniques, as known from the suppurative form of osteomyelitis, including decortication and long term use of antimicrobials but with poor results (Montonen et al. 1990). There simply was no causative agent to be detected in most instances, which eventually changed the thoughts about this lesion and, consequently, the treatment.

The improved medication against tuberculosis, syphilis and other specific infections resulted in the fact that oro- facial manifestations were hardly mentioned anymore in the world literature. That does not imply that these infections did not occur but probably not in the developed world as much as they used to. It is likely that in the developing world, this was still a problem, but there were simply no OMF surgeons in many of these countries who were prepared to write about these diseases. A condition which had not disappeared is actinomycosis. Early recognition and proper antimicrobial treatment had, however, changed the picture

completely. Cervico-facial actinomycosis used to be a killer in the old days, posing enormous dilemmas for the surgeons involved. The days of surgical exploration and rinsing with potassium-iodine and/or sulfanilamide were definitely gone.

An excellent book on the management of infections of the oral and maxillofacial regions was presented by Topazian and Goldberg (1981), who described the state of the art in the early 1980s.

1990–2010 The fundamentals of the management of infectious diseases had not changed in this period but some new conditions occurred as a result of immune suppression, be it acquired or drug induced and because of the side effects of biphosphonates. Clinicians are also more alert to bacterial resistance to the commonly used antimicrobials because of overuse of these drugs over the years. Plain penicillin, for instance, used to be the drug of choice for any odontogenic infection because streptococci always used to be sensitive to this drug. In many countries that is no longer the case.

Patients with AIDS or persons carrying the HIV virus became a giant problem for healthcare providers and certainly caused the OMFS profession to be alert to the typical oral manifestations. In addition to that, these individuals are very sensitive to infections, including specific infections such as tuberculosis.

The surprise of this period was undoubtedly the discovery that biphosphonates cause osteonecrosis of the jaw bones (Marx 2003). Since this publication, a large number of cases have been reported, cautioning the profession to be alert. Infection is only secondary to the primary problem but long-term antimicrobial treatment is certainly important in the treatment, along with surgical debridement of all necrotic bone and tension-free primary closure of the overlying mucosa (Williamson 2010). This is similar to the treatment of osteoradionecrosis.

The debate about chronic diffuse sclerosing osteomyelitis went on and several new suggestions were made about its etiology and treatment. Van Merkesteyn et al. (1990) introduced the concept that the condition should be considered a tendo-periostitis because of overuse of the masseteric muscles. This idea was not unequivocally followed and probably rightly so, because promising results had been achieved by influencing the bone metabolism using calcitonin (Jones et al., 2005) and biphosphonates (Yamazaki et al., 2007 and Kuijpers et al., 2011). If these treatments appear to be successful in the long run, then this condition should no longer be considered an infectious disease.

As mentioned in the previous section, specific infections in the oro-facial area are rare but currently an interesting phenomenon can be observed. Tuberculosis is emerging again since there is increasing global resistance to antituberculous drugs (Kakisi et al., 2010). It presents itself mostly in the soft tissues and lymph nodes, of course, but apparently also in the maxilla and mandible and even the TMJ.

In the last ten years, several case reports of tuberculous osteomyelitis affecting the mandible have been described, especially by authors from developing countries and often in the pediatric and radiological literature. It often concerns extrapulmonary presentations of the disease and frequently occurs in HIV patients (Bendick et al., 2002). In the developed world, it remains a rare phenomenon and, in particular, the bones are rarely affected (Chaudlary et al., 2004) but the migration of people means that even in the western world, every once in a while, a surprise finding occurs (Heibling et al., 2010). Actinomycosis, of course, is still around but is usually diagnosed at an early stage and, therefore, easily treated. It may also still involve the jaw bones (Finley and Beeson, 2010).

Despite the improved dental care in many parts of the world, odontogenic infections are still relatively frequently encountered. The present generation of clinicians, however, has the tools to deal adequately with them. Yet, danger lies around the corner and a certain degree of alertness is warranted, because the course of events may still run out of control.

The most dramatic example is the evolution of a seemingly simple odontogenic infection into a fulminant necrotizing fasciitis. Although the first reports of this often fatal condition were described in the ENT literature in the late 1970s, because of pharyngeal infections, it soon appeared that odontogenic infections could also cause this dramatic spread, which is mostly based on a mixed infection.

It is particularly during the last two decades that numerous case reports have appeared in OMFS literature. The most frightening observation is that, recently, cases have been reported caused by staphylococcus resistant to methicillin (Zhang et al. 2010). Apart from this unusual but potentially fatal condition, resistance against the currently known antimicrobials is increasing and will, therefore, play a more prominent role in the future.

The massive number of AIDS and HIV infected patients in the developing world who are not adequately treated to control the underlying condition, still pose an enormous problem. Although better drugs are on the market, they are often not available for patients in the developing world (Bendick et al. 2002). Hence, it might be expected that unusual infections that were thought to be eliminated will appear again and even present in the developed world because of the migration of people.

Trauma

Before 1960 Although trauma has been with us since the dawn of time, it is only relatively recently that we have been able to approach it scientifically. For this reason, the reports of treatment do not necessarily follow any logical pattern, really amounting to a series of case reports contained within the literature from the earliest pre-Christian times to Egypt in 2000 B.C. when a dislocation of the mandible is described as well as a fractured mandible. Hippocrates, described reduction and fixation of mandibular fractures with strips of calico glued to the skin immediately adjacent to the fracture and laced together over the scalp. The ancient physicians of Alexandria and Rome also mention the ligation of teeth using fine gold wire or Carthugian leather strips glued to the skin. The principles laid down by Hippocrates really extended through the literature as far as the turn of the first millennium.

It was probably Salicetti in 1474, in Bologna, who first described the simple expedient of ligating the teeth of the lower jaw to the corresponding teeth of the upper jaw to effect immobilization of a fracture. Previously, it had been recognized that within three weeks, union of jaw fractures was complete.

The 16th and 17th centuries saw the introduction of gunpowder and the first reports of gunshot wounds. It was Ambroise Paré to whom we must attribute the first significant change in the management of facial wounds through copious irrigation of wounds and the application of balms rather than cauteries. His particular care to facial injuries and his application of what he described as “a dry suture” facilitated secondary healing of facial wounds, particularly compound injuries.

The next milestone was with Richard Wiseman, a surgeon in the latter part of the 17th century who described the management of maxillofacial injuries. As well as describing the signs and symptoms of a fracture, he also described many individual cases, including a child with a comminuted fracture of the cribiform plate of the Ethmoid. He also described the disturbance in occlusion and related protrusion or recession of the lower jaw and the destruction of soft tissues in association with these injuries (Rowe, 1971). These astute clinical observations were added to those studies of anatomy and physiology at the Italian schools of Bologna and Padua as the eighteenth century arrived. Together they laid the foundation for serious advances in the systematic management of jaw injuries.

Chopart and Desault (1780) were the first to describe a different type of approach by introducing the concept of a dental splint which consisted of a shallow trough of iron, inverted over the occlusal surface of the lower teeth, which they protected with cork on lead plates. A bar projected from the front in the incisor region, being bent at right angles and fastened by thumbscrews to a submandibular plate of sheet iron. Movement of the fragments was thus prevented by compression between the occlusal surface of the teeth and the lower border of the mandible.

Variations of this principle were employed during the next 100 years being introduced into Germany by Rütenick in 1799, who further stabilized the fracture by using a head harness, in England by Lonsdale in 1833 and the Netherlands by Hartigs and Grebber (1840) but each was a modification of the original principle which still found employment even after World War II for the fixation of some epithelial inlay splints in the edentulous mandible (Rowe, 1971). Different forms of supportive bandaging were introduced, accompanied by wedges of cork between the occlusal surfaces of the teeth to maintain the teeth apart and facilitate feeding. Slightly earlier than this, in 1825, Naysmith, co-operated with Robert Liston by providing a cast gold cap splint. This was soldered together and affixed to the teeth, where they had the effect of preventing displacement of the mandible in a mandibulectomy case, until the majority of the forces of soft tissue contraction had dissipated.

The advent of ether anesthesia in 1846 and chloroform a year later saw a significant increase in the scope for treating jaw injuries when Fouchard in France and Buck in the U.S.A. began to use direct intraosseous silver wires. Results were very variable due to the development of sepsis and consequently sequestration. A variation by Wheelhouse, involved driving silver pins through each piece of bone and winding silk thread around each pin in a figure eight to approximate the bone ends.

War has always provided opportunity for development in surgery and so it was with the American Civil War of 1861–1865 and the Franco-Prussian War of 1870–1871, in quick succession, a large proportion of mandibular fractures arising from horse-kicks or falls onto the chin as well as gunshot wounds.

In 1861, Gunning produced his splint, although he was probably unaware that it followed the same principle as the one developed by Naysmith in 1825. From dental impressions, a monobloc construction was produced and bound to the jaws by a bandage passing under the chin and over the vertex of the skull. Teeth in the line of fracture were extracted. Later in the war (1864) Bean, who treated many fractures, made a significant advance by sectioning dental models of the jaws and carefully realigning them before constructing a Gunning type of splint (Rowe, 1971).

The first reports of swaged metal splints appear simultaneously by Allport in America and Hayward in London. Allport’s gold splints were swaged so as to leave

1959 Croatian medical artist rendering of anterior open bite injury. During this time period, the use of medical artists was the only way of recording these injuries other than black-and-white photography. Courtesy of Miso Virag.

the occlusal and incisal edges free and having correctly aligned them, the splints were soldered together. Soft gutta-percha was used to attach them to the teeth. Hayward covered the occlusal surfaces of the teeth and also used soft gutta-percha for attachment. A separate sub-mental, gutta-percha splint was placed in position and a bandage or rubber bands used to connect it to two arms projecting from the splint and curving backwards around the commissures of the mouth. Despite further modifications by Kingsley, all these splints are essentially modifications of that original splint of Chopart and Desault of 1780 (Rowe, 1971).

The inherent weakness in all these splints was the lack of secure fixation to the jaws and various attempts now begin to appear to overcome this. Hamilton Adams in 1871 used fine nuts and bolts passing through the interdental spaces. Some three years later, Moon, in London used fine inter-dental wires to achieve the same result. It was at about this time that Woodward, in the U.S.A., melted down silver coins (silver & copper) to produce open cast metal cap splints, attached to the crowns of the teeth by small screws. The two splints were located to one another by lugs and through the means of eyelets soldered to them the jaws could be wired together, thus giving mandibular, maxillary or inter-maxillary fixation (Rowe, 1971). Although a significant advance, the very complicated nature of the process and the lack of a cementing medium for attaching the splints to the teeth meant that they did not catch on rapidly. However, attention is now shifting to the improved accuracy of reduction provided by focusing on the occlusion.

During the Franco-Prussian War, Hammond described using arch bars on both the lingual and buccal aspects fixed to the teeth by fine inter-dental eyelet wires. This was adapted in both the wiring of arch bars and the continuous loop method. At the same time, Suerson, in Berlin, was chiefly employing the Gunning principles, but, when treating malunions, conceived the idea of separate splints for each section and by driving wedges of hickory wood of ever increasing thickness between these, gradually realigned the arches. This seems to be the first account of an attempt at realignment of displaced arches.

In 1887, Gilmer returned to an almost forgotten technique, the direct wiring of teeth. This resurrection of an old principle, suitably modified, was a significant advance and became increasingly important as orthodontic techniques became adapted by surgeons to the treatment of fractures. Angle applied his principles of fixed anchorage points and individual bands cemented to selected teeth in each jaw as a means for restoring a correctly aligned dentition (Hoffman-Axthelm, 1985).

So now, for the first time, we see science being applied to the management of these injuries. This, together with the huge advances in surgery, occasioned by the introduction of anesthesia, the institution of antiseptic and later aseptic techniques and the introduction of x-rays for clinical purposes by Röntgen in 1895, changed the scene dramatically.

Other significant advances which followed at that time included the reconstructive work of Abbe, Estlander and Thiersch; the treatment firstly of fractured zygomas by Matas (1896) and then a middle third by Bouvet in 1901 and the surgical approaches to the zygoma of Lothrop (1906), Keen (1909) and Manwaring (1913), coupled with the description of fracture lines by Rene le Fort in 1901, meant that by the onset of World War I, surgeons were in a position to consider treating the mutilating injuries resulting from trench warfare. The scale of these injuries, 26 million casualties of the 56 million involved in armed conflict, was due largely to trench warfare and the destructive nature of the high energy explosives which rendered the face prone to more severe injuries than had previously been seen.

However, the sound principles laid down at the turn of the century did not undergo any radical change rather there were a series of refinements in techniques, often following the application of orthodontic principles to splint construction. Circumferential wires were used in

some cases, Gunning’s type splints in others, especially edentulous cases and both open and closed cast silver cap splints in dentate patients were used to a greater extent than previously. Fresh cases were treated by sectioning the models, restoring the occlusion in the laboratory and forcing the segments into the splints at the time of reduction and immobilization. In cases where treatment was delayed, reduction was effected using orthodontic techniques. The use of interdental eyelet wires was demonstrated by Ivy (1914) to be an effective way of providing intermaxillary fixation in the dentate patient and was increasingly practiced.

Quite independently, the same sort of development took place in the German-speaking part of Europe and in France. Splints, arch bars and the principles of traction to reduce displaced fragments also were used, as presented by Hoffman-Axthelm (1995). The name of Claude Martin from Lyon should be mentioned in this context, but also those of Bruhn, Hauptmeyer, Kuhl and Lindemann, (1915), Misch & Rumpel (1916) and Klapp & Schröder (1917), who devoted monographs to the treatment of the facial injuries of the military.

Replacement of both hard and soft tissues had reached a remarkable degree of sophistication with surgeons developing ingenious techniques to achieve outstanding results but sepsis, leading to gangrene, hospital-based infection as well as other general infections, all contributed to the high level of morbidity and mortality of that time. There followed certain specific improvements in the surgical care of facial fractures. Notable among these was the development at East Grinstead of sectional splints, one for each segment, linked together by intraorally located locking plates, which underwent later modification to be located extraorally. Middle third fracture management also underwent improvement where cheek-wires, first developed by Federspiel, were used to fix the posterior part of the maxilla to the plaster of Paris head cap (Rowe & Killey (1955).

The use of circumferential wiring, prosthetic replacement of soft tissues, the general management of soft tissue injuries, including the lavage with hypochlorite solution, all helped to keep down infection. However, the description of the use of the tube pedicle by Gillies (1917) and Faltrow (1917), the precision techniques of Kazanjian (1949), brought forward from World War I and improvements in bone grafting also demonstrated the need for special centers where reparative surgery could be carried out. It also saw the union of different like-minded surgeons from a variety of backgrounds resulting in improvements in patient care through a team approach.

In England, the first such center at the Queen’s Hospital in Sidcup was established under the leadership of Major Harold Gillies, who assisted in the care of jaw injuries by Kelsey Fry and Fraser. However, many other notable names were involved, including Kilner from the British Forces, Blair, Ivy, Kazanjian and Curtis from the American forces, Pickerill from New Zealand and Valadier working in France.

Both sides in the conflict adopted a principle of establishing field hospitals where teams of surgeons would work together providing stabilization of the injuries before evacuating the casualties to rear positions. In the case of the British and American forces, this often meant to the U.K. It was the need for rapid stabilization that led Adams (1942) to introduce his internal suspension techniques. The rate of evacuation was slow by comparison with the process in 2000 since air evacuation had not yet been developed.

By 1945, the end of World War II, there was an increasing realization that when bone ends are brought into close proximity with one another, more rapid healing occurs. With the advent of antimicrobials at the same time, a greater use of direct approaches to the fracture sites led to the advent of direct interosseous bone wiring or osteosynthesis. Such wires were generally applied to either the upper or the lower borders of the mandible and the fronto-zygomatic suture, all solid pieces of bone.

During this war pin fixation was used, particularly in the treatment of compound, comminuted and frequently

1961 Croatian medical artist rendering of middle third fractures. Courtesy of Miso Virag.

infected jaw fractures. Despite a reduction in their use, the concept was retained and used by Fordyce in the “Boxframe” technique. A variety of pins were used from the fine threaded Clouston-Walker pin, modified for the East Grinstead pattern and MacGregor pins to the coarse threaded, tapered Moule pin. It was not until the Vietnam War that the American forces came to use biphasic pin fixation, popularized by Morris (1949), that external pin fixation was again to become the treatment method of choice. In France, Ginestet (1958), working in the military hospital of Val de Grace, also favored percutaneous pins with fixation by an extraoral bar, fixed to these pins with screws.

The vast experience of the American, British and German surgeons with the treatment of injuries and the increase in traffic accidents led to the first comprehensive books on maxillofacial trauma written by Rowe and Killey (1955, 1968), Kazanjian and Converse, (1949, 1959, 1974), Dingman and Natvig (1964) and Reichenbach (1969).

1960–1990 With the advent of antimicrobials, recognition of the value of direct fixation became widely accepted in orthopedic practice and was adapted for maxillofacial purposes. Initially, direct bone wiring was used to control the edentulous posterior fragment in the mandible. Grossly comminuted mandibular fragments also were wired together.

Although the use of bone plates had previously been attempted, [Konig, (1905), Lambourne (1907), Lane, (1914) and Sherman, (1924)], it was not until Roberts (1964), Battersby (1967), Snell (1969) and Michelet et al. (1971) introduced stainless steel or vitallium mini-plates, fixed with monocortical screws, that the present vogue for use in the OMF sphere of surgery was established. The lack of malleability in these initial mini-plates limited their usefulness, for they broke just as soon as any attempt was made to bend them.

The introduction, initially of malleable stainless steel, followed by titanium, enabled Champy et al. (1976) to prepare a scientific basis for the application of mini-plates in the treatment of mandibular fractures through an intraoral route, although Michelet et al. (1973) had also recommended an intraoral approach. Inevitably, numerous clinicians and manufacturers provided their own modifications but the principles of application, as laid down by Champy et al., remained unchanged. Use of micro-plates has a particular role in the treatment of fractures in children.

Bioresorbable plates made initially of polylactic acid and more recently of a combination of this with other suitable materials, have been developed by Bos, (1983), Rozema, (1991) and Suuronen, (1992), using poly-L-lactide. The biodegradation tends to be accompanied by significant collection of fluid beneath the skin, probably caused by a foreign body, inflammatory reaction.

The compression osteosynthesis techniques of orthopedic surgeons were translated to maxillofacial surgery by Spiessl (1969), Luhr (1968, 1972) and Becker & Machtens (1970). The use of specially designed taps and matching screws allowed both cortices to be engaged, which, when combined with the specially designed plates, produced firm apposition of the fractured bone ends under a degree of compression. This results in primary bone healing by direct osteoblastic activity within the fracture, as opposed to the secondary bone healing through callus formation.

Intra-medullary pinning, the use of titanium as well as non-metallic mesh, particularly in the treatment of malunions and fractures of the edentulous mandible, all have a place. Williams (1994) developed a modification of the circlage principle in the management of fractures of the severely atrophic edentulous mandible.

Detailed descriptions of all these techniques were published in a textbook by Rowe and Williams, “Maxillofacial Injuries” (1985). Maxime Champy

1990–2010 One of the most significant developments in the management of trauma in recent years has been the evolution of immediate care as proposed in the U.S.A. with the introduction of the principles of “Advanced Trauma Life Support.” These principles have been advanced even further into the immediate management of injured military personnel: • Their extremely rapid evacuation by helicopter to highly equipped and staffed field hospitals where intensive care facilities are provided; • The almost immediate air evacuation to specialist units in the home countries by teams of intensivists who can ensure a continuity of care throughout the whole procedure. It is, in many respects, developments around resuscitation and immediate care that have improved the outcomes for all patients, including those with maxillofacial injuries, rather than any single surgical technique developed within the specialty.

However, the consequence of an earlier presentation of resuscitated patients and the move towards earlier surgery by trauma teams has meant that facial injuries are being tackled at an earlier stage. This led to a different approach with early exposure of fracture sites, direct plating of them and reconstruction of the facial skeleton from the cranial base downwards (Gruss & Mackinnon, 1986). This direct approach has greatly facilitated the rehabilitation of facial appearance but unless adequate attention is paid to the occlusion, function can be prejudiced.

With the move to shorter hospital stays and earlier mobilization of the injured, this development is in keeping with the overall modern philosophy of trauma management. There is always a risk that patients may be seen as being over-treated when simpler techniques may be more appropriate. This is a tendency to be avoided in the face of over-enthusiasm. Management of civilian injuries has always followed those acquired in armed conflict and the recent conflicts, both in Iraq and Afghanistan, have resulted in these principles of resuscitation and early intervention being taken forward into civilian practice.

Despite these advances, there remain controversies over the treatment of specific injuries and in some instances lessons of the past seem to have been forgotten. One notable example among these is those associated with fractures of the mandibular condyle both in children and adults (Izuka et al., 1991). There are many proponents of open reduction and rigid fixation of condylar fractures and several techniques have become available (Eckelt and Loukota, 2010). It is claimed that better functional results are achieved with these methods as compared to non-surgical treatment. Double-blind, randomized studies, however, are lacking and one cannot escape the impression that there is a tendency towards overtreatment.

Where children are concerned, Rowe, as long ago as 1968, urged caution and a conservative approach, a view shared by Walker (1994) and a lesson which was reiterated by Hovinga et al. (1999). In an almost identical series treated operatively with a wide exposure, Izuka et al. (1998) had later problems with all his cases. In adults Smets et al. (2003), in a retrospective analysis, concluded that only in cases of shortening of the ascending ramus by 8mm or more or where there was considerable displacement of the condylar fragment, was surgical intervention indicated. This was in keeping with recommendations formulated by Silvennoinen et al. (1992).

Ellis (1999) noted significant positional changes in the condylar fragment during conservative treatment and concluded that care needed to be exercised before basing treatment decisions on the degree of displacement. So, the fact that open operation and internal fixation is clinically feasible through a variety of approaches and techniques does not mean that condylar fractures should always be treated in this way.

Enormous improvements in technology have resulted in better diagnosis of the detail of severe injuries, yet even with that degree of sophistication, there remain areas where application of reconstructive surgery fails to produce the expected outcome. A good example of this is with orbital fractures. Here the use of axial tomography by Koorneef & Zonneveld (1987) demonstrated not only the exact location of injury but also the soft tissue damage caused by the trauma. Development of their techniques enabled the estimation of orbital volumes and the construction of grafts of appropriate volume for use in reconstructive surgery. Further refinement of this technique became possible with the introduction of 3D computed models.

Studies on unaffected orbits might be helpful in creating pre-shaped implants particularly for the posterior portion of the medial wall and floor of the orbit (Kamer et al., 2010). Although various forms of allografts have provided a means for restoring orbital volumes, the conical nature of the orbit is very difficult to mimic, thus good results are not reliably achieved.

The developments in resuscitation, CT scanning, wide open reduction, internal fixation, immediate bone grafting and soft tissue handling have revolutionized the potential for restoring the pre-injury appearance and function of patients, sustaining pan-facial fractures. The facial buttresses remain the key to satisfactory reconstruction, a feature stressed by others in previous years, notably Sicher & Tandler (1928), Rowe & Killey (1955) and Merville (1974). The use of bone plating, coupled with a wide exposure of the buttress fracture sites will produce a rigid fixation but, as shown by Ellis and Walker (1996), absolute rigidity is not always consistent with optimum healing and can easily produce a malalignment of the dentition, a feature not usually seen where the correct establishment of the occlusion was one of the basic requirements for satisfactory restoration of function.

Drawing all these developments together, there has emerged a drive in the U.S.A. to establish major treatment centers capable of providing the full range of treatments for these patients. A similar move in the U.K. by the Royal College of Surgeons (2010) has recognized the value of such an approach but, in line with many European countries, recognized the local geography as well as the distribution of the population makes such centers impractical. However, a system of networking can provide the same type of clinical expertise.

Clinical pathology

Before 1960 It is virtually impossible, within the scope of this section, to provide a complete overview of the development of this branch of OMF surgery since the space allotted is limited. For this reason, a choice had to be made of those lesions that appear to occur with enough frequency to warrant a historical description. The authors acknowledge that this may lead to an arbitrary description of the course of events in clinical pathology and that some rare but interesting lesions are left out but the main aim is to emphasize particularly those topics that had a significant impact on the daily practice of surgeons.

At this stage, terms as we know them today, with regard to the pathology that may occur in the oral cavity and the jaws, were, for a large part, already known for more than a century. Particularly the etiology and pathogenesis of odontogenic cysts but also many odontogenic and non-odontogenic tumors were described in the period before World War II. For the sake of understanding the development in the periods to be described, it is necessary to go briefly over the early development, especially of cysts and odontogenic tumors.

It was the Frenchman Magitot (1872), who first recognized that all cysts of the jaws had to do with teeth: “tout kyste spontanité des machoires est de nature essentiellement et exclusivement dentaire.” He also coined the term “follicular cyst,” instead of dentigerous cyst, realizing that the cyst originated from the tooth follicle. The term dentigerous still exists today but only points towards the fact that a tooth is inside the cyst. Most importantly, however, he recognized the epithelial lining as an essential part of the lesion.

Before this time there were several theories of which the so-called “mesoblastic origin” prevailed, particularly in the Anglo-Saxon world. Malassez (1885) described the epithelial islands as found in the periodontium of teeth. He was at that time not aware of their origin, despite the fact that Hertwig (1874) had already discovered the epithelial sheath in amphibians that is essential for root formation. Malassez (1885) did, however, link his finding to the origin of radicular cysts, a name that he ascribed to Aguilhon de Sarran (1884). It was von Brunn (1874) who discovered the epithelial sheath in the developing human tooth, while Partsch (1892) finally formulated the presently accepted theory about radicular cysts that these cysts originate on the basis of epithelial proliferation in an apical granuloma.

This non-intentional French-German cooperation completely escaped the English-speaking world until Turner (1898) also discovered epithelial islands in the wall of cysts and disregarded the “mesoblastic origin” of cysts. It illustrates again the ignorance that existed, mainly because of the language barrier and the handicap of not being able to communicate in one scientific language.

More importantly, it was also Partsch (1892), who came up with a rational treatment that is still currently valid. He advocated what we today would call marsupialisation and to keep the opening patent until the defect was shallow enough to allow for easy cleansing. In 1910, he recommended enucleation and primary closure for small cysts. Apart from these two odontogenic cysts other, rarer types were described over time; naso-labial (Klestadt, 1913), naso-palatine duct (Meyer, 1914), lateral periodontal (Bauer, 1927) and primordial (Kronfeld 1933).

The first attempt at classifying odontogenic cysts and tumors stems from Broca (1866). He also introduced the term odontoma, which was used later by several clinicians for various odontogenic tumors in a very confusing manner. For instance, Axhausen (1940) describes clearly an ameloblastic fibroma but calls it a soft tissue “odontoma.” The term “ameloblastoma,” instead of adamantinoma as it was called before, was suggested by Ivy and Churchill (1930). The term adamantinoma, however, suggests the presence of enamel and was, therefore, less desirable.

Thoma & Goldman (1946) finally presented the first useful classification based on a differentiation between epithelial, mesenchyemal and mixed tumors. They reserved the term “odontoma” for the types we presently know but also recognized soft tissue odontomas. In the course of time, many classifications would follow.

Most other tumors that occur in the mouth or jaws were described in books on general pathology, or were written up as case reports in various dental or surgical journals. A major turnaround came with the publication of the first edition of Thoma’s “Oral Pathology” (1941). In retrospect, one can only have the greatest admiration for this giant in both oral surgery and pathology alike. This very comprehensive text contained all diseases and pathological conditions of the mouth and jaws known at that time, including oral manifestations of metabolic and other general diseases.

Thoma had already written a book in 1934 entitled: “Clinical Pathology of the Jaws.” Born and educated in Switzerland, he understood both German and French, something that becomes very obvious when reading his texts as he frequently refers to German and French sources. In the introduction he writes: “This textbook on pathology not only covers the histological study of oral disease, but also endeavors to correlate the microscopic picture with the roentgen and clinical findings, thereby demonstrating the value of pathology as a vital part of clinical practice.” He was the right person to make this statement since he was unique in combining the two disciplines, which nobody

after him would ever be able to copy. His book had four editions during this period and served worldwide as the “bible” of oral pathology. In 1960, the fifth edition appeared written together with Goldman.

It is not surprising that oral pathology had its roots in the U.S.A. A whole generation of well-known oral pathologists was educated in the U.S.A. where this was a dental specialty from 1950. The Academy of Oral Pathologists was established in 1947. This academy was also one of the co-founders of the first journal on Oral Surgery, Oral Medicine and Oral Pathology in 1958, with Thoma as editor-in-chief. The first volumes of this journal are full of case reports of all sorts of pathological conditions, with an emphasis on cysts, tumors and other conditions that typically arise in the mouth and jaws.

Oral pathology was, thus, a well-organized and respected specialty in the U.S.A. with some outstanding clinicians who have contributed substantially to the current knowledge. Among them are Shafer, Hine and Levy, who published another classic text in 1958: “A Textbook of Oral Pathology.” This book was also upgraded and reworked over the years and eventually four editions appeared, the last one in 1983. A handy atlas that many surgeons had at reach when doing clinics was Bhaskar’s “Synopsis of Oral Pathology,” which first appeared in 1961 and had five subsequent updated editions.

Despite the American dominance in oral pathology, some European colleagues also made a significant contribution during this period. Particularly the group around Pindborg in Copenhagen, Denmark, who were very successful in discovering some novelties. Philipsen (1956) first used the term “Keratocyst” and described the typical histology in the Danish dental journal. Before that time, this cyst was often called a cholesteatoma.

Pindborg & Hansen (1963) first mention the high recurrence rate, up to 60 percent, of these cysts. This was soon followed in several European follow-up studies with a substantial number of cases (Panders & Hadders, 1969 and Browne, 1970). It is somewhat surprising, given the number of oral pathologists in the U.S.A., that it took approximately ten years before American studies appeared (Payne, 1972 and Donoff et al., 1972), showing the same tendency. Another novelty was the first description of the odontogenic calcifying tumor by Pindborg (1958), followed by the description of the calcifying odontogenic cyst by Gorlin et al. (1962). Lucas, finally, published the first British book on “Pathology of Tumours of the Oral Tissues” in 1964.

A key paper with great impact on the surgical management of ameloblastomas appeared in 1958. Small and Waldron recognized the infiltrative growth of ameloblastoma and as a consequence, advocated resection of at least 1cm of healthy looking bone beyond the apparent radiological margins. This paradigm is still valid and followed by many surgeons today.

The publication of the first edition of “Syndromes of the Head and Neck” by Gorlin and Pindborg (1964) was an eye opener for most clinicians. It had an enormous impact on the day-to-day practice of many surgeons and made them realize that solitary findings in and around the oral cavity could be signs of systemic conditions. This book can be considered the beginning of the serious study of dysmorphology within the head and neck area.

Robert Gorlin

1960–1990 During the next period many new discoveries were made and further refinement of the existing classifications of cysts and (odontogenic) tumors was carried out (Pindborg & Kramer, 1971). Since the clinical implications are particularly important, the discussion will be limited to those topics with implications for surgery.

Cysts of the jaw received much interest and several monographs appeared on this topic, with recommendations on their treatment (Killey & Kay, 1966, Shear, 1976). A German text, (Harnisch, 1971), completely ignores the findings of Gorlin and Pindborg and largely refers to old German literature, not paying much attention to the importance of the histology. The two items that were of clinical importance are the unicystic ameloblastoma and the odontogenic keratocyst simply because of their potential aggressiveness.

In a key paper, written by Vickers and Gorlin in 1970, they describe early histopathological features of neoplasma in cysts, unequivocally proving that ameloblastomas can originate from cysts. The term “unicystic ameloblastoma” stems from Robinson and Martinez (1977), who emphasized the differences from the solid or multicystic variant. Ackerman et al. (1988) reclassified this entity in three subtypes with diagnostic and therapeutic significance. Since that time, numerous studies have appeared that either are pro- or contra-aggressive treatment of these unicystic ameloblastomas. This dispute lasted throughout this whole period and would, more or less, be settled some 20 years later (Lau & Samman, 2006).

The story of the odontogenic keratocyst (OKC) is no less interesting or complex. Numerous retrospective studies also have appeared about this condition, focusing on the clinical, radiographic or histological features and, above all, showing a high recurrence rate varying from 10-60 percent

depending on the follow-up period and the way the followup was organized. Stoelinga (1971) and Stoelinga and Peters (1973) showed that the possibility existed for epithelial islands, located in the mucosa overlying these cysts and probably derived from the basal layer of the mucosa, to play a role in the origin and tendency for recurrence. The ultimate proof of this hypothesis would come in the next period. The multiple occurrences of OKC’s in the “Multiple Basal Cell Naevi Syndrome” (Gorlin & Goltz, 1960) also drew a lot of attention and many colleagues found that this syndrome is not rare at all.

One more lesion that deserves attention in this context is the “Central Giant Cell Granuloma” (CGCG). A key paper was written by Chuong et al. in 1985. They emphasized the difference between aggressive and non-aggressive lesions. In those days curettage or curettage with peripheral ostectomy was common practice (Eisenbrud et al., 1988). No mention was made of any recurring or aggressively growing lesion after therapy, as is currently known.

Two more editions (1976, 1990) of “Syndromes of the Head and Neck” appeared during this period with Gorlin as first author. Each new edition contained a considerable extension of new syndromes, which meant that the clinicians had access to the wealth of knowledge of these authors and their contributors.

Under the auspices of the World Health Organization (WHO), two publications appeared that were also of interest to the OMF Surgeon: “Histological Typing of Oral and Oropharyngeal Tumours” (1971), and “Odontogenic Tumours, Jaw Cysts and Allied Lesions” (1971). Both of these books contained up-to-date information of the growing knowledge about these lesions and subsequent editions, appearing in the next period, would attest to the increased insight into these conditions, largely gathered in this period. This is especially true for the non-neoplastic bone lesions such as, among others, cemento-osseo-fibrous dysplasia. The clinical implications, however, were somewhat limited because, for surgeons, the overriding factor is whether the tumor needs to be resected with a wide margin or whether enucleation is sufficient. One very relevant clinical change included the name change of “adenoameloblastoma” into “adenomatoid odontogenic tumor,” which put it in the benign non-aggressive category.

1990–2010 Further progress was made with regard to the understanding of the clinical presentation and pathological behavior of various tumors, both odontogenic and non-odontogenic, mainly through analysis of large case series. For instance, Reichart et al. (1995) presented a biological profile of 3,677 cases of ameloblastoma and revealed that more than 50 percent of recurrences occurred in the first five years postoperatively. Strong support was given for resection of these tumors with margins up to 2 cm into healthy bone by MacIntosh (1991) and Williams (1993).

Gortzak et al. (2006) however, on the basis of growth characteristics of large mandibular ameloblastomas, made a plea for a more conservative approach. They discovered that small tumor nests were found in the cancellous bone but none further away than 4 mm. They did not find any invasion into the subcutaneous tissues either and found the periosteum to be a good barrier. They also suggested, following the recommendation of Nakamura et al. (2001), saving the inferior alveolar nerve, where possible, since in none of their specimens was the nerve invaded, nor in the specimens from Nakamura et al.

A thorough overview of a large number of unicystic ameloblastomas was presented by Philipsen and Reichart (1997). They concluded that those cysts with intramural proliferations must be treated radically. The ongoing discussion on the preferred treatment of unicystic ameloblastoma was well illustrated in a paper from Lau & Samman (2006). Enucleation and treatment with Carnoy’s solution came out favorably in their systemic review, second best after resection but much better than enucleation alone. This was also the case with cysts with intramural proliferations reaching to the periphery of the cyst wall. Considering the morbidity that goes along with resections, in their opinion, the second option is to be preferred.

There were also some case series reported on rare but aggressive tumors, such as odontogenic myxoma, that give insight into the clinical presentation of these lesions (Simon et al., 2004). The other odontogenic tumors are extremely rare, apart from odontoma and usually completely benign. The most updated WHO classification is from 2005. This issue also contains a section on non-odontogenic tumors and bone-related lesions, with brief recommendations for treatment. Since most of these tumors are benign, simple excision is often the method of choice, the exception being the central giant cell granuloma (CGCG) and some aggressive fibrous dysplasias.

Various new approaches to the treatment of CGCG came to the surface during this period. It began with intralumin injections of corticosteroids (Jacoway et al., 1988), followed by calcitonin therapy (Harris, 1993). Both therapies appear to have limited value and are certainly not the solution in all cases (de Lange et al., 2006). Kaban et al. (2002) introduced the concept of inhibiting the angiogenesis in some aggressive CGCG’s by treating them with interferon alpha.

The cystic lesions of the jaws, still representing the bulk of the pathology seen in an OMFS practice, underwent a reclassification again as two new entities were incorporated;

the glandular odontogenic cyst (GOC) and the botryoid cyst. Both are to be considered aggressive in that they have a strong tendency to recur after simple enucleation or curettage. The GOC was described in 1987 by Padayachy and van Wyk but they used the term sialo-odontogenic cyst. Gardner et al. (1988) introduced the term “GOC” and that is the name used in the WHO classification from 1993. The term “botryoid cyst,” although mentioned by Weathers and Waldron (1973), came into fashion during the late 1980s, but reports of case series appear in the 1990s and later (Gurol et al.,1995 and Ramer & Valauri, 2005) This multilocular lesion has a strong predilection for the body of the mandible. In other words, the differential diagnosis of cysts had substantially expanded over the years, with important clinical implications.

The story of the OKCs came to a surprising apotheosis. An extensive report of all the recent research can be found in “Cysts of the Oral and Maxillofacial Regions” from Shear and Speight (2005). The WHO experts from 2005, as well as the authors of the aforementioned book acknowledge that the origin of some keratocysts is located in the overlying mucosa as a result of offshoots of the basal layer of the mucosal epithelium. This is in accordance with the theory as proposed by Stoelinga in 1971 and 1973 and repeatedly mentioned in subsequent studies.

A prospective study on 82 keratocysts revealed that the epithelial islands often found, were almost always located in the area where the cyst is connected with the mucosa (Stoelinga, 2001). This has serious implications for the surgical treatment of these lesions. Last but not least, the experts of the WHO renamed the lesion “Odontogenic Keratocystic Tumor,” which also correctly identifies the role of the epithelial clusters so often found in the wall of these cysts. During this period, several new textbooks on oral and maxillofacial pathology appeared in many languages, among them Cawson et al. (1996). It is simply not possible to mention them all but it certainly reflects the importance of clinical pathology for the average OMF surgeon. An exception will be made for the book of Marx and Stern (2003), because it has the advantage that recommendations for the surgical management are emphasized. It was also provided to the participants of the 17th ICOMS in Bangalore as a gift from the organizing committee. What a generous gift it was!

In summary, clinical pathology underwent an enormous evolution and is probably still developing. The more we seem to understand, the more questions arise. The more sophisticated techniques with which to investigate tumors and other lesions has led to a refinement in the diagnostic practice that 50 years ago was unthinkable. Yet, the words of Thoma (1941) are still valid; “surgeons need to have a thorough understanding of pathology in order to make rational decisions.”

Robert E. Marx

Oncology

Before 1960 The early origins of the management of carcinoma of the head and neck follow much the same pattern as for other areas of the body, simply because of the lack of any obvious means with which to treat the disease. The lack of understanding of the pathophysiology and the spread of cancer was only resolved by the works of the early anatomists, as reviewed by Subramanian et al. (2006), notably Gaspar Asellius (1622), Antony Nuck (1692) and Paolo Mascagni, who published the first description of the lymphatic network in 1787.

A little later, several authors reported their studies on the functional anatomy of the lymphatic system. Astley Cooper (1840) reported the presence of breast cancer cells in the lymphatics, thereby demonstrating spread through these channels and Virchow (1860) showed that lymph nodes formed a barrier to arrest further dissemination of these cancer cells.

It was these studies that led Warren (1847) to perform an experimental dissection of carcinoma in the neck and Kocher (1880) excised a carcinoma of the tongue with an incontinuity dissection of the regional lymph nodes.

Butlin (1885), Jawdynski (1888) and Regulskiy (1894) all removed tumors and their associated lymphatics for oral carcinomas but the major breakthrough came in 1906 when Crile published his paper on the technique of radical neck dissection. Although the technique seems very similar to that of Jawdynski, the fact that it received much wider publicity meant that his ideas spread rapidly.

In essence, he believed that head and neck cancer was a local disease and, therefore, that each case should be curable by a complete excision. This theory was built on the observation that in less than one percent of cases was there any evidence of secondary cancer in distant organs. He believed, therefore, that the logical technique was that of a “block dissection” of the regional lymphatic system, as well as the primary lesion and that such a dissection was indicated whether the nodes were palpable or not. He also believed that the handling of the carcinomatous tissue should be strictly avoided as long as the lymphatic channels remained intact, thereby avoiding further dissemination of the growth.

The limits of Crile’s resections were: the clavicle, the strap muscles and the posterior border of sternocleidomastoid muscle. He removed the sternocleidomastoid muscle, the posterior belly of the digastric muscle, internal jugular vein and the accessory nerve, leaving the platysma intact. In this way, he believed that cases of carcinoma of the head and neck should yield better results than for any other portion of the body!

In parallel with these surgical developments, Röntgen (1895) discovered X-rays and Leopold Freund (1897) successfully treated a young girl with a superficial “naevus” by using them (Heilmann, 1996), while others reported similar success, notably with lupus. Initially, treatments focused on superficial lesions but by 1889, other sources of radiation, such as thorium and uranium as well as radium were recognized. The use of radiation to treat deeper tumors was some time in coming about and only in 1912 did Coutard, in France, develop treatment for head and neck tumors with fractionated, low-dose radiotherapy. He used one or two low-dose fractions per day, extended over at least two weeks and longer for larger tumors, which provided significantly less oedema and necrosis than with single-dose treatments (Jungling, 1924). This was the period when hyperfractionation was first discovered as well as the relationship between single-dose treatments and late complications.

The use of applicators which contained buried sources of radium, usually as needles, were also introduced at this time, largely for treatment of lesions of the cervix. These delivered beta particles, very effectively over shorter distances but lacking deeper penetration.

Progress between these early observations and 1960 was focused on the one hand on the use of radiation and how to use it to the greatest effect without causing excessive oedema and necrosis. On the other hand, the surgical approaches necessary to effectively eliminate the disease were balanced with the feasibility of successful restoration of function following excision of the primary lesion.

Both the radiotherapists and surgeons were involved in the evolution of training but, unfortunately, there was singular lack of exchange of results or ideas between them. The development of fractionation and rotational therapy were significant advances, yet both were surrounded by controversy. Wintz (1937) argued for single-dose therapy on the basis that the cells of the body were endowed with variable radio-sensitivity and capacity to recover from radiation damage, depending on their cellular metabolism. Furthermore, in a rapidly growing tumor, cells recover more rapidly than do adjacent connective tissue cells with their slower metabolism. Therefore, the difference in response will favor the tumor cells if the cancericidal dose is not given in the first instance.

Counter to this was the biological argument that in the same tumor, there would be cells of different sensitivity, depending on what stage of the division cycle in which they were found. For this reason, it was more logical to use smaller daily doses to catch the most advantageous time for irradiation. In 1924, the Roentgen was introduced as a unit and provided a major step in determining the exact dose of radiation.

By the 1930s, it became evident that high energy photons were advantageous in radiotherapy. The Siemens Company developed tubes capable of delivering up to 1000mV and gamma rays were used in radiotherapy, while the possible use of neutrons was first mentioned. Subsequently, the therapeutic use of these megavoltage machines was developed and in addition to the Betatron, linear accelerators were being built (Heilmann, 1996).

From the point of view of head and neck specialties, the introduction of electrons was important in developing techniques for focusing more precisely on the primary site than was feasible with gamma radiation. This fundamental development in treatment reduced oedema and necrosis significantly.

It was also during the 1950s that attention was turned to the possible use of chemotherapy. Unfortunately, solid tumors of the region were found to be resistant to each of the commonly used agents. Nevertheless, there was a strong belief that this form of therapy would find a solution to the systemic management of cancer and research into their use persisted. It took a further decade before methotrexate and, subsequently, bleomycin, were seen to have beneficial effect, particularly on premalignant, superficial lesions.

In an attempt to flood the tumors with higher doses of the therapeutic agents, intra-arterial regional perfusion was attempted, similar to that tried in the limbs for the treatment of melanomas. Unfortunately, this was unsuccessful and simply produced a series of patients with green faces caused by the methylene blue dye used to define the anatomical area supplied by the artery involved!

The parallel surgical developments during this time are best reviewed from the point of view of the regional lymphatics and the primary lesion. It is true to say that surgical reconstruction of orofacial defects was very much in its infancy and the available techniques were more appropriate for traumatic or congenital defects than for those produced by cancer surgery.

During this time, however, surgery to the neck nodes made significant progress. The standard, set by Crile, served until 1951 when Hayes Martin contended that a routine prophylactic radical neck dissection was not practical in the management of cancer of the tongue and lips (Carlson et al., 2006). This was drawn from an extensive review of almost 1,500 radical neck dissections carried out between

1928 and 1950; his statistics being drawn from some 655 operations on 599 patients. He concluded that prophylactic radical neck dissection was illogical and unacceptable for cancer of the oral cavity. He also contended that no one could carry out prophylactic radical neck dissections to a degree sufficient to effect significant improvements in cure rate; the radical neck dissection was too radical a technique for the N0 neck.

This paved the way for the development of several modifications of the radical neck dissection which, while retaining oncological safety, reduced the significant morbidity which was so prevalent with the radical procedure. These modifications sought to retain the sternocleidomastoid muscle, spinal accessory nerve and internal jugular vein or at least one or two of those vital structures.

Surgical reconstruction of primary lesions during this same period was still very limited to simple bone grafting and the use of split skin grafts. The techniques of soft tissue transfer were being developed but it was really in the period after 1960 that so much change occurred.

Although salivary gland tumors were recognized long before 1960, their pathophysiology was poorly understood and consequently, their clinical management was inadequate. Broca (1866) assumed that the most common tumor of the salivary glands was of a mixed epithelial and mesenchymal origin. This long-standing assumption continued with clinicians and pathologists alike until halfway through the 20th century. This lack of understanding can be explained on the basis that these tumors are relatively rare and often treated by clinicians from different disciplines. Consequently, it was some time before sufficient cases existed as a series from which conclusions could be drawn.

One of the earliest authorities in this area was Rauch (1959), who published his experience of some 4,245 cases of pleomorphic adenomas, clearly stating that this was an epithelial tumor presenting with a variety of histological patterns. Surgery of the salivary glands at this time tended to be reported in an anecdotal fashion and benign tumors, including pleomorphic adenomas, were enucleated or treated with a wedge excision.

It is obvious that clinicians struggled with the assumed multifocal presentation of pleomorphic adenomas, since high recurrence rates were published, as was illustrated in papers by McFarland (1941,1943), who recommended radiotherapy for these tumors, since the high recurrence rates were attributed to their multifocal character. The approach changed with the results presented by Bailey (1941), who emphasized the need to remove the whole superficial lobe of the parotid with preservation of the facial nerve. This set the standard for years to come, with surgery and radiotherapy being advocated. Even so, the recurrence rate was still 15 percent (Corcoran et al., 1983). These same authors proposed the use of radiotherapy followed by surgery for all parotid tumors but their survival rate was only 30 percent (Gallegos et al., 1991).

1960–1990 The significant improvements in the treatment of cancer of the mouth and associated structures, as seen during this period, are well recorded by Loré (1962) as well as in his subsequent books. This theme was taken up by Soutar and Tiwari (1994), who demonstrated not only the value of systematic excision but also the use of osseomyocutaneous flaps in reconstruction.

In the U.S.A., the importance of specialization was seen at the Memorial Sloan-Kettering Cancer Center, where Shah collated their results in his publications (1996).

During this period, through several review articles and monographs, the specific pathology of salivary gland tumors became much better understood, particularly with reference to the pseudo-encapsulation of the pleomorphic adenoma (Eneroth, 1964, 1971, Thackray, 1972, 1974). This in turn led to a rational approach to parotid and other major salivary gland tumors, as well as to those of the minor salivary glands which, although much less common, were more frequently malignant when they did occur.

Removal of the superficial lobe of the parotid was standard treatment, the facial nerve being preserved. Frozen sections were recommended for appropriate diagnosis on the spot and if necessary, the deep lobe was removed when the tumor was found to be located within it. Malignant tumors were often treated with additional neck dissection and/or radiotherapy (Rankow & Polayes, 1976). Tumors of the submandibular and sublingual glands were approached with great caution because of their propensity to be malignant lesions. Rankow and Polayes recommended complete removal of these glands with preservation of the lingual and hypoglossal nerves, resulting in excision biopsies, to avoid the seeding of malignant cells into the wound bed.

The work of Thackray et al. (1972, 1974) laid the foundation for all classifications of these tumors in the years to come. This included all the benign as well as all of the malignant tumors, including the well-known adenoid cystic and adeno-carcinomas, together with the mucoepidermoid tumors and the great variety of histologically different tumors that may occur in both the major and minor salivary glands, with differing prognoses that tended to confuse the clinician.

The first tissue flaps to be used extensively were those classified as axial pattern flaps, marked by having their own arterial blood supply and, in use, they were transposition flaps, which meant dependence on this blood supply until

vessels grew in from the periphery. It is not the purpose of this book neither to evaluate each variety nor to explore the full scope but some of the commonly used ones are worthy of mention because of their position in the specialty’s evolution. The first and most commonly used flap was the lateral forehead flap, based on the anterior branch of the superficial temporal artery, which forms a midline corkscrew anastomosis with the matching artery on the opposite side. This allowed use of the entire forehead skin, from one zygomatic arch to the other. The donor site was made good with a thick split skin graft. This was a true “workhorse” flap of that period, which, in addition to surface coverage use, could readily be inserted intraorally for lining use or doubled on itself to provide both.

The second major flap was the deltopectoral flap, developed by Bakamjian and Poole (1977). Based on the perforating vessels of the internal mammary artery. This large and versatile flap could be extended out to the shoulder, providing a large amount of tissue for closure of extensive defects but, additionally, it could also be folded on itself to provide lining as well as coverage for through and through defects.

Further axial pattern, transpositional flaps were developed, notably the pectorals major myocutaneous flap, based on the thoracoacromial branches of the axillary vessels, the latissimus dorsi flap which, as well as being supplied by the thoracodorsal branches of the subscapular vessels, also received multiple vascular pedicles on its deeper surface. This flap could also include a pedicled muscle and bone flap of serratus anterior and subjacent rib, which could be used to reconstruct the mandible.

Finally, where facilities and expertise existed for major reconstruction, microvascular anastomoses allowed for the development of free flaps, the first and most important of which was the radial forearm free flap (known as the Chinese flap), Yang et al. (1981) This flap has been extensively used, including the split radius to reconstruct lost parts of the mandible (Vaughan,1990). It still has its place in reconstructive surgery but other types of flaps have largely replaced its use.

Although many have been described, those most used include the latissimus dorsi flap (Bailey & Godfrey, 1982); the dorsalis pedis flap with its long pedicle of larger vessels (McLeod & Robinson, 1982); the SCIA groin flap (O’Brien et al.,1979), based on the superficial circumflex iliac vessels and the DCIA flap, based on the deep circumflex iliac vessels and providing a compound bone and skin flap with a long vascular pedicle (Saunders & Mayou, 1979, Taylor & Townend, 1979). Where bone grafting was not indicated, a titanium implant could be fitted to the lingual aspect of the mandible to retain its overall shape (Bowerman & Conroy, 1969).

It is timely to reflect on surgery to the neck nodes during this period. Bocca and Pignatano (1967) published their work on a more conservative functional neck dissection, where only the lymphatic tissue of the neck was removed, rendering it a more appropriate operation for the N0 neck. Recurrence rates for these dissections, both for N0 and neck positive patients were low at 8.1 percent and Calearo and Teatino (1983) achieved 3.5 percent, thereby justifying such a treatment as against the radical neck dissection for these patients.

Research by Woolgar (1988) demonstrated that upon serial sectioning of material from block dissection specimens, micro-metastases could be demonstrated in previously described, pathologically negative specimens. Furthermore, there could be “skip” areas between such deposits.

In 1991, Robbins et al. recommended a standardized classification of all neck dissections, dividing the neck into levels I–V depending on the anatomical location of the nodes. This facilitated discussion on management as well as pathology. The supra-omohyoid neck dissection had attracted attention as a possible means for staging in the management of the N0 neck associated with oral carcinomas. This involves removal of levels I–III of the lymph nodes, preserving the other structures, but it is no replacement for elective neck dissection, although it does help to address the issue of occult disease.

What was ascertained in this period was the need for combining techniques but in that process, never to compromise the full therapy of one mode in the mistaken belief that two types of treatment reinforced one another and hence, demanded less than the full regime of either. For the majority of head and neck lesions, surgery and radiotherapy produce the standard against which any alternatives should be measured.

1990–2010 The improved histopathological investigation of neck dissection specimens demonstrated by Woolgar (1997, 1999) came in association with what might be seen as the next era and be referred to as “super-selective neck dissection.” This approach, originally developed for melanoma patients, specifically analyses lymphoscintigraphy guided biopsies of sentinel nodes. Meticulous examination of these specimens showed that even microscopic extracapsular spread had a profound influence on the progress of the disease and such detail is likely to be mandatory if progress is to be made. Immunohistochemical analysis has been shown to be a feasible way of examining this pathological material, as have other molecular techniques. Elsheikh et al. (2006) concluded that molecular analysis is exquisitely sensitive in detecting very small cancer deposits within lymph nodes.

With the emphasis on unraveling of the sequences of the human genome, it was to be hoped that new avenues of treatment might be open to the management of oral squamous cell carcinoma. Unfortunately, the genome of oral cancer has proven to be extremely complicated. Progress along this route is consequently much slower than had been hoped (Fernandez, 2011).

Surgically, the potential for the development of endoscopic neck dissection has been demonstrated clinically by Weiner et al. (2004) but it will take some time before the oncological value of such an approach can be assessed.

When it comes to the primary lesion, the experience gained with the use of microvascular surgery has led to the use of various flaps with successful incorporation of bone grafts, suitable for the placement of implants, both for the mandible and maxilla (Urken et al., 1997, Chan et al.,1997, Bak et al., 2010, Bianchi et al., 2010). Whether this has led to a higher patient satisfaction, however, remains to be seen (Schliephake & Jamil, 2002).

As a consequence of the enormous success of microvascular grafts for the reconstruction, particularly of lost parts of the face, the first successful human allograft of facial tissue, for replacement of cheeks and lips, was carried out by Devauchelle et al. (2005). Further developments in tissue transfer include the use of double flaps for extended composite defects, particularly of the chin area (Gaggl et al., 2007). Tissue engineering, of course, holds promise, but has certainly not achieved a stage where it will replace currently used methods (Terheyden et al., 2004, Warnke et al., 2006, Suuronen, 2010).

The WHO Classification of salivary gland tumors (Eveson et al., 2005) has further refined the terminology within these neoplasms. In clinical practice, only five salivary gland carcinomas are likely to be encountered (Speight & Barrett, 2009). These authors also considered clinical staging, histological grading and perineural invasion important prognostic factors in malignant salivary gland tumors, pointing out that T1 and T2 tumors less than 4cm in size generally do well, regardless of other features.

Fine needle aspiration biopsies and cytology have been used, but the variability of histology within a single tumor makes this an unreliable diagnostic test. This is controversial with the American Head and Neck Society recommending that it is only useful where the tumor is likely to be metastatic in nature, while the Scottish Intercollegiate Guidelines recommend that it should always be used. As a result, Kieran et al. (2010) concluded that FNA should be performed on all those aged 60 years or over. Where it is practiced, success depends on the establishment of a very close working relationship between surgeon and pathologist, who must also be an experienced cytologist.

In their study of salivary gland cancer in younger patients, Rutt et al. (2011) found mucoepidermoid carcinomas to be those most frequently encountered but in young adults this changes to adenoidcystic carcinomas and there is a female predominance (Chomette et al., 1982). Ryan et al. (2010) noted that patients who received radiation therapy for these lesions were more likely to suffer a recurrence and Jenson et al. (2010) found that control using conventional radiotherapy required a very high dose and consequently favored the use of intensity modulated radiation therapy (IMRT) to achieve better local control. IMRT also avoids high dose radiation in areas where implants are to be inserted, particularly in the symphyseal area of the mandible and is preferably used for oropharyngeal cancer. (Lee et al., 2007, Verdonck et al., 2010).

In a randomized controlled trial of IMRT versus conventional radiotherapy, Nutting et al. (2011) showed that sparing the parotid glands with IMRT significantly reduced the incidence of xerostomia and leads to recovery of salivary secretion and improvements in associated quality of life. This strongly supports a role for IMRT in squamous cell carcinoma of the head and neck. Cryotherapy with liquid nitrogen is also effective because of the propensity for some salivary gland tumors to spread along tissue planes, which also explains why poorly focused radiotherapy is not always the most effective mode of treatment. Even with intense freezing, the neural sheaths remain intact and regeneration of neural tissue is, therefore, possible.

Looking at parotid squamous cell carcinoma, Bhide et al. (2009) noted that in general, five year loco-regional control was better for patients who had definitive surgery and post-operative radiotherapy (82 percent compared to 21 percent for those who had radiotherapy alone).

However, analysis of publications by Brown (2011) on the survival data for oral squamous cell carcinoma, covering 7,786 patients, throws doubt on the value of post-operative radiotherapy, especially when the increased morbidity associated with this therapy is taken into account. He makes a plea, which has frequently been made by others, for prospective randomized trials and better audit of outcome data.

One of the most important trends is the regular involvement of multidisciplinary teams in the management of head and neck oncology patients, meeting together and making joint decisions on the best course of treatment for each individual. This extends to outcome audit and Quality of Life Assessment (Rogers et al., 1999). Internationally agreed outcome parameters are, however, necessary to be able to compare results (Rogers et al., 2010)

This whole development has proved to be a very long road and yet despite this, the survival rates for head and neck cancer remain stubbornly unchanged. Consequently,

there remains much work still to be done, which includes a re-examination of long held dogmas on protocols and management of this disease.

Preprosthetic surgery

Before 1960 Some of the techniques used in preprosthetic surgery were developed before but mostly just after World War II in the German-speaking part of Europe. The split skin graft was described by Thiersch in 1874. It is, therefore, somewhat surprising that the real spread of preprosthetic surgery only took place in the 1970s. This had largely to do with the earlier mentioned language barrier that existed between the Anglo-Saxon world and continental Europe where German used to be the most important language for medical publications. There simply was very little crossover or exchange of information until about half way through the 1960s, when the influence of the journals became apparent.

This is borne out by the description of simple preprosthetic measures in most American textbooks during this period which only mention procedures such as: alveoloplasties to remove bony irregularities or correct alveolar prognathism, and vestibuloplasties followed by secondary epithelialization and other rather minor procedures. Techniques such as vestibuloplasties with lowering of the floor of the mouth and split skin grafting evolved over the years through the input of several pioneers in the German-speaking area but were almost unnoticed on the other side of the Atlantic (Pichler & Trauner, 1930, Trauner, 1952, Schuchardt 1952, Rehrman, 1953, Obwegeser, 1963). Axhausen (1940) shows in his book an excellent example of a vestibuloplasty at the anterior mandible covered with a skin graft. A detailed description of the history of the development of these techniques is described by Davis and Davis in the book of Fonseca and Davis (1986).

The only novelty in this area, stemming from the U.S.A., is the description of the lip switch technique by Kazanjian (1924). He also described in the same paper a technique for increasing the depth of the anterior lingual fold. The lip switch was later modified by Edlan and Mejchar (1963). Worth mentioning also is the mylohyoid ridge reduction technique without grafting, as described almost simultaneously by Brown (1953) and Downton (1953) and independently by Caldwell in 1955. The latter demonstrated that some Americans, at that time, did not even read British publications.

Preprosthetic surgery in the maxilla was almost exclusively limited to alveoloplasties until Celesnik (1954) introduced the tuberoplasty and Obwegeser (1959), the submucous vestibuloplasty, although Schuchardt (1952) had already described the vestibuloplasty in the maxilla, covered by split skin grafts.

Bone augmentations using bone grafts or alloplastic material were not performed during this period, except for a German pioneer, Clementschisch (1948), who described autogenous rib onlay grafts to augment atrophic mandibles.

The real breakthrough came after the publication of the paper of MacIntosh and Obwegeser in 1963. Obwegeser had also presented his work on maxillary vestibuloplasties at the first ICOS in London in 1962. Preprosthetic surgery was to take off in the years to come, not only in the U.S.A. but also in other, non-German-speaking countries. Hugo Obwegeser

1960–1990 The rapid spread of preprosthetic surgery during this period had probably, not only to do with the introduction of new techniques, but also with the growing affluence of the developed world. This certainly was elective surgery, meant for a group of patients who had lost their teeth at a fairly early age. For a large part, this was the result of poor dental care, which was not the highest priority in times of war or the immediate post-war period. In other words, there was a large contingent of people who were potential candidates for this type of surgery.

There were four new developments during this period that had an enormous impact. The first was the introduction of the mucosal graft as suggested by Propper (1964) and later popularized by Steinhauser (1969) and Tideman (1972). The use of mucosal grafts circumvented the need for taking skin grafts, with its inherent and unavoidable donor site morbidity and visible scar formation. The area to be grafted was smaller than was possible with skin but this was turned into an advantage, because in this way less damage was done to the mental nerves.

Follow-up studies on vestibuloplasties pointed toward a lack of appreciation of a numb lip and chin as a result of freeing of the mental nerve (de Koomen, 1977). Patients’ appreciation improved substantially when care was taken, not to extend the graft beyond the mental foramen (Huybers et al. 1985). In general, the two major disadvantages of these vestibuloplasties, including nerve dysaethesias and sagging chins, could be avoided by careful planning and limiting the extent of the surgery (Stoelinga, 1992).

The second introduction was the absolute heightening of the severely atrophic mandible and maxilla. The pioneers were Härle (1975) and Schettler (1976), who independently

developed the visor and sandwich osteotomies. It is only fair to mention here that Barros Saint-Pasteur had already described a sandwich technique in 1966. This was an important improvement over the rib onlay technique (Terry et al., 1974), which, again in a follow-up study, had been shown to be highly unreliable in that rapid resorption occurred, almost to 100 percent, in a matter of two years (Fazili et al., 1978). The two techniques were further refined by various clinicians and widely used over a 20-year period.

Although these methods were much better than the onlay technique, there were also drawbacks, such as nerve dysesthesias and unwanted resorption under a mucosally borne denture (Stoelinga et al. 1983). For the maxilla, the sandwich principle resulted in a Le Fort I osteotomy with interposed grafting, bringing the maxilla downward and forward (Bell et al., 1977). This principle stood the test of time, since it is currently still used when implants are planned for severely resorbed maxillae.

The third development concerned the introduction of hydroxylapatite in both a solid as well as particulate form. It was the particulate form that caught the attention of the profession, since it had the potential to augment the jaws in a stable fashion, since resorption was not very likely (Kent et al., 1982). Mixing it with particulate autogenous bone made it an ideal graft material, because the hydroxylapatite grains acted as a scaffold, preventing graft resorption (Fonseca 1986). In a follow-up study this was proven, in that very little resorption was observed after the first year, in the areas posterior to the mental foramina, where the mixture was deposited. (Satow et al. 1997).The main drawback was the difficulty both in application and containment of the particles, whereas additionally mucositis tended to occur because of the thin mucosa overlying the layer of hydroxylapatite. This, of course, was not a problem when it was used to fill a flabby ridge in the maxilla (Terry, 1983). The fourth introduction that really brought about a revolution into preprosthetic surgery was, of course, the titanium implants of Brånemark et al. (1977). Before this time several implants had been tried, including subperiosteal implants made of chrome-cobaltmolybdenum alloys, implants that were screwed into the jaws and so called blade implants. They all failed, sooner or later, since the materials used were not biocompatible as was titanium, or better to say titanium oxide and also allowed downgrowth of epithelium, which resulted in extrusion. Brånemark and his group coined the term osseointegration which meant that the bone really attached to the surface of the implants, which was the major breakthrough in the application of implants in general.

The publication of Adell et al. in 1981 opened the eyes of many clinicians and from then on implant dentistry developed. In retrospect, it is somewhat amazing that it took so long before the profession and dentistry as a whole jumped at this opportunity. This probably had to do with a hesitation that was fed by the frustrating experiences associated with older types of implants. The major developments with regard to implant surgery and preimplant surgery in particular, took place in the next period.

In this period several monographs solidly devoted to preprosthetic surgery appeared, illustrating the enormous popularity this branch of surgery had achieved (Starshak & Sanders, 1980, Fonseca & Davis, 1986, Hopkins, 1987, Härle, 1987). The publication of these books was preceded by a publication of a Consensus Conference, organized by the IAOMS in 1983 in Berlin (Stoelinga, 1984). This was a unique event, because the prosthodontists, who looked critically at the results that surgeons tended to present in a more positive way, were also present.

From this event biennial conferences evolved where surgeons and prosthodontists came together to discuss matters of mutual interest, resulting in consensus statements, published in the International Journal. This conference took place alternately in the U.S.A. and Europe and lasted until 2008.

A publication that has had a significant impact on the way of thinking in reconstructive preprosthetic and pre-implant surgery alike was presented by Cawood and Howell (1988). They proposed a classification of resorption patterns, based on studies of dry skulls. This classification is, at present, the gold standard when discussing treatment options for patients who are candidates for pre-implant surgery, because it facilitates the interdisciplinary cooperation, using a terminology that is universally understood. Before that time, terms such as knife-edge ridge or severe resorption etc. were used, leaving much to the imagination of the readers. Per-Ingvar Brånemark

1990–2010 It is fair to mention that, by now, conventional preprosthetic surgery had almost ceased to exist. It had become apparent that the term “reconstructive preprosthetic surgery” had to be replaced by “pre-implant surgery,” because implants had changed the scene profoundly. Yet the techniques, as employed in the previous period, served as the basis for modern pre-implant surgery. This is well described by Cawood et al. (2007).

The profession had become heavily involved in implant dentistry and so had several other dental disciplines. The number of implant systems had exploded

and various improvements were also introduced, making implant dentistry a reliable and popular adjunct in the armamentarium of the dental profession. Implant dentistry has made it possible to truly rehabilitate the edentulous and partially dentate patient to an extent that hitherto was unthinkable.

Pre-implant surgery, however, still has a place because enough bone volume needs to be present in the strategic areas where implants are planned to be inserted. For this reason, sinus floor augmentation was soon introduced by Boyne and James (1980) and Tatum (1986), but only widely applied in the 1990s and at the present time. A modified Le Fort I osteotomy with bone grafts in the floor of the sinus and nasal aperture and simultaneous implant insertion was proposed by Sailer (1989). This was soon followed and modified by several others.

The increased knowledge about the healing of bone grafts has contributed significantly to the success of various grafting techniques. It is particularly the reports of the Swiss-Austrian working group on the healing of fractures (Arbeitsgemeinschaft für Osteosynthesen Frage), that improved the understanding of this healing process. They introduced the concept of primary fracture healing as a result of rigid fixation. It was Spiessl (1969) who introduced this principle in oral and maxillofacial surgery. This concept is currently widely used in trauma surgery but it also applies, to a certain extent, to the healing of bone grafts, in that rigid fixation is mandatory for these grafts to take. The grafted bone heals by creeping substitution, which implies that all grafted bone resorbs but will be replaced by new bone (Fonseca et al., 1980).

This explains why onlay grafting with corticocancellous blocks became successful, provided rigid fixation is present, be it through implants or plates and screws. Several techniques have recently been described for augmenting alveolar ridges with cortico-cancellous block grafts, either simultaneously with the insertion of implants or as a single procedure, followed by implant placement at a later stage.

Another technique for increasing bone volume, in limited sized defects, was introduced by Buser et al. (1990). They favor the use of guided tissue regeneration using a membrane to protect the graft from ingrowth of fibroblasts. This technique also has many followers and seems to serve its purpose in selected cases.

Last, but not least, a true “hype” has crept into this branch of the profession called “distraction osteogenesis.” Several preliminary results have been presented on the results of augmentation of the symphysis of the mandible and even local augmentation of the deficient alveolar process. As promising as the results may appear, until now little evidence exists that this technique will provide better and more reliable results than bone onlay grafting and it is questionable whether the method, in general, is more patient friendly, considering the cumbersome device that has to be inserted. There are, however, certain indications where this technique may prevail.

Unlike, for instance, orthognathic surgery, little evidence-based practice is employed in pre-implant surgery (Blackburn, et al. 2008). The literature is replete with recommendations based on case series or, at best, follow-up studies with limited value because of insufficient followup or other confounding factors. Properly designed and prospectively carried out studies are rare and, thus, solid conclusions cannot easily be drawn.

Surgery of the temporomandibular joint

Before 1960 Surgery of the temporomandibular joint (TMJ) has a relatively long history. Both American and German literature contain early reports of treatment of ankylosed joints in the second half of the 19th century but according to Merrill (1986), the first surgery described in English literature concerns a condylectomy for a patient with arthritis, carried out by Humphrey of Cambridge, England, in 1856.

In those days, before antimicrobial treatment was available, inflammatory diseases affected the joints more often than is currently seen and even specific infections, such as gonorrhea, were not uncommon (Axhausen, 1940 and Thoma, 1948). This would sometimes result in ankylosis and require a surgical intervention to allow the patient to function again. Ankylosis was, thus, far more frequently seen than is the case today, at least in the developed world. The treatment ranged from various ostectomies in the ascending ramus to allow for free movement of the main body of the jaw with or without interposition of alloplastic material and true condylectomies.

A detailed description of all these techniques written by German- and English-speaking colleagues is to be found in the book of Hoffmann-Axthelm (1995). A chapter written by Stiebitz summarizes all techniques known until 1950. Apart from ankylosis and arthritis, conditions that are currently called internal derangements were already known in the late 1800s and sometimes surgically treated with rather drastic means. The chapter in the first edition of Thoma’s “Oral Surgery” describes all possible procedures that were performed in those days (Thoma, 1948).

It strikes the reader that few new procedures have been introduced since then, apart from some technical advances in both instruments and implants. Fundamentally, however, the procedures described have hardly changed.

What has changed, however, are the means of establishing a proper diagnosis and the better understanding of the pathology of some of the conditions involved. Annandale (1887) is generally credited with the first surgical reposition of displaced disks, whereas Lanz (1909) first described a meniscectomy for a painful joint, followed by many other authors. Even condylectomy was suggested by Ireland (1951) to treat a “clicking jaw.” It is not particularly clear who described the first joint transplantation but in the book of Klapp and Schröder (1917), several case reports are described of metatarsal joint transplantations to restore function in patients who had lost their joint and ascending ramus because of gunshots. This was long before Dingman and Grabb (1966) introduced this technique in the English literature. It was Axhausen (1933) who described the first case of chondromatosis of the TMJ.

The understanding of the pathophysiology of a painful joint received a great boost by the publication of Costen (1934) in which he pointed out the importance of dental occlusion and vertical dimension. The term “TMJ pain dysfunction syndrome,” however, stems from Schwartz (1956) He emphasized that the pain was often located in the masticatory muscles. His theory dominated the thoughts about the pathophysiology of TMJ dysfunction for almost 20 years. Drastic surgery for TMJ dysfunction became less popular and was replaced by more subtle procedures, such as high condylectomy (Baldridge & Henny 1957) and eminectomy (Myrhaug, 1951 and Irby, 1957).

A novel technique to treat chronic dislocating joints was introduced by LeClerc and Girard (1943) and later refined by Deautrey (1974). It entailed down fracturing of the zygomatic arch as to prevent dislocation of the condyle out of the fossa. An alternative technique had been used by Sutton Tayler since the late 1950’s, which involved simple subperiosteal bone graft augmentation of the articular eminence (Williams, personal communication).

The dental profession and particularly the prosthodontists, however, began to show interest in the non-surgical treatment of the pain dysfunction syndrome, which also contributed to a more conservative approach for a while. By the end of this period, TMJ surgery was carried out for ankylosis, arthritis, chronic dislocations and what was then called a painful joint not responding to conservative treatment. Refinement of the diagnosis of TMJ dysfunction was advanced during the next periods.

1960–1990 The treatment of ankylosis followed the patterns as laid out in the preceding period. Gap arthroplasties, with or without interposition of autogenous grafts, i.e. dermis, muscles or alloplastic material e.g. silastic, were still the gold standard. Large studies are lacking but there are plenty of case reports and small case series that recommend these procedures. Textbooks which were published in this period also favor these techniques.

The same is true for the treatment of chronic dislocations of the TMJ. Both eminectomies and down fracturing of the zygomatic arch were successfully carried out. Several case series attested to the validity of these techniques.

Surgery for tumors and conditions, such as chondromatosis and synovial cysts, is also reported in this period, where the usual pre-auricular approach is utilized. These conditions often went unnoticed for several years because diagnostic means were lacking until the introduction of magnetic resonance imaging (MRI).

An important development in these years is the introduction of growth center transplants using rib grafts. It soon became obvious that costochondral grafts were the best choice to adapt to the mandibular growth pattern. The intention was to insert a graft with the potential to grow with the individual (Ware & Taylor, 1965, Ware, 1966). This was taken on by many surgeons as a means for treating children with asymmetric growth because of ankylosed joints, or who suffered from hemifacial microsomia (MacIntosh & Henny, 1977, Rowe, 1982, Mulliken et al., 1989). It also became clear that these grafts were still somewhat unpredictable as undergrowth as well as overgrowth occurred at times.

Contrary to the concept of replacing the condyle with an autogenous graft, the idea of an alloplastic joint prosthesis was put forward by several authors in the 1960s and 1970s, among them the most popular from Christensen (1971) and Kent et al. (1983). They were mainly used to replace the condyle in cases of ankylosis, or after resections for tumors, although so-called reconstructions, including fossa and condyle, were advocated after failed, multiple attempts to surgically treat degenerative arthritis.

An excellent and complete account of these early developments is presented by Driemel et al. (2009). They describe the developments in the English, German and French speaking areas, including the serious problems that were associated with the Vitek® joint systems that had such a negative impact on the further introduction and development of alternative systems for quite a while.

The term “pain dysfunction syndrome” was slightly modified to “myofascial pain dysfunction syndrome” as suggested by Laskin (1969) with an emphasis on the psycho-physiological factors that contributed to the muscle pain. This concept had to be revised, however, when new imaging techniques were introduced that made the relation between the disc and condylar head visible. It concerned arthrograms and later MRI. As a result, the term “internal derangement” was introduced (Farrar & McCarty, 1979).

The definition is defined differently by various authors but basically it refers to a condition whereby the disc is not in its proper anatomical position, either at closed and/or open position of the mandible and most often anteriorly displaced. It caused a new wave in open TMJ surgery, particularly in the U.S.A., with procedures such as repositioning of the anteriorly displaced disc with simultaneous reduction of the elongated posterior ligament (McCarty & Farrar, 1979) and disc removal with or without replacement with an autogenous graft, i.e. cartilage (Hall & Link,1989) or alloplastic material, i.e. silastic sheets (Wilkes, 1991).

The long-term results of all these procedures were not unequivocally positive, although Wilkes (1991) claimed successes of over 90 percent in a long-term retrospective study. It is of interest to note that another technique for treating a painful joint, as suggested by Ward (1961), went almost unnoticed. It entailed a condylotomy carried out

with a Gigli saw in a blind fashion. The idea was to shorten the ramus with minimal change of the position of the condylar head. Banks and MacKenzie (1975), however, reported good results on a group of 211 patients treated over a rather long period.

An authoritative and complete review of the then existing techniques is presented by Merrill (1986). He admits that surgery of the TMJ is rapidly changing. This was largely because of the better understanding of the pathophysiology and better imaging methods. (Bronstein et al. 1981, De Bont et al. 1986, Holmlund & Hellsing 1989)

Another novelty concerned the introduction of the arthroscope for examination of the TMJ (Onishi 1975). This application enabled surgeons to examine the joint spaces and to eliminate adhesions so as to improve mobility of the disc. There were also surgeons who claimed that disc repositioning was possible using an arthroscopic approach (Murakami & Takatoki, 1986, Moses & Poker, 1989, McCain et al., 1992).The sheer number of patients treated makes one wonder what the criteria were that made these surgeons decide to do this kind of surgery.

1990–2010 The debate about whether an autogenous graft or alloplastic joint replacement is preferable for cases of ankylosis in adult patients, or otherwise severely deformed joints, went on. The introduction of CAD-CAM produced models, on which custom-made prosthesis could be made, had brought about a revolution when considering major joint reconstruction. The idea of an alloplastic joint prosthesis came from the successful application of these prostheses in orthopedic surgery. The review, as presented by Driemel et al. (2009), provides a complete overview of the development of these devices since 1950. The three major players in this area are the TMJ Concept® prostheses, that have a reasonable track record (Mercuri 1998), TMJ implant® to which the name of Christensen is attached (1971) and the Biomet® total TMJ prosthesis. The latter is not custom made but consists of fixed sizes and shapes that are available off the shelf.

Westermark (2010) presented a long-term follow-up on these, reporting good results after a maximum of eight years. Guarda-Nardini et al. (2008) concluded, after a study of the pertinent literature over a period of 16 years, that the findings on all three systems were promising but that multi-center trials are necessary, taking into account inter-operator variability. Contrary to the proponents of alloplastic prostheses, several colleagues still favor the use of an autogenous graft, mainly costochondral in nature, to replace a condyle and part of the ascending ramus (Perrot et al., 1994, Peterson et al., 1998, Zhi et al. 2009). Yet, comparative studies reveal a tendency for re-ankylosis in some patients (Saeed et al., 2002).

Dimitroulis (2005), however, rightly made the point that alloplastic TMJ prostheses tend to be placed in relatively young patients, as compared to hip and knee prostheses. The life expectancy of these patients is in the order of 30 to 40 years instead of 10 to 15 years, as is often the case for patients with hip and knee prostheses. It remains to be seen, therefore, whether these TMJ prostheses will stand the test of time, or whether placement of a new prosthesis will be necessary over the years. The treatment of ankylosis in growing individuals still remains

“There probably is no other branch of our profession where opinions differ so much about indications and surgical approaches as there are for diseases and abnormalities of the TMJ.”

a challenge and in these cases, costochondral grafts appear still to be favored in combination with covering the fossa with either the original disc or a temporalis muscle flap (Peterson et al., 1992, Kaban et al., 2009).

A novelty worth mentioning is the miniplate eminoplasty for the treatment of recurring dislocation of the TMJ, as suggested by Puelacher and Waldhardt (1993). This simple but very effective technique, makes clever use of the introduction of miniplates in the armamentarium of the oral and maxillofacial surgeons by blocking the condyle on its way to dislocate out of the fossa with a plate that is bent to do just that. Excellent results are reported by Kutenberger and Hardt (2003) on 20 patients followed for three to seven years. This procedure appears to be less unpredictable than the earlier mentioned eminectomies and downfracturing of the zygomatic arch and certainly produces less irreversible damage.

Treatment and diagnosis of the painful and dysfunctional joint underwent a reappraisal mainly because of a paper by Nitzan et al. in 1991. They reported on the results of simple lavage of the joint spaces, without the need for arthroscopy. Several follow-up studies showed good results, even in cases of closed lock.

This observation casts some doubt upon the mechanical theories of disc displacement as a result of muscle traction caused by habits and/or occlusal or articular malfunction. Soon a new theory was proposed by Nitzan and Marmary (1998) and Nitzan and Etsion (2002), which they called the “anchored disc phenomenon,” which might cause the adhesion of the disc to the fossa and/or eminence. It is suggested that the lubrication by phospholipids that are protected by hyaluronic acid, is impaired. This is caused by reactive oxygen species that degrade hyaluronic acid and are released as a result of overloading of the joint. Whatever the truth may be, this theory explains the successful results of simple lavage of the upper joint space in various stages of disc displacement. The use of arthroscopy gradually went out of fashion because of the successes achieved with arthrocentesis (Brennan & Ilankovan, 2006).

There probably is no other branch of our profession where opinions differ so much about indications and surgical approaches as there are for diseases and abnormalities of the TMJ. This is particularly true for the conditions that were previously described as pain dysfunction of the TMJ, but that over the years had several name tags attached to it which are not necessarily overlapping. Terms used in various publications, such as internal derangement, non-reducing disc displacement, painful TMJ hypomobility, chronic locking of the TMJ, closed lock, osteoarthritis and osteoarthrosis, already point towards descriptive diagnoses that leave much to the imagination of both the authors of these articles as well as the readers.

One cannot escape the impression that, when reading the various papers on the treatment of these conditions, apples were compared with pears. The results of the many clinical studies where certain modes of treatment are discussed are often contradictory. This comes through loud and clear when reading the reviews of Dimitroulis (2005) in which he critically assesses the role of surgery in the management of disorders of the TMJ. Procedures that were carried out in the 1970s and 1980s with high success rates claimed, turned out to be less recommendable. Thousands of patients, particularly in the U.S.A., had multiple operations performed without the desired result. In retrospect, one can only wonder about the course of events, but certainly the lack of a proper, less descriptive, diagnosis was part of the reason. Dimitroulis remains optimistic on the grounds that he expects that molecular biology might offer the tools to better diagnose the conditions we used to treat by universal means. It might lead to more specific treatment geared to the state of the condition to be treated. Only the future will tell, but there certainly is a need for some evidence-based treatment in TMJ surgery before the profession jumps on the next bandwagon.

Orthognathic surgery

Before 1960 Not surprisingly, oral and maxillofacial surgeons were challenged from the beginning to attempt to correct dentofacial deformities as there were plenty of patients who needed corrective surgery. As widely assumed, Hullihen (1849) was the first surgeon who performed an osteotomy of the mandible. It concerned a subapical, segmental osteotomy to close an anterior open bite. Both in the U.S.A. and in continental Europe, however, several surgeons had designed and developed techniques for sectioning mandibles in order to set back or advance the jaw, as early as the late 1800s and at the beginning of the 20th century. It was Blair (1907), who probably carried out the first mandibular setback by a body ostectomy in 1897 but also an advancement osteotomy in the ascending ramus ten years later.

Detailed descriptions of all the techniques used in the German-speaking area can be found in Wassmund’s book from 1935, which pays attention to every single name that had contributed to the slightest alterations in a given operation. To a lesser extent, this was also true for France (Dechaume et al., 1977). In the U.S.A., similar procedures are described in the various textbooks on oral surgery that appeared before, during or immediately after World War II.

It is only fair to note that most of the procedures currently used were designed in the period after the war. In the maxilla, the exception was the subapical anterior

maxillary osteotomy, according to Wassmund (1926) and the Le Fort I osteotomy, thought to be designed first by von Langenbeck (1859), according to Drommer (1986). The first real Le Fort I osteotomy, including separation of the pterygo-maxillary junction was, however, probably carried out by Schuchardt (1942). In the Karl Schuchardt

mandible, the subapical, anterior alveolar osteotomy, as suggested by Hullihen (1849), but popularized by Hofer (1942), still has some application.

After the war, elective corrective surgery became very popular, certainly helped by the availability of adequate antimicrobial drugs. The popularity of the Le Fort I osteotomy was further enhanced by publications of Gillies and Rowe (1954) and Obwegeser (1965, 1969). Wunderer (1962) reported on a modification of the subapical anterior maxillary osteotomy, completely relying on the buccal mucoperiosteal pedicle. This method facilitated the intrusion of this segment, as compared with the Wassmund procedure. Kufner (1960) described the quadrangular osteotomy to advance the middle third of the face.

The publications of Trauner and Obwegeser (1959) on the sagittal split osteotomy, however, caused a complete revolution in the approach to mandibular corrective surgery. Most previously suggested methods, carried out in the horizontal or vertical ramus, were abandoned, including the low condylar osteotomy as proposed by Kostecka (1931). The only exception was the vertical osteotomy of the ascending ramus as designed by Robinson (1956). Obwegeser presented a paper on the versatility of the sagittal split osteotomy at the 3rd ICOS in New York in 1968, where it made quite an impact. From then on, the sagittal split osteotomy would replace most other types of mandibular osteotomies in the U.S.A. and elsewhere.

1960–1990 The further development of orthognathic surgery was, for a large part, due to the input of orthodontists. It was particularly the American orthodontists who saw the opportunities but also paid attention to some of the drawbacks, such as relapse (Profitt & White, 1970 and Poulton & Ware, 1971). They also provided the tools for proper clinical and radiological follow-up. They advocated the preoperative and postoperative orthodontic alignment of teeth, assuring a stable occlusion, which in turn would contribute to the stability of the results. Tricks, such as the use of an acrylic splint (wafer) to stabilize temporarily the occlusion, or leveling of a deep curve of Spee postoperatively, to increase lower facial height, were certainly the result of their input.

This aspect of a coordinated approach, working as a team, was lacking in all papers that had come from the European mainland. West and McNeill worded this very well in 1977: “Joint diagnosis and treatment planning and analysis of longitudinal treatment responses, based on traditional orthodontic principles, have contributed to the continuing advancement of knowledge and improvement in standards of care.”

It is particularly the follow-up with standardized cephalometric radiographs that opened the eyes of many clinicians. It soon appeared that even during intermaxillary fixation in case of advancement of the mandible using a bilateral sagittal split osteotomy, the mandible was slipping back (McNeill et al., 1973). The wire osteosyntheses simply were not rigid enough to prevent this movement. The impact of this coordinated approach soon became visible in the literature, with numerous papers accompanied by a plethora of suggestions on how to prevent or minimize relapse. Surgical over-correction, particularly for advancement of the mandible and various different wiring techniques were suggested. The sagittal split technique also underwent some modification, as the suggestions of Dal Pont (1958), Hunsuck (1968) and later Epker (1977), were incorporated into the standard procedure. The upper border wiring probably became the standard, instead of the circumferential wire, until lower border wiring came in fashion, just before rigid fixation was widely used (Booth, 1981). An article from Hinds and Kent (1969) on the versatility of the horizontal chin osteotomy made this a popular way for improving the chin contour, instead of silastic implants that were hitherto widely used, particularly among plastic surgeons.

Maxillary surgery, particularly segmental surgery, was also popular, particularly in the late 1960s and early 1970s. Bell et al. (1969, 1971, 1973)had performed experimental research on monkeys, proving that Le Fort I and anterior and posterior maxillary segmental osteotomies were safe with regard to blood supply. He showed that fast revascularization and bone healing occurred, provided the mucoperiosteal pedicles were intact. Although the posterior segmental maxillary osteotomy was introduced by Schuchardt in 1954, as a two-staged procedure, this technique only became popular after the modification by West and Epker (1972). They recommended this procedure, performed bilaterally, for closure of an anterior open bite. This is a valid option today, if one wants to circumvent too much rotation of the maxilla, leading to a backwards rotation of the anterior teeth with subsequent flattening of the naso-labial angle.

The Le Fort I osteotomy, however, as described before, became the workhorse for corrections of the middle third of the face. Not only were advancements possible, for which it was originally described but also vertical movements, including extrusion with interposed bone grafts and intrusion, as reported by various authors (Schendel et al., 1976, Bell & Bride, 1977). Patients with a short or long face could be well treated by vertical lengthening or shortening of the maxilla. This made it possible to really affect the appearance of the middle face.

It became particularly useful for treatment of the cleft lip and palate patient, who often had severe maxillary hypolasia in all three dimensions. It also appeared possible to tilt the maxilla over a horizontal axis, by posterior intrusion, to close an anterior open bite, or the other way around, to bring the anterior part downwards.

This canting of the maxilla was mandatory when treating patients with some types of anterior open bite (Epker & Fish, 1977). Research was also carried out with regard to the split from the pterygoid plate. Several authors had shown that the original technique, making use of the heavy curved chisel, would sometimes cause unwanted bleeding from the venous plexus in this area, or even fractures of the skull base (Wikkeling & Koppendraaier, 1973 and Lanigan, 1987). Trimble et al. (1983) suggested, therefore, splitting the tuberosity distal of the 2nd molar, while Precious (1991) just fractured the maxilla down, without splitting the maxilla from the pterygoid plate. Last but not least, the surgically assisted orthodontic expansion or distraction, as it presently is called, came in vogue as a means for facilitating the preoperative coordination of the dental arches. This technique came from orthodontics as well, because Dirchsweiler (1956) recommended palatal expansion in young individuals by opening the mid palatal suture, without surgical intervention. This technique also gained popularity and appeared to be very useful indeed for selected patients (Bell & Epker 1977).

It did not take long before surgeons were beginning to do bimaxillary procedures to correct more precisely the imbalance between maxilla and mandible. Obwegeser

(1970) is probably the first to have published about this possibility, describing a case of maxillary hypoplasia combined with mandibular hyperplasia treated by a bimaxillary osteotomy. The 1970s and early 1980s were really the boom times for this type of surgery, with lots of articles appearing that presented follow-up studies and suggestions for improved techniques. Another novelty introduced during this period, was the maxillary osteotomy following the lines of the Le Fort II pattern (Henderson & Jackson, 1972). The extracranial Le Fort III osteotomy had already been introduced by Gillies and Harrison (1950). These procedures, although not often necessary, completed the scope of the surgeon who was doing orthognathic surgery. Although Hinds and Kent (1972) had published the first monograph on orthognathic surgery, the appearance of the book of Bell, Proffit and White (1980) finally caused surgeons and orthodontists to work together all over the world; the message being that a coordinated surgical-orthodontic approach would provide superior results. This was the first book on the subject that presented orthognathic surgery in a comprehensive way, emphasizing how diagnostic tools and properly coordinated treatment lead to the best results, both from a functional as well as esthetic point of view. Another means of fixation that had already quite a history finally came to the surface in this period. Surgeons had been struggling with wire osteosynthesis for years, neglecting the developments in trauma surgery, or at least, not David Precious considering them fit for this type of surgery. Spiessl has to be credited for his pioneering work in this area. He advocated lag screws to fix the fragments in cases of sagittal split osteotomies in 1974, applying the principles of rigid fixation. It took quite a while before this was followed by others (Paulus & Steinhauser, 1982). Bernd Spiessl It soon became clear that positional screws were a better choice because these would not squeeze the nerve William H. Bell between the fragments (Jeter at al 1984), while stability was achieved with less relapse than was seen with wire osteosynthesis (Van Sickels et al., 1986).The evolution of small plates, as proposed by Champy et al. (1976), also made it possible to fix the fragments of the sagittal split osteotomy (McDonald et al., 1987, Rubens et al., 1988). This also was true for maxillary surgery, where mini- and later micro-plates replaced the wire osteosyntheses. It was especially beneficial for the extrusion le Fort I osteotomy

to use plate fixation, since late relapse, up to 50 percent, often occurred when using wires (Quejada et al., 1987). The introduction of all these techniques made the surgery more reliable and predictable since the relapse tendency was further diminished

It is safe to state at this point that the input of orthodontists and experimental and clinical research brought orthognathic surgery to the next level of development, something that was augmented by the introduction of rigid fixation. The time of pioneering was over; further refinements would come from technology that would be introduced in the next period. A detailed review of the historical development of orthognathic surgery, up to this period, is presented by Steinhauser (1996).

1990–2010 In the late 1980s, a new indication for orthognathic surgery began to emerge, which came to its full expression in the next decade. It is particularly Riley, Guilleminault and Powell (1989 &1993) who laid the foundation for the wide application of mandibular advancement, along with the hyoid with or without the maxilla, for patients with sleep apnea. Their research prompted many colleagues from all over the world to participate in teams in the treatment of patients with severe sleep disorders.

Currently, it seems that maxillo-mandibular advancement may be the best solution to increase posterior pharyngeal space in most cases (Prinsell 1999). It also caused the profession to look into the possible effects of mandibular set-back surgery on the posterior airway space (Hochban et al., 1996, and Tselnik & Pogrel, 2000). Caution appeared to be warranted in certain patient groups with other risk factors.

The search for maximum stability continued during this period, resulting in several retrospective and even prospective studies, showing that both the bicortical screws and plates fixed with monocortical screws were equally stable for mandibular advancement surgery using the sagittal split technique (Dolce et al., 2000, Borstlap et al. 2004, and Joss & Vassalli, 2009). The choice of the method of fixation became mainly a preference of the surgeon and the patient. These considerations are also valid for set-back procedures using the sagittal split method, although there are less known studies which refer to the hyperplastic mandible. This may also be attributed to the fact that many surgeons still prefer the vertical ramus osteotomy (Robinson 1956) for this purpose.

In Le Fort I osteotomies, stability with plate osteosynthesis did not appear to make much of a difference, for understandable reasons (Haers et al., 1999), except, of course, for the extrusion osteotomy. Micro-plates were particularly favored because of ease of application. This, of course, is also applicable for the high level maxillary osteotomies, where stability with wire osteosyntheses is difficult to achieve and certainly for all sorts of segmental osteotomies, including genioplasty.

During this period, much more attention was paid to possible complications and side effects of the various osteotomies that were routinely carried out. For the mandible, it mainly concerned nerve dysesthesia and progressive condylar resorption. Permanent nerve dysesthesia, occurring in approximately 15 percent of cases when using the sagittal split osteotomy, is probably related to several factors, such as age, the need for dissecting the nerve out of its canal and the stretching of the nerve (Borstlap et al., 2004). Teerijoki-Oksa et al. (2002), however, made it quite clear that holding a medial tunnel retractor in place may knick the nerve, particularly when this stays in place for quite a while. There is certainly a need to bring the number of permanent nerve deficits down further and many surgeons would prefer the vertical ramus osteotomy, to set the mandible back for that reason alone (Zaytoun et al.,1986).

Although some case reports have been presented in the time that wire osteosyntheses were widely used, progressive condylar resorption (PCR), as it is currently called, was first well described by Arnett and Tamborello (1990). Since this publication, several clinicians have recognized this problem and have come up with suggestions about its etiology. It is likely that this only came to the surface when rigid fixation was used, because before that time all relapse was thought to be caused by backwards slippage of the wired distal fragment. One simply did not look at the change in morphology of the condyle. In any event, this is an awkward condition that seems to occur particularly in women with a high mandibular plane angle and often in patients that have an open bite as well (Hoppenreijs et al., 1998). Recommendations for treatment vary from redo operations to replacement of the condylar unit (Hoppenreijs et al., 1999 & Troulis et al., 2007).

An excellent account of all possible complications is to be found in “Risks and Benefits of Orthognathic Surgery,” edited by Precious and Lanigan (1997). It goes beyond the scope of this section to deal with all of them, but it certainly deserves a lot of attention from all surgeons who like to perform elective orthognathic surgery.

A new technique that made its “grand entrée” in this arena is called osteodistraction. It was McCarthy et al. (1992) who introduced this concept in maxillofacial surgery and they soon got a long list of followers. The profession quickly focused its research on developing intraoral devices, instead of the extraoral pins that caused awkward scars. This became extremely successful and currently there are

many devices available for applications in both mandible and maxilla (Wangerin & Grob, 1994 and Chin & Toth, 1996). At present, the principle of distraction osteogenesis is widely used for all sorts of procedures. The main advantage of this technique being that bone grafts are not necessary in cases where distances have to be bridged. For this reason, the method is extremely suitable for patients with maxillary hypoplasia, including patients with cleft lip and palate but also for patients with hemifacial microsomia. There is ongoing dispute as to whether conventional osteotomies are to be preferred in preference to distraction in straightforward cases, or the other way around. It looks like a pendulum that will go back and forth as time goes by.

Another new technique, that has already made inroads in many branches of surgery, is minimally invasive surgery, making use of endoscopic instruments. An excellent review of its current and possible future applications is presented by Resnick et al. (2009). The use of resorbable osteosyntheses has also made its way into orthognathic surgery, although they were already frequently used in trauma surgery and are dealt with in that section.

There is, of course, another technical advance that needs to be mentioned and that is the 3-D imaging technique. This has brought about a revolution in many ways, as 3-D models can be prepared for studying complicated reconstructive cases but also for mimicking the operations to assess the best possible solution for the patient. This technique will also allow for circumventing the need for cast models by producing virtual models and constructing real, intermediate splints, purely based on proper 3-D imaging (Xia et al., 2000, Swennen et al., 2007, Choi et al., 2009). Last, but not least, it provides a means for the documentation and study of changes brought about by corrective surgery in a three-dimensional fashion that was hitherto was not possible (Khambay et al., 2002).

The development of orthognathic surgery has gone from simple surgical techniques to correct gross facial deformity, that were developed decades ago, to a highly sophisticated specialty, that has the tools to correct all possible deformities with a high degree of accuracy at the present time. This is well illustrated in the book of Reyneke (2003). There currently is much more emphasis on the esthetic component, which is in keeping with the development of the specialty as a whole, which includes facial esthetic surgery. Many colleagues are, nowadays, carrying out adjunctive esthetic procedures in conjunction with orthognathic surgery, such as liposuction and cosmetic rhinoplasties. It is to be expected that this development will continue.

Cleft lip and palate and craniofacial surgery

Before 1960 It is not surprising that children born with cleft lip and palate have drawn the attention of surgeons for a long time. This is probably true for many parts of the world but in Europe several 16th, 17th and 18th century surgeons attempted to close lips, among them Paré, as illustrated in his well-known book. They all confined surgery to the lips, as the cleft sides were pared and brought together and fixed in a straight manner. The latter was done with a pin that was stuck through both sides, around which a figure of eight thread was wrapped. Alternatively, a triangular needle was used to suture the skin and lip mucosa together. In the 19th century, curved full thickness incisions

came in fashion, which allowed for lengthening of the lip but still created a straight lip closure Rose (1891). The history of the development of cleft lip and palate treatment over the centuries is described in detail by Stiebitz in the book of Hoffman-Axthelm (1995) and by Millard (1976 and 1977).

It was French surgeons, in particular, who took the initiative to improve the techniques for closure of cleft lips. The name of Malgaigne (1843) is attached to a “cheiloplasty” in which the surgery tried to circumvent a straight closure and to avoid a whistling deformity. He pared the upper part of the cleft sides combined with a horizontal relaxing incision, which allowed for lip lengthening. Later the name of Merault (1871) became known for his using the same technique with a slight modification. In Germany, von Bruns (1844) claimed to be the first to use this type of closure. It is interesting to learn that two great names in cleft surgery, Veau and Blair, practiced the Merault technique, with modifications, for unilateral cleft lip up until the beginning of the 20th century.

There were several other pioneers, including von Langenbeck and Hagedorn (1884), who tried to improve

“It was French surgeons, in particular, who took the initiative to improve the techniques for closure of cleft lips.”

on the existing techniques of lip closure. The latter introduced the principle of a Z-plasty, avoiding a straight scar and at the same time providing lengthening of the lip. This principle was later refined by LeMesurier and even Millard.

The closure of the alveolar cleft posed a more complicated challenge, particularly when a complete bilateral cleft was involved. It was common practice in the first part of the 19th century to remove the premaxilla (Roux, Dieffenbach), while some would reduce it (Fergusson) and others forcefully set it back (von Bruns, Langenbeck). Bringing both sides together by compression of the cheeks was also attempted, using various extraoral types of apparatus, the best known being the “Hainby’s truss” as recommended by Fergusson in 1864.

One has to realize that all these operations were carried out on babies or young children, without the use of general anesthesia. This was not without risk, as appears from reports of Billroth and Krönlein. In the years between 1860 and 1867, Billroth reported 18.7 percent mortality, whereas Krönlein mentioned as much as 43 percent from the Langenbeck clinic in Berlin (HoffmanAxthelm, 1995)

Graefe (1816) and Roux (1819) were the first to attempt to close the soft palate, soon followed by several others, among them Gustav Passavant, known from the cushion in the posterior pharyngeal wall that is named after him. He cleverly predicted: “since early closure of the lip-alveolus is the most important factor in achieving spontaneous narrowing of the anterior palatal cleft, it might be expected that early closure of the soft palate will result in narrowing of the posterior palatal cleft.” He reported on the successful operation on five children varying in age from 6 weeks to 2.7 years, all operated upon without general anesthesia! It also is not clear from these descriptions whether attempts were made to align the palatine muscles.

The story about closure of the cleft of the hard palate began with attempts to mobilize only the mucosa. Several surgeons in Germany, England and the U.S.A. experimented along these lines, among them Dieffenbach, Passavant, Fergusson, Pollock and Warren. The breakthrough, however, came with von Langenbeck, who in 1862 and 1863 presented the results of successfully closed palates of patients varying in age from 7 to 59 years, using mucoperiosteal flaps. Again, all these operations were carried out without the use of general anesthesia. Until that time, surgeons were afraid of including the periosteum in the flaps, fearing that the underlying bone would become necrotic. His method was soon adopted by surgeons from all parts of the world (Hoffmann-Axthelm, 1995).

The introduction of chloroform anesthesia meant that early operations were carried out on children in the second half of the 19th century. This was also the period when obturators were introduced to take advantage of the action of the split pharyngeal constrictor muscle. The names of Kingsley from the U.S.A. and Schiltsky from Germany became widely known in relation to these devices (Hoffmann-Axthelm, 1995).

In the U.S.A., Truman Brophy (1916) dominated the art of cleft surgery for many years. When reading his text, in which he devotes 230 pages to the treatment of cleft lip and palate, he shows little modesty. He obviously was a self-confident man, very much aware of what was going on in Europe but quite convinced of his methods being right, considering his comments in the book directed to his colleagues.

He would stick to a strategy that was completely against the then common practice by propagating a reversed sequence: “The lips should not be operated on until after the bones have been approximated and united.” His technique looks rather gruesome nowadays, including introducing silver wires through the maxilla, cranial of the palate, to hold the approximated fragments in place. In cases of bilateral cleft, he first brought the premaxilla backwards after a wedge excision in the vomer and carried it back and fixed it by means of silver sutures. The palatal shelves were approximated as described before, trying to achieve bony union. Lips were closed six weeks to three months later. He also advocated operating early, since the bone would still be soft and malleable. It took years before it was realized that this treatment had a detrimental effect on the growth of the maxillofacial complex. His disciples, Blair and Ivy (1923) did not follow their master’s example but adapted the strategy of Victor Veau.

A true new era in the treatment of children with cleft lip and palate began with the introduction of the double layer closure of clefts by Victor Veau (1882–1949), using the nasal mucosa, both from the lateral side and the vomer. He simultaneously freed the alar base and turned it across the cleft just inside the entrance to the nostril. He also emphasized the need to approximate the muscles using wires, in fact creating a three-layer closure and closed the anterior palate simultaneously. He was, at the same time, aware that he was operating on growing individuals in which growth could be impaired by early surgery.

Victor Veau

He published his work in two monographs in 1933 and 1938. It is astonishing to read the detailed descriptions of both the classification and surgical treatment of cleft lip and palate, particularly in his standard text “Bec de Lievre.” He devoted his life not only to the treatment but also to the study of the embryology related to cleft lip and palate. Even today, it is worthwhile studying his observations. His work had a great influence on his contemporaries as is borne out in the books of Wassmund (1939) and Axhausen (1940) but also by publications in English, for instance, Blair, Ivy and Brown (1923, 1936, 1944) and Kilner (1937).

Other major forward steps were the first attempts at improving speech by carrying out pharyngoplasties. Rosenthal (1924) presented a caudally pedicled posterior pharyngeal flap to insert into the velum, while Sanvenero-Rosselli (1932) used a cranially based flap. Various modifications have since been published but almost all are based on these two principles. In the period from roughly 1940 to 1960, numerous wellknown surgeons came up with suggestions for improving the esthetics of the lip and nose, including lengthening of the lip, creating a Cupids bow and avoiding the notching of the upper lip. Those names include, although no completeness is claimed, Le Mesurier, Tenisson, Limberg and Trauner.

Last but not least, primary bone grafting of the alveolo-palatal cleft was carried out by several surgeons, most of whom were European. According to Stellmach (1973), this procedure was performed in 1914 by Drachter but also by Kazanjian (1951) and Axhausen (1952). However, it was particularly Schmid (1964), who in the 1950s advocated this procedure. Conversely, Stellmach (1973), based on a review of the then existing literature and on his own long term experience, pointed towards the disappointing results with regard to growth inhibition, which led to cross bites and maxillary hypoplasia.

Although the principles of primary cleft lip and palate surgery by the end of this period were known, little was understood about the impact on growth, although there was a growing awareness that because of surgery, growth retardation did occur. Schweckendieck (1973), in a paper in a year book of the German Society, mentions this as a general feeling among German surgeons (although not a single non-German author is mentioned!!) and specifically points to the advantages of early closure of the soft palate (nine months) followed by lip and naso-alveolar closure two to three weeks later, limited to the soft tissues only. His father began to follow this protocol in 1944 and reported good results also with little growth retardation in the long run (Schweckendieck 1955 &1958).

Gustavo Sanvenero-Rosselli 1960–1990 There were five important and noticeable developments during this period which would fundamentally change the treatment of patients with cleft lip and palate, whereas other breakthroughs occurred that opened the pathway to craniofacial surgery.

First, the introduction of cephalometrics made it possible to register and monitor growth and development of the jaws of the growing child and thus, to quantify the amount of growth impairment. It was particularly orthodontists who made these observations and became the “watchdogs” in the cleft lip and palate teams, as the impact of certain techniques on growth could be objectively documented.

Evaluation of dismorphic growth in both operated as well as non-operated patients contributed enormously to the improvement in techniques with which to approach cleft lip and palate patients and patients with craniofacial syndromes. There is no doubt that Pruzansky (1920–1984), the founding director of what is probably the first cleft lip and palate and craniofacial team in the world, at the University of Illinois, was the leading authority in this area. In a series of articles during his professional life, he produced invaluable and groundbreaking information that paved the way for a more rational approach to the treatment of clefts as well as to craniofacial deformities (Cohen & Rollnick, 1985). His information had a particular impact on timing of the surgical interventions.

Another pioneer who promoted the team approach and also stressed the importance of keeping careful records, including casts, cephalometric radiographs, photographs etc., in order to gain knowledge but also to assess critically one’s own results, was Berkowitz. In an authoritative publication, he reviewed the then-existing literature on orofacial growth in cleft lip and palate patients and suggested future studies to improve treatment (Berkowitz, 1977). At the end of his career he presented a multi-authored book on the state of the art of cleft lip and palate management (Berkowitz, 2006).

As a result of cephalometric studies, one of the most important discoveries of this particular time period was the observation that individuals with unoperated clefts had almost normal facial growth (Dejesus, 1959, OrtizMonasterio et al., 1966, Bishara et al., 1976, 1986). This observation has been repeatedly confirmed by various studies until today. This led to the conclusion that almost all growth impairment had to be attributed to the effects of surgery. This in turn led to a treatment protocol that limited

the surgical interventions and modified the sequencing, including the postponement of the closure of the hard palate, as previously recommended by Schweckendieck (1955).

An original idea to allow the palatal shelves to grow and to facilitate the feeding of babies, while postponing the closure of the hard palate, was introduced by Hotz in the early 1960s (Hotz & Gnoiski, 1978). They recommended the use of an acrylic plate to obturate the cleft, soon after birth. This early orthopedic treatment, actively guiding the fragments into the desired position by selective grinding of the acrylic plate, was widely adopted, particularly in Europe, despite the fact that it required frequent followup and often the fabrication of new plates to catch up with growth.

Second, teams of specialists of various origin began to work together to approach the complex problems in a rational way, based on growing evidence that growth, speech and psychological development of the child were intimately related to each other. The possible problems with regard to dysfunction of the eustachian tube were also recognized and heralded expertise from the ENT discipline (Soudijn & Huffstadt, 1972). It was Pruzansky (1955), who became the initiator and great promoter of this idea. He emphasized not only the clinical advantages but also the need to carry out research to improve results.

His example was soon followed in several places all over the world, acknowledging the importance of a multidisciplinary approach in which next to the cleft surgeons, orthodontists, ENT surgeons, speech pathologists, pediatricians, dentists and disciplines providing psychological and social support, were equally important. This philosophy came through loud and clear with the introduction of the Cleft Palate Journal in 1962.

Third, the introduction of secondary bone grafting of the alveolo-palatal cleft. This grafting was done in order to promote the eruption of the canine in the cleft, which in turn would improve the dental arch form. This so-called early secondary bone grafting was introduced by Nordin and Johanson in 1955 and, as seen in German literature (Stellmach, 1973), was followed by many clinicians.

It was Boyne and Sands (1972), however, who pointed towards the proper timing (between nine and 11 years) to allow the canine to erupt through the grafted bone. It is of interest to note that Freitag and Fallenstein (1984) adapted the timing of the grafting in cases where a lateral incisor could be brought into the arch. This brought about a revolution in the treatment of the dental arches because, depending on the number of missing teeth, in many cases, an uninterrupted dental arch could be achieved through adequate orthodontic treatment. This in turn facilitated the surgical advancement of the hypoplastic maxilla when such a procedure was indicated. Several studies were subsequently published to attest to the validity of this technique using various donor sites for the bone graft, including anterior iliac crest, rib and chin but also calvarium and tibia (Abyholm et al., 1981, Bergland et al., 1986, Sindet-Pedersen & Enemark, 1988, Witsenburg & Freihofer, 1990, and Borstlap et al., 1990).

Fourth, development in orthognathic surgery made it possible to treat the under-developed maxilla and restore the vertical and anterior-posterior position, combined with adequate orthodontic treatment. This concept was initiated by Obwegeser (1971) in the 1960s. Simultaneous grafting of the cleft and osteotomy of the maxilla was suggested by Henderson and Jackson (1975). The concept of segmental advancement and aligning the segments, along with simultaneous bone grafting of the alveolo-palatal cleft was introduced Henk Tideman by Tideman et al. (1980).

Another useful osteotomy for treatment of a midface hypoplasia, often as a result of cleft lip and palate, concerned the quadrangular osteotomy, as first described by Kufner (1971). This osteotomy had its drawbacks because the infraorbital nerve was often damaged but produced satisfying esthetic results, particularly when extended into the zygomatic bone (Obwegeser, 1969, Souyris, 1973).

Last, but not least, the introduction of the subcranial Le Fort III, in the early 1940s (Gillies, & Harrison, 1950), (Gilles & Rowe, 1956) and the Le Fort II (Henderson & Jackson, 1973) osteotomy made it possible to correct deformities of all areas of the midface as sometimes seen in this patient group but also in some syndromic patients. Again, Obwegeser (1969) pointed to the usefulness of this osteotomy in some cleft patients, combining it with a Le Fort I osteotomy so as to allow for differential advancement of the midface and the tooth bearing part of the maxilla. The results of the Zurich experience were presented by Obwegeser (1973) and Freihofer (1973), followed by many others both in Europe and the U.S.A.

Secondary surgery on the adult cleft lip and palate patient also became more sophisticated and particularly the closure of secondary palatal fistulae using intraoral tissues, including tongue flaps and bone grafting, became the standard (Jackson, 1972). Lip revisions and corrections of the nose were often necessary, particularly in the adult patient group, initially operated upon by less experienced surgeons or being subjected to less advanced techniques.

The above-mentioned developments took place almost simultaneously, beginning in the early 1960s and extending over the whole of this period. Further improvement in surgical techniques primarily for closure of the lip, however, were also reported. The two most important improvements, which had many followers, were the wave line of Pfeifer (1970), and the advancement rotation flap of Millard (1959, 1964). These techniques were applied to both unilateral as well as bilateral cleft lips, although in the latter case, staged procedures were often used depending on the position of the premaxilla.

The management of the protruded or extruded premaxilla was subject to a lot of debate. A review of the then existing literature is presented by Eppley et al. (1986), in which they concluded that “secondary reconstruction should be directed towards proper skeletal positioning of the premaxilla.” This should be done after orthodontic alignment and after the age of 8 years. It would entail an osteotomy of the vomer and nasal septum, bone grafting of the defects and proper mucosal coverage with either rotational flaps from the vestibule or tongue flaps.

Fifth, probably the most exciting and revolutionary development in this period was the emergence of craniofacial surgery, including intracranial access to the midface and the treatment of craniosynostosis at an early age so as to promote the normal development of the brain in patients with one of the craniosynostotic syndromes. It also allowed for correction of the position of the orbits and the reduction of telecanthus.

The pioneer in this field, without any doubt, is Tessier, who first published in 1967 the intracranial approach to the orbits to treat hypertelorism. He showed that if the orbital contents were circumferentially mobilized, the eye itself could be moved permanently in any direction without affecting the vision. He also demonstrated that simultaneous intracranial and extracranial surgery was possible. This brought about a revolution in the treatment of patients with Apert and Crouzon syndromes and all other syndromes caused by craniosynostosis (Tessier, 1967). It is somewhat beyond the scope of this book to go into detail but this was the basis for further development and refinement of techniques for treating these complicated and often rare syndromes. The progress made in these years is well illustrated in a standard text written by authors from Europe and the U.S.A. (Stricker et al. 1990).

Apart from these daring procedures, the history of which is well recorded by Ortiz-Monasterio in the book of Jackson et al. (1982), Tessier also showed that extensive areas of the craniofacial skeleton could be completely devascuralized, repositioned and still somehow healed. This trick became very useful in the context of access surgery to the brain and orbital content.

1990–2010 By this time, the general consensus was to try to reduce the iatrogenic growth impairment as much as possible by limiting the number of surgical procedures and by postponing the closure of the hard palate. Lips are closed first by most surgeons at an age varying from six to nine months, depending on the weight of the baby and the soft palate is closed about a year later. Pharyngoplasties, if necessary, are carried out at around six years.

The timing of hard palate closure varies from two to 11 years between the different teams. The development of speech is a decisive factor when deciding to close the hard palate early but it clashes with the idea of postponing the surgical closure in order not to disturb the maxillary growth. Various retrospective studies, however, are not conclusive whether delaying hard palate closure until the early teens is of any benefit (Novarraz et al., 1993, Stein et al., 2007). When postponing from nine to 11 years, it can be done simultaneously with the grafting of the alveolopalatal cleft. There is currently no consensus as to what should prevail and, thus, teams differ in the timing of this procedure.

The above-mentioned approach would result in a minimum of three operations before the age of 16, at which possible secondary corrections on lip and nose can be done. Where maxillary hypoplasia is developing, an osteotomy might be planned, which implies that no orthodontic compensation for the skeletal deformity should be carried out. Despite all efforts to promote adequate growth of the maxilla, advancement surgery of the maxilla is still needed in about 25 percent of cases (DeLuke et al., 1997, Steinberg et al., 1999).

In this context, it is only fair to quote the work of Delaire (1977), who in a series of articles in the 1970s pointed towards the roles the nasal septum and vomer play in the growth of the maxilla. He also emphasized the need to restore the normal anatomy of the muscles of the lip and soft palate, if normal development is Jean Delaire to be achieved. This was largely published in French and did not initially receive the attention it deserved but subsequent publications in English in the late 1980s and early 1990s spread his philosophy about cleft lip and palate repair with special attention to the proper attachments of the nasolabial muscles (Delaire & Precious, 1986, Markus, Delaire & Smith, 1992).

This surgery is preferably carried out at the age of six months simultaneously with the closure of the soft palate. The hard palate is then closed about a year later using

only the fibro-mucosa. His ideas have had great influence among many cleft surgeons. It is particularly the idea of using limited sized flaps to close the hard palate and not to denude the palatal bone that has gained acceptance among many surgeons.

The main emphasis during this period is on monitoring growth and several, mostly retrospective, studies are published on the supposed effects of certain modifications of treatment on maxillary growth. A pioneer in this arena is Ross (1987), who in a series of seven papers, published on the effects of certain modes of treatment on maxillary growth. Many others followed in the subsequent years (Semb & Shaw, 1990, Noverraz et al., 1993, Liao et al., 2006, Friede, 2007, Geraedts et al., 2007). In general, however, the current studies are retrospective in nature and not randomized, which makes it difficult to arrive at evidence-based conclusions.

A randomized, prospective study revealed that no advantages are to be expected from early orthopedics in UCLP patients (Bongaarts et al., 2009). This outcome study was certainly surprising and a blow for those who had adopted the original ideas of Hotz.

Orthognathic surgery for cleft lip and palate patients underwent further refinement, as is nicely presented by Posnick and Tiwana (2006). It was particularly orthodontic input that improved results, as the surgery was already known about in the years preceding this period. As mentioned in the orthognathic section, distraction osteogenesis has made its inroads into this type of surgery and certainly in relation to the treatment of CLP and patients with craniofacial anomalies. Numerous reports have appeared that advocate distraction versus osteotomy and bone grafting as the method of choice. Particularly for the high-level midface osteotomies this seems to be a sensible way of doing things (Figueroa et al., 2004, Cheung et al., 2005).

Another novelty in the treatment of the CLP patient is the placement of implants in the grafted alveolar cleft area to replace missing teeth (Kearns et al., 1997, Takahashi et al.,2008). Timing of this procedure is important since most of these grafts are placed in still growing individuals.

Today, the art of cleft lip and palate repair has become a multidisciplinary endeavor, requiring the expertise of many specialists. Future prospective studies, preferably of a randomized nature, have to be carried out to make further progress. This will take time since outcome studies, per definition, will need to have a follow-up of, at least, 16 years.

Craniofacial surgery also made major progress during this period. The advent of CT scans with accurate 3-D models made the diagnosis of some rare anomalies possible and the planning of the operations easier. Special procedures were developed by several craniofacial surgeons to approach the anomalies caused by the synostosis of the various cranial sutures (Zöller et al., 2002). The introduction of distraction osteogenesis reduced the morbidity and even mortality of, for instance, the monobloc advancement, including the fronto-orbital skeleton with the maxilla on the Le Fort III level (Arnaud et al., 2007).

The latest development in craniofacial surgery concerns the endoscopic, minimally invasive, release of the synostosis. The existing skull malformation is gradually molded with the help of a helmet, allowing for expansion in recessed areas and compression in areas of compensated growth. A prerequisite for success is timely surgery, that is to say, around three months of age. The first results of this technique look very promising and the authors report few and no disastrous complications (Jimenez, Barone, 2007).

An excellent account on the development of craniofacial surgery from the days of Tessier until today is presented by Arnaud (2010). Several pioneers in craniofacial surgery are interviewed and answers to the questions raised are literally printed in this article.

Epilogue

At this stage, the profession has moved away from dogmatic statements by individuals, based on personal experience, to properly constructed outcome audits, which in turn have fueled research projects along many fronts, frequently involving multidisciplinary teams of workers. Together with advances produced with industry and various emerging technologies, such as nano technology and tissue engineering, it has constantly broadened the scope for surgical advances and continues to do so.

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General Textbooks

Axhausen G. Die Algemeine Chirurgie in der Zahn-, Mund-und Kieferheilkunde. JF Lehmanns Verlag, Munchen-Berlin, 1940. Archer W A. Oral Surgery A step by step atlas of operative techniques. W.B.Saunders Company, Philadelphia and London, 1952, 1956, 1961, 1966, 1975. Bhaskar SN. Synopsis of Oral Pathology. The CV Mosby Comp, St Louis, 1961, 1965, 1969. Blair VP, Ivy RH, Brown JB. Essentials of Oral Surgery. The CV Mosby Company, St Louis, 1923, 1936 and 1944. Brophy TW. Oral Surgery: a treatise on the diseases, injuries and malformations of the mouth and associated parts. Henri Kimpton, 1916. Bruns von P, Garré C, Küttner H. Chirurgie des Kopfes 4e Edition Band I. Ferdinand Enke Verlag, Berlin, 1916. Cawson RA, Langdon JD, Eveson JW. Surgical pathology of the mouth and jaws. Wright, 1996. Chompret J, Dechaume M, Richard. Technique Chirurgale Bucco Dentaire. Masson et Cie, Editeurs Paris, 1935. Dechaume M, Huard P. L’art Dentaire, Stomatologie et Odontologie. L’Editeurs Roger Dacosta, Paris, 1977. Garretson J E. A System of Oral Surgery: a consideration of diseases and surgery of the mouth, jaws and associated parts. JB Lippincott & Co, Philadelphia, 1873. Hoffman-Axthelm W. Die Geschichte der Mund-, Kiefer-und Gesichtschirurgie. Quintessenz Verlag-GmbH, Berlin, 1995. Kruger GO. Textbook of Oral and Maxillofacial Surgery. The CV Mosby Company. St Louis, Toronto, London, 1959, 1964, 1968, 1974, 1979. Langdon JD, Patel MF. Operative Maxillofacial Surgery. Chapman & Hall Medical, London, 1992. Laskin D N. Oral and Maxillofacial Surgery. Vol. I&II, The CV Mosby Company, St Louis, Toronto, Princetown, 1985. Marx RE, Stern D, Oral and Maxillofacial Pathology. A rationale for Diagnosis and Treatment. Quitessence Publishing Co, Inc, Chicago, Berlin etc., 2003. Mead S V. Oral Surgery. The CV Mosby Company, St Louis. 1934, 1940, 1944. Perthes G. Die Verletzungen und Krankheiten der Kiefer. Verlag von Ferdinand Enke, Stuttgart, 1907. Peterson L J, Indressano A ,Th,Marciani R D, Roser St M. Principles of Oral and maxillofacial Surgery Vol I,II,III, JB Lippingcott Comp, Philadelphia, 1992. Peterson LJ, Ellis E, Hupp JR, Tucker MR. Contemporary Oral and Maxillofacial Surgery. JB Lippingcott Comp, Philadelphia, 1998. Pichler H, Trauner R. Mund-und Kieferchirurgie. Urban& Schwarzenberg. Berlin, Wien, 1942.

References (continued)

Shafer WG, Hine MK, Levy BM. A Textbook of Oral Pathology. WB Saunders Comp, Philadelphia, London, 1958, 1963, 1974, 1983. Sontag E, Rosenthal W. Lehrbuch der Mund– und Kieferchirurgie, Georg Thieme Verlag, Leipzig, 1930. Trauner R. Kiefer–und Gesichtschirurgie. Urban&Schwarzenberg. Berlin, München, Wien. 1973. Thoma KH, Oral Surgery. CV Mosby Company, St Louis, 1948, 1952, 1958, 1963, 1969. Thoma KH, Oral Pathology. CV Mosby Comp, St Louis, 1941, 1942, 1950, 1954. Thoma KH, Goldman HM. Oral Pathology. CV Mosby Comp. St Louis 1960. Ward Booth P. Schendel S. Hausanen JE. Maxillofacial Surgery Vol. 1 & 2, 2006. Wassmund M, Lehrbuch der praktischen Chirurgie des Mundes und der Kiefer, band 1 & 2 “Verlag von Ambrosius Barth, Leipzig, 1935, 1939.