The Biggest Movement: Orthognathic Surgery Undergoes Another Paradigm Shift

Article Outline

• A Meeting With the Godfather
• Paradigm Shifts in Orthognathic Surgery
• Bell’s Assessment of the Current Paradigm Shift
• Copyright

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A Meeting With the Godfather 

The only thing missing in the darkened room was demitasse cups, tapping against saucers. Instead, only Styrofoam squeaked to the Godfather’s words. He sat in the corner in his usual professorial tweed suit and sweater vest. But the comforting drone of the PowerPoint projector did not match the revolutionary but measured presentation of the Godfather. All leaned toward him to hear better as he uttered his startling words:

“They won’t buy that stuff anymore.” “The old ways of doing business are over.” “We need to make new alliances.” “Others are waiting to seize our turf.”

The experienced surgeons in the group could not be sure the young residents understood the importance of what they were hearing. William (Bill) Bell presented informally and genially on Friday rounds and took a leap so great it seemed to question all we once “knew” about orthognathic surgery. Here was the living icon, the Godfather of orthognathic surgery, explaining that the standard orthognathic operations of our practice were undergoing fundamental change and were in fact moribund. New technology, new economics, new alliances, even a new world sociologic view were all changing our ways. The health and beauty achieved today with orthognathic surgery is but a step along a complicated path toward comprehensive correction of skeletofacial deformities to be achieved in the future.

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Paradigm Shifts in Orthognathic Surgery 

Kuhn (1962) invented the term “paradigm shift” to describe an irrefutable scientific discovery that is the complete undoing of previously accepted knowledge. Once the shift is completed, all previous understanding of a clinical scientific topic is abandoned and is supplanted by new knowledge/new understanding.

The first such occurrence in orthognathic surgery was the appearance of Hugo Obwegeser at Walter Reed Hospital in 1967. Orthognathic surgery to that point was nearly almost exclusively limited to the treatment of prognathism with extraoral vertical ramus osteotomies and body ostectomies. Obwegeser introduced a versatile osteotomy, the sagittal ramus osteotomy of the mandible that could address deformities in 3 dimensions. American surgeons were so energized by his work that several did fellowships with Obwegeser and returned with even broader understanding and skills. Importantly, mandibular deficiency and laterognathias could now be treated.

The 1970s brought the development of intraoral vertical ramus osteotomies and segmental osteotomies. Remarkably, there was no discussion of vertical dysplasia until David Hall, Roger West, Bruce Epker, Larry Wolford, and William Bell, among others, almost simultaneously and independently developed operations to address vertical maxillary excess and deficiency. Like the inventions of the automobile and the airplane, great thinkers, working apart, nearly simultaneously identified a problem and their own solution to it. Weirdly, vertical dysplasias in maxillary growth essentially had to be discovered simultaneously with the operations to correct them. This was the final paradigm shift in understanding the 3-dimensional nature of skeletofacial deformities. Within a few years, centers that performed more than 90% of their osteotomies in the mandible were performing a majority in the maxilla. Finally, 2-jaw surgery to comprehensively address deformities became routine.

To digest these remarkable advances, many important but less revolutionary changes followed. The most problematic aspects of this treatment now needed to be addressed including the extended recovery with maxillomandibular fixation orthognathic surgery patients sustained as well as subsequent dental and skeletal relapse that compromised initially favorable results. As each of these issues was addressed, new ones were identified and solved.

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Bell’s Assessment of the Current Paradigm Shift 

In spite of these remarkable achievements for the modern world, William Bell contends that orthognathic surgery currently remains too complicated, too invasive, too time-consuming, too expensive, and too unpredictable. Additionally, it is not consistently covered under health insurance plans. Technological, economic, and social advances will make the correction of skeletofacial deformities more widely achieved by greater numbers of people by simpler, less expensive, more predictable, less time-consuming, and more broadly available means.

Here are some of the trends that will drive the next paradigm shift in orthognathic surgery.

As the Godfather summarized the state of the family business so eloquently, the room was stunned, but energized. One could imagine Michael Corleone would be sitting to his left. In a way he was, as Bryan Bell sat rapt, listening to his father’s words, and making plans for the coming paradigm shift.