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The History of Minimally Invasive
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Approach in Oral and Maxillofacial
Surgery
Michael Shterenshis
Before we condemn or applaud an operator, before we adopt him as an example, we
should carefully examine his reasons for any given mode of operation.
(M. Jourdain. A Treatise on the Diseases and Surgical Operations of the Mouth, 1851)
Abstract
The history of the modern minimally invasive (MI) approach to oral and
maxillofacial surgery (OMS) is short, but it has a very rich background.
The development of minimally invasive surgery includes progress in
endoscopy, development of intraoperative navigation, tissue engineering
(TE), and, specifically for maxillofacial surgery, development of mandibu-
lar distraction. In endoscopic surgery, the minimally invasive approach
started when illumination and observation were combined with irrigation/
suction and intervention with microsurgical instruments. Frame-based ste-
reotaxy of neurosurgery did not contribute to maxillofacial surgery. The
selective intraoperative localization of anatomical structures of the facial
part of the skull became possible with further computed tomography (CT)
and magnetic resonance imaging (MRI) progress that stimulated the
development of frameless stereotaxy. The method of distraction osteogen-
esis is based on the tension-stress principle developed by G.A. Ilizarov in
the 1950s and 1960s. Osteogenetic treatment of the jaws has its own his-
tory which started in 1799, well before Ilizarov was born. The engineering
of cartilage and bone tissue brought benefits to the treatment of disorders
of the temporomandibular joint (TMJ). Regenerative dentistry became
another main field in the application of tissue engineering in OMS.
1
M. Shterenshis, MD
Department of Sciences, Alexander Muss Institute
for Israel Education (AMIIE-AMHSI),
Hod HaSharon, Israel
e-mail: shteren20@yahoo.com
© Springer-Verlag GmbH Germany 2018
O. Nahlieli (ed.), Minimally Invasive Oral and Maxillofacial Surgery,
http://doi.org/10.1007/978-3-662-54592-8_1
1.1 Introduction
The history of minimally invasive (MI) surgery
began with Hippocrates or even with the Ancient
Egyptian Edwin Smith Papyrus [1]. It was
Hippocrates who described the use of some sort of
pre-endoscopic device, the rectal speculum, in his
book On Hemorrhoids which was included in his
larger collection of works, The Art of Medicine [2].
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M. Shterenshis
The specula were used for centuries for dilating
openings of cavities of the body for better visibility and observation. Their constant improvement
and their combination with mirrors enabled them
to be used as laryngoscopes in the middle of the
nineteenth century (Fig. 1.1) [3].
While this was the beginning of endoscopy, it
was not the beginning of minimally invasive surgery because such devices were used only for
observational purposes. In endoscopic surgery
the minimally invasive approach started when
illumination and observation were combined
with irrigation/suction and intervention with
microsurgical instruments. Yet it was the devel-
opment of the endoscopy that brought minimally
invasive surgery to life.
The development of minimally invasive surgery included progress in endoscopy, development of the intraoperative navigation, tissue
engineering (TE), and, specifically for maxillofacial surgery, development of the mandibular distraction.
1.2 The Development
Endoscopy
of
The historical development of the endoscope can
be traced through several steps to minimally
invasive surgery:
• Observation—mirrors, specula
• Natural illumination + observation—improved
specula
• Artificial illumination + magnifica-
tion + observation—early endoscopes
• Illumination + observation + magnifica-
tion + delivery of medications—improved
endoscopes
• Illumination + observation + magnifica-
tion + delivery of medications + irrigation/
suction + microsurgical interventions—mod-
ern endoscopes
Fig. 1.1 Laryngoscopes in the middle of the nineteenth
century. From De Labordette, 1866 [3]
In simple terms, the modern endoscope must
combine visibility with accessibility. And that is
how minimally invasive endoscopically assisted
surgery was born. In 1805 the German physician
of Italian descend, Philip Bozzini from Frankfurt,
combined the light of a candle, mirrors, and
lenses inside a light-transmitting device called
“the lichleiter” [
stand, and its tin lamp holder was covered with
leather, its upper third being uncovered brass. A
candle inside one half of the lamp holder gave
light, and the other half had an opening in its posterior wall for the observer’s eye. The light was
reflected into the examining tube. Later, a
concave mirror was fixed inside the lamp holder.
The device was designed to view the urethra and
the rectum. The Medical Faculty of Vienna, being
asked by the Austrian government to report on
4]. It was a convex vase-shaped
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this, dismissed it as a toy. This somewhat clumsy
device (Fig. 1.2) did not, at the time, attract much
attention, but with further improvements made
by two French physicians, Jean Pierre Bonnafont
Fig. 1.2 “The lichleiter” of Philip Bozzini from Frankfurt
(1805) was the first endoscope. A candle inside one half
of the lamp holder gave light, and the other half had an
opening in its posterior wall for the observer’s eye. From
Bozzini P., 1807 [4]
and Antonin Jean Desormeaux, it became a valuable instrument in the mid-1800s. Desormeaux
replaced the candle of Bozzini with a spirit lamp
(burning alcohol) as a source of illumination, but
his main improvement was in changing the angle
of the lens. He understood the importance of a
proper light source:
“The means of lighting are of great importance.
The luminous points near the focus of the lens arc
useful, the others are useless, if not injurious.
Hence, it follows that we must have an intense
light of small volume. Large flames will not do;
candles, oil-lamps, and petroleum are useless;
gazogene (a mixture of alcohol and turpentine)
seems to me the best, its flame is intense but small,
and the lamp well adapted to the instrument.
Before I settled upon this lamp, I thought of the
electric light, but it is too cumbersome to be car-
ried around, and requires an assistant. It would,
moreover, double the price of the instrument.
Sunlight, so convenient for the laryngoscope,
would not answer for the endoscope, because its
rays cannot be controlled, and we must control
light to make it useful in the employment of the
endoscope” [5].
Desormeaux designed his device in 1843 but
it came into practice worldwide when he published his main book on the subject in 1865 [6]
(Fig. 1.3). It was Desormeaux who invented the
word “l’endoscopie.” By coincidence, that same
year of 1865 Francis Richard Cruise of Dublin
published his book “The Endoscope” [7]. He
noticed that illumination produced in the endoscope of Desormeaux was not sufficient for distinguishing between certain colors that might be
important for the diagnosis of different pathological conditions. He therefore tried to improve
visibility by adding a flat silver reflector within
the device. The endoscope of Desormeaux,
however, was conveniently constructed and portable (Figs. 1.4 and 1.5). The practitioners were
able to sketch the observed parts and pathological changes (Fig. 1.6) and these early endoscopic pictures have survived in the books of the
time. Both Desormeaux and Cruise indicated
that the endoscope could be used, not only for
observation, but also for treatment.
This approach was developed further by
Robert Newman of New York. While using the
Desormeaux-type endoscope, he designed vari-
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Fig. 1.3 The endoscope
of Antonin Jean
Desormeaux (1843).
Desormeaux replaced the
candle of Bozzini with a
spirit lamp (burning
alcohol) as a source of
illumination and changed
the angle of the lens.
From Desormeaux A.J.,
1865 [
6]
M. Shterenshis
ous instruments for therapeutic manipulations
(Figs. 1.7 and 1.8). Some of the instruments he
used were as follows:
“Holders with sponges at their ends to absorb fluids and cleanse the parts through the tubes.
Small cylindrical pieces of silver fitting into a
caustic holder. These pieces are dipped into melted
crystals of nitrate of silver, and are applied to the
diseased parts through the tube as a solid stick.
Small glass brushes as a better carrier of solutions
through the tubes” [8].
1 The History of Minimally Invasive Approach in Oral and Maxillofacial Surgery
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Fig. 1.5 The Desormeaux endoscope in use. From
Desormeaux A.J., 1865 [6]
cation remained. By the end of the nineteenth
century the practitioners were able to achieve a
magnification of only 2.5×. The German urologist Maximilian Carl-Friedrich Nitze (Fig.
tried to improve visibility by upgrading both illumination and magnification. In 1877, Nitze introduced microscope technology to the endoscope
and expanded its field of vision. The combination
of lenses he used actually turned an endoscope
into a mini-microscope that included a wideangle lens which was fully immersible in the
urine of the bladder. The lenses produced the
combined objective, which then magnified the
image. Improving magnification and widening
the field of vision were major advancements in
the ability to visualize the interior of the body.
Nitze also improved the light bulb when Tungsten
lamps became available; and from this moment
on the endoscopes became electrical
instruments.
Nitze was irritated by the fact that the image
Fig. 1.4 The endoscope of Desormeaux was conve-
niently constructed and portable. From Desormeaux A.J.,
1865 [6]
directed back to the eye was upside down and
tried, by manipulating the lenses, to improve this
situation, but in vain. He became the most distinguished endoscopist of his time, a position that
Yet this was not the beginning of minimally
invasive endoscopy-assisted surgery, because the
micro-forceps and the basket had not yet been
introduced. While the problem of illumination
was more or less settled, the problem of magnifi-
permitted him to publish “The Textbook of
Endoscopy,” Lehrbuch der Kystoskopie, in 1889
9]. It was already possible, at that time, to take
[
photographic pictures of the endoscopic images
and Nitze published his Atlas of such images in
5
1.9)
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M. Shterenshis
Fig. 1.6 The early endoscopic images as sketched in the
1860s. From Desormeaux A.J., 1865 [6]
1894 [10]. The images taken from the endoscope
became more precise but were in black-andwhite (Fig. 1.10). Nitze’s Lehrbuch der
Kystoskopie became a classical textbook. In its
second edition, which appeared in 1907, he was
able to demonstrate a “retrograde-view” scope
that had the capability to look at the bladder from
all directions (Fig. 1.11). He accomplished this
feat by turning the prism system of the endoscope
into a small 3-in-1 telescope for endoscopy [11].
By this means the resolution and magnification
were both improved. Yet the problem of the
upside-down image remained, until it was
resolved by the addition of another set of optical
lenses that reversed the image. In the beginning
Fig. 1.7 The endoscope designed by Robert Newman of
New York. From Newman R., 1872 [8]
of the twentieth century the endoscopic tube had
4.1 mm in diameter.
After these innovations the principal design of
the endoscope remained almost unchanged until
the 1960s. The endoscopes of the 1930s offered
only 20× magnification. Further improvements
of the technique were introduced in the following
stages: the rigid endoscopes → the semirigid
endoscopes → the flexible endoscopes. It was
also desirable to design a smaller diameter
device.
The situation changed in the 1960s. Quartz
rod-shaped lenses were invented in Britain by
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Fig. 1.8 Robert Newman designed various instruments
for therapeutic manipulations that can be performed via
the endoscope. From Newman R., 1872 [8]
Harold Hopkins. The length of these rod lenses
was considerably greater than their width. A light
was attached to the lenses. The usefulness of this
new generation of endoscopes was quickly recognized by urologists and gastroenterologists
[12–14]. The possibility for semirigidity was
achieved but the glass contained in these endoscopes made them fragile. Finally, when such
prominent medical equipment producers as Karl
Fig. 1.9 Maximilian Carl-Friedrich Nitze (1848–1906),
Germany. Nitze introduced microscope technology to the
endoscope and expanded its field of vision
Storz, Olympus, and Philips turned their attention to this problem in the 1970s, the flexible
fiber optic was invented and the problem was
solved. These optic fibers were narrower than a
human hair, having a diameter between 5 and
25 μm and being able to flex without breaking.
Flexible endoscopes were introduced, and these
innovations enabled the diameter of the tube to be
reduced, leaving more space inside it for an irrigation channel and for microsurgical instruments.
Further technical improvements in the 1980s and
1990s gave minimally invasive surgery a very
reliable tool.
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Fig. 1.10 In the 1890s
photographic pictures of the
endoscopic images replaced
early drawings. The images
taken from the endoscope
became more precise but
were in black-and-white.
From Nitze M., 1889 [
10]
M. Shterenshis
1 The History of Minimally Invasive Approach in Oral and Maxillofacial Surgery
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Fig. 1.11 In 1907 Nitze
designed a “retrogradeview” endoscope that
had the capability to
observe the investigated
part from all directions.
From Nitze M., 1907
11]
[
1.3 What About the Maxillofacial
Area?
The first endoscopes were designed as rectoscopes, uteroscopes, and urethroscopes. They
were quickly followed by endoscopes modified
for laryngoscopy, bronchoscopy, and esophagoscopy. By the 1910s these devices had become
generally accepted in the medical field [15].
What is important for the current volume is that
endoscopy-assisted manipulations performed via
the endoscope’s channel were readily accepted.
Their main application was the removal of
foreign bodies from the upper respiratory tract
and the bronchi [16]. “Broncho-electroscopes” of
that time were now equipped with forceps
(Fig. 1.12).
All these devices inevitably used the oral cavity as a passage, but no attention was paid to the
cavity itself. For centuries practitioners were satisfied with the direct observation of the oral cavity and the application of simple mirrors. Yet,
there was a desire for self-examination of the oral
cavity that could be performed with the help of an
artificial light source and mirrors. The first
attempts for such self-examination were very
clumsy (Figs. 1.13 and 1.14). The oral cavity is
much more accessible for direct investigation,
compared to the uterus or the urine bladder. The
mirror and the light reflector were enough for
such examination (Fig. 1.15). Therefore the
development of the investigation of the organs of
the oral cavity came through the combined efforts
of endoscopy and direct laryngoscopy [17–19].
The endoscopic approach introduced an artificial
light source for such examination in 1860s
(Figs. 1.16 and 1.17).
Being concentrated on bronchoscopy and
removal of foreign bodies, the peroral endoscopy
stimulated the design of various specific instruments to be used for endoscopy-assisted manipulations. In the 1910s and 1920s various
practitioners developed “universal non-slipping
forceps,” “bronchial dilating forceps,” ring forceps, single-curette forceps, “curettes of aural
type,” hooks, aspirator, bellows and bougies, and
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Fig. 1.12 “Broncho-electroscopes” of the 1910s were
now equipped with forceps. From Brünings W., 1912 [16]
Fig. 1.13 The first attempts for endoscopic self-
examination. From Czermak J.N., 1861 [17]
M. Shterenshis
Fig. 1.14 The first attempts for endoscopic self-
examination. From Fournié E., 1863 [18]
various other endoscope-applicable instruments
were enthusiastically designed [20–22]. The
instruments that were most widely used in the
1930s were forceps, suction tubes, and dilators
[23]. Some of these instruments were then introduced, after numerous modifications, into minimally invasive endoscopically guided surgery.
While otorhinolaryngologists have, for
decades, used endoscopes to observe the nasal
cavity, nasopharynx, and larynx, the introduction
of endoscopy into maxillofacial surgery was for a
while delayed. It was theoretically possible to
enter the ducts of the salivary glands with endoscopes, but the device needed some improvements to achieve this. The diameter of the
endoscopic tube should be as small as possible.
While it is true that more fibers translate to more
“pixels,” when the fibers are much smaller than
5 μm their physical strength and structural integrity are lost and fracturing can occur. That is why
the range of 5–25 μm has become standard. Other
possible applications of the endoscope within the
oral cavity were endoscopically assisted root
canal treatment and dental implantation
procedures.
The need for minimally invasive approach to
the diseases of the salivary glands was well
understood. The morbidity following traditional
surgery for parotid and submandibular sialadenectomy included a number of complications
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