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Contents
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Part I Introduction
1 Milestones Contributing to the History of Craniofacial
Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Ulrich Meyer
Part II Diseases: Craniosynostoses
2 History of Craniosynostosis Treatment . . . . . . . . . . . . . . . . . . . . . 15
Ulrich Meyer
3 Diagnosis and Classification of Craniosynostoses . . . . . . . . . . . . 27
Ulrich Meyer
4 Treatment Principles in Craniosynostosis . . . . . . . . . . . . . . . . . . 43
Christian Linz and Tilmann Schweitzer
Part III Diseases: Orofacial Clefts
5 History of Cleft Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Ulrich Meyer
6 Classification of Orofacial Clefts . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Rüdiger M. Zimmerer, Anna Katharina Sander,
and Bernd Lethaus
7 Treatment Principles in Orofacial Clefts . . . . . . . . . . . . . . . . . . . 79
Philipp Kauffmann and Henning Schliephake
Part IV Diseases: Branchio-oculo Facial Syndromes
8 Diagnosis and Classification of Branchial Arch Diseases . . . . . . 91
Ulrich Meyer and Valentin Kerkfeld
9 Treatment Principles of Branchial Arch Diseases . . . . . . . . . . . . 117
Valentin Kerkfeld and Ulrich Meyer
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Part V Diseases: Dysgnathias
10 History of Orthognathic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 125
T. Fillies and T. Seier
11 Classification of Jaw Malformations (Dysgnathias)
in Craniofacially Malformed Patients . . . . . . . . . . . . . . . . . . . . . . 131
Ulrich Meyer
12 Orthodontic Treatment Principles in Craniofacially
Malformed Patients Prior to Orthognathic Surgery . . . . . . . . . . 147
Bernhard Wiechens and Phillipp Brockmeyer
13 Orthodontic Therapy in the Context of Orthognathic
Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Werner Schupp, Julia Funke, and Julia Haubrich
14 Decision-Making in Orthognathic Surgery by Virtual
Planning and Execution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Ulrich Meyer and Kerkfeld Valentin
Part VI Diseases: Deformational Cephaly
15 Prevention and Treatment of Deformational Cephaly. . . . . . . . . 205
Helena Sophie Kriege, Christoph Runte, Ulrich Meyer,
and Dieter Dirksen
Contents
Part VII Diseases: Soft Tissue Malformations
16 Treatment Principles of Skin Malformations . . . . . . . . . . . . . . . . 219
Maria Ahls and Jan D. Raguse
17 Diagnosis and Treatment of Vascular Anomalies . . . . . . . . . . . . . 225
Ulrich Meyer
Part VIII Patient-Related Treatment Aspects: Patient Evaluation
18 Dental, Occlusal, and Functional Evaluation of Patients . . . . . . 241
Christoph Runte
19 Stereoscopic Imaging of Craniofacial Malformations . . . . . . . . . 251
Christoph Runte, Markus Dekiff, and Dieter Dirksen
Part IX Biological Procedures in Craniofacial Reconstruction:
Distraction Osteogenesis
20 Craniofacial Tissue Regeneration Through
Distraction Osteogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Valentin Kerkfeld and Ulrich Meyer
Contents
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xvii
Part X Biological Procedures in Craniofacial Reconstruction:
Tissue Engineering
21 Bone and Cartilage Tissue Engineering and Regenerative
Medicine in Craniofacial Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 279
Valentin Kerkfeld, Hans Peter Wiesmann, Jörg Handschel,
and Ulrich Meyer
22 Oral Mucosa Tissue Engineering in Craniofacial Surgery . . . . . 299
Günter Lauer
Part XI Biological Procedures in Craniofacial Reconstruction:
Microsurgery
23 Microsurgical Jaw Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . 313
Majeed Rana and Henriette Möllmann
Part XII Planning of Craniofacial Malformation Surgery:
Surgical Planning Principles
24 Technical Performance of the Personalized Approach
in Combined Guided Orthognathic/Bone Augmentation
Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
Sven-Olrik Streubel, Michael A. Luedtke,
Maria Isabel Osorio Garcia, David Al, and Bernd Hoffmann
25 Planning Principles in Distraction Osteogenesis Including
Simultaneous CAD/CAM-Based Facial Reconstructions . . . . . . 337
Valentin Kerkfeld and Ulrich Meyer
26 Aspects of Dysgnathic (Distraction) Intervention
in Childhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
W. Kater, M. Trommlitz, and D. Karnaus
27 Virtual TMJ Positioning Using Digital Data Transfer
for CAD/CAM Fabrication of Splints . . . . . . . . . . . . . . . . . . . . . . 355
Röhrs Axel and Ulrich Meyer
Part I
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Introduction
Milestones Contributing
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totheHistory ofCraniofacial
Surgery
UlrichMeyer
1
Introduction
Although craniofacial treatment often involves
manipulation of bone, craniofacial surgery is not
tissue specic; craniofacial surgeons deal with
bone, skin, nerve, muscle, teeth, and other related
anatomy. Craniofacial surgery is in a broader
sense dened by the anatomy (as the skull and
facial region); in a more narrow sense, it is
dened as the surgery of craniofacial deformities.
Malformations typically treated by craniofacial
surgeons include craniosynostosis (isolated and
syndromic), rare craniofacial clefts, cleft lip and
palate, branchio-oculo-facial syndromes, dys-
gnathia, ear and nose anomalies, congenital soft
tissue alterations, and other rare congenital
anomalies in the head region. Craniofacial anomalies have been known throughout history, and
both Hippocrates and Homer have touched upon
the subject. It is important to note that craniofacial medicine (as an operative and conservative
treatment eld) was developed through the work
of researchers, physicians, and surgeons.
Treatment of these patients is multidisciplinary,
done by a wide range of medical specialists.
The origins of the craniofacial eld can be
traced back to ancient times, marking the initial
U. Meyer (*)
Center for Jaw-, Face- and Skull Surgery,
Münster, Germany
e-mail: praxis@mkg-muenster.de,
meyer@kieferklinik-muenster.de
stages of its evolution. Developments in neurosurgical techniques, reconstructive techniques,
and dental/orofacial treatments on different disease entities (tumors, trauma, deformation) are
the basis for the recent state of surgical therapy.
The surgical treatment of deformities was done
over centuries and was dened in medicine in retrospect as plastic surgery. The publication of Karl
Ferdinand von Graefe’s work, “Rhinoplastik” [1]
(translated as “Rhinoplasty”), and its Latin counterpart, “Rhinoplastice” [2], played a signicant
role in incorporating the term “plastic” into the
terminology of reconstructive procedures. This
development ultimately led to Eduard Zeis naming the specialty of plastic surgery as “plastische
Chirurgie” in 1838 [3]. The word plastic in plas-
tic surgery means “reshaping” and comes from
the Greek πλαστική (τέχνη), plastikē (tekhnē),
“the art of modelling” of malleable esh. Plastic
surgery was since then the semantic term used for
the specialty to reconstruct deformed or lost
tissues.
History ofNeurosurgery
There is much evidence that as early as 10,000BC,
ancient humans practiced trephination (or the
drilling of holes) of the cranial vault. Neurosurgery,
or the premeditated incision into the head for pain
relief, has been around for thousands of years, but
notable advancements in neurosurgery have only
come within the last hundred years [4]. At a burial
© Springer Nature Switzerland AG 2023
U. Meyer (ed.), Fundamentals of Craniofacial Malformations,
https://doi.org/10.1007/978-3-031-28069-6_1
3
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Fig. 1.1 Skull trephination in ancient times (Thomas Quine, from https://www.ickr.com/photos/quinet/87663584,
licensed under CC BY-2.0)
U. Meyer
site dated to 6500 BC in France, 40 out of 120
prehistoric skulls were found to have holes from
trephination procedures. The Incas appear to have
practiced trepanning since the late Stone Age [5]
(Fig. 1.1), a method that is compared to similar
techniques used today [6]. By the 1400s, Incas
proved to be “skilled surgeons,” as survival rates
rose to about 90%, infection rates following the
procedure were low, and evidence was found
showing that some individuals survived the surgery on multiple occasions [6].
The ancient Chinese physician and surgical
pioneer Hua Tuo is said to have performed neuro-
surgical procedures [7]. In Al- Andalus from 936
to 1013 AD, Al- Zahrawi performed surgical
treatments of head injuries, skull fractures, spinal
injuries, hydrocephalus, subdural effusions, and
headache [8]. Avicenna also presented in Persia
at that time a detailed knowledge about skull
fractures and their surgical treatments [9]. The
rst real advances in neurology and neurosurgery
after the Greek epoche occurred in the
Renaissance. New ndings in anatomical studies
and their publication led to an accelerated development of this eld. An extraordinary example is
Johann Peyligk’s Compendium Philosophiae
Naturalis, published in Leipzig, Germany, in
1499. This work contained 11 woodcuts, depicting anatomical structures like the dura mater and
pia mater as well as the ventricles [10]. A signi-
cant advancement occurred in the eld of neurosurgical anatomy with the publication of Andreas
Vesalius’ “De Humani Corporis Fabrica” in
1543, marking a revolutionary step forward in
neurology and neurosurgery. It includes detailed
images depicting the ventricles, cranial nerves,
pituitary gland, meninges, structures of the eye,
vascular supply to the brain and spinal cord, and
an image of the peripheral nerves [11].
Neurosurgery saw limited progress until the late
nineteenth and early twentieth centuries, when
notable advancements emerged, such as the
placement of electrodes on the brain and the
removal of supercial tumors. The rst reported
surgical procedure for correction of craniosynostosis was performed in 1890 by Lannelongue
who advocated releasing, but not resecting, the
fused suture [12]. Lane followed the intervention
2years later in the United States [13], but these
surgeries had alarming outcomes with high morbidity and mortality. Faber and Towne reported in
1927 their success of a more extensive craniotomy [14]. Since then, the development of anesthetic and blood management over the years has
1 Milestones Contributing totheHistory ofCraniofacial Surgery
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provided the opportunity for more difcult and
advanced craniosynostosis surgery.
History ofPlastic Surgery
Treatments for the plastic repair of a facial structure (surgery of a broken nose) were rst mentioned in the Edwin Smith Papyrus [15] (Fig.1.2).
This publication is the world’s oldest surviving
surgical document. Written in hieratic script in
ancient Egypt around 1600BC, the text describes
anatomical observations and the examination,
diagnosis, treatment, and prognosis of 48 types
of medical problems in exquisite detail. Among
the treatments described are surgical therapies
like closing wounds with sutures, preventing and
curing infection with honey and moldy bread,
stopping bleeding with raw meat, and immobili-
zation of head and spinal cord injuries. Translated
in 1930, the document reveals the sophistication
and practicality of ancient Egyptian medicine.
In contrast to surgical procedures involving
the cranial skeleton, which can be more readily
reconstructed by archaeologists and physicians
even when performed in ancient times, reconstructive craniofacial procedures focusing on soft
tissues, such as the nose or ears, were more commonly performed during that era. The relative
simplicity of soft tissue surgery compared to
skull surgery contributed to a more rapid advancement in the eld of plastic surgery compared to
neurosurgery. Reconstructive surgery techniques
were often being carried out in India by 800BC
[16]. In India, during this time, it was common
practice for criminals and war captives to have
their noses amputated because the nose was considered as a symbol of reputation and respect.
Fig. 1.2 Edwin Smith Papyrus (Jeff Dahl, from https://commons.wikimedia.org/wiki/File:Edwin_Smith_Papyrus_
v2.jpg, Public Domain)
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Fig. 1.3 Statue of Sushruta (Heroesdontexist, from
https://commons.wikimedia.org/wiki/File:A_statue_of_
Sushruta_at_RACS,_Melbourne.jpg, licensed under CC
BY-SA 4.0)
U. Meyer
Thus, a group of potters known as the Koomas
developed nasal reconstruction to help remedy
this problem [17]. Sushruta was a physician who
made contributions to the eld of plastic and cat-
aract surgery in the sixth century BC [18]
(Fig.1.3). His method involved using aps from
the cheek and forehead that are still staples of
reconstruction of nasal deformities to this day
(Fig. 1.4). Sushruta’s developments were preserved in his book, Sushruta Samhita.
The Romans performed various medical procedures beginning around the rst century
BC.Aulus Cornelius Celsus presented detailed
anatomical studies of the skeleton, which was
used as a basis for plastic surgeons. The Indian
publications of both Sushruta and Charaka,
originally written in Sanskrit, were translated
into the Arabic language during the Abbasid
Caliphate in 750 AD [17, 19]. The Arabic translation of the Indian books was the basis for the
knowledge transfer in anatomy (Fig.1.5) and in
medicine into Europe via intermediaries [20].
During the Roman Empire, surgeon Paulus
Fig. 1.4 Indian method of nasal reconstruction
(Wellcome Library, London. Indian method of the restoration of the nose by plastic surgery, from article by B.L. to
Mr. Urban, concerning Cowasjee, a man who had his nose
reconstructed with the aid of plastic surgery. Line engraving 1794 By: Longmate Gentleman’s Magazine
B.L.Published: 9th October 1794, licensed under CC BY
4.0)
Aengineta (625–690AD) described techniques
for correcting nasal deformities and fractures of
the mandible. His procedures were groundbreaking at the time and have proven to be
instrumental in the history of plastic surgery
[21]. Clinical developments in plastic surgery
led to sophisticated techniques, like pedicled
aps to reconstruct facial structures (Fig.1.6). A
disadvantage for an accelerated development of
this eld during this epoche was the fact that
through religious reasons, physicians and
researchers did not dissect either human beings
or animals, and thus their knowledge was based
in its entirety on clinical experience.
1 Milestones Contributing totheHistory ofCraniofacial Surgery
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Fig. 1.5 Anatomical studies on the brain. [Figure source:
Gaspare Tagliacozzi—De curtorum chirurgia per insitionem—Illustration n. 8 (Source=http://books.google.it/boo
ks?id=5qg1lwTm79c)]
7
In Italy, particularly in Sicily, Gaspare
Tagliacozzi of Bologna [22] became familiar
with the techniques described in older publications, including those of Sushruta. Many consider Gaspare Tagliacozzi (1545–1599) as the
father of modern plastic surgery. His 1597 publication entitled “De Curtorum Chirurgia per
Insitionem” [23] set the basis for modern plastic
surgery. Tagliacozzi penned in 1597 the most
infamous phrase in plastic surgery: “We restore,
repair, and make whole those parts … which
nature has given but which fortune has taken
away, not so much that they may delight the eye
but that they may buoy up the spirit and help the
mind of the aficted.” As an exceptional case,
Aulus Cornelius Celsus left some surprisingly
accurate anatomical descriptions, some of
which—e.g., his studies on the facial skeleton—
are of special interest to plastic surgery.
However, because of the dangers associated
with surgery in any form, especially that involving the head or face, it was not until the nine-
teenth and twentieth centuries that such surgery
became common. In 1845, Johann Friedrich
Dieffenbach wrote a comprehensive text on rhi-
Fig. 1.6 Pedicled arm-nose ap [Typ 525.97.820,
Houghton Library, Harvard University, Illustration, plate
8, from De curtorum chirurgia per insitionem, 1597, by
Gaspare Tagliacozzi (1545–1599). Cropped version,
Public Domain]
noplasty, titled Operative Chirurgie, and
introduced the concept of reoperation to improve
the cosmetic appearance of the reconstructed
nose [24]. Following Dieffenbach, von
Langenbeck made major contributions to the
modern approaches for correcting congenital
cleft lip/palate and jaw deformities. One of the
founders of modern facial plastic surgery is generally considered to have been Sir Harold Gillies
[25]. As an otolaryngologist, he developed many
of the techniques of modern facial surgery in caring for soldiers suffering from disguring facial
injuries during the First World War. The rst Le
Fort III operation, which involves advancing the
face forward, was performed by him; however,
2 weeks later, the patient’s facial structures
relapsed and Sir Harold said that he would never
repeat the procedure.
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U. Meyer
History ofMaxillofacial Surgery
The historical development of oral and maxillofacial surgery has followed a rather stepwise,
intermittent course. During the time between the
nineteenth and twentieth centuries, orthognathic
surgery evolved. The rst mandibular osteotomy
is considered to be Hullihen’s [26] procedure in
1849 for the correction of a protruded alveolar
mandibular segment. The rst osteotomy of the
whole mandibular body for the correction of
prognathism was performed by Blair [27] in
1897. He was also the rst author to present a
classication of jaw deformities. The operations
performed, described, and published by Blair and
Angle [28] marked the beginning of the development of oral surgery. Complex surgical procedures became possible with the invention of
general anesthesia in the mid-nineteenth century
and were helped later with the discovery of penicillin by Sir Alexander Fleming.
Dental, oral, and maxillofacial surgical techniques to correct facial deformities were later on
used to treat patients mainly suffering from craniofacial malformations (especially clefts) or
trauma. As complex trauma cases had their origins in war injuries, orofacial techniques developed fast during and after the First and Second
World War. Whereas the origins of cleft surgery
can be attributed to general and plastic surgery,
evolution of orthognathic surgery belongs more
to oral surgery. The basic operations were related
to the surgical removal of impacted or displaced
teeth (indicated by orthodontics) to enhance dental treatments of malocclusion and dental crowding. The majority of maxillofacial surgery prior
to the First World War was focused on the soft
tissues of the face.
However, trench warfare during World War I
changed the view on treatment modalities and
redened the world of plastic surgery. Craniomaxillofacial injuries during the First World
War were remarkable in both number and extent
of damage. Prior to World War I, there were
very few practicing surgeons in general, and
almost none who were capable of treating complex facial wound including dental, jaw, and soft
tissue structures. It took just a few years before
surgeons were learning how to appropriately
manage these injuries. In 1921, Blair published
his important paper: “Reconstructive surgery of
the face” [28]. With the onset of World War II,
plastic surgeons again found themselves reinventing the specialty. World War II presented
oral and craniofacial plastic surgeons with a
myriad of new craniofacial challenges due to
advances in weaponry. Complex injuries and
displacement of the craniofacial skeleton were
common, and it was here that modern skeletal
craniofacial plastic surgery was introduced. In
1949, Kazanjian and Converse published one of
their most important works: “Surgical Treatment
of Facial Injuries” [29].
One of the most future driving developments
in craniofacial therapies was the cooperation and
collaboration of surgeons with dentists. It was
recognized that complex orofacial wounds,
including jaws and teeth, can only be treated
through the knowledge of surgeons and dentists.
As Germany had a huge number of orofacially
injured patients and as these patients were logistically concentrated in three hospitals (Düsseldorf,
Hamburg, and Berlin), these clinics (Westdeutsche
Kieferklinik, Düsseldorf; Nordwestdeutsche
Kieferklinik, Hamburg; and Charitè, Berlin) were
pioneering in the development of the double
degree (medical and dental degree as a prerequisite for the specialization on cranio-maxillofacial
surgery, Mund-, Kiefer, und Gesichtschirurgie)
educational concept.
Orthognathic techniques were indeed developed based on a deeper understanding of both
disciplines. Blair [28] published the horizontal
subcondylar osteotomy of the mandible to correct class II dysgnathia by advancement of the
mandibular body. This technique required prolonged intermaxillary xation, which was
already regarded as an inconvenience due to a
lack of bone contact between the osteotomized
segments. Orthognathic surgery was more
widely popularized rst in Germany and then
became a standard procedure as the BSSO operation technique was established. On the way to
the BSSO technique, Schuchardt [30] modied
the horizontal at osteotomy by introducing a
technique in which a cortical osteotomy was
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