SPECIAL CONTRIBUTION

J Oral Maxillofac Surg 62:1303-1307, 2004

Simon P. Hullihen and the Origin of Orthognathic Surgery

Shahid R. Aziz, DMD, MD*
Orthognathic surgery has evolved into one of the standards of care in oral and maxillofacial surgery. It is an area unique to the maxillofacial surgeon. Its early evolution is often credited to Vilray Blair, MD, the famed St Louis plastic surgeon who, in conjunction with Edward Angle, developed organized orthognathic surgery. The most signicant developments in 20th century orthognathic surgery were based across the Atlantic in Switzerland, Austria, and Germany, specically involving Wassermund, Trauner, and Obwegeser, to name a few. What is often overlooked is the true origin of orthognathic surgery: Wheeling, VA, in 1847 (now Wheeling, WV), by the surgeon Simon P. Hullihen, MD, DDS1 (Fig 1). Hullihen was born in western Pennsylvania on December 10, 1810, to a family of Irish farmers. He was the second of 3 boys. Hullihens early childhood was uneventful until age 9, when he fell into a lime kiln, severely burning both legs. This injury left Hullihen bedridden for 2 years, under the constant care of local physicians. It was this experience that initiated his interest in medicine. Over the next several years, Hullihen spent time observing the local physicians, as well as working on his fathers farmit was a combination of the mechanical development and a taste for science that ultimately led him to develop a career in oral and maxillofacial surgery. As a teenager, he had already developed a reputation as an innovative thinker:
The anecdote is related of him that when a boy he saw another boy who had swallowed a shhook, to which the line was attached. Medical aid was called, and the best surgeons at once gave up that it would be impossible to remove the hook without much danger to life. At his re*Assistant Professor, Department of Oral and Maxillofacial Surgery, University of Medicine and Dentistry of New JerseyNew Jersey Dental School, Newark, NJ. Address correspondence and reprint requests to Dr Aziz: Department of Oral and Maxillofacial Surgery, UMDNJNew Jersey Dental School, 110 Bergen St, Room B854, Newark, NJ 07013; e-mail: azizsr@umdnj.edu
2004 American Association of Oral and Maxillofacial Surgeons

quest, the boy Hullihen was permitted to try. Cutting a hole through a large bullet, he slipped it on the shing-line, and pressing down upon the hook, pushed it from the esh, and drawing both out, the point of the hook was found in the bullet.2

0278-2391/04/6210-0020$30.00/0 doi:10.1016/j.joms.2003.08.044

Hullihen went on to receive his medical degree from Washington Medical College in Baltimore in 1832 at the age of 22. He initially stayed on as an instructor, followed by brief practice in Canton, OH, and Pittsburgh, PA. It was his time in Pittsburgh when he met his wife-to-be, Elizabeth Fundenburg. They married in April 1835. Immediately following his marriage, Hullihen left via steamboat for Kentucky, where he planned to establish practice. He unfortunately became gravely ill, and disembarked the boat in Wheeling, VA, to seek medical attention. After spending time in Wheeling, Hullihen decided that this was the place to settle. He announced his intention to devote his practice to dentistry and surgery of the head, neck, and oral cavity. The Wheeling medical community greeted his arrival with scorn; at the time most dentists were of the barber-surgeon genre, rarely classically trained in medicine or dentistry. Other Wheeling physicians wondered why Hullihen, educated as a physician, would devote his career to dental surgery. Ultimately, he was met with signicant mistrust. As a practical joke, a few months after Hullihen opened his practice, 2 medical students presented Hullihen with a chicken with a broken leg, requesting treatment. Rather than turn the patient away, allowing himself to be the victim of this joke, Hullihen accepted the chicken and subsequently splinted the leg, with the medical students as his surgical assistants. He then told these men you must leave this patient with me for about ten days, during which time he should be kept under a barrel in my cellar and provided with proper diet. At the end of that time you will please call for him.3 After 2 weeks, the medical students did not return to collect their chicken. Undaunted, Hullihen returned the chicken to them with a fee of $20. Payment was subsequently refused; rather than leave the matter where it lay, Hullihen sought legal means, sued the students for his fee, and won.

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SIMON P. HULLIHEN AND ORIGIN OF ORTHOGNATHIC SURGERY

also used an adhesive strap from one cheek to another prior to surgery (Fig 2):
by thus conning the cheeks forward, a force is obtained and exerted upon the jaw, sufciently great to close in a few weeks the widest cleft of the alveolar arch, and at the same time correct any projections of its process . As soon as the cleft edges of the alveolar arch are brought together so as to touch each other in the slightest manner, the operation for the cure of the harelip may be properly performed .4

FIGURE 1. Simon P. Hullihen, MD, DDS (1810 1857) (Reprinted with permission from Ambrecht EC: Hullihen, the oral surgeon. Int J Orthod Oral Surg 23:377, 511, 598, 711, 1937).1

Perhaps what is most interesting is while it is now common to repair cleft lips in the rst year of life, Hullihen did this before the advent of anesthesia! Cleft palates, however, Hullihen noted required a signicant amount of patient cooperation and therefore required surgery later in life. He advocated waiting until the child was 9 or 10 years of age. Hullihen also fabricated obturators for adult cleft palate patients. For his leadership in oral surgery, the Baltimore College of Dentistry (now the University of Maryland Dental School) awarded Hullihen an honorary Doctorate of Dental Surgery in 1842. Although he had no formal dental training, Hullihen was a strong proponent of a sound medically based dental curriculum, to elevate the profession from its barber surgeon ancestry to the level of the physician. He later gave the Valedictory Address to the schools graduating class of 1850, in which he noted that dental education needed to combine in the same person a thorough medical and mechanical education. An efcacious union of medical and mechanical skill is the only course, the only plan to make an accomplished Dental Surgeon.1

Hullihen focused primarily on oral surgery. He developed a reputation for surgical excellence and catered to a patient base throughout the Ohio River Valley and beyond. Hullihens meticulous records give a history of his surgical cases during the last 10 years of his life: Cataract: 200 cases Hare lip: 100 cases Cleft palate: 50 cases Cancer (oral): 150 cases Antrum: 200 cases Strabismus: 100 cases Making new nose: 25 cases Making new lips: 50 cases Making new underjaws: 10 cases General surgery: 200 cases He became particularly well known for his treatment of cleft lip and palate. Hullihen advocated surgical repair in infancy, before the eruption of dentition. He

FIGURE 2. Hullihens adhesive strap (from Hullihen SP: Hare-lip and its treatment. Am J Dent Sci Ser 1 4:244, 1844).

SHAHID R. AZIZ

1305 cicatrix distracting anterior mandible as it developed. Hullihen used these spaces to treat the prognathism by performing wedge resection of bone bilaterally combined with what is now known as an anterior subapical osteotomy, as described by Kole in 1959 (Fig 4).
The operation was commenced by sawing out, in a V shape, the elongated portions, together with the rst bicuspid on the left side, each section extending about three-fourths of the way through the jaw. I then introduced a bistoury at the lower point of the space from which the section was removed on the right side, and pushed through the soft parts, close to and in front of the jaw, until it came out at the lower point of the space on the left side. The bistoury was then withdrawn, and a slender saw introduced in the same place, and the upper three fourths of the jaw, containing the six front teeth was sawed off on a horizontal line ending at the bottom of the spaces before named.5

Hullihen was an avid writer, and he published many case reports and technique papers in the medical and dental literature. Perhaps the most important was a case report entitled Case of Elongation of the Underjaw and Distortion of the Face and Neck, Caused by a Burn, Successfully Treated, published in 1849 in the American Journal of Dental Science. It is the rst documentation in the medical literature of true orthognathic surgery. Hullihen wrote about a young lady severely burned as a child with a scar contracture causing a signicant prognathism: Miss Mary S, aged 20, daughter of the Hon. Wm S., of Ohio, came to Wheeling in the Spring of 1848, to obtain relief from the effects of a very severe burn, which she received fteen years before. The burn was primarily conned to the neck and lower part of the face, and its cicatrix produced a deformity of the most dreadful character. Her head was drawn forward and downwardthe chin was conned within an inch of the sternumthe underlip was so pulled down that the mucous membrane of the left side came far below the chinthe under jaw was bowed slightly downward, and elongated, particularly in its upper portion, which made it project about one inch and three eighths beyond the upper jaw She was barely able to turn her head to either side she could not close her jaws but for an instant, and then only by bowing her head forward; she could not retain her saliva for a single instant, and as might be expected, her articulation was very indistinct5 (Figs 3A, B). Hullihen decided that a 3-phase surgical plan was in order: the initial procedure focused on correcting the skeletal deformity of the mandible, followed by resection of the large cicatrix of the right face and neck and then correction of the lower lip defect. Hullihen noted that correcting the malocclusion was most importantit provided for the restoration of function. He noted that there were edentulous spaces between the rst premolar and the canine on the right; in the left mandible, there was a space between the premolars. Most likely, these spaces were secondary to the

Once the bone wedges were removed and the osteotomy completed, Hullihen then took an impression of the new mandibular occlusion, created a stone cast, and fabricated a silver plate (occlusal splint) combined with maxillomandibular xation to immobilize the anterior mandible in its new position and facilitate bony healing. Postoperatively, Hullihen noted that the patient was relatively comfortable, without any significant complications. He left the splint on for 6 weeks to allow for bony union. The second phase of surgery was performed on July 31, 1848. Hullihen excised the large cicatrix, which extended from the right cheek to the clavicle and sternum. This cicatrix prevented the patient from any signicant movement of her head. He reconstructed the residual defect with a pedicled deltoid ap, sutured into place with ne thread sutures. Hullihen dressed the ap with adhesive plaster. Unlike the prior operation, the patients postoperative course at this point was a bit more involved. Hullihen wrote that she had what appears to be a psychotic episode postoperatively, perhaps from the analgesia given:

FIGURE 3. (A) Preoperative appearance. (B) Preoperative occlusion. (A and B from Hullihen SP: Case of elongation of the underjaw and distortion of the face and neck, caused by a burn, successfully treated. Am J Dent Sci 9:157, 1849.)

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SIMON P. HULLIHEN AND ORIGIN OF ORTHOGNATHIC SURGERY

FIGURE 4. Preoperative mandible (from Hullihen SP: Case of elongation of the underjaw and distortion of the face and neck, caused by a burn, successfully treated. Am J Dent Sci 9:157, 1849).

the patient was somewhat distressedwas very unmanageablewould talk incessantly, and occasionally sat up in bed.5 She also developed urinary retention, which required catheterization for relief. The third and nal surgery, performed 2 to 3 weeks after the second, was focused at correcting the lower lip deformity. The underlip, from being dragged down and greatly stretched by the former projection of the under jaw, was rendered greatly too largeso much so that it pouted out an inch or more further than the upper lip.5 Hullihen decided to close this in a V-Y fashion (Figs 5A, B). In his article, Hullihen drew a rendering of the patient 3 weeks after the nal surgery, illustrating a remarkable transformation: her prognathism was corrected and there was a restoration of facial/neck form (Fig 6). In light of this surgery taking place in a preantibiotic as well as preanesthesia era, what he accomplished is remarkable. Hullihens lack of a modern dental education is, however, evident. Hullihen corrected the prognathism but created an edge-to-edge occlusion anteriorly (Fig 7). This could be a combination of surgical limitations but perhaps more likely

FIGURE 6. Postoperative appearance (from Hullihen SP: Case of elongation of the underjaw and distortion of the face and neck, caused by a burn, successfully treated. Am J Dent Sci 9:157, 1849).

resulted from a lack of formal dental/orthodontic training. In addition, Hullihen performed this surgery 50 years before Edward Angles classic treatise on the Classication of Occlusion. The cephalometric analysis used in todays orthognathic surgery was developed 100 years after Hullihens surgery. Hullihen also did not comment on the complications of the orthognathic surgery. Mandibular subapical osteotomies place the mental foramen/neurovascular bundle at risk. In addition, preoperative radiographic evaluation must be used in treatment planning to avoid the mental nerve as well as tooth root apices. Hullihen never documented the status of the mental nerves,

FIGURE 5. (A, B) V-Y closure of lip (A and B from Hullihen SP: Case of elongation of the underjaw and distortion of the face and neck, caused by a burn, successfully treated. Am J Dent Sci 9:157, 1849).

SHAHID R. AZIZ

1307 amongst American surgeons he had no superior, probably no equal. In dentistry he was not equaled in America. With all these gifts of nature and attainment in science and art, a few hours sickness brought him down to the gates of death.1 In respect, the Wheeling community erected a 30foot marble monument in Wheelings Mount Wood Cemetery, which still stands today. The exhaustive research of Hullihens career by Edward Ambrecht, an oral surgeon in Wheeling, led to his being recognized as the Father of Oral Surgery in 1936. To commemorate this honor, the Wheeling Dental Society held Hullihen Day on August 18, 1936. The American Association of Oral and Maxillofacial Surgeons dedicated their 55th annual meeting to Hullihens memory. Simon Hullihens contributions to our specialty were enormous. His work, coupled with that of James Garretson, Chalmers Lyons, Truman Brophy, and others, paved the way for organized oral and maxillofacial surgery and elevated the dental profession as a whole from a trade to a respectable, intellectual branch of medicine. The inscription on Hullihens monument reads1:
Eminent as a surgeon The wide fame Of his bold original genius Was everywhere blended With gratitude For his benefactions

FIGURE 7. Postoperative occlusion (from Hullihen SP: Case of elongation of the underjaw and distortion of the face and neck, caused by a burn, successfully treated. Am J Dent Sci 9:157, 1849).

bilaterally, although it is likely that the nerve on the right, involved in the cicatrix, was damaged or nonexistent after the burn injury. Without radiographs, Hullihen could only guess at the horizontal cut in the mandible to avoid the apices of the involved teeth. He did not make mention of tooth vitality postoperatively, as well. Todays maxillofacial surgeon has at his or her disposal modern tools and technology. Obviously the treatment planning for a case such as this would be signicantly different. Hullihen, however, given the technology of the 19th century, provided this young woman a great service and in turn placed his name in the annals of orthognathic surgery. Hullihens most lasting legacy in Wheeling was founding Wheeling Hospital, in which the rst hospital dental unit was created. Tragically, his brilliant career was suddenly cut short. On March 27, 1857, at the age of 47, Hullihen died of complications from typhoid pneumonia, contracted from exposure after being overheated in the operating theater at Wheeling Hospital. In his brief career of 22 years, Hullihen performed over 1,100 maxillofacial surgeries. As word spread through Wheeling, the town declared his death a public calamity. His obituary read,

References
1. Ambrecht EC: Hullihen, the oral surgeon. Int J Orthod Oral Surg 23:377, 511, 598, 711, 1937 2. Goldwyn R: Simon P. Hullihen: Pioneer oral and plastic surgeon. Plast Reconstr Surg 52:250, 1973 3. Editors Table. North Am Med Chir Rev 2:19, 1858 4. Hullihen SP: Hare-lip and its treatment. Am J Dent Sci Ser 1 4:244, 1844 5. Hullihen SP: Case of elongation of the underjaw and distortion of the face and neck, caused by a burn, successfully treated. Am J Dent Sci 9:157, 1849