331

CLINICS IN
PLASTIC
SURGERY
Clin Plastic Surg 34 (2007) 331355

Orthognathic Surgery and a Tale of

How Three Procedures Came to Be:
A Letter to the Next Generations
of Surgeons
Hugo L. Obwegeser, MD, DMD

- In the beginning. Sagittal splitting of the mandibular ramus

The transoral sagittal splitting of the The osseous genioplasty
mandibular ramus The LeFort I
The transoral osseous genioplasty Surgical instruments
The LeFort I-type osteotomy - Acknowledgments
Birth of orthognathic surgery - Further readings
From maxillofacial to craniofacial - References
- Postscript

Today the transoral sagittal splitting of the ramus, passed a large curved awl with a heavy thread at-
the osseous genioplasty, and the LeFort osteotomy tached to a Gigli saw transcutaneously around the
have become commonplace procedures used by ascending ramus above the lingula. With that, the
multiple specialties to solve a range of problems. ascending ramus was cut on both sides within 15
There was a time when that was not always so. minutes. The patient then was placed in maxillo-
This is a tale of how they came to be. mandibular fixation for 6 to 8 weeks. In 1952, Trau-
ner asked me to follow up on all of our 36 cases
In the beginning. of Kostecka operations. Roughly 50% of our cases
had nonacceptable complications: partial or total
The transoral sagittal splitting of the relapse, open bite, pseudoarthrosis, irreversible in-
mandibular ramus jury to the mandibular nerve, and even worse to
When I started my training in maxillofacial surgery the facial nerve, parotid gland fistula, or other com-
in 1947 with Richard Trauner at the Maxillofacial plications. The occlusal relapses, Trauner assumed,
Unit of the Dental School of the University of were caused by inadequate bony union because of
Graz in Austria, orthognathic surgery was virtually the extremely small area of contacting bone surfaces
nonexistent. It was a series of unsatisfying proce- of the two fragments further compounded by the
dures primarily to correct so-called prognathism. pull of the temporalis muscle dislocating the frag-
Among them were the Blair [1] and the Kostecka ments. Thus we sought for a procedure that would
[2] procedures (Fig. 1). The patient was seated in produce broader contacting bone surfaces for a
a dental chair, given sedation followed by a local in- stable union.
filtration and a block anesthesia. The assistants role I searched the literature and in K.E. Hogemans
was to hold the head steady. The surgeon then monograph (1951) on Surgical Orthopaedic

Department of Maxillofacial Surgery, University Hospital Zurich, Switzerland.

E-mail address: pkpatelmd@mac.com (P.K. Patel).

0094-1298/07/$ see front matter 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.cps.2007.05.014
plasticsurgery.theclinics.com
332 Obwegeser

Fig. 1. As originally depicted, correction of mandibular deformities by the blind techniques of (A) Blair in 1914
(A) and (B) Kostecka in 1931. (From Blair VP. Surgery and diseases of the mouth and jaws. 3rd edition. St. Louis:
The C.V. Mosby Company; 1914 and From Kostecka F. Die chirurgische therapie der proggeni. Zahnaertzliche
Rundschau. 1931;40:66987.)

Correction of Mandibular Protrusion, I found was considered unthinkable in those days. How-
a compendium of what was available to the surgeon ever, I knew that with my experience in treating
at that time. I disliked all the ones with an extraoral mandibular fractures by proper repositioning of
approach because of the unpredictable quality of the fragments and intermaxillary fixation within 24
the scar and the added risk to the mandibular hours of the accident resulted in minimal complica-
branch of the facial nerve. The few transoral tech- tions. The surgical procedure as a controlled trauma
niques that were published failed to produce the would be the same.
required broad contacting bone surfaces needed With this in mind, I tried sagittal splitting the
for stable bony healing. I wanted an osteotomy that ramus transorally on a cadaver at the Institute of
could be performed transorally only, avoiding a Anatomy (Graz, Austria) and reported to Trauner
skin incision, and which would produce broad con- that it was possible. He said that Perthes and
tacting bone surfaces, even after the repositioning. Schlossmann already had tried a type of sagittal
While thinking about this, I turned a cadaver splitting of the ramus by means of an extraoral ap-
mandible in my hands around several times, and proach. Some time later when I reviewed G. Perthes
the solution became obvious. If the mandibular article of 1922 [3], however, the osteotomy referred
ramus could be split along its sagittal plane, then by him was by A. Schlossmann, an oblique trans-
one of the requirements, the need for a broad verse osteotomy by means of an extraoral approach
bony surface area for healing, could be satisfied. similar to one published years later by V. Kazanjian
The procedures up until then focused only on bev- in 1951 (Fig. 2) [4,5]. The Schlossmann-Kazanjian
eling the transverse plane as variations of horizon- approach was an oblique transverse osteotomy in
tal osteotomies. I had twice seen on radiographs a limited attempt to increase the contact area. Nei-
fractures in a sagittal pattern. The question was ther, however, was a true sagittal splitting procedure
could it be done technically. After cross-sectioning that sufficiently increased the bony surface area as
a dry cadaver mandible at several points, I was cer- to what I had conceived. Interested, Trauner sug-
tain that the contents of the mandibular canal gested that we should operate together, on one side
could be left untouched, as there was sufficient in- his idea of a reverse L-shaped osteotomy of the ra-
tervening cancellous bone. The inner and outer cor- mus by means of a combined extraoralintraoral
tex had to be cut at different levels, and these two approach, and on the other side my idea of the
corticotomies connected along the sagittal plane. sagittal splitting of the ramus, transorally only.
As far as the second requirement of executing the The first case was an edentulous 27-year-old
procedure without an external skin incision, woman with a protruding mandible, operated upon
a transoral (intraoral) approach was needed. This on Feb. 17, 1953 (Fig. 3). Acrylic splints were fixed
 Orthognathic Surgery 333

Fig. 2. (A) Schossmanns oblique osteotomy through an extraoral approach as depicted by Perthes in 1924. (B)
The oblique osteotomy as depicted by Kazanjian in 1951. (From Perthes G. Uber Frakturen und Luxationsfrak-
turen des Kieferkopfchens und Ihre operative Behandlung, Arch Klin Chir 1924;133:41833, 1924. Kazanjian
VH. The treatment of mandibular prognathism with special reference to edentulous patients. J Oral Surg Oral
Med Oral Pathol 1951;4:6808.)

to the jaws for postoperative intermaxillary fixation. 212 weeks followed by elastics. Although the clinical
With the patient in a half-sitting position and under outcome was acceptable, the transoral technique
local anesthesia, the procedure was performed with was less than as I had hoped it would be.
Trauner and I operating as primary surgeons, and Two months later another opportunity arose, our
H. Kole assisting. Trauner completed his portion second case, when a 24-year-old prognathic woman
of the operation first. I asked the patient to open with nearly full dentition presented to us (Fig. 4).
her mouth wide, and I made a mucosal incision Even with the initial difficulties, Trauner remained
along the left ascending ramus. I used a Stichsage supportive. The first mandibular premolars had
(keyhole) saw to cut the cortical plates. I first cut been removed previously with the anterior teeth
the lateral cortical plate from the inner angle to the slightly retracted by the patients dentist to soften
outer angle of the jaw. Then I cut the medial cortical her prognathic appearance. In preparation, some
plate above the lingula all the way back to the poste- equilibration of the teeth was required to achieve
rior border. I then connected these cuts along the an- a stable occlusion, and continuous loop wiring
terior border of the ramus using a fissure bur. Then was applied to the maxillary and mandibular teeth.
when I tried to split the ramus using an osteotome, The operation was performed on April 22, 1953, by
the ramus unexpectedly shattered instead of split- Trauner and myself as the primary surgeons and
ting! The mandible was set back with splints and this time assisted by Professor Schuchardt from
the patient kept in intermaxillary wire fixation for Hamburg, Germany, who was a visitor for a week

Fig. 3. First attempt of the transoral sagittal split of the left ramus on February 17, 1953, by H Obwegeser and
a transcutaneous inverted L procedure on the right side by R Trauner. Patients profile (A) before and (B) after
the procedure. (C) The postoperative radiograph.
334 Obwegeser
 Orthognathic Surgery 335

at our department. After premedication for seda- and 5 months after surgery, the final result in occlu-
tion, the patient was placed in a half-sitting sion as well as in facial contour was very pleasing. It
position on the operating table. Mandibular block remained unchanged after 33 years. With this case,
and local anesthesia were used. This time, Trauner the transoral sagittal splitting procedure of the
asked me to operate first. I chose the left side, and mandibular rami was born (Fig. 5). We published
I started with an incision from the first molar this in German in 1955 [6].
back and up along the anterior border of the ramus, These early cases I did without special instrumen-
right to the bone. Next I raised the periosteum on tation, using what was only available to me at the
the lingual side above the lingula back to the poste- time. Additionally, inadequate intraoral lighting
rior ramal border. There I hooked a curved perios- and lack of the development of head and neck an-
teal elevator around it and cut the inner cortical esthesia in those days added additional challenges.
plate, this time with a long Lindemann bur, to the The first case I did under general anesthesia was on
depth where some bleeding became visible. The April 9, 1956, in Zurich, Switzerland (Fig. 6). In
Lindemann burs broke, one after another, and I 1954, I had left Trauner and at the invitation of Pro-
completed the medial corticotomy with a Stichsage fessor P. Schmuziger, Chief of Oral-Maxillofacial
(keyhole) saw, as I did with the first case. Next I Surgery and Professor R. Hotz, Chief of Orthodon-
raised the periosteum on the buccal side, from the tics at the Zurich Dental School, I joined the De-
angle horizontally back to the posterior border partment of Maxillofacial Surgery at the University
and sectioned the lateral cortex with a keyhole Hospital. Hotz in 1956 had a patient on whom
saw, followed by a fissure bur, just above the angle. he had wanted me to perform the sagittal splitting
Then I connected the lingual and buccal corticoto- procedure instead of referring the patient to Schmu-
mies by drilling a series of holes with a rose bur ziger. She was 14 1/2 years old with a rather long
and connecting them with a Lindemann bur along and narrow mandible with partial anodontia. She
the anterior ramus. With the first blow of the osteo- had mandibular prognathism (antemandibulism),
tome, unintentionally, the coronoid process frac- and when I traced her lateral cephalometric radio-
tured off. I then decided to further deepen and graph, she also had a maxilla that was small and ret-
widen the cortical cuts with a series of fissure rodisplaced. At that time, repositioning the maxilla
burs. After that it became easier to open or split was not possible, and the only option was a man-
the two cortical plates with an osteotome. I dibular setback with crown and bridgework. In
positioned a wide thin osteotome within the osteot- those days, however, there was no such thing as
omy gap, not so deep for fear of injuring the nerve, a panoramic radiograph, but the PA film showed
and with a gentle twisting maneuver, the cortical the mandible to be rather narrow, and I was not
plates this time easily fell apart. The mandibular sure that I could split the rami. We scheduled the
ramus was sagittally split! As the fragments would surgery for April 9, 1956, in a private hospital, as
almost be self adapting when moving the mandible she was a private patient from another country at
back on the split side and as we had yet to complete Hotzs request. I had never had an opportunity to
the procedure on the right side, we decided that operate in a private hospital before, nor had to con-
wire fixation might not be necessary. We spread tend with an anesthesiologist. Up till then I had
some penicillin powder and did a rather tight clo- done the procedures under local anesthesia. I had
sure of the periosteum and of the mucosa. On the to convince him of a nasotracheal intubation in-
other side, Trauner performed his inverted L-shaped stead of an oral intubation, and that was something
osteotomy through a combined oral and extra-oral new to the anesthesiologist. When I explained the
approach. A circumferential wire secured the frag- procedure and the need to turn the head, the com-
ments. This was followed by 6 weeks of intermaxil- bat started. Schmuziger who was my assistant, ex-
lary fixation. The recovery was uneventful. There pressed a view to his students that this procedure
was initially numbness of the lip on the side of the could be performed only on paper. Thus I began
sagittal splitting procedure, but this recovered com- an operation without much enthusiasm. I first se-
pletely by 1 year after the procedure. On the side of cured the cast cap splints, because the patients teeth
the inverted L transcutaneous approach, the perma- were not suitable for intermaxillary fixation. I
nent scar remained visible for many years. One year started the procedure on the right side. I did the

=
Fig. 4. (A) The patient record and operative report dated April 22, 1953, of the first successful transoral sagittal
split of the left ramus by H. Obwegeser and a transcutaneous inverted L osteotomy on the right side by R. Trauner.
(B) Preoperative appearance. Postoperative appearance (C) at 5 months and (D) after 33 years on the left side. The
occlusion (E) before and (F) after surgery. Postoperative appearance of the right side (G, H). The radiograph shows
the wire fixation on the inverted L right side and without wire fixation on the sagittal-splitting left side.
336 Obwegeser

Fig. 5. Illustration from the 1955 Trauner Obwegeser paper of the first sagittal splitting of the rami. (From Ob-
wegeser HL. In: Trauner R, Obwegeser H, editors. Zur Operationstechnik bei der Progenia und anderen Unter-
kieferanomalien. Dtsch Zahn Mund Kieferhlkd 1955;23:1125.)

cortical cuts with Lindemann burs very carefully, considerable amount of difficulty with poor light-
until I saw some bleeding indicating that I was at ing and instrumentation, I managed finally to adapt
the level of the cancellous bone. I did the cut above the free lateral ramus fragment to the rest of the
the lingula on the medial side and then a cut hori- ramus and the distal segment with direct wire fixa-
zontal just above the angle on the lateral side. Then tion. I closed the wound over a rubber drain. The
I made a series of holes using a rosehead bur along operation took over 4 hours. I thanked God that
the anterior surface just medial to the oblique ridge. it was over and hoped for the best.
With a short Lindemenn bur, I connected these The operation was more stressful that I had expe-
holes from the medial corticotomy to the lateral rienced before when I had performed it under local
corticotomy. I had learned by now that without anesthesia and sedation. I had to constantly battle
these series of holes as a guide, I found it difficult with the anesthesiologist, who was concerned that
to control the Lindemann bur alone without slip- I would pull the tube out of the nose, and my assist-
ping off the anterior surface of the ramus and caus- ing pessimistic chief. The postoperative course was
ing a fracture I had not planned. Despite the poor difficult for me and the patient. With each day, there
visualization of the operative field, the splitting was increasing swelling and bruising I had not had
on the right side went well, but took a long time. before. With each passing day, I feared some serious
On the left side, I ran into problems I had not complication. I did only what any surgeon would
encountered before. When I did the splitting by do. I went to the monastery church of Einsiedeln
striking a broad thin osteotome about 5 mm in and prayed, promising God I would never do this
depth only, and twisting it, the lateral ramus broke procedure again if this girl got away without com-
off. As I had detached it of its periosteum, it was plications. She had a wonderful aesthetic and func-
now a free fragment. This was my first sagittal split- tional result. No external scars. Six years later, she
ting since my new position in Zurich with my chief, sent me her wedding photographs. I on my part
Schmuziger, watching. Not particularly what I of the Faustian bargain, broke my promise to
would like to have had happened given his views. God. I continued to perfect the sagittal splitting pro-
I am not sure of Schmuziger was aware of my cedure until it became routine.
dilemma, as only I could barely see the operative We published this first in German in 1955 and
field. I ignored it for the time being. I set the man- then in English 1957. In the 1955 paper, we showed
dible back in the preplanned occlusion. On the the lateral cortical cut from distal of the second mo-
right side, I fixed the position with an anterior lar horizontally back to the posterior border well
border wire. I closed that side. On the left side, I re- above the angle. In the 1957 English publication,
turned to my problem. There was no contact however, we showed the lateral cortex cut from dis-
between the proximal and distal segments. With tal of the first molar to the posterior border just at
 Orthognathic Surgery 337

Fig. 6. First sagittal splitting of the rami performed under general anesthesia on April 9, 1956. (A) Preoperative
and (B) postoperative appearance. (C) Model surgery. (D) Preoperative and (E) postoperative occlusion with
prosthodontic restoration. (F) Preoperative and (G) postoperative lateral cephalograms.

the angle of the mandible together with some pho- the distal segment (Fig. 8). The change was the
tographs of the splitting itself (Fig. 7) [7]. The lat- horizontal orientation of the lateral corticotomy
eral corticotomy could be varied. With these two of the ramus to the vertical corticotomy of the man-
publications, we showed that the correction of dibular body. The story would not be complete
mandibular anomalies could be achieved transor- without my relating how Dal Ponts contribution
ally alone. In the years to come, I and others would came to be. In 1957, G. Dal Pont came to Zurich
continue to improve upon it. as a trainee of Professor Schmuziger, who was our
For the sagittal splitting of the rami procedure, chief, and he would assist both Schmuziger and
the variation that followed was the placement of me with all cases. From watching, he conceived
the lateral corticotomy so as to increase the surface the idea of changing the lateral corticotomy from
area of the bony contact to improve union and the horizontal ramus to the vertical body. We tried
accommodate a wider range of advancement of it with Dal Pont assisting, and it worked. In late
338 Obwegeser

Fig. 7. Illustration from the publication of the sagittal splitting procedure in the 1957 English article by Trauner
and Obwegeser. Intraoperative photographs of the sagittal splitting procedure published in the 1957 English
article by Trauner and Obwegeser. Fig. 4 Different surgical steps in Obwegeser technique. (A) Ramus exposed.
(B) Cortical incisions. (C) Broad bone surfaces facing each other after splitting of the ramus. (From Obwegeser
HL. Surgical procedures to correct mandibular prognathism and reshaping of the chin. In: Trauner R, Obwegeser
H, editors. The surgical correction of mandibular prognathism and retrognathia with consideration of genio-
plasty. Oral Surg Oral Med Oral Pathol 1957;10:67789.)

1958, Dal Pont went back to Italy and E. Steinhauser literature [9]. Unfortunately, Dal Pont failed to in-
took his place. Before we had an opportunity to clude us as coauthors, failed to mention that the
publish it, Dal Pont published it on his own in case shown in the article was my patient, and failed
1959 in Italian [8] and in 1961 in the American to mention that it was a modification of my original
 Orthognathic Surgery 339

Fig. 8. Evolution of the mandibular osteotomies. (A) Blair 1907 (B) Schlossmann-Perthes-Kazanjian 1922-1951 (C)
Schuchardt 1954 (D) Obwegeser 1955 (E) Obwegeser 1957 (F) Dal Pont 1958 (G) Obwegeser 1968. The dates in-
dicate the publication and not the date of the first procedure by the surgeon. It should be noted that
Schuchardts 1954 publication was based on his experience when he assisted me with a transoral sagittal
splitting of the ramus on April 22, 1953. Furthermore, Dal Ponts publication in 1958 showed photos of a patient
of Obwegeser and that the procedure was done when Dal Pont was a trainee at Zurich. No mention of this was
made in his article.

technique. When Dal Pont had finished his training placed the patient in intermaxillary fixation and re-
in Zurich and returned to Italy, he never performed sected the overlapping segment of the lingual sec-
the operation he published as his own in his clinical tion of the angle. I then fashioned the lateral
practice. In addition to the buccal osteotomy being cortical plate and fixed it to the lingual fragments
performed vertically, Hunsuck and Epker years later with wire fixation. I also simultaneously performed
advocated that the osteotomy on the lingual side a transoral osseous genioplasty to reduce the verti-
should be incomplete, only just past the entrance cally long chin. I published this in 1964 [12].
of the neurovascular bundle. This would result in
an incomplete fracture, along the medial aspect of The transoral osseous genioplasty
the ramus (Fig. 9) [10,11]. This I had already expe- The correction of the chin deformity has its own
rienced when Dal Pont was with us. Although ac- parallel history. Up until the mid- to late 1950s, cor-
ceptable for mandibular advancement cases as it rection of retrogenia was achieved solely by onlay
provides a longer area of bone contact, for the set- techniques through a submental skin incision. Au-
back, the lateral segment is displaced because of togenous grafts (bone and cartilage) and alloplastic
the cortical component on the lingual aspect. implants (titanium, Silastic, and acrylic) were used
When directed instead toward the ramal angle, the to create the chin prominence. The results of corti-
splitting can be done more completely, allowing cal bone grafts, while initially pleasing, were tempo-
better adaptation of the fragments with less risk to rary. Resorption was inevitable, followed by an
the nerve. inevitable secondary procedure. Although alloplas-
Thus by the early 1960s, the sagittal splitting tic materials had the advantage of ease of prefabri-
technique became routine in my hands; however, cated natural shape and permanence, they were
as so often happens, a patient arrives at the door- fraught with complications of infection, displace-
step, and the routine must be modified. I had ment, and erosion of the bony symphysis into the
a patient who had a severe open bite deformity. dental roots.
Neither a mandibular procedure alone and nor As with the sagittal splitting osteotomy, the need
my routine sagittal splitting procedure would lend was to develop a technique that could be accom-
itself easily to solve the occlusal problem that pre- plished entirely transorally, allow sufficient bony
sented itself. I needed to rotate the mandible. It contact for union, and maintain the advancement
occurred to me that through the sagittal split with minimal resorption. The idea came to me by
approach, I could perform a transoral angle chance when I had the occasion to see a young
osteotomy (Fig. 10). I first performed a posterior lady who had a significantly retruded chin but an
maxillary osteotomy and brought the segment su- acceptable occlusion (Fig. 11). As I traced the lateral
periorly. I then removed the lateral cortical plate cephalogram, I realized that I could alter her chin
from the ramus and placed it in a physiologic solu- contour by simply sectioning it transversely and ad-
tion. I isolated and repositioned the nerve. This vancing it. By leaving it pedicled on the musculature
then allowed me to make an angle osteotomy. I of the floor of the mouth, its vascularity would be
340 Obwegeser

Fig. 9. Complete splitting of the mandible as originally described by Obwegeser (1955, 1957). The incomplete
splitting of the mandible as advocated by later variations of Dal Pont 1959, Hunsuck 1968, and Epker 1977. Un-
like with a complete splitting, the lateral segment would be displaced, as the medial tooth bearing segment is
set back (arrow) because of the cortical plate on the lingual aspect. This must be addressed with these later var-
iations. With mandibular advancement, the incomplete splitting would not interfere.

maintained, and the contour of the submental re- these patients, although the mandible appeared
gion would be altered favorably. I made my familiar prognathic, the deficiency was clearly in the lack
transoral incision as in fracture cases. I used a Linde- of midfacial skeleton development, with only lim-
mann bur to make an osteotomy of the symphysis ited involvement of the mandible. Although a
directing the osteotomy plane from low posteriorly transoral mandibular setback would achieve proper
to high anteriorly. The last few millimeters of the occlusal relation, it would be at the expense of an
cut, I accomplished with a chisel. Once separated, optimal aesthetic outcome. The necessary tech-
I could easily pull the symphysis by 10 mm, pedi- nique to be able to reliably reposition the maxilla
cled on the geniohyoid muscle. I fixed it in the came long after the success of the sagittal splitting
new position with a circum-mandibular Supramid osteotomy of the mandible. Thus many patients
thread on each side over an acrylic dental splint. whose occlusions were restored with the mandibu-
The operation went well, and there were no compli- lar procedure were left with a flat appearance of
cations. After 3 weeks, I removed the threads. The their face and the stigma of their underlying defor-
operation was simple and went surprisingly well mity still apparent.
with a satisfying outcome. I published this in Why did it take so long? The problem was not
1957 [7]. Thus the transoral approach to correcting only surgically sectioning the maxilla safely, but re-
chin deformities was born. The only other prior positioning it and maintaining it in the new posi-
publication of sliding the inferior border of the tion. The surgical mobilization of the maxilla has
chin forward was by Hofer in 1942. The approach a long history, as Drommer recounted in 1986. It
that was published was extraoral, and the astute started with as a means of gaining access to the
reader will note that Hofer performed the procedure epipharynx and the skull base first reported by Lan-
on a cadaver and not a patient (Fig. 12) [13]. genbeck in 1859 and by Cheever in 1867; the max-
In the years that followed, variations in the genio- illa was sectioned horizontally through facial
plasty continued with limiting the need for exten- incisions. Only later was it sectioned for mobiliza-
sive exposure, various osteotomies to control the tion to correct the occlusal deformities. In 1935,
width and angulation, and with Neuner suggesting Wassmund reported in his book that in 1927 he
a double-step advancement. In its essence, the had detached the maxilla as a Guerin-type fracture
transoral procedure has remained for 50 years as without separating it from the pterygoid processes.
one of the simplest of technical procedures that He then used elastics to close an open bite. Never-
a surgeon can have in his rucksack to solve a wide theless, this was not a complete mobilization of
variety of chin deformities. the maxilla. Axhausen published repeatedly in
1934, 1936, and 1939 successfully repositioning
The LeFort I-type osteotomy of the maxilla in post-traumatic and cleft patients
With the transoral techniques addressing mandibu- using elastics after complete osteotomy of the max-
lar deformities, numerous patients could be treated illa, including separation from the pterygoid pro-
more easily. There remained, however, a group of cesses. It is hardly understandable that Axhausens
patients whose primary deformity lay within the procedure did not become routine by mid-twenti-
midfacial structures: the maxilla and zygoma. In eth century. In 1942, Schuchardt published
 Orthognathic Surgery 341

Fig. 10. The transoral angle osteotomy (H Obwegeser 1964). (A) Preoperative and (B) postoperative appearance
at 1 year. (C) Preoperative cephalogram. (D, E) Planned Obwegesers transoral angle procedure combined with
Schuchardts maxillary procedure. (F, G) Preoperative occlusion. (H) Model surgery. (I) Postoperative occlusion.
342 Obwegeser

Fig. 11. The first transoral ap-

proach to correcting the chin de-
formity. (A) Preoperative and (B)
postoperative appearance. (C)
The transoral osseous genioplasty
as illustrated in 1957 article. (D)
Preoperative and (E) postopera-
tive cephalogram. (From Obwe-
geser HL. Surgical procedures to
correct mandibular prognathism
and reshaping of the chin. In:
Trauner R, Obwegeser H, editors.
The surgical correction of man-
dibular prognathism and retro-
gnathia with consideration of
genioplasty. Oral Surg Oral Med
Oral Pathol 1957;10:67789.)

a post-traumatic war case in which he detached the characterized by retromaxillism with collapsed seg-
maxilla and in a second operation the pterygoid ments. He used horizontal vestibular incisions to
processes and then used weight traction for reposi- approach the maxilla, despite the palatal surgery
tioning the dislocated maxilla. He stated pessimisti- and concern for blood supply. But he only rotated
cally that this procedure would have a large the collapsed cleft segments with a green-stick frac-
indication in cleft cases, but it would probably ture at the pterygoidmaxillary junction, as did
never come into use. In 1951 and 1952, when I Schmid to correct the cross-bite, and I had never
was with Sir Harold Gillies, I watched him correct seen him advance the maxilla. He fixed them in
the cleft deformity in numerous patients the new position using cast cap splints fixed to
 Orthognathic Surgery 343

Fig. 12. The sliding osseous genioplasty as depicted by Hofer in 1942. Although not indicated, the case shown
was a cadaver (No clinical pictures were shown in the article.) (From Hofer O. Operation del Prognathie und
Microgenie. Dtsch Zahn Mund Kleferhlkd 1942;9:12132.)

a vertical bar to a head cap. He then placed cancel- and needed correction of the maxilla, our thoughts
lous bone grafts on the steps of the canine fossa were focused on the mandible. With the mandible
open to the maxillary sinus. The grafts were covered now solved, in 1960 I earnestly refocused my
on the vestibular side only. The sagittal discrepancy thoughts toward the maxilla.
he corrected by setting the mandible back. The pa- The solution came by chance. I was forced to
tients retained their dish face or at best a flat solve the midface problem in a case referred to
appearance. me by the Chief of Plastic Surgery at the University
Through the 1950s, I had not been satisfied fully Hospital. The patient was an 18-year-old man who
with my own approach. To correct deformities of had suffered a car accident by driving into the back
the maxilla, cleft or traumatic, I used vertical vestib- of a lorry, 6 weeks before my consultation. He pre-
ular incisions to maintain the blood supply. sented to me with the maxilla retrodisplaced in two
Through these slit openings, I sectioned the maxilla segments (palatal split) and telescoping into the
using a Lindemann bur to cut across the anterior nose and maxillary sinus, resulting in a severe ante-
maxillary surface, a forked-type nasal septal osteo- rior openbite and retromaxillism (Fig. 13). Addi-
tome I had designed to separate the vomer and me- tionally he lost three upper incisors, and the
dial maxillary walls, and a specially designed vestibular mucosa was scarred circumferentially
slightly flexible osteotomes with round edges to ver- with multiple oralnasal fistulae. Thus I could not
tically separate the pterygoid plate. Previously I approach the maxilla through vertical vestibular in-
would facture the pterygoid plate horizontally, but cisions as was my usual approach. Instead, I ex-
I came to feel that the pull of the pterygoid muscu- posed the maxilla by excising the circumferential
lature contributed to the relapse. I then would use vestibular scar through the oralnasal fistula. As
a Rowe disimpaction forceps. When it felt loose, I the two halves of the maxilla now were healed ro-
would pull the maxilla with wires into occlusion. tated medially and retrodisplaced into the maxillary
After 4 weeks of intermaxillary fixation, there was sinus, I had to free them there and perform osteot-
certain amount of inevitable relapse. I had felt omies from the canine fossa to the tuberosities us-
that the approach was acceptable as long as the re- ing osteotomes and a fissure-type burs. Then I
quired repositioning was within a limited extent. raised the nasal mucosa and detached the septum.
Although maintaining blood supply, the vestibular I then cut the lateral nasal wall, followed by separat-
mucosal bridge did not permit a greater extent of ing the pterygoid plates vertically. With each step, I
advancement, and the placement and fixation of confirmed that the vascularity was not jeopardized.
bone grafts in the steps of the canine fossae for Instead of the use of the Rowe disimpaction forceps,
stability was difficult. which I felt would damage the remaining palatal
Thus even around the time of 1960, neither in blood supply to the maxilla further, I simply
Europe nor in the United States, there did not exist pressed firmly on the anterior maxilla. The maxilla
a reliable procedure for mobilizing the maxilla that separated easily in what became known as the
would allow the surgeon the freedom to fully cor- down-fracture technique. To mobilize it forward, I
rect the patients deformity without compromise. then used strong, slightly curved osteotomes to
Although Trauner and I in 1952 were aware of the pull it forward slowly. I then needed to surgically
patient who presented with so-called prognathism recreate the palatal fracture so that I could
344 Obwegeser

Fig. 13. First case of advancement of the maxilla in two segments through a circumferential vestibular approach
was performed in 1964 to correct a post-traumatic deformity (H. Obwegeser 1967). (A) Severe anterior open bite
caused by post-traumatic telescoping retromaxillism in two segments. (B) Oralnasal communication and vestib-
ular scarring on both sides. (C) Model surgery indicating 9 mm advancement and 15 mm vertically down. (D) The
final occlusion after complete mobilization of two halves of the maxilla.

independently reposition each half of the maxilla to vestibular mucosa to cover the grafts, yet left open
establish the occlusion. Without the descending to the maxillary sinus and nasal cavity. The postop-
palatine artery, the blood supply of the maxilla at erative course was uneventful, and the result both
first was poor, but recovered after awhile. I used in appearance and occlusion was far better than I
wire fixation to secure the maxilla in place. I then had achieved before. Adequate mobilization was
closed the fistula with mobilization of the vestibu- the key step in advancing the maxilla, whether cleft
lar mucosa. Thus I was able to establish the occlu- or noncleft cases. With experience, I felt comfort-
sion, and the case taught me that the maxilla can able with advancements up to 20 mm. In the early
be mobilized extensively and can receive an ade- days, in nearly all cleft cases I reopened the cleft to
quate blood supply from the palate alone. This achieve the needed mobilization and occlusion and
case in 1964 is the first case of what was to become then as a second stage closed the cleft once the oc-
the standard LeFort I-type osteotomy. clusion was stable. Subsequently, I learned that I
In the years to come, I succeeded in advancing the could in numerous cases close the cleft simulta-
maxilla in cleft patients, without the need to estab- neously with the advancement by moving the lesser
lish the occlusion with a mandibular setback as in segment medially, and placing the canine in the lat-
years past. The first case in which there was an ex- eral incisor position. This solved the dental gap
treme discrepancy between the jaws was done on problem, as in those days we did not have osseoin-
April 14, 1968, in which the maxilla was advanced tegrated implants.
15 mm on the side of the lesser segment and 13 mm
on the contralateral side (Fig. 14). Downfracture Birth of orthognathic surgery
was as before, but mobilization was extremely diffi- By the late 1960s, I felt comfortable repositioning
cult until I opened the cleft, moved the segments the mandible and the maxilla. I had not done
laterally, and felt the scar tissue. Now I could release them simultaneously, however. It was on Septem-
the scar. I got both segments absolutely loose; that ber 5, 1969, that the first simultaneous sagittal split-
was the entire key to the success. Now I could ad- ting of the ramus and the LeFort I type osteotomy
vance as far forward as needed. The blood supply was done (Fig. 15). Although I could establish the
remarkably was still satisfactory. I used blocks of occlusion with either procedure, when I hand
cancellous bone from the iliac crest to fill the hori- traced the cephalometric radiograph, I realized
zontal and vertical gaps. I then mobilized the that I needed to move the maxilla forward and
 Orthognathic Surgery 345

down along with setting the mandible back. Both in instrumentation with thin saw blades allowed for
jaws had to be moved to improve the aesthetic refined osteotomies.
result. To find out how much I needed to move Thus looking back, I was fortunate in many ways.
each jaw, I hand traced what I considered was an Fortunate to have began my career at a time when
ideal profile on a transparent sheet over the existing so many maxillofacial problems remained un-
profile. This gave me a carpenters rough estimate. I solved. I was fortunate to have had Trauner as my
planned to make the final decision in the operating teacher. Trauner taught to me to see problems and
room. The operation went smoothly. When both find solutions. I was also equally fortunate to
jaws were completely free, I fixed them to each have had Sir Harold Gillies and Eduard Schmid as
other. I then repositioned the maxilla and mandible my teachers. Each taught me that it was not so
as one unit according to my imagination, and when much knowledge of what came before, but the
I was satisfied with the aesthetic result, I completed imagination of solving problems as the patients
the fixation with wire and bone grafts. I kept the pa- presented themselves. In the middle of difficulty
tient in 6 weeks of intermaxillary wire fixation. The lies opportunity. The surgeon today can disassem-
result both in terms of occlusion and appearance ble each of the elements of the craniofacial skeleton
was excellent. With this first case, orthognathic sur- and then reassemble it. He only is limited by his
gery became a subspecialty in its own right. I pub- imagination to seek the solution. If I may end this
lished this in 1970. As with the mandibular tale with the words of another:
procedures, modifications continued in the design Imagination is more important than knowledge.
of the midfacial osteotomy, and in time internal For knowledge is limited to all we now know and
fixation with plates and screws became a reality. understand, while imagination embraces the entire
Still, the essential component that the surgeon world, and all there ever will be to know and under-
had to execute remained: adequate mobilization. stand. Albert Einstein.
Various combinations of mandibular and maxillary
procedures now could correct most maxillofacial
deformities (Fig. 16). Before what today many sur- Postscript
geons would consider mandibular distraction as the
only approach, we were able to use the long lateral Although I have long since left the task to others, I
component (that is placing the vertical corticotomy will describe for those interested how I preferred to
as close to the mental foramen as possible) or the do the transoral procedures for many years with
circular splitting of the mandible to correct the appropriate instrumentation. I will begin by split-
most severe deformities (Fig. 17). What remained ting the mandibular ramus.
was the cranioorbital region.
Sagittal splitting of the mandibular ramus
Incision
From maxillofacial to craniofacial The mandibular procedure should be able to be per-
In 1967 at the International Plastic Surgery Con- formed with minimal bleeding. The operative field
gress in Rome, Tessier presented the transcranial is infiltrated generously with a vasoconstricting
and the subcranial LeFort III procedures to correct agent. I prefer to start on the abnormal side if there
the cranial and orbital deformities. With that, is one. I place a rubber mouth gag on the opposite
craniomaxillofacial surgery became a reality. side to hold the mouth wide open. The incision is
The story now is well known. With Tessiers clear placed in the mucosa laterally well away from the at-
demonstration, the cranioorbital deformities tached gingiva of the first molar. It then is deepened
could be corrected, and with my work, the maxil- vertically through the periosteum between the buc-
larymandibular deformities could be addressed. cinator crest and the oblique line. Then it is extended
Thus the patient presenting with a severe dish-face further superiorly along the external oblique line to
deformity could be solved by combing a LeFort III the base of the coronoid process. The periosteum is
to address the orbital component and the LeFort I elevated in the retromolar region and along the
simultaneously to address the occlusal relation anterior border of the ascending ramus, a few milli-
(Fig. 18). meters on either side of it. The inferior attachment of
In 1968, when Hans Luhr published his work on the temporalis muscle is dissected off. Once the
plate and screw fixation, it revolutionized internal anterior border is exposed, I place a ramus clamp
fixation, limiting the need for extended intermaxil- on the neck of the coronoid process.
lary fixation and increased stability with less reli-
ance on complex interlocking joints and bone Medial corticotomy
grafts. And finally what could be accomplished Next, I elevate the periosteum on the lingual side
only by a rotary bur in my early days, improvements between the lingula and the semilunar notch only
346 Obwegeser
 Orthognathic Surgery 347

as far back as to the concavity above the entrance of Care should be taken to leave as much of the masse-
the mandibular nerve into the foramen. A Freer is ter muscle as possible attached to the lateral aspect
used to palpate the semilunar notch. Then I use of the ramus to maintain blood supply and stabili-
an acrylic bur to start my lingual cortical cut. It zation of proximal segment. In a typical mandibular
makes a broad defect in the wide anterior border. setback or advancement procedure, I normally
This permits better visualization along the medial direct the lateral corticotomy from the second
aspect. Then I raise the rest of the periosteum all molar region toward the angle. I prefer this place-
the way back to the posterior border and around ment in most instances as the nerve is more medially
it. Next, to keep the lingual soft tissues away and located when compared with a lateral corticotomy
to protect the mandibular nerve, I like the narrow that is located in the body and as the sagittal split
mandibular channel retractor, inserted and hooked can be more easily completely made through the
behind the posterior border. Under direct vision, full breadth of the ramus. I will vary this lateral cut
one now can elongate the lingual cortical cut all according to each individual case, however. In a
the way back, including the posterior border. case of micromandibulism such as a bird-face ap-
As far as the cortical cut above the lingula is pearance, it will reach almost as far anterior as the
concerned, I have given up using the Lindemann mental foramen, starting behind the second bicus-
bur, not only because it breaks easily, but also be- pid. Here I use a slender rotating bone-cutting bur,
cause I want to be able to shorten the ascending ra- going only as deep as necessary to see bleeding
mus length on its medial side, particularly when I points from the cancellous bone. A 1.5 mm bur
want to set the mandible back. For that reason, will do this cut through the lateral cortical plate. It
the Lindemann bur makes too narrow a cut. In- should continue around the lower posterior border.
stead, I prefer using a bone-cutting bur of 3.0 mm
diameter (Fig. 19). Using this much broader diam- Sagittal corticotomy
eter bur, I deepen the medial cortex until I see The medial and the lateral bone cuts are then ready
bleeding points from the cancellous bone all the to be connected. The sagittal corticotomy follows
way back. Above the lingula, I want a rather broad the anterior border just on its inner side, using a nar-
defect in the medial cortical plate of the ramus to row bone-cutting bur or an oscillating saw. Techni-
prevent overlapping of the distal fragment over cally, it may be easier to first drill with a small rose
the inner cortical plate of the proximal fragment. I bur a series of holes through the cortex along the
generally prefer the splitting of the entire ramus lingual aspect of the anterior rim (see Fig 11F)
breadth. Otherwise the distal cancellous part of which then are connected by a bone cutting bur
the tooth bearing fragment will overlap the cortical or saw. Care must be taken that the cutting instru-
plate of the proximal fragment, pushing it laterally ment goes through the cortical bone only, no deep-
when the mandible is retropositioned posteriorly. er than 4 to 5 mm.
This occurs when the lingual cortical cut is not
deep enough all the way back to the posterior bor- Splitting the ramus
der. An incomplete splitting will occur, just behind I open the sagittal corticotomy by 2 to 3 mm with
the lingula, leaving at least one third of the ramus a wedge osteotome first. Then I insert a bone separa-
breadth unsplit. Even for cases of retromandibu- tor, but only a few millimeters deep. Its fork-like
lism in which the mandible is lengthened, I will cre- blades are flexible. With that instrument, the split-
ate a similar medial cortical defect to fully split the ting is done very gradually in an incremental fash-
mandible, although in these cases, the incomplete ion. The separation of the two cortical plates occurs
splitting will not interfere with the advancement. gradually until the two halves completely separate
along the full breadth of the ramus (see Fig. 17E).
Lateral corticotomy If the ramus does not split easily, then frequently
With this completed, I then elevate the periosteum a blow with a thin osteotome directed laterally
on the buccal side of the ramus where I want to place away from the nerve on the inferior border will help.
my lateral cortical cut. I free it around the inferior With the gradual splitting, the nerve can be visu-
border and place a mandibular channel retractor. alized if it crosses between the medial and lateral

=
Fig. 14. The first case of correction of excessive retromaxillism as result of a cleft that was corrected with a LeFort
I-type osteotomy (H Obwegeser 1969). (A) Patients preoperative appearance and (B) lateral cephalogram. (C)
Model surgery indicating independent repositioning of the two segments, 13 mm and 15 mm advancement.
(D) Illustration showing the LeFort I type advancement and (E) bone grafting. (F) The postoperative appearance
and (G) lateral cephalogram. Note that the nose was corrected with advancement of the maxillary platform
alone. (H) Preoperative and (I) postoperative with (J) prosthodontic restoration occlusal outcome.
348 Obwegeser

Fig. 15. The first case of simultaneous advancement of the maxilla and retropositioning of the mandible (H Ob-
wegeser 1970). (A, B) The patients appearance, (C) lateral cephalogram, and (D) occlusion. (E) The model sur-
gery and planning using clinical photographs with overlay tracings of the (F) lateral cephalogram. (G)
Illustration of the planned procedure with transoral mandibular setback and maxillary advancement in two
planes with bone grafting. (H, I) The postoperative result, (J) lateral cephalogram, and (K) occlusion.

segments with the bone separator in place. If this is wires. With mandibular setback, removing any re-
the case, then the nerve can be freed from the lateral sidual cortex on the medial aspect of the lateral
segment so as to remain with the distal tooth-bear- ramal fragment may be necessary to fully adapt
ing segment and the osteotomy continued. the fragments without laterally displacing the prox-
imal fragment. This is achieved easily with the bone
Repositioning separator in place providing a good view in between
The separation between the medial and lateral the segments and protecting the nerve.
elements must be complete to allow independent
repositioning of the mandibular body from the Osteosynthesis
mandibular ramus. The mandible then is fixed in Although the technique of splitting the ramus is
the planned occlusion by using intermaxillary well-established today with essentially minor
 Orthognathic Surgery 349

Fig. 15 (continued)

variations based on surgeons preference, osteosyn- placement. Once fixed into position, the contour
thesis will continue to evolve from wire fixation of the ascending ramus should be assessed. With
used when I first started more than a half a century mandibular setback, it may become necessary to re-
ago to titanium fixation at the end of my surgical ca- duce anterior border of the proximal segment at the
reer and a future promise of resorbable fixation. Al- retromolar junction to allow an appropriate space
though plates have been advocated by some, my and mucosal closure distal to the molar.
preference has been placement of 1.5 mm diameter
screws that merely adapt the two fragments without Closure
compression and displacement at the temporo- Before closing the wound with a continuous suture,
mandibular joint. With the mandible fixed in the the operative field is rinsed again with an antibiotic
desired occlusion, the condyle on the proximal ra- solution. I like to place a thin rubber drain within
mus fragment is manipulated into the glenoid fossa the wound for overnight.
and held with an adaptation clamp, or any other
suitable instrument in that position by the assistant. The osseous genioplasty
I then place through a transbuccal approach three The procedure itself is as I had described it in 1957.
1.2 mm pins to hold the two segments temporarily The exposure in the symphyseal region, however, is
in position until the screws can be placed. The pins kept as minimal as needed to accomplish the
then are pulled out sequentially, one after the other, osteotomy. This will maintain the vascularity of
using the holes in the cortical plates for screw the symphysis. The osteotomy is done with a thin
350 Obwegeser

Fig. 16. Correction of severe anterior open bite deformity. Preoperative appearance and lateral cephalogram. (D)
Model surgery and (E) surgical plan: maxillary impaction, transoral angle osteotomy with clockwise rotation of
the mandible, and an advancement osseous genioplasty. (F, G) Postoperative appearance and (H) lateral
cephalogram.

reciprocating saw and the fixation accomplished The LeFort I

with titanium plates and screws. This procedure, be- Today, mobilization of the maxilla is performed
cause of its simplicity and ability to solve a great va- more often than repositioning of the mandible.
riety of lower third problems, should be mastered The technique may differ from one surgeon to an-
by all surgeons. other, although not very much in its essential
 Orthognathic Surgery 351

Fig. 17. Correction of bird-face deformity caused by ankylosis since birth (H Obwegeser 1971). (A, B) Preoper-
ative appearance and (C) occlusion. (D) Preoperative cephalogram and (E) planned osteotomies release of the
fused temporomandibular joint and placement of stacked layers of lyo-cartilage, maxillary anterior segment,
sagittal splitting procedure of the ramus, and a triple-step osteotomy of the symphysis. This was done in two
stages with release of the ankylosis followed by maxillarymandibular surgery. (F) Illustration of the reposition-
ing of the skeletal elements and (G) postoperative cephalogram. (HJ) The postoperative result with release of
ankylosis and occlusion.

components. It has changed only slightly in my above the attached gingiva from one zygomatic
hands since 1962. crest to the other. This is done with a knife in a sin-
gle cut vertically to the alveolar process through the
Incision and exposure periosteum. At the lateral extent, I direct the inci-
Before the procedure, the epipharynx is packed with sion superiorly for some millimeters to achieve
gauze to protect nasotracheal tube at the time of the enough access to the tuberosity area without tearing
osteotomy. The operative field is infiltrated with it with the retractor. The maxilla and the inferior
a vasoconstricting agent. I then perform the vestib- part of the zygoma then is exposed easily. The in-
ular incision through the mucosa, at least 5 mm fraorbital nerve is visualized. The periosteum then
352 Obwegeser

Fig. 18. Correction of a dish-face deformity with simultaneous LeFort III and LeFort I procedures in an 18-year-
old. (A) The preoperative appearance and (B) lateral cephalogram. Illustration of the planned procedure. (C, D)
LeFort III to correct the naso-orbito-zygmatic region with simultaneous LeFort I to correct maxillarymandibular
relationship. (E) The postoperative lateral cephalogram and appearance (F) 3 years and (G) 11 years after
surgery.

is raised carefully behind the zygomatic crest and The LeFort I-type osteotomy
into the pterygoidmaxillary junction. If this is Next I make vertical marks with a fine bur on the
not done carefully, then a rent in the periosteum zygomatic crest and at the anterior region of the ca-
will occur, and Pichats fat pad will come through nine fossa. These reference marks will enable me to
the opening readily. This will plague the remainder measure the amount of sagittal and vertical move-
of the operative procedure. For this exposure, I pre- ment of the maxilla. If the maxilla has to be im-
fer the upwardly bent retractor inserted at the junc- pacted, I mark the amount of resection necessary
tion between the maxilla and the pterygoid process. on the antral wall.
Finally, the edge of the pyriform aperture is freed, I still use the same horizontal osteotomy for sep-
and the mucoperisteal covering of the floor of the arating the maxilla as I did at the beginning in the
nose is raised on both sides along the entire length 1960s. However, sectioning of the maxillary walls
of the hard palate and on the lateral walls of the at that time was accomplished with burs and with
nasal cavities to the level of the inferior turbinates. osteotomes. The osteotomy today is accomplished
On the medial aspect along the nasal crest of the more elegantly and more precisely using a thin re-
palatine bones, elevating the mucoperiosteum ciprocating saw blade with minimal loss of precious
without tearing may present some difficulties. bone and far cleaner without the fragments gener-
Care must be taken to prevent this from happening, ated with an osteotome. Moreover, the osteotomy
especially when approaching the juncture of the design and execution with the reciprocating saw eas-
nasal crest of the palatine bones with the septum. ily allows varying its angulation from the standard
Maintaining an intact mucoperiosteum is even LeFort I type pattern depending on the movement
more important when a deviated septum is being desired. Once the maxillary walls are sectioned, I
corrected at the same time. then vertically separate the pterygoid plate from
 Orthognathic Surgery 353

Fig. 19. The sagittal splitting osteotomy of the mandible. The medial corticotomy is facilitated with the use of
a bur to contour the lingula. The lateral corticotomy can be varied depending on the planned procedure. The
splitting should be complete. The procedure can be used to solve various mandibular deformities.

the maxilla using a very thin, slightly curved, flexible saw with the spreader in place. Next the anterior
osteotome as I did then. This is then followed by down-fracture is accomplished with the bone sepa-
separating the nasal septum from the hard palate us- rator inserted at the nasal aperture rim (medial
ing a guarded septal osteotome. To avoid the risk of maxillarynasal buttress). This is the reverse of my
transecting the nasotracheal tube and protecting the previous procedure and as others still describe.
posterior pharyngeal wall, the epipharynx is packed Once the maxilla is down-fractured, it must be
with gauze. mobilized fully. To advance the maxilla, I routinely
use the so-called maxillary mobilizer type elevator I
The mobilization of the maxilla had designed. For cases where my typical maneu-
For many years I have ceased initiating the down vers for advancement were difficult, I had an instru-
fracture at the anterior nasal region, and instead ini- ment made by Medicon Instrumente (Tuttligen,
tiated it at the lateralposterior maxillaryzygomatic Germany), which I called a maxillary advancer.
buttress, following the suggestion of my nephew One leg rests on the zygoma, and the other part is
Joachim Obwegeser, MD, DMD. I insert the bone designed as a curved blade inserted behind the
separator within the osteotomy at the zygomatic tuberosity. The advancement then is achieved grad-
crest and apply gentle pressure (Fig. 20). The maxilla ually, millimeter by millimeter. After one side is
typically comes down easily. Otherwise any resis- done, the next is dealt with in the same way. This
tance requires either an osteotome or reciprocating should be done from side to side in increments.
354 Obwegeser

Fig. 20. Down-fracture initially at the (A) zygomatic buttress followed by (B) anterior down-fracture. Mobiliza-
tion with a broad (C, D)retromaxillary retractor, and when needed with an (E) intraoperative gradual distrac-
tion using a maxillary distractor device (Medicon Intrumente, Tuttligen, Germany).

With the maxillary advancer, one can move the bone grafts. These include a block of cancellous
maxilla anteriorly by more than 20 mm. The max- bone wedged into the gap behind the tuberosity
illa must be so loose that it can be repositioned eas- and several blocks to bridge the steps in the canine
ily with a pair of forceps. This is a must. fossae.
Although the full mobilization in most cases can
be accomplished without the necessity of this in- Closing the alveolar gap
strumentation, it is particularly useful in cleft cases In unilateral and in bilateral cleft cases, the dental
where there is significant resistance against the gap of the lateral incisor can be eliminated by ad-
complete mobilization because of soft-tissue cica- vancing the lateral alveolar process so that the ca-
tricial scar formation. A surgeons finger can iden- nine is positioned next to the central incisor. The
tify easily where the knife or the scissors needs to canine then subsequently is contoured to match
sever still-resisting scars. It is better to cut them the appearance of a lateral incisor. The segmental
than to pull so hard with the maxillary advancer advancement decreases the orthodontic treatment
or any other instrumentation. Scars do not include time of the staged bone graft, followed by either or-
large vessels, and there is little risk of severe bleed- thodontic movement of the canine or placement of
ing when cutting. a dental implant.
Today, many surgeons will resort to the use of dis-
traction devices to gradually advance the cleft Osteosynthesis
maxilla. Although in some circumstances this may As with many other procedures, wire fixation is re-
be appropriate, it should be remembered that placed by titanium plates and with the promise of
most cleft patients can be treated appropriately resorbable fixation in the future. I place the plates
and more efficiently, even when requiring signifi- at the medial nasal piriform buttress and at the
cant advancement with the classic LeFort I-type pro- zygomaticmaxillary buttress, but prefer fixation
cedure as described. as semirigid to allow postoperative guidance of
the occlusion with dental elastics when the patient
Bone grafting is actively functioning. In my experience, there is
In cases in which I had advanced the maxilla by at approximately 0.5 to 1.5 mm difference between
least 8 to 10 mm or more, I would use autogenous the surgeons positioning intraoperatively when
 Orthognathic Surgery 355

the patient is under general anesthesia compared Further readings

with active functioning as they resume oral
function. Obwegeser HL. Die Kinnvergrosserung. Oesterr Z
Stomal 1958;55:53541.
Closure Obwegeser HL. Cirugia del mordex apertus. Re Asoc
Before closing the wound with a continuous suture, Dodont Argent 1962;50:43041.
Obwegeser HL. Operative Behandlung der zahnlosen
the operative fields including the maxillary sinuses
Progenia ohne intermaxillare Fixation. Schweiz
are rinsed with an antibiotic solution. Monatschr Zahnhlkd 1968;78:41625.
Obwegeser HL. Surgical corrections of small or retro-
Surgical instruments
displaced maxillae. Plast Reconstr Surg 1969;43:
As with any other craft, tools are important to the 35265.
surgeon. Operative procedures are most efficiently Obwegeser HL. Mandibular growth anomalies: termi-
done when the instruments are fewer in number, nology, aetiology, diagnosis, and treatment. Ber-
can be used to accomplish multiple tasks, and lin: Springer; 2001.
when appropriately designed. The surgeon must
be as familiar with the tools of his or her trade as
with the procedure. They are extensions of the
hands, of the dexterous fingers, to accomplish tasks References
of the trade. Every craftsman knows the importance
of the quality of good tools and maintaining them. [1] Blair VP. Surgery and diseases of the mouth and
Many instrument makers have provided instru- jaws. St. Louis (MO): The C.V. Mosby Co.; 1914.
[2] Kostecka F. Die chirurgische therapie ider pro-
ments named after the surgeon who developed
ggeni. Zahnaertzl. Rundsch 1931;40:669.
them; however, few manufacturers will have their [3] Perthes G. Operative Korrektur der Progenia.
quality checked and repeatedly checked by the Zentralbl Chir 1922;49:15401.
surgeon whose instrument that bears his name. [4] Perthes G. Uber Frakturen und Luxationsfraktu-
This is true with my own instruments. Many com- ren des Kieferkopfchens und Ihre operative
panies will produce Obwegeser instruments, but Behandlung. Arch Klin Chir 1924;133:41833.
few have the right to engrave Original Obwegeser, [5] Kazanjian VH. The treatment of mandibular
as KLS-Martin (Jacksonville, United States) and prognathism with special reference to edentu-
Medicon (Tuttligen, Germany). My experience lous patients. J Oral Surg Oral Med Oral Pathol
with many so-called Obwegeser instruments of 1951;4:6808.
[6] Trauner R, Obwegeser H. Zur Operationstechnik
other companies is disappointing. Since my early
bei der Progenia und anderen Unterkieferano-
days, appropriately designed powered hand pieces malien. Dtsch Zahn Mund Kieferhlkd 1955;23:
have made a significant difference in the ease of 1125.
executing the osteotomies. The hand pieces ideally [7] Obwegeser HL. Surgical procedures to correct
should be lightweight, slender, and not obscure manidbular prognathism and reshaping of the
the already limited field of view of the surgeon. chin. In: Trauner R, Obwegeser H, editors. The
My preference is manufactured by W&H Dental- surgical correction of mandibular prognathism
werk Burmoos GmbH, Austria, 5111 Burmoos. The and retrognathia with consideration of genio-
surgeon in training should know his or her instru- plasty. Oral Surg Oral Med Oral Pathol
ments, how they are used, and be familiar with their 1957;10:67789.
[8] Dal Pont G. Losteotomia retromolare per la
quality.
correzione della progenia. Minerva Chir 1959;
Thus, now looking back across half a century, I al- 14:113841.
most envy those who are able to learn today with [9] Dal Pont G. Retromolar osteotomy for the cor-
modern instruments, techniques, and reliance on rection of prognathism. J Oral Surg 1961;19:
experience gained by those who came before. Few 427.
procedures can alter the human face so fundamen- [10] Hunsuck EE. A modified intraoral sagittal split-
tally as these three procedures. I hope that these ting technique for correction of mandibular
words will continue to inspire the generations of prognathism. J Oral Surg Anaesth 1968;2:
surgeons to follow. 24952.
[11] Epker BN. Modifications in the sagittal osteoto-
my of the mandible. J Oral Surg 1977;35:1579.
Acknowledgments [12] Obwegeser HL. Der offene Biss in chirurgischer
Sicht. Schweiz Monatschr Zahnhlkd 1964;74:
I wish to express my very sincere thanks to Dr. Pra- 66887.
vin K. Patel for his generous editorial assistance in [13] Hofer O. Operation del Prognathie und Microge-
translating my original manuscript into the form nie. Dtsch Zahn Mund Kleferhlkd 1942;9:
in which it appears. 12132.