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Clin Plastic Surg 34 (2007) 331–355

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Orthognathic Surgery and a Tale ofHow Three Procedures Came to Be:A Letter to the Next Generationsof SurgeonsHugo L. Obwegeser, MD, DMD

- In the beginning.The transoral sagittal splitting of the

mandibular ramusThe transoral osseous genioplastyThe LeFort I-type osteotomyBirth of orthognathic surgeryFrom maxillofacial to craniofacial

- Postscript

Sagittal splitting of the mandibular ramusThe osseous genioplastyThe LeFort ISurgical instruments

- Acknowledgments- Further readings- References

Today the transoral sagittal splitting of the ramus,the osseous genioplasty, and the LeFort osteotomyhave become commonplace procedures used bymultiple specialties to solve a range of problems.There was a time when that was not always so.This is a tale of how they came to be.

In the beginning.

The transoral sagittal splitting of themandibular ramus

When I started my training in maxillofacial surgeryin 1947 with Richard Trauner at the MaxillofacialUnit of the Dental School of the University ofGraz in Austria, orthognathic surgery was virtuallynonexistent. It was a series of unsatisfying proce-dures primarily to correct so-called prognathism.Among them were the Blair [1] and the Koste�cka[2] procedures (Fig. 1). The patient was seated ina dental chair, given sedation followed by a local in-filtration and a block anesthesia. The assistant’s rolewas to hold the head steady. The surgeon then

0094-1298/07/$ – see front matter ª 2007 Elsevier Inc. All righplasticsurgery.theclinics.com

passed a large curved awl with a heavy thread at-tached to a Gigli saw transcutaneously around theascending ramus above the lingula. With that, theascending ramus was cut on both sides within 15minutes. The patient then was placed in maxillo-mandibular fixation for 6 to 8 weeks. In 1952, Trau-ner asked me to follow up on all of our 36 casesof Koste�cka operations. Roughly 50% of our caseshad nonacceptable complications: partial or totalrelapse, open bite, pseudoarthrosis, irreversible in-jury to the mandibular nerve, and even worse tothe facial nerve, parotid gland fistula, or other com-plications. The occlusal relapses, Trauner assumed,were caused by inadequate bony union because ofthe extremely small area of contacting bone surfacesof the two fragments further compounded by thepull of the temporalis muscle dislocating the frag-ments. Thus we sought for a procedure that wouldproduce broader contacting bone surfaces for astable union.

I searched the literature and in K.E. Hogeman’smonograph (1951) on ‘‘Surgical Orthopaedic

Department of Maxillofacial Surgery, University Hospital Zurich, Switzerland.E-mail address: pkpatelmd@mac.com (P.K. Patel).

ts reserved. doi:10.1016/j.cps.2007.05.014

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Fig. 1. As originally depicted, correction of mandibular deformities by the blind techniques of (A) Blair in 1914(A) and (B) Koste�cka 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 Koste�cka F. Die chirurgische therapie der proggeni. ZahnaertzlicheRundschau. 1931;40:669–87.)

Correction of Mandibular Protrusion,’’ I founda compendium of what was available to the surgeonat that time. I disliked all the ones with an extraoralapproach because of the unpredictable quality ofthe scar and the added risk to the mandibularbranch of the facial nerve. The few transoral tech-niques that were published failed to produce therequired broad contacting bone surfaces neededfor stable bony healing. I wanted an osteotomy thatcould be performed transorally only, avoiding askin incision, and which would produce broad con-tacting bone surfaces, even after the repositioning.

While thinking about this, I turned a cadavermandible in my hands around several times, andthe solution became obvious. If the mandibularramus could be split along its sagittal plane, thenone of the requirements, the need for a broadbony surface area for healing, could be satisfied.The procedures up until then focused only on bev-eling the transverse plane as variations of horizon-tal osteotomies. I had twice seen on radiographsfractures in a sagittal pattern. The question wascould it be done technically. After cross-sectioninga dry cadaver mandible at several points, I was cer-tain that the contents of the mandibular canalcould be left untouched, as there was sufficient in-tervening cancellous bone. The inner and outer cor-tex had to be cut at different levels, and these twocorticotomies connected along the sagittal plane.As far as the second requirement of executing theprocedure without an external skin incision,a transoral (intraoral) approach was needed. This

was considered unthinkable in those days. How-ever, I knew that with my experience in treatingmandibular fractures by proper repositioning ofthe fragments and intermaxillary fixation within 24hours of the accident resulted in minimal complica-tions. The surgical procedure as a controlled traumawould be the same.

With this in mind, I tried sagittal splitting theramus transorally on a cadaver at the Institute ofAnatomy (Graz, Austria) and reported to Traunerthat it was possible. He said that Perthes andSchlossmann already had tried a type of sagittalsplitting of the ramus by means of an extraoral ap-proach. Some time later when I reviewed G. Perthesarticle of 1922 [3], however, the osteotomy referredby him was by A. Schlossmann, an oblique trans-verse osteotomy by means of an extraoral approachsimilar to one published years later by V. Kazanjianin 1951 (Fig. 2) [4,5]. The Schlossmann-Kazanjianapproach was an oblique transverse osteotomy ina limited attempt to increase the contact area. Nei-ther, however, was a true sagittal splitting procedurethat sufficiently increased the bony surface area asto what I had conceived. Interested, Trauner sug-gested that we should operate together, on one sidehis idea of a reverse L-shaped osteotomy of the ra-mus by means of a combined extraoral–intraoralapproach, and on the other side my idea of thesagittal splitting of the ramus, transorally only.

The first case was an edentulous 27-year-oldwoman with a protruding mandible, operated uponon Feb. 17, 1953 (Fig. 3). Acrylic splints were fixed

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Fig. 2. (A) Schossmann’s 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;133:418–33, 1924. KazanjianVH. The treatment of mandibular prognathism with special reference to edentulous patients. J Oral Surg OralMed Oral Pathol 1951;4:680–8.)

to the jaws for postoperative intermaxillary fixation.With the patient in a half-sitting position and underlocal anesthesia, the procedure was performed withTrauner and I operating as primary surgeons, andH. Kole assisting. Trauner completed his portionof the operation first. I asked the patient to openher mouth wide, and I made a mucosal incisionalong the left ascending ramus. I used a Stichsage(keyhole) saw to cut the cortical plates. I first cutthe lateral cortical plate from the inner angle to theouter angle of the jaw. Then I cut the medial corticalplate above the lingula all the way back to the poste-rior border. I then connected these cuts along the an-terior border of the ramus using a fissure bur. Thenwhen I tried to split the ramus using an osteotome,the ramus unexpectedly shattered instead of split-ting! The mandible was set back with splints andthe patient kept in intermaxillary wire fixation for

21⁄2 weeks followed by elastics. Although the clinicaloutcome was acceptable, the transoral techniquewas less than as I had hoped it would be.

Two months later another opportunity arose, oursecond case, when a 24-year-old prognathic womanwith nearly full dentition presented to us (Fig. 4).Even with the initial difficulties, Trauner remainedsupportive. The first mandibular premolars hadbeen removed previously with the anterior teethslightly retracted by the patient’s dentist to softenher prognathic appearance. In preparation, someequilibration of the teeth was required to achievea stable occlusion, and continuous loop wiringwas applied to the maxillary and mandibular teeth.The operation was performed on April 22, 1953, byTrauner and myself as the primary surgeons andthis time assisted by Professor Schuchardt fromHamburg, 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 anda transcutaneous inverted L procedure on the right side by R Trauner. Patient’s profile (A) before and (B) afterthe procedure. (C) The postoperative radiograph.

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at our department. After premedication for seda-tion, the patient was placed in a half-sittingposition on the operating table. Mandibular blockand local anesthesia were used. This time, Traunerasked me to operate first. I chose the left side, andI started with an incision from the first molarback and up along the anterior border of the ramus,right to the bone. Next I raised the periosteum onthe lingual side above the lingula back to the poste-rior ramal border. There I hooked a curved perios-teal elevator around it and cut the inner corticalplate, this time with a long Lindemann bur, to thedepth where some bleeding became visible. TheLindemann burs broke, one after another, and Icompleted the medial corticotomy with a Stichsage(keyhole) saw, as I did with the first case. Next Iraised the periosteum on the buccal side, from theangle horizontally back to the posterior borderand sectioned the lateral cortex with a keyholesaw, followed by a fissure bur, just above the angle.Then I connected the lingual and buccal corticoto-mies by drilling a series of holes with a rose burand connecting them with a Lindemann bur alongthe anterior ramus. With the first blow of the osteo-tome, unintentionally, the coronoid process frac-tured off. I then decided to further deepen andwiden the cortical cuts with a series of fissureburs. After that it became easier to open or splitthe two cortical plates with an osteotome. Ipositioned a wide thin osteotome within the osteot-omy gap, not so deep for fear of injuring the nerve,and with a gentle twisting maneuver, the corticalplates this time easily fell apart. The mandibularramus was sagittally split! As the fragments wouldalmost be self adapting when moving the mandibleback on the split side and as we had yet to completethe procedure on the right side, we decided thatwire fixation might not be necessary. We spreadsome penicillin powder and did a rather tight clo-sure of the periosteum and of the mucosa. On theother side, Trauner performed his inverted L-shapedosteotomy through a combined oral and extra-oralapproach. A circumferential wire secured the frag-ments. This was followed by 6 weeks of intermaxil-lary fixation. The recovery was uneventful. Therewas initially numbness of the lip on the side of thesagittal splitting procedure, but this recovered com-pletely by 1 year after the procedure. On the side ofthe inverted L transcutaneous approach, the perma-nent scar remained visible for many years. One year

and 5 months after surgery, the final result in occlu-sion as well as in facial contour was very pleasing. Itremained unchanged after 33 years. With this case,the transoral sagittal splitting procedure of themandibular rami was born (Fig. 5). We publishedthis in German in 1955 [6].

These early cases I did without special instrumen-tation, using what was only available to me at thetime. Additionally, inadequate intraoral lightingand lack of the development of head and neck an-esthesia in those days added additional challenges.The first case I did under general anesthesia was onApril 9, 1956, in Zurich, Switzerland (Fig. 6). In1954, I had left Trauner and at the invitation of Pro-fessor P. Schmuziger, Chief of Oral-MaxillofacialSurgery and Professor R. Hotz, Chief of Orthodon-tics at the Zurich Dental School, I joined the De-partment of Maxillofacial Surgery at the UniversityHospital. Hotz in 1956 had a patient on whomhe had wanted me to perform the sagittal splittingprocedure instead of referring the patient to Schmu-ziger. She was 14 1/2 years old with a rather longand narrow mandible with partial anodontia. Shehad mandibular prognathism (antemandibulism),and when I traced her lateral cephalometric radio-graph, she also had a maxilla that was small and ret-rodisplaced. At that time, repositioning the maxillawas not possible, and the only option was a man-dibular setback with crown and bridgework. Inthose days, however, there was no such thing asa panoramic radiograph, but the PA film showedthe mandible to be rather narrow, and I was notsure that I could split the rami. We scheduled thesurgery for April 9, 1956, in a private hospital, asshe was a private patient from another country atHotz’s request. I had never had an opportunity tooperate in a private hospital before, nor had to con-tend with an anesthesiologist. Up till then I haddone the procedures under local anesthesia. I hadto convince him of a nasotracheal intubation in-stead of an oral intubation, and that was somethingnew to the anesthesiologist. When I explained theprocedure and the need to turn the head, the com-bat started. Schmuziger who was my assistant, ex-pressed a view to his students that this procedurecould be performed only on paper. Thus I beganan operation without much enthusiasm. I first se-cured the cast cap splints, because the patient’s teethwere not suitable for intermaxillary fixation. Istarted 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 sagittalsplit 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. Theocclusion (E) before and (F) after surgery. Postoperative appearance of the right side (G, H). The radiograph showsthe wire fixation on the inverted L right side and without wire fixation on the sagittal-splitting left side.

=

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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;23:11–25.)

cortical cuts with Lindemann burs very carefully,until I saw some bleeding indicating that I was atthe level of the cancellous bone. I did the cut abovethe lingula on the medial side and then a cut hori-zontal just above the angle on the lateral side. ThenI made a series of holes using a rosehead bur alongthe anterior surface just medial to the oblique ridge.With a short Lindemenn bur, I connected theseholes from the medial corticotomy to the lateralcorticotomy. I had learned by now that withoutthese series of holes as a guide, I found it difficultto control the Lindemann bur alone without slip-ping off the anterior surface of the ramus and caus-ing a fracture I had not planned. Despite the poorvisualization of the operative field, the splittingon the right side went well, but took a long time.On the left side, I ran into problems I had notencountered before. When I did the splitting bystriking a broad thin osteotome about 5 mm indepth only, and twisting it, the lateral ramus brokeoff. As I had detached it of its periosteum, it wasnow a free fragment. This was my first sagittal split-ting since my new position in Zurich with my chief,Schmuziger, watching. Not particularly what Iwould like to have had happened given his views.I am not sure of Schmuziger was aware of mydilemma, as only I could barely see the operativefield. I ignored it for the time being. I set the man-dible back in the preplanned occlusion. On theright side, I fixed the position with an anteriorborder wire. I closed that side. On the left side, I re-turned to my problem. There was no contactbetween the proximal and distal segments. With

considerable amount of difficulty with poor light-ing and instrumentation, I managed finally to adaptthe free lateral ramus fragment to the rest of theramus and the distal segment with direct wire fixa-tion. I closed the wound over a rubber drain. Theoperation took over 4 hours. I thanked God thatit was over and hoped for the best.

The operation was more stressful that I had expe-rienced before when I had performed it under localanesthesia and sedation. I had to constantly battlewith the anesthesiologist, who was concerned thatI would pull the tube out of the nose, and my assist-ing pessimistic chief. The postoperative course wasdifficult for me and the patient. With each day, therewas increasing swelling and bruising I had not hadbefore. With each passing day, I feared some seriouscomplication. I did only what any surgeon woulddo. I went to the monastery church of Einsiedelnand prayed, promising God I would never do thisprocedure again if this girl got away without com-plications. She had a wonderful aesthetic and func-tional result. No external scars. Six years later, shesent me her wedding photographs. I on my partof the Faustian bargain, broke my promise toGod. I continued to perfect the sagittal splitting pro-cedure until it became routine.

We published this first in German in 1955 andthen in English 1957. In the 1955 paper, we showedthe lateral cortical cut from distal of the second mo-lar horizontally back to the posterior border wellabove the angle. In the 1957 English publication,however, we showed the lateral cortex cut from dis-tal of the first molar to the posterior border just at

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

the angle of the mandible together with some pho-tographs of the splitting itself (Fig. 7) [7]. The lat-eral corticotomy could be varied. With these twopublications, we showed that the correction ofmandibular anomalies could be achieved transor-ally alone. In the years to come, I and others wouldcontinue to improve upon it.

For the sagittal splitting of the rami procedure,the variation that followed was the placement ofthe lateral corticotomy so as to increase the surfacearea of the bony contact to improve union andaccommodate a wider range of advancement of

the distal segment (Fig. 8). The change was thehorizontal orientation of the lateral corticotomyof the ramus to the vertical corticotomy of the man-dibular body. The story would not be completewithout my relating how Dal Pont’s contributioncame to be. In 1957, G. Dal Pont came to Zurichas a trainee of Professor Schmuziger, who was ourchief, and he would assist both Schmuziger andme with all cases. From watching, he conceivedthe idea of changing the lateral corticotomy fromthe horizontal ramus to the vertical body. We triedit with Dal Pont assisting, and it worked. In late

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Fig. 7. Illustration from the publication of the sagittal splitting procedure in the 1957 English article by Traunerand Obwegeser. Intraoperative photographs of the sagittal splitting procedure published in the 1957 Englisharticle 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 ObwegeserHL. Surgical procedures to correct mandibular prognathism and reshaping of the chin. In: Trauner R, ObwegeserH, editors. The surgical correction of mandibular prognathism and retrognathia with consideration of genio-plasty. Oral Surg Oral Med Oral Pathol 1957;10:677–89.)

1958, Dal Pont went back to Italy and E. Steinhausertook his place. Before we had an opportunity topublish it, Dal Pont published it on his own in1959 in Italian [8] and in 1961 in the American

literature [9]. Unfortunately, Dal Pont failed to in-clude us as coauthors, failed to mention that thecase shown in the article was my patient, and failedto mention that it was a modification of my original

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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 thatSchuchardt’s 1954 publication was based on his experience when he assisted me with a transoral sagittalsplitting of the ramus on April 22, 1953. Furthermore, Dal Pont’s publication in 1958 showed photos of a patientof Obwegeser and that the procedure was done when Dal Pont was a trainee at Zurich. No mention of this wasmade in his article.

technique. When Dal Pont had finished his trainingin Zurich and returned to Italy, he never performedthe operation he published as his own in his clinicalpractice. In addition to the buccal osteotomy beingperformed vertically, Hunsuck and Epker years lateradvocated that the osteotomy on the lingual sideshould be incomplete, only just past the entranceof the neurovascular bundle. This would result inan incomplete fracture, along the medial aspect ofthe ramus (Fig. 9) [10,11]. This I had already expe-rienced when Dal Pont was with us. Although ac-ceptable for mandibular advancement cases as itprovides a longer area of bone contact, for the set-back, the lateral segment is displaced because ofthe cortical component on the lingual aspect.When directed instead toward the ramal angle, thesplitting can be done more completely, allowingbetter adaptation of the fragments with less risk tothe nerve.

Thus by the early 1960s, the sagittal splittingtechnique became routine in my hands; however,as so often happens, a patient arrives at the door-step, and the routine must be modified. I hada patient who had a severe open bite deformity.Neither a mandibular procedure alone and normy routine sagittal splitting procedure would lenditself easily to solve the occlusal problem that pre-sented itself. I needed to rotate the mandible. Itoccurred to me that through the sagittal splitapproach, I could perform a transoral angleosteotomy (Fig. 10). I first performed a posteriormaxillary osteotomy and brought the segment su-periorly. I then removed the lateral cortical platefrom the ramus and placed it in a physiologic solu-tion. I isolated and repositioned the nerve. Thisthen allowed me to make an angle osteotomy. I

placed the patient in intermaxillary fixation and re-sected the overlapping segment of the lingual sec-tion of the angle. I then fashioned the lateralcortical plate and fixed it to the lingual fragmentswith wire fixation. I also simultaneously performeda transoral osseous genioplasty to reduce the verti-cally long chin. I published this in 1964 [12].

The transoral osseous genioplasty

The correction of the chin deformity has its ownparallel history. Up until the mid- to late 1950s, cor-rection of retrogenia was achieved solely by onlaytechniques through a submental skin incision. Au-togenous grafts (bone and cartilage) and alloplasticimplants (titanium, Silastic, and acrylic) were usedto create the chin prominence. The results of corti-cal bone grafts, while initially pleasing, were tempo-rary. Resorption was inevitable, followed by aninevitable secondary procedure. Although alloplas-tic materials had the advantage of ease of prefabri-cated natural shape and permanence, they werefraught with complications of infection, displace-ment, and erosion of the bony symphysis into thedental roots.

As with the sagittal splitting osteotomy, the needwas to develop a technique that could be accom-plished entirely transorally, allow sufficient bonycontact for union, and maintain the advancementwith minimal resorption. The idea came to me bychance when I had the occasion to see a younglady who had a significantly retruded chin but anacceptable occlusion (Fig. 11). As I traced the lateralcephalogram, I realized that I could alter her chincontour by simply sectioning it transversely and ad-vancing it. By leaving it pedicled on the musculatureof the floor of the mouth, its vascularity would be

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Fig. 9. Complete splitting of the mandible as originally described by Obwegeser (1955, 1957). The incompletesplitting 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 isset 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-gion would be altered favorably. I made my familiartransoral incision as in fracture cases. I used a Linde-mann bur to make an osteotomy of the symphysisdirecting the osteotomy plane from low posteriorlyto high anteriorly. The last few millimeters of thecut, I accomplished with a chisel. Once separated,I could easily pull the symphysis by 10 mm, pedi-cled on the geniohyoid muscle. I fixed it in thenew position with a circum-mandibular Supramidthread on each side over an acrylic dental splint.The operation went well, and there were no compli-cations. After 3 weeks, I removed the threads. Theoperation was simple and went surprisingly wellwith a satisfying outcome. I published this in1957 [7]. Thus the transoral approach to correctingchin deformities was born. The only other priorpublication of sliding the inferior border of thechin forward was by Hofer in 1942. The approachthat was published was extraoral, and the astutereader will note that Hofer performed the procedureon a cadaver and not a patient (Fig. 12) [13].

In the years that followed, variations in the genio-plasty continued with limiting the need for exten-sive exposure, various osteotomies to control thewidth and angulation, and with Neuner suggestinga double-step advancement. In its essence, thetransoral procedure has remained for 50 years asone of the simplest of technical procedures thata surgeon can have in his rucksack to solve a widevariety of chin deformities.

The LeFort I-type osteotomy

With the transoral techniques addressing mandibu-lar deformities, numerous patients could be treatedmore easily. There remained, however, a group ofpatients whose primary deformity lay within themidfacial structures: the maxilla and zygoma. In

these patients, although the mandible appearedprognathic, the deficiency was clearly in the lackof midfacial skeleton development, with only lim-ited involvement of the mandible. Although atransoral mandibular setback would achieve properocclusal relation, it would be at the expense of anoptimal aesthetic outcome. The necessary tech-nique to be able to reliably reposition the maxillacame long after the success of the sagittal splittingosteotomy of the mandible. Thus many patientswhose occlusions were restored with the mandibu-lar procedure were left with a flat appearance oftheir face and the stigma of their underlying defor-mity still apparent.

Why did it take so long? The problem was notonly surgically sectioning the maxilla safely, but re-positioning it and maintaining it in the new posi-tion. The surgical mobilization of the maxilla hasa long history, as Drommer recounted in 1986. Itstarted with as a means of gaining access to theepipharynx and the skull base first reported by Lan-genbeck in 1859 and by Cheever in 1867; the max-illa was sectioned horizontally through facialincisions. Only later was it sectioned for mobiliza-tion to correct the occlusal deformities. In 1935,Wassmund reported in his book that in 1927 hehad detached the maxilla as a Guerin-type fracturewithout separating it from the pterygoid processes.He then used elastics to close an open bite. Never-theless, this was not a complete mobilization ofthe maxilla. Axhausen published repeatedly in1934, 1936, and 1939 successfully repositioningof the maxilla in post-traumatic and cleft patientsusing elastics after complete osteotomy of the max-illa, including separation from the pterygoid pro-cesses. It is hardly understandable that Axhausen’sprocedure did not become routine by mid-twenti-eth century. In 1942, Schuchardt published

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Fig. 10. The transoral angle osteotomy (H Obwegeser 1964). (A) Preoperative and (B) postoperative appearanceat 1 year. (C) Preoperative cephalogram. (D, E) Planned Obwegeser’s transoral angle procedure combined withSchuchardt’s maxillary procedure. (F, G) Preoperative occlusion. (H) Model surgery. (I) Postoperative occlusion.

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Fig. 11. The first transoral ap-proach to correcting the chin de-formity. (A) Preoperative and (B)postoperative appearance. (C)The transoral osseous genioplastyas illustrated in 1957 article. (D)Preoperative and (E) postopera-tive cephalogram. (From Obwe-geser HL. Surgical procedures tocorrect mandibular prognathismand reshaping of the chin. In:Trauner R, Obwegeser H, editors.The surgical correction of man-dibular prognathism and retro-gnathia with consideration ofgenioplasty. Oral Surg Oral MedOral Pathol 1957;10:677–89.)

a post-traumatic war case in which he detached themaxilla and in a second operation the pterygoidprocesses and then used weight traction for reposi-tioning the dislocated maxilla. He stated pessimisti-cally ‘‘that this procedure would have a largeindication in cleft cases, but it would probablynever come into use.’’ In 1951 and 1952, when Iwas with Sir Harold Gillies, I watched him correctthe cleft deformity in numerous patients

characterized by retromaxillism with collapsed seg-ments. He used horizontal vestibular incisions toapproach the maxilla, despite the palatal surgeryand concern for blood supply. But he only rotatedthe collapsed cleft segments with a green-stick frac-ture at the pterygoid–maxillary junction, as didSchmid to correct the cross-bite, and I had neverseen him advance the maxilla. He fixed them inthe new position using cast cap splints fixed to

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Fig. 12. The sliding osseous genioplasty as depicted by Hofer in 1942. Although not indicated, the case shownwas a cadaver (No clinical pictures were shown in the article.) (From Hofer O. Operation del Prognathie undMicrogenie. Dtsch Zahn Mund Kleferhlkd 1942;9:121–32.)

a vertical bar to a head cap. He then placed cancel-lous bone grafts on the steps of the canine fossaopen to the maxillary sinus. The grafts were coveredon the vestibular side only. The sagittal discrepancyhe corrected by setting the mandible back. The pa-tients retained their dish face or at best a flatappearance.

Through the 1950s, I had not been satisfied fullywith my own approach. To correct deformities ofthe maxilla, cleft or traumatic, I used vertical vestib-ular incisions to maintain the blood supply.Through these slit openings, I sectioned the maxillausing a Lindemann bur to cut across the anteriormaxillary surface, a forked-type nasal septal osteo-tome I had designed to separate the vomer and me-dial maxillary walls, and a specially designedslightly flexible osteotomes with round edges to ver-tically separate the pterygoid plate. Previously Iwould facture the pterygoid plate horizontally, butI came to feel that the pull of the pterygoid muscu-lature contributed to the relapse. I then would usea Rowe disimpaction forceps. When it felt loose, Iwould pull the maxilla with wires into occlusion.After 4 weeks of intermaxillary fixation, there wascertain amount of inevitable relapse. I had feltthat the approach was acceptable as long as the re-quired repositioning was within a limited extent.Although maintaining blood supply, the vestibularmucosal bridge did not permit a greater extent ofadvancement, and the placement and fixation ofbone grafts in the steps of the canine fossae forstability was difficult.

Thus even around the time of 1960, neither inEurope nor in the United States, there did not exista reliable procedure for mobilizing the maxilla thatwould allow the surgeon the freedom to fully cor-rect the patient’s deformity without compromise.Although Trauner and I in 1952 were aware of thepatient who presented with so-called prognathism

and needed correction of the maxilla, our thoughtswere focused on the mandible. With the mandiblenow solved, in 1960 I earnestly refocused mythoughts toward the maxilla.

The solution came by chance. I was forced tosolve the midface problem in a case referred tome by the Chief of Plastic Surgery at the UniversityHospital. The patient was an 18-year-old man whohad suffered a car accident by driving into the backof a lorry, 6 weeks before my consultation. He pre-sented to me with the maxilla retrodisplaced in twosegments (palatal split) and telescoping into thenose and maxillary sinus, resulting in a severe ante-rior openbite and retromaxillism (Fig. 13). Addi-tionally he lost three upper incisors, and thevestibular mucosa was scarred circumferentiallywith multiple oral–nasal fistulae. Thus I could notapproach the maxilla through vertical vestibular in-cisions as was my usual approach. Instead, I ex-posed the maxilla by excising the circumferentialvestibular scar through the oral–nasal fistula. Asthe two halves of the maxilla now were healed ro-tated medially and retrodisplaced into the maxillarysinus, I had to free them there and perform osteot-omies from the canine fossa to the tuberosities us-ing osteotomes and a fissure-type burs. Then Iraised the nasal mucosa and detached the septum.I then cut the lateral nasal wall, followed by separat-ing the pterygoid plates vertically. With each step, Iconfirmed that the vascularity was not jeopardized.Instead of the use of the Rowe disimpaction forceps,which I felt would damage the remaining palatalblood supply to the maxilla further, I simplypressed firmly on the anterior maxilla. The maxillaseparated easily in what became known as thedown-fracture technique. To mobilize it forward, Ithen used strong, slightly curved osteotomes topull it forward slowly. I then needed to surgicallyrecreate the palatal fracture so that I could

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

independently reposition each half of the maxilla toestablish the occlusion. Without the descendingpalatine artery, the blood supply of the maxilla atfirst was poor, but recovered after awhile. I usedwire fixation to secure the maxilla in place. I thenclosed the fistula with mobilization of the vestibu-lar mucosa. Thus I was able to establish the occlu-sion, and the case taught me that the maxilla canbe mobilized extensively and can receive an ade-quate blood supply from the palate alone. Thiscase in 1964 is the first case of what was to becomethe standard LeFort I-type osteotomy.

In the years to come, I succeeded in advancing themaxilla in cleft patients, without the need to estab-lish the occlusion with a mandibular setback as inyears past. The first case in which there was an ex-treme discrepancy between the jaws was done onApril 14, 1968, in which the maxilla was advanced15 mm on the side of the lesser segment and 13 mmon the contralateral side (Fig. 14). Downfracturewas as before, but mobilization was extremely diffi-cult until I opened the cleft, moved the segmentslaterally, and felt the scar tissue. Now I could releasethe scar. I got both segments absolutely loose; thatwas the entire key to the success. Now I could ad-vance as far forward as needed. The blood supplyremarkably was still satisfactory. I used blocks ofcancellous bone from the iliac crest to fill the hori-zontal and vertical gaps. I then mobilized the

vestibular mucosa to cover the grafts, yet left opento the maxillary sinus and nasal cavity. The postop-erative course was uneventful, and the result bothin appearance and occlusion was far better than Ihad achieved before. Adequate mobilization wasthe key step in advancing the maxilla, whether cleftor noncleft cases. With experience, I felt comfort-able with advancements up to 20 mm. In the earlydays, in nearly all cleft cases I reopened the cleft toachieve the needed mobilization and occlusion andthen as a second stage closed the cleft once the oc-clusion was stable. Subsequently, I learned that Icould in numerous cases close the cleft simulta-neously with the advancement by moving the lessersegment medially, and placing the canine in the lat-eral incisor position. This solved the dental gapproblem, as in those days we did not have osseoin-tegrated implants.

Birth of orthognathic surgery

By the late 1960s, I felt comfortable repositioningthe mandible and the maxilla. I had not donethem simultaneously, however. It was on Septem-ber 5, 1969, that the first simultaneous sagittal split-ting of the ramus and the LeFort I type osteotomywas done (Fig. 15). Although I could establish theocclusion with either procedure, when I handtraced the cephalometric radiograph, I realizedthat I needed to move the maxilla forward and

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down along with setting the mandible back. Bothjaws had to be moved to improve the aestheticresult. To find out how much I needed to moveeach jaw, I hand traced what I considered was anideal profile on a transparent sheet over the existingprofile. This gave me a carpenter’s rough estimate. Iplanned to make the final decision in the operatingroom. The operation went smoothly. When bothjaws were completely free, I fixed them to eachother. I then repositioned the maxilla and mandibleas one unit according to my imagination, and whenI was satisfied with the aesthetic result, I completedthe fixation with wire and bone grafts. I kept the pa-tient in 6 weeks of intermaxillary wire fixation. Theresult both in terms of occlusion and appearancewas excellent. With this first case, orthognathic sur-gery became a subspecialty in its own right. I pub-lished this in 1970. As with the mandibularprocedures, modifications continued in the designof the midfacial osteotomy, and in time internalfixation with plates and screws became a reality.Still, the essential component that the surgeonhad to execute remained: adequate mobilization.Various combinations of mandibular and maxillaryprocedures now could correct most maxillofacialdeformities (Fig. 16). Before what today many sur-geons would consider mandibular distraction as theonly approach, we were able to use the long lateralcomponent (that is placing the vertical corticotomyas close to the mental foramen as possible) or thecircular splitting of the mandible to correct themost severe deformities (Fig. 17). What remainedwas the cranio–orbital region.

From maxillofacial to craniofacial

In 1967 at the International Plastic Surgery Con-gress in Rome, Tessier presented the transcranialand the subcranial LeFort III procedures to correctthe cranial and orbital deformities. With that,craniomaxillofacial surgery became a reality.The story now is well known. With Tessier’s cleardemonstration, the cranio–orbital deformitiescould be corrected, and with my work, the maxil-lary–mandibular deformities could be addressed.Thus the patient presenting with a severe dish-facedeformity could be solved by combing a LeFort IIIto address the orbital component and the LeFort Isimultaneously to address the occlusal relation(Fig. 18).

In 1968, when Hans Luhr published his work onplate and screw fixation, it revolutionized internalfixation, limiting the need for extended intermaxil-lary fixation and increased stability with less reli-ance on complex interlocking joints and bonegrafts. And finally what could be accomplishedonly by a rotary bur in my early days, improvements

in instrumentation with thin saw blades allowed forrefined osteotomies.

Thus looking back, I was fortunate in many ways.Fortunate to have began my career at a time whenso many maxillofacial problems remained un-solved. I was fortunate to have had Trauner as myteacher. Trauner taught to me to see problems andfind solutions. I was also equally fortunate tohave had Sir Harold Gillies and Eduard Schmid asmy teachers. Each taught me that it was not somuch knowledge of what came before, but theimagination of solving problems as the patientspresented themselves. In the middle of difficultylies opportunity. The surgeon today can disassem-ble each of the elements of the craniofacial skeletonand then reassemble it. He only is limited by hisimagination to seek the solution. If I may end thistale with the words of another:

‘‘Imagination is more important than knowledge.For knowledge is limited to all we now know andunderstand, while imagination embraces the entireworld, and all there ever will be to know and under-stand.’’ Albert Einstein.

Postscript

Although I have long since left the task to others, Iwill describe for those interested how I preferred todo the transoral procedures for many years withappropriate instrumentation. I will begin by split-ting the mandibular ramus.

Sagittal splitting of the mandibular ramus

IncisionThe mandibular procedure should be able to be per-formed with minimal bleeding. The operative fieldis infiltrated generously with a vasoconstrictingagent. I prefer to start on the abnormal side if thereis one. I place a rubber mouth gag on the oppositeside to hold the mouth wide open. The incision isplaced in the mucosa laterally well away from the at-tached gingiva of the first molar. It then is deepenedvertically through the periosteum between the buc-cinator crest and the oblique line. Then it is extendedfurther superiorly along the external oblique line tothe base of the coronoid process. The periosteum iselevated in the retromolar region and along theanterior border of the ascending ramus, a few milli-meters on either side of it. The inferior attachment ofthe temporalis muscle is dissected off. Once theanterior border is exposed, I place a ramus clampon the neck of the coronoid process.

Medial corticotomyNext, I elevate the periosteum on the lingual sidebetween the lingula and the semilunar notch only

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as far back as to the concavity above the entrance ofthe mandibular nerve into the foramen. A Freer isused to palpate the semilunar notch. Then I usean acrylic bur to start my lingual cortical cut. Itmakes a broad defect in the wide anterior border.This permits better visualization along the medialaspect. Then I raise the rest of the periosteum allthe way back to the posterior border and aroundit. Next, to keep the lingual soft tissues away andto protect the mandibular nerve, I like the narrowmandibular channel retractor, inserted and hookedbehind the posterior border. Under direct vision,one now can elongate the lingual cortical cut allthe way back, including the posterior border.

As far as the cortical cut above the lingula isconcerned, I have given up using the Lindemannbur, not only because it breaks easily, but also be-cause I want to be able to shorten the ascending ra-mus length on its medial side, particularly when Iwant to set the mandible back. For that reason,the Lindemann bur makes too narrow a cut. In-stead, I prefer using a bone-cutting bur of 3.0 mmdiameter (Fig. 19). Using this much broader diam-eter bur, I deepen the medial cortex until I seebleeding points from the cancellous bone all theway back. Above the lingula, I want a rather broaddefect in the medial cortical plate of the ramus toprevent overlapping of the distal fragment overthe inner cortical plate of the proximal fragment. Igenerally prefer the splitting of the entire ramusbreadth. Otherwise the distal cancellous part ofthe tooth bearing fragment will overlap the corticalplate of the proximal fragment, pushing it laterallywhen the mandible is retropositioned posteriorly.This occurs when the lingual cortical cut is notdeep enough all the way back to the posterior bor-der. An incomplete splitting will occur, just behindthe lingula, leaving at least one third of the ramusbreadth unsplit. Even for cases of retromandibu-lism in which the mandible is lengthened, I will cre-ate a similar medial cortical defect to fully split themandible, although in these cases, the incompletesplitting will not interfere with the advancement.

Lateral corticotomyWith this completed, I then elevate the periosteumon the buccal side of the ramus where I want to placemy lateral cortical cut. I free it around the inferiorborder and place a mandibular channel retractor.

Care should be taken to leave as much of the masse-ter muscle as possible attached to the lateral aspectof the ramus to maintain blood supply and stabili-zation of proximal segment. In a typical mandibularsetback or advancement procedure, I normallydirect the lateral corticotomy from the secondmolar region toward the angle. I prefer this place-ment in most instances as the nerve is more mediallylocated when compared with a lateral corticotomythat is located in the body and as the sagittal splitcan be more easily completely made through thefull breadth of the ramus. I will vary this lateral cutaccording to each individual case, however. In acase of micromandibulism such as a bird-face ap-pearance, it will reach almost as far anterior as themental foramen, starting behind the second bicus-pid. Here I use a slender rotating bone-cutting bur,going only as deep as necessary to see bleedingpoints from the cancellous bone. A 1.5 mm burwill do this cut through the lateral cortical plate. Itshould continue around the lower posterior border.

Sagittal corticotomyThe medial and the lateral bone cuts are then readyto be connected. The sagittal corticotomy followsthe anterior border just on its inner side, using a nar-row bone-cutting bur or an oscillating saw. Techni-cally, it may be easier to first drill with a small rosebur a series of holes through the cortex along thelingual aspect of the anterior rim (see Fig 11F)which then are connected by a bone cutting buror saw. Care must be taken that the cutting instru-ment goes through the cortical bone only, no deep-er than 4 to 5 mm.

Splitting the ramusI open the sagittal corticotomy by 2 to 3 mm witha wedge osteotome first. Then I insert a bone separa-tor, but only a few millimeters deep. Its fork-likeblades are flexible. With that instrument, the split-ting is done very gradually in an incremental fash-ion. The separation of the two cortical plates occursgradually until the two halves completely separatealong the full breadth of the ramus (see Fig. 17E).If the ramus does not split easily, then frequentlya blow with a thin osteotome directed laterallyaway from the nerve on the inferior border will help.

With the gradual splitting, the nerve can be visu-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 LeFortI-type osteotomy (H Obwegeser 1969). (A) Patient’s 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 appearanceand (G) lateral cephalogram. Note that the nose was corrected with advancement of the maxillary platformalone. (H) Preoperative and (I) postoperative with (J) prosthodontic restoration occlusal outcome.

=

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Fig. 15. The first case of simultaneous advancement of the maxilla and retropositioning of the mandible (H Ob-wegeser 1970). (A, B) The patient’s 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 twoplanes with bone grafting. (H, I) The postoperative result, (J) lateral cephalogram, and (K) occlusion.

segments with the bone separator in place. If this isthe case, then the nerve can be freed from the lateralsegment so as to remain with the distal tooth-bear-ing segment and the osteotomy continued.

RepositioningThe separation between the medial and lateralelements must be complete to allow independentrepositioning of the mandibular body from themandibular ramus. The mandible then is fixed inthe planned occlusion by using intermaxillary

wires. With mandibular setback, removing any re-sidual cortex on the medial aspect of the lateralramal fragment may be necessary to fully adaptthe fragments without laterally displacing the prox-imal fragment. This is achieved easily with the boneseparator in place providing a good view in betweenthe segments and protecting the nerve.

OsteosynthesisAlthough the technique of splitting the ramus iswell-established today with essentially minor

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Fig. 15 (continued)

variations based on surgeon’s preference, osteosyn-thesis will continue to evolve from wire fixationused when I first started more than a half a centuryago to titanium fixation at the end of my surgical ca-reer and a future promise of resorbable fixation. Al-though plates have been advocated by some, mypreference has been placement of 1.5 mm diameterscrews that merely adapt the two fragments withoutcompression and displacement at the temporo-mandibular joint. With the mandible fixed in thedesired occlusion, the condyle on the proximal ra-mus fragment is manipulated into the glenoid fossaand held with an adaptation clamp, or any othersuitable instrument in that position by the assistant.I then place through a transbuccal approach three1.2 mm pins to hold the two segments temporarilyin position until the screws can be placed. The pinsthen are pulled out sequentially, one after the other,using the holes in the cortical plates for screw

placement. Once fixed into position, the contourof the ascending ramus should be assessed. Withmandibular setback, it may become necessary to re-duce anterior border of the proximal segment at theretromolar junction to allow an appropriate spaceand mucosal closure distal to the molar.

ClosureBefore closing the wound with a continuous suture,the operative field is rinsed again with an antibioticsolution. I like to place a thin rubber drain withinthe wound for overnight.

The osseous genioplasty

The procedure itself is as I had described it in 1957.The exposure in the symphyseal region, however, iskept as minimal as needed to accomplish theosteotomy. This will maintain the vascularity ofthe symphysis. The osteotomy is done with a thin

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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 ofthe mandible, and an advancement osseous genioplasty. (F, G) Postoperative appearance and (H) lateralcephalogram.

reciprocating saw and the fixation accomplishedwith titanium plates and screws. This procedure, be-cause of its simplicity and ability to solve a great va-riety of lower third problems, should be masteredby all surgeons.

The LeFort I

Today, mobilization of the maxilla is performedmore often than repositioning of the mandible.The technique may differ from one surgeon to an-other, although not very much in its essential

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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 thefused 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 twostages with release of the ankylosis followed by maxillary–mandibular surgery. (F) Illustration of the reposition-ing of the skeletal elements and (G) postoperative cephalogram. (H–J) The postoperative result with release ofankylosis and occlusion.

components. It has changed only slightly in myhands since 1962.

Incision and exposureBefore the procedure, the epipharynx is packed withgauze to protect nasotracheal tube at the time of theosteotomy. The operative field is infiltrated witha vasoconstricting agent. I then perform the vestib-ular incision through the mucosa, at least 5 mm

above the attached gingiva from one zygomaticcrest to the other. This is done with a knife in a sin-gle cut vertically to the alveolar process through theperiosteum. At the lateral extent, I direct the inci-sion superiorly for some millimeters to achieveenough access to the tuberosity area without tearingit with the retractor. The maxilla and the inferiorpart of the zygoma then is exposed easily. The in-fraorbital nerve is visualized. The periosteum then

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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 maxillary–mandibularrelationship. (E) The postoperative lateral cephalogram and appearance (F) 3 years and (G) 11 years aftersurgery.

is raised carefully behind the zygomatic crest andinto the pterygoid–maxillary junction. If this isnot done carefully, then a rent in the periosteumwill occur, and Pichat’s fat pad will come throughthe opening readily. This will plague the remainderof the operative procedure. For this exposure, I pre-fer the upwardly bent retractor inserted at the junc-tion between the maxilla and the pterygoid process.Finally, the edge of the pyriform aperture is freed,and the mucoperisteal covering of the floor of thenose is raised on both sides along the entire lengthof the hard palate and on the lateral walls of thenasal cavities to the level of the inferior turbinates.On the medial aspect along the nasal crest of thepalatine bones, elevating the muco–periosteumwithout tearing may present some difficulties.Care must be taken to prevent this from happening,especially when approaching the juncture of thenasal crest of the palatine bones with the septum.Maintaining an intact muco–periosteum is evenmore important when a deviated septum is beingcorrected at the same time.

The LeFort I-type osteotomyNext I make vertical marks with a fine bur on thezygomatic crest and at the anterior region of the ca-nine fossa. These reference marks will enable me tomeasure the amount of sagittal and vertical move-ment of the maxilla. If the maxilla has to be im-pacted, I mark the amount of resection necessaryon the antral wall.

I still use the same horizontal osteotomy for sep-arating the maxilla as I did at the beginning in the1960s. However, sectioning of the maxillary wallsat that time was accomplished with burs and withosteotomes. The osteotomy today is accomplishedmore elegantly and more precisely using a thin re-ciprocating saw blade with minimal loss of preciousbone and far cleaner without the fragments gener-ated with an osteotome. Moreover, the osteotomydesign and execution with the reciprocating saw eas-ily allows varying its angulation from the standardLeFort I type pattern depending on the movementdesired. Once the maxillary walls are sectioned, Ithen vertically separate the pterygoid plate from

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

the maxilla using a very thin, slightly curved, flexibleosteotome as I did then. This is then followed byseparating the nasal septum from the hard palate us-ing a guarded septal osteotome. To avoid the risk oftransecting the nasotracheal tube and protecting theposterior pharyngeal wall, the epipharynx is packedwith gauze.

The mobilization of the maxillaFor many years I have ceased initiating the downfracture at the anterior nasal region, and instead ini-tiated it at the lateral–posterior maxillary–zygomaticbuttress, following the suggestion of my nephewJoachim Obwegeser, MD, DMD. I insert the boneseparator within the osteotomy at the zygomaticcrest and apply gentle pressure (Fig. 20). The maxillatypically comes down easily. Otherwise any resis-tance requires either an osteotome or reciprocating

saw with the spreader in place. Next the anteriordown-fracture is accomplished with the bone sepa-rator inserted at the nasal aperture rim (medialmaxillary–nasal buttress). This is the reverse of myprevious procedure and as others still describe.

Once the maxilla is down-fractured, it must bemobilized fully. To advance the maxilla, I routinelyuse the so-called maxillary mobilizer type elevator Ihad designed. For cases where my typical maneu-vers for advancement were difficult, I had an instru-ment made by Medicon Instrumente (Tuttligen,Germany), which I called a maxillary advancer.One leg rests on the zygoma, and the other part isdesigned as a curved blade inserted behind thetuberosity. The advancement then is achieved grad-ually, millimeter by millimeter. After one side isdone, the next is dealt with in the same way. Thisshould be done from side to side in increments.

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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 themaxilla anteriorly by more than 20 mm. The max-illa must be so loose that it can be repositioned eas-ily with a pair of forceps. This is a must.

Although the full mobilization in most cases canbe accomplished without the necessity of this in-strumentation, it is particularly useful in cleft caseswhere there is significant resistance against thecomplete mobilization because of soft-tissue cica-tricial scar formation. A surgeon’s finger can iden-tify easily where the knife or the scissors needs tosever still-resisting scars. It is better to cut themthan to pull so hard with the maxillary advanceror any other instrumentation. Scars do not includelarge vessels, and there is little risk of severe bleed-ing when cutting.

Today, many surgeons will resort to the use of dis-traction devices to gradually advance the cleftmaxilla. Although in some circumstances this maybe appropriate, it should be remembered thatmost cleft patients can be treated appropriatelyand more efficiently, even when requiring signifi-cant advancement with the classic LeFort I-type pro-cedure as described.

Bone graftingIn cases in which I had advanced the maxilla by atleast 8 to 10 mm or more, I would use autogenous

bone grafts. These include a block of cancellousbone wedged into the gap behind the tuberosityand several blocks to bridge the steps in the caninefossae.

Closing the alveolar gapIn unilateral and in bilateral cleft cases, the dentalgap of the lateral incisor can be eliminated by ad-vancing the lateral alveolar process so that the ca-nine is positioned next to the central incisor. Thecanine then subsequently is contoured to matchthe appearance of a lateral incisor. The segmentaladvancement decreases the orthodontic treatmenttime of the staged bone graft, followed by either or-thodontic movement of the canine or placement ofa dental implant.

OsteosynthesisAs with many other procedures, wire fixation is re-placed by titanium plates and with the promise ofresorbable fixation in the future. I place the platesat the medial nasal piriform buttress and at thezygomatic–maxillary buttress, but prefer fixationas semirigid to allow postoperative guidance ofthe occlusion with dental elastics when the patientis actively functioning. In my experience, there isapproximately 0.5 to 1.5 mm difference betweenthe surgeon’s positioning intraoperatively when

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the patient is under general anesthesia comparedwith active functioning as they resume oralfunction.

ClosureBefore closing the wound with a continuous suture,the operative fields including the maxillary sinusesare rinsed with an antibiotic solution.

Surgical instruments

As with any other craft, tools are important to thesurgeon. Operative procedures are most efficientlydone when the instruments are fewer in number,can be used to accomplish multiple tasks, andwhen appropriately designed. The surgeon mustbe as familiar with the tools of his or her trade aswith the procedure. They are extensions of thehands, of the dexterous fingers, to accomplish tasksof the trade. Every craftsman knows the importanceof the quality of good tools and maintaining them.Many instrument makers have provided instru-ments named after the surgeon who developedthem; however, few manufacturers will have theirquality checked and repeatedly checked by thesurgeon whose instrument that bears his name.This is true with my own instruments. Many com-panies will produce Obwegeser instruments, butfew have the right to engrave ‘‘Original Obwegeser,’’as KLS-Martin (Jacksonville, United States) andMedicon (Tuttligen, Germany). My experiencewith many so-called Obwegeser instruments ofother companies is disappointing. Since my earlydays, appropriately designed powered hand pieceshave made a significant difference in the ease ofexecuting the osteotomies. The hand pieces ideallyshould be lightweight, slender, and not obscurethe already limited field of view of the surgeon.My preference is manufactured by W&H Dental-werk Burmoos GmbH, Austria, 5111 Burmoos. Thesurgeon in training should know his or her instru-ments, how they are used, and be familiar with theirquality.

Thus, now looking back across half a century, I al-most envy those who are able to learn today withmodern instruments, techniques, and reliance onexperience gained by those who came before. Fewprocedures can alter the human face so fundamen-tally as these three procedures. I hope that thesewords will continue to inspire the generations ofsurgeons to follow.

Acknowledgments

I wish to express my very sincere thanks to Dr. Pra-vin K. Patel for his generous editorial assistance intranslating my original manuscript into the formin which it appears.

Further readings

Obwegeser HL. Die Kinnvergrosserung. Oesterr ZStomal 1958;55:535–41.

Obwegeser HL. Cirugia del mordex apertus. Re AsocDodont Argent 1962;50:430–41.

Obwegeser HL. Operative Behandlung der zahnlosenProgenia ohne intermaxillare Fixation. SchweizMonatschr Zahnhlkd 1968;78:416–25.

Obwegeser HL. Surgical corrections of small or retro-displaced maxillae. Plast Reconstr Surg 1969;43:352–65.

Obwegeser HL. Mandibular growth anomalies: termi-nology, aetiology, diagnosis, and treatment. Ber-lin: Springer; 2001.

References

[1] Blair VP. Surgery and diseases of the mouth andjaws. St. Louis (MO): The C.V. Mosby Co.; 1914.

[2] Koste�cka F. Die chirurgische therapie ider pro-ggeni. Zahnaertzl. Rundsch 1931;40:669.

[3] Perthes G. Operative Korrektur der Progenia.Zentralbl Chir 1922;49:1540–1.

[4] Perthes G. Uber Frakturen und Luxationsfraktu-ren des Kieferkopfchens und Ihre operativeBehandlung. Arch Klin Chir 1924;133:418–33.

[5] Kazanjian VH. The treatment of mandibularprognathism with special reference to edentu-lous patients. J Oral Surg Oral Med Oral Pathol1951;4:680–8.

[6] Trauner R, Obwegeser H. Zur Operationstechnikbei der Progenia und anderen Unterkieferano-malien. Dtsch Zahn Mund Kieferhlkd 1955;23:11–25.

[7] Obwegeser HL. Surgical procedures to correctmanidbular prognathism and reshaping of thechin. In: Trauner R, Obwegeser H, editors. Thesurgical correction of mandibular prognathismand retrognathia with consideration of genio-plasty. Oral Surg Oral Med Oral Pathol1957;10:677–89.

[8] Dal Pont G. L’osteotomia retromolare per lacorrezione della progenia. Minerva Chir 1959;14:1138–41.

[9] Dal Pont G. Retromolar osteotomy for the cor-rection of prognathism. J Oral Surg 1961;19:42–7.

[10] Hunsuck EE. A modified intraoral sagittal split-ting technique for correction of mandibularprognathism. J Oral Surg Anaesth 1968;2:249–52.

[11] Epker BN. Modifications in the sagittal osteoto-my of the mandible. J Oral Surg 1977;35:157–9.

[12] Obwegeser HL. Der offene Biss in chirurgischerSicht. Schweiz Monatschr Zahnhlkd 1964;74:668–87.

[13] Hofer O. Operation del Prognathie und Microge-nie. Dtsch Zahn Mund Kleferhlkd 1942;9:121–32.