331
CLINICS IN
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.
The transoral sagittal splitting of the
mandibular ramus
The transoral osseous genioplasty
The LeFort I-type osteotomy
Birth of orthognathic surgery
From maxillofacial to craniofacial
- Postscript
Today the transoral sagittal splitting of the ramus,
the osseous genioplasty, and the LeFort osteotomy
have become commonplace procedures used by
multiple 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 the
mandibular ramus
When I started my training in maxillofacial surgery
in 1947 with Richard Trauner at the Maxillofacial
Unit of the Dental School of the University of
Graz in Austria, orthognathic surgery was virtually
nonexistent. It was a series of unsatisfying proce-
dures primarily to correct so-called prognathism.
Among them were the Blair [1] and the Kostecka
[2] procedures (Fig. 1). The patient was seated in
a dental chair, given sedation followed by a local in-
filtration and a block anesthesia. The assistants role
was to hold the head steady. The surgeon then
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.
plasticsurgery.theclinics.com
PLASTIC
SURGERY
Clin Plastic Surg 34 (2007) 331355
Sagittal splitting of the mandibular ramus
The osseous genioplasty
The LeFort I
Surgical instruments
- Acknowledgments
- Further readings
- References
passed a large curved awl with a heavy thread at-
tached to a Gigli saw transcutaneously around the
ascending ramus above the lingula. With that, the
ascending ramus was cut on both sides within 15
minutes. 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 cases
of Kostecka operations. Roughly 50% of our cases
had nonacceptable complications: partial or total
relapse, open bite, pseudoarthrosis, irreversible in-
jury to the mandibular nerve, and even worse to
the facial nerve, parotid gland fistula, or other com-
plications. The occlusal relapses, Trauner assumed,
were caused by inadequate bony union because of
the extremely small area of contacting bone surfaces
of the two fragments further compounded by the
pull of the temporalis muscle dislocating the frag-
ments. Thus we sought for a procedure that would
produce broader contacting bone surfaces for a
stable union.
I searched the literature and in K.E. Hogemans
monograph (1951) on Surgical Orthopaedic
doi:10.1016/j.cps.2007.05.014
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
a compendium of what was available to the surgeon
at that time. I disliked all the ones with an extraoral
approach because of the unpredictable quality of
the scar and the added risk to the mandibular
branch of the facial nerve. The few transoral tech-
niques that were published failed to produce the
required broad contacting bone surfaces needed
for stable bony healing. I wanted an osteotomy that
could be performed transorally only, avoiding a
skin incision, and which would produce broad con-
tacting bone surfaces, even after the repositioning.
While thinking about this, I turned a cadaver
mandible in my hands around several times, and
the solution became obvious. If the mandibular
ramus could be split along its sagittal plane, then
one of the requirements, the need for a broad
bony 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 radiographs
fractures in a sagittal pattern. The question was
could it be done technically. After cross-sectioning
a dry cadaver mandible at several points, I was cer-
tain that the contents of the mandibular canal
could 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 two
corticotomies connected along the sagittal plane.
As far as the second requirement of executing the
procedure 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 treating
mandibular fractures by proper repositioning of
the fragments and intermaxillary fixation within 24
hours of the accident resulted in minimal complica-
tions. The surgical procedure as a controlled trauma
would be the same.
With this in mind, I tried sagittal splitting the
ramus transorally on a cadaver at the Institute of
Anatomy (Graz, Austria) and reported to Trauner
that it was possible. He said that Perthes and
Schlossmann already had tried a type of sagittal
splitting of the ramus by means of an extraoral ap-
proach. Some time later when I reviewed G. Perthes
article of 1922 [3], however, the osteotomy referred
by him was by A. Schlossmann, an oblique trans-
verse osteotomy by means of an extraoral approach
similar to one published years later by V. Kazanjian
in 1951 (Fig. 2) [4,5]. The Schlossmann-Kazanjian
approach was an oblique transverse osteotomy in
a limited attempt to increase the contact area. Nei-
ther, however, was a true sagittal splitting procedure
that sufficiently increased the bony surface area as
to what I had conceived. Interested, Trauner sug-
gested that we should operate together, on one side
his idea of a reverse L-shaped osteotomy of the ra-
mus by means of a combined extraoralintraoral
approach, and on the other side my idea of the
sagittal splitting of the ramus, transorally only.
The first case was an edentulous 27-year-old
woman with a protruding mandible, operated upon
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.
With the patient in a half-sitting position and under
local anesthesia, the procedure was performed with
Trauner and I operating as primary surgeons, and
H. Kole assisting. Trauner completed his portion
of the operation first. I asked the patient to open
her mouth wide, and I made a mucosal incision
along the left ascending ramus. I used a Stichsage
(keyhole) saw to cut the cortical plates. I first cut
the lateral cortical plate from the inner angle to the
outer angle of the jaw. Then I cut the medial cortical
plate 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. Then
when I tried to split the ramus using an osteotome,
the ramus unexpectedly shattered instead of split-
ting! The mandible was set back with splints and
the patient kept in intermaxillary wire fixation for
212 weeks followed by elastics. Although the clinical
outcome was acceptable, the transoral technique
was less than as I had hoped it would be.
Two months later another opportunity arose, our
second case, when a 24-year-old prognathic woman
with nearly full dentition presented to us (Fig. 4).
Even with the initial difficulties, Trauner remained
supportive. The first mandibular premolars had
been removed previously with the anterior teeth
slightly retracted by the patients dentist to soften
her prognathic appearance. In preparation, some
equilibration of the teeth was required to achieve
a stable occlusion, and continuous loop wiring
was applied to the maxillary and mandibular teeth.
The operation was performed on April 22, 1953, by
Trauner and myself as the primary surgeons and
this time assisted by Professor Schuchardt from
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

at our department. After premedication for seda-
tion, the patient was placed in a half-sitting
position on the operating table. Mandibular block
and local anesthesia were used. This time, Trauner
asked me to operate first. I chose the left side, and
I started with an incision from the first molar
back and up along the anterior border of the ramus,
right to the bone. Next I raised the periosteum on
the 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 cortical
plate, this time with a long Lindemann bur, to the
depth where some bleeding became visible. The
Lindemann burs broke, one after another, and I
completed the medial corticotomy with a Stichsage
(keyhole) saw, as I did with the first case. Next I
raised the periosteum on the buccal side, from the
angle horizontally back to the posterior border
and sectioned the lateral cortex with a keyhole
saw, 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 bur
and connecting them with a Lindemann bur along
the anterior ramus. With the first blow of the osteo-
tome, unintentionally, the coronoid process frac-
tured off. I then decided to further deepen and
widen the cortical cuts with a series of fissure
burs. After that it became easier to open or split
the two cortical plates with an osteotome. I
positioned 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 cortical
plates this time easily fell apart. The mandibular
ramus was sagittally split! As the fragments would
almost be self adapting when moving the mandible
back on the split side and as we had yet to complete
the procedure on the right side, we decided that
wire fixation might not be necessary. We spread
some penicillin powder and did a rather tight clo-
sure of the periosteum and of the mucosa. On the
other side, Trauner performed his inverted L-shaped
osteotomy through a combined oral and extra-oral
approach. A circumferential wire secured the frag-
ments. This was followed by 6 weeks of intermaxil-
lary fixation. The recovery was uneventful. There
was initially numbness of the lip on the side of the
sagittal splitting procedure, but this recovered com-
pletely by 1 year after the procedure. On the side of
the inverted L transcutaneous approach, the perma-
nent scar remained visible for many years. One year
=
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.
Orthognathic Surgery 335
and 5 months after surgery, the final result in occlu-
sion as well as in facial contour was very pleasing. It
remained unchanged after 33 years. With this case,
the transoral sagittal splitting procedure of the
mandibular rami was born (Fig. 5). We published
this in German in 1955 [6].
These early cases I did without special instrumen-
tation, using what was only available to me at the
time. Additionally, inadequate intraoral lighting
and 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 on
April 9, 1956, in Zurich, Switzerland (Fig. 6). In
1954, I had left Trauner and at the invitation of Pro-
fessor P. Schmuziger, Chief of Oral-Maxillofacial
Surgery and Professor R. Hotz, Chief of Orthodon-
tics at the Zurich Dental School, I joined the De-
partment of Maxillofacial Surgery at the University
Hospital. Hotz in 1956 had a patient on whom
he had wanted me to perform the sagittal splitting
procedure instead of referring the patient to Schmu-
ziger. She was 14 1/2 years old with a rather long
and narrow mandible with partial anodontia. She
had 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 maxilla
was not possible, and the only option was a man-
dibular setback with crown and bridgework. In
those days, however, there was no such thing as
a panoramic radiograph, but the PA film showed
the mandible to be rather narrow, and I was not
sure that I could split the rami. We scheduled the
surgery for April 9, 1956, in a private hospital, as
she was a private patient from another country at
Hotzs request. I had never had an opportunity to
operate in a private hospital before, nor had to con-
tend with an anesthesiologist. Up till then I had
done the procedures under local anesthesia. I had
to convince him of a nasotracheal intubation in-
stead of an oral intubation, and that was something
new to the anesthesiologist. When I explained the
procedure 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 procedure
could be performed only on paper. Thus I began
an operation without much enthusiasm. I first se-
cured the cast cap splints, because the patients teeth
were not suitable for intermaxillary fixation. I
started the procedure on the right side. I did the
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,
until I saw some bleeding indicating that I was at
the level of the cancellous bone. I did the cut above
the lingula on the medial side and then a cut hori-
zontal just above the angle on the lateral side. Then
I made a series of holes using a rosehead bur along
the anterior surface just medial to the oblique ridge.
With a short Lindemenn bur, I connected these
holes from the medial corticotomy to the lateral
corticotomy. I had learned by now that without
these series of holes as a guide, I found it difficult
to 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 poor
visualization of the operative field, the splitting
on the right side went well, but took a long time.
On the left side, I ran into problems I had not
encountered before. When I did the splitting by
striking a broad thin osteotome about 5 mm in
depth only, and twisting it, the lateral ramus broke
off. As I had detached it of its periosteum, it was
now a free fragment. This was my first sagittal split-
ting since my new position in Zurich with my chief,
Schmuziger, watching. Not particularly what I
would like to have had happened given his views.
I am not sure of Schmuziger was aware of my
dilemma, as only I could barely see the operative
field. I ignored it for the time being. I set the man-
dible back in the preplanned occlusion. On the
right side, I fixed the position with an anterior
border wire. I closed that side. On the left side, I re-
turned to my problem. There was no contact
between the proximal and distal segments. With
considerable amount of difficulty with poor light-
ing and instrumentation, I managed finally to adapt
the free lateral ramus fragment to the rest of the
ramus and the distal segment with direct wire fixa-
tion. I closed the wound over a rubber drain. The
operation took over 4 hours. I thanked God that
it was over and hoped for the best.
The operation was more stressful that I had expe-
rienced before when I had performed it under local
anesthesia and sedation. I had to constantly battle
with the anesthesiologist, who was concerned that
I would pull the tube out of the nose, and my assist-
ing pessimistic chief. The postoperative course was
difficult for me and the patient. With each day, there
was increasing swelling and bruising I had not had
before. With each passing day, I feared some serious
complication. I did only what any surgeon would
do. I went to the monastery church of Einsiedeln
and prayed, promising God I would never do this
procedure again if this girl got away without com-
plications. She had a wonderful aesthetic and func-
tional result. No external scars. Six years later, she
sent me her wedding photographs. I on my part
of the Faustian bargain, broke my promise to
God. I continued to perfect the sagittal splitting pro-
cedure until it became routine.
We published this first in German in 1955 and
then in English 1957. In the 1955 paper, we showed
the lateral cortical cut from distal of the second mo-
lar horizontally back to the posterior border well
above 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
 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-
tographs of the splitting itself (Fig. 7) [7]. The lat-
eral corticotomy could be varied. With these two
publications, we showed that the correction of
mandibular anomalies could be achieved transor-
ally alone. In the years to come, I and others would
continue to improve upon it.
For the sagittal splitting of the rami procedure,
the variation that followed was the placement of
the lateral corticotomy so as to increase the surface
area of the bony contact to improve union and
accommodate a wider range of advancement of
the distal segment (Fig. 8). The change was the
horizontal orientation of the lateral corticotomy
of the ramus to the vertical corticotomy of the man-
dibular body. The story would not be complete
without my relating how Dal Ponts contribution
came to be. In 1957, G. Dal Pont came to Zurich
as a trainee of Professor Schmuziger, who was our
chief, and he would assist both Schmuziger and
me with all cases. From watching, he conceived
the idea of changing the lateral corticotomy from
the horizontal ramus to the vertical body. We tried
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
in Zurich and returned to Italy, he never performed
the operation he published as his own in his clinical
practice. In addition to the buccal osteotomy being
performed vertically, Hunsuck and Epker years later
advocated that the osteotomy on the lingual side
should be incomplete, only just past the entrance
of the neurovascular bundle. This would result in
an incomplete fracture, along the medial aspect of
the 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 it
provides a longer area of bone contact, for the set-
back, the lateral segment is displaced because of
the cortical component on the lingual aspect.
When directed instead toward the ramal angle, the
splitting can be done more completely, allowing
better adaptation of the fragments with less risk to
the nerve.
Thus by the early 1960s, the sagittal splitting
technique became routine in my hands; however,
as so often happens, a patient arrives at the door-
step, and the routine must be modified. I had
a patient who had a severe open bite deformity.
Neither a mandibular procedure alone and nor
my routine sagittal splitting procedure would lend
itself easily to solve the occlusal problem that pre-
sented itself. I needed to rotate the mandible. It
occurred to me that through the sagittal split
approach, I could perform a transoral angle
osteotomy (Fig. 10). I first performed a posterior
maxillary osteotomy and brought the segment su-
periorly. I then removed the lateral cortical plate
from the ramus and placed it in a physiologic solu-
tion. I isolated and repositioned the nerve. This
then 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 lateral
cortical plate and fixed it to the lingual fragments
with wire fixation. I also simultaneously performed
a 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 own
parallel history. Up until the mid- to late 1950s, cor-
rection of retrogenia was achieved solely by onlay
techniques through a submental skin incision. Au-
togenous grafts (bone and cartilage) and alloplastic
implants (titanium, Silastic, and acrylic) were used
to create the chin prominence. The results of corti-
cal bone grafts, while initially pleasing, were tempo-
rary. Resorption was inevitable, followed by an
inevitable secondary procedure. Although alloplas-
tic materials had the advantage of ease of prefabri-
cated natural shape and permanence, they were
fraught with complications of infection, displace-
ment, and erosion of the bony symphysis into the
dental roots.
As with the sagittal splitting osteotomy, the need
was to develop a technique that could be accom-
plished entirely transorally, allow sufficient bony
contact for union, and maintain the advancement
with minimal resorption. The idea came to me by
chance when I had the occasion to see a young
lady who had a significantly retruded chin but an
acceptable occlusion (Fig. 11). As I traced the lateral
cephalogram, I realized that I could alter her chin
contour by simply sectioning it transversely and ad-
vancing it. By leaving it pedicled on the musculature
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-
gion would be altered favorably. I made my familiar
transoral incision as in fracture cases. I used a Linde-
mann bur to make an osteotomy of the symphysis
directing the osteotomy plane from low posteriorly
to high anteriorly. The last few millimeters of the
cut, 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 the
new position with a circum-mandibular Supramid
thread 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. The
operation was simple and went surprisingly well
with a satisfying outcome. I published this in
1957 [7]. Thus the transoral approach to correcting
chin deformities was born. The only other prior
publication of sliding the inferior border of the
chin forward was by Hofer in 1942. The approach
that was published was extraoral, and the astute
reader will note that Hofer performed the procedure
on 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 the
width and angulation, and with Neuner suggesting
a double-step advancement. In its essence, the
transoral procedure has remained for 50 years as
one of the simplest of technical procedures that
a surgeon can have in his rucksack to solve a wide
variety of chin deformities.
The LeFort I-type osteotomy
With the transoral techniques addressing mandibu-
lar deformities, numerous patients could be treated
more easily. There remained, however, a group of
patients whose primary deformity lay within the
midfacial structures: the maxilla and zygoma. In
these patients, although the mandible appeared
prognathic, the deficiency was clearly in the lack
of midfacial skeleton development, with only lim-
ited involvement of the mandible. Although a
transoral mandibular setback would achieve proper
occlusal relation, it would be at the expense of an
optimal aesthetic outcome. The necessary tech-
nique to be able to reliably reposition the maxilla
came long after the success of the sagittal splitting
osteotomy of the mandible. Thus many patients
whose occlusions were restored with the mandibu-
lar procedure were left with a flat appearance of
their face and the stigma of their underlying defor-
mity still apparent.
Why did it take so long? The problem was not
only surgically sectioning the maxilla safely, but re-
positioning it and maintaining it in the new posi-
tion. The surgical mobilization of the maxilla has
a long history, as Drommer recounted in 1986. It
started with as a means of gaining access to the
epipharynx and the skull base first reported by Lan-
genbeck in 1859 and by Cheever in 1867; the max-
illa was sectioned horizontally through facial
incisions. Only later was it sectioned for mobiliza-
tion to correct the occlusal deformities. In 1935,
Wassmund reported in his book that in 1927 he
had detached the maxilla as a Guerin-type fracture
without separating it from the pterygoid processes.
He then used elastics to close an open bite. Never-
theless, this was not a complete mobilization of
the maxilla. Axhausen published repeatedly in
1934, 1936, and 1939 successfully repositioning
of the maxilla in post-traumatic and cleft patients
using elastics after complete osteotomy of the max-
illa, including separation from the pterygoid pro-
cesses. It is hardly understandable that Axhausens
procedure did not become routine by mid-twenti-
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
a post-traumatic war case in which he detached the
maxilla and in a second operation the pterygoid
processes and then used weight traction for reposi-
tioning the dislocated maxilla. He stated pessimisti-
cally that this procedure would have a large
indication in cleft cases, but it would probably
never come into use. In 1951 and 1952, when I
was with Sir Harold Gillies, I watched him correct
the cleft deformity in numerous patients
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.)
characterized by retromaxillism with collapsed seg-
ments. He used horizontal vestibular incisions to
approach the maxilla, despite the palatal surgery
and concern for blood supply. But he only rotated
the collapsed cleft segments with a green-stick frac-
ture at the pterygoidmaxillary junction, as did
Schmid to correct the cross-bite, and I had never
seen him advance the maxilla. He fixed them in
the new position using cast cap splints fixed to

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-
lous bone grafts on the steps of the canine fossa
open to the maxillary sinus. The grafts were covered
on the vestibular side only. The sagittal discrepancy
he corrected by setting the mandible back. The pa-
tients retained their dish face or at best a flat
appearance.
Through the 1950s, I had not been satisfied fully
with my own approach. To correct deformities of
the maxilla, cleft or traumatic, I used vertical vestib-
ular incisions to maintain the blood supply.
Through these slit openings, I sectioned the maxilla
using a Lindemann bur to cut across the anterior
maxillary surface, a forked-type nasal septal osteo-
tome I had designed to separate the vomer and me-
dial maxillary walls, and a specially designed
slightly flexible osteotomes with round edges to ver-
tically separate the pterygoid plate. Previously I
would facture the pterygoid plate horizontally, but
I came to feel that the pull of the pterygoid muscu-
lature contributed to the relapse. I then would use
a Rowe disimpaction forceps. When it felt loose, I
would pull the maxilla with wires into occlusion.
After 4 weeks of intermaxillary fixation, there was
certain amount of inevitable relapse. I had felt
that the approach was acceptable as long as the re-
quired repositioning was within a limited extent.
Although maintaining blood supply, the vestibular
mucosal bridge did not permit a greater extent of
advancement, and the placement and fixation of
bone grafts in the steps of the canine fossae for
stability was difficult.
Thus even around the time of 1960, neither in
Europe nor in the United States, there did not exist
a reliable procedure for mobilizing the maxilla that
would allow the surgeon the freedom to fully cor-
rect the patients deformity without compromise.
Although Trauner and I in 1952 were aware of the
patient who presented with so-called prognathism
Orthognathic Surgery 343
and needed correction of the maxilla, our thoughts
were focused on the mandible. With the mandible
now solved, in 1960 I earnestly refocused my
thoughts toward the maxilla.
The solution came by chance. I was forced to
solve the midface problem in a case referred to
me by the Chief of Plastic Surgery at the University
Hospital. The patient was an 18-year-old man who
had suffered a car accident by driving into the back
of a lorry, 6 weeks before my consultation. He pre-
sented to me with the maxilla retrodisplaced in two
segments (palatal split) and telescoping into the
nose and maxillary sinus, resulting in a severe ante-
rior openbite and retromaxillism (Fig. 13). Addi-
tionally he lost three upper incisors, and the
vestibular mucosa was scarred circumferentially
with multiple oralnasal fistulae. Thus I could not
approach the maxilla through vertical vestibular in-
cisions as was my usual approach. Instead, I ex-
posed the maxilla by excising the circumferential
vestibular scar through the oralnasal fistula. As
the two halves of the maxilla now were healed ro-
tated medially and retrodisplaced into the maxillary
sinus, 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 I
raised 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, I
confirmed that the vascularity was not jeopardized.
Instead of the use of the Rowe disimpaction forceps,
which I felt would damage the remaining palatal
blood supply to the maxilla further, I simply
pressed firmly on the anterior maxilla. The maxilla
separated easily in what became known as the
down-fracture technique. To mobilize it forward, I
then used strong, slightly curved osteotomes to
pull it forward slowly. I then needed to surgically
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
establish the occlusion. Without the descending
palatine artery, the blood supply of the maxilla at
first was poor, but recovered after awhile. I used
wire fixation to secure the maxilla in place. I then
closed 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 can
be mobilized extensively and can receive an ade-
quate blood supply from the palate alone. This
case in 1964 is the first case of what was to become
the standard LeFort I-type osteotomy.
In the years to come, I succeeded in advancing the
maxilla in cleft patients, without the need to estab-
lish the occlusion with a mandibular setback as in
years past. The first case in which there was an ex-
treme discrepancy between the jaws was done on
April 14, 1968, in which the maxilla was advanced
15 mm on the side of the lesser segment and 13 mm
on the contralateral side (Fig. 14). Downfracture
was as before, but mobilization was extremely diffi-
cult until I opened the cleft, moved the segments
laterally, and felt the scar tissue. Now I could release
the scar. I got both segments absolutely loose; that
was the entire key to the success. Now I could ad-
vance as far forward as needed. The blood supply
remarkably was still satisfactory. I used blocks of
cancellous 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 open
to the maxillary sinus and nasal cavity. The postop-
erative course was uneventful, and the result both
in appearance and occlusion was far better than I
had achieved before. Adequate mobilization was
the key step in advancing the maxilla, whether cleft
or noncleft cases. With experience, I felt comfort-
able with advancements up to 20 mm. In the early
days, in nearly all cleft cases I reopened the cleft to
achieve the needed mobilization and occlusion and
then as a second stage closed the cleft once the oc-
clusion was stable. Subsequently, I learned that I
could in numerous cases close the cleft simulta-
neously with the advancement by moving the lesser
segment medially, and placing the canine in the lat-
eral incisor position. This solved the dental gap
problem, as in those days we did not have osseoin-
tegrated implants.
Birth of orthognathic surgery
By the late 1960s, I felt comfortable repositioning
the mandible and the maxilla. I had not done
them simultaneously, however. It was on Septem-
ber 5, 1969, that the first simultaneous sagittal split-
ting of the ramus and the LeFort I type osteotomy
was done (Fig. 15). Although I could establish the
occlusion with either procedure, when I hand
traced the cephalometric radiograph, I realized
that I needed to move the maxilla forward and

down along with setting the mandible back. Both
jaws had to be moved to improve the aesthetic
result. To find out how much I needed to move
each jaw, I hand traced what I considered was an
ideal profile on a transparent sheet over the existing
profile. This gave me a carpenters rough estimate. I
planned to make the final decision in the operating
room. The operation went smoothly. When both
jaws were completely free, I fixed them to each
other. I then repositioned the maxilla and mandible
as one unit according to my imagination, and when
I was satisfied with the aesthetic result, I completed
the fixation with wire and bone grafts. I kept the pa-
tient in 6 weeks of intermaxillary wire fixation. The
result both in terms of occlusion and appearance
was excellent. With this first case, orthognathic sur-
gery became a subspecialty in its own right. I pub-
lished this in 1970. As with the mandibular
procedures, modifications continued in the design
of the midfacial osteotomy, and in time internal
fixation with plates and screws became a reality.
Still, the essential component that the surgeon
had to execute remained: adequate mobilization.
Various combinations of mandibular and maxillary
procedures now could correct most maxillofacial
deformities (Fig. 16). Before what today many sur-
geons would consider mandibular distraction as the
only approach, we were able to use the long lateral
component (that is placing the vertical corticotomy
as close to the mental foramen as possible) or the
circular splitting of the mandible to correct the
most severe deformities (Fig. 17). What remained
was the cranioorbital region.
From maxillofacial to craniofacial
In 1967 at the International Plastic Surgery Con-
gress in Rome, Tessier presented the transcranial
and the subcranial LeFort III procedures to correct
the cranial and orbital deformities. With that,
craniomaxillofacial surgery became a reality.
The story now is well known. With Tessiers clear
demonstration, the cranioorbital deformities
could be corrected, and with my work, the maxil-
larymandibular deformities could be addressed.
Thus the patient presenting with a severe dish-face
deformity could be solved by combing a LeFort III
to address the orbital component and the LeFort I
simultaneously to address the occlusal relation
(Fig. 18).
In 1968, when Hans Luhr published his work on
plate and screw fixation, it revolutionized internal
fixation, limiting the need for extended intermaxil-
lary fixation and increased stability with less reli-
ance on complex interlocking joints and bone
grafts. And finally what could be accomplished
only by a rotary bur in my early days, improvements
Orthognathic Surgery 345
in instrumentation with thin saw blades allowed for
refined osteotomies.
Thus looking back, I was fortunate in many ways.
Fortunate to have began my career at a time when
so many maxillofacial problems remained un-
solved. I was fortunate to have had Trauner as my
teacher. Trauner taught to me to see problems and
find solutions. I was also equally fortunate to
have had Sir Harold Gillies and Eduard Schmid as
my teachers. Each taught me that it was not so
much knowledge of what came before, but the
imagination of solving problems as the patients
presented themselves. In the middle of difficulty
lies opportunity. The surgeon today can disassem-
ble each of the elements of the craniofacial skeleton
and then reassemble it. He only is limited by his
imagination to seek the solution. If I may end this
tale with the words of another:
Imagination is more important than knowledge.
For knowledge is limited to all we now know and
understand, while imagination embraces the entire
world, and all there ever will be to know and under-
stand. Albert Einstein.
Postscript
Although I have long since left the task to others, I
will describe for those interested how I preferred to
do the transoral procedures for many years with
appropriate instrumentation. I will begin by split-
ting the mandibular ramus.
Sagittal splitting of the mandibular ramus
Incision
The mandibular procedure should be able to be per-
formed with minimal bleeding. The operative field
is infiltrated generously with a vasoconstricting
agent. I prefer to start on the abnormal side if there
is one. I place a rubber mouth gag on the opposite
side to hold the mouth wide open. The incision is
placed in the mucosa laterally well away from the at-
tached gingiva of the first molar. It then is deepened
vertically through the periosteum between the buc-
cinator crest and the oblique line. Then it is extended
further superiorly along the external oblique line to
the base of the coronoid process. The periosteum is
elevated in the retromolar region and along the
anterior border of the ascending ramus, a few milli-
meters on either side of it. The inferior attachment of
the temporalis muscle is dissected off. Once the
anterior border is exposed, I place a ramus clamp
on the neck of the coronoid process.
Medial corticotomy
Next, I elevate the periosteum on the lingual side
between the lingula and the semilunar notch only
346 Obwegeser
 Orthognathic Surgery 347

as far back as to the concavity above the entrance of
the mandibular nerve into the foramen. A Freer is
used to palpate the semilunar notch. Then I use
an acrylic bur to start my lingual cortical cut. It
makes a broad defect in the wide anterior border.
This permits better visualization along the medial
aspect. Then I raise the rest of the periosteum all
the way back to the posterior border and around
it. Next, to keep the lingual soft tissues away and
to protect the mandibular nerve, I like the narrow
mandibular channel retractor, inserted and hooked
behind the posterior border. Under direct vision,
one now can elongate the lingual cortical cut all
the way back, including the posterior border.
As far as the cortical cut above the lingula is
concerned, I have given up using the Lindemann
bur, 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 I
want 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 mm
diameter (Fig. 19). Using this much broader diam-
eter bur, I deepen the medial cortex until I see
bleeding points from the cancellous bone all the
way back. Above the lingula, I want a rather broad
defect in the medial cortical plate of the ramus to
prevent overlapping of the distal fragment over
the inner cortical plate of the proximal fragment. I
generally prefer the splitting of the entire ramus
breadth. Otherwise the distal cancellous part of
the tooth bearing fragment will overlap the cortical
plate of the proximal fragment, pushing it laterally
when the mandible is retropositioned posteriorly.
This occurs when the lingual cortical cut is not
deep enough all the way back to the posterior bor-
der. An incomplete splitting will occur, just behind
the lingula, leaving at least one third of the ramus
breadth 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 the
mandible, although in these cases, the incomplete
splitting will not interfere with the advancement.
Lateral corticotomy
With this completed, I then elevate the periosteum
on the buccal side of the ramus where I want to place
my lateral cortical cut. I free it around the inferior
border 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 aspect
of the ramus to maintain blood supply and stabili-
zation of proximal segment. In a typical mandibular
setback or advancement procedure, I normally
direct the lateral corticotomy from the second
molar region toward the angle. I prefer this place-
ment in most instances as the nerve is more medially
located when compared with a lateral corticotomy
that is located in the body and as the sagittal split
can be more easily completely made through the
full breadth of the ramus. I will vary this lateral cut
according to each individual case, however. In a
case of micromandibulism such as a bird-face ap-
pearance, it will reach almost as far anterior as the
mental foramen, starting behind the second bicus-
pid. Here I use a slender rotating bone-cutting bur,
going only as deep as necessary to see bleeding
points from the cancellous bone. A 1.5 mm bur
will do this cut through the lateral cortical plate. It
should continue around the lower posterior border.
Sagittal corticotomy
The medial and the lateral bone cuts are then ready
to be connected. The sagittal corticotomy follows
the 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 rose
bur a series of holes through the cortex along the
lingual aspect of the anterior rim (see Fig 11F)
which then are connected by a bone cutting bur
or 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 ramus
I open the sagittal corticotomy by 2 to 3 mm with
a wedge osteotome first. Then I insert a bone separa-
tor, but only a few millimeters deep. Its fork-like
blades are flexible. With that instrument, the split-
ting is done very gradually in an incremental fash-
ion. The separation of the two cortical plates occurs
gradually until the two halves completely separate
along the full breadth of the ramus (see Fig. 17E).
If the ramus does not split easily, then frequently
a blow with a thin osteotome directed laterally
away 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 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
the case, then the nerve can be freed from the lateral
segment so as to remain with the distal tooth-bear-
ing segment and the osteotomy continued.
Repositioning
The separation between the medial and lateral
elements must be complete to allow independent
repositioning of the mandibular body from the
mandibular ramus. The mandible then is fixed in
the planned occlusion by using intermaxillary
wires. With mandibular setback, removing any re-
sidual cortex on the medial aspect of the lateral
ramal fragment may be necessary to fully adapt
the fragments without laterally displacing the prox-
imal fragment. This is achieved easily with the bone
separator in place providing a good view in between
the segments and protecting the nerve.
Osteosynthesis
Although the technique of splitting the ramus is
well-established today with essentially minor

Fig. 15 (continued)
variations based on surgeons preference, osteosyn-
thesis will continue to evolve from wire fixation
used when I first started more than a half a century
ago 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, my
preference has been placement of 1.5 mm diameter
screws that merely adapt the two fragments without
compression and displacement at the temporo-
mandibular joint. With the mandible fixed in the
desired occlusion, the condyle on the proximal ra-
mus fragment is manipulated into the glenoid fossa
and held with an adaptation clamp, or any other
suitable instrument in that position by the assistant.
I then place through a transbuccal approach three
1.2 mm pins to hold the two segments temporarily
in position until the screws can be placed. The pins
then are pulled out sequentially, one after the other,
using the holes in the cortical plates for screw
Orthognathic Surgery 349
placement. Once fixed into position, the contour
of the ascending ramus should be assessed. With
mandibular setback, it may become necessary to re-
duce anterior border of the proximal segment at the
retromolar junction to allow an appropriate space
and mucosal closure distal to the molar.
Closure
Before closing the wound with a continuous suture,
the operative field is rinsed again with an antibiotic
solution. I like to place a thin rubber drain within
the wound for overnight.
The osseous genioplasty
The procedure itself is as I had described it in 1957.
The exposure in the symphyseal region, however, is
kept as minimal as needed to accomplish the
osteotomy. This will maintain the vascularity of
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
hands since 1962.
Incision and exposure
Before the procedure, the epipharynx is packed with
gauze to protect nasotracheal tube at the time of the
osteotomy. The operative field is infiltrated with
a vasoconstricting agent. I then perform the vestib-
ular incision through the mucosa, at least 5 mm
above the attached gingiva from one zygomatic
crest to the other. This is done with a knife in a sin-
gle cut vertically to the alveolar process through the
periosteum. At the lateral extent, I direct the inci-
sion superiorly for some millimeters to achieve
enough access to the tuberosity area without tearing
it with the retractor. The maxilla and the inferior
part of the zygoma then is exposed easily. The in-
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
into the pterygoidmaxillary junction. If this is
not done carefully, then a rent in the periosteum
will occur, and Pichats fat pad will come through
the opening readily. This will plague the remainder
of 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 the
nose is raised on both sides along the entire length
of the hard palate and on the lateral walls of the
nasal cavities to the level of the inferior turbinates.
On the medial aspect along the nasal crest of the
palatine bones, elevating the mucoperiosteum
without tearing may present some difficulties.
Care must be taken to prevent this from happening,
especially when approaching the juncture of the
nasal crest of the palatine bones with the septum.
Maintaining an intact mucoperiosteum is even
more important when a deviated septum is being
corrected at the same time.
The LeFort I-type osteotomy
Next I make vertical marks with a fine bur on the
zygomatic crest and at the anterior region of the ca-
nine fossa. These reference marks will enable me to
measure 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 necessary
on the antral wall.
I still use the same horizontal osteotomy for sep-
arating the maxilla as I did at the beginning in the
1960s. However, sectioning of the maxillary walls
at that time was accomplished with burs and with
osteotomes. The osteotomy today is accomplished
more elegantly and more precisely using a thin re-
ciprocating saw blade with minimal loss of precious
bone and far cleaner without the fragments gener-
ated with an osteotome. Moreover, the osteotomy
design and execution with the reciprocating saw eas-
ily allows varying its angulation from the standard
LeFort I type pattern depending on the movement
desired. Once the maxillary walls are sectioned, I
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
osteotome as I did then. This is then followed by
separating the nasal septum from the hard palate us-
ing a guarded septal osteotome. To avoid the risk of
transecting the nasotracheal tube and protecting the
posterior pharyngeal wall, the epipharynx is packed
with gauze.
The mobilization of the maxilla
For many years I have ceased initiating the down
fracture at the anterior nasal region, and instead ini-
tiated it at the lateralposterior maxillaryzygomatic
buttress, following the suggestion of my nephew
Joachim Obwegeser, MD, DMD. I insert the bone
separator within the osteotomy at the zygomatic
crest and apply gentle pressure (Fig. 20). The maxilla
typically comes down easily. Otherwise any resis-
tance requires either an osteotome or reciprocating
saw with the spreader in place. Next the anterior
down-fracture is accomplished with the bone sepa-
rator inserted at the nasal aperture rim (medial
maxillarynasal buttress). This is the reverse of my
previous procedure and as others still describe.
Once the maxilla is down-fractured, it must be
mobilized fully. To advance the maxilla, I routinely
use the so-called maxillary mobilizer type elevator I
had 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 is
designed as a curved blade inserted behind the
tuberosity. The advancement then is achieved grad-
ually, millimeter by millimeter. After one side is
done, the next is dealt with in the same way. This
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
maxilla 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 can
be accomplished without the necessity of this in-
strumentation, it is particularly useful in cleft cases
where there is significant resistance against the
complete mobilization because of soft-tissue cica-
tricial scar formation. A surgeons finger can iden-
tify easily where the knife or the scissors needs to
sever still-resisting scars. It is better to cut them
than to pull so hard with the maxillary advancer
or any other instrumentation. Scars do not include
large 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 cleft
maxilla. Although in some circumstances this may
be appropriate, it should be remembered that
most cleft patients can be treated appropriately
and more efficiently, even when requiring signifi-
cant advancement with the classic LeFort I-type pro-
cedure as described.
Bone grafting
In cases in which I had advanced the maxilla by at
least 8 to 10 mm or more, I would use autogenous
bone grafts. These include a block of cancellous
bone wedged into the gap behind the tuberosity
and several blocks to bridge the steps in the canine
fossae.
Closing the alveolar gap
In unilateral and in bilateral cleft cases, the dental
gap 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. The
canine then subsequently is contoured to match
the appearance of a lateral incisor. The segmental
advancement decreases the orthodontic treatment
time of the staged bone graft, followed by either or-
thodontic movement of the canine or placement of
a dental implant.
Osteosynthesis
As with many other procedures, wire fixation is re-
placed by titanium plates and with the promise of
resorbable fixation in the future. I place the plates
at the medial nasal piriform buttress and at the
zygomaticmaxillary buttress, but prefer fixation
as semirigid to allow postoperative guidance of
the occlusion with dental elastics when the patient
is actively functioning. In my experience, there is
approximately 0.5 to 1.5 mm difference between
the surgeons positioning intraoperatively when

the patient is under general anesthesia compared
with active functioning as they resume oral
function.
Closure
Before closing the wound with a continuous suture,
the operative fields including the maxillary sinuses
are rinsed with an antibiotic solution.
Surgical instruments
As with any other craft, tools are important to the
surgeon. Operative procedures are most efficiently
done when the instruments are fewer in number,
can be used to accomplish multiple tasks, and
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
of the trade. Every craftsman knows the importance
of the quality of good tools and maintaining them.
Many instrument makers have provided instru-
ments named after the surgeon who developed
them; however, few manufacturers will have their
quality checked and repeatedly checked by the
surgeon whose instrument that bears his name.
This is true with my own instruments. Many com-
panies will produce Obwegeser instruments, but
few have the right to engrave Original Obwegeser,
as KLS-Martin (Jacksonville, United States) and
Medicon (Tuttligen, Germany). My experience
with many so-called Obwegeser instruments of
other companies is disappointing. Since my early
days, appropriately designed powered hand pieces
have made a significant difference in the ease of
executing the osteotomies. The hand pieces ideally
should be lightweight, slender, and not obscure
the already limited field of view of the surgeon.
My preference is manufactured by W&H Dental-
werk Burmoos GmbH, Austria, 5111 Burmoos. The
surgeon in training should know his or her instru-
ments, how they are used, and be familiar with their
quality.
Thus, now looking back across half a century, I al-
most envy those who are able to learn today with
modern instruments, techniques, and reliance on
experience gained by those who came before. Few
procedures can alter the human face so fundamen-
tally as these three procedures. I hope that these
words will continue to inspire the generations of
surgeons to follow.
Acknowledgments
I wish to express my very sincere thanks to Dr. Pra-
vin K. Patel for his generous editorial assistance in
translating my original manuscript into the form
in which it appears.
Orthognathic Surgery 355
Further readings
Obwegeser HL. Die Kinnvergrosserung. Oesterr Z
Stomal 1958;55:53541.
Obwegeser HL. Cirugia del mordex apertus. Re Asoc
Dodont Argent 1962;50:43041.
Obwegeser HL. Operative Behandlung der zahnlosen
Progenia ohne intermaxillare Fixation. Schweiz
Monatschr Zahnhlkd 1968;78:41625.
Obwegeser HL. Surgical corrections of small or retro-
displaced maxillae. Plast Reconstr Surg 1969;43:
35265.
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 and
jaws. St. Louis (MO): The C.V. Mosby Co.; 1914.
[2] Kostecka F. Die chirurgische therapie ider pro-
ggeni. Zahnaertzl. Rundsch 1931;40:669.
[3] Perthes G. Operative Korrektur der Progenia.
Zentralbl Chir 1922;49:15401.
[4] Perthes G. Uber Frakturen und Luxationsfraktu-
ren des Kieferkopfchens und Ihre operative
Behandlung. Arch Klin Chir 1924;133:41833.
[5] Kazanjian VH. The treatment of mandibular
prognathism with special reference to edentu-
lous patients. J Oral Surg Oral Med Oral Pathol
1951;4:6808.
[6] Trauner R, Obwegeser H. Zur Operationstechnik
bei der Progenia und anderen Unterkieferano-
malien. Dtsch Zahn Mund Kieferhlkd 1955;23:
1125.
[7] Obwegeser HL. Surgical procedures to correct
manidbular 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.
[8] Dal Pont G. Losteotomia retromolare per la
correzione della progenia. Minerva Chir 1959;
14:113841.
[9] Dal Pont G. Retromolar osteotomy for the cor-
rection of prognathism. J Oral Surg 1961;19:
427.
[10] Hunsuck EE. A modified intraoral sagittal split-
ting technique for correction of mandibular
prognathism. J Oral Surg Anaesth 1968;2:
24952.
[11] Epker BN. Modifications in the sagittal osteoto-
my of the mandible. J Oral Surg 1977;35:1579.
[12] Obwegeser HL. Der offene Biss in chirurgischer
Sicht. Schweiz Monatschr Zahnhlkd 1964;74:
66887.
[13] Hofer O. Operation del Prognathie und Microge-
nie. Dtsch Zahn Mund Kleferhlkd 1942;9:
12132.