Pioneer steps in correcting secondary cleft lip and palate deformities: My philosophy and procedures

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Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 1023e1047

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Pioneer steps in correcting secondary cleft lip and palate deformities:My philosophy and procedures

Hugo L. Obwegeser*

Zürich, Switzerland

Fig. 1. My teachers: Prof. Hermann von Chiari, Chief of the Institute for Pathology andMicrobiology of the University of Vienna, Austria, 1945. Prof. Richard Trauner, Chief ofDentistry and Maxillofacial Surgery. University of Graz, Austria, 1949. Prof. EduardSchmid, Chief of the Dept. für Gesichtschirurgie, Marien hospital Stuttgart, Germany,1952. Sir Harold Gillies, International Founder of Plastic and Reconstructive Surgery,Basingstoke, England, 1951. Mr. Norman Rowe, Chief Dept. of Oral Surgery, Basingstoke,

1. Introduction

In September 2012 my nephew, Professor Joachim Obwegeser,organized an international meeting on the correction of secondarycleft deformities at my former Department of Cranio-maxillofacialSurgery at the University Hospital, Zürich. He had kindly invitedme to deliver an introductionary paper on the subject as I have beenthe first to report new possibilities on that subject at an interna-tional meeting in 1969. As the audiencewas very enthusiastic aboutmy lecture and had expressed the suggestion to publish the lecturein full length, I decided to do so.

First of all I want to mention my intention to present what Ihave done for these poor cleft patients to make them free fromtheir disfigurement. What I am going to demonstrate is old stuff,because of my high age (93 years). Nevertheless it was a veryimportant invention to our specialty and I am reporting on itwith some pride.

At the “First International Conference on Cleft Lip and Palate”from 14e17 April 1969 at Houston/Texas, I had the opportunity topresent for the first time to an international audience my philos-ophy and techniques in my paper “Surgical Correction of De-formities of the Jaws in Adult Cleft-Cases”. Plastic surgeons andorthodontists have been the major part of the audience. It was newfor all of them. My presentation was rather revolutionary at thosedays and was accepted with astonishment and enthusiasm by themajority of the audience.

After that presentation Dr. Samuel Perkowitz, the chief ortho-dontist at the famous Ralf Millard Cleft Centre in Miami, has askedme to record my philosophy and procedures in the correction ofsecondary cleft deformities, so that these facts should be stored inthe national library and will not be forgotten. I have done this in theform of a DVD.

As a prerequisite for the correction of secondary cleft de-formities it is essential that the surgeon is familiar with all aspectsof the repair of primary clefts. In addition the surgeon must also bevery experienced in the field of orthognathic surgery. As a pupil ofRichard Trauner I was well trained in all aspects of primary cleftwork and I had already acquired all the experience needed in

* Zürich, Switzerland. Tel.: þ41 44 825 32 93; fax: þ41 44 887 18 35.

http://dx.doi.org/10.1016/j.jcms.2014.08.0031010-5182/© 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by

orthognathic surgery, mainly due to my own development of thenecessary surgical procedures.

In this publication I will use the same cases which I presented atthat meeting at Houston in 1969 and I will add a few special caseswhich I feel necessary for teaching purposes. Finally I will end mypublication with some important conclusions which I have drawnfrom my extensive experience with this subject.

First of all, I want to pay my high respect and gratitude to myteachers (Fig. 1). Without them I would not have become able toproduce ideas for procedures to correct the often very severe facialdisfigurement of cleft patients. I also want to thank my former co-workers and staff. They have also been a part of my activity. Andmyspecial gratitude I owe my nephew Joachim Obwegeser, as without

England, 1951 and Paul Tessier, Chief Dept. Plastic Surgery, Military Hospital, Paris,1954, have been good friends of mine. We exchanged knowledge and experience andlearned from each other.

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Fig. 2. Unilateral short lip after primary lip closure according to the Veau technique.Reoperation by Ralf Millards technique has produced a symmetrical lip.

Fig. 3. Typical whistling defect deformity of the upper lip after primary closure ofbilateral CLP. Good correction after insertion of a mucosal flap from the inferior pro-truding lip.

H.L. Obwegeser / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 1023e10471024

his help I could not transfer the illustrations into the computer fordigital handling for a publication like this.

2. My professional background

After my publication of the sagittal splitting technique I wasfrequently invited for lecturing in the USA. Many young colleaguesaskedme formyexplanation that I have been able to produce severalnew ideas in our specialty. They expressed their opinion that I musthave no time left for hobbies because of my professional engage-ment. I told them that without time for hobbies I would not be soproductive. I would not imagine only working all day and every daywithout interruption. I told them that enjoy five hobbies. Theydepend of the seasons of the year and my age. In wintertime andspring I amskiing. I likedskiing in thebeautifulmountainsofwesternAustria that ismyhomearea. In fall I enjoyedhunting for reddearandchamois. Fromspring till fall Iwasa enthusiastic riverfisherman.Andall year I was fond of antiquity exhibitions. My fifth hobby e I musthave forgotten it e it was a hobby all young man enjoy.

All I know inmy profession I owemy teachers. No doubt, it is myprofessional background that let me produce new ideas. I alwaystold them the more pre-specialization in nearby field a person hasthe morewill he have his mind open for recognizing a real problemin his final specialty and also the solution for it. One of my manyprinciple says: It is not difficult to find a solution to a problem, it isonly difficult to identify the problem.

My professional background is as follows: M.D. degree in April1945 at the University of Innsbruck, Austria, at my age of 24 and ahalf. I had my training in general surgery each six months duringmy military services and after the war in a general hospital in mynative town. Following this I had the privilege to train for two yearswith Professor Herman von Chiari at his Viennese Institute forPathology and Microbiology. After that I trained six years inDentistry and Maxillofacial Surgery with my main teacher RichardTrauner at the Maxillofacial Unite of the Dental School of the Uni-versity of Graz. During these six years I passed my Dental Examineand spent each six months in the various sections of the dentalschool, a very valuable training in retrospect. After these six years Ispent five months each in Plastic and Reconstructive Surgery withSir Harold Gillies at Basingstoke, England and later with EduardSchmid in Stuttgart. Norman Rowe and Paul Tessier were very goodfriends and colleagues of mine, and we learned from each other. AllI know I owe my teachers.

3. What is the subject?

In secondary cleft deformities we have to distinguish betweendeformities of the soft tissues including the nose and deformities ofthe facial skeleton.

4. Soft tissue deformities

Soft tissue deformities may either involve the lips or the palatalcovering or even the soft palate. Shortness of the upper lip is quitecommon in unilateral as well in bilateral cleft lip cases, often foundas a result of the primary closure in the area of the former cleft. Inbilateral cleft cases we often find awhistling deformity of the upperlip and an ectropion of the lower lip. In both cases of clefts, in uni-lateral as well as bilateral, we find typical deformities of the nose.

4.1. Fig. 2: Shortness of the upper lip

It is often observed in unilateral cleft cases after primary cleft lipclosure by the Veau-technique Reoperation of the lip using theMillard procedure produces in my experience very satisfying

results. Both sides become equal in height as seen in the illustrationof my case.

4.2. Fig. 3: Whistling deformity of the upper lip

In bilateral cleft lip cases a whistling deformity of the upper lipmay result. For the repair of a pronounced deformity I like to use aflap of the mucosa of the lower lip, in particular when simulta-neously an ectropion of the inferior lip exists. The illustrationpresents a typical whistling defect of the upper lip and a slightectropion of the lower lip and its repair by the insertion of amucosal flap from the lower lip. I have learned this from EduardSchmid.

4.3. Deformities of the nose

Every cleft lip and palate case is accompanied by a typical nasaldeformity. The deformity of the nose in unilateral cases is muchmore difficult to correct than the correction of the nose in a bilateralcase. In adult cases it is more easily done together with the Le Fort-I

H.L. Obwegeser / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 1023e1047 1025

advancement than as a separate operation. When the maxilla iscompletely mobilized there is open access to the floor of the nose,the septum, the turbinates and the floor of the nose. A deviatedseptum and a deformed naso-palatine crest and also a hyperplasticturbinate are easily corrected. Also in this problem following SirHarold Gillies principle “Replace into normal position what isnormal and retain it there” brings perfect results. For the elongationof a too short a columella in a bilateral cleft case Ralf Millards forkflap procedure brought excellent results in my hands.

I disclaim describing all details of nose correction here, as theydo not differ very much from ordinary nasal corrections.

4.4. Fig. 4a,b: It is a case with a extremely wide primary cleft of thepalate

In a non-operated case the cleft in the hard palate can be thatlarge that its closure may produce a real problem for not veryexperienced surgeons. Illustration Fig. 4a shows the widest cleft ofthe hard and soft palate I have ever seen in an adult, non-operatedupon before. After measuring the width of the cleft and that of thetwo palatal artery flaps I repaired it according to the Veau-technique, additionally with simultaneous reconstruction of themissing hard palate by the insertion of decorticated flattenedpieces of a split rip. Some of the stitches of the nasal layer are leftlong and pulled through the bony reconstruction and the united

Fig. 4. a,b: The widest cleft palate I have ever seen in a non-operated palate situationin adult patient. Three layer closure by reconstructing the hard palate with decorti-cated pieces of split ribs. The stitches of the nasal layer were pulled through the piecesof bone and also the oral mucosal layer, thusly avoiding empty spaces and haemato-mas. b: Perfect result of hard and soft palate after reconstruction.

palatal artery flaps. Using these stitches, the nasal as well as the oralmucosal flabs are adapted to the inserted pieces of bone, therebyavoiding empty spaces and a haematoma. Fig 4b shows that even insuch extremely wide clefts a perfect result can be achieved for thesoft as well as the hard palate, when using perfect surgicaltechniques.

4.5. Fig. 5: Secondary defects of the hard palate

Secondary defects of the hard palate include automatically itscovering palatal mucosa and its part of the nasal layer. In recon-structing any defect of the hard palate it is a must to mobilize thenasal mucosa rather radically and also that of the nasal septum oreven of the vomer. Safe results will definitely be achieved when notonly the soft tissues are united but also the missing bone of thehard palate is reconstructed.

Fig. 5 shows a large unilateral defect of the hard palate and thetechnique and the result of its repair. This awkward large defectwas closed by mobilization and sewing up of the usual nasal layers.Some of the stitches are left long and pulled through burr holes ofan inserted bone graft and a covering oral layer. That was build byrotation of the intact palatal artery flap from the other side over thedefect plus a wide flap from the vestibular mucosa. The long leftstitches from the nasal layer have been gently knotted for adapta-tion of the nasal and oral covering onto the bone graft for avoidanceof an empty space and haematoma. In addition, a vaseline gauze,hold in place by a plate, covered the free part of the bone graft andof the hard palate till granulation tissues, growing out of the bones,created the necessary prerequisites for self-epithelialization.

Fig. 5. Disgusting unilateral defect of the hard palate. Three layer reconstructioncreated a good result.

4.6. Fig. 6aec: Nothing but wholes and scars on the hard palate

If such a situation is found thenwe know an insufficient surgeonhas produced it by several attempts to close the palate. In such asituation tissues from a distance must be brought into the defect. In1963 I used a tubed pedicle flap raised from the chest and thenattached to the reopened lip. The skin flap was then attached to thepharyngeal wall and to the edges of the defect in the soft and thehard palate, as can be seen at the illustration of Fig. 6a on thebottom on the left side. In the next operation (Fig. 6b) the tube wasdefatted and a cancellous bone graft was inserted for the recon-struction of the missing hard palate and an additional one also forbuilding the alveolar process. After some weeks the skin must be


completely thinned or replaced by a skin graft. Now, the situation isready for proper prosthodontic work as can be seen on the bottomof the right side of the illustration.

Fig. 6c shows the reopened lip and the situation after it has beenclosed again, using Millard's technique. Normal function andnormal appearance resulted.

Fig. 6. aec: a: Nothing but holes and scars in the hard palate. Reconstruction of thedefect by insertion of a tube pedicle and bone grafts for the hard palate and thealveolus. b: Perfect result was achieved. C: The reopened lip was closed by the RalfMillard technique.

5. Jaws only

In most cases of secondary cleft deformities the deformity andretrodisplacement of the maxilla is the main problem. Before wewere able to advance the maxilla the mandible only was retro-positioned for the correction of a mandibular-maxillary discrep-ancy, mostly using my sagittal splitting technique (Fig. 7), some-times achieving an acceptable result (Fig. 8aec), mostly someimprovement only (Fig. 9aeb). However, the main problem is themaxilla, its retro-position, its small seize (micro- and retro-maxillism) and the malposition of its segments. The patientshown in Fig. 8a has almost a circular nonocclusion, in addition anopen bite and a missing second incisor. She also suffers from aprognathic appearance. According to the model planning, by retro-positioning of the mandible an acceptable intermaxillary relation-ship should be achievable and also the outer appearance wouldimprove (Fig. 8c). As at those days I was not able to reposition themaxilla anteriorly I decided to usemy sagittal splitting procedure ofthe ramus for the best I could do. In addition the department ofcrown and bridge work would also be able to help to improve theocclusal picture (Fig. 8b). Movement of parts or of a whole jawshould never be executed without prior accurate model andsplinting planning.

6. Mobilization of the maxilla

Many have tried to mobilize the maxilla for the correction of itsretroposition. Axhausen published in 1934, 1936, 1939 that hecorrected the retro-displacedmaxilla in post-traumatic as well as incleft cases. However, his technique has never become popular. K.Schuchardt published in 1942 awar case inwhich he had pulled themaxilla forward by weight traction. He stated that that procedurewould have awide indication in corrective cleft surgery, but for thatpurpose it will probably never come into use, he wrote.

J.M. Converse and H. Shapiro in 1952, and also I. Cupar in 1954(Fig. 10) have suggested a circular vestibular incision for theosteotomy of the anterior surface of the maxilla plus, after raisingthe palatal flaps, a transpalatal osteotomy for its mobilization. Inmyopinion this will result with complete necrosis of the maxilla. Somevisitors confirmed that I am right.

H.D. Gillies tried hard to improve the cleft patients appearanceby lateral rotation of the maxillary segments. Together with N.

Fig. 7. Drawing of my sagittal splitting procedure of the mandibular rami.

Fig. 8. aec: a: A typical open bite situation in a 19 year old female after primaryclosure of a unilateral CLP. b: Occlusal situation after mandibular set back and closureof the open bite by the sagittal splitting procedure of the mandible and some crownand bridge work. c: Patients appearance before and after correction: It is an acceptableimprovement although the flat face is not corrected.

Fig. 9. a,b. a: In lateral skull radiographs a severe dish face deformity after closure of anunilateral CLP in childhood and after repositioning of the mandible only. b: The resultwere much better when the maxilla had also been advanced.


Rowe he published in 1954 what he had achieved. During mytraining with him in 1951e52 I had the privilege to assist himseveral times. He reopened the cleft and rotated both halveslaterally and fixed themwith a cap splint in the planned position tofind occlusion with the mandibular teeth. However, he neveradvanced the segments anteriorly. But he did the first importantstep for the final success for the Le Fort I emobilization, by placingcancellous bone grafts onto the steps in the canine fossae. In spitethe fact that he could not cover the graft completely with mucosaon its side to the maxillary sinus and nasal cavity, the bone graftshealed in perfectly. This fact was the key for me to successfuladvancing the maxilla in cleft cases up to 20 mm and also more.

Another important step was the separation of the maxilla fromthe pterygoid processes and filling the gap between the tuberosityand the pterygoid process with bone grafts after the maxilla hasbeen advanced. That was suggested by myself (Obwegeser 1962,1964, 1965 and in 2001). Fig. 11 shows that I secured the neces-sary blood supply by undermining the vestibular mucosa andperforming the osteotomy via three vertical incisions.

Many authors reported some or total relapse after maxillaryadvancement. For achieving stable results the maxilla must be thatloose that it can be overcorrected with a pair of tweezers only andthat its stability is guaranteed by filling the gaps of bone with bone

Fig. 10. In drawings the ConverseeCupar procedure for advancing the maxilla. I wonder from where the blood supply will be secured. I have never tried it, however, some visitorshave informed me that they experienced necrosis.


grafts. If that is carried out properly, then the maxilla has fewertendencies to a relapse than themandible has after its repositioningwith the sagittal splitting technique.

R. Drommer has reported in 1979 that the maxilla will evensurvive after a circular vestibular incision and ligation of the pala-tine artery when the palatal covering has not been mutilated. Healso published an excellent paper in 1986 on the history of the LeFort I e osteotomy.

Fig. 11. Drawing of H Obwegeser's technique to mobilize the maxilla through verticalincisions in the undermined vestibular mucosa (1962).

6.1. Fig. 12a,b: It is a case of inferior position and rotation of thepremaxilla and slight collapse of both lateral segments

Illustration Fig. 12a shows the occlusal situation in this case ofinferior position and rotation of the premaxilla and slight collapseof both lateral alveolar segments with bilateral palatal fistulas in abilateral CLP-case before surgery (operated upon in 1961e62). In afirst step the cleft palate was reopened through the fistulas and thelateral segments were osteotomized via a vestibular approach androtated laterally. The segments were then repositioned as plannedon the model operation and stabilized with a wire splint. In asecond step after three months the malpositioned premaxilla wasosteotomized from its palatal aspect at its bony strut via an incisionon its palatal covering muco-periosteum. The reopened cleft wasclosed and the three segments were stabilized by bone grafts whichwere covered with nasal and oral mucosal flaps. Fig. 12b shows thevery acceptable occlusion that has been achieved and the bonegrafts in the alveolar clefts. In Fig. 12c the pre- and post-operativeocclusion is shown and also the prosthodontic reconstruction.

6.2. Fig. 13a,b: It is a case with collapse of both segments in anunilateral CLP-case

The photo demonstrates the collapse of both, the small and thelarge segment, in an unilateral CLP-case (operated upon in1965e66) and its correction according to the model-operation andthe result of our efforts. This case is a typical sample of a verydeformed maxilla in an unilateral cleft lip and palate case. Illus-tration Fig. 13b demonstrates the situation of the bone grafts withthe perforating stitches of the closed nasal layer. The alveolarprocess required a separate piece of bone. The picture on the bot-tom of the right side shows the final result of the formerly collapsed

Fig. 12. a,b: A bilateral CLP deformity is corrected via the undermined vestibularmucosa. a): In a first intervention the two lateral segments are repositioned. Threemonths later the premaxilla was repositioned and the palatal cleft was closed in threelayers. Simultaneously bone grafts secured the position of all three segments. b) Theresult was very pleasing.

Fig. 13. a,b: A typical unilateral CLP- deformity with severe collapse of both segments.a): The model operation informed us what we can achieve and the drawings tell howwe close the defect. b): The pictures taken during the operation show the bone graftsfor the reconstruction of the hard palate and the alveolus and also the final result.


maxilla. It is now a normal upper arch with a good condition forfinal prosthodontic work. That was achieved by a removable bridgereconstruction with the Dolder bar system, performed by theProsthodontic Department of our Dental School.

6.3. Fig. 14aec: A collapse of all three segments in a bilateral CLP-case

Fig. 14a shows the collapse of all three segments in a bilateralcleft and the steps in the reconstruction (operated upon in1966e67). This situation is very typical for a bilateral cleft jawdeformity, as seen on the upper left picture. The model operationshows that by repositioning of all three segments with simulta-neous reopening of the cleft good prerequisites for the final pros-thodontic work can be achieved. In a first operation reopening ofthe cleft with lateral rotation of both lateral segments was done asseen on the bottom on the left side of this illustration. The nextpicture (Fig. 14b) demonstrates by drawings the second operation:osteotomy and repositioning of the premaxilla and three layerclosing with bone grafting. It also demonstrates the radiographicsituation before, during and after the reconstruction and Fig. 14cshows the final palatal and occlusal situation. The prosthodontic

work was done by the department for crown and bridge work atour Dental school.

7. H. Pichler's law

It says: “In facial reconstructive surgery first the bone, then thesoft tissues”. This principle requests that the maxilla and themandible must be completely free for repositioning the threesegments wherever wanted. A posttraumatic case caused me tofind the solution for that problem.

That posttraumatic case (Fig. 15a,b) caused me to use a circularvestibular incision for cutting the lateral aspects of the maxilla. Inthat case the trauma has split the maxilla in two halves. They havebeen telescoped into the maxillary sinuses, with a medial palatalsplit and loss of three front teeth (see Fig. 15a on the left side of thetop). There was a scar running around almost the whole vestib-ulum, as shown on the right side of the top. That included severaloro-nasal and oro-sinus fistulas. I had no other chance but to cutcarefully in the vestibular scar, step by step checking the circulationon the palatal mucosa. As the palatal mucosa proofed to remainwell vascularized, the circular vestibular incision became to meroutine for cutting the anterior maxillary wall. When I trained withSir Harold Gillies and Mr. Norman Rowe then I had seen that they

Fig. 14. aec: A case of a bilateral CLP with very severe deformity of the palate. a): Allthree segments are compressed. The plan of treatment the same again: in a firstintervention the lateral segments are repositioned. b): In a second operation thepremaxilla is repositioned and the palate is closed in three layers as shown in thedrawings. Bone grafts stabilize the segments in their new position. c) In spite the se-vere deformity the final result after additional bridge work is very satisfying.


cut the compressed maxillary segments through a vestibular inci-sion and rotated them laterally. But they did not reposition themanteriorly.

Fig. 15a: It shows on the top on the left side the preoperativesevere open bite, but no occlusion, on the bottom the modeloperation. It tells that the maxilla has to come forward for 9 mmand in the front region downwards for 15 mm. In the same illus-tration the mobilized maxilla is seen.

Fig. 15b: shows the occlusion, before and after prosthodonticreplacement of the missing three incisor teeth. In the radiographsthe skeletal situation, before and after replacement of the segmentsis seen. This case taught me that a circular incision in the vestib-ulum is not doing any harm to the blood supply of the maxilla.Because of this experience resulted my final procedure for themobilization of the maxilla (Fig 16).

7.1. Fig. 17aed: A unilateral CLP-case with severe retromaxillismand collapse of both alveolar segments

This was the first CLP-case in which I could reposition intonormal what was still normal (one of Sir Harold Gillies mainprinciples). It was the first case of severe retromaxillism in anunilateral CLP-case, that gained from the fact that I now couldmobilize the whole maxilla and reposition the segments into theplanned new position (operated upon in 1968): Fig. 17a shows thepatients profile and his lateral cephalograms and Fig.17b the typicalclass III occlusion of such cases. Both, the patient's profile appear-ance as well as its skeletal background are very typical for theconsequences of radical primary surgery of a unilateral cleft lip andpalate situation. Themodel planning (Fig. 17b) suggested reopeningof the cleft and advancing the maxillary segments and narrowingthe two sections of the maxilla. Because of the large amount ofadvancement of the two segments of the maxilla (up to 18 mm)bone grafting at the steps in the canine fossae and between thetuberosities and the pterygoid processes became necessary asshown in the drawing of the planned surgery. In Fig. 17c the lateralpre- and post-operative cephalograms demonstrate the result ofthe advancement of the maxilla. The large bone block behind thetuberosity (20 mm) is easily recognizable on the right side cepha-lograms. The new position of the maxillary segments permitted asatisfying prosthodontic restoration as can be seen on the occlusalphotograph.

The next illustration (Fig. 17d) presents the aesthetic improve-ment of the patients profile view through this corrective surgery,performed on the maxilla only. There was no other additional nasalcorrection done. The nasal hump was automatically corrected bythe advancement of the maxilla.

7.2. Fig. 18aeg demonstrates the circular nonocclusion and severeretromaxillism and ectropion of the lower lip in a case of unilateralCLP

This case shows a typical occlusal and profile appearance of abilateral cleft lip and unilateral alveolus and palate with severeretro- and micro-maxillism with circular nonocclusion and ectro-pion of the lower lip. The patient had orthodontic treatment frombabyhood till adolescence, when the orthodontist was not anylonger able to prevent the mandible to overgrow the maxilla. It is ainteresting case of complex planning and treatment problems(operated upon in 1970).

Fig. 18a shows the profile view of the 17 years old girl and theskeletal cause of it while the illustration Fig. 18b shows the circularnonocclusion and the model planning for its correction. Accordingto profile planning andmodel operation themaxilla must bemovedanteriorly, in two segments for occlusal reasons, and the anterior

Fig. 15. a,b: A posttraumatic case was referred to me almost two months after the accident: a)The maxilla was split in two halves, compressed and telescoped into the nasal andsinus cavities. Three incisor teeth have been lost. In the vestibulum a circular scar was running all the way around. There were fistulas into the nose as well as into the maxillarysinuses. Because of that situation undermining the vestibular mucosa was impossible. I had to cut in the scar all he way around, but step by step carefully checking the blood supplyof the palatal mucosa. The result was my first circular incision for proper access to the maxilla. It was the all decisive case for the final Le Fort I osteotomy for mobilisation of themaxilla. b): The result was perfect after dental bridge work.

Fig. 16. This drawing shows my final Le Fort I-osteotomy. The maxilla is completelydetached from the surrounding skeleton. That includes separating the tuberosity fromthe pterygoid processes. All defects of bone must be filled with bone grafts.

Fig. 17. aed: A case of typical facial deformation after repair of a unilateral CLP. a): There itypical. The model operation tells that the maxilla must be advanced in two pieces. Bone grafalso the huge bone block in the space between tuber maxillae and pterygoid process. Afterprofile of the patient shows that also the nasal hump was corrected without touching the


alveolar segment of the mandible must be repositioned afterextraction of the first bicuspid on each side, for correction of theectropion of the lower lip.

In illustration Fig. 18c the planned operation is shown indrawings. Bone grafts will have to be placed at the steps in thecanine fossae as well as between the tuberosities and the pterygoidprocesses. At the beginning of our maxillary advancement we didthis almost routinely. For small steps we used deep frozen bankbone. For steps from 10 mm and more we used autologous bonegrafts, as we had experienced pseudarthrosis of the maxillabecause of non-union when we had used bank bone or none. Withthis operation a very acceptable intermaxillary relationship wasachieved as seen on the right side of Fig. 18c. The nextFigure (Fig. 18d) shows that an almost normal alveolar arch hasbeen created, a good prerequisite for the orthodontist (Prof. PaulSt€ockli) to create a nice occlusion and appearance in an unilateralCLP-case. Fig. 18e shows the occlusion before and after surgery andafter orthodontic treatment. Without touching the nose or thelower lip, just by moving the skeletal framework into normal po-sition, a very good profile was achieved as seen on the cephalo-metric radiographs and on the photographs taken before andeighteen months after surgery (Fig. 18f,g).

s pronounced retromaxillism and a typical humpy nose. b): The occlusion is also veryting is unavoidable. c): The lateral radiographs show the difference before and after andreplacement of the missing incisor the occlusion looks perfect. d): The postoperativenose at all.

Fig. 18. aeg: A 17 year old female was referred to me as the orthodontist who had taken care of her since babyhood, could not prevent the mandible of forward growth. a): I found asevere retromaxillism and a slight humpy nose. The lateral cephalograms demonstrates the skeletal cause. b): There is circular nonocclusion and the model operation tells that themaxilla must come forward in two pieces for 5 mm. Simultaneously the inferior mandibular alveolus must be retropositioned, the best procedure to correct the ectropion of thelower lip. c): The drawings showwhat wewill have to do and the occlusal picture demonstrates the result. d, e): These two pictures show the maxillary arch before and after surgeryand after final orthodontic .treatment. f, g): Show in cephalograms and in profile the change through this surgery.


Fig. 19a,b: It is a case of a unilateral CLP with a gap in themaxillary dental arch because of a missing second incisor and amoderate retromaxillism. The plan was to correct the slight retro-maxillism and to close the gap of the missing incisor by advancingthe two alveolar segments independently and simultaneouslyclosing the gap of the missing second incisor, another step forwardin the correction of CLP-deformity. (I do not know why it took methat long to use that chance).

This case demonstrates another important step forward inachieving normal occlusion and appearance by advancing andnarrowing the maxillary segments in an unilateral cleft case(operated upon in 1976). Illustration Fig. 19a shows the presur-gical occlusion and the model operation for evaluating thenecessary skeletal surgery and in the drawing the surgical detailsof the maxillary procedure is shown. Whenever possible theadvancement of the two cleft segments should be planned so thatthe gap created by a missing tooth can be closed. A remainingpalatal cleft fistula can then simultaneously be closed withoutdifficulty. The final occlusion should be equal as planned on themodel operation as seen in Fig. 19a on the right side of thebottom.

Fig. 19. a, b: This case demonstrates an other important pioneer step in the correctionof secondary cleft deformities. It is a unilateral CLP-case with slight retromaxillismonly, but missing the second incisor on the cleft side. a) This photograph shows thepreoperative occlusion. The model operation indicates: the maxilla has to be advancedin two sections, simultaneously closing the gap of the missing incisor and for profileimprovement advancing the prominence of the chin. b) That ends with an excellentresult.

If necessary, as it was in this case for the chin prominence, someadditional profile improvement has to be planned and performed atthe same operation. The final profile views (Fig. 19b) demonstratethe profile improvement after that single surgical intervention.

8. Jaws plus lip and nose

8.1. Fig. 20aee: A bilateral cleft case presents a complex situationwith some soft tissue and maxillary but mainly mandibulardeformities (operated upon in 1966)

The profile view of the patient (Fig. 20a) demonstrates a verymassive chin prominence and a vertical elongation of the inferiorthird of the face. The cephalometric radiograph shows the maincause of this rather severe deformity: It is the retropositon of thepremaxilla and the rather very large mandible. Fig. 20b shows thepatients terrible occlusal situation. This horizontal as well as ver-tical occlusal discrepancy required, according to the model oper-ation, a forward positioning of the premaxilla and a remarkablereduction of the seize of the mandible by removing an inferiorbicuspid on each side, followed by a retro-positioning of theanterior alveolar segment and simultaneously a repositioning ofthe whole mandible by the sagittal splitting procedure. All thiswas performed in one operation. Thereby an acceptable man-dibularemaxillary relationship could be achieved, whichpermitted the patients dentist to supply the patient with a fixedbridgework after the fistula in the left alveolar cleft region wasalso closed. There existed also a shortness of the upper lip as oftenseen in bilateral cleft lip cases. The illustrations Fig. 20cee showthat by an additional reoperation of the bilateral lip situationfinally a very acceptable functional and aesthetic situationresulted.

8.2. Fig. 21aed: A bilateral CLP-case with circular non-occlusionand dish face deformity and a dropping nose due to severe micro-retromaxillism

This case shows the situation of a bilateral cleft with extremelycollapsed maxilla and protruding mandible and with dropping tipof nose (operated upon in 1962e63), before I was able to advancethe maxilla.

There was a severe dish face deformity due to retro- and micro-maxillism and there was circular nonocclusion as seen on the topright picture of Fig. 21a. According to the model planning themaxilla had mainly to be widened. But the premaxilla had to berotated anteriorly and the mandible had to be retropositioned for10 mm. The operation at the maxilla was carried out accordingly,with reopening of the cleft and the mandible was repositioned bythe use of the sagittal splitting procedure. In a first intervention thelateral maxillary segments were rotated laterally with simulta-neous reopening of the cleft. A splint and bone grafts in the caninefossae secured them in the new position. In a second operation thepremaxilla was repositioned and the reopened palate was closedwith bone grafts interpositioning for stabilization of all three seg-ments. In an additional intervention the mandible was osteotom-ized by the sagittal splitting and fixed in the planned position.Fig. 21b shows on the right side that the first three steps ofcorrective surgery achieved a good intermaxillary relationship.That is also seen in the cephalometric pictures. Its facial contourproofed the planning.

The same illustration (Fig. 21b) shows the change in the occlu-sion, of course, with prosthodontic work and it shows in the lateralcephalometric radiographs the wanted change of the facial skel-eton. The following illustration (Fig. 21c) shows on the left side thepatients appearance after the maxillo-mandibular discrepancy had

Fig. 20. aee: A bilateral CLP-case presents a maxillary anomaly, but mainly an anomaly of the mandible. The outer appearance is difficult to diagnose. The lateral cephalogramssuggests rather a pronounced micro-retromaxillism, but the evaluation of the case shows that the main cause for this patients anomaly is the macro- and ante-mandibulism. Thisbecomes obvious when the occlusion is inspected and the model operation tells that only the premaxilla has to be repositioned while the mandible has to be reduced in size veryremarkably by simultaneously repositioning the whole mandible and also its anterior alveolar segment after extraction of the two first bicuspids. After that skeletal surgery the lipneeds to be reconstructed. d, e) That ended in a good frontal appearance as well as a good profile.


Fig. 21. aed: This case is a typical facial deformity after a bilateral CLP. a): The patient presents a severe dish face deformity with a dropping nose and a circular nonocclusion. I hadto correct that deformity in 1962e63, before I was able to reposition the maxilla. The model operation showed that an acceptable intermaxillary relation can be gained byrearranging the upper arch and retro positioning the mandible for 10 mm. In a first intervention I rotated the lateral segments into proper occlusion with the mandibular teeth. In asecond intervention I repositioned the premaxilla and closed the cleft palate in the typical three layer way, that means that bone grafts secured the three segments in their position.b): Finally the mandible was repositioned by the sagittal splitting technique of the rami as planned on the models. c): After skeletal surgery the bilateral cleft of the lip becameobvious. The reoperation of the bilateral lip gave me the chance to reconstruct the missing columella by the use of Ralf Millards fork flap technique a) The result was quite acceptablealthough the maxilla had not been advanced.


been corrected through corrective surgery on both jaws. Now thelip was reoperated on and simultaneously the missing columellawas reconstructed by Millard's fork flap procedure and also thenasal deformity was corrected, altogether ending up with a func-tionally and aesthetically pleasing result, as can be seen on the rightside of Fig. 21c and on the Fig. 21d with the patient's pre-and postsurgical profile views. This case was operated upon before I hadexperience in simultaneously repositioning the whole maxilla andthe mandible.

8.3. Fig. 22aee: This case is a situation of unilateral cleft lip andpalate with severe retro- and micro-maxillism plus some degree ofasymmetric antemandibulism (operated upon in 1969)

In unilateral as well as in bilateral cleft cases it can becomenecessary not only to reposition the collapsed alveolar segments ofthe maxilla and bring them forward but also to reposition themandible by the sagittal splitting procedure or parts of it in order toachieve good skeletal relationship. After proper model planning

and preparation of splints this can often be executed in one oper-ation. This was my first case of simultaneous repositioning of thewhole maxilla as well as the whole mandible. Fig. 22a shows thepatients preoperative profile appearance and its skeletal back-ground in the lateral cephalograms. Illustration Fig. 22b shows onthe models the preoperative occlusion and the model operationproofs that by advancing the maxilla in two segments and retro-positioning and slight rotating the mandible a good intermaxil-lary relationship could be achieved. The model planning (on theright side of Fig. 22b) showed that, according to the profile plan-ning, both maxillary segments had to be advanced and narrowedindependently and the mandible had to be repositioned anteriorlyand shifted for 3 mm to the left side. Drawings of the plannedoperation (Fig. 22c) show in details what the model operationsuggested according to the profile planning. Bone grafts wereplanned to be placed onto the steps in the canine fossae in order tocope with the rather flat infraorbital areas. In a second stage theshortness of the upper lip had to be corrected as well as the nasaldeformity. As seen on illustration Fig. 22d a good profile has been

Fig. 22. aee. An other typical secondary unilateral CLP- deformity in a young adult. a): Severe dish face deformity and a protruding mandible seem the main cause for thisdeformity. b): The model operation suggests that a good intermaxillary relation can be achieved by advancing the maxilla in two sections and simultaneously repositioning themandible by a sagittal split procedure. c): The drawings tell clearly what the surgery has to do. d): The two cephalograms show clearly the skeletal back ground of the anomalybefore and after the correction. e): After the nasal deformity was also corrected the final result was very satisfying.


Fig. 23. aeg: This 21 year old femalewith her facial deformity after anunilateral CLP presented a typical anomaly of themaxilla but also a severe anomaly of themandible. a): The dish faceand the dropping nose cannot be overlooked. But there is also a asymmetry of the mandible and a certain amount of antemandibulism. The cephalograms proof the diagnosis. b): Theorthopantomogram of the mandible shows the classical anomaly of hemimandiular elongation as first published by Obwegeser and Makek (1986). The model planning demonstrates thenecessity for advancing the maxilla in two sections and repositioning and rotation of the mandible by the sagittal splitting technique. c): The drawings show what the model planningsuggests and theocclusalpicture showthesituationbefore andafter the surgery. d):After theskeletal correctionhasbeenperformed the soft tissuesarewaiting tobe improved. Lipandnasalcorrectionaredonesimultaneously. f)Thenosehasbecomesymmetricandsoalso looks theskeleton.g,h):Thecomparisonof thepreoperativesituationwith thefinal resultproofsmygoal inthe correction of secondary cleft deformities: The cleft patient has a right to have an outer appearance as normal as any other person.


Fig. 24. aei: A case of unilateral CLP with a complex facial anomaly after orthodontic treatment for several years. a): This young grown up lady suffers from hypoplasia of the facialhalve of the cleft side plus an ectropion of the lower lip. b): She has a good upper dental arch with a missing second incisor. In addition she has a palatal fistula behind the incisors.Such a hypoplasia of the cleft side of the face is not rare, as can be seen on the skull of an other case. c): The profile planning intends to produce a slight ante profile. d): The modeloperation suggests advancing the maxilla as well as the mandible, but primarily reposition the inferior alveolar front segment for permitting to advance the mandible as much asnecessary (13 mm), together with the maxilla in two segments. That permits the closure of the gap of the missing second incisor. The drawings illustrate the planned operation. e):After finishing the orthodontic treatment the planned surgery created a perfect occlusal result. f): There was still the need to correct the hypoplasia of the cleft side. I did ittransorally with some lyocartilage onlays. The patient wanted to have the nasal correction done by her plastic surgeon in the States, although it could have been executed at thesame operation. g): The lateral cephalograms demonstrate the final skeletal result. h, i): The final profile and front views of the patient show the result of surgery. We have notachieved a slight ante profile face as we had intended, but still a good result.


Fig. 24. (continued).


achieved through these two operations. There is a clear increase invertical dimension as well as a forward shift in the infraorbitalregion recognisable. The last photograph (Fig. 22e) shows the pa-tients frontal views of this case before and after these two opera-tions. This was my first case of simultaneous repositioning of bothjaws, an other important step in the development of correctivesurgery of secondary cleft deformities. Since then it has becomeroutine practice all over the world.

8.4. Fig. 23aeg: It is a case of simultaneous existence of a typicalmaxillary and also a typical mandibular anomaly in an unilateralCLP-case

The maxillary anomaly is the result of a unilateral cleft lip andpalate with severe micro- and retro-maxillism and the asymmetricantemandibulism is the result of a unilateral hemi-mandibularelongation. The front view proofs the cause of the asymmetry(Fig. 23a): The mandible is clearly too far anteriorly and shiftedover to the left side while the anomaly of the middle face has its

Fig. 25. aeg: a): This 20 year old patient presents a severe micro- and retro-maxillism afterto create an acceptable profile and a good intermaxillary relation for the dentist to supply thFort III þ I osteotomy for the necessary advancement of the face and also for some vertical incfor bridging the bony defects. d): These pictures show the achieved intermaxillary relation asituation before and after surgery. f, g): After additional correction of the lip deformity and ato lead a normal life.

cause in a asymmetric hypoplasia of the middle third of the face,in addition with the usual dropping nose, typical for a unilateralcleft lip and palate situation. The lateral cephalograms, on theright side of the illustration shows the skeletal background of theanomaly. In the orthopantomogram (Fig. 23b) the typical pictureof a hemi-mandibular elongation on the right side of the mandibleis seen and in the maxilla on the left side the cleft lip and palatedeformity. The model operation proofs clearly that the maxillaryhalves have to be advanced unequally and the mandible must beshifted over to the right side for 6 mm. In illustration Fig. 23c theplan of surgery is shown by the drawings: the mandible will needa unilateral sagittal splitting of the right ramus only and themaxilla requires a sectioning in the cleft region and an unequaladvancement of the two halves and medial rotation of both sec-tions. With that amount of surgery on the skeleton a good inter-maxillary relationship should result as seen on the right side ofthe Illustration Fig. 23c. Fig. 23d shows that after the skeletalrearrangement the lip and nose can be corrected in order to finishthe surgical correction. The final result is seen on illustrations

the repair of an unilateral CLP in childhood. b): The teeth did not occlude. The goal wase patient with a good functioning dental appliance. The model operation suggested a Lerease of it. c): The drawings explain the surgery. That includes quite some bone graftingnd the final dental bridge work. e): The lateral cephalograms demonstrate the skeletallso of the nose the patient received an acceptable outer appearance that permitted him


Fig. 26. aer). This last case became the case of my life. He was referred to me at his age of ten. a): He was born with two complete noses and a wide medial facial cleft, tworudimentary eyes and two complete premaxillae with four incisor teeth each and an exorbitant hypertelorism. A plastic surgeon has tried to close the medial cleft by suturing thetwo medial alae together. In aadirion he inserted an Abbe' flap for the same purpose. He was a charming boy and wanted badly the correction. He was 10 years and two months oldwhen he was referred to me. b): The few of the maxilla showed the surplus of teeth with the medial cleft and the oblique few of the skull impressed by the wide lateral position ofthe eye sockets. c): I made my plan on the basis of Tessiers' hypertelerism operation without knowing how things are behind the face. There were no radio-tomograms nor MRIavailable at those days (1969). I planned to excise everything between the two nasal bridges. When the skeleton and the base of the skull will be freed I will have to adapt mysurgery according to the local situation. The neurosurgeon was as much surprised as I was when he found two cristae Galli with a lamina cribrosa on each side after he had raisedthe brain from the bottom of the anterior cranial fossa. That finding made it clear to me how much I will have to excise from the anterior cranial fossa. d): The photographs takenduring the surgery show clearly the two nasal frameworks and also the rudimentary orbital coni of the two rudimentary eyes, that had been removed in early childhood. They alsoshow the gap between the two facial halves after the excision of the surplus of the anterior cranial fossa and the new nasal bony framework after the two sides were rotated


together. e): We had achieved a nice result, but the neurosurgeon had to remove the large cranial flap after a week because of heavy purulent infection. The children's hospital gothim free of the infection by antibiotics. The patient could leaf for home with a helmet. Ten months later he returned with a severe facial deformity. The mandible had grownforward, but not the maxilla. The model planning showed that I will have to advance the maxilla and reposition the inferior alveolar segment to correct this unpleasant deformity. f):An acceptable appearance resulted. g): 13 months after the removal of the infected cranial bone flap the neurosurgeon reimplanted that piece of bone after its autoclaving. However,an infection again forced him to remove it. Ten months later I reconstructed the cranial defect by implantation of 14 halve decorticated pieces of ribs. h): With that new brain coverhe left for home again. Two and a half year later we experienced again that the mandible had grown forward, but not the maxilla. I decided to wait till growth is finished. After that Ishould be able to make him a normal face that will not alter again. I): At his age of 18 and a halve he arrived with a most grotesque facial deformity, as can be seen in this illustration.j): The drawings of this illustration make it clear that I planned to advance the maxilla plus the infraorbital and paranasal areas and to reposition the anterior alveolar process of themandible plus the whole mandible for 11 mm. k): A good facial skeleton resulted. Only the nasal cartilage and the columella have been missing. l): For the reconstruction of the



columella I used a caterpillar flap from the nose and for the missing cartilage a L shaped piece of cartilage form the ribs. m): The final result was very convincing. It remained likethat for more than 25 years when I saw him last. n): The final dental arch of the maxilla was o.k., in spite the missing incisors. o): The lateral cephalometrics before we started thecorrection at his age of ten and at the age of 22 demonstrate that it was worth while to go through all this efforts. p): He had finally a perfect nose and good nasal breathing and hisspeaking was good enough for his native town to employ him in the cities telephone business. q): I visited him in his town 25 years after I had finished his surgery and found apleasant young man as happy as the surgeon himself.




Fig. 23eeg. These photographs show the very pleasing result ofthat surgery.

8.5. Fig. 24aei: It is a case of unilateral cleft lip and palate with arather pronounced hypoplasia of the cleft side of the face, withectropion of the lower lip and a disturbing retroprofile line(operated upon in 1979)

This complex anomaly of a unilateral cleft is clearly seen inFig. 24a. It is not a rare condition in cleft cases that there is aremarkable hypoplasia of the midfacial area on the cleft side. Inaddition her lower lip ectropion and her retroprofile line were verydisturbing.

The patient had been referred after she had had already someorthodontic treatment. She had good dental arches and an oro-nasal fistula at the palate in its anterior region (Fig. 24b). Her hy-poplasia of the right side of her face obviously had a skeletalbackground. That can also be observed at the skull of an unilateralcleft, as shown on the bottom of the same picture. My planningintended to produce a symmetrical face with a vertical or even ananteprofile line (Fig. 24c). In order to achieve this it will be neces-sary to advance the maxilla as well as the mandible. For thecorrection of the ectropion of the lower lip I find the surgical retro-positioning of the inferior frontal segment more efficient thanwhatcan be achieved by orthodontic measures.

Illustration Fig. 24d shows the model planning and the opera-tion plan in drawings: The plan for the corrective surgery of themaxillo-mandibular complex included as a first step the extractionof the first inferior bicuspids and simultaneous retro positioning ofthe inferior frontal segment. This was felt necessary for thecorrection of the ectropion of the lower lip and for additionaloverjet for the necessary amount of advancement of the mandible.After this preliminary surgery the new orthodontist (Prof. PaulSt€ockli) arranged the teeth to such perfection that the surgicalcorrection became an easy job: advancing the maxilla in two seg-ments with placing them into proper occlusion, on the right sidesimultaneously closing the gap of the missing second incisor, andalso advancing the mandible by the sagittal splitting procedure.Fig. 24e shows the occlusion achieved through this combined or-thodontic and surgical treatment in comparison to the occlusionwhen the patient had arrived.

Illustration Fig. 24f shows that not only the occlusion but alsothe facial appearance had remarkably improved. There was stillthe hypoplastic region of the right zygoma area that requiredaugmentation. In a further intervention I corrected that hypoplasiaof the right midfacial region by transoral implantation of someslices of lyophilized bank cartilage and in addition I used mysliding transoral chin procedure to advance its prominence andincrease the inferior facial height. She then went back to herplastic surgeon in the States, by whom she wanted to have the stillnecessary nasal correction done. Fig. 24g demonstrates in thelateral cephalograms the change in the facial skeleton and the twolast figures (Fig. 24h,i) show the patients improvement in profileand in the frontal views.

This case is a typical example for the necessity to follow thethree important principles in treating these deformities. First:proper detailed diagnosis; second: consistent treatment plan;third: execution of the plan by very experienced specialists.

8.6. Fig. 25aeg: It is a case of bilateral cleft lip and palate withsevere retromaxillism and hypoplasia of the middle third of the face(operated upon in 1972/73)

The skeletal framework (Fig. 25a) of this very severe dish facedeformity requests obviously that the whole middle third must be

advanced and vertically increased, but the mandible should be leftuntouched. To achieving that goal a Le Fort III þ I will be indicated(H. Obwegeser, 1969). Fig. 25b demonstrates the patient's circularnonocclusion and the model planning: according to it the maxillamust be advanced for 20 mm in two pieces and it must be widenedby reopening the cleft. In Fig. 25c the planned operation is shown indrawings. Bone grafts are a must since the advancement createsdefects of 20 mm. There is not only an extensive advancement ofthe middle third of the facial skeleton by a Le Fort III osteotomynecessary as inaugurated by Tessier (1967) for the wantedimprovement of the facial skeleton but also an increase of thevertical height. For that an additional Le Fort I osteotomy has to beperformed, that will permit to place the tooth bearingmaxilla into aplanned intermaxillary relationship for the later prosthodonticwork and also, very important, for the needed facial height. Thatwill create a gap between the upper halve of the middle third andthe inferior halve. That gap requires a massive bone graft. Conse-quently I performed a Le Fort III and an additional Le Fort Iadvancement with reopening the cleft in a first shot. In a secondoperation the reopened cleft was closed again and the nasaldeformity was also corrected with a very satisfying result. Fromthen on this simultaneous Fort III þ I operation has become routinein my clinic.

Fig. 25d shows on the left side the occlusal situation before andafter that surgery. The new intermaxillary relationship permittedthe prosthodontist to construct a functionally and aestheticallyvery satisfying result, in particular by the use of the Dolder barsystem.

After that the columella was elongated and the nasal deformitycorrected, as seen on the cephalometric radiographs (Fig. 25e) Theyalso show that with the simultaneous LF III þ I advancement theanatomical cause of the severe dish face deformity was correctedand the height of the midfacial third was increased to normal asseen here on the lateral cephalometric radiographs. The last twophotographs of this case (Fig. 25f,g) show that the patient is nowready to live a normal life.

8.7. Fig. 26aer: The last case is the case of Antonio. It is a case offacial duplication plus a large medial facial cleft (operated upon1969e78)

Antonio had come from southern Italy. He became the case ofmy life. He was referred to me by Prof. Hugo Kr€ahenbühl, the Chiefof the University Clinic for Neurosurgery in Zürich. To him thepatient was sent because he suffered from a congenital abnormalwalking. In treating his congenital facial skeletal deformity Ilearned more about the influence of surgery on the growing facialskeleton than by collective experience.

For the child's psychological support I wanted the parents tostay in town for the time of his hospitalization. As they were ratherpoor working people from the south of Italy they could not affordthe child's hospitalization or any treatment costs. For that reason Ipersonally felt responsible for the parent's full pension in a nearbyhotel and I asked the government of the Canton of Zürich to permitto have the boy free of charge hospitalized and treated for scientificreasons at our department.

The patient was born with two complete noses and a widemedial cleft as can be seen on Fig. 26a. He was referred to me in1969, at his age of 10 years. In babyhood the medial cleft had beenclosed by a plastic surgeon in his home townwith the utilization ofthe medial wings of the two noses and an Abb�e flap operation wasused for closure of the very wide cleft lip. There was extremehypertelorism. The tips of the two noses were 5 cm apart. As can beseen in Fig. 26b the large upper jaw had a fully developed pre-maxilla on each side. At those days only standard radiographs were


available but no CT and noMRI. Nevertheless the oblique skull viewshows very impressively the amount of hypertelorism.

I made my plan for correcting this anomaly without knowing atthose days how much damage surgery can do to the growing facialskeleton. Fig. 26c shows in drawings my treatment plan based onTessier's hypertelorism operation technique (1967). Both halves ofthe midface, including the orbit and the maxillary half of each side,should be rotated medially, after removal of all tissues between thetwo nasal crests. As soon as the anatomy becomes clearer duringsurgery, surgical details will have to be adapted accordingly.

A day before surgery, every person participating in the proce-dure, was given a written detailed plan, including the estimatedtime for each step. The operation was performed on the 4th of July1969.

When the neurosurgeon was raising the brain from the anteriorcranial fossa he found, to our great surprise, two complete cristaegalli with a lamina cribrosa on each side of them as shown in thedrawings. That finding made it clear how much I had to excise inthe anterior cranial fossa.

Illustration Fig. 26d demonstrates the skeletal situation whenthe skull was freed. The two bony nasal frameworks were clearlyrecognizable and between them two rudimentary eye sockets. Afterthe orbital coni wire sectioned and everything between the twohalves of the facial skeleton, including the two premaxillae, hadbeen excised, both halves could be rotated together. Bony defectswere bridged with bone grafts from the iliac crest and ribs.

Because of postoperative purulent meningitis the neurosurgeonhad to remove the large cranial bone flap and I had to take away thebone grafts at the defects of the orbital walls. Under heavy antibi-otic treatment at the children's hospital the infection was over-come. The patient had to wear a helmet. With that he left for hometogether with his parents: After 10 months a severe maxillo-mandibular discrepancy had developed clearly seen in the cepha-lometric radiograph of Fig. 26e which I corrected by advancing themaxilla and retro-positioning the anterior mandibular alveolarsegment as seen on the model operation and demonstrated withthe drawings of the planned procedure as seen in Fig. 26e.

The next illustration (Fig. 26f) shows that in spite of the formerremoval of the bone grafts at the defects of the lateral orbital wallsthe result was quite pleasing again. The facial skeleton showed asomehow normal shape in the radiograph, particularly comparedwith the preoperative situation.

Thirteen months after the removal of the infected cranial boneflap the neurosurgeon re-implanted the autoclaved cranial boneflap, but without success because of a new purulent infection. Tenmonths after the newly infected bone flap had been removedagain, that is 23 month after the primary operation, I recon-structed the very large skull defect with 14 half ribs of the patient(Fig. 26g).

Illustration Fig. 26h shows in lateral cephalograms on the leftside the skeletal situation onemonth after the reconstruction of thecranial defect; this was one year and one month after I had cor-rected the newly developed maxillo-mandibular discrepancy. Andon the right side the skeletal situation 2½ years later is shown:again, everything has grown forwards but not the middle third ofthe facial skeleton.

Two more years later, when the skeletal growth had ceased, alarge maxillo-mandibular discrepancy had developed again asshown in illustration Fig. 26i .It again asked for correction. I wasnow convinced that at this time the skeleton will remain as I placeit. It has been so obvious that the middle third lacked of growth dueto my surgery while the forehead and the mandible did not reactnegatively to the extensive denuding surgery. For the correction ofthis very severe facial skeletal anomaly again I performed a retro-positioning of the protruded anterior mandibular alveolar

segment plus a sagittal splitting of the mandible for its push backand simultaneously I advanced the maxilla plus the paranasal-infraorbital regions including the anterior part of the zygomas.The drawings in illustration Fig. 26k demonstrate clearly my plan ofsurgery.

As can be seen on the next illustration (Fig. 26l) it resulted in agood intermaxillary relationship. The missing columella and nasalframework still had to be reconstructed for a good profile. For thereconstruction of the missing columella I used a caterpillar flapfrom the nasal dorsum. For the missing nasal framework I inserteda L-shaped piece of rib cartilage, as I had learned it from EduardSchmid. The procedure is nicely seen in details in Fig. 26m. Thiswhole procedure produced a very acceptable final result (Fig. 26n).Regrettably, at those days we still used infraorbital incisions for theosteotomies of the orbital cones. The scars will remain visible forever.

The situation of the maxilla with the teeth, before we correctedthis anomaly and the final stage of it, is seen in Fig. 26o. The lateralcephalograms (Fig. 26p) show the skeletal situation when I startedthe correction at age of 10 years and on the right one year andeleven months after the last operation, that is close to his age of 20years. He had a good profile and a firm skull again.

His final view from below at his age of 18 years and 7 months incomparisonwith his presurgical situation at the age of ten is seen inFig. 26q. His nose was fairly normal and so was his nasal breathing.His speech quality was good enough that his native town couldemploy him in the city's telephone business.

The last illustration shows the patient again, 25 years later,together with his surgeon. Both seem to be happy.

9. Conclusions

9.1. The aim

The aim in any cleft case must be the achievement of normalappearance and normal chewing and speech function, not merelybe the avoidance of secondary surgery, as formulated by some or-thodontists; it must be, without any compromise, normal appear-ance and function, whatever may be needed for that.

9.2. Surgical basics

It is a fact that any surgery on the maxilla before growth hasceased, even just elevating the palatal artery flaps (Herfert, 1954),causes lack of growth of that part. Scars can also influence themaxillary growth negatively. That means do as little surgery on themaxilla for the primary repair as possible.

Lip closure: In babyhood, gentle lip closure or lip adhesionoperation only. Avoid any Abb�e-flap operation, also in the adultcases, whenever possible. I have never seen an undisturbed lowerlip after the Abb�e-flap operation even when it had been performedby the most experienced surgeon.

Hard and soft palate: Closure of the soft palate only, just beforethe child starts talking. No surgical closure of the hard palate andthe alveolar cleft before maxillary growth has finished. The palataldefect is covered with a plate, which must be adapted according tothe growth of the maxilla and eruption of the teeth. After eruptionof the permanent teeth the remaining alveolar and palatal fistulacan easily be closed without causing growth impairment.

In cases with congenital hypoplasia of the base of the maxillaand of the paranasal-infraorbital bony structures at the side of thecleft, as can be observed on skulls as well as on patients, the maxillamay require advancement after growth has finished. Then a re-sidual palatal fistula can easily be closed and a missing tooth gapcan be eliminated by simultaneous approximation of the cleft


segments. The paranasal-infraorbital hypoplasia is corrected bycontouring onlays or by surgical advancement of the affected areas.

The nose: A nasal deformity can nowadays be corrected to suchperfection that even the specialist may not recognise that a typicalcleft nose deformity had existed, even in very severe unilateral cleftcases (Triaca, 1994).

Palato-pharyngeal insufficiency: This may require a pharyngo-plasty procedure. I got very good results only when I closed thenaso-pharyngeal seal so much that the patient could not breathethrough his nose. Then he was forced to lead the air through themouth only. Thereby the patient could now produce normalarticulation and pronunciation, however, with a typical closednasality.When I reopened the connection of the soft palatewith thepharyngeal wall 6e12 months later the patient produced a normalspeech, with no further nasality. After a usual pharyngeal flapoperation, a disturbing amount of open nasality often remained.

9.3. Orthodontic treatment

In my experience, the goal of orthodontic treatment must be thearrangement of the permanent teeth in proper position to therespective base of the jaw, independent of the relation of themaxillary teeth to those of the mandible. Over-expanding themaxillary dentition or retruding themandibular teeth cannot correctthe skeletal anomaly. The surgeon can only produce a good aestheticresult when he brings the base of the maxilla into proper relationwith the normal mandible. In my experience it is often necessary toextract amaxillarybicuspidoneach side inorder tobeable to arrangethe teeth in proper angulation. In craniostenosis cases it may evenbecome necessary to extract two teeth on each side.

There is no indication for orthodontic rearrangement of thedeciduous teeth. In babyhood and up to the age of 14e15 years theorthodontist should feel responsible for providing the plate tocover the palatal defect and for caries prophylaxis and for the oc-casional need for the extraction of a tooth. Two years before thefinal surgical correction is needed he will, together with the sur-geon, discuss the necessary procedure.Within one and a half or twoyears he has plenty of time to arrange the teeth with orthodonticmethods so that they will fit into proper occlusion when the sur-geon moves the skeletal parts for restoring normal appearance.

9.4. Logopaedic speech assistance

This is suggested for every case. The logopedist has an easy jobonly when the surgeon and the orthodontist create proper pre-requisites for normal articulation and pharyngeal closure. Withoutthese two prerequisites even the best speech therapist may notsucceed to achieve an undisturbed pronunciation.

9.5. Prosthodontic work

It is natural that the patient prefers fixed crown and bridgeworkwhen some teeth are missing. From my point of view there is al-ways a possibility for some change in the cleft region, even afteryears. For that reason and for hygienic purposes I found the Dolder-bar construction with a removable superstructure the most idealsolution for the replacement of missing teeth.

9.6. Special instrumentation for maxillofacial surgery

For good surgery good instruments are wanted. This is partic-ularly true for our field of work on the facial skeleton. For theprocedures which we had frequently used I had specially designed

instruments made by different instrument making companies. Ihave experienced that during the process of new production of theinstruments which finally had achieved the shape and quality Iwanted, the new instruments had changed. Other instrumentmakers had produced them and other companies copied myoriginal instruments. The results were often so bad that I had togo to the court for forbidding them to use my name for theseinstruments. That means that only those instruments are ofaccepted quality which I had the right to check their production inintervals.

It is not easy to get every instrument made in the quality onewants. Regrettably that is true for my maxillary advancer. I have asample piece but no further production of it, although it is a veryimportant help for advancing the maxilla.

The following companies are selling these checked instrumentsof my design: KLS in USA, Martin and Medicon in Europe and theirdistributing agencies anywhere in the world. These are the onlycompanies which hold the right to place on the instruments“original Obwegeser”. All others are selling instruments as Obwe-geser instruments, but their quality may be and often is notacceptable for me.

9.7. A special hand-piece for surgery on the facial skeleton

A special hand-piece for burs to work on the facial skeleton wasconstructed for me by the W&H Company from Bürmoos, Austria.That company is well known for its hand-pieces for dental work.However, the usual straight hand-pieces are too short for our workin the depth of the mouth. Therefore I asked them to produce alonger hand-piece for our work. I also wanted that it should hold allbur type instruments with a shafts diameter of 2.35 mm. I did notwant that we need special burs made for our work, except very fewones. I used that hand-piece constantly for the sagittal splittingprocedure of the mandibular rami or whenever I had towork in thedepth. It is also an excellent hand-piece for the removal of impactedwisdom teeth. I do not know any other company that produces sucha special hand-piece.

References

Axhausen G. Dtsch Zahn Mund u Kieferhlk I: 334e342, 1934Axhausen G. Dtsch Zschr Chir 248: 515e522, 1936Axhausen G. Dtsch Zahn Mund u Kieferhlk 6: 582e600, 1939Converse JM, Shapiro H. Plast Reconstr Surg 10: 473e510, 1952Cupar J. Oesterr Z Stomat 51: 565e577, 1954Drommer R. J Maxillofac Surg 7: 264e270, 1979Drommer R. J Maxillofac Surg 14: 119e122, 1986Gillies HD, Rowe NL: L'osteotomie du maxillaire sup�erieur enoisag�e essentiellment

le cas de bec-de-li�evre total. Rev Stomatol 55: 545e552, 1954Herfert O: Experimental contribution to the problem of injury to the maxillary

growth by primature cleft palate surgery. Dtsch Zahn Mund u Kieferhlk20(9e10): 369e381, 1954

Obwegeser HL: Cirugía del “mordex apertus”. Rev Asoc Odontol Argent 50:430e441, 1962

Obwegeser HL: Der offene Biss in chirurgischer Sicht. Schweiz Monatsschr Zahn-heilkd 74: 668e687, 1964

Obwegeser HL: Eingriffe am Oberkiefer zur Korrektur des progenen Zustandbildes.Schweiz Monatsschr Zahnheilkd 75: 365e373, 1965

Obwegeser HL: Surgical correction of small or Retrodisplaced maxillae. PlastReconstr Surg 43: 352e365, 1969

Obwegeser HL, Makek M. J Maxillofac Surg 14: 183e208, 1986Schuchardt K: Ein Beitrag zur chirurgischen Kieferothop€adie unter Ber-

ücksichtigung ihrer Bedeutung für die Behandlung angeborener und erworb-ener Kieferdeformit€aten. Dtsch Zahn Mund u Kieferhlk 9: 73, 1942

Tessier P: Dysosotosis cranio-faciales (syndromes de Crouzon et d’Apert) ost�eoto-mies totales de la face. In: Transaction of the Fourth international Congress ofplastic and reconstructive surgery Rome, October 1967. Amsterdam: ExcerptaMedica Fondation, 774e783, 1967 1969

Triaca A: Correction of unilateral cleft nose deformity. Paper read at the worldCongress on Rhinoplasty, april 29eMay 1, Philadelphia; 1994

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Pioneer steps in correcting secondary cleft lip and palate deformities: My philosophy and procedures