Hugo L. Obwegeser (1920–2017) – The father of modern orthognathic surgery

MD, DMD, FDS.RCS (Eng.), Hon. FRCS (Eng.), Hon. FDS.RCPS (Glas.), Hon. FFD.RCS (Ire.)

(Photograph by Hengameh B. Naini)

(From: Naini FB, Gill DS, editors. 2017. Orthognathic Surgery: Principles, Planning and Practice. Oxford: Wiley-Blackwell; reprinted with permission)

Hugo Lorenz Obwegeser justifiably ranks as one of the giants of twentieth century medicine and surgery. He is internationally recognised for his contributions to the foundation and development of reconstructive surgery of the facial skeleton. Through his innovative work and intellectual calibre he exerted a profound influence on modern Orthognathic surgery, that most wonderful and rewarding subspecialty of both Cranio-Maxillofacial surgery and Orthodontics. As such, the orthodontic community owes him a huge debt of gratitude.

Together with my wife, I had the great pleasure of meeting Professor Obwegeser at his home in Schwerzenbach (Zurich) on a beautiful spring day in March 2012. It was an incredibly memorable day. Then aged 92, Professor Obwegeser’s voice was strong and commanding, and the stories and anecdotes simply wonderful. I learned more in one day than I thought possible. He was a wine connoisseur, and we shared a bottle of Swiss white wine – his favourite – which was simply delicious. After my first glass Professor Obwegeser picked up the bottle to pour some more and I politely placed my hand over my glass – he just said ‘remove your hand’ with combined decisiveness and good humour, and suffice it to say I did as I was told! Professor Obwegeser was Austrian by birth. He was born on the 21 October 1920 in the town of Hohenems, in the Austrian part of the Rhine valley. He obtained his original dental degree in Austria, dentistry being a subspecialty of medicine in Austria at that time, but the Nazi Anschluss had by that stage gained momentum and he realised he could no longer stay in Austria, hence the move to Switzerland, which was to become his home. He spoke at length and with great respect about his teachers, particularly Hermann Chiari, Richard Trauner and Eduard Schmid, and of his friendship with Professor Norman Rowe and Dr Paul Tessier. He said, ‘I feel like an honorary Briton. I have received so many accolades and have so many friends in Britain’. However, primarily it was his admiration for Sir Harold Gillies that he recollected at some length, with whom he had trained and worked for 5 months in Basingstoke (October 1951 to February 1952). He referred to Gillies with great affection, always as ‘Sir Harold’, and described him as ‘the most important pioneer of modern plastic surgery’.

I asked Professor Obwegeser if he would write the introductory chapter to Orthognathic Surgery: Principles, Planning and Practice. Of the other 94 authors to the book, many were the recognised leaders in their field. Yet, it was interesting that as we went through their names Professor Obwegeser explained that either they had been his students, students of his students, or even ‘third-generation Obwegeser students’. Needless to say, Professor Obwegeser’s chapter is a tour de force, with clear descriptions and the original colour photographs of the first patients to have the original orthognathic procedures – and his chapter was the first to be completed (Obwegeser, 2017). He asked to be kept informed of progress during the book’s development, and I, of course, obliged. He always finished his letters ‘Your teacher from Zurich’, and I would finish my letters ‘Your student from London’. The editors and all the authors were immensely proud that the book was dedicated to Professor Obwegeser – the father of modern orthognathic surgery – and particularly that he was so happy with the book upon publication.

The milestones in Professor Obwegeser’s professional career essentially reflect the development of modern orthognathic surgery:

• Sagittal split osteotomy – In the early years of Professor Obwegeser’s training and work, Orthognathic surgery was, to all intents and purposes, a fledgling subspecialty of oral surgery, essentially consisting of mandibular set-back procedures, the so-called ‘prognathic operation’. In the Maxillofacial Department of Graz University his teacher, Richard Trauner (who had been a pupil of Hans Pichler) desired a better procedure for repositioning of the mandible. The young Hugo Obwegeser embraced the challenge and took it upon himself to find a solution. He explained how he spent hours holding a cadaveric mandible in his hands, observing it from different angles. He had seen previously two trauma patients, both with a sagittal plane of fracture of the mandibular ramus. He thus invented and named the ‘sagittal splitting’ osteotomy technique of the mandible, undertaking the procedure first in 1953, via an intraoral approach. The distinct advantage of the technique is that no bone grafting is required for mandibular advancement surgery, and the procedure can be undertaken intraorally, with no external facial scars. A modification of the original Obwegeser sagittal split osteotomy, moving the lateral corticotomy anteriorly and vertically directed along the body of the mandible, was undertaken by Professor Obwegeser later during an operation, having been suggested by an observer named Giorgio Dal Pont. Unfortunately, on his return to Italy, Dal Pont made the unconventional decision of publishing this technique but failing to mention Professor Obwegeser.

• Genioplasty – Professor Obwegeser undertook the first osseous genioplasty on a living patient, via an intraoral approach, in 1957; he later described variations of the technique, including a triple-step advancement.

• Le Fort I osteotomy – The Le Fort I-type osteotomy of the maxilla for Orthognathic surgery, including its full mobilisation (which Professor Obwegeser described as the key to success with this procedure), pterygomaxillary disjunction, advancement into the desired position, with placement of a bone graft between the pterygoid plates and maxillary tuberosities, was described in 1965.

• He described all three of the above procedures as undertaken via intraoral incisions, and thereby no facial scars. These three procedures remain the mainstay of modern orthognathic surgery.

• First bimaxillary osteotomy – In 1969 Professor Obwegeser became the first surgeon to describe the simultaneous repositioning of the maxilla and mandible in one operation, i.e. the first bimaxillary osteotomy, which was published the following year.

• Classification of mandibular asymmetry – In a now classic paper (Obwegeser and Makek, 1986), this complex subject was clarified. This paper continues to be used as the standard reference for graduate education in the field.

• He emphasised the importance of planning orthognathic surgery based on the desired facial aesthetic result, rather than dental occlusal result. This approach to planning orthognathic surgery is now widely accepted.

• He developed a number of ‘Obwegeser’ instruments, which continue to be used for Cranio-Maxillofacial surgery.

• The 1966 lectures – All these new procedures and techniques created a plethora of possibilities in the correction of dentofacial and craniofacial deformities. In 1962 Professor Obwegeser was invited to lecture at the South American Dental Congress in Buenos Aires. Following his presentations he was approached by the then Chief of the Dental Corps of the US Army, General Bob Shira. Shira went on to become the President of the American Association of Oral Surgeons and in 1966 invited Professor Obwegeser to deliver a 3-day postgraduate lecture series at the Walter Reed Army Medical Center in Washington D.C., which is widely regarded as the inspiration for the subsequent advances of modern orthognathic surgery, and its establishment as a distinct field.

• In 1967 Dr Paul Tessier described and demonstrated two techniques that revolutionised craniofacial surgery – the Le Fort III advancement procedure, and his transcranial technique for the correction of hypertelorism and various other orbital deformities. These techniques proved useful to Professor Obwegeser, and the two men became lifelong friends and often collaborated and taught together. Professor Obwegeser recalled a particularly memorable visit to Iran, together with Dr Tessier, which as he mentioned proudly was ‘As special guests, at the express invitation of His Imperial Majesty’. Between 1958 and 1987, Professor Obwegeser’s unit, known as the ‘Zurich-School’ of Cranio-Maxillofacial Surgery, became a hub for surgeons from all over the world, keen to learn these new and challenging procedures.

• In 1970, after many battles and struggles, Professor Obwegeser was the key figure in the foundation of the European Association for Cranio-Maxillo-Facial Surgery (EACMFS). In fact, it was his decision that the specialty should be called Cranio-Maxillo-Facial Surgery, rather than just Maxillofacial Surgery. He said, ‘We deal with the entire craniofacial skeleton, and the name must reflect what we do’. He was a stickler for precise terminology, which he felt must go hand in hand with the precision and accuracy required of such surgery, particularly Orthognathic surgery, working to millimetres. The EACMFS is now established as the most prominent and highly respected professional group for the specialty in Europe and beyond, promoting Cranio-Maxillofacial surgery, attempting to establish uniform training requirements for the specialty in Europe, and encouraging such development internationally The predominant aim was to endeavour to ensure that specialist training in Cranio-Maxillofacial surgery was based on a solid foundation of dual medical and dental qualifications and core training in surgery. In fact, it was at the insistence of Professor Obwegeser that members should have a double-qualification, and core general surgical training. He mentioned to me, ‘though Cranio-Maxillofacial surgery should be predominantly a medical specialty the importance of a solid foundation in dentistry cannot be underestimated for a Cranio-Maxillofacial surgeon – it is what sets us apart from any other head and neck surgeon, especially plastic surgeons!’ At a time when the issue of the requirement of a dental degree at all appears to be discussed at most international maxillofacial meetings, perhaps the leaders of the profession would do well to heed the advice of their pioneer.

  In respect for their founder, and his commitment to education, the EACMFS established the ‘Hugo Obwegeser Travelling Scholarship’, designed to encourage trainee members of the EACMFS to travel to other countries within Europe to enhance their education and training. After retirement, Professor Obwegeser put his invaluable experience into a book, Mandibular Growth Anomalies (Obwegeser, 2001), which is full of clinical insight, exemplary case reports, and will no doubt remain a reference source for years to come.

Professor Obwegeser’s work bestrode the latter half of the twentieth century, towering particularly over the development of Orthognathic surgery, and many of the world’s most celebrated clinicians continue to regard him as a cherished mentor. However, Professor Obwegeser was first and foremost a family man. In personal correspondence one of his grandchildren informed me that Christmas was always the annual highlight, with the entire family gathering at their ‘grandparents’ house’. The family conveyed that they miss him dearly, but are incredibly proud of his love for them and his many achievements for his profession, and firmly believe that he is looking down on them as a guardian angel. Professor Obwegeser passed away peacefully on the 2 September 2017, surrounded by his family. He is survived by his beloved Luise, his wife of nearly 70 years, 6 children, 17 grandchildren and 6 great-grandchildren.

It is fitting that the final words should belong to Professor Obwegeser (Obwegeser, 2017): ‘It fills me with immense pride to know that the procedures I pioneered for the correction of dentofacial and craniofacial deformities are helping to improve the quality of life of countless patients, and allowing great professional satisfaction for the clinicians serving these patients’.