Maxilofacial Ao

I
Manual of Internal Fixation in the Cranio-Facial Skeleton

II
SpringerVerlag Berlin Heidelberg GmbH

III
Manual of Internal Fixation

in the Cranio-Facial Skeleton
Techniques Recommended by the AO/ASIF Maxillofacial Group
Editor: Joachim Prein
Chapter Authors:
Leon A. Assael · Douglas W. Klotch · Paul N. Manson
Joachim Prein · Berton A. Rahn · Wilfried Schilli
With 190 Figures in 565 Separate Illustrations
123
IV Kapitel 1
Joachim Prein, M.D., D.M.D. ISBN 978-3-642-63732-2

Professor of Maxillofacial Surgery
Chairman of Clinic for Reconstructive Surgery Library of Congress Cataloging-in-Publication Data
Manual of internal fixation in the cranio-facial skeleton: tech-
Unit for Maxillofacial Surgery niques recommended by the AO/ASIF-Maxillofacial Group /
University Clinics of Basel, Kantonsspital J. Prein … [et al.]. p. cm. Includes bibliographical refer-
4031 Basel, Switzerland ences.
ISBN 978-3-642-63732-2 ISBN 978-3-642-58789-4 (eBook)
DOI 10.1007/978-3-642-58789-4 1. Facial bones – Sur-
gery – Handbooks, manuals, etc. 2. Cranium – Surgery –
Handbooks, manuals, etc. 3. Internal fixation in fractures –
Handbooks, manuals, etc. 4. Surgery, Plastic – Handbooks,
manuals, etc. I. Prein, J. (Joachim), 1938– . II. Arbeitsge-
meinschaft für Osteosynthesefragen. [DNLM: 1. Skull – sur-
gery. 2. Fracture Fixation, Internal – methods. 3. Facial Bones
– surgery. 4. Surgery, Plastic – methods. WE 705 M294 1998]
RD763.M336 1998 617.5`2059 – dc21 DNLM/DLC for
Library of Congress 97-35559 CIP
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V
Chapter Authors and Contributors
Leon A. Assael, D.M.D. Christian Lindqvist, M.D., D.D.S., Ph.D.

Professor of Oral and Maxillofacial Surgery Professor of Oral and Maxillofacial Surgery
Chairman of Department Oral Head of Department of Oral and Maxillofacial Surgery
and Maxillofacial Surgery University of Helsinki
The School of Medicine of the 00130 Helsinki, Finland
University of Connecticut Health Center
Farmington, CT 06030, USA Nicolas J.Lüscher, M.D.
Professor of Plastic Surgery
Wolfgang Bähr, M.D., D.M.D. Head of Plastic Surgery Unit
Ass. Professor of Maxillofacial Surgery Clinic for Reconstructive Surgery
University Clinic for Maxillofacial Surgery University Clinics of Basel, Kantonsspital
79106 Freiburg i.B., Germany 4031 Basel, Switzerland
Benjamin Carson, Professor Paul N. Manson, M.D.

Department of Neurosurgery Professor of Plastic Surgery
Johns Hopkins University Chief of Division of Plastic, Reconstructive
Baltimore, MD 21205, USA and Maxillofacial Surgery
Johns Hopkins University
Christopher R. Forrest, M.D., M.Sc., F.R.C.S.(C) Baltimore, MD 21287–0981, USA
Ass. Professor, Craniofacial Program
Division of Plastic Surgery Bernard L. Markowitz, M.D., F.A.C.S.
The Hospital for Sick Children Ass. Professor of Plastic Surgery
Toronto, Ontario M5G 1X8, Canada Division of Plastic Surgery
University of California
Beat Hammer, M.D., D.M.D. Los Angeles, CA 90095, USA
Ass. Professor of Maxillofacial Surgery
Clinic for Reconstructive Surgery Stephan M. Perren, M.D., Dr. sc. (h.c.)
Unit for Maxillofacial Surgery Professor of Surgery
University Clinics of Basel, Kantonsspital AO Development
4031 Basel, Switzerland 7270 Davos, Switzerland
Chairman of AO/ASIF Technical Commission
Douglas W. Klotch, M.D., F.A.C.S.
Associate Professor of Surgery John H. Phillips, M.D., F.R.C.S. (C)
Director of Division of Otolaryngology Professor of Plastic Surgery
Department of Surgery, College of Medicine Medical Director, Craniofacial Program
University of South Florida Division of Plastic Surgery
Tampa, FLA 33606, USA The Hospital for Sick Children
Chairman of Maxillofacial Technical Commission Toronto, Ontario M5G 1X8, Canada
VI Chapter Authors and Contributors
Carolyn Plappert Mark A. Schusterman, M.D.

Product Manager Maxillofacial Ass. Professor of Plastic Surgery
STRATEC Medical Chairman of Department of Plastic Surgery
4437 Oberdorf, Switzerland University of Texas
M.D. Anderson Cancer Center
Joachim Prein, M.D., D.M.D. Houston, TX 77030, USA
Professor of Maxillofacial Surgery
Chairman of Clinic for Reconstructive Surgery Peter Stoll, M.D., D.M.D.
Unit for Maxillofacial Surgery Ass. Professor of Maxillofacial Surgery
University Clinics of Basel, Kantonsspital University Clinic for Maxillofacial Surgery
4031 Basel, Switzerland 79106 Freiburg i.B., Germany
Chairman of European Maxillofacial
Educational Committee Patrick K.Sullivan, M.D.
Associate Professor of Plastic Surgery
Berton A. Rahn, M.D., D.M.D. Brown University
Professor of Maxillofacial Surgery Providence, R.I. 02905, USA
AO Research Institute
7270 Davos, Switzerland Craig A. Vander Kolk, M.D.
Associate Professor
Wilfried Schilli, M.D., D.M.D. Director of Cleft and Craniofacial Center
Professor emeritus of Maxillofacial Surgery The Johns Hopkins Outpatient Center
Director emeritus of University Clinic 8152D, Baltimore, MD 21287–0981, USA
for Maxillofacial Surgery
79106 Freiburg i.B., Germany
VII
Foreword
Clinical research continues to confirm that no truth is total care of the severely traumatized patient in the first
more transitory than that in the sphere of scientific hours following the accident.
knowledge.Developments in the field of traumatology at The further development of the AO/ASIF concept led
the end of this century provide a striking example of to today’s comprehensive craniofacial surgery in the
this. As early as 1890 Lambotte carried out osteosynthe- fields of traumatology, orthognatics, tumor, and recon-
ses with plates and screws. These remained a mere epi- structive surgery.
sode, however, until Danis renewed the idea of internal AO/ASIF courses contributed fundamentally to the
fixation 50 years later. Danis combined internal fixation development of these fields. In the course of its world-
with the new technique of interfragmentary compres- wide response, the AO/ASIF philosophy has been able to
sion, which led to primary bone healing that allowed full attract distinguished authors to join the faculty of
function at the same time. Reacting to disconcerting sta- AO/ASIF courses. By sharing their clinical, experimen-
tistics about the results of conservative fracture treat- tal, and theoretical experience, they take part in shaping
ment, Mueller then applied interfragmentary compres- a special internal fixation technique in the craniofacial
sion to 80 patients in Switzerland and confirmed its use- skeleton. The philosophical aspect of AO/ASIF courses
fulness. in theory and practice assures high standards of quality.
Mueller, recognizing the need for further develop- After all, the enormous progress in metal implantology
ments in clinical application, and scientific analysis, should not hide the fact that lack of knowledge and
assembled a group of friends consisting of general and experience, on the one hand, and false compromises, on
orthopedic surgeons in 1958 with the aim of creating the the other, can cause much greater damage than with
necessary armamentarium for internal fixation and to conservative methods.
form a study group for clinical trials. This group came to Thus this interdisciplinary manual provides stan-
be known as the Arbeitsgemeinschaft für Osteosynthese- dards for the application of the AO/ASIF principles. The
fragen (AO), and later in English-speaking countries as scientific and technological background is based on the
the “Association for the Study of Internal Fixation” laws of nature. Resulting from the interaction between
(ASIF). Building on the conviction that the objectivity of pure research and clinical practice, it comprises in the
nature is not merely an illusion, the initiators of widest sense the fields of organization, biomechanics,
AO/ASIF – Müller,Allgöwer,Willenegger, Schneider, and anatomy, and osteology as well as metallurgy and the
Bandi – transformed the pragmatically oriented concept application of tools.
into a scientific method of applied physics, mathemat- The accumulated knowledge is integrated in topo-
ics, and biology. In combination with systematic teach- graphically defined surgery of the skull (splanchnocra-
ing of specialists in AO/ASIF courses, subjectivity was nium), including the walls of the upper respiratory and
thus excluded as much as possible from the choice of digestive tracts.
means. The goals and principles of AO/ASIF are built on The bottom line of this surgery is internal fixation.
this basis and are summarized in the AO/ASIF philoso- The differences in its application are dictated by the
phy. variety of craniofacial bones with respect to their func-
Convinced of its benefit by this approach, the maxil- tion and structure. On the one hand, we are dealing with
lofacial unit of the Department of Surgery at the Univer- a motional apparatus in the area of the mandible; on the
sity of Basel adopted the AO/ASIF philosophy in 1966. other, the maxilla represents a supportive frame of
The consistent application of the two principles of ana- lamellas,among others for nose and eyes,and the cranial
tomical reduction of fracture fragments and stable vault a supportive frame of diploë for the brain. Corre-
internal fixation guaranteed the immediate, active, and spondingly, two qualities of stability are being distin-
pain-free opening and closing of the lower jaw. The guished in practice: functionally stable and locally stable
results were also considerably improved by the early fixation.
VIII Foreword
In the past 10 years there has been a rapid increase in

the degree of perfection in treating most complicated
fractures, disturbances of growth in the regio mastica-
toria and facialis, and malformations in the areas of the
nose, eyes, and skull. These operations are further
improved by preoperative planning with spiral 3 DCT,
3D laser stereolithography, and virtual-reality pros-
thetic design. These techniques still depend highly on
international cooperation. Initial experiences have
shown how complex craniofacial injuries, including the
loss of functionally and anatomically important bone
parts, can be simulated ad hoc and immediately treated
with adequate autologous bone, if necessary in combi-
nation with hydroxyapatites.
Looking back to the beginnings in the 1970s and
1980s, one can observe with great satisfaction that this
progress has been the work of distinguished representa-
tives of the disciplines involved. I am most thankful for
the honor of their personal friendship and acquain-
tance.
This manual will be a safe standard for teaching and
applying internal fixation in AO/ASIF courses as well as
in the operating room.
Great acknowledgement is due to the editor and the
authors.
Prof. Dr. Dr. Bernd Spiessl

IX
Preface
This Manual of Internal Fixation in the Craniofacial This first AO/ASIF Manual on Internal Fixation Tech-
Skeleton is the result of fascinating developments in niques in the Craniofacial Skeleton is the product of col-
internal fixation techniques for the facial skeleton over laborative work on the part of many cranio-maxillofa-
the past 30–40 years. These techniques are based on the cial specialists worldwide. Since the first maxillofacial
AO/ASIF philosophy for fracture care in the general course in Davos in 1974 and the first AO/ASIF course in
skeleton – ensuring early pain-free movement, precise the United States in 1984, 20 courses have been con-
anatomical reduction, and adequate fixation according ducted in Davos and 109 worldwide, with several thou-
to the various functional forces. The principles and tech- sand persons participating. In addition to these courses,
niques described here have grown out of continuous numerous international workshops have been orga-
international cooperation involving a great number of nized to deal with specialized topics. The principles pre-
specialists working in the craniofacial area. It also con- sented in this Manual have developed out of both the
tinues the ideas originally developed by pioneers in the good and the disappointing experiences during this
field who carried out important clinical and experimen- experimental, educational, and practical work. An
tal research. In this context we should mention particu- important feature of all the courses on internal fixation
larly Champy, Michelet, Luhr, Spiessl, and Tessier. in cranio-maxillofacial surgery is that they were orga-
In its early days in the 1950s and 1960s this approach nized by and for oral and maxillofacial surgeons, plastic
to internal fixation of facial bones found application surgeons, and ENT surgeons. In this Manual we try to
principally in the treatment of trauma patients. The demonstrate the results of this close international coop-
favorable experiences gathered in the meantime, how- eration, including the substantial clinical experience
ever, have led to many of the advantages of internal fix- and research carried out principally in the AO/ASIF
ation being extended to the reconstruction of tumor Research Institute in Davos.
defects and the stabilization of major osteotomies in The fact that this Manual deals only with techniques
orthognathics and craniofacial surgery. for open internal fixation does not reflect an opinion on
Today we also appreciate the important role that our part that every fracture should be operated on. How-
facial trauma plays in the early definitive treatment of ever, it is our opinion that internal fixation – employing
polytraumatized patients, particularly in reducing adult the appropriate technique for the correct indication –
respiratory distress syndrome and multiple organ fail- entails substantial safety and diminishes morbidity for
ure. Close cooperation among all those working in the patients. One could even maintain that adequate and
various related disciplines and specialties for the cranio- safe internal fixation provides the best protection
maxillofacial area is essential to ensure optimal results against infection and is of even greater importance than
for patients. This is especially so regarding the partici- antibiotics. Internal fixation, especially in traumatology,
pation of the neurosurgeon in cases of traumatology can also have a very considerable socioeconomic impact
and craniofacial surgery. The concept of early definitive when one considers the various factors that affect treat-
treatment sometimes means many hours of surgery, and ment costs – including the duration of surgery, cost of
therefore another crucial participant in the treatment materials, training of the surgeon, as well as the patients’
team is the anesthesist, and important progress has also absence from work.
been made in this area over recent years. This Manual is divided into seven chapters, with a
Four major advances underlie the great progress in single author responsible for each; only the first chapter
craniofacial surgery in recent decades: (a) the technique on research and instruments has two authors. Interna-
of approach, (b) the technique of internal fixation with tional contributors, who are mentioned before each
plates and screws, (c) the development of optimal mate- respective chapter, have put in their knowledge and have
rials such as titanium, and (d) modern imaging tech- made significant contributions.
niques like CT and MRI. The material presented here reflects our present
knowledge of the subject, and its correct application can
X Preface
surely mean comfort and benefits to our patients. On the

other hand, however, it represents only the latest mile-
stone on the way to further progress. We hope that this
Manual proves an important help both during courses
and during surgery.
In the name of all the coauthors and contributors
who have invested a tremendous amount of time,
knowledge, and work, I wish to thank especially Mrs.
Helga Reichel-Kessler, whose continuous and never-
ending encouragement was essential in finalizing the
manuscript and thus in completing the whole project.
I want to thank especially Mr. Kaspar Hiltbrant for his
very clear and precise drawings, which are a particular
feature of this Manual. I am also grateful to Mrs. Ruth
Rahn, who provided very important prestudies for these
drawings.
Finally, I thank the staff of Springer-Verlag for their
excellent help in preparing this Manual for publication.
Prof. Dr. Joachim Prein

XI
Contents
1.6.1.3
List of Screws . . . . . . . . . . . . . . 21
1 Scientific Background . . . . . . . . . . . . . . . . 1 1.6.1.4
Technique of Screw Insertion . . . . . 23
Chapter Authors: J.Prein and B.A.Rahn 1.6.1.5
Instruments for Screw Insertion . . . . 24
Contributors: J.Prein, B.A.Rahn, C.Plappert, 1.6.2 Plates . . . . . . . . . . . . . . . . . . . 28
and S.M.Perren 1.6.2.1
Craniofacial Plates . . . . . . . . . . . 28
1.6.2.2
Mandible and Reconstruction
1.1 Introduction . . . . . . . . . . . . . . . . . . . 1 Plates . . . . . . . . . . . . . . . . . . . 30
1.1.1 The AO/ASIF Foundation . . . . . . . 1 1.6.3 Instruments . . . . . . . . . . . . . . . 37
1.1.2 Research . . . . . . . . . . . . . . . . . 2 1.6.4 Power Tools . . . . . . . . . . . . . . . 42
1.1.3 Development . . . . . . . . . . . . . . 2 1.7 Set Configurations . . . . . . . . . . . . . . . . 44
1.1.4 Education . . . . . . . . . . . . . . . . 2 1.7.1 European Set Configuration . . . . . . 44
1.1.5 Documentation and Clinical 1.7.2 North American Set Configuration . . 44
Investigations . . . . . . . . . . . . . . 3 1.8 External Fixation Devices . . . . . . . . . . . . 48
1.1.6 Fracture Classification . . . . . . . . . 3 References and Suggested Reading . . . . . . . . . . 48
1.2 Bone as a Material . . . . . . . . . . . . . . . . 5
1.2.1 Structure . . . . . . . . . . . . . . . . . 5
1.2.2 Chemical Composition . . . . . . . . . 6 2 Anatomic Approaches . . . . . . . . . . . . . . . . 51
1.2.3 Mechanical Properties . . . . . . . . . 6 Chapter Author: J.Prein
1.2.4 Mechanical Glossary . . . . . . . . . . 6 Contributor: N.J.Lüscher
1.3 Fractures in the Cranio-Maxillo-Facial
Skeleton . . . . . . . . . . . . . . . . . . . . . 7
1.3.1 Origin of Skull Bones . . . . . . . . . . 7 3 Mandibular Fractures . . . . . . . . . . . . . . . . 57
1.3.2 Load-Bearing Structures in the Chapter Author: W.Schilli
Cranio-Maxillo-Facial Skeleton . . . . 7 Contributors: P.Stoll, W.Bähr, and J.Prein
1.3.3 The Fracture . . . . . . . . . . . . . . . 8
1.3.4 Biological Reaction and Healing 3.1 Introduction . . . . . . . . . . . . . . . . . . . 57
of Bone . . . . . . . . . . . . . . . . . . 8 3.2 Treatment Planning . . . . . . . . . . . . . . . 57
1.4 Indications for Operative Treatment 3.3 Cost Effectiveness . . . . . . . . . . . . . . . . 57
of Fractures . . . . . . . . . . . . . . . . . . . 12 3.4 Adequate Stability . . . . . . . . . . . . . . . . 58
1.5 Operative Reduction and Internal Fixation . . 12 3.5 Mistakes in Application and Technique . . . . 58
1.5.1 Reestablishing Stability . . . . . . . . . 12 3.6 Failures . . . . . . . . . . . . . . . . . . . . . . 59
1.5.2 Implant Materials . . . . . . . . . . . . 13 3.7 Indications for Osteosynthesis . . . . . . . . . 59
1.5.2.1 Stainless Steel . . . . . . . . . . . . . . 13 3.8 Indications for Perioperative
1.5.2.2 Titanium . . . . . . . . . . . . . . . . . 13 Antibiotic Cover . . . . . . . . . . . . . . . . . 59
1.5.2.3 Biodegradable Polymeric Materials . . 14 3.9 General Remarks . . . . . . . . . . . . . . . . 59
1.5.3 Implant Removal . . . . . . . . . . . . 14 3.10 Localization and Types of Fracture . . . . . . 59
1.5.4 Principles of Stabilization . . . . . . . 15 3.11 Fractures of the Symphysis and the
1.5.4.1 Splinting . . . . . . . . . . . . . . . . . 15 Parasymphyseal Area . . . . . . . . . . . . . . 60
1.5.4.2 Compression . . . . . . . . . . . . . . 15 3.11.1 Transverse Fracture Line
1.6 Design and Function of Implants Without Dislocation . . . . . . . . . . 60
and Instruments . . . . . . . . . . . . . . . . . 19 3.11.2 Transverse Fracture Line
1.6.1 Screws . . . . . . . . . . . . . . . . . . 19 With Dislocation . . . . . . . . . . . . 63
1.6.1.1 Function of Screws . . . . . . . . . . . 19 3.11.3 Fracture Line With Basal Triangle . . . 65
1.6.1.2 Types of Screws . . . . . . . . . . . . . 19 3.11.4 Comminuted Fractures . . . . . . . . . 66
XII Contents
3.12 Fractures of the Horizontal Ramus . . . . . . 66 4.2.1.3 Diagnosis . . . . . . . . . . . . . . . 112

3.12.1 Transverse Fracture Line 4.2.1.4 Le Fort I Fractures . . . . . . . . . . 114
Without Dislocation . . . . . . . . . . 67 Treatment . . . . . . . . . . . . . . 114
3.12.2 Transverse Fracture Line Airway Management . . . . . . . . 115
With Dislocation . . . . . . . . . . . . 67 Exposure . . . . . . . . . . . . . . . 116
3.12.3 Oblique Fracture Line With/Without Reduction . . . . . . . . . . . . . . 116
Dislocation . . . . . . . . . . . . . . . 70 Occlusion . . . . . . . . . . . . . . . 118
3.12.4 Fracture Line With Basal Triangle . . 72 Fixation . . . . . . . . . . . . . . . . 118
3.12.5 Comminuted Fractures . . . . . . . . 72 Bone Grafting . . . . . . . . . . . . 121
3.13 Fractures of the Mandibular Angle . . . . . . 73 Palatal Fractures . . . . . . . . . . . 121
3.13.1 Transverse Fracture Line Alveolar Ridge . . . . . . . . . . . . 122
Without Dislocation . . . . . . . . . . 75 4.2.2 Upper Midface (Le Fort II and III) . . . . . 122
3.13.2 Transverse Fracture Line Contributor: J.Prein
With Dislocation . . . . . . . . . . . . 76 4.2.2.1 Anatomy . . . . . . . . . . . . . . . 122
3.13.3 Angular Fractures With Basal 4.2.2.2 Diagnosis . . . . . . . . . . . . . . . 122
Triangle . . . . . . . . . . . . . . . . . 78 4.2.2.3 Treatment . . . . . . . . . . . . . . 122
3.13.4 Comminuted Angular Fractures . . . 79 References and Suggested Reading . . . . . . . . . 126
3.13.5 Comminuted Fractures of the
Ascending Mandibular Ramus . . . . 81
3.14 Condylar and Subcondylar Fractures . . . . 83 4.3 Naso-Orbital-Ethmoid Fractures . . . . . . . . 127
3.14.1 Transverse Fracture Line Contributors: B.Hammer and J.Prein
With Dislocation . . . . . . . . . . . . 83
3.15 Fractures of the Atrophic Mandible . . . . . 87 4.3.1 Definition . . . . . . . . . . . . . . . . . . . 127
3.16 Infected Fractures . . . . . . . . . . . . . . . 87 4.3.2 Anatomy . . . . . . . . . . . . . . . . . . . 127
3.17 Defect Fractures . . . . . . . . . . . . . . . . 88 4.3.3 Fracture Patterns . . . . . . . . . . . . . . . 127
3.18 Mandibular Fractures in Children . . . . . . 92 4.3.4 Plates Used for Internal Fixation
References and Suggested Reading . . . . . . . . . 92 of NOE Fractures . . . . . . . . . . . . . . . 130
4.3.5 Exposure . . . . . . . . . . . . . . . . . . . 130
4.3.6 Diagnosis . . . . . . . . . . . . . . . . . . . 130
4 Craniofacial Fractures . . . . . . . . . . . . . . . 95 4.3.7 Operative Treatment . . . . . . . . . . . . . 130
Chapter Author: P.N.Manson 4.3.7.1 Management of Central Fragment . 130
4.3.7.2 Transnasal Canthopexy . . . . . . . 132
4.1 Organization of Treatment 4.3.7.3 Nasal Reconstruction . . . . . . . . 132
in Panfacial Fractures . . . . . . . . . . . . . . . . 95 4.3.8 NOE Fracture-Related Problems . . . . . . 132
Contributor: P.N.Manson 4.3.8.1 Lacrimal Duct Injuries . . . . . . . 132
4.3.8.2 Frontal Sinus . . . . . . . . . . . . . 132
4.1.1 Introduction . . . . . . . . . . . . . . . . . 95 4.3.8.3 Skull Base Injuries . . . . . . . . . . 132
4.1.2 Surgical Sequencing of Le Fort Fracture 4.3.8.4 Orbital Reconstruction . . . . . . . 132
Treatment . . . . . . . . . . . . . . . . . . . 95 References and Suggested Reading . . . . . . . . . 132
4.1.3 Occlusion . . . . . . . . . . . . . . . . . . . 95
4.1.4 Upper Face: The Cranial Unit . . . . . . . . 98
4.1.5 Upper Midfacial Unit . . . . . . . . . . . . 98 4.4 Zygomatic Complex Fractures . . . . . . . . . . 133
4.1.6 Lower Face . . . . . . . . . . . . . . . . . . 102 Contributors: B.Markowitz and P.N.Manson
4.1.7 Linking the Upper and Lower Face . . . . . 103
4.1.8 Edentulous Fractures . . . . . . . . . . . . 103 4.4.1 Definition . . . . . . . . . . . . . . . . . . . 133
4.1.9 Soft Tissue . . . . . . . . . . . . . . . . . . 103 4.4.2 Treatment . . . . . . . . . . . . . . . . . . . 134
4.1.10 Soft-Tissue Injury . . . . . . . . . . . . . . 103 4.4.3 Exposure . . . . . . . . . . . . . . . . . . . 134
4.1.11 The “Double Insult” to Soft Tissue . . . . . 107 4.4.4 Reduction . . . . . . . . . . . . . . . . . . . 134
References and Suggested Reading . . . . . . . . . 107 4.4.5 Stabilization . . . . . . . . . . . . . . . . . 135
4.4.6 Internal Orbit . . . . . . . . . . . . . . . . . 137
4.4.7 Soft-Tissue Closure . . . . . . . . . . . . . 138
4.2 Le Fort I–III Fractures . . . . . . . . . . . . . . 108 References and Suggested Reading . . . . . . . . . 138
4.2.1 Lower Midface (Le Fort I) . . . . . . . . . . 108
Contributors: C.R.Forrest and J.H.Phillips
4.2.1.1 Anatomy . . . . . . . . . . . . . . . 108
4.2.1.2 Classification . . . . . . . . . . . . . 108
Contents XIII
5.3.6 Reconstruction of Tumor Defects

4.5 Orbital Fractures . . . . . . . . . . . . . . . . . 139 With Vascularized Bone Grafts
Contributor: P.N.Manson and Their Fixation With Plates . . . . 168
5.3.7 Repair of the Anterior Defect Using
4.5.1 Definition . . . . . . . . . . . . . . . . . . . . 139 a Microvascular Free Bone Flap and
4.5.2 Diagnosis . . . . . . . . . . . . . . . . . . . . 142 Fixation With Universal Fracture
4.5.3 Treatment . . . . . . . . . . . . . . . . . . . . 142 Plates (Microvascular Plates),
4.5.4 Reconstruction of Ethmoid Defects . . . . . 143 UniLOCK, or Mini Plates . . . . . . . 168
4.5.5 Zygomatic (Lateral and Inferior Wall) 5.3.8 Repair of Tumor Defects With
Injuries . . . . . . . . . . . . . . . . . . . . . 144 Anterior Soft-Tissue Extension
4.5.6 Naso-Orbital-Ethmoid Fractures . . . . . . . 146 with Microvascular Free Bone Flap
4.5.7 Superior Orbital Rim and Roof Fractures . . 146 and Bridging Plate . . . . . . . . . . . 170
References and Suggested Reading . . . . . . . . . 147 5.3.9 Reconstruction of the Condyle:
General Remarks . . . . . . . . . . . 170
5.3.10 Joint Repair With Costochondral
4.6 Cranial Vault . . . . . . . . . . . . . . . . . . . 148 Grafts . . . . . . . . . . . . . . . . . . 171
Contributors: P. Sullivan and P.N.Manson 5.3.11 Alloplastic Replacement of the
Condylar Process . . . . . . . . . . . 173
4.6.1 Frontal Sinus and Frontal Bone . . . . . . . . 148 5.3.12 Condylar Prosthesis for Latero-
4.6.2 Special Conditions Influencing mandibular Defects Including
Open Reduction and Internal Fixation . . . . 148 the Joint . . . . . . . . . . . . . . . . 175
4.6.3 Sinus Function and Operative Treatment . . 148 5.3.13 Management of Mandibular
4.6.4 Types of Fixation . . . . . . . . . . . . . . . . 148 Resection Including the Condyle
4.6.5 Esthetics . . . . . . . . . . . . . . . . . . . . 151 Using Microvascular Bone Flaps
4.6.6 Osteotomy . . . . . . . . . . . . . . . . . . . 151 and Various Plates for Fixation . . . 177
4.6.7 Exposure . . . . . . . . . . . . . . . . . . . . 152 5.3.14 Repair of the Lateral Mandible
References and Suggested Reading . . . . . . . . . 154 Including the Condyle: Osseous
Free Flap and Bridging Plate . . . . . 179
5.3.15 Repair of the Lateral Mandible
5 Reconstructive Tumor Surgery in the Mandible . 155 and Condyle: Microvascular Free
Chapter Author: D.W.Klotch Flap and Reconstruction Plate
Contributors: D.W.Klotch, C.Lindqvist, With Condylar Prosthesis
M.Schusterman, and J.Prein (Schusterman) . . . . . . . . . . . . . 179
5.3.16 Condylar Reconstruction: Condylar
5.1 Diagnosis . . . . . . . . . . . . . . . . . . . . 155 Transplant and Vascularized Bone
5.2 Patient Selection . . . . . . . . . . . . . . . . 155 Flap Reconstruction . . . . . . . . . . 181
5.3 Description of Procedures . . . . . . . . . . . 156 5.4 Complications . . . . . . . . . . . . . . . . . 181
5.3.1 Mandibular Osteotomy . . . . . . . . 156 5.5 Technical Errors . . . . . . . . . . . . . . . . 181
5.3.2 Stabilization of Curetted Mandibular 5.5.1 Plate Failure . . . . . . . . . . . . . . 182
Defects . . . . . . . . . . . . . . . . . 158 5.5.2 Screw Failure . . . . . . . . . . . . . . 182
5.3.3 Segmental Resection for 5.5.3 Soft-Tissue Failure . . . . . . . . . . . 182
Benign Tumors . . . . . . . . . . . . 159 5.5.4 Joint Failure . . . . . . . . . . . . . . 182
5.3.4 Plate Application for Tumors 5.5.5 Bone Failure . . . . . . . . . . . . . . 183
with Extension Through the References and Suggested Reading . . . . . . . . . 183
Anterior Buccal Cortex . . . . . . . . 161
5.3.4.1 Plate Application for Anterior Tumor
Extension Using the Mandible Fix 6 Stable Internal Fixation of Osteotomies
Bridge Device . . . . . . . . . . . . . 162 of the Facial Skeleton . . . . . . . . . . . . . . . . . 185
5.3.4.2 Fixation With Miniplates . . . . . . . 164 Chapter Author: L.A.Assael
5.3.4.3 Fixation With a Reconstruction Contributors: L.A.Assael and J.Prein
Plate . . . . . . . . . . . . . . . . . . 164
5.3.4.4 Three-Dimensional Computer 6.1 Introduction . . . . . . . . . . . . . . . . . . 185
Modeling . . . . . . . . . . . . . . . . 165 6.2 Treatment Planning for Internal Fixation
5.3.5 Application of Bone Grafts of Osteotomies . . . . . . . . . . . . . . . . . 185
Following Bridging Plate 6.3 Surgical Procedures . . . . . . . . . . . . . . 187
Stabilization . . . . . . . . . . . . . 165 6.3.1 Mandibular Surgery . . . . . . . . . . 187
XIV Contents
6.3.1.1Sagittal Split Osteotomy . . . . . . . . 187 7.4 Planning and Reconstruction . . . . . . . . . 205

6.3.1.2Other Ramus Osteotomies . . . . . . 190 7.5 Surgical Technique: Anterior Cranial
6.3.1.3Genioplasty . . . . . . . . . . . . . . 191 Expansion and Reconstruction . . . . . . . . 205
6.3.1.4Mandibular Segmental Surgery . . . 191 7.6 Posterior Cranial Expansion . . . . . . . . . 210
6.3.2 Midface Surgery: 7.7 Complete or Subtotal Calvarial
Le Fort I Osteotomy . . . . . . . . . . 192 Expansion . . . . . . . . . . . . . . . . . . . . 211
6.4 Evaluation of Outcomes . . . . . . . . . . . . 193 7.8 Hypertelorism . . . . . . . . . . . . . . . . . 214
6.5 Complications . . . . . . . . . . . . . . . . . 197 7.9 Monoblock Osteotomies . . . . . . . . . . . . 215
6.6 Summary . . . . . . . . . . . . . . . . . . . . 198 7.10 Orbital Dystopia . . . . . . . . . . . . . . . . 215
References and Suggested Reading . . . . . . . . . 198 7.11 Craniofacial (Hemifacial) Microsomia . . . . 215
7.12 The Treacher Collins Malformation . . . . . 217
7.13 Encephaloceles . . . . . . . . . . . . . . . . . 217
7 Craniofacial Deformities . . . . . . . . . . . . . . 199 7.14 Bone Lengthening by Continuous
Chapter Author: P.N.Manson Distraction . . . . . . . . . . . . . . . . . . . 219
Contributors: P.N.Manson, C.A.VanderKolk, 7.14.1 Distraction for Mandibular
and B. Carson Deformities . . . . . . . . . . . . . . 219
7.14.2 Midface Distraction . . . . . . . . . . 222
7.1 Introduction . . . . . . . . . . . . . . . . . . 199 References and Suggested Reading . . . . . . . . . 222
7.2 Incisions for Craniofacial Reconstruction
and Patient Positioning . . . . . . . . . . . . 201
7.3 Craniosynostosis . . . . . . . . . . . . . . . . 201 Subject Index . . . . . . . . . . . . . . . . . . . . . 225
Chapter 1 1
Scientific and Technical Background 1

Chapter Authors: Joachim Prein
Berton A.Rahn
Contributors: Joachim Prein
Berton A.Rahn
Carolyn Plappert
Stephan M.Perren
from ideas and from research and development activ-

1.1 Introduction ities are licensed to the three Synthes producers, Mathys
AG Bettlach, Stratec Medical Oberdorf, both in Switzer-
1.1.1 The AO/ASIF Foundation land, and Synthes USA, Paoli. The royalties which they
pay finance the activities of the AO/ASIF Foundation.
The Association for the Study of Internal Fixation The activities of the Foundation are supervised by an
(ASIF) was founded in 1958 in Switzerland under its international Board of Trustees, comprising 90 leading
original German name “Arbeitsgemeinschaft für Osteo- surgeons in various specialities in orthopedics and
synthesefragen (AO),” a working group to deal with trauma, including cranio-maxillo-facial surgery. The
questions on internal fixation of fractures. This group in Academic Council establishes the basic medical and sci-
the meantime has become an international organization entific goals of the foundation, taking specific regional
dedicated to improving the care of patients with muscu- needs and socioeconomic aspects into account. It pro-
loskeletal injuries and their sequelae through research vides input to research and development and suggests
and education in the principles, practice, and quality new therapeutic recommendations and teaching meth-
control of the results of treatment. In 1984 this study ods to be associated with them. The Academic Council
group was transformed into a nonprofit foundation pro- is responsible, on behalf of the Board of Trustees, for the
viding an umbrella structure for its activities in the strategic and middle-range planning, and a Board of
fields of research, development, education, and docu- Directors ensures that the goals of the Academic Coun-
mentation. New technologies and products developing cil can be implemented.
Fig. 1.1
The AO/ASIF Center. This institution serves as an international ment, education, and documentation relevant to trauma care.
service center, coordinating the various worldwide activities of It is located in an attractive Alpine environment in Davos, Swit-
the foundation and providing support in research, develop- zerland
2 Chapter 1 · Scientific and Technical Background
Products before they are adopted by the AO/ASIF are

submitted to a Technical Commission, with representa- 1.1.3 Development
tives from both the medical and the manufacturing
sides. Speciality Technical Commissions exist for vari- The goal of development activities at the AO/ASIF is to
ous fields of surgery, including a Maxillofacial Technical support the AO/ASIF Foundation in attaining its medi-
Commission. Although it is not possible to incorporate cal objectives by providing new techniques and safe
into this commission every single speciality group per- equipment for treating injuries to the skeletal and loco-
forming surgery in the cranio-maxillo-facial region, this motor system. Such development should be as universal
Technical Commission tries to cover, across the special- as possible and of high quality and safety standards. In
ity borders, the medical needs in a most comprehensive combination with the appropriate theoretical and prac-
way. In the Maxillofacial Technical Commission, as tical teaching these methods should be simple enough
within all Technical Commissions, the medical side out- for general use.
weighs the manufacturing side by a five to three major- AO/ASIF development comprises the Development
ity. This principle ensures that professional decisions Coordination Group, the AO/ASIF Development Insti-
regarding medical concepts and ideas are not domi- tute (ADI), the development groups of each of the three
nated by commercial issues. On the other hand, this manufacturers, and the AO/ASIF Technical Commis-
structure allows for direct input from the medical mar- sion, the only organization authorized to approve a
ket place reflecting the needs of the surgeons in the field. device. The ADI involves 30 collaborators, mainly tech-
The AO/ASIF Center (Fig. 1.1), located in Davos, Swit- nically and application oriented. It functions in close
zerland, is conceived as an international service center, collaboration between clinicians, research, and the three
providing worldwide support in research, development, manufacturers and is guided and supervised by its own
education, and documentation. Steering Committee, consisting of three medical per-
sons and one representative from each of the three man-
ufacturers. Documentation and decisions in all phases
1.1.2 Research conform to ISO 9001, EN 46001, MDD 93/42 EEC, FDA,
and Japanese Standards.
To promote the AO/ASIF Foundation as a clinical and
scientific research organization several mechanisms
have been set up to encourage research relevant to 1.1.4 Education
trauma care. The AO/ASIF Research Institute (ARI) in
Davos is a nonprofit institution dedicated to basic and AO International (AOI) is the educational link, within
applied research in the treatment of trauma of the the foundation, between national and regional AO/ASIF
skeletal system and in related topics. Its scientific inde- sections, surgeons, operating room staff, hospitals, and
pendence is maintained by an international scientific working groups involved in trauma and orthopedic -
Board of Trustees. A multidisciplinary team of some 60 surgery throughout the world. This body coordinates
coworkers includes specialists in surgery, dentistry, biol- courses worldwide, selects from an extensive faculty
ogy, materials science, biomechanics, and biomedical pool to assign speciality-specific and region-specific
engineering. The Research Institute works with clinical course faculty, and supports these teaching efforts with
and basic scientists and with manufacturers in address- appropriate educational material. In these courses the
ing topics relevant to the understanding and treatment scientific background is presented, the principles devel-
of musculoskeletal injuries and their sequelae. A num- oped from this basic knowledge, and the way in which
ber of other institutions are included in the worldwide these principles are to be applied in a practical situation.
network of common interests and receive support from Bone models presenting the most important fracture
the foundation. The AO/ASIF Research Commission patterns are used for practical training, and videotapes
provides grants to support research projects dealing show the appropriate procedures in a step-by-step
with trauma, surgery of the skeletal system, and related approach.
basic and clinical topics. Its aim is to provide “seed Fellowships and scholarships are available in many
money” intended especially to fund work on novel con- countries in approved AO/ASIF teaching clinics for sur-
cepts and work by young researchers. geons and for operating room personnel. Membership
in the AO/ASIF Alumni Association is open to AO/ASIF
faculty members, former scholarship fellows, and par-
ticipants of advanced AO/ASIF courses.This Association
promotes communication between surgeons and the
AO/ASIF bodies and supports symposia and meetings
to alumni up to date on current trends and activities in
the fields of research, development, education, and doc-
umentation.
1.1 · Introduction 3
1.1.5 Documentation and Clinical Investigations 1.1.6 Fracture Classification
In its early days the AO/ASIF Documentation Center A comprehensive classification has been developed by
sought to collect information on all cases treated within the AO/ASIF group that includes the site of the fracture,
the group. This offered an enormous help during the its degree of severity, and the approach to treatment.
pioneering phase in assessing the efficiency and the This classification (Fig. 1.2) is based on the differentia-
risks of approaches which at the time often seemed very tion of bone segment fractures into three types, their
aggressive methods of treatment. Today the emphasis is further division into three groups and their subgroups,
more on prospective studies. A decentralized documen- and the arrangement of these in an ascending order of
tation system has been developed. This system uses a severity according to the morphological complexities of
uniform design that permits local documentation but the fracture, the difficulties in their treatment, and their
the possibility of pooling data between different centers. prognosis. In graphic representations the colors green,
The documentation department provides guidelines orange, and red and darkened arrows indicate the
and assistance in coordinating such multicenter studies, increasing severity. A1 indicates the simplest fracture
from the planning phase to the final evaluation. with the best prognosis, and C3 the most difficult frac-
Bone segment Type Group Subgroup Scale of severity
Fig. 1.2
The principle of the comprehensive AO/ASIF classification. In Darkening arrows, increasing severity in terms of both
ascending severity the fractures are subdivided into three potential difficulties in treatment and the expected prognosis
major types: A, B, and C.Within each type a further tripartition of outcome. Green, lowest severity; yellow, intermediate sever-
into groups (A1, A2, A3, etc.) and subgroups (A1.1, A1.2, etc.) is ity; red, highest severity. (From Müller et al. 1991)
performed, again ranked in order of increasing severity.
Fig. 1.3 In this classification the cranio-maxillo-facial area is not

The anatomic location in the AO/ASIF classification. In devel- considered as a single entity; only the mandible is
oping this comprehensive classification system the authors included, listed among varia together with the patella,
focused primarily on long bones.
An adaptation to the specific needs of cranio-maxillo-facial clavicle, and scapula. The anatomical relationships and
surgery has not yet been performed, but it appears feasible to patterns are more complex in cranio-maxillo-facial
subdivide this area into mandible, facial, and cranial regions. fractures than in long bones, and typical fracture planes
The mandible could then further be subdivided into collum, frequently involve more than one bone. Therefore a
ramus, and corpus; the facial area into lateral, central caudal, comprehensive fracture classification, although offering
and central cranial; and the cranial area into a frontal region,
cranial vault, and skull base. (From Müller et al. 1991)
certain interesting features, would require major mod-
ifications to become suitable for cranio-maxillo-facial
surgery.
ture with the worst prognosis. Classifying a fracture Classifications of cranio-maxillo-facial fractures
thus establishes its severity and provides a guide to its began with the classical Le Fort types, an approach
treatment. which is simple and practicable but not sufficient for
The AO/ASIF classification system was developed fractures of a higher degree of complexity. In the case of
based particularly on fractures of long bones (Fig. 1.3). the mandible the early descriptive types of fracture clas-
1.2 · Bone as a Material 5
sification were gradually replaced or supplemented by ual transitions may occur between cortical and cancel-
an approach concentrating on the number of fragments, lous structures. By eroding new cavities inside the com-
the site, displacement and occlusion, soft tissue involve- pact structure osteoclasts carve cancellous bone out of
ment, and accompanying fractures in the upper jaw (see the cortical bone, or osteoblasts fill the spaces in the can-
Spiessl 1986). cellous network to transform it into compact bone. Dur-
Classifications in the cranio-maxillo-facial region ing growth-related remodeling processes no net bone
hitherto were limited to specific functional areas, such loss should occur; under pathological conditions, such
as the mandible or the midface, and attempts were made as osteoporosis, the balance between osteoblastic and
to differentiate and to regionally expand the classifica- osteoclastic activities is disturbed, resulting in a weak-
tions taking into account the increasing complexity and ening of skeletal structures.
severity of fracture patterns caused by the increasing On a microscopic level the arrangement of the
influences of high-velocity injury. These efforts led to a organic fibers is used to discriminate between different
subdivision into comminuted fractures of the upper forms of organization. Woven bone contains bundles of
midface, lower midface, with or without concomitant collagen fibers arranged as in connective tissue and con-
mandibular fractures, central midface, and craniofacial nected to the neighboring connective tissue, for
and panfacial fractures. It is now accepted that only instance, the periosteum. This type of tissue can be
imaging in three dimensions can identify and encom- interpreted as connective tissue stiffened by the incor-
pass the complex fracture patterns observed in the cra- poration of mineral to become bone. In the embryonic
nio-maxillo-facial area, and it is this three-dimensional skeleton woven bone is almost ubiquitous. In adults
approach that will provide the basis for any future com- ossified collagen bundles are still found at the insertion
prehensive classification system. sites of tendons and ligaments. The mechanism of
Developing a comprehensive approach for a cranio- woven bone formation is encountered in situations
maxillo-facial fracture classification comparable to that requiring rapid bone repair processes since this mecha-
described for long bones requires that the specific needs nism allows ossification of relatively large areas in a
of this specific region are addressed. When the entire short period of time. Usually the quality of such rapidly
cranio-maxillo-facial area is to be classified at the same formed woven bone structures is inferior to a slowly
hierarchical level as a single long bone, a further subdi- developing compact bone, and after its rapid formation
vision of the anatomical site is absolutely necessary. it frequently undergoes further remodeling to result in a
Describing the anatomic location with sufficient preci- structure adapted to the local requirements.
sion requires subdivisons at least to segment and sub- In the adult the major portion of both cortical and
segment levels. If the principle of tripartition as cancellous bone consists of lamellar bone. Lamellar
described in the original AO/ASIF classification is to be bone appears to be on a more specific level of differenti-
maintained, an adaptation for the cranio-maxillo-facial ation. The arrangement of its collagen fiber bundles
region could consist of a subdivision into mandible, seems to follow certain functional criteria. Comparable
facial region, and cranial regions. The mandible could to technical composite structures, such as steel-rein-
then further be subdivided into collum, ramus, and cor- forced concrete or fiber-glass, the orientation of these
pus; the facial area into lateral, central caudal, and cen- collagen bundles presents a relationship to the mechan-
tral cranial region; and the cranial area into frontal area, ical function of the corresponding bone site. The forma-
cranial vault, and skull base. The original idea of further tion of these highly differentiated lamellar bone struc-
classification according to complexity and severity tures, deposited layer after layer, proceeds much more
could then follow the suggested pattern depicted in slowly than the formation of woven bone. Osteoblasts
Fig. 1.2, using the types A, B, C, the groups A1,A2,A3, B1, usually are able to form approximately 1–2 mm lamellar
B2, etc., and then further subgroups. bone per day. These layers are deposited superficially on
the surfaces of compact bone or on cancellous bone tra-
beculae. Remodeling processes, a concerted action
1.2 Bone as a Material between resorption and formation, take place on both
the outer surface and in the interior of compact bone.
1.2.1 Structure During internal remodeling osteoclasts drill tunnels
into the compact bone; osteoblasts follow and deposit
In the gross aspect, cancellous bone is distinguished new bone concentrically on the walls of the tunnel until
from compact and from cortical bone. These terms the lumen is narrowed to the dimension of the central
describe the arrangement of the bony substance but capillary. Such newly formed structures are called sec-
provide no information on its origin or composition. In ondary osteons or Haversian systems. The result of this
cancellous bone a contiguous system of trabeculae is remodeling is a gradual internal renovation of an exist-
visible, whose dimensions, volume density, and arrange- ing structure while it permanently continues to fulfill its
ment vary with site, loading conditions, and age. Grad- function. This internal remodeling mechanism allows
adaptation of the bony structure to a changing environ- primarily the collagen structures, which determine the
ment. tensile behavior. This composite structure is compar-
The blood supply to the bone in the cranio-maxillo- able to structures designed for technical applications,
facial region is abundant, with many collaterals found at such as steel-reinforced concrete or fiber-glass. Compact
most sites. Inside the bony structures the nutritional bone is a highly anisotropic material, i.e., its mechanical
pathways follow the Haversian systems, and these canals properties differ along different axes. The orientation of
are cross-connected by the Volkmann canals. Each its internal components is believed to be related to the
system usually contains a single vessel of the capillary functional requirements and the loading history of the
type. There is evidence that inside these intracortical corresponding region. The inhomogeneous appearance
low-pressure systems the flow direction alternates that bone sometimes presents on a microscopic level
depending on the current conditions. Peripheral to these may be due to its modeling and remodeling history.
capillaries the perfusion pathways follow the canalicular Anisotropy does not seem to play a major role in inter-
system related to the osteocytes. These canaliculi allow nal fixation.
perfusion over a distance of a few tenths of a millimeter Even during normal daily activities bone must resist
beyond the capillaries. large forces. The ultimate strength of bone is approxi-
The blood supply of compact bone, especially in a mately 1 MPa, about one-tenth that of steel. The dimen-
thick cortex, requires correspondingly long low-pres- sions of bony structures are oversized in relation to the
sure connections inside the bone and makes the com- requirements of normal use, and the strength of a bone
pact structure more susceptible to disturbing influ- therefore retains reserves for the requirements of heavy
ences. Once the intracortical circulation is interrupted, a physical activity. Compression applied to bone can be
long remodeling process is required to reattach the maintained due to the springlike compressibility of the
intracortical vessels to circulation. In cancellous struc- material. Young’s modulus of axial stiffness of cortical
tures the vascular supply reaches the bone surfaces bone is about 20 GPa. By way of illustration, a human
directly, and there are only few and short intraosseous tibia loaded axially with 1000 N would undergo a short-
vessels. All the biological reactions – resorption, remod- ening by 10 mm. The reserves of this spring effect are
eling, healing – may thus take place more rapidly and thus limited, and minimal bone resorption, for example,
more intensely. In the mandible the structure conforms at an implant-bone interface or between fragment ends,
more to the type found in long bones; in the craniofacial would immediately lead to a loss of preload. The com-
region the bones often consist of thin sheets, which parably small loss (10%–20%) observed without
although compact in their design still have the nutri- resorption is explained by the time-dependent deforma-
tional characteristics of cancellous bone, a high surface tion under load (“creep,” or, vice versa, “stress relaxa-
to volume ratio, and thus probably are less prone to dis- tion”). A special characteristic of bone is its brittleness.
turbance of circulation. As a result the susceptibility to When deformed, for example, in elongation, it tolerates
infection is low, and the healing times are short. a deformation of only 2% before it breaks, resulting in
characteristics which are closer to the behavior of glass
than of rubber.
1.2.2 Chemical Composition Bone is found in a compact form in the skeleton, and
in a more or less loose arrangement, as cancellous bone.
Bone matrix is a composite of organic and inorganic The strength of cancellous bone varies but is typically
constituents. The inorganic portion comprises approxi- less than 10% of cortical bone. The mechanical proper-
mately 65% and consists principally of hydroxyapatite ties of cancellous bone depend on the amount of “bone”
[Ca10(PO4)6(OH)2], in addition to magnesium, potas- material that it contains, the design, orientation, and
sium, chlorine, iron, and carbonate in significant connections of trabeculae in relation to the direction of
amounts. Of the organic constituents 90% are collagen, load, and the microstructure inside the trabeculae.
predominantly of type I, and the remaining 10% are
noncollagen proteins, including approximately 23%
osteonectin, 15% osteocalcin, 9% sialoproteins, 9% 1.2.4 Mechanical Glossary
phosphoproteins, 5% a2-HS glycoproteins, 3% albu-
min, and further proteins in smaller amounts. A force (expressed in newtons, N) acting upon a mate-
rial results in a state of internal stress. A force acting
with a lever arm is called a moment; this is expressed in
1.2.3 Mechanical Properties newton meters (Nm). The unit of stress (s), force/area,
is N/m2. Force deforms a material. The deformation
The material “bone”is a composite consisting of mineral ratio, strain (e = dL/L), is unitless and is reported as per-
components, which are primarily responsible for its centage change of the original dimension. The relation-
compressive characteristics, and organic components, ship between the acting force and the resulting deforma-
1.3 · Fractures in the Cranio-Maxillo-Facial Skeleton 7
tion is called stiffness: the less the stiffness the larger the rather than to local or regional boundary conditions,
deformation. The term rigidity is often used synony- such as dimensions of the bony structures, blood supply,
mously with stiffness in the medical literature. All three and loading history.
elements – force, stress, strain – may be split into static
(constant) and dynamic (changing over time) compo-
nents. 1.3.2 Load-Bearing Structures
A load may consist of up to three components of force in the Cranio-Maxillo-Facial Skeleton
and three components of moment. Load acts upon a
material or device. It may or may not change with time. The anatomy of the cranio-maxillo-facial skeleton is
A load which does not change with time is called static, designed to provide protection for soft structures of
while a periodically or intermittently changing load is vital importance and to permit mastication. Important
dynamic in nature. The compression exerted by an protective functions include encasement of the central
implant applied under tension is static, the forces gener- nervous system, eyes, and respiratory pathways. The
ated by the function (e.g., mastication) are dynamic or shell of the cranial vault consists of a composite struc-
functional forces. ture, including an outer and inner compact layer con-
No component under consideration neither the static nected by a cancellous intermediate. The hemispherical
force generated by the implant, the dynamic force result- design, together with the layered structure, makes it spe-
ing from function, nor the amount of surface area upon cially suited to protect against direct impact. In the mid-
which the forces act – is distributed evenly over a frac- face the cellular structure, reenforced by the orbito-
ture area. Therefore at different sites different mechani- zygomatic frame, is able to act as a shock-absorbing
cal conditions may exist at different times. structure.
During mastication the mandible moves relative to
the rest of the skull. Forces act at the attachment sites of
the masticatory musculature and in the occlusal plane.
1.3 Fractures in the Cranio-Maxillo-Facial Skeleton These forces are transmitted from the teeth to the alveo-
lar bone, and from there to the bony structures of man-
1.3.1 Origin of Skull Bones dible and maxilla. The maxilla is connected by four main
trajectories to the orbito-zygomatic frame, which is then
Two different mechanisms of bone formation are connected to the neurocranium.
observed during embryogenesis: membranous and These structures are of paramount importance in the
endochondral bone formation. In membranous bone repair of facial fractures, and they are addressed specif-
formation the ossification process takes place by direct ically in the respective chapters. The mandible has a
mineral deposition into the organic matrix of mesen- shape which is closer to the shape of a tubular bone. The
chymal or connective tissue. In the skull this is the major major muscle forces meet the mandible in the area of the
mechanism observed. The frontal, parietal, and nasal angle and in the ascending ramus. Reactive forces in the
bone, the maxilla, zygoma, and the mandible are all of occlusal plane are generated during mastication. This
membranous origin. tends to bend the anterior portion of the mandible cau-
In endochondral bone formation primarily a carti- dally. Thus an important tensile component is created in
laginous template is formed. This cartilage is gradually the alveolar portion of the mandible. In the case of an
transformed; it becomes mineralized and is then interrupted mechanical integrity of the mandible the
replaced by bone.While this mechanism is the main pro- repair must concentrate primarily on these tension
cess of formation for long bones, in the skull the carti- zones, and the correct placement of the implants is
laginous origin is restricted to the nasal septum and to determined by the location and type of fracture and its
internal bony components of the nose, occipital bone, relationship to the tension zones. However, it cannot be
and cranial base. Appositional growth in all bones, assumed that placement of an implant on the presum-
whether of membranous or endochondral origin, pro- able tension side immobilizes a fracture under all pos-
ceeds via membranous bone formation. Due to the sible physiological loading conditions. The correspond-
ongoing modeling and remodeling processes scarcely ing chapter on the treatment of mandibular fractures
any original bony material is left in the skull after expands on these aspects and indicates the preferred
growth is completed, and no remainders of calcified car- sites of implant placement for the specific types of frac-
tilage are detected. It is often discussed whether the ori- tures.
gin of the bone plays a significant role in later repair pro- Loading of the occlusal plane may reach quite high
cesses. This question has not yet been addressed in a values. Maximum bite forces in an average population
comprehensive manner, but there is no evidence that are found in an order of magnitude of 200–300 N in the
possible differences in repair processes observed in long incisor area, 300–500 N in the premolar region, and
bones are actually due to the embryological origin 500–700 N in the molar area. Electromyographic inves-
tigations have shown that the masticatory musculature including vascular and nerve damage, soft tissue contu-
is activated in a more or less symmetric fashion, even sion, and other injuries.
when the load in the occlusal plane acts asymmetrically. Concomitant injuries may include nerve damage
The values found during normal mastication are usually (mandibular, infraorbital, optical, facial nerves), and
much smaller, amounting to only a fraction of the max- vessels. Due to a rich network of collaterals, however, the
imum biting force. latter does not pose severe problems to the blood supply
In the case of a fracture in the angle of the mandible, of the region. Even lethal complications may result from
70 mm distant to the incisors, and a biting force in the dramatic blood loss through an injured maxillary
incisor area of 300 N, a moment (force times lever arm) artery. Penetration of the skin or the mucosa, in contrast
of approximately 20 Nm would result. The higher loads to the situation in long bones, is unproblematic in the
in the premolar or molar region, combined with the cor- cranio-maxillo-facial area.
respondingly shorter lever arms, result in similar values The vascular situation in the mandible is to some
for the moment. Additional torsional components must extent comparable to the situation in a long bone. The
be considered the greater the load deviates from the cortex reaches a certain thickness, and if the intracorti-
midline. cal circulation is interrupted, a corresponding delay
Assuming the mandibular body to have a height of must be expected until the blood supply has been rees-
30 mm, and muscle forces to act symmetrically, a unilat- tablished. In contrast to long bones, however, closed
eral fracture must still bear 10 Nm of this moment. This muscle compartments do not pose a problem in the
means that under maximum loading conditions, and skull. In the midfacial and cranial region the bony walls
provided that the fragment ends are in contact, an are thin; they frequently remain attached to the sur-
implant placed at the cranial border of the mandible and rounding soft tissues. Experience in cranio-facial sur-
its anchoring devices must still be able to resist a load of gery reveals that even if the soft tissues are stripped, the
more than 300 N. connection to circulation recovers rapidly. Thus the sus-
ceptibility to infection is minimal, and the tendency for
healing is good.
1.3.3 The Fracture In summary, the fracture event leaves us with an
interrupted force transmission in the involved skeletal
The skeleton provides a rigid frame for physical activity parts, with an interrupted blood supply inside the bone,
and for the protection of soft organs. The basic require- and with a more or less disturbed circulatory situation
ment for optimal function is adequate anatomic shape in the environment of the injured bone, whereby the
and stiffness (i.e.,resistance to deformation under load). nutritional problem is by far not as severe as in a long
Fractures are the result of mechanical overload. Within bone.
a fraction of a millisecond the structural integrity and
thus the stiffness of the bone can be interrupted. The
shape of the fracture depends mainly upon the type of 1.3.4 Biological Reaction and Healing of Bone
load exerted and upon the energy released. Torque
results in spiral fractures, avulsion in transverse frac- Healing is defined as restoration of original integrity.
tures, bending in short oblique fractures, and compres- Clinically this goal is reached when the bony structures
sion in impaction and in higher comminution. The lat- can resume their full function, even if on a microscopic
ter mechanisms are encountered principally in cancel- level the structure of the bone has not yet reached the
lous areas and in shell-like structures as they are found appearance of an unaltered bone. For successful healing
in the cranio-facial area, where the honeycomb design minimal requirements of both a mechanical and a bio-
acts as a shock absorber. logical nature must be met. Biologically the healing pro-
The degree of fragmentation depends upon the cess depends on the presence and appropriate function-
energy stored prior to the process of fracturing; thus ing of cells that are able to participate in the various
wedge fractures and multifragmentary fractures are phases of the healing process. These cells must reach the
associated with high energy release. In this context the site of repair, and their activities must be supported by
rate of loading plays a role. adequate nutritional supply. A sufficient blood supply is
A special phenomenon is the implosion which occurs therefore a primary prerequisite. Biological events in
immediately after disruption. Such an implosion is fol- fracture healing at any time are strongly affected by the
lowed by marked soft tissue damage due to cavitation, mechanical boundary conditions. Biological reactions
comparable to the damaging mechanism in a gunshot in turn may affect the mechanical environment.
wound. Thus in addition to the disruption of the intra- The situation at the onset of fracture healing is char-
cortical blood vessels, the vascular damage is extended acterized by the intracortical blood supply to the frag-
into the neighboring soft tissue regions. This damage is ment ends being interrupted by the fracture trauma, by
then superimposed to the direct action of the trauma, an injured soft tissue bed, and possibly by damage to
major afferent or efferent vessels. Depending on the characteristic for minimal strain, or the healing via a
local situation and the fracture pattern, intracortical cascade of tissue differentiation which is observed
perfusion of the fragment ends is interrupted over a dis- under interfragmentary motion. This can be attributed
tance of several millimeters. Surgery then may produce to the fact that the degree of immobilization changes
additional trauma. with time, and that even in the same fracture different
As a reaction to disturbed blood supply, a process of strain conditions may be present (Fig. 1.4). At one site
internal and surface remodeling of the affected bone the conditions for direct remodeling across the fracture
begins; the first traces of resorptive activity may become plane could be met primarily, produced by full immobil-
visible 2–3 weeks after injury. During this remodeling ization of the fracture by the implant, or secondarily
process nonperfused bone is replaced by new vital bone. when callus has bridged at other sites which would then
In parallel, beginning as early as the end of the first provide the conditions for remodeling across the frac-
week, new bone formation is observed predominantly in ture only at a later stage. The simultaneous occurrence
the subperiosteal region. The further course of the entire of both patterns is also possible when the mechanical
healing process is then determined by an interrelation- conditions within the same fracture vary. Then at one
ship between mechanics and biology. site immobilization is sufficient for direct union while at
Simplistically, only the healing patterns under the other sites interfragmentary motion determines a heal-
two mechanical extremes are described, namely abso- ing pattern with resorption of the fragment ends and a
lute immobilization of the fracture and full range of union via a differentiation cascade.
interfragmentary motion, ignoring that the situation After complete immobilization of the fracture plane
may be different at different sites and may change with the radiological aspect of a healing fracture differs from
time. the conventional appearance in which the progress of
Under interfragmentary motion the tissues are con- healing can be judged by the amount of callus formed.
tinuously torn and squeezed. The tolerance of various The fracture is barely visible after a perfect alignment.
types of tissues to deformation differs, being high (up to After internal remodeling has begun, there is a gradual
100%) for connective tissue, much lower for cartilage reduction of radiological density in the fracture area
(10%–15%), and lower still for bone (2%). Tissue can be which is due to the internal remodeling activities. With
assumed not to form under circumstances that would time the fracture site appears increasingly diffuse in the
not allow its existence. If minimal deformation exists radiogram and gradually disappears. It is difficult to
from the start, the conditions are met for the formation determine from the radiological appearance when func-
of bone. These are the conditions which allow the osteo- tion can be allowed again. Experience shows that the
clasts, as a cutter head, to drill their canal across the remodeling of a mandible to full load bearing and plate
immobilized contact zone, and the newly formed oste- removal requires 4–6 months, a shorter period than in
ons to link the two fragments together. This process is long bones, with a recommended period to implant
called direct or primary bone union. Smaller gap areas, removal of 1.5 years in the tibia and 2 years in the femur.
when immobilized by neighboring contact zones, still In the midfacial and cranial regions the healing process
permit direct lamellar ossification inside the gap. In is even faster. Here bony fixation of fragments may be
larger but still immobilized gaps woven bone formation observed even after 1 month. This is due to the excellent
in a first step subdivides the space; the smaller compart- circulatory conditions in this region of the body and to
ments produced by this subdivision are filled by lamel- the thin dimensions and the cancellous character of
lar bone in a second step. bone, allowing a more rapid recovery of interrupted
In the case of high interfragmentary motion, the blood supply. The healing of grafted bone follows the
strain in the fracture gap exceeds the level tolerated by same rules, with accessibility to circulation of the bony
bone, and ossification is not possible. Here one observes structures of the graft and the mechanical relationship
a tissue differentiation cascade from granulation tissue at the graft-host interface playing an important role.
to connective tissue, fibrocartilage, mineralized cartil- The current preference is to reduce the iatrogenic dis-
age, woven, and finally compact bone. Along this diffe- turbance of blood supply to bone by designing implants
rentiation cascade there is a gradual increase in strength that interfere less with blood supply and by introducing
and in stiffness of these tissues, while at the same time more biology-friendly fixation techniques. These so-
the tolerance for strain is reduced. This brings about a called “bio-logical” plating techniques offer advantages
gradual reduction of motion and thus a reduction of especially in comminuted fractures, where additional
interfragmentary strain. This differentiation cascade exposure would result in the production of dead bone,
permits a consecutive tissue always to be formed under and in condylar fractures. For this type of treatment it is
the protection of its precursor. hoped that a certain compromise on the mechanical side
There are clearly various degrees of immobilization is compensated by the clear gain on the biological side
of a fracture. Even in the same fracture plane a certain by preserving vascular connection to the bony frag-
part may present the pattern of direct healing which is ments.
d
Fig. 1.4
normal
▼
Patterns of fracture healing. The appearance of a healing frac-

ture is determined by the geometry of the fracture zone, the
degree of immobilization at various sites, and their changes
occurring over time.
An absolutely perfect alignment of the entire fracture is not
Stiffness of Fracture
delayed union
possible; direct contact between the fragment ends is restricted
to only small portions. The remainder consists of a gap of var-
ying width. Complete absence of interfragmentary motion is
possible only in contact areas and in gap zones in their close
vicinity. If this zone is completely immobilized, whether from
the beginning or as a sequel to bony bridging at other sites,
direct intracortical remodeling across the fracture plane may
nonunion
take place at contact sites (a). In a first step small immobilized
gaps are filled directly with lamellar bone (b). Then secondary
remodeling (c) in the axis of the bone gradually leads to recon-
struction of the original integrity. This phenomenon of frac- 2 4 6 8 10 weeks
ture healing without intermediate steps of tissue differentia- Healing Time
tion is called direct, or primary, bone healing. Pure direct heal-
ing, an extreme healing pattern on the one side of the scale, Fig. 1.5
seems to be relatively rare.
The further away from the contact areas, the higher is the Fracture healing: recovery of mechanical function. Initially a
chance of interfragmentary motion of various degrees, and the healing fracture presents low strength and low stiffness. Dur-
gap is usually wider. The healing pattern in these zones is char- ing approximately the fourth to sixth weeks a dramatic change
acterized by resorption of the fragment ends, callus formation, in mechanical properties occurs towards the properties of nor-
and interfragmentary ossification via a cascade of tissue diffe- mal bone. In an undisturbed situation mineralization across
rentiation. This leads to a gradual immobilization during the the fracture plane takes place at this time. If the loading of the
healing process. This pattern, found on the other extreme of mineralizing fracture does not exceed certain limits, healing
the scale, is frequent. Intermediate stages, for instance, the sub- proceeds normally. Undue loading of such a uniting fracture at
division of a wide gap by the formation of woven bone (d), may a critical moment may disturb the mineralization process and
be observed between the two extremes. lead to a delay in bony union, or, if compensatory healing
At a specific phase during the healing process it may happen mechanisms fail, to a nonunion.
that some sites of the same fracture are under relative motion
while others become immobilized. Thus in a single fracture it
is possible to observe a broad spectrum of different healing
patterns. As a routine, however, only a narrow band from the Potential complications in fracture healing include
full range of healing patterns reflects the situation of that spe-
infection,refracture,delayed healing,nonunion,implant
cific fracture.
failure, and implant loosening. Some of these complica-
tions are related to the use of implants, and some are
more general phenomena in fracture healing.
Over the past decade distraction osteogenesis has Due to the rapid healing in the cranio-maxillo-facial
been very popular for lengthening procedures in long region the bone regains sufficient strength very early. In
bones and in bone segment transfer, and it is now gain- contrast to the situation in long bones, in the cranio-
ing increasing importance in the cranio-maxillo-facial maxillo-facial area a refracture does not occur without
field. During distraction woven bone forms in the dis- adequate trauma.
traction gap. The speed of distraction must be high The flora in infection may include both aerobic and
enough to prevent bony bridging, and slow enough to anaerobic germs, and Aspergillus and Actinomyces.
permit the differentiation to bone. A total amount of Infection generally begins when the soft tissues are
1 mm per day, in one to four steps, has been found to be severely damaged, and perfusion to the bone and its sur-
adequate. Under continuous distraction the daily dis- rounding tissues is interrupted. An open wound alone,
traction distance can be approximately doubled, which in the skin or in the oral cavity, with implant exposure,
means that the overall treatment time can be corre- does not necessarily mean that a deep infection will
spondingly reduced. ensue.
Efforts at pharmacological enhancement of healing Nerve injury may be due to the original trauma, for
by systemic or regionally applied substances, osteody- instance, in mandibular fractures. Since it cannot be
namic agents, cytokines, hyperbaric oxygen, or physical excluded that surgical procedures further compromise
stimulation, for example, by electric, magnetic, or ultra- nerves, it is very important that the neurological situa-
sound effects have shown varying degrees of success in tion be described prior to surgery in order to avoid non-
experimental settings. These methods have not yet justified claims.
matured to a stage at which they can be considered for Healing is considered to be delayed when the union
general clinical application. takes clearly longer than the expected duration, for the
midface more than 4–6 weeks (Fig. 1.5). With the man- ∑ Fractures of the atrophic mandible in geriatric
dible, if little occurs within 12 weeks, one can expect patients
there to be a problem and must take some action. Dis- ∑ Infected fractures of the mandible.
covering a delayed union in conventional radiograms is
difficult, and not reproducible. Standardized, soft radio- Another absolute indication for internal fixation which
grams repeated at intervals can sometimes be investi- affects even the type of fixation is the patient’s inability
gated for changes. Once a nonunion or pseudarthrosis or unwillingness to cooperate. This is sometimes the
has developed, it does not require resection since the tis- case with elderly, mentally retarded patients, alcoholics,
sue in a nonunion represents only an early stage of tis- and drug addicts. The first and most important reason
sue differentiation, and the only problem is too excessive for adequate internal fixation must be the immediate
a strain to permit mineralization of the moving fracture restoration of form and function, the relief of pain, and
gap. The use of a stiffer and stronger implant, for exam- the avoidance of late sequelae. Socioeconomic factors
ple, a reconstruction plate of any type, would allow the such as short hospitalization time and early return to
further progress of the differentiation process. work are of secondary concern but do play a role
Screw loosening, with subsequent loss of stability, depending on the economic situation, which may vary in
may be a source of complications. Monocortical screws different parts of the world.
lacking angular stability in the plate are especially prone Especially in polytrauma patients there is an absolute
to such complications. Other possible causes include and principal indication for early definitive care. In
insufficient numbers of screws, their inappropriate these patients surgery should be performed for all frac-
placement, and undue functional loading. Inadvertent tures simultaneously. Swelling is not a reason for delayed
stripping of screws during insertion, perhaps hidden treatment of facial fractures.
behind a higher moment with self-tapping screws, may Sufficient (adequate) stability is the safest protection
be problematic in a thick cortex; direct mechanical bone against infection and is more important than antibio-
damage can be induced by the insertion of non-self-tap- tics. Furthermore, stability prevents the collapse of the
ping screws into a pilot hole that is too narrow. reconstruction in traumatology and tumor surgery. In
orthognathic surgery internal surgery together with
precise planning helps to predict the result, but it cannot
1.4 Indications for Operative Treatment of Fractures prohibit relapse if the planning is not well coordinated
with pre- and postoperative orthognathic treatment.
Modern bone surgery aims at rapid recovery of form
and function. This must be the goal of every surgeon
treating craniofacial fractures and tumors with consec-
utive bone defects or performing osteotomies for the 1.5 Operative Reduction and Internal Fixation
correction of craniofacial deformities. The degree of
stability required in each situation depends on the frac- 1.5.1 Reestablishing Stability
ture pattern. Optimal, not maximal, stability is required.
Under these conditions undisturbed healing takes place, Fracture treatment in general strives for complete and
and the fixation is optimal or adequate.Absolute and rel- early recovery of skeletal function. Therefore solid, com-
ative indications can be defined for internal fixation in plication-free union in appropriate anatomical shape is
patients with facial fractures. The decision for conserva- the basic goal. The appropriate anatomical shape varies
tive or surgical treatment depends on the type and con- depending on site and character of the fracture. In an
dition of fracture and on the patient’s condition and sit- intra-articular fracture precise reconstruction of the
uation. It is an absolute precondition for surgeons using articular surfaces is a goal in its own right. Any incon-
internal fixation for fractures to understand conserva- gruity of the articulating surfaces gives rise to areas of
tive treatment first. high stress and thus promotes posttraumatic arthrosis.
Closed and simple fractures can well be treated with Fractures through the dentate regions require a precise
conservative methods, the simplest method being inter- realignment, as occlusion may otherwise be endan-
maxillary fixation for several weeks. gered, and fractures involving the orbit demand perfect
Functionally stable internal fixation is indicated for: reconstruction to avoid problems with vision. In addi-
tion, the esthetic appearance of the face, which is deter-
∑ Multiple or comminuted fractures of mandible and mined largely by its underlying skeletal parts, deserves
maxilla special attention. Early reconstruction of the normal
∑ Panfacial fractures anatomy generally offers the best prospects for optimal
∑ Defect fractures recovery of function and esthetics and is preferred to
∑ Wide open fractures “tolerable malalignment” which requires corrective sur-
∑ Dislocated midface fractures gery at a later stage.
1.5 · Operative Reduction and Internal Fixation 13
The general goals of operative treatment include the 1.5.2.1 Stainless Steel
early anatomical reduction of fracture fragments, main-
taining their position after reduction, and guaranteeing Stainless steel consists mainly of iron (62.5%), chro-
union in the desired position. Completely immobilizing mium (17.6%), nickel (14.5%), and molybdenum
the fracture requires that the means of fixation act (2.8%) and further components in minor amounts. The
directly at the fracture site. These fixation devices must implant quality of 316L stainless steel meets the metal-
neutralize the loads occurring under everyday func- lurgical requirements established by the American Soci-
tional requirements in a specific situation. To obtain ety of Testing and Materials (ASTM) and the Interna-
appropriate stability one must therefore consider the tional Organization for Standardization (ISO). Two
personality of the patient, type and site of the fracture, grades of carbon contents and four grades of cold work
soft tissue conditions, and many other boundary condi- are defined from annealed to extra hard. For AO/ASIF
tions which can affect the outcome. In selecting an maxillo-facial implants steel was the metal of choice
appropriate implant it is necessary to estimate the until 1986. Corrosion resistance and compatibility are
expected magnitude and duration of load for each spe- fair. Implant metals are protected from corroding by a
cific case.A special danger is underestimation of loading passive layer consisting of nonsoluble corrosion prod-
conditions, for instance, in collum fractures and frac- ucts. Corrosion is observed principally when one metal
tures in an atrophic mandible. While miniplates in the component frets against another metal component
horizontal ramus of the mandible can perform perfectly (fretting corrosion, Steinemann 1977).
when they are loaded in tension, their stabilizing func- Surgeons in many countries prefer not to remove
tion may be insufficient when they are placed at a site implant material. One of the reasons may be that the
subjected to varying types of load. In addition, the removal of up to 10 plates and 50–60 screws used in fix-
requirements for a fixation device change over time. ing facial fractures often means an additional major sur-
During a normal healing process bone takes over grad- gical intervention. For this reason the Maxillofacial
ually, and the implant is unloaded. If the healing process Technical Commission has decided to ask for implants
is delayed, the implant must take care of additional load, made of commercially pure titanium. Although tita-
and it may then undergo fatigue failure. nium is more expensive than steel, it may be more cost
After a fracture the transmission of compressive effective in the long run because of its favourable char-
forces can still take place across a fracture plane. The acteristics (no known allergies, no second intervention).
bone remains able to take over the compressive tasks,
and the implant must substitute for the lost tensile prop-
erties. This load sharing between the bone and the 1.5.2.2 Titanium
implant allows implant dimensions to be used that are
much smaller than those necessary for the full loading Commercially pure titanium consists of titanium and
spectrum. In the case of a bony defect and in commin- oxygen. It is extremely insoluble and consequently is
uted zones a plate is loaded in bending. Sooner or later inert and biocompatible. Today it is available in grades
even a strong plate will fail in fatigue, since plates are not I–IV, combining high strength and ductility. The basic
designed to cover a prosthesis function permanently. differences in grades lie in their oxygen content. All cra-
Under such conditions the bone regeneration must be nio-maxillo-facial implants are available in titanium.
monitored carefully, and active intervention is required Only the 2.7 line (screws and implants) is still available
if the healing process does not proceed in the expected in steel.
way. Severe trauma of the facial skeleton may require a
great number of screws and plates, and titanium
implants are therefore preferable because they can be
1.5.2 Implant Materials left in place.According to Steinemann (1988) the body is
saturated with titanium, and no additional soluble tita-
An implant material for fracture fixation must be strong nium can thus become active. In contrast to steel and its
and ductile, adaptable to fit the bone surface, and bio- components, pure titanium is physiologically inert, and
compatible. Today one uses principally metals such as its unmatched tissue tolerance has been scientifically
stainless steel, chromium-molybdenum alloys, or com- and clinically proven. Titanium has a high corrosion
mercially pure titanium. Except for a short period in the resistance due to the spontaneously forming thin oxyde
early 1970s when soft titanium was used, the metal of layers on the surface which guarantees that the material
choice of cranio-maxillo-facial surgery was stainless behaves passively.
steel until approximately 1986. For the maxillo-facial The golden color of AO/ASIF titanium implants is
field, however, titanium is now almost exclusively the due to the anodizing process. A variety of colors can be
material of choice. produced, depending on the thickness of the oxyde film.
No accompanying corrosion is observed even in cases of
unstable internal fixation with tissue stained dark by criteria are less important at sites of easy access in out-
pure titanium abrasion particles (O. Pohler, personal patients in whom the procedure can be performed
communication, 1988). Pure titanium and its wear prod- under local anesthesia.
ucts behave passively and provoke neither toxic nor There are a whole series of criteria which favor
allergic reactions. AO choose not to add alloys to pure implant removal, related to both the patient’s concerns
titanium in order to preserve its excellent biocompat- and medical considerations. Patients may request that
ibility. Implants of titanium alloys are available only for the implant be removed for cosmetic reasons when it is
special high-strength indications outside the maxillo- shining through thin skin. A general feeling of distur-
facial area. bance may be caused by subacute complications includ-
ing chronic infection, compatibility problems, and aller-
gic reactions. If the implant is at a prominent location,
1.5.2.3 Biodegradable Polymeric Materials such as the eyebrow region, it may lead to mechanical
problems, for instance, in impact sports, and in cold cli-
Since it is generally desirable for no foreign body mate- mates an implant immediately underneath the skin can
rial to remain, efforts are being made to develop biode- increase sensitivity to coldness. Problems with dentures
gradable materials. However, biodegradable polymeric in the upper and lower jaws may also encourage implant
materials are not yet available for use with conventional removal.
techniques of internal fixation which dissolve after a Complications such as screw loosening, implant fail-
certain period in the body, and which combine adequate ure, and infection very often require surgery. If screws
strength, ductility, maintenance of compression and loosen before the fracture unites, restabilization is
degradability, and lack of tissue reaction. A search has needed. An argument for removing loose screws is the
been going on for biodegradables and ceramic material chance of their migration to undesired sites. Infection in
especially for surgery of the facial bones. A decade ago the presence of an implant is not necessarily a reason for
we expected to be using mainly biodegradable material removing the implant. If the fixation is considered to be
by now. For many reasons, however, including stiffness stable, an implant can be left until the fracture is com-
of the material, bending characteristics, and especially pletely united since controlling an infection is easier
the unfavorable characteristics of late resorption this under conditions of stability; the implant can be
has not come true. While adequate biodegradable removed later when the bone has united. Wound con-
implants are not yet available for fracture fixation in tamination is not a contraindication for the placement
highly loaded areas or defect reconstruction, it seems of an implant since stability helps in fighting infection.
that for the fixation and reconstruction of midfacial If an infected internal fixation is unstable, implant
walls (especially orbital walls) resorbable implants will removal and restabilization are mandatory.
be available in the near future. Resorbable implants are The materials used in implants for fracture fixation
especially desirable for bone surgery in children because have proven their biocompatibility. Stainless steel, how-
of the danger of implants being displaced through the ever, contains components that may be problematic if
growth and bone apposition of the growing facial skele- released from the alloy. This can happen when implants
ton. On the other hand, one must be sure that the pro- fret against each other, which leads to destruction of the
cess of resorption does not disturb the growth process. oxide layer on the surface of the implants. In this context
allergic reactions deserve special attention. It has been
shown that up to 20% of certain populations are sensi-
1.5.3 Implant Removal tive to nickel, a major constituent of stainless steel. The
occurrence of severe allergic reactions is an indication
In treating fractures the function of the implant extends for replacing the steel implants with their titanium
only so long as is required for the affected bone to equivalents.
acquire enough strength to resist the corresponding In children implant removal is advocated not primar-
functional loads. Thereafter, in the case of nonresorb- ily for growth disturbance but rather for their possible
able materials, the options exist of removing the translation by drift phenomena. As long as major
implants or leaving them without function. No general growth must take place, there is a chance that these
recommendations can be given for implant removal, and growth mechanisms can lead to an intracranial dis-
the pro’s and con’s must be balanced in each individual placement of the implants. Plate removal remains an
case. issue in pediatrics in view of the long life expectancy of
An argument against removal is that this would mean very young patients, and the lack of knowledge about
an additional surgical intervention, with additional the very long term outcome.
costs, a risk of damaging important structures (e.g., The major function of an implant during the healing
nerves) during the procedure, an additional, but minor, process is the mechanical protection of the fracture site.
risk of infection, and the hazards of anesthesia. These A frequently mentioned indication for implant removal
is their adverse stress protection effect. Experience with bone or implant to bone. The effect of compression is
heavily loaded long bones of the lower extremity shows twofold: it produces preload in the fracture plane, and it
that this aspect is of only minor concern unless extreme acts by increasing interfragmentary friction. Thus the
amounts of hardware are used. It cannot be denied that fracture remains immobilized as long as the axial pre-
a fractured bone treated by implants placed directly on load is higher than the tensile loads produced by func-
the bone surface undergoes a remodeling in the vicinity tion, and as long as the interfragmentary friction pre-
of the implants, and that a first step in this remodeling vents displacement by shear forces. In bone the com-
process consists of temporary porosis. This process pression may be maintained over a period of several
takes place during the first few postoperative months, weeks to several months, usually long enough to allow
and it is located in the zone where blood supply to the for a bony connection between the fragment ends.
bone was disturbed. A remodeling of bone underneath Compression is no absolute precondition for undis-
the plates and around the screws soon leads to an adap- turbed healing, but in specific applications it means
tation of the bone structure to the new loading condi- more safety and includes a biological and mechanical
tions. This porosis is completely absent when intracorti- advantage. Biologically compression means undis-
cal circulation is preserved by using circulation-friendly turbed healing because it guarantees absolute stability
implants and implantation techniques. even under the condition of function. Mechanically it
allows load sharing between bone and implant. Under
these conditions the implants for the osteosynthesis can
1.5.4 Principles of Stabilization be smaller than in load-bearing osteosynthesis where
larger and thicker plates are necessary. Compression
1.5.4.1 Splinting provides a maximum strength with a minimum of fixa-
tion material.In the facial skeleton compression for frac-
Splinting consists of connecting a more or less stiff ture fixation is applicable only in noncomminuted, sim-
device to the fractured bone. This device reduces the ple fractures of the mandible; occasionally it may be use-
mobility of the fracture in proportion to the stiffness of ful at other locations.
the splint-bone composite but does not aim at com- When resorption at the fragment end has taken place
pletely abolishing fracture mobility. (late surgery, infection) compression cannot be used.
External splinting seeks to reduce the fracture frag- In the maxillary area, because of the thin bones, com-
ments without surgical intervention. Such external pression can rarely be applied. On the other hand,
splints may be fixed to the teeth or applied to mucosal or because of the different type of functional load (static)
skin covered surfaces. Under these conditions there is there is almost no need for compression in the midface
always a soft intermediate structure, either periodon- area.
tium or soft tissues, and forces are not directly transmit- In some areas, such as the zygomatico-frontal suture,
ted from the splint to the bone. As a consequence a cer- the root of the zygomatic arch, and sagittal fractures of
tain mobility at the fracture site remains. Under most the palate, compression with lag screws may guarantee
circumstances this mobility does not interfere with the the repositioned position of the fracture with small and
healing process, but it cannot be guaranteed that the few implants only. Compression osteosynthesis can be
initial alignment of the fragments will be maintained to performed either with compression plates or with lag
its full extent until the bone has united. screws.
In internal splinting the stabilizing devices are fixed
directly to the fracture fragments, with the bone- Compression with a Plate. The special geometry of the
implant complex still allowing for some interfragmen- plate hole (Fig. 1.6a–c) together with eccentric place-
tary motion. Internal splints usually lead to more reduc- ment of the screw (Fig. 1.6d) allows interfragmentary
tion in interfragmentary motion than external splints. compression in an axial direction when the screw is
Wire sutures or flexible plates are among the devices driven fully into the screw hole (Fig. 1.6e,f). The screw
that are considered to act as internal splints. External hole is a section of an inclined and horizontal cylinder
fixators, having internal and external components, that permits the downward and horizontal movement of
belong to the same category of fixation devices in terms a sphere, the screwhead (Fig. 1.6c). As soon as the screw
of their functional effect. head arrives at the outer rim of the plate hole, it meets
the intersection of the inclined and horizontal cylinder.
The screw head then makes the spherical contact in the
1.5.4.2 Compression plate hole and glides horizontally towards the opposite
(inner aspect) of the plate hole. Since the screws also
The use of compression is an elegant method to exclude engage the bone, they move the bone inwards towards
interfragmentary motion. Compression fixation con- the fracture line. Only one screw on each side of the frac-
sists in pressing together two surfaces, either bone to ture line should be placed eccentrically (Fig. 1.7a–c).
a b c
d e f
Fig. 1.6 a–f

a The screw head moves in the oval-shaped plate hole like a
ball in an angled cylinder.
b The screw hole is a section from of an inclined and a hori-
zontal cylinder.
c Movement of the screw head with its spherical undersurface
in the DC hole of the plate.
d The eccentrically placed screw arrives at the rim of the plate- a
hole.
e As the screw is driven in, it glides within the platehole to its
final position (f).
Fig. 1.7 a–c

Compression with a plate.
▼
a The two innermost screws should be placed eccentrically

within the DC holes.
b As these screws are driven in, they approximate the frag-
ments.
c With final tightening of the screws compression is achieved. c
If the fracture was preloaded before the first two Fig. 1.8 a–c
screws were placed, tightening of the screws causes axial If a plate is correctly overbent (a), the inner screws should be
compression. The other holes of a plate should then be placed first (b). If the outer screws are placed first, the fracture
in the cortex near to the plate may be opened because then the
loaded with screws in a centric (neutral) position. It plate may be too long in relation to the bone spanned between
should always be kept in mind that a plate acts eccentri- the outer screw holes. Depending on the strength needed, the
cally, and complete closure of a fracture results only additional screws are placed mono- or bicortically.
immediately underneath the plate while on the opposite
side a gap may result. Overcoming this tendency may
require a plate or splint to be used as a tension band, of the mandible (Fig. 1.9a), in chin fractures (see also
or slight overbending of the plate, as indicated in Fig. 3.4a,b), and in more complicated applications such
Fig. 1.8a–c, or combining the plate with an additional lag as the mandibular angle (see Fig. 3.20a).
screw across the fracture plane. Since all screws of the maxillo-facial set are fully
threaded, a so-called “gliding hole” must be drilled into
Compression with a Lag Screw. Any screw from the max- the first (near) cortex and a threaded hole into the sec-
illo-facial set can be used as a lag screw. In most ond (far) cortex. The first hole is overdrilled so that the
instances 2.4 or 2.0 screws are used as lag screws. The lag hole in the cortex has at least the size of the outer diam-
screw technique is used either for fracture fixation or for eter of the screw thread. A special drill guide is placed
the fixation of bone grafts. Ideally a lag screw should into the first hole to locate the second hole centrally in
cross the fracture plane at a perpendicular angle. Use of the far cortex. Thereafter the hole in the far cortex is
the lag screw technique in the mandible is ideal after a drilled to the diameter of the pilot hole. lts size is deter-
sagittal split osteotomy, in oblique fractures of the body mined by the size of the core of the screw. lf used with-
a b
Fig. 1.9 a, b
a Oblique fractures can be fixed very efficiently with lag b If no gliding hole is placed, and both holes are threaded, the
screws. A gliding hole (same size as the diameter of the fracture can be neither closed nor be compressed.
thread) must be drilled into the outer cortex. A thread hole
is made in the far cortex. As the screw is tightened (lower
screw) the fracture is closed and compressed.
Fig. 1.10 a, b
Compression with a lag screw and plate. b If no lag screw is used above an oblique fracture line, the
a If a lag screw in combination with a DC plate is used for fix- plate must be fixed first to the fragment which forms an
ation, the lag screw should be placed first. Thereafter the obtuse angle with the fracture; then as the screw in the oppo-
remaining screws must be placed in a neutral position. site fragment is activated (right) the spike of the opposite
fragment is driven against the plate.
1.6 · Design and Function of Implants and Instruments 19
out a plate, a countersink for the screw head is cut into

the bone before placement of the screw. Self-cutting 1.6 Design and Function of Implants and Instruments
screws can then be placed immediately; for non-self-
cutting screws a thread corresponding exactly to the AO/ASIF implants and instruments are highly standard-
thread of the screw is cut into the far cortex with a tap. ized and meet with special technical specifications of
The use of self-cutting screws as lag screws may be haz- material and dimension. Their continuous evaluation by
ardous, however, since the holding capacity of their tip the Technical Commission guarantees a high standard
is diminished due to the flutes. of quality and technical development and especially the
If the gliding hole is in one fragment and the threaded maintenance of tolerances within the system. Combin-
hole in the other as the screw is tightened, the fragments ing instruments and implants from different manufac-
are squeezed together, and interfragmental compression turers may lead to complications such as broken drills
is generated (Fig. 1.9a). The type of compression gener- and taps, broken screws, and damaged implants.
ated by a lag screw is referred to as static interfragmen- Although a clinical study conducted by Rüedi (1975)
tal compression. It is static because it does not change showed no negative clinical effect, mixing of implants
significantly with load. A lag screw is the most efficient and screws made of different materials (titanium and
way of achieving interfragmental compression and steel) should be avoided. A mixed metal system
therefore stability, but it does not provide a great deal of increases the risks inherent in product liability, a major
strength. Therefore rarely only a single lag screw is concern of clinical complications.
applied. At least three lag screws are generally placed in Systems of different dimensions designated by num-
fractures of the mandible or sagittal split osteotomies, or bers are used at various areas of the facial skull. The
a lag screw is used in combination with a plate. When- smallest system is the 1.0 system. The designation of the
ever a lag screw is used through a plate hole in the case system indicates the screw size (diameter of the thread).
of a dynamic compression (DC) plate (Fig. 1.10a), all the
other screws must be placed in a neutral position, or the
fragments may shift.
To achieve maximal interfragmentary compression 1.6.1 Screws
the lag screw must be inserted into the middle of the
fragment equidistant from the fracture edges and 1.6.1.1 Function of Screws
directed at a right angle to the fracture line. If the screw
is not inserted perpendicularly to the fracture plane, a Screws are the basic element for the fixation of plates or
shearing force is introduced as it is tightened, and the similar devices onto bone or as lag screws to hold frag-
fragments may dislocate. Similarly, insertion of a screw ments together. The correct selection and placement of
at an acute angle to the fracture plane introduces a screws are the key to successful stabilization of fractures
shearing moment as it is tightened, and the fragment or osteotomies. The best plate is useless if it is not fixed
tend to displace. These fundamental errors in screw correctly with screws. Screws are designated according
insertion are often responsible for a loss in reduction. to the outer diameter of their thread (Fig. 1.11).
With loss in reduction, decreased structural continuity
and stability are inevitable. If the oblique plane is too
short or the opposite cortex has been damaged so that a 1.6.1.2 Types of Screws
lag screw cannot be applied, the plate must be fixed first
to the fragment which forms an obtuse angle with the In cranio-maxillo-facial surgery all screws are fully
fracture (Fig. 1.10b). threaded and have an asymmetrical buttress thread pro-
file (Fig. 1.11) This type of a thread is a cortical thread.
Only the 1.0 standard and the 1.2 emergency screws have
a metric thread due to their size.
Screws used in cranio-maxillo-facial surgery are
between 1.0 and 2.7 mm in size. Only for the special
reconstruction plates (UniLOCK and titanium hollow
reconstruction plate, THORP) special screws are used.
For each screw there is an emergency screw which is
slightly larger in size and must be used in case the regu-
lar screw strips.
All screw heads to date have a cruciform recess except
the 2.7 screw and its emergency screw, 3.2 mm, which
have a hexagonal recess (Fig. 1.11). Another exception is
the 4.0 mm THORP screw head which due to its locking
Screw Drive
Head diameter
Cruciform recess
Thread pitch
Thread diameter
Core diameter Hexagonal socket
Screw tip
Inset Non fluted Fluted

(thread forming) (thread cutting)
Fig. 1.11 flutes at the tip to facilitate penetrating the pilot hole and
Cranio-maxillo-facial screws are fully threaded. Except for 1.0 cutting their thread simultaneously (Fig. 1.11). While
and 1.2 emergency screws, they have an asymmetrical buttress fluted screws are thread cutting, nonfluted screws are
thread profile. Screw tips are either blunt or fluted. Nonfluted
screws are thread forming and have a higher torque whereas thread forming. In thick and solid bone it is advisable to
fluted screws are thread cutting and therefore self-tapping. place a thread with a tap before inserting the screw
Inset: In thin bone one must ensure that at least two threads because otherwise the torque during insertion may
engage within the bone. Screws should have a small pitch in become too high, and the screw may break. On the other
these instances. hand, 2.7 screws and the 4.0 screw for the THORP system
are blunt screws that require a pretapped hole. All the
other screws from 1.0 to 3.0 can be used in a self-tapping
device, which uses an additional locking screw, has a manner, and most have flutes.
special recess.In the future a star drive may gain increas- Another major difference between screws is the man-
ing importance. ner in which they couple with the screwdriver. Two types
Screws are also differentiated by the manner in which of screwdrivers are available, those with a screw-holding
they are inserted in the bone (pretapped or self-tap- device (holding sleeve) and those which are self-retain-
ping), their function, and their size, according to the ing. These screws couple securely with the screwdriver,
thickness of bone for which they are intended. which completely obviates any screw-holding device on
While pretapped or non-self-tapping screws have the screwdriver (see Fig. 1.18a–f).
blunt tips, most self-tapping screws have two or three
Craniofacial Screws
Screw Thread Core Pitch Head Drive

(Ø in mm) (Ø in mm) (Ø in mm) (Ø in mm)
Standard screw 1.0 0.7 0.25 1.6
Emergency screw 1.2 0.9 0.25 1.6

1.6.1.3 List of Screws Fig. 1.12

List of cranio-facial screws.
Craniofacial Screws 1.0–2.0 (Fig. 1.12). The size of screws
generally used in the cranial and midfacial areas is
between 1.0 and 2.0 mm. From January 1998 on all these
screws will have fluted tips. The pitch in small screws is
smaller than in larger screws.All screw heads have a cru-
ciform recess.
Mandible Screws
Screw Thread Core Pitch Head Drive

(Ø in mm) (Ø in mm) (Ø in mm) (Ø in mm)
UniLOCK screw 2.4 2.4 1.7 1.0 4.0
UniLOCK screw 3.0 3.0 2.4 1.0 4.0
Emergency screw Not existing
THORP screw 4.0 3.0 1.25 4.5
Emergency screw Not existing
Mandible Screws 2.0–4.0 (Fig. 1.13). Screw sizes for the Fig. 1.13
mandible vary between 2.0 and 4.0 mm. The pitch of the List of mandible screws.
2.0 screw for the mandible is 1.0 mm, in contrast to the
2.0 screw for midface application with a pitch of 0.6 mm.
The 2.0 and 2.4 screws have a cruciform drive, while the
2.7 screw has a hexagonal drive, and the THORP screw
has a special configuration for the application of the
locking screw.
a b
c d
1.6.1.4 Technique of Screw Insertion Fig. 1.14 a–d

Technique of screw insertion.
Correct and precise placement of the screw is one of the a Drilling of the pilot hole with a drill corresponding to the
core diameter of the screw.
most important steps in plate fixation and, as a conse- b The length of the hole in the bone is measured with a depth
quence, fracture and osteotomy fixation. It must be well gauge either through the plate hole or after countersinking.
understood that the stability of the fixation depends on Note: Measure before tapping if tapping is necessary.
the rigidity of the plate but, most importantly, on the c Tapping through a tissue protector.
holding capacity of the screws. Incorrect handling of the d Placement of the screw thereafter.
screw hole in the bone either when drilling or at the time
of the placement of the screw may cause failure due to
early mechanical overload of the system.
It is very important to use the various instruments for of the screw hole depends on whether self-tapping or
placement of the screws in the correct sequence. The pretapped screws are used. Thread tapping with the tap
correct drill bit should correspond to the core diameter is followed by placement of the screw (Fig. 1.14).
of the screw. Cooling of the drill during drilling is very Self-tapping screws with flutes at their tips are
important to prevent overheating the bone. The length designed in a way that once a pilot hole is drilled, and the
length of the screw is measured, they can be inserted by 1.6.1.5 Instruments for Screw Insertion
simply screwing them in. The pilot hole is somewhat
larger than the core of the screw. Because the screw must The instruments for screw insertion include drill bits
cut its own thread when it is inserted, it may encounter (Figs. 1.15, 1.16), drill sleeves (Fig. 1.17a,b), depth
considerable resistance, particularly in thick cortical gauges (Fig. 1.17d), taps (whenever necessary;
bone. In these instances, even if a self-cutting screw is Fig. 1.17e,f), and screwdrivers (Fig. 1.17g–i, 1.18).
used, it is better to use a tap before the torque resistance
becomes greater than the strength of the screw, which Drill Bits (Fig. 1.15).Various drill bits are available for the
then causes a fracture of the screw. In addition, resis- different types of screws in different lengths, with and
tance to screw insertion may interfere with the accuracy without stop, and with various couplings (correspond-
of insertion, particularly when the surgeon is trying to ing to different power tools). Drill bits correspond to the
insert the screw obliquely into bone to lag fragments core diameter of each screw for which they should be
together. It may be problematic to go in and out with used to place the pilot hole. They have either two or three
self-tapping screws several times. At reinsertion it may
happen that a second thread is cut accidentally on top of
the first thread in the bone. This new path which
destroys the earlier cut thread is disadvantageous and Drill bit a Coupling
may considerably lower the holding capacity of the
screw or lead to stripping of the screw.
The flutes in the tip areas of the screw reduce the Coupling
holding capacity of the screw in this area. This is espe-
cially disadvantageous when the screw is used in a lag Quick coupling
manner. Lag screws should either be blunt or their tip
2 mm longer than the depth gauge indicates
Studies show that in extremely thin cortical bone,
such as midfacial bones, self-tapping screws hold better Mini quick coupling
than non-self-tapping screws of corresponding size.
Non-self-tapping screws are clearly superior in cancel-
lous bone and in flat bones such as those of the man-
dible, skeleton, and pelvis. Stryker (J-Latch) coupling
Non-self-tapping screws with a blunt tip require pre-
g length
drilled pilot holes and then a careful cutting of their

g
thread into the bone with a tap that corresponds exactly

Universal coupling
Drilling
to the profile of the screw thread. Because the thread is

cut with a tap, the size of the pilot hole corresponds
almost to that of the core of the screw, and the screw
thread has a much deeper bite into the adjacent bone.
Much less heat is generated when the screw is inserted b Drill bit point
because there is less resistance. The tap is designed in
such a way that it is not only much sharper than the
thread of the screw, but it also has a more efficient mech-
anism of clearing the bone debris which therefore does
not accumulate and clog its threads to obstruct its inser-
tion. This allows the surgeon to work with much greater
precision, particularly in thick cortical bone. The screws
can easily be removed and reinserted without the fear of Drill diameter
inadvertantly cutting a new channel as the screw alone
is not able to cut a channel in cortical bone. The screws Drilling depth
are spun, and therefore their core is perfectly straight
and their surface is polished. Thus at the time of removal with stop without stop
fully threaded screws are easily removed. Depending on
the pitch of the screw, in very thin bone only few threads Fig. 1.15 a, b
can gain a hold in the bone (see inset in Fig. 1.11). It is Drill bit consisting out of shaft with coupling, drilling length,
therefore important that these delicate thin bones are and drill diameter, which corresponds to the core of the screw
and cuts the pilot hole.
not partially destroyed when inserting screws. a The various couplings for the drill bits.
b The tips of the drills may be either with or without stops.
Screw Drill bit Tap
Thread Ø in mm Threaded hole Ø in mm Gliding hole Ø in mm Ø in mm
1.0 0.76 – –
1.3 1.0 – –
1.5 1.1 1.5 Optional
2.7 2.0 2.7 Standard
4.0 3.0 – Standard
Fig. 1.16 flutes. They should be used with drill guides of corre-
List of screws with corresponding drill bits for either threaded sponding size.
holes or gliding holes. Taps are either not necessary, optional, Care must be taken not to damage drill bits by con-
or indicated as for 2.7 or 4.0 screws.
tact with metal or to use unnecessary bending forces
during drilling. Irrigation is mandatory during drilling
to prevent heat damage to the bone.
Drill Sleeves (Fig. 1.17a). Drill sleeves are available in

short and long dimensions for the various drill bits.
There are special drill guides (Fig. 1.17b,c) for centric or
eccentric placement of the screw hole for plates with DC
holes.
Drill guides for transbuccal usage are shown with the
transbuccal instrumentation (see Fig. 1.33).
Depth Gauges (Fig. 1.17d). The purpose is the placement

of correct screw length which guarantees good screw
hold in opposite cortex. The screw tip should exit
slightly the cortex to guarantee optimal holding capac-
ity. The gradation of screws and depth gauges is gener-
ally every 2 mm. If the measurement indicates place-
ment between the calibration points, the longer screw
should be chosen.
Depth measurement is not necessary when using a
drill with stop. Depth must be measured before tapping
when using pretapped screws.
Taps (Fig. 1.17e,f). Although most of the screws are self-

tapping and have fluted tips, taps are available for all of
them (except 1.0 and 1.3 screws). When screws are used
in hard cancellous bone with a considerable thickness
(4–8 mm), it is recommended to use a tap in order not to
break the screw.
Instruments for Screw Insertion Fig. 1.17 a–i

a Drill sleeves for precise placement of screw holes and for
protection of soft tissues. Double sleeves for various screw
a sizes offer the appropriate diameters (pilot hole and gliding
hole) for the drill bits.
b Double drill guide for centric or eccentric placement of
screw holes for plates with dynamic compression holes.
c Eccentric placement of the first two screws.
d Depth gauge measures the length of the hole in the bone and
b allows correct selection of the screw length.
e Tap for 2.4 screw with quick coupling.
f Tap for 2.0 screw with mini-quick coupling.
g Handle with mini-quick coupling.
h Short handle with quick coupling.
0 6
i Long handle with quick coupling.
i
Instruments for Screw Insertion
f g
The thread diameter marked on the tap corresponds Fig. 1.18 a–g
to the screw size. Taps for 1.5 and 2.0 screws are used a Screwdriver with cruciform tip with holding sleeve and
with handle with mini-quick coupling whereas for 2.4, mini-quick coupling.
b Screwdriver with cruciform tip for 2.4 screws with holding
2.7, and 4.0 screws they match with those with quick sleeve and quick coupling.
couplings. c Screw attachment to tip of screwdriver with holding sleeve.
d Screwdriver with self-holding tip cruciform and mini-quick
Screwdrivers (Fig. 1.18). Screwdrivers with holding coupling.
sleeves and with self-retaining tips are available. For e Screwdriver with self-retaining tip and quick coupling.
f,g Screw attached to tip of screwdriver via self-holding tip.
transbuccal application they are used without a holding
sleeve (see Fig. 1.34c). Screwdrivers for 1.0–2.0 screws
are provided with mini-quick couplings; for 2.4 and 2.7
screws they have quick couplings.
Craniofacial Plates
b
Adaption plate 1.0/1.3/1.5/2.0
L-Plate
l left
l f L-Plate
l right
h Y-Plate 1.0/1.3/1.5/2.0 T-Plate 1.0/1.3 H-Plate 1.0/1.3/2.0
1.0/1.3/1.5/2.0
X-Plate Double Y-Plate Box or Frame Plate 1.3 Orbital Rim Plate 1.0/1.3/1.5
1.0/1.3/1.5/2.0 1.0/1.3
Fig. 1.19 a, b
1.6.2 Plates a Magnified view of round plate holes for cranio-facial plates.
b Cranio-facial plates are designed for the various screw sizes
in between 1.0 and 2.0. These are used mainly for the mid-
1.6.2.1 Craniofacial Plates (Figs. 1.19, 1.20) face and cranial areas. Their thickness varies in between
0.5 and 0.9 mm.
The shape of plates for midfacial and cranial applica-
tions corresponds generally to adaption plates. They
have the form of X, Y, double-Y, H, T, L (left- and right-
curved for orbital rim), and straight plates. Their thick-
ness varies in between 0.5 mm (for the 1.0 system) and
0.9 mm (for the 2.0 system).
For special indications orbital floor plates, burr hole
covers or screen as a cover for cranial or other bone
defects are available.
Another special plate for the 2.0 system is the DC
plate which can be used at the lateral orbital rim area
and occasionally for pediatric mandibular fractures, as
a tension band plate for mandibular fractures, and for
fixing subcondylar fractures.
Craniofacial Plates
Orbital floor plate universal Orbital wall plate right Orbital wall plate left
1.0/1.5 1.0/1.3/1.5 1.0/1.3/1.5
Burr hole cover

1.0/1.3/1.5/2.0
Screen 1.0/1.3 Zygomatic DCP® 2.0
Fig. 1.20
Special plate configurations (orbital floor plates, burr hole cov-
ers, screen, zygomatic DC plate).
Inset: Application of burr hole covers for fixation of cranial
bone after osteotomies or fractures.
Inset
Mandible Plates 2.0 LC-DCP® Plates 2.4
Fig. 1.21 Fig. 1.22 a–d

Small 2.0 plates for noncomminuted mandibular fractures. a 2.4 plates with bidirectional DC holes. Thickness 1.65 mm.
These are thicker (1.0 mm) and therefore stronger than 2.0 b Limited contact design for minimal contact with the bone
miniplates for the midface. without impairing the implant strength.
c Straight six-hole 2.4 LC-DC-plate.
d Crescent six-hole 2.4 LC-DC-plate for chin and angular area
of the mandible. (Thickness 2.0 mm).
1.6.2.2 Mandible and Reconstruction Plates If the plate holes of the reconstruction plates are sup-
(Figs. 1.21–1.28) plied with a thread, special 2.4 screws (UniLOCK screw)
with a second thread below their head can be locked in
Plates for mandibular fractures or defect reconstruction these holes.
vary in thickness from 1.0 mm (2.0 system) to 3.0 mm The same is possible with the specially designed but
(THORP system). The mini-mandible plates (2.0 technically more demanding THORP system (Fig. 1.27).
system) have round holes while the straight or crescent Both plates, THORP and UniLOCK, are fixed to the bone
plates for the 2.4 system have a bidirectional dynamic in a manner similar to an external fixator but much
compression unit (DCU) screw hole. The 2.4 fracture closer to the bone surface. Since these plates need not be
plates have a limited contact design (undercuts) to pressed against the bone surface, they are more circula-
reduce interference with the vascular supply of the bone tion friendly, while the angular stability of the screw in
when pressed against the surface of the bone (LC-DC the plate still guarantees sufficient stability.
plates).
Other special plates have notches at the edges. These
notches allow bending in all three dimensions; espe-
cially bending edgewise and twisting is possible. The
thinner and smaller variety is for special fracture situa-
tions (universal fracture plate; Fig. 1.24) while the
stronger reconstruction plate is used to stabilize defect
situations or comminuted zones (Fig. 1.25). Care must
be taken not to overload these implants as this entails
the danger of fatigue fractures. While universal fracture
plates can be used only in load-sharing situations where
the bone protects the plate, reconstruction plates can act
temporarily as load-bearing implants.
Orthognathic Plate for Sagittal Split Osteotomy
a b
Fig. 1.23 a, b
This special orthognathic plate (SplitFix Plate or Adjustable a Preliminary fixation before advancement of mandible.
Sagittal Split Plate) facilitates temporary and permanent fixa- b Situation after advancement. Definite fixation can now be
tion of the bone segments after a sagittal split osteotomy. It performed, with two additional screws in the distal frag-
allows intraoperative correction of the joint-bearing fragment ment.
without removal of the plate. The plate is used especially for
mandibular advancement procedures.
Universal Fracture Plates 2.4
Fig. 1.24 a, b
Universal fracture plates for 2.4 screws. Their design is similar 2.0 2.3
to reconstruction plates, but they are weaker. They should be mm mm
used only in load-sharing situations. They must be protected
by bone. They can also be used for the fixation of microvascu-
lar grafts. Plate thickness: 2.0 mm.
a Straight universal fracture plates.
b Prebent angulated universal fracture plate for the left side.
c Plate/screw profile of 2.4 screw with Universal Fracture
Plate.
c
Reconstruction Plates 2.4
d e
2.5
mm
Fig. 1.25 a–g

Reconstruction plates 2.4 are much stronger than universal 2.5
fracture plates. Plate thickness 2.5 mm. These are used for tem- mm
porary load bearing situations.
Note: Plates cannot be used as permanent load-bearing
implants.
If supplied with threaded holes, they can be used either in
the regular manner with the regular 2.4 screw or as a locking
system together with the special locking 2.4/3.0 screws.
a Oval-shaped plate holes with thread.
b Straight plate.
c Prebent angulated reconstruction plate for the right or left
side (left side shown).
d 2.4 MF cortical screw for reconstruction plates.
g
e UniLOCK screw with additional thread for plate hole and
threaded inset for plate hole protection during bending.
f Plate/screw profile of reconstruction plate without thread
and regular 2.4 screw.
g Plate/screw profile of UniLOCK system. Reconstruction
plate with threaded hole and special 2.4 locking srew.
Reconstruction Plates 2.7
Fig. 1.26 a–e

Reconstruction plates for 2.7 screws are slightly stronger than
2.4 reconstruction plates. Plate thickness 3.1 mm. These are the
only implants available in stainless steel as well as titanium.
a Straight reconstruction plate. e
b Angulated reconstruction plate left side.
c Angulated reconstruction plate with condylar head left side.
Available in three different sizes.
Note: Not yet (1997) approved by the United States Food and
Drug Administration.
d Condylar implant left side, available in three different sizes.
e Reconstruction plate for replacement of almost complete
mandible.
THORP Reconstruction Plates 4.0
c d
3.0 3.2
mm mm
Fig. 1.27 a–d THORP

Titanium hollow reconstruction plate (THORP). Plate thick-
ness 3.0 mm. Screws with special heads can be locked in plate
hole with special locking screws.
a Straight plate.
b Angulated plate left side.
c Hollow and solid 4.0 screws with additional locking screw.
d Plate/screw profile of THORP system. Plate with special 4.0
screw with locking screw in place.
Fig. 1.28 a–d

Recapitulation of plate/screw profiles: 2.0 2.3
a 2.4 screw with universal fracture plate mm mm
b Reconstruction plate without threaded holes and regular 2.4
screw.
c UniLOCK system. Reconstruction plate with threaded holes
and special 2.4 locking screw.
d THORP system. Plate with special 4.0 screw with locking
screw.
a
Fracture
2.5
mm
b
Recon
2.5
mm
c
UniLOCK
3.0 3.2
mm mm
d
THORP
Single Vector Percutaneous Distraction Device
Fig. 1.29 a–d

a Single vector percutaneous distraction device for mandibu-
lar ramus distraction; available with a left or right foot to
facilitate anterior or posterior position of screws on the
mandible. Fixation to the mandible with 2.0 screws. Distrac-
tor with two feet which can be separated by activation of the
head of the internal shaft at its end and lengthengs up to
30 mm.
b Activation screwdriver with internal hexagonal drive. One
full turn counterclockwise equals 0.5 mm advancement. The
marking on the screwdriver indicates rotational direction
for lengthening.
c,d Schematic drawing of applied distractor device which
functions transbuccally.
Activator
a
c d
Plate Cutting Instruments
Fig. 1.30 a, b
1.6.3 Instruments (Figs. 1.30–1.34) a Plate cutting forceps for all plates from 1.0 to 2.0.
b Plate cutter for 2.4 plates and THORP reconstruction plates
(Shortcut™ 2.4/THORP). The device must be used in pairs.
Special instruments for correct and precise adaptation
of the plates onto the surface of the bone are necessary.
These include bending and cutting devices, which differ
in size for the various systems.
Difficult contouring of plates should be carried out
with the aid of separate malleable templates which can
be bent manually to the shape of the bone and are avail-
able for all mandibular plates and the 2.0 and 1.5 cra-
niofacial system.
Bending Instruments for 1.0–2.0 Plates
Fig. 1.31 a–c

a Pair of bending pliers, pointed, for 1.0 to 2.0 plates.
b Pair of bending pliers with special inset for the plate hole,
thus preventing the deformation of the plate hole during
bending.
c Left: close up of mouth of bending pliers shown in a.
Right: mouth of bending pliers shown in b. c
Bending Instruments for 2.4, 2.7 and THORP-Plates
Fig. 1.32 a–d

a Bending irons for 2.4 plates.
b Bending irons for 2.4 plates with locking mechanism, avail-
able only in North America
c Bending pliers which can be adjusted to the thickness of the
plate and to the grip of the surgeon by turning the knob at
the end of the handle. Plates should be bent between the
holes and in small steps to avoid sharp indentations. Espe-
cially for reconstruction plates bending templates are often
first molded to the bone and then used as a model when con-
touring the plate.
d Pair of bending pliers with insets for the plate hole to pre-
d vent deformation of the plate hole.
Transbuccal Instruments
Thread
Fig. 1.33 a, b
Transbuccal instruments. For technique see Fig. 1.34a–c.
a Set of instruments for transbuccal placement of 2.0 or
smaller systems. As cheek retractor a ring or a blade is avail-
able. Sleeves are fixed to the handle via a thread.
b Set of instruments for transbuccal placement of 2.4 system.
As cheek retractor a ring or a blade is available.
a Fig. 1.34 a–c

Technique of screw insertion with transbuccal instruments.
a Transbuccal placement of sleeve. The cheek retractor intra-
orally can bear ring or blade. Drilling of pilot hole.
b Length of screw hole is measured with depth gauge through
same sleeve.
c Placement of self-cutting 2.0 screw through transbuccal
sleeve.
c
Power Tools
e g
Fig. 1.35 a–h

a Micro Drive plus air drill for facial, hand, and foot applica- 1.6.4 Power Tools (Figs. 1.35, 1.36)
tions. Forward and reverse. Speed: 0–15000 1/min.
b Drill attachment, straight. Maximum speed 3000 1/min.
c Drill attachment 90°. Maximum speed 7500 1/min.
d Oscillating drill attachment 45°. Oscillating motion around
270°.
e Reciprocating saw. Piston stroke 3 mm. Maximum speed
6000 oscillations 1/min.
f Oscillating saw. Sawblade deviation 15°. Maximum fre-
quency 6000 oscillations 1/min.
g Saw blade for reciprocating saw.
h Saw blades in different widths and lengths for oscillating
saw.
Power Tools
c b a
g f
Fig. 1.36 a–i

a COMPACT™ AIR DRIVE II. Air-driven power tool, forward e Key for Jabobs chuck.
and reverse without work interruption. Power and speed can f Small air drive. Air-driven power tool. Forward and reverse
be regulated by a soft button placed at the air inlet. This without work interruption. Drill speed is controlled with the
allows a good control and precise working. Speed 500 1/min. lower trigger operated by the middle finger. The upper trig-
Cannulation diameter 3.2 mm. ger allows reversing the drill and is operated with the index
b–e Various attachments for Compact air drive. finger. Quick coupling for insertion of AO/ASIF instruments
b Chuck with quick coupling: can be coupled with COM- with quick coupling geometry. Speed 800 l/min
PACT™ AIR DRIVE; accepts AO/ASIF instruments with g Drill attachment for instruments with dental coupling
quick coupling geometry. (mini-quick coupling)
c Drill attachment for instruments with dental coupling h Jacobs chuck.
(mini-quick coupling) i Key for Jacobs chuck.
d Jacobs chuck with key; accepts tools with round shaft
1.0–6.0 mm, with triangular shaft 1.0–6.5 mm, Schanz
screws.
1.7 Set Configurations
1.7.1 Set Configuration Exept North America (Figs. 1.37,

1.38)
1.7.2 North American Set Configuration (Fig. 1.39)
Fig. 1.37 a–d

a Compact MF™. The craniofacial system includes implant
modules in the dimensions 1.0, 1.3, 1.5, 2.0 mm and a 2.0 mm
mandible system. The whole system can be stored in a large
Vario Case™.
b Modules and instrument tray are shown open. The modules
contain plates, screws, and the dimension-specific instru-
ments, such as drill bits and screw driver
c Standard instrument tray contains only the most necessary
instruments for the operation like the bending and cutting
devices, screwdriver handles, plate holding forceps, and
transbuccal instruments. All the implant modules in four
different dimensions can be used with the same instrument
tray.
d Additional instrument tray contains instruments such as
drill sleeves, reduction forceps, depth gauge.
1.7 · Set Configurations 45
Set Configuration (except North America)
c d
Set Configuration (except North America)
Fig. 1.38 a, b
a Compact 2.4™. A mandible system containing a reconstruc-
tion module and a trauma module. The system can be stored
in a small Vario Case™.
b Modules and instrument tray shown open.
The reconstruction module (above left) contains rigid recon-
struction plates 2.4, and the dimension-specific instruments
(drill bits, screwdrivers)
The trauma module (bottom right) contains Universal Frac-
ture plates 2.4, LC-DC plates 2.4, drill bits, and screwdriver.
The instrument tray contains the most necessary instru-
ments such as cutting and bending device, screwdriver han-
dles, drill sleeve, depth gauge, reduction forceps, and plate-
holding forceps.
1.7 · Set Configurations 47
Set Configuration (North America)
a b
c d
Fig. 1.39
a The Craniofacial Modular Fixation System available on the c The Mandibular Modular Fixation System available on the
North American market contains one instrument and four North American market contains two instruments trays and
implant modules with the dimensions 1.0, 1.3, 1.5, and 2.0. two implant modules for all rigid internal fixation applica-
The set can be used for all fractures and orthognathic oper- tions in the mandible: trauma, reconstruction, and orthog-
ations in the midface and cranium. nathics.
b The instrument tray for the craniofacial modular fixation d The instrument trays for the mandibular modular fixation
system concentrates on the most necessary universal instru- system contains all universal instruments such as bending
ments for the application of the screws and plates in the dif- and cutting instruments, transbuccal instruments needed
ferent sizes. for the trauma and the reconstruction module
External Fixation Devices

References and Suggested Reading
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31:479
Ashhurst DE (1986) The influence of mechanical conditions on
the healing of experimental fractures in the rabbit. A micro-
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Assael LA (1990) Considerations in rigid internal fixation of
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SM (1990) Defektbehandlung langer Röhrenknochen durch
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Champy M, Lodde JP (1971) Synthesis mandibulare. Location
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tigation of effect of various agents on periosteal bone forma-
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Frodel J, Marentette L (1993) Lag screw fixation of the upper
craniomaxillofacial skeleton. Arch Otolaryngol Head Neck
Fig. 1.40 a, b Surg 119:297
a External HALO Frame Fixator as it was used in the 1980s. No Fuji N, Yamashiro M (1983) Classification of malar complex
more available. fractures using computed tomography. J Oral Maxillofac
b External Pin Fixation Device, developed 1985. At the mo- Surg 41:562–567
ment not available because of lack of indications. Gautier E, Cordey J, Lüthi U, Mathys R, Rahn BA, Perren SM
(1983) Knochenumbau nach Verplattung: biologische oder
mechanische Ursache? Helv Chir Acta 50:53–58
Gautier E, Cordey J, Mathys R, Rahn BA, Perren SM (1984)
Porosity and remodelling of plated bone after internal fixa-
tion: result of stress shielding or vascular damage? Elsevier
Science, Amsterdam
Goodship AE, Kenwright J (1985) The influence of induced
micromovement upon the healing of experimental frac-
tures. J Bone Joint Surg Br 67:650–655
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Plattenosteosynthese. Unfallheilk 84:439–443
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struction and corrective bone surgery. Springer, Berlin Hei-
delberg New York
Gruss JS, Mackinnon SE (1986) Complex maxillary fractures.
Role of buttress reconstruction and immediate bone grafts.
Plast Reconstr Surg 78:9–22
Gunst MA, Suter C, Rahn BA (1979) Die Knochendurchblutung
nach Plattenosteosynthese. Helv Chir Acta 46:171–175
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Haas N, Gotzen L, Riefenstahl L (1985) Biomechanische Unter- Phillips JH, Rahn BA (1989) Comparison of compression and
suchungen zur Plattenfixation an die Hauptfragmente. torque measurements of self-tapping and pretapped screws.
Orthopedics 123:591 Plast Reconstr Surg 83:447
Haug (1993) Basics of stable internal fixation of maxillary frac- Rahn BA (1987) Direct and indirect bone healing after opera-
tures craniomaxillofacial fractures: principles of internal tive fracture treatment. Otolaryngol Clin North Am 20:425–
fixation using the AO/ASIF technique. pp 135–157 440
Hayes WC (1980) Basic biomechanics of compression plate fix- Rhinelander FW (1978) Physiology of bone from the vascular
ation. In: Uhthoff HK, Stahl E (eds) Current concepts of viewpoint, vol 2. Society for Biomaterials, San Antonio, pp
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(1969) Some effects of rigidity of internal fixation on the Rüedi T (1975) Titan und Stahl in der Knochenchirurgie. Hefte
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London
Chapter 2 51
Anatomic Approaches 2
Chapter Author: Joachim Prein
Contributor: Nicolas J.Lüscher
Good exposure to the fracture site is the key to anatomic Explanation of Abbreviations
reposition and stable osteosynthesis. Nerve or vascular
damage by surgical approaches to the bone must be BPI Blepharoplasty incision
strictly avoided. A careful neurological evaluation of CI Coronary incision
sensory (supraorbital, infraorbital, or mental nerve) and EBI Eyebrow incision
motor nerves (facial or occulomotorius nerve) is there- FA Facial artery
fore mandatory before operating on the patient. The FB Frontal branch of the facial nerve
most often damaged nerve is the marginal branch of the FLI Face lift incision
facial nerve during osteosynthesis of the horizontal FN Facial nerve
branch of the mandible. The open fracture treatment FSO Foramen supraorbitale
with osteosynthesis must include the careful planning of GI Glabellar incision
the skin incisions for optimal cosmetic and functional ION Inferior orbital nerve
results. LBI Lower blepharoplasty incision
For good planning of the skin incision it is important LCL Lateral canthal ligament
to have a wide exposure of the complete face during the LD Lacrimal duct
operation. The nasal intubation tube is fixed over the LEI Low eyelid incision
nose and the frontal midline in mandibular fractures. In LG Lacrimal gland
simple midface fractures the intraoral tube goes down- MA Malar arch
wards to the chest wall. In panfacial fractures different MB Marginal branch of facial nerve
routes for intubation may be necessary, such as nasal, MCL Medial canthal ligament
oral submental, and, exceptionally, tracheotomy, MCS Monocortically placed screws
depending on the local and individual situation. We MN Mental nerve
perfer to cover the gastric and the intubation tube with NLS Nasal lacrimal sack
a translucent, sterile sheet (e.g., Op-Site). OF Orbital fat
After the operation the wounds are usually drained SCI Subciliar incision
with Redon suction drains in a closed system using a SI Stab incision
small skin incision in the skinlines for better scarring of SL Skin lacerations
the drainage holes. The wound is always closed in layers, SM Submental skin fold
and the muscles are carefully adapted with resorbable SON Supraorbital nerve
suture material. For skin closure we use separate TCI Transconjuctival incision
stitches, 3.0 or 4.0 for the coronary approach (or sta- UBI Upper blepharoplasty incision
ples), 5.0 for the face and mandible, and 6.0 for the eye-
lids with monofil nonresorbable suture material.
Careful taping reduces the tension on the skin and
edema.All patients are taught to massage their skin inci-
sions starting 4 weeks after the operation, to apply pres-
sure, and to avoid ultraviolet light as long as the scars are
hyperemic and red.
Never forget that every patient considers the scars as
the surgeon’s signature.
52 Chapter 2 · Anatomic Approaches
EBI
UBI
TCI
LBI
SCL
FN
FLI
FA
MB
SL
Fig. 2.1
Lateral approaches to the facial skeleton. Skin lacerations (see Fig. 2.3, SL) may be used for the
Mandible: The lobule of the ear, angle of the mandible, and approach to fractures and can be extended into the direction of
mouth must always be visible during the operation to allow skin lines or combined with separate incisions.
perfect orientation for correct skinline incisions. Orbit and Zygoma: The subciliar incision (SCI) is the most
The modified face lift incision for the approach to the man- common exposure for the malar bone, inferior orbital rim, and
dibular joint turns around the lobule and can be extended orbital floor. The orbicularis muscle is separated in its fibers
downwards to the horizontal skin folds of the neck to allow 5 mm below to the skin incision.
exposure of the angle of the mandibula (FLI). The main stem Lower blepharoplasty incision (LBI) is less advisable
of the facial nerve may be damaged (FN) N during the osteosyn- because of the danger of postoperative ectropion, especially in
thesis of condylar neck fractures and should be, whenever pos- elderly patients. Too much traction on the skin margins during
sible, exposed. Careful use of the Langenbeck hook is manda- drilling must be avoided.
tory to avoid nerve damage. The skin extension of a transconjunctival incision (TCI) dis-
Exposure of the horizontal branch of the mandible follows inserts the lateral canthal aponeurosis and gives a very direct
the skin lines, which may cross the margin of the mandible or approach to the bone.
not. The marginal branch (MB) may overlap the margin of the The eyebrow incision (EBI) for the exposure of the lateral
mandible by 1 cm. Therefore after incising the skin the pla- orbital rim is nicely hidden in the hair, but we prefer the upper
tysma and fascia colli must be incised 1 cm below the skin inci- blepharoplasty incision (UBI) for a direct and very atraumatic
sion to avoid proximity to the nerve. If the facial artery (FA) is approach to the lateral and superior orbital rim.
dissected, the plane of the marginal branch is always above the
vessel.
Chapter 2 · Anatomic Approaches 53
MCS
MN
Fig. 2.2
Intraoral approaches to the facial skeleton. to raise up again posteriorly in the mandible. Therefore in the
All mucosal incisions are placed 2 mm above or below the horizontal area the screws must be placed very low to avoid
attached gingiva. To give good exposure, transmucosal nerve damage.
approaches must be very long. In the mandible care must be Intermaxillary fixation can either be via dental splints, with
N which perfo-
taken to avoid damage to the mental nerve (MN), the help of unicortically placed short screws (MCS), or with
rates the bone between and below the tooth roots 4 and 5. Prox- miniplates fixed with screws in the alveolar ridge of the max-
imal to the mental foramen the nerve canal goes down 2–3 mm illa and mandible.
SL
SM
Fig. 2.3
Submental approach.
Use of the submental skin fold (SM). The skin is separated from
the muscle to give way to the bone with minimal bleeding. Skin
lacerations (SL) can be included in the skin line incisions or
used as a second and separate approach.
Chapter 2 · Anatomic Approaches 55
NLS
OF
MCL
LG
LCL
LD
OF
BIP
Fig. 2.4
The canthal ligaments and the lacrimal system. The lacrimal duct (LD) and the nasal lacrimal sack (NLS) are
The medial canthal ligament (MCL) is a well-defined anatomic deep to the ligament and can most often be preserved. The lat-
entity with a very strong attachment to the bone. The bony eral canthal ligament (LCL) is not a ligament but a broad apon-
insertion point (BIP) of the medial ligament must be placed in eurotic structure. For exposure of the orbital cavity and floor
correct position during osteosynthesis. the lacrimal gland (LG) and the orbital fat (OF) are mobilized
via the subperiosteal plane.
CI
CI GI
SON EBI
FSO UBI
FB LBI
TCI SCI
ION LEI
MA
SI
Fig. 2.5
Anterior approaches to the facial skeleton. Lower blepharoplasty incision (LBI) may lead to postopera-
In all complex fractures of the midface the coronary incision tive ectropion. The low eyelid incision (LEI) gives a good and
(CI) is mandatory. The W incision of the skin margins respects direct view to the orbital rim, but the scar may be visible and
the hairline and can easily be sutured back at the end of the produce an eyelid edema.
operation. The plane of dissection is subgaleal and subperios- Most of the malar fractures include the intraorbital foramen,
teal, about 2 cm above the orbital rim. The supraorbital nerve therefore the infraorbital nerve (ION) N must always be shown
N must be identified and occasionally burried out of a
(SON) for decompression. Avoid nerve compression by an osteosyn-
small foramen (FSO). thesis plate.
Lateral dissection is deep on the temporal fascia to avoid The frontal branch (FB) of the facial nerve lays in the deep
damage to the frontal branch (FB) of the facial nerve, exposing subcutaneous layer and goes up to the frontal muscle about
easily the malar arch (MA). 1.5 cm posterior to the lateral canthus.
The glabelar incision (GI) either vertical or horizontal To approach the upper orbital rim we perform a lateral
exposes the root of the nose and can be used to place a nasal upper blepharoplasty incision (UBI), which leads directly to
bone graft with screw fixation. the zygomaticofrontal suture. The eyebrow incision (EBI) is an
Four incisions are possible to approach the lower margin of alternative. Lacerations can be included in the skinline
the orbit.We prefer either the subciliar incision (SCI) in the first approach to the orbit.
eyelid fold 4–5 mm below the rim that may be extended later- Stab incisions (SI) are cut in the skinlines for closed reduc-
ally up to 2 cm [cave frontal branch of the facial nerve (FB)!] or tion with the hook in malar fractures or for wound drains.
the transconjuctival incision (TCI) that may be extended
cutting the lateral canthus.
Chapter 3 57
Mandibular Fractures 3
Chapter Author: Wilfried Schilli
Contributors: Peter Stoll
Wolfgang Bähr
Joachim Prein
sary to use inert osteosynthesis material, for example,

3.1 Introduction titanium, which makes implant removal unnecessary.
The aim of adequate internal fixation of facial fractures Age and Sex of Patient. Postoperative healing is gener-
including mandibular restoration of form and function ally better when the patient is young. This is also the case
with plates and screws is to provide for undisturbed with bone healing. On the other hand, elderly patients
healing under the condition of function and without any frequently exhibit diminished osseous density due to
period of intermaxillary fixation (IMF). It is therefore osteoporosis. The biting strength of young men is gen-
necessary to carry out an adequate fixation for each erally greater than that of women. The consequence is
individual fracture type. The question of how to per- that a more stable fixation device should be preferred in
form adequate fixation depends on the different fracture young men.
types, the general health and compliance of the patient,
and the timing of the operation. While one fracture can General Remarks. Medically compromised patients with
adequately be fixed with one miniplate only, another metabolic diseases such as diabetes, allergies, and hem-
fracture may have to be stabilized with a reconstruction orrhage and patients addicted to drugs must be treated
plate in order to be adequately fixed. In addition to these with particular caution. Metabolic diseases may affect
factors, the choice of fixation depends on the experience otherwise uneventful postoperative wound healing.
and judgement of the surgeon. When in doubt, it is Allergic reactions to titanium are not known.
always safer to select a stronger plate and screw or go for In addition, patients with cardiac or pulmonary dis-
a double plate fixation instead of a single plate fixation. eases may exhibit problems with general anesthesia.
Failures are almost always due to a misjudgement of the These patients should be treated under particular anes-
surgeon and not to the hardware. It is of utmost impor- thesiological care either in general or local anesthesia.
tance to recognize and understand failures in order to Psychiatric and neurological diseases (e.g., epilepsia)
provide for a safe and quick repair. do not allow IMF and require open reduction of the frac-
An absolute prerequisite is the ability of the surgeon ture.
to identify and secure the correct occlusion prior to
stable fixation of facial fractures with plates and screws.
During surgery intermaxillary fixation is a must. 3.3 Cost Effectiveness
Number of Plates and Screws. The number of plates and

3.2 Treatment Planning screws used for fracture treatment should be limited to
achieve adequate stability. Overtreatment (oversize!)
Not only the type of fracture but also the patient’s per- should be avoided.
sonality, age, sex, and general condition is of great
importance for treatment planning. Return to Work. The overall aim of fracture treatment is
safe restoration of form and function. By utilizing open
Personality of Patient. Highly educated and intelligent reduction and adequate internal fixation IMF for sev-
patients show better compliance with therapeutic meas- eral weeks can be avoided. In economic terms this may
ures and advice while those with a low social standard be cheaper in numerous cases because the patient is
may be negligent in their postoperative behaviour. allowed to return to work earlier.
These patients require more supervision. It is our expe-
rience that persons with a low social standard often do
not present for implant removal. Therefore it is neces-
58 Chapter 3 · Mandibular Fractures
however. Here a load-bearing osteosynthesis with a

3.4 Adequate Stability stronger fixation device must be performed (see
Sect. 3.15). Defect or comminuted fractures require
The definition of this parameter is difficult. While one bridging osteosynthesis via reconstruction plates. In
fracture may be adequately fixed with only one mini- this context it must be stressed that even the strongest
plate, the other may have to be fixed with a strong recon- plate may fracture with time (due to fatigue) when the
struction plate. The choice depends on the experience bony continuity is not restored.
and judgement of the surgeon, the condition of the
patient, and the specific fracture type. Compression in Comminuted Areas. Comminution
Reasons for failure are almost always due to the sur- means a lack of bony support. Compression in commin-
geon, rather than to the hardware used. It is very impor- uted areas is impossible and leads to dislocation of the
tant to reanalyze failures in order to recognize and fragments.It is therefore necessary at first to simplify the
understand the reason for the complication. The aim is fracture via reduction of the small bone pieces and fixa-
to carry out a safe and quick repair. tion with small plates and screws and to bridge the
Compression is only an additional tool for stabiliza- whole area thereafter with a reconstruction plate. The
tion, not the prerequisite. Compression supports – at screws of the reconstruction plate should not engage the
least in the initial phase of fracture healing – sharing of small bone pieces in the comminuted area (“bridging
functional load between hardware and bone. Neverthe- osteosynthesis”).
less exact and meticulous reduction of the fragments is
compulsory. Insufficient Fixation of the Plate (Too Few Screws). If
In all cases mentioned it is not antibiotic treatment compression of the fragments is not achievable, it is bet-
but stability of the fragments which is the prerequisite ter to use more screws for fixation of the plate. In cases
for uneventful bone healing. It must be stressed that of a defective or comminuted fracture at least three
antibiotic cover is only a supporting factor. screws on each sides of the defect or the comminution
Whenever possible the third molar should not be are mandatory. Thin and weak bone generally requires
removed prior to open reduction and fixation of the the use of more screws than thick and hard bone.
fracture, as it facilitates to some extent exact reposition-
ing of the fracture surfaces. Osteotomies to remove a Screw in the Fracture Gap. Good visibility helps to avoid
third molar should be avoided if possible in order not to the positioning of a screw in a fracture gap. Nevertheless
loose bony support of the fragments. in oblique fractures the postoperative X-ray may reveal
poor position of a screw, i.e., in the fracture gap, which
was not realized during the operative procedure. There-
3.5 Mistakes in Application and Technique fore it is necessary to supervise also the lingual aspect of
the fracture before drilling the screw holes.
Insufficient Reduction of the Fracture With Incongruency
of the Fracture Surfaces and Interposition of Soft Tissue. Stripping of the Screw Holes. Drill bit, tap (if necessary),
Good visibility of the fractured area during open reduc- and screw should be used in the same direction.
tion is important. For example, in subcondylar fractures Repeated insertion and removal of screws is to be
it is inappropriate to use an intraoral approach under all avoided. In weak and demineralized bone, tapping may
circumstances with poor visibility and loss of the ability not be advisable.
to control reduction. If there is any doubt, it is better to
prefer an extraoral approach. Plate Bending Error (Æ Gapping, Torsion, Increased
Intercondylar Distance). Bending errors can be produced
Poor Positioning of Screw (Æ Nerve Damage, Root Dam- especially by using stronger plates. It is therefore impor-
age). To avoid nerve and root damage the plate must be tant to supervise not only the buccal aspect of the frac-
placed adequately, for example, not at the level of the ture after fixation of the plate but also the lingual. A gap
mandibular nerve channel or the tooth roots. If this is on the lingual side can be avoided by overbending the
not possible, the direction of the screw holes must be in plate. Lingual gaps especially in the chin area may result
such a way that the screw bypasses these structures, or it in a cross-bite situation and increased intercondylar dis-
must be placed in a monocortical manner. tance.
Torsion of the plate may produce occlusal interfer-
Choice of Inadequate Hardware (Too Weak, Too Small), ence, for example, tilting of the smaller fragment or an
Especially When in Combination With Subcondylar Frac- open bite. Therefore final intraoperative supervision of
tures. Young men generally require stronger hardware. occlusion is compulsory.
The functional forces in elderly patients with edentulous
and atrophic mandibles should not be underestimated,
3.10 · Localization and Types of Fractures 59
∑ Fractures in uncooperative patients

3.6 Failures ∑ Fractures in medically compromised patients
∑ Patients in which IMF is not advocated
Nonunion/Pseudarthrosis ∑ On patient’s request
Infection/Osteomyelitis. The above situations require

surgical revision. Nonunion and pseudarthrosis must be 3.8 Indications for Perioperative Antibiotic Cover
stabilized by using a reconstruction plate. If there is
bone loss, the fibrous tissues within the gap may be ∑ Medically compromised patients
removed and replaced by corticocancellous bone grafts. ∑ Severely comminuted fractures
Infection and osteomyelitis must be treated as soon ∑ Heavily contaminated fractures
as possible. It is not advisable to manage local infection ∑ Severely lacerated soft tissues
with fistulation by using antibiotics. Antibiotics play ∑ Difficult fractures with predictably long operation
only a supporting role. The reason of infection/osteomy- time
elitis in the majority of the cases is instability of the frac- ∑ Delayed fracture treatment (more than 24 h)
ture and loose hardware. Therefore the only effective
measure to manage the situation is reoperation, clean- The intravenous administration starts prior to surgery
ing of the infected area and application of a reconstruc- and lasts not longer than 24 h. This antibiotic prophy-
tion plate. It is important to use at least three screws on laxis is not sufficient as therapy for a preoperatively
each side of the fracture. The screws must not be placed infected fracture. It cannot replace insufficient mechan-
in the infected area. ical stability. Mechanical stability remains the best pro-
tection against infection.
Broadening of the Face (Increased Intercondylar Dis-
tance), Especially in Combination With Condylar and Sub-
condylar Fractures. Broadening of the face is esthetically 3.9 General Remarks
and functionally unacceptable. Therefore this complica-
tion also requires reosteosynthesis by using a strong ∑ The first step in reduction is restoration of occlusion.
plate. Overbending is compulsory. The reduction must be secured with IMF either by
splints or other fixation devices.
Malocclusion. Malocclusion may be seen postoperatively ∑ Selection of access depends mainly on the localiza-
as the result of an insufficient intermaxillary fixation tion and type of fracture and the possibility of frac-
during surgery. While slight occlusal interferences after ture reduction and supervision.
open reduction and internal fixation of mandibular ∑ In dentate patients supervision of occlusion is man-
fractures may eventually be corrected by grinding the datory. In edentulous patients it is very advisable to
occlusal surfaces of the teeth, serious malocclusion use the prosthesis as a guideline for the correct inter-
requires reosteosynthesis in the correct position of the maxillary relation.
fragments. ∑ General anesthesia, mostly via nasal or submental
intubation, is therefore necessary.
Hardware Fracture (Plate/Screw). Hardware fractures ∑ Tension band plates are fixed whenever possible with
require removal and in the case of instability reosteo- bicortical screws. In situations in which tooth roots
synthesis. or the mandibular nerve can be lacerated, these
screws are placed in a monocortical manner. Com-
pression and reconstruction plates used at the infe-
3.7 Indications for Osteosynthesis rior margin of the mandible are fixed with bicortical
screws.
Fractures Requiring Open Reduction
and Adequate Fixation
3.10 Localization and Types of Fracture
∑ Severely dislocated fractures
∑ Open fractures The localization and type of fracture define the treat-
∑ Complicated/comminuted fractures ment strategy and the surgical access and are described
∑ Infected fractures in the following sections. The various options for fixa-
∑ Mandibular fractures in combination with condylar tion according to the severity of the fractures are
or subcondylar fractures described for each localization.
∑ Panfacial fractures
∑ Fractures in patients with edentulous jaws
Simple fractures may be carried out under local anes-

3.11 Fractures of the Symphysis thesia.
and the Parasymphyseal Area
Definition. Fractures of the symphysis and parasymphy- 3.11.1 Transverse Fracture Line Without Dislocation
seal area are those located in the anterior part of the (Fig. 3.1)
mandible between the canine teeth. They include the
area of the chin and the insertion of the anterior mus- At least three types of fracture fixation are possible:
cles of the floor of the mouth. Since these fractures are
often not dislocated, they can cause diagnostic prob- ∑ A dental splint including at least three teeth on either
lems. Clinically a sublingual hematoma may be the only side of the fracture in combination with a four-hole
symptom. Furthermore, especially in connection with miniplate (2.0) or a four-hole LC-DC plate,placed just
these fractures condylar or subcondylar fractures must underneath the apices of the tooth roots (Fig. 3.2).
be excluded. ∑ Two four-hole miniplates (2.0), fixed with monocor-
Radiographically the fracture can be hidden by the tically applied screws for the superior plate and
overprojection of the vertical spine. Clinically in dentate bicortical screws for the inferior plate. The superior
patients this type of fracture is considered an open frac- plate neutralizes the tensile forces (Fig. 3.3).
ture since the fracture line runs through the alveolus.
Special Conditions Influencing Adequate Internal Fixa-

tion. The intraoral approach allows sufficient supervi-
sion of the reduction. All types of osteosynthesis can be
applied via this approach. The creation of a gap on the
lingual aspect of the fracture must be avoided. The dan-
ger of widening of the mandibular arch and thus broad-
ening of the face is especially present in symphyseal
fractures in combination with subcondylar fractures
(see Fig. 4.1.7a). In the chin area jaw function produces
tortional as well as compressive and tensile forces. The
largest tensile loads are located at the area of the alveo-
lar crest and at the inferior border (Rudderman 1992).
Procedure. Generally the intraoral approach is used via

an incision of the mucosa in the vestibulum. The extra-
oral approach may be used in cases with skin laceration.
a
b
Fig. 3.1 Fig. 3.2 a, b
Transverse fracture of the symphyseal area without disloca- a Open reduction and internal fixation with a four-hole mini-
tion. plate (2.0) in combination with a dental splint.
b Open reduction and internal fixation with a four-hole 2.4
LC-DC plate in combination with a dental splint.
3.11 · Fractures of the Symphysis and the Parasymphyseal Area 61
∑ Two or three long lag screws that cross the fracture Fig. 3.3 a, b
line in a horizontal direction. These screws must gen- a Open reduction and internal fixation by using two four-hole
erally be longer than 20 mm. For an optimal place- miniplates (2.0). The superior plate must be fixed with
monocortically placed screws (as indicated in inset).
ment of the screw head the countersink must be used b A 19-year-old woman. Postoperative radiograph showing
(Fig. 3.4). Both screws are placed in the bone below two miniplates (2.0) in a symphyseal fracture. In this situa-
the tooth roots. tion the surgeon chose to apply a short two-hole plate super-
∑ Stronger plates such as reconstruction plates (Uni- iorly and therefore a longer six-hole miniplate inferiorly.The
LOCK or THORP) may be necessary when these frac- right subcondylar fracture was stabilized with a five-hole
miniplate (2.0), whereas the condylar fracture on the left
tures occur in combination with subcondylar frac- could not be internally fixed. Therefore IMF for 10 days with
tures or with panfacial fractures. elastics was used.
Fig. 3.4 a, b
a Open reduction and internal fixation by using at least two
horizontal 2.4 lag screws. The superior screw must be placed
within the external cortex in in order not to damage the
tooth roots (see inset).
b Postoperative radiograph showing two horizontal lag
screws. The splint was installed for intraoperative fixation of
the occlusion and postoperative functional treatment of the
subcondylar fracture on the left side.
Fig. 3.5
Transverse fracture of the symphyseal area with dislocation.
3.11.2 Transverse Fracture Line With Dislocation

(Fig. 3.5)
This type of fracture requires wider surgical access to

supervise reduction. Fixation of the reduced fracture
with either a dental splint or a 2.0 plate in the area of the
alveolar crest (tensile area), together with temporary
IMF. Fixation of the fracture at the inferior border with
either a 2.4 LC-DC plate (Fig. 3.6) or a Universal Fracture
plate is necessary. When the LC-DC plate is preferred,
the compression device is used via the excentric drill
guide (see Fig. 1.17b,c). Slight overbending is necessary.
In physically strong and/or uncooperative patients the
2.4 DC plate may be too weak to close the lingual gap. In
b
such cases the slightly stronger 2.4 Universal Fracture
plate is advisable (Fig. 3.7). A reconstruction plate with
at least six holes may be more appropriate in the pres- Fig. 3.6 a, b
ence of a concomitant uni- or bilateral subcondylar frac- a Open reduction and internal fixation with a four-hole mini-
ture. plate (2.0) and a four-hole 2.4 LC-DC plate. The superior
plate is fixed with monocortically placed screws.
b Postoperative radiograph showing a four-hole miniplate
(2.0) and a six-hole LC-DC plate.
Fig. 3.7 a, b
a Open reduction and internal fixation by using a four-hole
miniplate (2.0) and a four-hole 2.4 Universal Fracture plate.
b Fracture of the symphyseal area stabilized with a miniplate
(2.0) and an eight-hole 2.4 Universal Fracture plate. The two
inner holes have been left empty because of some bone com-
minution in this area. The stronger plate was especially nec-
essary because of this comminution and the loss of the left
lower incisor.
Fig. 3.8 a–c

3.11.3 Fracture Line With Basal Triangle a Fracture of the symphyseal area with basal triangle. Open
reduction and internal fixation by using a four-hole mini-
plate (2.0) and a ten-hole 2.4 Universal Fracture plate.
In this situation a 2.4 Universal Fracture plate at the base b Radiographic appearance of a symphyseal fracture with
is used. The main fracture ends should at least be fixed basal triangle in a partially edentulous mandible.
with three screws. The triangular piece of the base can c Fixation with a six-hole miniplate (2.0) for adaptation and a
further be fixed with 2.4 screws to the plate or with 2.0 2.4 Universal Fracture plate at the base for stabilization. The
or 2.4 screws acting as lag screws in a vertical direction. screw holes in the area of comminution are left empty. Note:
three screws on each side.
In the tensile area a miniplate (2.0) is used (Fig. 3.8).
a b
Fig. 3.9 a–c

a Comminuted fracture of the symphyseal area.
b Open reduction and internal fixation with a dental splint and
a ten-hole 2.4 reconstruction plate.
c Comminuted symphyseal fracture after open reduction and
internal fixation with an eight-hole adaptation plate in com-
bination with a ten-hole 2.4 reconstruction plate. Plate holes
above the comminuted fracture area are left empty. Load-
bearing osteosynthesis! c
3.11.4 Comminuted Fracture (Fig. 3.9a) 3.12 Fractures of the Horizontal Ramus
The fragments are reduced by using a dental splint and Definition. Fractures of the horizontal ramus are those
IMF. Bridging of the fracture area is with a 2.4 recon- located between the canines and the last molar. Particu-
struction plate. Distortion of the main fracture ends lar attention must be given to the mental nerve. Both AP
must be avoided by using the plate holes in a neutral projection and orthopantomogram are mandatory since
manner. This is of great importance, especially in the type of fracture directs the surgical approach. In
patients with teeth. Care must be taken not to use screws dentate patients this type of fracture is always an open
too close to a fracture line. The thicker bony pieces may fracture since the fracture line runs through the alveo-
be fixed with screws to the plate (Fig. 3.9b,c). Stripping lus.
of the lingual periosteum is not advised in order to avoid
disturbance of the blood supply of the small bone Special Conditions Influencing Adequate Internal Fixa-
pieces. tion. The intraoral approach allows sufficient supervi-
Special attention must be given to the condylar area sion in the anterior part of the horizontal ramus. In the
since most of these comminuted chin fractures are posterior part a gap of both the inferior and the lingual
observed in combination with condylar or subcondylar aspects of the fracture cannot always be supervised via
fractures. Especially when bilateral or in combination the intraoral approach. An extraoral approach may then
with panfacial fractures, these fractures should be inter- be more appropriate. This is also a question of the expe-
nally stabilized, if anatomically possible. rience of the surgeon and is therefore his decision.
3.12 · Fractures of the Horizontal Ramus 67
a b
Procedure. An intraoral approach is generally chosen. In Fig. 3.10 a–c

the molar area additional stab incisions may be neces- a Fracture of the horizontal ramus without dislocation.
sary for the transbuccal placement of the screws. In b Stabilization with two four-hole miniplates (2.0).
c Repair of a horizontal ramus fracture with two four-hole
heavily comminuted fractures an extraoral approach is miniplates (2.0). The subcondylar fracture on the opposite
seldom avoidable. Of course, cases with overlying skin side has been stabilized with a four-hole mini DC plate (2.0).
lacerations are approached through the wound (“occa-
sional approach”).
Special attention must be given to the mental nerve (Fig. 3.10b,c). In strong male patients and in uncooper-
when using the intraoral approach and to the marginal ative patients it may be necessary to use a 2.4 plate with
branch of the facial nerve when using the extraoral bicortical screws at the inferior border. As tension band
approach. For this reason a transbuccal approach is a dental splint may also be used (see Fig. 3.2).
often chosen (see Fig. 1.34).
Generally all these fractures are operated on under
general anesthesia. 3.12.2 Transverse Fracture Line With Dislocation
(Fig. 3.11a)
3.12.1 Transverse Fracture Line Without Dislocation This type of fracture requires wider surgical access to
(Fig. 3.10a) supervise reduction. Reduction is secured with a 2.0
miniplate in the alveolar crest (tensile area) or a tension
Two four-hole miniplates (2.0), monocortically applied band-splint. Fixation of the fracture in the inferior bor-
screws for the tension-band plate, and bicortical screws der with a 2.4 LC-DC plate (Fig. 3.11b,c). Overbending
for the plate at the inferior mandibular border are used in this area is less important than in the anterior part of
a b
the mandible. In stronger male patients the 2.4 LC-DC Fig. 3.11 a–c
plate may be too weak to withstand the functional forces a Fracture of horizontal ramus with dislocation.
and to close the lingual gap. In such cases a stronger 2.4 b Repair of a fracture of the horizontal ramus with a four-hole
miniplate (2.0) as tension band and a four-hole 2.4 LC-DC
Universal Fracture plate is advisable (Fig. 3.12). plate.
c Repair of a lateral fracture with a four-hole miniplate (2.0)
as tension band and a four-hole LC-DC plate.
Fig. 3.12 a–e ▼

a Preoperatively the same situation as in Fig. 3.11a on the right
side, but in combination with an angular fracture on the left
side. Fixation with a miniplate (2.0) as tension band in com-
bination with a 2.4 Universal Fracture plate.
b, c Radiographic appearance pre- and postoperatively. Two
dislocated fractures in a young dentate man. Fixation with a
miniplate (2.0) with monocortically placed screws and a 2.4
Universal Fracture plate with bicortically placed screws.
Angular fracture see in Fig. 3.19b.
d,e (see page 70)
c
Fig. 3.12 d, e Fig. 3.13 a–e
▼
d,e Pre- and postoperative X-rays of horizontal ramus fracture a Oblique fracture of the horizontal ramus. Repair with three
in edentulous area in a strong man. Fixation with a miniplate lag screws.
(2.0) in combination with a 2.4 Universal Fracture plate. b,c Pre- and postoperative X-ray of a severely dislocated
Most of the screws are bicortically placed. oblique fracture of the horizontal ramus. After open reduc-
tion adequate fixation with three 2.4 lag screws was
achieved.
d Clinical example of an oblique fracture of the horizontal
3.12.3 Oblique Fracture Line With/Without Dislocation ramus in the premolar area. Typically, the fracture is hardly
visible on the OPT.
e Ideal stabilization in this case with four 2.7 lag screws.
Fractures with an oblique fracture line have a wide sur-
face and can therefore be fixed either only with lag
screws or a lag screw in combination with plates. If sta-
bilization with screws only is performed, three screws
should be placed (Fig. 3.13). The area underneath the
screwhead should be flattened, and therefore the coun-
tersink is used. If only two lag screws can be placed, a
combination of these lag screws with a 2.4 LC-DC plate
or a Universal Fracture plate is necessary, together with
a splint for tension-banding (Fig. 3.14).
a
b
e
Fig. 3.14
Repair of an oblique fracture with one lag screw in combina-
tion with a 2.4 LC-DC plate at the lower border and a dental
splint as tension band. Note: placement of lag screw in inset.
The lag screw must be placed first and thereafter the remain-
ing screws are placed in a neutral position.
Fig. 3.15 a–d

▼
a Fracture of the horizontal ramus with basal triangle.

b Open reduction and adequate fixation with a four-hole mini-
plate (2.0) as tension band and an eight-hole Universal Frac-
ture plate.
c Stabilization of a dislocated fracture with basal triangle
with a miniplate (2.0) as tension band in combination with b
a 7 hole 2.4 Universal Fracture plate. Empty hole above the
fracture line in between triangle and corpus.
3.12.4 Fracture Line With Basal Triangle (Fig. 3.15a)
Osteosynthesis is performed with a 2.4 LC-DC plate or a

2.4 Universal Fracture plate at the base of the mandible.
In appropriate situations the triangle can be fixed either
to the plate with a 2.0 or 2.4 lag screw or to adjacent bone
with a separate lag screw. In the tensile area a 2.0 mini-
plate with monocortically placed screws or a tension
band splint is used (Fig. 3.15b,c).
3.12.5 Comminuted Fractures (Fig. 3.16a)

c
The fragments are reduced and approximated by using
1.5 or 2.0 miniplates or lag screws. The fracture area then
is bridged with a 2.4 or 2.7 reconstruction plate. Of
course, the screws must be placed in a neutral position
since compression in the presence of a comminuted
fracture is inappropriate and may lead to distortion and
consequently to malocclusion (Fig. 3.16b,c).
3.13 · Fractures of the Mandibular Angle 73
Fig. 3.16 a–c

a Comminuted fracture of the horizontal ramus.
b Open reduction and rigid fixation with two miniplates (2.0)
for fracture adaptation and a 2.4 reconstruction plate. Note:
three screws on each side of the nonfractured area are man-
datory.
c Stabilization of a comminuted fracture of the horizontal
ramus with two long mini adaptation plates for primary fix-
ation of the various fragments. Bridging of the comminuted
area with a 12-hole reconstruction plate. Note: three screws
on either side.
a 3.13 Fractures of the Mandibular Angle
Definition. Fractures of the mandibular angle are those

located posterior to the second molar and comprising
the triangle between horizontal and ascending ramus.
Frequently the fracture line runs through the area of an
impacted third molar. Since the orthopantomogram
alone often does not show the degree of dislocation,
additional AP projections are mandatory.
The type of the fracture, the degree of dislocation,
and the experience of the surgeon determine the surgi-
cal approach. If a third molar is partly impacted or in
contact with the second molar, the fracture must be
regarded as an open fracture.
Special Conditions Influencing Adequate Internal Fixa-

tion. Control of the inferior fracture aspect is limited
when using the intraoral approach. The need for intra-
b operative intermaxillary fixation may be an additional
obstacle in reduction of the fragments.
Procedure. The intraoral approach can be used in cases

with no or only slight dislocation. While some of the
screws for the plate fixation in the tension-band area can
be placed via this approach, it is often necessary to use
an additional stab incision for correct transbuccal place-
ment of the screws at the base of the mandible.
Fractures with a high degree of dislocation or com-
minuted fractures need an extraoral approach for cor-
rect reduction and supervision of the placement of the
plate. The correct application of longer and stronger
plates is extremely difficult via an intraoral approach.
When using the extraoral approach, special attention
must be given to the mandibular branch of the facial
nerve (see Fig. 2.1).
In some instances local anesthesia may be sufficient
for the treatment of a simple and nondislocated fracture
when using a one-plate fixation in the area of the linea
obliqua. All other cases, however, are usually carried out
c under general anesthesia.
It is not compulsary to remove a third molar which is
located in the fracture line (especially not with an oste-
otomy) since this procedure might hinder the correct
reduction and lessen stability of the fixation. This may
a b
mean weakening of the tension zone. In cases in which Fig. 3.17 a–d
removal of the wisdom tooth is advisable it should be a Transverse angle fracture without dislocation with fully
performed after fixation of the fracture with plates. retained wisdom tooth.
b Fracture repair with a single six-hole miniplate (2.0).
c,d Pre- and postoperative X-ray of fracture situation in a
young woman, as shown in a,b. The fully retained wisdom
tooth was not removed.
Fig. 3.18 a, b
3.13.1 Transverse Fracture Line Without Dislocation a Transverse angle fracture. Repair with a six-hole miniplate
(Fig. 3.17a) (2.0) at the superior border and a four-hole miniplate (2.0)
at the inferior border.
b Postoperative X-ray. Fixation of the nondislocated angular
One-plate fixation is possible using a 2.0 miniplate (four fracture with two miniplates (2.0). A six-hole plate for the
or six holes; two or three screws on each side) with tension band at the superior border and a four-hole plate at
monocortically applied screws, when necessary (area of the inferior border. Note: the wisdom tooth was not
tooth roots) at the area of the linea obliqua, but this kind removed.
of fixation cannot neutralize all the forces that may
occur during function (Fig. 3.17b–d).
Especially in men this fracture is better managed
using two 2.0 miniplates, one in the area of the linea obli-
qua and the second at the inferior border (Fig. 3.18).
Again, the plate should be fixed with bicortically placed
screws whenever possible. In stronger men it might be
necessary to use a 2.4 LC-DC plate with bicortical screw
fixation at the inferior border in combination with the
2.0 miniplate in the tension-band area (Fig. 3.19).
Fixation of the fracture is also possible using a single
lag screw in anteroposterior oblique direction (Fig. 3.20)
if the bone is strong and not osteoporotic. This tech-
nique, however, requires considerable experience on the
part of the surgeon since there is danger of damaging
the inferior alveolar nerve during drilling and tapping.
a a
Fig. 3.20 a, b
a Repair of a nondislocated transverse preangular fracture
with one single lag screw. The lag screw crosses the fracture
line in an anterior buccal to posterior lingual direction.
b b Clinical situation as shown in a.
Fig. 3.19 a, b
a Transverse angle fracture. Repair with a four-hole miniplate 3.13.2 Transverse Fracture Line With Dislocation
(2.0) as tension band and a four-hole 2.4 LC-DC plate at the (Fig. 3.21a)
inferior border.
b Postoperative X-ray showing the fixation of a transverse
angle fracture, as indicated in a. Strong male patient! This type of fracture shows damage of the periosteal and
the pterygoid/masseter “bandage.” Interposition of
muscle fibers makes the reduction more difficult. In
these cases a one-plate fixation using a 2.0 miniplate
might not be sufficient. An additional 2.0 (see
Fig. 3.18a,b) or 2.4 LC-DC plate (see Fig. 3.19a,b) is
placed at the inferior border of the mandibular angle.
Stronger patients require a 2.4 Universal Fracture plate
(Fig. 3.21b–d).
c
d
Fig. 3.21 a–d c Open reduction and adequate fixation of dislocated angle
a Angle fracture with dislocation. The muscle sling of mas- fracture with a four-hole miniplate (2.0) as tension band and
seter and pterygoideus pulls the proximal fragment crani- a six-hole 2.4 Universal Fracture plate.
ally. d Postoperative X-ray. Repair of a dislocated angle fracture by
b Dislocated angular fracture on the left side. Anterior-super- means of a four-hole miniplate (2.0) as tension band and a
ior dislocation of the proximal fragment because of the trac- six-hole 2.4 Universal Fracture plate. Note: the wisdom tooth
tion of the muscle sling is well visible. has been left in place.
a b
Fig. 3.22 a–c

a Angle fracture with basal triangle. 3.13.3 Angular Fractures With Basal Triangle
b Open reduction and adequate fixation with a four-hole mini- (Fig. 3.22a)
plate (2.0) at the superior border and an eight-hole angu-
lated 2.4 Universal Fracture plate.
c Postoperative X-ray of an angle fracture with basal triangle. An angulated 2.4 Universal Fracture plate or a 2.4 Recon-
Repair with a six-hole miniplate (2.0) and in this case a ten- struction Plate with six to eight holes is used at the base
hole 2.7 reconstruction plate. of the mandible. The triangle can either be fixed to the
plate or with lag screws (2.0 or 2.4) to the main frag-
ments. In the tensile area a 2.0 miniplate is generally
used (Fig. 3.22b,c). As always, care must be taken not to
place the screws too close to the fracture line. If in doubt,
it is always safer to use a longer plate and leave the hole
close to the fracture line empty.
a b
Fig. 3.23 a–c

3.13.4 Comminuted Angular Fractures (Fig. 3.23a) a Comminuted fracture in the left mandibular angle. The frac-
ture is both transverse and longitudinal.
b,c Internal fixation of a comminuted fracture, in the left man-
Comminuted fractures of the angular area are often dibular angle with a lag screw for the longitudinal fracture
observed in combination with other mandibular frac- and an eight-hole reconstruction plate (2.7), bridging the
tures and maxillary fractures. After temporary inter- comminuted area. Since it was a wide open fracture and the
maxillary fixation all mandibular fractures must be mandibular nerve well visible, fixation could easily be per-
exposed before the reduction and fixation of the frag- formed with the anterior screws placed below the nerve and
the posterior screws placed above the nerve.
ments is done. This can be performed either with lag
screws (Fig. 3.23 b) or with 1.5 or 2.0 miniplates (see
Fig. 3.25). Simpler fractures should be fixed first. In com-
minuted areas, such as in Fig. 3.24 (right angle) and
Fig. 3.25, at first adaptation is performed with mini-
plates, and thereafter the fractured area is completely
bridged with the stronger 2.4 reconstruction plate. Sec-
ondary distortions of the fracture area are prohibited by
using the plate holes in a noncompressive manner
(Figs. 3.23–3.25). The fixation of coexisting subcondylar
fractures in these instances is very important.
Fig. 3.24 a, b
Postoperative X-ray after stabilization of a panfacial fracture.
The comminuted fracture of the right mandibular angle was
stabilized with miniplates (2.0) together with a prebent angu-
lated Universal Fracture plate. Note: stabilization of both sub-
condylar fractures with DC miniplates. Combination of mini-
plate fixation together with reconstruction plate for the chin
b fracture.
3.13.5 Comminuted Fractures

of the Ascending Mandibular Ramus
This type of fracture may require a combined subman-

dibular and preauricular approach. The fracture is sim-
plified by using 2.0 miniplates and subsequent bridging
and the whole fracture stabilized by a 2.4 Universal Frac-
ture plate or 2.4 reconstruction plate (Fig. 3.25).
Fig. 3.25 a–g

a Comminuted fracture of the ascending mandibular ramus. a
b Open reduction and adaptation of the fragments with differ-
ent miniplates (2.0).
c Subsequent bridging of the comminuted area with a 2.4 Uni-
versal Fracture plate.
d–g (see page 82).
c
f g
Fig. 3.25 d–g

d Preoperative X-ray showing the comminuted fracture of the
ascending mandibular ramus, as shown in a.
e Open reduction and simplification of the fracture with sev-
eral mini adaptation plates (2.0).
f Bridging of the comminuted area with a 2.4 Universal Frac-
ture plate.
g Postoperative X-ray exhibiting the different fragments in
their regular position.
3.14 · Condylar and Subcondylar Fractures 83
Condylar fracture
High subcondylar fracture
Low subcondylar fracture

Fracture at condylar basis
Fig. 3.26
3.14 Condylar and Subcondylar Fractures Fracture classification according to Köhler.
Definition. As shown in Fig. 3.26, condylar and subcon-

dylar fractures are classified according to the level of the In general, especially nondislocated fractures are treated
fracture line (Köhler 1951). conservatively, as this shows excellent long-term results.
In the case of condylar fractures the fracture line runs In the case of a high-grade dislocation or luxation of
inside the capsule of the temporomandibular joint. the small fragment, conservative treatment with at least
These fractures cannot be fixed with plates or screws. 2 weeks of intermaxillary fixation or direct or indirect
Subcondylar fractures are situated below the capsule. extension is possible. However, a reduction of fragments
They are classified into high and low condylar fractures is almost never achieved. Therefore in some special
as well as fractures of the basis of the condylar process. instances open reduction and internal fixation are desir-
Fractures on the basis of the condylar process are at able.
the level of the bottom of the sigmoid knotch (incisura Either an intra- or an extraoral approach to the sub-
semilunaris). condylar area is possible. Using an intraoral approach,
Various patterns of dislocation and luxation of the however, makes the reduction of the fragments and
proximal fragment are possible. especially the application of plates and screws extremely
For treatment planning both AP projections and an difficult. In addition, it does not allow sufficient supervi-
orthopantomogram are mandatory. Generally these sion of the reduction. The extraoral approach is per-
fractures are closed fractures. formed via a submandibular (Risdon) or preauricular
incision; sometimes the combination of both
Special Conditions Influencing Internal Fixation. As a approaches is necessary (see Fig. 2.1). When using the
rule condylar fractures are treated conservatively, one of preauricular access alone, the necessary extension of the
the reasons being the danger of necrosis of the proximal fracture exposure for a better reduction and fixation
fragment (condylar head). This is due to interruption of may not be possible. Care must be taken not to lacerate
the vascular supply by denudation during an open- the frontal branch of the facial nerve when using the pre-
reduction procedure. auricular approach, and the marginal branch of the
The decision about the kind of treatment for subcon- facial nerve when using the submandibular approach.
dylar or fractures at the base of the condylar neck All procedures are performed under general anesthesia.
depends on several factors. These are:
∑ Status of dentition 3.14.1 Transverse Fracture Line With Dislocation

∑ Degree of dislocation
∑ Condition of the patient After exposing the fracture from either approach, pull-
∑ Concomitant fractures of the mandible, such as cor- ing the mandibular angle in a caudal direction may facil-
pus fractures and bilateral subcondylar fractures itate reduction of the dislocated or luxated small frag-
∑ Bimaxillary fractures or panfacial fractures. (For ments. If necessary, reduction is secured using one or
more precise information about indications for inter- two reduction forceps. Fixation of the fracture at the
nal fixation of subcondylar fractures, see “References posterior border of the ascending mandibular ramus
and Suggested Reading”). and the condylar process with a four-hole mini-DC plate
and bicortical screws. In general, one plate is sufficient.
Care must be taken not to use a plate that is too thin, as Fig. 3.27 a, b
this may lead to plate fracture (Hammer 1997). Regular a Internal Fixation of bilateral low subcondylar fractures with
miniplates that are ordinarily used for midface fractures DC miniplates (2.0).
b Postoperative X-ray after adequate fixation of bilateral low
are too thin. It is also important that there is room for subcondylar fractures with DC miniplates (2.0) in a panfa-
two bicortical screws on each side of the fracture cial fracture situation.
(Fig. 3.27).
In fully dentured patients with fractures of the base
of the condylar process, which may also be considered as
the ascending ramus, Universal Fracture plates for sta-
bilization may be advisable (Fig. 3.28).
3.14 · Condylar and Subcondylar Fractures 85
Fig. 3.28 a–c

a Adequate fixation of bilateral fractures of the base of the Fracture plates. Note the malocclusion visible on the preop-
condylar process (ascending ramus) in a fully dentured erative X-ray. These strong plates for that situation were
strong man with six-hole 2.4 Universal Fracture plates. indicated because fracture repair had to be performed
b, c Pre- and postoperative X-rays of bilateral fractures of the 3 weeks after the accident. Under these circumstances the
base of the condylar process. Fixation with 2.4 Universal considerable scar contracture must be taken into account.
a b
Fig. 3.29 a–d

a Dislocated fracture of the horizontal ramus of an extremely c, d Pre- and postoperative X-ray of a dislocated fracture of
atrophic mandible. the horizontal ramus in an extremely atrophic mandible.
b Adequate fixation of the fracture with a 2.4 Universal Frac- Fixation with a long 2.4 Universal Fracture plate. Note:
ture plate. Note: screw placement in vicinity of the fracture the height of the mandible in the very atrophic area is
is not possible. Therefore the screw must be placed in angle lower than the width of the plate.
and chin area.
3.17 · Defect Fractures 87
3.15 Fractures of the Atrophic Mandible (Fig. 3.29a) 3.16 Infected Fractures (Fig. 3.30a)
Definition. An atrophic mandible shows resorption of Definition. Open fractures can generally be regarded as
the alveolar process.Atrophic edentulous mandibles can contaminated. Since fractures in the dentate area have
be extremely thin. The muscular forces acting upon the communication with the oral cavity, they are also
bone are incomparable to forces acting upon dentate regarded as open fractures.
mandibles. In fractures of the atrophic and edentulous Infections with clinical relevance show swelling,pain,
mandible functional load must be transmitted by using hyperthermia, reddening and secretion of pus. In the
a stable fixation device.In contrast to dentate mandibles, case of acute infection radiographic signs can be miss-
tension – neutral – and compression zones are situated ing. Chronic cases exhibit the typical signs of osteomye-
closely together due to the reduced height of the bone. litis.
Therefore only one plate can be applied, which should
counteract the masticatory forces and take over the Special Conditions Influencing Adequate Internal Fixa-
functional load. tion. Instability produces and maintains the infectuous
In addition to its reduced dimension the quality of process. In the case of inappropriate osteosynthesis and
the edentulous and atrophic mandibular bone must also screw loosening the hardware acts as a foreign body and
be taken into consideration. Osseous density is fre- must be removed. An osteosynthesis can be inappropri-
quently diminished due to osteoporosis. The bone is ate because of the wrong plate selection (too short, too
weak and fragile; screws can fail due to stripping of the weak) or loosening of screws.
bone threads. In very weak bone it is advisable to use the Osteosynthesis of an acutely infected fracture or
screws without pretapping. pseudarthrosis must be a safe procedure. Under these
Since atrophy occurs mainly in the area of the alveo- conditions absolute immobility is mandatory. Therefore
lar process and here especially in the lateral horizontal the 2.4 reconstruction system is recommended
branch, fracture management differs from that de- (Fig. 3.30). It is important not to place any screws into
scribed earlier in this chapter. In some instances screws infected bone. This area must be spared from insertion
can be placed only in the angular and chin areas. There- of screws. The reconstruction plate acts as a bridging
fore long plates must often be used. device. Large areas of infected or necrotic bone require
curettage and immediate cancellous bone grafting.
Procedure. If available, the prosthesis should also be Antibiotic therapy alone does not eliminate the infec-
used in edentulous patients for correct establishment of tion as long as the fracture is unstable.
the intermaxillary relation. The prosthesis can be fixed
temporarily with wires or screws to the jaw.
Since the plates must carry a full functional load, it is
recommended to use 2.4 Universal Fracture plates or
Reconstruction plates. Anterior fractures without com-
minution can be approached by an intraoral access,
whereas posterior fractures of the horizontal ramus and
comminuted fractures are subject to an extraoral
approach. The plate must be long enough so that the
screws do not need to be placed to very low or thin areas
of the mandible (Fig. 3.29). The rule is: The weaker the
bone, the stronger the plate must be.
Even if these elderly patients do not wear dentures,
one should not underestimate the functional load.
Fatigue fractures of miniplates are often observed and
are therefore not considered for fracture stabilization in
these instances.
a b
c d
Fig. 3.30 a–d

a Acutely infected fracture of the mandibular angle, 6 weeks 3.17 Defect Fractures (Fig. 3.31a)
after removal of an infected wisdom tooth.
b Bridging of the infected area with a 2.4 reconstruction plate.
Note: screws must not be placed into infected bone. At least Definition
three screws must be used outside the fractured area. Defect fractures exhibit loss of bone in the fractured
c Adequate fixation of acutely infected fracture of the mandib- area. A “jigsaw puzzle” reduction and simplification by
ular angle, as shown in b. Simultaneously a bone graft was 2.0 plates is not possible. The only orientation for the
placed into the empty infected socket. correct distance of the remaining bone stumps is given
d On special request of the patient, the plate was removed 4 -
months after fixation. Note: complete reossification.
by IMF in the case of a nonfractured and dentate max-
illa.
Even with soft-tissue defects and when a plate cannot
be covered with soft tissue primarily, the bone frag-
ments must be stabilized by bridging osteosynthesis
with a reconstruction (UniLOCK or THORP) plate
(Fig.3.31b–d and Fig.3.32).It is advisable to perform the
fixation with at least three, or if possible four, screws on
each side. Primary bone grafting is performed only
when the defect area can be closed well with soft tissues.
Fig. 3.31 a–d

a Defect fracture of the mandible in the area of chin and left
horizontal ramus. The chin segment with the incisor teeth is
extremely dislocated. The premolars are lost.
b X-ray of above situation.
c Postoperative X-ray showing bridging osteosynthesis for the
defect area with a 21-hole reconstruction plate. The segment
of the alveolar ridge in the chin area was stabilized with one
lag screw. Because of unfavorable soft-tissue conditions pri-
mary bone grafting was not performed.
d X-ray after bone grafting of left mandibular corpus, as well
as several tooth extractions, bridge work, and plate removal.
Nowadays, if not especially requested, these plates are not
removed.
d
b c
Fig. 3.32 a–c Fig. 3.33 a–e

▼
a Bridging osteosynthesis with 24-hole reconstruction plate a Diagram showing bilateral mandibular fractures in a 7-year-
from angle to angle after a wide open defect fracture of the old child.
mandible, due to a gunshot laceration. b Diagram showing stabilization of bilateral mandibular frac-
b The bridging plate was used for stabilization of both hori- ture in a 7-year-old child with 2.4 plates and screws.
zontal ramus and chin area. Although due to the soft-tissue c OPT showing fixation of bilateral mandibular fractures with
loss the plate could not be covered primarily, there was no 2.7 system. Today the 2.4 system, as shown in b, would be
problem with infection. appropriate. There is barely room to place these plates and
c Bone and soft-tissue reconstruction was performed later. screws at that young age.
d OPT showing the same patient as in c 5 years later. The plates
were removed 1 year after osteosynthesis. The X-ray shows
no tooth damage due to plate and screw placement, but due
to the fracture.
e Postoperative X-ray in a 8-year-old child. Internal fixation of
a paramedian fracture with a DC miniplate (2.0) because of
comminution.
a b
e
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Niederdellmann H, Akuamoa-Boateng E, Uhlig G (1981) Lag year experience report. J Craniomaxillofac Surg 24, Suppl 1,
screw osteosynthesis: a new procedure for treating fractures 123
of the mandibular angle. J Oral Surg 39:938–940 Wächter R, Stoll P, Bähr W, Schilli W (1996) Versorgung der
Passeri LA, Ellis E, Sinn DP (1983) Complications of non-rigid komplexen infizierten Unterkieferfraktur mit dem THORP-
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Surg 51:382 Gesichtschir 41
Prein J, Beyer M (1990) Management of infection and nonun-
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Am 2(1):187–194
Chapter 4 95
Craniofacial Fractures 4
Chapter Author: Paul N.Manson
Contributers: C.R.Forrest
B.Hammer
P.N.Manson
B.Markowitz
J.H.Phillips
J.Prein
P. Sullivan
palate, dentition, and alveolar processes of the maxilla

4.1 Organization of Treatment in Panfacial Fractures and the mandible. The mandibular unit consists of hor-
izontal and vertical sections. The vertical section
Contributor: Paul N.Manson includes the condyle, ramus, and angle. The horizontal
section is the body and symphysis and parasymphysis
areas.
4.1.1 Introduction In the upper face are the frontal and upper midfacial
units. The frontal unit consists of the most superior
In the case of multiple facial fractures an order of treat- frontal and temporal bones, the supraorbital rims, the
ment should be developed. In the past “inside out,”“top orbital roofs, and the frontal sinus. The upper midfacial
to bottom,” or “bottom to top” philosophies have pre- unit is composed of the zygomas laterally, the nasoeth-
vailed, each with its own vigorous proponents [1]. moid area centrally, and the internal portion of the
Recently an “outside to inside” management scheme for orbits bilaterally (Fig. 4.1.1c). The upper and lower mid-
the midface has been proposed emphasizing the zygo- face meet at the Le Fort I level. Each unit is therefore
matic arch [2]. The exact order of treatment is not as divided into sections based on central, lateral and hori-
important as the development of a plan which permits zontal and vertical divisions.
accuracy of anatomic positioning of the various facial Midface fracture treatment is predicated on an accu-
segments. Exposure, identification, and fixation of the rate physical examination and on evaluation with a
facial buttresses (Fig. 4.1.1a), guarantees best correct thorough computed tomography (CT) scan. Although it
alignment and stabilization of facial fractures. Because may seem obvious, patients must have other significant
of the face’s complexity and multiple parts it is impor- injuries evaluated prior to undertaking facial surgery.
tant that an order of facial fracture treatment be devel- The airway is protected by intubation or tracheostomy.
oped to address Le Fort (midface) and accompanying The endotracheal tube should either be placed through
fractures. Such midface “extended” fractures (combin- the nose, through a gap in the dentition, behind the
ing two or more areas) are referred to as “panfacial”frac- molar teeth, submentally, or a tracheostomy (possibly
tures. endoscopically) may be employed.
The approach described provides a uniform format
for recreating facial dimensions, and proceeds from
intact cranial vault and cranial base landmarks through 4.1.3 Occlusion
the entire anterior portion of the face. The treatment of
all Le Fort and any associated fractures may be inte- Attention is directed first to the dentition. Arch bars are
grated into this plan, which provides for both simple and applied to the teeth of the maxilla and the mandible. If
panfacial injuries of all degrees of complexity. The treat- fractured, the hard palate must be reduced and stabi-
ment plan minimizes extraneous prepping and brings lized with stable fixation before intermaxillary fixation
order to operative intervention by efficient, sequential (Fig. 4.1.2; see also Figs. 4.2.6, 4.2.10). One or two mini-
manipulation. plates (2.0) are applied in the roof of the mouth and at
the piriform aperture. Two-dimensional palate stabil-
ization of the maxillary dental arch is therefore com-
4.1.2 Surgical Sequencing of Le Fort Fracture Treatment pleted. This step sets a template for the correct width of
the whole lower face by providing an anatomically
The face is divided into upper and lower halves at the Le reduced maxillary arch as a template for mandibular
Fort I level (Fig. 4.1.1b). Each facial half is divided into reconstruction. Similarly, alveolar fractures of the man-
two facial units. In the lower face are the occlusal and dible may be reduced with small 2.0 or 1.5 plates, or per-
mandibular units. The occlusal unit consists of the teeth, haps the 1.3 or microsystem (Fig. 4.1.3). This step stabi-
96 Chapter 4 · Craniofacial Fractures
Fig. 4.1.1 a–c

a Horizontal and vertical buttresses of the facial skeleton
(arrows)
b View of face with division line for upper and lower facial
halves at the Le Frt I level.
c View of face: identification of the four facial units: frontal,
upper midface, occlusal, and mandibular units.
Occlusal unit: components are the teeth, the palate, the alveo-
lar processes of the maxilla and the mandible.
Units of the mandible: vertical, horizontal; vertical consists
of condyle, ramus and angle; horizontal consists of body, sym-
physis, and parasymphysis.
The upper face consists of the frontal sinus area medially
and two lateral frontal-temporal-supraorbital segments.
The upper midface unit consists of the zygomas laterally, and
the nasoethmoid areas centrally,and the internal portion of the
orbits bilaterally.
4.1 · Organization of Treatment in Panfacial Fractures 97
4.1.4 Upper Face: The Cranial Unit
Frontal bone fracture fragments, as removed, are

marked in sequence after exposure is provided by a cor-
onal incision (see Fig. 2.5). After neurosurgical explora-
tion any remaining mucosa of the fracture involved
frontal and ethmoid sinuses is removed. The frontal
sinus is obliterated or cranialized depending on the
presence or absence of a relatively intact posterior wall
Fig. 4.1.2 (see Sect. 4.1.6). Obliterative sinus and cranial base bone
Sagittal fractures of the maxilla should be stabilized by an grafting must be complete to eliminate the sinus cavity
approach through the roof of the mouth. The maxillary alveo- and isolate the nose from the intracranial cavity. The
lus is stabilized at the pyriform aperture. One or two plates of
the 2.0 system are used. frontal bar is reconstructed and the anterior sinus wall
reassembled. The lower section of the supraorbital rim
and lower anterior frontal sinus form the “frontal bar”
(Fig. 4.1.4a), and this provides the inferior stable land-
mark in frontal bone reconstruction. Temporal bone
alignment must be correct in narrowness (facial width)
and length through the anterior cranial fossa to ensure
proper projection of the frontal bar (Fig. 4.1.4b).
Using the frontal bar and intact superior cranial vault
as guides, the remainder of the frontal bone segments
are assembled and checked for symmetry. The frontal
vault segments may need expansion for proper contour,
assessed for symmetry with both sides. Bone fragments,
initially linked with wires or small plates and screws, are
then stabilized to adjacent intact bone. The initial fron-
tal bone assembly may be performed on a back table
while neurosurgery is in progress.
Orbital roof reconstruction is then completed by
either replacement or bone grafts as required, and roof
reconstruction stabilized to the frontal bar (Fig. 4.1.4c)
and placed in a largely extraorbital position. Care must
Fig. 4.1.3 be taken to stabilize the orbital roof fragments in ana-
Alveolar fractures of the mandible should be reduced with tomic position and not to “overgraft” the superiorly
small monocortically placed screws of the midface system. arching orbital roof too far inferior by utilizing flat or
intraorbitally placed bone which produces a downward
and forward deformity of globe position (see Sect. 4.5).
lizes dentition.Alginate impressions of the dentition are 4.1.5 Upper Midfacial Unit
obtained and aid in the preparation of models or splints
that key any remaining fractures for an accurate reduc- Initially all fragments of the orbital rims including the
tion. The patient is then placed in intermaxillary fixa- superior, lateral, inferior, and medial segments are
tion. The occlusal relationship obtained is then com- linked with interfragment wires. In the upper midfacial
pared to the ideal as determined from an analysis of unit the nasoethmoidal area is reduced first as it is
dental models. In patients who are edentulous or par- important to secure a narrow intercanthal distance by
tially edentulous it is necessary to use the original den- tightening the transnasal wire (Fig. 4.1.5). This step is
tures for intermaxillary fixation (see Fig. 4.1.8). Special the most important procedure in nasoethmoidal frac-
attention should be paid to the presence of subcondylar ture reduction, as the wire links one medial orbital rim
fractures. If present, they may lead to errors in the trans- to the other. The nasoethmoidal area, reduced with
verse or vertical dimension. interfragment and transnasal wires, is then linked
Preinjury photographs can be helpful in establishing superiorly to the frontal bar reconstruction and inferi-
the facial dimensions to be achieved. They also docu- orly to the maxillary alveolus with stable fixation, a tech-
ment preexisting facial asymmetry. nique called “junctional” rigid fixation (see Fig. 4.1.5).
Fig. 4.1.4 a–c

a The frontal bar should be stabilized as the key lower land-
mark in frontal bone reconstruction.
b Temporal bone alignment must be correct in narrowness
(facial width) and length through the orbital roofs to ensure
proper projection of the frontal bar.
c Prior to frontal bone replacement, the orbital roof recon-
struction is completed by replacement with bone grafts
which should be stabilized to the frontal bar (see also
Fig. 4.5.4b). b
Fig. 4.1.5
The nasoethmoidal area should be reduced first by a transna-
sal reduction of the medial orbital rims performed superior
and posterior to the lacrimal fossa. Initially, all bone fragments
in the nasoethmoidal area can be linked with wires. Junctional
stable fixation then stabilizes the assembled nasoethmoidal
unit to the frontal bone superiorly, to the inferior orbital rim
(midface plates recommended) and the pyriform aperture
inferiorly.
This step stabilizes projection of the nasoethmoidal Fig. 4.1.6 a, b
▼
complex; Le Fort I level and orbital rim fixation stabilize a Initial alignment of the zygoma is achieved by positioning
the lower projection. Plates extending along the medial its five peripheral articulations. Positioning wires are placed
at the zygomaticofrontal suture, the inferior-orbital rim, and
orbital rim anterior to the canthal ligament produce an eventually the zygomatic arch.
unnatural thickness and should be avoided. b The arch is then reduced, holding the malar eminence for-
Stable fixation of the zygoma begins by exposing all ward, compressing the arch inward, which stabilizes midfa-
articulations of the zygoma with adjacent bones (see cial width and emphasizes anterior projection of the malar
Fig. 4.4.1). These are the zygomaticofrontal suture, the eminence.
inferior orbital rim, the zygomaticomaxillary buttress,
the zygomatic arch and the lateral and inferior internal
orbit. Placing wires in the zygomaticofrontal suture and zygoma at the inferior orbital rim and in the lateral
the inferior orbital rim provides initial positioning of orbit, must be checked for alignment, especially in the
the zygoma (Fig. 4.1.6). The zygomaticomaxillary but- naso-orbital-ethmoidal segment (see Sects. 4.3, 4.5).
tress is visualized to confirm approximate position. Next The zygoma is then stabilized with a midface or 1.3
the arch is reduced beginning with the intact segment plate at the inferior orbital rim in panfacial fractures as
posteriorly, holding the anterior arch segments in a flat the use of a microplate in this region is not sufficient for
reduction which emphasizes the anterior projection of cases in which nasoethmoid support is lost (see
the zygoma. If the most posterior fracture in the zygo- Fig. 4.1.5). When multiple segments of the inferior orbi-
matic arch is oriented sagittally, a lag or tandem screw tal rim are present, the segments are initially linked with
technique should be used, or perhaps the superior interfragment wires or with smaller microplates with
aspect of the glenoid fossa plated (see Fig. 4.4.6, insets 4 one loose screw in each segment. They should then be
and 5). A 2.0 midface plate is placed over the remaining held superiorly and anteriorly as stable fixation is com-
arch segments. Before arch reduction is begun, the pleted. The zygomaticofrontal suture is then reduced
b
with a midface plate after the inferior orbital rim is

related anteriorly. Proper zygomatic reduction can be
confirmed only by simultaneously visualizing multiple
areas of alignment with adjacent bones. After stabiliza-
tion of the orbital rim is complete, the inferior orbit
must be reconstructed with split cranial, rib, or iliac
crest grafts. Stable posterior bone “ledges” are identified
medially, laterally, and inferiorly. Bone grafts should
then be strutted between the reconstructed rim and the
stable posterior ledges, completing the reduction of the
internal orbit and, in so doing, the upper midface. If
desired, the bone grafts may be stabilized behind the
orbital rim with miniplates or screws.
a
4.1.6 Lower Face
At first intermaxillary fixation in the patient’s regular

occlusion is performed (see Chap. 3). Fractures in the
horizontal portion of the mandible are exposed through
intraoral or extraoral incisions (see Figs. 2.1–2.3) and, if
necessary for primary and temporary approximation,
linked with interfragment wires. Comminuted fractures
can also be simplified with miniplates. Internal fixation
is performed allowing at least three screws for each frag-
ment. The occlusion is checked before and after both the
wire and plate reduction.After the initial wire reduction,
adjustments in bone position are made, and stable plate
fixation is completed in the horizontal mandibular seg-
ment. Simple angle fractures may be reduced through
intraoral incisions. Complicated angle fractures are
more easily reduced with extraoral approaches. The
width of the mandible is supervised by using the ana- b
tomically reduced maxillary arch and dental inclination
as guides to prevent rotation and excessive width at the
angles. The lingual cortex of the mandible is not rou- Fig. 4.1.7 a, b
tinely visualized in fracture reduction; the fracture As the proper width of the mandible is achieved, fractures in
tends to gap if complete approximation of the entire the anterior symphysis/parasymphysis area tend to “gap” on
their buccal surface.
thickness of the mandible fracture surfaces is not a If insufficient correction of mandibular width is obtained,
achieved. There is a tendency (in parasymphysis frac- the fracture may appear to be in reduction on the buccal sur-
tures in combination with bilateral subcondylar frac- face anteriorly, but actually there is an excessive width at the
tures) for the bicondylar width to be too wide and to angles allowing the lateral mandibular segments to rotate
have an excessive width and flaring at the mandibular lingually, tipping the dentition, creating an open bite by
bringing the lingual and palatal cusps out of alignment.
angles. The lateral mandibular dentition tends to rotate b Situation as in a but with correct fixation of the chin fracture
lingually and to “flare” at the angle increasing the lower by means of a correctly bent reconstruction plate.
facial width (Fig. 4.1.7).
Open reduction of the vertical (ramus and condylar)
segment of the mandible is required if significant mal-
alignment or overlapping of ramus or subcondylar frac- fracture of the ramus, exposure is performed via either
tures exists. Condylar head dislocation produces a loss a preauricular or a Risdon incision. In questionable
of ramus height which may change facial dimensions, cases the facial nerve is best identified and protected.
complicating the treatment of multiply fractured The temporomandibular joint is examined at the time of
patients. Condylar dislocation in the presence of a loose open reduction through a preauricular incision, and
Le Fort fracture is an indication for open reduction to meniscus injury is assessed and corrected. The use of a
stabilize the height of the ramus and the forward projec- temporoparietal flap is indicated if the meniscus is
tion of the mandible. Depending on the location of the destroyed. Reconstruction of the ramus precedes the
horizontal mandible and stabilizes it in proper position ation point, and the plates may then need to be removed
in relation to the cranial base (projection). Open reduc- before a denture can be tolerated. Proper maxillary pro-
tion assists in supervising facial width at mandibular jection is confirmed only by relating the maxillary and
angles. mandibular alveolar ridges with temporary splints and
dentures. Maxillary buttress reconstruction is therefore
a guide for maxillary height, but not projection.
4.1.7 Linking the Upper and Lower Face
The lower and the upper facial units are then united at 4.1.9 Soft Tissue
the Le Fort I level by plating the four anterior maxillary
buttresses (see Fig. 4.1.5). Midface height and facial Current facial fracture reduction schemes emphasize
length are set by using an intact or an anatomically complete degloving of all bones by detaching soft tissue
reconstructed buttress as a guide. One or more but- and incising fascial layers. It is important when closing
tresses can almost always be reconstructed anatomically incisions to close or reposition attachments to the reas-
by piecing together existing fragments. In the absence of sembled craniofacial skeleton. Generally this is the best
a reconstructed buttress, lip-tooth position provides the performed by first closing the periosteum. The areas for
best clue to facial height. Old photographs may suggest periosteal closure are the zygomaticofrontal suture,
the correct lip-tooth relationship. inferior orbital rim, medial and lateral canthus areas,
The Le Fort I level fixation of the nasomaxillary but- periosteum over the frontal process of the zygoma, mus-
tress is the third area in which nasoethmoidal projection cular layers of the gingival buccal sulcus and mandibu-
is stabilized. The other two areas are the frontal bar and lar incisions, and incision in the temporal fascia for
inferior orbital rim. zygomatic arch exposure. Marking the edges of the per-
Buttress bone gaps exceeding 5 mm are grafted for iosteal incisions with sutures allows precise identifica-
both functional and esthetic reasons. It is currently our tion at the end of the case for periosteal closure. These
recommendation to bone graft defects in the anterior areas are illustrated in Fig. 4.1.9.
sinus wall (see Fig. 4.1.5) as this prevents prolapse of soft This approach emphasizes multiple areas of align-
tissue into the sinuses. Nasal bone grafting to improve ment for each fractured bone with the possibility of
the height in the nose or to smooth the dorsal nasal con- initial wire and final stable fixation. The important
tour completes the facial reconstruction (see Figs. 4.1.5, dimension is facial width. Control of facial width
4.2.5b,d). Nasal bone grafting is performed most accu- involves dissection to established cranial base land-
rately after the nasomaxillary buttress reconstruction marks; supervision of facial width in fact reciprocally
and anterior nasal spine stabilization of the septum have emphasizes facial projection. Control of facial width is
been completed. If the medial canthal ligaments have the most important first step in injury restoration and is
been detached, they should be reattached following possible only with extended approaches.
bone grafting of the medial orbit and nose to a separate
set of transnasal wires placed before the nasoethmoidal
reduction is completed. These are passed transnasally 4.1.10 Soft-Tissue Injury
posterior and superior to the lacrimal fossa and pulled
tight just prior to closure of incisions (see Sect. 4.3; The fundamental challenge in facial fracture treatment
Figs. 4.1.5, 4.3.3 b, 4.3.4b). is restoring the preinjury facial appearance and not sim-
ply linking together edges of bone at fractures. Defor-
mity following facial fractures results from both soft-tis-
4.1.8 Edentulous Fractures sue changes and from bone malalignment. Deformity of
both bone and soft-tissue significantly increases in the
In edentulous maxillary fracture treatment there is a presence of highly comminuted fractures, especially
tendency to avoid intermaxillary fixation and merely when they involve the upper midfacial and orbital areas.
align the four anterior maxillary buttresses. This tech- The contribution of blunt soft-tissue injury and soft-tis-
nique may overlook posterior displacement of the max- sue contracture to residual facial deformity has not been
illa despite what appears to be satisfactory alignment of emphasized in the literature on facial fracture. Contused
the anterior maxillary buttresses as the maxilla is not soft tissue heals with a network of internal scaring
related in anteroposterior dimensions to a properly whose configuration is dictated by the position of the
positioned mandible. If available, the original dentures underlying bone fragments. When soft tissue heals over
of the patient provide correct intermaxillary fixation malreduced fractures, shrinkage and contracture of the
(Fig. 4.1.8). If broken, these dentures may be repaired soft-tissue envelope occur. Scarring and internal rigid-
first. Plate and screw fixation in an edentulous maxilla ity occur in the pattern of the unreduced bone segments.
may require the use of alveolar bone as a stable lower fix- The internal scaring thickens soft tissue, opposing res-
b
Fig. 4.1.8 a–c

In edentulous maxillary fracture treatment there is a tendency a Midface fracture of an edentulous patient with dislocated
to avoid intermaxillary fixation and merely to align the four midface in posterior-caudal direction.
anterior maxillary buttresses. This technique tends to result in b Same fracture as in a after correct reduction with correct
posterior displacement of the maxilla despite apparent align- mandibulomaxillary fixation with the patient’s prosthesis
ment of the anterior maxillary buttresses as the maxillary den- and fixation with miniplates (2.0 and 1.3).
tal arch is not brought into proper anterior/posterior relation- c Fixation of a Le Fort I fracture with miniplate and bone
ship by positioning it to a properly positioned mandible. grafts, using the patient’s dentures for correct alignment.
toration of the preinjury appearance, even if the under- Fig. 4.1.9

lying bone is finally replaced into its proper anatomic
position. Examples of soft-tissue rigidity accompanying occur for each incision. The areas of closure are diagrammed
and include the temporal fascia, the frontal musculature, the
malreduced fractures include the conditions of enoph- zygomaticofrontal suture,(the periosteum over the frontal pro-
thalmos, medial canthal ligament malposition, short cess of the zygoma), the inferior orbital rim and the muscular
palpebral fissure, rounded canthus, and inferiorly dis- layers of the intraoral incisions. Refixation of the medial and
placed malar soft-tissue pad. Secondary management of lateral canthal ligaments completes the reconstruction.
any one of these conditions is more challenging and less
effective than is primary reconstruction. A unique
opportunity thus exists in immediate fracture manage-
ment to maintain expansion and position of the soft-tis-
sue envelope and determine the geometry of soft-tissue
fibrosis by providing an anatomically aligned facial
skeleton as support. Excellent restoration of appearance
results from primary soft-tissue positioning.
4.1.11 The “Double Insult” to Soft Tissue References and Suggested Reading
Delayed reconstruction of facial fractures at 7–14 days Gruss J, Bubak PJ, Egbert M (1992) Craniofacial fractures: an
post injury results in a second soft-tissue injury by dis- alogorithm to optimize results. Clin Plast Surg 19:195–206
Gruss JS, MacKinnon SE (1986) Complex maxillary fractures:
section and incisions in healing areas of contusion and role of buttress reconstruction and immediate bone grafts.
hemorrhage. Two injuries are created: the initial injury Plast Reconstr Surg 78:9–22
and the surgical manipulation. Delayed treatment Gruss JS, MacKinnon SE, Kassel EE et al (1985) The role of pri-
creates a “double insult” to the already contused and mary bone grafting in complex cranio-maxillofacial trauma.
damaged soft tissue. This is especially harmful, causing Plast Reconstr Surg 75:17–24
Gruss JS, Pollock RS, Phillips JH, Antonyshyn O (1989) Com-
subcutaneous fibrosis. The skin, following delayed facial bined injuries of the cranium and face. Br J Plast Surg
fracture repairs, is more thickened, rigid, lusterless, red- 42:385–398
dened, hyperpigmented, and fibrotic than skin from Gruss JS, Van Wyck L, Phillips JH et al (1990) The importance
early injury repairs where the initial contusions, frac- of the zygomatic arch in complex midfacial fracture repair
tures, incisions, and dissection are all part of a single and correction of post-traumatic orbito-zygomatic defor-
mities. Plast Reconstr Surg 85(6):878–890
soft-tissue injury and recovery. Kelly K, Manson PN, van der Kolk C, Markowitz B (1990)
Accurate skeletal reconstruction requires anatomic Sequencing Le Fort fracture treatment. J Craniofac Surg
assembly and stabilization of the basic configuration of 1:168–178
the bone buttresses. Missing or unstable bone fragments Manson PN (1986) Some thoughts on the classification and
should be replaced with bone grafts and the existing treatment of Le Fort fractures. Ann Plast Surg 17:356–363
Manson PN, Glassman D, Van der Kolk C, Petty P (1990) Rigid
skeletal framework expanded with bone grafts, where
stabilization of sagittal fractures of the maxilla and palate.
required. The thorough reconnection of all buttress Plast Reconstr Surg 85:711–716
fragments must proceed from intact bone to intact bone Manson PN, Markowitz B, Mirvis S et al (1990) Toward CT-
and must be complete and accurate in three dimensions based facial fracture treatment. Plast Reconstr Surg
throughout the entire area of injury. Conceptualizing 84:202–214
Markowitz BL, Manson PN (1989) Pan-facial fractures: organ-
each unit of the facial skeleton in three dimensions and
ization of treatment Clin Plast Surg 16:105–114
emphasizing supervision of width, restoration of projec- Merville L (1974) Multiple dislocations of the facial skeleton. J
tion and correction of the facial height in each unit Maxillofac Surg 2:187–203
allows assembly of the whole skeleton based on a con- Rorich R, Shewmake K (1992) Evolving concepts of craniomax-
ceptually precise framework for bone reconstruction. illofacial trauma management. Clin Plast Surg 19:1–10
Performing the bone reconstruction early in compli-
cated facial injuries allows the most natural restoration
of the preinjury appearance to be determined by the
combined relationship of bone and soft tissue.
to the zygomatic process of the frontal bone and lat-

4.2 Le Fort I–III Fractures erally to the zygomatic arch
∑ The pterygomaxillary (posterior) buttress which
Contributors: Lower Midface (Le Fort I) attaches the maxilla posteriorly to the pterygoid
Christopher R.Forrest plates of the sphenoid bone.
John H.Phillips
Upper Midface (Le Fort II+III) The posterior support of the maxilla is derived from the
Joachim Prein pterygoid plates, while the anterior support comes from
the medial and lateral anterior buttresses. Anatomic
alignment and fixation of the medial and lateral but-
4.2.1 Lower Midface (Le Fort I) tresses is important in achieving anatomic reduction of
the maxilla in relation to the cranial base and to restore
4.2.1.1 Anatomy proper vertical height and horizontal projection
(Fig. 4.2.1).
The midface consists of the paired maxillae, palatine
bones, and medial and lateral pterygoid processes of the
sphenoid bone. It acts as a link between the cranial base 4.2.1.2 Classification
and the occlusal plane and provides protection in an
anterior-posterior plane for the face, protection for the Maxillary fractures have traditionally been classified
skull base, and a site for muscle and ligament attach- according to lines of fracture based on anatomic lines of
ments. weakness as described by René Le Fort in 1901, as fol-
Anatomic support for the midface is provided lows:
through a series of buttresses or struts that are used to
distribute masticatory forces from the teeth to the skull ∑ Le Fort I fracture (Fig. 4.2.2): low horizontal fracture
base (Sicher and DeBrul 1970; Manson et al. 1980; Gruss with disrupture of the tooth-bearing section of the
and Mackinnon 1986). Buttresses exist in the horizontal maxilla
and coronal planes (Gentry et al. 1983; see Fig. 4.1.1a), ∑ Le Fort II fracture (Fig. 4.2.3a): triangular or pyram-
but the vertical struts of the midface are clinically most idal central midface fracture
important with respect to the management of midface ∑ Le Fort III fracture (Fig. 4.2.4): high horizontal frac-
fractures. Although these vertical buttresses are quite ture alongside the junction between the cranial and
strong in the sense of vertically directed stresses, they facial skeleton.
are unable to withstand equivalent forces directed in a
transverse plane. Although this provides a uniform method to describe
The three principle vertical buttresses of the maxilla the general level of the major fracture line and allows
consist of (Fig. 4.2.1): references regarding the probable points of stability
required in surgical treatment, these classic patterns are
∑ The nasomaxillary (medial) buttress which extends rarely encountered in clinical practice. In addition, this
from the cuspid and anterior portion of the maxillary classification scheme does not incorporate vertical or
alveolus along the pyriform aperture, the medial side segmental alveolar fractures or the issues of comminu-
of the orbit through the anterior lacrimal crest, and tion or bone loss. Manson (1986) has elaborated on the
the nasal process of the maxilla to the superior orbi- Le Fort classification to take these issues into account:
tal rim and nasoethmoid region.
∑ The zygomaticomaxillary (lateral) buttress extends
from the maxillary alveolus above the anterior molar
4.2 · Le Fort I–III Fractures 109
➊ ➋
➌
∑ Horizontal Fig. 4.2.1

– Dentoalveolar fractures Diagram of maxillary buttresses showing anterior maxillary
– Le Fort I (transverse, Guérin) fractures buttress (medial; ➊), lateral buttress (zygomaticomaxillary;
➋), pterygomaxillary buttress (posterior; ➌). These represent
– Le Fort II (pyramidal) fractures regions of thicker bone designed to provide support for the
– Le Fort III (craniofacial dysjunction) fractures maxilla in the vertical dimension.
∑ Vertical (sagittal)
– Medial palatal split
– Lateral palatal (maxillary tuberosity) split
4.2.3 a
Fig. 4.2.2 Fig. 4.2.3 a, b

Le Fort I fracture. Le Fort II fracture.
a Typical postero-caudal dislocation with open bite.
b Correct internal fixation with 2.0 L-plates for the lateral-ver-
tical buttresses. 1.3 adaption plate infraorbitally and for the
nasoethmoidal region. Inset showing fixation with one 2.0 Y-
plate instead of two 1.3 mini plates.
4.2.3 b
Fig. 4.2.4
Le Fort III fracture with postero-caudal dislocation and ante-
rior open bite.
4.2.1.3 Diagnosis
The diagnosis of midface fractures is usually made clin-

ically, although this may be more difficult if the maxilla
fracture is incomplete or impacted. Clinical signs of
bilateral ecchymosis, edema involving the midface, and
orbits should alert the clinician to examine the patient
for malocclusion, maxillary mobility, and missing teeth.
Digital examination of the hard palate may reveal evi-
dence of a sagittal or maxillary tuberosity fracture. Res-
olution of facial swelling may reveal elongation (“equine
facies”) or flattening (“dish face,” see Fig. 4.2.5a,c) of the
midface due to maxillary displacement. Dorsal and cau-
dal pull by the medial pterygoid muscles may produce
an anterior open bite and tendency to class III malocclu-
sion (Fig. 4.2.5a,c). Sagittal palatal fractures may result
in lateral rotation and superior tilting of the maxillary
segments, producing increased transverse width of the
maxillary arch with cross-bite (Fig. 4.2.6).
d
b
Fig. 4.2.5 a–d

a Diagram showing dorsal and caudal pull by the medial pter-
ygoid muscles to produce an anterior open bite and ten-
dency to class III malocclusion.
b Diagram after fixation of fracture situation as shown in
Fig. 4.2.5a, including the reconstruction of the nasal dorsum
with a bone graft.
c Lateral cephalogram showing dorsal-caudal dislocation of
midface in Le Fort III fracture situation. Note: key area at
zygomatic arch fracture.
d Lateral cephalogram after reposition and correct stabiliza-
tion of Le Fort III and I fractures. Note: stabilization with
miniadaption plate at zygomatic arch area and immediate
reconstruction of nasal ridge with a bone graft and stabiliza-
tion with lag screws.
Fig. 4.2.6 4.2.1.4 Le Fort I Fractures

Diagram showing Le Fort I fracture and paramedian sagittal
palatal fracture on the left side with lateral rotation and super- In 1866 Guérin described a pattern of maxillary fracture
ior tilting of maxillary segments.
which has subsequently become more commonly
referred to as the Le Fort I fracture (see Fig. 4.2.2). The
line of the fracture extends transversely above the tooth
Clinical diagnosis of a maxillary fracture may be con- roots through the maxillary sinus and nasal septum,
firmed using plain facial radiographs, and especially the posteriorly across the pyramidal process of the palatine
water’s view. The latter projection gives the best infor- bone and pterygoid process of the sphenoid bone.
mation about midfacial structures. However, 5-mm axial The primary aims of treatment of Le Fort I maxillary
CT images provide the best means of visualizing the fractures are the restoration of correct midfacial vertical
fracture patterns, degree of comminution, and bone height and anterior projection and restoration of occlu-
loss. In severe fracture situations three-dimensional CT sion.
images may provide additional information regarding
displacement of the midface in relation to the mandible Treatment
and orbits but should be used to satisfy clinical impres-
sions. With chipped or missing teeth a chest film should 1. Systematic radiographical evaluation of the extent
be obtained to rule out aspiration. and pattern of injury, sometimes including CT.
2. Restoration of original occlusion using mandibulo-
maxillary fixation.
3. Direct exposure of all involved fractures.
4. Reduction and anatomic realignment of the maxil-
lary buttresses to reestablish normal maxillomandib-
Fig. 4.2.7 require early maxillary reduction and intermaxillary

Diagram showing ideal internal fixation of Le Fort I fracture fixation, including anterior and posterior nasal packing.
with Y and L miniplates at anterior and medial buttresses. Surgical treatment of Le Fort I fractures should be
Note: Temporary IMF in correct occlusion during surgery.
performed as soon as possible. General oral hygiene is
administered throughout the treatment period. Delay of
surgical treatment for more than 7 days may result in
ular and maxillo-zygomatico-orbital relationships to difficulty in reducing the maxilla from its retruded posi-
restore normal maxillary height, anterior projection, tion due to bony fragment impaction and soft-tissue
transverse width, and occlusion. contraction.
5. Internal fixation (osteosynthesis) using miniplate
and screw fixation (Fig. 4.2.7). Airway Management. Airway management during sur-
6. Use of primary bone grafts to reconstruct and stabi- gery may be ideally secured using a reinforced nasotra-
lize comminuted (absent) maxillary buttresses to cheal tube sewn to the membranous nasal septum. This
prevent midface collapse or elongation (Figs. 4.1.5, allows adequate exposure and facilitates application of
4.2.13). intermaxillary fixation. However, severe swelling, nasal
mucosal disruption, associated basal skull fracture, etc.
The initial treatment of midface fractures incorporates may prevent placement of a nasotracheal tube. In cases
the general principles of trauma management and of an isolated maxillary fracture the endotracheal tube
includes establishment and maintenance of airway, may be secured to a molar with 26-gauge wire and posi-
supervision of hemorrhage, investigation, and manage- tioned behind the third molar, thereby affording resto-
ment of associated injuries (cervical spine, neurological ration of premorbid mandibulomaxillary occlusal rela-
injury, etc.). Bleeding from the greater palatine or inter- tionships. In cases of combined maxillary and mandib-
nal maxillary arteries may be life threatening and may ular fractures judicious use of a tracheostomy may be
necessary. The endoscopic placement of the tracheos-

tomy is especially atraumatic and less visible postoper-
atively. In addition to this, submental placement of the
endotracheal tube may be another very helpful way of
anaesthezising these patients without interfearing with
the occlusion.
Exposure. Maxillary fractures in the Le Fort I plane may

be exposed through an upper gingivobuccal sulcus inci-
sion (see Fig. 2.2). Rarely, exposure may be obtained
directly through soft-tissue lacerations. Both maxillae
may be widely exposed subperiosteally to identify all
four anterior buttresses. In segmental alveolar fractures
preservation of vascular supply to tooth-bearing alveo-
lar fragments may be achieved through a segmental
upper buccal incision. Care must be taken in dissection
to avoid the infraorbital nerve, which is located approx-
imately 1 cm below the inferior orbital rim below the
medial limbus. When comminution of the buttresses
occurs, care is taken to identify and anatomically replace
the fragments to achieve proper midface height. If these
fragments are too small to be replaced with adequate fix-
ation, they should be discarded and primary bone grafts
employed to reconstruct the buttresses.Attempts to pre-
serve vascular supply to small fragments hinders expo-
sure to the buttresses and may preclude anatomic reduc-
tion. Small fragments should be retrieved from the max-
illary antrum as they may act as sequestra and result in
maxillary sinusitis. Torn maxillary sinus mucosa is
removed, but a formal drainage of the sinus is seldom a
necessary.
Reduction. Prior to reduction of the maxilla arch bars

should be affixed to the maxillary and mandibular den-
tition to facilitate restoration of the original occlusal Fig. 4.2.8 a–c
relationship. a Diagram showing comminution in Le Fort I area on the right
If surgical treatment is delayed, or the maxilla is side and caudally dislocated joint. The occlusion is correct.
Facial height on the right side on the comminuted area is too
severely impacted, reduction from the retrodisplaced long.
position may be difficult without osteotomy. Disimpac- b Fixation of Le Fort I fracture with premature contact on
tion forceps or a 24-gauge wire loop placed through a comminuted side and open bite on opposite noncommin-
drill hole near the thick bone of the anterior nasal spine uted side. Mandibular condyle now in correct position.
followed by manual traction may be necessary. It is c Diagram showing fixation of the midface fracture in an
edentulous patient with the help of patient’s dentures to set
important to overstretch the anterior position of the the correct vertical hight. Fixation of Le Fort I area with
midface relative to the mandible, such that passive repo- plates and bone grafts because of fracture gap of more than
sitioning of the midface results in anatomic reduction. 5 mm. The prostheses are fixed to the alveolar process and
Difficulties arise with posterior relapse postoperatively the palate with 2.4 screws. Anterior view.
if force is required to hold the maxilla in position while
applying the internal fixation plates. The external
dynamic forces of scar tissue contraction and muscle
pull may overcome the static forces of miniplate fixation believes that anatomic reduction of the medial and lat-
and consequently result in relapse. eral buttresses will result in proper placement of the
Failure to appreciate the importance of mandibulo- midface in three dimensions. If mandibulomaxillary fix-
maxillary fixation in the treatment of all midface frac- ation is not used, the posterior (pterygoid) buttress may
tures may result in postoperative malocclusion, com- be intruded, or more commonly extruded while appear-
monly in the form of anterior open bite. This occurs in ing to be anatomically reduced at the anterior but-
cases of noncomminuted fractures when the surgeon tresses. This posterior extrusion results in premature
b c
contact of the posterior molars, producing an anterior side (Fig. 4.2.8a,b). A similar situation may develop if a
open bite, as shown on preoperative diagram (Figs. 4.2.2, Le Fort I fracture occurs in conjunction with a zygo-
4.2.5a). Mandibulomaxillary fixation is mandatory in matic fracture. Care must be taken not to internally fix
the treatment of all Le Fort fractures so that the mandib- the zygoma in an inferiorly displaced position, or else a
ular ramus can be used to set the height of the posterior relative increase in vertical height exists in the maxilla
(pterygoid) buttress prior to internal fixation. If treat- on that side.
ment must be delayed, intermaxillary fixation alone pre- In the edentulous maxilla it may be necessary to use
vents many of the deformities of the untreated fractured the patient’s dentures or a Gunning splint to set the cor-
maxilla. rect vertical height of the face (Fig. 4.2.8c). If neither is
Care must be taken to ensure that no subcondylar available, anatomic buttress alignment may be followed
fractures are present prior to fixation, and that the man- by denture adjustment to account for minor occlusal
dibular condyles are seated properly in the glenoid discrepancies.
fossa. A unilateral open bite deformity may occur in In conjunction with occlusion, anatomic alignment
cases in which the buttresses are comminuted on one of the medial and lateral buttresses provides the key to
side only. Inadvertent subluxation or dislocation of the the restoration of midface vertical height and horizontal
temporomandibular joint inferiorly on the comminuted projection. Comminution of all four anterior buttresses
side may result in fixation of the lateral buttress with an is fortunately rare. It is typical that there is at least one
increased vertical height. The opposite buttresses are buttress in large enough fragments to allow for ana-
reduced and fixed anatomically. When mandibulomax- tomic assessment of vertical height. This buttress may
illary fixation is released, and the condyle repositions, be plated first (Fig. 4.2.9) and the bone fragments rigidly
premature contact of the comminuted side occurs, fixed onto the plate using a lag screw technique. The
resulting in open bite on the opposite noncomminuted other buttress heights are then set accordingly, and pri-
mary bone grafting may be performed (see Fig. 4.2.13). Fig. 4.2.9
If all anterior buttresses are so severely comminuted Le Fort I fracture with comminution of both medical and one
that correct midface height cannot be determined at any posterior buttress on the right. No comminution at left poste-
rior buttress, which therefore is stabilized first. The height of
of the buttresses, the surgeon may use the mandible to the remaining buttresses is set according to this reconstruc-
assess the appropriate anterior projection, and subjec- tion. Lip-tooth position provides the best clue to facial height
tive judgement to set the relative midface height. Unfor- where no buttress can be reassembled from existing fragments.
tunately, liptooth relation at rest may not be a reliable Note correct temporary IMF.
indicator depending on the amount of facial edema.
Occlusion. Restoration of occlusion is paramount to the Difficulty can arise when teeth are missing or the
appropriate treatment of midface fractures. Failure to patient is edentulous. In these circumstances the
reestablish the original occlusal patterns through the surgeon’s subjective judgement may be necessary to
application of mandibulomaxillary fixation prior to determine the “best fit.”Sagittal fractures of the palate or
internal fixation and reliance on anatomic positioning segmental dentoalveolar fractures add further degrees
of the buttresses alone may result in postoperative mal- of instability, making assessment and restoration of pre-
occlusion, as indicated above. morbid occlusion difficult. Careful palpation of the pal-
With an intact maxillary arch it is important to deter- ate reveals unstable tooth-bearing segments to alert the
mine the patient’s correct occlusion using information surgeon of these difficulties.
obtained by history, pretrauma photographs, dental
records, and wear-facet patterns on the teeth. The use of Fixation. The use of miniplate fixation in treating maxil-
acrylic wafer dental splints created from dental impres- lary fractures has eliminated the need for prolonged
sions taken under anesthesia may assist in determining mandibulomaxillary fixation, allowing for improved
normal occlusion and maintaining it during surgery. oral hygiene, better nutrition, better airway, less weight
Fig. 4.2.10 mandibular fractures in which the use of compression

Diagram showing fixation of Le Fort I fracture and paramedian plates promotes primary bone healing. However, in the
sagittal palatal fracture. Insets, the various types of fixation for midface compression is rarely employed due either to
the sagittal palatal fractures.
Inset 1: Miniplate fixation anteriorly above incisor teeth and bony comminution or the thinness of the bone which
nasal floor inside left nose. would result in overlap of fragment ends with subse-
Inset 2: Lag screw fixation anteriorly. quent shortening. The exception to this is the use of
Inset 3: Plate fixation anteriorly and palatal roof intraorally. compression with lag screw stabilization of a palatal
split with screw placement anteriorly through the ante-
rior nasal spine region (Fig. 4.2.10, inset 2).
loss, and lower infection rates and may act to shorten the Without compression the stability in the fracture site
duration of hospitaliation. In addition, internal fixation depends upon the inherent rigidity of the miniplate and
keeps reduced fragments in position; there is less friction between the fragment ends. If a small gap exists
resorption of bone grafts and earlier return to function between the fragment ends, and the dynamic external
(Gruss and Phillips 1992; Schilli et al. 1981). Previous forces from mastication are greater than the rigidity of
methods of buttress fixation using interosseous wires the implant, movement in the gap can occur with detri-
were intrinsically unstable and led to telescoping of segmental effects on bone healing. The presence of move-
ments and inability to withstand stresses, with bony ment may lead to a high-strain condition, which is not
relapse. conducive to bone formation. As a result a fibrous non-
Compressive clamping of a miniplate to bone by the union and fragment end resorption may occur. How-
tensile force induced in the screw is the basis of fixation ever, in practice, nonunion of maxillary fractures is rel-
by bone plates. Compression was first advocated by atively rare.
Danis (1949) for stabilization of bone fractures. This has Stripping of the bone thread is one of the commonest
been shown to be benefitial in treating long bone and problems encountered during the insertion of a screw at
Screw
Head diameter
Thread pitch
Thread diameter
In
nset
Core diameter
surgery. This is a problem especially when fixing plates Fig. 4.2.11

to thin cortical bone in the midface area. Therefore it is Basic screw design showing the thread and core diameter as
important to position the buttress plates as far laterally well as the pitch (distance between two threads).
Inset shows the relation in between pitch and thickness in
and as close to the pyriform fossa as possible as these bone.At least 2 threads should engage in cortical bone in order
areas represent the thickest regions of bone in the mid- to provide sufficient holding capacity.
face and provide for good screw purchase and fixation
(see Fig. 4.2.7).
The ability of the screw to provide holding power
depends upon screw design, the changes in bone as the bony fragment or bone graft is being lag-screwed onto a
result of screw insertion, the reaction of the bone to the plate to bridge a bone defect, the increased torque asso-
implant material, the resorption and remodeling of ciated with self-tapping screws may result in displace-
bone during fracture healing, and the reaction of bone ment and difficulties maintaining the position of the
to loading as the result of muscle forces. For proper bone segment. Tapping has been shown to decrease
screw anchorage one condition that must be met is that insertional torque by 35%–40% (Hughes and Jordan
the bone cortex thickness be at least as thick as the dis- 1972). If a screw must be reinserted into the same drill
tance separating two threads of the screw (pitch angle, hole at surgery due to the cutting ability of the flutes, the
Fig. 4.2.11 and inset; Diehl et al. 1974). Therefore in very risk of cross-threading is increased with self-tapping
thin bone, such as found in the maxilla, screws with screws, leading to poor screw purchase. However, these
smaller pitch angles may have some theoretical advan- potential disadvantages of the self-tapping system are
tage as this results in more screw threads having contact far outweighed by its benefits in increased compressive
with the bone. In addition, it has been demonstrated that forces in thin bone.
screws with smaller pitch angles have slightly higher Recent in vivo studies on the biomechanics of the
compressive values in 2-, 3-, and 4-mm bone thickness facial skeleton by Rudderman and Mullen have shown
(Phillips and Rahn 1989; Kuhn et al. 1995). that treatment of structural defects of midface should be
The holding power of the fluted portion has been directed to the reconstruction of normal pretraumatic
demonstrated to be 17%–30% less than that of the fully load paths (Rudderman and Mullen 1992). This is best
threaded nonfluted portion (Bechtol et al. 1959). This is performed by the reconstruction/reconstitution of nor-
seldom a problem in midface as the screw tip and mal buttresses.
cutting flutes can protrude safely into the maxillary Plates should be applied separately to the medial and
antrum and maintain its holding power. lateral buttresses. Optimal placement of the lateral but-
More torque is required to insert a self-tapping screw tress plate is from the thick bone of the zygomatic body
due to the cutting of the bone threads. This places along the lateral aspect of the anterior maxilla where the
increased stress on the screw which can lead to screw bone is thickest. The medial buttress plate is best placed
failures and microfracturing of the surrounding bone along the rim of the pyriform fossa. Placement of load-
which can predispose to screw loosening. When a small bearing plates across the thin bone of the anterior max-
illa should be avoided as screw holding power is signifi- maxillary antrum, creating overlying contour defects.
cantly decreased. Passive contouring of the plate to Bone grafts may be used to prevent this deformity.
ensure a perfect fit to the underlying bone is important The general principles of internal fixation should be
as attempts at in situ plate bending place undue stress on applied to the use of bone grafts as this has been shown
the bone leading to screw stripping and microfractures to prevent resorption and allow maintenance of volume
of the bone. Continuous irrigation when creating the in the presence of infection (Fialkov et al. 1993).
drill hole is important to prevent bone necrosis and ring Although bone grafts may be harvested from several
sequestra. sites (ilium, rib, calvarium), split calvarial bone is the
Care must also be taken to avoid inadvertent place- material of choice for buttress reconstruction. It is read-
ment of screws into tooth roots. The position of the ily available in large quantities, accessible within the
canine tooth root should be used to determine the same operative field, tolerates being exposed to the open
superior extent of the tooth roots. On occasion a low maxillary antrum when rigidly fixed, has minimal
lying fracture along the lateral buttress directly adjacent donor morbidity, provides for excellent screw purchase
to the tooth roots prevents application of the plate; oth- and fixation, and may be rigidly fixed to miniplates or
erwise screwplacement between tooth roots. It is best to lag-screwed onto underlying bone due to its high corti-
span the plate from the zygomatic body to the thick cal component. In addition, it is strong enough to with-
bone near the anterior nasal spine in these circum- stand the forces of soft-tissue contraction and mastica-
stances, in addition to the use of primary bone grafts. It tion. The main disadvantage of calvarium is brittleness
has not been necessary to fix the posterior buttresses or the inability to shape and contour the bone due to its
internally, however IMF can substitute for posterior but- low modulus of elasticity as the bone tends to fragment
tress support. when attemps are made to bend it.
Plates become the path for load distribution, and if
placed abnormally, force distribution may place undue Palatal Fractures. Sagittal fractures of the maxilla and
loads on plates and thus lead to high-stress concentra- palate are present in 15% of patients with Le Fort frac-
tions. This may ultimately lead to screw fatigue and fail- tures (Manson et al. 1983) and are associated with
ure. Placement of multiple screws (at least two) on each increased instability due to rotation of dentoalveolar
side of fracture leads to a more even distribution of segments which may not respond to conventional forms
loading (load sharing between plate and bone). If bio- of fixation. Fractures involving the palate commonly
mechanics are not considered with regards to internal divide the palate longitudinally, adjacent to the midline
fixation, the incidence of infection, nonunion and tissue as this represents a line of weak thinner bone (medial
injury may increase. palatal split; see Fig. 4.2.6). The fracture usually exits
In the edentulous maxilla, bone stock may be dimin- anteriorly between the incisors or lateral incisor and
ished, and for adequate fixation plates may be placed low canine tooth and results in buccal, anterior, and lateral
on the buttress through residual alveolar bone. However, displacement of the segment. Alternatively, palatal frac-
this may interfere with denture fitting, and the plates tures may occur through the maxillary tuberosity (lat-
may have to be removed once bone healing is complete. eral palatal split), involving a dentoalveolar segment
bearing the molar teeth. This fragment may displace
Bone Grafting. Primary bone grafting (iliac, split rib, or superiorly, laterally and posteriorly. Both fracture pat-
calvarium) has been advocated to reconstruct defects in terns may coexist and are extremely difficult to treat.
the medial or lateral buttresses where bone has been lost Rarely, coronal or transverse fractures of the palate may
or comminuted (Gruss and Mackinnon 1986; Gruss and occur.
Phillips 1992; Manson et al. 1985). The use of miniplate Conventional fixation techniques involving extensive
fixation has reduced the need for immediate bone graft- plate and screw fixation along the pyriform aperture
ing but the ability of plates to bridge bone gaps is loca- and anterior nasal spine have not consistently provided
tion dependent (Gruss and Phillips 1992). Masticatory satisfactory accuracy or stability to correct the increased
forces and cyclical loading on the maxilla can result in transverse maxillary arch dimension or changes in incli-
implant fatigue and failures if miniplates are used to nation of the dentoalveolar segments that occur with
span significant bone gaps without restoration of bony palatal fractures. Manson et al. have described tech-
continuity using bone grafts. niques of transpalatal miniplate fixation through lacer-
Gaps in the maxillary buttresses greater than 5 mm ations or incisions in the palatal mucosa supplemented
should be replaced with bone grafts. Bone grafts may be by arch bar placement and fixation at the pyriform aper-
lag-screwed under a miniplate used to span the bone gap ture, in addition to the usual fixation along the medial
or may be held in place directly onto the buttress using and lateral maxillary buttresses (Fig. 4.2.10, insets; Man-
lag screws at either end (see Fig. 4.1.5, 4.2.8c, and 4.2.13). son et al. 1983, 1990). Reduction and fixation of the pal-
Loss of the anterior wall of the maxilla may predispose ate is performed initially to restore proper width of the
to invagination of the overlying soft tissues into the maxillary arch and is followed by buttress fixation. It is
recommended to maintain mandibulomaxillary fixa- 5 mm axial and, if possible, coronal CT images are the
tion for 3 weeks postoperatively followed by motion and basis for a precise diagnosis and consequently the ther-
soft diet. As bone healing tends to be slower following apeutic approach.
palatoalveolar fractures, it is recommended to watch for
occlusal discrepancies and drift up to 4 months after fix-
ation. Due to local symptoms hardware removal in the 4.2.2.3 Treatment
roof of the mouth may be required.
Midfacial fractures should be treated as early as pos-
Alveolar Ridge. When alveolar ridge fractures occur in sible, at least within the first week after the accident. As
isolation, management consists of reduction of the den- soon as the general condition of the patient allows it,
toalveolar segment and fixation to stable adjacent max- definitive treatment should be undertaken. Fractures of
illary segments using 26-gauge wire loops or arch bars. the upper midface are generally quite extensive and
This is immobilized for 4 weeks, during which time the include damage to the soft tissues. As noted by Manson
patient maintains a soft diet and regular oral hygiene. (see Sect. 4.1), delayed treatment of midfacial fractures
If there are associated maxillary fractures, it becomes may mean a second injury to the already contused soft
difficult to achieve stability in this fashion. The use of an tissues. Edema should not be a reason to delay treatment
acrylic wafer splint may provide some degree of stabil- since – on the contrary – we have observed that edema
ity, but open reduction and plate fixation is usually subsides faster when correct anatomic bone conditions
required. Mini- or microplate systems may be employed. have been achieved. This is especially true for orbital
An attempt at achieving two points of stabilization pre- edema.
vents rotation and tilting of the dentoalveolar segment, Intubation must not interfere with the ability to use
and care must be taken to avoid placing screws in the mandibulomaxillary fixation during surgery. The origi-
apices of the adjacent teeth. Screws should not be longer nal occlusion is one of the most important landmarks
than 4 mm to avoid tooth root injury. Soft-tissue attach- for correct reduction and fixation of midfacial fractures.
ments must be maintained to the dentoalveolar seg- Therefore either nasal, oral (behind the teeth, or if teeth
ments. Loss of gingival tissue from these segments due are lacking), submental intubation, or an endoscopically
to trauma or exposure may devascularize the teeth. If a placed tracheostoma is necessary.
segment becomes devascularized, stability of the frac- In addition to the infraorbital approaches and the
ture is improved by replacement and fixation. However, transconjunctival and upper blepharoplasty approach
should it remain clearly nonviable, a tooth extraction or (see Figs. 2.1, and 2.5), the coronal incision is the most
removal of the segment may be necessary. important approach. In recent years we have learned
that extensive facial degloving is feasible, and via this
exposure accurate skeletal reconstruction is possible.
4.2.2 Upper Midface (Le Fort II and III) The coronal approach is mandatory especially for the
correct reconstruction of the nasoethmoidal area and
The rules described in Sect. 4.2.1 also apply for the the correct placement of the zygomatic arch area. A
reduction and fixation of fractures of the upper midface. hemicoronal incision should not be used. Eyebrow inci-
sions and other routes via the nasal dorsum should be
4.2.2.1 Anatomy exceptions. A gingivobuccal incision is necessary for a
correct fixation of the link between the upper and lower
The upper midface includes both zygomatic bones, the midface (Le Fort I area).
orbits whose superior sections belong to the upper face, A very important precondition is a team approach.
and the central nasoethmoidal region (see Fig. 4.1.1c). Since most of the upper midface fractures appear in
As it has been said before the classic fracture patterns combination with skull base fractures,the neurosurgeon
II and III as described by Le Fort are rarely seen. These in most areas is the most important partner. Depending
fractures are observed mostly in combination with skull on the special situation all specialties (oral-maxillofa-
base or cranial vault fractures as well as with Le Fort I cial, plastic surgery, neurosurgery, ENT, and ophthal-
and mandibular fractures. In these instances they are mology) should be involved at the same time in the
part of panfacial fractures. treatment of panfacial fractures.
It is also important to visualize all fractures first
4.2.2.2 Diagnosis before any fracture is stabilized. In severely comminuted
fracture situations a preliminary approximation may be
In addition to the clinical evaluation – which generally performed with wire before definite fixation with plates
provides only a rough impression since swelling and the and screws is undertaken.
overlying soft tissues hide the underlying bony struc- Upper midface fractures are located between the cra-
tures – X-ray evaluation via plain facial radiographs and nial vault and the occlusal unit.
b c
Fig. 4.2.12 a–c Although establishment of the correct occlusion is

a Diagram showing reconstruction and fixation of outer facial absolutely mandatory as a guideline, for correct reduc-
frame, consisting mainly of correct positioning of zygomatic tion of upper midfacial fractures it may be misleading.
bones to the cranial vault and posterior root of zygoma. This
may be the first step in an outside to inside management. Formerly, when we used wire for fixation together with
b CT scan, axial view. Severe fracture of left zygoma with con- craniofacial suspension, we often observed a consider-
siderable displacement of the zygomatic arch, necessitating able amount of telescoping in the Le Fort II and III areas
exposure via coronal approach. with facial deformation although the occlusion was cor-
c CT scan, axial view. Repair of zygomatic arch with 2.0 mini- rect.
plates after exposure of both zygomatic arches for compari-
son reasons.
Gruss (1986) stressed the importance of the correct
reconstruction of the outer facial frame (Fig. 4.2.12a) for
proper reestablishment of the facial dimensions. The fix-
ation of both zygomas in the correct position in relation
to the cranial vault guaranties correct facial width and
helps to find the correct position for the nasoethmoidal Fig. 4.2.13
complex. Therefore it is also a key area for reestablishing Fixation of central midface to the outer facial frame and to the
the correct facial projection and facial length. This is frontal bar within the nasal ridge with the 1.3 system. Inset: Fix-
ation at the nasal ridge area with one 2.0 plate as an other
part of the presently advocated concept of an “outside to option. The vertical buttresses are stabilized with the 2.0
inside” management. Even in unilateral upper midface system or a bone graft. Intermaxillary fixation is kept only dur-
fractures it may be necessary to use a coronal approach ing surgery.
since it may be important to compare the position of the
unfractured zygomatic arch with the reduced arch
(Fig. 4.2.12b,c). Reconstruction of the central part of the In extensive midface fracture situations (panfacial
upper midface – the nasoethmoidal complex – is exten- fractures) the vertical buttresses should be stabilized
sively described in Sect. 4.3. with the 2.0 system. The links to the cranial vault at the
Reestablishment of the correct intercanthal distance zygomaticofrontal sutures should also be stabilized with
by means of correctly placed transnasal wires is a very the 2.0 system in these instances. If fixation in the nasal
important step (see Figs. 4.1.5, 4.3.3b, 4.3.4b). Securing root area is performed with one plate, it should prefer-
the links between central and lateral upper midface in ably be a 2.0 plate (Fig. 4.2.13, inset), while in the situa-
the area of the inferior orbital rim, as well as fixation to tion of fixation with two plates the 1.3 system could be
the frontal bar and along the medial buttress, follows used (Fig. 4.2.13). The horizontal buttresses in the zygo-
thereafter (Fig. 4.2.13). After the complete reconstruc- matic arch area are fixed preferably with the 2.0 system
tion of the orbital frame the orbit itself is reconstructed (see Figs. 4.2.5b, and 4.2.12c) while stabilization in the
(see Sect. 4.5). Thereafter the occlusal unit with correct orbital rim area is adequate with 1.3 plates (Figs. 4.2.12,
mandibulomaxillary fixation is fixed with plates and 4.2.13).
and screws at the buttress zones (medial and lateral) to Figure 4.2.14 presents a further example of a typically
the upper midface. dislocated Le Fort III fracture with a zygomatic fracture
a b
Fig. 4.2.14 a, b
a Diagram of a Le Fort III fracture with zygomatic fracture on
the left and typical dislocation.
b Diagram showing fixation of fracture shown in a, using the
2.0 and 1.3 system.
on the right and its stabilization. Figure 4.2.15 demon-

strates adequate fixation of a Le Fort III fracture on the
left in combination with an orbital fracture on the left
and a Le Fort II fracture on the right on a water’s view.
Fig. 4.2.15
X-ray (water’s view) after fixation of a Le Fort II fracture on the
right, and a severe orbitozygomatic fracture on the left. The
patient was edentulous in the maxillary area.
Klotch DW, Gilland R (1987) Internal fixation vs conventional

References and Suggested Reading therapy in midface fractures. J Trauma 27:1136–1148
Kuepper RC, Harrigan WF (1977) Treatment of midfacial frac-
tures at Bellevue Hospital Centre, 1955–1976. J Oral Surg
Adams WM (1942) Internal wiring fixation of facial fractures. 35:420–422
Surgery 12:523–540 Kuhn A, McIff T, Cordey FW et al (1995) Bone deformtion by
Bechtol CO, Ferguson AB, Laing PG (1959) Metals and engi- thread-cutting and thread-forming cortex screws. Injury 26
neering in bone and joint surgery. Williams and Wilkins, [Suppl]1:12–21
Baltimore Le Fort R (1901) Etude experimentale sur les fractures de la
Ciaburro H, Dupont C, Prevost Y, Cloutier GE (1973) Forward machoire inferieure. I, II, III. Rev Chir Paris 23:208, 360, 479
traction in the correction of the retrodisplaced maxilla. Can Luce EA, Tubbs TD, Moore AM (1979) Review of 1000 major
Med Assoc J 108:1511 facial fractures and associated injuries. Plast Reconstr Surg
Danis A (1949) Theorie et pratique de l’osteosynthèse. Masar, 63:26–30
Paris Manson PN (1986) Some thoughts on the classification and
Diehl K, Hanser U, Hort W, Mittelmeier H (1974) Biomechani- treatment of Le Fort fractures. Ann Plast Surg 17:356–363
sche Untersuchungen über die maximalen Vorspannkräfte Manson PN, Crawley WA, Yaremchuk MJ et al (1985) Midface
der Knochenschrauben in verschiedenen Knochenabschnit- fractures: advantages of immediate extended open reduc-
ten. Arch Orthop Unfall Chir 80:89 tion and bone grafting. Plast Reconstr Surg 76:1–10
Ferraro JW, Berggren RB (1973) Treatment of complex facial Manson PN, Glassman D, Vander Kolk C et al (1990) Rigid sta-
fractures. J Trauma 13:783–787 bilization of sagittal fractures of the maxilla and palate. Plast
Fialkov JA, Phillips JH, Walmsley SL (1994) The effect of infec- Reconstr Surg 85:711–717
tion and lag screw rigid fixation on the union of membra- Manson PN, Hoopes JE, Su CT (1980) Structural pillars of the
nous bone grafts in a rabbit mode. Plast Reconstr Surg facial skeleton: an approach to the management of Le Fort
93:574–581 fractures. Plast Reconstr Surg 66:54–61
Gentry LR, Manor WF, Turski PA, Strogher CM (1983) High- Manson PN, Shack RB, Leonard LG et al (1983) Sagittal frac-
resolution CT analysis of facial struts in trauma: normal tures of the maxilla and palate. Plast Reconstr Surg 72:
anatomy. Am J Radiol 140:523 484–488
Gruss JS, Mackinnon SE (1986) Complex maxillary fractures: Phillips JH, Rahn BA (1989) Comparison of compression and
role of buttress reconstruction and immediate bone grafts. torque measurements of self-tapping and pretapped screws.
Plast Reconstr Surg 78:9–22 Plast Reconstr Surg 83:447–456
Gruss JS, Phillips JH (1992) Rigid fixation of Le Fort maxillary Rudderman RH, Mullen RL (1992) Biomechanics of facial
fractures in rigid fixation of the craniomaxillofacial skele- skeleton. Clin Plast Surg 19:11–29
ton. Butterworth-Heinemann, London Schilli W,Ewers R,Niederdellmann H (1981) Bone fixation with
Hughes AN, Jordan BA (1972) The mechanical properties of screws and plates in the maxillo-facial region. Int J Oral Surg
surgical bone screws and some aspects of insertion practice. 10 [Suppl]1:329
Injury 4:25–38 Sicher H, DeBrul EL (1970) Oral anatomy, 5th edn. St. Louis
4.3 · Naso-Orbital-Ethmoid Fractures 127
4.3 Naso-Orbital-Ethmoid Fractures
Contributors: Beat Hammer

Joachim Prein
4.3.1 Definition
The term naso-orbito-ethmoid (NOE) fractures is

employed for injuries involving the area of confluence of
the nose, orbits, and ethmoids (Gruss 1985; Paskert et al.
1988). A number of delicate structures are involved in
these fractures: the nose, medial and lower orbits, fron-
tal sinus and anterior skull base, and the pyriform rim.
Managing all these structures and reconstructing the
complex three-dimensional architecture of the NOE
area are among the most difficult problems in treating
facial trauma.
4.3.2 Anatomy
The main structural buttress of the NOE area is the fron-

tal process of the maxilla, which articulates cranially to
the internal angular process of the frontal bone. This
buttress contains the insertion of the medial canthal lig- Fig. 4.3.1
ament (Fig. 4.3.1) and extends superiorly beyond it. The The frontal process of the maxilla is the main structural but-
canthal bearing area is also referred to as a “central frag- tress of the naso-orbital-ethmoid area, containing the inser-
tion of the medial canthal ligament (inset). It is refered to as the
ment” (Markowitz et al. 1991), which shows typical frac- “central fragment.”
ture patterns (see below). The thin and easily commin-
uted lamina papyracea of the ethmoids is located poste-
rior to the central fragment. Cranially the internal
angular process of the frontal bone is anterior and dorsal nasal bone grafting is determined by the degree
superior to the anterior wall of the frontonasal duct. of comminution to these structures.
Patency of the frontonasal duct may be lost in highly
comminuted NOE fractures, and obliteration of the
frontal sinus is then necessary (Stanley 1979). 4.3.3 Fracture Patterns
Between the two central fragments the nasal bones
arch to form the proximal nasal skeleton. These small Three typical fracture patterns can be distinguished
and fragile bones often have multiple fractures. How- (Markowitz et al. 1991), which occur either unilaterally
ever, skeletal support and projection of the nose or bilaterally. The fracture patterns differ in the degree
depends proximally on the support of the nasal pyramid of displacement and comminution of the canthal liga-
and distally on the cartilaginous septum. The need for ment bearing “central” fragment.
4.3.2 a 4.3.2 b
Type 1 (Fig. 4.3.2). In Type I fractures there is a single Fig. 4.3.2 a, b

large fragment bearing the canthal ligament. This frag- a NOE fracture, type I. There is a single large fragment con-
ment is easily stabilized with miniplates or the 1.3 taining the insertion of the medial canthal ligament.
b Stabilization of a NOE fracture, type I. The 2.0 and 1.3 sys-
system. Type I injuries may be either complete or incom- tems are used. Remark: under certain circumstances, stabil-
plete (greenstick fracture at the internal angular process ization can be carried out without the plate at the frontona-
of the frontal bone and may be uni- or bilateral). sal juncture, e.g., in fractures undislocated at the internal
angular process of the frontal bone.
Type II (Fig. 4.3.3). Here there is some degree of commi-
nution of the central fragment, but the canthal ligament Fig. 4.3.3 a, b
▼
is attached to a fragment large enough to be stabilized a In NOE fractures type II there is some degree of fragmenta-
with wires or the 1.3 plate and screw system. The com- tion of the central fragment. However, the fragment contain-
ing the insertion of the canthal ligament is large enough to
minution is external to the canthal ligament insertion. be stabilized with a plate.
b Stabilization is achieved with a combination of 1.3 plates and
Type III (Fig. 4.3.4). In Type III fractures comminution a transnasal wire. The wire is inserted through the ligament-
extends beneath the insertion of the canthal ligament. bearing fragment and should prevent outward rotation of
Canthal detachment is required to achieve the bone this fragment.
reduction. Direct canthopexy is necessary, with atten-
tion to construction of the canthal insertion point which Fig. 4.3.4 a, b
▼
should be posterior and superior to the lacrimal fossa. a NOE fracture type III. There are multiple small fragments.
The fragment containing the insertion of the canthal liga-
ment is too small to be stabilized. There may even be avul-
sion of the canthal ligament.
b Stabilization of a NOE fracture type III. The small bone frag-
ments are aligned and stabilized with 1.3 mini- or 1.0 micro-
plates. To reconstruct the canthal ligament insertion, a direct
transnasal canthopexy is necessary. The insertion point is
created posterior and superior to the lacrimal fossa. If the
bone in this area is missing, the insertion point may be
created with a bone graft or a 2.0 plate as shown in the fig-
ure. The most common error is to insert the ligament too far
anteriorly.
4.3.3 a 4.3.3 b
4.3.4 a 4.3.4 b
(Paskert et al. 1988;) allows examination of septal sup-

4.3.4 Plates Used for Internal Fixation of NOE Fractures port for the nose, thereby assessing the need for dorsal
bone grafting.
Plates from the midface sets 1.0 (micro) and 1.3/1.5
(miniplates) are used to stabilize NOE fractures. Micro- Computed Tomography. While the NOE injury itself is
plates are especially helpful in putting the very small evaluated clinically, CT scans are indispensable in the
fragments of the nasal root together. They also may be diagnosis of associated injuries (orbits, frontal sinus,
used to link a large central fragment to the frontal bone. skull base) and to confirm the pattern of the NOE frac-
Miniplates are indicated when increased mechanical ture. Details for the other fractures are given in the sec-
stability is required. Because of their relative thickness tions dealing with these injuries.
they should not be employed anterior to the lacrimal The NOE fracture diagnosis requires (at a minimum)
crest. fractures surrounding the “central fragment”; these
NOE fractures are the only type of injury in which include fractures of the nose, orbit, medial orbital wall,
stainless steel wires are still used for transnasal reduc- and inferior orbital rim. Fractures of the internal orbit
tion and fixation. In type II or III injuries transnasal wir- (floor and medial orbital wall) are routine.
ing of the central fragment or/and direct transnasal can-
thopexy is used to reduce the intercanthal distance, or
distance between the frontal process of the maxilla. 4.3.7 Operative Treatment
Operative treatment should be undertaken as early as

4.3.5 Exposure possible. This consists of graded exposures with ana-
tomic reduction and rigid fixation of bone fragments.
A combination of coronal, lower eyelid, and upper buc- Special attention must be paid to the medial canthal
cal sulcus incisions is usually employed. The coronal flap ligament. The fracture usually extends into the naso-
is reflected to expose the nose. In most cases dissection maxillary or zygomaticomaxillary buttress, and there-
of at least two-thirds of the orbital circumference is nec- fore a buccal sulcus incision is necessary.
essary. Stripping of the canthal ligament from the bone
is avoided, except in type III injuries where the fractures
extend beneath the canthal insertion. 4.3.7.1 Management of the Central Fragment
If there are fractures of the posterior frontal sinus
wall or anterior skull base, cranial base exploration and Type I Injuries (see Fig. 4.3.2). A large canthal ligament
dural repair may be required. If the anterior wall of the bearing fragment may be reduced and stabilized with
frontal sinus is fractured, all fragments are temporarily plates alone. In this case plates at the infraorbital rim
removed, which exposes the interior of the sinus and the and pyriform aperture stabilize the fragment. Before
nasofrontal duct. placing the plate at the infraorbital rim the articulation
The orbital floor and the infraorbital rim are exposed of the fragment with the nasal process of the frontal
through a lower eyelid incision. bone must be ensured to avoid malrotation. This frac-
Type I fractures undisplaced at the internal angular ture is stabilized by a 1.3-mm plate at the inferior orbi-
process ot the frontal bone do not require exposure with tal rim and a 2.0-mm plate at the pyriform aperture.
a coronal incision but only the lower eyelid and gingival Microplates are not sufficient to stabilize the fragment
buccal sulcus. against rotation.
Type II Injuries (see Fig. 4.3.3). The ligament bearing

4.3.6 Diagnosis fragment is isolated without stripping the ligamentous
insertion. Temporary alignment of the bone fragments
Clinical Examination. Every injury to the central midface with wires may facilitate reduction. Two 0.3-mm (28-
is suspicious for a NOE fracture. The clinical examina- gauge) transnasal wires are passed through drill holes in
tion should include mobility and comminution of the the central fragment. The wires must be placed posterior
central fragment and loss of septal support for the nose. and superior to the lacrimal fossa. The task of this wire
Severe nasal fractures may be misdiagnosed as NOE is to secure the correct rotational position of the central
injuries, but more frequently NOE fractures are misdi- fragment and maintain the correct intercanthal dis-
agnosed as nasal fractures.An accurate diagnosis can be tance. Miniplates, 1.3, or microplates are employed to
made with bimanual examination.Furtheron motion of stabilize the multiple small fragments of the nose
the canthal-bearing segment can be detected between (Fig. 4.3.5b), or, interfragmental wires can be used.
finger and clamp, placing the clamp internally and the
finger externally. Gentle pressure on the nasal dorsum
a b
Fig. 4.3.5 a–c

a Incision for open rhinoplasty approach accross the colu- c
mella.
b, c A calvarial bone graft restores the projection of the nose.
The bone graft is cantilevered to the frontal bone with a 2.0
miniplate. The tip of the graft is placed between the two
crura of the alar cartilages.
Type III Injuries (Figs. 4.3.4). In Type III injuries the cen-
tral fragment is too small to be used for canthopexy, or 4.3.8 NOE Fracture-Related Problems
fractures extend beneath the canthal insertion. There
may also be even avulsion of the medial canthal liga- 4.3.8.1 Lacrimal Duct Injuries
ment, although this is a rare event. Reconstruction of
these fractures requires a direct transnasal canthopexy Lacrimal duct injuries resulting in obstruction are
after bone reconstruction. Initially the canthal ligament present in less than 10% of fractures involving this area.
is completely detached. If a bone fragment is left Primary exploration of the lacrimal apparatus is gener-
attached to the canthal ligament, it may interfere with ally not recommended unless an open laceration has
direct canthopexy. Small bone fragments may be aligned divided the lacrimal system.
and fixed with 1.3 or microplates.
4.3.8.2 Frontal Sinus

4.3.7.2 Transnasal Canthopexy
The management of frontal sinus injuries is discussed in
There are two important steps in canthopexy: First the Sect. 4.6.
ligament is identified and transfixed with a suture. This
is done through a small transverse external incision
medial to the palpebral fissure (Stanley 1979). This 4.3.8.3 Skull Base Injuries
suture is passed directly to the internal aspect of the cor-
onal incision and to a separate set of transnasal wires. Associated skull base injuries may be repaired transcra-
The second step involves choosing the insertion point nially. For skull base injuries localized to the anterior
for the transnasal wire. It should be chosen posterior cranial fossa, “subcranial” management (a minicraniot-
and superior to the lacrimal fossa. In some cases, the omy) is often another option providing limited expo-
fragile bone of this area is comminuted. The insertion sure.
point of the transnasal wire must then be constructed.
This can be done with a bone graft fixed with a miniplate
placed along the medial orbital wall. The wire is then 4.3.8.4 Orbital Reconstruction
passed through the bone graft, or one of the holes of the
miniplate (see Fig. 4.3.4b) (Hammer 1995). The bone Section 4.5 deals with the management of internal orbi-
graft must be positioned with a miniplate to be stable. tal fractures.
4.3.7.3 Nasal Reconstruction References and Suggested Reading
The nasal bones are reduced and stabilized with mini-, Gruss JS (1985) Naso-ethmoid-orbital fractures: classification
microplates or wires, and the glabella and frontal sinus and role of primary bone grafting. Plast Reconstr Surg 75
(3):303–315
are reconstructed by bone reassembly. If there is lack of Hammer B (1995) Orbital fractures. Diagnosis, operative treat-
septal support, dorsal nasal bone grafting is necessary to ment, secondary corrections. Hogrefe-Huber, Bern, pp 52–54
reestablish the height and anterior projection of the Markowitz BL, Manson PN, Sargent L,Vander Kolk CA,Yarem-
nose. Cranial bone grafts or rib are the choices. To allow chuk M, Glassman D, Crawley WA (1991) Management of the
precise placement of a rib graft and provide columella medial canthal tendon in nasoethmoid orbitae fractures: the
importance of the central fragment in classification and
support an open rhinoplasty approach is preferred treatment. Plast Reconstr Surg 87 (5):843–853
(Fig. 4.3.5a). Placement of the dorsal nasal bone graft Paskert JP, Manson PN, Iliff NT (1988) Nasoethmoidal and
and fixation to the nasal root with a miniplate are shown orbital fractures. Chir Plast Surg 15 (2):209–223
in Fig. 4.3.5b,c and see Fig. 4.2.5b,d. Nonabsorbable Stanley RB Jr (1979) Fractures of the frontal sinus. Clin Plast
sutures suspend the cartilaginous septum to the dorsal Surg 16 (1):115–123
graft. The tip of the graft is placed underneath and
between the domes of the alar cartilages. In this way a
naturally appearing, smooth nasal tip can be obtained.
4.4 · Zygomatic Complex Fractures 133
Fig. 4.4.1
4.4 Zygomatic Complex Fractures The five articulations of the zygoma with the craniofacial skele-
ton are visualized. Any of the multiple zygomatic fracture sites
may be exposed either to confirm alignment or to provide fix-
Contributors: Bernard L.Markowitz ation.
Paul N.Manson The best areas to determine reduction are the internal sur-
face of the orbit ➎, and the zygomaticomaxillary buttress ➌,
inferior orbital rim ➋, and the zygomatic arch ➍ (the multiple
4.4.1 Definition articulations of the zygoma).
Inset: The placement of bone hook underneath malar emi-
nence allowing reduction of the fracture in an anterolateral
Zygomatic fractures include any injury which disrupts direction.
the five articulations of the zygoma with the adjacent
craniofacial skeleton (Fig. 4.4.1): the zygomaticofrontal
suture, infraorbital rim, zygomaticomaxillary buttress,
uttress,
zygomatic arch, and zygomaticosphenoid suturee. The
degree to which the sutures are involved depends on the
direction and magnitude of the fracturing forcee. Dis-
➊
➎
➋ ➍
➌
placement is parallel to the direction and force of the

injury and the action of the masseter muscle. Regional,
monoarticular fractures (isolated zygomatic arch, etc.)
are also seen.
4.4.2 Treatment
Displaced or unstable zygomatic fractures benefit from

open reduction. The extent of open reduction is deter-
mined by displacement and comminution of the five
articulations. There are two reasons to explore any of the
multiple zygomatic fracture sites: to confirm alignment
and to provide fixation. Operative exposure may be used
for one or both purposes. In many zygomatic fractures
the degree of stability and the minimal displacement do
not justify open reduction. The majority of displaced
zygomatic fractures (type I; Fig. 4.4.2) may be managed
with inferior exposures and stabilization. Fractures
which exhibit lateral displacement of the zygomatic arch
(type II) (Figs. 4.4.3) require superior exposures in addi- Fig. 4.4.2
tion to inferior approaches (see Figs. 2.1, 2.5). Low energy zygoma fracture. No lateral displacement of the
arch. In this case anterior approach.
4.4.3 Exposure
For details see Chap. 2.
∑ Inferior orbital exposure

– Subciliary
– Extended subciliary
– Transconjunctival
– Lateral canthotomy
∑ Inferior maxillary exposure
– Gingival buccal sulcus incision
∑ Superior orbital exposure
– Brow
– Lateral limb of upper blepharoplasty
– Canthal detachment with lower eyelid incision a
– Coronal
4.4.4 Reduction
Reduction of zygomatic fractures is performed through

a combination of incisions as explained in Chap. 2.
Exposure of the fracture site provides an opportunity to
confirm alignment and provide fixation. As a general
principle, alignment of the zygoma must be confirmed
in at least three areas and fixation in at least two. An
anterolateral and superior reduction force, directed b
from underneath the medial aspect of the malar emi-
nence, is usually necessary to reposition the displaced Fig. 4.4.3 a, b
zygoma. High-energy zygoma fracture. Considerable lateral displace-
One way to achieve this is via a bone hook, which is ment of the zygomatic arch and displacement of body. Coronal
introduced underneath the malar eminence through a approach required.
small 3 mm incision in the skin of the cheek (Fig. 4.4.1, Table 4.1. Fracture sites as points of alignment and strength
inset). Further access is achieved through either the of fixation as suture sites
mouth, the upper sulcus incision, or the external inci- Value of fracture sites Strength of fixation
sions by dividing the deep temporal fascia above the as points of alignment as suture sites
zygomatic arch, near the zygomaticofrontal suture, (≠ Increasing value) (≠ Increased strength)
exposing the temporalis muscle, and then placing a Zygomatic arch–orbit Z-F suture
blunt elevator (such as Dingman) behind the malar emi- (greater wing sphenoid)
nence. A force opposing that of the injury is generated, Inferior orbital rim Z-M buttress
and the fracture is reduced. Z-M buttress Zygomatic arch
Z-F suture Inferior rim
For intraoral reduction the zygomaticomaxillary
buttress is followed superiorly to its junction with the
malar eminence. At times fibers of the masseter need to after the initial reduction maneuver, and appropriate
be elevated. A blunt elevator is positioned beneath the plates chosen for fixation. Fractures that “snap” back
eminence or within the lateral aspect of the maxillary into place and are stable have different fixation require-
sinus and an appropriate reduction force produced by ments (Fig. 4.4.4) than injuries that are comminuted and
delivering force to the malar eminence. Movement of the require positioning placement, such as temporary inter-
displaced bone into anatomic alignment is sometimes osseous wires, or constant reduction force to maintain
appreciated by a “click” and confirmed by inspecting the position prior to rigid fixation (Figs. 4.4.5, 4.4.6;
each buttress articulation. Minor adjustments in posi- Pearl 1990).
tion are performed with Brown forceps prior to fixation. For most type I zygoma fractures stabilization of the
The zygomaticosphenoid suture is a commonly over- inferior orbital rim, zygomaticomaxillary buttress, and
looked determinant of anatomic alignment (see zygomaticofrontal suture are routinely advised (see
Fig. 4.4.1). Considerable experience is required to appre- Fig. 4.4.5). Stable injuries may have two plate fixations
ciate the use of this area as an isolated fracture align- (see Fig. 4.4.4). The initial fixation is provided by at least
ment site. The zygomaticomaxillary buttress is an excel- a miniplate at the zygomaticofrontal suture or the
lent determinant, the infraorbital rim is a good determi- zygomaticomaxillary buttress while the remainder of
nant, and the zygomaticofrontal suture is a poor the fracture sites may then be managed with 1.3 plates.
determinant of proper reduction. Zygomatic arch reduc- When the buttress is comminuted, or the fracture pat-
tions sets midfacial width and, reciprocally, malar emi- tern is not conducive to microplating, miniplates should
nence projection (Table 4.1). be placed at the zygomaticofrontal suture and zygoma-
ticomaxillary buttress. Microplates or 1.3 system plates
are placed at the inferior orbital rim.
4.4.5 Stabilization The 90° or 110° L or Y miniplate is best suited for the
zygomaticomaxillary buttress (see Fig. 4.4.5). The low
The “stability” of the reduction (determined by the profile mini-DC plate or the 2.0, 1.5 or 1.3 system is used
degree of comminution within the zygomatic complex at the zygomaticofrontal suture (Fig. 4.4.6, insets 1–3).
and at its articulations) determines the type and num- Screw holes must be directed away from tooth roots near
ber of fixation devices to be used. Frequently 1.3 and the maxillary alveolus. A single 1.3 plate usually suffices
miniplating systems (1.5 and 2.0) are used in combina- at the inferior rim.
tion. Low-profile 1.3-mm plates are less conspicuous in
areas where devices may be visible and palpable (infra- Type II Fractures. For type II fractures (Fig. 4.4.3), in
orbital rim), but they may not be sufficient to ensure addition to the described anterior points of fixation, the
rigidity at the zygomaticofrontal suture. The stronger zygomatic arch is exposed, reduced, and stabilized.
but larger 2.0 miniplates are best reserved for areas cov- Zygomatic arch fixation is the initial step in the stabil-
ered by adequate soft tissue (zygomaticomaxillary but- ization of type II fractures after eventual placement of
tress, zygomatic arch, and in some cases zygomatico- positioning wires at the Z-F suture and the infraorbital
frontal suture; Figs. 4.4.4–4.4.6; see also Table 4.1). rim. The anterior articulations are then stabilized as
The zygomaticofrontal suture contains the strongest described above.
bone for stabilization; the zygomaticomaxillary buttress The key to correct zygomatic arch reduction and sta-
is a good location for stabilization. The inferior orbital bilization is the appreciation of its normal anatomy. The
rim and zygomatic arch are fair areas for stabilization zygomatic arch is not a true arch but is straight in its
(Figs. 4.4.4–4.4.6). middle portion. It is best stabilized with an adaption
miniplate of the 2.0 system, fashioned by “overflatten-
Type I Fractures. Numerous plating schemes are success- ing” the central zone and then securing the reduction
fully employed for the stabilization of zygomatic frac- with 2.0 screws (see Fig. 4.4.6). At times an oblique sag-
tures. Fracture stability must be considered carefully ittal fracture at the posterior aspect of the arch may be
4.4.4
4.4.5
4.4.6
4 5
Fig. 4.4.4 Fig. 4.4.6

▼
Two-plate fixation of the zygoma. Miniplate (1.3) fixation at the Miniplate fixation in a comminuted fracture of the lateral
inferior orbital rim and miniplate (2.0) fixation at the zygomat- upper midface. In addition to the fixation type in Fig. 4.4.5 fix-
ico-frontal suture. The three insets show the various options in ation of the zygomatic arch is performed with a 2.0 miniadap-
between 1.3 and 2.0 adaption plates at the lateral orbital rim. tation plate. Inset 4, lag screw fixation for a sagittal fracture at
the posterior aspect of the arch. Inset 5, plate fixation for the
roof of the glenoid fossa. Insets 1–3 show the various options
Fig. 4.4.5 for fixation at the zygomatico-frontal suture.
▼
Miniplate fixation in a comminuted fracture at three anterior

fracture sites. Miniplate fixation at the zygomaticofrontal
suture and zygomaticomaxillary buttress and 1.3-mm plate fix-
ation at the orbital rim. The limbs of the L or Y miniplate in the managed with a lag screw (1.5 or 2.0 mm; see Fig. 4.4.6,
zygomaticomaxillary buttress must be bent around tooth inset 2). Screws should be diverted away from the tem-
roots. poromandibular joint. Plating the roof of the glenoid
A longer L or Y miniplate is best suited for the comminuted fossa may be required prior to arch plating (see
zygomaticomaxillary buttress. The separate buttress fragment
is lag-screwed to the plate.
Fig. 4.4.6, inset 3).A lag screw may be placed through one
of the posterior holes of the plate.
4.4.6 Internal Orbit
Once the external orbital rim is stabilized, the internal

orbit is evaluated and its continuity assessed. If a defect
exceeding 5 mm is present, it must be entirely exposed
and stable ledges identified for graft stabilization. Orbi-
tal wall defects larger than 1–2 cm are grafted with split
(outer table) calvarial bone grafts or alloplast (Medpor References and Suggested Reading
1.5 mm or polyvynil sheets). Titanium plates alone are
used for small or large defects (see Fig. 4.5.6). Skull outer Jackson IT (1989) Classification and treatment of orbito-zygo-
table or split rib grafts are used for larger defects. Grafts matic and orbitoethmoid fractures – the place of bone graft-
ing and plate fixation. Clin Plast Surg 16:77–91
must be placed accurately to restore orbital volume. Larsen OD, Thomsen M (1976) Zygomatic fractures. Scan J
Globe position, because of edema, is frequently an Plast Reconstr Surg 12:59–63
imprecise guide to adequate restoration of orbital vol- Lundin K, Ridell A, Sanberg N, Ohman A (1973) One thousand
ume. Once grafts are placed, globe motility (forced duc- maxillofacial and related fractures at the EENT Clinic in
tion) examinations are assessed and compared to pre- Gothenburg: a two year prospective study. Acta Otolaryngol
75:359
and postdissection ductions. The grafts are then Manson PN, Ruas E, Iliff N et al (1987) Single eyelid incision for
anchored with lag or tandem screws. If complex (three exposure of the zygomatic bone and orbital reconstruction.
or four wall fractures) are present, internal mesh or Plast Reconstr Surg 79:120–126
stable fixation should be used to provide a platform for Matsunaga RS, Simpson W, Toffel PH (1988) Simplified proto-
orbital volume correction (see Sect. 4.5). col for treatment of malar complex fractures. Facial Plast
Surg 5:269
Pearl RM (1990) Prevention of enophthalmos: a hypothesis.
Ann Plast Surg 25:132–133
4.4.7 Soft-Tissue Closure Stanley RB Jr (1989) The zygomatic arch as a guide to recon-
struction of comminuted malar fractures. Otolaryngol Head
Strict attention must be given to layered closure which Neck Surg 115:1459–1462
Tajima S (1977) Malar bone fractures: experimental fractures
includes resuspension of the soft tissue. Lateral canthal
on the dried skull and clinical sensory disturbances. J Max-
reattachment is performed if the canthus has been illofac Surg 5:150–156
detached (see Fig. 4.1.9). The lateral canthus is isolated Watumull D, Rohrich RJ (1991) Zygoma fracture fixation: a
and a 3-0 nonabsorbable suture is passed through the graduated approach to management based on recent clinical
canthus and hooked through a plate hole at the zygom- and biomechnaical studies. In: Manson PN (ed) Problems in
plastic and reconstructive surgery. Lippincott, Philadelphia
aticofrontal suture. When an extended transconjuncti-
Yanigasiwa E (1973) Pitfalls in the management of zygomatic
val incision is used, the divided canthus is carefully reap- fractures. Laryngoscope 83:527–543
proximated.The malar fat pad is resuspended to an orbi-
tal rim plate with a 4-0 Prolene prior to closing the
periosteal incisions in the lateral orbit and inferior orbi-
tal rim. The lower eyelid incision is closed with a Vicryl
muscle suture. The skin is closed with interrupted 6-0
plain gut sutures.
The coronal incision is closed in two layers, the galea
with 2-0 Vicryl and the scalp with staples. The superfi-
cial layer of the deep temporal fascia is repaired with 2-0
Vicryl as is the periosteum over the zygomaticofrontal
suture.
Avoiding Complications. Problems associated with zygo-

matic fracture treatment can often be avoided by precise
diagnosis, careful dissection for exposure, anatomic
reduction by direct observation, stable fixation, the
appropriate use of bone grafts, and soft-tissue closure.
4.5 · Orbital Fractures 139
4.5 Orbital Fractures
Contributor: Paul N.Manson
4.5.1 Definition
Fractures involving the orbit are common injuries that

involve multiple surgical specialties. The magnitude of
fractures within the orbit varies considerably. Simple
fractures may involve only a portion of the internal bone
area of the orbit, the common “blow-out” fracture. More
commonly, multiple portions of the orbit are fractured
with the orbital rim and several internal orbital walls
therefore injured simultaneously. Most fractures of the
orbit therefore require stabilization of both the rim and
the internal portions of the orbit (Fig. 4.5.1). The
regional approaches for stabilizing fractures of the rim
are discussed in the Sect. 4.4 and Chap. 2 but are
reviewed again here in the context of a broad recon-
structive perspective for fractures of the orbit.
As a general principle the orbital rim is reconstructed
by aligning its fractured parts with adjacent stabilized or
intact structures. Simultaneously visualizing multiple
areas of alignment increases the accuracy of the reduc-
tion. Initially, interfragment wiring or loose “two screw”
fixation in a plate provides temporary but adjustable
positioning of rim segments. Stable fixation then stabi-
lizes the position while final adjustment is provided by
manual positioning.
The bony orbit may be conceptualized in anterior, Fig. 4.5.1
middle, and posterior sections (see Fig. 4.5.1): The ante- The orbit consists of the rim and the internal orbit. The inter-
rior third of the orbit is the thick bony orbital rim. The nal orbit is conceptualized in anterior, middle, and posterior
sections. The anterior third of the orbit consists of the thick
middle section of the orbit is thin and often breaks bony orbital rim which is divided into three sections. The rim
before the rim, absorbing fracture forces. The posterior has three components, supraorbital section, nasoethmoidal
section of the orbit is thick and is thus protected from area, and zygomatic section. The middle section of the orbit is
fracture by the dislocation of the anterior and middle thin, often breaking before the rim and consists of four sec-
orbital segments. tions. The posterior portion of the orbit is thick and contains
the superior and inferior orbital fissures and the optic fora-
The orbital rim is divided into three segments: super- men.
iorly, the supraorbital section; medially, the nasoeth-
moidal section; laterally and inferiorly, the zygomatic
section. The supraorbital region consists of the frontal
bone laterally and the frontal sinus medially; the section
begins medially at the frontomaxillary suture (the junc- Fig. 4.5.2

tion of the internal angular process of the frontal bone The roof is bowed anteroposteriorly and mediolaterally. The
with the frontal process of the maxilla). The supraorbi- floor inclines at a 30° angle from anterior to posterior. The
floor of the orbit contains a postbulbar constriction. The optic
tal area extends laterally to the zygomaticofrontal suture foramen is located posterior and superior to the usually intact
and the external angular process of the frontal bone. The section of the orbital floor, 35–38 mm behind the rim.
lateral and inferior portions of the orbital rim are
formed by the zygomatic bone. The lower two-thirds of
the medial orbital rim represents the nasoethmoidal men or notch) located in the supraorbital rim at the lim-
area; the important characteristic here is the attachment bus of the cornea in straight forward gaze, and the infra-
of the medial canthus with the medial horn of the leva- orbital foramen, located 8–10 mm below the inferior
tor palpebrae superioris, and the medial attachment of orbital rim, parallel to the limbus of the cornea when the
Lockwood’s ligament around the superior aspect of the eye is in straight forward gaze. The third foramen is the
lacrimal fossa. zygomaticofacial foramen located in the lateral section
Whitnall’s tubercle is located on the inner aspect of of the malar eminence. Because these openings weaken
the lateral orbital rim, 10 mm below the zygomatico- the bone, fractures commonly occur in these areas and
frontal suture and 2–4 mm posterior to the anterior bruise the nerves and produce symptoms of anesthesia
margin of the lateral orbital rim. This provides attach- or hypesthesia in the nerve distribution.
ment to the lateral canthal complex, consisting of the lat- The middle third of the orbit is thin and is composed
eral canthal tendon, the lateral extension of the levator of four sections: the roof, medial wall, floor, and lateral
tendon, and Lockwood’s suspensory ligament. Three wall. The roof is a portion of the frontal bone and separ-
foramina perforate the superior and inferior orbital ates the anterior cranial fossa from the orbital cavity. It
rims. These are the supraorbital foramen (either a fora- is a thin extension of the supraorbital rim and is arched
AEF
PEF
Fig. 4.5.3 multiple partitions through the ethmoid sinuses. Ante-

The medial wall separates the orbit from the ethmoid sinuses riorly the lacrimal bone and its crest articulate with the
and nasal cavity. There is a postbulbar constriction of the orbit frontal process of the maxilla. The anterior and poste-
behind the globe in the medial wall and floor. The medial wall
is directly in line with the optic foramen posteriorly. AEF, anterior ethmoidal foramina in the medial wall of the orbit
rior ethmoidal foramen. PEF, posterior ethmoidal foramen. are at the same vertical level as the optic canal. The eth-
The lateral orbit is formed by the greater wing of the sphenoid. moid foramina are located 24 and 35 mm, respectively,
The anterior lip of the sphenoid is usually fractured in high- from the anterior lacrimal crest and serve as guides to
energy orbital fractures. Alignment of the lateral orbit forms the optic nerve located 40–45 mm from this bony land-
one of the most accurate guides to volume restoration.
mark and 5–8 mm posterior to the posterior ethmoid
foramen.
superiorly, anteroposteriorly, and mediolaterally. It is The floor of the orbit separates the orbit from the
important to reconstruct the contour of the roof and maxillary sinus. The orbital floor has an initial shallow
floor (Fig. 4.5.2) in accordance to its curving structures, convex section behind the rim, then inclines upward
extending backward from the supraorbital rim, permit- behind the globe, and inclines to meet the medial wall,
ting a space for the globe in its proper position. The roof, creating a distinct bulge behind the globe (see Fig. 4.5.2).
from anterior to posterior, first inclines upward, then These convex curves of the medial wall and floor create
posteriorly, then finally inferiorly near the orbit apex. a “postbulbar constriction” of the orbital cavity (see
The medial wall of the orbit consists of the thin orbi- Figs. 4.5.2 and 4.5.3), which must be reconstructed when
tal plate of the ethmoid bone which separates the orbit the orbit is rebuilt following fractures. Generally floor
from the ethmoid sinuses and nasal cavity (Fig. 4.5.3). fractures first involve the floor medial to the infraorbital
The medial wall of the orbit is formed by the thin orbi- nerve groove or canal and then extend to the lower half
tal plate of the ethmoid bone but gains strength from of the medial wall of the orbit.
The lateral portion of the orbit (see Figs. 4.5.1, 4.5.3)

is formed by the greater wing of the sphenoid, which
articulates with the orbital process of the zygoma. The
zygoma and the anterior half of the greater wing of the
sphenoid are commonly fractured simultaneously.
Achieving alignment of the entire lateral orbit is one of
the most critical components of orbital volume restora-
tion.
The posterior third of the orbit is constructed of
thicker bone and incorporates the superior and inferior
orbital fissures and the optic foramen (see Fig. 4.5.1).
The superior orbital fissure is surrounded by the greater
and lesser wings of the sphenoid bone. Important struc-
tures passing through this fissure include the third,
fourth, and sixth cranial nerves and the ophthalmic divi-
sion of the trigeminal nerve. The inferior orbital fissure
separates the orbital floor from the lateral orbital wall.
The infraorbital division of the maxillary portion of the
trigeminal nerve, the zygomaticofacial nerve, and the a
infraorbital artery all pass through this fissure posteri-
orly. Anteriorly the inferior orbital fissure contains liga-
mentous structures, fat, and veins. The optic foramen is
contained within the roots of the lesser wing of the sphe-
noid bone and transmits the optic nerve and ophthalmic
artery. It is located 40–45 mm from the inferior orbital
rim and is distinctly higher than the orbital floor, which
serves to protect it in dissection.
4.5.2 Diagnosis
Fractures of the orbit are diagnosed both by physical

examination and computed tomography (CT;
Fig. 4.5.4a). CT scans are obtained in the axial and coro-
nal planes with both bone and soft-tissue windows for
each orientation. A thorough physical and radiographic
examination is requisite to a satisfactory plan for recon-
struction. This should consist of a visual inspection, pal-
pation, assessment of visual acuity, visual fields, fundos- c
copy, and assessment of intraocular pressure. Duction
evaluations are indicated when there is diplopia. The
most common physical signs of an orbital fracture are plate. This prevents displacement or migration of the
periorbital ecchymosis and subconjuctival hematoma. implant; further, the use of stable fixation improves bone
Three-dimensional CT scans, while sometimes provid- survival. Ductions are assessed before dissection, after
ing additional perspective, are not required. dissection, and after insertion of the implant or graft to
access freedom of the muscular apparatus.
It is important in dissecting a fracture defect inside
4.5.3 Treatment the orbit to identify intact bone on all sides of the frac-
ture. The posterior portion of intact bone forms a guide
Isolated middle section (internal) orbital fractures to internal orbital reconstruction and represents the
(small fractures of the internal portion of the orbit) are intact bone “ledge.” Posteriorly this intact “ledge” is
best treated by bone grafting (Fig. 4.5.4b,c) or the use of often referred to as the “posterior ledge” and is usually
an alloplastic implant, as desired.Autogenous tissues are located some 35–38 mm behind the orbital rim. The new
generally preferred. The bone graft or alloplastic orbital floor should be positioned to incline from just
implant should be anchored behind the internal orbital behind the reconstructed rim to reach this intact
rim with the “lag” or “tandem” screw technique or a “ledge.” Recent studies emphasize the importance of
Fig. 4.5.4 a–c ligament system by the bone graft material. Reconstruc-
a CT scan, coronal view. Fracture of medial orbital wall and tion of floor and roof defects from a lateral perspective
orbital floor with considerable enlargement of the orbit. is seen in the insets of Fig. 4.5.4b.
b Small fractures of the floor or medial portion of the orbit are
best treated by on-lay bone grafting or alloplastic material.
The bone grafts or alloplastic material may be anchored
either with a microplate or with a lag screw. Stabilization of 4.5.4 Reconstruction of Ethmoid Defects
larger superior and inferior orbit grafts requires stable fixa-
tion to the rims. Ethmoid or medial orbital wall fractures are commonly
Insets: Orbital roof reconstruction either with extracranial
or intracranial plating and bone grafts performed prior to
a portion of a multiple wall orbital injury. Symmetric
frontal bone replacement. compression of the ethmoid air cells is frequently seen.
c Reconstruction of orbital floor and medial orbital wall with Restoration of bony orbital volume requires bone graft-
autogenous bone grafts, securing the correct orbital volume. ing to reduce effective orbital volume. Several layers of
bone graft should be placed at the ethmoid area to pro-
vide a thickness equal to that of the normal ethmoid
anatomic reconstruction of the bone defect rather than region (Fig. 4.5.5). When simultaneous defects of the
globe position at surgery as the best guide to volume res- floor and the medial orbital wall are present, a strut of
toration. Duction tests should be performed following stable fixation material may be required to provide posi-
the placement of either bone or alloplastic material. tioning support for other grafts (Fig. 4.5.6). A universal
These are compared to duction examinations per- orbital floor plate (see Fig. 1.20 and Fig. 4.5.6b) should
formed before the surgical dissection and after the sur- be cut to the minimum size required. The use of a tem-
gical dissection. In this manner stiff duction examina- plate may be appropriate for contouring.
tions from muscle contusion or edema can be distin- It should be emphasized that all internal orbital
guished from impingement of the musculofibrous plates require contouring, trimming of redundant
Fig. 4.5.5 Fig. 4.5.6 a, b
▼
Enlargement of medial orbital wall is seen by comparison of When extensive defects of both the floor and medial orbital
the width of the ethmoid cells in a CT scan. Several layers of wall exist simultaneously, a strut of stable fixation material
bone grafts are placed in the medial orbit area through a coro- such as an orbital wall plate (a) or an orbital floor plate (b) may
nal incision to provide thickness equal to that of the normal be required for stable positioning of the grafts. Alternately, a
ethmoid region contralaterally. graft can be linked to the orbital rim with a small plate which
allows supervision of position of the remainder of the grafts
(a).
wings, and anchoring tabs. All the wings cannot be left
intact; most of the anchoring tabs should be trimmed
except the exact minimum fixaton points desired. The
use of titanium implants or plastic sheets in large orbi-
tal defects exposed to the maxillary and ethmoid sinuses 4.5.5 Zygomatic (Lateral and Inferior Wall) Injuries
permits the possibility of a late infection. With titanium
plates the first infections were observed more than Zygomatic fractures involve injuries to the lateral and
1 year after implantation. Therefore the use of autoge- inferior portion of the orbital rim. The zygoma must be
nous bone alone is preferred where possible as late stabilized accurately by aligning it with all of its neigh-
infection is rare. Metallic implants cannot be considered boring bones. A small increase in the size in the orbital
a routine substitute for the use of autogenous material rim diameter produces a dramatic increase in orbital
unless no other solution is possible. volume; stabilizing the dimensions of the orbital rim
There are two varieties of internal orbital plates. One controls orbital volume. Therefore it is important to
is used for medial wall defects (see Fig. 1.20, 4.5.6a) and achieve an exact zygomatic reduction which stabilizes
one for inferior wall defects (see Fig. 1.20, 4.5.6 b). the orbital volume.
b
Generally the lower and lateral portions of the orbit approaches (see Fig. 2.5). Nasoethmoid fractures may be
are exposed with a lower lid incision. Either a skin-mus- either unilateral or bilateral. The injury is managed by
cle flap, or a transconjunctival incision with a lateral first dislocating the canthal bearing fragment laterally
canthotomy are preferred to incisions lower in the lid. and anteriorly (the attached canthal ligament should not
Both the lower and lateral orbit can be explored through be stripped in the reduction). Holes are drilled to link
this incision. this area loosely by interfragment wires to adjacent
The superior and upper medial portion of the orbit bone. The most important maneuver is to place two
must be approached with a coronal incision. Anterior wires posterior and superior to the lacrimal fossa for use
approaches alone may suffice for noncomminuted and as a transnasal reduction. This is the most important
medially displaced zygomatic fractures (a subciliary step in stabilizing a nasoethmoidal orbital fracture, as
skin-muscle flap and a gingivobuccal sulcus incison). the transnasal reduction of the medial orbital rims sta-
The lateral canthus may be detached to allow inspection bilizes the intercanthal distance (see Fig. 4.3.3b). Once
of the lateral orbit for a comparison of alignment of the all the nasal and medial orbital bones are linked to one
orbital process of the zygoma with the greater wing of another and linked transnasally, the wires are tightened,
the sphenoid. Conceptually, for grossly displaced and and the entire assembled segment of fractures is then
comminuted fractures, four articulations are visualized stabilized to adjacent bones with “junctional” rigid fixa-
for a zygomatic open reduction: the zygomaticofrontal tion. Practically, it is impossible to overcorrect bony
suture, inferior orbital rim, lateral wall of the orbit, and intercanthal distance.
maxillary buttress (through a gingival buccal sulcus
incision). The lateral canthus should be reattached at the
close of the procedure. The exploration of the lateral and 4.5.7 Superior Orbital Rim and Roof Fractures
inferior portions of the internal orbit is a component of
every zygomatic fracture reduction. Fractures in the area of the frontal bone and orbital roof
If a coronal incision is not used, the zygomatic arch are less common than zygomatic and nasoethmoidal
may require a separate temporal (Gillies’) reduction fractures. They are frequently seen in children. They
maneuver if medially displaced. No direct open reduc- may involve the frontal sinus or portions of the frontal
tion is required for medially displaced arch fractures. bone. Neurosurgical exploration requires bone removal.
When the zygomatic arch is laterally displaced, a coro- Bone segments should be marked in sequence as they
nal incision (see Fig. 2.5) is required. The coronal inci- are removed as a guide to their reassembly. Frontal bone
sion allows exposure for stable fixation of the zygomatic segments can be harvested for bone graft by section of
arch. Placing a bone hook (see Fig. 4.4.1, inset) beneath the internal table. These procedures can be performed
the malar eminence permits strong anterior traction on on a back table while neurosurgery is in progress. Once
the zygomatic body to achieve reduction. The arch, if the neurosurgeons have completed dural repair, the seg-
opened, should be reduced as flat as possible. Indeed, it ments, reassembled on a back table and stabilized either
is not an arch, as it is flat in its middle portion. Achiev- with wires or plates and screws, are placed into the
ing the proper straight reduction of the zygomatic arch defect. Remnants of frontal sinus mucosa are removed
reduces midface width and improves the anterior pro- and intra sinus bone grafts placed to reconstitute the
jection of the zygoma. anterior cranial floor. The frontal bone fragments are
replaced following orbital roof reconstruction. The roof
is stabilized by rigidly fixing a bone graft to the frontal
4.5.6 Naso-Orbital-Ethmoid Fractures bar. The orbital roof should not be reconstructed by
placing bone graft within the orbit, but by placing bone
The complex anatomy of nasoethmoidal orbital fracture graft targent to the normal position of the roof. The pre-
reduction makes this one of the most difficult of facial cise reconstruction of each internal orbital wall is
fractures to manage (see also Sect. 4.3). The simplest related directly to proper globe position.
nasoethmoid injury is fracture of the medial orbital rim.
The frontal process of the maxilla is therefore dislo-
cated. The simplest fractures show dislocation only at
the inferior orbital rim and pyriform aperture. In these
injuries the junction of the frontal process of the maxilla
with the internal angular process of the frontal bone is
undisplaced; therefore the areas requiring open reduc-
tion are visualized by subciliary and gingival buccal sul-
cus incisions.
If the medial orbital rim is dislocated at all its articu-
lations, reduction is achieved by coronal and inferior
Antonyshyn O, Gruss JS, Galbraith DJ et al (1989) Complex

orbital fractures. A critical analysis of immediate bone graft
reconstruction. Ann Plast Surg 22:220–233
Glassman RD, Manson PN, Vander Kolk CA et al (1990) Rigid
fixation of internal orbital fractures. Plast Reconstr Surg
86:1103–1104
Hammer B (1995) Orbital fractures. Diagnosis, operative treat-
ment, secondery corrections. Hogreve & Huber, Bern
Manson PN, Clifford CM, Su CT et al (1986) Mechanism of glo-
bal support and posttraumatic enophthalmos. I. The anat-
omy of the ligament sling and its relation to intramuscular
cone orbital fat. Plast Reconstr Surg 77:193–214
Markowitz BL, Manson PN, Sargent L et al (1991) Management
of the medial canthal tendon in nasothmoidal fractures: the
importance of the central fragment in classificaiton and
treatment. Plast Reconstr Surg 87:843–853
Mathog RH, Hillstrom RP, Nesi FA (1989) Surgical correction of
enophthalmos and diplopia. A report of 38 cases. Arch Otol-
aryngol Head Neck Surg 115:169
Pearl RM (1987) Surgical management of volumetric changes
in the bony orbit. Ann Plast Surg 19:349–358
Phillips JG, Gruss JS,Wells MD, Chollet A (1991) Periosteal sus-
pension of the lower eyelid and cheek following subciliary
exposure of facial fractures. Plast Reconstr Surg 88:145–148
Romano JJ, Wellisz T, Manson PN et al (1993) Experience with
porous density polyethylene implants in 97 patients with
facial fractures. J Craniofac Surg 4:142–147
Sullivan WG (1991) Displaced orbital roof fractures: presenta-
tion and treatment. Plast Reconstr Surg 87:658–661
Wolfe SA (1982) Application of craniofacial surgical precepts in
orbital reconstruction following trauma and tumor
removal. J Maxillofac Surg 10:212–213
Fig. 4.6.1 a, b
▼
4.6 Cranial Vault a Anterior view of frontal sinus. The two sides are asymmet-
ric, and the sinus may be also divided by lateral septae. The
nasal frontal duct orifice usually empties into the nose by a
Contributors: Patrick Sullivan short, funnel-shaped channel.
Paul N.Manson b Classification of frontal sinus fractures is by involvement of
the anterior table (Inset 1), posterior table (Inset 2) and nasal
frontal duct (Inset 3). Fractures are either nondisplaced or
4.6.1 Frontal Sinus and Frontal Bone displaced for each location.
The frontal sinus is a respiratory epithelial-lined cavity Any of these fractures may have nasofrontal duct injury
situated superior to the bony orbits and anterior to the (Hoffman and Krause 1991), and if so, operative inter-
frontal lobes (Fig. 4.6.1a). It is irregular in shape, asym- vention is preferred as sinus function following duct
metric, and is divided in the midline and often laterally injury is not predictable.
by irregular sinus septae. The sinus has been postulated
to serve a protective role for the ocular globes and the
frontal lobes. The location of the sinus adjacent to the 4.6.3 Sinus Function and Operative Treatment
cranial cavity makes inadequately treated injury to the
frontal sinus have grave consequences (Newman and There is general agreement that isolated nondisplaced
Travis 1973). anterior table fractures can be managed nonoperatively
Frontal sinus fractures can be classified by the ana- without significant sequelae. Displaced anterior table
tomic involvement of the anterior table, posterior table, fractures are usually explored and the displaced frag-
and nasofrontal duct. Fractures are either displaced or ments elevated with minimal manipulation of mucosa.
nondisplaced for each location (Fig. 4.6.1b). These inju- Sinus function may be preserved in these injuries in the
ries occur as isolated entities or in any combination with absence of nasofrontal duct injury. Injury to nasofrontal
other fractures. Clinical signs and pattern of injuries to duct or orifice is determined by radiographic character-
the anterior and posterior tables and nasofrontal duct, istics of the fractures, by the presence of fluid in the
visualized in radiological studies, are used to determine sinus (which implies absence of ductual function), and
appropriate treatment, operative or nonoperative (Stan- by visual inspection of the duct at surgery. Dye, saline, or
ley and Becker 1987), and type of operation. contrast studies may be used intraoperatively to assess
duct patency. None of these criteria are absolute as far as
predictability of duct function. The correlation of these
4.6.2 Special Conditions Influencing Open Reduction tests with clinical function has yet to be established.
and Internal Fixation
There have been multiple attempts to establish a corre- 4.6.4 Types of Fixation
lation of radiological findings with intraoperative find-
ings and the degree of injury in order to develop (Stan- Fragmentation of the anterior table is reconstructed
ley 1989) protocols for the various types of frontal sinus either with 1.0 microplates or the 1.3 system (Fig. 4.6.2),
fractures. Classification systems usually divide frontal depending on the strength required, to provide the best
sinus fractures into the following categories: cosmetic result. If the anterior wall is excessively frag-
mented, the bone pieces may be discarded and replaced
∑ Anterior table, displaced or nondisplaced with a bone graft (Fig. 4.6.3).
∑ Posterior table, displaced or nondisplaced There is significant disagreement on management
∑ Anterior and posterior table, displaced or nondis- strategy in the presence of posterior table fractures. The
placed
4.5 · Cranial Vault 149
3 b
degree of posterior wall displacement is evaluated on Fig. 4.6.2

preoperative radiological studies, and the need for sinus The contour of the frontal bone may be templated on the non-
exploration is determined by experience and the prob- fractured side; bone fragments are stabilized with plate and
screw fixation. Better contour and projection are established by
ability of damage to the dura and the possibility of sinus stable fixation than by wires because the bone fragments may
obstruction. be expanded and elevated to ensure proper contour. Recon-
The thickness of the posterior table has been used as struction of frontal sinus fractures with 1.3 plates. The plates
the limit of acceptable posterior wall displacement in should be bent to reproduce the convex contour.
which nonoperative management may be considered
(Rohrich and Hollier 1992). Some authors, however, for operative exploration. The dural tear is directly
believe that the presence of posterior table fractures, closed. When the dural closure is weak, the closure is
regardless of amount of displacement, requires an buttressed by a fascial graft and fibrin glue (Levine et al.
exploration of the sinus to rule out associated injury to 1986). In frontal sinus fractures with associated cranio-
the nasofrontal duct and dura which are difficult to facial injuries the approach has been to manage the
appreciate on radiographic studies (Fig. 4.6.4; Donald sinus simultaneously with other craniofacial injuries.
1986). Sinus infection or obstruction may lead to men- The technique of cranialization is preferred. The resis-
ingitis or intracerebral abscess and may result in serious tance of the frontal sinus to fracture is several times
morbidity if a nasofrontal duct injury is not appreciated greater than in midfacial areas of the craniofacial skele-
and managed. These considerations are cited as reasons ton but less than that of the surrounding frontal bone.
for operative inspection of any posterior table frontal This implies that there is a significant chance of asso-
sinus fracture. ciated injuries when injury to the frontal sinus is identi-
A CSF leak in a displaced fracture is a clear indication fied.
Fig. 4.6.3 ity in combined extensive fractures of the midface and

When the anterior table is excessively comminuted, the frontal cranium (Fig. 4.6.5). If the bone is comminuted,
esthetic result is improved by use of a bone graft to reconstruct bone grafts are used to fill in the defects and are stabi-
the entire anterior sinus wall. It is stabilized with either the 1.3
or microsystem. lized with screw fixation to the plates (Fig. 4.6.5). Final
contouring is then performed with a shaping burr.
4.6.5 Esthetics 4.6.6 Osteotomy
The normal forehead and cranial vault shapes are easily Fractures which are very significantly impacted, or
reconstructed with plate and screw fixation, especially which have already begun to heal may be freed and
when compared to wires. Better contours and projec- mobilized by craniotome following access incisions with
tions are established (see Fig. 4.6.2); bone gaps may be burr holes.
established when expanding the bone vault to its proper Bone flaps are often required to provide exposure for
contour. Bone grafts may be used to replace commin- dural intracranial injury management. Plate and screw
uted bone segments. fixation proves helpful in stabilizing these bone flaps to
One can bend 1.3 plates to recreate the shape of the promote rapid healing and provide optimal esthetic
normal forehead (see Fig. 4.6.2). Microplates are less vis- results.
ible beneath the soft-tissue cover of the forehead. The
thicker miniplates are occasionally necessary for stabil-
Fig. 4.6.4
4.6.7 Exposure Technique of sinus obliteration is demonstrated on insets.
Inset a: The sinus mucosa is removed.
Inset b: The intra sinus bone cortex is removed with a high
The coronal incision (see Fig. 2.5) gives excellent expo- speed burr. The posterior table is inspected for fracture and
sure and is optimal for access to the nasofrontal duct, dural integrity confirmed. Rigid fixation may stabilize pos-
posterior table, and intracranial region. Exploration of terior wall or bone graft segments.
the frontal sinus may also be performed via several Inset c: The nasal frontal duct is occluded with a bone graft.
other approaches. In very limited fractures the sinus can Inset d: The sinus cavity is filled with particulate bone, taken
from the calvarium with a neurosurgical perforator. The
be accessed through a laceration or a local incision. sinus is fully packed with particulate cancellous bone mate-
Local approaches permit only limited visualization rial. The anterior table is reassembled with stable fixation.
(sometimes of an ipsilateral sinus) and may not allow
bilateral assessment of nasofrontal duct injury. Dye
studies can be used to determine duct patency by the dict that the probability of duct function is low. Sinus
appearance of the contrast material in the nose. In cases obliteration (see Fig. 4.6.4) requires:
of bilateral frontal sinus fractures and in all severe inju-
ries the preferred approach employs a coronal incision 1. Removal of all sinus mucosa
with removal of at least the anterior table. 2. Removal of inner sinus bone cortex by high speed
Sinus obliteration is indicated when nasofrontal duct burr
injury or wall displacement implies sinus nonfunction, 3. Reapproximation of the displaced posterior table ele-
or when anterior and posterior table sinus fractures pre- ments and fixation, or removal
Fig. 4.6.5 the procedures (as in any duct reconstruction tech-

Cranialization of a frontal sinus fracture requires removal of niques) are unpredictable. If extensive comminuted
the mucosa, removal or replacement of the posterior wall, and fractures of the posterior table prevent adequate recon-
reconstruction of the anterior wall. Occasionally a galeal-fron-
talis flap is used to improve the seal between the nose and the struction of the posterior table, the frontal sinus may be
intracranial cavity. The floor of the frontal sinus and the floor cranialized by removal of the posterior table to permit
of the anterior cranial fossa must be extensively bone grafted expansion of the frontal lobes into the new space, a pro-
with layers of “formed to fit” calvarial bone grafts. The brain is cess which takes several months (see Fig. 4.6.5).
slowly able to expand to fill the defect. The diagnostic and treatment strategies for frontal
sinus fractures have undergone significant evolution.
Short- and long-term complications suggest that the
4. Occlusion of the nasofrontal duct with a “formed to more aggressive management strategy produces the
fit” calvarial bone graft best results. The lack of large, well-controlled studies
5. Filling of the sinus cavity with particulate bone, allows the selection of one treatment plan over another
packing the sinus fully to allow osteogenesis to occur to be based more on personal preference than on scien-
6. Replacement of the anterior table with stable fixation tific findings.
It is sometimes maintained that in cases of duct injury

the duct can be reconstructed (via the Sewal-Boyden
mucosal flap) to maintain patency or by stint duct intu-
bation (Prolo and Duvall III 1986; Luce 1987); however,
Donald PJ (1986) Frontal sinus fracture. In: Cummings CW,

Fedrickson JM, Harker LA, Krause CJ, Schuller DE (eds)
Otolaryngology – head and neck surgery. Mosby, St. Louis.
pp 901–921
Hoffman HT, Krause CJ (1991) Traumatic injuries to the fron-
tal sinus. In Fonseca RJ,Walker RV (eds) Oral and maxillofa-
cial trauma, vol 1. Saunders, Philadelphia, pp 576–599
Levine SB, Rowe LD, Keane WM et al (1986) Evaluation and
treatment of frontal sinus fractures. Otolaryngol Head Neck
Surg 95(1):19–22
Luce LA (1987) Frontal sinus fractures: guidelines to manage-
ment. Plast Reconstr Surg 80(4):500–508
Newman MH, Travis LW (1973) Frontal sinus fractures. Laryn-
goscope 83:1281–1292
Prolo DP, Duvall III AJ (1986) Long-term results with nasofron-
tal duct reconstruction. Laryngoscope 96:858–862
Rohrich RJ, Hollier lH (1992) Management of frontal sinus
fracture – changing concepts. Clin Plast Surg 19:219–232
Stanley RB (1989) Fractures of the frontal sinus. Clin Plast Surg
16:115–123
Stanley RB,Becker TS (1987) Injuries of the nasofrontal orifices
in frontal sinus fractures. Laryngoscope 97:728–731
Chapter 5 155
Reconstructive Tumor Surgery in the Mandible 5

Chapter Author: Douglas W.Klotch
Contributors: Douglas W.Klotch
Christian Lindqvist
Mark A.Schusterman
Joachim Prein
5.1 Diagnosis 5.2 Patient Selection
Aside from benign and malignant odontogenic and Benign mandibular tumors or tumorlike lesions are
osseous lesions of the mandible, tumors involving the generally discovered in the younger population with
mandible are usually squamous cell cancers arising dentition. Therefore discussion of patient selection is
from the oral mucosa. The majority of patients present- more relevant to the cancer patient. The mandible sup-
ing with these cancers to the head and neck surgeon ports the lower dental arch, the tongue and floor of the
have an extensive lesion which is identifiable on the head mouth structures, and the muscles for position and
and neck examination. Generally confirmation of the function of the lower lip. It therefore functions to pro-
pathology is readily obtained with biopsy and routine vide mastication and maintain support of the oral cav-
pathological examination. Primary tumors of the man- ity and oral pharyngeal airway, and it is necessary for the
dible are less common. Both these and metastatic lesions insertion of the tongue and floor of the mouth muscula-
may require more extensive open biopsy to confirm the ture required for the initiation of swallowing and artic-
diagnosis. Benign tumors of the mandible are either ulation of speech. Mastication is a complex function
found incidentally by routine dental radiography or which requires the interaction of synergistic and non-
present as a palpable mass with or without dental com- synergistic muscle function. The muscle function varies
plaints. Loss of inferior alveolar nerve function is sel- through the full range of motion which is provided by
dom seen even with larger tumors, unless there is exten- the temporomandibular joint. The temporomandibular
sive mandibular involvement. joint allows deviation, translocation, and hingelike
When oral cancer is suspected, a routine head and opening. Maintenance of condylar positioning is essen-
neck examination to evaluate the oral cavity, oropha- tial for pain-free mandibular motion and function.
rynx, nasopharynx, hypopharynx and larynx, and neck The mandible is a conduit for the third-division sen-
is indicated. Careful assessment of cranial nerve func- sory branch of the fifth cranial nerve which provides
tion is mandated, specifically loss of function of the infe- sensation to the lower dental arch and the skin above the
rior alveolar nerve (V3). Loss of lingual nerve, facial chin. In proximity in the surrounding soft tissues are the
nerve, or hypoglossal nerve function is usually found motor branches for mastication (V3), the sensory
only with more advanced primary oral cancers. Lesions branches to the floor of the mouth and the anterior
which involve the mandible are by definition T4,stage IV tongue, the mimetic muscles of the lower face, and the
oral cancers, and radiographic examination should hypoglossal nerve supply to the tongue. Violation of
include the chest. One can argue the merits of including these neural structures and the soft tissues and muscles
computed tomography (CT) of the chest and mediasti- which they supply is generally more important in deter-
num for advanced disease; however, a minimum of a mining function following tumor ablation than is bone
chest X-ray is required to examine the chest for poten- loss alone. If the anterior mandible is not removed, the
tial metastatic disease or synchronous primary disease. oral function may be adequate regardless of the size of
Generally a panorex view of the mandible is adequate to the bony defect as long as motor and sensory function is
assess mandibular disease. CT examination with bone not significantly altered. The anterior mandible, how-
windows may help to clarify more subtle mandible ever, is essential to provide support for the lip, floor of
involvement but is generally not needed. Bone scans are the mouth, and tongue. Failure to provide this support
very sensitive, but not specific to determine bone produces an oral cripple with speech, swallowing, and
involvement and as a rule are not ordered. Magnetic res- cosmetic disability characterized by the “Andy Gump”
onance imaging (MRI) gives very good soft tissue ima- deformity.
ges, however disease within the bone is not well demon- The pathological process and extent of disease deter-
strated. mines the amount of bone and soft tissue to be resected.
156 Chapter 5 · Reconstructive Tumor Surgery in the Mandible
Once this is determined, the treatment including adju- geon should communicate his preference to the anesthe-
vant therapy can be planned. Generally patient selection siologist. Tracheostomy is mandated for patients with
becomes a problem only when extensive resection for poor pulmonary status. It is generally required for dis-
malignancy is anticipated. Although osseous free flaps sections that extend to the posterior oral cavity or
ultimately promise the best functional result, their oropharynx and is more commonly needed when exten-
increased operating time adds to the potential morbi- sive bilateral neck dissection is required. It is never
dity and mortality in high-risk patients. The surgeon wrong to perform a tracheostomy, and if there is any
may choose to provide only soft-tissue closure for lateral doubt about the patient’s airway or pulmonary status, it
defects if the patient’s general health is poor. Anterior is safer for the patient to opt for tracheostomy.
defects pose a different problem. Higher incidence of
plate extrusion and wound complications are certainly
anticipated if immediate vascularized bone repair and 5.3 Description of Procedures
appropriate soft-tissue cover is not performed. The sur-
geon may have to accept this problem in high-risk 5.3.1 Mandibular Osteotomy
patients to avoid potential severe morbidity or mortal-
ity. Performing an osteotomy within the mandible may be
Patients who have significant pulmonary disease,car- required to obtain surgical access either for the tumor or
diac disease, or nutritional deficiency should be medi- for the reconstruction. Access to the lateral skull base
cally maximized before attempting extensive resection. and the lateral nasopharyngeal region may require dis-
Generally patients who can walk a flight of stairs with- placement or condyle removal to facilitate exposure.
out discomfort can tolerate surgery. Rapid attention to Lateral mandibulotomies can improve access to the par-
nutritional support is mandated, and since many apharyngeal space. Midline or paramedian mandibulot-
patients require extensive postoperative radiotherapy a omies enhance exposure to the oropharynx, anterior
PEG tube may be considered in extreme cases. Extreme medial skull base, and the parapharyngeal space. The
substance abuse and psychosocial dysfunction must fre- selection of the surgical approach is frequently related
quently be addressed. Such patients are often compli- to the tumor type, location, and the physician’s prefer-
cated by poor nutrition, poor dental care, poor general- ence. Certain guidelines are essential to minimize com-
ized health, and alcohol and tobacco abuse and require plications with these approaches since the osteotomy
team support to optimize care. Aggressive dental care is site cannot be equated with a fracture.
mandated for all patients requiring radiotherapy. Fol- Anterior midline or paramedian (anterior to mental
lowing this careful assessment of the tumor the patient’s foramen) mandibulotomy is usually performed in con-
general condition and preoperative function and the junction with a lip-splitting incision. Although this can
discussion of the surgery and rehabilitation, the surgeon be achieved without splitting the lip, a more extensive
may proceed with the treatment plan. This usually denuding of the mandible is required to displace the
includes a family consultation to allow optimal care for superior visor flap adequately to allow the osteotomy to
the patient. improve the exposure. Some microvascular surgeons
Most surgeons choose a course of antibiotic therapy prefer the anterior mandibulotomy approach to facili-
for patients undergoing mandible resection. For less tate soft-tissue free-flap placement in patients not
extensive benign cases a prophylactic course given on requiring mandibular resection. Osteotomies are gener-
call to surgery and for the first postoperative day is suf- ally made between the central incisors or between
ficient. When more extensive resection with elaborate canine and first premolar. This preserves sensory func-
reconstruction is performed, most surgeons use a ther- tion of the inferior alveolar nerve. The anterior surface
apeutic course of the same antibiotics. This regimen of the mandible is dissected to allow placement of a
provides an on-call dose with at least a 5-day postoper- seven- or eight-hole bridging plate (a reconstruction
ative antibiotic coverage. plate, either a THORP or UniLOCK, may be used). It is
A general anesthetic is required. Generally patients helpful to remove the inferior projection of the mental
can be intubated via either an orotracheal or nasotra- process with a cutting burr (see inset Fig. 5.1a). This
cheal route. The preference should be discussed between greatly simplifies plate bending and does not interfere
the surgeon and the anesthesiologist. The nasotracheal with the stability of the fixation since the bone in this
route provides the most exposure without interference region is dense and thick.
in the operative site. This is more time consuming to A template is contoured to the anterior inferior sur-
deliver and may be difficult if there are extensive septal face of the mandible to allow precise plate bending with-
deformities. Epistaxis can be an annoying complication out overmanipulating the plate. The plate is positioned
of nasotracheal intubation. It is preferable not to have inferior to the mental nerve and should be contoured to
the patient paralyzed when operating to allow observa- precisely fit the mandible. Although plates such as the
tion of the motor nerve function (i.e.,VII, XII). The sur- THORP and the UniLOCK plate do not require compres-
5.3 · Description of Procedures 157
Fig. 5.1 a–c
▼
a Placement and fixation of a seven-hole reconstruction plate
prior to performing the ostotomy.
Inset: Removal of inferior bony projection at the mental pro-
cess with a burr to simplify plate application in this area.
b Mandible after midline osteotomy. On both sides of the oste-
otomy three provisionally placed screw holes are visible.
c Fixation of the osteotomized mandible with a seven-hole
reconstruction plate, fixed with three screws on each side.
The innermost screws are placed well away from the osteo-
tomy.
sion of the plate against the bone surface to provide

stability, they still require reasonably precise bending. If
there is a significant gap between the plate and bone at
a several areas, it is possible to distort the ends of the man-
dible with resultant malocclusion as the THORP screws
are tightened. The UniLOCK system uses no compres-
sion between screwhead and plate hole. The locking
mechanism is achieved through a second thread under
the screwhead which engages in the plate hole. Nearly
perfect contouring of the standard reconstruction plate
is required to avoid malpositioning of the mandible by
screw placement since screws without locking mecha-
nism press the plate against the surface of the bone (see
also Fig. 1.28b–d).
Two bone screws are initially placed in either end of
the mandibular plate to prevent its displacement during
the drilling process (Fig. 5.1a). The residual screw holes
are drilled and tapped (if necessary), having premeas-
ured and recorded all screw lengths. The screws are then
removed, marking the end of the plate with a suture to
ensure correct orientation for plate reapplication. All
screws and hole lengths are properly marked on a dia-
gram. Care must be taken when self-tapping screws are
used. If possible they should only be placed once. If they
b are placed a second time, careful insertion along the
same axis of the previous placement is necessary in
order not to distort the existing threaded bone hole. The
osteotomy and surgical resection are performed
(Fig. 5.1b).
If radiotherapy is planned postoperatively, and an
incisor tooth root is exposed or lost, the tooth should be
removed to prevent subsequent infection which may
lead to osteoradionecrosis. It is helpful to keep the inner
screw holes empty using only the outer three screw holes
for radiated patients to decrease screw complications.
This is an individual judgement based on the proximity
of the hole to the osteotomy and the character of the
bone in combination with the quality of the soft-tissue
closure. Screws should be placed in all remaining screw
holes (Fig. 5.1c). If using the reconstruction plate, the
screws are placed in the neutral position. The osteotomy
site should not be placed under compression as maloc-
clusion and mandibular distortion may result. If screws
c are not secure in the bone, they should be removed.
Emergency screws may be positioned in these holes if radiographs prior to removal generally allows adequate
the plate system offers this option.Although the THORP plate length selection. A template is prebent to the con-
and UniLOCK plates are more forgiving of small bend- tour of the mandible, planning an adequate number of
ing errors, even they can distort the mandibular repair if screw holes in each stump. It is preferable to plan the
bent unprecisely. If this is noticed, the plate should be first screw to be placed at least 1 cm away from the tumor
removed and correctly bent to normalize the occlusal margin. This allows some leeway to account for possible
relationship and condylar position. miscalculation of the tumor size when selecting the
Lateral osteotomies may be performed without lip- plate length. If the benign tumor extends anteriorly, the
splitting incisions. Plate application follows the same anterior cortex may be burred away to allow the plate to
principles as for medial mandibulotomies. It is impor- be adapted to the mandible. It is better to plan for addi-
tant not to apply compression to these osteotomies since tional plate length when selecting the plate since it is far
occlusal disturbances result. In the case of radiated easier to shorten a plate than to reapply a new plate
patients compression is also not advised since bone because the one selected was too short.
integrity is essential for plate stability, and bone density Once the plate is adapted, the plate is held in place
is diminished secondary to the diminished vascular sup- with the plate-bone holding forceps. Holes are drilled,
ply of the mandible from the surgical approach and and the screw lengths are measured and recorded on a
radiotherapy. Lateral osteotomies are more susceptible diagram. After the placement of the plate it can gener-
to failure when bridging plates are not used since the ally be left in place during the removal of the lesion. If
vascular supply (facial artery) to the periosteum and the plate placement interferes with adequate removal, it is
nutrient vessel supply are normally interrupted. There is removed. The orientation of the plate may be marked
also less muscle vascularity to revascularize the body of with a suture and then the lesion adequately curretted or
the mandible than in the region of the chin. The THORP resected. If the mandible is fractured during removal,
and UniLOCK plate systems do not produce compres- the patient does not have to be placed in intermaxillary
sion and simplify this application process. fixation since the prebent plate has reestablished the
correct mandibular position, which is maintained once
the plate is secured into position. (This procedure is
5.3.2 Stabilization of Curetted Mandibular Defects comparable to that described in the following section;
see Fig. 5.3a–c). Cancellous bone may be used to fill the
A variety of benign disease processes such as dentiger- bone defect either prior to or after plate application
ous cysts (Fig. 5.2a), giant cell granulomas, and fibro- (Fig. 5.2c,d). If there is an incidental fracture, the bone
osseous lesions may be adequately treated by curettage graft is best applied after the plate is positioned, and the
and cleaning with a burr or by partial resection without mandibular contour and length is reestablished.
segmental resection of the mandible. Extensive cortical If the surgical approach was extraoral, prophylactic
thinning by the disease process or its removal may pro- antibiotic therapy is adequate since subsequent infec-
duce instability of the mandible. Large defects may be tion by intraoral contamination is unlikely. If an intra-
grafted primarily with autogenous cortical and cancel- oral approach was used, a therapeutic course of antibio-
lous bone which is frequently taken from the iliac crest. tics is preferred since intraoral contamination is
However, this does not provide immediate stability for present. Successful bone grafting via an intraoral
the weakened mandible. If a fracture of the mandible approach depends on a reliable closure of the oral
appears during the procedure, or there is suspected mucosa.
instability of the mandible, a bridging plate may be used Patients are placed on a blenderized diet for 2 weeks.
to protect or stabilize the area of the lesion. If the frac- Fastidious oral care is mandated for intraoral
ture occurs at the time of the procedure, the patient may approaches to prevent wound breakdown and subse-
be placed into intermaxillary fixation and the bridging quent infection. If patients are noncompliant, it may be
plate applied without compression in the same manner necessary to use a nasogastric feeding tube to ensure
in which one would fix a fracture with bone loss or com- proper wound healing.
minution. If a reconstruction plate is used to repair this
defect, a minimum of three or preferably four screws are
fixed at each segment (Fig. 5.2 b–d). If one selects the
THORP or the UniLOCK plate to repair this defect, only
three screws are required at each mandibular end to
achieve adequate stability.
When the procedure is planned in an atrophic man-
dible or extensive curettage is anticipated, it is preferable
to prebend the plate to the mandible contour prior to the
removal of the lesion or the tumor. Evaluation of the
Fig. 5.2 a–d

a Cystic lesion in a left mandible, appearing like a follicular 5.3.3 Segmental Resection for Benign Tumors
cyst. Within the cyst wall, however, an ameloblastoma was
found.
b The cyst had thinned the cortical walls and weakened the Benign tumors or tumorlike lesions, such as ameloblas-
mandible so that the reconstruction plate was fixed prior to toma, giant cell granuloma, keratocysts, and myxomas
the removal of the lesion. may require segmental resection of the mandible. Resec-
c After removal of the leasion, the bone defect was filled with tion of these tumors usually does not require sacrifice of
cancellous bone taken from the iliac crest. the mucosa unless the tumor occurs in the tooth row or
d Same situation as in Fig. 5.2c on X-ray. Note fixation of the
reconstruction plate with four screws on each side. The plate
in the soft tissues. Likewise, patients do not require adju-
should be removed only on special request. vant radiotherapy. Both these factors allow optimal con-
ditions for bone and soft-tissue healing. The surgeon
may choose the option of using primary nonvascular-
ized bone to repair these defects with an expected suc-
cess rate exceeding 90%.
Appropriate planning prior to resection is essential to
avoid selection of a plate that is too short to stabilize the
a b
c d
defect. Depending on the local situation a UniLOCK or Fig. 5.3 a–e

THORP plate can be used. The preoperative radiographs a Placement and provisional fixation of the reconstruction
(panorex) provide adequate information to determine plate prior to resection of the chin area.
b Situation after removal of the chin area. Two screw holes
the extent of the resection. Sometimes the lesion extends
within each lateral segment are visible.
further than anticipated and requires additional bone c Reapplication of the reconstruction plate after removal of
removal. If one plans to place the first screw 1 cm from the tumor and fixation with five or four screws on each side.
the planned osteotomy with at least four screws in each d Same defect as in c after insertion of a nonvascularized cor-
segment, incorrect plate selection is unlikely. Exposure ticocancellous bone graft of the iliac crest.
is obtained with an upper cervical incision carefully pre- e Same situation as in d. After resection of an anteriorly
located ameloblastoma primary reconstruction with a non-
serving the mandibular branch of the facial nerve. The vascularized bone graft was performed. Note that there is no
buccal periosteum is elevated, exposing the mandible screw fixation for the bone graft. On the left side the first
surface. A template is used to select the correct plate screw was placed too close to the osteotomy line.
length and to facilitate plate bending. If the plate is to be
bent over the mental region, shaving down the inferior
projection of the mental process with a cutting burr the residual screw holes. The remaining screw holes may
helps to simplify plate application (see inset of Fig. 5.1a). be drilled before or after removal of the tumor
This should not be performed with tumors extending (Fig. 5.3a). The plate is removed and labeled for reappli-
into this area. cation following the tumor resection (Fig. 5.3 b). Care is
The correctly adapted plate is fixed with at least two taken to free the mucosa and periosteum along the
screws in each segment to ensure proper placement of alveolar surface to avoid entering the oral cavity if pos-
sible.When the resection is within the row of teeth, entry mucosa opens up postoperatively. If bone grafting is
into the oral cavity is unavoidable. Following the resec- successful, a titanium plate need not be removed if it
tion the plate is replaced in the correct location to ana- does not disturb the patient. After full incorporation of
tomically repair the defect (Fig. 5.3c). Precise plate the bone graft and therefore closure of the bony defects
bending and handling of the plate guarantees correct because of the continuous bone remodeling, the plate is
positioning of the mandibular stumps. Significant dis- neutralized and does not cause any stress protection.
tortion would require placing dentate patients in IMF
and recontouring the plate to precisely position the
mandible. The plate is replaced and IMF is removed. The 5.3.4 Plate Application for Tumors with Extension
occlusion and mandibular position are rechecked. The Through the Anterior Buccal Cortex
mandible is put through a range of motion to ensure that
there is no deviation or dislocation of the condyle, and Benign tumors occasionally extend anteriorly through
that the occlusion continues to remain correct. When the buccal cortex. This prevents accurate prebending of
correct, the IMF may be released and the arch bars the plate to the mandibular contour without violating
removed. the tumor. There are several possible ways to solve this
The placement of a free nonvascularized bone graft problem. The patient may be placed in IMF prior to
immediately after resecting the tumor is acceptable only resection. If the resection is within the row of teeth,
under the conditions that closure of the oral mucosa is replacing the patient’s IMF following resection aligns
easy, and that no dehiscence is to be expected the mandible for correct plate bending and application.
(Fig. 5.3d,e). Most free bone grafts are lost if the oral If the resection extends proximal to the teeth, precise
c d
positioning of the condyle cannot be achieved by this Fig. 5.4 a–d

method alone. A Mandible Fix Bridge (Fig. 5.4) or man- a Placement of a fixation device prior to resection of the ante-
dibulomaxillary fixation with miniplates (2.0; Fig. 5.5) rior part of the mandible.
b Situation after resection. Note: the fixation devices are
or a reconstruction plate (Fig. 5.6) can be placed to placed in different posiltions.On the right side inferiorly and
bypass this anterior tumor extension to allow tumor on the left side on the superior aspect of the mandible.
resection with secondary contouring to the bridging c For the correct reconstruction of the mandible the previ-
plate which subsequently recontours the mandibular ously used bridging bow is reapplied. After that the recon-
defect. struction plate can be bent according to the positioning of
the mandibular stumps, followed by fixation with 2.4-mm
screws.
d After bridging the defect with the plate, the gap may be filled
5.3.4.1 Plate Application for Anterior Tumor Extension with a bone graft.
Using the Mandible Fix Bridge Device
Two base plates with attachment pins are positioned

inferiorly or superiorly on the mandible at least 1 cm
from the planned osteotomy sites. The base plates fit 2.4
self-tapping screws and are readily applied to the man-
dibular surface. The bridging bow is then adjusted by its
universal joints to couple with the attachment pins of
a b
the base plate. Once final adjustments are made, the Fig. 5.5 a–d
bow’s universal joints are rigidly tightened to ensure a Intermaxillary fixation of the mandible to the maxilla with
maintenance of the bow position (see Fig. 5.4a). The miniplates.
b After resection of the tumor the mandibular segments are
clamps are then loosened from the attachment pins. The kept in intermaxillary relation.
bridging bow is removed. The resection of the mandib- c,d (see page 164)
ular tumor is unhindered by the positioning device
(Fig. 5.4b). Following the resection the bow is then reat-
tached to the base plate. The bridging bow reestablishes
the original position of the residual mandibular seg- condylar fixation device is not available,any external fix-
ments with return of normal condylar orientation. A ator of the appropriate size may be used to achieve the
bridging plate (UniLOCK or THORP) can then be bent same function.
precisely to the contour of the mandible to provide pro-
jection at the anterior border of the mandible and stabil-
ization of the mandibular segments (see Fig. 5.4c). The
surgeon may use an alloplastic model to help in the pre-
liminary contouring of the plate. Experienced surgeons
can generally achieve this freehand. The Mandible Fix
Bridge is removed once the reconstruction plate is fit
precisely to recontour the defect (see Fig. 5.4d). If the
c d
Fig. 5.5 c, d the normal portion of the mandible, and the curved por-
c Bridging of the defect with a reconstruction plate (UniLOCK tion of the omega is either superiorly or inferiorly
or THORP). located to avoid the bulging tumor mass (see
d Filling of the bony defect with an autogenous bone graft and
removal of the miniplates. Fig. 5.6a,c). The plate is adapted precisely so that the
legs of the plate correspond to the mandible contour and
thus ensure stable positioning of the mandibular ends
5.3.4.2 Fixation With Miniplates following resection. Two screws are sufficient to fix each
leg into the uninvolved mandible. The plate is then
Further means for establishing an original positioning appropriately tagged and removed. The tumor is
of the mandibular bone stumps are an intermaxillary resected, clearing all the margins. The positioning plate
fixation with miniplates from mandible to maxilla (see is reapplied in the previously drilled screw holes. This
Fig. 5.5). reestablishes the normal anatomic relationships of the
mandible. Since this positioning plate is usually placed
at the superior margin of the mandible, a template can
5.3.4.3 Fixation With a Reconstruction Plate be bent in the middle portion of the mandible, assuring
that at least three and preferably four screw holes are
If one uses a plate to solve this problem, a previously available for each mandibular stump for plate fixation.
used sterilized reconstruction plate may be bent into an After bending a template the reconstruction plate
omega shape such that the legs of the omega attach to (THORP or UniLOCK) is accordingly bent and adapted
c d
Fig. 5.6 a–d 5.3.4.4 Three-Dimensional Computer Modeling

a Positioning of an Omega-like bent used reconstruction plate
for temporary alignment of the mandibular stumps. A three-dimensional computer generated model may be
b For the time of tumor resection the positioning plate may
also be removed. used to preshape the plate in the laboratory. This is an
c Replacement of the positioning plate and adaptation and fix- elegant, but expensive, means of achieving appropriate
ation of the reconstruction plate which bridges the defect. plate contouring. Such models are not immediately
d After removal of the positioning plate and fixation of the available and are useful only when significant time and
bone stumps with a bridging plate, a bone graft of either resources are available to provide this service.
type may be brought in.
to fit the mandible contour (see Fig. 5.6). Screw holes are 5.3.5 Application of Bone Grafts
drilled using copious irrigation. Hole length is meas- Following Bridging Plate Stabilization
ured, and if the system requires, holes are tapped prior
to placing appropriate length screws. Once the mandib- Once the bone defect has been stabilized precisely with
ular bridging plate has been securely screwed, the posi- a bridging plate (UniLOCK, THORP), primary or secon-
tioning plate is removed from the inferior surface of the dary grafting can be considered. If the mucosa is intact
mandible. Range of motion of the mandible, condylar or can be reliably closed, immediate nonvascularized
position, and occlusal relationships should be checked, bone grafts may be used, with excellent results. Very
and readjustment must be made prior to closure. large defects may be reconstructed with microvascular
Fig. 5.7
Fixation of a nonvascularized graft in the lateral mandible by
compressing the graft between the mandibular stumps. Inset,
the technique.
Fig. 5.8
In this case after bridging the defect with a reconstruction
plate, the nonvascularized bone graft is fixed to the mandibu-
lar segments via a lag screw technique.
grafts (see Fig. 5.10). Smaller defects may be repaired determined by the bridging plate selected for mandibu-
with cancellous bone obtained from the iliac crest. This lar stabilization.
highly cellular graft is extremely reliable even for previ- Fixation of bone grafts together with reconstruction
ously infected cases. However, a substantial loss of min- plates can be carried out by one of several means. If the
eral bulk of the graft is expected. Corticocancellous screws can be locked within the hole of the plate (as in
grafts are preferred for larger defects. Cancellous bone UniLOCK or THORP), it is safe to fix the grafts with
grafts require some means of stabilization, possibly with these screws. If the screws cannot be locked, however,
resorbable meshes. The means of fixation of the graft is grafts should not be fixed with these screws since the
a
2
Fig. 5.9 a–c screws may loosen during the process of revitalization
a Fixation of a nonvascularized bone graft with screws is feas- of the bone graft and promote infection.
able when locking of the screws into the plate hole is possible One possibility for stabilizing a nonvascularized
(inset 1, THORP; inset 2, UniLOCK).
b After resecting the angular area of the left mandible, the graft is to use the advantage of bidirectional screw holes
defect was bridged with a THORP plate and filled with a of the reconstruction plate, allowing for compression. If
nonvascularized bone graft fixed with two locking screws. the inner screws are loosened, a slightly oversized graft
c Same situation as in b 4 months later, showing a complete (approximately 2 mm larger than the defect) may be
incorporation without much resorption of the graft. wedged between the mandible edges (Fig. 5.7).When the
screws are tightened (inset in Fig. 5.7), the graft is com- Vascularized bone grafts heal similarly to fractures, and
pressed between the mandible edges stabilizing the stabilization can mimic techniques for fracture repair.
graft. Free vascularized composite bone grafts have
Another technique uses a mortise joint to fix the graft become the treatment of choice for repair of large seg-
to the mandible with lag screws. An oversized graft is mental mandibular and soft-tissue defects. The vascu-
harvested.A step incision is cut into the ends of the graft larized bone and soft-tissue flaps tolerate radiotherapy
so that the measurement from the inner bone edge is the with minimal complications of osteoradionecrosis,
exact dimension of the mandibular defect. The outer wound breakdown, plate extrusion, and screw or plate
flange of the bone graft overlaps the mandibular ends. It loss. Dental implants may be placed primarily to accel-
is preferable to cut back the outer cortex of the mandible erate the dental restoration process.
at both mandibular ends to precisely fit the flange of the The choice of fixation of the vascularized bone flap
bone graft. Lag screws may then be placed to fix the bone includes regular fracture plates (2.4), lag screws, mini-
graft securely in place (inset in Fig. 5.8). The bridging plates, Universal Fracture plates (microvascular plate)
plate provides temporary stability for functional load- and reconstruction plates (UniLOCK, THORP). The goal
ing (Fig. 5.8). Eventually, after completion of the healing of the fixation is to provide adequate stability to allow
process, the bone graft takes over the functional forces. bone healing without distortion of the occlusion or tem-
Plate designs that lock the screw to the plate such as poromandibular joint function. Longer grafts require
the UniLOCK and THORP allow screws to be placed segmental osteotomies for correct contouring of the
through the plate hole to fix the graft (Fig. 5.9). This can graft. Intuitively, this simulates segmental fractures. One
greatly facilitate the speed of repair. It does not negate could predict better control of maxillomandibular and
the benefits of lag screw fixation of the graft. With each condylar positioning using load bearing bridging plates.
of these techniques it is recommended to pack cancel- Regardless, the different schools of surgeons advocate a
lous bone liberally around the graft-mandibular joints variety of fixation methods, with similarly good results.
to ensure more predictable bone healing at the osteo- Bridging plates have another advantage in not requiring
tomy sites. patients to be placed in IMF to secure occlusal relation-
Primary, nonvascularized bone grafting is recom- ships. With tumors lacking anterior cortical extension
mended only when there are no mucosal defects and in the plate can be prebent to the mandibular contour prior
the occasional instances in which the mucosa can be to resection of the mandible. This provides precise
closed securely. Most studies predict significant bone recontouring of the mandibular defect, and osteotomies
loss if nonvascularized bone grafts are attempted for within the graft can be planned according to the plate
cases where there are mucosal defects. In fact, a dehis- shape (see Sect. 5.3.3; Fig. 5.3).
cence above the graft almost always causes the loss of a As mentioned in the sequence on three-dimensional
nonvascularized free graft. It is usually best to wait computer modeling, it may be helpful to prebend a plate
approximately 2 months or until adequate healing has on the basis of a three-dimensional model. This may be
occurred to provide secondary bone repair. The plates too expensive for consideration as a regular procedure.
allow immediate function without bone being present.
They are subject to breaking if the bone is not replaced.
This generally occurs, depending on the loading situa- 5.3.7 Repair of the Anterior Defect Using a Microvascu-
tion, after months or years. lar Free Bone Flap and Fixation With Universal Fracture
Dental implants may be placed secondarily in corti- Plates (Microvascular Plates), UniLOCK, or Mini Plates
cal cancellous bone grafts. A high rate of success can be
expected with this application. Primary implantation of Selection of bone donor site depends upon the size and
dental implants within nonvascularized bone is not rec- location of the bone defect, the amount of soft tissue
ommended. resected, and the preference of the surgeon. Both fibula
and iliac crest free flaps contain excellent bone. The iliac
crest is usually required when more soft-tissue repair is
5.3.6 Reconstruction of Tumor Defects needed. The scapula free flap may also be used. This has
With Vascularized Bone Grafts the advantage of excellent independent soft-tissue flaps.
and Their Fixation With Plates The bone, however, has a periosteal blood supply and
has substantially less volume. The decreased bone gen-
Vascularized tissue transfer provides optimal bone and erally requires a bridging plate (UniLOCK or THORP) to
soft tissue for major defect reconstruction. Nonvascu- guarantee mandibular form and function, while iliac
larized bone heals by creeping substitution and remod- crest and fibula flaps can be fixed with miniplates as
eling. The revitalization of the bone depends upon the well. The radial forearm flap with bone is rarely used in
vascularity of the surrounding tissue.Vascularized flaps our groups. Since the amount of bone is small, this
introduce viable bone and soft tissue to initiate repair. would require a reconstruction plate for fixation.
Fig. 5.10 a–c

a Reconstruction of the complete horizontal part of the man- b Clinical situation shown on X-ray, alike the situation in a.
dible, including the ramus on the left side with a microvas- c Situation as in a after removal of the anterior plates used for
cular free fibula bone graft. In this case fixation of the graft the fixation of the osteotomies within the graft. This allows
and the anterior osteotomies was performed with Universal for the placement of dental implants.
Fracture plates. Small bony gaps were filled with cancellous
bone taken from the iliac crest.Inset: monocortical screw fix-
ation to avoid injury to vessels.
The anterior surface of the mandible is widely technique is generally employed when using the iliac
exposed, and the osteotomy sites are marked with a crest or scapula free flap with skin for intraoral lining.
bone saw. A template is prebent to the contour of the
mandible. The template also can guide the selection of
plate length. The plate is measured so that the first screw 5.3.8 Repair of Tumor Defects With Anterior
is placed about 1 cm from the osteotomy, and at least Soft-Tissue Extension With Microvascular Free Bone Flap
four screws should be planned for each side. Extensive and Bridging Plate
anterior projection of the inferior border of the mental
process may be removed with a cutting burr if the tumor The method of supervising mandibular and condylar
does not extend into this region (see inset of Fig. 5.1). position for tumors extending anteriorly is decribed
This facilitates plate bending and decreases overprojec- above (see Figs. 5.4–5.6). Dentate patients may be placed
tion of the repair. The plate is contoured precisely to the in IMF to supervise maxillomandibular relationships.
anterior surface of the mandible. The plate is positioned, The method of using an oversized positioning device is
and at least two screws are placed in each side to ensure also described above.
that the remaining screw holes are placed correctly An alternative method uses the condylar positioning
without plate displacement (see Fig. 5.3a,d). Sharp device which provides an excellent unobstructed resec-
drills, correct drill guides, and copious irrigation is tion of the tumor. Base plates applied proximal to the
required to prevent screw failure. Either pretapped or planned mandibular osteotomies secure the positioning
nonpretapped holes are required depending on the kind bow. The bow is removed and the tumor is resected. The
of screws for fixing the reconstruction plate. Screw mandible is repositioned by reattaching the positioning
length is measured before tapping to avoid potential bow to the mandibular base plates. A bridging plate can
damage to the tapped bone threads. All screw holes are be contoured to the mandible to maintain the man-
drilled, measured, and tapped (if required), and a dia- dibular position. The bridging plate is applied, and the
gram of the plate and screw orientation is recorded. Spe- Mandible Fix Bridge base plates are removed (see
cial care must be taken when replacing self-tapping Fig. 5.4b,d). The free flap can be harvested and shaped
screws (2.4 UniLOCK) to avoid stripping previously cut and fixed to the plate as previously described
threads. It is preferable not to place all screws prior to (Fig. 5.11b,c).
resection to avoid this potential problem. This is less
likely to occur with pretapped holes (2.7 and THORP
screws). The plate is removed and the surgical resection 5.3.9 Reconstruction of the Condyle: General Remarks
completed.
The plate may be taken to the donor site to shape and Reconstructing the temporomandibular joint (TMJ)
fix the bone to the plate in situ before transacting the articulation is one of the most demanding challenges in
vascular pedicle to decrease ischemic time. This applies facial surgery. Restoration must address the complex
to the fibula free flap and is a matter of surgeon’s prefer- function of the joint while restoring occlusion, facial
ence. Screws are placed monocortically in the graft to symmetry, and projection and maintaining normal
decrease potential injury to the vessels behind the oppo- mastication. Many of the problems of joint reconstruc-
site cortex (see inset to Fig. 5.10a). The plate bone unit tion have been addressed in the literature in relation to
may then be fitted to the mandibular defect and the plate repair of the ankylosed joint. Efforts to provide repair
secured to the mandible. Vascular anastomosis is then with alloplastic condylar prostheses have been asso-
completed, followed by wound closure (Schusterman). ciated with the complications of malpositioning, infec-
An alternative is to fix the vascularized free flap with tion, glenoid fossa erosion, heterotropic bone forma-
Universal Fracture plates (Fig. 5.10b,c) or miniplates. In tion, and even erosion into the skull (middle cranial
these instances it is essential to have adequate bone in fossa; see also sections 5.3.11 and 5.3.12).
order to guarantee form and function of the mandible These problems are even more apparent with
and then sustain the soft tissues. The osteotomy defects patients requiring tumor ablation and repair, especially
should be filled with cancellous bone (inset to when combined with high-dose radiation therapy.
Fig. 5.10a). Lindqvist et al. (1992a) reported 3 of 11 condylar pros-
In another variation the bridging plate is placed first thesis used for tumor repair required removal secon-
to restore the mandibular defect. The graft must be fixed dary to infection. One patient aged 11 years had a plate
with a reconstruction plate only if it is taken from the fracture necessitating plate removal. Four of the
scapula (see Fig. 5.11b).After harvesting the grafts, oste- patients’ condyles were displaced out of the fossa.
otomies are performed in the bone graft to precisely fit Reconstruction of the TMJ with an alloplastic condyle
the mandibular defect and plate contour. The bone is after radical removal of the joint with planned postop-
secured to the plate. Intraoral soft-tissue closure is com- erative radiotherapy is probably contraindicated
pleted, followed by the microvascular anastomosis. This because of the high probability of failure and the poten-
a b
Fig. 5.11 a–c

a Extensive invasion of the horizontal part of the mandible by 5.3.10 Joint Repair With Costochondral Grafts
a malignant tumor necessiting an almost complete resection
of the horizontal mandible.
b Reconstruction of the horizontal branch of the mandible Repair of the condyle with costochondral cartilage is an
with a microvascular anastomosed scapular graft with two accepted modality for reconstructing the resected con-
soft-tissue flaps. In this case it is necessary to use a recon- dyle following the removal of benign lesions or anky-
struction plate (UniLOCK or THORP) for stabilization of the lotic joints. Other indications include dysplasias and
mandibular segments and fixation of the graft. While screw osteomyelitis. The goal of reconstructing the TMJ is not
placement within the mandibular stumps is bicortically, fix-
ation of the bone graft is carried out monocortically.
only to rehabilitate the complex mechanism of the nor-
c Clinical situation as described in a,b, shown on the Ortho- mal joint but also to restore facial symmetry, occlusion,
pan tomogram. and mastication. Alleviation of pain is of great impor-
tance, especially in the surgical treatment of degenera-
tive joint disease. Mandibular growth imposes addi-
tial erosion of the condyle into the middle cranial fossa. tional constraints on the reconstructive procedure in
Prosthetic reconstruction of the TMJ has largely been children.
abandoned in the United States due to legal ramifica- Because of a number of biological and anatomic sim-
tions relating to other artificial joint devices. None such ilarities to the mandibular condyle costochondral grafts
device is presently approved by the Food and Drug have been considered to be among the most acceptable
Administration. tissues for TMJ reconstruction. Primary nonvascular-
ized cartilage grafts are not recommended for patients
receiving planned postoperative radiotherapy. Benign
tumors involving the ascending ramus and condyle of
the mandible are amenable to reconstruction with costal
a b
1 2 3
chondral grafts in order to reconstitute the mandibular Fig. 5.12 a–d

and condylar defect. In ankylotic cases coronoidectomy a Situation after the resection of the left condylar and subcon-
must also be performed. Great care must be taken to pre- dylar area, as well as the coronoid process.An osteochondral
graft is shaped.A groove is carved into the remaining part of
serve the neurovascular bundle of the mandible. the ascending ramus to receive the graft.
Exposure is achieved through the submandibular b Fixation of the osteochondral graft with two 2.0 lag screws.
incision (see Figs. 2.1, 2.3), usually in combination with Inset 1: Fixation with lag screws with washers.
a preauricular incision followed by the resection of the Inset 2: Fixation with Universal Fracture plate.
condylar head and the ascending ramus segment. If pos- Inset 3: Fixation with 2 horizontally placed miniplates.
c Situation as in b, inset 3, shown radiographically.
sible, the meniscus is preserved as well as the joint cap- d Situation as in b, inset 1, shown radiographically.
sule. The length of the resection is measured.
The rib may be harvested, including about 5–10 mm
of cartilage. The fifth, sixth, or seventh ribs are suitable
for this purpose. Care must be taken not to tear the
parietal pleura during the resection of the rib. Small
pleural rents may be checked by inflating the lung with
positive pressure, with water in the wound looking for
air leaks. If no air bubbles are detected after the lung is
fully reinflated, the pleura may be closed without insert-
ing chest tubes.
The cartilage end of the costal chondral rib graft is
shaped to approximate the original condyle and to fit
within the condylar fossa (Fig. 5.12a). Sufficient rib
should be harvested to allow fixation with a minimum of
two or three lag screws. If the rib is soft, washers made

from cut portions of 2.0 adaptation plates are helpful to 5.3.11 Alloplastic Replacement of the Condylar Process
prevent screws from splitting or pulling through the
bone. Screws of 2.4 mm are particularly well suited for There are only few indications for using a condylar
this procedure (see Fig. 5.12, inset 1). The graft may also implant in TMJ arthroplasties. If an autogenous trans-
be applied to the mandible by fixation with miniplates plantation is contraindicated for any reason, such as the
(see Fig. 5.12, inset 3). Lindqvist et al. (1992a,b) have general condition of the patient, massive ankylotic
demonstrated success with this technique. However, structures, and reankylosis after autogenous arthro-
stability is not adequate to allow patients to function plasty, an allogenic joint prostheses may be the best
immediately. Depending on the situation, method for primary reconstruction. The same is true in
10 days–2 weeks of immobilization in IMF is recom- traumatic cases in which the condyle is lost or fractured
mended. into several pieces, and primary restoration of mandible
Other possibilities are to use the 2.0 mandibular plate and joint function by osteosynthesis is impossible
(six hole) or the 2.4 Universal Fracture plate (see (Fig. 5.13b). As noted above, this prosthesis in not
Fig. 5.12, inset 2). Two holes are placed with lag screws approved by the United States Food and Drug Adminis-
fixing the graft (through the plate) to the mandible. Two tration.
or three additional holes provide additional stability to A combined preauricular and sub- or retromandibu-
the graft. This repair is also best protected with 10 days lar approach is advisable (see Figs. 2.1, 2.3). After sub-
of intermaxillary fixation. stantial removal of ankylotic masses a new fossa is
created in the region of the damaged mandibular con- Fig. 5.13 a, b

dyle. In nontumor cases, however, no attempt should be a Schematic drawing with coronoidectomy because of an
made to remove the distroyed condylar process totally ankylosis.
b Replacement of the mandibular condyle and subcondylar
(Fig. 5.13b). On the contrary, it may be advisable to leave area with a joint prosthesis in an edentulous patient after
some of this bone as a precaution against penetration of traumatic loss of condyle.
the condylar head into the temporal fossa. Coronoidec-
tomy is always performed in cases of ankylosis. After
removing the desired amount of bone the correctly sized serve the disc intact in the fossa,if possible,unless a tem-
prosthesis (three different sizes) is chosen after evaluat- porary muscle flap including the fascia can be used to
ing the defect with a template. The goal is to choose a line the fossa. This can prevent to some extent the for-
prosthesis that is placed at the posterior aspect of the mation of ectopic bone and the possible erosion of the
ramus engaging with its most posterior hole into the joint head in the fossa. IMF is relieved before the patient
mandibular angle (Fig. 5.13). These prostheses are cur- is extubated.
rently made of stainless steel, and they should be fixed It may be difficult to place the condylar head correctly
with the 2.7 screws in a bicortical manner. Since these in the glenoid fossa. Lindqvist et al. (1992a,b) report
prostheses are rarely used, they will probably remain that in 23 instances in which a joint prosthesis was used
available only on special request and with the 2.7 screws. only 16 were initially found to be situated correctly in
IMF is always used intraoperatively. In edentulous the glenoid fossa. In one out of these 23 a perforation to
patients the fixation is with the patient’s total dentures, the skull base occurred 10 months after the insertion of
which are then fixed to the maxilla and mandible by the implant. In Basel we have had experience with 23
screws or wires. The mandible is thus immobilized dur- condylar prostheses over an average follow-up time of
ing plate bending and insertion. In these cases effort is 101 months in 17 patients; no erosion of the glenoid
taken to remove the condyle carefully in order to pre- fossa has yet been observed (Prein 1998).
Fig. 5.14 a–c

5.3.12 Condylar Prosthesis a Reconstruction plate with condylar head bridging the right
for Lateromandibular Defects Including the Joint hemimandibular defect.
b Orthopan tomogram showing a recurrent ameloblastoma in
the right mandible.
Condylar head prosthesis for replacing the lateral man- c Orthopan tomogram showing a THORP plate with condylar
dible including the ascending ramus currently uses the head, bridging a complete right hemimandibular defect.
2.7 reconstruction angled plate. Long and short, left and
right plates are available by special order in countries
other than the United States (see Fig. 1.26c,d). This
Fig. 5.15
Fixation of a microvascular anastomized bone graft to a recon-
struction plate with condyle. Since this is a vital bone graft, fix-
ation can well be performed with screws.
system uses the 2.7 screw, which has a hexagonal head

and requires pretapping. When patients require resec-
tion of the mandible but not the meniscus or joint cap-
sule, this plate may temporize to maintain mandibular
relationships until bone repair is feasible (Fig. 5.14).
Its use requires that the patient be placed in stable
occlusion with arch bars. Ameloblastoma and extensive
keratocysts are the most common pathology involving
the ascending ramus and condyle (Fig. 5.14b). The b
tumor can frequently be removed using an external inci-
sion with the dissection remaining extraorally. This
approach is helpful in decreasing wound infection. Care
is taken to assess the extent of the disease on the radio-
graphs. The area of resection is carefully marked to screws are placed firmly bicortically to ensure adequate
allow complete removal of the tumor. It is beneficial to stabilization of the plate. Fig. 5.14c shows this situation
plan for at least an additional 1 cm of bone removal with the THORP system.
when sizing the plate so as not to lack sufficient plate Adequate joint capsule usually remains for suturing
length. Since the condyle cannot be removed from the the tissue around the neck of the prosthesis. Likewise, a
fossa to allow precise adaptation of the plate to the glen- heavy 2-0 nonabsorbable suture is used to secure the
oid fossa, precise bending is not possible until the tumor most superior plate hole segment to the joint capsule. If
is resected. The template is prebent to the anterior lateral inadequate tissue remains, one can secure the plate to
surface of the mandible from inferior joint capsule to a the temporal fascia or zygoma superiorly. This helps to
point allowing at least five screws to be placed in the prevent the condyle from dislocating out of the glenoid
remaining mandible. Following the resection the patient fossa postoperatively. IMF is removed following soft-tis-
is placed in IMF, reestablishing the normal occlusion. sue closure. The arch bars are left in place in case the sur-
The plate is then positioned. Care is taken to place the geon wishes to apply loose elastics to help train the
condyle within the joint space without forcing the con- occlusion, or if there is concern about possible condylar
dyle to the posterior position. Further bending adjust- displacement. This is usually not necessary if plate
ments are made with the bending irons. The plate is bending has been precise.
secured to the mandible with at least four screws placed The condylar head prosthesis plate should be consid-
in the neutral position. Screw holes are drilled to 2.0 mm ered only a temporary repair. There is a tendency for
using copious irrigation. The screw length is measured plate fracture and for plate erosion into the temporal
with a depth gauge before tapping the holes. The 2.7 bone. Bone grafts may be attached to this plate to pro-
Fig. 5.16 a–c oid fossa (see Fig. 5.16c). Failure to position the graft
▼
a Fixation of a microvascular free fibular graft replacing cor- adequately and to supervise it may lead to malposition-
pus and ramus, including the condylar head, on the left side. ing the graft into the temporal fossa, which impairs cor-
Fixation of graft and osteotomy (angle) with Universal Frac-
ture plates. Bone gaps are filled with cancellous bone. rect functioning of the mandible.
b Fixation of a microvascular free fibular graft with a recon-
struction plate. Note the joint area is replaced by bone only,
no condylar head of the plate. 5.3.13 Management of Mandibular Resection
c Pre- and postoperative X-ray showing the defect of the left Including the Condyle Using Microvascular Bone Flaps
corpus and ramus of the mandible and the reconstruction of
this area with a microvascular anastomosed fibular graft
and Various Plates for Fixation
fixed with Universal Fracture plates. Situation corresponds
with a. Fortunately, malignancies rarely involve the TMJ. This
may be due to the limited lymphatics in this region, or to
the lack of interconnections of the ascending ramus to
the condyle with either a common canal or a blood sup-
vide more stability (Fig. 5.15). However, this resolves ply. When malignancies involve this region, they usually
only the problem of potential plate fracture. Most sur- also invade the joint capsule and the meniscus and
geons would recommend replacing this plate with bone require resection of these structures followed by high-
graft if the patient remains free of disease. Microvascu- dose radiotherapy. These extensive tumors frequently
lar free flaps are certainly considered a better choice for involve the lateral skull base and require skull base
young patients who can expect long-term survival. Fix- approaches with resection of the floor of the middle cra-
ation of these grafts is performed with either Universal nial fossa which limits the ability for primary mandibu-
Fracture plates (Fig. 5.16a) or bridging plates lar reconstruction. Microvascular osseous free flaps may
(Fig. 5.16b,c). be used for mandibular repair, including the condyle, if
Care must be taken to size the new condyle free end no significant defect has been created in the skull base.
of the graft adequately and to position it within the glen- The fossa may be covered with a temporalis flap. The
free end of the bone flap is carefully shaped to fit the Fig. 5.17
glenoid fossa (see Fig. 5.16). Reconstruction of the left mandible. The unaffected condyle
Careful osteotomies need to be planned with precise was left in place and used for fixation of the reconstruction
plate with two screws, one in the head and one in the subcon-
adaption of the graft to provide width, projection, and dylar area. In this situation a free nonvascularized bone graft
height of the mandible. There is a slight tendency of was used. Therefore stabilization must be performed with a
these grafts to migrate into the temporal fossa. There- reconstruction plate.
fore fixation of the graft to the residual mandible is gen-
erally best achieved with a bridging plate such as the
UniLOCK or THORP to prevent mandibular deviation attach to the base plates. The position is fixed using the
(see Fig. 5.16b). These plates are more difficult to adapt locking universal clamps. The fixation bow is removed
but provide the stability to maintain condylar and man- from the base plates allowing free access to the oral cav-
dibular positioning during functional load. The joint ity during tumor resection. Reapplication of the fixation
capsule should be secured around the condyle if pos- bow allows precise repositioning of the mandible for the
sible to help prevent dislocation from the glenoid fossa. adaptation of the plate and the bone graft. Base plates
If occlusal relationships are questionable, a period of are removed at the end of the procedure. The advantage
IMF is mandated. If occlusal relationships cannot be of installing arch bars over other techniques is that it
achieved after graft placement, careful readaptation of allows the surgeon to maintain or reapply IMF more eas-
the plate and graft are required prior to closure to pre- ily in the postoperative period if desired. It is helpful to
vent mandibular dysfunction. maintain patients in IMF with elastics for 2 weeks post-
Positioning of the graft in relationship to the remain- operatively to train the occlusion. Dentures or appropri-
ing mandible is difficult. It is beneficial to place the den- ate splints may be used in edentulous patients to help
tate patient into arch bars. The patient is placed in IMF restore normal position and function.
prior to final adaptation and fixation of the graft and Several techniques have evolved for repairing the lat-
plate. eral mandibular defect including the condyle. These
Another option is to position the mandible in rela- include using an osseous free flap in combination with a
tionship to the maxilla. A variety of techniques may be reconstruction plate with a condylar head (see Fig. 5.15).
used to achieve this positioning. The patient may have a Osseous free flaps may also have the proximal end of the
fracture plate placed between the noninvolved mandible bone contoured into a neo condyle (see Fig. 5.16a–c).
and the maxilla (see Fig. 5.5a). This is placed when the Hidalgo suggests removing the residual unaffected
patient is in the normal closed occlusal position. The condyle and using it as a free graft attached to the
plate can be removed to facilitate the resection. Once the osseous free flap. Adequate length of the condyle neck
resection is completed, the plate can be replaced, rees- generally remains to be attached with two or three
tablishing normal mandibular position for the adapta- screws to the bridging plate, which is necessary if no
tion of the graft and plate. This may also be achieved by vascularized grafts are transplanted (Fig. 5.17, 5.19a) or
the use of the Synthes Mandible Fix Bridge (see other stabilization plates in combination with microvas-
Fig. 5.4a). The base plates are attached to the maxilla and cular grafts (Fig. 5.18). This is preferable to producing a
the mandible. The mandible is placed in normal closed free condylar graft, which ultimately undergoes signifi-
occlusal position, and the fixation bow is adjusted to cant resorption and remodeling over time.Of course,the
Fig. 5.18 symphyseal area. The plate is fastened to the proximal

In this situation the same defect as in Fig. 5.17 was recon- mandible. The patient is maintained in IMF during the
structed with a vascularized bone graft. Therefore individual final contouring and positioning of the plate. In situ
Universal Fracture plates can be used for fixation.
bending of the plate may ensure correct graft position-
ing. The graft is situated with the preshaped neocondyle
placed in the glenoid fossa (see Fig. 5.16b). Residual soft
tissue at the joint should be sewn to make a cuff around
the condyle. The tissue cuff may be attached laterally to
latter condition and repair is not comparable to the sit- the proximal screw in the plate. Patients are maintained
uation in which the tumor involves the joint, with oblig- in IMF for 1–2 weeks.
atory resection of the entire joint to ensure tumor super- These extensive resections tend to be plagued by
vision. decreased function, and some mandibular deviation
usually occurs postoperatively. The functional results
are worse if postoperative radiotherapy is required.
5.3.14 Repair of the Lateral Mandible Including Postoperative mandibular rehabilitation is mandated
the Condyle: Osseous Free Flap and Bridging Plate for all patients to optimize function.
The approach to the mandible is similar to that

described above. The choice of whether to obtain the 5.3.15 Repair of the Lateral Mandible and Condyle:
free flap from the fibula or the iliac crest depends upon Microvascular Free Flap and Reconstruction Plate
the amount of soft tissue required, the total bone length, With Condylar Prosthesis (Schusterman)
and the preference of the surgeon. The iliac free flap pro-
vides adequate bone for the hemimandible reconstruc- This repair (see Figs. 5.13, 5.14) is technically feasible but
tion. The ipsilateral hip places the vascular pedicle pos- poses significant problems. The condylar head prosthe-
teriorly and is not recommended if contralateral donor sis is not approved by the Food and Drug Administra-
vessels are to be used. tion and is not available in the United States. Long-term
A temporalis flap may be used to cover the glenoid use of the condylar head prosthesis within a heavily
fossa if extensive soft-tissue dissection is required at the radiated field increases the possibility of skull base ero-
skull base. The proximal end of the bone flap should be sion by the prosthesis, with potential dislocation of the
contoured to approximate the size of the residual condyle into the middle cranial fossa. Therefore the use
patient’s condyle. A template contoured to the mandible of this technique is guarded.
prior to the resection helps to shape the bridging plate. The patient should be placed in arch bars if dentate.
The plate is bent according to the template and posi- If the patient is edentulous, a dental splint or dentures
tioned such that the proximal screw is in the region of may be fixed to the mandible and maxilla with 2.0 lag
the neo condylar neck. The plate should not extend to screws. It is helpful to trim the denture to be slightly
the joint. Four screws should fix the plate to the residual smaller than the planned osteotomy to facilitate tumor
mandible. Prior to securing the plate to the mandible, an removal. Once the resection is completed, the patient is
osteotomy should be made to fit the graft in the para- placed in IMF. The appropriately sized condylar head
Fig. 5.19 a–c

a Situation after resection of the horizontal part of the man- from the fibula. In this case the previously used reconstruc-
dible including the ascending ramus on the right side tion plate was removed, and fixation carried out with Uni-
because of osteosarcoma. A small part of the condyle versal Fracture plates to the mandibular stumps and mini-
remains in place and was used for fixation on the bridging plates for fixation of the osteotomies in the chin area.
plate with two screws. c Situation after removal of the miniplates in the chin area.
b Patient remained free of disease and reconstruction of the Additional bone graft in the chin area and placement of den-
mandible was performed with a free vascularized bone graft tal implants.
5.5 · Technical Errors 181
reconstruction prosthesis is chosen and bent to reestab- transcondylar screw hole length is chosen to avoid screw
lish the mandible contour. It is helpful to prebend a tem- protrusion.
plate prior to resection of the mandible. This helps in Patients are recommended to remain in IMF for
recontouring the plate more closely to the mandible. 2 weeks to ensure correct positioning and to allow pre-
Stay sutures placed in the lateral, medial, anterior, and liminary bone and soft-tissue healing. Functional reha-
posterior joint capsules aid in assuring correct condylar bilitation is advised to achieve maximal results.
placement within the joint space. Care must be taken not
to force the prosthesis into the posterior superior joint
position since this produces a canted open bite occlu- 5.4 Complications
sion at the side of the repair. Once contoured, the plate
should be fixed to the mandible with at least four bicor- Complications occurring from reconstruction of tumor
tical 2.7 pretapped screws. Small adjustments of the defects are related to technical errors, screw failure, soft-
plate may be made in situ. It is desirable to remove IMF tissue failure, joint failure, bone failure, and material
temporarily to ensure normal occlusion, joint function, failure.
and range of motion. This also facilitates the placement Many problems are obviously intrinsic to the healing
of the free flap. The plate is generally removed and the process and are unavoidable. The use of microvascular
free bone flap osteotomized and contoured to fit the bone flaps has greatly reduced the rate of soft-tissue and
plate. The final sizing of the graft may require adjust- plate failures compared to that when repairs relied only
ment once the prosthesis is secured in its previous estab- upon the plate providing mandibular integrity. Other
lished position (see Fig. 5.15). considerations involve patient selection, cost contain-
ment, and objective assessment of reconstruction bene-
fits for patients with these aggressive tumors.
5.3.16 Condylar Reconstruction: Condylar Transplant
and Vascularized Bone Flap Reconstruction
5.5 Technical Errors
If a planned resection includes disarticulation of the
condyle and a small condyle and neck remnant is found Technical errors involve inappropriate selection and
to be free of tumor, the condyle may be transplanted to application of stabilization. Likewise, appropriate con-
a vascularized free flap (Hidalgo). Another option is to touring, application, screw placement and vessel repair
leave the condylar head in place and attach it to the are imperative when free flaps are applied, but discus-
shaped bone flap (Figs 5.17, 5.18). Proponents of this sion of these issues are not within the scope of this text-
procedure are concerned with poor results achieved by book.
using vascularized free flaps to create the neocondyle. There remains some variance in the choice of fixation
Few patients with oral cancers are amenable to this pro- of free flaps for mandibular repair. Some authors select
cedure since lesions extending to the proximal mandible “miniplates” to position and stabilize osteotomy sites.
and TMJ usually have extensive involvement to the tis- Ease of application and less potential interference with
sues of the skull base.The majority of tumors allow pres- the graft and its vascular pedicle are the advantages of
ervation of substantial condylar neck and posterior this method of fixation. Although larger bridging plates
ramus to fasten securely a reconstruction plate are more difficult to bend, they allow more precise con-
(Fig. 5.19a). Although transplanted condyles have touring and supervision. They may also be helpful in
shown resorption apparent short-term function is providing increased stability for thinner bone flaps such
reported to be better than other bone reconstructions as the scapula. Regardless of the surgeon’s choice the sta-
even when patients receive radiotherapy. bilization must overcome the forces of mastication and
Exposure is described above. The free or microvascu- allow bone healing with maintenance of normal man-
lar flap may be secured to the residual mandible with dibular and joint relationships. Failure to position the
either a reconstruction plate,Universal Fracture plate,or mandible anatomically results in a rigidly fixed mistake.
miniplates (Fig. 5.19). Patients should be taken out of IMF (if used) to test the
In the case of a condyle transplanted or left in place functional range of motion and maxillomandibular
fixation to the microvascular bone flap is carried out position before accepting the repair. Then, if the repair
with miniplates or Universal Fracture plates. Two or and surgeon’s preference mandate, the patient may be
three screws, if possible, should be placed in the trans- placed in IMF for a short time.A period of IMF is gener-
planted condyle. The screws must not protrude into the ally not required when bridging plates are used to stabi-
articular surface. If screws are to be placed in the con- lize the defect. The only exception is the repair of large
dyle, they should not be placed bicortically (see Fig. 5.17 bone defects, including the condyle.
inset, 5.18). A screw 2 mm shorter than the measured
Care must be taken to place screws in viable bone. It

5.5.1 Plate Failure is safer to keep the screws about 1 cm from the osteot-
omy site. One can conveniently plan to keep the one seg-
Plate fracture is possible when any plate bears the entire ment hole nearest the osteotomy without a screw. Care
functional load for extended periods. The surgeon must must be taken to replace screws along the previously
accept that the bridging plate ideally is only a temporary formed thread axis. It is potentially easier to recut or
repair for tumor defects. Ultimately bone is required to damage a thread when reinserting self-tapping screws.
allow total functional rehabilitation.
Several technical errors can contribute to plate fail-
ure. Overbending must be avoided. It is important to use 5.5.3 Soft-Tissue Failure
prebent plates in the region of the angle to avoid over-
bending and metal fatigue when attempting to create the Adequate vascularized soft tissue must be available to
contour of the angle. The use of templates helps to sim- close the wounds without tension. Small lateral defects
plify the number of bends required to achieve the may be closed primarily if patients are not to receive
desired shape. Correct bending pliers help to prevent radiotherapy. Pectoralis major myocutaneous flaps may
bends that are too acute. provide excellent closure if flaps are not fatty, and the
random portion is not over the plate. These tend to be
far better for nonradiated patients. The pectoralis major
5.5.2 Screw Failure flap tends to separate from the mucosa for anterior
defects. Once significant flap dehiscence occurs, plate
The correct drill guides and the correct sharp drill bits exposure usually follows. Free vascularized bone flaps
and taps (when required) should be selected for each provide vascularized bone to which the deep tissues
system. A general rule is to discard a drill bit after each adhere. Plate exposures and small wound separations
use. This is far preferable to destroying a screw hole by tend to heal without secondary repair when free vascu-
burning through the bone and destroying the adjacent larized flaps are used. This is unlike the case when a
bone which is required to maintain screw anchoring. bridging plate alone is used to span the mandibular
Copious irrigation is also required to cool the bone and defect. When the soft-tissue closure separates and
remove debris during the drilling process. This is more exposes the plate, the deep tissues tend to tear away from
important with screws of larger diameter as for their the plate and require extensive secondary procedures to
holes more heat is produced during drilling. High-speed attempt repair.
drills are not recommended since they tend to produce
more heat during the drilling process.
There has been a misconception in the literature that 5.5.4 Joint Failure
screw design is the factor determining osseous integra-
tion. Osseous integration is a characteristic of the mate- A mobile pain-free TMJ is required to optimize oral
rial. Commercially pure titanium is essentially biologi- rehabilitation. Installing correct occlusion and stabiliz-
cally inert and allows osseous integration without a ing the correct proximal mandibular position are man-
fibrous capsule surrounding the implant. Therefore all dated to achieve this goal. Unfortunately, procedures
of the AO titanium screws are capable of osseous inte- which attempt joint repair frequently produce joint dys-
gration. Some designs allow more surface area or poten- function. The surgeon must realize that procedures
tial bone apposition (i.e., THORP). which involve the joint require rapid mobilization to
Urken et al (1992) have reported that the THORP rehabilitate function. Long periods of IMF are contrain-
screw entails fewer screw failures than the 2.7 screw of dicated. Aggressive functional rehabilitation is required
the older reconstruction plate. This was attributed to the during the healing process and is mandated through
unique screw design and locking feature of the plate to radiotherapy. Radiation induces fibrosis and extraos-
the screw. This may also be related to the screw dimen- seous calcification which lead to ankylosis and dimin-
sion. If one considers the surface of the screw to be pDL, ished joint function. The role of agents which increase
the surface of the 2.7 screw is 77% of that of the 3.5-mm oxygen transport or scavenge free radicals is still unan-
screw. Likewise, the 2.4 screw is 69% of that of the 3.5 swered but may help to diminish joint dysfunction in the
screw. Four 2.7 screws are therefore required for the future.
same bone surface contact as three 3.5 screws. This fact Careful maintenance of the joint offers the best pos-
is more important in bone that is more osteoporotic or sible repair. Whether the condyle can be transplanted
demineralized as seen with radiotherapy. It is essential and maintained in long-term function is less predict-
to prepare for three-screw holes for the UniLOCK or able.What is clear is that radiotherapy is the single most
THORP screw and preferably at least four screws if lock- critical factor in decreasing joint function when techni-
ing screws are not used. cal errors are avoided.
5.5.5 Bone Failure References and Suggested Reading
The residual mandible may be subject to failure by acute Adamo A, Szal RJ (1979) Timing, results and complications of
infection, secondary infection (usually of dental origin), mandibular reconstructive surgery: report of 32 cases. J Oral
or osteoradionecrosis. It is imperative to restore good Surg 37:755–763
Anthony JP, Rawnsley JD, Benhalm P et al (1995) Donor leg
dental hygiene in the remaining mandible if one antici- morbidity and function after fibula free flap mandible
pates the bone to tolerate extensive operative restoration reconstruction. Plast Reconstr Surg 96(1):146–152
especially in the field of radiotherapy. The incidence of Blackwell KE, Buchbinder D, Urken ML (1996) Lateral mandib-
osteoradionecrosis exceeds 5% and increases if fastidi- ular reconstruction using soft-tissue free flaps and plates.
ous dental care is not provided. Patients should have Arch Otolaryngol Head Neck Surg 122(6):672–678
Boyd B, Mulholland S, Gullane P et al (1994) Reinnervated lat-
dental consultation prior to planned surgery and radio- eral antebrachial cutaneous neurosome flaps in oral recon-
therapy. struction: are we making sense? Plast Reconstr Surg
Screws that loosen are generally associated with 92(1):1266–1275, 93(7):1350–1359
infection. These should be removed to prevent extensive Daniel RK (1978) Mandibular reconstruction with free tissue
soft tissue and bone destruction. The plate length needs transfers. Ann Plast Surg 1:346–371
Durkin JF, Heeley JD, Irving JT (1973) The cartilage of the man-
to be planned for the placement of an adequate number
dibular condyle. Oral Sci Rev 2:29
of screws to secure the plate. Exposed plates seldom lead Figueroa AA, Gans RJ, Pruzansky S (1984) Longterm follow-up
to bone loss unless the plate is inadequately fixed to the of mandibular costochondral graft. Oral Surg 58:257–268
bone. Futran ND, Urken ML, Buchbinder D et al (1995) Rigid fixation
The use of vascularized bone flaps has decreased of vascularized bone grafts in mandibular reconstruction.
Arch Otolaryngol Head Neck Surg 121(1):70–76
localized bone failure. Immediate bone repair produces
Gullane PJ (1991) Primary mandibular reconstruction: analy-
rapid bone healing, which decreases the functional load sis of 64 cases and evaluation of interface radiation dosime-
on the plate system. This decrease in local soft-tissue try on bridging plates. Larangoscope 101 [Suppl 54]:1–24
and screw failures reduces potential bone loss. Micro- Gullane PJ, Holms H (1986) Mandibular reconstruction: new
vascular iliac crest, fibula, or scapula free flaps have a concepts. Arch Otolaryngol Head Neck Surg 112:714–719
better blood supply than the denuded mandible, which Hoffman HT, Harrison N, Sullivan MJ et al (1991) Mandible
reconstruction with vascularized bone grafts. Arch Otola-
frequently has alveolar artery and facial artery injury. ryngol Head Neck Surg 117:917–925
These grafts are relatively tolerant to radiation. It will be Klotch DW, Futran N (1996) Considerations for reconstruction
interesting to determine whether there is an increase in of the head and neck oncologic patient. Springer, Berlin Hei-
bone loss in patients receiving immediate implants and delberg New York
postoperative radiotherapy. A higher incidence of Klotch DW, Prein J (1987) Mandibular reconstruction using AO
plates. Am J Surg 154:384–388
implant failure has certainly been observed in view of Klotch DW, Gumps J, Kuhn L (1990) Reconstruction of man-
radiotherapy. dibular defects in irradiated patients.Am J Surg 160:396–398
It has been well documented that plates do not signif- Klotch DW, Ganey T, Greenburg H, Slater-Haase A (1997)
icantly interfere with the delivery of standard radiother- Effects of radiation therapy on reconstruction of mandibu-
apy. Back scatter and shielding are not significant at dis- lar defects with a titanium reconstruction plate. Otolaryngol
Head Neck Surg 114(4):620–627
tances greater than 1 mm from the implant when Komisar A, Shapiro BM, Danziger E (1985) The use of osteo-
opposed ports are used. Therefore bone complications synthesis in immediate and delayed mandibular reconstruc-
are more likely due to the extensive devascularization tion. Laryngoscope 95:1363–1366
required by the surgical approach than to the interface Komisar A, Warman S, Danziger E (1989) A critical analysis of
of the implant and bone. immediate and delayed mandibular reconstruction using
AO plates. Arch Otolaryngol Head Neck Surg 115:830–833
Lawson W, Boek S, Loscalzo L et al (1982) Experience with
immediate and delayed mandibular reconstruction. Laryn-
goscope 92:5–10
Lindqvist C, Soderholm AL, Hallikainen D, Sjovall L (1992a)
Erosion and heterotopic bone formation after alloplastic
TMJ reconstruction. J Oral Maxillofac Surg 50:560–561
Lindqvist C, Soderholm AL, Laine, Patsama J (1992b) Rigid
reconstruction plates for immediate reconstruction follow-
ing mandibular resection for malignant tumours. J Oral
Maxillofac Surg 50:1032–1037
Lukash FN, Tenebaum NS, Moskowitz G (1990) Long-term fate
of the vascularized iliac crest bone graft for mandibular
reconstruction. Am J Surg 16:399–401
Moscoso JF, Urken ML (1994) The iliac crest composite flap for Saunders JR, Hirata RM, Jaques DA (1990) Definitive mandib-
oromandibular reconstruction. Otolaryngol Clin North Am ular replacement using reconstruction kplates. Am J Surg
27(6):1097–1117 160:387–389
Moscoso JF, Keller J, Genden E et al (1994) Vascularized bone Silverberg B, Banis JC, Acland RD (1985) Mandibular recon-
flaps in oromandibular reconstruction. A comparative ana- struction with microvascular bone transfer: series of 10
tomic study of bone stock from various donor sites to assess patients. Am J Surg 150:440–446
suitability for enosseous dental implants. Arch Otolaryngol Stoll P, Waechter R, Hodapp N, Schilli W (1990) Radiation and
Head Neck Surg 120(1):36–43 osteosynthesis. Dosimetry on an irradiation phantom. J Cra-
Prein J (in press) Review of benign tumours of the maxillofa- niomaxofac Surg 18:361–366
cial region and considerations for bone invasion. In: Green- Sullivan MJ, Baker SR, Crompton R, Smith-Wheelock M (1989)
berg A, Prein J (eds) Craniomaxillofacial bone surgery. Free scapular osteocutaneous flap for mandibular recon-
Springer, Berlin Heidelberg New York struction. Arch Otolaryngol Head Neck Surg 115:1134–1340
Prein J (in press) Condylar prosthesis for the replacement of Tucker HM (1989) Nonrigid reconstruction of the mandible.
the mandibular condyle. In: Greenberg A, Prein J (eds) Cra- Arch Otolaryngol Head Neck Surg 115:1190–1192
niomaxillofacial bone surgery. Springer, Berlin Heidelberg Urken ML, Buchbinder D, Weinberg H et al (1989) Primary
New York placement of ossseointegrated implants in microvascular
Raveh J, Sutter F, Hellem S (1987) Surgical procedures for mandibular reconstruction. Otolaryngol Head Neck Surg
reconstruction of the lower jaw using the titanium coated 101:56–73
screw reconstruction plate system: bridging defects. Otola- Urken ML, Weinberg H, Vickery C et al (1992) The combined
ryngol Clin North Am 20:535–558 sensate radical forearm and iliac crest free flaps for recon-
Sadove RC, Powell LA (1993) Simultaneous maxillary and man- struction of significant glossectomy-mandibulectomy
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Plast Reconstr Surg 92:141–146
Chapter 6 185
Stable Internal Fixation of Osteotomies of the Facial Skeleton 6

Chapter Author: Leon A.Assael
Contributors: Leon A.Assael
Joachim Prein
rate internal fixation at the time of surgery be achieved.

6.1 Introduction Bite registration is taken in a comfortable neuromuscu-
lar centric position that reflects the desired condylar
Internal fixation of osteotomies of the facial skeleton position. The use of a nondeformable silicone or alumi-
ensures bone healing under stable conditions that per- num wax bite registration is recommended. In order to
mits immediate full function. Internal fixation also confirm the accuracy of the bite registration temporo-
determines at the time of surgery the position of func- mandibular joint laminograms can be taken with the
tional bony units of the face. Internal fixation provides bite registration in place. In cases where a centric slide is
fixation forces to counteract functional muscle forces on a potential problem preoperative laminograms taken in
the facial skeleton and thereby helps to maintain the the planned centric position can be compared with
planned surgical position throughout the course of heal- postoperative laminograms in the planned final occlu-
ing. sion to assess the accuracy of condylar position. Confir-
For surgery involving such precise fitting subunits as mation of the bite with the mounted casts at the next
the maxilla and mandible, stable internal fixation patient visit can also ensure that there is no “slide” in the
requires careful planning and expert execution. Func- bite registration.
tional dental occlusion must be established with very Dental casts are trimmed to closely resemble the
low tolerance for error. While achieving stability is the bones to be moved. The maxillary cast is trimmed to the
greatest asset of internal fixation, it is also its greatest height of the palatal plane. It is trimmed back to show
demand. the location of the piriform rim, malar buttress, tuberos-
ity, and posterior maxilla. The mandibular cast is
trimmed to the height of the symphysis (incisal edge to
6.2 Treatment Planning for Internal Fixation gnathion). The cast height is trimmed to match the
of Osteotomies height of the horizontal ramus as determined by the
cephalogram back to the gonial angle. The back of the
Stable internal fixation demands that the final position cast is trimmed flat at the level of the gonial angles and
in which bony segments are placed is determined at the mid ramus.
time of surgery. Meaningful adjustments of bone posi- These two pairs of trimmed casts are then mounted
tion are not possible without a return to the operating on a semianatomic articulator with a face bow transfer
room. Careful, systematic preoperative planning is nec- (Fig. 6.1a,b). Each cast is waxed to a plaster base. The
essary to achieve fixation in the correct position. The two pairs of casts are mounted in sequence on the same
most important aspects of preoperative planning to articulator. Marks and measurements are made to assess
emphasize with stable internal fixation are: movements at all critical sites, including the occlusal
plane, Le Fort 1 osteotomy site, and chin. Marks on the
∑ Determining thoroughly the planned movements of external oblique ridge and inferior border in the third
bone in all dimensions molar areas determine movement at those locations.
∑ Determining the movements based on a correct con- Marks on the backs of the cast reflect the medial lateral
dylar position rotation of the segments.
Model surgery is performed to reflect the correction
After clinical, cephalometric, and model evaluation to of the occlusion and the planned movement of the bone
design the main features of the planned surgery the final as determined by the clinical and cephalometric assess-
planning for internal fixation is made from the model ment of the patient. In deciding on the final position of
surgery. Two sets of alginate casts are taken and poured segments attention is given to tissue tolerances and the
in stone plaster. Only with a bite registration that reflects limitations of applying internal fixation. For example, in
the desired postoperative condylar position can accu- the ramus planned for sagittal split particular attention
186 Chapter 6 · Stable Internal Fixation of Osteotomies of the Facial Skeleton
is given to rotational movements, ramus lengthening

movements, mandibular plane angle changes, and
amount of anterior-posterior change at both the exter-
nal oblique ridge and inferior borders. Records of these
movements are made and are brought to the operating
room for intraoperative confirmation of segment posi-
tion (Fig. 6.2)
Occlusal wafer splints are constructed for all patients
in order to accurately achieve the planned position of
segments. When the surgery is in both jaws, an interme-
diate splint that reflects the maxillary movement is
made. These splints are constructed as follows. After the
planned movements are completed on the first set of
casts, a final acrylic occlusal wafer is made by: (a) lubri-
cating the final casts and eliminating undercuts, (b)
applying cold cure acrylic wafer to the maxillary teeth
a first,and (c) when the acrylic is doughy,closing the man-
dible into occlusion leaving the bulk of acrylic attached
to the maxillary dentition. The resulting shallow occlu-
sal contacts in the mandible allow a path of closure in a
natural hinge axis permitting immediate mobilization
of the mandible and full function without intermaxil-
lary fixation (Fig. 6.3).
Intermediate Splint. If the surgery is for movements in

both jaws, an intermediate splint reflecting only the
maxillary movement is then constructed as follows:
1. The mandibular cast showing surgical movement is

removed and replaced with the uncut mandibular
cast. (Alternatively, the surgical cast may be broken
out and returned to its “preoperative” position using
the line measurements).
2. With the final splint in place and attached to the max-
illary casts that reflect the surgical movement of the
maxilla, the casts and splint are greased.
3. Cold cure acrylic is applied to both the mandibular
b occlusion and the maxillary occlusal splint as the
casts are closed to the first contact. The resulting
splint reflects only the maxillary movement against
the uncut mandible.
Fig. 6.1 a, b With the model surgery completed, the intermediate

a Trimmed mounted casts in a class 2 situation. The plaster and final splints are brought to the operating room.
has been trimmed to match the measurements to be taken These are accompanied by accurate three-dimensional
for bony movements. The hinge axis is reflective of the face
bow transfer. measurements of movements at all critical sites. These
b Movements on the articulator into class I situation.The ante- measurements can be recorded on a form or reflected in
rior displacement of the mandible is visible through the constructed templates.
marks on the cast. The critical sites for these measurements in maxillary
surgery are:
∑ Central incisor midline at the occlusal plane

∑ Anterior nasal spine
∑ Piriform rims at the palatal plane
∑ Canine tips
∑ Mesiobuccal first molars occlusal plane
∑ Zygomatic buttresses at the palatal plane
6.3 · Surgical Procedures 187
These measurements are essential to ensure good trans-

verse and vertical symmetry of the face in the surgical
plan.All movements are correlated with the clinical data
base. For example, if the database indicates a left ramus
that is 5 mm longer than the right with a deviation of
pogonion 7 mm to the right, these measurements ensure
that the surgical plan corrects not only the malocclusion
but the asymmetry as well. The need to alter the surgical
movements or incorporate adjunctive procedures such
as genioplasty or bone grafting becomes apparent at this
time.
It is essential that these exact measurements are
reflected in the position of osseous segments when
stable internal fixation is applied. This must incorporate
the establishment of the preoperative condylar position
and the reapplication of condylar position at the time of
surgery. With the intermediate splint and final splints in
place, movements of the jaws are compared with move-
ments on the casts in the operating room to determine
whether the proper position of segments and condylar
position has been achieved.
Fig. 6.2
Movements on the articulator for bimaxillary procedure. The
complex asymmetrical movement in this patient demonstrates 6.3 Surgical Procedures
the changes at pogonion, anterior nasal spine and the mandib-
ular rami. These are reflective of changes that are seen at the
time of osteotomy fixation. 6.3.1 Mandibular Surgery
6.3.1.1 Sagittal Split Osteotomy
Since introduced by Spiessl, lag screw fixation has

remained the most frequent means of stable internal
fixation of sagittal split osteotomies of the mandible.
Miniplate fixation and positional screw fixation are also
used.
Several modifications of technique are helpful in
achieving stable internal fixation of the sagittal split
osteotomy. The Dalpont modification extends the buccal
vertical cut down the anterior oblique ridge to the 2nd
molar area where it is completed in the horizontal body
of the mandible. This modification permits a greater
surface area for screws, particularly in mandibular
advancement surgery. In the Hunsuck modification the
split is along the lingual surface of the ramus behind the
nerve. This improves the ability to set back the mandible
without impinging posteriorly. It also helps in proce-
dures lengthening the ramus as the masticator sling is
extended less as the distal segment moves inferiorly. The
Hunsuck modification does not permit easy placement
of screws at the inferior border however. With the Hun-
suck modification it is often necessary to place all screws
at the superior border (Fig. 6.4)
Fig. 6.3
The technique for performing the sagittal split must
also include careful attention to the mandibular nerve,
The occlusal wafer on the casts. The final position of the
planned osteotomies is determined by the occlusal wafer con- which results in its placement in the distal segment
structed on the mounted dental casts. without impingement. When the segments are placed,
Inset: Occlusal cast visible from above on the mandibular teeth. the position of the nerve must be confirmed. The place-
ment of screws only on the superior border or the use of

monocortical plate fixation may result in less risk of
neurotmesis and compression injury of the mandibular
nerve.
The position of the distal segment of the sagittal split
is determined when the patient is placed in occlusion in
the final splint. Proximal segment position can be deter-
mined either by a condylar positioning device or manu-
ally. In either case the recorded movements of the model
surgery are compared with those achieved in the oper-
ating room at the superior and inferior border. If man-
ual positioning is performed, a Dingman bone holding
forceps or other clamp on the anterior border is a useful
device to maintain the segments since its paired beaks
engage while they are still separated. This prevents over-
compression of the proximal segment, which may result
in lateral positioning of the condyle.
Fig. 6.4
The surgeon may elect to position the proximal seg-
ment via direct measurements taken from the model
Hunsuck modification. The sagittal split osteotomy is modified
by incompletely performing the osteotomy to the posterior surgery or through the use of a condylar positioning
border above the lingula. This results in an osteotomy within device. Condylar positioning devices are designed to
the lingual cortical plate. reproduce the preoperative relationship between the
Fig. 6.5
Alternative condylar positioning devices.Attachment of a plate
from mandibular ramus to zygoma or maxilla prior to sagittal
split can position the proximal segment prior to screw fixation.
a b
Fig. 6.6 Inset b: The use of a shim of bone to prevent lateral condylar
Correct fixation of sagittal split osteotomy and anterior displacement can be performed with a single lag screw in the
advancement of mandible. Anterior gaps are kept and stabi- most proximal position followed by positional screws placed
lized with positioning screws. Posterior natural contact area is through the sandwiched shim bone graft. A piece of the dis-
stabilized with a lag screw. tal aspect of the proximal segment can be removed to serve
Inset a: Lateral condylar displacement due to lag screw fixation as this graft.
in natural gap area. Under these circumstances the distal Insets c,d,e: The various possible placements of either lag or
aspect of the proximal segment is displaced medially. positoning screws.
Fig. 6.7 Fig. 6.8 a–c

Fixation of sagittal split osteotomy for class 3 occlusion. Natu- Plate fixation of sagittal osteotomy. Monocortically applied
ral contact area in distal aspect of proximal segment where a plates provide accurate positioning but inferior fixation forces
lag screw is used. The other screws are placed as position in the mandibular sagittal split osteotomy.
screws. a One 2.0 miniplate.
b Two 2.0 miniplates.
c Split fix plate, or adjustable saggittal split plate.
proximal segment of the mandible and the maxillary screws and positioning screws in retropositioning of the
base. In this case a plate is bent and fixed to the lateral mandible.
border of the ramus and maxilla (cephelad to any max- Condylar position and stable internal fixation can
illary osteotomy) before the osteotomy is completed. also be achieved through the use of a monocortically
The plate is removed. Following the completion of the fixed plate with 2.0-mm screws on the external oblique
osteotomy the plate is replaced while the final ramus fix- ridge. This permits fixation without condylar displace-
ation is completed (Fig. 6.5). ment. Mechanical load resistance with this technique is
Understanding the planned movements in three inferior to that with screw fixation of the ramus. For this
dimensions assists the surgeon in deciding what modifi- reason two plates are used by some surgeons for each
cations in the osteotomy to perform, whether to use osteotomy (Fig. 6.8).
bone graft shims, and which method of internal fixation
to employ. In mandibular advancement surgery tight
clamping (or a lag screw at area of natural gap) of the 6.3.1.2 Other Ramus Osteotomies
ramus causes the condyle to position laterally (Fig. 6.6,
inset a). In this instance positional screws or a single lag The vertical ramus osteotomy is not commonly used
screw can be used at the point of natural contact fol- with stable internal fixation because of the many prob-
lowed by two positional screws (Fig. 6.6, inset b). Addi- lems in maintaining the preoperative condylar position
tionally, bone contact without condylar displacement and the risk to the mandibular nerve when transbuccal
can be assisted by placing a “shim” between the seg- screws are applied. There have been reports of miniplate
ments (Fig. 6.6, inset b) with lag screw fixation. Further fixation of the proximal segment, but the ability to apply
examples of the geometry of screw fixation are shown in immediate full function has not been established. As a
Fig. 6.6, insets c–e). Figure 6.7 shows the placement of lag result most vertical ramus osteotomies are still per-
Fig. 6.9
Inverted L osteotomy. Fixation with a stabilization plate with
four screws per segment is recommended since this osteotomy
is the mechanical equivalent of a mandibular continuity defect.
formed without direct osteosynthesis and with inter- Fig. 6.10

maxillary fixation. Genioplasty fixation. Miniplate or lag screw fixation can be
Inverted L osteotomies are used with stable internal employed to fix the genioplasty osteotomy.
fixation when the procedure is used for ramus lengthen-
ing and advancement with an interpositional bone graft.
The inverted L is especially useful in a short ramus such of straight plates, or a single T-, Y-, H-, or X-shaped 1.5-
as hemifacial microsomia when a large ramus lengthen- or 2.0-mm plate. When combined with a subapical oste-
ing and onlay bone grafting is planned. otomy, a single H-shaped plate or straight plates can
This procedure is performed with a retromandibular provide fixation to both osteotomies simultaneously.
transcervical incision. After intermaxillary fixation the Screws are usually 4–6 mm long.
proximal segment can be positioned with the AO bone Lag screws may be placed transorally with genio-
holding forceps spread apart with the wing nut engaged. plasty. The inferior border of the distal segment to the
Movements at the inferior and superior borders are lingual plate of the superior segment provides the
checked with the surgical plan to ensure condylar posi- appropriate direction for many situations. The advan-
tion. (Alternatively, a transoral condylar positioning tages of the 2.0 screw (16–22 mm long) are that mentalis
device attached to the coronoid process may be used.) muscle and muscle resuspension can be reattached
Fixation of the segments and graft are completed with a more easily, and that no plate is palpable in the mental
2.4 reconstruction plate or a Universal Fracture plate. fold (Fig. 6.10).
Four screws in both the proximal and distal segment are
recommended to permit full function in this procedure.
Onlay bone grafts,if indicated,can then be attached with 6.3.1.4 Mandibular Segmental Surgery
lag screws (Fig. 6.9).
Anterior mandibular subapical osteotomy is performed
in the usual manner, with attention to making the infe-
6.3.1.3 Genioplasty rior osteotomy at least 5 mm apical to the canine apex.
The segment is positioned in its occlusal wafer with
Anterior mandibular horizontal osteotomy is per- maxillomandibular fixation. A straight plate, T, L, H, or
formed with a power saw in the routine manner. For X plate can be employed to provide monocortical fixa-
complex movements temporary fixation can be tion with 2.0- or 1.5-mm screws. Lag screws are usually
obtained with a transosseous wire or a single lag screw. not practical due to the proximity of the tooth apices.
Final three-dimensionally stable fixation of this osteot- Fixation of subapical osteotomy can be combined
omy can be achieved with two or more lag screws, a pair with genioplasty fixation through the use of a variety of
The maxilla is positioned in all three dimenions for

fixation by assuring the following components:
∑ The placement of the teeth into the final occlusal

wafer
∑ The position of the condyles in centric relation
∑ The vertical position of the maxilla as measured at
the osteotomy site
Teeth must rest passively in the occlusal wafer with the

patient in maxillomandibular fixation. Wire fixation of
the appliances is normally performed with a stiff arch
wire and at least four maxillomandibular loops. Posi-
tioning of the condyle with the patient supine under
general anesthesia is often problematic. The tendency is
for the maxilla to come too far forward in superior
autorotation due to the forward slide induced at the pos-
terior medial sinus wall. This thick bone of the vertical
process of the palatine bone must be relieved after the
patient is in the splint, and interferences are identified.
An additional site of interference for upward and back-
ward movement of the maxilla is the pterygoid plates.
Since the pterygoid plates project forward superiorly,
relief of the tuberosity bone may be necessary to permit
upward movement.
Forcing the condyle too far backward during maxil-
Fig. 6.11 lary positioning may result in a maxilla that is fixed too
Subapical osteotomy and genioplasty. Miniplate fixation is far posteriorly. The mandible is best rotated into the
combined to support both osteotomies via the isthmus of bone final maxillary position with upward manual movement
between the segments.
of the angles of the patient’s mandible. Backward pres-
sure on the chin risks overseating the condyle.
The vertical position of the maxilla is determined
plate combinations. Fixation of the isthmus of bone from the model surgery. Measurements are easily taken
between the genioplasty should be part of the screw fix- at the piriform rim and zygomatic buttress. Measure-
ation scheme in order to prevent rotation of the segment ments in the midline or incisor can be made only with a
(Fig. 6.11). cranial positioning device. These devices are not neces-
sary when maxillary movements are measured from
models that are articulated via face bow transfer. For
6.3.2 Midface Surgery: Le Fort I Osteotomy example, a 4-mm downward movement at the piriform
rim accomplished by mandibular autorotation might
The performance of the Le Fort I osteotomy is not sub- result in 6 mm of movement at the incisor.Vertical posi-
stantially altered by the use of plate and screw fixation. tioning of the maxilla is also assisted by the placement
The surgeon should give attention to recording the of interpositional bone grafts when downward move-
movements of the maxilla by making score lines or holes ment is planned. These grafts are placed in the piriform
to measure maxillary movement. The location of the rim and zygomatic buttress regions.
osteotomy in the piriform rim should allow the place- Fixation of the Le Fort I osteotomy depends upon the
ment of screws apical to the teeth in the premaxilla. At direction of movement and the buttressing of the max-
least 5 mm of bone apical to the molars and premolars illa achieved by direct bone contact. If the patient is not
is helpful in permitting the safe placement of screws in in maxillomandibular fixation, the loads applied to the
these locations. Prior to the initiation of any fixation the osteotomy site are predominantly compressive. For
closure of nasal mucosal rents, any necessary turbinec- superior movement of the maxilla where bone contact is
tomy, septoplasty, and relief of the medial sinus wall excellent, the use of two plates at the piriform rim with
should be completed. Hemostasis should be ensured six screws per plate can be sufficient. The most widely
prior to fixation with attention to impingement around used are 2.0- and 1.5-mm screws with L plates or arched
the anterior palatine arteries. plates. The bone of the lateral piriform rim and the bone
6.4 · Evaluation of Outcomes 193
Fig. 6.12 Fig. 6.13

Miniplate fixation of the Le Fort I osteotomy. Plates at the piri- Interpositional bone grafts. The Le Fort I osteotomy performed
form rim and zygomatic buttress provide support in the thick- for downward movement can incorporate interpositional bone
est bone of the maxilla. grafts wedged beneath the miniplates. This should be per-
formed for gaps wider than 4 mm.
apical to the central and lateral incisor generally provide

the best stability. Bicortical fixation of these screws can 6.4 Evaluation of Outcomes
be achieved by passing the inferor screws as far as the
nasal floor and the superior screws can engage both the Patients are allowed full function after osteotomies per-
piriform rim and the lateral nasal wall. Usually for all formed with stable internal fixation. Initial postopera-
osteotomies where bone contact buttressing is incom- tive clinical evaluation should ensure that the patient is
plete, additional plates are subsequently placed at the closing into the splint perfectly. Postoperative radio-
zygomatic buttress (Fig. 6.12). For downward movement graphs assess jaw position, osteotomies and the position
of the maxilla interpositional grafts can be wedged of plates and screws are taken with the patient closed
beneath the miniplates (Fig. 6.13). into the splint (Fig. 6.14b). Lateral and posterior ante-
If segmental maxillary surgery is performed, the rior cephalograms and orthopantomogram are nor-
occlusal splint creates a single unit of the maxilla. Four mally taken (Fig. 6.14b–d).
plates are generally used to provide maximum stability Elastics are often used to guide the patients jaw func-
once the occlusal wafer is removed several weeks post- tion since proprioception of the postoperative jaw posi-
operatively. Cross-arch stability can be assisted by plac- tion is sometimes difficult. Elastics can manage only
ing a plate across the midline on the facial aspect of the very small errors in jaw position and should not be used
premaxilla. If the maxilla has been split for access as in to provide orthopedic forces.
a tumor case, transpalatine fixation is sometimes used The use of stable internal fixation does not obviate
(see Fig. 4.2.10, inset 3). the possibility of late surgical relapse. Careful assess-
a b
Fig. 6.14 a–d

Radiographic documentation. Comparison of the preoperative
and postoperative cephalograms (a,b) along with orthopanto-
mogram (c) and posterior anterior cephalogram (d) allows
complete radiographic analysis of the surgical outcome.
ment of stability in the first 3 months is necessary to

ensure uneventful initial healing phase.
Figures 6.15 and 6.16 show further clinical cases.
d
6.4 · Evaluation of Outcomes 195
a b
Fig.6.15 a–d
a Facial asymmetry due to loss of condylar area on the right
side during childhood. The mandibular ramus on the right
side is too short and in consequence the occlusal plane is
deviated. The facial height on the right side is shorter than
on the left. This facial asymmetry is comparable to hemifa-
cial microsomia.
b Surgical correction of facial asymmetry described in a. The
correction consists of a Le Fort I osteotomy, a sagittal split
osteotomy on the left, a chin osteotomy and correction with
a bone graft in the right mandibular area.
c Postoperative orthopantomogram of the situation shown in
b.
d X-ray showing posterior-anterior view of the same opera- d
tion as described in b.
Fig. 6.16 a–d

a Diagram of patient with extreme underdevelopment and
retroposition of the maxilla and elongation of the facial
height accordingly.
b Lateral cephalogram showing the retropositioning of the
maxilla and elongation of the facial height as described in a.
c Postoperative cephalogram as in b, after a high Le Fort III
osteotomy with an advancement of the midface and a sagit-
tal split osteotomy after retropositioning of the mandible.
Fixation of the osteotomies with the 2.0 system.
d Diagram showing the osteotomies and their fixation as men-
tioned in c. d
6.5 · Complications 197
6.5 Complications
Comminuted osteotomies may occur during mobiliza-

tion or during plate and screw fixation. This is most fre-
quent during the sagittal split osteotomy. Care should be
taken to identify weak areas for fixation and to avoid
overtightening screws. The most frequent sites for com-
minution are the lingual plate at the angle region, par-
ticularly when a third molar is present, and the buccal
plate in midramus. If comminution occurs, the commin-
uted segment can be built in larger subunits, permitting
stable internal fixation in most cases (Fig. 6.17).
Palpable hardware is most often a factor at the piri-
form rim and nasomaxillary region. The use of 1.5-mm
plates has not substantially reduced the palpability of
this hardware. Due to the thinness of the cortical bone in
the ramus osteotomy countersinking is seldom carried
out. Symptomatic hardware is rare, but when it is a fac-
tor it may be due to muscle gliding over plates and
screws during movement.
Malocclusion in stable fixation of osteotomies may be
the result of malpositioned segments or problems in the
splint, condylar position, temporomandibular joint disc
position, path of closure, or neuromuscular guidance.
Postoperative malocclusion calls for early analysis of the
cause and appropriate intervention. This may include
the use of temporomandibular joint imaging with the
b patient in correct maxillomandibular fixation. It may
include removal of the splint, removal of the plates and
screws and refixation in the corrected position, a new
clinical data base, and diagnostic casts.
Fig. 6.17
Comminution of the sagittal osteotomy. Reconstituting major
segments in the event of comminution usually produces stable
c internal fixation of the comminuted osteotomy.
Harsha B, Terry B (1986) Stabilization of Le Fort I osteotomies

6.6 Summary utilizing small bone plates. Int J Adult Orthod Orthog Surg
1:69
Jeter T,Van Sickels J, Dolwick M (1984) Modified techniques for
Stable internal fixation of osteotomies of the jaws internal fixation of sagittal ramus osteotomies. J Oral Maxil-
affords the opportunity for immediate function, assur- lofac Surg 42:270–272
ing the planned surgical position,and less relapse for the Kent J, Craig M (1996) Secondary autogenous and alloplastic
orthognathic surgical patient. Successful application of reshaping procedures for facial asymmetry. In: Atlas of oral
this technique depends upon careful planning and and maxillofacial surgery clinics of North America, vol 4. pp
83
achievement of the surgical treatment plan in the oper- Kirkpatrick T, Woods M, Swift J, Markowitz M (1987) Skeletal
ative setting. stability following mandibular advancement and rigid fixa-
tion. J Oral Maxillofac Surg 45:572–576
Precious D, Armstrong J, Morais D (1992) Anatomic placement
References and Suggested Reading of fixation devices in genioplasty. Oral Surg 73:2–8
Shafer D, Assael L (1993) Rigid intrnal fixation of mandibular
segmental osteotomies, vol 1. Atlas of oral and maxillofacial
Ardary W, Tracy D, Brownridge G, Urata M (1989) Comparative surgery clinics of North America. pp 41–53
evaluation of screw configuration on the stability of the sag- Smith B (1993) Presurgical management. In: Atlas of the oral
ittal split osteotomy. Oral Surg 68:125–129 and maxillofacial surgery clinics of North America, vol 1. pp
Ellis E (1990) Accuracy of model surgery: Evaluation of an old 1–15
technique and introduction of a new one. J Oral Maxillofac Spiessl B (1976) Rigid internal fixation after sagittal split oste-
Surg 48:1161 otomy of the ascending ramus. New concepts in maxillofa-
Ellis E, Hinton RJ (1991) Histologic examination of the tem- cial bone surgery. Springer, Berlin Heidelberg New York
poromandibular joint after mandibular advancement with Spiessl B (1989) “Osteotomies” in internal fixation of the man-
and without rigid fixation: an experimental investigation in dible. Springer, Berlin Heidelberg New York
adult Macaca mulatta. J Oral Maxillofac Surg 49: 1316–1327 Steinhäuser E (1982) Bone screws and plates in orthognathic
Ellis E, Tharanon W, Gambrell K (1992) Accuracy of face bow surgery. Int J Oral Surg 11:209
transfer. Effect on surgical prediction and postsurgical Taylor T (1993) Complications of osteotomies with rigid fixa-
result. J Oral Maxillofac Surg 50:562–567 tion. In: Atlas of the oral and maxillofacial surgery clinics of
Foley W, Frost D, Paulin W, Tucker M (1989) Internal screw fix- North America, vol 1. pp 87
ation: comparison of placement of pattern and rigidity. J Tucker M (1988) Use of rigid internal fixation for management
Oral Maxillofac Surg 47:720–723 of intraoperative complications of mandibular sagittal split
Franco J,Van Sickels J, Thrash W (1989) Factors contributing to osteotomy. Int J Orthod Orthognath Surg 3:71
relapse in rigidly fixed mandibular setbacks. J Oral Maxillo- Van Sickels J, Tiner B (1993) Midface and periorbital osteoto-
fac Surg 47:451–456 mies. In: Atlas of oral and maxillofacial surgery clinics of
Hackney F, Van Sickles J, Nummikoski P (1989) Condylar dis- North America, vol 1. pp 71–86
placement and temporomandibular joint dysfunction fol- Van Sickels J, Larsen A, Thrash W (1986) Relapse after rigid fix-
lowing bilateral sagittal split osteotomy and rigid fixation. J ation of mandibular advancement. J Oral Maxillofac Surg
Oral Maxillofac Surg 47:223–227 44:698
Harle W (1980) Le Fort I osteotomy using miniplates for cor-
rection of the long face. Int J Oral Surg 9:427
Chapter 7 199
Craniofacial Deformities 7
Chapter Author: Paul N.Manson
Contributors: Paul N.Manson
Craig A.Vander Kolk
Benjamin Carson
region. Since intracranial migration is especially prone

7.1 Introduction to occur in those with syndromal craniosynostosis,
some consideration for removing fixation materials,
The earliest craniofacial surgery began in the 1930s with especially in the temporal region, should be given in
Gillies’ Le Fort III osteotomy in a patient with Crouzon’s these cases. The placement of fixation material can also
syndrome. In the 1950s and 1960s Tessier demonstrated contribute to palpable or visible plates. Craniofacial sur-
that midface and intracranial approaches can be used geons were initially concerned about growth restriction
for cranial vault and facial osteotomies for correction. from fixation; however, it has been difficult to document
The field rapidly expanded with complex craniofacial that growth restriction exceeds 5%–8%. Currently its
deformity correction: hypertelorism, frontal and facial benefits therefore exceed its disadvantages by virtue of
retrusion, facial clefts, orbital dystopia, enophthalmos, the increased stability created.
Treacher Collins syndrome, and hemifacial microsomia Reliable internal fixation stabilizes osteotomy seg-
were managed. ments and thus maintains their position. Often the
The early surgical techniques consisted of direct vis- expansions created in craniosynostosis correction are
ualization of deformed segments, skeletal osteotomies, subject to considerable soft-tissue pressure. This pres-
wire fixation, and the use of liberal amounts of bone sure produces forces creating relapse which are effec-
graft to complete the reconstruction. Complex osteoto- tively opposed only by strong fixation material. Internal
mies were initially designed with “tongue in grove” and fixation stabilizes the reconstruction for protection of
“Z-plasty” techniques to splint and reenforce the recon- patient positioning postoperatively, even on the osteot-
struction. The current use of rigid fixation has made omized segment.
design of such complex osteotomies obsolete. Although Stable fixation counteracts soft-tissue forces acting
craniofacial surgeons largely prefer fresh, autogenous on the osteotomized segment in the early postoperative
bone for transplantation and reconstruction, the use of period. The patient can also be positioned on the recon-
newer materials (such as bone forming materials, structed area. Stable fixation prevents relapse and col-
hydroxyapatite, Medpor,and bioceramics) offer promise lapse of the reconstruction, decreasing the potential for
for the future if their long-term safety and efficacy can secondary revision.
be documented. Sufficient internal fixation also limits bone motion in
Craniofacial surgery has received a tremendous stim- the postoperative healing phase, thereby increasing
ulus from the development of computed tomography, to bone survival. It produces less complicated bone wound
include three-dimensional reconstructions. These healing, with progress toward primary bone healing.
reconstructions currently function to provide a detailed Stable fixation most probably decreases the tendency
and composite picture of the deformity and its correc- toward infection. The disadvantages of internal fixation
tion (Fig. 7.1). Surgical simulations may be performed include the cost and concerns about potential growth
with computer imaging, providing a standard for plan- restriction, loosening, migration, and plate prominence.
ning the reconstruction and assessing the postoperative Loosening, plate prominence, and translocation are seen
result. mostly in the temporal regions and in younger patients
The main advantage of internal fixation is that it and those with syndromal synostoses.
creates stability of osteotomized bone segments. It has
been shown that bone survives better with stable fixa-
tion in most circumstances. In young infants the use and
placement of stable fixation devices should be carefully
determined to avoid problems with translocation of
plates (intracranial or intracalvarial) which generally
occurs in syndromal synostoses and in the temporal
200 Chapter 7 · Craniofacial Deformities
a b
c d
Fig. 7.1 a–d

Three-dimensional CT reconstructions provide a detailed and
composite picture of the cranial deformity.
7.3 · Craniosynostosis 201
a b
Fig. 7.2 a, b
Incisions used for cranial reconstruction include the coronal The use of a posterior “T” incision extending from the coro-
incision and extensions. This involves an incision from ear to nal to allow for improved exposure for posterior reconstruc-
ear which is generally carried out behind the ear if lower exten- tion.
sion is required (dotted lines). It can be “zigzagged” for a less When hypertelorism with a bifid nose is present requiring
apparent incision (technique of Munro or “stealth” technique; resection of anterior skin and correction of the bifid nose, an
see also Chap. 2). anterior T can be extended to the nasal tip which allows direct
exposure and excision of excess tissue.
Fig. 7.3
The sphinx position.
7.2 Incisions for Craniofacial Reconstruction 7.3 Craniosynostosis

and Patient Positioning
Craniosynostosis, or premature fusion, can involve any
The coronal incision is the most common incision used cranial suture. Early fusion of the suture limits cranial
for craniofacial reconstruction (Fig. 7.2). When the full growth. There are eight identifiable cranial sutures.
cranium is reconstructed (Fig. 7.2b), a “T” is developed Three sets are paired: right and left coronal, right and
from the coronal incision which extends posteriorly to left lambdoid, and right and left squamosal (Fig. 7.4).
allow for reconstruction.When hypertelorism with bifid The two midline sutures include the sagittal suture and
nose is present, an anterior “T” (see Fig. 7.2b) allows the metopic suture (Fig. 7.5a). One should also be aware
exposure and permits excision of excess tissue. The that there is a nasal frontal suture (Fig. 7.5a) anteriorly
positioning for a full cranial reconstruction in older and cranial base suture extensions (Fig. 7.5b).
children can be the “sphinx” position (Fig. 7.3). When When sutures undergo premature fusion or have a
the reconstruction is staged, the anterior and posterior growth restriction, they decrease the ability of the skull
coronal or “T” incisions are used, and the patient is posi- to adapt to the growing brain. It is now known that the
tioned prone for the posterior and supine for the ante- size of the brain in patients with craniosynostosis is gen-
rior. erally normal or increased. The complex relationship
between the dura, brain, and signals providing suture
Sagittal
Coronal
Squamosal
Lambdoid
Fig. 7.4
There are three sets of paired
p cranial sutures, the right
g and left
coronal, the right and left lambdoid, the right and left squamo-
sal.
closure are not presently known. Several general theo- The term “plagiocephaly” is derived from the Greek
ries have been formulated to predict the etiology. Vir- and means literally “twisted skull.” It is used to describe
chow stated that the deformity is related to the fusion of the syndrome in which a coronal or lambdoidal suture
the suture itself. Moss’ theory was related to the postu- fuses prematurely and results in lack of growth. The
late that the abnormality begins in the cranial base in the term “anterior plagiocephaly” refers to involvement of
synchondroses and secondarily affects the cranial vault. the coronal suture and “posterior plagiocephaly” to that
Other investigators have suggested that the abnormality of the lambdoidal suture. Coronal suture synostoses
begins in the mesenchymal blastema and is related to cause ipsilateral or bilateral frontal flattening. In unilat-
the dura where tensile forces of the growing brain are eral deformities one finds a decrease in the transverse
not adequately transmitted in signal fashion to the diameter of the ipsilateral orbit, anterior placement of
suture, providing an inadequate stimulus to grow. the ear, deviation of the chin point to the opposite side,
Recent reports suggest that abnormalities of growth deviation of the nose to the ipsilateral side, contralateral
factors occur within the suture. It is known that some of frontal “bossing,” and contralateral occipital flattening
the syndromal synostoses, such as Crouzon’s syndrome, (Fig. 7.6).
have a mutation in the FGFR-2 gene. Fibroblast growth True lambdoidal synostosis is rare; many posterior
factor is one of the growth factors. In the Boston crani- postural or positional deformities can be mistaken for
osynostosis syndrome there is a mutation of a Homeo- synostosis; three-dimensional computed tomography is
box gene, MSX-2, which is thought to control the growth necessary to document fusion of the suture to confirm
and expression of other genes that control differentia- partial or complete synostosis (Fig. 7.7). Positional
tion and growth. As craniosynostosis develops, the deformities are generally managed by the use of a hel-
growth of the skull is limited in a direction perpendicu- met or positioning techniques for infant sleeping which
lar to the suture. A flattening in the region around the molds or relieves sleeping pressure on the skull. When
suture results in cranial deformity. There is usually com- both coronal and lambdoidal sutures are involved, ante-
pensatory overgrowth on the contralateral side. When rior or posterior brachycephaly occurs. The deformity
multiple sutures are fused, the tendency to develop consists of anterior-posterior flattening, increased verti-
increased intracranial pressure increases as the ability to cal height of the skull and shortening of the cranial base
compensate with compensatory overgrowth decreases. (Fig. 7.8).
7.3 · Craniosynostosis 203
Sagittal
Metopic
Coronal
Squamosal
Lambdoid
Nasofrontal
Fig. 7,5 a, b
a There are two midline individual sutures, the sagittal suture
and the metopic suture. The nasofrontal suture is present at
the junction of the nose and frontal bone.
b Cranial base sutures are sometimes used for base osteoto-
mies.
Fig. 7.6
The deformity of plagiocephaly is related to unilateral coronal
synostosis. Ipsilateral frontal flattening, contralateral frontal b
bossing, ipsilateral occipital flattening, deviation of the chin
point to the opposite side, deviation of the nose to the ipsilat-
eral side and movement of the ear position anteriorly are char-
acteristic of the deformity.
▼
Fig. 7.7
Postural synostoses generally consist of ipsilateral flattening
with contralateral bulging posteriorly. Posterior positioning of
the ear is seen. These are managed by sleeping positioning
techniques, and helmet therapy for head molding.
Fig. 7.8
Invo
olvement of both coronal sutures produces anterior brachy-
ceph
cephaly.
Fig. 7.9
Sagittal synostosis produces scaphocephaly.
7.5 · Surgical Technique: Anterior Cranial Expansion and Reconstruction 205
Apert’s syndrome. Anterior cranial expansions include

procedures performed for either right or left isolated
coronal synostosis, right and left bilateral coronal syn-
ostosis, and metopic synostosis. Posterior cranial
expansion is used for the right or left isolated and bilat-
eral lambdoid deformities. Subtotal or total calvarial
expansion is used for sagittal synostosis if it does not
respond early to osteotomy. Le Fort III, frontal cranial
advancement, and monoblock procedures correct the
midface and frontal bone deformities singularly or
simultaneously (monoblock).
Fig. 7.10
Trigonocephaly is produced by premature closure of the 7.4 Planning and Reconstruction
metopic suture. It is often accompanied by hypotelorism.
The planning for reconstruction is based on a physical
examination and an initial diagnosis which is supported
Isolated sagittal suture synostosis is one of the most by data obtained from axial and three-dimensional
common synostoses. Skull growth is restricted laterally, computed tomography (see Fig. 7.1). This scan can be
causing an increased anterior-posterior length of the placed in a data base for archival data collection and
skull. Sagittal synostosis in infants under 4 months of retrieval. Both bone and brain windows should be col-
age is managed initially by resection of the involved lected to provide maximal information. Brain windows
suture. Thereafter sutural resection and osteotomies are evaluate the amount of compression of the brain and the
required to expand the cranial vault. Sagittal synostosis restriction of the fluid spaces or ventricles secondary to
demonstrates impaired growth in an elongated skull the growth restriction. Redistribution of the subarach-
with increased anterior-posterior length. This produces noid fluid with brain compression directly below the
dolichocephaly or scaphocephaly (Fig. 7.9). When the area of synostosis often occurs with digital impressions
metopic suture undergoes premature fusion, there is in the bone.Cerebral circulation may be decreased in the
diminished growth in the right and left sides of the fore- scan. Compensatory changes are sometimes seen on the
head, with a prominent ridge anteriorly. The triangular contralateral side in unilateral deformities.
skull shape produced is known as trigonocephaly
(Fig. 7.10). Hypertelorism is also frequently noted in
these patients. Bilateral coronal synostosis produces 7.5 Surgical Technique: Anterior Cranial Expansion
brachycephaly, a tower skull with reduced anterior-pos- and Reconstruction
terior growth.
The deformities resulting from synostosis are always Anterior cranial expansion begins with a coronal inci-
more complex than those seen in the local area around sion. The frontal and temporal areas are exposed sub-
the involved suture. Compensatory changes are seen at a periosteally, leaving the temporalis muscles attached to
distance in the skull. Delashaw has postulated that other the subcutaneous tissue. This provides a generous expo-
sutures of the cranium try to compensate for the synos- sure to the entire frontal and both temporal regions (see
tosis. The variable effects produced require considera- Fig. 7.2).
tion not only of the area of major growth restriction but An anterior bone flap (Fig. 7.11) is developed which
contralateral areas as well. Therefore in treating a pla- permits dissection along the anterior cranial base to
giocephaly there are techniques for both unilateral and expose the orbital rooves and crista gali. The olfactory
bilateral forehead osteotomies. Most surgeons generally nerves are not disturbed.
prefer a bilateral osteotomy because the compensatory The orbits are dissected medially, superiorly, and lat-
changes on the noninvolved side are addressed better by erally down to the body of the zygoma. Osteotomies are
the bilateral osteotomy, permitting increased symmetry performed (Fig. 7.12) across the roof of the orbits; the
to be achieved. sphenoid and frontal process of the zygoma are sec-
Three types of reconstruction are commonly per- tioned at the malar eminence on the involved side and at
formed in craniofacial reconstruction: anterior cranial the zygomaticofrontal suture on the uninvolved side
expansion, posterior cranial expansion, and total cranial (Fig.7.12a).If the deformity is bilateral (Fig.7.12b),such
expansion. There are two varieties of hypertelorism pro- as in metopic synostosis, the osteotomies are performed
cedures, the “box” orbital osteotomy and the “V” exci- at the junction at the malar eminence and the frontal
sion bipartition or facial split osteotomies of Vander process of the zygoma. This allows a complete “lateral
Muellen, Monasterio, and Tessier, which are used in canthal advancement” with anterior rotation. Osteoto-
Fig. 7.11 Fig. 7.12 a, b
▼
The anterior frontal bone flap can be removed following its dis- After dissecting the orbits medially, superiorly and laterally
section by peripheral or central burrholes. Its removal permits down to the body of the zygoma, osteotomies may be per-
dissection along the anterior cranial base, roof of the orbits and formed on the involved side at the malar eminence and at the
exposure of central structures such as the cribriform plate and zygomaticofrontal suture on the uninvolved side. Advance-
crista gali. The olfactory nerves are not disturbed. ment of the frontal process of the zygoma produces a complete
lateral canthal advancement by anterior rotation of the lateral
orbit. Frontal bar advancement may be unilateral (a) or bilat-
eral (b).
mies are made across the nasofrontal suture. This expo- tioned by plates placed in the temporal hollow region
sure allows the entire area of the deformity to be (Fig. 7.16).
accessed, osteotomized, and repositioned. Finally, the frontal bone is contoured by bending bar-
When a temporal region is recessed, the temporal rel stave or partial or complete peripheral osteotomies.
bone can be removed and replaced in an improved posi- The frontal bone is then plated into position (Fig. 7.17;
tion (Fig. 7.13). The temporal regions were formerly junctional stable fixation). The bone dust saved from the
used for a “tongue in groove” articulation of bone for osteotomies and burrholes is then placed on the areas of
stabilization (Fig. 7.14). Now, however, temporal bones the osteotomies.An anterior osteotomy is generally per-
can be widely exposed, removed, recontoured, and repo- formed at the nasofrontal region, which avoids dissec-
sitioned without compromising stability because of tion of the insertion of the medial canthal ligament. In
stable fixation techniques, correcting the temporal con- younger infants the segments of bone can be bent with
tour. If the orbit is constricted in a mediolateral direc- finger manipulation or a Tessier bone-bending forceps.
tion, it can be osteotomized and an interpositional bone After the age of 1 year, the bone is too brittle for bend-
graft placed (Fig. 7.15). Otherwise, the frontal bar is bent ing; inner table scoring is then used to allow for bend-
to conform to a normal, bilateral symmetric configura- ing, as are greenstick fractures. Sometimes greenstick
tion and plated into position at the lateral temporal and fractures or partial osteotomies need to be supported by
nasofrontal junctions. It is generally plated and posi- plate and screw fixation to maintain position. The orbi-
b
Fig. 7.13
Retrusion of the ipsilateral temporal regiion can be managed by
replacement of the temporal bone in aan improved position.
Rigid
i id fixation
fi i stabilizes
bili theh repositioned
ii d segment.
Fig. 7.14
Prior to rigid fixation, the temporal regiions were advanced by
the use of a “tongue in groove” assemblyy of bone for stabiliza-
tion.
Fig. 7.15
If the orbit is constricted in a medial to llateral direction, it can
be osteotomized and an interpositionall bone graft placed to
correct iits width.
id h
Fig. 7.16
The frontal bar is bent (infant bone is maalleable) to produce an
ideal contour, and placed in an advanced position. Plates secure
its position and are generally placed in th
he temporal hollow so
that they are less visible and palpable. F
Fixation at the zygoma
and nasofrontal regions
g is completed.
p
Fig. 7.17 otomy begins 5–8 cm above the junction of the left
The frontal bone flap may be reversed 180° in plagiocephaly lambdoidal sutures and along the sagittal suture. It then
correction. It can be further contoured by peripheral, “barrel extends in a curvalinear fashion to involve the asterion
stave” or sectional osteotomies which can be stabilized with
small internal fixation devices. The frontal bone flap is stabi- region. The inferior osteotomy is performed below the
lized by marginal rigid fixation. Bone dust saved from the oste- transverse sinus. A central transverse osteotomy below
otomies and burrholes is placed into areas of osteotomy gap. the junction of the lambdoidal sutures divides a poste-
rior craniotomy into two segments (Fig. 7.18). The seg-
ments are elevated, and a lower “occipital bar” can be
harvested which allows the same facility of reconstruc-
tal segments are advanced into a slightly overcorrected tion as anterior by moving and positioning the “frontal
position and held in place with microreconstruction bar.”
plates or 1.3 plates. In children 3-mm screws should be For right or left isolated lambdoid suture synostosis,
used since these have not been shown to cause dural the bone segments may be rotated 190°. This allows the
penetration if intracranial migration occurs. Bone grafts expanded bone from the contralateral (compensatory)
can also be used in contour modes and lag screwed into area to be placed on the ipsilateral or flattened side. The
position. Some fixation is usually necessary at the naso- flattened ipsilateral bone can be placed loosely on top of
frontal junction. the bulging dura and the contour deformity corrected.
Extending the rotation a little bit beyond 180° assists in
providing adequate expansion and fixation.
7.6 Posterior Cranial Expansion If an occipital bar is not required, the advanced seg-
ment is held in place with “stepped” reconstruction
Isolated posterior cranial expansion is carried out plates bent to allow the appropriate advancement.“Bar-
through a biparietal incision (see Fig. 7.2). Subperiosteal rel stave” peripheral osteotomies are sometimes per-
dissection is used to expose the occiput and lambdoid formed in the bone flap to increase the contour. The bar-
areas down to the occipital region, in the junction of the rel staving allows contouring to be performed. This
posterior neck muscles. A two-piece parietal-occipital same technique can be used in the frontal bone.
craniotomy is usually performed in a transverse fashion,
completely encompassing the skull deformity. The oste-
7.7 · Complete or Subtotal Calvarial Expansion 211
Fig. 7.18
The posterior cranial expansion involves removal of the poste-
rior skull and vertex with creation of a one of two segments and
posterior expansion and vertical height reduction. A lower
occipital bar can be harvested, which allows advancement and
repositioning.
The occipital bar has been advanced strongly posteriorly.
7.7 Complete or Subtotal Calvarial Expansion
Full cranial expansion is an extensive operation

reserved only for those patients with total calvarial
deformities which cannot be corrected by simpler pro-
cedures. One-stage full cranial expansion procedures
are generally avoided in those under 2 years of age, due
to blood replacement and monitoring difficulties and
the potential for significant complications related to the
sphinx position, such as air embolism. Two-stage ante-
rior and posterior cranial expansions are sometimes
performed to permit correction of the deformities with
less complicated operations (Fig. 7.19). Older individu-
als, however, can have a full cranial expansion with or
without a frontal bar in one stage. The use of the frontal
bar depends upon the deformity observed.
A full cranial expansion allows all of the bone seg-
ments of the frontal, parietal, and occipital areas to be
Fig. 7.19
Staged anterior and posterior cranial expansions allow for
expansion of the entire calvarium in two
o stages.
Fig. 7.20
Creation of a midline bar extending o over the sagittal sinus
region posteriorly allows brain support and osteotomy stabil-
ity in total calvarial reconstruction.
7.7 · Complete or Subtotal Calvarial Expansion 213
Fig. 7.21
In brachycephaly the vertical height should be shortened,
which is permitted by anteroposterior and lateral expansion.
removed, appropriately contoured, and repositioned. A

bar is usually left either in the center or posteriorly to
provide brain support (Fig. 7.20). Subtotal cranial
expansions are generally performed in patients with
recurrent or severe deformities who have not achieved
significant correction with simpler procedures. These
patients usually demonstrate delayed growth, and some
have microcephaly resulting in “secondary synostosis.”
In some cases a frontal bar advancement is required
along with a posterior expansion which is a full cranial
expansion. One must tailor the expansion to the amount
of stretch that the scalp can tolerate and still be able to
close the incision. In almost all cases this requires mobil-
ization of the scalp and galeal scoring.
The reconstruction proceeds with the placement of
the frontal bar in an appropriate position. The two wings
of the frontal bar and frontal bone are then “fanned” lat-
erally to increase the frontal width. The temporal and
parietal segments, usually separated in individual seg-
ments, are then advanced laterally and “step-plated” to
the basal skull. This allows for lateral expansion of sig-
nificance. These bone segments sometimes require con-
touring, barrel staving, or shortening superiorly to allow
the bone to be rotated laterally and inferiorly and main- stability of expansion. Occasionally there is so much
tain the proper height. The possibility of too much ver- expansion that scalp closure is not possible even with
tical expansion is managed by superior osteotomies; a “criss-cross” galeotomies. This situation must be cor-
decision needs to be made as to how much superior vol- rected by decreasing the amount of interpositional bone
ume increase is required. graft in the expansion and replating the segments in a
Finally, the occipital and lambdoid segments are less expanded position.
advanced anteriorly into position and rotated laterally
to decrease the anterior-posterior skull length which
improves the transverse diameter. If decrease in the 7.8 Hypertelorism
anterior-posterior length of the skull is desired, the
frontal and occipital bones are moved posteriorly and The correction of hypertelorism classically involves
anteriorly, respectively, so that the skull length is “box” osteotomies performed around the orbital region
decreased. The brain is compressed in the anterior-pos- (Fig. 7.22). Complex osteotomies, or facial bipartitions
teror dimension and moves laterally to occupy the (Fig. 7.23), are designed to reduce the transverse diame-
expanded lateral bone framework. In patients who dem- ter of the upper face and improve the width of the max-
onstrate brachycephaly, the expansion should occur illary arch and the entire maxilla, creating a “V” excision
anteriorly and posteriorly, and the vertical height should where the orbits are rotated into position. The path of
be reduced (Fig. 7.21). these osteotomies must be guided to avoid teeth. The
Bone defects cannot be expected to heal by spontane- presence of the slanted orbit (inferior displacement of
ous osteogenesis in patients who are over 2 years of age. the lateral orbit) requires correction by orbital rotation.
Therefore bone is split from the inner tables of the skull The osteotomy cuts are visualized in Fig. 7.22 and 7.23.
so that a full bone reconstruction can be completed. The use of 1.3 plates and screws is ideal for these osteot-
Bone defects should be filled with grafts in anyone over omized segments.
3 years of age. The grafts are positioned to provide
Fig. 7.22
The correction of hypertelorism involvees orbital osteotomies
of the “box”configuration. Resection of a central nasal segment
andd medial
di l movement off the
h orbits
bi permits correction of the
hypertelorism.
7.11 · Craniofacial (Hemifacial) Microsomia 215
Fig. 7.23 tical correction in orbital dystopia. A single orbit can be

Facial bipartition osteotomies involve rotation of the entire moved up or down (Fig. 7.25). A minicraniotomy or a
maxilla and frontal bone as a single unit. A central “V” is standard frontal craniotomy provides the exposure.
excised permitting the orbits to rotate into position. This is
especially useful in correction of the inferior rotation of the lat- Some overcorrection (4 mm) is suggested. The judicious
eral orbit. Additionally, the width of the maxillary dental arch use of plate and screw fixation in cranial osteotomies
is improved by lateral rotation. The use of this osteotomy allows the surgeon to obtain consistently good results
avoids the inferior orbital osteotomy illustrated in Fig. 7.22 while minimizing complications.
which would impair developing teeth.
7.11 Craniofacial (Hemifacial) Microsomia
7.9 Monoblock Osteotomies The syndrome of craniofacial (hemifacial) microsomia

involves malar hypoplasia, the possibility of facial weak-
In monoblock osteotomies the use of a simultaneous ness, paralysis, underdevelopment, or absence of the
advancement of the midface and frontal bone allows zygoma, lateral and inferior orbit, and temporal man-
correction of the exorbitism and midface retrusion in a dibular joint (Fig. 7.26). In its complete form the cleft is
single operation (Fig. 7.24). The operation has been a Tessier #7 cleft with macrostomia, microtic external
plagued by a 10% incidence of infection which occurs ear and underdeveloped ipsilateral tongue, soft palate,
from nasal-subcranial communications and contamina- and muscles of mastication. The parotid gland and duct
tion in “dead space” behind the advanced frontal bone. can be absent. The seventh cranial nerve may have
Most patients benefit from the use of stable fixation as absent, partial, or complete function, hypoplasia, or
opposed to wires. aplasia. When the external and the middle ear are
affected, conductive hearing loss is present.
The osseous manifestations involve mandibular defi-
7.10 Orbital Dystopia ciency, which can vary from minor flattening of the con-
dylar head to complete absence of the entire mandibu-
Simultaneous orbital osteotomies are used for the verti- lar ramus, with deviation of the mandible and the lower
cal correction of cranial-orbital deformities, such as ver- face toward the affected side. The maxilla is tilted, and
Fig. 7.24
The monoblock osteotomy involves advvancement of the mid-
face and frontal bone simultaneously to ccorrect exorbitism and
midface retrusion. The dead space in com mmunication with the
nose behind
b hi d the
th advanced
d d frontal
f t l bone
b is
i subject to infection.
Fig. 7.25
A single orbit can be moved up and do own by exposure pro-
vided by a small frontal bone flap. In orrbital dystopia correc-
tions some over-correction is suggested. Marginal fixation sta-
bilizes the osteotomy.
7.13 · Encephaloceles 217
Fig. 7.26 the zygomatic arches, fusion of the temporalis and the
In hemifacial microsomia a short mandible and maxilla are masseter, macrostomia, palatal clefts, choanal atresia,
found on the ipsilateral side. The syndrome is classified by the and absence of the malar prominence characterize the
amount of mandibular hypoplasia and development of the
condyle. deformity.
Skeletal correction involves soft-tissue transfer from
the upper to the lower eyelids, osteotomies or bone
grafting of the mandible, maxillary osteotomy
therefore the occlusal plane is canted superiorly.Various (Fig. 7.27), genioplasty and reconstruction of the zygo-
degrees of zygomatic hypoplasia are seen with absence mas with calvarial bone grafts. Lateral canthopexies
of the zygomatic arch and condylar fossa in severe cases. improve the lateral position of the eyelids, and generally
The orbit may be inferiorly dystopic, and cranial asym- a soft-tissue flap must be added to the lateral portion of
metry may be present. The surgical procedures involved the lower lid.
in correction use mandibular osteotomies, and recently
also bone lengthening, costal chondral bone grafting,
and bimaxillary osteotomies with genioplasty 7.13 Encephaloceles
(Fig. 7.26).
Encephaloceles are bone defects in the cranial vault or
base which allow prolapse of meninges and brain tissue
7.12 The Treacher Collins Malformation into the nose, orbit, or temporal region. These are
approached by frontal bone flap and repositioning of the
The malformation in Treacher Collins syndrome is prolapsed meninges and brain tissue. A bone graft
thought to be a combination of the Tessier #6, #7, and #8 (Fig. 7.28) can be placed over the defect. Excess skin is
clefts. Absence of the zygoma, coloboma of the lateral resected.
lower eyelid, antimongoloid slant of the palpebral fis-
sure, deformity of the orbit, and absence of the eye-
lashes, hypoplasia of the mandibular ramus, anterior
open bite, severe retrusion of the chin and an absence of
Fig. 7.27
The Treacher Collins malformation is mmanaged by orbital and
zygomatic bone graft reconstructions thhe lateral and inferior
portions of the orbit and the zygomatic arch.
The mandible is advanced with bilateral interpositional
bone graft, and osteotomies. The maxilla must be rotated as
well.
b a
7.14 · Bone Lenghthening by Continuous Distraction 219
raphy examinations for more complex deformities. The

7.14 Bone Lenghthening by Continuous Distraction orthodontist may have to play an important role, assist-
ing the surgeon in planning the movement and position
In recent years Ilizarov’s idea of bone lengthening via of the osteotomy. Patients frequently require functional
distraction after osteotomies has been introduced into orthodontic treatment following the procedure in order
craniomaxillofacial surgery. to maintain or improve the occlusion. The orthodontist
can assist the surgeon in monitoring the process of the
distraction to obtain the ideal functional occlusal and
7.14.1 Distraction for Mandibular Deformities esthetic results.
The procedure begins by placing a nasal airway for
In the past many deformities of the mandible required bilateral and, to a lesser extent, unilateral procedures.
complex reconstruction. The reconstruction either took Appropriate antibiotics are usually given. A buccal inci-
the form of the bone graft being plated in a mandibular sion is performed near the site of the proposed mandib-
defect followed by stable fixation, or, occasionally, the ular osteotomy. A subperiostal dissection is then per-
tissues required vascularized bone to optimize the final formed. The location of the osteotomy is planned with
results. consideration of the position of the inferior alveolar
Distraction osteogenesis has the advantage of allow- nerve and tooth follicles. The osteotomy should ideally
ing reconstruction of mandibular deformities in a con- be perpendicular to the plane of the movement that is
trolled fashion with the native bone. In mandibular desired. A burr can be used to mark the position of this
defects from either trauma or tumor this can be accom- osteotomy. The position of the pin placement is then
plished by performing an osteotomy of the bone on determined. The ideal condition of the pin should be
either side of the defect, transporting this bone across parallel to the direction of the movement and perpen-
the defect to reach ultimately the other side of the defect, dicular to the osteotomy (Fig. 7.29a).
creating bone as the segment is moved into position. In A trocar is used to place the pins after a small incision
congenital defects in which the mandible is smaller on a is made in the skin. A drill guide is used to protect the
unilateral or bilateral basis (hemifacial microsomia, or soft tissues. Once the drill hole has been completed, pins
Treacher Collins syndrome) the mandible can be in- are placed. Some distraction devices require placement
creased in size by, again, creating an osteotomy and of plate and screws, which are then the focus of the dis-
lengthening the bone in the direction in which normal traction.An osteotomy is then performed along the buc-
growth should occur. cal surface with a Lindeman round burr or a reciprocat-
Patients with congenital deformities are those most ing saw. The completion of the osteotomy along the lin-
commonly undergoing distraction at this time. Patients gual cortex is performed with an osteotome. The
with asymmetries of the mandible in moderate defor- completion of the osteotomy is then confirmed. The
mities are the best candidates. Mild deformities require device is then placed and activated to determine
a choice between a scar versus improved bone symme- whether the segments can move (Fig. 7.29b).
try. In severe deformities the mandible may be too small Standard postoperative care includes pin tract clean-
to perform an adequate osteotomy. Bilateral deformities ing for an external device, thorough cleaning for inter-
frequently have a significant esthetic deformity, but are nal devices, and probably liquid, progressing to soft diet
of more concern for functional problems with the air- depending on the amount of stability. Distraction begins
way and sleep apnea. Distraction can open the airway in the early postoperative period. Some physicians allow
and decrease the need for tracheostomy by bringing the a latency period of 5 days, and some begin distraction
mandible forward. immediately. Distraction should be initiated within
Evaluation prior to the procedure usually requires 5 days. It begins with 1 mm distance per day, using a
orthodontic assistance, as do regular osteotomies and cycle of at least two times or preferably four times a day.
the traditional advancement techniques. The records Follow-up is on every 3rd day to assess the device posi-
include cephalometric, panorex, and computed tomog- tion and care, making sure that distraction is occurring.
Obviously, if the device is activated in the wrong direc-
tion, compression occurs, and the result is compro-
mised. Cephalometrics and panorex records are
obtained after 1 week, 2 weeks, 1 month, and 2 months.
Fig. 7.28 a, b
The device is activated until the desired skeletal
reconstruction is achieved. Visual confirmation of this
▼
Encephaloceles involve defects in the cranial base with pro-

lapse of the meninges and brain tissue. Correction involves reconstructive result should be obtained. The device is
exposure with a frontal bone flap (a), retraction or resection of left in place until there is evidence of further consolida-
the prolapsed tissue and bone graft obliteration of the defect tion on the X-ray.
(b).
Fig. 7.29 a, b
a For distraction unilaterally in the left m
mandibular angle area
the osteotomy is completed and the pilot holes in a perpen-
dicular direction to the osteotomy linee are prepared.
b After serial activation of the device (1 mm per day) the
b desired bone lengthening is achieved.
An illustration of a real Single Vector Percutaneous Distraction
Device is shown in Fig. 1.29a–d.
7.14 · Bone Lenghthening by Continuous Distraction 221
Fig. 7.30 a, b
a Bilateral osteotomies in the zygomaatic arches, pterygoid
junctions, nasofrontal junction and orbits are completed.
b The holes for the Schanz screws of the left distraction device
are visible.
b After serial activation of the devices the movement of max-
illary Le Fort III segments is performeed.
7.14.2 Midface Distraction References and Suggested Reading
Midface distraction is potentially a new area for investi- Argenta L, David LR, Wilson JA, Bell WO (1996) An increase in
gation and clinical application. This would be appropri- infant cranial deformity with supine sleeping position. J Cra-
ate for patients such as clefts and Binder’s syndrome, niofac Surg 7:5–11
Arnaud E, Renier D, Marchac D (1994) Development of the
along with Crouzon’s and Apert’s syndromes (Fig. frontal sinus and glabellar morphology after frontocranial
7.30a). Preoperative evaluations and consultation are remodeling for craniosynostosis in infancy. J Craniofac Surg
performed similar to the mandible. The device for dis- 5:81–94
traction by nature has fewer degrees of freedom since Bruneteau RJ, Mulliken JB (1992) Frontal plagiocephaly: synos-
the devices are typically not worn on the middle portion totic, compensational or deformational. Plast Reconstr Surg
89:21–31
of the face. Typically they utilize the zygomatic arch as Chadduck WM, Chadduck JD, Boop FA (1992) The subarach-
the point of force application. Clinical experience of the noid spaces in craniosynostosis. Neurosurg 30:867–871
future will indicate the most appropriate distraction Cohen MM (1991) Etiopathogenesis of craniosynostosis. Neu-
devices for this purpose. At present posterior-anterior rosurg Clin North Am 2:507
advancement is possible with a slight rotation side to Cohen SR et al (1993) Surgical techniques of cranial vault
expansion for increases in intracranial pressure in older
side. Other options for midface distractions can occur
children. J Craniofac Surg 4:167–173
with orthodontic manipulation using rubber bands and David LR, Wilson JA, Watson NE, Argenta LC (1996) Cerebral
a fixed orthodontic appliance after osteotomy in the area perfusion defects secondary to simple craniosynostosis. J
planned for advancement. A maxillary tuberosity-pter- Craniofac Surg 7:177–185
ygoid dysjunction is usually required. Follow-up and Eppley BL, Sadove AM (1994) Effects of resorbable fixation on
craniofacial skeletal growth: modifications in plate size. J
techniques of distraction are similar to those described
Craniofac Surg 5:110–114
for the mandible (Fig. 7.30b). Gault DT et al (1990) Intracranial volume in children with
craniosynostosis. J Craniofac Surg 1:1
Jabs EW et al (1993) A mutation in the homeodomain of the
human MSX2 gene in a family affected with autosomal dom-
inant craniosynostosis. Cell 75:443
LeBourq N et al (1992) Value of 3D imaging for a study of cra-
niofacial malformations in children. J Neuroradiol 18:225
Lo LJ, Marsh JL et al (1996) Plagiocephaly: differential diagno-
sis based on endocranial morphology. Plast Reconstr Surg
97:282–291
McCarthy JG, Glasberg SB et al (1995) Twenty-year experience Posnick JC, Lin Ky, Chen P,Armstrong D (1994) Metopic synos-
with early surgery for craniosynostosis. I. Isolated craniofa- tosis. Quantitative assessment of presenting deformity and
cial synostosis – results and unsolved problems. Plast surgical results based on CT scans. Plast Reconstr Surg
Reconstr Surg 96:272–283 93:16–23
McCarthy, Glasberg SB et al (1995) Twenty-year experience Prevot M, Renier D, Marchac D (1993) Lack of ossification after
with early surgery for craniosynostosis. II. The craniofacial cranioplasty for craniosynostosis: a review of relevant fac-
synostosis syndromes and pansynostosis – results and tors in 592 consecutive patients. J Craniofac Surg 4:247–254
unsolved problems. Plast Reconstr Surg 96:284–298 Ripley CE, Pomatto J et al (1994) Treatment of positional pla-
Munro IR (1993) Rigid fixation, skull reconstruction, and fiscal giocephaly with dynamic orthotic cranioplasty. J Craniofac
responsibility (editorial) Surg 5:150–159
Ohman J, Richtsmeier J (1994) Perspectives on craniofacial Sadove AM, Eppley BL (1991) Microfixation techniques in
growth. Clin Plast Surg 21:489–499 pediatric craniomaxillofacial surgery. Ann Plast Surg
Persing JA, Posnick J et al (1996) Cranial plate and screw fixa- 27:36–43
tion in infancy. An assessment of risk. J Craniofac Surg Turk AE, McCarthy JG, Thorne CH,Wisoff JH (1996) The “back
7:267–270 to sleep campaign” and deformational plagiocephaly: is
Posnick JC (1996) Monobloc and facial bipartition osteoto- there cause for concern? J Craniofac Surg 7:12–18
mies: a step-by step description of the surgical technique. J Waitzman AA, Posnick JC,Armstrong DC, Pron GE (1992) Cra-
Craniofac Surg 3:229–250 niofacial skeletal measurements based on computed tomog-
Posnick JC et al (1992) Indirect intracranial volume measure- raphy. II. Normal values and growth trends. Cleft Palate Cra-
ment using CT scans: clinic applications for craniosynosto- niofac J 29:118–128
sis. Plast Reconstr Surg 89:34–45 Williams JK, Cohen SR et al (1995) Outcome assessment in
Posnick JC, Armstrong D, Bit U (1995) Metopic and sagittal craniosynostosis: a longitudinal, statistical study of reoper-
synostosis: intracranial volume measurements prior to and ation rates. Presented at the VI International Symposium of
after cranio-orbital reshaping in childhood. Plast Reconstr Craniofacial Surgeons, St. Tropez, France
Surg 96:299–315 Wolfe SA, Morison G, Page KL, Berkowitz S (1993) The mono-
Posnick JC, Goldstein JA, Saitzman AA (1993a) Surgical correc- bloc frontofacial advancement: do the pluses outweigh the
tion of the Treacher Collins malar deficiency: quantitative minuses? Plast Reconstr Surg 91:977–987
CT scan analysis of long term results. Plast Reconstr Surg Yaremchuk MJ (1993) Commentary on craniofacial growth fol-
92:12–22 lowing rigid fixation. J Craniofac Surg 4:245–246
Posnick JC, Kin KY, Jhawar BJ, Armstrong D (1993b) Crouzon Yaremchuk MJ, Thomas GS et al (1994) The effects of rigid fix-
syndrome: quantitative assessment of presenting deformity aiton on craniofacial growth of rhesus monkeys. Plast
and surgical results based on CT scans. Plast Reconstr Surg Reconstr Surg 93:11–15
92:1015–1024
Posnick JC, Lin KY, Chen P,Armstrong D (1992) Sagittal synos-
tosis: quantitative assessment of presenting deformity and
surgical results based on CT scans. Plast Reconstr Surg
92:1015
Kapitel 1 225
Subject Index
A – microfractures 121 E
Adequate internal fixation 12, 57, 60, – remodeling 6 Ecchymosis 112
66, 73 – strength 6 Encephalocele 217
Adjustable sagittal split plate 31, 190 – woven 5, 11 Equine facies 112
Allergic reactions 14, 57 Brachycephaly 202, 205
Ameloblastoma 176 Buttresses F
„Andy Gump“ deformity 155 – anterior 117 Facial degloving 122
Antibiotic treatment 58, 59, 156, 158 – facial 95, 96, 100, 103, 108 Facial units 95
AO/ASIF Academic Council 1 – nasomaxillary 108 Facial width 103, 123
AO/ASIF Board of Trustees 1 – pterygomaxillary 108 Fatigue
AO/ASIF Center 2 – fracture of hardware 13, 58, 59, 84,
AO/ASIF Documentation Center 3 C 121, 182
AO/ASIF Fellowships 2 Callus 9 Fibula free flap 170
AO/ASIF Foundation 1 – formation 11 Fracture classification 3, 83, 108
AO International (AOI) 2 Canthal-bearing fragment 146 Fracture
Apert’s syndrome 205 Canthopexy, transnasal 130 – alveolar ridge 122
Approaches Comminution 58, 72, 79 – angular 79
– anatomic 51 Compression 6 – atrophic mandible 87
– anterior 56 – fixation 15 – blow out 139
– extraoral 73 – interfragmental 19 – comminuted 72
– intraoral 53, 60, 67, 73 Condylar head – condylar and subcondylar 83, 117
– lateral 52 – dislocation 102 – contaminated 87
– submental 54 – prosthesis 176, 179 – cranial vault 148ff
Articulator, semianatomic 185 Condylar positioning device 188 – defect 87
Atrophic mandible 87 Condylar reconstruction 170, 181 – edentulous 103
Coronoidectomy 172, 174 – horizontal ramus 66
B Corrosion 13 – in children 92
Biocompatibility 14 – resistance 13 – infected 87
Biodegradable material 14 Cranialization of frontal sinus fracture – Le Fort I 108, 114
Bite 153 – Le Fort II 108
– anterior open 112, 117 Craniosynostosis 201 – Le Fort III 108
– forces 7 Crouzon’s syndrome 202 – mandibular angle 72
– registration 185 CSF leak 150 – naso-orbital-ethmoid, type 1–3
Bone 5 127ff
– brittleness 6 D – oblique 8
– cancellous 5 Dalpont modification 187 – orbital 139ff
– costochondral 171 DC-hole 16 – orbital roof 146
– formation DC-plate 16ff – palatal 121
– – endochondral 7 Dental implants 168 – panfacial 95, 124
– – membranous 7 Dental splint 60 – patterns 127
– grafts 121 Dentigerous cyst 158 – sagittal, in maxilla 98
– – calvarial 121, 153 Depth gauges 25 – spiral 8
– – fibular 171 Dish face 112 – symphysis 60
– – iliac 121 Distraction – transverse 60, 67, 75, 83
– – non-vascularized 168 – intraoral device 36 – zygomatic complex 133
– – rib 121 – midface 222 Frontal bar 98
– – vascularized 168 – osteogenesis 11, 219 Frontal sinus 148
– healing 6, 8, 9, 15 Dolichocephaly 205 Functionally stable internal fixation 12
– – direct 9 Drill bits 24
– – secondary 9 Drill sleeves 25 G
– hook 133, 146 Dynamic compression plate (DCP) 19 Genioplasty 191
– lengthening 217, 219 Giant cell granuloma 158
– matrix 6 Gillie’s reduction 146
226 Subject Index
Glenoid fossa 178 L – UniLOCK 30

Gliding-hole 17 Lacrimal duct injuries 132 Plating technique, biological 9
Graft-host interface 9 Lag screw 17, 19, 61, 70, 189 Posterior cranial expansion 210
Growth restriction 199 Ligaments Power tools 42
Gunning splint, see Splint – lateral canthal 140 Preload 15
Gunshot lacerations 90 – medial canthal 103 Pseudarthrosis 59
Lip-tooth relationship 103
H Load R
Haversian System 5 – bearing 15 Radiotherapy and plates 183
Healing – dynamic 7 Remodelling process 5, 7, 9
– delayed 11 – functional 15 Reposition, anatomic 51
– direct 9 – sharing 13, 15, 121 Resorbable implants 14
– patterns 8 – static 7 Rigidity 7
– undisturbed 12 Lockwood’s ligament 140
Hemifacial microsomia 215 S
Hunsuck modification 187 M Sagittal split osteotomy 17, 185 ff
Hypertelorism 205, 214 Malocclusion 59 Scaphocephaly 205
Mandible Fix Bridge 162, 170, 178 Scarring 103
I Mastication 7, 155 – internal 106
Implant Mixoma 159 Screw(s)
– materials 13 Monocortical screws 12 – bicortical 59
– mixing 19 Motion, interfragmentary 9, 15 – drivers 27
– removal 14 – fracture 24
– stainless steel 13 N – insertion 24
– Titanium 13 Nasofrontal duct 148 – loosening 12
Incisions 51 Nerves – monocortical 12
– blepharoplasty 52 – motor 51 – non self-tapping 12, 24
– coronal, coronary 56, 122, 146, 152, – sensory 51 – positional 189
201 Newton meters 6 – self-tapping 24, 157
– eyebrow 52 Nonunion 12, 59 Set configurations 44
– face lift 52 Shearing force 19
– gingivobuccal sulcus 53, 116 O Single Vector Percutaneous Distraction
– glabelar 56 Occlusion 57, 95, 98, 118 Device 36
– inferior maxillary 134 Osseous integration 182 Sinus
– inferior orbital 134 Osteoblasts 5 – frontal 148
– lower blepharoplasty 52 Osteoclasts 5 – infection 150
– low eyelid 56 Osteomyelitis 59, 87 – obliteration 152
– posterior „T“ 201 Osteoporosis 5, 87 – obstruction 150
– preauricular 102 Osteosynthesis Skin incisions, see Incisions
– Risdon 83 – bridging 58 Soft tissue
– Stab 56, 73 – load-bearing 58 – closure 138
– subciliar 56 – load-sharing 58 – „double insult“ 107
– superior orbital 134 Osteotomies – failure 182
– transconjunctival 52 – complications 197 – positioning 106
– upper blepharoplasty 52 – condylar position 185 Sphynx position 201
Infection 59 – facial sekeleton 185ff Splint 15
– flora 11 – intermediate splint 186 – dental 60
Instruments – inverted „L“ 191 – external 15
– bending 38 – Le Fort I 192 – Gunning 117
– plate cutting 37 – mandibular 156 – intermediate 187
– transbuccal 40 – model surgery 185 – internal 15
Intercanthal distance 124 – subapical 191 – occlusal wafer 186
Intermaxillary fixation 12, 57, 59, 95, „Outer facial frame“ 123 Stability
102 – adequate 12, 58
Intubation P – absolute 15
– nasotracheal 156 Pitch angle 120 Stiffness 7
– orotracheal 156 Plagiocephaly 202 Strain conditions 6, 9
Plate(s) Stress 7
J – adjustable sagittal split 31, 190 – protection 15, 161
Joint – craniofacial 28
– ankylotic 171 – DC 16ff T
– failure 182 – mandibular 30 Taps 25
– prosthesis 171 – orbital 144 Technical Commissions 2
– reconstruction 30 Tension
K – /screw profile 35 – band 17, 59
Keratocysts 159, 176 – SplitFix 31, 190 – side 7
– THORP 34 – zones 7
Subject Index 227
Third molar 58, 73

Tissue
– connective 5
– differentiation 9, 11
Titanium, see Implant materials
Torque 8, 120
Trajectories 7
Translocation of plates 199
Treacher Collins Malformation 217,
218
U
Units of face
– cranial 98
– facial 95
– lower face 102
– mandibular 96
– midfacial 96, 98
– occlusal 95
V
Volkmann canals 6
W
Whitnall’s tubercle 140
Wires, transnasal 124
Y
Young’s modulus 6

Maxilofacial Ao

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I

Manual of Internal Fixation in the Cranio-Facial Skeleton

Springer­Verlag Berlin Heidelberg GmbH

Manual of Internal Fixation

Editor: Joachim Prein

With 190 Figures in 565 Separate Illustrations

Joachim Prein, M.D., D.M.D. ISBN 978-3-642-63732-2

SPIN: 10494528 24/3135 – 5 4 3 2 1 0

Chapter Authors and Contributors

Leon A. Assael, D.M.D. Christian Lindqvist, M.D., D.D.S., Ph.D.

Benjamin Carson, Professor Paul N. Manson, M.D.

Carolyn Plappert Mark A. Schusterman, M.D.

In the past 10 years there has been a rapid increase in

Prof. Dr. Dr. Bernd Spiessl

surely mean comfort and beneﬁts to our patients. On the

Prof. Dr. Joachim Prein

3.12 Fractures of the Horizontal Ramus . . . . . . 66 4.2.1.3 Diagnosis . . . . . . . . . . . . . . . 112

5.3.6 Reconstruction of Tumor Defects

6.3.1.1Sagittal Split Osteotomy . . . . . . . . 187 7.4 Planning and Reconstruction . . . . . . . . . 205

Scientiﬁc and Technical Background 1

from ideas and from research and development activ-

Products before they are adopted by the AO/ASIF are

1.1.5 Documentation and Clinical Investigations 1.1.6 Fracture Classification

Bone segment Type Group Subgroup Scale of severity

Fig. 1.3 In this classiﬁcation the cranio-maxillo-facial area is not

Patterns of fracture healing. The appearance of a healing frac-

Fig. 1.6 a–f

Fig. 1.7 a–c

a The two innermost screws should be placed eccentrically

out a plate, a countersink for the screw head is cut into

Core diameter Hexagonal socket

Inset Non ﬂuted Fluted

Screw Thread Core Pitch Head Drive

Standard screw 1.0 0.7 0.25 1.6

Emergency screw 1.2 0.9 0.25 1.6

Standard screw 1.3 0.9 0.5 2.4

Emergency screw 1.7 1.1 0.6 1.6

Standard screw 1.5 1.1 0.5 3.0

Emergency screw 2.0 1.4 0.6 3.5

Standard screw 2.0 1.4 0.6 3.5

1.6.1.3 List of Screws Fig. 1.12

Screw Thread Core Pitch Head Drive

Standard screw 2.0 1.4 1.0 3.5

Emergency screw 2.4 1.7 1.0 3.5

Standard screw 2.4 1.7 1.0 4.0

Emergency screw 2.7 1.9 1.0 4.0

UniLOCK screw 2.4 2.4 1.7 1.0 4.0

UniLOCK screw 3.0 3.0 2.4 1.0 4.0

Emergency screw Not existing

Standard screw 2.7 1.9 1.0 5.0

Emergency screw 3.2 2.1 1.25 5.0

THORP screw 4.0 3.0 1.25 4.5

Emergency screw Not existing

1.6.1.4 Technique of Screw Insertion Fig. 1.14 a–d

drilled pilot holes and then a careful cutting of their

SpringerVerlag Berlin Heidelberg GmbH