Principles of Fixation for Maxillofacial

Trauma Patients

PRESNTER: DR. SIYUM (OMFSRII)

04/23/2023
MODERATOR: DR. TEWODROS (OMFS, CONSULTANT)
1
OUTLINE
 Objectives
 Introduction
 Biology of bone and bone healing
 Biophysics of facial skeleton
 Methods of fixation
 Mandibular fixation
 Midface and upper face fixation
 Bioabsorbable plate fixation
 Complications of internal fixation
 Summary
 04/23/2023
References 2
 OBJECTIVES
 To discuss about materials used for fixation of maxillofacial skeleton
 To discuss about different methods of fixation
 To discuss about complications of internal fixation

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 INTRODUCTION
 Bone fractures have been treated with various conservative techniques for
centuries and it was not until the 18th century that internal fixation was
first documented.
 Albin Lambotte(Belgian surgeon), coined the term internal fixation.
He developed and manufactured a variety of bone plates and screws
and much of his armamentarium remained in use until the 1950s.
 In the 20th century, Sherman improved on Lambotte’s designs and created
parallel, threaded, finepitched, self-tapping screws.

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Cont…
 These early alloys were inflammatory and replaced entirely by titanium.
 Luhr helped advance the principles of compression and dynamic
compression.
 Spiessl later popularized dynamic compression bone plating of the
mandible.
 From Luhr and Spiessl’s work, eccentric dynamic compression plating was
developed and adapted for craniomaxillofacial trauma use, but lost
popularity due to its highly technique-sensitive nature and no proven
benefits over other modern fixation methods.

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 BIOLOGY OF BONE AND BONE
HEALING
 Bone is a complex and ever-evolving connective tissue and serves multiple
purposes:-
It is main constituent of the human skeletal system
It is essential for the regulation of serum electrolytes (calcium &
phosphate)
Containing hematopoietic elements in the marrow cavities, necessary
to manufacture blood components and regulate the immune system.
 Bone is comprised of:-
Calcified bone matrix
Three major cell types (osteocytes, osteoblasts, and osteoclasts)
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Cont…
 Bone healing can be broadly categorized in two ways, primary & secondary
Primary or direct bone healing:
Requires rigid fixation & immobility of fracture segments with a
minimal gap between them (<100 μm).
Osteoclasts migrate to the fracture site  widen adjacent haversian
systems allowing osteoblasts to deposit bone matrix, or osteoid, w/c
eventually calcify into organized mature lamellar bone.

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 Cont…
Secondary or indirect bone healing:
More complex and occurs when a significant gap or interfragmentary
motion is present.
Involves the formation of a fibrocartilaginous intermediary bone callous
Has four distinct stages of indirect bone healing:
1. The initial or inflammatory stage.
2. The second or soft callus stage
3. Third phase or hard callus stage
4. Final or remodeling stage

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Cont…
1. Inflammatory stage.
A hematoma is formed & stabilized, drawing inflammatory cells to the site.
Necrotic and nonviable bone near the fracture is cellularly débrided
Repair by angiogenesis and activation of osteoprogenitor cells and fibroblasts is
initiated.
2. Second or soft callus stage
characterized by conversion of the hematoma to a fibrocartilaginous mass to bridge
the fracture.
3. Third phase or Hard callus stage
Osteoid is calcified and periosteal and endosteal bone ingrowth starts to replace
the soft callus.

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 Cont…
4. Final or remodeling stage
 Woven bone of the hard callus
matures and organizes to a
trabecular structure to re-create
the native preinjury structure.

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 BIOPHYSICS OF THE FACIAL
SKELETON
 Due to its dynamic nature, the mandible bears
most of the forces applied by facial musculature
to the skeleton.
 Beam mechanics dictates that the mandible is a
class III lever, with the condyle being the
fulcrum, the muscles of mastication acting as the
applied force, and bite load acting as the
resistance.
 For the purposes of understanding rigid fixation
across fractures, beam mechanics applies.

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Cont…
 Mandible exhibits maximum tension at the superior
border and maximum compression at the inferior
border.
 At the zone of tension, a tension band can be
applied(monocortical low profile miniplate, lag screw
or arch bar).
 The inferior border is a biologically sound location for
hardware placement.
 Bicortical screw fixation here is extremely stable, (due
to adequate vascular soft tissue).

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 METHODS OF FIXATION

 Traumatic injuries of the facial skeleton can be properly managed and

treated in numerous ways.
1. AO-ASIF guidelines of rigid fixation follow four basic principles to ensure
adequate treatment of fractures:
1. Bony segment reduction.
2. Stable fixation and immobilization of fragments.
3. Maintaining blood supply.
4. Early function.

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Cont…
 Advancements in techniques and biomaterials and an understanding of
biophysics have greatly changed how we currently apply fixation to facial
fractures.
 Internal fixation with titanium hardware is still the most commonly used
method.
 Various sizes and shapes of plates and screws exist to meet the needs of
the surgeon for the treatment to each individual patient and fracture type.

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Cont…
 Adequate exposure of fracture segments is carried out while not
compromising the adjacent blood supply.
 Maintaining vital periosteum aids in fracture healing, preventing
postoperative wound breakdown and decreasing the rate of hardware
infection.

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Cont…
 Fracture segments can be reduced using various methods:
Manual anatomic reduction
Bone reduction forceps
Interdental fixation
Combination of these
 The fracture segments are stabilized by bending and adapting plates
directly to the bony segments and fixated with screws.

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Cont…
2. Skeletal pin external fixation is indicated:
1. If surgical exposure of fracture sites may interrupt blood supply, such as
severely comminuted fractures.
2. If wounds are contaminated, posing a risk for hardware infection.
 Technique:
Transcutaneous access to the mandible with stab incisions and blunt dissection.
The mandible is drilled and skeletal pins are inserted into the fractured segments.
Ideally, two pins should be placed into each large segment to prevent rotation.
The external components of the skeletal pins are stabilized by being fastened to a
rigid external bow or linking segments with the use of other, smaller subunit bars.
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Cont…
3. Maxillomandibular fixation (MMF) or interdental fixation is widely used
in the management of almost all injuries affecting the jaws.
 Prior to the development of modern internal fixation, MMF was the
mainstay of facial fracture treatment.
 By stabilizing the dentition in its known pretraumatic occlusion, bone
segments will assume an anatomically acceptable configuration.

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Cont…
 Because MMF compresses fractures at the alveolus, the inferior border of
the mandible may still demonstrate a gap.
 By combining this method with compression of the inferior border with
bone reduction forceps and application of internal fixation methods, an
ideal reduction can be achieved.
 Several hardware designs and techniques are available for MMF:
Arch bars
Ivy loops
Stout interdental wires
MMF screws.
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Cont…
 The advantage of MMF with the application of arch bars is that they
provide a tension band at the alveolar component of maxillomandibular
fractures.
 This aids in resisting tensile forces of the fracture near the teeth.
 In fractures not involving dentate portions of bone—that is,mandibular
angle, ramus, or condyle fractures—arch bar application may not be
necessary to obtain MMF.
 If a stable and reproducible occlusion can be obtained, the use of MMF
screws or Ivy loops can provide reduction and stabilization of the fracture
in a much shorter, less technique-sensitive manner.
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Cont…

 Indications of MMF:
Minimally or nondisplaced biomechanically favorable fractures with
premorbid occlusion.
Severely comminuted fractures.
Intracapsular condylar fractures in which premorbid occlusion can be
reestablished.
 Advantages of MMF:
Considerably less invasive
More cost-effective
Reduces complications associated with open surgery

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Cont…
 Diadvantages of MMF:
Invokes an aspiration hazard in patients with severe gastroesophageal
reflux, nausea, seizure disorder, alcoholism and dysphagia.
Needs patient compliance to prevent loosening of wires and mobilizing
the forming callus.

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 RIGID VERSUS FUNCTIONALLY STABLE FIXATION

 Internal fixation can be subclassified as rigid and nonrigid.

Rigid fixation: any type of directly applied bone fixation that prevents
interfragmentary movement between fracture segments when that bone
is under active load.
 Examples of rigid fixation of a fracture include:
 Reconstruction plate
 Two bone plates
 Two lag screws
 A compression plate and arch bar across a fracture.

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Cont…
 With the exception of the use of a load-bearing reconstruction plate, rigid
fixation techniques rely on two point fixation—a stabilizing unit, such as a
bone plate at the inferior border, and a tension band, such as a miniplate
or arch bar superior to that.
 On a histologic level, the benefit of rigid internal fixation with minimal gap
between the bone segments allows for primary bone healing via haversian
remodeling.

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Cont…
Nonrigid fixation is fixation that allows for movement between the bone
fragments across a fracture line.
 Many older techniques, such as interosseous wiring or interdental bridal
wiring, stabilize fractures to approximate segments but do not prevent
interfragmentary movement.
 Depending on the magnitude of movement across the fracture, nonrigid
fixation may result in nonunion or malunion.

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Cont…
 Example of nonrigid technique in mandibular trauma is the Champy
method for the fixation of angle fractures.
 In 1978, Champy described the use of a single miniplate to the superior
border of mandibular angle fractures, with excellent results.
 This technique has been termed functionally stable because it allows for
activation of the mandible during healing, even with interfragmentary
motion.

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Cont…
 Although functionally stable fixation of the mandibular angle reduces
operative time, risk of dental injury, and cost, it is not ideal in all
situations.
 Concomitant fractures of the mandible must be treated rigidly to prevent
motion at multiple sites.
 The Champy method relies on the contralateral condyle being seated
correctly in the glenoid fossa, without disruption of the
temporomandibular relationship.

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 COMPRESSION PLATE
OSTEOSYNTHESIS
 The use of compression plating systems in the maxillofacial skeleton has
been used to treat mandibular fractures for many years.
 Although many surgeons prefer the ease of use of locking bone and
reconstruction plates, compression and dynamic compression plating, if
applied correctly, can be advantageous in immobilization and fixation of
mandible fractures.
 The goal of compression osteosynthesis, as described by AO, is establishing
absolute stability across a fracture.

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Cont…
 This is defined as zero movement occurring between bones across the
fracture, as well as complete immobility of the hardware against the bone.
 This creates an ideal environment for primary bone healing by generating
friction between the bone segments in compression and minimizing the
gap between them.

Dynamic compression plate

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Cont…
Dynamic compression plates are designed with eccentric holes with
inclined planes.
 On either side of the midline of the plate, the plate holes are elongated,
with the lateral side having the highest portion of the inclined plane and
the medial with the lowest portion, or closest to the bone, of the inclined
plane.

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Cont…
 The plate should be adapted so that one eccentric hole is on each side of
the fracture, closest to the fracture line.
 The outer planes of each hole are the active, or compression, sites.
 As screws are drilled and fastened into this high point of the inclined plane,
they follow the plane down toward the bone as friction is created between
the screw head and plane surface.
 When completely tightened, they lie on the innermost portion of the hole
closest to the bone.

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Cont…
 Because this is completed on either side of the fracture, the bone
segments are compressed toward each other while the plate remains
static, minimizing the bone gap and achieving compression.
 As noted, the screw will migrate down the plane approaching the fracture
line and draw the bone segment toward its counterpart
 The remainder of the holes distal to the fracture line are then drilled and
secured with bone screws in a passive position so as to not compress or
distract the bones and hardware further.

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Cont…

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Cont…
 The resultant compression at this site, typically the inferior mandibular
border, may result in excessive tension at the superior border or alveolus.
 It is necessary to neutralize these forces to prevent gap formation in the
zone of tension of the mandible.
 This is typically achieved by the use of a tension band, such as:
An arch bar,
Superior lag screw,
Monocortical miniplate.

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Cont…
 Compression osteosynthesis is best applied in transverse fractures of the
mandibular symphysis or body without comminution or bone loss.
 Obliquely oriented fractures can pose problems in this technique due to
the nonsymmetrical nature of the fracture line.
 Plates are adapted and applied to the outer, or buccal, cortex of the
mandible.

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Cont…
 Compression is applied parallel to the plate; equal distribution of forces
occurs best in fractures that are completely perpendicular to the
compression plate.
 In cases in which there is avulsion of bone at the fracture site, compression
plating can distort the premorbid anatomy and contours of the mandible,
leading to malocclusion and increased stress across the TMJs.

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 NONCOMPRESSION
OSTEOSYNTHESIS
 Noncompression osteosynthesis is widely used in managing traumatic
injuries to the maxillofacial skeleton.
 This can be accomplished with a variety of methods including non-
compression bone plates and reconstruction plates, both of which are
available with locking mechanisms.
 These methods have broader applications and less degree of operator
error when compared with compression osteosynthesis.

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 MANDIBULAR FIXATION

 The mandible lends itself to a number of fixation techniques secondary to

its
Geometry,
Length,
Bicortical structure,
Complex applied muscle forces.
 Unlike most bones of the facial skeleton, the mandible is repeatedly
stressed and strained by the function of the masticatory apparatus.
 Fixation must be sufficient to withstand these forces during the healing
period.
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Cont…
 Other factors that should be taken into account when selecting the width of
the fracture plate are:
Quantity and quality of overlying soft tissue,
Patient compliance,
Risk of reinjury.
 Thicker plates provide more stability than thinner counterparts, but:
May be palpable under soft tissue,
May require more dissection,
Are more difficult to adapt,
Have higher rates of dehiscence.
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Cont…
 After selecting the appropriate plate, the mandible fracture is exposed and
reduced and the plate is adapted to the inferior border of the buccal cortex
of the mandible.
 The plate may be overbent, if desired, to compensate for lingual segment
splay.
 Two (ideally three) screws are required on each side of the fracture to
ensure stability and prevent rotation of bone segments.

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 Cont…
 When placing screws, the same angle used to
drill should be replicated to prevent distorting
the osteotomy or breaking the screw.
 When the screws most proximal to the fracture
are secured, the remainder are drilled and
placed with the same method in an alternating
fashion in regard to the fracture.

FIG. A, Four-hole fracture plate with

bicortical locking screws used to fixate
a mandibular symphysis fracture.
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 Cont…
LOCKING PLATES
 Locking screws are double-threaded; at the head of the
screw and core of the screw.
 This design helps the screw to lock into the plate by
preventing shifting of bone segments and deformation of
the plate as the screws are tightened.
 Locking plate and screw systems prevent loosening and
extrusion of the screw from the plate.
FIG: Mandibular fracture
locking plates of different
designs.

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Cont…
MINIPLATES
 Miniplates have several applications
in mandible fracture fixation.
 These methods call for monocortical
fixation of miniplates, but bicortical
fixation of miniplates has applications
in the mandible as well.

Fig: Miniplates are available in several shapes and

configurations.
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 Cont…
 As a tension band, the monocortical application of the miniplate is enough.
 After application of an inferior border fracture plate, a miniplate can be
adapted to the mandible superior to the neutral zone.
 Miniplates are more prone to screw loosening and infectious complications
due to decreased stability and strength compared with thicker hardware.

FIG:
 Four-hole miniplate with 2.0-mm
monocortical screws used as a tension
band.
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Cont…
RECONSTRUCTION PLATES
 Mandibular reconstruction plates are thicker and have a longer span than
fracture plates, and are designed to be load bearing to span gaps and
defects.
 Rigid fixation with reconstruction plates is a reliable method, with relatively
low complications in reconstructing mandibular defects.
 Reconstruction plates can be used to treat:
Mandibular defects,
Mandibular fractures that are comminuted, atrophic, or grossly
unstable.
04/23/2023 45
 Cont…

 UniLOCK reconstruction plates 2.4.

 Low-profile reconstruction plate to fixate edentulous atrophic mandible
fracture.
 Heavy reconstruction plate used to bridge a segmental defect. In this case,
the plate is load-bearing.
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 Cont…
LAG SCREWS
 Lag screw osteosynthesis is highly effective and efficient when used in the
proper setting and eliminates the need for plate bending and the use of
several screws.
 Lag screw osteosynthesis is a fracture compression technique that can be
carried out by using true lag screws or a lag technique with long bone
screws.
 The classic application of this technique is in fixation of transverse
mandibular symphysis and parasymphysis fractures or obliquely oriented
body and angle fractures.
04/23/2023 47
Cont…
 This method provides a high degree of fracture compression, resulting in
very stable fixation.
 If done properly, this can be completed faster than with compression or
noncompression plate osteosynthesis, with fewer postoperative
complications.
 Unlike plate osteosynthesis, lag screw osteosynthesis directly traverses the
fracture line, more evenly distributing compressive forces between
segments and resulting in excellent stability and minimal to no lingual
splay.

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FIG: Lag screws having threadings to allow compression of segments.

 Postoperative orthopantomogram demonstrating correct

hardware placement and compression of the fracture.
 To maximize the benefits of lag screw fixation, screws should be
placed at an angle that bisects the lines perpendicular to the
A. 22-year-old man with a transverse mandibular fracture and perpendicular to the bone surface where the screw
symphysis fracture. will enter.
B. Application of two lag screws across the
fracture.
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  MIDFACE AND UPPER FACE
FIXATION
 Unlike the mandible, most of the facial skeleton is not subject to major
muscular forces except zygoma w/c is under significant effects from the
masticatory musculature.
Elective zones of osteosynthesis of
midface and upper face
 The blue colored zone is for
miniplate
 The red zone is for microplates.
 The green zone is either for
microplates or miniplates.
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1. Lower midface (Le Fort I and palatal
fractures)
 Fixation of palatal fractures involves
 LeFort I# fixation is achieved by
use of long plates and screws
applying miniplates 1.5 or 2.0,
anteriorly subnasaly and submucosally
and screws to nasomaxillary and
in the palatal vault.
zygomaticomaxillary buttresses.

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2. Upper midface (Le Fort II and III)
 Nasomaxillary & zygomaticomaxillary pillars and the
zygomatic arches are fixed by miniplates of 2.0, 1.5mm.
 FZ suture, infraorbital rim and glabella, are fixed with
miniplates 1.5, 1.3mm.
 Frontomaxillary area and infraorbital rims are fixed with
miniplates 1.3 mm.
 Small fragments and bone in nonloaded areas (frontal
sinus walls) are fixed with microplates 1.3, 1.0 mm.

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3. ZMC & Zygomatic arch fractures
 A 1, 2, 3, 4 or 5-point fixation at:-
1. Zygomaticomaxillary buttress
with 1.5, 2.0 mm miniplates.
2. Zygomaticofrontal suture with
1.3, 1.5 mm miniplates.
3. Infraorbital rim with 1.3 mm
low-profile plates.
4. Zygomatic arch
5. Lateral orbital wall

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4. Nasoorbitoethmoidal (NOE) fractures
 Upper NOE#, 1.3 mm miniplates.
 Lower NOE#, larger plate systems
(1.5, 2.0 mm).

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Cont…
 Main frame for the use of different
plate–screw osteosynthesis systems
in these area:
Cranial vault: microsystems
Midface: microsystems
Lateral orbital rim: from
microsystems to minisystems

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 BIOABSORBABLE PLATE FIXATION

 Although, Plates and screws made of titanium, have been regarded as the
“gold standard”, they have following disadvantages that have led to the
development of biodegradable osteosynthesis materials:-
Interference with later diagnostic radiological investigations,
Palpability under the skin, Loosening of screws, Hot and cold
irritabilities, late infection, Impingement of dental prostheses.
Growth inhibitions of craniofacial bones in infants followed by passive
migration,
Need for secondary intervention to remove osteosynthesis materials.

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Cont…
 There are several varieties of bioabsorbable materials; the most modern
are:
Polylactic acid (resorb into lactate)
Polyglycolic acid (takes 1-3 yrs to resorb into CO2)
 These plates provide half the strength of a bicortically fixated bone plate.
 Complication rates of bioabsorbable fixation are less than or equal to
those with metal fixation.

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 Cont…
 They are recommended for the
stabilization of:-
Sections of the face that are not
strongly load-bearing (midface &
cranium),
Exceptionally in growing patients.
 Bioabsorbable systems have been used
and studied extensively in pediatric
craniofacial surgery.

Fig. Resorbable plates and screws used at d/t areas of midface and condylar
neck fixation
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 COMPLICATIONS OF INTERNAL
FIXATION
 Modern methods of internal fixation provide many benefits over closed
reduction of fractures but, as in all surgical procedures, complications
exist.
 These complications include:
1. Surgical site infection
2. Dental injury
3. Nerve injury
4. Malocclusion

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Cont…
1. SURGICAL SITE INFECTION
 Surgical site infection is multifactorial in nature and has patient- and
surgeon-dependent factors.
Elements that contribute to postoperative infection are:
a. Surgical site ( Eg. mandibular angle due to decreased bone to bone contact)
b. Access(Combined transoral-transfacial approaches to a single mandibular# site)
c. Type of hardware ( use of excess hardware )
d. Technical errors(Poorly adapted plates or screws, lack of irrigation during drilling)
e. Fracture mobility
f. Medical comorbidities suppressing immune function( DM, HIV-AIDS,
radiotherapy, malnourishment, and chronic alcoholism)

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Cont…
Management is the
administration of
antibiotics, with or
without surgical
débridement,
irrigation, and
hardware removal.
 Pt with DM and chronic alcoholism presenting 2 years ORIF done for bilateral
mandibular fractures and complaining of purulent drainage from bilateral neck.
 CT scan shows chronically infected hardware and extensive osteolysis, resulting
in a free-floating anterior segment.
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Cont…
2. DENTAL INJURY
 Dental structures are usually damaged by misguided drilling or screws.
Prevention:
1. Bicortical fixation of the mandible at the inferior border to avoid tooth roots.
2. Monocortical fixation of the maxilla and mandible just apical to the apex of
teeth.
3. Using d/t methods of fixation like single load-bearing inferior border plate or
using an arch bar as a tension band.
4. By securing screws just between tooth roots by approximating their location.
5. Preoperative imaging for measuring distances between teeth.

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Cont…
3. NERVE INJURY
 Inferior alveolar canal harbors the neurovascular bundles which should be avoided
to prevent postoperative paresthesia, dysesthesia, or anesthesia.
 IAN canal runs approximately 2 mm inferior and 2 mm anterior to the mental
foramen.
 Bicortical fixation should follow the inferior border and tension bands should be
secured just above the neutral zone.
 The mental nerve should be identified and protected throughout the operation.
 Precautions should be taken when fixating maxillary, inferior, and superior orbital
rim fractures to avoid damage to the infraorbital and supraorbital nerves.

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Cont…
4. MALOCCLUSION
 Malocclusion can result from:
Poorly bent plates or overtightening bone screws in a poor sequence,
Malunion,
Misalignment of the jaws
Nonunion resulting from poor fracture stability and interfragmentary
movement, may require reoperation or closed reduction of the fracture.

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Cont…
 Misdirected occlusal forces can result in:
Patient dissatisfaction,
TMJ disorders,
Parafunctional dental habits,
Damage to teeth and periodontium.
 Prevention:
Establishing a stable occlusion prior to osteosynthesis.
Accurate bending of plates and application of screws perpendicular to the plate
Examine patients closely physically and radiographically for 4 to 8 weeks
following fracture treatment.
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Cont…

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 Summary
 Besides meticulous planning, surgical fracture repair involves four
sequential surgical steps; adequate exposure, fragment reduction,
adequate internal fixation and meticulous wound closure
 The decision which implant to use is based on the surgeon’s experience
and the relative emphasis that he or she places on the relevant factors such
as fracture type and dislocation and patient related factors.
 Failure is usually due to the surgeon not assessing the situation correctly
and the underestimation of the loading conditions which exceed those
required for the bone-implant unit to permit uninterrupted healing.

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 References

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 THANK YOU!!!

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