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New Concepts

in Maxillofacial
Bone Surgery
Editor: Bernd Spiessl

Contributors: C. Bassetti . D. Cornoley


T. Gensheimer . H. Graf . E. Holtgrave . W. Huser
W.-A. Jaques G. Martinoni . R. Mathys
J. Prein . Th. Rakosi . W. Remagen . R. Schmoker
B. Spiessl . H. M. Tschopp

With 183 Figures and 36 Tables

Springer-Verlag
Berlin' Heidelberg New York 1976

BERND SPIESSL M. D., D. D. S.


Professor of Maxillofacial Surgery,
Head of the Division of Plastic and Reconstructive
Surgery, Department of Surgery, University of Basle,
Kantonsspital, CH-4000 Basle, Switzerland

ISBN-13: 978-3-642-66486-1
DOI:I0.1007/978-3-642-66484-7

e- ISBN-13: 978-3-642-66484-7

Library of Congress Cataloging in Publication Data. New concepts in maxillofacial


bone surgery. Bibliography: p. Includes indexes. 1. Jaws-Surgery.
2. Jaws-Fracture. 3. Facial bones-Surgery. 4. Maxillofacial prosthesis.
I. Spiessl, Bernd. II. Bassetti, C. [DNLM: 1. Face-Surgery. 2. JawSurgery. 3. Maxillofacial injuries-Surgery. WU610 N532] RD526.N48
617' .522 76-40328
This work is subject to copyright. All rights are reserved, whether the whole or
part of the material is concerned specifically those of translation, reprinting, re-use
of illustrations, broadcasting, reproduction by photocopying machine or similar
means, and storage in data banks. Under 54 of the German Copyright Law
where copies are made for other than private use, a fee is payable to the publisher,
the amount of the fee to be determined by agreement with the publisher.
by Springer-Verlag Berlin Heidelberg 1976
Softcover reprint of the hardcover 1st edition 1976

The use of registered names, trademarks, etc. in this publication does not imply,
even in the absence of a specific statement, that such names are exempt from the
relevant protective laws and regulations and therefore free for general use.

Preface

The present volume is concerned with bone surgery in the area of the
facial skeleton. We find this branch of maxillofacial surgery especially challenging because in our work within the Surgical Department of the University of Basle, we are constantly being confronted
with the principles of internal fixation - in the care of polytraumatized patients, in organizing joint AO-ASIF courses 1 or during trauma conferences.
The problems of fracture disease and the unpleasant sequelae of
unanatomical healing are by no means alien to maxillofacial surgery.
Our main aim is to broaden our experience of the basic principles of
stable anatomical fixation and early function in this branch of
trauma and corrective surgery. It soon became apparent that primary healing of fractures and osteotomies, as well as undisturbed revascularization of bone transplants and long-term tolerance of inert
implants and joint prostheses depend on the stability of fixation under preload.
Considering the complex biomechanics of the masticatory apparatus, special efforts had to be made to achieve stability in fractures, non-unions and implantations by adapting already existing instruments and implants to the specific requirements of the upper and
lower jaws. New possibilities were added to time-honoured procedures. It was found that a new miniature dynamic compression plate
proved very effective in stabilizing mandibular fractures. In sagittal
split osteotomy of the ascending ramus - the most important operative intervention in the lower jaw - the lag screw principle was
shown to be successful, the emphasis being placed on fixation of the
fragments by interfragmentary pressure. In this case, stable fixation,
standing up to immediate function, is no less important than the performance of the osteotomy itself.
The distinctive feature of this book is that it originates from a team
whose members work closely together in everyday practice.

1 AO/ASIF = Arbeitsgemeinschaft fur Osteosynthesefragen (Association for the Study of Internal Fixation).

They have endeavoured to apply the principle of stability uniformly to reconstructive and orthopaedic surgery of the face as well
as to implantology.
We were painstaking in researching the literature on the subject,
and are indebted to the authors cited in the index for the contribution they have made to our own knowledge.
I would like to express my sincere thanks to my secretary, Mrs.
Helga Reichel, for preparing the manuscript and undertaking the
arduous task of proof-reading.
I am further grateful to Mr. Dietmar Hund and his co-workers in
the photographic department of the Kantonsspital Basel, University of Basel, who were responsible for nearly all the photographs.
Furthermore my thanks go to all who assisted in the making of this
book -last not least to the Publishers with their excellent editorial
staff.
B.

VI

SPIESSL

Preface

I t was my privilege and delight to see our team of maxillo-facial surgeons under the dynamic leadership of Prof. Bernd Spiessl become
progressively intrigued (and infected!) by the potentialities of precise and stable internal fixation. As there is hardly any other branch
of surgery so much in need of precision, even down to the 10 fA.-Ievel,
internal fixation in maxillo-facial surgery was by no means easy to
achieve - especially so because precise fixation in this field has to
stand up to immediate functional loads magnified by significant
leverage effects. Mere application of the small fragment-set of instruments and implants did not work.
It was a great pleasure to see the basic ideas of the spherical gliding principles, underlying the development of the DC-plate by Perren, Russenberger and myself, to be taken up by the Spiessl-team in a
most unconventional and ingenious way. They encountered the need
to stabilize a bone from the bending side. This is a factor complex
which we try to avoid in weight-bearing long bones at all costs. The
brilliant idea of introducing a right angle geometry to the DC-hole,
the outer holes providing a rotational force and thus compressing
the opposite cortex, was one such development which I took pleasure in following with considerable admiration. That all the
biomechanical data worked out by Perren and his collaborators concerning stabilization under preload came to fruition in a new related
field was another source of joy. It therefore stands to reason that my
very best wishes accompany this book, dedicated to a better
rationale and therefore better understanding of improved patient
care in the field of maxillo-facial surgery.
M.

ALLGOWER

VII

Contents

A. Transplantation of Autogenous Bone


1. Clinical Aspects of Free Autogenous Bone Transplantation. By H. M. TSCHOPP ..........................
1.1. Architecture ofthe Bone Graft .................
1.1.1. Compact Cortical Bone ..................
1.1.2. Cancellous Bone .......................
1.2. Behavior of the Bone Graft After Free Transplantation ......................................
1.3. Practical Application of Bone Transplantation ...
1.3.1. Choise of the Right Bone Transplant .....
1.3.2. Vascularization atthe Recipient Site .......
1.3.3. Absolute Immobilization of the Graft ......
1.4. Removal of the Bone Graft ....................
1.4.1. Iliac Bone Graft ........................
1.4.2. Femoral Bone Graft ....................
1.4.3. Rib Graft. . . . . . . . . . . . . . . . . . . . . .. . . . . . . .

4
4
4
5
5
5
5
6
6

2. Osteoplastic Treatment of Large Cysts of the Jaw.


By B. SPIESSL and E. HOLTGRAVE. .. .. .. .. .. .. .. .. ..
2.1. Introduction ................................
2.2. Procedure ..................................
2.2.1. Transplantation of Cancellous Bone .......
2.2.2. Case Histories .........................
2.3. Clinical Results ..............................
2.4. Discussion ..................................
2.5. Summary ...................................

7
7
8
8
8
10
11
12

3. Free Composite Rib Transplantation Using Neurovascular Microsurgical Anastomoses. By H. M.


TSCHOPP........................................

13

3.1. Animal Experiments .........................


3.2. Results .....................................
3.3. Summary ...................................

13
14
18

3
3
3
4

IX

B. Traumatology and Reconstructive Surgery

1. Principles of Rigid Internal Fixation in Fractures of


the Lower Jaw. By B. SPIESSL .....................
1.1. Indication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.2. Principles ...................................
1.2.1. Accurate Anatomical Reduction .........
Occlusal Repositioning .... . . . . . . . . . . . . . .
Basal Repositioning ....................
1.2.2. Absolute Stability ......................
1.2.3. Tension Band and Stabilization Plate .....
1.3. Plates (DCP and EDCP) ......................
1.4. Instrument Set ..............................

21
21
23
23
23
24
24
26
27
33

2. Rigid Internal Fixation of Compound Mandibular


Fractures. By J. PREIN andB. SPIESSL ................
2.1. Introduction ................................
2.2. Case Reports. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.3. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35
35
35
40

3. Experimental Studies on the Effect of Rigidity Using


an Excentric Dynamic Compression Plate (EDCP).
By R. SCHMOKER .................................
3.1. Theoretical Considerations ....................
3.2. Results .....................................
3.3. Discussion ..................................
3.4. Summary ...................................

41
41
47
50
52

4. Internal Fixation of Mandibular Fractures Using an


Excentric Dynamic Compression Plate (EDCP).
By R. SCHMOKER.. . . .... .. .. .. .. .. .. .. .. .. .. .. .. .
4.1. Patient Population ...........................
4.2. Time of Treatment ...........................
4.3. Type of Treatment ...........................
4.4. Results .....................................
4.5. Summary ...................................

53
53
53
S3
55
57

5. Anatomic Reconstruction in Mandibular Fractures


with Loss of Bony Substance. (A Case Report).
By W.-A. JAQUES, B. SPIESSL and H. M. TSCHOPP.. .. .
5.1. Introduction ................................
5.2. Case Report ... .. .... ..... . .... . . ..... . .... ..
5.2.1. Treatment ofthe Fracture ................
5.2.2. Reconstruction of the Missing Bone .......
5.2.3. Restitution of Dentition .................
5.3. Discussion ..................................
5.4. Summary ...................................

59
59
59
59
59
59
60
62

6. Principles of Treatment in Combined Fractures of the


Upper and Lower Jaw. By H .. M. TSCHOPP and G. MARTINONI . " .. " .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .
6.1. Timing of Surgery ............................
6.2. Preoperative Management of the Patient .........
6.2.1. Preparation ofthe Wound " . . . . . . . . . . . . . .
6.2.2. Teeth in the Fracture Line .. . . . . . . . . . . . . . .
6.2.3. Occlusal Retention .....................
6.3. Surgical Procedures ..........................
6.3.1. Fractures of the Maxilla . . . . . . . . . . . . . . . . . .
6.3.2. Fractures of the Mandible ................
7. The Surgical Approach in the Treatment of Facial
Fractures. By G. MARTINONIandH. M. TSCHOPP. . . . . . .
7.1. Fracture of the N aso-ethmoidal Region ..........
7.2. Fracture at the Site of the Sutura Frontozygomatic a .... .. . . . . .. . . .. . . .. .. . . .. .. . . .. . .
7.3. Fracture at the Site of the Lower Orbital Rim,
Blow-out Fracture, and Fracture of the Malar
Complex....................................
7.4. Fracture ofthe Zygomatic Arch ....... :........
7.5. Fractures of the Nose .........................
7.6. IntraoralIncisions ............................
7.7. Submandibular and SubmentalIncisions .........

63
63
63
63
64
64
64
64
71

75
75
76

76
76
77
77
77

C. Orthopaedic Maxillofacial Surgery


1. Temporal Bolting Osteoplasty in the Treatment of
Excessive Condylar Movement. By B. SPIESSL .......
1.1. Introduction ................................
1.2. Technique ..................................
1.3. Postoperative Treatment . . . . . . . . . . . . . . . . . . . . . .
1.4. Discussion ..................................

81
81
83
85
85

2. Treatment of Ankylosis by a Condylar Prosthesis of


the Mandible. By B. SPIESSL, R. SCHMOKER and
R. MATHYS ......................................
2.1. Introduction ................................
2.2. The Condylar Prosthesis ......................
2.3. Technique ..................................
2.4. Case Report ................................
2.5. Summary ...................................

88
88
88
88
90
91

3. Bone Transplantation for Broadening of the Apical


Base (Combined Operative and Conservative Treatment of Pronounced Maxillary Protrusion). By E.
HOLTGRAVE, TH. RAKOSI and B. SPIESSL . .. .... .. .. ..
3.1. Introduction ................................

93
93
XI

3.2. Procedure ..................................


3.2.1. The Transplantation of an Autogenous Rib
Graft to Broaden the Apical Base ........
3.2.2. The Transplantation of an Autogenous Cancellous Bone from the Iliac Crest to Broaden
the Apical Base ........................
3.3. Case History ................................
3.4. Results .....................................
3.4.1. Radiographic Results ...................
3.4.2. Clinical Results ........................
3.5. Discussion ..................................

94
94
97
97
97
97

4. Preoperative Planning of Sagittal Split Osteotomy of


the Ascending Mandibular Ramus (Simulography).
By R. SCHMOKER .................................
4.1. Introduction ................................
4.2. Previous Methods of Simulation ................
4.3. Theoretical Considerations ....................
4.4. Principle ofthe Present Method ................
4.5. DescriptionoftheSimulograph .................
4.6. Summary ...................................

9S
9S
9S
99
99
101
102

5. Results of Rigid Internal Fixation and Simulography


in Sagittal Split Osteotomy of the Ascending Ramus.
A Comparative Clinical Investigation. By R. ScHMOKER,
B. SPIESSL and TH. GENS HEIMER ....................
5.1. Introduction ................................
5.2. SurveyoftheLiterature .......................
5.3. Theoretical Considerations ....................
5.4. Material and Method .........................
5.4.1. Diagnosis .............................
5.4.2. Age and Sex. . . . . . . . . . . . . . . . . . . . . . . . . ..
5.4.3. Dentition .............................
5.4.4. Orthodontic Treatment .................
5.4.5. Operation. . . . . . . . . . . . . . . . . . . . . . . . . . . ..
5.4.6. Preoperative Planning ..................
5.4.7. Prophylaxis with Antibiotics ............
5.4.S. Fixation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
5.4.9. Division into Groups ...................
5.5. Results .....................................
5.5.1. ObjectsoftheStudy .....................
5.5.2. Length of Stay in Hospital ...... .. .. .. .. ..
5.5.3. DurationofIntermaxillaryFixation .......
5.5.4. Resumption of Normal Diet ..............
5.5.5. Period of Unfitness for Work .............
5.5.6. Removal of the Arch Bars ................
5.5.7. Follow-up Treatment ...................
5.5.S. Rate of Recurrence .....................

103
103
103
107
107
107
lOS
lOS
lOS
lOS
lOS
lOS
109
109
109
109
109
110
110
110
110
110
110

XII

93
93

5.5.9. Disturbances of Sensation . . . . . . . . . . . . . . ..


5.5.10. Infection .............................
5.5.11. Other Complications ..................
5.5.12. Subjective Statements.. . ... . . .. .. . . .. ..
5.6. Discussion ..................................
5.6.1. Indication.............................
5.6.2. Preoperative Planning . . . . . . . . . . . . . . . . . . .
5.6.3. Length of Stay in Hospital ...... .. .. .. .. ..
5.6.4. Intermaxillary Fixation ..................
5.6.5. Resumption of Normal Diet ..............
5.6.6. Unfitness for Work .....................
5.6.7. Follow-upTreatment ...................
5.6.8. Disturbances of Sensation ................
5.6.9. Prophylactic Treatment with Antibiotics ...
5.6.10. Recurrence...........................
5.6.11. Advantages of Correct Positioning and
Rigid Internal Fixation .................
5.7. Summary ...................................

6. Rigid Internal Fixation After Sagittal Osteotomy of


the Ascending Ramus. By B. SPIESSL ................
6.1. Introduction ................................
6.2. Technique ..................................
6.2.1. Osteotomy ............................
6.2.2. Rigid Internal Fixation ..................
6.3. Discussion ..................................

111
111
111
111
111
111
112
112
112
112
113
113
113
113
113
114
114

115
115
116
116
118
122

D. Implantology
1. The Dynamic Compression Implant (DCI) as a Basis
for Allenthetic Prosthetics. Fundamental Principles
of Theory and Practice. By B. SPIESSL . . . . . . . . . . . . . . ..
1.1. Introduction ................................
1.2. Principle of Construction and Fixation ..........
1.2.1. Static Friction. . . . . . . . . . . . . . . . . . . . . . . . . .
1.2.2. Pretension and Transverse Compression. ..
1.3. The Area of Implantation ... . . . . . . . . . . . . . . . . . .
1.4. Induction of Periosteal Bone Formation ........
1.5. Summary of the Principles ....................

125
125
127
128
128
129
130
130

2. The Dynamic Compression Implant (DCI) - A First


Evaluation of 70 Cases. By W.-A. JAQUES. . . . . . . . . ..
2.1. Introduction ................................
2.2. Material and Method .........................
2.3. Discussion ..................................
2.4. Summary ...................................

134
134
134
139
140
XIII

3. Experimental Studies of the Load-Bearing Properties


ofImplanted Prostheses. By R. SCHMOKER, D. CoRNOLEY,
W. HUSER, B. SPIESSL and H. GRAF ..................
3.1. Introduction ................................
3.2. Theoretical Principles. . . . . . . . . . . . . . . . . . . . . . . ..
3.3. Method of Measurement ......................
3.4. Results .....................................
3.5. Discussion ..................................
3.6. Summary ...................................

141
141
141
142
143
143
143

4. Experimental Studies on the Stability of the Dynamic


Compression Implant (DCI). By R. SCHMOKER ........
4.1. Introduction ................................
4.2. Theoretical Considerations ....................
4.3. Method of Measurement ......................
4.4. Results .....................................
4.5. Summary ...................................

144
144
144
146
147
149

5. Histologic-Morphometric Investigations into Cadaver


Mandibles. The Bony Structure as a Site for an Implant
Prosthesis. By C. BASSETII, W. REMAGEN and B. SPIESSL
5.1. Introduction ................................
5.2. Material and Method .........................
5.3. Results .....................................
5.4. Discussion ..................................

150
150
150
150
153

6. A Total Mandibular Plate to Bridge Large Defects


of the Mandible. By R. SCHMOKER, B. SPIESSL and
R. MATHYS ...................................... 156
6.1. Introduction ................................ 156
6.2. The New Plate .............................. 158

7. Anatomic Reconstruction and Functional Rehabilitation of Mandibular Defects after Ablative Surgery.
By B. SPIESSL, J. PREIN and R. SCHMOKER .............
7.1. Introduction ................................
7.2. Case Report ................................
7.3. Discussion ............................... '. ..
7.4. Summary ...................................

160
160
160
164
166

E. Postoperative Infections and Prophylaxis


1. Treatment of Infected Fractures and Pseudarthrosis
of the Mandible. By J. PREIN andR. SCHMOKER ........
1.1. Introduction ................................
1.2. Case Report ................................
1.3. Discussion ..................................
XIV

169
169
169
174

2. Preventive Antibiotics in Elective Maxillofacial


Surgery.ByW.-A.JAQUES .........................
2.1. Introduction ................................
2.2.MaterialandMethod .........................
2.3. Results .....................................
2.4. Discussion ..................................
2.5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..

175
175
175
176
179
179

References. . . . . . . . . . . . . . . . . . . . . . . . .. .. . . . . . . . . . . ..

181

Subject Index. . . . . . .. . . . . . . . . . . . . . . . . .. . . .. . . . . . . ..

187

xv

A
Transplantation of
Autogenous Bone

1. Clinical Aspects of Free Autogenous Bone Transplantation


By H. M. Tschopp

The extent to which bone grafts survive after


free transplantation depends entirely on the
rapidity with which the blood supply to the graft
is re-established. In the first place, therefore, it
is the vascularization at the site of transplantation which plays an important role in the survival
of the graft. On the other hand, the rate of vessel
ingrowth is determined by the structure and intrinsic architecture of the transplant itself.
In order to fully understand the events accompanying the transplantation of bone, it is essential to review some of the histophysiologic properties peculiar to all calcified structures.

1.1. Architecture of the Bone Graft

Bone should be regarded as an organized "soft


tissue" of which part of the intercellular substance has been made rigid by depositions of calcium salts (HAM, 1952; TRUETA, 1963). This calcification of the organic intercellular substance
explains the peculiar difficulties imposed on the
nutrition and growth of a living bone cell. The
osteoblasts which are derived from peri-vascular mesenchymal cells maintain a syncytium in
contiguity with each other (VITALLI, 1970). Fine
cytoplasmatic processes extend in all directions
and also reach the adjacent vessels responsible
for the nutrition ofthe cell. The organic intercellular substance which is deposited along these
cytoplasmatic processes and around the cellbody is subsequently calcified by a complicated
mechanism which is not fully understood. The

bone cells are thus embedded in a rigid substance and more or less deprived of their natural
means of nutrition and of the ability to rid themselves of waste products.
In order to survive a system of canaliculi and
lacunae is created which is subsequently filled
with tissue fluids and nutrition of the cell is accomplished by diffusion of food substances
(HAM, 1952).
This mechanism of nutrition, however, is not
very efficient and works only over very short distances. Therefore the majority of bone cells are
separated not more than 0.1 mm from the supplying capillary either in the Haversian system
of compact bone or in osteons of cancellous
bone.

1.1.1. Compact Cortical Bone


In order to fulfill its static and dynamic function
within the skeletal system, a dense structure of
bone is formed as a cortex, which has good
weight-bearing properties and also allows for
muscular attachments. The main vessels responsible for the nutrition of compact bone are the
blood vessels entering through Volkman's canals. These vessels divide and orient themselves
perpendicularly to the weight-bearing forces
(positive barotropism). Around the supplying
vessels the calcified structures are laid down in
layers as supporting columns (osteons). This
compact calcified structure of cortical bone,
however, limits the possibilities of nutrition.
3

1.1.2. Cancellous Bone


Cancellous bone is similar in structure to compact bone. Its main difference consists in the fact
that trabeculae are formed which build a system
of scaffoldings within the cortex. The orientation of these trabeculae is dependent on the direction of the outgrowing osteogenetic vessel
(TRUETA, 1963). The trabeculae in cancellous
bone are very small and their surface is completely covered with osteogenetic cells. By morphometric measurements it has been estimated
that the overall surface of bone cells in a cube of
1000 cm 3 may cover an area of 200-350 m 2,
which is approximately the size of a tennis court
(VITALLl, 1970).
This relatively high proportion of surface cells
to bone cells makes the conditions for nutrition
of cancellous bone much more favorable.

1.2. Behavior of the Bone Graft


After Free Transplantation
The question whether osteogenesis in autogenous bone grafts is due to the activity of surviving cells in the graft (theory of survival) or to
metaplasia in host tissue cells (theory of induction) is still a classic issue of debate. While in
small cancellous bone transplants both sources
may be involved in supplying osteogenetic cells,
most investigators would agree at the present
time, that the majority of cells in a larger piece of
bone, whether cancellous or cortical bone, will
not survive free transplantation (BARTH, 1894;
HAM, 1952; LERICHE, 1928; PHEMISTER, 1914).
The dead bony matrix, however, has an osteoinductive potency and serves as a scaffold
which is eventually invaded by a network of new
capillaries. This process of revascularization occurs mainly from elements in the host bone
(periosteum, endosteum, intermediate bone)
and/ or surrounding host tissues. The osteogenetic cells which are derived from the capillaries
subsequently act as foci of new bone formation,
first by osteoclastic resorption of the dead bony
matrix, and second by deposition of a reticular
bone.
4

After this first phase of regeneration has been


accomplished (its duration depending on the
size of the graft) the reticular bone is slowly converted into a structural, lamellar bone with
force-bearing properties. Thus the second phase
of the healing process is commenced where the
graft is able to respond adequately to functional
stimuli by a process of remodelling and adaptation (Table 1).
Table 1. Healing process in bone grafts
1. Phase: Inductive Regeneration
2. Phase: Functional Adaptation

According to Roux's law of functional


stimulation a bone graft has to be subjected to a
continuous stress and strain in order to establish
the functional reason for its existence.

1.3. Practical Application of Bone


Transplantation
In the light of the foregoing one may postulate
that three conditions have to be fulfilled in order
to obtain a successful bone transplant:
1. Choice of the right bone transplant,
2. Good vascularization at the recipient site,
3. Absolute immobilization of the graft.

1.3.1. Choice of the Right Bone Transplant


The more trabeculae of the bone graft which are
in contact with tissue fluids and the vascular system of the host, the higher will be the percentage
of the bone cells that survive. Cancellous bone,
whether taken from the iliac crest or the
trochanter major, is superior to the compact
cortical bone graft.
The current opinion on the transplantation of
autogenous bone grafts versus homogenous and
heterogenous bone grafts states that vascular
penetration of the heterogenous implant is six or
more times lower than in autogenous bone
grafts (STRINGA, 1957). Moreover large areas of
the homo grafts and heterografts are often totally excluded from the circulation and may subsequently act as a sequestrum and provoke infection.

1.3.2. Vascularization at the Recipient Site


The vascularity at the recipient site is the main
success determining factor in free transplantation of bone. Irradiated tissue, scar tissue, or a
transplantation bed which is inadequately covered by skin or mucous membranes is not apt to
nourish a free bone graft properly and guarantee
its survival.
If the recipient site is inadequately vascularized the blood supply to the bone graft has
to be maintained during or immediately after
transplantation. This is only possible if pedicled
grafts are used or bone transplantation is carried
out by microsurgical vascular anastomoses. The
pedicled graft is a bone transplant which retains
its muscular attachments during transplantation and thus is vascularized from the beginning.
These musculo-skeletal flaps have been extensively and successfully used in orthopedic as well
as in plastic and reconstructive surgery for the
transfer of a living bone to defects of the extremities or the head and neck region (BAADSGAARD, 1965; BLAIR, 1918; CONLEY, 1972;
SNYDER et al., 1970; WATSON-JONES, 1933).
The other possibility of transplantation of a
living bone graft was initiated by the introduction of the operating microscope. This instrument has made it possible to transplant a free
composite musculo-ske1etal graft in one stage by
re-establishing its blood supply immediately
after transplantation using microvascular anastomoses (TAYLOR et al., 1975; OESTRUP et al.,
1974; TSCHOPP, 1976) (see Chap. A 3).

1.3.3. Absolute Immobilization of the Graft


The first phase of the bone-healing process can
only take place if the capillaries growing into the
transplant find absolute stable conditions. Rigid
internal fixation of the graft is therefore mandatory.
This is accomplished by means of lag screws,
metallic plates (see Chap. B 5), or transcutaneous fixation and immobilization by means of
pins (Roger-Anderson) and an external head
frame.
As soon as the first phase of the bone-healing
process has been terminated the fixation mate-

rial used for stabilization of the graft has to be


removed. This allows for better functional
stimulation of the graft and enhances the process of remodelling and adaptation.

1.4. Removal of the Bone Graft

1.4.1. Iliac Bone Graft


The middle of the iliac crest is exposed by a skin
incision parallel to and beneath the iliac crest in
order to avoid the branch of the femoral cutaneous nerve. At the lateral edge of the crest the
periosteum is incised and the crest elevated with
an osteotome, its medial connection being maintained by the periosteum (Fig. 1 a). The external
cortex and cancellous bone underneath the cov-

Fig. 1. Schematic drawing illustrating removal of a


bone graft from iliac crest (a) and from the tuberculummajus femoris (b). In both cases cortical bone is
elevated on a periosteal hinge in order to gain access
to cancellous bone, which is removed with a curette

ering crest is removed using an osteotome or oscillating saw. If cancellous material alone is required, it may be obtained with a curette. Excessive bleeding from the bone is stopped by packing topical hemostatic agents (Gelfoam, Sorbacel, Hemostasin, etc.) into the bone cavity.
The covering iliac crest is repositioned and
fixed to the periosteum using interrupted resorbable sutures. A suction drain is inserted (not
in direct contact with the bleeding bone) and the
wound closed in layers.
The iliac crest should not be used as a graft in
order to preserve the muscle attachement and
diminish morbidity. On the other hand, growth
5

disturbances are avoided in children if the cartilagineous portion of the crest is spared and
only the underlying bone removed.

by means of a Doyen elevator (Fig. 2a). The rib


graft is then removed and closure of the periosteum accomplished with interrupted resorbable
sutures. A suction drain is introduced and the
wound closed in layers.

1.4.2. Femoral Bone Graft


If a larger amount of cancellous bone has to be
obtained, it is preferably removed from the
tuberculum majus femoris (trochanter major).
Through a perpendicular incision above the
trochanter major the tuberculum is exposed and
a window chiseled into the outer cortex.
Part of the periosteum is left on the cortical
cover in order to act as a hinge (Fig. 1b). The
cancellous bone is removed with a curette and
the bone cover replaced and fixed with interrupted resorb able sutures. After introduction of
a suction drain the wound is closed in layers.

6
7

1.4.3. Rib Graft

Fig. 2. Schematic drawing illustrating removal of a rib


graft (7th rib). After incision of periosteum (marked
by short dashes), elevation of periosteum is accomplished by means of a Doyen elevator. Appropriate
size of rib is removed and the graft split longitudinally
with an osteotom

Over the lateral aspect of the sixth or seventh rib


a skin incision is made parallel to the rib. The
underlying musculature is split and the rib exposed. The periosteum is incised and elevated

Since the rib graft represents a mostly cortical


graft it is split in its whole length in order to bring
the cancellous trabeculae from the inside in contact with the surrounding host tissues (Fig. 2b).

2. Osteoplastic Treatment of Large Cysts of the Jaw


By B. Spiessl and E. Holtgrave

2.1. Introduction
In general surgery, juvenile bone cysts have
been treated for a long time with autogenous
cancellous bone (HELLNER, 1958). ScHRAMM
(1970rmixed the latter partly with homologous
bone. REICHENBACH (1954, 1956) and BJORN
(1954) used cancellous bone from the iliac crest
for large cystic cavities in the jaw. Although
these operations were successful, the method did
not gain acceptance since the removal of cancellous bone required at least ten days' stay in
hospital (REICHENBACH, 1965; KALLENBERGER,
1954). Therefore, Reichenbach modified his
original treatment and used homologous bone
(macerated bovine cancellous bone), but, as he
reported, with varied success.
Other authors advocate the method of cystectomy and cystotomy described by PARTSCH
(1910). In the case of very large cysts, this
treatment is in two stages: firstly the fluid is

drained from the cyst, and secondly when reossification takes place, treatment is continued by
surgery as described by PARTSCH (HEID SIECK ,
1968).
ScHULTE (1959, 1960) has described another
method which entails filling the cyst with the patient's own blood. Venous blood is mixed with
penicillin (in the case of large cysts 400.000 IV
and more per ml) and Gelastypt and introduced into the cystic cavity. As penicillin reduces coagulation, thrombin is added.
The great advantage of these methods is that
they can be employed on an outpatient basis.

They also have disadvantages, however, which


can be very serious in individual cases.
In the method described by PARTSCH (1910),
the long period of follow-up treatment and the
lacking histologic diagnosis are unfavorable for
the patient. In the case of extended uni- or multilocular cysts of the lower jaw, precise histologic data are extremely important, since an
adamantinoma or even squamous-cell carcinoma can otherwise be overlooked. ScHULTE'S
method of filling the cyst with the patient's own
blood is also subject to certain disadvantages in
the case of extended cysts. Residual cavities are
often left as a result of insufficient bone formation. Furthermore, the risk of sensibilization as a
result of the local administration of penicillin
should not be underestimated.
In our department, large cysts were treated
surgically by Partsch's method for some time.
For instance, an infected, extended, follicular
cyst of the upper jaw would be treated for two
years with an acrylic mould, without any decrease in the size of the defect. The remaining
cavity was found to be very unpleasant by the
patient, and was subsequently filled with autogenous cancellous bone from the iliac crest,
and covered by a mucoperiosteal flap. The cancellous bone was incorporated without complications.
Radiography showed complete ossification
after three months. We have continued to treat
large cysts by packing them with cancellous
bone, provided firstly that the contents of the
cyst can be completely removed, and secondly
that the cause can be eradicated.

Fourteen patients have been treated in this


way so far, and the following advantages of the
therapy are apparent:
1. The danger of spontaneous fracture is soon
counteracted
2. Rapid and complete ossification of the cystic
cavity
3. Short treatment period
4. The cancellous bone is less susceptible to infection
5. Infected cysts can also be successfully treated
6. All the material required for histologic examination is obtained.

2.2. Procedure
2.2.1. Transplantation of Cancellous Bone

For removal of cancellous bone from the iliac


crest see p. 5. In the case of large cysts, autogenous cancellous bone is ideally suited to
primary osteoplasty, because neither the site of
the transplant, nor the transplanted material is
subjected to functional stress. The absence of
mechanical motion promotes rapid and continuing revascularization of the transplanted bone.
Parallel with the rapid revascularization there is
an increase in the resistance to infection. No
comparable increase is observed with any other
method of filling cystic cavities.
As early as the second World War, MOWLEM
(1944) confirmed the high resistance to infection of autogenous cancellous bone. Today, autogenous cancellous bone is used routinely for
osseous bridging in infected fractures, infected
pseudarthrosis or defect pseudarthrosis.
Fresh autogenous cancellous bone is also
used for transplanting vital osteoblasts, which
survive at least in the periphery where vascularization takes place most rapidly. This bone
tissue directly and immediately induces new
bone formation (ScHWEIBERER, 1970).
2.2.2. Case Histories

Some typical cases are described in the following:


1. Female, 14 years old. Follicular cyst with impacted

premolar (Fig. 3).

Fig. 3. Follicular cyst with tooth 35 impacted

Fig. 4. 9 months after surgery. Tooth 35 is moving into


position in row ofteeth. Transplanted spongiosa from
iliac crest is incorporated
Therapy: The cyst was opened intraorally, the
cystic tissue removed, and the bone cavity filled
with cancellous bone, the impacted tooth being retained. Nine months later, radiographic examination showed that the impacted tooth had erupted
and was normally aligned (Fig. 4).
The latest examination showed that the tooth was
vital and normally positioned in the row of teeth
(Fig. 5).
2. Follicular cyst in the region of the angle of the
mandible, initiated by an impacted wisdom tooth,
and preceded by an abscess (Fig. 6). The infection
was treated by incision and drainage, and the patient was then admitted to the hospital. Following
wide incision of the cyst from the vestibule and extraction of the wisdom tooth and cystic tissue, the
bone cavity was packed with cancellous bone
(Fig. 7). Radiographic examination after one year
showed total ossification (Fig. 8).

Fig. 8. 12 months after surgery. Spongiosa transplant


is incorporated

Fig. 5. 2 years after surgery. Position of 35 normal. No


orthodontic treatment given

Fig. 6. Infected follicular cyst with 38 impacted. 37 and


36 are vital

Fig. 9. Large follicular cyst involving whole horizontal


ramus of mandible . Teeth 35, 36, and 37 are devitalized

Fig. 7. 3 months after surgery. Incorporation of transplant beginning

Fig. 10. 13 months after surgery. Transplanted bone is


incorporated; devitalized teeth have been extracted

3. Large multilocular cyst comprising a large area of


the mandible. The etiology and cause could not be
accurately determined. Suspected diagnosis:
adamantinoma (Fig. 9).
Therapy: In view of the suspected diagnosis, the
cyst was opened by means of a submandibular incision. The whole of the cystic tissue was removed.
Histologic findings via frozen section showed the
presence of a cyst and not an adamantinoma. The
large cavity was then packed with cancellous bone
and the devitalized teeth were extracted. Primary
healing took place. The patient was discharged ten
days after the operation, and thereafter received
outpatient treatment. Radiographic examination
after 13 months showed the formation of normal
bone (Fig. 10).

2.3. Clinical Results (Table 2)

Osteoplasty using cancellous bone was performed in 14 patients following cystectomy. The
rapid physiologic incorporation of the cancellous bone was very striking. Even primarily infected cysts can be filled with autogenous cancellous bone without risk, when the infection has
receded. Secondary healing occurred in two
cases after cancellous bone transplants. Otherwise, a remarkably rapid ossification of the cystic lumen was demonstrated by radiography.
After only three months, the outline of the cyst
could no longer be distinguished.

Table 2
Patient

Diagnosis

Therapy

M. O.

Residual cyst

O.P.

Follicular cyst
lower jaw, left

L.A.

Radicular cyst

G.R.

Follicular cyst

B.I.

Follicular cyst

KR.

Residual cyst

H. E.

Residual cyst

G.E.

Radicular cyst

B.O.

Radicular cyst

G. I.

Follicular cyst

K U.

Radicular cyst

N.A.

Residual cyst

U.N.

Radicular cyst

H.O.

Follicular cyst

Cancellous
bone
Extraction of
38, Cancellous
bone
Resection 13,
Cancellous
bone
Cancellous
bone
Cancellous
bone
Cancellous
bone
Cancellous
bone
Extraction of
32 and 33,
Cancellous
bone
Extraction of
34, Cancellous
bone
Extraction of
38, Cancellous
bone
Cancellous
bone
Cancellous
bone
Extraction of
21122, Cancellous bone
Extraction of
38, Cancellous
bone

10

Duration of
in-patient
treatment
in days

Duration of Clinical
operation findings
h= hours
m= minutes

Radiographic
findings

Access for
surgery

1 h 10 m

Intraoral

1 h 40 m

Intraoral

50m

Intraoral

1 h 40 m

Intraoral

1 h 10 m

Intraoral

10

1 h 40 m

Intraoral

10

1 h 40 m

Paresthesia-

Extraoral

50m

Intraoral

1 h 10 m

Intraoral

1h

Intraoral

1 h 40 m

1 h 10 m

Intraoral

1h 30 m

Intraoral

1 h 15 m

Secondary
healing

Secondaryhealing

Intraoral

Intraoral

radially, and subsequently osseous trabeculae


are formed.
In the case of large cavities, regeneration also
begins at the periphery and proceeds toward the
center. The regenerative capacity, however,
abates with time, and this is even more marked
in elderly patients. Even in juveniles, the mean
regeneration period is two years and more. If osteogenesis eventually ceases, residual cavities
are formed (&HULTE, 1959, 1960, 1965).
2.4. Discussion
The regeneration of bone depends substanCavities in soft tissue resulting from purulent tially on the blood supply to the connective tisliquefaction, e. g., dentogenic abscesses in pre- sue which has formed. The osteogenic capacity
formed crevices, heal completely by gradual of a given section of bone is proportional to its
vascularity. Poor vascularization must be exshrinkage.
Bone, however, is not able to fill up large pected at the center oflarge cavities, so that the
cavities, and can only reduce their size to a lim- formation of new bone is impaired.
Before an attempt is made to draw a practical
ited extent. This is especially apparent in the
conclusion
from this experimental and clinical
case of cysts treated surgically by the method of
PARTSCH (1910). If the cavity is completely filled experience, it must be remembered that in the
by the local formation of new bone, then the treatment involving filling the cystic cavity with
process takes months if not years. Recurrence blood, as recommended by SCHULTE (1969),
due to insufficient cover or the reinfection of a penicillin is admixed, thus incurring the risk of
residual cavity is the rule rather than the excep- sensibilization and the development of allergy.
In considering the question of the best treattion.
For more than a century, there has been no ment of large cysts, (e. g., excluding the preferlack of attempts at primary eradication of large ence of outpatient treatment, or the rejection of
cysts of the jaw. Many suggestions have been inpatient treatment because of the limited
made involving the use of organic and inorganic courses of action open to the therapist) then our
substances such as plaster fillings, filling with the conception will be appreciated: no procedure
patient's own blood with fibrin or a gelatine offers such potential for succes than that of fillsponge, and recently using macerated ing the bone cavities with new, autogenous canheterogenous bone ("Kiel chips") and material cellous bone.
Autogenous cancellous bone contains all the
from bone banks. It is now known, however,
that neither the inorganic substances, nor col- elements of vital bone: cells, collagenous fibrils,
lagenous fibrils, nor blood clots possess os- basic intercellular substance or cement subteogenic properties (AxHAUSEN, 1954; SCHWEI- stance, and apatite crystals.
The bone cells are nourished initially by diffuBERER, 1970; STRINGA, 1957; VITALLI, 1964).
sion and subsequently by revascularization. It is
Thus, none of the procedures achieved the
primarily the cells in the peripheral areas which
statistically significant success rate that could be
are in contact at an early stage with the nutritient
expected from the therapeutic efforts.
tissue fluids and connected to the capillaries
The method of using the patient's own blood, leading to the transplant. Even in the first few
as described by &HULTE (1969), is suitable for days, the osteogenic cells in the transplanted
the treatment of small cysts of the jaw (about material multiply and form fibrous bone.
cherry-sized).
This early osteogenesis is the work of survivAccording to the histologic investigations of ing transplanted bone cells and not of bone at
&HWEffiERER (1970), a hematoma in a cavity is the transplant site. At the same time as the fiorganized only from the peripheral zone. The brous bone is being formed, a breakdown of the
vessels follow the shrinking connective tissue bony substance in the transplant takes place via
Primary healing was observed in all cases at
the site where cancellous bone was removed
from the iliac crest. There was practically no impairment of walking. The average operating
time was 11/4 hours, and the average stay in hospital six days.

11

osteoclasts, the process closely correlating with


osteogenesis. What happens is that the collagenous fibrils and apatite crystals are absorbed, while the basic intercellular and cement
substances, the- mucopolysaccharides, exert an
influence on the osteogenesis.
The mucopolysaccharides act as an organizing factor, inducing the development of osteoblasts from undifferentiated mesenchymal cells
of the growing connective tissue (AxHAUSEN,
1952, 1953, 1962; ScHWEmERER, 1970).
According to current opinion, osteogenesis is
autochthonous in the one phase (the surviving
osteoblasts in the transplanted cancellous bone
directly form new bone), and in the other phase
inductive (connective tissue at the transplant
site ).
The autochthonous (osteoblastic) is the more
powerful of the two phases. Both supplement
each other, provided that the location of the
transplant is adequately nourished and the
transplanted material is stable. In the case of
cysts of the jaw, these conditions are provided in
optimal form:
1. good vascularization,
2. close contact with a wide surface of the bone
and the adjacent mucous membranes after
closure,
3. the absence of mechanical motion.
This is confirmed by the healing process in the
14 cases mentioned, all of which involved ex-

12

tended, and in some instances infected, cysts of


the lower jaw and anterior upper jaw.
The advantages of primary osteoplasty are:
1. maximum therapeutic success rates, and
2. shortening of the treatment period.
Patients prefer a brief operation under general anesthesia which is not so psychologically
stressing as surgery with a local anesthetic, as the
survey during the follow-up examination demonstrated. The necessary, average 6-day stay
in hospital is justified by the success achieved.
Osteoplasty using cancellous bone can therefore
be summed up as a psychologically, physically,
and materially economic method of treating
large cysts of the jaw.

2.5. Summary
In 14 patients cavities caused by cysts in the
upper and lower jaw were filled with autogenous
cancellous bone from the iliac crest. Even after
3 months there was radiologic evidence of
physiologic incorporation and replacement of
bone. The technique described does not increase the time required for the operation, and
actually reduces the treatment period. Postoperatively, there is practically no impairment
of walking.

3. Free Composite Rib Transplantation Using Neurovascular


Microsurgical Anastomoses
By H. M. Tschopp

Free rib grafts are frequently used in maxillofacial surgery for reconstruction of the mandible
and facial contour restoration. Such transplantation, however, entails a temporary but critical
separation of the graft from the blood circulation. This invariably leads to necrosis of most of
the graft's parenchymal cells and the final result
is often a poor reward for the high investment.
In the last two decades, enormous progress
has been made in the field of microsurgical vessel and nerve anastomoses. This has made it possible to unite vessels measuring 0.5-1.0 mm in
external diameter and still obtain acceptable patency rates (BUNCKE et aI., 1973; SMITH, 1966;
STRAUCH et aI., 1967).
These microsurgical vessel and nerve anastomoses provide the only means by which the
blood supply can be re-established in a free bone
and muscle graft immediately after transplanta-

tion. In a series of animal experiments, an attempt was made to transfer a unit of rib with the
corresponding intercostal musculature, and
immediately afterwards re-establish the blood
supply to the graft using microsurgical vascular
anastomoses. In addition to the vascularization
procedure neurorrhaphy was also performed in
order to allow for later functional stimulation of
the graft.

3.1. Animal experiments


In a series of 11 dogs, a rib with the intercostal musculature was removed from the chest wall and its nutrient vessels and nerve dissected free. The composite
graft of autogenous muscle and bone was then transplanted to a defect, created at the lower margin of the
mandible (Fig. 11).

Fig. 11. Schematic review of


different operative procedures. (1) Composite rib and
intercostal muscle graft prepared for transplantation, (2)
Dissection of facial nerve (N),
vein (V), and artery (A) at recipient site, (3) Creation of a
corresponding defect at lower
border of the mandible, (4)
Transplantation of composite
graft to mandible. Internal
fixation of the rib graft and
neurovascular anastomoses
have been accomplished.
Magnified inset demonstrates
the site of anastomoses (V:
vein, N: nerve, A: artery)

13

The blood and nerve supply was re-established


immediately afterwards using the dissecting microscope.
Suture anastomosis was performed between the
facial vein and artery and the intercostal vein and artery and also between the intercostal nerve and a
branch from the facial nerve.
In addition to these 11 microsurgical transplants,
four composite bone and muscle units were transplanted in the same way but without microsurgical
anastomoses. This group served as a control. In order
to study the behavior of the bone graft after transplantation, four contrasting flu oro chromes were
given postoperatively in a predetermined sequence:
Xylenol-orange in the first and second postoperative
week, Calcein in the third and fourth, Oxytetracycline
in the fifth and sixth, and Alizarin complexone in the
seventh and eighth postoperative week (Table 3).

Table 3

XO

WEEKS

OP

C
OTC :
AK :

XYLENOLORANGE
CAlCEIN
TERRAMYCIN
ALIZARINCOMPLEXON~

After 16 weeks the animals were sacrificed and decapitated. Intravascular filling with a radiopaque
medium was achieved using finely dispersed Barium
sulfate administered through the common carotid artery (Table 4).
Table 4
SUBSTANCE

OOSE

HEPARIN

5000 IU Iv

RONICOL

150 mg

la

DECAPITATION

SALlNESOLUTION

1000 mila

INDIA-INKSOLUTION

200 mila

MICROPAQUE
SOLUTION

200

14

mila

~.

3.2. Results
The evaluation of the muscle graft revealed the
following results:
In 7 out of 11 microsurgical muscle transplants electromyographic examination showed
distinct potentials which did not differ markedly
from the potentials elicited in the platysma muscle of the same animal (Fig. 12).
The microangiographic study demonstrated a
good patency of the intercostal artery in 6 muscle transplants (Fig. 13). In one graft, however,
only a fine line of Barium sulfate was present in
the main intercostal artery, indicating that
thrombosis and partial recanalization had occurred.
The histologic examination in 7 transplants
showed macroscopically well healed vessels and
nerves at the site of anastomosis, and microscopically normal muscle and also areas of degeneration and regeneration (Fig. 14).
In silver-impregnated sections of the muscle
graft nerve axons were seen ramifying over muscle fibers 16 weeks after transplantation
(Fig. 15).
In order to evaluate the rib graft, longitudinal
and transverse sections were taken, which
clearly demonstrated that the original texture of
the graft had persisted (Fig. 16a).
Fluorescence microscopy of these sections
showed the typical color pattern, which is, in a
centripetal direction, two stripes of Xylenolorange, two stripes of Calcein, two stripes of
Oxytetracycline, and two stripes of Alizarin
complexone, each coloured ring around the osteon representing one dose of a fluorochrome,
given at an interval of one week.
Special attention was paid to the presence of
Xylenol-orange which was administered in the
first and second postoperative week. This period
up to the second postoperative week represents
the time where no mineralization or remodelling
is present after a conventional free bone transplantation.
In seven bone transplants Xylenol-orange
and the other fluorochromes were seen
throughout the entire rib graft, in the periphery
as well as in its center. Some areas showed a
vague discoloration as described in the remodelling process of fibrous bone.

CONTROL

TRANSPLANT

No.6

Fig. 13. Radioangiography (dog No.6) demonstrating a patent facial and intercostal artery 16 weeks after transplantation. Small vascular connections can be
seen between the intercostal artery and the inferior
alveolar artery. Arrow indicates site of microsurgical
anastomosis (1: 1)

.-

..

Fig. 14. Longitudinal section


of intercostal muscle graft at
higher magnification. Fibrosis
and atrophy of muscle fibers is
still present 16 weeks after
transplantation. Occasional
disintegration of muscle fibers, regeneration of fibers (arrow) and chains of small dark
nuclei can be seen. Muscle
striations are well preserved.
(x 330)

15

Fig. 15. Silver-impregnated


section of muscle graft at
higher magnification. Axons
can be seen ramifying over
muscle fibers 16 weeks after
transplantation. (x 680)

Fig. 16 a. Longitudinal section


through rib graft (G) at site of
internal fixation with the
mandible (M). Cortical and
cancellous structures of graft
have been preserved 16 weeks
after transplantation. (x 1.5)

Fig. 16b. Longitudinal section


of rib graft (G) at site of internal fixation with mandible
(M). The screw alley is apparent. Vascular anastomoses
were not patent in this animal. Cancellous structure inside graft has been replaced
by a greasy tissue. Some cortical regions of the graft look
fairly normal 16 weeks after
transplantation. (x 1.5)

16

In the best of the four control rib grafts which


were done without microsurgical anastomoses,
some ca1cein was found in peripheral areas
(Fig. 16b). Most of the fluorochrome depositions,
however, were present in the Oxytetracycline and
Alizarin complexone period, that is in the fifth
to ninth postoperative week. In the other grafts
of the control group and in the 4 grafts where
microsurgical anastomoses had failed, a nonviable bone transplant was seen without fluorochrome depositions. The microradiographic
studies revealed in all but four animals filling of

the Haversian vessels with the contrast medium


in several areas throughout the entire rib graft
(Fig. 17). There was no contrast medium present in the four rib grafts of the control group
(Fig. 18).
These findings indicate that in the best conventional rib graft, the blood circulation is established only after about one month, whereas
in microsurgical rib grafts mineralization and
remodelling processes start in the first few days
after transplantation.

Fig. 17. Microradiograph of a


rib graft 16 weeks after transplantation. Barium sulfate is
present in several Haversian
vessels throughout the rib
graft. (35 f-t, x 70)

Fig. 18. Microradiograph of a


rib graft 10 weeks after transplantation. Vascular anastomoses were not patent in
this animal. There is no contrast medium present in vessels of Haversian system.
(50 f-t, x 35)

17

3.3. Summary
The experimental results demonstrate that a
bone graft of considerable size survives free
transplantation, and that active and rapid bone
union with the host bone is possible without the
graft undergoing the slow and uncertain process
of replacement.
This, however, can only be accomplished if
the blood supply to the graft is re-established by
means of microsurgical vascular anastomoses
immediately after transplantation. On the other

18

hand, a sufficient portion of the intercostal muscle graft survives free transplantation as functioning muscle in order to allow for its clinical
application, which would include its use for large
reconstructions of the mandible and adjacent
musculature, such as the mylohyoid, the
geniohyoid, and the genioglossus muscle. These
muscle entities are important for deglutition and
in speech.
Further practical experience, however, is
necessary in order to fully assess its clinical significance.

B
Traumatology and
Reconstructive
Surgery

1. Principles of Rigid Internal Fixation in Fractures of the Lower Jaw


By B. Spiessl

1.1. Indication
One criticism leveled against rigid internal fixation states that the problem of occlusion is insoluble in many cases. Negative experience in this
connection issues from the erroneous idea that
rigid internal fixation is feasible without rigid retention of the occlusion.
The omission of a rigid retention of the occlusion, however, implies limitation of the indication. This is one of the reasons why rigid internal
fixation is used in certain fractures of the mandible and not in others.
Thus, nonsurgical treatment is frequently
preferred if sufficient teeth are present, even
when there are quite serious dislocations. For
instance, according to LENTRODT and HOLTJE
(1975), the University Clinic for Maxillofacial
Surgery in Hamburg still treats about two-thirds
of all fractures of the mandible conservatively.
The question of when rigid internal fixation is
indicated should not be answered dogmatically.
Paradoxically, as ALLGOWER (1975) has stated,
it is not the fear of incomplete healing of the
fracture which leads us to determine the indication for rigid internal fixation - no-one denies
that consolidation of a fracture can be achieved
by nonsurgical means. It is rather the fear of delayed post-traumatic disorders such as arthropathy, deformation, dysgnathia, and
pseudarthrosis on the one hand, and on the
other the burden placed on the patient by intermaxillary fixation.
If we regard every fracture as an emergency,
a consideration to be taken seriously, then we

have to prefer a method which aims at the best


possible, immediate, definitive treatment. Viewed in these terms, rigid internal fixation is
never an end in itself. It is rather a way of
eliminating the immediate results of fracture,
such as pain and loss of function, and restoring
the normal situation in the most rational manner.
Further objections to rigid internal fixation
are the scar on the neck, and possible damage to
the marginal mandibular branch of the facial
nerve.
ESCHMANN (1975) has photographed 101
scars following surgery for rigid internal fixation
and examined them in the light of sub jective and
objective criteria. About 35% of the scars were
classed as aesthetically very good; 50% were
satisfactory and 15% were poor. Only 5% of the
scars were subjectively disturbing. This result
was achieved despite the fact that the incisions
by no means all corresponded to the lines of
maximal skin elasticity: In the area of the chin
the incision frequently cut across the natural
skin folds so that the scar was much broader.
The conclusion to be drawn from this observation is that the skin must be incised precisely
in or along the line of maximal elasticity, the incision beginning at the lower edge of the mandible (see Fig. 19 and p. 77).
In order to avoid an external scar, the intraoral approach will attain its due significance in
the treatment of simple fractures. For example,
median and paramedian fractures can be treated
intraorally by retracting the soft tissues of the
chin.

21

Fig. 19. Incisions along skin folds for exposure of mandibular fractures in the pars angularis, pars molaris, and
pars canina

Even retrocanine fractures can be dealt with


intraorally provided that they are not severely
dislocated and that an appropriate instrument
set is available (see p. 120). From the surgical
point of view, however, the intraoral procedure
has major disadvantages, such as the extreme
denudation of the fragments, difficult reduction,
and stretching of the adjacent soft tissue. It is
doubtful, therefore, whether this procedure can
be generally recommended. Furthermore, such
considerations are unimportant in answering the
question of the indications for rigid internal fixation.
What is important is that there is no essential
reason for limiting rigid internal fixation exclusively to certain types of fractures. It must be
22

emphasized that the technique offers unique advantages over conservative therapy in the
treatment of difficult fractures such as comminuted, compound and defect fractures. A choice
between the two treatments really exists only in
the case of simple fractures where there is normally little or no dislocation. The individual circumstances dictate whether a conservative or
surgical method is appropriate, though with an
edentulous jaw or in the case of multiple injury,
it is clear that internal fixation will be chosen.
However, the conception of practically unlimited indications for rigid internal fixation depends on surgery with a high degree of asepsis,
and a team of traumatologists, who understand
the principles involved.

1.2. Principles

1.2.1. Accurate Anatomical Reduction

The principles of rigid internal fixation have


been laid down by the Association for the Study
of Internal Fixation (ASIF).
The objective of the procedure is the immediate active and pain free mobilization without jeopardizing the healing process. This aim is
achieved by:
1. accurate anatomic reduction (with the emphasis on occlusal and basal repositioning)
2. absolute stabilization of the fragments
3. surgical technique involving thorough protection of the tissues.

- Occlusal Repositioning
The first point to be considered with regard to
the anatomic reduction of the fragments is the
preoperative manual restoration of the occlusion, and intermaxillary fixation during surgery.
Thus, rigid internal fixation requires mastery
of nonsurgical fracture-treatment, involving
mainly manual repositioning and the immediate
application of a rigid arch bar to act as a tension
band. The occlusion is secured during surgery by
means of special intermaxillary ligatures

Fig. 20. Intermaxillary clamps and prostheses in situ for temporary fixation of a fractured edentulous jaw in
central occlusion

23

(Ernst's ligatures), with or without tension bands


(see Figs. 75 and 74, p. 55, 54), depending on
whether the fracture is within the area of the row
of teeth or beyond. Acrylic is used to make the
Ernst's ligature rigid, as well as the tension band.
There can be no doubt that continuous wire ligatures are no substitute for this because of lack of
rigidity.
In the case of an edentulous jaw, intermaxillary clamps are used (Fig. 20).
- Basal Repositioning
The second point for consideration is extraoral, basal reduction. The partial splint applied
as a tension band and the intercuspation
achieved by rigid intermaxillary ligatures allow
the anatomically exact reduction of the fragments without the danger of occlusal redislocation.
Furthermore, a preload can be built up using
the reduction pliers, because the tension band

and intercuspation ensure that the excentrically


applied pressure is transformed into axial compression (Fig. 21). (This is illustrated by the example on the right of the picture.)
Pressure rollers can be attached to increase
the pressure considerably (see Figs. 62 and 63,
p.46).
1.2.2. Absolute Stability
"Absolute stability" is a clinical concept. It would
be more correct to talk of relative stability, which exists in a given dynamic system if the variations in pressure occurring when an external force acts upon the
(plate-bone) system remain within certain limits and
the state of equilibrium is re-established. Since, in
clinical practice, systems are frequently described as
relatively stable when they are in fact unstable (e.g.
bone wiring), the concept of absolute stability has
become accepted with regard to the stability actually
achieved. It is clear, of course, that absolute stability,
i. e. a stability maintained for as long as desired and
related to all dimensions of a dynamic system simultaneously, does not exist.

E (= Excentric Forces)

100
Tension Band (T B )
+
I ntercuspidal Fixation

TB

Axial Compression

Fig. 21. (a) Excentric compression (E), produced by means of reduction pliers, is transformed into axial compression by tension band (TB) and intercuspation (rigid intermaxillary ligatures). Because of elasticity of
periodontium, values for pressure are smaller in occlusal area of fracture than in basal area. E = Excentric
Force, TB = Tension Band, ~ = axial compression, (b) Excentric stress (E) is changed into proportionate
compressive stress (D 20) by the tension band (TB), (axial compression)

24

C
r

Fig. 22. Healing of a dog's radius under compression. (Drawn from photographs by SCHENK) (a) Because of the
physiologic bow of the radius, after osteotomy and fixation a very small gap exists in cortex next to plate, and a
much wider gap in opposite cortex. Osteotomy surfaces show a very irregular zone of necrosis, (b) After 8 days
the small gap (b') has not changed, while wider gap in opposite cortex (b") now contains a number of vessels
that have grown in, both from periosteum and from medullary canal. Osteoblasts have migrated from vessel
walls and have begun to lay down osteoid on necrotic edges of the fragments thus joining them together, (c) In
third stage of healing (8-10 weeks) revascularization ofthe necrotic fragment occurs in two ways. In cortex next
to plate where there was a minimal gap, vessels grow in from widened Haversian canals. In opposite cortex
where there was a wider gap, the vessels come from Haversian canals as well as from outside. Under compression the close apposition of cortical fragments next to plate does not allow any vessels to grow in from either the
endosteum or periosteum, while in opposite cortex the vessels are growing in from both these sites. Both gaps,
however, heal by primary vascular bone formation, (d) Magnification of a capillary bud arising from the Haversian canal, shows that bone resorption is immediately followed by bone formation. At the head of the column of
penetrating cells are multinucleated osteoclasts (a) which are resorbing necrotic bone (e) and are making room
for the capillaries (b) and their accompanying osteoblasts (c) to grow in. The osteoblasts lay down osteoid (d)
and soon change into concentrically arranged osteocytes. (MULLER, M. E. et aI., 1970)

25

The concept of compression leads on to a


further basic principle of rigid internal fixation,
termed "absolute stability".
The practical application of the principle is
based on clinical and experimental experience,
which shows that two fragments immobilized
under pressure unite without visible callus formation. The fracture heals by angiogenic ossification.
What occurs is either (Fig. 22):
Adjacent to the plate: primary bone healing
with lamellar bone building in axial direction
(contact healing), or opposite the plate: lamellar
bone building which is not axially directed
(gap-healing).
The consolidation designated as primary
bone healing is regarded as an indication of absolute stability, the latter being achieved most
reliably by interfragmentary compression.
The technical principle of stabilization is
based essentially on the effect of frictional binding. The reciprocal compression of two fragments produces a frictional force. The friction
prevents a shifting of the two fragments as long
as the frictional binding produced by the compression is greater than the external functional
forces.
A further principle of rigid internal fixation
involves the application of biomechanicallaws.

The fractured bone is essentially exposed to


the same bending and pressure forces as the intact bone. This basic experience is a determining
factor (Fig. 23).
The photographic representation of trajectories by KUPPERS (1971) shown in Fig. 24, illustrates the side on which the flexural moments
are acting. The pulling trajectory is observed on
the oral, and the pressure trajectory on the basal
side.

TRACTION TRAJECTORY

PRESSURE TRAJECTORY

Fig. 24. Photographic representation of the trajectories (summational picture) in a model of an edentulous mandible. 3 types of compressive stress trajectories are recognizable: the 2 almost parallel traction
and pressure trajectories on oral and basal side, and
pressure trajectory running perpendicularly into articular surface (K. KUPPERS, 1971)

1.2.3. Tension Band and Stabilization Plate

Fig 23. Bending and pressure forces acting on fractured mandible during functional stress

26

One of the basic principles of applied


mechanics states that bending is diminished or
eliminated by counter-bending. The tensionband principle is based on this. This representation of the tensional forces was produced by
PAUWELS in 1965. It shows diagrammatically
how the flexural tractive and compressive forces
subjected to excentric stress, are contracted by a
tension band on the opposite side, and transformed into symmetrical axial compression
forces (see Fig. 21).
With the use of a crane, for instance, with a
bent or straight arm, the flexural tractive forces
are reduced by means of a tension band
(Fig. 25). These examples demonstrate that the
tension band is a basic factor in the rigid internal
fixation of fractures of the lower jaw.

" traction
ca I I us "

"pressure
call us "

Fig. 25. Crane with tensioning for the cross-beam.


Analogous situation in a case of mandibular fracture
with tension band

As we observed, the alveolar side of the fracture is primarily exposed to tractional forces by
the tension of the muscles. However, it is also
exposed to alternating lingual and buccal torsional and shearing forces.
To create a state of stability from the interplay of forces, a mechanism which counteracts
and neutralizes all the forces involved must be
constructed. It is apparent that this mechanism
must be a combination of tension band and
stabilization plate (Fig. 26).

Fig. 27 a and b. Fixation callus as mechanism of neutralizing forces (PAUWELS, 1965). (a) On the traction
side of fracture, a periosteal callus (traction callus)
has formed due to action of tractional forces (t). The
blastema (intermediary tissue) enclosed between
traction callus and end of the broken bone has developed into cartilaginous tissue under effect of hydrostatic pressure, (b) Because of increase in hydrostatic pressure in the cells of cartilaginous tissue, progressive expansion within blastema occurs. This produces a curvature and increased tension in the periphery of the callus, which in turn attempts to increase
the inclination of upper end of fracture. This distortion of fracture acts in opposition to traction callus on
traction side, which has, in the meantime, become
stronger. Progressive expansion of intermediary tissue thus produces a firm bracing of ends of fracture
and ensures their stability during functional stress

Nature is the best teacher in this instance: the


principle of this force-neutralizing mechanism is
realized in the fixation callus (Fig. 27).
In the case of a femur fracture, tractional
forces act on the convex side, so that a powerful
tractional bracing of collagen fibers forms on
this side. By contrast, the angle itself is under
pressure, so that the major mass of the callus
forms there, until finally the ends of the fractured bone are pressed together with great force
and immobilized.
'"", \_ . {/!.,
.".'I::l.-' _

..r;:J .e. .iil

"

.... _'

Fig. 26. Principle of neutralizing forces: axial compression by tension band and stabilization plate

1.3. Plates (DCP and EDCP)


Mastication involves bending forces between
50 and 120 kp. To neutralize these, plates with
27

Fig. 28 (a). DCP (dynamic


compression plate), (b) EDCP
(excentric dynamic compression plate) with a transverse
hole on each side

great tensional strength are required (Fig. 28):


the DCP (Dynamic Compression Plate) and the
EDCP (Excentric Dynamic Compression
Plate ).

The special feature of the DCP is the hole


made according to the rules of spherical
geometry (Fig. 29). On application, the spherical gliding principle comes into effect, the result

Fig. 29 a-e. Spherical gliding principle with the DCP (ALLGDWER et aI., 1970). (a) Course ofa sphere in a cylinder with a bend in it. Downward movement is transformed into horizontal movement. Change in direction occurs at the point of intersection oftwo cylinders. Sphere cannot move laterally (b) Basic form of screw hole corresponding to section of bent cylinder. Spherical shape of screw head in accordance with the principle of horizontal movement of the sphere. When spherical screw head is turned, it glides in the section of the inclined
sphere. Fragment grasped by screw is thus moved horizontally (spherical gliding principle). In horizontal section of cylinder, the screw is guided further toward fracture gap. By this second movement, a locking action
between screw and plate is avoided, (c) Actual screw hole from the combination of 2 hemicylinders with screw
head and neck to fit, (d) Screw head lies on the gliding plane of inclined hemicylinder, (e) Path taken by screw in
vertical and horizontal direction after it is tightened. (SPIESSL and SCHROLL, 1972)

28

the basal side through the screw holes


positioned along the axis, and on the oral side
through the other screw holes (see Fig. 56,

p.43).

::..~ .... ;

'~.:=.:.

:.:...;'::":':.::-::'~::.',

:~~ :~ ...:::!': :::':":'=":.

::~':'. ':',

::.:~.:- .. :~. ~ ':

'.,

.: ...

. . .

.....

! . . ,. .

Practically every type of fracture can be


rigidly fixed using these two sorts of plate. Exceptions are the large defect fractures caused by
gunshot wounds. In such cases, whole sections of
the mandible have to be bridged, and plates of
special shape and strength are available for this
(see chap. D.6.).
The DCP and EDCP are rectilinear fixation
systems. Their main advantage is that they can
be used everywhere with great flexibility. At the
stage of bending the plate, controlled overbending is of great importance. The buccal fixation of

.....

Fig. 30a--c. Action of the DCP. (a) Left screw is inserted but not tightened, (b) Adaptation phase. Right
screw is inserted and tightened firmly. During tightening, the head of screw moves on the gliding plane of
hole in plate, so that plate moves in direction of arrow.
As soon as plate meets the head of screw on the left,
the screw draws fragment in same direction (shaded
section). Fracture gap is now apparent only as a line,
(c) Compression phase. Left screw is tightened. Plate
is drawn to left in direction of arrow, and moves fragment on right toward the gap. At the same time, screw
on left, which is firmly anchored in fragment, forms a
resistance, so that compression of fragment results

of which is adaptation in the first phase and compression in the second (Fig. 30). The interfragmental compression is over 30 kp.
The EDCP is an excentrically acting DCP. A
screw hole is positioned at 900 to the axis on each
side. Interfragmental pressure is produced on

Fig. 31 a and b. Incorrect internal fixation due to using


a poorly adapted DCP in the form of: (a) a nonbent
plate, (b) After tightening of screws there is complete
adaptation of plate against surface of bone. Result:
distraction offragments on the lingual side. Compression acting only on part of fracture area.

Fig. 31 c andd. Correct application of the DCP, taking


curved shape of jaw into consideration: (c) Plate is
slightly over bent, (d) After tightening of screws this
overbent plate produces compression over whole
fracture area

29

the plate on the buccal side of the mandible


causes or intensifies distraction on the lingual
side ofthe fracture (Fig. 31a and b). By slightly
overbending the plate, this is prevented or
eliminated (Fig. 31c and d).
A further advantage is that the instrument
set required for the straight plates is simple,
conveniently arranged, and economical.
Moreover, the individual plates can be used in
combination (as tension band and stabilization
plate simultaneously), and they can be easily
removed.

Fig. 32. Tension band arch bar + stabilization plate


(DCP)

Fig. 33. (a) Rigid internal fixation of a comminuted


fracture with tension band arch bar and 8-hole DCP.
No intermaxillary fixation, (b) Status after 3 months.
Tension band arch bar was removed after 8 weeks.

30

As far as the practical use of these plates is


concerned, experience has shown that this system of balanced forces can be applied in
80-90% of fractures of the lower jaw.
For fractures within the dental arch, the following formula applies (Figs. 32 and 33):

Tension band - arch bar

Stabilization plate (DCP)

For fractures beyond the dental arch, the following formula applies (Fig. 34 and 35 a-d):

Compression- tension band plate (DCP)

Stabilization plate (DCP)

Fig. 34. Tension band plate (DCP) + stabilization


plate (DCP)

(a fracture of the angle of the mandible with a


wisdom tooth in the fracture gap, which had
to be removed).

Fig. 35. (a) Fracture of angle of mandible with impacted wisdom tooth, (b) Following extraction of wisdom
tooth: compression-tension band plate (3-hole DCP) and
stabilization plate (4-hole DCP) (c) Retromolar fracture of angle of mandible with triangular fragment at
base of mandible, (d) 3-hole DCP and 8-hole DCP.
Note: Anterior cortex screw of the 3-hole DCP grips
only outer cortex so as not to damage roots of molar

31

In the case of edentulous jaw with total atrophy of the alveolar process, the following formula applies (Fig. 36):

Further possible uses for the EDCP can be


found on p 57.

DCP or EDCP

Fig. 36. (a) Oblique fracture on right and transverse fracture on left without dislocation on this side, (b) Pseudarthrosis following conventional treatment elsewhere with intermaxillary fixation by means of gunningtype
splints. Anesthesia dolorosa

32

Fig. 36. (c) Stabilization of pseudarthrosis by means of interfragmentary compression produced by a 4-hole
DCP. Substantial improvement in pain, (d) Consolidation after 6 months. Condition immediately after removal
of plate

1.4. Instrument Set


At the beginning, it was stated that the third
aim of the technique discussed is the maintenance of the blood circulation in the fragments
and adjacent soft tissues by surgery guaranteeing protection of the tissues.

The main prerequisite for such surgical technique is an instrument set with which the most
difficult fixation problems can be solved
(Figs. 37 and 38).1
1 The instrument set of the AO is obtainable from
Synthes Ltd., 4437 Waldenburg, Switzerland.

33

Fig. 37. Basic mandible Set


(complete standard set). Synthes: Swiss Association for the
Study of Internal Fixation
(AS IF)

Fig. 38. Instruments and implants of basic set. 1 st row right, from above to below: Reduction forceps for small
bones, Forceps for small plates, Depth gauge for small screws, Small hexagonal screwdriver, 2.5 mm with across
flats, mandible reduction forceps with compression rollers. 2nd row left, from above to below: Drill guide
2.0 mm diameter, DCP drill guide, 2.0 mm diameter, small countersink, Tap 2.7 mm diameter, Tap sleeve,
3.5 mm diameter, EDCP and DCP mandible plates, screw forceps, screw rack, with cover

34

2. Rigid Internal Fixation of Compound Mandibular Fractures


By J. Prein and B. Spiessl

2.1. Introduction

The main a~ms of internal fixation of simple


mandibular fractures apply also to compound
fractures. They are:
1. absolute stability
2. good repositioning and thorough adaptation
3. atraumatic surgical technique.
The special biomechanical situation existing
in mandibular fractures has been explained in
the preceding article. As has been described, the
first and most important aim, absolute stability,
is achieved by applying the tension-band principle. This entails the use of plates, screws or
splints, to counteract and neutralize the tension
and pressure forces acting on the bone.
Besides guaranteeing primary and rapid bone
healing, absolute stability provides a high degree of protection against infection.
It has been demonstrated in animal studies
that an implant by itself does not cause infection.
Only a few days after plate fixation of tibial osteotomies, RITTMANN et al. (1975) injected a
suspension of Staphylococci into the stabilized
fracture area. By means of this experiment he
was able to show that primary bone healing
takes place within a fracture which has been
rigidly stabilized, despite the presence of infection.
Our own studies in sheep mandibles showed
that as mobility between the fracture ends increases, the danger of infection, nonunion, and
pseudarthrosis also increases (PREIN et aI.,
1974). We performed fractures and osteotomies
in sheep mandibles and used different means of
stabilization, including wire ligatures and plates.
The tension-band principle was applied in all
cases. One of the conclusions drawn from the

experiments was the above-mentioned fact that


the danger of infection increases with instability.
Our clinical experience, which will be illustrated
by several cases, shows that primary healing can
be achieved even in wide open and contaminated compound fractures.
2.2. Case Reports
The first patient was a young man who had a motorcycle accident. He had a wide open compound fracture
in the chin area with loss of the alveolar process and

Fig. 39. Wide open compound fracture in chin area


with loss of alveolar process and teeth

35

teeth, including all incisors and premolars on the left,


and no other injuries (Fig. 39). He was operated on
five hours after the accident, under naso- tracheal intubation. After thorough cleaning of the wounds, intermaxillary fixation with wire ligatures in the molar
area was performed. As can be seen in Fig. 40, the
main fragments and remaining pieces of bone in between were fixed by means of three plates. On the right
side posterior to the mental foramen, we were able to
use a tension-band plate (three holes) and a stabilization plate (four holes), in accordance with the ten-

sion-band principle. The mental nerve had been lost


during the accident. Because of the loss of too much
bone on the left side, only a stabilization plate could
be used. It was not possible to apply two plates, one as
a tension band and the other as a stabilization plate,
since the two sides where tension and pressure forces
act lie too close together, this also applies for very
atrophic jaws. Where only one plate can be used without tension band, however, it must be longer than
the normal 4- hole stabilization plate to guarantee
stability.
Fig. 40. Fixation of open
compound fracture of chin by
means of three plates

Fig. 41. (a) condition of


wounds immediately after
surgery, with suction drainage
installed, (b) condi tion of
wounds 3 weeks after surgery
T

Fig. 42. Complete bony healing 6 months after accident.


Plates were removed and restoration of alveolar process
was commenced

36

After thorough atraumatic closure of the soft tissues and suction drainage, primary healing occurred
(Fig. 41). The patient remained in hospital for 10
days and returned to work after 4 weeks.
Six months after the accident, the plates were removed via a submental incision (Fig. 42). At the same
time restoration of the alveolar process by means of a
bone transplant was commenced. Further details on
this reconstruction can be found on page 59.
The second case for consideration involved a
poly traumatized young man, who had been in a car
accident. The facial in juries were similar to those seen
in the first case, but in addition, he had an open fracture of both femora. Two teams operated on him at
the same time, one dealing with the femoral fractures,
and the other with the facial injuries. As the patient

had a Le Fort-I-Type fracture of the maxilla and most


of his teeth had to be removed, intermaxillary fixation
during surgery was not possible. The patient lost all
his teeth, except for the canine tooth on the right and
one molar.
After the normal arch in the lower jaw had been restored by means of arch bars and acrylic material, a
bony defect was visible on the left side (Fig. 43). Because of this defect it was impossible to establish stable fixation by means of compression. In this case,
therefore, we used a normal 6-hole forearm plate
made of titanium, although we knew we would not be
able to cover it with soft tissues (Fig. 44). We were
encouraged to do this by the results obtained by BURRI
(1974), who stabilized infected tibial fractures with
plates although he was unable to cover them with soft
tissues.

Fig. 43. Case 2: After restoration of normal arch in lower


jaw a bony defect was visible
on left side

Fig. 44. Stabilization of defect


fracture of chin by means of a
normal ASIF forearm plate,
which could not entirely be
covered with soft tissues

37

Of course, in our case the mental nerve was torn on


both sides. There was no fear of damage to the mandibular nerve from the screws. Postoperatively the
patient received careful oral hygiene treatment and
there were no complications. As can be seen in the
photograph (Fig. 45) taken 4 months after surgery,
the plate remained uncovered. Bony union was observed, however, and 5 months after the accident the
plate could be removed (Fig. 46).

In accordance with the previously mentioned tension-band principle and the special situation in cases
of mandibular fractures, it was necessary to use two
different types of tension band. The anteriorly
situated fracture required a tension-band arch bar,
while the other fracture received a tension-band
plate. See the schematic drawing in Figure 48. The
same is shown by the radiographies (Fig. 49). We
used a long 8-hole plate as a stabilization plate at the

Fig. 45. Partially uncovered forearm plate for


stabilization of chin fracture of case 2, four months
after accident
Fig. 47. Compound fracture with great amount of dislocation. Ascending ramus had been pulled in an anterior direction, and fragment in between in direction
of floor of mouth

Fig. 46. Condition of patient's chin area 5 months


after accident and after removal of plates. There
was bony union
Our third case concerned a young woman, who was
involved in a car accident. She suffered a compound
fracture of the right mandible just in front of the angle. There were two fracture lines: one behind the
second molar and the other one between the second
premolar and first molar.
Because of the direction of the trauma and the pull
of the muscles, there was a great amount of dislocation. The ascending ramus had been pulled in an anterior direction, and the fragment with the two molars
was pulled in the direction of the floor of the mouth
(Fig. 47).

38

Fig. 48. Stabilization of compound fracture of case 3


according to tension-band principle. Different
methods for tension banding are visible. Tensionband arch bar and tension-band together with one
stabilization plate at base

Fig. 49. Radiographs showing same as in schematic drawing of Fig. 48

lower margin of the mandible. Intermaxillary fixation


was maintained during surgery. The importance of
fixation of the normal occlusion cannot be emphasized too often. It is an absolute necessity during
surgery. If ommitted, occlusal disturbances will be the
consequence in most cases.
As is demonstrated in Figure 50, occlusion was undisturbed. The patient returned to work as a teacher 3
weeks after surgery.
The last case we wish to present in this chapter concerns a young man who had a motorcycle accident. He
apparently fell from his machine and sustained a
compound fracture in the area of his chin. In addition,
both his articular processes were broken, and there
was a fair amount of dislocation with severe disturbance of the occlusion.

Fig. 50. Undisturbed occlusion in the third case with


markedly dislocated compound fracture of right
mandible. End of the tension-band arch bar visible

Fig. 51. Compound fracture


of case 4 with two fractures in
an oblique direction and one
longitudinal fracture

39

In this case, because ofthe fractures of the articular


processes intermaxillary fixation for 14 days was
necessary. In view of the functional treatment required after 14 days, it was mandatory to stabilize the
chin fracture by internal fixation.

of the main fracture, were activated according to the


gliding-hole principles ofthe DCP to create compression.
The healing process was uneventful and the patient
was discharged 6 days after the accident.

Arch bars with acrylic material were applied to


function as a tension band in the lower jaw. After repositioning on the oral side and intermaxillary fixation in norm-occlusion, the fracture was exposed
through a submental incision (Fig. 51). There were
two fractures in an oblique direction and one longitudinal fracture. On the outer surface there were

2.3. Conclusion

The above-mentioned cases demonstrate that


in compound fractures in particular, internal
fixation is indispensable. If the correct technique
is employed, the risk of infection or non-union

Fig. 52. Stabilization of compound fracture of case 4 by


means of a 6-hole DCP plate
together with 3 screws right
from the fracture line acting as
lag screws
two small pieces of bone. For stabilization we used the
special 6-hole DCP plate of the ASIF set for mandibular fractures. This was developed in the last few
years as a result of our own experience (Fig. 52). In
order to replace and stabilize the two small fragments
on the outer surface, the three screws on the right of
the main fracture were inserted as lag screws (see also
Figs. 73 p. 54), while the other two screws, on the left

40

is low, and is by no means higher than in cases


treated conservatively (ESCHMANN, 1975).
The necessity for good stabilization has been
explained. Thorough repositioning on the oral
and basal side is necessary for undisturbed occlusion. Atraumatic technique and rigid internal
fixation will guarantee primary bone healing.

3. Experimental Studies on the Effect of Rigidity Using an Excentric


Dynamic Compression Plate (EDCP)
By R. Schmoker

3.1. Theoretical Considerations


Optimum stability in an internal fixation of a
fracture is obtained by equally distributing the
compression forces over the whole fracture region. An asymmetric distribution of compression forces (Fig. 53) on the other hand can lead
to a lower stability than if the ends of the fracture had simply been butted without any compression being applied, even in spite of considerable interfragmental pressure produced by the Fig. 53. Gap appearing on opposite side when a comfixation.
pression plate is applied at base of lower jaw
Instability occurs when the ends of the fracture can rotate with respect to one another. Such
an axis of rotation can lie in any direction but
will pass through the fracture gap through the
site of the pressure peak. A dental arch bar functioning as a tension band compensates tension
forces (Fig. 54) and guarantees the reduction in
the occlusal region during the operation and
period of healing. An arch bar is not able to influence the long-term interfragmental pressures, although it can compensate the shortterm pressure fluctuations during normal jaw
function. Nor is it able to maintain interfragmental pressures for more than a short time because of tooth movement. (It is well known that
constant forces of the order of 1 N per tooth, or
ION for a whole set of teeth, can be used in dental orthopaedics.)
Since interfragmental pressures, in general,
need to be larger than this to prevent micromovements, a fixation system directly on the
bone is required. For a transverse fracture in Fig. 54a--c. Tension and pressure side oflower jaw in
the lateral ramus of the lower jaw, this position functional use. (a) There are tension forces in the alwould correspond approximately to that of the veolar process and pressure forces at margin

41

Fig. 54 (b) With a fracture a gap opens on tension side, (c) Neutralization of tension forces by an arch bar functioning as tension-band

mandibular canal. Clearly a fixation cannot be


positioned here and must, therefore, be placed
on the surface of the bone.
The most favorable position to apply a compression force at the surface is the point nearest
the center of the fracture plane. However, the
compression forces produced from a plate
positioned in this way are reduced away from
the plate with the result that a gap could open
between the fracture ends at that side. Such a
pressure gradient can in general be compensated by bending the plate in excess of the
amount needed to match the contour of the
bone (called "overbending" the plate). In the
case of fractures of long bones we can, in addition, mount the plate on the tension side of the
fracture.
For fractures of the lower jaw, it is not possible to place the plate dorsal to the foramen mentale and centrally between the marginal and occlusal sides because the screws would penetrate
the mandibular canal. Consequently the plate
can only be screwed on excentrically, cranially
toward the alveolar side or caudally toward the

42

base of the lower jaw. This excentric applica tion


of the plate can lead to gaps appearing on the
opposite side (see Fig. 53) which tend to be
larger, the greater the compression applied.
Gaps of this type cannot be closed by overbending the plate prior to its application.
When the plate is applied to the occlusal tension side of the fracture, the pressure fluctuations over the fracture area during function are
smaller than if the plate is applied on the basal
pressure side. A plate can only be mounted in
the alveolar region in a toothless part ofthe jaw.
If teeth are present, then only the pressure side
can be used, and we are faced by an additional
problem of counteracting the increased pressure
fluctuations during jaw function.
In order to obtain axially directed compression forces over the whole of the fracture plane,
we have taken a new approach to the tensionband principle and have developed in addition
to the compression tension-band plate a new
fixation, the so-called excentric dynamic compression plate (EDCP) (Fig. 55). This plate, together with the special reduction compression

Fig. 55 a and b. Excentric


dynamic compression plate.
(a) Model with transversely
directed holes positioned away
from fracture, (b) model with
transversely directed holes
positioned near to fracture
b

pliers, which assist its fixation, allows compression forces to be obtained both centrically under
the plate (Fig. 56a) and excentrically beside the
plate in the alveolar process (Fig. 56 b). The
compression in the alveolar process is obtained
from two transverse compression holes. When
screws are put in toward the margin of the lower
jaw and driven home, the fragments are rotated
around the screws near to the fracture, which
function as axes of rotation, and the fragments
are consequently pressed together in the alveolar process.
Experiments demonstrate that the transverse
positioning of the compression holes is particularly important to the effectiveness of the plate.
Oblique positioning of the compression holes
gives rise to a transverse component of the compression forces as well. However, this can only
be effective when the screw in the hole of the
plate can cover a certain distance and the bone
fragments are able to move horizontally. Such
horizontal movement is blocked, however, if the
screws next to the fracture have been driven
home and the fracture gap is already under
compression. In this case, the major effect of the
forces originating from the oblique holes is to in-

l
~~
.~

@(Q)

:;.<~

b
Fig. 56 a and b. Excentric dynamic compression plate:
The outer hole is transverse. (a) When screws are
driven home, next to fracture, in longitudinal holes a
compression arises at margin of lower jaw, (b) When
screws are driven home toward margin of lower jaw,
in transverse holes, a rotation of the fragments around
inner screws, as axis of rotation, results in a compression in alveolar process

43

crease the longitudinal compression at the base (Fig. 57 a). In this case the holes in the bone
of the jaw: the excentric forces, which would have to be drilled toward the alveolar process
spread the compression over the remainder of (Fig. 57 b). When the screws next to the fracture
the fracture area, are minimal; this is also true are being driven home, the fragments are rowhen four rather than two obliquely directed tated around the screws away from the fracture
which have previously been fixed and the~efore
holes are used.
To summarize: The principle of the EDCP is also produce compression in the alveolar profirst to fix the base of the jaw in compression (us- cess. Plates with six or more holes with a correing the two longitudinal screws next to the frac- . sponding grouping of the holes work on the
ture and then to rotate the jaw fragments about same principle.
these screws to bring the upper part of the fracAn important advantage offered by the
ture into compression as well. The transverse EDCP over the DCP is that there is a smaller
compression holes ensure that this rotation can chance that instability can arise during lower jaw
be achieved in an optimal fashion with a minimal function. The reasons for this are as follows:
decrease of the initial compression force. The
If a normal DCP is fixed on a fractured long
transverse positioning of the holes is therefore bone, then when the screws are driven home, a
clearly superior to the oblique positioning.
static force results on the screw which is directed
Depending on the kind of fracture and the against the fracture gap. If the plate lies on the
consistency of the bone, there is the danger that tension side of the bone, then even with the
a screw can break out when being driven home if greatest functional stress, only forces in the
the longitudinal compression holes are too near same direction can arise (Fig. 58). If the plate
the fracture gap. In a second model of plate, the lies on the pressure side on the other hand,
longitudinally directed holes are positioned the forces on the screw during masticatory funcaway from fracture, and the transversely directed tion, are in the opposite direction to the static
holes are positioned next to the fracture forces exerted on them by the plate (Fig. 59).
If these dynamic forces exceed the static
forces, then the screws are subjected to forces
whose direction changes intermittently, with the
danger that the screws will be loosened and become unstable.
A further important aspect in the fixation of
the plate is the exact positioning of the screw
holes in the bone with respect to the holes in the
plate. GAlEAZZI(1972) was able to show that a
slightly excentric position for the screw in a conical hole in a plate changes the distribution of the
pressure to a significant degree. To demonstrate
this, a number of experienced bone surgeons
were asked to fix plates to a long-bone fracture
in experimental conditions. After the fixations
were complete, the compression forces were
measured.
b
-------_______L~______________
It was found that when the screws had been
Fig. 57 a and b. Excentric dynamic compression plate driven excentrically slightly away from the frac(inner hole transverse). (a) When screws are driven ture, higher compression was obtained, and
home, fracture far, in longitudinal holes a compres- when the screws were driven slightly near to the
sion arises at base of lower jaw, (b) When screws are . fracture, the compression was reduced. This sort
driven home toward alveolar process in transverse
holes, a rotation of fragments around outer screws as of consideration is particularly important in the
axis of rotation results causing a compression in al- fixation of fractures of the jaw with DCP plates,
but in this case the problem is caused by driving
veolar process

44

r
Fig. 58. Proportion of forces on long bone when a
plate is applied at tension side of fracture: Static (narrow arrow) and dynamic (wide arrows) forces are arranged in same directions, resulting forces stay over
zero

Fig. 59. Proportion of forces on long bone when


a plate is applied at pressure side of fracture: Static
(narrow arrows) and dynamic (wide arrows) forces
are arranged in opposite directions, resulting force
alternates from positive to negative

Fig. 60. Proportion of forces on lower jaw with application of DCP, where the neutrally drilled fracturefar hole was accidentally put in excentrically toward
base of lower jaw. The static force that acts on screw
(narrow arrow) is arranged in same direction as the
forces (wide arrows) that arise in functional stress

Fig. 61. Proportion of forces on lower jaw with application of a DCP where neutrally drilled fracture-far
hole was accidentally put on excentrically toward alveolar process of lower jaw. The static force that acts
on screw (narrow arrow) is in opposite direction to the
forces (wide arrows) that arise during functional
stress. The resulting force, that acts on the screw, alternates from positive to negative

45

home the screws with transverse rather than


longitudinal excentricity. This can cause forces
to act on the screws during jaw function, which
fluctuate from positive to negative leading to
variations in the stability of the fixation.

Fig. 62. Reduction compression pliers. With both lateral pressure rollers the fragments can be rotated into
the position that is best for a reduction. After reduction they can be precompressed at base of lower jaw
with the grips on reduction pliers and in alveolar process with pressure rollers

This can be illustrated by considering DCP


plates where the screws have been put in excentrically toward the base (Fig. 60) or toward the
alveolar process of the jaw (Fig. 61). The latter
case leads to forces that intermittently change
from positive to negative, because in the first
case a force results which has the same direction
as the functional stress, and in the second these
forces act in the opposite direction. The transverse position of the hole of the EDCP is, so to
speak, a security factor which only permits the
correct forces to bear on the fracture areas.
In order to obtain exact reduction and precompression in the alveolar process, it is advisable to use special reduction compression pliers
(Figs. 62-65) that have been developed for use
with the EDCP. Pressure rollers can be fixed to
the side of the anchorage of the reduction pliers
and are pressed with a screw against the margin
of the lower jaw, causing a rotation of the fragments around the retaining screws (see figs. 62
and 63). These lateral pressure rollers for the
reduction and prepressure in the alveolar process are necessary when using the EDCP for the
following reasons:

1. Reduction can be realized in the whole fracture region. The ends of the fragments can be
brought exactly parallel to one another so that
the complimentary structures on the fracture
faces interdigitate correctly when the pliers
are closed.
2. The fracture can be set under a higher and
more uniform compression.

3. The compression force is not obtained entirely


with the excentrically placed screws in the plate

Fig. 63. Reduction compression pliers mounted on a


model of lower jaw. Compression in alveolar process
is achieved using both lateral pressure rollers

46

and consequently both the screws and the


holes in the plate will be less deformed. (The
reduction compression pliers have the same
function as the tightener for plates, which is
fixed on a bone during an operation: MULlER
et aI., 1969).

Fig. 64. Tightener for reduction compression pliers

As experiments on models have shown, the


fracture can be reduced more easily using the
handles of the pliers when they are not hindered
in their mobility by a screw fixation. However,
higher compressions can be obtained with the
pressure rollers than can be obtained by hand
and so a screw tightener (pliers tightener) has
also been developed which allows the compression in the basal part of the fracture to be increased (see figs. 64 and 65) .
The tightener can be put on the branches of
the reduction compression pliers and is a slightly
modified version of the plate-tightener developed by MULlER

Fig. 65 . Tightener for reduction compression pliers in


position on the grips of a pair of pliers for obtaining
compression

3.2. Results
Simple experiments on models (Fig. 66) have
shown that the compression techniques that result in compression on the tension side have a
greater stability. The summary of the results of
these experiments is shown diagrammatically
(Fig. 67): curves 1-5 show the values for the
techniques with tension banding and 6-11 for
those without tension banding.

Fig. 66. Experimental plan for measuring stability

47

From curves 8-11 it is evident that stability


decreases both with increasing compression
(curves 10 and 11) and decreasing plate length
(curves 8 and 9). Curves 6 and 7 show the values
for the EDCP, and it is clear that it produces a
higher stability than the other plates without the
tension-band principle (curves 6--11). For the
same length of plate (4-hole model), the values
do not reach the values of the bracing system

consisting of stabilization plate plus tension


banding (curves 4 and 5). The greatest stability
is obtained with the EDCP and with the tension-band principle with compression (curves 1
and 2).
Figure 68 demonstrates in a comparable
presentation the strain forces that produce instability in the different fixation system.

STABILITY
REPRESENTED AS
GAP APPEARING

IN 101M

With tension banding:


1. 4-hole EDCP + 2- or 4-hole Compression Tension Band Plate
2.4-hole EDCP + arch bar, functioning
as tension ba nd
3.4-hole DCP + 2-hole Compression
Tension Band Plate
4.4-hole DCP + 3-hole Tension Band
Plate
5. 4-hole DCP + archbar, functioning as
tension band

0=

STABLE

O.S

Without tension banding:


6. 6-hole EDCP
7. 4-hole EDCP
8. 6-hole small fragment plate
9. 4-hole small fragment plate
10. 4-hole DCP
11. 6-hole DCP

1.S
2
2.S
3
4

10

2.S

SO

7.510

100 150 200 300

STRAIN

IN N

Fig. 67. Comparative presentation of stability of some systems of fixation with and
without tension banding

STRAIN IN N
I>l TIE BEGINNING
CF INSTABILITY

300

250

200
WITHOUT TENSION BANDING
6 HOLE DCP

ISO

100

4 HOLE EDCP
6 HOLE EDCP
WITH TENSION BANDING
, HOLE DCP. ARCHBAR FUNCTIONING I>S TENSION BAND

SO

, HOLE DCP 3 HOLE TENSION BAND PLATE


, HOLE DCP 2 HOLE COMPRESSION TENSION BAND PLATE
, HOLE EDCP. ARcteAR FUNCTIONING AS TENSION BAND
, HOLE EDCP. 2 OR' HOLE COMPRESSION TENSION BAND PLATE

48

Fig. 68. Comparative presentation of strain forces that effect instability in several systems of fixation

Fig. 69. Experimental plan for


measuring
interfragmental
compression

100 r-------------------------------------~ '00


300 ~------------------------------------_1 300
ALVEOlAR

200

~------------------------------------_1 200

100 ~------------------------------------_1 U
0

'00

400

300

Fig. 70. Development of interfragmental compression


basal under the plate and far
from alveolar process in the
case of a 6-hole DCP

BASAl

200
100
0

In another experiment (Fig. 69), the interfragmental compression that is reached with the
different techniques of internal fixation was determined with special miniature instruments for
measuring forces. With the DCP with or without
an arch-bar functioning as a tension band, the
forces are limited to the region under the plate
and amount on average to 200 N for a 2-hole
plate and 300 and 350 N for 4- and 6-hole
plates. On the opposite side in the alveolar process no compression force could be measured
(Fig. 70).
The experiments with the EDCP (Fig. 71)
turned out completely differently in this respect.
In driving home the screws in the horizontally
directed holes, a force of about 200 N results at

r....

1"""'\

r'

"

I'

200

I .a.. DCP

300

100

4 ICllE OCP

, tCllE DCl'

the base of the lower jaw. In driving home the


screws in the transversely directed holes there is
a decrease of pressure to about 150 N. At the
same time, however, a compression force of
150 N also arises in the alveolar process (with
the 6-hole plate this reaches 200 N).
The same reciprocal behavior of the compression forces at the basal and oral side is even more
pronounced in the experiments with the reduction compression pliers (Fig. 72). On closing the
handles of the pliers, a compression force of
about 200 N can be obtained at the margin of the
lower jaw as with the simple reduction pliers. By
activating the compression rollers this force decreases continuously to zero while the compression force on the oral side increases continu-

49

400 .-------------------------------------~

wo

r--------------------------------------4

300

300

200 r--------------------~ ----------------~ 200

AUlEOt.A~

100 r---------------~~~~----------------__4 '00

40O

100

300
BASAL

200

_.-

,00

300

J'\.

.~
~

0
II

ALYEOt.AR

IKI

400

400

300

300

200

400

'-

300

(OotPfll:[sg:)t IN

o
400

200

"'-

ously to 200 N. At an intermediate position between the two extreme positions of the rollers, a
pressure of about 100 N could be measured on
the basal and oral sides. The same results are obtained in combination with the arch bar functioning as a tension band because it has -- as
with the DCP -- no influence on the compression force obtained with the EDCP.
Under precompression with the reduction
compression pliers and the tightener, and using
a 6-hole EDCP, or with the combination of
compression tension-band plate plus stabilization plate, average values of 300-350 N are
obtained on each side, basal and alveolar
(Table 5).

3.3. Discussion

The first experiment was designed to test stability as a condition for primary bone healing.
Since this depends on the stability of the fixation, we were able to draw the following conclu-

50

,00

300

200
100

Fig. 71. Development of interfragmental compression


basal under the plate far from
the plate in alveolar process
for a 4-hole EDCP

200
IJ

100

BASAL

200

100

Fig. 72. Reciprocal conditions


of compression forces in the
basal and alveolar regions on
compression with reduction
compression pliers

sions as to the effectiveness of the EDCP:


1. Dependence of the stability on the length of
plate:
a 6-hole plate gives higher stability than a 4hole plate.
2. Dependence of the stability on the localization of the compression:
Compression on the tension side gives higher
stability than if the compression is only on the
pressure side. Consequently, if a stress has
caused a gap to open on the tension side of the
fracture area, the gap closes again when the
stress is removed. The EDCP and the compression tension-band plate are the only two
systems where this happens.
3. Dependence of the tension banding:
Conditions are more stable with an arch bar
or plate functioning as a tension band than
without it. A dentally fixed arch bar functioning as a tension band effectively absorbs fluctuating tension forces and maintains the reduction in the occlusal region during the operation and subsequent healing.

Table 5. Summarizing presentation of the compression forces (in Newton) from the different techniques of
internal fixation
Combination of

2-hole
DCP

4-hole
DCP

6-hole
DCP

4-hole
EDCP

6-hole
EDCP
2-longitudinal
holes

6-hole
EDCP
4-longitudinal
holes

Alone
Arch bar functioning
as tension band
2- hole compression
tension band plate
Arch bar functioning
as tension band +
reduction pliers
Arch bar functioning
as tension band +
reduction compression
pliers
Reduction compression
pliers + pliers tightener

01200

0/300

0/350

1501150

200/100

1501250

01200

0/300

0/350

150/150

200/100

1501250

200/0

150/150

150/250

150/300

01200

0/250

0/350

0/400

1501250

200/200

150/350

200/200

250/150

250/250

2501250

300/250

300/300

Compression
tension band plate +
reduction compression
pliers
Compression tension
band plate + reduction
compression pliers +
pliers tightener

(0/200
till
200/0)
1001100
(0/550
till
300/0)
200/200

2001200

250/250

250/300

250/250

300/300

300/350

4. Dependence on the kind of tension-band


principle:
Tension banding with compression was more
efficient than tension banding without compression.
In the second experiment, the localization
and size of the interfragmental compression
forces were tested. Special attention was paid to
the compression force on the tension side because only an equally spread compression force
prevents micromovements and guarantees stability. Our results can be summarized as follows:
1. A compression force on the tension side can
be obtained with the EDCP or with the compression tension-band plate and can reach
200-350 N. The forces of several DCP holes
arranged one after the other and the forces
from the reduction compression pliers and the
pliers tightener augment one another.

2. The forces at the base and the alveolar process of the lower jaw are reciprocal:
increasing compression in the alveolar process causes a decrease in the compression at
the base of the lower jaw and vice versa.
3. The arch bar functioning as a tension band
has no influence on the interfragmental compression forces. It prevents neither the onesided compression on the base of the lower
jaw under the DCP nor the compression in
the alveolar process obtained by using the
EDCP.
From these two experiments we can draw the
following conclusions:
1. A compression force spread over the whole
fracture region is obtained with a compression tension-band plate or with an EDCP.
2. The arch bar has a satisfactory tension-band
function but has no influence on the interfragmental compression.

51

3. A long plate is more stable than a short one.


4. When using the EDCP or the compression
tension-band plate, the pressure rollers on the
reduction compression pliers should be used.

3.4. Summary
Longitudinal pressure at the fracture site for increasing the stability has been used in bone
surgery for a long time. Two main problems
must be solved when a fracture of the lower jaw
is to be fixed in compression:
1. How to obtain longitudinal compression on
the occlusion (tension) side without damaging
the roots of the teeth or the mandibular nerve.
2. How to prevent gaps appearing on the occlusal side, from compression at the basal
(pressure) side or through functional stress.
Solutions to these problems are provided by
both the excentric dynamic compression plate
(EDCP), where the pressure effect occurs not

52

only under the plate but also beside it, and by the
compression tension-band plate.
According to the conditions of dentition, occlusion, and the localization of the fracture, this
internal compression fixation is supplemented
by an arch bar with a tension-band function.
Reduction compression pliers can be used to obtain an exact reduction and precompression in
the alveolar process.
The excentric pressure effect is reproducible,
and the compression force in the occlusal and
marginal region can be determined qualitatively
and quantitatively from simple experiments on
models.
The most stable condition is obtained with the
EDCP or with the compression tension-band
plate, in both cases after precompression using
the reduction compression pliers and the pliers
tightener. Compression forces of about 300 N
are obtained interfragmentally in the alveolar
process as well as at the base of the lower jaw.

4. Internal Fixation of Mandibular Fractures Using an Excentric


Dynamic Compression Plate (EDCP)
By R. Schmoker

In the present paper, the clinical aspects of the


use of the EDCP are examined on the basis of a
follow-up study of 25 cases.

4.1. Patient Population

Of the 25 mandibular fractures treated with excentric dynamic compression plates, 9 were in
the region of the angle of the mandible or at the
level of the wisdom tooth, and 16 were in the
area between the canine and the second molar.
Twenty-two of the 25 EDCP's were applied to
fully or partially dentulous patients, and 3 to
edentulous patients. The mandibular fractures
were accompanied by additional local injuries,
consisting of 13 cases with a second mandibular
fracture, 10 cases of anesthesia of the mental
nerve, 10 cases of a tooth in the fracture gap, 9
cases of dental luxation, dental fracture or fracture of the alveolar process, 3 cases of unilateral
or bilateral fractures of the articular process, 3
cases of Le Fort fractures, and 2 cases in which
the fracture was also open extraorally. The
causes of the fractures were as follows: 4 sport
injuries, 4 fights, 2 industrial accidents, 2 domestic accidents, and 10 road accidents. Most of the
10 patients who had been involved in road accidents had received multiple injuries. In these
cases, the rigid internal fixation ofthe mandible
was performed simultaneously with the general
surgical treatment. The predominant accompanying injuries were: concussion: 7; fractures
of limbs: 5; brain contusion: 3; intrathoracic or
abdominal bleeding: 2; contusion of the thorax:
2; aspiration: 2.

4.2. Time of Treatment

Related to the time of admission to hospital, the


rigid internal fixation was carried out within
24 h in 20 cases, after one day in 1 case, after 3
days in 2 cases, after 5 days in 1 case, and after 9
days in 1 case. The delays occurred with those
patients who required initial treatment in the intensive care unit. The reasons for the delays
were one case of shock (3 days); one case of
pneumonia caused by aspiration (9 days); 2 concussions (1 day and 3 days). In the case of one
patient, the regression of an extreme swelling,
which was already present on admission, took 5
days.
Immediate treatment lowers the risk of infection and the frequency of later complications. It
shortens the period of posttraumatic pain, the
lenght of stay in hospital, the period of unfitness
for work, and the period of psychologic stress. In
cases of mUltiple injury, immediate treatment
makes the care of the patient substantially
eaSIer.

4.3. Type of Treatment

In the 25 instances of rigid internal fixation, 18


4-hole and 7 6-hole EDCP's were used. In 3
cases of oblique fracture, basal compression was
achieved by means of lag screws inserted
through a plate in the region of the fracture
(Fig. 73). In one case, a cancellous bone screw
was substituted for a cortex screw, which could

53

not be inserted firmly enough (see Fig. 73). For


reduction of the fracture, reduction pliers with
lateral pressure rollers were used. In 10 cases involving fractures distal to the row of teeth, the
occlusion was retained during surgery with
Ernst's ligatures (Fig. 74). In 6 cases involving
fractures within the row of teeth, the retention
of the occlusion during surgery was achieved
with Ernst's ligatures and arch bars functioning
as tension bands (Fig. 75), in 2 edentulous patients with dentures by extraoral fixation (see
Fig. 20), and in 4 cases ofLe Fort or collum frac-

Fig. 73. Compression of an oblique fracture by means


of a lag screw inserted through one of the middle holes
in plate (2nd screw from left). The hole without
thread (gliding hole) is in fragment proximal to plate;
the hole with thread (thread hole) is in fragment distal
to plate. Axis of screw bisects angle formed by perpendiculars on surface of fracture and fracture line. A
cortex screw which did not grip the cortex firmly
enough was substituted by a cancellous bone screw
(4th screw from left)

tures, by means of arch bars on the upper and


lower jaw with intermaxillary fixation (Fig. 76).
In 3 patients without dentures, no retention was
necessary during the operation.
The EDCP was most frequently indicated in
cases where no tension-band plate could be applied, i. e., in the following cases:
1. fractures distal to the mental foramen either
in an area with teeth or in a toothless area with
atrophy of the alveolar process
2. fractures of the angle of the mandible with
impacted wisdom tooth
3. fractures immediately distal to the row of
teeth, with or without a tooth in the gap.
There were 17 of these exceptional cases among
the 25 cases with indication for the EDCP. It is
interesting to note that all these 17 cases were
stabilized without tension-band plate or arch
bars, merely by the excentric action of the
EDCP.
Mobilization and food intake immediately
followed surgery in 21 cases. In 4 cases involving
Le Fort fractures or fractures of the collum
mandibulae, the jaws were immobilized by intermaxillary fixation for 4 and 2 weeks respectively.
The immediate postoperative mobilization
and resumption of normal diet form the main
advantage over conservative therapy. This is

'-

Fig. 74. Ernst's ligature in a


fracture outside the row of
teeth. Stabilization ofthe wire
ligature by means of aerylic
(see insert)

54

Fig. 75. Ernst's ligature and arch bar functioning as


tension band in a fracture within the row of teeth. Occlusal hooks are pinched off

Fig. 76. Splinting of upper and lower jaws in the case


of additional Le Fort or collum fractures

particularly apparent with elderly patients. It is


one of the main reasons for regarding rigid internal fixation as indicated even in simple fractures of the jaw. If the patients involved are conscious, the 2 possible types of fracture treatment
are discussed with them, the advantages and disadvantages of conservative and surgical therapy
being explained: surgical treatment with anesthesia, scar formation, immediate resumption of
normal diet, 2-3 follow-up examinations, and
unfitness for work for 2-3 weeks; and on the
other hand, conservative treatment with arch
bars, inability to open the mouth, 6 weeks liquid
diet, 4--6 weeks definite unfitness for work and
1-2 follow-up examinations per week.

of stay in hospital for patients with in juries to the


jaw, facial skeleton, and craniocerebral region
was 6.6 days.
The length of stay in hospital can be shortened by appropriate early treatment. When the
fracture is stabilized immediately, swelling and
pain disappear rapidly. The patient can be discharged from hospital at a time when conservative therapy would only be at the stage of taking
the impression necessary for preparing splints in
the laboratory - assuming general anesthesia
were not required for the process.
The period of unfitness for work was 11-38
days (mean 21.9 days) for patients with jaw injuries alone. Unfitness for work lasting more
than 2-3 weeks was mainly due to postconcussion syndrome, cervical syndromes, intermaxillary fixation in cases of fractures of the collum
mandibulae, etc. With further facial or
craniocerebral traumas, the period of unfitness
for work was 35-47 days and more, up to permanent disability among the cases with mUltiple
injuries.
The fractures healed without complications in
all cases. No pseudarthrosis, nonunion, instability, fracture of the plate, gap or bone infections
occurred. This illustrates the good stability of
the internal fixation achieved with the EDCP.

4.4. Results

The length of stay in hospital for patients who


had received injuries to the jaw only (including
open fractures, double mandibular fractures,
comminuted fractures and cerebral concussion)
was 4-7 days (mean 5.3 days).
For patients with additional injuries to the facial skeleton or craniocerebral regions, the
length of stay in hospital increased to 16-17
days, and for those with multiple injuries, the
stay lasted from 12-129 days. The mean length

55

The stability can be explained as follows: The


EDCP is fitted on the pressure side, but because
of its effect of excentric compression, it exercises
in addition the same function as a compression
plate on the traction side. The increased stability
thus obtained was measured experimentally in
stress tests on models and cadaver mandibles.
In the soft tissues, 2 parodontal infections occurred: 1 involved dentitio difficilis with a partially impacted wisdom tooth, and the other was
a parodontal abscess following crushing of the
gingiva in an accident. In this connection, it must
be emphasized that all teeth in the gap without
fractured roots were left in place. The
prophylactic administration of antibiotics in this
investigation (penicillin and streptomycin in 6
cases; Penbritin in 7 cases; Keflin in 6 cases; no
prophylactic antibiotics in 6 cases) had no effect
on the occurrence of infection (1 infection of the
soft tissues occurred in the group with antibiotics, 1 in the group without).
In 3 cases the scars were slightly hypertrophic. One scar resulted from laceration and
contusion of the soft tissues which extended to
the fracture. The other 2 cases involved surgical
scars which did not follow the skin folds. Five
further scars were thickened and visible, but
were not felt to be disturbing by the patients, so
no correction was undertaken. The remaining
17 scars were invisible or scarcely visible (see
also p. 21).
Of the 10 cases of anesthesia and hypesthesia
of the mental nerve, the anesthesia remained
unchanged in one case, disappeared completely
in another, and receded in the remaining eight.
No paresthesia or neuralgia occurred; also no
iatrogenic postoperative anesthesia was observed.
Therefore, anesthesia of the mental nerve,
which is relatively unpleasant for the patient,
occurred in 40% of cases after the accidents.
Thus the importance of the best possible repositioning must be emphasized. This can only be reliabily achieved by surgery, and during the
operation it is frequently apparent that the fracture is still markedly dislocated in the basal area,
despite the fact that the correct occlusion has
been achieved by manual reduction. Damage

56

caused to the mandibular nerve by a fixation


screw is regarded as iatrogenic. It can be avoided
with a great degree of certainty with both the
DCP and, as in this case, the EDCP if a careful
technique is employed. No lesions of the facial
nerve were observed after the accident or after
surgery.
The occlusion was perfectly satisfactory in all
cases but one. In the latter instance, tooth no. 7
in the fracture gap, which was in this case the
most distal tooth, had not been incorporated in
the arch bar. It was pressed into the correct position by means of the intermaxillary retention
with Ernst's ligatures during surgery. But it later
produced occlusal interference and had to be
corrected by grinding. This emphasizes once again the importance of the arch bars functioning
as tension band, which not only exert a tensional
function (neutralization of the distraction forces),
but also guarantee retention of the occlusion
in the area of the fracture gap during surgery and
in the healing phase.
For this reason, arch bars functioning as a tension band should be used for all fractures where
teeth are present, irrespective of whether they
can be secured only to 1 tooth in a fragment
rather than 2, or even if they can only be secured
to a tooth in the fracture gap. It is apparent from
previous experiments that the arch bars have no
negative or positive effect on the interfragmentary compression. The good results obtained
with regard to the occlusion contradict the view
that in rigid internal fixation, the occlusion presents a problem that is difficult to solve (see
p. 21). On the basis of experience gathered in
general surgical traumatology, it may be assumed that the negative view is based on inadequate application of the ASIF principles, which
may mean in particular that no arch bars functioning as a tension band were used, and rigid
occlusal retention was absent during surgery.
Since rigid occlusal retention is one of these
principles, the necessary stability cannot generally be obtained with continuous interdental
wire ligatures and intermaxillary wire or
rubber-band fixation (even though satisfactory
rigid internal fixation is possible in a few cases
where there is very good articulation).

4.5. Summary
On the basis of the above-mentioned 25 cases,
the indications for the use of the EDCP are, in
brief as follows: The main indications are fractures in the area of the lateral teeth, where the
plate must be applied basally because of the
mandibular nerve, and fractures at the angle of

the mandible, where the use of the compression


tension-band plate is sometimes not possible
because of an impacted wisdom tooth.
The following principles generally apply:
1. at the angle of the mandible:
compression tension-band plate

stabilization plate (Fig. 77 a),

c
Fig. 77a-<;. Indications for different fixation techniques: (a) At the angle of the mandible: Compression-tension-band plate and stabilization plate. If lack of space: EDCP, (b) In the area ofthe lateral teeth: EDCP with
arch bar functioning as tension band for dentulous jaw, without arch bar for edentulous jaw, (c) In the area of
the front teeth: DCP with arch bar functioning as tension band for dentulous jaw, without arch bar for edentulous jaw

57

in unfavorable circumstances: EDCP


2. in the area of the lateral teeth:
EDCP arch bar (Fig. 77b)
3. in the area of the frontal teeth:
DCP arch bar (Fig. 77 c)
Clinical application confirmed the following
basic rules for the use of the EDCP:
1. For repositioning, the reduction compression
pliers with lateral pressure rollers should always be used.

58

2. With excentric drilling, special consideration


must be given to the following factors with regard to the height of the jaw:
high (dentulous) jaw, markedly excentric
(= excentric drill guide drawn in excentric
direction) ;
jaw not so high (edentulous), slightly
excentric (= excentric drill guide pulled in the
opposite direction);
with an atrophic jaw, neutral drilling (compression is produced only by reduction compression pliers).

5. Anatomic Reconstruction in Mandibular Fractures with Loss of


Bony Substance (Case Report)
By W.-A. Jaques, B. Spiessl and H. M. Tschopp

5.1. Introduction

Compound mandibular fractures may be combined with defects involving the alveolar process
and/or the body of the mandible. The treatment
of such fractures is difficult since the continuity
of the mandible has to be restored. On the other
hand, in compound and comminuted fractures,
bone healing may be delayed because of nonunion, pseudarthrosis, or infection at the fracture
site. The result may be asymmetry of the mandible and functional disability. In comminuted
fractures of the mandible with loss of bony substance, the main aim of primary reconstructive
surgery will be to create the best conditions for
bone healing.
The secondary reconstructive measures will
aim at an anatomic as well as functional rehabilitation of the masticatory apparatus.
This aim is achieved in 3 steps:
1. treatment of the fracture
2. transplantation of a bone graft
3. Restoration of dentition.
In the following chapter a case of a severe
comminuted fracture of the anterior part of the
mandible with loss of bony substance in the alveolar region is described and discussed.

5.2 Case Report

5.2.1. Treatment of the Fracture (see Chap. B 2)


An 18-year-old male patient sustained an open fracture of the mandible in a motorcycle accident. The

mandible was comminuted in the area of the chin, and


the alveolar ridge completely lost between 35-43.
Internal fixation of the fracture was accomplished
on the right side with a tension plate (3 holes) and a
stabilization plate (4 holes). On the left side a very
narrow bony bridge remained, which only allowed the
fixation of one long plate (10 holes) (Fig. 78 a and b).
The continuity of the mandible was thus reconstructed.

5.2.2. Reconstruction of the Missing Bone


After 7 months the missing alveolar process was reconstructed using autogenous bone from the iliac
crest. The scar was excised at the lower lip and chin
area and access gained to the mandible through a
separate submental incision (Fig. 79 a). The bone was
denuded at the site ofthe planned transplantation and
the contact areas roughened with a burr.
From the right iliac crest a piece of cortex and cancellous material was removed and cut in such a manner as to fit precisely into the defect of the mandible.
The bone transplant was then fixed with a plate

(6 holes) and the wound closed in layers (Fig. 79b).


Healing took place uneventfully.

5.2.3. Restitution of Dentition


Two months after the last intervention, the plate was
removed through an intraoral approach. The bone
transplant had healed nicely and bony union was evident. An impression was taken subperiosteally from
the frontal region of the mandible in order to build a
well-fitting metallic implant. After two weeks, the
metallic implant could be inserted through the same
intraoral approach and fixation accomplished to the
transplanted bone as well as the compact mandible

59

Fig. 78 a. Intermaxillary fixation by means of wire ligatures (arrows). On the right side stabilization was
achieved with a 3-hole tension-band plate and a 4hole stabilization plate. On the left, a lO-hole plate
was applied. Two empty holes lay above comminuted
area and could not be used for further stabilization

Hr

Fig.78b. Schematic drawing


of fracture before and after
surgery

Fig. 79. (a) 7 months after primary fixation the plates were removed through a submental incision. Consolidation of fractures was achieved, (b) An autogenous bone transplant was fixed with a 6-hole plate guaranteeing
absolute stability
using four lag screws (Fig. 80 a and b). Special care
was taken to pass the four screws through both cortices in order to achieve greater pressure forces. Later
a denture was fitted on the three transmucosal abutments and complete rehabilitation was thus achieved
(Fig. 80c and d).

5.3. Discussion

If the bony fragments remain in a state of absolute stability, primary bone healing takes

60

place without callus formation. Internal fixation


by means of plates and screws, according to the
technique described by the Association for the
Study of Internal Fixation (ASIF), fulfills this
condition in every respect. The danger of infection, pseudarthrosis, or ankylosis (SPIESSl,
1975; SCHENK, 1975; RAHN et aI., 1975) is diminished. If bone transplantation is necessary,
autogenous material is always used (see Chap.
A 1).

Fig. 80 a-d. Functional rehabilitation with implant dentures. (a) Laboratory model with the implant and temporary superstructure. Note special oval-shaped "gliding holes", (b) Implant after insertion through an incision
on the oral side. Fixation of frame to mandible and to transplanted bone by means of 4lag screws, (c) 4 months
after implantation the three abutments are surrounded with a normal mucosa. Implant is well tolerated, (d) Definitive superstructure is removable. It is anchored bilaterally in molar area on 2 telescopic crowns and in the
front on 3 implant abutments

Bone transplants removed from the iliac crest


have the following advantages:
1. Cancellous bone represents an ideal structure
for revascularization from the host tissues.
2. The cortical bone allows for internal fixation
by means of lag screws and thus guarantees
immobilization of the transplant.
3. The technique of removal is simple and the
postoperative disability minimal.
After rigid internal fixation of the transplant using lag screws or plates, revascularization and
bony union are enhanced (RAHN, 1975;
SCHENK, 1975; SPIEssr., 1975).
The time elapse between implantation of the
bone transplant and removal of the fixation
material seems to be important.
A plate which is left in place over a long
period of time would probably inhibit the functional stimulation of the graft, and thus would
provoke resorption of the graft to some extent.

The remaining teeth in the mandible or an


edentulous alveolar ridge often make it impossible to fit a prosthetic appliance. In many cases
vestibuloplasty has to be performed or the lingual sulcus reconstructed, which seldom gives a
functionally satisfactory result.
The search for an alternative method was
therefore justified. In the treatment of fracture,
it is an accepted fact that allogenic material such
as implants, plates, etc. are well tolerated if they
are absolutely stable (GAN:!, 1975). Therefore
the determining factor is not the kind of material
used for the implant but rather the possibility of
an absolutely rigid internal fixation of the implant. This is only possible if the sum of all static
forces which unite the implant to the bone is
greater than the sum of the functional forces
acting on the bone (SPIEssr., 1975).
The functional forces may be described as
pressure, traction, and shearing forces, which
61

Fig. 81. Screw fixation of implant. Drawing shows the special DC action of lag screws.
Hemispheric head of screw
glides downward on the oblique plane of longitudinal
hole. A directional force is
thus obtained. Screw and
bone represent a rigid system.
Implant is pressed on surface
of mandible as screws are
driven home

can only be counteracted by rigid internal fixation of the implant.


This was accomplished in our case by means
of four lag screws which, in accordance with the
principle ofthe ASIF technique, were able to fix
the implant rigidly on the reconstructed alveolar
crest as well as on the remaining mandible.
Pressure forces between the implant and the
bony surface are achieved when the screw is
tightened and the hemispheric head glides
downwards on the oblique plane of the longitudinal hole. A directional force is thus obtained.
The screw and bone represent a rigid system.
Therefore the implant is forced to move toward
the mandible and is compressed to the bone as
the screws are driven home (Fig. 81, see also

62

Fig. 29, p. 28) (PERRENet aI., 1969). In this patient, a rigid denture could not be attached to the
remaining teeth because the defect was too
large. A removable prosthetic bridge was built
which was held in place by four teeth and the
three abutments of the implant. The result thus
achieved was functionally as well as aesthetically
satisfying.

5.4. Summary

A case of a comminuted open fracture of the


mandible with loss of the alveolar ridge in the
symphysal area is presented, and the therapy
and rehabilitation are discussed.

6. Principles of Treatment in Combined Fractures of the Upper and


Lower Jaw
By H. M. Tschopp and G. Martinoni

In the treatment of compound facial fractures,


ever increasing emphasis is laid on an early
anatomic reconstruction and complete functional rehabilitation of the patient.
During recent years, progress has been made
in the development of certain ancillary techniques and operative procedures which help to
accomplish this aim.
In the following chapter the basic principles
of treatment are summarized and some modern
techniques presented.

6.1. Timing of Surgery

Surgery must be started as early as possible to


achieve the best functional as well as aesthetic
result. A primary repositioning and fixation under the 12-hour limit, however, is not always
possible. In patients with multiple injuries, any
major surgical intervention at the site of the facial fracture has to be delayed until circulatory,
respiratory, and intestinal problems are controlled, and complications arising from the central
nervous system can be managed adequately. In
these cases only the most necessary and vital
measures are undertaken, such as nasal or oral
intubation, tracheotomy, packing of the nose
and mouth or temporary fixation of severely dislocated fractures by interdental wire ligatures.
Massive hematoma formation and an ensuing
edema may render the subsequent repositioning
and fixation of the fractures more difficult. It is,

therefore, more appropriate to delay the primary


intervention until the hematoma has regressed
and edema has subsided (Table 6). A secondary repositioning and fixation after a longer interval has to be considered in cases of delayed
union, nonunion, and pseudarthrosis (see
Chap. E 1).

Table 6. Time Schedule for Surgery


Primary fixation
- under 12 hours
Delayed primary fixation - over 12 hours
Secondary fixation in
- delayed union,
non-union, or
pseudarthrosis

6.2. Preoperative Management


of the Patient

6.2.1. Preparation of the Wound


Injuries of the maxillo-facial region are often
accompanied by major contusions or lacerations
of the overlying soft tissues. Since these wounds
are frequently contaminated with foreign material, it is very important that the wound as well
as the oral cavity are thoroughly cleaned before
surgery. Using copious amounts of saline solution and dilute peroxide, debris, hematomas,
63

and foreign bodies are removed (Table 7). A


pulsating jet-spray may serve this purpose very
well and in addition helps to improve the vascularity of the badly traumatized tissues (Fig. 82,
see also Fig. 94).

Table 7. Treatment of Compound Open Fractures


Soft tissues
Bone

6.2.3. Occlusal Retention

The proper relationship between the upper and


lower jaw can only be established by fixation
and retention of the teeth in normal occlusion
prior to surgery. Such an intermaxillary fixation
is accomplished with interdental arch bars reinforced by acrylic material or using ligatures of
Ernst (see Chap. B. 4, Fig. 74).

Lavage with H 2 0/H2 0 2


Debridement
Extirpation of free bone fragments
Minimal detachment of periosteum
Suction drainage
Antibiotics

.-

Fig. 83. Schematic drawing illustrating intraoral closure of an open mandibular fracture on the left side .
A: Tooth at fracture site has been extracted and a
mucoperiosteal advancement flap outlined (marked
by short lines), B: Closure of alveolus by advancement of flap and fixation of wound edges with interrupted sutures

6.3. Surgical Procedures


Fig. 82. Pulsating jet apparatus containing peroxide
and saline solution. CA =compressed air

6.2.2. Teeth in the Fracture Line

All teeth at the site of a fracture should be preserved whenever possible in order to re-establish the functional status present before injury.
If a tooth in the line of fracture, however, is
loosened, has a fracture of its root or an apical
infection, it should be extracted preoperatively
(see Chap. E 1). In these cases a mucoperiosteal
advancement flap from the buccal side may be
used to close the alveolar cavity afterwards
(Fig. 83).

64

6.3.1. Fractures of the Maxilla

The middle-face represents a system of cavities


(orbita, sinuses, and oro-nasal cavity) which are
reinforced by strong pillars (Fig. 84 a and b).
These supporting facial struts absorb the forces
of mastication and distribute them in a caudocranial direction along the pterygoideal,
zygomatico-temporal, and naso-ethmoidal region to the fronto-maxillary, temporo-maxillary, and ethmoidomaxillary sutures. The architecture of the middle-face, however, is not
strong enough to counteract shearing forces occurring suddenly during an accident. These
forces may result in complete comminution of
the cavity system of the middle-face and the result may be severe disfigurement.

v
8

Fig. 84. Schematic drawing illustrating cranio-facial


development. (a) Maxillary region is composed of a
number of functional cranial components which are
related to vision, olfaction, respiration, chewing,
swallowing, and speech. In the course of development, force distributing and supporting osseous pillars are formed, (b) Growth of both neural and facial
skeleton is accomplished around the functioning
spaces, (i. e., neurocranium with the eyes, nasal,
paranasal, and oral cavities)

Fig. 85. Drawing illustrating different modalities of


wire fixation in fractures of middle face. K: Transfacial Kirschner wire for fixation of malar complex

Fig. 86. Drawing illustrating bimanual repositioning


of a dislocated and impacted Le Fort II fracture by
means of two pairs of Rowe forceps. Each pair of forceps is introduced with one blade into either side of
nose. The other blades are applied intraorally on the
palate. Arrow indicates direction of disimpaction

In order to achieve a functionally stable internal fixation of fractures of the middle-face,


interosseous wire ligatures are used. This is in
contrast to the fractures of the mandible where
rigid internal fixation by means of a dynamic
compression plate and a tension band is necessary (see p. 24ff). In comminuted fractures of
the malar complex with no medial support at the
naso-ethmoidal region, transfacial Kirschner
wires can be used to suspend and fix the bony

fragments to the other side (Fig. 85). In severe


"dish-face" deformity (fracture of Le Fort II
and III) repositioning of the maxilla is achieved
by means of Rowe's disimpaction forceps
(Fig. 86). Further traction and retention of occlusion is then maintained by an external cranial
fixation apparatus (Georgiade head frame)
(Fig. 87). Another possibility of fixation is provided by the application of plates and lag screws
(Fig. 88 a-c).
65

Fig. 87. Schematic drawing illustrating a Georgiade


head frame in situ. Rubber-band traction of maxilla is
accomplished. Middle face is suspended by means of a
rigid wire which is applied intraorally on the arch bars
and fixed extra orally on head frame with plaster of
Paris
Fig.88b

Fig. 88c

Fig. 88a

66

Fig. 88 a-c. Severe gun-shot wound with loss of soft


tissues, part of maxilla, and a large part of mandible,
1: Reconstruction of floor of orbit with a plate, 2:
Stabilization of comminuted maxilla by an arch bar
reinforced with acrylic material, 3: Reconstruction of
the continuity of mandible with a long plate fixed on
both remaining mandibular stumps, 4: Suspension of
malar complex by a 3-hole plate

Comminuted fractures of the naso-ethmoidal


region are preferably approached through a skin
incision which is made over the dorsum of the
nose following the skin folds (Fig. 89a-d) (see

Chap. B 7). Special attention is drawn to the lacrimal apparatus and canthal ligaments. The lacrimal apparatus is reconstructed by a fine pliable
silicone tube, which is passed with a special in-

Fig. 89 a. Comminuted fracture of naso-ethmoidal region


combined with a Le Fort III
fracture. Exposure of nasoethmoidal region through a
skin incision over the dorsum
of nose and elongation of incision to infraorbital region on
both sides

Fig. 89b. Status 1 week after surgery. Note pull-out


wires on the temporal areas on both sides. These
pull-out wires allow extraction of wires suspending
maxillary complex to frontal bone (see also Fig. 85)

Fig. 89c. Profile view demonstrating reconstruction


of nose and pull-out wire at the temporal region (arrow)

67

strument through the punctum lacrimale and


lacrimal duct into the nose (Fig. 90). Avulsed
canthal ligaments can be reattached using the
same nasal incision. A fine 0.3-mm wire is used
for this purpose. As a pull-out wire it can be passed through the nose by means of an Archimedean drill (Fig. 91 a and b). In severe naso-ethmoidal fractures the different paranasal sinuses
have to be explored and bone fragments removed which have lost their connection to the
soft tissues. An adequate drainage is inserted via
the nose and left in place for about two weeks.
Fig. 90. A fine lacrimal probe is demonstrated with a
thin pliable silicon tubing which can be pushed over
pointed tip of probe. Schematic drawings on the right
demonstrate the introduction of silicon tubing into a
lacerated lacrimal apparatus. The probe is first
brought through punctum lacrimale into wound and
silicon tubing pushed over the tip of probe. The probe
is then pulled back and tube passed through punctum
lacrimale to the outside. The other end of tube is introduced through the sacculus lacrimalis into nose
Fig. 89d. Postoperative result after 6 months

68

Fig. 91 a. Archimedean drill


with a No. 10 cannula as a drill
head. After removal of the
drilling device a fine stainless
steel wire can be passed
through the cannula

Fig. 91 b. Schematic drawing


illustrating reattachment of
avulsed canthal ligaments.
A: A cannula is drilled through
nasal bones just above the anterior bony crest of lacrimal
sacculus.
B: After removal of drilling
device, two fine stainless steel
wires are passed through the
cannula.
e: Canthal ligaments on both
sides are picked up with the
wire and fixed to nasal bones.
For this purpose the wire is
brought through a second drill
hole to the other side.
D: Wires can be fixed over
small lead plates which facilitate later removal of wires

In saddle-nose deformity, retention of the


lateral nasal wall is achieved using lead-plates
and fine transnasal Kirschner wires. If necessary, the Kirschner wires can be bent upwards
and rubber-band traction accomplished using an
external head frame (Fig. 92a-d).
Comminuted fractures of the maxillary
sinuses are exposed by an intraoral approach.

Retention of the fragments is facilitated by a


balloon catheter, which is inserted into the sinus
through the lateral nasal wall (Fig. 93a and b).
By filling the balloon catheter with water, the
position of the bone fragments is checked from
the intraoral approach or by palpation through
the skin. This balloon catheter can be left in
place as a supporting device for 2-3 weeks. It
also serves as a drainage catheter.

69

c
70

Fig. 92. (a) Profile view demonstrating a severe nasoethmoidal fracture, (b) Retention of the nasal fragments
using Kirschner wires, lead
plates, and a special repositioning
instrument,
(c)
Kirschner-wires are bent
upward and fixed by wire or
rubber bands to a head
frame, (d) Special instrument
(SPIESSI, 1971) for repositioning of a nasal fracture.
Adjustable guide device on
the right side allows exact
placement of the Kirschner
wires

Fig. 93 a. Balloon catheter as


used in urology (tip has been
cut off). Balloon may be filled
with 30-50 cc of sterile water
(according to dimensions of
maxillary sinus)

Fig. 93 b. Schematic drawing


illustrating a comminuted fracture of maxillary sinus. A: Introduction of balloon catheter
through nose into maxillary
sinus, B: Balloon catheter
is filled with water and position of bone fragments
checked by palpation or inspection, C: Balloon catheter
in situ after repositioning of
fracture

6.3.2. Fractures of the Mandible

In distinction to the maxilla, the mandible is subjected to the dynamic forces of mastication.
These forces are uniformly distributed from the
alveolar process through the reinforcing crests of
the mandible to the condyles on both sides. The
neck of the condyles forms the most delicate
part of this system.
In combined facial fractures the mandible at
the site of the symphysis, horizontal ramus, ascending ramus, or condyle may be fractured.
The predisposing fracture site, however, is the
region of the canine tooth or a missing tooth.

In combined fractures of the maxilla and the


mandible, further points of relation, such as the
malar, nasal, and chin prominences often cannot
be taken into consideration for reconstruction of
the facial contours, because these regions may
also be comminuted.

As a first measure, the only readily accessible


relationship between the upper and lower jaw is
established, that is the intermaxillary dental relationship. The right occlusion is set and retention accomplished by means of arch bars and intermaxillary fixation reinforced by acrylic material (see Chap. B 4, Fig. 76).

71

To achieve the best anatomic reconstruction,


one then proceeds by first approaching the
easiest fracture of the lower jaw and continuing
to the most difficult one, thus successively reestablishing the whole continuity of the mandible. Some elementary rules in the treatment of
mandibular fractures are summarized in Tables
8-11).
In order to counteract the dislocating muscle
forces acting on the lower jaw, internal fixation
of the fragments is accomplished by means of
dynamic compression plates (Table 12). The
general principles of rigid internal fixation in
fractures of the mandible have been outlined in
Chapter B 1 and will not be further discussed.
If a bony defect is present it is bridged by a
large plate which reaches the solid parts of the
mandibular stumps and is fixed there by several
screws (see Chap. D 5). Loose bone fragments
are then connected to the plate by screws or wire
ligatures (Fig. 94 a-f).

Table 8. Simple Fracture


First:
Second:

Occlusal Retention
Interfragmentary Fixation

<

Table 9. Open Fracture


First:
Second:
Third:

Intraoral closure of the wound


(~ Muco-periosteal advancement
flap)
Interfragmentary fixation
Closure of soft tissues and skin

Table 10. Compound Fracture


First:
Second:

Internal fixation of simple part


Internal fixation of compound part

Table 11. Modality of Treatment in fractures of the


mandible
operative

conservative

Simple Fracture:
Simple Fracture:
- without dislocation
- with dislocation
- in edentulous patient
Fracture in children
- in fractures of the angle Fracture with infection
Complicated Fracture:
Fracture of the condyle
- open fracture
- comminuted fracture
- fractures with bony defect
- concomitant facial fracture

PRINCIPlIS Of RIGID FIXATION

TINSION BAND

ARCH BAR

PLATE

DYNAMIC COMPRESSION PLATE


EXCEHTR IC DYNAMIC COMPRESS ION

Table 12

72

Fig. 94a. Severe gun-shot


wound with extended soft
tissue laceration and loss of
frontal portion of mandible

b
Fig. 94 b. Wound cleaning is accomplished with jetspray using copious amounts of peroxide and saline
solution
Fig. 94c. Schematic drawing illustrating the comminution of mandible and defect in frontal region
Fig. 94d. Schematic drawing illustrating the reconstruction of mandible using a long plate and screw fixation of bone fragments

d
73

Fig. 94 e. Plate is seen in situ


before fixation of fracture
fragments and closure of
wound

..... Fig. 94f. Status after surgery

A primary bone transplantation for reconstruction of the mandibular continuity is only


undertaken in those cases where:
1. early surgery is possible
2. good mucosal and skin coverage is present
3. contamination by foreign material is minimal.
In severe cases of compound facial fractures
systemic antibiotics should be administered during and after surgery in order to diminish the risk
of postoperative infection.

74

7. The Surgical Approach in the Treatment of Facial Fractures


By G. Martinoni and H. M. Tschopp

In compound fractures of the facial skeleton


anatomically correct repositioning and fixation
of bone fragments can only be accomplished if
the fracture site is completely exposed.
It is very important that the skin incisions are
placed along the natural skin folds or parallel to
them. Scars following the wrinkle lines of the
face are least conspicuous. Skin incisions which
are not correctly placed, however, may produce
a visible scar deformity and be a constant source
of embarrassment to the patient. In the head and
neck area especially, the surgeon's intervention
is most visible and also subject to much scrutiny.
The skin folds as lines of expression generally
lie perpendicular to the underlying mimic mus-

culature (Fig. 95). They are caused by the


wrinkling that accompanies the muscular contraction. By contrast, the lymphatic drainage is
oriented along or parallel to the wrinkles. A scar
lying obliquely or transversely to these wrinkles
will therefore be subjected to constant tearing
from the mimic musculature and, on the other
hand, will represent a barrier to the lymphatic
backflow. In these cases, a visible scar or even
scar deformity may result.
In the following chapter some of the most important skin incisions for approaching the underlying facial skeleton are shown, and the
operative procedures described.

7.1. Fracture of the Naso-ethmoidal regiou

Fig. 95. Schematic drawing demonstrating direction


of facial wrinkle lines

The skin incision is made transversely over the


dorsum of the nose, terminating at a point at or
below the inner canthal ligament. In order to
expose the medial orbital region and the bony
nasal structures as well as the canthal ligament
and the lacrimal apparatus, this incision can be
elongated on both sides in a semicircular way
down to the infraorbital region and upward to
the eyebrows on both sides (Fig. 96). Through
this approach, the bony structures are completely exposed. The medial canthal ligament
and the lacrimal apparatus are visualized and if
necessary reconstruction undertaken. After repositioning and fixation of the fracture, the
wound is closed in layers using 4/0 resorbable
75

material for the deeper layers and a 5/0


monofilic suture material for skin closure. The
wounds are immobilized by steri-strips. Sutures
are removed after 4 days.

oculi are separated bluntly with scissors in order


to gain access to the infraorbital rim (Fig. 97).
Care has to be taken not to injure the orbital
septum. On the facial side of the infraorbital
rim, approximately 1 mm under the bony margin, the periosteum is incised and elevated from
the facial as well as orbital bone in order to expose the infraorbital nerve and the floor of the
orbit. Access is gained into the depth of the orbit
back to the incisura orbitalis inferior.

Fig. 96. Schematic drawing demonstrating different


skin-incisions in fractures of naso-ethmoidal region
(a) and in fractures of malar complex (b, c, d). See text
for further explanation

Fig. 97. Schematic drawing illustrating infra-palpebral skin incision. Sagittal section through orbit
demonstrates subperiosteal approach to the fracture
of floor of orbit. Note that septum orbitale is left intact

7.2. Fracture at the Site of the Sutura


Fronto-zygomatica

After repositioning and fixation of the fracture,


or decompression of the infraorbital nerve, the
periosteum is closed with interrupted sutures of
4/0 resorbable material. The skin is closed with
a 5/0 monofil continuous suture and the wound
is immobilized with steri-strips. Sutures are removed after 5-7 days.

The skin incision is approximately 2 cm long,


just beneath the eyebrows on the lateral aspect
(see Fig. 96b). All tissues are transsected including the periosteum, and the fracture is exposed.
After repositioning and fixation of the malar
fracture, the musculo-periosteal layers are
closed with 4/0 resorbable material and the skin
is closed with a 5/0 monofilic continuous suture.
Sutures are removed after 4 days.

7.3. Fracture at the Site of the


Lower Orbital Rim, Blow-out Fracture,
and Fracture of the Malar Complex
Skin incision approximately 2 cm long in a skin
fold 3--5 mm below the margin of the lower lid.
The muscle bundles of the musculus orbicularis
76

7.4. Fracture of the Zygomatic Arch


(a) Small stab-incision at the buccal region just
beneath the zygomatic arch in order to introduce the bone-hook into the fossa infra temporalis (see Fig. 96d).
Repositioning of the fracture is then accomplished and the wound closed with 1 or 2 fine interrupted sutures.
(b) Temporal approach as described by GILLIES et aI., (1927). A skin incision is made approximately 2 cm long in the hair-bearing skin
of the temporal region (see Fig. 96c). The inci-

sion reaches the temporal fascia. An elevator is


inserted through this access and brought to the
infratemporal fossa just underneath the fracture
of the zygomatic arch. After the repositioning of
the fracture, the temporal fascia is closed with
3/0 resorbable material. Closure of skin is
accomplished with a continuous 4/0 monofilic
suture. Sutures are removed after 7 days.
7.5. Fractures of the Nose

mobilized subcutaneously by exposing the m.


platysma colli. The platysma is transsected approximately two finger-widths underneath the
mandible and the incision deepened to reach the
fascia colli, the latter being incised.
Through this approach the capsule of the
submandibular gland is reached and access
gained to the fracture site (Fig. 99). Since the
marginal mandibular nerve lies underneath the
platysma and on top of the superficial fascia, it
will be preserved during surgery.

In many nasal fractures revision of the cartilaginous septum and the perpendicular plate of
the ethmoid is indicated. The incisions are hidden in the vestibulum nasi.
(a) Transfixion incision through the membranous septum just anterior to the cartilage.
After elevation of the perichondrium, the septum and the perpendicular plate can be explored
and if necessary repositioned. This incision also
allows a repositioning of the nasal dorsum.
(b) Intercartilaginous incision for repositioning of the osseous and cartilaginous parts of the
nose. Oosure of these incisions is performed
with interrupted sutures of 4/0 resorbable material or 4/0 monofilic suture material.
Sutures are removed after 7 days.
7.6. Intraoral Incisions

These incisions through the mucoperiosteum of


the vestibulum are necessary for the exposure of
maxillary fractures (Le Fort I, II, III), repositioning of the zygomatic arch (as described by
THOMA, 1948) or in cases of mandibular fractures which can be treated through an intraoral
approach.
Closure of the wound is accomplished with a
continuous 4/0 monofilic suture. Sutures are
removed after 8 days.

Fig. 98. Drawing illustrating submandibular skin incisions at different sites. (a) Skin incision in fractures of
the angle of mandible or ascending ramus, (b) Skin incision in fractures of horizontal ramus, (c) Skin incision in fractures of frontal region

7.7. Submandibular and Submental Incisions

( a) In cases of fractures of the angle of the mandible and of the ascending ramus, the skin incision is located approximately 1-2 finger-widths
below the lower margin of the mandible
(Fig. 98).
Care has to be taken to follow a skin fold precisely or to parallel this direction. The skin is

Fig. 99. Schematic drawing illustrating step-like incision in order to preserve the marginal mandibular
nerve: a Platysma muscle, b Cervical fascia, c Submandibular gland, d marginal mandibular nerve

77

Depending on the location of the fracture, it


may be necessary to ligate and transsect the facial artery and vein.
(b) Submental incision: The skin incision is
located just underneath the mandible since the
possibility of injuring the facial nerve is minimal.
Laterally, the incision runs at a slight upward
angle in order to follow the wrinkle lines (see
Fig. 95). The incision is deepened and reaches
the fracture site from below.
In submandibular as well as submental inci-

78

sion, closure is accomplished after a suction


drain has been inserted into the wound. Closure
of the wound is performed in layers by first
suturing the muscle with a continuous 4/0 resorbable suture. The skin is closed with a continuous intracutaneous monofilic suture. The
wound is immobilized with steri-strips. The suction drain is removed after 24 h and the intracutaneous sutures are removed after 2-3
weeks. Immobilization by steri-strips is maintained for approximately 14 days.

c
Orthopaedic
Maxillofacial
Surgery

1. Temporal Bolting Osteoplasty in the Treatment of Excessive


Condylar Movement
By B. Spiessl

1.1. Introduction
Like the shoulder joint, the temporomandibular
joint is of a muscular type. Its movements are
guided and checked mainly by articular surfaces
and muscular traction (BRAUS and ELZE 1954).
While such joints are very free in their movements, they are liable to dislocation if the innervation of the muscles fails because of spasm,
tiredness, or negligence of the patient. The muscles then inhibit only those movements which far
exceed the norm. As is well known, the two main
types of luxation become apparent in this excessive condylar movement:
1. subluxation (without locking of the jaw), and
2. true dislocation with locking
The therapeutic objective is to limit the excessive condylar movement.
The limits of the mobility are determined by:
1. articular surface
2. masticatory muscles
3. capsule and ligaments.
To leave these control units of the joint
mechanism as intact as possible is an old principle of orthopaedic surgery. Thus, operations on
the inner part of the joint, the capsule, and the
muscles did not gain complete acceptance.
The simplest conceivable method of preventing the dislocation of the condyle is arthrorisis: the blocking of the abnormal
movement of the joint in one direction by the extra-articular transplantation of a bone graft.
Two techniques of extra-articular bolting have
been developed.
In one of these, local bone from the zygomatic
arch is used, either as a free transplant

(GINESTETet aI., 1967, AUBRY and FREIDEL, 1942)


or as a pedicle graft (GOSSEREZ and DAUTREY,
1967). The method of GOSSEREZ and DAUTREY
is particularly interesting (Fig. 100).

Fig.IOO. Extra-articular bolting by means of a pedicled transplant from the zygomatic arch (prearticular
approach)

The other technique involves transplanting a


bone graft from the iliac crest to the articular
tubercle (REHRMANN, 1967). The pre-articular
approach to the joint is common to both
methods. For the transplantation, REHRMANN,
(1967) has successfully used a bone graft,
2.5 cm long and 0.5 cm thick, which is inserted
below the base of the skull to a point before
the spine of the sphenoid bone (SELLE and
HASHEMI-NETAD, 1967), (Fig. 101).
We, too, prefer a free graft from the iliac
crest, but because of difficulties in establishing a
routine procedure, we have chosen a different
approach. The transplantation of the bone graft
proceeds from the temporal fossa. The need for
pre-auricular access to the joint is thus elimi-

81

Fig.lOl. Extra-articular bolting by means of a free


transplant from the iliac crest positioned below base
of the skull (infratemporal region) = prearticular approach. Zone of danger: damage to N. trigeminus, A.
meningea, and plexus pterygoideus is easily possible
Fig. 103. Sketch of position of L-shaped graft in front
of articular tubercle. Graft lies in temporal fossa of
root of zygomatic arch

Fig. 102. Triangular area dorsal to the branches of facial


nerve as orientation aid for direct access to joint. (I am
grateful to Professor von
HOCHSTETIER, Anatomische
Anstalt, Basel, for the preparation)

82

Fig. 104. Skin incision and application of graft below the


horizontal fibers of temporal
muscle. Note: The intermaxillary fixation by means of
Ernst's
ligature
during
surgery

nated. It is well known that to avoid injury to the


facial nerve with pre-articular incisions, only a
triangular area formed by an angle of approximately 30 from the tragus may be used
(Fig. 102). With this access it is, of course, possible to expose the joint correctly. "But every
experienced surgeon knows that the exposure is
often difficult and not always complete!". This
statement by AXHAUSEN (1931) still holds good.
It implies the fact that the direct approach is
more or less time-consuming and traumatic. For
this reason, we use an indirect approach via the
temporal fossa to the root of the zygoma tic arch.
This obviates the necessity of exposing the joint
and avoids the attendant disadvantages. The
pathway for the insertion of the bone graft is
easy to locate. It proceeds directly in front of the
articular tubercle (Fig. 103) without the danger
of injury to the nerves and vessels (see also Fig.
101).

1.2. Technique

The mean operating time for both joints is


75 min. If the hair is washed on the day before
the operation, it is not necessary to shave the
head, even with female patients. The 3---4 cm incision begins at the upper part of the auricle and
proceeds posterially at a shallow angle
(Fig. 104). The edges of the incision are well
mobilized above the superficial lamina of the
fascia investing the temporal muscle so that the
incision does not inhibit the introduction of the
bone graft. Any branches of the temporomandibular artery or vein are ligated. The auriculotemporal nerve lies parallel to the incision,
and is easily protected.
The superficial lamina of the fascia is transsected. The incision of the underlying muscle
begins at the level of the upper edge of the external ear, and follows the direction of the mus83

cle fibers as closely as possible. The horizontal


fibers must be protected because they pull the
mandible in posterior direction and thus naturally inhibit luxation. This effect is considerably
intensified by the later positioning of the transplant below the muscle. In acting as a fulcrum,
the transplant produces maximum tension in the
muscle fibers when the mouth is opened
(Fig. 105). This is one aim of the operation.
After separating the deep fascia, the bone is
exposed in the direction of the infratemporal
fossa. The root of the zygomatic arch will automatically be encountered as an inclined plane
along which the raspatory slides. The anterior
ridge can be easily felt. The distance is always
4-5 em (see Fig. 104). At this point, the muscle
is forced toward the semilunar notch with a
right-angled raspatory, creating room for the
transplant.

from this. The graft is shaped to fit the surface of


the temporal bone as well as the prominence at
the root of the zygomatic arch.
The insertion of the graft is simple. The soft
tissues are retracted and the graft is inserted
from above into its place in the exposed fossa using a special instrument (Fig. 106). Finally, the

Fig. lOS. Fulcrum effect of the L-shaped graft in the


area of horizontal muscle fibers. External projection
movement of jaw is inhibited by graft

The second aim of the operation is to position


the bone graft in front of the articular tubercle.
This is best achieved by means of an L-shaped
transplant. Before the arthrorisis commences,
a piece of bone measuring 2.5 x 2.5 em is removed from the upper part of the ilium below
the crest in full thickness. An L-shaped graft
with equal sides of a good 1.5 cm length is made
84

Fig. 106. Special instruments. Left: Forceps for the


application of the L-shaped bone graft. The end of
one arm is bent at right angles and grasps the bone
graft frontally. This prevents bone from fracturing on
insertion. The cm-scale is used for checking how far
graft must be inserted. Right: Sound, corresponding
to one arm of forceps. Distance between the prominence at the root of zygomatic arch and anterior edge
of the wound is measured with the sound (see also
Fig.104)

Fig. 107. Tomogram showing


position of L-shaped bone
graft in front of articular
tubercle

fossa serves as a support for the horizontal portion of the graft (Fig. 107). Suction drainage is
inserted posteriorly. The wound is closed layer
by layer.

1.3. Postoperative Treatment

In view of the short operating time (less than 2 h


in all cases), the routine prophylactic administration of antibiotics is not necessary.
When discharged, the patient is urged not to
open his mouth more than the width of one
finger for 4 weeks. From week 4, mouth-opening exercises are started and continued until the
distance between the incisors is equal to 3
finger widths.

1.4. Discussion

The above-described method has two essential


advantages: firstly the indirect access, and secondly the double function of the transplant as a
fulcrum for the horizontal temporal muscle
fibers and as a bony barrier at the articular
tubercle.

The advantage of the indirect approach lies in


the simple, time-saying and safe insertion of the
graft. By contrast, the lateral positioning of a
larger graft just below the base of the skull is not
entirely without danger, considering the topography of the location. Severe bleeding from the
pterygoid plexus can be expected, as HAFFERL
(1969) has illustrated (Figs. 108 and 109).
Furthermore, there is a possibility of injury to
the auriculotemporal nerve, mandibular nerve,
and middle meningeal artery in the vicinity of
the spine of the sphenoid.
As the method described is quite simple, it
can be employed in cases where surgery was
previously considered inadvisable. This applies
mainly to luxation without locking of the jaw. In
such cases, pain is less predominant than the
clicking noise, which can be so violent as to be
more annoying to others than to the patient. The
worst that can be expected in such cases is arthrotic changes in which, however, an operation
is not usually justified. These patients are thus
frequently discharged without having received
successful treatment. The method described is
especially suitable for these cases in view of the
low risk involved and only minor strain for the
patient.

85

A. mnxWnrls
3f. pterygoid us mcdlnll.

l'lexlls plcr)goldcuo

N. bllcooli

V. mlLxlllnrls

hord4 t)'mpnnl
Ductu J)llrotldcu
d glnnduln buccnle
1I. bucclnat r

N. rncinn
A. V. X. nlvoolnrls
Inrorlor

X .llngllnll.

Fig. 10

Xn. l

Il1roornl~s

profundl

'"""-\'1:----

X. mllxlllnri.

_ A. alveolari . lIperlor
pO"l~rlor

.'. mandlbulnrl.

.\. mlLxUlarl

X. nuriculolrmpOrnn.
t n. mcnlngcn media
Chord

tympani

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M. pLerygold,'"

med!:'II_

~""1~.~t:~'--.---"---- X. buccall.

Inferior

X.lingulIli
~f.

bucclnalor

Fig. 109
Fig. 108. Topography of pterygoid plexus following removal of zygomatic arch, ascending ramus, and lateral
pterygoid muscle (HAFFERL, 1969)
Fig. 109. Topography of branches of the mandibular nerve and maxillary artery

(HAFFERL,

1969)

As Fig. 108, Fig. 109 also shows how easily the illustrated anatomic structures can be injured if a bone graft is
driven in immediately below base of the skull to sphenoid spine

86

A similar situation exists with subluxation


(hypermobility) as a component of the pain-dysfunction syndrome (myoarthropathy). Pain is
the dominant factor in this case. According to
SHORE (1970), it is 90% attributable to occlusal
factors. A great proportion of the remaining patients does not respond to therapy. The method
described was also successfully employed in
these patients.

A method is judged by its practicability and


by the results it achieves. The practicability is
expressed to some extent by the frequency with
which it is employed. Since 1973, we have performed 28 bolting osteoplasty operations. With
the exception of one instance of trismus of long
duration among ourfirst cases, no complications
have been observed.

87

2. Treatment of Ankylosis by a Condylar Prosthesis of the Mandible


By B. Spiessl, R. Schmoker and R. Mathys

2.1. Introduction

2.2. The Condylar Prosthesis

For obvious reasons, the concept of prostheses


for the temporomandibular joint has aroused
little interest in the past. The reasons are: (1) the
complexity and small size of the joint; (2) the
difficulty of access due to its covered position at
the lower edge of the temporal bone; and (3) the
varied topography, taking into account the
course of the facial nerve, the proximity of the
cranial fossae and auditory canal, as well as important venous plexus, nerves, and blood vessels. There are also reasons for fitting such a
prosthesis. By putting both fists together tightly,
the arms forming a rigid arc, one can imitate the
movement of the lower jaw, thus giving an idea
of how a condylar prosthesis of the mandible
should function.
With a ball and socket joint on each side, a
certain degree of lateral movement can be obtained in addition to the normal joint function.
Our conception of a condylar prosthesis of the
mandible is based on this premise (SPIESSL,
1975). The usefulness of such a prosthesis is determined by:
1. Rapid normalization of masticatory function,
at least in terms of free and firm up and down
movements of the jaw, performed with sufficiently powerful closure.
2. briefer and simpler follow-up treatment.
3. certain avoidance of a recurrence of ankylosis,
4. causal correction in the case of dislocation of
the chin owing to unilateral shortness of the
mandible.

By a condylar prosthesis of the mandible we


mean the replacement of the articular process by
a prosthesis, the socket being retained or remodelled.
The prosthesis consists of a head, neck, and
process (Fig. 110 a). The head is hemispherical in
shape. The neck represents a retention plate
(see Fig. 110b), to which the process is attached
laterally at right angles. The retention plate acts
as a support for the prosthesis on the stump of
the jaw. The plate-like process follows the angle
of the jaw. It extends to the first molar.
A minimum of seven cortical screws are used,
thus achieving maximum friction between bone
and plate. The frictional binding produced by
the pressure provides the stability necessary for
permanent function without complications.
The angle and the free end of the plate contain V-shaped notches on the edges (see
Fig. 110a and b) to permit the final adjustment
to the shape to be made with a special bending
instrument (see Chap. D. 5). The exact fit of the
plate is achieved by using a soft metal pattern,
which can be bent in situ (Fig. 111). These metal
patterns are an indispensable aid to the accurate
fitting of the prosthesis.

88

2.3. Technique

The emplacement of the prosthesis requires


generous access to the joint and ascending
branch with unimpaired visibility. This is ob-

Fig. 110. (a) Condylar prosthesis (inner side) made of steel with spherical head, retention plate as neck and process (3 DC holes, (see p. 28) and 4 round holes, (b) Condylar prosthesis (outer side)

Fig. 111. The process is bent


to the required angle with
bending pliers. A readily
bendable model prosthesis is
used as a pattern

Fig. 112. Preauricular and subangular incisions to


gain good access from the joint to the angle of the
mandible

Fig. 113. Preauricular fixation of the prosthesis with


screws using a trocar drill guide (see instrument set,
Fig. 130, p. 120)

89

tained by means of two incisions, one preauricular and the other submandibular (Fig. 112). A
subperiosteal channel is made so that the soft
tissues may be held from the joint as a bridged
flap without distortion or excessive strain.
The plate is screwed directly at the angle of
the mandible, but in the region of the joint a special drill guide is used (Fig. 113). (Instrument
set, see Fig. 130, p. 120).
2.4. Case Report

So far, four prostheses have been satisfactorily


incorporated, two unilaterally and in one case
bilaterally.

One case of unilateral prosthesis emplacement


involved a 21-year-old female patient with total
ankylosis and an undersized left lower jaw reSUlting from a fracture of the jaw at the age of
12. The patient had had two unsuccessful operations for the ankylosis elsewhere. As a result of
the shortened lower jaw, there was a displacement of the median line, and thus of the chin, to
the left.
Figure 114 shows the prosthesis in place in
the X-ray film after two years. The remodelled
socket is readily visible (Fig. 115 a and b).
The postoperative status showed that maximum opening of the mouth was possible im-

Fig. 114. Findings from radiographic examination after 2 years. No signs of bone resorption neither in the vicinity of the joint socket nor in the area of the ascending ramus

a
Fig. lIS. (a) Prosthesis with the mouth closed, (b) Prosthesis with the mouth open

90

mediately after surgery. The asymmetry of the


face was largely eliminated (Fig. 116).
The second case presented bilateral ankylosis
following untreated bilateral fractures of the
joints. Even on the first day after surgery, the

Fig. 116. Postoperative findings: maximum opening


of the mouth. Chin in the middle

patient was capable of actively opening the


mouth. The incorporated condylar prostheses
are readily visible in the X-ray film (Fig. 117).
The third case involved a 36-year-old Turkish
patient who stated that he had been able to open
his mouth only 5 mm since childhood. Satisfactory results were also achieved in this case.

Three cases in two years do not, of course,


permit any definitive assessment. However, the
initial experience is positive, the applied
methods demonstrating what can be achieved:

1. rapid normalization of masticatory function


2. incorporation without infection

Fig. 117. Radiographic examination findings with


prostheses on both sides. (After 2 years, the patient
moved house without giving her new address)

3. causal correction in the case of shortening of


the mandible.

2.5. Summary
Partial prosthetic arthroplasty means the replacement of the condylus by a prosthesis, with
the socket being retained or remodelled. The
91

prosthesis consists of a head, neck, and process.


The most important factor is rigid fixation. This
requires a special set of instruments 1 and a procedure which is described. Experience to date
1 Available from R. Mathys, Instrumentenfabrik,
CH-2544 Bettlach.

92

takes in four prostheses, including two unilateral


and one bilateral. The initial experience is regarded as positive since the technique achieved
rapid normalization of masticatory function, incorporation without infection, and causal correction in the case of shortening of the mandible.

3. Bone Transplantation for Broadening of the Apical Base


(Combined Operative and Conservative Treatment of Pronounced
Maxillary Protrusion)
By E. Holtgrave, Th. Rakosi and B. Spiessl

3.1. Introdnction

Before the dentition has ceased, the growth of


the jaw and even of the middle part of the face
can be stimulated and normalized by special orthodontic measures. This has been shown by
long-term observations by HAUSSER (1962) and
KORKHAUS (1963). The growth occurs not only
in transverse and sagittal directions, but also
vertically. Consequently, the apical base in
juveniles can be stimulated to further development. These changes are no longer possible
when the dentition has ceased, as the process of
bone remodelling then takes place much more
slowly. The broadening of the dental arch or retrusion of the upper anterior teeth more or less
produces a tilting of individual groups of teeth,
thus creating unfavorable positioning. A high
rate of recurrence must be expected. A reduction in the number of teeth and adaptation to the
underdeveloped maxilla does not always have
the desired functional and aesthetic result because there is still a lack of space.
For such cases, SPIESSL (1968) described a
surgical procedure for broadening the apical
base.
By transplanting autogenous bone on both
sides of the anterior nasal spine, a thickening of
the alveolar arch is achieved, and thus also a
broadening of the apical base in sagittal direction. During the retrusion of the upper anterior
teeth, the roots can grow into the transplanted
bone. By this means, a better stabilization of the
teeth is observed at the conclusion of treatment,
and the tendency to recurrence is reduced.

The prerequisite of this method of treatment


are vital teeth and a healthy periodontium. In
addition, the collaboration ofthe patient must be
ensured for the subsequent orthodontic therapy.
In most cases of protrusion of the anterior
maxilla, an elevation of the anterior alveolar
process occurs. This makes occlusal levelling
necessary. This is achieved either by repositioning osteotomy or, in less pronounced cases, by
grinding of the teeth. Therefore, the aim of the
combined surgical and orthodontic treatment is:
1. to broaden the apical base in sagittal direction,
2. to prevent recurrence: the roots of the teeth
grow into the transplanted bone,
3. to maintain the vitality of the teeth.
The first seven cases in which these principles
were followed were treated between 1968 and
1970.
Bone from the rib was transplanted in three
cases, and in four cases cancellous bone was
used to broaden the apical base. Five of the
seven patients returned for follow-up examination. The main points for consideration were:
1. resorption of the transplant
2. resorption of the roots of the teeth
3. recurrence of protrusion
4. loosening of the teeth
5. vitality of the teeth.
3.2. Procedure
3.2.1. The Transplantation of an Autogenous
Rib Graft to Broaden the Apical Base
With the patient under intubation anesthesia, a
piece of rib is removed. After exposing the base
93

Fig. 118a. Operative broadening of apical base in sagittal


direction by transplanting
autogenous bone from ribs

of the jaw on each side of the nasal spine, the


piece of rib is divided sagitally and fitted into
position in such a way that the cancellous part
rests on the base of the jaw (Fig. 118 a). The recipient bone is roughened with a burr in order to
remove a portion of the cortex and therefore
guarantee rapid vascular connection to the graft.
The wound in the mucosa is then closed with an
atraumatic suture, and teeth 14 and 24 are extracted.

3.2.2. The Transplantation of an Autogenous


Cancellous Bone from the Iliac Crest to
Broaden the Apical Base
A V-shaped incision is made in the mucoperiosteum below the anterior nasal spine and the mucosa tunnelled to the level of the premolars. The
maxillary base is packed with cancellous bone
from the iliac crest. Here, too, the first premolars
are then extracted.

b
Fig. 118 b. Lateral tomogram of maxillary base before
treatment

3.3. Case History

The procedure is illustrated by the following


cases.
Case 1. Z. B., age 25: Initial findings: protrusion
and narrow upper jaw resulting from an underdeveloped apical base (Fig. 118 b) and disocclusion
(Fig. 118c).
Treatment: Transplantation of an autogenous rib
graft (see Fig. 118 a) and extraction of the first premolars in the maxilla. Orthodontic treatment with a

94

Fig. 118 c. Clinical picture of the maxillary protrusion


before treatment

Fig. 118d. Clinical picture following combined surgical and


orthodontic treatment

e
Fig. 118e. Tomogram of maxillary base 6 years after
surgery. Transplanted bone was not resorbed. Roots
of teeth fit against transplanted bone

f
Fig.118f. Side-view of maxillary base 6 years after
beginning of treatment. Sagittal broadening can be
observed

95

fixed appliance from the second week after surgery.


The clinical and radiogra phic results of the trea tment,
and the extent of the retrusion can be seen in Figure
118d, e, f, and g.

Fig. 118g. Diagram of X-ray


pictures before and after
treatment showing the extent
of retrusion
Case II. H. N., age 20: Initial findings: maxillary
protrusion and crowding of the teeth with disocclusion and pronounced vertical deviation in the anterior
lower jaw (Fig. 119 a).
Therapy: Transplantation of autogenous cancellous bone and extraction of the first premolars in the
maxilla. Orthodontic treatment with a fixed appliance
(Fig. 119b).
Shortly before the conclusion of the orthodontic
treatment, occlusal levelling ofthe lower jaw was undertaken. It was achieved by repositioning osteotomy, following exact simulation in a model. The
clinical and radiographic results of the treatment can
be seen in Figure 119 c. Figure 119 d shows the extent
of the retrusion.

c
Fig. 119c. Tomogram of maxillary base 5 years after
treatment. Transplanted bone is still present. Roots of
the teeth have grown into transplanted cancellous
bone

Fig. 119d. Clinical picture 6 years after combined


surgical and orthodontic treatment

Fig.119a and b

96

Fig. 11ge. Diagram of X-ray


pictures before and after
treatment to illustrate the extent of retrusion

3.4. Results
3.4.1. Radiographic Results

To determine whether the bone transplant and


the roots of the teeth had been resorbed, lateral
tomograms of the upper anterior jaw and
radiographies of teeth were made. The transplanted bone was visible on all films, demonstrating that the bone had been incorporated at
the site of transplantation (see Fig. 118e and
119c). The roots of the teeth are either directly
below the transplanted bone or have grown into
it. No resorption of the roots was observed.
3.4.2. Clinical Results

In no case was there a recurrence of maxillary


protrusion. On examination, the upper anterior
teeth were all observed to be vital and firmly in
place. The results are summarized in Table 13.

3.5. Disrussion
According to HAUSSER'S investigations (1962),
the dimensions of the apical base depend to a
large extent on the axis of the front teeth. A
change in this regard affects the apical base in
terms of bone remodelling. HXuPL (1958) confirmed this when he showed that functional
stimulation is of great importance to the juvenile
dentition.
On completion of dentition, however, a state
of functional adaptation is reached (HXupL,
1958), i. e. the capacity for bone remodelling is

greatly diminished. This is one of the reasons for


the poor results achieved in treating patients
when the dentition has ceased.
In the operation procedure described above
the remodelling process, which is necessary for
the movement of the teeth, is made possible by
the apposition of autogenous bone. This can also
be achieved in adults, as the illustrations show.
The radiographic findings show that an apical
base which is underdeveloped can be enlarged
sagittally by means of a bone transplant. In all
the cases which were examined the transplanted
bone was incorporated at the transplant site.
Within a period of six years, no resorption was
observed.
The apices were covered by the transplanted
bone or grew into the transplanted cancellous
bone.
The transplantation is easily performed. The
average operating time is 30 min; the patient
remains in hospital for three days, and does not
work for one week.
The quantity of bone required is so small that
minimal accessibility to the iliac crest is sufficient for its removal. No postoperative impairment of walking has been observed.
On the basis of this experience, the present
authors prefer to use autogenous cancellous
bone, especially as its removal takes only 15 min
(including suturing of the wound).
A further advantage in using cancellous bone
is the rapid revascularization and thus higher resistance to infection (see also p. 3ft).

Table 13
Patient

Diagnosis

Surgical method Date of


operation

Transplanted
bone

Resorption
Roots
Recurof teeth rence

Test of
vitality

K.R.

Angle
Cl. IIII

Cancellous bone
transplant
13. 1. 70

z. B.

Angle
Cl. IIII
Angle
Cl. IIII
Angle
Cl. IIII

Rib graft
13.2.68
transplant
Rib graft
1. 10.68
transplant
Cancellous bone
19. 8. 69
transplant

Angle
Cl. IIII

Rib graft
transplant

J. B.

R.N.
R.M.

1. 11. 68

Operative
occlusal
levelling
Segment
osteotomy
lower jaw

+
+

Segment
osteotomy
lower jaw

97

4. Preoperative Planning of Sagittal Split Osteotomy of the Ascending


Mandibular Ramus (Simulography)
By R. Schmoker

4.1. Introduction
The prerequisite for successful surgical correction of dysgnathism is meticulous planning of
the operation. The essential points pertaining to
the abnormality are obtained through profile
radiography and teleradiography (latterly also
xeroradiography), and by means of plaster
models. In planning the operation, not only
functional factors must be taken into consideration but also the wishes of the patient with regard to improving his appearance.
The required degree of precision in the planning depends upon the degree to which the surgical method has been perfected; the use of rigid
internal fixation has fundamentally changed the
situation especially with regard to operations to
correct mandibular prognathism and retrognathism. In the absence of fixation or with mere
adaptation of the fragments with wire, the results of the operation can still be corrected to
some extent during the phase of intermaxillary
fixation. The advantage is opposed by serious
disadvantages such as the high rate of recurrence, the tendency to the formation of an open
bite deformity, the danger of delayed bone healing, and the risk of infection at the unstable osteotomy site. In addition the long period of intermaxillary fixation puts too great a burden on
the patient. In this connection, the period of unfitness for work is a major factor, which is not infrequently responsible for the operation being
rejected. If, however, the fragments are stabely
fixed (see Chap. C 6), the mouth can be opened
immediately after the operation. The emphasis

98

in the treatment is thus switched and reduced to


the preoperative phase and the operation itself.
The follow-up treatment is no longer the decisive factor in the permanent success of the operation. This treatment is substantially simplified
and shortened.
With rigid internal fixation, postoperative
displacement of the fragments is no longer possible. The correct positioning of the proximal
fragment is therefore required, so that the functioning of the temporomandibular joint is not
subsequently impaired. The adjustment of the
distal fragment by means of simulated occlusion
presents no problems. The proximal fragment,
however, must be brought into a position which
agrees with the original or central position of the
joint.

4.2. Previous Methods of Simulation


Various authors determined the osteotomy line
and the necessary adjustment of the fragments
by using teleradiography. In this correction, the
mandible is adjusted into the desired position by
using drawings or paper patterns of the outline.
In addition, TRAUNER (1973) determined the
center of the movement invol ved. This is used in
planning the osteotomy lines. Radiography,
however, is insufficient as the sole source of information for planning the osteotomies, because
lateral differences cannot be taken into consideration, the adjustment of the skeletal sections
can only be planned two-dimensionally, and the
occlusion cannot be assessed.

A three-dimensional procedure, taking into


account the occlusal situation was described by
SCHMUZIGER (1961) and OBWEGESER (1955). It
involves preparing a model of the whole jaw
with dentition, using teleradiography and a plaster model. SPIESSL and SCHARGUS (1971) developed a simulator on the same principle. In
their method an Araldite model is obtained
from an alginate impression. The row of teeth is
sawn from the alveolar crest, and imposed on a
model of the lower jaw produced by a technician. The dimensions required for the model of
the mandible are obtained by means of clinical
measurements and teleradiography. In place of
the heads of the condyloid process, standardized
metal spheres which fit the retaining mechanism
of the simulator are used. These are transsected
by the technician after the surgeon has drawn in
the osteotomy lines, and the fragments are then
fixed in the new position. The techniques of employing models of the jaws with dentition for the
simulation of operations to correct prognathism
and retrognathism are unsatisfactory, despite
the great effort involved. The reason is that the
most important procedure in the simulation, the
determination of the osteotomy lines, cannot be
planned on the basis of actual measurements.
The one line limiting the segment to be removed
can only be established approximately by the
surgeon, in accordance with his ability to visualize the three-dimensional areas involved.
The supplementary lines are determined by the
technician on the basis of trial cutting and correcting. Therefore several models are required,
which may be obtained from a silicone mould of
the original model.

4.3. Theoretical Considerations


The following important requirements must be
taken into consideration in a good method of
simulation:
The occlusion must be regarded as the most
important factor. The planning procedure must,
therefore, be three-dimensional. The whole
procedure of simulation should be one which the
surgeon can carry out himself, so that he can become familiar with the peculiarities of the case.

Simulation does not mean the preparation of a


perfect model by the dental technician, but
rather study of and planning for the case in question by the surgeon. The whole procedure
should be kept as simple as possible. Repeated
experimental trans section of the model on a trial
and error basis without finally determining the
exact size and shape of the fragment to be removed, must be regarded as a makeshift measure, and is ultimately unsatisfactory.

4.4. Principle of the Present Method


In planning osteotomies, the simulation of the
operation by means of drawings has gained acceptance in general orthopaedic surgery. The
data are obtained from standardized radiographic pictures. With regard to the jaws, however, the problem arises of how the occlusion
can be represented on the one plane of the
paper. Teleradiography is insufficient for this.
The movement must be performed for each side
of the dentition separately. This is possible only
with a model of the row of teeth. Therefore, an
apparatus was developed which allows the intermaxillary relation on each side to be drawn
on paper.
This apparatus, with which the relation of the
upper and lower jaws to each other is determined, was given the name "simulation drawing
device" (simulograph) 1. The process of abstraction from three dimensions to the two-dimensional plane is based on diascopic transfer
using a special sighting instrument to avoid errors in the parallaxes.
In principle the simulograph is an articulator
in which the mandible is freely movable. In addition, the relation of the mandible and maxilla
can be adjusted as desired.
The device has two sighting instruments on
the sides, by means of which the required
movement of the jaws can be exactly determined. Using teleradiography, the lateral position of the outline of the mandible, the course of

Obtainable from Stoppani AG, Konigstr. 29,

CH-3000 Bern

99

the nerve canal, and the position of the root of


the most distal tooth can be determined
(Fig. 120). The extent and direction of movement in this projection can be measured with the
sighting instrument. Thus, the position of the
mandible before and after movement is obtained separately for each side of the jaw in
lateral projection on the paper.
The movement can be a rotational or translational one; the latter may be regarded as a special case of rotation, in which the center of rotation is in infinity.
When the center of rotation relevant to the
movement has been located, and when the extent of the rotation has been determined, the
movement is determined exactly. Any given
point on the mandible describes a portion of a
circle during displacement (Fig. 121). All such
circles have a common center, which is identical
Fig. 120. Lateral projection of outline of mandible.
Course of nerve canal and position of root of most distal tooth are determined by teleradiography

Fig. 121. Center of rotation of


di placement of mandible lie
at the common center of all
c ncentric circle. Any point
on lower ja\ (A, B, ,D) decribe a portion of one of
the e concentric circle on
di placement

100

with the center of rotation. Therefore, the


center of rotation can be calculated by simple
geometry. The center of rotation is used in determining the size of the fragment of bone to be
removed. After marking the nerve canal and the
root of the most distal tooth, the position of the
lag screws is established (Fig. 122). The dimen-

sions can be measured on the drawing and transferred to the bone by the surgeon using calipers.
The data obtained from the drawing can also be
transferred by the technician to a model of the
jaws with dentition or to a plaster model.

4.5. Description of the Simulograph


(Fig. 123)

Fig. 122. Extent and direction of the displacement of


two points on mandible, A and B, are determined
separately for each side of the jaw with a special sighting device. By means of these points, the center of rotation, R, is determined geometrically. Using the
center of rotation, size of fragment of bone to be removed is determined (shaded area) . After marking
nerve canal and most distal tooth, position of the
three lag screws is established

The sighting device consists of two transparent


plates, fixed vertically to a base, and a sighting
instrument positioned perpendicularly to the
plates.
The sighting instrument can take the form of a
second transparent plate on each side, parallel
to the former plates and 3 em away from
them: A network of coordinates is engraved on
all four plates. It may also be a sight in the form
of a tube lying perpendicular to the plates, movable in the plane of the plates and at the optimum distance from the model for visual observation. As a refinement, a similarly movable
microscope may be used.
The narrowing of the field of vision by the
sight or microscope or alignment of the two networks of coordinates forces the investigator to
strictly vertical observation of the plate.

Fig. 123. Simulograph

101

4.6. Summary
The use of rigid internal fixation has helped to
obtain better results in osteotomies performed
for correction of mandibular prognathism or retrognathism. The fixation by means of lag screws
guarantees an absolute immobilization of the
fragments in a chosen position. Furthermore,
together with the correct positioning of the
fragments, it reduces the danger of recurrence of
prognathism or open-bite deformity after surgery.
The danger of delayed bone union or infection
at the site of osteotomy is diminished, and the
time of intermaxillary fixation shortened.
In order to accomplish such rigid internal fixation of the mandibular fragments after osteotomy, however, accurate preoperative planning and simulation of the operative procedure
are essential.

102

This paper deals with a new preoperative


evaluation of the mandibular deformity using
upper and lower jaw models in articulation.
Each side of the mandible is drawn separately on
paper. The process of abstraction from the
three-dimensional articulatory plane to a twodimensional plane is made possible by a diascopic apparatus with a special sighting instrument to avoid errors in the parallaxes. On the
paper, the center of rotational displacement is
marked. This center of rotation is important in
order to assess the amount of bone which has to
be removed after the new occlusion is obtained.
The nerve canal (n. alveolaris inferior) is also
drawn and the positions determined where the
three lag screws have to be introduced.
This concept of a preoperative evaluation
procedure is simple, accurate, and can be performed by the physician himself.

5. Results of Rigid Internal Fixation and Simulograpby in Sagittal


Split Osteotomy of tbe Ascending Ramus. A Comparative Clinical
Investigation
By R. Schmoker, B. Spiessl and Th. Gensheimer

The present paper examines the indications for


sagittal split osteotomy on the basis of a follow-up investigation of 75 out of approximately
100 cases. Emphasis is placed on the significance of rigid internal fixation (see Chap. C6)
and preoperative planning utilizing simulography for the positioning of the proximal segment (see Chap. C4). The effects of these factors on the healing process, follow-up treatment, and recurrence are examined.

5.1. Introduction
I t is known from arcograrnrnetric measurement
in cases of mandibular prognathism that as a rule
the relation of the dimensions of the dental arch
between the upper and lower jaw does not differ from that in normal subjects. The cause of
the dysgnathia lies rather in a disturbance of the
alignment of the jaws. For this reason, surgical
correction consisting of osteotomy in the ascending ramus of the mandible with shifting of
the whole row of teeth is preferable to shortening the dental arch within the row of teeth. This
applies also to other forms of dysgnathia, e.g.,
retrognathia or asymmetry of the mandible.
Among the techniques of osteotomy of the
mandible, the one that,has gained acceptance, in
the German-speaking countries at least, is the
principle of sagittal splitting as described by
BWEGESER (1961) and TRAUNER(1967, 1974).
A further advance in the surgical-orthopaedic
treatment of prognathism is rigid internal fixa-

tion of the fragments in the correct position (see


Fig. 131). An investigation of 75 cases was undertaken to determine the effect of fixation and
correct positioning on the postoperative course
and the final results.

5.2. Survey of the Literature


For horizontal osteotomy of the ascending
ramus as described by KOSTECKA (1928), LINDEMANN (1938), SCHUCHARDT (1954), etc., recurrence rates of 20 to 56% are quoted
(REICHENBACH et aI., 1966; ULLIK, 1942; AuGENSTEIN, 1950/51; WANG and NORDERUD,
1953; HOGEMANN, 1955; HAYMandHERRMANN,
1957; RUDOLPH, 1963; BECKER, 1966; KOLE,
1963/65; WIRTH, 1965; TRAUNER, 1967/1974;
BERGNER, 1971; and - quoted according to
TIEGELKAMP and OBWEGESER, 1955: WINTER,
LOSSIUS, TAUSCHER, and GOLDSTEIN).
The factors which are considered as recurrence in the previously mentioned papers include negative overjet alone. If edge to edge bite
and open bite, or other postoperative changes
are included, the rate of recurrence increases to
100% (RIDELLet aI., 1971; REITZIK, 1972). Follow-up investigations of sagittal split osteotomy
of the ascending ramus (Tables 14-16)
(TRAUNER, 1967, 1974; OBWEGESER, 1961; DAL
PONT, 1958) are described by the following authors: EGYEDI (1964); WHITE et al. (1969);
SERGL et al. (1970); GUERNSEY and DE CHAMPLAIN (1971); BIERMANN et al. (1974); BEHRMANN (1972); GRIMM and BEIlLICH (1973);
103

+>-

"""'
o

30%
53%

Preoperative orthodontic
treatment

Reduction of tongue size

15-39 yrs.

17: 83%

83%
6%
0%
12%

17

71%
29%
0%

12-20 yrs.

3%

93%

38

WHITE,
1969

Dentition:
Fully dentulous
Partially dentulous
Edentulous

Age distribution

Relation of male to female

Type of dysgnathism:
Mandibular prognathism
Asymmetry
Open bite deformity
Mandibular retrognathism

No. of cases

EGYEDI,
1974

et al.

24%

14.5-37 yrs.

36: 64%

28

1970

SERGL

GRIMM/

23%

15.5-32 yrs.

27: 73%

64%
9%
32%
0%

22
87%
0%
13%
0%

65

DE CHAMPLAIN, BEITLICH,
1971
1973

GUERNSEY/

Table 14. Indication for sagittal split osteotomy as stated by various authors

73.5%
20-29 yrs.

43: 57%

15-49 yrs.

24: 76%

25

1974

31

SIMPSON,

BIERMANN

et at, 1974

16-24 yrs.

25 : 75%

16

60%
6%
6%
6%

32

WHITE,

WANG/

1975

mean 22 yrs.

12.5 : 87.5%

1974

VUAYARAGHAVAN,

Vt

,....

= Head-chin cap
= Monoblock
C= Only negative overjet counted
d = In edentulous cases 100 %

Edge to edge bite, open bite deformity


Change in the adjusted occlusion

50%

18-25%

6
6

6
2

overcompensation
yes

28

38

Antibiotics
Length of stay in hospital (days)
9-14
Duration of immobilization (in weeks)
With wire-ligatures
6
With rubber band
4
Duration of unfitness for work (in weeks)
Follow-up treatment
up to 48
Duration (in months)
a
b
Type
Frequency
Negative overjet
16%

Surgeon
Duration of operation
Preoperative planning

No. of cases

SERGL et aI.,
1970

EGYEDY,
1964

50%

18%

6-8
4

22

GUERNSEY/DE
CHAMPLAIN,
1971

40%

64

34%

14%

65

BEHRMANN, GRIMM/
1972
BEITLICH,
1973

Table 15. Follow-up treatment and results of sagittal osteotomy as stated by various authors

7%C

11

7
3

2 h 35 min

31

BIERMANN
et aI., 1974

44%

25

SIMPSON,
1974

36%

31

TRAUNER,
1974

0\

.....

38

a = No. and % of surgeons


b_
.
- pneumoma

Severe bleeding
Fracture
7%
Blockage of the airways
by edema
Damage to facial nerve
Disturbance of sensation
of lingual nerve
Disturbance of sensation
of mental nerve
Initial
33%
Irreversible
3.5%
Infection
Necrosis
Pseudarthrosis
General complications
Dissatisfaction with
operation

No. of cases

EGYEDI,
1964

100%
59%
0%

6%
6%

17

WHITE,
1969

4%

4.Sb

38%
12.5%
12.5%
0.3%
2.6%

83%
36.4%
0%

68%
39%
23%

3%
71%
39%

82%

22

25

20%
24%

4%

4%

31

25%
5.3%

31

NIEDERSIMPSON,
DELL MANN! 1974
DIECKMANN,
1974

4%

65

KOBLIN,
1974

20%
0%

64 a

BIERMANN
et aI.,
1974

38%
16%

22

GUERNSEY! BEHRMANN, GRIMM!


BEITLICH,
DE
1972
CHAMPLAIN,
1973
1971

20%
0%

28

SERGL
et aI.,
1970

Table 16. Complications associated with sagittal split osteotomy as stated by various authors

15 and 30%
74%
2.6%
2.6%

39 and 31

TRAUNER,
1974

KOBLlNand REIL (1974); NIEDERDELLMANN and


DIECKMANN (1974); SIMPSON (1974); TRAUNER
(1974); VIJAYARGHAVAN et al. (1974); WANG
and WHITE (1974/75).
TIEGELKAMP (1955) raises the point that the
remodeling process following the surgical separation of the two ascending rami can take years.
RUDOLPH (1963) thus considers that the problem of maintaining the surgical adjusted lower
jaw in its new position does not usually arise until after the intermaxillary fixation is removed.
However, RIDELLet al. (1971) observed that the
proximal fragment can shift even during the
period of intermaxillary immobilization, despite
fixation of the fragments with wire ligatures.
EGYEDI (1964) observed the same phenomenon,
noting a discrepancy in many cases between the
model and the teleradiographic examination.
On the basis of a case of prognathism with open
bite, he assumed that the teeth are drawn from
the alveoli during intermaxillary fixation, and
the bases of the jaws open. When the fixation is
removed, the teeth may follow the movement of
the bone. An open bite deformity may result.

5.3. Theoretical Considerations


The problem connected with the fixation of the
fragments after osteotomy is the same as with
the fixation of a mandibular fracture. Sagittal
splitting of the ascending ramus of the mandible
corresponds to an extreme oblique fracture at the
angle of the mandible. The most suitable means
of achieving fixation are provided by the techniques for treatment of fractures of the mandible
(SPIESSL, 1972), which are based on the ASIF
principles (MULLER, ALLGOWER, WILLENEGGER,
1963, 1969). These fractures of large areas are
treated by means of rigid internal fixation and
interfragmentary compression with lag screws
(SPIESSL, 1974).
A set of instruments 1 has been developed for
this with which transbuccal insertion of the
screws can be carried out with intraoral access
for the osteotomy (see Chap. C6). However, the

1 Obtainable from R. Mathys, Instrumentenfabrik,


CH-2544 Bettlach

repositioning and fixation of the fragments are


made difficult because, unlike fracture fragments, they do not fit together exactly. When
stable fixation is employed, the positioning of the
fragments cannot be changed postoperatively.
Therefore, it is necessary that the positioning of
the proximal fragments in the sagittal plane
should be planned and determined independently on each side (see Chap. C 4). This is made
possible by preoperative simulography (see
Fig. 123). The correct positioning of the proximal fragments is necessary for the stable fixation.
With regard to fixation, a distinction can be
drawn between unstable and stable. In contrast
to wire ligatures or KmscHNER wires, compression is achieved between the fragments by
means of one lag screw. Thus, the displacement,
though not the rotation, of the fragments is prevented. With two lag screws, rotation in the
sagittal plane is also eliminated, but slight rotation in the horizontal plane is still possible. To
achieve absolute stability, therefore, a third
screw must be inserted on each side. The two
sides are then stabilized by changing the contact
area from a line to a plane.
The problem arises of how these three screws
can be put into place, taking into consideration
the position of the mandibular canal and the
roots ofthe teeth. Simulography is employed for
this also: the root of the last tooth, the nerve
canal, the osteotomy line, and the outlines of the
fragments are established and marked in the
prospective positioning. By using this plan, the
best position for the screws can be determined
(see Fig. 122).

5.4. Material and Method (Tables 17 and 18)


5.4.1. Diagnosis
Sagittal split osteotomy was considered indicated in
the following cases of dysgnathia:
Mandibular prognathism
67
Asymmetry
20
Open bite deformity
14
Mandibular pseudoprognathism
5
Mandibular retrognathism
4
Extreme overbite
4

107

5.4.2. Age and sex

5.4.5. Operation

Operations were performed on 24 male and 51


female patients. The age distribution was as follows:
15-20 years 35
15-16 years 7
17-18 years 13
19-20 years 15
21-30 years 26
21-25 years 13
26-30 years 13
31-40 years 6
41-50 years 6
51-60 years
1
1
61-70 years

38 osteotomies were performed by the Head of Department, 17 by senior residents, and 20 by residents.
Rigid internal fixation was applied in 30 of the osteotomies, the Head of Department operating in 11 of
these cases, the senior residents in 4, and the residents
in the remaining 15.

5.4.3. Dentition
Fully dentulous or almost so
Partially dentulous
One jaw edentulous
Both jaws edentulous

47
22
2
4

5.4.4. Orthodontic Treatment


Orthodontic treatment had already been tried in 26
patients, had not been tried in 49, and was given to 8
patients in preparation for the operation.

5.4.6. Preoperative Planning


The osteotomies which were fixed with 3 lag screws
on each side were all planned using simulography. For
the others, models of the whole jaw with dentition
were prepared.

5.4.7. Prophylaxis with Antibiotics


For more than 2 years, all osteotomies have been included in an antibiotics study; 13 patients were
treated with Kellin, 13 with penicillin-streptomycin, 6
with Penbritin, and 5 received no antibiotics. The administration of antibiotics began with the premedication and was continued for 5 days.

Table 17. Indications for sagittal split osteotomy


No. of cases investigated in follow-up study

75

Prognathism
90%
27%
Asymmetrie
Open bite deformity
19%
Cheilognathouranoschisis 7%
5%
Retrognathism
Extreme overbite
5%
32: 68%
Relation of male to female
47%
15-20 years
Age distribution
35%
21-30 years
31-40 years
8%
41-50 years
8%
1%
51-60 years
1%
61-70 years
Dentition:
63%
Fully dentulous
29%
Partially dentulous
3%
One jaw edentulous
5%
Both jaws edentulous
35%
Previous orthodontic
treatment
Preoperative orthodontic
11%
treatment
0%
Reduction in size of tongue
Type of mandibular
dysgnathism:

108

5.4.B. Fixation
The fragments were fixed with wire ligatures,
Kirschner wires, lag screws, or not at all.
Without fixation
6
Fixation with wire ligatures
6
Fixation with Kirschner wires
4
Fixation with 1 screw
13
Fixation with 2 screws
16
Fixation with 3 screws
30

5.4.9. Division into Groups

Length of stay in hospital


Duration of intermaxillary fixation
Period before resumption of normal diet
Period before removal of arch bars
Wearing of monoblock, head chin cap, etc.
Recurrence
Complications
Operation, postoperative treatment, and results from
the patients' point of view.

5.5.2. Length of Stay in Hospital

To elaborate the advantages and disadvantages ofthe


different fixation techniques, the patients were divided into the above-mentioned six groups.

5.5. Results (Tables 18 and 19)

5.5.1. Objects of the Study


The method used was assessed critically and from all
angles by taking the following factors into consideration:

The length of stay in hospital varied from 3 to 23 days.


The average was 9 days.
The mean duration for the individual groups was as
follows:
1. group without fixation in the
13.5 days
area of the osteotomy
11.5 days
2. group with wire ligatures
12.5 days
3. group with Kirschner wires
11.5 days
4. group with 1 screw fitted
5. group with 2 screws fitted
8.8 days
6. group with 3 screws fitted
6.3 days

Table 18. Performance, follow-up treatment and results of sagittal split osteotomy
Without
fixation
6
No. of cases in follow-up
investigation
Surgeon:
Head of Department
Senior residents
Residents
Duration of operation
Preoperative planning:
Models of the whole jaw with 100%
dentition
Simulogra ph y
0%
Antibiotics:
None
Penicillin/Streptomycin
Penbritin
Keflin
Length of stay in hospital (days)
13.5
9.7
Duration of intermaxillary
immobilization (weeks)
Resumption of normal diet
14.3
(after weeks)
Period of unfitness for work
12.2
Follow-up treatment
with activator
66%
with head-chin cap
33%
Monoblock
0%
Change in adjusted occlusion
33%
(Recurrence )

Means of fixation
Wire
Kirschner 1
ligatures wires
Screw
6

13

Total
2
Screws
16

3
Screws
30
37%
13%
50%
2-4.5 h

75
50%
23%
27%
2-4.5 h

100%

100%

100%

100%

0%

60%

0%

0%

0%

0%

100%

40%

11.5
9.8

12.5
7.25

11.5
5.7

8.8
3.8

6.3
0.2

7%
17%
8%
17%
3-23
0-15

13

12.5

10.5

2-20

10.1

12.5

8.7

7.5

2-20

50%
17%
1%
50%

75%
0%
0%
50%

0%
23%
36%
15%

0%
0%
44%
12.5%

0%
0%
0%
0%

109

5.5.3. Duration of Intermaxillary Fixation


The duration of intermaxillary fixation varied widely
from 0 to 15 weeks. In this connection, the greatest
differences between the different fixation techniques
were apparent, as is shown below:

1. group without fixation in the


osteotomy area
2. group with wire ligatures
3. group with Kirschner wires
4. group with 1 screw fitted
5. group with 2 screws fitted
6. group with 3 screws fitted

9.7 weeks
9.8 weeks
7.25 weeks
5.7 weeks
3.8 weeks
0.2 weeks
(0 weeks in 27 cases
2 weeks in 2 cases
1 week in 1 case)

After the removal of the intermaxillary fixation, a


control period of several days followed in which rubber band fixation was employed the whole day initially, and later only during the night.

5.5.4. Resumption of Normal Diet


The period before resumption of normal diet also varied lasting between 2 and 20 weeks. The mean lengths
of time were as follows:
1. group without fixation
14.3 weeks
2. group with wire ligatures
13 weeks

Table 19. Complications in sagittal split osteotomy


No. of cases in follow-up
investigation

1.3%
Severe bleeding
1.3%
Fracture
Blockage of airways by edema 0%
Fixation in wrong position
3%
Damage to facial nerve
0%
Disturbances of sensation
of lingual nerve
0%
Disturbances of sensation
of mental nerve
initial
80%
irreversible
50%
including:
4%
irreversible anesthesia
irreversible paresthesia
1.3%
1.3%
neuralgia
Infection
11%
Necrosis
0%
Pseudarthrosis
0%
1.3%a
General complications
1.3%
Patient not satisfied with
operation
a

= hepatitis due to halothane

110

75

(1 of 30)

3. group with Kirschner wires

12.5 weeks
10.5 weeks
8 weeks
4 weeks

4. group with 1 screw fitted


5. group with 2 screws fitted
6. group with 3 screws fitted

5.5.5. Period of Unfitness for Work


This period varied from 2 to 20 weeks. The mean
lengths of time were as follows:
1. group without fixation
12.2 weeks
2. group with wire ligatures
10.1 weeks
3. group with Kirschner wires
12.5 weeks
4. group with 1 screw fitted
8.7 weeks
7.5 weeks
5. group with 2 screws fitted
6. group with 3 screws fitted
4 weeks

5.5.6 Removal of the Arch Bars


The arch bars were removed after a period of 2 - 18
weeks.
1. group without fixation
11.7 weeks
2. group with wire ligatures
11 weeks
3. group with Kirschner wires
10 weeks
4. group with 1 screw fitted
9 weeks
5. group with 2 screws fitted
6.7 weeks
6. group with 3 screws fitted
3.8 weeks

5.5.7. Follow-up Treatment


Follow-up treatment with an activator was given in 10
cases; with a head-chin cap in 6 cases, and with
monoblock in 12 cases.
MonoActivator Headchin cap block
Group without
66%
fixation
Group with wire
50%
ligatures
75%
Group with
Kirschner wires
Group with 1 screw
0%
fitted
Group with 2 screws 0%
fitted
Group with 3 screws 0%
fitted

33%

0%

17%

0%

0%

0%

23%

36%

0%

44%

0%

0%

5.5.8. Rate of Recurrence


The rate of recurrence was 0 - 50%.
1. group without fixation
2. group with wire ligatures
3. group with Kirschner wires
4. group with 1 screw fitted
5. group with 2 screws fitted
6. group with 3 screws fitted

33%
50%
50%
15%

12.5%
0%

5.5.9. Disturbances of Sensation


a) Mental Nerve: The most frequent complication was
a disturbance of sensation of the mental nerve. At the
time of the investigation, the following were observed:
1. hypoesthesia
42-56%
2. irreversible anesthesia
3-4%
3. paresthesia
1-1.3%
4. neuralgia
1-1.3%
The percentage of hypoesthesia and anesthesia was
higher immediately after the operation (80%). After
1 year it was 50%. After 2 years and more, the disturbances of sensation were mostly confined to small
hypoesthetic areas, but the rate was still 50%.
b) Lingual Nerve: Disturbance of sensation in the lingual nerve was observed in one case.

5.5.10. Infection
Infection was a less frequent complication. Eight"
cases occurred, two in the area of fixation with
Kirschner wires, four in the area of a screw, one superficially at the emanation of the suction drainage.
Three of the cases of infection were in the group without antibiotics, five were in the group which received
antibiotics.

5.5.11. Other Complications


The following instances of other complications mentioned in the literature were observed:
1. severe bleeding
1
2. fracture
1
3. screws wrongly positioned
1
4. hepatitis (halothane)
1
5. pseudarthrosis
0
6. necrosis
0
7. lesion of the facial nerve
0

5.5.12. Subjective Statements


Complications reported by the patients but not objectively verified:
1. pain at the osteotomy site during
1
changes in the weather
2. increased susceptibility to caries
2
resulting from a long period of
intermaxillary fixation
There were 7 patients who reported pain in the region
of the temporomandibular joint for several days after
surgery and 10 patients reported discomfort in the region of the temporomandibular joint (clicking, subluxation, occasional pain). The following information

on the first occurrence of discomfort was gathered:


1. first observed since the operation
1
2. first observed before the operation
1
3. no definite statement
6
In retrospect, 70 patients would have the operation
again, 3 would not (2 because of recurrence, 1 could
not give a reason); 2 were undecided.
By far the most unpleasant aspect of the whole treatment was felt by almost all patients without stable fixation to be the intermaxillary immobilization with the
attendant difficulty in eating.
The most unpleasant aspect for the patients with rigid
internal fixation was the insertion and removal of the
arch bars before and after surgery. The postoperative
anesthesia of the lower lip was also considered unpleasant.

5.6. Discussion

5.6.1. Indication
The fact that the forms of dysgnathism such as
mandibular prognathism, mandibular retrognathism, open bite deformity, and asymmetry
with deviation of the mandible depend on a disproportion not in the size but in the positioning
of the dental arch of the mandible, was confirmed in our patients. In almost all cases, simply
retruding the lower jaw produced a good occlusion. To achieve this, preoperative orthodontic
treatment was required in only eight cases,
mainly involving cheilognathouranoschisis.
An operation in the alveolar process with extraction of teeth would not have produced a better or even equally good result in any of the cases
treated. An additional advantage was that no
further plastic surgery of the chin was necessary.
There were only two cases with mandibular retrognathism by extreme overbite where osteotomy in the alveolar process was required to
lower the excessively high frontal part of the
dentition at the same time as the sagittal split
osteotomy.
An interesting point is the decrease in the importance of marked overbite for the prevention
of recurrence. With unstable fixation at the osteotomy site, overbite and secure intercuspation
in the molar and premolar area must be aimed at
to prevent recurrence. With rigid internal fixation, however, even in cases of poor dentition

111

without overbite and adequate lateral intercuspation no recurrences were observed.


Of the patients, 26 had already received orthodontic treatment, either to adjust the relation
of the jaws or to correct dental displacement.
In the conservative treatment of crowding, some
permanent teeth were often extracted. In these
cases in particular, with a combination of dental
displacement and disregulation of the dental
arches, the retrusion of the mandible is clearly
preferable to operations in the dental arch. In
the latter operations, even more teeth must be
sacrificed in addition to those extracted in the
course of the orthodontic treatment. Otherwise,
the orthodontician is limited in his therapeutic
possibilities in cases where later surgical correction is likely to be necessary.
For many authors, an important argument in
favor of operations in the dental arch as opposed
to those in the ascending ramus with transsection of the mandible is the need for tedious intermaxillary fixation in the latter case. This intermaxillary fixation places a great burden on
the patient, but without it, recurrence or open
bite deformity could not previously be prevented. Furthermore, in the subsequent retention phase, where head-chin cap, mono block , or
even an activator is required, a great deal depends on the cooperation of the patient. This
applies especially to patients who have previously not cooperated adequately in the orthodontic treatment and had to be referred for
surgical correction. These disadvantages do not
apply when rigid internal fixation of the osteotomy fragments is employed. Any further
dental fixation is unnecessary. In this respect,
the patient has even less strain put upon him
than would be the case with an operation in the
alveolar process.

ion, this, together with the stability of the fixation, is the main guarantee for avoiding recurrence.

5.6.3. Length of Stay in Hospital


With the improved fixation of the osteotomy
fragments there is a marked decrease in the
length of stay in hospital. Stable fixation shortens the postoperative phases of pain and swelling. Postoperative care is much more simplified, the patient does not have to get used to
difficulties in eating, nor learn the complicated
dental hygiene procedures for cleaning the arch
bars. There are further reasons for the possibility of earlier discharge from the hospital: the patient's diet no longer has to be specially prepared, and less frequent postoperative examinations are necessary. This point is particularly
important for patients who live far from the hospital.

5.6.4. Intermaxillary Fixation


It was noteworthy that the patients who required intermaxillary fixation regarded it as the
most unpleasant aspect of the treatment. With
improvement of fixation at the osteotomy site,
the need for long intermaxillary fixation decreases. Where rigid internal fixation with three
lag screws on each side is employed, intermaxillary fixation is dispensed with completely. The
fitting of wire-acrylic arch bars before surgery
and their removal in one of the first follow-up
examinations were also found to be unpleasant.
Special ligatures (Ernst's ligatures) can be
used instead, however, and these need only be in
place while the screws are being inserted during
surgery.

5.6.2. Preoperative Planning


For rigid internal fixation, the precise planning
and determination of the necessary repositioning are indispensible for the exact positioning of
the proximal fragments and the correct placement of lag screws. The correct positioning of
the proximal fragments is achieved using the
data obtained by simulography, and in our opin112

5.6.5. Resumption of Normal Diet


The period up to the resumption of normal diet
could also be shortened. It must be pointed out,
however, that patients without any form of intermaxillary fixation do not refer to normal diet
until they can once again bite hard food. By con-

trast, patients who have been on a liquid diet for


3 months consider the first semisolid food taken
after the removal of the intermaxillary fixation
as normal food.
5.6.6. Unfitness for Work
The better the fixation of the fragments at the
osteotomy site, the shorter this period was.
However, patients with light jobs were not certified as unfit for work for the whole duration of
intermaxillary fixation.
5.6.7. Follow-up Treatment
In all osteotomies without fixation of the bone
or with fixation with wire ligatures or KIRSCHNER
wires, a period of follow-up treatment of up to
12 months with an activator or head-chin cap
was necessary. This requires a high degree of
cooperation from the patients. If the cooperation was not maintained for a sufficient length of
time, there was a recurrence after several
months. Where rigid internal fixation with three
screws on each side was employed, no such follow-up treatment was necessary.
5.6.8. Disturbances of Sensation
Disturbances of sensation connected with the
mental nerve form the most frequent complication observed. This is a serious disadvantage of
sagittal split osteotomy.
5.6.9. Prophylactic Treatment with Antibiotics
On the basis of the antibiotic study, it seems that
the risk of infection is increased when antibiotics
are not administered (see Chap. E 2).
5.6.10. Recurrence
The factors regarded as constituting recurrence
included not only negative overjet, but also edge
to edge bite, open bite deformity, and any irreversible change in the occlusion aimed at.
Despite meticulous follow-up treatment in
the case of osteotomy without rigid internal fix a-

tion and where the positioning of the proximal


fragment was not planned by means of simulography, the rate of recurrence was 12.5 - 50%.
Short-term recurrence corrected by orthodontic
treatment is not included in these figures.
It may be concluded from these observations
that without compressive internal fixation with
lag screws, and without correct positioning of
the proximal fragment, the rate of recurrence
revealed by critical appraisal and by long-term,
accurate observation is 100%. This can be
favorably influenced in 50 - 75 % of the cases if
the dentition is good and an orthodontic type of
treatment with an activator and head-chin cap is
preserved with, or if the dentition is improved by
fitting dental bridges. In the remaining cases, the
desired occlusion can no longer be achieved by
any means. Even long-term intermaxillary fixation will produce, at the most, extrusion or retrusion of the lower anterior teeth if there is a
tendency to open bite deformity or ventral displacement of the mandible (e. g., if correct positioning is lacking).
On the other hand, if correct positioning of
the proximal fragment was ensured by means of
preoperative simulography, and rigid internal
fixation was applied, there was no instance of recurrence even in cases with unfavorable occlusion. We believe this result can be explained by
two facts:

1. With rigid internal fixation, primary bone healing occurs. Functional remodeling takes
place under conditions of absolute stability.
In other words, there is no danger of a recurrence because gradual shifting at the osteotomy site is not possible, even during the
remodeling process, which is particularly intensive under functional stress. By contrast,
indirect (dental) fixation is insufficiently stable, and recurrence during the period of intermaxillary fixation is very probable. In addition, such fixation is of inadequate duration
because it cannot be retained during the
whole remodeling phase.
2. Preoperative planning using simulography allows the positioning of the proximal fragment
in muscular equilibrium. A recurrence is thus
prevented, which would involve the whole
mandible together with the stable fixation.

113

In 1 of the 30 cases where rigid internal fixation was used, the fragments were fixed in the
wrong position. From immediately after the operation, the desired occlusion was not apparent.
Light rubber band traction such as is used to
produce terminal occlusion, was tried without
success. Two weeks intermaxillary fixation with
stronger rubber band traction was also unsuccessful. Therefore, the screws were finally removed. Examination during the operation
showed the osteotomy site to be clinically stable
after the screws were removed.
Postoperatively, however, an open bite deformity developed within a few days. By using
intermaxillary rubber band traction, it was subsequently possible to correct this and the slight
deviation caused by the wrong positioning of the
fragments. 10 weeks' intermaxillary fixation
with wire ligatures were followed by several
weeks' retention with rubber band traction.
Even after such long treatment, a slight open
bite deformity was observed anteriorly. It is apparent from this example that:
1. The fixation with screws was so stable that the
wrongly adjusted positioning could not be
changed even with the most powerful rubber
band traction.
2. At a time when the osteotomy site was to a
large extent clinically stable, an open bite deformity developed under functional stress as
soon as the screws were removed.
3. It was possible to correct the wrongly adjusted occlusion without difficulty by means
of rubber band traction when the screws had
been removed.
4. After 10 weeks' intermaxillary fixation and
several weeks follow-up treatment with rubber band traction, a minimal open bite deformity was still observed.

114

5.6.11. Advantages of Correct Positioning


and Rigid Internal Fixation

Rigid internal fixation in sagittal split osteotomy


showed advantages similar to those observed
in its use with mandibular fractures (see Chap.
Bland B 2).

5.7. Summary

Sagittal split osteotomy is rightly indicated for


the correction of different forms of dysgnathism.
The surgical technique profits by the possibilities
available with internal fixation as shown in
fracture treatment according to the principles
of the ASIF. For two reasons, rigid internal
fixation in osteotomy requires preoperative
planning using simulography: It permits correct
positioning of the proximal fragment and also
correct positioning of the lag screws.
Without rigid internal fixation, despite 2-3
month's intermaxillary fixation, careful examination showed a recurrence in most cases.
It was possible to treat this successfully in
about half the cases involved, by means of an
activator and head-chin cap. On the other hand,
with stable fixation using three lag screws on
each side and with preoperative planning
utilizing simulography, there was no instance
of recurrence in 30 cases so treated. These
two factors were not only responsible for the
avoidance of recurrence, but also for greatly
shortening the length of stay in hospital and the
period of unfitness for work. They also made
intermaxillary fixation and later follow-up
treatment unnecessary.

6. Rigid Internal Fixation After Sagittal Split Osteotomy of the


Ascending Ramus
By B. Spiessl

6.1. Introduction

In current surgical orthopaedics, osteotomy


techniques are more varied than fixation techniques. Fixation often forms a subsidiary part of
the orthopaedic operation.
Operations for prognathism provide a typical
example. The emphasis is placed on enlarging
the areas of the fragments with the object of reducing the factors that may jeopardize healing
or lead to recurrence. The conventional
methods offixation are, however, retained. The
result is an unstable osteotomy gap. Despite the
enlarged area of the fragments, the best that can
be expected is absence of infection and only secondary bone healing.
Depending on the degree of interfragmentary
disturbance, either of the following may develop:
1. cartilaginous and connective tissue leading to
secondary ossification (secondary bone healing - callus formation)
2. osteolysis induced by movement (interfragmentary resorption) leading to infection and
pseudarthrosis.
Secondary bone formation corresponds to the
irritation callus, which becomes a fixation callus
after several months have elapsed.
It is true that by using additional wire sutures,
major errors of fragment positioning can be
avoided and interfragmental movement reduced.
But even minimal relative movements produced
by swallowing and speaking lead to one of the
above-mentioned forms of secondary bone
healing.
The substrates forming as a reaction in the osteotomy gap consist of cartilage, connective tis-

sue, resorptive granulation tissue or irritation


callus. These are the actual cause of the tendency to recurrence and the formation of an
open bite, as well as causing the development of
pseudarthrosis. Muscular traction and poor intercuspation only aid the process.
Experience has shown that despite major osteotomy, 6--8 weeks' fixation, and the use of
wire sutures, a considerable number of disorders
of the healing process and of recurrences are
observed, e. g., TRAUNER (1974): 16 out of 18,
and BIERMANN (1974): 9 of 31.
This negative experience means that more intensive follow-up treatment is necessary to reduce the sequelae of unstable fixation to a
minimum. The consequence is a series of unpleasant factors for the patient:
1. prevention of mastication and opening of the
mouth for an average of 6 weeks,
2. fairly long stay in hospital,
3. long period of unfitness for work,
4. long period of follow-up treatment,
5. high rate of complications in the form of recurrence, infection, pseudarthrosis, and
open-bite.
The question which, therefore, arises is
whether these disadvantages can be avoided,
and if so, how.
One thing has become clear: the fixation is no
less important than the precise performance of
the osteotomy. To maintain this precision until
consolidation is achieved, rigid internal fixation
of the fragments is required. Our concept is thus
based on large-area osteotomy and fixation
which is stable during movement.
115

6.2. Technique
6.2.1. Osteotomy
With regard to rigid internal fixation, the splitting osteotomy of the ascending mandibular
ramus is performed from above the angle of the
mandible (as described by DAL PONT, 1958) to
the molar part of the corpus mandibulae. The
osteotomy line in front of the angle of the mandible is exactly established before surgery (see
Fig. 122, Chap. C 4).
With splitting osteotomy, the danger of injuring large vessels (retromandibular vein, inferior
alveolar artery, internal maxillary artery, as well

as the alveolar nerve) is greater than usual, so


that a refined technique to eliminate this complication is vital. The basic requirement for solving the problem is a special osteotomy instrument set.
The first obstacle of risk of injury to the larger
vessels is mainly attributable to inadequate retraction of the soft tissue in the severely limited
access to the osteotomy site. The muscular walls
of the upper pterygomandibular space and possibly the adipose body of the cheek must be optimally retracted without hindering the surgeon.
For this, two special hooks are required: the
forked retractor and a modified Hohmann
elevator (Fig. 124a-c). The stable forked retractor is provided with a sharp-edged interdigi-

116

,
~

c
Fig. 124. Special retractors for
sagittal split osteotomy of ascending mandibular ramus:
(a) Internal retractor to protect vascular nerve bundle and
parotid at posterior edge of
ascending ramus, (b) cheek
retractor
(external),
(c)
forked retractor for left side
(see also Fig. 128)

tal groove, into which the anterior edge of the


coronoid process fits. In use, the instrument also
acts as a raspatory for the removal of remaining
tendinous fibers.
The Hohmann elevator (see Fig. 124a) has a
narrowed section to protect the vascular nerve
bundle, and at the end, a flat, thorn-shaped extension, which fits around the rear edge of the
jaw at the level ofthe osteotomy. Serious injury
to the soft tissues by the burr is precluded by the
curved end of the retractor.
Because of the dimensions and anatomically
adapted shapes of the two instruments, they
guarantee optimal tissue protection and a good
view into the depth of the wound.
The cheek retractor is also constructed on the
principle of the Hohmann elevator (see
Fig. 124b).
The second problem involves splitting the ascending ramus without damaging the inferior alveolar nerve. In surgical-anatomical terms, this
entails the precise detachment of the lateral cortex between the median and lateral cortical incisions. The procedure must be carried out with
great accuracy in order to protect the nerve canal. Two factors are of great importance: firstly,
the osteotome must be guided accurately along
the borderline between the cortex and cancellous bone (Fig. 125) and secondly, a special osteotome with a finely tapering blade is required.

In view of the danger of nerve in jury, the area


of osteotomy is divided into a preangular (1),
angular (2), and supraangular section (3)
(Fig. 126). The orientation of the nerve canal to
the lateral cortex in the above-mentioned sections can be seen in the illustration.
In the angular section, there is practically no
cancellous bone between the canal wall and the
lateral cortex. A cancellous bone layer of the
same thickness as the bordering cortex is present
only in the preangular section. The supraangular
section is without canal.
Therefore, the osteotomy process is most difficult in the angular and supraangular sections,
where, furthermore, the ramus is broadest because of the projecting oblique line of the mandible.1f the width is reduced at this point, which
means that the depth of the splitting is also diminished, it is clear that the detachment of the
external cortex in the connecting layer is thereby
made substantially easier. So before starting the
actual splitting, the external cortex is removed
to the extent depicted in the simulogram (see
Fig. 122). The bone must be completely removed at that point anyway, because when the
fragments have been definitively positioned,
their anterior edges must terminate at the same
level. This is important for two reasons; firstly,
for the normal shape of the isthmus faucium
(without bulging between the pterygomandibu-

Fig. 125. Condition following


precise detachment of lateral
cortex. Note: nerve canal remained closed

117

in between : no cancellous bone

~.

In between: no cancellous bone

Fig. 126. Preangular (1) , angular (2), and supraangular (3) , section . Incisions a, b, c, and d show position
of nerve canal in relation to lateral cortex. In c and d
(angular and upraangular) there is hardly any cancellous bone between wall of canal and latera l cortex

lar fold and buccal plane) and secondly for the


correct positioning of the fixation screws later.
Following the decortication of the oblique
line of the mandible, the boundary area between
the cancellous bone and the cortex is readily apparent (Fig. 127); the osteotome is guided along
this border line with light taps. The osteotomy
proceeds close to the medial and lateral cortical
incisions. No osteotomy will be performed in the
angular section (Fig. 128). The final connections in the angular section are carefully severed
by means of separating movements with an osteotome. Since we have been applying this technique, the number of postoperative disturbances
of sensation has decreased significantly.

6.2.2. Rigid Internal Fixation

Fig. 127. Condition following removal of linea obliqua with a burr. Precise borderline between cancellous bone and lateral cortex is visible. Splitting area
is markedly reduced

118

An elementary method of rigid internal fixation


entails interfragmental compression achieved
by means of lag screws. The system consists of a.
cortex screw, a gliding hole, and a thread hole.
When the screws are tightened, interfragmental
pressure is created (Fig. 129).

Fig. 128. Site of operation following decortication of


oblique line. Only cortical lamella is detach d with osteotome. In situ: forked , inner, and outer retractors

Fig. 129. Interfragmentary compression of sagittally


split mandible (cross section) by means of lag screws.
On left of picture: in left fragment, traction (thread)
hole, in right fragment, gliding hole. Right of picture:
Process occurring when screw head makes contact
and screw is tightened: interfragmentary compression. (SPIESSL, B., TSCHOPP, H. M. 1974).

/I

119

The use of lag-screws is ideal for fixation after


sagittal splitting in surgery for both prognathism
and retrognathism. The necessary instruments 1
(Fig. 130) include a trocar with a handle, a metal
jacket with a fine point, a drill guide, and a ring
to act as cheek retractor. The instruments permit the fragments to be screwed into position
perfacially, and vertically to the lateral surface
of the jaw. Further instruments required include
the ASIF air drill, tap, and screw driver.
Before the screws are put in place, the fragments are exactly positioned and temporarily
fixed (Fig. 131).

b
c

d
e

Fig. 130. (a) Trocar with handle, (b) Removable


metal point, (c) Mountable ring as cheek retractor,
(d) Drill guide for 2.7 mm bit, (e) Drill guide for
2.0 mm bit, (f) Depth gauge, (g) Tap for 2.7 mm
cortical screws, (h) Imbus screw driver
1 Obtainable from R. Mathys, Instrumentenfabrik,
CH-2544 Bettlach.

120

The intermaxillary fixation of the peripheral


fragment is undertaken first. The correct positioning of the fragments is based on the occlusion (simulated preoperatively in a model). If
the occlusion can be easily adjusted, it may be
adequately fixed using Ernst's ligatures (see
Fig. 74). If, however, the simulation shows that
despite "spot grinding", a natural (optimal) intercuspation cannot be achieved, it is recommended that firm arch bars be applied (e. g.,
wire-acrylic) in the upper and lower jaws to
achieve the best intercuspation practicable (see
Fig. 75). This is especially so with incomplete
dentition, especially when posterior support is
lacking because of the absence of molars.
The second step is the interfragmentary fixation at the angle of the mandible using special
fixation forceps (see Fig. 131). The correct position of the proximal fragment is obtained by
shortening its end by the amount determined by
simulography (see Fig. 121). When the shortened fragment is now connected with the retropositioned fragment, the ascending ramus
will be in a central (physiologic) position. Using
special forceps, both fragments are fixed in this
position.
Through a stab incision along the skin folds,
the trocar is guided with the metal point in place,
to the site where the angle of the mandible is exposed. A minimum of three screws are applied
within a radius of 2 cm from this point
(Fig. 132).
The rigid internal fixation is achieved by interfragmental compression with cortex screws,
according to the principles of perfacial screwing
(see Fig. 141).
The cortex screw will act as a lag screw only
when it can obtain a grip in the far cortex and not
in the nearest cortex to the screw head. This requires a larger hole to be cut in the cortex
nearest to the screw head, and a smaller one for
the far cortex, which should be tapped. The
larger hole is referred to as the gliding and the
far one as the thread hole (see Fig. 129).
Immediately after the screws have been tightened on both sides, the intermaxillary fixation
can be removed. The maintenance of the intermaxillary fixation for 4 or 5 days is desirable
only in exceptional cases as a prophylaxis
against postoperative pain.

Fig. 131. Temporary fixation


of fragments by intermaxillary wire ligatures and reduction forceps. Trocar drill in
place. (SPIESSL, B., Tschopp,
H. M. 1974)

Fig. 132. Plan showing positions of screws, taking into


consideration nerve canal

121

We consider that the screws should always be


removed, and do so after 6--12 months. This can
be done on an out-patient basis under local
anesthesia. The same instrument set as described above is used.

6.3. Discussion

Since it has been possible to fix the fragments in


the correct position with complete functional
stability, intermaxillary fixation can no longer
be considered a satisfactory component of prognathism 9perations, either in medical terms or
with regard to method. The emphasis is no

122

longer placed on follow-up treatment. This is


made substantially easier and shorter because of
the objectives that can be attained with rigid internal fixation:
1. guaranteed positioning of the fragments,
2. primary bone healing and
3. immediate mobilization.
The following advantages of the system may
be summarized:
1. briefer stay in hospital
2. no orthodontic follow-up treatment
3. immediate ability to open mouth (semisolid
food)
4. from week 3-4, normal food
5. shorter period of unfitness for work
6. practically no danger of recurrence.

D
Implantology

1. The Dynamic Compression Implant (DCI) as a Basis for


AUenthetic Prosthetics.
Fundamental Principles of Theory and Practice
By B. Spiessl

1.1. Introduction

Experimental work and clinical experience in


the field of rigid internal fixation in general
(MULLERet aI., 1969; PERRENet aI., 1975; RAHN
et aI., 1975) and in mandibular fractures in particular (see Chap. B 1), provide a basis for the
development of practical implant prosthetics.
The theoretical and practical points raised in
the following are based up to now, on 120 implant cases (April, 1972 - April, 1976). Of
these, 70 have been critically evaluated with
reference to certain parameters in a follow-up
study (see Chap. D 2).
Clinical experience demonstrates that implants are incorporated without irritation where
mechanical movement is absent, e. g., in the dorsum of the nose, orbital base, glabella, and calvaria (the neurosurgeon, for instance, is consistently successful in covering defects in the calvaria with synthetic implants).
Similar observations can be made with bone
transplantation (see Chap. A 1, 2, 3). It is apparent from clinical experience and from experiments that the incorporation of a transplant and
induction of bone formation succeed in locations where mechanical motion is absent.
The theoretical principle, on which the implantation of a framework to secure the prosthesis is based, is that bone is not an "inert" supporting substance. Injury to bone always elicits
the same chain of reactions, regardless of
whether due to fracture or mechanical damage
caused by the insertion of an implant: rapid pro-

liferation of osteoblasts and osteoclasts in the


endosteum and periosteum. The process is
based on the principle of inducing osteogenesis.
However, the formation of such tissue depends
on the type of mechanical strain (KROMPECHER,
1937; PAUWELS, 1965; BASSET, 1962; BASSETet
aI., 1961; SCHENK, 1975; etc.). Bone forms directly only when mechanical movement is absent. By contrast, shearing forces stimulate the
formation of cartilaginous tissue, and tractional
forces the formation of connective tissue. Thus,
mechanically induced reaction in the bone must
be taken into account in the implantation of any
allenthetic prosthetic material. GANZ et al.,
(1975) confirmed this principle in a classic experiment which is particularly relevant to the
placement of implants.
For this experiment a bone under dynamic
stress was chosen (sheep tibia), and only one end
of the implant was stably fixed to it (Fig. 133).
The result was a relative shifting between the
free end of the implant and the surface of the
bone. It is immaterial whether this relative
movement comes either from the bone (inherent elasticity) or from the implant (e. g., in cases
of instability), when either is under stress.
The relative movement is eliminated if the
free end of the implant is fixed with an experimental screw in such a way that the implant is
subjected to tension, designated technically as
"preload" (Fig. 134). This bracing mechanism
precludes mechanical movement and creates a
state referred to clinically as "absolute stability." The preload within the metal-bone system
125

Fig. 133. Shortening of bone


subjected to stress during
walking because of its elasticity. One end of implant is fixed
firmly to bone. At opposite,
free end of plate, mutual displacement of plate and bone
occurs

-7

I~'

.
~I
I

Fig. 134. High static preload of experimental screw is


reduced under stress of walking; monitoring with aid
of pressure measuring plate in vivo

Fig. 135. Static preload of experimental screw is less


than stress during walking: alternating load oscillating
through zero occurs. Result: fine movement of screw
( =static force < dynamic force)

is maintained even under functional stress; it


merely decreases by a certain amount at the
moment when stress is applied.
If, however, the screw is positioned without
producing a tensional force (Fig. 135), the preload of the implant is less than the dynamic
stress. An alternating load oscillating through
zero results. In consequence, the plate unilaterally transfers the dynamic load to the screw at
the other end. This is now free to move. The
micromovements of the screw lead to resorption
of the bone, which is replaced by cartilaginous
tissue (Fig. 136).
The explanation of these processes is that,
under certain conditions, one category of cellsthe undifferentiated mesenchymal cells - can
apparently produce different types of tissue

(BASSET, 1962). The possibility of such cell


modulation (transition from one functional
form to another) is verified most strikingly in the
use of endosteal implants, positioned in the jaws
without compression (pretension).
During mastication, the implants (e. g.,
screw-, needle-, or blade implants) are subjected to an alternating load oscillating through
zero. The results are micromovements between
the implant and the bone, which do not lead to
osteogenetic but rather to fibroblastic differentiation. The proliferative connective tissue
forms an additional barrier against the possible
advance of (angiogenic) bone tissue. The micromovements cause an increasing loosening of
the implant. This condition sooner or later leads
to infection. Resorptive granulation tissue is

126

This process is reproducible in any vital bone,


which indicates that the loosening of the screws
frequently observed with implants in the jaw is
due to movement-induced osteolysis.
By contrast, pretension leads to active incorporation of the screw, as BAUMANN'S experiments in dog jaws demonstrated. Pretension is,

therefore, an essential requirement for the permanent incorporation of an implant in the bone.

OJ

I ~. .:1

RESORPTION
CAR T Il AGE - TIS SUE

To subject the implant to immediate functional stress instead of pretension, on the assumption that bony reconstruction will follow, is
questionable. In my opinion, the most important
factor is absolute stability, which is achieved by
pretension and ensures that loosening does not
occur, despite early functional stress.
This is the basis of undisturbed incorporation
and toleration of the implant. The interaction
between bone, implant, and mucous membrane
can thus be held in equilibrium for a long period
of time (reckoned in years).
According to our clinical experience so far,
the theory of stability stated here presents a
practical approach to allenthetic prosthetics.

CAllUS

Fig. 136. Biological processes around experimental


screw with alternating load oscillating through zero.
Resorption of contact surfaces of bone, replacement
by cartilaginous tissue, and marked callus formation

formed and destroys the contact zones between


the implant and the bone. This process is designated as osteolysis (GANZ et aI., 1975).
This osteolysis, which is induced by movement, could be the main cause of the failures recorded so far in dental implantology. Further
animal experiments by MAITER et aI., (1974)
support this view.
Single-hole plates without and single-hole
plates with pretension were screwed to intact
sheep tibiae. Comparison of the two groups
showed striking differences: significantly more
instances of loosening of the screw were observed without pretension than with.
Mechanical analysis showed that only the
screws without pretension were subjected to an
alternating load oscillating through zero. Micromovements which caused osteolysis were recorded only in this group.

1.2. Principle of Construction and Fixation


The implant has to withstand the pressure, tractional and shearing forces engendered by mastication, and still maintain its stability for as long as
required. Thus, an absolute stable metal-bone
system must be aimed at.
Apart from metallurgical and constructional
considerations, the required stability is achieved
by ensuring that the static strain exerted by the
implant on the mandible exceeds the dynamic
functional strain exerted on the implant. Taking
as a basis the dynamic forces created by mastication (maximum force in the molar area on biting: 65 28.8 kp, measured by RAHN et aI.,
[1975]), the implant must elicit a static force
which is, if possible, several times greater than
the maximum value of the dynamic force.
As long as the static force is greater, bone is
formed rather than connective or resorptive
granula tion tissue in the reaction area of the implant within or on the surface of the bone. The
situation is one of adaptive remodeling rather

than resorptive degeneration.


127

Fig. 137. pedal plier for pre ing implant t


( tatic c mprc ion pha e)

The required static force and the biologically


favorable stress between the contact zones of
the implant and the bone are achieved by:
1. large supporting area
2. precise fitting
3. static transverse compression
4. maximal extension on the buccal side of the
jaw (covered by soft tissues)
5. minimal extension on the lingual side
6. alveolar crest kept as free as possible
7. implant construction characterized by economic use of the most rigid and best tolerated
material.

1.2.1. Static Friction


Apart from the screws, the static friction between implant and bone is the most important
factor with regard to stability. The stability increases by the extent by which the static friction
exceeds the transverse masticatory forces. The
large supporting surface created by lateral extension of the implant leads firstly to a uniform
and even stressing of the jaw by pressure and
traction and secondly to a decrease in the distortion tendency of the implant.
To ensure that the implant fits exactly and to
exclude distortion as far as possible, it is made by
a stellite molding technique based on a precise
impression of the surface of the bone.
128

b n

1.2.2. Pretension and Transverse Compression


The definitive, stable emplacement of the implant is achieved by means of pretension and
transverse compression. The implant is thus fitted in two stages: in the first it is pressed to the
bone with special forceps designed to create a
preload (static compression phase) (Fig. 137);
in the second, it is screwed firmly into place,
transversely to the axis of the mandible, with
pressure screws (dynamic compression phase)
(Fig. 138).
The implant is provided with four to five
spherical gliding holes (see Fig. 29). The appropriate pressure screw (cortex screw) is inserted excentrically (see Fig. 141c). The displacing effect of the screw, produced when the
spherical head meets the side of the gliding hole,
increases the pretension.
With the thickness of the cortex at the rim of
the mandible, mean pressure forces of 15-30 kp
are achieved transversely to the axis of the mandible (= static transverse compression) (see
p.147, Chap. D 4). By means ofthe basal (marginal) position of the screw holes (Fig. 139),
both a lesion of the mandibular canal and shifting of the implant are prevented. With the holes
in a higher position, these phenomena can occur
in view of the high torque when the srew is
turned (see Chap. D 4).

The positioning of the screws (pressure screws)


transversely to the long axis of the bone (neutral
axis approximately following the course of the
mandibular canal) is important, because it per-

DC
~- K : 30-40Kp.

Fig. 139. Construction of DCI. Screw holes are


positioned basally

Fig. 138. Mechanics of DCI (dynamic compression


implant). Force components in screw hole: K = displacement force of screw, Z = traction force in axial
direction to screw, P = result of Z + K

mits the optimum development of transverse


forces. These neutralize mainly those intermittant pressure and traction forces which lead in
time to rocking movements of the implant. The
elevating forces are created by an alternating
load when biting or chewing on one side or the
other takes place.
1.3. The Area of hnplantation

The area of implantation consists of the cortex


and mucoperiosteum. Its efficiency depends on
the degree of vascularization. In most cases, this

is greatly reduced as a result of previous interventions and inadequate prosthetic treatment.


A poorly fitting or badly shaped denture puts
excessive strain on the mucoperiosteal tissue.
The results are irritation and congestion in
the vascular system. Chronic edema of the
mucoperiosteum occurs and is followed by
losening and detachment of the connective tissue. The end result is replacement by fibrotic tissue or poor vascularity (in extreme cases: "denture irritation hyperplasia"). There is, therefore, a lack of soft tissue with good vascularity,
particularly on the alveolar and lingual sides of
the alveolar crest. It is clear that in such circumstances as little implant material as possible
should lie between the alveolar crest and mucous membrane so that the connections to the
Haversian canals can completely reform.
Otherwise, wound dehiscence and spontaneous
perforation of the mucous membrane are unavoidable in areas where too much metal lies
below the sudace. A special technique of wound
closure is required here, so that the circulation
of the blood in the edges of the wound is not also
artificially disturbed. Tension-free adaptation
of the edges of the wound is required for this.
In the adjacent bone, the normal marrow is
replaced by fibrous marrow, and the process is
accompanied by degeneration of the osseous

129

trabeculae (reduction of density and structure in


the mandible). The cortex becomes thinner
(1 mm or less). The Haversian canals widen and
finally open to the medullary cavity. The substantia compacta is thus peeled apart, converted
to cancellous bone, and incorporated in the
medullary cavity. The changes of the bone thus
caused cannot be described as pressure atrophy,
but rather as a consequence of intensified degeneration processes, mainly elicited by functional disturbances of circulation (HAUPL,
1960).
The area of implantation is thus distinctly ineffecient. The atraumatic detachment of the
periosteum is all the more important, especially
at the areas of adherence or roughness. An intact, or, at the most, minimally damaged periosteum is required for the formation of a bone rim
around the implant, which is what should be
aimed at.

development of the various types of cell in osseous tissue, the bone is provided with the ability
to repair a destroyed (defect) surface in its original basic form. We attempt to use this osteogenesis, which depends on certain stimuli, by
sinking the abutments of the implant in grooves
in the bone, positioned transversely to the axis
of the mandible (Fig. 140). As at the edges of
the implant, a bone ridge forms over these (the
angle between the side of the implant and the
bony surface is filled in). This results from
periosteal and cortical reaction.

1.4. Induction of Periosteal Bone Formation

Several mechanisms must be considered with


regard to the induction of periosteal bone formation: damage to the periosteum, increased tension in the bone, and the genetically patterned
reaction.
GEISER (1963) observed reactions following
periosteal injury in animal experiments. With
temporary lifting of the periosteum, marked callus formation took place.
MATIERet al., (1974) investigated the biological reaction of the bone to rigid internal fixation
plates in animal experiments. They observed
callus formation on all sides of the plate, thus
confirming what had already been observed
clinically. The bone surrounding the implant,
which is under pressure, represents a zone of
locally increased tension, producing a stressconcentration, when subjected to functional
forces. This stress-concentration acts as a
stimulus for the formation of mature, lamellar
bone in the contact zone between the implant
and the bone.
A further question of interest is why empty
alveoli, screw holes, or small defects spontaneously fill up with bone following osteotomy. According to the modern view on the origin and
130

Fig. 140. Grooves in bone, transverse to mandibular


axis, for sinking abutments

The reconstructive principle always remains


the same, and the newly formed bone hardly
ever grows above the height of the implant, i. e.,
it is not completely walled in.

1.5. Summary of the Principles

On the basis of our experience with the area


of implantation, we proceed according to the
following principles:
1. atraumatic detachment of the periosteum
2. removal of sharp-edged bone fragments and
mucosal ridges with poor blood perfusion
3. exact impression of the bone down to the
lower edge of the mandible
4. maintenance of the muscular insertion

5. sinking of abutments into grooves in the bone


which are positioned transversely to the axis
of te mandible
6. laterofixation of the implant, i. e., fitting of

the base of the implant on the external side of


the jaw by means of perfacial screwing
(Fig. 141) (instrument set, see Fig. 130)
7. insertion of the implant on the same day.

Fig.141. (a) Introduction of


trocar through stab incision,
(b) Removal of metal point.
Fitting of m([lUntable ring,
which acts as cheek retractor,
(c) Sharp point of trocar
is positioned firmly against
surface of bone. Introduction
of excentric drill guide 2.0 mm
(see outlined section), (d)
Introduction of 2 mm bit

131

q~-;-

' 4 -_ _ _ _

r:---"'o

J
h

)~

-L~)
132

Fig. 141. (e) Drilling through


bone at lower edge of mandible, (f) Removal of bit and
drill guide; introduction of
depth gauge, (g) Measurement of length of drill hole,
(h) Thread-cutting with tap
for a 2.7 mm cortical screw,
(i) Insertion of screw in excentrically positioned drill hole
with imbus screw driver

Since 1972, we have followed the abovementioned principles and utilized the
biomechanical concept of the dynamic compression implant (DCI), in over 120 cases. The re-

sults achieved support our concept and we feel


that we should continue, with the ultimate aim
of evolving a routine procedure that can be considered as a basis for implantation surgery.

133

2. The Dynamic Compression Implant (DCI) - A First Evaluation


of 70 Cases
By W.-A. Jaques

2.1. Introduction
Extreme atrophy of the jaws of edentulous patients still presents a hard challenge to oral surgeons. Conventional preprosthetic surgery is of
little help.
For subperiosteal implants, as for the treatment of mandibular fractures by internal fixation, the three basic principles remain the same
(SpmssL, 1974):
1. Absolute stability
2. Ideal adaptation
3. Optimal vascularization.
They have already been discussed in the previous chapter (see Ch. D.l). The main aim of
this study was to develop a reproducible, comparative method of evaluating a group of patients with implants operated on according to
these principles.

2.2. Material and Method


Between April, 1972 and April, 1975, 70 patients (25
male and 45 female) were operated on; 64 total mandibular, 4 total maxillar implants, and 2 partial implants for the anterior part of the mandible were applied. All were made of Stellite. A total of 5 different
surgeons were involved. As a rule we chose the twostage operating procedure with a 3-7 weeks interval.
Laboratory and prosthetic techniques were identical.
For practical reasons, our patients have been divided into four groups, according to the different
types of implants. This has automatically resulted in a
grouping according to the duration of postoperative
observation.

134

Group I consists of 22 patients operated on between April, 1972 and November, 1973 (Implant
Type I).
Group II consists of 18 patients operated on between December, 1973 and June, 1974 (Implant
Type II).
Group III consists of 26 patients operated on between September, 1974 and April, 1975. Their implant (Type III) best corresponds to the concept of
the Dynamic Compression Implant or DCI (SPIESSL,
1974).
Group IV consists of four total maxillary and two
partial mandibular implants. It is the least homogeneous and for this reason will receive least comment.
The main characteristics of the different types of
implants are summarized in Table 20.

In spite of difficulties in evaluating this inhomogenous population, we attempted to develop a standard method which could be used
later for similar assessments (JAQUES, 1976).
Our patients have been assessed as follows:
1. Subjective findings: the patient's assessment
of his own implant.
2. Objective findings: our objective evaluation
of the local situation.
3. Radiographic findings: obtained by .a
panoramic tomography and an occlusal view.
Experience has shown that the results of these
three methods of evaluation should not be given
equal weight. The objective and radiographic
findings each comprise 40% of the total score,
while subjective findings only 20%.
Our 70 patients were reassessed between
April and August, 1975. Depending on the findings, minus or penalty points were assigned.
Theoretically a maximum of 100 points was pos-

Table 20. Characteristics of the four implant types


Type I

Type II

Type III

Implant frame

Thick meshes

Surface
Number of screws
Lingual extension
Number of gripped cortices
Abutment bases
Amount of metal on the
crest
Counter sinking of distal
screwheads
Abutment grooves
Compression distally
Compression anteriorly
Material
Number of Implants

Polished
3
Maximal
4

Thick meshes and Slender


occlusal bar
Polished
Rough, porous
3-4
4
Minimal
Minimal

~
+++

No

Yes

Yes

No
No
No
Stellite
22

No
Yes
No
Stellite
16

Yes
Yes
Yes
Stellite
26

6-8

sible. Table 21 illustrates the evaluation


parameters and their penalty values.
In Table 23 the follow-up periods for each
implant group are shown.
With regard to Table 23, the short duration of
the observation periods for the four implant
groups should be emphasized. All the results,
especially those of group III, must be therefore
interpreted with caution.
This study does not provide definitive values,
but rather a precise picture of the implant status
at a given moment. It will be useful for further
reassessment.
Disturbances of sensation frequently occurred but mostly disappeared after a few months.
In group I, the sensation disturbances are almost all permanent. This is due to our operating
technique: the distal screws of the first implants
were placed in the middle of the retromolar
area. Although not longer than 8 mm, they
caused irritation or even damage to the mandibular nerve. Secondary sensation disturbances, as reported by OBWEG ESER (1959), were
never observed.
Two patients of group III complained of
habitual pain while chewing. This prognostic ally
rather serious symptom appeared very soon
after the implantation. It is probably a sign that a

Type IV
Total maxillar
and partial
mandibular
implants

distal screw is loose. The reason for it will be discussed later.


We believe that the significance of dehiscence
is minimal. Rather than a reaction of the body to
foreign material, it is much more likely to be a
result of poor vascularization.
A relation between abutment denudation,
pockets, plaques, and infection could not be
found. The increase in signs of infection in
group IV, despite the shorter observation
period, is very significant. We believe that it is
due to the lesser stability of the lighter implant
frame itself and to the loosening of the distal
screws.
In most cases, preoperative radiographic data
were either not available or not comparable, so
that an exact evaluation of the bone resorption
was very difficult. The distinction between resorption due to the operation alone or due to the
implant frame itself, and that due to the
physiologic process could not be made.
All 9 patients in group I who feature in stages
5 and 6 were the ones in whom distal screws had
been removed or re jected. We can therefore assume that instability produces chronic infection
and pathologic bone resorption (SPIESSL, 1974).
No pathologic bone resorption was observed in
any instance around the anterior screws, which
always remained stable.
135

Table 21. Synopsis of the criteria of evaluation and their penalty values
A. Subjective findings:
1. General appreciation
Very satisfied
Satisfied
Dissatisfied
2. Feeling of looseness or insecurity
Insecure on one side
Insecure on both sides
Loose on one side
Loose on both sides
3. Sensation disturbances
Hypesthesia on one side
Hypesthesia on both sides
Paresthesia on one side
Paresthesia on both sides
Anesthesia on one side
Anesthesia on both sides
4. Pain
In one temporomandibular joint
In both joints
Superficial diffuse
Superficial localised
On change in the weather
On chewing
Habitual on chewing
Permanent

Points
0
1
2
1
2
3
4
1
2
3
4
5
6

Maximal
20 points

1
2
3
4
5
6
10
20
Total A

B. Objective findings:
1. Denudations
Abutment neck 0- 2 mm (= stage 1 and 2) 0
1
Abutment neck 2- 5 mm (= stage 3)
3
Abutment neck 5-10 mm (= stage 4)
5
Abutment neck >10 mm (= stage 5)
1
Peripheral frame < 5 mm
3
Peripheral frame 5-10 mm
Peripheral frame > 10 mm
5
Over screw head on one side
5
Over screw head on both sides
10
Screw removed or rejected
10
2. "Periodontal" findings
Number of abutment surfaces with
pockets
> 3mm
0- 2 abutment surfaces
0
From
3- 5
1
From
6- 8
2
From
9-11
3
From
12-14
4
From
15-16
5
From
3. Infection
10
Fistula
10
Pus or granulation tissue
5
Inflammation of mucosa
4. Looseness
10
Instability

Total B

136

Maximal
40 points

Table 21 (continned)
C. Radiographic findings:

Stage 1. No pathologic findings


2. Localized or generalized bone
resorption less than 1 mm without
any other findings
3. Bone resorption from 1-3 mm
4. Bone resorption and pathologic
lowering of the implant 1 mm)
5. Bone resorption (1-3 mm) and
pathologic lowering (> 1 mm)
6. Pathologic lowering (>3 mm)

4
10

Maximal
40 points

18
28
40
Total C

Table 22. Results


No. of
Patients:

Age
<30
30-39
40-49
50-59
60-69
>69

Table 23. Follow-up periods

years
years
years
years
years
years

4
4
7
24
23
8

Group

No. of
implants

Follow-up in months
Extreme values Mean values

22

II
III

16
26
6

41-16
19-12
12- 2
19- 3

IV

26.5
17
5
10.5

Table 24. Subjective findings


Symptoms
Very satisfied
Satisfied
Dissatisfied
Insecure while chewing
on one side
on both sides
Feelings of looseness
on one side
on both sides
Hypesthesia
on one side
on both sides
Paresthesia
on one side
on both sides
Anesthesia
on one side
on both sides
Pain in one temporomandibular joint
In both joints
Superficial diffuse
Superficial localized
On change in weather
Occasionally on chewing
Habitually on chewing
Permanent

Groups
I
II
21
1

10
5
1

III

18
8

IV
4
1
1

5
3

1
2

2
1

1
1

4
2
3

3
1

2
2
3

1
3

2
1

137

Table 25. Objective findings


Symptoms

1. Denudations
No. of abutments
denuded over

0- 2 mm
2- 5 mm
5-10 mm
> 10 mm
< 5mm
Peripheral frame
5-10 mm
>lOmm
Over screw head on one side
Over screw head on both sides
Screw removed or rejected

(stage
(stage
(stage
(stage

1 and 2)
3)
4)
5)

Groups
I

II

III

IV

62

57

100

16

tn

30%

2
4
4
3

2
1

33%

5
6

4. Looseness
Instability
Fracture

Table 26. Radiographic findings

3
4

138

Groups
I
II

III

IV

11

No pathologic findings
Localized or generalized bone
resorption, less than 1 mm, without
5
any other pathologic findings
Similar to stage 2, with bone
resorption from 1-3 mm
4
Similar to stage 3, with pathologic
lowering of implant frame less than
1 mm
2
Similar to stage 4, with pathologic
lowering between 1 and 3 mm
6
Bone resorption or pathologic
lowering of implant frame more
3
than 3 mm

11%

!l

1
1

~l

3%

24%

5
7
4
3
1
1

3. Infection
Fistula
Pus or granulation tissue
Localized or generalized inflammation of mucosa

1
2

~I

2. "Periodontal" findings
Pockets
> 3 mm around abutments
0- 2 abutment surfaces (of 16)
from
from
3- 5 abutment surfaces (of 16)
from
6- 8 abutment surfaces (of 16)
from
9-11 abutment surfaces (of 16)
from
12-14 abutment surfaces (of 16)
from
15-16 abutment surfaces (of 16)

Stage X-ray findings

-1

2
3
4
4
2
1

4
12
4
46%
2
1

2
4
4

6
4
9

1
1
2

1
1

30%

52%

After having assessed all 70 patients we calcula ted for each of them and then for each group
an "implant-score."
Group I 22 Implants Average score 33
Group II 16 Implants Average score 18
Group III 26 Implants Average score 13
Group IV 6 Implants Average score 22
For the assessment of the true value of an implant, however, the duration of observation
should be taken into consideration. The time
factor has been introduced into table 27 as the
denominator.
Table 27.
Average Penalties
Mean coefficient = - - - - .
Duration of Observation (months)
33

Group II

-=

1.0

Group III

-=

2.6

Group IV

-=

2.2

18
13

S
22

10

This mean coefficient merely represents an


attempt to measure the rate of complications per
unit-time. These scores are relative and only
meaningful in that they can be compared with
each other and later with the results of other,
similar evaluations.
Comparing the results of our study with the
actual clinical status of our implants, we decided
to classify them according to a six grades scale.
The limit of failure was set at about 60 penalty
points. The following stages were then defined
(Table 28):
Table 28. Evaluation scale
Penalty

Result

0-12
13-24

Very good. Perfect, or only minimal faults.


Good. Some minor faults. Implant well
tolerated.
Fair. Many imperfections. Implant survival
not in danger. Some corrections desirable.
Poor. Many major faults. Implant survival
dubious. Corrections mandatory.
Very poor. Implant must be removed.
Corrections inadequate.
Failure. Implant already rejected or to be
removed very soon.

2S-36
37-48
49-60
61-72

Table 29.
Results

Groups
I

II

III

IV

i}

Very good 7}
7}
IS} 88%
SO%
Good
2 43% 6 81% 8
1
3
2
Fair
3
1
2
Poor
Very poor 4}
6%
Failure
3 33% ~}
Already
removed 1

1.27

Group I

26
18

In accordance with this scale, our implants


were classified as follows (Table 29):

2.3. Discussiou
Our first type of implant (group I) can be
compared with other, conventional subperiosteal implants. Their technical characteristics, their clinical evolution as well as their prognosis resemble those described in previous papers. Pain, extensive exposures, infections,
looseness of the distal ends of the implant, and
pathologic bone resorption at the same level are
most characteristic. All these symptoms have
the same reason: Instability.
Our second type of implant (group II) has
been described elsewhere as a "functionally
stabile implant" (SPIESSL, 1974). The main
symptoms are the same but their frequency
changes. Pain nearly disappears. All implants
are stable. Exposure becomes predominant,
since infection and bone resorption are always
found to be in relation to wide dehiscence,
mostly at crest level. This may be caused
through the extremely large perforated struts,
which are one of the characteristics of this type
of implant.
Only our type III implant (group III) merits
the name of Dynamic Compression Implant
(DCI). The duration of observation, however, is
too short to draw any definitive conclusions about it.
139

The use of new anterior dynamic compression


screws was accompanied by some complications. In those patients with extreme atrophy,
the porotic bone offers a poor retention for the
distal "oblique" screws. As the action of the anterior screws becomes predominant, there is a
tipping of the implant which causes a loosening
of the posterior screws. In several cases, a small
fistula appeared just above a distal screw head
1-3 months after implantation. As a rule, this
fistula healed rapidly, after the loose screw had
been changed or tightened. In conclusion, we
still think that the absolute stability of the implant is of primary importance. We believe, that
bony atrophy, epithelial migration, infection,
and finally rejection occur only where micromovements result in chronic irritation.
Since this study, our method of fixation has
been further improved in that we now use four
similar DC screws, which all grasp two healthy

140

thick cortices. As previously, two screws are introduced horizontally into the chin. The other
two are also fixed horizontally in the posterior
part of the jaw.
A further study will deal with this new type of
implant.

2.4. Summary
There were 70 patients with 3 different types of
subperiosteal implants assessed with conventional methods. The analysis of the clinical features by means of a new evaluation system produced useful comparisons which led us to develop a new type of implant fixation. Since instability results in chronic irritation, and thus in
infection and finally rejection, we think that absolute stabilization of the implanted structure is
mandatory, hence the so-called Dynamic Compression Implant (DCI) (SPIESSL, 1974).

3. Experimental Studies of the Load-Bearing Properties of Implanted


Prostheses
By R. Schmoker, D. Cornoley, W. Huser, B. Spiessl, H. Graf

3.1. Introduction

3.2. Theoretical Principles

The basis for the successful incorporation and


good tolerability of an implant is its stability. By
contrast with previous subperiosteal and enossal
implants, the DCI is stable even under functional stress immediately after implantation; it is
not necessary to wait for a healing period to
elapse. Apart from elements of the subperiosteal implant (support on the surface of the
bone) and of the enossal implant (fixation to the
bone with screws), the main principle of the DC!
is fixation under pretension. Processes which
can occur with implants include inflammation at
the point of exit of an abutment, the growth of
mucosal epithelium below the implant, and
foreign body reaction with replacement of the
bony implant site with granulation tissue or connective tissue. These processes can be prevented
or at least delayed for years, if the implant is stable under functional stress.
The concept underlying the stability is that
the static fixation forces produced in accordance
with the principles of compression osteosynthesis must exceed the lifting forces occurring
during functional stress. These lifting forces
were determined for a given stress in experiments using isolated cadaver mandibles (see p.
144). The stress chosen was in the order of magnitude of the masticatory forces measured in
dentulous subjects. It is interesting to compare
the values for stress, which were previously
measured in dentulous subjects with those measured in a patient with an implanted prosthesis
in the upper and lower jaw.

In the case of a dentulous subject, the maximum


masticatory force is limited by the sensitivity of
the periodontium. In the case of subjects with
total or partial prostheses, the limiting factor is
the firmness with which the denture remains in
place. Lifting forces act on the denture in accordance with the leverage principle. These forces
are intensified because the vertical masticatory
force is resolved into transverse and sagittal
components, the magnitude of which depends
on the cusp-fissure situation and the angle of inclination of the masticatory surfaces of the teeth.
The components in question cannot be determined exactly in vivo, either in dentulous subjects or in those with prostheses, because the
basis for measurement, tooth or prosthesis, is
displace able to a greater or lesser degree. However, a patient with stable implants in the upper
and lower jaw gives us the opportunity for the
first time of making an exact measurement of
the transverse and sagittal masticatory force
components, the measuring device being in effect screwed to the bone via the implant. Such
firm fixation with screws also provides stable
reference points for measurement of movement
of the temporomandibular joint and of the jaw.
As in the case of a naturally dentulous subject
or one with dentures, the maximum masticatory
force can be measured with a simple
dynamometer. To measure the different components of the masticatory force, however, a device is required which measures the components
separately in vertical, transverse, and sagittal di141

rections. To determine the functional forces


created during chewing, the measuring devices
must be incorporated in a special prosthesis. The
devices should disturb the patient as little as possible while he is chewing.

3.3. Method of Measurement

The forces acting on the abutments of an implant were measured in a patient fitted with
rigidly fixed implants in the upper and lower
jaws. The maximum masticatory force was measured in the area of the first molar using a
dynamometer with a special attachment to bite
on. This consisted of two metal bars provided
with exchangeable synthetic plates, and via
these metal bars the masticatory force was
transferred to an annular dynamometer which
recorded the highest force registered (Fig. 142).
The height of the attachment to bite on was
15 mm. The maximum masticatory force was
also measured for purposes of comparison in
five subjects with natural dentition.
Special measuring prostheses were made 1 to
determine the components of the masticatory
force (Fig. 143). A wax prosthesis, which cor-

Fig. 143. Measuring prostheses for upper and lower


jaws

Fig. 144. Miniature dynamometer and gold masticatory surfaces which can be fitted to it

Fig. 142. Dynamometer with biting attachment,


measuring bars and dial

By W. Huser, Zahntechnisches Labor, 4600


Olten, Switzerland.
1

142

Fig. 145. Measuring prosthesis with miniature capsule- type dynamometer inserted (left); masticatory
surface fitted to the above (right)

responded with the normal implanted prosthesis


in the opposing jaw, was set up in a Condylator.
Removable miniature dynamometers were inserted in place of the distal premolars. Masticatory surfaces were modeled on them. Several
types were molded in gold, and could be fitted
on the miniature dynamometers (Figs. 144,
145). The measuring prostheses were tested in
the Condylator and then in the patient for occlusal interference outside the masticatory surfaces equipped for force measurement. The
measuring prostheses must always be employed
in conjunction with a normal prosthesis. The
measuring device was a quartz crystal multicomponent dynamometer\ with which the
three spatial components of a force could be
measured separately. The miniature capsules
were connected to an amplifier and from there
to a recording device.
To determine the maximum masticatory
force components, a measuring prosthesis and a
normal prosthesis were inserted and the patient
was requested to bite as hard as possible, on the
right or left, mesially or distally. The functional
masticatory force components were determined
by continuously recording the forces acting
while the subject was eating dried meat.

3.4. Results
The maximum masticatory force in the molar
area, measured with a simple dynamometer, was
40-75 kp, giving a mean of 58 kp (left side
40-66 kp, mean 51 kp; right side 55-75 kp,
mean 66 kp). The values for the maximum masticatory force in the comparative group varied
from 22 to 75 kp with a mean of 40 kp.
On simultaneous measurement in all three directions, the maximum components of masticatory force were 20 kp in the vertical direction, 11 kp in the transverse (greater to the left
than to the right), and 5 kp in the sagittal direction (5 kp on protrusion, 3 kp on retrusion).
1 Produced by Kistler Instrumente AG, 8408
Winterthur, Switzerland.

High values were also recorded for the force


components during mastication. The results
must be analyzed in greater detail and compared
with those obtained in subjects with natural
dentition, and those with partial or total prostheses.

3.5. Discussion
The values recorded for masticatory force are
strikingly high. They are quite comparable with
the values from the group with natural dentition.
In terminal occlusion, the values are probably
even higher than with the 15 mm biting attachment. Of the components of masticatory force,
those in the transverse and sagittal direction in
particular were very high. Such values can never
be obtained with prostheses lying on the mucosa
because of leverage and loss of grip of the dentures.
All three components taken together do not
amount to the complete maximum masticatory
force determined with the annular dynamometer. The reason is that with the measuring
prostheses, not only the teeth with the measuring devices but also the other came into slight
contact. The transverse and sagittal forces measured were less than those exerted in the study
on implant stability using cadaver mandibles
(see p. 144).

3.6. Summary
Using specially made measuring prostheses with
miniature dynamometers incorporated, the
maximum components of masticatory force and
the force components occurring during normal
chewing were measured in vertical, transverse,
and sagittal directions in a patient with rigidly
fixed implants in the upper and lower jaws. Because of the stability of the prostheses, achieved
by securing the implant to the bone with screws,
very high values were recorded, especially in
transverse and sagittal direction.
143

4. Experimental Studies on the Stability of the Dynamic Compression


Implant (DCI)
By R. Schmoker

4.1. Introduction
Clinical experience has shown that the success of
the implantation of an allenthetic material depends on the stability of fixation. In principle,
the implanted framework supporting a prosthesis is subject to the same conditions as a plate
implanted to achieve rigid internal fixation in
fractures.
The search for new implant materials to prevent infections around the abutments will be difficult, if not totally unsuccessful, in the case of all
methods of implant fixation which are not based
on the principle of absolute stability. It will
hardly be possible to find a more physiologic
material than a vital tooth, but even with the vital tooth, mechanical movement results in infection.
The principle of the rigid implant is based on
experience gathered in osteosynthesis, as summarized in the basic tenets of the Association for
the Study of Rigid Internal Fixation (MULLER
et aI., 1969).
In view of the importance of stability, the
forces acting between the implant and the jaw
bone must be investigated in greater detail.

4.2. Theoretical Considerations


Under functional stress, both axial and transverse forces are exerted on the abutments. The
axial forces have a stabilizing effect on the
abutments in the middle of the crest, but the
144

transverse forces are opposed to these stabilizing forces. When the implant is simply
positioned on the alveolar crest, it is raised from
its base by mastication on the opposite side. This
lifting force depends on the masticatory force,
the angle of inclination of the masticatory surfaces of the teeth, the length of the abutment,
the position of the abutment in relation to the
middle of the alveolar crest, and the distance of
the opposite side from the force-bearing abutment. Due to the length of the abutment on the
one hand, and the distance of the opposite side
from the force-bearing abutment on the other
hand, the lengths of the levers are different, and
the resulting force will equal only a fraction of
the masticatory force.
To achieve functional stability, the resulting
lifting forces must not exceed the fixation forces.
The sum of the lifting and fixation forces may
rise and fall, but it must not fall below zero. The
lifting forces can be restricted by adhering to the
principles of static mechanics: the abutment
must be mounted on the middle of the crest; the
implant must be extended to the broad supporting areas lateral to the middle of the crest, and
must grasp the lateral buccal surface and a narrow lingual margin in the area of the symphysis
(SPIESSL, 1974).
The main components of the stability are static
friction and fixation with screws. To produce the
static friction, the two principles of producing
compression by means of screws in accordance
with the principles of compression osteosynthesis can be employed.

In the first, the compression is directed along


the length of the screw in accordance with the
lag screw principle; and in the second, the compression is directed transversely to the length of
the screw according to the pressure screw principle. The latter principle involves the excentric
insertion of the screw into a DCP hole made according to the spherical gliding principle (PERRENet aI., 1969) (Fig. 146 and see Fig. 29). The
DCP hole in question is positioned transversely
to the rim of the mandible (see Fig. 138).

Fig. 147. Fixation of implant by axial force produced


by screw inserted in vertical direction in area of linea
obliqua

Fig. 148. Fixation of implant by screw inserted in


horizontal direction into DCP hole (excentrically toward base of chin). DCP hole is positioned transversely to mandible. (a) Hole drilled in bone is
positioned excentrically toward rim of mandible, (b)
When screw is tightened, DCP hole is centered and
implant is moved toward rim of jaw, and thus is pressed onto alveolar crest
Fig. 146. Spherical gliding principle

In the case of lag screw compression, the implant is pressed onto the bone foundation axially
by the action of the screw head in the gliding
hole of the implant (Fig. 147 and see Fig. 129).
The resistance to lifting forces is limited by the
resistance of the cortical thread holes in axial direction. It is thus dependent on the degree of osteoporosis and the care taken in drilling the

holes and cutting the threads. It is, however, to a


large extent independent of the length of the
screws.
By contrast, in the case of pressure screw
compression with the DCP hole, the screw must
be inserted perpendicularly to the direction of
the desired force pressing down the implant on
the alveolar crest (Fig. 148a). The screw is inserted excentrically into the DCP hole
(Fig. 148b), but when it is tightened, the DCP
145

hole is centered. What happens is that the implant moves in the direction of the rim to the
mandible under the forces arising because of the
inclined plane. The implant is thus pressed onto
the surface of the crest (Fig. 148). In this case,
the resistance to lifting forces acting on the
abutments is limited by the resistance of both
parts of the cortex in transverse direction.
Therefore, while it also depends on the degree
of osteoporosis and the care taken in drilling the
holes and cutting the threads, it also depends on
the distance of the two parts of the cortex from
each other, in other words, on the length of the
screw.
Depending on the horizontal and vertical distance of the screws from the middle of the crest,
a lifting force acts on the parts of the implant
removed from the screws.
The fixation force increases the further the
screw is positioned basally from the crest and the
nearer the head of the screw lies to the perpendicular line through the middle of the crest.
Conversely, the lifting force in the part of the
implant farthest from the screws increases the
nearer the screw is basally to the crest and the
farther away the head of the screw is from the
perpendicular line through the middle of the
crest.
The most stable conditions in a given jaw can
be expected when all screws are inserted as pressure screws as basally as possible. These static
forces pressing on the implant form the basis of
the absolute stability of the implant. They must
be greater than the dynamic functional forces.

4.3. Method of Measurement


The static fixation forces created by the threedimensional screw fixation were measured at
different points between the implant and the
bone. The effect of the dynamic forces was also
investigated. For this purpose, the decrease in
the static fixation forces caused by the dynamic
forces acting axially and also by those acting
transversely on the abutments was measured.
High forces were employed to test the rigidity of
the framework implant.
146

Fig. 149. Implants a) with two holes for lag screws and
two DCP holes, b) with four DCP holes at base of
mandible

Miniature capsule type dynamometers 1 were


fitted between implane and bone in edentulous
cadaver mandibles. The implant had four abutments and four screw holes (Fig. 149), consisting of two excentric ones at the base of the chin
for the pressure screws, and two conical ones at
the oblique line to receive the lag screws. The
fixation was performed using the ASIF instrument set for rigid internal fixation of the mandible 3 .
Firstly, the fixation force was measured for
each screw separately and then for the screws in
combination. In a further test, the abutments
were subjected to axial stress. The magnitude of

1 The force-measuring instruments were special


miniature capsule-type dynamometers, produced by
the Kistler Instrumente AG, CH-8408 Winterthur.
2 The implant was produced by Huser, Zahntechno Labor, CH-4600 Olten, Switzerland.
3 Obtainable from Synthes, CH-4437 Waldenburg, Switzerland.

FIXATION FORCE
IN KP

50

]0

10

1----+-+=l-'r--.---r------r----r-~:..J___+__ ~~~~REMENT

Fig. 150. Measurement of fixation forces at various locations on implant. Values for
forces are indicated by bars

the force employed was read from the instruments below the abutments.
The resulting lifting force on the other side
and under the other abutment on the same side
was determined from the change in the fixation
pressure forcing the implant to the bone. In a final test, the abutments were subjected to transverse loading by means of a spring balance, and
again the change in the fixation pressure forcing
the implant to the bone was determined on the
same and on the opposite side.

4.4. Results

The fixation force of the separate screws was


20-30 kp for the lag screws, and for the pressure
screws 15-25 kp. The fixation force of the
screws in combination was 10-20 kp between
the lag screw in the linea obliqua and the pressure screw at the base of the chin. Between the
two pressure screws in the middle of the front
part of the mandible it was 40-50 kp (Fig. 150).

The values for the force produced by a screw in


axial and transverse directions agree with the
values obtained in experiments on compression
osteosynthesis in the mandible. The force depends on the thickness and strength of the bone.
The force acting transversely to the length of the
screw originates in the transformation of the
axial force on an inclined plane, and is always
somewhat less than the axial force. In addition, a
lifting force in the part of the implant farthest
away from the screws is deducted. The magnitude of the lifting force depends on the distance of the screw head from the crest and from
the perpendicular line through the middle of the
crest. This lifting force component also explains
the low value recorded for the lag screw in combination with a pressure screw. The explanation
of the lower fixation force in the area of the lateral teeth by comparison with that in the area of
the front teeth probably lies in the low resistance
to bending of the implant in the area of the lateral teeth. This is due to the great distance of the
screws from each other in the latter area, and the

147

weakness of the framework at the point of exit of


the mental nerve.
To permit the development of high forces and
obtain a firm hold for the screws, it is vital that
the screw should be anchored in both cortices. In

this connection the mandible may be compared


to a tube filled with foam rubber. Screws which
grasp only one wall of the tube are unstable,
especially when subjected to forces acting transversely to the length of the screw. With axial

FIXATION FOR:E
IN KP

80

80

70

70

60
[l(NANOMETER
UNDER LEFT
DISTAL ABUTMENT

I
I

50

30

20

40

30

20
10

80

III

70

70

60
DVNANOMETER
IHlER RIGHT
DISTAL ABUTMENT

60
50

40

10

60

I'

50

50

40
30

40
30

20
10

20
10

FIXATION OF
MtANT Wl1I-I
SCREWS

RIGHT ABUTMENT
SUBJECTED TO AXIAL
LOADING OF 50 KP

LEFT ABUTMENT
SUBJECTED TO AXIAL
LOADING OF 50 KP

Fig.15I. Abutment subjected


to axial force of 50 kp - no reduction in fixation force is observed on opposite side

FIXATION FORCE

NKP

DVNANOMETER
IHlER LEFT
DlSV.L ABUTMENT

80

80

70

70

60

60

50

50

40

40

30

30

20
10

DYNANOMETER
UNDER RtGHT
DISTAL AIJJTMENT

20

10

80

80

70

70

60

60

50

50

40

40

30

30

20
10

FIXATION OF
IMR.ANT WITH
SCREWS

148

Fig. 152. Abutment subjected


to transverse force of 25 kp.
o On loaded side and on opposite side, only slight deviations
in fixation force were obLEFT ABUTMENT
SUBJECTED 10 TRANSserved
VERSE UllDING OF 25 KP
20

10

RIGHT ABUTMENT
SUBJECTED 10 TRANSVERSE LOADH; OF 2S KP

loading of one abutment with forces up to 50 kp,


not the slightest reduction in the fixation force
on the other side of the implant was observed
(Fig. 151). When a transverse force of up to
25 kp was exerted on the abutment, slight decreases of less than 1 kp were observed in the
fixation force both on the side where force was
exerted and on the opposite side of the implant
(Fig. 152). The minor effect of the axial and
transverse forces exerted on the fixation forces
in the implant is due to the favorable form of the
implant with regard to the positioning and
length of the abutments and the extension of the
supporting surfaces.
4.5. Summary
It has been shown clinically that the healing pro-

cess encountered at the site of a subperiosteal


implant which is implanted as a sustainer for

dentures is greatly dependent on the method of


fixation. The inflammatory reactions around the
abutments are less pronounced and epithelial
attachment enhanced if an absolutely rigid fixation exists between the implant material and the
mandible.

In order to study the stability of a framework


implant under different conditions, measurements were undertaken on isolated cadaver
mandibles. The dynamic forces acting on the
fixed implant in an axial and transverse direction
were recorded using a specially designed
dynamometer. The effects on the static forces of
fixation were registered and evaluated. It could
be demonstrated that the forces of fixation
which were achieved by applying the general
principles of compression osteosynthesis were
many times greater than the shearing forces encountered at the time of functional stress.

149

5. Histologic-Morphometric Investigations into Cadaver Mandibles.


The Bony Structure as a Site for an Implant Prosthesis
By C. Bassetti, W. Remagen and B. Spiessl

5.1. Introduction
Following positive experience with rigid internal
fixation in the treatment of mandibular fractures
(SPIESSL and SCHROLL, 1972), the method of
functionally rigid implantation was successfully
introduced (SPIESSL, 1974). This raised the
question of the conditions for implantation offered by the bony structure of the lower jaw. By
means of a histologic-morphometric investigation of the bony structure of edentulous and
fully dentulous mandibles, the present paper
attempts to provide some initial basic facts to
answer the question.

These parameters, and the relevant theoretical


principles, are derived from investigations by MERZ
(1967), MERZ and SCHENK (1970), DELLING (1973).
In addition, 200 !-Illl microsections were obtained
from each preparation and subjected to microradiography (D2 Agfa-Gevaert material testing film,
25 kV, 150 mAs, 1 m focus-film distance with
0.6 mm focus) and the pictures obtained were enlarged 2. The photographs were used for measurement of the thickness of the cortex (mean value from
individual measurements made at intervals of 1 em
vertically to the outer contour of the bone, divided by
the photographic enlargement factor). They were also
used for documentation.

5.3. Results

5.2. Material and Method


The regions of the canine and the second molar were
investigated in 15 edentulous and 3 fully dentulous
cadaver mandibles t. Serial cross sections of 5 !-Illl
thickness were prepared from the bones which were
embedded in methyl methacrylate and were not decalcified (SCHENK, 1965). Histologic-morphometric
evaluation of the cross sections was undertaken, the
following parameters being investigated:
1. Density
(percentage of bony substance in the whole volume
of bone)
2. Specific surface
(bone surface in mm 2per mm 3 pure bone volume)
1 The material was obtained from autopsies performed at the Pathology Institute of the University of
Basle. We are grateful to Prof. H. U. Zollinger. It
should be noted that the mandibles were free of signs
of general or local bone diseases.

150

Tables 30 and 31 give the mean values with


standard deviations and regression coefficients r
for the investigated parameters 3. The regression coefficient r represents the linear reduction
(-value) or increase (+value) of the parameter
as a function of increasing age. The values
marked with asterisks are statistically significant
(* <": 5%, ** <": 1 % probability of error). Figures
153-156 show the values of the investigated
parameter for each individual with the regression
gradients of the edentulous group. The values
for the fully dentulous cases are not taken into
account and are given for information only.
2 We are grateful to Dr. J. Hug, Radiography
Department, Kantonsspital, Basle, for the contact
radiographic pictures.
3 We are grateful to Dr. E. Niiesch, Sandoz Ltd,
Basle, for assistance with the statistical evaluation.

Table 30. Morphometric values for the whole cortex: mean values
standard deviations, linear regression coefficient

Canine area

Density %
Specific surface
mm2
mm3

Second molar
area

Density %
Specific surface
mm2
mm3

Edentulous
cases

Fully dentulous
cases

95.6 1.7
-0.677**
2.4 1.2
0.689**

96.4 1.1
-0.478
2.0 0.4
0.383

96.4 1.2
-0.558*
2.1 0.5
0.612*

96.6 0.9
-0.75
2.0 0.2
0.592

* :<: 5% probability of error


** :<: 1 % probability of error

Table 31. Morphometric values for the whole cortex: mean values
standard deviations, linear regression coefficient

Canine area

Density %
Specific surface
mm2
mm3

Second molar
area

Density %
Specific surface
mm2

Edentulous
cases

Fully dentulous
cases

34.4 12.2
-0.321
12.4 3.5
0.502

44.3 5.5
-0.987
8.1 0.9
0.252

18.8 8.8
-0.715**
17.1 4.4
0.633*

45.4 23.9
-0.717
7.51.7
0.006

mm3
* :<: 5% probability of error
** :<: 1% probability of error

151

Canine area
cortical IS 06
(r = -0,677**)

611t. fully dentulous cases

100

edentulous cases
H

.r'\

,... r'\

vCf'

80

60

,.

-l..

20

40

30

-r--..--r-.---...

I-

20

spongiosa. lit.
(r= -0,321)

50

60

l-

80

70

years

Fig, 153

Canine area
611t. fully dentulous cases

o. edentulous cases

30

E
E

spongiosa. lit.
(r= 0,502)

520
>

In
C1I

"
VI

...

~ 10

Q.
<f)

-----

20

40

30

o.

lit.

60

50

80 years

70

Fig. 154

2nd molar area


corticalis 06
(r = -0,558*)

611t. fully dentulous cases

100

rz>U v

v~

corticails 06
(r=0689")

""Or'\

()

~A

edentulous cases
~

vu

0,...

r'\,...,...

0
0

80

~ 60
>-

~
c

spongiosa. lit.
(r = -0,715")

~ 40

~
20

20

152

30

40

r----.

50

~
I-a.

60

q-

~ r-e
70

80 years

Fig. 155

2nd molar area


1:;. .. fully dentulous cases
edentulous cases

o.

sponglosi ...
(r = 0.633*)

E
;:,-

-- ~
~
~
.,...., ~

...

0.612 *)

;:20

-(j)

~:;
Vl

'5

10

cortlcalis 01:;.
.. (r=

(j)

Fig. 156

20

V'

30

The additional measurement of the thickness


of the cortex shows a narrowing attributable to
age, in the region of both, the canine and the
second molar, teeth.

5.4. Discussion

The low number of fully dentulous mandibles is


due to their low rate of occurence in autopsy
material. A comparison of the results of both
groups is thus out of the question from the outset.
Osteoporotic changes in the bone are observed in all individuals after the age of 45, the
so-called osteoporotic threshold occuring about
the age of 62 (VITALLI, 1970). The mandible is
also subject to this process. It has been shown by
densitometric (ATKINSON and WOODHEAD,
1968) and microradiographic (MANSON and
LUCAS, 1962) studies that the density of the
lower jaw bone decreases after the age of 50, the
change being more marked on the alveolar side
than on the basal side of the mandible. The results show that even in our relatively small
group, the tendency to atrophy of the lower jaw
bone attributable to age is apparent. It is expressed by the reduction in density; at the same
time, the specific surface increases. The higher
the value for the specific surface of the cancel-

40

50

60

,.,"'I.T"'" 0I:l
70

80 years

lous bone, the lower the corresponding mean


diameter of the trabeculae. The atrophy of the
bone is very pronounced in the area of the second molar, where the cancellous bone is almost
totally absent in many cases (Fig. 157, 159). By
contrast, the canine region exhibits a mainly
solid bony structure into advanced age
(Fig. 158).
A relatively slight decrease in the density of
the cortex is observed in old age,with a substantially greater loss of thickness: the low standard
deviations show how minimal the individual
differences are due to old age. In the region of the
linea obliqua in particular, the cortex of the
edentulous jaw is very thin, often as a result of
resorption of bone due to inexact prosthesis
construction (HAUPL, 1960) (see Fig. 157,159).
On the other hand, greater individual differences are observed with regard to the density
and distribution of the cancellous bone, as the
somewhat high standard deviations of the cancellous bone show. For this reason, comparison
with measured values from other bony structures (e. g., the iliac crest) must be cautious.
The position of the mandibular canal is not
always constant in the region of the second molar in edentulous jaws. It is often found centrally
or even buccally. It may be concluded that single
implants should not be emplaced in the region of
the second molar. In this respect, the canine region presents no contraindication.
153

Fig. 157. Second molar region in 68-year-old individual. Tubular type bone. Cancellous bone consisting of only few trabeculae. Mandibular canal central.
Cortex thin at linea obliqua, and alveolar crest narrowed. (6.5 x original size)

Fig. 158. Densely structured canine region in 61year -old individual. Broad cancellous tra beculae, surrounded by thick cortex, especially on lingual side.
(6.5 x original size)

Fig. 159. Second molar region in 73-year-old individual. Cancellous bone markedly reduced. Mandibular canal on buccal side. Cortex particularly thin
at linea obliqua. (6.5 x original size)

154

Fig. 160. Canine region in 30-year-old fully dentulous


individual. Note thin cortex on buccal side of canine
root. (4.5 x original size)

Fig. 161. Second molar region of same individual. Extremely dense cancellous bone in caudal area. Mandibular canal on lingual side. (4.5 x original size)

At the present time, only the functionally stable implant prosthesis seems to offer long- term
success because of its absolute stability: independently of the density and distribution of the
cancellous bone, the structural character of the
cortex provides it with an optimally firm base.

By positioning the distal fixation screws basally,


instead of in the area of the oblique line as
was the case until recently, a more stable fixation can be achieved with a greater degree of
protection of the mandibular canal.

155

6. A Total Mandibular Plate to Bridge Large Defects of the Mandible


By R. Schmoker, B. Spiessl and R. Mathys

6.1. Introduction

A special plate is required for the treatment of


defect fractures and to stabilize bone grafts following partial resection in the treatment of
tumors of the mandible. The following demands
are made on such a plate:

1. Increased stability: two fragments have to be


held absolutely rigid without the aid of interfragmentary compression.
2. The healing of avulsed bone fragments of
cancellous bone or of transplanted bone chips
depends on immediate revascularization from
the surrounding tissue. Therefore, impairment of revascularization by the plate must be
reduced to a minimum.

3. A high degree of malleability: the plate has to


be fitted to large areas of the mandible.
All plates with an L- or V-shape in cross section are insufficiently malleable. Therefore a
large number of preformed models are required.
The L- or V-shaped plate quite definitely makes
the revascularization difficult. Providing the
plate with holes has no great advantage, because
despite the particular shape, the plate requires a
certain thickness, with the result that the necessary contact between the bone and surrounding
soft tissues is impeded.
Initially, normal ASIF forearm plates were
used (Fig. 162). These have the disadvantage
that the screw holes are too far apart, and
the screws themselves are too large for the
mandible.

Fig. 162. Treatment of gunshot wound with forearm plate

156

In a further development, the size of the plate


remained unchanged, but it was provided with
holes to take screws designed for small fragments (Fig. 163). To permit the insertion of as
many screws as possible in a bone fragment, the
holes were not positioned in a line, but at angles
to one another l . Clinical experience with the
plate (Fig. 164) has been positive, especially
with regard to stability (SPIESSL, 1976). In con-

nection with the transplantation of bone grafts,


it has been observed that while the lingual side
of the graft is well incorporated, the buccal cortex is resorbed and not remodeled. This is regarded as illustrating a disturbance of the process of revascularization at the side where the
plate is. Although the plate can be readily bent
using the ASIF plate pliers, adaptation to the
mandible can be difficult in certain cases.

Fig. 163. Total and hemimandibular pre bent defect bridging plate

Fig. 164. Treatment of a gunshot wound with a mandibular defect bridging plate
1 Obtainable from Synthes Ltd., CH-4437 Waldenburg.

157

6.2. The New Plate


A new plate was developed in collaboration
with the MATHYS Co. 1. It is twice as thick as the
normal rigid internal fixation plate for the jaw,
but equally wide. Thus, with this plate, substantially better revascularization is possible in suffi-

ciently stable conditions (Fig. 165). To improve


the malleability, V-shaped notches are made on
the edges of both sides of the plate between the
holes. Therefore, by using special pliers
(Fig. 166), the plate can also be bent edgewise.
The plate is thus bendable in all directions, and
can be adapted to any part of the mandible. The

Fig. 165. Total prebent mandibular defect bridging plate; bendable three-dimensionally

Fig. 166. Pliers for bending


three-dimensionally bendable
defect bridging plates: (a)
bending edgewise, (b) bending over the surface

1 Obtainable from R. Mathys,


Instrumentenfabrik, CH-2544 Bettlach.

158

straight plates vary in length from 8 to 24 holes.


Furthermore, preformed plates are available in
3 sizes for the left or right side of the mandible,
for the whole mandible, and even with a re-

placement for the condylar head (Fig. 167).


Animal experiments and the first clinical experience have been very satisfactory.

Fig. 167. Three-dimensionally bendable defect bridging


plates: (a) prebent plates, total, hemimandibular and with
replace of the condylar head,
(b) straight plates

159

7. Anatomic Reconstruction and Functional Rehabilitation of


Mandibular Defects after Ablative Surgery
By B. Spiessl, J. Prein and R. Schmoker

7.1. Introduction

7.2. Case Report

One ofthe major problems after extensive ablative surgery, including partial or total mandibulectomy, is apart from reconstruction of the
bony continuity, the best possible restoration of
masticatory function. This concerns mainly the
fixation of dentures in the lower jaw. On the
basis of increasing experience, together with a
precise and very special technique in the field of
bone surgery, in accordance with the ASIF principles, we have been successful in solving the
two main problems of bone replacement and
denture fixation. Special instruments and implants have been developed for this purpose as
can be seen in the preceding article. The details
of this technique are explained in the following
with a description of a few cases.

Our first patient, aged 38, had a partial resection of


his lower lip because of a small cancerous lesion. Only
5 months later he developed palpable lymph nodes on
both sides of his neck. Because affixation to the mandible on the right, a partial mandibulectomy was performed on this side and also a bilateral neck dissection. Radiation with a full tumor dose followed on
both sides. When the patient was free of recurrence 2
years later, a bone transplant from the iliac crest was
emplaced and fixed with an ASIF - forearm plate. xray examination 5 months later, showed signs of
loosening of the screws and bone resorption, so that
we had to remove the transplant and the plate. A new
stabilization with our special plate for mandibular defects was performed 2 years thereafter (Fig. 168) (see
Chap. D 6). Up to now, 6 months later, function remains good, and no signs of loosening or infection are
detectable. In the near future the bone transplantation will be undertaken.

Fig. 168. Bridging of defect of


this patient's right mandible
by means of special plate,
which can be bent in all dimensions with special pliers
(see Fig. 166). Ends of bone
are absolutely stably fixed in
their original (anatomically
correct) position with four
screws on each side

160

The next patient was a 70-year-old man, who presented with a swelling of his left mandible between the
canine tooth and the second molar. By means of a
biopsy, an ameloblastoma was diagnosed. We performed a left partial mandibulectomy and reconstruction with a resection plate (Fig. 169a), and at the
same time we restored the bony continuity by means
of a transplant from the iliac crest. Although there

the right side. Because of a palpable lymph node fixed


to the mandible, she underwent a partial mandibulectomy, together with the tumour resection and a radical neck dissection. The osseous defect was bridged
with a normal ASIF forearm plate with eight holes.
No bone transplantation was performed at the same
time because of the high risk of recurrence. Only 3
months later, the patient developed an infection, due

Fig.

169 (a). Resection plate


in situ, thus preparing primary bone grafting without
intermaxillary fixation. Cortex-cancellous bone graft will
be fixed to plate with screws
on its lingual side and in between stumps of mandible,
(b) Plate was removed after 6 months. Transplant is
well revascularized and incorporated. Graft is able to bear
weight
was an opening into the oral cavity, primary healing
occurred. Only 6 months after the first operation we
removed the plate (Fig. 169b). Complete bony union
on both sides of the transplant was seen (Fig. 170). In
this case it was no problem to supply the patient with a
dental prosthesis.
The third case was a 63-year-old woman suffering
from a cancerous lesion of the floor of the mouth on

to loosening of the screws, so that the plate had to be


removed. There was no sign of recurrence, however.
On the other hand, although the plate was in place
only a short time, we had the advantage of no cicatricial retraction. Then 10 months later, mainly because
of the patient's impatience, an osteoplasty together
with stabilization by means of our special plate (see
Chap. D 6) was undertaken. A longer plate was used

161

Fig. 170 (a). X-ray taken


immediately after first operation. Graft, which is fixed to
plate, is well visible. No intermaxillary fixation, (b)
X-ray control after removal of
plate. Graft is well incorporated and remodeled

Fig.171. Condition after resection and bone grafting between right angle of mandible
and canine area on left (arrows). DCI is partially fixed
(see three screws in frontal
part)

this time, so that good stabilization could be achieved


with at least four screws on each side, within the ascending ramus, and up to the mental foramen of the
opposite side. The healing process thereafter was uneventful.
Another 3 months later the plate could be removed. In view of the special anatomical situation after surgery, with only a few teeth left and no oral ves-

162

tibulum, this patient needed a dynamic compression


implant (DCI) for complete functional rehabilitation
(Fig. 171).
The fourth case was a 24-year-old man, presenting
with a great swelling of the whole horizontal part of
the mandible. By means of a biopsy, an ameloblastic
fibroma with partial sarcomatous degeneration was
diagnosed. For this reason, a resection of the whole

Fig. 172. Removed mandibular specimen, containing


ameloblastic fibroma with partial sarcomatous degeneration

Fig. 173. Special plate for stabilization of both ascending rami and fixation of bone graft

Fig. 174. Plate with fixed bone


graft in place

horizontal part of the mandible was necessary


(Fig. 172). By means of teleradiographs, a special
plate was prepared (Fig. 173) and resection and reconstruction of the mandible was performed at the
same time. The bone transplants were taken from the
iliac crest and fixed to the special plate by means of
screws (Fig. 174). A few weeks later there was an infection in the chin area, which was treated by means of
irrigation drainage. The plate was removed 3 months

later. We observed that the transplant was revitalized


on the lingual surface only, whereas directly under the
plate a great part of the bone was transformed into
fibrous tissue. The lingual part ofthe transplant, however, was believed to be stable enough for the plate to
be removed. Shortly thereafter the patient developed
a fistula. Radiographic examination showed a small
sequester as well as the signs of pseudarthrosis in the
chin area.

163

Fig. 175 (a). X-ray taken


after removal of plate und after reconstruction of whole
horizontal part of mandible,
(b) X-ray taken after implantation of DCI onto bone
grafted area
Restabilization with a special 12 hole DCP and a
bone transplantation with cancellous bone were performed 8 months after the first operation. Healing
thereafter was uneventful, and 4 months later this
plate could be removed. For reasons of functional rehabilitation, a Dynamic Compression Implant (DC!)
was applied 11/2 years after resection of the mandible
(Fig. 175).

7.3. Discussion

For anatomical reconstruction following mandibulectomy, a good means of stabilization is


necessary, for example, in the form of a plate. In
addition to stability, good conditions for revascularization of the transplant are necessary. A
thick and rigid plate guarantees stability, which
is one of the requirements mentioned, but its
very thickness interferes with the conditions
favorable to revascularization. The plate, which
we now use, has many obliquely arranged holes

164

and V-shaped grooves to facilitate bending, and


it fulfills to the greatest degree possible the two
conditions of stability and absence of disturbance of revascularization.
In the above, we deliberately presented cases
characterized by certain difficulties. The patients involved were treated during the last 5
years, during which we amassed a great deal of
experience. Our intention was to show that the
surgical and technical principles, which are constantly mentioned, are the result of both
theoretical and practical experience.
In the first case, because of extensive
radiotherapy, the prospects for revascularization were very poor. Apart from this, the first
plate used for stabilization was too short. Only
two screws were inserted in each fragment. It
must be emphasized emphatically that stable
conditions are not only dependent on the rigidity of the plate, but also on the mode of fixation
to the ends of the bone. In this case, the functional stress was too high for only two screws on
each side. Using our new plate, which is rigid

and fairly small at the same time, and with adequate fixation by means of four screws on each
side, the stabilization of the patient's right mandible was successful.
The second case was the easiest one to treat.
Only a bone resection without involvement of
the soft tissues was necessary. Although there
was an opening into the oral cavity during
surgery, we had primary healing and rapid incorporation of the bone transplant.
In contrast to this case, the third procedure
was very difficult because of the additionally
necessary resection of the floor of the mouth.
Here again, the plate which was used at first was
too short, so that the fixation with screws was inadequate at both ends. The result - and it is an
inevitable one - was infection necessitating removal of the plate. Using our special plate, however, together with an autogenous bone transplant, and sufficient fixation with at least four
screws on each side, there was no problem in
re-establishing the bony continuity. After only 3
months the plate could be removed. In cases like
this, in particular, the possibility of functional
rehabilitation of the patient is provided almost
only by a Dynamic Compression Implant (DCI) ,
and this treatment was successful in this case also.
All the difficulties connected with achieving a
high degree of stability without interfering with
revascularization are apparent in the case requiring the almost complete removal of the
horizontal part of the mandible. Here we had no
other choice than to use a very large and rigid
implant able to bridge the large defect. The implant had to be very thick and, as a consequence,
the conditions for revascularization in the chin
area were poor. By means of restabilization with
a smaller and shorter plate - for the chin area
only - and with a second autogenous bone
transplant, we succeeded in replacing the mandible. At the time of the second surgical procedure, a further advantage in addition to using a
smaller plate was the use of a cancellous bone
transplant, which can be more easily perforated
by new vessels, therefore guaranteeing faster
revitalization. In this case, as in the above mentioned cases, the only means employed for functional rehabilitation was a DCI, which was successfully incorporated.

In addition, it should be stated that up to now


we have used neither a polyester tray impregnated with polyether urethane (LEAKE and RAPPAPORT, 1975) nor a titanium mesh (RAPPAPORT,
et al., 1975). The use of these mesh type trays
seems to include certain disadvantages, which
justify an attitude of reserve.
The latest publications (RAPPAPORT et al.,
1975; COFFIN, 1975) indicate that the principle
of functionally rigid fixation of the stumps of the
jaw cannot be realized by means of the incorporation of mesh trays. Therefore, the advice
given in the papers is to denude the powerful
muscles of mastication, so that in the postoperative period there is no stress on the graft. Preservation of the muscles, however, is very important for an effective restoration of function.
If the incorporated mesh tray cannot be fixed
under functionally stable conditions, intermaxillary fixation will be necessary. This is a great
burden for the patient, however. We wish to
point out at this point that none of the patients
mentioned in this paper required intermaxillary
fixation.
There can be no doubt that the revascularization of bone chips or bone dust proceeds more
rapidly than that of cortical bone. Basically, the
concept of bridging a bony defect by means of a
mesh tray and cancellous bone is a good one. It
has not yet proven, however, that bone dust, following complete revascularization and the removal of the mesh, is solid enough to be functionally stable and support, e. g., a DCI.
We consider that by comparison with our
concept of incorporating a functionally stable
bone transplant, the necessity of leaving the
mesh in place for the stabilization of the transplanted bone, is a definite disadvantage.
Other reasons apart, it is very important to
achieve this functionally stable transplant, since
the bridging of large defects by means of trays
involves the danger of stress fractures (RAPPAPORT, 1975).
With regard to bone transplantation, however, we agree with Rappaport, that "autogenous cortical bone such as the iliac crest is probably the best source; however, it must be
stabilized until the osteoblastic activity induces
new bone." The latter is our aim achieved by
means of the special plate described.
165

7.4. Summary
Summarizing our experience with anatomical
reconstruction of the mandible, we would like to
stress once again the most important preconditions for successful reconstruction:

1. primary and absolutely stable fixation of the


ends of the bone in their original (anatomically correct) position;

166

2. stable fixation of the cortical cancellous bone


graft;
3. good conditions for revascularization;
4. good adaptation of bone to bone and bone to
soft tissue;
5. removability of the fixation plate following
incorporation of the transplant.

E
Postoperative
Infections and
Prophylaxis

1. Treatment of Infected Fractures and Pseudarthrosis of the


Mandible
By J. Prein and R. Schmoker

1.1. Introduction
While there is no risk of osseous infection in
conservatively treated closed fractures of the extremities, this is not true of mandibular fractures. The special anatomical situation of the
mandible with an intra- and extraoral side, and
the frequently occurring lacerations of the gingiva are responsible for the fact that most mandibular fractures are open fractures. This explains why the rate of infection in conservatively
treated mandibular fractures is as high as in
open fractures of the extremities. Infections in
surgically treated fractures of the extremities are
often attributable to the operative procedure itself, but this is by no means so often the case with
operatively treated mandibular fractures.
The rate of infection in operatively treated open
fractures of the extretnities lies between 3.7 and
17.8% (WILLENEGGER and LEDERMANN, 1970;
MATTER and GUT, 1964; RUEDI, 1972 and
1975/76; BURRI, 1974; BURRI et aI., 1971;
RITTMANN et aI., 1969; RITIMANN and PERREN,
1974). As experience grows, however, and
techniques and materials are perfected, the rate
of infection decreases considerably. The most
important argument against the internal fixation
of open fractures concerns introducing a foreign
body into a contaminated wound. This argument, however, is balanced by the advantage of
guaranteed fracture immobilization. It has been
observed that instability promotes infection
(BURRI, 1974; PREIN, et aI., 1975), while stability entails efficient prophylaxis against infection
(BURRI, 1974; RITTMANNet aI., 1969; RITIMANN
and PERREN, 1974).

As a consequence of the above-mentioned


facts we adhere to the following guidelines in the
treatment of infected mandibular fractures and
pseudarthroses:
1. Revision and drainage
2. Stabilization
3. Specific antibiotic treatment.

1.2. Case Report


The following cases of infected fractures and
pseudarthroses of the mandible are described to
illustrate our experience in practice.
The first patient was a young woman, aged 26, who
jumped out of a second floor window intending to
commit suicide. She suffered the following injuries:
1. Five fractures ofthe mandible (region of the angle
on the right, canine area on both sides and the neck
of the articular process on both sides)
2. Le Fort I, II, III type fractures
3. Fracture of the os zygomaticum on both sides
4. Multiple fractures of the alveolar process
5. Luxation and subluxation of various teeth
6. Fractured femur right and left (open fracture on
the right)
7. Fracture of the patella right and left.
Three different teams treated the multiple fractures simultaneously. Both fractures of the canine
area were stabilized with an eight-hole plate, while
the fracture of the mandibular angle was treated with a
three-hole DCP acting as a tension band and a fourhole DCP as stabilization plate (Fig. 176).
The postoperative course was uneventful up to the
4th week when the patient developed an abscess in
the region of the right mandibular angle. A wide

169

Fig. 176. Stabiliza tion of three


fractures of horizontal part of
mandible: one eight-hole
plate for two fractures in
canine area; a three-hole
plate as tension band, and a
four-hole DCP as stabilization plate for fracture of mandibular angle on right

opening was made and drainage obtained by means of


rubber tubes. There was continuous purulent drainage over the next 2 weeks, however. Clinically there
were no signs of instability, and on X-rays no absorption zones were seen.
However, the fractured root of a molar within the
fracture line was observed together with a parodontal
pocket. After extraction of this tooth, the infection
subsided within 1 week. The healing of the fracture
proceeded without complications. All the plates, together with those of the femur, were removed 1 year
later.
In this case, although an infection was present, the
plates were not removed immediately because there
were no signs of instability. The mistake which may
have been made was to leave the molar with the fractured root in place. But the first X-rays did not reveal
that the root of the tooth was fractured. On the other
hand we do not, as a matter of routine, remove teeth
which are in close contact with the fracture line and
clinically are not loosened.

increasing clinical experience we realized, however,


that these plates were too weak, and they are no
longer in use. The DCP's which we now use are made
of steel and are 2.2 mm thick.
The patient developed an abscess in the area ofthe
chin fracture 4 weeks after surgery. Clinically there
were no signs of instability. After incision and drainage, the canine tooth was removed also. But in this
case the infectious process continued. After 2 weeks
there was sequestration of some bony pieces and Xrays showed the signs of instability: bone resorption
zones around the screws and within the fracture line.
Finally instability was also observed clinically. Later,
10 weeks after the initial treatment we decided to remove the titanium plate and at the same time restabilized the fracture by means of a longer and
thicker plate (Figs. 177, 178). This was done despite
the fact that there was purulent drainage at the time of
surgery. The wound was closed primarily and suction
drainage was installed for a few days. Healing thereafter was uneventful. (Fig. 179).

The next patient was a 20-year-old girl, who fell off


her bicycle and sustained an open fracture of the
mandible in the right canine area. The fracture line
had a Y-shape, and the canine tooth was in close contact with the fracture line. In addition, the neck ofthe
articular process was fractured on both sides.
Treatment consisted of intermaxillary fixation for 4
weeks beca use of the fractures of the articular process
(2 weeks with wire and 2 weeks with rubber bands).
Furthermore, internal fixation of the fracture in the
canine area was achieved by means of a four-hole
DCP inserted through the laceration of the skin wi thout any further incision. At this time we were using
DCP's made of titanium of 1.8 mm thickness. With

The next patient was a 40-year-old man who was


hit by a falling tree at work. He sustained a compound
fracture of the mandible on the right side of the chin
and in addition a fracture of the articular process on
the left side, a Le Fort II/III type fracture of the maxilla, and a nasal fracture.

170

In the following we will only describe the course


and treatment of the mandibular fracture of the right
canine area. This compound fracture was stabilized by
means of a lO-hole DCP as a stabilization plate and a
tension band splint on the oral side. After an uneventful healing process during the first few weeks, we observed an abscess in the fracture area in the 14th week

Fig. 177. Osteomyelitis 10


weeks after primary stabilization with four-hole DCP
made of titanium, which was
too weak. This plate is no
longer used

Fig. 178. Restabilization by


means of thicker and longer
plate at time of removal of
above-mentioned titanium
plate (see Fig. 177)

Fig. 179. X-ray control after


removal of plate visible in
Fig. 178. Area of pseudarthrosis has healed
after surgery. An incision was made and a rubber tube
was installed for constant drainage. On X-rays we
found the signs of loosening of at least one screw.
Therefore, in the 16th week the plate was removed.
We found that one screw had become loose and a few
small bone pieces were sequestered. Despite this,

however, we had the impression that the fracture had


healed and was stable. But the infection continued
and after 24 weeks we observed mobility of the fracture area. On X-rays an apical osteolysis of the root of
the canine tooth was apparent and in addition the patient developed a fistula to the intraoral side.

171

We now considered this to be an infected pseudarthrosis (Fig. 180). Treatment consisted of restabilization with a long special plate (Fig. 181) (such as is
used for stabilization after resection of the mandible
in tumor surgery, see Chap. D 6). After debridement

and sequestrotomy, a bone defect existed which had


to be filled with autogenous cancellous bone
(Fig. 182), taken from the iliac crest. Healing thereafter was uneventful.

Fig. 180. Infected pseudarthrosis between second and


third tooth on right, 24 weeks
after accident

Fig. 181. Stabilization of infected pseudarthrosis by


means of special long plate,
tension band splint, and filling
of defect with autogenous
cancellous bone

Fig. 182. View of special long


plate and cancellous bone in
place

172

The last case concerned a 35-year-old man who


had fractured his mandible on the left side close to the
angle 9 years before. He had been treated elsewhere
with intermaxillary fixation and, according to his
statement, there had been purulent drainage for several months, during which multiple incisions were
made.
Finally a pseudarthrosis resulted with almost constant pain, especially marked when the patient was
eating.

On surgery we saw an avascular pseudarthrosis


with a small bony defect. Therefore we used an autogenous cancellous bone transplant and stabilized
the pseudarthrosis with a three-hole tension band plate
and a six-hole stabilization plate (Fig. 183). Healing
thereafter was undisturbed and the patient's discomfort ceased completely. Unfortunately, 1 1/2 years later, the patient returned to Italy without informing us.
Follow-up controls were thus no longer possible and
the plates could not be removed.

Fig. 183 (a). 9-year-oldpseudarthrosis of left mandible,


(b) Stabilization of pseudarthrosis by means of threehole plate acting as tension
band and six- hole plate as
stabilization plate

173

1.3. Discussiou

As can be seen from the cases described above,


stability is the main protective factor against infection. If infection occurs after rigid internal
fixation of mandibular fractures, the reason can
be either instability, a fractured root within the
fracture area, an apical ostitis, an infected pokket of a wisdom tooth, or a lack of aseptic conditions during surgery.
Knowing that stability is the best protection
against infection, we have to ask ourselves the
following questions at the time of surgery:
1. What is the correct length of the plate
needed?
2. Should a tension band be used together with a
stabilization plate?
3. Should an EDCP be used instead?
4. Has the plate been correctly bent?
5. Are there any screws crossing the fracture
line? (If so, they must be inserted as lag
screws.)
6. What compression forces can be applied
without danger of fracturing the bone? (This
applies especially to atrophic jaws with osteoporosis. )
If an infection occurs after rigid internal fixation, the treatment depends on the cause of the
infection.
If instability can be detected either clinically
or radiographically, restabilization has to be

174

achieved by re-osteosynthesis, even if infection


is present (see case 2).
If infection occurs under stable conditions,
there is no reason for removal of the plate (see
case 1). It is not correct to believe that the plate,
being a foreign body, automatically promotes
infection. If primary fixation has provided rigid
stability, it is vital that the plate must be left in
place, and the infection alone should be treated.
It has to be borne in mind, however, that it takes
a few weeks before osteolytic zones around the
screws and within the fracture area are visible on
X-rays as a sign of instability. Therefore, in cases
of continuous purulent drainage, repeated X-ray
examinations may be necessary.
The same rules which apply to the treatment
of infected fractures, also apply to the treatment
of infected or noninfected pseudarthroses (see
cases 3 and 4).
Above all, pseudarthrosis requires rigid
stabilization. Whether or not an additional osteoplasty will be necessary depends on the clinical aspect of the pseudarthrosis. In cases with a
bone defect, autogenous cancellous bone, as a
bone graft, derived from the iliac crest, will be
necessary. In cases of atrophic nonunion also,
where no new bone has been deposited, a bone
graft as described will be necessary (see case 4).
On the other hand, in reactive and well-vascularized cases of nonunion or pseudarthrosis, a
bone graft will not be needed.

2. Preventive Antibiotics in Elective Maxillofacial Surgery


By W.-A. Jaques

2.1. Introduction

2.2. Material and Method

The use of prophylactic antibiotics in general


surgery, as well as in orthopaedic and gynaecologic
procedures has been reviewed in numerous publications (ALEXANDER et aI., 1973; BURKE,
1963; DAVIDSON et aI., 1971; EVANS and POLLOCK, 1973). Their application in maxillofacial
operations has so far received only limited attention (P AlERSON et aI., 1970). The purpose of
the present study was to investigate the effectiveness of ampicillin as compared to cephalosporins in elective maxillofacial surgery. Antibiotics administered postoperatively have no effect on the incidence of wound infections.
In accordance with the procedure suggested
by BURKE, our patients received antibiotics in
the preoperative phase, in order to provide an
effective drug level. BURKE showed experimentally that the tissue defenses are established
within 1-3 h after surgical trauma, and that factors influencing the wound's response to bacteria are virtually inoperative after that time.
In addition to the importance of the early administration of preventive antibiotics, their concentration and the time they remain in the
wound after systemic administration must also
be considered. ALEXANDER's experiments suggest that antibiotics may vary considerably in
their potential usefulness as prophylactic agents
because of differences in their rate of diffusion
and concentration in the wound. Ampicillin and
the cephalosporins appeared to be especially effective, if administered as a parenteral bolus
1-2 h before the expected time of contamination.

From July 1, 1974 to Juni 30,1975, 237 patients, who


underwent 271 elective maxillofacial operations in
the Division of Plastic and Reconstructive Surgery of
the University of BasIe, Switzerland, were included in
the study under the following conditions:
1. A relatively extensive elective operation was planned. This was arbitrarily established as the extraction of a minimum of two impacted teeth.
The surgical procedure either had to reach the
bone level, or if limited to the soft tissues, last at
least 2 h.
2. Only patients who required general anesthesia
were included.
3. No evidence of clinical infection related or unrelated to the surgical procedure contemplated was
found on admission.
4. The patient had no history of penicillin allergy.
5. There had been no administration of systemic antibiotics within the 2 weeks prior to surgery.
On admission, the patients underwent a thorough
physical examination and a complete medical history.
Routine laboratory studies included at least hematocrit, white cell count, serum electrolytes, urea nitrogen, and creatinine, and urinanalysis. Patients with
pathologic renal function were excluded. On admission, each of the 237 patients was randomly assigned
to one of three study groups, according to month of
birth:
Group I
= (January to April) = Cephalosporins
Group II
= (May to August) = Ampicillin
Group III
= (September to December) = no antibiotics.
This method was found to produce an unequal
grouping, since socioecologic factors responsible for
the low birth rate in the months of May to August
were not foreseen by the investigator.

175

Antibiotics were given according to the following


schema: at the time of administration of the preoperative medication (about 1 h before incision) the patients were given 1 g intramuscularly (group I = 1 g
cephacetril: Celospor, Ciba, or cephalothin: Kellin,
Lilly, group II = 1 g ampicillin: Penbritin, Beecham).
These doses were repeated every 6 h either i. m. or
i. v. for 24-48 h and then orally for an addi tional 72 h
up to a total dose of 20 g (group I = cephalexin: Keflex, Lilly, or Ceporex, Glaxo).
Children or patients weighing less than 45 kg received half doses. On the day before the operation
and then immediately before it , the oral cavity was
thoroughly cleaned with a 0.2 % Chlorhexidine-spray
for at least 1 min.
Extraoral skin surfaces undergoing operative procedure were prepared with alcohol and Desogen,
Geigy.
Intraoral wounds were considered as "potentially
contaminated" (EVANS and POLLOCK, 1973; DAVIDSON et aI., 1971); and extraoral wounds as "clean."
Postoperatively, the patients were again allowed to
rinse their mouths with 0.2 % Chlorhexidine solution
twice daily, a third extensive cleaning being performed by the surgeon at the time of the daily examination. Extraoral wounds were left uncovered and
cleaned once daily with Desogen.
The condition of the wound was observed daily.
For the purpose of this study postoperative infections were defined as suggested by BERNARD as
"wound complications which required opening of the
wound by the surgeon because of classical signs and
symptoms which denote infection."
Because of their specific characteristics, bone infections occurring after the extraction of impacted
teeth up to 6 weeks postoperatively, were still considered to belong to this study.

were found to be not significant, except for the


ampicillin group II by comparison with the untreated group III (X2 = 4.68 P >0.05). Comparison of group I (cephalosporin) with group II

Table 32. Operative procedures


1." Potentially contaminated" operations:
Odontectomies (multiple)
Cystectomies with or without bone grafting
Multiple apicectomies
Isolated vestibuloplasty
Subperiosteal impression and vestibuloplasty
Isolated subperiosteal impression
Fixation of subperiosteal implants
Isolated orthopedic osteotomies
Isolated sagittal split osteotomies (Dal Pont)
Combined maxillomandibular osteotomies
Removal of internal fixation material
Rhino-septoplasties
Surgery of the maxillary sinus
(Caldwell-Luc)
Procedures in cleft lip and palate
Extensive tumor excision, and others
2. "Clean" operations:
Parotidectomy
Arthroplasty, arthrotomy, condylar replacement
Tumor excision and plastic reconstruction
Tumor excision and radical neck dissection
Internal fixation (only elective)
Orbital procedures
Removal of internal fixation material
Others
3. Concomitant nonmaxillofacial "clean"
procedures:
Bone or cartilage removal (for grafting)

38
5
2
8
9
12
21
15
14
10
5
16
7
9
10
13
13
4
2
12
4
7
4
34

2.3. Results
Table 33

The distribution of the patients according to the


type of operation is given in Table 32.
Table 33 gives the distribution according to
the treatment groups.
For the purely maxillofacial procedures with
an expected low rate of infection (*), the morbidity in group I, receiving cephalosporins was
4% (3 out of 75); in group II, receiving ampicillin, it was 0% (0 out of 42); compared with
11.6% (8 out of 69) in the control group which
received no antibiotics. The total of infections in
all operations is 5.9% (11 out of 186).
When submitted to statistical analysis (Dr.
BRENNWALD, Department of Surgery, Basle) ,
with the Chi-square method, these differences
176

-'" '"
6

~
..c: .<::

-- ,

<~ .;:l'"

0.. 0
~ 0..

'5. ~
8;.:::1

<'5

Z:E

"Clean" concomitant
operations
Infections

13

11

10

34

"Clean" maxillofacial
operations
Infections

19

16

16
1

51
1

"Potentially contaminated" operations


(*) Infections

75
3

42

69
8

186
11

Total patients
Total infections

94
3

58

85
9

237
12

u '"

"@
0

E-<

(ampicillin) and with group III (no antibiotics)


showed no significant differences.
(IIII = X2 = 1.66, P > 0.1,
IIII1 = X 2 = 2.52, P >0.1).
DAVIDSON et al. (1971) produced a valuable
computer analysis of some of the factors responsible for wound infections in 1000 operations in
general surgery. He found only 5 out of 14 factors which strongly influenced the infection rate.
These were: a potentially contaminated operation site, the presence of bacteria in the wound
at the end of the operation, old age, a long operation, and the nursing of patients in large multibed wards. Of these 5 factors we were able to
consider only the age of the patients and the
duration of the operation.
The difference between the infection rate in
young and old patients as shown in Table 34, is
not significant either in "clean" wounds or in
"potentially contaminated" wounds of the maxillofacial area: 4.2% (9 out of 215) in "young"
patients compared with 5.4% (3 out of 56) in

"older" patients. Within the different treatment


groups, the results were also not significant.
There were 96 operations which lasted more
than 2 h; 70 wounds were "potentially contaminated" and 26 were "clean." In this last category
no infection occurred, neither in the treated
groups nor in the control group.
The results of the 70 "contaminated" wounds
are given in Table 35.
In 10 operations which lasted more than 4 h,
3 wound infections occurred. In 10 operations
lasting 3-4 h, 1 infection occurred.
Of 50 operations lasting from 2 to 3 h, 1 infection occurred. Out of 32 operative procedures of especially long duration which were
treated prophylactically with cephalosporins,
only 1 infection occurred. No infection occurred
in the 18 patients of the ampicillin group.
With 20 operations performed in the control
group, 4 infections developed.
The incidence of wound infection for all the
procedures of long duration was 7.1 % (5 out of

Table 34. The incidence of wound infection in patients under and over 60 years of age
Type of wound

Treatment

Under 60 years
No. of No. of
wounds infections

Over 60 years
No. of No. of
wounds infections

"Clean" maxillo- Cephalosporins


Ampicillin
facial and
concomitant
NoAB

24
13
22

0
0
0

0
0
0

8
14
4

0
0
1

0
0
25

Total:

59

26

67
32
57

2
0
7

3
0
12.2

8
10
12

1
0
1

12.5
0
8.3

Total:

156

5.8

30

6.7

All wounds

215

4.2

56

5.4

Over 2 h
No. of Infect- %
wounds ed

Total
%

3.1
0

"Potentially
contaminated"
wounds

Cephalosporins
Ampicillin
NoAB

Table 35. Incidence of wound infection in relation to the duration of the operation
Treatment

Cephalosporins
Ampicillin
No antibiotics
Total

Over 4 h
No. of Infect- %
wounds ed

Over 3 h
No. of Infect- %
wounds ed

5
2

1
0

20
0

5
3

0
0

0
0

22
13

0
0

0
0

66.6

50

15

6.7

10

30

10

10

50

20
7.1

177

70) compared with 5.2% (6 out of 116) for the


operations of less than 2 h duration.
A combined influence of the two factors of
old age and long duration of operation was
found in 26 cases and resulted in 1 infection only.
As a matter of fact, this infection was a true iatrogenic complication, since it was caused by the peroperative retention of a piece of a silicon compound, which induced a staphylococcal abscess
and was rejected on the 7th postoperative day.

Other predisposing causes of wound infection


like obesity, diabetes, long-lasting preoperative
corticoid treatment, etc., were not investigated.
No correlation could be found within the different groups of treatment between the rate of
wound infection and the surgeon, nor did these
influence the length of stay in hospital.
The 12 wound infections which developed in
this series are shown with their main characteristics in Table 36.

Table 36. Characteristics of wound infections


No. Feminine Age Diagnosis
Masculine
1 Fern.
2 Fern.
3 Fern.
4 Masc.
5 Masc.

6 Fern.

7 Masc.
8 Fern.

9 Fern.

10 Fern.
11

Fern.

12 Masc.

178

80 Lymphosarcoma of
the chin
34 Impacted
teeth 38, 48
15

Treatment Operation

Surgeon

Excision
and repair
with flaps
Odontectomy
primary
closure
Cephalo- Odontectosporin
mies, primary
closure
Excision and
biopsy

Senior 2h

Chin
13th day

Senior 2h

Alveolus 38
20th day

Senior 2h

Alveolus 48
30th day

Senior 2h

Locally
6th day

Streptococcus
hemol. B4 0

Junior 5h

Periodontal
osteotomy
level
36th day
Osteotomy
level
mandible
6th day
Alveolus 48
3rd day

Streptococcus
viridans

Submental
inclusion of
foreign body
7th day
Osteotomy
level right
side 20th day

Staphylococcus aureus
coagulase + +

Impacted
18, 28, 38,
48
11 Dentogenic
myxoma of
the mandible
20 Dysgnathia Cephalo- Maxillary and
mandibular
with
sporin
overbite
segment
osteotomy
Maxillary and
33 Dysgnathia
with
mandibular
overjet
segment
osteotomy
Odontecto22 Impacted
mies, primary
18, 28, 38,
48
closure
Subperiosteal
61 Bony atrophy
of the
impression
mandible
Le Fort-IMaxillary
osteotomy
hypoplasia
after cleft lip
and palate
19 Dysgnathia
Maxillary and
with
mandibular
osteotomy
prognathism
Odontecto16 Impacted
18,28, 38,
mies, primary
48
closure
70 Bone atrophy Cephalo- Subperiosteal
of the
sporin
implantation
mandible
21

Dura- Infection
tion
and day of
occurrence

Senior 4h

Senior 2h
Junior 2h

Junior 5 h

Junior 4.5 h
Senior 2h
Senior 2h

Bacteriological findings

Streptococcus
viridans

Suction
Streptococcus
drainage exit viridans
6th day
Alveolus 38
30th day
Left lingual
edge of
implant
7th day

2.4. Discussion

Although maxillofacial operative procedures


can seldom be compared with major general
operations, the question of whether to use
prophylactic antibiotics to decrease postoperative infection was a logical one, since it can be assumed that intraoral wounds are commonly contaminated through endogenous nasal and oral
flora.
This assumption has led to an undiscriminated use of prophylactic antibiotics, the results
of which are still controversial.
We have therefore made an attempt to determine whether the preventive administration
of antibiotics, as proposed by BURKE(1963), reduces postoperative infections in the maxillofacial area.
Some of the difficulties encountered in interpreting the data from this study arose because of
the relatively low incidence of infection. Statistically fully significant results could be obtained
only with larger series.
The results of this study revealed that there
was a decrease in the rate of infection in "potentially contaminated" wounds in patients receiving cephalosporins or ampicillin compared with
those receiving no preoperative antibiotics;
submitted to statistical analysis, however, the
results were found to be not significant, so that
the prophylactic use of these antibiotics cannot
be advocated for maxillofacial procedures. Factors known to predispose to infection, such as
old age and duration of the operation were also
studied.
Some differences were apparent; only few of
them, however, were significant.
The infection rate was consistently lowered in
both antibiotic groups as compared with the
nontreated group, when the duration of the

operative procedure was considered. But our


series is too small to be submitted to statistical
analysis.
Despite the low statistical significance of our
results, we concluded that prophylactic antibiotic treatment with both cephalosporins and
ampicillin lowers the infection rate in patients
undergoing major maxillofacial operations.
For maxillofacial procedures, the effectiveness of cephalosporins seems to be less than that
of ampicillin.
The influence of old age was not found to be
determinant in this study. Operative procedures
lasting longer than 3 h seem to be the only true
indication of antibiotic prophylaxis.

2.5. Conclusion
The routine use of a prophylactic antibiotic in
elective maxillofacial operative procedures is
contraindicated. Its use should be reserved exclusively to
1. patients with a diminished natural mechanism
of resistence, because of old age or a special
disease,
2. patients undergoing an extensive surgical
procedure lasting more than 3-4 h, or receiving a large amount of foreign material,
3. patients in whom the proposed surgical procedure brings the hazard of massive bacterial
contamination.
For this purpose we used both cephalosporins
or ampicillin with good results. Although our
data suggest a slight superiority of ampicillin,
the statistical analysis showed no significant differences.
Antibiotics should be administered as a
parenteral bolus, 1 h before the operation, and
should be repeated every 6 h for 48 h.

179

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with use of Gelofoam. Oral Surg. 8, 950 (1955)
THOMA, K.: Oral Surgery. St. Louis: Mosby 1948

1963

TIEGELKAMP, R., o BWEGESER, H.: Zur Operationstechnik bei der Progenie und anderen Unterkiefer-

186

anomalien. Dtsch. Zahn-, Mund- und Kieferheilk.


23, 1 (1955)
TRAUNER, R.: Ober Ergebnisse von Kontrolluntersuchungen nach Operationen zur Korrektur falscher Zahn- und Kieferstellungen. Nova Acta
Leopoldina 33, 65-79 (1967)
TRAUNER, R: Kiefer- und Gesichtschirurgie.
Mtinchen, Berlin, Wien: Urban und Schwarzenberg, 1973
TRAUNER, R.: Ergebnisse von Nachkontrollen kieferorthopiidischer Operationen. Fortschr. Kieferu. Gesichtschir. XVIll, 64 (1974)
TRUETA, J.: The role of the vessels in osteogenesis.
J. Bone Jt. Surg. 45 B, 402 (1963)
TSCHOPP, H. M.: Microsurgical neuro-vascular anastomoses for transplantation of composite bone
and muscle grafts. An experimental study. Berlin,
Heidelberg, New York: Springer 1976
U LLIK, R: Ober Progenieoperationen nach K OSTECKA
Oest. Z. Stomat. 40, 255-270, 294-317 (1942)
VIJAYARGHAVAN, K., RICHARDSON, A., WHITLOCK,
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(1974)
VITALLI, H. P.: Die biologischen Grundlagen der
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(1964)
VITALLI, H.: Knochenerkrankungen, Histologie und
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WANG, J. H., N ORDERUD, R: A new operative technique for prognathism. En ny operasjjonsteknikk
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780 (1933)
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(1969)
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Subject Index

Accident(s), road, mUltiple injuries 53


Adaptation phase in rigid internal fixation 29
Additional local injuries 53
Alizarin complexone
-, contrast fluorochrome(s) 14
Alternating load in dynamic compression
implants 126
Anastomoses
-, microsurgical neurovascular 13-18
-, nerve 13-18
-, vascular 5, 13-18
Anatomic reconstruction of mandible after ablative
surgery 160-166
Anesthesia of mental nerve 53, 56
Ankylosis of temporomandibular joint
-, treatment 88--92
- -, instrument set 89
- -, prosthesis, condylar 88
- -, technique 88
Antibiotics in elective maxillofacial
surgery 175-179
-, Ampicillin 175-179
-, cephalosporines 175-179
-, Chlorhexidine 176
-, preoperative medication 176
-, preventive administration 175-179
-, prophylactic administration 175-179
Arch bar
-, as tension band 51, 56
-, dental 41, 50, 66
-, in combined fractures of maxilla and mandible 71
-. stabilization of comminuted maxilla 66
Atrophy of bone; see also Bone, osteoporotic
changes
-, in area of Dynamic compression implant
(DCI) 130
Balloon catheter
- in comminuted fractures of maxillary sinus 71
Basic implants set for treatment of mandibular
fractures 34

Basic mandible set for rigid internal fixation


-. complete standard set 34
Bone(s)
- atrophy, area of DCI 130
-, autogenous
- -, osteogenesis 4
- -, transplantation 3--6
- building, lamellar 26
-, canaliculi 3
-,cancellous
- -, architecture 4
- -, removal 6
-, cortical
- -, architecture 3
- -, nutrition 3
-, cortical reaction to DC! 130
-, cytoplasmatic processes 3
- density in mandible 150
-, fibrous 14
- formation, periosteal, induction 130
- graft(s)
- -, architecture 3
- -, autogenous 3-6
- -, behavior 4
- -, cancellous 4
- -, femoral, technique of removal 6
- -, iliac, technique of removal 5-6
- -, immobilisation 5
- -, microradiography 17
- -, remodelling 4
- -, rib, composite 6, 13
- - -, technique of removal 6
- -, stabilization 156
-, Haversian vessels 17
- healing 26
- -, contact 25-26
- -, due to stabilization 40
- -, gap 25-26
- -, osteotomy 115
- -, primary 26
- -, secondary in sagittal split osteotomy 115
-, intercellular substance 3

187

Bone(s) - lamellar 4
-, missing, reconstruction 59
-, os teo blasts 3
-, osteogenesis, revascularization 4
-, osteoinductive potency 4
-, osteoporotic changes 153
-, periosteal reaction to DCI 130
- remodelling 4, 14
- resorption 126, 135
-, revascularization 4
- structure, site of implant prosthesis 150
-, surface of mandible 150
- transplantation 3--6, 7-12
- -, application 3-6, 7-12
- -, autogenous 3--6, 7-12, 13, 93-97
- -, broadening the apical base 93-97
- -, cancellous 7-12, 173
- - -, removal 6
- -, extra-articular 81
- -, heterogenous 11
- -, homologous 7-12
- - mandible, reconstruction of 74
- -, microsurgical vascular anastomoses 5, 13-18
- -, primary 74
- -, revascularization 61
- -, rigid internal fixation 61
- -, via temporal fossa 81
- union 18, 38
Bridging of mandibular defect( s); see Reconstruction
of mandibular defects
Broadening of apical base
-, bone transplantation, advantages 93-97
- -, autogenous rib
- - -, results 97
- - -, technique 93-94
- -, cancellous bone from iliac crest, results 97
- - -, technique 94

Cadaver mandibles, histologic-morphometric


investigations 150-155
Calcein
-, contrasting fluorochrome(s) 14
Cancellous bone; see also Bone" cancellous
-,autogenous 11
- -, transplantation 7
- screw(s) 54
- -, indication 54
Canthal ligaments, avulsed
-, reattachment 69
Cheek retractor for perfacial screwing 131
Clamps, intermaxillary 23
Comminuted fractures of maxillary sinus; see
Fractures, maxillary sinus
Compound mandibular fracture(s); see Fracture(s),
mandibular, compound
Composite graft
-, autogenous muscle and bone 13-18
Composite rib transplantation 13-18

188

Compression
-, axial 24, 26, 42
-, excentric, forces, stress 24
-, interfragmentary 26
- -, experimental measuring 49
- phase 29
-, reduction forceps or reduction pliers; see
Reduction pliers
- rollers 34
-, technique
- -, experiments on models 47
Condylar prosthesis of mandible
-, advantages 88
-, definition 88
-, emplacement 90
-, instrument set 89
-, technique 88-90
Condylus mandibulae
-, excessive movement 81
-, treatment; see Temporal bolting osteoplasty
Contrasting fluorochromes
-, Alizarin complex one 14
-, Calcein 14
-, Oxytetracycline 14
-, Xylenol-orange 14
Contrast medium 17
Cystectomy 7
Cystotomy 7

DCI (Dynamic compression implant); see Dynamic

compression implant
DCP (Dynamic compression plate); see Dynamic
compression plate
Decortication of oblique line in sagittal split
osteotomy 119
Defect(s)
-, bone 37
bridging plate for large defects of mandible; see
Plate(s)
of mandible, bridged by plate 37, 156-158
Delay of primary intervention indication 63
Density of bony substance in mandible 150
Dentition
-, restitution in mandibular fractures with loss of
bony substance 59
Disadvantages of rigid internal fixation
-, intraoral procedure 22
Disimpaction forceps by ROWE; see ROWE's
disimpaction forceps
Disorders, post-traumatic 21
Dynamic compression implant (DCI)
-, absolute stability 140
-, area of implantation 129-130
-, bony structure of mandible 150
- -, histologic-morphometric evaluation 150--155
-, components 144
-, compression along screw 144
- - transversely to screw 145

Dynamic - compression implant (DCI), construction


127, 129
-, disturbances of sensation 135
-, evaluation of methods 134-140
-, fixation 127
-, instruments 128
- -, for perfacial screwing 131
-, lifting force 147
-, load bearing properties 141
- -, measurement 142
- -, measurement prosthesis 142
-, loosening 126
-, masticatory force components 141
- -, technique of measurement 143
-, mechanics 129, 143
-, osteolysis, induced by movement 127
-, periosteal and cortical reaction 130
-, pretension (preload) 127
-,principks 125-133,141,144
-, radiographic findings 137
-, screw, excentric insertion 145
-, spherical gliding principle 145
-, stability 141
- -, experimental studies 144-149
-, static friction 128
-, stress concentration 130
-, technique, principles 130-132
-, toleration 127
-, transverse compression 128
-, types 134-135
-, wound closure 129
-, wound dehiscence 129
Dynamic Compression Plate (DCP) 27-34,35-40,
57,59-60,66,71-74,171-173; see also Plate(s)
Dynamic forces 44
Dynamic stress, experimental 125
Dynamometer, miniature
-, capsule-type 142
-, for measuring fixation forces in Dynamic
compression implant (DCI) 146-148
-, for measuring masticatory forces 142
EDCP (Excentric dynamic compression plate); see
Excentric dynamic compression plate (EDCP)
Electromyographic recordings in composite rib
transplantation 15
Ernst's ligature, rigid 24, 64
Evaluation(s) in patients with implants 134-140
-, criteria 136
-, scale 139
Excentric drill guide for perfacial screwing 131
Excentric dynamic compression plate (EDCP)
27-34, 41-58; see also Plate(s), EDCP
Fixation
- callus 27
- forces in Dynamic compression implant (DCI)
- -,lagscrew(s) 147
- -, measurement 146-147
- -, pressure screw(s) 147

Fixation - forces in dynamic compression implant


(DCI), reduction 149
- in compound mandibular fractures 35-40
-, intermaxillary 38
-, intraoral 22
-, rigid internal 21-78
- -,approach 21
- -, indication 21-22, 30-32, 35-41, 54-55,
57-60,72,169-173
- -, objective 23
- -, objections 21
- -, principles 21-34
- -, scars 21
-, sagittal split osteotomy 109
- systems, rectilinear 29
-, temporary, of occlusion 23
-, transcutaneous 5
Fixation screw(s), damage of nerve 56
Flap(s), musculo-sceletal 5
Fluorescence microscopy 14
Fluorochromes 14
Forceps
- for application of L-shaped bone graft in temporal
bolting osteoplasty 84
-, disimpaction; see ROWE's dis imp action forceps
Forces
-, dynamic 44
-, functional 44
-, static 45
Fracture( s)
-, combined, articular process( es) and horizontal
ramus, therapy 40
-, combined, of upper and lower jaw 63-74
- -, intermaxillary dental relationship 71-72
- -, intermaxillary fixation 71-72
- -, principles of treatment 62-74
-, comminuted 62
-, compound facial 63-74
-, facial
- -, skin incision 75
- -, surgical approach 75-78
- in edentulous jaws 23
-, infected
- -, osseous bridging 8
- -, protection 173-174
- -, rate, after conservative treatment 169
- -, rate, after operative treatment 169
- -, reasons 174
- -, treatment 169-174
-, instability, definition 44
- of articular process 40
- of malar complex 76
- -, skin closure 76
- -, skin incision 76
- of mandible 21-34
- -, angle, treatment 169-170
- -, bone union 38
- -, compound 35-40
- -, contaminated 35
- -, skin incision 77

189

Fracture(s) of stabilization 38
- - mandible-treatment 24-78
- - -, delayed 53
- - -, principles 21-34
- -, with loss of bone substance, reconstruction
59-62, 66, 160-166
- - -, restitution of dentition 59-62
- of maxilla 63-66
- -, architecture of middle face 64--65
- -, treatment 64-66
- of maxillary sinus, comminuted, intraoral
approach 69
- -, retention by balloon catheter 69-71
- of naso-ethmoid, comminuted 67-71
- -,approach 67-71
- -, special instrument for reposition 70
- -, treatment 68-71
- of nose 67-70,77-78
- -, intercartilaginous incision 77
- -, skin closure 76
- -, skin incision 76
- -, special instrument for reposition 70
- -, transfixion incision 77
- of orbital region 76
- -, blow-out- 76
- - -, skin closure 76
- - -, skin incision 76
- - -, treatment 76
- -, floor of orbit, reconstruction with plate 66
- -, lower orbital rim 76
- - -, skin closure 76
- - -, skin incision 76
- -, Sutura frontozygomatica 76
- - -, skin closure 76
- - -, skin incision 76
- of zygomatic arch 76-77
- -, skin closure 76
- -, skin incision 76
- -, treatment 76-77
- stress 165
Fracture treatment
-, conservative, disadvantages 55
-, delayed 53
-, immediate 53
see also Rigid internal fixation
Frictional binding force 26
Georgiade head frame 65
Graft(s)
-, bone 3-6
- -, architecture 3
- -, autogenous 3-6
- -, behavior 4
- -, cancellous 4
- -, femoral 6
- -, heterogenous 4
- -, homogenous 4
- -, iliac 5
- -, regeneration 4
- -, rib, composite- 6, 13

190

Graft(s), iliac 5
-, musculo-skeletal

Haversian system 3, 17
Head frame, Georgiade 65
Hemostatic agents in bone graft removal 5
Histologic-morphometric investigations in cadaver
mandibles 150-155
-, bone structure 150
-, evaluation 150
Implant(s)
-, basic set 34
-, functionally stabile 139
-, loosening 126
-, metallic 59
- prosthesis; see Dynamic compression implant
(DCI)
-, toleration 127
Indication for rigid internal fixation 5, 13, 18,
21-22,30-32,35-41,54--55,57-60,72,169-173
-, bone transplantation 5, 13
-, bridging of defects 3--6, 13-18
-, EDCP 54
-, formula: compression-tension band plate (DCP) +
stabilization plate (DCP) 31
-, formula: DCP or EDCP 32, 58
-, formula: tension band-arch bar + stabilization
plate (DCP) 30
-, lag screws 5,40, 101, 112, 114, 118-122
-, protection of infection 35
-, sagittal split osteotomy 11, 115-127
Induction of new bone formation 8
-, periosteal 130
Induction of osteolysis, by movement 127
Infection(s)
-, after rigid internal fixation 169
-, cysts 10
- in closed fractures 169
- in sagittal split osteotomy 110
-, instability 174
-, osseous, in closed fractures 169
-, osteolytic zones as signs of instability 174
-, protection of 173-174, 175-179
- rate in mandible 169
- rate in operations in relation to age 177
- rate in relation to duration of operation 117
-, reasons for 174
- resistance of autogenous cancellous bone 8
-, treatment 169-174
-, wound(s)
- -, characteristics 178
- -, incidence 177
Instability in fixation
-, danger 35
-, definition 41
-, sequelae 135
-, signs 170, 174
Instruments
-, basic set (mandible set) 34

Instruments, Doyen elevator 6


-, forceps for application of L-shaped bone graft 84
- for perfacial screwing 131
- -, cheek retractor 131
- -, ex centric drill guide 131
- -, trocar 131
- for rigid fixation in sagittal split osteotomy 120
- for use of perfacial lag screws 120
-, oscillating saw 5
-, osteotome 5
-, pliers, special, for bending plate(s) 158
- -, special, for pressing DCI to bone 128
-, special, for resposition of nasal fractures 70
Interfragmentary compression in sagittally split
mandible 119
Intermaxillary fixation in sagittal split
osteotomy 112
Internal fixation; see Rigid internal fixation
Kiel chips 11
Kirschner wire, transfacial

65

Lag screw(s)
-, fixation force 147
-, indication 5, 40, 54
- in implants 62
- in sagittal split osteotomy 107
-, positions in sagittal split osteotomy 121
-, principles 120
-, technique 54
Lacrimal apparatus, lacerated
-, probe 68
-, reconstruction 67
-, silicon tubing 68
Lifting force of Dynamic compression implant (DeI),
magnitude 147
Ligature(s)
-, Ernst's 24, 64
-, rigid intermaxillary 24
-, wire, interosseous, indication 65
Loss of alveolar ridge
-, rehabilitation 59-62
-, therapy 59-62
Loss of bony substance in mandibular
fractures 59-62
-, reconstruction 59-62
-, therapeutic problems 59-62
Luxation of temporomandibular joint 81
-, treatment; see Temporal bolting osteoplasty
Mandibular canal, position 153
Mandibular fractures; see Fractures, mandibular
Mandibular nerve, damage 57
Mastication forces 27
-, measurement, technique 143
Maxilla
-, architecture 64-65
Maxillar fractures; see Fractures of maxilla

Measurement of fixation forces in dynamic


compression implant (DCI) 146
Mechanical motion, absence of 8, 12
Mental nerve
-, anesthesia 53, 56
-, hypesthesia 56
Mesh tray(s) 165
Microangiographic studies in microsurgical
anastomoses 14-18
Micromovement(s) between implant and bone,
sequelae 126
Microscope
-, dissecting 14
-, operating 5
Microsurgical anastomoses
-, composite graft 13
-, in rib transplantation 13-18
-, microangiographic study 14
-, nerve 13-18
-, radioangiography, artery 15
-, vessels 13-18
Middle face
-, architecture 64-65
-, fractures of; see Fractures of maxilla
Miniature capsule type dynamometer
for measuring fixation forces in Dynamic
compression implants (DCI) 146
for measuring masticatory forces 142-143
Mucopolysaccharides 12
Multiple injuries, timing of surgery 63
Muscle graft(s)
-, electromyographic recording 15
-, intercostal 15
-, silver impregnation 16
Nerve(s)
-, facial-; see Facial nerve
-, mandibular-; see Mandibular nerve
-, mental-; see Mental nerve
Neurorrhaphy 13
Neurovascular microsurgical anastomoses; see
Microsurgical anastomoses
Objectives of Rigid internal fixation 23
Occlusion
-, disturbances 39
-, fixation 39
- in rigid internal fixation 56
-, repositioning 23
-, retention 64
-, rigid retention 21
Operations, maxillofacial
-, "clean" 176
-, "potentially contaminated" 176
Osseous infection in closed fractures 169
Ossification of cystic cavity 8
Osteogenesis 11
-, autochthonous 12
-, inductive 12, 125
- -, by mechanical strain 125

191

Osteogenetic properties 11
Os teo inductive potency of bone 4
Osteolysis, induced by movement 127
Osteomyelitis after primary stabilization of
mandibular fracture 171
Osteoplasty 10
-, primary 8
-, temporal bolting 81-87
Osteoporotic changes in bone; see Bone, osteoporotic
changes
Osteotome; see Instruments
Oxytetracycline, contrasting fluorochrome(s) 14

Perfacial screwing; see Dynamic compression implant


(DCI) and Sagittal split osteotomy
Periosteal bone formation, induction 130
Plate(s)
-, DCP (Dynamic compression plate) 27-34,
35-40,57,59-60,66,71-74,171-173
- -, as tension band 51, 169
- -, without tension banding 48
- -, with tension banding 48
-, Defect bridging 156-159, 172
-, EDCP (Excentric dynamic compression plate)
27-34, 41-58
- -, advantage 44
- -, effect of rigidity 41-52
- -, effectiveness 50
- -, excentric application 42
- -, experimental studies 41-52
- -, function 43
- -, indication 32, 54, 57
- -, principles 44
- -, stability 56
- -, type of treatment 53
- -, with tension banding 48
- -, without tension banding 48
- holes
- -, longitudinal positioning 44
- -, oblique positioning 44
- -, transverse positioning 44
-, malleability 156
-, overbending 30, 42
- pliers, special, for bending 158
-, special, for stabilization of bone grafts 156-159
-, stabilization 26, 156
-, straight-, advantages 30
Polyester tray 165
Preload, definition 125
Preoperative management 63-64
Preparation of wound in maxillofacial area 63-64,
73
Pressure
-, interfragmental 41
- screw(s) 129
- -,fixation force 147
Pressure rollers, in combination with reduction
pliers 24, 46

192

Pretension (Preload), in Dynamic compression


implant (DCI) 126--127
Principles of Rigid internal fixation 21-34, 72
Prognathism, mandibular
-, sagittal split osteotomy 98-102
Prosthesis
- for temporomandibular joint; see Condylar
prosthesis of mandible
-, implanted, load-bearing properties 141
-, measuring, with miniature Capsule dynamometer
142
Protrusion, pronounced maxillary
-, combined operative and conservative
treatment 93-97
Pseudarthrosis of mandible
-, defect 8
-, infected 8, 169-174
- -, avascular 173
- -, cancellous bone transplant 174
- -, stabilization 172-174
- -, treatment 169-174
- - -, principles 169, 174
Pull-out wires
-, suspension of maxillary complex 67
Pulsating jet spray 64
Radioangiography, in composite rib
transplantation 15
Radiopaque medium 14
Reconstruction
- of floor of orbit 66
- of mandible 66
- - with long plate and screw fixation of bone
fragments 73
- of mandibular defects 160--166
- principles 166
Recurrence(s), rates of
-, after sagittal split osteotomy 110, 113
Reduction,
-, basal 24
- compression pliers 24, 34, 46
- forceps 34
- -, with compression rollers 34, 46
- -, compression force 49-52
- -, tightener 47
Rehabilitation, functional, of mandibular
defects 160
Removal of cancellous bone 8
Re-Osteosynthesis of mandibular fractures; see
Restabilization of infected fracture of mandible
Repositioning
-, basal 24
-, manual, of occlusion 23
-, of nasal fractures; see Fractures of nose
Restabilization of infected fracture of mandible with
special long plate 170--172
Restoration of function in replacement of the
mandible 165
Retention, occlusal; see Occlusion, retention

Revascularization
- of autogenous bone transplant 4
- of heterogenous bone transplant 4
Rib graft, technique of removal 6
Rigid internal fixation
-, advantages 55
-, aims 35
-, approach 21
-, by compression forces 41
-, disadvantages of intraoral procedure 22
-, indication 5, 13, 18, 21-22, 30-32, 54
-, infection 169
- -, protection 35
- -, treatment 169-174
- in compound mandibular fractures 35-40
in mandibular fractures 21-34, 35-58
- in sagittal split osteotomies 111, 115-122,
103-114
-, intraoral approach, disadvantages 22
-, objective 23
-, principles 21-34, 72
-, protection against infection 35
Roger-Anderson fixation 5
Roux's law of functional stimulation 4
Rowe's disimpaction forceps 65
Sagittal split osteotomy of ascending mandibular
ramus 98-133
-, complications 106, 109
-, fixation 109
- -, danger of wire- 98
- -, instable 111
- -, intermaxillary 112
-, follow-up treatment 108, 110
-, indication 104, 107, 111
-, infection 110
-, instruments 34, 116
-, interfragmentary compression 119
-, lag screws 118
-, length of hospital stay 109
-, osteotomy 116
-, planning, preoperative 98-102
-, principles 98-101
-, prophylaxis with antibiotics 109
-, results 103-114
-, recurrences, incidence of 103, 110, 113
-, rigid internal fixation 111, 115-122
-, simulation 98-102
-, simulograph, description 101
-, simulography 99-102
Scar(s), relevance in Rigid internal fixation 56
Screw(s)
-, cancellous bone-; see Cancellous bone screw(s)
-, excentric insertion 145
- holes, positioning 44
-, lag-; see Lag Screw(s)
-, loosening 44
- tightener; see Reduction compression pliers
Sensation disturbances, in patients with Dynamic
compression implants (DCI) 135

Simulography
- in prognathism and retrognathism 98-102
- in sagittal split osteotomy 98-102
Skin incision(s)
- for emplacement of condylar prosthesis 120
- in blow-out fractures 76
- in fractures at site of lower orbital rim 76
- in fractures at site of sutura frontozygomatica 76
- in fractures of horizontal ramus 77
- in fractures of malar complex 76
- in fractures of mental region 77
- in fractures of naso-ethmoidal complex and nose
76-77
in fractures of zygomatic arch 76
Spherical gliding principle
- of screw in Dynamic compression implant
(DCI) 145
- of screw in rigid internal fixation 28
Stabilization of bone grafts, special plate 156
Stability
-, absolute 24
-, absolute, in implants 139-140
-, dynamic compression implant (DCI), experimental
studies 144
-, functional, definition 144
Stabilization plate 26, 27
Static force(s), in relation to functional stress 45
Stay in hospital, length of 55
Stimulation of function in bone graft(s) 13
Stress
concentration as stimulus for formation of
bone 130
fracture(s) 165
Subluxation of temporomandibular joint, treatment;
see Temporal bolting osteoplasty
Suction drain in bone graft removal 5

Teleradiography in sagittal split osteotomy 98


Temporal bolting osteoplasty 81-87
-, access to temporomandibular joint 82
-, Ernst's ligature 83
-, extra-articular bolting 81-82
-, indication 85
-, instruments 84
-, postoperative treatment 85
-, skin incision 83
-, technique 83-84
'Temporomandibular joint
-, access 82, 85
-, luxation 81
- -, operative treatment 81-87
-, pre-articular approach 81
-, subluxation 81
-, true dislocation 81
-, type 81
Tension band 24, 26-27, 41
- as arch bar 50, 51
- -, indication 56

193

Tension band, combination with stabilization plate


27, 50
Time factor, evaluation in implants 139
Titanium mesh 165
Tooth, (teeth)
-, impacted 8
-, in close contact with fracture line 170
- movement 41
Tooth in fracture gap
-, incidence of infection 56
-, management 64
-, sequelae 170
Topography
- of branches of mandibular nerve and maxillary
artery 86
- of pterygoid plexus 86
Traction( al)
callus 27
- forces 27
- side 27
Trajectory
-, pressure - 26
-, traction - (pulling-) 26
Transcutaneous fixation 5
Transfacial Kirschner wires 65
Transplants
-, bone; see also Bone transplantation
- -, autogenous 3-18, 93

194

Transplants, bone, cancellous 7-12, 173


- -, cell(s) 12
- -, heterogenous 11
- -, homologous 7-12
- -, primary, for reconstruction of mandible 74
- -, revascularization 61
- -, rigid internal fixation 61
-, rib, free composite, microsurgical
anastomoses 13
-, vessel(s) 5
- -, by microsurgical vascular anastomoses 5
Trocar for perfacial screwing; see Instruments
Unfitness for work 55
Vascularization in area of implantation (DC!)
135
-, at recipient site of transplant 5
Volkman's canals 3

129,

Wound cleansing with jet spray 73


Wound infection in maxillofacial surgery; see
Infection(s), wound(s)
X-ray(s)
-, osteolytic zones as signs of instability 174
Xylenol-orange, contrasting fluorochrome(s) 14

Related Titles
W. W. Rittmann, S. M. Perren

Cortical Bone Healing after Internal Fixation


an Infection
Biomechanics and Biology. In cooperation with
M. Allgower, F. H. Kayser, J. Brennwald
The Dynamic Compression Plate (DCP)
By M. Allgower, P. Matter, S. M. Perren,
T. Riiedi
M. E. Miiller, M. Allgower, R. Schneider,
H. Willenegger

Manual of Internal Fixation


Technique Recommended by the AO-Group
(Swiss Association for the Study of Internal
Fixation, ASIF). In collaboration with W. Bandi,
A. Boitzy, R. Ganz, U. Heim, S. Perren, W. W.
Rittmann, T. Riiedi, B. G. Weber, S. Weller
(2nd edition in preparation)
U. Heim, K. M. Pfeiffer

Small Fragment Set Manual


Technique Recommended by the ASIF-Group
(Swiss Association for the Study of Internal
Fixation). In collaboration with H. C. Meuli
H. M. Tschopp

Microsurgical Neuro-Vascular Anastomoses for


Transplantation of Composite Bone and Muscle
Grafts (An Experimental Study)

Springer -Verlag
Berlin
Heidelberg
New York

Journals
Aesthetic Plastic Surgery
International Orthopaedics
World Journal of Surgery

Springer
AV
Instruction
Program

Films:
Internal Fixation
of Fractures:
Internal FixationBasic Principles and
Modern Means
M Allg6wer, Basle;
S. M. Perren, Davos
Internal Fixation
of Forearm Fractures
Th. Riiedi, Basle;
M. Allg6wer, Basle;
A. v. Hochstetter, Basle
Internal Fixation
of Noninfected
Diaphyseal Pseudarthroses
M. E. Milller, Bern;
R.Ganz,Bern
Internal Fixation
of Malleolar Fractures
B. G. Weber, St. Gall
Internal Fixation
of Patella Fractures
B. G. Weber, St. Gall
Medullary Nailing
S. Weller, Tiibingen;
F. Schauwecker, Tiibingen
Internal Fixation
of the Distal End of the
Humerus
C. Burri, VIm; A. Riiter, VIm

Springer-Verlag
Berlin
Heidelberg
New York

Allo-Arthroplasty:
Total Hip Prostheses (3 parts)
Part 1: Instruments.
Operation on Model
Part 2: Operative Technique
Part 3: Complications.
Special Cases
M. E. Miiller, Bern;
R.Ganz,Bern
Elbow-Arthroplasty
with the New GSB-Prosthesis
N. Gschwend, Zurich;
H. Scheier, Zurich

Slide Series:
Small Fragment Set Manual
Internal FixationBasic Principles
Modern Means
Biomechanics
Internal Fixation of Patella
and Malleolar Fractures
Total Hip Prostheses
Operation on Model and
in vivo/Complications and
Special Cases
ASIF-Technique for
Internal Fixation of Fractures
Technical data: 16 mm and
super-8 (Eastmancolor,
magnetic sound, optical
sound), EVR, videocassettes.

Internal Fixation
of Mandibular Fractures
B. Spiessl, Basle; J. Prein, Bas1e; All fIlms in English or
B. A. Rahn, Davos
German, several in French;
Slide series with
Corrective Osteotomy
multilingual legends
of the Distal Tibia
M. Allg6wer, Basle;
Th. Riiedi, Basle
Sales:
The Biomechanics
Springer-Verlag,
of Internal Fixation
D-l<m Berlin 33,
S. M. Perren, Davos;
Heidelberger Platz 3
B. A. Rahn, Davos;
J. Cordey, Davos
or
Springer-Verlag
New York Inc.
Internal Fixation
of Tibial Head Fractures
175 Fifth Avenue,
New York, NY 10010
C. Burri, VIm; W. Spier, U1m