14 M. Champy, ]. P. Loddd, R. Schmitt, ]. H. Jaeger, D.

Muster

par lambeau frontal. Ann. Chit. Plast. 17 (1972)
191
Marchac, D., ]. Cophignon, A. Rey, C. Cl. Chai: R~pa-
rations des fracas fronto-orbitaires par reposition
ou ost~otomie et greffes osseuses. Ann. Chit. Ptast.
19 (1974) 4[
Merville, L.: Multiple dislocations of the facial skele-
ton. J. max.-fac. Surg. 2 (1974) 187
MerviUe L., ]. Vincent: Traumatismes de la face. Dis-
locations multiples, in techniques chirurgicalcs,
orthopfidie, traumatologie. Encycl. M6d.-Chir.
(Paris) 3 - 23 - 10 - 45560 - Editor
Merville, L .C., ]. Vincent, H. Thomas: Dislocations
multiples de ]a face. Ann. Chir. Plast. 19 (1974)
105
Pastoriza, ]., P. Tessier, J. P. Delbet: Cranioplasties
de la voute. Ann. Chir. Plast. 18 (1973) 261
Peri, G., ]. Chabannes, ]. ]ourde, R. Menes: Int~r~t
de la reconstitution primaire de la route frontale
osseuse fracturfie. Ann. Chir. Plast. 17 (1972) 19
Peri, G., ]. Chabannes, ]. ]ourde, R. Menes: Trauma-
tismes r6cents du 1/3 m~dian crauio-facial (attitu-
des th~rapeutiques). Ann. Chir. Plast. 17 (1972) 260
Peri, G., ]. Chabannes, ]. ]ourdes, ]. Fain: Essai de
classification des traumatismes fronto-basaux. Ann.
Chit. Plast. 19 (1974) 297
Stricher, M., ]. Montaut, G. Malha, H. Hepner, ]. P.
Lodde: R6paration de la voute cranienne - InfarCt
des cranioplasties. Ann. Chit. Plast. 19 (1974) 289
Tessier, P.: Ost6otomies totales de la face, syndrome
de Crouzon, syndrome d'Apert, oxyc@halies, sca-
phocephalies, turric6phalies. Ann. Chir. plast. 12
(1967 a) 273
Tessier, P. G. Guiot, ]. Rougerie, ]. P. Delbet, ]. Pasto-
riza: Ost~ot0mies cranio-naso-orbito faciales, hyper-
telorisme. Ann. Chir. Hast. 12 (1967b) 103
L. C. Merville, M.D., D.M.D.
Clinic for Maxillo-Facial Surgery
Foch Hospital
9215, Suresnes-Paris, France
and 118 Bd Raspail F-75006 Paris

J. max.-fac. Surg. 6 (1978) 14-21

Mandibular Osteosynthesis by Miniature Screwed Plates Via a

Buccal Approach*
Maxime CHAMPY,J. P. LODDI~, R. SCHMITT, J. H. JAEGER, D. MUSTER

Service de Stomatologie et Chirurgie Maxillo-Faciale (Head: Prof. M. Champy, M.D., D.M.D.),

Centre Hospitalo-Universitaire de Strasbourg, France

Summary
The modified Michelet's (1973) technique of mandi-
bular osteosynthesis, which consists of monocortical
juxta-alveolar and sub-apical osteosynthesis, without
compression and without inter-maxillary fixation, is
described. This technique can be used in many types
of mandibular fracture, single or multiple, associated
or isolated, except in the case of a fracture of the
condylar neck and in the presence of pre-existing in-
fection. Infected fractures are treated by orthopaedic
methods. Materials used (plates and screws) and
particulars of the method have been tested by multi-
disciplinary experimentation, particularly by anatomi-
cal verification and biomechanical studies. The ideal
line of osteosynthesis is described. For the author, this
technique is a routine treatment of any type of mandi-
bular fracture.
Key-Words: Mandibular osteosynthesis; Miniaturized
screwed plates; Fracture compression.
;:" Paper read at the 3rd Congress of the E.A.M.F.S.,
London, September 1976.
Introduction
This study concerns 183 cases of m a n d i b u l a r
osteosynthesis with an up to five year follow-up.
The method used was our modification of
Michelet's Technique (1973), which consists of mo-
nocortical j u x t a - a l v e o l a r and sub-apical osteo-
synthesis, without compression and without inter-
maxillary fixation, using miniature malleable
plates.
Technique
The operation is performed under general an-
aesthesia and is accomplished as early as possible,
i. e. between one to six hours after trauma. Our
technique can be used in any type of m a n d i b u l a r
fracture, be it single or multiple, associated or
isolated, except in the case of fracture of the
condylar neck or ascending ramus, and in the
presence of pre-existing infection.

0301-0503/78 1300-0014 $ 05,00 1978 Georg Thieme Publishers

 Mandibular Osteosynthesis by Miniature Screwed Plates
A scrupulous disinfection of the oral cavity is
performed with chlorhexidine. The mucosal in-
cision is made 3 mm below the attached gingiva
(in order to permit easy suturing), the scalpel
incising the periosteum and preserving the
mandibular nerve.
The fracture and its adjacent area are exposed
by very careful periosteal elevation. A n assistant
placed at the head of the patient reduces the
fracture and che&s the occlusion while the ope-
rator selects the synthesis site and contours the
plate to the mandible's surface using W a l d -
sachs pliers. While the fragments are firmly
maintained in proper reduction, a hole is made
with a drill, and the first screw is placed. Sub-
sequent screws are inserted one at a time. Two
screws are placed on the posterior fragment, and
two on the anterior fragment.
Complex fixation is sometimes required when
several fracture lines are associated. Stability of
the fixation and quality of the cuspal interdigi-
ration are then tested, and finally the mucosa
is carefully sutured with non-resorbable silk
without drainage. Sutures are removed 10 days
later.
Some useful practical hints are as follows: Du-
ring the screw insertion, eccentricity of the holes
drilled in the bone should be avoided. There-
fore the drill should be chosen taking into ac-
count the core diameter of the screw (16/10 mm
for the material that we have invented). The
drilling should be strictly straight, preferably
with a guide and the cortical bone should only
be punctured once. Excessive drilling produces
a cone-shaped hole but not a cylinder, conse-
quently diminishing the number of effective
threads. The cortical thickness being approxima-
tely 3 mm, the use of a screw with 10/10 channel
results only in the anchorage of 3 threads. W h e n
the drilling results in a cone, 1 or 2 threads be-
come ineffective thus diminishing the plating
solidity.
It is necessary to cool the bone and to use a low
speed drill. For screw tightening, it is necessary
to use a screw-holding screw-driver, to execute
2 rotations and then to use the conventional
screwdriver. The threads of the screw should
not be distorted by excessive tightening and the
plate should be carefully contoured to the man-
15
dible's surface by means of modified Waldsachs
pliers.
Finally, the posterior screws are inserted first as
mentioned previously, and then the anterior
ones. As a consequence of its malleability, the
adaptation of the plate to the bone contour oc-
curs without creation of a countertorque effect.
Some special factors are now to be considered
according to the fracture site. In certain cases,
to ensure avoidance of tooth apices and mental
nerve compression by the plate, it may be useful
to lower the foramen by making a vertical slot
from the inferior dental foramen and set the
nerve inferiorly.
In front of the mandibular foramen, or, accu-
rately, in front of the canine, 2 malleable plates,
41/2 mm apart, are required to prevent torsion
moments. The inferior plate is inserted first, then
the sub-apical one. In the horizontal ramus, be-
hind the mental foramen, one sub-apical plate
is quite sufficient. The synthesis should done
higher the more posterior the fracture is located.
For osteosynthesis at the angle, it is known that
for several years Michelet et al. (1973) have used
the vestibular osseous fiat area located beside the
third molar as the osteosynthesis site; that is a
genuine ridge made by the external oblique line.
The plates are located in a frontal plane and
the screws positioned in a sagittal direction.
W h e n this area cannot be employed (too narrow
a ridge, impacted mandibular third molar, al-
veolar fracture, too young a subject, etc.) the
plate should be applied as high as possible, on
the lateral surface of the mandible using the
trans-buccal technique (even in the most difficult
cases, a skin incision is unnecessary): After ex-
posure of the angle through the intra-oral ap-
proach, the cheek is transfixed with a needle
and the osteosynthesis area is determined (as
high as possible). The skin is then punctured
with the knife, penetration of the musculo-apo-
neurotic tissue is achieved by means of the trocar
provided with its guide. The stilette is now
withdrawn from the trocar and the guide is
screwed on the retractor with lighting introduced
through the buccal approach. The screw-holding
screw-driver then enables screw fixation via the
transbuccal guide. W e use this transbuccal me-
thod in approximately 20/0 of the cases of osteo-
synthesis at the angle.
16 M. Champy, J. P. Loddd, R. Schmitt, J. H, Jaeger, D. Muster

logical was produced. Infection was found in

3.8O/o of 183 cases treated. Malunion occurred in
0.50/o and delayed union in 0.50/0. In 4.8/o,
grinding was needed to adjust the occlusion.
Once again, this should be compared with pre-
sently used orthopaedic procedures where the
incidence of side effects is more frequent.

Fig. 1 Mandibular Strains: Tensile stresses along
the alveolar border: Compressive stresses along the
lower border: + (from Champy et al, 197G Rev.
Storn,, Paris).
Results
Discussion
The particulars of the method, that is mono-
cortical, juxta-alveolar and sub-apical osteo-
synthesis, without compression and without inter-
maxillary fixation, have been che&ed by multi-
disciplinary experimentation with a group of
engineers ( Geboas )l.

W e have treated a total of 183 mandibular frac-
tures using 226 plates, and patients have been
followed up for periods of up to 5 years.
In no case did we find any displacement of the
fixation. All 183 patients were able to eat soft
food on the first postoperative day, and they
could eat normal food from the tenth postopera-
tive day. This should be compared with an aver-
age of 4 weeks using present orthopaedic me-
thods before solid food can be taken (Lentrodt
and Luhr 1969, Freihofer and Sailer 1973).
Recently, we have improved the material used
for the plates (Champy and Lodde 1976, Cham-
py et al. 1975, a, b, 1976). Since then, we have
treated a series of 100 cases in whom the inci-
dence of any side effects was less than 30/0
(Table i-4-2). Side effects and postoperative in-
fection were found to be very limited. Not a
single iatrogenic injury, either dental or neuro-
Monocortical fixation is sufficient. This has been
demonstrated by anatomical verifications and
biomechanical studies of the resistance of the
outer cortical plate. The latter included experi-
ments involving tearing out the screws using
Lhomargy's machine, studies of the shearing
strains of the screws and determination of the
breaking load of human mandibles. A synthesis
by plates screwed on the outer cortical plate is
solid enough to support the strains developed
by the masticatory muscles. The location of the
plates may be precisely determined by the study
of the stress distribution, of photo elasticity
and the calculation of the moments.
On the horizontal ramus, the masticatory forces
create within the mandible elongation strains
1 Geboas: Grupe d'4tudes en Biom6chanique often et
articulaire de Strasbourg (Group of Research in Bone
and Joint Biomechanic of Strasbourg).

Table 1 In which different types of plates are used 1971-1974.

Number of Cases Plates number Suppuration without Malunion Malocclusion

delayed recoverry

83 103 6 1 7

Table 2 With C. L. plates"-, since February 1975.

Number Number Wound Cellulitis Malunion Pseudarthrosis Mal-

of Cases of Plates dehiscence occlusion

100 123 1 1 - - 2

* C. L. plates = Champy-Lodde plates (Establissements Choc, 1 rue de Geroldseck, Strasbourg, France)

 Mandibular Osteosynthesis by Miniature Screwed Plates 17

Fig. 2
Photo elasticity of a model of
araldite (from Champy et al. 1976,
Rev. Stem., Paris) before (top)
and after synthesis.

Table 3 Biting forces.

Point of Incisor Canine Premolar Molar 170 1700

application
1500, .1500

Value (Da.N.) 29 30 48 66
1000i 1000

Table 4 Strains within the plate (DaN/ram2).

5GO 500

Position Point of application

of synthesis 100 100
inc. can. premoI, me1. 0
.100 1oo
(29)* (30)* (48) (66)* _200

- - t o o ai,es i ani~ inels ira. ~,~ lairss _ _

5-6 18 13 11 19 Fig. 3 Flexion moments of the mandible (from

7-8 45 40 53
~>8 31 28 32
* Numbers in parenthesis represent biting forces from
fig. 3.
along the alveolar border, and compression
strains along the lower border. Only the traction
strains are injurious and have to be neutralized
(Fig. 1). Study of the photo elasticity of a model
of araldite, which has been cut and then syn-
thetized by a screwed plate shows that only the
juxta-alveolar plate is able to re-establish an
approximately normal stress distribution. Fig. 2
shows that the application of a force P on the
model, reveals, in polarized light, compression
21 Champy et al. 1976, Rev. Stem., Paris).
17
isostatics at the lower part and traction isostatics
at the upper part. After section of the model, and
lower border synthesis, the application of the force
P leads to the appearance of a diastema at the up-
per borderl There is no tensile stress transmis-
sion at the upper part; it rejoins the plate
through the screws, moving along the section.
A plate screwed at the lower border does not
re-establish the stress distribution existing before
the section. In the case of an upper border syn-
thesis, the stress distribution is nearly the same
as inside the model of araldite. The compression
isostatics are absolutely identical. During the
test no separation occurs. The traction isostatics

2 J. max.-fac. Surg. 1/78

 18 M. Champy, J. P. Loddd, R. Schmitt, J. H. jaeger, D. Muster

100- .100
75- -75
Z
50- - 50

25- -25
10_ 10 9 8 1 ( -10
0- i 0
-25 - -.25

t
-50- -50
-75- -75
-I00 - -100
--molaire3 incisive8 n "mola~re~--molaires

Fig. 4 Torsion moments in the mandible (from Champy, Ann. chir. Plast. Paris, 21 (1976) 115).

lower border and that the loaded part is weaker

Fig. 5 Ideal line of osteosynthesis (from Champy,
Ann. Chir. Plast. Paris, 21 (1976) 115).
rejoin the plate through the screws instead of
being directly transmitted by the araldite, but
their distribution is similar to the model's. The
strain is distributed over the whole section's
height, and this reduces the strain intensities for
the same force applied.
W e see that, in the case of lower border fixation of
the plate, the strains are concentrated at the
than in the case of a fixation with a plate
screwed at the upper border. The strain being
inversely proportional to the section, we see that
the synthesis along the alveolar border is
stronger than that at the lower border.
The study of the moments, with regard to the
mathematical model of the mandible, shows that
at the level of the horizontal ramus there are al-
most only flexion moments, the value of which
increases from the front backwards (Fig. 3).
The theoretical study of the strains which are
exerted within the material, shows that these
do not exceed 55 D a N / m m 2 (Table 3 + 4).
In the anterior part of the mandible, in front of
the 4, there are mainly moments of torsion. They
are higher the nearer they are to the mandibular
symphysis (Fig. 4). Therefore, the principle of
osteosynthesis is to re-establish the mechanical
qualities of the mandible, taking into account
the anatomical conditions. In view of our re-
sults of the theoretical, biomechanical and ex-
perimental studies, we can deduce the ideal line
of osteosynthesis (Fig. 5).
Proximal to the 4, one plate is sufficient.
In front of the 4, one can place a strong solid plate
on the lower border, however one risks an ad-
aptation of the cortical surfaces to the shape of
the plate. Alternatively, one can place two mini-
ature plates separated by 4-5 mm in order to neu-
tralize the moments of torsion (Fig. 6).
 Mandibular Osteosynthesis by Miniature Screwed Plates 19

Fig. 6
Experimental osteosynthesis: in
behind the 4, one plate is
sufficient; in front of the 4, two
plates are necessary 4 to 5 mm
apart.

Fig. 7
Plating on the flat part beside
the third molar.

Fig. 8 a Fig. 8 b Fig. 8 c

Fig. 8a-c Total reconstruction of polytraumatized patient, in one stage. - (a) Condition before treatment:
Telecanthus, malar, maxillary and mandibular fractures, rupture of Stensons duct and facial nerve. -
(b) Frontomalar and bilateral mandibular osteosyntheses. - (c) Final condition. In the same operation can-
thopexy, orbital floor reconstruction, reduction of Le Fort I fracture~ suture of facial nerve and Stensons
duct were performed. No intermaxillary or cranial fixation was used.
20 M. Champy et al.: Mandibular Osteosynthesis by Miniature Screwed Plates
Thirteen recently removed mandibles were tested
in the laboratory with different fixations. No
alteration of any fixation could be found when
tested over the known range of masticatory
forces.
In the case of angle fractures, biomechanical
studies have demonstrated that the best site for
the plating is the vestibular osseous flat part
located in the third molar region (Fig. 7). The
easy accessibility and the extreme resistance of
the cortex favour this as the site of election for
angle osteosynthesis. But an osteosynthesis lo-
cated lower, on the outer surface of the man-
dible, is solid enough to support the strain de-
veloped by the masticatory forces in this region.
A plate positioned in that zone achieves a firm
osteosynthesis despite its slightly lower situation.
Tensile strength is reduced by only 10/0 com-
pared with the usual technique.
As a result of our multidisciplinary experimen-
tation and our clinical experience, we infer, in
contrast to Spiessl and Schargus (1971), Luhr
(1972), and Schilli (1973), that the compression
of the fragments is no longer advisable because:
There exists, due to the masticatory forces, a
natural strain of compression along the lower
border.
In the previously used methods, it is impossible
to measure the force of compression created bet-
ween the fragments. Consequently, this compres-
sion can be excessive and thus can result in bone
lysis.
The use of a too rigid lower border plate is in-
advisable because it will result in the "shield
effect".
References
Champy, M., A. Wilk, ]. M. Schnebelen: Die Behand-
lung der Mandibularfrakturen mittels Osteosyn-
these ohne intramaxitl/ire Ruhigstetlung nach der
Technik yon F. X. Michelet. Zahn- u. Kieferheilk.
63 (1975a) 339
Champy, M., ]. P. Lodde, ]. H. Jaeger, A. Wilk:
A propos des ost~osynth~ses fronto-malaires par
plaques viss~es. Rev. Stomat. (Paris) 76 (1975b) 483
Champy, M., ]. P. Lodde, ]. H. ]aeger, A. Wilk, ]. C.
Gerber: Ost6osynth~ses mandibulaires selon la
technique de Michelet. I. Bases biomficaniques.
The use of compression makes the reestablish-
ment of normal occlusion more difficult.
It requires access through a transcutaneous ap-
proach.
In comparison with trans-osseous wiring, the use
of plates has major advantages: it gives a solid
and stable osteosynthesis, the surgical procedure
is easier, and inter-maxillary wiring is not ne-
cessary. Biomechanical experimentation shows
that in no case can trans-osseous wires be solid
enough to support the strains developed by
masticatory forces.
Conclusion
Our multidisciplinary approach through anatomi-
cal, biomechanical and clinical considerations has
clearly demonstrated the use of miniature and
malleable screwed plates in the sub-apical po-
sition and without compression to be currently
the most successful and simplest method for
mandibular osteosynthesis. This conclusion is
based on the following arguments:
1. The surgical approach is simple without un,
necessary scarring;
2. The side effects are greatly reduced;
3. The necessity for post-operative dental cor-
rection is greatly reduced;
4. N o inter-maxillary fixation is necessary;
5. Lastly and most importantly, the reduction
of discomfort is of great benefit to the patient.
Thus, our modification of the Michelet's tech-
nique should prove a superior al6ernative to the
common orthopaedic approach and is the proce-
dure of choice in agitated, comatose and severely
traumatized patients (Fig. 8).
II. Pr6sentation d'un nouveau mat6riel. Rfsultats.
Rev. Stomat (Paris) 77 (1976) 569
Champy, M., J. P. Lodde: Justification dc la position
des plaques d'ost6osynth~se en fonction de la lo-
calisation des contraintcs. Rev. Stomat. (Paris) 77
(1976) 971
Freiho[er, H. P., H. S. Sailer: Experiences with intra-
oral trans-osseous wiring of mandibular fractures.
J. max.-fae. Surg. 1 (1973) 248
Lentrodt, ]., H. G. Luhr: Indication for conservative
and surgical treatment ~of facial bone fractures. Pan
 C. Heidsieck: Fixation of the Edentulous Residual Portion of the Mandible
Minerva Med. 11 (1969) 88
Luhr, H. G.: Die Kompressionsosteosynthese zur Be-
handtung yon Unterkieferfrakturen. Experimenteltc
Grundlagen und klinische Erfahrungen. Dtsch. zahn-
/irztl. Z. 27 (1972) 29
Michelet, F. X., I. Deymes, B. Dessus: Osteosynthesis
with miniaturized screwed plates in maxiIlo-facial
surgery. J. max.-fac, 1 (1973) 79
Schilli, W.: lndikation und Technik der stabilen Osteo-
synthese im Unterkiefer. Vortra,g auf der Jahres-
Fixation of the ~=dentulous Residual Portion of the Mandible
in Cases of Hemimandibulectomy
Carl HEIDSIECK
Dept. of Maxillo-FaciaI Surgery (Head: Prof. C. Heidsie&, M.D., D.M.D.),
Lister Krankenhaus, Hannover, W.-Germany
Summary
A new method of fixing the edentulous residual por-
tion of the mandibular stump is described: an extraoral
apparatus as suggested by Anderson (1936) and a
malar bone screw is used for attaching a rod to fix
the mandibular stump.
Key-Words: Hemimandibuleetomy; Fixation of stump.
Introduction
A completely satisfactory and simple w a y of fix-
ing the residual edentulous m a n d i b l e in cases of
hemimandibulectomy has not yet been found.
I n t r a o r a l prosthetic measures are only success-
ful if the device used is fixed by circumferential
wiring. If both the m a n d i b l e and the maxilla
are edentulous craniofacial wiring is also neces-
sary.
Nevertheless, there is a great tendency for the
remaining part of the mandible to displace. A
new method of fixation of the stump will there-
fore be presented.
Method
T h e following method demonstrates a simple
and uncomplicated w a y of fixing the remaining
m a n d i b u l a r stump: A n extraoral apparatus as
suggested by Anderson (1936) which has also
been in use for over two decades in the treatment
of m a n d i b u l a r defects (Matthews 1957, Held-
0301-0503/78 1300-0021 $ 05.00 1978 Georg Thieme Publishers
21
tagung der deutschen Gesellschaft fiir Kiefer- und
Gesichtschirurgie, Basel 1973
SpiessI, B., G. Scharguss: Das Okklusionsprobtem bei
der funktior~sstabilen Osteosynthese des bezahnten
Unterkiefers. Dtsch. Zahn-, Mund- u. Kieferheilk.
57 (1971) 293
Prof. Maxime Champy, M.D., D.M.D.,
Maxillo-Faciale Hospice Civils,
F-67005 Strasbourg
J, max.-fac.Surg. 6 (1978)21-23
sleek 1968 etc.), is fixed to the remaining man-
dible by two screws as shown in Fig. 1 + 2.
Screw insertion technique: Stab incision over the
m a l a r bone about 1 cm lateral to the border of
the bony orbit on a level with the orbital floor.
Insert drill casing until bone is contacted. Drill
through the m a l a r bone with a twist drill until
it passes into the cavity of the m a x i l l a r y antrum.
Drill-direction: Steeply caudal in the direction
of the cupid's bow of the upper lip; at right
angles in a m e d i a l - s a g i t t a l level. Insert the
screw with the aid of a h a n d drill chu& until
bone resistance is met again,
In order to obtain a fixation point in the m a l a r
region and to provide stability, a bone screw 1
with a continuous thread 75 m m in length and
2 mm in diameter is screwed through the m a l a r
bone until it abuts against the angle between the
lateral wall of the nose and the floor of the
m a x i l l a r y antrum. The end of the screw, which
still projects should be long enough for a rod to
be attached to the R o g e r - A n d e r s o n apparatus by
an a d d i t i o n a l j o i n t (Figs. 1 to 3).
A l l the necessary attachments (joints, rods, dril-
ling equipment etc.) are available in the so-cal-
led "Stuttgarter Kieferbruchbeste&"2.
1 Made by H. Greuder, Heidelberg 1, W.-Germany,
Hertzstr. 4.
2 Made by Dentaurum, Pforzheim, W.-Germany.