Anda di halaman 1dari 8

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

Muster

par lambeau frontal. Ann. Chit. Plast. 17 (1972) tismes r6cents du 1/3 m~dian crauio-facial (attitu-
191 des th~rapeutiques). Ann. Chir. Plast. 17 (1972) 260
Marchac, D., ]. Cophignon, A. Rey, C. Cl. Chai: R~pa- Peri, G., ]. Chabannes, ]. ]ourdes, ]. Fain: Essai de
rations des fracas fronto-orbitaires par reposition classification des traumatismes fronto-basaux. Ann.
ou ost~otomie et greffes osseuses. Ann. Chit. Ptast. Chit. Plast. 19 (1974) 297
19 (1974) 4[ Stricher, M., ]. Montaut, G. Malha, H. Hepner, ]. P.
Merville, L.: Multiple dislocations of the facial skele- Lodde: R6paration de la voute cranienne - InfarCt
ton. J. max.-fac. Surg. 2 (1974) 187 des cranioplasties. Ann. Chit. Plast. 19 (1974) 289
MerviUe L., ]. Vincent: Traumatismes de la face. Dis- Tessier, P.: Ost6otomies totales de la face, syndrome
locations multiples, in techniques chirurgicalcs, de Crouzon, syndrome d'Apert, oxyc@halies, sca-
orthopfidie, traumatologie. Encycl. M6d.-Chir. phocephalies, turric6phalies. Ann. Chir. plast. 12
(Paris) 3 - 23 - 10 - 45560 - Editor (1967 a) 273
Merville, L .C., ]. Vincent, H. Thomas: Dislocations Tessier, P. G. Guiot, ]. Rougerie, ]. P. Delbet, ]. Pasto-
multiples de ]a face. Ann. Chir. Plast. 19 (1974) riza: Ost~ot0mies cranio-naso-orbito faciales, hyper-
105 telorisme. Ann. Chir. Hast. 12 (1967b) 103
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 L. C. Merville, M.D., D.M.D.
de la reconstitution primaire de la route frontale Clinic for Maxillo-Facial Surgery
Foch Hospital
osseuse fracturfie. Ann. Chir. Plast. 17 (1972) 19 9215, Suresnes-Paris, France
Peri, G., ]. Chabannes, ]. ]ourde, R. Menes: Trauma- 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 Introduction
The modified Michelet's (1973) technique of mandi- This study concerns 183 cases of m a n d i b u l a r
bular osteosynthesis, which consists of monocortical osteosynthesis with an up to five year follow-up.
juxta-alveolar and sub-apical osteosynthesis, without The method used was our modification of
compression and without inter-maxillary fixation, is
described. This technique can be used in many types
Michelet's Technique (1973), which consists of mo-
of mandibular fracture, single or multiple, associated nocortical j u x t a - a l v e o l a r and sub-apical osteo-
or isolated, except in the case of a fracture of the synthesis, without compression and without inter-
condylar neck and in the presence of pre-existing in- maxillary fixation, using miniature malleable
fection. Infected fractures are treated by orthopaedic
plates.
methods. Materials used (plates and screws) and
particulars of the method have been tested by multi-
disciplinary experimentation, particularly by anatomi- Technique
cal verification and biomechanical studies. The ideal The operation is performed under general an-
line of osteosynthesis is described. For the author, this aesthesia and is accomplished as early as possible,
technique is a routine treatment of any type of mandi- i. e. between one to six hours after trauma. Our
bular fracture.
technique can be used in any type of m a n d i b u l a r
Key-Words: Mandibular osteosynthesis; Miniaturized fracture, be it single or multiple, associated or
screwed plates; Fracture compression. isolated, except in the case of fracture of the
condylar neck or ascending ramus, and in the
;:" Paper read at the 3rd Congress of the E.A.M.F.S.,
London, September 1976. presence of pre-existing infection.

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


Mandibular Osteosynthesis by Miniature Screwed Plates 15

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

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

W e have treated a total of 183 mandibular frac- Monocortical fixation is sufficient. This has been
tures using 226 plates, and patients have been demonstrated by anatomical verifications and
followed up for periods of up to 5 years. biomechanical studies of the resistance of the
In no case did we find any displacement of the outer cortical plate. The latter included experi-
fixation. All 183 patients were able to eat soft ments involving tearing out the screws using
food on the first postoperative day, and they Lhomargy's machine, studies of the shearing
could eat normal food from the tenth postopera- strains of the screws and determination of the
tive day. This should be compared with an aver- breaking load of human mandibles. A synthesis
age of 4 weeks using present orthopaedic me- by plates screwed on the outer cortical plate is
thods before solid food can be taken (Lentrodt solid enough to support the strains developed
and Luhr 1969, Freihofer and Sailer 1973). by the masticatory muscles. The location of the
Recently, we have improved the material used plates may be precisely determined by the study
for the plates (Champy and Lodde 1976, Cham- of the stress distribution, of photo elasticity
py et al. 1975, a, b, 1976). Since then, we have and the calculation of the moments.
treated a series of 100 cases in whom the inci- On the horizontal ramus, the masticatory forces
dence of any side effects was less than 30/0 create within the mandible elongation strains
(Table i-4-2). Side effects and postoperative in-
1 Geboas: Grupe d'4tudes en Biom6chanique often et
fection were found to be very limited. Not a articulaire de Strasbourg (Group of Research in Bone
single iatrogenic injury, either dental or neuro- 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 21 Champy et al. 1976, Rev. Stem., Paris).
~>8 31 28 32 17
isostatics at the lower part and traction isostatics
* Numbers in parenthesis represent biting forces from
fig. 3. 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-
along the alveolar border, and compression per borderl There is no tensile stress transmis-
strains along the lower border. Only the traction sion at the upper part; it rejoins the plate
strains are injurious and have to be neutralized through the screws, moving along the section.
(Fig. 1). Study of the photo elasticity of a model A plate screwed at the lower border does not
of araldite, which has been cut and then syn- re-establish the stress distribution existing before
thetized by a screwed plate shows that only the the section. In the case of an upper border syn-
juxta-alveolar plate is able to re-establish an thesis, the stress distribution is nearly the same
approximately normal stress distribution. Fig. 2 as inside the model of araldite. The compression
shows that the application of a force P on the isostatics are absolutely identical. During the
model, reveals, in polarized light, compression 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


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
Fig. 5 Ideal line of osteosynthesis (from Champy, qualities of the mandible, taking into account
Ann. Chir. Plast. Paris, 21 (1976) 115).
the anatomical conditions. In view of our re-
sults of the theoretical, biomechanical and ex-
perimental studies, we can deduce the ideal line
rejoin the plate through the screws instead of
of osteosynthesis (Fig. 5).
being directly transmitted by the araldite, but
Proximal to the 4, one plate is sufficient.
their distribution is similar to the model's. The
In front of the 4, one can place a strong solid plate
strain is distributed over the whole section's on the lower border, however one risks an ad-
height, and this reduces the strain intensities for aptation of the cortical surfaces to the shape of
the same force applied. the plate. Alternatively, one can place two mini-
W e see that, in the case of lower border fixation of ature plates separated by 4-5 mm in order to neu-
the plate, the strains are concentrated at the 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 The use of compression makes the reestablish-
in the laboratory with different fixations. No ment of normal occlusion more difficult.
alteration of any fixation could be found when It requires access through a transcutaneous ap-
tested over the known range of masticatory proach.
forces.
In comparison with trans-osseous wiring, the use
In the case of angle fractures, biomechanical of plates has major advantages: it gives a solid
studies have demonstrated that the best site for and stable osteosynthesis, the surgical procedure
the plating is the vestibular osseous flat part is easier, and inter-maxillary wiring is not ne-
located in the third molar region (Fig. 7). The cessary. Biomechanical experimentation shows
easy accessibility and the extreme resistance of that in no case can trans-osseous wires be solid
the cortex favour this as the site of election for enough to support the strains developed by
angle osteosynthesis. But an osteosynthesis lo- masticatory forces.
cated lower, on the outer surface of the man-
dible, is solid enough to support the strain de- Conclusion
veloped by the masticatory forces in this region.
Our multidisciplinary approach through anatomi-
A plate positioned in that zone achieves a firm
cal, biomechanical and clinical considerations has
osteosynthesis despite its slightly lower situation.
clearly demonstrated the use of miniature and
Tensile strength is reduced by only 10/0 com-
malleable screwed plates in the sub-apical po-
pared with the usual technique.
sition and without compression to be currently
As a result of our multidisciplinary experimen- the most successful and simplest method for
tation and our clinical experience, we infer, in mandibular osteosynthesis. This conclusion is
contrast to Spiessl and Schargus (1971), Luhr based on the following arguments:
(1972), and Schilli (1973), that the compression 1. The surgical approach is simple without un,
of the fragments is no longer advisable because: necessary scarring;
There exists, due to the masticatory forces, a 2. The side effects are greatly reduced;
natural strain of compression along the lower 3. The necessity for post-operative dental cor-
border. rection is greatly reduced;
In the previously used methods, it is impossible 4. N o inter-maxillary fixation is necessary;
to measure the force of compression created bet- 5. Lastly and most importantly, the reduction
ween the fragments. Consequently, this compres- of discomfort is of great benefit to the patient.
sion can be excessive and thus can result in bone Thus, our modification of the Michelet's tech-
lysis. nique should prove a superior al6ernative to the
The use of a too rigid lower border plate is in- common orthopaedic approach and is the proce-
advisable because it will result in the "shield dure of choice in agitated, comatose and severely
effect". traumatized patients (Fig. 8).

References

Champy, M., A. Wilk, ]. M. Schnebelen: Die Behand- II. Pr6sentation d'un nouveau mat6riel. Rfsultats.
lung der Mandibularfrakturen mittels Osteosyn- Rev. Stomat (Paris) 77 (1976) 569
these ohne intramaxitl/ire Ruhigstetlung nach der Champy, M., J. P. Lodde: Justification dc la position
Technik yon F. X. Michelet. Zahn- u. Kieferheilk. des plaques d'ost6osynth~se en fonction de la lo-
63 (1975a) 339 calisation des contraintcs. Rev. Stomat. (Paris) 77
Champy, M., ]. P. Lodde, ]. H. Jaeger, A. Wilk: (1976) 971
A propos des ost~osynth~ses fronto-malaires par Freiho[er, H. P., H. S. Sailer: Experiences with intra-
plaques viss~es. Rev. Stomat. (Paris) 76 (1975b) 483 oral trans-osseous wiring of mandibular fractures.
Champy, M., ]. P. Lodde, ]. H. ]aeger, A. Wilk, ]. C. J. max.-fae. Surg. 1 (1973) 248
Gerber: Ost6osynth~ses mandibulaires selon la Lentrodt, ]., H. G. Luhr: Indication for conservative
technique de Michelet. I. Bases biomficaniques. and surgical treatment ~of facial bone fractures. Pan
C. Heidsieck: Fixation of the Edentulous Residual Portion of the Mandible 21

Minerva Med. 11 (1969) 88 tagung der deutschen Gesellschaft fiir Kiefer- und
Luhr, H. G.: Die Kompressionsosteosynthese zur Be- Gesichtschirurgie, Basel 1973
handtung yon Unterkieferfrakturen. Experimenteltc SpiessI, B., G. Scharguss: Das Okklusionsprobtem bei
Grundlagen und klinische Erfahrungen. Dtsch. zahn- der funktior~sstabilen Osteosynthese des bezahnten
/irztl. Z. 27 (1972) 29 Unterkiefers. Dtsch. Zahn-, Mund- u. Kieferheilk.
Michelet, F. X., I. Deymes, B. Dessus: Osteosynthesis 57 (1971) 293
with miniaturized screwed plates in maxiIlo-facial
surgery. J. max.-fac, 1 (1973) 79
Prof. Maxime Champy, M.D., D.M.D.,
Schilli, W.: lndikation und Technik der stabilen Osteo- Maxillo-Faciale Hospice Civils,
synthese im Unterkiefer. Vortra,g auf der Jahres- F-67005 Strasbourg

J, max.-fac.Surg. 6 (1978)21-23

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 sleek 1968 etc.), is fixed to the remaining man-


A new method of fixing the edentulous residual por- dible by two screws as shown in Fig. 1 + 2.
tion of the mandibular stump is described: an extraoral Screw insertion technique: Stab incision over the
apparatus as suggested by Anderson (1936) and a
malar bone screw is used for attaching a rod to fix m a l a r bone about 1 cm lateral to the border of
the mandibular stump. the bony orbit on a level with the orbital floor.
Insert drill casing until bone is contacted. Drill
Key-Words: Hemimandibuleetomy; Fixation of stump. 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.
Introduction Drill-direction: Steeply caudal in the direction
A completely satisfactory and simple w a y of fix- of the cupid's bow of the upper lip; at right
ing the residual edentulous m a n d i b l e in cases of angles in a m e d i a l - s a g i t t a l level. Insert the
hemimandibulectomy has not yet been found. screw with the aid of a h a n d drill chu& until
I n t r a o r a l prosthetic measures are only success- bone resistance is met again,
ful if the device used is fixed by circumferential In order to obtain a fixation point in the m a l a r
wiring. If both the m a n d i b l e and the maxilla region and to provide stability, a bone screw 1
are edentulous craniofacial wiring is also neces- with a continuous thread 75 m m in length and
sary. 2 mm in diameter is screwed through the m a l a r
Nevertheless, there is a great tendency for the bone until it abuts against the angle between the
remaining part of the mandible to displace. A lateral wall of the nose and the floor of the
new method of fixation of the stump will there- m a x i l l a r y antrum. The end of the screw, which
fore be presented. 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
Method an a d d i t i o n a l j o i n t (Figs. 1 to 3).
T h e following method demonstrates a simple A l l the necessary attachments (joints, rods, dril-
and uncomplicated w a y of fixing the remaining ling equipment etc.) are available in the so-cal-
m a n d i b u l a r stump: A n extraoral apparatus as led "Stuttgarter Kieferbruchbeste&"2.
suggested by Anderson (1936) which has also
1 Made by H. Greuder, Heidelberg 1, W.-Germany,
been in use for over two decades in the treatment Hertzstr. 4.
of m a n d i b u l a r defects (Matthews 1957, Held- 2 Made by Dentaurum, Pforzheim, W.-Germany.

0301-0503/78 1300-0021 $ 05.00 1978 Georg Thieme Publishers

Minat Terkait