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J. Cranio-Max.-Fac. Surg. 16 (1988)

Summary
Miniplate osteosynthesis has proven to be an invaluable aid when used in severe cranio-maxillo-facial trauma and has thus eliminated the necessity for external fixation devices. Primary exact anatomical reduction, and fixation of the fragments with miniplates, gives both good aesthetic and functional results. Key Words Cranio-maxillo-facial trauma - Primary reconstruction - Miniplate osteosynthesis

j. Cranio-Max.-Fac.Surg.16 (1988) 18-21 GeorgThiemeVerlagStuttgart New York

Primary Reconstruction with AO-Miniplates after Severe CranioMaxillofacial Trauma

Peter Stoll and Wilfried Schilli
Dept. of Oral and Maxillo-FacialSurgery(Head:Prof.W. Schilli,M. D., D. M. D.),UniversityHospital,Freiburg/Breisgau,W.-Germany Submitted 30.9.86; accepted 18.2.87

to the much more delicate primary osteoplasty. Intermaxillary fixation is not necessary.

Introduction
Failures and errors in the treatment of severe midface fractures often lead to residual traumatic deformity and disability which are extremely difficult or impossible to correct secondarily. These visible alterations may depress patients and render them unsuitable for many professions. In the face, the aesthetic appearance has to be considered equal in importance to function. The displacement of bony fragments can also be responsible for such malfunctions as double vision, anosmia and malocclusion. The problem Since midface injuries heal rapidly and are often consolidated after three weeks even in poor position, many authors have recently stressed the importance of primary repair within the first few days (Stoll et al. 1983, Raveh et al. 1984, Stoll et al 1985, Gruss et al. 1985, Manson et al. 1985). Secondary repair requires osteotomies and often underlying bone grafts and can also be extremely difficult due to the contraction of soft tissues. Primary dislocation of parts of the midface by the trauma itself, or secondary muscle pull, can produce malocclusions such as an open bite and anterior or lateral crossbite. After scar formation and shrinkage of soft tissues, subsequent reconstructive efforts to eliminate the malocclusion are often inadequate. On the other hand primary repair and internal fixation are clearly visualised at open operation and therefore relatively easy to do. Especially in comminuted or defect-fractures, interfragmentary wiring is often inadequate to achieve three-dimensional stability. Cranial support of the maxilla is practically non-existent following central midface "blowout"-fractures. The use of frontal or zygomatic wire suspension (Adams 1942, Edwards 1965, Kufner 1970) cannot avoid the danger of displacement of the maxilla in a vertical direction during the tightening of the wires, even when combined with intermaxillary fixation. Therefore, Gruss et al. (1985) and Manson et al. (19.85) recommend immediate extended open reduction and bone grafting. We accomplish the goal of reconstruction, in aiming for one stage repair, by the use of screws and AO-miniplates. By means of this rechnique we achieve results comparable

Material and Method

In the last two years (1984 and 1985) 56 patients with major facial injuries were treated (Department of Oral and Maxillo-Facial Surgery, University Hospital, Freiburg/Br., W.-Germany). Most cases were comminuted fractures with loss of cranial support of the maxilla or infraorbital bony defects (Fig. 1). These defects were bridged with long AOminiplates without primary bone grafting. In the same way we repaired defects and depressions of the forehead (Fig. 2). Plates and screws were removed after 6 to 12 months. At this time patients underwent clinical and radiographic review (Tab. 1 and 2). Of particular interest was the aesthetic result. Function and subjective complaints were also recorded. Radiographically the position of the midface was analyzed by lateral cephalometry (Rakosi 1979), while bone healing and sinus-radiolucency were assessed by Water's projection.

Results
In all cases we observed stable bony healing of the fractures. No secondary bone grafting was necessary. Consistent reconstruction of the facial skeleton and stabilization with screws and plates avoided production of the so-called "dish-face" deformity. Unfavourable aethetic results such as flattening and asymmetry were recorded in 20.3 %. Malocclusion was

Tab. 1

Clinical Examination. Function - occlusion articulation anosmia visual acuity

Aesthetics - dish face - asymmetry - nose deformity

of the teeth

Subjective complaints headache sensitivity to weather changes maxillary sinus s y m p t o m a t o l o g y

Primary Reconstruction with AO-Miniplates

J. Cranio-Max.-Fac. Surg. 16 (1988)

19

Fig. 1 a

Fig. 1 b

Fig. 1 d

Fig, 1 c

Fig. 1 e

Fig. 1 a - e Comminuted fracture in the mid-face area with large bony defects and loss of cranial support of the maxilla; stabilisation with AO-miniplates.

relatively rare (9.7 %). Subjective complaints were found in 21.4 % (Tab. 3). Cephalometric analysis in most cases showed normal values and, especially, tilting of the maxilla was acceptable. The ANB-angle which best demonstrates the 'position of the maxilla appeared to be in the normal range.

Water's projection showed, in the majority of the cases, no

gaps in the continuity of the facial skeleton. Only in a few cases were bony steps and poor sinus-radiolucency recorded. Discussion and Conclusion Since the utilization of miniplate osteosynthesis in complex midfacial injuries (Schilli et al. 1977, 1981, Schilli and Niederdellmann, t980; Stoll et al., 1985), in our experience secondary deformities and disturbances of function seldom seem to occur. The incidence of unfavourable

Tab.2

X-ray Examination,

Lateral cephalometric radiograph - SNA - SNPr. - SNB -incl. - basis - ISN - S Spp Water's projection - bone steps - bone defects - sinus tranlucency

(Rakosi 1979)

a n g l e ~ p o s i t i o n of midface

Tab.3

Results of Clinical Examination. miniplate osteosynthesis wire suspension (Stollet al. 1985) 43.8 % 21% 56.3%

unfavourable aesthetics: (fLattening, asymmetry) disturbance of occlusion subjective complaints

20.3% 9.7% 21.4%

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J. Cranio-Max.-Fac. Surg. 16 (1988)

P. Stoll and W. Schilli

Fig.2a

Fig.2d

Fig.2b

Fig. 2 c
Fig.2a-e Defect and depression of the forehead and midface area; reduction and stabilisation with AO-miniplates.

Fig. 2 e

results using internal wire suspension is much higher (Stoll et al. 1985). The advantages of miniplate osteosynthesis are obvious. Early function without intermaxillary fixation can be achieved. In comminuted fractures with loss of cranial support, intermaxillary immobilization does not guarantee normal projection of the maxilla. Only by open reduction and interfragmentary miniplate osteosynthesis is adequate restoration possible. Bony fragments must not be removed, since they are essential when performing a "jig-saw puzzle"-reconstruction. Furthermore, primary one-stage reconstruction can minimize or eliminate extensive secondary surgical treatment such as osteotomies and osteoplasties. Due to the import-

ance of anatomical maxillo-facial reconstruction, primary repair has a high priority. In this sense we agree completely with Gruss et al. (1985) and Manson et al. (1985). Nevertheless, in our experience, the need for primary bone grafting is seldom indicated when using miniplate osteosynthesis.

References Adams, W.M.: Internal wiring fixation of facial fractures. Surg. 12 (1942) 523-540 Edwards, J. W.: Modified technique for the placement of circum-zygomatic wires. Br. J. Oral Surg. 2 (1965) 205 Gruss, J.S., S.E. Mackinnon, E.E. Kassel, P.W. Cooper: The role of

Primary Reconstruction with AO-Mioniplates

primary bone grafting in complex cranio-maxillo-facial trauma. Plast. Reconstr. Surg. 75 (1985) 17-24 Kufner, J.: A method of cranio-facial suspension. J. Oral Surg. 28 (1970) 260-262 Manson, P.N., W.A. CrawIey, M.J. Yaremchuk, G.M. Rochman, J.E. Hoopes, J.H. French: Midface fractures: Advantages of immediate extended open reduction and bone grafting. Plast. Reconstr. Surg. 76 (1985) 1-10 Rakosi, Th.: Atlas und Anleitung zur praktischen Fernr6ntgenanalyse. Hanser, Miinchen (1979) Raveh, J., M. Redli, T.-M. Markwalder: Operative management of 194 cases of combined maxillo-facial-frontobasal fractures: Principles and surgical modifications. J. Oral Maxillo-Fac. Surg. 42 (1984) 555-564 Schilli, W., H. Niederdellmann, F. Hdrle: Schrauben nnd Platten am Mittelgesicht und Orbitaring. In: Schuchardt K., R. Becker (ed.): Fortschritte der Kiefer- und Gesichts-Chirurgie. Vol. 22 Thieme, Stuttgart (1977) 47-49

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Schilli, W., H. Niederdellmann: Verletzungen des Gesichtssch~idels. In: Aktuelle Probleme der Chirurgie und Orthop~idie, Vol. 8, Huber, Bern (1980) 43-75 Schilli, W., R. Ewers, H. Niederdellmann: Bone fixation with screws and plates in the maxillo-facial region. Int. J. Oral Surg. 10 (1981) 329 Stoll, P., W. SchiIli, U. Joos: The stabilization of midface-fractures in the vertical dimension. J. max.-fac. Surg. 11 (1983) 248-251 StoII, P., U. Joos, W. Schilli: Vermeidung des "dish-face" bei der Versorgung yon Mittelgesichtsfrakturen. In: Fortschritte der Kieferund Gesichtschirurgie, Vol. 30, Thieme, Stuttgart (1985) 121-124 Dr. Dr. P. Stoll, M. D., D. M. D. Zentrum fiir Zabn-, Mund- und Kieferhei[kunde Abteilung III Zahn-, Mund- uncl Kieferchirurgie Hugstetter Stra~e 55 D-7800 Freiburg/Breisgau, W.-Germany