Indications for lag screw. Technique?

Article they requested was not on lag screws:

JCraniomaxillofacial trauma form 1997, Lag screw techniuq of mandible fractures, Ellis
It is a simple technique, has a wide application and achieves great stability but over the years
has been found to be very techinquesensitive. Most useful for mandibular body, angle and
symphis of non-compound fractures.
From the AO foundation

1 Principles

Lagscrewfixation
CB

Lag screw fixation uses stabilization by compression that relies on the bony buttressing
of the fracture to help stability (load-sharing osteosynthesis).
Lag screws should always be placed perpendicular to the fracture plane to prevent
displacement of the fragments when the screws are tightened and the bones are
compressed.

Biomechanicsofthesymphysis

The mandibular symphysis undergoes torsional forces (twisting) during function.

Therefore, fixation strategies must take this into account. When using anything less
stable than a reconstruction plate, two points of fixation should be applied.
In general, the further apart the points of fixation, the more stable the construct. For
symphysis fractures, when two lag screws are applied, they should be separated as
much as possible without injuring vital structures.
Illustration shows Champys ideal lines of osteosynthesis for symphysis fractures.

Specialconsiderations
Following special considerations may need to be taken into account:

Multiplefracturesplatingbeter
Edentulousatrophicfracturesnotindicatedwillfractureatrophicmandible
Teethinthelineoffracturesnotindicatedunlessremovedfirst
Involvementofalveolararea
Infectedfracturewithorwithoutboneloss
Complications

Click on any subject for further detail.

2 Reduction

Drillingmonocorticalholes
It is necessary to predrill two monocortical holes below the apices of the teeth on either
side of the fracture to help place the reduction forceps. Manipulate the mandible
fragments until anatomic reduction is achieved. Apply the reduction forceps and then

place the patient into occlusion and secure with MMF.

Some surgeons prefer to place the patient into occlusion and apply MMF before using
the reduction forceps.

Clampapplication
The clamp has to be placed perpendicular to the line of fracture to prevent fracture
displacement when tightening the reduction clamp.

3 Fixation

Lagscrewinsertion
Depending on the fracture plane orientation, lag screw alignment will vary. For sagittal
fractures through the anterior mandible, lag screws placed through the outer cortices
from one side to the other within the substance of the mandible (buccal cortex to
buccal cortex) provide extremely stable fixation.
Note that the screws and the resultant compression are directed perpendicular to the
bevel of the fracture.

For fractures that obliquely pass through the mandible, lag screws are placed from the
buccal to the lingual cortices.
Note that the screws and the resultant compression are again directed perpendicular to
the bevel of the fracture.

Numberofscrews
In general, a minimum of two lag screws should be used to provide stable internal

fixation of mandibular symphysis fractures.

Because the symphysis undergoes twisting during function, a single lag screw cannot
prevent such motion from occurring.

Alternative:screwsplacedfromoppositesides
Occasionally it is more convenient to place screws from opposite sides. From a
biomechanical standpoint it is irrelevant.

Confirmationofreduction
Confirm adequate reduction. There should be no gap at the lingual aspect that would
lead to occlusal disturbance and mandibular widening.
MMF should be released and the occlusion checked.
Because two points of fixation have been applied (two lag screws), it is not essential
that the mandibular arch bar remains in position to function as another point of fixation

Completedosteosynthesis
X-ray shows the completed osteosynthesis.

What methodologies are available for the edentulous mandible?

Luhr HG, Reidick T, Merten HA. Results of treatment of fractures of the atrophic
edentulous mandible by compression plating: a retrospective evaluation of 84
consecutive cases. J Oral Maxillofac Surg. 1996 Mar;54(3):250-4; discussion 254-5.
PMID:8600229

1 Diagnosis
8.4.11
CB

Generalconsiderations
With increasing mandibular atrophy, the physical size of the mandible decreases. In the

severely atrophic mandible, even very minor trauma can cause fracture. Additionally,
pathologic fracture during mastication can occur. Very often, due to the fragile nature
of the jaw, these fractures occur bilaterally.
Orthopantomogram (OPG), mandible series radiograph and CT scans can be used to
diagnose and plan the treatment of the atrophic edentulous mandible fractures.

Clinicalexamination
The patient shows extraoral ecchymosis associated with an atrophic edentulous
mandible fracture.
The patient exhibits pain and mobility of the anterior mandible.

Patient shows intraoral ecchymosis in the floor of the mouth associated with an
atrophic edentulous mandible fracture.

Typicalexampleofanatrophicedentulousmandiblefracture.
Axial CT scan showing bilateral fractures.
Note that although there appears to be a large bone stock, this patients mandible has
only approximately 7 mm of vertical height.

Panoramic radiograph of atrophic edentulous mandible fractures.

Note the extreme amount of vertical atrophy.

3-D reconstruction of the same case.

2 Decision/Indication

Observationandsoftdiet
Observation may be indicated for patients medically unfit for general anesthesia.
Atrophic edentulous mandible fracture patients are often elderly with medical
problems presenting severe anesthetic risks.
One major complication of observation and soft diet would be nonunion of the
mandibular fracture.

Closedreduction
Historically, atrophic edentulous fractures were treated closed by wiring in the patients
dentures or fabricating Gunning style splints with postoperative mandibulomaxillary
fixation (MMF).
Standard treatment with closed reduction often resulted in prolonged periods of MMF
which was difficult for these patients. Additionally, the fractures were often poorly
aligned. Postoperative malunions and nonunions were very common.
Photograph shows a patient denture.

Photograph shows a Gunning style splint.

ORIF
Indications for ORIF are any displaced atrophic mandible fracture requiring surgical
intervention.
Following the AO principles of anatomic reduction of fractures and immediate
function, ORIF of atrophic edentulous mandible fractures with load-bearing
osteosynthesis has a distinct advantage for these patients. The technique has evolved to
provide the patient with an excellent chance for mandibular union while the ability to
masticate is preserved.
Literature has supported the efficacy of this technique.

Externalfixation
Indications of external fixator might be the temporary stabilization of a fracture while
the patient is treated medically, or if soft-tissue maturation around the fracture site is
required.

Complications,including malunion and nonunion are significant when external fixators

are used as they do not provide absolute stability at the fracture site.

3 Treatment of an edentulous atrophic fracture with a reconstruction

plate

In the following, the treatment of an edentulous atrophic fracture with a reconstruction

plate is described step-by-step.

4 Approach

Extraoralappraoch
When treating atrophic edentulous mandible fractures, the surgeon will generally find
it easier to use an extraoral surgical approach. The fracture fragments can be
manipulated under direct visualization and stabilized while the reconstruction plate is
being bent and applied to the mandible.

Intraoralapproach
An intraoral approach is possible but technically more difficult as the surgeon will
need several sets of trained hands just to retract the soft tissues of the cheeks and
tongue. Additionally, stabilization and fixation of the fractures is much more difficult
via an intraoral approach. One should also be aware that the inferior alveolar nerve is
located on the superior surface of the atrophic mandible. Therefore one must be
extremely careful making intraoral incisions to expose atrophic fractures, or the nerve
can be damaged.

5 Principles

The atrophic edentulous mandible fracture presents with several factors which make
treatment very difficult. There is a lack of bone which is generally cortical in nature
and has a lower healing potential. There are no teeth present to help reduce the
fractures. Often the patients are elderly and medically compromised.
Atrophic mandible fractures require transfacial open reduction, load-bearing internal
fixation, and often immediate bone grafting.

6 Choice of implant

Generalconsiderations
Load-bearing osteosynthesis is indicated in treatment of the atrophic edentulous
mandible fracture. We currently recommend the locking reconstruction plate 2.4. The
plate must be of sufficient length to place screws in adequate bone which is generally
found in the symphysis and angle regions. The body region of the mandible is a
common area of fracture and generally has bone of poorer quality unsuitable for screw
placement. When dealing with bilateral fractures, the plate must span from angle to
angle, covering the entire lateral surface of the mandible. At least three screws on
either side of the fracture are recommended. Often more screws are necessary due to
the poor quality of the bone.

The locking reconstruction plate is generally left in place and not removed unless
clinical symptoms require hardware removal.

Pitfall:insufficientlystableimplant
It may be tempting to use small plates when treating fractures in an atrophic small
jaw. However, when using small plates, plate fracture and displacement is very
common secondary to the muscle pull involved in the atrophic edentulous mandible.
X-ray shows fractured plate and fracture displacement.

Clinical photograph shows same case.

Alternativestothelockingreconstructionplate2.4
There are fractures involving the edentulous jaws which are not atrophic in nature.
When there is sufficient bone to buttress the fracture and provide adequate healing, the

surgeon may choose to use a smaller reconstruction plate.

The locking plate system 2.0 (large or extra-large profile) provides all the advantages
of a locking reconstruction plate 2.4 but with a smaller profile. Many surgeons have
successfully used the locking system 2.0 on edentulous fractures.

Platedesign
The locking reconstruction plate combines all the advantages of a standard
reconstruction plate with the locking principle.
The thread in the plate holes provides rigid anchorage for the 2.4 mm locking screw.
This construction acts as an internal fixator. 3.0 mm screws are also available.
The conventional 2.4 mm nonlocking cortex screw can also be used with this plate.
Wide angulation of the screw is possible which, in certain clinical situations, can be an
advantage.
Other advantages of the locking principle are:

Theplateneedsonlylimitedadaptation
Itexertsnopressureonthebone
Theriskofscrewslooseningisreduced.

7 Plate bending

Templating
It is very common to use large reconstruction plates that span from angle to angle. By
using a template the bending process is facilitated.

Bending
Clinical image shows the template and the reconstruction plate bent accordingly.

Pearl:reductionandtemporaryfixation

It can be very helpful to reduce and stabilize the fracture with adaptation plates to
allow appropriate bending of the template and reconstruction plate. This is particularly
applicable in fractures that are widely displaced, mobile, or unstable.
The adaptation plates are placed on the inferior border to allow excellent
reconstruction plate adaption to the lateral surface of the mandible.
After the locking reconstruction plate has all planned screw holes used, the adaptation
plates are removed.

Pearl:perfectadaptation
Perfect adaptation of the plate is not required as the locking reconstruction plate 2.4
acts as an internal external fixator.

8 Fixation

Generalconsiderations
The locking reconstruction plate 2.4 is fixed to the native mandible using either 2.4
mm or 3.0 mm screws. At least three screws must be present on either side of the

fracture. In the atrophic edentulous mandible fracture, the screws are generally placed
in the symphyseal region and the angular region. The bone in the symphysis is very
often dense cortical bone which may require tapping of the screw hole.

Applyingtheplate
Apply the plate and stabilize it either with digital pressure or plate-holding forceps.
One of the benefits of using a locking reconstruction plate is that perfect adaptation is
not required and small discrepancies can be tolerated.

Placementoffirstscrews
Place one screw on either side of fracture in the planned holes closest to the fracture.
A threaded drill guide must be used to allow for centric placement of the drill hole for
use with the locking screw. Copious irrigation must be applied to cool the bone. A
depth gauge is used to determine the appropriate screw length.

Additionalscrewplacement
Once the screws are placed on either side of the fracture (on the first side) the surgeon
has the option of completing all screws on that one side or placing one screw on either
side of the fracture (on the opposite side) before completing all screws.

Clinical image shows the plate fixed to the mandible.

Harvestingofbonegraft

Due to the poor healing quality of the bone, an autogenous bone graft is often used to
facilitate bony union. Common sites of bone graft harvest include the iliac crest or
tibia.

Clinical images show ...

... the bone graft harvest site in the tibia.

Bonegraftapplication
Autogenous cancellous bone grafts can be added to fracture sites and can be used to
augment the native mandible to facilitate healing.

Completedosteosynthesis
X-ray shows the completed osteosynthesis.

9 Aftercare following treatment of an edentulous atrophic fracture

with a reconstruction plate

If MMF screws are used intraoperatively in conjunction with the patients prostheses,
they are usually removed at the conclusion of surgery if proper anatomic fracture
reduction and fixation have been achieved.
Postoperative x-rays are taken within the first days after surgery. In an uneventful
course, follow-up x-rays are taken after 46 weeks.
The patient is examined approximately 1 week postoperatively and periodically
thereafter to assess the stability of the fracture and to check for infection of the surgical

wound. During each visit, the surgeon must evaluate the patients ability to perform
adequate oral hygiene and wound care, and provide additional instructions if necessary.
Follow-up appointments are at the discretion of the surgeon, and depend on the
stability of the mandible on the first visit. Weekly appointments are recommended for
the first 4 postoperative weeks.
Postoperatively, patients will have to follow three basic instructions:
1. Diet
Depending upon the stability of the internal fixation, the diet can vary between liquid
and semi-liquid to as tolerated, at the discretion of the surgeon.
2. Oral hygiene
Patients having only extraoral approaches are not compromised in their routine oral
hygiene measures and should continue with their daily schedule.
Patients with intraoral wounds must be instructed in appropriate oral hygiene
procedures. A soft toothbrush (dipping in warm water makes it softer) should be used
to clean the oral cavity. Chlorhexidine oral rinses should be prescribed and used at
least three times each day to help sanitize the mouth. For larger debris, a 1:1 mixture of
hydrogen peroxide/chlorhexidine can be used. The bubbling action of the hydrogen
peroxide helps remove debris.

Where do the pterygoids attach? What do they do?

MedialPterygoid
8.4.12
CB

Originandinsertion
Itconsistsoftwoheads.

Thebulkofthemusclearisesasadeepheadfromjustabovethemedial
surfaceofthelateralpterygoidplate.
Thesmaller,superficialheadoriginatesfromthemaxillarytuberosityandthe

pyramidalprocessofthepalatinebone.
Itsfiberspassdownward,lateral,andposterior,andareinserted,byastrong
tendinouslamina,intothelowerandbackpartofthemedialsurfaceoftheramus
andangleofthemandible,ashighasthemandibularforamen.Theinsertionjoinsthe
massetermuscletoformacommontendinousslingwhichallowsthemedial
pterygoidandmassetertobepowerfulelevatorsofthejaw.

Innervation
Likethelateralpterygoid,andallothermusclesofmasticationthemedialpterygoidis
innervatedbytheanteriorroot(motorroot)ofthemandibularbranchofthe
trigeminalnerve(V).

Actions
Giventhattheoriginisonthemedialsideofthelateralpterygoidplateandthe
insertionisfromtheinternalsurfaceoftheramusofthemandibledowntotheangle
ofthemandible,itsfunctionsinclude:

Elevationofthemandible(closesthejaw)
Minorcontributiontoprotrusionofthemandible
Assistanceinmastication
Excursionofthemandible;contralateralexcursionoccurswithunilateral
contraction.

LateralPtyergoid:
Originandinsertion
Theupper/superiorheadoriginatesontheinfratemporalsurfaceandinfratemporal
crestofthegreaterwingofthesphenoidbone,andthelower/inferiorheadonthe
lateralsurfaceofthelateralpterygoidplate.
Inferiorheadinsertsontotheneckofcondyloidprocessofthemandible;
upper/superiorheadinsertsontothearticulardiscandfibrouscapsuleofthe
temporomandibularjoint.

Innervation
Themandibularbranchofthefifthcranialnerve,thetrigeminalnerve,specificallythe
lateralpterygoidnerve,innervatesthelateralpterygoidmuscle.

Function
Theprimaryfunctionofthelateralpterygoidmuscleistopulltheheadofthecondyle
outofthemandibularfossaalongthearticulareminencetoprotrudethemandible.A
concertedeffortofthelateralpterygoidmusclesactsinhelpinglowerthemandible
andopenthejawwhereasunilateralactionofalateralpterygoidproduces
contralateralexcursion(aformofmastication),usuallyperformedinconcertwiththe
medialpterygoids.
Unliketheotherthreemusclesofmastication,thelateralpterygoidistheonlymuscle
ofmasticationthatassistsindepressingthemandible(openingthejaw).Atthe
beginningofthisactionitisassistedbythedigastric,mylohyoidandgeniohyoid
muscles

What is the rate of lingual injury associated with mandible fractures? What about of alveolar
nerve?

DamageofInferiorAlveolarNerveinMandibleFractureCases
DainiusRazukevicius,Stomatologija,BalticDentalandMaxillofacialJournal,6:12225,2004

8.4.13
CB

Whenmandibularfractureoccurson anglezone,inferioralveolarnervealwaysisinjured,
andatitsinnervationpointemergesensationdisorders(lowerlips,chin,alveolarprocess).
Patientsfeelonthisareadiscomfort,paresthesia,sometimesevenpain.Thisconditionhas
negative influence on psychoemotional status of person and reduces working capacity.
Lesionsofinferioralveolarnerveandvascularbundlehaveaninfluenceoncourseoflower
jawhealing
Lingual nerve injury seems to be more associated with condylar process fractures. Could
not find any rates in the literature though, certainly less common than alveolar nerve
injury.