Concepts of Rigid Fixation in Facial
Fractures
Melvyn Yeoh, DMD, MD*, Larry L. Cunningham Jr, DDS, MD
KEYWORDS
 Mandible fracture  Rigid fixation  Fracture repair
KEY POINTS
 Rigid fixation for maxillofacial fractures has been in use for over the last 40 years.
 The concept of rigid fixation uses hardware in the form of bone plates and screws to absorb part or all of the functional load
of the fracture site preventing any motion across the fracture.
 Many different systems and materials have been introduced over the years and have evolved to the current systems we use
today.
 The use of titanium plates and screws in maxillofacial fractures is now considered the standard of care in the repair of
maxillofacial fractures.
Introduction
Rigid fixation for maxillofacial fractures has been in use
for over the last 40 years. The concept of rigid fixation uses
hardware in the form of bone plates and screws to absorb
part or all of the functional load of the fracture site
preventing any motion to the fracture. Rigid fixation first
originated in the orthopedic literature in 1932 by Key and
then in 1949 by Luhr whom described compression of bony
fragments as an adjunct to fracture healing.1,2 Subsequently
in 1958, Bagby and Janes published an article on the use of
bone plates to achieve immobilization of the fracture
and active compression.3 The early articles on rigid fixation
for maxillofacial fractures had mixed results, as the
appliances used were designed for extremities fractures.4,5 It
was not until 1973 when Michelet described the use of
miniaturized screws and plates in the reduction and immo-
bilization of fractures in detail with the experience of 300
cases.6 Since then, many different systems and materials
have been introduced and have evolved to the current sys-
tems we have today. The use of these miniaturized plates and
screws in maxillofacial fractures is now considered the
standard of care in the repair of maxillofacial fractures
(Fig. 1).
Pathways of maxillofacial skeletal fracture
healing
Fracture healing involves a complex set of events to restore
the bone to its preinjured form. The mechanical stability of a
Disclosure Statement: The authors have nothing to disclose.
Oral and Maxillofacial Surgery, University of Kentucky, College of
Dentistry, 800 Rose Street, D-508, Lexington, KY 40536-0297, USA
* Corresponding author.
E-mail address: Melvyn.Yeoh@uky.edu
Atlas Oral Maxillofacial Surg Clin N Am 27 (2019) 107–112
1061-3315/19/ª 2019 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.cxom.2019.05.002
fracture site determines the type of healing. Bone healing,
like soft tissue healing, can occur via a secondary or primary
route. Secondary bone healing occurs when there is increased
mechanical strain resulting in the ability of the fractured
ends to move during the healing process or when precise
anatomic reduction is not achieved. Movement of the frac-
ture segments result in a large amount of external and in-
ternal callus, which is the body’s way to immobilize the
fracture. Secondary bone healing consists of 3 main stages:
inflammation, repair, and remodeling. During the inflamma-
tory phase, a hematoma is formed and provides a source of
hematopoietic cells capable of secreting growth factors.
Fibroblast and mesenchymal cells then migrate to the frac-
ture site allowing granulation tissue to form around the
fractured ends after which osteoblasts and fibroblasts start to
proliferate. In the repair phase, a primary callus will start to
form normally within 2 weeks, and when the bone ends do not
meet, a bridging callus forms. The size of the callus is inverse
to the extent of immobilization and the distance between the
fractured ends. The remodeling phase begins in the middle of
the repair phase continuing long after clinical union, allowing
the remodeling woven bone produced in the repair phase to
become lamellar bone.7,8
Primary bone healing occurs when there is minimal strain
and good anatomic reduction such as when rigid fixation is
performed. Primary bone healing is predicated on the direct
restoration of lamellar bone. The callus formed when good
anatomic reduction is achieved is minimal compared with
secondary bone healing.8,9 Medullary bone portion when
placed into apposition will allow osteogenic elements and
capillary blood supply to traverse the fracture line and result
in longitudinal bone healing with remodeling in about 3 to
4 weeks. Repair of the cortical bone occurs by growth of
capillaries and osteogenic elements across the fracture lines
by cortical tunnels, also known as contact healing. Cortical
bone completely heals after fracture in approximately
16 weeks.7
oralmaxsurgeryatlas.theclinics.com
108 Yeoh & Cunningham Jr

Fig. 1 Three-dimensional reconstructed image of a patient with panfacial fractures. (A) Prerepair of the fractures. (B) Rigid fixation of
multiple facial fractures to recreate pretraumatic form.

Compression and tension forces
Frederic Pauwels described the early concepts of load transfer
within bone. He observed that a curved tubular structure under
axial load always has a compression side as well as a tension
side.10 In fracture healing, there is general agreement that
compression have been shown to promote rapid healing and a
greater resistance to separation when a fracture is placed
under compression. Compression does not necessarily promote
osteogenesis, but it provides the intimate apposition and me-
chanical stability allowing the fractured bone to heal
primarily.11
At any time, to be in equilibrium, the bone will be under
both compressive and tensile forces, depending on the me-
chanics of the articulation of the bone and the attached
muscular attachments. Rigid fixation should address both the
tension and compression areas of a fracture. When the tension
areas of a bone are addressed, it eliminates overcompressive
forces, allowing equal distribution of forces over the fracture
areas, which allows the bone to heal optimally.12 When one
looks at mandible fractures, compressive and tensile forces are
different depending on location. In fractures distal to the
canine region, the alveolar region is predominantly under
tension when the inferior border is under compression. But
when looking in the area anterior to the canine region, the
forces are mixed with the alveolar and inferior border of the
mandible having almost equal tensile and compressive forces
during function12,13 (Fig. 2).
sharing scenario, the bone bears most of the functional
loads.14,15 Load-sharing osteosynthesis includes lag screw fix-
ation, compression plating, or miniplate fixation. In the lag
screw osteosynthesis technique, the screw threads engage the
cortical bone across the fracture line from the site of screw
insertion. The site of insertion of the screw is overdrilled, and
when the screw is tightened, the fractured segments are
placed under compression. Insertion of at least 2 screws is
recommended to eliminate the possibility of rotational move-
ments16 (Fig. 5).
Compression plates were specifically designed for the
maxillofacial region. These compression plates used an
eccentric compression hole that when used with a conical
screw caused a horizontal translation of the bone relative to
the plate. The plates are designed so that when placed across
a fracture, the eccentric compression hole screws converge as
they are tightened, exerting compression across the
fracture.17

Load-bearing versus load-sharing concepts in

rigid fixation

Currently when rigid fixation is being considered for fractures,

there are 2 basic types of fracture fixation techniques: load-
bearing osteosynthesis and load-sharing osteosynthesis. In
load-bearing osteosynthesis, the plate bears all the forces of
function at the fracture site; this is accomplished with a
locking reconstruction plate (Figs. 3 and 4). In load-sharing
osteosynthesis, stability at the fracture site is through fric-
tional resistance between the fractured bone ends and the
hardware used to hold the ends together. In the ideal load-
Fig. 2 Symphyseal fracture of the mandible fixated with a plate
in the tension zone and a plate in the compression zone. A mini-
plate with screws inserted monocortically is used to avoid the
teeth roots for the tension zone. A heavier plate with bicortical
screws is used for the compressive zone.
Concepts of Rigid Fixation in Facial Fractures
Fig. 3 Segmental defect of the right mandible that has been
reconstructed with a load-bearing plate. Forces previously borne
by the bone in the area has been replaced with a titanium plate.
The concept of miniplate fixation was first reported in 1973
by Michelet and colleagues6 when he advocated the use of
small, malleable, noncompressible Vitallium plates. They
favored intraoral placement of these plates for mandible fac-
tures and were placed without the use of concomitant post-
operative maxillomandibular fixation. These plates were
placed along the external oblique ridge of the mandible as a
tension band. In 1978, Champy and colleagues13 reported a
modification of the Michelet technique using a similar arma-
mentarium. The system designed by Champy was made of
stainless steel. Champy described an ideal line of
Fig. 4 Segmental defect of the right mandible reconstructed
with a vascularized bone graft and a small load-bearing plate.
109
Fig. 5 Panoramic radiograph illustrating the use of 2 lag screws
for fixation of a mandibular symphysis fracture.
osteosynthesis for fractures throughout the mandible. Small
miniplates were used and strict attention was paid to the
tension band principle with placement of these miniplates as
close to areas of maximal tension in the mandible. Champy’s
subsequent results with his technique resulted in an infection
rate of 3.8%, malunion rate of the fracture site of 0.5%, and
nonunion rate of the fracture site of 0.5%.
Materials for rigid fixation
Many different methods, systems, and materials have been devised for
rigid fixation of maxillofacial fractures. Interosseous wiring for inter-
fragmentary compression has been used but has not been found to be
successful without concomitant maxillomandibular fixation, as it was
found that wiring alone did not maintain compression adequately.18,19
Wires lack adequate rigidity, directional and surface to bone interac-
tion to maintain rigidity under functional forces. Wires have a small
surface area and are not in intimate contact with the bone throughout
their length, resulting in lack of directional control. Also, excessive
tightening of the bone to increase compression often leads to shearing
of the bone as a result of stress concentration.
Plates and screws function to rigidly support the fracture sites and
transfer the functional load to the hardware. When considering use of
hardware for rigid fixation, choices must be made regarding the proper
plate length, thickness required, and the size and type of screws. Plate
length is usually based on the type of fracture being repaired and the
number of screws necessary on either side of the fracture. Areas with
higher dynamic forces during function, such as the mandible, require a
longer plate. Conversely, shorter plates may be adequate in the mid-
face where the dynamic forces are lower.20,21 In ideal conditions, 3
screws are placed on either side of mandibular fracture segments to
Fig. 6 A selection of load-bearing plates for fixation of the
mandible ranging from 2.0 mm in thickness to 2.9 mm in thickness.
110
Fig. 7 A selection of load-sharing plates for fixation of the
midface ranging from 0.6 mm to 1.0 mm thickness.
guard against inadequate stabilization and 2 screws are placed on
either side of fractures in the remaining craniofacial regions. These
screws are ideally placed at least several millimeters from the fracture
areas in the nontraumatized bone.
Many plate options exist. When considering the options for stabili-
zation, they can be divided into either load-bearing fixation or load-
sharing fixation. Load-bearing fixation that uses larger size plates such
as reconstruction plates for mandibular fractures come in profile sizes
ranging from 1.5 mm up to 3.0 mm14 (Fig. 6). Load-sharing fixation
options are usually smaller miniplates and come in 1.0 mm or less
profile (Fig. 7). Depending on the type of fracture being repaired,
either the load-bearing fixation category or the load-sharing fixation is
chosen. A variety of options are available to the surgeon: differences in
thickness, internal screw diameter, titanium grade, malleability, and
surface area of contact on the bone.
Generally, the type of rigid fixation is chosen based on the intrinsic
forces present at the anatomic site and the bone quality of the fracture
segments. For example, if a young healthy man has a mandible frac-
ture, there is a tendency for greater bite forces placed on the
mandible, and a stronger thicker plate with larger screws will be used.
Also, if there is poor bone quality with significant bone atrophy or
significant comminution, a similar load-bearing fixation may also be
used (Fig. 8). If there are fractures in an area that have relatively lower
forces, such as the zygomatic complex, one can consider small mini-
plates to realign the segments, as the amount of forces the plate must
withstand is significantly lower relative to the mandibular region.
The use of locking plates is relatively new. Locking plates allow for
the screw head to be locked into the plate, turning the plate and screw
apparatus into an “internal-external fixator” (Figs. 9 and 10). There are
both theoretic and biochemical advantages to the use of this tech-
nique. It is thought that with the use of the locking plate there would
be decreased risk of malocclusion secondary to poor plate contouring
and lower frequency of screw loosening. However, studies have not
shown a clear benefit over nonlocking plates and screws.19
Fig. 8 (A) Preoperative panoramic radiograph of comminuted mandibular bilateral bodies and symphysis region fractures; (B) use of a
load-bearing plate to fixate the mandibular bilateral bodies and symphysis region fractures.
Yeoh & Cunningham Jr
Another concept that should not be overlooked is the screw choice.
Screws can be divided into monocortical and bicortical screws. Mono-
cortical screws only traverse through one of the bony cortices. When
fixating nonmandibular facial fractures, monocortical screws are the
screws of choice. But when fixating mandibular fractures, bicortical
screws are sometimes helpful, as they can ensure that the hardware is
able to off-load the force from the entire width of the mandible. When
monocortical screws are used in mandibular fractures, their limited
bony purchase results in only functionally stable fixation and thus must
be placed along areas of less dynamic tension such as Champy’s lines.
Champy’s lines of tension are regions in the mandible that Champy and
colleagues13 in 1978 defines as regions of the mandible that would only
require a small monocortical plate to allow for stable fixation. These
lines run from the angle through the body into the parasymphyseal and
symphysis regions.
Screws also vary based on their diameter. As the screw’s diameter
increase, so does the stability against the forces placed against the
fracture site increase. In general, smaller screws are effective for
simple fractures and larger-diameter screws are more suited for
comminuted or multiple fracture sites. Also, the larger and heavier a
plate is used, the thickness of the screws increase accordingly. Screws
can also be used alone without the use of plates to fixate fractures.
Specialized screws such as lag screws can also be used to stabilize
simple fractures. They are placed at a 90-degree angle to the fracture
in a plane parallel to the long axis of the bone.
Summary
Fixation of maxillofacial fractures had not deviated from the
techniques described in 1959 by Adams up until the 1970s.22
Fractures of the upper midface such as the infraorbital rim was
repaired with interosseous wires, whereas the lower midface
and mandible were treated in a closed fashion with inter-
maxillary fixation and suspension wiring before rigid fixation of
the maxillofacial skeleton. These techniques were used to
preserve the appropriate facial height and preinjury occlusion.
As rigid fixation plating systems for maxillofacial bony fractures
have improved, increased points of fixation for mid- to upper-
face fractures have allowed for improved three-dimensional
stability (Fig. 11). This stability allows preservation of the
appropriate facial height, whereas stronger plates have
allowed for reliable reduction of the lower midface and
mandible, preserving the preinjury occlusion. As rigid fixation
systems have evolved in the last 40 years, the size of plates has
decreased to minimize palpability and exposure while main-
taining the same biochemical strength. However, the rigid
fixation systems are only as good as the surgeons applying
them. With adherence to basic surgical principles, rigid fixation
allows the surgeon to treat the maxillofacial trauma patient in
a way that produces predictable outcomes with reduced pa-
tient morbidity.
Concepts of Rigid Fixation in Facial Fractures 111

Fig. 9 (A) Nonlocking screws: note the absence in threads at the screw head. (B) Locking screws: note the threads at the screw head,
which allows the screw to be affixed directly into the plate.

Fig. 10 (A) Use of a locking plate and nonlocking plate to fixate a comminuted fracture of the mandible s/p gunshot wound injury. (B)
Panoramic radiograph showing the alignment of the segments with the plates present.

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