TECHNIQUES OF RIGID

INTERNAL FIXATION
GUIDED BY:
PRESENTED BY:
DR ASHISH KUMAR
DR NASIM
PRINCIPLES OF FRACTURE FIXATION
• In the late 1950s, the AO (Arbeitsgemeinschaft fur
Osteosynthesefragen) or the Association of the Study of Internal
Fixation (ASIF) Swiss Association for the Study of Internal Fixation
(AO/ASIF) promulgated four biomechanical principles in fracture
management.
Indications for open reduction

• Grossly displaced fractures with gross displacement or over riding

(tele scoping) of the fractured segments.
• Unfavorable fractures at the angle.
• Old fractures which do not get reduced due to the fibrous adhesions.
• Malunited fractures at the condylar neck where the proximal segment
gets displaced medially.
• Fractures in epileptic patients where inter maxillary fixation is contra-
indicated.
 FIXATION

DIRECT FIXATION INDIRECT FIXATION

(INTERNAL FIXATION) (CLOSED FIXATION)

SEMI MAXILLOMANDIBULAR
RIGID NON RIGID
RIGID
FIXATION

NON
COMPRESSION FIXATION CRANIOMAXILLARY OR
COMPRESSION TRANSOSSEOUS
FIXATION OSTEOSYNTHESIS MANDIBULAR SUSPENSION
MINIPLATE WIRING

LOCKING
DCP EXTERNAL
PLATE
FIXATION

RECONSTRUCTION
EDCP PLATE

LAG
THORP
SCREW
RIGID INTERNAL FIXATION
• Any form of fixation applied directly to the bones which is strong
enough to prevent interfragmentary motion across the fracture when
actively using the skeletal structure.
• There are two basic types of fracture fixation,

Load-bearing osteosynthesis

Load-sharing osteosynthesis
LOAD SHARING OSTEOSYNTHESIS
• Stability at the fracture site is created by the frictional resistance between
the bone ends and the hardware used for fixation.
• This requires adequate bony buttressing at the fracture site.
• Examples of load-sharing osteosynthesis include
lag screw fixation technique
compression plating
miniplate fixation
• Load-sharing osteosynthesis cannot be used with defect fractures or
comminuted fractures, due to the lack of bony buttressing at the fracture
site.
This is an example of load-sharing osteosynthesis for
the treatment of a simple angular fracture.
The two miniplates share the loads with the bone in
an anatomical region where the bone stock and force
distribution are not ideal.
LOAD BEARING OSTEOSYNTHESIS
• The plate assumes all the forces of function at the fracture site
• Clinical uses are the management of

atrophic edentulous fractures,

comminuted fractures,
defect fractures, and
other complex mandibular fractures
 This is an example of load-bearing osteosynthesis for the
treatment of a defect fracture in the angular region.
The osteosynthesis assumes all the masticatory loads while the
bone graft matures and consolidates in a protected
environment.
COMPRESSION OSTEOSYNTHESIS
• Absolute stability in which no movement occurs at the area of
interfragmentary contact or between the bone and the fixation
device.
• Compression of the fractured bone segments enhances the likelihood
of successful primary bone healing in two ways.
1.Generation of the preload;
2.Friction produced by compression of the fractured bone segments
reduces fracture mobility produced by torsional forces.
DYNAMIC COMPRESSION PLATE (DCP)
• In 1977, Luhr adapted the principle of dynamic compression to
maxillofacial region for treatment of mandibular fractures; however,
Spiessl was first to apply the AO/ASIF principles to the management
of mandibular fractures.
• The forces of mastication are overcome by the plate and the bony
buttressing at the fracture site.
• This technique ensures good interfragmentary compression and thus
good bony buttressing at the fracture site.
INDICATIONS CONTRAINDICATIONS
Simple linear fractures Atrophic edentulous mandible
fractures,
Defect fractures,
Comminuted fractures, and
Other complex mandibular
fractures
Simple fractures with an extreme
oblique pattern (sagittal fractures)
Eccentric dynamic compression plates(EDCP)
• When the DCP and tension band cannot be applied because of
anatomic constraints
• presence of an impacted third molar,
• an edentulous mandible, or
• avulsion of bone from the fracture,
• The eccentric dynamic compression plate (EDCP) may be used for
plating the mandibular fracture in above cases.
DESIGN

• Produces compression at the superior border of the fractured mandible.

• Inner holes are designed to produce compression across the fracture site.
• Standard compression holes, along with two oblique outer compression holes.
• Eccentric compression holes are aligned at an angle oblique to the long axis of the plate.

Production of rotational movement of the fracture segments with the

inner screws acting as the axis of rotation.
• This rotation of the segments establishes compression at the superior border of the
mandible.
 The goal of the
EDCP is to first
establish
longitudinal
compression across
the fracture at the
inferior border and
then to rotate the
fragments around
the screws to
achieve additional
compression at the
level of the alveolus.
 LOCKING PLATES

• Intimate contact of plate with bone is unnecessary in locking plates as when screws are
tightened they get “locked” to plate thus stabilizing the fractured segments.
• More stability
• Locking plates do not disrupt cortical bone perfusion as compared to conventional plate
which compresses the undersurface of bone plate to cortical bone.

Less time consuming as absolute adaptation is not mandatory.

Incidents of resorption of buccal and lingual cortices are very few when compared with that of
conventional system (approximately 50%)

• Screws are unlikely to loosen from plate.

Screw heads as well as the plate holes are threaded so as to
“lock” with each other.
Screw and plate forms a single unit and with both it acts as
two unit fixation
RECONSTRUCTION PLATES
Guk jin seol et al. Reconstruction plates used in the surgery for
mandibular discontinuity defect. J korean assoc oral maxillofac surg.
2014 dec; 40(6): 266–271.
RECONSTRUCTION PLATE

 Severely oblique fractures,

 Comminuted fractures, and
 Fracture with bone loss
 Non-atrophic edentulous mandible fracture
Compression plate may not be long enough to avoid
screw engagement of the overlapping fracture
segments, thereby preventing compression in the
oblique fracture.
Therefore, a reconstructive plate may be the best
method of fracture fixation.
 The reconstruction plate has larger overall
dimensions than compression plates, resulting in
increased strength.
This larger size is designed to stabilize the fragments
against functional displacement in the absence of
compression
 The reconstruction plate can be contoured in
three dimensions, allowing adaptation to almost
any site.

 First pilot holes are drilled, then the holes are tapped with
the appropriately sized tap, and screws are inserted. If
necessary, emergency screws are available.
 Atleast three screws be placed in each of the fractured
segments, and
 If an osseous gap is being bridged, it is suggested that at
least four screws be placed in each segment.
• Disadvantage of increased periosteal reflection.
• If the blood supply to the comminuted fragments is compromised,
the proximal and distal ends of the fracture may be fixed to the
reconstruction plate while performing a supra periosteal dissection in
the area of the comminuted fracture.
• Thus, the interposed comminuted bone is free from the
reconstruction plate but attached to periosteum.
• This technique preserves periosteal and osseous blood supply, yet
also provides stability.
 Titanium hollow screw Osseo
integrated reconstruction plate
( THORP )
F. Sutter and J. Raveh: Titanium-coated hollow screw and reconstruction
plate system for bridging of lower jaw defects: Biomeehanical aspects.
Int. J. Oral Maxillofac. Surg. 1988; 17; 267-274
 COMPLICATIONS
ASSOCIATED WITH Screw
RECONSTRUCTION
PLATES
loosening

Instability
Mobility
of the
of the
plate bone
segments

Mobile
plates and Nonunion
screws
often get Malunion
infected
If long-term fixation is required (e.g. a post- traumatic bone graft), early loosening of the screws and
mobility of the plate could lead to wound dehiscence, infection, loss of the entire graft, or a
combination of these complications.

• In order to improve on the reconstruction plate, a

modification called the titanium hollow screw Osseointegrated
reconstruction plate was developed by Raveh.
• The design of this system provides stability without applying
pressure to the underlying bone.
• This system was designed with screws that will not become
loose over long periods and a plate that can provide adequate
long- term functional stability.
  The anchorage is achieved by using hollow cylinder
titanium screws with perforated walls. The screw is
coated with plasma-sprayed titanium.
 The reconstruction plate is also made of titanium; the
plate holes are entirely cylindrical.
• This system does not allow relative movement between the implant elements
and the bone, as no intermediate soft tissue layer forms between the screw
and bone.
• New bone can permeate the lateral perforations and the lumen of the screw,
improving the stability with increasing implantation time.
• Implantation of a plate without exerting pressure on the compact bone.
• Transmission of loads along the stable incorporated hollow screws to the bone
is physiologically optimal due to the elasticity in the screw-plate system.
• The optimal load transmission also promotes the growth of new bone into the
grooves in the underside of the plate.
• The bone under the plate is therefore spared unnecessary pressure, thus
preventing resorption and loosening.
After drilling and tapping, the screw is turned in and the conical expansion bolt inserted to
lock the screw in the plate hole.
 The THRP principle: the plate can be applied with
the desired compression Px and then locked in place
with the expansion bolt.
 Even if it is necessary that the plate does not have
contact with the bone, side loads Py may still be
tolerated because of the rigid screw-plate fixation
 3D PLATES

Farmand M: The 3D plating system in maxillofacial surgery. J Oral

Maxillofac Surg. 1995;51(3):166–167

• A three dimensional miniplate is formed by joining two

miniplates with interconnecting vertical cross-bars.
• The name “three dimensional plate” suggest that the plate
stabilizes the fractured segments in all three dimensions.
• The fundamental idea of three dimensional bone plates is
based on principal of quadrangle as a geometrically stable
configuration for support.
• Increased stability is achieved by the geometrical shape of
quadrangular plate rather than by its thickness or length.
 DESIGN
•When mandible is in function, primarily three forces are of concern, namely
bending, vertical displacement and shearing
•Two horizontally placed miniplates are further joined by using vertical cross
bars at 90 degrees these acts as vertical struts and further minimize bending

• Since the entire plate acts as one single unit because of the inter
connections and the quadrangular shape (it acts as a tetragon),
• The vertical displacement and the shearing of the bone is also reduced
to minimal thus holding the bone fragment in three dimensions
ADVANTAGES DRAWBACKS

Easy adaptation Inability to fix at mental foramen region

Less operating time More quantity of implant

Less Infection rate

Cost effective
BIO RESORBABLE PLATES

BALI K RISHI et al. To evaluate the efficacy of biodegradable plating system

for fixation of maxillofacial fractures. Natl j maxillofac surg. 2013 jul-dec;
4(2): 167–172
 BIO RESORBABLE PLATES

• Despite titanium plates and screws being gold standard it

has few disadvantages as follows(especially rigid fixation)

Growth disturbance

Thermal sensitivity
Plate migration

Need for subsequent removal

Incompatiblity with future imaging needs

Chemical composition:
a) Polyglycolic acid(PGA)
b) Polylactic acid(PLA)
c) Polyesterspolyparadioxanon(PDS)
d) Poly L Lactide (PLLA)
 Features :
 Increased tensile and flex strength
 Easily adapt
 Variety of sizes and shapes
 Hex drive break away delivery system simplifies screw placement
 Eliminates growth restriction and implant migration
 Resorb completely and eliminates second surgery
 No late stage inflammatory reaction

Advantages
 Small
 biocompatible
 Adaptable
 Adequate stability to achieve bone union
 resorbs in timely fashion
 The bio-resorbable plate is placed in water bath of 55 degree Celsius
for 1 to 2 minutes, allowing the plate to become malleable.
 Fracture is reduced and plate is then adapted as per required.
 After adequate adaptation, plate is secured with resorbable screws
(minimum two on each side) with lengths ranging from 6 to 12 mm.
 Adequate tapping is required during placement of screws.
ADVANTAGES DRAWBACKS

Bioresorbable property Low strength of implant

Elimination of need for postoperative plate removal Movements of fractured segments

Reduced impact on growing mandible Expensive

Reduced postoperative pain Technique sensitive

Reduced operative time

Reduced toxicity
 LAG SCREW

• Lag screw osteosynthesis, via either true lag screw

or a conventional screw and the lag screw
technique, has been used to treat maxillofacial
fractures effectively.
• When properly used, lag screw fixation offers the
most rigidity of all rigid fixation techniques.
• It is possible to achieve between 2000 and 4000 N
of compressive force when using lag screw,
compared with the 600 N achieved with prebent
compression plates.
• Used for fixation of midline and paramidline
fractures of the mandible as well as for fractures of
the mandibular angle.
 An oversized hole (gliding hole)
is drilled through the proximal
cortex.
 The diameter of this hole must
be at least as large as the
thread diameter of the screw
 The remainder of the hole (in the distal segment) must be smaller
than the thread diameter.
 This is often referred to as the traction hole.
 When the screw is tightened, the distal fragment is pulled into
compression against the proximal fragment by the screw head.
This compression creates friction, thus reducing the amount of
inter-fragmentary movement.
 Countersinking of the near cortex
should be performed to distribute
compressive forces over a broader
area and thus prevent
microfractures of the bone
adjacent to the screw
head.
 Once the receptor site is
prepared, the screw can be
inserted to achieve compression of
the two segments.
• Lag screws may be used alone if the fracture is
sufficiently oblique to allow the placement of
at least two screws.
• Techniques have been described for however,
caution must be observed when only one
screw is used.
• In these instances, supplemental stabilization
with miniplates is recommended.
• The lag screw fixation technique developed
by the AO/ASIF group necessitates careful
orientation of the screws to the fracture line.
• The correct placement of the screws helps
distribute the compressive forces evenly
across the fracture interfaces without
distracting the fragments.
• Because lag screw technique compresses the
fracture fragments together, the screw must
be placed perpendicular to the fracture
plane.
• Otherwise, the fracture will displace when
the screw is tightened.
 HERBERT CANNULATED BONE SCREW

• The Herbert screws are a compressive cortical

cannulated Titanium screw with differential
pitch pattern of threads at both ends and a
blank smooth central shaft.
• Developed by Herbert and Fisher in 1992.
• Provides primary and functionally stable bone
healing through compression and rigid fracture
fixation.
Yehia A. El-mahallawy ET AL. The use of herbert cannulated bone screw in the
treatment of mandibular fractures. Alexandria dental journal. (2018) vol.43
pages:142-148
• Specialized to achieve interfragmentary compression
• Headless
• Threads at both ends
• Pitch differential between the leading and trailing threads
• Compression by the difference in thread pitch
• Coarser pitch moves a greater distance with each turn than does the
finer pitch
 They avoid the problems caused by conventional lag
screws:-
 Failure to achieve compression,
 Limited mobility of the adjacent joint, and
 Difficulty in pre-determining traction screw length
 Sufficient functional and stable fixation of the fracture
fragments, but with less fragment compression.
 A 0.8mm Kirschner guide wire was drilled and
tapped into the opposite cortex of the distal
fracture segment.
 The depth of the K-wire was measured using a
depth gauge to determine the length of the
screw to be utilized.
 A 2mm cannulated spiral drill was used under
the guidance of the K-Guide to make the
osteotomy, followed by Herbert Bone Screw
placement, with the aid of the cannulated
torque shank screwdriver.
DRAWBACKS
• Technique sensitive treatment modality that requires surgical
expertise
• Strict attention to its placement prerequisites
• Expensive
 MINIPLATES

• The term “miniplate” is a generic term and refers to all plates

used in CMF surgery with a plate thickness of 1.3 mm or less.
• Mandibular miniplates are designed to be used with
monocortical screws.
• Bicortical screws maybe used for additional stability in some
cases.
• Semi rigid fixation
• Given by Champy et al in 1978
• Forces of mastication produce tensional forces on upper
border & forces of compression on lower border.
• Champy put forward the lines where plates & screws have
to be placed - “ideal osteosynthesis lines.”
• It corresponds to course of a line of tension at base of the
alveolar process.
• Only in symphysis region, 2 plate required to overcome
torsional movements.
 ADVANTAGES

 Monocortical plates
 Easy to use
 Applied intraorally, small incision , less soft tissue dissection , less likely to be palpable.
 Can be used without any associated complication.
 Provides functionally stable fixation
 Little interfragmentary movement present, torsional movement seen under functional
loading.
 Less bulky
 DISADVANTAGES

• Accurate position and number of mini-plates are important to

neutralize bending and torsion moments during mandibular
function.
• Fatigue fracture of the plate.
• After reduction and fixation, if the gap between the fracture
fragments is more than 0.15 mm bone healing will be obscured.
• Fracture of screw is problematic.
• Difficult in removal.
• Foreign material left after treatment.
CONCLUSION
• The concepts and philosphies of the different systems used in the
mandibular fracture management is varying from time to time.
• Rigid internal fixation has become a popular method to treat fractures of
the facial skeleton which can produce three dimensional stability of the
fracture site, promoting primary fracture healing.
• But the ultimate treatment goal remains the same, that is anatomical
reduction of fragments, functionally stable fixation of the fragments,
preservation of blood supply to the fragments and early, active pain free
immobilization.
• Respect soft tissues and choose appropriate fixation methods for achieving
goals of fracture reduction to permit motion as soon as possible by
understanding the requirements and limitations of each method of rigid
internal fixation.
REFERENCES
• Oral n maxillofacial trauma- Fonseca
• Peterson's Principles of Oral and Maxillofacial Surgery - Michael Miloro, G.
E. Ghali, Peter Larsen, Peter Waite
• Maxillofacial trauma and esthetic facial reconstruction- Peter Ward Booth
et al
• Textbook of oral and maxillofacial surgery-Rajiv M Borle
• Imran Khan: Recent Advances in Treatment of Mandibular Fractures
• F. Sutter and J. Raveh: Titanium-coated hollow screw and reconstruction
plate system for bridging of lower jaw defects: Biomeehanical aspects. Int.
J. Oral Maxillofac. Surg. 1988; 17; 267-274
• www.aofoundation.org