J Oral Maxillofac Surg
49:13-21. 1991
Lag Screw Fixation of Anterior
Mandibular Fractures
EDWARD ELLIS III, DDS, MS,* AND G.E. GHALI, DDSt
A technique of applying lag screws for treating fractures of the anterior
mandible is presented. A review of 41 patients who had lag screws placed
to treat such fractures showed that it is a successful method of providing
rigid internal fixation. The advantages of this technique over bone-plate
fixation are discussed.
Fractures of the anterior mandible are common
facial injuries. Although many of these can be
treated satisfactorily with closed reduction, open
reduction and internal fixation are commonly used
to align the fragments and keep them in contact,
which promotes osseous union. With the recent en-
thusiasm for rigid forms of internal fixation, exper-
imentation with various forms of plate and screw
fixation have been attempted. Fractures in the an-
terior mandible are readily treated by application of
either bone plates and/or bone screws.
A useful method of providing rigid fixation in the
anterior mandible is by using lag screws. The term
lag screw is probably the most misunderstood of all
terms involved with rigid internal fixation, probably
because it is used both to describe a type of screw,
as well as a technique of screw placement. A true
lag screw has threads only on its terminal end (Fig
1). When used, the threads engage the far cortex,
while the head seats against the near cortex, pro-
viding compression upon tightening. A lag screw
technique (resulting in compression) is achieved
with a cortical screw (Fig l), which has threads
along its entire length, by overenlarging the hole in
the near cortex. This latter procedure has been
Received from the Department of Oral and Maxillofacial Sur-
gery, University of Texas Southwestern Medical Center, Dallas.
* Associate Professor.
t Resident.
Supported in part by a grant from the Chalmers J. Lyons
Academy-James R. Hayward Research Fund.
Address correspondence and reprint requests to Dr Ellis: Di-
vision of Oral and Maxillofacial Surgery, University of Texas
Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas,
TX 75235.
0 1991 American Association of Oral and Maxillofacial
geons
0278-2391/91/4901-0004$3.00/O
more commonly used in maxillofacial surgery than
the true lag screws.
The lag screw technique was first introduced to
maxillofacial surgery by Brons and Boering in 1970,
who cautioned that at least two screws are neces-
sary to prevent rotational movement of the frag-
ments in oblique fractures of the mandible.’ Others
have similarly illustrated the versatility of lag
screws for mandibular fractures.‘33 The purpose of
this report is to describe the technique of lag screw
placement in fractures of the anterior mandible and
to review our early experience in their use.
Anatomy and Biomechanics of the
Anterior Mandible
The anterior mandible, from mental foramen to
mental foramen, is uniquely suited to the applica-
tion of lag screw fixation for three reasons. The
most important is the curvature of the anterior man-
dible. This allows placement of lag screws across
the symphysis, from one side to the other, for sag-
ittal fractures, and from anterior to posterior for
oblique fractures and those of the anterior body re-
gion. The second reason the anterior mandible is
well suited to lag screw fixation is the thickness of
the bony cortices, which provide extremely secure
fixation when the screws are properly inserted. The
final reason is that there are no anatomic hazards
below the apices of the teeth until the mental fo-
ramina are encountered. This makes lag screw
placement extremely simple.
The direction of forces that are distributed
through the anterior mandible vary with the activity
Sur- of the mandible. This means that the classic zones
of tension on the superior and compression on the
inferior surfaces of the mandible are not absolute.
13
14
FIGURE 1. Top, A lag screw. Note the absence of threads
except at the terminus of the screw. Below, Cortical screw. This
screw can be used to impart compression to a fracture by over-
drilling the outer (near) cortex so the threads only engage the far
cortex.
Instead, the anterior mandible undergoes shearing
and torsional (twisting) forces during functional
activities.4.5 Therefore, application of fixation de-
vices must take these factors into consideration.
This is why Champy, who advocates only one small
bone plate in most regions of the mandible, always
places two bone plates in the symphysis.4 When
using bone screws to secure fixation, one bone
screw may not provide adequate stability, since the
shear forces may allow rotation of the mandibular
fragments around the screw. The only resistance to
rotation about one screw is the compaction (fric-
tion) of the fragments into one another by virtue of
the compression imparted from the lag screw. Ap-
plication of an arch bar to the teeth may prohibit the
rotational force; however, application of a second
lag screw is the best insurance for providing
rigidity.’ Fortunately, there is usually ample space
available for the routine placement of two screws in
fractures of the anterior mandible.
Technique
The application of lag screw fixation for fractures
of the anterior mandible requires relatively few in-
struments; however, correct instruments are essen-
tial to the technique. (AO/ASIF instruments are
available from Synthes Maxillofacial Instrument
Company, Paoli, PA, or from other manufacturers.)
The necessary instruments are included in the stan-
dard mandibular fracture kits; however, longer
screws than those that normally accompany the set
are necessary. The lag screw technique for the an-
terior mandible can require 2.7-mm screws up to 40
mm in length. Therefore, every screw length up to
LAG SCREW FIXATION OF ANTERIOR MANDIBLE
40 mm should be available before attempting to
treat fractures with lag screws.
Following application of maxillary and mandibu-
lar arch bars, a vestibular incision is made from just
posterior to one mental foramen to the same area on
the other side. Anterior to the mental foramina, the
incision is made out in the lip, splitting the mentalis
muscle to facilitate a two-layer closure. Subperi-
osteal dissection of the anterior, lateral, and inferior
borders of the mandible from one mental foramen to
the other is essential for complete exposure of the
fracture and for proper instrumentation. Dissection
under, or between the bundles of the mental nerves
when necessary for adequate retraction and expo-
sure, helps protect the nerve from injury due to
stretching. The entire fracture is examined follow-
ing slight distraction to note the obliquity and the
relationship of the cortices. If there are extensive
areas of comminution, the lag screw technique
should be abandoned, because it has little chance of
success in cases where the continuity of the cortices
is disturbed. Fortunately, this is unusual in frac-
tures of the anterior mandible.
Once the fracture has been examined and cleaned
of extraneous debris, the mandible is placed into
maxillomandibular fixation (MMF) while simulta-
neously reducing the fracture. A towel clip with the
tips bent slightly outward can be used to assist in
firmly reducing the fracture before application of
lag screws. A small bur is used to drill holes ap-
proximately 10 mm away from each side of the frac-
ture to provide a purchase for the modified towel
clip. The towel clip is inserted into these holes and
tightened, reducing the fracture. The location of the
towel clip must not be an area where the lag screws
are to be inserted. Frequently, it must be inserted in
the region of the root apices, taking care to avoid
them. The lingual cortices should also be checked
to assure that they are in firm apposition, since
other fractures of the mandible, especially those of
the condyle and ramus, may cause an increase in
the radius of the dental arch and inferior border.
Therefore, the surgeon must not be lulled into a
false sense of security that the fracture is properly
reduced by solid apposition of the buccal cortices.
It is helpful to dissect below the inferior border of
the mandible in the area of the fracture to directly
expose the lingual cortex and assure its proper re-
duction.
Selecting the point of entry into bone and align-
ment of the drill is crucial since it will determine the
success of the procedure and, when improperly ex-
ecuted, may cause undesirable complications. Al-
though the lag screw technique in other bones usu-
ally involves drilling the screw hole at an angle that
ELLIS AND GHALI 15

FIGURE 2. Illustration dem-

onstrating the A0 orthopedic
technique for determining an-
gulation of screw placement.
The angle between the outer
cortex and the line of fracture
is bisected to determine the
proper drill path. This tech-
nique of screw placement
makes little sense in the ante-
rior mandible and may cause
overriding of the fragments
when the screw is tightened.
Instead, the screw should be
placed perpendicular to the
fracture.

is the bisection of the angle between the line of able in most fractures of the anterior mandible.
fracture and the outer cortex (Fig 2),6 the curvature Therefore, the path of screw insertion should disre-
of the anterior mandible and frequent lack of frac- gard this principle of lag screw insertion for long
ture obliquity make this impossible and/or undesir- bones, and instead traverse the fracture in as per-

FIGURE 3. Attempting to use the A0 orthopedic principle demonstrated in Figure 2 for fractures of the anterior mandible, often results
in improper/inadequate placement of screws. A, The screw is placed obliquely to sagittal fractures of the symphysis. The tightening of
this screw tends to cause displacement of the fragments. This is similar to using a compression plate on a very tangential (oblique)
fracture, which also causes overriding of the segments. Attempting to use the A0 orthopedic principle frequently results in placement
of the screw into or very near the fracture on the lingual cortex (B), or misses the lingual cortex altogether (C and D). C, The screw
glances off the lingual cortex although it may feel as if the screw is secure. However, upon tightening, it shears and loosens. D, Screw
misses the lingual cortex and ends up in medullary bone. A screw inserted into medullary bone has insufficient strength to resist
displacement of the fracture during function. The management of this problem is to continue drilling until the buccal cortex is reached,
and a long screw is used (see Fig 4B).
16
pendicular a manner as possible. When the screw is
perpendicular to the line of fracture, the compres-
sive load imparted by the lag screw becomes ex-
tremely effective in securing rigid stabilization of
the fragments without causing displacement upon
tightening. For the same reason that compression
plates are not applied to oblique fractures, lag
screws applied obliquely to the fracture cause dis-
placement of the fracture. Figure 3 shows examples
of improper placement of lag screws, which results
in inaccurate reduction, complications, and/or in-
stability. One must remember that medullary bone
offers insufficient resistance to bone screw fixation
and, therefore, a bony cortex must be engaged with
the terminal threads of the screw. Figure 4 shows
proper screw placement for various types of frac-
tures in the anterior mandible.
Selection of the proper point of entry for the drill
in the buccal cortex is based on placing it suffL
ciently away from the fracture so that an ample
amount of bone is present between the head of the
screw and the fracture after drilling and counter-
sinking. This is especially important when drilling
along the curved surface of the anterior mandible.
The remaining bony bridge must resist all forces of
mastication, since the screw head rests directly on
it. Another factor to consider in determining the
location of the bone screw is providing sufficient
space for a second screw. Thus, the first screw
should be placed just above the inferior border.
Once the proper angulation and point of entry has
been established, the 2.7-mm drill is initially placed
almost perpendicular to the buccal cortex at the se-
lected point of entry to prevent skidding of the drill
bit, and a hole is begun in the buccal cortex. The
LAG SCREW FIXATION OF ANTERIOR MANDIBLE
FIGURE 4. Ihustration show-
ing proper placement of
screws for fractures of the an-
terior mandible. A, The screw
is placed perpendicular, or B,
nearly perpendicular, to the
line of fracture when it is sag-
ittal. C and D, When the frac-
ture is oblique, screws are
simply inserted across the
fracture in as perpendicular a
manner as possible.
drill is then redirected to the previously selected
angulation and the drilling completed through the
buccal cortex and medullary bone of the first (near)
fragment only (Fig 5A). The drill and drill guide are
withdrawn from the wound and a countersinking
tool is used at slow speed to provide a smooth plat-
form for screw-head seating (Fig 5B). It is impera-
tive that two facts be considered while countersink-
ing the hole. First, the same angulation should be
used as established by the initial 2.7-mm drill hole.
To facilitate this, a countersinking tool with an ad-
justable guide-pin that extends beyond the counter-
sinking flutes into the drill hole can be used. Sec-
ond, countersinking must be adequate to allow
complete seating of the screw head. This means that
a considerable amount of buccal cortex must be re-
moved when a screw is inserted into a rounded sur-
face or in an oblique manner on a straight surface
(Fig 6). The most appropriate method to determine
the adequacy of countersinking is to place the 2.0-
mm (“centering”) drill guide into the drill hole. This
drill guide, to be used in the next step, has a tip that
fits tightly into the 2.7-mm hole and a shank with an
outer diameter slightly larger than the head of the
screw. If insertion into the drill hole cannot be
smoothly accomplished without binding on the
bone medial to the drill hole, countersinking is in-
adequate and must be completed (Fig 7). However,
one must avoid countersinking deeper and deeper
into the bone to the point where the screw head
rests on medullary instead of cortical bone.
Drilling through the second (far) fragment with a
2.0-mm drill is the next step. To ensure that the
2.0-mm drill is perfectly centered in the 2.7-mm
hole previously drilled through the near cortex, a
ELLIS AND GHALI

FIGURE 5. Illustration show-

ing technique of placing lag
screws for sagittal fracture of
the anterior mandible. A,
Drilling near cortex with 2.7-
mm drill. Note that the drilling
extends only to the fracture. A
drill guide should be used to
stabilize the drill and protect
soft tissues. B, The near cor-
tex is countersunk using coun-
tersinking tool with guide pin,
which extends into 2.7-mm
hole. C, Drilling 2.0-mm hole
completely through mandible
using centering drill guide.
The tip of the drill guide has an
outer diameter of 2.7 mm, al-
lowing it to seat firmly into the
previously drilled hole in the
near cortex. The inner diame-
ter of the drill guide is 2.0 mm,
centering the 2.0-mm drill in
the 2.7-mm hole. D, Result af-
ter drilling. Note the near cor-
tex (right) has been drilled to
2.7 mm diameter, and the far
cortex to 2.0 mm diameter. E,
Depth gauge used to deter-
mine length of screw. F, Tap-
ping the far cortex. Note that
the tap (and screw in next
step) slides through the near
cortex, since it has the same
outer diameter (2.7 mm). G,
Result following tapping. Note
screw threads only in far cor-
tex. H, Screw inserted. Since
the threads only engage the far
cortex, compression is applied
during tightening.

special “centering” drill guide is used (Fig 50.
This drill guide has an outer diameter of 2.7 mm on
its working end, allowing a snug fit into the hole
previously drilled through the near cortex. It has an
inner diameter of 2.0 mm, acting as a drill guide for
the 2.0-mm drill, perfectly centering it within the
2.7-mm hole in the near cortex. Drilling through the
second (far) segment with the 2.0-mm drill is then
performed (Fig 5C). During the drilling, it is impor-
tant to use slow-speed, copious irrigation, and re-
peatedly withdraw the drill flutes from the drill
guide to clear bony debris. If not done, the drill
becomes quite warm due to both the inability of
irrigant to reach the flutes and clogging of flutes
with debris.
A depth gauge is inserted through the drill hole
and the screw length is determined (Fig 5E). The
hole in the far segment is then tapped using a long
tap (Fig 5F). To prevent tissue entanglement and to
help avoid wobble, the same drill guide as used in
drilling the 2.7-mm hole should be used as a tap-
guide. Care should be taken to ensure that the same
direction used during drilling is used for tapping.
The hole should be thoroughly irrigated before plac-
ing the screw.
After selection of the appropriate length screw, it
is inserted on a screw driver into the screw hole.
The outer hole (or clearance hole) is free of threads
and the screw should slip through until it con-
tacts the threads in the far segment (Fig 5D and G).
Thus, when tightened, the screw will compress the
two segments of bone together. While the final
tightening proceeds, the surgeon must carefully ob-
serve the bony cortices around the head of the
screw for signs of crazing. Frequently, the screw is
overtightened to the point of creating microfrac-
18 LAG SCREW FIXATION OF ANTERIOR MANDIBLE

FIGURE 6. Illustration dem-

onstrating the importance of
properly countersinking the
screw. If inadequate or no
countersinking is performed
(A), tightening of an obliquely
placed screw will cause pre-
mature contact and binding of
the screw on the bone, result-
ing in displacement of the
screw and/or segments or
causing fractures of the near
cortex. B, Proper countersink-
ing.

tures around the screw head. This should be
avoided if possible. It is essential that the screw exit
the far cortex for maximal strength (Fig 5H).
A second screw is then inserted in the same man-
ner as just described (Fig 8). With sagittal fractures
of the mandible between the incisors, it frequently
is easier to place the second screw from the oppo-
site direction. Because the buccal cortex on the
other side of the fracture has not yet been dis-
rupted, a greater area of bone for screw placement
is provided (Fig 9). In fractures of the anterior man-
dibular body (Fig lo), placing a second screw may
not be possible without damaging the mental nerve.
There are two choices in this instance. The first is to
supplement the fixation with a bone plate placed
superior to the lag screw (Fig 1OD). The second is
the maintenance of the arch bar and compression
(bridle) wire, and placement of the patient on a soft
diet (Fig 1OC). However, the rigidity produced by
one lag screw and an arch bar is not yet known and
is therefore not recommended routinely. If used, it
requires that the patient be extremely cooperative.
The intraoral incision is closed in two layers with
resorbable sutures. The MMF is then removed and
the patient is maintained on a soft diet.
Material and Methods
All patients treated by open reduction and inter-
nal fixation of fractures between the mental foram-
ina by the lag screw technique previously described
between November 1, 1988, and November 31,
1989, were included in this retrospective study. The
patients’ charts were reviewed for information
about additional fractures, and the presence of a
tooth in the line of fracture. Notes on the operative
findings and postsurgical course were evaluated for
extraction of the tooth in line of fracture, duration
of MMF if used, postsurgical occlusal relationship,
infection, and need for further intervention because
of complications. When possible, clinical examina-
tions were performed in December 1989 and Janu-
ary 1990. Otherwise, only the patients’ charts, in-
cluding postsurgical notes, were used for tabulation
of the above data.
Results
Forty-one patients were identified who were
treated using bone screws for anterior mandibular
fractures. Seven were female, the remainder male.

FIGURE 7. Illustration show-

ing effect of inadequate coun-
tersinking for an obliquely
placed screw. The 2.0-mm
drill guide does not seat se-
curely, causing the 2.0-mm
drill to become misaligned
with respect to the 2.7-mm
hole. A, Inadequate counter-
sinking. B, Proper counter-
sinking.
ELLIS AND GHALI 19

They ranged in age from 14 to 59 years. Two lag

screws were placed in the majority of patients (29);
however, in two patients, three lag screws were
used. A single lag screw was placed in seven pa-
tients; a single lag screw combined with a small
compression plate (using 2.0-mm screws) was used
in three patients. The anterior mandibular fracture
was the only mandibular fracture in 13 patients.
Twenty-nine patients had associated mandibular
fractures, of which 17 were fractures of the angle,
nine were subcondylar (six unilateral, three bilat-
eral), one was in the body, one was in the ramus.
and one was a dentoalveolar fracture.
All patients had a tooth in the line of fracture.
Five patients had the tooth in the line of fracture
removed at surgery. Because of associated frac-
tures, MMF was used in nine patients: two patients
for 1 week, four for 4 weeks, and three for 6 weeks.
No MMF was used as a supplement to lag screw
fixation of a symphyseal fracture. Follow-up ranged
from 4 to 61 weeks, with a mean of 12 weeks. All
fractures except the one noted below were found to
be stable at follow-up appointments. No postsurgi-
cal malocclusion resulted. Two patients developed
postsurgical infections (4.9%), both thought to be
due to a nonvital tooth in the line of fracture that FIGURE 9. Lag screws placed from opposite sides of a sagittal
was subsequently removed. Both patients had two fracture. A, Intraoperative view. B, Postoperative view follow-
lag screws placed to secure the two halves of the ing healing of fracture. The crisscross technique of screw place-
ment may be easier, because more bone is available for drilling
mandible. In one patient, a soft-tissue infection de- and countersinking on the side opposite the initial screw.
veloped 1 week following surgery and the tooth in
the line of fracture, which was noted to be loose,
was removed. This patient had a large segment of bone that included the inferior border maintained in
position using a third lag screw during surgery. The
patient had also been placed in MMF for an asso-
ciated subcondylar fracture. The infection persisted
at a subclinical level, and at 6 weeks postsurgery,
the labial soft tissue had a dehiscence, exposing
some granulation tissue and nonvital bone. A se-
questrectomy was performed at this time and the
previously repositioned bony segment, which was
found to be loose and necrotic, was removed. How-
ever, the fracture was united and the patient healed
uneventfully. The second patient developed a soft
tissue swelling 3 weeks postsurgery. This patient
had no extraction at the time of surgery. One tooth
associated with the fracture was removed. The fol-
lowing week, more swelling was noted and the
other tooth adjacent to the fracture was noted to be
loose and was removed. The fracture was noted to
have slight mobility at that time. The patient was
placed into MMF, but was uncooperative and re-
peatedly removed the fixation. At 8 weeks’ postsur-
FIGURE 8. Example of lag screws in symphyseal fracture. A,
gery, the patient was taken to the operating room
Preoperative panoramic radiograph showing sagittal fracture of
midsymphysis. B, Postoperative panoramic radiograph showing where the lag screws (which were slightly loose)
placement of two lag screws perpendicular to fracture. from one were removed and external pin fixation was placed.
buccal cortex to the other. He had a satisfactory course thereafter. One addi-
20
FIGURE 10. Illustration
showing application of lag
screws for fractures of the an-
terior mandibular body in the
vicinity of the mental foramen.
Placing screws from buccal to
buccal (A), or buccal to lingual
(B) both have utility. C, Use of
a single lag screw combined
with arch bar and bridle wire
for fractures around the men-
tal foramen. D, Supplementa-
tion of fixation by application
of a 2.0-mm bone plate, using
monocortical screws to avoid
roots, if necessary.
tional patient had further surgical intervention at 9
months. This patient had been treated with two lag
screws, no MMF, and underwent an uneventful
postoperative course. However, a 9-month radio-
graph showed a small radiolucency around the head
of one of the bone screws. No symptoms were
present. This screw was found to be loose and was
removed. Dense fibrous connective tissue sur-
rounded the head of the screw where the labial cor-
tical bone had once been. The other screw was not
loose, but was also removed.
Discussion
Besides the many advantages that rigid fixation of
mandibular fractures offers, the use of lag screws as
a type of rigid fixation has several unique advan-
tages over bone-plate fixation. The major advantage
is that lag screws can be applied more rapidly, since
the time-consuming task of adapting a bone plate is
obviated. This also allows a more anatomically ac-
curate reduction, because it takes considerable skill
to perfectly adapt a bone plate to the complex con-
tours of the mandible. In our experience, displace-
ment of bone fragments is much more common dur-
ing placement of a bone plate, since the adequacy of
plate contouring is not thoroughly known until the
screws are inserted and the plate is drawn to the
mandible. Displacement of bone segments almost
never occurs while applying lag screw fixation
when one adheres to the details previously de-
scribed.
Lag screws also permit the rapid application of
fixation without a decrease in rigidity of the frac-
LAG SCREW FIXATION OF ANTERIOR MANDIBLE
D
ture reduction. Although no research has yet been
done that compares the rigidity of fixation with a
bone plate versus lag screw fixation of anterior
mandibular fractures, one frequently gets the im-
pression that lag screws provide much more rigidity
than do bone plates. This is especially evident when
the screws are applied perpendicular to the frac-
ture. The fracture gap frequently completely disap-
pears from sight due to the great amount of com-
pression that can be imparted with the screws. An-
other advantage is the costs incurred: these are
greatly diminished because the screws cost much
less than a bone plate.
The results of this retrospective study show that
lag screw fixation of anterior mandibular fractures
is an extremely simple and successful method of
rigidly securing the fragments, permitting active use
of the mandible during healing. Only two patients
experienced problems that required intervention.
All seven patients treated with only one lag screw
(in addition to an arch bar and bridle wire) had no
postoperative difficulties. These patients were all
cautioned to maintain a soft diet, because the rigid-
ity of the fixation with only one screw is unknown.
However, their compliance with this regimen was
not determined. However, even in the face of these
results, we still do not recommend the use of only
one lag screw, because adequate numbers to justify
its routine implementation are not yet available.
We are in disagreement with Niederdellmann et
al, who state that “lag screw osteosynthesis is not
meant to replace osteosynthesis with plates,” and
who reserved the use of lag screws for very special
circumstances.’ We now use lag screw fixation as
ALAN SCHWIMMER
our first choice for providing rigid internal fixation
of anterior mandibular fractures. Rarely do we have
the need or desire to use bone plates in the anterior
mandible. However, there are special circum-
stances where the use of lag screws are contraindi-
cated. The most important is when there is commi-
nution and/or bone loss in the fracture gap. One
must understand completely that the lag screw tech-
nique of fixation is one that relies on compression of
bone fragments. If the intervening bone is unstable
due to comminution, or is missing, compressing
across this region will cause displacement of inter-
vening bone fragments, overriding of segments,
and/or shortening of the fracture gap, resulting in
problems with the occlusion. In such situations, ap-
plying a bone plate without compression across this
gap can achieve rigid fixation without disturbing the
occlusion. Fortunately, the vast majority of frac-
tures of the anterior mandible result in fragments
J Oral Maxillofac Surg
49.21-22.1991
Discussion
Lag Screw Fixation of Anterior
Mandibular Fractures
Alan Schwimmer, DDS
Beth Israel Medical Center, New York, NY
Doctors Ellis and Ghali have presented an extremely
innovative technique for the use of lag screws as a means
of obtaining functionally stable fixation in mandibular
fractures. Lag screws, or traction screws, provide maxi-
mum interfragmentary compression with a minimum
amount of implanted material. Because of their effi-
ciency, they represent an ideal method of internal fixa-
tion, and in orthopedic surgery lag screws are often the
first choice when rigid fixation is used.
Lag screw fixation also has been useful in the treatment
of midface trauma. Direct lag screw fixation is often not
practical for the stabilization of midface fractures; how-
ever, the use of lag screws has been shown to be effective
in the stabilization of split calvarial grafts. Recent studies
by Phillips, Rahn, and McCarthy have demonstrated im-
proved retention of bone graft volume when cranial grafts
have been stabilized with lag screws.
Anatomic considerations often prevent the use of lag
screw fixation in the treatment of mandibular fractures.
Niederdellman has described the use of a single unpro-
tected lag screw for the fixation of transverse fractures at
the angle of the mandible.’ With this technique, the lag
screw is placed on the tension side of the fracture; there-
fore, compression is achieved along the unstable portion
of the fracture. Spiessl has recommended the use of lag
screws in oblique fractures of the body of the mandible.2
However, in these cases a minimum of three lag screws
21
that are large enough to permit the application of lag
screw fixation.
1. Brons R, Boering G: Fractures of the mandibular body
treated by stable internal fixation: A preliminary report. J
Oral Surg 28:407, 1970
2. Niederdellmann H, Schilli W, Dtiker J, et al: Osteosynthesis
of mandibular fractures using lag screws. lnt J Oral Surg
5:117, 1976
3. Leonard MS: The use of lag screws in mandibular fractures.
Otolaryngol Clin North Am 20:479, 1987
4. Charnpy M, Lodde JP, Schmitt R, et al: Mandibular osteo-
synthesis by miniature screwed plates via a buccal ap-
proach. J Maxillofac Surg 6:14, 1978
5. Niederdellmann H: Fundamentals of healing of fractures of
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are used. In oblique fractures that allow placement of
only a single lag screw, protection of the lag screw by a
stabilization plate is recommended.
With the publication of this technique, Drs Ellis and
Ghali have expanded the use of lag screws for the func-
tional stabilization of mandibular fractures. This proce-
dure appears to be easily executed; however, any surgeon
attempting to use this technique must be familiar with the
basic principles of rigid internal fixation. A lack of under-
standing of these basic principles will result in failure. It
is therefore advisable that one first develop proficiency in
the more routine methods of plate and screw stabiliza-
tion. Once experience is gained in these techniques,
greater success can be expected when using the proce-
dure described by Drs Ellis and Ghali.
The technique described in this article does adhere to
several principles of lag screw fixation. To begin with, it
is important to note that the authors recommend using
dedicated instruments when using this technique. At-
tempts to improvise instrumentation will compromise the
success of the procedure. Of special importance is the use
of the centering guide to align the traction hole and the
gliding hole coaxially. Failure to pay close attention to
this step will result in misalignment of the fracture and a
decrease in the compressive force of the lag screw.
It should also be reemphasized that a 20-mm screw is
the longest available in the standard Synthes set. When
using lag screws for the stabilization of transverse frac-
tures, whether at the angle or in the anterior mandible,
screws longer than 20 mm are often required. Therefore,
if the surgeon is planning lag screw fiiation of a trans-
verse mandibular fracture, it is essential that screws of 30
to 40 mm in length be available.