Rigid internal fixations

Made by-
ROSHALMARIA THOMAS
IV YEAR B.D.S.
RIGID INTERNAL FIXATION

 What is fixation?
 Fixation in orthopedics is the process by which an injury is rendered immobile. This may be
accomplished by internal fixation, or by external fixation.
 What is internal fixation?
 Internal fixation is an operation in orthopedics that involves the surgical implementation
of implants for the purpose of repairing a bone
 What is osteosynthesis?
Osteosynthesis is the reduction and internal fixation of a bone fracture with implantable
devices that are usually made of metal. It is a surgical procedure with an open or per
cutaneous approach to the fractured bone. Osteosynthesis aims to bring the fractured bone
ends together and immobilize the fracture site while healing takes place. In a fracture that is
rigidly immobilized the fracture heals by the process of intramembranous ossification

INDICATIONS for internal fixation
Trauma- facial bone fracture
Orthognathic surgery
Reconstruction of craniofacial deformities
Reconstruction of bony defects 2 ͦ to ablative tumour
surgery.
Augmentation of atrophic mandible in the elderly
Iatrogenic -2 ͦ to anterior/lateral mandibulotomy

History of Fracture Treatment and Development
Of Modern Osteosynthesis
 In the Preantibiotic era, closed reduction of fractures was understandably the rule for most fractures.
However, when closed reduction was insufficient, external fixation appliances served to maintain skeletal
units in position, frequently without the need for MMF (Maxillo-mandibular fixation) .Following the
development of antibiotics, the open treatment of fractures began to be used on a more frequent basis.
 Rigid internal fixation (RIF) is “Any form of fixation applied directly to the bones which is strong enough to
permit active use of the skeletal structure during the healing phase and also helps in healing”.

Bone fractures have been treated with various conservative techniques for centuries and it was
not until the eighteenth century that internal fixation was first documented.
 Icart, a French surgeon in Castres, performed ligature fixation with brass wire on a young
man with a humeral fracture.
 1886, when Hansmann of Hamburg published a technique using retrievable metal bone
plates with transcutaneous screws.
 Soon after, a Belgian surgeon, Albin Lambotte, improved these techniques and coined the
term internal fixation.
 Lambotte developed and manufactured a variety of bone plates and screws and much of his
armamentarim remained in use until the 1950s.
 In the twentieth century, Sherman improved on Lambotte’s designs and created parallel,
threaded, finepitched, self-tapping screws. This hardware was made of corrosion-resistant
vanadium steel, which was a strength improvement over silver and ivory fixation materials.

 1970s-titanium
 In the 1930s, Eggers rediscovered an older design for sliding slot plates, which eventually led to
the development of a compression plate by Danis in 1947.
 Luhr helped advance the principles of compression and dynamic compression, but it wasn’t until
1977 that he developed these techniques to the maxillofacial skeleton.
 Spiessl later popularized dynamic compression bone plating of the mandible using
Arbeitsgemeinschaft für Osteosynthesefragen-Association for the Study of Internal Fixation (AO-
ASIF) techniques.
 From Luhr and Spiessl’s work, eccentric dynamic compression plating was developed and
adapted for craniomaxillofacial trauma use, but lost popularity due to its highly technique-
sensitive nature and no proven benefits over other modern fixation methods.

BIOLOGY OF BONE AND BONE HEALING
 Bone is a complex and ever-evolving connective tissue and serves multiple purposes. Besides
being the main constituent of the human skeletal system, bone is highly metabolically active and
essential for the regulation of serum electrolytes—namely, calcium and phosphate.
 Marrow cavities are filled with hematopoietic elements necessary to manufacture and maintain
blood components and regulate the immune system. Bone is comprised of calcified bone matrix
and three major cell types, osteocytes, osteoblasts, and osteoclasts.
 Bone’s organized structure is illustrated in cross section revealing the haversian system, or
osteon. Each osteon contains concentric layers of compact bone surrounding a central
haversian canal, which harbors the neurovascular bundle supplying the unit. Cells suspended in
this highly calcified, highly vascular structure are perfused via small capillary-containing
cylindrical cavities called canaliculi

 Bone healing can be broadly categorized in two ways, primary and secondary.
 Primary, or direct bone healing, requires rigid fixation and immobility of fracture segments with a
minimal gap between them (less than 100 μm). Osteoclasts migrate to the fracture site and widen
adjacent haversian systems, allowing osteoblasts to deposit bone matrix, or osteoid, eventually to
calcify into organized mature lamellar bone.
 Secondary, or indirect bone healing, is more complex and occurs when a significant gap or
interfragmentary motion is present.
 Secondary bone healing involves the formation of a fibrocartilaginous intermediary bone callous
 There are four distinct stages of indirect bone healing but the end product is the same as mature
bone formed in primary healing. The initial insult propagates the inflammatory stage.
 A hematoma between and around the fracture develops and stabilizes, drawing inflammatory cells
to the site.
 Necrotic and nonviable bone near the fracture is cellularly débrided and repair is initiated by
angiogenesis and the activation of osteoprogenitor cells and fibroblasts.

 The second, or soft callus, stage is characterized by conversion of the hematoma to a
fibrocartilaginous mass to bridge the fracture.
 Fibroblasts and mesenchymal elements are highly active in laying down new collagen to
create the substrate into which the third phase, or hard callus stage, develops.
 During this period, osteoid is calcified and periosteal and endosteal bone ingrowth starts to
replace the soft callus as a result of endochondral bone formation.
 Finally, in the remodeling stage, the woven bone of the hard callus matures and organizes
to a trabecular structure to re-create the native preinjury structure.
 Although distinct, both types of bone healing may occur simultaneously in the same
fracture. As three-dimensional structures, bones may have varying levels of contact and
fracture reduction in the same general site, resulting in endochondral and lamellar elements
in different areas at the same point in time

BIOPHYSICS OF THE FACIAL SKELETON
 Although complex, the facial skeleton does not consist of
many moving parts. The major axis of bony motion in the
face is around the mandibular condyles, or
temporomandibular joints (TMJs). The muscles of facial
expression originate on various bones of the
craniomaxillofacial skeleton, are invested in the superficial
musculoaponeurotic system, and insert on each other and
the facial skin. These have little effect on forces exerted on
facial bones.
 The muscles of mastication and suprahyoid muscles,
however, produce significant forces on the jaws and
surrounding osseous structures. Bite force is generated by
contracture of the masseters, temporalis, and medial
pterygoids; the sum of these vectors allows for occlusion of
the teeth via movement of the mandible.
 Due to its dynamic nature, the mandible bears most of the
forces applied by facial musculature to the skeleton.

Mechanical Stress on mandible under Function
 The force of the masseter, medial pterygoid, and temporalis muscle results in
upward and forward vector of force on the posterior aspect of the mandible.
 The suprahyoid musculature places a downward and posterior force on the
anterior portion of the mandible.
 With the pterygomasseteric sling functioning as a point of fulcrum, the superior
border of the angle/posterior mandible is placed under tension while the inferior
border is placed under compression

 Beam mechanics dictates that the mandible is
a class III lever, with the condyle being the
fulcrum, the muscles of mastication acting as
the applied force, and bite load acting as the
resistance This rationale applies to one side
of the mandible at a time, but as a horseshoe-
shaped bone, the mandible is more than a
simple class III lever.
 When loaded, the mandible exhibits
maximum tension at the superior border and
maximum compression at the inferior border .
This is a gradient and, between the zones of
tension and compression, lies a neutral zone
in which opposite forces total zero.
 In this model, it would be mechanically
advantageous to apply rigid fixation hardware
along the zone of tension, or superior border.
Biologically, this is complicated by the
presence of teeth, thin cortical bone, and thin
overlying soft tissue. The neutral zone is
dynamic and depends on from bilateral
muscle contracture on a unilateral fracture

 Adequate exposure of fracture segments is carried out while not compromising the adjacent
blood supply. Maintaining vital periosteum aids in
1. fracture healing,
2. preventing postoperative wound breakdown and
3. decreasing the rate of hardware infection.
 Primary closure of the wound may or may not require local flaps to maintain well-vascularized
soft tissue coverage.
 Cases in which surgical exposure of fracture sites may interrupt blood supply, such as severely
comminuted fractures or contaminated wounds, pose a risk for hardware infection and may be
an indication for skeletal pin external fixation.

 Prior to the development of modern internal fixation, Maxillomandibular
fixation (MMF) was the mainstay of facial fracture treatment.
 By stabilizing the dentition in its known pretraumatic occlusion, bone
segments will assume an anatomically acceptable configuration.
 Because MMF compresses fractures at the alveolus, the inferior border of
the mandible may still demonstrate a gap. By combining this method with
compression of the inferior border with bone reduction forceps and
application of internal fixation methods, an ideal reduction can be achieved.
 MMF is still used as a primary modality of fracture treatment in patients for
whom internal fixation may not be indicated.
 Minimally or nondisplaced biomechanically favorable fractures in patients
with a sufficient complement of teeth to provide a stable premorbid
occlusion, severely comminuted fractures, or intracapsular condylar
fractures in which occlusion can be reestablished are some common
scenarios for which 2 to 8 weeks of MMF without surgery may be indicated.
 MMF is considerably less invasive and more cost-effective and reduces
complications associated with open surgery

INTERNAL FIXATION
 Internal fixation permits more precise anatomical bone reduction of the fracture site but
requires direct surgical exposure of fractures, especially for transosseous wiring or plate
fixation
 Internal fixation of mandibles can be undertaken in the following ways
 Circumferential wiring or nylon straps
 Transosseous wiring;upper and lower border
 Intramedullary pins; kirschners wire or Steinmann pin
 Rigid internal fixations

PRINCIPLES OF FIXATION
 AO-ASIF guidelines of rigid fixation follow four basic principles to ensure adequate treatment of
fractures:
1. bony segment reduction,
2. stable fixation and
3. immobilization of fragments,
4. maintaining blood supply, and early function.

Materias used for RIF
Metallic and Resorbable(biodegradable) osteosynthetic devices.
1. Metallic
 Stainless steel
 Vitallium- trade name for alloy of chromium, cobalt & molybdenium
 Titanium
2. Resorbable materials
 Polylactic acid(PLA)
 Polyglycolic acid(PGA)
 Polydioxanone(PDA)
 Copoloymers e.g PLLA+PDLA; PLLA + PGA(Lacto Sorb)

Metabolism of biodegradable implants:
Hydrolysis→ short chained fragments→
phagocytosis(macrophages+
PMNs)→Lactate(monomers)→Pyruvate(gluconeogenes
is &/or Kreb’s cycle)→ CO₂ +H₂O
Excretion- urine, faeces, expired air.
Degradation time depends on - temperature, pH,
presence of water, mechanical strain on implant,
polymer configuration

Varios concepts of Fixation
 Rigid internal fixation & Non rigid fixation
 Load-bearing & load-sharing fixation
 Compression & Non compression plates osteosynthesis
 Locking & Non locking plate-screw system

Rigid internal fixation
• rely on two point fixation—a stabilizing
unit, such as a bone plate at the inferior
border, and a tension band, such as a
miniplate or arch bar superior to that.
• rigid internal fixation with minimal gap
between the bone segments allows for
primary bone healing
• Fractures with a significant gap or
interfragmentary motion,heal by
secondary intention
Non rigid internal fixation
• allows for movement between the bone
fragments across a fracture line.
• Do not prevent interfragmentary
movement.
• Depending on the magnitude of
movement across the fracture, nonrigid
fixation may result in nonunion or
malunion.
• Champy method for the fixation of angle
fractures-functionally stable
•

Load bearing
• plate assumes all the
forces
Load sharing
• there are different
levels of force
distribution between
the plate(s) and the
bone

 Although functionally stable fixation of the mandibular angle reduces
operative time, risk of dental injury, and cost, it is not ideal in all
situations.
 When fracture occurs at the angle, the upward and forward rotation of
the posterior mandible combined with the downward and posterior
movement of the anterior mandible results in distraction at the superior
border and with bony contact remaining at the inferior border of the
mandible .
 Concomitant fractures of the mandible must be treated rigidly to
prevent motion at multiple sites.
 The Champy method relies on the contralateral condyle being seated
correctly in the glenoid fossa, without disruption of the
temporomandibular relationship.
 If a contralateral fracture is present and not treated rigidly, bite forces
across the angle can transmit to the distal segment, causing rotation
around the opposite fracture line.
 This may result in widening of the mandible and subsequent
malocclusion and facial width alteration. By treating the other fracture
site rigidly, the angle can essentially be treated as an isolated injury.

Non locking plates
require precise adaptation of the plate to the
underlying bone
Without this intimate contact, tightening of the
screws will draw the bone segments toward the
plate, resulting in alterations in the position of the
osseous segments and the occlusal relationship
compress the undersurface of the plate to the
cortical bone.
Increased incidence of inflammatory complications
from loosening of the hardware
Locking plates
unnecessary for the plate to intimately contact
the underlying bone in all areas.
As the screws are tightened, they "lock" to the
plate, thus stabilizing the segments without the
need to compress the bone to the plate
do not disrupt the underlying cortical bone
perfusion as much as conventional plates
unlikely to loosen from the plate

 Examples of rigid fixation of a fracture include application of a reconstruction plate, two bone
plates, two lag screws, or a compression plate and arch bar across a fracture.
INTERNAL FIXATIONS
RIGID
ADAPTATIONAL
PLATES
MESH
COMPRESSIONAL
BICORTICAL SCREWS AND
PLATES
LAG SCREWS
NON RIGID

COMPRESSION OSTEOSYNTHESIS
 Zero movement occurring between bones across the fracture, as well as complete
immobility of the hardware against the bone.
 Today, most mandibular plating modules include dynamic compression plates for
surgeons who wish to use compression osteosynthesis. compressive plating techniques
are extremely technique-sensitive and prone to operator error

 Dynamic compression plates are designed with eccentric holes with inclined planes.
 On either side of the midline of the plate, the plate holes are elongated, with the lateral side
having the highest portion of the inclined plane and the medial with the lowest portion, or
closest to the bone, of the inclined plane.
 The plate should be adapted so that one eccentric hole is on each side of the fracture, closest
to the fracture line.
 The outer planes of each hole are the active, or compression, sites. As screws are drilled and
fastened into this high point of the inclined plane, they follow the plane down toward the bone
as friction is created between the screw head and plane surface.
 When completely tightened, they lie on the innermost portion of the hole closest to the bone.
Because this is completed on either side of the fracture, the bone segments are compressed
toward each other while the plate remains static, minimizing the bone gap and achieving
compression.
 The remainder of the holes distal to the fracture line are then drilled and secured with bone
screws in a passive position so as to not compress or distract the bones and hardware further.

 To instrument the dynamic compression plate properly and achieve successful compression,
the plate must first be bent and accurately adapted to the bony segments.
 The fracture must be stabilized and reduced by MMF, a superior border miniplate, bone
reduction forceps, or a combination of these techniques prior to bending the dynamic
compression plate.
 Once adapted to the reduced fracture, the compression elements can be drilled. Drill guides
provided by the manufacturer for compression plating are helpful in placing the screw hole
correctly to achieve maximum compression.
 The drill guide has active and passive positions, with arrows to indicate the orientation. The first
hole adjacent to the fracture is drilled in a bicortical fashion with a drill guide with the active, or
compression, arrow facing the fracture. This corresponds to the outer, or high, incline of the
hole.
 A depth gauge is used to measure the desired screw length and the screw is inserted partially
to stabilize the position of the plate.
 The most proximal hole on the opposite side of the fracture is drilled in the same fashion in the
active position and the screw is inserted and tightened completely. As noted, the screw will
migrate down the plane approaching the fracture line and draw the bone segment toward its
counterpart.
 The first screw is then tightened completely, producing the same effect on the opposite side and
creating compression between the bony segments.

 The remainder of the holes are then drilled in the passive position and bicortical screws are
inserted to stabilize the plate to the fractured mandible. These serve to share the load further
and reduce forces that would tend to counteract interfragmentary compression.
 Dynamic compression plates actively draw fractured segments together. The resultant
compression at this site, typically the inferior mandibular border, may result in excessive
tension at the superior border or alveolus.
 It is necessary to neutralize these forces to prevent gap formation in the zone of tension of the
mandible. This is typically achieved by the use of a tension band. An arch bar, superior lag
screw, or monocortical miniplate can be used as a tension band to reduce the distraction at the
superior border. This applies to any load-sharing internal fixation system but holds especially
true for compression plating.
 Compression osteosynthesis is best applied in transverse fractures of the mandibular
symphysis or body without comminution or bone loss.
 Obliquely oriented fractures can pose problems in this technique due to the nonsymmetrical
nature of the fracture line. Plates are adapted and applied to the outer, or buccal, cortex of the
mandible. Compression is applied parallel to the plate; equal distribution of forces occurs best
in fractures that are completely perpendicular to the compression plate.

NONCOMPRESSION OSTEOSYNTHESIS
 Noncompression osteosynthesis is widely used in managing traumatic injuries to the
maxillofacial skeleton. This can be accomplished with a variety of methods
 Non-compression bone plates and reconstruction plates, both of which are available with locking
mechanisms. These methods have broader applications and less degree of operator error when
compared with compression osteosynthesis.

MANDIBULAR FIXATION
 Fixation must be sufficient to withstand masticatory forces during the healing period.
 Fracture plates are manufactured in various widths and universal fixation systems generally allow
interchangeable screw diameters to be used in multiple plates, depending on the level of fixation
desired.
 Other factors that should be taken into account when selecting the width of the fracture plate are
 quantity and quality of overlying soft tissue,
 patient compliance, and
 risk of reinjury.
 Thicker plates provide more stability than thinner counterparts, but may be palpable under soft
tissue, may require more dissection, are more difficult to adapt, and have higher rates of
dehiscence.

plate selecttion
fracture
exposed and
reduced
plate is
adapted to
buccal cortex
held in place
using plate
holding
forceps

two screws on each side of
fracture-placed first on site
most proximal to the fracture
line and secured
holes drilled
bicortically
using drill guide
place screws
screws most
proximal to the
fracture are
secured
remainder of
screws are
drilled and
placed

INSTRUMENTATION Reduction forceps
 Towel clip type
 Bone holding clamps
 Reduction/Compression forceps
 Plate holding forceps
 Screw driver ± holding sleeve (hexa, cruciform, phillip)
 Plate benders
 Bending irons
 Bending pliers (flat, pronged, side bender)
 Plate cutters
 Templates
 Drilling machine
 Drill bits
 Drill guides (neutral or eccentric)
 Depth guages
 Tap
 Transbuccal instruments (trocar + cannula, guide, retractor)

 Locking plates- useful in securing plates that cannot be perfectly adapted to fractures or if
bone quality is poor.
 Locking screws are double-threaded;
 the head of the screw has an additional larger diameter thread that secures into the
thread pattern of the plate hole.
 Locking plate and screw systems prevent loosening and extrusion of the screw from
the plate, even if it does not integrate to the mandible and resists mechanical yielding
under stress.

 Miniplates
 Champy method of mandibular angle fracture fixation and its use
as a tension band..
 These plates accept the same screws as standard mandibular
fracture plates
 The Champy method of mandibular angle fixation involves
exposing and reducing a fracture, as described earlier, and using
the biomechanical advantage to place a miniplate at the zone of
tension—that is, the superior border

 This method has been proven to exhibit enough stability to withstand tensile forces at the superior border
under function during the healing period.
 Care must be taken to place this plate in the zone of tension while avoiding tooth roots. Even with
monocortical fixation, damage to dental structures can occur because the relationship of teeth to the
mandibular buccal cortex vary from patient to patient. In the edentulous mandible, tension bands should
be placed at the superior border to maximize tensile force resistance. Miniplates are also more prone to
screw loosening and infectious complications
 May be regular or 3D
 Profiles usually 1-1.3mm
 2.0mm used in mandible
 1.3, 1.5,mm used in middle and upper third
 May accommodate locking mechanism in plates (small, medium, large, extra large profile mandibular
plates)
 Come in different shapes and lengths
 May also come as meshes

Compression plates(Spiessel et al)
There are basically two types:
Regular
EDCP
Reconstruction plates
 Mandibular reconstruction plates are thicker
 Have a longer span than fracture plates
 Designed to be load bearing to span gaps and defects.
 Reconstruction plates can be used to treat mandibular fractures that are
comminuted, atrophic, or grossly unstable.
 When used to span a gap, four screws should be placed on each side of the
defect to allow the plate to bear the most, if not all, the load of the mandible.
 Due to their size and thickness, reconstruction plates frequently pose problems
in adapting to the mandible.
 The built-in locking mechanism can circumvent the need for perfect adaptation
to bone.
 Reconstruction plates exhibit a high degree of elastic deformation.
 The locking mechanism proves to be essential in large spans with complex
contours for which perfect plate adaptation is not possible.
Can vary in thickness from 2mm and above
Plates not as thick as 3mm are not recommended for defect bridging
May use 2.4, 2.7 or 3.0mm screws depending on system.
UFP (Universal Fracture Plate) 2.4mm

 LAG SCREWS(Brons and Boering)
 Lag screw osteosynthesis is a fracture compression technique that can be carried out
by using true lag screws or a lag technique with long bone screws
 fixation of transverse mandibular symphysis and parasymphysis fractures or obliquely
oriented body and angle fractures.
 The premise of this technique is its ability to engage and pull, or lag, the distal cortex
toward the proximal cortex across a fracture.
 This method provides a high degree of fracture compression, resulting in very stable
fixation
 Lag screw osteosynthesis directly traverses the fracture line, more evenly distributing
compressive forces between segments and resulting in excellent stability and minimal
to no lingual splay.
 After the fracture is exposed and reduced, a gliding hold is prepared from the near-
cortex to the fracture close to the inferior border.

 This hole is of a larger diameter than the screw to be used to ensure that it does not
actively engage this cortex. Next, a long drill guide is inserted into the glide hole and, using
a drill of smaller diameter than the screw threads, the osteotomy is completed from the
fracture line to the distal cortex. This is the traction portion of the osteotomy.
 A depth gauge is used to measure the distances between the cortices and the appropriate
screw length is selected.
 A long bone screw or true lag screw is inserted passively through the gliding hole and
purchased into the traction hole.
 When completely tightened, the engaged distal cortex will be drawn proximally and create
compression at the fracture line. This process should be repeated with a second screw or
second method of fixation to prevent rotation around a single axis
 When treating transverse or sagittal fractures of the symphysis, the screws should be
placed through the outer cortex on either side. In oblique fractures, it may be necessary to
engage the outer cortex proximally and inner cortex distally.

EMERGENCY SCREWS
 1.0- 1.2
 1.3- 1.7
 1.5- 2.0
 2.0- 2.4
 2.4- 2.7
 2.7- 3.0

MIDFACE AND UPPER FACE FIXATION
 The zygoma is the only other bone that displays significant effects from the masticatory musculature.
 Complex craniomaxillofacial trauma involving the frontal sinus, orbits, naso-orbito-ethmoid (NOE)
complex, zygomaticomaxillary complex, and maxilla-miniplate or microplate fixation
 Thin soft tissue and overlying skin encasing the orbital and nasal complexes requires low-profile plates
to prevent
 show-through,
 palpability, or
 dehiscence
 Compared with the mandible, midface and upper facial bones are thinner and more fragile. It is
important to take advantage of the facial buttresses in fixating fractures to achieve screw and fracture
stability
 Even with the pull of the masseter attachment at the zygoma, zygomaticomaxillary complex fractures
can be managed with miniplate or microplate fixation at multiple points, with stable results.
 The contraction of the masseter muscle produces distracting forces at the zygomaticofrontal and
zygomaticomaxillary sutures, both of which are important points of fixation, with adequate bone stock
for screw stability.
 Increased points of fixation resist these forces but may or may not make a clinical difference

BIOABSORBABLE PLATE FIXATION
 The advent of bioabsorbable fixation devices negates the need for hardware removal
and can prevent many complications associated with long-term retention of permanent
hardware.
 Bioabsorbable implants were initially developed and used for pediatric craniofacial
surgery in 1996, but have been described in the literature as early as 1971 for
application in the facial skeleton
 The advantage of a resorbable system for pediatric fractures lies in absorption of the
plate in vivo before it can translocate to an unfavorable area
 There are several varieties of bioabsorbable materials; the most modern are
permutations of a polylactic acid and/or polyglycolic acid polymer
 Reported resorption rates for these materials range from 12 to 36 months, as described
by manufacturers, but many reports indicate that these plates can be palpated past the
3-year mark.
 The most commonly reported complications associated with this technique include not
only plate palpability, but foreign body reactions, effusions, and infections.
 Polylactic acid and polyglycolic acid plates, on average, provide half the strength of a
traditional bicortically fixated bone plate across a fracture. In the mandible, this can
produce negative outcomes

Surgical Approaches
Use of existing laceration
Intraoral
Makes use of a vestibular incision
With appropriate instruments and skill, can be used from
symphysis to condyle.
Use of transbuccal instruments, special contra-angled
instruments and endoscope may be necessary in posterior
regions.
Extraoral
Reserved for cases not treatable by intraoral access

 Submental
 Simple or extended
 Submandibular
 Retromandibular
 Preauricular
 Facelift/ Rhytidectomy
 Others

SYMPHYSIS and PARASYMPHYSIS
 2 lag screws/ lag technique
 A lag screw and a miniplate
 Archbar and lower border plate
 2 miniplates
 Reconstruction plate (preferably locking)
 3D plates
BODY
 Lag screws
 One miniplate
 Two plates
 One large plate (recon. Plate)
 3D plates
ANGLE AND RAMUS
 Single miniplate
 Oblique ridge
 Buccal surface
 Two miniplates
 3D plates
 Reconstruction plate
CONDYLE
 Ideally, two miniplates should be
applied in a triangular fashion with one
plate below the sigmoid notch and one
plate along the posterior border.
 Single DCP
 Single large profile 2.0 mand plate
 3D plate

ORTHOGNATIC SURGERY
 Different plate systems are available for orthognathic surgeries.
 3D plates and plates with angles are frequently utilised
 Other plates in mandibular modules may be used
RECONSTRUCTION
 Plates may be used to retain bone graft or flap
 Recon plates which may be locking or non locking are used
 Locking plates are preferred
 They require at least 3 screws on either side for adequate stability.
 Condylar pieces are available for replacement

ADVANTAGES OF RIF
 Permits primary bone healing
 Increases 3D mechanical and functional stability
 Allows precise anatomic reduction and enhance bone healing
 Requires no distraction of th efracture cleft
 Requires no additional fixation
 Provides greater patient comfort- airway maintained and function is immediately
restored

LIMITATIONS
 Stress shielding- osteopenia likely to occur with adaptational plates
 Foreign body reactions- less likely with titanium
 Expensive
 Interference with CT scans n radiotherapy
 Metal bulk

BIBLIOGRAPHY
 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- Chitra Chakravarthy
 Textbook of oral and maxillofacial surgery-Rajiv M Borle
 Mathog's Atlas of Craniofacial Trauma - Robert H Mathog, Terry Shibuya, Michael A.
Carron
 Illustrated lecture notes in oral and maxillofacial surgery- George Dimitroulis
 https://www.aofoundation.org

Rigid internal fixations

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Editor's Notes