Craniomaxillofacial Fractures: Principles of Internal Fixation Using the AO/ASIF Technique

206 Pages·1993·18.83 MB·English

by  Alex M. Greenberg (auth.)

Craniomaxillofacial Fractures
Alex M. Greenberg
Editor
Craniomaxillofacial
Fractures
Principles of Internal Fixation
Using the AO/A SIF Technique
With 358 illustrations
Springer-Verlag
New York Berlin Heidelberg London Paris
Tokyo Hong Kong Barcelona Budapest
Alex M. Greenberg, D.D.S.
Diplomate, American Board of Oral and Maxillofacial Surgery
30 East 60th Street, Suite 1504
New York, NY 10022 USA
Library of Congress Cataloging-in-Publication Data
Greenberg, Alex M.
Craniomaxillofacial fractures: principles of internal fixation using
the AOI ASIF technique I Alex M. Greenberg.
p. cm.
Includes bibliographical references and index.
ISBN 0-387 -97902-6. -- ISBN 3-540-97902-6
1. Facial bones--Fractures. 2. Jaws--Fractures. 3. Skull-
-Fractures. 4. Internal fixation in fractures.
[DNLM: 1. Fracture Fixation, Internal--methods. 2. Maxillofacial
Injuries--surgery. 3. Skull Fractures--surgery. WU 619 G798c]
617.1'56--dc20
DNLM/DLC
for Library of Congress 92-2423
Printed on acid-free paper.
©1993 Springer-Verlag New York, Inc.
Softcover reprint of the hardcover I st edition 1993
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Production managed by Karen Phillips; manufacturing coordinated by Jacqui Ashri.
Photocomposed pages prepared from the editor's Wordperfect files using QuarkXPress.
9 8 765 432 1
ISBN-13: 978-1-4613-9289-7 e-ISBN-13: 978-1-4613-9287-3
DOT: 10.1007/978-1-4613-9287-3
In loving memory of my mother, Nancy Greenberg.
To my father, Rubin Greenberg,
for his love, endless strength, inspiration, and generosity.
To Dr. Bruce L. Greenberg
for being an extraordinary brother, colleague, and partner.
To Karen and Jesse Greenberg
for their special love and support.
Contents
Acknowledgments ix
Contributors xi
1 Introduction 1
Alex M. Greenberg
2 Etiology, Distribution, and Classification of Fractures 5
Richard H. Haug and Alex M. Greenberg
3 Evaluation of the Craniomaxillofacial Trauma Patient 21
Richard H. Haug and Matt J. Likavec
4 Fracture Healing Principles Applied to Rigid Fixation of the
Craniomaxillofacial Skeleton 33
Alex M. Greenberg and Joachim Prein
5 Basics of AO/A SIF Principles and Stable Internal Fixation of
Mandibular Fractures 41
Alex M. Greenberg
6 Lag Screw Technique and Advanced Applications 69
Alan Schwimmer
viii Contents
7 Mandibular Pseudoarthrosis and Non-Unions 77
Alan Schwimmer
- Mandibular Fractures: Atlas of Cases 85
8 Basics of Stable Internal Fixation of Maxillary Fractures 135
Richard H. Haug
- Maxillary Fractures: Atlas of Cases 145
9 Basics of Stable Internal Fixation of Zygomatic Fractures 159
Alex M. Greenberg
- Zygomatic Fractures: Atlas of Cases 167
10 Stable Internal Fixation of Cranial Surgery 179
Richard H. Haug and Matt J. Likavec
- Cranial Fractures: Atlas of Cases 185
11 Pancraniomaxillofacial Fractures 193
Alex M. Greenberg, Beat Hammer, and Joachim Prein
- Pancraniomaxillofacial Fractures: Atlas of Cases 199
Index 207
Acknowledgments
I would like to acknowledge the many individu their experiences. Special thanks to Prof. Dr.
als who have been responsible for igniting my Berton Rahn for his illuminating discussions
interest in rigid internal fixation and its applica concerning bone healing at the Laboratory for
tion to the craniomaxillofacial skeleton. Experimental Surgery in Davos, Switzerland,
Foremost is Dr. Alan Schwimmer, Director of and his support for an AO/A SIF maxillofacial
Oral and Maxillofacial Surgery at Beth Israel research grant for a study concerning mandibu
Medical Center in New York. As a dental intern lar lag screw fixation under the direction of Dr.
and chief oral and maxillofacial surgery resident Schwimmer in which I was a co-investigator.
he was my mentor, and was responsible for My deep appreciation to Dr. Richard Haug of
instilling in me the highest principles regarding the Division of Oral and Maxillofacial Surgery at
the ethical responsibilities of surgical decision the Cleveland Metropolitan Hospital for his con
making and patient care. It was under the direc siderable contributions to this text. Dr. Haug,
tion of Dr. Schwimmer that I first became formerly my chief resident, has been an extraor
exposed to the AO/A SIF principles and tech dinary friend and colleague.
niques. I am greatly indebted to Dr. Matt Likavec for
I am grateful to the AO/A SIF International his contribution of innovative concepts for the
Foundation for its support in providing me with application of maxillofacial rigid internal fixa
an AO/A SIF Maxillofacial Fellowship under the tion techniques to the cranium.
direction of Prof. Dr. Joachim Prein at the Many thanks to Carmella Clifford, AMI, for
Clinic for Plastic and Reconstructive Surgery at her outstanding interpretation of the clinical
Kantonsspital Basel in Basel, Switzerland. I am cases that have formed the atlas section of the
especially thankful to Prof. Dr. Prein and Beat text, as well as other numerous illustrations.
Hammer, M.D., D.D.S., for their essential assis The fine artistic contribution of Mr. Hugh
tance, and contributions in the preparation of Thomas is also greatly appreciated.
this text. It has truly been an honor to have Special thanks to the staff of Springer-Verlag
been a fellow, AO/A SIF faculty member, and co for their unwavering commitment and support
author with such exceptional colleagues. Prof. of this project.
Dr. Prein and Dr. med. Hammer have become
special friends who have provided me with a Alex M. Greenberg, D.D.S.
wide perspective on the "fine points" of these NewYork,NY
techniques and have allowed me to share in January 1993
Contributors
Alex M. Greenberg, D.D.S.: Private Practice, 30 Matt J. Likavec, M.D.: Assistant Professor,
East 60th Street, Suite 1504, New York, NY Division of Neurological Surgery, Metrohealth
10022 USA; Assistant Clinical Professor, Divi Medical Center and the Case Western Reserve
sion of Oral and Maxillofacial Surgery, Columbia University, 2500 Metrohealth Drive, Cleveland,
University School of Dental and Oral Surgery, OH 44109 USA.
New York, NY; Assistant, The Presbyterian
Hospital Dental Service, Columbia Presbyterian Joachim Prein, M.D., D.D.S.: Chefarzt, Klinik
Medical Center, New York, NY; Clinical fur Wiederherstellende Chirurgie, Kantonsspital
Instructor, Division of Oral and Maxillofacial Basel, Spitalstrasse 21, CH-4031 Basel Switz
Surgery, The Mount Sinai School of Medicine, erland.
New York, NY; Teaching Affiliates: The Mount
Sinai Medical Center, New York, NY; Beth Israel Alan Schwimmer, D.D.S.: Associate Professor
Medical Center New York, NY; City Hospital of Dentistry, The Mount Sinai School of
Center, Elmhurst, NY. Medicine, New York, NY; Associate Director,
Department of Dental Medicine, Chief, Oral and
Beat Hammer, M.D., D.D.S.: Klinik fur Maxillofacial Surgery, Beth Israel Medical
Wiederherstellende Chirurgie, Kantonsspital Center, 1st Avenue and 16th Street, New York,
Basel, Spitalstrasse 21, CH-4031 Basel, NY 10003 USA.
Switzerland.
Richard Haug, D.D.S.: Assistant Professor of
Surgery, Division of Oral and Maxillofacial
Surgery, Metrohealth Medical Center and the
Case Western Reserve University, 2500
Metrohealth Drive, Cleveland, OH 44109 USA.
1
Introduction
Alex M. Greenberg
Introduction to the mat, a new frame of reference for surgeons
involved in the management of craniomaxillofa
AD/A SIF Principles of
cial fractures. By classifying craniomaxillofacial
Craniomaxillofacial Fracture
fractures according to their sites, as well as
Fixation Technique indicating varieties of acceptable means of fbm
tion, this volume should assist trauma surgeons
in their diagnosis and treatment planning. For
During the past three decades rigid internal fbm the first time, a text has been written that
tion has become an accepted modality in the specifically addresses all the problems of cran
operative treatment of fractures. The AO/A SIF iomaxillofacial fracture injuries that may be
(Swiss Association for the Study of Internal treated with rigid AO/A SIF internal fixation.
Fixation), founded in 1958 by Maurice E. Muller, This is not a text concerning the comprehensive
Martin Allg6wer, Hans Willinegger, aed Robert management of the facial trauma patient.
Schneider has successfully disseminated infor Rather, we are attempting to clarify numerous
mation concerning basic research and operative methods of internal fbmtion for handling classi
techniques throughout the world in a coherent cal fractures of the craniomaxillofacial skeleton.
and responsible manner with publications, fel As in orthopedics, it is now possible by means
lowships, and the organization of hands-on prac of open reduction and rigid internal fbmtion to
tical courses.l There has been a natural evolu improve the treatment of many facial injuries
tion of AO/A SIF rigid internal fixation technique previously managed by closed reduction and wire
from its beginnings in orthopedic surgery to its osteosynthesis. No fracture is exactly the same
application in the craniomaxillofacial skeleton, owing to variations in bone quality, size, type
which was facilitated largely through the initial and energy of impact, and other associated
efforts of Bernd Spiess1.2 With the development injuries. When clinicians are able to group frac
of hardware specifically designed for the require tures in a general classification scheme, they can
ments of the craniomaxillofacial skeleton, many more easily select the correct hardware and
of the inadequacies of traditional treatment appropriate steps involved in operative proce
methods now have modalities for their solution. dures, leading to superior cosmetic and func
The purpose of this text is to introduce, in a tional results. There are certain features of the
combination of technical review and atlas for- craniomaxillofacial skeleton that can cause con-
2 Alex M. Greenberg
fusion in treatment, as there are numerous 3. Atraumatic surgical technique.
bones in close proximity, each with different 4. Early pain free mobilization.
osseous quality and quantity, as well as function
1. Anatomic reduction. Of particular impor
al and cosmetic aspects. Craniomaxillofacial
tance in the management of craniomaxillofacial
fractures may be subdivided into a broad range
injuries are the requirements of anatomic
of types that range from minor dental injuries to
reduction for correct ocular function, occlusion,
extensive fragmentation of the combined adja
cosmesis, and temporomandibular joint move
cent neurologic and facial structures (see Table
ment. Exact anatomic reduction of segments is
1.1).
critical because of the unforgiving nature of
There is still high regard for the nonrigid
rigid fixation techniques. Even slight variations
fracture treatments based on the vast practical
in segment orientation can result in significant
experience of our older colleagues. For example,
cosmetic and functional deficits. Therefore, it is
in the past, open reduction of midfacial frac
critical not only to obtain anatomic reduction,
tures, especially at the Lefort levels I and II, was
but also to maintain the reduction in its proper
considered to be dangerous and unpredictable
orientation by the meticulous application of the
surgery with a high potential for complications.
hardware for fixation. When fractures involve
Current experience indicates that rigid fixation
the dental arches, maxillomandibular fixation
of these fractures can offer a more stable and
must always be utilized to avoid the sequelae of
predictable outqome.
occlusal disharmonies.
One of the few forums for multi medical and
2. Stable internal fixation. Hardware variability
dental specialty groups, the AO/A SIF courses
is required to manage the different bones of the
have provided an outstanding opportunity for
craniomaxillofacial skeleton. Because of the
the exchange of fresh ideas and innovative
honeycomb nature of the midfacial structures,
approaches. This text is meant to appeal to all
miniplates generally provide absolute stability
who deal with problems in the treatment of
without compression. This differs from the
craniomaxillofacial fractures.
mandible, where it is possible to achieve static
compression with larger hardware, which is nec
Table 1.1. Distribution of craniomaxillofacial essary to resist functional forces during the
fractures.
period of initial fracture healing.
Cranial 3. Atraumatic surgical technique. The preser
vation of periosteal attachment and associated
Craniofacial
soft tissue vascular supply will aid the healing
Maxillofacial
process, especially in situations where fragmen
Maxilla isolated
tation occurs. For example, with gunshot
Mandible isolated wounds it is often impossible to preserve many
Dentoalveolar fragmented pieces owing to the thermal,
Dental mechanical, and associated soft tissue injuries
involved. Certain anatomic sites are predisposed
to fragmentation, such as the maxilla, where it
is encountered and is often extensive, and where
AO/A SIF Principles
debridement may be unavoidable, with the
removal of many devascularized fragments.
The principles of the AO/A SIF were first postu 4. Early pain-free mobilization. The avoidance
lated in 1958 and have certainly withstood the of the debilitating experience of maxillo
test of time.2 The AO manual states that "Life is mandibular fixation permits immediate
movement, movement is life.,,2 This is the guid mandibular movement without the development
ing basis of the AO/A SIF principles for the man of fracture disease, which in the craniomaxillo
agement of craniomaxillofacial injuries with facial region leads to temporomandibular joint
rigid internal fixation. By follOwing these tac and associated cervicofacial muscle dysfunction.
tics, we can obtain predictable outcomes. The Jaw function also permits more rapid nutrition
four basic principles of the AO/A SIF are: al recuperation and reintroduction of the trau
ma patient back into SOCiety's mainstream.
1. Anatomic reduction. The indications for rigid internal fixation are
2. Stable internal fixation. not absolute (see Table 1.2), and certainly many