Manual of Internal Fixation in the Cranio-Facial Skeleton: Techniques Recommended by the AO/ASIF Maxillofacial Group

238 Pages·1998·46 MB·English

by  Leon A. Assael D.M.D.

I
Manual ofInternal Fixation in the Cranio-Facial Skeleton
II
Springer­Verlag Berlin Heidelberg GmbH
III
Manual of Internal Fixation
in the Cranio-Facial Skeleton
Techniques Recommended by the AO/ASIF Maxillofacial Group
Editor:Joachim Prein
Chapter Authors:
Leon A.Assael · Douglas W.Klotch · Paul N.Manson
Joachim Prein · Berton A.Rahn · Wilfried Schilli
With 190 Figures in 565 Separate Illustrations
123
IV Kapitel 1
Joachim Prein,M.D.,D.M.D. ISBN 978-3-642-63732-2
Professor ofMaxillofacial Surgery
Chairman ofClinic for Reconstructive Surgery Library ofCongress Cataloging-in-Publication Data
Manual ofinternal fixation in the cranio-facial skeleton:tech-
Unit for Maxillofacial Surgery
niques recommended by the AO/ASIF-Maxillofacial Group /
University Clinics ofBasel,Kantonsspital
J.Prein … [et al.]. p. cm. Includes bibliographical refer-
4031 Basel,Switzerland
ences.
ISBN 978-3-642-63732-2 ISBN 978-3-642-58789-4 (eBook)
DOI 10.1007/978-3-642-58789-4 1.Facial bones – Sur-
gery – Handbooks, manuals, etc. 2. Cranium – Surgery –
Handbooks,manuals,etc. 3.Internal fixation in fractures –
Handbooks, manuals, etc. 4. Surgery, Plastic – Handbooks,
manuals, etc. I. Prein, J. (Joachim), 1938– . II. Arbeitsge-
meinschaft für Osteosynthesefragen. [DNLM: 1.Skull – sur-
gery. 2.Fracture Fixation,Internal – methods. 3.Facial Bones
– surgery. 4.Surgery,Plastic – methods. WE705M2941998]
RD763.M336 1998 617.5`2059 – dc21 DNLM/DLC for
Library ofCongress 97-35559 CIP
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© Springer-Verlag Berlin Heidelberg 1998
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Softcover reprint of the hardcover 1st edition 1998
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V
Chapter Authors and Contributors
Leon A.Assael,D.M.D. Christian Lindqvist,M.D.,D.D.S.,Ph.D.
Professor ofOral and Maxillofacial Surgery Professor ofOral and Maxillofacial Surgery
Chairman ofDepartment Oral Head ofDepartment ofOral and Maxillofacial Surgery
and Maxillofacial Surgery University ofHelsinki
The School ofMedicine ofthe 00130 Helsinki,Finland
University ofConnecticut Health Center
Farmington,CT 06030,USA Nicolas J.Lüscher,M.D.
Professor ofPlastic Surgery
Wolfgang Bähr,M.D.,D.M.D. Head ofPlastic Surgery Unit
Ass.Professor ofMaxillofacial Surgery Clinic for Reconstructive Surgery
University Clinic for Maxillofacial Surgery University Clinics ofBasel,Kantonsspital
79106 Freiburg i.B.,Germany 4031 Basel,Switzerland
Benjamin Carson,Professor Paul N.Manson,M.D.
Department ofNeurosurgery Professor ofPlastic Surgery
Johns Hopkins University ChiefofDivision ofPlastic,Reconstructive
Baltimore,MD 21205,USA and Maxillofacial Surgery
Johns Hopkins University
Christopher R.Forrest,M.D.,M.Sc.,F.R.C.S.(C) Baltimore,MD 21287–0981,USA
Ass.Professor,Craniofacial Program
Division ofPlastic Surgery Bernard L.Markowitz,M.D.,F.A.C.S.
The Hospital for Sick Children Ass.Professor ofPlastic Surgery
Toronto,Ontario M5G 1X8,Canada Division ofPlastic Surgery
University ofCalifornia
Beat Hammer,M.D.,D.M.D. Los Angeles,CA 90095,USA
Ass.Professor ofMaxillofacial Surgery
Clinic for Reconstructive Surgery Stephan M.Perren,M.D.,Dr.sc.(h.c.)
Unit for Maxillofacial Surgery Professor ofSurgery
University Clinics ofBasel,Kantonsspital AO Development
4031 Basel,Switzerland 7270 Davos,Switzerland
Chairman ofAO/ASIF Technical Commission
Douglas W.Klotch,M.D.,F.A.C.S.
Associate Professor ofSurgery John H.Phillips,M.D.,F.R.C.S.(C)
Director ofDivision ofOtolaryngology Professor ofPlastic Surgery
Department ofSurgery,College ofMedicine Medical Director,Craniofacial Program
University ofSouth Florida Division ofPlastic Surgery
Tampa,FLA 33606,USA The Hospital for Sick Children
Chairman ofMaxillofacial Technical Commission Toronto,Ontario M5G 1X8,Canada
VI Chapter Authors and Contributors
Carolyn Plappert Mark A.Schusterman,M.D.
Product Manager Maxillofacial Ass.Professor ofPlastic Surgery
STRATEC Medical Chairman ofDepartment ofPlastic Surgery
4437 Oberdorf,Switzerland University ofTexas
M.D.Anderson Cancer Center
Joachim Prein,M.D.,D.M.D. Houston,TX 77030,USA
Professor ofMaxillofacial Surgery
Chairman ofClinic for Reconstructive Surgery Peter Stoll,M.D.,D.M.D.
Unit for Maxillofacial Surgery Ass.Professor ofMaxillofacial Surgery
University Clinics ofBasel,Kantonsspital University Clinic for Maxillofacial Surgery
4031 Basel,Switzerland 79106 Freiburg i.B.,Germany
Chairman ofEuropean Maxillofacial
Educational Committee Patrick K.Sullivan,M.D.
Associate Professor ofPlastic Surgery
Berton A.Rahn,M.D.,D.M.D. Brown University
Professor ofMaxillofacial Surgery Providence,R.I.02905,USA
AO Research Institute
7270 Davos,Switzerland Craig A.Vander Kolk,M.D.
Associate Professor
Wilfried Schilli,M.D.,D.M.D. Director ofCleft and Craniofacial Center
Professor emeritus ofMaxillofacial Surgery The Johns Hopkins Outpatient Center
Director emeritus ofUniversity Clinic 8152D,Baltimore,MD 21287–0981,USA
for Maxillofacial Surgery
79106 Freiburg i.B.,Germany
VII
Foreword
Clinical research continues to confirm that no truth is total care ofthe severely traumatized patient in the first
more transitory than that in the sphere of scientific hours following the accident.
knowledge.Developments in the field oftraumatology at The further development ofthe AO/ASIF concept led
the end of this century provide a striking example of to today’s comprehensive craniofacial surgery in the
this.As early as 1890 Lambotte carried out osteosynthe- fields oftraumatology,orthognatics,tumor,and recon-
ses with plates and screws.These remained a mere epi- structive surgery.
sode,however,until Danis renewed the idea ofinternal AO/ASIF courses contributed fundamentally to the
fixation 50 years later.Danis combined internal fixation development of these fields.In the course of its world-
with the new technique of interfragmentary compres- wide response,the AO/ASIF philosophy has been able to
sion,which led to primary bone healing that allowed full attract distinguished authors to join the faculty of
function at the same time.Reacting to disconcerting sta- AO/ASIF courses.By sharing their clinical,experimen-
tistics about the results of conservative fracture treat- tal,and theoretical experience,they take part in shaping
ment,Mueller then applied interfragmentary compres- a special internal fixation technique in the craniofacial
sion to 80 patients in Switzerland and confirmed its use- skeleton.The philosophical aspect ofAO/ASIF courses
fulness. in theory and practice assures high standards ofquality.
Mueller, recognizing the need for further develop- After all,the enormous progress in metal implantology
ments in clinical application, and scientific analysis, should not hide the fact that lack of knowledge and
assembled a group offriends consisting ofgeneral and experience,on the one hand,and false compromises,on
orthopedic surgeons in 1958 with the aim ofcreating the the other, can cause much greater damage than with
necessary armamentarium for internal fixation and to conservative methods.
form a study group for clinical trials.This group came to Thus this interdisciplinary manual provides stan-
be known as the Arbeitsgemeinschaft für Osteosynthese- dards for the application ofthe AO/ASIF principles.The
fragen(AO),and later in English-speaking countries as scientific and technological background is based on the
the “Association for the Study of Internal Fixation” laws of nature.Resulting from the interaction between
(ASIF).Building on the conviction that the objectivity of pure research and clinical practice,it comprises in the
nature is not merely an illusion, the initiators of widest sense the fields of organization,biomechanics,
AO/ASIF – Müller,Allgöwer,Willenegger,Schneider,and anatomy,and osteology as well as metallurgy and the
Bandi – transformed the pragmatically oriented concept application oftools.
into a scientific method of applied physics,mathemat- The accumulated knowledge is integrated in topo-
ics,and biology.In combination with systematic teach- graphically defined surgery ofthe skull (splanchnocra-
ing of specialists in AO/ASIF courses,subjectivity was nium),including the walls ofthe upper respiratory and
thus excluded as much as possible from the choice of digestive tracts.
means.The goals and principles ofAO/ASIF are built on The bottom line of this surgery is internal fixation.
this basis and are summarized in the AO/ASIF philoso- The differences in its application are dictated by the
phy. variety ofcraniofacial bones with respect to their func-
Convinced ofits benefit by this approach,the maxil- tion and structure.On the one hand,we are dealing with
lofacial unit ofthe Department ofSurgery at the Univer- a motional apparatus in the area ofthe mandible;on the
sity of Basel adopted the AO/ASIF philosophy in 1966. other, the maxilla represents a supportive frame of
The consistent application ofthe two principles ofana- lamellas,among others for nose and eyes,and the cranial
tomical reduction of fracture fragments and stable vault a supportive frame ofdiploë for the brain.Corre-
internal fixation guaranteed the immediate,active,and spondingly,two qualities of stability are being distin-
pain-free opening and closing of the lower jaw. The guished in practice:functionally stable and locally stable
results were also considerably improved by the early fixation.
VIII Foreword
In the past 10 years there has been a rapid increase in
the degree of perfection in treating most complicated
fractures,disturbances of growth in the regio mastica-
toria and facialis,and malformations in the areas ofthe
nose, eyes, and skull. These operations are further
improved by preoperative planning with spiral 3 DCT,
3D laser stereolithography, and virtual-reality pros-
thetic design.These techniques still depend highly on
international cooperation. Initial experiences have
shown how complex craniofacial injuries,including the
loss of functionally and anatomically important bone
parts,can be simulated ad hoc and immediately treated
with adequate autologous bone,if necessary in combi-
nation with hydroxyapatites.
Looking back to the beginnings in the 1970s and
1980s,one can observe with great satisfaction that this
progress has been the work ofdistinguished representa-
tives ofthe disciplines involved.I am most thankful for
the honor of their personal friendship and acquain-
tance.
This manual will be a safe standard for teaching and
applying internal fixation in AO/ASIF courses as well as
in the operating room.
Great acknowledgement is due to the editor and the
authors.
Prof.Dr.Dr.Bernd Spiessl
IX
Preface
This Manual of Internal Fixation in the Craniofacial This first AO/ASIFManual on Internal Fixation Tech-
Skeleton is the result of fascinating developments in niques in the Craniofacial Skeletonis the product ofcol-
internal fixation techniques for the facial skeleton over laborative work on the part of many cranio-maxillofa-
the past 30–40 years.These techniques are based on the cial specialists worldwide.Since the first maxillofacial
AO/ASIF philosophy for fracture care in the general course in Davos in 1974 and the first AO/ASIF course in
skeleton – ensuring early pain-free movement,precise the United States in 1984, 20 courses have been con-
anatomical reduction,and adequate fixation according ducted in Davos and 109 worldwide,with several thou-
to the various functional forces.The principles and tech- sand persons participating.In addition to these courses,
niques described here have grown out of continuous numerous international workshops have been orga-
international cooperation involving a great number of nized to deal with specialized topics.The principles pre-
specialists working in the craniofacial area.It also con- sented in this Manual have developed out of both the
tinues the ideas originally developed by pioneers in the good and the disappointing experiences during this
field who carried out important clinical and experimen- experimental, educational, and practical work. An
tal research.In this context we should mention particu- important feature ofall the courses on internal fixation
larly Champy,Michelet,Luhr,Spiessl,and Tessier. in cranio-maxillofacial surgery is that they were orga-
In its early days in the 1950s and 1960s this approach nized by and fororaland maxillofacial surgeons,plastic
to internal fixation of facial bones found application surgeons,and ENT surgeons.In this Manual we try to
principally in the treatment of trauma patients. The demonstrate the results ofthis close international coop-
favorable experiences gathered in the meantime,how- eration, including the substantial clinical experience
ever,have led to many ofthe advantages ofinternal fix- and research carried out principally in the AO/ASIF
ation being extended to the reconstruction of tumor Research Institute in Davos.
defects and the stabilization of major osteotomies in The fact that thisManualdeals only with techniques
orthognathics and craniofacial surgery. for open internal fixation does not reflect an opinion on
Today we also appreciate the important role that our part that every fracture should be operated on.How-
facial trauma plays in the early definitive treatment of ever,it is our opinion that internal fixation – employing
polytraumatized patients,particularly in reducing adult the appropriate technique for the correct indication –
respiratory distress syndrome and multiple organ fail- entails substantial safety and diminishes morbidity for
ure.Close cooperation among all those working in the patients. One could even maintain that adequate and
various related disciplines and specialties for the cranio- safe internal fixation provides the best protection
maxillofacial area is essential to ensure optimal results against infection and is ofeven greater importance than
for patients.This is especially so regarding the partici- antibiotics.Internal fixation,especially in traumatology,
pation of the neurosurgeon in cases of traumatology can also have a very considerable socioeconomic impact
and craniofacial surgery.The concept ofearly definitive when one considers the various factors that affect treat-
treatment sometimes means many hours ofsurgery,and ment costs – including the duration of surgery,cost of
therefore another crucial participant in the treatment materials,training ofthe surgeon,as well as the patients’
team is the anesthesist,and important progress has also absence from work.
been made in this area over recent years. This Manual is divided into seven chapters,with a
Four major advances underlie the great progress in single author responsible for each;only the first chapter
craniofacial surgery in recent decades:(a) the technique on research and instruments has two authors.Interna-
ofapproach,(b) the technique ofinternal fixation with tional contributors, who are mentioned before each
plates and screws,(c) the development ofoptimal mate- respective chapter,have put in their knowledge and have
rials such as titanium,and (d) modern imaging tech- made significant contributions.
niques like CT and MRI. The material presented here reflects our present
knowledge ofthe subject,and its correct application can
X Preface
surely mean comfort and benefits to our patients.On the
other hand,however,it represents only the latest mile-
stone on the way to further progress.We hope that this
Manualproves an important help both during courses
and during surgery.
In the name of all the coauthors and contributors
who have invested a tremendous amount of time,
knowledge,and work,I wish to thank especially Mrs.
Helga Reichel-Kessler, whose continuous and never-
ending encouragement was essential in finalizing the
manuscript and thus in completing the whole project.
I want to thank especially Mr.Kaspar Hiltbrant for his
very clear and precise drawings,which are a particular
feature of thisManual.I am also grateful to Mrs.Ruth
Rahn,who provided very important prestudies for these
drawings.
Finally,I thank the staffofSpringer-Verlag for their
excellent help in preparing thisManualfor publication.
Prof.Dr.Joachim Prein