FIXATION

Fixation of an unstable zygoma can be carried out through standard

approaches to the regions of the inferior and lateral rims, the zygomatic arch,
and the arch of the tuberosity. Whenever existing lacerations exist, they should
be used.
Approaches to the inferior Rim
The basic transcutaneous incisions used to gain access to the inferior rim
and floor of orbit are the inferior rim and floor of the orbit are the infraorbital,
the subtarsal, and the subciliary. The difference among the there incisions is the
location. The fourth standard incision is the transconjunctival.
Infraorbital Incision
The inferior rim incision is made just over the rim inferior to the septum.
It offers and most direct route to the inferior. It offers the most directroute to
the inferior rim and therefore results in less trauma to the adjacent tissue when
floor reconstruction is undertaken. The technique has the further advantage of
being relatively free of postoperative ectropion. A significant drawback to its
use is the residual scar, which is particularly troublesome in the young.
The skin incision is made in the eyelid tissue, avoiding the cheek tissue.
For cosmeltic purposes, the lateral limit of the incision should not extend
beyond the lateal asapect of the pupil. Medially, the incisions limit is the
punctum. If further exposure is necessary, an extension may be carried out
laterally and somewhat inferiorly, but no farther than the lateral canthal margin.
This is done to preserve the lateral lymphatic drainage, 90% of which traverses
lateral lymphatic drainage, 90% of which traverses lateral to the orbit and 10%
medial.

The globe is protected by means of tarsorrhaphy sutures. Following

palpation of the rim and the fracture site, a stepped incision is started through
skin and muscles and carried 2 to 3mm inferior to the periosteum.

The

periosteum is incised slightly above that level. Below the attachment of the
orbital septum he periosteum is elevated, exposing the rim and the floor. one
must take care not to carry the dissection too far inferior to the rim to avoid
endangering the contents of the infraorbital canal. closure of the periosteal
layer is easily carried out, as well as closure of the muscle layer and skin flap.
subcutaneous closure with 6-0 or 7-0 resorbable suture provides a cosmetic
result.
Subtarsal incision
The substarsal incision is popular because of its relative ease and freedom
from complication. The 2.5-cm incision is made in the natual skin crease 3 to
4mm below the eyelash margin. It extends from the punctum medially to
approsimately 1 cm lateral and inferior to the lateral and inferior to the lateral
canthus if necessary.
The safest approach is to initially incise the skin only. Dissect inferiorly
for 2 mm then incise the orbicularis muscle with tenotomy scissors, dissecting
inferiorly along the plane between the orbital septum and the laterally
positioned muscle until arriving at a point approximately 1 to 2 mm below the
superior aspect of the rim. The periosteum is then incised and elevated to
expose the rim and floor if need be.
A number of technical points have to be observed. God traction of the
flap is necessary to successfully carry out the step dissection. double skin hooks
are preferable, and the skin has to be held taut to accomplish the dissection.
Once the muscle layer is pierced, care should be taken to place the dissection
scissors horizontally medial to the muscle and lateral to the septum before the

muscle resection.

Finally, the periosteum should be incised inferior to its

attachment.
When closing, it is important to securely close the periosteal layer. It is
not necessary to close the muscle layer for fear of distortion.

Again,

subcutaneous closure using 6-0 or 7-0 resorbable suture yields good cosmetic
results.
There are two variations of this technique. The first involves dissection
of the skin from the underlying muscle, dissecting to a level just inferior to the
rim and then resectioning the periosteum. This technique has resulted in an
increased incidence of postoperative ectropion as well as a dusky appearance to
the flap,19 perhaps because of diminished vascularity.
The second variation is the skin muscle technique.

The septum is

exposed, and that plane is used to reach the level just inferior to the rim margin
and the periosteal resection. This variation is a popular one that is predictable
and relatively free of complications. The skin muscle flap has been reported to
have a 6% incidence of early tropion, which usually resolves.19
Blepharoplasty Incision
The blepharoplasty incision is distinguished from the other skin incisions
previously described by its superior location on the lid.

It is made

approximately 2 min below the Grey line and extends to the level of the tarsal
plate, then inferiorly along the septum to the level of the rim. Alternatively, the
initial dissection is carried out subcutaneously to the rim level. The lateral
extent of the incision depends on need; it is identical to the substarsal approach
and is made in the natural crease.
Transconjunctival Incision

The transconjunctival approach bypasses the aesthetic concern of a skin

incision. It offers limited access to the floor and rim unless supplemented by a
lateral canthot omy, which significantly increase the access. There are two
variations of the transconjunctival approach: the preseptal27 and postseptal27
approaches.
Preseptal Apporch A corneal shield is initially placed, and a Desmarres reactor
is used to retract the lower lid. A 5-0 plain suture is placed through the
conjunctiva in the inferior for nix. This helps to stabilize the conjunctiva during
its undermining the dissection.
An incision is made with Iris scissors 2 to 3 mm inferior to the inferior tarsal
border, extending from the lacrimal punctum to the lateral canthus.

Blunt

tenotomy scissors are then used to dissect through the septum and the inferior
lid retractor muscles. The dissection is continued lateral to the septum to the
lower rim, approximately 2mm inferior to the superior border of the rim. The
periosteum is incised with a sharp scalpel. If possible, closure of the periosteum
is carried out using 4-0 resorbable suture; 6-0 or 7-0 resorbable suture should be
used in a running fashion in the closure of the conjunctiva. Alternatively, the
conjunctiva can be closed in an interrupted fashion but the knot must be buried.
Postseptal Approach Using Sharp scissors, an incision is made througha the
conjunctiva above the inferior tarsal border, extending from the punctual region
laterally to the attachment of the lateral canthus. The conjunctiva is undermined
in an inferior direction, and its superior border may be sutured to the inferior
margin of the upper lid using 6-0 silk sutures, thus eliminating the need for an
eye shield. A retractor is used to protect the orbital contents. Dissection is
carried out swiftly to the periosteal layer, which is incised again approximately

2mm below the rim margin.

Following completion of the procedure, the

periosteum and the conjunctiva are sutured in the previously describe fashion.
There is some controversy over which of the techniques is superiors: the
preseptal or postesptal. The advantage of the preseptal approach is avoidance of
the herniation fat, which can be a nuisance during delicate surgery.

The

preseptal approach is technically more demanding, takes longer, and can result
in the buttonholing of the thin overlying skin. The advantages of the postseptal
approach are that it is swift, direct and less technically demanding.

The

probability of herniation fat can be diminished by making the incision no lower

than 1 or 2mm superior to the inferior tarsal border.
The periosteal closure is controversial. Poor approximation can result in
the creation of postoperative ectropion. Indeed, one of the singular advantages
of the transconjuctival approach to the rim is the diminished incidence (12%) of
entropion and ectropion.
Lateral Canthotomy
The performance of a lateral canthotomy given the transconjunctival
approach the exposure necessary to perform most, if not all, of the common
reconstructive procedures involving the inferior rim and the floor.
Iris scissors are used to incise to the lateral canthus throughs the
preexisting crows foot, if possible, a distance of approximately 1 to 1.5cm.
The conjunctival incision is joined to the canthotomy incision by dividing the
inferior arm of the lateral canthal tendon. Closure is obtained by suturing the
severed inferior limb ends together

using a 4-0 suture or, if difficulty is

encountered identifying the ends, suturing the limb to the orbital rim. The
conjunctival incision is closed with 6-0 or 7-0 resorbable suture, and the skin is
closed with 6-0 nylon suture.
Approaches toa the Lateral orbital Rim.

The

classically

displaced

zygomaticofrontal suture area.

zygoma

fractures

laterally

at

the

The location of the suture is often at the

inferiormost extent of the eyebrow region. The soft tissue in this region is quite
sessile; therefore, wide exposure is obtained with a relatively small incision.
Also, the incision may be made largely in the eyebrow to hide the subsequent
scar.
Eyebrow incision.
If

possible, the fracture site is palpated and marked to a point not

extending L/4 cm inferior to the lateral margin of the brow hair. The overlying
tissue is stablilized between the thumb and forefinger. A blade is used to incise
the skin and underlying tissue to the periosteum. Care must be taken to angle
the blade so that it is parallel to the hair shafts of the eyebrows. Severing these
could result in retardation of hair growth. The overlying tissue is undermined,
exposing the periosteum overlying the fraeture and beyond. The periosteum is
sharply incised in a superior to inferior direction, exposing the fracture and
sufficient borne to place an adequate wire or plate. the periosteal dissection is
carried out in a lateral and medial direction.

This approach is free of

complications. There are no vital structures in the region. It is swift and

predictable. Minimizing the subperiosteal dissection on the orbital or medial
side results in less edema.

Closure of the periosteum is performed using

resorbable 4-0 sutures, and the skin incision is closed in a subcutaneous

continuousfashion using 6-0 nylon or silk.
Upper Lid Incision
The second approach to the lateal orbital rim as through the upper lid. It
takes advantage of the consemetic healing aprovides by tissue of the upper lid
and the common presence of crows feet in the region.

the upper eyelid incision is made in the lateal aspect of the supractarsal
fold and, if necessary, extended laterally intoa the one of the natural creases of
the crows feet The dissection is carried out superficial to the orbital septum
and through the orbiculus oculi overlying the fracture site. The periosteum of
the lateral rim is explored, incised, and dissected free in a superior-inferior
direction. The incision is closed in layers. The periosteum and skin are closed
in the usual fashion.
Approaches to the zygomaticotemporal Suture Area
The approach to the zygomaticotemporal suture and the zygomatic arch is
indirect because of aesthetic considerations arch is indirect because of aesthatic
considerations and the course of the temporal branch of the facial nerve. The
two basic approaches to the zygomaticotemporal suture and the arch are the
traditional pretragal approach toa the temporomandibular joint with the Bramley
Alkayat modification and the coronal flap approach.
Pretragal Incision
Generally, the preauricular approach is suitable for easy access to the area
of the zygomaticotemporal suture. the temporal hair is shaved. The incision is
made through skin to the level of the temporal facia, extending from the level of
the auricular cartilage superiorly in a natural skin crease if present. if no skin
crease is present, the incision extends posteriorly, hugging the eartilage as the
dissection ascends to the superior aspect of the helix and then makes a gentle
forward arch superiorly and anteriorly approximately 4cm. The later part of the
incision is within the hairline.
Dissection is swiftly carried out to the level of the temporal fascia. once
it is identemporal fascia is incised, following the arc of the orginal incision and
extending to an area inferior to the arch. The point of dissecting the superficial

temporal facia, which courses over the arch from the deep temporal facia that
courses medial to the arch, is approximately 2cm superior to the zygomatic
arch. Dissecting deep to the zygomatic arch. Dissecting deep to the superficial
temporal fascia ensures avoidance of the temporal branch of cranial nerve VII,
which runs in the substance of the superficial layer of the temporal facia. A
vertical incision is made through the periosteum at the root of the zygoma and
the periosteum is peeled off its bony attachment, exposing the region of the
zygomaticotempoal suture.
Coronal flap Incision
The coronal flap technique offers an excellent exposure of the arch. it
can also be used to expose the lateral and supraorbital rims, as well as the body
of the zygoma if the inferior incision is carried to the level of the earlobe. A
further advantage of this approach is that when bone grafting is necessary, the
calvarial bone is an excellent source.
the hair is braided and separated along the line extending from the
preauricular area on one side opposite and temporal fascia region, a suitable
vasoconstrictor is injected, and an incision is made atleast 2cm behind the
hairline. using a No. 10blade, an initial incision is made to the subgaleal plane
cutting through skin, subcutaneous tissue, and galea.

The flap is quickly

detached from the underlying loose areolar connective tissue for a distance of
approximately 1.5 cm, and Rainey hemostatic clips are quickly applied. The
flap is advanced anteriorly to a level approximately halfway down the forehead
and laterally superficial to the temporal fascia, which is continuous with the
perircanium to a level inferior to the arch.

The dissection is continued

anateriorly. The temporal fascia is incised commencing at the arch level and
following the outline of the initial incision superiorly approximately 2.5cm, then
gently arching superiorly and medically, exposing the temporal muscle and
joining the periauricular layer. The dissection is carried out with dissecting

scissors. Muscle bleeders coagulated. The fascia is now dissected off the
superior portion of the arch commencing at the root of the arch, as well as any
portion of the lateral rim and body of the zygoma. once the reduction and
immobilization are completed, closure of the periosteum over the arch is
accomplished. Drill holes are made in the arch and lateral rims to suspend the
sofa tissue and to prevent postoperative sagging caused by the dissection of the
temporal facia; 3-0 proline sutures are used for this task. The galea is closed
using 2-0 resorbable suture, and the skin is closed with staples. A flat suction
drain is routinely placed in the subgaleal plane and is usually removed in 24 to
48 hours. The staples are removed in 14 days.
Use of the coronal flap is contraindicated in an individual with either a
receding or potentially receding hairline. It is possible to place the incision 2 or
3 cm behind the exiting hairline; however, this may be risky. if the patient
ultimately loses hair, an unsightly scar may remain.
When using the coronal f lap for the reduction of a single zygoma, it is
not necessary to carry the incision all the way to the opposite preauricular
region. The incision invariably provides adequate exposure if carried to the
level of the temporal line on the opposite side.

MANATEMENT OF MIDFACE INJURIES

The midface is defined as the area between a superior plane drawn through the
zygomatiocofrontal sutures tangential to the base of skull and an inferior plane
at the level of the maxillary dental occlusal surfaces. These planes do not
paralledl each other but coverage posteriorly at a level approximating that of the
foramen magnum. The mid face can therefore be considred a triangular region
with its widest dimension facing anteriorly. This arrangement helps protect

vital posterior structures such as the proximal spinal cord as well as cranial
nerves and vessels entering and exiting the cranium.
Different functional and anatomic units joined by direct sutural
connections form the midface. it is a composite arrangment with contributions
from the orbits. naso-or-bital-ethmoid (NOE) complex, zygomatic complex,
and maxilla. Consequently, injuries to this region may involve these structures
and their soft tissue contents to varying extents.

The comprehensive

management of midface injuries therefore involves a mandatory evaluation of

these structural neighbors as well as corrective measures that take into account
the separate complexes and their respective functions.
This chapter does not cover the specialized techniques required for the
diagnosis and treatment of dentoalveolar fractures, nasal injuries, zygomatic
complex and orbital fractures, and associated injuries of the soft tissues, even
though these areas may be involving in midface fractures. These topics are
covered elsewhere in this textbook. instead, the authors address specific issues
concerning the surgical anatomy of the composite midface, diagnosis and
classification of midface injuries, sequencing of treatment, surgical approaches,
operative techniques used to reduce and fixate midface fractures, and potential
complications of treatment or injufry. Because the NOE complex possesses
features distinct from the remainder of the midface management of injuries to
this area is considered separately.
Surgical Anatomy
In this section, several issues that relate directly to the pattern and
subsequent treatment of midface injuries are discussed. The bony morphology
and important soft tissue structures are also described.
Bony Architecture

Areas of Weakness As previously stated, the midface is composed of the

maxilla,

orbits,

NOE

complex,

and

paired

zygomatic

complexes.

Developmental sutures between these structures represent potential areas of

weakness and are often the sites of fracture Common sutural fracture sites are
the frontozygomatic suture, zygomaticomaxillary suture, zygomaticosphenoid
suture, nasofrontal suture, maxillofrontal suture, nasomaxillary suture, and
midpalatal suture.
Fractures are not confined to these junctions but also occur in areas of
relative weakness.

B ones are less resistant to external forces when they

surround an anatomic space of neurovascular bundle. Areas weakened in this

manner include the mid-maxilla containing the maxillary sinuses bilaterally, the
posterior maxilla where the pterygomaxillary junction separates the maxilla
from the pterygoid plates, the midfraorbital rims advancement to the infraorbital
foramen, the medial orbital walls overlying air cells of ethmodial sinus, and the
lateral orbital walls, which are thinned out to accommodate the globe and
adnexae medially and the temporalis muscle laterally.
Areas of Strength Fractures also result from the diversion of forces from
areas of relative strength of weaker adjacent sites.

Strength is imparted to

regions where bone is thickened, contains a higher ratio o cortical to cancellous

bone, or surrounds hard tissue structures that help absorb forces without
disruption. An analogy has been drawn to architectural concept of support, and
this has led to the characterization of these areas as vertical and horizontal
pillars of the face. The horizontal pillars are composed of the supraorbital rims
joined by the nasal process of the frontal bone, the infraorbital rims, and the
alveolar process of the maxilla. Vertical support is derived from the zygomatic
butteresses, pyfiform apertures (continuing superiorly as the frontal processes of
the maxilla), and pterygomaxillary junctions. These areas provide structural
reinforcement to the midface and help maintain its integrity unless excessive
force is applied.

Soft Tissue Attachments

Lining Tissues the Midface skeleton is characterized by the presence of several
air-filled cavities. Where present, soft tissue invests the bones on two sides.
The outer or facial surfaces are covered by a firmly attached periosteal layer.
This primitive structure contains a rich nonaxial network of vascular and neural
elements that supplies the underlying bone. The periosteum is also a repository
of undifferentiated mesenchymal cells that, under certain conditions, undergo
transformation to ostegenic cells.

The inner surfaces of the midface (i.e.,

surfaces adjacent to anatomic spaces) and ;covered by specialized forms of

epithelium that support the particular function of the space. The maxillary sinus
and nasal cavity, for instance, are lined with ciliated epithelium containing
secretary cells. This membrane also contains a rich vascular network, providing
the bones of the midface with multiple nutrient sources. Thickened areas of the
midface that do not contain spaces (e.g., the zygomatic buttress) derive an
additional endosteal vascular supply from the cancellous marrow.

This

combination of periosteal, endosteal, and lining vascularity supports the

survival of separate fracture segments even when gross communution is present.
Muscular Attachments Unlike the mandible, the midface is a static
structure. Consequently, muscular forces applied to this region are reduced in
magnitude. Closed reduction techniques or the fixation of fractures with wires
and small bone plates are therefore more likely to be successful. Three muscles
of mastication derive

origins from different portion of the midface: the

masseter (zygomatic arch) and the medial and lateral pterygoids (pterygoid
plates).

Fractures extending into these sites rarely undergo significant

displacement. This reflects the relatively broad area of muscles attachments

that tend to splint the fracture interfaces.

other muscles connected to the

midface include the various facial mimetic muscles (zygomaticus major and
minor, lavatory superioris, levator anguli oris, levator superioris alaeque nasi,

and risorius), the extraocular muscles, and the buccinator. Aside from the
extraocular muscles, which provide movement to the globe, and the buccinator,
which functions as a diaphragm, the remaining muscles insert into the overlying
skin and subcutaneous tissues. Lack of firm anchorage reduces the ability of
mimetic muscles to displace fractured segments. However, their orientation and
tone are responsible for facial form and symmetry, and failure to reestablish
their bony attachments may create an alteration of the soft tissue drape.
Anatomy of the noe complex.
Bony anatomy the NOE complex is vulnerable to injury because of its
prominent position at the junction of the upper and middle thirds of the face.
Like the midface, it is a wedge-shaped structure oriented so that the narrow
portion faces anteriorly and the broader base lies posteriorly between the two
orbits. This arrangement compensates for the inherent weakness created by
large underlying sinus spaces (the ethmoidal sinuses). Additional strength is
sprovided by the organization of the complex into a lattice with individual
bones oriented at different angles to one another.

The NOE complex is

composed of our paired bones: the lateral nasal bones, the frontal processes of
the maxilla, the lamina papyraceae of the ethmoid bone, and the lacrimal bones.
The perpendicular and cribirform plates of the ethmoid bone, the nasal process
of the frontal bone, and the sphenoid bone complete the bony skeleton in the
midline. The area between the two medial orbital walls and below the anterior
cranial fossa is sometimes referred to as the interorbital space. Within the upper
portion of the nasal cavity lie the superior and middle turbinates, but these
structures do not contribute to the structural support of the complex.
Medial Canthal Anatomy. The medial aspects of the upper and lower
eyelids converge into an acute angle and form the medial canthus. Here, deep
and superficial extensions of the apreseptal and pretarsal orbicularis oculi
converge into a common tendon. The tendon, which functions as the origin of

the orbicularis oculi muscle, divides into anterior and posterior bands before
attaching to the bone. The anterior limb is the larger and more significant of the
two. It inserts broadly into the frontal process of the maxilla, the anterior
lacrimal crest (part of the maxillary bone), and the lateralmost aspect of the
nasal bone. If disrupted by injury, restoration of this attachment is essential to
the successful reconstruction of the NOE complex. The smaller posterior limb
of the medial canthal tendon is poorly defined and inserts into the posterior
lacrimal crest, which is part of the lacrima l bone. It is composed of the deep
head of the pretarsal orbicularis oculi (horners muscle) and is generally ignored
during reconstruction. Between the anterior and posterior canthal limbs lie the
lacrimal punctum, superior and inferior canaliculi, and superior one third of the
lacrimal sac, which projects 1 to 2mm above the level of the tendon. The
superior and inferior canaliculi travel for a shaort distance vertically
(approximately 2mm) before assuming a more horizontal orientation
(approximately 2mm) before assuming a more horizontal orientation
(approximately 10mm). They converage and form a common canaliculus that
enters the nasolacrimal sac at its posteroinferior third. The nasolacrimal duct,
which is approximately 20mm in length, travels vertically within the maxilla to
open into the inferior meatus of the nose at the anteriorly located lacrimal fold.
Together, these structures are responsible for the collelction and drainage of
tears from the conjunctival fornices into the inferior meatus of the nose.
Damage to any portion of the system may lead to excessive tearing from the
eye, a condition known as epiphora.
Lefort classification
Classic descriptions of midface injuries invoke the patterns described by
French surgeon Rene LeFort, who observed three levels of fracture determined
by the magnitude and direction of an externally applied blunt force. Fractures
occurred along lines of relative weakness and avoided areas of strength, as

described previously. The Lefort I fracture is a horizontal fracture through the

maxilla above the level of

the alveolar process.

It extends through the

midportion of the pyriform rims and nasomaxillary suture anteriorly and

continues posteriorly below the zygomticbuttresses before culminating as a
horizontal fracture of the pterygoid plates.

Such fractures permit separate

mobility of the maxilla relative to the rest of the midface. A LeFort 1 fracture is
also known as a Guerin fracture. LeFort II fracturesinvolve seperation of the
nasofrontal suture anteriorly. These continue posteriorly through the thinmedial
orbital walls and weakened infraorbital floor and rim adjacent to the infraorbital
canal and foramen and extend inferiorly through the anterior maxilla aand
backward below the zygomatic buttresses and pterygoid plates. This fracture,
also known as a pyramidal fracture, allows the central portion of the midface
and maxilla to be mobilized independently from the cranial base, but the lateral
orbital walls remain intact.

The leFord III fracture is also known as a

craniofacial dysjunction, because the entire midface is separated from the skull
base. This is a result of fractures through the nasofrontal suture, medial orbital
walls, orbital floors, lateral orbital walls, zygomaticofrontal sutures, zygomatic
arches, maxilla (below the buttresses), and ptergoid plates.
Fracture patterns in the midface are the result of multivariate interactions
between the forces applied to the skeletal components and the resistance offered
by these structures. The amount of force obviously affects the type and pattern
offracture. A less known variable is the angle of impact. It has been suggested
that forces applied obliquely to the horizontal pillars of the midface tend to
provide leFord III fracture.
EVOLUTION OF TREATMENT MODALITIES
In the post 20 years, the approach to the management of midface injuries
has changed, largely as a result of the development of rigid fixation devices.

Before this Development, closed reduction and indirect stabilization of fractures

constituted the mainstay of treatment. Following restoration of maxillary and
mandibular occlusal relationships, maxillomandibulr or caniomandibular forms
of fixation were used to stablize fractures until healing occurred.

Indirect

fixation techniques used supension of fractured bones from stable superior

structures.

Circumzygomatic, infraorbital, and zygomalticofrontal wires

provided superior stabilization, and plaster of Paris headcaps or frontal pins

were used as extracranial forms of fixation.

Wiring of fracture sites or

tansfixion with pins and Kireschner wires directly stabilized the segments, but
this approach was discouraged in comminuted fractures, because the soft tissue
dissection required to pass transosseous wires was believed to compromise the
vitality of the fractures bone. Fractures fixated with wires were also subject to
displacement around the long axis of the wire, as this technique is most
effective in resisting superior-inferior and lengthwise distraction and less stable
when rotary forces are applied(see the section of biomechanics and healing of
the midface). Even if bone was missing, consideration was rarely given to
grafting a recently traumatized site, for fear of infection. These practices were
called into question when critical reviews of postoperative results identified
significant numbers of patients with a lack official projection, foreshortening of
the midface, facial asymmetries, and nonunion of fracture sites.
ANATOMIC REFERENCES OF MIDFACE FRACTURES
Rigid fixation can be defined as the promotion of immediate, pain-free
mobilization of a fracture without compromising healing. This is achieved
through the accurate reduction and absolute stabilization fracture segments.
Although the term rigid fixation appears to focus on the method fixation, it
applies equally to through exposure of fracture sites and an anatomic alignment
of the segments.

The application of rigid fixation techniques to midface

fractures has been shown to correct several of problems encountered by closed

techniques.

exposure and alignment of the pyriform rims and zygomatic

buttresses restore the vertical pillars of the face, which reduces the incidence of
midface foreshortening. By exposing the zygomatic and orbital complexes
bilaterally with their articulations (i.e., frontozygomatic sutures, infraorbital
rims, zygomatic arches and buttresses, medial and lateral orbital walls), facial
symmetry is more easily restored.
Using the vertical and horizontal pillars of the midface as anatomic
guides does not diminish the importance of relating the maxilla to the mandible
when sufficient dentition is present for defining an occlusal relationship.
Although the facial pillars provide alternative reference points on which
midface position can be based, inaccuracies can still occur, especially when
significant comminution or displacement of fracture sites is present. Cranial to
caudal sequencing in the management of multiple fractures of the midface may
produce

malpositioned

skeleton

relationships are not restored.

if

the

complex

three-dimensional

This is not to suggest that the traditional

bottom-up approach that uses the mandible as a horizontal and vertical

reference is always accurate. The irregular shape of teeth and preexisting
malocclusions contribute to the difficulties of establishing a correct relationship
between the maxillary and mandibular dentition. Such inconsistencies are often
more obvious to and patient who complains of a bite being off, whereas small
steps of diastemata at other fracture sites may go unnoticed. It is therefore
prudent to establish a satisfactory occlusal relationship before proceeding with
reduction and fixation of the remaining facial fracture. An analysis of study
casts obtained before surgical intervention is often useful in determining he
correct maxillary-mandibular relationship. Fabrication of an interocclusal splint
can then be used to guide the reduction of fractures.
Types of Rigid fixation

Rigid fixation of midface fractures uses bone plates of different

thicknesses secured by screws ranging in diameter from 1 to 2mm. Standard
nomenclature for the different types of plates has not been adopted by the
industry, with a selection of microplates and miniplates available for fixation of
midface fractures. As evident from Table 8-3, microplatesvary in thickness
from 0.5 to 0.65mm, and miniplates can be between 0.5 and 0.85mm thick. the
various plate thicknesses and screw diameters result in different levels of
rigidity when the fixation is tested under laboratory conditions. However, this
information remains inconclusive, because the actual loads imposed on the
midface during physiologic function have not been fully determined. At this
time, miniplates appear to provide sufficient stabilization for fracture healing in
different regions of the midface. The midface is essentially astaticstructure, so
the requirements for rigid fixation are less dependent on the plate thickness and
more dependent on plate thickness and more dependent on the ability of resist
deformation.
Surgical Access to the Midface
Midface injuries may be addressed through formal incisions or
lacerations that conveniently expose underlying fractures. With the exception
of the middle and lower thirds of the nose, three approaches provide full
exposure of the entire midface and may be used separately or in combination,
depending on the type of injury sustained.
Maxillary Vestibular Incision A transoral, maxillary vestibular incision
extending from one zygomticbuttress to the other providesdirect exposure of the
maxilla, pyriform rims, and zygomatic but tresses. The flap can usually be
retracted far enough superiorly to visualize the frontal processes of the maxilla
and infraorbital rims.

However, sufficient relaxation and the infraorbital

neurovascular bundle seldom allow proper fixation of these areas through the

vestibule.

When extensive comminution of the maxillar walls is present,

dissection in the subperiosteal plane may detach small bone fragments. Unless
the free pieces are large enough to fixate, they should be removed to prevent
sequestation. The resulting defect may be reconstructed with a bone graft, if
indicated.
Lower Eyelid Incisions Access to the infraorbital rim, orbital floor and walls,
and frontal process of the maxilla is obtained with approaches through the lowar
eyelid. Incisions may be created through lid skin (subciliary, infraorbital) or
through the con-junctival surface (transconjunctival). A lower incidence of
ectropion has been reported with transconjunctival approaches, although this
technique is by no means free from complications.
Before considering different approaches, a brief review of lower eyelid anatomy
is necessary (Fig. 8-24). The lower lid is lined with conjunctiva on its inner
aspect and covered with loose skin and the palpebral portion of the orbicularis
oculi muscle on the facial surface. Mechanical support for the lid is provided by
a fibrous skeleton, which is continuous with the orbital periosteum. Within the
inferior two thirds of the lid, the fibrous skeleton attaches directly to the anterior
lacrimal crest and bony orbital margins and is known as the septum orbitale.
Toward the marginal third, the septum is thickened to form a tarsal plate that is
more rigid and adapts the lid closely to the corneal surface. The tarsal plates
anchor te eyelashes and contain the meibomian glands. Their oily secretion
delays the evaporation of tears. The septum is thickened in its medial extent,
where it forms the medial palperbral ligament. The ligament and medial canthal
tendon (extension of the orbicularis oculi) are confluent in this area and anchor
the medial canthus tightly to bone. Laterally, the orbital septum remains thin.

It also fuses with the orbicularis occuli muscle, forming a raphe that rovides a
looser connection between the lateral canthus and orbital rim.
Transconjunctival Approach A transconjunctival approach can nbe used to
expose the infraorbital rim, orbital floor, and both medial and lateral orbital
walls. Lid retraction is facilitated by first incising through the lateral canthal
skin with a scalpel blae or iris scissors (Fig. 8-25A). A canthal releas should be
distinguished fro a canthotomy, where the insertions of the raphe into the orbital
margin aredetached. If a wide dissection of the orbit or exposure of the lateral
rim to the forntozygomatic suture is required, a formal can thotomy becomes
necessary.

An incision made paralles to the alperbral fissure heals very

aesthetically, without distorting the lateral canthus.

Following canthal release, eversion of the lower lid with skin hooks or two
traction sutures exposes the conjunctiva (Fig. 8-25B). After insertion of a
corneal protector, the conjunctiva is infiltrated with local anesthetic combined
with a vasoconstrictor. An incision through the superficial conjunctiva is made
approximately halfway between the lid margin and fornix below the level of the
tarsal plate. Either electrocautery or a scalpel may be used. Alternatively, an
iris scissors is inserted through the lateral canthal incision and used for a
subconjunctival dissecton toward the medial canthus. The conjunctiva is then
divided sharply with the scissors (Fig. 8-25C).

The medial extent of the

dissection must avoid the inferior punctum and canaliculus.

Once the

conjunctival incision is joined to the canthal release, additional retraction of the

lid is possible.
The transcorjunctival dissectionmay be continued in a pre-or postseptal plane.
Preseptal idssection (i.e., between the septum and overlying orbicularis oculi
muscle)

avoids orbital fat herniation into the field. However adhesions between the thin
skin-muscle falp to the underlying septum may produce unaesthetic results.
Postseptal dissections preserve a greater thickness of tissue, but control of the
orbital fat becomes necessary. Malleable copper retractors can be conformed to
the orbit and used to retract the fat from the field. Whichever plane is selected,
the dissection continues toward the infraorbital rim. An inward bias avoids
perforations through the flap into the face. Frequent palpation of the rime
guides the dissection, which is performed with electrocautery or a sharp-tipped
scissors. If the rim has been fractured and displace, the displaced segment
should not be used as a reference. Instead, the dissection is directed toward
intact areas of the orbit. The rim can be defined through the overlying soft
tissue by applying counterpressure with two retractors placed on either side of
the bony margin (Fig. 8-25D). If a postseptal approach is adopted, the final
incision through the orbital periosteum is made close to the rim, as the orbital
fat pad has already been violated. With preseptal approaches, the dissection is
contined approximately 5mm below the rim before incising through the
periosteum. Subperiosteal dissections are then completed to fully expose the
fractures and adjacent areas, which are used as anatomic references for
reduction and stabilization (Fig. 8-25E).
Closure of a transconjunctival incision begins with the periosteal llayer,
especially if a graft was placed within the orbit. The periosteum is sutured with
a resorbable 5-0 suture such as chromic catgut. Deep tissues do not rewquie
approximation, which, if performed imprecisely, can distort the alignment of the
lid. Some surgeons do not close the conjunctival layer, which heals well as a
esult of the natural rigidity of the supporting tarsal plate.

However, if

periorbital fat continues to herniated through the incision, either a continuous

or a judiciously spaced interrupted resorbable 6-0 suture can be used. The last
incision closed is the lateral canthal release or canthotomy. If the raphe was not
detached, securing the canthal tissue to the periosteum with a deep suture is

often adequate. However, when a canthotomy has been performed and the
periosteum elevated, proper reattachment of the lateral canthus requires suturing
to a transossseous hole created at the level of the canthal attachment. A slow
resorbing suture such as 5-0 Vicryl is passed through the lower edge of the
lateral canthal incision. Next the needle is passed deep into the incision to
engage the periosteum or a transosseous hole. Following this, the suture is
passed through the upper edge of the incision and tied under a small amount of
tension. The desired effect is a reapproximation of the canthus against the
sclera at the same level as the medial lcanthal attachment. Previously, the
position of the lateral canthus was felt to be approximately 2 mm superior to the
medial canthus. This followed analysis of subjects with their eyes open. When
the lids are closed, as they are during surgery, the medial and lateral canthi
actually lie on the same horizontal plane. Once the lateral canthus has been
properly secured, the remaining skin incision is closed with 5-0 or 6-0 fast
resorbing sutures.
Subciliary approaches to the orbit employ a horizontal cutaneous incision
made 2 to 3 mm from the lid margin. The dissection can be performed in a
plane between the orbicularis oculi muscle and the septum or superficial to the
muscle just below the skin. The latter approach is particularly prone to creating
a buttonhole defect if the dissection fails to follow the skin contour. Both
dissections are continued approximately 5 mm below the rim margin before
incising through the periosteum. By approaching the orbit in a stepped fashion,
the incision does not directly overlie the fracture site. Additional exposure of
the orbit may be achieved by incorporating a releasing incision below the lateral
canthus. Closure of the subciliary incision is performed in layers with deep
periosteal sutures followed by cutaneous re-approximation.
Incisions through the lower lid, regardless of approach, are more likely to be
associated with complications than any other access used in the management of

midface injuries.

Many of these complications are related to scarring.

Adhesion of the skin to the underlying tarsal plate and septum may produce
unsightly dimpling. If the scar contracts or adheres to the orbital rim, retraction
of the lower lid creates an ectropion (Fig. 8-26). Lid retraction or disruption of
the tarsal plate separates the lower lid from the cornea. Loss of this important
seal produced epiphora or dehydration, resulting in secondary conjunctivitis.
Increased amounts of scleral show accentuate globe asymmetry. Failure to
reattach the lateral canthal tissues to the orbital periosteum produces a diathesis
between the lid and sclera, as well as a loss of medial-lateral canthal alignment.
Coronal Approaches The superior components of the midface, including the
frontal bone, NOE complex, forntozygomatic sutures, and zygomatic arches, are
approached through a coronal incision and flap (Fig. 8-27). This technique
enables wide exposure of the region while camounflaging the incision behind
the hairline. Depending on the degree of exposure required, a coronal flap may
be developed centrally to access the frontal bone, NOE complex, and frontozygomatic sutures, or it may be extended laterally to expose the zygomatic
arches. The coronal incision connects the helicalfacial junction on one side of
the face to the other Inferior extensions within the preauricular creases may be
required if the zygomatic arches need exposure. Adopting an anterior curvature
with the incision as it crosses the skull facilitates access to the NOE complex.
Fluid dissection with saline and a vasoconstrictor in the subgaleal plane before
making the incision is helpful. The scalp is a highly vascularized structure, and
a coronal flap should be developed in short segments with adequate hemorrhage
control before proceeding further. Traditional methods of securing bleeding
margins include oversewing the edges with 2-0 silk sutures or applying a series
of Raney or Michel clips along the incision. Recently, the development of a
special cautery tip that concentrates heat to a small area (Colorado Tip)
effectively produces hemostasis as the incision is made. Depending on the
individual cautery units, low power settings such as a coagulation setting of

10, a cut setting of 6, and a blend mode of 5 are adequate for both incision
and hemorrhage control. After dividing the galea aponeourosis, the flap is
developed above the pericranium. A curved Mayo scissors is very eff3ctive in
relesing the loose connective tissue attachments between the inferior surface of
the galea and the pericranium. As the flap is retreacted forward, thesuperficial
temporalis fascia (part of the superficial musculoaponeurotic system [SMAS])
covering the temporalis muscle becomes apparent. Lateral extensions of the
coronal flap to gain greater anterior release or to expose the zygomatic arches
must protect the motor temporal branch of the facial nerve.
Facial Nerve The course of this branch has been described by Bernstein and
Nelson and related to several superficial landmarks. After the main temporal
branch leaves the parotid gland, approximately four rami (range three to five)
are formed that pass fro deep to superficial. These cross the zygomatic arch at
least 1.8 cm anterior to the helical-facial junction and 2 cm behind the frontal
process of the zygoma along a horizontal line drawn from the lateral canthus of
the eye. Alternatively, the anteriormost ramus has been described as passing
one fingers breadth behind the lateral orbital margin.

The branches run

superiorly in the fat pad just below the superficial temporalis fascia (SMAS) to
the lateral margin of the frontalis muscle. Here they pass beneath the muscle to
innervate it from it from its deep surface somewhere between the eyebrow and 2
cm higher. An other set of landmarks developed by Correia and Zani describe
two diverging lines from the tip of the earlobe to the lateral extent of the highest
forehead crease and to the eyebrow; this area encloses the course of the nerve.
When a full lateral dissection is required to expose the zygomatic arch or to
facilitate anterior retraction of the flap, an angled incision is made behind the
temporal branch through the superficial and deep temporal fascia layers. The
flap is elevated just superficial to the temporalis muscle belly and deep to the
temporal fat pad, which contains the nerve. This dissection is connected with
the central subgaleal flap more than 2cm above the eyebrow to protect the

branch to the frontalis muscle. Across the root of the zygomatic arch, an
incision is made through the periosteum of the arch approximately 1 cm in front
of the anteriormost concavity of the auditory canal. This avoids the posterior
rami of the temporal branch, which may cross the arch supraperiosteally
anywhere from 0.8 to 3.5 cm anterior to the canal.
Coronal Flap: Modifications and Closure Designing the pericranial incision for
exposure of the frontal bone and NOE complex should take into consideration
the possibility of a pericranial flap for sealing defacts in the floor of the anterior
cranial fossa.

When this is required, a high incision on the frontal bone

produces an inferiorly based pericranial flap ofsufficient length for rotation

through the frontal craniotomy. If the incision is made too low across the nasal
root, the resulting superiorly based flap is too short to cover the cranial defect.
Closure of the coronal flap is performed in layers using resorbable sutures for
the periosteum and galea. Skin closure is achieved with surgical staples, which
are removed after 7 to 10 days. A flat suction drain (e.g., 7-mm Jackson- Pratt
drain) is placed transversely across the cranium in the subgaleal plane and
extoriorized through a small incision in the lateral aspect of the flap just behind
the superior helix. If significant postoperative bleeding is anticipated, two
drains may be used. When the soft tissue around the zygoma and arch has been
dissected, resuspension of the facial minietic muscles prevents the development
of postoperative soft tissue ptosis.

Transosseous holes and drilled in the

frontozygomatic regions, and the laterial facial soft tissues are attached with
nonresorbable sutures. When the temporalis muscle is elevated to expose the
lateral orbital wall, resuspension of the muscle to a screw or hole in the superior
temporal line is similarly important.
In additiona to the potential for temporal branch injury, coronal flap have
been associated with alopecia along the incision line and the development of
temporal wasting. Alopecia is believed to result from the necrosis of hair

follicles as a result of heat dispersion from the cautery. Temporal wasting is still
not fully understood and may be secondary to atrophy of the temporal fat or
failure of the muscle to attach itself superiorly enough to restore its former
length and bulk.
Midface Degloviing Incision

The midface degloving incision was

originally used as a means to access the nose and paranasal sinuses for the
purpose to tumorresection. Also known as the sublabial degloving approach, it
combines the elements of a maxillary vestibular incision with an open
rhinoplasty approach to provide excellent exposure of the anteriorand posterior
maxillary walls, infratemporal fossae, nasal skeleton, orbital floors, inferior
portions of the medial and lateral orbital walls, and zygomas. It is therefore an
excellent method to expose the central midface for the reduction and fixation of
fractures without the production of cutaneous scars. Early concerns over the
potential impact of such a dissection of facial growth centers appear notbe
founded.
Before incision, hemostasis is aided with the infiltration of lidocaine and
a vasoconstrictor along the maxillary vestibule and the topical application of 4%
cocaine to the nasal mucosa. Starting with the nose, bilateral intercartilagious
incisions are made between the upper and lower lateral nasal cartilages. These
incisions are continued laterally along the anterior margins of the pyriform
apertures and through the nasal floor into the maxillary vestibule. Medially, a
transfixion incision is created through the membranous septum extending from
the nasal tip to the floor.

Superiorly, this is connected with the

intercartilaginous incisions; inferiorly, the incision is continuous with the nasal

floor dissection. Following completion of the nasal incisions, the soft tissue is
elevated from the dorsum of the nose through the intercartilaginousincisions
with a Freer elevator. This dissection is per formed in a supraperichondrial
plane over the upper lateral cartilages until the nasal bones are reached. At this
level, the periosteum is incised using a curved Joseph blade, and subperiosteal

dissection is begun. This extends superiorly to the nasofrontal junction and

laterally to the nasomaxillary sutures. Care must be taken notto disarticulate the
upper laterally to the nasomaxillary sutures.

Care must be taken not to

disarticulate the upper lateral cartilages from nasal bones. A standard maxillary
vestibular incision from first molar to first molar follows completion of the
nasal dissection, Medially, the vestibular, nasal floor, and transfixion incisions
are connected so that a single subperiosteal plane of dissection is raised, while
protecting the infraorbital nerves. The midface degloving dissection exposes
the entire midface to the level of the orbital floors and nasal root.
Incision closure is achieved with 3-0 chromic suture for the transfixion
vestibular incisions and a slower resorting Vicryl 4-0 suture for the nasal sill,
intercartilaginous areas, and floor. Careful reapproximation of the transfixion
of the transfixion incision is important to position the nasal tip correctly. A
standard rhinoplasty dressing using transversely applied surgical tape over the
dorsum of the nose and a protective splint helps reduce edema and adapt the
nasal soft tissues to the underlying skeleton.
Complications related to this procedure are minimal and relate primarily
to adverse scarring in the nasal vestibule. Nasal synechiaeor increased alar
show many develop following incorrectly placed transfixion sutures.
Surgical Approaches to the NOE Complex
Superior components of an NOE injury occurring alone or in combination
with other midface fractures may be accessed through the coronal flap, provided
sufficient anterior release is achieved. If the flap is tethered by attachments of
the supraorbital and supraorbital and supratrochlear neurovascular bundles,
freeding the nerves from the foramen provides additional relaxation. Small
osteotomes and burs are used to remove the inferior margin of the foramen. The
bundles are then mobilized through the defect and dissection into the soft tissue
flap. When a coronal flap is used to approach an NOE complex fracture,

limited access to the medial portion of the infraorbital rims and inferiorregions
of the frontal process of the maxilla requires additional incisions. This is
especially true when plate stabilization of fracture necessitates a wider exposure
of the field.
The infraorbital rim can be approached entirely through a lower lid
incision, whereas the frontal process is exposed with an intraoral maxillary
vestibular incision.

Unilateral, incomplete, single-segment injuries with

fractures through the frontal process of the maxilla and infraorbital rims without
involvement of the frontonasal articulation may be treated with inferior
approaches alone. Other approaches to the NOE complex include a preexisting
laceration over the nasal bridge, a vertical incision along the nasal dorsum, a
transverse gullwing incision within the eyebrows, unilateral or bilateral nasal
Lynch incision, or an H-shaped incision across the nasal bridge. These of fer a
greater degree of direct access than a coronal flap but produce less aesthetic
results in a prominent area of the face.
The Lynch incision is a curved incision made over the lateral nasal bones
anterior to the attachment of the medial canthus. The skin in this region is often
very thin, and the bone is easily exposed through this approach. Both sides of
the NOE complex can be accessed through single Lynch incision, and this may
be sufficient for limited reconstruction. When bilateral canthopexies or bone
graft reconstruction is indicated, winder exposure of the complex becomes
necessary.
Reducing Midface Fractures
Proper reduction of midface fracture is arguably the most important step
in the management of these injuries. Several major complications are the result
of inadequate or improper reduction of the segments. Methods and vectors of
reduction depend largely on the fracture pattern, in addition to the degree and
direction of displacement.

Earlier (see the section on paterns sof injury),

mention was made of midface fractures that do not follow the classic levels
described by leFord. Characterization of fractures according to the components
that require separate reduction was emphasized, and recognition of these
components forms the basis of successful treatment of midface injuries. Before
reducing a fracture, adequate exposure of the different fracture site must be
performed.
A universal rule of mechanics states that application of a movement (i.e.,
reduction force)close to an articulation (i.e., fracture site) results in not only a
greater movement of the articulation but also more control over the direction of
movement. A LeFord I fracture can therefore be effectively reduced with the
help of forceps applied to the nasal floor and palate, which essentially bridge
the fracture line. The Rowe disimpaction forceps is an example of such an
instrument that grasps the maxilla with left and right twin blades.

After

positioning the forceps, the operator locks his or her wrists and uses coordinated
movements to rock the maxilla into place. When the midface has been
displaced posteriorly and inferiorly, a downward force should force should first
be applied to disimpact the maxilla in the area of the pterygoid plates before
distracting it forward into alignment with the mandible. In sufficient anterior
distracting it forward into alignment with the mandible. If sufficient anterior
displacement cannot be achieved, a bluntended instrument such as a Seldin
reactor can be placed into the pterygomaxillary junction to distract the maxilla
into position. Occasionally, palatal fractures prevent application of thr Rowe
forceps, and an alternative instrument must be used. The Hayton-Williams
maxillary forceps uses twin blades that engage the lateral surfaces of the
maxilla. LeFord II and III fractures can also be reduced with disimpaction
forceps. However, the further the fracture sites are from the point of force
application, the less efficient the reduction. When inadequate alignment results,
individual segments are reduced separately. Direct reduction is achieved with
an elevator, bone hook, or wire inserted through the fragment.

Indirect

techniques employ a bone hook or Carroll-Girard screw that engages the

zygomatic body ad reduces fractures at the frontozygomatic suture, infraorbital
rim, buttress, and zygomaticotemporal articulation. Traction using elasticbands
applied to maxillary and mandibulararch bars constitutes another method for
reducing fractures of the midface. However, once again this may not effectively
reduce all midface fractures, especially in the fracture sites are distance from the
dentition. Reduction of midface fractures at the LeFord II and III levels may
produce a reactionary bradycardia known as the oculocardiac reflex.

This

response is mediated by the ophthalmic branches of the trigeminal nerve

(afferent limb) and follows traction on the orbital contents, especially the
medial rectus muscle. Relays between the descending spinal trigeminal tract
and the visceral motor nucleus of the vagus nerve within the reticular formation
(efferent limb) produce a slowing of the heart rate. The reflex may be corrected
by releasing reduction forces. however, if hemodynamic compromise persists,
the bradycardia is treated with the administration of IV atropine.
Impure fractures of the midface require reduction techniques directed
specifically at the separate fragments. Accordingly, a hemi-LeFord II fracture
with a contralateral ZMC component requires reduction of both LeFort II
fracture and the affected ZMC.
The complex anatomy of the midface requires examination of all fracture
sites before the adequacy of reduction can be established.

Problem areas

include the zygomaticosphenoid suture and sites of comminution.

midface is considered to the composed of circular rings with

If the

gradually

increasing diameters, small errors in the alignment of medial structures will

result in progressively larger discrepancies further laterally. This feature is
discussed in the section on complications of the midface injuries.
Reducing NOE Complex Fractures.

Reduction of an NOE complex fracture is usually performed as separate

maneuver from the alignment of associated midface fractures. Special attention
must be paid to two important features of this injury. (Fig. 8-34). Because the
complex is shaped as a wedge, restoring projection to the complex requires
proper reduction of the base. In addition, fracture reduction is sequenced to
restore alignment of the bones making up the central fragment before reduction
and fixation of the inferior (pyriform rim) and lateral (medial orbital
rim)elements.

Reconstruction of the central fragment is most commonly

achieved with transnasal wiring. If a complete, unilateral, single-segment (type

I, unilateral) fracture is present with lateral displacement of the medial orbital
walls, transnasal wiring is used to reduce the fracture.
Biomechanics and Healing of the Midface
Fracture Displacement Vectors Before embarking on a description of the
different types of fixation available for stabilizing midface fractures, the
physiologic forces exerted on the midface and the characteristics of fracture
healing should be reviewed briefly.

An excellent account of midface

biomechanics has been provide by Ruderman and Mullen, and the reader is
referred to this article for a more complete discussion of this important subject.
The study of forces and the biologic response of different maxillofacial skeletal
structures is confounded by the nonuniform geometry of the bones and the
number of orientation of the many attached muscles and ligaments.
physical (photoelastic and rigid body)

Both

and mathematical (finite element

analysis) models have been employed to simulate the various skeletal

components.

However, neither the technology nor the synthetic materials

currently exist to accurately reproduce the complex forces applied to the

midface.

In the absence of a complete understanding of potentially

destabilizing forces, treatment has been directed instead to restriction of

movement of a fractured segment

of bone is capable of displacement in

ixdirections. Three transalatory and three rotational movement can occur about
the x (horizontal), y (vertical), and z (sagittal)axes. Whereas translation in all
three dimensions may be restrained by a plate or wire of adequate tensile and
compressive strength, rotary movements require constraint at three separate
points not on the same axis. The farther these fixation points lie from one
another the greater the ability of the deice to counteract rotation. Plates are
more capable than wires of resisting rotation, because each side of a plate
constitutes a point of stability (Fig. 8-41). Wider plates (i.e., fixation points
farther apart) are therefore more effective against rotary movements than
narrow plates, which is a consideration when microplates are used in the
fixation of midface fractures. Similarly, three wires or several plates oriented at
different angles from one another provide more rigidity than.