return to: Facial Fracture Management Handbook

by Dr. Gerry Funk

A Brief History of Facial Fracture Fixation

The management of facial fractures has undergone considerable change over the last 60 years. These changes have been the result of an evolution in the understanding of bony facial structural dynamics and tremendous innovations in the materials used to fixate fractures. Prior to 1940 most severe midfacial fractures were managed with either intermaxillary fixation or external splinting or both. As pointed out by William Milton Adams external splinting of facial fractures is cumbersome, difficult and time consuming and rarely adequately fixates complex fractures of the facial bones (Adams 1942).

Dr Adams introduced a method of internal wire fixation of facial fractures without the use of external fixation in 1942. He also pointed out that in certain situations in which infection was a concern or in cases of severe fractures with bone loss, external fixation may retain a useful function.

Today external fixation of facial fractures is rarely used unless bone loss with infection contraindicates the use of internal fixation or some form of closed reduction. This occasionally is the case in some mandible fractures but rarely occurs in the midface. The term "Adams' suspension wires" is frequently associated with Dr. Adams however in his original manuscript, the term "suspension" is not present. His work was directed at developing a means of internally fixating severe midfacial fractures without the use of external fixation. He did not advocate compressive suspension of the lower maxillary segment, and he always attempted an anatomic reduction using interfragmentary wires. This was augmented with vertical stabilizing (not suspension) wires around the inferior orbital rim and zygomatic process of the frontal bone. Through the years the notion of suspending the midface was set forth as the result of his work and the work of others. Consequently, for years Adams' suspension wires, vertically compressing the lower maxillary segment were felt to be essential to avoid midfacial elongation and malunion as the fractures healed (Rowe et al. 1970). Experimental and clinical work has shown that the notion of suspension is not correct. Suspending the lower maxillary segment with wires looped around the zygoma or through holes in the inferior orbital rim adds nothing to properly applied intermaxillary fixation in the vast majority of cases. If enthusiastic impaction of the lower maxillary segment is performed it may actually result in midfacial shortening (Sofferman et al. 1983, Joy et al. 1969). Dr Adams' contribution to facial fracture management was however monumental because he ushered in the age of internal fixation by providing something better than external fixation.

With the increased use of internal fixation, attention was focused on the structural dynamics of the bones being fixated. In the late 1970's and 1980's a number of papers appeared describing the anatomy and role of the midfacial bony buttresses in the reconstruction of the severely fractured midface. The nasomaxillary and zygomaticomaxillary bony buttresses were likened to the pillars of a building which connected the occlusal plane to the skull base (Gruss et al. 1986, Manson et al. 1980). Wide surgical exposure and visualization of all the fractured midfacial bones and restoration of the integrity of these buttresses was recognized to be crucial in the reduction and fixation of midfacial fractures (Manson et al. 1980, Manson et al. 1985).

The development of methods and devices with which to reconstruct the bony facial buttresses evolved as internal fixation became more widely accepted. In the early 1970's simple wire ligatures were used to fixate the facial bones into anatomic reduction. These were frequently supplemented with bone grafts to supply rigidity and replace comminuted fragments (Manson et al. 1985). The rigidity supplied by bone grafts has now been largely replaced by the use of miniplates and screws which serve to both rigidly fixate bone fragments and to restore structural integrity to the midfacial bony buttresses (Klotch et al. 1987, Stanley et al. 1988, Kellerman et al. 1987). The plate and screw systems have undergone considerable change from the cumbersome stainless steel plates to the current titanium or vitallium mini and micro plate systems.

The fixation of mandible fractures, has also undergone considerable change in the past 50 years. The techniques of compression plating and the concept of absolute stability allowing direct bone healing, which were developed for the management of long bone fractures are now fundamental in the fixation of many mandible fractures. We will consider the techniques of compression plating in detail in the section on mandible fractures.

References

Adams,W,M.: Internal wiring fixation of facial fractures. Surgery 12: 523-540, 1942.

Rowe,N.L., Killey,H.C.: Fractures of the facial skeleton, ed 2. London E & S Livingstone, 1970.

Sofferman,R.A., Danielson,P.A., Quatela,V., Reed,jR.R.: Retrospective analysis of surgically treated LeFort fractures. Is suspension necessary? Arch. Otolaryngol. 109, 446-448, 1983.

Joy,E.D., McGaba,L.E., Bear,S.E.: Facial elongation after treatment of horizontal fracture of the maxilla without vertical suspension. J. Oral Surg. 27: 560-562, 1969.

Gruss,J.S., Mackinnon,S.E.: Complex maxillary fractures: role of buttress reconstruction and Immediate bone grafts. Plast. Reconst. Surg. 78: 9-22, 1986.

Manson,P.N., Hoopes,J.E., Su,C.T.: Structural Pillars of the facial skeleton: an approach to the management of LeFort fractures. Plast. Reconst. Surg. 66: 54-61, 1980.

Manson,P.N., Crawley,W.A., Yaremchuk,M.J., et al: Midfacial fractures: advantages of immediate extended open reduction and bone grafting. Plast. Reconst. Surg. 76: 1-10, 1985.

Klotch,D.W., Gilliland,R.: Internal fixation vs. conventional therapy in midface fractures. J. Trauma. 27: 1136-1144, 1987.

Stanley,R.B., Funk,G.F.: Rigid internal fixation for fractures involving tooth-bearing maxillary segments. Arch. Otolaryngol. 114: 1295-1299, 1988.

Kellerman,R.M., Schilli,W.: Plate fixation of fractures of the mid and upper face. Otolaryngol. Clin. N. Am. 20: 559-571, 1987.