ANATOMY & BIOMECHANIC

MAXILLOFACIAL BUTTRESSES
dr. Hemastia Manuhara Harba'i, Sp. THT-BKL
OUTLINE
Anatomy Maxillofacial Buttresses
Biomechanic
Healing Process
 GOALS OF RECONSTRUCTION

Goals for midface and maxillary defects

reconstruction are:
• Wound closure
• Support orbital contents/maintenance
of ocular globe position
• Speech
• Mastication
• Maintain patent nasal airway
• Facial contour

Smith, Elana B., MD; Patel, Lakir D., MD; Volume 32, Issue 1. Pages 231-254. 2021
 BIOMECHANISM
OF THE MIDFACE

Midface shape resembles the shape of a tent

Tent poles represent Tarpaulin represents the

the bony midface overlying soft tissues

Cornelius, C.-P., Schubert, W., Kusumoto, K., Hillerup, S., & Gellrich, N. (2023). Biomechanics of the Midface. AO Foundation Surgery Reference.
https://surgeryreference.aofoundation.org/cmf/trauma/midface/further-reading/introduction
Dimension vectors of a midface:
• Vertical
• Sagittal
• Transvers
 BIOMECHANISM
OF THE MIDFACE

To begin the reconstruction sequence

of midface, begins with establishing
the most reliable structures:

• Occlusion
• Outside-to-inside (Joe's outer frame)
• Up-to-down

Cornelius, C.-P., Schubert, W., Kusumoto, K., Hillerup, S., & Gellrich, N. (2023). Biomechanics of the Midface. AO Foundation Surgery Reference.
https://surgeryreference.aofoundation.org/cmf/trauma/midface/further-reading/introduction
 BIOMECHANISM
OF THE MIDFACE

Under or Over Contouring of the

bony midface can lead to

Aesthetic compromise Functional

disorders
• Malocclusion
• Orbital
dysfunction

Cornelius, C.-P., Schubert, W., Kusumoto, K., Hillerup, S., & Gellrich, N. (2023). Biomechanics of the Midface. AO Foundation Surgery Reference.
https://surgeryreference.aofoundation.org/cmf/trauma/midface/further-reading/introduction
 SURGICAL PRINCIPLES

Dental occlusion is the most important

parameter to:
• Reestablishing facial contour
• Reduction of fracture
• Obtaining post operative chewing function
The most common placing in MMF --> arch bars

Cornelius, C.-P., Schubert, W., Kusumoto, K., Hillerup, S., & Gellrich, N. (2023). Biomechanics of the Midface. AO Foundation Surgery Reference.
https://surgeryreference.aofoundation.org/cmf/trauma/midface/further-reading/introduction
 SURGICAL PRINCIPLES

Achieve anatomical correct repositioning of all

midfacial bones by reestablish the height,
width, and projection of the midfacial
buttresses

Cornelius, C.-P., Schubert, W., Kusumoto, K., Hillerup, S., & Gellrich, N. (2023). Biomechanics of the Midface. AO Foundation Surgery Reference.
https://surgeryreference.aofoundation.org/cmf/trauma/midface/further-reading/introduction
 SURGICAL PRINCIPLES

All fractures should be exposed and

reduced before plating

Pre- and Post operative 3-D imaging

allows an objective assessment of
the surgical results

Cornelius, C.-P., Schubert, W., Kusumoto, K., Hillerup, S., & Gellrich, N. (2023). Biomechanics of the Midface. AO Foundation Surgery Reference.
https://surgeryreference.aofoundation.org/cmf/trauma/midface/further-reading/introduction
 PANFACIAL FRACTURES
(Sequencing of repair)
Main goals:
• Restore the anatomy in all three
dimensions
• Plating the maxillofacial butttress
wherever necessary

Cornelius, C.-P., Schubert, W., Kusumoto, K., Hillerup, S., & Gellrich, N. (2023). Panfacial Fractures (Sequencing of
Repair). AO Foundation Surgery Reference. https://surgeryreference.aofoundation.org/cmf/trauma/midface/further-
reading/panfacial-fractures-sequencing-of-repair
Gonzales-Ulloa, M. (1956) Restoration of the Face Covering by Means of Selected Skin in Regional Aesthetic Units.
British Journal of Plastic Surgery
, 9, 212-221.
https://doi.org/10.1016/S0007-1226(56)80036-2
 Buttress Notes

Includes the lateral walls of orbit,

Lateral Maxillary (yellow)

FACIAL
maxillary sinus

Includes medial orbital, lateral nasal

Medial Maxillary (purple)

BUTTRESSES
walls

Posterior Maxillary (pink) Includes pterygoid plates

Posterior Vertical (orange)

Upper Transverse Maxillary (blue) Includes the orbital floor

Lower Transverse Maxillary (green) Includes the hard palate

Upper Transverse Mandibular

(magenta)

Lower Transverse Mandibular (orange)

Source:faculty.washington.edu/jeff8rob/trauma-radiology-reference-resource/2-hn/maxillofacial-buttresses/
 FACIAL
BUTRESSES

A. Nasomaxillary
B. Zygomaticomaxillary
C. Pterygomaxillary
D. Ethmoid-vomerian
E. Supraorbital
F. Suborbital
G. Alveolar
Crespo Reinoso, P., Jerez Robalino, J., & González de Santiago, M. (2021). Biomechanics of midface trauma: A review of concepts. Journal of Oral and Maxillofacial Surgery,
Medicine, and Pathology, 33(4), 389–393. https://doi.org/10.1016/j.ajoms.2021.01.010
 SOFT TISSUE TRAUMA

A total of 700 facial soft tissue injuries

segregated into the number of injuries for
different facial areas, indicated by color

Note the "T" distribution across the

forehead, nose, lips, and chin. Also note the
concentration of injuries at the lateral brow

Hussain K, Wijetunge DB, Fubnic S, et al. A comprehensive analysis of craniofacial trauma. J Trauma. 1994;36:34)
 PANFACIAL FRACTURES
(Sequencing of repair)

Two options for sequencing:

Bottom-Up Top-Down

Cornelius, C.-P., Schubert, W., Kusumoto, K., Hillerup, S., & Gellrich, N. (2023). Panfacial Fractures (Sequencing of
Repair). AO Foundation Surgery Reference. https://surgeryreference.aofoundation.org/cmf/trauma/midface/further-
reading/panfacial-fractures-sequencing-of-repair
 PANFACIAL FRACTURES
BOTTOM-UP SEQUENCING

Re-establish the maxillo-mandibular

unit as the first major step of the
sequencing (Bottom-up)

Once the maxillomandibular unit is

established, most surgeons start from
the calvarium and proceed in a caudal
direction with reduction and fixation

Cornelius, C.-P., Schubert, W., Kusumoto, K., Hillerup, S., & Gellrich, N. (2023). Panfacial Fractures (Sequencing of
Repair). AO Foundation Surgery Reference. https://surgeryreference.aofoundation.org/cmf/trauma/midface/further-
reading/panfacial-fractures-sequencing-of-repair
 PANFACIAL FRACTURES
TOP-DOWN SEQUENCING

Starting with the reduction and fixation at

the level of the calvarium and working in a
caudal direction (Top-down)

Note: Reestablishment of the proper

maxillomandibular unit is still very
important

Cornelius, C.-P., Schubert, W., Kusumoto, K., Hillerup, S., & Gellrich, N. (2023). Panfacial Fractures (Sequencing of
Repair). AO Foundation Surgery Reference. https://surgeryreference.aofoundation.org/cmf/trauma/midface/further-
reading/panfacial-fractures-sequencing-of-repair
 BIOMECHANISM
OF THE MANDIBLE

• Outer cortex of the mandible is strong

with average thickness of 3.3 mm
• Thicker in the chin region and
reinforced laterally
• In the symphysis region: the thickest
at the lower border behind the 3rd
molar

Cornelius, C.-P., Schubert, W., Kusumoto, K., Hillerup, S., & Gellrich, N. (2023). Biomechanics of the Midface. AO Foundation Surgery Reference.
https://surgeryreference.aofoundation.org/cmf/trauma/midface/further-reading/introduction
 BIOMECHANICS OF THE
MANDIBLE

• Superior portion of the

Mandbile: tension zone

• Inferior portion of the

Mandible: compression zone

Cornelius, C.-P., Schubert, W., Kusumoto, K., Hillerup, S., & Gellrich, N. (2023). Panfacial Fractures (Sequencing of
Repair). AO Foundation Surgery Reference. https://surgeryreference.aofoundation.org/cmf/trauma/midface/further-
reading/panfacial-fractures-sequencing-of-repair
 IDEAL LINES OF
OSTEOSHYNTHESIS

Maxime Champy: popularized

osteosynthesis as the treatment
of mandible fractures

Load sharing osteoshynthesis

applied in a simple fracture
patterns
Cornelius, C.-P., Schubert, W., Kusumoto, K., Hillerup, S., & Gellrich, N. (2023). Panfacial Fractures (Sequencing of
Repair). AO Foundation Surgery Reference. https://surgeryreference.aofoundation.org/cmf/trauma/midface/further-
reading/panfacial-fractures-sequencing-of-repair
 IDEAL LINES OF
OSTEOSHYNTHESIS
Plate needs to be put in one of the two Champy lines in the mandibular angle

Cornelius, C.-P., Schubert, W., Kusumoto, K., Hillerup, S., & Gellrich, N. (2023). Panfacial Fractures (Sequencing of
Repair). AO Foundation Surgery Reference. https://surgeryreference.aofoundation.org/cmf/trauma/midface/further-
reading/panfacial-fractures-sequencing-of-repair
 OSTEOSYNTHESIS

Load Bearing Load Sharing

Cornelius, C.-P., Schubert, W., Kusumoto, K., Hillerup, S., & Gellrich, N. (2023). Panfacial
Fractures (Sequencing of Repair). AO Foundation Surgery Reference.
https://surgeryreference.aofoundation.org/cmf/trauma/midface/further-reading/panfacial-
fractures-sequencing-of-repair
 LOAD BEARING OSTEOSYNTHESIS

• Requires large and rigid plate

• Tools: reconstruction plates combination
with locking screws.
• Clinical uses: Atrophic edentulous
fractures, comminuted fractures, the
necessity to span an infected bone
segment, and other complex mandibular
fractures

Cornelius, C.-P., Schubert, W., Kusumoto, K., Hillerup, S., & Gellrich, N. (2023). Load Bearing vs
Load Sharing. AO Foundation Surgery Reference.
https://surgeryreference.aofoundation.org/cmf/basic-technique/load-bearing-vs-load-sharing
 LOAD SHARING
OSTEOSYNTHESIS

• Smaller plates can be used

• Clinical uses: simple fractures
• *the green arrows represent
load sharing that occurs at the
angle of the mandible

Cornelius, C.-P., Schubert, W., Kusumoto, K., Hillerup, S., & Gellrich, N. (2023). Load Bearing vs
Load Sharing. AO Foundation Surgery Reference.
https://surgeryreference.aofoundation.org/cmf/basic-technique/load-bearing-vs-load-sharing
 FRACTURES HEALING

Following the fracture,

secondary healing begins,
which consists of four steps:
• Hematoma formation
• Fibrocartiloginous callus
formation
• Bony callus formation
• Bone remodelling

Atlas of Craniomaxillofacial Osteosynthesis: Microplates, Miniplates, and Screws. Fransz Haerie, Maxime Champy, Bill
Terry 2nd Edition, Thieme, 2009.
 DELAYED UNION VS NON-UNION

Delayed Union
Non-Union
• Fracture has not healed in the time
frame that would be expected • Established when a minimum of 9
• Time frame of healing differs from months has elapsed since injury
different locations around the and the fracture shows no visible
body and the degree of soft tissue progressive signs of healing for 3
injury months
• Generally the time frame for
delayed union is 3-6 months

John C, Delayed Union and Malunion of Fracture, Chapter 36, Campbells' Operative Orthopaedics. 14th edition. 2012
 SOFT TISSUE HEALING

• Singer AJ, Clark RA. Cutaneous wound healing. N Engl J Med. 1999 Sep 2;341(10):738-46. doi: 10.1056/NEJM199909023411006. PMID: 10471461.
 SIGNS OF INFLAMMATION

Clinically the wounded are presents with the classic signs of

inflammation
• Rubor: redness caused by inflammatory induced
hyperemia
• Calor: heat from dilated vessels, bringing warmer core
blood to the wound
• Tumor: swelling with initial exudate fluid plus increased
inflammatory fluid in tissue
• Dolor: pain related to lowered pH effect on
nocireceptors and pressure from swelling
• Functio laesa: loss of function caused by pain and
protective selective muscle inhibiton
 ABRASIONS TRAUMATIC TATTOO
• Results from tangential trauma that • If dirt and debris in abrasions are not
removes the epithelium and a portion removed completely, the dermis and
of the dermis leaving a partial epithelium will grow over the
thickness injury that is quite painful particulates and create a traumatic
• Topical anaesthetics can give good tattoo that is very difficult to manage
anasthesia for cleansing, but if more • There are two types: blast injuries
involved debridement is needed, (military casualtive) and abrasive
general anaesthesia is advisable injuries

Reid V. Mueller. Facial trauma: Soft tissue injuries. Plastic Surgery Vol.3: Craniofacial, Head and Surgery and Pediatric
Plastic Surgery. Elsevier 4th
SIMPLE LACERATIONS COMPLEX LACERATION
• Sharp objects cutting the tissue • Soft tissue is compressed between a
usually cause simple or clean bony prominence and an object, it wil
lacerations burst or fracture resulting in a complex
• Immediate closure can be done after laceration pattern and significant
irrigation and minimal debridement contusion of the tissue

Reid V. Mueller. Facial trauma: Soft tissue injuries. Plastic Surgery Vol.3: Craniofacial, Head and Surgery and Pediatric
Plastic Surgery. Elsevier 4th
 AVULSIONS
• Many wounds of the face suggest
tissue loss upon initial inspection,
but closer examination reveals that
the tissue has simply retracted or
folded over itself
• Avulsive injuries that remain
attached by a pedicle will often
survive, and the likelihood of
survival depends on the relative
size of the pedicle to the segment of
tissue it must nourish

Reid V. Mueller. Facial trauma: Soft tissue injuries. Plastic Surgery Vol.3: Craniofacial, Head and Surgery and Pediatric
Plastic Surgery. Elsevier 4th
BR Seckel. Facial danger zones:a voiding nerve injury in facial plastic surgery. Can J Plast Surg 1994:2(2):59-66
 GENERAL TREATMENT CONSIDERATION

• The ultimate goal of soft tissue healing: to restore form and function
with minimum morbidity
• Most surgeons routinely use 1:100.000 epinephrine:lidocaine in the
local anaesthetics for facial infiltration --> prolonged duration of
anaesthesia and less bleeding
• Wound should be cleansed of foreign matter and nonviable tissue
removed

Reid V. Mueller. Facial trauma: Soft tissue injuries. Plastic Surgery Vol.3: Craniofacial, Head and Surgery and Pediatric
Plastic Surgery. Elsevier 4th
 FOLLOW UP AND POTENTIAL
COMPLICATIONS
• Make sure to have good Unfavorable outcomes include:
postoperative radiologic • Scarring
documentation of a proper • Edema
reduction and stability • Sensory and motor dysfunction
• Post operative follow up • Atrophy
needed • TMJ Dysfunction
• Dental problems

Cornelius, C.-P., Schubert, W., Kusumoto, K., Hillerup, S., & Gellrich, N. (2023). Panfacial Fractures (Sequencing of
Repair). AO Foundation Surgery Reference. https://surgeryreference.aofoundation.org/cmf/trauma/midface/further-
reading/panfacial-fractures-sequencing-of-repair
THANK YOU