SOURCE: Dept. of Otolaryngology, UTMB, Grand Rounds
DATE: APRIL 17, 1996
RESIDENT PHYSICIAN: Michael Bryan, M.D.
FACULTY: Brian Driscoll, M.D.
SERIES EDITOR: Francis B. Quinn, Jr., M.D.
|Return to Grand Rounds Index|
Vertical buttresses: nasomaxillary, zygomaticomaxillary, and pterygomaxillary Horizontal buttresses: frontal bar, orbital rims, zygomatic processes of temporal bone, the maxillary alveolus and palate, and serrated edges of the greater wing of the sphenoid
The buttress system absorbs and transmits forces applied to the facial skeleton. Masticatory forces are transmitted to the skull base primarily through the vertical buttresses, which are joined and additionally supported by the horizontal buttresses. The skull base itself a major component of the horizontal support framework, although not classically thought of as part of the buttress system. When external forces are applied, these components prevent disruption of the facial skeleton until a critical level is reached and then fractures occur. In any rigid structure, fractures occur at areas of weakness, and/or where stress concentrations occur. The areas where facial fractures tend to occur are weaker both collectively and individually, so that they tend to act like a "crumple zone" for the cranium and skull base when excessive force is absorbed. The classic fracture patterns described by LeFort in 1901 coincide with these areas of the facial skeleton, with fractures occur through the the junctions of horizontal and vertical buttresses, at suture lines, and thinner segments of bone.
Most facial trauma results in complex forces applied to the skeleton, with fracture patterns rarely being simply a classic unilateral or bilateral LeFort pattern. Fractures can be isolated or occur in combinations that blur the division between classifications. Comminution, crush injuries to the anterior maxillary wall, and zygomaticomaxillary complex fractures are very common and do not classically fit the LeFort classification.
Epistaxis is frequently seen in traumatic facial injuries, and hypovolemic shock or airway compromise can result secondary to profuse bleeding. This requires rapid intervention, and the principles of management are not altered in these cases except that the possibility of a skull base fracture must be considered when instrumenting the nose. Embolization or surgical ligation of bleeding sources are performed if local epistaxis control measures fail to control bleeding.
After the ABC's, the history and physical exam are performed. The most important goals to achieve are the recognition and treatment of intracranial injury, or CSF leak, or ophthalmologic injury. Visual acuity is the most important ophthalmologic exam, and should be performed promptly. Traumatic optic neuropathy or open globe injuries are emergencies and delay in treatment compromises outcome. Monocular diplopia is an indicator of globe or retinal injury, and likewise requires immediate ophthalmologic consultation. In the absence of findings that generate an emergent consult, the remaining eye exam is carried out. Evaluation of EOM may be compromised by edema of the soft tissues, and forced duction testing is required if there is suspicion of entrapment. Some studies show that almost 4 out of 5 midface fractures are associated with some kind of eye injury. The percentage here is less in recent experience, but we adhere to the policy of mandatory ophthalmologic consultation prior to any surgical repair involving the orbit.
In the absence of obvious CSF rhinorrhea, the patient should asked about a salty taste or post nasal drip. Active epistaxis will usually make this assessment unreliable. If a CSF leak is detected or suspected, the most likely sources are the frontal sinus, cribiform plate, or fovea ethmoidalis fractures. If a CSF leak is suspected, a thin cut CT scan through the skull base is indicated.
After ophthalmologic screening, the face, ears, nose mouth, and mandible should be methodically examined. The result of any bilateral LeFort fracture is a mobile midface, or if the fracture line is impacted, significant pain with attempt to mobilize the midface with traction on the maxillary central incisors or central maxillary alveolus. Look for asymmetry, facial shortening, facial elongation (not likely in the acute setting), raccoon eyes (raises the suspicion of skull base fractures or LeFort II), hypoesthesias, rhinorrhea or otorrhea, traumatic blindness, hemotympanum, restricted EOM, septal hematoma, trismus, and malocclusion. Systematic palpation of the bony prominences should be performed, looking for severe point tenderness or step offs. Most maxillary fractures present with palatal edema and ecchymosis. Dentition should be evaluated and oral surgery consultation requested if a complicated dentoalveolar injury is found. Fractured alveolar segments place the involved teeth at risk for pulp necrosis, and the risk increases commensurate with the amount of time that the segment remains mobile. Digital exam of the oral cavity is mandatory and may reveal discontinuities in the alveolar arch, or tenderness at the maxillary tuberosities indicating as seen in Lefort I and zygomatic complex fractures.
The goal of treatment is to reestablish skeletal relationships while restoring and/or preserving function of vital structures. The most important concerns are the restoration of dental occlusion, ocular position, ocular mobility, and orbital volume. Aesthetics are important but secondary to the foregoing. The basic principle is to reconstruct from two areas of reference: the cranium and the dental occlusion. The face hangs from the skull base and this in turn is rigidly fixed to the cranium. Rebuilding "from the top down" and from the sides in allows proper facial dimensions and orientation to be reconstructed. If open treatment is indicated, adequate exposure is paramount with reduction and fixation of fractured elements to stable reference points. Inferiorly, the dental occlusion must be restored prior to fracture repair to preserve function of the masticatory system. Therefore, MMF/IMF, whether performed and removed intraoperatively or left in place postoperatively, is often the first step in repair of facial fractures. Anytime the palate/alveolar buttress system is not stable relative to the skull base, MMF/IMF should be the first step unless contraindicated for some other reason. However, it should never be used to "pull" the patient into occlusion.
The timing of treatment of facial fractures is the subject of some controversy. Although some advocate immediate repair in the stable patient, no significant deleterious effects appear to result from a delay of 7 to 14 days, which may allow edema to diminish and provide easier manipulation of bones and soft tissue. Waiting longer than this is not preferred because fibrosis and healing begin to occur, making late repair more difficult. Soft tissue envelope contraction is cited as the major cause of difficulty and poor outcome in late correction of post traumatic defects. Circumstances that may mandate delayed repair are when the patient is not stable or has an increased ICP. Derdyn, et. al., performed a retrospective study evaluating the outcome of treatment of patients who sustained combined neurologic injury and facial fractures and found that patients with an ICP of greater than 15 mmHg tended to do worse with early fracture repair. They also found that upper and midface injured patients had worse outcomes than lower level facial injuries.
Early fracture repair (<3 days) in patients with an ICP of less than 15 was not associated with a significant increase in morbidity or mortality. The presence of a CSF leak is not an absolute contraindication to early repair of fractures, but Derdyn et. al. noted that if ICP is borderline preoperatively, the repair of fractures and concomitant treatment of the leak may result in an increased ICP postoperatively. Their recommendations included intraoperative ICP monitoring of patients with significant neurologic injury undergoing facial fracture repair. Other relative contraindications to early repair are GCS of 5 or less, evidence of intracranial hemorrhage, midline intracranial shift, and basal cistern effacement on CT, all of which are associated with poor prognosis.
Gruss has written extensively about zygomatic fractures and is an advocate of open reduction and fixation for the most part, but states that "...if the surgeon assesses that there is minimal displacement at all five sites of fracture with no comminution, then it is highly likely that the periosteal hinge is still present at the majority of fracture sites, and a simple elevation of the fracture by means of a Gillies or intraoral approach can be attempted." The lack of a consensus on this topic is reflected in the variability of subjective surgical judgement, generating reports of the frequency of "stable" zygomatic fracture reduction ranging from 16% to 92%. (I have been trying to teach this to my residents for years. /ed.)
The use of mini and micro plating systems have become the norm in treatment of facial fractures. The surgeon should be able to use these systems and apply them appropriately. Taicher and Ardekian found a reduced incidence of neurologic injury when miniplate fixation was used to repair zygomatic complex fractures versus other methods. This was reinforced by Rohrich and Watumulla in a retrospective review of patients with zygomatic complex fractures treated by various methods of fixation at a large urban trauma center. They found that patients treated with rigid fixation systems suffered less late post-operative deformity and neurologic deficits than those treated with wire fixation or simple reduction. In their study, half of the zygomatic complex fractures treated with reduction only had postoperative malar flattening. The authors suspect that this could have been secondary to poor patient selection and acknowledge that two previous studies reported good long term results with closed reduction of zygomatic fractures that were stable to palpation after reduction. Nevertheless, this clinical study bears out the predictions of anatomic studies by Davidson, Rhinehart, and O'Hara, all demonstrating the superiority of plating systems to alternative methods of fixation when there is significant dynamic load that may act to distract or mobilize the fracture, such as in zygomatic fractures.
Interestingly, Davidson's study reported that three point interosseous wiring resulted in a stable configuration, but the maximum force applied to the reduced fracture was 5.5 kg, whereas a normal zygoma can be subjected to forces as high as 120 kg in dentulous patients and 50 kg in edentulous patients. Del Santo et al showed that patients with zygoma fractures don't generate normal levels of masseteric force, but still significantly higher than the 5.5 kg used by Davidson. Rhinehart basically repeated Davidson's study using loads of up 45 kg and found that three point wire fixation did not prevent rotation, but two point rigid fixation did. O'Hara et al repeated the experiment with a twist: they used forces similar to those thought to be possible in patients with zygoma fractures (2 to 22 kg) but employed microplates in their combinations of fixation devices. O'Hara found that the combination of a miniplate at the ZM buttress and a microplate at the FZ suture line yielded acceptable stability, and that the addition of a microplate to the inferior orbital rim added little. Combinations of miniplates and microplates proved to be more stable than corresponding miniplate-wire combinations.
The use of rigid fixation techniques have been associated with a higher incidence of infections and complications in some applications. Separate studies by Leach and El-Degwi demonstrate a higher rate of postoperative infection with the use of rigid mandibular fixation. However, reviews of rigid fixation in the repair of midface fractures (Macias et. al.) do not reveal the same problems with infection or other postoperative complication. The incidence of postoperative infection is believed to be about 5-10% with ORIF of midface fractures. The most common complication of rigid fixation techniques in midface fracture repair has been pointed out by Gruss, who states that there appears to be an "epidemic" of patients showing up in craniofacial surgeons offices with problems related to improperly reduced fractures that were fixed in position with rigid plating systems by other surgeons. The rigid plating systems may in fact magnify this type of problem whereas less rigid fixation may be more forgiving. These problems aside, there is near universal acceptance that rigid plating of midfacial fractures is effective and safe when properly performed.
Miniplate systems provide a significant amount of rigidity and strength and are applicable in just about any area of the facial skeleton. Relative contraindications to their use are in cases where the plate will be obtrusive or cosmetically obvious. Cosmetic concerns should not compromise a repair because the plates can be removed after healing has occurred if they are aesthetically problematic. Microplates have been specifically to be used where there is a need to establish a spatial relationship but rigidity is a secondary concern. They may offer a solution in areas where the thicker miniplates will be noticeable, but their use as the sole fixation device when one or both of the reduced/fixed bones is subject to the stress of muscular attachment has not generally been acceptable. To overcome this problem, some surgeons have reported good results by using multiple (usually two) microplates side by side across a fracture line. Long term follow up is not available, but initial results with multipoint microfixation were reported to be good.
An area of ongoing research is in the use of biodegradable plate systems. Several investigators have achieved excellent results when utilizing polyactic-polyglycolic acid copolymer plates and screws in animal models. Bony union equivalent to that produced with the use of titanium systems of similar thickness was obtained. The plates and screws completely resorbed within one year and produced no inflammatory reaction. These systems are apparently being used on a limited basis in Europe now and there have been a few complications including sterile fistulization over the sites of screws, so the use of these devices is not widespread. Impregnation of the materials with antibiotics and growth factors has been proposed but not tried yet. Continued development of these devices is certain, especially because of the potential reduction in the effects on bone growth in pediatric patients (see below).
Because of the growth of popularity of rigid fixation systems, wire fixation is not as popular as it once was, but still is a useful method of fracture fixation. As mentioned above, some studies have shown that even three point wire fixation may not adequately stabilize some fractures, but biomechanical testing is not equivalent to in vivo situations and historical evidence would suggests otherwise. Advocates of interosseous wiring point to the apparent correlation of the advent of rigid plating and an increase in the number of patients seeking secondary correction of facial and orbital defects after primary rigid fixation.
Alternatively, interosseous wiring can be used without postoperative MMF, but a soft diet is indicated for several weeks. Rigid plating allows early function, but reduction and plate conformation must be perfect. Intraoperative MMF with the mandible passively positioned is paramount. Comminuted fractures that are not amenable to plate or wire fixation are treated with MMF and suspension. The arch bar of the maxilla is suspended from the pyriform, zygomatic arch, the orbital rims, or extraskeletally to a halo in patients who have extensive facial comminution. Palatal fractures are not infrequently associated with LeFort I fractures, and are treated directly with interosseous wire, plating, or with a palatal splint affixed to intact dentition. Edentulous patients are treated the same way except that if interosseous fixation is not possible, either a custom acrylic occlusal splint or the patients own denture is used to define the occlusion, which is less critical in these patients. If rigid fixation is performed, the MMF can removed at the end of the case. If this is done occlusion should be rechecked with the jaw passively manipulated. Malocclusion at this stage must be corrected.
Repair begins with MMF/IMF to establish occlusion. Disimpaction may be necessary using the Rowe forceps. Once occlusion is established, the patient can be treated with suspension from the maxillary arch bar to the zygomatic arches, lateral orbital rims or superior orbital rims with 24 gauge wire. Open treatment can be carried out by exposing, reducing, and wiring or plating the inferior orbital rim fracture. Medial canthal incisions can be created for access to the medial canthal tendon and/or reduction fixation of the nasofrontal area performed with wires or plates. Labiobuccal or inferior rim incisions can provide exposure of the ZM suture for fixation with wires or plates. If rigid fixation is performed, the MMF/IMF can removed at the end of the case. If this is done occlusion should be rechecked with the jaw passively manipulated. Malocclusion at this stage must be corrected.
The principle of repair is the same as for other LeForts, and multiple approaches are necessary. The bicoronal flap combined with the midfacial degloving allow maximal exposure, but multiple discontinuous approaches, such as the labiobuccal, lateral brow, inferior rim, and the open sky are frequently used, thus maintaining attachement of the soft tissues to the stable skeleton maximally.
Surgery for diplopia without clear evidence of entrapment is a little controversial because a large series of patients has demonstrated that the vast majority (>95%) of patients will have no symptoms in six months. Residual enophthalmos of less than 2 mm can be observed. The repair is via a transconjunctival, subciliary, inferior fornix, or lower lid approach. The floor can be repaired with bone grafts (calvarial bone is ideal), fascia (for small defects), or allograft materials. Titanium mesh is an excellent choice for floor reconstruction. Gelfilm has been used successfully in cases of small defects. Silastic sheeting should probably be avoided as it has an increased incidence of late complications requiring removal (Morrison, et. al.) . Intraoperative forced duction testing is mandatory to ensure that no residual entrapment remains. The orbit naturally has a concavity just posterior to the inferior and superior rims, and when repairing a floor fracture, recreation of this profile is desirable. This can be accomplished by maintaining the anterior edge of any graft posterior and inferior to the orbital rim. This also minimizes the possibility of graft migration. The use of titanium mesh fixed to the orbital rim negates the concern of migration.
Biomechanical analysis have been performed to evaluate the most efficacious way of repairing these fractures. As noted above, Davidson, Rhinehart, and O'Hara have probably done the most logical studies, but controversy still exists. Despite their studies demonstrating the superiority of rigid fixation involving at least two sites, the prevailing method utilized in a survey of over 200 surgeons in Great Britain was the Gillies incision with FZ rigid fixation only. While some have apparently achieved good results with these methods, the evidence suggests that this may not consistently work. The FZ suture line is the least useful site to detect the degree of rotation of the fracture because many rotated and displaced fractures will not appear significantly displaced at the FZ. Additionally the stability of a single plate at the FZ is questionable under dynamic loads. The importance of proper repair can be seen in patients who have undergone insufficient reduction and/or fixation of the zygomatic complex fracture. They typically have flattening of the malar eminence, facial widening on the affected side, and frequently have unequal pupillary height with enophthalmos secondary to inadequately treated orbital wall fractures causing increased orbital volume.
If open reduction/fixation is to be done, good visualization is necessary to ensure adequate anatomic reduction of displaced fractures. Multiple approaches are usually necessary, most often incorporating labiobuccal, transconjunctival (or subciliary), lateral brow incisions and or Gillies incisions. Coronal and hemicoronal approaches can be used, especially if fixation of the zygomatic arch is planned. This is a slightly controversial point as some authors insist that reduction and fixation of the arch is the key to obtaining a good result in cases where there is a displaced arch fracture. Gruss has written extensively about these injuries and is a major proponent of this technique. He stresses the need for exploration and reduction/fixation based on late post operative assymmetries after craniofacial procedures wherein other areas of rigid fixation were relied on to maintain midfacial projection, and the arch was reduced but not fixed. This seems to contradict results of some biomechanical studies (see below).
Children have a low incidence of midfacial fractures; probably due to the relatively larger cranial size, and the lack of complete maxillary sinus pneumatization.
Intracranial injuries, CSF leaks, and ocular injuries must be suspected and ruled out in patients with facial injuries.
Increased intracranial pressure (>15 mmHg) is a relative contraindication to proceeding with repair of facial fractures in patients with concomitant head injuries.
There is little difference in the outcome of stable patients whose fractures are treated very early versus those treated in a more delayed fashion.
Rigid and semirigid plating systems perform well with few complications when used to repair midfacial fractures provided proper reduction is obtained.
The dental occlusion must be used as the lower frame of reference when treating fractures that result in instability of the maxillary alveolus relative to the skull base.
Interdental wiring should never be used to "pull" the patient into occlusion during the repair of fractures.
The most common complication after rigid repair of facial fractures appears to be malunion secondary to inadequate reduction.
Bone grafting should be considered in the repair of comminuted fractures that result in gaps of > 5 mm between segments.
Membranous bone is generally a better substrate for bone grafting in the face.
Bains RA, Rubin PA; Blunt orbital trauma. Int Ophthalmol Clin 1995 Winter;35(1):37-46
Busch RF; Mandibular osteosynthesis with intraoral miniplates and cortical bone screws. Ear Nose Throat J 1995 Dec;74(12):814-5, 819-20
Davidson J, Nickerson D, Nickerson B; Zygomatic fractures: Comparison of methods of internal fixation. Plast Reconstr Surg 1990 July; 86:25-32
Derdyn C, Persing JA, Broaddus WC, Delashaw JB, Jane J, Levine PA, Torner J; Craniofacial trauma: An assessment of risk related to timing of surgery. Plast Reconstr Surg 1990 Aug;86(2):238-45
Ellis E; Fractures of the Zygomatic Complex and Arch. In Fonseca RJ, Walker RV, eds: Oral and Maxillofacial Trauma , Chapter 18, pp 435-500. Philadelphia, W.B. Saunders Co., 1991
Eppley BL, Sandove AM; A comparison of resorbable and metallic fixation in healing of calvarial bone grafts. Plast Reconstr Surg 1995 Sep;96(2):316-22
Evans GR, Clark N, Manson PN, Leipziger LS; Role of mini- and microplate fixation in fractures of the midface and mandible. Ann Plast Surg 1995 May;34(5):453-6
Evans GR, Clark N, Manson PN; Identification and management of minimally displaced nasoethmoidal orbital fractures. Ann Plast Surg 1995 Nov;35(5):469-73
Freihofer HP; Effectiveness of secondary post-traumatic periorbital reconstruction. J Craniomaxillofac Surg 1995 Jun;23(3):143-50
Friedman CD, Costantino PD; General concepts in craniofacial skeletal augmentation and replacement. Otolaryngol Clin North Am 1994 Oct;27(5):847-57
Frodel JL, Marentette LJ; The coronal approach: Anatomic and technical considerations and morbidity. Arch Otolaryngol Head Neck Surg 1993 Feb; 119: (2): 201-7
Frodel JL, Marentette LJ; Lag screw fixation in the upper craniomaxillofacial skeleton. Arch Otolaryngol Head Neck Surg 1993 Mar; 119: (3): 297-304
Gordon KF, Reed JM, Anand VK; Results of intraoral cortical bone screw fixation technique for mandibular fractures. Otolaryngol Head Neck Surg 1995 Sep;113(3):248-52
Gruss JS, Van Wyck L, Phillips JH, Antonyshyn O; The importance of the zygomatic arch in complex midfacial fracture repair and correction of posttraumatic orbitozygomatic deformities. Plast Reconstr Surg 1990 Jun;85(6):878-89
Gussack GS, Luterman A, Rodgers K, Powell RW, Ramenofsky ML; Pediatric maxillofacial trauma: Unique features in diagnosisi and treatment. Laryngoscope 1987 Aug; 97: 925-30
Hammer B, Prein J; Correction of post-traumatic orbital deformities: operative techniques and review of 26 patients. J Craniomaxillofac Surg 1995 Apr;23(2):81-90
Hill CM; A modified miniplate for use in malar complex fractures [letter]. Br J Oral Maxillofac Surg 1995 Oct;33(5):334
Isaacs RS, Sykes JM; Maxillomandibular fixation with intraoral cortical bone screws [letter; comment]. Laryngoscope 1995 Jan;105(1):109
Larkin EB, Dutton GN, Heron G; Imparied perception of moving objects after monor injuries to the eye and midface: The Pulfrich phenomenon. Br J Oral Maxillofac Surg 1994 ;32:71- 5
Leach J, Truelson J; Traditional methods vs rigid internal fixation of mandible fractures. Arch Otolaryngol Head Neck Surg 1995 Jul;121(7):750-3
Leone CR; Periorbital trauma. Int Ophthalmol Clin 1995 Winter;35(1): 1-24
Lew D, Sinn DP; Diagnosis and Treatment of Midface Fractures. In Fonseca RJ, Walker RV, eds: Oral and Maxillofacial Trauma , Chapter 19, pp 515-542. Philadelphia, W.B. Saunders Co., 1991
Lindqvist C; Future of biodegradable osteosynthesis in maxillofacial fracture surgery [editorial]. Br J Oral Maxillofac Surg 1995 Apr;33(2):69-70
Macias JD, Haller J, Frodel JL; Comparative postoperative infection rates in midfacial trauma using intermaxillary fixation, wire fixation, and rigid internal fixation implants. Arch Otolaryngol Head Neck Surg 1993 Mar; 119: (3): 308-9
McLoughlin P, Gilhooly M, Wood G; The management of zygomatic complex fractures-- results of a survey. Br J Oral Maxillofac Surg 1994 Oct;32(5):284-8
Mitchell DA, MacLeod SP, Bainton R; Multipoint fixation at the frontozygomatic suture with microplates: a technical note. Int J Oral Maxillofac Surg 1995 Apr;24(2):151-2
Morrison AD, Sanderson RC, Moos KF; The use of silastic as an orbital implant for reconstruction of orbital wall defects: review of 311 cases treated over 20 years. J Oral Maxillofac Surg 1995 Apr;53(4):412-7
Nolasco FP, Mathog RH; Medial orbital wall fractures: classification and clinical profile. Otolaryngol Head Neck Surg 1995 Apr;112(4):549-56
O'Hara DE, DelVecchio DA, Bartlett SP, Whitaker LA; The role of microfixation in malar fractures: a quantitative biophysical study. Plast Reconstr Surg 1996 Feb;97(2):345-50; discussion Gruss JS; 351-3
Oikarinen KS; Clinical management of injuries to the maxilla, mandible, and alveolus. Dent Clin North Am 1995 Jan;39(1):113-31 Periorbital trauma. Int Ophthalmol Clin 1995 Winter;35(1):1-24
Randall DA, Bernstein PE; Epistaxis balloon catheter stabilization of zygomatic arch fractures. Ann Otol Rhinol Laryngol 1996 Jan;105(1):68-9
Reher P, Duarte GC; Miniplates in the frontozygomatic region. An anatomic study. Int J Oral Maxillofac Surg 1994 Oct;23(5):273-5
Rhinehart GC, Marsh JL, Hemmer KM, Bresima S; Internal fixation of malar fracturs: An experimental biophysical study. Plast Reconstr Surg 1989 Jul;84(1):21-5
Rohrich RJ, Watumull D; Comparison of rigid plate versus wire fixation in the management of zygoma fractures: a long-term follow-up clinical study. Plast Reconstr Surg 1995 Sep;96(3):570-5
Sadove AM, Eppley BL; Microfixation techniques in pediatric craniomaxillofacial surgery. Ann Plast Surg 1991 Jan;27(1):36-43
Slade CS; Bone grafts in orbital reconstruction. Int Ophthalmol Clin 1995 Winter;35(1):47- 56
Smyth AG; A modified miniplate for use in malar complex fractures. Br J Oral Maxillofac Surg 1995 Jun;33(3):169-70
Stanley RB; Maxillary and Periorbital Fractures. In Bailey BJ et al. eds: Head and Neck surgery - Otolaryngology ; Chapter 77, pp 973-989. Philadelphia, J. B. Lippincott Co. 1992
Szachowicz EH; Facial bone wound healing. An overview. Otolaryngol Clin North Am 1995 Oct;28(5):865-80
Torgersen S, Gjerdet NR, Erichsen ES, Bang G; Metal particles and tissue changes adjacent to miniplates. A retrieval study. Acta Odontol Scand 1995 Apr;53(2):65-71
Uglesic V, Virag M; A method of zygomatic arch stabilization. Br J Oral Maxillofac Surg 1994 Dec;32(6):396-7
Valentino J, Marentette LJ; Supplemental maxillomandibular fixation with miniplate osteosynthesis. Otolaryngol Head Neck Surg 1995 Feb;112(2):215-20
Westermark A, Jensen J, Sindet-Pedersen S; Zygomatic fractures and infraorbital nerve disturbances. Miniplate osteosynthesis vs. other treatment modalities. Oral Surg Oral Diagn 1992;3:27-30