Craniomaxillofacial Reconstructive and Corrective Bone Surgery: Principles of Internal Fixation Using the AO/ASIF Technique docx

Craniomaxillofacial
Reconstructive and
Corrective Bone Surgery
:
Principles of Internal
Fixation Using
the AO/ASIF Technique
Alex M. Greenberg, DDS
Joachim Prein, MD, DDS,
Editors
Springer
Craniomaxillofacial Reconstructive
and Corrective Bone Surgery
Alex M. Greenberg, DDS
Assistant Clinical Professor, Division of Oral and Maxillofacial Surgery, Columbia University
School of Dental and Oral Surgery; Clinical Instructor, Division of Oral and Maxillofacial
Surgery, Mount Sinai School of Medicine; and Assistant Attending, Division of Oral and
Maxillofacial Surgery, Beth Israel Medical Center, and Associate Attending, Division of Oral
and Maxillofacial Surgery, St. Luke’s/Roosevelt Hospital, New York, New York, USA
Joachim Prein, MD, DDS
Professor of Maxillofacial Surgery; and Head, Clinic for Reconstructive Surgery, Kantonsspital
Basel, Basel, Switzerland
Editors
Craniomaxillofacial
Reconstructive and
Corrective Bone Surgery
Principles of Internal Fixation Using
the AO/ASIF Technique
With 863 Illustrations, 87 in Color
Alex M. Greenberg, DDS Joachim Prein, MD, DDS

Assistant Clinical Professor Professor of Maxillofacial Surgery
Division of Oral and Maxillofacial Surgery and
Columbia University School of Dental Head, Clinic for Reconstructive Surgery
and Oral Surgery Kantonsspital Basel
and CH-4031 Basel, Switzerland
Clinical Instructor
Division of Oral and Maxillofacial Surgery
Mount Sinai School of Medicine
and
Assistant Attending
Division of Oral and Maxillofacial Surgery
Beth Israel Medical Center
and
Associate Attending
Division of Oral and Maxillofacial Surgery
St. Luke’s/Roosevelt Hospital
New York, NY, USA
Library of Congress Cataloging-in-Publication Data
Craniomaxillofacial reconstructive and corrective bone surgery : principles of internal
fixation using the AO/ASIF technique / edited by Alex M. Greenberg, Joachim Prein.
p. cm.
Includes bibliographical references and index.
ISBN 0-387-94686-1 (hardcover : alk. paper)
1. Facial bones—Surgery. 2. Jaw—Surgery. 3. Skull—Surgery. 4. Internal fixation in
fractures. I. Greenberg, Alex M. II. Prein, J. (Joachim), 1938–
[DNLM: 1. Facial Bones—surgery. 2. Bone Diseases—surgery. 3. Surgery,
Plastic—methods. 4. Internal Fixators. 5. Bone Plates. 6. Skull—surgery. WE 705 C8909 1997]
RD523 .C73 1997
617.5Ј2059—dc20 96-035162
Printed on acid-free paper.

© 2002 Springer-Verlag New York, Inc.
All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the
publisher (Springer-Verlag New York, Inc., 175 Fifth Avenue, New York, NY 10010, USA), except for brief excerpts in
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tronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is for-
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The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as
such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights.
While the advice and information in this book are believed to be true and accurate at the date of going to press, neither
the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be
made. The publisher makes no warranty, express or implied, with respect to the material contained herein.
Production coordinated by Chernow Editorial Services, Inc., and managed by Terry Kornak; manufacturing supervised by
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Typeset by Matrix Publishing Services, York, PA.
Printed and bound by Walsworth Publishing Co., Marceline, MO.
Printed in the United States of America.
987654321
ISBN 0-387-94686-1 SPIN 10524755
Springer-Verlag New York Berlin Heidelberg
A member of BertelsmannSpringer ScienceϩBusiness Media GmbH
To my wife, Sigal Greenberg,
and
my daughter, Aurie Greenberg,
for their special love, support, and inspiration
To my father, Rubin Greenberg,
for his love and devotion to his family
In loving memory of my mother, Nancy Greenberg
AMG
This book represents my tribute and thanks to so many surgical
colleagues worldwide for their help, collaboration, fellowship, and

lifelong friendship over my professional career.
JP
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These are exciting times for the diverse group of surgeons who perform craniomaxillofacial surgery.
The AO/ASIF (Swiss Association of Internal Fixation) has played a crucial role in the growth of
this field through its leadership in research, teaching, and cooperation with industry. As clinicians
fascinated by the extraordinary progress in the field, the goal is to advance this new knowledge
by teaching AO/ASIF courses and writing textbooks that supplement these courses and related
workshops.
This textbook adopts the case presentation format used in Craniomaxillofacial Fractures: Prin-
ciples of Internal Fixation Using the AO/ASIF Technique. The breadth of the subject meant that
a coeditor was advisable and, fortunately, Joachim Prein accepted that role. To make this a com-
prehensive textbook, 75 international authorities wrote chapters in the areas of oral and max-
illofacial surgery, plastic and reconstructive surgery, and otolaryngology and head and neck
surgery.
This textbook presents progress in craniomaxillofacial surgery through the technical and scien-
tific advances in biomaterials, microvascular surgery, dental implantology, and surgical techniques.
Section I covers basic considerations in the diagnosis of craniomaxillofacial defects and disorders.
Section II comprises chapters on the biomechanics and biocompatability of internal fixation and
dental osseointegration implantology. These developments have helped to revolutionize cran-
iomaxillofacial bone surgery by providing the structural support that also meets the functional needs
of the patient. Section III is the first of three sections on specific considerations in craniomaxillo-
facial reconstructive and bone surgery. This first section includes the AO/ASIF mandibular hard-
ware system and basic aesthetic considerations. Section IV provides a regional approach to each
section of the midface and mandible that may require reconstruction because of defects resulting
from trauma, infections, and tumors. Section V reviews elective osteotomies of the skull and fa-
cial bones, including the maxilla, mandible, upper midface, and skull. The two appendices present
updated material on the ITI dental implant system and distraction osteogenesis of the mandible.
Chapters 22 and 41, in particular, also present up-to-date information on the AO/ASIF hardware
systems of instrumentation and implants separate and distinct from the other chapters to allow eas-

ier understanding of these biomaterials.
The editors hope that this textbook will be an indispensable reference for medical students, resi-
dents in training, and attending surgeons in the diverse fields of craniomaxillofacial surgery. Surgery
cannot develop without honoring the achievements of the past and the assimilation of current knowl-
edge; this textbook is intended to assist in this process.
Alex M. Greenberg, DDS
New York, New York, USA
Joachim Prein, MD, DDS
Basel, Switzerland
January 2002
vii
Preface
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Acknowledgments
The editors would like to acknowledge the many individuals who have contributed to this book.
First are the many chapter authors from Europe, Asia, North America, and South America who
represent all aspects of the discipline. They are a truly outstanding group of surgeons, who have
contributed greatly to the progress evident in this book. Many have been AO/ASIF (Swiss Asso-
ciation for Internal Fixation) faculty members and have been active in teaching courses all over
the world.
We also thank Synthes Maxillofacial, Paoli, Pennsylvania; the Institut Strauman, Waldenburg,
Switzerland; and Professor Tomas Albrektsson, Department of Biomaterials/Handicap Research,
Gothenburg University, Gothenburg, Sweden, for providing financial support to reproduce the many
color figures in this textbook.
We are also appreciative of the assistance of Fr. Inge Jundt, Secretary, Clinic for Reconstrucitve
Surgery, at Kantonsspital Basel, Basel, Switzerland, for her role in the preparation of the manu-
script; Synthes Maxillofacial, Paoli, Pennsylvania; and STRATEC, Oberdorf, Switzerland, for ad-
vice concerning technical aspects of AO/ASIF hardware and instrumentation, and Ms. Laurel
Lhowe for her outstanding illustrations.
Alex M. Greenberg, DDS

New York, New York, USA
Joachim Prein, MD, DDS
Basel, Switzerland
ix
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Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Alex M. Greenberg and Joachim Prein
Section I Basic Considerations in the Diagnosis of Craniomaxillofacial Bone
Defects and Disorders
2 Evaluation of the Craniomaxillofacial Deformity Patient . . . . . . . . . . . . . . . . . . . . . . 5
Jackson P. Morgan, III and Richard H. Haug
3 Craniofacial Deformities: Review of Etiologies, Distribution,
and Their Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Craig R. Dufresne
4 Etiology of Skeletal Malocclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Bruce L. Greenberg
5 Etiology, Distribution, and Classification of Craniomaxillofacial
Deformities: Traumatic Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Richard H. Haug and Jackson P. Morgan, III
6 Etiology, Distribution, and Classification of Craniomaxillofacial
Deformities: Review of Nasal Deformities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
John G. Hunter
7 Review of Benign Tumors of the Maxillofacial Region and Considerations
for Bone Invasion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Joachim Prein
8 Oral Malignancies: Etiology, Distribution, and Basic Treatment Considerations . . . . 65
Anna-Lisa Söderholm

9 Craniomaxillofacial Bone Infections: Etiologies, Distributions,
and Associated Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Darin L. Wright and Robert M. Kellman
xi
Contents
10 A New Classification System for Craniomaxillofacial Deformities . . . . . . . . . . . . . . 90
Richard H. Haug and Alex M. Greenberg
Section II Biomechanics of Internal Fixation and Dental Osseointegration Implantology
11 Craniomaxillofacial Bone Healing, Biomechanics, and Rigid Internal Fixation . . . . 101
Frederick J. Kummer
12 Metal for Craniomaxillofacial Internal Fixation Implants
and Its Physiological Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Samuel G. Steinemann
13 Bioresorbable Materials for Bone Fixation: Review of
Biological Concepts and Mechanical Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Riitta Suuronen and Christian Lindqvist
14 Advanced Bone Healing Concepts in Craniomaxillofacial Reconstructive
and Corrective Bone Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Tomas Albrektsson, Lars Sennerby, and Anders Tjellström
15 The ITI Dental Implant System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Hans-Peter Weber, Daniel A. Buser, and Dieter Weingart
16 Localized Ridge Augmentation Using Guided Bone Regeneration in
Deficient Implant Sites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Daniel A. Buser, Dieter Weingart, and Hans-Peter Weber
17 The ITI Dental Implant System in Maxillofacial Applications . . . . . . . . . . . . . . . . 164
Dieter Weingart, Daniel A. Buser, and Hans-Peter Weber
18 Maxillary Sinus Grafting and Osseointegration Surgery . . . . . . . . . . . . . . . . . . . . . 174
Jeffrey I. Stein and Alex M. Greenberg
19 Computerized Tomography and Its Use for Craniomaxillofacial
Dental Implantology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198

Morton Jacobs
20A Radiographic Evaluation of the Craniomaxillofacial Region . . . . . . . . . . . . . . . . . . 210
Dorrit Hallikainen, Christian Lindqvist, and Anna-Lisa Söderholm
20B Atlas of Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
Christian Lindqvist, Dorrit Hallikainen, and Anna-Lisa Söderholm
21A Prosthodontic Considerations in Dental Implant Restoration . . . . . . . . . . . . . . . . . 232
James H. Abjanich and Ira H. Orenstein
21B Overdenture Case Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
Alex M. Greenberg
Section III Craniomaxillofacial Reconstructive and Corrective Bone Surgery
22 AO/ASIF Mandibular Hardware . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
Joachim Prein and Alex M. Greenberg
xii Contents
23 Aesthetic Considerations in Reconstructive and
Corrective Craniomaxillofacial Bone Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
R. Gregory Smith and Luc M. Cesteleyn
Section IV Craniomaxillofacial Reconstructive Bone Surgery
24 Considerations for Reconstruction of the Head and Neck Oncologic Patient . . . . . . 289
Douglas W. Klotch and Neal D. Futran
25 Autogenous Bone Grafts in Maxillofacial Reconstruction . . . . . . . . . . . . . . . . . . . 295
Michael Ehrenfeld and Christine Hagenmaier
26 Current Practice and Future Trends in Craniomaxillofacial Reconstructive
and Corrective Microvascular Bone Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
Hubert Weinberg, Lester Silver, and Jin K. Chun
27 Considerations in the Fixation of Bone Grafts for the Reconstruction
of Mandibular Continuity Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
Peter Stoll, Joachim Prein, Wolfgang Bähr, and Rüdiger Wächter
28 Indications and Technical Considerations of Different Fibula Grafts . . . . . . . . . . . . 327
Peter Stoll
29 Soft Tissue Flaps for Coverage of Craniomaxillofacial Osseous Continuity

Defects with or Without Bone Graft and Rigid Fixation . . . . . . . . . . . . . . . . . . . . 335
Barry L. Wenig
30 Mandibular Condyle Reconstruction with Free Costochondral Grafting . . . . . . . . . . 343
Christian Lindqvist
31 Microsurgical Reconstruction of Large Defects of the Maxilla, Midface,
and Cranial Base . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356
Rainer Schmelzeisen
32 Condylar Prosthesis for the Replacement of the Mandibular Condyle . . . . . . . . . . . 372
Joachim Prein
33 Problems Related to Mandibular Condylar Prosthesis . . . . . . . . . . . . . . . . . . . . . . 377
Christian Lindqvist, Anna-Lisa Söderholm, and Dorrit Hallikainen
34 Reconstruction of Defects of the Mandibular Angle . . . . . . . . . . . . . . . . . . . . . . . 389
Mark A. Schusterman and Elisabeth K. Beahm
35 Mandibular Body Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395
Anna-Lisa Söderholm, Dorrit Hallikainen, and Christian Lindqvist
36 Marginal Mandibulectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411
Sanford Dubner and Keith S. Heller
37 Reconstruction of Extensive Anterior Defects of the Mandible . . . . . . . . . . . . . . . . 414
Joachim Prein and Beat Hammer
38 Radiation Therapy and Considerations for Internal Fixation Devices . . . . . . . . . . . 419
Peter Stoll and Rüdiger Wächter
Contents xiii
39 Management of Posttraumatic Osteomyelitis of the Mandible . . . . . . . . . . . . . . . . 433
Robert M. Kellman and Darin L. Wright
40 Bilateral Maxillary Defects: THORP Plate Reconstruction with
Removable Prosthesis. Technique/Atlas Case Reports . . . . . . . . . . . . . . . . . . . . . . 439
Christian Lindqvist, Lars Sjövall, Anna-Lisa Söderholm, and Dorrit Hallikainen
41 AO/ASIF Craniofacial Fixation System Hardware . . . . . . . . . . . . . . . . . . . . . . . . . 445
Alex M. Greenberg and Joachim Prein
42 Microvascular Reconstruction of the Condyle and the Ascending Ramus . . . . . . . . 462

Rainer Schmelzeisen and Friedrich Wilhelm Neukam
43 Orbital Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 478
Beat Hammer
44 Nasal Reconstruction Using Bone Grafts and Rigid Internal Fixation . . . . . . . . . . . 483
Patrick K. Sullivan, Mika Varma, and Arlene A. Rozzelle
45 Transfacial Access Osteotomies to the Central and
Anterolateral Skull Base . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489
Robert B. Stanley, Jr.
Section V Craniomaxillofacial Corrective Bone Surgery
46 Orthognathic Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497
Peter Ward-Booth
47 Considerations in Planning for Bimaxillary Surgery and the Implications
of Rigid Internal Fixation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 522
Brian Alpert, George M. Kushner, and Gerald D. Verdi
48 Reconstruction of Cleft Lip and Palate Osseous Defects and Deformities . . . . . . . . 539
Klaus Honigmann and Adrian Sugar
49 Maxillary Osteotomies and Considerations for Rigid Internal Fixation . . . . . . . . . . 581
Alex M. Greenberg
50 Mandibular Osteotomies and Considerations for Rigid Internal Fixation . . . . . . . . . 606
Victor Escobar, Alex M. Greenberg, and Alan Schwimmer
51 Genioplasty Techniques and Considerations for Rigid Internal Fixation . . . . . . . . . 623
Frans H.M. Kroon
52 Long-Term Stability of Maxillary and Mandibular Osteotomies with
Rigid Internal Fixation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 639
Joseph E. Van Sickels, Paul Casmedes, and Thomas Weil
53 Le Fort II and Le Fort III Osteotomies for Midface Reconstruction and
Considerations for Internal Fixation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 660
Keith Jones
xiv Contents
Section VI Craniofacial Surgery

54 Craniofacial Deformities: Introduction and Principles of Management . . . . . . . . . . 671
G.E. Ghali, Wichit Tharanon, and Douglas P. Sinn
55 The Effects of Plate and Screw Fixation on the Growing Craniofacial Skeleton . . . . 693
Michael J. Yaremchuk
56 Calvarial Bone Graft Harvesting Techniques: Considerations for Their Use
with Rigid Fixation Techniques in the Craniomaxillofacial Region . . . . . . . . . . . . . 700
John L. Frodel, Jr.
57 Crouzon Syndrome: Basic Dysmorphology and Staging of Reconstruction . . . . . . . 713
Jeffrey C. Posnick
58 Hemifacial Microsomia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 727
John H. Phillips, Kevin Bush, and R. Bruce Ross
59 Orbital Hypertelorism: Surgical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . 738
Antonio Fuente del Campo
60 Surgical Correction of the Apert Craniofacial Deformities . . . . . . . . . . . . . . . . . . . 749
E. Clyde Smoot, III and William L. Hickerson
Appendix A1 Distraction Osteogenesis of the Mandible . . . . . . . . . . . . . . . . . . . . . . . . 757
Alex M. Greenberg and Joachim Prein
Appendix A2 ITI Strauman Dental Implant System . . . . . . . . . . . . . . . . . . . . . . . . . . . 765
Alex M. Greenberg
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 769
Contents xv
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James H. Abjanich, DDS
Assistant Clinical Professor, Division of Postgraduate Prosthodontics, Columbia University
School of Dental and Oral Surgery, New York, NY 10022, USA
Tomas Albrektsson, MD, PHD, ODhc
Professor and Head of Biomaterials/Handicap Research, Department of Surgical Sciences,
Gothenburg University, S-413 12 Gothenburg, Sweden
Brian Alpert, DDS
Professor and Chair, Department of Oral and Maxillofacial Surgery, School of Dentistry,

Louisville, KY 40292, USA
Wolfgang Bähr, MD, DDS, PhD
Oral and Maxillofacial Surgeon, Plastic Surgeon, Christoph-Mang-Strasse 18-20, 79100
Freiburg, Germany
Elisabeth K. Beahm, MD
Assistant Professor, Department of Plastic Surgery, MD Anderson Cancer Center, University
of Texas Medical Center, Houston, TX 77030-4095, USA
Daniel A. Buser, DMD
Professor, Department of Oral Surgery and Stomatology, School of Dental Medicine, University
of Bern, CH-3010 Bern, Switzerland
Kevin Bush, MD
Assistant Clinical Professor of Surgery, Division of Plastic Surgery, University of British
Columbia, Vancouver, British Columbia V67 2C7, Canada
Paul Casmedes, MD, DDS
Oral and Maxillofacial Surgery, Austin Surgical Arts, Austin, TX 78731, USA
Luc M. Cesteleyn, MD, DDS
Assistant Adjunct Clinical Professor, University of Michigan, Department of Maxillofacial
Surgery, University of Ghent, 9000 Ghent, Belgium
Jin K. Chun, MD
Clinical Associate Professor of Surgery, Division of Plastic Surgery, Mount Sinai Hospital,
New York, NY 10029, USA
Contributors
xvii
Sanford Dubner, MD
Assistant Clinical Professor of Plastic Surgery, Albert Einstein College of Medicine, Lake
Success, NY 11042, USA
Craig R. Dufresne, MD, FACS, FICS
Clinical Professor of Plastic Surgery, Georgetown University, Director, Center for Facial
Rehabilitation, Fairfax Hospital, Chevy Chase, MD 20815, USA
Michael Ehrenfeld, MD, DDS, PhD

Chair, Department of Oral and Maxillofacial Surgery, Ludwidg-Maximillians-University,
80337 Munich, Germany
Victor Escobar, DDS, PhD
Staff Oral and Maxillofacial Surgeon, Department of Oral and Maxillofacial Surgery,
Christie Clinic Association, Champaign, IL 61822, USA
John L. Frodel, Jr., MD, FACS
Associate Professor, Division of Otolaryngology and Plastic Surgery, University of New Mexico
Health Science Center, Albuquerque, NM 87131-5341, USA
Antonio Fuente del Campo, MD
Associate Professor of Plastic and Craniomaxillofacial Surgery, Universidad National
Autonoma de Mexico, Mexico City DF 53830, Mexico
Neal D. Futran, MD, DMD
Associate Professor, Department of Otolaryngology—Head and Neck Surgery, University of
Washington School of Medicine, Seattle, WA 98195, USA
G.E. Ghali, MD, DDS, FACS
Associate Professor of Surgery, Chief, Division of Oral and Maxillofacial Surgery/Head and
Neck Surgery, Department of Surgery, Louisiana State University Health Sciences Center,
Shreveport, LA 71130-6101, USA
Alex M. Greenberg, DDS
Assistant Clinical Professor, Division of Oral and Maxillofacial Surgery, Columbia University
School of Dental and Oral Surgery; Clinical Instructor, Division of Oral and Maxillofacial
Surgery, Mount Sinai School of Medicine; Assistant Attending, Division of Oral and
Maxillofacial Surgery, Beth Israel Medical Center; Associate Attending, Division of Oral and
Maxillofacial Surgery, St. Luke’s Roosevelt Hospital, New York, NY, USA
Bruce L. Greenberg, DDS
Orthodontist, 30 East 60 Street, New York, NY 10022, USA
Christine Hagenmaier, MD, DDS
Assistant Clinical Professor, Department of Oral and Maxillofacial Surgery,
Ludwig-Maximillians-University, 80337 Munich, Germany
Dorrit Hallikainen, MD, PhD, Docent

Turku University, Institute of Dentistry, Senior Radiologist (Retired), Department of Diagnostic
Radiology, Helsinki University Central Hospital, 00610 Helsinki, Finland
Beat Hammer, MD, DDS
Associate Professor of Maxillofacial Surgery, Clinic for Plastic and Reconstructive Surgery,
Kantonsspital Basel, CH-4031 Basel, Switzerland
xviii Contributors
Richard H. Haug, DDS
Professor and Division Chief, Division of Oral and Maxillofacial Surgery, Head, Department of
Hospital Dentistry, Assistant Dean for Hospital Affairs, University of Kentucky College of
Dentistry, Lexington, KY 40536-0297, USA
Keith S. Heller, MD
Chief, Head and Neck Surgery, Long Island Jewish Medical Center, Clinical Professor of
Surgery, Albert Einstein College of Medicine, Lake Success, NY 11042, USA
William L. Hickerson, MD, FACS
Associate Director, Plastic and Reconstructive Surgery, Joseph M. Still Burn Center, Augusta,
GA 30909, USA
Klaus Honigmann, MD, DDS
Associate Professor of Maxillofacial Surgery, University Clinic for Plastic and Reconstructive
Surgery, Kantonsspital Basel, CH-4031 Basel, Switzerland
John G. Hunter, MD, FACS
Chief, Division of Plastic Surgery, New York Methodist Hospital; Assistant Attending, New
York Presbyterian Hospital; Clinical Assistant Professor of Surgery, Weill Medical College of
Cornell University, New York, NY 10021, USA
Morton Jacobs, MD
Chairman of Radiology, Manhattan Eye, Ear, and Throat Hospital, Manhattan Diagnostic
Radiology, New York, NY 10022, USA
Keith Jones, FDSRCS (Eng.)
Consultant Oral and Maxillofacial Surgeon, Maxillofacial Unit, Derbyshire Royal Infirmary
NHS Trust, Derby DE1 2GY, UK
Robert M. Kellman, MD

Professor and Chairman, Department of Otolaryngology, State University of New York Health
Science Center, Syracuse, NY 13210, USA
Douglas W. Klotch, MD, FACS
Clinical Professor of Surgery, Department of Otolaryngology—Head and Neck Surgery,
University of South Florida College of Medicine, Tampa, FL 33613, USA
Frans H.M. Kroon, DMD, PhD
Department of Oral and Maxillofacial Surgery, Academic Medical Center, University of
Amsterdam, NL-1105 A2 Amsterdam, The Netherlands
Frederick J. Kummer, PhD
Associate Director and Research Professor, Department of Bioengineering, Hospital for Joint
Diseases, Orthopedic Institute, New York, NY 10003, USA
George M. Kushner, MD, DMD
Associate Professor of Oral and Maxillofacial Surgery, Director, Advanced Educational Program
in Oral and Maxillofacial Surgery, University of Louisville School of Dentistry, Louisville, KY
40290, USA
Christian Lindqvist, MD, DDS, PhD, FDSRCS (Eng.)
Professor, Departments of Oral and Maxillofacial Surgery, Institute of Dentistry, Helsinki
University and Surgical Hospital, Helsinki University Central Hospital, 00114
Helsinki, Finland
Contributors xix
Jackson P. Morgan, III, DDS
Oral and Maxillofacial Surgery, 5202 Waters Avenue, Savannah, GA 31404, USA
Friedrich Wilhelm Neukam, MD, DDS, PhD
Professor and Chairman, Department of Oral and Maxillofacial Surgery,
Friedrich-Alexander-Universität Erlangen-Nuremberg, 91054 Erlangen, Germany
Ira H. Orenstein, DDS
Assistant Clinical Professor, Division of Postgraduate Prosthodontics, Columbia University
School of Dental and Oral Surgery; Staff Dentist, Department of Veterans Affairs, Bronx, NY
10468, USA
John H. Phillips, MD, FRCS(C)

Associate Surgeon, Center for Craniofacial Care and Research, Department of Plastic Surgery,
Hospital for Sick Children, Toronto Institute of Aesthetic Surgery, Toronto, Ontario M5R 2J3,
Canada
Jeffrey C. Posnick, MD, DMD, FRCS(C), FACS
Clinical Professor of Plastic Surgery, Departments of Otolaryngology/Head and Neck Surgery,
Oral and Maxillofacial Surgery, and Pediatrics, Georgetown University School of Medicine,
Chevy Chase, MD 20815, USA
Joachim Prein, MD, DDS
Professor of Maxillofacial Surgery, Head, Clinic for Reconstructive Surgery, Kantonsspital
Basel, CH-4031 Basel, Switzerland
R. Bruce Ross, DDS, MSc
Department of Dentistry, Hospital for Sick Children, University of Toronto, Toronto,
Ontario M5F 1X8, Canada
Arlene A. Rozzelle, MD, FACS, FAAP
Assistant Professor, Wayne State University; Chief, Plastic and Reconstructive Surgery,
Children’s Hospital of Michigan, Detroit, MI 48230, USA
Rainer Schmelzeisen, MD, DDS, PhD
Professor and Chairman, Department of Oral and Maxillofacial Surgery and Plastic Surgery,
Freiburg University, D-79106 Freiburg, Germany
Mark A. Schusterman, MD
Clinical Professor, Division of Plastic Surgery, Baylor College of Medicine, Houston, TX
77030, USA
Alan Schwimmer, DDS
Associate Professor of Dentistry, Albert Einstein College of Medicine, Division of Dental
Medicine, Beth Israel Medical Center, New York, NY 10003, USA
Lars Sennerby, DDS, PhD
Professor of Biomaterials/Handicap Research, Department of Surgical Sciences, Gothenburg
University, 413 90 Gothenburg, Sweden
Lester Silver, MD
Professor of Surgery, Chief, Division of Plastic Surgery, Mount Sinai Hospital, New York,

NY 10029, USA
xx Contributors
Douglas P. Sinn, DDS
Professor and Chairman, Division of Oral and Maxillofacial Surgery, Department of Surgery,
University of Texas Southwestern Medical Center, Dallas, TX 75390-9109, USA
Lars Sjövall, DDS
Specialist, Fixed and Removable Prothodontics, Jarvenpaan Hammaslaakarikeskus, 04400 Jar-
venpaa, Finland
R. Gregory Smith, MD, DDS
Assistant Adjunct Clinical Professor, Department of Oral and Maxillofacial Surgery, University
of Florida; Assistant Adjunct Professor, Department of Oral and Maxillofacial Surgery, Case
Western Reserve University, Cleveland, OH; PonteVedra Cosmetic Surgery, Ponte Verdra
Beach, FL 32082, USA
E. Clyde Smoot, III, MD, FACS
Plastic Surgery, Lake Charles Medical and Surgical Center, Lake Charles, LA 70601, USA
Anna-Lisa Söderholm, MD, DDS, PhD, Docent
Senior Maxillofacial Surgeon, Department of Oral and Maxillofacial Surgery, Surgical Hospital,
Helsinki University Central Hospital, 00029 Helsinki, Finland
Robert B. Stanley, Jr., MD, DDS
Professor, Department of Otolaryngology—Head and Neck Surgery, University of Washington
School of Medicine, Chief, Department of Otolaryngology—Head and Neck Surgery,
Harborview Medical Center, Seattle, WA 98104-2499, USA
Jeffrey I. Stein, DDS
Chief, Oral and Maxillofacial Surgery, White Plains Hospital Center, White Plains, NY 10601-
4710, USA
Samuel G. Steinemann, DrPhil
Professor Emeritus, Faculty of Science, Institute of Experimental Physics, University of
Lausanne, CH-1015 Lausanne, CH-4054 Basel, Switzerland
Peter Stoll, MD, DDS, PhD
Professor, formerly, Department of Oral and Maxillofacial Surgery, University Hospital,

D-79106 Freiburg, Germany, and Oral and Maxillofacial Surgeon, Plastic Surgeon, D-79098,
Freiburg, Germany.
Adrian Sugar, BChD, FDSRCS (Eng.)
Consultant, Oral and Maxillofacial Surgery, Maxillofacial Unit, The Welsh Centre for Burns,
Plastic Surgery and Maxillofacial Surgery, Morriston Hospital NHS Trust, Swansea SA6 6NL,
UK
Patrick K. Sullivan, MD
Associate Professor, Department of Plastic Surgery, Director, Craniofacial Service, Brown
University School of Medicine, Providence, RI 02905, USA
Riitta Suuronen, MD, DDS, PhD, Docent
Lecturer, Department of Oral and Maxillofacial Surgery, Helsinki University; Consultant,
Department of Oral and Maxillofacial Surgery, 00-14 Helsinki, Finland
Wichit Tharanon, DDS
Head, Cranio-Maxillofacial Reconstruction Unit, Director, Dental and Craniofacial Implant Cen-
ter, Faculty of Dentistry, Thommasat University, Klong Luang, Pathum-Thani, 12121 Thailand
Contributors xxi
Anders Tjellström, MD, PhD
Associate Professor of ENT Surgery, ENT Clinic of Sahlgren’s University Hospital, SE
413 45 Gothenburg, Sweden
Joseph E. Van Sickels, DDS
Professor and Director of Residency Education, Division of Oral and Maxillofacial Surgery,
University of Kentucky College of Dentistry, Lexington, KY 40536, USA
Mika Varma, MD
Assistant Professor of Surgery, Department of Surgery, University of California, San Francisco,
San Francisco, CA 94143, USA
Gerald D. Verdi, MD, DDS
Clinical Professor, Division of Plastic and Reconstructive Surgery, Department of Surgery,
Adjunct Clinical Professor, School of Dentistry, University of Louisville, Louisville, KY 40202,
USA
Rüdiger Wächter, MD, DDS

Oral and Maxillofacial Surgery, D036937 Fulda, Germany, and formerly, Department of Oral
and Maxillofacial Surgery, Freiburg University, Freiburg, Germany
Peter Ward-Booth, FDSRCS (Eng.)
Consultant Maxillofacial Surgeon, Queen Victorial Hospital NHS Trust, East Grinstead,
West Sussex RH19 3DZ, UK
Hans-Peter Weber, DMD
Associate Professor and Chairman, Department of Restorative Dentistry, Harvard School of
Dental Medicine, Boston, MA 02115-5888, USA
Thomas Weil, MD, DDS
Oral and Maxillofacial Surgery, Austin, TX 78759, USA
Hubert Weinberg, MD
Clinical Professor of Surgery, Division of Plastic Surgery, Mount Sinai Hospital, New York,
NY 10029, USA
Dieter Weingart, MD, DMD
Professor and Chairman, Department of Oral and Maxillofacial Surgery and Plastic Surgery,
Katharinenhospital, D-70174 Stuttgart, Germany
Barry L. Wenig, MD, MPH, FACS
Professor, Northwestern University Medical School, Director, Division of Head and Neck
Surgery, Department of Otolaryngology, Evanston Northwestern Health Care, Chicago, IL
60612, USA
Darin L. Wright, MD
Spokane Ear, Nose, and Throat Clinic, Spokane, WA 99201, USA
Michael J. Yaremchuk, MD
Clinical Professor of Surgery, Harvard Medical School; Chief, Craniofacial Surgery,
Department of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston,
MA 02114, USA
xxii Contributors
1
Introduction
Alex M. Greenberg and Joachim Prein

From the observation by Danis that bone healing was pro-
moted by stabilization, even in the presence of compression,
instrumentation and hardware were developed to allow func-
tionally stable internal fixation by AO/ASIF pioneers All-
göwer, Müller, Schneider, and Willenegger, and were intro-
duced to the field of orthopedics in the 1950s.
1
The
maxillofacial surgeons were exposed to these fixation con-
cepts as a result of their close cooperation with the orthope-
dic surgeons and traumatologists over 30 years ago. Within
the AO Group, this was seized and further adapted into the
field of maxillofacial surgery by Spiessl and Schilli among
others, who performed a series of clinical and laboratory re-
search experiences that dealt with biomechanical and metal-
lurgical problems, resulting in the development of a variety
of stainless steel implants to provide stable internal fixation
of the mandible. These implants provided rigid internal fixa-
tion of fracture and osteotomy segments via absolute stabil-
ity supplemented by compression. The introduction of a
reconstruction plate allowed for the bridging of defects. In
his textbooks New Concepts in Maxillofacial Bone Sur-
gery (1976) and Internal Fixation of the Mandible: A Man-
ual of AO/ASIF Techniques (1989), Spiessl documented this
development.
2,3
Following these early successful experiences with func-
tionally stable internal fixation of the mandible, the field of
application was widened and finally included the entire cra-
niomaxillofacial region. With the development of lighter and

more biocompatible titanium implants, the concepts of inter-
nal hardware–supported osteosynthesis were able to evolve
from the conceptual need for “rigid or absolutely stable in-
ternal fixation” to a “functionally stable internal fixation,”
which is based on the surgeon’s judgment and experience to
provide adequate protection from functional forces of the ma-
turing callus and bone healing in each individual situation.
Resorbable plates and screws are now able to provide ade-
quate functionally stable internal fixation in selected circum-
stances without the need for possible hardware removal, and
is an advance from purely metallic implants. These new
AO/ASIF techniques for the application of internal fixation
to fractures of the entire craniomaxillofacial skeleton were
reviewed in Greenberg’s 1993 textbook, Craniomaxillofacial
Fractures: Principles of Internal Fixation Using the AO/ASIF
Technique.
4
This edition presents a complete representation of the pro-
gression of the field of craniomaxillofacial surgery as it has
evolved from these earlier works. It represents the entire field
as it has developed from traumatology and advanced into the
entire range of craniomaxillofacial reconstructive and correc-
tive bone surgery. By eliminating the sole focus on the bio-
mechanical requirements of internal fixation and examining
considerations regarding the surgical methods for operating
on all these problems, the field of craniomaxillofacial surgery
has matured as a result of these technical accomplishments.
However, the continued importance of hardware in this evo-
lution is evident through the development of rigid fixation ap-
plications for bone lengthening through the principles of dis-

traction osteogenesis.
With the concurrent publication in 1998 of Prein’s Manual
of Internal Fixation in the Cranio-Facial Skeleton: Tech-
niques Recommended by the AO/ASIF Maxillofacial Group
5
,
a concise presentation of the AO/ASIF surgical techniques in
an atlas format is now available. These two new texts permit
a clear understanding of craniomaxillofacial surgical tech-
niques and clinical experience in a complementary manner.
It has always been the fundamental policy of the AO Group
to develop a faculty to provide the education to use the im-
plant materials prior to clinical application, which has brought
considerable advantages for patients through the refinement
of new surgical procedures, whether for treatment of trauma,
tumors, or malformations. Regardless of the problem, there
are major advantages for the management of them all.
This policy has impacted the educational process from in-
ternal pressures within the surgical community and increased
public awareness because the use of these implants requires
greater responsibility and improved accuracy in the perfor-
mance of these techniques. When used correctly, through the
appropriate learning of techniques, the benefit to the patient’s
care is immeasurable. Whether it is greater comfort and safety
1
gained from immediate function or decreased danger from in-
fection, greater security is achieved by the stability of these
methods.
From an economic point of view, there is a reduced bur-
den on the public, which has gained from these developments

in internal fixation, with decreased morbidity, disability, and
mortality. The medical community, however, suffers because
of longer operating time, decreased use of facilities, reduc-
tion in procedures, direct cost of equipment and implants, and
the costs of continuing education. The question of what the
future holds remains. Who will make the decisions regarding
the availability of these highly effective, technically de-
manding techniques? Will this be guided directly and indi-
rectly by national governments, municipalities, local hospi-
tals, staff, or industrial establishments? Will the great
advances of the past 25 years in the evolution of craniomax-
illofacial surgery from issues related mainly to the mandible,
with the progression to the entire skull, continue in an envi-
ronment in which the ability of doctors to make decisions is
impacted by the concern of others? In the future, who will
develop new techniques? In the current environment, can
there be a similar process as it related to metallurgically based
implants, in the search of a superior material (e.g., biore-
sorbable ones)? The correct relationship between industry,
medical and research personnel, and government, based on
appropriate economic models, is necessary to permit the con-
tinued research and development that has until today brought
the field of craniomaxillofacial surgery to its present state.
The chapters in this book will permit the reader to gain a
complete appreciation of the broad spectrum of problems in
the craniomaxillofacial region that may be addressed by a va-
riety of clinicians with subanatomic specializations. This is
further demonstrated by the international array of representa-
tive colleagues from these various disciplines. We hope that
with this inclusion of all of these specialists we can promote

the necessary close cooperation between the disciplines, by
showing that there cannot be any boundaries between these
different groups. Rather, we hope for continued progress in
the level of communication among these different specialties
that has been of benefit to all concerned, especially the pa-
tients, through the continued availability of the resources nec-
essary to advance the art and science of this evolving surgi-
cal subspecialty.
References
1. Müller ME, Allgöwer M, Schneider R, Willenegger H. Manual
of Internal Fixation. New York: Springer-Verlag; 1990.
2. Spiessl B, ed. New Concepts in Maxillofacial Bone Surgery. New
York: Springer-Verlag; 1976.
3. Spiessl B. Internal Fixation of the Mandible: A Manual of
AO/ASIF Principles. New York: Springer-Verlag; 1989.
4. Greenberg AM, ed. Craniomaxillofacial Fractures: Principles of
Internal Fixation Using the AO/ASIF Technique. New York:
Springer-Verlag; 1993.
5. Prein J, ed. Manual of Internal Fixation in the Cranio-Facial
Skeleton: Techniques Recommended by the AO/ASIF Maxillofa-
cial Group. New York: Springer-Verlag; 1998.
2 A.M. Greenberg and J. Prein