J Stomatol Oral Maxillofac Surg 120 (2019) 229–233

Available online at

ScienceDirect
www.sciencedirect.com

Review

From rigid bone plate fixation to stable dynamic osteosynthesis in

mandibular and craniomaxillo-facial surgery: Historical evolution of
concepts and technical developments
N. Pham Dang a,b,*, I. Barthélémy a,b, F. Bekara c
a
Department of oral and maxillofacial surgery, NHE CHU de Clermont-Ferrand, université d’Auvergne, Clermont-Ferrand, 63003, France
b
UMR Inserm/UdA, U1107, neuro-Dol, trigeminal pain and migraine, université d’Auvergne, Clermont-Ferrand, 63003, France
c
Department of Oral and Maxillofacial surgery, hôpital la Peyronnie, CHU, 34070 Montpellier, France

A R T I C L E I N F O A B S T R A C T

Article history: Historically, extensive observation of limb fracture healing led to a consensus that only complete rigid
Received 9 October 2018 immobilization could guarantee recovery. This agreement was arrived at because for a long time
Accepted 14 January 2019 progress in treatment was driven by clinicians and did not stem from the application of biological
Available online 21 January 2019
research. The clinical approach was based on immobilization of the fracture by rigid osteosynthesis
plates and bicortical screws. Subsequently, after extrapolation of the ideas of Lane, the concept of rigid
Keywords: compressive osteosynthesis rapidly gained in acceptance. It was not until the second half of the 20th
Mandible fractures
century that maxillofacial surgeons concluded that the principles of osteosynthesis should be based on
Biomechanics
Miniplate
biomechanical studies and not only on clinical observation. The concept of stable dynamic
Osteosynthesis osteosynthesis stems from basic research. This paper traces the evolution of concepts in maxillofacial
Mandibular reconstruction osteosynthesis.
Fracture healing C 2019 Elsevier Masson SAS. All rights reserved.

Mandible
Rigid fixation
Static osteosynthesis
Dynamic osteosynthesis

1. Introduction ments enabled oral and maxillofacial surgeons to advance from

rigid bone plate fixation to stable dynamic osteosynthesis.
During the second half of the 20th century major technological The aim of this presentation is to clarify which terms should be
advances were made in France in the treatment of maxillofacial used for each of the different techniques of fracture treatment and
fractures. The Hamburg surgeon Carl Hansmann (1852–1917) was to outline the principles which first led to the fixation techniques
the first to experiment the plate and screw system, in 1886. He was for mandible trauma.
also the first advocate of rigid plate fixation in maxillofacial
surgery, which until then had only been used for fractures of the
extremities. Simultaneously, the Scottish William Arbuthnot Lane 2. Terminology
(1856–1943), in a publication of 1894 [1], and the Belgian Albin
Lambotte (1866–1955) [2] pioneered internal fixation of displaced When discussing osteosynthesis it is of paramount importance
fractures. At the same time, Joseph Lister (1827–1912), the British to use uniform terminology. For logical reasons, the name of a
surgeon and medical scientist, laid the foundations of antiseptic surgery technique should depend on its nature and results and not
medicine [3]. However, because of the high rate of complications on the name, form or features of the material used. According to
such as infection and facial nerve lesions osteosynthesis of this principle, osteosynthesis can be rigid or dynamic and the
mandible fractures was for many years put on hold. Almost a result can be described as stable, unstable or solid. The term used
century later new concepts and progress in technical develop- should reflect the reality of the situation. This is why we propose
the following definitions.
A fixation is said to be ‘‘unstable’’ when it needs to be completed
by an intermaxillary fixation (IMF), which historically was the case
* Corresponding author at: Université d’Auvergne, NHE CHU de Clermont-
of osteosynthesis with steel wire. This approach had the drawback
Ferrand, 1, place Lucie-Aubrac, 63000 Clermont-Ferrand, France.
E-mail address: [email protected] (N. Pham Dang). of periosteal stripping of both sides of the mandible [2] with

https://doi.org/10.1016/j.jormas.2019.01.011
2468-7855/ C 2019 Elsevier Masson SAS. All rights reserved.
230 N. Pham Dang et al. / J Stomatol Oral Maxillofac Surg 120 (2019) 229–233

impairment of the main blood supply to the bone [4]. An unstable physiological bone healing is only possible when rigid fixation of
fixation is a failure. the fracture is performed. It is accepted that bone healing is
In contrast, osteosynthesis is deemed to be ‘‘stable’’ when the characterized by the absence of periosteal callus formation, called
broken limb can, before the fracture heals, be moved freely without soudure per primam (primary bone healing). According to Müller
application of force. For the mandible this means that the fixation and Perren, the appearance of any periosteal callus after plate
does not require any associated IMF and that passive movements fixation can be an indicator of an unknown degree of instability
are possible and do not prevent the healing process. The fixation is and infection [12].
stable at rest and during effortless movements. Liquid food is In line with these precepts, Danis developed numerous
authorized [5]. Preferably, only very light masticatory pressure techniques of osteosynthesis based principally on inter-fragmen-
should be applied. tary compression using screws and a device that he called
The term ‘‘solid’’ refers to osteosynthesis that allows full ‘‘coapteur’’, which was basically a plate designed to produce axial
operation of the mandible, including mastication, whether or not compression between two main bone fragments [13]. His model
bone healing is complete. Most of the time, osteosynthesis is solid was extrapolated by Luhr [14] and Spiessl [15] to the management
only when bone healing is complete. of mandibular fractures: stability was enhanced by increasing the
The term ‘‘functionally stable’’ does not make a clear distinction friction forces between fracture surfaces and using specific rigid
between a stable and a solid fixation: both are functional but only plates with bicortical screws specially designed to provide inter-
one is solid. fragmentary compression. This method consists in stable internal
The term ‘‘rigid’’ indicates that the plate absorbs any force fixation of fractures by an eccentric dynamic compression plate
applied on the operated mandible. The plate can withstand all (EDCP).
efforts exerted by the masticatory muscles without suffering any In 1967, Franchebois and Souyris started using modified Müller
deformation. This term is sometimes used not only to designate the plates, a design that allows inter-fragmentary compression in the
plate but also osteosynthesis itself or, in other words, the result of treatment of fractures of the mandible by tightening a tensor
the process. Depending on the force applied a plate is qualified as temporarily anchored to the bone and the plate [16,17]. In this
either rigid, elastic or flexible. In contrast, synthesis can only be approach, the plates are fixed to the inferior border of the
stable, solid or unstable. Mechanically speaking, the term ‘‘semi- mandible. As a result of stable internal fixation, intermaxillary
rigid’’ does not make any sense. fixation was no longer necessary. The technique allowed free
Evolution of the concepts from orthopedic surgery to treatment mobility of the mandible and a soft or semi-solid diet. Initially, it
of facial fractures was restricted to subjects contraindicated to IMF such as epileptics
At the end of the 19th century, the possibilities offered by and edentulous patients and in cases of pseudoarthrosis and
surgical treatment of fractures drew the attention of oral and plurifocal fractures.
maxillofacial surgeons [6]. Lambotte coined the term osteosyn- Thus, although intermaxillary fixation was no longer a
thesis and established the ground rules for the technique: requirement, new challenges emerged: the difficulty to concomi-
maintaining the bone[1_TD$IF]’s blood circulation, limiting dissection, tantly control dental occlusion and fracture reduction, and avoid
and preserving the periosteal covering [2]. He used a trapezoidal disjunction of the alveolar rim at the fracture angles.
metallic resorbable plate made of nickel silver, a copper alloy with To counter the problem, Michelet along with Franchebois and
nickel and often zinc. His work had a considerable impact on Souyris developed the intra-oral approach [16,18,19]. The method
orthopedic surgery but not on craniofacial surgery. The risk of avoids skin scars, facial nerve damage, restores occlusion, allows
lesions of the facial nerve during the cervical incision, the difficulty traumatized teeth to be treated and direct observation of the
in restoring the dental occlusion owing to the rigidity of the plates, alveolar bone. As a result of the endo buccal incision, the plates
the risk of lesions of the alveolar nerve, the damage inflicted upon could not be placed at the inferior border of the mandible, and
the tooth roots by the bicortical fixation of the screws and the high because of the position of the tooth roots bicortical screws could no
infection rate before the discovery of antibiotics impeded progress. longer be used. Souyris and Michelet suggested placing the plates
Bradley et al. [7] stated that in the tooth portion, a fracture is a on the upper border of the mandible
compound fracture directly communicating with the mouth using monocortical screws to avoid alveolar rim disjunction and
cavity. They emphasized the importance of adapting and fully systematic tooth lesions while respecting the principle of rigid
immobilizing the fractured surfaces (a mandatory requirement for fixation [17,18].
recovery of the dental occlusion) and recommended that all teeth From the principle of rigid compression fixation to stable
should be removed from the line of fracture to avoid chronic dynamic osteosynthesis
suppurative osteomyelitis. Since then, the treatment of fractures, As in skin surgery, compression of a biological tissue damages
malformations, cancers and bone fragment loss due to cancer or its blood supply. Sustained compression on the fracture surfaces
infection has become safer as control of the biological and can suppress or at least reduce the blood supply. For these reasons,
mechanical factors that ensure better fixation and biologic healing continuous compression seems illogical and inappropriate. En-
has improved. hancing or disturbing bone healing in the area adjacent to the
fracture surfaces depends on how much compression is exerted on
the fracture surfaces, under the plate and around the screws. The
3. From clinical observation to empirical therapeutic so-called ‘‘dynamic compression’’ of Luhr and Spiessl was in fact a
applications single mechanical compression while the term ‘‘dynamic’’ implied
several repeated micro-movements caused by muscular activity.
3.1. From bicortical to monocortical osteosynthesis Although Luhr[2_TD$IF]’s plate was called a dynamic compression plate
(DCP) only one-time static compression could be obtained. This
The first theories stated that the injured limb bone should be stage in the development was still empirical and based on clinical
completely immobilized by rigid plates. The technique was first observations.
experimented in 1895 when Lane [8] developed a metal plate to be In 1870, Wolff is credited with originating the trajectory
used for internal fixation. Many authors, such as Aubry and relating bone structure to the mechanical forces imposed upon it:
Ginestet, advocated this technique in the treatment of fractures of where stresses of pressure and tension occur in bone, formation of
the mandible [9,10,11]. The approach is based on the idea that bone takes place [20]. A hundred years later, McKibbins (1978)
 N. Pham Dang et al. / J Stomatol Oral Maxillofac Surg 120 (2019) 229–233 231

advanced the principle of ‘‘secondary fracture healing’’ [21]. This undertaken in Strasbourg from 1972 to 1974 by the Groupe d’
process is possible when complete rigidity is not achieved, which Etude en Biomécanique Ostéo-Articulaire de Strasbourg (GEBOAS),
results in greater motion at the fracture site and a degree of who not only created a new concept but also described the features
intermittent displacement between the bone ends. Healing of the plates and screws to be used for the method
progresses via the three-stage process of inflammation, callus [2,8,13,24,25]. The GEBOAS performed static and dynamic
formation and remodeling. The goal of this complex process is a experiments to establish objective principles in mandibular
stepwise increase in the mechanical stability of the fracture site osteosynthesis.
that is achieved by progressively replacing fragile provisional
tissues with more stable ones, eventually reaching a point that 4.1. The cortical bone
allows vascular ingrowth and mineralization processes to occur.
Finally, the procedure of stable dynamic osteosynthesis was In the late 1970s, studies described the external surface of the
adopted and the technique of rigid fixation was abandoned, mandible, calculated the distance between each dental root tip and
thereby introducing a new rationale in the treatment of fractures. external surface of the outer cortical layer of the mandible and to
the inferior border of the mandible and clarified the position of
3.2. The concept influences the design of the plate and not vice versa dental root tips in relation to the occlusal line and the inferior
alveolar nerve. The observations showed that the cortical bone of
Many publications have focused on the study of plates, their the mandible had an average thickness of 3.3 mm and that the
form, dimension, nature and tolerance [6]. Defining the concepts basilar area is thicker and the apical alveolar area considerably
underlining the treatment methods is more important than stating thinner [5].
the nature or dimensions of the material used. Maxillofacial plates
and screws are smaller than the material used for limb surgery. 4.2. Clenching forces
Thus, once the concept of stable-dynamic osteosynthesis was
adopted, the first publications used the term miniplate osteosyn- The GEBOAS measured the breaking load of an isolated
thesis as opposed to material used for limb fractures. The use of the mandible with an Adamel Lhomargy machine and were then able
term miniplate quickly became widespread and was soon to determine the resistive forces of the plates and the bite force.
universally accepted [18]. To date osteosynthesis of mandible The value obtained helps to determine the mechanical resistance
fractures has been qualified by the material used and not by the of the plates. Torsional moment, or torque, was also analyzed in the
technique. Adaptive osteosynthesis, which means restoring the curved symphyseal region [5] (Fig.1).
morphology of the fracture by precisely adapting its surfaces
would have been a more appropriate term. 4.3. The localization of plates and screws on a fractured straight beam
The term ‘‘miniplate osteosynthesis’’ led to problems when
Michelet began to work with resorbing plates [22,23]. The Once the clenching forces had been measured, it was necessary
procedure still corresponded to adaptive osteosynthesis but the to determine the distribution of the strains developed inside the
term ‘‘miniplates’’ was a misnomer because of the dimensions of mandible. When pressure is applied on the free end of a straight
the resorbable plates [19]. unilaterally fixed beam, traction strains are recorded on the upper
border and compression strains are visible on the lower border.
4. From experimental studies to stable dynamic osteosynthesis However, at the point of force application, forces are shifted. When
a load is placed on the extremity of the fractured straight beam, if
During a period that could be called the empirical stage the the fracture is fixed in the lower border of the beam, compression
methods used were a direct application of contemporary and traction strains are recorded on the lower border and diastasis
knowledge of general orthopedic surgery to the mandible. occurs at the upper end of the fracture line. If the plate is located
There then followed a period in which the compression along the upper border of the beam, traction strains are
principle was extrapolated to mandibular surgery and the neutralized. Compression strains remain concentrated at the
techniques used followed or preceded knowledge of the bone lower border. No disjunction occurs (Fig.2). When a force is
healing process [13,24]. New developments in this third stage, the directly applied to the upper extremity of the fracture line,
experimental period, arose mainly from biomechanical studies compression strains are observed at the point of application of the
[(Fig._1)TD$IG]

Fig. 1. Torsion moments in the symphysal region.

[(Fig._2)TD$IG]
232 N. Pham Dang et al. / J Stomatol Oral Maxillofac Surg 120 (2019) 229–233

Fig. 2. Photo-elastic stress analysis of an acrylic bar.

[(Fig._3)TD$IG]
which is a curved model. A study carried out under the
supervision of M. Grossman of the Laboratoire de spectroscopie
et de photonique iconique de l’Institut de Physique (Pharok
Piam) [29] used a laser beam to examine recently collected post-
mortem fractured and synthesized mandibles. Two cameras
were placed in a rigid position and centered on the fracture line
of the mandible. One camera was lit by a laser flash light with the
image obtained serving as a reference. The osteosynthetized
mandible was then subjected either to traction strains or to
torsion strains. Further photographs were taken and merged
with the reference images to measure with greater accuracy the
interference fringe caused by superimposition. These results
showed micro-movements between the osteosynthetized frag-
ments, which was contrary to the expected result of strict
immobilization principles that had been recommended until
then. They also demonstrated that in no case could the new mode
of fixation be considered as rigid. These observations confirmed
that mechanical stimulations spread from one fragment to
another help the healing process by recreating conditions similar
to bone physiology [30,31].
A case series involving two patients suffering from a
mandibular fracture secured with a plate included direct
examination of their stabilized fractures. On the 10th day, surgical
Fig. 3. Ideal line of osteosynthesis. exposure of the fracture site showed that the periosteum had
completely covered the fracture line, screws and plates. The
force and traction strains at the lower border, the opposite of what periosteum had thickened and showed no signs of inflammation.
is observed when the force is applied at a distance [5,26]. This Light and careful pressure on the dental crown, at the top of the
neutralizes traction stresses and reestablishes the normal run of fracture line, showed slight, fleeting diastasis of the inferior border
concomitant compression stresses. The later works of Farmand of the mandible.
reported that the direction of torsion and traction forces was This direct observation of the surgical site demonstrated that
reversed at the impact point of a clenching force. Subsequently, bone healing was of a periosteal nature and not primary bone
studies of a curve beam subjected to a load showed that torsion healing. It also confirmed that the different strain forces were
strains could be neutralized by two plates [27]. Thus, a fracture of reversed at the impact point of a masticatory force applied to the
the mandible behind the canine can be fixed with a single plate fracture line. Stable dynamic fixation of a mandibular fracture
whereas a fracture of the symphysis requires two plates to allows recovery of the physiological condition of the bone [5].
neutralize the torsion forces exerted in the curved area (Fig.3) [28].
4.5. The ideal plates and screws for stable dynamic osteosynthesis
4.4. Periosteal bone healing
Once the location of the plates and screws has been
Other investigations were performed to determine whether established, resistance of the external cortical bones to the
the upper position of the plates is transferable to the mandible, pull-out forces applied on the screws can be assessed. The choice
 N. Pham Dang et al. / J Stomatol Oral Maxillofac Surg 120 (2019) 229–233 233

of osteosynthesis material should be compatible with the specific References

biological and mechanical imperatives of the mandible: toler-
[1] Verbeek O. Osteosynthesis and the Lane technic. Am J Surg 1955;90:410–8.
ance, solidity and ductility. GEBOAS used a modified Young[3_TD$IF]’s [2] Lambotte A. Contribution to conservative surgery of the injured hand. By Dr. A.
modulus to achieve the proper rigidity and flexibility of the Lambotte. 1928. Clin Orthop Relat Res 1987;214:4–6.
metal. The rigidity, elastic limits and breaking point of material [3] Lister J. On the antiseptic principle in the practice of surgery. Br Med J
1867;2:246–8.
under loading were then measured. Bendable stainless steel was [4] Bradley D. Fractures of the upper end of the femur. 2. Treatment. Nurs Times
the first suitable material to be used but was progressively 1970;66:1552–5.
replaced by titanium. The shape of the plate (thickness of [5] Champy M, Loddé JP, Schmitt R, Jaeger JH, Muster D. Mandibular osteosyn-
thesis by miniature screwed plates via a buccal approach. J Maxillofac Surg
1.00 mm, length varying from 4 holes with or without a bar) and 1978;6:14–21.
accommodation of the screw holes were influenced by the design [6] Vrebos J, Dupuis CC. From circumferential wiring to miniaturized plates and
of Shermann et al. The characteristics of the screws depend on the screw. The history of osteosynthesis of the mandible with special reference to
Dr A Lambotte. Eur J Plast Surg 2005;170:178–228.
thickness and structure of the cortical bone. Different materials
[7] Bradley RL, Huber KH, Klein MM. Latent osteomyelitis; report of 7 cases. Am
have been used to manufacture the plates and screws. Hansmann Surg 1965;31:394–8.
used gold and Lamotte nickel silver (resorbable). Later came [8] Lane WA. The operative treatment of fractures. London: Medical Publishing
steel, stainless steel, titanium and finally resorbable Phusiline Co.; 1905. p. 32–3.
[9] Aubry M, Palfer-Solier M, Ginestet G, Palfer-Sollier M, Pons J. Chirurgie
plates and resorb plates, developed by Champy and Gerlach, stomatologique et maxillo-faciale: atlas de technique opératoire, 11th ed,
respectively [19,23,32]. Michel et al. started using Phusiline, Paris: Flammarion; 1963. p. 256–349.
which is perfectly tolerated, in 1971 but later abandoned the [10] Ginestet G, Merville L. Indications and techniques for the vertical osteotomy of
the perpendicular rami of the mandible. Rev Fr Odontostomatol 1966;13:711–
technique [33,34]. 24.
[11] Beal G, Levignac J. Mandibular osteosynthesis. Rev Stomatol 1955;56:424–7.
[12] Müller ME, Perren SM. Callus and primary bone healing. Monatsschr Unfall-
5. Conclusion heilkd Versicher Versorg Verkehrsmed 1972;75:442–54.
[13] Danis R, Soulisse-Martin. Théorie et pratique de l’ostéosynthèse, Université
libre de Bruxelles (1834-1970), 1949.
For a long time the aims of surgical treatment of the fractures of [14] Luhr HG. On the stable osteosynthesis in mandibular fractures. Dtsch Zah-
the jaw using plates and screws were always the same: restore the narztl Z 1968;23:754.
occlusion and ensure bone healing. The historical evolution of the [15] Roth H, Müller W, Spiessl B. Treatment of extensive bone defects in the jaws
with hydroxyapatite granules. Schweiz Monatsschrift Zahnmed Rev Mens
principles of treatment and the technical developments of the
Suisse Odonto-Stomatol Riv Mens Svizzera Odontol Stomatol 1984;94:222–7.
treatment methods occurred in three stages. The first stage, which [16] Franchebois P, Souyris F, Gelly G. 6 years of experience in osteosynthesis of
should be called adaptive osteosynthesis, consisted in strict anterior fractures of the mandible by infra-oral approach. Rev Stomatol Chir
immobilization of the fracture with rigid plates and a bicortical Maxillofac 1967;68:658–61.
[17] Souyris F, Caravel B, Reynaud JP. Mandibular osteosynthesis with screwed
fixation. The surgical approach was extra-oral with a high risk of plates without blocking: original method and results after 5 years. Rev
damaging teeth roots, facial nerves and the inferior alveolar nerve. Stomatol Chir Maxillofac 1973;74:253–63.
Restoring the occlusion was problematic. The second stage, rigid [18] Michelet FX, Deymes J, Dessus B. Osteosynthesis with miniaturized screwed
plates in maxillo-facial surgery. J Maxillofac Surg 1973;1:79–84.
compression osteosynthesis, required the development of special [19] Michelet FX, Moll A. Surgical treatments of fractures of the corpus mandibulae
rigid compressive plates derived from the coapteur of Danis. The without blockage, with diminutive screwed plates inserted via the endobuccal
method consisted in increasing stability by increasing compression route. Rev Odontostomatol Midi Fr 1971;29:87–105.
[20] Wolff J. The classic: on the inner architecture of bones and its importance for
and friction forces. Restoration of the occlusion was not easy and bone growth. 1870. Clin Orthop 2010;468:1056–65.
damage to the inferior alveolar nerve was frequent. Bone healing [21] McKibbin B. The biology of fracture healing in long bones. J Bone Joint Surg Br
was of the primary healing type. The third stage, stable dynamic 1978;60:150–62.
[22] Sedel L, Chabot F, Christel P, de Charentenay X, Leray J, Vert M. Biodegradable
osteosynthesis, consisted in the restoration of the lines of force in implants in orthopedic surgery. Rev Chir Orthop Reparatrice Appar Mot
the mandible and the transfer of micro-movements between the 1978;64(2):92–6.
two fragments. The material used is adaptable, which results in [23] Heidemann W, Fischer JH, Koebke J, Bussmann C, Gerlach KL. In vivo study of
degradation of poly-(D,L-) lactide and poly-(L-lactide-co-glycolide) osteosyn-
easy protection of the nerves and teeth and restoration of the
thesis material. Mund- Kiefer- Gesichtschirurgie MKG 2003;7:283–8.
occlusion. [24] Uhthoff HK, Poitras P, Backman DS. Internal plate fixation of fractures: short
The biomechanical study performed by the Strasbourg bone history and recent developments. J Orthop Sci Off J Jpn Orthop Assoc
and joint research group (GEBORS) showed that fixation of a bone 2006;11:118–26.
[25] Sherman W. Vanadium steel bone plates and screws. Surg Gyn Obst
structure had to be performed with a technique that neutralized 1912;14:629–34.
the traction and rotation forces and restored the compression and [26] Champy M, Loddé JP, Grasset D, Muster D, Mariano A. Mandibular osteosyn-
friction forces. thesis and compression. Ann Chir Plast 1977;22:165–7.
[27] Farmand M. Experiences with the 3-D miniplate osteosynthesis in mandibular
fractures. Fortschr Kiefer Gesichtschir 1996;41:85–7.
Funding [28] Ellis E, el-Attar A, Moos KF. An analysis of 2,067 cases of zygomatico-orbital
fracture. J Oral Maxillofac Surg 1985;43:417–28.
This research did not receive any specific grant from funding agencies in the public, [29] Champy M, Lodde JP, Jaeger JH, Wilk A, Gerber JC. Mandibular osteosynthesis
commercial, or not-for-profit sectors. according to the Michelet technic. II. Presentation of new material. Results Rev
Stomatol Chir Maxillofac 1976;77:577–82.
[30] Sarmiento A, Sobol PA, Sew Hoy AL, Ross SD, Racette WL, Tarr RR. Prefabricated
Disclosure of interest
functional braces for the treatment of fractures of the tibial diaphysis. J Bone
Joint Surg Am 1984;66:1328–39.
The authors [4_TD$IF]declare that they have no competing interest. [31] Cornell CN, Lane JM. Newest factors in fracture healing. Clin Orthop 1992;297–
311.
[32] Champy M, Blez P, Kahn JL. Osteosynthesis using resorbable plates in maxil-
Acknowledgment lofacial surgery: hopes and disappointments. Chir Memoires Acad Chir
1992;118(10):596–600.
[33] Michelet FX, Deymes J, Dessus B. Osteosynthesis with miniaturized screwed
Acknowledgment and gratitude to Emerit Professor Professor plates in maxillo-facial surgery. J Maxillofac Surg 1973;1(79):84.
Maxime Champy for its essential assistance in this work. I hope [34] Hernández Altemir F. Sub-mental vs. retromolar intubation. Anaesthesia
2006;61:1123.
that this work reflects a fair and accurate vision of your thought.