to the fronto-nasal compartment. Subsequently, the infraorbital frame is conntected to the central midface complex by establishing a stable longitudinal axis along the ventro-median facial struts (zygomaticomaxillary and infraorbital-nasal struts) (Gruss et al. 1985 b; Manson et al. 1985, 1987; Manson et al. 1999).

Reconstruction of the orbital walls can only be undertaken following complete reconstruction of the osseus orbital frame (Hammer and Prein 1998; Prein et al. 1998). Extemely comminuted sections of the orbital wall must be replaced by bone transplants.

•Reconstruction principles concerning the transverse and sagittal midfacial projection are based on correct primary osteosynthesis of the zygomaticoorbital and naso-ethmoidal compartments (Sailer and Grätz 1991; Prein et al. 1998)

stability, which makes postoperative intermaxillary fixation superfluous (Hoffmeister and Kreusch 1991; Jensen et al. 1992; Assael 1998).

•Stability of the frontofacial and midfacial reconstruction protects skull base reconstruction, as the endangering mobility to the duraplasty is eliminated

•Midfacial osteosynthesis on the other hand, makes it possible to reconstruct the original facial dimensions — the sagittal projection, as well as the transverse (facial width) and vertical (facial height) projections — with correct occlusion

In the case of multiple strut fractures or an instable/ deficient osteosynthesis, fragment dislocation against the neutralizing forces must be anticipated. This is evident by the vertical struts in midfacial elongation and by the horizontal midfacial struts in broadening of the facial skeleton (Ernst et al. 2004).

11.3  Osteosynthesis of the Midface

Great progress in treating craniofacial fractures was made by the transition from wire osteosynthesis to rigid internal fixation in craniofacial reconstruction using different plating systems. Osteosynthesis using microor miniplates is today regarded as “conditio sine qua non” (Schilli 1977; Champy et al. 1978,1986; Paulus and Hardt 1983; Stoll et al. 1985; Schwenzer 1986; Jackson et al. 1986; Klotch and Gilliand 1987; Weerda and Joss 1987; Prein and Hammer 1988; Luhr 1988, 1990; Mühling and Reuter 1991; Hoffmeister and Kreusch 1991; Hausamen et al. 1995; Joss et al. 1996; Assael 1998; Prein et al. 1998; Härle et al. 1999; Eufinger et al. 1999; Greenberg and Prein 2002).

•The aim of a functional, stable osteosynthesis in an anatomically correct position is always to neutralize all forces acting on the fragments (for example, tension, pressure, and rotational forces) to prevent the fragments from dislocation (Prein et al. 1998; Härle et al. 1999)

Standardized miniand microplates possess a high degree of ductility and permit an optimal adaptation to the thin facial bones, so enabling a precise and anatomically exact reconstruction, sustaining functionally important bone sections. The plates and screws, which vary in dimension, provide a three-dimensional

11.3.1  Plating Systems

Different osteosynthesis systems are used to reconstruct the facial skeleton according to the highly variable cranial bony structures. The systems are described according to screw diameter. All titanium osteosynthesis plates are monocortically fixed with self-cutting screws.

11.3.2  Miniplates: Microplates

• Plate thickness/form

Osteosynthesis plates should readapt fractured bony fragments in an accurate anatomical position and neutralize forces acting against the fragments (Greenberg and Prein 2002; Ernst et al. 2004). If forces are not sufficiently neutralized; the fragments are loosened and redislocated. Subsequent fissuring with the risk of fissural osteitis or pseudarthrosis may be the consequence.

Due to their flexibility, straight plates offered with a diverse number of holes can be modulated in all three dimensions and ideally adapted to the required demands.

Preformed plates with a variable amount of holes are inserted where plates with a stong curvature are