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Authors of section


Edward Ellis III, Warren Schubert

Executive Editors

Zein Gossous, Uzair Luqman, Rafael Cypriano, Peter Aquilina, Irfan Shah, Florian M Thieringer

General Editor

Daniel Buchbinder

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ORIF, strut plate (strut/box/ladder plate)

1. Principles

Biomechanics of the symphysis

The mandibular symphysis undergoes rotational forces (twisting or torsional) during its function and fixation strategies must take this into account.

When using anything less stable than a reconstruction plate, two points of fixation should be applied. This can be:

  • Two lag screws
  • Two plates
  • 3D plate (such as a ladder, box, or strut plate)
  • A single stronger plate in combination with an arch bar

The illustration shows Champy's ideal lines of osteosynthesis for symphysis fractures.

The illustration shows Champy's ideal lines of osteosynthesis for symphysis fractures.

Special considerations

The following special considerations may need to be considered:

2. Patient preparation

This procedure is typically performed with the patient placed in a supine position.

Patient positioning

3. Approach

For this procedure, the transoral approach to the symphysis is typically used.

Incision line for the transoral approach to the symphysis

4. Reduction

Preparation for reduction

The fracture is exposed, and arch bars are applied.

91 P170 SS orif two lag srews

Drilling monocortical holes for placement of reduction clamp

It is necessary to drill a monocortical hole below the teeth' apices on both sides of the fracture to help place the reduction forceps.

Tip: Prior to drilling the holes, look at your reduction forceps while it is maximally closed. Make sure you drill your holes far enough from the fracture so that the clamp will be able to grasp and hold the fracture segments. Usually, you will want the span from the fracture to this hole to be at least 1 cm. Also look at the end of your reduction forceps before you drill the hole. Some forceps ends or ‘teeth’ are angulated, and some are straight. You will want the trajectory of your drill hole to best accommodate the trajectory of the end of your reduction clamp.
Drill holes for clamp placement

Clamp application

Manipulate the mandibular fragments until anatomic reduction is achieved. Apply the reduction forceps and then place the patient into occlusion with MMF.

Some surgeons prefer to place the patient into occlusion and apply MMF before using the reduction forceps.

The clamp must be placed perpendicular to the fracture line to prevent fracture displacement when tightening the reduction clamp.

Clamp application

5. Fixation

Choice of implant

For a symphysis fracture, a simple box plate may be adequate.

Box and strut plates

A parasymphyseal fracture is often somewhat oblique and requires more than a four-hole box plate for increased stability and more options for screw placement.

Plate for oblique fractures

Plate application

The plate is adapted to lie passively along the symphyseal or parasymphyseal cortex.

Position the plate in the desired location (overlying Champy lines).

Plate application

Depending on the plate's size and postion, monocortical screws may be needed for the superior holes to prevent damage to the tooth roots. Monocortical or bicortical screws can be used for the inferior holes.

Insert a monocortical screw superiorly on one side of the fracture, and then insert another monocortical screw on the other side of the fracture.

After the superior screws are inserted, it can be decided whether mono- or bi-cortical screws are used in the inferior holes.

Sequence for screw insertion

Confirmation of reduction

Confirm adequate reduction. There must be no gap in the lingual aspect. Such a gap would lead to occlusal disturbance and mandibular splaying (or widening laterally).

MMF may be released and the occlusion checked.

The arch bars are generally removed at the end of the case, or can be maintained as a tension band device.

6. Case

This patient sustained a symphyseal and subcondylar fracture.

This patient sustained a symphyseal and subcondylar fracture.

The symphyseal fracture was treated with a 3D box plate.

A hybrid arch bar was used to put this patient in MMF during the procedure. The arch bar and elastics were left on postoperatively to treat the left sub condylar fracture.

The symphyseal fracture was treated with a 3D box plate.

7. Aftercare following ORIF of mandibular symphysis, body, angle, and ramus fractures

Use of jaw bra

If significant degloving of the soft tissues of the mandible has occurred, there may be a consideration for using a jaw bra or similar support dressing.

Arch bars

If arch bars or MMF screws are used intraoperatively, they are usually removed at the conclusion of surgery if proper fracture reduction and fixation have been achieved. Arch bars may be maintained postoperatively if functional therapy is required or if required as part of the fixation.


Postoperative x-rays are taken within the first days after surgery. In an uneventful course, follow-up x-rays are taken after 4–6 weeks.

Follow up

The patient is examined approximately 1 week postoperatively and periodically thereafter to assess the stability of the occlusion and to check for infection of the surgical wound. During each visit, the surgeon must evaluate the patient's ability to perform adequate oral hygiene and wound care and provide additional instructions if necessary. Many patients need to be seen regularly for replacement of their intermaxillary elastics and to encourage range of motion in their TMJ in the later course of the treatment.

Follow-up appointments are at the discretion of the surgeon and depend on the stability of the occlusion on the first visit. If a malocclusion is noted and treatable with training elastics, weekly appointments are recommended.

The patient should be warned to continue routine follow up with their dentist. Fractures near the dental roots can often result in delayed loss of tooth viability, requiring periapical films and additional dental procedures.


If a malocclusion is detected, the surgeon must ascertain its etiology (with appropriate imaging technique). If the malocclusion is secondary to surgical edema or muscle splinting, training elastics may be beneficial. The lightest elastics as possible are used for guidance, because active motion of the mandible is desirable. Patients should be shown how to place and remove the elastics using a hand mirror.

If the malocclusion is secondary to a bony problem due to inadequate reduction or hardware failure or displacement, elastic training will be of no benefit. The patient must return to the operating room for revision surgery.

Basic postoperative instructions


Depending upon the stability of the internal fixation, the diet can vary between liquid and semi-liquid to “as tolerated”, at the discretion of the surgeon. Any elastics are removed during eating.

Oral hygiene

Patients having only extraoral approaches are not compromised in their routine oral hygiene measures and should continue with their daily schedule.

Patients with intraoral wounds must be instructed in appropriate oral hygiene procedures. The presence of the arch-bars and any elastics makes this a more difficult procedure than normal. A soft toothbrush (dipping in warm water makes it softer) should be used to clean the surfaces of the teeth and arch-bars. Any elastics are removed for oral hygiene procedures. Chlorhexidine oral rinses should be prescribed and used at least three times each day to help sanitize the mouth. Chlorohexidine may cause staining of the teeth and should not be used longer than necessary. For larger debris, a 1:1 mixture of hydrogen peroxide (0.25%)/chlorhexidine (0.12%) can be used. The bubbling action of the hydrogen peroxide helps remove debris. A water flosser, providing a water jet, is a very useful tool to help remove debris from the wires. If a this is used, care should be taken not to direct the jet stream directly over intraoral incisions as this may lead to wound dehiscence.


Physiotherapy can be prescribed at the first visit and opening and excursive exercises begun as soon as possible. Goals should be set, and, typically, 40 mm of maximum interincisal jaw opening should be attained by 4 weeks postoperatively. If the patient cannot fully open his mouth, additional passive physical therapy may be required such as Therabite® or tongue-blade training.

91 R100 Aftercare