Operative Techniques in Otolaryngology (2008) 19, 123-127

Internal fixation of mandibular angle fractures with the

Champy technique
David M. Saito, MD, Andrew H. Murr, MD, FACS

From the Department of Otolaryngology–Head & Neck Surgery, University of California, San Francisco, California.

KEYWORDS: Fractures of the angle of the mandible are prone to complications including malocclusion and non-
Champy; union. Although a standard rigid fixation technique allowing immediate load bearing using large plates
Mono-cortical mini- and tension bands has a long track record, the non-rigid mono-cortical plate technique using load
plate; sharing engineering principles popularized by Champy has gained the confidence of many surgeons.
Load sharing This article describes the Champy technique in detail in contrast to the technique of load bearing
fixation.
© 2008 Elsevier Inc. All rights reserved.

Fractures of the angle account for 23% to 42% of all
mandibular fractures.1-3 These fractures generate the high-
est frequency of complications relative to all other mandible
fractures, with reported rates from 0% to 32%.4 There are
several unique properties of the mandibular angle that per-
tain to fracture management. The cross-section of bone at
the angle is less than that in more anterior locations, pro-
viding less surface contact area to allow stabilization be-
tween fragments. The angle is less surgically accessible than
parasymphyseal or body fractures via a transoral approach.
Fractures are generally posterior to the molar dentition,
which prevents optimal stabilization by maxillomandibular
fixation. Also, the presence of a third molar has been linked
to an increased risk of angle fractures,5,6 and may hinder
fracture reduction, decrease bony surface contact area, dis-
rupt the vascularity to the fracture site, and be a source of
pathogenic organisms.7 The angle fracture can be further
complicated by distraction and rotation by opposing forces
of the elevator muscles (masseter, medial and lateral ptery-
goids, temporalis) and the depressor muscles (geniohyoid,
genioglossus, mylohyoid, digastric). The angle is subject to
forces up to 60 DN during mastication, which any success-
ful fixation method must be able to withstand.
The standard options for treatment of angle fractures
Address reprint requests and correspondence: Andrew H. Murr,
MD, FACS, Department of Otolaryngology–Head & Neck Surgery, Uni-
versity of California, San Francisco, Box 0342, 400 Parnassus Ave, UC
Clinics 730, University of California, San Francisco, San Francisco, CA
94143-0342.
E-mail address: ahmurr@ohns.ucsf.edu.
1043-1810/$ -see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.otot.2008.04.006
include maxillomandibular fixation (MMF) for 4 to 6 weeks
versus open reduction and internal fixation with or without
MMF. The application of MMF creates several well-known
and significant problems for both patient and surgeon. The
patient’s inability to open the mouth leads to nutritional
deficits, suboptimal wound healing, and weight loss. The
MMF hardware often creates painful abrasions and ulcers in
the oral mucosa. Also, prolonged immobilization of the
temporomandibular joint leads to ankylosis and bone re-
sorption. MMF can even lead to life-threatening complica-
tions, as when patients with nausea and/or substance abuse
aspirate gastric contents during episodes of emesis.
Because of such problems, the use of rigid fixation is
appealing as it allows early recovery of mandible function
with limited or no need for postoperative maxillomandibu-
lar fixation. In the 1960s, the Schenk studies illustrated how
bone healing could be accelerated with compression of the
fragments.8 For decades, the AO/ASIF (Arbeitgemeinshaft
fur Osteosynthesefragen/Association for the Study of Inter-
nal Fixation) has stressed the need of rigid fixation with
fragment compression to promote primary bone healing and
has provided guidelines for its application at the mandibular
angle.9 The AO recommends placement of internal fixation
plates in such a fashion that avoids injury to the underlying
mandibular canal and tooth roots. This can be accomplished
with a 6-hole compression plate or reconstruction plate with
bicortical screws inserted along the inferior border of the
mandible. Alternatively, a 2-plate technique can be em-
ployed with a bicortical compression plate or reconstruction
plate along the inferior border and a four-hole monocortical
124
Figure 1 AO technique with inferior compression plate and supe-
rior tension band. Note the holes drilled on either side of the fracture for
use of reduction forceps. (Color version of figure is available online.)
tension band just inferior to the tooth roots (see Figure 1).
The tension band may be substituted with a set of arch bars
to counteract tension along the alveolar ridge.
In practice, however, the AO technique is challenging to
perform correctly at the mandibular angle. Surgical acces-
sibility through a transoral route may be challenging and
many surgeons prefer an external transbuccal approach,
which carries the risk of damaging the marginal branch of
the facial nerve and the possibility of infection and promi-
nent scarring. Furthermore, when bending the compression
plate, failure to precisely coapt the plate to the outer cortex
of the mandible will create a gap on the lingual surface of
the fracture. Also, a fracture that is oriented in a sagittal
direction cannot be effectively compressed and may actu-
ally be distracted by applying a compression plate. In fact,
compression at the angle is not currently recommended at
the angle because of this factor. Finally, the thinness of the
bone at the inferior border of the angle leads to less avail-
able surface area for fragment approximation and somewhat
less toleration of fracture compression.
In the late 1970s and early 1980s, Champy and col-
leagues developed an internal fixation technique using only
1 or 2 monocortical plates inserted along the superior ridge
of the mandibular angle.10,11 This method was born from
the realization, through a series of elegant experiments, that
there existed “ideal lines of osteosynthesis” across the man-
dibular angle where the compressive and tensile forces from
mastication could be countered with only monocortical fix-
ation. The plates can be applied via a transoral approach.
Maxillomandibular fixation may be applied for a short pe-
riod after fixation or forgone completely.
The Champy technique offers advantages over the AO
standard method of internal fixation and is a viable option
for appropriate patients. A recent survey of the practices of
110 AO faculty members revealed that 51% usually use the
Champy technique for a simple fracture of the angle, and it is
used more commonly by more experienced surgeons.4 By
precise application of these low-profile monocortical plates,
the surgeon uses only the minimal amount of hardware nec-
essary to fixate the fracture against predictable force patterns.
The thin plates can be easily coapted to the surface of the bone.
Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008
Monocortical screws pose very little risk to the mandibular
canal and inferior alveolar nerve. By using a transoral ap-
proach, the surgeon can avoid a large external skin incision
and minimize risk to the facial nerve. The transoral ap-
proach is also technically easier than an external approach,
can be swiftly performed, and requires minimal tissue dis-
section with less tissue devitalization.
Although the Champy technique forgoes fragment com-
pression and primary bone healing, its success rate for
treating angle fractures has been proven through many clin-
ical studies with complication rates as low as 3.8%.10 The
successful clinical experience is seemingly at odds with the
results of numerous in vitro studies on the biomechanics of
angle fracture fixation, all of which conclude that monocor-
tical miniplates offer insufficient resistance to the displacing
forces of mastication.12-14 This may be partly explained by
the fact that patients’ bite forces are subnormal for many
weeks after sustaining a fracture, so that a less rigid form of
fixation is adequate for fragment stability during the healing
phase.15
The Champy technique does have its limitations in prac-
tice and is not well-suited for all angle fractures. Because
the use of monocortical plates does not allow primary bone
healing, it is critical to follow patients in the outpatient
setting to ensure that secondary bone healing occurs. This
may be challenging or impossible in the setting of home-
lessness, substance abuse, and other socioeconomic barri-
ers. Reduction of a displaced or unfavorable fracture can be
challenging via a transoral approach. These fractures are
better visualized and reduced via an external approach and
using reduction forceps. Similarly, a comminuted fracture
should be adequately exposed and fixated with a reconstruc-
tion plate via a transcervical approach.
There are current topics of discussion regarding the de-
tails of the Champy technique, especially whether it is
preferable to use one or two miniplates along the superior
mandible border. In 1996, Ellis and Walker16 noted that the
use of a single 2-mm monocortical plate was associated
with a low complication rate (16%), most frequently local
infection that was treated with outpatient incision and drainage
and later removal of the miniplate under local anesthesia. In
contrast, these authors reported a much higher complication
Figure 2 Four-hole fixation for maxillomandibular fixation.
(Color version of figure is available online.)
Saito and Murr Champy Technique
Figure 3 Diagram depiction of Champy’s lines of osteosynthe-
sis at the mandibular angle. (Reprinted with permission.20)
rate of 29% when paired miniplates were employed.17 Ellis
speculates that using one miniplate avoids unnecessary dissec-
tion and preserves blood supply to the fracture site. However,
other studies would indicate that two miniplates lead to better
stability and lower complication rates. Fox and Kellman found
a low 18% complication rate in 68 patients treated with paired
2-mm miniplates.18 Similarly, Levy and coworkers19 found a
very low complication rate of 3% in fractures treated with
paired miniplates compared with a 26% complication rate in
fractures fixed with a single miniplate.
Champy technique
The patient is brought to the operating room and intubated
with a nasal RAE tube. The patient’s occlusion is first
placed into MMF. This can be achieved using either arch
bars and intermaxillary wires or four-hole fixation with
screws placed into the mandible and the maxilla at the nasal
maxillary buttress (see Figure 2).
Figure 4 A 2-mm miniplate precurved in 90° orientation, shown
with drill guide screwed into place. (Color version of figure is
available online.)
125
Figure 5 An Obwegeser retractor is used to expose the plate and
ensure proper positioning. The drill guide is then screwed into the
miniplate and used as a guide for drilling. (Color version of figure
is available online.)
Care must be taken to avoid drilling into the tooth roots.
Premorbid occlusion is thus restored and attention can be
turned to exposing the angle fracture. The gingivo-buccal
sulcus over the angle and along the ipsilateral alveolar ridge
is infiltrated with 1% lidocaine with 1:100,000 epinephrine
for hemostasis. The planned incision is marked at intervals
with pinpoint marks using needle-point electrocautery. At
least 5 mm of gingiva should be left attached to the alveolar
ridge to allow adequate tissue for closure at the end of the
case. The electrocautery is then used to incise the mucosa
and dissect down the periosteum of the mandible. The
dissection proceeds with a Freer or Cottle elevator to expose
the fracture and the surrounding periosteum. The use of
Sewall or Obwegeser toe-in retractors can greatly aid in
adequate exposure. In Champy’s model of mandible biome-
chanics, the ideal lines of fixation are located along the
alveolar portion of the angle of the mandible posterior to the
third molar (see Figure 3).
With the fracture adequately exposed and reduced, a
4-hole 2-mm monocortical miniplate is positioned spanning
the fracture line over the superior ridge of the mandible
angle. Miniplates are now available that are prebent in a 90°
orientation to aid in optimal coaptation to the mandible
angle (Figure 4). Otherwise, bending of the miniplate
should be performed to allow two screw holes on either side
of the fracture.
The drill hole must be performed absolutely perpendic-
ular to the periosteum and should only proceed through the
outer cortex. A drill guide can be screwed into the hole of
the plate to ensure correct drilling orientation (Figure 5).
A 6-mm screw is used to secure the plate. The remaining
3 holes are drilled with the plate in situ. A transbuccal
trochar may be necessary to drill the holes into the distal
fracture segment in a true perpendicular fashion and secure
the bone screws (Figure 6).
This is performed by making a 5-mm incision through
the skin overlying the mandible angle with a scalpel. Then,
focused blunt dissection proceeds through the soft tissues
with a clamp until the tips protrude through the buccal
mucosa. The clamp is removed and the trochar can be
126 Operative Techniques in Otolaryngology, Vol 19, No 2, June 2008

Figure 6 A transbuccal trochar may be necessary to drill per- Figure 8 Paired miniplates for internal fixation of left angle
pendicular holes in the distal fracture segment. (Color version of fracture. (Color version of figure is available online.)
figure is available online.)

Conclusion
inserted into the wound, so that the tip is lined up with the
plate holes of interest. The drill guide is then threaded Early recovery of mandibular function is a clear benefit in
through the trochar and screwed into the miniplate screw the treatment of mandible fractures. Both the AO/ASIF and
hole, allowing drilling to take place in the correct perpen- the Champy technique are acceptable options for internal
dicular trajectory. The drill guide is then removed and the fixation of an angle fracture and offer different profiles of
advantages and disadvantages. For fractures that are dis-
screwdriver, with 6 mm screw attached, is threaded through
tracted or comminuted, and for patients in whom weekly
the trochar to secure the screw into the newly drilled hole
follow-up is not likely, the AO/ASIF compression tech-
(Figure 7). A second 4-hole miniplate can then be secured,
nique is preferred for its superior exposure, fragment reduc-
if desired, along the superior lateral border of the angle
tion, and rigid stability. However, for simple angle frac-
(Figure 8). tures, the Champy technique is an elegant and effective
The surgical wound is irrigated with Bacitracin irriga- method of internal fixation that reduces surgical time and
tion. The wound is closed with 0-chromic in a running
locking fashion. No surgical drain is necessary. The IMF
wires are removed with the arch bars left in place to allow
placement of guiding elastic bands if deemed necessary in
the postoperative period. Postoperative plain films of the
mandible will demonstrate placement of the hardware and
reduction of the fracture line (Figure 9).

Figure 7 After drilling, the screwdriver is inserted into the

transbuccal trochar and used to secure the bone screws. (Color Figure 9 Anterior–posterior plain film of mandible with miniplate
version of figure is available online.) spanning fracture line.
Saito and Murr Champy Technique
dissection, minimizes risk to the facial and inferior alveolar
nerves, and allows early return of function with acceptable
complication rates.
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