Failure of miniplate osteosynthesis for the management of atrophic mandibular fracture

Fractures of the severely atrophic (<10 mm) edentulous mandible are not common, and these fractures with a vertical height of 10 mm or less have long been recognized as being particularly problematic. Although there are advances in the treatment of the atrophic mandibular fracture, the treatment remains controversial. There are some options for treatment planning because of using small miniplates to large reconstruction plates. However, when the fixation method fails, it causes malunion, nonunion, and/or infection, and sometimes it has been associated with large bone defects. The authors describe a clinical report of a failed miniplate fixation for atrophic mandibular fracture management. The authors used a load-bearing reconstruction plate combined with autogenous bone graft from iliac crest for this retreatment. The authors show a follow-up of 6 months, with union of the fracture line and no complication postoperatively. © 2013 by Mutaz B. Habal, MD.

Position paper from the IBRA Symposium on Surgery of the Head - The 2nd International Symposium for Condylar Fracture Osteosynthesis, Marseille, France 2012

Background: This is a position paper from the 2nd International Bone Research Association (IBRA) Symposium for Condylar Fracture Osteosynthesis 2012 was held at Marseille, succeeding the first congress in Strasbourg, France, in 2007. The goal of this IBRA symposium and this paper was to evaluate current trends and potential changes of treatment strategies for mandibular condylar fractures, which remain controversial over the past decades.Methods: Using a cross-sectional study design, we enrolled the consensus based on the panel of experts and participants in the IBRA Symposium 2012. The outcomes of interest were the panel and electronic votes on management of condylar base, neck and head fractures, and panel votes on endoscopic and paediatric condylar fractures. Appropriate descriptive and univariate statistics were used.Results: The consensus derived from 14 experts and 41 participant surgeons, using 12 case scenarios and 27 statements. The experts and participants had similar decision on the treatment of condylar base, neck and head fractures, as well as similar opinion on complications of condylar fracture osteosynthesis. They had a parallel agreement on using open reduction with internal fixation (ORIF) as treatment of choice for condylar base and neck fractures in adults. Endoscopic approaches should be considered for selected cases, such as condylar base fractures with lateral displacement. There was also a growing tendency to perform ORIF in condylar head fractures. The experts also agreed to treat children (> 12 years old) in the same way as adults and to consider open reduction in severely displaced and dislocated fractures even in younger children. Nevertheless, non-surgical treatment should be the first choice for children <6 years of age. The decision to perform surgery in children was based on factors influencing facial growth, appropriate age for ORIF, and disagreement to use resorbable materials in children.Conclusions: The experts and participating surgeons had comparable opinion on management of condylar fractures and complications of ORIF. Compared to the first Condylar Fracture Symposium 2007 in Strasbourg, ORIF may now be considered as the gold standard for both condylar base and neck fractures with displacement and dislocation. Although ORIF in condylar head fractures in adults and condylar fractures in children with mixed dentition is highly recommended, but this recommendation requires further investigations. (C) 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Iliac osteosynthesis with nylon clamp associated to polymethylmethacrylate bone cement - experimental study in dogs cadavers

Fractures of iliac body are generally consequences of traumas of great impact. These fractures lead to a lack of locomotor response and in specific cases, surgery is needed. Among the possible therapeutic lines, implants become a good option. In this paper, the authors used dog corpses to develop a surgery technique of iliac osteosynthesis, employing nylon clamps and bone cement of polymethylmethacrylate (PMMA). Sixteen hemi pelvises of eight dog corpses, which had its iliac bodies totally fractured previously, were utilized. The osteosynthesis was reached through the implantation of six nylon clamps, distributed equally between the bone fragments. With the use of the nylon clamps there were bone realignment and a contact surface to fixation of the biomaterial. The technique developed in corpses was easily executed, effective in reduction, alignment and stabilization of the fracture. The authors suggest more studies in vitro to evaluate immobilization resistance and functionality in dogs with this condition.

Tibial osteosynthesis in a guinea pig (Cavia porcellus)

A guinea pig was presented with left pelvic limb lameness after unknown trauma. Radiographs revealed complete oblique diaphyseal fracture of the distal third of the left tibia and fibula. The guinea pig was treated surgically with an intramedullary pin. The day after surgery the guinea pig was using the limb comfortably (grade 1/5 lameness). Callus formation was obtained 21 days after surgery without complications.

Ultra-som pulsado de baixa intensidade em fraturas diafisárias: aplicação clínica em cães

Os efeitos da estimulação ultra-sônica sobre a consolidação óssea têm sido demonstrados por trabalhos experimentais e clínicos. Este estudo teve por objetivo investigar a aplicação clínica do ultra-som pulsado de baixa intensidade como tratamento adjuvante de fraturas diafisárias em cães. Foram utilizados 16 cães de raças variadas, com faixa etária entre sete meses e seis anos, peso corpóreo entre 2,5 e 43kg, portadores de fraturas diafisárias fechadas recentes localizadas no rádio e ulna, fêmur ou tíbia e fíbula, estabilizadas por procedimentos de osteossíntese (fixação esquelética externa, pinos intramedulares ou a associação desses métodos). Os cães foram divididos em dois grupos: fraturas estabilizadas tratadas por ultra-som de baixa intensidade (grupo tratado, n=8); fraturas estabilizadas, não tratadas por estimulação ultra-sônica, (grupo controle, n=8). Os animais foram avaliados por exames clínicos e radiográficos nos períodos pré-operatório, pós-operatório imediato e a cada 30 dias posteriores aos procedimentos cirúrgicos. Realizou-se tratamento com ultra-som pulsado (sinal senoidal com freqüência de 1,5MHz, largura de pulso de 200µs e freqüência de repetição de 1kHz) de baixa intensidade (30mW cm-2), aplicado de modo estacionário no foco de fratura. A terapia ultra-sônica foi realizada 20 minutos por dia, durante 21 dias consecutivos, a partir do período compreendido entre o 1° e o 9° dia pós-operatório. O teste t de Student, empregado na análise estatística, mostrou diferença significante (P<0,001 e alfa=0,05) entre as médias dos parâmetros de tempo para consolidação óssea observadas nos animais dos grupos tratado (média de 67,5 dias) e controle (média de 106 dias). Este protocolo de estimulação ultra-sônica promoveu sinais clínicos e radiográficos acelerados da consolidação óssea nas fraturas tratadas. Os resultados deste estudo sugerem que o ultra-som pulsado de baixa intensidade pode ser indicado como terapia adjuvante de fraturas diafisárias recentes em cães.

Placas de aço inoxidável 316L aplicadas no reparo de fratura experimental diafisária do rádio e ulna de cães

O objetivo do presente trabalho foi o de estudar a resistência à corrosão em placas de aço inoxidável 316L, com diferentes tipos de acabamento e tratamento superficial, e a possível interferência dessa reação corrosiva na consolidação óssea. Utilizaram-se placas semi-acabadas, polidas, tratadas com jatos de microesferas de vidro e passivadas, as quais foram aplicadas na epífise distal do rádio de cães. Foram utilizados 12 animais, divididos em dois grupos, nos quais, após osteotomia bilateral do rádio e ulna, foram realizadas osteossínteses do rádio, totalizando 24 procedimentos. Avaliou-se a evolução clínica e radiográfica das regiões que receberam os implantes aos 30, 60, 90, 180, 240 e 360 dias. Os animais do grupo 1 (GI) foram sacrificados aos 180 dias e os do GII aos 360 dias para estudo histológico e de microscopia eletrônica de varredura do local da osteotomia sob a região dos implantes metálicos e para estudo da resistência à corrosão no organismo, pelos implantes metálicos, por meio de análises química e metalográfica (microscopia óptica e eletrônica de varredura e espectroscopia de espalhamento de energia por raios X). Os animais recuperaram a função dos membros operados 24 horas após a cirurgia. Radiograficamente, verificou-se a consolidação óssea em todos os animais. Macro e microscopicamente não foram observados sinais de corrosão nos implantes metálicos, exceto em uma placa passivada, aplicada no rádio esquerdo de um animal, na qual a corrosão foi detectada pela microscopia óptica e eletrônica de varredura. Este estudo permite concluir que as placas de aço inoxidável 316L, independente do acabamento superficial a que foram submetidas, não sofreram corrosão ou reações adversas e foram efetivas no tratamento das fraturas experimentais do rádio e ulna de cães.

Modular hybrid total hip arthroplasty. Experimental study in dogs

Background: This prospective experimental study evaluated the surgical procedure and results of modular hybrid total hip arthroplasty in dogs.Methods: Ten skeletally mature healthy mongrel dogs with weights varying between 19 and 27 kg were used. Cemented modular femoral stems and uncemented porous-coated acetabular cups were employed. Clinical and radiographic evaluations were performed before surgery and at 30, 60, 90, 120, 180 and 360 days post-operation.Results: Excellent weight bearing was noticed in the operated limb in seven dogs. Dislocation followed by loosening of the prosthesis was noticed in two dogs, which were therefore properly treated with a femoral head osteotomy. Femoral fracture occurred in one dog, which was promptly treated with full implant removal and femoral osteosynthesis.Conclusions: The canine modular hybrid total hip arthroplasty provided excellent functionality of the operated limb.

Parafusos bioabsorvíveis na reparação de fraturas experimentais de sesamóides proximais em eqüinos

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Finite Element Modeling for Development and Optimization of a Bone Plate for Mandibular Fracture in Dogs

This study aimed to develop a plate to treat fractures of the mandibular body in dogs and to validate the project using finite elements and biomechanical essays. Mandible prototypes were produced with 10 oblique ventrorostral fractures (favorable) and 10 oblique ventrocaudal fractures (unfavorable). Three groups were established for each fracture type. Osteosynthesis with a pure titanium plate of double-arch geometry and blocked monocortical screws offree angulanon were used. The mechanical resistance of the prototype with unfavorable fracture was lower than that of the fcworable fracture. In both fractures, the deflection increased and the relative stiffness decreased proportionally to the diminishing screw number The finite element analysis validated this plate study, since the maximum tension concentration observed on the plate was lower than the resistance limit tension admitted by the titanium. In conclusion, the double-arch geometry plate fixed with blocked monocortical screws has sufficient resistance to stabilize oblique,fractures, without compromising mandibular dental or neurovascular structures. J Vet Dent 24 (7); 212 - 221, 2010

In vitro evaluation of conventional and locking miniplate/screw systems for the treatment of mandibular angle fractures

This in vitro study evaluated the influence of the type of miniplate and the number of screws installed in the proximal and distal segments on the stability and resistance of Champy's osteosynthesis in mandibular angle fractures. Sixty polyurethane hemimandibles with bone-like consistency were randomly assigned to four groups (n = 15) and sectioned in the mandibular angle region to simulate fracture. The bone segments were fixed by different osteosynthesis methods using 2.0 mm miniplates and 2.0 mm x 6 mm rnonocortical screws. In groups 1 and 2, two conventional (G1) or locking (G2) screws were installed in each bone segment using a conventional (G1) or a locking (02) straight miniplate; in groups 3 and 4, three conventional (03) or locking (04) screws were installed in the proximal segment and four conventional (G3) or locking (04) screws were installed in the distal segment using a conventional (G3) or a locking (G4) seven-hole straight miniplate. The hemimandibles were loaded in compressive strength until a 4 mm displacement occurred between the segments, vertically or horizontally. Locking plate/screw systems provided significantly greater resistance to displacement than conventional ones (p < .01). Locking miniplates offered more resistance than conventional miniplates. Long locking miniplates provided greater stability than short ones.

In Vitro Biomechanical Evaluation of the Use of Conventional and Locking Miniplate/Screw Systems for Sagittal Split Ramus Osteotomy

Purpose: The aim of this in vitro study was to assess the biomechanical stability of 9 different osteosynthesis methods after sagittal split ramus osteotomy by simulating the masticatory forces and using a 3-point biomechanical test method.Materials and Methods: Forty-five polyurethane hemimandibles with bone-like consistency were randomly assigned to 9 groups (n = 5) and subjected to sagittal split ramus osteotomy. After 4-mm advancement of the distal segment, the bone segments were fixed by different osteosynthesis methods using 2.0-mm miniplate/screw systems: group A, one 4-hole conventional straight miniplate; group B, one 4-hole locking straight miniplate; group C, one 4-hole conventional miniplate and one bicortical screw; group D, one 4-hole locking miniplate and 1 bicortical screw; group E, one 6-hole conventional straight miniplate; group F, one 6-hole locking straight miniplate; group (3: two 4-hole conventional straight miniplates; group H. two 4-hole locking straight miniplates; and group 1, 3 bicortical screws in an inverted-L. pattern. All models were mounted on a base especially constructed for this purpose. Using a 3-point biomechanical test model, the hemimandibles were loaded in compressive strength in an Instron machine (Norwood, MA) until a 3-mm displacement occurred between segments vertically or horizontally. Data were analyzed by analysis of variance and Tukey test (alpha = 1%).Results: The multiparametric comparison of the groups showed a statistically significant difference (P<.01) between groups that used 2 miniplates (groups G and H), 1 miniplate and 1 bicortical screw (groups C and D), and only bicortical screws (group D compared with groups that used only 1 miniplate with 2 screws per segment (groups A and B) and 3 screws per segment (groups E and F).Conclusion: The placement of 2.0-mm-diameter bicortical screws in the retromolar region, associated or not with conventional and locking miniplates with monocortical screws, promoted a better stabilization of bone segments. Locking miniplates presented a better performance in bone fixation in all groups. (C) 2010 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 68:724-730, 2010

Mandibular Angle Fracture Treated With New Three-Dimensional Grid Miniplate

Fractures of the mandibular angle deserve particular attention because they represent the highest percentage of mandibular fractures and have the highest postsurgical complication rate, making them the most challenging and unpredictable mandibular fractures to treat. Despite the evolution in the treatment of maxillofacial trauma and fixation methods, no single treatment modality has been revealed to be ideal for mandibular angle fractures. Several methods of internal fixation have been studied with great variation in complications rates, especially postoperative infections. Recently, new studies have shown reduction of postsurgical complications rates using three-dimensional plates to treat mandibular angle fractures. Nevertheless, only few surgeons have used this type of plate for the treatment of mandibular angle fractures. The aim of this clinical report was to describe a case of a patient with a mandibular angle fracture treated by an intraoral approach and a three-dimensional rectangular grid miniplate with 4 holes, which was stabilized with monocortical screws. The authors show a follow-up of 8 months, without infection and with occlusal stability.

Hepatozoon canis infection of wild carnivores in Brazil

Hepatozoon canis was diagnosed in a crab-eating fox (Cerdocyon thous) found on a highway in the region of Botucatu, São Paulo, Brazil, after being hit by a car. The fox had bilateral fractures of the olecranon, which was corrected by osteosynthesis. Hematologic findings included a neutrophilia, eosinophilia, monocytosis and mild anemia. In the Leishman-stained blood film, gametocytes of Hepatozoon canis in neutrophils were identified measuring 9.1+/-0.54x5.3+/-0.46 mu m. (C) 1997 Elsevier B.V. B.V.

Rigid internal fixation with titanium versus bioresorbable miniplates in the repair of mandibular fractures in rabbits

The purpose of this study was to compare by qualitative histology the efficacy of rigid internal fixation with titanium system and the Lacto Sorb® system in mandibular fractures in rabbits. Thirty male adult rabbits Oryctolagus cuniculus were used. Unilateral mandibular osteotomies were performed between the canine and first premolar. The animals were divided into two groups: for Group I - rigid internal fixation was performed with titanium system 1.5 mm (Synthes, Oberdorf, Switzerland), with two screws of 6 mm (bicortical) on each side of the osteotomy. For Group II-rigid internal fixation was performed with PLLA/PGA system 1.5 mm (Lacto Sorb®, WLorenz, Jacksonville, FL, USA). The histological analysis evaluated the presence of inflammatory reaction, degree of bone healing and degree of resorption of the Lacto Sorb® screws. The results of both fixation systems were similar, only with a small difference after 15 and 30 days. In Group I a faster bony healing was noted. But after 60 days, bony healing was similar in both groups. It is concluded that both PLLA/PGA and titanium plates and screws provide sufficient strength to permit mandibular bone healing. The resorption process of PLLA/PGA osteosynthesis material did not cause acute or chronic inflammatory reaction or foreign body reaction during the studied period. © 2004 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Tomographic, Histological, and Immunohistochemical Evidences on the Use of N-Butyl-2-Cyanoacrilate for Onlay Graft Fixation in Rabbits

Background: The bone tissue responses to Cyanoacrylate have been described in the literature, but none used N-butyl-2-cyanoacrilate (NB-Cn) for bone graft fixation. Purpose: The aims of the study were: (a) to analyze the bone grafts volume maintenance fixed either with NB-Cn or titanium screw; (b) to assess the incorporation of onlay grafts on perforated recipient bed; and (c) the differences of expression level of tartrate-resistant acid phosphatase (TRAP) protein involved in bone resorption. Materials and Methods: Eighteen New Zealand White rabbits were submitted to calvaria onlay grafting on both sides of the mandible. On one side, the graft was fixed with NB-Cn, while on the other hand the bone graft was secured with an osteosynthesis screw. The computed tomography (CT) was performed just after surgery and at animals sacrifice, after 1 (n=9) and 6weeks (n=9), in order to estimate the bone grafts volume along the experiments. Histological sections of the grafted areas were prepared to evaluate the healing of bone grafts and to assess the expression of TRAP protein. Results: The CT scan showed better volume maintenance of bone grafts fixed with NB-Cn (p≤0.05) compared with those fixed with screws, in both experimental times (analysis of variance). The immunohistochemical evaluation showed that the TRAP expression in a 6-week period was significantly higher compared with the 1-week period, without showing significant difference between the groups (Wilcoxon and Mann-Whitney). Histological analysis revealed that the NB-Cn caused periosteum damage, but provided bone graft stabilization and incorporation similar to the control group. Conclusion: The perforation provided by screw insertion into the graft during fixation may have triggered early revascularization and remodeling to render increased volume loss compared with the experimental group. These results indicate that the NB-Cn possesses equivalent properties to titanium screw to be used as bone fixation material in osteosynthesis. © 2010 Wiley Periodicals, Inc.