Biomechanical in vitro evaluation of three stable internal fixation techniques used in sagittal osteotomy of the mandibular ramus: a study in sheep mandibles

Among the osteotomies performed in orthognathic surgery, the sagittal osteotomy of the mandibular ramus (SOMR) is the most common, allowing a great range of movements and stable internal fixation (SIF), therefore eliminating the need of maxillomandibular block in the postoperative period. Objectives: The purpose of this study was to evaluate the biomechanical resistance of three national systems used for SIF in SOMR in sheep mandibles. Material and methods: The study was performed in 30 sheep hemi-mandibles randomly divided into 3 experimental groups, each containing 10 hemi-mandibles. The samples were measured to avoid discrepancies and then subjected to SOMR with 5-mm advancement. In group I, 2.0x12 mm screws were used for fixation, inserted in an inverted "L" pattern (inverted "L" group). In group II, fixation was performed with two 2.0x12 mm screws, positioned in a linear pattern and a 4-hole straight miniplate and four 2.0x6.0 mm monocortical screws (hybrid group). In group III, fixation was performed with two-hole straight miniplates and eight 2.0x6.0 mm monocortical screws (mini plate group). All materials used for SIF were supplied by Osteosin - SIN. The hemimandibles were subjected to vertical linear load test by Kratos K2000MP mechanical testing unit for loading registration and displacement. Results: All groups showed similar resistance during mechanical test for loading and displacement, with no statistically significant differences between groups according to analysis of variance. Conclusion: These results indicate that the three techniques of fixation are equally effective for clinical fixation of SOMR.

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.

Periodontal effects of rapid maxillary expansion with tooth-tissue-borne and tooth-borne expanders: A computed tomography evaluation

Introduction: The force delivered during rapid maxillary expansion (RME) produces areas of compression on the periodontal ligament of the supporting teeth. The resulting alveolar bone resorption can lead to unwanted tooth movement in the same direction. The purpose of this study was to evaluate periodontal changes by means of computed tomography after RME with tooth-tissue-borne and tooth-borne expanders. Methods: The sample comprised 8 girls, 11 to 14 years old, with Class I or II malocclusions with unilateral or bilateral posterior crossbites Four girls were treated with tooth-tissue-borne Haas-type expanders, and 4 were treated with tooth-borne Hyrax expanders. The appliances were activated up to the full 7-mm capacity of the expansion screw. Spiral CT scans were taken before expansion and after the 3-month retention period when the expander was removed. One-millimeter thick axial sections were exposed parallel to the palatal plane, comprising the dentoalveolar area and the base of the maxilla up to the inferior third of the nasal cavity. Multiplanar reconstruction was used to measure buccal and lingual bone plate thickness and buccal alveolar bone crest level by means of the computerized method. Results and Conclusions: RME reduced the buccal bone plate thickness of supporting teeth 0.6 to 0.9 mm and increased the lingual bone plate thickness 0.8 to 1.3 mm. The increase in lingual bone plate thickness of the maxillary posterior teeth was greater in the tooth-borne expansion group than in the tooth-tissue-borne group. RME induced bone dehiscences on the anchorage teeth's buccal aspect (7.1 ± 4.6 mm at the first premolars and 3.8 ± 4.4 mm at the mesiobuccal area of the first molars), especially in subjects with thinner buccal bone plates. The tooth-borne expander produced greater reduction of first premolar buccal alveolar bone crest level than did the tooth-tissue-borne expander. © 2006 American Association of Orthodontists.

In vitro biomechanical evaluation of sagittal split osteotomy fixation with a specifically designed miniplate

Recent studies have evaluated many methods of internal fixation for sagittal split ramus osteotomy (SSRO), aiming to increase stability of the bone segments while minimizing condylar displacement. The purpose of this study was to evaluate, through biomechanical testing, the stability of the fixation comparing a specially designed bone plate to other two commonly used methods. Thirty hemimandibles were separated into three equal groups. All specimens received SSRO. In Group I the osteotomies were fixed with three 15 mm bicortical positional screws in an inverted-L pattern with an insertion angle of 90°. In Group II, fixation was carried out with a four-hole straight plate and four 6 mm monocortical screws. In Group III, fixation was performed with an adjustable sagittal plate and eight 6 mm monocortical screws. Hemimandibles were submitted to vertical compressive loads, by a mechanical testing unit. Averages and standard deviations were submitted to analysis of variance using the Tukey test with a 5% level of significance. Bicortical screws presented the greatest values of loading resistance. The adjustable miniplate demonstrated 60% lower resistance compared to bicortical screws. Group II presented on average 40% less resistant to the axial loading. © 2012 International Association of Oral and Maxillofacial Surgeons.

The effect of locked screw angulation on the biomechanical properties of the S.P.S. Free-Block plate

Objectives: Among the locked internal fixators is one denominated S.P.S. (Synthesis Pengo System) Free-Block, which was designed with a locking ring that allows the screw to be locked and positioned obliquely. Due to the paucity of biomechanical studies on this system, the present work aimed to evaluate the influence of locked screw angulation on the resistance of the S.P.S. Free--Block plate. Methods: Forty synthetic bone cylinders with 10 mm fracture gap were used. Forty seven-hole 3.5 mm stainless steel plates (two AO-like dynamic compression holes and five locked holes) were assembled according to the orientation of the locked screws: mono cortical screws were positioned at 90° to the long axis of the cylinder (Group 1), and monocortical screws were positioned at 70° to its cylinder long axis (Group 2). In both groups, AO-like dynamic compression hole screws were positioned bicortically and neutrally. For each group, six specimens were tested until failure, three in bending and three in compression, to determine the loads for fatigue testing. Subsequently, for each group, 14 specimens were tested for failure --seven by bending and seven in compression. Results: No significant failure differences were observed between Groups 1 and 2 under static-loading or fatigue test. Clinical significance: In a fracture gap model the orientation of the locked monocortical screws did not show any influence on the mechanical performance of the S.P.S. Free-Block to tests of axial compression and four-point bending. © Schattauer 2013.

Osteossíntese de tíbia com uso de fixador esquelético externo conectado ao pino intramedular tie-in em cães

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Avaliação in vitro do uso de uma miniplaca convencional e locking, de 4 e 7 furos, para tratamento das fraturas de ângulo mandibular

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Avaliação radiográficada fusão das corticias lateral e medial do ramo mandibular: estudo em mandíbulas secas

Purpose: to radiographically evaluate the distance between mandibular lingula and the exact spot where buccal and lingual cortical bone plates merge in the mandibular ramus. Materials and Methods: 54 dry mandibles, divided into 3 subgroups (SG1: dentate, SG2: partially dentate and SG3: edentulous) were used in this study. Lingula position was marked with a metallic sphere and radiographs were taken. The distance between mandibular notch and lingula (I/L) and the distance between mandibular lingula and cortical bone plates fusion (L/FC) were measured. Statistical analysis was applied to the values obtained. Results: mean values for L/FC were 8,18mm, 7,30mm and 8,98mm for SG1, SG2 e SG3 respectively. Moreover, mean values for I/L were 14,02mm, 13,90mm and 12,34mm for SG1, SG 2 and SG3 respectively. The results also showed that cortical bone plates fusion took place in half I/L distance in 28,57% of the mandibles in SG1, in 46,67% of the mandibles in SG2 and in 9,09% of the pieces in SG3. Conclusions: there were no statistically significant differences in the height where cortical bone plates took place in all 3 subgroups. In SG3, the correlation between the mean value for L/FC and the mean value for I/L suggests a reduction in bone density and bone mass, which can correlate to the evaluation of older mandibles in this subgroup.

Controvérsias no tratamento das fraturas mandibulares em crianças: relato de caso clínico

Introduction: The treatment of mandibular fractures has undergone many changes, especially after the introduction of rigid internal fixation techniques. Currently, the use of resorbable materials presents some advantages over metallic devices, particularly when applied in children. Objective: The authors discuss the controversies involved in the treatment of mandibular fractures in children, mainly related to fixation of fractures. Case Report: In this paper, we present a case of a 5 years treatment patient with mandibular angle fracture treated by open reduction and internal fixation with plates and screws. Final Comments: Aiming to not interfere in the development of tooth germs and mandibular bone growth a second surgery for removal of the fixation devices is indicated.

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.

Biomechanical in vitro evaluation of three stable internal fixation techniques used in sagittal osteotomy of the mandibular ramus: a study in sheep mandibles

Among the osteotomies performed in orthognathic surgery, the sagittal osteotomy of the mandibular ramus (SOMR) is the most common, allowing a great range of movements and stable internal fixation (SIF), therefore eliminating the need of maxillomandibular block in the postoperative period. Objectives: The purpose of this study was to evaluate the biomechanical resistance of three national systems used for SIF in SOMR in sheep mandibles. Material and methods: The study was performed in 30 sheep hemi-mandibles randomly divided into 3 experimental groups, each containing 10 hemi-mandibles. The samples were measured to avoid discrepancies and then subjected to SOMR with 5-mm advancement. In group I, 2.0x12 mm screws were used for fixation, inserted in an inverted "L" pattern (inverted "L" group). In group II, fixation was performed with two 2.0x12 mm screws, positioned in a linear pattern and a 4-hole straight miniplate and four 2.0x6.0 mm monocortical screws (hybrid group). In group III, fixation was performed with two-hole straight miniplates and eight 2.0x6.0 mm monocortical screws (mini plate group). All materials used for SIF were supplied by Osteosin - SIN. The hemimandibles were subjected to vertical linear load test by Kratos K2000MP mechanical testing unit for loading registration and displacement. Results: All groups showed similar resistance during mechanical test for loading and displacement, with no statistically significant differences between groups according to analysis of variance. Conclusion: These results indicate that the three techniques of fixation are equally effective for clinical fixation of SOMR.

Symptomatic plate removal after treatment of facial fractures

AIMS: To identify the rates and reasons for plate removal (PR) among patients treated for facial fractures. MATERIALS AND METHODS: A retrospective review of files of 238 patients. RESULTS: Forty-eight patients (20.2%) had plates removed. The reason for removal was objective in 33.3% and subjective in 29.2%. The most common subjective reason was cold sensitivity, and the most common objective reason was wound dehiscence/infection. Women had PR for subjective reasons more often than men (p=0.018). Removal was performed more often for subjective reasons after zygomatico-orbital fractures than after mandibular fractures (p=0.002). Plates inserted in the mandible from an intraoral approach were removed more frequently than extraorally inserted mandibular plates, intraorally inserted maxillary plates, and extraorally inserted plates in other locations (p<0.001). Orbital rim plates had a higher risk of being removed than maxillary or frontal bone plates (p=0.02). CONCLUSIONS: Subjective discomfort is a notable reason for PR among Finnish patients, suggesting that the cold climate has an influence on the need for removal. Patients receiving mandibular osteosynthesis with miniplates from an intraoral approach are at risk of hardware removal because of wound dehiscence/infection and loose/broken hardware, reminding us that more rigid fixation devices should not be forgotten despite the widespread use of miniplates.

Collateral Damage-Penetrating Head Injury and Orbital Injury: A Case Report

We report a case of an accidental death or potential suicide by revolver with subsequent injury of another person. A 44-year-old man shot himself in the head while manipulating his.38 caliber special revolver in the kitchen in the presence of his wife, standing approximately 1.5 m next to him. After passing through the husband's head, the lead round-nose bullet entered the region underneath his wife's left eye. When the bullet left the man's head, it retained the energy to penetrate the soft tissue at this distance, including the skin and thin bone plates like the orbital wall. Owing to the low energy of the projectile, the entry wound was of atypical in shape and without loss of tissue. Only a small line-resembling a cut-was externally visible. The man died in the hospital from his injuries; his wife suffered visual loss of her left eye.

Computational simulation of the early stage of bone healing under different configurations of locking compression plates

Flexible fixation or the so-called ‘biological fixation’ has been shown to encourage the formation of fracture callus, leading to better healing outcomes. However, the nature of the relationship between the degree of mechanical stability provided by a flexible fixation and the optimal healing outcomes has not been fully understood. In this study, we have developed a validated quantitative model to predict how cells in fracture callus might respond to change in their mechanical microenvironment due to different configurations of locking compression plate (LCP) in clinical practice, particularly in the early stage of healing. The model predicts that increasing flexibility of the LCP by changing the bone–plate distance (BPD) or the plate working length (WL) could enhance interfragmentary strain in the presence of a relatively large gap size (.3 mm). Furthermore, conventional LCP normally results in asymmetric tissue development during early stage of callus formation, and the increase of BPD or WL is insufficient to alleviate this problem.

Synthesis Pengo System plates for the treatment of long-bone diaphyseal fractures in dogs

A Brazilian orthopaedic company designed a stainless steel plate called Synthesis Pengo System (S.P.S.), which has one fixed and one changeable extremity. According to the assembly of the changeable extremity, it is possible to obtain dynamization or neutralization of the fracture site. Since the S.P.S. plate was developed for use in human patients, the aim of this study was to evaluate this system in long-bone diaphyseal fractures in dogs. Eight dogs with closed diaphyseal fractures of the femur (n = 1), radius and ulna (n = 5), and tibia (n = 2) were used. Patients were aged seven months to three years and weighed 18 to 31.2 kg. The S.P.S. plate was assembled with one fixed extremity and one changeable extremity in dynamization mode. The trail bar was positioned for synthesis modules with holes for cortical screws. The modules were positioned close to one another in two fractures and for away from the fracture site in the others. The bone healing occurred by external callus. Since motion at the fracture site determines the amount of callus required, the secondary bone healing that was observed in all of the cases indicated less rigid fixation of this system. A potential benefit of this system was a lesser interface contact with the bone since it was only done by trail bar. The major disadvantage was the prominence of the implant. It was possible to conclude that the S.P.S. plate appears to be a suitable method for the treatment of diaphyseal fractures in dogs.