Abstract
The current gold standard of care for mandibular segmental defeat reconstruction is the use of Ti-6Al-4V immobilization hardware and fibular double barrel graft. This method is often successful immediately at restoring mandible function, however the highly stiff fixation hardware causes stress shielding of the grafted bone and stress concentration in the fixation device over time which can lead to fixation device failure and revision surgery. The purpose of reconstructive surgery could be to create normal stress trajectories in the mandible following engraftment. We investigate the use of a two stage mechanism which separates the immobilization/healing and regenerative phases of mandibular segmental defect treatment. The device includes the use of a very stiff, Ti-6Al-4V, releasable mechanism which assures bone healing. Therefore it could be released once the reconstructed boney tissue and any of its ligamentous attachments have completely healed. Underneath the released Ti-6Al-4V plate would be a pre-loaded nitinol (NiTi) wire-frame apparatus that facilitates the normal stress-strain trajectory through the engrafted bone after the graft is healed in place and the Ti-6Al-4V fixation device has been released. Due to the use of NiTi wires forming a netting that connects vascularized bone and possibly bone chips, bone grafts are also more likely to be incorporate rather than to resorb. We first evaluated a healthy adult mandible during normal mastication to obtain the normal stress-strain distribution. Then, we developed the finite element (FE) model of the mandibular reconstruction (in the M1-3 region) with the proposed fixation device during the healing (locked state) and post-healing (released state) periods. To recreate normal stress trajectory in the reconstructed mandible, we applied the Response Surface Methodology (RMS) to optimize the Bone Bandaid geometry (i.e., wire diameters and location). The results demonstrate that the proposed mechanism immobilizes the grafted bone in the locked state properly since the maximum resultant gap (21.54 micron) between the graft and host mandible surfaces are in the safe region (less than 300 micron). By considering the von Mises criteria for failure, FE analysis together with experimental studies (i.e., compressive and tensile testing on the inferior and superior fixation devices, respectively) confirm that the proposed fixation devices do not fail, showing safety factor of at least 10.3. Based on the Response Surface Methodology (RSM) technique, the optimal parameter values for the wires are achieved (0.65 mm and 1 mm for the superior and inferior wires, respectively) and the required level of preload on each wire are calculated (369.8 N and 229 N for the inferior and superior wires, respectively). The FE results for stress distribution on the reconstructed mandible during the released state closely match that of a healthy mandible.
Highlights
The current standard of care mandibular segmental defect reconstruction uses permanently placedSurgical Grade 5 (Ti-6Al-4V) titanium plates and a fibular double barrel graft, or sometimes in the case of small defects, an iliac crest bone graft
The bone is shielded in regions previously stressed and higher levels of stress may be applied in areas that had previously seen less stress
We have proposed a two-stage process to address the competing needs of immobilization during healing period and re-establishment of normal stress-strain trajectories in grafted bone once the bone is healed
Summary
The current standard of care mandibular segmental defect reconstruction uses permanently placedSurgical Grade 5 (Ti-6Al-4V) titanium plates and a fibular double barrel graft, or sometimes in the case of small defects, an iliac crest bone graft. The fibular or iliac bone graft should integrate well enough to support chewing following mandibular reconstruction. When compared to mandibular cortical bone stiffness, Ti-6Al-4V has a much higher stiffness This high stiffness may alter the mandibular loading pattern previously seen during chewing and possibly shield the grafted and/or host bone from carrying a normal load [1]. Fixation failures due to either stress shielding or stress concentration necessitate revision surgeries. These additional procedures would be avoided if materials with more useful mechanical properties are used for post-surgical skeletal fixation and if those devices have both material properties and geometries that supported the recreation of normal stress-strain trajectories [4,5]
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