Rigid Fixation Techniques Research Articles

Skeletal stability after mandibular advancement: A comparison of two rigid internal fixation techniques

Objective: To compare two different methods of rigid fixation for any difference in postoperative stability after mandibular advancement. Material and Methods: Thirty-eight patients with Class II malocclusion treated by bilateral sagittal split osteotomy (BSSO) and mandibular advancement were selected for this retrospective study. Group A (n = 16) had noncompressive bicortical screws inserted in the gonial area through a transcutaneous approach and Group B (n = 22) had the bone segments fixed with unicortical screws and miniplates on the lateral surface of the mandibular body. Cephalograms were taken preoperatively, 2 days postoperatively, and 6 months after the operation, and a computer program was used to superimpose the three cephalograms and register the advancement and postoperative instability. Results: There was a minimal difference in advancement of the mandible in the two groups. Statistical analysis showed no significant difference in postsurgical stability. However, positive correlation between the amount of advancement and the amount of postsurgical instability was demonstrated using a linear multiple regression test ( P = .0002). Conclusion: This study indicates that the two different methods of internal rigid fixation of the segments after surgical advancement of the mandible give equal stability postoperatively and their use is a matter of surgical choice.

The perimeter marking technique for rigid fixation of frontal sinus fractures: Procedure and report of cases

Purpose : Fractures of the frontal sinus region frequently need operative intervention in the form of reconstruction and obliteration. This requires removing the anterior table of the frontal sinus to gain access to the floor as well as the entire lateral extent of the sinus. Prior techniques to obtain this access have involved fabrication of preoperative radiographic templates. This article describes a technique of perimeter marking for delineating the precise location of the frontal sinus perimeter without the use of a radiographic template. Methods: A 7-cm bayonet forceps is used for the perimeter marking. One prong is placed inside the sinus to the maximum peripheral extent and the corresponding prong then reflects its position on the external surface of the outer table. A no. 701 bur in a high-speed drill marks the perimeter adjacent to the bayonet forceps. After sinus marking is complete, the osteotomy is accomplished using either a drill or oscillating saw. Results: Because the exact perimeter of the proposed osteoplastic flap is known prior to the osteotomy, bone plates can be preinserted, removed, and then replaced at the end of the procedure to anatomically reconstruct the frontal contour. Additionally, it is possible to remove a large region of the anterior table during the osteoplasty in one segment. Conclusion: This technique creates an unobstructed view of the lateral recesses of the frontal sinus and makes esthetic reconstruction of the frontal bar region possible.

Applications of Dental Splints with Regard to Modern Techniques of Rigid Fixation

Dental splints have been used in the treatment of maxillofacial fractures since the early 1700s. They have recently come into disfavor due to advancements in technology, the development of rigid fixation, and the application of craniofacial techniques. However, dental splints are still indicated in the management of maxillofacial fractures. These splints assist in anatomical reduction of the fractured segments, help immobilize and maintain the reduction prior to and during application of either maxillomandibular or rigid fixation, and act as stabilization during rehabilitation. Once surgeons become familiar with their applications, the time required to construct them is minimal.

A Biomechanical Analysis of Atlantoaxial Stabilization Methods Using a Bovine Model

The reliability and initial postoperative stability of six widely used C1-C2 surgical constructs were evaluated by nondestructive biomechanical testing of ten fresh bovine upper cervical spine segments. The six fixation techniques were the simple midline sublaminar C1 wiring (SMW), the modified Gallie wiring (MGW), the Brook wedge arthrodesis (BWA), the bilateral lateral mass screw (LMS), and the Clark arthrodesis without (CWO) and with (CW) the adjunctive use of polymethylmethacrylate (PMMA) cement. Instability was produced by resection of the base of the dens. Intact, destabilized, and instrumented constructs were tested in unconstrained flexion, extension, torsion, anterior, and posterior shear forces. The LMS and CW techniques proved the most effective in achieving C1-C2 stability. Sublaminar C2 wiring methods tended to have greater torsional and shear stiffness. Less rigid fixation techniques frequently loosened. All non-PMMA-enhanced wired constructs failed to restore the ability to adequately resist the posterior translation of C1 on C2. Stabilization of an unstable atlantoaxial articulation is best accomplished by a lateral mass screw or sublaminar C1-C2 PMMA-enhanced technique. Other techniques provided less consistent and reliable surgical fixation. Because of the inadequacy of wired constructs to resist posterior shear in patients with this instability pattern, the usual treatment may need to be modified to include more prolonged or protective external immobilization or more rigid fixation techniques. Although less rigid, the SMW and the MGW techniques are safer because they require less-frequent passage of sublaminar wires, avoid potential problems with PMMA, and obviate the hazards of further lateral dissection and insertion of the transarticular screws.

Acute open reduction and rigid internal fixation of proximal interphalangeal joint fracture dislocation

We report the application and results of a technique of open reduction and rigid internal fixation of dorsal fracture/dislocation of the proximal interphalangeal joint with an interfragmentary screw in two cases. Articular congruity was restored, and the proximal interphalangeal joint was stabilized. This technique permitted immediate range-of-motion exercises. Excellent results were obtained in both cases. Previous descriptions have not detailed the indications, the surgical approach, or the results of this technique.

Complex Orbital Fracture Repair Using Rigid Fixation of the Internal Orbital Skeleton

Large orbital fractures involving more than one orbital wall are frequently associated with enophthalmos and vertical globe dystopia. The authors repaired 22 orbits in 20 patients using the technique of rigid fixation of the internal orbital skeleton. Eleven orbits were reconstructed with titanium or vitallium implants that were custom-shaped to span the bony defect and fixed to the orbital rim. Seven orbits were reconstructed with bone grafts rigidly supported by a miniplate, and, in four cases, direct lag screw support of bone grafts was used. The intraoperative goal was to restore the native orbital anatomy and volume. Autologous calvarial bone grafts were used to supplement the repair to achieve the desired volumetric effect and to cover additional wall defects. A reoperation for additional orbital augmentation was needed in one enophthalmic and one anophthalmic orbit. There were no cases of overcorrection, migration, infection, or extraocular muscle entrapment. In complex orbital fractures, the technique of rigid internal orbital fixation appears to yield a stable and predictable result with the prevention of postoperative globe malposition.

Recent Advances in the Management of Orbital Trauma: Surgical Anatomy and Evaluation

The 1980s brought about an evolution in the evaluation and treatment of craniomaxillofacial trauma. Not only have the utilization of rigid internal fixation techniques become the standard of care in the treatment of facial fractures, but an improved understanding of pertinent surgical anatomy and pathophysiology has allowed more precise primary reconstruction. In no area has this been more true than in the evaluation and treatment of bony orbital trauma. During this same period, an enhanced appreciation of the sequelae of mismanaged orbital trauma has occurred. Both aesthetic and functional orbital dystopias are not uncommon, and secondary correction is extremely difficult. Accordingly, the surgeon's goals at the time of evaluation of isolated or combined orbital trauma are proper diagnosis and primary reconstruction, when appropriate, of the injured orbit. This, in turn, can only be performed with an absolute and thorough understanding of bony orbital anatomy. BONY ORBITAL ANATOMY AND PATHOPHYSIOLOGY

Nasal Reconstruction with Full-Thickness Cranial Bone Grafts and Rigid Internal Skeleton Fixation Through a Coronal Incision

The use of iliac and rib bone as onlay grafts to the nasal dorsum often fails because endochondral grafts resorb unpredictably. Membranous cranial bone grafts are less likely to resorb, especially when used with rigid internal fixation techniques. However, when split, they are often too thin and can be difficult to contour. Full-thickness cranial bone grafts were used to achieve nasal augmentation in 26 patients with end-stage nasal skeleton deficiency. All procedures were carried out using only a coronal incision. Grafts were harvested through a craniotomy, carved meticulously, and secured rigidly with miniplates or bicortical screws. Donor sites were reconstructed with split cranial grafts, leaving an intact cranial vault. No graft was lost to infection, and there was no significant donor-site morbidity. In carefully selected patients this method of full-thickness cranial bone graft reconstruction yields good results.

Rigid Internal Fixation vs. Traditional Techniques for the Treatment of Mandible Fractures

Treatment results were compared between mandibular fractures repaired with vitallium miniplates versus intermaxillary fixation (IMF) and wire osteosynthesis in 79 patients treated over a 4-year period. The postoperative courses of 35 patients treated with 46 plates were compared to those of 44 individuals treated with traditional reduction techniques. The plated group contained nine complications (26%) versus ten (23%) in the non-plated group. This difference was not statistically significant, despite the presence of more severe fractures in the plated group. Major complications (nonunions, malocclusions) were noted in only three (8%) of the plated group; there were six complications (14%) in the non-plated group. We conclude that the plating of mandibular fractures incurs no greater overall risk of complications than traditional methods of fixation, and a lower risk of major complications, and that the advantages of plate fixation, including decreased time of intermaxillary fixation and cost effectiveness, make this the method of choice in complex mandibular fractures, even in a high-risk population.

Short-term and long-term soft-tissue profile changes after mandibular advancements using rigid fixation techniques: Roberto Hernández-Orsini Birmingham: University of Alabama School of Dentistry, 1989

This study was designed to describe short- and long-term soft tissue profile changes that follow surgical advancement of the mandible, to provide a database for prediction of facial changes following surgery. A number of hard and soft tissue landmarks were identified on serial cephalometric tracings of 31 patients. The long-term data (x = 14.0 months postsurgery) showed that changes in soft tissue landmarks overlying the skeletal structures followed their hard tissue counterpart in a 1:1 ratio in the horizontal direction. Horizontal hard to soft tissue landmark changes between mandibular incisor and lower lip, however, were found to be different; the average ratio was 0.43:1.00. Short-term data (x = 2.7 months postsurgery) showed soft tissue changes to be stable when compared to long-term changes.

Salvage of Lisfranc's Tarsometatarsal Joint by Arthrodesis

Sixteen patients with fractures or fracture-dislocations of the tarsometatarsal (Lisfranc) joint who failed initial treatment were salvaged by arthrodesis using a technique of rigid internal fixation. Preoperative symptoms included local pain in all patients, progressive flatfoot deformity with forefoot abduction in 12 patients, and ankle or lateral impingement pain in five. The technique involved exposing the joint, denuding it of cartilage and scar, and reduction and fixation with lag screws. A total of 49 joints were fused. When significant deformity was present, reduction was performed before arthrodesis. Clinically symptomatic and radiographically proven nonunion occurred in four sites in three patients. One healed after revision. Good to excellent results were obtained in 11 patients (69%). Five patients had a fair or poor results. All but one of the patients were subjectively improved. Four patients were symptom free and returned to their preinjury lifestyles. Accurate reduction and early treatment had a significant positive relationship with outcome. Injuries that occurred in the workplace and those that incurred a long delay until treatment showed a significant negative correlation to outcome. Neither the age of the patient nor the number of joints fused had a significant impact on result.

The skeletal stability of Le Fort I downfracture osteotomies with rigid fixation

Twenty subjects receiving Le Fort I downfracture osteotomies stabilized with rigid fixation were studied for relapse. The analysis was based on longitudinal cephalometric radiographs taken within 2 weeks presurgically, 1 week postsurgically, and after a minimum period of 6 months postsurgically. Vertical and sagittal changes in the maxilla were evaluated in reference to the Frankfort horizontal plane. It was found that the mean postsurgical relapse was minimal and not significant. It was smaller than that reported for patients who had received stabilization of the maxilla with intraosseous and maxillomandibular wiring. It was concluded that the rigid fixation technique is dependable and yields stable postsurgical results in the maxilla.

Cantilever nasal bone grafting with miniscrew fixation.

A technique of rigid miniscrew fixation of cantilever nasal bone grafts is described. This produces stable, predictable nasal contour and tip projection without significant bone graft resorption.

Stability of simultaneous maxillary intrusion and mandibular advancement: A comparison of rigid and nonrigid fixation techniques

This study examines the short-term stability of bimaxillary surgery following Le Fort I impaction with simultaneous bilateral sagittal split osteotomies and mandibular advancement using two standard techniques of post-surgical fixation. Fifteen adults had skeletal plus dental maxillomandibular fixation, and fifteen adults had rigid internal fixation using bone plates in the maxilla and bicortical bone screws between the proximal and distal segments in the mandible. The group with rigid internal fixation did not undergo maxillomandibular fixation. Radiographic cephalograms were analyzed during the postsurgical period to evaluate skeletal and dental stability. There was no statistical difference in postsurgical stability with rigid internal fixation or skeletal plus dental maxillomandibular fixation other than the vertical position of the maxillary molar; the skeletal plus dental maxillomandibular fixation group had a significant amount of post-surgical intrusion of the maxillary molar when compared with the rigid internal fixation group. Although the other measures showed no statistically significant difference between the experimental groups, the amount of variability in postsurgical stability in the group with skeletal plus dental maxillomandibular fixation was greater than that found in the group with rigid internal fixation.

Stability of simultaneous maxillary intrusion and mandibular advancement: A comparison of rigid and non-rigid fixation techniques : Larry J. Skoczylas, DDS, MS, (Ellis, E., Fonseca, R.J., Gallo, W.J.) University of Michigan School of Dentistry, 1011 N. University, Ann Arbor, MI 48109

Stability of simultaneous maxillary intrusion and mandibular advancement: A comparison of rigid and non-rigid fixation techniques : Larry J. Skoczylas, DDS, MS, (Ellis, E., Fonseca, R.J., Gallo, W.J.) University of Michigan School of Dentistry, 1011 N. University, Ann Arbor, MI 48109

Stimulated molar bite force following advancement of the mandible: A comparison of rigid and non-rigid fixation techniques in Macaca mulatta: Edward Ellis, III, DDS, MS. University of Michigan, School of Dentistry, Ann Arbor, MI 48109 (Dechow P, Carlson DS)

Stimulated molar bite force following advancement of the mandible: A comparison of rigid and non-rigid fixation techniques in Macaca mulatta: Edward Ellis, III, DDS, MS. University of Michigan, School of Dentistry, Ann Arbor, MI 48109 (Dechow P, Carlson DS)

Microvascular Free-Tissue Transfer with Rigid Internal Fixation for Reconstruction of the Mandible Following Tumor Resection

The authors described their experience using rigid internal fixation techniques in combination with free microvascular tissue transfer for the immediate reconstruction of mandibular defects following tumor ablation. The technique allows immediate return of jaw motion and limited function while assuring maintenance of occlusion and reasonable cosmesis.

The Place of Internal Skeletal Fixation in Surgery of the Hand

Basic concepts in managing fractures of the hand are presented. Techniques of stabilization and rigid internal fixation both offer important advantages to the patient when selection of the procedure follows careful evaluation of the problem and consideration of the alternatives. Indications for and possible pitfalls of each technique are evaluated.