Bioabsorbable osteofixation for orthognathic surgery
© Park; licensee Springer. 2015
Received: 11 January 2015
Accepted: 11 January 2015
Published: 19 February 2015
Orthognathic surgery requires stable fixation for uneventful healing of osteotomized bony segments and optimal remodeling. Titanium plates and screws have been accepted as the gold standard for rigid fixation in orthognathic surgery. Although titanium osteofixation is the most widely used approach, the use of bioabsorbable devices has been increasing recently. Biodegradation of bioabsorbable devices eliminates the need for a second operation to remove metal plates and screws. However, long-term stability and relapse frequency in bioabsorbable osteofixation are still insufficiently studied, especially in cases of segmental movements of great magnitude or segmental movements to a position where bony resistance exists. This paper reviews the background, techniques, and complications of bioabsorbable osteofixation and compares bioabsorbable and titanium osteofixation in orthognathic surgery in terms of skeletal stability.
KeywordsOrthognathic surgery Bioabsorbable plate Biodegradation Skeletal stability
Successful orthognathic surgery requires a comprehensive surgical plan, effective osteofixation system for long-term skeletal stability, and achieving satisfactory esthetic facial appearance. Recently, bimaxillary orthognathic surgery has become popular because mandibular setback does not completely remove the midfacial symptoms of mandibular prognathism, which is often found in oriental races. Consequently, oral and maxillofacial surgeons need to perform more complicated surgery, which requires major segmental movements, i.e., those of greater magnitude or movements to a position where bony resistance exists.
Recent trends in orthognathic surgery include control of the occlusal plane to reduce the length of the face and application of so called “functional orthognathic surgery”, which means surgery first, orthodontic treatment later for patient’s convenience. These trends result in major bone movements with unstable occlusal interdigitation. Therefore, the need for rigid fixation becomes more important in modern orthognathic surgery. For a long time, titanium plates and screws have been considered to be the “gold standard” for rigid fixation in orthognathic surgery. Although titanium binds to the bone and asymptomatic bone plates can be retained , titanium plates should be removed due to growth disturbance, possible hypersensitivity to cold exposure, interference with radiological evaluation, possible stress-shielding effect as well as patients’ requests [2-5].
Oral and maxillofacial surgeons are increasingly using bioabsorbable devices because they eliminate the need for troublesome second operations to remove metal devices. Numerous clinical studies have documented comparable results between the use of resorbable and titanium plates and screws in orthognathic surgery regarding postoperative stability and relapse frequency [6-10]. However, there are few reports concerning postoperative skeletal stability after bioabsorbable osteofixation in a series of orthognathic cases accompanying major maxillomandibular segmental movements . This review highlights the evolution of resorbable osteosynthesis technology and postoperative stability of bioabsorbable osteosynthesis in orthognathic surgery.
Commercially available resorbable or bioabsorbable devices for osteofixation
Year of invention
Polymers and copolymers of PGA, PLLA, and PDLA were given preference over pure PGA and PLLA . Lactosorb® (Walter Lorenz Surgical Inc., Jacksonville, Florida, USA) is a copolymer of PLLA (82%) and PGA (18%). The copolymer is structured to provide adequate strength for 6–8 weeks and to allow a resorption time of 12–18 months . It is metabolized via the citric acid cycle and is eventually excreted by the lungs as carbon dioxide and water .
Ballon et al. have conducted a clinical study using a new polymer composition for resorbable osteosynthesis, poly-l/d-lactide-trimethylenecarbonate (TMC) (Inion, Tampere, Finland). P-l/d-lactide-TMC osteosynthesis seemed to have less strength against compressive forces after maxillary elongation and it is less resistant to the forces exerted by the tongue pressing against the mandible after setback .
The Le Fort I osteotomies are stabilized with four L-shaped resorbable or bioabsorbable plates and secured bilaterally in the pyriform aperture and zygomatic buttress. Reliable results have also been reported with the use of a biodegradable mesh [38,39]. Segmental Le Fort I osteotomy is also stabilized with the above standard fixation, i.e., the use of four 1.2 mm-thick, 7-hole L-type poly-l/d-lactide plates .
The drawbacks of using resorbable devices include their higher cost and some technical problems due to the characteristics of the material itself, postoperative plate fractures, and development of delayed foreign-body reactions. In 2003, Landes et al. reported that 27% of patients had complications after resorbable plate osteosynthesis of sagittal split osteotomies with major bone movement . The complication rate is now decreasing thanks to the development of new material compositions as well as improvement of surgical skills. Cheung et al. have concluded that the introduction of resorbable devices did not lead to an increase in intraoperative morbidities and postoperative complications .
Material-specific complications during operation include screw fractures, the need for wider dissection due to the larger sizes of resorbable devices, and difficulties in molding the devices into the desired shape. Screw fractures occur most often in screw heads when excessive force from the screwdriver is applied. A new hole is drilled through the fractured screw or an emergency screw can be used if adequate fixation cannot be obtained with a regular one. The need to increase the dimension for application during surgery has been recently met by using smaller products. Poly-l/d lactide plates and u-HA/PLLA composite plates are easily bendable with fingers at room temperature, combining wave-forms with angles and torsions, and can be maintained in the desired position without heating so far as slower bending and less force are applied. OsteotransMX® plates are bendable to 40 degrees at room temperature . Preshaped bent plates are also commercially available, or a boiling-water bath can be used.
An increasing number of clinical reports concerned with skeletal stability and relapses after bioabsorbable polymer osteosyntheses in orthognathic surgery are found in PubMed. Haers et al. reported predictable short-term skeletal stability with the use of poly-l/dl-lactide plates and screws in 10 consecutive cases of bimaxillary procedures with simultaneous genioplasties . Shand et al. reported mild mobility of the maxilla in the early postoperative period with the use of Lactosorb® bicortical screws for stabilization of mandibular SSRO in bimaxillary orthognathic surgery. However, stability was within normal limits at 6 weeks postoperatively .
Mandibular mobility in the early postoperative period was noted, especially when strong elastics were applied immediately postoperatively, but this problem could be easily overcome by gradual application of rubber force and avoidance of occlusal stress. In the author’s experience, none of bimaxillary orthognathic surgery patients (n = 153) treated after 2002 had fragment displacement that required refixation. All minor occlusal discrepancies were successfully controlled with elastic bands and guided occlusion. No malocclusions were noted during the follow-up period of at least 2 years. However, Ahn et al. reported a higher incidence of complications in patients with resorbable fixation compared with nonresorbable fixation in terms of postoperative anterior open bite and relapse frequency .
According to a preliminary report from another group, postoperative osseous movement was small when poly- l/dl-polylactide plates were used . As a result, resorbable osteofixation permitted clinically faster occlusal and condylar setting than titanium osteosynthesis, because segments showed low mobility in cleft lip and palate orthognathic surgery . Other researchers have demonstrated that resorbable devices did not increase segmental mobility or long-term instability compared with titanium plates in orthognathic surgery, including sagittal splitting of mandibular ramus and mandibular advancement [50,51]. In mandibular setback surgery, Paeng et al. suggested that bicortical resorbable screws offered a clinically stable outcome except for vertical measurements, compared with titanium fixation (n = 25) . Ueki et al. concluded that the change in condylar angle after SSRO was greater in the group with titanium fixation than in the group with PLLA fixation (n = 20 per group) .
In bimaxillary orthognathic surgery, PLLA/PGA plates appear to provide stable osteosynthesis for maxillary advancement of up to 5 mm . In another study on the bimaxillary procedure, a slight tendency for vertical relapse was reported in the group with PLLA osteofixation compared to the titanium osteofixation group, but the differences were not clinically significant and finally normal occlusion was established in both groups . Another retrospective study aimed to determine the differences in postoperative stability between poly-l/d-lactide and titanium plate systems used for fixation in bimaxillary orthognathic surgery, in particular maxillary posterior impaction surgery (n = 30) . Six months after surgery, there was no significant difference between the groups, as analyzed by lateral cephalogram. Furthermore, when segmental Le Fort I osteotomy for major movement of maxilla (n = 15) in bimaxillary orthognathic surgery was performed, the maxillary position remained stable with resorbable osteosyntheis .
No significant difference in the postsurgical relapse rate after mandibular setback surgery was found in the resorbable plate group . Absolute postoperative skeletal instability was not significantly different between resorbable and titanium plating systems for osteofixation in bimaxillary orthognathic surgery [57-59]. In contrast, Landes et al. reported compromised segmental stability in maxillary elongation and in mandibular setback with u-HA/PLLA composite osteosynthesis. They applied one 1.4-mm 4-hole plate and 8-mm monocortical screws at a mandibular SSRO site and recommended longer intermaxillary fixation, double osteosynthesis or use of larger plates . However, in most studies the groups were not matched for the magnitude or direction of fragment movement. Prospective studies with larger patient numbers are needed.
The use of bioabsorbable devices has resolved several problems of titanium fixation, such as the need for a second operation and interference with radiological evaluation. From the literature review, the author concluded that bioabsorbable osteosynthesis systems are reliable for fragment fixation in orthognathic procedures with major maxillomandibular segmental movements. The use of bioabsorbable devices leads to predictable postoperative long-term skeletal stability, which appears to be similar to that provided by titanium devices. In the future, we need less expensive bioabsorbable devices that degrade rapidly in the body.
- Haug RH (1996) Retention of asymptomatic bone plates used for orthognathic surgery and facial fractures. J Oral Maxillofac Surg 54:611–617PubMedView ArticleGoogle Scholar
- Lalor PA, Revell PA, Gray AB, Wright S, Railton GT, Freemen MA (1991) Sensitivity to titanium: a cause of implant failure? Br J Bone Joint Surg 73:25–28Google Scholar
- France TJ, Birely BC, Ringelman PR, Manson PN (1992) The fate of plates and screws after facial fracture reconstructioin. Plast Reconstr Surg 90:568–573View ArticleGoogle Scholar
- Schmidt BL, Perrott DH, Mahan D, Kearns G (1998) The removal of plates and screws after Le Fort I osteotomy. J Oral Maxillofac Surg 56:184–188PubMedView ArticleGoogle Scholar
- Ji B, Wang C, Liu L, Long J, Tian W, Wang H (2010) A biomechanical analysis of titanium miniplates used for treatment of mandibular symphyseal fractures with the finite element method. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 109:e21–e27PubMedView ArticleGoogle Scholar
- Edwards RC, Kiely KD, Eppley BL (2001) Fixation of bimaxillary osteotomies with resorbable plates and screws: Experience in 20 consecutive cases. J Oral Maxillofac Surg 59:271–276PubMedView ArticleGoogle Scholar
- Matthews NS, Khambay BS, Ayoub AF, Koppel D, Wood G (2003) Preliminary assessment of skeletal stability after sagittal split mandibular advancement using a bioresorbable fixation system. Br J Oral Maxillofac Surg 41:179–184PubMedView ArticleGoogle Scholar
- Kwon TK, Kim YD, Shin SH, Kim WK, Kim JR, Chung IK (2005) Stability after surgical correction of mandibular prognathism using bilateral saggital split ramus osteotomy and fixation with poly-L/DL-lactide copolymer screws (BiosorbTMFX). J Korean Assoc Maxillofac Plast Reconstr Surg 2:160–163Google Scholar
- Eppley BL (2007) Bioabsorbable plate and screw fixation in orthognathic surgery. J Craniofac Surg 18:818–825PubMedView ArticleGoogle Scholar
- Tuovinen V, Suuronen R, Teittinen M, Nurmenniemi P (2010) Comparison of the stability of bioabsorbable and titanium osteosynthesis materials for rigid internal fixation in orthognathic surgery. A prospective randomized controlled study in 101 patients with 192 osteotomies. Int J Oral Maxillofac Surg 39:1059–1065PubMedView ArticleGoogle Scholar
- Kulkarni RK, Pani KC, Neuman C, Leonard F (1966) Polylactic acid for surgical implants. Arch Surg 93:839–843PubMedView ArticleGoogle Scholar
- Cutright DE, Hunsuck EE, Beasley JD (1971) Fracture reduction using a biodegradable material, polylactic acid. J Oral Surg 29:393–397PubMedGoogle Scholar
- Suuronen R, Kallela I, Lindqvist C (2000) Bioabsorbable plates and screws: Current state of the art in facial fracture repair. J Craniomaxillofac Trauma 6:19–27PubMedGoogle Scholar
- Ylikontiola L, Sundqvuist K, Sàndor GK, Törmälä P, Ashammakhi N (2004) Self-reinforced bioresorbable poly-L/DL-lactide [SR-P(L/DL)LA] 70/30 miniplates and miniscrews are reliable for fixation of anterior mandibular fractures: a pilot study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 97:312–317PubMedView ArticleGoogle Scholar
- Choi J, Kim JR, Ha TJ, Yu JB, Kim IK (2005) The prognosis of fixation of mandibular fractures with biodegradable plates and screws. J Korean Assoc Maxillofac Plast Reconstr Surg 1:32–38Google Scholar
- Mohamed-Hashem IK, Mitchell DA (2000) Resorbable implants (plates and screws) in orthognathic surgery. J Orthod 27:198–199PubMedView ArticleGoogle Scholar
- Turvey TA, Bell RB, Tejera TJ, Proffit WR (2002) The use of self-reinforced biodegradable bone plates and screws in orthognathic surgery. J Oral Maxillofac Surg 60:59–65PubMedView ArticleGoogle Scholar
- Peltoniemi HH, Tulamo RM, Toivonen T, Hallikainen D, Tormala P, Waris T (1999) Biodegradable semirigid plate and miniscrew fixation compared with rigid titanium fixation in experimental calvarial osteotomy. J Neurosurg 90:910–917PubMedView ArticleGoogle Scholar
- Bergsma EJ, de Bruijn WC, Rozema FR, Bos RR, Boering G (1995) Late degradation tissue response to poly (L-lactide) bone plates and screws. Biomaterials 16:25–31PubMedView ArticleGoogle Scholar
- Bergsma EJ, Rozema FR, Bos RR, de Bruijn WC (1993) Foreign body reaction to resorbable poly (L-lactide) bone plates and screws used for the fixation of unstable zygomatic fractures. J Oral Maxillofac Surg 51:666–670PubMedView ArticleGoogle Scholar
- Surronen R, Haers PE, Lindqvist C, Sailer HF (1999) Update on bioresorbable plates in maxillofacial surgery. Facial Plast Surg 15:61–72View ArticleGoogle Scholar
- Wiltfang J, Merten HA, Schultze-Mosgau S, Schrell U, Wenzel D, Kessler P (2000) Biodegradable miniplates (LactoSorb): long-term results in infant minipigs and clinical results. J Craniofac Surg 11:239–243PubMedView ArticleGoogle Scholar
- Edwards RC, Kiely KD, Eppley BL (2001) The fate of resorbable poly-L-lactic/polyglycolic acid (LactoSorb) bone fixation devices in orthognathic surgery. J Oral Maxillofac Surg 59:19–25PubMedView ArticleGoogle Scholar
- Mazzonetto R, Paza AO, Spagnoli DB (2004) A retrospective evaluation of rigid fixation in orthognathic surgery using a biodegradable self-reinforced (70 L:30DL) polylactide. Int J Oral Maxillofac Surg 33:664–669PubMedView ArticleGoogle Scholar
- Kim BC, Padwa BL, Park HS, Jung YS (2011) Stability of maxillary position after Le Fort I osteotomy using self-reinforced biodegradable poly-70 L/30DL-lactide miniplates and screws. J Oral Maxillofac Surg 69:1442–1446PubMedView ArticleGoogle Scholar
- Hochuli-Vieira E, Cabrini Gabrielli MA, Pereira-Filho VA, Gabrielli MF, Padilha JG (2005) Rigid internal fixation with titanium versus bioresorbable miniplates in the repair of mandibular fractures in rabbits. Int J Oral Maxillofac Surg 34:167–173PubMedView ArticleGoogle Scholar
- Shikinami Y, Okuno M (1999) Bioresorbable devices made of forged composites of hydroxyapatite (HA) particles and poly L-lactide (PLLA): part I. Basic characteristics. Biomaterials 20:859–877PubMedView ArticleGoogle Scholar
- Shikinami Y, Okuno M (2001) Bioresorbable devices made of forged composites of hydroxyapatite (HA) particles and poly L-lactide (PLLA): part II. Practical properties of miniscrews and miniplates. Biomaterials 22:3179–3211View ArticleGoogle Scholar
- Shikinami Y, Matsuse Y, Nakamura T (2005) The complete process of bioresorption and bone replacement using devices made of forged composites of raw hydroxyapatite particles/poly L-lactide (F-u-HA/PLLA). Biomaterials 26:5542–5551PubMedView ArticleGoogle Scholar
- Landes CA, Ballon A, Tran A, Ghanaati S, Sader R (2014) Segmental stability in orthognathic surgery: Hydroxyapatite/poly L-lactide osteoconductive composite versus titanium miniplate osteosynthesis. J Craniomaxillofac Surg 41:930–942View ArticleGoogle Scholar
- Ballon A, Laudemann K, Sader R, Landes CA (2012) Segmental stability of resorbable P(L/DL)LA-TMC osteosynthesis versus titanium miniplates in orthognatic surgery. J Craniomaxillofac Surg 40:e408–e414PubMedView ArticleGoogle Scholar
- Maurer P, Holweg S, Knoll WD, Schubert J (2002) Study by finite element method of the mechanical stress of selected biodegradable osteosynthesis screws in sagittal ramus osteotomy. Br J Oral Maxillofac Surg 40:76–83.Google Scholar
- Kallela I, Laine P, Suuronen R, Lindqvist C, Iizuka T (2005) Assessment of material- and technique-related complications following sagittal split osteotomies stabilized by biodegradable polylactide screws. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 99:4–10PubMedView ArticleGoogle Scholar
- Ueki K, Marukawa K, Shimada M, Nakagawa K, Alam S, Yamamoto E (2006) Maxillary stability following Le Fort I osteotomy in combination with sagittal split ramus osteotomy and intraoral vertical ramus osteotomy: a comparative study between titanium miniplate and poly-L-lactic acid plate. J Oral Maxillofac Surg 64:74–80PubMedView ArticleGoogle Scholar
- Kim YK, Kim YJ, Yun PY, Kim JW (2009) Evaluation of skeletal and surgical factors related to relapse of mandibular setback surgery using the bioabsorbable plate. J Craniomaxillofac Surg 37:63–68PubMedView ArticleGoogle Scholar
- Ko EW, Huang CS, Lo LJ, Chen YR (2013) Alteration of masticatory electromyographic activity and stability of orthognathic surgery in patients with skeletal class III malocclusion. J Oral Maxillofac Surg 71:1249–1260PubMedView ArticleGoogle Scholar
- Ueki K, Okabe K, Miyazaki M, Munozawa A, Mori A, Marukawa K, Nakagawa K, Yamamoto E (2011) Skeletal stability after mandibular setback surgery: comparisons among unsintered hydroxyapatite/poly-L-lactic acid plate, poly-L-lactic acid plate, and titanium plate. J Oral Maxillofac Surg 69:1464–1468Google Scholar
- Sittitavornwong S, Waite PD, Dann JJ, Kohn MW (2006) The stability of maxillary osteotomies fixated with biodegradable mesh in orthognathic surgery. J Oral Maxillofac Surg 64:1631–1634PubMedView ArticleGoogle Scholar
- Meara DJ, Knoll MR, Holmes JD, Clark DM (2012) Fixation of Le Fort I osteotomies with poly-DL-lactic acid mesh and ultrasonic welding–a new technique. J Oral Maxillofac Surg 70:1139–1144PubMedView ArticleGoogle Scholar
- Kim MK, Park YW (2009) Post-operative skeletal stability of the maxilla treated with Le Fort I and U-shaped osteotomies in simultaneous maxillomandibular orthognathic surgery. J Korean Assoc Maxillofac Plast Reconstr Surg 31:485–491Google Scholar
- Landes CA, Kriener S (2003) Resorbable plate osteosynthesis of sagittal split osteotomies with major bone movement. Plast Reconstr Surg 111:1828–1840PubMedView ArticleGoogle Scholar
- Cheung LK, Chow LK, Chiu WK (2004) A randomized controlled trial of resorbable versus titanium fixation for orthognathic surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 98:386–397PubMedView ArticleGoogle Scholar
- van Bakelen NB, Buijs GJ, Jansma J, de Visscher JG, Hoppenreijs TJ, Bergsma JE, Stegenga B, Bos RR (2013) Comparison of biodegradable and titanium fixation in maxillofacial surgery: a two-year multi-center randomized controlled trial. J Dent Res 92:1100–1105Google Scholar
- Laine P, Kontio R, Lindqvist C, Suuronen R (2004) Are there any complications with bioabsorbable fixation devices? A 10 year review in orthognathic surgery. Int J Oral Maxillofac Surg 33:240–244PubMedView ArticleGoogle Scholar
- Turvey TA, Proffit WP, Phillips C (2011) Biodegradable fixation for craniomaxillofacial surgery: a 10-year experience involving 761 operations and 745 patients. Int J Oral Maxillofac Surg 40:244–249PubMed CentralPubMedView ArticleGoogle Scholar
- Haers PE, Sailer HF (1998) Biodegradable self-reinforced poly-L/DL-lactide plates and screws in bimaxillary orthognathic surgery: short term skeletal stability and material related failures. J Craniomaxillofac Surg 26:363–372PubMedView ArticleGoogle Scholar
- Shand JM, Heggie AA (2000) Use of a resorbable fixation system in orthognathic surgery. Br J Oral Maxillofac Surg 38:335–337PubMedView ArticleGoogle Scholar
- Ahn YS, Kim SG, Baik SM, Kim BO, Kim HK, Moon SY, Lim SH, Kim YK, Yun PY, Son JS (2010) Comparative study between resorbable and nonresorbable plates in orthognathic surgery. J Oral Maxillofac Surg 68:287–292Google Scholar
- Landes CA, Ballon A (2006) Five-year experience comparing resorbable to titanium miniplate osteosynthesis in cleft lip and palate orthognathic surgery. Cleft Palate Craniofac J 43:67–74PubMedView ArticleGoogle Scholar
- Turvey TA, Bell RB, Phillips C, Proffit WR (2006) Self-reinforced biodegradable screw fixation compared with titanium screw fixation in mandibular advancement. J Oral Maxillofac Surg 64:40–46PubMed CentralPubMedView ArticleGoogle Scholar
- Stockmann P, Bohm H, Driemel O, Muhling J, Pistner H (2010) Resorbable versus titanium osteosynthesis devices in bilateral sagittal split ramus osteotomy of the mandible - the results of a two centre randomized clinical study with an eight-year follow-up. J Craniomaxillafac Surg 38:522–528View ArticleGoogle Scholar
- Paeng JY, Hong J, Kim CS, Kim MJ (2012) Comparative study of skeletal stability between bicortical resorbable and titanium screw fixation after sagittal split ramus osteotomy for mandibular prognathism. J Craniomaxillafac Surg 40:660–664View ArticleGoogle Scholar
- Ueki K, Nakagawa K, Marukawa K, Takazakura D, Shimada M, Takatsuka S, Yamamoto E (2005) Changes in condylar long axis and skeletal stability after bilateral sagittal split ramus osteotomy with poly-L-lactic acid or titanium plate fixation. Int J Oral Maxillofac Surg 34:627–634Google Scholar
- Costa F, Robiony M, Zorzan E, Zerman N, Politi M (2006) Stability of skeletal Class III malocclusion after combined maxillary and mandibular procedures: titanium versus resorbable plates and screws for maxillary fixation. J Oral Maxillofac Surg 64:642–651PubMedView ArticleGoogle Scholar
- Park JM, Park YW (2010) Postoperative stability of fixation with absorbables in simultaneous maxillomandibular orthognathic surgery. J Korean Assoc Maxillofac Plast Reconstr Surg 32:126–131Google Scholar
- Lee JY, Kim YK, Yun PY, Lee NK, Kim JW, Choi JH (2014) Evaluation of stability after orthognathic surgery with minimal orthodontic preparation: comparison according to 3 types of fixation. J Craniofac Surg 25:911–915PubMedView ArticleGoogle Scholar
- Landes CA, Ballon A (2006) Skeletal stability in bimaxillary orthognathic surgery: P(L/DL)LA-resorbable versus titanium osteofixation. Plast Reconstr Surg 118:703–721PubMedView ArticleGoogle Scholar
- Landes CA, Ballon A, Sader R (2007) Segment stability in bimaxillary orthognathic surgery after resorbable Poly(L-lactide-co-glycolide) versus titanium osteosyntheses. J Craniofac Surg 18:1216–1229PubMedView ArticleGoogle Scholar
- Moure C, Qassemyar Q, Dunaud O, Neiva C, Testelin S, Devauchelle B (2012) Skeletal stability and morbidity with self-reinforced P (L/DL) LA resorbable osteosynthesis in bimaxillary orthognathic surgery. J Craniomaxillofac Surg 40:55–60PubMedView ArticleGoogle Scholar
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.