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.
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.
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