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The mandibular staple bone plate has been used to reconstruct the atrophic or deformed mandible in more than 400 cases. A survey was undertaken to evaluate those cases; results indicate that 90% of patients have satisfactory function.
A new type of mandibular bone plate implant has been described that immobilizes the mandible more ridigly than do previous bone appliances. Because of this characteristic, maxillomandibular fixation may be eliminated in a large percentage of fractured mandibles, or the time for immobilization is, at least, reduced.
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Compression of bone fragments to accelerate, or at least facilitate, bone healing was first applied in 1932 by Key to arthrodesis of the knee. Subsequently the same principle was applied to fractures, first by percutaneous pins as developed by Roger Anderson and then by implanted compression plates. Two types of compression plate have been evolved. One employs an axially oriented force produced by a separate screw or temporarily applied compression device, designed just for this purpose, as originated by Danis in 1949. The other, devised by me in 1956, is a so-called self-compressing plate, which generates compression force by inserting eccentrically placed chamfered screw-heads into slots in the plate so that the screws (as well as the bone fragments in which they are inserted) are translated toward each other. Numerous modifications of these two basic designs are now available.
Use of the self-compression plate has proved to be a reliable method for treatment of various mandibular fractures. It has been uncommon, however, to use the plates in preoperatively infected mandibular fractures. Based on acceptable results in general traumatology for cases with open-wound fractures, I inserted bone plates into initially infected mandibular fracture sites. The purpose of this paper is to report the results.
Plating in handsurgery has become a more frequently used method since the special instruments of the Swiss AO and the self-compression plates of Mittelmeier (made by Osteo AG) have been introduced. The results of biomechanical measurements, comparing the interfragmental compression power and tensile strength of the small-fragment-plates of the AO with the crescent-formed plates of Mittelmeier are reported. The compression power of the first reach their maximum by 8 kp, the latter an average of 20 kp. A gapping of the fracture occures under a deflection-momentum of 4 kp - cm using AO-plates and 10 kp - cm using the crescent-formed plates. The bending stiffness under deflection momentum to the off side of the plate is in the crescent plate 10 times higher. Only an angulating bending in the middle gives in both plates an all over good contact to the fragments. Finger osteosyntheses are very rigid against a deflection momentum in the level of the plate. (Regarding that, we fixe the plate sidewise on the bone.) Our conclusion is, that the better biomechanical stability of the self-compression plates--Mittelmeier-plates--is a result of the higher compression powers.
The results of 104 operations for traumatic compression of the brain have been studied. The advantages of bone-plastic approach are demonstrated. The indications for a primary removal of a flat bone graft plate in acute and subacute traumatic compression of the brain are precised. The results of a delayed plasty of skull defects following decompression trepanation are analysed. The flap bone plates, removed (on indications) during decompression trepanation through bone-plastic approach and kept in a weak formalin solution were used as grafts. Good results were obtained in the most of cases.
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Seven cases have been presented to demonstrate the reconstructive potential and the longevity of the mandibular staple in a variety of unusual cases. The use of the staple provides a surgical method to rehabilitate various types of mandibular deformities. Functional success without major complications has occurred in 90% of cases recently reported.
To briefly summarize our results, two of the five three-pin staples (40%) have survived and have functioned well for more than six years. Four of the five four-pin staples (80%) have survived five years or longer and are functioning well. Twenty-four of the 25 seven-pin staples (96%) are functioning well, some for a period of 4-1/2 years; a few in this group have been used a little less than a year. Our total percentage of survival with good function is 30 of 35, or 86%, which includes our pilot study of the three- and four-pin staples. A more significant statistic, however, might be those patients with staples who we feel have been free of any significant trouble; these are 27 of 35, or 77%. All of our patients have been subjected to peer review examination and grading by members of the oral surgery staff at Sinai Hospital. They were examined and graded according to three criteria. The first was clinical appearance which included firmness of the staple and clinical appearance of the gingiva (Fig 16). The second was radiographic evidence of bone loss along the transosteal pins and retentive pins (Fig 17). The third category was patient evaluation of improved function and stability of the lower denture (Fig 18). The peer review group used marks A, B, C, D, as excellent, good, fair, and failure. Four points were assigned to A, 3 points to B, 2 points to C, and 1 point to D, so that the grade averages for all three categories were as follows: clinical appearance, 3.6; radiographic appearance, 3.5; and patient evaluation, 3.9. The conclusion of the review group was that the mandibular staple was functioning well and that it was clinically useful. I have presented an overview of some of the characteristics of metallic implants that make them implantable devices, and some of the qualities of the host tissues that will allow placement of foreign material. We do not yet understand all of the factors that make alloplastic materials biocompatible or some of the reasons for rejection by the host. We need continued research in animal models to study new devices and new materials that might permit biologic attachments of the host to implant. We also need controlled clinical studies with peer review to establish reliability of those devices that are clinically useful. The mandibular staple has had an initial clinical trial that seems very promising and is worthy of continued clinical study and clinical application.
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