Stability of biodegradable metal (Mg-Ca-Zn alloy) screws compared with absorbable polymer and titanium screws for sagittal split ramus osteotomy of the mandible using the finite element analysis model

Research progress and perspective of metallic implant biomaterials for craniomaxillofacial surgeries

Craniomaxillofacial bone serves a variety of functions. However, the increasing number of cases of craniomaxillofacial bone injury and the use of selective rare implants make the treatment difficult, and the cure rate is low. If such a bone injury is not properly treated, it can lead to a slew of complications that can seriously disrupt a patient's daily life. For example, premature closure of cranial sutures or skull fractures can lead to increased intracranial pressure, which can lead to headaches, vomiting, and even brain hernia. At present, implant placement is one of the most common approaches to repair craniomaxillofacial bone injury or abnormal closure, especially with biomedical metallic implants. This review analyzes the research progress in the design and development of degradable and non-degradable metallic implants in craniomaxillofacial surgery. The mechanical properties, corrosion behaviours, as well as in vitro and in vivo performances of these materials are summarized. The challenges and future research directions of metallic biomaterials used in craniomaxillofacial surgery are also identified.

Application of numerical simulation studies to determine dynamic loads acting on the human masticatory system during unilateral chewing of selected foods

Introduction: This paper presents its kinematic-dynamic computational model (3D) used for numerical simulations of the unilateral chewing of selected foods. The model consists of two temporomandibular joints, a mandible, and mandibular elevator muscles (the masseter, medial pterygoid, and temporalis muscles). The model load is the food characteristic (i), in the form of the function F_i = f(Δh_i)-force (F_i) vs change in specimen height (Δh_i). Functions were developed based on experimental tests in which five food products were tested (60 specimens per product). Methods: The numerical calculations aimed to determine: dynamic muscle patterns, maximum muscle force, total muscle contraction, muscle contraction corresponding to maximum force, muscle stiffness and intrinsic strength. The values of the parameters above were determined according to the mechanical properties of the food and according to the working and non-working sides. Results and Discussion: Based on the numerical simulations carried out, it can be concluded that: (1) muscle force patterns and maximum muscle forces depend on the food and, in addition, the values of maximum muscle forces on the non-working side are 14% lower than on the working side, irrespective of the muscle and the food; (2) the value of total muscle contraction on the working side is 17% lower than on the non-working side; (3) total muscle contraction depends on the initial height of the food; (4) muscle stiffness and intrinsic strength depend on the texture of the food, the muscle and the side analysed, i.e., the working and non-working sides.

Advanced Hydrogel systems for mandibular reconstruction

Mandibular defect becomes a prevalent maxillofacial disease resulting in mandibular dysfunctions and huge psychological burdens to the patients. Considering the routine presence of oral contaminations and aesthetic restoration of facial structures, the current clinical treatments are however limited, incapable to reconstruct the structural integrity and regeneration, spurring the need for cost-effective mandibular tissue engineering. Hydrogel systems possess great merit for mandibular reconstruction with precise involvement of cells and bioactive factors. In this review, current clinical treatments and distinct mode(s) of mandible formation and pathological resorption are summarized, followed by a review of hydrogel-related mandibular tissue engineering, and an update on the advanced fabrication of hydrogels with improved mechanical property, antibacterial ability, injectable form, and 3D bioprinted hydrogel constructs. The exploration of advanced hydrogel systems will lay down a solid foundation for a bright future with more biocompatible, effective, and personalized treatment in mandibular reconstruction.

Applications of Biodegradable Magnesium-Based Materials in Reconstructive Oral and Maxillofacial Surgery: A Review

Reconstruction of defects in the maxillofacial region following traumatic injuries, craniofacial deformities, defects from tumor removal, or infections in the maxillofacial area represents a major challenge for surgeons. Various materials have been studied for the reconstruction of defects in the maxillofacial area. Biodegradable metals have been widely researched due to their excellent biological properties. Magnesium (Mg) and Mg-based materials have been extensively studied for tissue regeneration procedures due to biodegradability, mechanical characteristics, osteogenic capacity, biocompatibility, and antibacterial properties. The aim of this review was to analyze and discuss the applications of Mg and Mg-based materials in reconstructive oral and maxillofacial surgery in the fields of guided bone regeneration, dental implantology, fixation of facial bone fractures and soft tissue regeneration.

Titanium or Biodegradable Osteosynthesis in Maxillofacial Surgery? In Vitro and In Vivo Performances

Osteosynthesis systems are used to fixate bone segments in maxillofacial surgery. Titanium osteosynthesis systems are currently the gold standard. However, the disadvantages result in symptomatic removal in up to 40% of cases. Biodegradable osteosynthesis systems, composed of degradable polymers, could reduce the need for removal of osteosynthesis systems while avoiding the aforementioned disadvantages of titanium osteosyntheses. However, disadvantages of biodegradable systems include decreased mechanical properties and possible foreign body reactions. In this review, the literature that focused on the in vitro and in vivo performances of biodegradable and titanium osteosyntheses is discussed. The focus was on factors underlying the favorable clinical outcome of osteosyntheses, including the degradation characteristics of biodegradable osteosyntheses and the host response they elicit. Furthermore, recommendations for clinical usage and future research are given. Based on the available (clinical) evidence, biodegradable copolymeric osteosyntheses are a viable alternative to titanium osteosyntheses when applied to treat maxillofacial trauma, with similar efficacy and significantly lower symptomatic osteosynthesis removal. For orthognathic surgery, biodegradable copolymeric osteosyntheses are a valid alternative to titanium osteosyntheses, but a longer operation time is needed. An osteosynthesis system composed of an amorphous copolymer, preferably using ultrasound welding with well-contoured shapes and sufficient mechanical properties, has the greatest potential as a biocompatible biodegradable copolymeric osteosynthesis system. Future research should focus on surface modifications (e.g., nanogel coatings) and novel biodegradable materials (e.g., magnesium alloys and silk) to address the disadvantages of current osteosynthesis systems.

Bone Union Quality after Fracture Fixation of Mandibular Head with Compression Magnesium Screws

For some years now, fixation devices created with resorbable magnesium alloys for the mandibular head have been clinically available and are beginning to be used. It is thus valuable to evaluate the quality of unions in these cases. The aim of this study was radiological comparison of magnesium versus titanium open reduction and rigid fixations in the mandible condylar head. Thirty-one patients were treated for fractures of the mandibular head with magnesium WE43 alloy headless compression screws (diameter 2.3 mm) and, as a reference group, 29 patients were included with similar construction titanium screws (diameter 1.8 mm). The 12-month results of the treatment were evaluated by the texture analysis of CT. Near similar treatment results were found with magnesium screws in traditional titanium fixation. Magnesium screws result in a higher density of the bone structure in the mandibular head. Conclusions: The quantitative evaluation of bone union after surgical treatment of mandibular head fracture with magnesium compression headless screws indicates that stable consolidation was achieved. Undoubtedly, the resorption process of the screws was found to be incomplete after 12 months, evidenced by a marked densification of the bone structure at the fracture site.

Biodegradation behaviors of magnesium(Mg)-based alloy nails in autologous bone grafts: In vivo study in rabbit skulls

OBJECTIVE

In this study, autologous bone grafts using bone-fixing nails made of magnesium-zinc-calcium ternary alloys were performed using rabbit skulls.

MATERIAL AND METHODS

Two types of nails for bone fixation were prepared: 2.5 mm width, 3 mm length and 2.5 mm width, 2 mm length. A disk-shaped bone with a diameter of 5 mm was resected from the parietal bone and fixed with a 3 mm long nail. As a control group, a 2 mm long nail was driven into the existing bone. The rabbits were sacrificed at 1, 4, 12, and 24 weeks after surgery. The resected samples were observed with micro X-ray CT, and embedded in methyl methacrylate to prepare non-decalcified specimens. The in vivo localization of elements was examined using energy-dispersive X-ray spectroscopy (EDS).

RESULTS

Micro X-ray CT images of samples showed volume reduction due to degradation in both the bone graft and control groups. No significant difference in the amount of degradation between the two groups was observed, however characteristic degradation processes were observed in each group. The samples stained with alizarin red S showed amorphous areas around the nails, which were considered as corrosion products and contacted directly with the newly formed bones. EDS analysis showed that corrosion products were mainly composed of magnesium and oxygen at an early stage, while calcium and phosphorus were detected on the surface layer during the long-term observation.

CONCLUSIONS

The degradation speed of the magnesium alloy nails varied depending on the shapes of the nails and surrounding tissue conditions. A calcium phosphate layer was formed on the surface of magnesium alloy nails, suggesting that the degradation rate of the nail was slow.

Research status of biodegradable metals designed for oral and maxillofacial applications: A review

The oral and maxillofacial regions have complex anatomical structures and different tissue types, which have vital health and aesthetic functions. Biodegradable metals (BMs) is a promising bioactive materials to treat oral and maxillofacial diseases. This review summarizes the research status and future research directions of BMs for oral and maxillofacial applications. Mg-based BMs and Zn-based BMs for bone fracture fixation systems, and guided bone regeneration (GBR) membranes, are discussed in detail. Zn-based BMs with a moderate degradation rate and superior mechanical properties for GBR membranes show great potential for clinical translation. Fe-based BMs have a relatively low degradation rate and insoluble degradation products, which greatly limit their application and clinical translation. Furthermore, we proposed potential future research directions for BMs in the oral and maxillofacial regions, including 3D printed BM bone scaffolds, surface modification for BMs GBR membranes, and BMs containing hydrogels for cartilage regeneration, soft tissue regeneration, and nerve regeneration. Taken together, the progress made in the development of BMs in oral and maxillofacial regions has laid a foundation for further clinical translation.

Biomechanical evaluation of unilateral subcondylar fracture of the mandible on the varying materials: A finite element analysis

Fixation materials used in the surgical treatment of subcondylar fractures contribute to successful clinical outcomes. In this study, we simulated the mechanical properties of four fixation materials [titanium (Ti), magnesium alloy (Mg alloy), poly-L-lactic acid (PLLA), and hydroxyapatite/poly-L-lactide (HA-PLLA)] in a finite-element analysis model of subcondylar fracture. Two four-hole plates were fixed on the anterior and posterior surfaces of the subcondyle of the mandible. In the simulation model of a subcondylar fracture, we evaluated the stress distribution and mechanical deformation of fixation materials. The stress distribution conspicuously appeared on the condylar neck of the non-fractured side and the center of the anterior plate for all materials. More stress distribution to the biologic component appeared with HA-PLLA than with Ti or Mg alloy, but its effects were less prominent than that of PLLA. The largest deformation was observed with PLLA, followed by HA-PLLA, Mg alloy, and Ti. The results of the present study imply the clinical potential of the HA-PLLA fixation material for open reduction of subcondylar fractures.

Investigation of a Modified Novel Technique in Bilateral Sagittal Splitting Osteotomy Fixation: Finite Element Analysis and In Vitro Biomechanical Test

Purpose

To evaluate the biomechanical properties of the modified novel 2-hole monocortical plate fixation (2HMCPf) and traditional 4-hole monocortical plate fixation (4HMCPf) techniques in bilateral sagittal splitting osteotomy (BSSO) synthesis using a finite element analysis (FEA) and an in vitro biomechanical test with the application of a shearing loading force on a sawbone mandible model.

Materials and Methods

A three-dimensional mandible models were generated using the geometry obtained from the computerized tomography image of a sawbone mandible. Plates and screws were generated and combined with the mandible in a CAD environment. The 2HMCPf and traditional 4HMCPf techniques for BSSO osteosynthesis were then analyzed under the occlusal load using the FEA. An in vitro biomechanical test was executed to verify the result of FEA. The force on fixation failure and pattern of failure were recorded.

Results

The results revealed that the von Mises Stress on the mandible cortical bone (75.98 MPa) and the screw/plate (457.19 MPa) of the 2HMCPf group was lower than that of the 4HMCPf group (987.68 MPa, 1781.59 MPa). The stress concentrated on the central region of the 4HMCPf group and the distal set of the 2HMCPf group. In vitro study using the sawbone mandible model showed mechanical failure at the region of the proximal segment near the osteotomy site with the 4HMCPf group (average 32.198 N) but no failure on the fixation sites with the 2HMCPf group. Instead, the mandible sawbone fractured on the condyle neck region (average 44.953 N).

Conclusion

From the biomechanical perspective, we proved that the 2HMCPf method was able to withstand a higher shearing loading force than the 4HMCPf fixation method in BSSO osteosynthesis.

Are Magnesium Screws Proper for Mandibular Condyle Head Osteosynthesis?

Recently, magnesium alloys have gained a significant amount of recognition as potential biomaterials for degradable implants for craniofacial bone screws. Purpose: The aim of this work was to compare screws made specifically for mandibular head osteosynthesis from different materials. Materials and Methods: Screws measuring 14 mm made by one manufacturer specifically for mandibular head osteosynthesis out of the following materials were selected: magnesium (MgYREZr), titanium (Ti6Al7Nb), and polymer (PLGA). The axial pull-out strength and torsional properties were investigated. Results: Each type of screw presented different pull-out forces (Kruskal–Wallis test, p < 0.001). The magnesium screw had the highest pull-out force of 399 N (cracked without the screw out being pulled out), followed by the titanium screw, with a force of 340 N, and the PLGA screw, with a force of 138 N (always cracked at the base of the screw head without the screw being pulled out). ANOVA was performed for the maximal torques before damage to the screw (torsional properties), revealing that the maximal torque of the magnesium screw was 16 N·cm, while that of the titanium screw was 19 N·cm. The magnesium screw was significantly weaker than the titanium screw (p < 0.05). The measured torque and pull-out force were not related to each other (p > 0.05). Conclusion: Among the screws compared, the metal biodegradable magnesium screw seems to be the most suitable material for multiscrew mandibular head osteosynthesis, considering the condition of the fragile screwdriver socket.

Effect of foods on selected dynamic parameters of mandibular elevator muscles during symmetric incisal biting

The paper focuses on research that enables the relationship between food and selected mechanical parameters do be determined. The main aim of the study was to designate, depending on the food: (1) the work of a single muscle (i.e. masseter, medial pterygoid, temporalis), and (2) the energy balance of mandibular elevator muscles based on the dynamic patterns of muscles. In turn, the indirect goal was to determine: (1) the muscle contraction, and (2) the average muscle contraction velocity based on the specified kinematic parameters, i.e. incisal biting velocity and incisal biting time. A hybrid model, consisting of a phenomenological model of the masticatory system and a behavioural model of incisal biting, was used in the calculations. The phenomenological model was based on an anatomically and physiologically normal mandible and healthy muscles, while the behavioural model was represented by the dynamic patterns of food. Calculations showed that muscle force is an important, but not the only, parameter that enables the quantitative and qualitative assessment of the functioning of the mandibular elevator muscles during symmetric incisal biting. Based on the obtained results, it can be stated that the dynamic patterns of muscles are a very important parameter, because on their basis, among others, muscle contraction, contraction time, work, and energy can be determined. The conducted calculations and analyses showed that the above-mentioned parameters depend on the mechanical properties of food (the dynamic patterns of food).

The Stability of Hydroxyapatite/Poly-L-Lactide Fixation for Unilateral Angle Fracture of the Mandible Assessed Using a Finite Element Analysis Model

Recently, a hydroxyapatite particle/poly-L-lactide (HA-PLLA) composite device was introduced as an alternative to previous fixation systems. In this study, we used finite element analysis to simulate peak von Mises stress (PVMS) and deformation of bone plates and screws with the following four materials—Ti, Mg alloy, PLLA, and HA-PLLA—at a unilateral mandibular fracture. A three-dimensional virtual mandibular model was constructed, and the fracture surface was designed to run from the left mandibular angle. Masticatory loading was applied on the right first molars. Stress was concentrated at the upper part and the neck of the screw. The largest PVMS was observed for Ti; that was followed by Mg alloy, HA-PLLA, and PLLA. The largest deformation was observed for PLLA; next was HA-PLLA, then Mg alloy, and finally Ti. We could rank relative superiority in terms of mechanical properties. The HA-PLLA screw and mini-plate deformed less than 0.15 mm until 300 N. Thus, we can expect good bone healing with usual masticatory loading six weeks postoperatively. HA-PLLA is more frequently indicated clinically than PLLA owing to less deformation. If the quality of HA-PLLA fixation is improved, it could be widely utilized in facial bone trauma or craniofacial surgery.

The Potential of Magnesium Based Materials in Mandibular Reconstruction

The future of biomaterial design will rely on development of bioresorbable implant materials that completely and safely degrade in vivo after the tissues grow, without generating harmful degradation products at the targeted anatomic site. Permanent biomaterials such as Ti6Al4V alloy, 316L stainless steel, and Co-based alloys currently used in mandibular reconstruction often result in stress shielding effects due to mismatch in the Young’s modulus values between the bone and the implant, resulting in implant loosening. Also, allergic responses due to metal ion releases necessitates revision surgery to prevent long term exposure of the body to toxic implant contents. Bioresorbable metals are perceived as revolutionary biomaterials that have transformed the nature of metallic biomaterials from bioinert to bioactive and multi-bio functional (anti-bacterial, anti-proliferation, and anti-cancer). In this aspect, magnesium (Mg)-based materials have recently been explored by the biomedical community as potential materials for mandibular reconstruction, as they exhibit favorable mechanical properties, adequate biocompatibility, and degradability. This article reviews the recent progress that has led to advances in developing Mg-based materials for mandibular reconstruction; correlating with the biomechanics of mandible and types of mandibular defects. Mg-based materials are discussed regarding their mechanical properties, corrosion characteristics, and in vivo performance. Finally, the paper summarizes findings from this review, together with a proposed scope for advancing the knowledge in Mg-based materials for mandibular reconstruction.

Comparative study of biomechanical stability of resorbable and titanium fixation systems after sagittal split ramus osteotomy with a novel designed in-vitro testing unit

INTRODUCTION

Sagittal split ramus osteotomy (SSRO) is one of the most popular surgical procedures for correction of mandibular deformities. Several clinical and biomechanical studies exist in the literature which, comparing the stability of different osteosynthesis materials and techniques, were performed using two or three-point biomechanical test models. The aim of this study was to compare the stability of biodegradable and titanium materials for SSRO on one-piece polyurethane mandible samples which were fixed in a novel designed 6-point testing unit.

MATERIALS AND METHODS

16 polyurethane one piece replicas of human mandibles were used and bilateral SSRO were performed by the manufacturer according to Dal Pont modification. Mandibles were fixed with titanium and PLLA/PGA fixation materials. Displacement amounts were measured under loading forces using a non-contact extensometer, and strain values at the screws were recorded by strain gauges.

RESULTS

Bicortical titanium screws (Group 2) showed significantly lower displacement values, while bicortical PLLA/PGA screws (group 4) showed significantly higher displacement values at 40-360 N forces. (p < 0.05). The highest strain value was measured on screws that were inserted upright in a proximal segment near the osteotomy line.

CONCLUSION

To achieve more realistic results in biomechanical studies, test models should imitate jaw movements and test environments should be as similar as possible to physiological conditions. Newly designed six-point testing units will contribute to future biomechanical studies.