Abstract
Oral and maxillofacial surgery (OMFS) is a broad scope medical and dental specialty that focuses on the diagnoses and treatment of a wide range of disorders including those that affect the head and neck, as well as the facial complex and skeleton. A number of tools and materials can be used intraoperatively with the intention of increasing the success rate of a surgical procedure and shortening the healing time for patients. In this chapter, we will explore several elements of surgical intervention relating to the use of varying types of bone grafts, along with implementing growth factors and enhancers including bone morphogenetic protein (BMP), transforming growth factor-β (TGF-β), platelet-derived growth factor (PDGF), fibroblast growth factor (FGF), and platelet-rich plasma (PRP). In addition, we will examine the use of biodegradable materials including bone plates, membranes, and scaffolds. Further, we will discuss the use of implantable devices in the surgical treatment of patients for replacement of teeth and fixation of hard tissue structures using customizable titanium plates and screws within the realm of OMFS. Finally, we consider what the future holds with regard to technologically assisted surgery.
1 Introduction
The methods that currently exist for treating maxillofacial defects are not as robust as they could be. Moreover, large contributors to success are the surgeon’s skill and the patient’s own bodily reactions to materials used intraoperatively [1]. Often, patients are left with oral and maxillofacial defects or fractures, which range in size due to such things as congenital anomalies, acquired pathologies, and trauma. For instance, complete or partial resection in the midface or mandible due to oncologic surgery or following trauma requires the use of grafting materials, whether natural or synthetic, to resolve the void created. Further, bone graft materials are applied to congenital defects such as cleft palate, facial clefts, and facial asymmetries [2]. To enhance the effectiveness of such grafts, growth factors are used. Growth factors are steroid hormones or proteins that aid in cellular differentiation, proliferation, growth, and maturation. Growth factors may also have both inhibitory and stimulatory effects and have been shown to aid in the regeneration of bodily hard and soft tissues. Growth factors are also involved in a multitude of processes including mitogenesis, angiogenesis, metabolism, and wound healing [3]. In this chapter, we place emphasis on BMP, TGF, FGF, and PDGF. Within the realm of oral and maxillofacial surgery, oral implantology is becoming more popular among patients hoping to bridge gaps within their dentition for improvement in form, function, and esthetics. As will be discussed later in the chapter, there are a multitude of different implant systems and numerous types of implant materials, shapes, and coatings that are used at the surgeon’s preference and skill level [4]. This chapter will also explore different options concerning inter-maxillary and mandible fractures and how to fixate with plates, and screws, either biodegradable or permanent, in an effort to speed healing and recovery.
2 Grafting and Growth Factors
2.1 Grafting
Recovery and maintenance of natural structures has been a great challenge within the realm of oral and maxillofacial surgery. For a number of years, autogenous bone has been the gold standard for grafting due to its osteogenic, osteoinductive, and osteoconductive properties. However, there are several drawbacks to using autogenous bone including morbidity, availability, and inability to customize shape and potential resorption [5,6,7,8]. To date, the perfect grafting material has not been identified, as this may be very patient specific. This section focuses on autografts; however, properties of various bone grafts and bone substitutes will be discussed later in this chapter.
Autogenous grafts may include cortical, cancellous, or cortico-cancellous bone with multiple factors determining successful incorporation. The healing process of these grafts requires both osteoconduction and osteoinduction. Embryonic origin, extent of revascularization, biomechanical features, type of fixation, and availability of growth factors are all factors of significant importance for incorporation of autogenous bone grafts [9]. Albrektsson and colleagues used a rabbit model to investigate the survivability of both cortical and cancellous bone grafts. It was found that trauma to the graft compromised cell viability in addition to a lag in the revascularization time, whereas the carefully handled graft revascularized and remodeled faster [10]. Furthermore, it was found that the cancellous bone grafts demonstrated a faster rate of revascularization than the cortical grafts [11,12,13]. More regarding grafting techniques will be discussed later in this chapter.
With regard to healing, it has been suggested that soft tissue pressure applied by the periosteum and/or the flap covering the graft may in fact increase the osteoclastic activity [14, 15]. As will be discussed in more detail later in the chapter, rigid fixation, a technique often used in the operating room, is important for healing. Several studies have concluded that rigid fixation (Figs. 3.1 and 3.2) increases the survival rate of the graft [16, 17].
Mandibular angle fracture with rigid fixation [18]
Rigid fixation of mandibular fracture using plates and screws [19]
2.2 Growth Factors Relevant to Surgery
Currently, researchers are investigating proteins and carriers for the delivery of growth factors (GFs): however, there are questions that exist with regard to the efficacy of these materials [20]. GFs are present in bone matrix and plasma , albeit in low concentrations [21]. GFs are biological mediators that have been shown to help in the regeneration of the natural periodontium. They are key factors in cellular differentiation, proliferation, and maturation. In addition, these GFs have been shown to have both stimulatory and inhibitory effects [3].
2.2.1 Bone Morphogenetic Protein
In 1971, it was shown that prote in extracted from demineralized bone matrix induced the formation of the bone. This extracted protein was named BMP [22]. BMPs can provoke local immediate action, bind to extracellular antagonists, or interact with the extracellular matrix proteins and, subsequently, target cells. Interestingly, BMPs can regulate morphogenesis during development while also inducing bone and cartilage formation [23]. In their work, Karsenty and Kingsley describe how BMPs form a large group of proteins, which affect migration, differentiation, and cell growth. This protein group is the TGF-β superfamily [24, 25]. The TGF-β superfamily includes a number of proteins such as BMPs, osteogenic proteins, cartilage-derived morphogenic proteins, and growth differentiation factors [26]. Mesenchymal stem cells exhibit several BMP receptors [27] while also synthesizing the BMP antagonists noggin, gremlin, follistatin, and sclerostin. The osteoconductive biomaterial BMP/hydroxyapatite has been used in oral and maxillofacial surgery for contour augmentation by means of a macroporous delivery system [28].
2.2.2 Transforming Growth Factor
TGF-β increases the chemotaxis as well as the mitogenesis of the osteoblast precursors while also acting to stimulate osteoblast deposition of collagen matrix for wound healing and the regeneration of the bone [29]. TGF-β is produced by osteoblasts and is found at the highest concentration in platelets [30]. This growth factor stimulates the expression of bone matrix proteins [31] and moderates the breakdown activity of matrix metalloproteinases, among others [32]. The differentiation and proliferation of osteoblastic cells, along with the inhibition of osteoclast precursor formation, may be attributed to TGF-β [33]. Unlike BMP, TGF-β does not have the capacity to induce ectopic bone formation [34]. During the healing of bone fractures, the release of TGF-β, BMP 1–8, and growth differentiation factors (GDFs) 1, 5, 8, and 10 are plentiful [35]. Signaling molecules that are released after a bone fracture and during the progression of healing include pro-inflammatory cytokines, TGF-β superfamily, and other growth factors like PDGF, fibroblast growth factor , and insulin-like growth factors, as well as angiogenic factors such as vascular endothelial growth factor, angiopoietins 1 and 2, and matrix metalloproteinases [36]. TGF-β is found in high amounts in PRP which will be discussed in a later section.
2.2.3 Platelet-Derived Growth Factor
PDGF has the important biological activity of initiating connective tissue healing while also increasing mitogenesis and macrophage activation [29]. PDGF is produced by monocytes, macrophages, osteoblasts, endothelial cells, and platelets [37]. There are three types of PDGF, including PDGF AB, AA, and BB, with PDGF BB being the most biologically potent. In the early stages of fracture healing, PDGF plays a key role in acting as a chemotactic agent for inflammatory cells and as an inducer for osteoblasts and macrophages [34]. Hock and Canalis proposed that PDGF acts as a stimulant for osteoblasts, as well as osteoclast lineages, which may allow for decreased healing time [38]. As mentioned previously, PRP, which on its own will be discussed in a following section, is an autologous source of PDGF and TGF-β. Moreover, both of these growth factors play a primary role in the creation of platelet gels that, unlike fibrin glue, have a high concentration of platelets that release bioactive proteins necessary for tissue repair and regeneration .
2.2.4 Fibroblast Growth Factor
FGF may be produced by macrophages, mesenchymal cells, monocytes, chondrocytes, and osteoblasts. FGF is essential in the process of bone resorption and chondrogenesis [39]. Of the two isoforms that exist, α-FGF plays a key role in chondrocyte proliferation, while β-FGF is significant in the maturation of chondrocytes and bone resorption during the process of fracture healing, which often occurs after oral and maxillofacial surgery. Basic fibroblast growth factor (bFGF) is a growth factor that may be isolated from the pituitary glands of bovine [40]. bFGFs have also been isolated from a number of cells and tissues in tumors [3]. FGF-2 is considered a mitogen that has an effect on angiogenesis, thereby inducing a differentiation stimulus for mesodermal cells. In the short term, FGFs prevent the mineralization of the bone; however, in the long term, they act to speed and support bone development [41]. This was shown in a study by Takayama and colleagues where topical application of FGF-2 had a healing effect on bone fractures [42].
3 Growth Factor Enhancements
At the foundation of any surgical discipline is the science of wound healing. The oral and maxillofacial surgeon is usually blessed to work in an environment with rich vasculature; surgical and traumatic wounds tend to heal. But there will be compromised patients and ambitious reconstructive goals, and the surgeon will take any advantage given to assist his patient’s natural healing process.
As discussed previously, growth factors with cytokine-mediated healing have been shown to assist in the biological healing process . Many of these growth factors can be resultant from platelets, including PDGF, TGF, VEGF, and EGF [43]. Platelet-derived products have been used as early as the 1970s, starting with fibrin glue [44]. Fibrin adhesives are still commercially available today (e.g., Tisseel from Baxter Healthcare) and are primarily used for hemostasis of diffuse microvascular bleeding . Its use is well documented in multiple surgical specialties, including oral and maxillofacial surgery [45]. Fibrin glue evolved into other autologous platelet concentrates including PRP [46], platelet gel, and platelet-rich fibrin (PRF) [47]. The literature reveals multiple studies with favorable treatment effects, not only in dentistry but also in orthopedics, dermatology, and ophthalmology [48]. Unfortunately, the literature has not come up with any consensus in terminology for platelet derivatives [49], and even less uniformity in their preparations, which likely accounts for inconsistencies in reported therapeutic effects.
3.1 The Biology of Wound Healing
Injury to tissue, whether surgical or traumatic, starts a cascade of events to allow wound healing. There are overlapping phases of inflammation, proliferation, and remodeling. The initial priority is to prevent hemorrhage, then prevent infection, and ultimately, restore the injured tissue [50]. The immediate reaction to injured tissue is vasoconstriction to limit bleeding. Coagulation factors are activated and multiple cascades are set into motion. A fibrin matrix is formed at the injured vasculature, and circulating platelets aggregate at the exposed subendothelium, creating a platelet plug. This plug functions not only for hemostasis but also orchestrates subsequent healing [51]. Activated platelets in the plug degranulate and create cellular signals through cytokines and growth factors.
Entire chapters can be devoted to each individual component of the wound healing process. We will limit and simplify our discussion to the roles of fibrin and platelets.
Platelets are anuclear structures arising from bone marrow precursors. The platelet membrane contains receptors for many molecules, including thrombin, and the cytoplasm contains granules that are released on activation [52]. Fibrin is a fibrous protein, which is activated by thrombin. Activated platelets and resulting thrombin allow fibrin to form a cross-linked mesh with the platelet plug to finalize a blood clot.
3.2 Collection and Preparation of Platelet Derivatives
Platelet derivatives have few contraindications, specifically in patients with platelet counts less than 105/microliter, hemoglobin level less than 10 g/dL, or presence of active infections [53]. PRP has shown great variability in centrifugation protocol. Current PRP procedures start with the collection of whole blood in acid/citrate/dextrose, which are then centrifuged. The red blood cells are removed, and the PRP then undergoes a second centrifugation step to obtain a supernatant of platelet-poor plasma (PPP) and the pellet of platelets. Growth factor release of the PRP happens with platelet activation from thrombin, either bovine thrombin or autologous thrombin obtained by adding calcium gluconate to the PPP. Thrombin is combined to the PRP and allows handling as a gel [48].
PRF is considered a second-generation platelet concentrate, notably with a simplified preparation in comparison to PRP. Whole blood is collected without anticoagulants and centrifuged to form a fibrin clot, which contains the platelets. As opposed to PRP where the activation of the platelets is due to thrombin, the PRF activation is a result of the centrifugation process itself. The PRF clot is homogenous and is interpreted to have the cytokines incorporated into the fibrin mesh, allowing for an increased lifespan of these intrinsic growth factors and cell signaling molecules [52]. The inflammatory markers present also indicate degranulation of the leucocytes, which may play a role in the reduction of infection [54].
3.3 Applications in Oral and Maxillofacial Surgery
Both PRP and PRF continue to be used and reviewed in the literature. The therapeutic effects are not validated with multi-center randomized trials, and there still exists discrepancies in overall benefits. In the literature, benefits have been documented when platelet concentrates are used in multiple maxillofacial applications. In post-extraction sites, including third molars, healing times have been improved, with reduction of complications including alveolar osteitis [55,56,57,58,59,60,61]. However there are studies that show no significant benefit using scintigraphic evaluation [62]. Many studies discuss platelet concentrates used in combination with bone grafting for both reconstruction and for site preparations for dental implants. Studies showed accelerated healing, particularly of the soft tissue [63]. Reviews of the literature in regard to sinus augmentation show increased bone density [64] but no significant improvement in bone formation or implant survivability [65, 66]. In the setting of poor wound healing, we see applications of platelet derivatives in the setting of medication-related osteonecrosis of the jaws (MRONJ) and other oral mucosal lesions, with cautious interpretation of results suggesting benefits of their use [67,68,69,70]. Successful treatment of alveolar cleft bone grafting has been shown by multiple teams [71,72,73].
In the temporomandibular joint (TMJ) , platelet concentrates have been hypothesized to help, given that the cartilage is avascular and has difficulty with self-repair. Bone growth was significantly improved in osteoarthritis in the rabbit model, with improved, but not significant, regeneration of the cartilage [74]. Injections of platelet concentrates into the TMJ have been shown to be effective for treatment of temporomandibular osteoarthritis [75,76,77] and better than arthrocentesis alone [78]. However, it has been pointed out that growth factors associated with PRP, including VEGF, may be detrimental to cartilaginous healing [79].
3.4 Future Applications
The common complaint in the systematic reviews of PRP and PRF therapy continues to be a large discrepancy in preparation and use of platelet concentrates. Good evidence is available that there is a quantifiable increase in growth factors when using platelet-rich products [80,81,82,83]. However, large multi-center trials need to be conducted to prove the efficacy of these treatments reliably and reproducibly.
4 Implantable Devices
4.1 Replacement of Teeth
Oral implants have become the sought-after method of treatment, which is scientifically accepted and well documented in the literature [84,85,86]. Oral implants were introduced some 30–40 years ago [87,88,89]. Since then, implants have revolutionized the concept of replacing missing teeth and improved the quality of life for patients [90, 91]. Today, there are over 1300 different implant systems worldwide. They vary in shape, dimension, bulk, surface material, topography, surface chemistry, wettability, and surface modification [92]. Titanium is the material most commonly used for oral endosseous implants, due to its mechanical strength, excellent biocompatibility, and osseointegration [93]. Some studies have reported regarding the clinical disadvantages of titanium, such as host sensitivity to titanium, electrical conductivity, corrosive properties, and esthetic concerns as a result of their dark-grayish coloring [94,95,96]. Furthermore, elevated titanium concentrations have been found in close proximity to oral implants [97] and in regional lymph nodes [98]. However, the clinical relevance of these facts is still unclear [99]. Ceramic materials have been suggested as a substitute to titanium for oral implants because of their esthetic benefits and excellent biocompatibility in vitro and in vivo [100,101,102], great tissue integration, low affinity to plaque, and favorable biomechanical properties [103]. These ceramic materials have already been investigated and clinically used since approximately 30–40 years ago. The first ceramic material utilized was aluminum oxide [104, 105], and later, the Cerasand ceramic and the ceramic anchor implant were introduced [106, 107]. The physical and mechanical properties of alumina ceramics are high hardness and modulus of elasticity, which make the material brittle. In combination with the relatively low bending strength and fracture toughness, alumina ceramics are vulnerable to fractures. Based on these drawbacks, there are no alumina implant systems remaining on the market [86, 108]. Currently, the material of choice for ceramic oral implants is zirconia (ZrO2), containing tetragonal polycrystalline yttria (Y2O3) (Y-TZP). In comparison to alumina, Y-TZP has a higher bending strength, a lower modulus of elasticity, and a higher fracture toughness [86, 109, 110]. Through in vitro and in vivo studies, zirconia has become an attractive alternative to titanium for the fabrication of oral implants [103]. However, animal studies have indicated a better bone-to-implant contact with titanium implants than with Y-TZP implants [101, 111]. In addition, early failures were significantly higher for zirconia implants than for titanium implants [103].
Surface topography is one of the important parameters for the achievement of osseointegration and can be classified into macro-, micro-, and nanoscale [112]. The three major modifications of macrotopography are screw threads (tapped or self-tapping), solid body press-fit designs, and sintered bead technologies. Recently, studies were mainly focused on micro- and nanogeometry. The osteoblast activity is significantly increased at 1–100 μm of the surface roughness compared to a smooth surface [113]. Increased surface roughness of dental implants can be achieved by machining, plasma spray coating, grit blasting, acid etching, sandblasting, anodizing, and applying a biomimetic coating, or other combinations of the several mentioned techniques [114,115,116,117] resulted in greater bone apposition [118] and reduced healing time [119].
4.2 Reconstruction of the Craniomaxillofacial Skeleton
Reconstruction of the craniomaxillofacial skeleton, resulting from resection of benign and malignant tumor, osteomyelitis, or osteoradionecrosis, still remains a challenge for the surgeon [120].
4.2.1 Natural Bone Grafts
Since the nineteenth century, autologous bone has been successfully used as bone substitute [121]. Different donor sites are described in the current literature. Intraoral donor sites include the symphysis of the mandible, mandibular ramus, and maxillary tuberosity [122]. The common extraoral donor sites for non-vascularized bone grafts are the iliac crest and rib. The non-vascularized iliac crest graft is a treatment possibility for reconstruction of moderate mandibular defects [123], whereas the costochondral graft from the rib is used predominantly for condylar reconstruction [124, 125]. During the past decade, a variety of donor sites for vascular bone flaps and soft tissue have been recommended. The osteocutaneous radial forearm free flap [126, 127], fibular free flap [127, 128], scapula free flap [128], and iliac crest free flap [129] are the most commonly utilized donor sites for vascularized reconstruction.
Allogenic bone refers to the bone that is harvested from one individual and transplanted into another individual, both of the same species. Due to the limitations of autologous bone grafting, allogenic grafts are considered an effective alternative. Allografts, to a limited extent, can be customized by being machined and shaped to fit the defect. It can be available in a variety of forms, including cortical and cancellous. The disadvantage, however, is that compared to autografts, they have a higher failure rate due to their immunogenicity [130, 131].
Xenograft bone has been taken from a donor of another species [122], usually of bovine origin. Mineral xenograft has been applied in oral and maxillofacial surgery for several years [132]. Demineralized bone, harvested from human donors, has been frequently used in craniofacial reconstruction [133, 134]. The demineralization is achieved through the process of acidification, resulting in a matrix containing type I collagen and osteoinductive growth factors, predominantly BMP. Based on porosity, it can be easily formed and remodeled intraoperatively [135, 136].
4.2.2 Synthetic Bone Grafts
Craniofacial reconstruction using alloplastic implants has shown to be associated with low rates of infection and other types of morbidity [137]. Computer-aided designed and manufactured (CAD/CAM) titanium implants which are prefabricated are a reasonable option for secondary reconstruction [138]. The major disadvantages are the thermosensitivity and limited possibility of intraoperative customization [136]. Synthetically manufactured bioactive glass-ceramic is an option as a single CAD/CAM implant for craniofacial reconstruction with good clinical outcomes. As opposed to titanium implants, it allows intraoperative remodeling and adjustment without thermosensitivity [139]. Calcium phosphates belong to the group of bioactive synthetic materials. The most commonly used are hydroxyapatite, tricalcium phosphate, and biphasic calcium phosphate [140,141,142]. Calcium phosphates are osteoconductive, do not cause any foreign body response, and are nontoxic [136].
Hard tissue replacement (HTR) -sintered polymers consist of poly(methyl methacrylate (pMMA), poly(hydroxyethyl methacrylate) (pHEMA), and calcium hydroxide. The porosity of the plastic allows for the indwelling growth of blood vessels as well as connective tissue [136]. HTR implants can be used for the reconstruction of large defects of the cranio-orbital region when combined with simultaneous bone tumor resection [143]. The implants are fixated with titanium or resorbable plates and screws.
Polyetheretherketone (PEEK) is a synthetic material that has been used for a number of years in neurosurgery due to its excellent biocompatibility, good mechanical strength, and radiographic translucency. In recent years, studies of maxillofacial reconstructions have been reported using PEEK for the construction of patient-specific implants [144,145,146]. The major disadvantage of computer-designed PEEK is its high cost [147].
Porous polyethylene (PPE) or high-density polyethylene (HDPE) is a linear highly compressed (sintered) aliphatic hydrocarbon. It is a biocompatible, durable, and stable material. Furthermore, it shows rapid surrounding soft tissue ingrowth without capsule formation around it [137, 148, 149]. PPE has proven to be a reasonable alternative to PEEK as a material for craniofacial reconstructions. The use of this material seems to be safe and has minimal morbidity [149]. In summary, autografts are osteoconductive, osteoinductive, and osteogenic; however, they have limited availability and have donor-site morbidity. Allografts are osteoconductive and osteoinductive but are not osteogenic; they carry the same disadvantages as autografts with the addition of having disease transmission risk. Xenografts are osteoconductive, but not osteoinductive or osteogenic, and carry the potential for foreign body reaction. Alloplastic materials are osteoconductive but often costly [150].
5 Maintenance of Structural Integrity and Fixation
5.1 Plates and Screws
Today, nearly all the metal plates and screws for the fixation of the craniomaxillofacial skeleton consist of titanium and are stored in sets that can be re-sterilized. Titanium is the most biocompatible and corrosion-resistant metal and has an innate ability to fuse with human bone [151, 152]. Therefore, it has received much attention in the area of craniofacial reconstruction [153]. Prior to the use of titanium, several other materials were applied for craniofacial applications. These metals, which included stainless steel and vitallium, an alloy from cobalt, chrome, and molybdenum, have fallen out of favor because of their corrosion profile and/or lack of inertness [154, 155]. Furthermore, vitallium and stainless steel produce more artifacts on computed tomography scans and magnetic resonance imaging than titanium [156,157,158]. There exist miniplates of different shapes with corresponding osteosynthesis screws of different lengths (Fig. 3.3) [159].
Postoperative x-ray of a complex midface fracture treated with several malleable fixation plates
5.1.1 Midface
Osteosynthesis screws are also based on different systems. For the midface , osteosynthesis is based on systems 1.0, 1.3, 1.5, and 2.0. The numbers refer to the outer screw thread diameter in mm. Low profile plates are recommended for the infraorbital rim because the structural forces are not significant in this region. In contrast, increased stability with stronger implants is needed for the zygomaticomaxillary buttress where high masticatory forces are transmitted [160, 161].
Depending on the size and location of the orbital defect, reconstruction can be achieved by using implants of various materials with different benefits and disadvantages. Currently, the ideal implant material for orbital reconstruction still remains unclear [153]. The use of silastic implants, bioactive glass, and porous polyethylene to bridge the bony defect has been extensively documented in the literature [162,163,164]. In addition, titanium mesh (Fig. 3.4) or pre-shaped plates, such as the 3D titanium orbital plate, are applied in special cases [165, 166]. Biodegradable polyglycolic acid [167] and polydioxanone [168] are options as resorbable alloplastic materials. Alternatively, autogenous transplants can be used [169,170,171,172]. Considering donor-site morbidity of autologous transplants and infections with nonresorbable materials, resorbable implants for reconstruction could be recommended [168].
Postoperative x-ray of an orbital floor fracture treated with a titanium mesh
5.1.2 Mandible
Different osteosynthesis plating systems are in use for application to the mandible . According to Arbeitsgemeinschaft für Osteosynthesefragen (AO)/Association for the study of Internal Fixation (ASIF) principles, the types of plates include mandible plates 2.0, locking plates 2.0, (locking) reconstruction plates, dynamic compression plates, and universal fracture plates [173,174,175,176]. Mandibular miniplates are designed to be used with monocortical screws (Fig. 3.5). Bicortical screws can be used for additional stability in selected cases. In approaches with limited space (e.g., condylar and subcondylar regions), plates of modified design, such as the compression plate, the trapezoid plate, or the delta plate, are applied [177, 178]. Lag screw osteosynthesis of fractures of the mandibular condyle is a method to combine functional stability with simple removal of osteosynthesis materials, without re-exposure of the temporomandibular joint region [179, 180].
Postoperative x-rays shows fracture fixation with six mandibular miniplates 2.0
5.1.3 Absorbable Materials
Absorbable osteosynthetic material is an option to make metal removal unnecessary [181]. A complete resorption occurs approximately 1 year in experimental models [182]. Further advantages are the absence of thermal sensitivity and radiological artifacts [136]. Use of bioresorbable miniplates has been suggested in the pediatric population because of possible growth disturbances associated with titanium-based hardware [183]. A variety of biodegradable implants are commercially available in the field of oral and maxillofacial surgery. Polymers of α-hydroxy acids as glycolic acid (PGA), L-lactic and D, L-lactic acids (PLLA, PDLLA), and their copolymers are the substances largely used as osteosynthesis materials [184,185,186,187,188]. These materials have proven clinical success throughout the world; however, there are some arguments against biodegradable fixation. The complications of biodegradable fixation are infections, foreign body reactions, malocclusions, and malunions [188]. Furthermore, the duration of surgery is more challenging and costly [187, 189].
6 Summary
Oral and maxillofacial surgery is an incredible and evolving field. Injuries, defects, and pathologies to the head, neck, and face, as well as hard and soft tissues of the oral region, are often taken care of by specialists extensively trained as oral and maxillofacial surgeons. As further research is completed and scientists continue exploration of materials and methods, techniques and strategies are altered to benefit the patient in clinical settings. In this chapter, we focused on the use of different grafting materials, both natural and synthetic for bone regeneration and defect repair, growth factors that aid in healing and growth of tissues, as well as fixation devices used in the repair of maxillofacial bone fractures. The techniques discussed are effective; however, future work needs to be outlined in order to improve efficiency and efficacy, both inside and outside of the operating room.
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Fahmy, M.D., Gupta, A., Guentsch, A., Peisker, A. (2020). Materials Used Intraoperatively During Oral and Maxillofacial Surgery Procedures. In: Tayebi, L. (eds) Applications of Biomedical Engineering in Dentistry. Springer, Cham. https://doi.org/10.1007/978-3-030-21583-5_3
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