Evaluation of failure of a titanium conventional plate in mandibular reconstruction and improve the performance with fibula free flap
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Abstract
Maxillofacial extensive defects are caused by various factors such as tumor, osteomyelitis and trauma. Reconstruction of such injuries become a major challenge for maxillofacial surgeons. Clinical experiments indicate that one of the serious problems associated with conventional plate systems is the frequent incidence of complications such as screw loosening, plate exposure and plate fractures. To improve the performance of reconstruction system with new procedure. A 42-year-old male patient suffering from Ameloblastoma tumor in the lateral large defect was selected as case study. Initially, after cutting the cancerous tissue, a titanium conventional plate (TCP) model had been utilized as mandibular reconstruction system which failed due to plate exposure. Patient’s CT-scan images were prepared, and geometry and shape of the plate were evaluated using computer-aided design & computer-aided manufacturing (CAD/CAM) and additive manufacturing (AM) technology. Then, its effect on the biomechanical performance of the failed system TCP model was investigated by finite element method (FEM). Fibula Free Flap FFF model as alternative and improved reconstruction system was selected. FEM evaluation of two models showed inevitable results which tip the scales in the favor of FFF model. The maximum Von-Mises stress had been exerted at the interface between screw-cortical bone. In TCP model, the peak value of Von-Mises stress exerted at the interface between screw-bone was 110 MPa, which exceeded the yield strength of the cortical bone, while, this factor fell to 68 MPa in FFF model. Furthermore, comparison with TCP model, the sensitivity of the plates and screws to the chewing load variations in FFF model decreased 20%. The results showed that the FFF model was more stable and flexible than the TCP model. Keywords: Mandible reconstruction; Fibula free flap; Computer-aided design & computer-aided manufacturing (CAD/CAM); Finite element method (FEM); Loading sensitivity analysis.
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[13] Mal o P, Rangert B, Nobre M. All-on-4 immediate-function concept with Branemark system® implants for completely edentulous maxillae: a 1-year retrospective clinicalstudy. Clin Implant Dent Relat Res. 2005; 7:88-94. https://doi.org/10.1111/j.1708-8208.2005.tb00080.x
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[15] Ciocca L, Mazzoni S, Fantini M, Persiani F, Baldissara P, Marchetti C, Scotti R. A CAD/CAM-prototyped anatomical condylar prosthesis connected to a custom-made bone plate to support a fibula free flap. Medical & biological engineering & computing. 2012; 50:743-9. https://doi.org/10.1007/s11517-012-0898-4
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[17] Vajgel A, Camargo IB, Willmersdorf RB, de Melo TM, Laureano Filho JR, de Holanda Vasconcellos RJ. Comparative finite element analysis of the biomechanical stability of 2.0 fixation plates in atrophic mandibular fractures. Journal of Oral and Maxillofacial Surgery. 2013; 71:335-42. https://doi.org/10.1016/j.joms.2012.09.019
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[19] Narra N, Valášek J, Hannula M, Marcián P, Sándor GK, Hyttinen J, Wolff J. Finite element analysis of customized reconstruction plates for mandibular continuity defect therapy. Journal of Biomechanics, 2014; 47: 264-268. https://doi.org/10.1016/j.jbiomech.2013.11.016
[20] Sato FR, Asprino L, Noritomi PY, da Silva JV, de Moraes M. Comparison of five different fixation techniques of sagittal split ramus osteotomy using three-dimensional finite elements analysis. International Journal of Oral and Maxillofacial Surgery. 2012; 41:934-941. https://doi.org/10.1016/j.ijom.2012.03.018
[21] Erkmen E, Şimşek B, Yücel E, Kurt A. Comparison of different fixation methods following sagittal split ramus osteotomies using three-dimensional finite elements analysis: Part 1: advancement surgery-posterior loading. International Journal of Oral and Maxillofacial Surgery. 2005; 34:551-8. https://doi.org/10.1016/j.ijom.2004.10.009
[22] Kim HS, Park JY, Kim NE, Shin YS, Park JM, Chun YS. Finite element modeling technique for predicting mechanical behaviors on mandible bone during mastication. The journal of advanced prosthodontics. 2012; 4:218-26. https://doi.org/10.4047/jap.2012.4.4.218
[23] Moiduddin K, Anwar S, Ahmed N, Ashfaq M, Al-Ahmari A. Computer assisted design and analysis of customized porous plate for mandibular reconstruction. IRBM. 2017; 38:78-89. https://doi.org/10.1016/j.irbm.2017.01.003
[24] Moiduddin K. Implementation of computer-assisted design, analysis, and additive manufactured customized mandibular implants. Journal of Medical and Biological Engineering. 2018; 38:744-56. https://doi.org/10.1007/s40846-018-0370-5
[25] Field C, Li Q, Li W, Thompson M, Swain M. A comparative mechanical and bone remodelling study of all-ceramic posterior inlay and onlay fixed partial dentures. Journal of dentistry. 2012 Jan 1;40(1):48-56. https://doi.org/10.1016/j.jdent.2011.10.003
[26] Wang C, Li Q, McClean C, Fan Y. Numerical simulation of dental bone remodeling induced by implant‐supported fixed partial denture with or without cantilever extension. International journal for numerical methods in biomedical engineering. 2013; 29:1134-47. https://doi.org/10.1002/cnm.2579.
[27] Jahadakbar A, Shayesteh Moghaddam N, Amerinatanzi A, Dean D, Karaca HE, Elahinia M. Finite element simulation and additive manufacturing of stiffness-matched niti fixation hardware for mandibular reconstruction surgery. Bioengineering. 2016; 3:36. https://doi.org/10.3390/bioengineering3040036
[28] Qaisi M, Kolodney H, Swedenburg G, Chandran R, Caloss R. Fibula jaw in a day: state of the art in maxillofacial reconstruction. Journal of Oral and Maxillofacial Surgery. 2016; 74:1284-e1. https://doi.org/10.1016/j.joms.2016.01.047
[29] Park SM, Lee JW, Noh G. Which plate results in better stability after segmental mandibular resection and fibula free flap reconstruction? Biomechanical analysis. Oral surgery, oral medicine, oral pathology and oral radiology. 2018; 126:380-9. https://doi.org/10.1016/j.oooo.2018.05.048
[30] Orabona GD, Abbate V, Maglitto F, Bonavolontà P, Salzano G, Romano A, Reccia A, Committeri U, Iaconetta G, Califano L. Low-cost, self-made CAD/CAM-guiding system for mandibular reconstruction. Surgical oncology. 2018; 27:200-7. https://doi.org/10.1016/j.suronc.2018.03.007
[2] Fantini M, De Crescenzio F, Ciocca L. Design and manufacturing of customized surgical devices for mandibular rehabilitation. International Journal on Interactive Design and Manufacturing (IJIDeM). 2013; 7:227-37. https://doi.org/10.1007/s12008-012-0177-5
[3] Bujtár P, Simonovics J, Váradi K, Sándor GK, Avery CM. The biomechanical aspects of reconstruction for segmental defects of the mandible: a finite element study to assess the optimisation of plate and screw factors. Journal of Cranio-Maxillofacial Surgery. 2014; 42:855-62. https://doi.org/10.1016/j.jcms.2013.12.005
[4] Li P, Shen L, Li J, Liang R, Tian W, Tang W. Optimal design of an individual endoprosthesis for the reconstruction of extensive mandibular defects with finite element analysis. Journal of Cranio-Maxillofacial Surgery. 2014; 42:73-8. https://doi.org/10.1016/j.jcms.2013.02.005
[5] Lee S, Goh BT, Tideman H, Stoelinga PJ, Jansen JA. Modular endoprosthesis for mandibular body reconstruction: a clinical, micro-CT and histologic evaluation in eight Macaca fascicularis. International journal of oral and maxillofacial surgery. 2009; 38:40-7. https://doi.org/10.1016/j.ijom.2008.11.020
[6] Bhatt V, Langford RJ. Removal of miniplates in maxillofacial surgery: University Hospital Birmingham experience. Journal of oral and maxillofacial surgery. 2003; 61:553-6. https://doi.org/10.1053/joms.2003.50108
[7] Lamphier J, Ziccardi V, Ruvo A, Janel M. Complications of mandibular fractures in an urban teaching center. Journal of oral and maxillofacial surgery. 2003; 61:745-9. https://doi.org/10.1016/S0278-2391(03)00147-2
[8] Murthy AS, Lehman Jr JA. Symptomatic plate removal in maxillofacial trauma: a review of 76 cases. Annals of plastic surgery. 2005; 55:603-7. doi: 10.1097/01.sap.0000183802.38116.37
[9] Peled M, El-Naaj IA, Lipin Y, Ardekian L. The use of free fibular flap for functional mandibular reconstruction. Journal of oral and maxillofacial surgery. 2005; 63:220-4. https://doi.org/10.1016/j.joms.2004.06.052
[10] Goh BT, Lee S, Tideman H, Stoelinga PJ. Mandibular reconstruction in adults: a review. International journal of oral and maxillofacial surgery. 2008; 37:597-605. https://doi.org/10.1016/j.ijom.2008.03.002
[11] Hidalgo DA. Fibula free flap: a new method of mandible reconstruction. Plastic and reconstructive surgery. 1989; 84:71-9.
[12] Gurtner GC, Evans GR. Advances in head and neck reconstruction. Plastic and reconstructive surgery. 2000; 106:672-82.
[13] Mal o P, Rangert B, Nobre M. All-on-4 immediate-function concept with Branemark system® implants for completely edentulous maxillae: a 1-year retrospective clinicalstudy. Clin Implant Dent Relat Res. 2005; 7:88-94. https://doi.org/10.1111/j.1708-8208.2005.tb00080.x
[14] Ferri J, Piot B, Ruhin B, Mercier J. Advantages and limitations of the fibula free flap in mandibular reconstruction. Journal of oral and maxillofacial surgery. 1997 May 1;55(5):440-8. https://doi.org/10.1016/S0278-2391(97)90685-6
[15] Ciocca L, Mazzoni S, Fantini M, Persiani F, Baldissara P, Marchetti C, Scotti R. A CAD/CAM-prototyped anatomical condylar prosthesis connected to a custom-made bone plate to support a fibula free flap. Medical & biological engineering & computing. 2012; 50:743-9. https://doi.org/10.1007/s11517-012-0898-4
[16] Ramos A, Completo A, Relvas C, Mesnard M, Simões JA. Straight, semi-anatomic and anatomic TMJ implants: the influence of condylar geometry and bone fixation screws. Journal of Cranio-Maxillofacial Surgery. 2011; 39:343-50. https://doi.org/10.1016/j.jcms.2010.07.006
[17] Vajgel A, Camargo IB, Willmersdorf RB, de Melo TM, Laureano Filho JR, de Holanda Vasconcellos RJ. Comparative finite element analysis of the biomechanical stability of 2.0 fixation plates in atrophic mandibular fractures. Journal of Oral and Maxillofacial Surgery. 2013; 71:335-42. https://doi.org/10.1016/j.joms.2012.09.019
[18] Al-Ahmari A, Nasr EA, Moiduddin K, Anwar S, Kindi MA, Kamrani, A. A comparative study on the customized design of mandibular reconstruction plates using finite element method. Advances in Mechanical Engineering. 2015; 23:1687814015593890. https://doi.org/10.1177/1687814015593890
[19] Narra N, Valášek J, Hannula M, Marcián P, Sándor GK, Hyttinen J, Wolff J. Finite element analysis of customized reconstruction plates for mandibular continuity defect therapy. Journal of Biomechanics, 2014; 47: 264-268. https://doi.org/10.1016/j.jbiomech.2013.11.016
[20] Sato FR, Asprino L, Noritomi PY, da Silva JV, de Moraes M. Comparison of five different fixation techniques of sagittal split ramus osteotomy using three-dimensional finite elements analysis. International Journal of Oral and Maxillofacial Surgery. 2012; 41:934-941. https://doi.org/10.1016/j.ijom.2012.03.018
[21] Erkmen E, Şimşek B, Yücel E, Kurt A. Comparison of different fixation methods following sagittal split ramus osteotomies using three-dimensional finite elements analysis: Part 1: advancement surgery-posterior loading. International Journal of Oral and Maxillofacial Surgery. 2005; 34:551-8. https://doi.org/10.1016/j.ijom.2004.10.009
[22] Kim HS, Park JY, Kim NE, Shin YS, Park JM, Chun YS. Finite element modeling technique for predicting mechanical behaviors on mandible bone during mastication. The journal of advanced prosthodontics. 2012; 4:218-26. https://doi.org/10.4047/jap.2012.4.4.218
[23] Moiduddin K, Anwar S, Ahmed N, Ashfaq M, Al-Ahmari A. Computer assisted design and analysis of customized porous plate for mandibular reconstruction. IRBM. 2017; 38:78-89. https://doi.org/10.1016/j.irbm.2017.01.003
[24] Moiduddin K. Implementation of computer-assisted design, analysis, and additive manufactured customized mandibular implants. Journal of Medical and Biological Engineering. 2018; 38:744-56. https://doi.org/10.1007/s40846-018-0370-5
[25] Field C, Li Q, Li W, Thompson M, Swain M. A comparative mechanical and bone remodelling study of all-ceramic posterior inlay and onlay fixed partial dentures. Journal of dentistry. 2012 Jan 1;40(1):48-56. https://doi.org/10.1016/j.jdent.2011.10.003
[26] Wang C, Li Q, McClean C, Fan Y. Numerical simulation of dental bone remodeling induced by implant‐supported fixed partial denture with or without cantilever extension. International journal for numerical methods in biomedical engineering. 2013; 29:1134-47. https://doi.org/10.1002/cnm.2579.
[27] Jahadakbar A, Shayesteh Moghaddam N, Amerinatanzi A, Dean D, Karaca HE, Elahinia M. Finite element simulation and additive manufacturing of stiffness-matched niti fixation hardware for mandibular reconstruction surgery. Bioengineering. 2016; 3:36. https://doi.org/10.3390/bioengineering3040036
[28] Qaisi M, Kolodney H, Swedenburg G, Chandran R, Caloss R. Fibula jaw in a day: state of the art in maxillofacial reconstruction. Journal of Oral and Maxillofacial Surgery. 2016; 74:1284-e1. https://doi.org/10.1016/j.joms.2016.01.047
[29] Park SM, Lee JW, Noh G. Which plate results in better stability after segmental mandibular resection and fibula free flap reconstruction? Biomechanical analysis. Oral surgery, oral medicine, oral pathology and oral radiology. 2018; 126:380-9. https://doi.org/10.1016/j.oooo.2018.05.048
[30] Orabona GD, Abbate V, Maglitto F, Bonavolontà P, Salzano G, Romano A, Reccia A, Committeri U, Iaconetta G, Califano L. Low-cost, self-made CAD/CAM-guiding system for mandibular reconstruction. Surgical oncology. 2018; 27:200-7. https://doi.org/10.1016/j.suronc.2018.03.007
| Files | ||
| Issue | Vol 7, No 2 (Spring 2020) | |
| Section | Original Article(s) | |
| DOI | https://doi.org/10.18502/jcr.v7i2.4504 | |
| Keywords | ||
| Mandible reconstruction Fibula free flap Computer-aided design & computer-aided manufacturing (CAD/CAM) Finite element method (FEM) Loading sensitivity analysis | ||
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How to Cite
1.
Kargarnejad S, Ghalichi F, Pourgol Mohammad M, Garajei A. Evaluation of failure of a titanium conventional plate in mandibular reconstruction and improve the performance with fibula free flap. J Craniomaxillofac Res. 2020;7(2):67-75.
