published_or_final_version / Nursing Studies / Master / Master of Nursing

Bilateral mandibular ostectomies were performed between premolars 3 and 4 in 10 adult canine specimens. A type I external fixator incorporating a full interdental pin was placed stabilizing a 0.5 cm fracture gap. Four different pin configurations were tested in dorsoventral bending five separate times on each of the ten mandibles: 1) intact mandibular bodies with fixator; 2) ostectomized mandibular bodies and complete fixator; 3) ostectomized mandibular bodies with the caudal pins of the rostral fragment cut; 4) ostectomized mandibular bodies with all pins of the rostral fragment cut. The full interdental pin remained intact in all configurations. Total stiffness and gap stiffness were then determined for each fixation geometry on a materials testing machine. The mean total stiffness(Nm/rads) for the four configurations was 1) 1543.6, 2) 301.6, 3) 290.5, 4) 267.0. The mean gap stiffness(Nm/rads) for the right hemimandible was: 2) 2041.1, 3) 1763.5, 4) 1679.9. The mean gap stiffness of the left hemimandible was: 2) 2110.8, 3)1880.1, 4)1861.1. There was no gap stiffness for the first configuration since a fracture gap was not present. Two-way ANOVA was performed on the gap stiffness and the total stiffness. There was a significant decrease in total stiffness between intact mandibles and ostectomized mandibles regardless of external fixator configuration. However, there was not a significant difference in total stiffness or gap stiffness among the different external fixator configurations applied to ostectomized mandible. External fixator configurations with only the full interdental pin engaging the rostral fragment were as stiff as configurations which had two or four additional pins in the rostral fragment for the applied loads. External fixators for rostral mandibular fractures may be rigidly secured with rostral fragment implants applied extracortically avoiding iatrogenic trauma to teeth and tooth roots. / Master of Science

The purpose of this study was to compare the stiffness of a Type II external skeletal fixator (ESF) to a 3.5 mm locking compression plate (LCP) in axial compression, mediolateral, and craniocaudal bending in a fracture gap model. The hypothesis was that the Type II ESF would demonstrate comparable stiffness to the LCP. A bone simulant consisting of short fiber reinforced epoxy cylinders and a 40 mm fracture gap was used. The LCP construct consisted of a 12 hole 3.5 mm plate with three 3.5 mm bicortical locking screws per fragment. The Type II ESF construct consisted of 3 proximal full fixation pins (Centerface®) per fragment in the mediolateral plane, and 2 carbon fiber connecting rods. Five constructs of each were tested in non-destructive mediolateral and craniocaudal bending, and axial compression. Stiffness was determined from the slope of the elastic portion of force-displacement curves. A one-way ANOVA and a Tukey-Kramer multiple comparisons test were performed, with significance defined as p < 0.05. In mediolateral bending, the stiffness of the Type II ESF (mean ± standard deviation; 1584.2 N/mm ± 202.8 N/mm) was significantly greater than that of the LCP (110.0 N/mm ± 13.4 N/mm). In axial compression, the stiffness of the Type II ESF (679.1 N/mm ± 20.1 N/mm) was significantly greater than that of the LCP (221.2 N/mm ± 19.1 N/mm). There was no significant difference between the constructs in craniocaudal bending. This information can aid in decision-making for fracture fixation, although ideal stiffness for healing remains unknown. / Master of Science / Optimum fracture stabilization requires a balance between providing a stable mechanical environment and preserving the blood supply to healing tissues. When the complexity of a fracture precludes reconstruction of the bony column, the fixation method chosen for repair must counteract the forces of weight bearing, including compression and bending. Knowledge of the relative construct stiffness is important for a clinician to determine the ability of a fixation technique to withstand all forces acting on a fracture, while supporting bone healing. The purpose of this study was to compare the stiffness of a Type II external skeletal fixator (ESF) and a locking compression plate (LCP) when non-destructive physiologic loads are applied in axial compression, mediolateral bending, and craniocaudal bending. Five constructs of each were tested in non-destructive mediolateral and craniocaudal bending, and axial compression. Stiffness was determined from the slope of the elastic portion of force-displacement curves. There was a significant difference between the stiffnesses of the Type II ESF and the LCP in all modes of loading except craniocaudal bending. The Type II ESF was significantly stiffer in mediolateral bending than the LCP, and the Type II ESF was significantly stiffer in axial compression compared to the LCP. There was no statistically significant difference in stiffness in craniocaudal bending. This information will aid a clinician in selecting an appropriate fixation method for a non-reconstructable fracture, but further studies are required to assess the importance of increased stiffness in a clinical setting.

A fixação híbrida do ramo mandibular é uma combinação de duas técnicas já anteriormente descritas na literatura e que oferecem bons resultados. A primeira delas é a fixação realizada por meio de miniplacas e parafusos monocorticais e a segunda é a fixação realizada por meio de parafusos bicorticais, buscando combinar os pontos positivos de cada uma delas com a finalidade de obter um resultado satisfatório para o paciente. A osteotomia sagital bilateral de mandíbula (OSBM) pode alterar a posição do côndilo na cavidade glenoide, ocasionando uma recidiva no posicionamento esquelético e muscular. O aumento na incidência de desordens temporomandibulares e reabsorções ósseas na cabeça do côndilo são fatores que devem ser investigados, assim como a relação entre esses fatores e o tipo de osteossíntese empregada. O presente estudo teve como objetivo comparar e quantificar o volume do côndilo mandibular antes e após a OSBM com fixação híbrida. A amostra foi composta por 20 pacientes (n=40) de ambos os sexos e com idades entre 18 e 30 anos que foram submetidos à cirurgia ortognática bimaxilar no período entre 2012 e 2014 no Hospital de Reabilitação de Anomalias Craniofaciais da Universidade de São Paulo (HRAC-USP). Os pacientes foram submetidos ao exame de tomografia computadorizada de feixe cônico (TCFC) nos períodos pré e pós-operatório à cirurgia ortognática. As aquisições das imagens tomográficas foram feitas no tomógrafo de feixe cônico (i-CAT®, Award-Winning Cone Beam 3D Dental Imaging) do setor de Radiologia do HRAC-USP, sendo realizada a mesma técnica tomográfica para todos os pacientes. O procedimento cirúrgico foi realizado em todos os pacientes pelo mesmo cirurgião e por meio da mesma técnica cirúrgica. Foi realizada a osteotomia sagital bilateral de mandíbula modificada por Arnett (1993) e a fixação de todas as mandíbulas foi realizada com a técnica híbrida. Os exames de TCFC foram importados pelo Mimics® (Medical Image Segmentation for Engineering on AnatomyTM), o qual analisou-as obtendo assim a variação volumétrica bilateral do côndilo mandibular. Para diminuir a possibilidade de erros, todas as tomografias foram avaliadas pelo mesmo examinador, o qual foi previamente calibrado. Para a calibração e cálculo do erro do método, foram utilizadas 20 hemimandíbulas medidas duas vezes com um intervalo de sete dias, obtendo assim o coeficiente de correlação interclasse (ICC), cujo valor foi de 0,99. Os resultados sugerem uma atividade de remodelação óssea no côndilo, com áreas de reabsorção e de neoformação óssea, sendo encontrada uma média de 5,20% de reabsorção. A análise estatística por meio do teste t pareado mostra que houve diferença estatisticamente significante (p<0,05). O cálculo do poder da amostra resultou num valor de 0,96. Apesar de possuir muitos recursos e possibilitar uma forma intuitiva de segmentação e mensuração dos exames de TCFC através da reconstrução em 3D, o Mimics® apresenta algumas limitações, como a dificuldade de padronização dos valores dentro da escala de Hounsfield e a dificuldade de delimitação do limite inferior do côndilo no plano axial, possibilitando uma mensuração volumétrica mais precisa. Em vista da metodologia empregada neste estudo, pode-se concluir que existe remodelação óssea significativa após a osteossíntese com fixação híbrida da osteotomia sagital bilateral de mandíbula, não associada a distúrbios da articulação temporomandibular / The hybrid fixation of the mandibular ramus is a combination of two successful techniques previously described and well known. The first one is the bicortical screws fixation and the second is the miniplates and monocortical screws fixation, aiming to achieve the best treatment for the patient. The bilateral sagital split osteotomy (BSSO) can alter the condyle position in the glenoid cavity, causing a skeletal and muscular relapse. The incidence increasing of temporomandibular disorders and bone resorptions at the top of the condyle are factors that must be investigated, as well as the relationship between these factors and the type of internal rigid fixation used. This present study aims to compare the condyle volume before and after BSSO using hybrid fixation. The sample is composed by 20 patients (n=40) of both sex and ages between 18 and 30 that were submitted to bimaxillary orthognathic surgery among 2012 and 2014 in the Hospital for Rehabilitation of Craniofacial Anomalies (HRAC-USP). All the patients were submitted to a cone beam computed tomography (CBCT) exam on pre and postoperative periods for the orthognathic surgery. The tomography images aquisition was obtained by the cone beam tomograph (i-CAT®, Imaging Sciences International) of the Radiology sector in the HRAC-USP considering the same technique for all the patients. The surgical procedure was performed in all the patients by the same surgeon using the same surgical technique. The BSSO modified by Arnett (1993) was accomplished using the hybrid fixation technique. The CBCT exams were imported by Mimics® (Medical Image Segmentation for Engineering on AnatomyTM), which analysed them to obtain the bilateral volumetric variation of the condyle. To reduce the error possibility, all the CBCT exams were analysed by the same examinator, who were previously calibrated. For the calibration and method error calculation, 20 hemimandibles were used for the measurements performed in a 7 days intermission, obtaining the interclass correlation coefficient (ICC), which value was of 0.99. The results suggest a remodelation activity on the condyle, with bone resorption and neoformation areas, which were founded 5.20% resorption mean. Statistical analysis using t test demonstrates that were founded significant statistical difference (p<0.05). The power sample calculation resulted in 0.96. Despite the several resources and possibility of an intuitive form of segmentation and analysis of the CBCT exams through the 3D reconstruction, the Mimics® software presents some limitations, as the difficult form of value padronization in the Hounsfield scale and the difficult to delimit the inferior limit of the condyle on the sagital plane, which would permit a more accurate volumetric calculation. Considering the methods used in this present study, it can be concluded that a significative condyle resorption occurs after the bilateral sagital split osteotomy using hybrid fixation, non-associated with temporomandibular disorders

A fixação híbrida do ramo mandibular é uma combinação de duas técnicas já anteriormente descritas na literatura e que oferecem bons resultados. A primeira delas é a fixação realizada por meio de miniplacas e parafusos monocorticais e a segunda é a fixação realizada por meio de parafusos bicorticais, buscando combinar os pontos positivos de cada uma delas com a finalidade de obter um resultado satisfatório para o paciente. A osteotomia sagital bilateral de mandíbula (OSBM) pode alterar a posição do côndilo na cavidade glenoide, ocasionando uma recidiva no posicionamento esquelético e muscular. O aumento na incidência de desordens temporomandibulares e reabsorções ósseas na cabeça do côndilo são fatores que devem ser investigados, assim como a relação entre esses fatores e o tipo de osteossíntese empregada. O presente estudo teve como objetivo comparar e quantificar o volume do côndilo mandibular antes e após a OSBM com fixação híbrida. A amostra foi composta por 20 pacientes (n=40) de ambos os sexos e com idades entre 18 e 30 anos que foram submetidos à cirurgia ortognática bimaxilar no período entre 2012 e 2014 no Hospital de Reabilitação de Anomalias Craniofaciais da Universidade de São Paulo (HRAC-USP). Os pacientes foram submetidos ao exame de tomografia computadorizada de feixe cônico (TCFC) nos períodos pré e pós-operatório à cirurgia ortognática. As aquisições das imagens tomográficas foram feitas no tomógrafo de feixe cônico (i-CAT®, Award-Winning Cone Beam 3D Dental Imaging) do setor de Radiologia do HRAC-USP, sendo realizada a mesma técnica tomográfica para todos os pacientes. O procedimento cirúrgico foi realizado em todos os pacientes pelo mesmo cirurgião e por meio da mesma técnica cirúrgica. Foi realizada a osteotomia sagital bilateral de mandíbula modificada por Arnett (1993) e a fixação de todas as mandíbulas foi realizada com a técnica híbrida. Os exames de TCFC foram importados pelo Mimics® (Medical Image Segmentation for Engineering on AnatomyTM), o qual analisou-as obtendo assim a variação volumétrica bilateral do côndilo mandibular. Para diminuir a possibilidade de erros, todas as tomografias foram avaliadas pelo mesmo examinador, o qual foi previamente calibrado. Para a calibração e cálculo do erro do método, foram utilizadas 20 hemimandíbulas medidas duas vezes com um intervalo de sete dias, obtendo assim o coeficiente de correlação interclasse (ICC), cujo valor foi de 0,99. Os resultados sugerem uma atividade de remodelação óssea no côndilo, com áreas de reabsorção e de neoformação óssea, sendo encontrada uma média de 5,20% de reabsorção. A análise estatística por meio do teste t pareado mostra que houve diferença estatisticamente significante (p<0,05). O cálculo do poder da amostra resultou num valor de 0,96. Apesar de possuir muitos recursos e possibilitar uma forma intuitiva de segmentação e mensuração dos exames de TCFC através da reconstrução em 3D, o Mimics® apresenta algumas limitações, como a dificuldade de padronização dos valores dentro da escala de Hounsfield e a dificuldade de delimitação do limite inferior do côndilo no plano axial, possibilitando uma mensuração volumétrica mais precisa. Em vista da metodologia empregada neste estudo, pode-se concluir que existe remodelação óssea significativa após a osteossíntese com fixação híbrida da osteotomia sagital bilateral de mandíbula, não associada a distúrbios da articulação temporomandibular / The hybrid fixation of the mandibular ramus is a combination of two successful techniques previously described and well known. The first one is the bicortical screws fixation and the second is the miniplates and monocortical screws fixation, aiming to achieve the best treatment for the patient. The bilateral sagital split osteotomy (BSSO) can alter the condyle position in the glenoid cavity, causing a skeletal and muscular relapse. The incidence increasing of temporomandibular disorders and bone resorptions at the top of the condyle are factors that must be investigated, as well as the relationship between these factors and the type of internal rigid fixation used. This present study aims to compare the condyle volume before and after BSSO using hybrid fixation. The sample is composed by 20 patients (n=40) of both sex and ages between 18 and 30 that were submitted to bimaxillary orthognathic surgery among 2012 and 2014 in the Hospital for Rehabilitation of Craniofacial Anomalies (HRAC-USP). All the patients were submitted to a cone beam computed tomography (CBCT) exam on pre and postoperative periods for the orthognathic surgery. The tomography images aquisition was obtained by the cone beam tomograph (i-CAT®, Imaging Sciences International) of the Radiology sector in the HRAC-USP considering the same technique for all the patients. The surgical procedure was performed in all the patients by the same surgeon using the same surgical technique. The BSSO modified by Arnett (1993) was accomplished using the hybrid fixation technique. The CBCT exams were imported by Mimics® (Medical Image Segmentation for Engineering on AnatomyTM), which analysed them to obtain the bilateral volumetric variation of the condyle. To reduce the error possibility, all the CBCT exams were analysed by the same examinator, who were previously calibrated. For the calibration and method error calculation, 20 hemimandibles were used for the measurements performed in a 7 days intermission, obtaining the interclass correlation coefficient (ICC), which value was of 0.99. The results suggest a remodelation activity on the condyle, with bone resorption and neoformation areas, which were founded 5.20% resorption mean. Statistical analysis using t test demonstrates that were founded significant statistical difference (p<0.05). The power sample calculation resulted in 0.96. Despite the several resources and possibility of an intuitive form of segmentation and analysis of the CBCT exams through the 3D reconstruction, the Mimics® software presents some limitations, as the difficult form of value padronization in the Hounsfield scale and the difficult to delimit the inferior limit of the condyle on the sagital plane, which would permit a more accurate volumetric calculation. Considering the methods used in this present study, it can be concluded that a significative condyle resorption occurs after the bilateral sagital split osteotomy using hybrid fixation, non-associated with temporomandibular disorders

Le desserrage des tiges est une complication fréquente des plâtres avec tiges transcorticales (TP) chez les grands animaux, nécessitant souvent leur retrait prématuré avant la guérison des fractures. Les charges excessives centrées sur le cortex à l’interface os-tige proximo-externe et disto-interne causent de l'ostéolyse. En utilisant un modèle de veau nouveau-né, ce projet a évalué un nouveau système de tige-manchon et anneau integré dans un plâtre (PS) optimisé pour réduire la contrainte péri-implant et le stress à l'interface os-implant. On a émis l'hypothèse que les PS se traduiraient par une ostéolyse péri-implant moindre par rapport aux TP. Dix veaux en bonne santé, de 3 semaines d'âge, ont été implantés avec les TP ou PS dans le métacarpe droit, à raison de 2 implants par veau. Les veaux ont été observés quotidiennement pour le confort et la boiterie et ont été euthanasiés à 28 jours. Les données recueillies comprenaient les radiographies à la chirurgie et à l'euthanasie et les mesures histomorphométriques de contact os-implant sur des échantillons non-décalcifiés avec les implants in situ. Les données ont été analysées en utilisant le test de Cochran-Mantel-Haenszel, une valeur de P <0,05 a été considérée comme significative. L'épaisseur corticale était plus importante pour les implants distaux que proximaux pour les deux groupes lors de la chirurgie (P = 0,03), mais était similaire entre les groupes (P > 0,3). Les veaux avec TP ont développé une boiterie plus tôt (au jour 21) que les veaux avec PS (P = 0,04). Histologiquement, il y avait plus de contact direct os-implant cortical pour les implants PS distaux que les implants TP (P = 0,04). La jonction métaphyso-diaphysaire osseuse où les implants proximaux étaient situés est impropre aux deux systèmes; chacun a un minimum de contact os-implant et de l'ostéolyse extensive. Le système PS n'ayant pas causé une ostéolyse importante lorsque implantés dans l'os diaphysaire et peut-être une alternative convenable aux TP pour des fractures comminutives des membres distaux. / Pin loosening is a common complication of transfixation pincasts (TP) in large animals, often necessitating premature removal before fracture healing. The excessive loads centered on the proximo-external and disto-internal cortices of the bone-pin interface cause osteolysis. Using a neonatal calf model, this project evaluated a novel pin-sleeve and ring cast system (PS) optimized to decrease peri-implant strain and evenly share stress at the bone-implant interface. It was hypothesized that PS would result in less peri-implant osteolysis compared to TP. Ten, 3-week-old, healthy calves were implanted with either TP or PS in the right metacarpus, 2 implants per calf. Calves were scored daily for lameness and were euthanized at day 28. Collected data included radiographs at surgery and euthanasia and histomorphometric measures of bone-implant contact on non-decalcified specimens with the implants in situ. Data was analyzed using Cochran-Mantel-Haenszel test; a P-value <.05 was considered significant. The cortical thickness was larger for distal implants than proximal implants for both groups at surgery (P = 0.03), but were similar between groups (P > 0.3). TP calves developed lameness sooner, at day 21, than PS calves (P = 0.04). Histologically, there was more direct cortical bone-implant contact for PS distal implants than TP implants (P = 0.04). The metaphyseal-diaphyseal junction where the proximal implants were situated is unsuitable bone for either system; each had minimal bone-implant contact and extensive osteolysis. The PS system did not cause significant osteolysis when instrumented in diaphyseal bone and is a suitable alternative to TP for comminuted distal limb fractures.

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