Miniplates for Osteosynthesis of Middle Facial Fractures

Miniplates for Osteosynthesis of Middle Facial Fractures INTRODUCTION Numerous biomechanical studies illustrate the stability of the rigid fixation for mandibular fractures4-6. However, little research has focused on the maxilla, despite the fact that Le Fort fractures and osteotomies are common clinical presentations. For the treatment of Le Fort maxillary fractures, the primary aims include the restoration of correct midfacial vertical height and anterior projection and restoration of occlusion. Nonetheless, the removal rate of the miniplates and screws were approximately 50% in orthognathic surgery (Le Fort I osteotomy), due predominantly to infection or wound dehiscence7. The other problem is that patients sometimes complain of weak clenching after the operation, therefore questions regarding minimum number of plates and stability following fixation have risen in recent times. Miniplate osteosynthesis, developed by Champy in 19751, is todays standard for the treatment of facial fracture. More recently resorbable plates2 and screws and 3-dimensional miniplating system3, have been introduced for fixation of facial fractures. Many studies have proved the efficacy of three dimensional plating systems in mandible fractures but very little research have been carried out on midface fractures. We studied the efficacy of three dimensional plates in midface fractures and found them efficacious enough to stabilize the bone fragments during osteosynthesis. Three dimensional miniplating system was introduced by Farmand (1992)3. The basic concept of three-dimensional fixation is that a geometrically closed quadrangular plate secured with bone screws creates stability in three dimensions. The three dimensional plates are positioned perpendicular to the fracture line. The screws adapt each part of the plate separately without any tension to the bone. The cross linking provides the stability to the system. Three dimensional miniplates are easy to adjust, requires minimal tissue dissection thus least disturbing the blood supply and because of its design fixation points remain in the vicinity of fracture line. Its low profile design and space between plate holes permits excellent revascularization. The biomechanical and technical advantages of three dimensional miniplate systems over two dimensional miniplate system promoted the current study to evaluate the efficacy of the 3-D titanium miniplates as a viable treatment modality in the osteosynthesis of middle third facial fractures. MATERIAL AND METHOD Subjects for the present study were selected amongst the patients, attending the outpatients department and emergency services of Department of Oral Maxillofacial Surgery, Kothiwal dental college and research centre,Moradabad. Study comprised of thirty patients, with isolated lefort I fracture,20 patients had bilateral fracture and 10 patients had unilateral lefort I fracture . All patients were taken up randomly irrespective of age, sex caste and creed. Patients were diagnosed on the basis of clinical examination and radiographic interpretation. Preoperative evaluation included careful examination of the soft tissues and underlying skeleton. A thorough physical examination was carried out to exclude any other injuries. All selected patients were informed about the experimental nature of the study and the possible complications were explained. Their co-operation was solicited and informed consent was obtained. The patient received prophylactic antibiotic coverage and analgesics at the time of initial presentation. INVESTIGATIONS Radiographs: The following radiographs were used to confirm clinical diagnosis and to assess the exact location of fracture and degree of displacement Occipitomental view and submentovertex view for midface PA – Mandible view OPG view (Orthopantomogram) CT scan as needed Other investigations Routine Blood investigation Urine analysis Urine analysis TREATMENT PLANNING All patients were admitted to the hospital prior surgery. Erich’s arch bar were placed on upper and lower standing teeth to stabilize the fracture segment and to achieve occlusion before plating. ARMAMENTRIUM Basic instrument set for maxillofacial surgery Instrument used for intermaxillary fixation 3-DIMENSIONAL TITANIUM MINIPLATE 1.7 MM SYSTEM PLATES DESIGN: 4 different designs of three-dimensional titanium miniplates were included. 2ц¦2 holed square plate 2 x 2 holed rectangular plates 3 x 2 holed continuous rectangle or double rectangle 42 holed –continuous rectangle plate All the plates had 1.7 mm diameter holes. PROFILE HEIGHT 0.6 mm (low profile plates) SCREWS Non compression, self-tapping, monocortical screws with round head. Diameter : 1.7 mm Length : 5mm, 7mm and 9 mm DRILL BIT: Diameter: 1.2 mm CONVENTIOANAL TITANIUM MINIPLATE 1.7 MM SYSTEM 1ц¦2 holed – straight plate PROFILE HEIGHT 1.0mm SCREWS Non compression, self-tapping, monocortical screws with round head. Diameter : 1.7 mm Length : 5mm, 7mm and 9 mm DRILL BIT: Diameter: 1.2 mm ACCESSORIES Screwdrivers Bone plate holding forceps Bone plate bending forceps Plate cutting pliers OPERATIVE TECHNIQUE FOR THREE DIMENSIONAL MINIPLATES Patients were operated either under general anesthesia (Naso-tracheal intubations) or local anesthesia. Strict asepsis was followed. In this study, the fracture sites were exposed through standard intraoral vestibular incision.(Fig.1), Following reduction of the fragments and temporary maxillomandibular fixation, a suitable 3D plate was selected and bent with a plate bending pliers to conform the proper adaptation of plates to bone surface. The three dimensional titanium miniplates were then positioned in such a way that the horizontal cross-bars were perpendicular to the fracture line and the vertical ones were parallel to it (Fig.2). Holding the plate perpendicular to the reduced fracture, drilling was performed through the hole in the plate strictly perpendicular to the bone surface. The drilling was performed at slow-speed along with copious saline irrigation to prevent damage to the bone by heat. To avoid injury to the dental roots the superior holes were drilled strictly monocortically, and directed into the space between the roots. Later screws of suitable length were selected for fixation of the plate. In each case the upper screws were tightened first, followed by the lower ones. For screw tightening the rotations were executed using the screw-holding screw driver. Maxillomandibular fixation was released and occlusion was checked by moving the lower jaw. The site was closed using 3-0 silk suture material. No maxillomandibular fixation was required in any of the patient. OPERATIVE TECHNIQUE FOR THREE DIMENSIONAL MINIPLATES Operative technique for conventional plate was similar to the one used for three dimensional miniplate.Intraoral vestibular incision was used in all the patients and after fracture reduction either conventional 2 dimensional L shaped plate was fixed at zygomaticomaxillary buttress region and 2 hole with gap miniplate was placed over nasomaxillary buttress region. POSTOPERATIVE MANAGEMENT Postoperative course of medication consisted of injection ceftriaxone 1gm 12 hourly (i.v.), injection metrogyl 100ml 8 hourly (i.v.) and analgesic and multivitamin preparation continued till 5th postoperative day. All patients were put on liquid diet for first 2 weeks. All patients were encouraged to maintained good oral hygiene. Sutures were removed on the 7th postoperative day. All patients were followed up at regular interval that is at 1st week, 3rd week, 6th week and 3 month postoperatively regarding restoration of function, stability of system used and any complication. Assessment of the patients was done under following parameters: Pain Visual Analogue Scale (VAS) (0-10) Swelling present/absent. Occlusion intact/deranged Mobility of fracture segment-present/Absent Infection/wound dehiscence -present/Absent Hardware failure present/Absent STATISTICAL ANALYSIS The following statistical tools were employed for the present study: Mean, Standard Deviation, Student’t’ test, Paired‘t’ test and Chi-square test RESULTS We obtained following results in our study Patients in the 31-40 years of age were the predominant age group presenting with midface fractures (50%). Males were most commonly affected with Lefort I fracture (92.84%). The most common cause of midface fracture was found to be road traffic accident (92.8%). There is significant decrease in pain at 3 WK, 6 WK and 3rd Months from the Baseline (1WK) for both the groups Swelling was present in 15 patients (50%). It decreased significantly at 3W, 6WK, 3 MONTHS, from baseline (1WK)(fig.3) There is significant improvement (75%) in post traumatic Parasthesia of infraorbital nerve following fixation with 3-D plating system.(Fig.4) Occlusion was achieved in all the patients after surgery No sign of infection and hardware failure was present in any patient. DISCUSSION Le Fort I maxillary fractures are among the injuries encountered most frequently in patients who suffer facial trauma and it is common in orthognathic surgery. Fixation of maxillary Le Fort I fractures(/osteotomy) by RIF of the facial skeleton has become an accepted, and even expected, form of treatment. When the teeth of the maxilla and mandible are clenched, anatomic support for the midface is provided through a series of buttresses or struts that distribute masticatory forces from the teeth to skull base.19-21 The vertical struts of the midface are clinically the most important in management of Le Fort I maxillary fractures. The 3 principal vertical buttresses of the maxilla are the nasomaxillary (medial) buttress, zygomaticomaxillary (lateral) buttress, and the pterygomaxillary (posterior) buttress.4 The internal fixation of Le Fort I fractures should use miniplates and screws and be fixed at anterior and lateral buttresses for the ideal internal fixation, whereas the posterior buttress should be without fixation due to the surgical difficulty of the operative approach.4 Surgical treatment of Le Fort I fracture according to the â€Å"ideal internal fixation† produces satisfactory results, but patients sometimes complain of weak clenching after the operation. Very few comparisons of the different maxilla fixation modalities and their behavior have been reported currently. In clinical Le Fort I fracture treatment, restoration of the correct midfacial vertical height and anterior projection and restoration of occlusion are critical. Therefore, questions have arisen regarding the stability and number of plates required of adequate fixation of lefort fractures. The fixation of 2 miniplates on each side as suggested by AO/ASIF, provides adequate stability and conventionally it has been the standard treatment for lefort fractures , Farmand8 in 1992 developed new titanium miniplate system that takes advantage of biogeometry to provide stable fixation and he called it as three dimensional plating system. A geometrically closed quadrangular plates secured with bone screws creates stability in three dimensions. .These plates have low profile design, excellent biocompatibility, and minimal rebound after bending. The present study was carried on patient’s age group 10- 50 years with the mean being 33.14 years. The maximum number of patients were in a age group between 31- 50 years (nearly 50%).This is in accordance with the study of Khateeb T,Abdulla FM(2007)9. There was predominance of males in this study, male is to female ratio being 13:1,and percentage of male patients being 92%. .Motamedi MH (2003)10 observed in a retrospective study on 237 patients, percentage of male patients being 89% and that of female patients being 11%, our study is in accordance with this study. In this study road traffic accident (92%) were found to be the major etiological factor for the fracture of the middle third of the facial skeleton .These findings coincides with the findings of, Iida S, Kogo M 11 who reported road traffic accident to be the most common cause of injury in a retrospective analysis of 1502 patients with facial fractures. In the present study it was observed that among the maxillary fractures, Lefort II fractures( approx78%) were most common, this finding is in accordance with the study Motagemi MH (2003)10 which reported the incidence of Lefort II fractures to be 54.6% among all maxillary fractures in a five year retrospective study on 237 patients . In the present study, post traumatic parasthesia of the infraorbital nerve was present was present in 4 cases (57.14%) (out of the 7 patients with zygomatic complex fractures) which was clinically inferred as compression of nerve by fracture fragments .Anesthesia was relieved in 3(75%) out of 4 patients in a three month follow up period which found to be due to infra orbital nerve relieved from compression by means of reduction of fractured segments in to its correct position. c. Demen et al (1988)12 reported the presence of sensory disturbances of infraorbital nerve in 219 cases (80.2%) out of 273 patients The influence of treatment approach on the recovery of the injured infraorbital nerve is controversial in the literature .Several authors reported that frequency of persistent sensory disturbance is independent of the method of reduction and fixation of fracture. Deman and box (1993)12 state that reduction and fixation are important factors in recovery from sensory disturbances of infraorbital nerve. Taicher (1993)13, observed that there is higher recovery rate of infraorbital nerve with miniplate osteosynthesis than with other method of treatment .We report a (75%) recovery rate of in our study, Our results support these findings .This significantly high recovery rate with 3 D plate can be explained by the fact that fixation with 3 D plate provides better stability to the complex in all the three dimensions of movement? However there is no study in the literature on the recovery of infraorbital nerve after fixation with 3-D plates. In the present study occlusion was achieved in all the patients after surgery. Conventional treatment with maxillomandibular fixation is associated with its well known limitations and disadvantages. Klotch DW(1987)14 studied internal fixation versus conventional therapy in midface fractures and found that a more stable occlusion is achieved with internal fixation .S Anand, Thangavelu (2004)15studied the use of three dimensional plate fixation of fractures and osteotomies and stated that satisfactory occlusion was achieved in all the patients after internal fixation with 3- plates and no patient required any maxillomandibular fixation. Claude Guimond(2005)16 studied the use of 3-D plate for fixation of mandibular factures and reported similar findings in their study. As three dimensional plates provide stability in three dimensions of movement the need for maxillomandibular fixation is greatly diminished or moreover eliminated. Our study is in accordance with these studies. No patient reported for any type of postoperative infection, wound dehiscence during the period of three month follow up. Lia G (1997)17 reported the similar results in his study .He found no post operative complications in 30 treated cases of 3 D titanium bone plating. S Anand, Thangavelu (2004)15 studied the role of 3-dimensional plating system and did not reported any infection in their study .Claude Guimond(2005)16studied the use of 3-D plating in mandibular fractures and reported a significantly low rate of infection as compared with other systems. Farmand(1995)3 studied the use of 3-D plates in fixation of fracture and osteotmies and reported an significantly low rate of post operative infection with 3-D plates. No infection in our cases could be attributed to the preoperative antibiotic therapy in all patients,and proper sterilization technique. In none of the patients plates need to be removed exhibiting there excellent biocompatibility in this short period of study. Farmand(1992)18, in their respective studies on the use of three dimensional plates in oral and maxillofacial region did not report any hardware failure with the use of these plates ,our study is in accordance with these studies. Thus as a result of clinical experience it can be inferred that the use of 3 D plates and screw system in the management of midfacial fractures give good results in term of function ,esthetic and acceptability. However, owing to fewer numbers of cases, no definitive conclusions can be drawn, for this; studies with larger sample size and long term follow up are recommended.

callaway golf co. :: essays research papers

Callaway Golf Co.   Ã‚  Ã‚  Ã‚  Ã‚     Ã‚  Ã‚  Ã‚  Ã‚     Ã‚  Ã‚  Ã‚  Ã‚  In 1982, Ely Reeves Callaway had bought his small wedge and putter golf business and called it Hickory Stick USA and created clubs that were enjoyable for the average golfer. He called these clubs the Demonstrably Superior and Pleasingly Different (DSPD) clubs. This was a code he had always lived by. The family of Ely Callaway are not involved with the company today because he was told to choose his successor, and had chose Ron Draqpeau. He is a man who only shared the same vision and thought of golf, but also had the skills as a leader to continue his wonderful golf company. The goal was to make a good product and tell the truth about the game. In those days Ely would provide them to his customers personally in the back of his Cadillac. He made sales calls and talked to pros, amateurs, and those who came to be known as an average golfer. Finally, Hickory Stick USA came to be knows as Callaway Hickory Stick U.S.A, and not too long after that, Callaway Golf.   Ã‚  Ã‚  Ã‚  Ã‚  By 1985, the company moved from the California desert to its coastal Carlsbad home. Which is presently the main headquarters of the company today as well. This was where he saw opportunities in undeveloped land, along with a talented labor force fueled by the nearby aerospace industry. Around that same time he met and lured a man named Richard C. Helmstetter away from a successful career designing high-end pool cues in Japan. Mr. Helmstetter and his R&D team designed and created a larger, more forgiving stainless steel driver. Today, there are a total of 2,600 employees working with the Callaway Golf Company.   Ã‚  Ã‚  Ã‚  Ã‚  Celebrities such as Bill Gates, Kenny G., Celine Dion, and Alice Cooper uses the latest technology of Callaway Golf. Even the pros such as, Annika Sorenstam, Charles Howell III, and Phil Mickelson use Callaway Golf as well! It had eventually become one of the biggest names on the tour.   Ã‚  Ã‚  Ã‚  Ã‚  Mr. Callaway had once stated, â€Å" We feel we have been extremely fortunate in our success as a company so much so that we would like to give something back to the community that helped make us so successful.† Therefore in 1993, they have donated $1 million. They were established with the mission to improve the community where Callaway Golf employees work and live. This was the same year that has signed an amateur golfer at the time, Annika Sorenstam, as a staff professional.

Learning theorists Essay

In most cases, the more students use construction to understand new material-the more they use what they already know to help them understand and interpret the material-the more effectively they will store it in long-term-memory. Different people often construct different meanings from the same stimuli, in part because they each bring their own unique experiences and knowledge bases to the same situation. For example, when the â€Å"Rocky† passage on page 267 was used in an experiment with college students, physical education majors frequently interpreted it as a wrestling match, but music education majors (most of whom had little or no knowledge of wrestling) were more likely to think that it was about a prison break. Furthermore, people often interpret what they see and hear based on what they expect to see and hear. Prior knowledge and expectations are especially likely to influence learning when new information is ambiguous. As teachers, we will find our students constructing their own idiosyncratic meanings and interpretations for virtually all aspects of the classroom curriculum. For example, as the Rocky exercise illustrates, the activity of reading is often quite constructive in nature: Students combine the ideas that they read with their prior knowledge and then draw logical conclusions about what the text is trying to communicate. So, too, will we find constructive processes in subject areas like math, science, and social studies. When we want our students to interpret classroom subject matter in particular ways, we must be sure to communicate clearly and unambiguously, so that there is little room for misinterpretation. Retrieval isn’a always an all-or-nothing phenomenon. Sometimes we retrieve only certain parts of whatever information we are looking for in long-term memory. In such situations, we may construct our â€Å"memory† of an event by combining the tidbits we can retrieve with our general knowledge and assumptions about the world. Were you able to retrieve the missing letters from your long-term memory? If not, then you may have found yourself making reasonable guesses, using either your knowledge of how the words are pronounced or your knowledge of how words in the English language are typically spelled. For example, perhaps you used the I before e except after c rule for word 4; if so, then you reconstructed the correct spelling of retrieval. Perhaps you used your knowledge that ance is a common word ending. Unfortunately, if you used this knowledge for word 2, then you spelled existence incorrectly. Neither pronunciation nor typical English spelling patterns would have helped you with hors d’oeuvre, a term borrowed from French. When people fill in the gaps in what they’ve retrieved based on what seems â€Å"logical,† they often make mistakes-a form of forgetting called reconstruction error. Our own students sometimes will fall victim to reconstruction error, pulling together what they can recall in ways that we may hardly recognize. If important details are difficult to fill in logically, we must make sure our students learn them well enough that they can retrieve them directly from their long-term memories.

Euthanasia Is The Practice Of Ending A Patient s Life...

Euthanasia is the practice of ending a patient’s life with the intention of relieving them from pain and suffering. The topic is interesting because there is a huge difference in people’s opinions of it- from those who support it to those who do not. A few arguments that support euthanasia are the rights for humans to decide when to die, that death is not a bad thing so it coming sooner is more of a relief for them, it is wrong to deny someone the right to die when they are suffering, and it may be cost effective for people who are terminally ill and will die soon anyway. A few arguments that are against euthanasia include patients being judgment-impaired due to the effects of their illness, it seems like a cop-out for doctors because it is easier to euthanize a patient than to care for them, a patient’s decision to be euthanized can have a serious impact on others in their life, patients may feel pressured to chose euthanasia because it is cheaper than medical c are, and euthanasia is mainly promoted by people who have had a loved one die because they were in agonizing pain. Autonomy which is the ability to decide, supports any decision a patient will make, whether it is to be euthanized or not. Beneficence is the assumption that a healthcare provider is actively seeking the patient’s good and will give their opinion on whether euthanasia is the right decision or not. The two ethical theories that can be used to defend and criticize euthanasia are the duty-oriented