Commentary

As noted in this review under “General aspects of bone surgery,” rigid internal fixation (RIF) is a major breakthrough in maxillofacial trauma and reconstructive surgery. RIF using plates and screws allows immediate function after repairing facial fractures and reconstructive operations. No longer do “jaws need to be wired shut” for fixation (maxillomandibular fixation). Advantages of RIF include early return to function and work, and shorter length of hospital stays. Tangible disadvantages include the increased cost of materials and operating time, and the possible need for removal of plates and screws. Theoretical disadvantages include a possible mutagenic effect of titanium, although there is no evidence for this in human clinical studies.

RIF plates and screws made of biodegradable materials are effective in achieving RIF and early return to function and have the obvious advantage of degrading. In animal and human studies, however, degradation is often incomplete and the residual plate material may be associated with infection or inflammation necessitating removal.

There is some controversy over the use of plates and screws made of titanium (the current gold standard for fixation materials) versus biodegradable materials. The authors state that, “the major drawback to the general use of biodegradable devices is the lack of clinical evidence.” I disagree with this reasoning. For better or worse, clinicians commonly use devices and techniques without good clinical evidence. Instead, the handling properties and application of currently available biodegradable fixation devices, compared with titanium, are sufficiently poor and awkward to impede their general distribution alongside their lack of clear, unambiguous clinical or biological advantages. As the authors show in their well-conducted review of the topic, neither short- nor long-term advantages of biodegradable materials are at all apparent.

I do agree with the authors' statement that another significant reason for the limited use of biodegradable RIF devices, “is surgeons' resistance to modify the conventional treatment techniques with which they have the most experience.” Surgeons, however, will quickly convert to new techniques given clear advantages of the technique or material. Most maxillofacial surgeons currently in practice have adopted the use of RIF (with titanium or biodegradable devices). We now rarely wire the teeth together for fixation despite our comfort and extensive experience with the latter operation.

For those interested in a current assessment of titanium and biodegradable materials in the clinical setting of maxillofacial fixation, I recommend this excellent review.