Genioplasty with wires

[Meefly]

Hi

Just wondered if any learned people know the pros/cons of surgeons still using wires to fixate the bone rather than the more widely used plates and screws these days; was there any particular reason for the move to titanium plates?  Does using wires preclude the surgeon from making certain bone cuts or certain movements of the chin?

Thanks

[kavan]

Hi

Just wondered if any learned people know the pros/cons of surgeons still using wires to fixate the bone rather than the more widely used plates and screws these days; was there any particular reason for the move to titanium plates?  Does using wires preclude the surgeon from making certain bone cuts or certain movements of the chin?

Thanks

Patients don't like having their 'mouths' wired shut for that long. Plates and screw fixation allows them to use their TEETH to CHEW much sooner than they could if things were all wired up.

[Meefly]

Sorry I think I didn't phrase my question properly; I was referring to wires to secure the chin bone in a sliding genioplasty only, which I believe does not warrant wiring the jaw shut.

this is how the surgeon explains it on real self.

"Plates and screws are necessary for mandibular fractures and for ortognatic surgery of the jaw involvin major osteotomies; however the sliding genioplasty consists in an apical or marginal osteotomy affecting exslusively the chin and not any structural or support pillars of the jaw, neither its integrity, therefore no strong fixation is required; the piece of bone slided forward is tiny compared with the rest of the jaw and stands for no supporting forces or tractions, in addition the healing is amazingly quick and satisfactory in all cases. All this makes plates and screws unnecessary.

I use very thin steel wires to fix the piece, 2 or 3 anchors suffice, and they remain buried unther the osseous callus formed around the area. In my vast experience I never had a case of migration, intolerance or revomal was required. However a majority of plates and screws produce pain, irritation, disturbance, may migrate or need removal with years. I am talking about follow up times beyond 10 years, an additionally I never had one case of consolidation problems, pseudartrosis or infection."

[kavan]

OK, then they are probably 'K wires' which are good for what he told you they were good for.

[Bobbit]

Sorry I think I didn't phrase my question properly; I was referring to wires to secure the chin bone in a sliding genioplasty only, which I believe does not warrant wiring the jaw shut.

this is how the surgeon explains it on real self.

"Plates and screws are necessary for mandibular fractures and for ortognatic surgery of the jaw involvin major osteotomies; however the sliding genioplasty consists in an apical or marginal osteotomy affecting exslusively the chin and not any structural or support pillars of the jaw, neither its integrity, therefore no strong fixation is required; the piece of bone slided forward is tiny compared with the rest of the jaw and stands for no supporting forces or tractions, in addition the healing is amazingly quick and satisfactory in all cases. All this makes plates and screws unnecessary.

I use very thin steel wires to fix the piece, 2 or 3 anchors suffice, and they remain buried unther the osseous callus formed around the area. In my vast experience I never had a case of migration, intolerance or revomal was required. However a majority of plates and screws produce pain, irritation, disturbance, may migrate or need removal with years. I am talking about follow up times beyond 10 years, an additionally I never had one case of consolidation problems, pseudartrosis or infection."

Even standard sets of Titanium plates can be expensive and often do not precisely fit the need and are used anyway for lack of something better.    Wire can give the surgeon a lot of flexibility.  In the applications where either could be used, wires probably take longer in the operating room and probably require more experience and skill.  But they involve less total mass of metal left in the body.

If the surgeon does a lot of surgeries of a particular variety,  he can get the plate manufacturer to make some customized plates for specific applications to the specific design/configuration wanted by the surgeon.  At that point,  they may actually be "proprietary" to that specific surgeon for at least a few years.   


 

[Meefly]

Thanks very much for the info.  It makes me wonder why almost all surgeons have switched to titanium plates; to make the surgery quicker and easier?

[Bobbit]

Thanks very much for the info.  It makes me wonder why almost all surgeons have switched to titanium plates; to make the surgery quicker and easier?

One factor is that they were likely never taught by someone with the patience or experience to use the wires.   The older surgeons still know how to do the wire work.   Someone who trained extensively with one of the old guys will likely know how to do wire work.

But there is a proper time and place for plates & screws. 

But there is also a proper time and place for wire - - but few younger surgeons are skilled in that - - so the just plates & screws, even if wire would be more appropriate.

[needadvancement]

Any digital photos of this wiring technique? I cant seem to find much info on this procedure.

[Bobbit]

Any digital photos of this wiring technique? I cant seem to find much info on this procedure.

Think of  a surgeon who drills a tiny hole (maybe 1 mm in diameter) in the bone on one side of a fracture line and then a tiny hole on the other side and then threads a very small diameter wire through one hole and out the other and over the top and then "ties it off"  by twisting the ends and bending the ends down flat against the surface of the bone.  Sort of like taking single stitches to close a skin wound - -  but using wire for the "sutures".

[ditterbo]

Sounds much less disruptive to the muscle then a frigging right angled plate holding the chin bone in place. No need to go back in later and remove the hardware either.

[jawline]

There's a similar question that was asked on realself, various answers but one surgeon says that plates and screws give more stability in the healing phase.

https://www.realself.com/question/nyack-ny-sliding-genioplasty-plates-screws


Seems there are various articles that seem to say the same:

"Initially, wiring procedures were used to stabilize the osteotomized segments. Rigid fixation techniques were introduced in an attempt to decrease the post-surgical relapse rate."

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3777031/

"In the 1980s, plate and screw fixation was introduced. This was an improvement over previous wire fixation for segment stabilization."

https://pocketdentistry.com/genioplasty-2/


One of the Q&A on Eppley's site where he says that:

"You are referencing old chin fixation techniques that only used wire fixation which are far less stable. While I doubt they could even then relapse back to the their original position, they were less secure the further the chin was advanced."

https://www.eppleyplasticsurgery.com/can-a-sliding-genioplasty-relapse-back/


Seems Arnett and Gunson also use plates and screws in sliding genioplasty:

"Small titanium plates and screws are typically used in both procedures to secure implant and bone materials."

https://www.arnettgunson.com/genioplasty/


Theres also this thread from a few years ago, the user got an 8mm genioplasty with wire fixation but had relapse then had another genioplasty later using plates and screws:

http://jawsurgeryforums.com/index.php?topic=4962.0/


Going against what the previous articles have said in regards to stability, an abstract from a comparison study states:

"There was no difference in skeletal stability between the two groups."

https://www.ncbi.nlm.nih.gov/pubmed/9427445


Found this image for the wire fixation:



It's from the following website (slide number 10):

https://www.slideshare.net/sylvainchamberland/orthognatic-surgery-chirurgie-orthognathique


It seems that the surgeon prefers wire fixation (slide 74 onwards):

https://www.slideshare.net/sylvainchamberland/functional-genioplasty-in-growing-individuals-v-angchamberland-orthodontiste


An abstract in regards to replacing a silicone chin implant that was infected 25 years post surgery:

"To minimize the presence of exposed hardware in this contaminated field, we used intraosseous Kirschner wire fixation for osteosynthesis of the advanced genial segment. Our patient experienced no complications from this procedure, the infection cleared, and a successful aesthetic outcome was achieved with this technique."

https://www.ncbi.nlm.nih.gov/pubmed/22976700


An abstract of the cost comparison of wires and plates (again, here they say accurate and stable fixation):

"For patients requiring genioplasty to advance and-or superiorly reposition the chin, it is possible to use wire osteosynthesis to achieve accurate and stable fixation while reducing the fixation cost by more than C$500.00 per case."

https://www.ncbi.nlm.nih.gov/pubmed/24271827


Maybe wires are stable for smaller movements? And plates are needed for larger movements? Though the spanish surgeon says even with large movements he only uses wire fixation. It does seem that wires would give the surgeon more flexibility and the cost would be lower than using plates and screws. Plus as pointed out there'd be no need to remove hardware in the future. So I suppose it just comes down to a risk of relapse.

[kavan]

To the best of my knowledge, 'K wires'/Kirchner wires allow for a variety of movements; large and small. Also versatility for more 'exactness' than what standardized hardware allows. The standardized hardware comes in 'X' mm increments (forgot what 'X' was) where as the wires don't have that limitation. Plates and screws would be more of a time saver though for both the surgeon and the patient under anesthesia.

[jawline]

To the best of my knowledge, 'K wires'/Kirchner wires allow for a variety of movements; large and small. Also versatility for more 'exactness' than what standardized hardware allows. The standardized hardware comes in 'X' mm increments (forgot what 'X' was) where as the wires don't have that limitation. Plates and screws would be more of a time saver though for both the surgeon and the patient under anesthesia.

This is pretty much what that spanish surgeon seems to say. You can get more precise with the movements in all directions. The plates, from what I've read, come in 2mm increments, I do wonder though what happens if someone needed an odd number movement, would they have to go either mm less or more or maybe they'd modify the plate. Thats a good point you made about less time under anesthesia, I never thought about that, maybe thats another reason they moved over to using plates and screws.

Heres the link in regards to the plate increments:

https://books.google.co.uk/books?id=gyxTBwAAQBAJ&pg=PA287&lpg=PA287&dq=sliding+genioplasty+plates+increments&source=bl&ots=5gM1hK9V61&sig=2ieH9NBlzik1y_e7EmW5KbGXTm4&hl=en&sa=X&ved=0ahUKEwibqpHhyYrZAhWMJ8AKHePkBzMQ6AEIWzAK#v=onepage&q=sliding%20genioplasty%20plates%20increments&f=false

[kavan]

This is pretty much what that spanish surgeon seems to say. You can get more precise with the movements in all directions. The plates, from what I've read, come in 2mm increments, I do wonder though what happens if someone needed an odd number movement, would they have to go either mm less or more or maybe they'd modify the plate. Thats a good point you made about less time under anesthesia, I never thought about that, maybe thats another reason they moved over to using plates and screws.

Heres the link in regards to the plate increments:

https://books.google.co.uk/books?id=gyxTBwAAQBAJ&pg=PA287&lpg=PA287&dq=sliding+genioplasty+plates+increments&source=bl&ots=5gM1hK9V61&sig=2ieH9NBlzik1y_e7EmW5KbGXTm4&hl=en&sa=X&ved=0ahUKEwibqpHhyYrZAhWMJ8AKHePkBzMQ6AEIWzAK#v=onepage&q=sliding%20genioplasty%20plates%20increments&f=false

They don't modify the plate. They err on the side of 1mm too much or 1mm too little.

[needadvancement]

This is pretty much what that spanish surgeon seems to say. You can get more precise with the movements in all directions. The plates, from what I've read, come in 2mm increments, I do wonder though what happens if someone needed an odd number movement, would they have to go either mm less or more or maybe they'd modify the plate. Thats a good point you made about less time under anesthesia, I never thought about that, maybe thats another reason they moved over to using plates and screws.

Heres the link in regards to the plate increments:

https://books.google.co.uk/books?id=gyxTBwAAQBAJ&pg=PA287&lpg=PA287&dq=sliding+genioplasty+plates+increments&source=bl&ots=5gM1hK9V61&sig=2ieH9NBlzik1y_e7EmW5KbGXTm4&hl=en&sa=X&ved=0ahUKEwibqpHhyYrZAhWMJ8AKHePkBzMQ6AEIWzAK#v=onepage&q=sliding%20genioplasty%20plates%20increments&f=false

I had been thinking about a very complicated SG and I still don't know if it's possible in one setting, it's a horizontal and vertical advancement of the chin bone and also has a cut made in the middle to spread them apart for a wider chin. All at once, is it possible for either methods and would the wiring technique be more suitable for this?
Appriciate the info.