2017-18 HSC Section 3 Green Book

Plastic and Reconstructive Surgery • January 2016

suspension wires, arch bars, maxillomandibular fixation screws, orthodontic bands and brack- ets, and several different techniques using stain- less steel circumdental wires such as Ivy loop and Ernst ligatures. 11 The use of stainless steel Erich arch bars remains the standard method of choice for most maxillofacial surgeons. The develop- ment of new materials and technology along with the surgeon’s desire to use products that reduce operating time, increase safety, and still have good surgical outcomes have created a market- place for newer methods such as the use of max- illomandibular fixation screws. The most recent development in maxillomandibular fixation is the SMARTLock system from Stryker Craniomaxillo- facial. The SMARTLock system is a blend between traditional arch bars and modern maxillomandib- ular fixation screws. This study was performed to evaluate the SMARTLock system. Overall, the SMARTLock system was success- ful in treating patients who required maxilloman- dibular fixation. The SMARTLock system was relatively easy to use and could be placed quickly in a variety of patients with different fracture pat- terns. The system was used in both maxillary and mandibular fractures successfully. The system was also used in unilateral, bilateral, open, and closed fractures successfully. The system was successfully used in partially edentulous patients (Fig. 2) and patients with severe periodontal disease (Fig. 3) where traditional arch bars could not have been used. Examples are shown in Figures 1 through 4. Of note, the system was also used in other appli- cations on patients that were excluded from this study. One patient had replacement of a custom alloplastic temporomandibular joint and required maxillomandibular fixation intraoperatively. The SMARTLock system was removed after the joint was replaced. Another patient had the SMART- Lock system applied to facilitate maxillomandibu- lar fixation for a tongue flap to close a chronic oronasal fistula. The SMARTLock system was placed quickly in most situations and took approximately 62 seconds per screw to place. Time to place the system was 14.4 minutes on average. This involved

Table 8. Comparison of Application Time of the 319 Screws

Time (min)

SMARTLock system application time  Kendrick et al. (present study)  Stryker Early Product Surveillance 8 Erich arch bars and circumdental wire application time  Engelstad and Kelly, 2011 10  Chao and Hulsen, 2015 9

14.4 16.1

42

25.5 95.1 34.6

 Rai et al., 2011 6

 Ayoub and Rowson, 2003 1  Chao and Hulsen, 2015 9

62

Average time

54.3

in the form of endodontic therapy. No teeth were extracted. A cost analysis comparison between the appli- cation of traditional arch bars with circumdental wires and the application the SMARTLock system was performed. The average time for placement of the SMARTLock system was 14.4 minutes in this study (Table 8). 1,6,8–10 A review of the literature shows an average application time of 54.3 minutes for Erich arch bars. A 2005 study of 100 U.S. hos- pitals determined that the cost of operating room use is approximately $62 per minute. 11 The cost for Erich arch bars and circumdental wires was estimated to be $60. The cost of the SMARTLock system was estimated to be $2470, which is the sum of two plates ($325 per plate) and 14 screws ($140 per screw). The analysis showed that there is no increased cost of using the SMARTLock sys- tem (Table 9). Discussion Immobilization and splinting of the mandible and maxilla have been used throughout history for the treatment of maxillofacial patients. Max- illomandibular fixation was first introduced in 460  bc by Hippocrates, who treated mandible frac- tures by external manipulation and placement of gold wire to hold the teeth in occlusion. 12,13 Sev- eral techniques and modifications of these tech- niques have developed over the past 2000 years, including external bandages, splints, skeletal

Table 9. Cost Analysis

Arch Bar/Wire

SMARTLock

Savings

Application time, min Cost of materials

54.3

14.4*

39.9

$60.00 $3366.60 $3426.60

$2470.00† $892.80 $3362.80

–$2410.00 $2473.80

Operating room cost of application

Total cost

$63.80

*Assumes 14 screws per person. †$325 per plate and $130 per screw.

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