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Oral Implantol (Rome). 2016 Jan-Mar; 9(Suppl 1/2016 to N 4/2016): 107–111.
Published online 2017 February 14. doi:  10.11138/orl/2016.9.1S.107
PMCID: PMC5333745

Metals used in maxillofacial surgery

SUMMARY

The goal of maxillofacial surgery is to restore the shape and functionality of maxillofacial region. In the past years, there has been a tremendous progress in this field because of significant advances in biotechnology that provided innovative biomaterials to efficiently reconstruct the maxillofacial injured region. By using appropriate selection of the implant biomaterial, it is possible to reconstruct the native tissue, both in form and function. The ideal biomaterial should mimic native tissues regarding density, strength, and modulus of elasticity. Autografts are currently the gold standard for replacement of missing tissues, but synthetic biomaterials have been widely used because they eliminate the discomfort to take the replacement tissue from the donor site. Among synthetic biomaterials, different metals may be utilized to efficiently reconstruct the maxillofacial injured region. This article makes an effort to summarize the most important metals in use in maxillofacial surgery, and point out advantages and disadvantage of each type.

Keywords: metals, vitallium, gold, stainless steel, titanium, maxillofacial surgery

Introduction

Trauma or injuries of the maxillofacial region represent a major problem for surgeons. The goal of maxillofacial surgery is to restore the shape and functionality of maxillofacial region. In the past years, there has been a tremendous progress in this field because of significant advances in biotechnology that provided innovative biomaterials to efficiently reconstruct the maxillofacial injured region. Among them, there is a distinction between naturally occurring or synthetic biomaterials. Naturally occurring materials include autogenous grafts, allografts, and xenografts. Alloplasts are generally synthetic materials. It should be evidenced that there is no evidence for an ideal material (either synthetic or naturally occurring) for maxillofacial surgery. On the opposite, the choice of the selected material depends on many factors including the type of fractures, the necessity to be biocompatible, stable and not deformable over time, or resorbable. In this article, we review the metals commonly used in maxillofacial surgery, highlighting their advantages and disadvantage.

Metals in use for maxillofacial surgery

Metals for maxillofacial surgery may require specific characteristics and mechanical properties (1). These include tensile strength, shear stress, elasticity, and yield strength (Table 1).

Table 1
Required characteristics of metals used for maxillofacial surgery.

The first introduced metals were vitallium (an alloy of cobalt, chromium, and molybdenum) gold, and stainless steel (2). However, these metals were proved to be problematic because of corrosion and poor handling properties. Thus, in 1967 the use of titanium was introduced and revolutioned the field of maxillofacial reconstruction (3).

In the following sections, we will examine the use of each of these metals in maxillofacial surgery (Table 2).

Table 2
Metals used for maxillofacial surgery and their biological response when implanted.

Vitallium

Vitallium is a base metal alloy that has been used in dentistry and medicine since 1929 (4). Vitallium (or CoCrMo) has been widely used in orthopedic and maxillofacial surgery and is well tolerated. Its use for reconstruction of midface bone defects has been reported in single case reports without significant evidence for morbidity or complications during the 1990s (5). At the beginning its use was particularly encouraged in cases of orbital fractures where reconstruction of the bony orbit is essential to maintain normal appearance and function of the eye (6). In large follow-up, no postoperative orbital infections were observed with no requirement of vitallium implant removal (5). Nonetheless, its use is not recommended in absence of rigid fixation and, in successive studies with animal models, this alloy was found to be less biocompatible than titanium, with decrease in the biomechanical fixation and increase in intra- and extracellular accumulation of metal ions in the immediate implant surrounding area (7). In addition, evidence for difficult to shape radiographic scatter has been evidenced (8). Despite these data, the choice between titanium alloy and CoCrMo should eventually be done by a comprehensive review of all factors influencing clinical implant survival.

Stainless steel (Iron-Chromium-Nickel Based Alloys)

Stainless steel has adequate strength, flexibility, ductility, and bio-compatibility for most maxillofacial implant applications. In addition, it is relatively cheap and easy to manufacture (9). Stainless steel alloys are used for orthopedic and implant devices. Their use for management of mandibular angle fractures has recently been proposed by Kanubaddy et al. (10).

Disadvantages are represented by corrosion (11, 12), late-onset implant failure, and presence of radiographic scatter at MRI (13). In addition, iron based alloys are subjected to allergic reactions in susceptible patients, due to the presence of nickel into the alloy. They have high galvanic potentials and corrosion resistance (2). This can result in galvanic coupling and biocorrosion, if titanium, cobalt, zirconium or carbon implant biomaterials are used with it (14).

Gold

Gold implants are used in reconstructive surgery, especially for middle ear and upper lid closure in facial nerve paresis-induced lagophthalmos (15). However, in order to achieve better therapeutic benefits, clinical reports have documented that the surface of gold implants should be modified or encased in biocompatible alloplastic materials.

Gold is also applied to a long list of dental prostheses, including inlays, onlays, crowns, bridges, periodontal splints, and post and cores (16). Within this range of use, gold has sufficient strength and corrosion resistance, and it is relatively biocompatible. In addition, gold dental prostheses have a long-life cycle.

Reported complications may include, among others, migration, extrusion, and allergy (1720). In most recent years aesthetic concerns and cost made gold a less popular prosthesis than in the past and thus these types of implants have been replaced by cheaper and more biocompatible materials.

Titanium

Titanium exhibits mechanical properties desirable for internal rigid fixation, and, when combined with its degree of biocompatibility (21), makes it a favorable material for fixation. For these reasons, and to overcome the defects of the other metals previously used, titanium has become the standard gold for reconstruction of the maxillofacial skeleton (22).

Titanium has been used successfully as an implant material and this success with titanium implants (2327) is credited to its excellent biocompatibility due to the formation of stable oxide layer on its surface (28, 29). The commercially pure titanium is classified into 4 grades which differ in their oxygen content. Grade 4 has the most (0.4%) and grade 1 the least (0.18%) oxygen content. The mechanical differences that exist between the different grades of titanium is primarily because of the contaminants that are present in minute quantities.

Titanium is a common choice in the repair of orbital floor fractures. In addition, the development of hybrid materials (polyethylene with reinforced titanium mesh) has further increased its use in such fractures (22). These materials have the advantage of strength and shape retention offered by titanium while the polyethylene provides a porous biocompatible surface that allows for tissue ingrowth.

The success of titanium in maxillofacial surgery is certainly due to its biological and mechanical properties (30). In fact, has been widely reported as biomaterials such titanium are able to support the bone growth (31), as their mechanical properties are similar to bone tissue (32, 33). Titanium is an inert, non corrosive and malleable metal. Furthermore, titanium offers the advantage of visibility on postoperative imaging with minimal distortion at MRI (34). More recently, titanium mesh cranioplasty has revealed to be an extremely safe and reliable alternative to autografts and even more preferable to replacement with natural bone autografts in case of large size cranial defects (35, 36).

Disadvantages of this metal are represented by the cost and possibly by aesthetic issues related to the gray color of titanium, which becomes more pronounced when soft tissue situation is not optimal and the dark color stands out through the thin mucosa.

Conclusions

The metals used for maxillofacial surgery have been developed over years to overcome the defects that emerged with their use. These defects range from problems related to metal corrosion, difficult to shape them to the required form, late-onset implant failures, to problems related to their cost and presence of scatters in radiographic examination. At last, titanium has mostly overcome the other metals in maxillofacial surgery, although the use of other metals has not yet been abandoned. The choice of the metal by the maxillofacial surgeon is still dictated by the type of fracture and by the specific mechanical property requirement in each specific case.

References

1. Niinomi M. Mechanical properties of biomedical titanium alloys. Mater Sci Eng A. 1998;243(1–2):231–6.
2. Saini M, Singh Y, Arora P, Arora V, Jain K. Implant biomaterials: A comprehensive review. World J Clin Cases. 2015 Jan 16;3(1):52–7. [PMC free article] [PubMed]
3. Gilardino MS, Chen E, Bartlett SP. Choice of internal rigid fixation materials in the treatment of facial fractures. Craniomaxillofac Trauma Reconstr. 2009;2:49–60. [PMC free article] [PubMed]
4. Gore D, Frazer RQ, Kovarik RE, Yepes JE. Vitallium. J Long Term Eff Med Implants. 2005;15(6):673–86. [PubMed]
5. Sargent LA, Fulks KD. Reconstruction of internal orbital fractures with Vitallium mesh. Plast Reconstr Surg. 1991;88(1):31–8. [PubMed]
6. Sengezer M, Sadove RC. Reconstruction of midface bone defects with vitallium micromesh. J Craniofac Surg. 1992 Nov;3(3):125–33. [PubMed]
7. Jakobsen SS, Baas J, Jakobsen T, Soballe K. Biomechanical implant fixation of CoCrMo coating inferior to titanium coating in a canine implant model. J Biomed Mater Res A. 2010 Jul;94(1):180–6. [PubMed]
8. Barone CM, Eisig S, Wallach S, Mitnick R, Mednick R. Effects of rigid fixation device composition on three-dimensional computed axial tomography imaging: direct measurements on a pig model. J Oral Maxillofac Surg. 1994 Jul;52(7):737–40. [corrected to Mitnick R] discussion 740–1. Erratum in: J Oral Maxillofac Surg. 1994 Oct;52(10):1099. [PubMed]
9. Panje WR, Hetherington HE. Use of stainless steel implants in facial bone reconstruction. Otolaryngol Clin North Am. 1995 Apr;28(2):341–9. [PubMed]
10. Kanubaddy SR, Devireddy SK, Rayadurgam KK, Gali R, Dasari MR, Pampana S. Management of Mandibular Angle Fractures: Single Stainless Steel Linear Miniplate Versus Rectangular Grid Plate-A Prospective Randomised Study. J Maxillofac Oral Surg. 2016 Dec;15(4):535–541. [PubMed]
11. Ellerbe DM, Frodel JL. Comparison of implant materials used in maxillofacial rigid internal fixation. Otolaryngol Clin North Am. 1995 Apr;28(2):365–72. [PubMed]
12. Byrne JE, Lovasko JH, Laskin DM. Corrosion of metal fracture fixation appliances. J Oral Surg. 1973 Aug;31(8):639–45. [PubMed]
13. Eppley BL, Sparks C, Herman E, Edwards M, McCarty M, Sadove AM. Effects of skeletal fixation on craniofacial imaging. J Craniofac Surg. 1993 Apr;4(2):67–73. [PubMed]
14. Wennerberg A, Albrektsson T. On implant surfaces: a review of current knowledge and opinions. Int J Oral Maxillofac Implants. 2010;25:63–74. [PubMed]
15. Bladen JC, Norris JH, Malhotra R. Indications and outcomes for revision of gold weight implants in upper eyelid loading. Br J Ophthalmol. 2012 Apr;96(4):485–9. [PubMed]
16. Demann ET, Stein PS, Haubenreich JE. Gold as an implant in medicine and dentistry. J Long Term Eff Med Implants. 2005;15(6):687–98. [PubMed]
17. Sönmez A, Oztürk N, Durmus N, et al. Patients’ perspectives on the ocular symptoms of facial paralysis after gold weight implantation. J Plast Reconstr Aesthet Surg. 2008;61:1065–8. [PubMed]
18. Rofagha S, Seiff SR. Long-term results for the use of gold eyelid load weights in the management of facial paralysis. Plast Reconstr Surg. 2010;125:142–9. [PubMed]
19. Björkner B, Bruze M, Möller H, et al. Allergic contact dermatitis as a complication of lid loading with gold implants. Dermatitis. 2008;19:148–53. [PubMed]
20. Inchingolo F, Tatullo M, Abenavoli FM, et al. Oral piercing and oral diseases: a short time retrospective study. Int J Med Sci. 2011;8:649–52. [PMC free article] [PubMed]
21. Gargari M, Comuzzi L, Bazzato MF, Sivolella S, di Fiore A, Ceruso FM. Treatment of peri-implantitis: Description of a technique of surgical 2 detoxification of the implant. A prospective clinical case series with 3-year follow-up. ORAL and Implantology. 2015 Jan;8(1):1–11.
22. Elias CN, Lima JHC, Valiev R, et al. Biomedical applications of titanium and its alloys. J Minerals Met Mater Soc. 2008;60(3):46–9.
23. Bramanti E, Matacena G, Cecchetti F, Arcuri C, Cicciù M. Oral health-related quality of life in partially edentulous patients before and after implant therapy: A 2-year longitudinal study. ORAL and Implantology. 2013;6(2):37–42. [PMC free article] [PubMed]
24. Gargari M, Prete V, Pujia A, Ceruso FM. Full-arch maxillary rehabilitation fixed on 6 implants. ORAL and Implantology. 2013;6(1):1–4. [PMC free article] [PubMed]
25. Gargari M, Prete V, Pujia M, Ceruso FM. Development of patient-based questionnaire about aesthetic and functional differences between overdentures implant-supported and overdentures tooth-supported. Study of 43 patients with a follow up of 1 year. ORAL and Implantology. 2012;5(4):86–91. [PMC free article] [PubMed]
26. Milillo L, Fiandaca C, Giannoulis F, Ottria L, Lucchese A, Silvestre F, Petruzzi M. Immediate vs non-immediate loading post-extractive implants: A comparative study of Implant Stability Quotient (ISQ) ORAL and Implantology. 2016;9(3):123–131. [PMC free article] [PubMed]
27. Spinelli D, Ottria L, De Vico G, Bollero R, Barlattani A, Jr, Bollero P. Full rehabilitation with nobel clinician® and procera implant bridge®: Case report. ORAL and Implantology. 2013 Apr;6(2):25–36. [PMC free article] [PubMed]
28. Tschernitschek H, Borchers L, Geurtsen W. Nonalloyed titanium as a bioinert metal-a review. Quintessence Int. 2005;36:523–530. [PubMed]
29. Calcaterra R, Di Girolamo M, Mirisola C, Baggi L. Effects of repeated screw tightening on implant abutment interfaces in terms of bacterial and yeast leakage in vitro: One-time abutment versus the multiscrewing technique. International Journal of Periodontics and Restorative Dentistry. 2016;36(2):274–280. [PubMed]
30. Diamanti MV, Del Curto B, Barlattani A, Bollero P, Ottria L, Pedeferri M. Mechanical characterization of an innovative dental implant system. Journal of Applied Biomaterials and Biomechanics. 2009;7(1):23–28. [PubMed]
31. Giannitelli SM, Basoli F, Mozetic P, Piva P, Bartuli FN, Luciani F, Arcuri C, Trombetta M, Rainer A, Licoccia S. Graded porous polyurethane foam: A potential scaffold for oro-maxillary bone regeneration. Materials Science and Engineering C. 2015;51:329–335. [PubMed]
32. Tatullo M, Marrelli M, Falisi G, et al. Mechanical influence of tissue culture plates and extracellular matrix on mesenchymal stem cell behavior: A topical review. Int J Immunopathol Pharmacol. 2016;29:3–8. [PubMed]
33. Andreasi Bassi M, Andrisani C, Lico S, Ormanier Z, Ottria L, Gargari M. Guided bone regeneration via a preformed titanium foil: Clinical, histological and histomorphometric outcome of a case series. ORAL and Implantology. 2016 Oct-Dec;9(4):164–174. [PMC free article] [PubMed]
34. Dorri M, Nasser M, Oliver R. Resorbable versus titanium plates for facial fractures. Cochrane Database Syst Rev. 2009;(1):CD007158. [PubMed]
35. Jeyaraj P. Efficacy and Versatility of the 3-D Titanium Mesh Implant in the Closure of Large Post-Craniectomy Osseous Defects, and its Therapeutic Role in Reversing the Syndrome of the Trephined: Clinical Study of a Case Series and Review of Literature. J Maxillofac Oral Surg. 2016 Mar;15(1):82–92. [PMC free article] [PubMed]
36. Marrelli M, Falisi G, Apicella A, et al. Behaviour of dental pulp stem cells on different types of innovative mesoporous and nanoporous silicon scaffolds with different functionalizations of the surfaces. J Biol Regul Homeost Agents. 2015;29(4):991–7. [PubMed]

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