Volume 7, Issue 11, November – 2022 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165

Novel Bone Adhesives in Fracture Fixation & its

Possible Significance in Midfacial Surgery –
A Review
Dr. Pradeep Christopher 1, Head of the Department of Oral & Maxillofacial Surgery, Thai Moogambigai Dental College &
Hospital, Chennai
Afritha Noureen A2, Intern, Thai Moogambigai Dental College & Hospital, Chennai
Haleema Fathima S3, Intern, Thai Moogambigai Dental College & Hospital, Chennai
4
Dr.Gayathri , Reader, Department of Oral & Maxillofacial Surgery, Thai Moogambigai Dental College & Hospital, Chennai
Dr. Mohamed Afradh 5, Reader, Department of Oral & Maxillofacial Surgery, Thai Moogambigai Dental College & Hospital,
Chennai

Abstract:- One of the most frequent medical conditions Through a complex interplay between the facial skeleton and
requiring inpatient hospitalization is fractures. In order to its soft tissue envelope, the surgical treatment of cranio-
maximize the possibility of the fracture surfaces to join and maxillofacial injuries entails the restoration of both form and
fuse, surgical treatment of fractures typically begins with function. [5] Management is done by following the sequence:
a reduction of the fracture, which places the bone Reduction, fixation/immobilization, and preventing infection.
fragments in their original location and close proximity to Widely used method of fixation for managing maxillofacial
one another. Then, they are either externally cast- fractures is internal fixation which involves fixation of bone
stabilized or implanted with screws, plates, and wires, fragments in their anatomical location with the help of plated
among other implants. Medical and surgical management and associated screws until bone healing is accomplished. [6]
techniques have advanced significantly as a result of the Though it is the conventional technique followed, it still has
incredible improvement in technology. Recently, the use of disadvantages like plate fractures, patient discomfort and is also
bone adhesives/bone glue in the treatment of fractures has technique sensitive. With the tremendous technological
been suggested. The idea behind "bone adhesives" is to fix advancement, medical and surgical management strategies has
simple and comminuted fractures as well as secure been greatly evolved. The use of bone adhesives has been
orthopedic implants and devices like plates and screws. In proposed for last few years in management of fractures. In
this article, we will give an overview on existing bone terms of not having produced adhesives that meet the various
adhesive and its types, conventional internal fixation, its requirements of a successful product, this is still in its relatively
disadvantages and how bone adhesives can possibly early phases. Although there are many bone cements and bone
overcome the drawbacks of other fixation techniques. void fillers available, none of them make the claim to have
adhesive characteristics. PMMA bone cement is likely the most
Keywords:- Fracture, Bone Adhesives, Bone Glue, Internal popular of these items. [7]
Fixation.
The aim of this article is to review on the current state of
I. INTRODUCTION the art of bone adhesives in order to understand how close to
surgical fixation of facial fractures, bone adhesive might be and
This Any injury to the face or jaw brought on by physical in comparison with the conventional technique.
force, foreign objects, animal or human bites, or burns is
referred to as maxillofacial trauma. [1] It is classified into II. WHAT IS INTERNAL FIXATION ?
injuries involving the lower, middle and upper thirds of the
face. Motor vehicle collisions, interpersonal violence, falls, and Internal fixation is the most crucial form of treatment for
sports-related incidents are the most frequent causes of face maxillofacial fractures in order to regain form and function.
fractures. Their relative frequency varies geographically. The The basic principles for internal fixation is formulated by AO
most significant mechanism on a global scale is motor vehicle in 1958. [6]
collision. [2] The most prevalent fractures are nasal, followed
by dentoalveolar, mandibular, midface, and orbital floor Anatomic reduction: Reduction and fixation of fracture to
fractures, and finally frontal sinus fractures. [3] regain normal anatomy

Management of such injuries, which can range from Stable fixation: Depending on the type of Fracture fixation
simple fracture to severe facial communition, can be quite with relative or absolute stability may be necessary.
difficult. The presence of the upper airway and the close
proximity to the cranial and cervical structures that may be Preservation of blood supply: By careful reduction, handling
concurrently implicated aggravate injuries to this highly and preservation of vascularity of the bone and soft tissues
vascular zone. It can be life threatening and cause long term
complications including damage to vital sensory structures. [4]

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 Volume 7, Issue 11, November – 2022 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
Early and active mobilization: early and safe mobilization for attracted a lot of interest. [17] Bone adhesive is defined as,
the purpose of treating the injured part synthetic, self-curing organic or inorganic material used to fill
up a cavity or to create a mechanical fixation (IUPAC). In the
Internal fixation employs usage of systems like trans 1940s, PMMA was utilized for the first time in a clinical setting
osseous wiring, compression plates, non-compression in plastic surgery to repair gaps in the skull. [18]
miniplate, lag screws, reconstruction plates etc.,
A consistent areal distribution of the physical forces could
III. DISADVANTAGES OF CURRENT INTERNAL be achieved by the adhesive acting across the entire surface
FIXATION from a mechanical standpoint. It could also address some of the
drawbacks of metallic implants, which are related to their
Before Internal rigid fixation techniques have a number relative high stiffness and rigidity as compared to bone material
of potential side effects, including as infection, nonunion, (e.g., physical stress and tissue damage in the area of bone
visible or painful hardware, and the frequently ignored problem fracture repair). [16]
of misalignment of the fracture pieces during reduction. Plate
palpability was shown to be the most frequent cause of Broken fragments might theoretically be put together
hardware removal at a major university centre (University of quickly and directly, as well as the adhesive could eventually
Michigan Medical Center) in a study by J S Orringer et al, be replaced by the regrowing bone. [19] Because of this, the
followed by discomfort, hardware loosening, and plate need for increased healthcare system expenses and secondary
exposure. [8] Greater exposure and soft tissue manipulation interventions would both be avoided. Since the production
were needed to avoid insufficient or inappropriate fracture capacity and material costs are mostly unknown, it is difficult
reduction and to guarantee proper plate fixation. Thereafter, to determine the expenses of such a bone adhesive system at
concerns about potential rises in infection rates emerged. [9] this time. And also less complications such as infections,
problems with wound healing, thrombosis, embolisms,
Miniplates can have negative effects that necessitate allergies, and intolerances might be anticipated as a result of
removal, including as plate prominence and palpability, shorter surgical procedures and the use of materials with better
infection, plate migration, exposure, and temperature potential for designing biocompatibility. [16]
intolerance. The most frequent reasons for craniofacial plate
removal of the midface are prominence and discomfort, while The following are the characteristics for a successful bone
infection and exposure are the most frequent reasons for plate adhesive, [20]
removal linked with maxillo-mandibular fracture patterns. [10] • High degree of adherence to bone, frequently with
impurities such lipids and proteins
In their collection of cases involving severe craniofacial • Bonds to moist surfaces and maintains binding strength in
injuries, Francel et al [11] reported a 7% infection rate, and a humid environment.
O'Sullivan [12] et al reported a 4% infection incidence. Ewers • Mechanical resistance to tension, compression, and shear.
and Harle reported infection rates of 1.1% and osteomyelitis of • Simple and simple to produce and use in operating room
2.2% in a series of 590 face fractures. [13] In their series of 74 circumstances.
patients who underwent elective midface craniofacial surgery, • Adequate working time and rapid setting time
traumatic craniofacial injury treatment, and cranial vault • Biocompatible & non toxic
reconstruction, Beals and Munro reported no infections. [14] • Sterilizable
• Allow adequate fracture healing
The microplate systems were created as a modification of • Cost effective
current systems created for maxillary and mandibular fracture • Adequate shelf life
treatment because thin, brittle bones require accurate three-
dimensional orientation. Schortinghuis et al [15] reported a V. TYPES OF BONE ADHESIVES
clinical series of 44 patients who sustained craniofacial trauma
repaired by open reduction and internal fixation with Traditional bone cements might be made of synthetic or
microplates. No plate-related infections, palpability, or biologically inspired substances. Researchers used dental
malunion were reported. However, three patients required knowledge to employ methacrylate resins in bone surgery in
reoperation for complaints of pain. Only one patient's the 1940s and 1950s. The primary study areas on bone
complaints were attributed to the microsystem as a loosened adhesives are under the categories of synthetic, biomimetic,
screw was noted, whereas the other two patients had persistent and biobased approaches: [16]
pain after plate removal. From 0% to 2% of patients who • Synthetic adhesives: The most often investigated type of
underwent microplate fixation reported having pain among the bone adhesives are fully synthetic formulations, such as
articles reviewed by Böker KO et al. [16] polyacrylic acid [19,21,22] or polyester [23], because of their
capacity to customize adhesive properties, cross-linking
IV. BONE ADHESIVES & ITS CHARACTERISTICS intensity, functional groups, and viscosity. Recent
investigations have shown that polyurethanes [24], which have
The creation of bone adhesives that can bind bone long been regarded as biocompatible, function quite well.
surfaces together, bear stresses at fracture gaps, and permit Methacrylates and cyanoacrylates are believed to have a strong
biological components of bone healing to take place while potential for attaching to bone because they are members of the
gradually degrading to make way for bone ingrowth has adhesive class. Cyanoacrylates are very promising for joining

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Volume 7, Issue 11, November – 2022 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
bones because of their characteristics and also they have been adhesive to that achieved with plates and screws in an animal
further developed to obtain micro tensile and shear bond model.
strengths between 1 and 2 MPa; the latter for N-butyl Perry et al. [39] conducted a study to determine whether
cyanoacrylate is much higher than a plate and screw standard. adhesive techniques could play a role in bone fixation in
[25, 26] Yet, the mechanical requirements have not been met specific cases. They compared the current "Champy" miniplate
by synthetic adhesives and also has insufficient system to bonded stainless steel using cyanoacrylate or dental
biocompatibility. [27] Biomimetic approaches have been composite cement in vitro, and found that the Champy system
suggested as a solution to these problems. failed at a force (N) that was significantly higher than the
• Biomimetic adhesives: The foundation of TetraniteTM is adhesives.
O-phospho-L-serine, which is a constituent of numerous
proteins found in natural secretions. It is bioresorbable, has an M. A. Shermack et al [40] carried out a study to see if the
immediate adhesive strength, satisfies practically all criteria for healing and strength offered by plate and screw fixation could
a bone adhesive, and is presently undergoing FDA approval. be achieved by cyanoacrylate fixation of the bone flap in a
[28, 29] rabbit craniotomy model.

Pajari-Palmer [30] and colleagues described a "Novel Fibrin glue (FG), also known as fibrin sealant, has been
Class Injectable Bioceramics" made similarly to TetraniteTM utilised in a variety of orthopaedic procedures to promote
in association with the phosphoserine-based technique. osteogenesis in human maxillary and mandibular bone, to fix
However, α-Tricalciumphosphate and phosphoserine were osteochondral fractures, to fix osteochondral fragments, and to
used in place of tetracalciumphosphate, and they were able to fix bone chips during spinal surgery. [42] Heiss et al. [44]
cure in moist environments and demonstrated bond strengths described a recently created alkylene bis (dilactoyl)-
that were up to 40 times stronger than those of commercial methacrylate as a bone adhesive with some similarities to
cyanoacrylates (0.1 MPa) and 100 times stronger than surgical polymethylmethacrylate (PMMA), which has been widely
fibrin adhesives (0.04 MPa). A brand-new mussel adhesive has utilised in dentistry [43] and orthopaedic surgery for anchoring
been created. Using an enzyme from Methanocaldococcus prosthesis. PMMA is the most affordable, widely available, and
jannaschii, pre-modified intestinal bacteria were used to create biocompatible of these polymers, enabling instant fixation to
this. [31] Malkoch [32] and his group's work on allyl, cancellous bone (which is not usually the case for the other
methacrylamide, and thiol groups is another example of bio- materials). PMMA cement added to screws results in improved
inspired methods. About 0.3 MPa was the shear strength of the primary stability. [45, 46]
created adhesive.
• Biobased adhesives: In rabbits, a proteinogenic, However not enough data is available for its application
autologous fibrin adhesive was effectively evaluated as a K- in the maxillofacial region. Endres, Kira et al. [47] described
wire substitute. [33] In addition to proteinogenic adhesives, an innovative method using bone adhesive to attach thin
sugar-based ingredients can also be used to make bone cortical bone pieces to osteosynthesis plates. The plate is
adhesives. Studies on two-component chitosan and dextran secured to thick cortical bone structures with standard screws,
bone adhesive hydrogels provided evidence to support this. [34, and adjacent or delicate bone pieces are connected to the plate
35] Another instance of biobased approaches is the with bone cement through the screw holes in the plate.
incorporation of calcium carbonate and hydroxyapatite in
biocomposites that will be utilized as chitosan-based bone For the clinical application of adhesively fixing
adhesives. [36] The most promising results were seen in a osteosynthesis plates in midfacial surgery, a modified PMMA
formulation with 4% calcium carbonate and hydroxyapatite, bone cement was developed by adding a photoinitiator to the
2% chitosan, with strong adherence to the bone surface (0.27 PMMA powder component, which can be light-cured. Unlike
MPa) and cohesion failure, that is, failure in the adhesive typical PMMA bone cements, which can take up to 15 minutes
substance rather than at the surface-adhesive interface. [36] to polymerize, it enables a surgeon to control the precise
moment at which the polymerization starts. This saves the
VI. BONE ADHESIVES IN MIDFACIAL SURGERY surgeon and his team valuable time when adhesively fixing an
osteosynthesis plate during midfacial surgery. [47]
Use of adhesive systems for internal fixation were
advocated in various in vitro and in vivo studies in last few VII. BONE BONDING AGENT
years and concluded that they can be useful for bone bonding.
[37, 38, 39, 40, 41] Bone bonding agents, which are comparable in
composition to dentin bonding agents that have been in clinical
P Maurer et al [37] performed a study Using two distinct use for many years, may have the ability to resolve the problem
adhesive methods (Clearfil New Bond and Histoacryl) and of the bonding partners' incompatible wetting qualities. [41, 48,
compared the tensile bond strengths reached between 49, 50] According to various investigations, using dentin
composite and bone and between bone and bone. adhesives proved to create a stronger bond strength to bone
than that produced with the cyanoacrylate glue because the
Amanrante et al. [38] investigated the viability of dentin bonding agents are amphiphilic in nature and can bond
obtaining bone fixation of the upper face skeleton with n-butyl- with both hydrophilic dentin and hydrophobic composites.
2-cyanoacrylate and contrasted the fixation achieved with this [37,38,39,40]

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ISSN No:-2456-2165
Monomers with hydrophilic and hydrophobic biodegradability, they have proven to have week mechanical
characteristics dominate the composition of amphiphilic bone strength and little bone attachment. [52 53, 54]
bonding agents. It contains hydrophilic functional groups like
hydroxy groups R-OH and carboxy groups R-COOH, where R X. CONCLUSION
is a stand-in for the organic remainder, as well as hydrophobic
monomers like MMA molecules. The bone bonding agent will Bone adhesive is a futuristic and researched possible
penetrate the surface of the bone after application, creating a treatment modality that would revolutionize the current status
hybrid layer. In order to maximize the wetting of hydrophilic of the bone repair and restoration. Even with numerous studies
bone, the hydrophilic monomers in the bone bonding agent are to its name there is no adhesive that delivers all the desirable
used. [47] (Fig. 1) properties in a single commercial available product. The three
main requirement of bone adhesive i.e biocompatibility,
biodegradability and bond strength is a challenging factor that
is one of the major cause for the failure for the adaptation of
bone adhesive alone with the complex bone environment. In
this review we have concluded that though there are multiple
researches and studies conducted in the adaptation and
production of bone adhesives they are mostly in vivo and in
vitro studies. Bone adhesives in orthopedic fractures have less
clinical studies to its name and even lesser studies when
pertaining to midfacial fractures. Though the vision of a
adhesive that could fix fractures remain attractive to surgeons
it is a need that would remain unmet as it seems unlikely that
conventional osteosynthesis would be replaced any time soon.

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