Accepted Manuscript

Herbert cannulated bone screw osteosynthesis in anterior mandibular fractures

treatment: a comparative study with lag screw and mini-plate

Yehia El-Mahallawy., MSc, Haytham Al-Mahalawy., PhD

PII: S0278-2391(18)30115-0
DOI: 10.1016/j.joms.2018.01.034
Reference: YJOMS 58152

To appear in: Journal of Oral and Maxillofacial Surgery

Received Date: 30 December 2017

Revised Date: 25 January 2018
Accepted Date: 26 January 2018

Please cite this article as: El-Mahallawy. Y, Al-Mahalawy. H, Herbert cannulated bone screw
osteosynthesis in anterior mandibular fractures treatment: a comparative study with lag screw and mini-
plate, Journal of Oral and Maxillofacial Surgery (2018), doi: 10.1016/j.joms.2018.01.034.

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 ACCEPTED MANUSCRIPT
Title: Herbert cannulated bone screw osteosynthesis in anterior mandibular fractures

treatment: a comparative study with lag screw and mini-plate.

Corresponding author:

Yehia El-Mahallawy. MSc.

Lecturer, Oral and Maxillofacial Surgery Department, Faculty of Dentistry, Alexandria

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University, Alexandria, Egypt.

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E-mail: yehia.el-mahallawy@alexu.edu.eg

Champlion st, Azrite, Alexandria, Egypt

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Fax: (00203)4868286

Phone: +201007217014

Coauthor:
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Haytham Al-Mahalawy. PhD
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Assistant Professor, Biomedical Dental Sciences Department, College of dentistry,

Abdurrahman Bin Faisal University, Dammam, Saudi Arabia.

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E-mail: haelmahalawy@iau.edu.sa
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Oral and Maxillofacial Surgery Department, Faculty of Dentistry, Fayoum University,

Fayoum, Egypt.
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Abstract:

Purpose: Herbert bone screw is a successful minimally invasive mean of fracture fixation

that is used routinely in orthopedic surgery. The aim of this study was to evaluate the clinical

and radiographic performance of Herbert bone screw in the treatment of anterior mandibular

fractures and compare it with the commonly established treatment modalities; lag screw and

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2.0-mm miniplates.

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Materials and methods: This study implemented a randomized clinical trial and enrolled a

sample of patients with anterior mandible fractures. The primary predictor variable was

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treatment group categorized as Herbert bone screw (HBS), lag screw (LS), or miniplate (MP)

fixation of the fracture. The primary outcome variables were the presence of interfragmentary

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mobility and radiodensitometric appraisal of fracture healing progression. The secondary
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outcome was the postoperative clinical evaluation. Other variables collected were grouped
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into demographic, fracture location, and intra-operative clinical data. All of the recorded data

were documented, tabulated, computed, and analyzed. Statistical significance was set at 5%
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level.
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Results: Twenty-one patients were selected and randomly allocated into the three groups

based on the fixation modality utilized. There were no significant differences in demographic
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data for the 3 groups. There were no statistically significant differences in clinical evaluation
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outcomes. However, there was a statistically significant difference in the gain of mean
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postoperative bone density between the HBS and MP groups (P=0.012), and between LS and

MP groups (P=0.045), but not between HBS and LS groups.

Conclusion: Herbert cannulated bone screw osteosynthesis provides a successful and

minimally invasive treatment modality for the management of anterior mandibular fractures.

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Introduction

The mandible is the second most commonly fractured part of the maxillofacial

skeleton, even though it is the largest and strongest facial bone. Mandibular fractures
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comprise between 40 and 62% of all facial fractures . The anterior region of the mandible

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represents the central horizontal part of the mandible, it is bounded bilaterally by vertical

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lines just distal to the mandibular canine teeth, including those that run in the midline of the

mandible; the symphysis and parasymphysis regions 3. Anterior mandible fractures (AMFs)

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represent a considerable entity of mandibular injuries, where the literature gave them as low

as 14% and as high as 30% of all mandibular fractures 4-6.

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Open reduction and internal fixation of these fractures is considered the gold standard
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treatment option in which various hardware where used in order to incline the patients into an

early return to the pre-existing state of function and aesthetics 4. The use of two monocortical
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miniplates was described by Champy et al following the concept of ideal lines of osteosynthesis
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in order to counteract the torsional and rotational trajectories in the anterior mandible 7.
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Traction osteosynthesis was introduced in the maxillofacial region in 1970 by Brons and
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Boering as a rigid scheme for management of mandibular fracture. This was first utilized in
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anterior mandibular fractures (AMFs), as this region of the mandible is uniquely shaped for
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application of the screw. Brons and Boering mandated the placement of two lag screws in AMFs
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considering the biomechanics of this area. Other studies inquired about the need for two fixation

devices, especially in the parasymphyseal region, and they advised the use of a lower border

miniplate or lag screw along with a mandibular arch bar 9. Choosing one treatment modality

over the other is based on the surgeon’s preference, experience and the armamentarium

availability 10.
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In 1984, Herbert and Fisher proposed a new method for rigid fixation to manage

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scaphoid bone fracture, from this point forth, it demonstrates to be a successful, minimally

invasive, mean of providing rigid internal fixation between fracture segments in various

terrains of orthopedic surgery. Their design overcomes the drawbacks of the lag screw, such

as limited mobility of adjacent joint and difficulty in determining the screw length 12. Herbert

bone screws (HBS) are a compressive, cortical, headless, cannulated titanium screws. Unlike

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the lag screws, they gain their compressive power from the differential pitch pattern of

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threads at both ends of the screw. The distal end threads are of the reverse buttress type, they

are longer in length and with a smaller diameter than those at the proximal end which are of

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the standard V-shaped type. The central shaft of the screw is smooth, which edges over the

threaded design of the lag screw were threads cross the fracture line 12.

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The utilization of the HBS in the maxillofacial field was recently adopted, where the
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13,14,
contemporary literature contains two in-vitro biomechanical studies a case series for its
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performance in diacaptiular condylar fractures , a study about its use along with three-

dimensional navigation systems in angle fractures 16. Furthermore, its clinical performance in
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comparison to lag screw in mandibular fractures was recently investigated 17,18.

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This study was designed to address the clinical and radiographic performance of the

newly adopted HBS in AMFs osteosynthesis, and compare it with the commonly established
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treatment modalities for AMFs; the lag screw and two 2.0-mm monocortical miniplates. The
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investigator hypothesized that there would be no difference in the clinical and radiographic
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performances between the HBS, LS, and MP in the management of AMFs. The specific aims

were: 1) design and implement a randomized clinical trial, 2) detect and compare the

presence of interfragmentary mobility between the different tested fixation modalities, 3)

estimate and compare the radiodensitometric mean bone density across the fracture line, and

4) determine the clinical advantages and disadvantages of this newly utilized fixation device.

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Materials and Method

Study Design

The clinical and radiographic behaviors of the Herbert bone screw (HBS) in the

treatment of AMFs were explored and compared to that of the lag screw and miniplates in a

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randomized, controlled, parallel-grouped clinical trial.

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Patients were selected from the cases admitted to the Emergency Ward of Alexandria

University Hospital in the period between January 2016 to January 2017. The selected

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subjects must be adults with no gender predilection, suffering from recent, uninfected, non-

comminuted, unfavorable fracture anterior to the mental foramen that demands open

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reduction and internal fixation. Patients sustaining other associated facial fractures were
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excluded, along with those with infected fracture lines or a systemic disease that could cause
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interference with the fracture healing. The selected patients were randomly allocated into

three groups according to the type of the utilized fixation device; Herbert bone screw (HBS)
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group; where two 2.3-mm Herbert bone screws, with a shaft diameter of 1.25 mm, a cortical
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head diameter of 2.3 mm and a 2.0 mm cancellous head, were used to treat the patients

(Figure 1). Lag screw (LS) group; where two 2.7-mm lag screws, with a head diameter of
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3.2-mm, were used to treat the patients. Mini-plates (MP) group; where two parallel 2.0 mm
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standard miniplates with a minimum of four holes, were used to treat the patients. The three
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fixation devices were obtained from the same manufacturer (JEIL Medical Corporation

Company: Seoul, Korea). Group allocation was performed using simple randomization

processes with the envelope method of sampling. The three groups were matched based on

the location of the fracture, the presence of concomitant mandibular fractures and their

number, and the patient’s medical histories.

The ethical clearance for performing this clinical trial was granted from the Research

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Ethics Committee, Faculty of Dentistry, Alexandria University. All patients signed an

informed consent before the enrollment in this study.

A detailed history taking and a thorough clinical examination were performed and

recorded for every patient. A preoperative computerized tomogram (CT) scan (Ingenuity

Core; Philips Medical Systems, Cleveland, OH) was obtained to show the extent of fracture

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line, the degree and direction of displacement, and the relation of teeth involved in the

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fracture line (Figure 2). All patients received intravenous preoperative prophylactic antibiotic

therapy in the form of amoxicillin 1000 mg + clavulanic acid 200 mg (Augmentin 1.2 g;

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GlaxoSmithKline, UK).

Surgical procedures

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The surgical procedures for all patients were performed by the same surgeon under
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general anesthesia using nasotracheal intubation. The oral cavity was prepared by thorough
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irrigation with antiseptic povidone-iodine 7.5% (Betadine: Purdue Products L.P) solution

followed by submucosal injection of 1.8-mL of 2% Lidocaine with 1:100:000 epinephrine

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(Novocol Pharmaceutical of Canada, Inc., Cambridge, Canada). The fracture line was sought
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through an intraoral vestibular incision. The occlusion was secured with temporary IMF and

the fracture segments were manually reduced.

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For HBS group patients, a 0.8mm Kirschner guide wire (K-Guide Wire) was placed
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and tapped into the cortex of the distal fracture segment just 5 mm below the apices of
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anterior teeth. The depth of the K-Guide wire was measured using a depth gauge to determine

the length of the screw to be utilized. A 2mm cannulated spiral drill was used under the

guidance of the K-Guide wire to make the osteotomy, then HBS was inserted with the aid of

the cannulated torque shank screwdriver. A second screw with the same dimension was

placed near the lower border in a similar manner and direction to avoid rotation of the

compressed fracture line (Figure 3).

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Two 2.7-mm cortical lag screws were used in each patient in the LS group. For the

upper screw, a gliding hole was performed 5 mm below the apices of anterior teeth in the

near cortex using the 2.7-mm drilling pit, followed by drilling the distal bone fragment by the

2.0-mm drilling pit using cantering drill guide fitted in the gliding hole. The near cortex is

countersunk to grant a smooth platform for screw-head seating. The length of the osteotomy

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was determined, and the screw is tightened through the larger gliding hole into the smaller

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traction hole of the distal bone segment. A second screw with similar length and diameter

was added near the lower border to stabilize the fracture. For patients in MP group, two 2.0-

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mm miniplates were contoured, applied and fixed using 7-mm long monocortical screws,

where a minimum of two screws were placed on either side of the fracture line for each

applied plates.
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In all of the three groups, patients with associated concomitant fractures in posterior
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mandibular areas were treated with 2.0-mm miniplates. At the end of the surgery, the

temporary IMF was released, the occlusion was checked and the incision was sutured in
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layers. All patients received postoperative antibiotics in the form of amoxicillin 500 mg +
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clavulanic acid 125 mg (Augmentin 625 mg; GlaxoSmithKline, UK) orally three times per

day for 5 days. The patients were instructed to follow a soft diet for two weeks with careful
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and meticulous oral hygiene.

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Study Variables
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The primary outcome variable was fracture healing with postoperative stability. This

parameter was determined clinically by evaluating the postoperative interfragmentary

mobility, and radiographically by comparing the radiodensitometric estimate of the mean

bone density at the fracture line in three months CT-Scan with the preoperative one. A region

of interest (ROI) around the fracture line was used to get the mean bone density using the

CT-scan software. All of the measurements were in Hounsfield Units (HU) 19.

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The secondary outcome variable was the postoperative clinical evaluation, which was

conducted at one week, four weeks, six weeks and twelve weeks intervals. It involved the

state of occlusion, sensory nerve function (assessed subjectively and objectively using

nociceptive methods), development of infection, and wound healing. Other variables were

categorized into clinical demographic characteristics, fracture location in the anterior

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mandibular region, and intra-operative clinical data. An immediate postoperative

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radiographic appraisal was performed using panoramic radiograph (Orthophos XG 3D;

Sirona Dental Systems GmbH, Bensheim, Germany) to assess the adequacy of fracture line

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reduction (Figure 4).

Statistical data analysis

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IBM SPSS software package version 20.0. (Armonk, NY: IBM Corp) was used for
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statistical analysis of the data. Kolmogorov-Smirnov test was used to verify the normality of
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the data. F-test (ANOVA) was used for normally distributed variables, while the Kruskal

Wallis test was used for the abnormally distributed variables. The significance of the
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obtained results was judged at the 5% level.

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Results

Twenty-one patients met the inclusion criteria. Each treatment group consisted of

seven patients. The demographic data revealed a male gender predilection in all of the groups

(76.2%, n=16), where the male to female ratio was 3.2:1, with a mean age of 29± 1.87 years.

The most common etiological factor was found to be claimed falls (47.6%, n=10); the

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remaining injuries were as a result of Road Traffic Accident (RTA) (38.1%, n=8), Inter-

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Personal Violence (IPV) (9.5%, n=2), and sports-related injuries (4.8%, n=1).

The exact location of the fracture line varied in the anterior region of the mandible.

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Nine patients (42.9%) had a symphyseal fracture, six (28.6%) patients had a right

parasymphyseal fracture, and the remaining six had a left parasymphyseal fracture. Seven

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patients (33.3%) had isolated AMF, where the remaining fourteen (66.7%) had concomitant
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mandibular fractures. Six patients (28.6%) had bilateral subcondylar fractures, four patients
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(19.0%) had right subcondylar fracture, and three patients (14.3%) had left subcondylar

fracture. Only one patient had an associated left body fracture. There were no statistically
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significant differences between the groups concerning the demographic results or the fracture
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location (Table 1).

Clinical evaluation variables were summarized in Table 2. The occlusal examination

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showed an appropriate intercuspal and canine occlusal relations in all of the cases in the three
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groups. There was no need for selective grinding in any case during the follow-up period. In
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HBS group, 28.6% (n=2) showed altered sensation in the lower lip at the first postoperative

week. The same percentage was found in MP group, while only a 14.3% (n=1) was noted in

LS group cases. All of the five cases regained normal lower lip sensation by the end of the

follow-up period (twelve weeks).

14.3% (n=1) of the cases in HBS group showed postoperative wound dehiscence at

first postoperative week, which was treated by irrigation and wound debridement. Healing by

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secondary intention was attained without the need of re-suturing. No wound dehiscence was

encountered in the other two groups. Infection was not encountered in any of the cases in all

of the three groups. There were no statistically significant differences between the groups

concerning the postoperative clinical evaluation (Table 2).

Injury to the root of the mandibular canine occurred in two patients in the LS group

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and one patient in the MP group, while no teeth injury was noted in the HBS group. The

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difference between the groups was not significant (P=2.136). A postoperative periapical

radiograph was used to confirm the injury, as the patients didn’t report any subjective pain.

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Root canal treatment was performed after the sixth postoperative week, and the follow-up

period was without any noted sequelae.

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Regarding the primary outcome variables, interfragmentary mobility across the
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fracture line was assessed. Only one case (14.3%) in LS group showed slight mobility at the
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first postoperative week, which was not noted at the sixth postoperative week. No mobility

was noted in any of the cases in the other two groups. This difference between groups was
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not statistically significant (P=1.000).

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All of the three groups showed a statistically significant gain in the mean bone density

in the three months’ postoperative CT-scan when compared to the preoperative estimates
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(P<0.001) (Figure 5). Intragroup comparison of the mean bone density came out with HBS
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group as the one with the highest percentage of gain in mean bone density (24.78 ± 1.19%),
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followed by LS group (22.29 ± 0.96%) and MP group (19.48 ± 1.36%). The difference

between the mean bone density between HBS group and MP group was statistically

significant (P=0.012). This was also found when comparing LS and MP groups (P=0.045),

however, this was not found when comparing the results of HBS group with that of LS group

(P=0.19) (Tables 3 and 4).

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Discussion

The literature contains a wide variety of choices for internal fixation of anterior

mandibular fractures. This includes reconstruction bone plates, lag screws, double miniplates,

3D-geometric bone plates, and the use of arch bar along with a single miniplate or lag screw
3,4,6,9
. All of these reported methods are considered to be rigid or at least functionally stable

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where they are stable enough to dissipate functional strains and minimizes interfragmentary

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mobility during active use of the mandible.

Choosing one treatment modality over the other is based on the surgeon’s preference,

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experience, clinical situation, fracture line condition, and the availability of the
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armamentarium . This may be contributed to the fact that there is no sufficient evidence

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about the superiority of one modality over the other regarding its postoperative clinical
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performance. Several previous studies consider lag screw osteosynthesis to be a standard
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treatment modality in AMFs as it provides unsurpassed interfragmentary compression,

functional stability, rapid application, low-cost, and has a low rate of postoperative
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3,6,10
complications . On the top of that, it allows a more anatomically accurate reduction,
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revealed by the elimination of the lingual gap and low rate of bone fragments displacement

when compared to bone plates. Despite that, the use of two miniplates is more popular as it is
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less technique sensitive and demands less technical skill 6. This study intended to introduce a
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new minimally invasive approach for the management of symphyseal and parasymphyseal
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fractures.

In this study, standardizing the same manufacturer for the three treatment modalities

made us able to compare the financial burden that was put on the patients with AMFs. Lag

screws were the least expensive while miniplates were the most expensive.

Results of this study regarding the postoperative occlusion state showed that all the

subjects in the three groups exhibited an appropriate intercuspal and canine occlusal relations

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and there was no need for selective extraction, selective grinding or even elastic traction in

any case. This could be explained by the utilization of the temporary intra-operative IMF,

which ensured that the reduction was based on adequate anatomical occlusal relation.

Kotrashetti and Singh registered a 26.7% (n=2) of cases with postoperative malocclusion in

the group treated with HBS and a similar percentage in the group treated with lag screw,

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where they required elastic traction for 15 days to regain their premorbid occlusion 18. Also,

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Lee and Sawhney reported 2.3% of malocclusion when miniplates were utilized in the

symphyseal region, all of which were higher than what this study stated 20.

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28.6% (n=2) of the cases in HBS group, 14.3% (n=1) of the cases in LS group, and

28.6% in MP group showed altered sensation of the lower lip at the first follow-up period.

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All of the cases (n=5) regained normal lower lip sensation by the end of the twelve weeks
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follow up. Kotrashetti and Singh were faced with similar percentage while using the HBS and
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a higher percentage in the lag screw group (33.3%), which eventfully turned back to normal

by the end of the follow up period 18. Schenkel and Jacobsen reported that one-third of their
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patients suffered from postoperative paresthesia, however, only 70% of their affected cases
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returned to normal sensation at the end of their follow-up 21.

None of the cases in this study developed infection. 14.3% (n=1) of the cases in HBS
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group experienced postoperative wound dehiscence, but with no accompanying hardware

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exposure. Daily irrigation was performed and it healed with secondary intention with no
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effect on the fracture stability. None of the cases in either LS group or MP group experienced

wound dehiscence where wound healing was uneventful. Kotrashetti and Singh did not

encounter wound dehiscence while using HBS or lag screw 18. While Agnihotri et al reported

10% (n=4) of the cases with postoperative wound dehiscence in the cases treated with lag screw,

which healed by secondary intention without the need for hardware removal. On the other hand,

10% (n=4) of their cases treated with miniplates developed wound dehiscence that developed

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infection in the fracture area that prompted plate removal 6. This debates the external placement

of the bone plates versus the internal positioning of the hardware in the traction

osteosynthesis systems. Where the internal positioning may profit from avoiding hardware

exposure. Multiple factors may play role in dehiscence development, including the strong

mentalis muscle pull, poor suturing technique, contamination, infection, and smoking habits

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.

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Two cases in the LS group and one case in the MP group showed root injury. In these

cases, the root apex of the canine appeared to be injured. No iatrogenic injury was noted in

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the HBS group. Ellis reported a similar number of patients with iatrogenic tooth injury (two

with the lag screw and three with the bone plates); however, the difference between the

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groups was not statistically significant, which is in accordance with results of this study 10.
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Injury to the roots of the mandibular anterior teeth is possible if care is not taken during the
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application of the fixation devices. The blind placement of the lag screw makes it more

sustainable to create injuries than the platting systems, especially in the symphyseal region
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where the teeth are visible and easy placement of the plate below the undulations of the
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alveolar bone that surrounds them. HBS system takes advantage from the use of the K-Guide

wire which allows parallel placement of adjacent screws and gives indication about the
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direction of the screw inside the bone.

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Another noted transgression in the lag screw system is the tendency to accidentally
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over drill the traction hole in the distal bony segment, decreasing the grip of the screw in the

far buttress, leading to suboptimal fixation which requires preparation of another osteotomy

or applying a washer under the screw head 10. HBS use a 2.0 mm cannulated spiral drill that

mounts the pre-inserted K-Guide wire to drill the osteotomy, making it of a similar caliber all

over its length, which eliminates the need of multiple drills pits and decrees the probability of

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osteotomy over drilling. This could explain its accurate and minimally invasive insertion

technique.

A statistically significant increase in the mean bone density in the three months CT-

scan, when compared to the preoperative one, in all of the three groups was recorded. The

difference in mean bone density between HBS group and MP group was statistically

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significant, while between HBS and LS group was not. Osteosynthesis relaying on the axial

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compression tends to achieve more rapid bone healing than non-compressive systems, as they

promote an unsurpassed rigidity and great compression across the entire length of the fracture

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line, hence a faster bone healing with early functional stability . The results of this study

contradict the outcome reached by Kotrashetti and Singh, where they announced a

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statistically significant difference between HBS and lag screw, where HBS showed a higher
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bone isodensity values 18. This disagreement in results could be attributed to the difference in
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case selection. In our study we selected AMFs, while in Kotrashetti and Singh study, they

included cases with various types of mandibular fractures, which may affect the accuracy of
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the obtained mean bone density results. Furthermore, the utilization of the three-dimensional
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CT-scans to obtain the mean bone density is far more accurate than the isodensity values

obtained from the two-dimensional panoramic radiograph.

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Miniplates, lag screws and the newly adopted HBS all met the requirements stated by
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the Swiss Association for the Study of Internal Fixation (AO/ASIF) in order to achieve stable
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rigid fixation and a brisk functional recovery. While both screws have the added leverage of

attaining interfragmentary compression and elimination of the lingual gap with a minimum of

the implant materials and internal placement of the hardware, HBS edges over lag screw in

its ability to achieve greater compression and at the same time reducing the steps of its

installation, minimize the amount of drilling, and reduce the caliber of the osteotomy 23. The

compressive feature in the HBS comes from the differential pitch pattern between its leading

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and trailing ends which tends to generate a greater amount of interfragmentary compression
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than the conventional lag screw . This was demonstrated in this study by the higher

percentage of the reported cases with interfragmentary mobility in the first postoperative

week in the LS group (14.3%) than in HBS group.

Ellis stated that improper countersinking of the osteotomy is one of the most

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commonly practiced errors while utilizing the lag screw, where lack of countersinking

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resulted in cracks in the cortical bone that support the screw head, while errors of improper

countersinking angulation and excessive countersinking were noted which eventually

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weakened the proximal bony buttress . HBS is a headless screw that does not require

cortical countersinking. This gives the chance for the HBS application in articular surfaces,

such as the temporomandibular joint 15.

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The clinical performance of the HBS did not show significant difference when
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compared to the well-established lag screw. Yet HBS osteosynthesis is a technique sensitive

treatment modality that requires surgical expertise and adequate preoperative planning. This
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outcome may point out the novelty of the treatment modality in the maxillofacial trauma
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field. Accordingly, further studies with larger sample size are required to validate the attained

favorable clinical and radiographic outcomes in this study.

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Furthermore, the use of HBS along with the K-Guide wire could open the door for the
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utilization of the intraoperative fluoroscopy technique (C-arm radiograph) which may

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provide trans-mucosal fixation device placement, immediate verification of the accuracy of

reduction, and validation of the screw position. This could be an important venue for future

investigations. Within the limitation of this study, it is possible to conclude that the use of

traction osteosynthesis principle in the form of the HBS offers a significantly faster bone

healing when considered in the management of AMFs.

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Acknowledgements

We are extremely grateful to the stuff of the Oral and Maxillofacial Surgery

Department of Alexandria University for their great support in achieving this work.

Conflict of interest

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The authors declare that they have no conflicts of interest.

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Table 1. preoperative demographic data

HBS Group LS Group MP Group P-value

Age, years, mean ±SD 31.57 ±10.8 26.43 ±3.3 29.0 ±10.1 0.664

Gender (%) 1.000

Male 71.4% (n=5) 85.7% (n=6) 71.4% (n=5)

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Female 28.6% (n=2) 14.3% (n=1) 28.6% (n=2)

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Medical history Free Free Free

Trauma Etiology 0.576

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Falls 71.4% (n=5) 42.9% (n=3) 28.6% (n=2)

Road Traffic accidents 28.6% (n=2) 42.9% (n=3) 42.9% (n=3)

Interpersonal violence 0%
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Sports related injuries 0% 14.3% (n=1)
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Concomitant mandibular fractures (%) 1.000

No other fracture 42.9% (n=3) 28.6% (n=2) 28.6% (n=2)

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Left body 0% 14.3% (n=1) 0%

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Right subcondylar 14.3% (n=1) 14.3% (n=1) 28.6% (n=2)

Left subcondylar 14.3% (n=1) 14.3% (n=1) 14.3% (n=1)

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Bilateral subcondylar 28.6% (n=2) 28.6% (n=2) 28.6% (n=2)

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SD, Standard Deviation

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Table 2. Postoperative clinical evaluation

HBS Group LS Group MP Group P-value

None union of the fracture 0% 0% 0% 1.000

Occlusal discrepancies 0% 0% 0% 1.000

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Altered lower lip sensation 28.6% (n=2) 14.3% (n=1) 28.6% (n=2) 0.576

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Surgical wound dehiscence 14.3% (n=1) 0% 0% 1.000

Infection 0% 0% 0% 1.000

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Injuries to lower anterior teeth 0% 28.6% (n=2) 14.3% (n=1) 0.740

Injuries to the mental nerve 0% 0% 0% 1.000

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Table 3.Mean bone density values for the three groups

CT-Scan intervals HBS Group LS Group MP group P-value

Preoperative 965.50 ± 24.1 976.99 ± 14.0 972.19 ± 16.6 0.535

Three months postoperative 1204.80 ± 35.0 1194.8 ± 24.4 1161.57 ± 24.6 <0.038*

Percentage of change ↑24.78 ± 1.19 ↑22.29 ± 0.96 ↑19.48 ± 1.36

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P-value <0.001* <0.001* <0.001*

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P value for F test (ANOVA) with repeated measures for comparing between different

period in each group

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*: Statistically significant at p ≤ 0.05

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Table 4. Three month’s mean bone density intragroup comparison.

Three months postoperative

Main Group Comparison group
MBD (P-value)

HBS group LS group 0.190

HBS group MP group 0.012*

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LS group MP group 0.045*

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Significance between groups was done using Post Hoc test (LSD) for ANOVA with

repeated measures.

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*: Statistically significant at p ≤ 0.05

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Figure Legends:

Figure 1. Description of Herbert Bone Screw design showing the differential pitch pattern of

threads at both ends of the screw: A, the shorter and wider proximal end (cortical head) with

the standard V-shaped threads. B, the smooth central shaft of the screw. C, the longer and

narrower distal end (cancellous head) with the reverse buttress threads.

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Figure 2. Preoperative CT-Scan, axial cut, showing the fracture line in the symphyseal

region.

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Figure 3. Symphyseal fracture treated with 2 HBS. A, Intraoperative photograph showing K-

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guide wire in place and the depth gauge measuring the depth of the wire. B, Intraoperative
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photograph showing two HBS in place.
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Figure 4. Immediate postoperative panoramic radiograph showing two 2.3-mm Herbert Bone
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Screws.
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Figure 5. Three months’ Postoperative 3D CT-Scan view showing complete bone healing at
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the fracture line using two 2.3-mm Herbert bone screws.

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