AAP IMPLANTATE AG

Joint Replacement Implants

AAP Implantate AG is a German-based international medical technology company that specializes in developing, manufacturing and marketing implants for healing bone fractures (osteosynthesis) and joint replacements (endoprosthetics), in bone cements and cementing techniques (also endoprosthetics) as well as bone replacement substances and antibiotical carriers (orthobiologics).

Along with its head office in Berlin the company has a branch in Dieburg near Frankfurt am Main, Germany. Our implants support minimally invasive operating methods that are easy on the patient and help to accelerate the natural healing process. As well as offering patients reliable implants, we offer customers a balanced cost-benefit ratio and a high standard of service. All-in solutions include a complete set of tried and tested surgical instruments for safety on the operating table.

Medicine is calling for innovative approaches in the field of replacement joints, especially to solutions in the preparation of prostheses which largely support the natural movement processes and lastingly guarantee their full functionality. We supply physicians with bone cements and specially developed mixing systems to anchor replacement joints securely in the bone for artificial hip and knee joint development.

HIP ENDOPROSTHETICS

In hip endoprosthetics, AAP Implantate AG has both tried and trusted standard products and forward-looking new developments. In standard products, we can look back on many years of manufacturing experience. In combination with modern hip surgery, the innovative new developments are intended to continue to take changing medical requirements into account.

FORWARD LOOKING HIP PROSTHESIS SYSTEM: VARIOFIT®

VarioFit® combines innovation and tried and trusted features of hip endoprosthetics in a forward looking hip prosthesis system. VarioFit® thereby sets new standards for restoration of a patient-compatible hip anatomy and gives the operator unprecedented intra-operative flexibility even if shaft und socket are already finally fixed.

VARIOFIT® HIP SHAFT WITH PROXIMAL ANCHORING, ANATOMICAL SHAFT GEOMETRY, DISTAL MICROSTRUCTURE AND PROXIMAL MACROSTRUCTURE

The VarioFit® hip shaft offers all the biomechanical preconditions for long-term stability to the patient`s benefit. The design of the anatomical shaft geometry facilitates ideal force input and guarantees outstanding rotation stability. The proximal macrostructure and distal microstructure of the cement-free shaft surface is designed to support targeted bone integration of the proximal anchoring. The two-part VarioFit® prosthesis in cement-free and cemented versions with a shaft length of 160 mm

VARIOFIT® CONE

The VarioFit® Cone with grid is a brilliantly simple solution. VarioFit® cones come with a patented, rotation-safe grid for optimal setting of pre-torsion and CCD angles. As a consequence, any of the positions identified prior to surgery can be transferred clearly and with repeatable precision to cone and shaft. This ensures optimal setting of the center of the femoral head and the leg length. Four cone versions (0°, 5°, 12.5° und 20°) can be placed on the shaft in 12 positions.

CEMENT FREE TITANIUM IMPLANT

Other features of the VarioFit® hip system include:

• 7 sizes (9-15 mm) of cement free titanium implant in left and right versions
• 6 sizes (10-15 mm) of CoCr implant for cementing in left and right versions
• The VarioFit® toolkit handles well and its precision makes the operator feel secure

SM STRAIGHT SHAFT HIP ENDOPROSTHESIS

Since 1982, the SM straight shaft hip endoprosthesis made of a cobalt chrome cast alloy (CoCrMo, ISO 5832/4 ASTM F75) has been implanted successfully a thousand times. Clinical reliability and simple, flexible handling combine with high economy at this implant.

ACETABULUM COMPONENTS

The thought-out and simple-to-handle instruments make a fast and efficient operative approach possible. A variety of application possibilities arises from the modular erection of the system both in the cementable range and in the hybrid version with the acetabulum components without cement.

The SM straight shaft hip endoprosthesis shows a CCD corner of 135° and is available in four shaft strengths with or without collars in the cone size 12/14 respectively.

Knee Endoprosthetics

In knee endoprosthetics, AAP Implantate AG has an internationally tried and trusted knee implant with outstanding long-term results. Our aim will continue to be, especially against the backdrop of growing cost pressure in the health sector, to provide operators with reliable, inexpensive knee implants.

MEBIO KNEE

The MEBIO Knee is a modular prosthetic system for axis-free total surface replacement. It is now by far the most frequently used form of knee joint replacement. The system comprises a femur component (Co-Cr-Mo), a tibia component (Co-Cr-Mo with a UHMWPE polyethylene plateau and a UHMWPE patella component for optional use. The components are all available in various sizes and strengths.

Two pegs and a textured back anchor the femur component securely in the cement. The joint surface permits limited rotation around its axis and allows it to slide backwards in flexion. The tibia component has a central shaft and a textured back. The shaft base is ventrally widened. This gives better rotation stability after the implant. The patella is a dome-shaped component with a central anchoring peg.

The outstanding quality of this prosthesis system is confirmed by the data in the Swedish Knee Arthroplasty Register, which has existed since 1975 and which by 1997 held records on more than 50,000 primary knee endoprostheses. During a 9-year period, the Scan Knee, which is marketed in Germany as the MEBIO Knee, showed extremely low cumulative revision rates (in %). (Robertsson O, Knutson K, Lewold S, Lidgren L.

BONE CEMENTS

Thanks to its special properties, bone cement fulfils two important functions within the framework of its particular application. It serves as a filler between prosthesis components and bone to anchor the endoprosthetic parts firmly and securely to the bone. As such, it acts as a medium that takes on the job of transferring and distributing forces. Thanks to its ability to intermesh with and penetrate the porous bone surface, especially in spongy areas, it enlarges the area of contact between cement and bone considerably. This results in a decisive increase in its load-bearing capacity.

Bone cement fulfils a second function as a tried and tested vehicle for pharmaceutical agents. When charged with appropriate antibiotics, it has proven particularly effective in preventing bacterial infections in connection with artificial joint replacements.

AMINOGLYCOSIDE ANTIBIOTIC; AND STANDARD VISCOSITY, X-RAY POSITIVE, FAST-SETTING BONE CEMENT: PALACOS® R

Palacos® R is a standard viscosity, X-ray positive, fast-setting bone cement that can be supplied with or without the aminoglycoside antibiotic, Gentamicin. Palacos® has a shorter mixing time than other cements, followed by an extended working duration. The use of Palacos® R cements marketed by AAP Implantate AG has been scientifically recorded for more than 15 years in the Swedish National Hip Arthroplasty Register data now covering 169,419 primary implantations.

Palacos® Low Viscosity (LV) does not generally require pre-cooling when mixed with vacuum mixing systems. Palacos® Low Viscosity (LV) is only available in a 40g pack and, in contrast to Palacos® R, with 1 g (instead of 0.5 g) Gentamicin.

EASYMIX® VACUUM CEMENTING SYSTEM

The authors make express reference to the connection between a reduction in revision risk and the type of cement used. Palacos® R with and without Gentamicin showed the best results and the lowest risk quotients. Combining Palacos® R bone cements with Gentamicin or Palacos® R and the EASYMIX® vacuum cementing system that we market makes it possible to vacuum mix a bone cement of standard viscosity without pre-cooling provided that the mixing system is used properly and that the room temperature is below 22º C.

In these conditions, even without pre-cooling the cement it can be proven that vacuum mixing produces neither inhomogeneity in the cement matrix nor increased porosity (larger volume of trapped air). However, this only applies if the cements are used in conjunction with our EASYMIX® vacuum mixing system.

Cementing Techniques

For at least a decade many publications have been pointing out the significance of mixing and cementing techniques, especially in connection with the risk of subsequent revisions as a result of aseptic loosening. The link between improved cementing technique and improved long-term results in hip endoprosthetics is regarded as certain. The elements of modern cementing technique include mixing the cement in a vacuum and cleansing the bone surface by jet lavage before introducing the cement.

Cement mixed by hand in the conventional way is porous. It contains up to 30% air. Cement mixed in a vacuum can be almost non-porous. Reduced porosity increases the cement`s strength (endurance and flectional resistance) considerably. In the medium term the risk of revision is reduced significantly. This is borne out by the Swedish prospective multi-center study of 169,419 primary implants (risk quotient 0.74 after 8 years).

In addition, vacuum mixing reduces the quantity of monomer fumes emitted to below the detection limit. It reduces to a minimum the exposure of operating room staff to monomer fumes and improves their working conditions.

Jet lavage cleansing of the bone surface prior to cementing increases the strength of the bone-cement interface and reduces blood penetration into the cement. This increases the bone cement`s mechanical strength. It also helps to prevent bone marrow embolisms and thromboses.

EASYMIX® VACUUM CEMENTING SYSTEM

The EASYMIX® vacuum cementing system is an effective yet extremely reasonably priced bone cement mixing system that is easy to use. It consists of an EASYMIX® vacuum pump, and EASYMIX® cement gun and various cartridge sets. Just a few easy moves produce an excellent mixing result. It takes only 20 seconds to mix a fully homogeneous cement mass.

The EASYMIX® pump works evenly and reliably at supply pressures in the range of 5 to10 bar. It has a return valve, so it does not have to be operated continuously, but only for 20 seconds to evacuate the mixing system. The active carbon filter, in combination with a sterile filter, has a particularly high capacity for binding monomer fumes. The closed system minimizes the emission of monomer fumes.

The EASYMIX® vacuum cementing system cuts the cement residue in the system to a minimum, and permits a more economical use of bone cement. EASYMIX® is available in one- or two-cartridge packs for up to 80 grams of bone cement powder and all disposable items required for mixing and introducing the cement in a vacuum. If cement is to be mixed without vacuum, the EASYMIX® vacuum cementing system is currently the only closed system available that almost entirely prevents the emission of monomer fumes into the surroundings.

MICROAIRE® HI SPEED HIGH PRESSURE PULSE LAVAGE

The MicroAire® Hi Speed Pulse Lavage System is a reasonably priced high pressure rinsing system for preparing the implant site in joint replacement operations. It can also be used for other purposes such as rinsing dirty or contaminated wounds in a way that is gentle on the tissue, for cleaning infected wound areas or for cooling the operation area while bone is being worked on with instruments.

In cemented endoprosthetics (hip, knee, revisions) cleaning the implant site rinses out preparation-related detritus and bone marrow. Intensive cleansing of the bone surface by high pressure pulse lavage prior to cementing increases the depth to which the bone cement penetrates into the bone, improving the interconnection of cement and bone and thus increasing the strength of the bone-cement interface.

It reduces blood penetration into the cement, thereby increasing the bone cement`s mechanical strength. In addition, intensive lavage helps to prevent fat embolisms and circulation problems. The MicroAire® Hi Speed Pulse Lavage is operated with a high pressure pulse lavage handset that is available for many different systems of compressed air supplies.

We supply an extensive range of accessories (sterile-packed disposal items), such as various nozzles, hose systems, hose and pulse lavage nozzle sets (including special ones for total endoprosthesis hip and knee operations) and splashguards. Nozzles can be changed easily during surgery.

Osteosynthesis Implants for Fracture Healing

One of the product highlights in the osteosynthesis implants segment are cannulated screws. With the help of a guide wire, these screws can be placed exactly at the site of the bone fracture. They are self-tapping and self-cutting, permitting a faster, safe operation process. By supplementing the range with a 2.7 mm diameter screw, AAP Implantate AG offers users the possibility of treating a wider range of fractures, especially in hand and foot surgery.

DYNAMIC HIP SCREW SYSTEM FOR FEMURAL NECK FRACTURES, AND AC-PLATE

The Dynamic Hip Screw System (DHS) for fast, efficient treatment of femural neck fractures and the AC Plate for operative treatment of traumatic injuries to the shoulder corner joint and the clavicle have been outstandingly proven in practice many times over.

BIORIGID NAIL™ TIBIA, BIORIGID NAIL™ FEMUR FOR TUBULAR BONE FRACTURES

The Biorigid Nail™ Tibia and Biorigid Nail™ Femur set new standards in modern trauma surgery. We have developed a complete system based on the principle of interlocking grooves for use in the treatment of tubular bone fractures of the upper and lower thigh. Besides broadening the range of fractures that can be treated, this will optimally meet the demand for individual solutions based on standardized implants.

ANGLE STABLE PLATES

The angle stable plates for treating fractures of the upper and lower arm feature a spherical thread on the screw head and in the hole plate, ensuring that the plate stays at a stable angle. This means that the plate is fixed permanently and retains a firm hold even in osteoporotic bone. This property enables the physician to undertake exercises with the patient immediately after the operation, thereby shortening the rehabilitation period. What is more, the spherical shape of the thread holes makes it possible to use the much expensive standard screws.

ANGLE STABLE PROXIMAL HUMERUS PLATE WITH STABLY ANGLED ANCHORING AND COUNTERSUNK SCREW HEADS

For anatomical, stable reconstruction of complex fractures and early mobilization, the angle stable proximal humerus plate is the perfect choice.

Anatomical Design

• Avoids soft-tissue irritation due to the rounded shape of plate conforming to the profile of the lateral head of the humerus
• Prevents subacromial impingement due to a short cranial end to the plate and countersunk screw heads
• No loosening of screws in relation to the plate

Intraoperative Flexibility and High Stability Thanks to Novel Geometry of Plate Holes

• Stably angled anchoring with spherical threads on the screw head and in the plate holes:

1. All plate holes can be fitted with stably-angled self-tapping screws (cortical screw 3.5/ cancellous screw 4.0) or conventional small fragment screws
2. When standard screws are used, the angle to the standard plane of the plate can be freely selected up to 10°

• Good primary stability due to the stably-angled anchoring and diverging screw alignment in the head of the humerus
• Avoids secondary dislocation or loosening of implants
• Eyes for fixation of the tubercles
• Speedy rehabilitation as exercise therapy is possible immediately after the operation

Indications

• Complex 2, 3 and 4 fragment fractures of the proximal humerus, even in osteoporotic bone
• Pseudarthroses
• Osteotomies of the proximal humerus

ANGLE STABLE DISTAL RADIUS PLATE

The angle stable distal radius plate is the has been designed for the stable, palmar treatment of flexion and extension fractures .

Secure, Lasting Retention of Resulting Repositioning

• Stably-angled anchoring of the distal screws in the plate close to the joint, with a novel spherical thread on the screw head and in the plate holes

1. All plate holes with the spherical thread can be fitted either with stably-angled self-tapping screws (cortical screw 3.5) or with conventional small fragment screws
2. When conventional screws are used, the angle to the standard plane of the plate can be freely selected up to 15°

• Avoids secondary loss of reduction due to permanent dorsal fixation of the distal fragments with stably-angled screws
• Angular stability ensures a firm hold even in osteoporotic bone
• Exercise-stability attained enables early functional follow-up treatment even in complex fractures

Indications

• Simple intra- and all extra-articular fractures of the distal radius, even in osteoporotic bone
• Osteotomies of the distal radius

Anatomical design

• Access with few complications
• Optimal plate fitting due to anatomically pre-contoured plates in left-handed and right-handed designs in two lengths
• No intraoperative correction of the plate necessary, as the angle of inclination is already adapted to the contour of the distal radius

TRAUMA SHOULDER SYSTEM BASED ON SCHAUWECKER AND MÜLLER

The trauma shoulder system based on Schauwecker and Müller permits for the first time ever direct, anatomical fixation of the rotator cuff in treating comminuted fractures of the humerus head in older people. The advantages of the implant are:

• For the first time ever, the rotator cuff can be connected to the implant via a large number of fixing points
• The shaft module is fixed primarily (no test prosthesis needed), after which the individual shaft is built up
• Prosthesis length can be adjusted by means of spacer disks of varying sizes
• Individual modules can be interlinked, making it possible to vary prosthesis rotation
• The prosthesis is designed to permit optimal lateralization across various head sizes
• Various head sizes and diameters available

Osteosynthesis Implants Screw Systems

AAP Implantate AG offers cannulated screw systems in seven diameters with reinforced leading wires. These systems can individually be combined on a standard sieve.

TITANIUM CANNULATED SCREWS

The titanium cannulated screws of AAP Implantate AG are manufactured from high-strength alloying. Their features include:

• Labeled Screw Head: The labeling of the screw head with laser technology gives the user safety by the retraceability of the implant
• Self Cutting: The thread is cut by the screw. The cut in the backward direction permits easy explantation of the screw at threads grown tightly
• Self Drilling: Through the distinctive cut of the milling flanks the screw drills easily and surely into the bone
• Large Drilling: By the large drilling, the screw can be lead with a Kirschner wire with a diameter of 3 mm

BASIC INTRAMEDULLARY NAIL: BIORIGID FEMUR™ SYSTEM

Building on the basic intramedullary nail, additional modules for the Biorigid Femur™ System guarantee application in a wide range of indications. The system is built on a hierarchy of trays and comes with a standard set of complementary instruments.

UNREAMED INTRAMEDULLARY NAIL: BIORIGID NAIL™ FEMUR

The Biorigid Nail™ Femur is an unreamed intramedullary nail that is locked into the medullary cavity via central drill holes and a unique system of grooves. The stability of this design of interlocking grooves has been proved. The nail is made from a titanium alloy (TiAl6V4), a non-allergenic, biocompatible material that guarantees extreme stability. Its anatomical curvature means that the Biorigid Nail Femur is perfectly adapted to the bone`s natural condition.
 
Universal application: The same nail can be used to treat fractures of both the left and right femur. In addition to insertion of the implant from the hip, problem-free retrograde access from the knee using the same set of instruments is available as standard.

Adjustability: Nail length is adjustable within a range of 150 to 480 mm. The nail design permits the unique hybrid locking system via central drill hole and grooves. Locking can be made dynamic by means of the elongated hole on the proximal end of the nail.

DISTAL INTERLOCKING

The CondyLock™ module permits what is probably the most distal interlocking of femur fractures. This enlarges the window of indications for the Biorigid Nail™ Femur even to fractures extremely close to the condyle.

UNREAMED TIBIAL NAILING SYSTEM: BIORIGID NAIL™ TIBIA FOR BIOLOGICAL OSTEOSYNTHESIS AND INTRAMEDULLARY FRACTURE STABILIZATION

With its Biorigid Nail™ Tibia unreamed tibial nailing system, AAP Implantate AG has set new standards in the biological osteosynthesis of fractures of the lower leg. The new patented concept of interlocking grooves permits the use of stable 4.5 mm interlocking screws while increasing the load-carrying cross-section to more than 50% above that of implants with central holes.

The Biorigid Nail™ Tibia can be used to treat indications ranging from simple, closed fractures to complex open, comminuted fractures. At the same time, the proximal AP locking and the interlocking grooves at the distal extremity permit the treatment of fractures ranging from those at the passage from the middle to proximal third of the tibia to diaphyseal fractures and fractures close to the ankle joint.

Where the soft tissue is badly damaged and primary treatment is with an external fixateur, the Biorigid Nail™  Tibia permits an early change of procedure to intramedullary fracture stabilization, which is easy on the patient and reduces the risk of infection round the fixation pins.

X-RAY-FREE DISTAL TARGETING

Ultra-biocompatibility: The Biorigid Nail™ Tibia is made from a titanium alloy (TiAl6V4) with elastic properties that more closely approximate those of the human bone than do those of other metallic materials. Its non-allergenic, bio-inert behaviour guarantees outstanding biocompatibility and provides a high degree of protection against nickel allergies.

Optimized operating technique: The X-ray-free distal targeting device meets the demand of users to reduce X-ray exposure. It enables precision distal targeting to be maintained even if the nail implant becomes elastically deformed.

Gentle implantation: There is no need to drill open the medullary cavity. This reduces the associated risk of heat necroses and fat embolisms. The distal extremity of the Biorigid Nail is very rounded and fitted with a dorsal runner. This prevents the nail from becoming stuck during insertion into the medullary cavity. At the same time, the longitudinal dorsal groove relieves the pressure in the medullary space during implantation. The arteria nutricia that runs close to the groove is also relieved, so vascularization of the bone is not impeded.

HOOK PLATE: AC PLATE BY DREITHALER

AC Plate by Dreithaler is an anatomically designed hook plate for the safe and uncomplicated treatment of AC joint injuries. The AC Plate by Dreithaler guarantees safe retention of the injured AC joint to enable healing of the injured ligaments, while ensuring immediate stability during exercise and earlier mobility of the patient as well as good cosmetic results due to small incisions. An extended version with four holes is available for treatment of lateral clavicular fractures.

Anatomical Adaptation

• Short Plate Body (short skin cuttings and therewith avoidance of injury to the N. supraclavicularis)
• Plate position under the muscular fascia of the deltoideus and m. trapezius (good covering of the soft parts)
• Placement of the hook on the dorsal side of the join (no injury to the lig. acromioclaviculare and the discus at removement of the metal)
• Angled hook (15°-20°; adjusted to the acromioclavicular angle)
• Low hook depth (prevents subacromial impingement)

Indication

• AC joint dislocation (Rockwood III-V, Tossy III)
• Lateral fraction of the clavicle
• Modified Weaver-Dunn operation for old AC joint luxations of Rockwood types III, IV and V/Tossy III

Orthobiologics: Bone Replacement Materials, Antibiotics Carrier

Treating damage to the muscular-skeletal organ system by means of metal implants is set to remain the ``gold standard`` of muscular-skeletal healing for the foreseeable future. However, in recent years, a paradigm shift to biologically active implants has taken place in orthopedics. There has been a move away from ``repairing`` fractures and joint damage to ``healing`` them.

Orthobiology or orthobiologics has become a synonym for the inclusion of biology and biochemistry in the development of bone replacement materials for muscular-skeletal healing. Orthobiological products, or orthobiologicals for the delivery of medicine include resorbable bone and tissue replacement materials. AAP Implantate AG is engaged in research into innovative bone replacement materials and tissue engineering. The knowledge we`ve acquired in bone replacement materials and regeneration has led to a focus on the bone mineral hydroxylapatite, which occurs naturally in the body.

PASTY NANOCRYSTALLINE HYDROXYLAPATITE IMPLANT, OSTIM® AND INJECTABLE BONE MATRIX IN PASTE FORM

Ostim® is a ready-to-use, injectable bone matrix in paste form, suitable for making good defects in fractures in the spongy area. It is a pasty nanocrystalline hydroxylapatite implant for peripheral filling or reconstructing of bone defects consisting of 100% synthetic, nanoparticular, phase free hydroxylapatite. The Ostim® syringe in the double sterile pack can be used to apply paste to the bone defect directly or by means of applicators.

It does not harden off when mixed with blood or spongiosa, so it is highly suitable for increasing the volume of autologous or homologous material. The volume stability of Ostim® 35 enables it to resist bleeding pressure. Its viscosity enables it to be applied to form-fit in close contact with the bone. Thanks to its paste-type properties, Ostim® is quickly converted into bone and new bone formation is visible after three months.

Indications

• Metaphyseal fractures and cysts
• Acetabulum reconstruction and periprosthetic fractures during hip prosthesis exchange operations
• Osteotomies
• Filling cages in spinal column surgery
• Combination with autogenous and allogenous spongiosa
• Filling in defects in children

PROPHYLAXIS CARRIER MATERIAL: PEROSSAL®

PerOssal®, a prophylaxis carrier material for the treatment of bone infections, is used for permanent filling or reconstruction of bone defects. PerOssal® makes available a bone replacement material that after surgical cleaning of the wound can be inserted into even infected bone defects with a simultaneous delivery of antibiotics, making it a good example of orthobiologics. PerOssal® is rapidly and completely absorbable. Thus the defect can be filled quickly with new, autogenous bone and the patient can be spared a further operation to remove the implant. The PerOssal® component responsible for this, a nanocrystalline hydroxylapatite, is sold by AAP Implantate AG in Germany as Ostim®.

STABLE HYDROXYLAPATITE CERAMIC ANORGANIC MATERIAL: CERABONE®

Cerabone®, a stable hydroxylapatite ceramic material with an interconnecting system of pores, is made of anorganic material. It can be supplied as a molding block in different sizes and as granules of differing dimensions. Its osteoconductive properties  make it suitable as a bone replacement material for permanent filling in or reconstruction of congenital or acquired bone defects and for increasing volume in spongiosaplasty. Cerabone®`s  advantages are:

• Spongiosa structure, with interconnecting macroporous and microporous pore system, is identical to that of human bone.
• Low porosity fluctuation and highly uniform spongy structure make for higher stability (pressure and shear resistance) and greater load-bearing capacity than comparable ceramics
• Optimal pore width (100–1,500 µm), whereas pore width of at least 50 µm is required for problem-free integration of implant and bone. With Cerabone®, complete bone building throughout and integration is possible
• Particularly high degree of purity of the hydroxylapatite structure
• Cerabone® molding blocks are available in larger sizes than other hydroxylapatite ceramics (up to 20x20x40 mm). So even elongated bone defects can be bridged or treated with one continuous molding block
• Easy intraoperative working (molding) of the molding block allow Cerabone® to be adjusted optimally to the particular bone defect
• Cerabone® has excellent biocompatibility

Cerabone®`s areas of application include permanent filling or reconstruction of aseptic bone defects in accident surgery and orthopedics, orthodontic and facial surgery, and plastic reconstruction.