In an External Fixation System, pins are inserted in the skin into the bone and held in place by an external frame. Thus, there is no placement of Orthopedic implants internally.
The usual indications are open fractures such as a tibia fracture which needs dressings or attention to a wound or flap. It can also be used with closed fractures, for example, unstable radius fracture.
External fixation is most successful in superficial bones, for example, tibial shaft. Avoid it in deeper bones, e.g. the humerus or femur – here the chance of pin tract sepsis is greater.
Indications for External Fixators:
External Fixators are often used in the management of tibial fractures.
Indications for External Fixators
- Bad soft tissue damage/ Severe open fractures
- Infected fractures
- For “Damage Control Orthopedics” (where the patient’s initial condition is too critical for prolonged surgery) to maintain length and provide stability. The exfix is replaced by definitive fixation (IM pin or pate) once the patient stabilizes. A temporary exfix can be placed over the joint for plateau or pilon fractures that are length unstable. It is later removed when ORIF is performed, once soft tissue swelling subsides.
Advantages of External Fixation
- The method provides rigid fixation of the bones in cases in which other forms of immobilization, for one reason or another, are inaccurate. This is most common in open, severe II and III fractures in which traction or cast methods wouldn’t permit access for Management of the soft tissue wounds and in which dissection and exposure to orthopedic implant an internal fixation appliance would devitalize and contaminate larger areas and might significantly increase the risk of infection or loss of the limb itself.
- Neutralization, compression, or fixed distraction of the fracture fragment is possible with external fixation, as dictated by the fracture configuration. Uncomminuted transverse fractures can be optimally compressed, length can be maintained in comminuted fractures by pins in the major distal and proximal fragments (neutralization mode), or fixed distraction can be obtained in fractures with bone less in one of paired bones, such as the ulna or radius, or in leg-lengthening procedures.
- The method allows direct surveillance of the limb and wound status, including wound healing, viability of skin flaps, neurovascular status, and tense muscle compartments.
- Associated treatment, for example, skin grafting, dressing changes, bone grafting, and irrigation, is possible without disturbing the fracture alignment or fixation. Rigid external fixation allows simultaneous and aggressive treatment of bone and soft tissues.
- Immediate movement of the distal and proximal joints is allowed. This aids in reduction of edema and nutrition of articular surfaces and retards capsular fibrosis, muscle atrophy, joint stiffening, and osteoporosis.
- The extremity is elevated without pressure on the posterior soft tissues. The orthopedic pins and frames can be suspended by ropes from overhead frames on the bed, relieving pressure on the posterior soft tissue part and aiding edema resolution.
- Early patient mobilization is allowed. With rigid fixation, the limb can be moved and positioned without fear of loss of fracture place. In uncomminuted, stable fractures early ambulation is often possible; this may not be the case if these fractures are treated by casting or traction. Use of external fixation also enables the mobilization of some patients with pelvic fractures.
- Insertion can be performed with the patient under local anesthesia if required. If the general medical condition of a patient is such that use of a spinal or general anesthetic is contraindicated, the fixator can be inserted using local anesthesia, although this is not optimal.
- Rigid fixation can be used in infected, non-unions or acute fractures. Rigid fixation of the bone fragments in infected fractures or in infected established nonunions is a critical factor in obliterating and controlling the infection. This is infrequently possible with traction or casting methods, and implantation of internal fixation devices is usually ill-advised. Modern external fixators in such instances can provide rigidity not afforded by other methods.
- Rigid fixation of infected, failed arthroplasties in which joint reconstruction is not possible and in which arthrodesis is desired can be achieved.
A thumb sprain is a severe condition that can occur in athletes, physically active people or simply anyone who experiences an injury relating to their hand. Many would consider this as a minor injury that will gradually heal on its own when, in fact, a thumb sprain can affect your ability to grasp, therefore impairing the functionality of the affected hand. So, it is necessary to consult a doctor, who will examine and treat you in time using orthopedic instruments, procured from reputed orthopedic instrument Manufacturer.
The main ligament that controls the function of your thumb is called the ulnar collateral ligament, spanning between the index finger and thumb. During a fall, instinctively one extends his arm to catch oneself, therefore causing the hand to bear most of the impact. This is the most common reason for thumb sprains, as the impact from a fall can cause an extensive tearing or stretching of the ulnar collateral ligament.
Skiers are usually most susceptible to severe thumb sprains, a condition also known as “skier’s thumb”. When a fall occurs in the process of skiing, the ski pole creates extra stress on the thumb ligament and increases the chances of a tear. Contact, ball sports, racket are other activities where the thumb is at risk of a sprain because of trauma such as a sudden hit or a fall.
Thumb sprains are among the toughest conditions to self-diagnose, as the onset of pain may not be immediate. Other symptoms may include swelling, tenderness, or bruising. If you experience any type of thumb injury, it is important to visit an orthopedic specialist whether you notice any symptoms or not, as leaving a sprain untreated may lead to complications in the thumb function.
When the ligament is partially torn your thumb will need to be immobilized with a splint or cast for approximately 4-6 weeks until the thumb regains its full stability. When the ligament is fully torn and/or there is any sign of bone fracture, you will need surgery followed by a recovery period of 6-8 weeks. The surgery is performed by the orthopedic surgeons using various instruments accessible from top orthopedic implant companies in india.
A bone plate may be placed so that it may be utilized for one of the following kinds of structural support:
- Compression Mode
- Neutralization Mode
- Buttress plate
- Antiglide plate
- Bridge plating or span plating
- Tension band
Plates are available in various shapes and sizes depending on the bone size and its anatomical shape. Similarly, Bone Screw size is dependent on the size & type of plate used. A small plate will typically be used for a small bone, which allows space only for the screw of smaller size.
Depending upon the fracture type and location, a plate can be used in any one of the following methods
The word compression in fixation of a fracture means bringing the two fragments closer to one another so that the fragments oppose well.
When the plate is utilized to achieve compression with the fracture fixation, it is said to be utilized in compression mode. This mode is utilized on oblique and transverse fractures.
In this kind of plating, a lag screw is utilized to neutralize shear, bending and rotational forces. The goal of this kind of plating is not to attain compression (this has already been attained by the lag screw).
This type of plating is also utilized as an adjunct where bone screws are used alone in long bones an accurate reconstruction with interfragmentary compression can be attained, but screws are not strong in resisting twisting or bending forces. Addition of a bone plate offers further resistance to such forces.
The fibular fracture normally seen in ankle injuries is usually fixed with lag screws protected by a neutralization plate.
The orthopedic plate is put on the tensile surface of the bone, but it is not pre-bent.
A buttress is an architectural structure built against or projecting from a wall which helps to reinforce or support the wall.
A buttress plate is utilized to prevent collapse in fracture patterns which are unstable under compressive forces.
A buttress plate is very thin in comparison to compression plate and is usually applied on the compressive surface of the bone.
This is the most commonly used plates around joints.
Here there is a comparatively soft cancellous bone core enclosed by a thin layer of cortical bone. Correct osteosynthesis may be attained by lag screws alone but under load, there may be a risk of screws cutting out of the bone or bending.
The addition of a bone plate will prevent such deformity under axial load. The plate should be located where the maximum load is predicted to be. Proximal tibia, for example, plates may be needed on one side or another to protect a fixation of tibial plateau fracture.
For the most common anatomical buttressing needs, there are specially shaped plates.
In antiglide plating, the plate is fixed to the bone in such a manner that it prevents the distal fragment from overriding when force is applied along the long bone axis.
The distal fragment is firmly impacted between the plate and the fracture surface of the proximal plane.
This principle is generally applied in distal fibula fracture. It can be termed as a variation of compression plating.
The wrist contains two forearm bones: the ulna and the radius. The most commonly encountered fracture in the wrist is that of the distal radius, the end of the larger of the two arm bones at the thumb-side of the wrist. Generally, Distal radius fractures occur about one inch from the end of the radius and are caused due to injury when one falls on an outstretched hand or if one has osteoporosis or low bone density. The injury causes swelling, pain, and bruising and can create a deformed appearance to the wrist.
The length of time for recovery differ greatly between patients. It is essential to have your recovery guided by your physician and a certified hand therapist. It is necessary to keep the wrist elevated and to keep the fingers moving by making a tight fist as often as possible. There is no reason to use a squeeze ball. An empty fist is the best. It is very common to have swelling and stiffness in the fingers and hand for quite some time after a wrist fracture.
Stable fractures that do not affect the joint alignment are treated without surgery. Initial treatment generally includes elevating the arm, icing, and anti-inflammatory medications to control swelling and pain. A splint may be used for 1 to 3 weeks to allow for swelling. After the swelling is subsided, the splint will be replaced by a fiberglass cast. After the injury, the wrist is typically immobilized for as many as 6 weeks. A sling may be worn for comfort, but it is important to work on maintaining a full range of movement of the elbow and shoulder to prevent stiffness. Regaining range of motion of the forearm and wrist is the focus for the first few months, followed by strengthening. In most cases, return to sports may be expected no before 3 months from the start of treatment. After the cast is taken off, a removable splint can be worn either for strenuous or full-time activities until the fracture is fully healed.
For more serious fractures, surgery may be needed to correct the alignment of the bone. Sometimes a cast alone can be used, or it may be essential to insert metal pins, bone screws and an orthopedic plate.
Another common fracture is of the scaphoid bone which is a small bone in the thumb-side of the wrist. It is a common sports injury and is often a result of a fall toward an outstretched arm.
Treatment depends on the location of the break. Fractures at the end of the bone, close to the thumb, often heal in a few weeks when placed in a cast. If the scaphoid is broken in the middle of the bone or closer to the forearm, healing can be more difficult and need a long-arm cast or surgery.
When the scaphoid is broken at the proximal pole or waist, surgery may also be recommended. The surgery requires orthopedic implants that can be accessed from the top orthopedic implant manufacturers in India. Wires and bone screws are used to stabilize the bone, so it can heal properly. After surgery, the wrist may be put into a cast, however, even with surgery, these fractures can be hard to heal.
What is a Hip Fracture?
A hip fracture is a severe injury that may hamper your ability to walk. Most people fracture their hips at the upper area of the femur, where the thighbone meets the hip joint. The injury usually requires surgery and physical therapy for a full recovery. The surgeons use ortho implants and orthopedic tools in the surgical procedure.
Hip Fracture Treatments
A fractured hip is a far more serious injury than just any broken bone. A hip fracture, especially in the old age, can greatly hinder the quality of life. If you suspect you have fractured your hip, the best thing to do is to take immediate medical treatment.
When to Seek Medical Attention
While women over the age of 65 are at the highest risk, anyone can suffer a fracture of the hip. If you have any of the following symptoms, you must consult an Orthopedic Specialist at once.
- Severe pain from the hip or groin area- Swelling or inflammation in the hip
- Bruising- Unable to put pressure or weight on the leg
- If you have recently suffered an accident or fall and are experiencing any of these symptoms, seek immediate medical attention.
Do I Need Surgery?
In most cases, surgery is the best way to fix a fractured hip with the help of orthopedic Hip implants. If you are in stable medical condition, most surgeons will want to operate 8 to 24 hours after you have arrived at the hospital. Delaying further will only add to your suffering and pain and increase the chance for complications and infections.
What to Expect if you Need Hip Surgery?
When you first go to the hospital, your doctor will most likely need to do some imaging test to confirm the diagnosis. This could mean either computed tomography (CT) scan or magnetic resonance imaging (MRI).
After you are properly diagnosed, your doctor will schedule surgery as soon as possible. If you have any other health problems, your doctor might delay your procedure and wait until you are in stable enough medical condition for hip surgery.
Recovery After Hip Surgery
After your surgery, your physician will work with you to customize a recovery plan that fulfills your needs. Every patient is different and there recovering pace too. In most cases, you will stay in the hospital for around 4 days before being discharged to initiate your physical therapy. A rehab program is vital and reduces the need for a walker or cane.
The most important thing to remember after your surgery is to be patient. Recovery can be a challenging and long effort and could take as long as a year. Even then, some patients may never be able to move around as they could before their hip fracture. The best thing is to keep a positive outlook and not be discouraged.
Who at a Risk of a Broken Hip?
While anyone can break their hip, these fractures are more common among women and old people, because of decreased bone density and length. Here are some more aspects that put one at greater risk of fracturing their hip:
- Heredity: If your family members typically have a thin, tall frame or if any of them have fractured their hips before.
- Lack of activity: Those who do not get enough exercise that bears weight on their hips (even something as simple as walking) may not have strong hip bones.
- Improper nutrition: Vitamin D and calcium help our bones grow strong. Diets that do not have these components may result in weak bones.
- Arthritis: Those with arthritis typically have weakened bones, putting them at higher risk of a hip fracture.
- Other medical conditions: Any conditions that cause problems with balance or dizziness may put one at greater risk of falling, which can result in a broken hip.
Cervical implants are orthopedic devices orthopedic surgeons use to decompress and stabilize the spine. These devices are implanted either from the front (anterior) of the spine or from the back (posterior). Information about anterior implants starts below.
The aims of cervical spine surgery include:
- Reduce pressure on the nerve(s) by decompression (for instance, surgically removing tissues pushing on a nerve).
- Stabilize the cervical spine by fusing 2 or more cervical vertebrae together.
Anterior cervical approach implants
Interbody cage or spacers
Cages (an orthopedic implant) and spacers are placed between 2 vertebrae. Their purpose is to:
- Keep space between vertebrae (if space gets so narrow, nerve roots may be pinched).
- Preserve spinal alignment (for instance, a healthy neck has a specific curve; a spacer can facilitate to restore this curve) and/or,
- Promote spinal fusion (for instance, join (fuse) 2 or more vertebrae together).
Cages are available in various sizes and shapes; some are cylinder-shaped, and others are box-shaped. Cages are placed or fit into the spine between vertebrae. Usually, cages are made from bone, metal, plastic, or carbon fiber. Bone chips (autograft, allograft, other bone graft alternatives, or other bone growth stimulating materials (for instance, demineralized bone matrix) can be packed into the cage. During the months after surgery, the hope is the cage will allow and improve fusion between the vertebrae above and below. Fusion increases spine stability.
Spacers are solid devices and bone cannot be packed inside. A spacer is utilized to facilitate to restore or correct spine alignment.
Anterior cervical plates are attached to the front of 2 or more vertebrae. Bone plates help to:
- Increase stability of the cervical spine immediately after surgery.
- Increase the chances for a successful solid fusion.
- Stabilize the cervical spine while healing.
- Help to reduce the time the patient can need wearing a cervical collar after surgery.
Plates are made with screw holes through which bone screws are positioned into the adjacent (to be fused) vertebral bodies to anchor the plates into accurate place. Both plates and screws are available in various sizes and designs. Most plates are made from metal (mostly titanium); some are produced from plastics. Certain newer plates are manufactured from composite substances that dissolve after fusion happens. Some designs of the plate are self-compressing to help promote spinal fusion.
Artificial Cervical Discs– Spine surgeons of the world have an interest in cervical artificial discs to treat degenerative disease. It’s believed keeping movement between vertebrae is better than spinal fusion. Early studies report cervical artificial discs can help slow down the process or prevent adjacent level disc degeneration. The process is called disc arthroplasty. Artificial discs are produced from various materials. Some designs are all plastics and metal composites and other metal. There are numerous ongoing, and some finished, FDA trials of artificial discs underway in the United States. Devices are being cleared for sale and implantation as the studies show safety and efficacy compared to fusion in selected cases.
If your surgeon suggests cervical surgery, you may be encouraged that cervical decompression and stabilization processes are some of the most successful operations spine surgeons perform presently. Patients often have a rapid recovery and quickly return to activities of everyday living with marked improvement of their symptoms.
Siiora.com has launched its new orthopedic product range of cervical implants which includes Variable Angle Cervical Locking Plate and Cervical Locking Screws in titanium.
Clavicle (collarbone) fractures make up 44% to 66% of all fractures of shoulder. A doctor can often diagnose a clavicle fracture during a physical evaluation, but X-rays and other tests are often recommended. The fracture may also require surgical intervention when Orthopaedic or trauma Implant may be used to fix the fracture.
Diagnosing Clavicle Fractures
X-rays can help determine the extent and location of the injury. At times it is essential to distinguish between a clavicle fracture and an injury to the joint at the top of the shoulder, called the acromioclavicular joint. A CT scan may also be required for more detailed images.
During the physical examination, the physician may do the following tasks:
- Note areas of tenderness
- Observe skin discoloration
- Look for deformities
- Address any open wounds
- Palpate or touch the shoulder blade and ribs to determine if there is an accompanying injury
- Listen to the lungs with a stethoscope, and observe differences in breathing
- Evaluate the shoulder’s range of motion
A doctor may conduct a neurological examination to make sure that motor functions and sensation are normal. The clavicle is located near a series of nerves found based in the shoulder and neck called the brachial plexus. Injury to the brachial plexus is uncommon but can happen with a clavicle break.
The physician will also ask about the medical history of patient, how the injury occurred, and any symptoms associated with it.
Common Causes and Risk Factors of Clavicle Breaks
They may be caused by:
- An athletic event resulting in a fall or direct hit. Clavicle fractures related to sports are commonly seen in children and young adults. Caution is advised when playing contact sports- including rugby, football, and hockey- and when participating in “extreme” sports where falls can happen- such as skateboarding and biking.
- A fall on the shoulder or an extended arm.
- A direct hit to the shoulder in a collision of motor vehicle.
Falling on the shoulder is the common cause of clavicle fractures.
Risk factors for clavicle breaks include:
- Young age, reaching a high point between the ages of 10 and 19. The clavicle is not entirely developed until about 20 years of age.
- Advanced age in both females and males over the age of 70.
- The onset of osteopenia, which is the early stage of reduced bone maps that can eventually lead to osteoporosis.
While certain people are at greater risk for a clavicle fracture, they can affect any person.
Nonsurgical Treatment for a Clavicle Fracture
Nonsurgical treatment for a broken clavicle can include the following:
- A wrap or arm sling is typically worn after the break occurs. This helps to prevent arm movement as the collarbone recovers.
- Pain medication, typically nonsteroidal anti-inti-inflammatory drugs such as ibuprofen or naproxen, can be taken to reduce pain.
- Physical therapy exercises will be recommended once the collarbone starts to mend. The patient will start with mild movements to ease stiffness. More intense exercises will be added after the recovery of bone.
Surgical Treatment for a Clavicle Fracture
Clavicle surgery may be required if the fractured pieces of bone are not in their anatomical and correct location. (The medical term for this is a displaced fracture). In these cases, the bones need to be secured and moved to heal properly. Bone plates, bone screws, and pins are often used during the surgical process. Rehabilitation after surgery includes exercises that can be done at home or with a physical therapist.
Stress fractures are a type of overuse injury characterized by small cracks in the bone. When muscles are fatigued and can’t absorb repeated impact, the shock is transferred to the bones. Weak bones caused by Osteoporosis may also be more vulnerable to stress fractures. These fractures can occur from sports or normal daily activities.
Stress fractures mostly occur in the bones of the lower leg and foot. The second or third long bones between the mid-foot and toes are the most often effected. Stress fractures sometimes appear in the heel, on the top of the foot, the outer bone of the lower and the navicular.
One of the most common occurrences of stress fractures occurs in runners who have been confined indoors during an off season and then, return to running without proper conditioning.
Improper foot gear is another reason due to which athletes get stress fractures. A well-known and old shoe can alter the dynamics of the foot and contribute to stress fractures. Athletes that change surfaces, like going from a grass tennis court to a hard court, can increase their risk for stress fractures, or from an outdoor running track to an indoor track. Other conditions, such as flatfoot or bunions, can alter the mechanics of the foot making it more vulnerable to stress fractures.
Symptoms of Stress Fractures
- Pain that develops slowly and is relieved with rest
- Swelling on top of the outside the ankle or foot
- Possible bruising
Treatment of stress fractures
Most stress fractures will heal if activity level is decreased and protective footwear is worn for two to four weeks. A stiff-soled shoe, a removable leg brace shoe, or sandal may be needed to provide support. Athletes are often advised to switch to a sport that puts less stress on the leg and foot while the bone heals, such as bicycle riding and swimming.
For stress fractures in the outer side of the foot or in the talus or navicular bones that take longer to heal, a cast may be applied to the foot or the use of crutches may be recommended until the bone heals. In some cases, surgery may be essential. The orthopedist may insert a bone screw into the bone to ensure proper healing. The orthopedic implants such as bone screws, etc. can be accessible from the orthopaedic implant manufacturer.
A fibula fracture occurs when there is an injury in the leg to one of the two bones of the leg. The leg (the segment between the ankle and knee) is made up of two bones. The larger bone, the tibia, carries most of the weight of the body). The smaller bone, the fibula, is located on the outside part of the leg.
The fibular bone starts just below the knee joint on the outside of the leg and extends all the way down to the ankle joint. The bone is a thin, long bone, hollow in its center. While the bone does little to support the body weight, it is a critical site of attachment for ligaments at both the ankle and knee joint and is also connected to the tibia by a thick ligament called the syndesmosis.
While the fibula is a significant bone, it is possible to extract much of the bone for surgical procedures where the bone is needed elsewhere in the body. When these grafting procedures are performed, people can function very normally, despite missing a large part of the fibula bone.
Types of Fibula Fractures
There are several types of injury to the fibula bone. For this discussion, I will divide them into more manageable topics:
- Fibula fractures that occur due to injury to the ankle joint
- Fibula fractures that occur in conjunction with tibia fractures
- Stress fractures of the fibula
These are not the only types of injury that can occur to the fibula but account for the majority of cases of injury to the fibula bone. By far the most common are injuries that occur when the ankle joint is damaged. Typically, the ankle buckles or is twisted and the fibula is injured as part of the injury.
As mentioned, fibula fractures can occur in association with injuries to the ligaments, other bones, tendons, and tendons around the knee and ankle. The most common symptoms related to the fibula fracture include:
- Pain directly over the fibula bone (outside of the leg)
- Swelling in the fracture part
- Bruising over the injury site
Diagnosis of a fibular fracture can typically be done with an x-ray image. Other imaging studies such as CT scan or MRI are typically not necessary, but there are some situations where a fibular fracture may not show up on a regular x-ray. These conditions include injuries such as stress fractures. Your physician will examine the injury site, the ankle and knee joints for associated injuries which may impact the treatment of the fibular fracture.
Fibula fractures typically occur as part of an ankle injury. Whenever a fibula fracture is found, the ankle joint should be examined for an injury that can be possible.
The most common kind of fracture to occur to the fibula bone is an isolated injury to the end of the fibula bone at the level of the ankle joint. These injuries occur in a similar manner to a badly sprained ankle, and mostly the injury can be treated similarly to a badly sprained ankle.
The components of a ring fixator system are categorized into 2 categories: main and secondary. The main parts are the standard elements utilized to correct skeletal deformities: rings, wire-fixation bolts, wires, and buckles, pin clamps, and pins.
The secondary parts of the system comprised of the elements essential for the assembly of the fixator: rods, plates, posts, supports, hinges, washers, bushings, sockets, nuts and bolts. To assemble the several pieces of equipment various kinds of wrenches and wire tensioner are required. There are no screws in this system and screwdrivers aren’t required.
A ring with multiple holes and a flat surface is the main component of a circular external fixator (Ilizarov).
The ring encloses a limb segment: 2 or more rings are connected to make a frame. The ring’s flat surface supports the heads of the nuts and bolts. The surface-nut interface or surface -bolt guarantees firm fixation of the wires, threaded rods, and bolts while treatment. The flat surface of the rings is essential for attaining a secure wire inclination and plane orientation. All rings in a frame are aligned perpendicular to bone’s long axis. A ring is made of carbon fiber or stainless steel provides strong support for the frame and is intended to bear high stresses of the tensioned wire, up to 150 kg. The ring’s internal diameter measures from 80 to 240 mm. A whole set has rings of 12 different diameters to suit several limb thicknesses.
A ring fixator set has several half and full rings. A full ring is lighter, has more holes than 2 connected half-rings, and doesn’t need connecting bolts and nuts. The holes in the ring are utilized for introduction of a threaded rod, a connector plate or a hinge. On the negative side, a full ring must be placed before the introduction of wires. If clinical state demands the removal of a full ring during the treatment tenure, then it must be cut with specific instruments.
Every half-ring, depending on its size, has eighteen to twenty-eight holes in the mid-segment of the flat surface. The standard holes are equally distance threaded (4 mm apart) and are of same size (8 mm in diameter). Threaded rods or bolts are affixed in the holes. 2 half-rings are joined by bolts and nuts to make a full ring. The ends of the plate don’t have standard-sized hole, are offset as well as ledged to fit together on an even plane to form a full ring.
The half-rings may also be connected to make an oval ring, three- and four-leaf clover rings and another specialized construct with the help of additional devices to make more space between the ring and the limb.
A five-eighths ring enables joint motion and is usually deployed near knee and elbow joints. Besides motion, these rings enable the introduction of cross wires, a distinct benefit near these joints. This ring can be used in the middle of a regular frame to offer access for management of soft tissue. Though, 5/8 ring is weaker than a full ring; a three-point connection to a full ring reinforces as well as strengthen it. Wires attached to a 5/8 rings are tensioned only after such stable connection is established. These rings can be accessible in three sizes from 130 to 160 mm.