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Dental Composite Offers Comparable or Greater Pullout and Shear Strength to Lateral Mass Screw Fixation in a Human Cadaveric Model

  • International Journal of Spine Surgery
  • August 2026,
  • 20
  • (4)
  • 591-597;
  • DOI: https://doi.org/10.14444/8871

Abstract

Background Lateral mass screw fixation is the common method of fixation for an instrumented posterior fusion of the subaxial cervical spine. While screws have established efficacy, adhesive material that can be applied to the bony surface may be a promising alternative strategy owing to ease of application, size, and avoidance of screw loosening, malposition, or fracture.

Methods Eighteen fresh frozen human cadaveric subaxial cervical vertebrae were prepared for biomechanical testing. In each vertebra, 1 side underwent lateral mass screw fixation, and the contralateral side underwent composite fixation. On the screw side, a 12 × 3.5-mm lateral mass screw was inserted using a standard free-hand technique by a spine surgeon. For the dental composite side, the lamina was treated with etching acid solution and a dental bonding agent over a 10-mm diameter area before an orthodontic metal bracket was attached using dental composite. Nine specimens in each group were subjected to an axial load to failure (pullout) test, where the load was perpendicular to the vertebral surface. The remaining specimens were subjected to cyclical testing, where the load was applied cranially (shear) relative to each vertebra and gradually increased with each cycle until failure occurred. Differences were assessed with paired t tests with a 2-sided level of significance of α = 0.05.

Results Under axial load (pullout), the dental composite (203.4 ± 43.4 N) showed higher ultimate load than the screws (127.7 ± 21.2 N; P < 0.001). The predominant failure mode under axial load was the composite pulling off the cortical bone surface, whereas the screw pulled through the cancellous and cortical bone. In cyclical testing, the ultimate shear load of dental composite (163.7 ± 48.4 N) did not differ from lateral mass screws (173.6 ± 65.5 N; P = 0.7). The composite failure mechanism under shear loading for half of the specimens was composite separation from bone, whereas the rest failed due to fractures distant from the composite site, indicating robust fixation integrity of composite to bone.

Conclusions Dental composite displayed similar shear strength and greater pullout strength compared with lateral mass screws.

Clinical Relevance An adhesion-based fixation strategy may serve as a viable alternative to traditional screws in specific clinical scenarios that are worthy of further investigation.

Level of Evidence 3.

Introduction

Lateral mass screw fixation is the common method of fixation for an instrumented posterior fusion of the subaxial cervical spine.1,2 Instrumented fusion has demonstrated benefits in increasing fusion rate compared with uninstrumented fusion.3 However, there are drawbacks, including the difficulty of screw placement, operative time, risk to adjacent structures, and limitations of osteoporotic bone.4,5

Despite these downsides, there are few widely used choices other than screw fixation for instrumentation of the spine. Perhaps one feasible alternative is to fix instrumentation to the spine with adhesive rather than a screw. The field of orthodontics utilizes composites that provide robust and durable fixation of brackets onto teeth, which allows for realignment of the teeth. Dental composite comprises an organic resin matrix and inorganic fillers. The resin matrix comprises monomers that polymerize on light exposure, creating a solid matrix surrounding the inorganic filler.6,7 If instrumentation can be applied to the surface of the spine with sufficient fixation strength utilizing adhesives similar to dental composite, this would have powerful advantages, including ease of application, smaller size, and avoidance of screw loosening, malposition, or fracture.

In this exploratory research, we investigate the feasibility of utilizing dental composite to fix dental brackets onto human spinal bone. We also compare the pullout and shear strength of the brackets fixed with dental composite to traditional lateral mass screws in human cadaveric cervical vertebrae. We hypothesize that dental composite may provide pullout and shear strength comparable to lateral mass screws.

Methods

Eighteen human cervical vertebrae (C1–T2) were harvested from 2 fresh-frozen cadaveric specimens (mean age, 88 years; mean body mass index, 16.9). All soft tissues were carefully and comprehensively removed, and each vertebra was individually isolated, sealed in plastic bags, and stored at −20°C to preserve their mechanical and structural integrity. Vertebrae were thoroughly examined to exclude signs of decomposition, congenital anomalies, or developmental defects that could affect their mechanical properties. Specimens were thawed overnight at room temperature. Each vertebra was re-examined and further cleaned to remove any residual soft tissue. The bone surfaces were dried to ensure that they were free of moisture.

Each vertebra was potted in a cubic mold (5 × 5 × 5 cm) using dental acrylic, securing the specimen by the vertebral body. A transverse screw was inserted through the mold and vertebral body to enhance fixation to the base. For screw placement, we prioritized the subaxial cervical spine (C3–C7), using 9 vertebrae and a total of 17 lateral mass screws. An experienced spine surgeon inserted all screws to ensure procedural consistency. Using a freehand technique guided by anatomical landmarks and following standard surgical procedure, the cortex was initially pierced with a 2-mm awl. A 2.5-mm drill bit was used to create the pilot pathway for a 3.5-mm screw. Pathway accuracy was confirmed by palpation with a ball-tip sounding probe. Direct visualization ensured no cortical surfaces, including the articular cortex, were violated. A 3.5-mm tap was used at the entry point to maintain proper trajectory alignment. Finally, a 12 mm × 3.5-mm lateral mass screw was inserted monocortically. A 3.5-mm titanium rod, prebent to a 90° angle for docking with the biomechanical testing machine, was secured with a corresponding locking screw.

Following screw testing, if the cortical surface of the lamina remained intact and no structural damage was present that could affect the specimen’s mechanical properties, the specimen was used for composite testing. In addition, dental composite was applied to the remaining subaxial vertebra (1), C1 (2), and C2 (2), T1 (2), and T2 (2). On each side of the mentioned specimens, dental composite was applied to the lamina (posterior arch for C1) chosen for its large surface area. The surface was cleaned and dried to remove residual soft tissue and moisture. A 37% etching acid solution was applied to create microscopic surface irregularities for improved bonding. After etching, a layer of OptiBond Solo Plus dental bonding agent was applied and dried according to the manufacturer’s instructions. The bonding agent was cured using a light source for 40 seconds.

Flowable composite material (Filtek Bulk Flowable), composed of zirconia/silica and ytterbium trifluoride fillers and multiple organic resins, was applied to a prepared surface area of 314.16 mm² (10-mm radius) with a volume of 0.7 mL. An orthodontic metal bracket (first/second molar nonconvertible buccal tube) was embedded in the composite material. The composite was polymerized using a curing light for 40 seconds, as recommended by the manufacturer. Each dental bracket featured a nonconvertible tube through which a double 304 stainless steel wire was passed to connect the construct to the biomechanical testing machine, ensuring consistent fixation for evaluation (Figure 1).

Dental composite and bracket applied to the lateral mass of a human cervical vertebra with fine metal wire passed for testing.
Figure 1

Dental composite and bracket applied to the lateral mass of a human cervical vertebra with fine metal wire passed for testing.

Pullout Testing

Pullout testing was conducted using a material testing system (Instron E10000). A priori power analysis conducted on preliminary data found that a sample size of n = 8 per group was enough to reach a power of 0.8. For the screw pullout test, potted specimens were positioned with neutral tilt and rotation relative to the pedicle screw axis, and the axial tensile force was applied. The 90° rod was attached to the machine’s testing arm to ensure pure vertical force application. For dental composite pullout testing, the specimens were positioned so that the lamina and composite area aligned at 90° with the applied force. Neutral tilt and rotation were estimated using the cortical surface of the lamina as a reference. The double 306 stainless steel wire was connected to the machine to ensure pure vertical force application. Once specimens were positioned, a 5 N preload was applied, and the crosshead position was set to zero. Constructs were then loaded at 10 mm/min from the zero position until macroscopic failure. This loading speed was chosen based on similar speeds in prior biomechanical studies and to provide more consistent results.8 Lower speeds are more repeatable, but higher speeds are closer to those seen in vivo. Ultimate load and stiffness before failure were recorded. Pullout testing protocol was performed similar to prior studies on lateral mass screws.9,10 The testing setup is demonstrated in Figure 2.

Testing setup demonstrating potted vertebrae connected to the biomechanical testing machine via stainless steel wire (A) or through prebent 3.5-mm rod (C). Failure of the composite-bracket construct most commonly occurred at the composite-bone interface (B), while lateral mass screws pulled out of bone (D).
Figure 2

Testing setup demonstrating potted vertebrae connected to the biomechanical testing machine via stainless steel wire (A) or through prebent 3.5-mm rod (C). Failure of the composite-bracket construct most commonly occurred at the composite-bone interface (B), while lateral mass screws pulled out of bone (D).

Shear Testing

Shear testing was conducted using the same material testing system (Instron E10000). Another power analysis conducted on prior data found that a sample size of n = 8 per group was enough to reach a power of 0.8 for shear testing. For the screw group, potted specimens were positioned such that the screw axis was at 90° relative to a straight bar. The bar was connected to the machine to ensure the shearing force acted at 90° relative to the screw axis and parallel to the cortical surface where the screw was inserted. For composite shear testing, specimens were positioned so that the cortical surface with the composite was parallel to the applied force vector. The galvanized steel wire loop was connected to the machine. All specimens underwent sinusoidal cyclic testing at 0.5 Hz until failure, with load applied cranially relative to each vertebra and gradually increased peak load every cycle by 0.1 N until failure occurred. Shear testing protocol was performed similar to prior studies on lateral mass screws.9,10 The increasing shear until failure test was a custom test designed based on Zdeblick et al’ s method of increasing shear load each cycle.10

Statistical Analyses

Descriptive statistics are presented as means ± SDs. Data normality was assessed with Shapiro-Wilk tests. Differences between screw and composite mechanical testing results were assessed with paired t tests with a 2-sided level of significance of α = 0.05 (Microsoft Excel for Microsoft 365 MSO [version 2503]).

Results

Pullout Test

Pullout testing was successfully performed on 9 lateral mass screws and 9 dental composite applications. To achieve these 9 successful dental composite applications, 17 tests were conducted. In some cases, the composite bonded the bracket to the bone with a strength exceeding the experimental setup’s capacity to facilitate bracket pullout. Failure mechanisms included wire breakage during pull-out testing (n = 4), specimen dislodgment from the potting cement (n = 3), and vertebral body fracture under tension (n = 1). As bracket pullout from the bone was not achieved in these cases, the corresponding data were deemed unusable.

The mean pullout strength of the composite was higher than that of lateral mass screws (203.4 ± 43.4 N vs 127.7 ± 21.2 N; P = 0.00152; Figure 3A). The mechanism of failure for the screws was screw pullout from cancellous and cortical bone. The mechanism of failure for the composite was pull-off of the composite from the bone surface (Figure 2B). In other words, failure occurred at the interface between composite and bone and not at the interface between the bracket and composite. In 6 specimens, there was intrasubstance cracking of the composite around the bracket. In the remaining 3 specimens, portions of cortical bone remained attached to the undersurface of the composite that had pulled out.

Results from (A) axial pullout and (B) cyclic shear testing of lateral mass screws vs dental composite. Data presented as mean ± SD. *P < 0.05.
Figure 3

Results from (A) axial pullout and (B) cyclic shear testing of lateral mass screws vs dental composite. Data presented as mean ± SD. *P < 0.05.

Cyclical Shear Test

In cyclical testing, the mean ultimate shear load of the composite group was comparable to that of lateral mass screws (163.7 ± 48.4 N vs 173.6 ± 65.5 N; P = 0.79; Figure 3B). The mechanism of failure during cyclic testing in the screw group was most frequently fracture and displacement. Two specimens had >8 mm of displacement with screws, indicating failure without fracture. Similar to pullout testing, the composite group had no failures at the bracket-composite interface. In 4 specimens, the composite separated from bone, with portions of cortical bone remaining attached to the undersurface of the composite. In the remaining 4 specimens, failure occurred distant from the composite-bone interface, specifically fractures at the pedicle. This indicates robust fixation integrity of the composite to bone.

Discussion

This is the first description of using a dental composite to fixate instrumentation onto human bone outside of the mouth. This exploratory research demonstrated the feasibility of a novel technique of applying dental composite to the human cervical spine. We found that the composite provided fixation strength on pullout testing that was 59% greater than the current standard, lateral mass screw fixation, and showed no difference in cyclical shear testing. These results raise the intriguing possibility of an alternative strategy for spinal instrumentation—one that relies on fixation to the bony surface—that is sufficiently strong and durable to promote fusion.

Dental composites are materials used to fill cavities and fix orthodontic brackets to teeth. They consist of an organic resin matrix and inorganic filler particles, which photo-polymerize when exposed to a specific wavelength of light.11,12 When applying dental composite to teeth, it must be etched with 37% phosphoric acid to demineralize the surface and expose the collagen fibers, creating a rough surface for better bonding of the composite. The tooth surface is then dried to remove moisture prior to applying the composite.13 There are compositional differences between the tooth surface and cortical bone. Teeth contain an outer surface of enamel, which, like cortical bone, has a high percentage of hydroxyapatite but lacks collagen. Underneath, teeth have dentin, which contains collagen and provides structural support. However, unlike cortical bone, dentin and enamel have limited remodeling or regenerative properties, whereas bone has osteoclasts and osteoblasts to perform these functions. Despite these differences, dental composite is effective on cortical bone and has comparable bond strength to that of dentin.14,15 While the acid etching serves to create microroughness and does not penetrate the cortical surface,15 dental composite has been demonstrated as cytotoxic to osteoblastic-like cells in vitro.16,17 Furthermore, the effect of acid etching or composite itself on important local neural structures (eg, nerve roots and dura) has not been studied. Additional in vitro and in vivo studies are needed to determine the implications of these results for application safety in the cervical spine.

In this study, we examined dental composite and orthodontic bracket fixation in the posterior cervical spine. While lateral mass screws are the standard method of posterior cervical instrumentation for fusion, there are downsides to screw fixation.2–4 These include the risk to adjacent structures with screw malposition, limitation of fixation strength in osteoporotic bone, and potential for loosening or fracture. In addition, in the revision setting, there are limited options if screws have loosened to the extent that the lateral mass can no longer accommodate screw fixation.2,16–21 An alternative to screw fixation that could avoid these drawbacks would represent an important advance. Hooks and sublaminar wires have been tried previously but have fallen out of favor due to significant problems such as inferior biomechanical properties, increased revisions, pseudoarthrosis, and neurological injury.22–24

A technique similar to dental composite could serve as a promising alternative to screw fixation, given the relative ease and safety of application, as well as the potentially low profile of implants. Our study demonstrates that the pullout strength of composite/bracket constructs is greater than that of lateral mass screws with comparable shear strength. Interestingly, the mode of failure in multiple specimens was the bone-bone interface, as opposed to composite-bone, suggesting that the composite integrates with the vertebral surface with a high degree of tensile strength. Furthermore, composite/bracket constructs could be used in anatomical locations where screw placement is challenging or not possible. Because the composite and bracket are applied to the vertebral surface, there is potential for a safer surgical corridor and more minimally invasive approach.

The present study is the first to demonstrate an application for biomaterials similar to dental composite in spine surgery. Other composite materials, such as hydroxyapatite, have been investigated as a material for interbody grafts for anterior cervical discectomy and fusion,25,26 posterior lumbar interbody fusion,27 and anterior lumbar interbody fusion.28 However, none of these studies used these biomaterials as a means of segmental instrumentation to stabilize a motion segment, nor has dental composite been used for this application.

Limitations

There are important limitations to this proof of concept study. First, this is a biomechanical study in human cadaveric specimens. The performance of composite may differ in live tissue under clinical conditions. Although typical lateral mass screws and composite/brackets were used for experimentation, strength testing was performed on individual vertebrae and did not test constructs involving motion segments. An additional weakness is that the same vertebrae were used to test the screw and composite, thus unapparent damage from testing or insertion could lead to influence on the second test. Although visibly damaged specimens were not used for re-testing, there could have been impact that was not readily apparent. Pullout and shear strength were examined in this study because screw pullout has a large biomechanical impact on the stability of a construct,5 but this may not be the most relevant for composite/bracket fixation. More comprehensive testing is needed to characterize the biomechanical strength of this strategy relative to lateral mass screws. Additionally, while dental composite is approved for use in orthodontics, it is not approved by the US Food and Drug Administration for this indication and has not been tested in human subjects internally. The composite is not designed for this application, although this may represent an opportunity to create formulations optimized for application on spinal bone and tailored for this application. Despite these shortcomings, the results of this study demonstrate the feasibility of adhering instrumentation onto the surface of bone and form the basis for further research, such as the ability to immobilize actual motion segments to promote spinal fusion.

Conclusion

Under in vitro conditions, dental composite as an alternative method for instrumentation of the subaxial cervical spine fusion showed similar resistance to shear load and greater pullout strength compared with lateral mass screws during human cadaveric biomechanical testing. The mode of failure was often the bone-bone interface, indicating significant osseointegration strength of the composite.

Footnotes

  • Funding The authors received no financial support for the research, authorship, and/or publication of this article.

  • Declaration of Conflicting Interests The authors report no conflicts of interest in this work.

  • Disclosures James Mok reports royalties/licenses from MiRus. The remaining authors have nothing to disclose.

  • Ethics Approval This study was reviewed and determined to be exempt from Institutional Review Board oversight.

References

  1. 1.
    ↵
    Coe JD , Vaccaro AR , Dailey AT , et al . Lateral mass screw fixation in the cervical spine: a systematic literature review. J Bone Joint Surg Am. 2013;95(23):2136–2143. 10.2106/JBJS.L.01522
    Google ScholarOpenURLCrossRefAbstract/Full TextPubMed
  2. 2.
    ↵
    Al Barbarawi MM , Allouh MZ , Qudsieh SM , Barbarawi A . Cervical decompressive laminectomy and lateral mass screw-rod arthrodesis: surgical experience and analytical review of 4120 consecutive screws. Br J Neurosurg. 2021;35(4):480–485. 10.1080/02688697.2021.1887450
    Google ScholarOpenURLCrossRef
  3. 3.
    ↵
    Lorenz M , Zindrick M , Schwaegler P , et al . A comparison of single-level fusions with and without hardware. Spine (Phila Pa 1986). 1991;16(suppl):S455. 10.1097/00007632-199108001-00029
    Google ScholarOpenURLCrossRef
  4. 4.
    ↵
    Chen Z , Lv G , Zhang O , et al . Risk factors of instrumentation failure after laminectomy and posterior cervical fusions (PCF). BMC Musculoskelet Disord. 2024;25(1):1. 10.1186/s12891-023-07116-z
    Google ScholarOpenURLCrossRefPubMed
  5. 5.
    ↵
    Hostin RA , Wu C , Perra JH , Polly DW , Akesen B , Wroblewski JM . A biomechanical evaluation of three revision screw strategies for failed lateral mass fixation. Spine (Phila Pa 1986). 2008;33(22):2415–2421. 10.1097/BRS.0b013e31818916e3
    Google ScholarOpenURLCrossRef
  6. 6.
    ↵
    Chen MH . Update on dental nanocomposites. J Dent Res. 2010;89(6):549–560. 10.1177/0022034510363765
    Google ScholarOpenURLCrossRefPubMed
  7. 7.
    ↵
    Sowan N , Dobson A , Podgorski M , Bowman CN . Dynamic covalent chemistry (DCC) in dental restorative materials: implementation of a DCC-based adaptive interface (AI) at the resin-filler interface for improved performance. Dent Mater. 2020;36(1):53–59. 10.1016/j.dental.2019.11.021
    Google ScholarOpenURLCrossRef
  8. 8.
    ↵
    Brasiliense LBC , Lazaro BCR , Reyes PM , et al . Characteristics of immediate and fatigue strength of a dual-threaded pedicle screw in cadaveric spines. Spine J. 2013;13(8):947–956. 10.1016/j.spinee.2013.03.010
    Google ScholarOpenURLCrossRef
  9. 9.
    ↵
    Johnston TL , Karaikovic EE , Lautenschlager EP , Marcu D . Cervical pedicle screws vs. lateral mass screws: uniplanar fatigue analysis and residual pullout strengths. Spine J. 2006;6(6):667–672. 10.1016/j.spinee.2006.03.019
    Google ScholarOpenURLCrossRefPubMed
  10. 10.
    ↵
    Zdeblick TA , Kunz DN , Cooke ME , McCabe R . Pedicle screw pullout strength. Correlation with insertional torque. Spine (Phila Pa 1976). 1993;18(12):1673–1676. 10.1097/00007632-199309000-00016
    Google ScholarOpenURLCrossRef
  11. 11.
    ↵
    Wang Y , Zhu M , Zhu XX . Functional fillers for dental resin composites. Acta Biomater. 2021;122:50–65. 10.1016/j.actbio.2020.12.001
    Google ScholarOpenURLCrossRef
  12. 12.
    ↵
    Habib E , Wang R , Wang Y , Zhu M , Zhu XX . Inorganic fillers for dental resin composites: present and future. ACS Biomater Sci Eng. 2016;2(1):1–11. 10.1021/acsbiomaterials.5b00401
    Google ScholarOpenURLCrossRef
  13. 13.
    ↵
    Hitmi L , Bouter D , Degrange M . Influence of drying and HEMA treatment on dentin wettability. Dent Mater. 2002;18(7):503–511. 10.1016/s0109-5641(01)00075-6
    Google ScholarOpenURLCrossRefPubMed
  14. 14.
    ↵
    Maurer P , Bekes K , Gernhardt CR , Schaller HG , Schubert J . Comparison of the bond strength of selected adhesive dental systems to cortical bone under in vitro conditions. Int J Oral Maxillofac Surg. 2004;33(4):377–381. 10.1016/j.ijom.2003.10.020
    Google ScholarOpenURLCrossRefPubMed
  15. 15.
    ↵
    Maurer P , Bekes K , Gernhardt CR , Schaller HG , Schubert J . Tensile bond strength of different adhesive systems between bone and composite compared: an in vitro study. J Craniomaxillofac Surg. 2004;32(2):85–89. 10.1016/j.jcms.2003.11.001
    Google ScholarOpenURLCrossRefPubMed
  16. 16.
    ↵
    Katonis P , Papadakis SA , Galanakos S , et al . Lateral mass screw complications: analysis of 1662 screws. J Spinal Disord Tech. 2011;24(7):415–420. 10.1097/BSD.0b013e3182024c06
    Google ScholarOpenURLCrossRefPubMed
  17. 17.
    ↵
    Soliman MAR , Aguirre AO , Khan S , et al . Complications associated with subaxial placement of pedicle screws versus lateral mass screws in the cervical spine (C2-T1): systematic review and meta-analysis comprising 4,165 patients and 16,669 screws. Neurosurg Rev. 2023;46(1):61. 10.1007/s10143-023-01968-8
    Google ScholarOpenURLCrossRef
  18. 18.
    ↵
    Tschoeke SK , Gahr P , Krug L , Kasper AS , Heyde CE , Ertel W . Late diagnosis of pedicle screw malplacement with perforation of the thoracic aorta after posterior stabilization in a patient with multiple myeloma. Spine (Phila Pa 1986). 2011;36(13):E886–E890. 10.1097/BRS.0b013e318202e4d1
    Google ScholarOpenURLCrossRef
  19. 19.
    ↵
    Odate S , Fujibayashi S , Otsuki B , et al . Reoperation for misplaced pedicle screws: a multicenter retrospective study. Spine (Phila Pa 1986). 2022;47(21):1525–1531. 10.1097/BRS.0000000000004398
    Google ScholarOpenURLCrossRef
  20. 20.
    ↵
    Dimar J , Bisson EF , Dhall S , et al . Congress of neurological surgeons systematic review and evidence-based guidelines for perioperative spine: preoperative osteoporosis assessment. Neurosurgery. 2021;89(Suppl 1):S19–S25. 10.1093/neuros/nyab317
    Google ScholarOpenURLCrossRef
  21. 21.
    ↵
    Narayanan R , Tarawneh OH , Trenchfield D , et al . Preoperative hounsfield units predict pedicle screw loosening in osteoporotic patients following short-segment lumbar fusion. Spine (Phila Pa 1986). 2024;49(24):1722–1728. 10.1097/BRS.0000000000004995
    Google ScholarOpenURLCrossRef
  22. 22.
    ↵
    Kuklo TR , Potter BK , Lenke LG , Polly DW , Sides B , Bridwell KH . Surgical revision rates of hooks versus hybrid versus screws versus combined anteroposterior spinal fusion for adolescent idiopathic scoliosis. Spine (Phila Pa 1986). 2007;32(20):2258–2264. 10.1097/BRS.0b013e31814b1ba6
    Google ScholarOpenURLCrossRef
  23. 23.
    ↵
    Songer MN , Spencer DL , Meyer PR , Jayaraman G . The use of sublaminar cables to replace Luque wires. Spine (Phila Pa 1986). 1991;16(suppl):S422. 10.1097/00007632-199108001-00022
    Google ScholarOpenURLCrossRef
  24. 24.
    ↵
    van Laar W , Meester RJ , Smit TH , van Royen BJ . A biomechanical analysis of the self-retaining pedicle hook device in posterior spinal fixation. Eur Spine J. 2007;16(8):1209–1214. 10.1007/s00586-006-0288-4
    Google ScholarOpenURLCrossRefPubMed
  25. 25.
    ↵
    Yoshii T , Yuasa M , Sotome S , et al . Porous/dense composite hydroxyapatite for anterior cervical discectomy and fusion. Spine (Phila Pa 1986). 2013;38(10):833–840. 10.1097/BRS.0b013e3182801390
    Google ScholarOpenURLCrossRef
  26. 26.
    ↵
    Pang H , Tian H , Qiu S , Wang N , Wang YQ . Progress of titanium strut for cervical reconstruction with nano-graphene oxide loaded hydroxyapatite/polyamide composite and interbody fusion after corpectomy with anterior plate fixation. Artif Cells Nanomed Biotechnol. 2019;47(1):3094–3100. 10.1080/21691401.2019.1637883
    Google ScholarOpenURLCrossRef
  27. 27.
    ↵
    Yoshii T , Hashimoto M , Egawa S , Hirai T , Inose H , Okawa A . Hydroxyapatite/collagen composite graft for posterior lumbar interbody fusion: a comparison with local bone graft. J Orthop Surg Res. 2021;16(1):639. 10.1186/s13018-021-02798-4
    Google ScholarOpenURLCrossRef
  28. 28.
    ↵
    Mobbs RJ , Maharaj M , Rao PJ . Clinical outcomes and fusion rates following anterior lumbar interbody fusion with bone graft substitute i-FACTOR, an anorganic bone matrix/P-15 composite. J Neurosurg Spine. 2014;21(6):867–876. 10.3171/2014.9.SPINE131151
    Google ScholarOpenURLCrossRef
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International Journal of Spine Surgery

Vol. 20, Issue 4

1 Aug 2026

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Keywords

dental composite, pullout, lateral mass screws, loosening, fixation failure, revision, posterior cervical fusion