Fixation of Mandibular Angle Fractures: in Vitro Biomechanical Assessments and Computer-Based Studies

See discussions, stats, and author profiles for this publication at: https://www.researchgate.
net/publication/232249720
Fixation of mandibular angle fractures: In vitro biomechanical assessments

and computer-based studies
Article in Oral and Maxillofacial Surgery · December 2013

DOI: 10.1007/s10006-012-0367-0 · Source: PubMed
CITATIONS READS
19 469
1 author:
Bruno Chrcanovic
Malmö University
169 PUBLICATIONS 2,950 CITATIONS
SEE PROFILE
Some of the authors of this publication are also working on these related projects:
On clinical and mechanical aspects in implant supported screw retained multi-unit CAD-CAM metal framework View project
Nanostructured materials for biomedical applications View project
All content following this page was uploaded by Bruno Chrcanovic on 22 January 2015.
The user has requested enhancement of the downloaded file.

Oral Maxillofac Surg (2013) 17:251–268
DOI 10.1007/s10006-012-0367-0
REVIEW ARTICLE
Fixation of mandibular angle fractures: in vitro

biomechanical assessments and computer-based studies
Bruno Ramos Chrcanovic
Received: 3 September 2012 / Accepted: 5 October 2012 / Published online: 14 October 2012
# Springer-Verlag Berlin Heidelberg 2012
Abstract However, despite its greater biomechanical stability, the

Purpose The purpose of this study was to review the literature two-miniplate technique has some disadvantages that should
regarding the evolution of current thoughts on fixation of also be taken into account. Studies with biodegradable
mandibular angle fractures (MAFs), based on in vitro biome- plates suggest the use of at least two plates for each MAF.
chanical assessments and computer-based studies. There are few studies with compression plates, and they
Methods An electronic search in PubMed was undertaken in have not yet reached a consensus. The solitary lag screw
August 2012. The titles and abstracts from these results proved to withstand the functional loading of the mandible;
were read to identify studies within the selection criteria. however, only few biomechanical assessments were per-
Eligibility criteria included studies from the last 30 years formed. In vitro studies have shown good biomechanical
(from 1983 onwards). stability with the use of 3-D grid plates. The use of mallea-
Results The search strategy initially identified 767 studies. ble miniplates alone is not sufficient to withstand the early
Thirty-one studies were identified without repetition within postoperative bite force. Some studies suggest that the seg-
the selection criteria. Two articles showing significance in ment of the tension band miniplate located at the distal
the development of treatment techniques was included. Ad- fragment of the MAF should be fixed with three screws.
ditional hand searching yielded five additional papers. Thus, The studies also showed some limitations. None considered
a total of 38 studies were included. the stabilization of the fracture site afforded by the masse-
Conclusions The osteosynthesis positions as well as the ter–pterygoid muscle pouch. Most of the studies did not
plating technique play important roles in the stability of evaluate plating system strength in the long term and there-
MAF repair. The only in vitro study evaluating the use of fore did not observe the effect of resorption on the strength
wire osteosynthesis concluded that wires placed through the of the different biodegradable plating systems. Another lim-
lower border approach would provide greater stability than itation of many studies is the absence of a control group. A
those at the upper border. Many studies indicate that the use confounding factor that could not be tested in in vitro
of two miniplates avoids (or decreases) lateral displacement investigations is the additional resistance to displacement
of the lower mandibular border and opening of the inferior of jagged fracture margins present in the human fracture.
fracture gap. Some studies even suggest that the use of two
miniplates may be considered a more “rigid” fixation tech- Keywords Mandibular angle fracture . Fixation .
nique for MAFs than the use of a reconstruction plate. When Osteosynthesis . In vitro . Biomechanical assessments .
using two miniplates, the biplanar plate orientation provides Computer-based studies
greater biomechanical stability than the monoplanar one.
Introduction
B. R. Chrcanovic (*)
Department of Prosthodontics, Faculty of Odontology,
About 19–40 % of all facial fractures are fractures of the
Malmö University,
205 06 Malmö, Sweden mandible, and 12–30 % of all mandibular fractures are
e-mail: [email protected] fractures of the mandibular angle [1–6]. Among mandibular
252 Oral Maxillofac Surg (2013) 17:251–268
fractures, the angle is the first most frequent region for controlled and repeatable conditions is an important tool to
fractures caused by sportive activities, the second most investigate a variety of fixation devices and techniques and
frequent region for fractures caused by violence, and the to optimize device design on a rational basis [14]. That is
third most fractured region in cases of traffic accidents why in vitro biomechanical studies are so important for the
involving automobiles [6]. The frequent involvement of development of the clinical management of fractures.
the mandibular angle in facial fractures can be attributed to Finite element analysis (FEA) is a numerical analysis
its thin cross-sectional bone area and the common presence technique that can determine the displacements, stresses,
of a third molar [7]. Before the advent of antibiotics, open and strains over an irregular solid body given the complex
reduction of mandibular fractures was associated with a high material behavior and the loading conditions imposed upon
frequency of infection. Techniques to repair jaw fractures that body [15]. The stress analysis obtained from FEA
were further influenced by the limits of the technology of modeling can provide information regarding interactions
the day [8]. Traditional methods of mandible fracture fixa- between hardware and bone during normal patient function-
tion included wire osteosynthesis and maxillomandibular ing and perhaps suggest means of lowering the rate of
fixation (MMF). These injuries are currently treated by postoperative complications after open reduction and inter-
plate/screw osteosynthesis and, depending on the case, the nal fixation (ORIF) of this trauma [16]. Some computer-
bone segments are secured by one-miniplate fixation, two- based studies have specifically analyzed these interactions
miniplate fixation, a lag screw, or by a single rigid plate at in cases of MAFs [16–20].
the inferior border of the mandible. The purpose of this study was to review the literature
Although there is a widely accepted consensus about the regarding the evolution of current thoughts on fixation of
need for surgical reduction and fixation of a mandibular MAFs, based on in vitro biomechanical assessments and
angle fracture (MAF), a variety of different treatment mo- computer-based studies.
dalities have been described. In the literature, discussion is
still ongoing about the preferred type of fixation. Fixation of
MAFs is possibly more critical than fixation of fractures Materials and methods
located in other regions of the mandible [9]. MAFs are
biomechanically complex because the major stress-bearing Objective
trajectories of the mandible are disrupted in this area [10].
The classical method of fixation proposed by Champy et al. This study aims to review the literature regarding the
[11] in the case of MAFs is designed to apply a miniplate at evolution of current thoughts on fixation of MAFs, based
the superior border of the mandible in the area of the on in vitro biomechanical assessments and computer-based
external oblique line with monocortical screws. However, studies.
questions concerning the stability provided by miniplate
fixation of MAFs have become a point of contention among Data source and search strategies
surgeons [12], based on recent clinical and experimental
studies. And this is an important subject because fracture An electronic search without language restrictions was un-
line stability is perceived to be a major determinant of the dertaken in July 2012 in PubMed website (U.S. National
clinical outcome, since the level of interfragmentary motion Library of Medicine, National Institutes of Health). The
strongly influences the morphological patterns of osseous following terms were used in the search strategy:
repair [13]. As the philosophies of treatment of maxillofacial
trauma alter over time, a periodic review of the different {Subject AND Adjective}
concepts is necessary to refine techniques and eliminate {Subject: (mandibular angle fracture [text words])
unnecessary procedures. This would form a basis for optimum AND
treatment. Adjective: (fixation OR wire osteosynthesis OR plate
Surgical intervention with stable internal fixation is war- OR miniplate OR lag screw [text words])}
ranted only if it results in good anatomic reduction and
provides the appropriate milieu for undisturbed healing. If Only references from the last 30 years (from 1983 on-
the fracture site is vulnerable to displacing forces, then the wards) were considered. All reference lists of the selected
advantages of early function are lost. Consequently, knowl- and review studies were hand-searched for additional papers
edge about the biomechanical competence, or lack thereof, that might meet the eligibility criteria for inclusion in this
of the individual fixation systems has important therapeutic study. The titles and abstracts (when available) from these
ramifications. It is essential that the treatment strategy have results were read for identifying studies meeting the eligi-
a sound biomechanical basis [14]. Determine the biome- bility criteria. For studies appearing to meet the inclusion
chanical competence of individual fixation systems under criteria, or for which there were insufficient data in the title
Oral Maxillofac Surg (2013) 17:251–268 253
and abstract to make a clear decision, the full report was

obtained and assessed.
Inclusion criteria
Eligibility criteria included in vitro biomechanical assess-

ments and computer-based studies related to fixation of
MAFs. The studies could have been conducted using cadav-
eric hemimandibles or mandibles from humans or any other
species, or synthetic hemimandibles or mandibles of any
kind of material. The studies could have used biodegradable
(resorbable, bioabsorbable) or titanium plates.
Exclusion criteria
Review articles without original data were excluded, al-

though references to potentially pertinent articles were noted
for further follow-up.
Results
The study selection process is summarized in Fig. 1. The

search strategy initially identified 767 studies. The initial
screening of titles and abstracts resulted in 71 full-text
papers; 40 were cited in more than one research of terms.
Thus, 31 studies were identified without repetition. Despite
not being published within the restriction of time proposed Fig. 1 Study screening process
here, one article was included due to its importance [11].
Another study [21] was not even an in vitro study or a
computer-based study, but it was very important in the the mandible. A plate was then secured to the lateral surface
development of new hardware for fixation of mandibular of the blocks along the superior border, and the complex
fractures. Additional hand-searching of the reference lists of was subjected to simple cantilever loading. The test showed
selected studies yielded five additional papers. The main that the pattern of stress distribution created in the plated
points of these 38 studies are presented below. blocks was similar to the uncut blocks. This study was
Michelet et al. [21] were the first to present “miniaturized instrumental in establishing the concept of tension band
screwed plates,” which can be considered the first “proto- plating for the treatment of mandibular fractures. Taking
type” of the modern miniplates. The miniplates, with 4 mm into account torsional tensile and compressive forces at all
of width and 12, 18, and 25 mm of length, were fixed with points of the mandible, the ideal lines of osteosynthesis were
two to four screws 5–7 mm long, each with a diameter of described. Moreover, the authors also reviewed 183 cases of
1.5 mm. The miniplates were not made of titanium but of mandibular fractures using a modification of Michelet’s
Vitallium, an alloy containing 60 % of cobalt, 20 % of osteosynthesis method [21]. They used what they called
chromium, 5 % of molybdenum, and other elements. The “monocortical juxta-alveolar and subapical osteosynthesis
authors were probably the first ones to suggest that the plate without compression”. In the paper, the authors stressed that
must be slightly curved to fit the sulcus of the external all 183 patients were able to eat soft food on the first
oblique line for the fixation of MAFs. The authors suggested postoperative day, and that they could eat normal food from
that the MMF could be either shortened or suppressed. The the tenth postoperative day. Moreover, infection was found
authors did not consider MAFs in separate, but stated that in only 3.8 % of the cases, malunion occurred in 0.5 %,
“the analysis of 300 cases (500 plates) shows the excellent delayed union in 0.5 %, and grinding was needed to adjust
results and the major advantage of this method.” the occlusion in 4.8 %. The patients were followed up for
Biomechanical studies of Champy et al. [11] resulted in periods up to 5 years. Although not considering the compli-
the concept of an ideal line of osteosynthesis. They used cations of MAFs in separate, the study is important because
blocks made of a photoelastic resin (araldite) to represent Champy et al. [11] were the first to report low rates of
complications when effectively using mandibular fixation use of two plates in the angle is suggested: one in the tension
without the use of postoperative MMF. The concept of an zone and another one in the compression zone.
ideal line of osteosynthesis was also a cornerstone of the Shetty and Caputo [24] tried to determine whether the
internal fixation of mandibular fractures with miniplates. In solitary lag screw fixation of MAFs is biomechanically
the case of MAFs, their biomechanical results demonstrated valid. The test combined two approaches. First, they inves-
that the best site for the plating is the vestibular osseous flat tigated the interfragmentary displacement measured on ca-
part located in the third molar region. Stabilization of the daver mandibles and then performed a photoelastic analysis
fracture with a miniplate positioned along this tension band conjoined with interfragmentary displacement measured on
will negate the muscular forces that naturally act to distract a composite photoelastic mandible analog. Cortical lag
the fragments. They also stated that an osteosynthesis locat- screws of 2.7 mm were used to reconstruct MAFs in cadaver
ed lower, on the outer surface of the mandible, is solid mandibles. Incremental loads up to 35 daN were applied to
enough to support the strain developed by the masticatory the first premolar adjacent to the fracture. The upper limit of
forces in this region. incremental loading of the mandibles was consistent with
In an in vitro study using 24 fresh baboon hemimandi- the values of masticatory forces reported in this region.
bles, Fisher et al. [22] evaluated four different intraosseous Mean maximal displacements at the superior border, mea-
wiring techniques to reduce and fixate unfavorable MAFs: sured at 35 daN, ranged from 0.05 to 0.375 mm, whereas the
(1) upper border figure-of-eight wire, (2) upper border range of mean maximum displacement registered at the
straight wire, (3) modification of the lower border combina- inferior border was 0.05–0.12 mm. The load–displacement
tion of straight and figure-of-eight wire, and (4) lower curves obtained for the photoelastic analog were similar to
border figure-of-eight wire. The holes for wiring were those in the cadaveric mandibles. In the photoelastic evalu-
drilled at a standard distance from the cut line. After wiring, ation, the isochromatic fringe patterns emanated from
the hemimandibles were placed in a tensile testing machine around the head of the screw in the distal fragment as well
and subjected to a constant force that simulated the action of as from the threads engaged in the proximal fragment.
the major elevator muscles. Graphic recordings of force Correlation of the force–displacement measurements to pho-
versus displacement were made. The mean forces required toelastic observation substantiated that the solitary lag screw
to displace each test mandible 1–5 mm for each wire con- functions as a tension band to provide a sufficient degree of
figuration demonstrated that wire efficacy is best provided, interfragmentary compression and stability to withstand
in descending order, by groups 4, 3, 1, and 2. There were functional loading of the mandible.
significant differences at all levels of displacement, indicat- Dichard and Klotch [25] evaluated the biomechanical
ing complete superiority of the lower border wires over strength of repairs of MAFs. Polyurethane mandibles were
those placed in the upper border. At the lower border, a used in a cantilever beam design. The model standardized
figure-of-eight wire is more effective than a combination the fracture location, load site, plate location, and site of
figure-of-eight and straight wire, and at the upper border, the deformation measurement. They evaluated nine types of
figure-of-eight wire is more effective than the straight wire. compression plate, reconstruction plate, and tension band/
Fisher et al. [22] probably developed the first laboratory stabilization plate systems. They concluded that the two-
system for testing the mechanical efficiencies of methods plate systems afforded a distinctly more rigid reconstruction
of direct intraosseous fixation of MAFs. than single plate systems, using either noncompression or
Kroon et al. [23] demonstrated that in the case of a MAF, eccentric DCPs.
treated with a single plate in the tension zone applied ven- Choi et al. [26] tested the stability of the two-miniplate
trally to the oblique line, a loading force close to the fracture fixation technique for biomechanical strength in vitro. Mus-
line causes distraction (i.e., tension) at the lower border. cle forces acting on the mandible were simulated through a
Thus, this approach apparently does not suffice to provide system of wires. Fixation with a four-hole miniplate with the
enough resistance to bending or torsional forces during use of monocortical 2.0-mm screws 5 mm in length was
function. The buccally positioned plate is more resistant to carried out in the area of the external oblique line in five
vertical loading forces but still allows a certain amount of mandibular models. In another five models, fixation was
lateral movement. In cases in which the fracture line is carried out with a two-miniplate fixation technique (the
completely ventral to the masseter–pterygoid muscle sling, second miniplate was applied at the inferior border of the
it has to be expected that the distraction effects during buccal cortex of the mandible). After loading of the man-
chewing and loading in the fracture region will result in dibles, measurements of the fracture gap in the in vitro
even more displacement at the lower border (reversing the model demonstrated that the two-miniplate fixation tech-
tension–compression zones) which apparently cannot be nique provided a significantly higher resistance to loading
resisted by a single plate on the tension side. Thus, it can force close to the fracture line compared with that provided
be implied by the observations of Kroon et al. [23] that the by the fixation method as described by Champy et al. [11],
showing a significant difference between the two fixation superior two-hole and a six-hole at the inferior margin,
methods (P<0.05). They also evaluated a sample of 40 and (4) two four-hole plates at the same positions. Appli-
patients who had MAFs treated with the two-miniplate cation of a functional load between 30 and 90 N was
fixation technique. In the same year, Choi et al. published performed at five different points on the mandible. The
another article in a different journal, which seems to be the stability of the fixation was measured according to
same research [27]. Kroon's method [23]. The results showed that significant
Shetty et al. [14] compared the initial mechanical stability findings consisting of lingual compression and inferior
of 18 mandible analogs with MAFs fixed with six different distraction could only be observed under functional load-
systems: (1) one 2.7-mm four-hole eccentric dynamic com- ing of the molar area of the fracture side. In the single-
pression plate applied at the lower border of the mandible, plated category, significant inferior splaying and lingual
(2) one Würzburg 2.7-mm plate applied at the lower border, compression of the fracture gap, compared with all two-
(3) one Luhr curved mandibular compression 2.7-mm plate plate categories, was detected with a more posterior axial
applied at the lower border, (4) a solitary lag screw, (5) one loading of the fractured side. In all two-plate categories,
2.0-mm Champy miniplate applied at the external oblique no significant dislocation during functional loading was
ridge, and (6) a Mennen clamp applied at the lower border. detected. Of all fractures, those treated with two four-hole
The compressive fixation systems were represented by miniplates showed the best results.
groups 1–4, and the adaptive fixation systems by groups 5 Nissenbaum et al. [30] compared the resistance to dis-
and 6. The reduced analogs were placed in a straining frame, placement of four-hole low-profile (0.8 mm thick) and stan-
and simulated masticatory loads were applied to three pre- dard (1.1 mm thick) titanium bone plates with an
determined occlusal sites. The results showed that the adap- experimental MAF model using 24 baboon hemimandibles.
tive fixation systems permit significantly higher motion at The plates were placed on the external oblique ridge. The
the fracture site, even at the attenuated masticatory forces resistance to displacement was then measured in a tensile
encountered in the early postoperative period. MAFs fixed testing machine. The mean displacement force in the stan-
by compressive systems provided significantly greater stabil- dard group was 68.7 kg, whereas in the low-profile group, it
ity. No significant differences were found in the instability was 46.5 kg. All standard plates bent, but none broke. In
profiles of the individual compressive systems, irrespective of contrast, all low-profile plates bent, but 75 % also fractured
their disparate features. through the edge of a screw hole. No screws bent or were
In an in vitro study using synthetic (polyurethane) hemi- displaced in bone.
mandibles in a cantilever beam design, Haug et al. [28] In an in vitro study, Rudman et al. [31] evaluated the
compared MAFs treated with various combinations of plate theory of tension band plating for MAFs by using a man-
thickness at the superior and inferior borders. There were dibular model under simulated physiologic conditions. The
three study groups, all using four-hole plates and always authors stated that the anatomy of the human mandible is
applying monocortical screws at the superior border and complex, and thus the rectangular block tested by Champy
bicortical screws at the inferior border: superior thinner et al. [11] may be an oversimplified model. Thus, ten ana-
miniplate and inferior thicker compression miniplate (con- tomically correct mandibles were fabricated with a photoe-
ventional group), superior thicker compression miniplate lastic resin. In five mandibles, unfavorable angle fractures
and inferior thinner miniplate (nontraditional group), and were created and fixed with a superior border four-hole 2.0-
superior and inferior thinner miniplates (two-miniplate mm miniplate, and five uncut mandibles served as controls.
group). The forces resisted by the conventional group The results showed that the fractured mandibles demonstrat-
(167.6±18.2 N), nontraditional group (156.3±33.9 N), and ed fringe patterns that were virtually identical to the control
two-miniplate group (154.0±18.4 N) were found to have no mandibles. The authors concluded that a single miniplate
statistical differences. One hundred percent of the failures positioned along the superior border of the external oblique
occurred with monocortical screws at the tension band/syn- ridge to fixate a MAF adequately recreated the natural
thetic bone interface of the superior border. Eighty percent distribution of stress within the mandible. However, the
of the failures occurred at the two most anteriorly positioned study also demonstrated that there is a disparate distribution
screws. of force through the outer screws (that are subjected to
Schierle et al. [29] conducted an in vitro study using 16 higher stress than the inner screws), which may contribute
polyurethane and 16 human mandibles. MAFs were simu- to failure by pullout of the outer screws. The one-miniplate
lated, and these two groups were divided in four subgroups fixation also showed the tension–compression reversal and
of four mandibles each, and plate fixation (all 2.0 mm) of poor resistance to torsional forces. Analyzing these three
the subgroups was performed according to the following negative aspects together, it can be suggested that there are
methods: (1) a superior six-hole plate, (2) a superior six- potential deficiencies with the technique of tension band
hole plate and an additional inferior two-hole plate, (3) a plating for MAFs.
In 1997, Schierle et al. [12] published another article. It is interfragmentary bone contact. In the case of fractures with
the same in vitro study published in 1996 in German [29], bone contact, the loads were transmitted through the fracture
but now published in English. Moreover, the author includ- surfaces and the plate; when there was no contact, the loads
ed a clinical study. were transmitted only through the plate. Maximum fracture
In an in vitro biomechanical study, Wittenberg et al. [10] mobility was set at 150 μm. And maximum plate strain was
investigated the effectiveness of fixation devices of simulat- set at the yield strain of PLA and titanium. For fractures
ed MAFs in 21 sheep mandibles. The following plating without interfragmentary bone contact, all plate fixations
methods were used for the experiment: (1) an eight-hole resulted in a fracture mobility and plate strain higher than
three-dimensional (3-D) plate, (2) an eight-hole mesh plate, the limits set, except for the symphysis fracture fixed with
and (3) a six-hole reconstruction plate with 2.0- and 2.4-mm two PLA midiplates. Interfragmentary bone contact signifi-
mono- and bicortical screws. Bending test was performed on cantly reduced fracture mobility and plate strain. For the
each mandible. Load displacements and gap were simulta- MAF with bone contact, all PLA plate fixations resulted in
neously recorded for incremental loads of 0, 50, 150, 250, fracture mobility above the limit, whereas the titanium mini-
and 350 N. Failure at the bone–screw interface was not seen plate fixation had fracture mobility below the limit. For the
in any of these groups, and no statistically significant differ- body and symphysis fracture with bone contact, only double
ences in inferior gaps were seen between the plates, indicat- PLA midiplate fixation resulted in fracture mobility below
ing that a 3-D or mesh plate can be used for fixation of the limit. The authors concluded that fixation with two PLA
MAFs, as stated by the authors. plates is always necessary to provide sufficient reduction of
In an in vitro study, Fedok et al. [32] evaluated the fixation fracture mobility and plate strain.
efficacy of various plating techniques for repair of MAFs Haug et al. [34] did a biomechanical evaluation of several
through a biomechanical model utilizing polystyrene mandi- plating techniques (lag screw technique, monocortical supe-
bles. A simple MAF was created in the models at a standard- rior border methods, the monocortical two-plate systems,
ized location and was repaired using five different plating monocortical tension bands systems, and reconstruction
techniques. Each experimental group consisted of 15 mandi- plates) for MAFs in 150 synthetic polyurethane mandibles.
bles. Measurement of fracture distraction under load applica- The parameters evaluated were yield load, yield displace-
tion generated a load deformation curve and corresponding ment, and stiffness. For incisal edge loading, minor differ-
slope for each technique. Comparison of load deformation ences were found between the groups. For contralateral
slopes allowed assessment of fixation stability. When applied molar loading, statistically significant differences existed
with a subapical, medially placed monocortical tension band, within and among categories. All of the systems failed the
bicortical compression plating demonstrated the most stable functional requirements for loading the contralateral molar
fracture fixation. The results showed that biplanar plate place- region because of torsional forces. The stiffness data
ment in both monocortical noncompression and bicortical revealed a trend that the single screw or monocortical supe-
compression techniques yielded a stronger fixation than rior border plate techniques were collectively the least stiff
monoplanar placement. and that stiffness increased with the two monocortical
Gutwald et al. [33] compared the mechanical behavior of plate techniques, the monocortical/bicortical two-plate
locking (n08) and conventional (n08) plate systems using technique, and reconstruction plate technique. A trend
16 cadaver mandibles with simulated MAFs. Strain gauges was also identified that showed that the reconstruction
were applied to the mandibles and were then subjected to plate systems yielded the least displacement and that, as
cranial, caudal, and torsional forces. The authors concluded the systems used smaller dimension plates, monocortical
that a higher stability was achieved with the locking plates. screws, and less plates and screws, the systems yielded
In a computer-based study, Tams et al. [17] addressed the greater displacements.
suitability of polylactide (PLA) plates for mandibular frac- Tams et al. [18] used a computer model to determine the
ture fixation. A computer 3-D biomechanical model of the suitability of two PLA midiplates and two PLA maxiplates
mandible that includes the masticatory muscles and the (same dimensions as described by Tams et al. [17]) for
temporomandibular joints was used. Fracture mobility and MAFs. A 3-D computer model of the mandible was used,
plate strain were calculated for postoperatively reduced bite and reduced bite forces were applied on 13 bite points. The
forces applied on all 13 bite points. Small plates with simulated angle fracture was located distal to the second
dimensions comparable to miniplates were used: PLA mid- molar. The software calculated the loads across the fracture,
iplates (length, 22.0; width, 5.0; thickness, 2.5 mm) and fracture mobility, and plate strain for each bite point. The
PLA maxiplates (length, 26.0; width, 7.0; thickness, first plate was positioned buccally on the external oblique
2.0 mm). One PLA midiplate, one PLA maxiplate, or two ridge. Two positions of the second plate were studied:
PLA midiplates were used for fixation of simulated solitary halfway up the height of the mandible (mid-PLA plate
angle, body, and symphysis fractures with and without fixation) or on the lower border of the mandible (low-PLA
plate fixation). Maximum fracture mobility necessary to In a computer-based study, Cox et al. [19] used FEA to
favor primary bone healing was set at 150 μm. The mid- assess whether rigid fixation by biodegradable polymer
iplate fixation resulted in a fracture mobility pattern compa- plates and screws can provide the required stiffness and
rable with that of maxiplate fixation but with greater values strength for a typical MAF. Two separate 3-D FEA models
at all bite points. With the mid-PLA plate fixation, the of the mandible were generated, one fixed with titanium
greatest fracture mobility was found for bite points close miniplates and the other with biodegradable plates. A com-
to the fracture, and the lowest mobility was found at the mercial finite element solver was then applied to this mesh
molars on the nonfractured side. With the low-PLA plate to compute stresses and bone interfragmentary displace-
fixation, a bimodal pattern of mobility was found; great ments. The study showed that the titanium fixation fixed
mobility occurred both on the fractured and nonfractured more rigidly the two bone segments in relative position.
side. The mid-PLA maxiplate fixation resulted in the lowest However, the biodegradable polymers were capable of with-
fracture mobility, with mobility below the set limit for all standing the stresses generated by the bite loads of postsur-
bite points. The low-PLA maxiplate fixation resulted in gical patients. The results indicated that mandibles show
fracture mobility of approximately the set limit for all bite nearly identical stress patterns, fixed with either titanium
points. The authors concluded that fixation with two PLA or biodegradable materials.
maxiplates is suitable for MAFs, and one plate should be Feller et al. [20] measured 20 mandibles of human cadav-
positioned buccally on the external oblique ridge and the ers to establish a model of the structure to be examined in a
other plate should be positioned halfway up the height of the FEA in order to compute mechanical stress occurring in
mandible. osteosynthesis plates used for fixation of MAFs. The com-
Haug et al. [35] conducted another in vitro study in 2002 putations were made for both a miniplate (thickness
and compared the mechanical behavior of locking and con- 1.0 mm) and a 2.3-mm module plate (thickness 1.5 mm).
ventional plate systems placed with precise adaptation and In the FEA tests, both the 1.0-mm miniplate and the 2.3-mm
intimate contact and varying the degrees of compromise module plate were sufficiently stable. The authors conclud-
(0.0, 1.0, and 2.0 mm offset) in order to stabilize simulated ed that in comminuted MAFs and in noncompliant patients,
MAFs. According to the authors, the offset was designed to the use of a stronger osteosynthesis material should be
resemble imprecise contouring and less than ideal adapta- considered, while in all other cases, application of a single
tion of the plate to the cortex, or varying degrees of cortical 1.0 mm of thickness (2.0-mm screws) miniplate was
resorption. A total of 130 synthetic polyurethane mandibles regarded as sufficient for fixation using ORIF. The authors
were used. Six-hole reconstruction plates of 2.4 mm at the also conducted a clinical study.
inferior border and six-hole monocortical superior border Feledy et al. [36] performed an in vitro biomechanical
plate of 2.0 mm were evaluated. For each type of plate, study to compare the use of a single curved 3-D grid
locking and nonlocking systems were used. The models eight-hole 2.0-mm miniplate with two 2.0-mm miniplates
were then subjected to loading at the incisal edge and molar to treat MAFs. The 3-D miniplate demonstrated an overall
region with a servohydraulic mechanical testing unit. Load/ better intrinsic stability, more resistance to out-of-plane
displacement data were recorded, and yield load, yield dis- fracture movement, and a higher load tolerance when
placement, and stiffness were determined. The results motion out-of-plane was challenged. Inadequate screw
showed that there were no statistically significant differ- seating resulted in an approximately 50 % reduction in
ences for yield load, yield displacement, and stiffness within fracture stability, suggesting that screw stability is more
the 2.4 and the 2.0 locking categories for both molar and important than plate configuration for minimizing motion
incisal edge loading, i.e., the degree of adaptation (amount across the fracture site. The authors also conducted a
of offset) did not affect the mechanical behavior of the clinical study.
locking systems evaluated. However, it did affect the non- Chacon et al. [37] compared the stability of titanium and
locking systems. For the 2.4 nonlocking category, there absorbable fixation systems for MAFs with a biomechani-
were statistically significant differences for yield load, yield cally experimental study. A bicortical osteotomy was made
displacement, and stiffness between the 0.0-mm offset in a human mandible in order to simulate a MAF and then
group and both the 1.0- and 2.0-mm offset groups for both fixed with a four-hole 2.0-mm miniplate. Two strain gauges
molar and incisal edge loading but not between the 1.0- and were bonded to the mandible on either side of the fracture.
2.0-mm groups. For the 2.0-mm nonlocking category, there The mandible was then placed on a dynamometer, and 30 lb
were statistically significant differences for yield load, yield loads were delivered on the ipsilateral molar. Loading was
displacement, and stiffness between both the 0.0- and 1.0- repeated ten times with a period of 3 min between loads.
mm offset groups and the 2.0-mm offset group for both The same process was repeated using a four-hole 2.1-mm
molar and incisal edge loading but not between the 0.0- resorbable miniplate. A significant difference was found
and 1.0-mm groups. between the two materials.
In an in vitro study, Jain et al. [38] compared the strength Esen et al. [9] compared the stability of titanium and
at a given tension in four biodegradable plating systems absorbable plate-and-screw fixation systems for MAFs.
from four different manufacturers, and a control group using The study used 21 sheep hemimandibles. MAFs were sim-
a 2.0-mm titanium-based system. Twenty-four fresh cadav- ulated using a saw. The hemimandibles were randomly
eric mandibles with simulated MAFs were used (12 dentu- divided into three groups of seven, and fixed with three
lous and 12 edentulous). Each mandible was held rigid as a different plating techniques (a single titanium plate, a single
material test system applied a downward force anteriorly. biodegradable plate, and double biodegradable plates). A
The critical tolerance was measured, and the type of failure cantilever bending biomechanical test model was used for
was noted. The analysis of variance revealed a significant the samples. The displacement values for the three groups
effect of the plating system. Failure was largely of two differed significantly. The variance analyses showed that
types: almost two thirds of the failures were due to actual titanium plate placement had more favorable biomechanical
cracks or breaks in the plate itself; about one third were due behavior than others, and that the group with two biode-
to stretching of the plate. The dentition status did not affect gradable plates had more favorable biomechanical behavior
the results. There was a greater tension across the plate in than the single biodegradable plate group.
female mandibles, owing the smaller size of the mandible Feichtinger et al. [41] demonstrated a technique in which
angle in females. A similar masticatory force will result in a 3-D computer navigation system helped to insert osteosyn-
greater tension across the plate, owing to the smaller mo- thesis screws. The study used ten synthetic (polyurethane)
ment arm. In MAF, the authors do not advocate using a mandibular models. In their experiment, the inferior alveolar
single craniofacial plate alone but may consider additional nerve was spared in all cases. The authors stated that this
plates, with or without MMF, or stronger resorbable plates computer-guided insertion method enables stable fixation of
capable of withstanding greater load-bearing forces. The the fracture via minimally invasive surgery and that is a
authors stated that resorbable plates hold promise in many helpful visualization tool that can prevent damage to the
aspects of craniofacial surgery and that improvement in their inferior alveolar nerve and enable secure anchoring of the
properties may, in the future, make them the gold standard in traction screw centrally in the cortical bone without causing
stable fixation. perforation.
Wang et al. [39] used edentulous dry mandibles to study Turgut et al. [42] performed a biomechanical study in 72
the stress distribution of MAFs fixed with one or two four- sheep hemimandibles. A simple MAF was created in a
hole 2.0-mm miniplates. The biomechanical model was uniform manner. The mandibles were fixed with four differ-
submitted to mechanically simulated loads of the mastica- ent plating techniques: (1) one superior four-hole miniplate;
tory muscles. Strain gauges were placed in 12 different (2) two four-hole miniplates (the proximal three holes of the
points in the mandible. The authors observed that the use superior plate were fixed with bicortical screws, and a
of one superior miniplate was insufficient to provide stabil- monocortical screw was placed into the distal fourth hole
ity of the lower border of the mandibular angle. The results of the superior plate; bicortical screws were placed into the
also showed that the use of two miniplates (one superior and plate at lower border); (3) two four-hole miniplates (mono-
one inferior) provided more stability of the MAF. cortical screws for the superior miniplate and bicortical for
Alkan et al. [40] evaluated the biomechanical behaviors the inferior miniplate), and (4) one 11-hole reconstruction
of four different miniplate fixation techniques for treat- plate using bicortical screws. Each fixation group containing
ment of MAFs in 20 sheep hemimandibles. The techni- 18 hemimandibles was divided into three and tested with
ques were (1) the Champy technique, (2) biplanar plate three-point bending, compression, and side-bending biome-
placement, (3) monoplanar plate placement, and (4) 3-D chanical test. The authors concluded that fixation of the
grid 2.0-mm eight-hole plate. Titanium 2.0-mm four-hole superior plate with bicortical screws resulted in a more
noncompression miniplates were used in groups 1, 2, and stable fixation of the fracture.
3. Standardization of all experimental factors except the In an in vitro biomechanical study, Bayram et al. [43]
fixation techniques was ensured. No miniplate fixation fixed 11 sheep hemimandibles with simulated MAFs with
system or hemimandible failures (breakage or fracture) four-hole 2.0-mm straight titanium plates, and another 11
were observed within the 0–700 N test range. The vari- hemimandibles with four-hole 2.5-mm straight biodegrad-
ance analyses showed that biplanar plate placement had able plates, all placed at the superior border. The authors
more favorable biomechanical behavior than the Champy then compared the fixation reliability and stability of the
technique and monoplanar plate placement. The 3-D grid different plates and screws by simulating the chewing forces
miniplate technique had more favorable biomechanical (20–200 N) occurring during the first 6 weeks after fixation.
behavior than the Champy technique but was not signifi- Significant differences were found between resorbable and
cantly different from biplanar or monoplanar plate place- titanium plates and screws at all forces. The stability of
ment techniques. MAFs with titanium miniplates under simulated chewing
forces was significantly higher than with the resorbable of rigid polyurethane resin. The replicas were divided into
system. No statistically significant differences in the 12 subgroups according to the miniplate material, the type
breaking force and maximum displacement values were of sectioning, and site-of-load application. The plates were
observed between the groups. The authors concluded that adapted and stabilized passively at the same site in both
metallic and resorbable fixation systems may not be used groups (external oblique ridge). Then a resistance-to-load
interchangeably for the treatment of MAFs under similar test was performed, with the force being applied perpendic-
loading conditions. ular to the occlusal plane at three different points (first molar
Kalfarentzos et al. [44] used synthetic mandible replicas at the plated side, first molar at the contralateral side, and
to evaluate the effectiveness of the 3-D square plate along between the central incisors). The results showed that at
with three other mandibular angle plating techniques (all of 1 mm of displacement, no statistically significant difference
2.0 mm). Twenty mandibles were divided into four groups. was found. At 2 mm of displacement, a statistically signif-
The following plating methods were used for the experi- icant difference between the subgroups was observed in two
ment: (1) 3-D square miniplates, 2×2 holes (placed in the circumstances: when a load was applied to the contralateral
upper border of the external oblique ridge and the upper first molar in a fracture unfavorable to treatment and when a
buccal side of the mandible); (2) 3-D miniplates, 6×2 holes load was applied between the central incisors in a fracture
(placed in the middle of the buccal surface of the mandible); favorable to treatment. In both these instances, the titanium-
(3) two four-hole miniplates (external oblique ridge and based group showed better results. Moreover, at the failure
inferior border of the mandible); and (4) one four-hole displacement, a statistically significant difference was observed
miniplate (external oblique ridge). Each group was sub- only when the favorable fracture was simulated and the load
jected to incisal and ipsilateral molar region loading ranging was applied on the first molar at the plated side. The authors
from 0 to 200 N. For ipsilateral molar loading, statistically concluded that despite more failure, the poly-L-DL-lactic acid-
significant differences existed within groups. For incisal based systems were still effective.
edge loading, no statistically significant differences were Kimsal et al. [16] employed FEA to investigate multiple
found for stiffness among the fixation methods tested. Three titanium fixation plate combinations used to secure a MAF.
of the tested plating techniques (groups 1, 3, and 4) demon- The study analyzed three fixation schemes: (1) a six-hole
strated limited gap change during bending loading, because bicortical angle compression plate at the inferior border of
the techniques comprised a plate bridging the fracture gap at the fracture, (2) a tension band alone at the superior border
the superior border. The authors concluded that it is reason- of the fracture, and (3) the combination of plates used in the
able to use 3-D plates for fixation of MAFs, since this first two schemes. A fracture was simulated and a 1-mm
fixation method can reproduce similar biomechanical scores callus section was placed between the two fractured mandi-
to the traditional plating techniques. ble sections. The bite force used for the model was a
Ribeiro-Junior et al. [45] evaluated in vitro the influence unilateral molar clench. The results showed that the dual-
of the type of miniplate (conventional or locking) and the plate system observed the lowest strain in the callus for both
number of screws installed in the proximal and distal seg- maximum and average values as well as the lowest stress in
ments on the stability and resistance of Champy’s osteosyn- the plates and experienced the highest stress in the bone.
thesis (only one miniplate at the external oblique line) in The tension band system observed the highest stress in the
MAFs. Sixty polyurethane hemimandibles sectioned in the plate but incurred callus strain just slightly higher than the
mandibular angle region were randomly assigned to four dual-plate system. The bicortical angle compression plate
groups. The models were then submitted to a compression system resulted in callus strains significantly higher than
test, simulating the forces applied by the masticatory both of the other models. It also had higher stress in the
muscles. The groups in which locking miniplates were used bone compared with the tension band configuration. The
for osteosynthesis differed significantly from the groups location of the maximum bone stress was found at screw
with conventional miniplate osteosynthesis, with the greatest holes posterior to the fracture line for all cases. The authors
biomechanical stability with the use of the locking miniplates. stated that combining the results of their study with previous
The long locking miniplates showed better performance in works suggests that the benefit of added stability of the
resisting mandible opening compared with the short mini- inferior plate is outweighed by the increased invasiveness
plates, though with no statistical significance (no statistically necessary to implant the second plate. The results of the
significant difference was found between the seven-hole and study support that the fixation provided by a single ten-
four-hole miniplates). sion band provides stability near that of the two-plate
Bregagnolo et al. [46] compared the four-hole 2.0-mm technique, while minimizing the amount of implanted
system made with poly-L-DL-lactic acid (70:30) to the anal- hardware and intrusion on the patient. Incidences of plate
ogous metallic titanium-based system using mechanical in fracture may eventually be mitigated with improved plate
vitro testing in 84 human dentate mandibular replicas made design techniques.
Esen et al. [47] used 18 sheep hemimandibles to evaluate analog [14, 24], epoxy resin [31], polystyrene [32], Syn-
two plating techniques using Champy’s method of fixing bone® [44], and sawbone blocks [36]. The cadaveric models
MAFs (either a single noncompression 2.0-mm titanium used in the literature are from humans [12, 24, 26, 27, 29,
miniplate or a single malleable 1.6-mm titanium miniplate). 33, 37–39], sheeps [9, 10, 40, 42, 43, 47, 48], and baboons
A cantilever bending biomechanical test model was used for [22, 30].
the samples. The displacement values in each group at each Champy et al. [11] used blocks made of araldite to
10 N stage up to 90 N were compared. Their results showed represent the mandible. However, there is a problem. The
that the noncompression miniplate had greater resistance to anatomy of the human mandible is complex, and a rectan-
occlusal loads than the malleable plate and that the mallea- gular block may be an oversimplified model. The stresses
ble plate alone was not sufficient to withstand the early that exist in the mandible result from the forces and direc-
postoperative bite force. tions of pull from several muscles and from occlusal forces.
In an in vitro biomechanical study, Pektas et al. [48] Thus, the application of a randomly directed force on plated
analyzed the effects of horizontally favorable and unfavor- rectangular blocks may not adequately represent the physi-
able MAF patterns on the fixation stability of titanium plates ologic loading of a mandible [31]. One study [31] used
and screws in 22 hemimandibles of sheep. Favorable frac- synthetic resin mandible models to perform the study. The
ture lines were created by forming a +15° angle with an problem is that the composition of the mandibles is homo-
established pilot line whilst unfavorable fracture lines geneous and lacks the trabecular and cortical components
formed a −15° angle with the same pilot line. The hemi- present in a human mandible. This may raise suspicion as to
mandibles were then fixed with four-hole 2.0-mm straight the validity of the homogeneous model.
titanium miniplates inserted into the superior border. Occlu- Fresh sheep mandibles are widely used in biomechanical
sal bite force was applied to the posterior mandible, and studies because of their similarities in size and thickness to
each hemimandible was subjected to a continuous linear human mandible [40, 43]. They are easy to obtain and
compression until plastic deformation was seen. The results enable reproducible measurements with biomechanical test-
showed that none of the models failed during testing, and ing units. The use of human mandibles is even better.
they met the criteria for this biomechanical study. No statis- However, the use of cadaveric mandible presents some
tically significant differences were found between the limitations. Conventional models using cadaveric mandibles
groups for the displacement values in the force range 60– for the biomechanical validation of fixation devices are
200 N. The difference for the maximum displacement val- burdened by the large variability in the properties and struc-
ues at breaking forces was statistically significant, whilst it ture of natural bone itself. Hence, it is important for the
was nonsignificant for breaking forces between groups. The development of a normative model that would ensure repli-
authors concluded that there was no evidence for the need to cability of material properties and fracture configuration
apply different treatment modalities to MAFs regardless of across the test constructs [14, 24]. Synthetic polyurethane
whether the factures are favorable or not. mandibles were designed to eliminate the variables associ-
ated with human cadaveric mandibles [34, 35]. Through
model consistency and uniformity of experimental fracture
Discussion location, bone thickness and strength can be removed as
variables, leaving plating technique (plating system design
Each fixation system seeks to restore structural and func- and plate location) as the variables examined in the exper-
tional integrity to the fracture site until the new bone is iment [32]. The advantages of polyurethane mandibles is
capable of withstanding the stresses of masticatory function. that they replicate cancellous bone, have a dense outer core
The magnitude of the resistance to displacing forces derives that replicates cortical bone, and are able to provide more
from the design of the plate used, its material properties, site uniform sampling [35]. Bredbenner and Haug [49] analyzed
of application, and force transfer mechanisms [14]. An the torque required to insert and to remove titanium screws
evaluation of the combination of device (i.e., an individual used in rigid internal fixation in seven different substrates.
plate or screw) and substrate (cadaveric mandibles or ana- Polyurethane mandible showed results similar to cadaveric
tomic replica), especially when replicating clinical condi- bone and was considered by the authors to be the material of
tions within clinical parameters, has a greater potential to choice for in vitro studies.
provide more meaningful information to the clinician [35]. Another point to consider is the use of hemimandibles or
In vitro biomechanical assessments on two kinds of man- complete mandible models. In contrast to the simpler canti-
dibular models are used: the synthetic and the cadaveric. lever beam used customarily to describe the behavior of the
The synthetic models used in the literature are made of mandible in hemimandibles models, the complete mandible
polyurethane [12, 23, 25, 28, 29, 34, 35, 41, 45, 46], model assumes support from the contralateral side. This
composite photoelastic mandible analog/cortical bone arrangement permits a more accurate assessment of the
physical effects of functional forces as they transfer from reconstruction than single plate systems, here including the
the ipsilateral to the contralateral side of the body of the use of one reconstruction plate. Although Haug et al. [34]
mandible [14]. had demonstrated that the reconstruction plate systems
Four types of fixations for the treatment of MAFs have yielded the least displacement of MAFs between several
been tested in in vitro biomechanical assessments and other plating techniques, the studies of Dichard and Klotch
computer-based studies. These include wire osteosynthesis, [25] and Turgut et al. [42] raise the question of what would
rigid fixation (2.4- and 2.7-mm plates), stable or semirigid actually be considered a more “rigid” fixation technique for
fixation (1.3-, 1.6-, and 2.0-mm miniplates), and lag screws. MAFs: a reconstruction plate or two miniplates.
Decision on which wiring technique to use is difficult The second type of plating uses thinner plates (1.3-, 1.6-,
since a great degree of individual variation exists in MAFs and 2.0-mm miniplates) for semirigid fixation. A striking
in the clinical situation, and no two fractures can be consid- difference in the application of semirigid miniplates, when
ered identical [22]. Fisher et al. [22] conducted the only in compared with rigid systems of osteosynthesis, is the use of
vitro study evaluating the use of wire osteosynthesis for monocortical versus bicortical screws. Monocortical screws
MAFs, analyzing four different intraosseous wiring techni- engage only one cortex and, being self-tapping, eliminate
ques (two in the superior border of the mandible, two in the the need for using a screw tap in the drilled hole, but their
inferior). They stated that if the amount of preoperative reduced anchorage also makes fixation less capable than
displacement of a MAF is large, and/or a large postoperative bicortical screws of resisting muscle forces especially if
fragment displacing force is anticipated, then the wires principles of fixation are not respected [52]. In a recent
placed through the lower border approach would provide computer-based study, Kimsal et al. [16] showed that the
greater postoperative stability than those at the upper border. fixation provided by one miniplate at the tension band
The authors hypothesized that this may be explained by the (according to the Champy’s recommendations) provides
fact that both buccal and lingual cortices are engaged by a stability near that of the two-plate technique while minimiz-
lower border wire, whereas the upper border wires used in ing the amount of implanted hardware and intrusion on the
this trial traverse the buccal cortex only. patient. The study also observed that the use of a single
The first type of plating uses large plates (2.4- and 2.7- inferior border compression miniplate is the least preferred
mm plates) for rigid fixation. This kind of plate provides biomechanically option. However, much of the literature on
sufficient rigidity to the fragments to prevent interfragmen- the biomechanics of MAFs fixed with miniplates focuses on
tary mobility during active use of the mandible. The plate is how to neutralize the negative bending moments that result
three-dimensionally bendable, allowing accurate contouring in opening of the fracture in the region of the lower border.
to the surface of the mandible. Each screw hole allows for Kroon et al. [23] showed that in the case of a MAF, treated
placement of compression in either direction or no compres- by a single plate in the tension zone, a loading force close to
sion, depending on where one drills the hole within the the fracture line causes distraction/tension at the lower bor-
confines of the screw hole slot. The use of three screws on der, i.e., the plate does not suffice to provide enough resis-
each side of the fracture with this bone plate is claimed to tance to bending or torsional forces during function. Based
provide adequate neutralization of functional forces in the on the principle that these negative bending moments are
absence of compression [50]. Some authors claim that a best resisted using a plate positioned as for caudal as possi-
reconstructive plate is recommended for use in patients ble, recommendations for fracture fixation have been made.
whom the surgeons anticipate will be noncompliant with For single plate fixation, Kroon et al. [23] recommended a
instructions, oral hygiene, and follow-up, because of the position buccal to the external oblique ridge instead of a
frequent self-removal of MMF [50]. In cases of MAFs with lingual position. Other authors have recommended the use
comminution or with continuity defect, surgeons may con- of a second plate on the lower border [27].
sider reconstruction plates that are thicker and therefore Thus, a MAF can be stabilized with the plate being
provide greater strength that would resist functional load placed superiorly (called tension bone plating) and infe-
better [51]. Comparing four different techniques with mini- riorly (called stabilization bone plating). Superiorly, it can
plates and one reconstruction plate to fixate simulated be placed in two ways: extending from the mandibular
MAFs in sheep hemimandibles, Turgut et al. [42] observed lateral border near the external oblique ridge to a point
that greater biomechanical stability was provided with posterior to the second molar in the area of the retro-
bicortical biplanar dual-plate method in three-point bending molar trigone (external oblique line), or along the supe-
and compression tests. Only in side-bending test that the rior lateral face. These are the two possible regions to
reconstruction plate had greater stability than bicortical fixate a miniplate according to the “ideal line of osteo-
biplanar dual-miniplate synthesis. Dichard and Klotch [25] synthesis” established by Champy et al. [11]. Inferiorly,
evaluated nine types of plate systems and also concluded the second miniplate is fixed in the inferior lateral face
that the two-plate systems afforded a distinctly more rigid of the mandible (Fig. 2).
One study even investigated the influence of the inferior

plate position on the fracture fixation stability. Tams et al.
[18] found that fracture mobility was greater with the low
position of the second plate than with the position halfway
up the height of the mandible.
When placing two miniplates, there are two modes of
fixation concerning the planes of placement of the mini-
plates: the monoplanar (plates positioned in one plane, in the
lateral aspect of the mandible) and the biplanar (plates
positioned in two planes: oblique line and superior or infe-
rior buccal cortex) (Fig. 2). Some studies evaluated the
difference in stability between the two techniques. The
study of Fedok et al. [32] demonstrated that plating tech-
nique (monocortical vs. bicortical) and plate placement
(monoplanar vs. biplanar) are important variables to consid-
er in repair of MAFs. The combination of a bicortical
compression plate technique along with placement of a
tension band subapical and medial to the external oblique
line produced the most stable fracture repair. In comparison,
the monocortical noncompression plating technique was
also found to be sufficiently biomechanically stable when
a similar biplanar placement of the plates was utilized. This
biplanar plate orientation produced a stable framework of
Fig. 2 Possible regions to fixate MAFs with miniplates: (1) external plates that effectively neutralized superior fracture distrac-
oblique line, (2) along the superior lateral face, and (3) inferior lateral tion forces as well as torsional and lateral forces created at
face of the mandible. Positions (1) and (2) are the two possible regions the fracture site. Plate placement in a biplanar orientation is
to fixate a miniplate according to the “ideal line of osteosynthesis”
established by Champy et al. [11]. Miniplates placed at positions (2) superior to monoplanar plate placement when applied to
and (3) constitutes a monoplanar fixation. Miniplates placed at posi- either a monocortical or a bicortical plating technique.
tions (1) and (3) constitutes a biplanar fixation Alkan et al. [40] also showed that the biplanar plate orien-
tation provided greater biomechanical stability than the
The results of several studies [12, 14, 23, 25–28, 31, 39, monoplanar one.
40] indicate that the use of the two-miniplate fixation tech- In the two-plate monocortical biplanar technique, the
nique to treat MAFs provides better stability compared with upper plate approximates an oblique plane, whereas the
Champy's method [11]. During function of the lower jaw, lower plate parallels the sagittal plane of the mandible. This
tension will occur at the level of the dentition whereas an creates a stable 3-D framework of plates, effectively neu-
effect of compression will be observed along the lower tralizing superior distractive forces as well as lateral or
border. In the chin area, torsional forces produce a combi- torsional forces. In the two-plate monocortical technique
nation of tension and compression [23]. The zones of ten- with monoplanar plate placement, the design lacks the sta-
sion and compression may reverse when forces are bility afforded by a plate approximating an oblique plane of
generated along the posterior teeth. The closer the load is the mandible, which reduces its ability to effectively neu-
applied to the fracture at the mandibular angle, the more tralize the torsional and lateral forces created under load at
there is a tendency for separation of the bony cortices at the the fracture site [32].
inferior border. This was clearly observed in two in vitro As observed by some studies, a large amount of lateral
studies [23, 31]. The use of two miniplates avoids lateral movement is observed at the fracture site during load appli-
displacement of the lower mandibular border and opening of cation, owing to poor lateral stabilization of the single plate
the inferior fracture gap, which are suspected to contribute monoplanar system. However, whether this gap in the lower
to the occurrence of complications [26]. Two in vitro studies border of the mandible is important to the clinical outcome
using the same type of synthetic mandibles in a cantilever or not remains to be seen. One important point to consider it
beam design applied one superior miniplate [23] or one is that the one-miniplate fixation technique may prove to be
superior and one inferior miniplate to fixate MAFs [28]. In more stable in a clinical setting, where the added support of
the first study (using one miniplate), failure occurred at 30 N pterygomasseteric musculature and surrounding soft tissue
or less [23], whereas failures in the second investigation may minimize lateral forces and, therefore, minimize lingual
(two miniplates) occurred between 154 and 167 N [28]. fracture distraction [32]. Another important point was made
by Fisher et al. [22]. It is possible that the absolute values for [11]. The study of Ribeiro-Junior et al. [45] showed that the
the forces recorded in in vitro studies are lower than they use of a larger number of screws may increase instability.
would be in the clinical situation in human beings. This is The authors observed that the use of longer miniplates
because fractures in patients usually have jagged ends that inherently leads to a greater difficulty in the passive adap-
would interdigitate when they are reduced, and so would tation of the material to the underlying bone, which is
assist in the prevention of postoperative displacement. In a another disadvantage of Champy’s method. The lack of
fracture, interfragmentary bone contact plays an important passive adaptation of the plate on the mandible may cause
role in transmitting loads across the fracture. In a fracture postoperative occlusal changes, torque of the mandibular
with interfragmentary bone contact after plate fixation, the condyle, and even excessive tension on the osteosynthesis
loads are transmitted partially through the plate and partially monocortical screw. In a study performed in a simple beam
through the fracture surfaces. Bending moments result in model with bovine ribs, Haug [54] evaluated the ability of
tension and compression zones in these surfaces [17]. Torsion various screw lengths and number of screws per fragment to
moments and shear forces are partially neutralized by the resist displacement when used as tensions bands. Screw
roughness or serration of the fracture surfaces [53]. In a length had no effect on the ability of the 2.0-mm adaptation
fracture without interfragmentary contact, loads are transmit- plate (0.85 mm in profile) to resist vertical forces. For the 2-
ted only through the plate [17]. Most (if not all) in vitro studies mm mini-DCP (1.5 mm in profile), increasing screw length
here reviewed performed straight osteotomies in animal or increased the weight resisted up to three screws per seg-
synthetic mandibles to simulate MAFs. ment, after which length had no effect. There was a slight
There is a recent computer-based study not supporting increase in rigidity of the system when three screws were
the use of two miniplates. Kimsal et al. [16] showed that a used on each fragment as opposed to two, but there was no
single tension band on the superior border provided more additional benefit with four screws. However, as this inves-
angle fracture stability than a single bicortical plate placed tigation was performed in a rectilinear model (bovine ribs),
inferiorly and provided comparable stability to a combina- their results do not apply to situations in which osteosyn-
tion plate fixation scheme. High stress in the single tension thesis is used to fixate MAFs. The miniplates in the study of
band configuration may explain clinical observations of Ribeiro-Junior [45] were installed in a region where the type
plate failure. Although the results of the study of Kimsal et of torsion was different from that tested by Haug [54].
al. [16] found that the use of a tension band and an inferior Ribeiro-Junior [45] also observed that, when using locking
bicortical angle plate to provide the most stability of those miniplates instead of normal miniplates in the external
tested, the authors stated that their study was unable to oblique line, long miniplates showed better performance in
determine whether the relatively small increase in stability resisting mandible opening compared with the short ones,
justifies the added intrusion of the extra bicortical plate. though with no statistical significance. Perrott [55] made an
Also, the double plate system stresses the surrounding bone interesting observation concerning this issue and when a
the most, which can contribute to screw loosening and third molar is present. If the third molar is to be extracted,
infection. Moreover, Kimsal et al. [16] support the use of there is often a need for a longer six-hole plate that extends
the single tension band configuration as a less invasive beyond the extraction site to permit placement of screws in
fixation approach to MAFs. solid bone. He also stated that extra holes in a longer plate
The two-miniplate technique has also some disadvan- allow more versatility in plate location and, if desired,
tages. When using an intraoral approach, the two-miniplate provide the opportunity to place additional screws.
fixation technique necessitates reflection of all soft tissues It is also important to consider the number of screws
from the mandible, increasing intraoperative trauma. When fixed on each side of the fracture when using two miniplates
using an extraoral approach to place the second miniplate on to fixate MAFs. In an in vitro study evaluating the two-
the inferior border, it increases the risk of bacterial contam- miniplate fixation, Haug et al. [28] noted that 100 % of all of
ination, scarring, postoperative edema, hematoma, and mar- their failures occurred with monocortical screws in the ten-
ginal mandibular nerve damage. The use of the two- sion band system of the superior border. All plates had four
miniplate fixation also prolongs the operation time. Thus, holes, and the authors fixed two screws on each side on the
despite greater biomechanical stability, the two-miniplate MAFs. The authors suggested that plate size or pattern has
technique has some disadvantages that should also be taken little bearing on clinical fracture fixation but that monocort-
into account before choosing between the fixation of MAFs ical screws appear to be the weak link in the system. As
with one or two miniplates. already mentioned before, the same author [54] investigated
Besides the number of miniplates used, it is also impor- 3 years earlier the effects of screw number and length on
tant to discuss the number of screws used on each plate. two methods of tension band plating. Monocortical, intra-
After miniplates are adapted to bone contours, it is standard cortical, and bicortical screws were investigated. It was
to place at least two screws on either side of the fracture site noted that at three screws per segment, optimal resistance
to vertical deformation was provided. At less than three the mechanical behavior of the locking systems on the fixation
screws per segment, the monocortical and intracortical of simulated MAFs. On the other hand, the same degrees of
screws failed more frequently. Although using the one- adaptation affected the mechanical behavior of the nonlocking
miniplate fixation, these findings support the observations systems evaluated. Gutwald et al. [33] and Ribeiro-Junior et
of the study with the two-miniplate fixation. Since bicortical al. [45] found greater biomechanical stability with the use of
screws should not be used to avoid damage to adjacent the locking miniplates in comparison with the conventional
teeth, the results from these two studies suggest that the miniplates. Result of Ribeiro-Junior et al. [45] also demon-
segment of the superior miniplate located at the distal frag- strated that long locking miniplates provide greater stability
ment of the MAF should be fixed with three screws. However, than short locking miniplates.
it is difficult to extrapolate the results of in vitro investigations There is a growing number of studies evaluating the use of
to actual patient care. 3-D plates for the treatment of MAFs [10, 36, 40, 44], all with
Concerning the use of thinner miniplates (1.3 or 1.6 mm), good results. The 3-D plates can be considered a two-plate
the plate is extremely malleable and does not require adap- system, with two miniplates joined by interconnecting cross-
tation to the underlying bone, and therefore it is very fast to bars [44]. Their shape is based on the principle of the quadri-
insert. However, Esen et al. [47] disapproved the use of lateral as a geometrically stable configuration for support.
malleable titanium miniplates for fixation of MAFs according Because the screws are arranged in the configuration of a
to Champy’s method, stating that the malleable plate box on both sides of the fracture, a broadband platform is
alone was not sufficient to withstand the early postop- created, increasing the resistance to twisting and bending to
erative bite force. Moreover, in a study comparing the the long axis of the plate [10, 44]. This stability represents the
resistance to displacement low-profile (0.8 mm thick) and gain achieved by distributional force sharing by means of the
standard (1.1 mm thick) titanium bone plates, Nissenbaum et adjoining strut bars. One of the advantages of the technique is
al. [30] observed that a standard-profile titanium plate the simultaneous stabilization of the tension and compression
resisted displacement significantly more than a low-profile zones, making the 3-D plates a time-saving alternative to
titanium plate. conventional miniplates. Moreover, this system is simple to
Concerning the use of compression plates, the defense of apply because of its malleability, low profile (reduced palpa-
its use is based on the fact that compression plating has been bility), and ease of application (requires little or no additional
shown to be associated with improved stability at the frac- contouring) [10, 36, 40, 44]. In in vitro studies, Wittenberg et
ture site by producing tight approximation of the fragments, al. [10] and Kalfarentzos et al. [44] compared the 3-D system
which is accomplished as a result of larger contact surfaces with traditional plating techniques of fixation and concluded
generated by the compressive forces [56]. Shetty et al. [14] that a 3-D plate can be used for fixation of MAFs and that this
biomechanically evaluated six MAF fixation methods divid- fixation method can reproduce similar biomechanical scores
ed in two groups, compressive and adaptive fixation sys- to the traditional plating techniques. Alkan et al. [40] showed
tems. They showed that the compressive systems were that the 3-D grid miniplate technique had more favorable
biomechanically superior to the adaptive systems. No sig- biomechanical behavior than the Champy technique.
nificant differences were found in the instability profiles of Biodegradable materials were eventually developed for
the individual compressive systems, irrespective of their fixation plates to definitively eliminate the need for retrieval
disparate features. The authors suggested that the efficacy [57]. The reduced mechanical properties of the biodegrad-
of the compression bone plates derives largely from their able plate systems, compared with the metal ones, still give
common ability to produce varying degrees of static inter- rise to the question of whether they are suitable for mandib-
fragmentary compression. Haug et al. [28] did not find any ular fracture fixation [17]. Esen et al. [9] and Bayram et al.
significant statistical difference in stability between com- [43] demonstrated that titanium plate and screw fixation
pression and noncompression plating systems to fixate system had greater resistance to occlusal loads than biode-
MAFs. Fedok et al. [32] observed that biplanar plate place- gradable plate and screw systems. According to Chacon et
ment in both monocortical noncompression and bicortical al. [37], both systems cannot be used interchangeably for the
compression techniques yielded a stronger fixation than treatment of MAFs under the same clinical conditions.
monoplanar placement. Comparing titanium and biodegradable plates, Jain et al.
The locking miniplate system has conical threaded holes [38] did not advocate using a single biodegradable plate
that lock the corresponding threaded screw to the plate. The alone for MAFs. In the biodegradable groups, 60 % of the
screws, plate, and bone form a solid framework with higher failures occurred due to fracture of the plate and 31 % due to
stability than the traditional miniplate system. Only three stretching of the plate. The authors stated that it may be
biomechanical studies evaluated the use of locking miniplates considered to use additional plates, with or without MMF, or
in MAFs. Haug et al. [35] showed that varied degrees of stronger biodegradable plates capable of withstanding great-
compromise (0.0-, 1.0-, and 2.0-mm offset) did not influence er load-bearing forces. However, when comparing fixation
systems made of titanium and biodegradable polymers, Cox has been showed that the solitary lag screw functions as a
et al. [19] demonstrated that, although the titanium plates tension band to provide a sufficient degree of interfragmentary
had shown a more rigid fixation, the biodegradable poly- compression and stability to withstand functional loading of
mers were capable of withstanding the stresses generated by the mandible [14, 24]. Although technically demanding, the
the bite loads of postsurgical patients. Also biomechanically solitary lag screw procedure provides superior fixation in
comparing the two fixation systems, Bregagnolo et al. [46] selected MAF cases [14]. According to the results of their
observed that the titanium-based group showed better study, Shetty and Caputo [24] advocated the use of a solitary
results, but when the authors analyzed the final vertical lag screw to fixate MAFs, stating that the technique
displacement, no statistically significant difference was provided a sufficient degree of interfragmentary com-
found, concluding that the biodegradable systems were still pression and stability to withstand functional loading of the
effective. The reduced mechanical properties of the biode- mandible. Shetty et al. [14] showed that MAFs fixed by
gradable implants are often compensated for by the use of compressive fixation systems (here included the solitary lag
larger plates. However, Tams et al. [17] stated that because screw technique) provided significantly greater stability than
of the reduced strength of biodegradable plate systems, it “adaptive” fixation systems.
can be expected that they are suitable for fractures with Common limitations of these biomechanical analyses
interfragmentary contact, which usually occurs in real frac- include inadequate definition of the boundary conditions
tures, but that they are less suitable or unsuitable for frac- used for testing or a focus on destructive bending tests that
tures without interfragmentary contact [17], which usually have limited clinical application. From a biomechanical
occurs in in vitro studies. Thus, the ability of the biodegrad- perspective, the prevalent representation of the mandible
able plates to resist stresses of real fractures must be greater angle as a region that is always in tension at the upper
than the stresses observed in in vitro studies. Moreover, it is border and compression at the lower border makes little
accepted that subnormal bite forces after fracture reduce the intuitive sense [14]. The results of experimental in vitro
requirements for fixation. studies provide a reasonable estimate of the rigidity and
On installation in the human body, the mechanical fixation strengths to be expected [14]; they do not all corre-
properties of the biodegradable materials begin to degrade spond to clinical outcomes and biomechanics are only one
as the material is gradually consumed. Therefore, adequa- factor to consider when treating fractures. Another limita-
cy on initial installation does not ensure that the same tion of the in vitro models is that the relatively severe testing
conclusion holds months after installation [19]. According configuration does not properly acknowledge the stabilizing
to Chacon et al. [37], the material composition of pure contribution by the investing muscles [14]. The complexity
poly-D,L-lactide acid maintains its strength for approxi- of the masticatory system and in vivo conditions may lead
mately 10 weeks before undergoing resorption. Thus, after fixation systems to behave in a distinct way other than in a
few months, the material properties will have changed, biomechanical testing unit [48]. Moreover, following frac-
and the bite force that a patient can generate will also ture treatment of the mandible, the occlusal force in the early
have increased [19]. As this fact was not considered in postoperative period is considerably less than the healthy
most studies, long-term strength comparisons cannot be person’s force of the bite, and this was not considered by all
extrapolated from these in vitro studies. Considering the in vitro studies. Gerlach and Schwarz [58] observed that the
degradation rate of such plates, and the risk of long-term vertical force applied in in vitro studies were more than bite
complications associated with degradation, biodegradable forces in patients with MAFs. This means that some fixation
plates as small as possible should be used [53]. Two systems that have been considered unsuitable for fixing
biodegradable midiplates have a larger volume than one MAFs in in vitro studies may be clinically effective. Al-
biodegradable maxiplate. However, because the midiplates though the results in vitro biomechanical study could estab-
were positioned on the mandible at a reasonable distance lish a reference for clinical applications in a limited frame,
from each other, it is expected that they will degrade they should be supported by in vivo experiments before
independently and therefore faster than one biodegradable clinical decisions are made [2009].
maxiplate [17]. Moreover, fixation with two small plates As the management of mandibular fractures continues to
instead of one large plate also might be a way of com- evolve, an increasing variety of internal fixation devices and
pensating for the reduced mechanical properties [9, 17]. techniques will become available. Clinically, the choice of
Although the technique using a solitary lag screw for the method will depend on the requirements of the local situa-
reduction of MAFs contravenes an axiom of lag screw tion, the surgeon's familiarity with a particular technique,
fixation of fragments, namely, a minimum of two lag screws the availability of specific instrumentation, and the expected
are required to ensure the integrity of fixation, and that it outcome [14]. It is essential that the treatment strategy have
was stated that the technique occasionally requires supple- a sound biomechanical basis and include due consideration
mentary MMF because of its technique sensitivity [28], it of possible complications involved.
Conclusions miniplates alone is not sufficient to withstand the early

postoperative bite force. Some studies suggest that the
The experimental results to date appear to be contradictory. segment of the tension band miniplate located at the distal
Such apparent contradictions, however, may be explained fragment of the MAF should be fixed with three screws,
by the fact that distraction or compression can occur at the although it is difficult to extrapolate the results of in vitro
superior or inferior aspects of a MAF depending on whether investigations to actual patient care.
force is applied near the fracture or at the level of the
incisors. None of the in vitro studies considered the stabili- Acknowledgments This work was supported by the CNPq, Conselho
zation of the fracture site afforded by the masseter–ptery- Nacional de Desenvolvimento Científico e Tecnológico-Brazil. The au-
thor would like to thank Ms. Beth Shultz for her help in providing Dr.
goid muscle pouch. Thus, for the mandibular angle, clinical Fred G. Fedok’s article, and Dr. Matthias Feichtinger and Dr. Hannes
studies are still superior because soft tissue supports the Peter Schierle for providing their articles.
local fracture. Such influences can hardly be simulated.
Most of the studies did not evaluate plating system strength Conflict of interest The author declares that he has no conflict of
interest.
in the long term and therefore did not observe the effect of
resorption on the strength of the different biodegradable
plating systems. Another limitation of many studies is the
absence of a control group. A confounding factor that could References
not be tested in in vitro investigations is the additional
resistance to displacement of jagged fracture margins pres- 1. Chrcanovic BR, Freire-Maia B, Souza LN, Araújo VO, Abreu
ent in the human fracture. An osteotomy behaves differently MHNG (2004) Facial fractures: a 1-year retrospective study in a
than fractures. Thus, it is important to keep in mind that the hospital in Belo Horizonte. Braz Oral Res 18:322–328
results of biomechanical studies do not all correspond to 2. Chrcanovic BR, Abreu MH, Freire-Maia B, Souza LN (2010)
Facial fractures in children and adolescents: a retrospective study
clinical outcomes, and biomechanics are only one factor to
of 3 years in a hospital in Belo Horizonte, Brazil. Dent Traumatol
consider when treating fractures. 26:262–270
From the observations of many studies, one can conclude 3. Chrcanovic BR, Souza LN, Freire-Maia B, Abreu MH (2010)
that the osteosynthesis positions as well as the plating tech- Facial fractures in the elderly: a retrospective study in a hospital
in Belo Horizonte, Brazil. J Trauma 69:E73–E78
nique play important roles in the stability of MAF repair.
4. Zandi M, Khayati A, Lamei A, Zarei H (2011) Maxillofacial
The only in vitro study evaluating the use of wire osteosyn- injuries in western Iran: a prospective study. Oral Maxillofac Surg
thesis for MAFs concluded that wires placed through the 15:201–209
lower border approach would provide greater postoperative 5. Chrcanovic BR (2012) Factors influencing the incidence of max-
illofacial fractures. Oral Maxillofac Surg 16:3–17
stability than those at the upper border. Many in vitro studies
6. Chrcanovic BR, Abreu MH, Freire-Maia B, Souza LN (2012)
indicate that the use of two miniplates for the fixation of 1,454 mandibular fractures: a 3-year study in a hospital in Belo
MAFs avoids (or decreases) lateral displacement of the Horizonte, Brazil. J Craniomaxillofac Surg 40:116–123
lower mandibular border and opening of the inferior fracture 7. Chrcanovic BR, Custódio AL (2010) Considerations of mandibu-
lar angle fractures during and after surgery for removal of third
gap, which are suspected to contribute to the occurrence of
molars: a review of the literature. Oral Maxillofac Surg 14:71–80
complications. Some studies even suggest that the use of 8. Marciani RD, Anderson GE, Gonty AA (1994) Treatment of
two miniplates may be considered a more “rigid” fixation mandibular angle fractures: transoral internal wire fixation. J Oral
technique for MAFs than the use of a reconstruction plate. Maxillofac Surg 52:752–756
9. Esen A, Ataoğlu H, Gemi L (2008) Comparison of stability of
When using two miniplates, the biplanar plate orientation
titanium and absorbable plate and screw fixation for mandibular
provides greater biomechanical stability than the monopla- angle fractures. Oral Surg Oral Med Oral Pathol Oral Radiol
nar one. Studies with biodegradable plates have not yet Endod 106:806–811
reached a consensus, but they suggest the use of at least 10. Wittenberg J, Mukherjee D, Smith B, Kruse R (1997) Biomechan-
ical evaluation of new fixation devices for mandibular angle frac-
two plates for each MAF. However, despite greater biome-
tures. Int J Oral Maxillofac Surg 26:68–73
chanical stability, the two-miniplate technique has some 11. Champy M, Loddé JP, Schmitt R, Jaeger JH, Muster D (1978)
disadvantages that should also be taken into account before Mandibular osteosynthesis by miniature screwed plates via a buc-
choosing between the fixation of MAFs with one or two cal approach. J Maxillofac Surg 6:14–21
12. Schierle HP, Schmelzeisen R, Rahn B, Pytlik C (1997) One- or
miniplates. Concerning the use of compression plates,
two-plate fixation of mandibular angle fractures? J Craniomaxillo-
there are few studies and they have not yet reached a fac Surg 25:162–168
consensus. The use of a solitary lag screw proved to 13. Perren SM, Rahn B, Cordey J (1975) Mechanik und Biologie der
withstand the functional loading of the mandible; howev- Frakturheilung. Fortschr Kiefer Gesichtschir 19:33–37
14. Shetty V, McBrearty D, Fourney M, Caputo AA (1995) Fracture
er, only few biomechanical assessments were performed.
line stability as a function of the internal fixation system: an in
In vitro studies have shown good biomechanical stability vitro comparison using a mandibular angle fracture model. J Oral
with the use of 3-D grid plates. The use of malleable Maxillofac Surg 53:791–801
15. Lovald ST, Wagner JD, Baack B (2009) Biomechanical optimiza- 34. Haug RH, Fattahi TT, Goltz M (2001) A biomechanical evaluation
tion of bone plates used in rigid fixation of mandibular fractures. J of mandibular angle fracture plating techniques. J Oral Maxillofac
Oral Maxillofac Surg 67:973–985 Surg 59:1199–1210
16. Kimsal J, Baack B, Candelaria L, Khraishi T, Lovald S (2011) 35. Haug RH, Street CC, Goltz M (2002) Does plate adaptation affect
Biomechanical analysis of mandibular angle fractures. J Oral Max- stability? A biomechanical comparison of locking and nonlocking
illofac Surg 69:3010–3014 plates. J Oral Maxillofac Surg 60:1319–1326
17. Tams J, Otten B, Van Loon J-P, Bos RRM (1999) A computer 36. Feledy J, Caterson EJ, Steger S, Stal S, Hollier L (2004) Treatment
study of fracture mobility and plate strains of biodegradable plates of mandibular angle fractures with a matrix miniplate: a prelimi-
for fixation of mandibular fractures. J Oral Maxillofac Surg nary report. Plast Reconstr Surg 114:1711–1716
57:973–981 37. Chacon GE, Dillard FM, Clelland N, Rashid R (2005) Comparison
18. Tams J, Van Loon JP, Otten B, Bos RR (2001) A computer study of of strains produced by titanium and poly d, l-lactide acid plating
biodegradable plates for internal fixation of mandibular angle systems to in vitro forces. J Oral Maxillofac Surg 63:968–972
fractures. J Oral Maxillofac Surg 59:404–407 38. Jain SA, Simmons OP, Hanemann MS, Baratta RV, Guerra AB,
19. Cox T, Kohn MW, Impelluso T (2003) Computerized analysis of Metzinger SE (2006) Comparison of tensile strength of resorbable
resorbable polymer plates and screws for the rigid fixation of plating systems used in monocortical mandible angle osteotomy
mandibular angle fractures. J Oral Maxillofac Surg 61:481–487 repair. Arch Facial Plast Surg 8:390–395
20. Feller KU, Schneider M, Hlawitschka M, Pfeifer G, Lauer G, 39. Wang H, Chen MS, Tang W, Tian WD (2006) Biomechanical
Eckelt U (2003) Analysis of complications in fractures of the study of rigid internal fixation for mandibular angle fracture. Hua
mandibular angle: a study with finite element computation and Xi Kou Qiang Yi Xue Za Zhi 24:393–396
evaluation of data of 277 patients. J Craniomaxillofac Surg 40. Alkan A, Celebi N, Ozden B, Baş B, Inal S (2007) Biomechanical
31:290–295 comparison of different plating techniques in repair of mandibular
21. Michelet FX, Deymes J, Dessus B (1973) Osteosynthesis with angle fractures. Oral Surg Oral Med Oral Pathol Oral Radiol
miniaturized screwed plates in maxillo-facial surgery. J Maxillofac Endod 104:752–756
Surg 1:79–84 41. Feichtinger M, Schultes G, Kärcher H (2008) The use of a 3D
22. Fisher IT, Cleaton-Jones PE, Lownie JF (1990) Relative efficien- navigation system in the treatment of mandibular angle fractures
cies of various wiring configurations commonly used in open by minimally invasive insertion of Herbert screws for osteosyn-
reductions of fractures of the angle of the mandible. Oral Surg thesis. Comput Aided Surg 13:47–54
Oral Med Oral Pathol 70:10–17 42. Turgut G, Kayali MU, Soydan AT, Gündüz O, Salman S, Oktar F,
23. Kroon FHM, Mathisson M, Cordey JA, Rahn BA (1991) The use Baş L (2008) Biomechanical comparison of a new technique of
of miniplates in mandibular fractures. An in vitro study. J Cranio mandibular angle fractures: biplanar and bicortical superior prox-
Maxillofac Surg 19:199–204 imal 3 holes and bicortical inferior plate fixation. J Craniofac Surg
24. Shetty V, Caputo A (1992) Biomechanical validation of the soli- 19:428–432
tary lag screw technique for reduction mandibular angle fractures. 43. Bayram B, Araz K, Uckan S, Balcik C (2009) Comparison of
J Oral Maxillofac Surg 50:603–607 fixation stability of resorbable versus titanium plate and screws
25. Dichard A, Klotch DW (1994) Testing biomechanical strength of in mandibular angle fractures. J Oral Maxillofac Surg 67:1644–
repairs for the mandibular angle fracture. Laryngoscope 104:201– 1648
208 44. Kalfarentzos EF, Deligianni D, Mitros G, Tyllianakis M (2009)
26. Choi BH, Kim KN, Kang HS (1995) Clinical and in vitro evalu- Biomechanical evaluation of plating techniques for fixing mandib-
ation of mandibular angle fracture fixation with two-miniplate ular angle fractures: the introduction of a new 3D plate approach.
system. Oral Surg Oral Med Oral Pathol Oral Radiol Endod Oral Maxillofac Surg 13:139–144
79:692–695 45. Ribeiro-Junior PD, Magro-Filho O, Shastri KA, Papageorge MB
27. Choi BH, Yoo JH, Kim KN, Kang HS (1995) Stability testing of a (2010) In vitro evaluation of conventional and locking miniplate/
two-miniplate fixation technique for mandibular angle fractures: an screw systems for the treatment of mandibular angle fractures. Int J
in vitro study. J Craniomaxillofac Surg 23:123–125 Oral Maxillofac Surg 39:1109–1114
28. Haug RH, Barber JE, Reifeis R (1996) A comparison of mandib- 46. Bregagnolo LA, Bertelli PF, Ribeiro MC, Sverzut CE, Trivellato
ular angle fracture plating techniques. Oral Surg Oral Med Oral AE (2011) Evaluation of in vitro resistance of titanium and resorb-
Pathol Oral Radiol Endod 82:257–263 able (poly-L-DL-lactic acid) fixation systems on the mandibular
29. Schierle HP, Schmelzeisen R, Rahn B (1996) Experimentelle angle fracture. Int J Oral Maxillofac Surg 40:316–321
Untersuchungen zur biomechanischen Stabilität unterschiedlicher 47. Esen A, Dolanmaz D, Tüz HH (2012) Biomechanical evaluation of
Miniplattenkonfigurationen am Kieferwinkel. Fortschr Kiefer malleable noncompression miniplates in mandibular angle frac-
Gesichtschir 41:166–170 tures: an experimental study. Br J Oral Maxillofac Surg 50:e65–
30. Nissenbaum M, Lownie M, Cleaton-Jones P (1997) Relative dis- e68
placement resistance of standard and low-profile bone plates in 48. Pektas ZO, Bayram B, Balcik C, Develi T, Uckan S (2012) Effects
experimental mandibular angle fractures. Oral Surg Oral Med Oral of different mandibular fracture patterns on the stability of mini-
Pathol Oral Radiol Endod 83:427–432 plate screw fixation in angle mandibular fractures. Int J Oral
31. Rudman RA, Rosenthal SC, Shen C, Ruskin JD, Ifju PG (1997) Maxillofac Surg 41:339–343
Photoelastic analysis of miniplate osteosynthesis for mandibular 49. Bredbenner TL, Haug RH (2000) Substitutes for human cadaveric
angle fractures. Oral Surg Oral Med Oral Pathol Oral Radiol bone in maxillofacial rigid fixation research. Oral Surg Oral Med
Endod 84:129–136 Oral Pathol Oral Radiol Endod 90:574–580
32. Fedok FG, Van Kooten DW, DeJoseph LM, McGinn JD, Sobota B, 50. Ellis E 3rd (1993) Treatment of mandibular angle fractures using
Levin RJ, Jacobs CR (1998) Plating technique and plate orienta- the AO reconstruction plate. J Oral Maxillofac Surg 51:250–254
tion in repair of mandibular angle fractures: an in vitro study. 51. Chrcanovic BR (2012) Open versus closed reduction: comminuted
Laryngoscope 108:1218–1224 mandibular fractures. Oral Maxillofac Surg (in press)
33. Gutwald R, Büscher P, Schramm A, Schmelzeisen R (1999) Bio- 52. Uppal N, Baliga M, Ramanathan A (2009) Improper reduction and
mechanical stability of an internal mini-fixation-system in maxil- fixation of bilateral anterior mandibular fractures: a case report.
lofacial osteosynthesis. Med Biol Eng Comp 37:280–281 Oral Maxillofac Surg 13:177–179
53. Rozema FR, Otten E, Bos RR, Boering G, van Willigen JD (1992) 56. Perren SM, Russenberger M, Steinemann S, Müller ME, Allgöwer
Computer-aided optimization of choice and positioning of bone M (1969) A dynamic compression plate. Acta Orthop Stand Suppl
plates and screws used for internal fixation of mandibular frac- 125:31–41
tures. Int J Oral Maxlllofat Surg 21:373–377 57. Matsushita K, Inoue N, Totsuka Y (2011) In vitro biomechanical
54. Haug R (1993) The effects of screw number and length on two evaluation of the effect of an additional L-shaped plate on straight
methods of tension band plating. J Oral Maxillofac Surg 51:159– or box plate fixation in sagittal split ramus osteotomy using a
162 bioabsorbable plate system. Oral Maxillofac Surg 15:139–146
55. Perrott DH (1996) Discussion: treatment of mandibular angle 58. Gerlach KL, Schwarz A (2002) Bite forces in patients after treat-
fractures using one noncompression miniplate. J Oral Maxillofac ment of mandibular angle fractures with miniplate osteosynthesis
Surg 54:871–872 according to Champy. Int J Oral Maxillofac Surg 31:345–348
View publication stats

Fixation of Mandibular Angle Fractures: in Vitro Biomechanical Assessments and Computer-Based Studies

Uploaded by

Document Informationclick to expand document information

Copyright:

Available Formats

Fixation of Mandibular Angle Fractures: in Vitro Biomechanical Assessments and Computer-Based Studies

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Fixation of Mandibular Angle Fractures: in Vitro Biomechanical Assessments and Computer-Based Studies

Uploaded by

Copyright:

Available Formats

See discussions, stats, and author profiles for this publication at: https://www.researchgate.

Fixation of mandibular angle fractures: In vitro biomechanical assessments

Article in Oral and Maxillofacial Surgery · December 2013

Nanostructured materials for biomedical applications View project

The user has requested enhancement of the downloaded file.

Fixation of mandibular angle fractures: in vitro

Abstract However, despite its greater biomechanical stability, the

and abstract to make a clear decision, the full report was

Eligibility criteria included in vitro biomechanical assess-

Review articles without original data were excluded, al-

The study selection process is summarized in Fig. 1. The

One study even investigated the influence of the inferior

Conclusions miniplates alone is not sufficient to withstand the early

View publication stats

You might also like