Art:10.1007/s10006 012 0367 0

Oral Maxillofac Surg (2013) 17:251268 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 Purpose The purpose of this study was to review the literature regarding the evolution of current thoughts on fixation of mandibular angle fractures (MAFs), based on in vitro biomechanical assessments and computer-based studies. Methods An electronic search in PubMed was undertaken in August 2012. The titles and abstracts from these results were read to identify studies within the selection criteria. Eligibility criteria included studies from the last 30 years (from 1983 onwards). Results The search strategy initially identified 767 studies. Thirty-one studies were identified without repetition within the selection criteria. Two articles showing significance in the development of treatment techniques was included. Additional hand searching yielded five additional papers. Thus, a total of 38 studies were included. Conclusions The osteosynthesis positions as well as the plating technique play important roles in the stability of MAF repair. The only in vitro study evaluating the use of wire osteosynthesis concluded that wires placed through the lower border approach would provide greater stability than those at the upper border. Many studies indicate that the use of two miniplates avoids (or decreases) lateral displacement of the lower mandibular border and opening of the inferior fracture gap. Some studies even suggest that the use of two miniplates may be considered a more rigid fixation technique for MAFs than the use of a reconstruction plate. When using two miniplates, the biplanar plate orientation provides greater biomechanical stability than the monoplanar one.
However, despite its greater biomechanical stability, the two-miniplate technique has some disadvantages that should also be taken into account. Studies with biodegradable plates suggest the use of at least two plates for each MAF. There are few studies with compression plates, and they have not yet reached a consensus. The solitary lag screw proved to withstand the functional loading of the mandible; however, only few biomechanical assessments were performed. In vitro studies have shown good biomechanical stability with the use of 3-D grid plates. The use of malleable miniplates alone is not sufficient to withstand the early postoperative bite force. Some studies suggest that the segment of the tension band miniplate located at the distal fragment of the MAF should be fixed with three screws. The studies also showed some limitations. None considered the stabilization of the fracture site afforded by the masseterpterygoid muscle pouch. Most of the studies did not evaluate plating system strength 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 not be tested in in vitro investigations is the additional resistance to displacement of jagged fracture margins present in the human fracture. Keywords Mandibular angle fracture . Fixation . Osteosynthesis . In vitro . Biomechanical assessments . Computer-based studies
B. R. Chrcanovic (*) Department of Prosthodontics, Faculty of Odontology, Malm University, 205 06 Malm, Sweden e-mail: brunochrcanovic@hotmail.com
Introduction About 1940 % of all facial fractures are fractures of the mandible, and 1230 % of all mandibular fractures are fractures of the mandibular angle [16]. Among mandibular
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fractures, the angle is the first most frequent region for fractures caused by sportive activities, the second most frequent region for fractures caused by violence, and the third most fractured region in cases of traffic accidents involving automobiles [6]. The frequent involvement of the mandibular angle in facial fractures can be attributed to its thin cross-sectional bone area and the common presence of a third molar [7]. Before the advent of antibiotics, open reduction of mandibular fractures was associated with a high frequency of infection. Techniques to repair jaw fractures were further influenced by the limits of the technology of the day [8]. Traditional methods of mandible fracture fixation included wire osteosynthesis and maxillomandibular fixation (MMF). These injuries are currently treated by plate/screw osteosynthesis and, depending on the case, the bone segments are secured by one-miniplate fixation, twominiplate fixation, a lag screw, or by a single rigid plate at the inferior border of the mandible. Although there is a widely accepted consensus about the need for surgical reduction and fixation of a mandibular angle fracture (MAF), a variety of different treatment modalities 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 located in other regions of the mandible [9]. MAFs are biomechanically complex because the major stress-bearing trajectories of the mandible are disrupted in this area [10]. The classical method of fixation proposed by Champy et al. [11] in the case of MAFs is designed to apply a miniplate at the superior border of the mandible in the area of the external oblique line with monocortical screws. However, questions concerning the stability provided by miniplate fixation of MAFs have become a point of contention among surgeons [12], based on recent clinical and experimental studies. And this is an important subject because fracture line stability is perceived to be a major determinant of the clinical outcome, since the level of interfragmentary motion strongly influences the morphological patterns of osseous repair [13]. As the philosophies of treatment of maxillofacial trauma alter over time, a periodic review of the different concepts is necessary to refine techniques and eliminate unnecessary procedures. This would form a basis for optimum treatment. Surgical intervention with stable internal fixation is warranted only if it results in good anatomic reduction and provides the appropriate milieu for undisturbed healing. If the fracture site is vulnerable to displacing forces, then the advantages of early function are lost. Consequently, knowledge about the biomechanical competence, or lack thereof, of the individual fixation systems has important therapeutic ramifications. It is essential that the treatment strategy have a sound biomechanical basis [14]. Determine the biomechanical competence of individual fixation systems under
controlled and repeatable conditions is an important tool to investigate a variety of fixation devices and techniques and to optimize device design on a rational basis [14]. That is why in vitro biomechanical studies are so important for the development of the clinical management of fractures. Finite element analysis (FEA) is a numerical analysis technique that can determine the displacements, stresses, and strains over an irregular solid body given the complex material behavior and the loading conditions imposed upon that body [15]. The stress analysis obtained from FEA modeling can provide information regarding interactions between hardware and bone during normal patient functioning and perhaps suggest means of lowering the rate of postoperative complications after open reduction and internal fixation (ORIF) of this trauma [16]. Some computerbased studies have specifically analyzed these interactions in cases of MAFs [1620]. The purpose of this study was to review the literature regarding the evolution of current thoughts on fixation of MAFs, based on in vitro biomechanical assessments and computer-based studies.
Materials and methods Objective This study aims to review the literature regarding the evolution of current thoughts on fixation of MAFs, based on in vitro biomechanical assessments and computer-based studies. Data source and search strategies An electronic search without language restrictions was undertaken in July 2012 in PubMed website (U.S. National Library of Medicine, National Institutes of Health). The following terms were used in the search strategy: {Subject AND Adjective} {Subject: (mandibular angle fracture [text words]) AND Adjective: (fixation OR wire osteosynthesis OR plate OR miniplate OR lag screw [text words])} Only references from the last 30 years (from 1983 onwards) were considered. All reference lists of the selected and review studies were hand-searched for additional papers that might meet the eligibility criteria for inclusion in this study. The titles and abstracts (when available) from these results were read for identifying studies meeting the eligibility criteria. For studies appearing to meet the inclusion criteria, or for which there were insufficient data in the title
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and abstract to make a clear decision, the full report was obtained and assessed. Inclusion criteria Eligibility criteria included in vitro biomechanical assessments and computer-based studies related to fixation of MAFs. The studies could have been conducted using cadaveric 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, although 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 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 development of new hardware for fixation of mandibular fractures. Additional hand-searching of the reference lists of selected studies yielded five additional papers. The main points of these 38 studies are presented below. Michelet et al. [21] were the first to present miniaturized screwed plates, which can be considered the first prototype of the modern miniplates. The miniplates, with 4 mm of width and 12, 18, and 25 mm of length, were fixed with two to four screws 57 mm long, each with a diameter of 1.5 mm. The miniplates were not made of titanium but of Vitallium, an alloy containing 60 % of cobalt, 20 % of chromium, 5 % of molybdenum, and other elements. The authors were probably the first ones to suggest that the plate must be slightly curved to fit the sulcus of the external oblique line for the fixation of MAFs. The authors suggested that the MMF could be either shortened or suppressed. The authors did not consider MAFs in separate, but stated that the analysis of 300 cases (500 plates) shows the excellent results and the major advantage of this method. Biomechanical studies of Champy et al. [11] resulted in the concept of an ideal line of osteosynthesis. They used blocks made of a photoelastic resin (araldite) to represent
Fig. 1 Study screening process
the mandible. A plate was then secured to the lateral surface of the blocks along the superior border, and the complex was subjected to simple cantilever loading. The test showed that the pattern of stress distribution created in the plated blocks was similar to the uncut blocks. This study was instrumental in establishing the concept of tension band plating for the treatment of mandibular fractures. Taking into account torsional tensile and compressive forces at all points of the mandible, the ideal lines of osteosynthesis were described. Moreover, the authors also reviewed 183 cases of mandibular fractures using a modification of Michelets osteosynthesis method [21]. They used what they called monocortical juxta-alveolar and subapical osteosynthesis without compression. In the paper, the authors stressed that all 183 patients were able to eat soft food on the first postoperative day, and that they could eat normal food from the tenth postoperative day. Moreover, infection was found in only 3.8 % of the cases, malunion occurred in 0.5 %, delayed union in 0.5 %, and grinding was needed to adjust the occlusion in 4.8 %. The patients were followed up for periods up to 5 years. Although not considering the complications of MAFs in separate, the study is important because Champy et al. [11] were the first to report low rates of
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complications when effectively using mandibular fixation without the use of postoperative MMF. The concept of an ideal line of osteosynthesis was also a cornerstone of the internal fixation of mandibular fractures with miniplates. In the case of MAFs, their biomechanical results demonstrated that the best site for the plating is the vestibular osseous flat part located in the third molar region. Stabilization of the fracture with a miniplate positioned along this tension band will negate the muscular forces that naturally act to distract the fragments. They also stated that an osteosynthesis located lower, on the outer surface of the mandible, is solid enough to support the strain developed by the masticatory forces in this region. In an in vitro study using 24 fresh baboon hemimandibles, Fisher et al. [22] evaluated four different intraosseous wiring techniques to reduce and fixate unfavorable MAFs: (1) upper border figure-of-eight wire, (2) upper border straight wire, (3) modification of the lower border combination of straight and figure-of-eight wire, and (4) lower border figure-of-eight wire. The holes for wiring were drilled at a standard distance from the cut line. After wiring, the hemimandibles were placed in a tensile testing machine and subjected to a constant force that simulated the action of the major elevator muscles. Graphic recordings of force versus displacement were made. The mean forces required to displace each test mandible 15 mm for each wire configuration demonstrated that wire efficacy is best provided, in descending order, by groups 4, 3, 1, and 2. There were significant differences at all levels of displacement, indicating complete superiority of the lower border wires over those placed in the upper border. At the lower border, a figure-of-eight wire is more effective than a combination figure-of-eight and straight wire, and at the upper border, the figure-of-eight wire is more effective than the straight wire. Fisher et al. [22] probably developed the first laboratory system for testing the mechanical efficiencies of methods of direct intraosseous fixation of MAFs. Kroon et al. [23] demonstrated that in the case of a MAF, treated with a single plate in the tension zone applied ventrally to the oblique line, a loading force close to the fracture line causes distraction (i.e., tension) at the lower border. Thus, this approach apparently does not suffice to provide enough resistance to bending or torsional forces during function. The buccally positioned plate is more resistant to vertical loading forces but still allows a certain amount of lateral movement. In cases in which the fracture line is completely ventral to the masseterpterygoid muscle sling, it has to be expected that the distraction effects during chewing and loading in the fracture region will result in even more displacement at the lower border (reversing the tensioncompression zones) which apparently cannot be resisted by a single plate on the tension side. Thus, it can be implied by the observations of Kroon et al. [23] that the
use of two plates in the angle is suggested: one in the tension zone and another one in the compression zone. Shetty and Caputo [24] tried to determine whether the solitary lag screw fixation of MAFs is biomechanically valid. The test combined two approaches. First, they investigated the interfragmentary displacement measured on cadaver mandibles and then performed a photoelastic analysis conjoined with interfragmentary displacement measured on a composite photoelastic mandible analog. Cortical lag screws of 2.7 mm were used to reconstruct MAFs in cadaver mandibles. Incremental loads up to 35 daN were applied to the first premolar adjacent to the fracture. The upper limit of incremental loading of the mandibles was consistent with the values of masticatory forces reported in this region. Mean maximal displacements at the superior border, measured at 35 daN, ranged from 0.05 to 0.375 mm, whereas the range of mean maximum displacement registered at the inferior border was 0.050.12 mm. The loaddisplacement curves obtained for the photoelastic analog were similar to those in the cadaveric mandibles. In the photoelastic evaluation, the isochromatic fringe patterns emanated from around the head of the screw in the distal fragment as well as from the threads engaged in the proximal fragment. Correlation of the forcedisplacement measurements to photoelastic observation substantiated that the solitary lag screw functions as a tension band to provide a sufficient degree of interfragmentary compression and stability to withstand functional loading of the mandible. Dichard and Klotch [25] evaluated the biomechanical strength of repairs of MAFs. Polyurethane mandibles were used in a cantilever beam design. The model standardized the fracture location, load site, plate location, and site of deformation measurement. They evaluated nine types of compression plate, reconstruction plate, and tension band/ stabilization plate systems. They concluded that the twoplate systems afforded a distinctly more rigid reconstruction than single plate systems, using either noncompression or eccentric DCPs. Choi et al. [26] tested the stability of the two-miniplate fixation technique for biomechanical strength in vitro. Muscle forces acting on the mandible were simulated through a system of wires. Fixation with a four-hole miniplate with the use of monocortical 2.0-mm screws 5 mm in length was carried out in the area of the external oblique line in five mandibular models. In another five models, fixation was carried out with a two-miniplate fixation technique (the second miniplate was applied at the inferior border of the buccal cortex of the mandible). After loading of the mandibles, measurements of the fracture gap in the in vitro model demonstrated that the two-miniplate fixation technique provided a significantly higher resistance to loading force close to the fracture line compared with that provided by the fixation method as described by Champy et al. [11],
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showing a significant difference between the two fixation methods (P <0.05). They also evaluated a sample of 40 patients who had MAFs treated with the two-miniplate fixation technique. In the same year, Choi et al. published another article in a different journal, which seems to be the same research [27]. Shetty et al. [14] compared the initial mechanical stability of 18 mandible analogs with MAFs fixed with six different systems: (1) one 2.7-mm four-hole eccentric dynamic compression plate applied at the lower border of the mandible, (2) one Wrzburg 2.7-mm plate applied at the lower border, (3) one Luhr curved mandibular compression 2.7-mm plate applied at the lower border, (4) a solitary lag screw, (5) one 2.0-mm Champy miniplate applied at the external oblique ridge, and (6) a Mennen clamp applied at the lower border. The compressive fixation systems were represented by groups 14, and the adaptive fixation systems by groups 5 and 6. The reduced analogs were placed in a straining frame, and simulated masticatory loads were applied to three predetermined occlusal sites. The results showed that the adaptive fixation systems permit significantly higher motion at the fracture site, even at the attenuated masticatory forces encountered in the early postoperative period. MAFs fixed by compressive systems provided significantly greater stability. No significant differences were found in the instability profiles of the individual compressive systems, irrespective of their disparate features. In an in vitro study using synthetic (polyurethane) hemimandibles in a cantilever beam design, Haug et al. [28] compared MAFs treated with various combinations of plate thickness at the superior and inferior borders. There were three study groups, all using four-hole plates and always applying monocortical screws at the superior border and bicortical screws at the inferior border: superior thinner miniplate and inferior thicker compression miniplate (conventional group), superior thicker compression miniplate and inferior thinner miniplate (nontraditional group), and superior and inferior thinner miniplates (two-miniplate group). The forces resisted by the conventional group (167.618.2 N), nontraditional group (156.333.9 N), and two-miniplate group (154.018.4 N) were found to have no statistical differences. One hundred percent of the failures occurred with monocortical screws at the tension band/synthetic bone interface of the superior border. Eighty percent of the failures occurred at the two most anteriorly positioned screws. Schierle et al. [29] conducted an in vitro study using 16 polyurethane and 16 human mandibles. MAFs were simulated, and these two groups were divided in four subgroups of four mandibles each, and plate fixation (all 2.0 mm) of the subgroups was performed according to the following methods: (1) a superior six-hole plate, (2) a superior sixhole plate and an additional inferior two-hole plate, (3) a
superior two-hole and a six-hole at the inferior margin, and (4) two four-hole plates at the same positions. Application of a functional load between 30 and 90 N was performed at five different points on the mandible. The stability of the fixation was measured according to Kroon's method [23]. The results showed that significant findings consisting of lingual compression and inferior distraction could only be observed under functional loading of the molar area of the fracture side. In the singleplated category, significant inferior splaying and lingual compression of the fracture gap, compared with all twoplate categories, was detected with a more posterior axial loading of the fractured side. In all two-plate categories, no significant dislocation during functional loading was detected. Of all fractures, those treated with two four-hole miniplates showed the best results. Nissenbaum et al. [30] compared the resistance to displacement of four-hole low-profile (0.8 mm thick) and standard (1.1 mm thick) titanium bone plates with an experimental MAF model using 24 baboon hemimandibles. The plates were placed on the external oblique ridge. The resistance to displacement was then measured in a tensile testing machine. The mean displacement force in the standard group was 68.7 kg, whereas in the low-profile group, it was 46.5 kg. All standard plates bent, but none broke. In contrast, all low-profile plates bent, but 75 % also fractured through the edge of a screw hole. No screws bent or were displaced in bone. In an in vitro study, Rudman et al. [31] evaluated the theory of tension band plating for MAFs by using a mandibular model under simulated physiologic conditions. The authors stated that the anatomy of the human mandible is complex, and thus the rectangular block tested by Champy et al. [11] may be an oversimplified model. Thus, ten anatomically correct mandibles were fabricated with a photoelastic resin. In five mandibles, unfavorable angle fractures were created and fixed with a superior border four-hole 2.0mm miniplate, and five uncut mandibles served as controls. The results showed that the fractured mandibles demonstrated fringe patterns that were virtually identical to the control mandibles. The authors concluded that a single miniplate positioned along the superior border of the external oblique ridge to fixate a MAF adequately recreated the natural distribution of stress within the mandible. However, the study also demonstrated that there is a disparate distribution of force through the outer screws (that are subjected to higher stress than the inner screws), which may contribute to failure by pullout of the outer screws. The one-miniplate fixation also showed the tensioncompression reversal and poor resistance to torsional forces. Analyzing these three negative aspects together, it can be suggested that there are potential deficiencies with the technique of tension band plating for MAFs.
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In 1997, Schierle et al. [12] published another article. It is the same in vitro study published in 1996 in German [29], but now published in English. Moreover, the author included a clinical study. In an in vitro biomechanical study, Wittenberg et al. [10] investigated the effectiveness of fixation devices of simulated MAFs in 21 sheep mandibles. The following plating methods were used for the experiment: (1) an eight-hole three-dimensional (3-D) plate, (2) an eight-hole mesh plate, and (3) a six-hole reconstruction plate with 2.0- and 2.4-mm mono- and bicortical screws. Bending test was performed on each mandible. Load displacements and gap were simultaneously recorded for incremental loads of 0, 50, 150, 250, and 350 N. Failure at the bonescrew interface was not seen in any of these groups, and no statistically significant differences in inferior gaps were seen between the plates, indicating that a 3-D or mesh plate can be used for fixation of MAFs, as stated by the authors. In an in vitro study, Fedok et al. [32] evaluated the fixation efficacy of various plating techniques for repair of MAFs through a biomechanical model utilizing polystyrene mandibles. A simple MAF was created in the models at a standardized location and was repaired using five different plating techniques. Each experimental group consisted of 15 mandibles. Measurement of fracture distraction under load application generated a load deformation curve and corresponding slope for each technique. Comparison of load deformation slopes allowed assessment of fixation stability. When applied with a subapical, medially placed monocortical tension band, bicortical compression plating demonstrated the most stable fracture fixation. The results showed that biplanar plate placement in both monocortical noncompression and bicortical compression techniques yielded a stronger fixation than monoplanar placement. Gutwald et al. [33] compared the mechanical behavior of locking (n 0 8) and conventional (n 0 8) plate systems using 16 cadaver mandibles with simulated MAFs. Strain gauges were applied to the mandibles and were then subjected to cranial, caudal, and torsional forces. The authors concluded that a higher stability was achieved with the locking plates. In a computer-based study, Tams et al. [17] addressed the suitability of polylactide (PLA) plates for mandibular fracture fixation. A computer 3-D biomechanical model of the mandible that includes the masticatory muscles and the temporomandibular joints was used. Fracture mobility and plate strain were calculated for postoperatively reduced bite forces applied on all 13 bite points. Small plates with dimensions comparable to miniplates were used: PLA midiplates (length, 22.0; width, 5.0; thickness, 2.5 mm) and PLA maxiplates (length, 26.0; width, 7.0; thickness, 2.0 mm). One PLA midiplate, one PLA maxiplate, or two PLA midiplates were used for fixation of simulated solitary angle, body, and symphysis fractures with and without
interfragmentary bone contact. In the case of fractures with bone contact, the loads were transmitted through the fracture surfaces and the plate; when there was no contact, the loads were transmitted only through the plate. Maximum fracture mobility was set at 150 m. And maximum plate strain was set at the yield strain of PLA and titanium. For fractures without interfragmentary bone contact, all plate fixations resulted in a fracture mobility and plate strain higher than the limits set, except for the symphysis fracture fixed with two PLA midiplates. Interfragmentary bone contact significantly reduced fracture mobility and plate strain. For the MAF with bone contact, all PLA plate fixations resulted in fracture mobility above the limit, whereas the titanium miniplate fixation had fracture mobility below the limit. For the body and symphysis fracture with bone contact, only double PLA midiplate fixation resulted in fracture mobility below the limit. The authors concluded that fixation with two PLA plates is always necessary to provide sufficient reduction of fracture mobility and plate strain. Haug et al. [34] did a biomechanical evaluation of several plating techniques (lag screw technique, monocortical superior border methods, the monocortical two-plate systems, monocortical tension bands systems, and reconstruction plates) for MAFs in 150 synthetic polyurethane mandibles. The parameters evaluated were yield load, yield displacement, and stiffness. For incisal edge loading, minor differences were found between the groups. For contralateral molar loading, statistically significant differences existed within and among categories. All of the systems failed the functional requirements for loading the contralateral molar region because of torsional forces. The stiffness data revealed a trend that the single screw or monocortical superior border plate techniques were collectively the least stiff and that stiffness increased with the two monocortical plate techniques, the monocortical/bicortical two-plate technique, and reconstruction plate technique. A trend was also identified that showed that the reconstruction plate systems yielded the least displacement and that, as the systems used smaller dimension plates, monocortical screws, and less plates and screws, the systems yielded greater displacements. Tams et al. [18] used a computer model to determine the suitability of two PLA midiplates and two PLA maxiplates (same dimensions as described by Tams et al. [17]) for MAFs. A 3-D computer model of the mandible was used, and reduced bite forces were applied on 13 bite points. The simulated angle fracture was located distal to the second molar. The software calculated the loads across the fracture, fracture mobility, and plate strain for each bite point. The first plate was positioned buccally on the external oblique ridge. Two positions of the second plate were studied: halfway up the height of the mandible (mid-PLA plate fixation) or on the lower border of the mandible (low-PLA
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plate fixation). Maximum fracture mobility necessary to favor primary bone healing was set at 150 m. The midiplate fixation resulted in a fracture mobility pattern comparable with that of maxiplate fixation but with greater values at all bite points. With the mid-PLA plate fixation, the greatest fracture mobility was found for bite points close to the fracture, and the lowest mobility was found at the molars on the nonfractured side. With the low-PLA plate fixation, a bimodal pattern of mobility was found; great mobility occurred both on the fractured and nonfractured side. The mid-PLA maxiplate fixation resulted in the lowest fracture mobility, with mobility below the set limit for all bite points. The low-PLA maxiplate fixation resulted in fracture mobility of approximately the set limit for all bite points. The authors concluded that fixation with two PLA maxiplates is suitable for MAFs, and one plate should be positioned buccally on the external oblique ridge and the other plate should be positioned halfway up the height of the mandible. Haug et al. [35] conducted another in vitro study in 2002 and compared the mechanical behavior of locking and conventional plate systems placed with precise adaptation and intimate contact and varying the degrees of compromise (0.0, 1.0, and 2.0 mm offset) in order to stabilize simulated MAFs. According to the authors, the offset was designed to resemble imprecise contouring and less than ideal adaptation of the plate to the cortex, or varying degrees of cortical resorption. A total of 130 synthetic polyurethane mandibles were used. Six-hole reconstruction plates of 2.4 mm at the inferior border and six-hole monocortical superior border plate of 2.0 mm were evaluated. For each type of plate, locking and nonlocking systems were used. The models were then subjected to loading at the incisal edge and molar region with a servohydraulic mechanical testing unit. Load/ displacement data were recorded, and yield load, yield displacement, and stiffness were determined. The results showed that there were no statistically significant differences for yield load, yield displacement, and stiffness within the 2.4 and the 2.0 locking categories for both molar and incisal edge loading, i.e., the degree of adaptation (amount of offset) did not affect the mechanical behavior of the locking systems evaluated. However, it did affect the nonlocking systems. For the 2.4 nonlocking category, there were statistically significant differences for yield load, yield displacement, and stiffness between the 0.0-mm offset group and both the 1.0- and 2.0-mm offset groups for both molar and incisal edge loading but not between the 1.0- and 2.0-mm groups. For the 2.0-mm nonlocking category, there were statistically significant differences for yield load, yield displacement, and stiffness between both the 0.0- and 1.0mm offset groups and the 2.0-mm offset group for both molar and incisal edge loading but not between the 0.0and 1.0-mm groups.
In a computer-based study, Cox et al. [19] used FEA to assess whether rigid fixation by biodegradable polymer plates and screws can provide the required stiffness and strength for a typical MAF. Two separate 3-D FEA models of the mandible were generated, one fixed with titanium miniplates and the other with biodegradable plates. A commercial finite element solver was then applied to this mesh to compute stresses and bone interfragmentary displacements. The study showed that the titanium fixation fixed more rigidly the two bone segments in relative position. However, the biodegradable polymers were capable of withstanding the stresses generated by the bite loads of postsurgical patients. The results indicated that mandibles show nearly identical stress patterns, fixed with either titanium or biodegradable materials. Feller et al. [20] measured 20 mandibles of human cadavers to establish a model of the structure to be examined in a FEA in order to compute mechanical stress occurring in osteosynthesis plates used for fixation of MAFs. The computations were made for both a miniplate (thickness 1.0 mm) and a 2.3-mm module plate (thickness 1.5 mm). In the FEA tests, both the 1.0-mm miniplate and the 2.3-mm module plate were sufficiently stable. The authors concluded that in comminuted MAFs and in noncompliant patients, the use of a stronger osteosynthesis material should be considered, while in all other cases, application of a single 1.0 mm of thickness (2.0-mm screws) miniplate was regarded as sufficient for fixation using ORIF. The authors also conducted a clinical study. Feledy et al. [36] performed an in vitro biomechanical study to compare the use of a single curved 3-D grid eight-hole 2.0-mm miniplate with two 2.0-mm miniplates to treat MAFs. The 3-D miniplate demonstrated an overall better intrinsic stability, more resistance to out-of-plane fracture movement, and a higher load tolerance when motion out-of-plane was challenged. Inadequate screw seating resulted in an approximately 50 % reduction in fracture stability, suggesting that screw stability is more important than plate configuration for minimizing motion across the fracture site. The authors also conducted a clinical study. Chacon et al. [37] compared the stability of titanium and absorbable fixation systems for MAFs with a biomechanically experimental study. A bicortical osteotomy was made in a human mandible in order to simulate a MAF and then fixed with a four-hole 2.0-mm miniplate. Two strain gauges were bonded to the mandible on either side of the fracture. The mandible was then placed on a dynamometer, and 30 lb loads were delivered on the ipsilateral molar. Loading was repeated ten times with a period of 3 min between loads. The same process was repeated using a four-hole 2.1-mm resorbable miniplate. A significant difference was found between the two materials.
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In an in vitro study, Jain et al. [38] compared the strength at a given tension in four biodegradable plating systems from four different manufacturers, and a control group using a 2.0-mm titanium-based system. Twenty-four fresh cadaveric mandibles with simulated MAFs were used (12 dentulous and 12 edentulous). Each mandible was held rigid as a material test system applied a downward force anteriorly. The critical tolerance was measured, and the type of failure was noted. The analysis of variance revealed a significant effect of the plating system. Failure was largely of two types: almost two thirds of the failures were due to actual cracks or breaks in the plate itself; about one third were due to stretching of the plate. The dentition status did not affect the results. There was a greater tension across the plate in female mandibles, owing the smaller size of the mandible angle in females. A similar masticatory force will result in greater tension across the plate, owing to the smaller moment arm. In MAF, the authors do not advocate using a single craniofacial plate alone but may consider additional plates, with or without MMF, or stronger resorbable plates capable of withstanding greater load-bearing forces. The authors stated that resorbable plates hold promise in many aspects of craniofacial surgery and that improvement in their properties may, in the future, make them the gold standard in stable fixation. Wang et al. [39] used edentulous dry mandibles to study the stress distribution of MAFs fixed with one or two fourhole 2.0-mm miniplates. The biomechanical model was submitted to mechanically simulated loads of the masticatory muscles. Strain gauges were placed in 12 different points in the mandible. The authors observed that the use of one superior miniplate was insufficient to provide stability of the lower border of the mandibular angle. The results also showed that the use of two miniplates (one superior and one inferior) provided more stability of the MAF. Alkan et al. [40] evaluated the biomechanical behaviors of four different miniplate fixation techniques for treatment of MAFs in 20 sheep hemimandibles. The techniques were (1) the Champy technique, (2) biplanar plate placement, (3) monoplanar plate placement, and (4) 3-D grid 2.0-mm eight-hole plate. Titanium 2.0-mm four-hole noncompression miniplates were used in groups 1, 2, and 3. Standardization of all experimental factors except the fixation techniques was ensured. No miniplate fixation system or hemimandible failures (breakage or fracture) were observed within the 0700 N test range. The variance analyses showed that biplanar plate placement had more favorable biomechanical behavior than the Champy technique and monoplanar plate placement. The 3-D grid miniplate technique had more favorable biomechanical behavior than the Champy technique but was not significantly different from biplanar or monoplanar plate placement techniques.
Esen et al. [9] compared the stability of titanium and absorbable plate-and-screw fixation systems for MAFs. The study used 21 sheep hemimandibles. MAFs were simulated using a saw. The hemimandibles were randomly divided into three groups of seven, and fixed with three different plating techniques (a single titanium plate, a single biodegradable plate, and double biodegradable plates). A cantilever bending biomechanical test model was used for the samples. The displacement values for the three groups differed significantly. The variance analyses showed that titanium plate placement had more favorable biomechanical behavior than others, and that the group with two biodegradable plates had more favorable biomechanical behavior than the single biodegradable plate group. Feichtinger et al. [41] demonstrated a technique in which a 3-D computer navigation system helped to insert osteosynthesis screws. The study used ten synthetic (polyurethane) mandibular models. In their experiment, the inferior alveolar nerve was spared in all cases. The authors stated that this computer-guided insertion method enables stable fixation of the fracture via minimally invasive surgery and that is a helpful visualization tool that can prevent damage to the inferior alveolar nerve and enable secure anchoring of the traction screw centrally in the cortical bone without causing perforation. Turgut et al. [42] performed a biomechanical study in 72 sheep hemimandibles. A simple MAF was created in a uniform manner. The mandibles were fixed with four different plating techniques: (1) one superior four-hole miniplate; (2) two four-hole miniplates (the proximal three holes of the superior plate were fixed with bicortical screws, and a monocortical screw was placed into the distal fourth hole of the superior plate; bicortical screws were placed into the plate at lower border); (3) two four-hole miniplates (monocortical screws for the superior miniplate and bicortical for the inferior miniplate), and (4) one 11-hole reconstruction plate using bicortical screws. Each fixation group containing 18 hemimandibles was divided into three and tested with three-point bending, compression, and side-bending biomechanical test. The authors concluded that fixation of the superior plate with bicortical screws resulted in a more stable fixation of the fracture. In an in vitro biomechanical study, Bayram et al. [43] fixed 11 sheep hemimandibles with simulated MAFs with four-hole 2.0-mm straight titanium plates, and another 11 hemimandibles with four-hole 2.5-mm straight biodegradable plates, all placed at the superior border. The authors then compared the fixation reliability and stability of the different plates and screws by simulating the chewing forces (20200 N) occurring during the first 6 weeks after fixation. Significant differences were found between resorbable and titanium plates and screws at all forces. The stability of MAFs with titanium miniplates under simulated chewing
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forces was significantly higher than with the resorbable system. No statistically significant differences in the breaking force and maximum displacement values were observed between the groups. The authors concluded that metallic and resorbable fixation systems may not be used interchangeably for the treatment of MAFs under similar loading conditions. Kalfarentzos et al. [44] used synthetic mandible replicas to evaluate the effectiveness of the 3-D square plate along with three other mandibular angle plating techniques (all of 2.0 mm). Twenty mandibles were divided into four groups. The following plating methods were used for the experiment: (1) 3-D square miniplates, 22 holes (placed in the upper border of the external oblique ridge and the upper buccal side of the mandible); (2) 3-D miniplates, 62 holes (placed in the middle of the buccal surface of the mandible); (3) two four-hole miniplates (external oblique ridge and inferior border of the mandible); and (4) one four-hole miniplate (external oblique ridge). Each group was subjected to incisal and ipsilateral molar region loading ranging from 0 to 200 N. For ipsilateral molar loading, statistically significant differences existed within groups. For incisal edge loading, no statistically significant differences were found for stiffness among the fixation methods tested. Three of the tested plating techniques (groups 1, 3, and 4) demonstrated limited gap change during bending loading, because the techniques comprised a plate bridging the fracture gap at the superior border. The authors concluded that it is reasonable to use 3-D plates for fixation of MAFs, since this fixation method can reproduce similar biomechanical scores to the traditional plating techniques. Ribeiro-Junior et al. [45] evaluated in vitro the influence of the type of miniplate (conventional or locking) and the number of screws installed in the proximal and distal segments on the stability and resistance of Champys osteosynthesis (only one miniplate at the external oblique line) in MAFs. Sixty polyurethane hemimandibles sectioned in the mandibular angle region were randomly assigned to four groups. The models were then submitted to a compression test, simulating the forces applied by the masticatory muscles. The groups in which locking miniplates were used for osteosynthesis differed significantly from the groups with conventional miniplate osteosynthesis, with the greatest biomechanical stability with the use of the locking miniplates. The long locking miniplates showed better performance in resisting mandible opening compared with the short miniplates, though with no statistical significance (no statistically significant difference was found between the seven-hole and four-hole miniplates). Bregagnolo et al. [46] compared the four-hole 2.0-mm system made with poly-L-DL-lactic acid (70:30) to the analogous metallic titanium-based system using mechanical in vitro testing in 84 human dentate mandibular replicas made
of rigid polyurethane resin. The replicas were divided into 12 subgroups according to the miniplate material, the type of sectioning, and site-of-load application. The plates were adapted and stabilized passively at the same site in both groups (external oblique ridge). Then a resistance-to-load test was performed, with the force being applied perpendicular to the occlusal plane at three different points (first molar at the plated side, first molar at the contralateral side, and between the central incisors). The results showed that at 1 mm of displacement, no statistically significant difference was found. At 2 mm of displacement, a statistically significant difference between the subgroups was observed in two circumstances: when a load was applied to the contralateral first molar in a fracture unfavorable to treatment and when a load was applied between the central incisors in a fracture favorable to treatment. In both these instances, the titaniumbased group showed better results. Moreover, at the failure displacement, a statistically significant difference was observed only when the favorable fracture was simulated and the load was applied on the first molar at the plated side. The authors concluded that despite more failure, the poly-L-DL-lactic acidbased systems were still effective. Kimsal et al. [16] employed FEA to investigate multiple titanium fixation plate combinations used to secure a MAF. The study analyzed three fixation schemes: (1) a six-hole bicortical angle compression plate at the inferior border of the fracture, (2) a tension band alone at the superior border of the fracture, and (3) the combination of plates used in the first two schemes. A fracture was simulated and a 1-mm callus section was placed between the two fractured mandible sections. The bite force used for the model was a unilateral molar clench. The results showed that the dualplate system observed the lowest strain in the callus for both maximum and average values as well as the lowest stress in the plates and experienced the highest stress in the bone. The tension band system observed the highest stress in the plate but incurred callus strain just slightly higher than the dual-plate system. The bicortical angle compression plate system resulted in callus strains significantly higher than both of the other models. It also had higher stress in the bone compared with the tension band configuration. The location of the maximum bone stress was found at screw holes posterior to the fracture line for all cases. The authors stated that combining the results of their study with previous works suggests that the benefit of added stability of the inferior plate is outweighed by the increased invasiveness necessary to implant the second plate. The results of the study support that the fixation provided by a single tension band provides stability near that of the two-plate technique, while minimizing the amount of implanted hardware and intrusion on the patient. Incidences of plate fracture may eventually be mitigated with improved plate design techniques.
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Esen et al. [47] used 18 sheep hemimandibles to evaluate two plating techniques using Champys method of fixing MAFs (either a single noncompression 2.0-mm titanium miniplate or a single malleable 1.6-mm titanium miniplate). A cantilever bending biomechanical test model was used for the samples. The displacement values in each group at each 10 N stage up to 90 N were compared. Their results showed that the noncompression miniplate had greater resistance to occlusal loads than the malleable plate and that the malleable plate alone was not sufficient to withstand the early postoperative bite force. In an in vitro biomechanical study, Pektas et al. [48] analyzed the effects of horizontally favorable and unfavorable MAF patterns on the fixation stability of titanium plates and screws in 22 hemimandibles of sheep. Favorable fracture lines were created by forming a +15 angle with an established pilot line whilst unfavorable fracture lines formed a 15 angle with the same pilot line. The hemimandibles were then fixed with four-hole 2.0-mm straight titanium miniplates inserted into the superior border. Occlusal bite force was applied to the posterior mandible, and each hemimandible was subjected to a continuous linear compression until plastic deformation was seen. The results showed that none of the models failed during testing, and they met the criteria for this biomechanical study. No statistically significant differences were found between the groups for the displacement values in the force range 60 200 N. The difference for the maximum displacement values at breaking forces was statistically significant, whilst it was nonsignificant for breaking forces between groups. The authors concluded that there was no evidence for the need to apply different treatment modalities to MAFs regardless of whether the factures are favorable or not.
Discussion Each fixation system seeks to restore structural and functional integrity to the fracture site until the new bone is capable of withstanding the stresses of masticatory function. The magnitude of the resistance to displacing forces derives from the design of the plate used, its material properties, site of application, and force transfer mechanisms [14]. An evaluation of the combination of device (i.e., an individual plate or screw) and substrate (cadaveric mandibles or anatomic replica), especially when replicating clinical conditions within clinical parameters, has a greater potential to provide more meaningful information to the clinician [35]. In vitro biomechanical assessments on two kinds of mandibular models are used: the synthetic and the cadaveric. The synthetic models used in the literature are made of polyurethane [12, 23, 25, 28, 29, 34, 35, 41, 45, 46], composite photoelastic mandible analog/cortical bone
analog [14, 24], epoxy resin [31], polystyrene [32], Synbone [44], and sawbone blocks [36]. The cadaveric models used in the literature are from humans [12, 24, 26, 27, 29, 33, 3739], sheeps [9, 10, 40, 42, 43, 47, 48], and baboons [22, 30]. Champy et al. [11] used blocks made of araldite to represent the mandible. However, there is a problem. The anatomy of the human mandible is complex, and a rectangular block may be an oversimplified model. The stresses that exist in the mandible result from the forces and directions of pull from several muscles and from occlusal forces. Thus, the application of a randomly directed force on plated rectangular blocks may not adequately represent the physiologic loading of a mandible [31]. One study [31] used synthetic resin mandible models to perform the study. The problem is that the composition of the mandibles is homogeneous and lacks the trabecular and cortical components present in a human mandible. This may raise suspicion as to the validity of the homogeneous model. Fresh sheep mandibles are widely used in biomechanical studies because of their similarities in size and thickness to human mandible [40, 43]. They are easy to obtain and enable reproducible measurements with biomechanical testing units. The use of human mandibles is even better. However, the use of cadaveric mandible presents some limitations. Conventional models using cadaveric mandibles for the biomechanical validation of fixation devices are burdened by the large variability in the properties and structure of natural bone itself. Hence, it is important for the development of a normative model that would ensure replicability of material properties and fracture configuration across the test constructs [14, 24]. Synthetic polyurethane mandibles were designed to eliminate the variables associated with human cadaveric mandibles [34, 35]. Through model consistency and uniformity of experimental fracture location, bone thickness and strength can be removed as variables, leaving plating technique (plating system design and plate location) as the variables examined in the experiment [32]. The advantages of polyurethane mandibles is that they replicate cancellous bone, have a dense outer core that replicates cortical bone, and are able to provide more uniform sampling [35]. Bredbenner and Haug [49] analyzed the torque required to insert and to remove titanium screws used in rigid internal fixation in seven different substrates. Polyurethane mandible showed results similar to cadaveric bone and was considered by the authors to be the material of choice for in vitro studies. Another point to consider is the use of hemimandibles or complete mandible models. In contrast to the simpler cantilever beam used customarily to describe the behavior of the mandible in hemimandibles models, the complete mandible model assumes support from the contralateral side. This arrangement permits a more accurate assessment of the
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physical effects of functional forces as they transfer from the ipsilateral to the contralateral side of the body of the mandible [14]. Four types of fixations for the treatment of MAFs have been tested in in vitro biomechanical assessments and computer-based studies. These include wire osteosynthesis, rigid fixation (2.4- and 2.7-mm plates), stable or semirigid fixation (1.3-, 1.6-, and 2.0-mm miniplates), and lag screws. Decision on which wiring technique to use is difficult since a great degree of individual variation exists in MAFs in the clinical situation, and no two fractures can be considered identical [22]. Fisher et al. [22] conducted the only in vitro study evaluating the use of wire osteosynthesis for MAFs, analyzing four different intraosseous wiring techniques (two in the superior border of the mandible, two in the inferior). They stated that if the amount of preoperative displacement of a MAF is large, and/or a large postoperative fragment displacing force is anticipated, then the wires placed through the lower border approach would provide greater postoperative stability than those at the upper border. The authors hypothesized that this may be explained by the fact that both buccal and lingual cortices are engaged by a lower border wire, whereas the upper border wires used in this trial traverse the buccal cortex only. The first type of plating uses large plates (2.4- and 2.7mm plates) for rigid fixation. This kind of plate provides sufficient rigidity to the fragments to prevent interfragmentary mobility during active use of the mandible. The plate is three-dimensionally bendable, allowing accurate contouring to the surface of the mandible. Each screw hole allows for placement of compression in either direction or no compression, depending on where one drills the hole within the confines of the screw hole slot. The use of three screws on each side of the fracture with this bone plate is claimed to provide adequate neutralization of functional forces in the absence of compression [50]. Some authors claim that a reconstructive plate is recommended for use in patients whom the surgeons anticipate will be noncompliant with instructions, oral hygiene, and follow-up, because of the frequent self-removal of MMF [50]. In cases of MAFs with comminution or with continuity defect, surgeons may consider reconstruction plates that are thicker and therefore provide greater strength that would resist functional load better [51]. Comparing four different techniques with miniplates and one reconstruction plate to fixate simulated MAFs in sheep hemimandibles, Turgut et al. [42] observed that greater biomechanical stability was provided with bicortical biplanar dual-plate method in three-point bending and compression tests. Only in side-bending test that the reconstruction plate had greater stability than bicortical biplanar dual-miniplate synthesis. Dichard and Klotch [25] evaluated nine types of plate systems and also concluded that the two-plate systems afforded a distinctly more rigid
reconstruction than single plate systems, here including the use of one reconstruction plate. Although Haug et al. [34] had demonstrated that the reconstruction plate systems yielded the least displacement of MAFs between several other plating techniques, the studies of Dichard and Klotch [25] and Turgut et al. [42] raise the question of what would actually be considered a more rigid fixation technique for MAFs: a reconstruction plate or two miniplates. The second type of plating uses thinner plates (1.3-, 1.6-, and 2.0-mm miniplates) for semirigid fixation. A striking difference in the application of semirigid miniplates, when compared with rigid systems of osteosynthesis, is the use of monocortical versus bicortical screws. Monocortical screws engage only one cortex and, being self-tapping, eliminate the need for using a screw tap in the drilled hole, but their reduced anchorage also makes fixation less capable than bicortical screws of resisting muscle forces especially if principles of fixation are not respected [52]. In a recent computer-based study, Kimsal et al. [16] showed that the fixation provided by one miniplate at the tension band (according to the Champys recommendations) provides stability near that of the two-plate technique while minimizing the amount of implanted hardware and intrusion on the patient. The study also observed that the use of a single inferior border compression miniplate is the least preferred biomechanically option. However, much of the literature on the biomechanics of MAFs fixed with miniplates focuses on how to neutralize the negative bending moments that result in opening of the fracture in the region of the lower border. Kroon et al. [23] showed that in the case of a MAF, treated by a single plate in the tension zone, a loading force close to the fracture line causes distraction/tension at the lower border, i.e., the plate does not suffice to provide enough resistance to bending or torsional forces during function. Based on the principle that these negative bending moments are best resisted using a plate positioned as for caudal as possible, recommendations for fracture fixation have been made. For single plate fixation, Kroon et al. [23] recommended a position buccal to the external oblique ridge instead of a lingual position. Other authors have recommended the use of a second plate on the lower border [27]. Thus, a MAF can be stabilized with the plate being placed superiorly (called tension bone plating) and inferiorly (called stabilization bone plating). Superiorly, it can be placed in two ways: extending from the mandibular lateral border near the external oblique ridge to a point posterior to the second molar in the area of the retromolar trigone (external oblique line), or along the superior lateral face. These are the two possible regions to fixate a miniplate according to the ideal line of osteosynthesis established by Champy et al. [11]. Inferiorly, the second miniplate is fixed in the inferior lateral face of the mandible (Fig. 2).
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Fig. 2 Possible regions to fixate MAFs with miniplates: (1) external oblique line, (2) along the superior lateral face, and (3) inferior lateral face of the mandible. Positions (1) and (2) are the two possible regions to fixate a miniplate according to the ideal line of osteosynthesis established by Champy et al. [11]. Miniplates placed at positions (2) and (3) constitutes a monoplanar fixation. Miniplates placed at positions (1) and (3) constitutes a biplanar fixation
The results of several studies [12, 14, 23, 2528, 31, 39, 40] indicate that the use of the two-miniplate fixation technique to treat MAFs provides better stability compared with Champy's method [11]. During function of the lower jaw, tension will occur at the level of the dentition whereas an effect of compression will be observed along the lower border. In the chin area, torsional forces produce a combination of tension and compression [23]. The zones of tension and compression may reverse when forces are generated along the posterior teeth. The closer the load is applied to the fracture at the mandibular angle, the more there is a tendency for separation of the bony cortices at the inferior border. This was clearly observed in two in vitro studies [23, 31]. The use of two miniplates avoids lateral displacement of the lower mandibular border and opening of the inferior fracture gap, which are suspected to contribute to the occurrence of complications [26]. Two in vitro studies using the same type of synthetic mandibles in a cantilever beam design applied one superior miniplate [23] or one superior and one inferior miniplate to fixate MAFs [28]. In the first study (using one miniplate), failure occurred at 30 N or less [23], whereas failures in the second investigation (two miniplates) occurred between 154 and 167 N [28].
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 miniplates: 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 inferior 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 technique (monocortical vs. bicortical) and plate placement (monoplanar vs. biplanar) are important variables to consider 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 plates that effectively neutralized superior fracture distraction forces as well as torsional and lateral forces created at the fracture site. Plate placement in a biplanar orientation is superior to monoplanar plate placement when applied to either a monocortical or a bicortical plating technique. Alkan et al. [40] also showed that the biplanar plate orientation provided greater biomechanical stability than the monoplanar one. In the two-plate monocortical biplanar technique, the upper plate approximates an oblique plane, whereas the lower plate parallels the sagittal plane of the mandible. This creates a stable 3-D framework of plates, effectively neutralizing superior distractive forces as well as lateral or torsional forces. In the two-plate monocortical technique with monoplanar plate placement, the design lacks the stability afforded by a plate approximating an oblique plane of the mandible, which reduces its ability to effectively neutralize the torsional and lateral forces created under load at the fracture site [32]. As observed by some studies, a large amount of lateral movement is observed at the fracture site during load application, owing to poor lateral stabilization of the single plate monoplanar system. However, whether this gap in the lower border of the mandible is important to the clinical outcome or not remains to be seen. One important point to consider it is that the one-miniplate fixation technique may prove to be more stable in a clinical setting, where the added support of pterygomasseteric musculature and surrounding soft tissue may minimize lateral forces and, therefore, minimize lingual fracture distraction [32]. Another important point was made
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by Fisher et al. [22]. It is possible that the absolute values for the forces recorded in in vitro studies are lower than they would be in the clinical situation in human beings. This is because fractures in patients usually have jagged ends that would interdigitate when they are reduced, and so would assist in the prevention of postoperative displacement. In a fracture, interfragmentary bone contact plays an important role in transmitting loads across the fracture. In a fracture with interfragmentary bone contact after plate fixation, the loads are transmitted partially through the plate and partially through the fracture surfaces. Bending moments result in tension and compression zones in these surfaces [17]. Torsion moments and shear forces are partially neutralized by the roughness or serration of the fracture surfaces [53]. In a fracture without interfragmentary contact, loads are transmitted only through the plate [17]. Most (if not all) in vitro studies here reviewed performed straight osteotomies in animal or synthetic mandibles to simulate MAFs. There is a recent computer-based study not supporting the use of two miniplates. Kimsal et al. [16] showed that a single tension band on the superior border provided more angle fracture stability than a single bicortical plate placed inferiorly and provided comparable stability to a combination plate fixation scheme. High stress in the single tension band configuration may explain clinical observations of plate failure. Although the results of the study of Kimsal et al. [16] found that the use of a tension band and an inferior bicortical angle plate to provide the most stability of those tested, the authors stated that their study was unable to determine whether the relatively small increase in stability justifies the added intrusion of the extra bicortical plate. Also, the double plate system stresses the surrounding bone the most, which can contribute to screw loosening and infection. Moreover, Kimsal et al. [16] support the use of the single tension band configuration as a less invasive fixation approach to MAFs. The two-miniplate technique has also some disadvantages. When using an intraoral approach, the two-miniplate fixation technique necessitates reflection of all soft tissues from the mandible, increasing intraoperative trauma. When using an extraoral approach to place the second miniplate on the inferior border, it increases the risk of bacterial contamination, scarring, postoperative edema, hematoma, and marginal mandibular nerve damage. The use of the twominiplate fixation also prolongs the operation time. Thus, despite greater biomechanical stability, the two-miniplate technique has some disadvantages that should also be taken into account before choosing between the fixation of MAFs with one or two miniplates. Besides the number of miniplates used, it is also important to discuss the number of screws used on each plate. After miniplates are adapted to bone contours, it is standard to place at least two screws on either side of the fracture site
[11]. The study of Ribeiro-Junior et al. [45] showed that the use of a larger number of screws may increase instability. The authors observed that the use of longer miniplates inherently leads to a greater difficulty in the passive adaptation of the material to the underlying bone, which is another disadvantage of Champys method. The lack of passive adaptation of the plate on the mandible may cause postoperative occlusal changes, torque of the mandibular condyle, and even excessive tension on the osteosynthesis monocortical screw. In a study performed in a simple beam model with bovine ribs, Haug [54] evaluated the ability of various screw lengths and number of screws per fragment to resist displacement when used as tensions bands. Screw length had no effect on the ability of the 2.0-mm adaptation plate (0.85 mm in profile) to resist vertical forces. For the 2mm mini-DCP (1.5 mm in profile), increasing screw length increased the weight resisted up to three screws per segment, after which length had no effect. There was a slight increase in rigidity of the system when three screws were used on each fragment as opposed to two, but there was no additional benefit with four screws. However, as this investigation was performed in a rectilinear model (bovine ribs), their results do not apply to situations in which osteosynthesis is used to fixate MAFs. The miniplates in the study of Ribeiro-Junior [45] were installed in a region where the type of torsion was different from that tested by Haug [54]. Ribeiro-Junior [45] also observed that, when using locking miniplates instead of normal miniplates in the external oblique line, long miniplates showed better performance in resisting mandible opening compared with the short ones, though with no statistical significance. Perrott [55] made an interesting observation concerning this issue and when a third molar is present. If the third molar is to be extracted, there is often a need for a longer six-hole plate that extends beyond the extraction site to permit placement of screws in solid bone. He also stated that extra holes in a longer plate allow more versatility in plate location and, if desired, provide the opportunity to place additional screws. It is also important to consider the number of screws fixed on each side of the fracture when using two miniplates to fixate MAFs. In an in vitro study evaluating the twominiplate fixation, Haug et al. [28] noted that 100 % of all of their failures occurred with monocortical screws in the tension band system of the superior border. All plates had four holes, and the authors fixed two screws on each side on the MAFs. The authors suggested that plate size or pattern has little bearing on clinical fracture fixation but that monocortical screws appear to be the weak link in the system. As already mentioned before, the same author [54] investigated 3 years earlier the effects of screw number and length on two methods of tension band plating. Monocortical, intracortical, and bicortical screws were investigated. It was noted that at three screws per segment, optimal resistance
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to vertical deformation was provided. At less than three screws per segment, the monocortical and intracortical screws failed more frequently. Although using the oneminiplate fixation, these findings support the observations of the study with the two-miniplate fixation. Since bicortical screws should not be used to avoid damage to adjacent teeth, the results from these two studies suggest that the segment of the superior miniplate located at the distal fragment of the MAF should be fixed with three screws. However, it is difficult to extrapolate the results of in vitro investigations to actual patient care. Concerning the use of thinner miniplates (1.3 or 1.6 mm), the plate is extremely malleable and does not require adaptation to the underlying bone, and therefore it is very fast to insert. However, Esen et al. [47] disapproved the use of malleable titanium miniplates for fixation of MAFs according to Champys method, stating that the malleable plate alone was not sufficient to withstand the early postoperative bite force. Moreover, in a study comparing the resistance to displacement low-profile (0.8 mm thick) and standard (1.1 mm thick) titanium bone plates, Nissenbaum et al. [30] observed that a standard-profile titanium plate resisted displacement significantly more than a low-profile titanium plate. Concerning the use of compression plates, the defense of its use is based on the fact that compression plating has been shown to be associated with improved stability at the fracture site by producing tight approximation of the fragments, which is accomplished as a result of larger contact surfaces generated by the compressive forces [56]. Shetty et al. [14] biomechanically evaluated six MAF fixation methods divided in two groups, compressive and adaptive fixation systems. They showed that the compressive systems were biomechanically superior to the adaptive systems. No significant differences were found in the instability profiles of the individual compressive systems, irrespective of their disparate features. The authors suggested that the efficacy of the compression bone plates derives largely from their common ability to produce varying degrees of static interfragmentary compression. Haug et al. [28] did not find any significant statistical difference in stability between compression and noncompression plating systems to fixate MAFs. Fedok et al. [32] observed that biplanar plate placement in both monocortical noncompression and bicortical compression techniques yielded a stronger fixation than monoplanar placement. The locking miniplate system has conical threaded holes that lock the corresponding threaded screw to the plate. The screws, plate, and bone form a solid framework with higher stability than the traditional miniplate system. Only three biomechanical studies evaluated the use of locking miniplates in MAFs. Haug et al. [35] showed that varied degrees of compromise (0.0-, 1.0-, and 2.0-mm offset) did not influence
the mechanical behavior of the locking systems on the fixation of simulated MAFs. On the other hand, the same degrees of adaptation affected the mechanical behavior of the nonlocking systems evaluated. Gutwald et al. [33] and Ribeiro-Junior et al. [45] found greater biomechanical stability with the use of the locking miniplates in comparison with the conventional miniplates. Result of Ribeiro-Junior et al. [45] also demonstrated that long locking miniplates provide greater stability than short locking miniplates. There is a growing number of studies evaluating the use of 3-D plates for the treatment of MAFs [10, 36, 40, 44], all with good results. The 3-D plates can be considered a two-plate system, with two miniplates joined by interconnecting crossbars [44]. Their shape is based on the principle of the quadrilateral as a geometrically stable configuration for support. Because the screws are arranged in the configuration of a box on both sides of the fracture, a broadband platform is created, increasing the resistance to twisting and bending to the long axis of the plate [10, 44]. This stability represents the gain achieved by distributional force sharing by means of the adjoining strut bars. One of the advantages of the technique is the simultaneous stabilization of the tension and compression zones, making the 3-D plates a time-saving alternative to conventional miniplates. Moreover, this system is simple to apply because of its malleability, low profile (reduced palpability), and ease of application (requires little or no additional contouring) [10, 36, 40, 44]. In in vitro studies, Wittenberg et al. [10] and Kalfarentzos et al. [44] compared the 3-D system with traditional plating techniques of fixation and concluded that a 3-D plate can be used for fixation of MAFs and that this fixation method can reproduce similar biomechanical scores to the traditional plating techniques. Alkan et al. [40] showed that the 3-D grid miniplate technique had more favorable biomechanical behavior than the Champy technique. Biodegradable materials were eventually developed for fixation plates to definitively eliminate the need for retrieval [57]. The reduced mechanical properties of the biodegradable plate systems, compared with the metal ones, still give rise to the question of whether they are suitable for mandibular fracture fixation [17]. Esen et al. [9] and Bayram et al. [43] demonstrated that titanium plate and screw fixation system had greater resistance to occlusal loads than biodegradable plate and screw systems. According to Chacon et al. [37], both systems cannot be used interchangeably for the treatment of MAFs under the same clinical conditions. Comparing titanium and biodegradable plates, Jain et al. [38] did not advocate using a single biodegradable plate alone for MAFs. In the biodegradable groups, 60 % of the failures occurred due to fracture of the plate and 31 % due to stretching of the plate. The authors stated that it may be considered to use additional plates, with or without MMF, or stronger biodegradable plates capable of withstanding greater load-bearing forces. However, when comparing fixation
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systems made of titanium and biodegradable polymers, Cox et al. [19] demonstrated that, although the titanium plates had shown a more rigid fixation, the biodegradable polymers were capable of withstanding the stresses generated by the bite loads of postsurgical patients. Also biomechanically comparing the two fixation systems, Bregagnolo et al. [46] observed that the titanium-based group showed better results, but when the authors analyzed the final vertical displacement, no statistically significant difference was found, concluding that the biodegradable systems were still effective. The reduced mechanical properties of the biodegradable implants are often compensated for by the use of larger plates. However, Tams et al. [17] stated that because of the reduced strength of biodegradable plate systems, it can be expected that they are suitable for fractures with interfragmentary contact, which usually occurs in real fractures, but that they are less suitable or unsuitable for fractures without interfragmentary contact [17], which usually occurs in in vitro studies. Thus, the ability of the biodegradable plates to resist stresses of real fractures must be greater than the stresses observed in in vitro studies. Moreover, it is accepted that subnormal bite forces after fracture reduce the requirements for fixation. On installation in the human body, the mechanical properties of the biodegradable materials begin to degrade as the material is gradually consumed. Therefore, adequacy on initial installation does not ensure that the same conclusion holds months after installation [19]. According to Chacon et al. [37], the material composition of pure poly-D,L-lactide acid maintains its strength for approximately 10 weeks before undergoing resorption. Thus, after few months, the material properties will have changed, and the bite force that a patient can generate will also have increased [19]. As this fact was not considered in most studies, long-term strength comparisons cannot be extrapolated from these in vitro studies. Considering the degradation rate of such plates, and the risk of long-term complications associated with degradation, biodegradable plates as small as possible should be used [53]. Two biodegradable midiplates have a larger volume than one biodegradable maxiplate. However, because the midiplates were positioned on the mandible at a reasonable distance from each other, it is expected that they will degrade independently and therefore faster than one biodegradable maxiplate [17]. Moreover, fixation with two small plates instead of one large plate also might be a way of compensating for the reduced mechanical properties [9, 17]. Although the technique using a solitary lag screw for the reduction of MAFs contravenes an axiom of lag screw fixation of fragments, namely, a minimum of two lag screws are required to ensure the integrity of fixation, and that it was stated that the technique occasionally requires supplementary MMF because of its technique sensitivity [28], it
has been showed that the solitary lag screw functions as a tension band to provide a sufficient degree of interfragmentary compression and stability to withstand functional loading of the mandible [14, 24]. Although technically demanding, the solitary lag screw procedure provides superior fixation in selected MAF cases [14]. According to the results of their study, Shetty and Caputo [24] advocated the use of a solitary lag screw to fixate MAFs, stating that the technique provided a sufficient degree of interfragmentary compression and stability to withstand functional loading of the mandible. Shetty et al. [14] showed that MAFs fixed by compressive fixation systems (here included the solitary lag screw technique) provided significantly greater stability than adaptive fixation systems. Common limitations of these biomechanical analyses include inadequate definition of the boundary conditions used for testing or a focus on destructive bending tests that have limited clinical application. From a biomechanical perspective, the prevalent representation of the mandible angle as a region that is always in tension at the upper border and compression at the lower border makes little intuitive sense [14]. The results of experimental in vitro studies provide a reasonable estimate of the rigidity and fixation strengths to be expected [14]; they do not all correspond to clinical outcomes and biomechanics are only one factor to consider when treating fractures. Another limitation of the in vitro models is that the relatively severe testing configuration does not properly acknowledge the stabilizing contribution by the investing muscles [14]. The complexity of the masticatory system and in vivo conditions may lead fixation systems to behave in a distinct way other than in a biomechanical testing unit [48]. Moreover, following fracture treatment of the mandible, the occlusal force in the early postoperative period is considerably less than the healthy persons force of the bite, and this was not considered by all in vitro studies. Gerlach and Schwarz [58] observed that the vertical force applied in in vitro studies were more than bite forces in patients with MAFs. This means that some fixation systems that have been considered unsuitable for fixing MAFs in in vitro studies may be clinically effective. Although the results in vitro biomechanical study could establish a reference for clinical applications in a limited frame, they should be supported by in vivo experiments before clinical decisions are made [2009]. As the management of mandibular fractures continues to evolve, an increasing variety of internal fixation devices and techniques will become available. Clinically, the choice of method will depend on the requirements of the local situation, the surgeon's familiarity with a particular technique, the availability of specific instrumentation, and the expected outcome [14]. It is essential that the treatment strategy have a sound biomechanical basis and include due consideration of possible complications involved.
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Conclusions The experimental results to date appear to be contradictory. Such apparent contradictions, however, may be explained by the fact that distraction or compression can occur at the superior or inferior aspects of a MAF depending on whether force is applied near the fracture or at the level of the incisors. None of the in vitro studies considered the stabilization of the fracture site afforded by the masseterpterygoid muscle pouch. Thus, for the mandibular angle, clinical studies are still superior because soft tissue supports the local fracture. Such influences can hardly be simulated. Most of the studies did not evaluate plating system strength 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 not be tested in in vitro investigations is the additional resistance to displacement of jagged fracture margins present in the human fracture. An osteotomy behaves differently than fractures. Thus, it is important to keep in mind that the results of biomechanical studies do not all correspond to clinical outcomes, and biomechanics are only one factor to consider when treating fractures. From the observations of many studies, one can conclude that the osteosynthesis positions as well as the plating technique play important roles in the stability of MAF repair. The only in vitro study evaluating the use of wire osteosynthesis for MAFs concluded that wires placed through the lower border approach would provide greater postoperative stability than those at the upper border. Many in vitro studies indicate that the use of two miniplates for the fixation of MAFs avoids (or decreases) lateral displacement of the lower mandibular border and opening of the inferior fracture gap, which are suspected to contribute to the occurrence of complications. Some studies even suggest that the use of two miniplates may be considered a more rigid fixation technique for MAFs than the use of a reconstruction plate. When using two miniplates, the biplanar plate orientation provides greater biomechanical stability than the monoplanar one. Studies with biodegradable plates have not yet reached a consensus, but they suggest the use of at least two plates for each MAF. However, despite greater biomechanical stability, the two-miniplate technique has some disadvantages that should also be taken into account before choosing between the fixation of MAFs with one or two miniplates. Concerning the use of compression plates, there are few studies and they have not yet reached a consensus. The use of a solitary lag screw proved to withstand the functional loading of the mandible; however, only few biomechanical assessments were performed. In vitro studies have shown good biomechanical stability with the use of 3-D grid plates. The use of malleable
miniplates alone is not sufficient to withstand the early postoperative bite force. Some studies suggest that the segment of the tension band miniplate located at the distal fragment of the MAF should be fixed with three screws, although it is difficult to extrapolate the results of in vitro investigations to actual patient care.
Acknowledgments This work was supported by the CNPq, Conselho Nacional de Desenvolvimento Cientfico e Tecnolgico-Brazil. The author would like to thank Ms. Beth Shultz for her help in providing Dr. Fred G. Fedoks article, and Dr. Matthias Feichtinger and Dr. Hannes Peter Schierle for providing their articles. Conflict of interest interest. The author declares that he has no conflict of
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Fig. 1 Study screening process

Oral Maxillofac Surg (2013) 17:251268

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Oral Maxillofac Surg (2013) 17:251268

Oral Maxillofac Surg (2013) 17:251268

Oral Maxillofac Surg (2013) 17:251268

Oral Maxillofac Surg (2013) 17:251268

Oral Maxillofac Surg (2013) 17:251268

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