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The biophysics of mandibular fractures: An


evolution toward understanding
ARTICLE in PLASTIC AND RECONSTRUCTIVE SURGERY MARCH 2008
Impact Factor: 3.33 DOI: 10.1097/01.prs.0000297646.86919.b7 Source: PubMed

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SPECIAL TOPIC
The Biophysics of Mandibular Fractures: An
Evolution toward Understanding
Randal H. Rudderman, M.D.
Robert L. Mullen, Ph.D.
John H. Phillips, M.D.
Alpharetta, Ga.; Cleveland, Ohio; and
Toronto, Ontario, Canada

Background: Predicting outcomes based on a variety of fixation techniques remains problematic in the treatment of mandible fractures. There is inherent difficulty in comparing the hundreds of published articles on the subject because of
the large number of variables, including injury patterns, assessment techniques,
treatment approach, device selection and application, and definition of outcome.
Methods: The authors review the behavior of the human mandible. Behavior of the
intact mandible, multiple fracture scenarios, and small and large (single and multiple) plating applications are reviewed.
Results: Several misconceptions in the literature are clarified. Factors that will
resolve the dichotomy between clinical results and current biomechanical theories
are presented such that a more logical biomechanical model may be used to
approach fixation of the mandibular fracture being treated.
Conclusions: Current mandibular biomechanics theory must be expanded to reflect the complex nature of the system and to more accurately describe conditions
that exist in the physical world. Otherwise, further analysis in advancements in
outcome and treatment will be relegated to chance. (Plast. Reconstr. Surg. 121: 596,
2008.)

reatment of mandible fractures before the


mid twentieth century was consistent in the
concept involving application of splinting techniques to achieve maxillomandibular fixation. Interest in fixation devices, providing the option for
early return to function, was stimulated in part by the
orthopedic success with internal fixation1 that provided for adequate healing and consistent results
while reducing the associated consequences of immobilization of the active joint.2 4 The variety of
internal fixation techniques resulted in significant
differences in success rates. Numerous in vitro tests
were conducted to describe the biomechanical behavior of facial structures to confirm or support the
various fixation techniques.59 Although bench testing uniformly indicated increased stiffness and
strength in multiple plate systems repair versus single-plate applications, the technique using single
small plates for treatment of fractures produced consistent favorable clinical results.10 In the 1970s and
1980s, the knowledge of biomechanics of the facial
skeleton suggested a model of mandible behavior
From private practice; the Department of Civil Engineering,
Case Western Reserve University; and the Craniofacial Center for Care and Research, The Hospital for Sick Children.
Received for publication April 1, 2005; accepted September
1, 2005.
Copyright 2008 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000297646.86919.b7

596

consisting of a tension zone at the upper margin and


a compression zone at the lower margin. This model
represented an oversimplification of the system and
today remains inadequate for describing fracture
behavior, device behavior, and variations in clinical
results.
A more accurate description of mandibular
biomechanics will have relevance in resolving the
paradox of similar clinical success obtained with
use of reconstruction plates and the small plate
techniques on the same fracture scenarios. Understanding the science of biomechanics is necessary to optimize current treatment systems and
direct decisions regarding future steps needed to
significantly improve outcomes.
This article expands on previous descriptions
of mandibular behavior and reviews two common
fracture patterns: posterior body/angle fractures
and symphyseal fractures. The expected displacement behavior of the fractures exposed to two bite
forcesincisor loading (midline) and molar loading (posterior)are described.

Disclosure: None of the authors has a financial


interest in any of the products, devices, or drugs
mentioned in this article.

www.PRSJournal.com

Volume 121, Number 2 Mandibular Fractures


FRACTURE STABILIZATION
The behavior of an intact system (normal mandible) differs from the behavior seen when a fracture
is present. An intact mandible develops tension and
compression zones during normal function, and
these zones are dynamic and contingent on the bite
target location and muscle recruitment pattern. Devices are applied during treatment of a mandible
fracture to stabilize the segments in the proper anatomical orientation so that, ultimately, healing will
occur and normal function will follow. For living
bone to heal, either a callus is formed providing an
internal split limiting motion at the fracture zone, or
devices are applied (internal or external) limiting
motion at the fracture site during healing. Each
condition helps provide the environment necessary
for further healing to occur at the fracture site and
to restore the ability to carry normal functional
loads. The goal of device application is to construct
an environment that functions normally during
healing.
Techniques that include application of a device for the treatment of a mandible fracture while
allowing function substantially affect the behavior
of the overall system. The fixation device acts to
transfer forces across the fracture zone. Both tensile and compressive stresses can be generated at
a fracture site when devices are applied. Each device application scenario will therefore modify the
stress conditions that occur with function and will
affect stresses generated at the fracture site. Even
the application of seemingly simple devices may
have profound effects on the entire system. Identifying which techniques potentially interfere with
and which ones promote soft-tissue contributions
to stability is not an obvious and simple venture.
Early devices used to stabilize fractures functioned by approximating segments (i.e., wire loop)
or restricting movement when loaded (i.e., arch bar,
splints, or plating system). An arch bar functions by
transfer of forces from one segment to the other
through the bar during loading. If the segments are
subject to displacement, the bar will serve to prevent
distraction and will be loaded in tension. Most thin
constructs of metals will deform by stretching under
tensile loads and will deform (fail) by buckling under compressive loads. Arch bars, because of inherent dimensions and material properties, are significantly more efficient in tensile conditions than
compression.
The bone segments approximated and stabilized by an arch bar contribute to load sharing under
compressive forces if the segments are in contact.
When maxillomandibular fixation is applied, the

restricted motion largely eliminates biomechanical


behavior of function.
Plates and screws applied to a fracture site modify the stresses during loading. Screws are inserted
into the bone and contact the plate. As the screw
tightens, compressive forces increase between the
plate and the bone surface. Movement of the plate
relative to the bone will not occur unless sufficient
force is applied to overcome friction between the
plate and bone. When the friction force is exceeded,
force is transferred by the bearing of the plate
against the side of the screw. More screws increase
the frictional force on the bearing area between the
plate and the bone and increase the force needed to
disrupt the construct. Systems that are locking (the
screw locks into the plate using additional threads in
the plate) rely on the screw/bone interface and the
screw/plate interface for stability. These systems behave in a manner similar to an external fixation
device (where there is no reliance of the plate/bone
interface for stability) but necessitate soft-tissue disturbance during application. In each system, stability
depends on the screw/bone contact, and local failure here will result in system failure.
Screw/Bone Stress Factors for System Stability
The screw/bone interface is critical in maintaining device stability. This construct must sustain
loading conditions without inadvertent concentration of stress that will result in bone damage.
Any damage to the bone at the screw insertion site
that results in micromotion will contribute to future instability. Because forces flow along areas of
greatest stiffness, the optimal system for device application would consist of materials and geometry
that simulate the behavior of the bone. If the system
is too stiff (rigid), concentration of stress in excess of
that tolerated by the bone in contact with the inner
screws may result in bone damage leading to mobility at the screw/bone interface and possible system failure. During and following healing without
screw loosening, the screw/plate/screw load path
will continue to carry most of the force across the
fracture site. This pattern of stress distribution is
significantly altered from the prefracture condition
but still allows for normal function.
It is a general misconception that it is always
best to repair a broken structure with the stiffest
materials. Materials and applications that simulate
the original structure, and do not interfere with
function and healing while providing adequate stiffness to resist excess motion, should generate the
most reproducible results in treatment and create an
appropriate environment for healing to occur.

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Plastic and Reconstructive Surgery February 2008


All forces must remain in equilibrium during
function regardless of the number or type of plates
applied. A complete force circuit will be established, with stress distributions seen along regions
that provide greatest resistance to deflection and
are therefore stiffest. Because no single position
along the bone surface in the human mandible is
subject to only one type of stress, any plate applied
will have to maintain stability in a variety of stress
conditions (compression and tension) while resisting rotation and shear forces during loading at
various bite locations.
Clinical evidence suggests that there is a need
for stress in a region of fracture healing for adequate maturation of the bone to occur. The orthopedic literature refers to loss of loading because of
excess plate application as stress shielding of a fracture zone (a condition consistent with structural mechanics). Any device used to stabilize a fracture that
is stiffer than the native bone will transfer stress away
from the fracture and therefore results in stress
shielding. The stiffer the device, the larger the mechanical effect of stress shielding. The debate is not
whether stress shielding occurs in treatment of the
mandible, but whether or not there is clinical significance during or following healing.11
If a fracture site must experience some load
for maturation, one of two conditions must exist
during healing: (1) the external dynamic forces
present after injury and plate application are initially significantly lower than normal, then increase toward normal during healing to contribute to greater stress at the fracture site; and (2) the
plate screw systems gradually lose some stability at
the screw/bone interface, reducing the force flow
through the plate as the bone/bone interaction at
the fracture bears more load. This second scenario
does not mean that the screws become clinically
loose, but that some micromotion occurs allowing
for change in stress flow patterns. In select conditions, seemingly weak plates may contribute to
conditions promoting adequate fracture healing.
These less stiff plates may allow for earlier loading
at the fracture site and earlier transfer of stress
across the injury area (less loading of the screw/
plate/screw system).
There remains today difficulty in comparing
techniques because of the variability in reported
results and an incomplete theory of biomechanics.
Some of the confusion persists because of a misunderstanding of basic mechanical principles. This
becomes compounded by treatments based on conclusions from simple in vitro scenarios. One of the
most difficult concepts for researchers to deal with
is the relationship between the stability of a system

598

in its natural functional state following repair and


the requirements of the repair device. The oftenquoted logical approach is to apply the largest, stiffest system so that the injury has the longest time to
heal before the repair system fails. When inanimate
objects are damaged (fractured), repair consists of
replacing material that is damaged or applying materials to reconstitute the segments to allow for return of the originally intended function. The parameters considered in evaluation of a repair
strategy include the identification of consistent parameters of strength and stiffness. Techniques for
repair can be too weak or too stiff, altering the stress
distribution and resulting in system failure. The stiffness required for stabilization may not be equivalent
to the conditions required for healing. In evaluating
the biomechanics of fracture treatment, one must
ask how our understanding of plate stiffness relates
to strength and healing of the fracture zone.12
Most techniques of internal fixation for mandible fracture describe single or multiple plate
applications (with the exception of lag screw technique and mesh plate techniques) and relate treatment results to the device. Traditional mandibular
biomechanics describes plate placement for fracture repair by defining a tension band (plate)
along the upper margin and a compression plate
along the lower margin. This is an oversimplified,
incorrect model that is not proven by mechanical
testing, as is discussed.

FRACTURE SCENARIOS
The most basic fracture conditions are reviewed:
(1) posterior body/angle fracture with bite load anterior, posterior, and contralateral to the fracture;
and (2) symphyseal fracture with midline and posterior bite load.
Posterior Body/Angle Fractures
Incisor Loading (Midline Load)
This scenario involves a fracture position at
the posterior body/angle region with a central
(incisor) bite target (Fig. 1). The bite target is the
point of force transition between the upper (maxilla) and lower (mandible) dental segments. The
bite target completes a force circuit between the
mandible and midface, where the load is transferred through this substance secondary to force
generated by muscular actions.
As muscular contraction occurs, the masseteric sling (masseter and medial pterygoid musculature) generates an upward movement of the
posterior mandible. Most obvious movement occurs at the fracture site with the mouth open. The

Volume 121, Number 2 Mandibular Fractures

Fig. 1. Posterior body/angle fracture with incisor loading.

midline load position (target) acts as a constraint


around which the mandible rotates. When the
fracture is anterior to the attachment of the masseter, regardless of the orientation of the fracture
(oblique, oriented anterosuperior or anteroposterior), the segment posterior to the fracture will
rotate, resulting in separation along the upper margin and less separation, or relative compression, of
the lower margin. The result is tension at the upper
border not on the bone but on immediately adjacent
soft tissue. Bone at the fracture site cannot experience tensile surface stress if surfaces created by the
fracture are not in contact during distraction. Soft
tissue (i.e., fascia, periosteum, or muscle) that remains adherent to each fracture segment may experience tensile loads that can be communicated
between each bone segment by soft-tissue attachments. The inferior mandible margin will experience some degree of compression, only if the segments are in contact, during movement (Fig. 2).
Traditional diagrams of the anterior mandible segment moving downward because of a midline force
are misleading, as the bite target itself does not generate force. This type of force component can only
occur if the anterior segment is actively pulled downward by submental musculature or by an additional
external force.
Molar Loading (Posterior Body)
Conditions change dynamically as the bite target moves posteriorly approaching the fracture
location (Fig. 3). Displacement will be noted at the
lower border as muscle activation occurs, placing
local soft tissue under tension. Compression at the
upper surface is experienced if bone segments are
in contact. When the fracture is anterior to the bite

Fig. 2. Posterior body body/angle fracture with incisor loading


will result in intact soft tissues surrounding the fracture on the
upper margin experiencing tensile forces and lower margin tissues and bone experiencing compressive forces.

Fig. 3. Posterior body/angle fracture with more posterior (molar) loading.

target, a shear component may be seen in combination with the rotatory movement, effecting further
displacement of the fracture segments (Fig. 4).
When the bite target is contralateral to the fracture of the body/angle region and the fracture is
within the attachment region of the muscle, the
ipsilateral soft-tissue/muscle components may assist
in stabilizing the fracture from additional movement
caused by muscle contraction, depending on fracture conditions.

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Plastic and Reconstructive Surgery February 2008

Fig. 4. Posterior body/angle fracture with posterior (malar) loading displacement will occur at the lower border, with the soft
tissues experiencing a tensile force. Compressive forces will occur at the upper border.

Symphysis Fracture
Incisor Loading (Midline Load)
This scenario involves a central incisor bite
target with the fracture position at the symphysis
region (Fig. 5). Analysis of symphysis fractures reveals a behavior pattern significantly different from
that predicted by accepted tension/compression
cantilever theory. Cantilever theory has generally
been depicted as a hemimandible loaded at the midline with the implied region of tension along the
upper margin.13 A curved structure, suspended by
soft tissue, with the active component of the force
generation laterally positioned (human mandible),
presents with behavior more consistent with a suspended beam14 (Fig. 6). Finite element analysis studies (and in vivo studies in primates) indicate tensile
stress at the midline in an intact system, with greater
tensile stress along the lingual surface than along the
buccal surface.15,16
When a midline fracture is present, the incisor
load position (target) acts as a constraint around
which the mandible rotates. Activation of the masseteric sling will produce a rotation around an anteroposterior axis of a hemimandible (fracture at the
midline) because of the point of attachment of the
muscle and the curved structure of the mandible.
The effect of this rotation and movement will be
seen at the midline as separation of the lower border
of the mandible greater than separation of the upper border (Fig. 7).
A compressive force along the upper mandible
border will occur if the segments are in contact.

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Fig. 5. Symphyseal fracture with incisor loading.

Fig. 6. Drawing of a suspended beam loaded in the midline


with force generated laterally (human mandible), which results in tension on lower border tissues and compression at
the upper border.

The inferior margin of bone will not experience


tension unless substantial soft tissue remains in
contact with the fracture segments.
When a bite load is generated at the fracture
location, three effects contribute to displacement
of the segments at the fracture site: (1) rotatory,
(2) axial (translation), and (3) shear.17 If the bite
target is adjacent to the fracture, one segment may
move vertically relative to the other, resulting in
sliding (shear) at the fracture location. There is no
scenario clinically or experimentally derived that
supports a tensile stress at the upper symphysis
margin when an incisor bite load condition exists.
Molar Load (Posterior Load)
A midline fracture will experience similar relative displacement patterns with an incisor bite

Volume 121, Number 2 Mandibular Fractures


SOFT-TISSUE CONTRIBUTION TO
STRESS DISTRIBUTION (CIRCUIT
THEORY)

Fig. 7. Incisor loading acts as a constraint around which the


mandible rotates. This results in tensile force on tissues and separation at the lower border.

target or molar bite target. With no bony contact


at the central segment fracture site (symphysis),18
the lateral mandibular segments will rotate with
midline distraction opposed by soft-tissue attachments spanning the fracture. The end effect will
be displacement at the inferior border (tension
of the soft tissue) and compression of the upper
border.
Variations in effects experienced at the fracture site are significant, contingent on bite target
locations. In three of the four common scenarios
described(1) symphysis fracture with incisor
bite position, (2) symphysis fracture with molar
bite position, and (3) body/angle fracture with
molar bite positionthe significant tensile component is at the lower margin and occurs within
the soft tissue (and minimally at the bone surfaces if there is significant tissue spanning the
fracture gap).
Tensile stresses are predictably generated at
the upper mandible margin when a body/angle
fracture is exposed to incisor bite load conditions.
Bone (or any solid structure) that is in multiple
segments (two or more) cannot experience tensile
forces across segments other than those developed by attached adjacent soft tissue. Fractured
segments may develop compressive stress only
when the bone surface is in contact.

Forces generated by muscle contraction of


the masseter sling affect mandible movement.
What is neither obvious nor often referenced is
the change in stress distribution within the soft
tissues that generates the forces within the bone.
Consider the masseter attachments that originate at the zygoma and insert at the mandible. Activation of the masseteric initiates mandible movement as muscle contraction generates force. At
activation, tensile stresses develop at the sites of muscle attachment to the bone (origin and insertion).
Stress that is tensile at the muscle attachment is converted to compressive stress at the bite target. As
force increases to modify the bite target, force is
distributed (flows) through the stiffest components
of the bone to the target point. (Force flows along
regions that are most resistant to deflection.) At the
target, the teeth and adjacent bone experience the
maximal compressive stress. This compressive stress
increases at the bite target until the geometry of the
target changes (i.e., the bite target is modified by
cleaving or crushing).
Stress generated in the bone must remain in
equilibrium at any moment to comply with laws of
physical behavior. Significant load sharing is distributed within the soft tissue as well during activation of the system.
As contraction occurs, the muscle itself becomes
stiffer (fiber alignment during activation occurs along
a predefined pattern based on geometry and physiology). A fully contracted muscle would be able to
transmit forces to another target because of its more
rigid nature during activation and therefore share in
load distribution during contraction.19
Consider a molar bite load. The masseter muscle itself, when activated, becomes stiffer, and acts
to carry some of the load in addition to generating
force. The significant proportion of the force generated is distributed locally, through the masseter
to the maxilla above and mandible below, and
then to the bite target. The contralateral masseteric sling generates force that acts to stabilize the
mandible from rotation. Forces are distributed from
the contralateral masseter to the contralateral maxilla above, the contralateral mandible below, across
the midface (and palate), and through the mandible
to the target to complete the circuit (Fig. 8).
Facial force circuits must by definition remain
in equilibrium and are present every moment
muscle contraction occurs. These circuits include
muscle forces generated and resulting stress pat-

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Plastic and Reconstructive Surgery February 2008


STABILIZATION TECHNIQUE
SCENARIOS
Force distribution and loading patterns on the
plate/screw construct and local bone are substantially different when one versus two plates are used
for treatment of mandibular fractures. In a twoplate system, one plate is typically placed at the
upper border and one is placed at the lower border. Consider a midbody fracture treated with either a single- or two-plate technique as follows.

Fig. 8. All stresses and vectors of force in the circuit must be in


equilibrium. When a bite target is on the right posterior teeth,
for example, the masseter on that side, when activated, becomes stiffer and acts to carry some of the load in addition to
generating force. The contralateral masseter also generates
force that acts to stabilize the mandible from rotation. A circuit
of force is created.

terns established within all solid structures, including soft tissues. The stiffest components, including
bone, activated muscle fibers, and fascia, will all
share in some load distribution.
Local muscle contraction can effect some degree of increased stability at the fracture site during contraction when a fracture occurs without
significant disruption of the periosteum and softtissue/muscle attachments. The effect is most significant when the fracture is within the attachment
region of the muscle. The contracted muscle acts
to carry some of the load generated, reducing the
load on the adjacent bone. Muscle contraction
and the resulting stiffness of the muscle can also
provide for additional stability at a fracture site by
reducing the displacement during loading. A bite
target anterior to the main vector of the masseter
will be associated with a greater degree of bending
stresses, and the effects of muscle support diminish with incisor loads. The greater the lever arm
(the longer the distance) from a posterior fracture
to a bite target, the higher probability of motion
at the fracture site and the less significant the
contribution of soft tissue for stability.

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Single-Plate Systems
Upper Border Plate
When an incisor (midline) bite target is present, the upper border plate at the fracture site will
experience primarily tensile loads, with a minimal
bending component. In a system with four or more
screws, the distribution of force among the screws
depends on very small (micron) changes in screw
spacing. With appropriate screw insertion, the
screws adjacent to the fracture will experience the
majority of the load (up to 90 percent of the stress
on the central two screws). As a load is applied,
tensile stresses begin to develop in the plate between
the screws across the fracture site. The stress is further directed into the bone by means of the bone/
screw interface. The bone along the fracture experiences no load transfer from the opposite bony
surface. The local stress distribution is secondary to
the transfer of loads through the plate. As healing
occurs (bone growth and maturation at the fracture
site), the healing tissues gradually begin to contribute to the transfer of forces generated during loading. The system at any point in time must remain in
equilibrium. If the total load on the system is F, and
the load carried by the plate/screw system is P and
that of the healing bone of the fracture site is B, then
at the time of device application, F P B, where
B 0 except in compression loading. Fractures are
known to be associated with alteration in the muscle
recruitment following injury.20 These studies indicate the probability of gradually increasing bite
forces with time after injury. Even when the fracture
is completely healed, some of the load continues to
be carried by the plate. Therefore, the system does
not return to the preinjury stress state while plates
are present and remain firmly attached.
Lower Border Plate
A single plate placed along the lower border of
a mandible body fracture, with an incisor bite
load, will need to resist distraction at the upper
border. The load condition becomes more bending, not pure tension or compression. In a fourscrew/plate scenario, when the plate is subject to

Volume 121, Number 2 Mandibular Fractures


bending, all of the screws now are subjected to
equal loading. If a single screw becomes loose and
fails to carry a load before adequate healing in this
condition, the entire construct is subject to failure.
If the plate is applied by means of an open
external approach, soft tissue must be dissected
for exposure and placement. Periosteal dissection
results in muscle elevation as well when in the
region of the masseter. The soft-tissue elevation
and disruption interferes with the potential for the
soft tissue to contribute to stability during function. Plates placed along the inferior border by
means of an intraoral approach also require softtissue elevation for plate application and reduce
the potential contribution of the soft tissue for
functional stability.
Two-Plate System
When a midbody fracture is treated with a
two-plate application and an incisor bite target is
present, the plate along the lower border of the
mandible is in a compression area during loading.
As a load is applied, compressive stress begins to
develop within the bone/plate system. The central
two screws in a four-screw system carry the majority
of the compressive load. The plate will therefore
experience varying amounts of compressive loads
depending on the amount of load transferred at
the fracture site. If no bone-to-bone contact is
present, all compressive loads will be transferred
through the plate.
If any one of the inner two screws becomes
mobile, the load then shifts to the outer screw.
This effect will occur in either plate (upper or
lower) under tensile or compressive load conditions. The possibility of loss of three-dimensional
stability significantly increases with screw mobility.
When two plates are used in concert, neither plate
will experience significant bending. The greater
the distance between the upper and lower plates,
the smaller the already small bending effect becomes, even if one plate is smaller than the other.
The significant contribution to greater resistance
to bending (increased stiffness) with two plates is
defined by general mechanics. This effect can be
calculated and confirmed by bench testing. Improved healing, however, does not necessarily follow the same relationship as increased stiffness or
strength of the system.

ANGLE FRACTURES AND SOFT-TISSUE


STABILIZATION
The treatment of angle fractures is among the
most problematic in mandibular trauma because

of the frequency of injury, variability in severity,


difficulty in approach and application, and variability in plating techniques and soft-tissue disruption during application. This all leads to variable
complication rates.21,22 The angle is considered to
be a weaker region of the mandible and therefore
succumbs to fracture at a high rate during injury.
However, the posterior body/angle region during
normal function is the region where the highest
loads are measurable at the occlusal surface. It is
important not to equate the ease of fracture occurrence in a region to the functional attributes
under normal conditions.
The angle geometrically is a thinner construct
than the anterior mandible. The molar region
functions with an efficiency greater than other
regions. The massetermedial pterygoid sling in
the posterior bodyangle region is oriented to
provide for mostly vertical force during function.
As muscle contraction occurs with a bite target in
this location, the majority of stress in the mandible
is attributable to compressive effects. The muscle,
once activated, becomes stiffer, and the muscle
fascia component acts to stabilize the area. The
recruitment patterns of the muscles of mastication
have been studied in humans and primates, and
the general effect of timing of activation relates to
the ability to balance the structure and resist lateral rotation.
A single-plate application has been used successfully for the treatment of angle fractures. The
plates used for this application are typically considered small plates. The location of plate application is often along the oblique line (upper border) of the mandible. This plate when loaded
experiences stress conditions dissimilar to the single
plate placed along the inferior border. The upper
plate becomes loaded primarily in tension with an
incisor bite condition. The central two screws are
maximally loaded during function. A molar bite load
would tend to distract the lower border. However, if
minimal displacement of the fracture occurs during
injury, the soft tissue spanning the fracture zone
may help stabilize the fracture region. Activation of the masseter will effect shortening and
stiffening of the muscle, which may reduce mobility at the fracture site during function following application of the plate. Because application
of this plate requires minimal dissection, a small
plate device placed along the superior margin,
with minimal dissection along the fracture, may
provide conditions where the nondisplaced soft
tissue can contribute to stability during function

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Plastic and Reconstructive Surgery February 2008


DISCUSSION
Divergent Techniques and Consistent Results
Multiple plate application techniques have been
promoted in the past 30 years for the treatment of
mandible fractures. As treatment options shifted
from wire to plate applications, proponents of AO
techniques and those of Luhr promoted large plating applications that were believed to be essential for
uneventful and predictable healing. The techniques
of the AO/ASIF and of Luhr when followed have
demonstrated reproducible results.2325 This approach is consistent with repair strategies used in
inanimate objects (where the largest plate is considered to provide the greatest margin of safety).
In contrast, Michelet and Champy26 29 advocated the use of small plate applications from the
early 1970s, a technique that has continued to be
used at present, with acceptable success rates.30 34
The review by Ellis in 1999 of 10 years experience
with multiple plating techniques indicated divergent success and complication results as well.10
The study and review in the literature by Ellis is
significant in several respects.3539 The procedures
were performed or proctored by the same individual in 95 percent of the cases. The outcome and
results were reviewed by the same individual, demonstrating consistency over the time period. The
treatment methods were applied to a somewhat
consistent patient population over a 10-year period. It is apparent that many other studies report
differing success and complication rates compared
with this study. The significance is not only the specific rate of complications and reliability of procedure, but the range of rates quoted for any particular
treatment regimen. The study by Ellis reveals the
most optimal success rates with the smallest plate
placed intraorally and the largest plate placed by
means of the open approach.40,41 These findings
present a challenge to accepted biomechanics theory of the mandible, because of the apparent paradox in clinical results.
When conditions in the physical world are not
explained by theory and results defy logic, the
details on which the theories are based must be
scrutinized to advance understanding of behavior.
To elucidate the behavior of biological systems,
additional parameters must be considered beyond
mechanical models. The primary parameters for
consideration are those that facilitate an environment that allows the organism to repair itself. The
essential and critical factors that enhance predictability in determining fracture repair in biological
systems include enhanced knowledge of (1) the
uninjured system behavior, (2) the motion that

604

can be tolerated at the injury site, (3) the amount


of load that can be tolerated or that is required
for adequate healing, and (4) the amount of
soft-tissue alteration (effecting soft-tissue stabilization) and interruption of direct blood supply
or nutrient pathways that can be tolerated and
result in predictable healing failures.
Quantitative knowledge regarding uninjured
system behavior exists. Modeling of mandible behavior is complicated by the difficulty of exploring
multiple load conditions and accurately establishing
boundary conditions. As modeling technology has
advanced, finite element analysis techniques have
become more accessible for behavioral analysis.42
Finite element analysis models require that boundary conditions be specified to arrive at a solution and
will not describe complete behavior without extensive variable load iterations.43 Finite element analysis
models helped confirmed both human models and
primate models of tension and compression variations in the mandible dependent on load position.
These finite element analysis techniques used to
evaluate the structural dynamics of the mandible
suggest an extremely complex behavior.44 The simplified concept of static tension and compression
zones used to describe mandible behavior is inconsistent with the geometry and boundary conditions
of the mandible. Kroon had performed an elegant
test confirming that tension and compression zones
reverse depending on load position. In vivo studies
in primates serve to confirm stress zones consistent
with the complex suspended-curved-beam behavior
described by finite element analysis and general mechanics theory.45 Primate studies and evaluation of
hominoid facial structures indicate other aspects of
complex behavior of the structure consistent with
the theory of variations in qualitative stress components based on bite locations.46 48 Currently, only
qualitative knowledge regarding the three other critical factors exists: (1) excess motion at the fracture
site may result in nonunion, fibrous union, or infection; (2) inadequate load applied at the fracture
site may result in bone atrophy, bone absorption,
and suboptimal ossification; and (3) compromised
blood supply may result in tissue death and failure
to heal.
If increased system stiffness or strength is the
objective in fracture treatment, the results of Ellis
demonstrating divergent techniques resulting in
similar success rates cannot be confirmed by any
current mechanical model. Evaluation of these
two divergent techniques described by Ellis reveal
the following: (1) differences in the amount of
soft-tissue disruption, (2) variations in surgical approach, and (3) differences in qualitative load and

Volume 121, Number 2 Mandibular Fractures


stress distribution of plates and screws applied, all
affecting the stress distribution during functional
loading of the bone, soft tissue, and device during
healing. An expected reduction in bite forces on
the side of the fracture is not sufficient alone to
account for the apparent paradox in behavior.
The divergent results demonstrate that the models
of behavior are incomplete, not including the effects of soft-tissue stabilization during function
and the effects of soft-tissue disturbance during
treatment. These soft-tissue effects are both passive (by anatomical attachment) and active (load
carrying and potential stabilization by contraction) at the fracture site. In vitro testing would be
expected to confirm that two plates will resist mobility when loaded as a beam construct. The inconsistent findings with two miniplates, including
a report of increased complications in a group
with two plates and maxillary mandibular fixation
versus two miniplates alone, suggest that there
may be other significant factors at play beyond
those of operator technique. Findings that maxillary mandibular fixation with two miniplates did
not reduce the complication rate further point
toward the requirement to include soft-tissue effects in biomechanical models. Furthermore, fracture treatments should be evaluated in terms of
providing not the greatest stiffness across the fracture but the optimal force transmission across the
fracture. It may not yet be feasible to quantitatively
define all of these components, but to omit their
contributions is to relegate further advancements
in technology to chance.

CONCLUSIONS
Biomechanics is the study of the function of
living materials. The inability to explain divergent
results of human mandible fracture treatment is
attributable to incomplete understanding of the factors affecting biomechanics. Existing clinical explanations of divergent findings are incomplete, oversimplified, and confusing. This confusion is not
simply a result of the difficulties encountered in
comparing inconsistent patient populations or complication definitions, or difficulty in comparing reports, but is a result of the unavailability of an accurate model for understanding bone healing. Any
theory on mandible behavior will be incomplete if it
ignores the effects of soft tissue, including the effects
of the fascial and periosteal attachments, and the
effects of muscle contraction in distracting and stabilizing fractures. The forces are transmitted not
only through bone but through soft tissues, creating
circuits of force.

The results associated with the smallest, most


flexible devices do not invalidate biomechanics
but serve to demonstrate a complexity of behavior
appreciated but not fully delineated.48 Complete
biomechanics theory includes not just bone/device interaction but also nutrition and metabolism, bone healing, and application techniques,
including operator skill. Techniques may preserve
or disrupt soft tissue, altering the contribution of
muscle contraction to stability, stress, and load
distributions and the overall outcome. In fracture
repair, the reduction process should not contribute to additional system damage. The stabilization
process should provide for a functional construct
that can adequately heal while the patient participates in near normal activities. The fixation system should provide adequate stiffness and strength
to allow for early return to function. In addition, the
system should not continue to significantly modify
the stress distributions after healing has occurred.
What is regarded as adequate fixation of specific
fractures? Conventional wisdom indicates that more
rigid fixation provides for a greater chance of uneventful fracture healing. More careful consideration suggests that the minimum amount of stiffness
to achieve immediate return to function and longterm return to preinjury conditions may represent
the optimal treatment option. Science advances by
discarding constructs that defy logic and provide
constructs that survive examination, confirming
more accurate description of the physical world.
When mandible biomechanics are described accurately, the seeming dichotomy of clinical observations is explained.
John H. Phillips, M.D.
Division of Plastic Surgery
The Hospital for Sick Children
555 University Avenue, Room 5429
Toronto, Ontario M5G 1X8, Canada
jphillips002@sympatico.ca

REFERENCES
1. Ruedi, T., and Murphy, W. M. AO Principles of Fracture Management. Stuttgart: Thieme, 2000.
2. Ellis, E., III, Simon, P., and Throckmorton, G. S. Occlusal
results after open or closed treatments of fractures of the
mandibular condylar process. J. Oral Maxillofac. Surg. 58: 260,
2000.
3. Haug, R. H., and Assael, L. A. Outcomes of open versus
closed treatment of mandibular subcondylar fractures. J. Oral
Maxillofac. Surg. 59: 370, 2001.
4. Throckmorton, G. S., and Ellis, E., III. Recovery of mandibular motion after closed and open treatment of unilateral
mandibular condylar process fractures. Int. J. Oral Maxillofac.
Surg. 29: 421, 2000.

605

Plastic and Reconstructive Surgery February 2008


5. Choi, B. H., Kim, K. N., and Kang, H. S. Clinical and in vitro
evaluation of mandibular angle fracture fixation with the
two-miniplate system. Oral Surg. Oral Med. Oral Pathol. Oral
Radiol. Endod. 79: 692, 1995.
6. Choi, B. H., Yoo, J. H., Kim, K. N., and Kang, H. S. Stability
testing of a two miniplate fixation technique for mandibular
angle fractures: An in vitro study. J. Craniomaxillofac. Surg. 23:
123, 1995.
7. Dichard, A., and Klotch, D. W. Testing biomechanical
strength of repairs for the mandibular angle fracture. Laryngoscope 104: 201, 1994.
8. Fedok, F. G., Van Kooten, D. W., DeJoseph, L. M., et al.
Plating techniques and plate orientation in repair of mandibular angle fractures: An in vitro study. Laryngoscope 108:
1218, 1998.
9. Haug, R. H., Barber, J. E., and Reifeis, R. A. Comparison of
mandibular angle fracture plating techniques. Oral Surg. Oral
Med. Oral Pathol. Oral Radiol. Endod. 82: 257, 1996.
10. Ellis, E., III. Treatment methods for fractures of the mandibular angle. Int. J. Oral Maxillofac. Surg. 28: 243, 1999.
11. Dechow, P. C., Ellis, E., III, and Throckmorton, G. S. Structural properties of mandibular bone following application of
a bone plate. J. Oral Maxillofac. Surg. 53: 1044, 1995.
12. Prein, J., Assael, L. A., Klotch, D. W., Manson, P. N., Rahn,
B. A., and Schilli, W. Manual of Internal Fixation in the CranioFacial Skeleton. New York: Springer, 1998.
13. Champy, M., Lodde, J. P., Jaeger, J. H., and Wilk, A. Biomechanical basis of mandibular osteosynthesis according to the
F.X. Michelet method. Rev. Stomatol. Chir. Maxillofac. 77: 248,
1976.
14. Rudderman, R. H., and Mullen, R. L. Biomechanics of the
facial skeleton. Clin. Plast. Surg. 19: 11, 1992.
15. Daegling, D. J., and Hylander, W. L. Biomechanics of torsion
in the human mandible. Am. J. Phys. Anthropol. 105: 73, 1998.
16. Daegling, D. J., and Hylander, W. L. Occlusal forces and
mandibular bone strain: Is the primate jaw overdesigned?
J. Hum. Evol. 33: 705, 1997.
17. Broek, D. Elementary Engineering Fracture Mechanics, 3rd Ed.
Boston: Martinus Nijhoff, 1984.
18. Hylander, W. L. Stress and strain in the mandibular symphysis of primates: A test of competing hypotheses. Am. J.
Phys. Anthropol. 64: 1, 1984.
19. Nigg, B. M., and Herzog, W. Biomechanics of the Musculoskeletal
System, 2nd Ed. Chichester: Wiley, 1999.
20. Tate, G. S., Ellis, E., and Throckmorton, G. Bite forces in
patients treated for mandibular angle fractures: Implications
for fixation recommendations. J. Oral Maxillofac. Surg. 52:
734, 1994.
21. Anderson, T., and Alpert, B. Experience with rigid fixation
of mandibular fractures and immediate function. J. Oral
Maxillofac. Surg. 50: 555, 1992.
22. Assael, L. A. Treatment of mandibular angle fractures: Plate
and screw fixation. J. Oral Maxillofac. Surg. 52: 757, 1994.
23. Luhr, H. G., and Hausmann, D. F. Results of compression
osteosynthesis with intraoral approach in 922 mandibular
fractures (in German). Fortschr. Kiefer. Gesichtschir. 41: 77,
1996.
24. Niederdellmann, H., and Schilli, W. G. Functionary stable
osteosynthesis in the mandible (in German). Dtsch. Zahnarztl.
Z. 27: 138, 1972.
25. Kushner, G. M., and Alpert, B. Open reduction and internal
fixation of acute mandibular fractures in adults. Facial Plast.
Surg. 14: 11, 1998.

606

26. Champy, M., Lodde, J. P., Jaeger, J. H., Wilk, A., and Gerber,
J. C. Mandibular osteosynthesis according to the Michelet
technic: Justification of new material: Results. Rev. Stomatol.
Chir. Maxillofac. 77: 252, 1976.
27. Champy, M., Lodde, J. P., Jaeger, J. H., and Wilk, A. Mandibular osteosynthesis according to the Michelet technic: I.
Biomechanical bases. Rev. Stomatol. Chir. Maxillofac. 77: 569,
1976.
28. Gerlach, K. L., and Pape, H. D. Principle and indication for
mini-plate osteosynthesis (in German). Dtsch. Zahnarztl. Z.
35: 346, 1980.
29. Khouri, M., and Champy, M. Results of mandibular osteosynthesis with miniaturized screwed plates: Apropos of 800
fractures treated over a 10-year period (in French). Ann. Chir.
Plast. Esthet. 32: 262, 1987.
30. Schmelzeisen, R., Schliephake, H., Schultze-Mosgau, S., and
Krause, A. 2.7 mm (AO) or 2.0 mm miniplate osteosynthesis
in mandibular fractures (in German). Fortschr. Kiefer. Gesichtschir. 41: 88, 1996.
31. Tuovinen, V. A retrospective analysis of treatment of 279
patients with isolated mandibular fractures with titanium
miniplates. Oral Surg. Oral Diagn. 4: 45, 1993.
32. Davies, B. W., Cederna, J. P., and Guyuron, B. Non-compression unicortical miniplate osteosynthesis of mandibular
fractures. Ann. Plast. Surg. 28: 414, 1992.
33. Thaller, S. R., Reavie, D., and Daniller, A. Rigid internal
fixation with miniplates and screws: A cost-effective technique for treating mandible fractures? Ann. Plast. Surg. 24:
469, 1990.
34. Moore, M. H., Abbott, J. R., Abbott, A. H., Trott, J. A., and
David, D. J. Monocortical non-compression miniplate osteosynthesis of mandibular angle fractures. Aust. N. Z. J. Surg. 60:
805, 1990.
35. Herford, A. S., and Ellis, E., III. Use of a locking reconstruction bone plate/screw system for mandibular surgery. J. Oral
Maxillofac. Surg. 56: 1261, 1998.
36. Ellis, E., III, and Walker, L. R. Treatment of mandibular
angle fractures using one noncompression miniplate. J. Oral
Maxillofac. Surg. 54: 864, 1996.
37. Ellis, E., III, and Walker, L. Treatment of mandibular angle
fractures using two non-compression miniplates. J. Oral Maxillofac. Surg. 52: 1032, 1994.
38. Ellis, E., III, and Sinn, D. P. Treatment of mandibular angle
fractures using two 2.4-mm dynamic compression plates.
J. Oral Maxillofac. Surg. 51: 969, 1993.
39. Ellis, E., III, and Karas, N. Treatment of mandibular angle
fractures using two mini dynamic compression plates. J. Oral
Maxillofac. Surg. 50: 958, 1992.
40. Potter, J., and Ellis, E., III. Treatment of mandibular angle
fractures with a malleable noncompression miniplate. J. Oral
Maxillofac. Surg. 57: 288, 1999.
41. Ellis, E., III. Treatment of mandibular angle fractures using
the AO reconstruction plate. J. Oral Maxillofac. Surg. 51: 250,
1993.
42. Johansson, T., Meier, P., and Blickhan, R. A finite-element
model for the mechanical analysis of skeletal muscles.
J. Theor. Biol. 206: 131, 2000.
43. Hart, R. T., Hennebel, V. V., Thongpreda, N., Van Buskirk,
W. C., and Anderson, R. C. Modeling the biomechanics of
the mandible: A three-dimensional finite element study.
J. Biomech. 25: 261, 1992.
44. Korioth, T. W., Romilly, D. P., and Hannam, A. G. Threedimensional finite element stress analysis of the dentate
human mandible. Am. J. Phys. Anthropol. 88: 69, 1992.
45. Daegling, D. J., and Hylander, W. L. Experimental observation, theoretical models, and biomechanical inference in the

Volume 121, Number 2 Mandibular Fractures


study of mandibular form. Am. J. Phys. Anthropol. 112: 541,
2000.
46. Daegling, D. J. Biomechanics of cross-sectional size and
shape in the hominoid mandibular corpus. Am. J. Phys. Anthropol. 80: 91, 1989.
47. Levy, F. E., Smith, R. W., Odland, R. M., and Marentette,
L. J. Monocortical miniplate fixation of mandibular angle

fractures. Arch. Otolaryngol. Head Neck Surg. 117: 149,


1991.
48. Schmelzeisen, R., McIff, T., and Rahn, B. Further development of titanium miniplate fixation for mandibular
fractures: Experience gained and questions raised from a
prospective clinical pilot study with 2.0 mm fixation plates.
J. Craniomaxillofac. Surg. 20: 251, 1992.

Online CME Collections


This partial list of titles in the developing archive of CME article collections is available online at www.
PRSJournal.com. These articles are suitable to use as study guides for board certification, to help readers refamiliarize
themselves on a particular topic, or to serve as useful reference articles. Articles less than 3 years old can be taken for CME
credit.
Pediatric/Craniofacial
The Use of Perioperative Corticosteroids in Craniomaxillofacial Surgery: A SurveyThemistocles L. Assimes
and Lucie M. Lassard
Endoscopically Assisted Reconstruction of Orbital Medial Wall FracturesChien-Tzung Chen et al.
Subunit Principles in Midface Fractures: The Importance of Sagittal Buttresses, Soft-Tissue Reductions, and
Sequencing Treatment of Segmental FracturesPaul Manson et al.
Maxillary Reconstruction: Functional and Aesthetic ConsiderationsArshad Muzaffar et al.
Cleft Lip: Unilateral Primary DeformitiesJames D. Burt and H. Steve Byrd
Optimal Timing of Cleft Palate ClosureRod J. Rohrich et al.
Efficacy of Preoperative Decontamination of the Oral CavityAdam N. Summers et al.
Primary Repair of Bilateral Cleft Lip and Nasal DeformityJohn B. Mulliken
Correction of Secondary Deformities of the Cleft Lip NoseSamuel Stal and Larry Hollier
Correction of Secondary Cleft Lip DeformitiesSamuel Stal and Larry Hollier
Common Craniofacial Anomalies: The Facial DystosesJeremy A. Hunt and Craig Hobar
Common Craniofacial Anomalies: Conditions of Craniofacial Atrophy/Hypoplasia and NeoplasiaJeremy
A. Hunt and Craig Hobar
Subciliary versus Subtarsal Approaches to Orbitozygomatic FracturesRod J. Rohrich et al.
Management of CraniosynostosisJayesh Panchal and Venus Uttchin
The Management of Orbitozygomatic FracturesLarry H. Hollier et al.
Common Craniofacial Anomalies: Facial Clefts and EncephalocelesJeremy A. Hunt and Craig Hobar
Velopharyngeal Incompetence: A Guide for Clinical EvaluationDonnell F. Johns et al.
Distraction Osteogenesis of the Craniofacial SkeletonJack C. Yu et al.
Cleft RhinoplastyAllen L. Van Beek et al.
The Management of Frontal Sinus FracturesReha Yavuzer et al.
The Spectrum of Orofacial CleftingBarry L. Eppley et al.
The Pediatric Mandible I: A Primer on Growth and DevelopmentJames M. Smartt et al.
The Pediatric Mandible II: Management of Traumatic Injury or FractureJames M. Smartt et al.
Two Hundred Ninety-Four Consecutive Facial Fractures in an Urban Trauma Center: Lessons Learned
Patrick Kelley et al.
Aesthetic Management of the Nasal Component of Naso-Orbital Ethmoid FracturesJason K. Potter et al.
Management of Mandible FracturesDavid Heath Stacey et al.

607