MANDIBULAR BONE MECHANICS AND EVALUATION OF

TEMPOROMANDIBULAR JOINT DEVICES

A dissertation submitted in partial fulfillment of the
requirements for the degree of
Doctor of Philosophy

By
SHIRISHKUMAR M. INGAWALE
M.S., Wright State University, 2007
B.E., University of Mumbai, 2002

2012
WRIGHT STATE UNIVERSITY

COPYRIGHT BY
SHIRISHKUMAR M. INGAWALE
2012

WRIGHT STATE UNIVERSITY
SCHOOL OF GRADUATE STUDIES
December 15, 2012
I HEREBY RECOMMEND THAT THE DISSERTATION PREPARED UNDER MY
SUPERVISION BY Shirishkumar Marutirao Ingawale ENTITLED Mandibular Bone
Mechanics and Evaluation of Temporomandibular Joint Prostheses BE ACCEPTED IN
PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF Doctor
of Philosophy.
Tarun Goswami, D.Sc.
Dissertation Director

Ramana Grandhi, Ph.D.
Director, Engineering Ph.D. Program

Andrew Hsu, Ph.D.
Dean, School of Graduate Studies
Committee on Final Examination

Tarun Goswami, D.Sc.

R. Michael Johnson, M.D., F.A.C.S.

Deepak G. Krishnan, D.D.S.

S. Narayanan, Ph.D.

David B. Reynolds, Ph.D.

ABSTRACT

Ingawale, Shirish, M. Department of Biomedical, Industrial, and Human Factors Engineering,
Wright State University, 2012. Mandibular Bone Mechanics and Evaluation of
Temporomandibular Joint Devices.

Knowledge of the mandibular and temporomandibular joint (TMJ) biomechanics is of
importance in various clinical scenarios as it helps better understanding of the structure and
function necessary to diagnose, prevent, and treat temporomandibular disorder (TMD). The
objectives of this dissertation research were to characterize biomechanical behavior of cadaveric
human mandible, and to design and analyze patient-specific total TMJ prostheses. We performed
a combined experimental-numerical study to validate the finite element (FE) models of 16
cadaveric human mandibles by comparing strain gauge measurements with FE-predicted surface
strains. Analysis of experimental data showed that strains at the condylar locations were
significantly different from those at other locations on the mandibular cortical surface, and that
sex and age of the subject did not have significant correlation with strain. Comparing the FEpredicted strain with the experimental data, we found strong statistical correlation and
agreement. This study demonstrated that our methodology of generating subject-specific FE
models and performing FE simulations is a valid and accurate non-invasive method to evaluate
the complex biomechanical behavior of human mandibles.
Stiffness variation and fatigue microdamage accumulation occur in bone as a result of
physiological loading. In this study, stiffness and damage accumulation in cadaveric mandibles
were derived from experimental data. Stiffness reduction showed a steep initial decline followed

iv

Age had negative correlation with maximum load before failure. Our custom-designed TMJ implants offer novel features such as locking mechanism. but the notches may not act as stress-risers in the device. A methodology was developed to design patient-specific total TMJ prostheses based on the patient’s medical images. The study demonstrated that our proposed methodology provides viable means for patient-specific design. initially. change in stiffness. anatomic condition. v . which transitioned into the region of saturation with nearly no change in damage. These unique design aspects can maximize the opportunity for accurate adaptation to host anatomy. and in areas of host bone surrounding the screws. Age and sex did not have significant effect on fatigue life. and improvement of the design and durability of total TMJ prostheses. The micro-strains developed in mandibular and fossa bone in the vicinity of fixation screws were well within safe limits. Higher stresses were found in the neck portion of fixation screws. perforated notches protruding into host bone. Peak von Mises stresses were within the limit of safety for the prostheses and host bone.by a transition into constant stiffness. Analysis of damage accumulation showed an abrupt increase. improved fixation and implant stability for challenging and complex anatomic situations. Results indicated that stress development in prosthetic notches could augment bone growth into perforated surface of notches. and surgeon’s requirements. customized osteotomy/cutting guides. and custom drill guides. and maximum damage accumulation in the mandibles. Stress and strain profiles in patient-specific total TMJ reconstruction were investigated through FE simulations under normal and over-loading conditions. Majority of damage accumulation was observed during first few hundreds of loading cycles.

........................................................................... BACKGROUND ...........1 In-Vivo Assessment..............2 TMJ Implants.............................2.....................................................................................................................4.........5 Bone – Material and Mechanical Properties .............................................. 12 2.. 5 2............................................................................................2 In-Vitro Biomechanical Analysis of Bone ...........5..................6 Biomechanics of the Mandible and TMJ ............ 11 2............6........6................................ INTRODUCTION.................... 28 3.......... 18 2........................................................... 10 2.......................................2 TMJ Anatomy and Function ...............................3 Post-surgery Assessment .................... 36 3..................................................................................................................................................................7 Problem Statement and Research Objectives ...1 Introduction ...........2 Materials and Methods ......1 Image Acquisition ................................TABLE OF CONTENTS 1..............................................................................................................6.........................4...... 27 2.......................... 22 2........................................1 Overview .......................... EXPERIMENTAL BIOMECHANICAL EVALUATION OF CADAVERIC HUMAN MANDIBLES ....................................................................... 37 vi ....................................................................5............................................................................................................................ 6 2......1 Alloplastic Replacement of TMJ ........... 24 2.................3 Temporomandibular Disorder (TMD) ........................ 30 3.......................................................... 16 2............................... 5 2....................................4 Treatment Options for TMD .............................................................................. 22 2.............................................................. 9 2....................................................................................................2 In-Vitro Assessment .............................................1 Bone Stiffness and Microdamage ................................................. 1 2............................................................... 19 2.... 30 3....

........................................................4 Results ............................................................................. 52 3............................3 Damage Development ... 48 3.........1 Introduction ........................................ 66 4............................................................... 70 4..................1 Statistical Analysis .........2... 73 4........2.......2.....................2 Materials and Methods .......................... 40 3.................3.. 46 3...................................................2 Strain Gauge Attachment ............ 82 4..........................................................................................3 Mechanical Testing .........................................................................4 Stiffness Reduction ........... 50 3.......................4 Discussion ...................................... 75 4..........2........................................... 46 3.................................................................................................................4 Data Analysis...... 73 4............................. 55 3............................................................................................................................................................................................4.........................5 Discussion ................................................................................ 96 vii ......5 Damage Accumulation ....................2................................3 Effect of Dental Status........................................................ 70 4................4...................................................... 38 3............... 81 4......1 Experimental Strain Measurement .......... THREE-DIMENSIONAL ANATOMICAL AND FINITE ELEMENT MODELING AND ANALYSIS OF CADAVERIC MANDIBLES ...........2 Subject-Specific FE Model Creation ......................................4....................................................................4.....................................3 Finite Element Analysis ...............................................................4.........................................................................................................................................................................2 Mandible Fracture ...................... 52 3.......................................................3 Results .2............ 78 4............................................................................................................

..................................... Introduction ...........................3 Future work ........ 147 5.................................................................................................. 162 6......3................ 156 5............................ SUMMARY...........3............................................................2 FEA of Total TMJ Implant ..1.......................................................... 103 5............... 164 REFERENCES .................2............................. CONCLUSIONS......................2 Materials and Methods ........................................... 166 viii ........1 Stress and Strain in Native Bone ......................................................................2........ 161 6.......................................................................... 107 5.....................1 Current state of the TMJ research ............ 158 6...........2 Dissertation research findings and contributions .............4 Discussion ..............................................2 Stress and Strain in TMJ Implants..............................5...1 Design of Patient-specific Total TMJ Prosthesis ............................. 139 5...................................................... DESIGN AND FINITE ELEMENT ANALYSIS OF PATIENT-SPECIFIC TOTAL TEMPOROMANDIBULAR JOINT IMPLANTS......................................................................................................... 109 5......................... 154 5................................................................................................3 Stress and Strain in Screws............................... 109 5.............................1..................... 103 5........................................................................3 Results ..................................3. AND FUTURE WORK ........................................................................................................ 161 6................1 Design Requirements for Total TMJ Prosthesis ............................. 152 5.............

..................... Normal anatomy of the jaw and the TMJ ................................................... 39 Figure 3...................................... 8......... 4............ Loading set-up of EnduraTEC materials testing machine using custom-designed fixture for mandibles.................................. 1.. 51 Figure 3.......... 43 Figure 3..................................................................................... ......................................... 5................................................ 35 Figure 3. 9.................... 44 Figure 3.... 54 ix ................... ......................................... Schematic of strain gauge attachment at five exactly defined locations on the cortical surface of the mandible ....... 3..... 1...... Schematic showing steps involved in the experimental-numerical biomechanical analysis of human cadaver mandible........... Loading set-up of EnduraTEC materials testing machine with custom-designed fixture for mandibles................................................. Axial stiffness reduction during cyclic compressive loading of mandibles in Group 3. 7................................... 7 Figure 2..... 2............ ............................... Anatomical structure of the temporomandibular joint (TMJ) ......... Schematic representation of load variation during mechanical testing of mandibles............................................. 8 Figure 3............................ 6..................... Failure of the mandibles at different location...... 2.........................................................................................LIST OF FIGURES Figure 2........................................... Axial stiffness reduction during cyclic compressive loading of mandibles in Group 2. 10.... ...................................... 53 Figure 3...... Axial stiffness reduction during cyclic compressive loading of mandibles in Group 1.................................. ......................................................................... 54 Figure 3........ ... ................. 45 Figure 3...................... Schematic showing stages of damage progress in cortical bone versus fatigue cycles .............................. 32 Figure 3...

.............................. 16. ........................................................ 76 Figure 4............... 55 Figure 3.................................... Damage accumulation in the mandibles from Group-2 during cyclic compressive incisor loading...... ......... 85 Figure 4....... A Mandibular FE model...... 58 Figure 3... 19.................................................... 15.................... Plot of experimental/measured strain and FE predicted maximum principal strain for mandibles in loading Group-1.................... Axial stiffness reduction during cyclic compressive loading of mandibles in Group 4....... 86 x . 13.............. 5....... 3D reconstruction of mandible in Mimics software........... 4........... Damage accumulation in the mandibles from Group-4 during cyclic compressive incisor spectrum loading........................................................ 79 Figure 4.... Damage prediction for Group-4 specimens................ 62 Figure 3..... 12.... ............................. ................................................................... 1........... ...... 2................Figure 3.......... 57 Figure 3.. Damage prediction for Group-1 specimens................ 80 Figure 4...... Damage prediction for Group-2 specimens............. 56 Figure 3....... ........ Maximum principal strain distribution in one of the mandible FE models ..................................................... and illustration of loading and boundary condition ....... 3...................................... 65 Figure 4....... 14.... .... Subject-specific anatomical reconstruction of the mandible ..... ..... ...................... Damage accumulation in the mandibles from Group-1 during cyclic compressive molar loading...... Damage accumulation in the mandibles from Group-3 during cyclic compressive molar spectrum loading............................. ............................. Damage prediction for Group-3 specimens............................................. 17................. 63 Figure 3.............................................................. Plot of experimental/measured strain and FE predicted maximum principal strain for mandibles in loading Group-2........ 58 Figure 3................................. 11........................... 64 Figure 3... 18.. 77 Figure 4... .. 6......

....................... Plot of experimental strain measured with strain gauge at location L2 on mandibles in all loading groups................................... 93 Figure 5....................................... 116 xi .... 111 Figure 5............................ Plot of experimental/measured strain and FE predicted maximum principal strain for mandibles in loading Group-4..................... . Plot of experimental strain measured with strain gauge at location L5 on mandibles in all loading groups........... 90 Figure 4..................... Plot of experimental strain measured with strain gauge at location L4 on mandibles in all loading groups.. ............ Plot of experimental strain measured with strain gauge at location L3 on mandibles in all loading groups............... 92 Figure 4.............. ...... Plot of experimental strain measured with strain gauge at location L1 on mandibles in all loading groups............................................ ........................ 3.......... ........................ 13...... ...... 8.......................... 89 Figure 4.. Custom-designed surgical guide for condylectom .... Shape outline of a custom-designed condylar/ramus prosthesis......... 112 Figure 5... .................................... Plot of experimental/measured strain and FE predicted maximum principal strain for mandibles in loading Group-3. 7....................... 9....... 1........... 10.............................. 4.......................Figure 4........................ ................................. 88 Figure 4.................. 12............................ 87 Figure 4.................. 11..... 91 Figure 4..................................... 2................ Methodology followed for design and preliminary analysis of the patient-specific total temporomandibular joint (TMJ) prostheses... 113 Figure 5................ .................................................................. Subject-specific 3D anatomical reconstruction of the patient’s mandible and fossa eminence performed from computed tomography (CT) data using Mimics software.

............................................... 15..... 9............... ................ ...........11 ............... 6. Inferior rectangular surface of the device has a circular grove for articulation with condylar head .......9 and 5.... 10.................. 5............ 8................... Shape outline of a custom-designed condylar/ramus prosthesis for the replacement of right TMJ of a patient................. A simple custom-design of the fossa prosthesis with screw holes ................................. 7............ 128 Figure 5.................... 126 Figure 5........ 16........... 125 Figure 5. 11........... Patient-fitted fossa implant with circular inferior surface which also has a circular grove for articulation with condylar head................. Shape outline of a custom-designed condylar/ramus component of the TMJ total joint replacement prosthesis for left TMJ of a patient.. 14... ................................ Patient-fitted design of a fossa prosthesis.... Patient-specific design of fossa prosthesis ...... 17............. 119 Figure 5.. Custom-designed condylar/ramus component of the TMJ total joint replacement prosthesis for left TMJ of a patient .... 12.. 128 Figure 5.... Custom-designed fossa prosthesis with circular articular surface .. 127 Figure 5.... 120 Figure 5............................ Shape outline of a custom-designed condylar/ramus component of the TMJ total joint replacement prosthesis for left TMJ of a patient.... 118 Figure 5. 117 Figure 5.................................... 130 xii ...........Figure 5... 124 Figure 5............... Shape outline of a custom-designed condylar/ramus/mandibular component of the TMJ prosthesis for reconstruction of left TMJ. Modification of the custom-designed condylar/ramus component ..... 13........ Modification and refinement of custom-designed condylar/ramus component shown in Figures 5................................................. .... Different shapes of the condylar head of the custom-designed condylar/ramus component of the TMJ prosthesis ..... 18.......................................... 123 Figure 5. 116 Figure 5............................... 129 Figure 5.... Patient-specific design of fossa prosthesis.........................................

............... 26.... Patient-specific design of a fossa implant with circular articular surface/hole in the inferior face of the device .......... 22.................. 27..... 143 Figure 5.................. 25................. Patient-specific total TMJ prosthesis. 19...... 136 Figure 5......... 20............................. Custom-designed screws with locking mechanism ........ Stress distribution in the host bone components during FE simulations of the total TMJ replacement with custom designed simple TMJ prostheses. 131 Figure 5........................... 137 Figure 5....................................................................... 30............................................................... Assembly of all parts of the FE model (including anatomic and prosthetic components)....... 23..................................... ...... 132 Figure 5.................................. 142 Figure 5................... A patient-specific total TMJ prosthesis..... 29.... ........ Peak von Mises stress in patient-specific ‘simple’ TMJ prosthesis (without notches) during FE simulations of two different loading scenarios... 144 Figure 5..................................................................... .............. A custom-designed locking screw for TMJ prosthesis. 24.................................................................... 3D finite element mesh of the components of patient-specific total TMJ prostheses ............................ 141 Figure 5. A patient-specific total TMJ prosthesis with medial notches in fossa and condylar components............... 133 Figure 5.............. Shape outline of the patient-specific total TMJ prosthesi ..................... and schematic representation of model constraints and load application for FE simulation of total TMJ prostheses and anatomical components.. 149 Figure 5. 145 Figure 5. 150 xiii ........ 28.......... 21.................................................................. 3D finite element mesh of the host bone components prepared for total prosthetic replacement of the left TMJ ..............................Figure 5.... .

..... ...................Figure 5................... .. 151 Figure 5............................... 33....................... 32............... Peak von Mises stress in condylar/ramus and fossa components of patient-specific total TMJ prostheses during FE simulations under normal and worst-case/over-load configurations..................................... ....... 36. ...... 155 Figure 5................... Peak von Mises stress in patient-specific ‘notched’ TMJ prosthesis (with medial notches) during FE simulations of two different loading scenarios... 31.......... Stress distribution in the host bone components during FE simulations of the total TMJ replacement with custom designed TMJ prostheses with medial notches................. 158 xiv ................. ..................... 153 Figure 5.......... 35............................................................... Peak von Mises stress in the fixation screws for condylar/ramus and fossa components of patient-specific total TMJ prostheses during FE simulations under normal and worst-case/over-load configurations... ................................. Peak von Mises stress in the mandibular and fossa bone adjacent to fixation screws of total TMJ prostheses during FE simulations under normal and worst-case/over-load configurations......................... Peak micro-strain in the mandibular and fossa bone adjacent to fixation screws of total TMJ prostheses during FE simulations under normal and worst-case/over-load configurations.............. 154 Figure 5...... 152 Figure 5......... 34..........

....................... Patient demographics.............. loading type....... 147 Table 5........ 95 Table 5......... t-test (to evaluate effect of sex on experimental strain)...................... Statistical analyses using non-parametric Mann-Whitney Test for specimens in Groups 1 and 2 .................................................. 3............... 3... ............... 37 Table 3.................... 94 Table 4......... Statistical analyses using Wilcoxon Signed Ranks Test (to analyze distribution of strain at condylar locations and other sites of strain measurement) ...... and observations about mechanical testing and finite element analysis (FEA) of mandibles subjected to cyclic compressive loading........ Material properties for anatomical and prosthetic TMJ components.... Indications for the alloplastic reconstruction of the TMJ .............LIST OF TABLES Table 3. load type......... 4............ 1............. Peak von Mises stresses developed in condyle/ramus and fossa components....... 47 Table 3............... Criteria for the successful alloplastic total reconstruction of the TMJ............................... 108 Table 5....... and observations for mandibles tested under cyclic compressive loading.............................. Demographics of the cadaveric mandible specimens... 1............... 84 Table 4.... 49 Table 4.................. 3......................... ........... and fixation screws of the simple and notched designs of patient-specific total xv ........ and Intra-class Correlation Test (to analyze ‘statistical agreement’ between experimental strain and FE strain) ...... . 2. Statistical analyses using Spearman’s Correlation Test (to analyze effect of age on experimental strain). 105 Table 5.......... Pearson’s Correlation Test (to evaluate statistical correlation between experimental strain and FE strain... 2............... 2.. ................................... 1........................ Patient demographics.............

.. Peak stress and strain developed in host bone surrounding the fixation screws of the simple and notched designs of patient-specific total TMJ prostheses during FE simulations under normal and worst-case/ over-loading configurations............................................................. 148 xvi ......................... 148 Table 5.TMJ prostheses during FE simulations under normal and worst-case/ over-loading configurations ................ ......... 5.........................................................................

ABBREVIATIONS. Average BIN Bilateral-incisor-normal BIO Bilateral-incisor-overload BIS Bilateral-incisor-spectrum BMN Bilateral-molar-normal BMO Bilateral-molar-overload BMS Bilateral-molar-spectrum CI Confidence interval Co-Cr Cobalt-Cromium Co-Cr-Mo Cobalt-Cromium-Molybdenum CT Computed tomography D Damage D(n) Damage at nth cycle Dmax Maximum damage E Enzyme ES Complex Fa Axial load/force FDA Food and Drug Administration xvii . AND ACRONYMS  Level of significance µ Micro (1 micro unit = 1 * 10-6 unit) 3D Three-dimensional Avg.SYMBOLS.

FE Finite element FEA Finite element analysis FEM Finite element model/modeling FEP Fossa eminence prosthesis H0 Null hypothesis Hz Hertz k Axial stiffness Km Michaelis constant = Substrate concentration at which V = ½ * Vmax Or = Cycles at Dmax * 1/2 ……. L2. L3. L5 Locations of strain gauges attached to cadaveric mandibles LD Linear distance LTF Load-to-failure m Meter mm Millimeter MRI Magnetic resonance imaging N Newton NIH National Institutes of Health o Degree Celsius C xviii . L4. (modified for damage prediction) kN Kilo-Newton ko Initial axial stiffness L1.

Standard deviation Ti-6Al-4V Titanium alloy which contains 6% Aluminum.p Probability P Product PMMA Polymethylmethacrylate PPT Pressure pain threshold PT Proplast/Teflon PTFE Polytetrafluoroethylene r Coefficient of correlation R2 Coefficient of determination S Substrate Std. 4% Vanadium. Dev. and nearly 95% Titanium by weight TMD Temporomandibular disoder TMJ Temporomandibular joint UHMWPE Ultra-high molecular weight polyethylene V Rate of enzymatic reaction Vmax Maximum rate achieved by the system at maximum or saturating substrate concentration Yrs Years δa Axial displacement xix .

Dr. guidance. Ronald Markert for his guidance about statistical analysis. and Dr. I would like to express my sincere gratitude to Dr. and encouraging me to pursue doctoral degree. and encouragement in efficiently and effectively completing this work. and Ms. Special thanks to Dan Nolan and Dan Miska for helping with cadaver management and specimen harvesting. Miami Valley xx . Narayanan. Tarun Goswami. and companies for their help: Wright State University’s College of Engineering. Krishnan for letting me observe live surgeries and connecting me with his professional contacts in the medical device industry. My sincere thanks to all my committee members: Dr. I am also thankful to the following institutes. Thanks to the Ph. and School of Medicine. and to Dr. training. insightful ideas. I am grateful to Dr. Darrell Carroll and Emily Liening for their help with CT scanning the cadaver specimens. S. support. organizations. Michael Johnson for their valuable time. and Dr. Narayanan.D. Alysoun Taylor-Hall. Industrial and Human Factors Engineering department for being accommodating and understanding over the past years. in Engineering Program for accepting me into the program and helping me stay on track. Phani Kidambi. Dr. Daisy Stieger for their encouragement. Deepak Krishan. Johnson for his timely help in harvesting cadavers for my study. I would also like to thank the staff of Biomedical. Greg Gould for assisting me in conducting the mechanical tests. S. and help in many ways during my graduate studies. Dr. Ms. Dr. Thomas Hangartner for providing the water-bath equipment for CT scanning of cadaver specimens. David Reynolds. I am indebted to him for accepting. Goswami for his continued guidance. and help in many ways. Special thanks to Dr.ACKNOWLEDGEMENTS I am privileged to have completed my doctoral dissertation research under guidance of Dr.

National Institutes of Health.. Inc. Inc. University of Cincinnati Medical Center. Thank you. sporting great attitude. I am eternally obliged to my friends. Inc. who over the years have become family. Ltd. I am very thankful to all of the current and past members of the Goswami Labs and Device Development Center for creating a vibrant and enthusiastic work environment. The TMJ Association. and helping me in many ways. and Synthes... Without their constant encouragement and steadfast friendship.Hospital. Materialise.. I would have been lost. xxi . TMJ Bioengineering Conference. Biomet Microfixation. Inc. TMJ Concepts.

my loving parents: Words cannot express how grateful I am for the way you raised me up.DEDICATION I dedicate this dissertation: To Aai and Bapu. To my extended family. relatives. my dear wife: Thank you for your unconditional love. I strive to bring more smiles. Shalaka: Thank you for always being understanding and supportive. To my dear siblings. and well-wishers: I am very thankful for your support and help in many ways xxii . There is no greater joy for me than seeing you smile. Sudarshan. and your vision and countless sacrifices to ensure a better life for me. friends. You are the best siblings one could have. To Vanita. Sharad. and unwavering support through thick and thin.

1. INTRODUCTION

Temporomandibular joint (TMJ), which connects the mandible or lower jaw to the skull and
regulates jaw movement, is one of the most complex and highly used joints in a human body.2, 3,
23, 24, 64

Temporomandibular disorder (TMD) is a set of problems concerning the TMJ and

associated components of the masticatory system. 20-25% of the population is reported to exhibit
one or more symptoms of TMD, and approximately one million new TMD patients are
diagnosed yearly in USA alone.23, 24, 122 With millions of people affected by TMD of varying
form and intensity, it is a problem that should be looked at more fully.24, 64
Various non-invasive, minimally invasive, and open surgery options including joint
replacement are currently available for TMJ patients. However, since a large fraction of TMD
causes are currently unexplained, further knowledge of structure and function of the TMJ
components, and etiology of TMD may help in more efficient prevention, diagnosis, and
treatment of TMD. The TMJ Bioengineering Conference, held in 2006 and 2009, underlined the
importance of collective interdisciplinary research efforts involving tissue engineering,
biomechanics, clinical community, and biology.24 Advanced technology and knowledge from
diverse interdisciplinary and multidisciplinary areas have been utilized to advance the
understanding of TMJ components. In recent years, the application of biomechanics to TMJ
research has shown promising outcomes. Through this dissertation, we present our TMJ research
from biomechanical point of view. This includes biomechanical evaluation of the cadaveric
human mandibles tested under different configurations of cyclic fatigue loading; patient-specific
three-dimensional (3D) anatomical reconstruction of the mandibles using computed tomography

1

(CT) images; biomechanical assessment of the mandibles using subject-specific finite element
(FE) method, which is validated by our experimental method; and design and analysis of the
patient-specific total TMJ prostheses.
Chapter 2 provides background information necessary to perform the proposed study, i.e.,
biomechanical evaluation of the natural and prosthetic human mandible and TMJ through
cadaver experiments and FE analysis. The chapter begins with information about the anatomy
and function of the mandible and TMJ, TMD, and treatment options for TMD patients. The
chapter then covers the fundamental idea behind the methodology used in this research. Finally,
based on the presented background material, the chapter proposes the problem statement and
research objectives.
Chapter 3 describes our experimental biomechanical study of the cadaveric human mandibles.
We performed mechanical testing of sixteen mandibles divided in four groups, with mandibles in
each group subjected to unique cyclic loading configuration. The chapter discusses acquisition of
cadaver mandibles and their CT scans, use of strain gauges, mechanical test set-up, and data
acquisition. We explored the strain development, stiffness variation, damage accumulation, and
failure modes in the mandibles. The chapter also describes statistical distribution of age,
maximum load before failure, cycles until failure, overall change in stiffness, and maximum
damage accumulation across the mandibles from all loading groups. Analysis of experimental
strain data, and its use in validating the numerical strain predictions through FE simulations are
discussed in the subsequent chapter.
Chapter 4 focuses on our methodology for subject-specific 3D anatomical reconstruction of
the mandibles using CT images, creation of FE volume mesh models, and FE simulations
2

accurately replicating the experimental technique. We discuss statistical aspects of the
experimentally acquired surface strains in cadaveric human mandibles under different
configurations of cyclic compressive loads. Analysis of experimental data showed that strain
measured at the condylar locations were significantly different from those at other locations on
the mandible, and that sex and age of the subject did not have significant correlation with the
strain. Strain patterns of each mandible were derived from the FEA paralleling the experimental
setup, and matched with the experimental data. Comparison of the FE numerical predictions of
mandibular strain with the experimental data showed a good statistical correlation and statistical
agreement between in-vitro measurements and FE results. Chapter 4 demonstrates that our
methodology of generating subject-specific FE models and performing FE simulations is a valid
and accurate non-invasive method to evaluate the complex biomechanical behavior of cadaveric
human mandibles. Such validated FE models which adequately reproduce mechanical behavior
of the mandibles can be used further to study the TMJ, and to design and pre-clinically evaluate
implants for the mandible and TMJ.
Chapter 5 explains our approach to developing novel patient-specific total TMJ prosthesis.
Our unique patient-fitted designs based on medical images of the patient’s TMJ offer accurate
anatomical fit, and better fixation to the host bone. The special features of our prostheses
promise an improved osseo-integration and durability of the TMJ devices. Our design process is
based on surgeon’s requirements, feedback, and pre-surgical planning to ensure anatomically
accurate and clinically viable device design. We use our validated methodology of subjectspecific FE modeling and simulations to evaluate the design and performance of TMJ prostheses.

3

Pre-clinical performance evaluation of our prosthetic system is performed through FE analysis
under loading scenarios which reflect the patient’s normal and or worst-case TMJ loading.
Chapter 6 ties together the results of Chapters 3, 4 and 5, and presents a summary of the key
findings of this research. The chapter provides a discussion of the findings in light of the broader
picture of the structural and biomechanical aspects of the mandible and our TMJ implant design,
highlights the significance of the findings from clinical and product development view points,
and provides recommendations for future research.

4

2. BACKGROUND

2.1 Overview
Temporomandibular joint (TMJ) connects the mandible or lower jaw to the skull and
regulates movement of the jaw (see Figure 1.1). TMJ is one of the most complex as well as most
used joints in a human body.2, 53 The most important functions of TMJ are mastication and
speech. Temporomandibular disorder (TMD) is a generic term used for any problem concerning
the jaw and TMJ. Injury to the jaw, the TMJ, or muscles of the head and neck can cause TMD.
Other possible causes include grinding or clenching the teeth; dislocation of the disc; presence of
osteoarthritis or rheumatoid arthritis in the TMJ; stress, which can cause a person to tighten
facial and jaw muscles or clench the teeth; aging.6, 14, 32, 43, 107, 129 The most common TMJ
disorders are pain dysfunction syndrome, internal derangement, arthritis, and trauma.16, 22-24
TMD is seen most commonly in people between the ages of 20 and 40 years, and occurs more
often in women than in men.22, 24, 64, 132 In 1996, the National Institutes of Health (NIH) estimated
that 10 million Americans had painful TMJ dysfunction, and more women were affected by it
than men. Some surveys have reported that 20-25% of the population exhibit symptoms of TMD,
with approximately one million new patients diagnosed yearly.22, 149 We have previously
published a comprehensive, state-of-the-art review about the structure, function, dysfunction,
treatment options, and biomechanics of the TMJ.63, 64

5

2.2 TMJ Anatomy and Function
TMJ is a bi-condylar joint in which the condyles, located at two ends of the mandible,
function at the same time. The movable round upper end of the lower jaw is called the condyle
and the socket is called the articular fossa (see Figure 1.1). Between the condyle and the fossa is
a disc made of fibrocartilage that acts as a cushion to absorb stress and allows the condyle to
move easily when the mouth opens and closes.3, 62 The bony structure consists of the articular
fossa; the articular eminence, which is an anterior protuberance continuous with the fossa; and
the condylar process of the mandible that rests within the fossa. The articular surfaces of condyle
and fossa are covered with cartilage.62 The disc divides the joint cavity into two compartments superior and inferior.62, 134 The two compartments of the joint are filled with synovial fluid which
provides lubrication and nutrition to the joint structures.53, 134 The disc distributes joint stresses
over broader area thereby reducing chances of concentration of the contact stresses at one point
in the joint. The presence of disc in the joint capsule prevents the bone-on-bone contact and
possible higher wear of the condylar head and articular fossa.9, 73, 92, 134 The bones are held
together with ligaments. These ligaments completely surround the TMJ forming the joint
capsule.
Strong muscles control movement of the jaw and the TMJ. The temporalis muscle which
attaches to the temporal bone elevates the mandible. The masseter muscle closes the mouth and
is the main muscle used in mastication60 (see Figure 1.2). Movement is guided by the shape of
the bones, muscles, ligaments, and occlusion of the teeth. TMJ undergoes hinge and gliding
motion.2 The TMJ movements are very complex as the joint has three degrees of freedom, with
each of the degrees of freedom associated with a separate axis of rotation. Rotation and anterior
6

translation are the two primary movements. Posterior translation and medio-lateral translation are
the other two possible movements of TMJ.29

Figure 2. 1. Anatomical structure of the temporomandibular joint (TMJ).3

7

et al. The lateral view of the skull (Panel A) shows the normal position of the mandible in relation to the maxilla. Normal anatomy of the jaw and the TMJ. the TMJ capsule. hyglossus. Source: Scrivani. and stylohyoid. Also shown (Panels B and C) are the deep muscles associated with jaw function and the TMJ intra-articular disc. 2.119 8 .Figure 2. and the masticatory muscles – temporalis. mylohyoid. masseter. anterior and posterior digastrics.

23. and often causes the TMD to worsen. The functional unilateral posterior cross-bite. arthritis. 42. 22-24. 147 Some surveys have reported that 20-25% of the population exhibit symptoms of TMD while it is estimated that 30 million Americans suffer from it. internal derangement.23. and traumas.6. 122 Disc displacement is the most common TMJ arthropathy and is defined as an abnormal relationship between the articular disc and condyle. 31 Different types of functional malocclusion have been shown to be partly responsible for signs and symptoms of TMD. 54.23. 153 The majority of TMJ patients is female. 100 9 . juvenile chronic arthritis – a chronic arthritis in childhood with an onset before the age of 16 years and a duration of more than three months – are also reported as TMD risk factors. habitual body posture during sleep. The most common TMJ disorders are pain dysfunction syndrome. 129 Almost 70% of TMD patients have disc displacement. and occurs more often in women than in men. 2224 TMD is seen most commonly in people between the ages of 20 and 40 years.23.16. 129 As the disc is forced out of the correct position there is often bone on bone contact which creates additional wear and tear on the joint. with approximately one million new patients diagnosed yearly. 44.3 Temporomandibular Disorder (TMD) TMD is a generic term used for any problem concerning the jaw joint. aged between 20–40 years. 140. 24.16.15.31. 140.31. 147 The female to male patient prevalence is reported to be varying from 3:1 to 8:1.2. 122.

and joint replacement.81 Arthroscopy is a surgery performed to put the displaced articular disc back into place. nonsurgical therapies first. Arthrocentesis is the simplest form of surgical intervention into the TMJ performed under general anesthesia for sudden-onset. 135 However.2. and remains controversial. wearing splints.22. Conditions that are always treated surgically involve problems of overdevelopment or underdevelopment of the mandible resulting from alterations of condylar growth. arthroscopy.4 Treatment Options for TMD Treatments for the various TMJ disorders range from physical therapy and nonsurgical treatments to various surgical procedures. and tumors of the TMJ. 67. mandibular ankylosis. The initial treatment does not always work and.24 It involves inserting needles inside the affected joint and washing out the joint with sterile fluids. closed lock cases in patients with no significant prior history of TMJ problems. The non-surgical treatment options include medication. 67. However. The majority of TMD patients can be successfully treated by non-surgical therapies. 135 Surgery can play an important role in the management of TMD. self-care. to keep the synovial joint lubricated and to maintain full range of the jaw motion. therefore. the plastic mouthpieces that fit over the upper and lower teeth to prevent the upper and lower teeth from coming together.53 Splints are used to help control bruxism – a TMD risk factor in some cases. and surgical interventions may be required for only a small part of the patient population. Usually the treatment begins with conservative. physical therapy.22. with surgery left as the last option. 43. lessening the effects of clenching or grinding the teeth. 43. discectomy. if the ligament and retrodiscal tissue was previously 10 . the long-term effectiveness of this therapy has been widely debated. more intense treatments such as joint replacement may be a future option.81 The surgical treatments include arthrocentesis.

4. TMJ replacement is performed in certain circumstances such as bony ankylosis. 151 The success of joint replacement surgeries significantly depends on the number of prior surgeries with better outcomes for patients with fewer previous TMJ surgeries. recurrent fibrous ankylosis. 132 2. and loss of the condyle from trauma or pathology.128. the current end stage treatment is joint replacement. removal of the painful pathologic disc causes the TMJ reduced absorbency and increased loading during articulation.107. conservative treatment options must be exhausted. which is often performed on individuals with severe TMD. then just popping the disc back into place is only a temporary fix as the joint still would not work as well as usual. absence of the TMJ structure due to pathology. 108 Joint replacement is a surgical procedure in which the severely damaged part of TMJ is removed and replaced with a prosthetic device.86. two or more previous TMJ surgeries. advanced rheumatoid arthritis. 108. all non-surgical. to remove the damaged and very often dislocating articular disc without going to a more extreme treatment such as a joint prosthetic. Therefore.32 Discectomy is a surgical treatment. 152 Long-term follow-up 11 . an anchor – Mitek mini anchor – and artificial ligaments have been used for several years to stabilize the articular disc to the posterior aspect of the condyle. and all conservative surgical methodologies should be employed.107. However. 132 Before a joint replacement option is ever considered for a patient. 107. in severe cases or after multiple operations.128. tumors involving the condyle and mandibular ramus area.stretched beyond its elastic range. aseptic necrosis of the condyle. severe degenerative joint disease.1 Alloplastic Replacement of TMJ While more conservative treatments are preferred when possible.

140 stipulated the life expectancy of TMJ implant as one of the most critical requirements. 86. 107. A total TMJ prosthesis was not described until 1974.91 The United States Food and Drug Administration (FDA). rigidly stabilized components.studies now available in the literature support the safety and efficacy of joint replacement under appropriate circumstances.4. condylar replacements. 108.123 Although alloplastic TMJ prostheses were in use since early 1960s. in 1993. and as total joint prostheses. To be a successful treatment option.152 van Loon. low wear. but not both. To reduce the frequency of painful and expensive revision surgery. 151 2.84. a TMJ implant must have biocompatible materials.71 Till then. a TMJ device should have an expected lifetime of more than 20 years. Many other alloplastic TMJ devices were introduced later. et al.151 However. functionally compatible materials. and fatigue. and corrosion resistant and non-toxic nature. The predicted in-vivo service life of such devices was one to three years.2 TMJ Implants TMJ devices are used as endosseous implants for articular disc replacements. those became popular in 1980s with the introduction of the Vitek-Kent prosthesis. surgeons had concentrated on implanting either a fossa or a condylar head. many of the alloplastic devices failed in delivering the intended results due to their vulnerability to the repeated mechanical stresses encountered in the TMJ with functional movements of the jaw. fossa replacements. adaptability to anatomical structures. halted the manufacture of the TMJ implants – except for Christensen and Morgan implants which were on 12 .

150. and (4) Walter Lorenz/Biomet implant. (3) TMJ Concepts implant. 139 Since December 30. The Christensen fossa eminence prosthesis (FEP) is fabricated entirely of Cobalt-Chrome (Co-Cr) alloy and is approximately 20 mm to 35 mm across and 0. only following four TMJ implants (from three manufacturers) are approved by the US FDA to date: (1) Christensen/TMJ Implants. 151 In 1993. (2) Christensen/TMJ Implants.5 mm thick with a polished articulating surface. Inc.. et al.150-153 The TMJ Concepts total joint prosthesis uses materials that are well proven in orthopedic joint reconstruction for hip and knee replacements. After FDA’s halting of the manufacture of any TMJ devices developed after 1976. Co-Cr bone screws and drill bits sized to the screws are used to fix the FEP to the base of the skull and condylar device to the ramus. Inc.138. Inc. total joint implant. 108 This device can support either unilateral or bilateral partial joint reconstruction. 108 Techmedica. 1998. The Christensen condylar prosthesis has a Co-Cr alloy frame work with a molded Polymethylmethacrylate (PMMA) head and is available in three lengths of 45.42. 50.) implant was re-approved by the FDA in 1997 based on the outcomes of a 5-year follow-up study on 36 patients with 65 TMJs presented by Wolford.the highest risk category. developed the joint prosthesis in 1989 as a custom-made device.138.. 139. in 1995. 151 The fossa component of this 13 . Inc. 123 Later.138.42. partial joint implant.123 The Christensen prosthesis system includes either a partial or total TMJ prosthesis available as a stock device. Techmedica’s (now known as TMJ Concepts. it was described as a total joint replacement system for the TMJ. 151 The Christensen TMJ implant system was introduced in early 1960s.42. TMJ implants were reclassified into Class III . and 55 mm.the market prior to the enactment of the medical device law in 1976 – due to lack of safety and efficacy information to support the indicated use.

108 The ramus of mandibular component is 14 .device is made from commercially pure titanium mesh (ASTM F67 & F1341) with an articular surface made of ultra-high-molecular-weight polyethylene (UHMWPE ASTM F648). et al. jaw function. 150. 153 Both the fossa and condylar components are secured with titanium alloy (Ti-6Al-4V) screws. The investigators reported statistically significant improved outcomes relative to post-surgical incisal opening. 153 The body of condylar component is made from medical grade titanium alloy (ASTM F136) with a condylar head of cobalt-chromium-molybdenum alloy (ASTM F1537). and diet for the TMJ Concepts prosthesis group compared to the Christensen prosthesis group.150 Wolford.84. 151 Osseointegration can contribute to improved patient function and decreased micro-movement. ASTM F799) alloy with a roughened titanium porous coating on the host bone side of the ramal plate. a patient-fitted TMJ Concepts prosthesis is reported to have provided a better fit and stabilization of its components to the host bone thereby mitigating any micro-movement leading to loosening of the components and maximizing the opportunity for osseointegration of components and fixation screws. which limits overall prosthesis wear and stress. 108. 108. 150.107. These studies evaluated 23 patients treated with Christensen prostheses (followed for a mean of 20.107. 85. pain.8 months) along with 22 patients implanted with TMJ Concepts prostheses (followed for a mean of 33 months).108 Compared to the “off-the-shelf” implant devices.107.150 performed direct clinical comparison of preimplantation and post-implantation subjective and objective data from two similar groups of patients who underwent reconstruction with two different TMJ reconstruction systems.150 Biomet’s Walter Lorenz TMJ implant is a “ball and socket” type prosthetic joint similar to a knee or hip implant. The condylar component of this prosthesis is manufactured from CobaltChromium-Molybdenum (Co-Cr-Mo. 150.

107. Barbick. 108 The swan neck curvature on the medial surface of condylar neck avoids the inherent fitting problems of the right angle design found in most metallic condylar prosthesis. The safety and effectiveness of revision surgery using a second set of W.available in lengths of 45 mm.139 The average patient follow-up for 19. et al. and satisfaction with the treatment outcome. increase in maximal incisal opening. 31 unilateral and 19 bilateral) reconstructed with Lorenz/Biomet prosthesis.107. a total of 268 joints (92 unilateral and 88 bilateral) were reconstructed with W. It also has an exaggerated circumferential lipping to protect the condyle from possible heterotopic bone formation and to avoid condylar dislocation. The fossa component is manufactured from a specific grade of ultra-high molecular weight polyethylene (UHMWPE) called ArCom which has shown a 24% reduction in wear compared to traditional UHMWPE.107.7 demonstrated that the Lorenz/Biomet prosthesis fits satisfactorily in the majority of patients undergoing surgical TMJ Concepts custom joint replacement with minimal anatomical reduction. and functional diet capability. Lorenz/Biomet total TMJ replacement system implants is not known. self-tapping bone screws made of titanium alloy (Ti-6Al-4V).6 months demonstrated improvement in patients’ condition through decrease in pain. 108 Both the condyle and fossa implants are attached to bone using self-retaining. 108 After three year follow-up of 50 patients (69 joints. According to 2007 FDA documentation. Long-term follow-up studies of this device are not available.107. 15 . mouth opening. and 55 mm. Lorenz/Biomet total TMJ replacement system after appropriate non-surgical treatment and/or previous implant failure. Quinn107. 50 mm. 108 The fossa is available in three sizes with predrilled holes for the screws. increase of function. 108 reported significant improvement in pain intensity.

progressive bone and soft-tissue destruction.2. silicone rubber and PT implants were found to gradually break down as they could not sufficiently withstand the contact stresses generated during functional movements of the jaw. 156 Silicone rubber and Proplast/Teflon (PT) were widely used materials in alloplastic TMJ implants from mid 1970s to late 1980s. fibrosis. and soft-tissue ingrowth into the more porous PT implants. in most patients. 108.4.33. Implants composed primarily of carbon fiber and polytetrafluoroethylene (PTFE/Teflon or PT) were introduced in the mid 1970s to reconstruct the TMJ after discectomy.33. 153 2.33. function and dysfunction of the TMJ. malocclusion.33. and severely limited joint function often requiring further surgery. inflammation. Understanding the structural aspects and biomechanical behavior of these bony 16 .1 Alloplastic Materials for TMJ Implants Alloplastic materials used as medical devices have traditionally been viewed as biologically inert substances that can be designed to achieve desirable mechanical properties. 151. However. 153 The structural failure of the implants resulted in formation of microparticulate implant debris which elicited a foreign-body response characterized by the presence of multinucleated giant cells. 91.5 Bone – Material and Mechanical Properties Mandibular and temporal bones play an important role in the form.2. 91. 108.33. alloplast materials initially provided pain relief and improved function of the joint. 156 In many TMJ patients. 156 Early reported successes with the use of these materials included greater implant stability. headaches. 156 The breakdown particles provoked the foreign body giant cell reactions resulting in severe pain. 91. 91.33.

4. The cortical and trabecular bone have the same material composition. Young’s modulus and Poisson’s ratio are the two main parameters that describe the mechanical properties of the bone material. in cases where post-yield characteristics of bone are not critical. the stress depends not only on the magnitude but also the rate of strain.19 The outer layer of bone is covered by a dense layer of calcified tissue called cortical bone. At the whole-bone level. Quantitatively.143 Due to viscoelastic behavior of bone.4 Bone displays non-linearity in its response to load after the yield strength of bone is crossed. Therefore. bone is often assumed materially isotropic during structural assessments. but they differ in structure and function. prior to yield strength the response of both cortical and trabecular bone to load is linear. 19 However.4 However.143 It has been recorded that both cortical and trabecular bone are stronger in the longitudinal direction than in the transverse direction.21 However. at low strain rates cortical and trabecular bones may be considered elastic. for simplicity.19 This structural arrangement makes cortical bone more rigid and less flexible compared to trabecular bone. The trabecular bone presents itself as a meshwork of needlelike structures.143 17 . the entire bone is considered as a single structure.components is an essential part of the TMJ research. both cortical and trabecular bone may be assumed to have a linear response to varying loads. whereas only 15 to 25 percent of the trabecular compartment is bone and the rest marrow.4 Bone is an anisotropic material in which a variation in mechanical properties depends on the orientation of the load acting on the bone. which incorporates the macroscopic geometric and material properties of bone. 80 to 90 percent by mass of the cortical compartment is bone.

twisting. Larger and/or more numerous strains can reduce bone strength below 20% of normal.36. or appearance. shape. dead bone cannot detect and repair microdamage.36 Normally bones detect their microdamage. 36 formulated this relation as expressed below: 18 . shortening.. Stiff bones deform or strain less than less stiff (more “compliant”) ones under the same load. Bone can carry loads that cause smaller strains indefinitely.e. Strain can include stretching. and then repair it by removing and replacing the damaged bone with new bone. strain gauges) can measure bone strain in the laboratory and invivo. of the affected bone.36 The decrease in stiffness and accumulation of microdamage can lead to complete fracture.2. it needs only enough strength to keep strains below the level that could cause larger amounts of microdamage. Special gauges (i. Repeated strains in the bone cause microscopic fatigue damage in bone.5.36. Stiffness is the resistance of the bone to its deformation or straining under a load. content of material.36. and/or bending. 98 Such damage degrades the physical integrity of the bone tissue. bone modeling and remodeling can normally repair the small amounts of microdamage indefinitely as long as the microdamage caused by the strain remains below the intrinsic modeling threshold of the bone. also known as stress fracture.1 Bone Stiffness and Microdamage Strain is the deformation or change in dimensions and/or shape caused by a load on any structure or structural material.36 Bone microdamage begins at the ultramicroscopic level. 66 However. and then progresses to microcracks and delamination which is accompanied by the decrease in stiffness of the affected bone. Frost34. Under this condition. Due to the inherent adaptability of the living bone. 40 It weakens bone without affecting its size.

etc.34. 36 Complete fractures of trabecular bone are suggested to stem from fatigue failures rather than from single loads above ultimate strength of the trabeculae. method of specimen extraction. aspect ratio. joints. and it affects women more than men or children. stress fractures take place. which occurs commonly in ageing bone. the results of these tests can be affected by specimen preparation (size. on the other hand.98 Excessive microdamage causes all spontaneous fractures.36 Normal mechanical usage of osteopenic bones (which are characterized by decreased calcification.2 In-Vitro Biomechanical Analysis of Bone Mechanical tests are widely acceptable method of directly assessing the geometric and material properties of cadaver bones. 36 If the damage accumulation rate exceeds the bone’s inherent capacity to repair. These fractures occur commonly in high intensity and repetitive activities. and ligaments.36 It needs to be investigated if the high prevalence of true osteoporosis in women has any correlation with the gender paradox of TMJ patient population.1) This relationship is reported to exist in the bones.5. If. test 19 .). so they are not really spontaneous. cartilage. collagenous tissue.19 However. This osteoporosis of osteopenic bones is less common. 2. fragility fractures result. tendons. damage accumulates at ‘normal’ rates but the bone’s repair mechanism is deficient. density or mass) could increase their microdamage and their fragility enough to cause spontaneous fractures and/or bone pain. shape.Remodeling Threshold < Peak Strains from Voluntary Actions < Modeling Threshold << Microdamage Threshold <<< Fracture Strain …………………………… Equation (2.

specimen-gripping techniques.142 In FE analysis. Accurate 20 . materially and geometrically. Stress cannot be directly measured using a sensor but only be estimated using mathematical formulas.143 For standard engineering structures. Each element is given a material property and a governing inter-element relationship (i.e. torsion tests and bending tests or indirect tests such as nano-indentation methods.19 FE models which are similar. to the actual bone can be used to perform stress and strain analyses on an element by element basis to study the role of 3D geometric and material properties of bone.methods (direct tests such as tensile tests. However. on the other hand. in the case of bone. geometric shapes called elements.). the protocols for testing have been well established. optical methods. The primary limitations of the strain gauge technique are that the test sites are limited to the area covered by the strain gauge. etc.143 The only way to directly assess material integrity of the bone is using strain analysis. deformation-rate. Since strain is an independent parameter that can be assessed using strain gauges attached to bone under mechanical loading. compressive tests. which are based on Young’s modulus and bone geometry. difficulties in gripping the specimens. such standard testing methods cannot always be utilized due to restrictions imposed by the complex geometry. finite.) and environmental conditions (loading-rate. can be directly assessed using strain gauges. Strain.. a complex geometry is discretized into simple. and the varying bone topography prevents easy attachment of the gauges at many locations. such strain measurements can be used to determine the accuracy of FE models simulating identical mechanical loading. etc. and in some cases the need to use relatively low loads to study bone response. material anisotropy and finite size of the bone specimens. linear or non-linear) to form the required model. specimen-hydration.

The authors dilated the grayscale twice to re-grow the volume to original size. et al. An optimized Poisson’s ratio was adopted for both cortical and trabecular bone.154 The resultant volume contained partial-volume corrected density values along the endosteal boundary.assignment of material properties to different components (such as cortical layer. and used an inhomogeneous isotropic material model for the trabecular volume of FE models of long bones. 21 . They held constant the Young’s modulus value of the cortex volume between periosteal and endocortical boundaries. The density values were assigned using a method previously published by Hangartner. cancellous section. Varghese. We performed anatomical reconstruction of the cadaveric mandibles from their CT scans as described in Chapter 4. teeth) of the FE model of bone is necessary to obtain precise replication of the bone’s biomechanical behavior in the results of FE simulations.47 Gröning. They assigned a same set of material properties to the entire bone and teeth components of the FE mesh by defining Young’s modulus and Poisson’s ratio. and created a FE volume mesh. Material properties to cortical component.45 reconstructed the mandibular anatomy from CT data of a human mandible. which replicated the grayscale values of the eroded periphery to the re-grown region as previously described by Wu. Different approaches have been used by researchers to assign the material properties to FE models of the bone reconstructed from patient’s medical images. et al.142 adopted consistent bone-material properties based on a parameter optimization study. A mask representing the endosteal region of the bone model was eroded twice to obtain material information without influence of partial-volume effect for the trabecular region near the endosteal boundary. et al. FE volume mesh was generated for each of the mandibular model.

mechanism of TMDs. geometry of elements. 22 . This information is of great importance in the field of patient rehabilitation. During natural loading of the joint.1 In-Vivo Assessment Very few studies about in-vivo biomechanical assessment of the TMJ can be found in the literature. the computer constructs the governing equations and solves them to provide the required analysis results. 143 2. Accurate FE models of human bones are in demand in the clinical environment. combinations of compressive. to determine the mechanical stress/strains that physiological activities induce in bones. nodal coordinates. i.cancellous component. tensile. especially in patients recovering from orthopedic procedures..e.19.6. 64. 77 2. Once the user defines the nature of the FE problem. In contrast to some earlier studies which reported the TMJ to be a force-free joint. inter-nodal relationships. and shear loading occur on the articulating surfaces.6 Biomechanics of the Mandible and TMJ Mandibular motions result in static and dynamic loading in the TMJ. thus increasing their treatment efficiency 48.132 The analysis of mandibular biomechanics helps us understand the interaction of form and function. and aids in the improvement of the design and the behavior of prosthetic devices. and teeth of each mandibular FE mesh from their respective masks in Mimics using the in-built ‘mask method’ of the software as described in Chapter 4. loading condition with constraints and type of analysis desired. structural or non-structural.

et al. The pressure pain threshold (PPT). Naeije and Hofman95 used these observations to study the loading of the TMJ during chewing and chopping tasks.64. and inflammatory disorders) compared to healthy control subjects. et al.14 showed that the TMJ was subjected to pressure forces during occlusion as well as during mastication and it was slightly eccentrically loaded in all positions of occlusion. and bite force were significantly lower in the patients as compared to that in controls. maximum jaw opening. when the traces do not coincide. osteoarthritis. In face of these contrary reports. Huddleston-Slater. there is compression in the TMJ during the closing stroke.Hylander 60 demonstrated that considerable forces were exerted on the TMJ during occlusion as well as mastication. and bite force in TMD patients (categorized as disc derangements. The 23 . and the kinematic centers of all contralateral joints showed a coincident movement pattern during chewing and chopping. However. The patients were also found to have longer duration of chewing cycles. Breul. Their analysis showed that the distances traveled by the condylar kinematic centers were shorter on the ipsilateral side than on the contralateral. the TMJ is not or only slightly compressed during chewing. The bite force and jaw opening in patients were significantly correlated with PPT. The indication that the ipsilateral joint is less heavily loaded during chewing than the contralateral joint may explain why patients with joint pain occasionally report less pain while chewing on the painful side. and both the medial and lateral condylar thirds were heavily loaded. Korioth and Hannam76 indicated that the differential static loading of the human mandibular condyle during tooth clenching was task dependent.58 suggested that when the condylar movement traces coincide during chewing. chewing. 95 Hansdottir and Bakke48 evaluated the effect of TMJ arthralgia on mandibular mobility.

et al. and as the applications of experimental devices inside the TMJ cause damage to its tissue.6.136 Tanaka.. the direct methods are not used often.e.9 performed sinusoidal indentation experiments and reported that the dynamic mechanical behavior of disc was nonlinear and time-dependent. Beek. forces. FE modeling has been used widely in biomechanical studies due to its ability to simulate the geometry.136 attempted to characterize the dynamic shear properties of the articular cartilage by studying shear response of cartilage of 10 porcine mandibular condyles using an automatic dynamic viscoelastometer. Indirect techniques utilized to evaluate mandibular biomechanics have had limited success due to their ability to evaluate only the surface stress of the model but not its mechanical properties. Excessive shear strain can cause degradation of the TMJ articular cartilage and collagen damage eventually resulting in joint destruction. lowest PPT) and the most impeded jaw function with respect to jaw opening and bite force were found to be more severe in the patients with inflammatory disorders than the patients with disc derangement or osteroarthritis. stresses and mechanical behavior of the TMJ components and implants during 24 .48 2. The results showed that the shear behavior of the condylar cartilage is dependent on the frequency and amplitude of applied shear strain suggesting a significant role of shear strain on the interstitial fluid flow within the cartilage. et al.most severe TMJ tenderness (i.2 In-Vitro Assessment As the TMJ components are difficult to reach. 64 Mechanical testing and finite element method (FEM) have been progressively used by TMJ researchers.

102.96 developed a 3D linear FE model and analyzed the biomechanical reactions in the mandible and in the TMJ during clenching under various restraint conditions.16 performed stress analysis of human TMJ using a two-dimensional FE model developed from magnetic resonance imaging (MRI). et al. et al.133 suggested. Tanaka. All these FE simulations considered symmetrical movements of mandible. 134 Chen. et al. Nagahara. 75. et al. Hart. Tanaka. 112. Vollmer.49 generated 3D FE models of a partially edentulated human mandible to calculate the mechanical response to simulated isometric biting and mastication loads. Koolstra and van Eijden74 performed a FE study to evaluate the load-bearing and maintenance capacity of the TMJ using a combination of rigid-body model with a FE model of both discs and the articulating cartilaginous surfaces to simulate the opening movement of the jaw.10 developed a 3D linear FE model and analyzed the biomechanical reactions in the mandible and in the TMJ during clenching under various restraint conditions.10. 16. Due to convex nature of the condyle.146 conducted experimental and FE study of human mandible to investigate its complex biomechanical behavior. et al. analyzing the differences in the stress distribution of the disc between subjects with and without internal derangement. 74. Beek. 135 developed a 3D model to investigate the stress distribution in the TMJ during jaw opening. the compressive stresses were dominant in the condylar region whereas the tensile stresses were dominant in the fossa-eminence complex owing to its concave nature. from the results of FE model of the TMJ based on magnetic resonance images. et al. 104. The results indicated that the 104 25 .simulated function. that increase of the frictional coefficient between articular surfaces may be a major cause for the onset of disc displacement.130. et al. and the models developed only considered one side of the joint. In 2006.

24 A theoretical model developed by Gallo. et al. Whiplash injury is considered as a significant TMD risk factor and has been proposed to produce internal derangements of the TMJ. exudation and redistribution of fluid. conforming to the indications by Tanaka. and was used to analyze biomechanical behavior of the soft components during a nonsymmetrical lateral excursion of the mandible to investigate possible consequences of bruxism. et al.130. Using this validated 26 . 102 However. 135 Later. Gallo. which produces fatigue that may influence the pathomechanics of degenerative disease of the TMJ. ligaments. Perez-Palomar and Doblare103 suggested that unilateral internal derangement is a predisposing factor for alterations in the unaffected TMJ side. This study suggested that a continuous lateral movement of the jaw may lead to perforations in the lateral part of both discs.39 for estimating the mechanical work produced by mediolateral stress-field translation in the TMJ disc during jaw opening/closing suggested that long-term exposure of the TMJ disc to high work may result in fatigue failure of the disc. The FE model included both discs.construction of the TMJ permitted its cartilaginous structures to regulate their mechanical properties effectively by imbibitions. Nickel. Perez-Palomar and Doblare104 used more realistic FE models of both TMJs and soft components to study clenching of mandible. it would be necessary to perform an exhaustive analysis of bruxism with the inclusion of contact forces between upper and lower teeth during grinding. et al. However. and the three body contact between all elements of the joints.38 studied the effect of mandibular activity on mechanical work in the TMJ. et al. this topic is still subject to debate.97 validated numerical model predictions of TMJ eminence morphology and muscle forces.68. and demonstrated that the mechanics of the craniomandibular system are affected by the combined orthodontic and orthognathic surgical treatments.

a future prosthesis must allow some 27 . et al. and the muscles do not apply similar forces at the joint when the subject has a total TMJ implant. The assessment showed a 24% and a 30% improvement in mouth opening after 2 years and 10 years. compared to a subject who has a normal. loss of translational movements of the mandible on the operated side has been often observed.numerical model to calculate ipsilateral and contralateral TMJ loads for a range of biting positions and angles. in most cases.6. and totally replaced TMJs. et al. at 2 years post-implantation. Mercuri.65 demonstrated that TMJ loads during static biting are larger in subjects with TMJ disc displacement compared to subjects with normal disc position. In the post TMJ replacement follow-up studies. scarring of the joint region and muscles of mastication. partially replaced. et al. improves range of motion and mouth opening in the TMJ patients. Iwasaki. healthy TMJ. As the loss of lateral jaw movement is a great disadvantage to total TMJ prosthesis replacement.89 obtained the measures of mandibular interincisal opening and lateral excursions. especially in anterior direction. there was a 14% decrease in left lateral excursion and a 25% decrease in right lateral excursion from the pre-implantation data. Less translation was reported in the partial (fossa) replacement and total TMJ reconstruction cases than in the normal joints. 2.72 assessed in-vivo kinematics and kinetics of the normal. owing to various factors such as loss of pterygoid muscle function.155 Komistek. However. The study suggests that total TMJ implants only rotate and do not translate. On the other hand.3 Post-surgery Assessment TMJ reconstruction using the partial or total TMJ prosthetics. respectively.

and lateral movements. Hence.155 In protrusive movements. protrusive.155 Mean linear distance (LD) of incisors during maximal mouth opening for the surgical patient group was 18% less than the normal subjects. in the surgical patient group. An electromagnetic tracking device and accompanying software were used to record the kinematics of the mandible relative to temporal bone during opening-closing. A large fraction of TMD causes are currently unexplained. Mean LD for mandibular right and left condyles was symmetrical in the normal group. a comprehensive understanding of the associated structures is essential. measurements for operated condyle and unoperated condyle were asymmetric and reduced as compared with normal subjects by 57% and 36%. the mean incisor LD away from the operated side and toward the operated side as compared with the normal group incisors were reduced by 67% and 32%. et al.155 followed a kinematic method that tracked the condylar as well as incisors path of the TMJ motion. For the surgical patient group. better understanding of the etiology of TMDs is 28 . bite and joint force. operated and unoperated condyles of surgical patients traveled less and significantly differently as compared with condyles of normal subjects.lateral translation as well as the anterior movement of mandible on the operated side when the mouth is opened. respectively. respectively. There is a great need and demand for relatively less expensive and more efficient treatment modalities including durable patient-fitted TMJ implants. jaw motions.155 2. Relations between muscle tensions. however.7 Problem Statement and Research Objectives With a large fraction of human population suffering from problems concerning the jaw and the TMJ. and craniofacial morphology are not fully understood. which moved almost identically.141 Yoon.

Study microdamage accumulation in human cadaver mandibles during cyclic fatigue tests simulating the physiological loading. Propose design features capable of offering better fixation and durability for such implants. Evaluate biomechanical performance of the designed TMJ implants. The goal of the proposed research is to aid better understanding of the form and function of the mandible and TMJ. Present a methodology to design a novel patient-fitted total TMJ implant system. 6. 3. Study strain profile at different locations on the surface of cadaver mandibles during fatigue tests. 5. 8. 29 .necessary to prevent not only occurrence of TMDs but also failure of an implanted joint in the same way as the joint it replaced. Perform patient-specific three-dimensional (3D) anatomical reconstruction of the mandible and TMJ to gain insight about structural aspects of the anatomy. 4. Validate the FE methodology of mandibular assessment by comparing with experimental measurements. This research will make contributions to furthering our knowledge of the biomechanical behavior of the mandible and TMJ by achieving the following goals: 1. Develop specimen-specific finite element (FE) models of human cadaveric mandibles. 2. 7. Study variation in stiffness of human cadaver mandibles during cyclic fatigue tests simulating the physiological loading scenarios. and perform FE simulations imitating experimental tests.

and injury or fractures of the mandible are some of the factors that either co-exist with or may cause the temporomandibular disorders (TMD) of varying degree of complications. ultimately leading to fatigue failures.3. also known as stress fractures. and then progresses 30 . TMJ. 106. 78. 52. and propose methods of artificial intervention for the treatment of diseases associated with the mandible.36 Bone microdamage begins at the ultramicroscopic level. and FE modeling and analysis offer practical alternative.24. 64 As mandible and associated components of the masticatory system are difficult to reach. predict changes due to alteration. and the masticatory system. 137 Functional overloading. EXPERIMENTAL BIOMECHANICAL EVALUATION OF CADAVERIC HUMAN MANDIBLES 3.64 Indirect techniques such as in-vitro mechanical testing of cadaveric specimens. and as the applications of experimental devices may cause damage to the masticatory tissue in living persons. knowledge of mandibular biomechanics during different loading conditions can provide valuable information useful to understand the mechanism of fracture.50. malocclusion. the direct methods of biomechanical investigation are not used often.1 Introduction Mandible is the most frequently fractured facial bone because of its prominence as it occupies a central and vulnerable position in the face. Cyclic loading of bone results in degradation of mechanical properties such as strength and stiffness. at loads well below the fracture strength of the bone.51.40 Repeated strains in the bone cause microscopic fatigue damage in bone. 106. 131 As millions of people suffer from problems concerning the mandible. Biomechanical analysis is a useful tool to understand the normal function. 64. 70.

36. 137. bone can be represented by a fiber-reinforced composite model based on the rule of mixtures.40 It is noteworthy that. and fracture modes in mandibular bone under cyclic fatigue loading.13. rate. damage accumulation. initiation of micro-cracks 31 . and fracture locations when subjected to cyclic compressive loading which closely resembles the physiological loading during repeated jaw closing or clenching activity.46. compressive. of the affected bone. act as the load-bearing fibers.46. and direction of applied load.1) for axial loading similar to that used for fiber-reinforced composite. limited information is available about stiffness. which are composed of collagen and minerals. 137 Bone characteristics under load in-vitro depend on type.e. microdamage accumulation.78. 98 Such damage degrades the physical integrity of the bone tissue.to microcracks accompanied by the decrease in stiffness of the affected bone. the key objective of our study is to identify the damage mechanism in the mandible characterized by stiffness variation. Fractures occur when the load on a bone exceeds the ability of the bone to carry that load. 55 In stage I.36. 55 The haversian osteons.. number of loading cycles before failure). and torsional loading. In view of this paucity of experimental knowledge. Fatigue damage in bone is characterized by a three stage model (see Figure 3. 137 To analyze material properties. 137 Anatomical regions of mandible are reported to have different biomechanical behavior depending on the direction of load. fatigue life (i.78. Information about fatigue failure mechanisms is necessary to identify the critical loading component and damage mechanism that cause fatigue failures under physiological conditions involving superimposition of tensile. also known as stress fracture. 40 The decrease in stiffness and accumulation of microdamage can lead to complete fracture. despite some individual studies focused on biomechanical assessment of the mandible.

144. 145 Figure 3. This is where a significant amount of stiffness reduction can be seen. 41. By stage III.begins in the interstitial bone tissue. the osteons are debonded and stiffness drops leading to crack growth. 99. Stiffness reduction slows into a linear progress as the material is weakened in stage II.25. 1. These stages of crack growth have been utilized in many studies of fatigue damage in bone. Source: Varvani-Farahani and Najmi144 32 . Schematic showing stages of damage progress in cortical bone versus fatigue cycles.

and the FE results are validated by comparing the numerical strain values with the experimental strain data collected during mechanical testing. specimen-specific 3D anatomical models are reconstructed from computed tomography (CT) images of the mandibles. and Chapter 4 focuses on analysis of the experimental strain data. and proved the relationship between the amount of strain in the bony microenvironment and the biological reaction. numerical analysis paralleling experimental set-up is performed through finite element method.Frost35 investigated Wolff’s concept of relationship between biomechanics and morphology of bony tissue.2 depicts the outline of the experimental-numerical study assessing biomechanical aspects of the cadaveric mandibles. The biomechanical behavior of the mandible is important in various clinical situations. 3D reconstruction. The aim of the experimental investigation covered in this chapter is to 33 . Chapter 3 discusses the experimental aspects of the study. We investigated in-vitro the biomechanical behavior of mandible under four different configurations of cyclic compressive loading. and has been studied by different approaches. Indirect methods such as mechanical testing and FE analysis have been widely used for in-vitro assessment of anatomical structures. 146 Although it is nearly impossible to standardize the real functional and para-functional behavior of the masticatory system in living persons. Mechanical testing of the cadaveric mandibles is performed under different loading conditions. the biomechanical properties of the human mandible can be determined experimentally using models to simulate standardized normal physiological and non-physiological loads. The schematic in Figure 3. and FE analysis of the mandibles.35. Direct biomechanical testing of bone provides useful information about mechanical integrity.

damage accumulation. Can a difference be stated for cadaveric mandibles tested under different fatigue loading conditions with respect to fatigue life (i.. Does incisor loading of the mandible result in a lower number of cycles until failure compared with molar loading? 4. and failure of the cadaveric human mandibles. and failure location of the mandible? 3. maximum load before failure. stiffness. maximum load before failure. and failure location? 2. The following questions are examined: 1. stiffness.examine the stiffness reduction.e. number of cycles until failure). Do age and sex have significant effect on number of cycles until failure. Does dental status of the mandible have a significant effect on number of cycles until failure. maximum load before failure. stiffness. damage accumulation. damage accumulation. and failure location when subjected to cyclic fatigue loads? 34 . damage accumulation.

Schematic showing steps involved in the experimental-numerical biomechanical analysis of human cadaver mandible. specimen-specific 3D anatomical models are 35 . Mechanical testing of the cadaveric mandibles is performed under different loading conditions.Figure 3. 2.

and the FE results are validated by comparing the numerical strain values with the experimental strain data collected during mechanical testing. cleaned of soft tissue and wrapped in cloth soaked with saline prior to sealing them in a plastic bag and freezing them at – 20 oC.2 Materials and Methods Sixteen fresh-frozen human cadaveric mandibles with no visible structural bone defects or fracture fixation devices were collected from adult human cadavers (nine females. 142 Once the mandibles were thawed. seven males. 3. and Wright State University IRB approval. the mandibles were moved from – 20 oC freezer to a 4 oC refrigerator and then thawed at room temperature for at least 3 hours. any remaining soft tissue attached to the bone surface was removed using scalpel. numerical analysis paralleling experimental set-up is performed through finite element (FE) method. All of the cadavers were obtained through Wright State University Anatomical Gift Program with the necessary consent. 24 hours prior to the experiment date.1). the bones were harvested. protocol. aged 61 years to 98 years) (see Table 3. 36 .reconstructed from CT images of these mandibles. On arrival of the cadavers. 30.

into a cylindrical water tank. Patient Code Gender Age (yrs) Dental Statusǂ 1 EH F 98 E 2 MD F 84 E 3 HL M 71 E 4 PS F 86 E 5 LV M 61 M 6 CE M 71 E 7 JL F 84 M 8 HK M 87 M 9 AM F 83 M 10 BS M 91 M 11 PO F 82 M 12 FH F 92 M 13 FK M 85 E 14 VV F 62 M 15 OM M 90 E 16 ES F 65 M ǂ Mandible Dental Status: E – edentulous (no teeth).1 Image Acquisition Prior to mechanical testing. The 37 .2. USA). No. WI. Demographics of the cadaveric mandible specimens. 1. 3. and trans-axial CT scans of entire specimen were obtained using a 16slice GE Light speed scanner (General Electric Health Care.mixed dental status (with one or more teeth missing) Table 3. The cleaned mandibles were immersed. M .Sr. one at a time. CT scans of all specimens were performed for 3D anatomical reconstruction to be done later. Milwaukee.

Tokoyo. 512 x 512 matrix and an isotropic voxel size of 0. 3. 200 mAs. one buccally on right mandibular body. 142 The positions of the strain gauges were selected based on the literature. below alveolar process.11. Japan) were used to measure surface strain. 28 The parameter used to describe this deformation process is μstrain (μm/m).625 mm3. another at the dorsal region of the left condylar process (L3).28.18. The attachment sites for strain gauges were defined as following: one strain gauge (L1) placed fronto-laterally at left mental protuberance.3 and 3. 110 The deformation of the bone surface leads to a corresponding change in the length of the strain gauge wire which is proportional to its electrical resistance. 127.scanning parameters are as following: 80 kVp.2 Strain Gauge Attachment Uniaxial strain gauges (KFG-1-120-C1-11 L3M3R. Strain gauges are simple to use. 110 and results of our prior FE simulation of a mandible specimen.6). and another at the dorsal region of the right condylar process (L5) as shown by the schematic in Figure 3. although care must be taken in selection and implementation to minimize error.2. Five strain gauges were attached at exactly defined five locations on the cortical surface of the mandibular bone after the attachment sites were cleaned and degreased using standard protocol (see Figures 3. anterior to oblique line (L2). caudal to first and second molars. anterior to oblique line (L4). Kyowa Electronics.625 x 0. caudal to first and second molars. 18.625 x 0.17.3. 38 . one buccally on left mandibular body.

strain at the 39 . Stamford.Figure 3. USA). L3: at the dorsal region of the left condylar process. During cyclic loading of each specimen. The strain gauges were named according to their site of attachment as following – L1: fronto-laterally at left mental protuberance. Panel-A shows the left lateral view. 3. CT. caudal to first and second molars. anterior to oblique line. USA). anterior to oblique line. below alveolar process. L2: buccally on left mandibular body. Schematic of strain gauge attachment at five exactly defined locations on the cortical surface of the mandible. CT. Stamford. L5: at the dorsal region of the right condylar process. caudal to first and second molars. which was linked to a computer to record the data using instruNet World PLUS (iW+) software (Omega. Each strain gauge was connected through a quarter-bridge wiring configuration of Wheatstone bridge circuit to the instruNet Data Acquisition System (Omega. and Panel-B shows the right lateral view of a mandibular 3D model depicting positions of the strain gauges. L4: buccally on right mandibular body.

custom-designed fixtures were used to set-up the mandible upside down in the machine so that it rested on the two condyles and either molars or incisors as required for a given loading configuration. compressive loads were applied to the mandibular angles on both sides of the mandible.5 and 3. Similar to previous studies by Schupp.3. and Groups 3 and 4 consisted of two mandibles each. Eden Prairie. MN.2. during. et al.45. The cyclic load was applied at 2 Hz using an EnduraTEC materials testing machine (ElectroForce Systems Group. The mandibles were placed in a reverse position for practical reasons (see Figures 3. axial. Groups 1 and 2 consisted of six mandibles each.3 Mechanical Testing Tests were conducted in axial compression mode.1 Loading configurations The mandibles were divided in four groups to undergo cyclic loading of four different configurations. Bose Corporation. images of the specimens were taken with a digital camera from approximately 400 mm before. 3.6). 3.2.117 and Gröning. et al. This helped in accurately defining the strain acquisition sites and boundary conditions during the FE simulations discussed in Chapter 4. Cyclic. In Group-1. To identify the site of attachment for each strain gauge. and after mechanical testing. the mandibles were loaded bilaterally with support at the molar 40 . USA) that allowed a controlled application of force simulating bite forces.gauge attachment sites was continuously measured and recorded throughout the experiment at a sampling rate of 2 Hz.

The BIN phase was immediately followed by a bilateral-incisor-overload (BIO) phase of cyclic compressive load varying between 210 N and 300 N for another 30. the mandibles were loaded bilaterally at the molar region. compressive load varying between 50 N and the upper limit for a given load block for 3. This bilateralmolar-spectrum (BMS) loading configuration consisted of cyclic. The BMN phase was immediately followed by bilateral-molar-overload (BMO) phase during which the load varied between 280N and 400N for another 30.000 cycles.4-B).000 cycles (see Figure 3. axial. axial. Mandibles in Group-4 were loaded bilaterally at the incisor region. During the bilateral-incisor-normal (BIN) loading phase.1.4-C). Group-2 specimens underwent bilateral loading through support at the incisor region (see Figure 3. This bilateralincisor-spectrum (BIS) loading configuration consisted of cyclic. In Group-3. During the bilateral-molar-normal (BMN) loading phase.000 cycles in each block. the BIS configuration of Group-4 included 20 load blocks with 41 . 101. Similar to Group-3 loading configuration.6-B).6-A). 12.region (see Figure 3. The chosen magnitudes of load are reflective of bite forces under functional and parafunctional loading of the mandible. The upper load limit for each block exceeded that of the previous block by 50 N. These forces are comparable to those previously reported in the literature.4-A). the load varied between 140N and 200N for 30.000 cycles. 6.000 cycles in each block. BMS configuration included 20 load blocks with the upper limit of 100 N for the first block and 1050 N for the last block.000 cycles (see Figure 3. 121 The load configuration of Groups 3 and 4 consisted of spectrum of load blocks (see Figure 3. the mandibles underwent load varying between 105 N and 150 N for 30. 5. compressive load varying between 50 N and the upper limit for a given load block for 3.

the upper limit of 100 N for the first block and 1050 N for the last block. 42 . The upper load limit for each block exceeded that of the previous block by 50 N.

Figure 3. Schematic representation of load variation during mechanical testing of mandibles. Panel-A shows molar load configuration of Group-1 in which applied axial load varies between 43 . 4.

44 . respectively.140 N and 200 N during bilateral molar normal (BMN) loading phase. Panel-C shows the spectrum loading configuration which is of similar form for molar (BMS) and incisor (BIS) loading of mandibles in Group-3 and Group-4. and between 280 N and 400 N during bilateral molar over-load (BMO) phase. Panel-B depicts incisor load configuration of Group-2 in which applied load varies between 105 N and 150 N during 30000 cycles of bilateral incisor normal (BIN) loading. 5. Loading set-up of EnduraTEC materials testing machine using custom-designed fixture for mandibles. and between 210 N and 300 N during next 3000 cycles or bilateral incisor over-load (BIO) phase. Note: The frequency of load variation in the visuals is not representative of actual experiment. Figure 3.

Figure 3. 6. Loading set-up of EnduraTEC materials testing machine with custom-designed
fixture for mandibles. Fixture arrangement for the molar loading of mandibles in Groups 1 and 3
(Panel-A), and the incisor loading in Groups 2 and 4 (Panel-B) are shown.

In all loading groups, any specimen without failure during the cyclic testing was subjected to
a load-to-failure (LTF) test at the displacement rate of 2mm/min. Visible fracture was considered
a failure of the mandible. Axial position and load data were collected every 10 second using an
axial displacement transducer and an EnduraTEC 2.2 kN axial/torsion bi-axial load cell (Model
No. 1215CEW-250), respectively. At the same time, strain at the gauge attachment sites was
continuously measured at a sampling rate of 2 Hz using the inStruNet Data Acquisition System
and a personal computer. The strain data from all strain gauges attached to one specimen (EH)
from loading Group-1 could not be recorded due to an unforeseen problem with the computer
system recording strain data. The experimental strain data, its statistical analyses, and
comparison with numerical strain predictions from FE analysis are discussed in Chapter 4.

45

3.3 Damage Development
The axial stiffness (k) and damage (D) of each specimen were determined from the data
collected for each of the mandibles. Stiffness is determined from the axial compressive load (Fa)
applied to the mandible and the axial displacement (δa) of the mandible determined from change
in axial position (see Equation 3.1).8
k = Fa / δa

---------- Equation (3.1)

Damage is determined as a resultant of the axial stiffness (k) and the initial axial stiffness (ko)
(see Equation 3.2).
D = k / ko

---------- Equation (3.2)

3.4 Results
Table 3.2 summarizes the demographics and observations for mandibles in all loading groups.
Due to the practical constraints associated with a typical cadaveric experiment, such as the
limited number of cadavers obtained during a given time span through an academic institute’s
anatomical gift program, our study includes only sixteen cadaveric mandibles. Due to the small
sample size, we would like to present this study as a unique and novel exploratory experiment.
The inferences from the statistical analysis of the study data are a bi-product of the novel
exploration. During mechanical testing, the cadaveric mandibles in Group-1 and Group-2

46

undergo similar loading pattern with only difference in location and magnitude of loads. Due to
this similarity in loading configurations, Group-1 and Group-2 are comparable with each other.
Similarly, Group-3 and Group-4 are comparable with each other.

Load
Type

Maximum
Load before
Failure+ (N)

Cycles
Until
Failure#

Sr. No.

Patient
Code

1

EH

398.9

2

MD

3

HL

4

PS

5

LV

6

CE

7

Stiffness (N/mm)

Maximum
Damage
Accumulation

Failure
Location*

Minimum

Maximum

Change
in
Stiffness

59,074

66.9588

166.9798

100.0209

0.5990

A

1009.9

60,000

74.3581

102.2028

8.0538

0.2182

B

2656.6

60,000

38.5239

74.6276

22.7615

0.4838

B

396.1

42,700

41.9272

98.1200

55.2300

0.5722

B

1429.2

60,000

91.4375

241.7625

127.3500

0.6218

B

399.1

54,490

48.9799

92.8988

42.1180

0.4667

D, E

JL

966.6

60,000

47.3497

97.7837

36.6076

0.5158

E

8

HK

671

60,000

41.6044

123.2044

77.0342

0.6623

A, E

9

AM

281

30,025

25.0099

176.0829

145.4035

0.8580

C, E

10

BS

1001.6

60,000

78.0178

125.5732

34.3499

0.3291

D

11

PO

299.8

30,674

33.2355

148.3740

114.8405

0.7760

A, D, E

12

FH

501.4

60000

69.6915

115.8779

44.4932

0.3986

D

13

FK

2449.4

60,000

44.4012

144.2950

91.6651

0.6923

B

14

VV

1984.9

60,000

91.7637

671.2330

561.0770

0.8618

B

15

OM

352.4

16,851

7.9775

211.9790

203.9810

0.9624

A, D

16

ES

312.4

34182

37.5582

358.1150

320.4420

0.8951

D

Group-1

Group-2

Group-3
Group-4

+

Failure during cyclic loading or load-to-failure test
If cycles = 60000, the specimen did not fail during cyclic loading, and later underwent load-to-failure test
*Failure location: A - mandibular angle; B – mandibular body; C – symphysis or parasymphysis; D – condylar neck;
E - condylar head
#

Table 3. 2. Patient demographics, loading type, and observations for mandibles tested under
cyclic compressive loading.

47

3.4.1 Statistical Analysis
Table 3.3 shows the statistical analyses of data for mandibles in loading groups 1 and 2. The
Mann-Whitney Test was used to evaluate significance of maximum load before failure, number
of cycles to failure, stiffness, and damage accumulation at 5% significance level (i.e.,  = 0.05).
Another non-parametric test, Spearman’s Correlation Test, was used to analyze significance of
age for  = 0.05.
The distribution of age (p = 0.31), maximum load before failure (p = 0.39), cycles until failure
(p = 1.0), change in stiffness (p = 0.589), and maximum damage accumulation (p = 0.49) were
not significantly different across cyclic molar loading (Group 1) and cyclic incisor loading
(Group 2). Age had weak negative correlation with maximum load before failure (r =  0.51),
cycles until failure (r =  0.01), overall change in stiffness (r =  0.12), and maximum damage
accumulation (r =  0.11). The correlation between age and maximum load before failure of the
mandibles in this study is comparable to the reports by Craig, et al.20 who studied biomechanical
response of the human mandible to impacts of the chin. Age was not found to have significant
effect on cycles until failure (p = 0.48), overall change in stiffness (p = 0.76), and maximum
damage accumulation (p = 0.50). Sex did not have significant effect on cycles until failure (p =
0.27), overall change in stiffness (p = 0.64), and maximum damage accumulation (p = 0.76) in
the mandibles from both loading groups. Correlation between failure location and age, and that
between failure location and sex could not be statistically determined due to small sample size
and more groups of failure locations.

48

05. 3. In our knowledge.31 Retain H0 1. this is the only study to date which explores mandibular biomechanics under spectrum of cyclic fatigue loads. no significant difference was found within and between Groups 1 and 2 for maximum load before failure.49 Retain H0 0. No. For  = 0.59 Retain H0 0. Statistical analysis was not performed due to small sample size. The experimental results of this novel exploration are reported in Table 3. cycles until failure. overall change in stiffness. Our unique molar and incisor spectral loading groups consisted of two specimens each.The mandibles in groups 3 and 4 were subjected to spectrum loading at molars and incisors.53 Retain H0 0. 49 .0 Retain H0 0.76 Retain H0 Table 3.39 Retain H0 0.49 Retain H0 0.76 Retain H0 0.07 Retain H0 0. Statistical analyses using non-parametric Mann-Whitney Test for specimens in Groups 1 and 2.64 Retain H0 0.27 Retain H0 0. respectively.2. Sr. 1 2 3 4 5 6 7 8 9 10 11 12 Null Hypothesis (H0) The distribution of maximum load before failure is the same across categories of groups 1 and 2 The distribution of cycles until failure is the same across categories of groups 1 and 2 The distribution of minimum stiffness is the same across categories of groups 1 and 2 The distribution of maximum stiffness is the same across categories of groups 1 and 2 The distribution of overall change in stiffness is the same across categories of groups 1 and 2 The distribution of maximum damage accumulation is the same across categories of groups 1 and 2 The distribution of maximum load before failure is the same across categories of sex The distribution of cycles until failure is the same across categories of sex The distribution of minimum stiffness is the same across categories of sex The distribution of maximum stiffness is the same across categories of sex The distribution of overall change in stiffness is the same across categories of sex The distribution of maximum damage accumulation is the same across categories of sex Significance (p-value) Decision 0.

the fracture in the mandibular condyle region was a prominent mode of failure.7 shows pictures of some of the specimens failed with fractures at different locations. As seen from Table 3. and one failed at the symphysis and parasymphysis.2. each mandible failed in either condylar neck or head region.maximum damage accumulation. six failed in mandibular body. However.4. higher percentage of fractures occurs in the symphyseal/ parasymphyseal region. sex was not found to have significant effect on these parameters. Per the general categorization of the mandibular fractures reported in the literature. Also. In addition. Thus. more of the mandibles from molar loading configuration (Groups 1 and 3) were seen to fail in the mandibular body region. 3. The loading configurations in our experiment represent only a small subset of the actual functional and para-functional loading of the mandible. in contrast with the generalized fracture occurrences of the mandible. the fracture at mandibular body was a prominent mode of failure.2 Mandible Fracture A visible fracture of the mandible was regarded as its failure during the mechanical testing. Thus. three out of eight specimens also failed at the mandibular angle. Figure 3. Out of the combined total of eight mandibles in these two groups of molar loading. out of the combined total of eight mandibles in these two groups. we observed more prominent fractures at the mandibular 50 . For the incisor loading configuration (Groups 1 and 3) of the mandibles. for incisor loading of the cadaveric mandibles in this study. for molar loading of the cadaveric mandibles in this study. these reported numbers are the generalization of fractures under nearly all of the possible loading scenarios in real world. and one each failed at mandibular angle and condylar neck/head region. Hence.

B.body during molar loading and at the condylar region during the incisor loading of the mandibles in our experimental set-up. Visuals show fractures at left condyle (Panels A. 51 . Failure of the mandibles at different locations. D). mandibular angle (Panels C. D). 7. Figure 3. and molar region of mandibular body (Panel C).

no reliable statistical analysis can be performed to evaluate the effect of dental status on failure location of the mandibles. Displacement of the specimen under a specific load measures the stiffness of the specimen.10 and 3. Smaller displacement or deformation at a given load produces higher stiffness values. Some of the specimens had no teeth.9. Statistical analysis was performed to explore whether the dental status of the cadaveric mandibles had a significant effect on number of cycles until failure. without any teeth) and mixed denture.4 Stiffness Reduction Stiffness is a measure of the resistance of an elastic body to deflection when an external force is applied.11 show the stiffness of the mandibles plotted against number of 52 . the distribution of cycles until failure. Since it is a structural property. we categorized the mandibles as edentulous (i..05. 3. Fisher’s Exact Test showed that the patient’s sex did not have a significant effect on the dental status of the mandibles. maximum load before failure. Figures 3. The t-test statistics demonstrated that. and failure location for the mandibles in all loading groups. 3. Based on their dental status.3 Effect of Dental Status Table 3. stiffness varies both by the specimen tested and applied load. damage accumulation.3.4. Due to small sample size and large number of failure locations of the mandible. and damage accumulation in all of the tested mandibles was same across the two categories of the dental status.1 summarizes the dental status of each cadaveric mandible harvested for this study. and others had one or more teeth missing.e.4. stiffness.  = 0. stiffness. 3. None of the mandibles had all teeth intact. maximum load before failure.8.

and 4.. 53 . stiffness undergoes a steep initial decline which transitions over the time into a region of nearly constant stiffness. Figure 3. Also shown in these visuals are the plots of average stiffness for each loading group plotted against number of cycles. Similar trend of stiffness reduction was observed in mandibles from all loading groups. As seen from each of the plots. at the end of 30.cycles for all specimens in loading groups 1. determined until none of the specimens in the given group failed. after every 3000 cycles for groups 3 and 4).e.000 cycles for groups 1and 2. 3. This variation in the applied load is reflected in stiffness values as fluctuations of higher magnitude which transition into nearly constant stiffness after few hundred cycles. respectively. 2. there is a sudden and significant change in the load. 8. Axial stiffness reduction during cyclic compressive loading of mandibles in Group 1. At the transition of applied axial load from one loading phase to the next (i.

Axial stiffness reduction during cyclic compressive loading of mandibles in Group 3.Figure 3. Figure 3. Axial stiffness reduction during cyclic compressive loading of mandibles in Group 2. 9. 54 . 10.

13. 3 and 4. at the transition of the applied load from one loading phase to the next. After a few hundred loading cycles.Figure 3. 3. Axial stiffness reduction during cyclic compressive loading of mandibles in Group 4. As seen from these plots. 3.14 and 3. respectively.5 Damage Accumulation Figures 3.15 show the damage accumulation plotted against number of cycles for loading groups 1. Damage accumulation undergoes a steep increase which transitions into a region of saturation with nearly no change in damage. 2. the damage accumulation transitions into the region of nearly 55 .4. Same trend of damage accumulation was observed among specimens in all loading groups. a sudden and significant change in accumulated damage is observed in all specimens due to fluctuations in axial stiffness values in that region.12. 3. The average of damage accumulation in all specimens of each group (derived for the number of cycles during which no specimen failed) is also plotted. 11.

41. 12. 144. The mandible bone damage observed in both loading configurations in this study follows the trends of Stage I and Stage II bone damage similar to previously reported in the literature. 145 Figure 3. Damage accumulation in the mandibles from Group-1 during cyclic compressive molar loading. 56 .constant damage.

Figure 3. Damage accumulation in the mandibles from Group-2 during cyclic compressive incisor loading. 13. 57 .

15. 14. Figure 3.Figure 3. Damage accumulation in the mandibles from Group-3 during cyclic compressive molar spectrum loading. Damage accumulation in the mandibles from Group-4 during cyclic compressive incisor spectrum loading. 58 .

5. including bone fracture fixation devices. Different models of bone damage assessment are reported in the literature.Equation (3. we could not use this approach for mandibular bone damage prediction due to lack of sufficient information needed for this method.1 Damage Prediction Numerical/probabilistic models capable of predicting damage accumulation in the bone based on experimental and/or clinical data can provide valuable information of clinical relevance. we used Michaelis-Menten equation for this purpose. diagnosing and preventing bone deterioration and fracture. and developing and improving treatment methods. 144. Michaelis–Menten kinetics is a best-known model of enzyme kinetics.3.41.4. Linear summation approach has been used by researchers to predict damage accumulation in metals.93 However. Hence. Ability to accurately predict bone damage can be of significance in understanding disease mechanism. E = Enzyme S = Substrate ES = Complex 59 .3) Where. 145 We attempted to develop a predictive damage model for mandibular bone from the experimental data. This model describes the rate of enzymatic reactions by relating reaction rate to the concentration of substrate as following: ---------.

Equation (3. V = Rate of enzymatic reaction Vmax = Maximum rate achieved by the system at maximum or saturating substrate concentration Km = Michaelis constant = Substrate concentration at which V = ½ * Vmax We modified the Michaelis-Menten equation to predict damage accumulation in cadaveric mandibular bone based on experimental data as following: ---------.5) Where.P = Product ---------.Equation (3.4) Where. D(n) = Damage at nth cycle 60 .

3. Nearly similar trend of damage prediction was seen for mandibles in loading Groups 2. and 4 as shown in Figures 3. As seen from this figure. the predicted damage closely follows the damage pattern of the experimentally derived damage during first loading phase (BMN). However. respectively.19. Similar approach was used previously by George-Whitney and Goswami for predicting damage accumulation in femur. 61 . Figure 3. 3. at the loading phase transition and during the second loading phase (BMO).17. Apart from the initial excursions and some outliers in the region of saturated damage. and 3.16 shows experimentally derived average damage and predicted damage plotted against number of fatigue load cycles for mandibles in loading Group-1.Dmax = Maximum damage Km = Cycles at Dmax/2 We modeled the mandibular bone damage using non-linear regression to the MichaelisMenten equation. They found strong correspondence between experimentally derived damage in femur and the damage predicted by Michaelis-Menten model.16. the prediction model produced more erroneous damage magnitude as seen in Figure 3. the predicted damage has extravagant peaks and valleys in the beginning of first loading phase (BMN) as well as at the time instance when applied load changes from first phase (BMN) to the second (BMO).18.

16. Damage prediction for Group-1 specimens.Figure 3. 62 . Figure shows a plot each for the average of experimentally derived damage and predicted damage plotted against number of loading cycles for all mandibles in the group.

17.Figure 3. Damage prediction for Group-2 specimens. Figure shows a plot each for the average of experimentally derived damage and predicted damage plotted against number of loading cycles for all mandibles in the group. 63 .

64 . 18. Figure shows a plot each for the average of experimentally derived damage and predicted damage plotted against number of loading cycles for all mandibles in the group. Damage prediction for Group-3 specimens.Figure 3.

George-Whitney and Goswami41 have modeled the damage accumulation in femur bone using the Michaelis-Menten equation. the current study where cadaveric mandibles underwent two loading phases each for Group. Damage prediction for Group-4 specimens. Strong correspondence was found between the experimental and damage predicted in that study. Figure shows a plot each for the average of experimentally derived damage and predicted damage plotted against number of loading cycles for all mandibles in the group. Their study included only one phase of applied load during mechanical testing.Figure 3.1 (BMN-BMO) and Group 2 (BIN-BIO). and 20 loading phases for the spectrum loading configuration of Groups 3 and 4. A more comprehensive 65 . 19. However.

The data provide insights about stiffness. Swasty. This study intends to provide meaningful information to the clinicians and medical device designers about biomechanical behavior of the mandible under cyclic fatigue loading at the molars and incisors. This may explain why we saw the negative correlation between the age and maximum load before failure of the mandibles. et al.126 reported that the human mandible continued to mature through 40 to 49 years of age. failure modes. The correlation between age and maximum load before failure of the mandibles in this study is comparable to the reports by Craig. The loading conditions utilized in this study are representative of bite forces under functional and parafunctional loading of the mandible. 66 . damage accumulation.5 Discussion We investigated in-vitro the biomechanical behavior of mandible under four different configurations of cyclic compressive loads applied at molars (Groups 1 and 3) and incisors (Group 2 and 4). and then the thickness of mandibular cortical bone decreased after this age. et al. Age and sex were not found to have significant effect on cycles until failure. and correlation between failure load and age of the patient.exploration is required to predict damage accumulation in bone more accurately under different loading scenarios.20 who studied biomechanical response of the human mandible to impacts of the chin. 3. Our study indicates that the older mandibles tend to fail at lower magnitudes of cyclic compressive load when compared with the mandibles of younger patients.

8 In all loading groups. the effect of variations in the cross-section.8 – 3. 66 However. and accumulation of microdamage. and maximum damage accumulation in the mandibles from both loading groups. Larger and/or more numerous strains can reduce bone strength below 20% of normal. 144. modulus of elasticity and viscoelastic properties of the mandibular bone was considered negligible for the purpose of calculations. the stiffness of mandibles underwent a steep initial decline in each of the loading phases followed by a saturation region of nearly constant stiffness (see Figures 3. 145 Similar to the stage I of the bone damage models reported in the literature.overall change in stiffness. dead bone cannot detect and repair microdamage. The stiffness of mandibles was derived from test data. The damage accumulated in the cadaveric mandibles showed a steep increase during first few hundred loading cycles followed by a region of saturation with nearly no change in the magnitude of damage.36 This can cause significant decrease in stiffness.41. The mandible bone damage observed in all loading configurations in this study followed the trends of Stage I and Stage II of the bone damage model similar to the previously reported studies. Therefore. thereby. Published test results have shown that such effect is small and can be neglected with sufficient accuracy. and the damage accumulation was determined from the stiffness. In this process. leading to stress fracture.46. 55 a significant amount of stiffness reduction occurs during initial loading 67 .11).36.36 Normally bones detect and repair such microdamage through modeling and remodeling provided the microdamage remains below the intrinsic modeling threshold of the bone. further exploration is needed to extrapolate findings of this cadaveric study for their application to the real-world clinical scenarios involving living mandible or grafts.

A comprehensive investigation is required to explore a possible correlation between high prevalence of true osteoporosis in women and the gender paradox of TMD population (which is significantly dominated by female patients). However. In molar loading configuration (Groups 1 and 3). condylar neck.36 The osteoporosis of osteopenic bones is reported to affect women more than men or children. incisor region. sex.cycles. The molar region of mandibular body was a prominent failure location with four out of six mandibles in Group-1 failing at this site. this form of fracture mode occurred in only one specimen (in incisor loading group) in the present study. the correlation of the failure location with age. and at the condylar region during incisor loading of the 68 . we cannot make any observations regarding the osteoporosis and mandibular fracture. condylar neck. In incisor loading configuration (Groups 2 and 4). Though mandible is reported to fracture more frequently in the symphyseal or parasymphyseal region in real-world scenarios. The condyles appeared to be the most susceptible failure location since each of the six mandibles in Group-2 failed at either condylar head or condylar neck or both. We considered the visible fracture as failure of the specimen under fatigue loading. the mandibles failed at either one or more of the following sites: mandibular angel. This stiffness reduction then slows into a nearly constant linear pattern in stage II.36 Since skeletal pathology of subjects in the present study is not known. due to small sample size and large number of failure locations. We observed more fractures at the molar region of the mandibular body during molar loading. the mandibles failed at either one or more of the following sites: mandibular angle. molar region. and dental status could not be statistically determined. condylar head (see Table 1). condylar head. Normal mechanical usage of osteopenic bones is suggested to increase their microdamage and their fragility enough to cause spontaneous fractures and/or bone pain.

Also. and potentially contribute to the deterioration/progress of the TMD. Our experimental study offers limited insight into the fatigue behavior of mandible as it is restricted to only compressive loading. Within the limitations of this study. As in case of a typical cadaver study. it can be concluded that the majority of the damage accumulation in the mandible under cyclic compressive loads at incisors or molars occurs during first few hundred of the fatigue cycles. and the damage accumulation during cyclic compression showed a steep initial increase which transitioned into a region of saturation with nearly no change in damage. Our experimental study has some notable limitations. Another limitation of our study is due to the type of loading used. we studied stiffness reduction and fatigue damage accumulation in mandibles. Since injury and fracture of the mandible are reported to co-exist with. the sample size of our specimens is small. Also. This study did not incorporate the tensile and shear loading.mandibles in our experimental set-up. Our analysis of stiffness variation showed steep initial decline in each of the loading phases followed by a saturation region of nearly constant stiffness. 69 . One possible explanation for this deviation in fracture modes can be that our experimental loading set-up represents only a small subset of the realworld functional and para-functional loading of the mandible. the older mandibles showed a tendency to fracture at lower magnitudes of cyclic compressive fatigue load. In summary. the subjects included in our study are of older age (between 61 years and 98 years) as we did not have control on the age of acquired cadavers. we investigated biomechanical behavior of cadaveric mandibles under four configurations of cyclic compressive loads.

and demonstrated the relationship between the amount of strain in bony microenvironment and the biological reaction. 63. 116 Knowledge of the 70 .35. 111 To be confident in the results of FE models of complex biological structures such as bones. the biomechanical properties of human mandible can be determined experimentally using models to simulate normal physiological and non-physiological loads. crucial to its application is the knowledge of how well finite element (FE) results replicate reality. experimental validation is required. and mechanism of associated disorders. Though FEA is a powerful modeling tool useful in predicting mechanical behavior of complex structures. Several researchers have attempted to explore the biomechanical behavior of mandible and associated components of masticatory system. 77 Frost35 investigated Wolff’s concept of relationship between biomechanics and morphology of bony tissue. 79. 146 Although it is nearly impossible to standardize the real functional and para-functional behavior of the masticatory system in living persons. thus increasing their treatment efficiency.1 Introduction Biomechanical behavior of the mandible is important in various clinical situations. Indirect methods such as mechanical testing and finite element analysis (FEA) have been widely used for in-vitro assessment of anatomical structures.64. 64. Analysis of mandibular biomechanics helps us understand the interaction of form and function.45.4.79. THREE-DIMENSIONAL ANATOMICAL AND FINITE ELEMENT MODELING AND ANALYSIS OF CADAVERIC MANDIBLES 4. It also aids in improving of the design and performance of the prosthetic devices.

45 The results of these studies confirm the reliability and practicality of using strain gauges for validation purpose. Most of the literature. and material properties can be defined using Young’s modulus based either on bone density values from the CT data or on data acquired from experiments or literature. deals with the measurement of surface strains on long bones such as femur and tibia to respond to a clinical question. 120 For experimental validation of FE bone models. 28. performed on the same mandibles paralleling the experimental 71 . The CT data can be used to accurately reconstruct anatomical components of interest. Such validated FE models can be useful in further exploration of the biomechanical aspects of mandible and TMJ necessary to improve the treatment modalities including enhancement of the designs of prosthetic devices by predicting their performance. 116 FE modeling and analysis requires precise knowledge of the material parameters as well as the geometry of the mandible under investigation. though. especially concerning the correlation of experimental and FE results. Use of this CT-based FEM methodology provides both subject-specific geometric parameters and material properties at the same time.64. 111. This chapter describes the experimental evaluation of strains/deformation of human cadaver mandibles under in-vitro loading conditions and numerical evaluation using FEA. 127. Fewer numerical and experimental studies are available for mandible. 146 or interferometry. 110. 64.110 Morphological data of the specimen can be obtained by non-invasive means through medical images such as three-dimensional (3D) computed tomography (CT). several studies have used strain in the bone measured either with strain gauges11.24. based on 3D reconstruction from CT data.biomechanical behavior of mandible gained from experimental studies can be used to validate the analytical/numerical models such as FEA. 142. 116.

Comparison between experimental and numerical data is performed to evaluate validity of the FE models and methodology. Following questions were examined: 1. L4) for the experimental strain data of four loading groups? 2. L2. The objective is to establish a non-invasive methodology to accurately predict biomechanical behavior of the mandibles under mechanical loading. Does ‘Age of Patient’ have a significant effect on magnitude of experimental strain? 3. What degree of statistical correlation and statistical agreement do experimental/measured strain data have with analytical (FE) strain for mandibles in all loading groups? 72 . Can a difference be stated in strain magnitudes measured at condylar surface locations (L3.setup. Does ‘Sex of Patient’ have a significant effect on magnitude of experimental strain? 4. The experimental part of the study is discussed in Chapter 3. We investigated in-vitro the biomechanical behavior of mandible under four different configurations of cyclic compressive loading as described in Chapter 3. Results of experimental and numerical methods were compared to evaluate statistical correlation and agreement between experimental/measured strain data and FE-predicted strains. The strain profiles were examined at five different locations on the cortical surface of mandible under these loading conditions through experimental and analytical (FE) methods. L5) with respect to other locations of strain acquisition (L1.

CT. Deformation of the bone surface leads to a corresponding change in length of the attached strain gauge wire which is proportional to its electrical resistance. L4. 110 Each strain gauge was connected through a quarter-bridge wiring configuration of Wheatstone bridge circuit to the instruNet Data Acquisition System (Omega. During cyclic loading of each specimen. Stamford. 28 Change in electrical resistance of the strain gauge. Stamford. L5) on the cortical surface of each mandibular bone after the attachment sites were cleaned and degreased using standard protocol as explained in Chapter 3. strain at the gauge attachment sites was measured and recorded throughout the experiment at a sampling rate of 2 Hz.17. and harvested. which was linked to a computer to record the data using instruNet World PLUS (iW+) software (Omega. The positions of strain gauges were selected based on literature and results of our prior FE simulation of a mandible specimen. 4. Japan) were used to measure surface strain. Five strain gauges were attached at exactly defined five locations (L1. L2. Prior to mechanical testing.2. cleaned of soft tissue and preserved as discussed in Chapter 3.1 Experimental Strain Measurement During mechanical testing. uniaxial strain gauges (KFG-1-120-C1-11 L3M3R. USA). Kyowa Electronics.28.2 Materials and Methods Sixteen fresh-frozen human cadaveric mandibles with no visible bone defects or fixation devices were collected from adult human cadavers. USA). CT scans of all specimens were performed for 3D anatomical reconstruction to be done for creating specimen-specific FE models. CT. which acts as one 73 . L3.4. Tokoyo.

during. Resultant output voltage of Wheatsone bridge circuit is proportional to the magnitude of deformation of the bone surface to which strain gauge is attached.arm of Wheatstone bridge. The parameter used to describe this deformation process is μstrain (μm/m). Eden Prairie. we did not include FE strain data of this specimen in this study as it could not have been validated against measured strains. Tests were conducted in axial compression mode. USA) that allowed a controlled application of force simulating bite forces. This helped in accurately defining the strain acquisition sites and boundary conditions during FE simulations. Due to loss of this experimental data. To identify the site of attachment for each strain gauge. As discussed in Chapter 3. in each of the four loading groups of mandibles. Bose Corporation. and the voltage is measured by the instruNet data acquisition system. forces were applied at mandibular angles on both sides of the specimens which were set up upside down in the test machine using custom-designed fixtures. MN. and after mechanical testing. 74 . Strain data from all strain gauges attached to one specimen (EH) from loading Group-1 could not be recorded due to an unforeseen problem with the computer system recording strain data. results in the unbalancing of the bridge circuit. images of the specimens were taken with a digital camera from approximately 400 mm before. The cyclic load was applied at 2 Hz using an EnduraTEC materials testing machine (ElectroForce Systems Group.

12 (Materialise. cancellous bone and teeth using inbuilt threshold values followed by manual editing and morphological and Boolean operations on the masks (see Figure 4.2). 75 . Independent masks were created each for the cortical bone.1).2 Subject-Specific FE Model Creation Subject-specific 3D anatomical reconstruction of each mandible specimen was performed using commercial software Mimics 14. cancellous bone and teeth were constructed. The volume mesh was generated with ten-node quadratic tetrahedral elements of type C3D10 (see Figure 4. and volume bound within each surface was meshed. MI.2.4. USA) from computed tomography (CT) scans. Surface models of cortical bone. Plymouth.

Figure 4. coronal. individual masks were created for cortical bone. 3D reconstruction of mandible in Mimics software. After forming 3D volume mesh. and sagittal. and teeth as indicated by yellow. 76 . 1. purple. Mimics enables users to perform segmentation of medical images in three different views – axial. From CT scan of the mandible. cancellous bone. 3D equivalent of the mandible was reconstructed by combining all masks. and red color respectively. material properties were assigned to each component of the mesh based on the masks.

maximum element size of 2 mm was considered optimal. 79. 1. A convergence study was performed comparing maximum principal strain in three mandibular FE models with different element sizes (maximum element lengths: 1.45. elastic. axial and coronal intersections of the surface model with triangular elements (panel-A) of a 3D reconstructed mandible. 2. and the results were within 3 – 6% of those from the 1 mm elements.0 and 2. 2. 111.5. The surface mesh was later converted into a 3D finite element volume mesh (panel-B) with ten-node quadratic tetrahedral elements of type C3D10. 77 . Subject-specific anatomical reconstruction of the mandible. isotropic material properties were assigned to the specimen-specific FE models using corresponding masks in Mimics.53 GHz processor was 8 – 10 hours.Figure 4. which was about 3 times faster compared to that for the 1 mm element size.5 mm).0. Homogeneous. 124 Following material properties. Based on the outcomes of this study. Figure shows the rightlateral. The computational time for the 2 mm element size on a 2.

similar constraints were applied to nodes at the tips of molar region on both sides for models in the molar loading Groups 1 and 3. 78 .6 GPa for teeth.which are values that lie within the range of published values for human mandibles. Poisson’s ratio: 0.3 Finite Element Analysis Boundary and loading conditions were carefully applied to the FE models using ABAQUS software to accurately reproduce the conditions used in mechanical tests of the cadaveric mandibles. To simulate the experimental loading conditions. 112. the nodes at tips of condyles of FE model that coincided with the position of the supports in mechanical test were constrained in all of their translational degrees of freedom and free in all their rotational degree of freedom. 17.45. 61. RI.7 GPa for cortical bone.25 for teeth.10 (SIMULIA. Additionally.49 GPa for cancellous bone. and to nodes at tips of the central incisor region for the models in the incisor loading Groups 2 and 4 (see Figure 4. Vertical compressive forces were applied to nodes in the region of mandibular angle on each ramus which coincided with the position of loading bar in experimental setup. 0. were used in this study – Young’s modulus: 14.3). Providence. 0. USA) to perform FE simulations paralleling our experimental setup and testing. 4.3 for cortical and cancellous bone.2. 118 The mandibular 3D volume mesh was then exported to a commercially available FEA software ABAQUS 6.

molars for Group-1 and Group-3 simulations (Panel-A). and Panel-B depicts incisor loading configuration (Groups 2 and 4). and illustration of loading and boundary conditions. Linear static FE analysis was performed. 111. 79. and incisors for Group-2 and Group-4 simulations (Panel-B). The FE-predicted strain data reported 79 . The maximum principal strain at the nodes of FE models that matched the position of strain gauges on the surface of mandible was recorded. 124 Load data similar to that of mechanical testing were used to perform FE simulations.45. The material properties associated to FE model were assumed to be homogeneous. PanelA shows schematic of molar loading simulation (Groups 1 and 3). 3. isotropic and with linear elastic behavior in accordance with other studies. Three runs/repetitions of FE simulation of each specimen were performed.Figure 4. These repetitions were carried out to account for any userinduced error due to variations such as deviations in accurately selecting the exact nodes for applying load and boundary conditions on the FE model. The asterisks indicate the regions of constrained nodes at the condylar heads during all loading configurations. A Mandibular FE model. The arrows point at nodes of the region where vertical compressive forces were applied. 110.

Figure 4. Strains of higher magnitude are seen in the condylar region and the region of load application compared to rest of the model. Figure 4. 80 .in Table 4. Maximum principal strain distribution in one of the mandible FE models.4 shows the visualization of FE strain profile for one of the specimens.1 are average of three simulations performed for each FE model. 4.

3 and 4. During statistical analysis. 81 .g. strain) by two different methods (e. we used Wilcoxon Signed Ranks Test (to check distribution of strain at condylar locations and other sites). and Intra-class Correlation Test (for statistical ‘agreement’ between experimental and FE strain).. it is necessary to evaluate the statistical correlation as well as the statistical agreement between the two data sets. Figures 4. L4 and L5. the strains at the condylar locations (L3 and L5) are higher than those measured at other locations on the same mandible. t-Test (for effect of sex). As seen from these plots. Also. 4.8 show the measured/experimental strains and FE-predicted maximum principal strains for the mandibles in loading Groups 1.. According to Markert.83 when comparing measurements of the same parameter (e. 4. 4. respectively.13 show the average experimental strain data for strain gauge locations L1.7 and 4.5.g. Spearman’s Correlation Test (for effect of age on experimental strain). Pearson’s Correlation Test (for correlation between experimental and FE strain). 2.6.4.9. Figures 4. plotted against the measurement locations on the surface of the specimen. 4. plotted for all specimens. L2.12 and 4. L3. The mean and standard deviation were calculated for experimental and FE strain values for each location. and this information was used for statistical analyses. mechanical testing and FEA). 4. the plots illustrate that the FE-predicted strains closely follow the profiles of experimental strains measured at the corresponding locations on the same mandible surface.10. to analyze the correspondence between the data from two methods more reliably. respectively.2.11.4 Data Analysis The measured strain data and the FE-predicted maximum principal strain data were reduced to acquire a reading every tenth second for each of the five selected locations on the mandible.

L5) were found to be significantly different from the strains measured at each of other three locations (L1. Wilcoxon Signed Rank Test was used to evaluate the distribution of experimental strains measured at different locations.3 Results Table 4.001 at  = 0. 82 . with an exception of location L3 (p = 0.1 summarizes the demographics and observations for mandibles in both loading groups. L2. Per Spearman’s Correlation Test.05). The distribution of strains measured at each of the condylar locations (L3. L4). L4) on the mandible bone surface (p ≥ 0.001) (see Table 4. no significant correlation was found between age of patient and experimental strain measured at five locations (p > 0. L2.3).05 for  = 0.05).4. Due to small sample size.042 for  = 0. The experimental strains measured at the condylar locations (L3. t-Test statistics showed no significant correlation between sex of patient and experimental strain at measure at five locations (p > 0.05 for  = 0. L5) were compared with those measured by the strain gauges attached to the mandible surface at other locations (L1.05) (see Table 4.2).

0002 0.4992 0.4939 0.3993 -0.1514 0.6873 0.4050 0.0350 -0. Dev.5878 0.6442 -15.3103 -0.0002 -0.5140 -0.1945 -0.0001 -0.0199 -0.4234 0.4117 0.3290 0.5247 10.0002 -0.0269 -0.0007 4.4253 0.0824 0.7373 -0.9052 -0.0002 0. Patient Load Type No. Std.0492 4.8514 0. Avg.0956 -0.0107 -0.5115 EH F 98 398. Avg.7337 0.0002 0.0844 0.2540 0. Dev.8578 0. Std.0099 0. Dev.0073 0.9 60000 B HL M 71 2656.0046 0.0781 0.0470 0.0002 0.0503 -0.0143 4.0006 93.0126 4.0051 0.7593 0.0001 1.4139 0.3010 0.1222 0.0002 -0. Avg.4177 6.4217 -20.0306 0.0144 4.0002 0.0073 -0. Dev.1337 -0. Dev.0002 -0.0186 1.0003 -0.4308 -12.3283 0.5689 0.0001 0.9497 0.5036 0.4161 -14.0001 -0.0659 -0. E Group-1 (BMNBMO) 4 9 AM F 83 281 30025 C.5252 7.4338 0. Std.1872 0.0002 0.3255 -0.3410 0.4591 1. + Failure during cyclic loading or load-to-failure test. Code Sex Maximum Cycles Age Load before Until (yrs) Failure+ (N) Failure# L1 L2 L3 L4 L5 L1 L2 L3 L4 L5 - - - - - - - - - - - -0.0501 -0.6370 0.0002 -0.6070 4.3980 -16.2361 0.0107 -0.3396 0.4886 -8.6035 0.2159 0.0974 -0.5474 -0. Dev.5054 0.7284 0. Dev.3783 -0.0043 -0.5660 0.0204 6.4931 0.1745 -0.0099 -0. Std.4953 0.0238 5.3029 0.4899 -25.4276 0.0002 -0.6800 0.0683 0.9 59074 A 2 MD F 84 1009.6870 0.4200 -44.0149 0.0002 -0.0472 -0.5136 0.3854 0.4 60000 D FK M 85 2449.6578 0.0231 -0.0039 2. Dev.3743 0.5460 0.0002 0. Avg.0295 -0.5428 -6.0096 -0.8936 .0001 -0.3248 -0.0012 -0. Std.2144 0.3480 0.5282 0. Std.0212 0.1903 -0. Std.0866 -0.0243 4.4870 6.5254 -23.0001 -0.2830 -9.1555 1.5264 -15.0946 -0.4928 6.8629 0.3609 0.3646 0. Dev.3337 0. Avg.8860 -0.2290 0.Sr.4846 0.0395 -0.0570 0.0002 -0.3399 0.0423 1.5106 0. E 7 JL F 84 966.9518 -0.0998 0.7160 0.0001 -0. Std. Avg. D ES F 65 312.4346 6.3217 0.6 60000 D 11 PO F 82 299.0186 -0.2648 4.4458 1.0002 -0. Dev.0002 0.2027 0.8884 -0.0001 0.9044 0.7348 0.0002 0.0456 0.0187 -0. Dev. Std.4089 -17.2198 -0.1265 0.1 54490 D.4345 0.5585 -0.0663 -8.4094 -17. Avg.0426 -0.7785 0.4171 -43.3598 M: Male.4178 -12. D. Std.3294 4.4 60000 B VV F 62 1984. Std. Dev.4 16851 A.0558 3.0207 -0.4863 -0. Std.0467 1.3495 0.0312 -0. Avg.0118 1.9637 -0.4146 0.0106 -0.9127 -24.7575 0.5376 -23.0325 -23.8172 0.6038 -0.4413 -0.0451 0.3173 0.5543 2.3311 0.9081 0.9 60000 B OM M 90 352.0002 0.0449 132.3746 0.5345 0.2 60000 B 6 CE M 71 399.4224 0.4724 -295.0009 -0.3010 0.4285 0.4252 0.5261 0. F: Female.6877 0.0001 -0.2788 0.0417 -9.7914 -8.4 34182 D Group-2 (BIN-BIO) 10 13 Group-3 (Molar Spectrum) 14 15 Group-4 (Incisor Spectrum) 16 FE Strain (µm/m) Strain Data 1 3 Experimental Strain (µm/m) Failure Location* Avg.8611 -0.4217 -20.4282 4. E BS M 91 1001.2889 0.4671 -26.7244 0.5676 0.4935 5.0123 -0.2271 0. Avg.0307 -0.3846 -17.1265 0. Dev. E 12 FH F 92 501.4937 0.8048 -0.0220 -0. Std.1444 0. Dev.0002 -0.0002 -0.0617 0.5426 10. Avg.0003 -0.4932 5.3790 -0. Avg.3356 0.6 60000 B PS F 86 396.3323 -8.0116 0. 83 0.0544 0.0694 0.2402 -0. Std.0197 -14.5187 5.4404 0. 0.0002 -0.4048 -14.3804 0.0002 0.9940 -0. Dev.2719 -0.0002 -0.2097 -0.1 42700 B 5 LV M 61 1429.4940 7.4768 7.4845 0.4690 -6.7023 0.0286 -0. Std.6 60000 E 8 HK M 87 671 60000 A.3553 -0.0150 0.7709 -0.0155 -0.2815 0.7114 5.3393 0.0002 -0.0270 0.0001 0.0503 0.3803 0. Avg.0404 0.0148 6.5123 3.0073 -0. Avg.3032 0.8459 -0.3142 0.0350 0.2618 -0.4249 -181.8 30674 A. Avg.5050 0.4244 -14.

Strain gauge nomenclature: L1 – fronto-laterally at left mental protuberance.: Average.mandibular angle. L2 – buccally on left mandibular body. Table 4. the specimen did not fail during cyclic loading. 1. L4 – buccally on right mandibular body. load type.# If cycles = 60000. and observations about mechanical testing and finite element analysis (FEA) of mandibles subjected to cyclic compressive loading. anterior to oblique line.: Standard Deviation. below alveolar process. E .condylar neck. D . C – symphysis and parasymphysis. caudal to first and second molars. * Failure location: A . Std. Patient demographics.condylar head. B – mandibular body. L5 – at the dorsal region of the right condylar process. L3 – at the dorsal region of the left condylar process. and later underwent load-to-failure test. Avg. 84 . Dev. anterior to oblique line. caudal to first and second molars.

. Plot of experimental/measured strain and FE predicted maximum principal strain (μm/m) (average ± standard deviation) for mandibles in loading Group-1. 85 . 5.Group-1 (BMN-BMO): Experimental and FE Strain MD 9 MD FE 6 HL 3 HL FE 0 PS PS FE Strain (µm/m) -3 LV -6 LV FE -9 CE -12 CE FE -15 -18 -21 -24 -27 L1 L2 L3 L4 L5 Location of Mandibular Strain Figure 4. Note 1 – Read legend as: XX = experimental strain for the specimen XX. MD = experimental strain for the specimen MD. E. Note 2 – Data for one specimen (EH) from this group are not included due to loss of information during experimental strain acquisition.g. MD FE = FE predicted strain for the specimen MD. XX FE = FE predicted strain for the specimen XX.

JL = experimental strain for the specimen JL. JL FE = FE predicted strain for the specimen JL. E. Note – Read legend as: XX = experimental strain for the specimen XX. XX FE = FE predicted strain for the specimen XX.Group-2 (BIN-BIO): Experimental and FE Strain 12 JL JL FE 8 HK HK FE 4 AM Strain (µm/m) AM FE BS 0 BS FE PO -4 PO FE FH -8 FH FE -12 -16 -20 L1 L2 L3 L4 L5 Location of Mandibular Strain Figure 4. 86 .g. 6. Plot of experimental/measured strain and FE predicted maximum principal strain (μm/m) (average ± standard deviation) for mandibles in loading Group-2..

Note – Read legend as: XX = experimental strain for the specimen XX. XX FE = FE predicted strain for the specimen XX. FK = experimental strain for the specimen FK..Group-3 (Molar Spectrum): Experimental and FE Strain FK 10 FK FE 5 VV 0 VV FE -5 Strain (µStrain) -10 -15 -20 -25 -30 -35 -40 -45 -50 L1 L2 L3 L4 L5 Location of Mandibular Strain Figure 4.g. FK FE = FE predicted strain for the specimen FK. E. Plot of experimental/measured strain and FE predicted maximum principal strain (μm/m) (average ± standard deviation) for mandibles in loading Group-3. 87 . 7.

XX FE = FE predicted strain for the specimen XX. 88 ..g. Plot of experimental/measured strain and FE predicted maximum principal strain (μm/m) (average ± standard deviation) for mandibles in loading Group-4.Group-4 (Incisor Spectrum): Experimental and FE Strain OM 10 OM FE -40 ES ES FE -90 Strain (µStrain) -140 -190 -240 -290 -340 -390 -440 L1 L2 L3 L4 L5 Location of Mandibular Strain Figure 4. 8. OM = experimental strain for the specimen OM. Note – Read legend as: XX = experimental strain for the specimen XX. E. OM FE = FE predicted strain for the specimen OM.

Plot of experimental strain (μm/m) (average ± standard deviation) measured with strain gauge at location L1 on mandibles in all loading groups.1 LV CE JL Strain (µm/m) -0.3 PO FH FK -0.2 HK AM BS -0.Location L1: Measured Strain 0 MD HL PS -0.6 GroupSpecimen Mandible Figure 4.5 -0. 9. 89 .4 VV OM ES -0.

5 FK VV OM -0.7 -0.6 ES -0. 10.4 PO FH -0. Plot of experimental strain (μm/m) (average ± standard deviation) measured with strain gauge at location L2 on mandibles in all loading groups.3 AM BS -0. 90 .8 Group Mandible Specimen Figure 4.1 PS LV CE -0.2 JL HK Strain (µm/m) -0.Location L2: Measured Strain 0 MD HL -0.

Plot of experimental strain (μm/m) (average ± standard deviation) measured with strain gauge at location L3 on mandibles in all loading groups. 11.Location L3: Measured Strain 12 MD 9 HL PS 6 LV 3 CE 0 JL Strain (µm/m) HK -3 AM -6 BS PO -9 FH -12 FK -15 VV OM -18 ES -21 -24 -27 Group Mandible Specimen Figure 4. 91 .

12.1 LV CE JL Strain (µm/m) -0. 92 .2 HK AM BS -0.5 -0.Location L4: Measured Strain 0 MD HL PS -0.6 Group Mandible Specimen Figure 4.3 PO FH FK -0.4 VV OM ES -0. Plot of experimental strain (μm/m) (average ± standard deviation) measured with strain gauge at location L4 on mandibles in all loading groups.

Location L5: Measured Strain 0 MD HL PS -50 LV CE JL Strain (µm/m) -100 HK AM BS -150 PO FH FK -200 VV OM ES -250 -300 MandibleGroup Specimen Figure 4. 93 . 13. Plot of experimental strain (μm/m) (average ± standard deviation) measured with strain gauge at location L5 on mandibles in all loading groups.

001 Table 4.005 L2 -3. Based on negative ranks . Statistical analyses using Wilcoxon Signed Ranks Test (to analyze distribution of strain at condylar locations and other sites of strain measurement). Based on positive ranks ˅.011 L1 -3.001 L2 -3.556b 0. For  = 0. L2.Location of strain measurement Condylar Z L1 -2. L5) are significantly different from those measured at other locations (L1.001.408 b 0.001 L4 -2.408b 0.001 L5 c Significance (2-tailed)˅ Non-condylar L3 b Wilcoxon Signed Ranks Test Statistics . strains measured at the condylar locations (L3.408 c 0.001 L4 -3. 94 .840b 0. 2. Significance at p ≥ 0. L4) on the surface of the mandible bone.408b 0.

47 0.659 -0.999 0.17 to 0.892 to 0.995 0.964 < R2 <0.000 L4 0.08 to 0.05 level (2-tailed) ± Correlation is significant at the 0.997 0.931 to 0. sex does not have significant effect on the experimental strains at any of the five locations.998 to 1.494 0.999) with narrow confidence interval.997 0. Strong correlation is found between the measured and FE strain data for locations L1.24 0.991 0.05 level (2-tailed) Table 4. For  = 0.988 0.951 to 0. and Intra-class Correlation Test (to analyze ‘statistical agreement’ between experimental strain and FE strain). 95 .991 to 0. L3 and L5 (0.972 to 0.042 0. and no significant correlation is found between age of patient and experimental strain (with an exception of location L3). L3 and L5 (0.992 0.999 0.984 0.05. Statistical analyses using Spearman’s Correlation Test (to analyze effect of age on experimental strain).795 0.Spearman's Rho Significance (2tailed)§ Correspondence between 'sex' and 'experimental strain' t-test Significance (2tailed)± L1 0.298 0. Pearson’s Correlation Test (to evaluate statistical correlation between experimental strain and FE strain.00 0.867 0. L2.064 0.999) with narrow confidence intervals. Strong statistical agreement is seen between the experimental and FE strain data for locations L1.809 to 0.17 to 0.659) with wider confidence interval (CI = -0. 3.936 0.936 < Intraclass Correlation Coefficient < 0.977 0.997 to 1.08 to 0.885 L5 0.964 0. t-test (to evaluate effect of sex on experimental strain).837 0.815 L2 0.978 § Correlation is significant at the 0.569) between the experimental and FEA results with a wider confidence interval (0. L2.22 L3 Location of strain measurement Correspondence between 'age' and 'experimental strain' Statistical correlation between 'experimental strain' and 'FE strain' Statistical agreement between 'experimental strain' and 'FE strain' Pearson Correlation 95% CI Intraclass Correlation 95% CI 0.569 0.999 0.885) is found for location L4.837). The strain measurement location L4 shows a moderate correlation (R2 = 0. A moderate statistical agreement (Intraclass Correlation Coefficient = 0.

and FE modeling and analysis offer practical alternative to the direct methods of investigating biomechanical behavior of the mandible and associated structures. L3 and L5 (0. a moderate statistical agreement (Intraclass Correlation Coefficient = 0.Pearson’s Correlation Test was used to analyze the concordance between experimental and FEA strain.885) was found between the experimental and FE strain values for location L4.999) with narrow confidence interval (see Table 4.3). FE modeling has been used widely in biomechanical studies due to its ability to simulate the geometry.4 Discussion Indirect techniques such as in-vitro mechanical testing of cadaveric specimens. However. FE and mean experimental strains showed close correspondence for all load configurations and measurement locations. L2. strains. Location L4 showed a moderate correlation (R2 = 0. We used the ‘Intraclass Correlation Test’ to analyze statistical agreement between experimental and FEA strain.569) between the experimental and FEA results with a wider confidence interval (0.659) with wide confidence interval (CI = .936 < Intraclass Correlation Coefficient < 0. 4.0.837).08 to 0.3).964 < R2 <0. FE and mean measured strain corresponded well for all load cases and for all strain gauges. forces. L3 and L5 (0.17 to 0. L2. Strong correlation was found between the measured and FE strain data for locations L1. Strong agreement was found between the experimental and FE strain data for locations L1. stresses and mechanical behavior of complex anatomical components and implants during 96 .999) with narrow confidence interval (see Table 4. Apart from some local deviations at location L4. Overall.

146 The combined assessment of strains and stresses can be helpful in improving the designs of fracture fixation and joint replacement devices for mandible and TMJ. Our study suggests that the validated FE models and analyses provide a reliable approach to evaluate in-vitro biomechanical behavior of the mandible. 146 Knowledge of strain may permit assessment of the regenerative capacity of bone. In our study. Most studies found in literature concerning experimental validation of FE models of bone report comparison of measured and analytical data in terms of statistical correlation. 146 However.24. From a biological view. we evaluated statistical correlation and statistical agreement between strain data obtained from the two methods. and its knowledge has an important impact in different clinical situations. 120 However. Strain distribution in mandible is extremely complex in nature. 77. FE results in terms 97 .64. and further reproduced during FEA. The key advantage of in-vitro loading is that. 111 It is important to note that the experimental strains recorded in our study are from in-vitro rather than in-vivo loading of cadaveric specimens. controlled.83 to be statistically more confident in the correspondence of experimental data and FE predictions. 110.111 The patient-specific computerized anatomical and FE models can be used to estimate nonmeasurable loads. and stress evaluation in different anatomical positions can be used to investigate potential fracture sites under artificial loading.35. experimental or clinical validation of theoretical predictions of FEA should be performed to be confident in the numerical results. strains determine the functional behavior of bone cells to a great extent. the experimental loading and constraints can be easily characterized. 64. strains and stresses to understand the underlying mechanism of the diseases. although it does not replicate behavioral loads. 142.simulated function.28. 45. as suggested by Markert.

and Vollmer.45 who compared strain profiles in cadaveric mandible using digital speckle pattern interferometry and FEA. et al.49. et al.146 who confirmed that the experimental validation of FEA can provide precise insight into the complex mechanical behavior of mandibles affected by mechanical loading which is difficult to assess otherwise.110 We performed relatively more accurate 3D anatomical reconstruction and more refined FE mesh compared to some 98 .of strain magnitude accorded well with experimental data. The magnitudes of strain differ due to use of muscle forces as opposed to forces applied at the mandibular angle in our loading cases.110 assessed maximal and minimal strains. Ramos. and we evaluated the maximal principal strain through FEA. In our study. et al. Moderate to strong statistical correlation and agreement between the experimental and FE predicted strain data was achieved in this study establishing confidence in the validity of the computed results. et al. et al. L5) compared to other locations on the mandible. significantly different strain magnitudes were generated at the condylar locations (L3. We used fresh-frozen cadaveric mandibles for our experiments whereas some other studies employed either dry cadaveric mandibles45 or synthetic mandibles.61 obtained the equivalent strains. Although our methodology somewhat differs from other published studies. et al. Hart. and Vollmer. These findings coincide with the results of experimental and numerical investigations described by Hylander59. Ramos.146 who reported significant changes in stress distribution and magnitude near condyles. Even then. Ichim. our results are comparable to studies by Gröning. et al.110 who demonstrated that FE models of the mandible can correctly reproduce experimental strains under different loading configurations. the behavior of the strains reported in these studies is qualitatively in conformance with the one obtained in our study.

An optimized Poisson’s ratio was adopted for both cortical and trabecular bone. although the elastic properties of fresh and dry human mandibles are reported to be heterogeneous and orthotropic. shape and biological behavior of the living human mandible. 124 results of our study indicate that homogeneous and isotropic elastic properties are sufficient.models in studies by Vollmer.45. 79. 118 Similar to other reports in literature.146 and Gröning. The density values were assigned using a method previously published by Hangartner. 111. since homogeneous and isotropic elastic properties were assumed in FE models of the mandibles. et al. This high degree of correspondence is notable. Overall. et al. et al.142 adopted consistent bone-material properties based on a parameter optimization study. when the experimental and FEA strain results are compared. The authors dilated the grayscale twice to re-grow the volume to original size. a very good statistical correlation and statistical agreement is found. A mask representing the endosteal region of the bone model was eroded twice to obtain material information without influence of partial-volume effect for the trabecular region near the endosteal boundary.45.47 Gröning. Varghese. and used an inhomogeneous isotropic material model for the trabecular volume of the FE models of long bones. et al. to accurately predict the strain magnitudes. They held constant the Young’s modulus value of the cortex volume between periosteal and endocortical boundaries.45 These aspects of our study methodology provide closer approximation to the actual size. et al.154 The resultant volume contained partial-volume corrected density values along the endosteal boundary. which replicated the grayscale values of the eroded periphery to the re-grown region as previously described by Wu. at least in our experimental setup. Different approaches have been used by researchers to assign the material properties to FE models of the bone reconstructed from patient’s medical images.45 99 . As previously discussed in Chapter 2.

one can use the segmentation in created for anatomical reconstruction to assign materials to mesh elements.45 to assign material properties to the FE models. 77. the accuracy of FEA describing the biomechanical behavior of bony specimens has been shown by different authors. They assigned a same set of material properties to the entire bone and teeth components of the FE mesh by defining Young’s modulus and Poisson’s ratio. and teeth of each mandibular FE mesh from their respective masks in Mimics using the in-built ‘mask method’ of the software as described in Chapter 4. Hence. and created a FE volume mesh.142 and Gröning. Though the present study used different approach than Varghese. one material is created. the first mask in the list is used for assigning a material to that element. However. and neither stresses nor dislocations in the specimen can be measured. our biomechanical assessment of the mandible has been limited to surface deformations. the close correspondence between FE results and experimental data in all these studies call for a study exploring the comparative accuracy and efficiency of these approaches using same set of FE models. By using the material assignment from mask. A prominent limitation of our study is the inability to experimentally measure strains at locations within the specimen because strain gauges can measure only the surface strain. If an element has the same intersection volume with several masks. We performed anatomical reconstruction of the cadaveric mandibles from their CT scans as described in Chapter 4. 146 Given the high degree of congruence between the experimental and 100 . For each element one of the materials is assigned based on the volume of intersection of that element with each mask. 142. Material properties to cortical component. cancellous component. et al. For each used mask.reconstructed the mandibular anatomy from CT data of a human mandible. 111. FE volume mesh was generated for each of the mandibular model. et al.49. 127.

numerical results of this study. cancellous. our combined numerical-experimental study demonstrated that mandibular FE models accurately replicating the geometry. various data within the specimen can be visualized using the FE calculations. Also. However. and different element types would allow further exploration of the correlation between experimental and numerical methods.18 The magnitudes of measured strain show that the locations of strain gauges selected in this study were not at the regions where specimen fractures occurred. and cartilage material properties. This leaves us with limited choices of locations for experimental measurement of strain. and constraints can predict strain profiles in strong correspondence with the experimental results. diagnose. Although a better estimation of gauge locations can be obtained through FE simulations prior to design of experiments. More detailed FE models incorporating and varying cortical. the topography of mandibular surfaces often presents hurdles in attaching a strain gauge at every/any location of choice. material properties. and treat TMD. design of the durable and efficient prostheses for mandible and TMJ is challenging due to complex geometry and function of associated anatomical components. Our future studies will use this validated FE methodology to evaluate otherwise difficult to assess parameters such as stress and strain in different components of the mandible and TMJ under different functional and parafunctional loading configurations. 101 .63 This promises to aid in developing and improving the methods to prevent. In summary. a validated FE method provides an alternate solution to this limitation. Our future work will extend the discussed methodology of subject-specific anatomical modeling and FEA to design and analyze patient-specific implants for mandible and TMJ.

102 . and to design and pre-clinically evaluate implants for mandible and TMJ.Such validated FE models which adequately reproduce mechanical behavior of mandible can be used further to study the TMJ.

107. psoriatic arthritis. Our unique patient-fitted designs based on medical images of the patient’s TMJ offer accurate anatomical fit. any pain relief attained is considered of secondary benefit.86. Introduction In treating the TMJ dysfunction. and ankylosis might be good candidates for receiving TMJ prosthesis. the end-stage TMJ pathology resulting in distortion of anatomical architectural form and physiological dysfunction dictates the need for total joint replacement (TJR). 87 The TMD patients with serious osteoarthritis. and better fixation to host bone. all nonsurgical approaches should be exhausted. We use the validated methodology of FE modeling and analysis to evaluate the device design by investigating stress and strain profiles under functional/normal and para-functional/worst-case TMJ loading scenarios. In some select patients. 5.1. feedback. 108 Before 1945. Special features of the prostheses have potential to offer improved osseo-integration and durability of the devices. and pre-surgical planning to ensure anatomically accurate and clinically viable device design. 87.26.27 103 . 88. The design process is based on surgeon’s requirements. 108 The goal of TMJ TJR is the restoration of mandibular function and form.86. rheumatoid arthritis. the technique of alloplastic reconstruction of TMJ was mainly limited to replacement of condyle. 87.27. 107. 86. 108. 151-153 TMJ resections have been carried out for about 150 years. DESIGN AND FINITE ELEMENT ANALYSIS OF PATIENT-SPECIFIC TOTAL TEMPOROMANDIBULAR JOINT IMPLANTS In this chapter we discuss our approach to developing novel patient-specific total TMJ prostheses.5.

1 lists indications for alloplastic reconstruction of the TMJ. resection dressings and prostheses were the dominant techniques. 107. 87. TMJ implants can be differentiated into fossa-eminence prostheses. Total TMJ implants are recommended when the glenoid fossa is exposed due to excessive stress in conditions such as degenerative disorders. By 1945 reconstruction of the TMJ involved the close cooperation of surgeons and dentists. 151153 Table 5. arthritis ankylosis. their relatively wide variety described over past six decades emphasizes that alloplastic TMJ reconstruction is still evolving. and multiply operated pain patients.26.Interposition of alloplastic implants. 26. 108.27 No evidence-based data on outcomes are available from that time. Although singular replacement of the fossa or condyle is preferred as a temporary solution. and total joint prostheses.27 Sterilization. biocompatibility and fixation of the alloplastic implants were main concerns in early days. the partial TMJ reconstruction finds comparatively declining usage by surgeons for clinical reasons. 104 . ramus prostheses and condylar reconstruction plates. 86. 27 In view of the rare application of TMJ prostheses.

86.107. 107. 87 material wear debris with associated pathologic responses. Destruction of autogenous graft tissue by pathology. 108 of joints with severe anatomic abnormalities 2. 87. 107. Indications for alloplastic TMJ reconstruction 1. 108 degeneration. Indications for the alloplastic reconstruction of the temporomandibular joint (TMJ).86. 108 failure of the prostheses secondary to loosening of the screw fixation or fracture from metal fatigue. mental status of the patient.86. 107. such as rheumatoid arthritis which results in anatomic mutilation of the joint components and functional disability. 108 5. 87. active or chronic infection at the implantation site. 107.86. 107.107.86.86. 107. Failed autogenous grafts in multiply operated patients. 86.86 6. uncontrolled systemic disease such as diabetes mellitus or myelodysplasia. No.86. 108 3. or resorption. Failed Vitek-Kent total or partial joint reconstruction. 1. 107. 108 lack of long-term stability. 108 Table 5.86.Sr. 87 inability of alloplastic implant to follow physical growth of the younger patients. Ankylosis or reankylosis. and allergy to materials that are used in the devices to be implanted. 108 Long-term studies 105 . 87. 107.86.86. Failed Proplast-Teflon that results in severe anatomic joint mutilation. 108 need for two-stage procedure in ankylosis cases. 107. 87 and unpredictable need for revision surgery. 108 The perceived potential disadvantages of the alloplastic TMJ TJR are cost of the device. 108 4.86. Relative contraindications to the use of alloplasts in reconstruction of the TMJ are age of the patient. Severe inflammatory joint disease.

there is only one study. which leaves the choice of prosthesis to surgeon’s personal experience.comparing functional and aesthetic results of various TMJ prostheses are not available (with an exception of one study by Mercuri.150 The history of alloplastic TMJ reconstruction has. There are two categories of the TMJ TJR devices approved for implantation by the United States Food and Drug Administration (FDA) – the stock or off-theshelf devices. and because its function is intimately related to occlusal harmony. At the time of implantation. 107. lack of attention to biomechanical principles. unfortunately. and the custom or patient-fitted devices. and based our TMJ prostheses design approach on the knowledge gained from clinical. biomechanical and scientific reports about the history. the surgeon has to ‘make fit’ the stock (off-the-shelf) device. We performed a comprehensive review64 of published literature regarding TMJ reconstruction. To date.150. the custom (patient-fitted) devices are ‘made to fit’ each specific case. by Wolford.108 The use of inappropriate materials and designs has resulted in success rate of many TMJ implants being 106 . et al.64. because TMJ is the only ginglymoarthrodial joint in human body. and clinical outcomes of TMJ prostheses. been characterized by multiple highly publicized failures based on inappropriate design. 108. designs. and ignorance of what already had been documented in the orthopedic literature. In contrast.84 with up to 14-year follow-up). a prosthetic TMJ necessitates characteristics not considered in orthopedic implant design. et al. reported in the literature that compares a stock and a custom TMJ TJR system. 141 In addition. This study concluded that patients implanted with the custom TMJ TJR system had statistically significant better outcomes in both subjective and objective domains than did those implanted with the stock system devices studied. efficacy.

141 Most of the published literature regarding TMJ implants has been clinical and case reports.87 107 . but also on adaptation of the implant to the bone to which it is to be fixed. primary stability of prosthetic components must be ensured by biointegration of the screws. 5. Table 5.2 lists summary of requirements for successful total reconstruction of the TMJ. (ii) to realize a close fit to the skull. Stability of alloplastic joint replacements depends not only on fixation. et al. Motion of the implanted prosthesis under a load can cause the surrounding bone to degenerate. and (iii) to achieve a long lifetime. requiring replacement. we undertook a study aimed at designing and evaluating customized total TMJ prostheses. To assure long-term success of the TMJ implants.1.86. leading to further device loosening and consequent failure. and need for more efficient and durable total TMJ implants.1 Design Requirements for Total TMJ Prosthesis van Loon. In view of paucity of this information.140 indicated that there are three major requirements in TMJ TJR – (i) to imitate the functional movement. screw fixation of TMJ implants is the most predictable and stable form of stabilization developed.84.lower than those for total hip and knee prostheses. 86.86 Currently. 125 Stability of TMJ prosthesis at the time of implantation is equally important for its success.86 Screws may loosen with time and function. 105. with much less studies investigating the design and biomechanics of the TMJ implants. 87. 87 The orthopedic experience with implantation of alloplastic joints has shown that better adaptation of the device to the host bone results in more stability and functional longevity of the implant.

The prostheses should be fitted correctly to the mandible and the skull. 105 5.86. 87. 140 4.140 9.140 8. and it must be performed aseptically. 105.86.140 6. 87. Simple and reliable implantation procedures.140 7. The devices must be stable in-situ.Sr. The devices must be designed with sufficient mechanical strength to withstand the loads delivered over the full range of function of the joint. 140 2.86. 105. The prostheses should imitate the condylar translation during mouth opening. 140 3. No. 87. The surgery to implant the prosthesis must be performed for the proper indications. and wear particles must be tolerated by the body.87 Surgeon’s attempt to make stock devices fit by bending or shimming may lead to component or shim material fatigue and/or overload fostering early failure under repeated cyclic 108 . and without restricting movements of non-replaced TMJ. The materials from which the devices are made must be biocompatible. the surgeon confronts with a difficult challenge of making ‘off-the-shelf’ components fit and remain stable.86. 105. Requirements/criteria for success of alloplastic total joint replacement devices 1. 87. During implantation of the stock TMJ prosthesis. Most patients requiring TMJ replacement have deformed local bony anatomy. 2. Expected lifetime of more than 20 years. Low wear rate.140 Table 5. and often the precious host bone needs to be sacrificed to make the stock TMJ components to create stable component-to-host-bone contact. Criteria for the successful alloplastic total reconstruction of the TMJ.

5.87 Potential micromotion of any altered or shimmed component adversely affects the screw fixation biointegration. Micromotion leads to the formation of a fibrous connective tissue interface between the altered component and the host bone. The screws secure implant components intimately to the host bone mitigating possibility of micromotion and maximizing the opportunity for biointegration. Also discussed are unique design features such as accurate fit of the prosthetic surface to the host bone in contact.2 Materials and Methods In this section.2.1 outlines our approach to developing a novel patient-specific total TMJ implant system. we discuss the methodology of designing condylar and fossa components of the custom-designed total TMJ prostheses. perforated notches of implant which protrude and fit into the custom-cut slots in native bone. 5. Our unique patient-fitted designs based on computed tomography (CT) 109 . and screws with locking mechanism.87 Our patient-specific TMJ implants are designed to accurately fit each patient’s specific anatomical condition. customized surgical guides.functional loading.1 Design of Patient-specific Total TMJ Prosthesis The schematic in Figure 5. These designs do not require any alteration or shimming of either the device or the host bone to achieve initial fixation and stability. They conform to any unique or complex anatomical host bone condition. and can cause early loosening of the screws leading to device failure.

RI. USA) as discussed in following sections of this chapter. The prostheses and accessories are designed using commercial software packages 3-matic v6. Plymouth.2). mask formation for the anatomic region of interest (i. segmentation.. feedback. bone and teeth).images of the patient’s TMJ and associated anatomic structures offer accurate anatomical fit and better fixation to the host bone. anatomical model comprising of the patient’s mandible and fossa eminence is developed from the CT scan by performing a series of operations such as image processing. MI. and pre-surgical planning to ensure anatomically accurate and clinically viable device design. and calculation of 3D equivalent similar to the 3D reconstruction method described in Chapter 4.0 (Materialise. 110 . Plymouth. Subject-specific 3D anatomical reconstruction of the patient’s mandible and skull/fossa/articular eminence is performed using commercial software Mimics v14. Pre-planning of the surgery is an integral part of the proposed design and development methodology.12 (Materialise. Our design process is based on surgeon’s requirements. Providence. and is intended to reduce intra-operative adjustments of the device components. Upon importing the patient’s CT images in Mimics. USA) and SolidWorks v2010 (SIMULIA. complexity of the already challenging operating procedure. The novel/unique features of the prostheses promise an improved osseo-integration and durability. MI.e. USA) from computed tomography (CT) scans (see Figure 5. and the overall time spent in the operating room. region growing.

Figure 5. 111 . 1. Methodology followed for design and preliminary analysis of the patient-specific total temporomandibular joint (TMJ) prostheses.

To help the surgeon accurately remove the damaged part of condylar neck/head. We utilize the computerized anatomical model and its 3D printed equivalent to acquire surgeon’s design requirements such as location of the facial nerve (to keep it from any damage or injury during surgery). clinical and design requirements and constraints is vital in ensuring the optimal design and performance of TMJ devices. etc.3. location of screws to secure the condylar and fossa components to host bone. location of the condylar osteotomy (i. number and dimension of screws.Figure 5.e. a surgical guide is custom designed for each reconstruction case as shown in Figure 5. Subject-specific 3D anatomical reconstruction of the patient’s mandible and fossa eminence performed from computed tomography (CT) data using Mimics software 5. the 112 . removal of the degenerated or damaged condylar bone).1 Surgical Pre-planning and Surgeon Input Close collaboration between device designer and surgeon (treating the given TMJ patient) is an important aspect of the proposed design and development approach. after putting the patient in intermaxillary fixation (IMF) and gaining access to TMJ capsule. 2. outline of shape for the planned condylar and fossa prostheses. During surgery.. Mutual sharing of knowledge and expertise.2.1.

Panel-A and B show the medial and lateral view. Panels C and D show medial and lateral-anterior view. In other words. Figure 5. respectively. of the surgical guide alone. the surgical guide is secured using screws at the condylar head and condylar neck/ramus depending on osteotomy location and surgeon’s preference. respectively.e. Custom-designed surgical guide for condylectomy (i. The location of condylectomy guide screw hole inferior to the anterioposterior excision line can be selected (and custom designed) such that the same screw hole can also be used later by one of the screws used to secure condylar/ramus implant to the host mandible. surgical guide is detached from the bone by removing the screws. of surgical guide placed at the location on mandible where osteotomy is to be performed.. After completing the osteotomy.surgical guide can be fixated to mandible using screws located superior and inferior to the line of osteotomy/condylectomy. 3. removal of damaged part of the condylar bone). The visuals 113 .

till the surgeon approves the designs. After sufficiently improving the designs. Our design approach and pre-surgical planning enables appropriate design of screws and predrilled screw holes in implants to avoid unintentional injury to facial nerve. For a given screw. soft tissue. optimal purchase. and other delicate structures in the vicinity of the complex surgical site. the prostheses graduate to the next stage where finished implants and accessories are ready for prototyping and pre-surgical simulation of the operating procedure 114 .demonstrate that custom-design of the device enables it to accurately adapt to the native bone. the screw-drill-guide is custom designed each for the condylar/ramus component and the fossa-eminence part of the TMJ prostheses. and rigid interface between the screw and host bone during and after implantation. suggested changes are incorporated to improve the device design. These drill guides are intended to create a hole of preferred dimension (diameter and depth) at the accurate location and orientation for each screw as prescribed by the surgeon. and templates are designed. In-vitro biomechanical assessment of patient’s host bone and TMJ prostheses is incorporated in the design validation and improvement loop as described later in this chapter. the prostheses. Following the similar design approach used for osteotomy guide. This feedback loop is kept open. drill guides. and location of its fixation screws as prescribed by the surgeon. a drill of smaller diameter than that of the particular screw is selected so ensure less bone damage. osteotomy guide. and the designs are fine-tuned. Based on surgeon’s initial design requirements. This methodology allows the designer to control size and shape of the device. In response to surgeon’s feedback about the initial designs.

In real-world scenario.1. surgeon’s prescription. Custom shape of the prosthesis maximizes the possibility of precise fit and secure fixation. before applying our methodology to actual clinical application. and thickness of condylar component. and pre-clinical biomechanical evaluation of the device designs) to ensure that the device provides sufficient mechanical strength and stability during functional and para-functional loading after implantation. the number and locations of screws. The minimal level of the condylar thickness.2. Figures 5. width.using anatomical models and finished prototypes. 5. width. the characteristic length. and dimensions of condylar neck and head vary from patient to patient. and number and location of screws are maintained (based on orthopaedic experience listed in the literature. Our custom-designed condylar components follow the anatomical geometry and contours on the lateral surface of ramus and condylar part of host anatomy to which the prosthesis is to be fixated.4 to 5. it has to be verified and validated through cadaver studies.12 show various such shapes of the condylar component of our TMJ prostheses. head diameter. 115 . Different shapes of the condylar and ramal parts can be designed per surgeon’s recommendations to conform to the patient’s unique/complex anatomical situation.2 Design of Condylar Prosthesis Anatomically accurate fit of TMJ prosthesis to the host bone is essential for stable fixation leading to efficacy and longevity of the device. Since these components are custom designed to meet the unique requirements of each individual patient’s situation.

Panels A and B show medial-anterior view and lateral-anterior view. respectively. Figure 5. Shape outline of a custom-designed condylar/ramus prosthesis for the replacement of right TMJ of a patient. Shape outline of a custom-designed condylar/ramus prosthesis. 4. respectively. of the prosthesis accurately adapting to the host bone.Figure 5. 5. Panels A and B show lateral-anterior view and lateral-posterior view. of the prosthesis accurately conforming to geometric shape of patient’s mandible. Panel-C shows medial-inferior view of the prosthesis shape outline. 116 .

117 .Figure 5. The osteotomy gap seen in the left mandibular body is due to removal of a tumor in that region. respectively. 6. This osteotomy gap can be filled with a graft. Shape outline of a custom-designed condylar/ramus/mandibular component of the TMJ prosthesis for reconstruction of left TMJ. Panels A and B show medial-anterior view and lateral-anterior view. and the mandibular component of this TMJ prosthesis is designed to provide mechanical support to the host bone and graft. of the prosthesis along with 3D anatomical model of the patient’s mandible after condylectomy.

Panel-C shows engineering dimensions of this patientspecific implant. Panel-A shows lateral view of the implant with screw holes. 7. Custom-designed condylar/ramus component of the TMJ total joint replacement prosthesis for left TMJ of a patient. Panel-B shows an enlarged view of the screw holes. where the first superiorly located screw hole has threads to incorporate locking-plate-screw mechanism by engaging the threads on the head of a locking screw described in the text.Figure 5. 118 .

Shape outline of a custom-designed condylar/ramus component of the TMJ total joint replacement prosthesis for left TMJ of a patient. 119 . Panel-C shows lateral view of the prosthesis with screw holes. The posterior-medial view in Panel-B shows that the medial surface of prosthesis is shaped to accurately follow geometric contours of the lateral surface of mandibular host bone for optimal geometrical match between the implant and host bone. 8.Figure 5. Dimensions of various parts of this patient-specific implant are shown in Panel-D. Panel-A shows anterior-lateral view of the implant with host bone after condylectomy.

The condylar heads can be designed in different shapes to offer larger articulating surface area to avoid stress concentration in small area of the articulating 120 . The prosthetic condylar head can be placed such that its center of location in located inferior to that of the natural condyle it replaced. and the condylar neck has a curvature to avoid problems seen in most right-angled designs of orthopaedic implants. 9. and maximizes the opportunity for optimal adaptation of implant to the host bone.Figure 5. The lateral surface of the implant is flat. condylar head is spherical. For the custom-designed condylar/ramus component. Shape outline of a custom-designed condylar/ramus component of the TMJ total joint replacement prosthesis for left TMJ of a patient. An important advantage of our patient-specific design approach is that the components can be precisely designed to withstand the loads encountered by unique anatomic condition. thereby allowing low-wear articulation of the reconstructed total TMJ and natural movements of the nonreplaced contra-lateral TMJ. Visuals in Panels A through E demonstrate that shape of medial surface of the prosthesis accurately follows the geometric contours of the lateral surface of the mandibular host bone. Ramal component can be shaped to accommodate the amount of available mandibular host bone. the center of rotation of its head can be moved vertically to correct the open bite deformity.

Custom-designed cutting guides and templates can be provided to the surgeon to accurately create a small grove in the host bone. This notch is intended to be placed in a custom-cut grove to be created on the lateral surface of mandibular ramus by the surgeon during implantation. These models demonstrate that our methodology of custom design enables the condylar component to conform to the anatomic situation of damaged and/or complex mandibular host bone. the notches also provide an avenue for load transfer between the prosthesis and host bone.condylar head and fossa as illustrated in Figure 5.12 show custom-designed condylar/ramus prostheses of varying shape and size. Though the shown designs of condylar component vary in size and shape per anatomic demands and surgeon’s prescription. Figures 5.10. Also seen protruding out of the medial surface of this device is a rectangular notch with perforations on its surface. In addition to providing better stabilization. Figures 5. This notch is intended to be placed into a custom-cut grove in the superior surface of mandibular condyle/ramus resulting from osteotomy (performed to remove damaged condylar head/neck).11 and 5.12 show a perforated notch protruding from the inferior surface or collar of condylar neck.11 and 5.12 show a condylar/ramus component with its medial surface accurately following the geometric shape of patient’s mandibular bone.4 to 5. This will reduce forces and resultant stress experienced by fixation screws which act as the only mode of load transfer between most TMJ 121 . Figures 5. One novel feature of our TMJ prostheses is the perforated notches protruding into the host bone. an important common design feature among all these models is that each device provides accurate adaptation to the host bone. This intentional removal of native bone is performed in exchange of the opportunity for maximizing implant stability through bony ingrowth into perforated surfaces of the notch.

especially for the condylar devices in which the collar of condylar prosthesis does not adequately contact the host bone or the medial surface of the implant does not adapt accurately to the complex geometry of patient’s mandible.prostheses. Though having both medial and superior notches in the condylar prosthesis is likely to be advantageous from biomechanical view point. it will be the surgeon’s choice to have either one or both notches for condylar implant. 122 . this may make surgical implantation of the device more challenging for the surgeon. Therefore.

Panel-A shows a prosthesis with spherical condylar head. 123 . The condylar heads are designed to offer larger articulating surface area to avoid stress concentration at small area which may lead to more wear of the articulating surfaces of reconstructed TMJ. Panels B and C show prostheses with elliptical head of different dimensions. Different shapes of the condylar head of the custom-designed condylar/ramus component of the TMJ prosthesis.Figure 5. 10.

shown in Figure 5. Perforated surfaces of these notches are designed to permit bone in-growth into the prosthesis after implantation to provide added stability. Modification of the custom-designed condylar/ramus component. protrudes out of the medial surface as a notch with perforations. 124 .9. The device also has pointed and perforated notch protruding from inferior surface of the implant’s collar/neck. Panel-A shows a grove in the flat lateral surface of the condylar implant. Dimensions of these notches can be customized to fit the size and shape of patient’s native bone. as shown in Panel-B.Implant Collar Superior Notch Medial Notch Figure 5. to include a novel feature – perforated notches protruding into host bone at implantation. 11. The enlarged views of medial notch and its perforations are shown in Panels D and E. The opposite side of this grove.

Panel-B shows a perforated notch each protruding from the medial surface of the ramus and inferior surface of the implant collar/neck. 12.Figure 5. Panels A and C show pre-drilled screw holes and a grove in the lateral surface of implant.9 and 5. lateral surface of the device is flat and medial surface is shaped to match the host bone geometry. 125 . Modification and refinement of custom-designed condylar/ramus component shown in Figures 5. As shown in Panel-C.11.

Panel-A demonstrates that the implant is designed for optimal usage of natural fossa eminence for fixation using screws.13 to 5. The implant has constant thickness throughout its body.5.2. and the shape of articulating surface is same as that of the natural articular surface. Figure 5.3 Design of Fossa Prosthesis Fitting the skull is a major problem in TMJ reconstruction patients because of the irregular shape of their TMJs. Panels B and C show different views of the implant illustrating the custom shape accurately conforms to the contours of host anatomy. Such custom designed fossa implants can correctly adapt to the natural components of patient’s TMJ. 126 .140. patient-fitted custom designs of fossa prosthesis can be developed such that the device fits accurately to the available host bone. and provide improved stability through locking screws and perforated notches fitting into patient’s skull.1.21 show different shapes and features of our custom-designed fossa prostheses. Using a similar design approach discussed earlier for the condylar implants. 13. 141 The patient-specific design approach enables developing accurately fitting models for the complex shape of patient’s fossa-eminence anatomy. Figures 5. A simple custom-design of the fossa prosthesis with screw holes.

127 . Visuals in panels D and E show that the superior surface of the implant is designed to accurately match the shape of natural fossa. The articular grove is designed such that it would prevent dislocation of the prosthetic condylar head during functional movements of the jaw. Patient-fitted design of a fossa prosthesis. Sufficient thickness is maintained for the lateral portion of implant to pre-drill screw holes which can host locking screws for better fixation and stability. The rectangular slot (with curved anterior and posterior edges) in inferior surface of the implant is designed to provide sufficient rotation and opportunity for anterior-posterior and medio-lateral translation of the matching prosthetic condylar head. Panels A. B and C illustrate accurate fit of the device to the patient’s natural fossa and eminence. 14.Figure 5.

B. Inferior rectangular surface of the device has a circular grove for articulation with condylar head. Figure 5. Patient-fitted fossa implant with circular inferior surface which also has a circular grove for articulation with condylar head. 15. C and D demonstrate the customized size and shape of the implant. 128 .Figure 5. Visuals illustrate customized size and shape of the device for accurate fit and fixation to native anatomical structure. Patient-specific design of fossa prosthesis. Superior edge of the lateral surface (which hosts screw holes) is custom cut to follow the curvature of native eminence and bone situation. Visuals in panels A. 16.

This anterior slope of articulating surface is intended to provide opportunity for anterior translation of the condylar head during movements of jaw.72 129 .Figure 5. The device has a rectangular grove (with curved anterior and posterior edges) in its inferior surface for articulation with condylar head. The uniquely designed articulating surface/hole is slanted in anterior direction. Patient-specific design of fossa prosthesis. This feature of our fossa prostheses provides an advantage over currently available total TMJ implants which. 17. when implanted. only rotate but do not translate during functional movements of the patient’s jaw.

Custom-designed fossa prosthesis with circular articular surface. 130 . Additionally. The device shown in panels A and B has relatively smaller articulating circular hole compared to the one shown in panels C and D. articulating surface of the device shown in panels C and D is slanted anteriorly to augment anterior translation of condylar head during mastication.Figure 5. 18.

thereby maximizing device stability by allowing ingrowth of bone into the prosthesis after implantation. Each perforated notch is designed to fit into surgically created mating grove in the host bone.Figure 5. The notches also provide a mode for load transfer between the prosthesis and native bone. thereby reducing the amount of load and resultant stress acting on the fixation screws. The surgeons can be provided with custom-designed templates and cutting guides to accurately cut the slots in native bone to accommodate perforated notches. 19. The device has a novel feature – perforated medial notches protruding into host bone at implantation. 131 . Patient-specific design of a fossa implant with circular articular surface/hole in the inferior face of the device.

Figure 5. Ramal component of the prosthesis is extended anteriorly up to the chin to support mandibular host bone and graft (with aesthetic dental implant) after removal of the imaginary tumor (shown in red) in the left mandibular body/molar region. 132 . 20. Shape outline of the patient-specific total TMJ prosthesis.

Figure 5. 21. Patient-specific total TMJ prostheses. 133 .

4 Design of Screws Unlike hip or knee joints. unlike stock TMJ implants. which may lead to further device loosening and possible failure.1. TMJ devices have to rely only on screws for initial fixation and stabilization of their components.86 Screws may loosen with time and function.5. The customdesigned screws of our TMJ prostheses system provide optimal fixation through locking 134 . et al.86 Hsu. Our methodology of designing patient-specific total TMJ prostheses based on anatomically accurate 3D models provides realistic and accurate options in deciding positions of fixation screws for the prostheses. Clinicians have underlined the need for improved methods of internal fixation of prosthetic TMJ devices to minimize or eliminate implant loosening and joint failure.56 reported that the position of inserted screws was more important than the number of screws for stable fixation of the condylar TMJ prosthesis. et al. the bony anatomy of mandibular ramus and temporal glenoid fossa do not afford the use of modular stock components for TMJ TJR that can be stabilized initially with press-fitting or cementation. Motion of implanted TMJ prosthesis under load can cause degeneration of the surrounding bone.87.87 Therefore. the custom-designed TMJ prostheses do not have any unused screw holes which may act as stress-risers under functional in-vivo loading post-implantation.140 indicated that use of bone screws with sharp threads in TMJ implants prevents movement between the screw head and prosthesis.2. 94 van Loon. The positions of pre-drilled screw holes in the prostheses can be selected to avoid unintentional injury to delicate structures in the vicinity while ensuring stable fixation of the devices. For long-term success of the TMJ implants. requiring replacement. Moreover. forces from the implant to the bone and vice versa must occur without relative motion or without intermittent loading.

The possibility of movement between the screws and prosthesis can be eliminated by using such locked screws.22 and 5. These drill guides are intended to create a hole of preferred dimension (diameter and depth).mechanism – a unique feature not currently offered by any of the US FDA-approved TMJ TJR devices (see Figures 5. and at the accurate location and orientation for each screw as prescribed by the surgeon. Threads on the screw-head surface provide high grade fixation by firmly engaging with the matching threads in the screw hole of either condylar/ramal or fossa implants.23). 135 . our methodology also provides the surgeons with customized screw-drill-guides and templates for the TMJ prostheses. In addition to the surgical condylectomy guides.

Figure 5. 136 . The threads on the screw-head surface provide improved/optimal fixation by firmly engaging in the matching threads in the screws holes of either condylar/ramal or fossa component of the total TMJ prosthesis. 22. Custom-designed screws with locking mechanism.

137 . Visuals show different features of the screw. Length of the screw head varies depending on the thickness of condylar or fossa prosthesis in the particular screw-hole location. with more threads per unit length of screw-head than the body/shaft. A custom-designed locking screw for TMJ prosthesis.Figure 5.5 mm – 3. The screw has varying pitch. 23. The body/shaft of screw is designed long enough to utilize maximum amount of host bone (condyle/ramus or fossa eminence). The outer diameter of screw is kept in the range of 1. but avoid protrusion of screws from medial surface of the bone. Total length of the screw depends on the size of prosthesis and native bone.00 mm as this range is reported to be optimal for the screws of TMJ implants.

5 Implant Materials Using advantageous physical characteristics of biocompatible materials is an essential aspect in the design and manufacture of a successful prosthetic device. Our choice of titanium alloy (Ti-6Al-4V) for condylar/ramus component and bone screws. Metallurgical flaws. we prefer not to use Co-Cr-Mb and Cr-Co for our TMJ prostheses. ductility.82 Hence. found in cast Cr-Co are suggested to cause the fatigue failure of Cr-Co TJR components resulting in noxious metallic debris in the patient’s body. Some of the important characteristics of materials used to manufacture the TMJ prostheses from are biocompatibility. and machinability. low wear-rate.87 In addition to its biocompatibility and biointegration. and harmless wear particles. and UHMPE for fossa component is based on their favorable characteristics and successful longterm applications reported in scientific and clinical literature. Titanium also offers properties of strength.82 UHMWPE is a linear unbranched polyethylene chain 138 . TMJ is a highly mobile joint in which articulating surfaces of the reconstructed joint undergo repeated mechanical stresses resulting from movement of the jaw. cobalt-chromium-molybdenum (Co-Cr-Mb). Unalloyed titanium reacts rapidly with oxygen in the air to form a thin (<10 μm) layer of chemically inert titanium oxide which provides a favorable surface for biointegration of prosthesis with bone.1.5. Advancement in materials research has led to materials such as medical grade pure titanium (Ti). mechanical strength. corrosion resistance. such as porosity.82 However. and ultrahigh molecular weight polyethylene (UHMWPE) becoming gold standard for low friction orthopaedic joint replacement.37 Wrought Co-Cr-Mb is reported to have excellent wear resistance when articulated against UHMWPE in the non-movable articulating surface of most orthopaedic TJR devices. titanium alloy (Ti-6Al4V).2.

25) – using our validated methodology described in Chapter 4. 139 .86 We performed FE simulations of two patient-specific total TMJ prostheses – one device with medial notches fitting into the groves created in the host bone (see Figure 5. and to evaluate the methods of device fixation to minimize or eliminate implant loosening and joint failure.2 FEA of Total TMJ Implant Methods for biomechanical assessment of prosthetic TMJ must be developed to make the implantation outcomes more predictable and reliable. 148 5. no cases of UHMWPE particulation-related osteolysis have been reported in the TMJ prostheses literature. UHMWPE is shown to have excellent wear and fatigue resistance for a polymeric material.115 Till year 2011.4 and 5.87. The objective of this study was to investigate stress and strain distribution in prosthetic components and host bone surrounding the screws under normal and worst-case/over-loading conditions.2. To account for the user-induced errors due to variations in selecting the nodes of FE mesh for applying boundary conditions and loads.24) and another ‘simple implant’ without such notches in the condylar and fossa components (see Figure 5.5 are average of the values obtained from three runs of each FE simulation. we performed three repetitions of FE simulation under each loading condition for both total TMJ prostheses systems.with a molecular weight of more than one million. Results reported in Tables 5.

140 . fossa. MI. Mesh convergence was achieved using the technique discussed previously in Chapter 4.5. and screws) were meshed.25).26 and 5. region growing. USA). mask formation for bone and teeth. For FE simulations.27). Using the design methodology discussed in previous sections of this chapter.24 and 5. and another ‘implant with notches’ – were designed for total reconstruction of the patient’s left TMJ (see Figures 5. and teeth) and prosthetic components (condyle. and calculation of 3D equivalent similar to the 3D reconstruction method described in Chapter 4. USA) from computed tomography (CT) scans of patient’s TMJ. segmentation.10 (SIMULIA.12 (Materialise. volume bound within surfaces of anatomical components (cortical bone. The finite element analyses were performed using a commercial FE package ABAQUS v6. 3D volume mesh was generated for each of these components with ten-node quadratic tetrahedral elements of type C3D10 (see Figures 5.1 FE Modeling and Mesh Generation Subject-specific 3D anatomical reconstruction of patient’s mandible and skull/ articular eminence was performed using commercial software Mimics v14. Providence.2. Upon importing the patient’s CT images in Mimics. two patient-specific total TMJ prostheses systems – a ‘simple implant’ without notches. anatomical model comprising of patient’s mandible and fossa eminence was developed from the CT scan by performing a series of operations such as image processing. cancellous bone. Plymouth.2. RI.

141 . A patient-specific total TMJ prosthesis with medial notches in fossa and condylar components. 24. Fossa prosthesis has two medial notches to be fit into host bone (Panels B and C). and is designed to allow optimal anterior and medial translation along with rotation of the prosthetic condylar head along the medio-lateral axis.Figure 5. Panel-A shows anterior-lateral view of the ‘notched implants’ with screw holes. The articular surface of fossa implant has medio-lateral openings.

142 . A patient-specific total TMJ prosthesis. 25. Panels C and D show two views of the total TMJ along with screws.Figure 5. Panels A and B show two views of the ‘simple’ total TMJ prosthesis along with left fossa bone and mandible after removal of left condyle.

panels C and D show surface mesh and anterior cross-section of volume mesh. 26. 3D finite element mesh of the host bone components prepared for total prosthetic replacement of the left TMJ. and panel-B shows a lateral cross-section of the 3D volume mesh of left fossa bone with screw holes. 143 .Figure 5. Similarly. respectively. Panel-A shows FE surface mesh of left fossa. of the mandible with screw holes and removal of damaged left condyle.

Similarly.2. Panels A.28. 144 . Panels D and E show FE mesh of the fossa component.2. 27. 5. and panel-F demonstrates FE mesh of a screw for device fixation.Figure 5.2 Model Constraints and Loads As illustrated in Figure 5. for the TMJ on contralateral side. the condylar head of the prosthetic TMJ was allowed to rotate along the medio-lateral axis. and translate in anterior-posterior direction. B and C show FE mesh of the condylar/ramal component of the ‘simple’ TMJ implant (without notches). 3D finite element mesh of the components of patient-specific total TMJ prostheses. and translate in anterior-posterior direction. The entire fossa host bone was constrained in all directions. the natural condylar head was allowed to only rotate along the mediolateral axis. but could rotate. The incisor teeth were fixed so that they could not translate in three directions.

Green arrows depict the location 145 .28. The interface between the prostheses and bone in contact was modeled with contact elements having a coefficient of friction of 0.57 The screw-to-prosthesis and screw-to-bone interfacial conditions were assumed to be bonded. were applied to the mandibular model in the angulus area as shown in Figure 5.3. Figure 5. Assembly of all parts of the FE model (including anatomic and prosthetic components).42 as reported in literature. each 200 N for normal loading condition and 400 N for over-loading /worst-case scenario.57 Since use of locking screws eliminates the possibility of movement between screw and prosthesis.The interface between prosthetic condylar head and articulating surface of fossa prosthesis was modeled as sliding contact with a coefficient of friction of 0. Two oblique bite forces. 28. and schematic representation of model constraints and load application for FE simulation of total TMJ prostheses and anatomical components. the interface condition between screw heads and TMJ prostheses (condylar and fossa) was assumed to be perfect bonding.

. The asterisks indicate constrained nodes at condyle. screw-toprosthesis. cancellous bone. Three repetitions/runs of FE simulation under each loading condition were performed for both types of total TMJ implants to account for any user-induced errors such as variation in selecting exactly the same nodes of FE 146 . 109 who have previously followed this practice since variation in material properties of these components have negligible influence on biomechanics of the mandible. and incisor teeth.2. All anatomical components of the model (i. The entire fossa host bone was constrained in all directions. and linearly elastic. The nodes at incisor teeth were so constrained such that they could only rotate.e. The prosthesis-to-bone. homogeneous. The interfacial and boundary conditions were kept similar for normal and over-load configurations. and only magnitude of applied forces was changed across the two loading configurations. Left prosthetic condylar head and right natural condylar head were constrained such that they could only rotate along the medio-lateral axis and translate in anterior-posterior direction.and direction of bite forces applied in the angulus region on both sides of the mandibular mesh. The interface between prosthetic condylar head and articulating surface of prosthetic fossa was modeled as sliding contact. and screw-to-bone interfaces were assumed to be bonded.2.3 Material Properties Young’s modulus and Poissson’s ratio of anatomical components (fossa and mandible bone with teeth). cortical bone.57 Static FE simulations were performed using ABAQUS software. titanium alloy (for condylar component and all screws). and UHMWPE (for fossa component) were selected as listed in Table 5. fossa. 5. All materials used in FE models were assumed to be isotropic.3. and teeth) were assigned properties of the cortical bone similar to other researchers45.

mesh across different simulations. The results summarized in Tables 5.4 and 5.5 are average of
three simulations for each loading condition for both types of total TMJ prosthesis.

Young's Modulus
(Mpa)

Poisson's Ratio

Host bone

1.47E+04

0.3

Titanium alloy (Ti-6Al-4V)
UHMWPE

1.10E+05
830

0.3
0.317

Part

References
Gröning, et al.45, Ichim, et al.61
Ramos, et al.109
Kurtz80

Table 5. 3. Material properties for anatomical and prosthetic TMJ components.

5.3 Results
The von Mises stress and micro-strain in the TMJ prostheses (fossa and condylar), screws,
and native bone in regions adjacent to screws were measured. Figures 5.29 and 5.30 show visuals
of stress profiles in the anatomical components and simple TMJ prostheses, respectively. Figures
5.31 and 5.32 show visuals of stress profiles in the corresponding anatomical components and
‘notched’ TMJ prostheses, respectively. Table 5.4 summarizes peak von Mises stress occurred
in prosthetic components and screws. Peak von Mises stress and strain developed in host bone
surrounding the fixation screws of simple and notched TMJ prostheses under normal and worstcase/over-loading configuration are summarized in Table 5.5.

147

Implant
Type

Loading
Type

Peak von Mises Stress in Implant Components (MPa)*
Condyle/Ramus

Condylar Screws

Fossa

Fossa Screws

Normal

44.3

61.4

11.3

28

Over-load

56.7

106.7

14.2

43.1

Normal

42.6

59.6

10.5

23.4

Over-load

59.1

108.3

13.4

38.6

Simple

With
Notches

*Average of three simulations performed under similar constraints and loading at three different
times (to account for variations induced by the user/operator)

Table 5. 4. Peak von Mises stresses developed in condyle/ramus and fossa components, and
fixation screws of the simple and notched designs of patient-specific total TMJ prostheses during
FE simulations under normal and worst-case/over-loading configurations

Implant
Type

Simple
With
Notches

Loading
Type

Peak von Mises Stress in Host Bone
adjacent to Screw Holes (MPa)*

Peak von Mises Strain in Host
Bone adjacent to Screw Holes
(µStrain)*

Condyle/Ramus

Fossa

Condyle/Ramus

Fossa

Normal
Over-load
Normal

4.7
13.6
4.3

3.5
7.4
3.2

1983
3586
1893

1253
1711
1210

Over-load

12.5

7.1

3374

1564

*Average of three simulations performed under similar constraints and loading at three
different times (to account for variations induced by the user/operator)

Table 5. 5. Peak stress and strain developed in host bone surrounding the fixation screws of the
simple and notched designs of patient-specific total TMJ prostheses during FE simulations under
normal and worst-case/over-loading configurations.

148

Figure 5. 29. Stress distribution in the host bone components during FE simulations of the total
TMJ replacement with custom designed simple TMJ prostheses. Panels A and B show von Mises
stress in the fossa bone under normal and worst-case/over-load configurations, respectively.
Panels C and D show von Mises stress in the mandibular bone under normal and worstcase/over-load configurations, respectively.

149

Figure 5. 30. Peak von Mises stress in patient-specific ‘simple’ TMJ prosthesis (without
notches) during FE simulations of two different loading scenarios. Panels A and B show von
Mises total TMJ prosthesis under normal loading configuration. Panels C and D show von Mises
stress profile in the prosthesis during FE simulation of worst-case/ over-loading scenario.

150

respectively. Panels C and D show von Mises stress in the mandibular bone under normal and worst-case/over-load configurations. Stress distribution in the host bone components during FE simulations of the total TMJ replacement with custom designed TMJ prostheses with medial notches. Panels A and B show von Mises stress in the fossa bone under normal and worst-case/over-load configurations. respectively.Figure 5. 31. 151 .

respectively (see Table 5. Panels A and B show von Mises total TMJ prosthesis under normal loading configuration. and Figure 5. These results are comparable to the findings reported by Roy Chowdhury. Panels C and D show von Mises stress profile in the prosthesis during FE simulation of worst-case/ over-loading scenario.1 Stress and Strain in Native Bone Small difference in the stress and micro-strain occurred in the host bone adjacent to screws in condylar and fossa components of both total TMJ prosthesis systems. For both types of implant designs.3.114 who studied stress distribution in the screws of a condylar implant and host 152 .Figure 5. 32.6 MPa under normal loading and over-loading. von Mises stress in the bone surrounding fixation screws was in the range of 3. Figure 5.2 – 4.7 MPa and 7. Peak von Mises stress in patient-specific ‘notched’ TMJ prosthesis (with medial notches) during FE simulations of two different loading scenarios. et al.5. 5.29.1 – 13.31).

bone. et al. According to Roberts. and from 1564 microstrain to 3586 microstrain during over-loading condition. Figure 5. The highest micro-strain in host bone in this study is below the hypertrophy limit. 33. Peak von Mises stress in the mandibular and fossa bone adjacent to fixation screws of total TMJ prostheses during FE simulations under normal and worst-case/over-load configurations. use of more screws at appropriate locations would further lower the chances of higher strains capable of bone formation around the screws. Moreover.. von Mises strain in the bone surrounding prosthetic screws ranged from 1210 microstrain to 1983 microstrain during normal loading. 153 .113 a strain higher than 4000 microstrain can cause hypotrophy of bone.

This observation is similar to findings reported by Hsu.30 and Figure 5. et al. et al. The trends in the stress and strain profiles under normal and overloading conditions were similar in both types of total TMJ prostheses.2 Stress and Strain in TMJ Implants FE simulations resulted in lower stress in anterior part of the condylar and fossa prostheses (see Figure 5.Figure 5. Ti-6Al-4V and UHMWPE. The von Mises stress found in condylar and fossa components of both types of implants were lower than the yield strength of their materials.109 although their FE studies included only the condylar TMJ implants with different loading conditions. Peak micro-strain in the mandibular and fossa bone adjacent to fixation screws of total TMJ prostheses during FE simulations under normal and worst-case/over-load configurations. 34. respectively.32).56 and Ramos. von Mises stresses of 154 . 5..3.

35. magnitude of von Mises stress was higher in the posterior region on the articulating surface. Other than where the actual loads and constraints were applied. the stress concentration was highest around the inserted screw and the screw holes in the host bone.higher magnitude were developed in condylar neck. Figure 5. and inferior region of ramal component compared with rest of the condylar/ramus prosthesis. For fossa component. posterior part of condylar head. Peak von Mises stress in condylar/ramus and fossa components of patient-specific total TMJ prostheses during FE simulations under normal and worst-case/over-load configurations. The medial notches in the 155 .

However. This trend of stress profile in screws is similar to that reported by Roy Chowdhury. the peak von Mises stresses in the condylar component were higher than those in the fossa component of the total TMJ prostheses (see Figure 5. the highest magnitude of stress values occurred at the neck portion of screws. This indicates that the stress developed in the notches under functional loading may augment bone growth into the perforated notches.4 and Figure 5.condylar and fossa prostheses are designed to provide improved stability by promoting postimplantation bone growth into the perforated surfaces of the notches. et al.114 who studied stress distribution in a stock condylar prosthesis and screws using FE method.3 Stress and Strain in Screws Peak stress and strain the implant fixation screws are summarized in Table 5. but higher than those in other parts of the host bone. Also. Stress profile in the host bone portion where the medical notches of the implant are inserted show stresses lower than that at the screw holes. In fixation screws for condylar and fossa components. 5. This may have resulted from the model constraints which allowed mobility of the condylar/ramal prosthesis along with natural mandible and kept the artificial fossa fixed in its position along with the host fossa bone.3. indicating that the notches may not act as stress risers in the device.36. The 156 . in all simulations.35). thereby maximizing the opportunity for improved stability of the prostheses. Von Mises stress in the notch regions of the condylar and fossa implants were less than that in the screw regions. the highest stresses in all screws were found to be less than the ultimate stress as well as yield point of the screw material (Ti-6Al-4V).

et al. As listed in Table 5.114 who reported highest stresses in the condylar screw placed most superiorly (near the neck of implant). thereby reducing the exposure of screws to higher loads and stresses.highest von Mises stresses found in screws in the present study are much less than those reported by Roy Chowdhury. This discrepancy suggests that screws used for fixation of the condylar component of patient-specific total TMJ prostheses undergo less load and resultant stress while transferring the functional loads between implant and host bone. these researchers applied a vertically downward force at the top of prosthetic condylar head whereas we applied load in mandibular angle region. et al.g. Also.69 and Roy Chowdhury. maximum von Mises stress generated in the screws was relatively higher than that in the corresponding prosthetic component these screws were used for fixation of. This may have happened as the screws carried more load when they served as a medium of load-sharing between the prosthesis and host bone. This is contradictory to findings by Kashi. at the location where condylar collar of the implant sits superiorly on natural ramus after condylectomy). 157 .114. Among the screws. the highest stresses occurred in the neck portion of two condylar screws – one placed most inferiorly.. This further suggests that the custom-designed implants offer better adaptation to the host bone (compared to their stock counterparts) and partly transfer the load directly to the bone in contact (e. et al. especially in the region of screw neck and at the site of prosthesis-bone junction.4. and another placed most posteriorly and at the curvature of the ramal part of the implant. both these studies included a stock condylar TMJ implant in which the implant collar did not contact or adapt to the host bone as it does in the present study. However. Screws used for both condylar and fossa components showed von Mises stresses of higher order at their interfaces with prostheses.

Peak von Mises stress in the fixation screws for condylar/ramus and fossa components of patient-specific total TMJ prostheses during FE simulations under normal and worst-case/over-load configurations. 5. In our knowledge. The present study can serve as a reference for the 158 .Figure 5.4 Discussion In view of scarcity of published literature about design methods and biomechanical analysis of total TMJ implants. 36. Few published studies have investigated biomechanics of the artificial TMJ implants. no study has reported FE analysis of total TMJ prostheses. the present study provides good reference work for patient-specific design and biomechanical evaluation of such designs through FE simulations.

clinicians regarding advantageous features of the patient-specific total TMJ implants. In summary. Although this represents a major simplification. It will be beneficial to evaluate the effect of screw positions on biomechanical performance of total TMJ prostheses. Other muscle forces which are normally present would also affect the mandibular biomechanics. material properties of bone were assumed to be homogeneous and isotropic. 57. Although several studies have suggested that forces from other muscles do not exert major effects in the mandible. Therefore. 57 future work should consider using more sophisticated FE models. The skill of the surgical approach (preauricular incision or retromandibular incision) and patient-related issues such as long-term effects were not considered. the surgeons should be careful when applying the findings from this study to clinical situation. and that the FE models can reproduce information 159 . Also. this study demonstrates that our custom-design approach offers potential for stable and durable total TMJ reconstruction. Future investigations should assess effect of altered bone quality on the performance of total TMJ replacement.56. Moreover. The main focus of this study was the patient-specific design and biomechanical analysis of the total TMJ prostheses. other studies have demonstrated that this is acceptable. Future work should also include more comprehensive non-linear and dynamic FE simulations using different implant materials. design methodology and FE findings of this study can provide industrial designers with reference data for improving their products. 90 Only two loading conditions (with loads applied at the mandibular angle) were used in this study. especially the custom-designed products intended for patients with complex and challenging anatomic situations.56. The present study used only one set of material properties for patient’s host bone. Limitations of this study must be considered when reviewing implant designs and evaluating FE results.

and pre-clinical FE tests for design verification and validation. 160 .useful in design and assessment of total TMJ prostheses. Findings of this study provide a good basis for future work focusing on developing a more refined and standardized method for custom design of total TMJ prostheses.

Published literature about mandibular and TMJ biomechanics is limited in amount and breadth of research scope. SUMMARY. and shoulder. However. 152.84. and soft tissue such as disc. CONCLUSIONS. and scientists as extensively as have been for other joints such as hip. very few FE studies are validated against experimental or clinical findings. and muscles are critical to the functioning of TMJ. clinicians. Limited information is available about strain development in mandible under multiple functional and para-functional loading scenarios. Structure and biomechanical behavior of bony components such as mandible and fossa. 153 and it needs significant improvement to reduce frequency of or to avoid the painful and expensive revision surgeries of reconstructed TMJ. Life-expectancy of currently USFDA-approved TMJ implants is reported to be between 3 to 14 years. Only one of the currently US-FDAapproved total TMJ prostheses provides custom-made designs. Relatively more studies on FE analysis of mandible and TMJ are reported in the literature.6. In our knowledge. delicate. 107. knee. and highly mobile joint.1 Current state of the TMJ research TMJ is a complex. Research and advancement of treatment for TMD has not been contributed to by engineers. 88. 161 . Most of the literature on experimental study of cadaveric mandible or TMJ includes one or two specimens tested for one loading condition under low magnitude forces. no published study comprehensively discusses the design methodology and biomechanical evaluation of total TMJ prostheses. Much needs to be known about stiffness variation and microdamage development in human mandibular bone. AND FUTURE WORK 6. ligaments.

Such 3D models provide valuable information about the structural state of these anatomic components necessary to make diagnosis and develop methods to prevent or treat the disorders. One of the major aims through the present study was to characterize stiffness variation and micro-damage development in cadaveric human mandible under fatigue loading. this dissertation research undertook studies aimed at achieving the objectives discussed in Chapter 2 (see Section 2. During this research. From our experimental measurements.6. we performed 3D anatomical reconstruction of the mandible and bony components of TMJ from CT images of several patients and cadaver specimens. Analysis demonstrated that stiffness reduced steeply. initially. initially. We performed experimental evaluation of 16 cadaveric human mandibles by conducting mechanical tests under four configurations of cyclic compressive loading conditions imitating functional and para-functional loads. which transitioned into the region of saturation with nearly no change in damage. This finding proved valuable for designing the total TMJ devices at later point of this dissertation research. We attempted to develop 162 . Majority of damage accumulation was observed during first few hundreds of cycles of the fatigue loading.2 Dissertation research findings and contributions In view of the above-mentioned need for more comprehensive biomechanical evaluation of human mandible and TMJ. During mechanical tests.7). followed by a transition into constant magnitude. Analysis of micro-damage accumulation showed an abrupt increase. we derived stiffness variation and microdamage accumulation in mandibles under four cyclic compressive loading conditions. experimental strain data were measured using strain gauges attached to the cortical surface of each cadaveric mandible at five different locations. Strains measured at condylar locations of the mandibles were found significantly different from those measured at other locations.

The unique design characteristics of our TMJ prostheses have the potential for correct adaptation to host TMJ anatomy. Another key objective of this dissertation research was to develop a validated method of FE modeling and analysis for biomechanical evaluation of human mandible. our custom-designed TMJ implant designs offer novel locking mechanism.predictive numerical model for damage accumulation in the mandible using Michaelis-Menten equation and our experimentally derived data. Following our previously validated FE methodology. FE models were generated from CT data of the cadaveric mandibles. we assessed stress and strain profiles in patient-specific total TMJ reconstruction through FE simulations under normal and over-loading conditions. Strong statistical correlation and statistical agreement were found between the experimentally measured strain and FE-predicted strain data. perforated notches protruding into host bone. This validated FE methodology and 3D models can be used for further evaluation of the complex biomechanical behavior of human mandibles. and customized osteotomy/cutting guides. and improved fixation and stability of the implants for challenging and complex anatomic situations. In addition to providing accurate fit to any challenging anatomic host bone situation. We performed a combined experimental-analytical study in which the surface strains in the cadaveric human mandibles were measured through strain gauges under four configurations of cyclic compressive loads. Our validated FE methodology may also prove valuable in assessing other anatomic parts such as spine. Peak stresses 163 . We also developed a methodology to design patient-specific total TMJ prostheses on the basis of patient’s CT images and surgeon’s requirements. Our methodology shows early promise. and used to perform FE simulations accurately replicating the experiments. and needs further exploration for reliable prediction of mandibular bone damage.

Also. Our simplified linear FE models still are of value in evaluating biomechanical properties of the mandible and TMJ. Moreover. necessary to better understand the onset and progression of the TMD. However. our method of 3D anatomical reconstruction can be further extended to develop models of the entire TMJ including bones. but a better numerical prediction may be expected by analyzing these models beyond the linear region using non-linear and dynamic FE analyses. FE analysis of such subject-specific 3D models of total TMJ. disc.and strains in the prostheses and host bone were found to be within the limit of safety. and its validation against experimental and/or clinical findings can potentially provide valuable insight into structural and functional aspects of the entire joint. The study demonstrated that our proposed methodology provides viable means for designing durable patient-specific total TMJ prostheses. This methodology can also be used for designing customized prostheses for other complex anatomic parts. 6. Our technique of assessing TMJ prostheses can be built upon to perform comprehensive dynamic FEA of total TMJ prostheses and host anatomy by including non-linearity and anisotropy of the model components. and ligaments. articular fibro-cartilage.3 Future work Non-linear models have the potential to better describe biomechanical behavior of bone. safe loading limits can be established to avoid failure of the reconstructed joints due to functional movements of the jaw. further 164 . linear models have been used to study mandibular biomechanics. by defining the limits of maximum loading on these FE models. To bring our custom-design approach to reality.

165 .steps such as prototyping. and subsequent design refinement are necessary. Experimental wear study and predictive numerical wear-rate modeling of TMJ implants will be very valuable. cadaveric implantation studies.

J. Oral Pathol. 106:508-508. 2. Oral Surg. Orofacial pain. Anatomy of the temporomandibular joint.. The temporomandibular joint (TMJ). Endod. 2007.php:1. O. H. occlusion. Bakke. Dolwick. Lorente.REFERENCES 1. Salvador. 2006. Y. Retrieved on 10/14/2007. M. J. Ahlberg. Adaptability of Biomet Lorenz TMJ Prosthesis to Joints that were Previously Treated With the TMJ Concepts Custom Joint Prosthesis. Endod. 2008. Bakke. Oral Med. Nissinen. J. Mechanical Testing of Bone and the Bone-Implant Interface. I. F. S. Cranio 21:248-252. and S. J. Cabratosa. X. and body mass index in a cohort of young adults. Draughn. Medrano.. Hurmerinta. M. Clavero. 5. 624 pp. 2007. 4. 2003. from http://www. J. 2000. 2001. Jensen. M.aaoms. K. Oral Surg. A. Abramowicz. Pedersen.org/tmj. Oral Med. Könönen. Rose. and A. Bite Force and Occlusion. K. An. J. Zak. M. A. H. Oral Radiol. Monill. 7. Maximal bite force and its association with signs and symptoms of TMD. and MRI 28:170-183. and M. and temporomandibular disorders in women with a history of juvenile chronic arthritis or persistent juvenile chronic arthritis. B. I. : CRC. Zepa. Semin. 6. Oral Radiol. F. 166 . and R. Oral Pathol. Alomar. 12:120-126. Serra. A. M. Kreiborg. 3. M. Barbick. P. CT. 92:406-414. Kovero. Orthod. jaw function. L.. M. Seminars in Ultrasound.. and S. American Association of Oral and Maxillofacial Surgeons (AAOMS).

2005. M. 14. Campbell. K. Care Injured 31:S-B14-S-B23. L. J. Feilzer. P. Oral Rehabil. Dent. R. Stiffness . Koolstra. Three-dimensional finite element analysis of the cartilaginous structures in the human temporomandibular joint. and R. J. M. F. 1993. Estrogen receptor analysis of human temporomandibular disc. J. G. Imai. Landgraf. R. 2001. and R.. B. CAastelo. Bite force determination in adolescents with and without temporomandibular dysfunction. G.. Pereira. Scheck.. Stress analysis of the human temporomandibular joint. Courey. Dent. Biomechanical analysis of stress distribution in the human temporomandibular-joint. J. J Oral Maxillofac Surg 51:1101-1105. Eng. J. Aarnts.. L. 32:577-583. Int. M. M. Bone quality: where do we go from here? Osteoporosis International 14:118-127. J. 13. L. M. and C. and T. Bouxsein. J. H. Ohnishi.an unknown world of mechanical science? Injury. 20:565-572. Chen. 1999. M. Gaviao. Res. Bourne. Bonjardim. U. 9. S. M. M. D. Matsumoto. Odziemie. Koolstra. 80:876-880. Med. 16. J. Anat. van Ruijven. T. Ann. Breul. 12. 10. Akyuz. Xu. Res. 11. A.8. and T. Mall. 40:1745-1753. M. H. J.. 15. Van Eijden. 2001. P. G. J. Dynamic Properties of the Human Temporomandibular Joint Disc. Pidaparti. van Eijden. 181:55-60. Prediction of strength and strain of the proximal femur by a CT-based finite element method J. 80:1913-1918. J. 167 . M. V. H. 2003. Nakamura. J. Beek. 2007. Matsuyama. Beek. M. and P. J.. I. 2000. Bessho. 1998. J. L. and K. J. Biomech. Baumgart. Phys. L..

A. Injury. Rho. 25. 1998. T. Oral splints: the crutches for temporomandibular disorders and bruxism? 9:345-361. J. Morphol. 61:494-506. K. Surg. Surg. Oral Biol. C. Lavigne. Athanasiou. Reich. T. Bir. Craig. T. 21. Currey. 23. 168 .17. Gautier. : CRC. Structure and function of the temporomandibular joint disc: implications for tissue engineering J. Biomech. Med. 26. S. Viano. D. E. 22. S. Bone Mechanics. Int. Int. U. Biomechanical response of the human mandible to impacts of the chin J. and K. 20. Age-dependent fatigue behaviour of human cortical bone Eur. J. 18. Dao. 1989. Oral Maxillofac. 1999. 19. 313 pp. 1999. 38:909-920. Care Injured 30:S-A14-S-A20. : Princeton Univ Press. Tashman. 2002. Sit. 436 pp. T. D. J. D. Crit. Driemel. Athanasiou. and R. Cordey. M. C. 1998. 9:345-361. Rev. Cowin. 2003. M.. 35:13011311. Care Injured 30:S-A7-S-A13. Braun. Diab. and S. 2005. 42:53-59. Müller-Richter.. Detamore. Reichert. M. M. A call to action for bioengineers and dental professionals: directives for the future of TMJ bioengineering Ann. Detamore. and G. 24. Kim. M. and E. A. J. D. J. and E. and D. Historical development of alloplastic temporomandibular joint replacement after 1945 and state of the art. Kunkel. Int. J. Bones: Structure and Mechanics. J. 2009. Gautier. Strain gauges used in the mechanical testing of bones Part II: "In vitro" and "in vivo". A. O. Oral Maxillofac. 2007. Strain gauges used in the mechanical testing of bones Part I: Theoretical and technical aspects Injury. J.. J. 2008. and J. S. 41:2972-2980. Vashishth. Behr.. Cordey. Eng. S. S. Biomed. Mao.

& Intervention: A Pocket Handbook. 1979. E. U. 2009. McCarty Jr. S oacute. M. 1973. G. T. 33. Skeletal structural adaptations to mechanical usage (SATMU): 2. Deformation characteristics of the human mandible in low impact experiments Int J Legal Med 117:257-262. 35. J. Brinkmann. Behr. Ill. and R. Reich. Driemel. Surg. Orthopaedic Examination. Unnewehr.: Charles C. The osseointegration of Mitek mini anchors in the mandibular condyle. H. M. Fischer. M. J. and L. Frost. B. Mechanical properties of bone Springfield. Schmidt. Fricton. and W. P. M. 226:414-422. Rec. Anat. 548 pp. Evaluation.. Historical development of alloplastic temporomandibular joint replacement before 1945. Ach. W. F. New York: McGraw-Hill Medical. and J. Long-term study of temporomandibular joint surgery with alloplastic implants compared with nonimplant surgery and nonsurgical rehabilitation for painful temporomandibular joint disc displacement. The TMJ dilemma. 169 . Reichert. R. . 32. O. Fields Jr. T. 30. Farrar. E.. 2003. Piffk oacute. J Alabama Dent Assoc 63:19. 2004. M.27. 322 pp. 2001. 1990. A. 60:1400-1411. 28. Dutton. Frost. Müller-Richter Dietmar Achim. J. 29. F. 1995. tonyi. Kunkel. P. Oral Maxillofac. Schiffman. DuChesne. J Oral Maxillofac Surg 59:1402-1406. Look. Surg. J. T.. Bajanowski. Int. J. Oral Maxillofac. Pueblo. 2002. M. Introduction to a new skeletal physiology. H. 38:301-307. Swift. and T. Evans. Wolford. 31. M. J. Thomas. Redefining Wolff's Law: The remodeling problem. B. R. 34. O. Colorado: The Pajaro Group.

J. G.pdf:04/14/2008.. Iwasaki. Spector. and S. L. M. Temporomandibular Disorders: A Clinical Approach. Quayle. C. D. Nickel. Gray. J. 2007. TMJournal http:// tmjournal.36. 42. C. 79:1740-1746. George-Whitney. H. Journal of Materials Science: Materials in Medicine 2012. D. Gallo. W. and D. 44. Mechanical work during stress-field translation in the human TMJ. Nickel. M. Vashishth. T. 41. A. J Orthop Res 9:760-775. A. and L. Davies. and T. Galante. and T. A Biomechanical Evaluation of Femurs Fixated with Cephalomedullary Nails. The Christensen temporomandibular joint prosthesis system: An overview. 1995.. Frost. Oral Rehabil. L. M. Lemons. 37. Goswami. J. 34:97-104. 38. Res. and J. R. R. S. 85:1006-1010... Chiaravalloti. 2000. J. G. Res. M. Gayton. Wright. J. Gerard. 2002. Gallo. 23:1047-1053. London: Ishiyaku Euroamerica. and A. J. Palla. The biologic effects of implant materials. C. L. 39.com/library/CP-009. George. 170 . Hudson. Dent. 40. M. Wilson Jr. 1998. L. Palla. M. Glaros. Submitted. Reduction in parafunctional activity: a potential mechanism for the effectiveness of splint therapy. Lausten. Dent. 1991. Stouffer.. J. W. 2005. M. Iwasaki. Orthop. A.. A brief review for orthopedic surgeons: Fatigue damage (microdamage) in bone (its determinants and clinical implications) J Orthop Sci 3:272-281. Prayson. Damage mechanisms and failure modes of cortical bone under components of physiological loading J. P. Z. O. 2006. R. M. Stress-field translation in the healthy human temporomandibular joint. Res. Owais. and S. 43.

C. 1996. L. Groning. 46. W. 120:112-117. Hebert. 66:77-84. A. Anderson. Oral Maxillofac. X. J. 51. 47. 32 pp. V. 1993. R. and R. 1998. Fang. Hangartner. D. Yang. R. 25:261-286. 1992. Bakke. R. Qiu. Li. Thomas Indresano. Pain. Liu. 42:1224-1229. 48:926-932. F. 69:1600-1607. V. Surg. D. 49. An epidemiologic survey of facial fractures and concomitant injuries J. Y. and P.. Liang. Comput. Hansdottir. N. Biomech. 2009. M. Oral Maxillofac. X. 2004. Oral Maxillofac. N. Assist. Van Buskirk.. and M.. Prather. Hart. Etiology of temporomandibular joint ankylosis secondary to condylar fractures: the role of concomitant mandibular fractures J. 50. Joint tenderness. J. O'Higgins. ME: IMPACC USA. Guo. Overcoming TMJ: There is hope. 2008. Hennebel. He. jaw opening. Haug.. 1990. Chen. Thongpreda. T. The OsteoQuant: an isotope-based CT scanner for precise measurement of bone density. J. E. Greenville. and bite force in patients with temporomandibular joint pain and matched healthy control subjects. Eng. Biomech. T. Orofac. J. 53. Surg. C. J. X. 171 . A. L. 17:798-798. H. Yang. 52. He. Surg. C. E. 18:108-113. L. Biomech. Traumatic Temporomandibular Joint Ankylosis: Our Classification and Treatment Experience. C.. Goldstein.45. Fagan. J. Ellis 3rd. Zhang. 2011. and B. chewing velocity. M.. and S. 48. J. Micromechanics of osteonal cortical bone fracture J. Tomogr. Modeling the biomechanics of the mandible: a three-dimensional finite element study. Validating a voxel-based finite element model of a human mandible using digital speckle pattern interferometry J. Zhang. and Y. and A.

L. and M. J. Hylander. M. Endod.. Ichim. I. C. 58.. T. Hsu. Hogan. Lobbezoo. 1991. Hibi. 2011. Mandibular biomechanics and development of the human chin. L. Naeije. M. 60. Fuh. Oral Radiol. J. Tu. J Oral Maxillofac Surg 69:1320-1328... J. H. Anthropol. F. 1992. Oral Rehabil. and L. Stress and strain in the mandibular symphysis of primates: A test of competing hypotheses Am. 62. Tsai. Nakazawa. Kieser. Am. Hsu. Chicago: Quintessence Publ. 2010.. Effect of Screw Fixation on Temporomandibular Joint Condylar Prosthesis. Dent. J. H. Visscher. The Intra-articular Distance within the TMJ during Free and Loaded Closing Movements. J. Tu. J. 2005. and M. Res. Biomech. Oral Surg. 78:1815-1820. and L. 55. Phys.54. Co. An experimental analysis of temporomandibular joint reaction force in macaques. L. 56. Dent. Anatomical atlas of the temporomandibular joint. Ueda. Body posture during sleep and disc displacement in the temporomandibular joint: a pilot study. J. Phys. R. Effect of bone quality on the artificial temporomandibular joint condylar prosthesis. 1979. W. Huang.. 61. A. J. Oral Pathol. W. Swain. 59. J. Res. and J. Fuh. A. Micromechanics modeling of Haversian cortical bone properties J. Oral Med. K. Garcia. Anthropol. 2006. 51:433-456. 32:85-89. M. Y. 172 . H. 116 pp. and M. 1984. Hylander. 64:1-46. 57. H. M. 85:638-642. 25:549-556. Ide. Huang. Huddleston Slater. 1999. 109:e1-e5.

Plast. and R. 2009. 72. Reconstr. L. Ingawalé. 1998. Kalamir. 70. C. Biomed. A. 2012. 67. A review. Orofac. edited by T. and J.63. Hjorth. Ortho. 65. Roy Chowdhury. 1989. 159-182. 71. Bonello. A. J. Mabe. A. Jee. prospective study J. J. and S. 37:976-996. J Musculoskelet Neuronal Interact. Vitiello. Surg. Kiehn. W. L. Y. Principles in bone physiology. Biomech. Kasch. Ingawalé. N. C. Marx. Temporomandibular disorders after whiplash injury: a controlled. Kashi. Gonzalez. and D. F. 68. Ohrbach. 2002. Jensen. 66. R. A. 69. Res... J. Kent. Saha. H. Goswami.. Komistek. treatments. S. 11:183-193. and T. D. Pain 16:118-128. J. R. Dent. 53:221-226. Svensson. "Biomechanics of the Temporomandibular Joint. S. 31:13. W. In vivo kinematics and kinetics of the normal and implanted TMJ. Dennis. Iwasaki. and biomechanics. 1:11-13. Croatia: InTech Publication. 2009. TMD and the problem of bruxism. A. Crosby. S. R. Pollard. D. M. 89:241-245. Open reduction of mandibular condyle fractures Journal of Oral and Maxillofacial Surgery 47:7-8. Converse. and T. T. Goswami. L. Temporomandibular joint: disorders.. Desprez. Reviews 1:90-93. T. H. A new procedure for total temporomandibular joint replacement. Goswami. P. Ann. D. 173 . and T. Bodywork Movement Ther. Anderson. 64. Finite Element Analysis of a TMJ Implant. S. B. pp. 2000. Nyhuus." In: Human Musculoskeletal Biomechanic. 2007. D. J. M. D.. Nickel. A. McCall. 1974. and C. J. Temporomandibular joint loads in subjects with and without disc displacement. Eng. 2009..

and van Eijden. Laskin. M. Koolstra. 543 pp.73. 209:369-380. G. J. Crit. Kurtz. J. Biomech. Biomech. Anat. London. 8:90-104.. 174 . Modeling the mechanical behavior of the jaws and their related structures by finite element (FE) analysis. J. and A. Korioth. Versluis. Crompton. Combined finite-element and rigid-body analysis of human jaw joint dynamics J. van Eijden. H. M. Kovan. Fagan. J. Pain 8:178-189. and T. J. E. G.. Korioth. Oxnard. 1994. H. W. UHMWPE Biomaterials Handbook: Ultra High Molecular Weight Polyethylene in Total Joint Replacement and Medical Devices. 77. M. M. Koolstra. C. J. C. B. A. 41:3488-3491. S. 2006. R. Greene. 2006. 210:41-53. Kupczik. 75. W. 2009. and A. H. M. Orofac. O’Higgins. 81. 209:369-380. van Eijden. 2006. 79. Hannam. 2007. C. 1997. and T. UK: Academic Press. An assessment of impact strength of the mandible J. 2005. Anat.. Anat. 80. M. K. 38:2431-2439. Assessing mechanical function of the zygomatic region in macaques: validation and sensitivity testing of finite element models. L. D. H. Rev. and P. and W. 74. 76. Hylander. Mandibular forces during simulated tooth clenching J. T. 2008. J. Koolstra. Med. V. T. Temporomandibular disorders an evidence-based approach to diagnosis and treatment. Prediction of volumetric strain in the human temporomandibular joint cartilage during jaw movement. 78. T. J. P. Oral Biol. Chicago: Quintessence Pub. Prediction of volumetric strain in the human temporomandibular joint cartilage during jaw movement. Dobson.

175 . and A. Surg. Mercuri. 2000. Morlier. Ballu. PA: WB Saunders. J Oral Maxillofac Surg 60:1440-1448. Sanders. Oral Med. Teaching Learning Med . 86. N. Ali. G. Cid. 87.. Philadelphia. and J. R. Mesnard. 90. G. R. F. White. Long-term follow-up of the CAD/CAM patient fitted total temporomandibular joint reconstruction system. J. G. 2007. 2012. M. 811. L. 85:631-637. J. Surg. 2002. Woolson. Endod. R. J.82. Petty. 58:70-75. Oral Radiol. M. Oral Maxillofac. Simoes. J Oral Maxillofac Surg 69:1008-1017. and R. E. M. Alloplastic temporomandibular joint replacement: rationale for the use of custom devices. Giobbie-Hurder. 66:1794-1803. Edibam. Oral Pathol.. 2011.. Giobbie-Hurder. 2008. Biomechanical Analysis Comparing Natural and Alloplastic Temporomandibular Joint Replacement Using a Finite Element Model. 84. Outcomes of total alloplastic replacement with periarticular autogenous fat grafting for management of reankylosis of the temporomandibular joint. "Metals and alloys. 83. Alloplastic temporomandibular joint reconstruction Oral Surg. L. J Oral Maxillofac Surg 65:1140-1148. edited by W. B. and A. The use of alloplastic prostheses for temporomandibular joint reconstruction. 1998. Int. L. Mercuri. A. A. G. Lemons. L. 88." In: Total joint replacement.. L. Oral Maxillofac. J. 85. J. D. Mercuri. Surg. Oral Maxillofac. A. pp. Wolford. Mercuri. Mercuri. A. (In press). Fourteen-year follow-up of a patientfitted total temporomandibular joint reconstruction system. Enhancing medical education by improving statistical methodology in journal articles. G. 41:1033-1040. Mercuri. Markert. L. 89. J. 1991. Ramos. L.

1998. Am.91. J. Validated numerical modeling of the effects of combined orthodontic and orthognathic surgical treatment on TMJ loads and muscle forces. S. 83:156-162. W. 9-20. 495 pp. edited by M. Oral Radiol. Dentofacial Orthop. W. 1999. J. 2001." In: Hip Surgery Materials & Developments. Nagahara. and T. Milam. and D. Spalding. Cabanela and L. M. Angle Orthod 69:372-379. Taylor. R. Nakamura. 2002. Hofman. S. Endod. Louis. Nickel. Oral Med. Orthod. P. P. M. MD: American Society for Testing and Materials (ASTM). C. Lee. 95. St. Milam. 98. Microcrack accumulation at different intervals during fatigue testing of compact bone. Displacement and stress distribution in the temporomandibular joint during clenching. D. F.. 93. E. 99. C. Biomech. and N. Tsuchiya. 121:73-83. S. 2003. Murata. 1992.. Oral Surg. K. Journal of Oral and Maxillofacial Surgery 59:45. 2003. E. J. Dent. and L. J. O’Brien.The process of lubrication impairment and its involvement in temporomandibular joint disc displacement : a theoretical concept. A. 36:973-980. E. J. Res. Sedel. Failed implants and multiple operations. Naeije. R. 82:528-531. Cyclic mechanical property degradation during fatigue loading of cortical bone Journal of Biomechanics 29:69-79. Discussion . Pattin. Landgraf. B. and S. 94. M. MO: Mosby. Carter. W. 92. Oral Pathol. Yao. 1996.. Caler. R. S. Advances in Fatigue Lifetime Predictive Techniques. Baltimore. editors. and R. Iwasaki. Morscher. 1997.. 97. Mitchell. Biomechanics of the Human Temporomandibular Joint during Chewing. 176 . "Implant stiffness and its effects on bone and prosthesis fixation. pp. 96.

2008. 1991. R. Doblare. R. A. Quinn. and L. Late complications of mandibular fractures Operat Tech Plast Reconstr Surg 5:266-274. 101. Med. and M. and M. Orthod. J. Surg. P. Doblare. Phys.. 811 pp. 102.100. Doblare. 34:759-766. L. Punjabi. Dentofacial Orthop. Molar bite force and its correlation with signs of temporomandibular dysfunction in mixed and permanent dentition. PA: Saunders. 2007. and S. Petty. Juliano. 30:700-709. Influence of unilateral disc displacement on the stress response of the temporomandibular joint discs during opening and mastication. 7:1-23. M. Total joint replacement. P. and M. Oral Maxillofac. Am. 211:453-463. Pereira. Guimaraes. A. Temporomandibular joint disc position and configuration in children with functional unilateral posterior crossbite: a magnetic resonance imaging evaluation. Perez del Palomar. S. L. 177 . and M. 1999.. Anat. Read. G. D. 2006. 2000. 129:785-793. Oral Maxillofac. G. 106. S. Bonjardim. A. J. D. A. Alloplastic Reconstruction of the temporomandibular joint. M. Philadelphia. E. 107. Biomech. 2007. Y. M. A. J. Pastore. Clin. editor. 104. Thaller. J. J. 103. 39:2153-2163. D. B. A. Castelo. Perez del Palomar. Finite element analysis of the temporomandibular joint during lateral excursions of the mandible. 1998. Quinn. P. Gaviao. Lorenz Prosthesis. Pellizoni. 2006. W.. 108. Sel. North Am. 105. Oral Rehabil. Dynamic 3D FE modelling of the human temporomandibular joint during whiplash. 12:93-104. Alonso. Surg. Perez del Palomar. Eng. P. Salioni.

A. "Ultra-high molecular weight polyethylene. C.. 10:123-161. Ambrosio.. S. W. and clinical perspectives. Sanford. Semin. 2007. J. Pal. S. 28:411-420. M. MO: Mosby. 2011. Strain in the ostrich mandible during simulated pecking and validation of specimen-specific finite element models. Huja. F.. Saha. Santis. Sci. pp. Doblare. J. 113. A. semi-anatomic and anatomic TMJ implants: the influence of condylar geometry and bone fixation screws. E. and J. 40:828836. Nicolais. molecular mechanisms. Numerical estimation of bone density and elastic constants distribution in a human mandible. Completo. R. 45-56. Surg. Ramos. Reina. Esposito. 112. Louis. Sedel. Mater. Mollica. 1998. A. Maloney. M. Simões. 51:1053-1059. J. A. 2004. A. Roychowdhury. Straight. J. Rev. Crit.. J. Mesnard. Cranio-Maxillofac. Mesnard. Biomed. P. Roberts." In: Hip Surgery Materials & Developments. Stress analysis of an artificial temporal mandibular joint. 218:47-58. Orthod. 115. and L. J. and M.109. Biomech. 111. 16:11911197. J. Numerical and Experimental Models of the Mandible Exp. Dominguez. M. W. E. 2011. Roberts. 110. An experimental and theoretical composite model of the human mandible J. R. and J. Bone modeling: biomechanics. Cabanela and L. Med. 2000. 39:343-350. Rayfield. Ramos. Garcia-Aznar. and S.. Eng. A. 178 . 2005. 114. Ballu. and J. Relvas. and W. Mater. Mech. M. edited by M. M. Anat. 2011. 116. St. A. E.. Talaia. L. J. Simões.

Houston. B. 2007. Med. Engl. 98:25-34. and B. 2003. R. Am. E. and J. and P. Brit J Oral Maxillofac Surg 38:360-369.. 120. A.. Dechow. Modeling elastic properties in finite-element analysis: How much precision is needed to produce an accurate model? Anat. Surg. J. 125. J. 283A:275-287. Temporomandibular disorders N. 42:405-417. F. 2005. B. Keith. Kaban. Rec. Gutwald. M. Schwartz-Dabney. S. and L. M. M. and G. S. P. C. 1996. Schupp. 120:252-277. and M. Arzdorf. NY: Wiley and Sons. Oral Maxillofac. Strait. de Assis. Oral Maxillofac. Total prosthetic replacement of the TMJ: experience with two systems 1988–1997. 54:671-679. K. Ross. D. W. Assoc. Spencer. B. V. Swanson. and D. B. 123. 121.. Hensher. J. 122. Q. Powell. P. Richmond. 359:2693-2705. Woo. Prevalence of mandibular dysfunction in young adults J. S. Wang. Singh. 2009. 124. J. A. Sinn.. C. A. S. The scientific basis of joint replacement. C. Phys. Anthropol. L. Speculand. Mandibular excursions and maximum bite forces in patients with temporomandibular joint disorders. M. 65:924-930. Freeman. D. Solberg. Surg... 182 pp. editors. R. B. D. New York. Patel. Biomechanical testing of different osteosynthesis systems for segmental resection of the mandible J. J. 2000. Biomechanical properties of the mandibular condylar cartilage and their relevance to the TMJ disc. 1977. S. 119. Dent. Linke. Biomech. Variations in cortical material properties throughout the human dentate mandible Am. 118. 1979. 179 . A. W. Scrivani. A. A. W. and R. Dechow. C. and M. Throckmorton. G. Detamore. 2008.117.

D. Dent.126. A. 2000. Tanne. 180 . D. Eng. Hirose. Yamaguchi. Iwabe. diagnosis.. Mercuri. T. J. Rodrigo. Lubrication of the temporomandibular joint Ann. Res. Threedimensional finite element analysis of human temporomandibular joint with and without disc displacement during jaw opening. Huang. Subject-specific finite element models of long bones: An in vitro evaluation of the overall accuracy J. Lee. E. K. Viceconti. M. 87:296-307. 26:503-511. S. L. 36:14-29.. Kawai. Tanne.. Phys. Miller. del Pozo. T. P. M. Biomed. E. Med. G. Oral Rehabil. 2004. T. Tanaka. J. 2008. J. S. K. Dalla-Bona. S. Cristofolini. Y. 127. 2006. 2006. Martelli. E. and treatment. J. K. 128. 39:2457-2467. Tanaka. Iwabe. Oral Maxillofac. Detamore. Degenerative disorders of the temporomandibular joint: etiology. Tanaka. M. Gansky.. E. C. S. M.. D. 2009. 131. Tanimoto. and A. Lee. F. and K. Asai.. and M. 132. Biomech. Tanaka. J. 129. 130. Tanne. The Effect of Removal of the Disc on the Friction in the Temporomandibular Joint. Hatcher. Maki. and K. Surg. Swasty. S. Takata. M. Miyawaki. Tanaka. 27:754-759. Tanaka. Anthropometric Analysis of the Human Mandibular Cortical Bone as Assessed by ConeBeam Computed Tomography. Journal of Oral and Maxillofacial Surgery 67:491-500. Taddei. Yamano. S. E.. E. Gill. H. T. Stress distribution in the temporomandibular joint affected by anterior disc displacement: a threedimensional analytic approach with the finite-element method. Kawai. and N. K. 2008. A. J. Miyauchi. M. Detamore. Tanaka. N. D. and K. Eng. and L. R. 64:1221-1224. D. van Eijden.

Modeling of the effect of friction in the temporomandibular joint on displacement of its disc during prolonged clenching J. 2001. Tanne. D. gov/MedicalDevices/Safety/AlertsandNotices/PatientAlerts/ucm070141. 136. Rodrigo. K. Miyawaki.. Surg. P. 27:754-759. Tanaka. J. M. and K. 2011. E. P. gov/new. and K. H. E. 139. T. Y. Y. B. http://www. Oral Maxillofac. Biomechanical properties of the body and angle of the sheep mandible under bending loads Dent Traumatol 27:179-183. Tanaka. Kawaguchi. and K. Shibazaki. FDA approval of four TMJ implants . Y. Kudo. E.. H.report to congressional requesters. T. and K. Stress analysis in the TMJ during jaw opening by use of a three-dimensional finite element model based on magnetic resonance images Int. van Eijden. Y. fda. T. Biomed. 138. A. D. Tanaka. Res. N. Yamaguchi. Fujita. United States Food and Drug Administration – Center for Devices and Radiological Health (US FDA/CDRH). 2001. M. M. Lee. Kawai. Oral Rehabil. J. Surg. N. E.133. Tanne. 2008. Stress distribution in the temporomandibular joint affected by anterior disc displacement: a threedimensional analytic approach with the finite-element method. 2008. 2007. Inubushi.. R. Tanne. Biomechanical response of condylar cartilageon-bone to dynamic shear. Koolstra. htm :1-31. 181 . T. http://www. M. Tanaka. J. Tanne. 66:462-468. Turkozan. J. Tanaka. Koolstra. 137. Rodrigo. Iwabuchi. Mammadov. Rego. 85A:127-132. Iwabuchi. Takata. J. 135. E. Unites States Govermental Accountability Office (GAO). G. K. Tanaka. T. 134. 2000. items/d07996. Matr. gao.. Y. Oral Maxillofac. pdf . van Eijden. M. Hirose.A Consumer Information Update. and C. TMJ Implants . J. 30:421-430.

. Temporomandibular Disorders and Hormones in Women. T. U.. B. Varghese.. and G. and G. A Fatigue Damage Model for the Fiber-reinforced Composite of Haversian Cadaveric Cortical Bone J. 28:91-96. P. de Bont.. 182 . G. L. Vollmer. J. and J. 2011. Int. G. Groningen temporomandibular joint prosthesis. Najmi. Composite Mater. M. Surg. L. Meyer. and H. and H. 142. Evaluation of temporomandibular joint prostheses Review of the literature from 1946 to 1994 and implications for future prosthesis designs. Cranio-Maxillofac. 147. Joos. Stegenga. L. Short. . 2011. 141. A. Surg.140. Varvani-Farahani. M. D. F. 146. 144. A. Spijkervet. J. Varvani-Farahani. Hangartner. A. Verkerke. A. L. R. Boering. 2002. Computedtomography-based finite-element models of long bones can accurately capture strain response to bending and torsion J. and J. J. J. J. 2008. Development and first clinical application. 44:1374-1379. U. Vegh. P. Fried. and T. Fatigue 32:420-427. D. Najmi. Cells Tissues Organs 169:187-192. Penmetsa. Oral Maxillofac. van Loon. 143. 2000. A damage assessment model for cadaveric cortical bone subjected to fatigue cycles Int. 145. B. Quantitative Computed-Tomography Based Bone-Strength Indicators for the Identification of Low Bone-Strength Individuals in a Clinical Environment. van Loon. P. Goswami. 2010. 2001. J. K. 31:44-52. Warren. Biomech. 1995. Journal of Oral and Maxillofacial Surgery 53:984-996.. de Bont. Varghese. Piffko. Experimental and finite element study of a human mandible. M. 42:2747-2760. B.

Proceedings Baylor Uni Med Cent 13:135-138. J. 152.. K. 2003. E. O. M. 150. TMJ Concepts/Techmedica custom-made TMJ total joint prosthesis: 5-year follow-up study. Oral Maxillofac. Histological findings in soft tissues around temporomandibular joint prostheses after up to eight years of function. Microscope Image Processing. K. 2007. 61:645-652. 1978. Wolford. N. E. C. Baltali.. L. L. Leiggener. Arthrography of the temporomandibular joint in patients with the TMJ paindysfunction syndrome. Zhao. A. J. R. 154. Comparison of 2 temporomandibular joint total joint prosthesis systems. Wolford. and E. J. Oral Pathol. 155. Rebellato. 2003. J. 65:1569-1576. Oral Maxillofac. Wolford. H. Int. Castleman. J Oral Maxillofac Surg 61:685-690. Med. An. and M. and S. D. Oral Surg.. 2011. Keller. Int. 576 pp. Oral Maxillofac. 151. Lindskog. L. Temporomandibular joint devices: Treatment factors and outcomes. Surg. Pitta. M. 32:268-274. Burlington. Custom-made total joint prostheses for temporomandibular joint reconstruction. and P. and K. Minn. Wu. 1997.. J. 2008.. D. Kademani. Wolford. Dingwerth. Westermark. L. 183 . Q. 153. M. Kinematic study of the temporomandibular joint in normal subjects and patients following unilateral temporomandibular joint arthrotomy with metal fossa-eminence partial joint replacement. Endod. Aagaard. R. D. Talwar. Oral Radiol. Oral Med. Wilkes. C. Franco. M. MA: Elsevier Academic Press. 40:18-25. H. Merchant.148. J. M. Reiche-Fischel. and P. C. 149. E. Yoon. Surg. Mehra. Pitta. 2000. F. 83:143-149. Surg.

J Oral Maxillofac Surg 54:873-878. Mukai. 184 . G. Protein interactions with particulate Teflon: implications for the foreign body response. H. Milam. and S. V. 1996. Zardeneta. B..156. Marker.