Dental Materials Journal 2014; 33(3): 368–372

Comparative evaluation of various miniplate systems for the repair of mandibular

corpus fractures
Sertan ERGUN1, Duygu OFLUOĞLU1, Alp SARUHANOĞLU1, Burçin KARATAŞLI2, Ediz DENIZ3, Sevda ÖZEL4
and Hakkı TANYERI1

1
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Istanbul University, Capa, Fatih, Istanbul 34093, Turkey
2
Department of Prosthodontics, Faculty of Dentistry, Istanbul University, Capa, Fatih, Istanbul 34093, Turkey
3
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Yeditepe University, Ciftehavuzlar-Kadikoy, Istanbul 34390, Turkey
4
Department of Biostatistics and Medical Informatics, Faculty of Istanbul Medicine, Istanbul University, Capa, Fatih, Istanbul 34093, Turkey
Corresponding author, Sertan ERGUN; E-mail: sertanergun@gmail.com

Miniplates have been used during the last decade to facilitate stability between bony fragments in the maxillofacial region and are
currently the preferred surgical method for the fixation of fractures and osteotomies. The aim of this study was to evaluate and
compare the biomechanical behaviors of six different types of miniplates used to reconstruct mandibular body fractures: Group 1
(straight, 2 holes, 12.0 mm spacing), Group 2 (straight, 4 holes, 9.0 spacing), Group 3 (straight, 6 holes, 9.0 mm spacing), Group 4
(L-shaped, 4 holes, 9.0 mm spacing, right hand plate), Group 5 (Y-shaped, 5 holes, 12.0 mm spacing), and Group 6 (double Y-shaped, 6
holes, 9.0 mm spacing). Thirty bovine hemimandibles and a custom-made 3-point biomechanical test frame mounted on a Shimadzu
universal test machine were used to evaluate the six different miniplate systems. Results revealed that Group 1 (straight, 2 holes,
12.0 mm spacing) and Group 4 (9.0 mm spacing, right hand plate) had the lowest biomechanical stability, whereas Group 6 (6 holes,
9.0 mm spacing) had the highest biomechanical stability. Group 6 also provided statistically greater resistance to displacement than
Group 1 and Group 4.

Keywords: Miniplates, Titanium, Rigid fixation

predisposing factor for both infection and nonunion. It

INTRODUCTION
Mandibular fractures are one of the most common
facial skeletal injuries. They can be caused by road
traffic accidents, assaults, falls, industrial injuries or
sports injuries, but the relative number of each varies
considerably between countries and areas. The body of
the mandible is one of the most common fracture sites,
followed by fractures at the condyle, angle, symphysis,
ramus, and coronoid process1,2).
A mandibular fracture treatment depends on the
arrangement of bone fragments in their anatomical
position, and its goals are to stabilize the fracture
and restore normal function with least morbidity.
Treatment and repair of mandibular fractures has
evolved over the years, and many repair techniques
have been introduced: ranging from maxillomandibular
fixation (MMF) and combinations of MMF and
wire osteosynthesis to fixation with lag screws and
reconstruction plates. In the last decade, rigid internal
fixation using compression and noncompression plating
systems has gained widespread popularity3,4).
Miniplates have been used to facilitate stability
between bony fragments in the maxillofacial region
and are currently the preferred surgical method for the
fixation of fractures and osteotomies. The advantages
of using miniplates include easy handling and easy
plate contouring and adaptation to the bone5). Miniplate
osteosynthesis ensures adequate fracture stability,
improves bone healing, and allows early functional
mobilization6). Movement at the fracture site is a known
has been reported that the site of most nonunions was in
the mandibular body7).
During fracture treatment planning, important
decisions that must be made include determining the
best position, orientation, and plate type and material.
The first and foremost consideration is the rigidity of
the repaired fracture section, and the second pertains
to the level of stress generated in the miniplates under
bite forces8). A variety of miniplates have been used
to repair mandibular corpus fractures. In the original
Champy version, a 4-hole miniplate without center
space was used9). Today, although this type of plate
is still applicable, alternatives that provide similar or
incrementally higher stability have emerged. The aim of
this study was to evaluate and compare the biomechanical
behaviors of six different types of miniplates used to
reconstruct mandibular body fractures.
MATERIALS AND METHODS
Hemimandible specimens
Fifteen mandibles obtained from similar bovines (mean
weight of 220 kg, fed on the same diet, collected from the
same abattoir, and slaughtered in similar manner) were
used in this study. The mandibles were stripped of their
soft tissues and divided into two pieces in the anterior
midline between the central incisors. The specimens
were kept moist until all tests were completed. Using
a diamond disk, a uniform vertical cut was made on
the mandibular corpus, in front of the first premolar, to

Received Nov 5, 2013: Accepted Feb 12, 2014

doi:10.4012/dmj.2013-315 JOI JST.JSTAGE/dmj/2013-315
 Dent Mater J 2014; 33(3): 368–372 369

simulate a fracture. force against the load applied at a point 1 cm distally to

the fracture line of the mandible. The load was measured
Miniplate systems as a unit of force in Newtons (N), and data were recorded
The hemimandibles were randomly divided into six from the start of the loading process until failure.
groups of five specimens per group. In each group, Failure was defined as fracture and/or osteotomy
the hemimandibles were fixated by a different type displacement, and the load was applied until loss of
of miniplate. These six groups of miniplate systems
(Trimed®, Elektron Medikal, Istanbul, Turkey) are shown
in Fig. 1 and were of the following configurations:
Group 1 — Straight, 2 holes, 12.0 mm spacing.
Group 2 — Straight, 4 holes, 9.0 mm spacing.
Group 3 — Straight, 6 holes, 9.0 mm spacing.
Group 4 — L  -shaped, 4 holes, 9.0 mm spacing, right
hand plate.
Group 5 — Y-shaped, 5 holes, 12.0 mm spacing.
Group 6 — D  ouble Y-shaped, 6 holes, 9.0 mm
spacing.
To reduce the influence of extraneous variables, all
miniplates used in this study were made of Grade
4 Titanium and were 1 mm thick, and monocortical
titanium screws were of 2 mm diameter and 5 mm
length.
To avoid poor adaptation, the miniplates were pre-
bent and adjusted. Screw holes were prepared using
a drill, and a simulated osteotomy on the mandibular
body was performed using an oscillating saw (Medicon,
Tuttlingen, Germany), at a distance of 10 mm mesially in Fig. 2 Diagram of the masticatory action of human
front of the first premolar tooth. The fractured segments mandible10).
were all repositioned and manually stabilized. After Load placed on the articular surface of mandibular
miniplates and screws were properly positioned, rigid condyle (A) is caused by the action of the major
fixation was performed in all groups. elevator muscles of the mandible acting on the
angle (B) and coronoid process. (C) when the
Biomechanical testing force of a bolus of food is applied on the lower
A custom-made 3-point biomechanical test frame incisors upon mouth closure. Load is transferred
(Tasarımmed) was mounted on a Shimadzu universal test to the mandibular body, where the sagittal split
machine (Autograph®, Trapezium 2 Software®, Version osteotomy (D) was fixed using a miniplate (E).
2.23) using a methodology similar to that designed by
Armstrong et al.10) (Fig. 2). Each hemimandible specimen
was positioned to allow the load resistance of mandibular
body fracture treated with miniplate osteosynthesis
to be evaluated during simulated mastication (Fig. 3).
The hemimandible was subjected to a compression test
with a loading rate of 1 mm/min to simulate quasi-static
conditions. The test machine recorded the resistance

Fig. 3 Position of hemimandible in a custom-made 3-point

biomechanical test frame (Tasarımmed, Istanbul,
Fig. 1 Six different types of miniplate systems (Trimed®, Turkey) mounted on a Shimadzu universal test
Elektron Medikal, Istanbul, Turkey) used for machine (Autograph®, Trapezium 2 Software®,
fixation in this study. Version 2.23).
 370 Dent Mater J 2014; 33(3): 368–372

the integrity of bone-screw-plate system occurred.

Maximum load was defined as the highest load recorded
just before any sudden decrease in load level occurred
(Fig. 4).
Statistical analysis
In each group, five hemimandible specimens were
tested. Means of compression loads in six groups were
statistically analyzed using Kruskal-Wallis test (SPSS
21.0).
RESULTS
Thirty hemimandibles were analyzed in this study, with
five specimens in each of the six groups. Standardization
of all experimental factors was ensured, except for the
miniplate shape. Descriptive statistics of the six groups
are shown in Table 1. Kruskal-Wallis test was used to
compare the differences in median score between the
groups. Group 1 (straight, 2 holes, 12.0 mm spacing)
and Group 4 (L-shaped, 4 holes, 9.0 mm spacing) had the
lowest biomechanical stability, whereas Group 6 (double
Y-shaped, 6 holes, 9.0 mm spacing) had the highest
biomechanical stability (p<0.05).
Pair-wise multiple comparisons showed that double
Y-shaped miniplate with 6 holes and 9.0 mm spacing
provided statistically greater resistance to displacement
than straight miniplate with 2 holes and 12.0 mm spacing
(p<0.001) and L-shaped miniplate with 4 holes and 9.0
mm spacing (p<0.001). In addition, the mean resistance
score of Y-shaped miniplate with 5 holes and 12.0 mm
spacing was greater than that of L-shaped plate with 4
holes and 9.0 mm spacing (p=0.002).

DISCUSSION
Literature review revealed that many studies have
examined different kinds of rigid fixation methods in
different locations of the mandible. Rigid fixation with
Fig. 4 Point of maximum load when decreasing force titanium miniplates was reportedly a superior technique
begins. when compared with resorbable miniplates11-13).

Table 1 Descriptive statistics of six groups of miniplate systems evaluated in this study
Mini plate systems Kruskal-Wa
Mini plate systems Kruskal-Wallis Test

Mini plateMini
systems Mini Mini
plate plate
plate systems systems
systems Kruska
Kruskal-Wallis Test
Kruskal-Wallis Test K
Mini plate systems Kruskal-Wallis T

χ2
Group 4 (L χ2 p
shape) Group 6
Group 1 (straight, 2 Group 2 (straight, 4 χ2 p
Group 4 (L Group 5 (double -Y shape) χ2
holes) Group 4Group
(L 4 (L
Group 1 (straight, 2
holes)
Group 4 (L shape) (Y shape) Group 6 χ2
Group 6 χ 2
p
Group 2 (straight, 4 shape) Group 6
Group 1Group
(straight,
Group 2 1 Group
1 (straight, 2 Group
2Group 22 (straight,
(straight, 4 Group
Group 3 6 Group
3 4(straight, Group 4 (L
4 Groupshape)
Group 55 (double
Group
Group
Group
-Y shape)
66 5Group (double (double
-Y shape)
holes) holes) shape) Group5 6 -Y shape)
(L shape) (Y shape)
Group 1 (straight, 2GroupGroup 2 (straight,
1 (straight, 4(straight,
2 holes)Group
(straight, (straight,
2 (straight, 4 holes) holes) holes)
holes) shape) Group 5
(Y shape) (double -
(double(Y-Yshape)
shape)
2 holes) 4 holes)
Group 3 6 holes)
(straight, 6 Group 5 Y shape) (Y shape)
(double -Y shape)
holes) holes)holes) holes) Group 3Group
(straight, 6 (Y shape) (Y
Number 5 5 holes)
5 3 (straight,
5 6 5 shape) 5
Number 5 Group 3 (straight, 6
5 Group 5 6 holes) holes)
3 (straight, 5 5 5
Number 5 5 holes) 5 5 5 5
holes)
Number
Mean force Mean force0.09
(kN)Number (kN)5 5
0.09
0.17 5 0.17
5 0.28 0.28
5 5
0.09
0.09 5 5
0.290.29 5 0.37
5 0.37 5 5
Mean 5 (kN)
umberforce 50.09 5Deviation
Standard 5
0.17 5 5
0.28 5 0.09 5 5 0.29 5 5 0.37 5
0.02 0.02 0.01 0.01 0.03 0.02
Mean
Standard of
force
Deviation the
(kN)
of theforce
Mean force (kN) (kN)
0.02 0.09 0.09 0.02 0.17 0.17 0.01 0.28 0.28 0.01 0.09 0.09 0.03 0.29 0.29 0.02 0.37
26.98 <0.001
0.37
Mean force
force (kN) of the
(kN) 0.09force 0.170.09 0.28 0.09 0.28 0.01 0.09 0.08 0.03 0.29
Standard Deviation
0.09 Median0.02 0.17 (kN) 0.02 0.28 0.01
0.17 0.29 0.30 0.37 0.37 0.37
0.02
force (kN) Standard Deviation of the 26.98 <0
Standard Deviation of 0.02
the 0.02 0.02 0.02 0.01 0.01 0.01 0.01 0.03 0.03 0.02 0.02
Minimum force (kN) 0.08 0.15 0.26 0.07 0.24 0.34 26.98 <0.001
Median
tandard force
Deviation (kN)
forceof
(kN)
the (kN)
force 0.09
0.02 0.02 0.02 0.17 0.01 0.28 0.08
0.01 0.03 0.03 0.300.02 0.02 0.37
he 0.02 0.01 0.01
Median Maximum force (kN) 0.11 0.20 0.29 0.10 0.32 0.40 26.98
orce (kN)force (kN) 0.09 0.17 0.28 0.08 0.30 0.37 26.98
Median
Minimum force
(kN) (kN)
forceMedian 0.08 0.09 0.15 0.17 0.26 0.28 0.07 0.08 0.30 0.37 26.98 <0.001
force (kN) 0.09 0.17 0.28 0.08 0.24 0.30 0.34 26.98 0.37 <0.001
Minimum force (kN) 0.08 0.15 0.26 0.07 0.24 0.34
Median force (kN) 0.09 0.17 0.28 0.08 0.30 0.37
0.09 0.17 0.28 0.08 0.30 0.37
Minimum
Maximum force (kN)
forceMinimum
(kN) (kN) 0.08
force0.11 0.08 0.20 0.15 0.15 0.29 0.26 0.26 0.10 0.07 0.07 0.32 0.24 0.24 0.40 0.34 0.34
Maximum force (kN) 0.11 0.20 0.29 0.10 0.32 0.40
Minimum force (kN) 0.08 0.15 0.26 0.07 0.24 0.34
 Dent Mater J 2014; 33(3): 368–372
Therefore, the present study focused on evaluating
the biomechanical stability characteristics of titanium
miniplates of varied shapes instead of evaluating rigid
fixation methods. The six types of miniplate systems
were thus selected for this study because of the
frequency of their use, based on our clinical experience
and retrospective analysis of our cases. To ensure that
only the biomechanical properties of the miniplates were
purely tested in this study, only one miniplate fixation
technique was used.
Mandibular corpus is one of the most frequently
fractured sites after a traumatic event. Miniplate with
screw fixation is reportedly a standard approach in
managing mandibular fractures. In a report by Ellis14),
other examples of rigid internal fixation include locking/
non-locking reconstruction bone plates, multiple bone
plates of the fracture site, single non-reconstruction
bone plates, or multiple lag screws14). He stressed that
anything less than rigid was non-rigid, and that these
approaches provided sufficient strength to prevent
fragmentary motion during function and allowed
primary osseous union to proceed14).
In the original Champy technique, the use of a single
stainless steel miniplate (1 mm thick) for the fixation
of mandibular fractures was reportedly sufficient and
accepted as rigid9). Arbag et al. also reported that one
titanium miniplate (1 mm thick) positioned inferiorly
provided good stability8). Nonetheless, in a two-miniplate
fixation technique, where the first plate was positioned
in the superior border as far as possible and the second
plate in the inferior border, improved stability was
obtained because of neutralized torsional forces at
the fracture site and primary intraoperative anatomic
alignment was achieved8).
Obviously, a two-plate technique is better if there is
adequate bony substance on either side of the fracture
line15). However, fixation with two miniplates might be
a more traumatic procedure than fixation with a single
miniplate16,17). Ellis and Walker reported that the single
miniplate is the simplest and most reliable technique18).
To the best of our knowledge, this is the first study which
compared the biomechanical properties of six different
types of miniplates via a 3-point biomechanical test
frame, whereby fractured segments were fixated with
one miniplate at each fracture region in the mandibular
body.
The universal test machine used in this study
recorded resistance force against the applied load until
loss of the integrity of bone-screw-plate system occurred.
Maximum load was defined as the highest load recorded
just before any sudden decrease in load level occurred.
Decrease in resistance force could be caused by plastic
deformation and/or fracture of the miniplates and screws
together with the increasing distance of the fractured
segments.
Our results revealed that single and double
Y-shaped plates demonstrated the highest biomechanical
stability and provided significantly greater resistance
to displacement than the other types of miniplates
evaluated in this study. Y-shaped miniplates allow
371
larger area coverage with more holes and screws, and
this advantage provides the effect of double miniplates
through a single construct. Additionally, Y-shaped
miniplates prevent the rotational movements of
immobilized fractured segments.
Our results also showed that single straight
miniplate with double holes and single L-shaped
miniplate presented the lowest biomechanical stability
when compared with the other single miniplates.
In a report by Matsushita et al.19), the combined use
of a straight plate with a L-shaped plate presented
significantly increased resistance force and improved
rigidity19). Our results could not be compared with their
study results19) because the design and methodology of
the two studies were different from each other.
In the present study, the miniplates tested could not
be discussed according to their number of holes because
of different shape types. Nonetheless, Group 2 (straight,
4 holes, 9.0 mm spacing) and Group 3 (straight, 6 holes,
9.0 mm spacing) could be compared with respect to the
number of holes as they were of the same plate shape
with the same spacing between the holes (9 mm).
The higher mean resistance score of Group 3 (p<0.05)
indicated higher biomechanical stability than Group
2, which was an expected outcome because of a higher
number of holes.
In the present study, resistance force was recorded
and load was applied at a point 1 cm distally to the
fracture line of the mandible. This location was selected
for two-fold reasons: it was far enough from the dentate
region of the mandible and that loading should not be
located within the fracture zone.
Various methods have been used in previous studies
to evaluate the biomechanical stability characteristics
of titanium miniplates in vitro through the fixation
of fractured mandibles. The wide variety of methods
ranged from using different types of bone specimens,
such as human cadaveric mandibles, animal mandibles
(sheep, bovine, rabbit, etc.), bovine and porcine ribs,
to artificial bone models (Synbone, Sawbones) and
evaluation by finite element analysis. Bredbenner and
Haug reported that different bone substitute materials
behaved differently from human cadaveric bone in
maxillofacial studies20). Using the bovine mandible
instead of human mandible seemed to be a limitation of
the present study.
Ideally, bone substitute materials should also
alleviate concerns involving economic, ethical and health
considerations associated with the use of cadaveric
tissue. On the other hand, Alkan et al. claimed that
fresh animal mandibles were the material of choice for
this type of biomechanical studies as human cadavers
may have natural variations that affect outcomes, and
formalin fixation alters the physical properties of the
human bone16). Fresh bovine mandibles were chosen for
this study because they were easy to obtain and their
use circumvented the aforementioned limitations and
problems. In the present study, the bovine mandibles
used had no effect on the biomechanical properties of the
six types of miniplates under evaluation.
372 Dent Mater J 2014; 33(3): 368–372
Functions such as mastication, phonation, and
deglutition could not be replicated on the custom-made
3-point biomechanical test frame. In the present study,
another limitation was the inability to evaluate the
interactions at bone/plate/material interface and the
specific behaviors of the reconstructed human mandible
during the performance of these normal functions.
In the present study, the osteotomy mimicking the
fracture line was located in the corpus, in the edentulous
area in front of the first premolar tooth at a distance of
10 mm mesially. The location of the osteotomy line had
no significance because the aim was to investigate the
biomechanical properties of different miniplate designs
at the same osteotomy line. Therefore, this region was
chosen because of the ease of accessibility and monitoring
during in vitro experimental procedures.
CONCLUSION
Double Y-shaped miniplate with 6 holes and 9.0 mm
spacing had greater resistance to displacement and
provided more favorable biomechanical behavior
than the other five types of miniplates in the repair of
mandibular body fractures.
ACKNOWLEDGMENTS
This study was supported by Tasarımmed, Istanbul,
Turkey and Elektron Medikal, Istanbul, Turkey.
REFERENCES
1) Gassner R, Tuli T, Hachl O, Rudisch A, Ulmer H. Cranio-
maxillofacial trauma: a 10 year review of 9,543 cases with
21,067 injuries. J Craniomaxillofac Surg 2003; 31: 51-61.
2) Ortakoğlu K, Gunaydın Y, Aydintug YS, Bayar GR. An
analysis of maxillofacial fractures: a 5-years survey of 157
patients. Mil Med 2004; 169: 723-727.
3) Shetty V, Atchison K, Der-Martirosian C, Wang J, Belin TR.
Determinants of surgical decisions about mandible fractures.
J Oral Maxillofac Surg 2003; 61: 808-813.
4) Chu L, Gussack GS, Muller T. A treatment protocol for
mandible fractures. J Trauma 1994; 36: 48-52.
5) Ellis E 3rd, Muniz O, Anand K. Treatment considerations for
comminuted mandibular fractures. J Oral Maxillofac Surg
2003; 61: 861-870.
6) Maurer P, Holweg S, Knoll WD, Schubert J. Study by
finite element method of the mechanical stress of selected
biodegradable osteosynthesis screws in sagittal ramus
osteotomy. Br J Oral Maxillofac Surg 2002; 40: 76-83.
7) Mathog RH, Toma V, Clayman L, Wolf S. Nonunion of
the mandible: an analysis of contributing factors. J Oral
Maxillofac Surg 2000; 58: 746-752.
8) Arbag H, Korkmaz HH, Ozturk K, Uyar Y. Comparative
evaluation of different miniplates for internal fixation of
mandible fractures using finite element analysis. J Oral
Maxillofac Surg 2008; 66: 1225-1232.
9) Champy M, Loddé JP, Schmitt R, Jaeger JH, Muster D.
Mandibular osteosynthesis by miniature screwed plates via
a buccal approach. J Maxillofac Surg 1978; 6: 14-21.
10) Armstrong JE, Lapointe HJ, Hogg NJV, Kwok AD.
Preliminary investigation of the biomechanics of internal
fixation of sagittal split osteotomies with miniplates using a
newly designed in vitro testing model. J Oral Maxillofac Surg
2001; 59: 191-195.
11) Schneider M, Stadlinger B, Loukota R, Eckelt U. Three-
dimensional fixation of fractures of the mandibular condyle
with a resorbable three-dimensional osteosynthesis mesh. Br
J Oral Maxillofac Surg 2012; 50: 470-473.
12) Pilling E, Mai R, Theissig F, Stadlinger B, Loukota R,
Eckelt U. An experimental in vivo analysis of the resorption
to ultrasound activated pins (Sonic weld) and standard
biodegradable screws (ResorbX) in sheep. Br J Oral Maxillofac
Surg 2007; 45: 447-450.
13) Pilling E, Eckelt U, Loukota R, Schneider K, Stadlinger
B. Comparative evaluation of ten different condylar base
fracture osteosynthesis techniques. Br J Oral Maxillofac Surg
2010; 48: 527-531.
14) Ellis E 3rd. Open reduction and internal fixation of combined
angle and body/symphysis fractures of the mandible: how
much fixation is enough? J Oral Maxillofac Surg 2013; 71:
726-733.
15) Alpert B. Clinical evaluation of 3 types of plate osteosynthesis
for fixation of condylar neck fractures. J Oral Maxillofac Surg
2001; 59: 738.
16) Alkan A, Metin M, Muğlali M, Ozden B, Celebi N.
Biomechanical comparison of plating techniques for fractures
of the mandibular condyle. Br J Oral Maxillofac Surg 2007;
45: 145-149.
17) Choi BH, Yi CK, Yoo JH. Clinical evaluation of 3 types of
plate osteosynthesis for fixation of condylar neck fractures. J
Oral Maxillofac Surg 2001; 59: 734-737.
18) Ellis E 3rd, Walker LR. Treatment of mandibular angle
fractures using one noncompression miniplate. J Oral
Maxillofac Surg 1996; 54: 864-871.
19) Matsushita K, Inoue N, Totsuka Y. In vitro biomechanical
evaluation of the effect of an additional L-shaped plate on
straight or box plate fixation in sagittal split ramus osteotomy
using a bioabsorbable plate system. Oral Maxillofac Surg
2011; 15: 139-146.
20) Bredbenner TL, Haug RH. Substitutes for human cadaveric
bone in maxillofacial rigid fixation research. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 2000; 90: 574-580.