Biomechanical comparison of different plating techniques in repair of mandibular angle fractures

Alper Alkan, DDS, PhD,a Nkhet elebi, DDS,b Bora zden, DDS, PhD,c Burcu Bas , DDS,b b and Samet Inal, DDS, Kayseri and Samsun, Turkey
ERCIYES UNIVERSITY AND ONDOKUZ MAYIS UNIVERSITY

Objective. The purpose of this study was to evaluate the biomechanical behaviors of different miniplate xation techniques for treatment of fractures of the mandibular angle. Study design. Twenty sheep hemimandibles were used to evaluate 4 different plating techniques. The groups were xated with Champy technique, biplanar plate placement, monoplanar plate placement, and 3-dimensional (3D) curved angle strut plate. A custom-made 3-point biomechanical test model was used for the samples. Each group was tested with compression forces by an Instron Lloyd LRX machine. The biomechanical behavior of the groups for the forces (N) that caused displacement of 1.75 mm were compared using the Instron software program and displacement graphics. Results. The variance analyses showed that biplanar plate placement had more favorable biomechanical behavior than Champy technique and monoplanar plate placement (P .05). In addition, the 3D curved angle strut plate technique had more favorable biomechanical behavior than the Champy technique (P .05) but was not signicantly different from biplanar or monoplanar plate placement techniques (P .05). Conclusion. The study demonstrated that 3D strut plates or dual miniplate techniques had greater resistance to compression loads than the Champy technique. In addition, biplanar plate orientation may provide a more favorable biomechanical behavior than monoplanar plate placement. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:752-6)

The angle is one of the most frequent fractured sites after traumatic events involving the mandible.1 The optimal treatment of angle fractures remains controversial.2 Apart from conservative measures, several surgical methods may be applied to treat mandibular fractures.3 Current trends use a variety and combination of transorally placed small plates secured with monocortical screws for the xation of angle fractures.4 Miniplate osteosynthesis allows early exercise and has the advantage of using plates that are easy to adapt.5 It is a standard treatment for fractures of the mandibular angle. The purpose of the present study was to evaluate the biomechanical behavior of 4 different types of rigid xation systems with miniplates that are used currently to reconstruct mandibular angle fractures.

Associate Professor, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Erciyes University. b Research Assistant, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ondokuz Mays University. c Assistant Professor, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ondokuz Mays University. Received for publication Jan 3, 2007; returned for revision Jan 27, 2007; accepted for publication Mar 17, 2007. 1079-2104/$ - see front matter 2007 Mosby, Inc. All rights reserved. doi:10.1016/j.tripleo.2007.03.014

MATERIALS AND METHODS Twenty hemimandibles taken from similar sheep (mean weight 40 kg, fed on the same diet, collected from the same abattoir, and slaughtered similarly) were used in this investigation. The mandibles were stripped of their soft tissues and divided in the anterior midline between the central incisors. The specimens were kept moist and refrigerated until all testing was complete. Because of the difculty in placing the mandibles in the biomechanical experimental test jig, all coronoid processes were removed. The models were sectioned in a uniform manner with a saw from the retromolar region on a line that connected to the angle of the mandible. The hemimandibles were randomly divided into 4 groups of 5 and xated with 4 different plating techniques (Figs. 1-4; Table I). Titanium 4-hole noncompression miniplates (Electron Medical, Trimed, Turkey) were used in groups 1, 2, and 3. To minimize the variables in this investigation, all the screws were 5 mm in length, fabricated titanium, and self-tapping. The fractured segments were all repositioned. Miniplates and screws were situated in the proper position, and rigid xation was noted in all groups. The plates were adapted with pliers and screwed in with a screwdriver. The fragments were stabilized manually during these stages. A custom-made 3-point biomechanical test model which was used in our previous biomechanical

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Fig. 1. Reconstruction with Champy technique. Fig. 3. Reconstruction with monoplanar plate placement.

screw-plate system). The Instron equipment recorded force versus displacement. A 1.75 mm displacement point was dened as the end point, and the loads that created this magnitude of displacement were measured on the displacement graphics. One-way analysis of variance was used to test the hypothesis that means were equal when comparing the 4 different plating techniques in terms of noncategoric scale variables. Once it was determined that differences existed among the means, pair-wise multiple comparisons were made using the Duncan multiple range test. RESULTS Twenty hemimandibles were analyzed in this experiment, with 5 in each group. Standardization of all experimental factors except the xation techniques was ensured. No miniplate xation system or hemimandible failures (breakage or fracture) were observed within the 0 to 700 N test range. The mean loads that created 1.75 mm displacement are shown in Table II. Pair-wise multiple comparisons are shown in Table III. The variance analyses showed that biplanar plate placement had more favorable biomechanical behavior than the Champy technique and monoplanar plate placement (P .05). In addition, the 3D curved angle strut plate technique had more favorable biomechanical behavior than the Champy technique (P .05), whereas it was not signicantly different from biplanar or monoplanar plate placement techniques (P .05).

Fig. 2. Reconstruction with biplanar plate placement.

studies6,7 was adapted to an Instron Lloyd LRX machine, and the samples were xed from the mandibular condyle and incisor regions (Fig. 5). The mandibles were then loaded at the mandibular angle with a compression force (N) that simulated masticatory loads, ranging from 0 to 700 N. The experimental end point was dened as failure (loss of integrity of the bone-

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Fig. 5. Custom-made 3-point biomechanical test model.

Table II. Some descriptive statistics of the groups (N)

Group 1 2 3 4 Mean (N) 55.55 188.89 81.61 155.55 SD 22.68 80.08 30.95 74.77 SE 10.14 35.79 13.84 33.44 Min. 37.037 92.59 55.55 74.074 Max. 92.59 277.77 277.77 277.77

Fig. 4. Reconstruction with 3-dimensional curved angle strut plate.

SD, standard deviation; SE, standard error.

Table I. Fixation techniques

Group 1 Fixation techniques Champy technique (a single miniplate placed just above the external superior oblique line) Biplanar plate placement (plates positioned in 2 planes) Monoplanar plate placement (plates positioned in 1 plane) 3-dimensional curved angle strut plate (Mondeal Medical Systems, Tuttlingen, Germany)

Table III. Pair-wise multiple comparisons of the mean loads of the groups
Group 1 2 3 4 Load (N) 55.55a 188.89c 81.61ab 155.55bc

2 3 4

Pair-wise multiple comparisons of the mean loads of the groups at 1.75 mm displacement. Groups with different superscriptsabc are different from each other.

DISCUSSION Internal rigid xation alleviates the need for protracted periods of xation and are associated with few complications and compliance problems.8 The evolution of internal xation was aided by the discovery of biocompatible materials that resisted corrosion, such as vitallium and titanium. Currently, titanium is the metal of choice for xation plates, mainly because of its high biocompability, ease of manipulation, and the potential for no second surgery.9 Titanium miniplates provide rigid xation for mandibular fractures. They can be easily adapted to the bone curvature and require only a simple surgical procedure. Although a spectrum of

techniques for treatment of angle fractures with miniplates has been proposed in the literature, no consensus exists as to the optimal miniplate xation modality. Using a 3-point loading model and animal sourced hemimandibles, the present investigation evaluated 4 different miniplate techniques that are most commonly used by maxillofacial surgeons. Because of similarities in size and thickness to human mandibles, we used fresh sheep mandibles. In a series of biomechanical studies on mandibular fractures, Haug et al.10,11,12 used polyurethane mandibles which replicate cancellous bone, have a dense outer core that replicates cortical bone, and are able to provide more uniform sampling.

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However, complex mandibular anatomy and the thickness of cortical bone in animal mandibles play a part in the strength of any xation techniques. Fresh sheep hemimandibles are easy to obtain for the investigation of biomechanics of the many and varied xation systems. They have previously been used for biomechanical research.13,14 Our choice of jig and method of loading were used in our previous biomechanical studies of plating techniques for fractures of the mandibular condyle6 and designed to replicate three main forces that act on the mandible in function. The adult human man may generate between 300 and 400 N maximal bite force.15 This magnitude is reduced when a fracture has occurred in the masticatory system.16 For this reason, when attempting to evaluate the biomechanics of various xation techniques, it is important to consider clinically relevant parameters to provide meaningful information to the clinician. In the literature, there are only a few investigations that evaluate the bite forces of the postsurgical population.16-19 Ellis et al.17-19 found that the bite forces in the acute postoperative period of the patients treated for mandibular angle fractures and orthognathic surgery patients are much less than it is recorded later in the postoperative period or in the nonoperated population. Based on the studies of bite force in postoperative patients, Haug et al.10 postulated that meaningful mechanical behaviour would be obtained within the ranges of 0 to 100 N range for incisal edge loading and 0 to 200 N for contralateral molar loading, in their biomechanical evaluation of mandibular angle fracture plating techniques with synthetic polyurethane replica mandibles. In the present study, we considered the loads up to 300 N, so a 1.75 mm displacement point was used as the end point. This end point was also used in our previous biomechanical study of plating techniques for fractures of the mandibular condyle.6 Champy recommended a single noncompression miniplate ventral to the oblique line for mandibular angle fractures.20 Some clinical studies conrmed the effectiveness of the Champy thechnique.21-23 In a clinical study, Ellis et al.22 evaluated the results in patients treated for fractures of the mandibular angle with a single miniplate. They concluded that using a single miniplate is a simple and reliable technique with a relatively small number of major complications. Although this technique has been documented with low complication rates by numerous authors,21-23 it leads to an opening of the lower fracture line, lateral displacement of the fragments at the inferior mandibular border, and a posterior open bite on the fracture side.24 In addition, this distraction gap can also contribute to infection.5 The present biomechanical study showed that Champy technique had less favorable biomechani-

cal behavior than biplanar plate placement and 3D curved angle strut plate. The need for a second miniplate to be applied to the lower border of the mandible has been discussed recently.21,25 This method is used to achieve a good anatomic repositioning and stable xation of the fracture, in which one plate is applied at the superior border and a second at the inferior border of the mandible. It reduces the separation of the fracture line and lateral displacement of the lower mandibular border.24 All biomechanical tests in which a second miniplate has been xed to the mandibular margin revealed less mobile fracture ends.21,26,27 In the present study, in accordance with the literature, biplanar plate orientation provided greater biomechanical stability than the monoplanar one. Although 2-miniplate xation of mandibular angle fractures had more biomechanical advantages in the present study, extremely high complication rates are reported in the literature.27 When using an intraoral approach, 2-miniplate xation technique necessitates reection of all soft tissues from the mandible, increasing intraoperative trauma. When using an extraoral approach to place the second miniplate on the inferior border, it increases the risk of bacterial contamination, scarring, postoperative edema, hematoma, and marginal mandibular nerve demage. In addition, 2-miniplate xation prolongs the operation time. Although the second and third groups were both xated with dual miniplates in our study, biplanar plate orientation provided greater biomechanical stability than the monoplanar one. This difference may arise from the location of the superior miniplate, which was settled above the superior oblique ridge. It was previously reported that plate placement in biplanar orientation is superior to monoplanar plate placement when applied to either a monocortical or a bicortical plating technique.15 Additionally, it is conrmed in the literature that greater biomechanical stability is obtained with a miniplate placed obliquely than horizontally.7 In a previous biomechanical study of comparing several xation methods used in sagittal split osteotomy,7 we found that the miniplate xed obliquely with 2 bicortical screws in the proximal segment provided the most biomechanical stability of the miniplate groups. Our ndings were in accordance with the literature. The 3D strut plate is a single plate composed of 2 curved miniplates buttressed with perpendicular strut bars.8 Its geometry allows an increased number of screws, stability in 3 dimensions, and malleability.4 Strut plates provide increased torsional stability, so it is typically used for symphyseal fractures, which are under a greater degree of torsional strain than the other areas of mandible.2 Feledy et al.8 examinated the utility

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10. Haug RH, Fattahi TT, Goltz M. A biomechanical evaluation of mandibular angle fracture plating techniques. J Oral Maxillofac Surg 2001;59:1199-210. 11. Haug RH, Street CC, Goltz M. Does plate adaptation affect stability? A biomechanical comparison of locking and nonlocking plates. J Oral Maxillofac Surg 2002;60:1319-26. 12. Haug RH, Peterson GP, Goltz M. A biomechanical evaluation of mandibular condyle fracture plating techniques. J Oral Maxillofac Surg 2002;60:73-80. 13. Dolanmaz D, Uckan S, Isik K, Saglam H. Comparison of stability of absorbable and titanium plate and screw xation for sagittal split ramus osteotomy. Br J Oral Maxillofac Surg 2004; 42:127-32. 14. Foley WL, Beckman TW. In vitro comparison of screw versus plate xation in the sagittal split osteotomy. Int J Adult Orthodont Orthognath Surg 1992;7:147-51. 15. Fedok FG, Van Kooten DW, DeJoseph LM, McGinn JD, Sobota B, Levin RJ, et al. Plating techniques and plate orientation in repair of mandibular angle fractures: an in vitro study. Laryngoscope 1998;108:1218-24. 16. Ellis E, Throckmorton GS. Bite forces after open or closed treatment of mandibular condylar process fractures. J Oral Maxillofac Surg 2001;59:389-95. 17. Throckmorton GS, Bushang PH, Ellis E. Improvement of maximum occlusal forces after orthognathic surgery. J Oral Maxillofac Surg 1996;54:1080-6. 18. Tate GS, Ellis E, Throckmorton GS. Bite forces in patients treated for mandibular angle fractures. J Oral Maxillofac Surg 1994;52:734-6. 19. Ellis E, Throckmorton GS, Sinn DP. Bite forces before and after surgical correction of mandibular prognathism. J Oral Maxillofac Surg 1996;54:176-81. 20. Champy M, Lodde JP. Mandibular synthesis. Placement of the synthesis as a function of mandibular stress. Rev Stomatol Chir Maxillofac 1976;77:971-6. 21. Schierle HP, Schmelzeisen R, Rahn B, Pytlik C. One- or twoplate xation of mandibular angle fractures? J Craniomaxillofac Surg 1997;25:162-8. 22. Ellis E 3rd, Walker LR. Treatment of mandibular angle fractures using one noncompression miniplate. J Oral Maxillofac Surg 1996;54:864-71. 23. Potter J, Ellis E 3rd. Treatment of mandibular angle fractures with a malleable noncompression miniplate. J Oral Maxillofac Surg 1999;57:288-92; discussion 292-3. 24. Choi BH, Suh CH. Technique for applying 2 miniplates for treatment of mandibular angle fractures. J Oral Maxillofac Surg 2001;59:353-4. 25. Choi BH, Yoo JH, Kim KN, Kang HS. Stability testing of a two miniplate xation technique for mandibular angle fractures. An in vitro study. J Craniomaxillofac Surg 1995;23:123-5. 26. Dichard A, Klotch DW. Testing biomechanical strength of repairs for the mandibular angle fracture. Laryngoscope 1994; 104:201-8. 27. Ellis E 3rd, Walker L. Treatment of mandibular angle fractures using two noncompression miniplates. Int J Oral Maxillofac Surg 1994;52:1032-36. Reprint requests: Dr. Nukhet Celebi Dis Hekimligi Fakultesi Ondokuz Mayis Universitesi 55139, Kurupelit, Samsun Turkey nukh@hotmail.com

of a single 2.0-mm matrix miniplate for mandibular angle fracture management clinically and compared the stability of it with 2 2.0-mm miniplates in a simulated fracture setting. The matrix miniplate demonstrated a better stability and more resistance to fracture movement. Clinically, in a series of 22 consecutive patients, they found no cases of nonunion, malunion, or plate failure. They also recommended that the matrix miniplate provided sufcient stability for fracture healing.8 Guimond et al.4 also conrmed advantages of these plates in mandibular angle fractures. In the present investigation, we found that 3D curved angle strut plate technique had more favorable biomechanical behavior than the Champy technique. On the other hand, no signicant differences were found biomechanically between 3D strut plate and dual miniplate xation techniques. The present study demonstrated that 3D strut plates or dual miniplate techniques had greater resistance to compression loads than the Champy technique, statistically. In addition, biplanar plate orientation may provide a more favorable biomechanical behavior than monoplanar plate placement.
The authors thank Assoc. Prof. Dr. Vedat Ceyhan from the Department of Agricultural Economics, Ondokuz Mayis University, for his help with statistical analysis. REFERENCES
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