Biomechanical evaluation of locking versus nonlocking 2.0-mm malleable L-miniplate fixation of simulated caudal mandibular fractures in cats.

OBJECTIVE: To evaluate the biomechanical properties of the mandibles of cats with experimentally created osteotomies simulating oblique ramus fractures, which were stabilized with malleable L-miniplates with either locking screws [locking construct (LC)] or nonlocking screws [nonlocking construct (NLC)], compared with those for intact mandibles. SAMPLES: 20 mandibles from 10 adult cat cadavers. PROCEDURES: A block study design was adopted to allocate the mandibles of each cadaver to 2 of the 3 test groups (LC, NLC, or intact mandible). Mandibles within each cadaver were allocated systematically to a test group. For mandibles assigned to an LC and an NLC, a complete oblique osteotomy was performed from the mid rostral aspect of the ramus in a caudoventral direction. All mandibles were loaded in a single-load-to-failure test through cantilever bending. Load and actuator displacement were recorded simultaneously. Mode of failure and radiographic evidence of damage to tooth roots and the mandibular canal were evaluated. Biomechanical properties were compared among the groups. RESULTS: No iatrogenic tooth root damage was evident, but all mandibles with an LC and an NLC had evidence of screw invasion into the mandibular canal. Plated mandibles had significantly less stiffness and bending moment than intact mandibles. Stiffness was not significantly different between the LC and the NLC; the NLC had a greater bending moment at failure than the LC. The pre-yield stiffness of plated mandibles decreased when the number of screw holes overlapping the mandibular canal increased. CLINICAL RELEVANCE: The use of a malleable L-miniplate in a caudal mandibular fracture model is feasible. Both the LC and the NLC were inferior mechanically to intact mandibles. Type of construct used did not affect the construct stiffness significantly in tested mandibles.

Finite element analysis of mini-plate stabilization of human mandible angle fracture - a comparative study.

PURPOSE: The purpose of this study was to analyze three patterns of mandible angle fracture treatment by means of the finite element analysis. METHODS: Investigation has been based on the mandible geometry reconstructed with use of hospitalized patient CT data. The KLS Martin mini-plates with corresponding screws were used to establish proper fracture stabilization. Models were run assuming isotropic and elasto-plastic material properties of connecting devices and cortical bone. The main masticatory muscles and artificial temporomandibular joint have been incorporated to assure mandible physiological movement. The gage loading has been applied in three different locations to cover wider range of possible mastication loading cases during daily routine. A different contact conditions have been applied to the fracture plane to simulate both load bearing and sharing behaviors. Prepared FEM models reflect the most frequently used surgery's approaches to mandible angle fracture treatment. A specific nomenclature has been introduced to describe particular model. The tension plate, with one connecting mini-plate, two-point fixation and combined fixation, both using two mini-plates respectively. RESULTS: Performed analysis allowed for a detailed estimation of the mini-plate connection response under the applied gauge loading. The equivalent stress within the mini-plates and surrounding cortical bone have been compared between all models. Regarding the fracture plane, the contact status and pressure have been considered. CONCLUSIONS: The combined fixation model, acting as a biplanar fastener system, presents the highest flexibility and connection efficiency.

Treatment of mandibular angle fracture: Revision of the basic principles.

Biodynamics of mandibular angle fractures has been extensively discussed in the literature in search for the best way to fixate and expedite recovery of trauma patients. Pioneers like Michelet and Champy had the greatest impact on evolving of osteosynthesis in maxillofacial traumatology; they introduced their basic principles frequently used to describe the biomechanics of mandibular fixation. Their concept states when a physiologic load is applied on mandibular teeth a negative tension will be created at superior border and a positive pressure will appear at inferior border. These simple definitions are the basis for the advent of fixation modalities in mandibular angle fracture. This article sought to reassess these principals based on load location via finite elements method.

Does the Length of Dental Implants Inserted in Areas of Inferior Alveolar Nerve Lateralization Interfere on Mandibular Resistance to Fracture?

The aim of this study was to compare, in vitro, the mechanical resistance to vertical displacement of the mandible after osteotomy for lateralization of the inferior alveolar nerve and installation of dental implants. One hundred eighty polyurethane mandibles were equally divided into 6 groups: G1-intact hemi-mandibles (control group), G2-hemi-mandibles after osteotomy for lateralization of the inferior alveolar nerve, G3-hemi-mandibles with installation of 3 bicortical dental implants (3.75 × 13 mm), G4-hemi-mandibles with installation of 3 dental implants that did not reach the basal cortical bone (3.75 × 11 mm), G5-hemi-mandibles after osteotomy for lateralization of the inferior alveolar nerve and installation of 3 bicortical dental implants (3.75 × 13 mm) and G6-hemi-mandibles after osteotomy for lateralization of the inferior alveolar nerve and installation of 3 dental implants that did not reach the basal cortical bone (3.75 × 11 mm). The specimens were subjected to linear loading tests. The highest mean value of maximum load was found in G1 (412.36N ±â€Š11.99), followed by G2 (396.87N ±â€Š23.94), G3 (319.63N ±â€Š57.28), G4 (303.34N ±â€Š18.25), G5 (231.75N ±â€Š63.64) and G6 (228.13N ±â€Š20.75). Based on this data, it can be concluded that the bicorticalization (or not) of the implants was not a statistically significant risk factor for the vertical displacement of polyurethane hemi-mandibles.

Comparison of two incisions for open reduction and internal fixation of mandibular body fractures: A randomised controlled clinical trial evaluating the surgical outcome.

PURPOSE: The purpose of the study is to compare the surgical access and post-operative outcome of two intra-oral incisions used for approaching a mandibular body fracture. METHODS: This clinical trial involved 60 patients with mandibular body fractures who were randomly allocated to control and study groups. The fractures were approached using the routine vestibular incision in the control group and crevicular incision with vertical release in the study group. The effects of incision design on the post-surgical outcome variables like swelling, trismus, paresthesia, wound healing and gingival recession were statistically analysed with non-parametric tests by using SPSS 22.0 software. Comparison of continuous variables between the groups and time points was done using Mann Whitney test and Friedman test respectively. Chi-square test was used to compare proportions between groups. Dunn's test with Bonferroni correction was used for pair wise comparisons. RESULTS: The study group demonstrated favourable surgical outcome in the immediate postoperative phase as compared to the control group. The difference in mouth opening, swelling and neurosensory impairment between the two groups was found to be statistically significant (p < 0.05). CONCLUSION: Crevicular incision was found to be an ideal alternative to vestibular incision in achieving surgical access and fixation of mandibular body fractures with reduction in postoperative patient discomfort and better surgical outcome.

Is masticatory performance affected after a unilateral condylar fracture? A cross-sectional study.

BACKGROUND: Mandibular fractures, especially condylar fractures, are one of the most common facial fractures. Trauma to this region could possibly compromise masticatory performance, which is a vital function for humans. OBJECTIVE: To objectively determine masticatory performance (Mixing Ability Test; MAT) in patients treated for a unilateral condylar fracture, thereby comparing patients in open and closed treatment groups, and assessing whether there is a positive relationship between this performance and subjective mandibular function (Mandibular Functional Impairment Questionnaire; MFIQ). METHODS: Fifty-eight patients were enrolled in a cross-sectional study and examined on an additional appointment at least 1 year after trauma, during which the patients performed the MAT and completed the MFIQ. The Spearman test was used to assess the correlation between the Mixing Ability Index (MAI) and the MFIQ score. A linear regression was used to explore the effects of different factors on the MAI. RESULTS: The correlation between objective masticatory performance and the subjective mandibular function was positive (r = 0.250; P = 0.033). Better masticatory performance was observed in patients who were male, received physiotherapy, had no other mandibular fractures and/or had satisfactory self-perceived occlusion. No significant difference in the MAI was found between the open and closed treatment groups. CONCLUSION: Independent of the chosen treatment, at least 1 year after treatment, individuals who experienced a unilateral fracture of the mandibular condyle exhibit masticatory capacity comparable with that of individuals who have not suffered such injuries.

Clinical outcomes in the treatment of unilateral condylar fractures: a cross-sectional study.

The treatment of mandibular condyle fractures has been the subject of considerable discussion, especially whether open or closed treatment should be used. There is a need for practical,evidence-based guidelines, and both objective and subjective parameters should be measured. To date, fewstudies have considered clinically relevant subjective parameters. This study was performed to evaluate the outcomes of the treatment of condylar fractures using the Mandibular Function Impairment Questionnaire (MFIQ) and the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) and to compare the outcomes of open and the closed treatment. Patients with condylar fractures and at least 1year of follow-up were examined. These patients completed the MFIQ and other questionnaires, and were examined according to the DC/TMD. Seventy-four of 171 eligible patients participated in this study. The mean MFIQ score was 10.70 (standard error 2.9) in the open group and 4.96 (standard error 1.3) in the closed group (P=0.023), an outcome in favour of the closed treatment group. Examination according to the DC/TMD did not reveal a significant prevalence of TMD complaints. Closed treatment appears to be a safe and appropriate modality for most unilateral condylar fractures. Although the open group in general showed similar outcomes, this treatment should be reserved for limited indications.

In vitro study of a modified sagittal split osteotomy fixation technique of the mandible: a mechanical test.

This study was performed to evaluate the compressive mechanical strength of rigid internal fixation (RIF) using 1.5-mm L-shaped plates fixed with monocortical screws in sagittal split osteotomy (SSO). Thirty synthetic hemimandibles, which had all undergone a 5-mm advancement, were divided into three groups: three 12-mm bicortical titanium screws were placed in an inverted L pattern in group A; one straight 2.0-mm system spaced titanium plate fixed with four 5-mm monocortical screws was used in group B; two 1.5-mm system L-shaped titanium plates, each fixed with four 5-mm monocortical screws, were used in group C. The models were subjected to compressive and progressive mechanical tests with forces applied in the area between the second premolar and first molar to verify resistance in Newtons (N). A displacement speed of 1mm/min was applied, with a maximum 10mm displacement of the distal segment or until disruption of the fixation. The deformity and/or eventual rupture of the plates were evaluated, and consequently their technical stability was determined. The results showed that the modified fixation technique tested in this study on synthetic mandibles resulted in adequate stability and superior mechanical behaviour compared to simulated osteosynthesis with the use of a straight 2.0-mm titanium plate.

A finite element analysis of the stress distribution to the mandible from impact forces with various orientations of third molars.

OBJECTIVE: To investigate the stress distribution to the mandible, with and without impacted third molars (IM3s) at various orientations, resulting from a 2000-Newton impact force either from the anterior midline or from the body of the mandible. MATERIALS AND METHODS: A 3D mandibular virtual model from a healthy dentate patient was created and the mechanical properties of the mandible were categorized to 9 levels based on the Hounsfield unit measured from computed tomography (CT) images. Von Mises stress distributions to the mandibular angle and condylar areas from static impact forces (Load I-front blow and Load II left blow) were evaluated using finite element analysis (FEA). Six groups with IM3 were included: full horizontal bony, full vertical bony, full 450 mesioangular bony, partial horizontal bony, partial vertical, and partial 450 mesioangular bony impaction, and a baseline group with no third molars. RESULTS: Von Mises stresses in the condyle and angle areas were higher for partially than for fully impacted third molars under both loading conditions, with partial horizontal IM3 showing the highest fracture risk. Stresses were higher on the contralateral than on the ipsilateral side. Under Load II, the angle area had the highest stress for various orientations of IM3s. The condylar region had the highest stress when IM3s were absent. CONCLUSIONS: High-impact forces are more likely to cause condylar rather than angular fracture when IM3s are missing. The risk of mandibular fracture is higher for partially than fully impacted third molars, with the angulation of impaction having little effect on facture risk.

Histopathological evaluation of the effect of locally administered strontium on healing time in mandibular fractures: An experimental study.

BACKGROUND: Mandibular fractures are the most common facial fractures. They can be treated by conservative techniques or by surgery. The authors hypothesized that the application of a single local dose of strontium chloride would accelerate the healing of subcondylar mandibular fractures, shorten the recovery time and prevent complications. OBJECTIVES: The aim of the present pilot study was to evaluate the effects of a single local dose of strontium chloride on the healing of subcondylar mandibular fractures in rats. MATERIAL AND METHODS: This randomized experimental study was carried out on 24 male Wistar albino rats. The rats were randomly divided into 3 groups: experimental group 1, receiving 3% strontium chloride; experimental group 2, receiving 5% strontium chloride; and the control group. A full thickness surgical osteotomy was created in the subcondylar area. A single dose of strontium solution (0.3 cc/site) was administered locally by injection on the bone surfaces of the fracture line created. Nothing was administered to the control group. The mandibles were dissected on postoperative day 21. The fractured hemimandibles were submitted to histopathological examination. RESULTS: The median bone fracture healing score was 9 (range: 7-9) in experimental group 1; 8 (range: 7-10) in experimental group 2; and 7.50 (range: 7-8) in the control group. When the groups were compared in terms of bone healing scores, there was a statistically significant difference between experimental group 1 and the control group (p < 0.05). CONCLUSIONS: This study is the first to show that local strontium may have positive effects on the healing of subcondylar mandibular fractures. In the authors' opinion, 3% strontium was beneficial for accelerating facial skeleton consolidation and bone regeneration in rat subcondylar mandibular fractures. This treatment procedure may be combined with closed fracture treatment or a conservative approach.

Dissection of the internal carotid artery and stroke after mandibular fractures: a case report and review of the literature.

BACKGROUND: We present a report of a patient with blunt trauma and mandibular fractures who developed a significant cerebral infarction due to an initially unrecognized injury of her left internal carotid artery. We believe that increased knowledge of this association will facilitate early recognition and hence prevention of a devastating outcome. CASE PRESENTATION: A 41-year-old ethnic Norwegian woman presented to our Emergency Room after a bicycle accident that had caused a direct blow to her chin. At admittance, her Glasgow Coma Scale was 15. Initial trauma computed tomography showed triple fractures of her mandible, but no further pathology. She was placed in our Intensive Care Unit awaiting open reduction of her mandibular fractures. During the following 9 hours, she showed recurrent episodes of confusion and a progressive right-sided hemiparesis. Repeated cerebral computed tomography revealed no further pathology compared to the initial scan. She had magnetic resonance angiography 17 hours after admittance, which showed dissection and thrombus formation in her left internal carotid artery, total occlusion of her left medial cerebral artery, and left middle cerebral artery infarction was detected. CONCLUSIONS: Carotid artery dissection is a rare but life-threatening condition that can develop after trauma to the head and neck. There should be a high index of suspicion in patients with a mechanism of injury that places the internal carotid artery at risk because blunt vascular injury may show delayed onset with no initial symptoms of vascular damage. By implementing an algorithm for early detection and treatment of these injuries, serious brain damage may be avoided.

An In Vitro Comparison Study of the Use of a Drill or a Saw in the Hunsuck-Dal Pont Modification of the Obwegeser Sagittal Split Osteotomy in Pig Mandibles.

PURPOSE: Fracture lines in unfavorable locations are referred to as "bad splits" in a mandibular sagittal split osteotomy (SSO). Several modifications of the technique by Obwegeser have been introduced to minimize this risk. This in vitro study was performed to determine whether the shape of the osteotomy cut affects the torque and the fracture pattern of an SSO in pig mandibles. MATERIALS AND METHODS: In a split-mouth model, 16 mandibles were split according to the Hunsuck-Dal Pont modification of the Obwegeser technique. Using an oscillating saw, sharp-edged osteotomies were created on one side of the mandible and round-edged osteotomies were created on the contralateral side using a Lindemann bur. Torque forces were measured during the splitting, and the lingual fracture pattern of each split was classified. RESULTS: Torque forces were significantly (P < .05 by paired t test) decreased by 0.77 N-m (15.6%) when a saw was used for the osteotomy. In the 2 groups, fractures were produced along the mandibular canal. The mandible was more often completely fractured, including the lower mandibular border, when the fracture was created with an oscillating saw (P = .06 by Pearson χ2 test). No correlation was found between the torque used and the fracture pattern. CONCLUSION: Compared with round-edged osteotomies, sharp-edged osteotomies in pig mandibles facilitated the Hunsuck-Dal Pont modification of the Obwegeser sagittal splitting procedure and produced predictable results with decreased torque.

Resistance of Mandibular Polyurethane Replicas to Fracture After Removal of Blocks From the Symphysis and Ramus.

BACKGROUND: When block grafts are harvested intraorally, the donor sites may act as stress concentrators and alter the structural integrity of the mandible. PURPOSE: The study aimed to compare displacement and load failure between intact polyurethane mandibular replicas and similar replicas from which blocks were taken at the symphysis or the ramus. It also aimed to identify trends of load failure. MATERIALS AND METHODS: Thirty-five mandibular replicas were tested to failure with an electromagnetic material testing unit. The variables evaluated in this investigation were maximal load, displacement at maximal load, and fracture location. RESULTS: Statistically significant differences in maximal load were detected between groups (P = 0.0008). Differences between fracture locations were also statistically significant (P < 0.0001). The mandibles from which blocks were removed at the symphysis were significantly more likely to break at a lower maximal load than were the control mandibles (P = 0.0010) or the mandibles from which blocks were removed at the ramus (P = 0.0162). They were also more likely than the control group to break at a lower displacement at maximal load (P = 0.0145). CONCLUSIONS: Location of the donor site significantly influences the structural integrity of mandibular replicas. In addition, the donor site significantly affects the location of mandibular fractures.

Finite element analysis of stress distribution on the mandible and condylar fracture osteosynthesis during various clenching tasks.

PURPOSE: The purpose of the study was to evaluate the effect of clenching tasks on the stress and strain of condylar osteosynthesis screws and plates, as well as on the stress, strain distribution and displacement on the whole mandible and bone surrounding screws. METHODS: Three-dimensional finite element models of the mandible, two straight four-hole plates and eight screws were established. Six static clenching tasks were simulated in this study: incisal clench (INC), intercuspal position (ICP), right unilateral molar clench (RMOL), left unilateral molar clench (LMOL), right group function (RGF) and left group function (LGF). RESULTS: Based on the simulation of the six clenching tasks, none of the inserted screws and plates were broken or bended. For the whole mandibular bone, the maximum von Mises stress and von Mises strain observed were yielded by the ICP. For the bone surrounding the inserted screws, the maximum von Mises stress and von Mises strain were yielded by the LMOL (49.2 MPa and 3795.1 µ). CONCLUSION: Clenching tasks had significant effects on the stress distribution on the condylar osteosynthesis and the bone surrounding screws. Contralateral occlusion task (LMOL) had the maximal results of von Mises stress and strain and healing problems could be occur, this result confirms the importance of soft diet after surgery.

The effect of extracapsular injuries on growth and development of the mandible condyle: an experimental study in growing dogs.

OBJECTIVE: To investigate the effects of condylar extracapsular injuries on the development of the mandibular condyle and try to find a way to treat condylar hyperplasia by electively using such injuries to restrict the overdeveloped mandibular condyle. STUDY DESIGN: Sixty 6-month-old beagle puppies were divided randomly into five groups: blank control; unilateral fracture to the condylar neck; unilateral fracture to the condylar neck treated with rigid internal fixation; unilateral periosteum injury; unilateral decortication of the condylar neck. Computed tomography, 99 mTc single-photon emission computed tomography, and tetracycline-calcein double-labeling were performed after surgery. The puppies were sacrificed 12 and 24 weeks after surgery. Morphologic analyses and examination of growth activity were done. RESULTS: Unilateral fracture of the condylar neck without fixation caused local morphologic changes during the early postoperative period, but compensatory growth of the condyle altered such changes after healing. The other types of injury failed to inhibit the growth of the condyle and the mandible, whereas functional deviation of the chin was found after unilateral fracture of the condylar neck with or without fixation. CONCLUSIONS: The four types of extracapsular injury described here failed to inhibit the growth of the mandibular condyle and could not be selected as alternatives to treat condylar hyperplasia.

Comparison of Different Fixation Types Used in Unilateral Mandibular Condylar Fractures: An In Vivo Study With New Biomechanical Model.

INTRODUCTION: The aim of this in vivo study is to compare the single-titanium, double-titanium mini plate, and single resorbable plate systems used in internal rigid fixation of the unilateral mandibular condylar fractures on new design biomechanical model. METHODS: Thirty synthetic polyurethane models were used for biomechanical testing. Fracture lines were created for each model. Fragments were fixed with single-titanium plates in Group A (n = 10), double-titanium plates in Group B (n = 10), and single biodegradable plate (PPLA) in Group C (n = 10). Masticatory forces were applied to the models and the biomechanical properties of the titanium plate and screws, resorbable plate, and screws were evaluated. RESULTS: The average failure force for Group A, Group B, and Group C is 199, 324, 177N and the average bone displacement for Group A, Group B, Group C is 1.9, 0.3, 2.1 mm, respectively. DISCUSSION: Double titanium plates showed the most acceptable results in the fixation of unilateral subcondylar fractures where the single titanium and biodegradable plate systems failed to provide enough stability in unilateral subcondylar fracture fixation. Biodegradable plate systems are still not an alternative in fixation of unilateral condylar fractures.

Multiple mandibular fractures. Treatment outlines.

Multiple mandibular comminuted fractures usually occur in high energy traumas. The authors describe the management and treatment of multiple mandibular fractures in a young patient after a suicide attempt.

[Radiographic and masticatory physiologic evaluation after conservative treatment of condylar fractures in children and adolescents].

OBJECTIVE: To evaluate the developmental and functional outcome of condylar fractures in children and adolescents after conservative treatment. METHODS: Eight children and adolescents with unilateral condylar fracture, aged 5-13 were included. A removable occlusal splint, the thickness of which was determined according to the age, the developmental stage of the dentition, the level of the fracture and the degree of dislocation, worn for 1-3 months, and the patients were asked to perform functional exercises. The patients were followed up by clinical observation, panoramic radiograph, temporomandibular joint(TMJ ) cone beam computed tomography(CBCT), and surface electromyography(sEMG) of masticatory muscles (superficial masseter, anterior temporalis, and anterior digastric muscles). Ramus height and body length of mandible were measured on panoramic radiograph. The patients were asked to return for follow-up visits at 1, 3, and 6 months after treatment, and then once a year. The patients underwent clinical examination at each follow-up visit, and radiological examinations at 6 months and then annually. RESULTS: All the patients showed clinically satisfactory results. CBCT showed smooth and continuous cortex. Panoramic X-ray revealed that the ramus height was shorter in the fractured side than in the contralateral side, while body length was longer. The mean asymmetry index(AI,x±s) for ramus height and body length were (3.29±2.68)% and (4.01 ± 2.54)%. sEMG showed either hypertension or hypotension in the masticatory muscles of the fractured side and asymmetries were obvious. The mean AI for sEMG activity of the anterior temporalis, masseter, and anterior digastric muscle were masseter: (15.0 ± 16.9)%; anterior temporalis: (21.5 ± 15.9)%; anterior digastric muscles: (11.9 ± 10.7)%. CONCLUSIONS: Conservative treatment of condylar fracture in children and adolescents had clinically satisfactory results, while mandibular development was slightly interrupted. Asymmetries of EMG activities of masticatory muscles were obvious. EMG could objectively reveal the functional recovery of condylar fracture in children.

Assessment of the Biomechanical Performance of 5 Plating Techniques in Fixation of Mandibular Subcondylar Fracture Using Finite Element Analysis.

PURPOSE: The aim of this study was to compare the performances of 5 plating techniques for fixation of unilateral mandibular subcondylar fracture. MATERIALS AND METHODS: Five titanium plating techniques for fixation of condylar fracture were analyzed using the finite element method. The modeled techniques were 1) 1 straight plate, 2) 2 parallel straight plates, 3) 2 angulated straight plates, 4) 1 trapezoidal plate, and 5) 1 square plate. Three-dimensional models were generated using patient-specific geometry for the mandible obtained from a computerized tomographic image of a healthy living man. Plates were designed and combined with the mandible and analyzed under a 500-N load. RESULTS: The single straight plate presented the most inferior performance; it presented maximum displacement and strain on cortical bone. The trapezoidal plate induced the least amount of strain on cortical bone and was best at resisting displacement. CONCLUSION: The trapezoidal plate is recommended for fixation of subcondylar fracture.