Assessment of the Biomechanical

Performance of 5 Plating Techniques in

Fixation of Mandibular Subcondylar
Fracture Using Finite Element Analysis
Mhd Ayham Darwich, BEng, MEng, PhD,* Mhd Hassan Albogha, DDS, MSc, PhD,y
Adnan Abdelmajeed, BEng, MEng, PhD,z and Khaldoun Darwich, DDS, MSc, PhDx
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.
Ó 2016 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 74:794.e1-794.e8, 2016

There is accumulating evidence that open reduction plates has frequently been presumed to perform more
and internal fixation (ORIF) is the treatment of choice favorably,7 although some investigators have reported
for mandibular condyle fractures.1-3 Important factors the opposite is true.10 Recently, frame-like plates
for the success or failure of ORIF are the design and (square and trapezoid) were introduced and found to
material of the plates used to produce rigid fixation provide better stability than 2 straight plates.11,12
of fractured condyles. Biodegradable plates seem to However, some investigators disagree.4 Therefore,
be functionally unstable, whereas titanium plates are further investigation must examine the mechanical per-
recommended for ORIF.4 An issue that remains contro- formance and efficacy of various plating techniques.
versial is identifying the best design and configuration Finite element analysis is a numerical technique that
of titanium plates to maximize fixation stability.5 simulates the mechanical behaviors of loaded construc-
There is evidence that 1 plate is insufficiently stable; tions. The technique has been used frequently in
therefore, 2 plates should achieve stable fixation.6-9 biomechanical studies to solve mechanical problems
Furthermore, a nonparallel arrangement of the 2 related to bone tissue and has proved beneficial in

*Lecturer, Faculty of Biomedical Engineering, Al Andalus Department of Maxillofacial Surgery, International University for
University for Medical Sciences, Qadmus, Syria; Faculty of Science and Technology, Damascus, Syria.
Engineering, Tartous University, Tartous, Syria. Address correspondence and reprint requests to Dr Albogha:
yVisiting Assistant Professor, Section of Orthodontics and 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; e-mail:
Dentofacial Orthopedics, Faculty of Dental Science, Kyushu [email protected]
University, Kyushu, Japan. Received September 25 2015
zLecturer, Faculty of Biomedical Engineering, Al Andalus Accepted November 19 2015
University for Medical Sciences, Qadmus, Syria. Ó 2016 American Association of Oral and Maxillofacial Surgeons
xAssociate Professor, Department of Oral and Maxillofacial Surgery, 0278-2391/15/01558-X
Faculty of Dental Medicine, Damascus University, Damascus, Syria; http://dx.doi.org/10.1016/j.joms.2015.11.021

794.e1
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DARWICH ET AL 794.e2

predicting bone mechanical response.13 In this tech- applying loads and constraints to the mesh and then
nique, a 3-dimensional (3D) model of the construction solved using the appropriate mechanical theory.
is discretized into a finite number of elements, resulting In the present study, the finite element modeling tech-
in a 3D mesh. The mechanical problem is defined by nique was used to compare the rigidity of fixation, safety

FIGURE 1. A, Displacement contours in the mandible for techniques 1 to 5. B, Peak values of displacement for techniques 1 to 5 compared with
peak displacement in a normal mandible. (Fig 1 continued on next page.)
Darwich et al. Finite Element Analysis of Plating Techniques. J Oral Maxillofac Surg 2016.

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794.e3 FINITE ELEMENT ANALYSIS OF PLATING TECHNIQUES

FIGURE 1 (cont’d). C, Scale of displacement values modified to show displacement contours in the condyle neck area.
Darwich et al. Finite Element Analysis of Plating Techniques. J Oral Maxillofac Surg 2016.

of bone, and integrity of plates among 5 fixation and fixed using screws 8 mm long and 2 mm in diameter.
techniques for mandibular subcondylar fracture. Trape- Plates were merged with the mandible in 5 models repre-
zoidal plates appeared to provide the best mechanical senting the 5 techniques, and each technique was
performance in finite element models, manifesting as analyzed using the finite element method in ANSYS 14
pronounced rigid fixation, less strain on bone, and (ANSYS, Inc, Canonsburg, PA).
good integrity of plate construction materials.
FINITE ELEMENT ANALYSES
Materials and Methods The models were discretized using tetrahedral ele-
ments, and shell elements 2 mm thick were added to
GENERATION OF 3D MODELS simulate cortical bone. All materials were considered
A computed tomographic image of a healthy living homogeneous and isotropic and their properties were
man was used to generate a 3D surface model of a assigned according to the previous literature.15-17
mandible (stereolithographic format) in 3DSlicer Cortical bone was assigned 14 GPa for the elastic
(http://www.slicer.org). The left mandibular condyle modulus (E) and 0.3 for the Poisson ratio (n).
was cut at the base to simulate a condylar base fracture Cancellous bone properties were assigned 1,500 MPa
(hereafter, subcondylar fracture).14 Three-dimensional (E) and 0.3 (n). Titanium alloy properties (E =
models for 5 plating techniques were designed: 1 straight 114 GPa; n = 0.34) were assigned to the plates. A
plate, 2 straight plates in parallel arrangement, 2 straight frictionless point-to-point gap contact element was
plates in nonparallel arrangement, 1 trapezoidal plate, used at the bone-to-titanium interface at the plate and
and 1 square-shaped plate (hereafter referred to as tech- the bone-to-bone interface at the fracture. The contact
niques 1 to 5, respectively). All plates were 1 mm thick element was solved using penalty formulation. Condyle

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DARWICH ET AL 794.e4

FIGURE 2. Maximum principal strain contours.

Darwich et al. Finite Element Analysis of Plating Techniques. J Oral Maxillofac Surg 2016.

movement was constrained in all directions, and a load linear elasticity theory, and each model consisted of
of 500 N was applied to the occlusal surfaces of the pos- roughly 50,000 elements and 22,000 nodes.
terior teeth to simulate the maximum clenching condi-
tion.18 This loading regimen exerts a posteriorly
oriented bending moment on the mandible in the POST-PROCESSING RESULTS
same direction as the bending moment generated Peak displacement in each model was calculated
under muscular forces.19 The models were solved using as a measurement of the rigidity of fixation

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794.e5 FINITE ELEMENT ANALYSIS OF PLATING TECHNIQUES

technique, in which less displacement was indicative At the fracture line area, all but technique 4 yielded
of greater rigidity. micromotion in the range of 100 to 200 mm (Fig 1C).
Recent studies have shown that maximum principal Only technique 4 yielded micromotion less than
strain (MaxPN) is a good indicator of mechanical 100 mm at the fracture line area.
behavior in bone when assessed using finite element
modeling.20,21 MaxPN was calculated for the STRAIN IN BONE
elements in cortical and cancellous bone when it The normal mandibular model predicted a high con-
exceeded 0.3%, the peak MaxPN found in the model centration of strain at the base of the condyle neck, a
of a normal mandible, without fracture, under the zone where subcondylar fracture likely occurs under
same conditions. excessive nonfunctional loads (Fig 2). The plating tech-
Peak von Mises stresses were calculated to predict niques presented distributions of strain more extensive
yielding in the fixation units (plates and screws). than that seen in the normal mandibular model (Fig 2).
This extensive distribution was remarkable in tech-
STATISTICAL ANALYSIS nique 1, in which strains extended as far as the anterior
Correlations between mandible displacement and border of the ramus. The least strain distribution was
other parameters (ie, strain in cortical and cancel- seen in technique 4, which showed a pattern very
lous bone or stress in fixation units) were used to similar to that seen in the normal mandible, except
identify rigidity for each plating technique. Correla- for focal concentrations of strain around the screws.
tions with a P value less than .05 were consid-
ered significant. VON MISES STRESS IN PLATES
All plates presented peak von Mises stresses well
below 300 MPa (Fig 3), far less than the yield strength
Results
of the titanium, which is 880 MPa.17 Although tech-
RIGIDITY OF FIXATION nique 5 showed the lowest von Mises stresses, it did
The 5 plating techniques showed different ranges not improve the rigidity of fixation compared with
of displacement (Fig 1A), but the trapezoidal plate the other techniques (Fig 4C).
(technique 4) was clearly superior. Its peak displace-
ment was very close to that seen in the normal CORRELATION BETWEEN RIGIDITY AND CORTICAL
mandibular model (1,217 vs 1,162 mm, respectively; BONE STRAIN
Fig 1B). In contrast, the single straight plate (tech- Peak displacement was significantly correlated to
nique 1) showed the greatest peak displacement, the MaxPN in cortical bone (P < .05; Fig 4A). Tech-
achieving as much as twice that in the normal nique 1 showed the greatest predicted displacement
mandibular model. (2,475 mm) and cortical bone strain (0.9%) among

FIGURE 3. Von Mises stress contours in fixation units.

Darwich et al. Finite Element Analysis of Plating Techniques. J Oral Maxillofac Surg 2016.

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DARWICH ET AL 794.e6

FIGURE 4. Spearman correlation test among A, peak displacement and maximum principal strain on cortical bone, B, maximum principal
strain on cancellous bone, and C, von Mises stress on plates. Red curves represent 95% bivariate normal density ellipses. Narrow and diag-
onally oriented ellipses indicate meaningful correlation.
Darwich et al. Finite Element Analysis of Plating Techniques. J Oral Maxillofac Surg 2016.

the models. In contrast, technique 4 showed least pre- Therefore, when a fracture is present in the condyle,
dicted displacement (1,610 mm) and the least cortical an adequately rigid fixation technique is necessary to
bone strain (0.4%). The other parameters (cancellous secure complete and correct healing. The authors
bone strain and plate stress) did not show meaningful found that various designs and arrangements of plates
correlations to displacement (Fig 4B, C). used for fixation of condyle fractures presented
important differences in rigidity and safety of bone.
There is a consensus that the 1 straight plate is un-
Discussion
suitable as a condylar fracture fixation tech-
The base of the condyle is subject to heavy physio- nique,8,9,24,25 but this technique was included in the
logic forces22,23; this phenomenon was confirmed in present study to serve as a reference for the other
the present study, in which high strain concentrations investigated techniques. The technique using 1
were present in this area of the condyle neck. straight plate not only presented the greatest

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794.e7 FINITE ELEMENT ANALYSIS OF PLATING TECHNIQUES

displacement among the models, but also resulted in the same amount of displacement. However, other re-
extensive bone strain contours. In contrast, the searchers have reported results that seemed to negate
technique using 2 straight plates presented slightly the claim that the performance of the trapezoidal plate
better performance for the nonparallel arrangement could be better than or similar to using 2 straight
compared with the parallel one. Aquilina et al10 plates.4,29 However, their mechanical tests using
reported that the parallel arrangement performed animal models were different from real physiologic
better, but their conclusion was based on a very small forces. They tested displacement of the condyle
difference in displacement (20 m) that might be clini- during anteroposterior or mediolateral loading on
cally minor. the condyle, but they did not test displacement
An initial method to increase rigidity of fixation under vertical loading, which is the most prominent
might be to increase the number of plates and screws, force that acts to displace fragments of the mandible
assuming that 2 plates and 8 screws would be more during mastication. Therefore, their findings might
rigid than a frame-like plate and 4 screws. However, not be comparable to those of Meyer et al.11,12
the present models showed that this is not true. The Interesting characteristics of trapezoidal plates are
fixation techniques showed small differences in stress its relatively small size and fixation using only 4
but meaningful differences in displacement. This screws. These characteristics have apparent clinical
finding could imply that rigidity of fixation might be advantages. The neck of the condyle is small and there
related to a factor other than the rigidity of the fixation is little room to place many screws without weakening
material. the bone. Using small plates such as the trapezoidal
A meaningful correlation was found between plate in combination with transoral endoscopic open
displacement and strain on cortical bone. A similar rela- reduction might decrease the surgical complications
tion was found in a previous study on fixation tech- that could be encountered when much more of the
niques for sagittal split ramus osteotomy of the fracture area needs to be stripped to place 2 straight
mandible.26 It can be inferred that the fixation tech- plates with 8 screws.30,31
nique that increases strain on cortical bone is likely to In conclusion, rigidity of fixation seems to depend
provide less rigid fixation. From this perspective, primarily on the design and arrangement of plates
increasing the number of plates or screws not only fails and the way these attributes affect strains on cortical
to improve rigidity of fixation, but also impairs bone bone. The authors recommend the use of trapezoidal
safety and jeopardizes the success of fixation. Impaired plates for fixation of subcondylar fractures because
bone safety might be attributed to the increased num- these plates, in models, produced the least amount
ber of screws used in the fixation technique, which re- of strain and therefore the most stable fixation.
sults in more bone being removed and replaced with
screws, thereby weakening the cortical bone. The trap-
ezoidal plate seems to overcome this pitfall. The frame
References
shape of the plate seems to provide adequate rigidity, 1. Kyzas PA, Saeed A, Tabbenor O: The treatment of mandibular
and the relatively small number of screws (only 4) mini- condyle fractures: A meta-analysis. J Craniomaxillofac Surg 40:
e438, 2012
mally affects the rigidity of cortical bone. 2. Vesnaver A, Ah
can U, Rozman J: Evaluation of surgical treatment
Meyer et al12,27 studied compression and tension in mandibular condyle fractures. J Craniomaxillofac Surg 40:647,
strain lines in the mandible and proposed that 2012
3. Shiju M, Rastogi S, Gupta P, et al: Fractures of the mandibular
osteosynthesis should follow certain ideal lines on condyle—Open versus closed—A treatment dilemma. J Cranio-
the mandible to achieve maximum rigid fixation. maxillofac Surg 43:448, 2015
Adopting this concept, Meyer et al11 introduced the 4. Pilling E, Eckelt U, Loukota R, et al: Comparative evaluation of
ten different condylar base fracture osteosynthesis techniques.
trapezoidal plate as the best design for fixation of sub- Br J Oral Maxillofac Surg 48:527, 2010
condylar fracture because it disturbed the bone strain 5. Omezli M, Dayi E: Review of biomechanical experimental
lines the least. They attributed its ideal performance to studies on different plating techniques of mandibular condyle
fractures. Ann Maxillofac Surg 1:48, 2011
the harmony between its lateral arms and the strain 6. Choi BH, Kim KN, Kim HJ, Kim MK: Evaluation of condylar neck
lines in the mandible. The authors found that the fracture plating techniques. J Craniomaxillofac Surg 27:109,
lateral arms of the trapezoidal plate were perpendic- 1999
7. Wagner A, Krach W, Schicho K, et al: A 3-dimensional finite-
ular to the contours of displacement and the 2 bases element analysis investigating the biomechanical behavior of
of the plate were parallel to the displacement con- the mandible and plate osteosynthesis in cases of fractures of
tours. This finding agrees with the principle intro- the condylar process. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 94:678, 2002
duced by Meyer et al that the plates should follow 8. Tominaga K, Habu M, Khanal A, et al: Biomechanical evaluation
specific lines on the mandible surface, and the trape- of different types of rigid internal fixation techniques for
zoidal plate seems to be the best plate to fulfill this subcondylar fractures. J Oral Maxillofac Surg 64:1510, 2006
9. Parascandolo S, Spinzia A, Parascandolo S, et al: Two load sharing
principle. De Jesus et al28 indicated that trapezoidal plates fixation in mandibular condylar fractures: Biomechanical
plates and 2 nonparallel straight plates produce almost basis. J Craniomaxillofac Surg 38:385, 2010

Downloaded for MAHMUT SAMİ YOLAL ([email protected]) at Kutahya Health Sciences University from ClinicalKey.com by
Elsevier on July 24, 2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.
DARWICH ET AL 794.e8

10. Aquilina P, Chamoli U, Parr WCH, et al: Finite element analysis of 21. Albogha MH, Kitahara T, Todo M, et al: Maximum principal strain
three patterns of internal fixation of fractures of the mandibular as a criterion for prediction of orthodontic mini-implants failure
condyle. Br J Oral Maxillofac Surg 51:326, 2013 in subject-specific finite element models [published online
11. Meyer C, Martin E, Kahn JL, Zink S: Development and biome- ahead of print April 1, 2015]. Angle Orthod. PMID:25830709.
chanical testing of a new osteosynthesis plate (TCPÒ) designed 22. Vollmer D, Meyer U, Joos U, et al: Experimental and finite
to stabilize mandibular condyle fractures. J Craniomaxillofac element study of a human mandible. J Craniomaxillofac Surg
Surg 35:84, 2007 28:91, 2000
12. Meyer C, Serhir L, Boutemi P: Experimental evaluation of three 23. Xiangdong QI, Limin MA, Shizhen Z: The influence of the closing
osteosynthesis devices used for stabilizing condylar fractures of and opening muscle groups of jaw condyle biomechanics after
the mandible. J Craniomaxillofac Surg 34:173, 2006 mandible bilateral sagittal split ramus osteotomy. J Craniomaxil-
13. Cristofolini L, Schileo E, Juszczyk M, et al: Mechanical testing of lofac Surg 40:e159, 2012
bones: The positive synergy of finite-element models and 24. Asprino L, Consani S, de Moraes M: A comparative biomechan-
in vitro experiments. Philos Trans A Math Phys Eng Sci 368: ical evaluation of mandibular condyle fracture plating
2725, 2010 techniques. J Oral Maxillofac Surg 64:452, 2006
14. Loukota RA, Eckelt U, De Bont L, Rasse M: Subclassification of 25. Choi BH, Yi CK, Yoo JH: Clinical evaluation of 3 types of plate
fractures of the condylar process of the mandible. Br J Oral Max- osteosynthesis for fixation of condylar neck fractures. J Oral
illofac Surg 43:72, 2005 Maxillofac Surg 59:734, 2001
15. Currey J: Cortical bone, in Black J, Hastings G (eds): Handbook 26. Albougha S, Darwich K, Darwich MA, Albogha MH: Assessment
of Biomaterial Properties. London, UK, Chapman Hall, 1998, of sagittal split ramus osteotomy rigid internal fixation tech-
pp 3–14 niques using a finite element method. Int J Oral Maxillofac
16. Keaveney TM: Cancellous bone, in Black J, Hastings G (eds): Surg 44:823, 2015
Handbook of Biomaterial Properties. London, UK, Chapman 27. Meyer C, Kahn JL, Boutemi P, Wilk A: Photoelastic analysis of
Hall, 1998, pp 15–23 bone deformation in the region of the mandibular condyle
17. Sarda S, Ginebra M, Rodriguez D, et al: Materials in dental im- during mastication. J Craniomaxillofac Surg 30:160, 2002
plantology, in Natali A (ed): Dental Biomechanics. Baton Rouge, 28. de Jesus GP, Vaz LG, Gabrielli MF, et al: Finite element evaluation
FL, CRC Press, 2003, pp 69–89 of three methods of stable fixation of condyle base fractures. Int
18. Braun S, Bantleon HP, Hnat WP, et al: A study of bite force, part 1: J Oral Maxillofac Surg 43:1251, 2014
Relationship to various physical characteristics. Angle Orthod 29. Lauer G, Haim D, Proff P, et al: Plate osteosynthesis of the
65:367, 1995 mandibular condyle. Ann Anat 189:412, 2007
19. van Eijden TM: Biomechanics of the mandible. Crit Rev Oral Biol 30. Lauer G, Pradel W, Schneider M, Eckelt U: A new 3-dimensional
Med 11:123, 2000 plate for transoral endoscopic-assisted osteosynthesis of
20. Schileo E, Taddei F, Cristofolini L, Viceconti M: Subject-specific condylar neck fractures. J Oral Maxillofac Surg 65:964, 2007
finite element models implementing a maximum principal 31. Sch€on R, Schramm A, Gellrich NC, Schmelzeisen R: Follow-up of
strain criterion are able to estimate failure risk and condylar fractures of the mandible in 8 patients at 18 months
fracture location on human femurs tested in vitro. J Biomech after transoral endoscopic-assisted open treatment. J Oral
41:356, 2008 Maxillofac Surg 61:49, 2003

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