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      Evaluation of labial versus labio-inferior lines of osteosynthesis using 3D miniplate for fractures of anterior mandible: A finite element analysis with a pilot clinical trial

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          Abstract

          Purpose

          The fractures of anterior mandible are subject to severe torsional forces due to muscles acting in opposite directions. 3D miniplate has been suggested as a good alternative by some researchers. However, finite element model (FEM) studies indicate that labio-inferior positioning of two miniplates perpendicular to each other offers better stability as compared to labial positioning. This study aims at combining the advantages of a single 3D miniplate and labio-inferior positioning of two conventional miniplates, which was assessed by finite element analysis along with a pilot clinical trial.

          Methods

          Two FEM models were created using CT data of a 24-year-old patient with Angle class I occlusion: control model with labial plating and study model with labio-inferior plating. The models were processed with MIMICS® (materialise, Leuven, Belgium), CATIA® (Dassault Systemes) and finite element analysis softwares. Parameters adopted for analysis were (1) displacement (mm) of fracture fragments during each screw fixation, (2) lingual splay and post fixation stability of fracture fragments with masticatory load, and (3) stress distribution (MPa) across fracture fragments. Moreover, a pilot clinical trial including five patients with anterior mandible fracture was conducted. The fractures were managed by intraoral open reduction and 3D miniplate fixation in labio-inferior position. Intraoperative interfragmentary gap, post fixation lingual splay and radiographic fracture union and complications were assessed clinically.

          Results

          Labio-inferior plating demonstrated less displacement (mm) of fracture fragments during screw fixation (0.059 vs. 0.079) as well as after application of masticatory load (1.805 vs. 1.860). Negligible lingual splay and less stress distribution (MPa) across fracture fragments (1.860 vs. 1.847) were appreciated in the study group as compared to control group. Clinical trial support the favorable outcome related to intraoperative and postoperative assessment parameters.

          Conclusion

          FEM analysis and clinical trial reveal better results with labio-inferior positioning of 3D miniplate when compared to labial positioning.

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          Most cited references19

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          Finite element analysis: A boon to dentistry

          The finite element analysis (FEA) is an upcoming and significant research tool for biomechanical analyses in biological research. It is an ultimate method for modeling complex structures and analyzing their mechanical properties. In Implantology, FEA has been used to study the stress patterns in various implant components and also in the peri-implant bone. It is also useful for studying the biomechanical properties of implants as well as for predicting the success of implants in clinical condition. FEA of simulated traumatic loads can be used to understand the biomechanics of fracture. FEA has various advantages compared with studies on real models. The experiments are repeatable, there are no ethical considerations and the study designs may be modified and changed as per the requirement. There are certain limitations of FEA too. It is a computerized in vitro study in which clinical condition may not be completely replicated. So, further FEA research should be supplemented with clinical evaluation.
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            An Epidemiological Study on Pattern and Incidence of Mandibular Fractures

            Mandible is the second most common facial fracture. There has been a significant increase in the number of cases in recent years with the advent of fast moving automobiles. Mandibular fractures constitute a substantial proportion of maxillofacial trauma cases in Lucknow. This study was undertaken to study mandibular fractures clinicoradiologically with an aim to calculate incidence and study pattern and the commonest site of fractures in population in and around Lucknow. Patient presenting with history of trauma at various centers of maxillofacial surgery in and around Lucknow were included in this study. Detailed case history was recorded followed by thorough clinical examination, and radiological interpretation was done for establishing the diagnosis and the data obtained was analyzed statistically. Out of 66 patients with mandibular fractures, highest percentage was found in 21–30 years of age with male predominance. Road traffic accidents were the most common cause of fracture with parasymphysis being commonest site. Commonest combination was parasymphysis with subcondyle. There was no gender bias in etiology with number of fracture sites. The incidence and causes of mandibular fracture reflect trauma patterns within the community and can provide a guide to the design of programs geared toward prevention and treatment.
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              A 3-dimensional finite-element analysis investigating the biomechanical behavior of the mandible and plate osteosynthesis in cases of fractures of the condylar process.

              The condylar region is one of the most frequent sites for mandibular fractures, with direct application of miniplates being the most commonly used open-fixation technique today. Yet, anatomic and biomechanical limitations continue to make this application technically challenging with a considerable complication rate. We sought to analyze such incongruencies with respect to the complex biomechanical behavior of the mandible. Individual human mandible geometry, the specific bone density distribution, and the position and orientation of the masticatory muscles were evaluated by performing computed tomography scans and a sequential dissection of the cadaver mandible. Three-dimensional finite-element analysis was performed for different fracture sites, osteosynthesis plates, and loading conditions. Osteosynthesis of fractures of the condylar neck with 1 or 2 miniplates of a diameter of 2.35 x 1.00 mm was found to be an insufficient fixation method. This also applies for plates (3.60 x 1.54 mm), according to Pape et al,(8) when used in singular fashion (high condylar neck fractures excepted). In cases of singular occlusal contacts in the molar region (particularly at the contralateral side of the fracture), the highest stress values inside the mandible and osteosynthetic devices could be observed. With even the static yield limit of titanium being exceeded in such cases, consecutive rapid failure of the miniplates becomes most likely when loading of the condylar region caused by bite forces cannot be prevented. We strongly recommend the use, whenever possible, of 2 plates in the manner described by Pape et al(8) for osteosynthesis of fractures of the condylar neck in combination with bicortically placed screws. The stiffness of a singular osteosynthesis plate made of titanium in a diametrical dimension of approximately 5.0 x 1.75 mm was found to be equivalent to the physiological bone stiffness in the investigated fracture sites. The actual stiffness of such a fixation plate is approximately 3 times higher than the stiffness of devices commonly in use.
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                Author and article information

                Contributors
                Journal
                Chin J Traumatol
                Chin. J. Traumatol
                Chinese Journal of Traumatology
                Elsevier
                1008-1275
                09 August 2019
                October 2019
                09 August 2019
                : 22
                : 5
                : 261-269
                Affiliations
                [1]Department of Oral and Maxillofacial Surgery, SRM Dental College and Hospital, Ramapuram Campus, Ramapuram, Chennai 600089, Tamil Nadu, India
                Author notes
                []Corresponding author. elavenil.omfs@ 123456gmail.com
                Article
                S1008-1275(19)30249-4
                10.1016/j.cjtee.2019.08.001
                6823702
                31493976
                4c0f6193-1527-4545-816d-816f87aa597d
                © 2019 Chinese Medical Association. Production and hosting by Elsevier B.V.

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                : 6 January 2019
                : 29 June 2019
                : 10 July 2019
                Categories
                Original Article

                mandibular fractures,finite element analysis,osteosynthesis,3d miniplate

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