ARTICLE IN PRESS

Journal of Cranio-Maxillofacial Surgery (2003) 31, 284–289

r 2003 European Association for Cranio-Maxillofacial Surgery.
doi:10.1016/S1010-5182(03)00073-8, available online at http://www.sciencedirect.com

Comparative evaluation of two osteosynthesis methods on stability following

sagittal split ramus osteotomy

Peter Maurer1, Wolf-Dietrich Knoll2, Johannes Schubert1

1
Department for Oral and Plastic Maxillofacial Surgery (Head: Prof. Dr. Johannes Schubert), Klinik und
Poliklinik für Mund, Kiefer- und plastische Gesichtschirurgie, Martin Luther-University, Halle-Wittenberg,
Halle, Germany; 2 Faculty of Engineering (Head: Prof. Dr. S. Otte), Institute for Equipment and Systems
Engineering Martin-Luther-University, Halle-Wittenberg, Germany

SUMMARY. Introduction: The aim of this study was to employ the finite element method (FEM) to compare the
stability of 2.0 mm titanium screws in a triangular configuration with that of a 2.0 mm titanium miniplate as
osteosynthesis material following bilateral sagittal split osteotomy. Material: A model of the mandible was
produced, consisting of 19854 elements and 4285 nodes. The mechanical parameters of the materials investigated
were taken from the literature and notified by the manufacturer. Results: On condition that the materials were
subjected only to their respective ultimate tensile stress, it was possible to neutralise a masticatory force of 1246 N
(Newtons) with the miniplate and of 1675 N with the bicortical triangular screw configuration. The strain limit was
determined by the peri-implant bone and not the osteosynthesis material. Conclusion: The finite element method
(FEM) appears to be suitable for simulating complex mechanical stresses in the maxillofacial area, as also
confirmed by the agreement between our data and those in the literature, and with clinical experience. It should
enable considerable savings to be made in terms of time, material and animal experiments in the future development
of osteosynthesis materials and techniques. r 2003 European Association for Cranio-Maxillofacial Surgery.

Keywords: Bilateral sagittal split osteotomy; Finite element analysis; Osteosynthesis; Mandible

INTRODUCTION MATERIAL AND METHODS

With the introduction of osteosynthesis procedures in
maxillofacial surgery, a noticeable increase in patient
comfort has been achieved in orthognathic surgery by
a shortening, or even complete avoidance, of inter-
maxillary fixation (Spiessl, 1976). The Obwegeser-
DalPont bilateral sagittal mandibular osteotomy is
nowadays a routine procedure in maxillofacial
surgery. A declared aim of this procedure is
undisturbed bone healing and the avoidance of
relapse. It is noteworthy how many different osteo-
synthesis procedures have been described in the
literature. This suggests that the osteosynthesis
method of choice has still not been found (Van
Sickels and Richardson, 1996). 2.0 mm bicortical
miniscrews or monocortical miniplates are used,
amongst other methods, for the retention of bone
fragments (Jeter et al., 1984; McDonalds et al., 1987).
The aim of this study, supporting wider investiga-
tions into the mechanical load of titanium osteo-
synthesis screws of various diameters and
configurations, was to use the finite element method
to compare the mechanical qualities of 2.0 titanium
screws in a triangular configuration (Maurer et al.,
1999) with those of a 2.0 mm titanium miniplate with
regard to retention following bilateral sagittal split
osteotomy. In using the finite element method
(FEM), the stresses in both the osteosynthesis
systems and in the surrounding bone were to be
examined.
The finite element method (FEM) is a mathematical
model allowing near realistic/virtual modelling. In the
course of this, by means of a process called
discretisation, a mathematical model is built up, in
similar way to building-block construction, from a
number of finite elements. It is therefore well adapted
to the actual structure. Under given conditions of
constraint and loading, the deformations and stresses
of these simple elements may be calculated. The
elements are connected to each other by nodes. The
deformation, and the measurements, including
strains, derived for the whole structure can be
calculated at each node, through the connection
conditions of the elements at the nodes (Bathe, 1990).
The geometrical data necessary for the calculation
and the mechanical qualities of the materials were
taken from the literature (Haribhakti, 1996; Schnei-
der, 1988), or notified by the manufacturer of the
osteosynthesis materials. The mandibular model used
in this study has been described previously by Maurer
et al. (1999) and consisted of 19,845 elements and
4285 nodes and it was assumed at the outset of the
investigation that the mechanical qualities of the test
bodies were homogenous, isotropic, and that the
osteosynthesis screws had been firmly applied to the
compact bone and, as a result of this, were subject to
the stresses of bending movement. The cancellous
bone could only absorb a small load, having an
elastic modulus of E ¼ 500 MPa (Terheyden et al.,

284
 ARTICLE IN PRESS
1999). After the operation, through the forces of the
screws, the bone halves were superimposed on each
other and could only be displaced in the direction of
this force. In accordance with the data in the
literature, the tests took as starting point for the
mandible a 5 mm thick medullary layer and with an
oral and vestibular compact bone thickness of 3 mm
in the lower jaw (Haribhakti, 1996). In the calculation
model, the spongiosa layer was halved and appor-
tioned to each of the two compact bone segments. A
gap of s ¼ 0:5 mm remained between the medullary
layers. On the assumption of symmetry, it was
sufficient to model only one half of the jaw. Torsion
of the lower jaw was excluded by suitable boundary
conditions. The right boundary (temporo-mandibu-
lar joint) was firmly fixed. For the mandibular
compact bone, the limit set by Schneider (1988) for
a maximum load (bending stress) of s ¼ 85 MPa
was used. The triangular screw configuration was
further investigated, having already proved itself
clinically and been experimentally tested (Foley
et al., 1989; Obeid and Lindqvist, 1991; Shetty et al.,
1996). For this, two screws were inserted bicortically
above the neurovascular bundle, and one below.
Figs. 1 and 2 show the selected measurements
of the model mandible with the screw configuration
and the miniplate arrangement, respectively. As the
Fig. 1 – Mandibular geometry (mm) with triangular screw configuration.
Osteosynthesis method 285
introduction of load (site and degree) in the lower
jaw influences the strain, a distance of 30 mm
anterior to the lower screw was chosen as the
position of the simulated application of masticatory
force. This region corresponds to the molar area,
which was regarded as the masticatory centre.
The bicortical screws simulated the function of
a positioning screw.
The prediction of stresses in the screws and in the
compact bone were carried out using the FEM
computer software programme ANSYSs.
A quantitative estimate of the distribution of stress
in the screws and in the surrounding bones was
carried out with the aid of a colour scale, which
differentiated between 20 different stress values.
It must be emphasised that the calculations by the
FEM represent an approximation of the deforma-
tions and of the spatial stress components of loaded
bodies (Bathe, 1990).
If the permitted load limit for each type of screw is
exceeded, it may result in failure of that screw. On the
other hand, the load limit of the compact bone can be
exceeded, whilst the load in the screws is below the
permissible limit. In the calculation model with
idealised lower jaw geometry, the bone gap and the
fit of the miniplate were simulated by contact
surfaces, which slide over one another.
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286 Journal of Cranio-Maxillofacial Surgery
Fig. 2 – Mandibular geometry (mm) this time with monocortical diagonal miniplate configuration.
RESULTS
Figs. 3 and 4 show the results of FE analysis carried
out on the osteosynthesis screws and plates as well as
in the surrounding mandibular compact bone when
masticatory force was applied as shown in Figs. 1
and 2.
The strength was evaluated using the hypothesis of
shape change energy according to Huber (1904), von
Mises (1913) and Henckey (1924). (Dubbel, 1990;
Radaj, 1995; Schwaigerer, 1997). This stability
hypothesis shows the best agreement between experi-
ment and calculation for the failure of the material
from plastic deformation and fatigue fracture.
The values of the von Mises reference tension are
shown as coloured bars in the figures. The strength
hypothesis translates the actual multiaxial tension
state into a monoaxial tension state equivalent to the
tensile strength. A direct comparison between the
marginal, i.e. permissible loading is consequently
possible. It could be seen that the highest reference
tensions have a value of about 610 N mm2 at the
lower screw in the triangular configuration with a
masticatory force of 167.5 N (Fig. 3, detail magnifica-
tion) which entails a marginal load with an assumed
permissible tension in the titanium of 610 N mm2. On
the other hand, the two upper screws are exposed to
very much less stress. In the compact bone, the limit
value of loading (85 N mm2) is reached with the
specified masticatory force. Magnification of the E
modulus of the cancellous bone from 500 to
1500 MPa does not lead to a noteworthy reduction
of tension (about 1.5%) in the screw. However, the
value is very much higher in the compact bone
(almost 10%).
Fig. 4 shows the von Mises reference tensions when
using the titanium miniplate. With the oblique
arrangement chosen, a marginal stress is attained
with a masticatory force of 124.6 N in the compact
bone. This means that this variant is almost
equivalent to the triangular screw configuration. In
the plate itself, only about two thirds of the
permissible stress is reached, and in the screws the
load reserve is even higher.
DISCUSSION
As already stated, the FE-analysis allows a near
realistic modelling of the loads within implants, plates
and the surrounding bone (Baiamonte et al., 1996).
Concurrently, the behaviour of the mandible as-
sumed in the model has since been confirmed by
Meyer et al. (2000). They compared mechanical
measurements in the mandible, the load values of
the same model calculated in the FE-analysis. They
discovered that there was good concordance between
the values determined in their experiment and the
stresses within the lower jaw, as calculated in the FE
model. Furthermore, they were able to show that the
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Osteosynthesis method 287

Fig. 3 – von Mises stress distribution in the mandible and in the osteosynthesis screws (triangular configuration) at a mastication force (F) of
167.5 N. The stress distribution in the lower screw is shown enlarged and reached the limit of its tensile strength.

lower jaw, with an applied force of up to 170 N,
exhibited ideal elastic behaviour, which was symme-
trical and shows an almost exact deformation curve.
In comparison with other anatomical sites in the
mandible, the angle showed, under a given force
applied at pogonion, the least deformation and also,
only a minor degree of torsion.
In this study the triangular configuration of the
2.0 mm titanium screws was able to withstand a
maximum masticatory force of 167.5 N (Fig. 3),
whilst the miniplate with monocortical screws in-
serted tolerated a maximum of 124.6 N (Fig. 4). The
monocortically held miniplate tested can therefore be
regarded as very similar to the linear configuration of
2.0 mm titanium screws, which in an earlier simula-
tion, was able to resist a masticatory force of 122 N
(Maurer et al., 1999). Furthermore, it was shown that
by installing the miniplate along the tensile stress
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288 Journal of Cranio-Maxillofacial Surgery

Fig. 4 – von Mises stress distribution in the mandible and in the osteosynthesis screws and plate at a mastication force (F) of 124.6 N. The
stress distribution, in the 2.0 mm miniplate, in the most proximal 2.0 mm screw, and in the adjacent cortical bone is shown enlarged.

lines (described by Champy in 1983), lower stresses
built up in the surrounding bone and a larger
maximum masticatory force could, therefore, be
neutralised by the miniplate.
In biomechanical experiments on bovine bone,
Anucul et al. (1992) compared bicortical 2.0 mm mini-
screws with 2 mm 4-hole-miniplates retained by
monocortical screws. They were able to demonstrate
that the bicortical screw osteosynthesis guaranteed a
more stable fixation of the bone fragments, if loaded
to the limit. The force needed for osteosynthesis to
fail was, in the case of the bicortical screws, on
average 3 times greater when compared with the
miniplate fixation. Up to a load threshold value both
systems behaved elastically in an identical way which
guaranteed that the fragments would return to their
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initial position. Pistner et al. (1997) also examined
biomechanically, various osteosynthesis procedures
following sagittal splitting bilaterally of the lower jaw
of a pig. This included a triangular, bicortical, 2 mm
titanium screw configuration, and 2 mm titanium
miniplate application. In doing so, they ascertained
that the force, required to induce failure of the screw
osteosynthesis was almost double that for the
miniplate retention. Therefore, the force values
suggested in the current study demonstrate a trend,
confirmed by earlier experiments.
Apart from such experimental investigations,
numerous clinical studies evaluating the results of
osteosynthesis techniques, can also be found in the
international literature. Despite the large difference in
masticatory forces tolerated by the osteosynthesis
systems, clinical studies do not show an increased
failure tendency of miniplate fixation (McDonalds
et al., 1987; Blomqvist and Isaksson, 1994). This is not
surprising, as the postoperative masticatory forces
measured after 6 weeks only reach a value of
65743 N (Kukiz et al., 1995).
CONCLUSION
This study compares the data already published on
clinical experiences with a modern testing procedure,
the finite-element-method (FEM). This method has
already proved itself in other oral and maxillofacial
areas, where there are complex mechanical load
situations. As previous studies have demonstrated
concordance between the theoretical FEM and
clinical practice, the former seems to have the
potential to enable essential savings in time and
material (including animal experiments) to be made
in the development of osteosynthesis materials.
Acknowledgements
We would like to thank you Dr. Siegfried Holweg for his help in
preparing the mathematical part of this paper.
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Dr. Dr. Peter Maurer
Klinik und Poliklinik für Mund-
Kiefer- und plastische Gesichtschirurgie
Martin Luther-University Halle-Wittenberg
Große Steinstrasse 19
Halle 06097
Germany
Tel: +49 345 55 73726
Fax: +49 345 55 73726
E-mail: peter.maurer@medizin.uni-halle.de
Paper received 21 June 2002
Accepted 5 June 2003