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The Biophysics of Mandibular Fractures: An
Evolution toward Understanding
Randal H. Rudderman, M.D.
Robert L. Mullen, Ph.D.
John H. Phillips, M.D.
Alpharetta, Ga.; Cleveland, Ohio; and
Toronto, Ontario, Canada
Background: Predicting outcomes based on a variety of fixation techniques remains problematic in the treatment of mandible fractures. There is inherent difficulty in comparing the hundreds of published articles on the subject because of
the large number of variables, including injury patterns, assessment techniques,
treatment approach, device selection and application, and definition of outcome.
Methods: The authors review the behavior of the human mandible. Behavior of the
intact mandible, multiple fracture scenarios, and small and large (single and multiple) plating applications are reviewed.
Results: Several misconceptions in the literature are clarified. Factors that will
resolve the dichotomy between clinical results and current biomechanical theories
are presented such that a more logical biomechanical model may be used to
approach fixation of the mandibular fracture being treated.
Conclusions: Current mandibular biomechanics theory must be expanded to reflect the complex nature of the system and to more accurately describe conditions
that exist in the physical world. Otherwise, further analysis in advancements in
outcome and treatment will be relegated to chance. (Plast. Reconstr. Surg. 121: 596,
2008.)
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FRACTURE SCENARIOS
The most basic fracture conditions are reviewed:
(1) posterior body/angle fracture with bite load anterior, posterior, and contralateral to the fracture;
and (2) symphyseal fracture with midline and posterior bite load.
Posterior Body/Angle Fractures
Incisor Loading (Midline Load)
This scenario involves a fracture position at
the posterior body/angle region with a central
(incisor) bite target (Fig. 1). The bite target is the
point of force transition between the upper (maxilla) and lower (mandible) dental segments. The
bite target completes a force circuit between the
mandible and midface, where the load is transferred through this substance secondary to force
generated by muscular actions.
As muscular contraction occurs, the masseteric sling (masseter and medial pterygoid musculature) generates an upward movement of the
posterior mandible. Most obvious movement occurs at the fracture site with the mouth open. The
target, a shear component may be seen in combination with the rotatory movement, effecting further
displacement of the fracture segments (Fig. 4).
When the bite target is contralateral to the fracture of the body/angle region and the fracture is
within the attachment region of the muscle, the
ipsilateral soft-tissue/muscle components may assist
in stabilizing the fracture from additional movement
caused by muscle contraction, depending on fracture conditions.
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Fig. 4. Posterior body/angle fracture with posterior (malar) loading displacement will occur at the lower border, with the soft
tissues experiencing a tensile force. Compressive forces will occur at the upper border.
Symphysis Fracture
Incisor Loading (Midline Load)
This scenario involves a central incisor bite
target with the fracture position at the symphysis
region (Fig. 5). Analysis of symphysis fractures reveals a behavior pattern significantly different from
that predicted by accepted tension/compression
cantilever theory. Cantilever theory has generally
been depicted as a hemimandible loaded at the midline with the implied region of tension along the
upper margin.13 A curved structure, suspended by
soft tissue, with the active component of the force
generation laterally positioned (human mandible),
presents with behavior more consistent with a suspended beam14 (Fig. 6). Finite element analysis studies (and in vivo studies in primates) indicate tensile
stress at the midline in an intact system, with greater
tensile stress along the lingual surface than along the
buccal surface.15,16
When a midline fracture is present, the incisor
load position (target) acts as a constraint around
which the mandible rotates. Activation of the masseteric sling will produce a rotation around an anteroposterior axis of a hemimandible (fracture at the
midline) because of the point of attachment of the
muscle and the curved structure of the mandible.
The effect of this rotation and movement will be
seen at the midline as separation of the lower border
of the mandible greater than separation of the upper border (Fig. 7).
A compressive force along the upper mandible
border will occur if the segments are in contact.
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terns established within all solid structures, including soft tissues. The stiffest components, including
bone, activated muscle fibers, and fascia, will all
share in some load distribution.
Local muscle contraction can effect some degree of increased stability at the fracture site during contraction when a fracture occurs without
significant disruption of the periosteum and softtissue/muscle attachments. The effect is most significant when the fracture is within the attachment
region of the muscle. The contracted muscle acts
to carry some of the load generated, reducing the
load on the adjacent bone. Muscle contraction
and the resulting stiffness of the muscle can also
provide for additional stability at a fracture site by
reducing the displacement during loading. A bite
target anterior to the main vector of the masseter
will be associated with a greater degree of bending
stresses, and the effects of muscle support diminish with incisor loads. The greater the lever arm
(the longer the distance) from a posterior fracture
to a bite target, the higher probability of motion
at the fracture site and the less significant the
contribution of soft tissue for stability.
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Single-Plate Systems
Upper Border Plate
When an incisor (midline) bite target is present, the upper border plate at the fracture site will
experience primarily tensile loads, with a minimal
bending component. In a system with four or more
screws, the distribution of force among the screws
depends on very small (micron) changes in screw
spacing. With appropriate screw insertion, the
screws adjacent to the fracture will experience the
majority of the load (up to 90 percent of the stress
on the central two screws). As a load is applied,
tensile stresses begin to develop in the plate between
the screws across the fracture site. The stress is further directed into the bone by means of the bone/
screw interface. The bone along the fracture experiences no load transfer from the opposite bony
surface. The local stress distribution is secondary to
the transfer of loads through the plate. As healing
occurs (bone growth and maturation at the fracture
site), the healing tissues gradually begin to contribute to the transfer of forces generated during loading. The system at any point in time must remain in
equilibrium. If the total load on the system is F, and
the load carried by the plate/screw system is P and
that of the healing bone of the fracture site is B, then
at the time of device application, F P B, where
B 0 except in compression loading. Fractures are
known to be associated with alteration in the muscle
recruitment following injury.20 These studies indicate the probability of gradually increasing bite
forces with time after injury. Even when the fracture
is completely healed, some of the load continues to
be carried by the plate. Therefore, the system does
not return to the preinjury stress state while plates
are present and remain firmly attached.
Lower Border Plate
A single plate placed along the lower border of
a mandible body fracture, with an incisor bite
load, will need to resist distraction at the upper
border. The load condition becomes more bending, not pure tension or compression. In a fourscrew/plate scenario, when the plate is subject to
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CONCLUSIONS
Biomechanics is the study of the function of
living materials. The inability to explain divergent
results of human mandible fracture treatment is
attributable to incomplete understanding of the factors affecting biomechanics. Existing clinical explanations of divergent findings are incomplete, oversimplified, and confusing. This confusion is not
simply a result of the difficulties encountered in
comparing inconsistent patient populations or complication definitions, or difficulty in comparing reports, but is a result of the unavailability of an accurate model for understanding bone healing. Any
theory on mandible behavior will be incomplete if it
ignores the effects of soft tissue, including the effects
of the fascial and periosteal attachments, and the
effects of muscle contraction in distracting and stabilizing fractures. The forces are transmitted not
only through bone but through soft tissues, creating
circuits of force.
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