J Oral Maxillofac Surg 64:457-465, 2006

A Biomechanical Comparison of 2 Techniques for Reconstructing Atrophic Edentulous Mandible Fractures

Matthew J. Madsen* and Richard H. Haug, DDS
Objectives: The purpose of this investigation was to evaluate and compare the biomechanical behavior of 2 techniques for the reconstruction of atrophic edentulous mandible fractures. Materials and Methods: Thirty polyurethane atrophic edentulous mandible replicas (Sawbones, Vashon Island, WA) were used in this investigation (10 controls, 10 replicas of 2 different xation techniques). The rst reconstruction technique was a traditional titanium locking reconstruction plate afxed to the lateral border (buccal surface) of the mandible. The second reconstruction technique used the same type of plate, but placed it on the inferior border of the mandible. Both constructs were subjected to vertical loading at the symphysis and torsional loading at the body regions of the mandible replicas by an Instron 1331 (Instron, Canton, MA) servohydraulic mechanical testing unit. Mechanical deformation data within a 0 900 N range were recorded. Maximum load, displacement at maximum load, and stiffness were determined. Means and standard deviations were derived and compared for statistical signicance using a Fishers Protected Least Signicant Differences Test with a condence level of 95% (P .05). Second- and third-order polynomial best-t curves were also created for each group to further evaluate the mechanical behavior. Results: For symphysis loading, statistically signicant differences were noted between the control group and both of the plating techniques for displacement at maximum load. However, no differences were noted between the experimental groups for displacement at maximum load, stiffness, or maximum load. For body loading, statistically signicant differences were noted between the control group and the inferior border plating group for displacement at maximum load. However, no differences were noted between the experimental groups for displacement at maximum load, stiffness, or maximum load. Conclusion: During this bench top investigation, there were no signicant differences noted in mechanical behavior between the 2 specic experimental groups for any of the conditions measured. When placed in the context of functional parameters, both of the plating techniques met or exceeded the requirements for loading. 2006 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 64:457-465, 2006

The management of the atrophic edentulous mandibular fracture (Fig 1) remains a surgical challenge despite many of the recent advances in fracture management. This is due to a number of factors, not the least of which is the relative infrequency of this form of

Received from the College of Dentistry, University of Kentucky, Lexington, KY. *Dental Student. Professor of Oral and Maxillofacial Surgery, Executive Associate Dean. Address correspondence and reprint requests to Dr Haug: College of Dentistry, University of Kentucky, 800 Rose St, Room D508, Lexington, KY 40536-0297; e-mail: rhhaug2@uky.edu
2006 American Association of Oral and Maxillofacial Surgeons

0278-2391/06/6403-0017$32.00/0 doi:10.1016/j.joms.2005.11.018

injury, the relative inexperience of all maxillofacial surgeons, as well as the paucity of information on this topic in the surgical literature. The frequency of atrophic edentulous mandible fractures is low and is considered to be less than 1% of all facial fractures.1 Yet while low, the frequency of all facial fractures in the geriatric population is thought to be on the rise because of the increased life expectancy of older individuals, the enhanced popularity of their leisure activities, and increased physical mobility of the older population.2 This trend is supported by census data reported by the US Department of Commerce that indicates that there will be an expansion of the elderly population by 50% by the year 2050.3 Thus, this problem will not decrease in occurrence, but is more likely to become more problematic. Management of this type of injury in prior decades has included wire osteosynthesis, the use of dentures, 457

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FIGURE 1. The typical radiographic appearance of a bilateral atrophic edentulous (bucket handle) mandible fracture. Madsen and Haug. Biomechanical Atrophic Mandible. J Oral Maxillofac Surg 2006.

Gunning stents, external pin xators, and even avoidance of treatment. With the introduction of rigid internal xation into the surgeons armamentarium, this technology has brought with it the potential for the increased stability during the repair of this type of fracture. Yet despite these improvements, complications still occur; they include infection, nonunion, masticatory disability, neurosensory decits, and both high direct costs as well as high indirect social costs.4 The reasons for these types of complications have been considered to be both biologic and biomechanical. The biologic problems associated with this patient population include the systemic diseases associated with advancing age,5-7 and reduction in local blood ow, osteoporosis, and change in bone quality.8-10 The biomechanical considerations include the loss of the buttressing effects associated with diminished bone height of the atrophic edentulous mandible, as well as the stability associated with the specic form of xation.11-13 While medical management can alter many of the biologic effects, there are some (such as bone quality and blood supply) that cannot be altered. Thus, the xation modality may be the only variable that can be reliably improved upon to enhance healing of the fractured atrophic edentulous mandible. While conventional wisdom has taught us that the application of a bone plate to the lateral border of the edentulous jaw, just as for the dentate mandible, should be advantageous, this application for the severely atrophic mandible may not be the best alternative. Numerous inadequacies are associated with this type of application to the atrophic edentulous mandible. The type and quality of soft tissue coverage of the atrophic edentulous mandible, when reconstructed by the traditional lateral border plate, often results in wound dehiscence (Fig 2) and can then be compounded by infection and non-union. Moreover, the application of a 2.4 mm outer thread diameter screw requiring 5 mm of bone between the

fracture site or the inferior or superior border requires a minimum of 12.5 mm of bone. This is not available in the severely atrophic edentulous mandible (Class 3, 10 mm) and thus subjects the reconstruction failure on a biomechanical basis. The argument that a bone graft will be helpful does not eliminate the potential for biomechanical failure, but only adds second site surgical morbidity to the list of potential problems in the management of this already complex injury. Over the past 5 years our group has reconsidered lateral border reconstruction plate management for atrophic edentulous mandibular fractures, and have placed the plate at the inferior border (Fig 3), much as one would place a transmandibular implant.14 For more than a dozen of these types of fractures managed, with 1 or more years of follow-up (the subject of another investigation), all have gone on to union, with only 2 patients suffering loose screws months after healing, which were removed without compromising the reconstruction. With these clinical observations in mind, the question then remains as to the differences in healing associated with these 2 types of xation techniques. Are the differences purely biological? Or are there biomechanical components? Therefore, the purpose of this investigation was to evaluate and compare the biomechanical behavior of a reconstruction plate placed on the inferior border of an atrophic edentulous mandible, to lateral border xation and a control, using polyurethane synthetic mandible replicas under benchtop conditions that resembled clinical function. These synthetic replicas (Sawbones, Vashon Island, WA) were chosen to eliminate many of the variables associated with human cadaveric and animal mandibles and have previously been used for biomechanical research.15-20 The polyurethane replicas have been created from exactly matched human anatomy in all

FIGURE 2. Wound dehiscence is a common postoperative sequelae of lateral boarder reconstruction plating for this form of mandible fracture. Madsen and Haug. Biomechanical Atrophic Mandible. J Oral Maxillofac Surg 2006.

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dimensions and proportions.15,16 The uniformity of these synthetic replicas provides more consistent sampling than cadaver bone, with a similar modulus of elasticity.15-20 Their use as human bone substitutes has been evaluated for these types of biomechanical investigations and have been veried as being acceptable alternatives.21 While direct inference to in vivo function cannot be made when using human bone substitutes, experimental trends can be identied. The parameters evaluated in this investigation were maximum load, displacement at maximum load and stiffness. Maximum load is that stress at which failure of the system is reached. Displacement at maximum load is the amount of displacement when system failure occurs. Stiffness is dened as the rate of change of stress as a function of strain (slope of the load/displacement curve). Each of these parameters was evaluated under conditions that simulated function: symphysis loading (vertical loads) and body region loading (torsional loads).

FIGURE 4. Inferior view of both plating techniques, each using a 14 hole, 3.0 locking reconstruction plate (Synthes Maxillofacial, 449.621) axed with locking 2.4 mm outer thread diameter, 10.0 mm long screws (Synthes Maxillofacial, 497.670). Madsen and Haug. Biomechanical Atrophic Mandible. J Oral Maxillofac Surg 2006.

Materials and Methods

A total of 30 synthetic polyurethane mandibles (Sawbones) were used in this study. To minimize variables, all screw and reconstruction plate sizes were consistent in the study. All screws were locking, 2.4 mm outer thread diameter, 10.0 mm in length, and fabricated of titanium (Synthes Maxillofacial, West Chester, PA, 497.670). All reconstruction plates were 20 holes, 160 mm in length, and fabricated of titanium (Synthes Maxillofacial, 497.670).
SAMPLE PREPARATION

FIGURE 3. The radiographic appearance of the inferior border reconstruction plate. Madsen and Haug. Biomechanical Atrophic Mandible. J Oral Maxillofac Surg 2006.

All 30 mandibles in the study were reduced to a consistent height of 10 mm by a single investigator. The alveolar ridge reductions were made using a Stryker TPS reciprocation saw (Stryker Instruments, Kalamazoo, MI). Ten uncut (unfractured) synthetic mandible replicas were reserved as control models (5 for symphysis [vertical] loading and 5 for body region [torsional] loading). Twenty more replicas were selected for the experimental groups. Following verication of a consistent 10 mm mandible height, 20-hole locking reconstruction plates that were 160 mm long and fabricated from titanium (Synthes Maxillofacial, West Chester, PA, 449.621) were contoured to each of the edentulous mandibles in the experimental groups. The experimental groups (Figs 4 6) were contoured as follows (Table 1): 10 plates contoured to the inferior border of the mandible, and 10 plates contoured to the lateral border. All plates were contoured using bending inserts to maintain plate integrity. Following contouring, the plates were cut to 14 holes. Plate xation was achieved using twelve 2.4 mm outer thread diameter, 10 mm long, locking screws (Synthes Maxillofacial, 497.670). Five mandibles from each of the experimental groups were reserved for symphysis (vertical) loading and 5 for body region (torsional) loading. The 20 plates and 240 screws were placed by a single investigator.

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Table 1. A DESCRIPTION OF FIXATION TECHNIQUES FOR CATEGORIES AND GROUPS

Group Control Inferior border

Fixation Technique No simulated fractures or xation. 3.0 titanium locking reconstruction plate (Synthes Maxillofacial, 449.621) xed with 12, 2.4 mm outer thread diameter, 10 mm long, locking screws (Synthes Maxillofacial, 497.760) xed on the inferior border of the mandible. 3.0 titanium locking reconstruction plate (Synthes Maxillofacial, 449.621) xed with 12, 2.4 mm outer thread diameter, 10 mm long, locking screws (Synthes Maxillofacial, 497.760) xed on the lateral border of the mandible.

FIGURE 5. Anterior view showing experimental plating techniques using a 14 hole, 3.0 reconstruction plate (Synthes Maxillofacial, 449.621) axed with locking 2.4 mm outer thread diameter, 10 mm long screws (Synthes Maxillofacial, 497.670). Note the simulated bilateral fractures in atrophic mandible models. Madsen and Haug. Biomechanical Atrophic Mandible. J Oral Maxillofac Surg 2006.

Lateral border

Madsen and Haug. Biomechanical Atrophic Mandible. J Oral Maxillofac Surg 2006.

INCISAL EDGE LOADING

The rst portion of this investigation consisted of anterior loading at the mandibular symphysis. Synthetic mandibles (N 15) were prepared by placing jig receiver holes into the coronoid/ramus region in a uniform manner using a standardized jig created from dental acrylic. Each mandibular replica was tested only once. Five uncut mandibles served as controls to dene limitations of the substrate (synthetic mandible replica). Five xated mandibles were used from each of the experimental groups. All samples were placed in a custom-fabricated jig similar to that described by Dichard and Klotch,18 permitting anterior or symphysis loading. Resistance to proximal segment rotation was provided by a stainless steel rod, 5 mm in diameter, placed through 3 eyelets in the jig and the coronoid/ramus regions of each mandible. Vertical loads were created and measured with an Instron 1331 (Instron Corp, Canton, MA) mechanical testing unit. This servohydraulic materials testing unit developed a liner displacement at a rate of 5 mm per minute, and a 13.34 kN load cell measured the result-

ant force. Data were acquired at a rate of 10 Hz and were stored through the use of Instron software. Loading was continued up to mechanical failure or the displacement limits of the servohydraulic testing unit (50 mm). The behavior of the constructs was evaluated within a 0 900 N range. Means and standard deviations were derived and compared for statistical signicance within the xation categories shown in Table 1 using a Fishers Protected Least Signicant Differences Test. A P .05 was considered signicant. Polynomial best-t curves (Fig 7) were then created for each group to further evaluate and compare the mechanical behavior within and among xation categories.
BODY REGION LOADING

FIGURE 6. Lateral view showing experimental plating techniques using a 14 hole, 3.0 reconstruction plate (Synthes Maxillofacial, 449.621) axed with locking, 2.4 outer thread diameter, 10 mm long screws (Synthes Maxillofacial, 497.670). Madsen and Haug. Biomechanical Atrophic Mandible. J Oral Maxillofac Surg 2006.

The second portion of this investigation consisted of posterior loading at the left mandibular body region. All mandibles (N 15) were prepared using coronoid/ramus receiver holes as previously described. Each model was tested only once. Five uncut mandibles were used as controls. The remaining 5 mandibles from each of the experimental groups were then used in this experimental section. The same testing jig described for incisal edge loading was used to secure the condyle/coronoid regions of the mandible replicas. To achieve torsion, a curved stainless steel rod 10 mm in diameter was secured to the Instron activator, engaged in the right body region only, and used to create loads as in the rst portion of the investigation. The Instron unit developed a liner displacement at a rate of 1 mm/minute and measured the resultant force. Data were acquired at a rate of 10 Hz and were stored through the use of Instron software. Loading was continued up to mechanical failure or the displacement limits of the servohydraulic test-

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Symphysis Loading

300 250 200 Load (N) 150 100 50 0 0 2 4 6 8 10 Displacement (mm)

Control Lateral Inferior

y = 1.2519x2 + 22.65x R2 = 0.999

FIGURE 7. Second order polynomial best-t curves for the load/ displacement data for symphysis loading. Madsen and Haug. Biomechanical Atrophic Mandible. J Oral Maxillofac Surg 2006.

ing unit (50 mm). The mechanics of the constructs for body region loading were evaluated within a 0 900 N range. The same mechanical evaluation parameters and statistical analysis were performed as described under incisal loading section. Polynomial best t curves (Fig 8) were created to evaluate biomechanical failure.

similar fashion. For each experimental group, load was resisted logarithmically along a straight slope until the failure point was reached, after which data recorded on the graph was discontinued. Lastly, some interesting observations were made regarding the xation systems when failure was reached (Table 4). For the lateral border xation technique, when loaded from the symphysis, at failure, the xation/substrate (polyurethane mandible) interface proximal to the last screw shattered. Screws did not bend. In torsion testing, the models fractured at the coronoid where the models were xated to the testing unit, or they fractured proximal to the last screw. An evaluation of the inferior border technique, when loaded from the symphysis, showed failure in a similar fracture pattern to the lateral border technique. Torsion testing of the inferior border technique, however, showed fewer coronoid fractures when compared with the lateral border plating technique. For each of the plate xation systems, the plates did not bend or deform before the atrophic mandible models shattered. Thus, we can conclude that the weak link in the reconstruction system was the substrate or mandible replica, and not the plate. Control models behaved differently than the 2 experimental methods. When loaded from the symphysis, control models shattered in the mandibular body. During torsional loading, all control failures were seen in the mid-symphysis area. Yet under all circumstances (control or experimental) the failure occurred well beyond the parameters for functional loading (see Discussion).

Results
From among the 30 synthetic mandibles, 20 plates, and 240 screws used in this investigation, some very exciting information was obtained and observations made. For symphysis loading, statistically signicant differences were noted between the control group and both experimental groups for displacement at maximum load (Tables 2, 3), but not for maximum load or stiffness. No statistically signicant differences were observed between the 2 experimental groups for stiffness, maximum load, or displacement at maximal load. For body region loading, statistically signicant differences were noted between the control group and the inferior border plating technique for displacement at maximum load, but not for maximum load or stiffness. No signicant differences were noted between the 2 experimental groups for stiffness, maximum load, or displacement at maximum load. The polynomial best t curves showed remarkably similar patterns of mechanical behavior between the experimental groups for both loading modalities. For both forms of loading, the control behaved in a disMolar Loading
40 35 30 Load (N) 25 20 15 10 5 0 0 5 10 15 Displacement (mm)
Control Lateral Inferior

20

25

30

y = 0.0014x3 - 0.0205x2 + 1.5003x R2= 0.999

FIGURE 8. Third order polynomial best-t curves for load/displacement data for body region loading. Madsen and Haug. Biomechanical Atrophic Mandible. J Oral Maxillofac Surg 2006.

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Table 2. SUMMARY OF RESULTS (MEAN STANDARD DEVIATION)

Symphysis Loading
Group Displacement at Max Load (N) Max Load (N) Stiffness (N/mm) Displacement at Max Load (N)

Body Region Loading

Max Load (N) Stiffness (N/mm)

Control Inferior border Lateral border

12.0 3.2 5.6 1.0 7.1 0.1

399.2 341.3 118.8 39.0 141.3 29.4

33 22.5 21.4 3.6 26.2 8.6

34.4 3.4 22.2 6.7 30.3 7.1

35.7 16.9 46.0 27.4 40.9 8.2

1.07 0.51 1.62 0.28 1.37 0.44

Madsen and Haug. Biomechanical Atrophic Mandible. J Oral Maxillofac Surg 2006.

Discussion
From among the 30 synthetic mandibles, 20 plates and 240 screws, used in this investigation, new and informative data was identied for the 2 techniques used for atrophic edentulous mandible fracture reconstruction. Data gathered from this study permit the following observations. First, a comparison of the polynomial best t curves (Figs 6, 7) showed some very similar mechanical behavior among the experimental groups. A rst order polynomial would take the form: x y z, a second order would take the form x2 y z, a third order would take the form x3 y z, and so on. To provide the most appropriate relationship (the straightest line on the load/displacement curve), a second order polynomial best-t curve was used for symphysis loading and a third order polynomial best-t curve was used for body loading. Thus for symphysis loading, the load increased proportionally to the square of the displacement (y 1.2519x2 22.65x), whereas for body loading, the load increased proportionally to the cube of the displacement (y 0.0014x3 0.0205x2 1.5003x). Failure or yield point (discontinuance of the line on the graph) did differ among the groups tested. A review of the statistical comparisons (Table 3) revealed no differences among the experimental groups in their abilities to resist loads. A review of the loads resisted (Table 2), coupled with the pat-

terns of behavior, revealed some interesting but understandable ndings. Yield load is the most important measure when considering biomechanical investigations. It is that load at which permanent deformation begins. Simply stated, it is the load under which failure of the system occurs. During this investigation, because of the linear pattern of the load displacement curve and then immediate drop off at failure, yield load and maximum load were the same. The loads resisted by the inferior border plating technique showed no signicant differences to the lateral border plating technique for both body and symphysis loading. Both groups resisted both vertical and torsional forces consistently. Failure patterns also showed similarities between the 2 experimental groups. When loaded from the symphysis, both models failed with a fracture proximal to the last screw. This can be explained by the lever arm created by the mandible transmitting the forces to the weakest area of the mandible, resulting in subsequent fracture. Hence, the area where the lever arm was longest resulted in an area where the models were less stable. Body region loading (torsion) resulted in a similar trend. When attempting to establish functional parameters to relate our experimental data to, the bite force literature provides some interesting information. While this type of data has existed since 1895,22 its

Table 3. STATISTICAL ANALYSIS SUMMARY USING FISHERS PROTECTED LEAST SIGNIFICANT DIFFERENCES

Categories Symphysis loading

Test Displacement at max load Max load Stiffness Displacement at max load Max load Stiffness

Statistical Signicance Yes No No Yes No No Control Control Control Control Inferior Control Control Control Control Inferior Control

Between Groups to lateral border to inferior border to lateral border to inferior border border to lateral border and all xation techniques to inferior border to lateral border to inferior border border to lateral border to all xation techniques

P Value .014 .002

Body region loading

.038

Madsen and Haug. Biomechanical Atrophic Mandible. J Oral Maxillofac Surg 2006.

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Table 4. FRACTURE ANALYSIS DESCRIBING TEST, FIXATION, AND FRACTURE LOCATION

Fracture Location Tension testing (loading from symphysis) 1. Anterior lateral border 2. Anterior lateral border 3. Anterior lateral border 4. Anterior lateral border 5. Anterior lateral border Torsion testing (loading from the body region region) 6. Lateral border 7. Lateral border 8. Lateral border 9. Lateral border 10. Lateral border Tension testing (loading from symphysis) 11. Inferior border 12. Inferior border 13. Inferior border 14. Inferior border 15. Inferior border Torsion testing (loading from the body region region) 16. Inferior border 17. Inferior border 18. Inferior border 19. Inferior border 20. Inferior border Control tension testing (loading from symphysis) 21. Control 22. Control 23. Control 24. Control 25. Control Control torsion testing (loading from the body region region) 26. Control 27. Control 28. Control 29. Control 30. Control
Madsen and Haug. Biomechanical Atrophic Mandible. J Oral Maxillofac Surg 2006.

Left side distal to 4th screw Left side distal to 4th screw Left side distal to 4th screw Left side distal to 4th screw Right side distal to 4th screw Left Left Left Left Left coronoid fracture side distal to 4th screw side distal to 4th screw coronoid fracture coronoid fracture

Left side distal to the 4th screw Left side distal to the 4th screw Right side distal to the 4th screw Right side distal to the 4th screw Left side distal to the 4th screw Left Left Left Left Left side distal to the 4th side distal to the 4th coronoid fracture side distal to the 4th side distal to the 4th screw screw screw screw

Left body/anterior border of ramus junction Right body/anterior border of ramus Right body/anterior border of ramus Right body/anterior border of ramus Right body/anterior border of ramus Mid-symphysis Mid-symphysis Mid-symphysis Mid-symphysis Mid-symphysis

communication in the scientic literature is not uniform and for the most part relates only information regarding healthy dentate patients. We have attempted to provide a relevant summary in the text to follow. Occlusal forces have been classied as swallowing, chewing, or maximum bite forces. Maximum body region bite forces for dentate patients have been identied from a low of 1.6 kg to a high of 443 kg (15.7 to 4,341.4 N).23-27 Yet, this magnitude of force would not be encouraged in the postoperative setting. Mean body region swallowing forces for dentate patients have ranged from 1.7 to 30.2 kg (16.7 to 296.0 N).22-25 Mean body region chewing forces for dentate patients have ranged from 1.6 to 26.7 kg (15.7 to 261.7 N)23-26 and are dependent upon the food source being chewed. Yet each of these recorded forces involves healthy individuals who have not been subjected to any surgical intervention or trauma and who have teeth. The edentulous bite force literature

is much more sparse.28-33 Maximum bite forces in the body region for edentulous patients have ranged from 2.9 to 19.4 kg (28.0 to 190.0 N).28-32 These forces diminish to less than one half at the symphysis region.29,30 Yet again, these are for maximum bite forces, and such would never be encouraged in the post-trauma or post-surgical population. Chewing forces for edentulous patients range from 0.9 to 5.1 kg (8.8 to 49.9 N) depending on the type and quality of the food. But again, these measures are for nontraumatized patients not having recently been subjected to surgery. It has been well established for dentate patients that during the rst weeks posttrauma or post-surgery that bite forces are reduced to less than one third of pre-trauma and pre-surgical bite forces.34-37 Thus, for post-trauma or post-surgical edentulous patients who would be chewing food, we would expect 0.3 to 1.7 kg (2.9 to 16.6 N) to be the acceptable range for functioning. The results of our

464 investigation identied trends in mechanical behavior that failed well beyond this range. Our investigation evaluated the biomechanical behavior of 2 rigid internal xation techniques used in reconstructing fractured atrophic edentulous mandibles. We used both a substrate that resembled natural tissue in shape, geometry, and anatomic dimension, yet was synthetic. While loading at the symphysis mimicked vertically deforming forces and body region loading mimicked torsionally deforming forces that are encountered under clinical circumstances, they cannot completely represent the complex interaction between the mandible and musculature in function. Thus, we can only expect to identify trends in behavior that would be helpful in making decisions clinically. The clinical implications of this study show that because of the biomechanical similarity of the 2 plating techniques, that the method that provides the least likelihood of intraoperative as well as postoperative complications would be the preferred method. As previously discussed, the likelihood of nonunion, brous union, infection, and masticatory disability is increased in the atrophic edentulous mandible. Clinical experience seems to show that the placement of a reconstruction plate on the lateral border of an edentulous atrophic mandible may result in lack of adequate soft tissue coverage and/or dehiscence leading to exposure and susceptibility to infection and non-union. Moreover, the amount of bone height available in the severely atrophic (Class 3) edentulous mandible is less than 10 mm, and does not permit the 5 mm of bone on either side of the 2.4 mm screw of a reconstruction plate to maintain biomechanical integrity. Thus, inferior border xation, although more difcult and technique sensitive in contouring, has shown improved results because of greater soft tissue coverage with a lesser likelihood of plate exposure, as well as enhanced biomechanical integrity.

BIOMECHANICAL ATROPHIC MANDIBLE

7. Bruce RA, Ellis E: The second Chalmers J. Academy Study of fractures of the edentulous mandible. J Maxillofac Surg 51:904, 1993 8. McGregor AD, MacDonald DG: Age changes in the human inferior alveolar artery-A histological study. Br J Oral Maxillofac Surg 27:371, 1989 9. Friedman CD, Constantino PD: Facial fractures and bone healing in the geriatric patient. Otolaryngol Clin North Am 25:1109, 1996 10. Bradley JC: A radiological investigation into the age changes of the inferior dental artery. Br J Oral Surg 13:82, 1975 11. Sikes JW, Smith BR, Mukherjee DP: An in vitro study of the effect of bony buttressing on xation strength of a fractured atrophic edentulous mandible model. J Oral Maxillofac Surg 58:56, 2000 12. Luhr HG, Reidick T, Merten HA: Results of treatment of fractures of the atrophic edentulous mandible by compression plating. J Oral Maxillofac Surg 54:250, 1996 13. Marciani RD: Invasive management of the fractured atrophic edentulous mandible. J Oral Maxillofac Surg 59:792, 2001 14. Powers MP, Bosker H, Van Pelt H, et al: The transmandibular implant: From progressive bone loss to controlled bone growth. J Oral Maxillofac Surg 52:904, 1994 15. Haug RH, Fattahi TT, Goltz M: A biomechanical evaluation of mandibular angle fracture plating techniques. J Oral Maxillofac Surg 10:1199, 2001 16. Haug RH, Nuveen EJ, Barber JE, et al: An in vitro evaluation of distractors used for osteogenesis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 86:648, 1998 17. Haug RH, Barber JE, Reifeis R: A comparison of mandibular angle fracture techniques. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 82:257, 1996 18. Dichard A, Klotch D: Testing biomechanical strength of repairs for the mandibular angle fracture. Laryngoscope 104:201, 1994 19. Kroon F, Mathison M, Cordes JR, et al: The use of miniplates in mandibular fractures. An in vitro study. J Craniomaxillofac Surg 19:199, 1991 20. Schmoker R: The eccentric dynamic compression plate: An experimental study as to its contribution to the functionally stable internal xation of fracture of the lower jaw. AO Bulletin, April 1976, pp 1-31 21. Bredbenner TL, Haug RH: Substitutes for human cadaveric bone in maxillofacial rigid xation research. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 90:574, 2000 22. Fields HW, Proft HW, Nixon W: Occlusal forces in normal and long-face adults. J Dent Res 65:135, 1986 23. Proft WR, Fields HW, Nixon W: Occlusal forces in normal and long-face adults. J Dent Res 62:566, 1983 24. Gibbs CH, Mahan PE, Lundan HC et al: Occlusal forces during chewing and swallowing as measured by sound transmission. J Prosthet Det 46:443, 1981 25. DeBoever JA, McCall WD, Holden S, et al: Functional occlusion: an investigation by telemetry. J Prosthet Dent 40:326, 1978 26. Metha NR, Roeber FW, Haddach AW, et al: Occlusal forces in three dimension during mastication. J Dent Res 56A:165, 1977 27. Gibbs CH, Mahan PE, Marderli A, et al: Limits of humerus bone strength. J Prosthet Dent 56:226, 1986 28. Michael CG, Javid NS, Colaizzi FA, et al: Biting strength and chewing forces in complete denture wearers. J Prosthet Dent 63:549, 1990 29. Fontijn-Tekamp FA, Slagter AP, vant Hof MA, et al: Bite forces with mandibular implant-retained overdentures. J Dent Res 77:1832, 1998 30. Fontijn-Tekamp FA, Slagter AP, Van Der Bilt A, et al: Biting and chewing in overdentures, full dentures, and natural dentitions. J Dent Res 79:1519, 2000 31. Tanaka M, Ogimoto T, Koyano K, et al: Denture wearing and strong bite reduce pressure pain threshold of edentulous oral mucosa. J Oral Rehab 31:873, 2004 32. Tortopidis D, Lyons MF, Baxendale RH: Bite force, endurance and masseter muscle fatigue in healthy edentulous subjects and those with TMD. J Oral Rehab 31:873, 2004

References
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