Int. J. Oral Maxillofac. Surg.

2014; 43: 12511256

http://dx.doi.org/10.1016/j.ijom.2014.07.011, available online at http://www.sciencedirect.com

Research Paper
Trauma

Finite element evaluation of

three methods of stable fixation
of condyle base fractures

G. P. de Jesus, L. G. Vaz,
M. F. R. Gabrielli, L. A. Passeri,
T. V. Oliveira, P. Y. Noritomi,
P. Jurgens
Department of Dental Materials and
Prosthodontics, Araraquara Dental School,
Sao Paulo State University (UNESP), Brazil

G. P. de Jesus, L. G. Vaz, M. F. R. Gabrielli, L. A. Passeri, T. V. Oliveira, P. Y.

Noritomi, P. Jurgens: Finite element evaluation of three methods of stable fixation of
condyle base fractures. Int. J. Oral Maxillofac. Surg. 2014; 43: 12511256. # 2014
International Association of Oral and Maxillofacial Surgeons. Published by Elsevier
Ltd. All rights reserved.

Abstract. The surgical treatment of mandibular condyle fractures currently offers

several possibilities for stable internal fixation. In this study, a finite element model
evaluation was performed of three different methods for osteosynthesis of low
subcondylar fractures: (1) two four-hole straight plates, (2) one seven-hole lambda
plate, and (3) one four-hole trapezoidal plate. The finite element model evaluation
considered a load applied to the first molar on the contralateral side to the fracture.
Results showed that, although the three methods are capable of withstanding
functional loading, the lambda plate displayed a more homogeneous stress
distribution for both osteosynthesis material and bone and may be a better method
when single-plate fixation is the option.

Condyle fractures are one of the most

controversial maxillofacial injuries regarding diagnosis, classification, and
treatment.1,2 One of the most used classifications considers the anatomical level of
the fracture: condylar head, neck, and
base.3,4
In growing patients, these fractures may
impair the growth of the craniofacial skeleton and result in mandibular deficiency,
asymmetry, or ankylosis.5,6 In adult
patients, condylar head and high subcondylar fractures have greater potential for
functional adaptation of the condyle without restoration of the anatomy than displaced base fractures with loss of ramus
0901-5027/01001251 + 06

height.7 Thus, high fractures with little

bone available for fixation are usually
treated non-surgically, whereas low displaced fractures are frequently treated surgically by reduction and stable internal
fixation.8
In the condylar region, functional loads
result in compressive stress patterns along
the posterior border of the ramus and
tensile stress patterns along the anterior
border of the ramus and in the zone situated below the sigmoid notch.9 Osteosynthesis of condylar fractures must
properly stabilize both areas, allowing
early function with minimum stress.10
Failure of osteosynthesis, such as plate

Keywords: finite element analysis; mandibular

condyle; mechanical processes.
Accepted for publication 21 July 2014
Available online 11 August 2014

fractures or loosening of screws has been

reported,7,1114 leading to a better understanding of the biomechanics of condylar
osteosynthesis and of how fixation methods behave in the condylar area.1518
Mechanical dynamic essays have led to
advances in our understanding of the stress
that occurs at the condylar process and to
the osteosynthesis materials applied to that
area, providing information that can be
used in other types of analysis. Finite
element analysis is a technique by which
a physical prototype can be studied by
creating a precise mathematical model.19
It is considered an efficient method for the
evaluation of the biomechanical behaviour

# 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

1252

de Jesus et al.

of the mandible.20,21 Mathematical models do not allow absolute clinical inferences but can offer a detailed description
of the distribution and relationship between forces and tensions within biological variability.22
This study aimed to evaluate the biomechanical behaviour of three methods of
plate osteosynthesis of condyle base fractures, in relation to load transferring and
tension distribution over the fixation materials and bone, through finite element
analysis.

the Strasbourg Osteosynthesis Research

Group (SORG). According to this classification, condyle fractures are defined as
diacapitular fractures (through the head of
the condyle), condylar neck fractures, and
condylar basis fractures.3,4
The element type used for this FEM
was tetrahedral with 10 nodes (Tet10).
A manual control was carried out, where
structures close to the plates and screws
had smaller element sizes so that they
could better demonstrate the stress
gradient.

Materials and methods

Construction of the osteosynthesis

models

Construction of the mandibular model

A three-dimensional finite element model

(FEM) of a human mandible without
anomalies was generated from DICOM
files of data collected by the Centre for
Information Technology (CTI; Renato Archer Information Technology Centre,
Campinas, SP, Brazil). The data were
derived from a dry mandible from which
computed tomography (CT) images were
obtained. The software InVesalius (version 2.1; CTI, Ministry of Science and
Technology, Campinas, SP, Brazil) was
used for image processing and the creation
of an STL model, which was later converted to CAD (computer aid-designed)
geometry with the software Rhinoceros
(version 4.0, Robert McNeel and Associates, Seattle, WA, USA) and exported for
FEM analysis with the software ANSYS
Workbench (version 14.0; Canonsburg,
PA, USA). For the study, a condylar base
fracture was simulated on the left side of
the mandibular model. It was classified in
accordance with the recommendations of

Three different digital models of commercially available titanium plates were provided by the manufacturer (Synthes,
Basel, Switzerland) as STL models, which
followed the same processing method as
described for the construction of the mandibular FEM model. Virtual screws were
created according to the manufacturers
specifications. The virtual plates and
screws were used to simulate the osteosynthesis of the condylar fracture created
on the mandibular model. Plate models
were 1 mm thick and stabilized with
6 mm  2 mm screws on the condyle segment and 8 mm  2 mm screws on the
mandibular ramus, following principles
of functionally stable internal fixation,23
to control tensile and compression functional stresses that develop on the bone
and osteosynthesis material.18 Plates and
screws are made of commercially pure
titanium. Screws from the particular manufacturer that provided the plate models
are made of a titanium alloy (Ti6Al
7Nb). Regarding the screws, although

Fig. 1. Fixation methods: (A) two straight plates; (B) lambda plate; and (C) trapezoidal plate.

the exact shape and thread design were

not considered, an external diameter of
2 mm was used. This corresponds to the
diameter of a 2-mm real screw including
the threads. The bone structure was differentiated between cortical and trabecular, in which the cortical structure has an
average thickness of 2 mm. No pre-tension was applied.
Types of osteosynthesis tested

Type 1 comprised two straight non-locking four-hole plates, one positioned along
the posterior mandibular border and the
other bellow the sigmoid notch in an
oblique fashion, at the anterior border of
the condylar process, with two screws on
each side of the fracture (Fig. 1A).
Type 2 comprised one seven-hole lambda plate, which is a locking plate, positioned along the posterior border of the
mandible with the oblique extension under
the sigmoid notch and two screws in the
condylar fragment and the remaining five
distributed along the ramus (Fig. 1B).
Type 3 comprised one four-hole trapezoidal plate, also a locking plate, positioned with the wider base centred in
the distal fragment and the narrow end
in the proximal condylar fragment. Two
screws were placed on each side of the
fracture (Fig. 1C).
Properties of materials

For the FEM analysis, the models were

considered homogeneous, isotropic, and
linear elastic: homogeneous due to the
same mechanical properties in all their
points; isotropic, because in all points
the mechanical properties do not change

Stable fixation of condyle base fractures

with direction; and linear elastic because
they return to the original shape when
tensions are removed.24 The necessary
mechanical properties required for this
analysis are Youngs module (E) and the
Poisson coefficient (n), which, according
to previous studies,25,26 are 13,700 MPa
and 0.3 for cortical bone, 7930 MPa and
0.3 for medullary bone, and 115,000 MPa
and 0.34 for plates and screws.
Loads and constraints

A simplified 250 N static force was applied perpendicularly to the occlusal plane
of the mandibular first molar; this has been
termed bite forces by Wagner et al. and
corresponds to the reaction forces of the
muscles of mastication. Mandibular
movements were restricted at the condyles
in all directions, and the fracture interface
(proximal and distal segments) was in
contact but free to displace or separate.
The interfaces between screws and plate
were determined to be in perfect contact
and firmly fixed with the cortical and
trabecular bone (no slip and no clearance),
simulating the locking plating system
(lambda and trapezoidal); as for the
straight plate, the screwplate and plate
bone interfaces were considered free for
displacement. Furthermore, the plates
were assumed not to receive or transmit
any force directly from the bone segments,
rather, the chain of force transfer was
defined as progressing from bone to screw,
from screw to plate, and finally returning
via the screws back to the bone.26 The
mandible was previously submitted to
testing by applying the force on both
ipsilateral and contralateral sides, aiming
to reduce the amount of analysis to be
done by taking into consideration only the
most critical situation. In order to do that, a
fractured mandible without the condylar
fragment was used. The right condyle and
the left fractured area had their movements restricted so the displacement

would not be possible. The tests showed

that for the studied conditions force applied to the contralateral side of the fracture was more critical than that applied to
the ipsilateral side.
Analysis of results

The models were evaluated according to

the main tension using a ratio in MPa (N/
mm2). The tension fields over bone and
osteosynthesis material were evaluated
using von Mises analysis (average stress
level) for the plates and screws and maximum tension for bone. A colour scale with
tension values varying in MPa was used and
each colour map presented a specific scale
according to the result under study. After
quantitative and qualitative analysis of the
results, the tested models were compared
verifying the tendencies of behaviour of the
different fixation methods, considering the
distribution of tensions and displacement
(measured in millimetres).
Results
Analysis of displacement

The fixation methods studied behaved

qualitatively in a very similar fashion.
There was only a very small difference
in displacement values. Since the mandible model was geometrically identical in
all tests, this suggests that the two straight
plates provided a somewhat more rigid
construct, followed by the lambda and
trapezoidal plates (Table 1).
Analysis of tension distribution

The von Mises analysis showed that when

two miniplates were used for fracture
fixation there was a concentration of tensions on the anterior plate, with high
values particularly between the two central holes close to the fracture line (Fig. 2).
For the posterior border plate, the behav-

Fig. 2. von Mises analysis of stress distribution over the plates.

1253

Table 1. Displacement of the fracture fragments at the fracture line.

Osteosynthesis type

Displacement
(mm)

Two straight plates

Lambda plate
Trapezoidal plate

00.42
00.44
00.45

iour was neutral, indicating low tensions

developing over the plate. The lambda
plate displayed a better distribution of
tensions throughout the whole surface of
the plate with much lower values (Fig. 2).
For the trapezoidal plate, an intermediate
situation occurred regarding tension
values, with a distribution that resembled
that of straight plates, concentrating tension on the side of the plate close to the
sigmoid notch (Fig. 2). Similar observations could be described for the screws.
The greater tension concentration occurred upon the screws closer to the sigmoid notch when the straight or
trapezoidal plates were used, with much
higher values for the trapezoidal configuration. Greater tension close to the screw
head was observed in all situations, especially regarding the screws fixed to the
proximal segment (Fig. 3). Data are provided in Table 2.
In the analysis of maximum tension, to
verify the distribution of tensions from the
screws to the bone, higher values were
found for the trapezoidal plate, followed
by the two-plate construct. The lowest
values were found for the lambda plate
(Fig. 4). Data are shown in Table 2.
Comparing the three fixation methods, it
can be seen that the lambda plate presented
a better distribution of tensions for this
study model. However, considering the
yield limit of titanium (9001000 MPa),
high values were encountered for both bone
and fixation materials in all osteosynthesis
methods tested, suggesting that such systems will not be absolutely fail-free under
all possible clinical conditions.

1254

de Jesus et al.

Table 2. Maximum tension values for plates/screws and bone surface.

Osteosynthesis type
Two straight plates
Lambda plate
Trapezoidal plate
Screws straight plates
Screws lambda plate
Screws trapezoidal plate

von Mises (MPa)

1694
957
988
789
514
1053

Discussion

The search for improved methods of condyle fracture fixation has been the subject
of several studies. Mechanical loading
tests are used to evaluate the behaviour
of fixation methods, allowing the study of
different osteosynthesis constructs.1518
One of the methods presently employed
to evaluate the distribution of tensions and
displacements of the fracture fragments

Maximum tension (MPa)

234
150
508

and osteosynthesis materials is finite element analysis, which presents results considered reliable.20,21 In order to achieve
accuracy, attention should be paid to the
properties of materials and constraints
applied to the finite element models prepared for testing.26,27
This type of analysis can be a very
useful instrument in the improvement of
surgical techniques and the development
of new biomaterials. Through simulations,

Fig. 3. von Mises analysis of stress distribution over the screws.

Fig. 4. Maximum tension distribution over bone.

more efficient solutions with new geometries of osteosynthesis materials are

sought, aiming to reduce tensions in the
fracture area and postoperative complications.2831 The study of new materials may
contribute to reduce the volume and
amount of implanted material while providing adequate stability.32
The more complex the model, the more
precise is the finite element analysis, as
well as the definition of the muscle action
vectors and loading in different regions.33
The FEM used in this study was simplified
to facilitate the analysis and interpretation
of data, considering only the most critical
condition. As stated by Wagner et al., 22
the force applied to the contralateral side
created greater loading in the subcondylar
fracture region, and for that reason it was
used in the analysis.
Osteosynthesis of subcondylar fractures
with two straight plates has been shown to

Stable fixation of condyle base fractures

be a suitable method that withstands the
functional loading transmitted to that area.1517,3436 In this study, the rigidity of the
construct was adequate, with little displacement at the fracture line. On the other hand,
rigidity promoted a higher concentration of
tensions dissipated in the fixation material
and bone. As expected, high values were
obtained for the anteriorly placed plate,
which surpassed the limit of titanium in
some regions, because the plate was positioned in the area of greater tensile
stress.10,22 These high tensions were transmitted both to the screws and the regions of
insertion of the screws into the bone. The
posterior border plate was practically under
compression tensions and did not compromise the stability of the construct.
Trapezoidal and lambda plates were
designed with the aim of providing osteosynthesis of subcondylar fractures with
better biomechanical properties, occupying less space and facilitating endoscopically assisted techniques. Models of
trapezoidal plates have been tested before,31,37 showing satisfactory results
when used for the fixation of subcondylar
fractures, and resisting well under physiological functional loading. The geometrical form and positioning of the plate have
a direct influence on that good performance. The present study showed a tension distribution similar to that
encountered with two straight plates, with
greater concentration on the anterior arm
of the plate, but lower tension values under
the plate. However, tensions observed in
the screws and over the bone were much
higher, indicating that the use of only one
screw on each side of the fracture, in the
traction zone, may result in complications
under high loading forces.
When analyzing the tension exerted on
the screws and how it would be transferred
to the bone surface, the models studied
showed some noteworthy results. Only the
lambda plate and trapezoidal plate were
locking plates. Authors have shown that
locking plates are advantageous, with
greater primary stability and a lower probability of screw loosening.28 However,
when comparing the lambda plate with
the trapezoidal plate, much higher values
were observed for the trapezoidal plate,
even higher than those found for the two
non-locking straight plates. Such high
values of stress indicate the possibility
of screw loosening or even screw fracture,
especially in screws located closer to the
areas of traction. Regarding the trapezoidal plate, this feature becomes even more
critical as the plate presents only two
screws on each side, which may explain
the high stress concentration.

The model of the lambda plate also

presented a satisfactory mechanical stiffness of the system, although the shift was
slightly larger than for the straight plates.
The stress distribution on the plate surface
was more homogeneous, showing a more
efficient dissipation of stresses to the bone.
This is also a case where the position and
shape of the plate may explain the results.
The lambda plate was located with its
longest arm in a region known to be more
affected by compression forces, following
the long axis of the condyle, and the other
arm was directed to the region more susceptible to tensile forces, near the sigmoid
notch, but more centralized. Despite that,
for the load conditions to which the system
was submitted, very high rates of tension
were observed on the plate and screws.
Although the results of studies with
FEM should not be directly transferred
to clinical situations, these data suggest
that all methods, under the load conditions
tested, could fail by plate or screw fracture
or by screw loosening.
To understand these results it should be
taken into account that the location, direction, and magnitude of the force applied to
the FEM was purposely critical, simulating a patient in the normal chewing and
maximum intercuspal position, a situation
that does not occur clinically. It is known
that in the surgical postoperative period
the material receives forces of much lower
intensity, such as chewing force values
around 100 N in patients at 4 weeks postoperative.16,38,39 As this study was a linear
programming model study, if the simulation was carried out with half the amount
of force (125 N), all values would also
decrease proportionally, reproducing a
system closer to the real clinical condition,
without changes in the pattern of stress
distribution. Under those conditions, all
systems could withstand the physiological
stresses. Another important issue to be
addressed in this study is the total restriction of condylar movements, which naturally leads to a transfer of tensions to the
condylar region and may simulate a more
severe condition.
In the study by Haug et al.16 it was
indicated that about 31% of the vectors
of masticatory forces (approximately
50 N) are transferred to the temporomandibular joint (TMJ) area in centric relation
in patients with condylar fractures. However, it is known that there are unintentional factors such as attrition or clenching
of the teeth that may lead to an increased
transfer to the fractured condyle. For all
that, Wagner et al.36 suggest that even if
one has a fastening system that withholds
well under physiological forces, some

1255

control of these factors is recommended

to avoid complications.
In general, the results suggest that the
lambda plate has a more favourable biomechanical behaviour, distributing the
stress more evenly and providing satisfactory mechanical rigidity to the system,
when subjected to load conditions identical
to those of two straight plates and trapezoidal plates. The use of a single plate has the
advantage of requiring a smaller area for
fixation.
Considering the experimental conditions employed, it is possible to conclude
that all methods tested provided adequate
rigidity for fixation of condyle base fractures; the lambda plate allowed better and
more homogeneous distribution of tensions to the osteosynthesis material and
bone and may be the best option when
single-plate fixation is to be applied.
Funding

None.
Competing interests

None.
Ethical approval

Not required.
Patient consent

Not required.
Acknowledgements. The authors would
like to thank the Renato Archer Centre
for Technology Information, Campinas,
SP, Brazil for the equipment and technical
support and Synthes for providing the STL
plate models and other information.

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Address:
Giorge Pessoa de Jesus
Department of Dental Materials and
Prosthodontics
Araraquara Dental School
Sao Paulo State University (UNESP)
Av. Ministro Valdemar Pedrosa
1539 Centro Manaus
Am CEP 69025-050
Brazil
Tel.: +55 9233054907
E-mail: giorgepessoa@ufam.edu.br