Tiga Cabang Model Osteotomy untuk Potongan Osteotomy Bilateral Sagittal Split Osteotomy (BSSO) adalah prosedur bedah

ortogonatik yang biasa dilakukan. Hal ini pertama kali dilakukan oleh Trauner dan Obwegeser pada 195 . Se!ak itu beberapa modi"ikasi teknik dilakukan dengan tu!uan untuk memperbaiki praktek bedah# meminimalisasi rasa sakit# dan memaksimalkan stabilitas prosedur ker!a. $okasi pemotongan pada Bilateral Sagittal Split Osteotomy (BSSO) berma%am&ma%am# tergantung pada ahli bedahnya. 'enelitian ini bertu!uan untuk menge(aluasi %ara ker!a mekanis dari sistem sekrup&lempeng di antara Bilateral Sagittal Split Osteotomy (BSSO dengan menggunakan )*+(Finite Element Analysis) tiga dimensi. +da beberapa "aktor yang menentukan modi"ikasi BSSO yang optimal pada pasien# antara lain, 1. posisi "oramen rahang bawah bagian lingual.. bagian syara" al(eolar rahang bawah/. adanya molar ketiga pada rahang bawah- dan 0. arah serta !arak pergerakan segmen distal. )iksasi internal biasa digunakan untuk menstabilkan segmen proksimal dan distal berdasarkan BSSO# penyembuhan tulang yang %epat# memulihkan "ungsi rahang atas dengan %epat seusai pembedahan# dan menurunkan kemungkinan untuk kambuh lagi. 1orkma2# dkk telah menemukan bahwa orientasi dan bentuk miniplate bukanlah "aktor utama yang mempengaruhi kestabilan. $okasi miniplates(superior# tengah# in"erior) ditentukan oleh ukuran utama yang menggunakan simulasi )*+(Finite Element Analysis). Sedangkan 3hampy# dkk menentukan bahwa garis ideal dari osteosynthesis adalah di rahang bawah# di mana "iksasi miniplate lebih stabil. Oleh karena itu# ketika membandingkan stabilitas teknik BSSO# tidak hanya diperlukan pertimbangan lokasi pembedahan osteotomy# melainkan !uga lokasi miniplate yang mungkin mempengaruhi stabilitas rahang bawah. )*+ digunakan untuk menangani masalah kompleks dalam kedokteran gigi. Beberapa penulis telah menuliskan keakuratan )*+ untuk menggambarkan kebiasaan biomekanikal dari spe%imen tulang. )*+ adalah metode numerik yang sesuai untuk pertanyaan&pertanyaan biomekanik dan sebuah alat penelitian yang (alid yang mampu menyediakan pengetahuan yang tepat pada kebiasaan mekanik kompleks dari rahang bawah. 4alam kasus ini#dapat ditaksir desain dari tiga %abang osteotomy# yaitu, 1. potongan ramus-

.. sudut rahang bawah/. dan daerah tubuh rahang bawah. 5ntuk itu# studi ini menggunakan simulasi )*+ untuk teknik BSSO dengan "iksasi lempengan di empat tempat berbeda METODE Model Rahang Bawah 6etode penelitian ini menggunakan computed tomography scan (Aquillion 64 DAS TSX1 14!"A# Toshi$a %edical System& To'yo& (epang) dan model rahang bawah sintetis (7598Synbone- +9- 6alans- Swit2erland) yang dibuat dari polyurethane. :eplika polyurethane dibuat dari segala dimensi dan proporsi anatomi manusia. 6odel tersebut terdiri atas 1/0#7/8 elemen dan .9#57. titik. 5ntuk %ontoh# tulang diambil untuk men!adi tahapan homogen. 1emudian osteotomy distimulasikan pada model dengan menggunakan teknik BSSO. Teknik BSSO 1estabilan biomekanik dari rahang bawah dibandingkan dengan tiga teknik BSSO. 4alam teknik Trauner&Obwegser# potongan %abang osteotomy dibuat hori2ontal dari daerah distal pada molar kedua hingga garis posterior di atas sudut rahang bawah. Teknik osteotomy ini pertama kali ditampilkan pada 1955 dan dipublikasikan di ;nggris pada 195 . 4alam metode Obwegeser yang diperkenalkan tahun 195 # potongan %abang osteotomy dibuat dari daerah distal pada molar kedua sampai titik tengah sudut rahang bawah. Sedangkan dalam metode Obwegeser&4al 'ont# potongan %abang osteotomy dibuat se%ara (ertikal dari bagian distal molar kedua hingga garis terbawah ramus atas. Teknik ini pertama kali ditampilkan pada 1957 dan dipublikasikan di ;nggris tahun 1981. Model sekrup dan miniplate 6asing&masing model distabilkan mengikuti dorongan osteotomy dengan menggunakan sekrup dan miniplate. 6iniplate&miniplate tersebut tidak diikat dan menempel pada permukaan tulang sedekat mungkin. 6iniplate&miniplate tersebut mempunyai empat lubang meman!ang yang terbuat dari lempengan titanium dengan menggunakan komputer tiga dimensi. Sedangkan sekrupnya berbentuk lingkaran sebesar . mm yang pas untuk penetrasi monokrotis dan "iksasi lempeng. Lokasi lempengan Tiga teknik BSSO dibagi dalam masing&masing empat kelompok.. 4i sini# stabilitas biomekanik rahang bawah di antara empat lokasi lempengan yang bertemu dalam setting klinis. 5ntuk itu# metode "iksasi miniplate ditempatkan pada posisi sebagai berikut,

1. miniplate diaplikasikan sepan!ang garis 3hampy sebagai osteosynthesis ideal# sedekat mungkin dengan garis al(eolar.. miniplate ditempatkan dalam translasi 5 mm dari lokasi awal/. miniplate ditempatkan dalam rotasi .<o searah !arum !am ke arah lokasi awal0. miniplate ditempatkan dalam rotasi .<o berlawanan !arum !am ke arah lokasi awal. 5ntuk memperkirakan stabilitas dalam teknik BSSO#pemindahan gigi insisi" dan molar# regangan maksimum (on mises dalam sistem sekrup# dan regangan tulang maksimum di sekitar sekrup diperlukan pelatihan dan pembandingan antar gigi sebelumnya. 'emindahan insisi ! regangan maksimum "on mises! dan regangan tulang maksimum 4alam membandingkan tiga teknik BSSO# metode O4 meunu!ukkan bahwa perpindahan insisi" paling sedikit# regangan mekanik maksimal# dan regangan (on 6ises paling sedikit ada pada metode O4# diikuti metode Ob dan TO. $ihat pada tabel, 'arameter 'embelokan ;nsisi"(mm) :egangan =on 6ises 6aksimum 'ada tulang(6'a) :egangan =on 6ises 6aksimum 'ada lempeng(6'a) :egangan =on 6ises 6aksimum 'ada sekrup(6'a) 6odel 1 . / 0 1 . / 0 1 . / 0 1 . / 0 6etode TO 5././ 5.8/5 8. 7< 8.979 .09.971 .89.0 / .79.5 1 .79. / 105/.151 109..758 1 8/.0 1 19/9./ . 9<0.5< 9.1../. 9.8.<</ 980.005 6etode Ob 0.17< 0.55< 0../5 0.881 19<.8/1 .19./75 191.<.9 .5/. 5 10.1. 97 105<.501 100/.878 1559.718 7. .0.8 919.9./ 750.09/ 97/../. 6etode O4 /.</7 /..87 /.... /.5/9 11<.09. 1/..0<9 1/1.579 1/9.5 . 11.0. . 1.0 . .9 1.18.7/7 1.97.8./ 7<9.901 757. 09 7.9.90 910.5/9

4alam tabel tersebut dapat dilihat bahwa seluruh aspek terdapat pada metode TO. ;ni artinya metode TO di seluruh lokasi miniplate dapat men!adi aspek terbaik. 5kuran pengungkit yang ke%il dalam metode O4 rupanya memegang peran penting dalam menghasilkan tegangan ke%il dan pergeseran yang ke%il pula. 4engan menggunakan simulasi )*+# 'uri%elli# dkk menyarankan bahwa teknik osteotomy dapat mendapatkan hasil terbaik dengan metode O4.

Sedangkan dalam penelitian in (itro# O2den membandingkan kestabilan metode O4 dengan BSSO dan hasilnya ternyata maksimal. Selain itu# 4al 'ont !uga mengatakan bahwa metode O4 lebih baik dan lebih mudah beradaptasi dengan lingkungan mulut# dan mudah untuk digunakan oleh para ahli. Three lateral osteotomy designs or bilateral sagittal split osteotomy# biome$hani$al e"aluation with three%dimensional inite element analysis &iromasa Takahashi1># Shigeaki Moriyama.# &aruhiko 'uruta1# &isao Matsunaga.# (uki Sakamoto. and Toshihiro )ikuta1

> 3orresponding author, Hiromasa Takahashi hiromasatakahashi?gmail.%om

+uthor +""iliations
1

4epartment o" Oral and 6a@illo"a%ial Surgery# )a%ulty o" 6edi%ine# )ukuoka 5ni(ersity# &05& 1 Aanakuma# Bonan&ku# )ukuoka# Bapan
.

4epartment o" 6e%hani%al *ngineering# )a%ulty o" *ngineering# )ukuoka 5ni(ersity# 7&19&1 Aanakuma# Bonan&ku# )ukuoka# Bapan )or all author emails# please log on. "ead * Face %edicine .<1<# *,0 doi,1<.1178C1 08&18<D&8&0

The ele%troni% (ersion o" this arti%le is the %omplete one and %an be "ound online at, http,CCwww.head&"a%e&med.%omC%ontentC8C1C0 :e%ei(ed, 18 Buly .<<9 +%%epted, .8 6ar%h .<1< 'ublished,.8 6ar%h .<1< E .<1< Takahashi et al- li%ensee Bio6ed 3entral $td. This is an Open +%%ess arti%le distributed under the terms o" the 3reati(e 3ommons +ttribution $i%ense (http,CC%reati(e%ommons.orgCli%ensesCbyC..<)# whi%h permits unrestri%ted use# distribution# and reprodu%tion in any medium# pro(ided the original work is properly %ited. +bstra$t Ba$kground

The lo%ation o" the lateral osteotomy %ut during bilateral sagittal split osteotomy (BSSO) (aries a%%ording to the surgeonFs pre"eren%e# and no %onsensus has been rea%hed regarding the ideal lo%ation "rom the perspe%ti(e o" biome%hani%s. The purpose o" this study was to e(aluate the me%hani%al beha(ior o" the mandible and s%rew&miniplate system among three lateral osteotomy designs "or BSSO by using three&dimensional (/&4) "inite element analysis ()*+). Methods The Trauner&Obwegeser (TO)# Obwegeser (Ob)# and Obwegeser&4al 'ont (O4) methods were used "or BSSO. ;n all the )*+ simulations# the distal segments were ad(an%ed by 5 mm. *a%h model was "i@ed by using miniplates. These were applied at "our di""erent lo%ations# in%luding along 3hampyFs lines# to gi(e 1. di""erent )*+ miniplate "i@ation methods. Ge e@amined these models under two di""erent loads. Results The magnitudes o" tooth displa%ement# the ma@imum bone stress in the (i%inity o" the s%rews# and the ma@imum stress on the s%rew&miniplate system were less in the O4 method than in the Ob and TO methods at all the miniplate lo%ations. ;n addition# 3hampyFs lines models were less than those at the other miniplate lo%ations. Con$lusions The O4 method allows greater me%hani%al stability o" the mandible than the other two te%hniHues. )urther# miniplates pla%ed along 3hampyFs lines pro(ide greater me%hani%al ad(antage than those pla%ed at other lo%ations. Ba$kground Bilateral sagittal split osteotomy (BSSO) is the most %ommon orthognathi% surgi%al pro%edure I1J. ;t was "irst des%ribed by Trauner and Obwegeser in 195 I.J. Sin%e then# se(eral modi"i%ations o" the te%hniHue ha(e been introdu%ed with the aim o" impro(ing surgi%al %on(enien%e# minimi2ing morbidity# and ma@imi2ing pro%edural stability. These modi"i%ations in%lude the te%hniHue des%ribed by 4al 'ont I/J- it is generally re%ogni2ed that the bu%%al

osteotomy %ut o" the Obwegeser&4al 'ont method is positioned more anteriorly than that o" the Obwegeser method I0J# thereby in%reasing the amount o" %an%ellous bone %onta%t. There are se(eral "a%tors determining the optimal modi"i%ation "or BSSO in a patient# in%luding the position o" the mandibular "oramen (lingual)# %ourse o" the in"erior al(eolar ner(e in the mandible# presen%e o" the mandibular third molars# and planned dire%tion and magnitude o" distal segment mo(ement I5J. Howe(er# the lo%ation o" the lateral osteotomy %ut "or BSSO (aries a%%ording to the surgeonFs pre"eren%e# and no %onsensus has been rea%hed regarding the ideal lo%ation "rom the perspe%ti(e o" biome%hani%s. +lthough biome%hani%s is only one o" the "a%tors determining the osteotomy te%hniHue to be used# it is important "or the surgeon to %onsider the presen%e o" !aw de"ormities while planning the treatment strategy. :igid internal "i@ation is routinely used to stabili2e the pro@imal and distal segments "ollowing BSSO# "or "ast bone healing# initiating early postoperati(e mandibular "un%tion# and de%reasing the amount o" relapse I8J. Similarly# a stable osteotomy design is desired. +lthough numerous studies ha(e been %ondu%ted to %ompare the di""erent types o" "i@ation te%hniHues# e@periments %omparing di""erent BSSO te%hniHues "or use in orthognathi% surgery are limited I J. 1orkma2 et al. I7J ha(e "ound that the miniplate orientation and shape are not the primary "a%tors a""e%ting the stability- the lo%ation o" the miniplates (superior# middle# or in"erior) was determined to be the main parameter by using "inite element analysis ()*+) simulation. 3hampy et al. I9J determined Kthe ideal line o" osteosynthesis in the mandible#K where miniplate "i@ation is the most stable. There"ore# when %omparing the stability o" BSSO te%hniHues# not only the lo%ation "or the osteotomy %ut but also the lo%ation o" the miniplate may in"luen%e mandibular stability. There"ore# to %ompare the stability o" di""erent lateral osteotomy methods absolutely# we should eliminate the possibility that the lo%ation o" the miniplates will a""e%t the stability. )*+ is widely used in engineering and %an also be used to sol(e %omple@ problems in dentistry I1<J. Se(eral authors ha(e reported the a%%ura%y o" )*+ "or des%ribing the biome%hani%al beha(ior o" bony spe%imens I11&1/J. Ge had earlier reported the "easibility o" )*+ simulation to %ompare e@perimental studies and )*+ simulations I10J. =ollmer et al. I15J ha(e "ound Huite a

high %orrelation between )*+ simulation and in +itro measurements o" mandibular spe%imens (%orrelation %oe""i%ient L <.99.). )*+ is there"ore a suitable numeri%al method "or addressing biome%hani%al Huestions and a power"ul resear%h tool that %an pro(ide pre%ise insight into the %omple@ me%hani%al beha(ior o" the mandible a""e%ted by me%hani%al loading# whi%h is di""i%ult to assess by other means I18&17J. ;n this study# we aimed to assess three lateral osteotomy designs (i.e.# %uts at the ramus# mandibular angle# and mandibular body regions) "rom the (iewpoint o" biome%hani%al stability and the %omple@ biome%hani%al beha(ior o" the mandible and s%rew&miniplate system. )or this# we used )*+ simulations o" three BSSO te%hniHues with miniplate "i@ation at "our di""erent lo%ations# resulting in 1. )*+ miniplate "i@ation methods. Ge then applied in%isal and %ontralateral molar %ompressi(e loads to %ompare the resultant in%isal and bilateral molar displa%ements as well as the ma@imum (on 6ises stress in the s%rew&miniplate system and ma@imum bone stress in the (i%inity o" the s%rews among the miniplate "i@ation methods. Here# we show that the Obwegeser&4al 'ont method "or BSSO allows the greatest me%hani%al stability o" the mandible. Methods Mandibular modeling Ge per"ormed a %omputed tomography (3T) s%an (+Huillion 80 4+S TSD&1<10CH+- Toshiba 6edi%al Systems# Tokyo# Bapan) o" a syntheti% mandible model (7598- Synbone +9# 6alans# Swit2erland) made o" polyurethane. The polyurethane repli%a was %reated "rom e@a%tly mat%hed human anatomy in all dimensions and proportions I19J. + three&dimensional (/&4) )*+ model was %onstru%ted "rom <.5&mm serial a@ial se%tions apart "rom the two&dimensional (.&4) 3T image. The model %onsisted o" 1/0#7/8 elements and .9#57. nodes. )or simpli"i%ation# bone was assumed to be a single homogenous phase. The material properties were de"ined as MoungFs modulus o" 1/. 9'a and 'oissonFs ratio o" <./ I.<J. Ge then simulated osteotomy on the model by using ea%h o" three BSSO te%hniHues. The distal segments were ad(an%ed by 5 mm parallel to the o%%lusal plane without allowing %hange in the %ondylar position and then"i@ed with bilateral

mono%orti%al miniplate "i@ation using "our s%rews per miniplate. Ge assumed that all the models had per"e%t slippage at the bone inter"a%es. +ll surgi%al simulations and analyses were per"ormed with 6e%hani%al )inder (ersion 8.< (:esear%h 3enter 3omputational 6e%hani%s# Tokyo# Bapan). The BSSO te$hni,ues 6andibular biome%hani%al stability was %ompared among three BSSO te%hniHues ()ig. 1). ;n the Trauner&Obwegeser (TO) method# the lateral osteotomy %ut was made hori2ontally "rom the distal region o" the se%ond molar to the posterior border well abo(e the mandibular angle. This osteotomy te%hniHue was "irst per"ormed in 1955 I.1J and published in *nglish in 195 I.J.

'igure -. S$hemati$ o the three lateral osteotomy designs or bilateral sagittal split osteotomy /BSSO0. (+) ;n the Trauner&Obwegeser (TO) method# the lateral osteotomy %ut was made hori2ontally "rom the distal region o" the se%ond molar to the posterior border well abo(e the mandibular angle. (B) ;n the Obwegeser (Ob) method# the lateral osteotomy %ut was made "rom the distal region o" the se%ond molar to the midpoint o" the mandibular angle. (3) ;n the Obwegeser&4al 'ont (O4) method# the lateral osteotomy %ut was made (erti%ally "rom the distal o" se%ond molar to the lower border o" the as%ending ramus. ;n the Obwegeser (Ob) method# whi%h was introdu%ed in 195 I.1J# the lateral osteotomy %ut was made "rom the distal region o" the se%ond molar to the midpoint o" the mandibular angle. ;n the Obwegeser&4al 'ont (O4) method# the lateral osteotomy %ut was made (erti%ally "rom the distal o" se%ond molar to the lower border o" the as%ending ramus. This osteotomy te%hniHue was "irst per"ormed in 1957 I.1J and published in *nglish in 1981 I/J. Miniplate and s$rew modeling *a%h model was stabili2ed "ollowing the simulated osteotomy by using miniplates and s%rews. The miniplates were not bent and "it the bone sur"a%e as %losely as possible. They were simulated as "our&hole# straight titanium miniplates (00 &..0- Synthes 6a@illo"a%ial# Gest 3hester# '+) o" 1.<&mm thi%kness by using the /&4 %omputer&aided design so"tware SolidGorks.<<7 (SolidGorks Bapan# Tokyo# Bapan). The s%rews were simulated as simple ..<&mm %ylinders o"

length appropriate "or mono%orti%al penetration and miniplate "i@ation. Ge assumed per"e%t adaptation between the plate hole and s%rew through whi%h it was mounted as well as between the s%rews and bone with no slippage at their inter"a%e I7J. The titanium plates and s%rews were modeled with MoungFs modulus o" 11< 9'a and 'oissonFs ratio o" <./0# using pre(iously reported data I..J. The material properties were the a(erages o" the (alues in the literature I./#.0J. Miniplate lo$ations The three BSSO te%hniHues were di(ided into "our subgroups ea%h. Ge %ompared mandibular biome%hani%al stability among "our miniplate lo%ations ()ig. .)# whi%h are "reHuently en%ountered inad(ertently in the %lini%al setting. There"ore# 1. di""erent )*+ miniplate "i@ation methods were de(eloped ()ig. /)# as "ollows,

'igure 1. Miniplate lo$ations. The baseline lo%ation was along 3hampyFs linesthe miniplate was applied along 3hampyFs lines o" ideal osteosynthesis as %lose to the al(eolar border as possible (the upper miniplates). (+) The miniplate was pla%ed in translation 5 mm in"erior to the baseline lo%ation. (B) The miniplate was pla%ed .<N in %lo%kwise rotation to the baseline lo%ation. (3) The miniplate was pla%ed .<N in %ounter%lo%kwise rotation to the baseline lo%ation.

'igure 2. The -1 inite element analysis /'E+0 miniplate i3ation models. TO&1 to 0# the Trauner&Obwegeser method- Ob&1 to 0# the Obwegeser method- O4&1 to 0# the Obwegeser&4al 'ont method. The miniplates were "i@ed as des%ribed in )igure .. 1. + miniplate was applied along 3hampyFs lines o" ideal osteosynthesis# as %lose to the al(eolar border as possible (O4&1# Ob&1# and TO&1 methods). .. + miniplate was pla%ed in translation 5 mm in"erior to the "irst lo%ation (O4&.# Ob&.# and TO& . methods). /. + miniplate was pla%ed .<N in %lo%kwise rotation to the "irst lo%ation (O4&/# Ob&/# and TO&/ methods).

0. + miniplate was pla%ed .<N in %ounter%lo%kwise rotation to the "irst lo%ation (O4&0# Ob&0# and TO&0 methods). Constraints The bilateral temporomandibular !oints were %ompletely %onstrained ()ig. 0+).

'igure 4. Establishing the $onstraints and loading. (+) The bilateral temporomandibular !oints were %ompletely %onstrained. (B) )or in%isal loading# a 88. &A %ompressi(e load was applied to the %entral in%isors perpendi%ular to the o%%lusal plane. (3) )or %ontralateral molar loading# a .8<.7&A %ompressi(e load was applied to the o%%lusal sur"a%e o" the right "irst molar perpendi%ular to the o%%lusal plane. Loading Ge e@amined these models under two di""erent loads. )or in%isal loading# a 88. &A %ompressi(e load was applied to the %entral in%isors perpendi%ular to the o%%lusal plane ()ig. 0B). )or %ontralateral molar loading# a .8<.7&A %ompressi(e load was applied to the o%%lusal sur"a%e o" the right "irst molar perpendi%ular to the o%%lusal plane ()ig. 03). The e"aluated parameters )or assessing the stability in the three BSSO te%hniHues# %entral in%isor displa%ement on in%isal and %ontralateral molar loadings# the ma@imum (on 6ises stress in the s%rew&miniplate system# and the ma@imum bone stress in the (i%inity o" the s%rews on both loadings were e@amined and %ompared. )or assessing the %omple@ biome%hani%al beha(ior on in%isal and %ontralateral molar loadings# "irst molar displa%ement bilaterally# the ma@imum (on 6ises stress in the bilateral s%rew& miniplate system# and the ma@imum bone stress in the (i%inity o" the bilateral s%rews in the O4& 1# Ob&1# and TO&1 methods were e@amined. Aamely# we %ompared the working side and balan%ing side on %ontralateral molar loading.

Results Central in$isor displa$ement! ma3imum bone stress! and ma3imum "on Mises stress 3omparisons o" the predi%ted %entral in%isor displa%ements# ma@imum predi%ted bone me%hani%al stress in the (i%inity o" the s%rews# and ma@imum predi%ted (on 6ises stress in the s%rew&miniplate system on in%isal loading and %ontralateral molar loading are shown in Table 1 and Table .# respe%ti(ely. On %omparing the three BSSO te%hniHues# the O4 method showed the least %entral in%isor displa%ement# least ma@imum bone me%hani%al stress in the s%rew (i%inity# and least (on 6ises stress in the s%rew&miniplate system on both loadings# "ollowed by the Ob method and TO method. Similarly# on %omparing the "our miniplate lo%ations# the 3hampyFs lines models (O4&1# Ob&1# and TO&1 methods) showed the least tooth displa%ement# least ma@imum bone stress in the s%rew (i%inity# and least ma@imum (on 6ises stress in the s%rew& miniplate system on both loadings# again "ollowed by the Ob method and TO method. Table -. Summary o" the %omparati(e results "or in%isal loading Table 1. Summary o" the %omparati(e results "or %ontralateral molar loading Detailed analyses o the Champy5s lines model in ea$h BSSO te$hni,ue The displa%ement "ields in the mandibles o" the 3hampyFs lines models on in%isal and %ontralateral molar loadings are presented in )igure 5. 3omparisons o" the predi%ted bilateral "irst molar displa%ements# ma@imum bone me%hani%al stress in the (i%inity o" the bilateral s%rews# and (on 6ises stress in the bilateral s%rew&miniplate systems on in%isal loading and %ontralateral molar loading are shown in Table / and Table 0# respe%ti(ely. :egional distributions o" (on 6ises bone stress in the (i%inity o" the s%rews and (on 6ises stress in the bilateral s%rew&miniplate system o" the 3hampyFs lines models on both loadings are shown in )igure 8 and )igure # respe%ti(ely. Table 2. ;n%isal loading Table 4. 3ontralateral molar loading

'igure 6. The displa$ement ields in the mandibles in the OD%-! Ob%-! and TO%- methods. The displa%ement "ields in the mandibles o" the 3hampyFs lines models were determined "ollowing (+) in%isal loading and (B) %ontralateral molar loading.

'igure *. Regional distributions o "on Mises bone stress in the "i$inity o the s$rews in the OD%-! Ob%-! and TO%- methods. The highest %on%entration o" bone me%hani%al stress was "ound at site / bilaterally in all three methods on (+) in%isal loading and (B) %ontralateral molar loading.

'igure 7. Regional distributions o "on Mises stress on the bilateral s$rew% miniplate systems in the OD%-! Ob%-! and TO%- methods. The site / s%rews and miniplates demonstrated (ery high tensile stresses in all three methods on (+) in%isal loading and (B) %ontralateral molar loading. On in%isal loading# "or a stru%turally symmetri%al mandible# the bilateral "irst molar displa%ements# ma@imum bone stress# and ma@imum stress on the s%rew&miniplate system were nearly symmetri%al. ;n %ontrast# on %ontralateral molar loading# the right "irst molar displa%ements# ma@imum bone stress# and ma@imum stress on the s%rew&miniplate system were higher than those o" the le"t side. The s%rew sites were numbered in all the models as 1&0 "rom distal (i.e.# the ramus) to pro@imal (i.e.# the symphysis) I.5J. The highest %on%entration o" bone me%hani%al stress was "ound at site / bilaterally. Similarly# the site / s%rew and miniplate demonstrated (ery high tensile stresses. Dis$ussion 5sing )*+ simulation# we ha(e shown that the magnitudes o" tooth displa%ement# the ma@imum bone stress# and the ma@imum stress on the s%rew&miniplate system in the O4 method were less than those in the Ob and TO methods at all the miniplate lo%ations on both in%isal and %ontralateral molar loadings. This means that the O4 method pro(ided greater resistan%e to the

simulated "un%tional "or%es than the other two te%hniHues. These results only re"er to the miniplate "i@ation te%hniHue and not to s%rews or semirigid systems. The smaller si2e o" the le(er arm in the O4 method probably plays an important role in yielding less stress and smaller displa%ement. By using )*+ simulation# 'uri%elli et al. I J suggested that their osteotomy te%hniHue presents better me%hani%al stability than the original O4 method. The 'uri%elli osteotomy is per"ormed at a region "urther distal to the osteotomy in the O4 method# per"ormed nearer to the mental "oramen. They spe%ulated that the si2e o" the le(er arm de%reases as a result o" the in%reased sur"a%e area o" medullary bone %onta%t I.8J- we agree with this interpretation o" the results. Howe(er# in our )*+ simulation# we did not %onsider bone %onta%t (i.e.# all the models were assumed to ha(e per"e%t slippage at the bone inter"a%es)# be%ause osseous healing starts and is not %ompleted in the early postoperati(e period. +s a matter o" %ourse# a larger sur"a%e o" bone %onta%t promotes "aster healing and has less displa%ement due to mus%le a%ti(ity. )urther# the magnitudes o" tooth displa%ement# the ma@imum bone stress# and the ma@imum stress on the plating system were less in the 3hampyFs lines models than in the other models in our study. This means that the 3hampyFs lines models pro(ided greater resistan%e to the simulated "un%tional "or%es than the models with other miniplate lo%ations. 3hampy and %olleagues determined Kthe ideal line o" osteosynthesisK in the mandible# where miniplate "i@ation is the most stable I. J. ;n the mandibular angle region# this line indi%ates that a plate may be pla%ed either along or !ust below the obliHue line o" the mandible I9J. Similarly# in our )*+ simulation# the models with miniplates pla%ed along 3hampyFs lines demonstrated a trend toward higher stability than those with other miniplate lo%ations. 5n"ortunately# the ideal sites "reHuently o(erlap tooth roots. +(oidan%e o" damage to the roots o" teeth and %ontents o" the in"erior al(eolar %anal is important I. J. ;n an in +itro study# O2den et al. I.7J %ompared the biome%hani%al stability o" ten di""erent "i@ation methods used in BSSO by using "resh sheep mandibles. Their osteotomy line was similar to that used in our O4 method. They tentati(ely %laimed that a miniplate pla%ed obliHuely

in a %lo%kwise pattern pro(ides greater stability than that pla%ed hori2ontally. ;n %ontrast# in our )*+ simulation# the miniplate pla%ed hori2ontally (O4&1 method) pro(ided greater biome%hani%al stability than that pla%ed obliHuely in a %lo%kwise pattern (O4&/ method). Similarly# in the other BSSO te%hniHues# the rotated miniplate model pro(ided less stability than the 3hampyFs lines models. There"ore# the relationship between angular (ariation o" a miniplate and orientation o" the loading may %ontribute to me%hani%al stability. Howe(er# this relationship has not been systemati%ally studied and warrants "urther in(estigation. 4al 'ont et al. I/J demonstrated that the ad(antages o" the O4 method are better and easier adaptation o" the "ragments- broader %onta%t sur"a%es- greater possibility "or %orre%tion o" prognathism# mi%rognathia# and apertognathia- and a(oidan%e o" as mu%h mus%ular displa%ement as possible. On the basis o" our "indings# we %an append another ad(antage, the O4 method pro(ides greater resistan%e to "un%tional "or%es than the other BSSO te%hniHues. 9ood stability o" the mandible in the early postoperati(e period may %ontribute to primary bone union# immediate postoperati(e "un%tion# and a shortened ma@illomandibular "i@ation period. 6oreo(er# 4ol%e et al. I.9J reported that most o" the relapse o%%urs within the "irst 7 weeks postsurgi%ally# %onsistent with the "indings o" other authors. )urthermore# when we obser(ed the 3hampyFs lines models %losely# the tooth displa%ements and stresses on the mandible bilaterally were in the same range on in%isal loading. ;n %ontrast# on %ontralateral molar loading# the displa%ements and stresses on the working side were greater that those on the balan%ing side. The magnitude o" all the parameters on the balan%ing side a%%ounted "or about 7<O o" that on the working side# whi%h is higher than we had thought. 1orioth and Hannam I/<J ha(e indi%ated that under %onditions o" stati% eHuilibrium and within the limitations o" the %urrent modeling approa%h# the human !aw de"orms elasti%ally during symmetri%al and asymmetri%al %len%hing tasks. This de"ormation is %omple@# and in%ludes the rotational distortion o" the %orpora around their a@es. ;n addition# the !aw de"orms parasagittally and trans(ersely. + wide range o" magnitudes o" %hewing "or%es a"ter BSSO has been reported I/1&//J. Ge assumed the early postoperati(e %ondition in this )*+ simulation. 6asti%atory loads o" 88. A

on the %entral in%isors and .8<.7 A on the right "irst molar were simulated# %orresponding to the mean immediate postoperati(e (mandibular ad(an%ement) bite "or%e I//J. +lthough su%h bite "or%es were not measured e@perimentally# it is possible to estimate them by multiplying the rates o" impro(ement I//J. Ge e(aluated the biome%hani%al beha(ior in the three BSSO te%hniHues "ollowing "i@ation using miniplates and s%rews. +lthough the applied in%isal loading mimi%ked (erti%ally de"orming "or%es and molar loading mimi%ked torsionally de"orming "or%es en%ountered under %lini%al %ir%umstan%es# they %annot %ompletely represent the %omple@ intera%tion between the mandible and mus%ulature in "un%tion. There"ore# we %an only e@pe%t to identi"y trends in beha(ior that will help in making de%isions %lini%ally I/0J. ;n our study# the highest %on%entration o" bone me%hani%al stress was "ound at site / in all the 3hampyFs lines models. Similarly# the highest %on%entration o" me%hani%al stress was "ound on the site / s%rews and upper outer rim o" the miniplate near site /. 3huong et al. I.5J produ%ed a /&4 "inite element model and e@amined the stress on "i@ation a"ter BSSO. They reported that the stress was %on%entrated on the upper outside rim o" the miniplate near site /# as seen in our results. ;t has been suggested that this stress %on%entration is responsible "or the s%rew loosening and miniplate breakage seen %lini%ally I/5#/8J. +rmstrong et al. I/ J reported the limitations o" in +itro e@perimental study "or %omparing the multitude o" rigid "i@ation systems. These limitations are almost the same as those o" )*+ simulation and in%lude the "ollowing, the "i@ation systems were tested by using "or%es applied (erti%ally# whereas mi@ed (erti%al# lateral# and rotational "or%es may be en%ountered %lini%ally as di%tated by the anatomi%al en(ironment- the in situ plates may be a""e%ted by the physiologi%al en(ironment (e.g.# in"lammation or in"e%tion)- and the plates were sub!e%ted to a single %ontinuous load and not repeatedly loaded as in normal "un%tion. ;n addition to these limitations# )*+ simulation also has some inherent limitations I1<#18J. The (alues o" the stresses pro(ided by )*+ are not ne%essarily identi%al to the real ones. ;n this study# we made se(eral assumptions and simpli"i%ations regarding the material properties and model generation. ;n )*+ models# bone

is "reHuently modeled as isotropi%# but it is a%tually anisotropi%. ;n this study# bone was modeled as homogeneous# isotropi%# and linearly elasti%. +nother %ru%ial limitation is that the miniplates were not bent# whereas the plates are o"ten adapted to "it the %ontour o" the bone sur"a%e %lini%ally. Aonetheless# the )*+ simulation allowed realisti% representation o" the stress distribution in the "i@ation material. Con$lusions The O4 method allows greater me%hani%al stability o" the mandible than the other two BSSO te%hniHues. ;n addition# miniplates pla%ed along 3hampyFs lines pro(ide greater me%hani%al ad(antage than those pla%ed at other lo%ations. Competing interests The authors de%lare that they ha(e no %ompeting interests. +uthors5 $ontributions H) %on%ei(ed the study design. HT %on%eptuali2ed the study design# wrote the manus%ript# and parti%ipated in the )*+ analyses. S6# MS# and H6 parti%ipated in the )*+ analyses. T1 edited and re(iewed the manus%ript. +ll authors read and appro(ed the "inal manus%ript. +$knowledgements Ge thank +sso%iate 'ro". 1a2uhiko Okamura# 4epartment o" 6orphologi%al Biology at )ukuoka 4ental 3ollege# Bapan# "or his thought"ul re(iew o" this manus%ript. This work was supported in part by a "und (<98<<8) "rom the 3entral :esear%h ;nstitute o" )ukuoka 5ni(ersity# Bapan.
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