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Article

Which of 51 Plate Designs Can Most Stably Fixate the Fragments in a Fracture of the Mandibular Condyle Base?

by
Marcin Kozakiewicz
1,*,
Jakub Okulski
1,
Michał Krasowski
2,
Bartłomiej Konieczny
2 and
Rafał Zieliński
1
1
Department of Maxillofacial Surgery, Medical University of Lodz, 113 Żeromskiego Str., 90-549 Lodz, Poland
2
Material Science Laboratory, Medical University of Lodz, 251 Pomorska Str., 92-213 Lodz, Poland
*
Author to whom correspondence should be addressed.
J. Clin. Med. 2023, 12(13), 4508; https://doi.org/10.3390/jcm12134508
Submission received: 5 June 2023 / Revised: 25 June 2023 / Accepted: 3 July 2023 / Published: 5 July 2023
(This article belongs to the Special Issue Treatment of Facial Fracture)
Browse Figures
Versions Notes

Abstract

:
In the surgical treatment of the most common fracture of the mandible, which is a fracture of the condylar base, a great choice of different plate shapes is observed. The aim of this study was to determine which shape gives the greatest fixation stiffness. To ensure homogeneity in comparison, tests were performed on polyurethane models divided at the level of the condylar base fracture and each were fixed with 51 plates. The plates were cut from a 1 mm thick grade 23 titanium sheet. The models were then loaded and the force required for 1 mm of fracture displacement was recorded. It was noted that in addition to osteosynthesis from two simple plates, there were also two dedicated single plates with similar rigidity. Among the large number of described designs of plates, there is considerable variation in terms of the stability of the fixation performed with them. The proposed Mechanical Excellence Factor allows a pre-evaluation of the expected rigidity of fixation with a given plate shape without the need for a loading experiment. The authors expect this to be helpful for surgeons in the application of relevant plates, as well for inventors of new plates for the osteosynthesis of basal fractures in mandibular condyle.

1. Introduction

Mandibular fracture is one of the most common facial bone injuries [1] and is a trauma in which oral and maxillofacial surgeons are important for the first aid, final treatment and management of late complications. Undoubtedly, such injuries involve fractures of the condylar process of the mandible, including its base fracture, which are the most common fractures of the mandibular condyle [2,3]. Therefore, these fractures of the base of the condylar process have been treated for decades [4]. This was due to the relatively easy surgical access (previously it was submandibular) [4,5,6], but the fixing material was quite imperfect. Initially, bone wiring was used [7,8,9], and in the 1950s experiments began with plates [10,11], but it was not until the 1980s that plate osteosynthesis became widespread [12]. In the meantime, in the 1960s, extraoral pins were used for fixation [13]. The introduction of direct-compression osteosynthesis was initiated in the 1970s [14]. The straight plates were made of various metal alloys [15,16,17,18]. Compression plates made of stainless steel [15] have given way to smaller miniplates made of titanium [19], and in the 1990s those plates became popular [20,21,22,23,24,25]. Then came the era of technical facilitation in operating on this difficult anatomical region—dedicated plates were created. The first to be created were squares, rectangles and deltas. Nowadays, they are treated in a number of surgical ways using a wide collection of dedicated titanium plates [26,27,28,29,30,31,32]. This plethora of choices raises the question of whether, therefore, each plate is equally suitable for treating fractures of the base of the condylar process. And in addition, there have recently been descriptions of new dedicated plates for fractures of the condylar process of the mandible [33,34,35,36,37,38]. Therefore, the state of the art of open reduction and internal fixation with titanium plates has been achieved. There are now dozens of these types of plates.
The aim of the study was to verify which design among 51 known plates most stably fixes fracture of the base of the condylar process of the mandible.

2. Materials and Methods

Most of the designs examined are for plates recommended by the developers and manufacturers for fixation of mandibular condylar process fractures. Some do not have this qualification but can easily be used to perform osteosynthesis of mandibular condyle fractures. They were included in the study in the hope that these shape designs would prove rigid enough for osteosynthesis of this fracture and indicate good new mechanical solutions for traumatology patients. Thus, 51 plate designs were selected (Table 1). In the first stage, 7 copies of each shape were made from titanium sheet, in grade 23 alloy certified for medical implants. Thickness of the titanium material was 1 mm.
Solid polyurethane foam mandibles were utilized in this study (Figure 1). The high variability in the density and the elastic modulus of bone affects biomechanical testing results [39]. Synthetic foam materials have been shown to produce less intra- and inter- specimen variability than cadaver bone [40]. A foam block has consistent material properties, similar to human cancellous bone. Solid polyurethane foam is widely used as an ideal medium to mimic human cancellous bone and has been confirmed by the American Society for Testing and Materials [41,42] as a standard material for testing orthopedic devices and instruments. In this study, polyurethane foam (Sawbones, Vashon, WA, USA: density 0.16 g/cc, compression modulus 58 MPa) was used as a substitute for bone [43,44,45,46].
The polyurethane models were then cut at the level of the condylar process base fracture [3,47]. Each such fracture was fixated with previously prepared plates. Predrilling was performed with a 1.5 mm drill. Each hole in the plates was filled by screws. All plates were fixed by self-tapping screws of 6 mm length and 2 mm external diameter. Plate models were grouped with seven plates for each design (i.e., each design was tested seven times). Thus, after fixation, 357 experimental condylar osteosynthesis were obtained.
The condyles were set at a 15° inferior tilt in the sagittal plane and at a 10° lateral tilt in the coronal plane to simulate actual masticatory force loading on the temporomandibular joint. This model results in the condyle exerting a force upwards and somewhat forwards and medially [48].
For testing purposes, Zwick Roell Z020 universal strength machine (Zwick-Roell, Ulm, Germany) with an individually made clamping system was used. Clamping system comprised flat 1 mm thick stainless steel based on 70 cm × 60 cm angulated aluminum block with milled 4 × M6 threaded holes for screwing the flat base plate. On the plate for stabilization of mandible, stainless steel try square was used. Pre-load force was 1 N and test speed was 1 mm/min. The action point of the compressive forces was located at the condyle. The load vs. displacement relationship, load for permanent deformation and maximum load at fracture were recorded using the lnstron chart recorder (testXpert II V3.31, Zwick Roell, Ulm, Germany). Permanent deformation was defined as the initial point that the load–displacement relationship was no longer linear. Maximum load was defined as the greatest load recorded just before any sudden decrease in load level.
The following features derived from the designs of the plates were noted: Number of Screws in Ramus, Number of Screws in Condyle, Total Fixing Screw Number, Height (mm), Width (mm), Plate Surface Area (mm2), % Round Holes (i.e., the percentage of circular holes in the plate among all holes designed in the plate), Number of Oval Holes in Plate (i.e., the number of oval holes designed in the plate), Oval Holes Share (the ratio of the number of oval holes for screws to the number of round holes designed in the plate).
In addition to the already known Plate Design Factor (PDF) [29,49,50], it was found to be statistically feasible to develop a new indicator describing, by a single number, numerous features of the plate design, incorporating more characteristic aspects of the design than the PDF: the Mechanical Excellence Factor (MEF). MEF was next calculated for each plate (Table 1).
The statistics analysis was performed in Statgraphics Centurion 18 (Statgraphics Technologies Inc. The Plains City, Warrenton, VA, USA). The ANOVA or Kruskal–Wallis test was applied for between-design comparisons. Independent χ2 tests were used to test the categorical variables. The relationship between the two quantitative variables was assessed by linear regression analysis. The best plate design was indicated based on objective description. A p-value less than 0.05 was considered statistically significant.

3. Results

The purpose of the factor analysis is to obtain a small number of factors which account for most of the variability in the eight variables. In this case, two factors have been extracted, since two factors had eigenvalues greater than or equal to 1.0 (Figure 2). Together, they account for 74.6% of the variability in the original data. Input data variables were Total Fixing Screw Number, Number of Screws in Condyle, Height (mm), Width (mm), Plate Surface Area (mm2), Percentage of Round Holes in Plate, Number of Oval Holes in Plate and Oval Holes Share. A factorability test (Kaiser–Meyer–Olkin Measure of Sampling Adequacy, KMO) was performed to provide indications of whether or not it is likely to be worthwhile attempting to extract factors from a set of variables. The KMO statistic provides an indication of how much common variance is present. For factorization to be worthwhile, KMO should normally be at least 0.6. and, here, KMO = 0.628, thus factorization is likely to provide interesting information about any underlying factors.
Next, factor loading rotation was performed in order to simplify the explanation of the factors. The rotated factors have the following equations (the coefficients in the equations correspond to the places on the graph plane in Figure 2 indicated by the factor loadings):
Factor 1 = Improvement Component = 0.924362∙Total Fixing Screw Number + 0.708092∙Number of Screws in Condyle + 0.804335∙Height[mm] + 0.802964∙Width[mm] + 0.752599∙Plate Surface Area + 0.189877% Round Holes − 0.0300946∙Number of Oval Holes in Plate − 0.11967∙Oval Holes Share
Factor 2 = Deteriorating Component = −0.108505∙Total Fixing Screw Number − 0.109∙Number of Screws in Condyle − 0.0375889∙Height[mm] − 0.0761193∙Width[mm] − 0.127803∙Plate Surface Area − 0.940781% Round Holes + 0.97506∙Number of Oval Holes in Plate + 0.980953∙Oval Holes Share
where the values of the variables in the equation are standardized by subtracting their means and dividing by their standard deviations.
Because of the opposite meaning of the loadings in Factor 1 versus Factor 2, a second-order factor analysis was performed. In this way, a single feature (MEF) combining information on eight features of the design of the mandibular condylar process fracture fixation plate was obtained (it accounts for 86.5% of the variability in the original data from Factor 1 and Factor 2). The distribution of the factor calculated in this way in the experimental data shows a slight skewness (standardized skewness is 3.854), so to normalize the distribution it was transformed by rooting—a normal distribution was obtained (standardized skewness = 0.089 and standardized kurtosis = −1.564). This is how MEF is constructed in its own way:
M e c h a n i c a l   E x c e l l e n c e   F a c t o r = 0.930016 · I m p r o v e m e n t   C o m p o n e n t − 0.930016 · D e t e r i o r a t i n g   C o m p o n e n t 2
MEF has a direct proportional relationship with the Plate Design Factor (Figure 3), with which it describes the mechanical strength of the structure. The authors are interested in introducing a measure called MEF because it incorporates more features of plate design than the known Plate Design Factor.
In this way, a numerical description of the designs of each plate was obtained. Table 1 below shows the obtained fixation stability results of each of the 51 titanium plate models. The reported average force displacing the condylar process fixation by 1 mm was 5.75 ± 3.77 N and did not have a normal distribution. The median was 5.14 N. Compared to the load of the intact mandibular model (28.33 ± 3.16 N), this value is significantly lower (Mann–Whitney (Wilcoxon) test W = 2499; p < 0.001).
Note (Figure 4) that the average experimental value of Fmax/dL for plate design corresponds to the MEF calculated from the design (CC = 0.90; R2 = 80%; p < 0.001). PDF is weaker in relation to Fmax/dL among the tested plated designs (CC = 0.86; R2 = 74%; p < 0.001). The number and share of oval holes in the structure of the plate are construction features that occur more often in relation to the lower forces that displaced the fixed fragments.
The results of the amount of force displacing the fixation by 1 mm between all tested plate designs showed significant differences (Kruskal–Wallis test, test statistic = 327; p < 0.001). The highest result was recorded for two-plate osteosynthesis with straight plates (15.17 ± 2.69 N). However, it was detected that the fixations by the ACP-T (plate 23) or XCP side-dedicated (plate 10) were not statistically weaker than double plain plate osteosynthesis (Figure 5 and Table 2).
In dedicated plates (excluding double plain plating), increasing the number of screws fixing the plate to the fracture fragments of the mandibular condylar process increases the rigidity of fixation. The best results were obtained with plates having 7–10 fixation holes (Kruskal–Wallis test, test statistics = 159; p < 0.001). The highest stability of fixation (i.e., highest displacement forces of 1 mm) was achieved for plates fixed with nine screws (8.66 ± 3.34 N/mm). All the collected results for the number of screws are shown in Figure 6.
Plate designs with an MEF higher than 20 are classified as promising plate designs. And designs that passed tests achieving a force displacing segments of 1 mm above 12 N were classified as strong plate designs (Figure 7).

4. Discussion

The use of a surgical method for treating a fracture of the mandibular condylar carries risk associated with the fixation material used. Complications that can occur after the use of osteosynthesis plates include screw loosening and plate fracture [51,52,53,54,55,56]. In order to maximize the chance of proper fracture healing in the postoperative period, numerous authors have been researching various methods of fracture fixation. The complexity of the problem can be seen in the multitude of types of plates available on the market (Table 1) for the fixation of mandibular condyle fractures.
The shapes of the plates used vary widely, from simple miniplates and miniplates with a reinforced bridge, used singly or two at a time, through square-shaped plates, to plates whose shape has been determined by the biomechanics of the mandible—trapezoid, delta, inverted Y, A-type, X-type or tau miniplates [57]. Studies on the rigidity of mandibular condylar process fracture fixation using different fixation materials have been performed by several methods. In the literature, there are studies of these plate shapes using finite element analysis, FEA [58,59], studies on animal mandibles [60,61,62], tests on polyurethane chaps [63,64] and clinical studies [65,66,67]. Due to the different natures of the aforementioned studies, their authors adopted different criteria for evaluating the plates tested. In the case of studies conducted on an animal model, the experiment consisted of loading an animal mandible with a certain force with fixation of a previously produced condylar process fracture and evaluating the displacement of the fragments. In the study conducted by Alkan et al. [60], the trial ended when the displacement reached 3.5 mm. In contrast, Pilling et al. [62] measured the force at which a loss of fixation stability would occur, which meant plate fracture, screw fracture, loss of screw stability or significant displacement. Studies using this method provide information on the force required for a given fixation to lose stability. It should be noted that the results obtained by this method in the form of force values may not match the conditions of osteosynthesis of condylar process fracture in humans due to the different anatomy of the mandible and the loading pattern of the condylar process area, which is different from the physiological one. Likewise, the results of our study do not inform about the clinical forces displacing the fragments, but only allow readers to differentiate between different plate designs. The authors of these studies report that polyurethane mandibles have similar strength parameters to human bone. In clinical studies, patients underwent radiographic evaluation after fracture osteosynthesis of the mandibular condylar process. In the study by Sugiura et al. [67], patients, six months after surgery, had a pantomographic examination and a posterior-anterior radiograph of the mandible to evaluate the proximal fragment medial flexion and vertical overlap of the fragments. The same radiographic studies were performed by Ahuja et al. In the study by Lechler [66], computed tomography was used for postoperative evaluation in addition to a pantomogram. In the case of studies conducted using the finite element method (FEA), the magnitude and direction of the displacement of the fragments relative to each other and the level of stress occurring in the plates and the bone adjacent to the plate, especially the bone surrounding the screws, are evaluated. Analysis of the results of tests performed using this method makes it possible to determine at what occlusal force the displacement of fragments relevant to the healing process or the loss of stability of the plate due to loosening of the screws can occur. Studies conducted by the finite element method (similar to the study on polyurethane models) provide constant test conditions for all tested variants of fixation of mandibular condyle fracture, so it is possible to reliably compare the tested plates in terms of osteosynthesis strength. The disadvantage is the considerably time-consuming nature of FEA, with the result that there are no comparative tests of more than a few plate types.
Each of the plates studied here can be used as a fixation material in the surgical treatment of fractures of the base of the condylar process of the mandible. Doubtless some plates would be better fitted for fractures running higher, and others for the fixation of fractures of the squat condylar process [3], but in general any can be used in this most common fracture of the condylar process of the mandible [2]. The comparison shows that the primacy of the most stable osteosynthesis has not changed. The best fixations mechanically are the double straight plates [68,69]. Two four-hole plates with a middle bridge are the state-of-the-art fixing material due to possibility of load sharing in an amount of 15.2 N in a one millimeter displacement. To reach this, round holes are needed for the screws in the 2.0 system. A detailed evaluation of the impact of compressible holes (i.e., oval-shaped) showed their adverse effect on fixation rigidity. The best are plates with seven, eight and nine hole/screws.
The following plates give the highest stability in the osteosynthesis of basal mandibular condyle fractures: TCP trapezoid pre-shaped 9, Endo-Condyle 25-283-25-91, XCP universal 3 + 5, XCP, XCP side-dedicated 3 + 5, TCP trapezoid TriLock 9 hole, XCP side-dedicated and ACP-T. The best mechanically are plates of large dimensions with a lot of round holes. The shapes of the holes significantly affect rigidity. For example, an XCP plate, if the design has only round holes, is one of the best mechanically. Adding two oval holes, on the lower part, nullifies this result and such a plate falls from the top to the middle of the peloton. A large number of holes worked well for TCP designs. Here, nine holes give excellent mechanical results. Transverse reinforcements of dedicated designs bring the mechanical strength closer to the two-plate ideal [28].
In verifying future plate designs for the fixation of mandibular condylar process fractures, the MEF is worth using. It is a combined measure of eight design features. Plate Design Factor used only four features of plate design and its evaluation loses the effect of oval holes on plate fixation rigidity. And it seems that the influence of oval holes has a negative influence on osteosynthesis rigidity [70]. The MEF values for a given plate design are strongly related to the measured average value of Fmax/dL (Table 1). Therefore, it seems to be a good tool to numerically describe the mechanical quality of plate designs.
Satisfied recovery, a key goal of precise fracture treatment, has become possible, as Artificial Intelligence (AI) technology in orthopedics has progressed in the following aspects: physical parameters can be predicted precisely through AI technology, bioactive implants made through three-dimensional printing technology can provide signals for endogenous repair and personalized surgical channels can be established through intelligent robotic technology. However, multilayer intelligent technology (MLIT) has not been used widely. With further study on biomechanical models for multiphysical parameter prediction, the stimulus response mechanism of bioactive implants and smart implants, the intelligent modeling of the 3D/4D printing process and variable structure in long-term therapy [71,72,73], satisfied repair may be achieved by MLIT [74]. This technology will be able to be assimilated into the best plate designs for the mandibular condyle in the future. By considering the advantages and disadvantages of plate design for the osteosynthesis of the mandibular condylar process base, Table 3 was constructed. An analysis of the best and worst features of osteosynthesis materials would likely provide valuable insights to improve the design, selection and implementation of the plates in condylar fractures. This information could potentially support improving patient outcomes, reducing complications and optimizing the overall effectiveness of the therapeutic approach.
Thanks to the skill of surgical teams, well-thought-out plate designs and reasonable surgical techniques in maxillofacial surgery, most fractures can be successfully treated at the primary and early secondary stages with plate and screw fixation [75]. This is possible even in major fragmented fractures, and most often it is not necessary to perform a total alloplastic joint replacement (as it is in orthopedics).
The present study is not a clinical answer to the question of effective osteosynthesis performed with specific types of plates, but rather a guideline for inventors for which direction to go in future projects. The reason for this is that, among other things, the fracture healing process depends on a great number of factors [26,76,77]. The composition of the materials used also affects the quality of the return and the condition of the patient [78,79,80,81]. These issues have not been addressed by the studies conducted, but future plate models with a high MEF can be selected for further development without conducting expensive strength tests. It is enough to analyze the series of plate design features that will be available from a known technical drawing. New plate designs are still appearing [57,82,83], and for this it will be worthwhile to compare them in a constant testing system.

5. Conclusions

The supremacy of the classic fixation of a mandibular condyle base fracture with two straight plates was confirmed. This is a type of osteosynthesis that will always find application and good results. However, it is noticeable that the large plate models give very similar osteosynthesis stabilities too, together with comfortable maneuverability.
Among the large number of described models of plates for the osteosynthesis of the mandibular condylar process, there is considerable variation in terms of the stability of the fixation performed with them. The proposed Mechanical Excellence Factor allows a pre-evaluation of the expected rigidity of fixation with a given plate without the need for a loading experiment. The authors expect this to be helpful in the future for inventors of new plates for the osteosynthesis of mandibular condylar process base fractures.

Author Contributions

Conceptualization, M.K. (Marcin Kozakiewicz); Methodology, M.K. (Michał Krasowski), B.K. and R.Z.; Software, M.K. (Marcin Kozakiewicz), M.K. (Michał Krasowski) and B.K.; Validation, M.K. (Marcin Kozakiewicz); Formal analysis, M.K. (Marcin Kozakiewicz); Investigation, J.O., M.K. (Michał Krasowski) and B.K.; Resources, M.K. (Marcin Kozakiewicz); Data curation, M.K. (Marcin Kozakiewicz); Writing—original draft, M.K. (Marcin Kozakiewicz); Writing—review & editing, M.K. (Marcin Kozakiewicz); Visualization, J.O.; Supervision, M.K. (Marcin Kozakiewicz); Funding acquisition, M.K. (Marcin Kozakiewicz). All authors have read and agreed to the published version of the manuscript.

Funding

This research was funded by the Medical University of Lodz (grant numbers 503/5-061-02/503-51-001-18 and 503/5-061-02/503-51-001-17).

Institutional Review Board Statement

Not applicable for studies not involving humans or animals.

Informed Consent Statement

Not applicable for studies not involving humans.

Data Availability Statement

The data on which this study is based will be made available upon request at https://www.researchgate.net/profile/Marcin-Kozakiewicz (accessed on 30 April 2023).

Conflicts of Interest

The authors declare no conflict of interest.

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Figure 1. Polyurethane model of mandibular condylar process base fracture fixated with “Y geometry” plate [34]. Average result for that plate is 5.83 ± 0.52 N/mm. This particular experiment corresponds to the brown line on the graph (Fmax = 143 N and the length of the displacement distance is 23.4 mm). Each line in the plot represents each of the 7 plates included in the study in a given group.
Figure 1. Polyurethane model of mandibular condylar process base fracture fixated with “Y geometry” plate [34]. Average result for that plate is 5.83 ± 0.52 N/mm. This particular experiment corresponds to the brown line on the graph (Fmax = 143 N and the length of the displacement distance is 23.4 mm). Each line in the plot represents each of the 7 plates included in the study in a given group.
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Figure 2. Factor analysis—factor loadings. By evaluating factor loadings, one can understand what the factors mean and name them. Therefore, Factor 1 can be called an improvement component and Factor 2 a deteriorating component of plate mechanical excellence based on 8 plate design features. Name of used variable presented in the plot: Total Fixing Screw Number, Number of Screws in Condyle, Height[mm], Width[mm], Plate Surface Area, % Round Holes, Number of Oval Holes in Plate and Oval Holes Share.
Figure 2. Factor analysis—factor loadings. By evaluating factor loadings, one can understand what the factors mean and name them. Therefore, Factor 1 can be called an improvement component and Factor 2 a deteriorating component of plate mechanical excellence based on 8 plate design features. Name of used variable presented in the plot: Total Fixing Screw Number, Number of Screws in Condyle, Height[mm], Width[mm], Plate Surface Area, % Round Holes, Number of Oval Holes in Plate and Oval Holes Share.
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Figure 3. Mechanical Excellence Factor (MEF) is related to Plate Design Factor (p < 0.001). The two characteristics are relatively strongly related (correlation coefficient, CC = 0.95) and the presented mathematical description model describes a significant majority of observations (R2 = 95.1). The regression equation plot is shown by the blue line. The green lines constrain the confidence limits (for a 95% confidence level). And gray lines constrain the prediction limits. A decrease in the relationship of both factors is observed for designs with lower PDF and MEF values.
Figure 3. Mechanical Excellence Factor (MEF) is related to Plate Design Factor (p < 0.001). The two characteristics are relatively strongly related (correlation coefficient, CC = 0.95) and the presented mathematical description model describes a significant majority of observations (R2 = 95.1). The regression equation plot is shown by the blue line. The green lines constrain the confidence limits (for a 95% confidence level). And gray lines constrain the prediction limits. A decrease in the relationship of both factors is observed for designs with lower PDF and MEF values.
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Figure 4. Relationship of experimental results to numerical description of plate design (p < 0.001). The graphs show the average, resulting from seven repetitions of load of the same design plate; (left) Plate Design Factor, PDF, and (right) Mechanical Excellence Factor, MEF, calculated for each of the 51 experimental groups. Each group represents 1 result in the graph.
Figure 4. Relationship of experimental results to numerical description of plate design (p < 0.001). The graphs show the average, resulting from seven repetitions of load of the same design plate; (left) Plate Design Factor, PDF, and (right) Mechanical Excellence Factor, MEF, calculated for each of the 51 experimental groups. Each group represents 1 result in the graph.
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Figure 5. Experimental results for each plate design. Forces needed for one-millimeter displacement of the fixed fragments: mean (red cross), median (thin vertical line inside the grey box). And on the top axis described in dark blue is the Mechanical Excellence Factor (MEF), reflected in the graph as thick vertical lines. The general trend of increasing plate rigidity with increasing MEF can be seen.
Figure 5. Experimental results for each plate design. Forces needed for one-millimeter displacement of the fixed fragments: mean (red cross), median (thin vertical line inside the grey box). And on the top axis described in dark blue is the Mechanical Excellence Factor (MEF), reflected in the graph as thick vertical lines. The general trend of increasing plate rigidity with increasing MEF can be seen.
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Figure 6. Forces needed for one-millimeter displacement of the fixed fragments in designs grouped by total number of fixing screws: mean (red cross), median (thin vertical line inside the box). The data apply only to dedicated plates—there are no data for two-plate osteosynthesis.
Figure 6. Forces needed for one-millimeter displacement of the fixed fragments in designs grouped by total number of fixing screws: mean (red cross), median (thin vertical line inside the box). The data apply only to dedicated plates—there are no data for two-plate osteosynthesis.
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Figure 7. Relationship of cumulative evaluation of plate construction (Mechanical Excellence Factor, MEF) to resistance to displacement force of fixated fragments of mandibular condylar process base fracture (p < 0.001). Above data present all experimental results collected (357 experiments). The two characteristics are relatively strongly related (CC = 0.86) and the presented mathematical description model describes a significant majority of observations (R2 = 73%). The regression equation plot is shown by the blue line. The points represent the experimental results obtained. The exact results of the load tests are shown in Table 1. The green lines constrain the confidence limits (for a 95% confidence level). And gray lines constrain the prediction limits. A group of designs with promising construction features (green rectangle signed PROMISING) and a group of designs that enable fixation with high stability (blue rectangle signed STRONG) are noticeable. The contents of the two sets partially overlap.
Figure 7. Relationship of cumulative evaluation of plate construction (Mechanical Excellence Factor, MEF) to resistance to displacement force of fixated fragments of mandibular condylar process base fracture (p < 0.001). Above data present all experimental results collected (357 experiments). The two characteristics are relatively strongly related (CC = 0.86) and the presented mathematical description model describes a significant majority of observations (R2 = 73%). The regression equation plot is shown by the blue line. The points represent the experimental results obtained. The exact results of the load tests are shown in Table 1. The green lines constrain the confidence limits (for a 95% confidence level). And gray lines constrain the prediction limits. A group of designs with promising construction features (green rectangle signed PROMISING) and a group of designs that enable fixation with high stability (blue rectangle signed STRONG) are noticeable. The contents of the two sets partially overlap.
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Table
Table 1. Compared plate designs placed from the weakest to the strongest fixing material.
Table 1. Compared plate designs placed from the weakest to the strongest fixing material.
NameDesign Code *DesignH
(mm)		W
(mm)		S
(mm2)		PDFMEFFmax/dL
(N/mm)
Grid Compression PlatePlate 35Jcm 12 04508 i00117.39.170921.00.99 ± 0.39
Kolsuz’s Rectangular PlatePlate 48Jcm 12 04508 i00211.410.149671.21.187 ± 0.21
Grid PlatePlate 36Jcm 12 04508 i003199.6801021.41.40 ± 0.38
Rectangle Plate 4 holesPlate 32Jcm 12 04508 i004118.537551.51.47 ± 0.16
Delta Condylar plate 3 oval holesPlate 37Jcm 12 04508 i0051711.464871.71.68 ± 0.63
Kolsuz’s Triangular PlatePlate 47Jcm 12 04508 i0061410.458791.71.71 ± 0.12
Small TrapezePlate 33Jcm 12 04508 i00711.611.641611.91.87 ± 0.21
Small Trapeze upper hole togetherPlate 34Jcm 12 04508 i00811.112.140612.22.17 ± 0.32
Triangle lower 2 hole mediallyPlate 45Jcm 12 04508 i00918.19.867902.22.24 ± 0.38
Square PlatePlate 31Jcm 12 04508 i010101039572.32.34 ± 0.66
Triangle lower 2 hole distallyPlate 42Jcm 12 04508 i01117.81067902.42.41 ± 0.54
Cut T-ACPPlate 44Jcm 12 04508 i01223.69.3851122.92.86 ± 0.37
Rectangle Plate 6 holesPlate 38Jcm 12 04508 i013201067943.13.14 ± 0.63
Delta Condyle Compression Plateplate 14Jcm 12 04508 i01415.38.81791913.23.20 ± 1.39
Patent pending small triangleplate 11Jcm 12 04508 i01513.581381513.33.27 ± 0.36
Inverted Yplate 28Jcm 12 04508 i01623.611.12032253.43.46 ± 0.51
Yang’s Keyhole PlatePlate 46Jcm 12 04508 i01719.79,.9801063.,53.53 ± 0.81
Cut ACP-Splate 08Jcm 12 04508 i01814.98.11651793.63.60 ± 1.29
XCP 3 + 5 with 2 compression holesPlate 40Jcm 12 04508 i01920.5161071384.04.01 ± 0.88
Endo-Condyle 25-288-08-09plate 21Jcm 12 04508 i02022.7112712894.14.08 ± 0.46
LambdaPlate 41Jcm 12 04508 i02125.113.3721064.44.37 ± 0.41
Delta TriLockplate 02Jcm 12 04508 i02215.48.81741874.64.62 ± 0.90
TCP, trapezoidplate 07Jcm 12 04508 i02310.411.41431565.04.98 ± 1.42
Lambda Thinnedplate 01Jcm 12 04508 i02425.6132192445.04.99 ± 2.46
A-Shape PlatePlate 43Jcm 12 04508 i02523.614.1981315.05.00 ± 0.62
Trapezoidal PlatePlate 51Jcm 12 04508 i02620181892135.35.29 ± 0.67
Strutplate 04Jcm 12 04508 i027199.62172325.35.32 ± 0.47
Endoscopic Retractive 9 holeplate 16Jcm 12 04508 i0281815.22702895.35.34 ± 0.80
Trapezoid Condylar Fracture Plateplate 24Jcm 12 04508 i02911.510.91601725.55.53 ± 1.35
TCP, anatomical TriLockPlate 09Jcm 12 04508 i03010.711.41511645.75.66 ± 1.13
PC7TPlate 49Jcm 12 04508 i0311512,8861105.75.72 ± 1.41
Y geometryPlate 50Jcm 12 04508 i03225191191555.85.83 ± 0.52
PC5Tplate 06Jcm 12 04508 i03313.511.82112236.16.08 ± 1.00
Delta Plateplate 27Jcm 12 04508 i03413.711.41761906.26.19 ± 1.02
Trapezoid BigPlate 39Jcm 12 04508 i03520.819.41311656.46.44 ± 0.45
Endoscopic Retractive 10 holeplate 17Jcm 12 04508 i03621.615.32903117.07.03 ± 0.56
PC7T modifiedplate 03Jcm 12 04508 i03713.511.71992137.17.14 ± 0.89
ACP-VTplate 12Jcm 12 04508 i03837213714047.47.41 ± 1.97
Rhombic 3D—round holesplate 26Jcm 12 04508 i03920132582747.47.43 ± 0.67
Rhombic 3D—oval holesplate 05Jcm 12 04508 i04020132212397.67.57 ± 1.60
cut ACP-Tplate 29Jcm 12 04508 i04120132242438.48.44 ± 2.25
ACP-Splate 25Jcm 12 04508 i0422616.35385478.88.80 ± 1.14
TCP, trapezoid, pre-shaped 9plate 15Jcm 12 04508 i04319.219.13623799.29.21 ± 1.77
Endo-Condyle 25-283-25-91plate 30Jcm 12 04508 i04426.516.13673889.49.38 ± 2.13
XCP universal 3 + 5plate 19Jcm 12 04508 i04522.71840742310.210.19 ± 1.65
XCPplate 22Jcm 12 04508 i04622.71839240811.311.31 ± 1.41
XCP side-dedicated 3 + 5plate 18Jcm 12 04508 i04722.72039341111.611.59 ± 4.03
TCP, trapezoid TriLock 9 holeplate 13Jcm 12 04508 i04818.118.233635311.811.81 ± 2.28
XCP side-dedicatedplate 10Jcm 12 04508 i04922.72039040814.314.26 ± 0.99
ACP-Tplate 23Jcm 12 04508 i05030.41541043014.614.58 ± 2.60
Double Plain Platesplate 20Jcm 12 04508 i05116.53.422723615.215.17 ± 2.69
* Names written with a lowercase letter correspond to the designs presented in an earlier publication [29], while names written with a capital letter are new designs. Abbreviations: H—height, W—width, S—surface area, PDF—Plate Design Factor, MEF—Mechanical Excellence Factor.
Table
Table 2. Multiple range tests for force displacing the fixation by 1 mm (Fmax/dL, N) by plate.
Table 2. Multiple range tests for force displacing the fixation by 1 mm (Fmax/dL, N) by plate.
NameMean Fmax/dLHomogenous Groups 1
Grid Compression Plate0.99X
Kolsuz’s Rectangular Plate1.19XX
Grid Plate1.40XX
Rectangle Plate 4 holes1.47XXX
Delta Condylar plate 3 oval holes1.68XXX
Kolsuz’s Triangular Plate1.71XXX
Small Trapeze1.87XXXX
Small Trapeze upper hole together2.17XXXXX
Triangle lower 2 hole medially2.24XXXXXX
Square Plate2.34XXXXXX
Triangle lower 2 hole distally2.41 XXXXX
Cut T-ACP2.86  XXXXX
Rectangle Plate 6 holes3.14   XXXXX
Delta Codyle Compression Plate3.20   XXXXX
Patent pending small triangle3.27    XXXXX
Inverted Y3.46    XXXXX
Yang’s Keyhole Plate3.53    XXXXX
cut ACP-S3.60     XXXXX
XCP 3 + 5 with 2 compression holes4.01      XXXXX
Endo-Condyle 25-288-08-094.08      XXXXX
Lambda4.37       XXXXX
Delta TriLock4.62        XXXXX
TCP, trapezoid4.98         XXXXX
Lambda Thinned4.99          XXXX
A-Shape Plate5.00          XXXX
Trapezoidal Plate5.29          XXXXX
Strut5.32          XXXXX
Endoscopic Retractive 9 hole5.34          XXXXX
Trapezoid Condylar Fracture Plate5.53           XXXX
TCP, anatomical TriLock5.66           XXXXX
PC7T5.72           XXXXX
Y geometry5.83            XXXXX
PC5T6.08             XXXXX
Delta Plate6.19             XXXXXX
Trapezoid Big6.44              XXXXX
Endoscopic Retractive 10 hole7.03               XXXX
PC7T modified7.14                XXXX
ACP-VT7.41                 XXXX
Rhombic 3D—round holes7.43                 XXXX
Rhombic 3D—oval holes7.57                  XXX
Cut ACP-T8.44                   XXX
ACP-S8.80                    XXX
TCP, trapezoid, pre-shaped 99.21                     XX
Endo-Condyle 25-283-25-919.38                     XX
XCP universal 3 + 510.2                      XX
XCP11.3                       XX
XCP side-dedicated 3 + 511.6                        X
TCP, trapezoid TriLock 9 hole11.8                        X
XCP side-dedicated14.3                         X
ACP-T14.6                         X
Double Plain Plates15.2                         X
1 Multiple comparison procedure to determine which means are significantly different from which others. At the top of the page, 26 homogenous groups are identified from 51 plate designs using columns of Xs. Within each column, the levels containing Xs form a group of means within which there are no statistically significant differences. The method that discriminates among the means is Fisher’s least significant difference (LSD) procedure. With this method, there is a 5.0% risk of calling each pair of means significantly different when the actual difference equals 0.
Table
Table 3. On the basis of the mechanical tests performed and the analysis of the Mechanical Excellence Factor, it is possible to indicate the unfavorable and favorable elements of the construction of the plate.
Table 3. On the basis of the mechanical tests performed and the analysis of the Mechanical Excellence Factor, it is possible to indicate the unfavorable and favorable elements of the construction of the plate.
Structural DefectsDesign Advantages
Small sizeBig dimensions
Thin armsBulky plates
Few holesMore than 6 holes
Oval holesTransverse arm connector
Long connectors between holesShort connectors between holes
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MDPI and ACS Style

Kozakiewicz, M.; Okulski, J.; Krasowski, M.; Konieczny, B.; Zieliński, R. Which of 51 Plate Designs Can Most Stably Fixate the Fragments in a Fracture of the Mandibular Condyle Base? J. Clin. Med. 2023, 12, 4508. https://doi.org/10.3390/jcm12134508

AMA Style

Kozakiewicz M, Okulski J, Krasowski M, Konieczny B, Zieliński R. Which of 51 Plate Designs Can Most Stably Fixate the Fragments in a Fracture of the Mandibular Condyle Base? Journal of Clinical Medicine. 2023; 12(13):4508. https://doi.org/10.3390/jcm12134508

Chicago/Turabian Style

Kozakiewicz, Marcin, Jakub Okulski, Michał Krasowski, Bartłomiej Konieczny, and Rafał Zieliński. 2023. "Which of 51 Plate Designs Can Most Stably Fixate the Fragments in a Fracture of the Mandibular Condyle Base?" Journal of Clinical Medicine 12, no. 13: 4508. https://doi.org/10.3390/jcm12134508

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