J Oral Maxlllofac
Surg
49 1171-1174.1991
Comparative Study of the Treatment of Mandibular Fractures With Vestibular and Lingual Wire Splints HENRY
V. KRUCHINSKY,
DMEDSC,*
AND
ANDREW
N. VOLKOVETS,
CMEDSCT
One hundred forty-two patients with mandibular fractures were studied during the 3-year period of 1988 to 1990. One hundred ten patients treated with lingual arch wires comprised the study group and 32 treated with routine labial/buccal arch wires formed the control group. Bone healing was analyzed with clinical and sonic methods in both groups. It was estimated that the clinical and sonic evidence of the mandibular body fragments union appeared earlier and the infection rate was lower in the study group than in the control group. It was concluded that lingual wire splints are preferable for treating fractures of mandibular body, alveolar ridge, and in patients with deep overbite.
and rather different.‘-7 Moreover, it was shown that the strain is concentrated on the lingual surface of the mandible under loading in the transverse p1ane.s At the same time. it was also shown that stable fixation of fractures could be achieved with minimal effort by placing the fixation appliance in accordance with the strain trajectories.‘.“.’ These facts made us undertake a comparative study of the treatment of mandibular fractures with labial/buccal arch bars and lingual wire splints.
Wire splinting in the treatment of mandibular fractures is widespread because of the efficiency, safety, and simplicity of this procedure. Oral and maxillofacial surgeons generally prefer placement of the arch bar on the labial/buccal surfaces of the teeth. However, biomechanical considerations of the mandible have changed this traditional view. Different forces affecting the mandible result in a varying distribution of strains and deformations of the bone. Strains are concentrated along the alveolar ridge and the lower border of mandible and are characterized by tension and compression.‘-” Strain distribution in the mandible in the sagittal and frontal planes has been evaluated better than that in the transverse plane. The majority of studies have ignored the mandibular body curvature and considered the strains in the lingual and vestibular cortical plates to be equal. In the latest biomechanical three-dimensional investigations of the mandible it was shown that deformation of the external and internal cortical plates was very complicated
Material and Methods CLINICAL
During the 3-year period 1988 to 1990, 142 patients with mandibular fractures were treated as inpatients by the Department of Oral and Maxillofacial Surgery at the Byelorussian State Institute for Advanced Medical Training. Minsk Regional Clinic. Patients with an inadequate number of teeth for arch bar splinting were eliminated from the study. All the subjects were divided into two groups according to the method of splinting. One hundred ten comprised the first study group and were treated with lingual arch wires. Thirty-two comprised the control group and were treated with traditional labial/buccal arch bars. The majority of injuries occurred in males; 93 (84.55%) in the first and 25 (78.13%) in the second group. The age of subjects ranged between 15 and 67 years. The age distribution is shown in Table 1.
Received from the Byelorussian State Institute for Advanced Medical Training, Minsk, Byelorussian, SSR. * Professor and Head of the Chair of Oral and Maxillofacial Surgery. t Lecturer of the Chair of Oral and Maxillofacial Surgery. Address correspondence and reprint requests to Dr Kruchinsky: Leninsky Ave. 93/3. Minsk, 220012 Byelorussian SSR. 0 1991 American
Association
of Oral and Maxillofacial
MATERIAL
Sur-
geons 0278-2391191/4911-0007$3.00/0
1171
1172
COMPARISON OF WIRE SPLINTS FOR MANDIBULAR
Table 1.
Age Distribution
No. in Experimental Group (%I
Age (yr) 15-20 21-30 31-40 41-50 51-60 More than61 Total
Table 3.
of Patients No. in Control Group (%I
23 (20.91) 51 (46.36) 22 (20.0) 8 (7.27) 4 (3.64) 2 (1.82)
1 (3.13) 17 (53.13) IO (31.25) 2 (6.25) 2 (6.25) 0
110(100.0)
32I 100.0)
Specialized emergency treatment was given within 3 days after injury in 71 (64.55%) cases in the experimental group and 19 (59.38%) in the control group. In other cases this interval was longer because of later admission. A sizable percentage of subjects sustained their injuries in fights or assaults. Industrial. vehicular, and sport accidents comprised the other causes (Table 2). There were 169 fractures in the experimental group and 51 in the control group. Sites of fracture are shown in Table 3. The number of fractures in the tooth-bearing area located in the anterior and posterior body was 83 of 169 (49.11%) in the experimental and 22 of 51 (43.14%) in the control group. In addition to fractures of the mandible, 20 patients (18.18%) in the first and 8 (25.0%) in the second group had also sustained other injuries, including wounds of the maxillofacial region, fractures of other facial bones, and brain concussion. Twentyfive patients (22.73%) in the experimental group and 7 (21.88%) in the control group had one or more systemic diseases. On the whole, the distribution of the various patient variables was similar in both groups. METHODS OF EXAMINATION
On fully cally, other when
admission, the patients were examined careby the oral and maxillofacial surgeon cliniradiographically, and with laboratory and special methods. Consultations were sought indicated.
Table 2.
Site of Fracture No. in Experimental Group (%j
Location Anterior body Posterior body Angle Ramus Condylar neck Total
No. in Control Group t%i)
52 (30.77) 64 (37.87) 3 (I .78) 19 (11.24)
14 (27.45) 8 (15.69) 17 (33.33) 0 I2 (23.53)
169 t 100.0)
51 (100.0)
31 (18.34)
Clinical and ultrasonic methods were used to evaluate the bone healing. Clinical findings were the main criterion to determine the period of maxillomandibular fixation. These included the absence of pain, inflammation, malocclusion. and mobility in the fracture site. Patients were followed for 6 to 32 months. Ultrasound evaluation of bone healing was done using the Ecchoosteometer (EOM Olc; Minmedprom, Moscow). The speed of the sound impulses from the fractured bone segment and from the intact segment were compared and expressed in percentages. Ultrasonometry was applied immediately after the reduction, and on the 7th, 14th. 21st, and 28th day in 35 patients in the first group and 21 in the second group. BASIC TREATMENT TECHNIQUES
Lingual
Splinting
A lingual splint was applied in the first group. Steel orthodontic wire (0.8 mm in diameter), which was bent according to the shape of the dental arch, was used as arch bar (Fig 1). The bars were ligated as far back as the third molar teeth, when possible. The ends of ligatures were directed into the buccal and labial embrasures to create the hooks for maxillomandibular fixation (Fig 2). Each hook had a U-shaped form to prevent it from unbending. Only mandibular splinting without maxillomandibular fixation was used in the several cases of uni- and bilateral body fractures with little displacement.
Causes of Trauma
Cause Fights/assaults Industrial accidents Vehicular accidents Sport accidents Total
FRACTURES
No. in Experimental Group (%)
No. in Control Group (%‘c)
98 (89.09) 5 (4.55) 6 (5.45) 1 (0.91)
27 (84.38) 2 (6.25) 3 (9.38) 0
1IO (100.0)
32 (100.0)
FIGURE I.
Lingual arch wire ligated to the teeth.
KRUCHINSKY
1173
AND VOLKOVETS
cal Graphics Corp) on an IBM PC compatible computer, ES 1841 (MZ PPEVM, MPOVT. Minsk). Results
FIGURE 2. fixation.
Diagram showing the hooks for maxillomandibular
LabiallBuccal
Splinting
Routine arch wires were applied in the second group. The same materials as in the lingual technique were used for arch wires and ligatures. Hooks for traction were made out of the ligature wires. Tooth Extraction The teeth in the fracture site were evaluated and their probability of survival, need for endodontic treatment, or need for extraction were estimated. Most of molars were extracted at the time of fracture reduction or within 10 days thereafter. Incisors, canines, and premolars were usually retained.
The majority of the patients were successfully managed with close reduction using wire splints and maxillomandibular elastic traction (Fig 3). However, in 27 cases (24.55%) in the study group, mandibular lingual splinting without maxillomandibular traction, and with only a supportive dressing, was used. Monosplints were applied in two cases (6.25%) in the control group. Clinical evidence of mandibular bone healing appeared much earlier in the study than in the control group. It was reflected in decreasing of the maxillomandibular fixation period for the patients in the first group (Table 4). This difference was nearly equal in the cases of uncomplicated single or double fractures and even greater in the cases of infection. Analysis of the inflammatory complications was an important part of the comparative study. Infection was seen in 5 of 83 mandibular body fractures (6.02%) in the study group, and in 3 of 22 (13.64%) in the control group (P < .05). It is also notable that in the study group the infection was arrested earlier than in the control group. Ultrasonometry also confirmed that body fracture healing was faster in the first group (Fig 4). The difference between weekly measurements in both groups was 7% to 8% (P < .05). Long-term clinical follow-up (6 to 32 months) was
Open Reduction When the methods of closed reduction were insufficient, intraoral transosseous wiring or miniplate fixation was used. In most of these cases, the fracture sites were located in non-tooth-bearing areas, the angle and ramus. These patients were excluded from the study. POSTOPERATIVECARE
Additional treatment consisted of routine pain medication. Antibiotics were administered to the 48 patients (43.64%) in the first and to the 19 patients (59.38%) in the second group. DATA ANALYSES
Statistical two-sample analyses were carried out using the Statgraf package (STSC, Inc and Statisti-
FIGURE 3. Radiographs showing a case in which lingual splints were used. A, Before reduction: B. after reduction.
1174 Table 4.
COMPARISON OF WIRE SPLINTS FOR MANDIBULAR
FRACTURES
Immobilization Period for Mandibular Fractures
No. of Fracture Sites and Presence of Infection
Experimental Group No.
of Patient\
Day\
14.0 15.45 17.50 19.98
39 61 2 8
Single Double Single complicated Double complicated
Control Group
i2 2 4
4.31* 6.32* 5.24 7.17*
No. of Pat~enta
Day\
II 14 0 7
20.10 2 6.79* 19.28 ? 6.1 I* NA 29.26 2 9.16*
Abbreviation: NA, data not available. * Statistically significant difference between groups tP < ,051.
done in 92 patients (83.64%) in the study group. There was no incidence of malunion or fibrous union. A slight malocclusion was present in four patients (3.64%). Discussion
References
The recent literature has emphasized the importance of biomechanical considerations in the treatment of mandibular fractures, especially in open reduction techniques.‘-3.9 Applying the same biomechanical principles to the closed reduction methods. we must choose the best location for the splint. As was shown in our previous studies, the lingual splint provided more stable fixation of bone fragments of the mandibular body because it was situated according to the main stress trajectories in the transverse plane. ‘O-l’ We must stress that prosthetic acrylic or cast lingual splints, described in many reports,‘3-‘” are very effective in treating mandibular fractures. They provide stable fixation of the body fragments even without maxillomandibular traction. We also use such splints in cases of difficult comminuted and unfavorable fractures, or when there is delayed healing. However, we believe that in most cases our method of lingual wire splinting provides satisfactory results. Effectiveness, simplicity, and rapidity of treatment are the main advantages of this proce-
65 0
dure. The patients treated with the lingual arch wire showed better results in fracture healing and a lower complication rate than the patients treated with the routine labiallbuccal arch wires.
21
28
FIGURE 4. Graph showing the difference between weekly increase of the speed of ultrasound in the fractured mandibular body segments in both groups. I, Lingual splinted patients; II, labialibuccal splinted patients.
I. Champy M, Lodde J-P, Jaeger JH, et al: Osteosyntheses mandibulaires selon la technique de Michelet. 1. Bases biomecaniques. II. Presentation d’un nouveau materiel. Rev Stomatol 77:569, 1976 2. Champy M. Lodde J-P: Syntheses mandibulaires. Localization des syntheses en fonction des constraintes mandibulaires. Rev Stomatol 77:971. 1976 3. Ewers R. Shilli W: Photoelastic experiments on the implantation of a bone graft into the mandible with stable compression osteosynthesis. Int J Oral Maxillofac Surg 8:462. 1979 4. Kardsz I, Korondi L. Szabo G: Photoelastic stress analysis on mandibular osteosynthesis. Int J Oral Maxillofdc Surg 15:263. 1986 5. Mongini F. Calderale PM, Barberi G: Relationship between structure and the stress pattern in the human mandible. J Dent Res 58:2334, 1979 6. Ferre JC, Legoux R, Helary JL, et al: Study of the deformations of the isolated mandible under static constraints by simulation on a physico-mathematical model. Anat Clin 7:183. 1985 7. Ferre JC, Legoux R, Helary JL. et al: Study of the mandible under static constraints by holographic interferometry. New biomechanical deductions. Anat Clin 7: 193. 1985 8. Keros-Naglic J: Deformation and strain measurements of the applied extensor appliance in the lower jaw model. Acta Med Iugosl 35:295, 1981 9. Cawood JT: Small plate osteosynthesis of mandibular fractures. Br J Oral Maxillofac Surg 23:77. 1985 10. Kruchinsky HV. Soubotko SN: Method of mandibular fractures treatment with arch wire. USSR Discoveries and Innovations 4:28, 1989 1I. Kruchinsky HV. Soubotko SN, Volkovets AN: Biomechanical basis of the mandibular fractures treatment with lingual wire splints, Part 1, in The 1st Congress of the Stomatologists of Moldavia. Kishinev. 1988, D 153 12. Volkovets AN, Kohanovskaya VM, Krylov GK: Results of the mechdnico-mathematical study of stress and deformation patterns in mandibular body, depending on its curvature, in Actual Questions of Maxillofacial Surgerv and Stomatology. Leningrad. 1989, p 20 13. Hardin JC: Triple fractures of the mandible with flaring rami. Their treatment with lingual splints. Arch Otolaryngol 98:387. 1973 14. Jackson MJ, Westmore SJ: Surgical prosthetic splints as an adjunct in treating facial fractures. Arch Otolaryngol 106:25, 1980 15. Thiele RB. Marcoot RM: Functional therapy for fractures of the condyloid process in adults. J Oral Maxillofac Surg 43:226. 1985
Surg
49 1171-1174.1991
Comparative Study of the Treatment of Mandibular Fractures With Vestibular and Lingual Wire Splints HENRY
V. KRUCHINSKY,
DMEDSC,*
AND
ANDREW
N. VOLKOVETS,
CMEDSCT
One hundred forty-two patients with mandibular fractures were studied during the 3-year period of 1988 to 1990. One hundred ten patients treated with lingual arch wires comprised the study group and 32 treated with routine labial/buccal arch wires formed the control group. Bone healing was analyzed with clinical and sonic methods in both groups. It was estimated that the clinical and sonic evidence of the mandibular body fragments union appeared earlier and the infection rate was lower in the study group than in the control group. It was concluded that lingual wire splints are preferable for treating fractures of mandibular body, alveolar ridge, and in patients with deep overbite.
and rather different.‘-7 Moreover, it was shown that the strain is concentrated on the lingual surface of the mandible under loading in the transverse p1ane.s At the same time. it was also shown that stable fixation of fractures could be achieved with minimal effort by placing the fixation appliance in accordance with the strain trajectories.‘.“.’ These facts made us undertake a comparative study of the treatment of mandibular fractures with labial/buccal arch bars and lingual wire splints.
Wire splinting in the treatment of mandibular fractures is widespread because of the efficiency, safety, and simplicity of this procedure. Oral and maxillofacial surgeons generally prefer placement of the arch bar on the labial/buccal surfaces of the teeth. However, biomechanical considerations of the mandible have changed this traditional view. Different forces affecting the mandible result in a varying distribution of strains and deformations of the bone. Strains are concentrated along the alveolar ridge and the lower border of mandible and are characterized by tension and compression.‘-” Strain distribution in the mandible in the sagittal and frontal planes has been evaluated better than that in the transverse plane. The majority of studies have ignored the mandibular body curvature and considered the strains in the lingual and vestibular cortical plates to be equal. In the latest biomechanical three-dimensional investigations of the mandible it was shown that deformation of the external and internal cortical plates was very complicated
Material and Methods CLINICAL
During the 3-year period 1988 to 1990, 142 patients with mandibular fractures were treated as inpatients by the Department of Oral and Maxillofacial Surgery at the Byelorussian State Institute for Advanced Medical Training. Minsk Regional Clinic. Patients with an inadequate number of teeth for arch bar splinting were eliminated from the study. All the subjects were divided into two groups according to the method of splinting. One hundred ten comprised the first study group and were treated with lingual arch wires. Thirty-two comprised the control group and were treated with traditional labial/buccal arch bars. The majority of injuries occurred in males; 93 (84.55%) in the first and 25 (78.13%) in the second group. The age of subjects ranged between 15 and 67 years. The age distribution is shown in Table 1.
Received from the Byelorussian State Institute for Advanced Medical Training, Minsk, Byelorussian, SSR. * Professor and Head of the Chair of Oral and Maxillofacial Surgery. t Lecturer of the Chair of Oral and Maxillofacial Surgery. Address correspondence and reprint requests to Dr Kruchinsky: Leninsky Ave. 93/3. Minsk, 220012 Byelorussian SSR. 0 1991 American
Association
of Oral and Maxillofacial
MATERIAL
Sur-
geons 0278-2391191/4911-0007$3.00/0
1171
1172
COMPARISON OF WIRE SPLINTS FOR MANDIBULAR
Table 1.
Age Distribution
No. in Experimental Group (%I
Age (yr) 15-20 21-30 31-40 41-50 51-60 More than61 Total
Table 3.
of Patients No. in Control Group (%I
23 (20.91) 51 (46.36) 22 (20.0) 8 (7.27) 4 (3.64) 2 (1.82)
1 (3.13) 17 (53.13) IO (31.25) 2 (6.25) 2 (6.25) 0
110(100.0)
32I 100.0)
Specialized emergency treatment was given within 3 days after injury in 71 (64.55%) cases in the experimental group and 19 (59.38%) in the control group. In other cases this interval was longer because of later admission. A sizable percentage of subjects sustained their injuries in fights or assaults. Industrial. vehicular, and sport accidents comprised the other causes (Table 2). There were 169 fractures in the experimental group and 51 in the control group. Sites of fracture are shown in Table 3. The number of fractures in the tooth-bearing area located in the anterior and posterior body was 83 of 169 (49.11%) in the experimental and 22 of 51 (43.14%) in the control group. In addition to fractures of the mandible, 20 patients (18.18%) in the first and 8 (25.0%) in the second group had also sustained other injuries, including wounds of the maxillofacial region, fractures of other facial bones, and brain concussion. Twentyfive patients (22.73%) in the experimental group and 7 (21.88%) in the control group had one or more systemic diseases. On the whole, the distribution of the various patient variables was similar in both groups. METHODS OF EXAMINATION
On fully cally, other when
admission, the patients were examined careby the oral and maxillofacial surgeon cliniradiographically, and with laboratory and special methods. Consultations were sought indicated.
Table 2.
Site of Fracture No. in Experimental Group (%j
Location Anterior body Posterior body Angle Ramus Condylar neck Total
No. in Control Group t%i)
52 (30.77) 64 (37.87) 3 (I .78) 19 (11.24)
14 (27.45) 8 (15.69) 17 (33.33) 0 I2 (23.53)
169 t 100.0)
51 (100.0)
31 (18.34)
Clinical and ultrasonic methods were used to evaluate the bone healing. Clinical findings were the main criterion to determine the period of maxillomandibular fixation. These included the absence of pain, inflammation, malocclusion. and mobility in the fracture site. Patients were followed for 6 to 32 months. Ultrasound evaluation of bone healing was done using the Ecchoosteometer (EOM Olc; Minmedprom, Moscow). The speed of the sound impulses from the fractured bone segment and from the intact segment were compared and expressed in percentages. Ultrasonometry was applied immediately after the reduction, and on the 7th, 14th. 21st, and 28th day in 35 patients in the first group and 21 in the second group. BASIC TREATMENT TECHNIQUES
Lingual
Splinting
A lingual splint was applied in the first group. Steel orthodontic wire (0.8 mm in diameter), which was bent according to the shape of the dental arch, was used as arch bar (Fig 1). The bars were ligated as far back as the third molar teeth, when possible. The ends of ligatures were directed into the buccal and labial embrasures to create the hooks for maxillomandibular fixation (Fig 2). Each hook had a U-shaped form to prevent it from unbending. Only mandibular splinting without maxillomandibular fixation was used in the several cases of uni- and bilateral body fractures with little displacement.
Causes of Trauma
Cause Fights/assaults Industrial accidents Vehicular accidents Sport accidents Total
FRACTURES
No. in Experimental Group (%)
No. in Control Group (%‘c)
98 (89.09) 5 (4.55) 6 (5.45) 1 (0.91)
27 (84.38) 2 (6.25) 3 (9.38) 0
1IO (100.0)
32 (100.0)
FIGURE I.
Lingual arch wire ligated to the teeth.
KRUCHINSKY
1173
AND VOLKOVETS
cal Graphics Corp) on an IBM PC compatible computer, ES 1841 (MZ PPEVM, MPOVT. Minsk). Results
FIGURE 2. fixation.
Diagram showing the hooks for maxillomandibular
LabiallBuccal
Splinting
Routine arch wires were applied in the second group. The same materials as in the lingual technique were used for arch wires and ligatures. Hooks for traction were made out of the ligature wires. Tooth Extraction The teeth in the fracture site were evaluated and their probability of survival, need for endodontic treatment, or need for extraction were estimated. Most of molars were extracted at the time of fracture reduction or within 10 days thereafter. Incisors, canines, and premolars were usually retained.
The majority of the patients were successfully managed with close reduction using wire splints and maxillomandibular elastic traction (Fig 3). However, in 27 cases (24.55%) in the study group, mandibular lingual splinting without maxillomandibular traction, and with only a supportive dressing, was used. Monosplints were applied in two cases (6.25%) in the control group. Clinical evidence of mandibular bone healing appeared much earlier in the study than in the control group. It was reflected in decreasing of the maxillomandibular fixation period for the patients in the first group (Table 4). This difference was nearly equal in the cases of uncomplicated single or double fractures and even greater in the cases of infection. Analysis of the inflammatory complications was an important part of the comparative study. Infection was seen in 5 of 83 mandibular body fractures (6.02%) in the study group, and in 3 of 22 (13.64%) in the control group (P < .05). It is also notable that in the study group the infection was arrested earlier than in the control group. Ultrasonometry also confirmed that body fracture healing was faster in the first group (Fig 4). The difference between weekly measurements in both groups was 7% to 8% (P < .05). Long-term clinical follow-up (6 to 32 months) was
Open Reduction When the methods of closed reduction were insufficient, intraoral transosseous wiring or miniplate fixation was used. In most of these cases, the fracture sites were located in non-tooth-bearing areas, the angle and ramus. These patients were excluded from the study. POSTOPERATIVECARE
Additional treatment consisted of routine pain medication. Antibiotics were administered to the 48 patients (43.64%) in the first and to the 19 patients (59.38%) in the second group. DATA ANALYSES
Statistical two-sample analyses were carried out using the Statgraf package (STSC, Inc and Statisti-
FIGURE 3. Radiographs showing a case in which lingual splints were used. A, Before reduction: B. after reduction.
1174 Table 4.
COMPARISON OF WIRE SPLINTS FOR MANDIBULAR
FRACTURES
Immobilization Period for Mandibular Fractures
No. of Fracture Sites and Presence of Infection
Experimental Group No.
of Patient\
Day\
14.0 15.45 17.50 19.98
39 61 2 8
Single Double Single complicated Double complicated
Control Group
i2 2 4
4.31* 6.32* 5.24 7.17*
No. of Pat~enta
Day\
II 14 0 7
20.10 2 6.79* 19.28 ? 6.1 I* NA 29.26 2 9.16*
Abbreviation: NA, data not available. * Statistically significant difference between groups tP < ,051.
done in 92 patients (83.64%) in the study group. There was no incidence of malunion or fibrous union. A slight malocclusion was present in four patients (3.64%). Discussion
References
The recent literature has emphasized the importance of biomechanical considerations in the treatment of mandibular fractures, especially in open reduction techniques.‘-3.9 Applying the same biomechanical principles to the closed reduction methods. we must choose the best location for the splint. As was shown in our previous studies, the lingual splint provided more stable fixation of bone fragments of the mandibular body because it was situated according to the main stress trajectories in the transverse plane. ‘O-l’ We must stress that prosthetic acrylic or cast lingual splints, described in many reports,‘3-‘” are very effective in treating mandibular fractures. They provide stable fixation of the body fragments even without maxillomandibular traction. We also use such splints in cases of difficult comminuted and unfavorable fractures, or when there is delayed healing. However, we believe that in most cases our method of lingual wire splinting provides satisfactory results. Effectiveness, simplicity, and rapidity of treatment are the main advantages of this proce-
65 0
dure. The patients treated with the lingual arch wire showed better results in fracture healing and a lower complication rate than the patients treated with the routine labiallbuccal arch wires.
21
28
FIGURE 4. Graph showing the difference between weekly increase of the speed of ultrasound in the fractured mandibular body segments in both groups. I, Lingual splinted patients; II, labialibuccal splinted patients.
I. Champy M, Lodde J-P, Jaeger JH, et al: Osteosyntheses mandibulaires selon la technique de Michelet. 1. Bases biomecaniques. II. Presentation d’un nouveau materiel. Rev Stomatol 77:569, 1976 2. Champy M. Lodde J-P: Syntheses mandibulaires. Localization des syntheses en fonction des constraintes mandibulaires. Rev Stomatol 77:971. 1976 3. Ewers R. Shilli W: Photoelastic experiments on the implantation of a bone graft into the mandible with stable compression osteosynthesis. Int J Oral Maxillofac Surg 8:462. 1979 4. Kardsz I, Korondi L. Szabo G: Photoelastic stress analysis on mandibular osteosynthesis. Int J Oral Maxillofdc Surg 15:263. 1986 5. Mongini F. Calderale PM, Barberi G: Relationship between structure and the stress pattern in the human mandible. J Dent Res 58:2334, 1979 6. Ferre JC, Legoux R, Helary JL, et al: Study of the deformations of the isolated mandible under static constraints by simulation on a physico-mathematical model. Anat Clin 7:183. 1985 7. Ferre JC, Legoux R, Helary JL. et al: Study of the mandible under static constraints by holographic interferometry. New biomechanical deductions. Anat Clin 7: 193. 1985 8. Keros-Naglic J: Deformation and strain measurements of the applied extensor appliance in the lower jaw model. Acta Med Iugosl 35:295, 1981 9. Cawood JT: Small plate osteosynthesis of mandibular fractures. Br J Oral Maxillofac Surg 23:77. 1985 10. Kruchinsky HV. Soubotko SN: Method of mandibular fractures treatment with arch wire. USSR Discoveries and Innovations 4:28, 1989 1I. Kruchinsky HV. Soubotko SN, Volkovets AN: Biomechanical basis of the mandibular fractures treatment with lingual wire splints, Part 1, in The 1st Congress of the Stomatologists of Moldavia. Kishinev. 1988, D 153 12. Volkovets AN, Kohanovskaya VM, Krylov GK: Results of the mechdnico-mathematical study of stress and deformation patterns in mandibular body, depending on its curvature, in Actual Questions of Maxillofacial Surgerv and Stomatology. Leningrad. 1989, p 20 13. Hardin JC: Triple fractures of the mandible with flaring rami. Their treatment with lingual splints. Arch Otolaryngol 98:387. 1973 14. Jackson MJ, Westmore SJ: Surgical prosthetic splints as an adjunct in treating facial fractures. Arch Otolaryngol 106:25, 1980 15. Thiele RB. Marcoot RM: Functional therapy for fractures of the condyloid process in adults. J Oral Maxillofac Surg 43:226. 1985
