J Oral Maxillofac Surg

55:489-494, 1997

An In Vitro Comparison of the Mechanical

Characteristics of Three Sagittal Ramus
0s teo tomy Fixation Techniques
MICHAEL T. MURPHY, DMD,” RICHARD H. HAUG, DDS,t
AND J. EDWARD BARBER, BS*

Purpose: The purpose of this in vitro investigation was to compare the me-
chanical characteristics of three techniques for the rigid internal fixation of
simulated sagittal ramus osteotomies in terms of their ability to resist vertical
loads resembling masticator-y forces.
Materials and Methods: Fifteen bovine ribs of similar size and shape were
subjected to uniform osteotomies resembling a sagittal ramus osteotomy. They
were divided into three groups and fixed with three 2.0-mm bicortical positional
screws in an inverted L-pattern, eight monocortical screws and a sagittal strut
plate, or a hybrid system using three 2.0-mm bicortical positional screws, five
2.0-mm monocortical screws, and a sagittal strut plate. The repaired ribs were
secured in a jig, subjected to vertically deforming forces, and evaluated for
yield load, yield point, maximum load, displacement at maximum load, load
at 3.0 mm displacement, and stiffness. The various groups were compared
statistically with a Scheffe multiple comparison test.
Results: No statistically significant differences existed between the positional
screw group and the hybrid group (P > .05). No statistically significant differ-
ences were noted in yield displacement, yield load, displacement at maximum
load, for any of the groups (f > .05). There were differences noted between
the monocortical strut group and other groups in maximum load, load at 3.0
mm displacement, and stiffness (P > .05).
Conclusions: The monocortically fixed sagittal strut plate offers less resis-
tance to maximum load and loads at 3.0 mm displacement and is less stiff
than either a three-positional screw system or a hybrid system. No differences
existed between the three positional screw systems and the hybrid system.
However, given the low yield loads and yield displacements, these differences
may not be clinically important.

The bilateral sagittal ramus osteotomy (BSRO) has suggestions for fixation have been proposed.“’ Rigid
been performed for the correction of mandibular internal fixation is now among the preferred techniques
growth deformities and malocclusion since the late for stabilization because it affords a rapid return to
195Os.‘,* Since that time, numerous modifications and presurgical function, better nutritional support, easier
airway maintenance, and reduced relapse.”
* Chief Resident, Division of Oral and Maxillofacial Surgery, Bicortical positional screws are among the most crit-
MetroHealth Medical Center, Cleveland, OH.
f Director, Division of Oral and Maxillofacial Surgery, Met- ically evaluated of the rigid internal fixation tech-
roHealth Medical Center, Assistant Professor of Surgery, Case West- niques, and these have become the standard by which
ern Reserve University School of Medicine, Cleveland, OH. other techniques are compared.‘0m21 Although relatively
$ Research Assistant, Department of Orthopedics, MetroHealth
Medical Center, Cleveland, OH.
simple and stable, they have been associated with risk
Address correspondence and reprint requests to Dr Haug: Division to the neurovascular apparatus and imprecise condylar
of Oral and Maxillofacial Surgery, MetroHealth Medical Center, positioning.” With these disadvantages in mind, mono-
2500 MetroHealth Dr, Cleveland, OH 44140.
cortically fixed sagittal strut plates have been de-
0 1997 American Association of Oral and Maxillofacial Surgeons signed.‘* Proponents of this device claim easier condy-
0278-2391/97/.5505-0010$3.00/O lar positioning and no risk to the neurovascular bundle.
489
490
FIGURE 1. Positional screw
Recently, hybrid systems have been proposed to take
into consideration the advantages of each technique.23
The purpose of this in vitro investigation was to
evaluate the ability of a three-positional screw system,
monocortical strut system, and a hybrid system to resist
vertical loads resembling masticatory forces in simu-
lated BSROs. Common engineering standards, includ-
ing yield load, yield displacement, maximum load, dis-
placement at maximum load, and stiffness, were
evaluated, along with load at 3.0 mm displacement.
Materials and Methods
Fifteen ribs from recently killed cows were selected
for uniformity in shape and dimension. They ranged
between 25.0 and 35.0 mm in height, 12.0 to 16.0 mm
in width, and 10.0 to 13.0 cm in length. They were
stripped of soft tissues and then frozen until used. At
the time of experimentation, the ribs were thawed and
4.0 cm was embedded in a polymethylmethacrylate
receptacle (Fast Tray, Sybron/Kerr Romulus, MI). Os-
teotomies resembling BSROs were created with a band
saw, using a customized jig to ensure uniformity. The
lateral osteotomy was created 35.0 mm from the poly-
methylmethacrylate interface and the medial osteot-
omy was created 25.0 mm from the lateral osteotomy.
The rib was then split with a chisel.
Five of the ribs were lengthened 1.0 cm and then
fixed in an inverted-L pattern with 2.0-mm x 1%mm
titanium screws (Synthes Maxillofacial, Paoli, PA)
(Fig 1). The 18.0-mm length assured bicortical fixa-
tion. The sagittal strut plate was used as a template to
assure uniform screw pattern and placement. Five bo-
vine ribs with BSROs were advanced 1.0 cm in the
same manner as the first group and fixed with a sagittal
strut plate (Synthes Maxillofacial, Paoli, PA) with
eight 2.0-mm x 4-mm titanium monocortical screws
(Synthes Maxillofacial, Paoli, PA) (Fig 2). The re-
maining five ribs were advanced 1.0 cm in the same
fashion and fixed with three 2.0-mm X 1S-mm diame-
ter titanium screws placed in the same inverted-L pat-
tern as the first group, through the sagittal strut plate
(Fig 3). Five 2.0 mm diameter monocortical screws
MECHANICAL SAGITTAL OSTEOTOMY
system. A, lateral view. B, medial view.
that were 4.0 mm in length were placed in the re-
maining holes. This assured bicortical fixation between
the proximal and distal segments, as well as fixation
to the sagittal strut plate.
The ribs were secured in a custom-fabricated jig and
subjected to vertical loads using an Instron 8511.20
(Ins&on Corp, Canton, MA) mechanical testing unit
and a cantilever beam design. They were loaded 30.0
mm from the medial osteotomy (90.0 mm from the
polymethylmethacrylate/jig interface) at a rate of 1.0
mm/set. Data were acquired at a rate of 10 points/
second and stored using the Instron software. The pa-
rameters evaluated were yield displacement, yield
point, maximum load, displacement at maximum load,
stiffness, and load at 3.0 mm of displacement. Yield
displacement is that distance at which the system be-
gins to permanently deform. Yield load is that load
at which the system begins to permanently deform.
Maximum load is the peak of the stress strain (load/
displacement) curve. Displacement at maximum load
is the distance at which maximum load is achieved.
Stiffness is defined at the rate of change of strain as a
function of stress and is expressed as kilograms force
per millimeter (kgf/mm). The load at 3.0 mm displace-
ment was originally chosen by Frost et alr”-r2 as an
arbitrary value to evaluate sagittal ramus osteotomy
fixation failure. It continues to be used as a standard
for BSRO comparison.20
After testing was performed, means and standard devi-
ations of the data were derived and compared for statisti-
FIGURE 2. Monocortical strut system (lateral view).
MURPHY, HAUG, AND BARBER 491

FIGURE 3. Hybrid system. A, lateral view. B, medial view.

cal significance using a Scheffe multiple comparison test.
An F-probability of >.05 was considered significant.
Results
A summary of the results appears in Table 1. Al-
though the sagittal strut plate with monocortical fixa-
tion had the highest yield displacement, no significant
differences existed between the three groups (F~z,lz~ =
0.86, P = .45) (Fig 4). Permanent deformation began
to occur at less than 1.0 mm of displacement. No sig-
nificant differences were noted between groups for
yield load (Fc2,,2j = 0.83, P = .46) (Fig 5). Permanent
deformation began to occur at loads less than 2.0 kg.
The greatest maximum load was achieved by the three-
positional screw system (14.22 + 4.59 kg), followed
by the hybrid (10.07 +- 1.39 kg) and monocortical
systems (6.17 + 0.92 kg) (Fig 6). Statistically signifi-
cant differences were found between groups in maxi-
mum load (Fc2,12j = 10.19, P < .003). Based on the
Scheffe multiple comparison test at the .05 significance
level, a difference was found between the positional
screw and the monocortical system. However, no sta-
tistically significant difference was found between the
hybrid system and the other two groups.
No significant differences were noted between
groups in displacement at maximum load (FC2,i2)=
1.92, P = .19) (Fig 7). Displacement at maximum load
occurred at distances as great as 22.54 mm, which is
well beyond any clinically accepted value for displace-
ment with BSRO fixation. Failure at maximum load
and displacement occurred in distinct patterns. In all
casesof the monocortically fixed sagittal strut plates,
the titanium struts deformed. With the positional screw
system, the screws sheared, the bone/screw interface
fractured, or both occurred. The hybrid system failures
included various combinations of strut deformation,
screw shear, and bone/screw interface fractures.
Statistically significant differences were found be-
tween groups in load at 3.0 mm displacement (FC2.12j
= 9.98, P < .003). Although no difference was noted
between the positional screw and hybrid group (Fig
S), differences were found between these groups and
the monocortical strut system. Similarly, statistically
significant differences existed between the groups in
stiffness (FC2,i2)= 9.98, P < .003). No significant dif-
ference existed between the positional screw and hy-
brid system for stiffness, but did exist between these
two groups and the monocortical system (Fig 9).
Discussion
With the development of titanium plates and screws,
rigid internal fixation of the BSRO has become the

Table 1. Summary of Results (Mean i- SD)

Positional
175 I T

Screw
System
Monocortical
Strut System
Hybrid
System
15I
Yield displacement
(mm) 0.19 5 0.22 0.73 2 1.11 0.39 t 0.09
Yield load (kgf) 1.31 2 0.51 1.25 + 1.17 1.81 -t 0.29
Displacement at
maximum load
md 14.99 % 6.19 9.00 i- 3.39 14.70 i 6.28
Maximum load
Cdl 14.22 -c 4.59 6.17 & 0.92 10.07 i 1.39
Load at 3.0 mm
displacement
Pos~t~onai Screw System Monacortical Strut System tlybr~d System
Cd-l 6.59 t 1.68 3.58 i- 0.44 6.35 k 1.10
Stiffness (kgf/mm) 3.40 -t- 0.86 1.82 i 0.45 3.23 i 0.39
FIGURE 4. Yield displacement (mm ?SD).
492 MECHANICAL SAGITTAL OSTEOTOMY

Positional Screw System mn~~oma~ strut system Hybrid System Pwtional Screw System Monocorbcal Strut System Hybrid System

FIGURE 5. Yield load (kgf ?SD). FIGURE 7. Displacement at maximum load (kgf *SD).

rule rather than the exception. Numerous in vitro inves-
tigations have been conducted that evaluated screw
size and pattern in assessing optimal resistance to de-
formation.“-*’ Most indicate that the inverted-L pattern
is the superior fixation design.11~13~16~18~‘9~z1
Numerous authors have compared bicortical screw
fixation with monocortical plate fixation, with varying
conclusions as to which is the superior tech-
nique. 12,16~17~19With the recent appearance of hybrid
systems using both bicortical and monocortical fixa-
tion, the possibility of an even more rigid system has
been proposed.23 Our study investigated this system
and noted some very significant observations and prob-
lems associated with traditional concepts in mechani-
cal testing of fixation devices.
Maximum load (or ultimate load) is an engineering
standard that has been used in the evaluation of fixation
systems. ‘5,‘6,20It represents the peak of the stress/strain
(or load/displacement) curve. Theoretically, this value
should indicate the maximum amount of force that
could be resisted by the system until the breaking point.
Although this may be of value in determing failure in
engineering or architectural design, it is of limited
value in assessing failure of BSRO fixation. Maximum
load is achieved at maximum displacement. It was
noted in our investigation that maximum displacement
ranged from a low of 4.45 mm to a high of 22.54 mm,
with small differences between each of the experimen-
tal groups. It is obvious that displacements of this mag-
nitude are unacceptable when considering stability and
relapse in the healing BSRO patient. Thus, maximum
load and displacement at maximum load should not be
considered satisfactory end points in assessing fixation
technique failure.
Foley et al and others have suggested a failure value
of load at 3.0 mm of displacement.5’24 This is an arbi-
trary value based on clinical beliefs as to when dis-
placement becames important in healing, without con-
sideration of the factors that affect healing.24 Because
of the many valuable contributions to the evaluation
of BSRO fixation by Foley’s group, this value has
become a standard for comparison and continues to be

Positional Screw System Mrmocortical Strut System Hybrid System Positional Screw System Monocortical Strut System Hybrid System

FIGURE 6. Maximum load (kgf *SD). FIGURE 8. Load at 3.0 mm displacement (kgf *SD).
MURPHY, HAUG, AND BARBER 493

45
1 tively.26,27 The yield load (and thus yield point) in our
in vitro investigation using human bone substitutes
(bovine rib) approached these values.
This investigation suggests that maximum load, dis-
placement at maximum load, and load at 3.0 mm of
displacement are of no value in the interpretation of
the effectiveness of rigid fixation systems when in clin-
ical use; yield point and stiffness are more valuable
end points. These values need to be interpreted with
serious consideration given to accurate postsurgical
bite force measures when evaluating the favorability
or unfavorability of a fixation technique.

Positional Screw System Monocortical Strut System Hybrid System References

FIGURE 9. Stiffness (kgf/mm -tSD)

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J Oral Maxillofac Surg
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Discussion
An In Vitro Comparison of the Mechanical
Characteristics of Three Sagittal Ramus
Osteotomy Fixation Techniques
Vivek Shetty, BDS, Dr Med Dent
University of California, Los Angeles, California
The advantages implicit to the rigid internal fixation of
surgically reconfigured mandible segments derive largely
from the characteristics of the fixation device used. Unlike
the load sharing between implant and bone that contributes
to the fixation stability of well-reduced fractures, the inter-
fragmentary diastema produced by mandibular repositioning
requires the load transfer between the segments to occur
mainly through the fixation device. Hence, a critical property
of any fixation system is its ability to withstand the various
mechanical forces placed on it during function. Murphy et
al use standard engineering parameters to characterize and
compare the mechanical capacity of the individual systems.
Given the implications of their study, it would be useful to
discuss key aspects of the test methods and how they relate
to the clinical situation.
Conventional models using bovine rib, although popular
because of their accessibility, are burdened by the large var-
ability in the properties and structure of natural bone. A
degree of diversity in the configuration of the specimens and
simulated osteotomies is inherent to even closely matched
samples. By implication, the neutral axis changes from speci-
men to specimen and results in a varying response to the
same bending moment. To complicate matters further, the
anisotropic nature of natural bone results in regional varia-
tions in mechanical properties within the same specimen
and between specimens. This confounding effect may be
reflected in the data reported by the authors. The maximum
displacements ranged from 4.45 mm to a high of 22.54 mm,
with small differences between the experimental groups. Be-
cause of the inability to separate the relative contributions of
bone and specimen configuration, the underlying assumption
that the experimental data represents the mechanical charac-
teristics of the individual systems may not be valid. The
instances of bone/screw interface fractures in the positional
screw and hybrid systems corroborates this suspicion. The
use of a reproducible model system with consistent material
and physical parameters would have permitted a more equi-
DISCUSSION
sag&al mandibular osteotomy. .I Oral Maxillofac Surg
54:234, 1996
24. Foley, Bill, Atlanta, GA, Personal communication, February 15,
1996.
25. Kim HC, Essaki S, Kameyama T, et al: Photoelastic analysis
of internal screw fixation after sagittal split ramus osteotomy.
J Cranio Maxillofac Surg 21:266, 1993
26. Tate GS, Ellis E, Throckmorton GS: Bite forces in patients
treated for mandibular angle fracture: Implications for fixa-
tion recommendations. J Oral Maxillofac Surg 52:734, 1994
27. Ellis E, Throckmorton GS, Sinn DP: Bite forces before and
after surgical correction of mandibular prognathism. J Oral
Maxillofac Surg 54:176, 1996
table comparison of the key parameters.’ By minimizing
potential interactions, such a model would help isolate the
mechanical abilities of the fixation systems tested and clarify
whether any differences or similarities reported represent
genuine trends.
In a mechanistic sense, the mode of deformation used by
the authors for testing may not be the most clinically rele-
vant. Vertical loading of a simple cantilever beam model
captures the relationship between load and displacement in
only one plane; actual clinical situations produce much more
complex stress-strain relationships in even the simplest three
dimensional representations of a mandible. Though bending
is the most commonly reported data using the cantilever
beam model, the major load transferences across an osteot-
omy site occur through a combination of tension, shear,
torsion, or bending. Each of these forces produces its own
unique load-deformation characteristics depending on the
properties of the fixation device. Correspondingly, the rela-
tive ranking of mechanical properties may change in various
loading modes, with a system superior in bending proving
to be weak in torsion. For example, the bending stiffness of
the thin monocortical strut plates is much greater when the
plates are stressed edgewise rather than flat.2 Subject to bend-
ing loads in only one plane, their cross-sectional shape and
stiffness may compare favorably to screw fixation, yet, the
low lateral flexibility and torsional stiffness of these plates
render them vulnerable to the more complex deformations
developing at the osteotomy site during function in a curved
beam structure such as the mandible.3 The large standard
deviations (Fig 4, 5) most likely represent the sensitivity of
the mechanical properties of the strut plates to small changes
in the alignment of the osteotomy sites relative to the plane
of loading.
The concerns expressed by Murphy et al about the conven-
tional choice of load at 3.0 mm displacement as failure raises
several important issues. Inceptive studies by Foley’s group
used porcine rib models and arbitrarily selected a 3.0 mm
deflection at the point of loading as fixation failure.4 The
boundary conditions used in the initial study included a
crosshead speed of 10 mm/min and a moment arm of 28
mm (distance of loading site from embedded end of test
specimen). Although the failure criterion used by Murphy
et al parallels that proposed by Foley’s group, the testing
conditions were actually quite different. Specifically, bovine