ORIGINAL ARTICLE

Evaluation of stress changes in the mandible

with a fixed functional appliance: A finite
element study
Anshul Chaudhry,a Maninder S. Sidhu,b Girish Chaudhary,c Seema Grover,d Nimisha Chaudhry,e
and Ashutosh Kaushikf
Ludhiana, Punjab, Gurgaon and Rohatak, Haryana, and Moradabad, Uttar Pradesh, India

Introduction: The aim of this study was to evaluate the effects of a fixed functional appliance (Forsus Fatigue
Resistant Device; 3M Unitek, Monrovia, Calif) on the mandible with 3-dimensional finite element stress analysis.
Methods: A 3-dimensional finite element model of the mandible was constructed from the images generated by
cone-beam computed tomography of a patient undergoing fixed orthodontic treatment. The changes were
studied with the finite element method, in the form of highest von Mises stress and maximum principal stress
regions. Results: More areas of stress were seen in the model of the mandible with the Forsus compared
with the model of the mandible in the resting stage. Conclusions: This fixed functional appliance studied by finite
element model analysis caused increases in the maximum principal stress and the von Mises stress in both the
cortical bone and the condylar region of the mandible by more than 2 times. (Am J Orthod Dentofacial Orthop
2015;147:226-34)

T
he aim of orthodontic treatment of children with
malocclusions is to produce a well-balanced facial
profile and an acceptable occlusion. Despite good
treatment planning and patient selection, facial es-
thetics may not be ideal, and this can be compounded
by relapse after an initially successful treatment. Dento-
facial orthopedists believe that functional appliances
train patients in maintaining correct oral and tongue
postures. In the treatment of Class II malocclusion, an
early phase of functional appliance treatment is
a
Senior lecturer, Department of Orthodontics, Christian Dental College, Christian
Medical College, Ludhiana, Punjab, India.
b
Director, postgraduate studies; professor and head, Department of Orthodon-
tics, Shree Guru Gobind Singh Tricentenary Dental College, Hospital and
Research Institute, Budhera, Gurgaon, Haryana, India.
c
Senior lecturer, Department of Orthodontics, Baba Jaswant Singh Dental Col-
lege, Hospital & Research Institute, Ludhiana, Punjab, India.
d
Professor, Department of Orthodontics, Shree Guru Gobind Singh Tricentenary
Dental College, Hospital and Research Institute, Budhera, Gurgaon, Haryana,
India.
e
Formerly, postgraduate student, Department of Prosthodontics, Kothiwal
Dental College, Moradabad, Uttar Pradesh, India.
f
Private practice, Rohatak, Haryana, India.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Anshul Chaudhry, Department of Orthodontics,
Christian Dental College, CMC, Ludhiana-141010, Punjab, India; e-mail,
dr.anshulchaudhry@gmail.com.
Submitted, March 2014; revised and accepted, September 2014.
0889-5406/$36.00
Copyright Ó 2015 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2014.09.020
226
commonly used to simplify subsequent therapy and to
optimize the development of the facial skeleton.
McNamara1 reported mandibular retrusion as the most
common characteristic of Class II malocclusion. Class II Di-
vision 1 malocclusions with mandibular deficiency have
been treated for more than a century with different types
of functional appliances. Woodside et al,2 Stockli and Wil-
lert,3 Vargervik and Harvold,4 and Ruf and Pancherz5
stated that typical muscular forces are generated by
altering the mandibular position sagittally and vertically,
resulting in orthodontic and orthopedic changes. The
pressure created by stretching of the muscles and soft tis-
sues is transmitted to the dental and skeletal structures,
moving the teeth and modifying growth.
Many removable functional appliances, such as acti-
vator, bionator, Fr€ankel, and Twin-block, have been
used to correct Class II Division 1 malocclusions; howev-
er, few fixed functional appliances have been used.
These fixed functional appliances for sagittal advance-
ment of the mandible have certain advantages over
removable functional appliances, such as less depen-
dence on patient compliance, and these can be used
concurrently with fixed mechanotherapy, thereby
reducing treatment duration.3 Fixed functional appli-
ances also enhance mandibular growth and tend to pro-
duce more horizontal condylar growth compared with
removable appliances.6-8
The theoretical basis of functional treatment in gen-
eral is the principle that a new pattern of function
Chaudhry et al
dictated by the appliance leads to the development of a
correspondingly new morphologic pattern. This new
pattern of function developed by wearing of functional
appliances refers to different functional components of
the orofacial system, including the tongue, lips, and
facial and masticatory muscles: mainly the protracting
muscles, ligaments, and periosteum. The new morpho-
logic pattern includes a different arrangement of the
teeth in the jaws, improvement of the occlusion, and
an altered relationship of the jaws.
The forces produced by the muscle contractions are
transmitted to selected teeth and their periodontia, the
jaws, and the temporomandibular joints. Anterior
displacement of the mandible can induce altered
postural activity in the pterygoid muscles, resulting in
additional condylar growth.9
Removable functional appliances have some disad-
vantages; they are normally large, have unstable fixa-
tion, cause discomfort, lack tactile sensibility, exert
pressure on the buccal mucosa, reduce space for the
tongue, cause difficulty in deglutition and speech, and
often affect the esthetic appearance. The lack of success
with functional appliances has in some circumstance
been attributed to a lack of patient compliance in wear-
ing the appliance. This led to the development of fixed
functional appliances.
Fixed functional appliances—more appropriately
termed “noncompliant Class II interarch correctors”—
have gained significant ground. A fixed appliance is
aimed at targeting the dentition and providing the
following dental corrections: facilitating mandibular
advancement by eliminating dental interferences, and
consolidating the arches to minimize the adverse dental
side-effects. A number of fixed functional appliances
have gained popularity in recent years to help achieve
better results in noncompliant patients: eg, the Herbst
appliance and the Forsus Fatigue Resistant Device (3M
Unitek, Monrovia, Calif). Remodeling changes in the
condylar head and glenoid fossa been reported after
functional appliance treatment for correction of Class
II skeletal dysplasia with mandibular retrognathia. The
posterior displacement of the condylar head and the
anterior relocation of the glenoid fossa with functional
appliances have been confirmed with numerous radio-
logic techniques.2,3,10-15
The remodeling changes in the condyle and dentofa-
cial complex have been studied routinely with cephalo-
metric analysis.16,17 The study of functional appliances
using computed tomography has shown a double
contour on the bony outline of the condylar head and
fossa articularis,18 whereas single photon emission
computerized tomography scans of the temporoman-
dibular joint (TMJ) showed significant increases in
American Journal of Orthodontics and Dentofacial Orthopedics
227
bone count, indicating increased bone formation in
the TMJ after mandibular anterior repositioning splint
treatment.19 Magnetic resonance imaging studies have
also shown that the mandibular condyle experiences
tensile stresses in the posterosuperior aspect that explain
condylar growth in that direction, whereas on the glen-
oid fossa, similar kinds of stresses are created in the pos-
terior connective tissue region and are correlated with
the increased cellular activity.17 The recent use of
cone-beam computed tomography (CBCT) in creating
the 3-dimensional (3D) model of the dentofacial skel-
eton has enhanced the precision and understanding of
the region.20,21
The biomechanical response of bone to orthopedic
forces is quite complex. The use of the finite element
method (FEM) initially in medical orthopedics and later
in dentistry, especially orthodontics, allowed precise
analysis of the biomechanical effects of various treat-
ment modalities. The FEM, which has been successfully
applied to the study of stresses and strains in engineer-
ing,22,23 makes it possible to evaluate biomechanical
components such as displacements, strains, and
stresses induced in living structures from various
external forces.24-27 The first finite element models
described the tooth-bone structure 2 dimensionally us-
ing average geometric relationships and homogeneous
and isotropic material models. The 3D finite element
models were later introduced in 1973 by Farah et al.28
The FEM has numerous advantages in orthodon-
tics.29 It is a noninvasive technique that measures the
actual amount of stress experienced at any point on
teeth, alveolar bones, periodontal ligaments, and cranio-
facial bones. It possibly can simulate the oral environ-
ment in vitro; the displacement of the tooth can be
visualized graphically. The point of application, magni-
tude, and direction of a force may easily be varied to
simulate the clinical situation; reproducibility does not
affect the physical properties of the involved material,
and the study can be repeated as many times as the oper-
ator wishes. Thus, the FEM has been introduced in or-
thodontics as a powerful research tool for solving
various structural biomechanical problems.
The FEM analyzes the biomechanical effects of
various treatment modalities and is an approximation
method to represent both the deformation and the 3D
stress distribution in bodies that are exposed to stress.
A pattern of stresses is created in the TMJ and orofa-
cial complex when the mandible is protracted with a
functional appliance. Whether this pattern remains the
same during treatment and whether all biologic tissues
respond in a similar predictable manner over time are
not known. Previous FEM studies of functional appli-
ances were on skulls or artificial models. Recently, Gupta
February 2015  Vol 147  Issue 2
228
et al20,21 used a CBCT model of a patient to check
changes in the TMJs. Previous researchers did not
study the stress changes produced in the orofacial
complex using a 3D patient model with a fixed
functional appliance.
It is assumed that bone responds to mechanical
stresses by showing particular kinds of compressive
and tensile stresses. Since stress and strain in living tis-
sues are thought to be key factors in biologic change,
it is important to elucidate the stress or strain to under-
stand its relationship to bone remodeling. In orthodon-
tics, various techniques have been used to measure these
biomechanical factors. However, it is not always possible
with these methods to quantify the stress or strain in an
internal area of a living structure.25
Therefore, a technique applicable to biomechanical
investigation for stress or strain in biologic tissues is
needed. The FEM is applicable to the biomechanical
study of strains and stresses generated in internal struc-
tures. Other studies have reported the relationship be-
tween stresses analyzed by the FEM and biologic
changes of bony structures.30-33 The limitation of an
FEM study is that it can record only instantaneous
stress patterns.
In this study, the stress patterns in the mandible in
the resting stage and the stress patterns created by simu-
lated mandibular protraction of a fixed functional appli-
ance were elucidated.
The purpose of this study was to evaluate the stress
pattern distribution in different parts of the mandible
and associated structures with a fixed functional appli-
ance (Forsus Fatigue Resistant Device) on a patient using
the FEM with a CBCT-generated 3D image.
MATERIAL AND METHODS
This study was designed to evaluate stress pattern
distributions in different regions of the mandible with
the Forsus appliance using the FEM. A 15-year-old girl
with a typical Class II Division 1 malocclusion with an
overjet of 11 mm was selected. Her chief complaint
was an unpleasant appearance and backwardly posi-
tioned mandibular front teeth. After a clinical examina-
tion, the patient was planned to be treated with a fixed
functional appliance, the Forsus. She had a skeletal Class
II relationship with an almost normal maxilla, a retro-
gnathic mandible, a positive visual treatment objective,
an abnormal musculature, and a favorable growth
pattern. All pretreatment records were taken for the pa-
tient including study models, photographs, CBCT scans,
and interocclusal biting force recordings. The Forsus was
planned to be given to the patient. Informed consent
was obtained from the patient's parents for her to
February 2015  Vol 147  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Chaudhry et al
Fig 1. Mesh diagram of a complete mandible.
participate in the study. The DICOM images of the
mandible, TMJ, and associated structures were gener-
ated using CBCT scans to construct the mesh diagram
(Fig 1) for the finite element analysis with Mimics soft-
ware (version 8.11; Materialise HQ, Leuven, Belgium)
and HyperWorks software (version 9.0; Altair Engineer-
ing, Huntsville, Ala).
Full bonding and banding of the maxillary and
mandibular arches was done using a 0.022-in MBT
(Mclaughlin Bennett Trevisi) prescription. After leveling
and alignment, the arches were U-shaped but in a Class
II relationship. When the rectangular wire stage reached
0.019 3 0.025-in stainless steel, the Forsus appliance
was used in single-step advancement. The attachment
of the appliance was at the canine and premolar interface.
The horizontal force values were calculated with a Dontrix
gauge (American Orthodontics, Sheboygan, Wis). The ver-
tical forces were recorded with a custom-made pressure
sensor by placing the sensor in the molar region.
The muscles also exert forces on the mandible. There-
fore, it is necessary to calculate the musculature forces
for the assessment of the stress patterns on the
mandible. The muscle areas were constructed by taking
references from books of anatomy; however, interoc-
clusal bite force recordings are specific for each patient.
Muscle force in maximum intercuspation was calculated
by multiplying the physiologic cross-sectional areas of
the each masticatory muscle by 0.37 3 102 N. For the
masseter, the calculated muscle force was 388.5 N; for
the lateral pterygoid, it was 37 N; for the medial ptery-
goid, it was 432.9 N; and for the temporalis, it was
333 N, as shown in Figures 2 and 3 and Table I, as per
the chart.34 The duration of treatment was 1 year
8 months.
Chaudhry et al
Fig 2. Muscular forces exerted by the lateral and medial
pterygoid muscles.
Fig 3. Muscular forces exerted by the masseter and tem-
poralis muscles.
For the finite element model construction, a CBCT
scan of the tooth and the mandible was taken into the
Mimics software. Surface data of the metal casting and
the mandible were generated using Solid Edge 2004
software (Siemens, Plano, Tex). From the 3D image of
the CBCT, a mesh diagram was generated using the Hy-
perWorks software. Finite element models were con-
structed from the DICOM images of slices 1 mm thick
generated by the DICOM software. The assembled finite
element model of the mandible was imported into Ansys
software (version 12.1; Canonsburg, Pa) for analysis. The
material properties assigned were Young's modulus (or
modulus of elasticity) and the Poisson ratio.20
A vertical biting force of 111.55 N was applied in the
molar region, and a horizontal force of 1948.24 N was
seen distal to the canine in the horizontal direction. The
model was restricted at the outer part of the skull at its
most posterosuperior edges. This allowed the visualization
of deformation and stress generation in the mandible.
RESULTS
The results showed changes in terms of von Mises
stresses and principal stresses. The total number of
American Journal of Orthodontics and Dentofacial Orthopedics
229
Table I. Physiologic cross-sectional areas (PCS) of the
each masticatory muscle and calculated biting force
Muscle PCS (cm2) Force (N)
Masseter 10.5 388.5
Temporalis 9 333
Medial pterygoid 11.7 432.9
Lateral pterygoid 1.0 37
Fig 4. Von Mises stress contours in cortical bone.
nodes was 462542, along with total elements
numbering 92972. The color changes in terms of areas
of maximum and minimum stresses were seen after the
material properties were assigned. Red shows the
maximum principal stress region, which is mainly tensile
stress, and blue shows the minimum principal stress re-
gion, which is compressive stress. The results of this FEM
analysis showed the areas of tension and compression in
the mandible and associated structures.
The results were calculated in terms of von Mises and
principal stresses in the following regions: cortical bone,
teeth, and condylar head.
In the resting stage of the mandible, the highest von
Mises stresses were 55.103 MPa in the cortical bone
(Fig 4), 27.91 MPa in the teeth (Fig 5), and 4.098 MPa
in the condyle (Fig 6).
The maximum principal stresses were 65.066 MPa in
the cortical bone (Fig 7), 20.96 MPa in the teeth (Fig 8),
and 4.117 MPa in the condyle (Fig 9).
There were changes with the fixed functional
appliance. The highest von Mises stresses were
166.918 MPa in the cortical bone (Fig 10),
329.707 MPa in the teeth (Fig 11), and 10.559 MPa in
the condyle (Fig 12).
The maximum principal stresses were 145.016 MPa
in the cortical bone (Fig 13), 187.077 MPa in the teeth
(Fig 14), and 11.725 MPa in the condyle (Fig 15).
February 2015  Vol 147  Issue 2
230
Fig 5. Von Mises stress contours in teeth.
Fig 6. Von Mises stress contours in condyle.
DISCUSSION
The FEM is a computational technique used to obtain
approximate solutions of boundary-value problems in
engineering. The FEM makes it practicable to elucidate
biomechanical components such as displacements,
strains, and stresses induced in living structures from
various external forces. Biomechanical studies have
shown that the compressive and tensile stresses from
functional orthopedic forces are the key determinants
to remodeling of the bones.25,35 The limitation of an
FEM study is that it can record only instantaneous
stress patterns.
In this study, the finite element model was con-
structed to evaluate the stress patterns on different parts
of the mandible. Since we know that functional appli-
ances bring the mandible forward, the muscles also get
February 2015  Vol 147  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Chaudhry et al
Fig 7. Principal stress contours in cortical bone in resting
stage.
Fig 8. Principal stress contours in teeth in resting stage.
stretched, and there is some growth in the TMJs as
well. Our findings suggest that the remodeling of the
bone to mechanical forces might be correlated with
the location of the tensile and compressive stress pat-
terns. The mandible, the articular disc in the TMJ, and
the condylar head are also affected during clenching of
the teeth.36
In some previous FEM studies, the effects of the
masticatory muscles were neglected; in other studies,
muscle forces in different amounts and proportions
were applied to the model. The mandible is not a static
structure that carries only the loads that affect it. The
mandibular position is maintained by the harmonious
balance of muscles, connecting tissues, neural system,
and facial skin. For this reason, we also considered the
muscle forces acting on the mandible in the resting
stage.
Chaudhry et al
Fig 9. Principal stress contours in condyle in resting stage.
Fig 10. Von Mises stress contours in cortical bone with
Forsus.
In the resting stage of the mandible, von Mises stress
in the cortical bone is maximum at the neck of the
condyle, probably because of the stretch of the lateral
pterygoid muscle, the middle of the sigmoid notch,
and a small part on the posterior border of the ramus,
whereas the head of the condyle, the coronoid process,
the angle of the mandible, and most of the body of
the mandible show minimum stress (Table II). In an
FEM study on mandibular first premolars, Tanne
et al37 investigated the stress levels induced in the peri-
odontal tissues by orthodontic forces and observed the
highest stress, approximately 120 g/cm2, at the level of
the cervix on the buccal and lingual points, with a
gradual reduction to zero stress near the center of the
root. In a similar study using the FEM, McGuinness
et al38 determined the stress induced in the periodontal
liga6ment in 3 dimensions when a maxillary canine was
American Journal of Orthodontics and Dentofacial Orthopedics
231
Fig 11. Von Mises stress contours in teeth with Forsus.
Fig 12. Von Mises stress contours in condyle.
subjected to an orthodontic force similar to that pro-
duced by an edgewise appliance. The maximum stress
induced at the cervical margin of the periodontal liga-
ment was 0.072 N/mm2.
In the resting stage, the maximum principal stresses
in the cortical bone were seen at the neck of the condyle
and the middle of the sigmoid notch because of the at-
tachments of the muscles in the corresponding areas
(Table II).
With a fixed functional appliance, the highest von
Mises stresses in the cortical bone were from the canine
to the premolar area and in the sigmoid notch (Table III).
In the resting stage, it was maximum at the neck of the
condyle, the middle of the sigmoid notch, and a small
part on the posterior border of the ramus, whereas the
head of the condyle, the coronoid process, the angle of
the mandible, and most of the body of the mandible
February 2015  Vol 147  Issue 2
232 Chaudhry et al

Fig 13. Principal stress contours in cortical bone with Fig 15. Principal stress contours in condyle with Forsus.
Forsus.

Table II. Resting stage of the mandible

Part Von Mises stress (MPa) Principal stress (MPa)
Cortical bone 55.103 65.066
Teeth 27.91 20.96
Condyle 4.098 4.117

Table III. Patient with the Forsus

Part Von Mises stress (MPa) Principal stress (MPa)
Cortical bone 166.918 145.016
Teeth 329.707 187.077
Condyle 10.559 11.725

Table IV. Maximum von Mises stresses in 2 models of

the Forsus
Fig 14. Principal stress contours in teeth with Forsus. Resting stage of
Part mandible (MPa) With Forsus (MPa)
Cortical bone 55.103 166.918
showed minimum stresses. In the cortical bone, there
Teeth 27.91 329.707
was an increase by 3 times in the stress when the patient Condyle 4.098 10.559
was wearing the Forsus. The teeth showed an increase in
stress of almost 12 times with the Forsus because it is a
tooth-borne appliance, whereas in the condyle, there medial surface of the coronoid process were the
was an increase of more than 2 times during appliance most affected regions. A von Mises stress value of
wear because of the constant sagittal positioning of 8.556 MPa was recorded on the medial side of the coro-
the mandible (Table IV). noid process. The stress regions formed by the Class II
Ulusoy and Darendeliler34 studied the stress region activator high-pull headgear showed that the slopes be-
with the FEM in a dry human mandible with the Class tween the coronoid and condylar processes and the
II activator and the Class II activator and high-pull head- anterior medial surface of the coronoid process were
gear combination. They found that the regions near the the most affected regions.
muscle attachments were affected the most. The inner In our study, the maximum principal stresses in the
part of the coronoid process and the gonial area had cortical bone were from the canine to the molar area,
the maximum stress values. The stress regions formed in the condylar neck, and in the sigmoid notch (Table
by the Class II activator showed that the slope between III), whereas in the resting stage, the maximum principal
the coronoid and condylar processes and the anterior stresses were seen at the neck of the condyle and the

February 2015  Vol 147  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Chaudhry et al
Table V. Maximum principal stresses in 2 models of
the Forsus
Resting stage of
Part mandible (MPa) With Forsus (MPa)
Cortical bone 65.066 145.016
Teeth 20.96 187.077
Condyle 4.117 11.725
middle of the sigmoid notch. In the teeth, these were
seen in the roots of the canines; in the resting stage,
the maximum stress was seen at the distal root of the
first molar. In the condyle, it was in the posterior region
of the superior surface.
In the cortical bone, the principal stress increased by
more than 2 times, and the teeth showed an increase in
stress of 9 times when compared with the resting stage.
The increase in stress in the condyle was 3 times
(Table V). In a magnetic resonance imaging study, Gupta
et al21 evaluated patterns of stress generation in the
TMJ after mandibular protraction with different types
of construction bites, where they changed the vertical
opening but kept the sagittal advancement the same.
Tensile stresses migrated more posteriorly on the
condylar head with increased bite height. The locations
of the tensile stresses in the glenoid fossa were similar
in all simulations, and the TMJ as a whole showed
increased loading with increasing vertical openings.
In a similar study, we compared the stress generation
in 3 models of the mandible with the Twin-block appli-
ance.39 In the first model, the stress pattern in the resting
stage—ie, only with the muscular forces—was seen. In the
second and third models, with the Twin-block appliance,
the vertical height of the bite was kept constant, and the
horizontal advancement was changed. On checking the
von Mises stress and principal stress pattern developed
by the removable appliance, we found that the stress
pattern generated by the Forsus was much higher.
CONCLUSIONS
In this study, we ventured toward understanding the
different biomechanical stresses produced in the various
regions of mandible by a fixed functional appliance.
When the mandible is protracted, a pattern of stresses
is created in the TMJ and the mandible. The stress distri-
bution in the whole mandible was determined using the
finite element model constructed from a DICOM image
generated by CBCT.
1. With the Forsus, a tooth-supported appliance, both
the von Mises and principal stresses increased many
more times in the teeth than in the mandible at the
resting stage.
American Journal of Orthodontics and Dentofacial Orthopedics
233
2. With the appliance, the increases in the von Mises
stress were by 3 times in the cortical bone and by
more than 2 times in the condyle.
3. With the appliance, the maximum principal stress
increased by more than 2 times in the cortical
bone and by more than 3 times in the condyle.
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