Received: 27 May 2023 | Revised: 30 June 2023 | Accepted: 14 July 2023

DOI: 10.1111/ocr.12698

RESEARCH ARTICLE

A finite element analysis of stress distribution with various

directions of intermaxillary fixation using orthodontic
mini-­implants and elastics following mandibular advancement
with a bilateral sagittal split ramus osteotomy

Mi-­Young Lee1 | Jae Hyun Park2,3 | Sung-­Jin Park4 | Na-­Young Chang5 |

Jong-­Moon Chae2,5

1
Department of Orthodontics, Seoul
National University Gwan-­ak Dental Abstract
Hospital, Seoul, South Korea
Objective: This finite element analysis (FEA) aimed to assess the stress distribution in
2
Postgraduate Orthodontic Program,
Arizona School of Dentistry and Oral
the mandible and fixation system with various directions of the intermaxillary fixation
Health, A.T. Still University, Mesa, Arizona, (IMF) using mini-­implants (MIs) and elastics following mandibular advancement with a
USA
3
bilateral sagittal split ramus osteotomy (BSSRO).
Graduate School of Dentistry, Kyung Hee
University, Seoul, South Korea Materials and Methods: A total of nine mandibular advancement models were set ac-
4
Department of Oral and Maxillofacial cording to the position of the MIs (1.6 mm in diameter, 8 mm in length) and direction of
Surgery, GangNam CHA Hospital, CHA
the IMF elastics (1/4 inch, 5 oz). Major and minor principal stresses in the cortical and
University School of Medicine, Seoul,
South Korea cancellous bones, von Mises stresses in the fixation system (miniplate and monocorti-
5
Department of Orthodontics, School cal screws), and bending angles of the miniplate were analysed.
of Dentistry, University of Wonkwang,
Wonkwang Dental Research Institute, Results: Compressive and tensile stress distributions in the mandible and von Mises
Iksan, South Korea stress distributions in the fixation system were greater in models with a Class III IMF
Correspondence elastic direction and a higher IMF elastic force than in models with a Class II IMF
Jong-­Moon Chae, Department of elastic direction and a lower IMF elastic force. The bending angle of the miniplate was
Orthodontics, School of Dentistry,
Wonkwang University Daejeon Dental negligible.
Hospital, 77 Doonsan–­ro, Seo-­gu, Daejeon Conclusions: Stress distributions in the bone and fixation system varied depending on
35233, South Korea.
Email: jongmoon@[Link] the direction, amount of force, and position of IMF elastics and MIs. Conclusively, IMF
elastics in the Class II direction with minimal load in the area close to the osteotomy
site should be recommended.

KEYWORDS
bilateral sagittal split ramus osteotomy, finite element analysis, fixation miniplate,
intermaxillary fixation, orthodontic mini-­implant and elastics

Mi-­Young Lee and Jae Hyun Park contributed equally as co-­f irst authors.

© 2023 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

102 | 
[Link]/journal/ocr Orthod Craniofac Res. 2024;27:102–109.
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LEE et al. 103

1 | I NTRO D U C TI O N
Highlights
Bilateral sagittal split ramus osteotomy (BSSRO) has been widely
used to correct mandibular retrognathism and has shown excellent • This study was done to assess the stress distribution in
1
long-­term postoperative stability. The BSSRO procedure is pur- various directions of the intermaxillary fixation (IMF).
posed to split the mandibular ramus area, followed by advancement • Stress distribution was greater when IMF elastics were
of the distal segment of the mandible, fixation into its planned posi- positioned anteriorly with greater force and Class III
tion using rigid internal fixation (RIF), and establishment of a planned direction.
intermaxillary occlusal and skeletal relationship using intermaxillary • IMF elastics in Class II direction with minimal load in the
fixation (IMF) with a surgical splint (Figure 1). area close to the osteotomy site are recommended.
Two different rigid internal fixation (RIF) methods use bicorti-
cal screws and monocortical miniplates to stabilize the fragments
after mandibular advancement by BSSRO. 2–­13 The bicortical screw study was that the stress distribution would not be different regard-
4,6–­13
method is considered to be a rigid, cost-­effective, and stable less of the direction of the IMF elastic force.
technique, but it might cause higher intraoperative blood loss and
condylar rotation2 than the monocortical miniplate method4 and can
possibly damage the inferior alveolar nerve.10 On the other hand, the 2 | M ATE R I A L S A N D M E TH O DS
3–­5,7–­13
monocortical miniplate method is also a safe and predictable
method. Furthermore, it provides less stress on the temporomandib- A computer-­aided design model was created for a finite element
ular joint (TMJ) and causes less nerve damage and relapse than the analysis using MIMICS Software (version 15.01; Materialize, Leuven,
bicortical screw method.4,5,9 Belgium) based on a CT scan of a dehydrated adult skull. The geomet-
14–­26
IMF after RIF is a necessary procedure that holds the sur- ric information of the human skull was imported into Visual Crash for
gically corrected intermaxillary relationships and helps to prevent PAM (Version 17.0; ESI Group, Paris, France) to create a tetrahedral FE
skeletal relapse. Orthodontic surgical archwires with soldered or mesh. The model was established with the mandible and skull, includ-
crimpable hooks and intermaxillary elastics or wiring have been ing the maxilla, and divided into cortical and cancellous bones. The size
23
used with a surgical splint for IMF. But IMF with surgical archwires of the tetrahedral meshes was set to 0.2–­5.0 mm. The material prop-
has had detrimental effects on the anterior teeth by loading verti- erties of each component are listed in Table 1.32–­35 It was assumed
23
cal forces due to muscle function after orthognathic surgery. In that both the cortical and cancellous bones were homogeneous in the
addition, there are problems with this method because the position maxilla and mandible. The conventional plate system and six monocor-
of the hooks cannot be controlled, and there is the possibility of tical screws for RIF and orthodontic MIs for IMF were comprised of ti-
bracket detachment. 24 tanium alloy (Jeil Medical Corp., Seoul, Korea). Young's initial modulus
To overcome these problems, bone screws15–­19,22,24,25 or ortho- was set to one megapascal (MPa), and the threshold stress and final
dontic MIs20,21,23,26 have been applied for IMF. IMF screws can be elastic modulus were set to 0.1 MPa. The foramen magnum of the skull
placed in various sites, but some authors suggest that the best po- was set to be fully fixed to serve as the origin point.
sition is between the canine and first premolar,15,22 and just a single BSSRO was conducted on the model, and the distal segment was
IMF screw in each quadrant is sufficient.15 IMF screws have both advanced by 5 mm. The proximal and distal segments were fixated
minuses and pluses. For instance, placing them requires an invasive with a single straight miniplate (titanium alloy, 1 mm in thickness, and
17 18
procedure; they can loosen; there is the potential for root dam- six holes), and monocortical titanium screws of 2 mm in diameter and
age;15 but on the other hand, they afford the high stability charac- 6 mm in length were used. The condylar region was assumed to be
teristic of skeletal anchorage,16,17,22,23 are easy to work with,17,18 and completely fixed. Bite force was excluded because it is not a factor
facilitate the use of lingual orthodontic treatment, clear aligners, and immediately after BSSRO. A splint placed between the maxillary and
20,23,26
the surgery-­first approach. An IMF elastic force of about 150 g mandibular teeth was fabricated to cover the incisal edges with a
is applied in various directions depending on the position of the IMF 5-­mm-­thick acrylic resin. It was assumed that the maxilla, proximal
screws, thus directing the vector of the IMF elastic force.14,15,17,20–­24 segment of the mandible, and teeth were firmly fixed with the splint.
Several finite element analysis (FEA) studies27–­31 have evaluated Orthodontic MIs (1.6 mm in diameter and 8 mm in length) were
the stress distribution on the bone and fixation system according placed between the central incisors, canine and first premolar, first
to different RIF methods after BSSRO for mandibular advance- and second premolars, and second premolar and first molar. They
ment. However, no study has investigated the stress patterns on were placed between the roots at a height of 5 mm from the cemen-
the osteotomy and fixation sites with various directions of the IMF. toenamel junction. A total of nine models were set according to the
Therefore, the aim of this study was to assess the stress distribution position of the MIs and direction of the IMF elastics (1/4 inch, 5 oz)
on the osteotomy and fixation (miniplates and monocortical screws) (Figure 1). The elastic force was calculated after modelling the IMF
sites with various directions of IMF using MIs and elastics following elastics in the activated position. The strain was calculated using
mandibular advancement with BSSRO. The null hypothesis of this the ratio of increased length to the original length, and the load was
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104 LEE et al.

F I G U R E 1 Intraoral photograph showing intermaxillary fixation using elastics between the mini-­implants with a surgical splint following a
bilateral sagittal split ramus osteotomy. Nine mandibular advanced models after bilateral sagittal split ramus osteotomy (BSSRO) depending
on the position of mini-­implants (MIs) and direction of the intermaxillary fixation (IMF) elastics: Model 1, anterior short Class III elastics
connecting MIs placed between the canines and first premolars; Model 2, middle short Class III elastics connecting MIs placed between the
first and second premolars; Model 3, posterior short Class III elastics connecting MIs placed between the second premolars and first molars;
Model 4, long Class III elastics connecting MIs placed between the maxillary second premolar and first molar and the mandibular canine
and first premolar; Model 5, anterior short Class II elastics connecting MIs placed between the maxillary canine and the first premolar and
the mandibular first and second premolars; Model 6, middle short Class II elastics connecting MIs placed between the maxillary first and
second premolars and the mandibular second premolar and first molar; Model 7, medium Class II elastics connecting MIs placed between the
maxillary canine and first premolar and the mandibular second premolar and first molar; Model 8, Combination of Models 1 and 2. Model 9,
anterior vertical elastics connecting MIs placed between the maxillary and mandibular central incisors

TA B L E 1 Material properties of components TA B L E 2 Intermaxillary fixation elastic forces in nine mandibular

advancement models
Young's modulus Poisson's
Components (GPa) ratio Stretched
Initial Stretched length/Initial Force (g)
Cortical bone 13.7 0.30
Model length length length (F = EA ε)
Trabecular bone 1.37 0.30
1 42.43 85.62 2.02 103.8
Dentin 20.7 0.30
2 42.43 82.82 1.95 97.1
Periodontal ligament (PDL) 0.000168 0.49
3 42.43 79.52 1.87 89.1
Titanium 113.0 0.33
4 42.43 95.36 2.25 127.2
Splint 2.0 0.30
5 42.43 84.43 1.99 100.9
6 42.43 81.12 1.91 93.0
7 42.43 88.41 2.08 110.5
calculated using Young's modulus and the area of the elastics (F = EA
ε, Table 2). The IMF elastics were applied bilaterally in all models 8 42.43 112.29 2.65 159.5

except Model 9. The elastic force was the greatest in Model 8 and 9 42.43 88.25 2.07 110.1
the least in Model 3.
Tensile (major principal stress) and compressive (minor principal The bending angle of the miniplate was measured in each model.
stress) stresses were measured in the cortical and cancellous bones. Upward and downward movements were recorded as negative and
The von Mises stress was also measured to indicate the deformation positive numbers, respectively (Figure 3 and Table 3).
and yield possibility of the fixation plate and monocortical screws.
The distributions of major and minor principal stresses and von
Mises stress were set in a range of −0.05 to 0.05 MPa (Figure 2). The 3 | R E S U LT S
maximum values of tensile and compressive stresses in the bone
were measured, as well as the maximum von Mises stress values of 3.1 | Major principal stresses on the bone (Figure 2
the fixation plate and monocortical screws (Table 3). Nonlinear static and Table 3)
simulations were performed using Virtual Performance Solution
software (version 2021; ESI Group, Paris, France). Visual Viewer The distribution of tensile stresses was more extensive in Models 1,
(version 17.0; ESI Group, Paris, France) was used for plotting. 4, and 8 than in the others. The maximum value of the major principal
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LEE et al. 105

F I G U R E 2 Distribution of major principal stresses (A, tension) and minor principal stresses (B, compression) in the mandible and
von Mises stresses (C) in the fixation system depending on the direction and amount of intermaxillary fixation (IMF) elastic force using
orthodontic mini-­implants (MIs)

stress of the cortical bone was the greatest in Model 7 and the least in in Model 5, likewise showing a downward direction. The miniplate
Model 9. The maximum value of the major principal stress of the can- showed upward bending in the Class III elastic direction models (1–­
cellous bone was the greatest in Model 9 and the least in Model 1. The 4, 8), and downward bending in the Class II elastic direction models
tensile stress in the cortical and cancellous bones generally showed (5–­7), and anterior vertical elastic direction in Model (9).
higher values in the Class II elastic direction Models (5–­7) than in
the Class III elastic direction models (1–­4). The distribution of tensile
stress tended to be higher in the posterior ramus than in other areas. 4 | DISCUSSION

In this study, the FEA model was constructed to simulate 5 mm of

3.2 | Minor principal stresses on the bone advancement of the mandibular distal segment with BSSRO, RIF of
(Figure 2 and Table 3) two segments (proximal and distal) with a single miniplate and six
monocortical screws, and IMF in various directions with intermaxil-
The distribution of compressive stress was more extensive in Models lary elastics and orthodontic MIs.
4 and 8 than in the others. The maximum values of minor principal Various RIF methods use bicortical screws, miniplates, and hy-
stress in the cortical bone were the greatest in Models 4 and 8, and brid techniques. 2–­13 When the amount of mandibular advancement
the least in Model 3. And they were the greatest in Model 9 and exceeds 7 mm, there is a greater tendency to relapse, so RIF with
the least in Models 1 and 5 in cancellous bone. Compressive stress two miniplates and screws was recommended to provide adequate
distribution tended to be higher in the sigmoid notch and anterior resistance with less displacement.31 On the other hand, Albougha
ramus than in other areas. et al.30 recommended using a single straight miniplate for RIF after
ramus osteotomy because it provided a sufficiently stable RIF with
minimal risks of bone fracture or failure. In this study, only 5 mm of
3.3 | Maximum values of von Mises stress in the mandibular advancement was performed with BSSRO, so RIF with
RIF system (Figure 2 and Table 3) one miniplate and six monocortical screws was used to fixate the
osteotomy site. Additional studies might be planned for cases with
The maximum values of von Mises stress in the monocortical screw greater than 7 mm of mandibular advancement using various other
and miniplate were the greatest in Models 4 and 8, and the least in RIF methods.
Model 6. The biomechanical function of RIF is clinically determined by the
interaction between the three elements: the miniplate, screws, and
bone. To achieve proper osteosynthesis, precise adaptation between
3.4 | Bending angle of the miniplate (Figure 2 and the underlying bone and the plate is required in a conventional bone-­
Table 3) plate-­screw system. Without this contact, the segmental position
and occlusal relationship could be altered. 27 Therefore, special ef-
The absolute value of the bending angle of the miniplate was the forts were made to adapt the plates in this study. However, since
greatest in Model 9, showing a downward direction, and the smallest bone quality and surgical technique are more important than the
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106 LEE et al.

fixation system, 29 healing patterns might differ in each clinical situa-

tion. That was a limitation of this FEA study.

0.0008858
0.000070
0.002589

0.000137
0.003945
0.001823

0.003142
Instability at the osteotomy site contributes to early relapse in

Model 9
BSSRO, which can lead to osteosynthesis failure.7 A high concen-
tration of stress in the fixation system can lead to excessive stress
at the osteotomy site, which interferes with osteosynthesis.8

−0.0004369
TA B L E 3 Maximum values of major and minor principal stresses in the bone, and von Mises stress in the fixation system in nine mandibular advancement models (MPa)

0.000306
Moreover, stress concentration causes long-­term sagittal relapse

0.000168
0.005081
0.000375

0.000267
0.003725
Model 8

related to the initial displacement of the fixation site.36 Therefore,

it would be desirable to use RIF that does not exert excessive force
towards the fixation site. In other words, the overall stress distribu-
tion should not be concentrated at the osteotomy site. Therefore,
this study used the monocortical miniplate method rather than the

0.0006259
0.000344

0.000050
0.000081
0.004681
0.000365

0.002858
Model 7

bicortical screw method to reduce stress at the osteotomy site.4,5,9

In the future, a study might be planned to consider bicortical screws
or other methods for RIF.
IMF stabilizes the postoperative occlusion, corrects postop-
0.0001589

erative occlusal discrepancies, and increases patient comfort by

0.000303

0.000032
0.000333

0.000079
0.004183

0.001920
Model 6

reducing the stress on the masticatory muscles immediately after

orthognathic surgery.16,22,23 IMF also has the advantage of high,
short-­term stability. 22 The IMF using orthodontic MIs minimizes
the effects on dentition and thus reduces dental side effects,16,23
0.0000315

but it also has some disadvantages, such as delaying the patient's

0.000302

0.000079
0.000282
0.004073

0.000132
0.002392
Model 5

recovery to normal function and preventing proper oral hygiene

maintenance.37
Depending on the clinician, IMF may be used in one direction or
in several directions (Class II, Class III, vertical, box, triangle, trape-
−0.0002243
0.000306

0.000168
0.005081
0.000375

0.000267
0.003725

In bending angle, positive values mean downward bending while negative values mean upward bending.

zoidal, rhomboidal, and cross-­arch) to guide the position of the man-

Model 4

dible. In this study, Class II, Class III, vertical, and box elastics were
used with 90–­160 g of force, while Kim et al. 24 used 150 g of force
for 24 h per day for 6 weeks. At this IMF stage, osteosynthesis at the
osteotomy site is incomplete, and so the proper application of IMF
−0.0002895
0.004000

0.000096
0.000067
0.000273
0.000313

0.001835

forces should be applied because stress distribution might be differ-

Model 3

ent depending on the direction and amount of force of the IMF elas-
tics, which may affect postoperative stability. Therefore, this study
aimed to determine the differences in stress distribution according
−0.0003939

to various IMF elastic directions.

0.000098
0.000284
0.000321
0.003815

0.000159
0.002255

In this study, stress distributions and maximum values of the

Model 2

major principal, minor principal stress, and von Mises stresses in-
creased as the IMF elastic force increased. IMF elastic forces were
differently applied in each model to reproduce real clinical situa-
−0.0007399

tions. Future studies might be necessary to determine the stress dis-

0.004042

0.000120
0.000282
0.000278

0.000214
0.003110
Model 1

tribution in various directions of IMF force and at the same amount

of IMF elastic force. Overall stress distributions increased as IMF
elastics with MIs were positioned more anteriorly and farther away
from the condyle, regardless of the direction of the IMF elastic force.
Cortical bone
Cortical bone

Cancellous
Cancellous

Even though Model 9 was unilateral, unlike other models, and the
Miniplate
Miniplate
bone
bone

Screw

overall elastic force was reduced by half, the tensile and compres-
sive stresses applied to the proximal segment were similar to those
of Model 2, and the maximum values of the tensile and compres-
Minor principal
Major principal

Bending angle

sive stresses of the cancellous bone were greater than the others.
von Mises
stress
stress
stress

In addition, the maximum value of von Mises stress applied to the

monocortical screws in Model 9 was higher than those of the Class II
elastic models (5–­7) (Table 3).
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LEE et al. 107

suggested that Class II elastics could cause more harmful stress to

the TMJ than Class III elastics. This might be because the previous
study was conducted focusing only on the TMJ, and so the results
were interpreted differently than ours.
In this study, judging from the aspect of stress distribution, the
position of the IMF elastics was more crucial than their direction.
This was confirmed by the fact that stress distribution in the bone,
including the osteotomy site, increased significantly as the IMF elas-
tics were positioned more anteriorly from the osteotomy site. As the
IMF elastic force was applied more posteriorly, the stress applied to
the TMJ, mandible, and osteotomy site decreased, which might be
considered to have a favourable effect on osteosynthesis. On the
other hand, as the IMF elastic force increased, the stress on the bone
F I G U R E 3 Bending angle of the miniplate. Positive values mean
downward bending, while negative values mean upward bending and fixation system also increased. Thus, the application of Class II
IMF elastics with minimal load in the area close to the osteotomy site
should be recommended.
The IMF elastic force acted as a moment rather than a linear Harada et al.39 insisted that bite force and the occlusal contact
force at the osteotomy site, and the distance from the condyle to area were the lowest two weeks after orthognathic surgery and
the IMF elastics affected the TMJ as a fulcrum. Therefore, the IMF's steadily recovered over the next two or three months, but even at
elastic position, in combination with the anteroposterior position of six months, the bite force was still only about half or less than that
MIs, can affect the stability of the osteotomy site, and the TMJ can in healthy subjects. Ellis et al.40 also suggested that bite force after
also be affected because the condyle is considered to be the point orthognathic surgery increased gradually over the next 2 or 3 years
of action. And if von Mises stresses on the miniplate and monocor- as it approached normal values. Therefore, the effect of bite force on
tical screws exceed the limit of yield strength, permanent deflec- the stress distribution was ignored in this study.
tion of the fixation system would be expected. In this study, the von In this study, the authors tried to suggest the most desirable di-
Mises stress on the fixation system was extremely low compared to rection and position of IMF elastics by observing the stress distribu-
the yield strength caused by the IMF elastic force. Therefore, the tions in the mandible and osteotomy site depending on the various
bending effects of the IMF elastics on the miniplate and monocor- positions of the MI and the directions of IMF force after mandibular
tical screws were negligible (Table 3). Nevertheless, an appropriate advancement with BSSRO. However, this study has some limitations.
amount of IMF elastic force application in the possible posterior po- The biomechanical environment could not be perfectly reproduced
sition should be considered for a more fail-­safe result. because of the different amounts of mandibular advancement, bite
In this study, when IMF elastic force was applied in the mandible, force, occlusal contact area, salivary PH, oral hygiene conditions,
tensile and compressive stresses were generated in the inferolateral condyle fixation, diversity of fixation methods, various types of re-
and mediosuperior areas of the mandible. This stress distribution lapse, immediate post-­operative changes in muscles, operators from
was not significantly related to the direction of the IMF elastic force, patient to patient, and other factors that were not taken into ac-
but it caused bending or torsion of the fixation plate. The bending count. In addition, this study only addressed mandibular advance-
angles of the miniplate in the Class II and III elastic force models ment using BSSRO; therefore, a mandibular setback study might be
were downward and upward, which might be related to increased necessary for a model with mandibular excess.
tensile and compressive stresses, respectively. Rotation and bending
of the proximal and distal segments of the mandible are phenomena
that cannot be observed clinically unless the fixation plate is de- 5 | CO N C LU S I O N S
formed or fractured. In this study, the bending angle of the miniplate
was negligible when applying the IMF elastic force, but this was not The authors assessed the stress distribution in the osteotomy and
consistent with the results of Fujioka et al.'s study.10 They suggested fixation sites with various directions of IMF using MIs and elastics
that the mandible was bent with the bending of the miniplate, so bi- following mandibular advancement with BSSRO. Consequently, the
cortical osteosynthesis would be better than monocortical miniplate stress distribution was different depending on the type of FE model,
osteosynthesis. so the null hypothesis was rejected.
In this study, as the Class III component of the IMF elastic force Compressive and tensile stress distributions in the mandible and
increased and was located anteriorly, the maximum values of com- von Mises stress distributions in the fixation system were greater in
pressive stress and von Mises stress increased. In contrast, the Class models with a Class III IMF elastic direction and a higher IMF elastic
II component of the IMF elastic force showed fewer stress distribu- force than in models with a Class II IMF elastic direction and a lower
tions in the mandible and fixation system than the Class III compo- IMF elastic force. Stress distribution in the bone, including the oste-
nent. This was contrary to the results of a previous study,38 which otomy site, was greater in the models with IMF elastics positioned
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108 LEE et al.

bicortical versus monocortical osteosynthesis. Plast Reconstr Surg.

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This paper was supported by Wonkwang University in 2023 and The
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The authors declare that there is no conflict of interest.
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