prospective randomized clinical trial comparing bite force in 2-mm locking plates versus 2-mm...

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J Oral Maxillofac Surg69:1995-2000, 2011

Prospective Randomized Clinical TrialComparing Bite Force in 2-mm LockingPlates Versus 2-mm Standard Plates in

Treatment of Mandibular FracturesMohit Agarwal, BDS, MDS*

Shadab Mohammad, BSc, BDS, MDS,†

Rakesh K. Singh, BDS, MDS,‡ and Vibha Singh, BDS, MDS§

Purpose: To compare the efficacy of the 2-mm locking miniplates to 2-mm standard miniplates in theosteosynthesis of mandibular fractures on the basis of clinical parameters and bite force recording.

Patients and Methods: A prospective randomized clinical trial was conducted at the Faculty of DentalScience, CSMMU (formerly King Georges Medical College), Lucknow, India, from January 1, 2007, to January31, 2008, to treat consecutive mandible fractures. The patients were randomly divided into 2 groups. Thepatients underwent osteosynthesis—group 1 with Synthes 2-mm locking titanium miniplates and group 2with Synthes 2-mm nonlocking titanium miniplates. The cause of trauma, the number of days from injury tosurgery, average age, gender, and site distribution were all reviewed. The assessment of the patients was doneat 1, 3, and 6 weeks and 3 months using the clinical parameters and bite force recording.

Results: A total of 20 patients with 32 fractures met the inclusion criteria. In our study, a statisticallysignificant difference was not found in the clinical parameters such as pain, swelling, infection, paresthesia,hardware failure, and mobility between the fracture segments. A statistically significant difference was foundbetween the change in bite force from the previous follow-up visit in groups 1 and 2. From 1 week to 3months, the change in the incisor bite force was significantly greater for group 1 than for group 2. At 6 weeksand 3 months, the change in right molar bite force from the previous follow-up visit was significantly greaterfor group 1 than for group 2. At the 1-, 3-, 6-week and 3-month follow-up visits, the change in left molar biteforce from the previous follow-up visit was significantly greater for group 1 than for group 2.

Conclusion: These findings show that the use of locking miniplates plate in mandibular fracture wasefficacious enough to bear the masticatory loads during osteosynthesis of the fracture. The lockingminiplates provide the advantage of a greater bite force, with clinical results almost similar to those seenwith nonlocking miniplate osteosynthesis.© 2011 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 69:1995-2000, 2011
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n the era of increasing automobilization, industrial-zation, and technology, the treatment of maxillofacialnjuries has attained a prominent position. The head,ecause it is the most exposed part of the body, is

nvolved in the greatest percentage of injuries of thentire body. The other causes of maxillofacial injuriesnclude interpersonal violence, falls, sporting injuries,

*Assistant Professor, Department of Oral and Maxillofacial Sur-

gery, Government Dental College, Jaipur, India; formerly Senior

Resident, Department of Oral and Maxillofacial Surgery, Faculty of

Dental Sciences, CSMMU, Lucknow, India.

†Professor and Head, Department of Oral and Maxillofacial Sur-

gery, Faculty of Dental Sciences, CSMMU, Lucknow, India.

‡Professor, Department of Oral and Maxillofacial Surgery, Faculty

of Dental Sciences, CSMMU, Lucknow, India. d

1995

nd industrial trauma. Miniplate osteosynthesis, firstntroduced by Michelet in 1973,1 and further devel-ped by Champy et al2 in 1975, is the current stan-

dard for the treatment of mandibular fracture.3–6

Champy et al1–6 determined the ideal lines of osteo-synthesis on which plates must be applied to resistthe torsional forces.

§Assistant Professor, Department of Oral and Maxillofacial Sur-

gery, Faculty of Dental Sciences, CSMMU, Lucknow, India.

Address correspondence and reprint requests to Dr Agarwal:

Government Dental College, Subhash Nagar, Behind TB Hospital,

Jaipur, Rajasthan 302016, India; e-mail: [email protected]

© 2011 American Association of Oral and Maxillofacial Surgeons

278-2391/11/6907-0034$36.00/0

oi:10.1016/j.joms.2010.10.014

mailto:[email protected]

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1996 BITE FORCE OF 2-MM LOCKING VERSUS STANDARD PLATES

Various types of miniplating systems have beendeveloped to provide stable fixation for mandibularfractures and osteotomies. A disadvantage of conven-tional miniplate systems has been that the plate mustbe perfectly adapted to the underlying bone to pre-vent alterations in the alignment of the segments andchanges in the occlusal relationship. With conven-tional bone plating systems, stability is achieved whenthe head of the screw compresses the fixation plateto the bone.7 A unique advantage of locking systemsis that it becomes unnecessary for the plate to haveintimate contact with the underlying bone, makingplate adaptation easier. Haug et al7 performed a studywith intentional maladaptation of the plates. Theyconcluded that the degree of adaptation affected themechanical behavior of the nonlocking systems, but itdid not affect the behavior of the locking systems. Inthe locking system, the hole in the bone plate hasbeen engineered to accept screws that lock to it by asecond thread under the head of the screw. Theseplates function as internal fixators, achieving stabilityby locking the screw to the plate. In 1999, Gutwald8

performed the first biomechanical comparison oflocking plates applied to the mandible. Gutwald8 con-cluded that greater stability was achieved with thelocking plates. Others have concluded the opposite.In 2006, Chiodo et al9 compared the failure strength

f locking and nonlocking Synthes (Synthes, Westhester, PA) 2-mm mandibular fixation plates in a

aboratory model. They concluded that in the labora-ory model, no significant differences were foundetween the 2 types of mandibular plates. The theo-ectical advantages proposed have included 1) lesscrew loosening; 2) greater stability across the frac-ure site; 3) less precision required in plate adapta-ion because of the internal/external fixator; and 4)ess alteration in the osseous or occlusal relation-hip with screw tightening. Ellis and Graham10 re-

ported encouraging results with the 2.0-mm lock-ing plate and screw system applied to a consecutiveseries of patients.

In 2004, Collins et al11 compared the standard.0-mm monocortical plates and the 2.0-mm lockinglates in the treatment of mandible fractures accord-

ng to the complication rates. They concluded thatandible fractures treated with 2.0-mm locking plates

nd standard 2.0-mm plates presented with similarhort-term complication rates. No study has com-ared the bite force in patients treated with lockingnd nonlocking miniplates, to our knowledge. In002, Gerlach and Schwarz12 stated that the maximalite force in patients with mandibular fracturesreated with miniplate osteosynthesis had reachednly 31% at 1 week postoperatively compared with aealthy control group. This value had increased to
8% at 6 weeks postoperatively. In 1994, Tate et al13
stated that sufficient internal fixation hardware mustbe applied to resist the maximal force of mastication.Thus, they hypothesized that the stability of fracturesegment would be ensured, even under full functionof the masticatory system. The biomechanical andtechnical advantages of locking miniplate systemscompared with conventional miniplate system pro-moted us to perform the present study to comparethe locking miniplates with standard miniplates in theosteosynthesis of mandibular fractures according tothe clinical parameters and bite force.

Patients and Methods

A prospective randomized clinical trial of the treat-ment of consecutive mandible fractures was con-ducted at the Faculty of Dental Science, CSMMU (for-merly King Georges Medical College), Lucknow,India, from January 1, 2007, to January 31, 2008. Ourlocal ethical board approved the present study. Pre-operatively, a detailed medical history of the patientswas recorded. The diagnosis was made on the basis ofthe clinical examination findings and radiographic inter-pretation. Routine investigations were performed. Allpatients provided informed consent before participat-ing in the present study. Strict inclusion criteria wereused, including randomization of consecutive pa-tients, irrespective of age, gender, caste, and creed;the presence of noncomminuted mandible fracturesat any site; and the absence of other facial fractures.The exclusion criteria were mandibular fracture withinfection and a history of diabetes, prolonged steroidtherapy, compromised immunity, or associated bonepathologic features. The patients were randomly di-vided into 2 equal groups. All patients underwentosteosynthesis using Synthes miniplates: group 1 withSynthes 2-mm locking titanium miniplates and group2 with Synthes nonlocking titanium miniplates. Thesurgical technique used to apply both plating systemswas the same. All patients underwent intermaxillaryfixation with elastics for 7 to 10 days. The cause oftrauma, interval from injury to surgery, average age,gender, and site distribution were all reviewed. Fol-low-up was done at 1, 3, and 6 weeks and 3 months.The following clinical parameters were assessed foreach patient at each follow-up visit: pain (visual ana-log scale 1 to 10), swelling, infection, paresthesia,hardware failure (plate fracture), mobility betweenfracture fragments, and bite force recording at theincisor, right molar, and left molar regions. All biteforce measurements were made using the indigenousbite force recorder, which consists of 4 strain gaugesmounted on steel bars, forming a wheatstone bridge.Load changes in the steel bar produced a measurablevoltage change across the 4 strain gauges, which was
converted into the kilogram force (kp). All measure-

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ments were made with the subject seated with thehead upright, looking forward, and in an unsupportednatural head position. The subjects were asked toremain in this position throughout the trial and torefrain from extraneous movements. The subjectswere instructed to bite on the pads of bite force gaugeto the maximal level.

Results

A total of 20 patients with 34 fractures met theinclusion criteria and were included in the presentstudy. In group 1, 10 patients with 18 fractures un-derwent osteosynthesis using Synthes locking tita-nium miniplates. In group 2, 10 patients with 16fractures underwent osteosynthesis using the Synthesnonlocking titanium miniplates. The most commoncause of injury was road traffic accidents (65% ofcases). The patients were divided into 4 age groups: 1to 15, 16 to 30, 31 to 45, and 46 to 60 years; the mostcommon age group was 16 to 30 years (60%). Morepatients were male (95%) than female (5%). Parasym-physis was the most commonly involved site, fol-lowed by the angle. The preoperative occlusion wasderanged in all the patients in both groups. However,

FIGURE 1. Incisor bite force in groups 1 and 2.

garwal et al. Bite Force of 2-mm Locking Versus Standard

Table 1. INCISOR BITE FORCE IN GROUP 1

Follow-UpBite Force

(kp)Change

(kp) tP

Value

reoperative 2.73 � 1.20 — — —wk 5.20 � 2.63 2.47 � 1.74 4.24 �.01wk 6.95 � 3.48 4.22 � 2.45 5.16 �.001wk 10.67 � 5.62 7.93 � 4.94 4.80 �.001mo 19.49 � 10.28 16.76 � 9.34 5.35 �.001

ata presented as mean � standard deviation.

Agarwal et al. Bite Force of 2-mm Locking Versus StandardPlates. J Oral Maxillofac Surg 2011.

lates. J Oral Maxillofac Surg 2011.

functional occlusion was achieved postoperatively inall patients. The patients were divided into 5 groupsaccording to the interval from injury to treatment: lessthan 1 day, 1 to 3 days, 4 to 7 days, 8 to 11 days, and12 to 15 days. Most patients (45%) were treatedwithin 8 to 11 days of injury, and mean intervalbetween injury and treatment was 8.7 days.

No significant difference was found in the clinicalparameters between the 2 groups. A significant de-crease in pain occurred from 1 week to 3 months inboth groups. No pain was observed at the 3-monthfollow-up visit in either group. No significant differ-ence in the pain experienced was found betweengroups 1 and 2 at the different follow-up visits. At 1and 3 weeks, swelling was present in 20% of patientsin both groups. At 6 weeks and 3 months, swellingwas present in 10% of the patients in group 1 and inno patient in group 2; however, the difference wasnot significant. No paresthesia was observed in anypatient in group 1. In group 2, only 1 patient pre-sented with paresthesia up to 3 weeks. The paresthe-sia had resolved at the 6-week follow-up visit. At 6weeks in group 2, 1 patient presented with infection;no patient in group 1 presented with infection; how-ever, the difference was not significant. At 3 months,1 patient in each group presented with infection.

In group 1, the incisor bite force had increasedsignificantly at the progressive follow-up visits com-

Table 2. INCISOR BITE FORCE IN GROUP 2

Follow-UpBite Force

(kp)Change

(kp) tP

Value

reoperative 4.08 � 1.22 — — —wk 4.98 � 1.54 0.90 � 0.91 2.94 �.05wk 6.69 � 2.33 2.61 � 1.75 4.46 �.01

6 wk 9.25 � 2.84 5.17 � 2.41 6.42 �.0013 mo 11.03 � 2.48 6.95 � 2.02 10.32 �.001

Data presented as mean � standard deviation.


Table 3. COMPARISON OF CHANGE IN INCISORBITE FORCE IN GROUPS 1 AND 2

Follow-UpGroup 1

(kp)Group 2

(kp) tP

Value

1 wk 2.47 � 1.74 0.90 � 0.91 2.53 �.053 wk 4.22 � 2.45 2.61 � 1.75 1.69 �.05 (NS)6 wk 7.93 � 4.94 5.17 � 2.41 1.59 �.05 (NS)3 mo 16.76 � 9.34 6.95 � 2.02 3.24 �.01

Abbreviation: NS, not significant.Data presented as mean � standard deviation.

Agarwal et al. Bite Force of 2-mm Locking Versus Standard
Plates. J Oral Maxillofac Surg 2011.

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pared with that recorded preoperatively (Table 1,Fig 1). In group 2, the incisor bite force had alsoincreased significantly at the progressive follow-upvisits compared with that recorded preoperatively(Table 2, Fig 1). From 1 week to 3 months, the changein the incisor bite force was significantly greater ingroup 1 than in group 2 (Table 3). At 3 and 6 weeks,no significant difference was observed in the changein the incisor bite force in groups 1 and 2 (Table 3).

In group 1, the right molar bite force had increasedsignificantly at the progressive follow-up visits com-pared with that recorded preoperatively (Table 4,Fig 2). In group 2, the right molar bite force had alsoincreased significantly at the progressive follow-upvisits compared with that recorded preoperatively(Table 5, Fig 2). From 6 weeks to 3 months, thechange in the right molar bite force from the previousfollow-up visit was significantly greater in group 1than in group 2 (Table 6). At 1 and 3 weeks, nosignificant difference was observed in the change inthe right molar bite force of groups 1 and 2 (Table 6).

In group 1, the left molar bite force had increasedsignificantly at the progressive follow-up visits com-pared with that recorded preoperatively (Table 7,Fig 3). In group 2, the left molar bite force had alsoincreased significantly at the progressive follow-up

FIGURE 2. Right molar bite force in groups 1 and 2.


Table 4. RIGHT MOLAR BITE FORCE IN GROUP 1

Follow-UpBite Force

(kp)Change

(kp) tP

Value





visits compared with that recorded preoperatively(Table 8, Fig 3). At 1, 3, and 6 weeks and 3 months,the change in left molar bite force from the previousfollow-up visit was significantly greater in group 1than in group 2 (Table 9).

Discussion

The rationale for using monocortical plates to treatmandibular fractures is that synthesis using a platescrewed on the outer cortical plate will be solidenough to support the strain developed by the mas-ticatory muscle. On the horizontal ramus, the masti-catory forces create, within the mandible, elongationstrain along the alveolar border and compressivestrain along the lower border. Only the traction strainwill be injurious and must be neutralized. The studyof movement with regard to the mathematical modelof the mandible by Champy et al1–6 showed that athe level of the horizontal ramus, the movement islmost only flexion, the force of which increases fromhe front to the back. In the anterior part of theandible, anterior to the first premolar, the move-ent is mainly torsion. The forces become greater as

hey become nearer to the mandibular symphysis.The theoretical advantage of using locking plates is

ntriguing; however, the clinical relevance must benalyzed. No study has compared the bite force in

Table 6. COMPARISON OF CHANGE IN RIGHTMOLAR BITE FORCE IN GROUPS 1 AND 2

Follow-UpGroup 1

(kp)Group 2

(kp) tP

Value

1 wk 8.39 � 5.72 5.55 � 3.68 1.32 �.05 (NS)3 wk 20.52 � 9.58 15.26 � 9.69 1.22 �.05 (NS)6 wk 37.92 � 10.44 22.73 � 7.40 3.84 �.013 mo 58.43 � 20.25 31.58 � 9.58 3.79 �.01

bbreviation: NS, not significant.Data presented as mean � standard deviation.


Table 5. RIGHT MOLAR BITE FORCE IN GROUP 2

Follow-UpBite Force

(kp)Change

(kp) tP

Value

reoperative 11.75 � 3.60 — — —wk 17.30 � 5.26 5.55 � 3.68 4.51 �.01

3 wk 27.01 � 8.66 15.26 � 9.69 4.72 �.016 wk 34.48 � 6.24 22.73 � 7.40 9.20 �.0013 mo 43.33 � 9.32 31.58 � 9.58 9.88 �.001




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patients treated with locking and nonlocking mini-plates to our knowledge.

The main disadvantage of the locking system hasbeen the cost. The extra cost to the patient will beconsiderable. The surgeon should be aware of thecost difference between the 2 systems before select-ing a locking plate. The locking system requires onlyminor additions to the instrument armamentarium.The system requires perpendicular placement of theplate/screw interface; thus, a locking drill guide isrequired. The technical difficulty added to the casewill be fairly minor. Postoperative intermaxillary fix-ation with elastics was done for 7 to 10 days in all ourpatients. Previous investigators have reported excel-lent results with 2.0-mm miniplate fixation and a shortperiod of maxillomandibular fixation.14 Follow-up ex-aminations at 1, 3, and 6 weeks and 3 months is anacceptable follow-up protocol for studying mandiblefractures compared with published studies.

No significant difference was found in the clinicalparameters between the 2 groups. The bite force isrelated to a number of factors, including tactile im-pulses, pain and pressure reception in the periodontalligament, the number of residual teeth, and patientage, because a reduction in bite force can occur withage owing to the age-dependent deterioration of the

FIGURE 3. Left molar bite force in groups 1 and 2.


Table 7. LEFT MOLAR BITE FORCE IN GROUP 1

Follow-UpBite Force

(kp)Change

(kp) tP

Value

reoperative 8.28 � 5.27 — — —wk 22.88 � 9.99 14.6 � 6.30 6.95 �.001

3 wk 36.07 � 14.65 27.79 � 11.85 7.30 �.0016 wk 51.55 � 16.83 43.27 � 13.80 9.38 �.0013 mo 71.35 � 25.27 63.07 � 21.30 8.88 �.001




dentition. It has long been known that a neuromus-cular protective mechanism occurs throughout thebody. For instance, one of the first protective mech-anisms called into play when a fracture occurs is“muscle splinting,” in which selective components ofthe neuromuscular system are activated or deacti-vated to remove the force from the damaged bone. In1994, Tate et al13 stated that sufficient internal fixa-ion hardware should be applied to resist the maximalorce of mastication. Thus, they hypothesized that thetability of fracture segment would be ensured evennder the full function of the masticatory system. Theorces that must be countered in a mandibular bodyracture have been derived from maximal voluntaryite force measurement, which, in a healthy adult,ould be about 15.3 kPa in the incisor and 48.3 and9.3 kPa in the left and right molar regions, respec-ively. The amount of force subjects with fracturesan generate is much less. Furthermore, one mustemember that the data reported concerned the max-mal voluntary bite force (ie, the most the subjectould voluntary generate). The amount of force useduring functional activities would probably be much

ess. Hence, the fixation requirements, determinedrom the maximal voluntary bite force of noninjuredubjects, might be inflated, and this fixation require-ent is perhaps a semirigid form of fixation such asonocortical fixation. In 2002, Gerlach and Schwarz12

stated that the maximal bite force in patients with

Table 8. LEFT MOLAR BITE FORCE IN GROUP 2

Follow-UpBite Force

(kp)Change

(kp) tP

Value




Table 9. COMPARISON OF CHANGE IN LEFT MOLARBITE FORCE IN GROUPS 1 AND 2

Follow-UpGroup 1

(kp)Group 2

(kp) tP

Value

1 wk 14.6 � 6.30 4.73 � 3.74 4.26 �.0013 wk 27.79 � 11.85 12.23 � 5.94 3.71 �.016 wk 43.27 � 13.80 18.99 � 6.08 5.09 �.0013 mo 63.07 � 21.30 28.69 � 7.42 4.82 �.001




mandibular fractures treated with miniplate osteosyn-thesis had reached only 31% at 1 week postopera-tively compared with a healthy control group. Thesevalues had increased to 58% at 6 weeks postopera-tively.

Similarly, in our study, a statistically significant pos-itive correlation was found between the postopera-tive week and the bite force for the anterior andposterior region of the fracture subjects. In groups 1and 2, a statistically significant low incisor bite forcewas found at 1 week after surgery when comparedwith that at 3 weeks. At 1 week, the incisor bite forcewas only 5.20 kp in group 1 and 4.98 kp in group 2compared with 6.95 kp in group 1 and 6.69 kp ingroup 2 at 3 weeks after surgery. No significant dif-ference was found between the incisor bite force at 6weeks (10.67 and 9.25 kp) and 3 months (19.49 and11.03 kp) compared with that in healthy subjects(15.3 kp). From 1 week to 3 months, the change inthe incisor bite force was significantly greater ingroup 1 than in group 2 (Table 3).

In our study, a statistically significant low rightmolar bite force was found at 1 week after surgerycompared with the right molar bite force at 3 weeksafter surgery. The right molar force was only 16.30and 17.30 kp at 1 week compared with 28.43 and27.01 kp at 3 weeks after surgery in groups 1 and 2,respectively. No significant difference was found be-tween the right molar bite force at 6 weeks (45.83and 34.48 kp in groups 1 and 2, respectively) and 3months (ie, 66.34 and 43.33 kp in groups 1 and 2,respectively) compared with that from healthy sub-jects (49.3 kp). At 6 weeks and 3 months, the changein the right molar bite force from the previous fol-low-up visit was significantly greater in group 1 thanin group 2 (Table 6).

A statistically significant low left molar bite forcewas found at 1 week after surgery compared with theleft molar bite force at 3 weeks after surgery. At1 week, the left molar bite force was 22.88 and 15.51kp in groups 1 and 2 compared with 36.07 and 23.01kp at 3 weeks after surgery, respectively. No signifi-cant difference was found between the left molar biteforce at 6 weeks (51.55 and 29.77 kp in groups 1 and2, respectively) and 3 months (71.35 and 43.33 kp ingroups 1 and 2, respectively) compared with that inhealthy subjects (48.3 kp). At 1, 3, and 6 weeks and 3months, the change in the left molar bite force fromthe previous follow-up visit was significantly greater
in group 1 than in group 2 (Table 9).
These findings have shown that the use of lockingminiplates for mandibular fracture fixation was effica-cious enough to bear the masticatory load duringosteosynthesis of the fracture. Along with the theo-retical advantages of greater stability, less precisionrequired in plate adaptation, and less alteration in theperiosteal blood supply, the locking plates allow for agreater bite force, with results almost similar to thoseseen with nonlocking miniplate osteosynthesis. Stud-ies with a larger sample size are necessary to corrob-orate the findings of the present study for their wideruse in clinical practice.

References1. Champy M, Lodde JP, Schmitt R, et al: Mandibular osteosyn-

thesis by miniature screwed plates via a buccal approach.J Maxillofac Surg 6:14, 1978

2. Champy M, Wilk A, Schnebelen JM: Die Behandlung der man-dibular Frakturen mittels osteosynthese Ohne intermaxillareRuhigstellung nach der Technik von Michelet. Dtsch ZahnMund Kieferheilk 63:339, 1975

3. Champy M, Lodde JP, Jaeger JH, et al: Osteosyntheses mand-bulaires selon la techniquee de Michelet. I. Bases biomecha-niques. Rev Stomatol 77:569, 1976

4. Champy M, Lodde JP: Etude des contraintes dans la mandibulefracture chezl’homme: measures theoriques et verification parjauges extensometriques in situ. Rev Stomatol 78:545, 1977

5. Champy M, Lodde JP, Grasset D, et al: Osteosyntheses man-dibulaire set compression. Ann Chir Plast 22:165, 1977

6. Champy M, Lodde JP, Wilk A, et al: Probleme und Resultatebeider Verwendung von dehnungsmestreifen am prapariertenunterkieferund bei Patienten mitunterkieferfrakturen. Dtsch ZMund Kiefer Gesichts Chir 2:41, 1978

7. Haug R, Street C, Goltz M: Does plate adaptation affect stabil-ity? A biomechanical comparison of locking and nonlockingplates. J Oral Maxillofac Surg 60:1319, 2002

8. Gutwald R: Biomechanical stability of an internal mini-fixationsystem in maxillofacial osteosynthesis. J Med Biol English Com-put 37:S280, 1999

9. Chiodo TA, Ziccardi VB, Janal M, et al: Failure strength of 2. 0locking versus 2.0 conventional Synthes mandibular plates: Alaboratory model. J Oral Maxillofac Surg 64:1475, 2006

10. Ellis E, Graham J: Use of a 2.0-mm locking plate/screw systemfor mandibular fracture surgery. J Oral Maxillofac Surg 60:642,2002

11. Collins C, Leonard G, Tolas A, et al: A prospective randomizedclinical trial comparing 2 mm locking plates to 2-mm standardplates in treatment of mandibular fractures. J Oral MaxillofacSurg 62:1392, 2004

12. Gerlach KL, Schwarz A: Bite force in patient after treatment ofmandibular angle fracture with miniplate osteosynthesis ac-cording to Champy. Int J Oral Maxillofac Surg 31:345, 2002

13. Tate GS, Ellis E III, Throckmorton G: Bite forces in patientstreated for mandibular angle fracture—Implications for fixa-tion—Recommendations. J Oral Maxillofac Surg 52:734, 1994

14. Chritah A, Lazow SK, Berger JR: Transoral 2 mm locking mini-plate fixation of mandibular fractures plus 1 week of maxillo-mandibular fixation: A prospective study. J Oral Maxillofac
Surg 63:1737, 2005

prospective randomized clinical trial comparing bite force in 2-mm locking plates versus 2-mm...

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