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ABSTRACT
Objective: To evaluate displacement and stress distribution on craniofacial structures associated
with fixed functional therapy.
Materials and Methods: A finite element model of the human skull was constructed from se-
quential computed tomography images at 2-mm intervals using a dry adult human skull. In this
study, linear, four-nodal, tetramesh and triangular shell elements were used with six degrees of
freedom at each of their unstrained nodes: three translations (x, y, and z) and three rotations
(around the x-, y-, and z-axes).
Results: The entire mandible moved anteroinferiorly. Maximum displacement was observed in
the parasymphyseal and midsymphyseal regions. The pterygoid plate was displaced in a pos-
terosuperior direction. The anteroinferior displacement of the mandibular dentition was most pro-
nounced in the incisor region, while the maxillary dentition was displaced posterosuperiorly. The
entire dentition experienced tensile stress except for the maxillary posterior teeth. Tensile stress
was also demonstrated at point A, the pterygoid plates, and the mandible, and minimal compres-
sive stress was demonstrated at anterior nasal spine. Maximum tensile stress and von Mises
stresses occurred in the condylar neck and head.
Conclusion: Fixed functional therapy causes a posterosuperior displacement of the maxillary
dentition and pterygoid plate and thus can contribute to the correction of Class II malocclusion.
The displacement was more pronounced in the dentoalveolar region as compared to the skeletal
displacement. All dentoalveolar structures experienced tensile stress, except for anterior nasal
spine and the maxillary posterior teeth. (Angle Orthod. 2009;79:668675.)
KEY WORDS: Fixed functional appliance; Stress; Displacement
Although many clinical studies have investigated the Microsoft Image Pro-Plus software. These tracings
displacement and stress caused by fixed functional were later imported into AUTOCAD engineering soft-
treatment, a recent study by Ulusoy and Darendeliler19 ware version 2004 (Autodesk Inc, San Rafael, Calif)
tried to quantify and explain the stress distribution pat- for modeling and saved in .iges (integrated graphics
tern.1217 Finite element models (FEMs) have been exchange system) format.
successfully used to study stress and strain, making it The FEM programs used in this study were Altair
practicable to show stress distribution and displace- Hypermesh version 7 (Altair Engineering Inc, Troy,
ment in living structures as induced by various appli- Mich) and FE-MAP, (NEi Nastran Software, Inc, West-
ances.20 The present FEM study was designed to in- minister, CA) which were run on a personal computer
vestigate the displacement and stress distribution ex- with a graphics accelerator. Only half of the cranium,
erted by a fixed functional appliance on various cra- with respect to the sagittal plane, was modeled and
niofacial structures. analyzed, as this would produce the same results as
a scan of the complete skull. The geometric entities
MATERIALS AND METHODS created in the previous step were meshed into finite
The present analytical model was developed from a elements and nodes (Figure 1).
dried adult human skull with the mandible and intact The complete geometry is defined as an assem-
permanent dentition and without any gross defects or blage of discrete pieces called elements, which are
discontinuity in the anatomy. Computed tomographic connected together at a finite number of points called
(CT) scan images of the skull were made in the axial nodes. In this study, linear, four-nodal, tetramesh and
direction at 2-mm intervals in the horizontal plane. The triangular shell elements were used, which were able
individual CT scan sections were traced on acetate to take membranes into account, ie, in-plane defor-
paper enlarged 400 times to the original skull size. mation as well as bending deformations. The shell el-
This was traced onto graph paper for digitization using ements had six degrees of freedom at each of their
Table 1. Youngs Modulus and Poissons Ratio of Various Materi- Table 2. Displacement of Various Craniofacial Structures (in mm)a
als Used in the Study20,21
Parameter Minimum Maximum Mean
Youngs Modulus
Dentition
Material (kg/mm2) Poissons Ratio
Maxillary anterior 0.00155 0.00207 0.00181
Tooth 2.0 103 0.15 Maxillary posterior 0.00155 0.00207 0.00181
Compact bone 1.37 103 0.15 Mandibular incisors 0.00777 0.00828 0.008025
Cancellous bone 7.93 102 0.15 Mandibular canines 0.00725 0.00828 0.007765
Mandibular premolars 0.0057 0.00673 0.006215
Mandibular molars 0.00414 0.00581 0.004975
Figure 3. Displacement pattern (in mm) of craniofacial structures a with fixed functional appliance.
Table 4. von Mises Stress Distribution of Various Craniofacial plane in the anterior region.9,2532 Pancherz8,9 showed
Structures (in MPa) similar orthopedic and distalizing effects. This is in
Parameter Minimum Maximum Mean contrast to our study, where a greater distalizing effect
Maxillary anterior 0 0.327 0.1635 was observed. Some investigators also reported a
Maxillary posterior 0.982 2.619 1.8005 downward tipping of the palatal plane and occlusal
Infratemporal fossa 1.31 2.292 1.801 plane.9,2629 However, in the present study, a rotational
Midsymphyseal 0 0.327 0.1635 effect on the palatal plane could not be established,
Center of body 0.982 1.965 1.4735
Coronoid 0 0.327 0.1635 as posterior nasal spine was not considered. Point A
Neck of condyle 4.584 5.239 4.9115 and ANS, however, remodeled in the upward and for-
Condylar head 2.619 4.584 3.6015 ward directions, in contrast to reports by other au-
thors.2832 We observed an anteroinferior displacement
of the mandibular dentition pointing to a clockwise ro-
seen in ANS. Stress induced in the entire mandible tation. This displacement has also been documented
was tensile in nature. Maximum tensile and von Mises by Cope et al,25 Covell et al,26 and Weiland and Bant-
stresses were reported in the condylar neck and con- leon.28 Proclination of the mandibular incisors was the
dylar head (Tables 3 and 4). However, other areas most pronounced dental side effect reported in the
demonstrated minimal von Mises stresses (Figure 5). present study. Several cephalometric studies have
supported this finding, although there were variations
DISCUSSION in the extent of this effect.810,2531 Oliveira et al24 re-
ported a significant mesial migration of the mandibular
In the present study, we validated our results in
molars during Herbst treatment, very similar to our
comparison with previously published human studies,
findings (Table 2).
as direct validation was not possible. Previously pub-
The entire mandible rotated in the forward and
lished human studies had reported only displace-
downward directions (Figure 3). Stucki and Ingervall29
ment.812 The present study assessed displacement
and others2527 demonstrated an increase in mandib-
and the distribution of stress on various craniofacial
ular length. The greatest displacement, seen in the
structures.
parasymphyseal and midsymphyseal regions in the
present study, correlated with the chin improvement
Displacement
shown by various cephalometric and clinical stud-
In clinical practice, a Class II correction is attained ies.712,2529 The anterior condylar displacement seen in
via fixed functional appliances, which induce skeletal the present study was also reported by Pancherz,4,8
and dental changes.4,812 Most of the studies carried who reported posterior rotation of the mandible. This
out on fixed functional appliances have reported a could account for the increased vertical dimension
greater dentoalveolar effect.2332 Our study reported a seen during Herbst treatment.
similar observation.
A limited restraining effect on the downward and for- Stress Distribution
ward growth on the maxilla was demonstrated (Figure
3). Nalbantgil23 reported this to be the only skeletal FEM can be used as an analytical model with stan-
effect that took place during Jasper Jumper therapy. dard shape and mechanical behavior.21,22 Therefore
A posterosuperior displacement of the maxillary jaw the results obtained provide insight into stress distri-
base (telescopic mechanism) was demonstrated in the bution of the craniofacial structures during fixed func-
present study. This is a result of a posterosuperiorly tional treatment (Figures 4 and 5 and Tables 3 and 4).
directed force on the maxillary jaw base.23 This tele- Experimental studies on morphologic changes of
scopic mechanism has also been reported by other the mandible have shown that condylar pull results in
investigators.9,2427 significant mandibular growth.15,18,32 This pull causes
Weiland and Bantleon28 reported a minimal postero- tensile stress along the viscoelastic tissue and muscle
superior displacement of the pterygoid plate. They fur- tendons attaching to the fibrocartilage of the condyle,
ther concluded that the changes at point A were a re- which is responsible for condylar growth.15 Graber33
sult of retrusion of the maxillary incisors. Our study and Joho34 reported that compressive stress in the
showed a similar effect on the maxillary dentition. The condyle led to decreased condylar glenoid fossa mod-
retrusion and extrusion of maxillary incisors and the ification.33,34 This is in contrast to Takano et al,35 who
distalization and intrusion of the maxillary molars seen found increased bone remodeling owing to increased
in the present study (Table 2, Figure 3) also have been synthesis of DNA and glycosaminoglycans. Biome-
reported by several investigators. In addition, they chanical studies have shown that principal stress is
have reported a downward tipping of the occlusal crucial in the remodeling of alveolar and craniofacial
bone.2325 Further histologic studies have shown the as this may increase the vertical dimension owing to
association of stretched viscoelastic tissue and bone clockwise rotation of the mandible.4,7,8
remodeling.15
The principal stress distribution given in Figure 4 CONCLUSION
suggests tensile stress throughout the dentoalveolar
The displacement resulting from fixed functional
structures, except for ANS, which experiences minimal
therapy was predominantly dentoalveolar in nature.
compressive stress. The tensile and von Mises stress-
Forward and downward displacement of mandibular
es were greatest in the condylar neck and condylar
incisors was the most pronounced dentoalveolar ef-
head (Figures 4 and 5 and Tables 3 and 4). It could
fect, followed by mandibular molar displacement.
not be determined whether these values were within
The mandible rotated in the forward and downward
the optimal range. Histologic studies by Ress36 have
direction, but the pterygoid plate and maxillary den-
shown attachment of the tendons of the lateral ptery-
tition demonstrated posterior and superior displace-
goid, masseter, and temporalis muscles to the con-
ment similar to that seen with the use of headgear.
dylar neck and condylar head. Thus the isometric con-
Tensile stress was found in the entire dentoalveolar
traction of these muscles during bite jumping may lead
structure, except at ANS.
to the increased tensile stress experienced by the con-
Maximum tensile and von Mises stresses were
dylar neck and head. However, other studies have re-
found in the condylar neck and condylar head.
ported decreased postural electromyographic muscle
activity during treatment.3740 The growth relativity hy-
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