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British Journal of Oral and Maxillofacial Surgery 50 (2012) e93–e95
Short communication
Management of mandibular fractures in children with a split acrylic splint: a case series Ayman Hegab ∗ Oral and Maxillofacial Surgery, Faculty of Dental Medicine, Al-Azhar Uni, Cairo, Egypt Accepted 3 November 2011 Available online 6 December 2011
Abstract Five children with mandibular fractures were treated with a split acrylic splint, which secured the fracture by wiring around the mandible. The occlusion was satisfactory, without infection or malocclusion. None required revision, and there was no deviation of the mandible, ankylosis, or disturbances of growth. © 2011 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Mandibular fracture in children; Split acrylic splint; Mandibular wiring
Introduction
Report of cases
The impact of craniofacial trauma in children is minimised because of their light weight and small size. The force of impact is absorbed by the forehead and the skull rather than the face. Their facial bones are more resistant to fractures because of their greater elasticity, poor pneumatisation, thick surrounding adipose tissue, and stabilisation of the mandible and maxilla by unerupted teeth.1 After the nasal bones, the mandible is the facial bone most often fractured in children.2 Treatment is influenced by many factors such as eruption of teeth, short roots, developing tooth buds and growth, particularly at the mixed dentition stage.3 Options include soft diet, closed reduction with intermaxillary fixation (IMF), and open reduction and internal fixation (ORIF). The aim of this study was to evaluate the use of split acrylic splint in the management of mandibular fractures in children.
Five children (2 girls and 3 boys, age range 3 years 5 months to 7 years 2 months) with isolated mandibular fractures were enrolled in the study. One patient had an associated subcondylar fracture on the right. Exclusion criteria were fractures of the mandibular angle, and other facial fractures. They were diagnosed by clinical examination and panoramic radiograph (Fig. 1). Under sedation, impressions are taken, and casts poured and sectioned to the desired mandibular position using the upper cast as a guide. The two pieces are then stuck together with sticky wax. A split acrylic splint is fabricated using selfcured acrylic resin (Fig. 2). The colour of the splint is clear to help show if there is any pressure area on the soft tissue. It has an open occlusal surface, and connected wires encircle the last tooth distally to give flexibility during insertion. The labial surface is sectioned and contains a hole or wire loop on each side which, when it is tightened by wire, compresses the fracture line and helps to reduce the fracture. Under general anaesthesia, the fracture is reduced by gentle manual reduction and fixed with the splint, which is secured by wiring around the mandible on each side in the molar region. The loop is tightening with a wire. Panoramic radiograph is done on the second postoperative day (Fig. 3).
∗ Correspondence address: Oral & Maxillofacial Surgery Department, Faculty of Dental Medicine, Al-Azhar Uni, Cairo, Egypt. Tel.: +97 466018386/+20 101981112. E-mail address:
[email protected]
0266-4356/$ – see front matter © 2011 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2011.11.003
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A. Hegab / British Journal of Oral and Maxillofacial Surgery 50 (2012) e93–e95
Fig. 1. Fracture of the mandibular body with a subcondylar fracture on the right.
The splint is removed after the fourth postoperative week under local anaesthesia in the outpatient clinic. Early movement of the mandible in the patient with a subcondylar fracture started one week postoperatively. The patients were reviewed postoperatively for up to 4 years. The occlusion was good and the patients regained their normal bite without infection or malocclusion. None required revision. The stability of the repairs was excellent (by gentle manual examination of stability of the fixed fracture). There was no sign of deviation of the mandible, ankylosis, or growth disturbances during follow up. All the patients were comfortable with the appliances.
Discussion Fig. 2. The split acrylic splint with an open occlusal surface and connected from the distal parts by a wire encircling the last tooth and a hole in the sectioned labial surface.
Treatment of mandibular fractures in children is complicated by the dynamic nature of developing mandible, the presence of unerupted teeth, and dental instability.3
Fig. 3. Good reduction of the mandibular and subcondylar fractures.
A. Hegab / British Journal of Oral and Maxillofacial Surgery 50 (2012) e93–e95
ORIF has an adverse effect on skeletal growth and unerupted teeth, and involves two operations including removal of the plate.4 Absorbable plates are less likely to disturb skeletal growth but may still damage unerupted teeth.5 The limitations of IMF include: loose anchorage because of attrition of deciduous teeth and physiological resorption of roots; dental instability at the mixed dentition stage; difficulties in securing IMF, as primary teeth are not sufficiently stable and may be avulsed and damage periodontal tissues; and partly erupted secondary teeth are not sufficiently stable in young soft bone. Restricted diet results in loss of weight and protein, and an increased risk of aspiration. Early movement in the case of an associated subcondylar fracture is not possible.6,7 Absolute compression of the fracture edges is unnecessary, and slight occlusal discrepancies correct spontaneously as permanent teeth erupt. The splint is the preferred treatment because it eliminates the need for IMF. It prevents ankylosis and disturbances of growth in growing patients; it is easy, atraumatic, does not damage the tooth buds, and eliminates the need for open reduction. Children do not easily tolerate having their jaws wired together, and the lingual extension of the splint provides adequate stabilisation and prevents vertical as well as horizontal displacement of the fracture. Finally,
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it allows the early mobilisation in the case of a subcondylar fracture. However, it cannot be used for fractures of the mandibular angle, and requires 3 procedures for impressions, insertion, and removal.
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