Case
Report
___________________________________________________
____________________
J Res Adv Dent 2015; 4:1s2:128-131.
Pivot Appliance: A Great Helping Hand to Oral & Maxillofacial
Surgeon in Management of Pediatric Mandibular Condylar
Fracture- A Clinical Report
Prabha Shakya1*
1Practicing
Doctor, Department of Prosthodontics, Mumbai, India.
ABSTRACT
Background: The advancing age, residual ridge resorption and decreased vascularity impairs the bone strength,
predisposing it to fracture during traumatic event and even to spontaneous fracture. Fractures of mandible are
common in elderly persons. Edentulous maxillary and / or mandibular fractures present a unique and
challenging surgical problem, particularly because of lack of occlusive dental surfaces to capitalize upon
maxillomandibular fixation (MMF). In such cases a close collaboration between an Oral & maxillofacial Surgeon
and a Prosthodontist becomes mandatory. A 65years old male patient reported with completely edentulous
maxilla and bilaterally fractured partially edentulous mandible was managed by a combined Prosthodontic –
Surgical procedure.
Keywords: Edentulous maxilla, Modified Gunning splint, Mandible fracture, Mini plate fixation.
INTRODUCTION
CASE REPORT
The fractures of edentulous mandible
represent a group of maxillofacial injuries that more
commonly affect the geriatric patients. The loss of
bone mass and decreased vascularity decreases the
strength of mandible and makes it vulnerable to
fracture. Several treatment modalities have been
successfully used for clinical management of such
injuries in patients with advanced age. However, the
treatment options suitable for mandible fracture
with edentulous arch have been a matter of
controversy.
A 65 years old male patient presented with
pain on the both side of the lower jaw. There was
history of trauma 15 days back. On extra-oral
examination, there was mandibular deviation and
mid line of the face sifted towards left side and
slight open bite. (Fig. 1)
Management fracture with edentulous jaw
is a challenging task for an oral & maxillofacial
surgeon. A case of management with partially
edentulous mandible fractured bilaterally and
complete edentulous maxilla using combination of
mini plate fixation and Gunning splint with precise
vertical dimensions is being presented.
Intra-oral examination revealed that 33, 35,
36, 37, 44, 45, 46, 47 and 48 teeth were present in
the mandibular arch while the maxillary arch was
edentulous (Fig 2, 3). The mandibular ridge was
atrophic at fracture site due to Edentulism. There
was no laceration or hematoma on the mucosa. No
other significant finding was observed in the oral
cavity.
Radiographic
examination
revealed
triangular mandibular body fracture on right side
and left parasymphyseal mandibular fracture (Fig.
4).
_______________________________________________________________________________________
Copyright ©2015
Fig 5: Showing post- operative radiograph.
Fig 1: Showing midline sifted on left side.
Fig 6: Showing Ehrling’s
embedded in acrylic.
type
arch
bar
Fig 2: Showing intra-oral view of mandible.
Fig 3: Showing intra-oral view of maxilla.
Fig 4: Showing pre- operative radiograph.
Fig 7: Showing Gunning splint in oral cavity.
Considering the age of the patient and
triangular body fracture of mandibular alveolar
ridge, open reduction with mini plate fixation and
stabilization was planned. Due to complete
edentulous maxilla, fabrication of modified one
piece gunning splint was planed. There was no
history of use of any removable dentures. When
complete dentures do not exist, the stabilization of
reduced fracture segments can be achieved by
employing Gunning splint. It is an acrylic, single unit
prosthesis with gap in the anterior region to allow
food intake. Mandibular Ehrling’s arch bar wiring
129
was done for fixation and stabilization. Gunning
splint was attached with maxilla by ligature wires.
Both the jaws were attached with ligature wire for
immobilization (Fig. 5)
PROSTHODONTIC PROCEDURE
Impressions were made with irreversible
hydrocolloid impression material (Algitax, dental
product of India, Mumbai, India) and casts were
poured with Type IV gypsum product (Kalstone,
Kalabhai Pvt Ltd, Mumbai, India). Maxillary
Temporary record bases were prepared with autopolymerizing acrylic resin (DPI-RR Cold Cure, The
Bombay Burmah Trading Corporation, Ltd, Mumbai,
India), and occlusal rim was fabricated on that.
Jaw relations were recorded with adequate freeway
space and correct occlusal vertical dimension was
recorded. Occlusal rim was mounted at established
vertical dimension. The wax - up for the splint was
done incorporating Ehrling’s type arch bar
bilaterally in the posterior segments and gunning
splint was fabricated following conventional
method (Fig 6). Holes were made in palatal area at
canine region for circumferential wiring of splint.
The splints were tried-in and stabilized (Fig 7).
Instructions were given regarding oral hygiene
maintenance.
DISCUSSION
Mandibular fracture is common. It is the
most commonly fractured bone in maxillofacial
skeleton because of its prominence.1 Fracture
mandible is 1.5 times more common than fracture
maxilla.1 Fracture of edentulous mandible mainly
affects geriatric persons, especially more in atrophic
mandible.2, 3, 4, 5, 6 The weakened mandible in
advanced
age
may
get
fractured
even
spontaneously.7, 8, 9, 10, 11, 12 The basic principles of
reduction of the fractured segments and
immobilization during healing defined centuries ago
stand true even today. Bean introduced customized
oral splints for fixation. The Bean articulator splint
restored occlusion and accelerated healing.14
Thomas Brian Gunning opined that reduction and
fixation should be achieved immediately, whenever
possible, to permit function. He designed splint with
extra-oral wings for treating fracture in edentulous
cases. The tension and compression zones are close
so it is preferable to use screws over plates for the
immobilization.13 Perioperative management is
more complex. Morbidity and mortality are
increased in geriatric patients after trauma.15, 16
Long period of stabilization is required which
further add to increased complications.17 Various
factors that weaken the mandible in old age
predispose it to fracture include reduced vascularity
in elderly and loss of bone mass due to teeth loss at
an early age.
Gunning splints are indicated for reduction,
fixation and immobilization of unilateral and
bilateral fractures of edentulous fractures of maxilla
and / or mandible.18, 19 These splints provide an
indirect control on the bone fragments, transmitted
through mucoperiosteum. The ease of fabrication of
gunning splint makes them acceptable to dentist as
well as patient. However gunning splints are
contraindicated in unfavorably displaced fractures
lying outside the denture bearing areas, in grossly
comminuted soft tissue and bone loss, and in severe
posterior displacement of fractures of mandible.
However, use of external fixation appliance in
atrophic mandible fracture is limited due to reduced
quantity
of
available
bone.
Miniplates
osteosynthesis is less invasive treatment and
suitable for atrophic edentulous mandible except
for comminuted defects.9 Gunning Splint as
conservative treatment option is viable.20 It has
been used satisfactorily for century but one
problem with this is that it is difficult to establish
vertical dimension of face.21 Proper reduction of
fractures of the edentulous mandible and / or
maxilla requires the incorporation of correctly
determined freeway space into the Gunning
Splint.5 It is advisable to ensure an adequate
vertical opening of the jaws, as this lessens the
likelihood of respiratory obstruction.
CONCLUSION
Gunning splints are valuable prosthesis in
managing fractures with edentulous mandible and/
or maxillary. Acrylic gunning splints are rigid
strong, easily adjusted, lightweight and are
tolerated by oral mucosa. These splints are excellent
way of managing closed reduction and fixation of
fracture of maxillary and / or mandibular bones.
CONFLICT OF INTEREST
No potential conflict of interest relevant to this
article was reported.
130
REFERENCES
1.
Banks P. Killey’s fracture of mandible. 4th ed.
London: Wright; 1991: 01-133.
2. Bruce RA, Strachan DS. Fractures of the
edentulous mandible: the Chalmers J Lyons
Academy Study. J Oral Surg. 1976; 34: 973-9.
3. Friedman CD, Costantino PD. Facial fractures
and bone healing in the geriatric patient.
Otolaryngol Clin North Am. 1990; 23:1109-19.
4. Ellis E, Moos KF, El-Attar A. Ten years of
mandibular fractures: An analysis of 2,137
cases. Oral Surg 1985; 59:120-9.
5. Scott RF: Oral and maxillofacial trauma in the
geriatric patient, in Fonseca RJ, Walker RV,
Betts NJ, et al (eds): Oral and Maxillofacial
Trauma, vol 2. Philadelphia, PA, Saunders,
1997, 1045-1072.
6. Madsen MJ, Haug RH, Christensen BS, Aldridge
E. Management of atrophic mandible fractures.
Oral Maxillofac Surg Clin North Am. 2009;
21:175-83.
7. Sidramesh M, Chaturvedi P, Chaukar D, D'Cruz
AK. Spontaneous bilateral fracture of the
mandible: a case report and review of
literature. J Cancer Res Ther. 2010; 6: 324-6.
8. Hiroshi M, Kunio I. Progressive systemic
sclerosis with spontaneous fracture due to
resorption of the mandible: A case report. J
Oral Maxillofac Surg 2006; 64:1137-9.
9. Fleming WE, Cook RM, Hueston JT. A case of
spontaneous fracture of the mandible
associated with infection of the right sublingual gland. Aust Dent J 1967; 12: 360-3.
10. Kelly DE, Harrigan WF. An unusual bilateral
pathological fracture. J Oral Surg 1977; 35: 4850.
11. De Silva BG. Spontaneous fracture of the
mandible following third molar removal. Br
Dent J 1984; 156: 19-20.
12. Bramley P, Forbes A. A case of progressive
hemiatrophy presenting with spontaneous
fractures of the lower jaw. Br Med J 1960; 1:
1476-8.
13. Matias JG, Andrade MR, Fernandes VS.
Edentulous mandible fractures osteosynthesis.
Acta Med Port. 2004; 17: 145-8.
14. Pollock RA. Management of Jaw Injuries in the
American Civil War: The Diuturnity of Bean in
the
South,
Gunning
in
the
North.
Craniomaxillofac Trauma Reconstr. 2011; 4:
85–90.
15. Watters JM, McClaran JC. The Elderly Surgical
Patient: Special Problems, VII. New York, NY,
Scienti?c American Inc, 1996.
16. Smith OC: Advanced age as a contraindication
to operation. Medical Record (New York) 1907;
72: 642-4.
17. Marciani RD. Invasive Management of the
Fractured Atrophic Edentulous Mandible. J
Oral Maxillofac Surg. 2001; 59: 792-5.
18. Harshkumar, Anitha Gopinathan: Management
of fractured mandible with gunning splint:
KDJV: 1:45-47.
19. Oikarinen K, Altonen M, and Kaupp H.
Treatment of mandibular fracture: Need for
internal fixation. J Craniofacial Surg,
1989;17(1),24-30.
20. Luhr HG, Reidick T, Merten HA. Results of
treatment of fractures of the atrophic
edentulous mandible by compression plating: a
retrospective evaluation of 84 consecutive
cases. J Oral Maxillofac Surg. 1996; 54: 250-5.
21. Goss AN, Brown RO. An improved Gunning
Splint. J Prosthet Dent. 1975; 33:562-6.
131