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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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CASE REPORT
Year : 2014  |  Volume : 32  |  Issue : 4  |  Page : 353-356
 

Vacuum formed splints: Novel method for managing oro-facial trauma


1 Department of Pediatric Dentistry, Sri Aurobindo College of Dentistry, Indore, Madhya Pradesh, India
2 Department of Pediatric Dentistry, B.V.P. Dental College, Sangli, Maharashtra, India
3 Department of Pediatric Dentistry, Modern Dental College and Research Centre, Indore, India

Date of Web Publication17-Sep-2014

Correspondence Address:
Shikha Choubey
Department of Pediatric Dentistry, Sri Aurobindo College of Dentistry, Indore - 452 002, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.140975

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   Abstract 

Objective: Trauma to the oro-facial structures in children is different from trauma in adults. There are several points of differentiation between the two, the most important being growth. Aim: The purpose of this paper is to present the advantages of a vacuum-formed splint which was chosen as a practical and effective conservative treatment approach for the management of maxillofacial trauma. Case Report: A 9-year old boy reported to the department of pediatric and preventive dentistry with right mandibular parasymphyseal fracture. The trauma presented with the unique challenge to save and support the unerupted and developing tooth buds. Therefore, a vacuum-formed splint was fabricated and cemented in place for the next 4 weeks. Conclusion: The splinting method used for stabilization of the injured teeth is an important issue in trauma therapy to support the periodontal healing. Pediatric maxillofacial traumas require different clinical treatment strategies compared with fractures of the adult population.


Keywords: Case report, vacuum-formed splint, orofacial trauma, parasymphysis fracture


How to cite this article:
Choubey S, Shigli A, Banda N, Vyawahare S. Vacuum formed splints: Novel method for managing oro-facial trauma . J Indian Soc Pedod Prev Dent 2014;32:353-6

How to cite this URL:
Choubey S, Shigli A, Banda N, Vyawahare S. Vacuum formed splints: Novel method for managing oro-facial trauma . J Indian Soc Pedod Prev Dent [serial online] 2014 [cited 2019 Oct 18];32:353-6. Available from: http://www.jisppd.com/text.asp?2014/32/4/353/140975



   Introduction Top


Jaw fractures and dislocation of teeth are common findings following oro-facial trauma. It is estimated that 3-4 in 10 children sustain injury to their primary teeth prior to school age. [1] Pediatric maxillofacial traumas are particularly uncommon in children younger than 5 years of age. [2]

In case of dislocation of teeth treatment outcome is influenced by several factors such as degree of dislocation, concomitant dento-alveolar injuries, stage of root formation, time period between trauma and treatment and for avulsed teeth, duration and medium of storage. [1]

Adequate treatment of mandibular fractures in children is done with several goals in mind. Not just the restoration of occlusion, function, and facial balance is necessary but also the adequate growth should be achieved. Proper treatment may prevent complications such as growth disturbance and infection. While in the adults, absolute reduction and fixation of fractures is indicated, in children minimal manipulation of facial skeleton is advocated. The goal of treatment of these fractures is to restore the underlying bony architecture to pre-injury position, in a stable fashion, as non-invasively as possible, with minimal residual esthetic and functional impairment. [3]

A large variety of fixation or stabilization techniques have been reported in the literature [4],[5],[6],[7],[8] [Table 1].
Table 1: Reported techniques for splinting[4-8]

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The purpose of this paper is to present the advantages of a vacuum-formed splint, which was chosen as a practical and effective treatment approach for maxillofacial trauma.


   Case Report Top


A 9-year-old boy reported to the Oral Surgery Department, with the chief complaint of pain and swelling in the lower jaw for past 1 day. There was a history of fall from the school terrace while playing about 24 hours ago. He had visited a local physician who had delivered primary care and sutured the soft tissue laceration on lip and chin [Figure 1]. On examination there was an unfavorable parasymphyseal fracture of the right side. The deformity was clearly visible on an occlusal film [Figure 2]. Arch bar stabilization was tried and was unsuccessful [Figure 3]. The option of open reduction was not pursued because of the age of the patient and the potential damage to the developing teeth in the jaw. The patient was then referred to the Department of Pedodontics and Preventive Dentistry for consultation. It was decided under the circumstances to fabricate a BiocrylR (Bioacrylic sheet 1.5 × 125 mms Duran SCHEU-DENTAL GmbH-Germany) close cap splint, with a vacuum forming unit (BiostarR). The impressions were recorded and the cast was cut at the site of fracture and reattached in normal anatomical position. The splint was fabricated on this cast [Figure 4]. Under local anesthesia, a closed reduction of the fracture fragments was done and the splint was cemented [Figure 5] in place using Type I Glass ionomer Cement (GC). A soft diet was recommended for the following few weeks. Within the first week as the swelling subsided, the splint loosened and was displaced. It was re-cemented after minor modifications.

After 4 weeks the splint was removed with no signs of inflammation and a healthy healing was observed. On 3 months recall, the fracture line was no longer visible on the radiograph and the desired result was achieved [Figure 6], [Figure 7], [Figure 8]. The 6-month follow-up showed neither delayed eruption of teeth nor occlusion disharmony and no signs of temporomandibular joint (TMJ) problems. The patient's 2-year follow-up visit showed a healthy dentition and signifies an uneventful healing.
Figure 1: Photograph of patient on arrival to the department showing lacerations on the chin

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Figure 2: Extra-oral photograph of the patient, 6-month postoperatively

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Figure 3: Occlusal radiograph showing fracture of the right parasymphyses

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Figure 4: Failed arch-bar stabilization. Notice the separated segments of the fractured fragments even upon wiring

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Figure 5: Vacuum formed splint constructed on the corrected surgical cast

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Figure 6: Intra-oral photograph of patient after cementation of the splint

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Figure 7: Occlusal radiograph of the patient on 6-month follow-up. Notice the healing of the fracture line, evident by the continuity of the lower border of the mandible

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Figure 8: Intraoral photograph at 6-months follow-up, where the proper occlusion is now established

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   Discussion Top


This case report is aimed toward exploring the least invasive and most effective way to treat mandibular fracture in children. Any splinting method used for stabilization should support periodontal healing. A cap splint of any type (acrylic or metal) is most efficient in doing so. The duration of splinting should be as short as possible. Both prolonged and rigid splinting may lead to adverse effects, such as ankylosis and replacement resorption. [9] In the above case a splinting regimen of 4 weeks was followed due to the unfavorable forces of the mandibular muscles. Children have a greater osteogenic potential than adults, which allows rapid union within three weeks and non-union, or fibrous union is rarely seen in pediatric patients. [10]

Inter-maxillary fixation is another alternative for parasymphyseal fracture treatment. In this case inter-maxillary fixation was not advised due to the growing age of the child. The use of rigid fixation in children is controversial and may cause growth retardation along cranial suture lines. [2] The other treatment modality of constructing customized arch bars would require considerable laboratory time. [11]

The high osteogenic potential of the pediatric mandible allows non-surgical management to be successful in younger patients with conservative approaches. [2] Kerem reported a case of remodeling of a parasymphyseal fracture in an 11-year-old child without any treatment. [12]

The use of gunning splints and oropharyngeal airway has also been described. [13]

Nowadays there are resorbable plates and screws available that are less likely to disturb facial skeletal growth but are still associated with the risk of damaging unerupted teeth even when using mono-cortical screws. The available bone area for inserting screws and plates between vital structures offers a great challenge associated with risk and a conservative approach is therefore of great value when treating pediatric jaw fractures. [2]

Due to the high growth potential and good vascularity of the bones in children, good healing has been observed even without any treatment. The tooth buds present in a pediatric mandible pose a unique challenge in the treatment and management of fractures. Sharma et al. observed that these tooth buds act like a glue and lead to undisturbed body and parasymphyses fracture. [14] Vacuum-formed splints have better advantages over arch bar with respect to chair side time, periodontal health, patient's compliance of maintaining oral hygiene, mastication and speech. [15]

Glass ionomer cement was used for cementation as it provides a great strength (1.23 MPa) and has the advantage of leaching fluoride which minimizes decalcification of teeth thus preventing caries. [11]

The advantages of a vacuum-formed splint above other methods are less laboratory time, non-invasive and maximum preservation of mandible and the developing tooth buds, while the chief disadvantage is the initial investment for a vacuum-forming unit.


   Conclusion Top


Prompt and appropriate management is necessary to significantly improve the prognosis for many dento-alveolar injuries. Time being the most important factor decides the treatment and its outcome.

 
   References Top

1.Von Arx T, Fillipi A, Lussi A. Comparison of a new ndental trauma splint device (TTS) with three commonly used splinting techniques. Dent Traumatol 2001;17:266-74.  Back to cited text no. 1
    
2.Kokabay C, Atac MS, Oner B, Gungor N. The conservative treatment of pediatric mandibular fracture with prefabricated surgical splint: A case report. Dent Traumatol 2007;23:247-50.  Back to cited text no. 2
    
3.John B, John RR, Stalin A, Elango I. Management of mandibular body fractures in pediatric patients: A case report with review of literature. Contemp Clin Dent 2010;1:291-6.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.Bedi R. The use of porcelain veneers as coronal splints for traumatised anterior teeth in children. Restorative Dent 1989;5:55-8.  Back to cited text no. 4
[PUBMED]    
5.Croll T. Bonded composite resin/ligature wire splint for stabilizationof traumatically displaced teeth. Quintessence Int 1991;22:17-21.  Back to cited text no. 5
    
6.Gupta S, Sharma A, Dang N. Suture splint: An alternative forluxation injuries of teeth in pediatric patients - a case report. J Clin Pediatr Dent 1997;22:19-21.  Back to cited text no. 6
    
7.Oikarinen K. Tooth splinting: A review of the literature andconsideration of the versatility of a wire-composite splint. Endod Dent Traumatol 1990;6:237-50.  Back to cited text no. 7
[PUBMED]    
8.Van Waes H, Gnoinski W, Ben Zur E. The wire/composite splint for splinting of traumatic loosened permanent teeth. Schweiz Monatsschr Zahnmed 1987;97:629-36.  Back to cited text no. 8
    
9.Fillipi A, von Arx T, Lussi A. Comfort and Discomfort of dental trauma splints - a comparison of a new device (TTS) with three commonly using splinting techniques. Dent Traumatol 2002;18:275-80.  Back to cited text no. 9
    
10.Tuna EB, Dunder A, Cankaya AB, Gencay K. Conservative Approach to Unilateral Condylar Fracture in a Growing Patient: A 2.5-Year Follow Up. Open Dent J 2012;6:1-4.  Back to cited text no. 10
    
11.Lloyd T, Nightingale C, Edler R. The use of Vacuum-formed splints for intermaxillary fixation in the management of unilateral condylar fractures. Br J Oral Maxillofac Surg 2001;39:301-3.  Back to cited text no. 11
    
12.Karem H, Usluer A, Yoleri L. Remodeling of a nontreated displaced parasymphyseal fracture of a child. J Craniofac Surg 2011;22:1358-60.   Back to cited text no. 12
    
13.Swaify GA, Dhanrajini PJ. A versatile splint for fractured mandible in infants. Saudi Dent J 1991;3:72-4.  Back to cited text no. 13
    
14.Sharma S, Vashisth A, Chugh A, Kumar D, Bihani U, Trehan M, et al. Pediatric mandibular fractures: A review. Intl J Clin Pediatr Dent 2009;2:1-5.  Back to cited text no. 14
    
15.Trupthi DV, Chowdhury S, Shah A, Singh M. Treatment of mandibular fractures using intermaxillary fixation and vacuum forming splints: A comparative study. J Maxillofac Oral Surg 2013; [In Press].  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1]



 

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    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
    References
    Article Figures
    Article Tables

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