Custom splint: A conservative approach to pediatric mandibular dentoalveolar trauma

Priyanka Venugopal; Reshma Raj VP; Parvathy Kumaran; Arun Mamachan Xavier

doi:10.4103/SDJ.SDJ_32_22

CASE REPORT

Year : 2022 | Volume : 6 | Issue : 3 | Page : 146-151

Custom splint: A conservative approach to pediatric mandibular dentoalveolar trauma

Priyanka Venugopal¹, Reshma Raj VP², Parvathy Kumaran¹, Arun Mamachan Xavier¹
¹ Department of Pediatric and Preventive Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi, Kerala 682041, India
² Trinity's Multispecialty Dental Clinic, Porathissery, Thrissur, Kerala 680125, India

Date of Submission	14-Jun-2022
Date of Decision	04-Aug-2022
Date of Acceptance	15-Aug-2022
Date of Web Publication	15-Nov-2022

Correspondence Address:
Parvathy Kumaran
Department of Pediatric and Preventive Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi, Kerala 682041
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/SDJ.SDJ_32_22

Abstract

Background: Traumatic dental injury is highly variable in children, commonly involving the anterior segments of the maxilla and mandible. The management of such injuries is challenging owing to the anatomical differences and stages of development. The aim of treatment (usually non-invasive) should always be to achieve a stable occlusion with minimal functional impairment. Case Report: This case report describes the conservative management of a mandibular dentoalveolar fracture in a 5-year-old child. On extra-oral examination, abrasions were noticed in the chin region with moderate facial edema in the lower part of the face. Intra-oral examination revealed labial ecchymosis in the mandibular anterior region and a step deformity between the distal aspect of #72 and #82. The displaced dentoalveolar segment was repositioned with finger pressure, and a modified closed cap splint was cemented to the reduced fractured jaw. Follow-up visits at 3 weeks and 1 year showed satisfactory healing. Conclusion: The goal in treating pediatric fractures is to restore the underlying bony structure to its preinjury position as soon as possible. The treatment of choice should be minimally invasive and should restore occlusion with minimal residual esthetic and functional impairment.

Keywords: Comprehensive dental care, fracture reduction, mandibular fracture, occlusal splints

How to cite this article:
Venugopal P, Reshma Raj VP, Kumaran P, Xavier AM. Custom splint: A conservative approach to pediatric mandibular dentoalveolar trauma. Sci Dent J 2022;6:146-51

How to cite this URL:
Venugopal P, Reshma Raj VP, Kumaran P, Xavier AM. Custom splint: A conservative approach to pediatric mandibular dentoalveolar trauma. Sci Dent J [serial online] 2022 [cited 2023 Mar 20];6:146-51. Available from: https://www.scidentj.com/text.asp?2022/6/3/146/361154

Background

Dentoalveolar fractures are defined as fractures in which displacement of the dentoalveolar segment, subluxation, tooth fracture, or occlusal derangement occurs in association with alveolar fractures.^[1] The causes of dentoalveolar fractures are daily life activities, sports injuries, road traffic accidents, and peer violence. These fractures are a frequent form of facial injury in children under 5 years of age. The literature has shown that the range of alveolar injury to maxilla and mandible is 5–65% and 8.1–50.6%, respectively, with an increased incidence in male patients.^[2] A thorough clinical and radiological examination is required to diagnose a traumatic alveolar injury.

The management of these injuries in children is often challenging owing to the stage of anatomical, psychological, and physiological development of the child. The primary goal of treatment is a conservative approach that includes early fracture reduction and stabilization for 3–4 weeks.^[3] The literature indicates that circummandibular wiring, resorbable plates, tape muzzles, dental splints, orthodontic resins, orthodontic brackets (with or without rubber elastics), percutaneous skeletal fixation, and nickel–titanium staples are used as stabilization techniques.^[4] Splinting and ligature wiring have proved successful in cases with minimally displaced dentoalveolar segments, while cap splints, intermaxillary fixation, mini-plates, or resorbable plates, which are preferred in treating severely displaced fractures. The subgingival positioning of the height of contour, spacing, reduced stability due to resorption, and need for a second surgery are the key factors why arch bar stabilization and circummandibular wiring are not recommended for treating alveolar bone fractures in children.^[5] Treatment must be patient-specific and satisfy individual needs. This report presents a case of a mandibular dentoalveolar fracture that required therapeutic modification in the form of a custom-fabricated modified closed cap acrylic splint.

Case Report

A 5-year-old boy reported to the department with a history of fall and bleeding from the mouth. The patient was conscious and well-oriented at the time of examination, and there were no signs of central nervous system injury.

On extra-oral examination, the face was apparently symmetrical, with lacerations over the chin region. Well-appreciated facial edema was present, affecting the lower lips and lower half of the face. There were no signs of periorbital edema. The mouth opening was in the normal range and the mandibular movements were not restricted. The temporomandibular joint (TMJ) was not tender on palpation.

Intra-oral examination revealed complete primary dentition with labial ecchymosis in the mandibular anterior labial mucosa and a step deformity between the distal aspect of #72 and #82 [Figure 1]A and B. The superior and lingual displacement of the mandibular anterior dentoalveolar segment resulted in a deep bite anteriorly and an open bite posteriorly [Figure 1]C. Multiple decayed teeth were present in both arches, with no evidence of injury to the lips, cheek, gingiva, tongue, or floor of the mouth.

Figure 1: Clinical (top) and radiographic (bottom) images of the intra-oral segments. A and B: Labial ecchymosis with displaced mandibular anterior dentoalveolar segment. C: Anterior deep bite with posterior open bite. The circle indicates the well-appreciated fracture segment with malocclusion in the panoramic radiographic image

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A pre-operative orthopantomogram revealed a superiorly displaced mandibular anterior dentoalveolar segment, confirming the diagnosis of dentoalveolar fracture between the distal aspect of #72 and #82 [Figure 1].

Following a detailed discussion with the parents regarding the pros and cons of the various treatment modalities, stabilization with a modified cap splint was finalized. Written informed consent was provided by the parents.

Mouth rinsing with 2% betadine solution was performed before the procedure. Bilateral inferior alveolar nerve block was administered and the displaced segments were repositioned using firm digital pressure. Once the occlusion was stabilized clinically [Figure 2]A using an irreversible hydrocolloid impression material, maxillary and mandibular impressions were taken to obtain a working model. The impressions were then used to fabricate a modified closed cap splint with relief in the mandibular canine to canine region anteriorly and the second primary molars posteriorly. The extent of tooth exposure was confined to the incisal and occlusal two-thirds [Figure 2]B. The margins were trimmed and retention and occlusal relief were evaluated. The splint was subsequently bonded for 3 weeks using GIC luting cement (Fuji I; GC Corporation, Tokyo, Japan) [Figure 2]C. During this phase of management, the patient’s parents were educated on the need for proper dental hygiene and a soft diet for the patient. The patient was prescribed 0.2% chlorohexidine gluconate mouth rinse, prophylactic antibiotics (Syp amoxicillin 40 mg/kg), and anti-inflammatory drugs (Syp paracetamol 40 mg/kg) to be taken once in 8 h, starting at 8 a.m. The patient was initially followed up at 7 days to evaluate post-operative healing, discomfort, and stability. After 21 days, when the healing was satisfactory and stable occlusion had been achieved, the splint was removed [Figure 2]D.

Figure 2: Reduction and stabilization. A: The fractured dentoalveolar segment after reduction. B: The prepared modified cap splint. C: The splint after cementation. D: Oral hygiene after the removal of the splint

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Due to the ongoing COVID-19 pandemic, the patient failed to report for periodic monthly reviews. Follow-up is crucial in such cases to monitor the future eruption of permanent dentition over a prolonged period and to ensure complete fracture healing. The teeth and periodontal tissue should also be examined clinically and radiographically at regular intervals to confirm vitality and mobility. In the present case, the patient was noted to have a high decayed, missing, and filled surfaces (DMFS) score. Because this was not addressed immediately due to the lack of follow-up, 1 year later the patient reported with dental infection and associated pain. A complete dental rehabilitation was performed, including restorations, pulpectomy, stainless steel crowns, extraction, and space maintainer. A post-operative orthopantomogram revealed normal dental age and development [Figure 3].

Figure 3: Follow-up at 1 year: Panoramic radiographic image showing optimal healing with normal dental age and development and intra-oral images after comprehensive dental rehabilitation

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Discussion

Dentoalveolar injury is not a disease but occurs as a result of various environmental factors. The low incidence of dentoalveolar injury in children compared with older individuals may be attributed to the resiliency of pediatric bones, high cancellous-to-cortical bone ratio, and small volume of face relative to the cranium.^[6] The diagnosis of a dentoalveolar fracture plays a crucial role in the final treatment outcome. A thorough general examination followed by oral and maxillofacial examination should be carried out, addressing extra- and intra-oral soft tissues, degree of displacement and mobility of teeth, percussion, and pulp testing. Periapical and occlusal radiographs remain the gold standard in the diagnosis of dentoalveolar trauma.

Immediate management of a dentoalveolar fracture is important, as any delay can render the fracture vulnerable to dentofacial deformity, deranged occlusion, and malunion. To minimize or avoid such ill effects, early re-establishment of the pre-existing anatomy with a conservative approach is necessary to stimulate the normal growth and development of the craniofacial complex and to ensure the child’s stable physical and emotional integrity.

The factors to be considered in the management of alveolar fractures include: (a) the patient’s age and cooperation; (b) the extent or location of the injury; (c) time between trauma and treatment; (d) injury to primary or permanent dentition; (e) the presence of fracture in the supporting bone; (f) stages of root development; and (g) the periodontal status of the remaining teeth.^[7] Mandibular dentoalveolar fractures without displacement and stable occlusion can be managed by constant observation and follow-up, maintaining a soft diet, and use of analgesics. However, displaced mandibular fractures often require immediate reduction and stabilization of the displaced segments for 3–4 weeks.^[3] Management by open reduction is often contraindicated due to the presence of developing teeth in the bone, making fixation almost impossible without damage to these structures.^[2]

Literature reviews of the use of cap splints to manage pediatric dentoalveolar fractures have been reported in five cases [Table 1]. In three of these reported cases, cap splints were used with interdental wiring in patients aged 7–12 years. Insufficient cooperation from the young patients in adhering to post-operative instructions, however, potentially delays the healing process. To overcome this, in the present case, however, a custom-fabricated modified closed cap splint was used successfully and efficiently to manage a displaced dentoalveolar segment. Earlier, Kumar et al.^[13] advocated the use of a similar cap splint in a para-symphysis fracture.

Table 1: A review of cap splints used to treat pediatric dentoalveolar fractures

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The technique with the use of a modified cap splint includes occlusion being partially open with acrylic stops over the deciduous first molars and the extent of tooth exposure confined to the incisal and occlusal one-third of the deciduous canine to canine anteriorly and second molar posteriorly. The appliance was fabricated in this manner to ensure unimpaired function, avoid premature contact of the stabilized mandibular anterior segment over the maxillary counterparts, and prevent the supraeruption of the teeth. The construction of the splint by itself ensured primary retention and superior stability, thereby eliminating the chances of dislodgment and the need for additional wiring. The luting cement provided secondary retention and the additional benefit of minimizing the decalcification of the teeth in primary dentition.

The splint was retained for 3 weeks. During the course of treatment, the patient did not report any discomfort. Upon removal of the splint, gingival health appeared normal, with stable alignment of the dentoalveolar segments. Minor post-operative occlusal discrepancies resolved spontaneously with the eruption of succedaneous permanent teeth and bone remodeling.^[14] Appropriate care of associated intra-oral soft tissue injuries is important: Maintenance of good oral hygiene following every meal to facilitate faster healing and 3–4 weeks of monitored soft dietary regimen should be emphasized in all such cases.^[3] At the patient’s 1-year follow-up, long-term treatment effects with a modified cap splint showed complete bone healing with no evidence of pulpal pathosis, resorption, occlusal abnormalities, or restriction of bone growth.

The COVID-19 pandemic has had a negative impact on children’s oral health-related quality of life. Frequent snacking and the inability to seek professional care have increased the risk of caries development and progression, as may be the case with this patient. The availability of teleconsultations must be emphasized to parents during this phase of the pandemic.

Conclusion

To summarize, the management of dentoalveolar fractures should not be restricted solely to improving esthetics, speech, and mastication; the patient’s overall quality of life must also be considered. Careful case selection, knowledge of the nature of the trauma, proper diagnosis, timely intervention, long-term stabilization, and timely follow-ups are key to a successful outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Bank P, Brown A Treatment of dentoalveolar injuries. In: Bank P, Brown A, editors. Fractures of Facial Skeleton. Oxford, UK: Reed Educational and Professional Publishing Ltd; 2000. p. 72-80.
2.	Haug RH, Foss J Maxillofacial injuries in the pediatric patient. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:126-34.
3.	Malmgren B, Andreasen JO, Flores MT, Robertson A, DiAngelis AJ, Andersson L, et al; International Association of Dental Traumatology. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 3. Injuries in the primary dentition. Dent Traumatol 2012;28:174-82.
4.	Madan N, Bajaj N Conservative treatment of pediatric mandibular fracture with removable acrylic splint. Indian J Dent Sci 2010;2:22-4.
5.	Adlakha VK, Bansal V, Chandna P, Agarwal A Mandibular fracture in an 18-month-old child. Indian J Dent Res 2011;22:723-5.
6.	Tanaka N, Uchide N, Suzuki K, Tashiro T, Tomitsuka K, Kimijima Y, et al. Maxillofacial fractures in children. J Craniomaxillofac Surg 1993;21:289-93.
7.	Blakey GH III, Ruiz RL, Turvey TA Management of facial fractures in growing patient. In: Fonseca RJ, Walker RV, editors. Oral and Maxillofacial Trauma. 2nd ed. Philadelphia: WB Saunders; 1997. p. 1003-41.
8.	Dehen M, Mrzilek M, Paling T Modified acrylic cap splint for dento-alveolar fractures. Int J Oral Maxillofac Surg 1989;18:85-6.
9.	Prabhakar AR, Tauro DP, Shubha AB Management of an unusual maxillary dentoalveolar fracture: A case report. J Dent Child (Chic) 2006;73:112-5.
10.	Khatri A, Kalra N A conservative approach to pediatric mandibular fracture management: Outcome and advantages. Indian J Dent Res 2011;22:873-6.
11.	Sangeetha KM, Surendra P, Roshan NM, Subba Reddy VV, Chaur RG, Srinivasa SB Management of dentoalveolar fracture with multiple avulsions: A case report with three years follow-up. Int J Case Rep Images 2014;5:835-8.
12.	Vidhya R, Madhu S, Kannan V, Anupam KTV Management of maxillary dento alveolar fracture with a modified splinting method: A case report. IOSR J Dent Med Sci 2017; 16:51-4.
13.	Kumar N, Richa Gauba K Modified closed cap splint: Conservative method for minimally displaced pediatric mandibular fracture. Saudi Dent J 2018;30:85-8.
14.	Patankar AP, Patankar SA, Suman G, Singh V, Bhosale A Lateral compression open cap splint (MacLennan)—A treatment modality for pediatric mandibular parasymphysis fracture: Case report. J Oral Med Oral Surg Oral Pathol Oral Radiol 2016;2:102-4.