Treatment planning poses difficulties in edentulous patients for orthognathic surgery prediction and fixation. Treatment of severe class III malocclusion frequently requires orthognathic surgical procedures. For such patients, orthognathic surgery would be the only option before prosthetic rehabilitation. This clinical report describes step-by-step fabrication of a surgical splint for an edentulous year-old patient with a severe class III malocclusion. Using splints for planning and guiding the surgery in edentulous patients facilitates accurate positioning of the jaws and saves time in the operating room. There is a group of edentulous and partially edentulous patients in which satisfactory reconstruction cannot be reached by dental rehabilitation alone.
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The Internet Journal of Geriatrics and Gerontology. Fractures of edentulous mandible are common in elderly persons. The advancing age, residual ridge resorption and decreased vascularity impairs the mandibular bone strength, predisposing it to fracture during traumatic event and even to spontaneous fracture.
Gunning splint is a prosthetic aid designed to stabilize the reduced fractured mandibular segments. It is a viable treatment option for atrophic edentulous mandible fracture. The rationale of conservative treatment approach using Gunning splint in elderly patient with case report is discussed. 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 atrophic edentulous mandible fracture has been a matter of controversy. The bone atrophy and advanced age favors the conservative treatment due to higher incidence of complications associated with geriatric edentulous mandible.
A case of conservative management of atrophic mandible fracture using Gunning splint with precise vertical dimensions is being presented. A 60 years old male patient presented with pain on the right side of the lower jaw. There was history of trauma four days back. On extra-oral examination, there was right mandibular deviation on opening the mouth and tenderness over left TMJ. Intra-oral examination revealed that the left mandibular canine was the only tooth present in the mandibular arch while the maxillary arch was edentulous.
The lone standing tooth was mobile and had calculus deposits. Fig 1 The mandibular ridge was atrophic. There was no laceration or hematoma on the mucosa.
No other significant finding was observed in the oral cavity. Radiographic examination revealed left subcondylar fracture and right parasymphyseal mandibular fracture.
Figure 1 Showing the lone standing tooth in mandibular arch. Considering the age of the patient and resorption level of mandibular alveolar ridge, closed reduction and stabilization was planned. 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. The permanent left mandibular canine was indicated for extraction because of poor periodontal status. However, it was planned to retain this tooth till jaw relation registration as it could be used as a reliable reference for establishing the occlusal vertical dimensions.
Prosthodontic procedure Impressions were made with irreversible hydrocolloid impression material and casts were poured with Type III gypsum product. The mandibular cast was not sectioned as there was no gross disfigurement. Temporary record bases were prepared with self polymerizing acrylic resin and occlusal rims were fabricated on them accommodating the single natural tooth present.
Jaw relations were recorded with adequate freeway space and correct occlusal vertical dimension using mandibular left canine as reference. Occlusal rims were mounted at established vertical dimension. The mandibular canine was trimmed from the cast. The single natural tooth indicated for extraction was removed with minimal intervention. Fig 3. The impingements visible as blenching under clear acrylic were removed. The splints were tried-in Fig 4 and stabilized. Instructions were given regarding oral hygiene maintenance.
Mandibular fracture is common. 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. He designed splint with extraoral wings for treating fracture in edentulous cases. It had mental band of linen to hold the jaw up in the splint. Treatment of atrophic edentulous mandible fracture is challenging due to the associated complications.
Morbidity and mortality are increased in geriatric patients after trauma. Long period of stabilization is required which further add to increased complications. Edentulous mandibular ridge undergoes resorption as the teeth are lost. This coupled with reduced central blood supply makes it vulnerable to fracture.
Edentulousness and increased age has been important risk factor for mandible fracture. Loss of teeth decreases mass of bone which weakens it and susceptible to fracture. Bony surface area and density are decreased. The atrophic edentulous mandibular fracture may be treated either by open or closed reduction. Controversies exist regarding the treatment of atrophic edentulous mandible fracture.
The other school of thought believes that these fractures can be successfully treated with closed reduction. There is inadequate evidence to support the effectiveness of a single approach, whether open or closed reduction should be used as no eligible randomized controlled trial has been identified. Systematic review has revealed that single approach for managing fractured atrophic edentulous mandible may not be effective.
Atrophy of mandible is most important factor. The major blood supply of mandible, subperiosteal plexus, may severely impair the vascularity during open reduction resulting in nonunion of fracture treated by open reduction.
Fracture treatment with open reduction have more post operative complications. Bruce and Strachan advocated that open reduction be reserved for fractures of large edentulous mandible and not for atrophic mandible fracture. However, it has also been reported that open reduction may be tolerated by elderly. Less precise alignment in edentulous patients may be acceptable as no opposing teeth and occlusion is involved.
Conservative treatment has a distinct advantage as a treatment option. The conservative treatment options for fracture mandible include use of existing dentures or Gunning splint to stabilize fracture, external fixation appliance Joe Hall Morris appliance and even no treatment at all. Gunning Splint can be used for stabilization when complete dentures are not available. It may be useful for grossly displaced edentulous fracture. Closed reduction with Gunning Splint is adequate when aggressive surgical approach is contraindicated.
Short conservative procedure without general anesthesia involves less risk than open surgical procedure under general anesthesia. External fixation appliance or Joe Hall Morris appliance may be used for edentulous mandible fracture. Transmucosal fixation for edentulous mandible fracture using external fixation principle within oral cavity can be a conservative option. Wood reported healing with transmucosal fixation in 5 patients out of 8 patients included in the study.
Miniplates osteosynthesis is less invasive treatment and sutaible for atrophic edentulous mandible except for comminuted defects. In the present case report, the vertical dimension of occlusion for the splint was determined using the lone standing tooth as reference before its extraction, providing adequate interocclusal space.
Advanced age, vulnerability to perioperative complications and compromised bone mass contribute to favor conservative treatment as a practical option for management of atrophic edentulous mandible fracture. If fracture segments are not grossly displaced, clinical management with Gunning splint serves the purpose with less complications such as infection and nonunion.
Manu Rathee, Dr, M. Mahesh Goel, Dr, M. S, LL. Anita Hooda, Dr, M. Arun Kumar, Dr, M. Renu Kundu, Dr, B. Keywords atrophic edentulous mandible, gunning splint, mandible fracture. Abstract Fractures of edentulous mandible are common in elderly persons. Figure 3 Showing the edentulous mandibular arch.
References 1. Management of the fractured edentulous atrophic mandible. Cochrane Database Syst Rev. Banks P. London: Wright; J Oral Surg. Facial fractures and bone healing in the geriatric patient. Otolaryngol Clin North Am. Ten years of mandibular fractures: An analysis of 2, cases. Oral Surg ; Philadelphia, PA, Saunders, , Management of atrophic mandible fractures. Spontaneous bilateral fracture of the mandible: a case report and review of literature.
New Method for Fabrication of Gunning Splint in Orthognathic Surgery for Edentulous Patients
Treating edentulous mandibular fracture is difficult in elderly patients due to compromised medical condition of the patient and various contraindications for the surgical approach. The complication rate of infection or malunion is higher compared to fractures in younger, dentulous patients. For edentulous patients, treatment planning poses greater difficulties during reduction and fixation of fractured atrophic mandible. Due to edentulism, guidelines provided by occluding teeth for reduction and fixation of fracture, are absent. Also, open reduction of fracture site is not helpful due to compromised medical condition of the patient at older age.
ABSTRACT Treating edentulous mandibular fracture is difficult in elderly patients due to compromised medical condition of the patient and various contraindications for the surgical approach. The complication rate of infection or malunion is higher compared to fractures in younger, dentulous patients. Edentulous patient. Mandibular fracture.
Use of Gunning Splint for the Treatment of Edentulous Mandibular Fracture: A Case Report
The Internet Journal of Geriatrics and Gerontology. Fractures of edentulous mandible are common in elderly persons. The advancing age, residual ridge resorption and decreased vascularity impairs the mandibular bone strength, predisposing it to fracture during traumatic event and even to spontaneous fracture. Gunning splint is a prosthetic aid designed to stabilize the reduced fractured mandibular segments. It is a viable treatment option for atrophic edentulous mandible fracture. The rationale of conservative treatment approach using Gunning splint in elderly patient with case report is discussed.
Establishing anatomic reduction of an edentulous mandible fracture is a frequently acknowledged challenge in craniomaxillofacial trauma surgery in elderly patients due to compromised medical condition, lack of occlusive dental surfaces to capitalize on maxillomandibular fixation and various contraindications for the surgical approach. The solution is to overcome such problems in an edentulous mandible is to create occlusal guidance by either making dentures or by fabricating intraoral splints to guide in the reduction of jaws in correct alignment. A case report is presented here where close collaboration between an oral surgeon and a prosthodontist comes into role. The oral surgeon, after assessing the exact nature and extent of fracture, must communicate with the prosthodontist regarding the type of splint and management of fracture for the improvement of the patient's prognosis.