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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 5  |  Issue : 1  |  Page : 63-65

A prosthodontist can play a vital role in management team of maxillofacial fractures in young patient: A clinical report


1 Department of Prosthodontics, Prathmesh Dental Clinic and Research Center, Mumbai, Maharashtra, India
2 Department of Prosthodontics, Government Dental College and Hospital, Indore, Madhya Pradesh, India

Date of Web Publication7-Dec-2015

Correspondence Address:
Shakya Prabha
22, Grandeur, Sector – 20, Near Central Bank of India, Kamothe, Navi Mumbai - 410 209, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2231-6027.171157

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  Abstract 

The aim of this case report is to present the treatment method used for a 6-year-old boy patient with a history of mandibular fracture due to fall from rooftop 2 days back. Treatment principles of this patient differ from that of an adult due to concerns regarding mandibular growth processes and dentition development. The goal of this fracture treatment is to restore the underlying bony architecture to its preinjury position in a stable fashion as noninvasively as possible and with minimal residual esthetic and functional impairment.

Keywords: Intermaxillary fixation, midline fracture of maxilla, modified acrylic occlusal splint, parasymphyseal fracture, pediatric dental trauma


How to cite this article:
Prabha S, Subhash S. A prosthodontist can play a vital role in management team of maxillofacial fractures in young patient: A clinical report. Int J Oral Health Sci 2015;5:63-5

How to cite this URL:
Prabha S, Subhash S. A prosthodontist can play a vital role in management team of maxillofacial fractures in young patient: A clinical report. Int J Oral Health Sci [serial online] 2015 [cited 2019 Nov 12];5:63-5. Available from: http://www.ijohsjournal.org/text.asp?2015/5/1/63/171157


  Introduction Top


Facial fractures in the pediatric age group generally account for about 5% of all facial fractures.[1],[2],[3] These incidences rise as children begin school and also peak during puberty and adolescence. A male dominance exists in all age groups.[4],[5] With increasing age and facial growth, in a downward and forward direction, the midface and mandible become more prominent, and the incidence of facial fractures increases, while cranial injuries decrease.[6]

The management of fractures in children differs from that of adults due to concern for growth and dentition development.[7],[8] Whereas absolute reduction and fixation of fractures is indicated in adults, concern for minimal manipulations of the facial skeleton is mandated in children. The small size of the jaw, existing active bony growth centers and the contained, overwhelmingly crowded deciduous teeth with permanent tooth buds located in great proximity to the mandibular and mental nerves, all significantly increase the therapy-related risks of pediatric mandibular fractures and their growth related abnormalities.

Intact active growth centers are important for preserving function, which have a significant influence on future facial development. Thus, restoration of the continuity after the fracture is important not only for immediate function but also for future craniofacial development.[9] Accordingly, the goal of treatment is to restore the underlying bony architecture to its preinjury position in a stable fashion as noninvasively as possible with minimal residual esthetic and functional impairment.


  Case Report Top


A 6-year-old boy reported to the dental out-patient department with gagging of occlusion and anterior open bite the following fall from rooftop 2 days back. Clinical examination revealed healing wound on right side of the forehead, open mouth appearance, derangement of occlusion with mandibular arch, and laceration at the midline of maxilla [Figure 1]a and [Figure 1]b. Step deformity with tenderness and mobility was elicited along the lower border of the mandible on the left side lateral incisor region. Preoperative orthopantomogram revealed left parasymphysis fracture and bilateral mandibular condylar fracture and midline fracture of maxilla was diagnosed on the occlusal view of maxilla radiograph [Figure 2]. The patient's parents were informed about the procedure, and written consent was obtained. There were two treatment options: (a) Close reduction; (b) open reduction. Conservative treatment was considered to closed reduction.
Figure 1: Pretreatment maxillary (a) and mandibular arch (b)

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Figure 2: Pretreatment radiographs

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Under local anesthesia, the mandibular body fracture was immobilized, fixed with the modified occlusal splint which was retained by circum mandibular wiring [Figure 3] and maxilla was reduced by Erich's arch bar wiring. Both jaws were attached with ligature wire for immobilization for 2 weeks. The patient was reviewed every week, and on the 3rd postoperative week, the circummandibular wiring and splint was removed under local anesthesia. No mobility was present at the fracture site. Postoperative recovery was uneventful and occlusion achieved was satisfactory. The patient was reviewed monthly for 6 months. The patient had perfect occlusion and good masticatory efficiency.
Figure 3: Modified occlusal splint

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Modified occlusal splint fabrication

  1. 1. Impression making: Maxillary and mandibular impressions were made by irreversible hydrocolloid (Algitax, the dental product of India, Mumbai, India) impression material with perforated stock impression trays.
  2. 2. Working cast preparation: Impressions were rinsed with disinfecting solution (2% glutaraldehyde) and then poured with type IV dental stone (Kalstone, Kalabhai Pvt Ltd, Mumbai, India) and the working casts were obtained [Figure 4].
  3. 3. The mandibular cast was cut at fracture site and reunion with the help of wax and obtained the preinjury occlusion [Figure 4].
  4. 4. Apply separating media (Acralyn-H, Asian Acrylates, Mumbai, India) over the entire cast for easy separation of the appliance from the cast.
  5. 5. An acrylic open occlusal splint was fabricated with Auto polymerizing acrylic resin (DPI-RR Cold Cure, The Bombay Burmah Trading Corporation, Ltd, Mumbai, India), and Ehrling's arch bar was attached on labial surface of splint for intermaxillary fixation (IMF) and stabilization and finished and polished [Figure 3].



  Discussion Top


A greenstick fracture is a fracture in which one cortex of the bone is broken, and the other cortex is bent. Pediatric patients are more likely than adults to sustain greenstick or incomplete fractures. A greenstick fracture will ensure the stability of the undisplaced segments in children <5 years.[10] Furthermore, the osteogenic potential of the periosteum in the developing craniofacial skeleton is very high and will lead to somewhat rapid and easier healing which occurs under the influence of masticatory stress, even when there is imperfect apposition of bone surfaces.[3] Therefore, management of greenstick fractures without displacement and malocclusion would merely be close observation, a liquid-to-soft diet, and avoidance of physical activities (e.g., sports and analgesics).[5] For greenstick/minimally displaced fractures, the conservative closed reduction is the most recommended treatment.[11]
Figure 4: Maxillary and mandibular working casts

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The closed reduction and immobilization approach can be achieved by means of acrylic splints, circumferential wiring, arch bar, or gunning splints.[11] These techniques provide a good reduced position, continuity of periosteal sleeve, and maintenance of the soft tissue, thus creating a positive environment for rapid osteogenesis and remodeling processes as well as prevention of any type of nonfibrous union. Furthermore, in the splinted mandible, the fracture segments are tightly fixed and serve in reducing tenderness and pain reactions during a child's daily activity.[3]


  Conclusion Top


In the cases of mandibular fractures of a young child, disruption of the periosteal envelope may have unpredictable effects on growth. Thus, if intervention is required, closed reduction is favored. Due to the technical difficulties of IMF, acrylic splints with circumferential wiring are recommended.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kaban LB. Diagnosis and treatment of fractures of the facial bones in children 1943-1993. J Oral Maxillofac Surg 1993;51:722-9.  Back to cited text no. 1
    
2.
Kocabay C, Ataç MS, Oner B, Güngör 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.
Rowe NL. Fractures of the jaws in children. J Oral Surg 1969;27:497-507.  Back to cited text no. 3
[PUBMED]    
4.
Gawelin PJ, Thor AL. Conservative treatment of paediatric mandibular fracture by the use of orthodontic appliance and rubber elastics: Report of a case. Dent Traumatol 2005;21:57-9.  Back to cited text no. 4
    
5.
Zimmermann CE, Troulis MJ, Kaban LB. Pediatric facial fractures: Recent advances in prevention, diagnosis and management. Int J Oral Maxillofac Surg 2006;35:2-13.  Back to cited text no. 5
    
6.
McGraw BL, Cole RR. Pediatric maxillofacial trauma. Age-related variations in injury. Arch Otolaryngol Head Neck Surg 1990;116:41-5.  Back to cited text no. 6
    
7.
Amaratunga NA. Mandibular fractures in children – A study of clinical aspects, treatment needs, and complications. J Oral Maxillofac Surg 1988;46:637-40.  Back to cited text no. 7
    
8.
Schweinfurth JM, Koltai PJ. Pediatric mandibular fractures. Facial Plast Surg 1998;14:31-44.  Back to cited text no. 8
    
9.
Moss ML, Rankow RM. The role of the functional matrix in mandibular growth. Angle Orthod 1968;38:95-103.  Back to cited text no. 9
[PUBMED]    
10.
Crean ST, Sivarajasingam V, Fardy MJ. Conservative approach in the management of mandibular fractures in the early dentition phase. A case report and review of the literature. Int J Paediatr Dent 2000;10:229-33.  Back to cited text no. 10
    
11.
Laster Z, Muska EA, Nagler R. Pediatric mandibular fractures: Introduction of a novel therapeutic modality. J Trauma 2008;64:225-9.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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