Prefabricated Acrylic Cap Splint: A Minimally Invasive and Conservative Intervention for Paediatric Mandibular Fractures: A Case Report

1. Postgraduate Student, Department of Paediatric and Preventive Dentistry, SGT Dental College, SGT University, Gurugram, Haryana, India. 2. Professor and Head, Department of Paediatric and Preventive Dentistry, SGT Dental College, SGT University, Gurugram, Haryana, India. 3. Professor, Department of Paediatric and Preventive Dentistry, SGT Dental College, SGT University, Gurugram, Haryana, India. 4. Senior Lecturer, Department of Paediatric and Preventive Dentistry, SGT Dental College, SGT University, Gurugram, Haryana, India. 5. Postgraduate Student, Department of Paediatric and Preventive Dentistry, SGT Dental College, SGT University, Gurugram, Haryana, India.

Abstract

Dental traumatic injuries in paediatric patients result in a painful experience for both the parents and the child. Although children may exhibit similar fracture patterns as seen in adult traumatic injuries, there are various factors to consider when treating fractures in paediatric patients, which pose challenges for paediatric dentists. There are numerous treatment options available for managing maxillofacial fractures, such as open reduction, closed reduction, immobilisation with open or closed cap splint, with or without circummandibular wiring, and the use of mini plates, among others. In this present case report, a five-year-old child presented with multiple step deformities in the mandible. Since the patient had deciduous dentition, the main concerns were the high possibility of disruption to the periosteal envelope, which could affect the growth of the mandibular processes, and damage to developing permanent tooth buds. These were key considerations when planning the appropriate treatment. Taking into account these potential complications associated with other invasive procedures, a minimally invasive conservative management approach was chosen for the child, which proved to be highly successful and cost-effective. Undisplaced fractures in paediatric patients should always be treated or stabilised using the closed reduction method.

Closed reduction, Dental trauma, Undisplaced fracture

Case Report

A five-year-old female patient presented to the paediatric and preventive department with a chief complaint of pain and swelling in the lower right facial region for the past two days following a fall from a terrace. The incident occurred on the 5th of February 2022. The patient was initially taken to a local hospital due to excessive bleeding, pain, and swelling and received treatment for these symptoms. The pain started suddenly, was moderate in nature, and persisted throughout the day. Pain relief was achieved with medication. Sutures were applied to the chin laceration. One tooth (tooth no. 71) was lost in the lower front tooth region. A Computed Tomography (CT) scan was performed on the same day, revealing a right body fracture along with a parasymphysis mandibular fracture (Table/Fig 1)a,b. There was no history of loss of consciousness or vomiting, and no significant medical history was reported. This was the patient’s first dental visit, and there was no known history of deleterious habits.

During the extraoral clinical examination, a diffuse, tender, hard swelling measuring 4×4 cm was observed in the right lower facial region. The swelling extended anteroposteriorly from the right parasymphysis to the right body of the mandible, and superioinferiorly from the right zygomatic arch to the inferior border of the mandible. A dressing was present in the chin region, and the patient had a restricted mouth opening of approximately 8-10 mm, along with disrupted occlusion. Intraoral examination revealed the presence of deciduous dentition. Palpation revealed tenderness and step deformity along the mandibular lower border in the parasymphysis and symphysis region. Tooth number 71 was avulsed, and tooth number 81 showed grade-2 mobility. An oblique fracture line was observed between the right lateral incisor and right canine, extending to the lower border of the mandible. This type of fracture would have presented difficulties and complications if treated with other methods.

A provisional diagnosis of soft tissue laceration along with mandibular fracture was made. Additionally, malocclusion resulting from dental trauma was ruled out. Differential diagnoses such as mandibular contusion, mandibular dislocation, and isolated dental trauma were also considered. Preoperative Orthopantomogram (OPG) confirmed step deformities in the right body, symphysis, and parasymphysis regions, as well as the left body of the mandible [Table/Fig-1a,b]. Based on this, a final diagnosis of step deformity at the symphysis, parasymphysis region, and body of the mandible, with suspected fracture, along with soft tissue laceration and Ellis class IX fracture with respect to teeth 54 and 85, was made. Various treatment options were discussed, including closed reduction under General Anaesthesia (GA) as suggested by the oral surgery department, Intermaxillary Fixation (IMF), open reduction of fractures, circummandibular wiring, and, most importantly, minimally invasive conservative management using an acrylic cap splint.

The treatment plan involved detailed discussions with the parents, and stabilisation with an acrylic cap splint was finalised after obtaining written informed consent. Tooth extraction was performed for tooth 81, and decayed teeth (teeth 54 and 85) were restored. The patient was advised to rinse the mouth with a 0.2% chlorhexidine solution and apply topical Betadine ointment over the sutured site on the chin. Suture removal was scheduled for one week later.

Maxillary and mandibular alginate impressions were taken under local anaesthesia, and diagnostic casts were made. Wax blockout was performed, and the extension of the cap splint was marked. Finally, the cap splint was fabricated using acrylic material (Table/Fig 2). Additionally, tooth 81, which had grade-II mobility, was extracted. The mandibular symphysis and parasymphysis fracture were immobilised with the acrylic cap splint, which was secured in the correct position using luting Glass Ionomer Cement (GIC) (Table/Fig 3).

A postoperative OPG was taken with the acrylic cap splint in place. The patient was followed-up once every week to monitor the healing process and address any issues. The acrylic cap splint was removed during the third week. The fractured site showed complete healing with no signs of mobility, and the patient achieved stable occlusion postoperatively (Table/Fig 4).

Preoperatively, the patient had a mouth opening of 10 mm, which improved to 30 mm by the third postoperative week. During monthly follow-ups for three months, the patient exhibited excellent occlusion and good chewing capacity (Table/Fig 5).

Discussion

Traumatic dental injuries in paediatric patients have an incidence rate of 4-6% out of the total maxillofacial injuries that occur. Children below five years of age have an incidence rate of ≤0.6-1.2%, suggesting that paediatric facial trauma is less common in this age group (1). The ideal approach to managing traumatic dental injuries or maxillofacial fractures varies between adults and children. In 16paediatric patients, immobilisation and stabilisation are the best and least invasive approaches to treat undisplaced fractures and restore deranged occlusion (2).

For minimally displaced or undisplaced fractures, treatment options include observational follow-up of the fractured site or closed reduction. Severely displaced fractures may require open reduction and rigid internal fixation. However, the use of plates and screws for internal fixation is not possible when permanent tooth buds are present within the affected jawbone (3). Therefore, this case report presents the successful management of a five-year-old girl with mandibular symphysis, parasymphysis, body, and angle greenstick fractures (2) using a minimally invasive approach, namely an acrylic cap splint. Fractured alveolar processes in the maxilla and mandible require reduction, immobilisation, and stabilisation for 2-4 weeks for proper treatment. Arch bars are not suitable for children due to the size of teeth in mixed dentition and the presence of newly erupted permanent teeth with immature roots (3).

More than half of paediatric dental fractures occur in the mandibular region. These fractures are treated with various goals in mind, including restoration of occlusion, restoration of function, and most importantly, restoration of normal growth and development of the mandible, as well as the developing permanent teeth (4). Treatment options for mandibular fractures include closed reduction with intermaxillary fixation, open reduction with intraosseous wires, and the use of miniplates and screws for internal rigid fixation. Other treatments include tape muzzles, circumferential wiring, acrylic splints, percutaneous skeletal fixation, nickel titanium staples, orthodontic resin, modified orthodontic brackets, and rubber elastics in combination with orthodontic brackets (5).

Nowadays, mandibular fractures are treated using recent advancements, namely vacuum-formed splints (6),(7). Saskianti T et al., reported a case with a right parasymphyseal fracture, which was treated using a modified acrylic closed cap splint. They used a 19-gauge orthodontic wire on the buccal and lingual surfaces to reinforce the splint (8). Dolas A et al., reported a case of a nine-year-old boy with an unfavourable parasymphyseal fracture on the right side of the mandible. It was initially treated with arch bar stabilisation, which was unsuccessful. Then, it was stabilised with a vacuum-formed splint, and healing was observed as early as four weeks (9).

In the present case, an acrylic cap splint was used to treat the fracture, which not only improves the occlusal morphology and helps maintain occlusion but also stabilises the fractured segment. Other advantages of acrylic cap splints include improved patient comfort, reduced bonding time, reduced chairside time, less laboratory time, non-invasiveness, protection of injured teeth, elimination of custom wire bending, ease of access to oral hygiene, and enhanced patient compliance, as discussed in previous studies (Table/Fig 6) (5),(10),(11),(12),(13),(14),(15). The present case demonstrated the successful achievement of stable occlusion with a minimally invasive immobilisation procedure.

Conclusion

The best possible treatment for paediatric mandibular fractures in a young child, whether in primary dentition or mixed dentition, is the stabilisation of undisplaced fractures with minimal and conservative management, such as a prefabricated acrylic cap splint. Therefore, it is crucial to consider all the pros and cons of various treatment modalities in a young paediatric patient with dental trauma before finalising a treatment strategy. A multidisciplinary approach is highly recommended.

DOI and Others

DOI: 10.7860/JCDR/2023/64650.18500

Date of Submission: Apr 11, 2023
Date of Peer Review: May 05, 2023
Date of Acceptance: Jun 01, 2023
Date of Publishing: Sep 01, 2023

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Apr 14, 2023
• Manual Googling: May 09, 2023
• iThenticate Software: May 26, 2023 (15%)

ETYMOLOGY: Author Origin

EMENDATIONS: 6