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CLINICAL DENTISTRY AND RESEARCH 2013; 37(1): 46-50
USE OF ACRYLIC OCCLUSAL SPLINT AND DIRECT BONDED
BRACKETS FOR INTERMAXILLARY FIXATION IN THE TREATMENT
OF UNILATERAL PARASYMPHYSEAL AND CONDYLAR FRACTURES:
A CASE REPORT
Demet Kaya, DDS, PhD
ABSTRACT
Clinical Instructor, Department of Orthodontics,
Faculty of Dentistry, Karadeniz Technical University,
The aim of this case report was to present the treatment
Trabzon, Turkey
method used for a 22-year-old male patient with a history of
İlken Kocadereli, DDS, PhD
mandibular fracture due to an assault. Unilateral parasymphyseal
Professor and Head, Department of Orthodontics,
and condylar fractures were diagnosed on the computerized
Faculty of Dentistry, Hacettepe University,
tomography (CT) images. The patient had a deviated open bite
Ankara, Turkey
on the right side due to the injury. After preparing an acrylic
Cenk Ahmet Akcan, DDS, PhD
occlusal splint according to the preinjury occlusion and direct
Assistant Professor, Department of Orthodontics,
bracket bonding, intermaxillary fixation (IMF) in combination
Faculty of Dentistry, Hacettepe University,
with open reduction was planned for the patient. IMF was
Ankara, Turkey
achieved with intermaxillary elastics. Four weeks after surgery,
Ersoy Konas, MD
IMF was released and a few training elastics were kept for
Associate Professor, Department of Plastic and
stability. Four months after injury, brackets and arch wires were
Reconstructive Surgery,
removed. The patient experienced minimal discomfort. No signs
Faculty of Medicine, Hacettepe University,
of complication were observed during the healing period. The
Ankara, Turkey
fractured segments were in good approximation. The occlusion
Mehmet Emin Mavili, MD
of the patient was returned to the preinjury position. One year
Professor, Department of Plastic and Reconstructive Surgery,
after injury, clinical evaluation showed that the occlusion was
Faculty of Medicine, Hacettepe University
stable and healing at the fracture sites was good.
Ankara, Turkey
Correspondence
Demet KAYA, DDS, PhD
Department of Orthodontics,
Faculty of Dentistry,
Karadeniz Technical University
61080, Trabzon, TURKEY
Phone: +90 462 377 47 59
Fax: +90 312 305 22 90
E-mail: [email protected]
46
Key words: Acrylic Occlusal Splint, Condylar Fracture, Direct
Bracket Bonding, Intermaxillary Fixation, Parasymphyseal
Fracture.
Submitted for Publication: 09.08.2011
Accepted for Publication : 09.10.2012
TREATMENT OF MANDİBULAR FRACTURE: A CASE REPORT
INTRODUCTION
Mandibular fractures are among the most common types
of facial fractures which can be caused by assaults,
traffic accidents, falls, sport accidents, and underlying
pathologies.1-3 The treatment of mandibular fractures
has still been a matter of debate. Although indications for
open and closed reduction of mandibular fractures were
described,4 there has been no decisive study about the
superiority of open versus closed reduction.5,6
A correct occlusion is critical for reduction of bone segments
regardless of surgical technique used because abnormal
malocclusion after injury is a common problem. To achieve
a proper dental alignment and provide stability in the
fractured segments, a period of intermaxillary fixation (IMF)
is needed.2 IMF is applied by using different methods such
as arch bars, looped wires, splints or orthodontic brackets
with/without intermaxillary elastics or wires. Arch bars and
looped wires are difficult to apply in the oral cavity and they
are not comfortable for patients as they are bulky. An IMF
technique applied by an acrylic occlusal splint in combination
with bracket bonding and intermaxillary elastics was used
as a reliable method in recent studies.7,8
The aim of this case report is to present the treatment of
a patient with a history of unilateral parasymphyseal and
condylar fractures due to an assault.
CASE REPORT
A 22-year-old male patient who suffered from mandibular
fractures was referred to the Department of Orthodontics
with a history of assault. The patient was medically
clear. Clinical examination showed a vertical fracture line
(parasymphyseal fracture) between mandibular right canine
and lateral incisor and a deviated open bite to the right side.
The fractured segments were separating from each other
when opening the mouth and the segments were approaching
each other when closing the mouth. He presented a limited
mouth-opening. He was unable to occlude in centric relation
(Figure 1). Radiographic examination (panoramic radiograph
and computerized tomography (CT) images) showed a left
subcondylar fracture, in addition to a right parasymphyseal
fracture. The patient did not have significant dislocation of
the condylar head (Figure 2).
An old photograph showing the patient’s smile and teeth
was asked for returning the interarch relationship to
the preinjury position (Figure 3). Dental impressions of
both jaws were taken, and surgical model setup of the
mandible was made to obtain the preinjury occlusion. An
acrylic occlusal splint was prepared in such a way that the
preinjury occlusion was established. The teeth are rinsed
and dried with airflow. After acid etching and bonding agent
application, the brackets were bonded to the maxillary and
mandibular teeth with composite resin. Passive orthodontic
arch wires (0.016x0.022 inch stainless steel wire) were
bent and inserted into the bracket slots. In the mandible,
the arch wire was cut between the right canine and lateral
incisor for manipulating the fractured segments during the
surgery. Crimpable surgical hooks were added to the arch
wires to apply intermaxillary elastics (Figure 4).
Following the presurgical preparation, the dislocated
segments were replaced by bone pliers with the guidance
of the acrylic occlusal splint under general anesthesia. The
patient’s occlusion fitted perfectly when the occlusal splint
was placed on the teeth. The fixation of the parasymphyseal
fracture was achieved by titanium plates, in addition to the
wire fixation at the dentoalveolar region (Figure 5). The
condylar fracture was treated with closed reduction.
One day after surgery, the acrylic occlusal splint was placed
on the teeth and intermaxillary elastics were positioned to
guide the mandible back to the preinjury position (Figure
6). During the period of IMF, the patient went on a liquid
diet and took oral care with a tooth brush and mouth
rinse. The patient was examined weekly. Four weeks after
surgery, the acrylic occlusal splint and intermaxillary elastics
were removed, and a few training elastics were kept for
intercuspation and stability. Then, the elastic force was
reduced gradually. The patient was advised to eat a soft
diet and to do mouth opening exercises to achieve jaw
function.
Four months after injury, brackets and arch wires were
removed (Figure 7). No signs of complication were observed
during the healing period. The patient was able to open
his mouth normally. The occlusion of the patient was
functional without any complaints related to TMJ such as
pain, ankylosis and internal derangements. The fractured
segments were in a satisfactory approximation and
remained in reducted position (Figure 8). One year after the
injury, the clinical evaluation showed that the occlusion was
stable and healing at the fracture sites was good (Figure 9).
DISCUSSION
For the diagnosis of the mandibular fractures, different
radiographic imaging methods are used. 92% of mandibular
fractures are diagnosed in the panoramic radiograph.9
However, a CT scan is more useful than panoramic
radiograph if the patient has multiple injuries and the
quality of panoramic radiograph is not good enough to
47
CLINICAL DENTISTRY AND RESEARCH
Figure 3 An old photograph showing the patient’s preinjury smile
and teeth.
Figure 1 The patient’s occlusion after injury.
Figure 4 Bracket bonding and wire bending before surgery.
Figure 2 Panoramic radiograph and computerized tomography (CT)
after injury.
diagnose the fracture. Wilson et al.10 reported that CT scan
was more sensitive in diagnosing mandibular fractures than
panoramic radiograph. In our case, CT scans were used in
addition to panoramic radiograph to screen the subcondylar
region clearly.
It was reported that the indications for open reduction and
internal fixation of mandibular fractures include symphyseal
and parasymphyseal fractures, displaced body and angle
fractures, and certain condylar fractures.4 Closed reduction was
48
Figure 5 Fixation of the parasymphyseal fracture achieved by
miniplate in addition to the wire fixation.
advised for the treatment of the mandibular condyle fractures
where the condyle is minimally displaced and the height of the
ramus is normal.11 Combined parasymphyseal and condylar
fractures make it difficult to obtain the preinjury arch form
when fixing the fractured segments. If the plate is not bent
to the curve of the mandible when plating a parasymphyseal
fracture, then a concomitant subcondylar fracture is displaced.4
Open reduction in combination with IMF facilitates to align the
fractured segments, restore the interarch relationship to the
TREATMENT OF MANDİBULAR FRACTURE: A CASE REPORT
Figure 6 Intermaxillary fixation after surgery.
Figure 7 The patient’s occlusion after removing of the brackets.
Figure 8 Panoramic radiograph four months after injury.
preinjury position and fix the fractured segments. Because
of this reason, IMF protocol was used with an acrylic occlusal
splint in addition to open reduction to overcome the difficulties
resulting from multiple fractures.
If the occlusion has been disrupted due to trauma, active
treatment is indicated. Active treatment includes an
intermaxillary fixation with intermaxillary elastics or wires
used to guide and maintain the mandible in the correct
position. Different types of IMF using different techniques
have been reported.7,12-16 IMF is commonly achieved
by using various attachments such as arch bars, loops,
Figure 9 The patient’s occlusion one year after injury.
splints or orthodontic brackets. Arch bars have long been
used as key attachments for the fixation of fractured
segments. However, arch bars may damage the gingival
and periodontal tissues. Lloyd et al.16 used a new technique,
vacuum-formed splints with intermaxillary elastics in their
case and ensured the retention of the splint by cementing
it on the teeth. However, the removal of the splint bonded
to all teeth requires a significant force to debond and may
cause discomfort for the patient. Terai and Shimahara14
reported that the advantages of thermoforming plates
were clarity, smoothness on the surface and ease of
cutting. Theoretically, bonding brackets on to the teeth
alone and applying elastic traction may cause the extrusion
of the teeth. IMF technique using an acrylic occlusal splint
in combination with bracket bonding and intermaxillary
elastics helps to hold fractured segments together without
tooth extrusion during the healing period.
For patients suffering from mandibular fractures, oral hygiene
with direct bonded bracket fixation is superior to controls using
arch bars.17 To bond and debond the brackets are painless as
there is no need to apply excessive force. Acrylic occlusal
splints are cheap, rigid, easy to fabricate, easily adjusted,
translucent, and well-tolerated by the oral mucosa. Also,
retention of the acrylic occlusal splint is acceptable. Jackson
and Wetmore18 reported that of the various splint materials,
acrylic was the easiest, fastest, and least expensive one.
Occlusion may be maintained with intermaxillary elastics or
wires. We preferred to use elastics to provide a favourable
tension and guide the teeth into preinjury occlusion. In the
literature, 1-6 weeks of intermaxillary fixation was reported.11
Our patient had four weeks of intermaxillary fixation because
the less the IMF, the better the postoperative TMJ function7.
In this case, no signs of complication were observed one
month after surgery and during the healing period. There
were no premature contacts and overeruption of any teeth.
49
CLINICAL DENTISTRY AND RESEARCH
Silvennoinen et al.19 showed a 13 % rate of malocclusion
in their series of patients with condylar fractures treated
by closed reduction. Longwe et al.20 reported that the
percentage of complications in patients with mandibular
fractures treated via miniplate fixation was 1%.
The patient had a crossbite on the right side and the
mandibular midline was shifted before the trauma. We
offered a detailed orthodontic treatment plan to the patient.
However, he did not accept the orthodontic treatment. One
year after surgery, the patient was only examined clinically
because he refused radiological examination. His occlusion
was clinically stable. Assael21 stated that complications
should be evaluated by looking at whether the patient
has pain, reduced function, and an unfavourable clinical
appearance, rather than radiographic criteria.
IMF with an acrylic occlusal splint in combination with
bracket bonding and intermaxillary elastics was useful for
the treatment of multiple mandibular fractures. An acrylic
occlusal splint and orthodontic brackets in combination with
intermaxillary elastics enabled substantial interdigitation of
the dentition. The patient experienced minimal discomfort.
However, it requires time to prepare the acrylic occlusal
splint, to bond the brackets and bend the wires to fit
perfectly into the bracket slots.
REFERENCES
1.Haug RH, Prather J, Indresano AT. An epidemiologic survey of
facial fractures and concomitant injuries. J Oral Maxillofac Surg
1990; 48: 926-932.
2.Barber HD, Bahram R, Woodbury SC, Silverstein KE, Fonseca RJ.
Mandibular fractures. In: Fonseca RJ, Walker RV, Betts NJ, Barber
HD, Powers MP, editors. Oral and maxillofacial trauma. St. Louis, MO:
Elsevier; 2005. p. 479-522.
3.Bormann KH, Wild S, Gellrich NC, Kokemuller H, Stuhmer C,
Schmelzeisen R et al. Five-year retrospective study of mandibular
fractures in Freiburg, Germany: incidence, etiology, treatment, and
complications. J Oral Maxillofac Surg 2009; 67: 1251-1255.
4.Stacey DH, Doyle JF, Mount DL, Snyder MC, Gutowski KA.
Management of mandible fractures. Plast Reconstr Surg 2006;
117: 48-60.
5.Andreasen JO, Storgard Jensen S, Kofod T, Schwartz O, Hillerup
S. Open or closed repositioning of mandibular fractures: is there
a difference in healing outcome? A systematic review. Dent
Traumatol 2008; 24: 17-21.
6.Brandt MT, Haug RH. Open versus closed reduction of adult
mandibular condyle fractures: a review of the literature regarding
the evolution of current thoughts on management. J Oral Maxillofac
Surg 2003; 61: 1324-1332.
50
7. Canter HI, Kayikcioglu A, Aksu M, Mavili ME. Botulinum toxin in
closed treatment of mandibular condylar fracture. Ann Plast Surg
2007; 58: 474-478.
8.Chen CY, Chang LR, Chen WH, Lin LW. Reduction of mandible
fractures with direct bonding technique and orthodontic
appliances: two case reports. Dent Traumatol 2010; 26: 204-209.
9.Chayra GA, Meador LR, Laskin DM. Comparison of panoramic and
standard radiographs for the diagnosis of mandibular fractures. J
Oral Maxillofac Surg 1986; 44: 677-679.
10. Wilson IF, Lokeh A, Benjamin CI, Hilger PA, Hamlar DD, Ondrey
FG et al. Prospective comparison of panoramic tomography
(zonography) and helical computed tomography in the diagnosis
and operative management of mandibular fractures. Plast Reconstr
Surg 2001; 107: 1369-1375.
11. Bos RR, Ward Booth RP, de Bont LG. Mandibular condyle
fractures: a consensus. Br J Oral Maxillofac Surg 1999; 37: 87-89.
12. Honig JF. The Gottingen quick arch-bar. A new technique of
arch-bar fixation without ligature wires. J Craniomaxillofac Surg
1991; 19: 366-368.
13. Baurmash H. Bonded arch bars in oral and maxillofacial surgery.
An update. Oral Surg Oral Med Oral Pathol 1993; 76: 553-556.
14. Terai H, Shimahara M. Closed treatment of condylar fractures
by intermaxillary fixation with thermoforming plates. Br J Oral
Maxillofac Surg 2004; 42: 61-63.
15. Divis BO. New device for interdental immobilization. Ann Otol
Rhinol Laryngol 1992; 101: 776-777.
16. Lloyd T, Nightingale C, Edler R. The use of vacuum-formed
splints for temporary intermaxillary fixation in the management
of unilateral condylar fractures. Br J Oral Maxillofac Surg 2001; 39:
301-303.
17. Utley DS, Utley JD, Koch RJ, Goode RL. Direct bonded
orthodontic brackets for maxillomandibular fixation. Laryngoscope
1998; 108: 1338-1345.
18. Jackson MJ, Wetmore SJ. Surgical prosthetic splints as an
adjunct in treating facial fractures. Arch Otolaryngol 1980; 106:
25-30.
19. Silvennoinen U, Iizuka T, Oikarinen K, Lindqvist C. Analysis of
possible factors leading to problems after nonsurgical treatment
of condylar fractures. J Oral Maxillofac Surg 1994; 52: 793-799.
20. Longwe EA, Zola MB, Bonnick A, Rosenberg D. Treatment of
mandibular fractures via transoral 2.0-mm miniplate fixation with
2 weeks of maxillomandibular fixation: a retrospective study. J Oral
Maxillofac Surg 2010; 68: 2943-2946.
21. Assael LA. Open versus closed reduction of adult mandibular
condyle fractures: an alternative interpretation of the evidence. J
Oral Maxillofac Surg 2003; 61: 1333-1339.