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Table of Contents   
CASE REPORT  
Year : 2015  |  Volume : 26  |  Issue : 5  |  Page : 542-544
Fracture management of an edentulous mandible in a geriatric osteoporotic patient


1 Reader, ITS Dental College, Greater Noida, India
2 All India Institute of Medical Sciences, New Delhi, India
3 Maulana Azad Instiute of Dental Sciences, New Delhi, India
4 Director-Professor, Maulana Azad Institute of Dental Sciences, New Delhi, India

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Date of Submission25-Nov-2014
Date of Decision18-Dec-2014
Date of Acceptance26-Oct-2015
Date of Web Publication17-Dec-2015
 

   Abstract 

Fracture of an edentulous mandible is a difficult task primarily due to the absence of teeth. The management becomes even more difficult if the patient is geriatric and osteoporotic. A simple technique of using bite block splint, maxillomandibular fixation screws, and intermaxillary fixation has been presented to enable healing of fracture of mandible in such cases. The technique, which crosses the boundaries of conventional fracture management provides, promising results with minimum morbidity thus imparting optimum quality of life ahead for the patient.

Keywords: Fracture, mandible, osteoporotic, splint

How to cite this article:
Krishnan S, Koli D, Nanda A, Verma M. Fracture management of an edentulous mandible in a geriatric osteoporotic patient. Indian J Dent Res 2015;26:542-4

How to cite this URL:
Krishnan S, Koli D, Nanda A, Verma M. Fracture management of an edentulous mandible in a geriatric osteoporotic patient. Indian J Dent Res [serial online] 2015 [cited 2020 Feb 17];26:542-4. Available from: http://www.ijdr.in/text.asp?2015/26/5/542/172084
Mandible is the most commonly fractured bone in the maxillofacial skeleton (owing to its prominence) and the predisposition to fracture increases with edentulousness and age. [1]

Maxillomandibular fixation (MMF) becomes a difficult task in cases with sparse or absent dentition and the complexity increases in geriatric patients. Decreased blood supply, atrophy of ridges, reduced healing potential, and lack of definitive occlusal surfaces to capitalize on for fracture reduction and MMF are the most notable limitations in such cases. [2],[3] The difficulty further increases in the presence of an underlying systemic bone condition like osteoporosis. The treatment plan must be individualized depending on bone available, degree of comminution, availability of dentures, medical comorbidities including smoking, and patient preferences. [4],[5]

The solutions to overcome problems in an edentulous mandible are to create an occlusal guidance by either existing dentures or by fabricating intraoral splints to guide in reduction of jaws in correct alignment.

The description henceforth will describe the technique of using resin bite block splint stabilized by MMF screws for treating fracture of edentulous mandible of a geriatric osteoporotic patient.


   Case report Top


A 79-year-old male patient was referred to the department with discontinuity of the lower jaw following trauma from tennis ball. Prior history of the patient revealed central dual energy X-ray absorptiometry scans, showing T-score value at - 2.9, confirming the diagnosis of osteoporosis. On extraoral examination, mild swelling and hematoma was seen on the right side corresponding to the inferior border of mandible and anterior to the angle of the mandible. On palpation, a discontinuity was noted 4 cm anterior to the angle of mandible, throughout the body of mandible. The discontinuity was associated with tenderness. On intraoral examination, partially edentulous maxillary arch with a lone standing periodontally compromised maxillary central incisor on the right side was seen. In the mandibular arch, avulsion site of lower left first premolar was seen (the site was sutured). This resulted in completely edentulous mandibular arch. A blue discoloration in the floor of the mouth was seen. A visible step was discernible intraorally and was confirmed on palpation on the right side corresponding to the first molar region. Palpation in the region of step was associated with mild tenderness. Mouth opening was almost satisfactory though reduced (25 mm) with pain on opening and closing jaw movement. No other relevant findings were noted. The clinical findings were suggestive of fracture of body of mandible on the right side. The same was confirmed in an orthopantomograph [Figure 1]a].
Figure 1: (a) Orthopantomogram at start of fixation, (b) orthopantomogram at completion of treatment

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Treatment plan

The treatment plan was to provide immobilization of the fractured segments of the mandible and splint them together. The presence of edentulous mandible implied decreased inferior alveolar artery blood flow and increased dependence on periosteal blood flow. Hence, it was planned to perform closed reduction. Since the patient did not possess a denture hence it was decided to extract the lone standing central incisor and proceed with the fabrication of gunning splint. The splint was planned to be stabilized with stainless steel MMF screws in maxilla and mandible followed by intermaxillary fixation (IMF) with arch bar embedded in resin of the splint.

The treatment plan was approved the Ethical Review Board prior to proceeding with the treatment procedure.

Treatment procedure

Preliminary maxillary and mandibular impressions were made. The mandibular analog was sectioned with a saw in the region of fracture [Figure 2]a]. The fracture site was evident in the analog as a discontinuity in the ridge. The sectioned segments were assembled in alignment which ensured continuity and sealed with wax. Following this, a base of the cast was poured to ensure the corrected alignment of the sections was maintained [Figure 2]b].
Figure 2: (a) Cast sectioned in region of fracture. (b) Cast reassembled using wax and forming a base. (c) Maxillomandibular fixation screws to stabilize resin bite blocks. (d) intermaxillary fixation

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On the mandibular sectioned cast and the maxillary cast, occlusal rims were fabricated, and jaw relation was recorded. Using the jaw relation, the analogs were mounted on the articulator. The maxillary anterior tooth was extracted as it was periodontally compromised lone standing anterior tooth, which compromised the overall prognosis of the treatment. Since the maxillary analog was already prepared, hence the same was trimmed on the analog as well. This was done to avoid making another impression and adding discomfort to the patient.

After the analogs had been mounted, resin bite blocks were prepared for each arch. The maxillary resin bite block was fabricated against the mandibular wax bite rim which was used to record jaw relation. The mandibular bite block was fabricated against this maxillary resin bite block. The height of the resin bite block in the anterior region was reduced in both maxillary and mandibular bite blocks so as to create an opening in the anterior region when both bite blocks contacted. The purpose of this opening was to permit food intake despite the IMF and enable the patient to be adequately nourished. Arch bar was embedded in both maxillary and mandibular resin bite blocks so as to enable IMF of these bite blocks. During the placement of arch bar, it was ensured that the hooks were symmetrically positioned in the maxillary and mandibular arch. This symmetry is essential to achieve calculable tension between the maxillary and mandibular arch bar.

Using a surgical drill, holes were drilled into the bone about 5 mm away from the border of the resin blocks. Each of these bite blocks was secured on the maxillary and mandibular ridge by using MMF screws [Figure 2]c]. MMF screws are made of stainless steel. They are self-drilling and self-tapping. The screw head is elongated and contains two holes in a cruciform configuration for wire placement. 0.4 mm diameter ligature wire is used to do IMF. IMF was done on one screw in maxillary arch and the corresponding screw in the mandibular arch. The IMF was started from the posterior section and continued in the anterior section, in order to avoid a posterior open bite. Fixation was also done using the arch bar on both the left and right side [Figure 2]d]. The IMF was continued for a period of 6 weeks.

Follow-up: Once the healing was ensured, the IMF was removed. The same was verified clinically and radiographically [Figure 1]b] Physiotherapy was prescribed at the first visit and opening and excursive exercises were begun soon. Goal was set at 40 mm of maximum interincisal jaw opening which was attained in 2 weeks' time postoperatively.

To rehabilitate the patient, a mucosa born complete denture was fabricated for the patient. A monthly recall of the patient for over 9 months is suggestive of satisfactory functioning without any complications.


   Discussion Top


The aim in treating fractured jaws is to retain the fractured extremities in close and perfect apposition, until provisional callus is used up, and union is affected. Stabilization of gunning splints in the past has been performed by techniques such as circum mandibular wiring, per alveolar wiring, circum zygomatic wiring, or with cortical screws. Peralveolar wiring is associated with significant drawbacks such as puncturing and contamination of maxillary sinus, and injuring the palatal vessels. The circum mandibular wiring is associated with injury to soft tissue and floor of mouth, and entrapment of wire into the fracture line during the process of tightening the wire.

Cortical screw technique is not new, however; according to some authors it is rarely applied. A modification of the cortical screws is to use MMF screws. These screws are not completely inserted, and 4-5 mm of these screws is left outside the bone level to allow tie wires to pass around them. Some of the authors recommend a minimum bone height of 10 mm and do not recommend it in maxilla and mandible.

In cases where antagonism of teeth cannot be attained due to completely edentulous state, we need to either use the existing dentures or fabricate the intraoral splint maintain the appropriate vertical dimension.

The technique described above has several favorable features which made the authors chose the same. The fixation takes less time, and no general anesthesia are required which is an advantage in patients who are medically unfit to undergo general anesthesia procedure. Operating cost is also reduced (cost incurred is only of the cortical screws, arch bar, and wires for fixation), and there is no facial scarring. Provision was made in the splint to permit feeding during the healing period. The benefit of using the resin bite block splint during fixation is to provide functional occlusion with complete denture rehabilitation postfixation. Hence, the alternative technique of fixation presented can be considered a useful resource to treat some mandibular fractures, among the wide variety of treatment options currently available.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Sidramesh M, Chaturvedi P, Chaukar D, D'Cruz AK. Spontaneous bilateral fracture of the mandible: A case report and review of literature. J Cancer Res Ther 2010;6:324-6.  Back to cited text no. 1
    
2.
Luhr HG, Reidick T, Merten HA. Results of treatment of fractures of the atrophic edentulous mandible by compression plating:A retrospective evaluation of 84 consecutive cases. J Oral Maxillofac Surg 1996;54:250-4.  Back to cited text no. 2
    
3.
Knotts C, Workman M, Sawan K, El Amm C. A novel technique for attaining maxillomandibular fixation in the edentulous mandible fracture. Craniomaxillofac Trauma Reconstr 2012;5:7-10.  Back to cited text no. 3
    
4.
Furr AM, Schweinfurth JM, May WL. Factors associated with long-term complications after repair of mandibular fractures. Laryngoscope 2006;116:427-30.  Back to cited text no. 4
    
5.
Thaller SR. Fractures of the edentulous mandible: A retrospective review. J Craniofac Surg 1993;4:91-4.  Back to cited text no. 5
    

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Correspondence Address:
Aditi Nanda
Maulana Azad Instiute of Dental Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.172084

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