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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 12  |  Issue : 1  |  Page : 36-39

Construction of a gunning splint; Case report on the handling of mandibular fractures in edentulous patients


1 Department of Prosthodontics Including Crown and Bridge, MM College of Dental Sciences and Research, Ambala, Haryana, India
2 Department of Prosthodontics and Crown and Bridge, Subharti Dental College, Meerut, Uttar Pradesh, India
3 Department of Prosthodontics and Crown and Bridge, School of Dental Sciences, Sharda University, Greater Noida, Uttar Pradesh, India
4 Department of Prosthodontics and Crown and Bridge, Luxmi Bai Institute of Dental Sciences and Hospital, Sirhind, Patiala, Punjab, India

Date of Submission06-Aug-2019
Date of Decision20-Sep-2019
Date of Acceptance16-Oct-2019
Date of Web Publication27-Jan-2020

Correspondence Address:
Bhumika Sharma
MM College of Dental Sciences and Research, Mullana, Ambala, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_92_19

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  Abstract 


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. For such conditions, “Gunning splint” is a better option as it provides close reduction and stabilization of mandibular fracture. 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.

Keywords: Edentulous, fracture, gunning splint, maxillomandibular fixation


How to cite this article:
Sharma B, Sharma P, Goswami R, Jain S, Samra RK. Construction of a gunning splint; Case report on the handling of mandibular fractures in edentulous patients. Indian J Dent Sci 2020;12:36-9

How to cite this URL:
Sharma B, Sharma P, Goswami R, Jain S, Samra RK. Construction of a gunning splint; Case report on the handling of mandibular fractures in edentulous patients. Indian J Dent Sci [serial online] 2020 [cited 2020 Feb 21];12:36-9. Available from: http://www.ijds.in/text.asp?2020/12/1/36/276891




  Introduction Top


The “Gunning splint” has been used as an aid to fixation of fractured edentulous mandible for over a century[1] and initially was presented by Thomas Brain Gunning and was designed for the immobilization of edentulous or partially edentulous jaw segments after reduction[2] 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.[3]

Furthermore, open reduction of fracture site is not helpful due to compromised medical condition of the patient at older age. For such conditions, closed reduction and fixation of the fractured segment with gunning type splint are preferred over open reduction technique. It holds together fractured segments of the mandibular bone and immobilizes the jaws in occlusion.[2]

A gunning splint consists of a type of monoblock resembling two-bite blocks joined together. It holds together fractured segments of bones and immobilizes the jaws. In an edentulous patient, no hard tissues will be available for stabilization and retention of splints. Therefore, the retention is mainly obtained by wiring to underlying bony tissues.[4] Immobilization is carried out by attaching the upper splint to maxilla by per-alveolar wiring and the lower splint to the mandibular body by circumferential wires. Intermaxillary splinting can be done by connecting two splints with wire loops or elastic band.[2]

In this clinical report, step by step method for fabrication of gunning splint and its intraoral fixation in an edentulous patient is discussed.


  Case Report Top


A 58-year-old male patient was referred to the Department of Prosthodontics from the Department of oral and maxillofacial surgery for the fabrication of gunning splint to immobilize the jaws for intermaxillary fixation. History revealed that the patient had a trauma to the face due to road traffic accident 5 days ago leading to mandibular condylar fracture [Figure 1]. On clinical examination, there was reduced mouth opening and pain and swelling at the fracture site [Figure 2]. Orthopantomograph showed displaced and bilateral condylar fractures [Figure 3]. General condition of the patient was debilitated and frail. Hence, it was decided to perform a closed reduction of the fractured mandible with gunning splint instead of open reduction.
Figure 1: Extraoral photograph of patient

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Figure 2: Reduced mouth opening

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Figure 3: Orthopantomogram of patient showing bilateral condylar fracture and displaced left condyle

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Procedure for the fabrication

After examination, preliminary impressions of the maxillary and mandibular arch were made with irreversible hydrocolloid impression material (Septodont Plastalgin 454 g) [Figure 4]. Impressions were immediately poured in dental stone to obtain casts. Now, the record bases were fabricated, and occlusal rims were made. Approximate jaw relation was made by clinical judgment and it was mounted on an articulator. Then, the occlusal rims were altered. One anterior opening was made in rims for feeding purpose, and posteriorly, interlocking mechanism (projections about 3 mm were made on the occlusal surface of the maxillary rim and a rectangular trough in the mandibular rim) was provided to avoid any movement between two splints [Figure 5]a and [Figure 5]b. The wax rims were finished, polished, and processed in heat-cured acrylic resin (Heat Cure, DPI, Mumbai). The arch bar was incorporated on the buccal side of each splint with the help of self-cured acrylic resin [Figure 6]. These arch bars were used for intermaxillary fixation of the splints. Holes were made in buccal flange for wiring the upper splint to maxilla with per alveolar wiring and for circumferential wiring of the lower splint in area of the first molar. The splints were checked in the patient's mouth for extension and frenum relief. Then, finishing and polishing of splints were carried out, and they were disinfected in glutaraldehyde solution (Cidex) [Figure 7].
Figure 4: Preliminary impressions

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Figure 5: (a) Occlusal rims with opening in midline. (b) Mandibular occlusal rim with trough

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Figure 6: Final splints with attached arch bar

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Figure 7: Finished and polished splints

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During the surgical procedure, first, the maxillary splint was fixed with per alveolar wiring. The mandibular splint was fixed by circummandibular wiring. After securing the splints to the underlying bone, intermaxillary fixation was done with archwires to provide firm immobilization [Figure 8]. This was kept for 6 weeks after which it was replaced with elastics. Orthopantograph showed complete reduction of fractured segments.
Figure 8: Maxillomandibular fixation screws to stabilize resin bite blocks

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  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.[4] Atrophic edentulous mandible has a reduced cross-sectional area as compared to dentate mandible. Due to decreased vascularity and dense sclerotic nature of bone, open reduction of mandible will lead to slow and complicated healing process of the fracture site.[5] If mandible is atrophic, then the fractured fragments will be more easily displaced. Due to decrease in bone height, it is not suitable for screwing and plating the fracture site. Close reduction with Gunning splint is advantageous because not only it preserves the periosteal blood supply but also provides firm mandibular fixation and immobilization.[6]

There are two types of dental splints: fixed dental splints and removable dental splints based on their property of allowing movement to the dental structures. These are used to immobilize the oral structures to aid in the healing process.

Fixed Dental Splints are further divided into the following types

  1. Sectional acrylic cap splint: It is also known as stouts or ribbon splint. It has the advantage with the simplicity of the design, and therefore, less laboratory equipment requirement
  2. Vacuum/pressure-formed splints: As the name depicts, these are formed either by vacuum forming or pressure forming. These splints as easy to fabricate with highly plasticized polymeric material in sheet form
  3. Interdental wiring: Thin soft stainless steel wires are used for this type of fixation
  4. Arch bar: Metal bars fitted to dental arch and are ligated to individual teeth. It has a disadvantage due to improper adaptation of the dental arch.


Removable splints are divided into 2 types

  1. Auto-repositioning: It is basically used to treat muscle problem and eliminate temporomandibular joint pain
  2. Anterior-repositioning: It is used for long-term cure of anterior disc-displacement. These are usually worn for 24 h for several months, leading to permanent reduction of disc displacement.


Advantages

  1. It does not require surgical exposure of fracture site
  2. It can be used in both dentulous and edentulous patients
  3. In edentulous cases, even the previous dentures can also be used as splints to stabilize the fractured segments, if the fracture line is present in the denture bearing area
  4. It is a minimally invasive technique.


Disadvantages

  1. Inadequately secured splints – if circummandibular wires placed too close to the fracture site
  2. Contraindicated in unfavorably displaced fractures
  3. The splints may become foul if proper oral hygiene is not maintained.



  Conclusion Top


In almost all the selected and planned cases of fractured atrophic edentulous mandible, a satisfactory union of the fractured segments can be obtained with gunning type of splint. These splints are easy to fabricate, rigid, strong, cost effective, well tolerated by the oral mucosa, and minimally invasive for the treatment of fractured jaw segments. Gunning type splints prove to be a very good treatment option for fractured atrophic edentulous mandible.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Goss AN, Brown RO. An improved gunning splint. J Prosthet Dent 1975;33:562-6.  Back to cited text no. 1
    
2.
Dharaskar S, Athavale S, Kakade D. Use of gunning splint for the treatment of edentulous mandibular fracture: A case report. J Indian Prosthodont Soc 2014;14:415-8.  Back to cited text no. 2
    
3.
Kaura SM, Singh J. Two piece gunning splint in edentulous patient with fractured maxilla. Indian J Dent Sci 2014;4:68-9.  Back to cited text no. 3
    
4.
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.  Back to cited text no. 4
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5.
Siadat H, Arshad M, Shirani G, Alikhasi M. New method for fabrication of gunning splint in orthognathic surgery for edentulous patients. J Dent (Tehran) 2012;9:262-6.  Back to cited text no. 5
    
6.
Libersa P, Roze D, Dumousseau T. Spontaneous mandibular fracture in a partially edentulous patient: Case report. J Can Dent Assoc 2003;69:428-30.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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