Intra-oral splinting in a maxillary fracture

Trauma resulted in a complete maxillary transverse fracture involving the hard palate and nasal bones starting from the distal root of the third premolar right side (107) to the mesial root of the fourth premolar left side (208)  with a fracture line going around this premolar having incorporated a fragment of alveolar bone, this way the tooth was totally loose.

A full head X-ray was performed to be able to precisely assess the extent and direction of the fracture, in Fig.1 we see the latero-lateral incidence view of the fracture, with the obvious detachment of the fractured fragment and the formation of a step of about 0,5-1 cm between fractured areas.

In the second X-ray from Fig.2, we have a rostro-caudal incidence view of the skull where we can clearly see the loose fragment of alveolar bone together with the 108 premolar (upper part of photo).

Intra-operatively we could further see the fracture line (Fig.3) involving the palate, palatinal mucosa, nasal bones and both crowns of the 3rd premolars also fractured. We decided to use a combined parapulpar pin-surgical wire frame-acrylic intra-oral splinting for this case.

This way we can perfectly stabilize also the loose PM4 right side together with the loose alveolar bone fragment. After repositioning of the loose fractured fragments we started applying the parapulpar pins between 2 to 4 pins for each maxillary tooth with the exception of the upper incisors.

First we had to use a small size round tungsten steel burr to make a small indentation for the pin drill supplied with the kit.

After drilling the proper diameter holes, we proceeded in manually inserting the pins using the specially adapted key also included in the kit.

After all the pins where in place we started modeling the U shaped 0,8 mm surgical wire and adapting it perfectly to the maxilla.

After the wire was shaped and modeled the surface was roughened with a diamond burr in order to better stick to the acrylic material.

We etched the surface of the enamelum of all maxillary teeth with 37% ortho-phosphoric acid for 45 seconds and  after we rinsed it using the air/water spray.

A light curing bonding liquid was applied, gently air dried and light cured.

The final fixation phase of the fracture consisted in applying the 2 component non-exothermic acrylic material ( Protemp Garant®) using a special dispensing gun and incorporating in this mass the pins and the surgical wire.

After polymerization of the acrylic we shaped and polished the surface using a flame shaped diamond burr to remove all anfractuous margins and irregularities and to prevent soft tissue trauma (Fig. 4).

After the occlusion was checked and any eventual surplus material removed, we covered the acrylic mass with a lacquer to prevent chemical reaction with oral fluids and also to soften the surface of the acrylic mass in the mouth and improve acceptance of this device by the dog.

After 5 weeks in a new anesthesia session a control X-ray was performed (Fig.5) and due to very good healing results and a good callus formation we decided to remove the fixation device.

We used round larger size burrs under water cooling fitted to a high-speed turbine and grooves where made in a chess table pattern (squares) thus facilitating the removal of bits (chipping off ) of material.

The trajectory of the surgical wire was first liberated (Fig.6) and the wire removed. After complete removal of the entire material we started taking the parapulpar pins out (Fig.7) and, filled all this little holes that resulted with light curing composite.

In the final stage all teeth where polished and appropriate pain management therapy instituted for the acute generalized gingivitis that we had as a result of these 5 weeks of foreign material (acrylic splint) presence in the oral cavity.

The dog recovered soon after surgery and owners reported that he fed already that day with an increased appetite.

DDr. Stoian Camil, PhD, Dipl. EVDC