An unusual approach to care
Faced with a difficult patient and challenging, bilateral mandibular fractures, we determined that device stability was paramount.
We constructed a U-shaped acrylic splint spanning both mandibles.
The patient was anesthetized, and the remnants of the composite were removed from the canine teeth. Tooth preparation for
the application of two composite orthodontic buttons on the mandibular canine teeth was performed exactly as described for
the placement of the composite splint above. Once the bonding agent was cured, we filled a silicon mold with flowable composite
(Photo 5). We then placed the mold on the distal and lingual aspect of the crown and light-cured it. When the mold was pulled
off, a button remained to act as an anchor for the rostral portion of the splint.
Photo 5: A silicon orthodontic button mold and flowable composite were used to form the rostral anchor for the acrylic splint.
Next, we used a 20-ga needle to pass a 26-ga wire around the mandibular body in a fashion similar to that used for mandibular
symphyseal repair. The wire exited dorsally on the lingual and vestibular mucosa and was tightened to rest just atop the dorsal
oral mucosa without impinging directly on the mucosa (Photo 6).
Photo 6: Circumferential mandibular wires form a portion of the splint anchor.
Two wires in front and back of the fracture line were used bilaterally. The wires were then bent to form loops. These loops
served as points of attachment for a Masel chain (used in human and veterinary orthodontics), which spanned from caudal loop
to caudal loop and incorporated the two canine buttons (Photo 7). Tension from a Masel chain aids in approximation of the
Photo 7: A Masel chain is shown spanning the right mandible. The chain was continued in a horseshoe pattern to incorporate
the left mandible before placing the acrylic and completing the splint.
The last step in splint fabrication involved using a temporary crown and bridge material. An associate held the fracture fragments
in apposition while the splint material was applied, working around the chain and incorporating it and the wires for maximal
stability. We kept the acrylic off the mucosa. A true bridge was formed spanning both jaws, thus avoiding the complication
of mucositis from acrylic and mucosa contact (Photo 8).
Photo 8: The finished splint was thick and rigid to provide stabilization and prevent destruction by a very active patient.
Remarkably, the patient tolerated the splint extremely well (Photo 9). The client was able to cage rest the patient for close
to two months, and radiographs taken at that time showed complete healing of both mandibles (Photos 10 and 11). The splint,
wires, Masel chain and composite buttons were removed.
Photo 9: The patient tolerated the final splint well.
Success at last, right? Not so fast. A portion of the titanium mesh had migrated slightly, penetrating the lingual mucosa
and creating a small laceration on the tongue. The mesh was removed, and the patient proceeded to do exceptionally well.
Photo 10: A radiograph of the right mandible at the time of device removal.
This was a very difficult and frustrating case, to say the least. Edentulous mandibular fractures are completely preventable
with regular dental oral examinations, periodontal prophylaxis both at home and in the hospital and periodic radiographic
evaluations. We hope our next case won't be quite as involved or as frustrating.
Photo 11: A radiograph of the left mandible at the time of device removal.
Dr. Beckman is acting president of the American Veterinary Dental Society and owns and operates a companion-animal and referral dentistry
and oral surgery practice in Punta Gorda, Fla. He sees referrals at Affiliated Veterinary Specialists in Orlando and at Georgia
Veterinary Specialists in Atlanta, lectures internationally and operates the Veterinary Dental Education Center in Punta Gorda.