Presented by

Dr; Hamada Mahross

Splint:
The word splint when considered as a verb means
to immobilize, support or brace.

Defined as "A rigid or flexible device that maintains

in position a displaced or a movable part Or an
appliance for the fixation of displaced or movable
parts.

Types of fractures;
-simple; fracture without wound
- compound; fracture with wound.
- comminuted; fracture of bone into fragments.
- green stick; bone lean as in child.
Fructure manipulation;
-favorable; fractured segments opposite direction of muscle
attraction.
- unfavorable; fracture segments with the direction of muscle
attraction, widening the fracture space.

Uses of splints:
1- In jaw fractures to immobilize the fractured parts in
their original position until repair has taken place.
2- used to apply gradual force when fibrous union
occurred at old fracture and an immediate
reduction is impossible or painful.
3-To support resected mandible in its new position.
4-In orthographic surgery to correct discrepancy of
basal bones.
5-In holding another appliance e.g. training flange
6-As an aid in specific procedure or therapy e.g. in
bone grafting and in periodontal treatment as splint
for loose teeth.

Requirements:
1- provide rigid fixation to the jaw fracture.
2-Simple in construction with the least amount of
pain or discomfort to the patient.
3- Minimum injury to the standing teeth, bone or soft
tissues.
4- Minimum disturbance to normal function.
5- minimal interference to occlusion and obtain the
patient occlusion as much as possible.

Treatment of jaw fractures

1- Reduction; placing the fractured
fragments in their normal
anatomical position. may be open
with bone plate or close with
splint.
2- Immobilization; means for fixing
the fragments, the prosthetic
appliances used called splints.
- maxilla considered as stable base
for fixation.
- mandible insufficient for fixation so
intermaxillary fixation important.
3- Rehabilitation; restoring the
function to normal.

Impression of fractured jaw

- Various types of splints must be constructed to allow various types of fractures so,
diagnostic and duplicating cast are obtained.
Jaw fractures are associated with Pain ,swelling, trismus and excessive
salivation.
Adequate light and suction should be present.
Use:
- hydrogen peroxide to dissolve blood and remove food debris.
Sodium bicarbonate to dissolve mucous and control excessive salivation.
Flavored mouth wash.
Control trismus and pain by local anesthesia.
make alginate impression and poured to produce casts, the cast with fractured jaw is
segmented with a saw at line of displacement and the 2 segments are reassembled into
their original position guided by the occlusion of the opposing arch and the 2 segments
attached with plaster base on the articulator.

Types of splints
A-For dentulous patients:
1- wiring;
- Direct wiring.
- Eyelet wiring.
- interdental wiring.
Arch bar.
- Hammond (double arch bar, buccal, lingual).
- Circumferential.
- Pinning (Roger Anderson pin)
2- Labiolingual splint.
3- Metal cap splint.
For completely edentulous patients:
1- Gunning splint.
2- Kingsley splint.

Direct wiring.

- Eyelet wiring.

 interdental wiring.

Arch bar.
Metallic or acrylic;
-

- Hammond (double arch bar, buccal, lingual).

Used when fracture with displacement.

- Circumferential.

- pinning.

- suspension

Labiolingual splint (stout sectional splint)

Indications
1-In alveolar fractures in children and loose anterior teeth.
2-In dentulous and partially edentulous patients for fixation of fractures
without or with minimal displacement.
Advantages
1-It fixes the fracture firmly and is retained by the teeth interproximaally
without cement.
2- not interfere with occlusion, as the occlusal surface is not covered.
3- Obevation of the tissues under the clear acrylic splint is possible.
4- radiolucent which permits radiographic evaluation while the splint in
place.
5- Easy to construct, adjust and remove.

Design:
It is an acrylic band fits around the
buccolabial surfaces and lingual
aspects, leaving the occlusal
surfaces uncovered.
- consists of three sections; a lingual
section fits around the lingual
surface of the teeth and two labial
sections around the facial surface
of the teeth.
A stainless steel wire connects the
two acrylic portions posteriorly
around the last remaining tooth.
This wire acts as a hinge.
A button divided into two halves in the
midline is used to secure the two
labial sections by wiring.
- made of clear acrylic resin, cast
metal splint is used when a longterm immobilization is needed.

The fenestrated splint

- is a modified labiolingual splint (one-piece acrylic
device or silicone). These splints are used for short
permanent clinical crowns, for deciduous teeth
when no undercuts are available for retention, and
for badly decayed teeth.
- It is designed to fit a dentulous maxilla and
mandible through fenestrations created for the
occlusal surfaces of the teeth

Construction:
1-An accurate alginate impression is made and
poured into dental stone.
2-If there is fracture displacement, the cast is sawed
at the fracture line and reassembled in the correct
position by a plaster base.
3-A half round wire 0.9 mm is well adapted to the
surface of the last standing tooth. The wire is then
bent at right angle to its length. This portion will
help to hold the wire in the flask.

4-Two layers of modeling wax are adapted over the

buccal and lingual surfaces of the teeth. When
there is edentulous area, it should be covered with
a base and sectioned mesiodistally after
processing.
5- A square wax button, 5 mm, is adapted in the
midline of the facial surface.

6- The button is cut down vertically at the center and

the splint is removed from the cast and then
polished.
7-The splint is lined by tissue conditioning material
before insertion.

The metal cap splint

Advantages
1-Provides effective fixation of jaw fracture even in the
presence of few teeth in each segment.
2-Rigid without being bulky, smooth and easy to clean.
Disadvantages
1-It interfere with occlusion as the occlusal surface is
covered.
2-Expensive and time-consuming procedure.

Design:
- covers the buccal, lingual and occlusal surfaces of
the teeth on both sides of the fracture and
cemented to the teeth.
1-One piece (simple) metal splint:
used when there is little displacement and reduction
made by the help of the natural teeth occlusion.

2- Two pieces (sectional) cap metal splint:

used when displacement cannot be reduced easily.
The two parts of the splint are connected together
by localizing plates and screws.

3- The Modified Cap Splint:

This type is exactly the same as the normal cast
metal cap splint except that the occlusal surfaces
of the teeth are left free.

Construction:
1- An alginate impression of both arches are made in
a shallow stock trays and poured into dental stone.
2- The cast is sawed at the fracture line and
reassembled in the correct position by a plaster
base

3-The undercuts in the interproximal, buccal and lingual

surfaces of the teeth are blocked out.
4-The cast is duplicated into investment.
5-The duplicate cast is mounted on a simple hinge articulator
opposing the other jaw cast.
6-The splint is waxed-up to cover the occlusal surface and
extends buccally and lingually below the gingival margin.
The wax should be pressed occlusally to follow the
curvature of the occlusal surface and should be thin. The
cusp tips of the posterior teeth may be left uncovered. This
will help to decrease jaw separation and will act as a free
escape for the cement.

7-The splint is cast in silver palladium or cobalt

chromium alloys.

Gunning splint
Indication:
- fixation of mandibular or maxillary fractures in
completely edentulous patients.
- when little displacement and no infection.

Design:
- as a one piece for the two arches or two separate
pieces.
- The splint can be made in conjunction with elastic
chin bandage to reduce pain and discomfort

Construction:
A- Old denture modification:
1- The fitting surface of the old denture is
relieved to create space for soft lining
material.
2-The upper and lower anterior teeth are
removed to facilitate feeding and
cleaning.
3-Hooks or arch bars are fixed to the
facial surface for intermaxillary fixation.
4- Faulty occlusion and reduced vertical
dimension is corrected by adding
colored self-curing resin to the occlusal
surface of the denture.
5-Soft liner is used to correct the denture
fit and faulty denture extension.
6- Intermaxillary fixation is carried out to
fix the upper and lower dentures

B- When there is no old denture:

1- Impression for both jaws are made using alginate
in a stock tray. The impression is poured into
dental stone.
2-The cast is sectioned, if there is displacement, and
reassembled guided by the ridge contour.
3-Double layer of modeling wax is adapted on both
casts with peripheral Underextension of 2 mm.
Since retention is not a problem, the palate may be
left uncovered to give space for the tongue.

4-Wax occlusion rims with a hollow occlusal surface,

are constructed with a height of 5 mm, in the
premolars, first and second molar area.
5-Wire hooks are fixed to the buccal surface of the
wax rim.
6-Tissue conditioning material is applied and the
splint is fitted into the patients mouth.

8-The mandibular part of splint is fixed to the

mandible by circumferential wiring and the
maxillary part is wired to the zygomatic arch. To
prevent slippage of the wires, grooves are cut in
the polishing surface to accommodate it.

9-The patient is guided to close in centric relation,

while softened gutta percha or self-curing acrylic is
placed in the grooves in the occlusal surface of the
rims. Then, intermaxillary fixation ( by metallic wire
or elastic bands) is carried out to fix the upper and
lower parts of splint.
10-The intermaxillary wiring may be removed early
leaving the splint till complete healing of the
fracture.

Kingsley splint
Indications:
1- fracture of edentulous mandible as an alternate
to gunning splint.
2- As an emergency treatment for depressed
maxillary fracture where traction is required.

Design:
An intraoral tray is fitted to the teeth or edentulous
ridge by compound impression material. The tray
has stout wires attacked and projecting between
the lips around the sides of the face. The wires
provide attachment for bandage over the head in
case of maxillary fracture and below the chin in
mandibular fracture.

TRISMUS

Trismus limits mandibular movement and restricts

opening of the mouth.
- Limited oral opening restricts mastication, impairs
speech and deglutition, and limits access for
dental treatment.

A simple test for trismus

Mouth opening usually 35 millimeters. This distance is usually equal to

the width of three fingers.
One simple test is the 'three finger test'. Ask the patient to insert three
fingers into the mouth. If all three fingers fit between the central incisors,
mouth opening is considered functional. If less than restriction is
happened.
Trismus tends to develop slowly. In some patients, it progresses so
slowly that they may not notice it until they can only open their mouth to
20mm or less.

Etiology
I- Acute Factors
1- Local trauma during an inferior alveolar nerve block
anesthesia.
2- Infection of the lateral pharyngeal space, as a sequel to
pericoronitis or oral surgery.
II- Chronic Factors
1-Temporomandibular joint dysfunction.
2-Poor joint architecture and malposition of the disk.
3- Rheumatoid arthritis.
4- Pathological processes as osteoma of condyle or zygoma,
cysts, and overgrowth condyle or coronoid process.
5. Intra-capsular or extra-capsular ankylosis.
III- Treatment Related Factors
1.Radiation therapy may limit mandibular movement if the
muscles of mastication or TMJ were in the treatment fields.
2. Surgical resection of the maxilla and mandible.

Treatment
1-Medical treatment
-When infection is the cause of trismus,
antibiotics are the treatment of choice.
-Arthritis, inflammation of the joint can be
treated with anti-inflammatory agents.
-Muscle relaxants may help in acute cases of
limited mandibular movement.

II. Surgical treatment

-Surgery is the treatment of choice for removal of
tumors, cysts or foreign bodies.
- Surgery may also be indicated if conservative
therapy has failed.

III. Physical treatment

A- Exercise
-It is helpful during radiation therapy, following orthognathic
surgery and for scleroderma patients.
These include opening the mouth as wide as possible 20
times at least three to four times per day.
-In addition 8 to 10 actively assisted lateral excursions
should be done to exercise the pterygoid muscles.
-For scleroderma patients, manually assisted exercise can
also be used.
- Chewing gum has little or no therapeutic effect on trismus
because it exercises primarily the closing muscle instead
of stretching the fibrotic tissues that hold the mandible
closed.

B. Mechanical devices
1- Simple devices
a-A tapered threaded acrylic screw can be used.
Placed and turned between the teeth to apply an
opening force to the mandible

b-Tongue depressors can be lubricated with

petroleum Jelly or glycerin and placed between the
arches for 1 minute to increase opening. Additional
depressors can be added one at a time to increase
opening

c-A wooden clothespin inserted between the

arches while the patient applying gradual
pressure.

2. Dynamic Bite Opener or Trismus Stent

A. The Dynamic Opening Device :It is a modified Kingsley splint, which consists of a
steel framework, attached to maxillary and
mandibular acrylic stents. Rods attached to the
metal framework and extend to the sides of the
face.

The device is inserted, and elastic bands between

the extra-oral rods produce bilateral opening force
that may be varied by using different elastics. used
intermittently to avoid fatigue.

B. The inflatable bite opener:Consists of:1- Maxillary and mandibular stents.

2- An inflatable pediatric blood
pressure bag.
3- Rubber bulb and tubing.
The stents are inserted and the
inflatable bag is placed between
the stents. The bag is inflated by
squeezing the rubber bulb,
forcing the stents apart. The
pressure is maintained for 10
seconds followed by 1minutes of
rest. The procedure is followed
for 10 minutes three times a day.

C. An intraoral prosthesis with interarch spring:used for dentulous and edentulous patients. The
spring clips are attached to mandibular stent and
the free end of the clip locks into a latch on the
maxillary stent. The springs provide a constant
force bilaterally which is controlled by adjusting the
size of loop.