Management of Guardman’s Fracture in a 2-Year-Old Child Using a Cap Splint Under General Anesthesia – A Case Report

INTRODUCTION

Facial skeletal injuries in very young children are relatively uncommon, accounting for less than 5% of all facial fractures due to anatomical and physiological factors such as bone elasticity, presence of tooth buds, and thick adipose tissue cushioning the face.^[1] The mandible, being the most prominent and movable bone of the lower face, is particularly susceptible to trauma, though its fractures are rarer in infants compared to older children.^[2]

Among pediatric mandibular fractures, Guardman’s fracture, also referred to as a symphyseal or para-symphyseal fracture, is typically caused by a fall on the chin, transmitting force along the midline to the mandibular symphysis.^[3] Clinical manifestations include chin laceration, anterior swelling, mobility in the lower anterior segment, deranged occlusion, and discomfort in mouth closure.

Treatment in such young patients is challenging because of small jaw size, the presence of developing tooth germs, and limited cooperation.^[4] The therapeutic approach must ensure bone stability, preserve developing dentition and minimize trauma to growth centers. Cap splint fixation under general anesthesia offers a conservative and effective solution, ensuring functional and esthetic recovery with minimal risk.^[5]

CASE REPORT

A 2-year-old boy reported to the Department of Pedodontics and Preventive Dentistry, Sri Aurobindo College of Dentistry, Indore, two days after sustaining a fall from bed. The child cried immediately after the incident, indicating preserved consciousness. Parents reported bleeding from the lower anterior region, difficulty in mouth closure, and mobility of the lower anterior teeth.

Extraoral examination revealed mild swelling and tenderness over the chin without laceration or ecchymosis [Figure 1]. Intraoral examination showed a step deformity in the mandibular anterior region with mobility of the lower incisors and disturbed occlusion. The mucosa was intact, with no evidence of soft-tissue tear or avulsion injury.

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Figure 1: Pre-operative view showing the fracture line on the buccal aspect of the mandibular symphysis (white oval).

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A mandibular occlusal radiograph demonstrated a clear fracture line in the symphyseal region extending between developing tooth buds, without displacement or follicular disruption, confirming the diagnosis of Guardman’s fracture [Figure 2].

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Figure 2: Impression of the mandibular arch obtained using medium-body (black circle) and light-body impression materials.

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Treatment plan

Considering the patient’s age, uncooperative behavior, disturbed occlusion, and the need for precise reduction, closed reduction using a prefabricated acrylic cap splint stabilized with circummandibular wiring under general anesthesia was planned.^[6] To achieve this, elastomeric impression materials were used to obtain accurate impressions of the mandibular arch, which were poured in dental stone to produce a precise working cast clearly demonstrating the fracture line. On the cast, the fractured segments were carefully realigned to restore normal occlusion. Following realignment, impressions of the corrected cast were made to serve as a template for splint fabrication. An open cap splint was then fabricated using heat-cured acrylic material, ensuring accurate adaptation to the contours of the realigned mandibular segments and providing stable fixation while minimizing trauma to the developing dentition [Figures 3–5].

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Figure 3: Computed tomography scan slice of the mandibular lower border showing a fracture in the symphyseal region (white circles).

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Figure 4: The dental cast was readjusted near the fracture line (white circle) to fabricate an open cap splint after aligning both mandibular segments.

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Figure 5: fresh impression made and cast poures after which open cap splint was placed

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Treatment procedure

Under general anesthesia with nasal intubation, intraoral manual reduction of the fracture was performed. Following aseptic preparation, the fracture line was exposed intraorally, and manual reduction was carefully performed to restore normal occlusion. A heat-cured acrylic cap splint, prefabricated on a model cast obtained from elastomeric dental impressions, was positioned intraorally and adjusted to achieve a snug, accurate fit. Circum-mandibular wiring was carried out using a trocar to pass stainless-steel wires through the lower border of the mandible bilaterally and around the splint, ensuring firm fixation [Figure 6]. Occlusion was verified for centric accuracy, and soft tissues were sutured. The patient was extubated uneventfully and monitored postoperatively. A five-day course of antibiotics and analgesics was prescribed, and the parents were advised to maintain meticulous oral hygiene and provide a soft diet for two weeks. The splint and circummandibular wires were removed after three weeks, following radiographic evidence of adequate bone healing. At the three-month follow-up, the fracture site exhibited complete bony union and normal mandibular function, with no deviation or malocclusion. The developing tooth buds remained unaffected, confirming the biological safety and efficacy of closed reduction with an acrylic cap splint in very young children.^[3,7,8]

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Figure 6: The cap splint (circles) was placed successfully followed by circum-mandibular wiring

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DISCUSSION

Mandibular fractures account for approximately 20–40% of all pediatric facial fractures; however, their occurrence in children below three years of age is rare due to the high elasticity and unmineralized structure of their bones.^[9] When such fractures do occur, the symphyseal region is most commonly involved, as it is the primary area of impact during chin injuries. The treatment philosophy for pediatric mandibular fractures differs fundamentally from that of adults. The primary objectives are to restore normal function and occlusion, facilitate adequate bone healing, and avoid any interference with developing dentition or mandibular growth centers.^[10]

Among the available treatment modalities, closed reduction using a cap splint remains the gold standard for nondisplaced or minimally displaced fractures in very young children.^[7] In the present case, elastomeric impressions were obtained, and casts were poured to accurately visualize the fracture line. The fractured segments were carefully realigned on the cast, restoring normal occlusion, which allowed for the fabrication of a custom-fit open cap splint using heat-cured acrylic material. This approach ensured precise adaptation to the mandibular contours, minimized intraoral manipulation, and protected the developing tooth buds during fixation. The cap splint stabilizes both alveolar segments, maintains proper occlusion, and prevents displacement without disturbing growth areas. Circum-mandibular wiring provided additional retention and stability.^[8]

Open reduction and internal fixation (ORIF) using titanium or resorbable plates offers direct stabilization but carries a significant risk of injuring developing tooth buds and growth centers.^[11] Therefore, ORIF is generally reserved for severely displaced fractures, older children above six years, or cases involving multiple fracture sites. Resorbable fixation systems employing bioresorbable materials such as poly-L-lactic acid (PLLA) or polyglycolic acid (PGA) plates have been proposed as alternatives to metallic fixation, eliminating the need for a second surgery. However, these systems are technically challenging in toddlers and are often unsuitable for small mandibular dimensions.^[12] In cases of minimally displaced fractures, functional therapy and observation with a soft or liquid diet may allow for spontaneous healing, leveraging the child’s high osteogenic potential. Nonetheless, this approach is not recommended when occlusion is disturbed or mobility persists beyond a few days.^[5,9]

Anesthetic management in young children presents unique challenges due to airway size, tongue proportion, and emotional immaturity. General anesthesia enables accurate fracture reduction, ensures airway safety, and provides a stress-free operative environment.^[7] Nasal intubation, in particular, facilitates unobstructed access to the oral cavity, allowing precise circummandibular wiring and secure splint placement.

Healing in pediatric mandibular fractures is typically rapid, often within two to three weeks, owing to high vascularity and osteogenic capacity. In the present case, early intervention using a cap splint fabricated on a realigned cast resulted in stable and functional recovery, consistent with previous literature.^[1,3,7] Long-term follow-up is essential to monitor tooth eruption patterns and mandibular growth.

Several studies support the efficacy of conservative management. Rowe and Killey^[1] emphasized that closed reduction is highly predictable in pediatric fractures, while Posnick^[2] highlighted the importance of preserving periosteal continuity to facilitate optimal bone regeneration. Rattan^[4] demonstrated that cap splint immobilization yields high success rates with minimal complications in children under five years. More recent reports^[8,10] further confirm that closed reduction under general anesthesia with custom splints remains the safest and most reliable approach for infants and toddlers, providing stable outcomes while minimizing the risk of growth disturbances. The use of preoperative impressions, cast realignment, and custom splint fabrication enhances precision, reduces intraoral manipulation, and ensures optimal functional and esthetic outcomes in this delicate patient population.

CONCLUSION

Cap splint fixation under general anesthesia is a safe, conservative, and effective treatment modality for managing Guardman’s fracture in very young children. It provides adequate immobilization, promotes rapid healing, preserves developing dentition, and avoids iatrogenic injury to mandibular growth centers. A multidisciplinary approach ensures optimal functional and developmental outcomes.