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An occlusal prosthesis to assure airway patency in the comatose patient
An occlusal prosthesis to assure airway patency in the comatose patient W. A. Levine, D.D.S.,* University
of Maryland,
C. 8. Hoek, D.D.S.,**
School of Dentistry,
and R. K. Fenster, D.D.S.***
Baltimore,
Md.
I
t is not uncommon for a patient who has been involved in a multiple-trauma accident to remain hospitalized for a prolonged period of time. The patient may suffer from multiple-system injuries including the central nervous system. The neurologic activity may be limited to a midbrain level, limiting the patient to spastic motor activity. Factitial injuries to the tongue and cheeks and extensive tooth grinding in the neurologically depressed patient are well documented in the literature. Ruminatory, reflex chewing has been dealt with using various oral prostheses including rubber and acrylic resin mouth guards, tongue stents, and intermaxillary fixation.‘-” These have met with varying degrees of success.
PATIENT
TREATMENT
On December 23, 1978, a 19-year-old white woman was admitted to the Maryland Institute of Emergency Medicine Service Systems with a diagnosis of a severe head injury, massive right pulmonary contusion with intrapulmonary hemorrhage and a torn falciform ligament. These injuries required immediate endotracheal intubation, mechanical ventilation, and surgical attention. On December 28, 1978, the development of a left lower lobe pneumonia further compromised the patient’s pulmonary status. This necessitated continued respiratory assistance, a need for high levels of positive end-expiratory pressure, and a tracheotomy. On January 18, 1979, evidence of a tracheoesophageal fistula was noted and an oral-endotracheal
*Second year postgraduate student, Department of Prosthodontics. **Second year resident, Department of Oral and Maxillofacial Surgery. ***Associate Professor, Department of Removable Prosthodontics; Director, Postgraduate Prosthodontics.
(x)22-3913/80/100451
+ 02800.20/O @ 1980 The C. V. Morby Co.
*
tube was inserted to bypass the fistula.* The patient remained unconscious and began to exhibit reflex chewing activity directed toward the endotracheal tube which tended to collapse the tube and interfered with ventilatory exchange. In an attempt to keep the tube patent, tongue blades were inserted to prop open the patient’s mouth creating a large palatal ulceration.
FABRICATION
OF THE OCCLUSAL
STENT
It was apparent that a prosthesis was needed to prevent further trauma to the patient’s palate, to permit healing of damaged tissues, and to allow for adequate ventilation. The prosthesis, fabricated in the dental laboratory, can be easily inserted. The prosthesis is a clear acrylic resin occlusal stent with bilateral, posterior platforms allowing space anteriorly through which the oral-endotracheal tube passes easily. Three holes are drilled in interproximal areas on both platforms for ligature wire. Maxillary and mandibular impressions are made and duplicate casts are poured. The duplicate cast on which the stent is fabricated is destroyed during separation, and the original cast is used to check stability after processing. The stent is waxed on the duplicate cast mounted in a hinge articulator. One layer of baseplate wax is carefully adapted over the maxillary teeth to the level of the height of contour. From the premolars posteriorly, layers of wax are added in a manner similar to the fabrication of an occlusion rim. The height is determined by the diameter of the oral-endotracheal tube which must pass freely through the open anterior segment (Fig. 1). The wax pattern on the cast is smoothed, flasked, and processed in clear acrylic resin. After retrieval, it is sandblasted to remove stone from the ocdusal portion. Some trimming will be necessary until the stent may be reseated firmly and positively on the
THE IOURNAL
OF PROSTHETIC
DENTISTRY
451
LEVINE,
Fig. 1. Wax up of occlusal stent on hinge articulator, allowing space through which the appropriate size endotracheal tube can pass.
HOEK. ANU
FENSTt.K
Fig. 3. Prosthesis is wired into place. Arrou~s show Z-Igauge ligature wire twisted inside counter-sunk holes to prevent ulceration.
SUMMARY Ruminatory reflex chewing activities in the comatose patient and the associated prostheses used in their treatment have been well documented in the literature. The comatose patient, whose condition is further complicated by the need for oral-endotracheal intubation, requires the aid of a prosthesis which will allow for long-term patency of the tube to maintain proper ventilation. REFERENCES 1.
Fig. 2. Processed acrylic resin stent. Arrows show counter-sunk holes drilled bilaterally through the platform. original cast. The prosthesis can now be trimmed to knife edge at its occluso-buccal and occluso-lingual borders. The platform is rounded and highly polished. The three bilateral holes can be counter-sunk so that the ligature wire can be bent inside to avoid irritating the patient’s buccal mucosa (Fig. 2). The prosthesis, inserted at bedside, is placed on the maxillary teeth, 24-gauge stainless steel ligature wire is passed through the interproximal spaces to ligate the prosthesis to the maxillary teeth (Fig. 3).
452
2. 3.
4.
Hanson, G. E., Ogle, R. G., and Grion, L. A.: A tongue stent for prevention of oral trauma in the comato.se patient. Crit Care Med 3:200, 1975. Jackson, J. J.: The use of tongue-depressing stents for neuropathologic chewing. J PR0STHE.I. DENT 40:309, 1978. Picrcell, M. P., Waite, D. E.. and Nelson, R.: Prevention of self-inflicted trauma in semicomatose patients. J Oral Surg 32:902. 1974. Blanc, V. F., and Tremblay, N. A. G.: The complications of tracheal intubation: A new classification with a review of the literature. Anesthesia and Analgesia 53:202. 1974.
Reprint requeststo: DR. R. K. FENSTER DIRECTOR, POSTCRADUATE UNIVERSITY OF MARYLAND SCHOOL OF DENTISTRY BALTIMORE, MD 2 1201
PROSTHODONTICS
OCTOBER
1980
VOLUME
44
NUMBER
4
of Maryland,
C. 8. Hoek, D.D.S.,**
School of Dentistry,
and R. K. Fenster, D.D.S.***
Baltimore,
Md.
I
t is not uncommon for a patient who has been involved in a multiple-trauma accident to remain hospitalized for a prolonged period of time. The patient may suffer from multiple-system injuries including the central nervous system. The neurologic activity may be limited to a midbrain level, limiting the patient to spastic motor activity. Factitial injuries to the tongue and cheeks and extensive tooth grinding in the neurologically depressed patient are well documented in the literature. Ruminatory, reflex chewing has been dealt with using various oral prostheses including rubber and acrylic resin mouth guards, tongue stents, and intermaxillary fixation.‘-” These have met with varying degrees of success.
PATIENT
TREATMENT
On December 23, 1978, a 19-year-old white woman was admitted to the Maryland Institute of Emergency Medicine Service Systems with a diagnosis of a severe head injury, massive right pulmonary contusion with intrapulmonary hemorrhage and a torn falciform ligament. These injuries required immediate endotracheal intubation, mechanical ventilation, and surgical attention. On December 28, 1978, the development of a left lower lobe pneumonia further compromised the patient’s pulmonary status. This necessitated continued respiratory assistance, a need for high levels of positive end-expiratory pressure, and a tracheotomy. On January 18, 1979, evidence of a tracheoesophageal fistula was noted and an oral-endotracheal
*Second year postgraduate student, Department of Prosthodontics. **Second year resident, Department of Oral and Maxillofacial Surgery. ***Associate Professor, Department of Removable Prosthodontics; Director, Postgraduate Prosthodontics.
(x)22-3913/80/100451
+ 02800.20/O @ 1980 The C. V. Morby Co.
*
tube was inserted to bypass the fistula.* The patient remained unconscious and began to exhibit reflex chewing activity directed toward the endotracheal tube which tended to collapse the tube and interfered with ventilatory exchange. In an attempt to keep the tube patent, tongue blades were inserted to prop open the patient’s mouth creating a large palatal ulceration.
FABRICATION
OF THE OCCLUSAL
STENT
It was apparent that a prosthesis was needed to prevent further trauma to the patient’s palate, to permit healing of damaged tissues, and to allow for adequate ventilation. The prosthesis, fabricated in the dental laboratory, can be easily inserted. The prosthesis is a clear acrylic resin occlusal stent with bilateral, posterior platforms allowing space anteriorly through which the oral-endotracheal tube passes easily. Three holes are drilled in interproximal areas on both platforms for ligature wire. Maxillary and mandibular impressions are made and duplicate casts are poured. The duplicate cast on which the stent is fabricated is destroyed during separation, and the original cast is used to check stability after processing. The stent is waxed on the duplicate cast mounted in a hinge articulator. One layer of baseplate wax is carefully adapted over the maxillary teeth to the level of the height of contour. From the premolars posteriorly, layers of wax are added in a manner similar to the fabrication of an occlusion rim. The height is determined by the diameter of the oral-endotracheal tube which must pass freely through the open anterior segment (Fig. 1). The wax pattern on the cast is smoothed, flasked, and processed in clear acrylic resin. After retrieval, it is sandblasted to remove stone from the ocdusal portion. Some trimming will be necessary until the stent may be reseated firmly and positively on the
THE IOURNAL
OF PROSTHETIC
DENTISTRY
451
LEVINE,
Fig. 1. Wax up of occlusal stent on hinge articulator, allowing space through which the appropriate size endotracheal tube can pass.
HOEK. ANU
FENSTt.K
Fig. 3. Prosthesis is wired into place. Arrou~s show Z-Igauge ligature wire twisted inside counter-sunk holes to prevent ulceration.
SUMMARY Ruminatory reflex chewing activities in the comatose patient and the associated prostheses used in their treatment have been well documented in the literature. The comatose patient, whose condition is further complicated by the need for oral-endotracheal intubation, requires the aid of a prosthesis which will allow for long-term patency of the tube to maintain proper ventilation. REFERENCES 1.
Fig. 2. Processed acrylic resin stent. Arrows show counter-sunk holes drilled bilaterally through the platform. original cast. The prosthesis can now be trimmed to knife edge at its occluso-buccal and occluso-lingual borders. The platform is rounded and highly polished. The three bilateral holes can be counter-sunk so that the ligature wire can be bent inside to avoid irritating the patient’s buccal mucosa (Fig. 2). The prosthesis, inserted at bedside, is placed on the maxillary teeth, 24-gauge stainless steel ligature wire is passed through the interproximal spaces to ligate the prosthesis to the maxillary teeth (Fig. 3).
452
2. 3.
4.
Hanson, G. E., Ogle, R. G., and Grion, L. A.: A tongue stent for prevention of oral trauma in the comato.se patient. Crit Care Med 3:200, 1975. Jackson, J. J.: The use of tongue-depressing stents for neuropathologic chewing. J PR0STHE.I. DENT 40:309, 1978. Picrcell, M. P., Waite, D. E.. and Nelson, R.: Prevention of self-inflicted trauma in semicomatose patients. J Oral Surg 32:902. 1974. Blanc, V. F., and Tremblay, N. A. G.: The complications of tracheal intubation: A new classification with a review of the literature. Anesthesia and Analgesia 53:202. 1974.
Reprint requeststo: DR. R. K. FENSTER DIRECTOR, POSTCRADUATE UNIVERSITY OF MARYLAND SCHOOL OF DENTISTRY BALTIMORE, MD 2 1201
PROSTHODONTICS
OCTOBER
1980
VOLUME
44
NUMBER
4