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Clinical applications of visible light-cured resin in maxillofacial prosthetics. Part II: Tray material
SECTION
EDITORS
Clinical applications of visible light-cured resin maxillofacial prosthetics. Part II: Tray material
in
Arie Shifman, D.M.D.* Israel DefenseForces Center of Oral and Dental Medicine, Tel-Hashomer, Israel As an alternative to autopolymerizing acrylic resin, visible light-cured resin for custom-made impression trays is advocated. This new system facilitates chairside tray fabrication for custom-made impressions and benefits maxillofacial prosthetic patients needing intraoral or extraoral prosthetic rehabilitation. (J PROSTHET DENT 1990;64:696-9.)
v-
rsrble light-cured (VLC) resins for relines and denture base offer many advantages to the practice of maxillofacial prosthetics.’ Among this family of resins, a tray material, blue tray material (Triad VLC custom Dentsply International Inc., York, Pa.) is a substitute for autopolymerizing acrylic resin for the fabrication of cus-
The views expressedherein are those of the author and do not necessarilyreflectthe viewsof the Medical Corps,IsraelDefense Forces. Neither the author nor the service has any financial benefit or commercial interest in the use of the equipment or materials describedherein. Presented before the American Academy of Maxillofacial Prosthetics meeting, San Diego, Calif. *Lieutenant Colonel, Israel Defense Forces; Chief, Department of Proekhodontics 10/l/18643
and Maxillofacial
Prosthetics.
tom-made trays. The benefits claimed for this material are: (1) easy manipulation, (2) unrestricted working time, and (3) most trimming can be completed before curing the material. The material may be initially cured with hand-held visible light and finally cured for a few minutes in a special curing chamber (Triad or Triad II curing unit, Dentsply). The finally cured material is highly rigid and dimensionally stable. Part I dealt with clinical applications of the VLC denture base and reline material1 This article describes additional clinical applications of the VLC tray material in the practice of maxillofacial prosthetics.
INTRAORAL
APPLICATIONS
Initial stages of conventional complete denture impressions are minimized with use of the VLC system. VLC custom-made impression trays may be made from the preliminary impressions at the same sitting, if casts are made in
Fig. 1. Partial curing of molded tray material in lingual region using hand-held visible light. Fig. 2. VLC custom-made tray formed on cast removable partial denture. Compare extended and molded lingual border of tray with grossly deficient lingual border of other side.
THE
JOURNAL
OF PROSTHETIC
DENTISTRY
695
Fig. 3. Postsurgical nasal defect. Fig. 4. VLC tray material is adapted on face of patient shown in Fig. 3. Fig. 6. Irreversible hydrocolloid facial impression is supported by VLC custom-made
Fig. 8. Postaurgical orbital defect. Fig. 6. Finished facial impression. Fig. 7. Nasal prosthesis sculpted in wax on cast made from facial impression. fast-setting plaster of paris. This procedure is of spcecial benefit to patients coming from long distances who need maxillofacial prosthetic treatment rendered in large medical centers. In addition, such patients often reveal irregular soft tissue configuration due to loss of tissue, closure of surgical flaps, or scarring. 2~3A chairside fabrication of cus696
tom-made trays for these patients is aided by a comparison of the clinical presentation with the preliminary cast. Trimming of or additions to the borders of the VLC tray material, as dictated by the clinical conditions, is performed while the material remains on the preliminary cast in the uncured state. Limited access of the preliminary impression material, for instance, into the lingual and retromylohyoid spaces may result in custom-made trays that are short in the congruent areas. To extend the deficient borders of a tray, VLC DECEMBER
1990
VOLUME
64
NUMBER
6
CLINICAL
APPLICATIONS
OF VLC RESIN:
PART
II
Fig. 9. Frame-formed VLC tray material is extended into orbital defect. Fig. 10. Sheet of VLC tray material is joined to frame and adapted on face. Fig. 11. VLC custom-made tray for orbital impression.
tray material is added to the appropriate areas and functionally molded in the mouth. Care is taken to apply the added resin to a clean, dry surface. At this stage, the tray material should be only partially cured, because completely cured resin will not bond to newly added resin. Hand-held visible light is used to initially cure the added material to prevent distortion of the borders of the tray upon removal from the mouth (Figs. 1 and 2). Uncured VLC tray material may be irritating to some patients. In this event, Triad VLC denture base or VLC reline material (Dentsply) should be substituted for use as the tray material. After completely curing and trimming the tray material, impressions are completed in the usual manner.
EXTRAORAL
APPLICATIONS
One of the most popular methods for making facial impressions is the use of irreversible hydrocolloid supported by a plaster of paris backing. The shortcoming of this technique, especially for large or full-facial impressions, is the THE
JOURNAL
OF PROSTHETIC
DENTISTRY
heavy bulk of two materials, causing tissue distortions and patient discomfort. The materials are difficult to control, the patient must be draped, and the facial region should be boxed. To eliminate the plaster of paris backing as a means of support for irreversible hydrocolloid impressions, an aluminum-wire face-mask frame4 or thermoplastic splint material5 have been proposed. However, making facial impressions in irreversible hydrocolloid material is further facilitated by using VLC custom-made impression trays.
Technique Sheet tray material (Triad VLC custom tray material) is adapted to the face and partially cured with hand-held visible light and subsequently completely cured in the curing chamber (Figs. 3 and 4). Alginate adhesive (Fix, De Trey, AD International, London, England) is applied to the impression surface of the tray material before making the final irreversible hydrocolloid impression (Figs. 5 and 6). Carving and sculpting of the prosthesis is carried out in the 697
SHIFMAN
Fig. 12. Additional sheet of VLC tray material is adapted on face. Fig. 13. Irreversible hydrocolloid facial impression is made in combined sectional trays. Fig. 14. Facial impression that is fully extended to outlined regions.
usual manner (Fig. 7). When there is a need for large regions of the face to be included in the impression, several sheets are adapted to the face, keyed, separately cured, and connected with small amounts of VLC tray material cured with the hand-held visible light (Figs. 8 through 14).
Advantages Making facial impressions with VLC custom-made trays offers a number of advantages in comparison with other impression techniques: 1. Facial impressions can be made with a custom-made tray that can be extended to all delineated borders. 2. In orbital defects, an inner shelf may be attached to the tray to confine the impression material to the minimum region needed for engaging of undercuts for retaining the final prosthesis (Figs. 8 through 11). 3. No protective draping or boxing is required.
698
4. Venting holes for airway tubes can easily be prepared in the tray in its uncured state. 5. Facial impressions are lighter, less bulky, and a reduced amount of irreversible hydrocolloid material may be used. The reduced bulk of the impression results in less tissue distortion. 6. Even thickness of the impression material is attained in a highly rigid tray support. 7. More working time is gained, since before the impression is made, most of the mixed irreversible hydrocolloid is spread over the tray rather than on the face. 8. Large facial impressions are made using separate tray sections that are subsequently joined together on the face prior to making the impression (Fig. 12). 9. Impressions can be made with the patient in an upright position to reduce the effect of weight and to facilitate breathing and patient comfort.
DECEMBER
1990
VOLUME
64
NUMBER
6
CLINICALAPPLICATIONSOFVLCRESIN:PARTII
10. Nasal impressions can even be made with the patient in a forward-inclined position, thus precluding the prepacking of sensitive nasal cavities. 11. Patient apprehension is lessened with reduced onface time of the impression.
Shifman A, Lspley JB. Prosthodontic management of postsurgical soft tissue deformities associated with marginal mandibulectomy. Part II. Surgical ftape. J PROSTHET DENT 1982;4&303-8. Pflughoeft FA, Shearer HH. Fabrication of a plastic facial moulage. J PROSTHET DENT 1971;25:567-71. AquiIino SA, White J, Taylor TD, Jordan RD. Thermoplastic custom trays for making regional facial impressions. J PROSTHET DENT 1985;
53~666-8.
REFERENCES 1. Shifman A. Clinical applications of visible lightiured resin in maxillofacial prosthetics. Part I: Denture base and reline material. J PROSTHET DENT 1990,64:5X3-82. 2. Shifman A, Lepley JB. Prosthodontic management of postsurgical soft tissue deformities associated with marginal mandibulectomy. Part I: Loss of the vestibule. J PROSTHET DENT 1982;48:178-83.
Nasal
conformer
David
J. Reisberg,
to restore D.D.S.,*
and Susan
facial W. Habakuk,
Reprint requests to: DR. ARIE SHIFMAN P.O. Box 1031 PETACH-TIKVAH 49110 ISRAEL
contour M.Ed.**
University of Illinois, Collegeof Medicine, Chicago, Ill. Surgical removal of the nose may have devastating psychologic effects on the patient. This article describes the fabrication and use of a nasal conformer to restore facial contour until a definitive nasal prosthesis can be made. (J PROSTHET DENT
1990;64:699-701.)
S
urgical removal of a portion of the face for a malignant tumor is a physically debilitating and psychologically demoralizing experience. Although a facial prosthesis can provide an excellent esthetic replacement, the definitive prosthesis cannot be made until wound healing is complete, usually a period of 2 to 3 months. In the meantime, the patient must wear a bandage to cover and protect the surgical site. A bandage covering a facial defect will draw unwanted attention and increase self-consciousness and anxiety. In addition, the alteration of the normal facial profile cannot be adequately camouflaged with a facial bandage (Fig. 1). This article describes a technique for making use of a nasal conformer to restore facial profile as an interim measure until a definitive nasal prosthesis can be made.
TECHNIQUE Five to 7 days after surgery, the initial phase of healing has begun and the patient is adequately comfortable to proceed with fabrication of the conformer. 1. Pack the defect with cotton or gauze lubricated with a
*Assistant Professor,Department of Pediatrics. **Clinical AssistantProfessor,Department of Pediatrics,and Department of Biomedical Visualization, College of Associated Health Professions. 10/1/18291
THEJOURNAL
OF PROSTHETIC
DENTISTRY
bacteriostatic surgical lubricant (Surgilube, E. Fougera and Co., Hicksville, N.Y.). Select a prefabricated nasal pattern of skin-colored wax (2 lb beeswax, 1.75 lb paraflln, 2 oz pink dental baseplate wax or oil paint pigments) and hold it passively against the packing to verify harmony with facial size, shape, and profile. The prefabricated pattern may be from a preoperative facial cast of the patient. Alternatively, an appropriate wax pattern may be selected from small, medium, and large noses previously made from silicone rubber molds. Modify the wax pattern to meet the needs of the individual patient. The pattern should fit within the borders of the defect to avoid irritation to healing marginal soft tissue. If eyeglassesare used, the nasal bridge should be sculpted to permit proper positioning of the eyeglass frame. Attach a wax sprue of at least 2 cm thickness to the tissue side of the wax pattern and make a two-piece mold of the pattern in dental stone (Coecai Dental Stone, Coe Laboratories, Chicago, Ill.). Eliminate the wax pattern, apply petroleum jelly as a separator and catalyze prosthetic foam (No. 2370 Prosthetic Foam, Factor II, Lakeside, Ariz.; formerly Q74290 Prosthetic Foam, Dow Corning Corp., Midland, Mich.), following the manufacturer’s instructions for use, and quickly pour the foam into both sides of the open mold.
699
EDITORS
Clinical applications of visible light-cured resin maxillofacial prosthetics. Part II: Tray material
in
Arie Shifman, D.M.D.* Israel DefenseForces Center of Oral and Dental Medicine, Tel-Hashomer, Israel As an alternative to autopolymerizing acrylic resin, visible light-cured resin for custom-made impression trays is advocated. This new system facilitates chairside tray fabrication for custom-made impressions and benefits maxillofacial prosthetic patients needing intraoral or extraoral prosthetic rehabilitation. (J PROSTHET DENT 1990;64:696-9.)
v-
rsrble light-cured (VLC) resins for relines and denture base offer many advantages to the practice of maxillofacial prosthetics.’ Among this family of resins, a tray material, blue tray material (Triad VLC custom Dentsply International Inc., York, Pa.) is a substitute for autopolymerizing acrylic resin for the fabrication of cus-
The views expressedherein are those of the author and do not necessarilyreflectthe viewsof the Medical Corps,IsraelDefense Forces. Neither the author nor the service has any financial benefit or commercial interest in the use of the equipment or materials describedherein. Presented before the American Academy of Maxillofacial Prosthetics meeting, San Diego, Calif. *Lieutenant Colonel, Israel Defense Forces; Chief, Department of Proekhodontics 10/l/18643
and Maxillofacial
Prosthetics.
tom-made trays. The benefits claimed for this material are: (1) easy manipulation, (2) unrestricted working time, and (3) most trimming can be completed before curing the material. The material may be initially cured with hand-held visible light and finally cured for a few minutes in a special curing chamber (Triad or Triad II curing unit, Dentsply). The finally cured material is highly rigid and dimensionally stable. Part I dealt with clinical applications of the VLC denture base and reline material1 This article describes additional clinical applications of the VLC tray material in the practice of maxillofacial prosthetics.
INTRAORAL
APPLICATIONS
Initial stages of conventional complete denture impressions are minimized with use of the VLC system. VLC custom-made impression trays may be made from the preliminary impressions at the same sitting, if casts are made in
Fig. 1. Partial curing of molded tray material in lingual region using hand-held visible light. Fig. 2. VLC custom-made tray formed on cast removable partial denture. Compare extended and molded lingual border of tray with grossly deficient lingual border of other side.
THE
JOURNAL
OF PROSTHETIC
DENTISTRY
695
Fig. 3. Postsurgical nasal defect. Fig. 4. VLC tray material is adapted on face of patient shown in Fig. 3. Fig. 6. Irreversible hydrocolloid facial impression is supported by VLC custom-made
Fig. 8. Postaurgical orbital defect. Fig. 6. Finished facial impression. Fig. 7. Nasal prosthesis sculpted in wax on cast made from facial impression. fast-setting plaster of paris. This procedure is of spcecial benefit to patients coming from long distances who need maxillofacial prosthetic treatment rendered in large medical centers. In addition, such patients often reveal irregular soft tissue configuration due to loss of tissue, closure of surgical flaps, or scarring. 2~3A chairside fabrication of cus696
tom-made trays for these patients is aided by a comparison of the clinical presentation with the preliminary cast. Trimming of or additions to the borders of the VLC tray material, as dictated by the clinical conditions, is performed while the material remains on the preliminary cast in the uncured state. Limited access of the preliminary impression material, for instance, into the lingual and retromylohyoid spaces may result in custom-made trays that are short in the congruent areas. To extend the deficient borders of a tray, VLC DECEMBER
1990
VOLUME
64
NUMBER
6
CLINICAL
APPLICATIONS
OF VLC RESIN:
PART
II
Fig. 9. Frame-formed VLC tray material is extended into orbital defect. Fig. 10. Sheet of VLC tray material is joined to frame and adapted on face. Fig. 11. VLC custom-made tray for orbital impression.
tray material is added to the appropriate areas and functionally molded in the mouth. Care is taken to apply the added resin to a clean, dry surface. At this stage, the tray material should be only partially cured, because completely cured resin will not bond to newly added resin. Hand-held visible light is used to initially cure the added material to prevent distortion of the borders of the tray upon removal from the mouth (Figs. 1 and 2). Uncured VLC tray material may be irritating to some patients. In this event, Triad VLC denture base or VLC reline material (Dentsply) should be substituted for use as the tray material. After completely curing and trimming the tray material, impressions are completed in the usual manner.
EXTRAORAL
APPLICATIONS
One of the most popular methods for making facial impressions is the use of irreversible hydrocolloid supported by a plaster of paris backing. The shortcoming of this technique, especially for large or full-facial impressions, is the THE
JOURNAL
OF PROSTHETIC
DENTISTRY
heavy bulk of two materials, causing tissue distortions and patient discomfort. The materials are difficult to control, the patient must be draped, and the facial region should be boxed. To eliminate the plaster of paris backing as a means of support for irreversible hydrocolloid impressions, an aluminum-wire face-mask frame4 or thermoplastic splint material5 have been proposed. However, making facial impressions in irreversible hydrocolloid material is further facilitated by using VLC custom-made impression trays.
Technique Sheet tray material (Triad VLC custom tray material) is adapted to the face and partially cured with hand-held visible light and subsequently completely cured in the curing chamber (Figs. 3 and 4). Alginate adhesive (Fix, De Trey, AD International, London, England) is applied to the impression surface of the tray material before making the final irreversible hydrocolloid impression (Figs. 5 and 6). Carving and sculpting of the prosthesis is carried out in the 697
SHIFMAN
Fig. 12. Additional sheet of VLC tray material is adapted on face. Fig. 13. Irreversible hydrocolloid facial impression is made in combined sectional trays. Fig. 14. Facial impression that is fully extended to outlined regions.
usual manner (Fig. 7). When there is a need for large regions of the face to be included in the impression, several sheets are adapted to the face, keyed, separately cured, and connected with small amounts of VLC tray material cured with the hand-held visible light (Figs. 8 through 14).
Advantages Making facial impressions with VLC custom-made trays offers a number of advantages in comparison with other impression techniques: 1. Facial impressions can be made with a custom-made tray that can be extended to all delineated borders. 2. In orbital defects, an inner shelf may be attached to the tray to confine the impression material to the minimum region needed for engaging of undercuts for retaining the final prosthesis (Figs. 8 through 11). 3. No protective draping or boxing is required.
698
4. Venting holes for airway tubes can easily be prepared in the tray in its uncured state. 5. Facial impressions are lighter, less bulky, and a reduced amount of irreversible hydrocolloid material may be used. The reduced bulk of the impression results in less tissue distortion. 6. Even thickness of the impression material is attained in a highly rigid tray support. 7. More working time is gained, since before the impression is made, most of the mixed irreversible hydrocolloid is spread over the tray rather than on the face. 8. Large facial impressions are made using separate tray sections that are subsequently joined together on the face prior to making the impression (Fig. 12). 9. Impressions can be made with the patient in an upright position to reduce the effect of weight and to facilitate breathing and patient comfort.
DECEMBER
1990
VOLUME
64
NUMBER
6
CLINICALAPPLICATIONSOFVLCRESIN:PARTII
10. Nasal impressions can even be made with the patient in a forward-inclined position, thus precluding the prepacking of sensitive nasal cavities. 11. Patient apprehension is lessened with reduced onface time of the impression.
Shifman A, Lspley JB. Prosthodontic management of postsurgical soft tissue deformities associated with marginal mandibulectomy. Part II. Surgical ftape. J PROSTHET DENT 1982;4&303-8. Pflughoeft FA, Shearer HH. Fabrication of a plastic facial moulage. J PROSTHET DENT 1971;25:567-71. AquiIino SA, White J, Taylor TD, Jordan RD. Thermoplastic custom trays for making regional facial impressions. J PROSTHET DENT 1985;
53~666-8.
REFERENCES 1. Shifman A. Clinical applications of visible lightiured resin in maxillofacial prosthetics. Part I: Denture base and reline material. J PROSTHET DENT 1990,64:5X3-82. 2. Shifman A, Lepley JB. Prosthodontic management of postsurgical soft tissue deformities associated with marginal mandibulectomy. Part I: Loss of the vestibule. J PROSTHET DENT 1982;48:178-83.
Nasal
conformer
David
J. Reisberg,
to restore D.D.S.,*
and Susan
facial W. Habakuk,
Reprint requests to: DR. ARIE SHIFMAN P.O. Box 1031 PETACH-TIKVAH 49110 ISRAEL
contour M.Ed.**
University of Illinois, Collegeof Medicine, Chicago, Ill. Surgical removal of the nose may have devastating psychologic effects on the patient. This article describes the fabrication and use of a nasal conformer to restore facial contour until a definitive nasal prosthesis can be made. (J PROSTHET DENT
1990;64:699-701.)
S
urgical removal of a portion of the face for a malignant tumor is a physically debilitating and psychologically demoralizing experience. Although a facial prosthesis can provide an excellent esthetic replacement, the definitive prosthesis cannot be made until wound healing is complete, usually a period of 2 to 3 months. In the meantime, the patient must wear a bandage to cover and protect the surgical site. A bandage covering a facial defect will draw unwanted attention and increase self-consciousness and anxiety. In addition, the alteration of the normal facial profile cannot be adequately camouflaged with a facial bandage (Fig. 1). This article describes a technique for making use of a nasal conformer to restore facial profile as an interim measure until a definitive nasal prosthesis can be made.
TECHNIQUE Five to 7 days after surgery, the initial phase of healing has begun and the patient is adequately comfortable to proceed with fabrication of the conformer. 1. Pack the defect with cotton or gauze lubricated with a
*Assistant Professor,Department of Pediatrics. **Clinical AssistantProfessor,Department of Pediatrics,and Department of Biomedical Visualization, College of Associated Health Professions. 10/1/18291
THEJOURNAL
OF PROSTHETIC
DENTISTRY
bacteriostatic surgical lubricant (Surgilube, E. Fougera and Co., Hicksville, N.Y.). Select a prefabricated nasal pattern of skin-colored wax (2 lb beeswax, 1.75 lb paraflln, 2 oz pink dental baseplate wax or oil paint pigments) and hold it passively against the packing to verify harmony with facial size, shape, and profile. The prefabricated pattern may be from a preoperative facial cast of the patient. Alternatively, an appropriate wax pattern may be selected from small, medium, and large noses previously made from silicone rubber molds. Modify the wax pattern to meet the needs of the individual patient. The pattern should fit within the borders of the defect to avoid irritation to healing marginal soft tissue. If eyeglassesare used, the nasal bridge should be sculpted to permit proper positioning of the eyeglass frame. Attach a wax sprue of at least 2 cm thickness to the tissue side of the wax pattern and make a two-piece mold of the pattern in dental stone (Coecai Dental Stone, Coe Laboratories, Chicago, Ill.). Eliminate the wax pattern, apply petroleum jelly as a separator and catalyze prosthetic foam (No. 2370 Prosthetic Foam, Factor II, Lakeside, Ariz.; formerly Q74290 Prosthetic Foam, Dow Corning Corp., Midland, Mich.), following the manufacturer’s instructions for use, and quickly pour the foam into both sides of the open mold.
699