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Increasing occlusal vertical dimension with an orthodontic ‘clothes pin appliance.’ A clinical report
Increasin ‘clothes p
nsion
S. A. Alexander,
.,* am
enner,
with
an ortho
.s .*+
State University of lTew York at Stony Brook, School of Dental Medicine, Stony Brook, N.Y.
ostsurgical and radiation therapy patients may require the use of an exercising device that will help to stretch and loosen fibrotic oral tissues, providing an increase in the vertical oral opening. Wound contraction of electrical burns to the oral eommissur therapy in the horizontal dimensi0n.l tion of the tissues may limit the patient’s opening sufficiently to prevent making accurate impressions for an obturator or the facile insertion and w~thdrawaI of a prosthesis. When a surgical procedure leaves the patient unilaterally edentulous in one arch, the fabrication of a traditional mouth exerciser may not be possible.2
TREATMENT
NE
The patient had a postsurgical left unilateral cleft of the hard palate and part of the soft palate with extraction of all left maxillary teeth and alveolar bone. The partially
*Associate Professor (Orthodontics), Department of Children’s Dentistry. **Professor (Prosthodontics), Department of Restorative Dentistry.
edentulous mandibular arch had been restored -with a removable partial denture. Only four right maxillary teeth remained (Nos. 11, 12, 13, and 17). For this patient it was necessary to make a unilaterab mouth exerciing device that could be placed over the occlusal surfaces of both maxillary and mandibular teeth. This device consisted of a helical coil spring and maxillary and mandibular occlusal indices that could be activated as required to exercise the soft tissues and to force the jaws open to increase the maximum mouth opening over a short period of time.
TREATMENT
PROCEDU
1. Make accurate sectional impressions of the opposing dental arches in irreversible hydrocolloid and pour the impressions in dental stone. Make a centric relation record to facilitate mounting the casts in an articulator. 2. Make a helical coil spring from a piece of round No. 5.045 Blue Elgiloy wire (Rocky Mountain Orthodontics, Denver, Colo.). The wire is bent into a 2% looped coil spring by using an orthodontic Bird Beak plier (Dentronix, Ivyland, Pa.) (Fig. 1). Bends for retention should be placed in upper and lower portions of the wire and it5 length must fit within the dental arch (Fig. 2).
ig. 2. Coil spring is formed by using laTo. 0.045 Blue Elgiloy wire with 2% turn helix. Fig. 2. Melical expansion spring placed on occluded casts to examine contour and relationship
of wire to maxillary
THE JOURNAL OF RROSTWETPC UEN’rISTRY
and mandibular
arches.
ALEXANDER
AND
RENNER
3. Spring initially stabilized with acrylic resin followed by “salt and pepper” technique of embeddingwire. Fig. 4. Tinfoil separation and addition of acrylic resin to opposing arch. Fig. 6. Completed appliance. Note embeddedarms of helical spring within acrylic resin. Fig. 6. Patient’s maximal opening is 7.5 mm. Fig. 7. Initial insertion of appliance activated at 13 oz as measuredby compressionof Dontrix gauge.Note dental tape knotted around helix to prevent accidental ingestion or aspiration. Fig. 8. Once inserted, posterior mandibular seat of appliance disarticulates from mandibular teeth as result of expansion force, but remains retentive. Fig.
3. Apply two coatsof separatingmedium (Alcote, Dentsply Int., York, Pa.) to the castsand allow them to dry. Using a “salt and pepper” technique, apply orthodontic acrylic resin to the mandibular cast, covering the oc2
clusal, buccal, and lingual aspects.Position the helical coil and embed it within the acrylic resin so that the coiled loop facesbuccally and is not located betweenthe occlusalsurfacesof the teeth (Fig. 3). As the acrylic resin JULY
1980
VOLUME
62
NUMBER
1
INCREASING
OCCLUSAL
VERTICAL
DIMENSION
begins to polymerize, trim excess material from the buccal and lingual sides of the cast. 4. Allow the mandibular half of the exerciser to polymerize and then proceed with the maxillary half. Apply a layer of tinfoil, as a separating medium, to the mandibular half and invert the articulator (Fig. 4). Again using a salt and pepper technique, apply orthodontic acrylic resin to the maxillary half of the cast, covering the occlusal, buccal, and lingual aspects. Make sure the upper portion of the retention loops for the coil is embedded in the acrylic resin. 5. As the acrylic resin begins to polymerize, trim excess material from the buccal and lingual sides of the cast. Allow the acrylic resin to completely polymerize. 6. Remove the exerciser from the stone casts, finish, and polish (Fig. 5). Record an initial measurement of mouth opening with a Boley gauge and correlate it with an initial tension on the coil spring of 13 oz as measured with a Dontrix gauge (ETM Corp., Monrovia, Calif.). Use two fixed points such as the tips of maxillary and mandibular canines as reference points for the measurements (Fig. 6). Add a long piece of dental tape to the helical coil spring to prevent accidental swallowing or aspiration during use. Adjust the appliance and fit it to the maxillary and
mandibular occlusal surfaces (Figs. 7 and 3). Each dental arch is adjusted separately to assure a stable occlusal relationship. 10. Give the patient instructions and a demonstration of how to insert and remove the appliance correctly. The appliance should be used during most of the day but not during mealtime.
DISCUSSION The patient was seen at weekly intervals to record the changes in mouth opening as measured between two fixed reference points. During the g-week time period that the appliance was used, an increase of 6 mm was obtained, as measured between the canines. This increase in jaw opening created sufficient space between the teeth for making impressions to fabricate a maxillary obturator. REFERENCES 1. Salmon RA, Glickman RS, Super S. Splint therapy for electrical burns of the oral commissures in children. J Dent Child 1987;54:161-4. 2. Schearer HH. Fabrication of e mouth exerciser. I1 PROSTHET DENT 1970;23:99-103. Reprint requests to. DR. STANLEY A. ALEXANDER SUNY AT STONY BROOK SCHOLL OF DENTAL MEDICINE STONY BROOK, NY 11794-8701
A CLINICAL REPORT should be no longer than three to four double-spaced, typewritten pagessupplementedby no more than eight good-quality, descriptive color illustrations. CLINICAL REPORTS will be evaluated in the samemanner as all other manuscriptsthat are submitted to the Journal for possiblepublication. Pleaserefer to Information for Authors.
THE
JOURNAL
OF PROSTHETIC
DENTISTRY
3
nsion
S. A. Alexander,
.,* am
enner,
with
an ortho
.s .*+
State University of lTew York at Stony Brook, School of Dental Medicine, Stony Brook, N.Y.
ostsurgical and radiation therapy patients may require the use of an exercising device that will help to stretch and loosen fibrotic oral tissues, providing an increase in the vertical oral opening. Wound contraction of electrical burns to the oral eommissur therapy in the horizontal dimensi0n.l tion of the tissues may limit the patient’s opening sufficiently to prevent making accurate impressions for an obturator or the facile insertion and w~thdrawaI of a prosthesis. When a surgical procedure leaves the patient unilaterally edentulous in one arch, the fabrication of a traditional mouth exerciser may not be possible.2
TREATMENT
NE
The patient had a postsurgical left unilateral cleft of the hard palate and part of the soft palate with extraction of all left maxillary teeth and alveolar bone. The partially
*Associate Professor (Orthodontics), Department of Children’s Dentistry. **Professor (Prosthodontics), Department of Restorative Dentistry.
edentulous mandibular arch had been restored -with a removable partial denture. Only four right maxillary teeth remained (Nos. 11, 12, 13, and 17). For this patient it was necessary to make a unilaterab mouth exerciing device that could be placed over the occlusal surfaces of both maxillary and mandibular teeth. This device consisted of a helical coil spring and maxillary and mandibular occlusal indices that could be activated as required to exercise the soft tissues and to force the jaws open to increase the maximum mouth opening over a short period of time.
TREATMENT
PROCEDU
1. Make accurate sectional impressions of the opposing dental arches in irreversible hydrocolloid and pour the impressions in dental stone. Make a centric relation record to facilitate mounting the casts in an articulator. 2. Make a helical coil spring from a piece of round No. 5.045 Blue Elgiloy wire (Rocky Mountain Orthodontics, Denver, Colo.). The wire is bent into a 2% looped coil spring by using an orthodontic Bird Beak plier (Dentronix, Ivyland, Pa.) (Fig. 1). Bends for retention should be placed in upper and lower portions of the wire and it5 length must fit within the dental arch (Fig. 2).
ig. 2. Coil spring is formed by using laTo. 0.045 Blue Elgiloy wire with 2% turn helix. Fig. 2. Melical expansion spring placed on occluded casts to examine contour and relationship
of wire to maxillary
THE JOURNAL OF RROSTWETPC UEN’rISTRY
and mandibular
arches.
ALEXANDER
AND
RENNER
3. Spring initially stabilized with acrylic resin followed by “salt and pepper” technique of embeddingwire. Fig. 4. Tinfoil separation and addition of acrylic resin to opposing arch. Fig. 6. Completed appliance. Note embeddedarms of helical spring within acrylic resin. Fig. 6. Patient’s maximal opening is 7.5 mm. Fig. 7. Initial insertion of appliance activated at 13 oz as measuredby compressionof Dontrix gauge.Note dental tape knotted around helix to prevent accidental ingestion or aspiration. Fig. 8. Once inserted, posterior mandibular seat of appliance disarticulates from mandibular teeth as result of expansion force, but remains retentive. Fig.
3. Apply two coatsof separatingmedium (Alcote, Dentsply Int., York, Pa.) to the castsand allow them to dry. Using a “salt and pepper” technique, apply orthodontic acrylic resin to the mandibular cast, covering the oc2
clusal, buccal, and lingual aspects.Position the helical coil and embed it within the acrylic resin so that the coiled loop facesbuccally and is not located betweenthe occlusalsurfacesof the teeth (Fig. 3). As the acrylic resin JULY
1980
VOLUME
62
NUMBER
1
INCREASING
OCCLUSAL
VERTICAL
DIMENSION
begins to polymerize, trim excess material from the buccal and lingual sides of the cast. 4. Allow the mandibular half of the exerciser to polymerize and then proceed with the maxillary half. Apply a layer of tinfoil, as a separating medium, to the mandibular half and invert the articulator (Fig. 4). Again using a salt and pepper technique, apply orthodontic acrylic resin to the maxillary half of the cast, covering the occlusal, buccal, and lingual aspects. Make sure the upper portion of the retention loops for the coil is embedded in the acrylic resin. 5. As the acrylic resin begins to polymerize, trim excess material from the buccal and lingual sides of the cast. Allow the acrylic resin to completely polymerize. 6. Remove the exerciser from the stone casts, finish, and polish (Fig. 5). Record an initial measurement of mouth opening with a Boley gauge and correlate it with an initial tension on the coil spring of 13 oz as measured with a Dontrix gauge (ETM Corp., Monrovia, Calif.). Use two fixed points such as the tips of maxillary and mandibular canines as reference points for the measurements (Fig. 6). Add a long piece of dental tape to the helical coil spring to prevent accidental swallowing or aspiration during use. Adjust the appliance and fit it to the maxillary and
mandibular occlusal surfaces (Figs. 7 and 3). Each dental arch is adjusted separately to assure a stable occlusal relationship. 10. Give the patient instructions and a demonstration of how to insert and remove the appliance correctly. The appliance should be used during most of the day but not during mealtime.
DISCUSSION The patient was seen at weekly intervals to record the changes in mouth opening as measured between two fixed reference points. During the g-week time period that the appliance was used, an increase of 6 mm was obtained, as measured between the canines. This increase in jaw opening created sufficient space between the teeth for making impressions to fabricate a maxillary obturator. REFERENCES 1. Salmon RA, Glickman RS, Super S. Splint therapy for electrical burns of the oral commissures in children. J Dent Child 1987;54:161-4. 2. Schearer HH. Fabrication of e mouth exerciser. I1 PROSTHET DENT 1970;23:99-103. Reprint requests to. DR. STANLEY A. ALEXANDER SUNY AT STONY BROOK SCHOLL OF DENTAL MEDICINE STONY BROOK, NY 11794-8701
A CLINICAL REPORT should be no longer than three to four double-spaced, typewritten pagessupplementedby no more than eight good-quality, descriptive color illustrations. CLINICAL REPORTS will be evaluated in the samemanner as all other manuscriptsthat are submitted to the Journal for possiblepublication. Pleaserefer to Information for Authors.
THE
JOURNAL
OF PROSTHETIC
DENTISTRY
3