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Partial Denture Prosthesis for War Injuries
PARTIAL DENTURE PROSTHESIS FOR W A R INJURIES Louis Em ory, D .D .S ., El P aso, T exas
design and maintenance of partial maxilla or mandible or both and who dentures for patients that have re have required extensive surgical recon ceived maxillofacial injuries continues struction. These patients have received to be a problem for the dental profession. numerous plastic operations, and bone As these men are released from army and grafts have been necessary. An attempt is navy hospitals it becomes apparent that always made to reconstruct the maxillary an enormous task remains to' test the in and mandibular ridge areas in such a genuity of the prosthodontists. Each of manner that dentures are possible. How these cases differs so greatly from all ever, when there is a loss of tissue, which others that general stateinents and a com must be replaced by means of a graft, parison of results have not been possible. the construction of a satisfactory denture It has been necessary to delay reports is questionable at first examination. Close until more definite conclusions could be cooperation between the plastic surgeon obtained. Reports of the prosthodontic and the prosthodontist is essential to pro treatment for maxillofacial injuries are duce denture-bearing areas that can per noticeably absent from the dental litera mit the design and construction of ap ture and the surgical aspects have re pliances that are stable, retentive and ceived most of the attention. functional. The time has arrived to compare ex Maxillofacial partial dentures present periences, and the purpose of this paper numerous problems. Each case possesses is to discuss the partial dentures for those its peculiarities and demands some impatients that have received maxillofacial provision in denture design. Simplicity is injuries. It is possible that this discussion essential, and a careful consideration of may clarify and explain some of the dif the fundamental principles established ficulties which have been encountered for routine denture construction is neces and thus enable more dentists to continue sary to obtain the desired results. The the treatment of these patients. The pa technical planning and designing will tients have been concerned about their meet with success only if established and future treatments and each one expresses accepted methods are followed faithfully. the hope that he will be furnished dental Compromise methods will be found lack attention after separation. ing in some detail, and only a maximum effort to meet the situation will produce M axillo facial P artial D en tures appliances that can be considered defini tive dentures for the present stage of . The discussion will be limited to those treatment. patients who have lost substance in either The function of routine dentures is to P re se n te d a s a c lin ic a l d e m o n stratio n to t h e £1 Paso reestablish mastication, to restore esthetic T e x a s D is tric t D e n ta l S o c ie ty , th e d e n ta l officers of F o r t B liss, B ig g s F ie ld a n d W illia m B e a u m o n t G en eral appearance and to offer comfortable H o sp ita l a t W illia m B e a u m o n t G e n e ra l H o s p ita l, El P aso , T e x a s , F e b r u a r y u , 1947. wear, whereas maxillofacial dentures M a jo r (D C ) U .S .A ., C h ie f of P ro s th e tic S e c tio n , must fill bone and soft tissue defects, W illia m B ea u m o n t G e n e ra l H o sp ita l. h e
T
634
Emory
J.A.D.A., Vol. 35, November I, 1947 . . . 635
Fig. /.•—L e ft: Intra-oral epithelial graft fo r a sulcus extension. R ig h t: Partial denture used to maintain shape of sulcus
cover
p a la t a l
p e r f o r a t io n s
an d
re sto re
th e s e m e n r e q u ir e s e v e r a l a p p lia n c e s s u c h
c o n t o u r t o o t h e r w is e u n s u p p o r t e d t is s u e s ,
a s s te n ts , w h ic h
in
t e r im
a d d it io n
to t h e o r d in a r y r e q u ir e m e n t s .
act
as te m p o ra ry
d e n tu re s, a n d
o r in
t h e p a t ie n t d e v e lo p s
T h is m u s t b e a c c o m p lis h e d o v e r d e n t u r e -
s o m e o f th e h a b its n e c e s s a r y to w e a r d e n
b e a r in g
t u r e s . C o s m e t ic
areas
r e g u la r w it h
th a t
are
d e f ic ie n t
and
ir
th e r e m a in in g te e th o c c u p y
in g e x t r e m e ly a b n o r m a l p o s it io n s .
n eces
t h e p r o b le m
and
t h e d e n t u r e s f u n c t io n a s a s te n t to m a in
E x t e n s iv e c o o p e r a t io n is r e q u ir e d f r o m th e s e p a tie n ts a n d
c o n s id e r a tio n s a r e
s a r ily in c o r p o r a t e d w it h
th is h a s b e e n o b ta in e d
t a in
g ra fte d
s e c tio n s
of
t is s u e
in
co rrect
a lin e m e n t . T h e r e s t o r a t io n o f o b lit e r a t e d
in m o s t in s t a n c e s . P a t ie n t s t h a t h a v e b e e n
b u c c a l a n d la b i a l s u lc i is n e c e s s a r y to p e r
w ith o u t
m it
t im e
d e n tu re s
becom e
fo r
an d
sary
e f fo r t r e q u ir e d
to
o p e r a tio n sev eral
It
is
fro m
to
p a t ie n t s
o th e r
im p a t ie n t
w ith
th e n e c e s th e se
to
o b ta in
w ho
have
r e s u lt s
s u r g ic a l
of
s it u a
m a n ip u la te
d if f ic u lt
u n fo rtu n a te or
p e r io d th is
m a y p r e f e r to fo re g o
a p p lia n c e s .
are
lo n g
a c c u sto m e d
t io n
g ra fts
a
w it h
co had bone
m o re
lip s a n d
fre e d o m
areas.
N e a r ly
m a x illo f a c ia l
ty p e
of
a ll
s u p p o r t to
c a s u a ltie s
r e q u ir e
th e den
of
th e
o p e r a tio n s
to
re s to r e p r o p e r d e p th to th e la b ia l o r b u c cal
s u lc u s
b efo re
an d
stru c te d .
n ecessary
p ro
c a r e f u l p la n n in g
th e
m ovem en t
f la n g e s o f t h e
tu r e s g iv e p r o p e r c o n to u r a n d th e se
o p e r a tio n s
lo n g e d t y p e o f t r e a t m e n t .
in
ch eeks. T h e
T o
d e n tu re s
o b ta in and
can
be
su ccessfu l
con
r e s u lt s
g o o d ju d g m e n t a r e
n e c e s s a r y t o d e t e r m in e t h e s it e f o r t h e in
Interim D en tures fo r S u rg ica l S c a ffo ld in g
c is io n
in
o rd er
to
p ro d u ce
a
n eat
and
f u n c t io n a l s u lc u s . Som e
m eans
s u p p lie d s t o r in g
o f m a s tic a tio n
a s s o o n a s p o s s ib le m u s c u la r
m a in t a in
s h o u ld
to a id
c o o r d in a t io n
f a c ia l
e x p r e s s io n .
be
in
re
and
to
T h erefo re,
th e s e p a t ie n t s a r e c o n s id e r e d f o r d e n tu r e s lo n g
b efo re
c ed u re
has
m o st been
of
th e
s u r g ic a l
c o m p le t e d .
A n in t r a - o r a l s k in g r a f t c o n stru c t a n n ecessary fo re
o b lit e r a t e d
fo r
d e n tu re s
m e th o d
th e se can
sev ere be
(F ig .
i)
to r e
s u lc u s is u s u a l l y c a s u a ltie s
c o m p le t e d .
d e s c r ib e d b y W e is s 1 h a s b e e n
be T h e ac
p ro
F o r tu n a te ly
i. 34 :38 9
Weiss, L . R .: T h e In tra-O ral Skin G ra ft. J.A.D .A . (M arch 1 5 ) 1 9 47 .
636
The Journal of the American Dental Association
c e p te d
an d
w id e ly
c e n te rs . S in c e tia l
d e n tu re s,
p re se n te d u t iliz e d T h e
o n ly
cases
p a r t ia l
o p e r a tio n has
p a r t ia l
been
to
a fte r
f la n g e f o r t h e n e w
th e
an
w ill
to m e . T h is is a t t a c h e d
be are
s u lc u s .
m ay
a d d it io n
s u lc u s . T h e
a n u n a ffe c te d
p a rt o f th e
c o n stru c t
w h ic h
o b ta in e d f ro m
of p ar
d e n tu re s
on
d e n tu re ,
f in a l d e n t u r e
in s tr u c te d
a t m a x illo f a c ia l
d is c u s s io n
th o s e
w h ic h
th e
p ro ced u re
p r im a r y th e
in
in
u sed
t h is is a
a
fo rm
p a t ie n t is
to w e a r th e d e n tu r e fo r a t r ia l
w it h
d e n tu re
a
is
In
a b o u t tw o
m oved
an d
stru c te d
f la n g e
b r a s s w ir e
a tta c h e d h o ld
to
fo rm
a
im p r e s s io n
gage
lo o p .
o f th e
o p e r a tio n .
T h e
add ed
by
u se
of d ry
been
m ad e
in c is io n
th e
has
T h is
com pound
at
serv es th e
com pound
a tta c h e d
and
is f ir s t
h e a t. A fte r th e an d
so fte n e d
to f ill t h e
area
to
t im e
th e
s u lc u s
p r e p a r e d s u r g ic a lly , t h e d e n t u r e w it h
m o ld e d
is
com pound
th e is
c o m p le t e ly . A f t e r
le a s t
w a te r.
f iv e to
r in s e
T h e
p la c e d
can
w it h
c o m p le t e d u s u a lly
in
about
r e t a in
th e
an d
a lc o h o l
m e n ts
s k in
g ra ft,
la r g e
s u lc u s , is
fo r
p a t ie n t
in
is
w it h
ic e
an d
in
e lim in a t e d r e s in .
h o u rs.
A ll
an d of
t im e In
re
th is
is
p o s s ib le ,
th e
m ean
s h a p e o f t h e s u lc u s to p r e v e n t
d e n tu re
p rep ared
th e d e n tu re
to r e m a in
rem o v ed
sh o rte st
fo u r
a n d c h ille d , i t is g la z e d b y t h e f la m e o f a n
th e
is r e L ow -
t im e , a s e c t io n o f c o m p o u n d is m o ld e d to
of
T h e
be
th e
in
cover
d e n tu re
m o u th
is
a c r y lic
is ,
to rc h .
th e
v e s te d in s u c h a m a n n e r t h a t th e w a x a n d com pound
d e n tu re
to
T h e
h is
d e n tu re
p r o p e r ly m o ld e d
enough
p e r m it t e d
m in u t e s .
c o n tr a c tio n
th e c o m p o u n d h a s b e e n
th e
in
th o r o u g h ly .
d r ie d c o m p o u n d s e c t io n , a n d
m ad e
14
and
p la c e
f u s in g im p r e s s io n w a x is p a in t e d o v e r t h e
o p e r a t io n , s e v e r a l h o le s a r e a
d erm a
th e c o m p o u n d
it s
w e e k s th e
at
and
of a
a d h e s iv e
to
c le a n s e d
fo rt c a n b e e x p e c te d . T h e d a y b e fo re th e
area
to
s u r g ic a l
is r e in s e r t e d a n d
th e
a n d h a ir le s s
m eans
re tu rn e d
p e r io d u n t il a s s u r e d t h a t n o g r e a t d is c o m
in
by
m o u th .
be
of a
body
th e
su ch
th e
g ra ft.
m o st
r e q u ir e s as
o p e ra te d
o n ly
th in n in g area.
T h e
in s ta n c e s ,
f in a l
m in o r a d ju s t
o f th e
T h ere
r e s u lt in g th e
is
f la n g e
u s u a lly
in an
Fig. 2.— L e ft: Patient with extensive cheiloplasty showing small orifice through which impres sions must be obtained. R ig h t: U pper partial denture and lower fixed bridge selected to supply missing teeth
Emory
J.A.D.A., Vol. 35, November I, 1947 . . . 637
overcorrection in this area to permit some contraction of the graft, and the denture must be trimmed slightly. Im pression T echnic
Impression-taking is the one phase that differs to a great extent from the procedures used in routine construction of partial dentures. Access is difficult dur ing the earlier stages of treatment. This is especially true of patients undergoing cheiloplasty (Fig. 2 ). Modified trays are required that are large enough to cover the teeth and ridges. Consideration must be given to bone grafts, soft tissue grafts, palatal perforations, heavily scarred areas and extensions of the sulcus so that overextension and excessive pressure are eliminated. Obviously, the impression must be accomplished in several stages to assure adequate models of these mouths. The technic is divided into three stages: (1) the preliminary impression, (2) the secondary impression and (3) the functional rebase impression. The algi nate impression materials and compound are used for the preliminary impressions. These produce study models to be used for designing special trays which are modified in the mouth by the addition of compound for proper extension. These trays, which are loosefitting, are filled with one of the alginate materials to pro duce the secondary impression. The re sulting model is used for designing the metal framework and for articulating the teeth. The accuracy of this model is de pendent on the care taken with the de sign of the tray and its compound exten sions. Because sectional impressions are used in many of these cases, trays are made in right and left halves. An in delible pencil line is drawn across the mid-line of the palate and is readily transferred to the alginate impression material. Impressions of each side are taken, so that they overlap slightly and receive the impression of the pencil line.
This line is accentuated by a pencil trac ing. The lines are transferred from the impressions to the models and aid in alining and assembling the completed models. An occlusal record helps to as sure a true relation of the two halves. The functional rebase is necessary for all den tures constructed on sectional models and also is extremely helpful in other cases. This is considered a corrective rebase im pression and permits a maximum den ture-bearing area, which is as essential for these partial dentures as for complete dentures. The saddles can be comfortable only if they conform to the functional shape of the tissues rather than to the anatomic shape.2 This is assured by us ing a wax rebasing technic, and a pro cedure similar to that suggested by Applegate3 produces a functional impres sion of the subjacent tissues. D esign and C o n stru ctio n
The teachings and suggestions for par tial denture design by Jones,4 Schuyler,5 Applegate6 and Steffel7 have made it possible for many dentists to arrive at a practical and successful approach to the problems of these difficult dentures. Be cause of the condition of these mouths, the designing of prosthetic appliances is a difficult task. All teeth are retained as long as possible, and as few as two are used to support these dentures. For prac tical purposes, clasp retained dentures de signed for both tissue and tooth-bearing construction are always used. To permit proper distribution of stresses, as many teeth as possible are clasped. Rests, in2. G ir a rd o t, R . L ., H isto ry a n d D evelo p m en t of P a r t ia l D e n tu re D e sig n . J.A.D.A. 2 8 :1 3 9 9 (S e p te m b e r) 1941. 3. A p p le g a te , O . C ., T h e C a s t B ase D e n tu r e . J.A.D.A. 2 4 :i2 8 o (A u g u s t) 1937. 4 . Jo n e s , R . R ., A tta c h m e n ts fo r P a r t ia l D en tu res a n d A b u tm e n ts. J.A.D.A. 2 8 :4 1 0 (M a r c h ) 1941. 5. S c h u y le r , C . H ., T h e P a r t ia l D e n tu re as a M e a n s o f S ta b iliz in g A b u tm e n t T e e th . J.A.D.A. 2 8 :1 1 2 1 ( J u ly ) 19416 . A jp p legate, O . C ., U s e of th e P a r a lle lin g S u r v e y o r in M o d e rn P a r t ia l D e n tu r e D esign C o n stru c tio n . J.A.D.A. 2 7 :1 3 9 7 (S e p te m b e r ) 1940. 7. S te ffe l, V . L . S im p lifie d C lasp P a r tia l D en tu res D esign ed fo r M a x im u m F u n c tio n . J.A.D.A. 3 2 : 1093 (S e p te m b e r 1) 1945.
638
The Journal of the American Dental Association
s iv e s t a g e s o f d e n t u r e s , d e p e n d in g o n t h e e x te n t o f s u r g ic a l tr e a tm e n t. I n m a n y in s t a n c e s , i t is d e s i r a b l e t o r e t a i n t h e m o d e ls fo r re c o rd s s t r u c t io n th e
an d
fo r
p o s s ib le
w ax
reb ase
m e th o d ,
u s in g
b a s e p la t e s
a tta c h e d
to
fram e w o rk
w ith
te e th
h ard
is
w ax,
T h ese
la te r r e c o n
o f th e d e n tu r e s . F o r th is r e a s o n
th e
th e
b a s e p la t e
th e
o c c lu d e d
p referred
s a d d le s
f it a c c u r a t e l y a n d
m o ld e d
in
th e m o u th . I f th e
ap p earan ce are
are
rem o v ed
d r ie d
is n e x t
o c c lu s io n
a c c e p t a b le , th e
an d
to
to t h e d e s ir e d
o u t lin e o f t h e d e n t u r e . T h e s e tu p t r ie d
in
p ro ced u re.
are
tr im m e d
s h e lla c
c a s t- g o ld
and
d e n tu re s
c a r e f u lly .
T h e
b a s e p la t e s a r e p a in t e d o n t h e t is s u e b e a r in g s u r f a c e s w it h im p r e s s io n w a x a n d in s e r t e d
in t o
th e
m o u th
fo r th re e
h a lf m in u t e s . S e v e r a l c o r r e c tio n s q u ir e d
b efo re
g lo s s y . T h e n o r m a lly ,
an d
im p r e s s io n s h o u ld
Fig. 3.— M odels produced by sectional im pressions. M axillary m odel demonstrates a large perforation into the nasal cavity and right antrum
3
m m .
c o n n e c to rs A ll c a s e s
are
are
u sed
w henever
o f c o m b in a t io n
r ig id
p o s s ib le .
e v e n t u a lly
is ' secu red . ro u n d ed
in
an d
th ic k n e s s .
v e ste d a n d
and c lo s e
a
f u n c t io n a l
T h e
p e r ip h e r y
s h o u ld
T he
p ro cessed fro m
to
a re
be
d e n tu re
about is
in
th is s ta g e , a n d
t h e o r i g i n a l m o d e ls a r e r e t a in e d f o r la t e r u se.
d ir e c t r e t a in e r s , s tr e s s - b r e a k e r s a n d
be
are
t h e in t e r io r is s m o o th
p a t i e n t is in s t r u c t e d
re
an d
be
Z in c u sed ,
fo r th is
o x id e but
and
w ax
eugenol
has
g re a te r
p a ste s
can
f le x ib ilit y
p u rp o se.
m e t a l w it h
D iscussion o f C a s e s
a c r y lic s a d d le s to p e r m it f r e q u e n t r e b a s e s an d
T h e
c o r r e c tio n s o f f la n g e a r e a s .
M o st
p a t ie n t s
r e q u ir e
sev eral
su cces
a
m o d e ls
ty p ic a l
in
F ig u r e
c o n d it io n
3
w h ic h
d e m o n stra te r e q u ir e s
an
Fig. 4.— Stent and denture for m andibular reconstruction of condition indicated in Figure 3
J.A.D.A., Vol. 35, November I, 1947 . . . 639
Emory
o p e r a t io n o f t h e s u lc u s in b o t h a r c h e s b e
p rev en t
fo re
th e
f in a l
T h is
p a t ie n t
gro u p th e
d e n tu re s is
an
th a t h as
m a x illa
tio n
of
th e
q u ir e d ,
an d
can
be
e x a m p le
r e c e iv e d
an d
of
in ju r ie s
m a n d ib le .
u p p er th e
c o n stru c te d .
an d
in ju r y
e v e n t u a lly
w ill b e
to
b o th
r e m a in in g
m o la r s
is
an
t e r i o r p a r t o f t h e m o u t h . T h e r e i s lo s s o f
F ig u r e p le te d
tio n
in t o
a n tru m .
th e
n a s a l c a v ity
O n ly
c o m p le t e d
fo r
th e a
lo w e r d e n tu re .
s te n t w a s r e q u ir e d th e
in
a
d e n tu re
of an
in
one
o b tu r a to r to
at
a id
sh o w s
th e
m o d e ls
and
com a
has been
by m eans of an
le f t m o la r c o n stru c te d
freed o m
(F ig .
4 ).
sp eech
fo r T he
c o n s is ts and
to
g ra ft,
stru c tu re .
E nough
p r e s e n t to
m ake
an d
th e
ab
d e n t u r e w a s d e s ig n e d f o r a t o o t h - b e a r in g
a s u lc u s in
tu b e
c lo s e d
been
e x t e n s iv e
p re se n t, in
5
d e n tu r e s f o r a p a t ie n t w h o h a d
has
A n
to b e
u n it
th e
arch
th e re w a s e n o u g h
a p p lia n c e ,
as
condem ned
d o m in a l
o f m o v e m e n t o f th e lo w e r lip to a llo w
m a x illa r y
been
r ig h t
t w o s e c tio n s to p e r m it in s e r t io n . A f t e r
th e o p e r a tio n
h ave
th e
to p r e p a r e
ste n t h a d
d e n tu re
f u ll d e n tu r e
an d
a n t e r io r , r ig h t m o la r a n d
r e g io n s . T h e
th ro u g h
s im ila r c o n d it io n . T h e m a x i ll a r y p e r f o r a
p r e m a x illa r y b o n e a n d a la r g e p e r f o r a t io n b o th
a
up
m a x illa r y
fo r r e m o v a l.
re
th e
p a s s in g
T h e
la r g e
lip s
in v o lv e s
fro m
a
R e c o n stru c
lo w e r
fo o d
p e r f o r a t io n .
m a x illa r y
m a x illa r y
h a n d lin g
te e th
o f th is
are
c o n d i
tio n a r o u t in e p r o c e d u r e . C a r e w a s t a k e n to
p ro d u ce
a
good
e s t h e t ic
r e s u lt .
T h e
lo w e r d e n t u r e i s s u p p o r t e d b y o n e m o la r on each
s id e , a n d is a n
t r e m e s it u a t i< 3 $ i n
e x a m p le o f a n
w h ic h
o f a w illin g p a t ie n t a id e d c o m p le t e ly v erse
s a t is f a c t o r y
c o n d itio n s .
T h ese
ex
th e c o o p e r a tio n in
p r o d u c in g a
r e s u lt
u n d er
p a r t ia l
ad
d e n tu re s
Fig. 5.— L e ft: M odels of mouth after closure of palatal perforation for a patient with extensive injury to both arches. R ig h t: Tem porary partial dentures
640
The Journal of the American Dental Association
B o th a r c h e s a r e n o t a lw a y s in v o lv e d in th e se
sev ere
occur
to
cases. A
th e
n u m b e r o f in ju r ie s
m a x illa r y
r e g io n
in
w h ic h
t h e f a c i a l b o n e s a r e i n v o l v e d . F i g u r e 8 is a n e x a m p le o f t h is g r o u p , a n d t h e m o d e ls d e m o n stra te
th e
p e r f e c t lo w e r
arch
and
th e in ju r e d m a x illa r y a r c h w h ic h h a s o n ly tw o
m o la r s
T he
m a x illa
r e m a in in g
and
th e
has
on
been
th e
le f t
s e v e r e ly
p r e m a x illa r y
r e g io n
s id e .
in ju r e d ,
d e stro y e d .
T h e p e r f o r a t io n in t o t h e n a s a l c a v it y h a d to
be
and
c lo s e d
by
a
la r g e
g ra ft. T h e n a sa l
th e s u p e r io r la b ia l a r e a s m u s t b e r e
c o n stru c te d . im p o s s ib le
B one
in
g ra fts
th e
are
d if f ic u lt
p r e m a x illa r y
area
or be
c a u s e t h e r e is n o f a v o r a b le a n c h o r a g e a n d o n ly s o f t t is s u e g r a f t s c a n b e u s e d t o c lo s e th e d e f ic ie n t a r e a s . T h u s t h e d e n t u r e h a s o n ly a s o f t t is s u e s u p p o r t in
Fig. 6.— Cast-gold fram eworks designed to be final-type dentures fo r condition indicated in Figu re 5
r e g io n serv e
to
A
be
c o n s id e r e d
f in a l ty p e
is
ty p e s .
s ib le . A
u n d e r c o n s t r u c t io n
(F ig .
s t a b iliz e
stra te d
com m on
in
m a x illa
F ig u r e
an d
u su al an d
s it u a t io n
7. T h e
m a n d ib le
in ju r y
has
face
o n ly a n d
been
le a v e s
dem on
in ju r y
to
p re se n ts
d if f ic u lt s it u a t io n
T h e
is
to
u n
fo r d e n tu re s.
one
th e
b o th
an
s id e
of
p o s te r io r
are
m is s in g
u n in ju r e d
an d
M o re
on
th e
a n t e r io r
in ju r e d
s id e is in t a c t .
s id e , b u t
It m ay be
a
upper
has
tim e s
n ot been
p o s
s p r in g w a s s e le c t e d th e
r ig h t to
s id e , b u t
m an age
th e
to th e
den
w ill
be
p o s s ib le
a fte r
to p e r m it m o r e f r e e d o m
an
to th e
u p p e r l a b i a l t is s u e s .
th e
te e th
d am aged
o b tu ra to r m a n y
le a r n e d
s ta b ility
o p e r a tio n
U n ilateral M a n d ib u la r D entures
p a t ie n t w it h o u t
sev eral
has
a id
a n t e r io r d e n tu re s
t u r e w it h o u t a n y a d d it io n a l a tt a c h m e n t s .
u p p e r a n d lo w e r t e e t h o n t h e in ju r e d s id e . A ll
an d
th e
T h ese
b a d ly
act as an
B o o s ty p e
p a t ie n t
A n o th e r
u n s t a b le .
s u r g ic a l c lo s u r e
a s in t e r m e d ia t e
6 ).
is
su p p o rt
lip s a n d w hen
can
an d
M a n d ib u la r in ju r ie s
in
w h ic h
lo s s o f b o n e s u b s t a n c e f a l l i n t o
th e re
is
tw o la r g e
th e
g ro u p s. O n e
co
th e a n t e r io r r e g io n o f th e m a n d ib le . T h e
gro u p
has
lo s t s u b s t a n c e
in
in c id e n c e b u t m a n y o f t h e s e p a t ie n t s h a v e
d e n tu re s
h a d a lm o s t p e r f e c t t e e t h in t h e u n in ju r e d
th o s e d is c u s s e d u n d e r t h e g r o u p in w h ic h
h a lf . T h is s it u a t io n a d d e d to t h e d if f ic u lty
b o th th e m a x illa a n d m a n d ib le h a v e b e e n
in
d e s ig n
d id
not
fo r
th e
p e r m it
c la s p s , a n d
p erfect
ro o m
fo r
in t e r d ig it a t io n th e
n ecessary
e x t e n s iv e p r e p a r a t io n
h ad
to
in ju r e d
of
in
th e se
th e
are
th e
a n t e r io r r e g io n .
d e m o n stra te s com m on
cases
th e
d e n tu re s
sam e
as
F ig u r e
fo r
a
m a n d ib u la r in ju r y . I n
9
m o re
th is , o n e
b e a c c o m p lis h e d to p r o v id e r o o m f o r r e s ts
s id e o f t h e j a w
a n d c la s p s . M o s t o f t h e s e p a t ie n t s r e q u ir e
to b e o n e o f t h e la r g e s t g r o u p s . T h e s e c o n
s u lc u s
g ra fts
an d
u s u a lly
a
m a n d ib u la r
d it io n s f o llo w
is in v o lv e d . T h is a p p e a r s
a c o u r s e s im ila r to th e c o m
b o n e g r a f t . T h e s o f t tis s u e s o n t h e in ju r e d
b in e d m a x i ll a r y a n d m a n d ib u la r in ju r ie s .
s id e
M o st o f th e m
fo r
are
dependen t on
su p p o rt
T hus
th e
to
d e n tu re s
e s t h e t ic e f fe c t.
th e
re sto re are
tw o
d e n tu re s
p ro p er
f u lln e s s .
im p o r t a n t
fo r
in
th e
c a s io n a lly Som e
h a v e r e q u ir e d a b o n e g r a f t
m o la r o r b ic u s p id
of
th e th e
ram u s a n t e r io r
r e g io n , a n d
m ust
be
r e g io n
oc
r e p la c e d . is
u s u a lly
J.A.D.A., Vol. 35, November I, 1947 . . . 641
Emory
Fig. 7.— M odels and dentures for a unilateral injury to both m axilla and mandible in v o lv e d ,
in
te e th
p o s s ib ly
an d
r e m a in
on
p o s te r io r
f u n c t io n o v e r th e e n t ir e a r c h a n d b e c o m e
s e v e r a l a n t e r io r te e th
d e p e n d e n t o n t h e d e n t u r e . T h e s e p a t ie n t s
w h ic h
th e
case
o th e r
th e
s id e
to
su p p o rt
a
a r e a w a r e o f t h e ir s it u a t io n a n d h a v e h a d
d e n t u r e . A b u c c a l a n d s o m e tim e s a la b io -
an
a lv e o la r
fro m
s u lc u s
s a t is f a c t o r y i
is a n
g ra ft
d e n tu re s
e x a m p le
h as been
u sed
an d
m a in t a in
th e
have
r e q u ir e d
are
b efo re
p o s s ib le . F ig u r e
o f th is g r o u p . T h e d e n
tu re
d e n tu re s
is
as a
s te n t to
g ra fte d
p ro v ed
to
su p p o rt
area. be
T h ese
f u n c t io n a l
a n d c o m f o r t a b le a n d r e q u ir e o n ly a s lig h t m o d if ic a t io n
in
th e ir
d e s ig n
an d
e x p la n a tio n
of
d e s ig n
in
c o rp o ra te d . P a tie n ts d e n tu re s
w h ic h
a
r e s u lt s
th e in ju r e d
s id e . T h e
l a t t e r is o n e o f t h e
is
an
e x a m p le
th e re
is
even
a fte r
o n ly
r id g e
area.
of
a
c o n d it io n
enough
t r im m in g
ro o m of
in
fo r a
th e
I
w h ic h s a d d le ,
m a n d ib u la r
con
Su m m ary
s t r e s s - b r e a k e r is i n A n
(F ig .
io ') .
w it h
u n ila t e r a l
have
h a rm fu l
m o s t u n f o r t u n a t e c o m p lic a t io n s . F ig u r e
s t r u c t io n . M o s t o f th e s e d e n t u r e s r e q u ir e a
th e
e lo n g a t io n o f t h e m a x illa r y t e e t h o n
enough
s a d d le - t y p e
r e m a in in g
te e th
so m e
a tte m p t h as of
th e
been
p r o b le m s
m ade
in
th e
to
d is c u s s
m a k in g
p a r t ia l d e n tu r e s f o r p a t ie n t s w it h
of
m a x il
lo f a c ia l in ju r ie s .
Such
p r o b le m s w il l n o t
p e n d e n t o n t h e d e n t u r e o n ly f o r it s v a lu e
be
w ith
th e
a s a s t e n t f o r t h e s u lc u s g r a f t . T h e y s o o n
th e
r e a liz e t h e a d v a n t a g e s o f d is t r ib u t in g th e
im p o r ta n t
to p e r m it m a s t ic a t io n a n d
a r e a t f ir s t d e
s e t t le d
f in a lly
f ir s t d e n t u r e s
c o m p le t io n
of
s in c e
th e y
w ill r e q u ir e
a d ju s tm e n ts
an d
re c o n stru c
642
The Journal of the American Dental Association
t io n s .
M an y
p la s tic
of
su rgery
th e se fo r
m en
years
w ill
to
r e q u ir e
com e,
an d
of
th e se
th e
p e r f o r a t io n s
th e s e o p e r a tio n s w ill n e c e s s it a t e a c h a n g e
s u p p ly .
in
m o s t in s ta n c e s .
of
th e s e
num ber
as
o b tu ra to rs
d e n tu re
d e s ig n
A m ong
th e
in
la r g e
r e le a s e d
fro m
tio n s
are
in e v it a b le . S o m e
th a t
s h o u ld
th e to
be
p r o f e s s io n tre a t
s e r v ic e ,
m an y
w ho
w ill
p a t ie n t s
p a t ie n t s
c o m p lic a
o f th e
c o n s id e r e d
th e se
of
by
be
th o se
c a lle d
s h o u ld
of
upon
be
d is
c u sse d b r ie fly : i.
A ll
checked. s u r g ic a l
p a la t a l
T h o se
p e r f o r a t io n s
p a tie n ts
tre a tm e n t
m ay
s h o u ld
w ho
r e c e iv e d
h ave
a
recu r
D e n tu re s
2.
serv e
s u r g ic a l
c lo s u r e h a s
fa c to rs
is
dependen t
a m o u n t o f s o f t t is s u e to
th o s e
not been w it h
b lo o d
p ro te c t
m an y
an d
a ls o
cases
in
p o s s ib le .
f ib r o u s u n io n
is n o t p r e s e n t . T h e
p o r tio n
m ay
a
n o r m a l u s e is m a d e
m o re
becom e
m o re
c a v it y . T h is
s h o u ld
an d
b e e x p e c te d
d e n tis ts
w ho
in
m an y
have
seen
la r g e n u m b e r s o f t h e s e c o n d it io n s u n d e r sta n d
th e
p r o b le m .
Su ccess
in
c lo s u r e
a fte r
o f t h e ja w s ,
b e o n c e t h e p a t ie n t is r e le a s e d f r o m
th e h o s
p i t a l a n d is n o lo n g e r o n a s o f t d ie t . T h e d e n tu re s
in g
m ay
fo r
th e se
s p r in g
p a t ie n t s
s it u a t io n ,
an d
ro e n tg e n o g ra m s c o n s o lid a t io n 3.
P a tie n ts
up
as
are
a
w ill
th e
u n s t a b le
b r o u g h t in t o o c c lu s io n . T h is is a n
in s t a n c e s ,
f ib r o u s
e v id e n t
c o m p la in
th e n a s a l
be
e x a m in e d c a r e f u lly fo r r e a s s u r a n c e t h a t a
an d
r u n n in g in t o
act
w h ic h
b o n e g r a f t s s h o u ld
r e n c e o f t h e o p e n in g . T h e s e p a t ie n t s w ill o f f lu id
on
th e
c lo s u r e s
in
P a tie n ts
an d
te e th
are
annoy
check
w it h
new
d is c lo s e
an y
bony
p re se n t. w ho
h ave
h ad
th e
ram u s
Fig. 8.— M odels and dentures for a patient with extensive reconstruction in the prem axillary region
J.A.D.A., Vol. 35, November I, 1947 . . . 643
Emory
r e p la c e d in
th e
w it h
a r t ic u la t io n . w ill
a
r e g io n
ta k e
g ra ft h av e
o f th e It
is
p la c e .
a
f a ls e
jo in t
t e m p o r o m a n d ib u la r
c e r t a in
th a t
S e v e ral cases
changes
un d er
ob
s e r v a t io n h a v e s h o w n a t e n d e n c y to f a v o r a
new
r e la t io n
an d
th e
r e m a in in g n a t u r a l t e e t h of
th e
tru e
c e n tr ic
o c c lu s io n
o f th e
is n o t in d ic a t iv e
r e la t io n .
M u s c u la r
im b a la n c e w ill e v e n t u a lly e f f e c t a c h a n g e a n d a t t e m p t to p r o d u c e a m o r e h a r m o n i ous
a lin e m e n t .
be
u sed
to
d e te r m in e
ja w s
as
fo r
a
C e n tr ic
s ta r tin g th e
o c c lu s io n p o in t
cannot
fro m
w h ic h
n o r m a l r e la t io n
o f th e
r e p r o d u c in g
d e n tu re s
in
th e
e d e n t u lo u s a r e a . 4.
C lo s e ly
a llie d
to
la r g e
g ro u p
of
p a tie n ts
bone
g ra fts
to
th e
th e
se g m e n ts w e r e
th e se
cases
is
th a t
h ave
h ad
m a n d ib le a lin e d
by
T h is p r o c e d u r e is d o n e o f t e n n u m b ers b o th
of
of th e
r e p o s it io n e d th e re
c o u ld
p o s it io n A
jo in t
to
be
to be
it s a
tru e
r o t a t io n
fra g m e n ts
to
th e
o r ig in a l
g ra fts.
p a t ie n t s d o n o t a p p e a r to h a v e a n y c o m
la r g e
O ne
or
not be
r e la t io n ,
and
a lm o s t a n y
It
p la in ts ences
or w it h
tu rb a n c e s
is
tru e
th a t
s y m p to m s , c o m p la in t s of
th e
at
but
s h o u ld b e g iv e n
it
is
not
stu d y
and
is
to
im p o s s ib le
r e p o s i
e x p e r i
fro m
d is
a r t ic u la t io n it c a n b e p r e d ic t e d t h a t c o m w ill a r is e .
r e s u lt
fro m
th e s e
t e m p o r o m a n d ib u la r
s id e r a t io n
w it h o u t s o m e
p resen t
a r is in g
t h a t p o s s ib le m a n if e s t a t io n s m ay
r e la t io n
e s t im a t io n .
m ay
on
t io n
in m a n y o f t h e c o n d it io n s r e q u ir in g b o n e
p lic a t io n s
d is t u r b a n c e s
as
w h ic h
w hen
m is s in g . heads
th e
t h e o r i g i n a l p o s it io n .
d is m is s e d
th o u g h t,
are
o th e r th a n
p r e d ic t io n
of
te e th
c o n d y la r
in
Fig. g.— U nilateral, free-saddle type, m andibu lar partial denture. T h is type is one of the most frequently required fo r m axillofacial cases
of
th e
d e n tu re
p r o d u c e s s t r a in F ro m
as
T h erefo re
due
con
to th e b a la n c e
m u s c u la r
im b a la n c e
o n o n e s id e o r t h e o t h e r .
th e n u m b e r o f p a t ie n t s w it h t e m
Fig. 10 .— L e ft: A unilateral free-saddle type denture with a stress-breaker. R ig h t: G old fram e work attached to shellac base-tray to be used for functional rebase impression after teeth are occluded
644
The Journal of the American Denfal Association
poromandibular disturbances treated, in which the cause for the complaint is vague and yet definite discomfort or sub luxation is present, it can be estimated that many of these maxillofacial condi tions will follow a similar course. The complications will depend on the limits of accommodation present in the struc tures of the joint and the closely related structures. 5. When time permits, some ortho dontic treatment may be attempted. O c clusal readjustment may be possible and a more normal alinement will permit finer results with dentures. 6. Many of these patients will lose the remaining supporting teeth eventually, and complete dentures will be necessary. It will be observed that many operations of the sulcus will be required. Many partial dentures ’ are possible with sulci only faintly resembling normal ones, but
complete dentures will require better situations. With careful planning, these patients will be able to tolerate com plete dentures. From the number of sat isfactory results observed, the loss of the few remaining teeth is regarded as a more favorable situation for dentures. As each patient presents himself to the profession for evaluation and possible reconstruction of intra-oral appliances, a careful study of the above-mentioned points should be made, and good judg ment should be used to eliminate any causes of discomfort. If any improve ment is possible, corrections should be made to the previous design and even tually satisfaction will be attained. Such achievement is especially gratifying after one realizes that these dentures are a sign of approaching the end of a long and difficult period of treatment.— Wil
liam Beaumont General Hospital.
PENICILLIN: NEW METHODS FOR ITS USE IN DENTISTRY C . A . S c riv e n e r. D .D .S.. O tta w a . Kan., a n d C . W . S c h a n tz .* D .D .S. G r e a t Lakes, HI.
literature is replete with en cal literature encourages interest in pos thusiastic reports relative to the sible dental applications. merits of penicillin. An extensive Currently reported uses of penicillin review of the methods of administrationand the methods of its application recall of the drug shows that tentative conclu the work which we conducted at the sions have been drawn and empirical Naval Training Center in San Diego, limitations already have been established. Calif. W e observed the mouths of 25 Although the uses of penicillin in den men undergoing treatment with peni tistry have been given little consideration, cillin for gonorrheal infections before the flood of material published in medi treatment was started, during treatment and after treatment was completed, in T h e assertio n s a n d o p in io n s exp ressed in th is a r tic le a r e th o se of th e a u th o rs a n d a r e n o t to b e c o n sid ered an attempt to determine the effect of the as re fle c tin g th e v iew s of th e N a v y D e p a r tm e n t o r th e treatment on. caries susceptibility. N av y a t la r g e . * C a p ta in (D C ) U S N ; S e n io r D e n ta l O fficer, N av al W e found that, among this limited T r a in in g C e n te r. e d ic a l
M
design and maintenance of partial maxilla or mandible or both and who dentures for patients that have re have required extensive surgical recon ceived maxillofacial injuries continues struction. These patients have received to be a problem for the dental profession. numerous plastic operations, and bone As these men are released from army and grafts have been necessary. An attempt is navy hospitals it becomes apparent that always made to reconstruct the maxillary an enormous task remains to' test the in and mandibular ridge areas in such a genuity of the prosthodontists. Each of manner that dentures are possible. How these cases differs so greatly from all ever, when there is a loss of tissue, which others that general stateinents and a com must be replaced by means of a graft, parison of results have not been possible. the construction of a satisfactory denture It has been necessary to delay reports is questionable at first examination. Close until more definite conclusions could be cooperation between the plastic surgeon obtained. Reports of the prosthodontic and the prosthodontist is essential to pro treatment for maxillofacial injuries are duce denture-bearing areas that can per noticeably absent from the dental litera mit the design and construction of ap ture and the surgical aspects have re pliances that are stable, retentive and ceived most of the attention. functional. The time has arrived to compare ex Maxillofacial partial dentures present periences, and the purpose of this paper numerous problems. Each case possesses is to discuss the partial dentures for those its peculiarities and demands some impatients that have received maxillofacial provision in denture design. Simplicity is injuries. It is possible that this discussion essential, and a careful consideration of may clarify and explain some of the dif the fundamental principles established ficulties which have been encountered for routine denture construction is neces and thus enable more dentists to continue sary to obtain the desired results. The the treatment of these patients. The pa technical planning and designing will tients have been concerned about their meet with success only if established and future treatments and each one expresses accepted methods are followed faithfully. the hope that he will be furnished dental Compromise methods will be found lack attention after separation. ing in some detail, and only a maximum effort to meet the situation will produce M axillo facial P artial D en tures appliances that can be considered defini tive dentures for the present stage of . The discussion will be limited to those treatment. patients who have lost substance in either The function of routine dentures is to P re se n te d a s a c lin ic a l d e m o n stratio n to t h e £1 Paso reestablish mastication, to restore esthetic T e x a s D is tric t D e n ta l S o c ie ty , th e d e n ta l officers of F o r t B liss, B ig g s F ie ld a n d W illia m B e a u m o n t G en eral appearance and to offer comfortable H o sp ita l a t W illia m B e a u m o n t G e n e ra l H o s p ita l, El P aso , T e x a s , F e b r u a r y u , 1947. wear, whereas maxillofacial dentures M a jo r (D C ) U .S .A ., C h ie f of P ro s th e tic S e c tio n , must fill bone and soft tissue defects, W illia m B ea u m o n t G e n e ra l H o sp ita l. h e
T
634
Emory
J.A.D.A., Vol. 35, November I, 1947 . . . 635
Fig. /.•—L e ft: Intra-oral epithelial graft fo r a sulcus extension. R ig h t: Partial denture used to maintain shape of sulcus
cover
p a la t a l
p e r f o r a t io n s
an d
re sto re
th e s e m e n r e q u ir e s e v e r a l a p p lia n c e s s u c h
c o n t o u r t o o t h e r w is e u n s u p p o r t e d t is s u e s ,
a s s te n ts , w h ic h
in
t e r im
a d d it io n
to t h e o r d in a r y r e q u ir e m e n t s .
act
as te m p o ra ry
d e n tu re s, a n d
o r in
t h e p a t ie n t d e v e lo p s
T h is m u s t b e a c c o m p lis h e d o v e r d e n t u r e -
s o m e o f th e h a b its n e c e s s a r y to w e a r d e n
b e a r in g
t u r e s . C o s m e t ic
areas
r e g u la r w it h
th a t
are
d e f ic ie n t
and
ir
th e r e m a in in g te e th o c c u p y
in g e x t r e m e ly a b n o r m a l p o s it io n s .
n eces
t h e p r o b le m
and
t h e d e n t u r e s f u n c t io n a s a s te n t to m a in
E x t e n s iv e c o o p e r a t io n is r e q u ir e d f r o m th e s e p a tie n ts a n d
c o n s id e r a tio n s a r e
s a r ily in c o r p o r a t e d w it h
th is h a s b e e n o b ta in e d
t a in
g ra fte d
s e c tio n s
of
t is s u e
in
co rrect
a lin e m e n t . T h e r e s t o r a t io n o f o b lit e r a t e d
in m o s t in s t a n c e s . P a t ie n t s t h a t h a v e b e e n
b u c c a l a n d la b i a l s u lc i is n e c e s s a r y to p e r
w ith o u t
m it
t im e
d e n tu re s
becom e
fo r
an d
sary
e f fo r t r e q u ir e d
to
o p e r a tio n sev eral
It
is
fro m
to
p a t ie n t s
o th e r
im p a t ie n t
w ith
th e n e c e s th e se
to
o b ta in
w ho
have
r e s u lt s
s u r g ic a l
of
s it u a
m a n ip u la te
d if f ic u lt
u n fo rtu n a te or
p e r io d th is
m a y p r e f e r to fo re g o
a p p lia n c e s .
are
lo n g
a c c u sto m e d
t io n
g ra fts
a
w it h
co had bone
m o re
lip s a n d
fre e d o m
areas.
N e a r ly
m a x illo f a c ia l
ty p e
of
a ll
s u p p o r t to
c a s u a ltie s
r e q u ir e
th e den
of
th e
o p e r a tio n s
to
re s to r e p r o p e r d e p th to th e la b ia l o r b u c cal
s u lc u s
b efo re
an d
stru c te d .
n ecessary
p ro
c a r e f u l p la n n in g
th e
m ovem en t
f la n g e s o f t h e
tu r e s g iv e p r o p e r c o n to u r a n d th e se
o p e r a tio n s
lo n g e d t y p e o f t r e a t m e n t .
in
ch eeks. T h e
T o
d e n tu re s
o b ta in and
can
be
su ccessfu l
con
r e s u lt s
g o o d ju d g m e n t a r e
n e c e s s a r y t o d e t e r m in e t h e s it e f o r t h e in
Interim D en tures fo r S u rg ica l S c a ffo ld in g
c is io n
in
o rd er
to
p ro d u ce
a
n eat
and
f u n c t io n a l s u lc u s . Som e
m eans
s u p p lie d s t o r in g
o f m a s tic a tio n
a s s o o n a s p o s s ib le m u s c u la r
m a in t a in
s h o u ld
to a id
c o o r d in a t io n
f a c ia l
e x p r e s s io n .
be
in
re
and
to
T h erefo re,
th e s e p a t ie n t s a r e c o n s id e r e d f o r d e n tu r e s lo n g
b efo re
c ed u re
has
m o st been
of
th e
s u r g ic a l
c o m p le t e d .
A n in t r a - o r a l s k in g r a f t c o n stru c t a n n ecessary fo re
o b lit e r a t e d
fo r
d e n tu re s
m e th o d
th e se can
sev ere be
(F ig .
i)
to r e
s u lc u s is u s u a l l y c a s u a ltie s
c o m p le t e d .
d e s c r ib e d b y W e is s 1 h a s b e e n
be T h e ac
p ro
F o r tu n a te ly
i. 34 :38 9
Weiss, L . R .: T h e In tra-O ral Skin G ra ft. J.A.D .A . (M arch 1 5 ) 1 9 47 .
636
The Journal of the American Dental Association
c e p te d
an d
w id e ly
c e n te rs . S in c e tia l
d e n tu re s,
p re se n te d u t iliz e d T h e
o n ly
cases
p a r t ia l
o p e r a tio n has
p a r t ia l
been
to
a fte r
f la n g e f o r t h e n e w
th e
an
w ill
to m e . T h is is a t t a c h e d
be are
s u lc u s .
m ay
a d d it io n
s u lc u s . T h e
a n u n a ffe c te d
p a rt o f th e
c o n stru c t
w h ic h
o b ta in e d f ro m
of p ar
d e n tu re s
on
d e n tu re ,
f in a l d e n t u r e
in s tr u c te d
a t m a x illo f a c ia l
d is c u s s io n
th o s e
w h ic h
th e
p ro ced u re
p r im a r y th e
in
in
u sed
t h is is a
a
fo rm
p a t ie n t is
to w e a r th e d e n tu r e fo r a t r ia l
w it h
d e n tu re
a
is
In
a b o u t tw o
m oved
an d
stru c te d
f la n g e
b r a s s w ir e
a tta c h e d h o ld
to
fo rm
a
im p r e s s io n
gage
lo o p .
o f th e
o p e r a tio n .
T h e
add ed
by
u se
of d ry
been
m ad e
in c is io n
th e
has
T h is
com pound
at
serv es th e
com pound
a tta c h e d
and
is f ir s t
h e a t. A fte r th e an d
so fte n e d
to f ill t h e
area
to
t im e
th e
s u lc u s
p r e p a r e d s u r g ic a lly , t h e d e n t u r e w it h
m o ld e d
is
com pound
th e is
c o m p le t e ly . A f t e r
le a s t
w a te r.
f iv e to
r in s e
T h e
p la c e d
can
w it h
c o m p le t e d u s u a lly
in
about
r e t a in
th e
an d
a lc o h o l
m e n ts
s k in
g ra ft,
la r g e
s u lc u s , is
fo r
p a t ie n t
in
is
w it h
ic e
an d
in
e lim in a t e d r e s in .
h o u rs.
A ll
an d of
t im e In
re
th is
is
p o s s ib le ,
th e
m ean
s h a p e o f t h e s u lc u s to p r e v e n t
d e n tu re
p rep ared
th e d e n tu re
to r e m a in
rem o v ed
sh o rte st
fo u r
a n d c h ille d , i t is g la z e d b y t h e f la m e o f a n
th e
is r e L ow -
t im e , a s e c t io n o f c o m p o u n d is m o ld e d to
of
T h e
be
th e
in
cover
d e n tu re
m o u th
is
a c r y lic
is ,
to rc h .
th e
v e s te d in s u c h a m a n n e r t h a t th e w a x a n d com pound
d e n tu re
to
T h e
h is
d e n tu re
p r o p e r ly m o ld e d
enough
p e r m it t e d
m in u t e s .
c o n tr a c tio n
th e c o m p o u n d h a s b e e n
th e
in
th o r o u g h ly .
d r ie d c o m p o u n d s e c t io n , a n d
m ad e
14
and
p la c e
f u s in g im p r e s s io n w a x is p a in t e d o v e r t h e
o p e r a t io n , s e v e r a l h o le s a r e a
d erm a
th e c o m p o u n d
it s
w e e k s th e
at
and
of a
a d h e s iv e
to
c le a n s e d
fo rt c a n b e e x p e c te d . T h e d a y b e fo re th e
area
to
s u r g ic a l
is r e in s e r t e d a n d
th e
a n d h a ir le s s
m eans
re tu rn e d
p e r io d u n t il a s s u r e d t h a t n o g r e a t d is c o m
in
by
m o u th .
be
of a
body
th e
su ch
th e
g ra ft.
m o st
r e q u ir e s as
o p e ra te d
o n ly
th in n in g area.
T h e
in s ta n c e s ,
f in a l
m in o r a d ju s t
o f th e
T h ere
r e s u lt in g th e
is
f la n g e
u s u a lly
in an
Fig. 2.— L e ft: Patient with extensive cheiloplasty showing small orifice through which impres sions must be obtained. R ig h t: U pper partial denture and lower fixed bridge selected to supply missing teeth
Emory
J.A.D.A., Vol. 35, November I, 1947 . . . 637
overcorrection in this area to permit some contraction of the graft, and the denture must be trimmed slightly. Im pression T echnic
Impression-taking is the one phase that differs to a great extent from the procedures used in routine construction of partial dentures. Access is difficult dur ing the earlier stages of treatment. This is especially true of patients undergoing cheiloplasty (Fig. 2 ). Modified trays are required that are large enough to cover the teeth and ridges. Consideration must be given to bone grafts, soft tissue grafts, palatal perforations, heavily scarred areas and extensions of the sulcus so that overextension and excessive pressure are eliminated. Obviously, the impression must be accomplished in several stages to assure adequate models of these mouths. The technic is divided into three stages: (1) the preliminary impression, (2) the secondary impression and (3) the functional rebase impression. The algi nate impression materials and compound are used for the preliminary impressions. These produce study models to be used for designing special trays which are modified in the mouth by the addition of compound for proper extension. These trays, which are loosefitting, are filled with one of the alginate materials to pro duce the secondary impression. The re sulting model is used for designing the metal framework and for articulating the teeth. The accuracy of this model is de pendent on the care taken with the de sign of the tray and its compound exten sions. Because sectional impressions are used in many of these cases, trays are made in right and left halves. An in delible pencil line is drawn across the mid-line of the palate and is readily transferred to the alginate impression material. Impressions of each side are taken, so that they overlap slightly and receive the impression of the pencil line.
This line is accentuated by a pencil trac ing. The lines are transferred from the impressions to the models and aid in alining and assembling the completed models. An occlusal record helps to as sure a true relation of the two halves. The functional rebase is necessary for all den tures constructed on sectional models and also is extremely helpful in other cases. This is considered a corrective rebase im pression and permits a maximum den ture-bearing area, which is as essential for these partial dentures as for complete dentures. The saddles can be comfortable only if they conform to the functional shape of the tissues rather than to the anatomic shape.2 This is assured by us ing a wax rebasing technic, and a pro cedure similar to that suggested by Applegate3 produces a functional impres sion of the subjacent tissues. D esign and C o n stru ctio n
The teachings and suggestions for par tial denture design by Jones,4 Schuyler,5 Applegate6 and Steffel7 have made it possible for many dentists to arrive at a practical and successful approach to the problems of these difficult dentures. Be cause of the condition of these mouths, the designing of prosthetic appliances is a difficult task. All teeth are retained as long as possible, and as few as two are used to support these dentures. For prac tical purposes, clasp retained dentures de signed for both tissue and tooth-bearing construction are always used. To permit proper distribution of stresses, as many teeth as possible are clasped. Rests, in2. G ir a rd o t, R . L ., H isto ry a n d D evelo p m en t of P a r t ia l D e n tu re D e sig n . J.A.D.A. 2 8 :1 3 9 9 (S e p te m b e r) 1941. 3. A p p le g a te , O . C ., T h e C a s t B ase D e n tu r e . J.A.D.A. 2 4 :i2 8 o (A u g u s t) 1937. 4 . Jo n e s , R . R ., A tta c h m e n ts fo r P a r t ia l D en tu res a n d A b u tm e n ts. J.A.D.A. 2 8 :4 1 0 (M a r c h ) 1941. 5. S c h u y le r , C . H ., T h e P a r t ia l D e n tu re as a M e a n s o f S ta b iliz in g A b u tm e n t T e e th . J.A.D.A. 2 8 :1 1 2 1 ( J u ly ) 19416 . A jp p legate, O . C ., U s e of th e P a r a lle lin g S u r v e y o r in M o d e rn P a r t ia l D e n tu r e D esign C o n stru c tio n . J.A.D.A. 2 7 :1 3 9 7 (S e p te m b e r ) 1940. 7. S te ffe l, V . L . S im p lifie d C lasp P a r tia l D en tu res D esign ed fo r M a x im u m F u n c tio n . J.A.D.A. 3 2 : 1093 (S e p te m b e r 1) 1945.
638
The Journal of the American Dental Association
s iv e s t a g e s o f d e n t u r e s , d e p e n d in g o n t h e e x te n t o f s u r g ic a l tr e a tm e n t. I n m a n y in s t a n c e s , i t is d e s i r a b l e t o r e t a i n t h e m o d e ls fo r re c o rd s s t r u c t io n th e
an d
fo r
p o s s ib le
w ax
reb ase
m e th o d ,
u s in g
b a s e p la t e s
a tta c h e d
to
fram e w o rk
w ith
te e th
h ard
is
w ax,
T h ese
la te r r e c o n
o f th e d e n tu r e s . F o r th is r e a s o n
th e
th e
b a s e p la t e
th e
o c c lu d e d
p referred
s a d d le s
f it a c c u r a t e l y a n d
m o ld e d
in
th e m o u th . I f th e
ap p earan ce are
are
rem o v ed
d r ie d
is n e x t
o c c lu s io n
a c c e p t a b le , th e
an d
to
to t h e d e s ir e d
o u t lin e o f t h e d e n t u r e . T h e s e tu p t r ie d
in
p ro ced u re.
are
tr im m e d
s h e lla c
c a s t- g o ld
and
d e n tu re s
c a r e f u lly .
T h e
b a s e p la t e s a r e p a in t e d o n t h e t is s u e b e a r in g s u r f a c e s w it h im p r e s s io n w a x a n d in s e r t e d
in t o
th e
m o u th
fo r th re e
h a lf m in u t e s . S e v e r a l c o r r e c tio n s q u ir e d
b efo re
g lo s s y . T h e n o r m a lly ,
an d
im p r e s s io n s h o u ld
Fig. 3.— M odels produced by sectional im pressions. M axillary m odel demonstrates a large perforation into the nasal cavity and right antrum
3
m m .
c o n n e c to rs A ll c a s e s
are
are
u sed
w henever
o f c o m b in a t io n
r ig id
p o s s ib le .
e v e n t u a lly
is ' secu red . ro u n d ed
in
an d
th ic k n e s s .
v e ste d a n d
and c lo s e
a
f u n c t io n a l
T h e
p e r ip h e r y
s h o u ld
T he
p ro cessed fro m
to
a re
be
d e n tu re
about is
in
th is s ta g e , a n d
t h e o r i g i n a l m o d e ls a r e r e t a in e d f o r la t e r u se.
d ir e c t r e t a in e r s , s tr e s s - b r e a k e r s a n d
be
are
t h e in t e r io r is s m o o th
p a t i e n t is in s t r u c t e d
re
an d
be
Z in c u sed ,
fo r th is
o x id e but
and
w ax
eugenol
has
g re a te r
p a ste s
can
f le x ib ilit y
p u rp o se.
m e t a l w it h
D iscussion o f C a s e s
a c r y lic s a d d le s to p e r m it f r e q u e n t r e b a s e s an d
T h e
c o r r e c tio n s o f f la n g e a r e a s .
M o st
p a t ie n t s
r e q u ir e
sev eral
su cces
a
m o d e ls
ty p ic a l
in
F ig u r e
c o n d it io n
3
w h ic h
d e m o n stra te r e q u ir e s
an
Fig. 4.— Stent and denture for m andibular reconstruction of condition indicated in Figure 3
J.A.D.A., Vol. 35, November I, 1947 . . . 639
Emory
o p e r a t io n o f t h e s u lc u s in b o t h a r c h e s b e
p rev en t
fo re
th e
f in a l
T h is
p a t ie n t
gro u p th e
d e n tu re s is
an
th a t h as
m a x illa
tio n
of
th e
q u ir e d ,
an d
can
be
e x a m p le
r e c e iv e d
an d
of
in ju r ie s
m a n d ib le .
u p p er th e
c o n stru c te d .
an d
in ju r y
e v e n t u a lly
w ill b e
to
b o th
r e m a in in g
m o la r s
is
an
t e r i o r p a r t o f t h e m o u t h . T h e r e i s lo s s o f
F ig u r e p le te d
tio n
in t o
a n tru m .
th e
n a s a l c a v ity
O n ly
c o m p le t e d
fo r
th e a
lo w e r d e n tu re .
s te n t w a s r e q u ir e d th e
in
a
d e n tu re
of an
in
one
o b tu r a to r to
at
a id
sh o w s
th e
m o d e ls
and
com a
has been
by m eans of an
le f t m o la r c o n stru c te d
freed o m
(F ig .
4 ).
sp eech
fo r T he
c o n s is ts and
to
g ra ft,
stru c tu re .
E nough
p r e s e n t to
m ake
an d
th e
ab
d e n t u r e w a s d e s ig n e d f o r a t o o t h - b e a r in g
a s u lc u s in
tu b e
c lo s e d
been
e x t e n s iv e
p re se n t, in
5
d e n tu r e s f o r a p a t ie n t w h o h a d
has
A n
to b e
u n it
th e
arch
th e re w a s e n o u g h
a p p lia n c e ,
as
condem ned
d o m in a l
o f m o v e m e n t o f th e lo w e r lip to a llo w
m a x illa r y
been
r ig h t
t w o s e c tio n s to p e r m it in s e r t io n . A f t e r
th e o p e r a tio n
h ave
th e
to p r e p a r e
ste n t h a d
d e n tu re
f u ll d e n tu r e
an d
a n t e r io r , r ig h t m o la r a n d
r e g io n s . T h e
th ro u g h
s im ila r c o n d it io n . T h e m a x i ll a r y p e r f o r a
p r e m a x illa r y b o n e a n d a la r g e p e r f o r a t io n b o th
a
up
m a x illa r y
fo r r e m o v a l.
re
th e
p a s s in g
T h e
la r g e
lip s
in v o lv e s
fro m
a
R e c o n stru c
lo w e r
fo o d
p e r f o r a t io n .
m a x illa r y
m a x illa r y
h a n d lin g
te e th
o f th is
are
c o n d i
tio n a r o u t in e p r o c e d u r e . C a r e w a s t a k e n to
p ro d u ce
a
good
e s t h e t ic
r e s u lt .
T h e
lo w e r d e n t u r e i s s u p p o r t e d b y o n e m o la r on each
s id e , a n d is a n
t r e m e s it u a t i< 3 $ i n
e x a m p le o f a n
w h ic h
o f a w illin g p a t ie n t a id e d c o m p le t e ly v erse
s a t is f a c t o r y
c o n d itio n s .
T h ese
ex
th e c o o p e r a tio n in
p r o d u c in g a
r e s u lt
u n d er
p a r t ia l
ad
d e n tu re s
Fig. 5.— L e ft: M odels of mouth after closure of palatal perforation for a patient with extensive injury to both arches. R ig h t: Tem porary partial dentures
640
The Journal of the American Dental Association
B o th a r c h e s a r e n o t a lw a y s in v o lv e d in th e se
sev ere
occur
to
cases. A
th e
n u m b e r o f in ju r ie s
m a x illa r y
r e g io n
in
w h ic h
t h e f a c i a l b o n e s a r e i n v o l v e d . F i g u r e 8 is a n e x a m p le o f t h is g r o u p , a n d t h e m o d e ls d e m o n stra te
th e
p e r f e c t lo w e r
arch
and
th e in ju r e d m a x illa r y a r c h w h ic h h a s o n ly tw o
m o la r s
T he
m a x illa
r e m a in in g
and
th e
has
on
been
th e
le f t
s e v e r e ly
p r e m a x illa r y
r e g io n
s id e .
in ju r e d ,
d e stro y e d .
T h e p e r f o r a t io n in t o t h e n a s a l c a v it y h a d to
be
and
c lo s e d
by
a
la r g e
g ra ft. T h e n a sa l
th e s u p e r io r la b ia l a r e a s m u s t b e r e
c o n stru c te d . im p o s s ib le
B one
in
g ra fts
th e
are
d if f ic u lt
p r e m a x illa r y
area
or be
c a u s e t h e r e is n o f a v o r a b le a n c h o r a g e a n d o n ly s o f t t is s u e g r a f t s c a n b e u s e d t o c lo s e th e d e f ic ie n t a r e a s . T h u s t h e d e n t u r e h a s o n ly a s o f t t is s u e s u p p o r t in
Fig. 6.— Cast-gold fram eworks designed to be final-type dentures fo r condition indicated in Figu re 5
r e g io n serv e
to
A
be
c o n s id e r e d
f in a l ty p e
is
ty p e s .
s ib le . A
u n d e r c o n s t r u c t io n
(F ig .
s t a b iliz e
stra te d
com m on
in
m a x illa
F ig u r e
an d
u su al an d
s it u a t io n
7. T h e
m a n d ib le
in ju r y
has
face
o n ly a n d
been
le a v e s
dem on
in ju r y
to
p re se n ts
d if f ic u lt s it u a t io n
T h e
is
to
u n
fo r d e n tu re s.
one
th e
b o th
an
s id e
of
p o s te r io r
are
m is s in g
u n in ju r e d
an d
M o re
on
th e
a n t e r io r
in ju r e d
s id e is in t a c t .
s id e , b u t
It m ay be
a
upper
has
tim e s
n ot been
p o s
s p r in g w a s s e le c t e d th e
r ig h t to
s id e , b u t
m an age
th e
to th e
den
w ill
be
p o s s ib le
a fte r
to p e r m it m o r e f r e e d o m
an
to th e
u p p e r l a b i a l t is s u e s .
th e
te e th
d am aged
o b tu ra to r m a n y
le a r n e d
s ta b ility
o p e r a tio n
U n ilateral M a n d ib u la r D entures
p a t ie n t w it h o u t
sev eral
has
a id
a n t e r io r d e n tu re s
t u r e w it h o u t a n y a d d it io n a l a tt a c h m e n t s .
u p p e r a n d lo w e r t e e t h o n t h e in ju r e d s id e . A ll
an d
th e
T h ese
b a d ly
act as an
B o o s ty p e
p a t ie n t
A n o th e r
u n s t a b le .
s u r g ic a l c lo s u r e
a s in t e r m e d ia t e
6 ).
is
su p p o rt
lip s a n d w hen
can
an d
M a n d ib u la r in ju r ie s
in
w h ic h
lo s s o f b o n e s u b s t a n c e f a l l i n t o
th e re
is
tw o la r g e
th e
g ro u p s. O n e
co
th e a n t e r io r r e g io n o f th e m a n d ib le . T h e
gro u p
has
lo s t s u b s t a n c e
in
in c id e n c e b u t m a n y o f t h e s e p a t ie n t s h a v e
d e n tu re s
h a d a lm o s t p e r f e c t t e e t h in t h e u n in ju r e d
th o s e d is c u s s e d u n d e r t h e g r o u p in w h ic h
h a lf . T h is s it u a t io n a d d e d to t h e d if f ic u lty
b o th th e m a x illa a n d m a n d ib le h a v e b e e n
in
d e s ig n
d id
not
fo r
th e
p e r m it
c la s p s , a n d
p erfect
ro o m
fo r
in t e r d ig it a t io n th e
n ecessary
e x t e n s iv e p r e p a r a t io n
h ad
to
in ju r e d
of
in
th e se
th e
are
th e
a n t e r io r r e g io n .
d e m o n stra te s com m on
cases
th e
d e n tu re s
sam e
as
F ig u r e
fo r
a
m a n d ib u la r in ju r y . I n
9
m o re
th is , o n e
b e a c c o m p lis h e d to p r o v id e r o o m f o r r e s ts
s id e o f t h e j a w
a n d c la s p s . M o s t o f t h e s e p a t ie n t s r e q u ir e
to b e o n e o f t h e la r g e s t g r o u p s . T h e s e c o n
s u lc u s
g ra fts
an d
u s u a lly
a
m a n d ib u la r
d it io n s f o llo w
is in v o lv e d . T h is a p p e a r s
a c o u r s e s im ila r to th e c o m
b o n e g r a f t . T h e s o f t tis s u e s o n t h e in ju r e d
b in e d m a x i ll a r y a n d m a n d ib u la r in ju r ie s .
s id e
M o st o f th e m
fo r
are
dependen t on
su p p o rt
T hus
th e
to
d e n tu re s
e s t h e t ic e f fe c t.
th e
re sto re are
tw o
d e n tu re s
p ro p er
f u lln e s s .
im p o r t a n t
fo r
in
th e
c a s io n a lly Som e
h a v e r e q u ir e d a b o n e g r a f t
m o la r o r b ic u s p id
of
th e th e
ram u s a n t e r io r
r e g io n , a n d
m ust
be
r e g io n
oc
r e p la c e d . is
u s u a lly
J.A.D.A., Vol. 35, November I, 1947 . . . 641
Emory
Fig. 7.— M odels and dentures for a unilateral injury to both m axilla and mandible in v o lv e d ,
in
te e th
p o s s ib ly
an d
r e m a in
on
p o s te r io r
f u n c t io n o v e r th e e n t ir e a r c h a n d b e c o m e
s e v e r a l a n t e r io r te e th
d e p e n d e n t o n t h e d e n t u r e . T h e s e p a t ie n t s
w h ic h
th e
case
o th e r
th e
s id e
to
su p p o rt
a
a r e a w a r e o f t h e ir s it u a t io n a n d h a v e h a d
d e n t u r e . A b u c c a l a n d s o m e tim e s a la b io -
an
a lv e o la r
fro m
s u lc u s
s a t is f a c t o r y i
is a n
g ra ft
d e n tu re s
e x a m p le
h as been
u sed
an d
m a in t a in
th e
have
r e q u ir e d
are
b efo re
p o s s ib le . F ig u r e
o f th is g r o u p . T h e d e n
tu re
d e n tu re s
is
as a
s te n t to
g ra fte d
p ro v ed
to
su p p o rt
area. be
T h ese
f u n c t io n a l
a n d c o m f o r t a b le a n d r e q u ir e o n ly a s lig h t m o d if ic a t io n
in
th e ir
d e s ig n
an d
e x p la n a tio n
of
d e s ig n
in
c o rp o ra te d . P a tie n ts d e n tu re s
w h ic h
a
r e s u lt s
th e in ju r e d
s id e . T h e
l a t t e r is o n e o f t h e
is
an
e x a m p le
th e re
is
even
a fte r
o n ly
r id g e
area.
of
a
c o n d it io n
enough
t r im m in g
ro o m of
in
fo r a
th e
I
w h ic h s a d d le ,
m a n d ib u la r
con
Su m m ary
s t r e s s - b r e a k e r is i n A n
(F ig .
io ') .
w it h
u n ila t e r a l
have
h a rm fu l
m o s t u n f o r t u n a t e c o m p lic a t io n s . F ig u r e
s t r u c t io n . M o s t o f th e s e d e n t u r e s r e q u ir e a
th e
e lo n g a t io n o f t h e m a x illa r y t e e t h o n
enough
s a d d le - t y p e
r e m a in in g
te e th
so m e
a tte m p t h as of
th e
been
p r o b le m s
m ade
in
th e
to
d is c u s s
m a k in g
p a r t ia l d e n tu r e s f o r p a t ie n t s w it h
of
m a x il
lo f a c ia l in ju r ie s .
Such
p r o b le m s w il l n o t
p e n d e n t o n t h e d e n t u r e o n ly f o r it s v a lu e
be
w ith
th e
a s a s t e n t f o r t h e s u lc u s g r a f t . T h e y s o o n
th e
r e a liz e t h e a d v a n t a g e s o f d is t r ib u t in g th e
im p o r ta n t
to p e r m it m a s t ic a t io n a n d
a r e a t f ir s t d e
s e t t le d
f in a lly
f ir s t d e n t u r e s
c o m p le t io n
of
s in c e
th e y
w ill r e q u ir e
a d ju s tm e n ts
an d
re c o n stru c
642
The Journal of the American Dental Association
t io n s .
M an y
p la s tic
of
su rgery
th e se fo r
m en
years
w ill
to
r e q u ir e
com e,
an d
of
th e se
th e
p e r f o r a t io n s
th e s e o p e r a tio n s w ill n e c e s s it a t e a c h a n g e
s u p p ly .
in
m o s t in s ta n c e s .
of
th e s e
num ber
as
o b tu ra to rs
d e n tu re
d e s ig n
A m ong
th e
in
la r g e
r e le a s e d
fro m
tio n s
are
in e v it a b le . S o m e
th a t
s h o u ld
th e to
be
p r o f e s s io n tre a t
s e r v ic e ,
m an y
w ho
w ill
p a t ie n t s
p a t ie n t s
c o m p lic a
o f th e
c o n s id e r e d
th e se
of
by
be
th o se
c a lle d
s h o u ld
of
upon
be
d is
c u sse d b r ie fly : i.
A ll
checked. s u r g ic a l
p a la t a l
T h o se
p e r f o r a t io n s
p a tie n ts
tre a tm e n t
m ay
s h o u ld
w ho
r e c e iv e d
h ave
a
recu r
D e n tu re s
2.
serv e
s u r g ic a l
c lo s u r e h a s
fa c to rs
is
dependen t
a m o u n t o f s o f t t is s u e to
th o s e
not been w it h
b lo o d
p ro te c t
m an y
an d
a ls o
cases
in
p o s s ib le .
f ib r o u s u n io n
is n o t p r e s e n t . T h e
p o r tio n
m ay
a
n o r m a l u s e is m a d e
m o re
becom e
m o re
c a v it y . T h is
s h o u ld
an d
b e e x p e c te d
d e n tis ts
w ho
in
m an y
have
seen
la r g e n u m b e r s o f t h e s e c o n d it io n s u n d e r sta n d
th e
p r o b le m .
Su ccess
in
c lo s u r e
a fte r
o f t h e ja w s ,
b e o n c e t h e p a t ie n t is r e le a s e d f r o m
th e h o s
p i t a l a n d is n o lo n g e r o n a s o f t d ie t . T h e d e n tu re s
in g
m ay
fo r
th e se
s p r in g
p a t ie n t s
s it u a t io n ,
an d
ro e n tg e n o g ra m s c o n s o lid a t io n 3.
P a tie n ts
up
as
are
a
w ill
th e
u n s t a b le
b r o u g h t in t o o c c lu s io n . T h is is a n
in s t a n c e s ,
f ib r o u s
e v id e n t
c o m p la in
th e n a s a l
be
e x a m in e d c a r e f u lly fo r r e a s s u r a n c e t h a t a
an d
r u n n in g in t o
act
w h ic h
b o n e g r a f t s s h o u ld
r e n c e o f t h e o p e n in g . T h e s e p a t ie n t s w ill o f f lu id
on
th e
c lo s u r e s
in
P a tie n ts
an d
te e th
are
annoy
check
w it h
new
d is c lo s e
an y
bony
p re se n t. w ho
h ave
h ad
th e
ram u s
Fig. 8.— M odels and dentures for a patient with extensive reconstruction in the prem axillary region
J.A.D.A., Vol. 35, November I, 1947 . . . 643
Emory
r e p la c e d in
th e
w it h
a r t ic u la t io n . w ill
a
r e g io n
ta k e
g ra ft h av e
o f th e It
is
p la c e .
a
f a ls e
jo in t
t e m p o r o m a n d ib u la r
c e r t a in
th a t
S e v e ral cases
changes
un d er
ob
s e r v a t io n h a v e s h o w n a t e n d e n c y to f a v o r a
new
r e la t io n
an d
th e
r e m a in in g n a t u r a l t e e t h of
th e
tru e
c e n tr ic
o c c lu s io n
o f th e
is n o t in d ic a t iv e
r e la t io n .
M u s c u la r
im b a la n c e w ill e v e n t u a lly e f f e c t a c h a n g e a n d a t t e m p t to p r o d u c e a m o r e h a r m o n i ous
a lin e m e n t .
be
u sed
to
d e te r m in e
ja w s
as
fo r
a
C e n tr ic
s ta r tin g th e
o c c lu s io n p o in t
cannot
fro m
w h ic h
n o r m a l r e la t io n
o f th e
r e p r o d u c in g
d e n tu re s
in
th e
e d e n t u lo u s a r e a . 4.
C lo s e ly
a llie d
to
la r g e
g ro u p
of
p a tie n ts
bone
g ra fts
to
th e
th e
se g m e n ts w e r e
th e se
cases
is
th a t
h ave
h ad
m a n d ib le a lin e d
by
T h is p r o c e d u r e is d o n e o f t e n n u m b ers b o th
of
of th e
r e p o s it io n e d th e re
c o u ld
p o s it io n A
jo in t
to
be
to be
it s a
tru e
r o t a t io n
fra g m e n ts
to
th e
o r ig in a l
g ra fts.
p a t ie n t s d o n o t a p p e a r to h a v e a n y c o m
la r g e
O ne
or
not be
r e la t io n ,
and
a lm o s t a n y
It
p la in ts ences
or w it h
tu rb a n c e s
is
tru e
th a t
s y m p to m s , c o m p la in t s of
th e
at
but
s h o u ld b e g iv e n
it
is
not
stu d y
and
is
to
im p o s s ib le
r e p o s i
e x p e r i
fro m
d is
a r t ic u la t io n it c a n b e p r e d ic t e d t h a t c o m w ill a r is e .
r e s u lt
fro m
th e s e
t e m p o r o m a n d ib u la r
s id e r a t io n
w it h o u t s o m e
p resen t
a r is in g
t h a t p o s s ib le m a n if e s t a t io n s m ay
r e la t io n
e s t im a t io n .
m ay
on
t io n
in m a n y o f t h e c o n d it io n s r e q u ir in g b o n e
p lic a t io n s
d is t u r b a n c e s
as
w h ic h
w hen
m is s in g . heads
th e
t h e o r i g i n a l p o s it io n .
d is m is s e d
th o u g h t,
are
o th e r th a n
p r e d ic t io n
of
te e th
c o n d y la r
in
Fig. g.— U nilateral, free-saddle type, m andibu lar partial denture. T h is type is one of the most frequently required fo r m axillofacial cases
of
th e
d e n tu re
p r o d u c e s s t r a in F ro m
as
T h erefo re
due
con
to th e b a la n c e
m u s c u la r
im b a la n c e
o n o n e s id e o r t h e o t h e r .
th e n u m b e r o f p a t ie n t s w it h t e m
Fig. 10 .— L e ft: A unilateral free-saddle type denture with a stress-breaker. R ig h t: G old fram e work attached to shellac base-tray to be used for functional rebase impression after teeth are occluded
644
The Journal of the American Denfal Association
poromandibular disturbances treated, in which the cause for the complaint is vague and yet definite discomfort or sub luxation is present, it can be estimated that many of these maxillofacial condi tions will follow a similar course. The complications will depend on the limits of accommodation present in the struc tures of the joint and the closely related structures. 5. When time permits, some ortho dontic treatment may be attempted. O c clusal readjustment may be possible and a more normal alinement will permit finer results with dentures. 6. Many of these patients will lose the remaining supporting teeth eventually, and complete dentures will be necessary. It will be observed that many operations of the sulcus will be required. Many partial dentures ’ are possible with sulci only faintly resembling normal ones, but
complete dentures will require better situations. With careful planning, these patients will be able to tolerate com plete dentures. From the number of sat isfactory results observed, the loss of the few remaining teeth is regarded as a more favorable situation for dentures. As each patient presents himself to the profession for evaluation and possible reconstruction of intra-oral appliances, a careful study of the above-mentioned points should be made, and good judg ment should be used to eliminate any causes of discomfort. If any improve ment is possible, corrections should be made to the previous design and even tually satisfaction will be attained. Such achievement is especially gratifying after one realizes that these dentures are a sign of approaching the end of a long and difficult period of treatment.— Wil
liam Beaumont General Hospital.
PENICILLIN: NEW METHODS FOR ITS USE IN DENTISTRY C . A . S c riv e n e r. D .D .S.. O tta w a . Kan., a n d C . W . S c h a n tz .* D .D .S. G r e a t Lakes, HI.
literature is replete with en cal literature encourages interest in pos thusiastic reports relative to the sible dental applications. merits of penicillin. An extensive Currently reported uses of penicillin review of the methods of administrationand the methods of its application recall of the drug shows that tentative conclu the work which we conducted at the sions have been drawn and empirical Naval Training Center in San Diego, limitations already have been established. Calif. W e observed the mouths of 25 Although the uses of penicillin in den men undergoing treatment with peni tistry have been given little consideration, cillin for gonorrheal infections before the flood of material published in medi treatment was started, during treatment and after treatment was completed, in T h e assertio n s a n d o p in io n s exp ressed in th is a r tic le a r e th o se of th e a u th o rs a n d a r e n o t to b e c o n sid ered an attempt to determine the effect of the as re fle c tin g th e v iew s of th e N a v y D e p a r tm e n t o r th e treatment on. caries susceptibility. N av y a t la r g e . * C a p ta in (D C ) U S N ; S e n io r D e n ta l O fficer, N av al W e found that, among this limited T r a in in g C e n te r. e d ic a l
M