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Role of the Orthodontist and the General Practitioner in the Treatment of Jaw Fractures
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7. L a k e , G. C ., and T o o l e y , G. E .: PostDisease. /. Kansas M . Soc., 26:41-47, Feb Mortem Records, 1934 to 1940, U . S. Marine ruary 1926. 6. P e t e r s o n , W. F., and N e d z e l , A. J .: Hospital, Seattle, Wash. U . S. Marine Hospital, Twelfth Avenue Dental Surgery and Endocarditis. J.A.D .A., 25:1462-1464, December 1938. and Judkins Street.
ROLE OF THE ORTHODONTIST AND THE GENERAL PRACTITIONER IN THE TREATMENT OF JAW FRACTURES B y P a u l A . R isk, D .D .S ., L a fa y ette , Ind.
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is interesting to note th at w hile today, w ith the increase in speed o f travel, there has been an increase both in the num ber o f ja w fractures and in the seriousness o f these injuries, a m a jo rity o f ja w fractures probably are not the result o f traffic accidents. T y p ic a l o f the alm ost universal in ad eq u a cy in h an d lin g ja w fractures a few years ago is this sum m ary in a text book o n oral surgery published in 1923.1 While there is no question that an ac curately made interdental splint fulfills the requirements of fixation once it is inserted, yet the making of a splint demands con siderable experience, at least two days of time devoted to nothing else, and involves some expense. Most cases of fracture of the lower jaw occur in persons in poor circum stances who apply for treatment to free dispensaries or dental colleges, where stu dents have to be depended upon for the making of splints. Busy dentists, even though experienced in this work, cannot give up everything and devote at least two days to the making of a splint. Dental students have other duties, such as operative work and lectures to interfere, and moreover are insufficiently experienced to produce accurate splints in the desired length of time. For these reasons, it has been our Read before 4the Section on Orthodontia at the Eighty-Second Annual Meeting of the American Dental Association, Cleveland, Ohio, September 1 0 , 1 9 4 0 . Jour. A .D .A ., Vol. 28, June 1941
experience that usually from two to three weeks elapse between the taking of the im pressions and the insertion of the splint, which may not fit accurately even then. In the meantime, unless some other means of fixation has been used, the fracture may be in process of union in malposition. There fore, for the fixation of the average case of fracture at the present time, we do not depend on splints, but employ immediate ligation of the lower to the upper teeth, thus reducing and fixing the fracture the first time the case is seen. E ven tod ay w e h a ve on ly p a rtially set aside teachings o f this nature. D u rin g the last several years, dentistry has m ade trem endous strides in ortho d on tic technic, in p artial denture tech nics an d in general prosthetics. D u rin g the same years, the orthopedic surgeon has ad ded m aterially to the m echanical aids th a t he uses in the care of fractures in general. T h e principles th at best serve in the treatm ent o f fractures as a w hole a p p ly in com plicated m andibular or m axillary in ju ry. T hese principles m a y be sum m ed u p in the w ords prom pt and ex a ct im m obilization. In the care o f these cases, the problem is not on ly to obtain prom pt and ex a ct im m obilization, but also to do so w ith a m inim um o f m anipulation o f the inju red parts, at the same tim e givin g the p a
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tient the greatest possible am ount o f freedom o f action during the convales cent period. E ven before a decision is m ade on the m ode o f treatm ent, some one has to d e cide w ho is best qualified to a p p ly these rules o f care. A ccid e n t cases are u sually sent to the most convenient hospital. T h e m edical m an, usually in the person o f the gen eral surgeon, sees these patients soon after admission. It is this surgeon w ho decides w hether he w ill assume fu ll care him self or w ill call in others to assist him . Since these cases are adm itted to all general hospitals, the general practitioner, both physician and dentist, near the sm all cou n ty seat hospital, as w ell as the specialist in the large city, is called. T h e care o f fractures o f the bones o f the low er part o f the face has resolved
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through the left mandible in the bicuspid area. Cast splints were made and cemented to the teeth early the next morning. The fractured segments were then immobilized by passage through tubes and the splint sec tions of a threaded wire, which was then held in place by a single nut. Infection delayed union. A t the end of a year, there still was insufficient union to permit the removal of the appliance. Con tact with the patient was then lost, but he returned nearly a year later with the ap pliance still in place. Twenty-two months after injury, there was a fair union and the appliance was removed.
Fig. 1.— Left, occlusal view. Right, splint from below.
itself into a question o f how best to a p p ly the recent advances in orthopedic procedures, orthodontics and prosthetic dentistry. As the orthodontist in a group dental practice, I h a ve attended a considerable num ber o f these accid en t cases, and I n ow w ish to present a series o f cases to illustrate m y attem pts to a p p ly recent den tal advances in the treatm ent o f ja w fractures. T w o early cases stand out as o f special in te re st: In the spring of 1927, a man, aged 45, presented himself for treatment of a frac tured jaw. Examination revealed that only four teeth remained, the lower cuspids and second molars. The upper jaw was eden tulous. There was a compound fracture
Fig. 2.— Splint on duplicate model and disassembled.
In 1927, I was called as a consultant to see a child 4J who, ten days before, had been in a railroad crossing accident. T he child, nervous, even hysterical, had re covered sufficiently from a cranial fracture to permit care of a compound fracture of the mandible between the cuspid and lateral incisor. There was considerable displace ment at the line of fracture. (Fig. 1.) Under ether anesthesia, modeling com pound impressions were taken, and cast overlay splints were made. T w o days later, under ether anesthesia, the splints were ce
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mented in place. Again, a threaded wire and nut served to aline and fix one side to the other. The patient was at once able to chew lightly. In these tw o cases, w e w ere forced to splint one side to the other, because im m obilization b y ligation o f the low er teeth to the upp er was impossible. H yd rocolloid impressions and an im proved casting technic resulted in better and lighter castings. A n appliance used in 1936 in the case o f a y o u n g w om an illustrates this change. (F ig. 2.) A compound fracture through the socket
0.040 tubing. As the threaded wire was run through these tubes, it was also run through a predetermined length of tubing placed between the two sections of the splint. With tightening of the nut, the fracture was re duced. The splint permitted the mouth to close with the teeth in normal occlusion. It had been so constructed as not to interfere with occlusion during chewing movements. Permitting the patient to do light chewing during convalescence added greatly to her comfort and freedom of action. A great v a riety o f injuries are seen by the dentist w h o is called freq u e n tly to assist w ith these cases. N o one type o f applian ce or even several types o f a p p li ances w ill serve. I f the orthodontist is to be called b y surgeons in his locality, he
Fig. 4.— Splint in position; anterior-posterior view.
Fig. 3.— Splint as seen from distal aspect, locked in corrected occlusion; showing amount of lateral displacement present.
of a lower cuspid and fractures of the al veolar process supporting the four lower incisors were evident. The lower cuspid in the line of fracture had been lost. The dental care then consisted of removing the lower incisor teeth and fragments of alveolar process, and suturing the intra-oral lacera tions. Hydrocolloid impressions were then taken. Splints were constructed that day and cemented in place early the next morning. Each half of the splint carried a piece of
m ust take the cases as they appear and cannot select those th at are m ore prop erly cases fo r the orthodontist from am ong those th at m igh t also b e cared fo r b y the oral surgeon or prosthodontist. Several edentulous cases illustrate this point. Several years ago, in the case of an elderly man with a fracture through the molar region of the mandible, the problem was simple. After repair of the dentures, the anterior teeth were removed and arch wire was vulcanized between the upper and lower dentures to maintain the original bite. The denture was inserted and a chin bandage ap plied.
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A very different problem was presented, several years ago, in a man aged 40, who had arrived in a local transient camp during the night and was referred to our office the following morning. He reported that he had fractured the mandible ten weeks before, and that an open reduction had been attempted soon after injury. Considerable lateral displacement of the chin, lack of union and anesthesia of the mandibular nerve anterior to the fracture were noted. Roentgenograms were taken, and the marks of the attempted open re duction could be clearly seen in the lateral view. The lower denture had been cut down distally to the right cuspid to keep it away from the line of fracture.
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thesia persisted. T he bite was quite different from the bite which the dentures indicated to be normal. In an attempt to restore the original bite, an impression was taken, to restore the full length of the lower denture. Next, splints duplicating the restored dentures were con structed and tubes and posts provided for locking the upper and lower splints together while the bite as it was before injury was duplicated. T he three parallel tubes were set in the lower splint section, while the opposing posts were placed in the upper. Stops soldered to the posts controlled the depth to which a post might be inserted in its tube. With the posts in position in the tubes, off-center holes were drilled through the tubes so as to notch the posts. By the passage of wire ligatures through these holes when the posts were in position, the upper splint section was locked to the lower in a
Fig. 6.— Multiple fractures of light edentu lous mandible.
Fig. 5.— Appearance of patient when splint was removed, traction bars being replaced that they might be photographed.
When the local transient camp director was told that care would be complicated and must include hospitalization, the patient was ordered transferred to the camp convenient to the university medical center hospitals. Eighteen days later, he appeared in the waiting room again, this time stating that he had merely been on the hospital waiting list and wished to be treated. By this time, there was a firm union, with the chin off center. T he mandibular anes
position duplicating the bite before injury. Comparing the completed splint, mounted to duplicate the original bite, with the splint mounted to duplicate the bite after injury, we see the degree of correction asked from the appliance. (Fig. 3.) Cast tubes were vulcanized in the upper portion of the splint to provide a means of applying traction between the upper splint section and a head cap, if it should be found necessary to hold the upper splint section in place. T o provide a precision fit between each traction bar and its tube, elliptical bar ma terial was used, and the tubes were cast from wax patterns of the bars to be used in them. A hole for locking the traction bar was provided. Both this locking device and the
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off-center hole in one of the tubes are easily seen. (Fig. 4.) Under local anesthesia, the lower splint section was fixed in the mouth by circum ferential wiring. Hypodermic needles with 0.025 inside diameter were cut down to serve as can nulas. Two stainless steel ligature wires, one 0.010 and one 0.011, were passed through the cannula each time it was inserted. The wires were ligated over the lower splint section at the midline and in the first molar region on each side.
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section in place, traction bars and cap could be discarded. The appliance was removed in one month. There was then a new, firm union. T he traction bars were replaced in position so that they might be shown in the photograph taken at the time that the splint was removed. Exact immobilization may ac count for our success, while lack of im mobilization may explain failure of treat ment at the time of injury. Several months ago I was called to the hospital to attend a man aged 65 (Fig. 6), who presented multiple simple fractures of a very light edentulous mandible. Splints were made by reproducing the dentures in clear acrylic resin. The lower half of the splint was fixed in position by circumferen tial wiring and then ligated to the upper half of the splint. T o protect the lips,
Fig. 7.— Splint in position.
Fig. 9.— First splint in position.
Fig. 8.— Types of clamp bands.
Next, we cut down through the scar left by the attempted open reduction and ex posed the healed fracture. The mandible was refractured by prying with a blunt in strument in the old fracture line. We then inserted the upper splint section with traction bars in position, and locked the two splint sections together. (Fig. 5.) The traction bars were then ligated to a head cap. The next day, it was found that the traction bars were not needed. As the shape of the upper alveolar ridge held the upper splint
rubber tubing was placed over the ligatures from two of the circumferential wires to the extension from the plaster cap. (Fig. 7.) It is interesting to note here that the roentgenogram of the splint in position im mediately after reduction shows only the metal parts of the splint. Clear acrylic resin casts no x-ray shadow. This very much simplified the x-ray studies of the union of this very light mandible. The upper part of the splint was removed in eleven days. The head cap was discarded in twenty-eight days and the lower splint removed fourteen days later. Several weeks after the splint was removed, the lines of fracture could no longer be seen in the roentgenogram.
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In m akin g appliances fo r the im m o bilization o f fractures, the several sizes o f Russell locks used either on ind ivid u al bands or on cast splints h ave been the most useful o f the several com parable types o f orthod ontic attachm ents. (Fig. 8 .) W hen I h ave used ind ivid u al bands, the clam p ban d has usu ally been found m ore satisfactory than the cem ented band. T h e clam p ban d m a y be fitted w ith m uch less m anipu lation o f the in jured p a rt and it elim inates the possibil ity o f loss o f cem ent in a laceration. A fte r a clam p band m ade o f ligh t m a terial has b een fitted ro u gh ly on the plas ter m odel or in the m outh, a final fit is assured if from 0.5 to 1 m m . is taken out o f its circum ference. T h is can be ac com plished b y cu ttin g through the tubing
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of three upper molars, one lower molar and the four lower incisors. A comminuted frac ture at the symphysis and fractures through one condyle and the upper ramus on the opposite side were also present. M y part of this patient’s care included extensive intra-oral suturing as well as the removal of the several displaced teeth and numerous bone fragments. Hydrocolloid impressions were then taken. This first part of the treatment was complete at about 11 o’clock that night. The extent of the lacera tions of the lips indicated that anything that we wished to do in the mouth must be completed within the few hours; i.e., before swelling would force a wait of perhaps a week. The next morning at 11, cast splints were cemented to the lower teeth. Each splint section included a 0.040 Russell lock. One side was fixed to the other side by 0.036 steel arch wire in the Russell locks. The
Fig. 1 o.— Second splint with steel arch bar as worn for two months.
that is to serve as the locking device. F lat tubing and threaded w ire w ere used in m aking m ost o f the clam p bands shown. A dental consultant, if necessary, should be called as soon as the general condition o f the patien t perm its. B y this, I m ean th at i f there are no contra indications, the d ental consultant should see the patien t w h ile he is still in the em ergency room , and not a d ay or two later. A girl aged 16, admitted to the hospital, presented severe lacerations of the face and lips. The chin was so collapsed upon the throat that both breathing and swallowing were difficult. The roentgenograms only partially indicated the extent of the injuries, which included extensive intra-oral lacera tions, fractures of the upper and lower al veolar process and the loss or displacement
mandible was then ligated to the maxillae. In this case, the extreme mobility of the segments contraindicated, if it did not render impossible, banding and ligation of individ ual teeth. The roentgenogram taken after reduction shows a fragment of cement in the line of fracture. (Fig. 9.) On the seventh day, clamp bands were placed on the upper first bicuspids. The articulation of the lower teeth with the upper was improved by adjustment of the lower arch bar and the addition of new in termaxillary ligatures. A t the end of four weeks, the appliance was removed. By this time, that is at the end of four weeks, the posterior fractures were united. Infection, however, had prevented union at the sym physis. New impressions were taken and the splint was remade. The condition at the beginning of treatment, which had prevented the tak ing of a really good lower impression, had
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passed. The threaded wire and nut used in the Russell locks permitted easy control of the distance between the two sides. (Fig. 10.) A 0.036 steel arch was soon substituted for the threaded wire and nut. This splint differed from the one, made immediately after the accident only in that it was so constructed as to require no cement. Better impressions permitted us to take advantage of undercuts rather than cement to hold the appliance in place. A heavy piece of band material set in a wax pattern at the distal portion served to hinge each casting. Tubes were placed in the wax at the mesial portion. After the castings were polished, a disk was used to cut through the mesial tubes. The open hinge thus formed then permitted the castings to be snapped to place. A threaded wire through a tube and a lock nut to clamp each splint to the teeth entirely eliminated the possibility of displacement. Light chew-
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the teeth. The central incisor section car ried hooks for ligatures. The two outside sections carried 0.040 Russell locks. A 0.036 arch section was locked in the Russell locks. The middle section was then ligated lightly to the arch bar through the Russell locks. Perhaps the most interesting case in the series was that of a man aged 23 who had been injured in a traffic accident three years previously. His injuries included a com minuted fracture of the anterior mandible, fracture of the left condyle and fracture of the right condyle and the right coronoid process. One lower lateral incisor had been knocked out and the other three lower in cisors had been displaced, but were sup ported by a sizable bone segment. Again,
Fig. 11.— Splint in place. ing was at once possible. Intermaxillary ligatures were no longer needed. Delayed union at the symphysis required that this new splint be worn for two months. It was removed three months after injury. One year after injury, a record of the con dition was made for presentation in court. A sim ilar applian ce served w hen the m and ibular in ju ry involved on ly the a l veolar process and the displacem ent o f the low er incisors and their supporting process. A boy aged 16 had knocked out his four upper incisors and two lower lateral incisors. (Fig. 11.) The lower central incisors were displaced. It was thought that there might be enough process attached to the central incisors that they could be saved. Three cast splint sections were clamped to
Fig. 12.— Three cast splint sections locked in position on reassembled model. severe lacerations indicated that any work in the mouth must be accomplished in a few hours or swelling might force a delay of as much as a week. T he full upper denture that the patient had been wearing had been broken in his mouth, had been spit out and had burned with the wreck. There was also a fracture across the left tuberosity. Since there were no general symptoms, hydrocolloid impressions were made imme diately after first aid care and x-ray ex amination. (Fig. 12.) The splint was applied and the anterior fractures were reduced at 4 o’clock that
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afternoon, less than ten hours after the patient was admitted to the hospital. Molar 0.022 Russell locks and 0.022 arch were used instead of the usual 0.040 locks, to per mit greater ease in adaptation of the arch wire. Vincent’s infection, noted on the fifth day, delayed the attempt to improvise a substi tute for the upper denture until the eleventh day. (Fig. 13.) This substitute shown for the upper denture was inserted on the twelfth day. When ligated to the lower splint, it served to immobilize the posterior fractures of the mandible. The splint was removed in seven weeks.
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after injury. Intermaxillary wiring was used, but, after two weeks, the general mouth condition required that all wire ligatures be removed. (Fig. 14.) A one-piece vulcanite splint, made from models poured from hydrocolloid impres sions, was substituted. T he two buccal sec tions were hinged to the lingual section with heavy band material. A single ligature through the labial sections at the midline locked the appliance in place. A slight error in occlusion, present when the appli ance was removed, was of no consequence, as the mouth was soon to be prepared for artificial dentures.
Fig. 13.— Left: Vulcanite substitute for upper denture ligated to lower splint. Right: Occlusal view.
Fig. 14.— One piece vulcanite mandibular splint. W here a one piece casting is clam ped to tw o or m ore teeth, the casting is seated either b y takin g a d van tage o f the elas ticity in the m etal or by w axin g a piece o f h e a v y ban d m aterial in one end o f the w a x section so that it m a y serve as a hinge in the com pleted appliance. B y setting all attachm ents in the w ax p a t tern, w e both sim plify the problem o f alinem ent and elim inate all soldering. Recently, a fracture through a lower cus pid area was complicated by severe chronic gingival inflammation. T he patient pre sented herself for treatment several days
Recently, I was called to attend a man aged 45 with a comminuted fracture of the mandible involving the whole area between the right lateral incisor and the right second bicuspid. The two lower right incisor teeth were loosened, but not displaced. The lower right cuspid and first bicuspid supported by a segment of alveolar process were displaced. The upper right first bicuspid was chipped and loosened. Worn occlusal surfaces to serve as guides to occlusion were absent. Missing teeth, malocclusion, including an end-to-end bite, and chronic gingivitis further complicated the problem.
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Hydrocolloid impressions, one upper and two lower, were taken as soon as the sur geon completed the first aid care of mis cellaneous lacerations. Cast splints bearing 0.040 Russell Locks were constructed for the two major segments. (Fig. 15.) The next morning the splint was put in place. T o provide full space to the segment bearing the right cuspid and bicuspid, the two splint sections were locked to the teeth by ligatures through loops at their open ends instead of by threaded wire and nut, A 0.032 steel arch bar was then locked in the Russell locks, fixing one side of the mandible to the other. Next, the small cen ter segment was lightly ligated to the arch bar. Again, a splint was in place and the fracture was reduced within twelve hours after admission of the patient to the hos pital. A slight error in occlusion was ap parently due to misplacement of some of the many small bone fragments near the
Fig. 15.— Two cast splint sections ligated to second lower model; middle segment ligated to arch bar.
lower border of mandible between the two principal segments. (Fig. 16.) On the sixth day, a steel arch 0.032 pre viously annealed to the upper model was ligated to the upper teeth. Intermaxillary elastics were then applied. On the eighth day, the patient left the city, returning on the twenty-eighth day, when all appliances were removed. Slight spot grinding cor rected a minor error in articulation. As a last example of some of the problems of fracture care, I should like to describe the case of a man aged 44 who presented a fracture through the lower incisor region extending across the roots of the left cuspid and first bicuspid, and a second mandibular fracture distally from the last molar on the
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right side. The four lower incisors were dis placed lingually. The maxilla presented multiple lines of fracture. Separation at midline had resulted in a 1-inch traumatic cleft in the palate. M y part of the patient’s care consisted of ligating a steel spring arch to the upper teeth in an attempt to reduce the width of the bone cleft while the surgeon attempted to close the soft tissue opening. An arch wire was ligated to the lower teeth and the mandible was ligated to the upper arch. Ten days later, the two lower left incisors were removed. A t that time the lower arch was changed in an attempt to improve artic ulation. On the eighteenth day, the upper right lateral incisor was removed. On the twenty-seventh day, the wire arches and all ligatures were removed. There was then union of the posterior mandibular fracture. Upper and lower hydrocolloid impressions were taken. Because of the fail ure of the attempts to close the cleft in the palate surgically, a cover of clear acrylic resin was made for this cleft. Lack of union of the anterior mandibular fracture neces sitated that one side of the mandible be splinted to the other and, at the same time, permit the patient to wear the cover for the cleft in the palate. (Fig. 17.) The splint consisted of a band supporting a 0.040 Russell lock cemented to the right cuspid and a cast clamp splint also carrying a similar Russell lock, locked on the left cuspid and left first bicuspid. This cast splint was open at its distal end. A carbon point through the wax model from which this splint was cast provided the tube for the wire locking ligatures. The two remaining lower incisors were ligated to the 0.032 steel arch bar. Be cause of delayed union, this splint, put in position on the twenty-eighth day, was worn until the eightieth day after injury. M y experience indicates that a splint clam ped tigh tly to the teeth m a y be left in position fo r lon ger than a m onth w ith ou t d anger o f perm anent enam el stain. Should it be desirable fo r a clam p splint to rem ain in position fo r an ex tended period, it is a sim ple m atter to add cem ent, and clam p the casting back in position w hile the cem ent is still soft.
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T h e earlier splints ju st shown w ere cast from coin silver. M o re recently, they h ave all been cast from econom y gold, selected gold scrap or casting gold. In selecting the cases to present here, I h a ve chosen those that best illustrate the fa c t th at in ju ry o f this type often requires m uch m ore than consultation w ith a d ental intern or w ith an oral sur geon. T h e y require that splints be m ade w ith the sam e precision th at the pros thodontist dem ands o f partial dentures. T h e y require th at orthodontic principles, i f applicab le in the case, be em ployed
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and prosthetic procedures o f some years ago, technics no longer considered good dental practice. T h e ab ility o f the den tal consultant to a p p ly ad van ced orthodontic and pros thetic principles is as im portant as, i f not m ore im portant than, his know ledge o f oral surgery. It is fo r the surgeon to determ ine w hether the general condition o f the p a tient w ill perm it im m ediate dental care. C ra n ia l fractu re and shock are the usual reasons fo r delay. I f the patien t’s con dition perm its early care, the dental con-
Fig. 16.— Intermaxillary elastics providing traction between lower splint and upper arch.
Fig. 17.— Cleft in palate after twenty-eight days; occlusal view of splint.
w ith the exactness that w e exp ect in a c arefu lly constructed orthodontic ap p li ance. A recent original article b y a surgeon2 describes num erous advances in the care o f ja w fractures, but still speaks o f lig a t in g an arch m ade from a piece o f coath an ger w ire to the low er teeth to im m obilize one side o f the m andible to the other. T h e textbooks o f today,3’ 4 w hen they describe the care o f fractures o f m axillary bones, all too often describe orthodontic
sultant should u sually be called w hile first aid is b eing adm inistered. In lacera tion o f the lips, a d elay of only a few hours m a y m ean that sw elling w ill force a fu rth er d elay o f at least a week. I t is essential that the dental consultant either h ave, or h a ve access to, a w ellequipped dental lab oratory and th at this laboratory be availab le a t all hours. R e li ance on a com m ercial den tal laboratory w h ich n orm ally operates on ly du rin g certain hours o f the d ay is not sufficient I t is essential that the dental consult
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ant, i f h e is to be called frequ ently, be w illin g to rearrange his office time schedule w hen a call comes in. H e must be w illin g to see these cases a t all hours. T h e surgeon desires d en tal assistance w ith such cases as are here described. M y experience has been th a t he wishes the dental consultant to take over and assume fu ll responsibility, and th at the am ount o f responsibility that this den tal con sultant is asked to assume is lim ited only b y his ow n willingness and ability.
b ib l io g r a p h y
1.
B l a i r , V . P., and I v y , R. H .: Essentials
of O ral Surgery. St. Louis: C . V . Mosby Co.,
19232. S
t r a it h
C.
,
L .:
Automobile
Injuries.
J .A .M .A ., 109:940, September 18, 1937. 3. W
arba sse
,
J. P., and S m
Surgical Treatment. Vol.
III.
yth
,
C. M .:
Philadelphia:
W. B. Sanders Co., 1937, p. 501. 4. S
cu dder
, C . L .: Treatment of Fractures.
Philadelphia: W. B. Sanders and Co., 1938. Schultz Building.
METHODS OF PRODUCING MORE LIFELIKE DENTURES, INCLUDING THE PREPARATION AND PROCESSING OF ACRYLIC RESINS B y W a l t e r J. P r y o r , D .D .S ., C levelan d , O h io
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H E art o f constructing lifelike dentures is progressing at a faster rate at the present m om ent than at any tim e in the history o f dentistry. T h e invention o f porcelain teeth, m ore than a cen tury ago, follow ed by the discovery o f the use o f rubber as a den ture base m aterial, m arked a definite im provem ent, but, durin g the past century, there was no outstanding developm ent in the esthetic phase o f denture w ork, w ith the possible exception o f the use o f por celain to im itate the gu m tissue, until the w ork o f J. L eo n W illiam s in aw akening the profession and the tooth m an u fac turer to the need o f better tooth forms. B oth o f these efforts w ere o n ly partly successful, since the general use o f por celain in fabricatin g the denture base is not p r a c tic a l; and w hile, o w in g to D r. R ead before the Section on Full Denture Prosthesis at the Eighty-Second M eeting of the American Dental Association, Cleveland, Ohio, September 11, 1940.
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W illiam s’ w ork, better tooth form s w ere m ade available, w e still struggled along w ith the unsightly pink rubber gu m and un natural appearing porcelain in teeth. O u r plan, o f necessity, was to keep the rubber gu m out o f sight and to stain and alter the porcelain teeth to produce m ore lifelike effects. A t this m om ent, how ever, tooth m anufacturers are ch an g in g their w hole system o f constructing porcelain teeth, and, ow in g to the dis covery o f the plastic m ethyl m eth acry late, the use o f rubber and other plastics as denture base m aterials is rap id ly d e creasing. T h e changes m ade in the character and ligh t refraction o f porcelain teeth are such that I find m yself n ow using teeth m ade b y several different m anufacturers w here form erly one source o f supply was sufficient. H eretofore, no m anufacturer h ad m ore than five or six so-called shades that w ere even usable. N ow , each seems to
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7. L a k e , G. C ., and T o o l e y , G. E .: PostDisease. /. Kansas M . Soc., 26:41-47, Feb Mortem Records, 1934 to 1940, U . S. Marine ruary 1926. 6. P e t e r s o n , W. F., and N e d z e l , A. J .: Hospital, Seattle, Wash. U . S. Marine Hospital, Twelfth Avenue Dental Surgery and Endocarditis. J.A.D .A., 25:1462-1464, December 1938. and Judkins Street.
ROLE OF THE ORTHODONTIST AND THE GENERAL PRACTITIONER IN THE TREATMENT OF JAW FRACTURES B y P a u l A . R isk, D .D .S ., L a fa y ette , Ind.
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is interesting to note th at w hile today, w ith the increase in speed o f travel, there has been an increase both in the num ber o f ja w fractures and in the seriousness o f these injuries, a m a jo rity o f ja w fractures probably are not the result o f traffic accidents. T y p ic a l o f the alm ost universal in ad eq u a cy in h an d lin g ja w fractures a few years ago is this sum m ary in a text book o n oral surgery published in 1923.1 While there is no question that an ac curately made interdental splint fulfills the requirements of fixation once it is inserted, yet the making of a splint demands con siderable experience, at least two days of time devoted to nothing else, and involves some expense. Most cases of fracture of the lower jaw occur in persons in poor circum stances who apply for treatment to free dispensaries or dental colleges, where stu dents have to be depended upon for the making of splints. Busy dentists, even though experienced in this work, cannot give up everything and devote at least two days to the making of a splint. Dental students have other duties, such as operative work and lectures to interfere, and moreover are insufficiently experienced to produce accurate splints in the desired length of time. For these reasons, it has been our Read before 4the Section on Orthodontia at the Eighty-Second Annual Meeting of the American Dental Association, Cleveland, Ohio, September 1 0 , 1 9 4 0 . Jour. A .D .A ., Vol. 28, June 1941
experience that usually from two to three weeks elapse between the taking of the im pressions and the insertion of the splint, which may not fit accurately even then. In the meantime, unless some other means of fixation has been used, the fracture may be in process of union in malposition. There fore, for the fixation of the average case of fracture at the present time, we do not depend on splints, but employ immediate ligation of the lower to the upper teeth, thus reducing and fixing the fracture the first time the case is seen. E ven tod ay w e h a ve on ly p a rtially set aside teachings o f this nature. D u rin g the last several years, dentistry has m ade trem endous strides in ortho d on tic technic, in p artial denture tech nics an d in general prosthetics. D u rin g the same years, the orthopedic surgeon has ad ded m aterially to the m echanical aids th a t he uses in the care of fractures in general. T h e principles th at best serve in the treatm ent o f fractures as a w hole a p p ly in com plicated m andibular or m axillary in ju ry. T hese principles m a y be sum m ed u p in the w ords prom pt and ex a ct im m obilization. In the care o f these cases, the problem is not on ly to obtain prom pt and ex a ct im m obilization, but also to do so w ith a m inim um o f m anipulation o f the inju red parts, at the same tim e givin g the p a
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tient the greatest possible am ount o f freedom o f action during the convales cent period. E ven before a decision is m ade on the m ode o f treatm ent, some one has to d e cide w ho is best qualified to a p p ly these rules o f care. A ccid e n t cases are u sually sent to the most convenient hospital. T h e m edical m an, usually in the person o f the gen eral surgeon, sees these patients soon after admission. It is this surgeon w ho decides w hether he w ill assume fu ll care him self or w ill call in others to assist him . Since these cases are adm itted to all general hospitals, the general practitioner, both physician and dentist, near the sm all cou n ty seat hospital, as w ell as the specialist in the large city, is called. T h e care o f fractures o f the bones o f the low er part o f the face has resolved
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through the left mandible in the bicuspid area. Cast splints were made and cemented to the teeth early the next morning. The fractured segments were then immobilized by passage through tubes and the splint sec tions of a threaded wire, which was then held in place by a single nut. Infection delayed union. A t the end of a year, there still was insufficient union to permit the removal of the appliance. Con tact with the patient was then lost, but he returned nearly a year later with the ap pliance still in place. Twenty-two months after injury, there was a fair union and the appliance was removed.
Fig. 1.— Left, occlusal view. Right, splint from below.
itself into a question o f how best to a p p ly the recent advances in orthopedic procedures, orthodontics and prosthetic dentistry. As the orthodontist in a group dental practice, I h a ve attended a considerable num ber o f these accid en t cases, and I n ow w ish to present a series o f cases to illustrate m y attem pts to a p p ly recent den tal advances in the treatm ent o f ja w fractures. T w o early cases stand out as o f special in te re st: In the spring of 1927, a man, aged 45, presented himself for treatment of a frac tured jaw. Examination revealed that only four teeth remained, the lower cuspids and second molars. The upper jaw was eden tulous. There was a compound fracture
Fig. 2.— Splint on duplicate model and disassembled.
In 1927, I was called as a consultant to see a child 4J who, ten days before, had been in a railroad crossing accident. T he child, nervous, even hysterical, had re covered sufficiently from a cranial fracture to permit care of a compound fracture of the mandible between the cuspid and lateral incisor. There was considerable displace ment at the line of fracture. (Fig. 1.) Under ether anesthesia, modeling com pound impressions were taken, and cast overlay splints were made. T w o days later, under ether anesthesia, the splints were ce
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mented in place. Again, a threaded wire and nut served to aline and fix one side to the other. The patient was at once able to chew lightly. In these tw o cases, w e w ere forced to splint one side to the other, because im m obilization b y ligation o f the low er teeth to the upp er was impossible. H yd rocolloid impressions and an im proved casting technic resulted in better and lighter castings. A n appliance used in 1936 in the case o f a y o u n g w om an illustrates this change. (F ig. 2.) A compound fracture through the socket
0.040 tubing. As the threaded wire was run through these tubes, it was also run through a predetermined length of tubing placed between the two sections of the splint. With tightening of the nut, the fracture was re duced. The splint permitted the mouth to close with the teeth in normal occlusion. It had been so constructed as not to interfere with occlusion during chewing movements. Permitting the patient to do light chewing during convalescence added greatly to her comfort and freedom of action. A great v a riety o f injuries are seen by the dentist w h o is called freq u e n tly to assist w ith these cases. N o one type o f applian ce or even several types o f a p p li ances w ill serve. I f the orthodontist is to be called b y surgeons in his locality, he
Fig. 4.— Splint in position; anterior-posterior view.
Fig. 3.— Splint as seen from distal aspect, locked in corrected occlusion; showing amount of lateral displacement present.
of a lower cuspid and fractures of the al veolar process supporting the four lower incisors were evident. The lower cuspid in the line of fracture had been lost. The dental care then consisted of removing the lower incisor teeth and fragments of alveolar process, and suturing the intra-oral lacera tions. Hydrocolloid impressions were then taken. Splints were constructed that day and cemented in place early the next morning. Each half of the splint carried a piece of
m ust take the cases as they appear and cannot select those th at are m ore prop erly cases fo r the orthodontist from am ong those th at m igh t also b e cared fo r b y the oral surgeon or prosthodontist. Several edentulous cases illustrate this point. Several years ago, in the case of an elderly man with a fracture through the molar region of the mandible, the problem was simple. After repair of the dentures, the anterior teeth were removed and arch wire was vulcanized between the upper and lower dentures to maintain the original bite. The denture was inserted and a chin bandage ap plied.
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A very different problem was presented, several years ago, in a man aged 40, who had arrived in a local transient camp during the night and was referred to our office the following morning. He reported that he had fractured the mandible ten weeks before, and that an open reduction had been attempted soon after injury. Considerable lateral displacement of the chin, lack of union and anesthesia of the mandibular nerve anterior to the fracture were noted. Roentgenograms were taken, and the marks of the attempted open re duction could be clearly seen in the lateral view. The lower denture had been cut down distally to the right cuspid to keep it away from the line of fracture.
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thesia persisted. T he bite was quite different from the bite which the dentures indicated to be normal. In an attempt to restore the original bite, an impression was taken, to restore the full length of the lower denture. Next, splints duplicating the restored dentures were con structed and tubes and posts provided for locking the upper and lower splints together while the bite as it was before injury was duplicated. T he three parallel tubes were set in the lower splint section, while the opposing posts were placed in the upper. Stops soldered to the posts controlled the depth to which a post might be inserted in its tube. With the posts in position in the tubes, off-center holes were drilled through the tubes so as to notch the posts. By the passage of wire ligatures through these holes when the posts were in position, the upper splint section was locked to the lower in a
Fig. 6.— Multiple fractures of light edentu lous mandible.
Fig. 5.— Appearance of patient when splint was removed, traction bars being replaced that they might be photographed.
When the local transient camp director was told that care would be complicated and must include hospitalization, the patient was ordered transferred to the camp convenient to the university medical center hospitals. Eighteen days later, he appeared in the waiting room again, this time stating that he had merely been on the hospital waiting list and wished to be treated. By this time, there was a firm union, with the chin off center. T he mandibular anes
position duplicating the bite before injury. Comparing the completed splint, mounted to duplicate the original bite, with the splint mounted to duplicate the bite after injury, we see the degree of correction asked from the appliance. (Fig. 3.) Cast tubes were vulcanized in the upper portion of the splint to provide a means of applying traction between the upper splint section and a head cap, if it should be found necessary to hold the upper splint section in place. T o provide a precision fit between each traction bar and its tube, elliptical bar ma terial was used, and the tubes were cast from wax patterns of the bars to be used in them. A hole for locking the traction bar was provided. Both this locking device and the
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off-center hole in one of the tubes are easily seen. (Fig. 4.) Under local anesthesia, the lower splint section was fixed in the mouth by circum ferential wiring. Hypodermic needles with 0.025 inside diameter were cut down to serve as can nulas. Two stainless steel ligature wires, one 0.010 and one 0.011, were passed through the cannula each time it was inserted. The wires were ligated over the lower splint section at the midline and in the first molar region on each side.
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section in place, traction bars and cap could be discarded. The appliance was removed in one month. There was then a new, firm union. T he traction bars were replaced in position so that they might be shown in the photograph taken at the time that the splint was removed. Exact immobilization may ac count for our success, while lack of im mobilization may explain failure of treat ment at the time of injury. Several months ago I was called to the hospital to attend a man aged 65 (Fig. 6), who presented multiple simple fractures of a very light edentulous mandible. Splints were made by reproducing the dentures in clear acrylic resin. The lower half of the splint was fixed in position by circumferen tial wiring and then ligated to the upper half of the splint. T o protect the lips,
Fig. 7.— Splint in position.
Fig. 9.— First splint in position.
Fig. 8.— Types of clamp bands.
Next, we cut down through the scar left by the attempted open reduction and ex posed the healed fracture. The mandible was refractured by prying with a blunt in strument in the old fracture line. We then inserted the upper splint section with traction bars in position, and locked the two splint sections together. (Fig. 5.) The traction bars were then ligated to a head cap. The next day, it was found that the traction bars were not needed. As the shape of the upper alveolar ridge held the upper splint
rubber tubing was placed over the ligatures from two of the circumferential wires to the extension from the plaster cap. (Fig. 7.) It is interesting to note here that the roentgenogram of the splint in position im mediately after reduction shows only the metal parts of the splint. Clear acrylic resin casts no x-ray shadow. This very much simplified the x-ray studies of the union of this very light mandible. The upper part of the splint was removed in eleven days. The head cap was discarded in twenty-eight days and the lower splint removed fourteen days later. Several weeks after the splint was removed, the lines of fracture could no longer be seen in the roentgenogram.
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In m akin g appliances fo r the im m o bilization o f fractures, the several sizes o f Russell locks used either on ind ivid u al bands or on cast splints h ave been the most useful o f the several com parable types o f orthod ontic attachm ents. (Fig. 8 .) W hen I h ave used ind ivid u al bands, the clam p ban d has usu ally been found m ore satisfactory than the cem ented band. T h e clam p ban d m a y be fitted w ith m uch less m anipu lation o f the in jured p a rt and it elim inates the possibil ity o f loss o f cem ent in a laceration. A fte r a clam p band m ade o f ligh t m a terial has b een fitted ro u gh ly on the plas ter m odel or in the m outh, a final fit is assured if from 0.5 to 1 m m . is taken out o f its circum ference. T h is can be ac com plished b y cu ttin g through the tubing
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of three upper molars, one lower molar and the four lower incisors. A comminuted frac ture at the symphysis and fractures through one condyle and the upper ramus on the opposite side were also present. M y part of this patient’s care included extensive intra-oral suturing as well as the removal of the several displaced teeth and numerous bone fragments. Hydrocolloid impressions were then taken. This first part of the treatment was complete at about 11 o’clock that night. The extent of the lacera tions of the lips indicated that anything that we wished to do in the mouth must be completed within the few hours; i.e., before swelling would force a wait of perhaps a week. The next morning at 11, cast splints were cemented to the lower teeth. Each splint section included a 0.040 Russell lock. One side was fixed to the other side by 0.036 steel arch wire in the Russell locks. The
Fig. 1 o.— Second splint with steel arch bar as worn for two months.
that is to serve as the locking device. F lat tubing and threaded w ire w ere used in m aking m ost o f the clam p bands shown. A dental consultant, if necessary, should be called as soon as the general condition o f the patien t perm its. B y this, I m ean th at i f there are no contra indications, the d ental consultant should see the patien t w h ile he is still in the em ergency room , and not a d ay or two later. A girl aged 16, admitted to the hospital, presented severe lacerations of the face and lips. The chin was so collapsed upon the throat that both breathing and swallowing were difficult. The roentgenograms only partially indicated the extent of the injuries, which included extensive intra-oral lacera tions, fractures of the upper and lower al veolar process and the loss or displacement
mandible was then ligated to the maxillae. In this case, the extreme mobility of the segments contraindicated, if it did not render impossible, banding and ligation of individ ual teeth. The roentgenogram taken after reduction shows a fragment of cement in the line of fracture. (Fig. 9.) On the seventh day, clamp bands were placed on the upper first bicuspids. The articulation of the lower teeth with the upper was improved by adjustment of the lower arch bar and the addition of new in termaxillary ligatures. A t the end of four weeks, the appliance was removed. By this time, that is at the end of four weeks, the posterior fractures were united. Infection, however, had prevented union at the sym physis. New impressions were taken and the splint was remade. The condition at the beginning of treatment, which had prevented the tak ing of a really good lower impression, had
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passed. The threaded wire and nut used in the Russell locks permitted easy control of the distance between the two sides. (Fig. 10.) A 0.036 steel arch was soon substituted for the threaded wire and nut. This splint differed from the one, made immediately after the accident only in that it was so constructed as to require no cement. Better impressions permitted us to take advantage of undercuts rather than cement to hold the appliance in place. A heavy piece of band material set in a wax pattern at the distal portion served to hinge each casting. Tubes were placed in the wax at the mesial portion. After the castings were polished, a disk was used to cut through the mesial tubes. The open hinge thus formed then permitted the castings to be snapped to place. A threaded wire through a tube and a lock nut to clamp each splint to the teeth entirely eliminated the possibility of displacement. Light chew-
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the teeth. The central incisor section car ried hooks for ligatures. The two outside sections carried 0.040 Russell locks. A 0.036 arch section was locked in the Russell locks. The middle section was then ligated lightly to the arch bar through the Russell locks. Perhaps the most interesting case in the series was that of a man aged 23 who had been injured in a traffic accident three years previously. His injuries included a com minuted fracture of the anterior mandible, fracture of the left condyle and fracture of the right condyle and the right coronoid process. One lower lateral incisor had been knocked out and the other three lower in cisors had been displaced, but were sup ported by a sizable bone segment. Again,
Fig. 11.— Splint in place. ing was at once possible. Intermaxillary ligatures were no longer needed. Delayed union at the symphysis required that this new splint be worn for two months. It was removed three months after injury. One year after injury, a record of the con dition was made for presentation in court. A sim ilar applian ce served w hen the m and ibular in ju ry involved on ly the a l veolar process and the displacem ent o f the low er incisors and their supporting process. A boy aged 16 had knocked out his four upper incisors and two lower lateral incisors. (Fig. 11.) The lower central incisors were displaced. It was thought that there might be enough process attached to the central incisors that they could be saved. Three cast splint sections were clamped to
Fig. 12.— Three cast splint sections locked in position on reassembled model. severe lacerations indicated that any work in the mouth must be accomplished in a few hours or swelling might force a delay of as much as a week. T he full upper denture that the patient had been wearing had been broken in his mouth, had been spit out and had burned with the wreck. There was also a fracture across the left tuberosity. Since there were no general symptoms, hydrocolloid impressions were made imme diately after first aid care and x-ray ex amination. (Fig. 12.) The splint was applied and the anterior fractures were reduced at 4 o’clock that
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afternoon, less than ten hours after the patient was admitted to the hospital. Molar 0.022 Russell locks and 0.022 arch were used instead of the usual 0.040 locks, to per mit greater ease in adaptation of the arch wire. Vincent’s infection, noted on the fifth day, delayed the attempt to improvise a substi tute for the upper denture until the eleventh day. (Fig. 13.) This substitute shown for the upper denture was inserted on the twelfth day. When ligated to the lower splint, it served to immobilize the posterior fractures of the mandible. The splint was removed in seven weeks.
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after injury. Intermaxillary wiring was used, but, after two weeks, the general mouth condition required that all wire ligatures be removed. (Fig. 14.) A one-piece vulcanite splint, made from models poured from hydrocolloid impres sions, was substituted. T he two buccal sec tions were hinged to the lingual section with heavy band material. A single ligature through the labial sections at the midline locked the appliance in place. A slight error in occlusion, present when the appli ance was removed, was of no consequence, as the mouth was soon to be prepared for artificial dentures.
Fig. 13.— Left: Vulcanite substitute for upper denture ligated to lower splint. Right: Occlusal view.
Fig. 14.— One piece vulcanite mandibular splint. W here a one piece casting is clam ped to tw o or m ore teeth, the casting is seated either b y takin g a d van tage o f the elas ticity in the m etal or by w axin g a piece o f h e a v y ban d m aterial in one end o f the w a x section so that it m a y serve as a hinge in the com pleted appliance. B y setting all attachm ents in the w ax p a t tern, w e both sim plify the problem o f alinem ent and elim inate all soldering. Recently, a fracture through a lower cus pid area was complicated by severe chronic gingival inflammation. T he patient pre sented herself for treatment several days
Recently, I was called to attend a man aged 45 with a comminuted fracture of the mandible involving the whole area between the right lateral incisor and the right second bicuspid. The two lower right incisor teeth were loosened, but not displaced. The lower right cuspid and first bicuspid supported by a segment of alveolar process were displaced. The upper right first bicuspid was chipped and loosened. Worn occlusal surfaces to serve as guides to occlusion were absent. Missing teeth, malocclusion, including an end-to-end bite, and chronic gingivitis further complicated the problem.
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Hydrocolloid impressions, one upper and two lower, were taken as soon as the sur geon completed the first aid care of mis cellaneous lacerations. Cast splints bearing 0.040 Russell Locks were constructed for the two major segments. (Fig. 15.) The next morning the splint was put in place. T o provide full space to the segment bearing the right cuspid and bicuspid, the two splint sections were locked to the teeth by ligatures through loops at their open ends instead of by threaded wire and nut, A 0.032 steel arch bar was then locked in the Russell locks, fixing one side of the mandible to the other. Next, the small cen ter segment was lightly ligated to the arch bar. Again, a splint was in place and the fracture was reduced within twelve hours after admission of the patient to the hos pital. A slight error in occlusion was ap parently due to misplacement of some of the many small bone fragments near the
Fig. 15.— Two cast splint sections ligated to second lower model; middle segment ligated to arch bar.
lower border of mandible between the two principal segments. (Fig. 16.) On the sixth day, a steel arch 0.032 pre viously annealed to the upper model was ligated to the upper teeth. Intermaxillary elastics were then applied. On the eighth day, the patient left the city, returning on the twenty-eighth day, when all appliances were removed. Slight spot grinding cor rected a minor error in articulation. As a last example of some of the problems of fracture care, I should like to describe the case of a man aged 44 who presented a fracture through the lower incisor region extending across the roots of the left cuspid and first bicuspid, and a second mandibular fracture distally from the last molar on the
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right side. The four lower incisors were dis placed lingually. The maxilla presented multiple lines of fracture. Separation at midline had resulted in a 1-inch traumatic cleft in the palate. M y part of the patient’s care consisted of ligating a steel spring arch to the upper teeth in an attempt to reduce the width of the bone cleft while the surgeon attempted to close the soft tissue opening. An arch wire was ligated to the lower teeth and the mandible was ligated to the upper arch. Ten days later, the two lower left incisors were removed. A t that time the lower arch was changed in an attempt to improve artic ulation. On the eighteenth day, the upper right lateral incisor was removed. On the twenty-seventh day, the wire arches and all ligatures were removed. There was then union of the posterior mandibular fracture. Upper and lower hydrocolloid impressions were taken. Because of the fail ure of the attempts to close the cleft in the palate surgically, a cover of clear acrylic resin was made for this cleft. Lack of union of the anterior mandibular fracture neces sitated that one side of the mandible be splinted to the other and, at the same time, permit the patient to wear the cover for the cleft in the palate. (Fig. 17.) The splint consisted of a band supporting a 0.040 Russell lock cemented to the right cuspid and a cast clamp splint also carrying a similar Russell lock, locked on the left cuspid and left first bicuspid. This cast splint was open at its distal end. A carbon point through the wax model from which this splint was cast provided the tube for the wire locking ligatures. The two remaining lower incisors were ligated to the 0.032 steel arch bar. Be cause of delayed union, this splint, put in position on the twenty-eighth day, was worn until the eightieth day after injury. M y experience indicates that a splint clam ped tigh tly to the teeth m a y be left in position fo r lon ger than a m onth w ith ou t d anger o f perm anent enam el stain. Should it be desirable fo r a clam p splint to rem ain in position fo r an ex tended period, it is a sim ple m atter to add cem ent, and clam p the casting back in position w hile the cem ent is still soft.
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T h e earlier splints ju st shown w ere cast from coin silver. M o re recently, they h ave all been cast from econom y gold, selected gold scrap or casting gold. In selecting the cases to present here, I h a ve chosen those that best illustrate the fa c t th at in ju ry o f this type often requires m uch m ore than consultation w ith a d ental intern or w ith an oral sur geon. T h e y require that splints be m ade w ith the sam e precision th at the pros thodontist dem ands o f partial dentures. T h e y require th at orthodontic principles, i f applicab le in the case, be em ployed
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and prosthetic procedures o f some years ago, technics no longer considered good dental practice. T h e ab ility o f the den tal consultant to a p p ly ad van ced orthodontic and pros thetic principles is as im portant as, i f not m ore im portant than, his know ledge o f oral surgery. It is fo r the surgeon to determ ine w hether the general condition o f the p a tient w ill perm it im m ediate dental care. C ra n ia l fractu re and shock are the usual reasons fo r delay. I f the patien t’s con dition perm its early care, the dental con-
Fig. 16.— Intermaxillary elastics providing traction between lower splint and upper arch.
Fig. 17.— Cleft in palate after twenty-eight days; occlusal view of splint.
w ith the exactness that w e exp ect in a c arefu lly constructed orthodontic ap p li ance. A recent original article b y a surgeon2 describes num erous advances in the care o f ja w fractures, but still speaks o f lig a t in g an arch m ade from a piece o f coath an ger w ire to the low er teeth to im m obilize one side o f the m andible to the other. T h e textbooks o f today,3’ 4 w hen they describe the care o f fractures o f m axillary bones, all too often describe orthodontic
sultant should u sually be called w hile first aid is b eing adm inistered. In lacera tion o f the lips, a d elay of only a few hours m a y m ean that sw elling w ill force a fu rth er d elay o f at least a week. I t is essential that the dental consultant either h ave, or h a ve access to, a w ellequipped dental lab oratory and th at this laboratory be availab le a t all hours. R e li ance on a com m ercial den tal laboratory w h ich n orm ally operates on ly du rin g certain hours o f the d ay is not sufficient I t is essential that the dental consult
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ant, i f h e is to be called frequ ently, be w illin g to rearrange his office time schedule w hen a call comes in. H e must be w illin g to see these cases a t all hours. T h e surgeon desires d en tal assistance w ith such cases as are here described. M y experience has been th a t he wishes the dental consultant to take over and assume fu ll responsibility, and th at the am ount o f responsibility that this den tal con sultant is asked to assume is lim ited only b y his ow n willingness and ability.
b ib l io g r a p h y
1.
B l a i r , V . P., and I v y , R. H .: Essentials
of O ral Surgery. St. Louis: C . V . Mosby Co.,
19232. S
t r a it h
C.
,
L .:
Automobile
Injuries.
J .A .M .A ., 109:940, September 18, 1937. 3. W
arba sse
,
J. P., and S m
Surgical Treatment. Vol.
III.
yth
,
C. M .:
Philadelphia:
W. B. Sanders Co., 1937, p. 501. 4. S
cu dder
, C . L .: Treatment of Fractures.
Philadelphia: W. B. Sanders and Co., 1938. Schultz Building.
METHODS OF PRODUCING MORE LIFELIKE DENTURES, INCLUDING THE PREPARATION AND PROCESSING OF ACRYLIC RESINS B y W a l t e r J. P r y o r , D .D .S ., C levelan d , O h io
T
H E art o f constructing lifelike dentures is progressing at a faster rate at the present m om ent than at any tim e in the history o f dentistry. T h e invention o f porcelain teeth, m ore than a cen tury ago, follow ed by the discovery o f the use o f rubber as a den ture base m aterial, m arked a definite im provem ent, but, durin g the past century, there was no outstanding developm ent in the esthetic phase o f denture w ork, w ith the possible exception o f the use o f por celain to im itate the gu m tissue, until the w ork o f J. L eo n W illiam s in aw akening the profession and the tooth m an u fac turer to the need o f better tooth forms. B oth o f these efforts w ere o n ly partly successful, since the general use o f por celain in fabricatin g the denture base is not p r a c tic a l; and w hile, o w in g to D r. R ead before the Section on Full Denture Prosthesis at the Eighty-Second M eeting of the American Dental Association, Cleveland, Ohio, September 11, 1940.
Jour. A .D .A ., V ol. 28, June 1941
W illiam s’ w ork, better tooth form s w ere m ade available, w e still struggled along w ith the unsightly pink rubber gu m and un natural appearing porcelain in teeth. O u r plan, o f necessity, was to keep the rubber gu m out o f sight and to stain and alter the porcelain teeth to produce m ore lifelike effects. A t this m om ent, how ever, tooth m anufacturers are ch an g in g their w hole system o f constructing porcelain teeth, and, ow in g to the dis covery o f the plastic m ethyl m eth acry late, the use o f rubber and other plastics as denture base m aterials is rap id ly d e creasing. T h e changes m ade in the character and ligh t refraction o f porcelain teeth are such that I find m yself n ow using teeth m ade b y several different m anufacturers w here form erly one source o f supply was sufficient. H eretofore, no m anufacturer h ad m ore than five or six so-called shades that w ere even usable. N ow , each seems to