Surgical prosthetics of oral and facial defects

SURGICAL PROSTHETICS NATHANIEL A.

OF ORAL AND FACIAL DEFECTS*

OLINGER, D.D.S. AND ELVIN F. AXT,

D.D.S.

NEW YORK CITY

I

N defining surgica1 prosthetics there are two viewpoints, but conciseIy, the term is used to designate the mechanicaI restoration of lost tissues. Surgical prosthetics of the intra-oraI cavity and the extra-oraI structures is that branch of dentistry which aims to reconstruct congenitaI and acquired defects by appliances intimateIy associated with surgica1 treatment. The purpose is twofoId, viz., the

physicians. It wouId be natura1 for a person with a perforation of the paIate, to conceive an idea that wouId bring him relief; and it is most probabIe that this was obtained by using a smaI1 sponge, a wad of Iint or a strip of thin Ieather, either thrust into the cIeft or covered it temporariIy. The foIIowing excerpts from ancient case records show that the pioneers of the fifteenth and sixteenth centuries experimented with the art of surgica1 prosthesis.

restoration of function as far as possibIe, and cosmetic improvement. SurgicaI prosthesis is the mechanica restoration of intra- and extra-ora defects.

HolIerius, in his “Observ. ad CaIcem de 1552 suggested that wax or Morbis Internis,” a sponge be used to stop up apertures in the hard palate. He was the first to Ieave a written report of an attempt to cIose a cleft. AIexander Petronius, in his “De Margo 1565 described methods for the CaIIico,” cIosure of cIefts. He recorded the first definite suggestion for a workabIe mechanism to act as a paIatine obturator. Petronius said, “If the decayed bone of the paIate faIIs off itself, or if we extract it, the pronunciation is altered so much, that the patient can scarceIy be understood. In certain cases, it is possibIe to repair this 10s~; for exampIe, when there is onIy a hoIe in the paIate, we can stop it up with cotton, with wax, a goId pIate, or in any other method that the technique of the artist suggests, making certain that these instruments reproduce the same concave form as the paIatine vauIt.” This is the first time that the use of a gold plate is mentioned, but apparentIy the credit for using this materia1 is not attributed to Petronius. Description by Ambrose Par& in 1579 is as foIIows: “Many times it happeneth that a portion or part of the bone of the palate, being broken by the shot of a gun, or corroded by the viruIency of the Lues Venerea, faIIs away, which makes it impossibIe for the patients to pronounce their words distinctIy, but rather obscureIy and snuffhng in sound. Therefore, I have thought it

HISTORICAL REVIEW The technique of surgicaI prosthesis was practised in the fifteenth century, accurate records attesting the fact that skiIIed practitioners artificiaIIy restored organs and essentia1 parts of the body, such as the orbit, nose, Iip, cheek, etc. Modern progress in this art owes much to the earIy pioneers in surgica1 prosthesis, whose experiments and innovations set a standard which guided and inspired the work of succeeding generations of technicians. The appIiances used by practitioners such as Petronius, Pare and Lusitanus, were concerned onIy with the stopping up of existing cIefts. From this operation we derive the term “obturator,” from the Latin obturare, meaning IiteraIIy “to stop and was commonIy appIied in those up,” earIy days. Today, by basicaIIy simiIar but improved appliances, we are attempting to restore defects of congenita1 or acquired origin to norma form and function. It is not inconceivabIe that the principIe of the obturator was known to the earIy

* Read before Am. CoIIege of Dentists, 24

Atlantic

City,

Dec.,

1932

NEW SERIES VOL. XXXI,

No. 1

Olinger-SurgicaI

a thing worthy of labor to demonstrate how it may be heIped by the art. “The cavity of the palate must be f3Ied with a pIate of silver or gold a IittIe bit bigger than the hoIe itseIf; but it shouId be as Iarge as a French crown, and made simiIar to a dish in figure; on the upper side near the brain, a smaI1 sponge must be fastened, which, when it is moistened with the moisture distiIIing from the brain, wiII sweI1 up enough to 611 the concavity of the paIate. ConsequentIy, the artificia1 pIate cannot faI1 down, but stands fast and firm as if it stood of itself.” Par6 aIso described another form of obturator, resembling to a great extent the modern cuff button. The appIiance consisted of two buttons or discs of different sizes, the Iarger fitted to the roof of the mouth and covered the opening, was connected by a revoIving stud or screw to an obIong plaque representing the extreme length of the perforation. The appIiante was put in pIace and the screw turned, thus locking it directly over the cIeft. Pierre Fauchard first pubIished his famous “Le Chirurgien Dentiste” 1728, in which he described and iIIustrated more compIicated mechanisms for these defects than had previously been used. He depended upon the device passing through the aperture and resting on the superior surface of the surrounding border. Fauchard was apparentIy the first to construct such appIiances for mouths in which artificia1 teeth aIso had to be suppIied. His object was to have a convex-concave plate cover the fissure through which passed two wings foIded together. When the pIate was in the proper position, the wings were turned out by means of a screw arrangement. Small pieces of sponge were attached to these wings to adapt the appIiance to the tissues. M. de Ia Barre, in 1820 was the first to describe the use of an elastic gum in the restoration of the veIum and uvuIae. The appIiances which Ia Barre constructed were quite ingenious, but so compIicated and requiring so much ski11 to make, that the profession at Iarge did not accept them. His mention and use of the so-caIIed “elastic gum” are noteworthy. Mr. SnelI was probabIy the first to conceive the idea of making a mode1 of the affected mouth, on which he wouId construct and mount his obturator. Up to this time, 1828, there is no record showing the use of a model. In his book Mr. SneII stated: “My method of

Prosthetics

American Journal of Surgery

23

constructing an obturator is with a goId pIate, accurateIy fitted to the roof of the mouth, extending backward to the OS palati, or the extremity of the hard palate, about an inch in Iength, being carried through the fissure.” This obturator was simiIar in construction to our so-caIIed retaining pIate. To that part of the pIate which corresponds to the nasa1 fossae, two vertica1 pIates are soIdered, meeting in’the center and carried upward through the fissure to the top of the remaining portion of the vomer, to which the appIiance shouId be exactIy adapted, the surfaces conforming to the natura1 shape of the nasal palatine floor. Thus the nasa1 secretions will be carried directIy backwards into the fauces. A piece of prepared elastic gum is then attached to the posterior part of the pIate where the natura1 soft paIate begins, extending downward on both sides as Iow as the remaining part of the uvula, and grooved at its IateraI edges to receive the fissured portions of the velum.

As is evident from these early records the principa1 oraI defect is the congenita1 cIeft paIate. Other deformities of Iess frequence are acquired, and are invariably associated with destruction of tissue and distortion of the remaining parts, which may invoIve the Ioss of a section of the maxiIIa, mandibIe, nose, orbit, ear or cheek. Classification ORAL

AND

FACIAL

PROSTHETIC

DEFECTS

TREATMENT MAIN

I.

FORM

FOR

TWO

GROUPS

Intra-ora Defects : (a) MaxiIIary : (I) denta1; (b) MandibuIar: (I) denta

(2)

aIveoIar. aIveo-

(2)

Iar. PaIataI:

(I) congenita1 (2) acquired. Extra-ora Defects: (a) OrbitaI (b) Aura1 (c) NasaI (d) Cranial. (c)

2.

SUITABLE

INTRA-ORAL

DEFECTS

Dental Defects. By far, the most common ora defect is denta1, invoIving the Loss of teeth due to caries, trauma by maloccIusion, or a direct bIow disIodging the teeth.

26

American Journal of Surgery

OIinger-SurgicaI

EdentuIous means the Ioss of a11 the teeth of both the upper and Iower jaws. The average individua1 rareIy reaches maturity without Iosing one or more teeth. In areas of missing teeth, considerabIe resorption takes pIace in the aIveoIar process, thus causing IabiaI and bucca1 depression with more or Iess marked cosmetic disfiguration as we11 as Ioss of facia1 symmetry. To the prosthodontist faIIs the task of repIacing the missing organs and restoring the function, the form of the ora cavity and the facia1 expression. Various causes for the continuous resorption of the aIveoIar process foIIowing the extraction of teeth may be due to IocaI pathoIogy, genera1 Iow resistance, and iIIfitting partia1 or fuI1 dentures, especiaIIy when too hastiIy inserted. The Iatter wiI1 cause a kneading action on the aIveoIar ridge, this irritation hastening resorption and causing a hypertrophy of the gums. Resorption of the aIveoIar ridges in the upper and Iower jaws may continue throughout Iife and cannot be controIIed and may progress unti1 the ridges eventuaIIy vanishes. In such a case aIveoIectomy may be necessary for esthetic reasons. MAXILLARY

AND

MANDIBULAR

DEFECTS

:

DENTURES

These may be cIassified as (a) immediate-temporary; (b) permanent. A. The immediate-temporary dentures are those that are constructed and ready for insertion before the extractions have been compIeted. An impression is taken of the mouth with the teeth in pIace, a cast is made, cutting each tooth off the mode1 and repIacing it with an artificia1 tooth until the fuI1 compIement of teeth is repIaced. Upon the second sitting the teeth are extracted and the denture inserted in the mouth, utiIizing the aIveoIar sockets for the artificia1 teeth. The immediate-temporary denture has its advantage by acting as a spIint to the injured tissues, preventing sweIIing, controIIing hemorrhage, compressing the bony

Prosthetics

JANUARY, 1936

tissues, permitting heaIing to take pIace more readily, and heIping to form a compact rounded ridge for a permanent denture. B. Permanent dentures are constructed for the patient after the aIveoIar sockets and ridges have compIeteIy heaIed. This generaIIy takes pIace in six to twelve months, depending upon the heaIth of the individua1. The procedure is as foIIows: impression, bite, setting up the teeth on an anatomica articuIator to determine occIusion, articuIation, esthetics and expression. ESTHETICS

No matter how skiIIfuIIy adapted for speech and mastication an artificia1 denture may be, such artificiaIity must be apparent to the possessor unIess the age, temperament, facia1 contour and the natura1 expression are taken into account. In extreme old age, the atrophied condition of the jaws, due to the gradua1 Ioss of a11 the teeth and the resorption of the aIveoIar processes, produces that decided aIteration in the features of the aged with which we are a11 so famiIiar. The change which invariabIy takes pIace in the angle of the Iower jaw in consequence of the disappearance of the teeth and processes, causes the chin to project, and when the jaws are cIosed, the nose and chin approxImate each other. Even when they are apart, the faIIing in of the Iips so encroaches upon the ora cavity as to make it too smaI1 for the tongue, and thus renders the speech feebIe and indistinct. It is that in such instances the prosthodontist exhibits his ski11 and artistry, not onIy by repIacing the Iost expression of the face, but aIso by restoring the medium through which the wants and thoughts of the individua1 are made known to others. PALATAL

DEFECTS

There are two types of paIata1 defects nameIy congenita1 and acquired. I. CongenitaI defects are due to Iack of union of the paIata1 processes of

NEWSERIES VOL.XxX1, No. I

2.

OIinger-SurgicaI

the maxiIIary bones and the IateraI processes of the nasa1 bones. This defect is reveaIed between the eighth and tenth weeks of intrauterine Iife. Acquired defects arise from (a) Trauma: such as gunshot wounds, injuries sustained in auto accidents, athIetic games, etc. (6) Disease: such as sarcoma, carcinoma, necrosis, OsteomyeIitis, tubercuIosis, syphiIis, etc. (c) Radium and x-ray burns. CONGENITAL

DEFECTS

The congenita1 cIeft paIate is the resuIt of arrested deveIopment in embryo of the parts invoIved, and the faiIure of these parts to unite during their deveIopmenta1 period in feta1 Iife. The fissure may extend to any degree varying from a sIight notch of the Iip or the uvuIa, to a compIete cIeft of the Iip, the aIveoIar process, the paIata1 bones and the veIum paIati. The formation of the maxiIIary process begins about the twenty-eighth day of feta1 Iife. At the end of the tenth week, the paIata1 processes have united. Union begins at the anterior aspect and progresses backward, the uvuIa being the Iast to unite. ConsequentIy, the size and extent of the fissure depends IargeIy upon the time of the interference in the process of deveIopment. The cause of the condition is uncertain and may be due to one or more factors; fauIty nutrition, materna1 impressions, syphiIis, aIcohoIism, crowded position of the fetus, etc. Some have thought the defect to be caused by the lack of sufficient caIcium phosphate in the system of the mother during gestation. This theory has very IittIe weight, as it is a fairIy weII-estabIished fact that union or coalescence of the tissue does not depend upon ossification, but takes pIace in advance of ossification. It is aIso known that a sufficient suppIy of caIcium saIts must be suppIied to the mother to offset the demands of the growing fetus.

Prosthetics

American ~0~d

of

surgery

27

The question of hereditary influences would seem to pIay an important part in the production of this defect, some famiIy histories presenting these hereditary inff uences, but most do not. Dr. CharIes B. of the Carnegie Institute Davenport, Department of Experimenta EvoIution, who has made extensive investigation aIong this Iine, writes: “ WhiIe we have been able to accumuIate a Iarge number of pedigrees, we have not been abIe to get the exact key to the method of inheritance of the cIeft paIate. We know mereIy in genera1 that it is inherited, or that heredity pIays an important part in its production.” Acquired defects are numerous, irreguIar in character, varying from a slight perforation in the hard or soft paIate to the compIete absence of the soft tissues and bony framework. There are severa methods for the retention of restorations for this type of defect: I. Adhesion, as in edentuIous cases 2. UtiIization of existing teeth as abutments 3. BuIbous extensions into existing perforations 4. In rare cases the use of spiral springs. In some cases it is necessary to empIoy a combination of the methods. Surgical and Prosthetic Correction. In properIy seIected cases, surgica1 restoration of the cIeft paIate is the desired method by a skiIfu1 ora or pIastic surgeon. However, there are severa definite contraindications to surgica1 treatment, nameIy: (I) age of the patient, (2) inabiIity of grafts to take, (3) extensive defect, or (a) secondary defect caused by excessive postoperative tension, or (6) insuffIcient amount of tissue Ieft for surgica1 repair without shortening the uvuIa, in which case speech wiI1 not be improved. In order to reaIize the significance of the contraindications for surgica1 intervention, and to devise and fit suitabIe prosthesis, it is important that one shouId be famiIiar with the norma structures of the tissues and their functions, as we11 as the abnorma1. This presupposes a thorough knowIedge of the anatomy and

28

American

Journal

of Surgery

OIinger-SurgicaI

Prosthetics

physioIogy of the parts involved, as we11 as their embryoIogy and histoIogy. The Iarynx and the ora and nasa1 struc-

FIG. FIGS. r-3.

Schematic

FIG.

I.

drawing

However successfu1. destruction

demonstrating

JANUARY, 1936 palatal surgery is not always Operative procedures causes of muscuIar tissue which is

FIG. 3.

2.

relationship of organs of)arynx, resonance cavities.

tures, with the cavities as resonators, constitute the speech mechanism. The structures of these organs and their reIationship demonstrated in Figures I, 2, and 3. The paIate, one of the most important parts of this voice mechanism, reguIates the size and shape of the ora resonating cavity, forming the tone of the voice and closing the nasa1 passages in the emission of certain sounds. It is principalIy because of defective speech that patients with cIeft paIate seek treatment. In surgery or prosthesis the object is to restore the deficient parts in a manner that wiI1 enable the muscIes to perform a11 the functions necessary for norma speech. If this restoration is possibIe, the patient, with proper training, shouId be abIe to speak with perfect articuIation and normaI tone quaIity. The perfect objective wouId be to surgicaIIy restore a11 the missing tissues so that norma speech wouId resuIt. UnfortunateIy, this goa cannot always be attained. FulIy recognizing the necessity for a compIete cIosure of the paIate in order to satisfy the yearning for norma speech, many surgeons of this modern age, such as Brown, Blair, Davis, Dorrance, Ivy, Vaughan, Kazanjian and Dunning, have done pIastic operations, skiIIfuIIy Iengthening the veIum in order to enabIe it to function properIy as an aid to speech.

oral nasal cavities

and the six

essentia1 to this indispensabIe organ of speech. The resuItant cicatricia1 rigidity of the parate mitigates against further effort for the possibIe restoration of norma speech function. At this point the cIosest cooperation shouId exist between the pIastic surgeon and the dentist. The method of procedure, surgery or prosthesis, shouId be decided jointIy wherever possibIe. Indications for Prosthetic Restoration. Prosthetic appIiances shouId be empIoyed: (I) When quick painIess resuIts are desired by the patient (2) When the deficiency is due to a disease that makes surgery a doubtfu1 procedure (3) When the defect is too extensive (4) When the physica condition of the patient contraindicates the strain of a Iong series of pIastic operations (3) When a temporary apphance is desired preceding a series of pIastic operations. MECHANICAL

TREATMENT

Heretofore, apparentIy the onIy object in constructing restorations for these cases has been to close off the nasal passages from the ora cavity. No account was taken of the important part the vomer has in breaking up the current of air during inspiration, nor of the part the nasa1

NEW SERIES VOL. XxX1, No.

I

OIinger-SurgicaI

cavity has in the production of resonance in voice and speech. In the appIiances that we are now constructing, a11these important factors are considered, and we attempt to reproduce a11 Iost or missing tissues in as normaI a state as possibIe. Technique in General. Using dentocoI1 as the medium, we take a fuI1 impression of the compIete cIeft, to obtain study modeIs with a11 the soft tissues in their proper reIationship. A second impression is taken to reproduce a working mode1 for the construction of an obturator retaining denture, which serves two-foId, to cIose over the maxiIIary defect and to support the vomer and velum attachment. In cases in which the teeth are a factor in construction, impressions of the mouth are obtained in modeIIing compound. The casts are then poured into Weinstein’s stone, and modeIs of the exposed teeth are made by fashioning a singIe Iayer of softened red wax over the teeth and then trimming off the excess wax down to the gingiva. For the retaining dentures, it is possibIe to use gold, siIver, pIatinum aIIoys or vuIcanite rubber, but because of its maximum strength with a minimum thickness, vitaIIium is preferabIe. For the construction of splints, impressions of the mouth are commonIy made in modeIIing compound. A mode1 of the spIint is then made by burnishing a singIe Iayer of red wax over the teeth on the casts as far as the gingiva. This method of obtaining impressions for splints has many advantages pver the use of plaster, the most outstanding being that in removing the compound impression the undercuts ‘draw,’ consequentIy in the finished state there is IittIe dif%cuIty in appIying the spIints due to the fact that undercuts are not Iacking. A hinged type movable veIum is preferabIe in those cases where there is considerabIe fIexibiIity to the uvuIa and the paIato-pharygea1 muscuIature, as we11 as in instances in which no attempt has been made to surgicaIIy cIose the posterior

Prosthetics

American

Journal

of Surgery

29

cIeft. A fixed, immovabIe veIum is preferabIe in the cases in which there is fixation from cicatricia1 tissue, as in an acquired, syphiIitic cIeft. The veIum is often reproduced in Iuxene, a synthetic resin, its color resembIing the paIate tissues and very compatibIe with them. It has sufficient weight to keep it in position when the paIata1 muscIes are reIaxed, and yet is not too heavy for the muscIes to raise in contraction. This movement is made possibIe by the hinge attachment. This type of restoration is most hygienic. Moreover, the vomer attachment is constructed of a meta which assumes body temperature and aids in the warming and moistening the inspired air. WhiIe restoration is a primary factor in repIacing norma function, education is necessary to improve speech, owing to the fact that the patient couId not enunciate properIy because of the Iack of tissues in his attempts to produce the various speaking sounds he brings to his aid other tissues or parts. Thus, it becomes difficult to overcome habits. The compIeted restoration put into pIace in the mouth, functions as an anatomica part. The patient becomes a pupi in phonoIogy and orthoEpy, and is instructed in perfect articulation, as we11 as normal voice tone and resonance. Tongue gymnastics are of great importance in bringing new Iife to the suppressed activities of this organ by voIuntary movements in direction, position and rapidity. CASE

REPORTS

To demonstrate the construction of suitable apphances typica cases are described: CASE I. L., aged 16 years, one of five chiIdren, was the onIy member of the immediate family who had a deformity. There was no history or indications of cleft parate in either the materna1 or paternal ancestors. The girI was robust and in exceIIent health. Oral defect: At birth there was a compIete biIatera1 cIeft with biIatera1 hare Iip. The hare Iip had been repaired at an early age, and an unsuccessful1 attempt made to cIose the maxiI-

30

American

Journal

OIinger-SurgicaI

of Surgery

Iary

cleft. The vomer missing. Mechanical Treatment:

FIG. 4A. FIGS. 4A and 48. CompIete

bone

was

A suitabIe

partiaIIy

FIG. 4B.

cleft of hard and soft paIates. c. DoubIe Robert Ivy.

appIiance, nasa1 and palatial. hinge attachment and vomer restoration.

the posterior

JANUARY,

Note

retaining denture end. A vitaIIium was then constructed over this working modeI. By using base pIate wax attached to the nasal aspect of the meta denture, we reproduced the missing portion of the vomer bone upward to approximate the tissues and as far back as the posterior border of the hard paIate. This was fitted and tried in the mouth to be sure of its cIose adaptation to the tissues.

1936

It was necessary to empIoy a hinged veIum attachment. In order to cIose the cIeft in the soft paIate with some device that wouId stay

De Trey

dentocoI1 impression tray was seIected and a perforated fusibIe meta section to approximate the posterior pharyngeal waI1 soft soIdered to

FIG. 5. Completed

Prosthetics

FIG. 4c.

hareIip,

subsequently

corrected

by Dr.

in position during the muscuIar movements of the tissue, a piece of base pIate gutta percha was shaped to fit the cIeft snugIy from side to side, thus forming the roof of the mouth and floor of the nasa1 passages, widening out as it extended backward, to form a ffange on both sides overIapping the upper edges of the paIata1 tissues. The movabIe section of the hinge was imbeded in its anterior portion and the whoIe attached to the retaining denture. This was then pIaced in position in the mouth and the proper approximation was obtained by carefu1 trimming or adding with Iow fusing Everett’s wax. The appIiance had to extend suffIcientIy posteriorIy and be so shaped that when raised by the muscuIature, as in the act of swaIIowing, it touched the posterior waI1 of the pharynx in order to entirely cIose off the passage into the nasaI cavity. This veIum was then reproduced in Iuxene. In addition to this restoration, education to improve speech was necessary. It was necessary to practice the phonetic sounds of the vowels foIIowed by a11 the expIosives: the object being to strengthen and deveIop the pharyngea1 and paIata1 muscuIature so that they wouId firmIy and invoIuntariIy cIose around the artificia1 veIum, compIeteIy preventing the vocaIized air escaping into the nose. See Figs. 4A, 4~, QZ, 5.

NEW SERIES VOL. XxX1, No.

I

OIinger-SurgicaI

CASE II. Mr. E., aged forty-two. History. A pimpIe at the junction of the hard and soft paIate on the Ieft side, was

Prosthetics

American JournaI of Surgery

immediateIy possibIe upon the insertion restoration. (Fig. 6~.) It is noteworthy that after severa

3 I

of the weeks,

Frc. 6~. FIG. 6~. FIG. 6~. Perforation at junction of hard and soft palate. FIG. 6~. Restoration in mouth.

opened and subsequent1.y became infected. The tissue surrounding this area hypertrophied and eventuaIIy sIoughed, Ieaving a perforation about the size of a pea. As biopsy reveaIed carcinoma, this area was treated with radium and x-ray. FoIIowing this intensive irradiation severa unsuccessfu1 surgica1 attempts were made to cIose the perforation. Description of Oral Defect. When first seen it was found that the mucous membrane of the whoIe paIate was intenseIy inflamed, and an irreguIar aImond sized perforation in the soft paIate at the maxiIIary junction. It was apparent that the irritation had been produced by a red rubber vuIcanite appIiance which he had worn to cIose over this aperture. This appliance was constructed of a materia1 contraindicated in these cases, was aIso iII&ting and covered entireIy both the hard and soft paIates. (Fig. 6~.) Mechanical Treatment. VitaIIium was seIected as the medium because of its compatibiIity with these tissues. A paIata1 bar was constructed the available teeth being utilized for its retention by cIasps. To the posterior aspect of this paIata1 bar, an ova1 ffange extension about 8 by 12 mm. was spot weIded to sea1 over the perforation. As is aIways true in this type of acquired case, normal speech was

the tissues of the paIate assumed a heaIthy appearance, and the irritation surrounding the defect cIeared up entireIy.

FIG. 7. Acquired cIeft in palate. Nose had been restored by pedicIe Aap from forehead.

CASEIII. Miss S., aged fifty. History. There was a Iarge cIeft of the soft paIate, which had its anterior margin at the

32

American Journal of Surgery

OIinger-SurgicaI

juncture of the hard and soft paIate and extended back as far as the uvuIa, being about 23 mm. in width. There was very Iittle movement of the remaining muscuIature due to the presence of scar tissue. (Fig. 7.) Etiology. A Iarge gumma invoIving the whole of the nose and haIf of the soft paIate, with breaking-down of tissue, was responsibIe for the condition. Treatment. The specific treatment, in this case, consisted in the construction of a retaining plate with an attached vuIcanite obturator. The obturator, in this case, was not to repIace a11 the tissues Iost, but was to cIose the nasopharynx and thus reestabIish articuIate speech. The nose was surgicaIIy constructed by means of a pedicIed ffap from the forehead and then made rigid by the impIantation of Costa1 cartiIage. An impression was taken with the correctibIe pIaster technique, the imprint. first. having been taken in soft modeIing compound, then trimmed to the desirabIe muscIe where necessary, and then given a pIaster wash to correct any defects in the in&a1 impression. This was then “boxed in” and poured in stone. The retaining plate was constructed by the regular pa&a1 denture technique with the exception that an undercut section was removed from the paIata1 aspect. of the pIate. This section was about 12 mm. wide and about 2-5 mm. Iong, running antero-posteriorIy. The purpose of removing this undercut section was to form a means of attaching the obturator portion. When the retaining pIate was compIeted (fitted, polished, etc.) a wire Ioop was set in pIace in this undercut section and the plate inserted in the mouth to see that the wire did not compress the tissues. The denture, with wire attached, was then removed and on this Ioop was fashioned a baI1 of softened carding wax, the approximate size and shape of the whoIe cleft. This was waxed fast to the denture and the whoIe then pIaced in position. The patient was requested to cIose the mouth, compress the cheeks and then swaIIow severa times. The act of swaIIowing wouId naturaIIy bring about a contraction of the muscuIature of the soft paIate to cIose off the nasopharynx. In this case, due to the scar tissues there was not much movement of the remnant of the paIata1 muscIe but what IittIe movement had taken pIace was recorded on the soft wax. This baII of wax was then chiIIed with coId water and

Prosthetics

JANUARY, 1936

the whoIe removed. A sIight imprint of the muscIes was seen on each side of the baI1. The excess wax was trimmed down to the extent of the imprint on the paIata1 aspect. The periphery of the wax was now softened and again pIaced in the mouth, the patient swaIIowing. There was some tendency to gagging due to the approximation of the wax with the dorsum of the tongue. In order to overcome this, the wax buIb had to be trimmed off short of the dorsa1 extremity of the soft paIate and in order to effect a suitable cIosure of the cIeft, the bulb was extended to reach the posterior waI1 of the nasopharynx, this being once more inserted and the patient. swallowing again. It was now thought that the cIeft was s&icientIy closed to permit correct articuIation of words. The most diffIcuIt words to enunciate in such a condition are the so-caIIed hissing consonant words such as scissors, siss, etc. These were pronounced with apparent ease so it was evident that the obturator wouId function properIy when compIeted.

At this point we wouId Iike to report two cases that demonstrate prosthesis as an adjunct to surgery. The first case comprises the construction of an intermaxiIIary retraction spIint to retrude a prognathous mandibIe upon sectioning. The second case iIIustrates the construction of an intermaxiIIary spIint of the GiImer type to immobiIize the mandibIe for the pIacing of a bone graft foIIowing resection of a portion of the mandibIe for OsteomyeIitis. CASE IV. Mr. A. C., aged twenty-three years. Existing Condition: There was pronounced protrusion of the mandibIe, necessitating biIatera1 sectioning of the mandibIe and subsequent removal of an inch of bone. The prognathous condition was probabIy due to acromegaIy. Mechanical Treatment: The specific treatment was the construction of a set of metaIIic spIints that wouId retract the jaws after the excision of a segment of bone. Impressions of the mouth were obtained in The casts were then modeIing compound. poured in Weinstein’s stone and models of the exposed teeth were made in wax, by fashioning a singIe Iayer of softened red wax over the

NEW SERIES VOL. XxX1, No.

I

Olinger-SurgicaI

teeth and then trimming off the excess as far down as the gingiva. This was constructed in a continuous strip, shaped to take the form of the desired splint. It was necessary now to provide some attachment to produce a retraction of the mandible. The method employed was to cut an Angie’s orthodontic band in half and form a Ioop on the cut ends; this provided a means of attaching the sections to the linished spIint. A wire Ioop was aIso piaced on each spIint (now in the wax) between the centra1 incisors for subsequent wiring together of the maxiha and mandibIe. These splints were cast in Weston’s meta according to the usual technique. The splints were fastened in pIace before the operation with a slow-setting crown and bridge cement. The operation, in generaI, consisted of severing the mandibIe in the region of the angIe, drawing it forward to sIip the retracting bands in place, and these were tightened by a Iocknut attachment unti1 the jaws were in their proper relation. A wire was then slipped through the anterior Ioops which were fastened together. CASE v. Miss IX I., aged twelve years. Existing Condition: This was a case of osteomyeIitis which had invoIved surgica1 remova1 of a section of the right mandibIe in the region of the angIe. The Iower jaw presented a marked undersIung condition on the Ieft side due to the remova of a section of bone on the right side and the subsequent drawing over of the fragments to approximate each other. The jaw was puIIed IateraIIy and posteriorIy. Mechanical Treatment: The treatment in this case, was the construction of a set of meta spIints to hoId the jaws in correct position after the operation for the correction of the deformity. The mandible was divided in the region of the ramus and the adhesions freed. The spIints were to have a single Iocking device which was to be pIaced on the side opposite the site of operation. Impressions of the mouth were obtained in modeling compound. This method of obtaining impressions for spIints has the advantage over the use of plaster in that there are no undercuts. A wax model of the spIints was made by burnishing a singIe layer of red base pIate wax over the teeth on the casts as far down as the gingiva. A Iocking device was constructed and set in place in the wax. The modeIs were then removed from the casts and their dista1 ends joined.

Prosthetics

American

Journal

of Surgery

33

FoIlowing the modeIs with this the sprues attached at the joint were invested in casting investment, and after subsequent “burning out” were cast in Weston’s meta1. Upon compIetion, the spIints were tried in place and then cemented fast, by the use of a slow-setting crown and bridge cement. EXTRA-ORAL

DEFECTS

ORBITAL DEFECTS. In malignancy of the orbit with extensive invoIvement necessitating compIete remova of the orbita contents and adjacent tissues, surgical prosthesis pIays a most important roIe in accompIishing a cosmetic resuIt. These restorations also protect the operative areas and permit easy, frequent inspections for possibIe recurrence. The foIlowing case demonstrates an invoIvement of the orbit and cheek as the resuIt of an extensive carcinoma of the upper jaw. CASEVI. History. Miss E. S., houseworker, aged fifty-eight years, Irish. She was First seen on JuIy 14, 1923, presenting a painless swehing of the Ieft side of the cheek and some buIging over the aIveoIar process in the Ieft upper moIar region. AI1 the teeth had been removed fourteen years previously. Family History: The famiIy history was essentially negative. Past History: Seventeen years ago she had kidney troubIe; she also had bronchopneumonia and has suffered from bronchitis more or Iess ever since. There had been no operations or any serious injuries. Present Illness: In February, 1923, the patient noticed some pain in the gums of the Ieft upper jaw and left occipita1 headache, radiating to the top of the head. With her finger she feIt a thickening in the upper jaw in the region of the Iast moIar. About the same time she noticed a sw&ng of the Ieft cheek. July 16, x-ray examination of the maxillary sinuses by Dr. Pancoast showed clouding of the Icft side. JuIy 27, Dr. Ivy made a smaI1 incision in the Ieft upper jaw entering the antrum, and the specimen taken for biopsy was reported (PoIycIinic HospitaI) as papiIIary squamous carcinoma.

34

American

Journal of Surgery

OIinger-SurgicaI

July 28, she was referred to Dr. Pancoast at the University HospitaI for radiation treatment. Examination at this time showed a wound in

FIG. 8~.

Prosthetics

1936 JANUARY,

Ieft maxiIIa. This interfered greatIy with articulate speech. The patient was unabIe to move the mandibIe more than 0.5 mm. on

FIG. 8~.

FIG. 8~.

Carcinoma of paIate, antrum and orbit. FIG. 8~. CompIete facial and orbita restoration.

the upper Ieft jaw at the premoIar

region at the site of the antra1 exploration. A sense of fuIIness and thickening over the Ieft cheek; apparentIy no nasa1 obstruction; no gIanduIar invoIvement on either side of the neck; very IittIe pain; no disturbance of vision. Treatment. July 28, JuIy 30, and August 3, radium was appIied to the Ieft antrum and upper jaw. X-ray treatment was given to both sides of face and neck on JuIy 28, October 5, and December IO, 1923. March I and November IO, rgzq, and December 29, 1925 (fuI1 doses). August 7, 1923, under endopharyngeal ether, the Crosby-Green operation was performed by Dr. MuIIer, exposing the interior of the Ieft antrum for the insertion of radium. August 21, radium was inserted into the antrum. On March 22, 1924, the Ieft eye was enucIeated and superior maxiIIa was resected by Dr. MuIIer. Subsequent pathoIogica1 examinations were negative for carcinoma. March I, 1925, the patient was referred to the Evans Institute for prosthesis. There was a Iarge opening through the Ieft cheek into the mouth and nose, aIso the Ieft side of the hard palate was missing due to the remova of the

account of adhesions, thus preventing the taking of impressions for prosthesis. The Ieft eye was absent and the socket contracted. March 27, 1925, at PoIycIinic HospitaI, under coIonic ether anesthesia, Dr. Ivy sectioned through the Ieft ascending ramus of the mandibIe to permit opening of her jaw. Impressions for prosthesis then couId be easiIy taken. October 23, at PoIycIinic HospitaI, under ether anesthesia, the Ieft eye socket was obIiterated by dissecting out the conjunctiva1 sac and suturing the Iid margins (Dr. Ivy). Prosthetic Treatment. The method of treatment consisted of repIacing the tissues lost through surgica1 operation with a prosthetic appIiance. This appIiance consisted of a fuI1 upper denture in the form of an obturator to remedy the Ioss of the paIata1 tissue; a fuI1 Iower denture, an artificia1 cheek to restore the contour of the face as accurateIy as possibIe, the pIacement of an artificia1 eye of suitabIe form and coIor, and upper Iid and Iower Iids. (See Figs. 8~, 8~.)

AURAL DEFECTS. may be congenita1, maIignancy. Our Iimited to the two

Defects

of the amide

traumatic experience Iatter types,

or due to has been prosthesis

NEW SERIES VOL. XxX1,

No.

I

Olinger--SurgicaI

being particularIy we11 adapted for these cases. In the foIIowing cases the Hanau method of eIectro-deposition was used.

Prosthetics

American Journal of Surgery

35

on the tissue aspect to prevent deposition of siIver thereon. SiIver was deposited to an approximate thickness of 40 gauge (the deposition

FIG. 9B. FIG. 9A. FIG. 9.4. Loss of right ear with Iower lobe remaining. FIG. QB. Restoration in position. CASE VII.

years. the patient had been in a raih-oad accident and among other injuries suffered the Ioss of all but the Iobe of the right ear. (See Fig. gA.) Mechanical Treatment consisted of the construction of a restoration of the missing aura1 portion to fit over the remaining stump of the ear. The appIiance seIected for this case was to be made with a goId base where contact is made with tIssue.s, and the body to be eIectroformed in siIver. The first step was to obtain accurate modeIs of both the mutiIated and intact ears, and negocoI1 was used as the impression medium. A mode1 of the intact ear was desired in order to accurateIy reproduce its opposite. A piece of 33 gauge goId was burnished over the portion of the mode1 of the mutiIated ear which represented the stump. This was more accurately adapted by swaging. Over this, a reproduction of the reverse of the intact ear was carved in Kerr’s bIue inIay wax, using the mode1 of the Ieft ear as a guide for the contour. This was removed in toto from the cast and prepared for eIectro-deposition. The wax pattern was now prepared for eIectroforming, first varnishing the goId base Histo y.

Mr. T., aged thirty-seven

SeveraI years previousIy

can be controIIed by the eIements of time and current utiIized), by the eIectroforming eIectropIating technique as developed by the Hanau Engineering Corporation. The restoration was tinted with flesh coIor lacquer as a basic tint. With the appliance in position, the fina tinting was done to harmonize with the complexion. was retained by means The prosthesis of the folIowing adhesive medium suggested by Dr. Herman Prinz of the University of Pennsylvania. Para rubber. Gum mastic. ChIoroform

2

.

.

parts

32 parts I oo

parts

The main advantage of the method employed in the construction of this appIiance Iies in the possibiIity to reproduce the irreguIar foIds of the ear. To swage such a restoration as has herein been described is impossibIe. With controIIed current, it is possibIe by the use of the Hanau method, to reproduce the detaiIs in the completed appIiance as originaIIy carved in the wax. There wiI1 be a sIight stippIed effect which adds naturaIness and aids in the retention of the coIoring material. (See Fig. 96.)

36

Olinger-Surgical

American Journal of Surgery

CASE VIII. Mr. B., aged sixty-eight. History. FoIIowing carcinoma of the right auricIe necessitating amputation, onIy a smaI1

FIG. FIG.

IOA.

FIG.

IOB.

IOA.

Prosthetics

JANUARY. 1936

tient had been treated with radium and x-ray therapy for carcinoma of the right IateraI section and portion of the septum of the nose.

FIG.

IOB.

Carcinoma of complete nose amputation. Nasal restoration, front views of the nasal prosthesis.

section of the upper and Iower Iobes remained. Treatment in this case was essentiaIIy the same as that described in Case VII with the exception that in this case the entire restoration was made by eIectro-deposition on a wax modeI, the portion approximating the tissues being subsequentIy goId pIated. The remaining stumps aided greatIy in the retention of the appIiance. It is pertinent to mention here that where the entire ear is absent, we are sometimes abIe to utiIize the aura1 cana in conjunction with spectacIe frames to hoId the prosthesis in position. It is aIso possibIe in some instances to obtain suf5cient retention by extending Aanges into artificia1 pockets formed by means of pIastic surgery. NASAL DEFECTS NasaI defects may be cIassified as partia1 or compIete, depending upon the extent of the Ioss of tissues. CASE IX. Mr. W., aged seventy-three years. History. SeveraI years previousIy the pa-

He was referred from the Newark City HospitaI by Dr. Lyndon Peer, who had removed a section of the nose by the eIectrosurgica1 knife, excising the entire diseased tissue Ieaving good margins of heaIthy tissue. Prosthetic Treatment. A cast was made of the face using negocoI1 as the impression medium. The nose was moIded to a normal contour with pIasticene. In this case a geIatin mixture was the medium seIected for the restoration. Thus it was necessary to construct a die and counterdie, in order to reproduce the section moIded of pIasticene. The formula for the geIatin was suggested by Dr. Batson of the Graduate SchooI of Medicine, University of PennsyIvania. It consists essentially of equa1 parts of geIatin and gIycerine with enough distiIIed water to bring the geIatin into solution, to which water soIubIe dyes are added unti1 the proper tint is obtained. This geIatin nose Iasts for a Iimited period and must be renewed. The patient is easiIy taught how to moId his own appIiance. The gelatin mixture is brought to meIting point by heat treatment in a doubIe boiIer. It is then poured into the moId and placed in a refrigera-

NEW SERIES VOL. XxX1, No. I

Olinger-SurgicaI

tor unti1 thoroughIy

cooIed. After its remova from the moId it is heId in position by gum mastic adhesive soIution.

CASE x.

Mrs. R., aged seventy-five

years.

History. Symptoms were noticed at the age of fifty. The Iesion beginning as a pimple on the tip of the nose, was later diagnosed as carcinoma. She had been treated for twenty-five years, but complete amputation of the nose was finaIIy indicated. The operation was performed by Dr. Lyndon Peer, and was foIIowed by radium and x-ray therapy. (See Fig. IOA.) Prosthetic Treatment. A cast of the face was made employing negocoll as the impression material. On this cast a nose was moIded to conform and harmonize with the other features, taking into consideration the age of the patient and using some oId photographs of the patient as a guide. Over this a wax veneer was appIied and when dry removed from the moId. The next step was to devise a method of retention. A ffange was extended laterally with a boot effect resting on the nasal spine. The wax and pIasticene were now removed and the mode1 reproduced in canauba for the purpose of eIectroforming a base to utilize tissue support. A siIver base of 30 gauge was eIectroformed by the Hanau technique. Upon compIetion of this portion it was thoroughIy dried under a bIast of warm air. To this was attached the wax veneer which constituted the desired contour to be reproduced in the compIeted appliance. Over this a 40 gauge thickness

of siIver was laid down by electro-deposition, this completing the restoration. The wax was now boiled out leaving a hoIIow, Iight but strong appliance. All but the portion in contact with the tissues was now varnished to make it non-conducting. The remaining portion was given a heavy pIatc of goId. The method of coIoring was the same as that employed in the ear restoration. In this case a speciaIIy constructed pair of spectacle i’rames with the nose piece attached to the appliance aided in the retention. (See Fig. IOB.)

EstheticaIIy and psychoIogicaIIy these prosthetic appliances are invaluable to the patient. To a great extent they eliminate

Prosthetics

American Journal of Surgery

37

the respuIsive appearance of a severe disfigurement. We again wish to emphasize the importance of cooperation between the surgeon and the prosthodontist in the care of patients with extensive facia1 disfigurements. SUMMARY I. SurgicaI reconstruction of missing parts is the idea1 procedure when feasible. 2. InoperabIe cases of cIeft paIate require a properIy constructed obturator for the cIosure of the cIeft and to aid norma speech. 3. Extensive maIignant growths of the face when surgically removed may be temporariIy or permanentIy covered by a prosthesis. 4. Prosthetic appIiances are usefu1 in avoiding contracture deformities during reconstructive intervaIs of surgica1 procedures. 5. In ora defects properIy constructed dentures may be made to fuIfi1 the double purpose of repairing a defect and restoring articuIate speech and esthetics. REFERENCES KAZANJIAN, V. H. DentaI

prosthesis in reIation to facia1 surgery. Surg. Gynec. Obst. 59: 70-80 (JuIy) 1934. J. Dental Research, 12: 651-670. 1933. Also in: NICHOLS: Prosthetic Dentistry, ” St. Louis, hlosbg, 1930, pp. 471-523. KINGSLEI-, N. W’. Oral Deformities. AppIeton, N. Y., I 880. CASE, C. A. Dental, Orthopedic and Prosthetic Correction of CIeft-PaIate. Chicago, Case, 192 I. FRAHM, F. W. The PrincipIes and Technique of FuII Denture Construction. BkIyn., DentaI Items of reparative

I&., 1934. DORRAKCE, G. 1~1.Arch. Surg., 21: 185-208 (Aug.) 1930. JESSNER. J. Am. J. Clin. Med. (Oct.) 1022. AXT, E. F. A case of surgica1 prosthesis. Dental Cosmos

(Aug.) 1927. VoI. LXIX. No. 8 pp. 828-830. Prosthesis as an aid to ora1 surgeon. Dental Surgeon, ‘929. MITCHEL, V. E. ArtificiaI

restoration of lost or missing tissues in congenita1 cIeft-paIate and other deformitics of the mouth. Dental Cosmos, 1917. Reprint.