- Email: [email protected]
The labial plate major connector in the partial mandibulectomy patient
was removed with a carbide bur (Figs. 4 and 5). Pressureindicating paste was used to adjust the regions of tissue impingement during swallowing, speech, neck extension, and head movements. After the final polish and delivery of the obturator prosthesis (Fig. 6), the patient was reevaluated after 24 hours. The patient reported elimination of nasality during speech, cessation of nasal leakage, and improved masticatory efficiency.
SUMMARY The treatment of a patient with a soft palate obturator prosthesis made with VLC resin was described. The procedure is accomplished conveniently at chairside, eliminating a laboratory procedure and thus saving time for both the patient and the maxillofacial prosthodontist.
The labial plate mandibulectomy
major connector patient
REFERENCES 1. Mazaheri M, Millard RT. Changes in reeonence related to differences in location and dimension of speech bulbs. Cleft Palate J 1965;2:167-75. 2. Ogle RE, Sorenson SE, Lewis EA. A new visible light-cured resin system applied to removable prosthcdontics. J PROSTHET DENT 1986;56: 497-506. 3. Khan Z, von Fraunhofer JA, Razavi R. The staining characteristics, transverse strength, and microhardness of a visible light-cured denture base material. J PROSDENT 1987;57:364-6. 4. Nimmo A. Correction of posterior palatal seal hy using a visible lightcured resin: a clinical rep0rt.J PR~STHET DENT 1988;59:529-31. 5. Nimmo A. Efficient denture repairs using a wsible light-cured resin. Compend Contin Educ Dent 1988;9:528-33. Reprint requests to: DR. ZAFRLJLLAKHAN UNIVERSITY OF LOUISVILLE SCHOOLOFDENTISTRY LOUISVILLE,KY40292
in the partial
Stanley H. Wakamura, D.D.S.,*Jack W. Martin, D.D.S., M.S.,** Gordon E. King, D.D.S.,*** and Donald C. Kramer, D.D.S., M.S.**** The University of Texas M. D. Anderson Hospital and Tumor Institute, Houston, Tex. The indications, design, and advantages of the labial plate major connector as compared with the labial and lingual bar major connector are reviewed. The mechanical principles of increased rigidity and strength are discussed. The article suggests that the labial plate major connector may have an advantage over the labial bar major connector and should be considered when a labial connector is indicated.(J PROSTHETD~~~1989;61:02:673-6.)
T
he treatment of a patient with cancer of the floor of the mouth may include surgery, radiation therapy, chemotherapy, or a combination of these modalities. Gross facial disfigurement and impaired mandibular function may result when the extent of surgery interrupts mandibular continuity. Maintaining continuity helps preserve normal muscle function and facial contours and leads to a more predictable and favorable prosthodontic treatment. When mandibular anterior teeth (especially mandibular canines) are surgically removed with a portion of the floor of the mouth and tongue, the facial muscles exert force on
*Fellow, Department of Dental Oncology. **Associate Dental Oncologist (Maxillofacial) fessor of Dental Oncology. ***Chairman, Department of Dental Oncology Dental Oncology. ****Associate Dental Oncologist and Associate tal Oncology. 10/l/16914
THEJOURNALOPPROSTHETICDENTISTRY
and Associate
Pro-
and Professor Professor
of
of Den-
the remaining dentition, which may lead to a severe lingual inclination of the teeth (Fig. 1). The design of a prosthesis must allow for the altered state of the remaining dentition. This article discusses the indications for and design of the labial plate major connector for the partially edentulous mandibulectomy patient.
INDICATIONS The major connector in a mandibular removable partial denture has traditionally been placed on or below the lingual surfaces of the mandibular teeth. When anatomic variation prevents insertion of a properly designed lingual major connector, the choice has been either a labial bar or a swing-lock removable partial denture. The labial plate major connector is a modification of the labial bar and offers several advantages over the bar-type design. The labially placed major connector is seldom needed or used. The first reported use of a major connector was in 1728 by Pierre Fauchard.l Fauchard recognized the importance of rigidity of the major connector and incorpo-
673
NAKAMURA
Fig. 1. Typical patient whose anterior mandible, alveolus, and floor of mouth have been resected.
2. Length of occlusogingival labial plate adds increased strength over labial bar.
Fig.
rated a labial connector as well as a lingual bar. In 1934, Roach2 described the use of a continuous truss bar placed in a labial position. Kelly,3 in 1950, described the use of a strut bar as a labially placed major connector for a removable partial denture in a patient who had experienced trauma to the mandible. Indications for the use of a labial plate major connector are (1) severe lingual inclination of the mandibular teeth, (2) large mandibular tori that cannot be removed surgically, (3) previous intolerance to a lingual bar, and (4) a high floor of the mouth, which would limit the width and compromise the rigidity of the lingual bar.
DESIGN The labial plate is a modification of the labial bar major connector. The design of a labial plate, as with all major connectors, must follow basic prosthodontic principles. The labial bar major connector may present a problem with rigidity because the distance encompassed by the frame674
ET AL
3. Casts of lingual bar and labial plate major connector illustrate close adaptation of labial plate as opposed to spaces left between lingual bar and tissues.
Fig.
work is greater than a lingual major connector. According to the law of beams, deflection (bending) varies inversely as the cube of depth and directly as the cube of length,4 ’ whereas doubling the width of a section makes it only twice as stiff. A greater advantage is thus gained with the cubed functions of depth and length. A labial plate increases the depth occlusogingivally over that of a labial bar. This .mechanical principle explains why the design of the labial plate major connector provides more rigidity (Fig. 2). Its depth is developed to the maximum extent of the properly 1 border-molded labial vestibule. The half-pear shape can be incorporated into the wax model of the labial plate, providing an angle iron effect. Support is obtained through the indirect retainers and occlusal rests. The labial plate makes possible more favorable direction of stresses because the minor connector is 1 located in the long axis of the tooth. The labial plate provides reciprocation of lingually placed clasps and avoids the space left by a labial bar that can irritate the tongue or cheek (Fig. 3). Teeth prepared for direct retainers should have the clasp tip end in embrasures, thereby minimizing irritation to the tongue. The advantages of the labial plate major connector are ’ (1) greater rigidity of the labial plate design as compared with the labial bar, (2) a smooth transition from the major connector to the teeth for better patient acceptance, (3) direction of the stresses along the long axis of the teeth because of the position of the minor connectors, (4) stability , and reciprocation for clasps provided by the labial plate, (5) the option of occlusal rests, extension bases, and indirect retainers provided in the usual manner, and (6) reduction in the amount of space that exists between the lingual bar major connector, the minor connector, and the teeth.
SUMMARY Careful treatment planning and patient evaluation are essential when treating the partially edentulous man-
DECEMBER
1989
VOLUME
62
NUMBER
6
LABIALPLATEMAJORCONNECTOR
dibulectomy patient. The basic principles of support, retention, and stability should be followed to provide a more rigid design of the prosthesis. The labial plate provides advantages over the labial bar and should be considered a favorable major connector. REFERENCES 1. Girardot RL. History and development of partial denture design. J Am Dent Assoc 1941;28:1399-1408. 2. Roach EF. Mouth survey and design of partial dentures. J Am Dent Assot 1934;21:1166-76.
The sleep apnea syndrome. Jack B. Meyer,
Jr., D.M.D.,*
and Rodney
Part
3. Kelly EK. Full and partial dentures after extensive bone grafts to the mandible. Dent Dig 1950;56:159-64. 4. Smyd ES. Mechanics of dental structures: guide to teaching dental engineering at the undergraduate level. J PROSTNET DENT 1952;2:668-92.
Reprintrequeststo: DR. JACK W. MARTIN UNIVERSITY OF TEXAS SYSTEM CANCER CENTER M. D. ANDEMON HOSPITAL 6723 BERTNER AVE. HOUSTON, TX 77030
I: Diagnosis
C. Knudson,
D.M.D., M.S.**
Wilford Hall U.S. Air Force Medical Center, San Antonio, Tex. Part I of this two-part article presents a review of the symptoms, pathophysiology, and diagnosis of the sleep apnea syndrome. The more common obstructive type is characterized by disturbed sleep and daytime hypersomnolence. Subjective signs and symptoms should be correlated with objective findings by way of polysomnography (sleep study) to confirm the diagnosis and determine the severity of obstructive sleep apnea. Electrocardiographic monitoring during polysomnography has revealed potentially life-threatening arrhythmias during sleep. Differential diagnosis should include central sleep apnea and narcolepsy to avoid inappropriate therapy and worsening of symptoms. (J F'ROSTHET DENT 1989$2:675-B.)
S
leep apnea syndrome is a relatively common and potentially life-threatening disorder. Heightened public awareness, more frequent recognition by health care providers, and sophistication in diagnostic instrumentation, have led to a dramatic increase in the number of diagnosed patients. The increasing demand for noninvasive treatment modalities, including intraoral prostheses, should motivate dentists to become more aware and knowledgeable of this disabling syndrome. In the late 19709, sleep apnea was estimated to affect approximately 50,000 individuals. This figure is now acknowledged as a gross underestimation; the actual figure is projected to be one million or m0re.l This figure includes more than 3% of men from 40 to 60 years of age.2 Even though sleep apnea syndrome tends to be more prevalent in obese men,3 reported cases in men of normal weight and women have increased.
The views expressed herein are those of the authors and do not necessarily reflect the views of the United States Air Force, the United States Army, or the Department of Defense. *Lieutenant Colonel, U.S. Army, DC; Fellow, Maxillofacial Prosthetics. **Lieutenant Colonel, U. S. Air Force, DC; Assistant Chairman for Maxillofacial Prosthetics. 10/l/15824
THEJOURNALOFPROSTAETWDENTISTRY
Much controversy exists over the modality of treatment best suited for patients suffering from this disorder and the ability to predict long-term success. Part I of this article presents a review of the sleep apnea syndrome, its pathophysiology, and the methods of diagnosis. The various options advocated for the treatment of sleep apnea and their complications will be discussed in Part II. Most important, the need for a multidisciplinary approach to the diagnosis and treatment of this syndrome, particularly obstructive sleep apnea (OSA), is needed to obtain timely and effective relief of symptoms. The sleep apnea syndrome, first described by Gastaut,4 is a disorder associated with repetitive cessation of breathing during sleep. Sleep apnea is defined as 30 or more apneic episodes (the cessation of airflow at the mouth and nose for more than 10 seconds) occurring during 7 hours of nocturnal sleep.2*5 In the symptomatic patient, apneic episodes last on average 20 to 60 seconds and may occur as frequently as 200 to 600 times a night. Obstructive, central, and mixed patterns of sleep apnea are possible. The most common form is obstructive sleep apnea, also known as occlusive apnea, which is characterized by cessation of airflow
because of upper airway obstruction
with the
presence of simultaneous respiratory effort. This respiratory effort continues despite obstruction until the individual is aroused
from sleep.
675
SUMMARY The treatment of a patient with a soft palate obturator prosthesis made with VLC resin was described. The procedure is accomplished conveniently at chairside, eliminating a laboratory procedure and thus saving time for both the patient and the maxillofacial prosthodontist.
The labial plate mandibulectomy
major connector patient
REFERENCES 1. Mazaheri M, Millard RT. Changes in reeonence related to differences in location and dimension of speech bulbs. Cleft Palate J 1965;2:167-75. 2. Ogle RE, Sorenson SE, Lewis EA. A new visible light-cured resin system applied to removable prosthcdontics. J PROSTHET DENT 1986;56: 497-506. 3. Khan Z, von Fraunhofer JA, Razavi R. The staining characteristics, transverse strength, and microhardness of a visible light-cured denture base material. J PROSDENT 1987;57:364-6. 4. Nimmo A. Correction of posterior palatal seal hy using a visible lightcured resin: a clinical rep0rt.J PR~STHET DENT 1988;59:529-31. 5. Nimmo A. Efficient denture repairs using a wsible light-cured resin. Compend Contin Educ Dent 1988;9:528-33. Reprint requests to: DR. ZAFRLJLLAKHAN UNIVERSITY OF LOUISVILLE SCHOOLOFDENTISTRY LOUISVILLE,KY40292
in the partial
Stanley H. Wakamura, D.D.S.,*Jack W. Martin, D.D.S., M.S.,** Gordon E. King, D.D.S.,*** and Donald C. Kramer, D.D.S., M.S.**** The University of Texas M. D. Anderson Hospital and Tumor Institute, Houston, Tex. The indications, design, and advantages of the labial plate major connector as compared with the labial and lingual bar major connector are reviewed. The mechanical principles of increased rigidity and strength are discussed. The article suggests that the labial plate major connector may have an advantage over the labial bar major connector and should be considered when a labial connector is indicated.(J PROSTHETD~~~1989;61:02:673-6.)
T
he treatment of a patient with cancer of the floor of the mouth may include surgery, radiation therapy, chemotherapy, or a combination of these modalities. Gross facial disfigurement and impaired mandibular function may result when the extent of surgery interrupts mandibular continuity. Maintaining continuity helps preserve normal muscle function and facial contours and leads to a more predictable and favorable prosthodontic treatment. When mandibular anterior teeth (especially mandibular canines) are surgically removed with a portion of the floor of the mouth and tongue, the facial muscles exert force on
*Fellow, Department of Dental Oncology. **Associate Dental Oncologist (Maxillofacial) fessor of Dental Oncology. ***Chairman, Department of Dental Oncology Dental Oncology. ****Associate Dental Oncologist and Associate tal Oncology. 10/l/16914
THEJOURNALOPPROSTHETICDENTISTRY
and Associate
Pro-
and Professor Professor
of
of Den-
the remaining dentition, which may lead to a severe lingual inclination of the teeth (Fig. 1). The design of a prosthesis must allow for the altered state of the remaining dentition. This article discusses the indications for and design of the labial plate major connector for the partially edentulous mandibulectomy patient.
INDICATIONS The major connector in a mandibular removable partial denture has traditionally been placed on or below the lingual surfaces of the mandibular teeth. When anatomic variation prevents insertion of a properly designed lingual major connector, the choice has been either a labial bar or a swing-lock removable partial denture. The labial plate major connector is a modification of the labial bar and offers several advantages over the bar-type design. The labially placed major connector is seldom needed or used. The first reported use of a major connector was in 1728 by Pierre Fauchard.l Fauchard recognized the importance of rigidity of the major connector and incorpo-
673
NAKAMURA
Fig. 1. Typical patient whose anterior mandible, alveolus, and floor of mouth have been resected.
2. Length of occlusogingival labial plate adds increased strength over labial bar.
Fig.
rated a labial connector as well as a lingual bar. In 1934, Roach2 described the use of a continuous truss bar placed in a labial position. Kelly,3 in 1950, described the use of a strut bar as a labially placed major connector for a removable partial denture in a patient who had experienced trauma to the mandible. Indications for the use of a labial plate major connector are (1) severe lingual inclination of the mandibular teeth, (2) large mandibular tori that cannot be removed surgically, (3) previous intolerance to a lingual bar, and (4) a high floor of the mouth, which would limit the width and compromise the rigidity of the lingual bar.
DESIGN The labial plate is a modification of the labial bar major connector. The design of a labial plate, as with all major connectors, must follow basic prosthodontic principles. The labial bar major connector may present a problem with rigidity because the distance encompassed by the frame674
ET AL
3. Casts of lingual bar and labial plate major connector illustrate close adaptation of labial plate as opposed to spaces left between lingual bar and tissues.
Fig.
work is greater than a lingual major connector. According to the law of beams, deflection (bending) varies inversely as the cube of depth and directly as the cube of length,4 ’ whereas doubling the width of a section makes it only twice as stiff. A greater advantage is thus gained with the cubed functions of depth and length. A labial plate increases the depth occlusogingivally over that of a labial bar. This .mechanical principle explains why the design of the labial plate major connector provides more rigidity (Fig. 2). Its depth is developed to the maximum extent of the properly 1 border-molded labial vestibule. The half-pear shape can be incorporated into the wax model of the labial plate, providing an angle iron effect. Support is obtained through the indirect retainers and occlusal rests. The labial plate makes possible more favorable direction of stresses because the minor connector is 1 located in the long axis of the tooth. The labial plate provides reciprocation of lingually placed clasps and avoids the space left by a labial bar that can irritate the tongue or cheek (Fig. 3). Teeth prepared for direct retainers should have the clasp tip end in embrasures, thereby minimizing irritation to the tongue. The advantages of the labial plate major connector are ’ (1) greater rigidity of the labial plate design as compared with the labial bar, (2) a smooth transition from the major connector to the teeth for better patient acceptance, (3) direction of the stresses along the long axis of the teeth because of the position of the minor connectors, (4) stability , and reciprocation for clasps provided by the labial plate, (5) the option of occlusal rests, extension bases, and indirect retainers provided in the usual manner, and (6) reduction in the amount of space that exists between the lingual bar major connector, the minor connector, and the teeth.
SUMMARY Careful treatment planning and patient evaluation are essential when treating the partially edentulous man-
DECEMBER
1989
VOLUME
62
NUMBER
6
LABIALPLATEMAJORCONNECTOR
dibulectomy patient. The basic principles of support, retention, and stability should be followed to provide a more rigid design of the prosthesis. The labial plate provides advantages over the labial bar and should be considered a favorable major connector. REFERENCES 1. Girardot RL. History and development of partial denture design. J Am Dent Assoc 1941;28:1399-1408. 2. Roach EF. Mouth survey and design of partial dentures. J Am Dent Assot 1934;21:1166-76.
The sleep apnea syndrome. Jack B. Meyer,
Jr., D.M.D.,*
and Rodney
Part
3. Kelly EK. Full and partial dentures after extensive bone grafts to the mandible. Dent Dig 1950;56:159-64. 4. Smyd ES. Mechanics of dental structures: guide to teaching dental engineering at the undergraduate level. J PROSTNET DENT 1952;2:668-92.
Reprintrequeststo: DR. JACK W. MARTIN UNIVERSITY OF TEXAS SYSTEM CANCER CENTER M. D. ANDEMON HOSPITAL 6723 BERTNER AVE. HOUSTON, TX 77030
I: Diagnosis
C. Knudson,
D.M.D., M.S.**
Wilford Hall U.S. Air Force Medical Center, San Antonio, Tex. Part I of this two-part article presents a review of the symptoms, pathophysiology, and diagnosis of the sleep apnea syndrome. The more common obstructive type is characterized by disturbed sleep and daytime hypersomnolence. Subjective signs and symptoms should be correlated with objective findings by way of polysomnography (sleep study) to confirm the diagnosis and determine the severity of obstructive sleep apnea. Electrocardiographic monitoring during polysomnography has revealed potentially life-threatening arrhythmias during sleep. Differential diagnosis should include central sleep apnea and narcolepsy to avoid inappropriate therapy and worsening of symptoms. (J F'ROSTHET DENT 1989$2:675-B.)
S
leep apnea syndrome is a relatively common and potentially life-threatening disorder. Heightened public awareness, more frequent recognition by health care providers, and sophistication in diagnostic instrumentation, have led to a dramatic increase in the number of diagnosed patients. The increasing demand for noninvasive treatment modalities, including intraoral prostheses, should motivate dentists to become more aware and knowledgeable of this disabling syndrome. In the late 19709, sleep apnea was estimated to affect approximately 50,000 individuals. This figure is now acknowledged as a gross underestimation; the actual figure is projected to be one million or m0re.l This figure includes more than 3% of men from 40 to 60 years of age.2 Even though sleep apnea syndrome tends to be more prevalent in obese men,3 reported cases in men of normal weight and women have increased.
The views expressed herein are those of the authors and do not necessarily reflect the views of the United States Air Force, the United States Army, or the Department of Defense. *Lieutenant Colonel, U.S. Army, DC; Fellow, Maxillofacial Prosthetics. **Lieutenant Colonel, U. S. Air Force, DC; Assistant Chairman for Maxillofacial Prosthetics. 10/l/15824
THEJOURNALOFPROSTAETWDENTISTRY
Much controversy exists over the modality of treatment best suited for patients suffering from this disorder and the ability to predict long-term success. Part I of this article presents a review of the sleep apnea syndrome, its pathophysiology, and the methods of diagnosis. The various options advocated for the treatment of sleep apnea and their complications will be discussed in Part II. Most important, the need for a multidisciplinary approach to the diagnosis and treatment of this syndrome, particularly obstructive sleep apnea (OSA), is needed to obtain timely and effective relief of symptoms. The sleep apnea syndrome, first described by Gastaut,4 is a disorder associated with repetitive cessation of breathing during sleep. Sleep apnea is defined as 30 or more apneic episodes (the cessation of airflow at the mouth and nose for more than 10 seconds) occurring during 7 hours of nocturnal sleep.2*5 In the symptomatic patient, apneic episodes last on average 20 to 60 seconds and may occur as frequently as 200 to 600 times a night. Obstructive, central, and mixed patterns of sleep apnea are possible. The most common form is obstructive sleep apnea, also known as occlusive apnea, which is characterized by cessation of airflow
because of upper airway obstruction
with the
presence of simultaneous respiratory effort. This respiratory effort continues despite obstruction until the individual is aroused
from sleep.
675