1999 JUDSON C.

HICKEY SCIENTIFIC WRITING AWARD

Impression procedure for creating a partial auricular prosthesis
Todd M. Kubon, BA, MAMS,a Kenneth S. Kurtz, DDS,b and John D. Piro, DDSc Toronto-Sunnybrook Regional Cancer Centre, Toronto, Ontario, Canada; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, and Columbia University School of Dental and Oral Surgery, New York, N.Y.
Severe anatomic undercuts associated with tissue remnants or a defect site can often be an obstacle in achieving an accurate impression for a facial prosthesis. This article describes a procedure that overcomes the problems encountered in achieving an accurate impression. The distinct properties of 2 impression materials are applied to create a 3-piece impression that can be reassembled to develop an accurate stone master cast. (J Prosthet Dent 2000;83:648-51.)

hen fabricating a facial prosthesis, severe anatomic undercuts associated with tissue remnants or a defect site can be an obstacle to achieving an accurate impression. The purpose of this article is to present a procedure that applies the distinct properties of 2 impression materials to create a 3-piece impression that can be reassembled to develop an accurate stone master cast. A patient treatment plan is used to illustrate this procedure.

CLINICAL TREATMENT
A patient was referred for consultation to the Maxillofacial Prosthetic Clinic by his otolaryngologist. The patients chief complaint concerned the appearance of his surgically altered right ear (Fig. 1). Because of recurrent infections, a cavity had been surgically created to provide access to the mastoid for periodic cleaning. The main concern for rehabilitation was the ability to maintain patency to the mastoid area without repeated surgical excision. It was determined that the patient would be best served with a removable auricular prosthesis, as opposed to autogenous reconstruction and concomitant risk of surgical failure. The removal of the custom auditory insert1 facilitates hygienic procedures subsequent to efficient mastoid monitoring. The insert also covers and protects the defect between periodic checkups by the otolaryngologist. For the patient, the main concern was the esthetic function of the prosthetic insert to camouflage the disfigurement. As described by the patient, I just want my ear to look normal again.
This manuscript was presented at the annual meetings of The American Anaplastology Association, Toronto, Ontario, June 1999; The American Academy of Maxillofacial Prosthetics, Philadelphia, Pa., October 1999; and The American College of Prosthodontists, New York, N.Y., October 1999. aAnaplastologist, Toronto-Sunnybrook Regional Cancer Centre. bAttending Prosthodontist, Department of Dentistry, Montefiore Medical Center. cAssociate Clinical Professor of Dentistry and Otolaryngology, Columbia University School of Dental and Oral Surgery. 648 THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 1. Patients surgically altered right ear.

Historically, it has only been necessary to make an impression of the expanded, or surgically altered, auditory meatus when constructing an auditory insert, because the main function was simply to plug the canal.1 To fabricate an insert that would not only function, but also replicate the lost esthetics of the ear, it was necessary to capture the anatomy and proportions of the helix in the impression. Making an impression of both the expanded ear canal and the contours of the helix would require that the impression be able to bend around the helix and pull out of the canal at the same time. Irreversible
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Fig. 3. Plaster matrix removed. Removal of polyvinyl siloxane component of impression from the defect.

Fig. 2. Polyether impression material has been applied behind helix. Application of polyvinyl siloxane into defect.

hydrocolloid is most commonly used when making an auricular impression.1-3 However, multiple paths of withdrawal can cause the irreversible hydrocolloid to tear because of its low tear strength.4 A single component impression material with higher tear strength could cause severe trauma to the tissues on retrieval of the set impression. The inability to capture both the defect and the surrounding anatomy in an impression can compromise the fit and esthetics of the prosthesis. The weight of the impression material can distort the natural position of the ear remnants. This can lead to an inaccurate cast. An inaccurate cast can create difficulty in achieving multiple adaptable margins and symmetry with the contralateral ear. A successful impression can be made by adapting the multiple tray technique as described by Salinas et al,5 which allows the creation of a 2-part impression that can be reassembled via key ways. For the impression, the patient must be positioned on his or her side. This procedure is similar to creating a 3-piece mold2 of a wax sculpture for fabrication of silicone prosthesis.

PROCEDURE
1. Block out the patients inner ear using lubricated cotton; lubricate any facial hair that may be associated with the defect site.
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2. If necessary, box the defect sites to control the flow of the impression material. (However, this step is not necessary.) 3. Syringe medium body polyether (Impregum Penta, ESPE, Norristown, Pa.) under the remaining parts of either the helix or lobe, allowing the impression material to support the remnants in their natural resting position. Use enough impression material to come level with the tissue remnant, blocking out the undercut, but not allowing the material to flow over on top of the tissue remnant (Fig. 2). (Polyether is used for this portion of the impression because of its high rigidity.4,7 Polyether allowed for the least amount of displacement of the tissue remnants under the weight of the additional impression materials.) 4. Syringe light-body polyvinyl siloxane (Reprosil, Caulk/Dentsply, Milford, Del.) over the remaining uncovered areas of the ear and any defect, if present (Fig. 2). Create an irregular surface area that will provide a pattern for the impression to be keyed. (Light-body polyvinyl siloxane is indicated for this portion of the impression because of its high resistance to deformation, ease of flow, and high tear strength on setting.4,7 This will allow the material to be retrieved from the defect without tearing or distorting the impression. Separating medium is not necessary because the chemical dissimilarity of the 2 impression materials will not allow them to bond. The absence of a separator
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Fig. 4. Impression is fully reassembled and ready to be cast.

Fig. 6. Final prosthetic result.

Fig. 5. Master cast for fabrication of final prosthesis.

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and the fact that these 2 materials are relatively hydrophilic4,7 will facilitate an intimate relationship between them.) 5. If the boxing material was used, remove it from the impression without disturbing or removing the impression. 6. Place plaster (Snow White Plaster No. 2, Kerr, Romulus, Mich.) around and over the entire impression and allow it to set. (Plaster serves as a matrix into which the other parts of the impression can be reassembled.) 7. Remove the impression. (The 3 parts will separate where needed to allow for its retrieval [Fig. 3].) 8. Disinfect the impression and reassemble it so that a master cast can be developed (Figs. 4 and 5). To ensure the successful fit of the finished prosthesis, it is crucial that the wax sculpture relate accurately to both the patients defect site and the cast. The preliminary wax sculpture should be able to be transferred from the cast to the patient without modification. The extent of the defect and the undercuts in the surrounding anatomy are not conducive to placing and removing the preliminary wax sculpture from the patient to the cast without distorting its shape. One must be able to rely on the accuracy of the impression that is made to ensure a successful fit of the final cast prosthesis. In using the retention provided in the undercuts of the anatomy, the patient is able to wear
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the prosthesis without the aid of adhesives. The patient is instructed to apply a light coating of lubrication under the margins so that they blend in with the skin (Fig. 6).

SUMMARY
A procedure for obtaining an accurate impression of an auricular defect site with undercut tissue remnants is described.
REFERENCES
1. Beumer J, Curtis T, Marunick M. Maxillofacial rehabilitation: prosthodontic and surgical considerations. St Louis: Ishiyaku EuroAmerica; 1996. p. 401-525. 2. McKinstry RE. Fundamentals of facial prosthetics. Arlington: ABI Professional Publications; 1995. p. 32-70. 3. Brnemark PI, Tolman D. Osseointegration in craniofacial reconstruction. Chicago: Quintessence Publishing Co; 1998. p. 214. 4. OBrien WJ. Dental materials and their selection. Chicago: Quintessence Publishing Co; 1997. p. 123-46.

5. Salinas TJ, Penchas J, Prada-Valverde V, Guerra LR. A multiple tray technique for implant-retained orbital prostheses. J Prosthet Dent 1995;73: 158-61. 6. Ma T, Taylor TD, Johnson M. A boxing technique for making moulages of facial defects. J Prosthet Dent 1990;63:564-6. 7. Phillips RW, Skinner EW. Skinners science of dental materials. Philadelphia: WB Saunders; 1991. p. 135-56. Reprint requests to: MR TODD M. KUBON C/O TORONTO-SUNNYBROOK REGIONAL CANCER CENTRE 2075 BAYVIEW AVE TORONTO, ONTARIO M4N 3M5 CANADA FAX: (416)480-6801 E-MAIL: todd.kubon@tsrcc.on.ca Copyright 2000 by The Editorial Council of The Journal of Prosthetic Dentistry. 0022-3913/2000/$12.00 + 0. 10/1/107443 doi:10.1067/mpr.2000.107443

Noteworthy Abstracts of the Current Literature

A 10-year longitudinal study of fixed prosthodontics: Clinical characteristics and outcome of single-unit metal-ceramic crowns Walton TR. Int J Prosthodont 1999;12:519-26.

Purpose. This article reported on the relationship between several clinical characteristics and the clinical outcome of treatment for 688 metal-ceramic crowns placed in 239 patients from the period of January 1984 and December 1992 in a prosthodontic practice in Sydney, Australia. Material and methods. Clinical and laboratory procedures were standardized as much as practical, and the patient profiles, instrumentation used, occlusal design philosophy and review criteria were previously published (Int J Prosthodontics 1997;10:325-31). Results. The clinical review examination of the crowns placed covered 87% by the author. Of these, 52% were in service for between 5 and 10 years and 48% for less than 5 years but > 1 year in service. 67% of the porcelain fused to metal crowns (PFM) were placed on vital teeth and the remained on endodontically treated teeth; 94% of these crowns examined were given a good prognosis rating. The repair and failure of PFM crowns during the 5- to 10-year observation was 3% for both groups. Crowns on nonvital teeth in the same grouping had a significantly higher failure rate (5%) than PFMs on vital teeth (1%) and anterior teeth had a significantly higher retreatment rate than crowns on posterior teeth. Retreatment for 25 crowns occurred within 66 months after cementation. Tooth fracture accounted for 56% of retreatments, caries and loss of retention for 24% of retreatments, and 2% of initially vital teeth were treated endodontically during this survey period. Conclusion. Single PFM restorations had a high expectancy of exceeding 10 years of clinical service when the described clinical and laboratory procedures were applied. 15 References. RP Renner

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