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Maxillofacial

Prosthetics
Multidisciplinary Practice

VAROUJAN A. CHALIAN
JOE B. DRANE
S. MILES STANDISH
Maxillofacial
Prosthetics

&
Maxiliofaciail
Prosthetics
Multidisciplinary Practice

VAROUJAN A. CHALIAN, D.D.S., M.S.D.


Associate Professor and Chairman, Department of Maxillofacial Prosthetics, Indiana
University School of Dentistry
Associate Professor, Department of Otorhinolaryngology, Indiana University School of
Medicine

JOE B. DRANE, D.D.S.


Professor and Head of Maxillofacial Prosthetic Services, University of Texas Dental Branch
and M. D. Anderson Hospital and Tumor Institute at Houston

S. MILES STANDISH, D.D.S., M.S.


Professor and Chairman, Division of Clinical Oral Pathology
Assistant Dean of Graduate and Post-Graduate Education, Indiana University School of
Dentistry

The Williams & Wilkins Co. BALTIMORE 1971

*
i

Copyright ©, 1972
THE WILLIAMS & WILKINS COMPANY 428 E.
Preston Street Baltimore, Md. 21202, U.S.A.

All rights reserved. This book is protected by copyright. No. part of this book may be
reproduced in any form or by any means, including photocopying, or utilized by any
information storage and retrieval system without written permission from the copyright
owner.

Made in the United States of America

Library of Congress Catalog Card Number 77-178044


SBN 683-01512-5

Composed and printed at the WAVERLY PRESS,


INC. Mt. Royal and Guilford Aves. Baltimore, Md.
21202, U.S.A.
Dedicated to Our Wives:
ZAROUG CHALIAN
ROSE DRANE
GERTRUDE STANDISH
for
Encouragement and
Understanding


CONTRIBUTORS

1. Babayan, Vigen K., Vice-President and geon, Maxillofacial, University of Texas M.


Director of Research and Development, D. Anderson Hospital and Tumor Institute
Stokely-Van Camp, Inc., Indianapolis, at Houston, Houston, Texas.
Indiana. 8. Drane, Joe B., D.D.S., Professor and
2. Barnett, Marvin O., D.M.D., Associate Head of Maxillofacial Prosthetic Services,
Professor and Chief of Maxillofacial University of Texas Dental Branch and
Prosthetic Services, University of M. D. Anderson Hospital and Tumor
Louisville School of Dentistry, Louisville, Institute at Houston, Houston, Texas.
Kentucky. 9. Garner, LaForrest D., D.D.S.,
3. Beck, H. O., D.D.S., M.S., M.S.D., F.A.C.D., Associate Professor
F.A.C.D., Associate Dean for Graduate and Chairman, Department of
Studies and Professor and Chairman, Orthodontics, Indiana University School
Removable Prosthodontics, University of of Dentistry, Indianapolis, Indiana.
Texas Dental Branch at Houston, 10. Guerra, Luis R., D.D.S., Assistant
Houston, Texas. Professor of Maxillofacial Prosthetics,
4. Bixler, David, Ph.D., D.D.S., Associate University of Texas Dental Branch at
Professor and Chairman, Oral- Facial Houston and University of Texas M. D.
Genetics, Indiana University School of Anderson Hospital and Tumor Institute
Dentistry, and Associate Professor of at Houston, Houston, Texas.
Medical Genetics, Indiana University 11. Hansen, Niles, D.D.S., M.S.D.,
School of Medicine, Indianapolis, Associate Professor of Periodontics,
Indiana. Indiana University School of Dentistry,
5. Bogan, Robert L., D.D.S., M.S.D., Indianapolis, Indiana.
Assistant Dean and Associate Professor, 12. Hennon, David K., D.D.S., Associate
Fixed and Removable Partial Professor of Preventive Dentistry,
Prosthodontics, Indiana University Indiana University School of Dentistry,
School of Dentistry, Indianapolis, Indi- Indianapolis, Indiana.
ana. 13. Hornback, Ned B., M.D., Associate
6. Chalian, Varoujan A., D.D.S., Professor and Chairman of Department
M.S.D., F.A.C.D., Associate Professor of Radiation Therapy, Indiana University
and Chairman, Department of School of Medicine, Indianapolis,
Maxillofacial Prosthetics, Indiana Indiana.
University School of Dentistry, and 14. Hutton, Charles E., D.D.S., Associate
Associate Professor, Department of Professor and Director of Hospital Oral
Otorhinolaryngology, Indiana University Surgery and Interns’ and Residents’
School of Medicine, Indianapolis, Program, Indiana University School of
Indiana. Dentistry, Indianapolis, Indiana.
7. Daly, Thomas E., D.D.S., Assistant
Professor, Restorative Dentistry, Uni-
versity of Texas Dental Branch at Hous-
ton, and Assistant Clinical Dental Sur
viii CONTRIBUTORS

15. Leonard, Fred, Ph.D., Scientific 26. Rosen, Morton S., D.D.S.,
Director, U. S. Army Biomechanical F.A.C.D., Associate Professor, Prosthetic
Research Laboratory, Walter Reed Army Dentistry, and Director of Cleft Lip and
Medical Center, Washington, D. C. Palate Institute, Northwestern
16. Lingeman, Raleigh E., M.D., University School of Dentistry, Chicago,
F.A.C.S., Professor and Chairman, Illinois.
Department of Otorhinolaryngology, 27. Sandlewick, John W., D.D.S., In-
Indiana University School of Medicine, structor of Maxillofacial Prosthetics, In-
Indianapolis, Indiana. diana University School of Dentistry,
17. McDonald, Ralph E., D.D.S., Indianapolis, Indiana.
M.S.D., F.A.C.D., Dean of Indiana 28. Shanks, James C., Ph.D., Professor of
University School of Medicine, Indi- Speech Pathology, Indiana University
anapolis, Indiana. Schools of Dentistry and Medicine,
18. Margetis, Peter M., Col., D.C., Indianapolis, Indiana.
Late Director, U. S. Army Institute of 29. Shellhamer, Robert H., Ph.D., Pro-
Dental Research, Walter Reed Army fessor of Anatomy, Indiana University
Medical Center, Washington, D. C. School of Medicine, Indianapolis, In-
(deceased). diana.
19. Maroon, Joseph C., M.D., Assistant 30. Standish, S. Miles, D.D.S., M.S.,
Professor of Neurosurgery, University of Professor and Chairman, Division of
Pittsburgh, Pittsburgh, Pennsylvania. Clinical Oral Pathology, and Assistant
20. Matalon, Victor, D.D.S., Assistant Dean of Graduate and Postgraduate
Professor of Maxillofacial Prosthetics, Education, Indiana University School of
University of Texas Dental Branch at Dentistry, Indianapolis, Indiana.
Houston and University of Texas M. D. 31. Starkey, Paul E., D.D.S., F.A.C.D.,
Anderson Hospital and Tumor Institute Professor and Chairman, Department of
at Houston, Houston, Texas. Pedodontics, Indiana University School of
21. Mazaheri, Mohammed, D.D.S., M.Sc., Dentistry, Indianapolis, Indiana.
F.A.C.D., Chief of Dental Services, 32. Tchalian, Marie, M.S., Research As-
Lancaster Cleft Palate Clinic, Lancaster, sistant, Nutrition Research Laboratory,
Pennsylvania. American University of Beirut, Beirut,
22. Metz, Herbert H., D.D.S., Lebanon.
F.A.C.D., Chief of Maxillofacial 33. Thompson, Lewis W., M.D., Associate
Prosthetic Services, Sinai Hospital of Professor and Director of Plastic Surgery
Detroit, Detroit, Michigan. Division, George Washington University
23. Musselman, Robert J., D.D.S., Medical ’Center, Washington, D. C.
M.S.D., Associate Professor and Head of 34. Tondra, John M., M.D., F.A.C.S.,
Department of Pedodontics, Louisiana Clinical Professor of Surgery, Plastic
State University School of Dentistry, New Surgery Section, Indiana University
Orleans, Louisiana. School of Medicine, Indianapolis, In-
24. Phillips, Ralph W., M.S., D.Sc., diana.
F.A.C.D., Research Professor of Dental 35. Urban, John J., Chief of Cosmetic
Materials and Assistant Dean, Indiana Processing Laboratory, Walter Reed
University School of Dentistry, Army Medical Center, Washington, D. C.
Indianapolis, Indiana. 36. Wheeler, Robert L., D.D.S., Teaching
25. Roberts, A. C., T.D., C.G.I.A., Associate, Cleft Lip and Palate Institute,
F. R.S.H., F.I.B.S.T., A.I.S.T., As soc. I. Northwestern University School of
Mech. E., Plastic and Maxillofacial Unit, Dentistry, Chicago, Illinois.
St. Luke’s Hospital, Bradford, Yorks,
England.
FOREWORD

This book on maxillofacial prosthetics is an exceptional contribution to the litera-


ture in prosthodontics. It is a comprehensive treatise on diagnosis and treatment
planning, as well as on the rehabilitation phases of patients with traumatic and
congenital defects and deformities resulting from intervening surgery due to disease.
The development of the rationale of treatment often challenges the prosthodontist and
demands originality in execution.
The contributors are nationally recognized authorities in their specialized skill. The
principal authors, Dr. V. A. Chalian, Dr. Joe B. Drane, and Dr. S. M. Stan- dish have
completed an outstanding and systematic approach to the subject of maxillofacial
prosthetics.
Besides serving as a comprehensive textbook for undergraduate and graduate
students in prosthodontics, this volume provides ready reference material for the
general practitioner and is an invaluable aid in extending our knowledge of max-
illofacial prosthetics.

H. 0. BECK, D.D.S., M.S., F.A.C.D. Professor


and Chairman Removable Prosthodontics
and Associate Dean for Graduate Studies
University of Texas Dental Branch

IX

c.
PREFACE

One of the most rapidly growing areas of dentistry, from the standpoint of both
interest and need, is maxillofacial prosthetics. During the past three decades, dentists
have added to their knowledge and skill in this challenging specialty. The refinement
of techniques and the development of new materials have aided the dentist and the
patient in realizing the vast improvement in esthetics and function of prosthetic
appliances.
The multidisciplinary approach to dental practice is evident throughout this book.
Skilled diagnosis and treatment planning are essential in the adequate treatment of
the patient handicapped by congenital and acquired maxillofacial defects. In an
orderly sequence, the authors have described the anatomy and physiology related to
maxillofacial prosthetic procedures, followed by descriptions of the complications
presented by certain pathologic states. Special impression techniques for reproducing
the unusual oral and extraoral structures are described in detail in easy-to-follow
procedures.
The book affords the dental student, the dental practitioner, the graduate student,
and the prosthodontist an excellent opportunity to become acquainted with all aspects
of the complex problems related to maxillofacial prosthetics. For example, the authors
quite properly emphasize the importance of modern periodontal and restorative
techniques in the maintenance of oral health. In addition, their realization of the role
that the general health of the patient plays in the success of maxillofacial prosthetics
is evidenced by the special attention that is given to nutritional considerations.
As noted in the title, this text represents a truly multidisciplinary approach to
problems that are rightfully deserving of the attention of the dental profession.

RALPH E. MCDONALD, D.D.S.,M.S., F.A.C.D.


Dean
Indiana University School of Dentistry
Indiana University—Purdue University at Indianapolis

XI
ACKNOWLEDGMENTS

A book of this scope is necessarily the work of many minds and many hands, and
the authors wish to acknowledge the efforts of all those persons from various
disciplines who helped to bring it into being.
Throughout the period of incubation of the book, as well as during the actual
writing, the authors have been enlightened and encouraged by their association with
the following colleagues: Dr. I. Kenneth Adisman, Dr. Joseph Barron, Dr. Heinz 0.
Beck, Dr. Mervin Cleaver, Dr. W. Bailey Davis, Dr. Edward Hinds, Dr. Richard H.
Jessee, Dr. William R. Laney, Dr. Victor Matalon, Dr. Herbert H. Metz, Dr. Timothy
O’Leary, and General Edwin H. Smith, Jr.
Sincere appreciation for their continuing interest and support regarding the project
is expressed to Chancellor Maynard K. Hine, of Indiana University- Purdue University
at Indianapolis; Dean Ralph E. McDonald, of the Indiana University School of
Dentistry; Dean Glenn W. Irwin, Jr., of the Indiana University School of Medicine; and
Dean Victor Olson, of the University of Texas Dental Branch.
The authors are grateful for the excellent work of the following members of the
Departments of Illustration and librarians of the Dental and Medical Schools. of
Indiana University: Mr. Richard Scott, Dr. Rolando DeCastro, Mrs. Alana Fears, Mrs.
Carol Ann Carter, Mr. Michael Halloran, Mr. James F. Glore, Mr. Craig G. Gosling,
Miss P. M. LaRiviere, and Mrs. Helen Campbell.
To Dr. Marvin 0. Barnett, Dr. Aziz A. Majid, Dr. John W. Sandlewick, Dr. Ariyadasa
Udagama, and Mr. Lee Schaeffer we extend our thanks for their help in collecting
materials for this book.
Special thanks are offered to Dr. Garo A. Chalian and Dr. Morton S. Rosen for their
valued assistance in reviewing the material and to Professor Paul Barton for editing
the manuscript.
Finally, the authors wish to acknowledge the industry and dedication shown by
Mrs. Zaroug Chalian and Mrs. Alene Keilholz in checking on details and typing the
manuscript.
V.A.C
J.B.D.
S.M.S.

xii
INTRODUCTION

It is the God-given right of every human being to appear human.


Few areas of dentistry offer more challenges to the technical skills and ingenuity, or
greater satisfaction, than the successful rehabilitation of function and esthetics in the
patient with gross anatomic defects and deformities of the head and neck regions. By
virtue of his training in the basic biologic sciences and his understanding of the
function of the oral apparatus, the facial musculature, deglutition, and phonation
together with highly developed technical skills in manipulating materials, the dentist
is particularly well qualified to perform this important service.
The dentist serves as a full member of the rehabilitation team and will ordinarily be
involved in pre-treatment planning as well as the construction of temporary or
permanent post-treatment appliances. The dentist’s functions may range from routine
maintenance of oral health to the removal of teeth in areas planned for radiation to the
construction of appliances in irradiated areas.
The demand for maxillofacial prosthetic devices for the rehabilitation of patients
with congenital or acquired (post-surgical, post-trauma) defects has intensified in
recent years. As surgical and radiation treatment procedures become increasingly
sophisticated, we can expect that more and more patients will be salvaged from cancer
as well as accidents. The extensive surgical procedures necessary to eradicate cancer of
the head and neck and to prevent local recurrence or regional metastasis often leave
extremely large physical defects which present almost insurmountable surgical
difficulties in restoring acceptable function or esthetics. Frequently the surgeon does
not wish to cover up a surgical defect with skin grafts, so that a prosthetic appliance is
constructed to permit adequate inspection of the treatment area postoperatively.
Despite remarkable advances in surgical management of oral and facial defects,
many such defects, especially those involving the eyes and ears, cannot be satis-
factorily repaired by plastic surgery alone. Further, the increased lifespan of in-
dividuals and the growing demand for health care services place additional obligations
on the dental profession to provide trained maxillofacial prosthodontists. Many recent
developments in polymer research and in the fabrication of appliances have permitted
the maxillofacial prosthodontist to restore large numbers of such people to society. As
techniques improve and this aspect of prosthetic dentistry is expanded to become part
of the curriculum of all dental schools, it is then that dentists will find an increased
demand for services of this type.
XIV INTRODUCTION

In this text, recognized authorities have contributed sections relating to their


specific fields.
The text provides the student as well as the experienced dentist with a practical
treatise on the recognition, management, and treatment of a wide variety of max-
illofacial defects. The introductory chapter briefly outlines the scope of maxillofacial
prosthetics, including the role of the specialty in dental schools and the medical
centers. Basic information in the relevant biologic sciences is reviewed, and the many
techniques available for the construction of specific rehabilitation devices are
described in detail. Because of space limitations, a working knowledge of the biologic
sciences and of certain technical skills, specifically in the field of prosthetics, is
presumed. The anatomy and physiology of the head and neck are discussed, with
special reference to defects that may be encountered in these regions. Congenital
defects of the head and neck with special emphasis on cleft lip and palate are
described. Various modalities of therapy, particularly for cancer of these regions, and
the influence that these procedures may have upon such prosthetic devices are also
covered.
Insofar as possible, this text describes the most generally accepted techniques and
materials used in constructing maxillofacial prosthetic devices for specific clinical
situations. Speech therapy and periodontics are considered in their relationships to
teeth that may be required to retain prosthetic devices. Both intraoral and extraoral
prosthetic devices, including orbital, nasal, auricular, and cheek prostheses, are
discussed, with some attention given to cranial and facial bone prostheses and
implants. Many illustrations and diagrams have been used to help describe various
techniques and appliances. A number of case histories illustrate the approach to
diagnosis and treatment planning and the construction of specific devices.
VAROUJAN A. CHALIAN JOE
B. DRANE S. MILES
STANDISH
CONTENTS

Foreword .................................................... ... ....................................................... ix


Preface ..................................................................................................................... xi
Introduction ........................................................................................................... xiii
1: The Evolution and Scope of Maxillofacial Prosthetics ................................... 1
Varoujan A. Chalian, Joe B. Drane, and S. Miles Standish
2: Diagnosis and Treatment Planning ...................... ......................................... 13
Varoujan A. Chalian, Joe B. Drane, and S. Miles Standish 3: Maxillofacial
Defects: Hereditary and Developmental Considerations . . 23
David Bixler
4: Anatomy and Physiology in Maxillofacial Prosthesis ..................................... 51
Robert H. Shellhamer
5: Oral Pathology for MaxillofacialProsthetics ........................................................ 63
S. Miles Standish, Varoujan A. Chalian, and Joe B. Drane
6: Materials for the Fabrication of Maxillofacial Prostheses .............................. 89
Ralph W. Phillips, Peter M. Margetis, John J. Urban, and Fred Leonard
7: Impression Techniques ....................................................................................... 108
Varoujan A. Chalian, Joe B. Drane, and S. Miles Standish
8: Retention of Prostheses .................................................................... .• .......... 121
Varoujan A. Chalian, Robert L. Bogan, and John W. Sandlewick
9: Intraoral Prosthetics .......................................................................................... 133
Varoujan A. Chalian, Joe B. Drane, and S. Miles Standish
10: Periodontics ...................................................................................................... 158
Niles Hansen
11: Surgery of Head and Neck Cancers ................................................................ 163
Lewis W. Thompson and Raleigh E. Lingeman
12: Radiation Therapy of Cancers of the Head and Neck Area ........................... 178
Ned B. Hornback
13: Dental Care of Head and Neck Cancer Patients Receiving
Radiation Therapy ......................................................................................... 196
Thomas E. Daly
14: Oral Surgery and Maxillofacial Prosthetics ...................................................... 208
Charles E. Hutton
15: Splints and Stents ............................................................................................ 234
Varoujan A. Chalian, Joe B. Drane, S. Miles Standish, and
Luis R. Guerra

XV
xvi CONTENTS

16: Nutritional Considerations for Maxillofacial Patients ................................... 257


David K. Hennori, Marie Tchalian, and Vigen K. Babayan
17: Plastic Surgery and Maxillofacial Prosthetics ............................................... 263
Lewis W. Thompson
18: Extraoral Prosthetics .................................................................................... 283
Varoujan A. Chalian, Joe B. Drane, Herbert H. Metz, A. C. Roberts, and S.
Miles Standish
General Considerations ........................................................................... 283
Part 1: Ocular Prosthesis ......................................................................... 286
Part 2: Polyvinyl Resin in Facial Prosthetics ....................................... 294
Part 3: Palamed in Facial Prosthetics .................................................. 314
Part 4: Methyl Methacrylate in Facial Prosthetics................................... 318
Part 5: Heat-vulcanizing Silicones for Construction of Extraoral
Prostheses ............................................................................................... 325
19: Cranial and Facial Implants.............................................................................. 330
Varoujan A. Chalian, Joe B. Drane, Joseph C. Maroon, Victor Mata- lon,
and S. Miles Standish
20: Psychosocial and Economic Aspects of Maxillofacial Patients ....................... 351
Marvin 0. Barnett and Varoujan A. Chalian
21: Cleft Lip and Cleft Palate Habilitation.......................................................... 358
Varoujan A. Chalian, LaForrest D. Garner, Mohammed Mazaheri, Robert
J. Musselman, Morton S. Rosen, James C. Shanks, Paul E. Starkey, Lewis
W. Thompson, John M. Tondra, and Robert L. Wheeler
Introduction ............................................................................................. 358
Part 1: Diagnosis and Treatment Planning .............................................. 360
Part 2: Surgical Management of the Cleft Lip and Cleft Palate . . . . 375
Part 3: Pedodontic Care for Children with Cleft Lip and
Cleft Palate ............................................................................................. 386
Part 4: Orthodontic Treatment for Patients with Cleft Lip
and Palate ................................................................................................ 393
Part 5: Prosthodontic Rehabilitation for Cleft Palate Patients ............ 404
Part 6: Disorders of Speech Associated with Maxillofacial Defects . 424
1
THE EVOLUTION AND SCOPE OF MAXILLOFACIAL
PROSTHETICS

Varoujan A. Chalian , Joe B. Drane, and S. Miles Standish

Heritage of Maxillofacial Prosthetics weight metallic restorations, the electrode


position of various kinds of metals on a wax
Maxillofacial prosthetics is the art and matrix was later introduced.
science of anatomic, functional, or cosmetic The prosthetic restoration of missing parts
reconstruction by means of nonliving of the face and jaws, as well as teeth, was
substitutes of those regions in the maxilla, performed by surgeons who practiced
mandible, and face that are missing or dentistry. Some of the pioneers in maxillo-
defective because of surgical intervention, facial prosthetics were Ambroise Pare, who is
trauma, pathology, or developmental or considered to be the first to use an obturator
congenital malformation. to close palatal perforations; Pierre Fauchard,
Early records indicate that artificial eyes, who in 1728 used perforations of palate to
ears, and noses were found on Egyptian retain artificial dentures; and Kingsley, who
mummies. The Chinese also made facial in 1880 described artificial appliances for the
restorations with waxes and resins of various restoration of congenital as well as acquired
types. In this work the physicians were defects of the palate, nose, and orbit.
assisted by sculptors and painters. Tetamore in 1894 described and illustrated
Tycho Brahe, a Danish astronomer of the nine cases of nasal deformities that received
16th century, lost his nose in a duel and prosthetic restorations. He stated that these
replaced it with an artificial nose made of artificial noses were made of a “very light
silver and gold. The London Medical Gazette of plastic material” that approximated the
1832 describes the case of the “Gunner with natural color. They were secured on the face
the Silver Mask,” a French soldier whose face by bow spectacles.
was seriously injured in battle. The left half of At the end of the 19th century, certain
the mandible was almost carried away, the workers in this country were making facial
alveolar process was fractured, along with the restorations with vulcanite. The surface of this
teeth of the left maxilla and the right half of material was painted in an effort to match the
the mandible anterior to the first molar on skin coloring.
that side. A physician designed a prosthetic In the early part of the 20th century,
restoration for him which looked like a mask. especially during and shortly after World War
This case demonstrated that metals could be I, prosthetic restorations were made through
used in prosthetic restorations about the face. collaboration of dentists and plastic surgeons.
To produce light Even so, as recently as

l
2 MAXILLOFACIAL PROSTHETICS

1953, the prosthetic reconstruction of head deglutition, or appearance. Patients with gross
and neck defects was largely neglected by the developmental or acquired defects are often
medical and dental professions. That was the depressed and may even exhibit marked
year when a group of dentists founded the antisocial behavior. Not uncommonly the
American Academy of Maxillofacial restoration of esthetics and/or function
Prosthetics. With the continuous advancement remarkably improves the patient’s attitude
of maxillofacial prosthetics, the American and his motivation to lead a normal,
Dental Association’s Council on Dental productive life.
Education has now recognized this specialty. The primary objective in each case is to
Today almost all patients with oral or facial construct a prosthesis which will restore the
defects are referred to dentists for the defect, improve esthetics, and thereby benefit
construction of maxillofacial prostheses. The the morale of the patient. The appliance may
reason is that within the profession of be temporary in the case of patients who will
dentistry lie the knowledge, artistic skills, undergo plastic surgery for the replacement of
materials, and techniques for the prosthetic parts lost through accidents, bullet wounds, or
repair of these defects. surgical removal; or it may be permanent, for
The need for this type of work has in- in some cases plastic surgery is contraindi-
creased with the passage of years, and when a cated, as in the case of certain cancer patients.
man, woman, or child sustains an injury or In either instance, an appliance which gives
suffers from a disease which requires the the greatest comfort and security should be
replacement of anatomic parts, particularly of constructed.
the face and head, it is a singular challenge to In some situations, prosthetic devices are
those who have been trained to construct designed solely to protect the adjacent tissue,
acceptable substitutes (Fig. 1.1). as in the radium-protective shield or various
cranial implants or stents for skin grafts. They
Objectives of Maxillofacial Prosthetics
may be designed primarily as therapeutic or
The most important objectives of maxil- healing devices, such as the radium needle
lofacial prosthetics and rehabilitation include: carriers stents and splints which are used
1. Restoration of esthetics or cosmetic during therapy or the immediate postoperative
appearance of the patient. period.
2. Restoration of function. The improvements in esthetics and
3. Protection of tissues. function are not only essential to the patient’s
4. Therapeutic or healing effect. physical well-being, but they also contribute to
5. Psychologic therapy. his mental attitude. For example, the impact
The restoration of esthetics in the patient of cancer and of the physical defects that
with gross defects of the face and head is a follow surgery or other forms of therapy often
valuable and often dramatic service provided seems catastrophic, and the patient develops
by the maxillofacial prosthodontist (Fig. 1.2). attitudes of resignation and hopelessness. It is
The replacement of missing parts such as a not enough simply to institute definitive
nose, eye, or ear or the construction of a device therapy to control or cure the patient’s disease.
to rebuild facial or cranial contour requires the Often, however, substantial efforts to restore
utmost in clinical skill and utilization of him to a normal appearance and function are
available materials. sufficient to restore hope and ambition to lead
Most dentists have noted at times in their a useful life.
patients the marked changes in attitude or
personality following comparatively minor Essentials of Maxillofacial
restorative procedures designed to improve Prosthetics Practice
speech, mastication, Prosthetic restorations must meet certain
general requirements. The prosthetist strives
for natural function and lifelike
EVOLUTION AND SCOPE 3

FIG. 1.1. A, artificial ear which was carved in wood by the patient. B, view of the wooden ear shown in F ig. 1.1,
A, with wire used for retention. C, left ear defect. D, polyvinyl auricular prosthesis. (A-D, courtesy of Dr. Victor
Matalon.)

appearance; he strives for an appliance which which will be durable and easily cleaned and
may be easily and swiftly placed and held in which will retain its color quality. To attain
place both comfortably and securely; and he these goals, each patient must be treated
strives for an appliance individually, for each presents
4 MAXILLOFACIAL PROSTHETICS

tating to the surrounding tissues yet strong


enough about the periphery to endure. They
should be translucent, lightweight, easily
processed and easily manipulated prior to
processing, resistant to various chemicals such
as ether and oils, physically resistant to
sunlight, heat, or cold, subject to little change
in volume during extremes of temperatures
during processing, nonplastic, and easily
washable.

Specialty Training and Practice


Specialty training in maxillofacial pros-
thetics is intended for those individuals who
wish to devote their professional careers to the
teaching, research, and/or practice of the
specialty. Achievement in this specialy is
based upon a fundamental knowledge in many
areas of the basic sciences (head and neck
anatomy, physiology, pathology, speech,
fundamentals of pros- thodontics, surgery,
etc.). While a working knowledge of the basic
sciences is presumed in potential trainees,
ample opportunity should be provided for in-
depth training in the basic areas according to
the interest of the trainee. Since clinical expe-
rience is an important aspect of the practice of
maxillofacial prosthetics, opportunity should
be afforded for clinical training, allowing the
trainee specifically to see, examine, and treat
numerous patients with head and neck defects
with the intention of returning each patient to
a normal social life and having in mind the
philosophy that “every human has the divine
right to look human.”
In addition to developing the skills related
to routine fixed, removable, and complete
prosthodontics, the student should be exposed
to patients with unusual congenital,
developmental, and acquired defects for
prosthetic reconstruction. Only in this way can
an opportunity be provided to work with
physicians in allied health disciplines in the
FIG. 1.2. A, partial resection of right mandible for
cancer treatment. B, tantalum mandibular implant
design and construction of intraoral and
wired in place. C, postoperative result showing ac- extraoral prostheses. Any specialty training
ceptable facial restoration. program in this discipline should be designed
to fulfill the requirements of the American
unique problems of adjustment and adapt- Board of Prosthodontics, requirements which
ability. encompass both didactic and clinical aspects.
Properties of Materials
The materials to be used must possess certain
qualities. They should be nonirri
EVOLUTION AND SCOPE 5

Maxillofacial Prosthetics in Dental Schools and mandibular defects, as well as extraoral


and Medical Centers defects such as orbital, nasal, auricular, and
Most patients who are treated by the cranial problems.
maxillofacial prosthetist have defects which The trainee in maxillofacial prosthetics
are closely connected with dentistry. Among should participate in the various seminars and
these defects, with the type of appliance clinics available at most medical centers,
commonly constructed, are: cleft palate including tumor, otolaryngology, oral surgery,
(obturator, speech appliance, superimposed ophthalmology, dermatology, and cleft lip and
denture), resected maxilla (obturator), palate clinics.
resected mandible (resection appliance), and
Physical Facilities and Equipment
facial fracture (splint).
Since all of these defects are in the mouth Adequate physical facilities are essential
and are directly or indirectly related to the for effective management of patients with
function of the teeth, it is important that a maxillofacial defects whether this is done
course in maxillofacial prosthetics be offered within a dental school, a hospital clinic, or the
in dental schools. Some dental schools have private office. A two-room maxillofacial studio
added a special course in maxillofacial (Fig. 1.3), with appropriate work tables,
prosthetics to their curricula. In the near impression tables, oxygen tank, suction
future, all dental schools will undoubtedly device, and shelves and cabinets for storage, is
institute such a course. desirable. A camera and tape recorder should
Because of the significant role of maxil- be used routinely for pre- and postoperative
lofacial prosthetics in restoring oral and records.
paraoral congenital, developmental, post- Chart Facilities
surgical, pathologic, and traumatic defects, The charts or forms are also very impor-
the maxillofacial prosthetist will need to be tant. They record vital information gained in
connected with a hospital as an active member taking a history and making a clinical
of the staff. For this reason, hospital routines examination, and they indicate the progress of
such as the filling out and interpretation of
treatment. Diagrams are helpful in indicating
charts, consultations, and medical rounds
the exact location and extent of the intraoral
must be part of the training of the or extraoral defect and the prosthetic repair
prosthodontist preparing himself for
(see Chapter 2).
maxillofacial prosthetics. Accordingly,
residency training in maxillofacial prosthetics Maxillofacial Prosthetics as an
is an important facet in making the Alternative to Plastic Surgery
prosthodontist an effective member of the
The maxillofacial prosthetist normally
hospital team.
provides appliances and devices to restore
An effective clinical program in maxillo-
esthetics and function to the patient who
facial prosthetics, whether in the dental school
cannot be restored to normal appearance or
or in the hospital environment, would include
function by means of plastic reconstruction.
daily experience in crown and bridge,
The prosthetist also may be called upon to
prosthodontics, removable partial
treat individuals who are poor surgical risks
prosthodontics (dentulous resected maxilla),
for extensive plastic surgery or those who
complete denture prosthodontics (edentulous
refuse further surgery.
resected maxilla), cleft palate prosthodontics,
resection prosthodontics (resected mandible), Types of Maxillofacial Deformities
splints and stents for surgery, radium- There are three types of maxillofacial
protector shield and radium source carrier, defects:
extraoral and paraoral prosthetics. Clinical Congenital
experience should also be available in the Cleft
management of the patient with various palate
maxillary Cleft lip
Facial cleft
6 MAXILLOFACIAL PROSTHETICS

FIG. 1.3 Maxillofacial prosthetics studio.

Missing ear The maxillofacial prosthetic approach has


Prognathism three main advantages: it requires little
Acquired surgery or no surgery, the patient spends less
Accidents time away from home and job, and the
Surgery reconstruction is often more natural-looking
Pathology (Fig. 1.5). However, there are certain
Developmental drawbacks, including the necessity of
Prognathism fastening the appliance to the skin and
Retrognathism removing it every day and the occasional need
By no means should maxillofacial pros- of constructing a new prosthesis.
thetic repair be considered a substitute for The Team Approach in Case Management
plastic repair, but in certain circumstances it
The maxillofacial prosthetist serves pri-
may be an alternative.
marily as a member of a team and must
Contraindications for plastic surgery in-
cooperate with the other members in planning
clude: advanced age of the patient, poor
health, very large deformity, and poor blood rehabilitative treatment for patients with
supply on postradiated tissue. maxillofacial defects. In this capacity, he is
called upon to consult with other team
On the other hand, maxillofacial prosthetic
members and to attend conferences with
repair is indicated when anatomic parts of the
head and neck are not replaceable by living several interdisciplinary specialties including
speech therapy, psychology or psychiatry,
tissue, when a recurrence of malignancy is
envisaged, and when radiotherapy is being physical therapy, and vocational
instituted (Fig. 1.4). It may also be indicated rehabilitation, as well as those services which
are mainly concerned with treatment of the
when fragments of facial bones are displaced
patient’s primary disease, such as surgery,
in a fracture. A temporary prosthesis may be
used to cover a defect when plastic surgery radiotherapy, and chemotherapy.
Some unusual requirements are imposed
repair requires many steps. Speech appliances
may be used when surgery is contraindicated upon the maxillofacial prosthetist in that
for closure of cleft palate.
EVOLUTION AND SCOPE 7

FIG. 1.4 A, large defect which cannot be satisfactorily reconstructed by plastic surgery. B, polyvinyl hemifacial
prosthetic restoration. Note Levin tube which will remain in place until the maxillary obturator is constructed.

FIG. 1.5. A, defect of the forehead and bridge of the nose not readily restored by plastic surgery. B, normal
contour has been restored by a prosthesis which is camouflaged by the eyeglasses and the hair style.
8 MAXILLOFACIAL PROSTHETICS

he not only uses the methods and techniques tient’s life is at stake. It is important, however,
of the conventional prosthodontist, but he for each individual member of the team to be
must have additional knowledge of the aware of the capabilities as well as the
anatomy, physiology, and pathology of the limitations of the various other specialties
orofacial structures involved. Inasmuch as involved.
many maxillofacial patients are partially or
The Surgeon
completely edentulous and in addition have
substantial defects to be restored, special Adequate preoperative consultation with
training and skills as well as imagination are the surgeon is often helpful both in the
required to meet these challenges. Because of management of the primary disease process
the ever-present possibility of recurrence of and in the postoperative rehabilitation of the
the disease and because these patients are patient. The prosthodontist may advise the
often elderly with tissues that have been surgeon of the natural history of any dental
considerably modified by either the primary disease present, and he may prepare moulages
disease process or the therapy instituted, the and stents which may aid in the immediate
prosthodontist must be especially alert to the postoperative recovery. If a temporary or
patient’s general health. permanent prosthetic applicance is
anticipated, the prosthodontist may advise the
Medical-Dental Relationships surgeon as to the most desirable type of tissue
The interplay between the maxillofacial base. It should be understood that the
prosthodontist and the other members of the eradication of the disease, e.g., a malignant
medical team is of greatest significance in the neoplasm, is the primary objective of the
hospital setting. An active hospital dental surgical procedure and that preparation of an
department which may include a maxillofacial adequate base for the reception of the appli-
prosthetic division can supply a wide range of ance must remain secondary (Fig. 1.6). That
dental services in the hospital setting. The is, the surgical procedure cannot be
prosthodontist must become familiar with the compromised for the convenience of the
various clinics and services of the hospital and prosthodontist if it endangers the cure or hope
with their contribution to the rehabilitation of of cure. On the other hand, elective procedures
the patient. He can use various hospital that would not jeopardize the primary
services, such as nursing, social work, speech objectives of the surgery may be adjusted to
therapy, occupational therapy, occupational suit the needs of the prosthodontist. Further,
rehabilitation, and physical therapy, in the unforeseen problems may arise at the time of
management of his patient. He must, of surgery which may require the surgeon to
course, be familiar with operating room or modify the original plan. Again, the life of the
treatment room procedures. He must know patient must take precedence over the
hospital protocol. When asked to consult on convenience of the prosthodontist (Fig. 1.7).
the rehabilitation of a given patient, he must When tissue stents or obturators are to be
be completely candid in his evaluation of the inserted at the time of surgery, the
case and of the degree of success that can be prosthodontist trained in maxillofacial
expected of maxillofacial prosthetics in prosthetics must be involved in the preop-
rehabilitating the patient. erative planning, and he must also be present
This text will repeatedly emphasize the at the operation, since he may have to revise
team approach. In general, the team member the appliance by the use of quick-cure acrylics
to whom a patient has been referred for or other materials. Postoperative management
therapy must assume the responsibility for of the surgical patient also requires liaison
coordinating the activities of the various between surgeon and prosthodontist. The
specialty areas involved and for the delegation surgeon assumes the main responsibility for
of authority when the pa assuring
EVOLUTION AND SCOPE 9

FIG. 1.6. A, extensive basal cell carcinoma involving the right forehead, face, and orbit. B, postoperative defect
with exenteration of the orbit. C, facial anatomy has been restored by a combination prosthesis of the orbit,
forehead, and face.

that the postoperative recovery period is Further, irradiated tissues may modify the
uneventful and that there is adequate healing type of appliance that might be required,
of the tissues. At consultation, the appropriate particularly if the appliance is to be supported
time for preparing impressions and inserting by these tissues.
prosthetic devices must be determined. The
time for this must be determined by the The Speech Therapist
surgeon to assure that the wound is not
disturbed and that healing is not impaired. In The speech therapist plays an important
some instances, the preparation of the role in rehabilitating the patient with max-
prosthetic device would in itself aid in the illofacial defects, and he often works closely
healing of the tissue by offering some with the prosthodontist in the design and
protection or maintenance of the appropriate fabrication of an appliance. Speech defects
space. resulting from developmental disturbances,
surgery, or other therapeutic measures
The Radiotherapist require careful analysis, and the speech
The use of radiation or radiomimetic agents requirements may modify the construction of
in treating cancer of the oral regions requires the proposed appliance. The prosthodontist
close cooperation between the therapist and must have some knowledge of the physiology
the dentist. Radium source carriers are often and mechanics of speech, and he must be pre-
required to control the radiation at the lesion pared to construct his appliance to fulfill the
site (Fig. 1.7). Radiation is sometimes requirements of phonation, resonance, and
combined with surgery in therapy of other articulation. Although many patients who
lesions, and a maxillofacial prosthesis may be once possessed normal speech are able to re-
required to rehabilitate the patient. establish effective speech with facility, others
Any dentist, even though he is not a require intensive retraining of the speech
prosthodontist, may be asked to render an mechanism. Factors which influence the
opinion regarding the management of teeth ability of the patient to adapt to the loss of
that may be in the line of radiation of the oral tissue and to a complex appliance include his
regions, to extract teeth preop- eratively, or to general health and vitality, intelligence,
maintain the health and integrity of the teeth hearing acuity, neuromuscular coordination,
in an irradiated area. and kinesthetic sensi-
10 MAXILLOFACIAL PROSTHETICS

FIG. 1.7. A, prosthetic device carrying radium needle. B, radium carrier in place over the tumor site. C,
radiograph showing the location of radium needle.

tivity, as well as his motivation and general rehabilitation of the patient (Fig. 1.8). Be-
morale. cause many patients with gross anatomic
defects of the head and neck have suffered
The Psychiatrist nearly catastrophic disease, they are often
The emotional aspects of gross defects of severely depressed and, occasionally, suicidal.
body integrity, especially of the head and neck Even though therapy has been effective and a
regions, may play a key role in the clinically successful prosthesis
EVOLUTION AND SCOPE 11

FIG. 1.8. A, enucleation of left eye. B, ocular prosthesis inserted in the socket. C, patient with ocular prosthesis
and eyeglasses.

has been constructed, the patient’s rehabil- apy, and even employment, should this be
itation cannot be considered complete until he required.
is also emotionally conditioned to accept his
Other Dental Specialists
deformity, the appliance, and the prospects of
recurrence of disease, as well as certain social The prosthodontist should not hesitate to
and financial adjustments. call upon other dental specialists to assist him
in the management and rehabilitation of the
The Social Worker patient with anatomic defects of the oral
regions and face. For example, the need to
In addition to the severe emotional distress
maintain periodontal health may require the
commonly observed in patients requiring
services of a periodontist, or an oral surgeon
maxillofacial prostheses, there are usually
may be called upon for extractions in fields to
financial, family, and employment problems.
be irradiated. Cooperation with the
The clinical social worker and vocational
orthodontist is almost invariably required in
rehabilitation counselor can often provide
the effective management of the cleft lip and
immediate practical solutions to these
palate cases. The oral pathologist will be of
problems, starting with the patient’s
value in the diagnosis of oral lesions,
admission. Because these specialists are
particularly those involving the odontogenic
trained to communicate with people at all
and salivary gland tissues. For problems
social and economic levels, they are often able
involving children, the pedodontist should be
to allay the fears and misconceptions of the
consulted.
patient and his family about the nature of the
disease, the treatment and prognosis, and the Challenges of the Future
possibilities for physical and social Although advances in both techniques and
rehabilitation. The social worker can often cut materials have been remarkable in the past
through much of the red tape associated with several years, the full potential and utilization
large medical centers and other government of maxillofacial prosthetics is not yet in sight.
agencies, such as welfare departments, to Developments in materials in industry,
provide a better service to the patient. He may particularly the various plastics and other
also be able to arrange for financial assistance, synthetic products, will have direct
physical or occupational ther application to the complex and exacting
requirements of maxillofacial prosthetics.
These developments, together
12 MAXILLOFACIAL PROSTHETICS

with appropriate basic and clinical research, Maxillofacial Prosthetics: Proceedings of an


will do much to advance the concepts of Interprofessional Conference, Washington,
D. C., September, 1966. U. S. Public Health
implantation and transplantation. As the Service Publication No. 1950.
scope of maxillofacial prosthetics training 3. Boucher, L. J., Adisman, I. K., and Rahn, A. 0.:
programs continues to expand both in depth Education in maxillofacial prosthetics. J. Prosth.
and breadth, the quality of patient service will Dent. 24: 94-99, 1970.
improve. Training programs will continue to 4. Bulbulian, A. JH.: Facial Prosthesis. W. B. Saun
ders Company, Philadelphia, 1945.
emphasize the technical procedures of 5. Chalian, V. A.: Maxillofacial Prosthesis. Univer
prosthetics, but the training will be extended sity of Texas, Dental Branch, Houston, 1960.
to include more sophisticated techniques in 6. Chalian, V. A.: Evolution of maxillofacial pros
the diagnosis and management of oral disease thetics. Alumni Bulletin, Indiana University
School of Dentistry, Spring Issue, 1970.
secondary to the patient’s main problem. With
7. Chalian, V. A., Cunningham, D. M., and Drane,
continued acceptance of the prosthodontist J. B.: Maxillofacial prosthetics departments in
who specializes in maxillofacial prosthetics as dental schools and medical centers. J. Prosth.
part of the team charged with rehabilitation of Dent. 15: 570-576, 1965.
these patients, cooperative effort in treatment 8. Laney, W. R.: Role of the prosthodontist in a
medical institution. J. Oral Surg. Anesth. Hosp.
planning is assured. This multidisciplinary Dent. Serv. 21: 106-112, 1963.
approach will result in added benefits to the 9. Laney, W. R., Drane, J. B., and Rosenthal, L.
patient. E. : Educational status of maxillofacial pros-
thetics: report of the Educational Survey
REFERENCES
Committee of the American Academy of Max-
1. Ackerman, A. J.: Maxillofacial prosthesis. Oral illofacial Prosthetics. J. A. D. A. 73: 647-651,
Surg. 6: 176-200, 1953. 1966.
2. Robinson, J. F., Jr., and Niiranen, V. J. (Editors): 10. Rahn, A. O., and Boucher, L. J.: Maxillofacial
Prosthetics: Principles and Concepts. W. B.
Saunders Company, Philadelphia, 1970.
2
DIAGNOSIS AND TREATMENT PLANNING

Varoujan A. Chalian , Joe B. Drane, and S. Miles Standish

Diagnosis and treatment planning for the The prosthodontist should be the most
patient referred for maxillofacial reha- knowledgeable member of the team charged
bilitation require the same thoroughness and with the management of this patient, not only
attention to detail afforded the regular dental about the actual mechanics and construction
patient seen in the dental office. Inasmuch as of the prosthetic device but also about the
many candidates for maxillofacial prostheses disease under treatment. In particular, he
are elderly and may have cardiovascular should have a sound basic knowledge of the
disease or other illnesses together with their natural history and expected clinical behavior
primary complaint, they require special of the developmental diseases of the oral
consideration of their medical or biologic regions, carcinoma involving the head and
problems in addition to physical neck regions, odontogenic tumors, and
rehabilitation. Management may be further salivary gland tumors. Further, he should
complicated by prior (or anticipated) surgery understand the usual medical and biologic
and/or radiation of tissues of the oral regions problems of such patients and their influence
in these patients. upon his management of the patient. He
It is unfortunate that many cases are not should be aware of the effects of age upon the
referred to the maxillofacial prosthodontist oral and facial tissues as well as the
until after therapy for the primary disease significance of any coincidental medical
process has been completed. Consultation with findings such as arthritis, anemia, diabetes,
the surgeon or radiotherapist prior to cardiovascular disease, and psychiatric
treatment permits the maxillofacial pros- problems. He should be able to identify any
thodontist to determine any special con- concomitant oral abnormalities that may
siderations that must be taken into account influence treatment or the general oral health
(Figs. 2.1 and 2.2). While the initial therapy of
of the patient.
the patient’s lesion is of prime importance, the
Because patients who may require complex
surgical procedures often may be modified in
rehabilitation procedures are frequently
minor ways which will greatly facilitate the
discouraged and apprehensive, special
construction of the prosthetic replacement
consideration must be given to their mental
(Figs. 2.3 and 2.4). Also, early involvement of
attitude, and they must be properly prepared
the maxillofacial prosthodontist (as well as
for psychologic acceptance of any prosthetic
persons from other disciplines such as the
psychologist, social worker, and speech device planned.
therapist) assures the patient that every effort Diagnosis
is being made to ensure his rehabilitation as a Although many patients are referred to the
useful member of society.
maxillofacial prosthodontist with a prior
diagnosis and the request to con-

13
14 MAXILLOFACIAL PROSTHETICS

FIG. 2.1. Basal cell carcinomas of the nose and FIG. 2.2. Carcinoma involving the anterior maxilla,
forehead. Surgical treatment of the lesion of the nose nasal cavity, antrum, and floor of the orbit. The extent
will require removal of the external nose together with of the presurgical irradiation is outlined. By careful
the underlying nasal cartilages and mucous placement of the surgical margins and tissue flaps,
membranes. Consultation with the maxillofacial pros- consistent with adequate removal of the entire lesion,
thodontist prior to surgery will permit the surgeon to the subsequent construction of a prosthetic appliance
provide an optimal tissue base for support of the that is both functional and esthetic may be facilitated.
prosthesis.

struct a specific prosthetic device, all new operative notes. Because substantial amounts
patients should be given a complete oral of materials may accumulate in the patient’s
examination and the medical history should individual file folder, it is often helpful to
be reviewed in detail. It is particularly maintain a master file card listing the
important that an orderly procedure be patient’s name, address, telephone number,
followed in the examination and diagnosis and hospital record number, referring physician or
that particular attention be given to each of dentist, personal physician, laboratory reports
the basic requirements of the oral reviewed, primary diagnosis, and a brief
examination: the patient record, the patient summary of the case (Fig. 2.5). Should it be
interview, the past medical history, the past necessary after treatment to return old
dental history, the present complaint, the radiographs or other patient records
present illnesses, the physical and oral submitted by the referring physician or
examination, the radiographic examination, dentist, this should be noted in the record.
and the laboratory examination. While the types of records required will
Patient Record. Appropriate records must vary somewhat depending upon whether the
be maintained for each patient. These may patient is hospitalized or being treated on an
include radiographs, laboratory reports, out-patient or private basis, they should
photographs, moulages, and study models as include standard intraoral diagnosis charts,
well as the usual personal data, dental charts, head and face diagrams, medical and dental
medical questionnaires, and questionnaire (or check lists),
DIAGNOSIS AND TREATMENT PLANNING 15

FIG. 2.3. A, exenteration of the orbit. The defect was closed, preventing the placement of an artificial eye. B,
surgical revision was carried out in the patient shown in A to provide a socket for an eye prosthesis.

and space for operative notes (Fig. 2.5). Before


seeing the patient for the first time, it is
helpful to review the medical record,
radiographs, laboratory reports, and other
available information. In this manner, the
initial examination can be conducted more
efficiently, without unnecessary repetition of
diagnostic procedures. Particular emphasis
should be given to hospital notes, if available,
since they may help in evaluating not only the
physical status of the patient but also his
psychologic acceptance of the disease and his
degree of cooperativeness. When appliances
involving some form of attachment to the
teeth are required, comparing earlier intraoral
radiographs with current dental findings can
provide some basis for judging the dental
caries rate or the progress of periodontal
disease.
Patient Interview. The first interview with
the patient should be conducted in pleasant
surroundings and in an efficient and
FIG. 2.4. A skin graft has been used to close a large professional manner. It is frequently helpful to
surgical defect (exenteration of the orbit and orbital talk with the patient in a setting other than
floor). An adequate appliance cannot be constructed the operatory prior to the actual
until surgical correction is carried out.
16 MAXILLOFACIAL PROSTHETICS

MAXILLO FACIAL PRO STHETICS D EPARTMENT

Patient's Name __________________________________________________________________________ Chart No. _____

Address ________________________________________________ Insurance _____________________ Date _________

Telephone No. _______________________ Occupation _____________________________________ Age ________ Sex

Present Ailment _______________________________________________________________________________________

Referring Physician ____________________________________________________________________________________

Primary Diagnosis _____________________________________________________________________________________

Hospital _ Admission ____________________________ Hospital Chart No.

Discharge _____________________________

Operation

Pathology Report ____________________________________________________________________________

X-Ray Report________________________________________________________________________________

Radiation _______________________________________________ Site _______________________ Dosage


Medical History

Remarks and Recommendations:

I, ihe undersigned, understand and accept the plan of treatment as presented to me and as outlined above. I further agree to
the obtaining of any necessary records, including photographs and/or movies for the purpose of diagnosis, treatment planning,
teaching or publication.

Signed:

FIG. 2.5. A, master file card and treatment consent form. B and C, oral and facial diagrams for recording de-
fects and treatment plan.

physical examination. The evaluation of the the planned prosthetic device. At this point,
patient actually begins from the moment he is the patient’s marital status and occupation
escorted into the office. During the should be confirmed, since these factors may
preliminary discussion, his gait, mobility, influence the treatment plan to be followed.
vigor, complexion, and speech can be noted For example, if the patient can reasonably be
and, most important, his attitude regarding expected to resume gainful employment with
the proposed treatment can often be public contact, esthetic consideration in the
determined. Additional information not construction of the appliance will often be of
available from his history can be recorded as primary concern (Figs. 2.6 and 2.7).
well as his expectations from
DIAGNOSIS AND TREATMENT PLANNING 17

FIG. 2.5, B, and C

Accurate notes should be made during the amount of scar formation, and resiliency of the
interrogation, and any instructions or supporting tissue should be determined. In the
statements made by the examiner to the rehabilitation of the patient who has had
patient should be recorded. These entries, radiotherapy for an oral malignancy, the
together with the clinical findings, progress treatment plan may need to be modified,
notes, and summaries, should be reviewed particularly if the irradiated tissues are
before each treatment visit. required to support an appliance.
In many instances it is necessary to con- The patient interview should confirm
duct the initial examination or other treat- information in the medical history, and
ment at the patient’s bedside in the hospital particular attention should be given to other
ward (Fig.-2.8). disease states that the patient may have
Past Medical History. Review of the pa- coincidentally with the primary complaint.
tient’s past medical history, with regard to the Past medical history, interrogation of the
present physical defect as well as other patient, and a medical questionnaire may be
medical or physical problems, is important in used to establish the presence or absence of
diagnosis and treatment planning. The nature such disease states as diabetes, arthritis,
of the disease process, its natural history, and anemia, tuberculosis, epilepsy, or other
the type of therapy employed must be diseases. It is not unusual for a patient to
considered in the long-range treatment plan. deliberately or inadvertently withhold
For example, in the case of a young patient significant information regarding his past
with a developmental or acquired defect, it medical history. Frequently, the patient
may be necessary to plan for periodic revision rationalizes that a disease process elsewhere
of the appliance if continued growth and in the body is unrelated to dental or oral
development are anticipated. If the physical problems (e.g., the patient with carcinoma of
defect is the result of surgical therapy for a the breast treated several years previously), or
neoplasm, the degree of postoperative healing, he
18 MAXILLOFACIAL PROSTHETICS

FIG. 2.6. A, exenteration of the orbit and osteotomy of the orbital rim and zygoma. The operated site is well
healed and provides an acceptable base for a prosthetic appliance. B, prosthetic appliance constructed for the
patient shown in A. The eyeglasses, which are not attached to the prosthesis, provide stability.

simply forgets (e.g., the patient who has been Chief Complaint. While most patients
taking thyroid medication for a long time). referred for maxillofacial prosthetic appliances
Quite often, properly phrased leading have been sent in for a specific device to be
questions can identify other disease states not constructed, it is often helpful to have the
indicated in the routine history. For example, patient describe in his own words what he
both direct and indirect inquiries about the feels is required and, most important, his
patient’s physical activities or hobbies, reasons for wanting the device. At this time he
previous hospital visits, medications can express his expectations of the
(including home remedies), allergies, weight rehabilitation procedure, and some judgment
changes, healing of oral or skin wounds, can be made regarding his attitude and ability
shortness of breath, or swollen or painful to cooperate. Frequently, the treatment plan
joints, may serve as a basis for further may be modified to fulfill the patient’s primary
interrogation and medical investigation. expectations, such as a need for a device to aid
Dental History. The interrogation should in speech and eating or to improve his
pursue the patient’s past dental history and appearance.
experiences, particularly as related to Physical Examination. The examination
frequency of dental care, oral hygiene habits, itself should be carried out in a properly
complications from tooth extraction, and the equipped office with adequate lighting. All
patient’s dental I.Q. Since maintenance of the available diagnostic techniques should be used
existing dentition in a healthy state may as required, including inspection, palpation,
determine the success or failure of the determination of function, aspiration, probing,
prosthetic appliance, considerable attention auscultation, transillumination, fluorescence
should be given to instruction in home care and, occasionally, therapeutic trial.
and periodic dental prophylaxis and Appropriate dental tests should not be
treatment. overlooked such as percussion, electric pulp
testing, and thermal
DIAGNOSIS AND TREATMENT PLANNING 19

FIG. 2.7. A, partial nasal defect. B, temporary nasal prosthesis. C, temporary nasal prosthesis in place. D,
surgical reconstruction of the nasal defect after 1 year. (Courtesy of Dr. J. Pantzer.)
20 MAXILLOFACIAL PROSTHETICS

FIG. 2.8. A, a medical bag is useful to transport needed supplies and instruments when it is necessary to attend
patients in the hospital wards. In addition to the usual hand instruments (mouth mirror, explorer, etc.), a
portable light is of value. B, a small hobby set with an assortment of burs, stones, and polishing wheels is useful
for bedside adjustments of appliances.

pulp testing. The mobility of teeth and depth tion and character of the normal lymph nodes,
of periodontal pockets, presence of calculus, is essential. The lymph nodes of the neck
and other obvious dental defects should be should be palpated with the patient sitting
evaluated and recorded. upright and the chin tilted downward or to
While the sequence of the examination is either side to relax the musculature and
unimportant, an orderly routine should be facilitate deep palpation. The parotid glands
followed to ensure that all areas have been should be palpated bilaterally to check for the
systematically observed for abnormalities. It is presence of nodules or enlargement. The
convenient to begin with the extraoral function of the temporomandibular joint and
examination to include the face, neck, skin, the muscles of mastication and facial muscles
hair, eyes, and ears. The face should be should be determined by having the patient
examined for asymmetry, enlargement, or open and close the jaws in protrusive and
other gross developmental defects. The excursive movements. A stethoscope is helpful
intercanthal distance, position of the ears, in detecting abnormal sounds or other func-
abnormal hair growth patterns, or other tional disturbances of the temporomandibular
developmental defects of the head and neck joint.
should be recorded since they may be The examination of the lips should note any
pertinent to the diagnosis. Close attention changes in consistency and color of the
should be given to the character of the skin vermilion border or developmental or acquired
and skin appendages, particularly on the defects at the commissures. Bimanual
exposed surfaces of the face and hands. In the palpation extending into the mu- cobuccal fold
elderly, lesions of senile keratosis or basal cell of both lips is necessary to determine muscle
carcinoma may be observed and should be re- tone or the presence of deep-seated nodules or
ferred for appropriate therapy. Areas of masses.
hyperpigmentation or failure of hair or beard Direct inspection of the buccal mucosa
growth may indicate previous radiation should be made with the jaws partially closed
therapy. Familiarity with the normal in order to relax the cheek muscles. Both
anatomic structures of the neck such as the direct inspection and palpation should include
thyroid gland, hyoid bone, thyroid cartilage, the mucobuccal fold areas, the substance of
and carotid sinus, as well as the loca the cheek mucosa and
DIAGNOSIS AND TREATMENT PLANNING 21

skin, the associated buccinator and mas- seter bone of the jaws should be palpated for
muscles, the pterygomandibular raphe, and evidence of asymmetry or enlargement.
the retromolar triangle areas. Radiographic Examination. Appropriate
Examination of the dorsum of the tongue radiographs should be used to provide the
should be extended to the posterior areas by information required for each individual case.
depressing the tongue. The deep substance as In addition to routine periapical radiographs,
well as the critical lateral borders of the other extraoral radiographs including Panorex
tongue may be palpated by grasping the tip of and cephalometric radiographs may be
the tongue with gauze squares and pulling the required. In some instances, laminographs of
tongue forward and laterally. In this manner, the temporomandibular joint, sialographs, or
the lateral borders may be palpated and direct functional radiographic studies during
visualization is enhanced as well. Special swallowing or phonation may be helpful in
attention is given to the orifices of the diagnosis and treatment planning.
submax- illary and sublingual salivary ducts Laboratory Examination. The maxillofacial
and the ventral surface of the anterior tongue. prosthodontist should not hesitate to use
Deep palpation of the floor of the mouth and appropriate clinical laboratory tests to aid in
associated major salivary glands requires diagnosis. He should, of course, have some
bimanual palpation, with one finger in the knowledge of the indications for specific tests
floor of the mouth and the others placed and their significance in establishing a
beneath the chin. Adequate relaxation of the diagnosis. Among the laboratory tests of
mylohyoid and suprahyoid muscles is particular value to the dentist are: biopsy,
accomplished by having the patient partially cytology, salivary function tests, examinations
close the jaws. of the blood and urine, microbiologic studies,
The palate is examined by direct inspection skin tests, and tests of endocrine function.
and palpation, with special attention given to Should a systemic disease not already
those areas where lesions are commonly identified in the medical history be suspected,
found: namely, the incisive papilla region, the the referring physician would ordinarily be
hard palate on either side of the midline, and consulted and any necessary tests ordered
the junction of the hard or soft palate. The following review of the presenting signs and
mobility and morphology of the soft palate symptoms. Certainly, appropriate tests such
should be determined by having the patient as biopsy or cytology should be performed as
say “Ah” and by directly stimulating the soft indicated for the definitive diagnosis of oral
palate and posterior oropharynx for the gag disease found coincidentally with the patient’s
reflex. primary problem. In many instances,
The oral examination should also include exfoliative cytology may be used to great
visual examination of the oropharynx and advantage, particularly in the regular
nasopharynx and the tonsillar pillars. A postoperative follow-up of the carcinoma
laryngeal mirror and appropriate light are patient. Since the patient who has had one
required for proper visualization of this area, oral malignancy has a severalfold chance of
including the vocal cords. developing a second malignancy, any
The teeth and periodontal structures suspicious mucosal change should be
should be examined individually, and res- investigated. Biopsy rather than cytology is
torations, caries, malformations, hypoplastic preferred when malignant transformation or
areas, mobility, position, and evidence of recurrence is suspected clinically.
abrasion or attrition should be recorded. Summary of Clinical Findings. Upon
Attention should be given to the health of the completion of the physical examination and
gingival tissues, amount of debris and calculus evaluation of the medical and dental history,
formation, and the depth of periodontal together with any laboratory findings, a final
pockets. summation should be pre
The alveolar process and supporting
22 MAXILLOFACIAL PROSTHETICS

pared and placed in the patient’s permanent agement of cardiovascular problems, diabetes,
record. or other concomitant diseases. These
practitioners should be aware of the entire
Treatment Plan
treatment plan so that their full cooperation
The primary objective in any treatment can be maintained.
plan is to cure or control the basic disease and The detailed treatment plan for the
to prevent further disability. For example, in maxillofacial prosthesis is established after
the case of the patient with a treated final evaluation of the physical and radi-
malignancy, the prime consideration in all ographic findings, analysis of study casts
aspects of the rehabilitation procedure is to and/or moulages, review of earlier portraits of
ensure that the patient remains free of the patient, and full consideration of the
recurrence. patient’s needs for the device and psychologic
Second, the overall objective of the total acceptance of it. While specific indications and
plan should contribute to the patient’s well- procedures for the construction of the various
being, acceptance by his family and friends, appliances are covered in other sections, it
and his return to society as a useful member. should be noted here that the treatment plan
Because the management of the maxillo- should not only define the physical nature of
facial prosthetic patient may often be complex the appliance and its construction but should
and require the coordinated effort of a number also provide for the anticipated postinsertion
of specialists, each should be involved to some follow-up visits and the future revisions of the
degree in preparing the treatment plan. Each appliance which are expected. The patient
member of the team should know the overall should clearly understand the limitations of
objectives, and the services to be rendered the appliance and the complications that may
should be closely coordinated. For example, arise. As in denture construction for the
preparatory surgery, institution of speech normal patient, the maxillofacial prosthetics
therapy, social rehabilitation, and psychologic patient should be warned of possible
consultation should be planned in advance as functional difficulties that may require
may be indicated by the clinical findings. One adjustments, the services of a speech
member of the team should have the therapist, or other special training.
responsibility of ensuring that the patient’s
best interests are fulfilled and the treatment REFERENCES
plan coordinated. 1. Chalian, V. A.: Maxillofacial Prosthesis. Univer
Because patients who are referred for sity of Texas, Dental Branch, Houston, 1960.
2. Gorlin, R. J., and Goldman, H. M., editors:
specialized therapy are sometimes lost to Thoma's Oral Pathology. The C. V. Mosby
routine follow-up by the other disciplines that Company, St. Louis, 1970.
may be involved, the overall treatment plan 3. - Mitchell, D. F., Standish, S. M., and Fast, T. B.:
should provide for the patient’s return at Oral Diagnosis/Oral Medicine. Lea & Febiger,
Philadelphia, 1969.
appropriate intervals to his regular dentist for
4. Shafer, W. G., Hine, M. K., and Levy, B. M.: A
routine dental care and to his physician for Textbook of Oral Pathology. W. B. Saunders
regular health care, man Company, Philadelphia, 1963.
3
MAXILLOFACIAL DEFECTS: HEREDITARY AND
DEVELOPMENTAL CONSIDERATIONS

David Bixler

The developmental problem of clefts of the prosencephalon. This forebrain is covered by


face has been recorded by historians for both mesoderm and ectoderm, and just below
centuries. Artists and sculptors also have this structure lies a deep horizontal groove,
given us permanent records of their the primary oral groove (stomodeum). The
occurrence. Only in the past 50 years or so, stomodeum is bounded above by the
however, has man made a serious, and frontonasal process, laterally by the maxillary
partially successful, attempt to investigate the processes, and below by the mandibular arch.
causes of facial clefts. Two kinds of clefts, The stomodeum, which represents the
those of the upper lip and palate, occur rather primitive oral cavity, progressively deepens
frequently and pose special problems in until it meets the blind end of the foregut.
surgical and prosthetic management. At this time ( 2 1 to 28 days), the seven basic
Accordingly, they are given extensive primordia of the face can be identified: the two
treatment in this chapter. The rarer clefts mandibular processes (which unite very early),
(those involving the upper face and lower jaw) two maxillary processes, two lateral nasal
are discussed in less detail. Finally, a few of processes, and two median nasal processes.3,
the more important, but uncommon, facial 75.

developmental abnormalities which the During the 3rd and 4th weeks, the fron-
surgery-prosthetics team encounters are tonasal process which gives rise to the
briefly considered. structures of the middle and upper face
rapidly develops by mesodermal proliferation.
Development of Face and Oral Cavity
This cellular growth, coupled with the
This section reviews the developmental progressive deepening of the stomodeum,
sequences leading to the normal, adult, separates out the basic facial elements: upper,
integrated, and functioning face and oral middle, and lower face. Formation and
cavity. No attempt will be made to analyze deepening of the nasal pits occur concurrently
these sequences in toto: the reader is referred and, by the 5th week, the facial primordia are
to a standard oral histology text for detailed easily identifiable, with the caudal portion of
information. the frontonasal process subdivided into two
Development of the Face lateral nasal processes and two median nasal
processes.
In the 3-week-old human embryo, the face The paired median nasal processes have
consists principally of the forebrain or

23
24 MAXILLOFACIAL PROSTHETICS

prominent and rounded inferolateral margins, nasal pits, along with proliferation of the
which are designated the globular processes of inferior margins, reduces pit size. Subsequent
the median nasal process. The globular union of these inferior margins creates the
processes are primarily united to the maxillary primary nostrils. The united inferior margins,
processes on both sides, and these areas of consisting of both ectoderm and mesoderm,
union represent the potential sites of clefts of gradually thin out and create the nasobuccal
the upper lip. However, as Robinson has 80 membrane posteriorly. This membrane
emphasized, these clefts do not represent subsequently disappears, which means that
failures of fusion since fusion is primary. Most the primary palate separates the nasal pits
of these facial changes represents decreasing from the stomodeum only in the anterior
depth and disappearance of developmental region. The two cavities thus created (nasal
grooves or pits that demarcate the various and oral) eventually communicate through the
united embryologic processes. They come primary choanae, once the nasobuccal
about as a result of differential growth of membrane disappears.
regions of the face, although some authors While the primary palate is being formed, a
have erroneously designated them as de- median furrow appears in the mandibular
velopmental fusions. arch with pits on either side of it. Normally
Formation of Primary Palate. these structures are obliterated by epithelial
Starting with the investigations of Dursey 33 and mesodermal proliferation at about 6
and His in the 1870s and up to the turn of
57 weeks, but these lower lip pits may persist
the century, it was believed that the primary into adult life as a developmental
palate was formed by fusion of the major malformation.
processes of the face. However, in 1910 It should also be noted that the postero-
Pohlman rejected that concept. More recent
77 lateral portions of the mandibular arch give
studies by Veau and Politzer, 102 Stark, and
90 rise to the maxillary processes. Normally these
Tondury have supported Pohlman’s idea that
98 two structures, the mandibular process and
embryonic clefts or grooves are produced by the maxillary processes, fuse laterally. When
unequal mesodermal proliferation. this fusion remains incomplete—fusion is not
Specifically, this concept states that the primary here—the cheeks do not develop to
primordia of the face contributing to the their full extent and the mouth is abnormally
primary palate are basically united by wide (mac- rostomia). An extremely rare
epithelium and that mesodermal proliferation developmental failure has been noted in which
provides support beneath these areas; without there is incomplete separation of the maxillary
this support, the epithelium will break down and mandibular processes. This results in a
and a cleft will be apparent at that point. Most condition in which the mouth can hardly be
embryologists accept this account of the un- opened and speech is unintelligible.
derlying mechanism which fails in the facial One important feature of mandibular
clefting process. growth is that it takes place in spurts. During
Let us now consider the embryology of the the first 3 or 4 weeks of life, the growth rate is
primary palate. During the 5th to 6 th weeks of small compared to that of the upper face.
embryonic development, the primary palate is However, changes in mandibular width and
formed. This primordial structure gives rise to: length occur in conjunction with primary
(1 ) the upper lip, (2 ) the anterior portion of the palate development at the 5th to 6 th week.
maxillary alveolar process, and (3) the Facial growth again lags until about the 1 0 th
premaxilla; it thereby represents a portion of week when another spurt occurs in
the embryonic frontonasal process and conjunction with secondary palatal
maxillary processes. development. Further development of the face
Progressive deepening of the olfactory or during this early
HEREDITY AND DEVELOPMENTAL CONSIDERATIONS 25

period takes place largely by differential allows the shelves to snap up into the hori-
growth of the lateral nasal maxillary proc- zontal position in a matter of seconds.
esses, thus bringing those laterally placed Once these palatal shelves meet in the
facial primordia (eyes and nose) into the midline, they fuse both with each other and
midline area and compressing the median superiorly with the nasal septum. This fusion
nasal processes. It is interesting that children occurs by mesodermal penetration and
with the median cleft face syndrome (see destruction of the epithelial boundaries
below) have a facial development between the shelves and septum. Failure to
characterized by widely spaced eyes and destroy this epithelium may result in either a
varying degrees of bifidness of the nose, complete open cleft or a partial cleft, including
apparently representing a growth arrest in the submucous type which is a bony cleft
this period.5,
32
covered by epithelium.
Development of a Secondary Palate. The fusion of the anterior part of the
As the primitive oral cavity increases in palatine processes with the nasal septum
height, the tissue separating the primitive establishes the future hard palate. The
nostrils grows downward and backward to posterior portion of the palatine processes,
form the nasal septum. Viewed from below, which forms soft palate and uvula, has no
the oral cavity appears as an incomplete developmental relationship with the nasal
horseshoe, with the anterior portion being septum.
primary palate and the lateral portions the Correlation of Face and Brain Development
maxillary processes. The oral cavity then
In the very early stages of the embryo, the
communicates with the nasal cavities on
either side of the tongue alongside the prechordal mesoderm comes to lie beneath the
rostral neural ectoderm by the process of
rudimentary palatine processes of the maxilla.
gastrulation. This mesoderm will induce the
The secondary palate, which gives rise to the
formation of adult neural structures from the
entire soft palate and all but a small portion of
embryonic neural ectoderm or prosencephalon.
anterior hard palate, is formed by the midline
Prechordal mesoderm not only gives rise to the
union of these two palatine processes.
As previously mentioned, a growth spurt of median facial bones but also induces the
differentiation of overlying ectoderm as
the mandible occurs at about 9 weeks of age. 113

nervous tissue and forms the final morphology


This allows the tongue sufficient space to drop
of the prosencephalon or forebrain. It follows
down between the mandibular arches and
that defects in prechordal mesoderm will be
assume its natural flat and wider shape.
reflected as defects in midline bony structures
Concurrent with this event, greatly increased
of the face and prosencephalon morphology. In
cellular activity, as judged both by mitotic
particular, organogenetic cleavages of the
figures and triti- ated thymidine studies, can
prosencephalon may become arrested at any
be observed in the lateral margins of the
developmental stage and result in the series of
palatal processes. Rapid differential growth in
anomalies designated the holoprosencephalies,
these processes creates a “shelf force” which
described in a later section.
elevates them into the normal horizontal
position. When this mandibular growth spurt Embryology of the Ear
does not occur, the tongue remains elevated, The adult ear is composed of all three
thereby blocking palatal closure and producing embryonic germ layers as indicated in Chart
the Pierre Robin syndrome of micrognathia, 3.1.
glossoptosis, and cleft palate. Walker and The developing ear has an intimate rela-
Fraser observed that these palatal shelves in
103 tionship with the embryonic first and
mice are actually under pressure from
differential growth since manual depression of
the tongue literally
26 MAXILLOFACIAL PROSTHETICS

Ectoderm Mesoderm Endoderm


External ear: Middle ear: Eustachian tube Middle ear
Auricle Ossicles (lower half)
External meatus Mastoid
Tympanic membrane (inner)
Tympanic membrane (outer) Tympanic membrane (middle)
Membranous labyrinth: Bony labyrinth:
Organ of Corti, utricle, saccule, Petrous portion of temporal
semicircular canals bone
CHART 3 . 1

second branchial arches, as evidenced in some ture ultimately becomes the tympanic
of the diseases discussed in this chapter, and membrane. With these general events in mind,
hence it is discussed in conjunction with we can now consider an outline of development
development of the branchial arches. At the of the ear.
time of formation of the primitive pharynx (3 Internal Ear. At about 3 weeks, a
weeks), five bilateral pouches in the wall of thickening of ectoderm representing the otic
this structure can be noted. These pouches, placode appears just above the first external
which ultimately become branchial arches 1 to cleft. It eventually becomes a pit, then a closed
5, are separated externally by grooves or clefts. pit by sinking below the surface ectoderm,
As these clefts deepen during development, the when it is called an otocyst (4 weeks). The
arches become increasingly prominent, and otocyst, which eventually comes to lie medial
eventually arches 1 and 2 meet across the to the outgrowing tubotympanic recess, will
midline between the heart and the flexed head give rise to all of the component parts of the
region. These two arches persist in the adult as inner ear: the utricle, saccule, semicircular
the mandible and hyoid, respectively, but the canals, and cochlear duct. By 9 weeks, the free
other three arches remain small and unpaired. canals and cochlear duct are evident, but com-
A normal, excessive development of the second plete development is not attained until about
branchial arch posteriorly results in arches 3 the 18th to 2 0 th week.
to 5 being overgrown and ultimately recessed Middle Ear. The lining membrane of the
behind and beneath arch #2. This overgrowth middle ear and air spaces of the Eustachian
creates a sinus (designated the cervical sinus) tube come from endoderm of the tubotympanic
out of the second branchial cleft, representing recess (first and second pharyngeal pouches).
the area where adult branchial clefts, cysts, The ossicles, however, develop by ossification
and fistulae develop. of cartilage and hence are mesoderm. Most
The first branchial cleft, then, is the only embryologists concur that malleus and incus
one of the four clefts not overgrown by the are derived from the mandibular (first) arch
second arch, and it represents the external cartilage, while the stapes comes from car-
auditory meatus of the adult. Each of the tilage of the hyoid (second) arch. A continuous
ectodermal branchial pouches has a process of ectoderm invasion and breakdown of
comparable endodermal pharyngeal pouch, the mesoderm surrounding these three cartilages
two separated by mesoderm. Deepening of the results in a hollow chamber and ossicles,
first branchial cleft by epithelial destruction structures which are both epithelium-lined.
and deepening of the first pharyngeal cleft on This process principally takes place over the
the inside (the tubotympanic recess) results in period of 20 to 34 developmental weeks.
a narrow, compressed band of tissue composed Regarding the ossicles themselves, mes-
of all three embryonic germ layers. This struc enchymal differentiation begins around the
1 2 th week and the cartilaginous ele
HEREDITY AND DEVELOPMENTAL CONSIDERATIONS 27

ments are complete by 16 weeks. Thereafter, the literature reports are incomplete in dif-
ossification is the predominant change, with ferentiating and describing this collective
the stapes last in sequence. group of clefts. Our types are then:
External Ear. As already noted, the Type I (a) CL, cleft lip
primodium of the external meatus is the first (b) CLP, cleft lip with cleft palate
branchial cleft. This early cleft is ultimately (c) CL(P), cleft lip with or without
filled by a core of invading ectodermal cells at cleft palate
about 4 weeks. These cells persist until about Type II CP, isolated cleft palate
the 2 0 th week and then undergo canalization The division into two groups has been made
from within outwards as the tympanic partly because of the repeated observation
membrane is formed at one end and the that families characteristically have either the
external meatus at the other. first or second type but that both types rarely
At 6 weeks, six tubercles appear around the occur in the same family. More importantly,
first branchial cleft: three on the mandibular lip formation and palatal closure are
arch and three on the hyoid arch. According to temporally separate events in the embryo.
Streeter, the significance of these tubercles
95
Further, reports in the literature show a
has been greatly overemphasized by many different incidence, a different sex
authors. Streeter believes them to represent predisposition, a different prevalence of
merely foci of mesenchymal proliferation and associated congenital anomalies, and different
not, as some have said, to represent specific proposed modes of inheritance for the two
em- bryologic components of the adult auricle. conditions. Accordingly, this section maintains
However, it does seem clear that the most the practice of recognizing two distinct
ventral tubercles of both the mandibular and entities: cleft lip either with or without cleft
hyoid arches eventually make up the tragus palate (CL(P)) and CP.
and antitragus, respectively. The remainder of Epidemiology
the ear is a product of both the fused tubercles Prevalence. The prevalence of CL(P) varies
and the areas immediately adjacent to them. according to race. For example,
At the 6 th week the mandibular and hyoid
arch contributions to the auricle are
apparently about equal. By the 8 th week,
though, it is clear that the hyoid mesenchyme
now contributes to more than 85% of the adult
auricle. This relationship of contribution by
the two arches is indicated in Figure 3.1.
Cleft Lip and Palate
In considering the problem of cleft lip and
cleft palate, most authors recognize two
discrete embryologic and clinical entities: (1 )
isolated cleft lip (CL) or cleft lip with cleft
palate (CLP), and (2) isolated cleft palate (CP).
One additional category must be designated in
order to allow for all possible combinations:
cleft lip either with or without cleft palate.
This category, designated CL(P), is needed FIG. 3.1. Development of the external ear. A and B, 7
because many of weeks; C, D, E, 8 to 12 weeks; F, 4th month; G, 5th
month. Mandibular arch contribution is left unshaded
while hyoid arch contribution is shaded. Adult ear
components are: (1) tragus, (2) anterior crus of helix, (3)
helix, (4) and (5) antihelix, (6) antitragus, (7) lobule.
28 MAXILLOFACIAL PROSTHETICS

Negroes appear to have the lowest prevalence, CL(P), with the additional problem that it is
approximately 1 per 3000 live births, 2,29, 58, 61 possible for an incompletely cleft palate to go
while among Caucasians it appears to vary unrecognized. Certainly a submucous cleft
66

between 1 per 600 and 1 per 1200. The most palate—one in which the bony defect is
generally accepted figure is approximately 1 covered by epithelium—should be classified
per 750 live births or 0.133%.55>88 The epidemiologically with the other cleft palates;
Japanese and others of the Mongoloid race and yet this condition may be diagnosed only
have been reported to have a very high in later childhood, when persistently nasal
prevalence, ranging from 1 per 400 to 1 per
73 speech becomes evident, and possibly not even
600; and Tretsven reported a prevalence of 1
100 then. Thus it seems probable that prevalence
17

per 100 in a tribe of Montana Indians. figures for CP are low. In general, however,
Greene has stated that, even though these
54 isolated cleft palate occurs in Caucasians at a
studies were made on select populations, they rate of about 1 per 3000 live births, in Negroes
strongly suggest real differences in prevalence 1 per 5000, and in Japanese 1 per 2000. These
among the three races of man. Table 3.1 frequencies, although lower than those for
summarizes prevalence figures of CL(P) from CL(P), are relatively the same according to
published reports. race.
Prevalence figures for CP are subject to the The condition of cleft uvula undoubtedly
same kinds of reporting errors as represents a developmental failure of pal-

TABLE 3.1. Incidence of cleft lip with or without cleft palate according to various authors
Year Investigator Place Ratio Incidence

1833-1863 Frobelius St. Petersburg, Russia 118:180,000 1:1525


1908 Rischbieth London, England 39:67,945 1:1742
1924 Davis, J. S. Baltimore, Maryland 24:28,085 1:1170
1929 Peron Paris, France 106:100,889 1:942
1931 Schroder Munster, Germany 28:34,000 1:1214
1931 Gunther Leipzig, Germany 102:102,834 1:1000
1933 Sanders Leiden, Rotterdam, Groningen, 16:15,270 1:954
Holland
1934 Grothkopp Hamburg, Germany 74:47,200 1:638
1934 Faltin Finland 1:950
1934 Sanverero-Roselli Italy 1:1250
1939 Edberg Goteborg, Sweden 28:27,000 1:960
1.939 Fogh-Andersen Copenhagen, Denmark 193:128,306 1:665
1940 Conway New York City 32:22,513 1:700
1940 Henderson Hawaii 35:18,024 1:550
1942 Grace Pennsylvania 250:202,501 1:800
1935-1944 Mueller Wisconsin 736:567,504 1:770
1949 Hixon Ontario, Canada 695:655,332 1:943
1950 Ivy Pennsylvania 766:583,690 1:762
1951 Wallace et al. New York City 1:1265
1953 Wallace et al. New York City 1:1202
1950-1954 Douglas Tennessee 1:1694
1955 Lending et al. New York City 1:1342
1960 Sesgin and Stark New York City 21:27,087 1:1289
1951-1961 Woolf and Woolf Utah 90:59,650 1:662
1956-1960 Green California 2,185:1,765,746 1:808
Hawaii 128:85,180 1:665
Pennsylvania 1,446:1,242,408 1:859
Wisconsin 694:485,104 1:701
HEREDITY AND DEVELOPMENTAL CONSIDERATIONS 29

atal fusion, although at a clinically insig- Birth Rank. Most authors have reported no
nificant level. From the point of view of the significant relationship between paternal age
epidemiologist, the embryologist, and the and the birth of a child with CL(P). 54’ 63 A
geneticist, the condition is a failure of fusion similar lack of association has been reported
nonetheless. Meskin et al. have reported that
65 frequently for birth rank, although Mazaheri
36 63

cleft uvula is about 1 0 times more common in and Fujino et al. have indicated a somewhat
47

Caucasians than is CL(P) and that it is greater risk for children later in the birth rank.
significantly more frequent in families with There is somewhat better agreement
cases of cleft lip and palate. These authors concerning the effect of maternal age upon the
suggest that cleft uvula represents an occurrence of a CL(P) birth. Mac- Mahon and
incomplete manifestation of cleft palate. Such McKeown, Woolf et al. , Fraser and Calnan,
62 111 46

an observation makes it appear that our Mazaheri, and Greene et al. have all shown
63 55

prevalence figures for both CL(P) and CP are that older mothers have a significantly higher
indeed low. risk of bearing a cleft child. Ho'wever, Fogh-
Sex Ratios and Frequency by Type. Andersen and McEvitt disagree.
36 64

There is general agreement that more males Geographic Distribution. Little pub-
than females are affected with CL(P). 46, 61* 63 lished information is available on the geo-
However, an excess of females with CP is the graphic distribution of congenital clefts, but
typical finding.46- 5 5 . 63 jq explanation for
0 most authors have found no obvious
these altered sex ratios is readily apparent. relationship. Since the occurrence of clefting
Birkenfeld 8 and Fogh-Andersen 36 have has a specific predilection for racial type, it
reported that, considering all lip and palate would seem logical that any geographic sample
clefts together, CL and CP each make up with a preponderance of one race would give
about 25% of the total and CL(P) comprises prevalence figures reflecting that
the remaining 50%. preponderance.
The clinical observation that lip clefts have Seasonal Distribution. A number of
a predilection for the left side (approximately authors reported no unusual seasonal variation
2 :1 ) is interesting and merits further in the birth of children with congenital clefts,
consideration. It has been observed that 46, 55,
1 1although Fujino and his associates in
1

babies with both the lip and palatal cleft have Japan reported a high incidence in spring and
47

the lip cleft on the left side about twice as a low incidence in summer and fall.
often as on the right side.29, 36 A similar
Pathogenesis of Cleft Lip with Cleft Palate
predilection has been noted in patients with
CL. However, in the case of CL, the clefting Since the grooves that represent the
prevalence is three or four times greater on primary fusion of the maxillary and median
the left side. Bilateral isolated cleft lip is rare nasal processes finally disappear at about the
6 th week of development, this period of time is
and comprises only about 6 to 1% of all
isolated cleft lips. critical for the development of an upper lip and
Also tending to separate CP from CL(P) as alveolar process without a cleft defect.
different clinical entities is the observation Although information is sparse about the
that associated congenital anomalies may cellular processes that occur in the critical
occur up to twice as often with isolated cleft areas at this time, it does appear that
palate as with CL(P)7, 26 These associated mesodermal proliferation takes place in the
anomalies include umbilical hernia, pyloric primordia of the developing primary palate. 90

stenosis, congenital heart disease, The secondary palate is timed for closure at
polydactylism, and talipes equino- varus. a later date (9 to 10 weeks), and here also a
Maternal and Paternal Age and mesodermal proliferation in the
30 MAXILLOFACIAL PROSTHETICS

lateral margins of the palatal shelves appears land, Ireland, Sweden, Germany, and the
to be closely related to palatal closure. Thus, it United States, which were reported at the
is possible that mesoderm alteration resulting first International Conference on Congenital
in a cleft lip might affect the development of Malformations in 1960. These studies
the palate also. However, because of the time comprised over 400,000 live births. Consid-
sequence it is impossible for a failure in palate ering all clefts of the lip and palate together as
development to produce a cleft lip. Fogh- these authors did, it can be seen that this
Andersen observed that, in the specific case
36 congenital malformation ranks highest on the
of cleft lip with a cleft palate, either one of the list of nine common major malformations
unilateral lip clefts appeared less frequently studied by them (congenital heart disease and
than the bilateral lip cleft. He stated, “The mental retardation excluded). Since the
circumstance that the double harelip is more sample sizes and the authors’ methods of
frequently combined with cleft palate than the collecting and tabulating data vary widely, it
single, may, to a certain extent, be explained is impossible to determine from such
by supposing cleft lip to be the primary composite data how much more frequent lip
anomaly of development and cleft palate an and palate clefts are, if at all, than the next
associated secondary malformation.” This has ranking congenital malformation, clubfoot.
been experimentally supported by studies of The two probably represent about the same
palate closure in the cleft lip mouse." Such a order of magnitude as public health problems
hypothesis emphasizes recognition of the but are 8 to 1 0 times greater in number than
possibility that cleft palate which occurs with anal atresia, shown at the bottom of the list.
a cleft lip is an etiologically different entity Thus it is obvious that cleft lip and palate
from an isolated cleft palate. represents an important medical problem not
Cleft Lip and Palate in Relation to Other only from the standpoint of treatment of the
Congenital Malformations basic deformity and its many attendant
problems in speech, hearing, and nutrition,
To gain perspective on the importance of
but also as a challenge to prevention.
cleft lip and cleft palate as public health
problems, one must view them in relation to Occurrence of Cleft Lip and Palate with Other
the total problem of congenital malformations. Congenital Malformations
Table 3.2 is a composite of 11 studies, Cleft lip and palate has been discussed so
conducted in Japan, Italy, France, Eng- far as a single developmental problem
TABLE 3.2.Frequency of occurrence of various occurring independently of other types of
congenital malformations throughout the world congenital malformations. Such is frequently
not the case. In fact, Greene et al. reported in
55

1964 that, in a sample of 4,451 individuals


with facial clefts, 377 (about 8 %) had at least
one other major congenital malformation. It is
interesting to note the frequency of an
associated malformation with a given type of
Combined data from over 400,000 subjects in the facial cleft. For example, these data confirmed
United States, Japan, Italy, France, England, Ireland, the generally accepted ratio of facial cleft
Sweden, and Germany. types as 1 :2 : 1 of CL:CLP:CP. However, the
1. Cleft lip and/or cleft palate ratio of the three cleft types in individuals
2. Clubfoot who have additional malformations showed a
3. Spina bifida somewhat different distribution,
4. Hydrocephalus
5. Polydactyly
6. Anencephaly
7. Anal atresia
HEREDITY AND DEVELOPMENTAL CONSIDERATIONS 31

as follows: CL, 10%; CLP, 37%; and CP, 53%; TABLE 3.3. Occurrence of clefts of lip and palate
or a 1 : 4 : 5 ratio. If we assume that CL(P) is a with other congenital malformations
single entity and CP a different condition, Selected congenital Facial Isolated Cleft Isolated
clefts cleft lip- cleft
then clefting of the palates generally, and malformation observed lip palate palate
specifically CP, appears to be more commonly
Total 4451 1209 1972 1270
seen with an additional congenital
At least one se- 377 36 143 198
malformation. This is a point of considerable lected malforma-
interest for the clinician since an isolated cleft tion
palate may alert him to other, perhaps Syndactyly 44 4 13 27
undiagnosed, problems of the patient. Congenital heart 54 6 24 24
Table 3.3 indicates the kinds of congenital disease
anomalies which occur most frequently with Malformed ears 39 2 18 19
clefts of the lip and palate, as reported by Spina bifida 45 5 21 19
Polydactyly 85 7 50
Greene et al. It is apparent that the most
55 28
Clubfoot 120 17 40 63
common associated anomaly is clubfoot, which
Micrognathia 49 49
occurred in almost one- third of the multiple
anomaly cases. Also, polydactyly appears to be
more commonly associated with CLP than TABLE 3.4. Incidence of facial clefting in various
either CP or CL. Micrognathia has a very high syndromes
association with CP, but this is probably due Condition Cleft lip ± Isolated cleft
to their simultaneous occurrence as part of the palate cleft palate

Pierre Robin syndrome.


Clefts of the lip and palate do have asso- Acrocephalosyndactyly —* 25
Arthromyodysplasia congenita 1 —*
ciation with certain medical syndromes and
Cleidocranial dysostosis —* 10
may appear as rather constant diagnostic
Craniofacial dysostosis —* 20
features. For an excellent summary and —* 10
Glossopalatine ankylosis
description of these syndromes, the reader is
Klippel-Feil syndrome —* 95
referred to Gorlin and Pindborg’s Syndromes Larsen’s syndrome —* 95
of the Head and Neck.52 Table 3.4 lists the Mandibulofacial dysostosis —* up to 30
estimated composite frequency which various Oculoauriculovertebral dysplasia 10 —*
authors have reported for CL(P) or CP in Orodigitofapial dysostosis -t -*
various syndromes that show them in a high Pierre Robin syndrome —* 75
frequency. Trisomy D 95 —*
Trisomy E 1 —*
It is interesting that a given syndrome
typically includes either CL(P) or CP, but not * Less than 1%.
both. A notable exception to this is Van der t Midline or lateral asymmetric clefts of palate in
Woude’s syndrome, which involves congenital 75% of cases.
fistulas of the lower lip in accociation with
either CL(P) or CP. 101 As in the instance of prominent role in so many apparently un-
multiple congenital anomalies, isolated cleft related medical disorders. One possible
palate appears to be much the more common explanation is related to the fact that palatal
in syndromes; and this seems logical since closure occurs near the end of the first
most of the syndromes also demonstrate some trimester. At that time practically all of the
of the congenital anomalies previously listed major morphogenetic movements have
in Table 3.3. occurred, and growth rather than differen-
At first glance, it seems odd that clefting of tiation is rapidly becoming the major em-
the lip and palate should play such a bryologic process. This means that any
teratogenic influence (either hereditary or
environmental) affecting some earlier
embryologic process has the temporal po
32 MAXILLOFACIAL PROSTHETICS

tential also to interfere with normal palatal ited. However, nearly everyone agrees that
44

development. the risk of having a child with CL(P) or CP is


much greater if the parents already have an
Etiologic Factors affected child or if one parent is so affected.
Heredity. Many investigators have at- Tables 3.6 through 3.8 show recurrence risk
tempted to identify and describe a possible figures according to various authors.
genetic basis for the occurrence of cleft lip and Various modes of inheritance have been
cleft palate. 8- 20- 24'26- 36- 56- 67- 79- ' There is
85 87
proposed in an attempt to account for the
widespread agreement that a hereditary basis repeated observation that the sex ratio for
exists for at least 20 or 30% of all cases of CL(P) is two males affected to each female
clefts of the lip and palate (Table 3.5), but this affected, whereas CP usually shows a pre-
leaves an amazingly high percentage of cases ponderance of affected females. Various
which are apparently due to environmental genetic hypotheses based on sex linkage8- 86

factors. Even in the cases with a recognizable and sex limitation36- 86- have been advanced,
87

hereditary component, there is considerable but all have been found wanting.
disagreement as to how this phenotype is By the same token, double recessiveness, 38

inher- polymerous recessiveness, 26- 56- dominance, 85

conditioned dominance, dominance with


36

TABLE 3.5. Familial occurrence of cleft lip and incomplete penetrance, and polygenic
79

palate inheritance 18- 25- 48- 79- 97- have been 1 1 1

Date Author
Total Familial offered as modes of inheritance. Today, almost
cases cases
all authorities consider the polygenic
hypothesis to be most useful and descriptive
1904 Haug 555 12 for explaining CL(P). In light of the reports by
1924 Davis 24 19
Fogh-Andersen and Fraser, it would seem
36 40

1926 Birkenfeld 204 20


1931 Schroder
to be valid to accept two, and only two, genetic
180 20
1934 Sanders 392 44.6
entities: CL(P) and CP, but with many
1935 Schroder 75 42.7 variations on that theme.
1935 Hantzschel 122 20.5
1957 Curtis 10 50
1961 Rank 160 32.5

TABLE 3.6. Recurrence risks for cleft lip ± cleft palate and isolated cleft palate with one child already
affected

i ?
Recurrence risks: I

Fogh-Andersen (1942) Cleft lip ± cleft palate 4.4%


Isolated cleft palate 1.8% — Hereditary disposition
12.0% + Hereditary disposition

Curtis and Walker (1961) Cleft lip db cleft palate 3.7%


Isolated cleft palate 2.5%

Curtis, Fraser, and Warburton (1961) Cleft lip ± cleft palate


4.0% — Hereditary disposition
3.6% + Hereditary disposition 3.6%
Consanguineous marriage
Isolated cleft palate 1.7% — Hereditary disposition
7.2% + Hereditary disposition 4.0%
Consanguineous marriage
HEREDITY AND DEVELOPMENTAL CONSIDERATIONS 33

TABLE 3.7. Recurrence risks for cleft lip ± cleft palate and isolated cleft palate with an affected parent

?
Recurrence risks: II
Fogh-Andersen (1942)
Cleft lip ± cleft palate 2%
Isolated cleft palate 1% + Hereditary disposition
Curtis and Walker (1961)
Cleft lip ± cleft palate 4%
Isolated cleft palate 5.8%

Curtis, Fraser, and Warburton (1961) Cleft lip ± cleft palate — Hereditary disposition
Isolated cleft palate — Hereditary disposition

TABLE 3.8. Recurrence risks for cleft lip ± cleft dant for cleft lip and palate, the noncleft co-
palate and isolated cleft palate with both an affected twin had an anomalous nervous and vascular
parent and child supply to the anterior maxilla that was typical
of the cleft twin. Van der Woude has 101

associated the occurrence of mandibular lip


pits with CL(P) and CP, and this has been
confirmed to be a syndrome by Curtis and
Recurrence risks: III Walker and Cer- venka et al. The presence
26 19

of pits in the mandibular process in the


Fogh-Andersen Cleft lip ± cleft palate 14 embryo can be noted to occur at the same
(1942) Isolated cleft palate 17 developmental time as the beginning of
primary palate formation.
Curtis and Walker Cleft lip ± cleft palate 19.4 Fukahara and Saito have claimed that
49

(1961) Isolated cleft palate 14.3 genetic “carriers” of the clefting trait, who are
themselves clinically not cleft, show
Curtis, Fraser, and Cleft lip ± cleft palate 16.7 characteristic changes in their bony facial
Warburton (1961) Isolated cleft palate 15.4
structure. These changes, such as palatal
defects, deviated nasal septum, rotation and
Another important variable concerns the crowding of maxillary anterior teeth, and a
diagnosis of cleft lip and palate. All inves- raphe or notching of the upper lip, may be
tigators agree on the diagnosis when an revealed by photographs and radiographs.
obvious, clinical cleft is present. However, it is More recent studies did not confirm these
quite possible that gene expression may be findings as clefting microforms,68-although
altered when placed against different genetic some authors do believe that facial
and environmental backgrounds. Thus the configuration is related to the clefting
gene may be present and may express itself process. 74

but not as the easily recognized and diagnosed Calnan16- described the clinical condition
17

cleft of the lip and palate. For example, Fogh- of submucous cleft palate. The classic triad of
Andersen has noted a high incidence of
36 diagnostic signs is: (1 ) bifid uvula, (2 ) midline
irregular shapes and forms in maxillary soft palate muscle separation but with intact
lateral incisors and cuspids of noncleft mucosal surface, and (3) midline posterior
individuals who have family histories of clefts. bony palate notching defect. The submucous
Woolf et al. , however, have presented data
112 defect undoubtedly represents the clinical
indicating no relationship between lateral condition of cleft palate with a milder form of
incisor anomalies and clefting. Bohn has 11 expression. However, even this condition has
reported that, in conjoined twins discor its
34 MAXILLOFACIAL PROSTHETICS

milder forms in which the only clinical tally induced. Obviously, any investigation
manifestation may be any one of the following: attempting to fit the square peg of envi-
bifid uvula, congenitally short soft palate, and ronmental teratogenesis into the round hole of
hypernasal speech. As previously noted, genetic hypothesis will go awry. It would
Meskin et al. 65 have reported that the appear then that families with more than one
incidence of bifid or cleft uvula is clefting experience would provide the most
approximately 1 0 times greater than that of fruitful area of investigation, since
CL(P) and is more common in families with a environmental agents may not be so likely to
history of lip and palate clefting. Notching of strike twice in the same place. Second, a series
the upper lip and asymmetric nares may well of morphogenetic movements, and not one
represent altered gene action in primary alone, is involved in the formation of an intact
palate formation. Finally, many authors have
49 lip and palate. Hence, it is probable that more
referred to the fact that individuals with lip than one gene may be involved in the
and palate clefts seem to show orbital production of a cleft lip and palate condition.
hypertelorism. This has been studied by Such polygenic traits as stature and I.Q. are
Moss and confirmed by Dahl. Hypertelorism
70 27
more readily affected and altered by environ-
in cleft individuals may mean that orbital mental conditions than are traits controlled by
width is a reflection of head width, a factor single genes. Thus, if cleft lip and palate are
alluded to by Fraser in considering the
42
polygenic traits, one would expect modification
etiology of cleft palate in the mouse. of gene expression. Hence, the study of
. Rarely in biologic systems do defects, polygenic traits is rendered more difficult by
whether of genetic origin or induced by expansion of the continuum of gene
teratogen or even by a multiplicity of caus- expressivity. It may well be that if one were to
ative factors, show a single, complete, take into consideration all of the
nonvarying type of clinical or laboratory aforementioned potential variant
manifestation. For example, not all diabetics manifestations of gene action, the often
have the same glucose tolerance curve; nor do proposed genetic hypothesis for CL(P) of
all mongoloid children demonstrate the same incomplete penetrance would recede in favor of
mental and physical handicaps. In considering variable gene expression. Recent studies on
the problem of cleft lip and palate, it is incomplete manifestations of “clefting gene”
fundamental, therefore, that an investigator activity indicate that such may in fact be
should be thinking of a phenotypic continuum true, but this still does not resolve the mode
22

of gene expression. If one assumes a genetic of inheritance question.


basis for the defect, the range of expression of In summary, about one-quarter of the cases
this defect will include those individuals who of cleft lip and palate appear to have a familial
have the genetic makeup for the defect but basis, but the truly hereditary cases
either do not show it themselves or manifest it undoubtedly are much more frequent. For
in a mild and uncharacteristic manner. these cases, various modes of inheritance for
Geneticists refer to such people as carriers, both CL(P) and CP have been proposed.
and they assume a most important role when Currently widely accepted is the polygenic
one entertains any genetic hypothesis. hypothesis with a sex- modified threshold for
As was brought out earlier, most authors CL(P). The reader is referred to the review
agree that there is a strong hereditary basis article of Fraser for more details on this
43

for the cleft lip-cleft palate trait, but there is subject. On the other hand, some authors still
disagreement as to its mode of inheritance. feel that CP may be an autosomal dominant
The reasons for this are probably twofold. trait with greatly reduced penetrance,
First, some of the observed clefts are quite although polygenic inheritance remains a
likely to be environmen tenable hypothesis here, too.
HEREDITY AND DEVELOPMENTAL CONSIDERATIONS 35

Environmental Factors and Teratogenic folic acid, and multiple vitamins) to pregnant
Agents women appeared to reduce the incidence of
this anomaly. However, the sample was too
As noted in a previous section, at least 2 0 %
small for definite conclusions.
of the cases of lip and palate clefts display a
In addition to nutritional deficiencies or
familial disposition. However, the remaining
excesses, a number of other environmental
80% do not show a clear pattern of
factors have been implicated, including
inheritance. In these cases, environmental
climate and anoxia. Buchner has stated
14 35 15

factors and teratogenic agents may be


that the four principal environmental causes
causative.106

of nonfamilial facial clefts are ( 1 ) acute virus


Probably the first clear demonstration of
infections, (2 ) avitaminosis, (3) oxygen
how teratogenic agents affect the incidence of
deprivation, and (4) glucose deprivation, the
cleft lip and palate was made by Fraser in the
later two both interfering with proper fetal
A/Jax strain of mice. ' He noted that
40 42

oxygenation.
treatment of pregnant mice with cortisone
The following sections deal with the
during the 8 th through 1 2 th days of gestation
etiology and pathogenesis of the less common
produced a marked increase in the incidence
facial clefts and some of the rarer
of clefting in this strain. Cortisone
developmental variants of the face and jaws
administration to the C57 black mouse,
which may come to the attention of the
however, was singularly unsuccessful in
dentist.5

inducing clefts. Fraser et al. have shown that


45

cortisone disrupts developmental timing so Holoprosencephaly (Arhinencephaly)


that palatal movement lags behind head Among the more grotesque congenital
growth and thus, even though the shelves anomalies affecting the face is a group
assume normal position, they are too far apart characterized by specific types of median
to fuse. In the C57 black strain, delay of faciocerebral defects. ’ ’ ’ These anomalies,
1 30 31 89

palatal movement by cortisone was minimal which appear in various related gradations
and did not disrupt timing sufficiently to and combinations, are given the designation of
prevent palatal fusion. holoprosencephaly. The facies appearing with
Other investigators have used excessive these defects are almost pathognomonic for
doses of vitamin A to induce clefts in ex- the anomaly and inevitably predict a severe,
perimental animals, 110and some authors highly characteristic brain malformation. The
report deficiencies of folic acid, vitamin A, underlying embryologic problem resides in a
riboflavin, and pantothenic acid to be ter- failure of prosencephalic cleavage. Normally,
atogenic. 105, 107 cleavage of the prosencephalon is of three
Although nutritional deficiency or cortisone types: (1 ) sagittal, resulting in cerebral
administration has never been proved to be hemispheres; (2 ) transverse, resulting in
teratogenic in humans, Strean and Peer 94 telencephalon and diencephalon; (3)
have reported that a large number of mothers horizontal, resulting in optic and olfactory
giving birth to cleft children have a history of bulbs. Thus, a failure of cleavage in these
physiologic, emotional, or traumatic stress in planes results in a holistic prosencephalon;
the first trimester. They believe that these hence the generic name of the defect, holo-
conditions result in excessive production of prosencephaly.
adrenal hormones (cortisone) which has been The association of median facial anomalies
shown to induce clefting in mice. These with holoprosencephaly is explained by the
observations have been seriously questioned fundamental embryologic process of induction
by Fraser.40 of the rostral neural ectoderm by prechordal
Conway and Peer et al. reported that
23 76 mesoderm. Prechordal mesoderm gives rise to
supplemental vitamin therapy (B complex, the median facial
36 MAXILLOFACIAL PROSTHETICS

bones, which are defective in these patients, Trisomy 13 or D! trisomy. Warkany et al . 108

and determines not only the differentiation of reported that, in 32 autopsies of children with
the overlying ectoderm as nervous tissue but Dx trisomy, 25 had arhinence- phaly, or
also its morphology. When prechordal holoprosencephaly, and that this brain
mesoderm is defective, the midline bones malformation is now considered typical of Di
resulting from it and the organogenetic trisomy. However, arhinence- phalic children
cleavages of the prosencephalon dependent have been reported with normal
upon it may become arrested at any chromosomes, and they are usually
30

developmental stage. Apparently the mandible distinguished by having none of the other
may also be affected, since some of these malformations associated with the
patients also show micrognathia, although the chromosome anomaly.
embryologic relationship here is less clear. A spectrum of craniofacial malformations
Of all the anomalies listed in Table 3.9, the which occurs in this grouping is illustrated in
necessary one for clinical diagnosis of Groups I Figure 3.2. The basic defect is perhaps best
to IV is orbital hypotelorism. However, characterized by the clinical and radiographic
median cleft defects must also be present to appearance of orbital hypotelorism. The most
ensure the diagnosis of brain defects. extreme example of orbital hypotelorism is
Interestingly, in those individuals showing the obviously cyclopia and the other conditions
bilateral cleft lip and palate and a missing or have a somewhat greater interorbital
hypoplastic premaxilla (Groups IV and V), the distance, although even the least affected
nasal septum is absent or severely hypoplastic individuals (those in Group V) still show
and even the ethmoid bone may be involved. marked orbital hypotelorism.
It should be noted that Group V patients
Median Cleft Face Syndrome
characteristically have the midline clefting
failures but do not usually have associated Hypotelorism, or too small a distance
congenital anomalies. However, a syndrome between the eyes, and the opposite, hyper-
has been described in which the affected telorism, both have important correlations
individual has the facial and central nervous with clefting of the face and facial structures.
system anomalies and in addition has multiple In the previous section, a series of
anomalies involving the extremities and the developmental problems is presented in which
cardiovascular, respiratory, and the subjects all have orbital hypotelorism.
gastrointestinal systems. These individuals These patients have a diagnostic facies
have an extra chromosome of the 13-15 (D) characterizing a single-lobed brain which
group and are designated as forecasts no potential for useful psychomotor
development or survival. By 31

TABLE 3.9. Severe degrees of holoprosencephaly [arhinencephaly]


Type of face Facial features Cranium and brain

I. Cyclopia Single eye or partially divided eye in single Microcephaly, alobar holoprosen-
orbit; arhinia with proboscis cephaly
II. Ethmocephaly Extreme orbital hypotelorism but separate Microcephaly, alobar holoprosen-
orbits; arhinia with proboscis cephaly
III. Cebocephaly Orbital hypotelorism, proboscis-like nose Microcephaly; usually has alobar
but no median cleft of lip holoprosencephaly Microcephaly
IV. With median cleft lip Orbital hypotelorism, flat nose and sometimes trigonocephaly;
usually has alobar
holoprosencephaly Microcephaly
V. With median philtrum- Orbital hypotelorism, bilateral-lateral cleft and sometimes trigonocephaly;
premaxilla anlage of lip with median process representing semilobar or lobar
philtrum-premaxillary anlage; flat nose holoprosencephaly
HEREDITY AND DEVELOPMENTAL CONSIDERATIONS 37

FIG. 3.2. Diagnostic facies of holoprosencephaly and parallelism with the brain. (Courtesy of Dr. W. E.
DeMyer.)

contrast, a completely different series of facial When orbital hypertelorism is combined with
anomalies is typically associated with any one of the aforementioned features, the
hypertelorism. A grouping of four types of probability of normal mentality is high. This is
facies, designated collectively as the median most important prognosti- cally since median
cleft face syndrome, has been lucidly presented clefts in patients with hypotelorism predict an
and discussed by DeMyer. These facial types
32
untreatable and hopeless failure in mental
are: (1 ) cranium bifidum occultum, development. Interestingly enough, when
hypertelorism, and median cleft nose and lip hypertelorism occurs in conjunction with
(Fig. 3.3); (2 ) cranium bifidum occultum, extracephalic anomalies, the probability of
hypertelorism, and median cleft nose (Fig. mental retardation is considerable. Only when
3.4); (3) hypertelorism and median cleft nose combined with the facial features noted above
and lip; (4) hypertelorism and median cleft does hypertelorism typically predict a normal
nose (Fig. 3.5). or near normal mentality.
According to DeMyer, the facial defects The reader should note the striking re-
commonly associated with orbital hypertel- semblance between Facies 1 (Fig. 3.3) and the
orism are: V-shaped frontal hairline, cranium embryonic face of about 6 to 8 weeks of
bifidum occultum, primary telecanthus development.
(increased distance between medial canthi of
Median Clefts of the Lip
the eyes), median cleft lip, median cleft of the
premaxilla, and median cleft palate. Median clefts of the lip may involve either
Apparently these defects may occur singly or the upper or lower lip. Those of the upper lip
in various combinations in otherwise healthy are the true midline “harelip” seen
patients. characteristically in rodents. The
38 MAXILLOFACIAL PROSTHETICS

FIG. 3.5. Facies Type IV of median cleft face syn-


drome. (Courtesy of Dr. W. E. DeMyer.)
FIG. 3.3. Facies Type I of median cleft face syndrome.
clefts may be only slight notches of the
(Courtesy of Dr. W. E. DeMyer.)
vermilion border or they may involve the
entire height of the lip. Typically, true median
clefts of the upper lip are associated with
either overt or occult bifid nose, varying
degrees of hypertelorism,12- 59- and even
109

with duplication of anterior nasal spine. In


pseudomedian clefts, such as are seen in the
arhinenceph- alies, the premaxilla and
prolabium may be quite small and pass
unnoticed. Hence, these clefts are actually
bilateral and are not true median clefts of the
lip. In individuals with true median clefts,
wide spacing of the central incisors is typically
present, although recent data indicate the
latter is an isolated phenomenon without
apparent association with other facial varia-
tions. Embryologically, median clefts of the
50

upper lip represent persistence of the paired


primordia of the median nasal and globular
processes, and they may occur as an isolated
phenomenon or as part of a syndrome
indicating arrested embryonic development.
Fogh-Andersen reported the incidence of
37

true median clefts of the upper lip to be about


4 per 1000 clefts of all types. It has been found
to occur by itself as part of a
FIG. 3.4. Facies Type II of median cleft face syn-
drome. (Courtesy of Dr. W. E. DeMyer.)
HEREDITY AND DEVELOPMENTAL CONSIDERATIONS 39

syndrome (orofacial-digital syndrome) and in various others have been reported. These
association with digital anomalies (syndactyly others are uniformly rare but somewhat
and polydactyly). The latter two associations predictable on the basis of the embryology of
have a genetic basis. the face. Since clefts of the lip, both lateral
Median clefts of the lower lip are quite and median, are discussed elsewhere in this
rare, with fewer than 30 cases reported in the chapter, the present discussion is confined to
literature. These clefts may be limited to soft
69
the rarer and unusual types, the lateral and
tissue and represented simply by a notching of oblique facial clefts. The incidence of these
the lip. On the other hand, the typical
13
clefts is not clearly established, with
situation involves a cleft of the mandible at Blackfield and Wilde estimating it at about 1
10

the symphysis, as well as the soft tissue facial cleft per 1 0 0 clefts of the lip and Fogh-
defect. The anterior portion of the tongue
28
Andersen reporting about 1 per 300 clefts of
37

may be hypoplastic or bifid with a short all types.


frenulum. When the cleft involves the floor of Lateral Clefts
the mouth, the bifid tongue is attached to the The lateral facial cleft results in the clinical
adjacent lateral alveolar ridges. Lower lip condition of macrostomia (Fig. 3.6, A). The
and/or jaw clefts probably represent a failure cleft may be unilateral or bilateral, rarely
of adequate union of the paired mandibular extending beyond the anterior border of the
processes at the ventral midline, which masseter muscle. It represents a failure of
normally occurs during the 6 th embryonic eradication of the developmental furrow
week. A failure of these processes to fuse may between the maxillary process and the
keep the ventral ends of the succeeding mandibular arch. Its etiology is unknown,
branchial arches from developing normally, although it may occur as part of an inherited
thus leading to an absent or rudimentary syndrome (mandibulofacial dysostosis), a
hyoid and thyroid cartilage. nonhereditary syndrome (first and second
Transverse (or Lateral) and Oblique branchial arch syndrome or the more
Facial Clefts descriptive term, hemifacial microsomia), or as
Congenital clefts of the face occur in any of an isolated phenomenon. 10

the areas representing embryologic fissures, The embryologic furrow may persist in the
grooves, or pits where fusion is primary but child and has been observed to extend
only epithelial in nature (Fig. 3.6). Clefts of horizontally across the cheek from the
the upper lip are the most commonly observed commissure of the mouth to the superior
facial clefts, although aspect or the ear. Thus, the clinical expression
of this cleft may vary from a very slight
enlarging of the mouth to a pronounced
macrostomia with a deep furrow extending
across the cheek.
The Oblique (or Naso-ocular) Cleft
This is the most uncommon of all clefts of
the face. The cleft line extends from the upper
lip, just lateral to the ala of the nose and
philtrum, toward the eye (Fig. 3.6, B). The
clefting area, which appears to represent the
embryologic line of fusion of the frontonasal
process, the lateral nasal process, and the
globular process of the maxilla, is sometimes
designated as the naso- optic groove. In depth,
the fissure may extend as far posteriorly as
the maxilla and
FIG. 3.6. Location of transverse (A) and oblique (B)
facial clefts in the human face.
40 MAXILLOFACIAL PROSTHETICS

hard palate, and it may involve the cranial Etiology. The etiology of this condition is
vault. When the fissure is incomplete, the unknown, although it can be traced to
ends of the furrow frequently show notching defective embryonic development. Some
defects (coloboma) of the eyelid, ala of the embryologists in studying the ventral portion
nose, or lip. There is no evidence for any of the mandibular arch in human embryos,
hereditary basis. The most recent hypothesis noted that there are two lateral sulci
on the cause of naso-ocular clefting is that it is extending across the entire ventral surface of
produced by either an absence of a specific the globular process in the 6.5-mm embryo. As
portion of the mesodermal mass in the naso- growth proceeds, these sulci are obliterated,
optic groove or from failure of the nasolacrimal beginning at the cephalic end, with complete
groove to become tubulated. However, a
91 closure present in the 12.5- mm embryo. When
recent report detailing the anatomic normal development is inhibited, the sulci
structures present in a case of naso-ocular may persist, leading to a furrow which
clefting tends to disprove the nasolacrimal deepens rather than becoming obliterated
groove hypothesis. 34 with time. The furrow edges eventually fuse to
form a canal opening at the upper end. Thus,
Congenital Lip Sinuses
it may be that a single gene is responsible for
Congenital lip sinuses, sometimes referred the growth retardation leading to the
to as lip pits, are rare developmental persistence of these embryonic furrows. The
anomalies, with some 2 0 0 cases reported in the association of this condition with clefts of the
literature.6, 21These sinuses appear as a lip and palate is more difficult to explain,
symmetric pair of openings or dimples on the although the two conditions have a close
vermilion border of the lower lip. Each dimple temporal em- bryologic relationship.
represents the opening of a blind-ending sinus
tract which characteristically penetrates the Congenital Double Lip
orbicularis oris muscle. The orifice of this tract Congenital double lip is another clinical
may be quite small or as large as 2 mm in rarity which occurs almost exclusively in the
diameter. Occasionally, a sinus opening may upper lip. Most of the reported cases have
be located in the midline of the lower lip, and occurred as part of the syndrome of Ascher, in
4

rarely it may even occur in the upper lip. which a blepharochalasis and nontoxic thyroid
Histologic examination of these sinuses enlargement have also been noted.
reveals an epithelially lined tract terminating Approximately a dozen cases have appeared in
in numerous mucous glands. These glands the literature.
96

occasionally deliver a mucous-like secretion, When the mouth is opened, a double


but there appears to be no tendency to vermilion with a transverse furrow of varying
obstruction or infection. depth can be seen between the two vermilion
The incidence of congenital lip pits appears borders. Interestingly, when the mouth is
to be slightly,- but probably insignificantly, closed, the deformity is not readily apparent
higher in females and characterized by since the furrow corresponds to the normal
autosomal dominant mode of inheritance. The 6
line of closure of the mouth. The clinician
studies of Van der Woude, in which these lip
101
should distinguish this condition from benign
pits occurred as part of a syndrome which or malignant growths which may lead to
included cleft lip and/or palate, indicate no sex apparent lip enlargement.
limitation or sex linkage and variable Etiology. The etiology of this condition is
expressivity of the condition. This finding has unknown but can be traced to an embryonic
now been confirmed and reviewed by Coccia developmental defect. In the fetus, the
and Bixler and Cervenka et al.
21 19
developing mucosa of the lip is divided into
two zones, the pars glabra (an outer smooth
and skinlike zone) and the pars
HEREDITY AND DEVELOPMENTAL CONSIDERATIONS 41

villosa (the inner, mucosa-like zone). It has thia. Micrognathic patients typically have
been suggested that the furrow creating the clinical retrognathia, but retrognathic pa-
double lip is an exaggerated boundary line tients may not necessarily have micrognathia.
between these two zones. Diagnosis and treatment of this condition has
been reviewed by Mugnier and Ginestet and
71 51

Micrognathia
is not considered here.
Micrognathia, sometimes descriptively Micrognathia means, then, a small jaw, but
designated retrognathia, is a severe facial the term is used almost exclusively for
deformity characterized by extreme shortness description of the mandible rather than the
of the body of the mandible. It should be maxilla. This usage is probably related to
distinguished from retrognathia, which means relative frequency of occurrence since
posterior displacement of the angle of the jaw underdevelopment of the maxilla is the less
relative to cranial structures. The latter common of the two conditions and is usually
condition may be produced by either decreased seen only in such conditions as cleft lip and
gonial angle or a posteriorly located condyle. palate, cleidocranial dysostosis, and
The differential diagnosis of these two acrocephalosyndactyly.
conditions, then, is dependent upon careful The etiology of micrognathia is varied but
measurement of the length of the body of the may be broadly classified into three groups: ( 1 )
mandible made from a lateral congenital, (2 ) developmental, and (3)
roentgencephalometric head- plate. Such acquired. No distinction is made here between
measurement may indicate a normal-sized jaw the first two types, although it should be noted
which is posteriorly displaced (retrognathia), that factors affecting mandibular growth such
but which may give the clinical appearance of as trauma and disease may lead to ankylosis
micrognathia. Figure 3.7 compares the of the temporomandibular joint and,
radiographic appearance of micrognathia and subsequently, micrognathia.
retrogna

FIG. 3.7. Roentgencephalometric comparison of retrognathia (left) and micrognathia (right). Note differing
length and position of mandible.
42 MAXILLOFACIAL PROSTHETICS

Congenital or Developmental Acquired


The most frequent cause of micrognathia in Any trauma such as forceps damage at
this category is maldevelopment of the first delivery or falls during infancy, or diseases
(mandibular) and second (hyoid) branchial such as rheumatoid arthritis, mastoiditis, or
arches. A not uncommon deformity of this type other suppurative involvement affecting the
appears in the microtia syndrome. In this
78 condyle, may arrest mandibular growth. Since
instance, the developmental failure, which is surgery and radiation may both affect
commonly unilateral, involves auricular condylar growth, the clinician must be careful
formation and the mastoid process, and the in using these treatments to avoid arrested
tympanic bone on the affected side as well as mandibular development.
the mandible may be severely retarded in Mandibular Prognathism
development. This results in a more posterior
This is a condition defined in part by the
position of the mandibular condyle on the
occlusal relation of the teeth and in part by
affected side. On the other hand, micrognathia
bony size and relationship of maxilla and
such as is seen in the Pierre Robin syndrome
is bilateral and, at least in some cases, mandible. Clinically, the person with
mandibular prognathism usually appears to
appears to be the result of a fetal insult (such
have the “bulldog” appearance characterized
as intrauterine compression), since the
by a mandible that extends out and beyond
mandible grows at a relatively normal rate in
the maxilla. This mandibular protrusion is
postnatal life even though it may never reach
invariably accompanied by a Class III (Angle)
full developmental potential. Agenesis of the
temporomandibular joint has been observed dental malocclusion. However, Class III
malocclusion classification does not pinpoint
but is quite rare. As might be expected, a
the primary defect and simply describes the
generalized atresia of the mandible
dental relationships. For example, it is
accompanies absence of the
possible for an individual to have a failure of
temporomandibular joint, and there may even
maxillary growth in conjunction with normal
be absence of the ramus. When the mandible
mandibular growth, such as is commonly seen
is completely missing (agnathia), only a
in patients with cleft lip and palate or clei-
remnant of tongue base is seen deep in the
docranial dysostosis. These patients have an
pharynx, and the ears approach each other in
apparent mandibular prognathism resulting
the midline. This congenital defect has been
from maxillary growth failure, but mandibular
given the designation of otocephaly.
growth in these instances may be normal and
Interestingly, maxilla development has been
not excessive.
observed to be quite normal in cases of
The etiology of mandibular prognathism is
congenital absence (agnathia) of the
of two general types, developmental and
mandible. 72 This is good evidence for
acquired. The developmental variety may be
development of the maxilla from a group of
hereditary, and a number of families have
mesenchymal cells separate from those
been described that exhibit mandibular
forming the mandible.
prognathism. The “Hapsburg jaw” , noted for
60 84
Since the spectrum of deformities of the
auricle, temporomandibular joint, mandible, 4 centuries in some of the royal houses of
Europe, is a classic example of the inherited
and facial symmetry are involved in several
prognathic type of mandible. Since
conditions, such as mandibulofacial dysostosis,
cephalometric studies were not performed on
hemifacial microsomia, microtia, and
the individuals of families in which this
otocephaly, Pruzansky and Allen attempted
78

condition appeared, it is not clear whether


to determine whether any correlations in
severity could be established between prognathism should be uniformly classified as
a true genetic condition. However, it has been
contiguous parts, particularly the auricle and
reported as a
temporomandibular joint. None was found.
HEREDITY AND DEVELOPMENTAL CONSIDERATIONS 43

dominant characteristic in certain families 93


cise, the other terms have not received wide
and a polygenic trait in others.60
use, and “first and second branchial arch
Trauma and disease may be responsible for syndrome” remains the most popular
some of the acquired types of prognathism. For designation. However, hemifacial microsomia
example, severe neck burns and contracture is the term of choice here because of its
may lead to open bite and resultant descriptive value and in the hope that a break
prognathism in children. Acidophilic tumors of from the general terminology will encourage a
the anterior pituitary in adults may also more precise classification of this spectrum of
produce mandibular prognathism since malformations.
excessive growth hormone produced by the Some confusion exists in the literature
tumor stimulates condylar growth. regarding the precise definition of this
Theoretically, prognathism may result from syndrome. For example, the disease man-
variations either in the relationships of dibulofacial dysostosis has several features in
craniofacial segments or in their dimensions. common with the first and second arch
Practically, jaw length seems to be a less syndromes but may be differentiated by
important factor in this condition than the size utilization of the criteria summarized in Table
and shape of cranial base. However, in 3.10.
considering surgical treatment for an affected Grabb reported the birth incidence of this
53

individual, one must evaluate jaw length in syndrome to be about 1 in 5600 live births; he
relation to the remaining growth potential noted that the actual incidence is probably
since there is normally a marked increase in higher than this because of failure to diagnose
the mandibular growth rate during at birth those minimally affected individuals.
adolescence. Surgery during this growth As with cleft lip and palate, a significantly
period would obviously be unsatisfactory since higher proportion of affected males has been
a permanent jaw relation could not be noted.53

maintained. In the following section, the specific


malformations seen in this syndrome are
Hemifacial Microsomia (First and Second described and assigned to the embryonic
Branchial Arch Syndrome) branchial arch from which they are derived.
During the past 2 decades, a group of Figures 3.8 and 3.9 show lateral and frontal
malformations has emerged from the con- views of children affected with this problem.
stellation of congenital malformations of the
First Branchial Arch
'face that has been designated the first and
second branchial arch syndrome. This 1. Muscles of mastication: those supplied by
syndrome has been so designated because the cranial nerve V (most often the temporalis and
craniofacial structures which are malformed masseter) are hypoplastic and show paresis.
are prinicpally derivatives of the embryonic 2. Palatal muscles: underdevelopment and
first and second branchial arches, including paresis of the tensor and levator veli palati
the first pharyngeal pouch, first branchial muscles without velopharyngeal insufficiency.
cleft, and primordia of the temporal bone. 3. Tongue: usually unilateral hypoplasia
A number of synonyms have been applied with deviation to the affected side on pro-
to the first and second arch syndromes and trusion. Ankyloglossia frequently seen.
these include necrotic facial dysplasia, 4. Parotid gland and duct: absence almost
intrauterine facial necrosis, hemifacial
104 invariably associated with both a large
microsomia and microtia, hemignathia and
13 preauricular tag anterior to the tragus and
microtia,92 and otomandibular dysostosis. 39 macrostomia.
Although the designation of this disease by 5. Macrostomia: a common finding rep-
simply naming the embryonic primordia resenting a failure of fusion of the em-
involved is not pre
44 MAXILLOFACIAL PROSTHETICS

TABLE 3.10. Differentiating features of disease involving embryonic first and second branchial arches
Mandibulofacial First and second arch Goldenhar’s
dysostosis syndromes’ syndromej
-
1. Hereditary basis Autosomal dominant with Only about 5% of cases
incomplete penetrance are familial
2. Eye:
Antimongoloid slant +++ + + *■
Colobomata Lower lid - Upper lid
Epibulbar dermoids - - +++
3. Symmetry Commonly bilateral Commonly unilateral Unilateral
4. Involvement of muscles of Bilateral if at all Unilateral Unilateral

mastication, facial expression, palate and tongue


5. Malar hypoplasia +++ + +
6. Vertebral anomalies - - +++

* Hemifacial microsomia.
4 Oculoauriculovertebral dysplasia.

bryonic mandibular and maxillary processes petrous portion which houses the inner ear
which is accentuated by a unilateral and is never involved.
hypoplasia of the mandible and condyle. It is interesting that the accompanying
6. Mandible: underdevelopment ranging congenital malformations most often reported
from hypoplasia to absence of ramus and/or in patients with the first and second branchial
condyle. arch syndrome are cleft lip and palate (7%),
7. Maxilla: hypoplasia evidenced by malformations of the vertebrae and/or ribs
decreased palatal width. Most obvious when (1 1 %), and of the eye and eyelid (1 0 %). Of the
unilateral. diseases involving the first and second arches,
cleft lip and palate is sometimes found in
Second Branchial Arch
mandibulofacial dysostosis, vertebral
1. Facial muscles: hypoplasia and paresis. anomalies in Gol- denhar’s syndrome, and eye
The facial nerve (VII) may or may not be and eyelid anomalies in both of these. Thus, it
hypoplastic. Interestingly, the chorda tympani appears that many of the cases appearing in
fibers in N. VII are invariably intact. the literature may be incorrectly classified,
2. Hyoid bone: always normal. and more precise differentiation of these three
Both Arches clinical entities is needed. Gorlin and
Pindborg believe this to be quite possible.
52

1. External ear: underdevelopment


ranging from hypoplasia to anotia. Typically, Congenital Deformities of Ear
the complete spectrum of auricular There is wide variation in the shape of the
malformations, including rudimentary lobule, normal auricle, and no two human ears are
“double ear,” and preauricular tags and exactly alike with regard to position, size, and
sinuses, is seen in these patients. External shape. However, some variations are
meatus is commonly missing. Note branchial disfiguring enough to warrant surgical and
arch contributions in Figure 3.1. even prosthetic reconstruction. This section
3. Middle ear: incus, malleus, and stapes considers only the more commonly observed
may all be hypoplastic or missing; Eustachian and probably inherited variations.
tube may be underdeveloped. Microtia. The auricle is distinctly un-
3. Temporal bone: glenoid fossa under- derdeveloped and malformed. In most in-
developed and may even be absent. Any
portion of bone may be involved, except
HEREDITY AND DEVELOPMENTAL CONSIDERATIONS 45

FIG. 3.8. Hemifacial microsomia: the first and second branchial arch syndrome.

stances, only remnants of the fundamental


structures of the ear persist, and these may
sometimes assume the appearance of the six
embryonic hillocks or tubercles of mesoderm
from which the external ear is at least partly
derived. The most severe instance of microtia
is obviously anotia, in which the entire
external ear is missing. In this instance,
reconstructive surgery seldom is successful,
and prosthetic restoration becomes the
treatment of choice.
As mentioned in the previous section,
microtia is often associated with the branchial
arch syndromes, some of which (such as
mandibulofacial dysostosis) are inherited as
single gene traits. Others, such as hemifacial
microsomia, have an unclear hereditary basis.
In general, it might be stated that the greater
the auricular deformity, the greater the
possibility of both meatal and middle ear
deformity.
Lop Ear. A malformed auricle in which
there is an acute downward folding (or
FIG. 3.9. The spectrum of ear and facial abnormalities deficiency) of the helix associated with
seen in hemifacial microsomia. malformation or deficiency of the anti
46 MAXILLOFACIAL PROSTHETICS

helix. This type of ear, which can appear tions of face and extremities may suggest a
smaller than normal because of the folding of syndrome whose manner of inheritance is
the helix, may be termed microtic when it is simple and readily discernible (such as al-
actually of normal size. ready mentioned for mandibulofacial dys-
Cup Ear. This deformity is best visualized ostosis). In this instance, genetic counseling
by observing a normal ear when it is cupped assumes greater importance. Furthermore,
with the hand in order to hear an indistinct evaluation of the auricular defect against the
sound. In this situation, the helix is swung family background of ear deformities may be
around anteriorly. Often a widened helical helpful in predicting severity of the defect in
margin is combined with poor antihelix the offspring of affected individuals.
development, two common deformities Finally, it should be emphasized that,
observed with the cup ear, and these further because of the intimate temporal and spatial
exaggerate the cupping deformity. embryologic relationships of the middle and
Protruding Ear. This type of ear ap- external ear, malformations of the auricle and
proximates the normal in size and shape, but particularly the severe type of microtia should
malformations usually include one or a be suspect as accompaniments of significant
combination of the following: a simple or middle ear deformities that may require a
poorly formed antihelix, excessive conchal detailed examination to reveal.
cartilage, lobule protrusion and/or excessive Facial Hemiatrophy (Romberg’s Disease)
size, and a thin, unrolled helix margin.
This is a condition which involves atrophy
Rogers82, who has carefully described and
of any or all of the superficial facial tissues
reviewed these four types, believes that they
and underlying subcutaneous tissue, muscle
represent a continuum of arrested or
and, less commonly, cartilage and bone. It is a
disturbed auricular development with anotia-
slowly progressive disease which has its onset
microtia representing the earliest and most
in the first and second decade of life, and
severe developmental arrest, and the lop, cup,
typically it affects only one side of the face,
and protruding ears representing later and
although both sides have been reported to be
hence progressively less severe developmental
affected. Characteristically, the disease seems
alterations.
to be limited to areas conforming to the
Hereditary aspects of auricular anomalies
distribution of branches of the trigeminal
without other physical abnormality are not
nerve. Although the subcutaneous connective
clear, although familial occurrences are
tissue is usually the most severely involved
frequently noted. It seems probable that the
tissue, bony involvement may also be quite
four broad, descriptive categories given here
severe if the onset of the disease occurs before
represent the phenotypic effects of more than
the time of skeletal maturation.
one gene or, in other words, a polygenic trait.
Etiology. The etiology of this disease is
In general, polygenic traits are difficult to
unknown, although a recent extensive review
study because of almost continuous variation
of the literature by Rogers indicates that
81

in phenotype and thereby do not show a


there is insufficient evidence to classify this
simple manner of inheritance. Polygenic
disease as hereditary. However, familial
inheritance has already been suggested for a
occurrence has been reported. Several
number of complex congenital malformations
hypotheses have been advanced to explain this
such as cleft lip and palate, clubfoot,
phenomenon, and the one receiving the widest
congenital dislocation of the hip, and others .
18

acceptance by neurologists is the following.


However, it is important for the clinician to
look beyond the affected ears of his patient
since the presence of additional malforma
HEREDITY AND DEVELOPMENTAL CONSIDERATIONS 47

Sympathetic Hypothesis. Basically, this


hypothesis states that the source of the
problem lies in progressive loss of sympathetic
nerve impulses (tonus) to the areas in
question. This progressive loss appears to be
initiated by any of a number of factors such as
local infection or trauma which make up the
typical history of the patient with hemifacial
atrophy.
Oral Manifestations. Atrophy of the bony
palate, overlying palatal tissues, and tongue
on the affected side may be features of this
condition. The teeth are not affected by the
atrophic process, although they may be quite
susceptible to dental caries because of atrophy
of the major salivary glands, particularly on
the affected side.
Hemifacial Hypertrophy
Asymmetrical growth and development of
the entire body or any of its parts is not
unusual. This asymmetry, which may be
imperceptible or may be quite marked, may
result from overgrowth of a single tissue, all
tissues, part of an organ, or an entire organ. FIG. 3.10. Hemifacial hypertrophy: severe involve-
Marked asymmetry caused by localized ment the right side of the face. (Courtesy of Dr. N. H.
overgrowth of all tissues in a part, such as Rowe.)
hemifacial hypertrophy, is perhaps one of the
rarest kinds of medical anomalies. 2. Enlargement of all tissues—teeth, bone,
Congenital hemihypertrophy may be of and soft tissues—within this area. A review
several types: article by Rowe83 describes in detail the oral
1. Complex hemihypertrophy involving an cavity and its structures in this condition.
entire half of the body or at least an arm or Etiology. The condition of hemifacial
leg. The enlarged parts may be all on the same hypertrophy is not a common one—less than
side of the body (ipsilateral) or on both sides 40 cases appear in the literature—and only
(contralateral). speculation is available as to its cause. The
2. Simple hemihypertrophy involving a condition involves embryonic derivatives of
single limb. the first branchial arch and the groove
3. Hemifacial hypertrophy involving one between the first and second arches. Some
side of the face (Fig. 3.10). etiologic factors that have been implicated are
Generally, the two criteria used for making hormonal imbalance, neural abnormality,
the diagnosis of hemifacial hypertrophy are: lymphatic abnormality, blood vascular
1. Unilateral enlargement of viscero- abnormality, incomplete twinning,
cranium bounded superiorly by the frontal chromosomal abnormality, and localized
bone (excluding eye), inferiorly by the inferior alteration of intrauterine development.
border of the mandible, medially by the Although familial occurrence has been
midline of the face, and laterally by the ear, reported, this anomaly does not appear to
the pinna being included. have a hereditary predisposition.
Surgical treatment of such patients is quite
difficult. However, even though
48 MAXILLOFACIAL PROSTHETICS

there may continue to be a relative facial 19. Cervenka, J., Gorlin, R. J., and Anderson, V.
disproportion throughout early life, growth of E.: The syndrome of pits of the lower lip and
cleft lip and/or palate. Genetic considerations.
the enlarged part typically ceases at the time
Amer. J. Hum. Genet. 19: 416, 1967.
of skeletal maturation. 20. Cisk, L., and Mather, K.: The sex incidence of
certain hereditary traits in man. Ann. Eugenics
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42. Fraser, F. C.: Some experimental and clinical 59. Kazanjian, V. H., and Holmes, E. M.: Treat
studies on the causes of congenital clefts of the ment of median cleft lip associated with bifid
palate and of the lip. Arch. Pediat. 77: 151, nose and hypertelorism. Plast. Reconstr. Surg.
1960. 24: 582-587, 1959.
43. Fraser, F. C. The genetics of cleft lip and cleft 60. Litton, S. F., Ackermann, L. V., Isaacson, J., and
palate. Amer. J. Hum. Genet. 22: 336-352, Shapiro, B. L.: A genetic study of class III
1970. malocclusion. Amer. J. Orthodont. 58: 565- 577,
44. Fraser, F. C., and Baxter, H.: The familial dis 1970.
tribution of congenital clefts of the lip and 61. Loretz, W., Westmoreland, W. W., and Rich
palate. Amer. J. Surg. 87: 656, 1954. ards, L. F.: A study of cleft lip and cleft palate
45. Fraser, F. C., Kalter, H., Walker, B. E., and births in California, 1955. Amer. J. Public
Fainstat, T. D.: The experimental production of Health 51: 873-77, 1961.
cleft palate with cortisone and other hormones. 62. MacMahon, B. and McKeown, T.: The inci
J. Cell. Comp. Physiol. 43: 237, 1954. dence of harelip and cleft palate related to birth
46. Fraser, G. R., and Calnan, J. S.: Cleft lip and rank and maternal age. Amer. J. Hum. Genet.
palate: seasonal incidence, birth weight, birth 5: 176, 1953.
rank, sex, site, associated malformations and 63. Mazaheri, M.: Statistical analysis of patients
parental age; a statistical survey. Arch. Dis. with congenital cleft lip and/or palate at the
Child. 36: 430, 1961* Lancaster Cleft Palate Clinic. Plast. Reconstr.
47. Fujino, H., Tanaka, K., and Sanui, Y.: Genetic Surg. 21: 193, 1958.
study of cleft lips and cleft palates based upon 64. McEvitt, W. G.: Cleft lip and palate and pre
2,828 Japanese cases. Kyushu J. Med. Sci. 14: natal age. Plast. Reconstr. Surg. 10: 77, 1952.
317, 1963. 65. Meskin, L. H., Gorlin, R. J., and Isaacson, R.
48. Fujino, H., Tashiro, H., Sanui, Y., and Tanaka, J.: Abnormal morphology of the soft palate. II.
K.: Empirical genetic risk among offspring of The genetics of cleft uvula. Cleft Palate J. 2: 40,
cleft lip and cleft palate patients. Jap. J. Hum. 1965.
Genet. 12: 62-68, 1967. 66. Meskin, L. H., Pruzansky, S., and Gullen, W.:
49. Fukahara, T., and Saito, S.: Possible carrier An epidemiologic investigation of factors re-
status of heredity cleft palate with cleft lip; lated to the extent of facial clefts. I. Sex of
report of cases. Bull. Tokyo Med. Dent. Univ. patient. Cleft Palate J. 5: 23-29, 1968.
10: 333, 1963. 67. Metrakos, J. D., Metrakos, K., and Baxter, H.:
50. Gier, R. E., and Fast, T. B.: Median maxillary Clefts of the lip and palate in twins. Plast.
anterior alveolar cleft. Oral Surg. 24: 496, 1967. Reconstr. Surg. 22: 108, 1958.
51. Ginestet, D. G.: Traitement de la micrognathie 68. Mills, L. F., Niswander, J. D., Mazaheri, M.,
mandibulaire. Rev. Franc. Odontostomat. 11: and Brunelle, J. A.: Minor oral and facial
175-190, 1964. defects in relatives of oral cleft patients. Angle
52. Gorlin, R. J., and Pindborg, J. J.: Syndromes Orthodont. 38: 19S-204, 1968.
of the Head and Neck. McGraw-Hill Book 69. Monroe, C. S.: Midline cleft of the lower lip,
Company, New York, 1964. mandible and tongue with flexion contracture
53. Grabb, W. C.: The first and second branchial of the neck: case report and review of the lit-
arch syndrome. Plast. Reconstr. Surg. 36: 485 - erature. Plast. Reconstr. Surg. 38: 312-319,
508, 1965. 1966.
54. Greene, J. C.: Epidemiology of congenital clefts 70. Moss, M. L.: Hypertelorism and cleft palate
of the lip and palate. Public Health Rep. 78: deformity. Acta Anat. (Basel) 61: 547, 1965.
589, 1963. 71. Mugnier, A.: Les retromandibulies du nourris-
55. Greene, J. C., Vermillion, J. R., Hay, S., Gib- son et du jeune enfant. Rev. Franc. Odonto-
bens, S. F., and Kerschbaum, S.: Epidemiologic stomat. 11: 1256-7, 1964.
study of cleft lip and cleft palate in four states. 72. Muller, T.: Malformations of the ears. S. Afr. J.
J. A. D. A. 68: 387, 1964. Lab. Clin. Med. 13: 383, 1966.
56. Hantzschel, K.: Die Eugenische Bedeutung der 73. Neel, J. V.: A study of major congenital defects
Angeborenen Spaltbildungen. In Fogh-An- in Japanese infants. Amer. J. Hum. Genet. 10:
dersen, P.: Inheritance of Harelip and Cleft 398, 1958.
Palate. Nyt. Nordisk Forlag, Copenhagen, 1942, 74. Pashavan, H., and Fraser, F. C.: Facial features
p. 56. associated with a predisposition to cleft lip.
Teratology 2: 267-268, 1969.
50 MAXILLOFACIAL PROSTHETICS

75. Patten, B. M.: Human Embryology, Ed. 2. 96. Swendloff, G.: Double lip. Oral Surg. 13: 627-
McGraw-Hill Book Company, New York, 629, 1960.
1953. 97. Tanaka, K., Fujino, H., Tashiro, H.. and
76. Peer, L. H., Strean, L. P., Walker, J. C., Bern- Sanui, Y.: Recurrent risk of cleft lip and palate
hard, W. G., and Beck, G. C.: Study of 400 among relatives of patients, with special
pregnancies with birth of cleft palate infants. considerations of sex and racial differences. Jap.
Plast. Reconstr. Surg. 22: 442, 1958. J. Hum. Genet. 12: 141-149, 1967.
77. Pohlman, E. H.: Die Embrvonale Metamor 98. Tondury, GFortschritte der Kiefer und Ge-
phose der Physiognomie und der Mundhohle sichts Chirurgie. Georg Thieme Verlag, Stutt-
des Katzenkopfes. Dissertation, Leipzig, 1910. gart, 1955.
78. Pruzansky, S., and Allen, K. R.: Congenital 99. Trasler, D. G., and Fraser, F. C.: Role of the
otocephalic deformities in man and animals. J. tongue in producing cleft palate in mice with
Dent. Res. 43: 821, (1964). spontaneous cleft lip. Develop. Biol. 6: 45-60,
79. Rank, B. K., and Thomson, J. A.: Cleft lip and 1963.
palate in Tasmania. Med. J. Aust. 47: 681, 100. Tretsven, V. E.: Incidence of cleft lip and palate
1960. in Montana Indians. J. Speech Hearing Dis. 28:
80. Robinson, H. B.: Development of the face and 52, 1963.
oral cavity. In Sicher, H.: Orban’s Oral His- 101. Van der Woude, A.: Fistula labii inferioris con
tology and Embryology, Ed. 6. The C. V. Mosby genita and its association with cleft lip and
Company, St. Louis, 1966. palate. Amer. J. Hum. Genet. 6(2): 244, 1954.
81. Rogers, B. O.: Progressive facial hemiatrophy 102. Veau, V. and Politzer, G.: Embryology of the
(Romberg’s disease): a review of 772 cases. harelip: the primary palate. Formation and
Transactions of the Third International Con- anomalies. Ann. Anat. Path. (Paris) 13: 275,
gress of Plastic Surgery, pp. 681-689. Ex- cerpta 1936.
Medica Foundation, Amsterdam, 1964. 103. Walker, B. E., and Fraser, F. C.: Closure of the
82. Rogers, B. O.: Microtic, lop, cup and protruding secondary palate in three strains of mice. J.
ears. Plast. Reconstr. Surg. 41: 208-231, 1968. Embryol. Exp. Morph. 4: 176, 1956.
83. Rowe, N. H.: Hemifacial hypertrophy. Oral 104. Walker, D. G.: Malformations of the Face. The
Surg. 15: 572, 1962. Williams & Wilkins Company, Baltimore,
84. Rubbrecht, V.: Der Unterkieferprognathismus 1961.
und Dessen Vererbung nach dem Menschen. 105. Warkany, J., and Deuschle, F. M.: Congenital
Province Dentaire, Gesetz, 1930, p. 322. malformations induced in rats by maternal
85. Sanders, J.: Inheritance of harelip and cleft riboflavin deficiency: dentofacial changes. J. A.
palate. Genetica 15: 433, 1934. D. A. 51: 139, 1955.
86. Schroder, C. H.: Die Vererbung der Hasen- 106. Warkany, J., and Kalter, H.: Experimental cleft
scharte und Gaumenspalte. Arch. Rassenbiol. palate interpretations and misinterpretations.
25: 369, 1931. Cleft Palate Bull. 7: 9, 1957.
87. Schroder, C. H.: Untersuchungen uber die Ve 107. Warkany, J., Nelson, R. C., and Schraffen-
rerbung der Hasenscharte und Gaumenspalte berger, E.: Congenital malformations in rats by
met Besonderer Beruchsichtigung des Erb- maternal nutritional deficiency. Amer. J. Dis.
gangs. Arch. Klin. Chir. 182: 299, 1935. Child. 65: 882, 1943.
88. Sesgin, M. J., and Stark, R. B.: Incidence of 108. Warkany, J., Passarge, E. and Smith, L. B.:
congenital defects. Plast. Reconstr. Surg. 27: Congenital malformations in autosomal trisomy
261, 1961. syndromes. Amer. J. Dis. Child. 112: 502-517,
89. Shehata, R.: Human cyclops. Alexandria Med. 1966.
J. 10: 218-227, 1964. 109. Weaver, D. F., and Bellinger, D. H.: Bifid nose
90. Stark, R. B.: The pathogenesis of harelip and associated with midline cleft of the upper lip.
cleft palate. Plast. Reconstr. Surg. 13: 20, Arch. Otolaryng. (Chicago) 44: 480-482, 1946.
1954. 110. Woolan, D. H. M., and Millen, J. W.: Effect of
91. Stark, R. B.: Plastic Surgery. Harper & Row, cortisone on the incidence of cleft palate in-
New York, 1962, p. 447. duced by experimental hypervitaminosis A.
92. Stark, R. B., and Saunders, D. E.: The first Brit. Med. J. 2: 197, 1957.
branchial syndrome; the oro-mandibular-au- 111. Woolf, C. M., Woolf, R. M., and Broadbent, T.:
ricular syndrome. Plast. Reconstr. Surg. 29: Genetic and non-genetic variables related to
229, 1962. cleft lip and palate. Plast. Reconstr. Surg. 32:
93. Stiles, K. A., and Luke, J. E.: The inheritance 65, 1963.
of malocclusion due to mandibular prog- 112. Woolf, C. M., Woolf, R. M., and Broadbent, T.
nathism. J. Hered. 44: 241-245, 1953. R.: Lateral incisor anomalies (microform of cleft
94. Strean, L. P., and Peer, L. A.: Stress as an etio lip and palate?). Plast. Reconstr. Surg. 35: 543-
logical factor in the development of cleft palate. 547, 1965.
Plast. Reconstr. Surg. 22: 442, 1958. 113. Wragg, L. E., Klein, M., Steinvorth, G., and
95. Streeter, G. L.: Development of the auricle in Warpeha, R.: Facial growth accommodating
the human embryo. Contrib. Embryol. 14: 111, secondary palate closure in rat and man. Arch.
1922. Oral Biol. 15: 705-719, 1970.
4
ANATOMY AND PHYSIOLOGY IN . MAXILLOFACIAL
PROSTHETICS
Robert H. Shellhamer

Cephalization, meaning the formation of a tined to split off into both upper respiratory
head, is a distinctive feature in the evo- and upper alimentary passages.
lutionary history of multicellular animals. In Mimicking structure seen in the fishes, in
the course of human development, as in other the early development of the human head and
vertebrates, one sees in the appearance of neck there is visualized a tube, the foregut or
head structure a repetitive staging of growth primitive pharynx, which extends caudally
and development which mimics structural from the stomodeum or ancestral mouth.
organization observed repetitively in the Ventrally, and extending bilaterally from the
phylogenetic succession of all animal forms. walls of the foregut, is a series of bays, called
This is otherwise referred to as ontogeny pharyngeal pouches. External and adjacent to
recapitulating phylogeny. these is a series of clefts (Fig. 4.8A),
Cephalization really signifies the concen- comparable to the gill slits of fish, which
tration of a brain and special senses at one present little tissue interval between the
end of the animal, the head. While the brain surface covering (ectoderm) and inner lining
deserves special attention for specific (endoderm) of the pharynx. Consequently,
purposes, it need not be discussed here. bounding the pharyngeal walls on each side,
Certain of the appended cranial nerves, six pairs of masses or bars of tissue are found
however, are pertinent and are discussed as between the series of external clefts and
applicable. internal bays or pouches. These bars are
Even though head formation is complex, its termed pharyngeal arches, or visceral arches
study can contribute immeasurably toward a in deference to their close relationship to the
clearer understanding of structure and primitive visceral tube. At once the history of
function in the adult form. In humans, the the development of the head and neck becomes
structure of the eye, ear, nose, and mouth a matter of accounting for the fate of the
have great relevance for maxillofacial cavity and its bays, the clefts, and the six
prosthetics specialists, who may fabricate a pairs of pharyngeal or visceral arches. Each
replacement for a lost or damaged ear, design arch is comprised of an ectodermal outer
and fit an artificial eye in a functioning socket, covering, an endodermal inner lining, and a
and artificially restructure a nose, or even a significant core mesenchymal mass.
major portion of an upper or lower jaw. For the most part, the ectodermal covering
Developmentally, the formation of cavities becomes the protective epithelial layer of skin,
in the head is important. This relates to the following in an uncomplicated fashion all body
central neuraxis (brain), and to the foregut, contours or bulging
the simple tubular structure des

51
52 MAXILLOFACIAL PROSTHETICS

masses, e.g., nose or auricle, and continuing each primitive visceral arch flares into dis-
with definite modifications for some distance tribution to the muscles derived from its own
into the cavities, as into the nares, the arch. The trigeminal nerve (nerve V)
external ear canal, and the conjunctival sac of distributes to the masticatory muscles be-
the eye. The endodermal lining per se gives cause, as the nerve of the first visceral arch, it
rise to mucosal linings which vary supplies the muscles derived from this arch,
histologically to meet the needs of particular including the tensor muscles of the soft palate
areas, for example, pseudo- stratified ciliated and of the middle ear. Emanating from the
epithelium in the respiratory cavities and, in second visceral arch, and sheetlike at the
the oral areas, epithelium with taste buds of outset, are the definitive facial mimicry
lymphoid or tonsillar tissue incorporated as muscles, and the nerve to these, as to all
needed. However, the fate of the pharyngeal muscles derived from the second arch, is the
pouches and their lining mucous membranes facial nerve. These muscles include the
is visualized as extensions of varying dimen- stapedius of the middle ear, the posterior belly
sions from the pouches, e.g., giving rise to the of the digastric, the stylohyoid, and all other
formation of the Eustachian tube muscles about the orifices of the face, that is,
(pharyngotympanic tube), continuous with the the auricular muscles, narial muscles, and the
lining of the middle ear. orbicularis muscles both of the orbit and
The fate of the mesenchymal core masses of mouth.
the visceral arches is more complicated. Each The anatomy of the facial orifices has great
gives rise to musculoskeletal structures, that relevance for the maxillofacial prosthodontist.
is, to the connective tissues, including It is fitting, then, to consider in turn the bony
cartilage and bone, and to muscles. orbit, the bony nasal opening (piriform
Incorporated into each arch is its own vascular opening), the oral opening and
and nerve supply. In visceral arch I, the maxillomandibular apparatus, and the
mandibular arch, an elongated Meckel’s external auditory meatus, as well as the
cartilage develops, to be supplanted in later collective and appended anatomy of these
development by the osseous mandible and the facial features. Associated with these are the
malleoincudal segment of the ossicular chain primary organs of special sense (visual,
of bones in the middle ear. The maxilla, too, olfactory, gustatory and statoacoustic), which
develops in visceral arch I, first as cartilage, gives added interest to each.
then with the gradual replacement of the
Orbit and Contents
latter, as bone. From the mass of visceral arch
II the hyoid bone is ultimately derived, as well The bony orbit, housing the globe (eye) and
as incudostapedial parts of the ossicular chain its adnexa, is comprised of numerous discrete
in the middle ear cavity. Muscles also appear, bones in sutural union with one another. The
concomitant with the development of cartilage orbital margin is essentially a framework of
and bone. Finally, from mesenchyme are bones (Fig. 4.1): the frontal bone superiorly
derived connective tissues, including those in and superolaterally, the zygoma laterally and
subcutaneous and submucous sites. Bearing interiorly, the maxilla interiorly and
nerves and vessels, such connective tissues inferomedially, and the nasal bone medially.
allow for the high degree of reactivity observed In the depths of the orbit are added the
in cutaneous surfaces and in mucous lining lacrimal and ethmoid (lamina papyracea)
membranes under changing environmental or bones in the medial wall, with the greater and
metabolic conditions. lesser wings of the sphenoid most deeply
Appended to the skull and maxilloman- situated, and a small contribution of palatine
dibular apparatus is the masticatory mus- bone. The orbit is thickest laterally, being
culature. As one might expect, the nerve of reinforced there by the strong zygoma, and it
is thinnest medially where the wafer-thin
lamina
ANATOMY AND PHYSIOLOGY 53

FRONTAL BONE eral orbital wall. In the medial orbital wall are
OPTIC CANAL LAMINA the anterior and posterior ethmoidal foramina,
SUPERIOR ORBITAL PAPYRACEA
FISSURE which permit access for vessels and nerves
SPHENOID BONE from the orbit to the lining membrane of the
LACRIMAL
BONE ethmoid air cells. The nasolacrimal fossa,
which houses the nasolacrimal sac, is also in
the medial wall.
INFERIOR ORBITAL
FISSURE Certain cutaneous nerves and vessels reach
ZYGOMA the face by way of additional foramina related
to the orbit. The supraorbital foramen,
sometimes only a notch, provides an avenue
for nerves and vessels to the frontal area from
FIG. 4.1. Bony orbit, anterior view, right side. the orbit. The infraorbital foramen offers a
pathway for maxillary nerve outflow and for
papyracea is in immediate lateral relation vessels to the face. On the outer surface of the
with the ethmoid air sinuses. It is important zygoma, its zygomaticofacial foramen trans-
to recognize that the floor of the orbit, which is mits nerve twigs from the maxillary nerve to
not especially thick (1 to 2 mm in the adult) the skin of the face over the zygoma.
and which is readily subject to fracture in While the most important structure in the
facial trauma, is also the roof of the large orbit is the eye, or globe, connective tissues of
maxillary sinus. some -note are associated with it (Fig. 4.2).
It appears, when viewing the skull and Lining the bony orbit is a connective tissue,
orbits from the anterior or facial aspect, that the periorbita, which is loose-fitting except
the bony walls flare and that each orbit is thus where it is more firmly bonded to the walls at
a cone. Careful observation, however, shows the suture lines and the foramina. It
that the lateral walls of the orbits obviously constitutes somewhat of a limiting barrier, the
slope away from the median plane, by some 45 orbital septum, to the front of the orbit where
degrees, but that the medial walls are in fact it is continuous with the tarsal plates of the
parallel with each other. upper and lower eyelid, and it serves as a
Openings into the bony orbit are numerous functional periosteum elsewhere for the bones
(Fig. 4.1). Communication between the orbit of the orbit (Fig. 4.3). Continuous from the
and the interior of the neurocranium is by way periorbita are sleeves of connective tissue
of the optic canal, through which pass the about the extraocular muscles of the globe,
optic nerve and ophthalmic artery. Through and such sleeves are continuous with the
the larger superior orbital fissure pass the bulbar fascia, or Tenon’s capsule, enveloping
oculomotor, trochlear, and abducens nerves the globe itself (Fig. 4.4). Structure
and the ophthalmic branches of the trigeminal adaptations of periorbital connective tissues
nerve and ophthalmic veins. The inferior contribute to (1) “check ligaments” which are
orbital fissure presents as a natural break in associated specifically with the lateral and me-
the orbital floor, thereby allowing the dial rectus muscles of the globe and which
maxillary division of the trigeminal nerve to affix each muscle to a certain extent to the
continue forward for a short distince in the bony wall, and (2) a “suspensory ligament” (of
orbit before entering the infraorbital canal in Lockwood), a somewhat variable entity
the orbital floor. It is significant that associated with the inferior oblique muscle. It
secretomotor nerve fibers to. the lacrimal suggests the presence of a true sling for the
gland from the facial nerve gain access into globe, with the potential of supporting the
the orbit through this fissure from the globe in the event of a blow-out fracture of the
sphenopalatine ganglion and then proceed to bony orbital floor.
the gland, situated high in the lat The extraocular muscles comprise a core
54 MAXILLOFACIAL PROSTHETICS

TEMPORALIS M. BONY ROOF OF ORBIT


AND FASCIAS WITH EXTENSION OF
THE FRONTAL SINUS
INTERVENING.
BONY LATERAL
ORBITAL WALL BONY MEDIAL ORBITAL
BONY FLOOR
OF ORBIT

MAXILLARY ETHMOID AIR SINUSES


ANTRUM
(SINUS)

FIG. 4.2. Schematized frontal section of the head to illustrate orbital contents and relations.

ORBITAL MEDIAL
SEPTUM PALPEBRAL LIG.
(PALPEBRAL
FASCIA )

FIG. 4.4. Sagittal section through the orbit to il-


FIG. 4.3. Schematized dissection of the orbit from lustrate composition of the bulbar fascia of Tenon and
the anterior with orbicularis muscle removed. The the continuity of it with fasciae of the extraocular
orbital septum is continuous with the periosteal lining muscles. SUP., superior; INF., inferior; M., muscle.
(periorbita) of the bony orbit. LIG., ligament.
orbital margins, is the circumferentially
of four rectus muscles (superior, inferior, positioned orbicularis oculi muscle. This
medial, and lateral) and a pair of obliquely muscle is constituted of multiple laminae and
positioned muscles (superior and inferior), all segments, but essentially it is designed for
attached through Tenon’s capsule to the globe active closure of the palpebral fissure, either
and each exerting specific influences on partially (palpebral muscle component) or
change in position of the globe in the bony fully and tightly (orbital muscle component)
orbit. Under control of the levator palpebrae by the apposition of the upper lid to the lower.
superioris muscle, only the upper eyelid is Additional fibers of the orbicularis muscle, the
significantly involved in widening of the lacrimal component or Horner’s muscle,
palpebral fissure or eye opening. The lower envelop the nasolacrimal sac, according to
eyelid is not similarly equipped to participate Last,8 and by their contraction tend to milk
markedly in palpebral fissure widening. the sac of its tear fluid contents. Nerve supply
Associated with both eyelids, and broadly to this muscle comes from the face, via
spread subcutaneously beyond the superficially distributing temporal and
ANATOMY AND PHYSIOLOGY 55

zygomatic branches of the important facial the skeletal framework of the skull, and it
nerve. Nerve supply to the levator palpe- brae derives intrinsic support from cartilaginous
muscle is from within the orbit via nerve III, structure and, to a lesser degree, from fi-
the oculomotor, the integrity of which is brofatty contributions.
necessary to permit normal palpebral fissure Developmentally, the nasal part of the
widening. respiratory passage has been secondarily split
Included in the extraocular adnexal off from the primitive foregut through the
structures is the provision for a lacrimal formation of the horizontally positioned
lubricating mechanism for the corneal and palate, properly viewed as both the floor of the
anterior scleral surfaces of the globe. The nasal cavity and the roof of the oral cavity.
lacrimal apparatus exists separately as se- Further partitioning of the single airway into
cretory and collecting components. The left and right chambers has occurred with the
lacrimal gland, in the upper and outer part of developmental appearance of the nasal
the bony orbit, elaborates tear fluid which is septum. The nose thus is not properly
secreted through as many as a dozen small speaking a proboscis, for its function has
ducts opening into the conjunctival sac, the become restricted to respiration consequent to
space between the globe and the internal its separation from the primitive alimentary
surfaces of each eyelid. The collecting tube.
apparatus, medially placed in the orbit, has Each nasal cavity (Fig. 4.5) extends from
two punctal openings, each surmounting a an external or facial naris to an internal naris
lacrimal papilla associated with upper and or choana, and it is bordered by: a medial,
lower eyelids. From each punctal opening a vertical but not uncommonly laterally
slender canaliculus, measuring 0.5 mm in deviated septal wall, a lateral wall that is
diameter and 10 mm in length, joins the irregular owing to the presence of three to five
nasolacrimal sac, the dilated upper end of the prominences called conchae or turbinates, a
nasolacrimal duct, which in turn opens into long floor, the palate, and a roof that is short,
the inferior meatus in the lateral wall of the narrow and irregular since it must follow the
nasal cavity. The integrity of the collecting contour of the roof of the nose, the floor of the
system is challenged as it may become anterior cranial fossa, and the anterior face of
involved in fractures of the bony maxilla, or in the body of the sphenoid bone. The nasal
tumors, maxillectomy, etc., since the cavity is thus comprised, in continuity, of the
nasolacrimal duct is housed in this bone. external naris, the vestibule, the nasal cavity
proper adjacent to the septal wall, the
Nose and Nasal Cavities
meatuses, and the posterior naris or choanal
The nose is a facial appendage, but it is also region, which is continuous into the pharynx.
a part of the airway. It is supported on The inferior, middle, and superior meatuses

FIG. 4.5. Sagittal views of the nasal cavity, right side, to illustrate concha intact (left) and concha removed
(right). With concha removed, orifices of paranasal sinuses and the nasolacrimal duct become obvious. SUP.,
superior; MID., middle; INF., inferior.
56 MAXILLOFACIAL PROSTHETICS

and the highest space, the sphenoethmoidal the paired apical or alar cartilages bound the
recess, are all created out of the presence of margins of the external nares, each cartilage
the inferior, middle, superior, and occasionally contributing a medial and lateral crus about
a supreme turbinate protruding from a lateral the narial opening. Smaller cartilages,
nasal wall (Fig. 4.5, A). Teleologically, their sometimes called lesser alar cartilages, may
presence is viewed as a design intended to occur.
increase the overall expanse of the mucous The separate cartilaginous parts of the
respiratory membrane of the upper airway. external nose, which are united to the osseous
The piriform opening, observed in the outline of the piriform opening by connective
middle of the facial aspect of a bony skull, is tissues, have union with each other through
bounded by left and right maxillary bones and build-up of fibrous connective tissues. This
superiorly by the paired nasal bones. enhances the relative flexibility and plasticity
Together, the two maxillae in articulation of the external nose. The nasal septum is
produce a sharp anterior nasal spine in the largely bony and cartilaginous, but its lower
midline interiorly, providing for septal or part, the columella, is composed of fibrofattv
columellar attachment. tissue and overlying skin and is flexible and
Within the nose, the osteologic structure of mobile. The tight adherence of the skin to
the walls is complex. The floor is rather subjacent tissues on the external nose,
simple, however, and is comprised of palatal especially overlying its tip, is matched by
processes of the maxillary and palatine bones. tight adherence of the mucous membrane to
Evidence indicates the presence of an the periosteum and perichondrium lining the
additional premaxillary bone which, along interior of the nose.
with the overgrowing maxillary bone, bears The collective paranasal sinuses, specifi-
the maxillary incisor teeth.7 The nasal bones, cally identifiable as ethmoid, which are
the cribriform or perforated part of the numerous, and as frontal, maxillary, and
ethmoid bone, and the body of the sphenoid sphenoid pairs, all have dose positional
bone form the roof of the nasal cavity. relationship to the nasal cavity. Their ostia
Medially, the septal wall is comprised of the (Fig. 4.5, B) communicate with the nasal
vertical plates of both the vomer and ethmoid cavity at superior and lateral points and
bones, with added midline projections of the permit access into the nasal cavity for mucus
maxillary and palatine bones at points of from the sinuses. The ciliated lining
juncture with the vomer and ethmoid bones. membrane of the nasal chambers, continuous
The irregularity of the lateral nasal wall is into the sinus cavities, moves the mucus
due in large measure to the osseous elaborated by the sinus membrane
superstructure of the maxilla, to the ethmoid
turbinates, to a separate inferior turbinate
bone, and to palatine and lacrimal bones.
Of interest developmental^, and preceding
the earliest formation of any bones, is the
appearance of a chondrocranium (cartilage
skull), and a component of it called the
cartilaginous nasal capsule. Such cartilage
persists in the adult nose to some extent. It is
visualized as the septodorsal cartilage, which
has a vertical component (the septal and twin
dorsal wings on the facial surface, but it is
referred to most commonly as the upper
lateral nasal cartilages (Fig. 4.6). Near the
apex of the nose,
FIG. 4.6. Structure of the external nose with skin
removed.
ANATOMY AND PHYSIOLOGY 57

by surface movement through the ostia and branches of the anterior ethmoidal and the
into the nasal cavity. infratrochlear branches of the ophthalmic
The mechanism for passage of lacrimal nerve.
fluid from the conjunctival sac to the nasal While a number of small muscles are
cavity is mentioned earlier, and the ostium of associated with the external nose, e.g.,
the nasolacrimal duct can be observed in the procerus and nasalis, only those situated
inferior nasal meatus. Also, while it is not in about the external nares are of functional or
the nasal cavity per se, the pharyngeal orifice practical interest beyond any consideration
of the Eustachian tube is associated with the given to involvement of the nasal muscles in
nasal cavity, and it appears as a large opening emotional reactions. Compression of the nares
in each lateral wall of the nasopharynx. is a function of the nasalis muscles, yet the
Functional relationships between the nasal alar parts of the nasalis muscles, in
cavity and the Eustachian tube must be kept combination with slips of the dilator naris
in mind inasmuch as local conditions affecting muscles, effectuate nasal dilation. All nasal
the nasal cavity do reflect upon the condition musculature is a part of the mimicry group
of both the Eustachian tube and middle ear. and as such is innervated by branches of the
The nasal cavity is lined by a respiratory facial nerve.
mucoperiosteum and mucoperichondrium. It is A number of nerves come into intimate
adapted for olfaction through structural relation to the paranasal sinuses in their
modification of the lining membrane in the anatomic course, and thus they may be
superior parts of its septal and lateral nasal involved in paranasal sinus problems. Such is
walls. The highly specialized endings of the the case with the infraorbital and with the
olfactory nerve terminate on receptors serving posterior, middle, and anterior superior
the sense of smell in this limited area of the alveolar nerves as they occur in close relation
membrane. Otherwise, autonomic sympathetic to the maxillary sinus; and such is also the
and parasympathetic nerves interact in their case with the anterior and posterior ethmoidal
distribution to the nasal mucosa and provide nerves related to the ethmoid sinuses and the
the basis for nervous control of secretomotor Vidian nerve related to the sphenoid sinus. En
and vasomotor functions of this reactive route, such nerves may on occasion actually
mucous membrane. Generally, the reactivity course in the mucous membranes of these
of the membrane is enhanced by the sinuses and thereby be subject to the environ-
distribution to it of branches of the maxillary mental influences brought to bear upon the
nerve, which is subservient to general sinuses themselves.
sensibility, i.e., pain, temperature, touch, etc.
The Ear
Arterial vascularity is provided largely from
the facial and maxillary branches of the The ear complex consists of internal,
external carotid arterial system, but a limited middle, and external parts, each exhibiting its
blood supply to the nasal mucosa is provided own specific structural and functional
through the orbit from the anterior ethmoidal characteristics. Deep in the confines of the
branches of the internal carotid artery as well. petrous temporal bone are the highly spe-
Secretomotor and vasomotor nerve fibers also cialized vestibular and cochlear apparatuses.
reach local areas of the mucosal membrane The neurosensory organ complex and the
over the nasal branches of the maxillary nerve eighth cranial nerve establish specific linkage
or as periarterial nerve plexuses. Externally, between the brain and the highly specialized
cutaneous innervation is derived from the receptors in the vestibular and cochlear
infraorbital branches of the maxillary nerve organs of special sense. The middle ear is also
and from the external nasal terminal confined to the petrous temporal bone but with
extension of its cavity into the nasopharynx by
way of the Eustachian tube. The primary
function
58 MAXILLOFACIAL PROSTHETICS

of the middle ear is that of mechanical HELIX


TRIANGULAR FOSSA
conduction of sound waves from the ear drum,
SCAPHA
or tympanic membrane, to the outer wall of
ANTHELIX
the inner ear. For this purpose, the middle ear CRUS OF HELIX
houses the articulating series of bones, the AURICULAR CONCHA
malleus, incus, and stapes, the collective TRAGUS
ossicular chain. Thus, the middle ear and AVUM CONCHAE
ossicular chain are interposed between the CTERNAL
vibrating membrane externally and the fluid MEATUS

medium of the inner ear internally in a system ANTITRAGUS


LOBULE
designed to allow the translation of air waves
HELICAL TAIL
to fluid waves. Ultimately stimulation of the FIG. 4.7. View of external ear and its cartilaginous
end receptors of the vestibular and auditory structure.
parts of the eighth cranial nerve is achieved.
The external ear (Fig. 4.7) is unques- ronment, as well as responding to emotional
tionably of greatest relevance to prosthetic influences. Important to the reaction
specialists. Practically speaking, its design is phenomena is an anastomotic network of
simple and its purpose singular. It collects vessels derived as arterial branches of the
sound waves which then effect a vibratory external carotid artery and as tributaries of
influence upon the tympanic membrane. Yet, the superficial or external jugular and deep or
for all its simplicity, the integrity of the internal jugular venous drainage paths.
external ear is of great moment to each The auricular muscles are difficult to
human, by reason of its being a conspicuous identify and are atavistic structures having no
part of facial features. The auricular special importance or prominence in the
appendage (Fig. 4.7, A) surmounts the head structural design of the human auricle. Many
laterally, is attached to the skeletal humans are indeed able to exert control over
framework of the squamous and tympanic auricular movement, and as the auricular
parts of the temporal bone, and is centered muscles are parts of the facial mimicry group
upon the bony outline of the external auditory they are supplied by the facial nerve.
meatus. Supported by a structure of fibrous A brief review of the development of the ear
tissue and elastic cartilage and roughly will point out why the prosthetic specialist
appearing as a conch shell (Fig. 4.7, B), the must often deal with problems brought on by
auricle has a tubular cartilaginous external congenital deformation of the ear. The
canal firmly bound to and communicating external ear is derived from tissues about the
with the osseous external canal of the first pharyngeal cleft between the first and
tympanic part of the temporal bone complex. second pharyngeal arches (Fig. 4.8). Internal
Skin, tightly bound to perichondrium and to to the developing tympanic membrane, which
periosteum, invests the auricle and is con- is the floor of the first cleft, is the outpouching
tinuous both into the external canal and onto of the first pharyngeal pouch of the primitive
the external surface of the tympanic foregut. This outpouching persists as the adult
membrane. Prolifically endowed with pe- communication between the middle ear cavity
ripheral cutaneous ramifications of the tri- and the nasopharynx, the Eustachian tube.
geminal, facial, glossopharyngeal, and vagus Externally, six elevations, or hillocks, may be
as well as of cervical nerves from the second observed in association with the first and
cervical segment, the auricular appendage is second pharyngeal arches, and collectively
exquisitely sensitive. It reacts promptly and these do give rise to the adult external ear
vigorously by flushing or blanching to changes (Fig. 4.8, B through D). From the cleft (Fig.
in the external envi- 4.8, A) is derived the external canal.
Deformations
ANATOMY AND PHYSIOLOGY 59

of the auricle do result from halts or other deep auricular and anterior tympanic
alterations in growth pattern of the hillocks. branches of the maxillary artery, and the
Cleft formation in the area anterior to the posterior facial or retromandibular vein, and
external ear canal is encountered with some its tributaries. The auriculotemporal nerve,
frequency. This, states Altman,1 results from which distributes widely to the capsule of the
defective growth of the hillocks or the temporomandibular joint, to the parotid gland,
pharyngeal cleft. and to the skin of the auricle, as well as to the
It is helpful for the prosthetic specialist to preauricular temporal scalp, is also within the
understand anatomic relationships in the parotid compartment.
region of the external ear and canal, since
Oral Region
insults of surgical, pathologic, or traumatic
origin can affect his role in treatment. Below The rostral or oral end of the alimentary
and in front of the auricle and canal is the tube comprises buccal or vestibular and oral,
parotid gland. The parotid duct courses faucial, and oropharyngeal parts. Supported
transversely across the face below the bony by the maxilla and mandible, the structures
zygomatic arch and enters the buccal cavity related to the cavity are continuous from the
opposite the second upper molar tooth by oral rima rostrally to the oropharynx caudally.
piercing the buccinator muscle. The gland is in The oropharynx is that part of the pharynx
a fascial parotid compartment which is other- associated with the oral cavity and continuous
wise occupied by lymphatics, lymph nodes, with it posteriorly through the faucial or
and nerves and by vessels traversing this tonsillar region. Articulation of the mandible
space. The facial nerve courses through the with the lower part of the neurocranium
substance of the gland, and it must be as- through the paired temporomandibular joints
siduously avoided or protected in parotid provides an apparatus which adds a mastica-
surgery in order to preserve the activity of the tory function to this part of the alimentary
facial mimicry muscles and hence to avoid the tube.
embarrassing development of facial The orbicularis oris, depressor angular oris,
asymmetry which would result from the loss of risorius, and levator anguli oris are component
the facial nerve. The parotid compartment is parts of the facial musculature about the oral
exceedingly vascular. It contains the external rima and, as described by DiDio and
carotid artery and its terminal branches, as Anderson,3 they constitute a labial pylorus.
well as superficial temporal and maxillary They are important in emotional expression
arteries and the and in alimentation, e.g., ingestion, chewing,
and swallowing. Their activity is a measure of
the integrity and soundness of the facial
nerve. The buccinator muscle, which is in the
framework of the cheek and hence included as
part of the wall of the buccal cavity, is more
significant in mastication, or at least in the
removal of ingested materials from the buccal
space. However, it is innervated by the facial
nerve.
The oral cavity is confined within the limits
of the maxillary and mandibular alveolar
arches and dentition and the structure of both
the palatal roof and lingual floor. Numerous
articles have appeared in the literature, such
as those of

FIG. 4.8. Development of the external ear from arch I


and arch II masses and from intervening branchial
groove I. (After F. Wood-Jones.)
60 MAXILLOFACIAL PROSTHETICS

Flisberg et al.5 and Fritzell,6 on the role of the lowing. The integrity of the suprahyoid
levator and tensor palati muscles in altering musculature aids in protecting the airway in
the dimensions of the cavity and orifice of the swallowing. The upward movement of the
Eustachian tube. These muscles and others larynx in the first stage of swallowing, as
associated with the soft palate, e.g., described by Roberts,10 permits interaction of
palatoglossus, palatopha- ryngus, and the base of the tongue and the epiglottis to
intrinsic muscles of the uvula, are signally achieve a degree of closure and protection to
effective when they are normally involved in the laryngeal opening. Additional protection to
swallowing, in phona- tion, and in sucking the airway is afforded by the activity of
functions. Collectively, they become active in muscles within the aryepiglottic folds at the
velopharyngeal functions as described by lateral margins of the laryngeal aditus.
Bjorck and Nylen2 and they do act in normal Irrespective of their bases of attachment
phona- tory activity, but they also permit elsewhere on the skull, the masticatory
swallowing without an ensuing nasal muscles require fixation on the mandible, and
regurgitation. It is important then to validate they are affixed to it through its periosteum.
the presence of a velar (soft palate) muscula- The innervation of the masticatory groups of
ture and to confirm, as indicated by Saunders muscles by way of the mandibular division of
et al.,12 that pharyngeal constrictor muscles do the trigeminal nerve is of special note. The
become active in closing off of the nasopharynx bony mandible develops as bilaterally paired
in swallowing and in phonatory activities. halves, but postnatally and in the adult, it
The integrity of the roof of the oral cavity, represents a unit structure as the halves fuse
the palate, is a necessary corollary to the at the mandibular symphysis. It is well to
integrity of function of the muscular emphasize the presence of two bilaterally
apparatus in the floor. The tongue is a separate neuromuscular masticatory appara-
muscular organ and, from its position on a tuses, since the integrity of one alone can,
floor of muscles collectively known as the oral with a degree of efficiency, be expected to
diaphragm, it interacts with the suprahyoid power the mandible in mastication.
muscles (Fig. 4.9). When activated in the Masticatory functions are of primary
initial phase of swallowing, the suprahyoid interest with regard to the maxilla and
muscles elevate the hyoid bone and mandible, and the identification with them of
consequently raise all that directly or alveolar ridges and upper and lower dentition
indirectly may be attached to it, e.g., hy- signifies this interest. Mastication does
popharynx, larynx, and esophagus. The ultimately impart to the jaws and the teeth
intrinsic and extrinsic tongue muscles par- the powers of chewing, ripping, grinding, etc.,
ticipate in the rendering of a bolus to a soft motions which are effected by muscles and
state and in ingestion and deglutition. The which primarily involve the movement of the
tongue becomes cupped during ingestion, mandible at the temporomandibular joints. In
thereby facilitating the accommodation of mastication, elevation of the mandible is the
larger volumes, and then moves the bolus most potent function of the musculature, and
forcibly backward and through the faucial this involves the temporalis, masseter, and
region as was shown by cineradiol- ogic medial pterygoid muscles. Depression, or jaw
methods by Ramsey et al.9 The force of the opening, is a less powerful phase of activity
tongue as it moves against the palate is indeed and involves the hyoid-fixated muscles, i.e.,
great, which emphasizes the importance of geniohyoid, mylohyoid, and anterior belly of
structural soundness of each for efficient the digastric, as well as the two-headed lateral
deglutition. Loss of lingual mass alone, or in pterygoid muscle. The latter muscle is of
the presence of palatal defects such as clefts, particular note by reason of its broad
presents concomitant problems in deglutition attachments to the
and swal
ANATOMY AND PHYSIOLOGY 61

FIG. 4.9. Schematized frontal section of the floor of the mouth to illustrate the muscular components of the oral
diaphragm. M., muscle; ANT., anterior.

skull inferior and medial to the tempero- support is given to the capsule and synovial
mandibular joint. A position is thereby membrane of the joint by the tempo-
established for its role of executing a recip- romandibular ligament. The temporoman-
rocating side-to-side functional effect on the dibular ligament is anchored to the man-
mandible when in concert with its fellow of dibular neck and to the zygomatic process of
the opposite side, the usual occurrence in the temporal bone complex, and it is affixed to
grinding phases of mastication. Unopposed, a the capsule and to the intracap- sular
lateral pterygoid would deviate the lower jaw articular disc. The articular disc, fibrous in
to the opposite side and forward, as well as structure, is interposed between the glenoid
depress it. Protraction or forward movement fossa of the temporal bone and the head of the
and retraction or backward movement of the mandible, and it effectively partitions the joint
mandible are added functional events of space into an upper and lower segment.
significance, for they have important bearing Sarnat11 and others have suggested that
on the displacement of the head of the sliding movements of the mandibular head
mandible from its fossa and excursion of the occur in the upper joint space, but that both
intra- articular disc in temporomandibular rotation and sliding occur in the lower joint
joint activity. space. Concomitant with depression is protrac-
Some ligamentous supports for the tem- tion of the mandible, which is attributable in
poromandibular joint appear more like broad large measure to the action of the lateral
fascial laminae than true ligaments. Thus, the pterygoid muscle. In elevation or jaw closing,
stylomandibular and spheno- mandibular the mandible retracts, essentially because of
ligaments and Charpy’s band at the the combined activities of the temporalis and
mandibular angle, have little direct bearing masseter muscles. The articular disc follows
upon temporomandibular joint support or the forward and backward excursions of the
function. True ligamentous mandibular condyle
62 MAXILLOFACIAL PROSTHETICS

with a freedom that is made possible, ac- sutural growth areas critically placed in active
cording to Dixon,4 by the laxity of tissue in the times of facial growth are somewhat
posterior attachment of the disc to the joint transverse in their orientation, as for example
capsule. The lateral pterygoid muscle, by zygomaticomaxillary, frontomaxil- lary, and
reason of its attachment to both the palatomaxillary sutures.
mandibular neck and to the joint capsule and REFERENCES
articular disc, becomes active in excursions of 1. Altman, F.: Malformations of auricle and ex
the mandible and disc. As the mandibular ternal auditory meatus. A. M. A. Arch. Oto-
condyle slides into and out of the glenoid fossa, laryng. 54: 115-159, 1951.
2. Bjorck, L., and Nylen, B.: The function of the
the opportunity exists, through muscle soft palate during connected speech. Acta Clin.
imbalance, for example, for abnormal events to Scand. 126: 434-444, 1963.
occur. Impingement types of traumatic injury 3. DiDio, L. J. A., and Anderson, M. C.: The
to the moving disc, marked by definite patho- Sphincters of the Digestive System. The Williams
& Wilkins Company, Baltimore, 1968.
logic subjective symptoms such as pain or 4. Dixon, A. D.: Structure and functional signifi
trismus, can result. The removal of a damaged cance of the intra-articular disc of the human
disc can be a tedious surgical exercise but, as temporomandibular joint. Oral Surg. 15: 48-61,
Silver and Simon15 pointed out, the efficiency 1962.
of the temperomandibular joint can be 5. Flisberg, K., Ingelstedt, S., and Oetegren, U.:
The value and “locking” mechanism of the
expected not to be significantly impaired Eustachian tube. Acta Otolaryng. Suppl. 182: 57-
consequent to its removal. 68, 1963.
Both the maxilla and mandible are laid 6. Fritzell, B.: The velopharyngeal muscles in
down developmentally in membrane, and speech. An electromyographic and cineradi-
ographic study. Acta Otolarvng. Suppl. 250,
growth proceeds as a combination of intra-
1969.
membranous and of endosteal and periosteal 7. Jones, F. W.: The premaxilla and the ancestry of
proliferation of bone. The primitive Meckel’s man. Nature (London) 159: 439, 1947.
cartilage, which antedates the mandible per 8. Last, R. J.: Wolff's Anatomy of the Eye and Or
se, is completely absorbed in the ossification of bit, Ed. 6, p. 239. W. B. Saunders Company,
Philadelphia, 1968.
the mandible, and the role that it plays in the 9. Ramsey, G. H., Watson, J. S., Gramiak, R., and
formation of this adult bone structure still can Weinberg, S. A.: Cinefluorographic analysis of
be questioned. Ossification of the mandible the mechanism of swallowing. Radiology 64: 498-
occurs initially in the 6th fetal week, but 518, 1955.
10. Roberts, R. I.: A cineradiographic investigation
growth proceeds through ages 25 to 30. Some of pharyngeal deglutition. Brit. J. Radiol. 30:
cartilage-replacement growth of bone occurs in 449-460, 1957.
the condyloid, coronoid, and symphy- seal 11. Sarnat, B. G.: The Temporomandibular Joint.
regions, and this does allow for age- related Charles C Thomas Company, Springfield, Illi-
growth changes in height and length of the nois, 1964.
12. Saunders, J. B. deC., Davis, C., and Miller, E.
mandible. R.: The mechanism of deglutition (second stage)
According to Scott,13 the intracarti- as revealed by cineradiography. Ann. Otol. 60:
laginous growth involving the maxilla con- 897-916, 1951.
tributes to age-related changes in facial 13. Scott, J. H.: Further studies on the growth of the
face. Proc. Roy. Soc. Med. 52: 263-268, 1959.
structure, notably at the numerous circu- 14. Scott, J. H.: The growth of the craniofacial skel
maxillary sutural areas marking the union of eton. Irish J. Med. Sci. Series 6, No. 248, 276-
the maxilla with frontal, nasal, zygomatic, 286, 1962.
ethmoid, and palatine bones. It is evident from 15. Silver, C. M., and Simon, S. D.: Meniscus inju
Scott’s work14 that essential ries of the temporomandibular joint: further
experiences. J. Bone Joint Surg. (Amer.) 45A:
113-124, 1963.
5
ORAL PATHOLOGY FOR MAXILLOFACIAL
PROSTHETICS
S. Miles Standish, Varoujan A. Chalian , and Joe B. Drane

It is axiomatic that all treatment proce- and defects, and he is perforce often consulted
dures involving living tissue must be pred- regarding clinical diagnosis, natural behavior,
icated on basic biologic concepts. To be most therapy, and prognosis.
effective, the maxillofacial prosthodontist The pathologic entities discussed in this
must have not only technical competence in chapter are by no means inclusive, but they do
rehabilitation procedures but also a working represent several of the more common defects
knowledge of the etiology, clinical features, with which the maxillofacial prosthodontist
natural history, and prognosis of the disease will be concerned.
or defect under treatment. This in turn Congenital and Developmental Defects
involves a practical understanding of such A large number of cranial,. facial, and oral
fundamental tissue responses as aplasia, defects may well be classed as congenital
hypoplasia, hyperplasia, degeneration, lesions even though the structural or
necrosis, inflammation, repair, and neoplasia. functional abnormality is not always fully
Clearly, knowledge in these areas has manifest at birth. Clearly, the distinction
practical application in both pretreatment between congenital and developmental lesions
consultation and diagnosis and treatment is somewhat arbitrary, inasmuch as both are
planning, as well as in posttreatment usually defects in development, the former
rehabilitation. Even though it is not the being present at birth and the latter arising
purpose of this chapter to review these basic de novo in postnatal, childhood, or even adult
pathologic processes or even to discuss all of life.
the head and neck lesions with which the By general agreement, disturbances in
maxillofacial prosthodontist might be development are those lesions associated with
concerned, their importance cannot be anomalous growth or maturation processes,
overemphasized. which usually make their appearance
Oral pathology must be then considered a sometime in the postnatal or early childhood
part of the maxillofacial prosthodontist’s store period. Again, many conditions classified as
of such knowledge, being required as a basis developmental may actually be congenital in
for diagnosis and treatment. Since he usually origin but are not ordinarily recognized at
functions as part of a team which may include birth as such. In fact, a number of these, such
a surgeon, radiologist, internist, speech as certain of the developmental or fissural
therapist, psychologist, or other specialist, he cysts, are nearly always discovered in the late
is required to be the most knowledgeable teens
about oral diseases
64 MAXILLOFACIAL PROSTHETICS

or adulthood, even though the fissural defect Altering the time of administration of the
must have been present at birth. For example, teratogenic agent makes it possible to induce
micrognathia may not be clinically obvious for other congenital defects, depending upon the
some time after birth, until comparative particular embryonic processes which are in
growth rates of other facial structures make critical stages of development (see also
the underdevelopment of the mandible more Chapter 3).
striking. Care must also be exercised to Classificatioh of congenital lesions is
determine whether the discrepancy is in the particularly unrewarding since, except for
mandible proper or is the result of congenital those of hereditary origin or due to maternal
or acquired hypoplasia of the condyle. (environmental) factors, an etiologic basis
A number of congenital (i.e., acquired in cannot be established in the majority of cases.
utero but not necessarily inherited) defects On a purely pathoanatomic basis, several
may require the services of the maxillofacial categories of congenital diseases are known:
prosthodontist, either primarily or working in (a) congenital dysplasias, (b) congenital
conjunction with the work of the surgeon. dystrophies, (c) congenital tumors, (d)
Congenital lesions are the result of in utero congenital infections, (e) inborn errors of
failure of orderly development, causing both metabolism.
structural and functional disturbances. In The term “dysplasia” implies an abnor-
some instances of “inborn errors of mality of development, while “dystrophy”
metabolism,” gross anatomic alterations are indicates defective or faulty nutrition. The
not generally obvious clinically, however. terms are often used interchangeably in the
Although a causative factor cannot always be sense that all dystrophies are dysplasias,
established, approximately 109o of the cases although the converse is not always true.
are recognized genetic diseases, and it seems The congenital dysplasias include such
highly probable that additional examples of condition as agnathia, congenital micro-
defects of hereditary origin will be discovered gnathia, hypertelorism, cranial deformities
as detection methods improve. (e.g., craniostenosis, craniosynostosis,
Several specific etiologic agents are known cranioschisis, and microcephaly), and
to induce congenital anomalies: e.g., maternal monostotic fibrous dysplasia.
infections, such as rubella (German measles), The congenital dystrophies include cranial
increased maternal age, nutritional dysotosis, cleidocranial dysostosis, gargoylism
deficiencies, and injury. The cases of (Hurler’s disease), osteochondrodystrophy
phocomelia or “seal limb” following maternal (Morquio’s disease), mongolism, osteogenesis
use of thalidomide, a presumably mild and imperfecta, and chon- droectodermal dysplasia
safe sedative drug, also illustrate the point. (Ellis-van Creveld syndrome).
The teratogenic effects of many known or The congenital tumors include congenital
suspected agents in inducing congenital neurofibromatosis (von Recklinghausen’s
defects in humans have been tested in disease of skin), congenital cranio-
pregnant experimental animals. Studies of pharyngioma (Rathke’s pouch cyst, pituitary
this type have provided valuable basic ameloblastoma), and the vascular nevi and
knowledge not only about how the agent itself anomalies such as Sturge-Weber syndrome
affects the fetus, but also about em- bryologic and hemangioma, infantile heman-
development. For example, cleft palate can be gioendothelioma, and lymphangioma.
induced at will in the offspring of pregnant Congenital infections represent structural
rats administered excess vitamin A, cortisone, defects induced by maternal-fetal transfer of
ACTH, insulin, antimetabolites, various an infectious agent: e.g., congenital syphilis,
anesthetics, or other agents on the 12th day of torulosis, and toxoplasmosis.
pregnancy. Inborn errors of metabolism include
ORAL PATHOLOGY 65

phenylketonuria, hypophosphatasemia, by plastic surgery can be performed. In cases


hypophosphatasia, congenital hypothyroidism, of deformity or absence of the external ear,
etc. absence of eyeballs, etc., surgical
As may be seen from the above examples, reconstruction is unsatisfactory or obviously
congenital defects may range in severity from impossible. Depending upon the age of the
the grossly deformed fetus (monster) to the patient and severity of the defect, surgical
comparatively minor defect in structure of a repair of the cleft palate may well require a
part (variant). A somewhat more severe defect prosthetic appliance preop- eratively in the
than the variant is the anomaly. For the most form of an obturator, or postoperatively in the
part, congenital defects of oral and facial struc- form of a splint or appliance, to restore
tures tend to show either partial (hypoplasia) masticatory efficiency and esthetics.
or complete (aplasia) failure of development, or
Cleft Lip
in some cases, increase in size (hypertrophy or
hyperplasia) of a part. Other congenital defects The cleft lip (harelip), which is the most
of the oral and paraoral regions result from common of the facial clefts, follows failure of
failure of fusion or entrapment of the several union (or perhaps failure of connective tissue
embryonic processes that are involved in the penetration of united epithelium) of the
complicated development of these areas. It globular portion of the median nasal process
follows then that many structural derange- with the lateral nasal and maxillary
ments of the face of congenital origin can result processes. Using the incisive foramen as the
from underdevelopment of one or more parts arbitrary division of cleft of the lip and palate,
and/or failure of fusion of parts, thereby Kernahan and Stark32 have classified cleft lips
presenting either single or multiple as unilateral, bilateral, or midline with
deformities. The particular struc- ■ tures complete or incomplete types. Midline clefts
involved will of course be determined by the are uncommon and occur when the median
developmental stage of the fetus at the time nasal process is completely absent. The more
the etiologic agent is active. Thus, cleft lips and extensive (complete) clefts of the lip usually
palates generally present as the sole anatomic involve all of the premaxillary structures, i.e.,
defect, whereas first branchial cleft anomalies the lip and alveolar ridge with extension into
usually are multiple, with such lesions as the nostril and palate as well.
transverse facial clefts, aplasia of the mandible Surgical closure of the cleft lip is ordinarily
and ear, and other disturbances occurring at carried out within the first 30 days after birth
the same time. Those syndromes having a and often within the first 2 weeks, provided
hereditary basis differ only in that the defects that there is stabilization of hematopoietic
of the anatomic structures involved are activity and body weight. Because lip closure
genetically predetermined.23 and satisfactory contouring are especially
Surgical repair of many of the gross difficult over a large unstable ridge defect,
structural defects of congenital origin can often many surgeons feel that the initial lip closure
be carried out as a primary procedure. For is not necessarily a definitive procedure and
example, closure of the divided orbicularis oris that it subsequently may be revised along
ring as well as surgical apposition of divided with any alveolar ridge or palatal defects. In
parts is necessary for successful repair of contrast, another philosophy of treatment
transverse facial clefts. On the other hand, holds that the initial surgery should be as
internal or external prosthesis may be complete as possible, using carefully measured
indicated in certain cases, either as a definitive and properly vascularized flaps.
treatment or to improve function or esthetics In the lip cleft with alveolar ridge in-
until repair volvement, a prosthetic appliance is almost
invariably necessary, regardless of the
66 MAXILLOFACIAL PROSTHETICS

treatment concept, to align and stabilize the ways require some type of prosthesis to
alveolar segments (with or without bone restore esthetics and masticatory function,
graft), to restore lip contour and facial profile, regardless of the treatment concept followed.
and to provide for masticatory function.
Other Congenital Defects
Cleft Palate Craniofacial 'Dysostosis. As noted earlier,
When the lateral halves of the palate fail to many congenital defects present as multiple
unite, resulting in cleft palate, the condition abnormalities originating in structures which
may vary in severity from the simple uvular develop simultaneously in the fetus. While
cleft (bifid uvula) to total hard palate cleft. individual variations occur, certain of these
Cleft palate then may occur concurrently or combined anomalies are seen often enough to
independently of cleft lip. The two defects also be recognized as distinct entities.
demonstrate a similar etiologic basis, in which Craniofacial dysostosis (Crouzon’s disease)
genetic factors are the most important. is an unusual and frequently hereditary
Epidemiologic and genetic studies indicate syndrome which classically presents defects of
that cleft lip and/or palate occurs about twice the face, cranium, eye, and tongue. Premature
as frequently in boys as in girls, while isolated synostosis of the cranial sutures produces
cleft palate shows a predominance in affected maxillary hypoplasia with a high or cleft
females. The frequency of affected to normal palate, mandibular prognathism, and
births for cleft lip with or without cleft palate protuberant frontal ridges and bosses. The
has been reported as 1 in 665,15 1 in 800,26 and parrot’s beak nose, hypertelorism,
1 in 1200 births.10 Cleft palate alone is much exophthalmos, optic neuritis, divergent
less common, Fogh-Andersen15 and Woolf et strabismus, and digital abnormalities may
al.64 reporting 1 in 2500 live births. also characterize this condition.
As with cleft lip, divergent concepts of The Pierre Robin syndrome is a somewhat
treatment also obtain with cleft palate, one milder form of craniofacial dysostosis with
view holding that early surgical closure may micrognathia, glossoptosis, and cleft palate.56
interfere with proper vascularization of the Oral-facial-digital Syndrome. This syn-
palate during the stage of most active drome, which involves congenital anomalies of
maxillary and palatal growth.25 The opposing oral, facial, and digital structures, occurs
view46 holds that the apparant inhibition of exclusively in females. The oral lesions
lateral growth of the maxilla may well be characteristically show submucous clefts of
inherent in the cleft palate patient and not the primary and secondary palates with
necessarily the result of early surgical closure. alveolar ridge clefts of both jaws seen in
Studies of adult patients with untreated cleft association with prominent frenum-like,
palates31 have shown that a medial collapse of fibrous bands extending from the buccal
the palate and reduced vertical growth of the mucosa into the ridge clefts. The tongue is
alveolus results in a maxillary retrognathism, often lobulated or not clearly demarcated from
indicating that surgical interference is not the tissues of the floor of the mouth.23
necessarily responsible for inhibiting develop- The facial defects include hypertelorism,
ment of this area. median cleftlike defect of the upper lip, short
Treatment of cleft palate cases may alar cartilages and columella, and certain
therefore involve surgical repair, prosthetic other miscellaneous defects (coarse hair,
appliances, or both, depending upon the extent alopecia, dry skin, syndactyly, and mental
of the defect and the time elected to carry out retardation).50
definitive treatment. Cases of combined cleft Mandibulofacial Dysostosis. Mandibulo-
lip and palate almost al facial dysostosis (Treacher-Collins syn
ORAL PATHOLOGY 67

drome) presents multiple defects as follows: (a) eventually undergo ulceration. A scaly crust
hypoplasia of facial bones (malar and develops over the ulcer, but healing is not
mandible), (b) antimongoloid palpebral complete. The repeated attempts of the tissue
fissures, (c) coloboma and absence of to re-epithelialize plus the proliferation of
eyelashes, (d) ear deformities, (e) macro- tumor cells laterally results in the
stomia and high palate, sometimes cleft, and characteristic elevated, rolled border. While
(f) miscellaneous skeletal defects. 41, 48 the basal cell carcinoma may invade locally
Related syndromes (Franceschetti, first and cause extensive destruction, lymph node
arch syndrome, second arch syndrome, etc.) metastasis rarely occurs.
present many features in common and are It is believed that the basal cell carcinoma
undoubtedly induced by teratogenic may arise from skin adnexa (hair follicles,
influences, including genetic factors, which sweat glands, sebaceous glands), from basal
affect the mesoderm of adjacent structures. 59 cells de novo, or from epithelial germ rests.
While there is no specific treatment for Since the basal cell is a pluri- potential cell, it
these disorders, many of them have cleft is not surprising that the basal cell carcinoma
palates as a presenting sign and therefore may may present in a variety of histologic forms:
require prosthetic devices for rehabilitation.
1. Undifferentiated (solid, primordial)
Malignant Epithelial Tumors 2. Differentiated
a. Cystic; simulates sebaceous glands
Basal Cell Carcinoma. Basal cell carci-
b. Adenoid (syringoid); simulates apo
nomas (“skin cancer,” “rodent ulcer”) occur crine glands
most frequently on exposed portions of the c. Keratotic (trichoepitheloid); simulates
face and scalp and show a positive correlation hair
with exposure to actinic rays of the sun. Thus,
Most basal cell carcinomas are of the
more skin cancer is observed in elderly males,
sportsmen, and outdoor workers and residents undifferentiated variety (Fig. 5.1). Although
their clinical behavior cannot be related
of southern states. Fair-skinned individuals
specifically to their histologic pattern, the
are particularly susceptible to basal cell
keratotic or trichopeitheloid type tends to
carcinoma because of the relative lack of
exhibit a relatively slow growth, while the
protection by melanin pigmentation.
The most common malignant tumor of the adenoid type often presents as deeply placed
and scattered foci of tumor, causing extensive
skin, basal cell carcinoma, may occur at any
scarring of adjacent tissues.
age, although most cases occur in middle or
Wide surgical excision of basal cell carci-
old age. Surprisingly, the age distribution of
noma is generally the treatment of choice for
these tumors includes a greater number of
young adults than does epidermoid carcinoma. most lesions about the face since irradiation,
especially in the vicinity of the eye, tip of the
The chief sites of predilection are the face,
ears, nose, forehead, and those areas of the nose, or ear, often causes complications. An
important advantage of surgery is the
face over bony prominences that are especially
opportunity for the pathologist to determine
exposed to sunlight. These lesions never arise
whether the margins of the specimen are free
on mucous membrane surfaces or the vermi-
of tumor. Plastic repair of the surgical defect
lion border of the lips, although they may
involve these structures by direct extension. can usually be accomplished by direct suture
or rotation of skin flaps to cover the wound.
Basal cell carcinomas present initially as
Extensive tumors necessitating exenteration
innocuous appearing, scaly or waxy nodules
of the orbit or through-and-through excision of
which slowly increase in size and
portions of the nose, cheek, or ear may require
prostheses. In extremely large sur-
68 MAXILLOFACIAL PROSTHETICS

FIG. 5.1. Basal cell carcinoma. Low power magnification (A) shows islands of relatively uniform epithelial cells
which are invading the subjacent connective tissue. Higher magnification (B) shows an island of basophilic cells
and a portion of the palisaded cells about the periphery.

gical defects, especially in those tumors that surface epithelium, this tumor is extremely
may have invaded underlying bone, in variable in its clinical behavior, depending
multicentric tumors, and in cases of upon its size, location, duration, degree of
questionable total excision, many surgeons are differentiation (Figs. 5.2 through 5.5), and
reluctant to complete repair with a full or presence or absence of regional metastasis at
split-thickness skin graft since recurrence of the time of discovery. All of these factors must
the tumor under the graft is difficult to detect. be taken into consideration when dealing with
Restoration with a prosthetic appliance is individual cases.1’12’
61, 65
particularly important to the psychologic well-
The true incidence of intraoral and lip
being of these patients and readily permits
cancer is difficult to determine since incidence
postoperative follow-up of the tumor site as
rates, especially for lip cancer, vary in
well.
different sections of the country. Cancer of the
The rate of recurrence of basal cell carci-
lip comprises from 25 to 50% of all patients
noma is quite low with present methods of
with oral cancer (combined lip and intraoral
detection and treatment. Hayes 28 has reported
sites). The most common intraoral site
the recurrence rates for previously treated
(excluding lip) is the lateral border of the
tumors as 24%, while tumors treated initially
tongue (52%), with other areas (floor of mouth,
recurred at only 3%.
16%; alveolar mucosa, 12%; palate, 11%;
Epidermoid Carcinoma. The epidermoid
buccal mucosa, 9%) involved with nearly equal
(squamous cell) carcinoma, the most common
frequency.61
of the malignant tumors of the oral cavity, is
Epidermoid carcinoma of the lip, which is
second in incidence only to the basal cell
found almost exclusively in males, dem-
carcinoma of the skin of the face. Arising in
onstrates a predilection for outdoor work-
nearly all instances from
FIG. 5.2. Epidermoid carcinoma, well differentiated. Proliferation of neoplastic epithelial cells into the
underlying connective tissue is shown. An epithelial pearl is seen in one portion of the section.
FIG. 5.3. Epidermoid carcinoma, moderately differentiated. The sheets of neoplastic epithelial cells show considerable
hyperchromatism, pleomorphism, and mitotic activity.
FIG. 5.4. Epidermoid carcinoma, poorly differentiated. Neoplastic epithelial cells are shown invading a portion
of the tongue adjacent to a residual muscle fiber. The cells are markedly pleomorphic and hvperchromatic.
FIG. 5.5. Epidermoid carcinoma, poorly differentiated. Another field of the same section shown in Fig. 5.4 shows
actively proliferating epithelial cells with a mitotic figure.
69
70 MAXILLOFACIAL PROSTHETICS

ers, individuals with fair skin and, most


particularly, pipe smokers (Fig. 5.6). The heat
transmitted from the pipe stem would appear
to be the chief factor in the development of
“pipe smoker’s cancer,” rather than trauma
per se. This tumor generally presents in its
early stage as a scaly and crusting ulcer along
the vermilion border. When further invasion of
the tumor occurs, the margin of the ulcer
presents a rolled appearance as the adjacent
epithelium attempts to cover the raw surface.
Proliferating tumor cells invade the subjacent
connective tissues and spread laterally under
the intact surface, causing induration of the
tissues well beyond the limits of the ulcer. Lip FIG. 5.7. Epidermoid carcinoma of the lateral border of
carcinomas are generally well differentiated the tongue arising in an area of leukoplakia.
lesions which grow comparatively slowly and
have a high cure rate (Fig. 5.2). Less well the lip. Larger tumors may require total lip
differentiated epidermoid carcinomas of the lip excision and skin graft.33
are seen infrequently and have a Carcinoma of the tongue comprises the
correspondingly poorer prognosis. An unusual most common intraoral site of epidermoid
variant, the spindle cell carcinoma, which has carcinoma, excluding the lips (Fig. 5.7). More
been reported following radiation therapy or men than womerf are affected by cancer of the
trauma to the lip, also has a poor prognosis. tongue, although a rather high incidence is
Its superficial resemblance to fibrosarcoma encountered in Scandinavian women with
occasionally causes difficulty in histologic Plummer-Vinson syndrome.
diagnosis.54 A number of possible etiologic factors
Lesions detected early (less than 2 cm in appear to be associated with carcinoma of the
diameter) are readily treated by a heart- tongue, although an absolute cause and effect
shaped excision which may be closed primarily relationship cannot be established. These
without deformity. Simple V- shaped excisions factors include syphilis, poor oral hygiene,
may result in notching of chronic trauma, and the use of alcohol and
tobacco.62
Carcinoma of the tongue characteristically
arises on the lateral border as an initially
painless mass or indolent ulcer. These tumors
may present as predominantly exophytic,
fungating masses with extension to the
ventral surface of the tongue and floor of the
mouth, or they may exhibit unusual
infiltrative characteristics with comparatively
minor changes in clinical appearance.
Carcinoma of the dorsum of the tongue is
uncommon, with a number of cases seemingly
being associated with a preexisting syphilitic
glossitis.
Carcinoma of the tongue may be treated by
radiation or surgical excision or a combination
of both. Obviously, treatment

FIG. 5.6. Epidermoid carcinoma of the lower lip.


ORAL PATHOLOGY 71

planning must be on an individual basis with


consideration given to the size and location of
the tumor, presence of metas- tases, physical
condition of patient, etc.2 Small tumors of the
anterior one-third of the tongue are often
amenable to wide wedge resection, whereas
the usually less well differentiated lesions
located farther posteriorly may be treated by
interstitial radium implants or combined
surgery and radiation (Figs. 4.5 and 5.5). In
some cases, extensive tumors of the base of
the tongue may require hemimandibulectomy
to permit external irradiation of the involved
area.
Tongue cancer has a generally poor FIG. 5.9. Epidermoid carcinoma of the floor of the
prognosis, with the overall cure rate estimated mouth.
below 25%. Cases with cervical metastasis at
the time of the primary diagnosis have a more extensive lesions, is generally indicated,
particularly poor prognosis as compared with although the proximity of the tumors to the
those that develop metastasis after the initial mandible may result in osteoradionecrosis. 2
treatment or those that never metastasize. 16, Carcinoma of the buccal mucosa has been
19, 53
related to the use of chewing tobacco or snuff,
Carcinoma of the floor of the mouth occurs betel nut chewing, or chronic trauma from
most commonly in the anterior portion on irregular teeth or artificial dentures. Cancer
either side of the midline and may extend to in this location usually presents as an
involve the base of the tongue, submaxillary indurated and frequently painful ulcer
and sublingual salivary glands, and adjacent opposite the line of occlusion of the teeth. The
mandibular alveolar ridge (Figs. 5.8 and 5.9). warty, innocuous appearing, verrucous
Treatment of cancer in this location is carcinoma is frequently seen in this location,
particularly difficult regardless of the therapy although it may occur on the gingiva, palate,
employed. Radiation treatment, especially of and floor of the mouth as well. Its clinical and
the histologic resemblance to papilloma makes
this variety particularly difficult to diagnose. 58
The usual variety of epidermoid carcinoma
of the buccal mucosa may vary considerably in
its degree of differentiation with the more
undifferentiated tumors occurring in the
posterior buccal mucosa opposite the third
molar teeth and extending into the tonsillar
pillar area. Metastasis to cervical nodes
appears relatively early, with nearly one-half
of the cases having metastasis at the time of
primary diagnosis. Treatment may be by
surgery, radiation, or both.34,39
Carcinoma of the gingiva poses special
problems in clinical detection since it may
simulate inflammation or infection of per-
iodontal or pulpal origin. Its clinical ap

FIG. 5.8. Epidermoid carcinoma of the floor of the


mouth.
72 MAXILLOFACIAL PROSTHETICS

pearance is also variable: it may present as an


erosive ulcer, verrucous growth, or simply a
red-velvety lesion with a granular surface
(Fig. 5.10). Invasion of the underlying alveolar
bone occurs promptly, and very often a loose
tooth in the area is the chief complaint of the
patient. Metastasis occurs more frequently in
carcinoma of the mandibular than the
maxillary gingiva. Pathologic fracture of the
mandible is not uncommon. Because of the
hazards associated with radiation of the jaw
bones, surgical resection is the treatment of
choice.34-39
Carcinoma of the palate usually presents as
an irregular ulcer occurring somewhat more
frequently on the soft than on the hard palate.
Arising on either side of the midline, these
tumors may extend broadly to involve the
adjacent alveolar mucosa, tonsillar pillars
and, of course, the underlying palatal bone.
Extension into the nasal cavity or
nasopharynx is not uncommon. Although
surgery and/or irradiation have been used in
FIG. 5.11. Carcinoma of the maxillary antrum. The
the treatment of palatal cancer, no definitive
markings on the face represent the target area for
studies have shown a distinct advantage of radiation therapy.
either form of treatment. Superficial cancer of
the palate may respond well to external radia-
tion by using a port directed through the open
mouth. A postsurgical oral-nasal or oral-antral
defect will require a prosthetic repair
appliance to close the opening in the early
rehabilitation phase of the patient.

FIG. 5.12. Carcinoma of the maxillary antrum


showing involvement of the maxillary alveolar process
and gingiva.

Carcinoma of the maxillary antrum, while


not strictly an intraoral tumor, may produce
symptoms of loosening of the teeth or
enlargement of the alveolar ridge and thus
FIG. 5.10. Epidermoid carcinoma of the maxillary first be brought to the attention of the dentist
gingiva. (Figs. 5.11 and 5.12). Facial
ORAL PATHOLOGY 73

swelling, nasal stuffiness or obstruction, or submaxillary gland is involved infrequently


“sinus trouble” may also be presenting (approximately 10%) and the sublingual gland
complaints. Unfortunately, carcinoma of the only rarely. Of the total number of salivary
antrum may be hopelessly advanced before a gland tumors reported, about one-fourth
definitive diagnosis is made. Treatment may involve intraoral structures, primarily the
be by hemimaxillectomy, radiation, or palate and, less frequently, the upper lip and
combined forms of therapy. such miscellaneous locations as the retromolar
Maxillofacial prosthetic appliances are areas, buccal mucosa, floor of the mouth, and
frequently used in the rehabilitation of such tongue.4, 14’ 44, 63
cases inasmuch as plastic repair of advanced Somewhat more women than men develop
cases is usually not feasible. tumors in the major salivary glands, although
no sex difference was found in intraoral sites
Salivary Gland Tumors in a review of 1320 minor gland tumors by
Tumors of the major and minor salivary Chaudhry et al.4 In this study, 800 of the
glands, while relatively uncommon, are of tumors were benign and 520 were malignant.
sufficient importance to the maxillofacial The wide variety and frequent duplication
prosthodontist to warrant brief discussion. of terms used to describe the neoplasms of
With certain exceptions, such as the oxyphil salivary gland origin (Chart 5.1) have posed
adenoma (Fig. 5.13) and papillary many difficulties in evaluating their incidence
cystadenoma lymphomatosum (Fig. 5.14) and natural history. The tendency in the past
which occur almost exclusively in the parotid to call all malignant salivary tumors simply
gland, the same histologic types of salivary adenocarcinoma or malignant mixed tumor
gland neoplasms may occur in either the has prevented
accessory or major glands. The parotid gland
is the most common site, while the

FIG. 5.13. Oxyphil adenoma (oncocytoma). Composed of sheets or cords of rather uniform cells with a dis-
tinctive eosinophilic cytoplasm, the oncocytoma occurs typically in the parotid gland as a well circumscribed
nodule.
74 MAXILLOFACIAL PROSTHETICS

FIG. 5.14. Papillary cystadenoma lymphomatosum (Warthin’s tumor). A, the cyst lining of this unusual salivary
gland lesion consists of a double row of epithelial cells lining a cystic cavity with lymphoid elements present in the
wall. B, higher magnification of A, showing the lining epithelium and lymphoid elements of the cyst wall.

proper evaluation of many of the reported previously slow-growing tumor may exhibit a
cases. This is particularly true of the less sudden spurt of growth, pain, fixation to skin,
common tumors such as the myoepithelioma facial paralysis, or ulceration, features which
and the acinar cell adenoma and often indicate malignant transformation.35
adenocarcinoma, which have not been re- In the parotid gland, the pleomorphic
ported in sufficient numbers to predict their adenoma generally presents as a painless,
behavior in a given case. firm, and occasionally nodular swelling which
The discussion here is restricted to the is not fixed to the skin or underlying
pleomorphic adenoma, adenocystic basal cell structures. The growth is slow and there is no
carcinoma, and mucoepidermoid carcinoma as facial nerve paralysis. Grossly, these tumors
examples of more commonly encountered have a pseudocapsule and often show a
benign and malignant salivary gland tumors. bosselated surface with the facial nerve
Pleomorphic Adenoma (Benign Mixed draped over the surface.
Tumor). This is the most common of all the Intraoral pleomorphic adenomas present
salivary gland tumors and occurs most simply as asymptomatic swellings and rarely
frequently in the parotid gland. It grows are ulcerated except when they have been
slowly but will become extremely large in size traumatized. In the mouth, these tumors
over a period of many years in this location, occur more frequently on the hard than the
although the patient with an intraoral soft palate, probably because of the greater
pleomorphic adenoma will seek treatment number of accessory glands in that location.
relatively early because of interference with The pleomorphic adenoma is not truly a
mastication. Occasionally, a
ORAL PATHOLOGY 75

mixed tumor (i.e., of multiple germ layer surgical excision. The recurrence rate of
origin) in the sense that Wilm’s tumor of the intraoral pleomorphic adenoma is extremely
kidney or teratoma of the ovary is a mixed low even with simple enucleation. In the
tumor. Rather, it is composed of both parotid gland, reported recurrence rates have
epithelial and connective tissue elements in been as high as 20 or 30% in some series,
varying proportions (Fig. 5.15). However, only although improved surgical techniques, chiefly
the epithelial (or ductal) portions of the tumor removal of the entire involved lobe of the
are neoplastic, while the areas of hyalinized gland, have resulted in quite satisfactory
connective tissue and myxoid, chondroid, or results. Care must be taken in parotid surgery
osteoid tissues are simply supporting stromal to preserve the integrity of the facial nerve
tissues and vary remarkably from tumor to and most of its branches if facial paralysis is
tumor or even in different areas of the same to be avoided. This tumor is radioresistant,
tumor (Fig. 5.16). The epithelial elements are and x-ray irradiation is therefore contraindi-
composed of uniform cells arranged in strands, cated.
cords, or ductlike structures. Areas of Adenocystic Basal Cell Carcinoma
squamous metaplasia and keratin pearl (Cylindroma). The so-called “cylindroma” is
formation may be present. Because of a histologically distinctive tumor which occurs
histologic variation in different parts of this in the skin, breast, lacrimal glands, paranasal
tumor, multiple histologic sections should be sinuses, and larynx, as well as the major and
made from several areas of the specimen. minor salivary glands. The parotid and
The pleomorphic adenoma is treated by submaxillary glands are the chief major gland
sites, while the palate is most commonly in-
CHART 5.1 volved intraorally. In common with most
malignant salivary gland tumors and in
Classification of Tumors of Salivary Gland Origin contrast to the benign varieties, these lesions
Benign present features of pain, fixation, induration,
Pleomorphic adenoma (mixed tumor of salivary ulceration, and invasion of underlying
gland origin) structures.40- 49
Papillary cystadenoma lymphomatosum (Warthin’s This tumor presents a distinctive histologic
tumor) appearance of ducts or cords of uniform
Oxyphilic adenoma (oncocytoma)
basophilic cells distributed in a honeycomb or
Acinar cell adenoma
Sebaceous cell adenoma
Swiss cheese pattern with a hyalinized
Benign lymphoepithelial lesion (Mikulicz’s disease, connective tissue stroma (Fig. 5.17). The
Sjogren’s syndrome) lumen of the ductlike structures may contain a
Benign stromal tumors Malignant mucoid material. Some superficial
Malignant pleomorphic adenoma (malignant mixed resemblances to the basal cell carcinoma,
tumor) which occurs only on the skin, may be seen in
Adenocarcinoma the remarkably uniform and basophilic
Adenoid cystic basal cell carcinoma (cylindroma, epithelial cells, in the rarity of mitotic figures,
baseloid mixed tumor, etc.)
and in the growth pattern of this tumor. Some
Acinar cell adenocarcinoma (acinic cell adeno-
carcinoma, mucous cell adenocarcinoma, serous
difficulty may also be experienced in
cell adenocarcinoma) distinguishing this tumor from the
Miscellaneous types (trabecular, pseudoada- extraosseous ameloblastoma, especially if one
mantine, papillary cystadenocarcinoma, undif- of the many histologic variants is encountered.
ferentiated, etc.) Relatively slow-growing, the adenoid cystic
Mucoepidermoid carcinoma carcinoma is nevertheless locally infiltrative
Epidermoid carcinoma (squamous cell carcinoma) and tends to spread rather insidiously along
Malignant stromal tumors perineural sheaths and the
76 MAXILLOFACIAL PROSTHETICS

FIG. 5.15. Pleomorphic adenoma. A, sheets, strands and cords of proliferating epithelial cells of ductal origin
are seen distributed in a somewhat hyalinized connective tissue stroma. Occasional duct structures are found. B,
another field from the specimen shown in A, demonstrating neoplastic epithelium in the lower portions of the field
with other areas of myxomatous stroma characteristic of the pleomorphic adenoma.

FIG. 5.16. Pleomorphic adenoma. Islands of osteoid and hyalinized connective tissue are shown with strands of
neoplastic epithelial cells scattered within looser, somewhat myxematous areas.
ORAL PATHOLOGY 77

periosteum. Thus, treatment must consist of retromolar area. Those lesions which are
wide surgical excision, and the patient must predominantly mucus-secreting (and pre-
be followed at frequent intervals for possible sumably better differentiated) may develop
recurrence. Especially deceptive because of its large and small mucus pools and thus grossly
slow growth and uniform cell pattern, the resemble the mucocele or pleomorphic
adenocystic basal cell carcinoma nevertheless adenoma. Their clinical behavior has
tends to recur locally, and approximately one- prompted several investigators to class this
third of the cases show late metastasis to type as benign and to designate them as
regional lymph nodes and to distant sites such mucoepidermoid tumors rather than
as the lungs and brain. carcinomas. Others prefer to regard all of the
Mucoepidermoid Carcinoma. Originally variants of this lesion as malignant but with
described as a distinct entity by Stewart et recognition of low grade and high grade
al.60 in 1945, the mucoepidermoid carcinoma histologic types.3, 4
is comprised of varying proportions of mucus- The high grade lesion is composed of sheets
secreting cells, epidermoid cells, and so-called of squamous cells with comparatively few
intermediate cells (Fig. 5.18). This tumor may mucous cells and intermediate cells. Because
occur at any age and in either sex. Most cases of lack of positive criteria and because of
occur in the parotid gland. It is of interest that variation in histologic pattern in different
nearly one-half of 51 intraoral salivary gland areas of the same tumor, those lesions which
tumors reported by Vellios and Shafer63 were fall halfway between the high and low grade
malignant, with 8 of these being types become even more difficult to evaluate
mucoepidermoid carcinomas in the in terms of expected clinical behavior.
Accordingly, each case must be evaluated in
terms of size

FIG. 5.17. Adenocystic carcinoma (“cylindroma”). A, low power photomicrograph showing the numerous
ductlike structures giving the characteristic Swiss cheese pattern. B, higher magnification of A, showing uniform
basophilic cells arranged around a central lumen containing loose material.
78 MAXILLOFACIAL PROSTHETICS

FIG. 5.18. Mucoepidermoid carcinoma. A, ductal elements with islands of squamous epithelium and occasional
mucus-producing cells are shown. B, higher magnification of the specimen shown in A shows the junction of
distended mucus-producing cells and squamous cells.

and location of the primary lesion, presence of subvarieties now being recognized. Each of
metastasis at the time of discovery, and these seems to have a rather consistent
adequacy of the excision, in addition to the clinical behavior and, as a consequence, it
histologic features. Clearly, a more becomes quite important to pinpoint the
conservative approach may be followed in specific type of odontogenic tumor. It should
those lesions which are predominantly mucus- be emphasized that the diagnosis of an
producing, whereas those having a prominent odontogenic tumor does not necessarily imply
epidermoid element resembling jaw resection, but such a decision must be
adenocarcinoma or squamous cell carcinoma based upon the natural history, location, size,
must be treated similarly to other malignant and histologic features of each individual case.
tumors with a high potential for metastasis. Thus, a precise understanding of the
characteristics of each of the known varieties
Odontogenic Tumors
of the odontogenic tumor is necessary if a
Because of their unique origin and spe- proper treatment plan is to be established.22’ 52
cialized nature, the odontogenic cysts and Admittedly, a number of types of odon-
tumors frequently present diagnostic and togenic tumors are not yet clearly defined and
treatment problems. The maxillofacial may represent transitional stages from one
prosthodontist is likely to be consulted type to another. A convenient classification
regarding these lesions, and it is important based upon the tissue of origin is given in
that he be familiar with the various types and Chart 5.2. It should be noted that the
their expected clinical behavior. odontogenic cysts listed are not true
Classification of the odontogenic tumors is neoplasms but are most conveniently included
particularly difficult in view of all of the here for purposes of discussion.
ORAL PATHOLOGY 79

Certainly many of the odontogenic cysts,


especially large ones, may be confused ra-
diographically with odontogenic tumors.
Ameloblastoma, the most common of the
odontogenic tumors, may resemble the
dentigerous cyst and may in fact arise from
odontogenic cyst epithelium.
The present discussion is confined to those
odontogenic tumors which may be of special
concern to the maxillofacial prosthodontist,
either in his capacity as a con-

CHAKT 5.2

Cysts and Tumors of Odontogenic Origin


FIG. 5.19. Ameloblastoma of the mandible.
I. Ectodermal origin
A. Odontogenic cysts sultant or as the clinician concerned with
1. Primordial rehabilitation.
2. Dentigerous
Ameloblastoma. As with nearly all of the
a. Eruption
3. Periodontal
odontogenic cysts and tumors, a great many
a. Apical synonyms have been used to describe the
b. Lateral ameloblastoma. “Adamantinoma” is a term
4. Gingival particularly popular with physicians, but the
5. Odontogenic keratocyst word adamantine means hard or pertaining to
6. Calcifying epithelial odontogenic cyst (Gorlin the enamel of the teeth and thus is not
cyst) appropriate, inasmuch as the ameloblastoma
B. Ameloblastoma does not produce enamel.
1. Simple ameloblastoma
The ameloblastoma is a benign tumor
2. Adenoameloblastoma
which is locally invasive. While occasional
3. Calcifying epithelial odontogenic tumor
(Pindborg tumor) case reports have described a malignant
4. Melanotic neuroectodermal tumor of infancy variety of ameloblastoma with metastasis to
(pigmented ameloblastoma, retinal anlage the lungs, other investigators have reviewed
tumor, melanotic progonoma) the literature and suggest that many of these
II. Mesodermal origin cases represent aspiration of tumor cells into
A. Odontogenic fibroma the lungs at the time of surgery rather than
B. Odontogenic fibrosarcoma truly malignant lesions.36
C. Odontogenic myxoma
In a review of 379 cases of ameloblastoma,
D. Cementoma
Robinson47 noted a nearly equal distribution of
1. Periapical cemental dysplasia (periapical
fibrous dysplasia) this tumor in males and females. It may occur
2. True cementoma (benign cementoblastoma) at any age, although the average age of
3. Gigantiform cementoma occurrence is in the fourth decade.55 Most
E. Central cementifving fibroma cases occur in the mandible, usually in the
F. Dentinoma molar-ramus area, and classically may present
III. Mixed origin as a multiloc- ular lesion on the x-ray (Figs.
A. Odontoma 5.19 and 5.20). It should be pointed out that
B. Ameloblastic fibroma
the radiographic diagnosis of ameloblastoma
C. Ameloblastic hemangioma
is extremely hazardous since a large number
D. Ameloblastic neurinoma
E. Ameloblastic sarcoma of these tumors resemble a simple cystlike
F. Ameloblastic odontoma
G. Ameloblastic fibro-odontoma
80 MAXILLOFACIAL PROSTHETICS

defect which is not itself diagnostic. As noted but do not metastisize, and have some his-
above, the dentigerous cyst may give rise to tologic similarity.
the ameloblastoma, and it follows that all The histologic features of the ameloblas-
cases of dentigerous cyst should be examined toma classically consist of nests or clumps of
histologically. Ameloblastomas probably tumor cells arranged to mimic the enamel
originate from odontogenic epithelium or the organ (Fig. 5.21). The outer periphery of these
cells that precede tooth development, and nests is composed of columnar cells
portions of the ameloblastoma frequently resembling ameloblasts which surround a
simulate odontogenesis histologically in its central area of stellate reticulum. Several
early stages. Possible sources of cells with other histologic patterns solid, cystic,
ameloblastic potential include the enamel follicular, plexiform, acantho- mous, basal cell,
organ, cell rests or remnants left over from granular cell, etc.) may be seen in the
tooth development, odontogenic cyst ameloblastoma, but no definite correlation has
epithelium, oral epithelium, and misplaced yet been established between these variants
epithelium in other locations of the body such and their clinical behavior.
as the pituitary gland (pituitary While there is considerable difference of
ameloblastoma). The origin from oral opinion concerning proper treatment of
epithelium is not surprising inasmuch as both ameloblastoma, most investigators agree that
the odontogenic apparatus and salivary these tumors, being well differentiated, tend
glands arise embry- ologically from to be radioresistant and are best treated
invaginations of oral epithelium. Some surgically. The extent of surgery employed
investigators have suggested that the should be based upon the clinical,
ameloblastoma is the counterpart of the basal radiographic, and histologic findings rather
cell carcinoma of the skin inasmuch as both than upon a general rule. Careful study of the
arise from appendages (the odontogenic original diagnostic specimen may well indicate
apparatus and hair follicles, respectively), are that the tumor
locally invasive

FIG. 5.20. Ameloblastoma of the mandible. This occlusal radiograph shows a multilocular and honeycomb
pattern which is typical of advanced cases. A definitive diagnosis must be established by biopsy.
ORAL PATHOLOGY 81

FIG. 5.21. Ameloblastoma. A, low power photomicrograph, showing numerous islands of tumor cells. Beginning
cystic degeneration is seen at the upper edge of the specimen. B, higher magnification of the specimen in A,
showing peripheral arrangement of ameloblast-like cells surrounding a central zone of stellate reticulum. C,
higher magnification of the specimen shown in A and B. The columnar-shaped ameloblasts are seen running
through the center of the field with the more loosely arranged stellate reticulum illustrated at the upper portion of
the photomicrograph.
82 MAXILLOFACIAL PROSTHETICS

FIG. 5.22. Adenoameloblastoma. A, ductlike structures characterize this unusual odontogenic tumor. The
lumen of the ducts occasionally contain material which has been variously described as enameloid, dentinoid or
amyloid. B, adjacent areas show sheets and whirls of odontogenic epithelium, some of which may be spindle-
shaped. Associated foci of calcification are sometimes seen in the lesion and may account for the unusual
radiographic appearance.

has been totally excised and further surgery is shows an equal distribution in the maxilla
not indicated. For example, the and mandible, and ordinarily occurs anterior
ameloblastoma arising in a dentigerous cyst to the molar region. In general, the
may grow into the lumen of the cyst or be adenoameloblastoma occurs more frequently
confined to the cyst wall and thus require no in young people than does the ameloblastoma,
further treatment other than careful follow- usually appearing before the age of 21. It
up. Local block resection rather than jaw presents clinically as an asymptomatic
resection is usually indicated for those cases radiolucency of the jaw, and it may cause a
not localized to a cyst wall or lumen since the localized enlargement. It is particularly well
limits of the tumor cannot be precisely circumscribed on the radiograph and may be
identified clinically. In any event, the patient confused with an odontogenic cyst or
with a relatively small ameloblastoma is ameloblastoma radiographically.
entitled to one or more recurrences before jaw Histologically, the adenoameloblastoma is
resection is decided upon. made up of closely packed epithelial cells,
Adenoameloblastoma. The adenoame- some of which are arranged in nests or cords
loblastoma is an uncommon type of odon- or cells which mimic a ductal or glandular
togenic tumor which must be treated as a pattern (Fig. 5.22). Occasional areas of
specific entity since its clinical behavior differs calcification may be present. Conservative
markedly from the simple variety of surgical excision is the treatment of choice
ameloblastoma.5 This tumor occurs about since these lesions are readily excised at
twice as frequently in females as males, initial surgery and do not recur.
ORAL PATHOLOGY 83

Calcifying Epithelial Odontogenic lesion. Treatment is essentially the same as


Tumor (Pindborg Tumor). This unique for ameloblastoma.22
odontogenic tumor was first described by Melanotic Neuroectodermal Tumor of
Pindborg in 1958. Its natural history, locally Infancy (Pigmented Ameloblastoma,
invasive properties and behavior is much like Retinal Anlage Tumor, Melanotic Pro-
the simple ameloblastoma. It occurs in the gonoma). Seen typically on the anterior
same general age group and is found most maxilla of female infants as a dark pigmented
frequently in mandibular molar area, usually mass with destruction of the underlying
related to an impacted tooth. Its radiographic alveolar bone, the melanotic neuroectodermal
appearance, in contrast to the ameloblastoma, tumor of infancy is traditionally grouped with
is commonly described as a “driven snow” the odontogenic tumors. However, it now
appearance. Histologically, it consists of generally is agreed that it is of
sheets of packed epithelial cells showing little neuroectodermal rather than odontogenic
supporting connective stroma (Fig. 5.23). Fre- origin. It may be confused clinically with
quently these cells will show considerable malignant melanoma or even with the
pleomorphism and often giant nuclei with an congenital epulis of the newborn which is also
abundant, eosinophilic cytoplasm. Inter- present at birth, often on the maxilla, and
cellular bridges may be present. Areas of which occurs predominantly in females. This
cellular degeneration are often seen and latter tumor is not pigmented, however.
spheroids of calcification with Liesegang rings Histologically, the pigmented ameloblastoma
are often scattered throughout the consists of masses of melanin-containing
cuboidal cells arranged in an alveolar pattern.
The central portions of these alveolar spaces
are filled largely with small round cells with
an indistinct cytoplasm. In spite of this bizarre
clinical and radiographic appearance, it is
treated by conservative surgery and does not
recur.51
Odontogenic Fibroma. This uncommon
odontogenic tumor occurs centrally within the
jaws and presumably arises from the
connective tissue of the periodontal
membrane, the dental papilla, or the dental
follicle. Histologically, it consists of a uniform
connective tissue stroma with occasional
scattered islands of odontogenic cell epithelial
rests. The presence of epithelium is a priori
evidence that this lesion is odontogenic since it
does not otherwise differ from the central
fibroma of bone. Since relatively few cases of
this lesion have been described, its natural
history cannot be established. It presents
radiographically as a radiolucent lesion,
usually well circumscribed, but often with a
multilocular or soap bubble appearance which
may be confused with ameloblastoma,
odontogenic myxoma or hemangioma of bone.
FIG. 5.23. Calcifying epithelial odontogenic tumor
Jaw enlargement is not uncommon and
(Pindborg tumor). Sheets of odontogenic epithelium
occasionally displacement of teeth occurs. Con-
composed of somewhat pleomorphic cells are shown.
Scattered foci of calcification with characteristic Lie- servative surgical excision is the treatment
segang rings characterize the lesion.
84 MAXILLOFACIAL PROSTHETICS

of choice since the lesion is benign and does Central Cementifying Fibroma. This
not tend to recur.51 lesion is seen typically in the young to middle
Odontogenic Myxoma. The odontogenic aged adult as an expansile lesion involving the
myxoma is a central radiolucent tumor of the body of the mandible. It is sharply
jaws which occurs most commonly in the circumscribed and may vary from a primarily
second and third decades and appears equally radiolucent lesion to a radiopaque mass. The
in the maxilla and mandible. Most cases have radiodensity varies with the amount of
been associated with missing or impacted calcification, i.e., cementi- cles that are
teeth and present as a radiolucent, often distributed throughout the very cellular
multilocular defect with expansion or connective tissue stroma (Fig. 5.24).
perforation of the cortex. Histologically, the Treatment is by simple enucleation, and
lesion consists of a very delicate, mucoid recurrence is not to be expected.
stroma with loosely arranged spindle-shaped Odontoma. The odontoma is a tumor of
or stellate cells which are remarkably uniform. odontogenic origin which shows full differ-
Its general appearance is that of embryonic entiation toward the formation of tooth
myxomatous tissue, and consequently it may structures. It may consist of multiple tiny
be reasonably mistaken for a residual dental teeth (compound-composite odontoma) or show
papilla. Since these lesions are generally tooth structure arranged in a haphazard
radioresistant, the treatment of odontogenic pattern (complex-composite odontoma).
myxoma is surgical excision. The recurrence Radiographically, the odontoma presents as a
rate is relatively high, particularly in the radiopaque mass which is outlined by a
maxilla, and some investigators have sharply circumscribed radiopaque border.
recommended surgery followed by cautery of Since these lesions may often interfere with
the surgical defect. the eruption of teeth or cause displacement of
adjacent teeth,

FIG. 5.24. Central cementifying fibroma. Islands of cementum-like material are shown distributed in a cellular
connective tissue stroma. The amount and density of the calcified portions of the tumor may vary from case to
case, and thus the radiographic appearance may range from a chiefly radiolucent lesion to one which is
radiopaque.
ORAL PATHOLOGY 85

their surgical removal is generally indicated.


Histologic examination of these lesions is
mandatory since the odontogenic activity may
result in the formation of ameloblastoma.
Particular difficulty is experienced in the early
developing odontoma which may be confused
histologically with ameloblastoma.
Ameloblastic Odontoma. The amelo-
blastic odontoma is composed of a well-dif-
ferentiated component of odontogenic epi-
thelium which is forming tooth structure and
in addition shows a markedly proliferating
element with ameloblastomatous features. On
the basis of the few reported cases, it seems
likely that this tumor shows considerable
variation in its clinical behavior and that
additional study will be required to predict
accurately the behavior of a given lesion on
the basis of its histologic pattern. For the
present, it seems reasonable to employ the
same criteria of treatment as for the
ameloblastoma.17
Ameloblastic Fibroma. This odontogenic FIG. 5.25. Ameloblastic fibroma. The connective
tumor is a true mixed tumor since the lesion tissue in this mixed odontogenic tumor is relatively
consists of both epithelial and mesenchymal loose and immature-appearing, with some features
elements. The lesion consists of strands or comparable to those seen in the dental papilla. The
odontogenic epithelium simulates the dental lamina.
cords of odontogenic epithelium which bear a
close resemblence to dental lamina (Fig. 5.25).
These cells are arranged in a primitive connective tissue stroma identical to the
connective tissue stroma which resembles the ameloblastic fibroma plus calcified elements of
dental papilla. Occurring in a relatively young enamel and dentin typical of the odontoma.
age group (usually the second decade and Accordingly, this lesion can be expected to
rarely beyond 21 years of age), these tumors behave in a very benign fashion typical of
demonstrate a slow growth so that the lesion either of the two elements described. This is in
presents as a single cystic defect in the contrast to the ameloblastic odontoma
radiograph. Some enlargement or bulging of described above, which can be expected to
the cortical plates and separation of the roots behave much like the simple ameloblastoma.
of the adjacent teeth may be present. Nearly Tissue Responses to Injury and Pros-
all cases reported have been in the mandible. thetic Materials
Treatment is surgical excision of a very
conservative nature since these tumors shell Tissue injury, whether it be physical
out of the bone quite readily and do not tend trauma, chemical injury, or x-ray irradiation,
to recur.52 results in cell and tissue necrosis which may
Ameloblastic Fibro-odontoma. Seen involve only a few scattered cells or gross
characteristically in young individuals in tissue destruction. A given injurious agent
association with an impacted tooth, the will generally cause more tissue damage if
ameloblastic fibro-odontoma is composed of directed to growth centers in the young child
strands and cords of odontogenic epithelium than if applied to mature bone of the adult.
distributed in an immature Also, the greater the tissue damage and
destruction, the
86 MAXILLOFACIAL PROSTHETICS

greater the scar formation and contracture. and provide effective protection to underlying
Thermal and chemical burns are particularly structures with subcutaneous metallic
likely to cause extensive destruction of tissue, (chrome-cobalt alloys) implants. Restoration of
necessitating extensive primary excision and bulk or contour of soft tissue may be
grafting. accomplished by a variety of synthetic
The latent effects of x-ray irradiation on the materials such as polyvinyl alcohol (Ivalon)
oral and paraoral tissues may complicate sponge or silicones sometimes used in
rehabilitation procedures and prosthetic augmentation mammoplasty.
appliances since tissues so treated show not Tissue reactions to internal prostheses (or
only poor healing but also poor resistance to any foreign body) may range from an
subsequent injury. Although the basis for this extremely mild cellular response to an active
effect is poorly understood, it is known that x- rejection response with severe inflammation
ray irradiation does modify the vascular bed, and necrosis of tissue. In the past several
and the obliterating endarteritis substantially years, a wide variety of synthetic materials
reduces the ability of the tissue to respond to has been developed which are suitable as
injury or infection in the usual manner. The internal prosthesis. As noted above, the local
effects of x-ray irradiation on oral structures tissue reaction to the placement of these
may be farther complicated by reduction of materials is variable, although most have been
salivary flow, resulting in increased oral flora carefully screened by prior animal studies for
and so-called radiation caries. The reduced tissue tolerance.6, 7i 21
blood supply to the alveolar bone, particularly Of particular concern in the long-term
to the mandible, makes these tissues placement of a foreign material within tissue
especially susceptible to infection is its safety and especially any carcinogenic
(osteoradionecrosis), and most radiotherapists effect it may have. It is well known that
recommend full- mouth extractions before several relatively inert substances (e.g.,
beginning tumor- icidal radiation therapy to methylmethacrylate) will induce sarcomas
these regions. when implanted subcutaneously in rats and
Loss of whole structures, such as a nose or mice for long periods of time. 9 The mechanism
ear, from traumatic injuries offers particular of tumor induction in these studies is not
indications for maxilloprosthetic replacement, known, and it should be emphasized that
either on a temporary basis or as permanent extrapolation of findings of this sort to humans
restorations. The choice of plastic repair or is not possible. Present evidence regarding the
prosthetic replacement may be made after carcinogenic effect in rodents of many of these
clinical evaluation of the patient’s age, general presumably chemically inert substances
health, mental attitude, and social indicates that their physical size and surface
requirements. Surgical repair of these finish may be the critical factors. For example,
structures with skin and cartilage grafts is Oppenheimer et al.45 have shown that
reasonably acceptable esthetically and subcutaneous implants of plastics in rats
obviates the special care required for a induced significant numbers of tumors when
prosthetic device. Exenteration of the orbit the plastics were in film or sheet form but only
and associated structures makes prosthetic rarely when the implant was in the form of a
reconstruction of the eye and eyelids virtually powder, textile, sponge, or other forms.
mandatory since functioning eyelids complete The choice of a synthetic or semisynthetic
with lashes are still beyond the realm of material to be used as an internal prosthesis
present plastic surgery methods. should be based upon known experimental and
Losses of tissue volume or contour following clinical evidence with special attention given
traumatic injury are especially adaptable to to the purpose of the implant.
internal prostheses. Cranial defects may be
restored to proper contour
ORAL PATHOLOGY 87

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rics 29: 360-364, 1953. R.: Cleft lip and heredity. Plastic Reconstr. Surg.
51. Shafer, W. G., and Frissell, C. T.: The melano- 34: 11, 1964.
ameloblastoma and retinal anlage tumors. 65. Wynder, E. L., Bross, I. J., and Feldman, R. M.:
Cancer 6: 360-364, 1953. A study of the etiological factors in cancer of the
52. Shafer, W. G., Hine, M. K., and Levy, M. B.: A mouth. Cancer 10: 1300-1223, 1957.
6
MATERIALS FOR THE FABRICATION OF
MAXILLOFACIAL PROSTHESES

Ralph W. Phillips, Peter M. Margetis, f John J. Urban, and Fred


Leonard

Auricular, nasal, and even ocular canite in fabricating maxillofacial prostheses. 9,


prostheses fabricated of various materials 16

have been found on Egyptian mummies, 11 and According to Beder,1 the first obturator was
the Chinese are known to have fabricated described in 1541 by Ambroi'se Pare. It
nasal and auricular prostheses using natural consisted of a simple disc attached to a
waxes and resins.3 Metals, usually gold or sponge. The sponge was inserted into the
silver, have also been used. In an interesting defect and, by absorbing moisture from
case reported by Saunders,12 a device was secretions, it would swell and draw the disc
fabricated of silver for Alphonse Louis, a tightly over the defect. The development of a
French soldier who became known as the gelatin-glycerine compound by Hennig, used
“Gunner with the Silver Mask.” He was widely during and after the first world war, 4
wounded by a shell fragment which removed marked the first soft and somewhat fleshlike
nearly all of the left side of the mandible and material to be developed for use in the
maxilla and the right half of the mandible fabrication of maxillofacial prostheses.
anterior to the first molar. The silver The most common materials currently in
prosthesis, which was color-matched with oil use for the fabrication of intra- and extraoral
paints, included an internal chin with a row of prostheses are polymeric in nature. These
silver teeth, a buccal cavity, and a device for include vinyl chloride polymers and
collecting oral fluids. copolymers, acrylic types, exemplified by
According to Bulbulian,3 Tetamore in 1894 polymethyl methacrylate, and finally silicone
described the successful fabrication of nasal rubbers, both of the heat-vulcanizing type and
prostheses out of a lightweight, nonirritating the room temperature vulcanization (RTV)
plastic material. The material may have been type.
cellulose nitrate,15 a plastic which John A recently introduced material and tech-
Wesley Hyatt developed in 1868 while nique6, 8 for the fabrication of extraoral
attempting to find a substitute for ivory in prostheses, a terpolymer of butyl acrylate,
billiard balls. At the turn of the century, methyl methacrylate, and methacrylamide, is
references began to appear in the literature discussed in detail later in the chapter.
regarding the use of vul- The properties of polymers depend to some
extent on the size and shape of the molecules
of which they are composed.
t Deceased.
89
90 MAXILLOFACIAL PROSTHETICS

Polymers are usually prepared from mon-


omers by the application of heat, of heat and
pressure, or of chemical catalysts.
To obtain specific properties, polymers may
be compounded with a variety of materials
such as reinforcing agents and softeners.
When so compounded, they are known
generally as plastics or elastomers, depending Vinyl chloride is polymerized in the presence of free
on whether they are rigid or soft and flexible. radical catalysts to form polyvinyl chloride:
If the plastic may be molded without
chemical changes—for example, by softening
it under heat and pressure and by cooling it
after it has been molded-it is classified as a
thermoplastic material. Such plastics are and vinyl acetate forms polyvinyl acetate on polymer-
fusible and are usually soluble in organic ization:
solvents. On the other hand, if a chemical
reaction takes place during the molding
process, so that the final product is chemically
different from the original substance, it is
classified as a thermoset material. Thermoset
plastics are generally insoluble and
infusible.14
Materials
Vinyl Polymers and Copolymers. Per- Polyvinyl chloride is a clear, hard resin
haps the most widely used plastics for the which is tasteless and odorless. It darkens
fabrication of maxillofacial prostheses are the when exposed to ultraviolet light and heat,
vinyl polymers and copolymers, the and it requires heat and light stabilization to
copolymers of vinyl chloride-vinyl acetate prevent discoloration during fabrication and
(vinyls) being the most commonly used. The use.
amount of vinyl acetate in the polymer varies On the other hand, the polyvinyl acetate is
from 5 to 20%. In the elastomeric form, when stable to light and heat but has an abnormally
properly compounded, the vinyls exhibit low softening point (35 to 40° C). When
properties which are superior to those of monomers of vinyl chloride and vinyl acetate
natural rubber in flex life and resistance to are copolylmerized in varying proportions,
sunlight and aging. Copolymers of vinyl many useful copolymer resins result. Physical
chloride and vinyl acetate are more flexible properties of flexible and rigid vinyls are
but less chemically resistant than polymethyl shown in Table 6.1.
chloride. Acrylic Resins. Acrylic resins are used in
The vinyls are derivatives of ethylene the fabrication of both intra- and extraoral
(CH2=CH2). Thus, the formula for vinyl prostheses. In powder form, these resins can
chloride is: be injection- and compression- molded or, in
dough form, they can be molded in gypsum
molds.
The acrylic resins are derivatives of eth-
ylene, and these contain a vinyl group in their
structural formula. Of dental interest are
those resins obtained from acids, CH 2
=CHCOOH, and methacrylic acids, CH 2
and vinyl acetate: =C(CH3)COOH. Both of these acids po-
MATERIALS FOR PROSTHESES FABRICATION 91

TABLE 6.1. Properties of flexible and rigid vinyls*

Flexible vinyl Rigid vinyl

Specific gravity 1.16-1.35 1.35-1.45


Refractive index 1.52-1.55
Tensile strength 1,500-3,500 5,000-9,000
Modulus of elasticity in tension (psi X 105) - 3.5-6
Compressive strength (psi) 900-1,700 8,000-13,000
Flexural strength (psi) 10,000-16,000
Impact strength, ft lb/inch (notch) 0.4-20
Varies depending on plasticizer
Hardness, Rockwell - -
Thermal conductivity, 10" * cal/sec (°C) 3.0-4.0 3.0-7.0
Water absorption, 24 hours (%) 0.15-0.75 0.07-0.4

* Courtesy of Boonton Molding Company, Boonton, N. J.

lymerize by additional polymerization. Al- merized by one of the methods previously


though the polyacids are hard and trans- discussed.
parent, their polarity, related to the carboxyl Methyl methacrylate is a clear, transparent
group, causes them to be soluble in water. The liquid at room temperature with the following
water tends to separate chains and to cause a physical properties: melting point of — 54.4°F
general softening and loss of strength. ( — 48°C), boiling point of 213.4°F (100.8°C),
Consequently, they are not used in the mouth. density of 0.945 gram per cubic centimeter at
The esters of these polyacids are of con- 68°F (20°C), and heat of polymerization of 12.0
siderable dental interest, however. For kilocalories per molecule. It exhibits a high
example, if R represents an alkyl radical, the vapor pressure, and it is an excellent organic
formula for a polymethacrylate would be: solvent. The polymerization of methyl
methacrylate can be initiated by ultraviolet
light or heat, as well as by chemical
initiations.
The degree of polymerization varies with
the conditions of polymerization, such as
temperature, method of activation, type of
initiator used, and purity of chemicals. A
volume shrinkage of 21 % occurs during the
polymerization of the pure monomer.
In dentistry, the first member of the series, Polymethyl Methacrylate. Polymethyl
methyl methacrylate, has been of most methacrylate is a transparent resin of re-
importance. markable clarity; it transmits light into the
Methyl Methacrylate. In dentistry, ultraviolet range to a wave length of 0.25. It is
polymethyl methacrylate by itself is not widely a hard resin with a Knoop hardness number of
used in molding procedures. Rather, the liquid 18 to 20. Its tensile strength is approximately
monomer, methyl methacrylate, is usually 8,500 pounds per square inch (600 kg per
mixed with the polymer, which is in the square centimeter), and its specific gravity is
powdered form. The monomer partially swells 1.19. Its modulus of elasticity is approximately
the polymer to form a plastic dough. This 350,000 pounds per square inch (24,400 kg per
dough is packed into the mold, and the square centimeter).
monomer is poly The resin is extremely stable; it will not
discolor in ultraviolet light, and it exhibits
92 MAXILLOFACIAL PROSTHETICS

remarkable aging properties. It will soften at TABLE 6.2. Properties of polymethyl methacrylate*
260°.F (125°C), and it can be molded as a
thermoplastic material. Between this Specific gravity 1.18
Refractive index 1.49
temperature and 400°F (200°C), depo-
lymerization takes place. At approximately Tensile strength 8,000
Elongation (%) 2.0-10.0
850° F (450° C), 90% of the polymer will Modulus of elasticity in tension 4.5
depolymerize to the monomer. Polymethyl
(psi X 10 s)
methacrylate of higher molecular weight will Modulus of elasticity in flexure 4.5
degrade by the evolution of monomer and (psi X 105)
concomitantly form a polymer of lower Shear strength 9,000
molecular weight. Compressive strength (psi) 12,000-18,000
Like all acrylic resins, polymethyl meth- Flexural strength (psi) 13,000-17,000
acrylate tends to take up water by a process of Impact strength, ft lb/inch 0.4
(notch)
imbibition. Its noncrystalline structure
indicates a high internal energy; thus, Deflection at failure (inches) 0.5-1.0
Hardness, Brinell, 2.5-mm ball, -18-20
molecular diffusion can occur into the resin
25-kg load
since less activation energy is required. Hardness, Rockwell M84
Furthermore, the polar carboxyl group, even Thermal conductivity, 10“4 4.0-6.0
though esterified, can form a hydrogen bridge cal/sec (°C)
with the water, if only to a limited extent. Water absorption, 24 hours (%) 0.3
Since both absorption and adsorption are
involved, the term “sorption” is usually used to * Courtesy of Boonton Molding Company, Boon-
ton, N. J.
include the total phenomenon. It has been
reported that typical dental methacrylate
resins show an increase of approximately 0.5% As a material for maxillofacial prostheses,
by weight after 1 week in water. Higher values silicones exhibit weathering properties and
have been reported for a series of methyl maintain good physical properties over a wide
methacrylate polymers. The sorption of water temperature range. As mentioned earlier in
is nearly independent of temperature from 0 to the chapter, silicones used in maxillofacial
60°C but is markedly affected by the molecular monomers can be cured either at room
weight of the polymer. The greater the temperature or by heat and, in either case,
molecular weight, the smaller the weight synthetic rubbers result which have had wide
increase. Sorption is reversible if the resin is application in medicine and more recently in
dried. dentistry.
Polymethyl methacrylate is soluble in RTV Silicones. According to Braley,2 the
organic solvents such as chloroform and room temperature-vulcanizing silicone
acetone. Physical properties of polymethyl rubbers are composed of comparatively short
methacrylate are shown in Table 6.2. chain silicone polymers which are partially
Silicones. The silicones were introduced end-blocked with hydroxyl groups. In addition,
around 1946, but only in the past few years a cross-linking agent such as
have they been used in the fabrication of tetraethyoxysilane (ethyl orthosilicate), shown
maxillofacial prostheses. Silicones consist of below, is used.
chains of alternate silicon and oxygen atoms
which can be modified by attaching various
organic side groups to the silicon atoms or by
cross-linking the molecular chains. Silicones
range in properties from rigid plastics through
elastomers to fluids.
MATERIALS FOR PROSTHESES FABRICATION 93

Fillers are added to strengthen the final rubber. group in an adjacent chain. Thus, the two
With the addition of a catalyst such as stannous polymers are cross-linked, with benzoic acid
octoate, condensation takes place between the formed as a by-product. A synthetic rubber
hydroxyl ion of the polymer and the alkyl group results which in recent years has found
of the cross-linking agent, yielding an alcohol, increasing rise in maxillofacial prosthetics.
and a network forms as a result of the cross- Various silicone rubbers have been made
linking. Bralev2 further suggests the following available for use by the maxillofacial
chemical configuration for the RTV rubber, prosthetist. These include Silastic S-6508,
calling attention to the fact that, although this Silastic 382, and Silastic 399 (Dow Corning
may represent a typical configuration, the Corporation, Midland, Michigan).
reaction is extremely complex, and that other Silastic S-6508 in the raw state is similar
permutations of related materials and methods to sticky modeling clay. It must be vulcanized
are used in RTV silicones. at 260°F and formed in pressure molds.
Because of this, it requires much more
sophisticated handling than the other two.
Silastic 382 is an opaque white fluid with a
viscosity like that of thick honey. It sets up to
a rubber without the evolution of heat within
a few minutes after its catalyst, stannous
octoate, is incorporated.
Silastic 399 resembles white Vaseline in its
raw state. It is easily spatulated but is
nonflowing. Upon mixing with catalyst 1, the
cross-linking agent, it becomes somewhat
milky, but it can be worked for several hours.
When catalyst 2 is added, it sets up to a
translucent rubber in 10 to 15 minutes. It was
devised especially at the request of the
maxillofacial prosthetist for a version of
Silastic 382 that would be tougher,
translucent, nonflowing, and easier to handle.
Typical physical properties of silicones used
RTV silicone rubber for maxillofacial prosthetics are shown in
Table 6.3.
Gypsum molds are used in the fabrication of During its early stages of use in maxillo-
protheses from RTV silicones. facial prosthetics, some difficulties were
Heat-vulcanizing Silicones. The encountered in tinting or color-matching
mechanism for the formation of a heat-
vulcanizing silicone rubber involves the use of a
diorganopolysiloxane, such as polydi- m ethyl, TABLE 6.3. Typical physical properties of silicones
siloxane. used for maxillofacial prosthetics*

Silastic Silastic Silastic


S-6508 382 399

Durometer 26 45 50
Tensile (psi) 785 300 525
Elongation (%) 490
100
230
Tear (psi) 65 29
When this material, a liquid, is heated with 20
benzoyl peroxide (C6H5—COO)2-, a reaction
-
* Courtesy of Silas Braley, Dow Corning Corpora
occurs between one of the methyl radicals in the
tion, Midland, Mich.
chain and a similar methyl
94 MAXILLOFACIAL PROSTHETICS

silicone rubber. A technique utilizing RTV impart a basic shade to the elastomer, is
silicone is suggested by Lepley.7 sprayed by an artist’s airbrush with pigment
The steps up to and including the fabri- dispersions diluted with xylene to a spraying
cation of the molds are similar to currently consistency. The catalyst used for curing RTV
used techniques. silicone elastomer is also sprayed with an
The RTV silicone* is blended with suitable airbrush for catalyzing the cure of the sprayed
earth pigments^ to produce the patient’s basic layer over the tinted prosthesis to give the
skin color. The catalyst is added and mixed illusion of depth and a realistic surface.
according to the manufacturer’s The pigment concentrates are prepared,
recommendations. While the material is still using Artskin Products pigments, by grinding
in a fluid state, it is carefully introduced into the pigment with RTV 399 silicone elastomer
the mold, which is then closed and the silicone in a mortar and pestle until a smooth pigment
rubber is allowed to cure for 30 minutes. The concentrate in silicone elastomer is obtained.
cured prosthesis is then removed from the The formulation prepared is-shown in Table
mold and thoroughly cleaned with chloroform 6.4.
preparatory to color-matching the prosthesis The desired amount of the pigment con-
to the patient’s individual requirement. A centrate is added to RTV elastomer, which is
medium for tinting can be made from uncured then cast to give a prosthesis of the required
RTV silicone, § distributed to the desired basic shade. In addition, the concentrates are
consistency with xylene to which pigments are used to prepare various spray-tinting
added. After the surface has been tinted with dispersions. The basic shade formulation for
artist’s brushes, using the patient’s skin the prosthesis is shown in Table 6.5.
coloring as a guide, the prosthesis is allowed to
stand overnight to permit the xylene to evapo-
rate. The catalyst is then gently applied over
the tinted surface with a brush or cotton TABLE 6.4. Basic shade formulations of silicone
applicator. Stippling or other skin elastomers
characterizations can be accomplished at this 399
Stock Silicone
time. The surface is allowed to cure for several Color pigment elastome
more hours before polishing. The glossy r

surface of the prosthesis is dulled to the gram grams

desired degree by abrading the surface with 073 White 0.10 5.0
448 Yellow 0.10 5.0
wet flour of pumice, using mild finger
115 Dark buff 0.10 5.0
pressure. The prosthesis is then fitted to the
111 Medium brown 0.10 5.0
patient, using a medical grade adhesive. T 109 Light yellow-brown 0.10 5.0
Further cosmetic effect may be achieved by the 112 Red-brown 0.10 5.0
patient with commercially available make-up 331 Black 0.10 5.0
creams. Formulation of red pigment concentrate for red shades:
Ouellette10 has recently described a new 893 Red Mixed together 0.15 5.0
technique for spray-coloring a silicone elas- 273 Blue 0.02
tomer. In this method, the RTV elastomer
prosthesis, containing pigments which * * * §
TABLE 6.5. Basic shade formulation for RTV
elastomer

* Dow Corning RTV silicone rubber 502. grams

$ Earth Pigments, Mineral Pigment Corporation, Pigmented silicone concentrates


Newark, N. J. 073 White 0.90
§ Dermol-Sil RTV silicone, Artskin Products 109 Light Yellow-brown 0.80
Company, Norfolk, Va. 115 Dark buff 0.20
T Development Aerosol Type B, Medical Adhesive, 399 Clear silicone elastomer 25.00
Dow Corning Corporation.
MATERIALS FOR PROSTHESES FABRICATION 95

TABLE 6.6. Basic shade spray dispersion for external be noted that the basic shade is not unique for
coloring each patient, but variations will be necessary
depending upon the patient’s skin color. Thus,
grams darker skins will necessitate a darker basic
Formulation shade.
Pigmented silicone concentrates To tint the prosthesis precisely to the
073 White 2.30
patient’s skin tone requirements, the red
109 Light yellow-brown 0.20
111 Medium brown
shade pigment spray dispersion (Table 6.6) is
1.00
115 Dark buff sprayed on the prosthesis until the desired
1.20
399 Clear silicone elastomer 5.30
reddish hue is obtained. Then the catalyst
Xylene solvent 25.00 spray (Table 6.6) is applied, and the sprayed
Red shade spray dispersion dispersion is permitted to cure at 50°C in an
(red shades) oven (3 to 4 minutes). Then the basic shade
Red pigment concentrate 5.00 spray dispersion (Table 6.6) is applied to
Clear silicone elastomer (RTV 399) 5.00 achieve overall color replication. Again the
Xylene solvent 25.00 catalyst spray is applied and the prosthesis
Clear spray dispersion placed in an oven at 50°C to permit cure of the
399 Clear silicone elastomer 10.00
dispersion.
Xylene solvent 25.00
Finally a catalyst spray dispersion is required: To eliminate the shiny texture that occurs
on the prosthesis after the final external
Catalyst spray formulation coloring or shade has been accomplished, a
Catalyst 1 40 drops thin layer of clear elastomer solution (Table
Catalyst 2 15 drops 6.6) is applied. The prosthesis is then sprayed
Xylene solvent 2.5 grams
lightly with catalyst, and the curing process is
observed. At the tacky stage, a piece of gauze
dampened in xylene is used to sponge the
The pigmented elastomer concentrates are prosthesis. This treatment results in a satin
compounded with xylene and RTV 399 finish and more lifelike appearance.
elastomer to form spray dispersions of the General Considerations in Materials
desired spraying consistency. These formu- Selection. The fabrication of maxillofacial
lations are shown in Table 6.6. prostheses presents various difficult problems,
The pigment concentrate which is used to such as those involved in obtaining
achieve the final custom tinting of the impressions and constructing molds for the
prosthesis is also summarized in Table 6.6. It complex shapes encountered in facial res-
is used to produce the necessary variations in torations. In addition, a heterogeneity of tones
skin tones to make the prosthesis appear and shades, the illusion of depth, and the
realistic. varying degrees of translucency present in the
In a typical procedure, the silicone RTV Truman skin require the prosthetist to
399 elastomer is compounded in accordance develop special techniques in tinting and
with the formulation shown in Table 6.5 by coloring the prosthesis to obtain realistic
mixing the pigments on a glass slab with a effects. Further, the range of mechanical
spatula with sufficient clear silicone properties and the degree of permanence
elastomer. The required quantity of the desired in materials present a challenge to the
pigmented concentrate is then added to materials scientist. An ideal material for the
silicone RTV used to cast the prosthesis. fabrication of facial prostheses must have
Catalysts 1 and 2 are then added in ac- excellent tissue receptivity, i.e., be nontoxic
cordance with the manufacturer’s instruc- and nonaller- genic. It must lend itself to
tions, and the prosthesis is cast and permitted accurate forming and fairing with retention of
to cure at room temperature. The cast fine detail and without the introduction of ob-
prosthesis is then of a basic shade and is
ready for external spray coloring. It is to
96 MAXILLOFACIAL PROSTHETICS

vious parting lines or distortion. A degree of low pressure casting techniques may be
translucency is required, and the material utilized.
must be essentially colorless when cast so that The technique developed at the United
it may be tinted to simulate pastel skin tones. States Army Medical Biomechanical Re-
It must be durable and resistant to abrasion search Laboratory uses low pressure molds
and outdoor weathering as well as to and differs from other designs in that it
commonly used stainants. Should the material results in a two^component prosthesis con-
show some tendency to stain, it should be easy sisting of an outer layer of “skin” made of
to clean, preferably with ordinary cleaning a synthetic elastomer which covers an
agents. The material should have a flexibility inner layer or foam filler made of silicone
corresponding to the surrounding skin to which foam rubber.
it adheres. That is, as the facial musculature The material developed for the fabrica-
underlying the prosthesis contracts and tion of the outer layer or skin of the two-
relaxes, the material should undergo similar component prosthesis is a latex-dispersed
contracting and relaxing and should remain synthetic elastomer: a terpolymer of butyl
flexible, ideally over the range of ambient acrylate (90%), methyl methacrylate (7.5%),
temperatures from —40 to 140°F. In addition, and methacrylamide (2.5%). The terpol-
the material must be able to adhere securely ymer is compounded with 37 parts of pol-
and comfortably and to exhibit a fine line yethyl methacrylate as a reinforcing agent.
marginal contact. In addition, 1.765 parts of formaldehyde,
Fabricating Techniques which acts as a cross-linking agent, are
added during the compounding procedure.
Because of the complexity of shapes re-
quired, the techniques for fabricating max- The compounding formula is represented
below:
illofacial prostheses should be simple and
Material Parts
inexpensive. Such methods as high tem-
perature, high pressure injection, or com- Terpolymer latex 100.00
Polyethvl methacrylate 37.00
pression molding are contraindicated because
Formaldehyde
of the necessity for fabricating expensive
1.76
tooling which would withstand these forces. 5
This material is essentially a chemically
Further, the materials used should be liquid or
saturated elastomer which is inherently
liquid dispersions which can be dipped or cast,
flexible without the addition of plasticizers. It
thereby making it possible to use inexpensive
shows excellent outdoor weathering and is oil-
plaster of Paris or plastic molds.
resistant. The elastomer is cross-linked and
Leonard lists the following chemical cri-
5

teria for synthesis of polymers for maxillofacial dimensionally stable. Detailed data on the
preparation and properties of the latex are
prostheses. The polymer should:
referenced earlier in the chapter. The
1. Be flexible without the addition of
elastomeric film cast from the compounded
plasticizers.
latex technique is known as the acrylate skin.
2. Be chemically saturated.
One of the unique features of the technique
3. Not have labile groups on chain back-
bone or side chains. of fabricating the two-component maxillofacial
prosthesis described -in this chapter is the
4. Be vulcanizable and thermosetting or
ease with which the acrylate skin or cosmetic
regularly oriented.
element of the prosthesis can be processed.
5. Have high gum stock strength or be
The process is particularly advantageous
compoundable with fillers whose refractive
because it uses latex dispersions of the
index is equivalent to the base polymer so ,that
polymer from which the acrylate film may be
translucent films can be achieved.
dipped and cast.
6. Be dispersed in liquid form so that
Since the two-component system for the
fabrication of maxillofacial prostheses has
MATERIALS FOR PROSTHESES FABRICATION 97

only recently been introduced and is com- ever, the stone should be kept in contact with
paratively unknown, the technique is detailed the alginate for at least 30 minutes and
in the following pages. preferably 60 minutes. Such models (Fig. 6.2)
Master of Original Molds. After the are used for the base of the clay sculpturing.
alginate impression has been removed, it is As a safety precaution, an extra stone master
soaked in a 2% solution of potassium sulfate. model is prepared and set aside. It is best
The next step in the process involves the prepared by duplicating the original stone
preparation of the working models necessary model, using a permanent flexible impression
for fabrication of the prosthesis. Careful material (Fig. 6.3) of either the silicone rubber
attention to detail is essential in preparing the or polysulfide rubber type.
master model since it represents an exact Molds for Preparing Trial Prostheses.
duplication of the patient’s defect and The next step involves preparing a mold for
surrounding tissue. The original model serves the fabrication of a trial prosthesis. || First, a
several purposes: not only does it provide a flexible matrix is prepared by pouring silicone
record of the defect, but it is also used as a RTV (Fig. 6.4) on the sculptured model (Fig.
study model for designing the prosthesis and 6.5), being certain to include sufficient area
for selecting sites to gain optimal retention. around the clay sculpturing to allow for
The models should be large enough to allow overextension of the subsequently prepared
for overlap of the synthetic elastomer for prosthesis to ensure adequate retention. After
retention. The amount of overlap, which the RTV silicone sets, stone is poured over the
depends on the location of the defect, is flexible matrix, allowing the stone to extend
considered later in the chapter. A typical beyond the periphery of the silicone and
master model is shown in Figure 6.1. thereby forming a two-piece stone mold
The original model is prepared by pouring incorporating the flexible matrix.
or casting dental stone in the alginate It is important to apply a separating
impression. The stone is mixed in a flexible medium to that portion of the stone model
rubber bowl with a stiff-bladed spatula. Using which will be contacted by the plaster matrix
a flexible blade can result in “dragging” the to facilitate the separation of the two mold
blade through the stone and water mixture, halves, as well as to ensure accurate
with a resultant inhomogeneous mix. Every reassembling of the mold sections. If the trial
effort must be made to avoid the inclusion of prosthesis does not need any modification, the
air bubbles in the stone. When the spatulation same mold (constructed above) can be used for
has been completed, the mixture should be processing the foam filler.
held on an automatic vibrator in order to Fabricating the Trial Prosthesis. The
remove air bubbles incorporated during the two-piece mold is separated, and the clay
mixing procedure. Bubbles not only weaken sculpturing is removed. Any remaining traces
the model but can also produce surface of clay are wiped from the mold surface with a
inaccuracies. The spatulation time soft cloth which has been saturated with
recommended by the manufacturer should be alcohol. When a large sprue hole is used, a
followed, as well as the proper ratio of water thin film of RTV silicone is rubbed on the
to powder. Excessive mixing as well as inner portions of the mold, with care being
excessive water weakens the stone model. taken not to cover any of the areas where
After the stone has been poured into the there will be stone-to
impression, the model should not be separated
from the impression until it is thoroughly set.
The minimal time for setting can vary from 10
to 30 minutes, depending on the rate at which
the stone sets and the type of impression
material. How ll It should be pointed out that simple partial auric-
ular and nasal prosthesis do not usually require the
fabrication of a trial prosthesis.
98 MAXILLOFACIAL PROSTHETICS

stone contact. The mold halves are aligned arbors and dental burs. If additional material
(Fig. 6.6) and held securely in position with is required, the trial prosthesis is returned to
clamps or tape. After the silicone has been the stone mold, and RTV silicone is mixed and
introduced through the large sprue hole, the applied to the desired area. When the silicone
filled mold is set aside and the silicone is has cured, the prosthesis is trimmed and
permitted to cure for approximately 15 fitted. If alterations have been 'made, a new
minutes. When small sprue holes are used, top half for the two-piece mold is made by
before the mold halves are assembled the placing the altered trial prosthesis on the base
cavity portion of the mold is filled with silicone portion of the original two-piece mold and
to a level just below'its edge. Before aligning fabricating a new mold half.
the mold halves, a thin film of RTV silicone is Internal Surface. In many instances, such
rubbed over the surface of the stone half, with as with nasal or extraoral buccal prostheses,
care being taken not to cover the areas which hollow spaces must be provided within the
will contact the opposing mold half. The mold prosthesis. In a nasal solid trial prosthesis
halves are then aligned and secured with (Fig. 6.7), the nares must be carved and
clamps or tape, and enough silicone is extended into the nasal fossae. The carving
introduced through the sprue holes to complete should be done in such a manner as to allow
the filling of the mold cavity. The mold is then the patient to breathe and still maintain
set aside until the RTV silicone has cured. sufficient rigidity in the prosthesis to ensure
Usually the material will overflow through the that it remains patent during this function.
vents or waste gates, with the sprue holes The walls of the nasal fossae should be smooth
forming buttons or mushroom patterns. This and accessible to facilitate cleansing of the
excess is removed prior to separating the mold prosthesis. Most of the material is removed
halves, not only to facilitate this operation but with a small, sharp scalpel, and the final
to prevent fracturing of the silicone trial pros- smooth surface is obtained by using a small,
thesis. Once the trial prosthesis is removed fine grit sandpaper disc and dental burs. All
from the mold, the sprues are cut as close as surfaces should be finished in such a manner
possible to the tissue contact surface. The as to completely eliminate any area that could
remainder of the sprue is trimmed and blended collect and trap secretions (Fig. 6.8). A full
into the surrounding surface. Complete length nasal septum is neither desirable nor
removal and shaping of the sprues are necessary since it would only serve to reduce
essential in keeping the correctly established air flow and add weight to the prosthesis.
contact surface on the tissue side of the trial Once the internal designing has been
prosthesis. completed, the altered trial prosthesis is
Fitting and Finishing the Trial Prosthesis returned to the top half of the two-piece mold
(Fig. 6.9) and a new stone base is cast (Fig.
External Surface. After all of the sprues and
6.10). Prior to use, waste gates and sprue
any other excess materials have been properly
holes are prepared.
trimmed, the trial prosthesis is positioned on Similar techniques are used in fabricating
the patient for an initial fitting. Careful
complete auricular and extraoral buccal trial
consideration is given to tissue contact,
prostheses. In a complete auricular case, the
establishing a final periphery, and shaping the auditory canal, when possible, is used as the
prosthesis to create a natural and esthetic
basic registering and seating point and is
contour with the surrounding tissue. The
therefore included as part of the trial
anatomy of the prosthesis is not checked for
prosthesis. On a particularly flat surface, an
size and contour. All tapering, reductions, or
extended auditory canal can be incorporated
alterations are accomplished with various as part of the final foam filler if required, but
sized sandpaper it is gener
MATERIALS FOR PROSTHESES FABRICATION 99

ally excluded to allow the outer skin to line surface include the removal and finishing of
the patient’s auditory canal for a short dis- the RTV silicone sprues, the shaping and
tance. The alterations to the tissue contact smoothing of the end of the auditory

FIG. 6.1. Master stone model, showing defect and surrounding area.
FIG. 6.2. Flexible impression supported by plaster matrix.
FIG. 6.3. Stone base used for sculpturing is also prepared at this time with sprue hole for future packing
procedure.
FIG. 6.4. Flexible (negative) mold.
FIG. 6.5. Clay nose sculptured on stone base shown in Fig. 6.3.
FIG. 6.6. Mold halves assembled, showing silicone sprue (stone base (Fig. 6.3) positioned on flexible mold (Fig.
6.4) to form hollow mold).
FIG. 6.7. Solid trial prosthesis (made in hollow mold of Fig. 6.6).
FIG. 6.8. Silicone trial prosthesis, showing internal design.
FIG. 6.9. Trial prosthesis repositioned into mold.
100 MAXILLOFACIAL PROSTHETICS

canal insert, and the preparing of a hole chloride foams were used and they produced
through the canal block. The hole is drilled successful fillers; however, special molds,
before inserting the canal block to allow air to usually metal, were required. Later the
escape, thus eliminating the chance of injury polyvinyl chloride foams were eliminated in
to the inner ear as a result of air pressure. It favor of polyurethane foams which could be
also makes that portion of the prosthesis more processed in properly lubricated stone molds.
flexible, besides allowing the patient to hear The use of polyurethane foam, although
during the fitting of the trial prosthesis. temporarily successful, produced fillers which
The preparation of a new mold if either the exhibited discoloration during comparatively
external or internal surface of the trial short periods of wear. This in turn affected the
prosthesis requires alteration has been dis- overall color match of the prosthesis to the
cussed; however, if the trial prosthesis re- patient. With the introduction of room
quires alteration of both the external and temperature-vulcanizing foams, such as RTV
internal surfaces, a completely new mold must S-5370 (Dow Corning), these new materials
be made in order to fabricate the final trial were used.
prosthesis. In this event, the external surface To prepare the silicone foam filler, the mold
should be altered first. If altered, the trial halves are separated and the silicone is
prosthesis is carefully positioned on the poured into the top half of the mold until the
master model originally produced from the mold is approximately two-thirds filled. The
alginate impression. When it is in place, a new stone base is then positioned over the top half
top half of the mold is processed as described (Fig. 6.11) and held securely by means of a
earlier. Upon completion, the mold halves are clamp or tape until the foam is cured,
separated, the trial prosthesis is removed, and approximately 15 minutes. The filler can also
the internal surface is altered. When the
be processed by an injection technique in
alterations have been accomplished, the trial
which the mold halves are clamped or taped
prosthesis is carefully positioned in the new
together and the silicone is introduced into the
top half of the mold. The mold is then
closed mold with a syringe. Either technique
completed by pouring a new stone base.
will produce a foam filler (Fig. 6.12). The color
Fabricating the Foam Filler. The final
of the silicones and their ease of processing
two-piece mold of stone is used for processing
make this material the one of choice for
the foam filler. Initially, polyvinyl
processing the foam fillers used in this
technique.
MATERIALS FOR PROSTHESES FABRICATION 101

FIG. 6.13. Presaturating of stone dipping mold.


FIG. 6.14. Immersion of stone dipping model into coagulant.
FIG. 6.15. Removal of excess coagulant from dipping model by use of an air jet.

Fabricating the Acrylate Skin. As


mentioned earlier, the acrylate skin is fab-
ricated by dip molding. The dipping model is
made by pouring artificial stone into the
flexible mold used for fabricating the trial
prosthesis, as shown above in Figure 6.4. If
the dipping model does not have an integral
stone handle, a wire handle can be attached to
the back of the model and secured with
additional stone or plaster. The first step in
processing the acrylate skin is to immerse the
dipping model into a beaker of water to
displace air which may have been trapped in
the stone model (Fig. 6.13). Failure to accom-
plish this would result in a skin containing
bubbles or small nodules. The dipping model
is then immersed in a beaker containing a
latex coagulant (Fig. 6.14). In practice, the
coagulant of choice is a dilute solution of
calcium nitrate in denatured ethanol. The
model is removed from the coagulant solution
after 4 to 5 seconds and is permitted, by the
FIG. 6.16. Dipping model immersed in latex.
use of air jet, to drain from any free-flowing
FIG. 6.17. Dipping model dwelling in latex.
coagulant (Fig. 6.15). The stone model is then FIG. 6.18. Dipping model being removed from
dipped into the terpolymer latex for a given latex.
dwell period (Figs. 6.16 to 6.19). The thickness FIG. 6.19. Shaking excess latex from dipping model.
of the film is a function of the time of dwell,
which can vary from a few seconds to a minute brush or other suitable instrument (Fig.
or more, depending upon the desired thickness 6. 20) .
of the film. The characterized film still on the dipping
In this wet condition, the coagulated film of model is covered with a matrix of soluble
polymer is weak and soft and, at this time, plaster (Figs. 6.21 to 6.25) and allowed to dry
skin texture and pores or other by air for 1 hour. It is then placed in a
characterization can be introduced with a circulating air oven at 60°C (Fig. 6.26) for
approximately 1 hour, then
102 MAXILLOFACIAL PROSTHETICS

FIG. 6.20. Characterization of uncured latex skin.


FIG. 6.21. Application of soluble plaster on outer surface of uncured latex skin.
FIG. 6.22. Excess latex skin is removed from back of dipping model to facilitate drying. FIG.
6.23. The soluble plaster is applied beyond the periphery of the uncured latex skin. FIG.
6.24. Soluble plaster matrix is completed.
FIG. 6.25. Completely covered uncured latex skin is allowed to bench-dry.

in a 100° C oven for Vi hour (Fig. 6.27). The ally large, a wide overlap affords the means
purpose of the soluble plaster matrix is to for the added retention needed because of the
keep the latex film from shrinking as the increased weight of the prosthesis. In some
water content is removed from the oven. The cases, an added cosmetic advantage can be
soluble plaster is softened by immersion in gained bv extending the acrylate skin so it can
boiling water (Figs. 6.28 to 6.30) and then blend into a natural skin crevice (Fig. 6.32) or
removed by the use of a suitable instrument, wrinkle. In addition, if the prosthesis extends
with care being taken not to damage the over an area of the face where skin movement
dipping model in the process. The acrylate will be a factor, sufficient overlap should be
film can be removed easily, and the dipping allowed to ensure adequate retention over the
model may now be used for processing area of tissue movement.
additional films if desired (Fig. 6.31). Once the acrylate skin has been properly
The skin is then positioned on the foam trimmed, the two-component prosthesis is
filler and, following the periphery, is cut fitted to the patient. If the prosthesis fits
oversized. The overlap results in a thin, accurately and no other changes or alterations
flexible surface which is used for adhesion and are indicated, the prosthesis is then ready for
stabilizing of the prosthesis. The amount of color-matching to the patient’s skin.
overlap is determined by various factors. If
the prosthesis is exception
MATERIALS FOR PROSTHESES FABRICATION 103

Coloring the Prosthesis. Of the many luminating energy. If white light is used to
factors which contribute to that quality of the illuminate an object and the unabsorbed
human skin described as “lifelike,” color portion is transmitted, the object is colored
occupies an extremely important position, and and transparent. If, however, the unabsorbed
every effort must be made to duplicate normal light is reflected and none is transmitted, the
skin color so that the prosthesis will look object is both colored and opaque. Therefore,
realistic. In order to reproduce skin color with objects which reflect or transmit all spectral
some degree of realism in a plastic medium, colors equally are white, while those which
such as a maxillofacial prosthesis, it is reflect or transmit none are black. In between
advisable first to explore the physical these two limits are many tints that vary ac-
phenomena which give rise to color and to cording to the degree to which objects reflect
study both the structure of skin and its or transmit some colors while absorbing
pigmentation. Visually, the color of an opaque others. Human skin pigments are found
or transparent object depends upon the distributed in the epidermis, the dermis, and
character of the light with which it is the subcutaneous tissue, and they contribute
illuminated and upon the object’s ability to to the overall skin color. When skin is
absorb selectively the different portions of the illuminated, a small part of the incident light
il- is reflected from the surface unchanged, as
though it were reflected from a mirror. The
amount of light so reflected contributes to that
quality of a surface referred to as gloss. The
remaining light enters the epidermis where,
selectively, it is either absorbed, transmitted,
or diffusely reflected according to the color
characteristics of the pigments present in that
particular layer. The reflected portion
contributes to the visual stimulus, while the
transmitted portion enters the dermis. In the
dermis, as well as in the subcutaneous tissue,
the process is repeated, so that overall skin
color is the result of a complicated process of
absorption, reflection, and transmission,
depending upon the relative position and
abundance of the color-producing pigments in
the skin and upon the turbidity of each layer.
Because the skin pigments are present in
varying concentrations from person to person,
the color characteristics of the human skin
vary. Factors such as the state of health and
even the state of mind of the individual, the
activity of the body, exposure to ultraviolet
rays, ambient temperature, the effect of
gravity on blood flow, all contribute to the
color of the skin at any given time.
With the use of pigments, excellent color
matches may be obtained between the
FIG. 6.26. After bench cure, the model is placed in
prosthesis and surrounding skin under a
circulating air oven for 1 hour at 60°C.
FIG. 6.27. Curing of the latex skin is completed by

transferring model to 100°C air-circulating oven for 30


minutes.
104 MAXILLOFACIAL PROSTHETICS

FIG. 6.28. After removal from oven, model is placed in boiling water.
FIG. 6.29. Soluble plaster disintegrated in boiling water.
FIG. 6.30.
Remaining soluble plaster is mechanically removed from the model. FIG.
6.31. Cured acrylate skin removed from dipping model.

given mode of illumination. However, as the appears to change precisely as does that of
incident lighting changes from natural ■ human skin under all types of illumination.
daylight to indoor artificial light, the pros- Efforts to find exact spectropho- tometric
thesis may change in color differently from duplicates of human skin pigments by
skin and thereby appear unrealistic or even examining commercially available pigments
“dead.” Thus, a prosthesis should be tinted so for their spectrophotometric properties have
that it appears to change color in the same not been successful. However, judicious
manner as does the human skin. Colorwise, a combinations of several pigments have
lifelike maxillofacial prosthesis could be achieved representative curves duplicating
defined as one that has a distribution of that of human skin to a reasonable degree.
pigments equivalent to that of human skin and Such a curve is shown in Figure 6.33.
whose overall color Experiments to achieve
MATERIALS FOR PROSTHESES FABRICATION 105

FIG. 6.32. Completed foam filler with and without acrylate skin in place.

400 450 500 570 590 610 690

WAVELENGTH (MILLIMICRONS)

■H VIOLET [W8 GREEN EZZD ORANGE


BLUE 1 1 YELLOW h?:

FIG. 6.33. Actual reflectance curve of human skin (solid line) and of experimental synthetic pigment mixture
(dashed line).
106 MAXILLOFACIAL PROSTHETICS

lifelike skin coloration with such pigment


combinations are underway at this time.
The colors being used at the Walter Reed
Army Medical Center are inorganic pigments
dispersed in a vinyl solution and applied with
an artist’s airbrush (Fig. 6.34). The surface of
the foam filler is included as part of the
coloring technique. If the color of the silicone
foam does not blend with the required basic
shade, it is tinted with the appropriate shade.
Coloring the filler enables the acrylate skin FIG. 6.35. Two-component prosthesis fitted and
coloring to be kept to a minimum, thereby ready for color matching on the right. Color matching
has been completed on the left.
eliminating an opaque look and obtaining a
more natural, translucent skin effect.
The acrylate skin is pigmented on the inner it adhere to the patient’s skin. Various medical
surface to give an illusion of depth; therefore, grade adhesives have been used; however, to
the colors are applied in the opposite sense date, commercially available rubber cement**
from those on the foam filler. The veins and is applied to the periphery of the acrylate skin
detailed skin blemishes are reproduced first, and allowed to air-dry until it is only slightly
and a minimum of base skin color is then tacky. The prosthesis is properly positioned
applied. The periphery should be colored and the acrylate skin containing the adhesive
sparingly, thus allowing the patient’s skin to is firmly pressed against the patient’s skin,
produce a gradual matching blend. Continued which has been cleansed with alcohol to
checking is exercised during the coloring remove oil and thereby ensure good adhesion.
technique. The prosthesis is positioned on the The periphery is rubbed or burnished with a
patient during the fitting procedure for piece of cotton or gauze to ensure complete
periodic color matching, and the color is adaptation to the patient’s skin. For daily
applied gradually until the desired effect is application of the prosthesis, the patient is
achieved. A final protective coat of clear instructed to remove the old rubber cement
polyvinyl chloride solution is then applied (Fig. adhesive by holding the periphery of the
6.35). acrylate skin between thumb and forefinger
Final Fitting and Application of and using a rubbing motion to roll off the
Prosthesis. The prosthesis is applied over the cement. The patient is also reminded to
defect and an adhesive is used to make cleanse the area with alcohol where the
prosthesis is to adhere. At this final fitting,
the patient is also instructed how to position
the prosthesis, how to use seating guides, and
how to manipulate the prosthesis to engage
mechanical retention areas if such devices
have been incorporated into the design of the
prosthesis.
Advantages of the Two-component
Prosthesis
Although several techniques and materials
currently being used result in the successful
fabrication of prostheses, the two-

FIG. 6.34. Tinting is accomplished by use of artist’s ** Best Test white rubber paper cement, Union
airbrush. Rubber and Asbestos Company, Trenton, N. J.
MATERIALS FOR PROSTHESES FABRICATION 107

component system appears to offer advantages REFERENCES


worthy of consideration by the maxillofacial 1. Beder, 0. E.: Surgical and Maxillofacial Pros
prosthetist. thesis. University of Washington Press, Seattle,
The simple technique of dip molding allows 1959.
the easy repetitive fabrication of many 2. Braley, S., Director, Dow Corning Center for Aid
to Medical Research: personal communication.
acrylate skins with the same dipping model.
3. Bulbulian, A. G.: Facial Prosthesis. W. B. Saun
Thus, a patient may have several acrylate ders Company, Philadelphia, 1945.
skins that can be tinted for use under various 3a. Chalian, V. A.: Maxillofacial Prothesis. University
lighting conditions, as well as additional ones of Texas. Dental Branch, Houston, 1960.
for seasonal variations. 4. Desfasses, P.: L’oeware de Madame Ladd. Presse
Med. 1: 345-346, 1918.
Because of the comparatively light weight 5. Leonard, F.: Unpublished data.
of the prosthesis, a minimal amount of 6. Leonard, F., Nelson, J., and Brandes, G.: Vul-
mechanical retention is necessary, which is a canizable saturated acrylate elastomers. In-
decided factor in patient comfort. If a dustr. Engin. Chem. 50: 1053-1058, 1958.
7. Lepley, J. B.: Application of RTV silicones in
temporary prosthesis is necessary, the
somato prostheses. In manuscript.
acrylate skin can be extended beyond tender 8. Margetis, P. M., Urban, J. J., Nielsen, C. A.,
or painful areas, thus keeping the adhesive and Leonard, F.: Maxillofacial prosthesis. Shira,
from contacting any unhealed tissue. R. B., and Ailing, C. C.: The Management of
Therefore a patient can comfortably wear the Maxillofacial Injuries. The Williams & Wilkins
Company, Baltimore. In press.
prosthesis without interference with normal 9. Ottofy, L.: An artificial nose for a Chinaman.
healing. Dent. Cosmos, 47: 558-560, 1905.
In the case of nasal restorations when the 10. Ouellette, J. E.: A new method for spray coloring
patient wears spectacles, the close adaptation silicone elastomer. Technical Report 6808, U. S.
Army Medical Biomechanical Research
of the acrylate skin will not allow expired air
Laboratory, Washington, D. C., August 1968.
to escape around the periphery of the 11. Popp, H.: Zur Geschichte der Prosthen. Med.
prosthesis, thereby obviating fogging of the Welt, 13: 961-964, 1939.
lenses, particularly in cool weather. Also, since 12. Saunders, R. L.: The gunner with the silver
the acrylate skin is adherent at its periphery, mask. Ann. Med. Hist., 3: Suppl. 3, 283-287,
1941.
and because it yields with the human skin as 13. Simonds, H. R., and Church, J. M.: A Concise
the patient speaks or smiles, parting lines or Guide to Plastics, Ed. 2. Reinhold Publishing
lines of demarcation between the patient’s face Corporation, New York, 1963.
and the prosthesis are minimized. 14. Skinner, E. W., and Phillips, R. W.: The Science
of Dental Materials, Ed. 6. W. B. Saunders
Acknowledgment. The authors gratefully acknowl- Company, Philadelphia, 1967.
edge the photographic assistance of Mr. Alonzo Spencer, 15. Sproxton, F.: The rise of the plastics industry.
Photographer, United States Army Medical Chem. Industr. 57: 607-616, 1938.
Biomechanical Research Laboratory. 16. Upham, R. H.: Artificial noses and ears. Boston
Med. Surg. J. 145: 522-523, 1901.
7
IMPRESSION TECHNIQUES
Varoujan A. Chalian, Joe B. Drane, and S. Miles Standish

Intraoral Impression Techniques to which a piece of dental floss has been tied
The technique of obtaining accurate in- (Figs. 7.4 to 7.8).
traoral impressions is well known. The Larger defects with gross superior or lat-
materials, of course, should be of the best eral undercuts can be packed with 4 X 4 -
quality and should produce the greatest inch gauze squares, which can be more readily
accuracy with the greatest ease. retrieved should they be shoved into the
However, there are variables in the pa- depths of the defect. Gross defects pose few
tient’s preoperative or postoperative oral problems, whether undercuts exist or not.
anatomy which should be considered. Often These are easier to enter and exit from with a
there are incomplete palatal closures and reproduction of everything the clinician needs
fibrous bands with perforations into the (Fig. 7.9). A large cleft or postsurgical result
maxilla, nose, or sinuses. These possible may have aces- sory perforations which are
maxillary defects should be looked for prior to not immediately visible, especially if grafting
any impression attempt. They may occur in or previous surgical repairs have been
the labial vestibule, alveolar ridge, or hard or performed (Figs. 7.10 to 7.11). The defect may
soft palate, and they may be so inconspicuous also require some special addition or
as to be hidden from immediate view (Figs. correction to the impression tray. This is
7.1 to 7.3). Consequently, the air syringe, a easily done with periphery wax or hard stick
good mirror light, and sometimes a smooth, compound added to build the tup or out to
blunt probe may be used to explore flaps, capture the anatomy as needed (Fig. 7.12 to
wrinkles, and ridges to check for these hidden 7.14).
perforations. The prosthodontist acquires clinical
Once these small defects are found, they judgment with regard to which areas need
should be blocked out with moist cotton or blocking out prior to impressions. This
gauze. The gauze or cotton can be lubricated judgment is best obtained by careful visual
with petrolatum for easier insertion. The examination, and the guideline should be,
small palatal opening shown in Figure 7.1 “when in doubt about undercuts and im-
threatens to absorb the impression material pression removal, pack the defect.”
and leave the unwary prosthodontist with a
problem in removing all of the impression Extraoral Impression Techniques
material. This difficulty also exists with The art of obtaining a facial impression
infants. Accidental intrusion into the nasal- (mask) in preparing a working model or
maxillary sinus cavity can be prevented by moulage is essential to a well-fitting, well-
packing the opening with cotton fabricated facial prosthesis. Making the
IMPRESSION TECHNIQUES 109

FIG. 7.1. A small maxillary defect. FIG. 7.2. An alveolar ridge and maxillary palatal
defect.

FIG. 7.3. A large maxillary defect. FIG. 7.4. Resected area packed.

facial impression requires much time and but not very much detail, can be obtained with
energy in preparing the patient and the orthopedic plaster bands or impression
materials and in carrying out the tech- compound. The model from these two
nique.The basic steps in obtaining an accurate materials can be used to form a lead ra-
impression are outlined in this chapter. diation-protector shield.
The materials vary according to the end The technique illustrated uses reversible
result desired. If great accuracy is needed, hydrocolloid because it is accurate and easily
reversible hydrocolloid or plaster of Paris is manipulated. Since this technique is
best. If the prosthodontist needs good detail adaptable to all materials, only one procedure
quickly, he can use irreversible hydrocolloid or is described in detail. However, use of the
silicone. General contours, other materials is described briefly and
illustrated below.
110 MAXILLOFACIAL PROSTHETICS

FIG. 7.5. Front view. FIG. 7.6. Impression in place.

FIG. 7.7. Impression removed with packing in place. FIG. 7.8. Model poured.
IMPRESSION TECHNIQUES 11

FIG. 7.9. A large single palatal cleft. FIG. 7.12. Impression tray altered to cover cleft more
FIG. 7.10. Further examination reveals a second extensively.
fenestration. FIG. 7.13. The impression of large and small defects.
FIG. 7.11. The small undercut defect packed; the large FIG. 7.14. Model poured.
one left alone.
112 MAXILLOFACIAL PROSTHETICS

FIG. 7.15. A, the patient prone and draped. B, the nostrils are blocked with cottop. C, an airway is maintained
with two straws, one in each commissure. Petrolatum is applied to the eyebrows and eyelashes. D, area to be
reproduced is boxed out in red wax strips. The subject is now ready to have the impression made.

Patient Preparation Before Facial Im- tion, or other problem occur during application
pression (Fig. 7.15) of the material. The face or external borders of
Position of Patient. The patient should be the defect or that part to be reproduced should
either reclined in a dental chair or, better, be boxed in with boxing wax held in place by
lying on a table with his head slightly an assistant. This confines the material and
elevated. This position achieves a relaxed avoids a mess. Last, or perhaps first, an
muscle tone of the face and easier material adequate airway needs to be considered. If the
application. Also, gravity helps to stabilize the mouth or nose enters into the impression, care
material. is needed to provide unhurried breathing and
Preparation of Patient. It is helpful and prevent anxiety in the patient. This airway
protective if the patient is draped with a sheet can be maintained with straws into the
and the hair is boxed out by the use of cloth nostrils or mouth or, with care, the impression
towels. This leaves uncovered only the material can be gently and carefully applied to
essential areas to be reproduced. The face the nose up to but not including the nares,
should be free of make-up and eyeglasses. The with a small paintbrush.
eyelashes, eyebrows, moustache, beard, etc.
Reversible Hydrocolloid (Fig. 7.16)
should receive a coating of petroleum or cocoa
butter as a suitable separating medium. The The hydrocolloid can be applied with a
area of the defect may need undercuts blocked small 1- to 2-inch paintbrush to all areas,
out with wet gauze or cotton. The deepest area building up the thickness until the entire
of the defect may be better filled in with gauze surface is covered with at least 3 mm of this
or cotton for a safety precaution. At times it is material.
well to tie a string to the blocking out material Once the desired thickness is applied, but
so that it can be retrieved rapidly should an before it completely sets, paper clips
unexpected swallowing, aspira
IMPRESSION TECHNIQUES 113

FIG. 7.16. A, thinner reversible hydrocolloid is applied to the face, using a l‘/ 2-inch paint brush. B, building up
uniform application, with L-shaped clips next to be added. C, whole area ready to receive the plaster of Paris. D,
plaster applied. E, mask is removed.
114 MAXILLOFACIAL PROSTHETICS

are bent into an L shape, and one end is Plaster of Paris (Fig. 7.18)
imbedded into the hydrocolloid for rein- This age-old material gives excellent
forcement. Upon cooling, in approximately 5 accuracy of slight facial defects, for example,
minutes, plaster of Paris is applied to the area in moulages before and after orthodontic
to a depth of lA to ¥2 inch at the borders. This treatment or before and after plastic
unites the hydrocolloid via the paper clips to surgery.<■ However, it is not to be used when
the firm backing of plaster. When the plaster the defect is fresh, bleeding or large, or where
has set and cooled, the subject is asked to deep undercuts exist and need to be
wrinkle his face to loosen the impression, reproduced. Also, the material should be more
keeping in mind the location of the undercuts. thinly mixed than for intraoral use; to
With a quick tug, the boxed out area increase the flow and adaptation, plaster of
containing the impression is removed. After Paris is painted on the face. Since the
removal, the accuracy should be checked, and material is exothermic during the initial
the impression is placed in cool water to setting phase, a light petrolatum coating
prevent cracking of the hydrocolloid under the should be applied to the whole area to be
dental plaster’s heat. The impression, or mask, reproduced. Glycerine as a separating medium
is then poured into stone to form the moulage. is applied to the plaster mask before the
Variations from the above procedure arise model is poured.
when using plaster of Paris compound or
orthopedic plaster bands. Since less detail is Orthopedic Plaster Band (Fig. 7.19)
necessary, these materials require no paper This easy-to-use material is on hand in all
clips or plaster backing to remove the unit in hospitals for emergency use. The pieces are
one piece. Also, fixing before pouring is cut to the width of the face while they are still
necessary only with reversible hydrocolloid or dry. For a whole face, six pieces overlapped
plaster. are usually necessary. These are dipped in
water and positioned over the lubricated face.
Irreversible Hydrocolloid (Fig. 7.17) Once set, the rough mask is removed and
painted with a separating medium of glycerin
This alginic acid derivative from kelp or petrolatum before being poured in stone.
seaweed requires no fixing and is instantly The resulting moulage is fine for constructing
available to use, and the mixing technique is radiation-protector shields.
known to all prosthodontists. There are a few
variations in the use of irreversible Impression Compound (Fig. 7.20)
hydrocolloid which should be known. This thermoplastic material is best used for
One variation from intraoral usage is that a rapid but rough impression which is to be
the ratio of powder to water is different. For poured only once. After several cakes of
every scoop of powder, 1 ¥2 to 2 parts of cool compound (three to five) have been warmed
water should be used. This enables the and tempered, they are flattened in the
material to flow readily into all undercuts and prosthodontist’s hands to the approximate size
depressions. A second variation in usage of the facial area and laid over this area. Then
compared to reversible hydrocolloid is that it the compound is pressed lightly to conform to
is not applied with a brush; it is poured over the face.
the face and pushed or directed to the desired A moulage obtained in this way is useful
areas with a brush or spatula. After being re- when a radiation-protector shield is to be
moved from the face, this impression should be made.
rinsed clean of any debris and immediately
Silicone (Fig. 7.21)
poured up, using stone or another material of
choice. Room temperature-vulcanizing (RTV)
silicone is an excellent material for ob-
IMPRESSION TECHNIQUES 115

FIG. 7.17. A, irreversible hydrocolloid applied and L-shaped paper clips inserted. Note airways. B, plaster of
Paris is applied after irreversible hydrocolloid has set. C. all clips to be covered. D, plaster has hardened, and
operator asks the patient to wrinkle his face as the whole impression is removed. E, cotton plugs and straws are
removed in one complete impression.
116 MAXILLOFACIAL PROSTHETICS

FIG. 7.18. A, plaster of Paris, mixed creamy and thin, is poured and brushed carefully onto the face. B, brushing.
C, build-up. D, no paper clips, only plaster added and built up. E, plaster is allowed to harden initially; it should
be removed before its exothermic stage is reached.
FIG. 7.19. A, orthopedic plaster band material; B, cut in narrow strips; C, dipped into cool water, D, applied to
face and smoothed to the subject’s contours. E, additional layers built up. F, build-up completed. G, material
allowed to harden. H, finished impression.
117
118 MAXILLOFACIAL PROSTHETICS

FIG. 7.20. A, a large biscuit of denture compound is warmed, flattened, and applied to the face. B, care must be
exerted in its application so as not to distort the face. C, facial contours followed. D, negative removed. E, good to
fair reproduction of gross structures is achieved.
IMPRESSION TECHNIQUES 119

8 'U8Tld
382
^Jedical
Grade
Elastomer

FIG. 7.21. A, medical grade silicone 382 material. B, material applied directly from refrigerated jar with spatula.
C, thin build-up. D, thin layers of gauze are used to reinforce this material. E, this gauze is applied all over, lightly
pressing it into place (F), then more silicone is added. Five minutes are needed for setting before removal.
120 MAXILLOFACIAL PROSTHETICS

FIG. 7.22. A, impressions made with four mediums: reversible hydrocolloid, irreversible hydrocolloid, plaster of
Paris, and orthopedic plaster band. B, moulages made from the four impressions; in the same ortler.

taining a clear, detailed reproduction of the with the four materials described, as well as
face. However, since a large amount of the moulages made from those impressions.
material is necessary to cover the face, other
factors should be considered before silicone is REFERENCES
used solely. These other factors are the cost, 1. Chalian, V. A.: Maxillofacial prosthesis. Univer
the number of moulages desired, and the sity of Texas M. D. Anderson Tumor Institute,
storage of the mask. This material is more Houston, 1960.
expensive to use than any other. However, 2. Dykema, R. W., Cunningham, D. M., and John
ston, J. F.: Modem Practice in Removable Partial
many pours can be made if needed, and it can Prosthodontics. W. B. Saunders Company,
be stored easily with little deformation or Philadelphia, 1969.
distortion. 3. Terkla, G. L., and Laney, W. R.: Partial Den
tures. The C. V. Mosby Company, St. Louis, 1963.
Comparison of Results
Figure 7.22 shows the impressions made
8
RETENTION OF PROSTHESES
Varoujan A. Chalian, Robert L. Bogan, and
John W. Sandlewick

In maxillofacial prosthetics there exists a tromolar, labial, septal, posterior nasal


broad variety of types and methods for gaining pharyngeal, or anterior nasal spine areas.
retention, stabilization, and immobilization as Large alveolar ridges and high palatal
required. Close evaluation of a case with the vaults generally provide more retention than
surgeon before and during surgery helps in flatter ridges. This anatomy may still not
finding means to create irregular defects for provide a completely stable replacement,
enhancing anatomic retention. depending upon the presence of lower natural
The following methods of retention are teeth or previously acquired undesirable
discussed for intraoral and extraoral pros- denture habits bv the patient (Fig. 8.1).
theses. In the larger defect cases encompassing
both the maxilla and mandible, as in a
Intraoral Prosthesis and Its Retention
commando operation, skill, ingenuity, and the
Anatomic Retention operator’s thoroughness, coupled with the
patient’s adaptive ability, can result in a “one
Intraoral retention includes the use of both
of a kind” successful prosthesis.
hard and soft tissues, that is to say, teeth and
Additional aids to anatomic retention
mucosal and bony tissues. The success of
include proper occlusion, proper post dam, and
intraoral retention relates to the size and
surface adhesion.
location of the defect and the outcome of the
surgery. Mechanical Retention
For instance, a small defect of the palate Under this category, the operator has a
can be closed by a conventionally designed myriad of devices and proven techniques to
removable bridge. This may merely provide an consider and use as the case demands.
obturation benefit or it may be a combination Temporary Mechanical Retention. This
of obturation plus a replacement for missing may be a stainless steel wrought wire of 18-
teeth. Further, it may have a speech bulb gauge size which can be quickly adapted to a
extension added to a pharyngeal extension, cast of the remaining teeth to retain the
and then it would be a combined obturator, temporary prosthesis during the healing
bridge for mastication, and speech therapy period. Some wire clasps come preformed and
appliance. can be readily incorporated into the acrylic
Anatomic undercut areas are a welcome palate of an obturator or saddle in a lower
feature in the postsurgical case. These may be prosthesis or a previously existing denture.
found in the palatal area, cheek, re-
122 MAXILLOFACIAL PROSTHETICS

FIG. 8.1. A, melanoma of the palate. B, postsurgical view of the excised palate with anterior ridge intact for
retention purpose. C, obturator inserted and retained by existing soft and hard tissues. D, prostheses in occlusion.

Other preformed stainless steel wire clasps rib graft or fractured mandibular segments
include Adams, Arrowhead, Akers, Roach, or during healing. (Fig. 8.3).
Hawley labial wires. Permanent Mechanical Retention:
Preformed stainless steel bands or crowns Cast Clasps. The most common method for
may be adapted to a child or adult to increase retaining a prosthesis uses a cast metal clasp
retentive form of a mutilated or conical tooth. which enters an undercut. The properly
Extra soldered lugs or bands with prewelded designed and fabricated clasp will provide
brackets can be used to provide undercuts on stability, splinting, bilateral bracing, and
these crowns for better clasp retention (Fig. reciprocation, as well as retention.
8.2). The cast clasp is most successfully adapted
When a maxillofacial prosthetist is not to a mouth previously conditioned to receive
available, an old denture can be wired in place it, i.e., a mouth with well-designed, surveyed,
to obturate a maxillary hemisection. This wire and fitted castings over the abutment teeth.
fixation or retention is internal to the This metal extension of the removable
infraorbital or zygoma bones. prosthesis is best referred to as the direct
Intraoral temporary retention may also be retainer. By its construction, the direct
illustrated by the construction and insertion of retainer has contact with
a tantalum tray to help retain a
RETENTION OF PROSTHESES 123

and so engages the abutment tooth to extend greatly enhances the flexibility of a clasp arm.
around it by more than 180 degrees to resist Material of Retentive Clasp Arm. Since a
displacement caused by reasonable dislodging wrought clasp is a fibrous structure, it is more
forces. flexible than a cast clasp with it more brittle
The clasp extends into an undercut or crystalline structure. Also, some cast metal
infrabulge area of the supporting tooth in alloys are inherently more flexible than
order to gain retention. It prevents damage to others. In comparing a representative type IV
the supporting tissues of the abutment teeth partial denture gold casting with an example
only if it is carefully designed as a part of the of the cobalt-chrome family of alloys, a marked
partial denture. difference in the flexibility of the two
Various qualities of clasp design influence materials is noted.
the degree of retention. These include the Contour of Retentive Clasp Arm. Two
length, the diameter, the taper, the material, factors exert an influence here. A clasp arm
and the general contours of the retentive which is half-round, as most cast clasp arms
clasp, as well as the depth of the undercut are, is more flexible than a round clasp arm of
used. the same diameter. The contour of the clasp
Length of Retentive Clasp Arm. The ability arm relative to its plane in space can also be a
of a clasp arm to flex and relax as it passes factor. A clasp arm
over the height of contour and come to rest in
an undercut area is directly proportional to
the cube of its length. As an example, a clasp
arm that is increased from 5 to 6 mm in
length, a 20% change, will have its load
deflection rate amplified bv approximately
75%.
Diameter of Retentive Clasp Arm. The
influence of this factor has been calculated to
be inversely proportional to the fourth power
of the diameter. Thus, a very small increase in
the cross-sectional diameter of a clasp arm can
significantly influence its ability to flex and
relax.
Form of Retentive Clasp Arm. A tapered
clasp arm has greater flexibility than one of FIG. 8.2. Orthodontic bands and prewelded brackets to
uniform contour. Proper tapering retain temporary prosthesis.

FIG. 8.3. Bilateral perforated tantalum trays used for immobilization of mandibular segments.
124 MAXILLOFACIAL PROSTHETICS

that traverses the tooth surface from the Although it is certainly not mandatory, it is
minor connector on one proximal aspect to the usually more convenient to locate the retentive
point of retention near the opposite proximal undercut on the buccal surface of the
surface has both a horizontal and a vertical abutment tooth. Reciprocation then is
component to its contour. As this clasp is accomplished via a guiding plane opposite the
asked to deform and pass over a height of retentive undercut on the abutment tooth in
contour, deformation occurs in the horizontal combination with a more rigid clasp arm on
component by a stretching of the molecules on the direct retainer. This latter clasp arm
the side adjacent to the tooth and by their contacts the plane at the same time when the
compression on the side away from the tooth retentive clasp arm contacts the suprabulge
surface. This requires a greater force than surface, and it remains in continuous contact
does the torsional movement or slipping of until the partial denture is completely seated.
molecules that occurs in the vertical Occlusal Rest. This part of the direct
component. Thus, the path of the clasp arm retainer is that unit of the partial denture
across the tooth surface may affect its load frame designed specifically to fit within a
deflection rate. prepared rest seat in the abutment tooth. It
Depth of Undercut Employed. This factor serves several purposes: to provide a positive
influences the amount of deformation point of orientation between the partial
necessary to pass over the height of contour on denture and its abutment; to resist overseating
an abutment tooth. It is perhaps the most the partial denture and subsequent
frequently varied factor in the establishment impingement of the periodontal tissues; and to
of retention. serve as a point for the transmission of stress
Reciprocating Clasp Arm. A retentive to the abutment tooth as nearly along its long
clasp is designed to deform as it passes over axis as possible.
the height of contour on the abutment tooth Although a rest seat may take various
and to return to its original passive state upon forms, it is customarily located on the occlusal
coming to place in the infrabulge area. The surface of posterior abutment teeth or on the
lateral component of force necessary to cause lingual surface of anterior abutments.
the clasp arm to flex is counteracted by an
Types of Extracoronal Direct Retainers
equal and opposite force against the tooth
surface. Since the abutment tooth is Cast Circumferential Clasp (Fig. 8.4).
suspended by a series of ligaments that permit The cast circumferential clasp, or Akers clasp
minute amounts of physiologic movement, a as it is sometimes called, is one of the most
part of this overall action is compensated for frequently used clasps because of its
by the displacement of the tooth. This reliability, ease of fabrication, and
movement occurs each time the partial adaptability. It is particularly indicated in
denture is seated in place and each time it is situations in which the prosthesis will be
removed. Repeated lateral displacement of totally tooth-supported and tilting leverages
this magnitude to the abutment tooth would will not be encountered, in modification
soon become pathologic and result in loss of spaces, or on the side of the arch opposite a
support and stability. unilateral edentulous space. It should be
This situation is kept under control by avoided on abutments adjacent to a free end
offering reciprocating support to the tooth on saddle replacement.
the side opposite the retentive clasp arm. This Cast-wrought Combination Circum-
support should be located on a line directly ferential Clasp (Fig. 8.5). This is an
opposite the retentive clasp tip and should be adaptation of the first clasp form described,
continuous throughout the period of time that and it substitutes a contoured wrought wire
the retentive clasp tip is applying a force for the cast clasp on the retention side. It may
against the abutment tooth. be used whenever the fully cast
circumferential clasp is indicated
RETENTION OF PROSTHESES 125

BUCCAL

PROXIMAL
FIG. 8.4 (top). Cast circumferential clasp.

PROXIMAL

FIG. 8.6 (bottom). Cast Roach-Akers combination clasp.


126 MAXILLOFACIAL PROSTHETICS

DISTAL LINGUAL
FIG. 8.7. Mandibular molar ring clasp and modification.

but, in addition, it may be used in a free end use in the anterior region because of its more
saddle situation. Because of its greater ability esthetic appearance. It has greater
to flex in any direction, tilting leverages are adaptability than many of the cast clasps and,
more likely to be dissipated without adverse because of its line contact with the enamel
forces being directed toward the abutment surface, it has less tendency to catalyze
tooth. recurrent decay.
This clasp is somewhat more complicated T-Bar Cast Circumferential Combi-
for the technician to fabricate, and it is nation or Roach-Akers Clasp (Fig. 8.6).
slightly more susceptible to distortion by the This clasp provides a cervical approach to the
patient and more likely to fracture after tooth surface and affords the opportunity to
repeated usage. It lends itself well to take advantage of an existing disto-
RETENTION OF PROSTHESES 127

FIG. 8.8. A, Baker snap-on attachments soldered to the cast frame work. B, cross-arch splinting, using 11-
gauge bar.

buccal or distolabial undercut. It is indicated made. This attachment is formed in the wax
in either unilateral or bilateral distal pattern, using a specially shaped mandrel
extension situations. mounted on the parallelometer. A reciprocal
It has the reputation of treating the arm is always necessary.
abutment tooth more kindly in that situation Snap-on Attachment (Fig. 8.8). This is
in which rotation of the base, under load, is a also a preformed precious-metal precision
problem. Unfortunately, it also is noted for piece designed to retain and to stabilize a
creating a food trap that requires meticulous prosthesis. A Baker bar or Anderson bar is the
attention by the wearer. rod connecting two abutment crowns, and the
Ring or Ring-around Clasp (Fig. 8.7). clip engages this rod.
This clasp form also uses an undercut This attachment is usually used in com-
adjacent to the edentulous area but reaches it bination with other retentive means such as a
by circumnavigating the tooth. It is especially clasp, precision attachment, or thimble-
applicable for use on lone-standing molar telescoping crown.
abutments distal to the edentulous space that Overlay (Telescoping) Crown and
are tipped or tilted to an exorbitant degree. Thimble Crown (Fig. 8.9). This is often used
There are other clasp forms, and modifi- when an overlay denture is planned or an
cations thereof, that lend themselves to extremely malposed tooth is needed for
certain situations; however, those illustrated stability but is not considered for orthodontia.
can serve adequately as a rather complete It is also used when a major change in the
armamentarium for the restorative dentist. vertical or centric dimension is indicated, as in
Prefabricated Precision Attachments. cleft lip-cleft palate, prognathic mandibles or
These attachments can be placed into cast resected mandibles.
crowns for the best in esthetic and mechanical Magnets (Fig. 8.10). Magnetized metal
retention. Construction problems exist here, discs in denture teeth or magnetized metal
and much more precise measures are rods can be inserted into the edentulous ridge
necessary for success. and the overlying saddle extension or can be
These preformed attachments are most easily inserted into the dentures themselves.
useful in rehabilitating cleft lip and cleft Magnetic retention is at the most an aid
palate cases. They can be used with or but not of itself an effective method to
without a reciprocal arm. properly retain a nonstabile denture. This
Semiprecision Attachments, Custom- consideration may be useful in a hemimax-
128 MAXILLOFACIAL PROSTHETICS

FIG. 8.10. A, stock repelling magnets. B, magnets


invested and waxed under the occlusal surfaces.

partial retention for many loose or perio-


dontally involved teeth. This retentive means
can be used when most other methods are
ruled out. However, other methods should be
considered first.
Intermaxillary “George Washington”
Springs (Fig. 8.12). These come preformed
and can be inserted into an upper and lower set
of dentures to help stabilize them on the ridges
during function.
Auxiliary Retentive Devices. These
FIG. 8.9. A, thimble crowns cemented on prog- natic
include buccal-lingual continuous clasp, valve
patient. B, telescoping crowns imbedded in the denture.
seal, Fourchard wing device for clefts, guide
C, superimposed denture inserted in the mouth to
correct the vertical and centric dimensions. (Courtesy of
planes, surface adhesion, and denture surface
Dr. J. Borkowski.) adhesion devices such as Porceline and
Durabone.
illectomy case or extremely atrophied ridges. Screws. These are specially made custom
Gate Type or Swing Lock Device (Fig. parts.
8.11). This retentive aid helps gain Implants. Implants include tantalum
RETENTION OF PROSTHESES 129

aid retention when the surgical wound is


large, the palate is flat, the anterior-posterior
lateral septal wall is not undercut but rather
angles away from the natural palate, the
maxillary tuberosities are nonexistent, the soft
tissue undercuts in the area of surgery are
missing, or "the patient’s salivary flow is
diminished due to pre- and postradiation
therapy.
Occlusion. The proper cusp height and
fossa depth as dictated by a healthy mandible
and related to the motion sequence recording
from the healthy temporomandibular joint can
also assure denture stability and retention.

Extraoral Retention
Anatomic Retention
This necessitates the use of both hard and
soft tissues of the head and neck area.
Retention of the dynamic extraoral area
depends on many factors for a successful end
result. These factors are related to the location
and size of the defect, tissue mobility or lack
thereof, undercuts, and the material weight of
the final prosthesis.
Hard tissues act as a base against which
to seat the prosthesis and to provide a better
seal of the prosthesis with the use of an
adhesive. Examples would be any bony wall of
a defect with which part of the prosthetic
device will come in contact or a cartilaginous
remnant of the ear.
Soft tissues prove to be more troublesome
because of their flexibility, mobility, lack of a
bony basal support, lower resistance to
displacement when a force is applied,
deficiencies as a base for firmly securing the
surgical adhesive during cementation, and the
physiologic nature of squamous ectodermal
tissues. An example of this would be the
orbital prosthesis (Figs. 8.13 and 8.14).
FIG. 8.11. A, close-up view of swing lock device. B,
Mechanical Retention
tissue side view of obturator with swing lock. C,
obturator is retained in the mouth by a gate type de-
Additional retention is mostly needed in
vice.
unusual cases such as large defects involving
half of the face or heavily radiated tissues
when the use of adhesives is not feasible. It is
tray, acrylic mandible and wire, and in-
advisable to use eyeglasses as an indirect
traosseus wire.
mechanical retention which at
Suction Cups. Inflatable balloon suction
cups are used for maxillary resection.
Adhesives. These become necessary to
130 MAXILLOFACIAL PROSTHETICS

FIG. 8.12. A, “George Washington” spring inserted in the buccal flanges of maxillary and mandibular den-
tures. B, maxillary obturator is retained by “George Washington” springs.

FIG. 8.14. A, right orbital exenteration. B, tissue side


FIG. 8.13. A, left orbital exenteration. B, cross- of orbital prosthesis and ocular prosthesis. C, orbital
section of orbital prosthesis and tissue side view of prosthesis retained bv tissue undercuts and auxiliary
prosthesis. C, orbital prosthesis inserted in the defect. nasal extension.
RETENTION OF PROSTHESES 131

the same time hides the margins of the


prosthesis (Fig. 8.15). The eyeglasses should
be free of and not a part of the prosthesis. In
addition to eyeglasses, an elastic strap may be
of use to hold the glasses on and help retain
the prosthesis (Fig. 8.16).
Magnets. These may be imbedded in a
nasal prosthesis or orbital prosthesis to help
secure it to a maxillary obturator which may
be in contact with the above prosthesis.
Snap Buttons and Straps. These are also
used on a large extraoral prosthesis.
Adhesives
Retention can be enhanced and may rely
entirely on the use of a surgical grade
extraoral adhesive. In general, each material
provides its own adhesive because of its
inherent physical and chemical properties.
The adhesives aid retention, marginal seal,
and border adaptation. This secures the
prosthesis against accidental dislodg- ment.

FIG. 8.15. Eyeglasses are seated over the auxiliary


nasal extension. Also note lateral button and rod for
additional support when adhesive is contraindicated.

FIG. 8.16. A, extensive left facial defect. B, facial prosthesis retained by eyeglasses, button, rod, and nasal
extension.
132 MAXILLOFACIAL PROSTHETICS

Combination of Anatomic, Mechanical, and Denture Prosthesis. W. B. Saunders Company,


Adhesive Retention Philadelphia, 1965.
2. Chalian, V. A.: Maxillofacial Prosthesis. Univer
Large facial replacements need to use all sity of Texas M. D. Anderson Tumor Institute,
available means of retention. The prudent use Houston, 1960.
of some or all available retentive means plus 3. Dykema, R. W., Cunningham, D. M., and John
any original improvisation by the ston, J. F.: Modern Practice in Removable Partial
Prosthodontics. W. B. Saunders Company,
prosthodontist can lead to better stability and Philadelphia, 1969.
retention. 4. McCracken, W. L.: Partial Denture Construction.
The C. V. Mosby Company, St. Louis, 1960.
REFERENCES 5. Terkla, G. L., and Laney, W. R.: Partial Den
1. Applegate, 0. C.: Essentials of Removable Partial tures. The C. V. Mosby Company, St. Louis, 1963.
9
INTRAORAL PROSTHETICS
Varoujan A. Chalian, Joe B. Drane, and S. Miles Standish

Maxillary Prosthetics Obturators for Congenital Defects of Palate


Probably the most common of all intraoral For congenital palatal defects, three types
defects are in the maxilla, in the form of an of obturators are available. To close an
opening into the nasopharynx. The prosthesis opening of the hard palate, a simple base plate
needed to repair the defect is termed a type helps to correct the swallowing, feeding,
maxillary obturator. and speech. The second type is an obturator
with a tail, consisting of a speech appliance or
Obturators
a speech aid prosthesis which restores soft
An obturator (Latin: obturare, to stop up) is and hard palate defects and a velopharyngeal
a disc or plate, natural or artificial, which extension which corrects the speech. The third
closes an opening. Our concern is with an type is an overlay or superimposed denture
apparatus designed to close an unnatural (see also Chapter 21, Part 5).
opening or defect of the maxilla such as a cleft
Obturators for Acquired Defects
palate or partial or total removal of the
Various obturators are used for acquired
maxilla for a tumor mass.
defects. For postpathologic and posttrau-
The obturator fulfills many functions. It
matic palatal defects, a base plate type
can serve in lieu of a Levin tube for feeding
obturator is used which can be temporary or
purposes. It can be used to keep the wound or
permanent. Postsurgical obturators include:
defective area clean, and it can enhance the
(1) the immediate temporary obturator (also
healing of traumatic or postsurgical defects. It
surgical obturator), (2) the temporary
can help to reshape and reconstruct the
obturator (also treatment or transitional), and
palatal contour and/or soft palate. It also
(3) the permanent obturator.
improves speech or, in some instances, makes
The immediate temporary obturator is a
speech possible.
base plate type appliance which is constructed
In the important area of esthetics, the
from the preoperative impression cast and
obturator can be used to correct lip and cheek
inserted at the time of resection of the maxilla
position. It can benefit the morale of patients
in the operating room.
with maxillary defects. When deglutition and
The temporary obturator is constructed
mastication are impaired, it can be used to
from the postsurgical impression cast which
improve function. It reduces the flow of
has a false palate and false ridge and
exudates into the mouth. The obturator can be
generally has no teeth. The closed
used a a stent to hold dressings or packs
postsurgically in maxillary resections.

133
134 MAXILLOFACIAL PROSTHETICS

bulb extending into the defect area is hollow. from the buccal flange areas to the zygomatic
The permanent obturator is constructed or orbital process of the maxilla (Fig. 9.1). No
from the postsurgical maxillary cast. This extension into the operated area is needed at
obturator has a false palate, false ridge, teeth, this time and, if preoperative casts are
and a closed bulb which is hollow. unobtainable, then the old denture is a
General Considerations Concerning Bulb welcome substitute. Later, at the surgeon’s
Design preference, usually in 1 to 3 weeks, the
immediate temporary device is removed, and
1. A bulb is not necessary with a central
the prosthodontist may proceed with
palatal defect of small to average size where
postsurgical impressions to fabricate a
healthy ridges exist.
temporary obturator (Fig. 9.2).
2. It is not necessary in the surgical or
The permanent obturator for the eden-
immediate temporary prosthesis.
tulous patient is constructed as follows. After
3. It should be hollow to aid speech res-
a postsurgical observation and adjustment
onance, to lighten the weight on the un-
period of 2 to 6 months,, an impression of
supported side, possibly to provide facial
irreversible hydrocolloid is again made. A
esthetics, and to act as a foundation for a
custom-made tray is then constructed which is
combination extraoral prosthesis in com-
designed to fit the cast obtained from this
munication with the intraoral extension.
primary impression. .
4. It should not be so high as to cause the
It should be emphasized that fistulas or
eye to move during mastication.
smaller defects must be blocked out prior to
5. It should be one piece, if possible, to
any impression attempt. The larger defects are
provide better color matching and maximal
easier to reproduce, and accordingly there is
patient acceptance.
less chance that a fragile por-
6. It should always be closed superiorly.
7. It should not be so large as to interfere
with insertion if the mouth opening is
restricted.
Obturators for Edentulous and Dentulous
Mouths
The maximal cooperation between surgeon
and prosthodontist is necessary to achieve soft
and/or hard tissue retention which permits
better construction of the obturator.
Prior to surgery, the patient is seen by both
the surgeon and the maxillofacial
prosthodontist for clinical examination and
radiographic evaluation. The case is evalu-
ated* from both the surgical and postsurgical
standpoints as a cooperative treatment of the
disease or deformity.
Procedure for Edentulous Mouth. It is
sometimes helpful if the edentulous patient
has his own upper denture. The first
immediate temporary or surgical obturator
needs only to close the wound, act as a stent,
and provide some physiologic function.
Generally, the upper denture is wired
FIG. 9.1. Patient’s denture wired in place from
lateral orbital process as immediate temporary obtu-
rator.
136 MAXILLOFACIAL PROSTHETICS

tion of impression material will break off and given a palatal shape. A false lid is made from
possibly be aspirated into the bronchi. autopolymerizing acrylic and perforated
A final impression now is made with a around the edges. This is set aside while the
rubber-base material. This is boxed, poured, case is flasked and processed. The lid is then
and trimmed, and the periphery is outlined added to the case to close the palatal portion
with a pencil. Any undesirable soft and hard of the hollow bulb, and the lid is sealeddo the
tissue undercuts are blocked out, but these case with quick-curing resin. This is followed
will be salvaged later to help increase the by the usual finishing and polishing of the
chance of better retention. For the trial fitting case (Fig.
and jaw records, all of the retentive areas are 9.3) .
not completely used so that the case can be Procedure for Dentulous Mouth (Fig.
withdrawn from the stone working cast. 9.4) . The impression of the maxilla is made
The stabilized baseplate is made and prior to surgery and boxed and poured in
flowed into the defect area. At this stage, a stone to provide the master cast. The surgeon
wax lid is fitted over the defect area to leave it is asked to mark the approximate resection
hollow and to provide the effect of a complete line on the case. Next, the teeth in the
palate. Then a wax occlusal rim is adapted and “resection area” are cut away with an emory
added to prepare the case for centric and cloth on a dental lathe, leaving the alveolar
vertical records. ridge intact. In this case, the right central
Because of the lack of a resistant base incisor is removed, with the healthy ridge
(palate) after surgery, the weight of the being preserved as a shoulder for the rest area
baseplate, the ascending pressures upon of the future obturator.
contact of both occlusal rims, and the lateral The deformed left palate and ridge in the
tilt, the usual tracing devices are not used. tumor area are reshaped to normal contour.
These records can be obtained by using Wire clasps are then adapted to the remaining
denture adhesive to stabilize the bases, then right first bicuspid and second molar, and the
trimming the wax rims according to the lip cast is waxed and processed for the baseplate
line, the line from ala to tragus, phonetics, type of immediate temporary obturator. After
trial and error, and, of course, live experience deflask- ing, polishing, and cold sterilization,
in denture construction. the immediate temporary obturator is ready
With the resulting records, the casts are for the surgeon.
mounted on a semi-adjustable articulator such The team approach is essential for suc-
as the Hanau, Adeler or Dentatus. The teeth cessful surgery. Immediately after partial
are selected and set into the rims. resection of the left maxilla, the prostho-
The wax try-in of the denture-obturator dontist inserts the immediate temporary
may require a longer than usual visit, de- obturator, and the surgeon closes the wound.
pending on the accuracy of the previous record The immediate temporary obturator is a very
visit. Extreme accuracy is rare, even with simple prosthesis, but it plays a most
unoperated patients. So many variables and important role in the treatment of tumors by
physical side effects can exist postoperatively holding the pack in the antrum, correcting the
(such as trismus, flat ridges, xerostomia, loss speech defect so that the patient can
of nerve innervation, to name a few) that this communicate with his doctors, nurses, and
wax trialfitting visit is likely to be the most relatives, and helping him to eat and drink.
important of all. After this immediate temporary obturator
Finally, the case is ready for laboratory has been worn for 7 days to 6 weeks,
processing. The false ridge area is filled in and depending on the individual healing of
contoured with the teeth. The palatal defect is wounds, the postoperative primary impression
filled in with modeling clay and is made with a stock tray and irre-
FIG. 9.3. A, tissue side of the obturator with the hollow bulb and normal complete mandibular prosthesis. B,
permanent obturator inserted in the mouth. C, obturator and mandibular denture in occlusion.
137
FIG. 9.4. A, palatal view, showing preoperative lesion of the left maxilla. B, surgeon marking approximate
resection line on the master cast. C, trimming of the teeth on the resection side. D, palatal view of immediate
temporary obturator. E, tissue side of immediate temporary obturator. F, resection of left maxilla. G, imme diate
temporary obturator inserted.
138
INTRAORAL PROSTHETICS 139

versible hydrocolloid. The cast is used for the The clasps and framework are cast and
construction of a custom-made acrylic tray seated on their respective teeth, in this case,
with a high bulb area on the resected side. the maxillary right lateral incisor, first
The tray is then tried in the mouth. bicuspid, and second molar.
Depending on the type of impression material Procedure for Two-piece Hollow Obturator
to be used, it is either perforated or coated (Fig. 9.6)
with adhesive for retention. The irreversible
At this point, the most frequently used
hydrocolloid or polysulfide rubber base
technique for hollow bulb obturator con-
impression material is then prepared, placed
struction will be described. This is referred to
in the tray, and carried to the mouth for the
as a two-piece obturator, as distinguished
maxillary impression. The patient’s head is
from the one-piece hollow obturator, which is
first positioned forward, then right and left
more hygienic and more esthetic, and which is
laterally, and finally backward and forward
described in detail later. One special note: the
again, with the patient’s head in the operator’s
author closes all obturator bulbs. All are
arms. This manipulation allows the
hollow, even the temporary ones, and he feels
impression material to flow into the undercut
that any attempt to leave the obturator bulb
areas of the hard and soft tissues. This
open on top, or “topless,” should be strictly
provides better retention areas in the future
avoided. An open bulb is unhygienic, foul-
obturator.
smelling, easy for the technician to construct,
The impression is then boxed and poured in
and unpleasant for the patient to tolerate.
stone (Fig. 9.5). The large undercut areas on
The master cast with the clasps in place is
the master cast are surveyed for clasp
then waxed over with baseplate wax
placement on abutment teeth.
approximately 2 mm thick. This includes the
Often the temporary obturator will need to
defect area, the base, the medial, and the
function comfortably for as long as 6 months.
posterior and the labial walls, keeping open
Consequently, a “no mouth preparation” type
the palatal ridge side. Next, modeling clay is
cast framework of gold or chrome-cobalt
put into the open defect area and, with the
should be constructed to provide more positive
patient’s normal palatal ridge being used as a
retention and comfort.
guide, the false

FIG. 9.5. Preoperative and postoperative master casts.


'F'

FIG. 9.6. A, palatal view of waxed-up obturator. B, waxed-up obturator with the modeling clay in the defect
area. C, tin foil applied over the modeling clay. D, false palate-ridge is separated. E. false palate perforated and
seated over processed base. F, palatal view of the finished temporary obturator. G, tissue side view of the hollow
bulb temporary obturator. H, temporary obturator inserted in the mouth.
INTRAORAL PROSTHETICS 141

palate and ridge are shaped and contoured in with a properly surveyed and executed gold or
clay, leaving an approximately 2-mm gold and porcelain veneer. Splinting of
thickness for the wax pattern on the reshaped adjacent teeth is advisable in almost all cases.
palate and ridge. The modeling clay is covered Multiple clasps, auxiliary rests, and
with tin foil as a separating medium, and next semiprecision or precision retentive means
the lid, false palate, and ridge are waxed. may be employed.
After the wax lid is separated, the tin foil and Once the teeth havfe been prepared and the
modeling clay from the master pattern are crowns cemented (Fig. 9.7), a polysulfide
discarded, and the wax lid and master cast rubber impression is made in a custom tray,
with the clasps and wax pattern are flasked with the same technique of head rotation that
separately. was described for the temporary obturator.
The two portions of the prosthesis are This impression is boxed and poured in stone.
boiled out and processed with heat-cure The master cast is surveyed for clasps^ and
methyl methacrylate. After processing, the partial framework design. The distribution of
two parts are de-flasked. forces is carefully studied for preservation of
The margin of the lid portion is perforated the teeth and minimal stress on the resected
or undercut for retention and then sealed over boundaries. Cast clasps are placed on the
the main base in its proper position. This is right remaining lateral incisor, bicuspid, and
accomplished by applying monomer to the molar teeth. The framework is seated on the
adjoining periphery and then by luting the master cast, undesirable undercuts are
two parts together with a doughlike mixture blocked out, an autopolym- erizable acrylic
of self-curing methyl methacrylate. baseplate is constructed, and a wax occlusal
The patient is allowed to wear the tem- rim is seated over the baseplate, including the
porary obturator for 2 to 6 months, pending a defected left ridge area. The baseplate with
possible recurrence of malignancy and to the frame is reinserted in the mouth, the
permit observation of tissue response and vertical dimension is ascertained, and the jaw
retentive stress. During this waiting period relation records are taken.
for periodical postsurgical and postinsertion Centric and vertical records demand
follow-ups, the healing is observed by the forethought about the tilting of the base
surgeon and the prosthodontist. It is during movement of the respective records.
imperative that tissue response to the Often a denture adhesive is needed for extra
temporary obturator be known before a stability. The powdered types are best for this.
permanent obturator is constructed. The The maxillary and mandibular casts are
addition of teeth, which provides function to mounted, and the teeth are selected and set
the obturator, places greater stress on the with a normal occlusion. After a wax try-in
wound area, and the response of the tissue to and rechecking of the centric registration, the
minimal stress must be known before case is ready for laboratory processing. The
additional stress can be applied. After the false ridge area is filled in and contoured with
temporary obturator has been worn for at the teeth. The palatal defect is still there and
least 2 months, the case should be reviewed it is filled in with modeling clay and reshaped,
and a decision should be made by both the using the patient’s preoperative palatal
surgeon and prosthodontist for construction of imprint as a guide. After the lid-false palate
a permanent obturator. has been separated, the tin foil and modeling
The final or permanent obturator for the clay are discarded, and the waxed-in obturator
dentulous maxilla is designed according to the and the lid are invested in two separate
best principles of crown and bridge and partial flasks. After curing and finishing, the lid-
denture construction. That is to say, all false palate part is perforated, seated over
abutment teeth are best crowned
142 MAXILLOFACIAL PROSTHETICS

FIG. 9.7. A, remaining right maxillary teeth are prepared. B, teeth are crowned and splinted. C, processed
hollow obturator and the lid (false palate). D, palatal view of hollow permanent obturator.

the main obturator, and sealed with auto- plate wax is also placed in the top half of the
polymerizable acrylic. flask over the teeth and palate area to form
A simple and accurate method of using an the top wall of the shim. This also allows for a
acrylic shim to process a hollow bulb without thickness of heat-cure acrylic on the palatal
lines of demarcation is next described. side of the denture.
(Procedure for One-piece Hollow Obturator Any good autopolymerizing acrylic resin is
(Figs. 9.8 and 9.9) mixed and rolled to about 2 mm in thickness
after reaching the doughlike stage. A layer of
After the wax try-in of the trial denture,
resin is then contoured over the wax relief in
the denture is festooned and finally waxed as
the defect site, with another layer over the
any conventional denture. The denture is
wax in the top half of the flask. The flask is
flasked and boiled out in the usual manner.
then closed and allowed to set for a minimum
When the case is completely flushed with
of 15 minutes. After curing, the flask is
boiling water and thoroughly dried, a shim is opened and the wax is flushed off the shim
constructed in the following manner: The
with a stream of boiling water. The excess of
undercut areas in the defect are blocked out,
acrylic is then removed from the shim and
and the entire defect area is relieved with one
placed back into the defect, using the three
thickness of baseplate wax. Three stops deep
stops for correct positioning for final
enough to reach the underlying stone of the
processing with heat-cure resin. At this point,
master cast are placed in the wax to facilitate
there is at" least one thickness of baseplate
proper positioning of the shim. One thickness
wax between the shim and the case, with the
of base exception of the three stops.
The heat-cure acrylic is mixed and pre-
INTRAORAL PROSTHETICS 143

FIG. 9.8. A, waxed-up obturator, flasked. B, flasked and boiled out model. C, undercuts blocked out with wax. D,
wax applied in the defect area, three stops created, and layer of wax applied on the opposing palatal area. E,
autopolymerizing acrylic applied over the waxed relieved area on both halves of the flask. F, hollow shim with the
stop. G, hollow shim placed back in the flask, using stops as a guide. H, postoperative cast and palatal view of
permanent hollow obturator. I, tissue side of hollow obturator. J, permanent obturator inserted in the mouth. K,
permanent obturator in occlusion. L, extraoral view without the obturator. M, extraoral view with the obturator.
(FIG. 9.8. F-M Continued on page 144).
144
a. Case waxed and flasked e. Flask closed for shim polymerization

f. Wax boiled out leaving shim with three stops

b. Wax boiled out

c. Stops prepared

d. Acrylic added to defect and to h. Shim becomes encased internally in the


stops to make hollow shim obturator bulb leaving no external seams

FIG. 9.9. Diagrammatic drawing of construction of one-piece hollow obturator.


145
146 MAXILLOFACIAL PROSTHETICS

pared in the usual manner. A layer of thick enough to allow for adjustment if
material is pressed to place in the bottom of necessary.
the defect, and the shim is reinserted for final 3. It is simple and consumes very little
processing. The heat-cure acrylic is placed in more laboratory time than a conventional
the top half of the flask, and the case is trial- denture.
packed at 1 , 0 00 pounds pressure. 4. Accuracy is assured.
After the final closure of the flask, the case
Snap-on Prostheses for Marginal Defects (Fig.
is cured, deflasked, finished, and polished in
9.10)
the customary manner, then inserted in the
Where there is a marginal defect of the
mouth. maxilla but with no associated palatal or
This technique has the following advan-
vestibular communication with the maxillary
tages.
sinus cavity, a snap-on removable partial
1. There are no lines of demarcation on the
prosthesis may be constructed to provide
denture to discolor.
retentive and esthetic results.
2. The undercut areas of the defect are
The abutment teeth adjacent to the

FIG. 9.10. A, postoperative view of maxilla after operation for reticulum cell sarcoma. B, abutment teeth are
prepared. C, try-in cast crowns and rods. D, bar rod and splinted crowns soldered and seated on the master cast.
INTRAORAL PROSTHETICS 147

FIG. 9.10. E, splinted crowns and rod cemented in the mouth. F, tissue side, showing retentive clip snap-on
attachments. G, palatal view of maxillary partial removal snap-on prosthesis. H, snap-on prosthesis inserted in
the mouth.

edentulous arch are prepared for full-cast clasps and semiprecision or precision rests are
crowns. Multiple abutments are used to also recommended.
provide maximal retentive support and to The extra retentive mechanisms provide a
distribute occlusal stresses. Incorporated into safety factor should repairs, relines, or metal
the two abutments nearest the edentulous failures occur in the postoperative years.
defect area are wax rod extensions of the same The final impression record duplicates the
1 1 -gauge size as the platinum- gold-palladium rod, abutments, and edentulous area
bar. As integral parts of the finished cast necessary to complete the prosthesis. The
crowns, these rods make it easy to solder the appropriate precious metal clip is adapted to
bar to the crowns with less chance of the master stone model rod, and the cast is
distorting the critical gingival crown margins. waxed for duplication. After duplication, the
The bar rod is bent to follow the general clip remains on the master cast until the
ridge contour, and soldering completes the framework has been cast and polished. This
union of bar to crowns. The final position of framework is then reseated on the master
the bar is 1 or 2 mm from the gingival crest case (which has been lightly dusted with
and abutment papilla. talcum powder), and a soldering index is made
Additional retentive means such as to enable the techni
148 MAXILLOFACIAL PROSTHETICS

cian to solder the clip attachment rigidly to centric stop for occlusion. Acrylic teeth which
the framework. The case is returned to the can be ground off or added to at chairside are
mouth to recheck the proper fit. Next comes best during the training phase. Then when
the wax try-in phase and final delivery of the facial symmetry and patient comfort have
completed case. been achieved, the final prosthesis is
This prosthesis snaps onto the rod in the fabricated.
front and clasps the crowned molars.
Mandibular Prosthetics
Snap-on Prosthesis for Anterior Segmental Guide Plane Prostheses
Defects (Fig. 9.11) In any mandibular resection, intermaxil-
The versatile snap-on mechanism can also lary alignment helps considerably in con-
be adapted to provide transpalatal splinting trolling the vertical dimension and centric jaw
when the anterior palatal defect is large. To relations postoperatively and in minimizing
minimize tilting, looseness, and occlusal stress the deviation of the mandible medially
on the remaining teeth, a clip attachment is towards the defected side (Fig. 9.13).
centrally placed to engage the palatal rod. The When the resection includes the body of the
patient shown in Figure 9.11 had a self- mandible, the ramus, and the condyle, an
inflicted gunshot wound in the mouth. The appliance termed a guide plane prosthesis
prosthesis had to possess the following must be constructed. Basically, this is a pair of
qualities: soft tissue stress-bearing, secure cast partial denture frameworks, designed for
prosthesis retention, and obturation of the the maxilla and mandible, which will engage
defect for speech and swallowing. It also had one another during jaw dynamics. The metal
to provide a foundation for reconstructing the framework of the upper partial denture
nasal prosthesis. Cast gold crowns were fabri- includes in its design a metal flange placed
cated and splinted. The resulting prosthesis horizontal to the buccal surface of the
used all principles of obturator design and the posterior teeth. On the framework of the lower
snap-on prosthesis previously described. partial denture, an inverted U-shaped bar is
Prostheses for Lateral Segmental Defects of designed which, when the casts are mounted
Edentulous Maxilla with No Palatal Opening on the articulator, extends just short of the
Figure 9.12 shows a patient with a lateral deepest portion of the buccal vestibule. During
segmental defect of both maxilla and function this lower bar slides against the
mandible. Prior to construction of the final upper horizontal flange, restoring the
prosthesis or resection appliance, the pros- mandible to a more normal alignment.
thodontist must educate the patient with a Mastication is limited to a hinge up- and-
trial temporary set of dentures and instruct down movement. However, this permits the
him to practice opening and closing his mouth. patient to retrain his damaged
This practice is best accomplished by neuromusculature and enables the prostho-
positioning the mandible while the patient dontist in time to achieve a properly designed
looks into a mirror. The prosthodontist prosthesis. Prosthetic rehabilitation of the
positions himself to the side or rear to grasp patient follows this retraining period. The
the patient’s chin button and guides it over restorative means, of course, depends upon
and back during opening and closing the presence or absence of teeth.
movements. With time and training, the Snap-on Prostheses for Segmental Resection of
patient can close more normally. Often trial Partially Dentulous Mandible
dentures for difficult cases are made to permit The teeth selected as abutments for the
the patient to have a positive experience of final removable partial denture design are
closure and
INTRAORAL PROSTHETICS 149

FIG. 9.11. A, anterior defect with transpalatal bar splint. B, tissue side view of prosthesis, showing clip at-
tachments. C, palatal view of snap-on prosthetic obturator. D, snap-on prosthesis inserted in the mouth. E.
patient’s extraoral view, showing multiple facial disfigurement. F, patient’s extraoral view with nasal prosthesis.
150 MAXILLOFACIAL PROSTHETICS

FIG. 9.12. A, lateral segmental defect of right maxilla. B, lateral segmental defect of right mandible. C, partial
maxillary and mandibular complete dentures and master casts. D, maxillary prosthesis inserted in the mouth. E,
maxillary and mandibular prostheses in occlusion.
INTRAORAL PROSTHETICS 151

surveyed, crowned, splinted, and cemented in Overlay or Superimposed Prostheses for


place. Bilateral bracing is often required to Marginal Excision of Dentulous Mandible
minimize stress on any one tooth and to offset (Fig. 9.16)
the lateral forces exerted by the slight jaw Marginal excision of the mandible in-
deviation which still persists. volving only the superior border of the
This bilateral bracing can use a Dolder, mandible is a problem for the patients who
Andrews, or Baker bar and appropriate clips. have few remaining teeth. These teeth are
The bar and clip attachment shown in Figure prepared and crowned, and removable partial
9.14 consists of an 11-gauge Baker bar and a denture of clasp design is then constructed. If
Baker clip. The final partial denture snaps the mandible has more than two posterior
onto this bar and clasps the crowned teeth. teeth in a row, splinting and snap-on
techniques can be used in constructing the
Prostheses for Segmental Resection of Fully prosthesis.
Dentulous Mandible (Fig. 9.15)
Prostheses for Marginal Excision of Eden-
When no edentulous spaces exist for the tulous Mandible (Fig. 9.19)
snap-on type prosthesis, the multiple abut-
ments should be crowned and splinted before Anterior marginal excision of a fully
the removable partial denture is constructed. edentulous mandible presents a major
This final prosthesis is both a partial denture problem. Because of the huge intraoral
and a resection prosthesis which provides vertical dimension which must be restored, a
heavier denture is often constructed to help
acceptable occlusion.
keep the prosthesis in the mouth. Sometimes,
through the exercise of imagi-

FIG. 9.13. A, extraoral view of mandibule after partial resection of right mandible. B, intraoral view of de -
viated mandible. C, intraoral view, showing guide plane prosthesis. Note the engagement of lower U-shaped bar
to the maxillary buccal flange. D, extraoral view showing the correction of deviated mandible.
152 MAXILLOFACIAL PROSTHETICS

FIG. 9.15. A, cast showing resected mandibular defect


with the frame design. B, tissue side of resection
prosthesis. C, resection prosthesis inserted in the
mouth.

Resection Prosthesis for Partially Resected


Edentulous Mandible (Fig. 9.17)
During denture design and construction for
FIG. 9.14. A, Baker bar splinted to crowns. B, tissue
side of the prosthesis. C, snap-on prosthesis inserted in
edentulous patients who have undergone
the mouth. partial segmental resection, including the
condyloid process when a mandibular implant
nation and skill, the operator can construct an is not feasible, additional care is required
unconventional prosthesis with the help of beyond the usual procedures. This additional
springs to bring the lower lip to normal care encompasses retraining of jaw function,
alignment and acceptable occlusion. reshaping of the
INTRAORAL PROSTHETICS 153

occlusal surfaces of the posterior denture directly to stabilize the denture during the
teeth, “plumping” of the denture base to add various mandibular excursions. This can be
whatever facial architecture can passively be done by grinding the buccals of the uppers
obtained, reassuring the patient, and and linguals of the lowers or by arranging the
summoning up courage to attempt the case. teeth to occlude.
Generally speaking, a “partial” complete Plumping of the denture base means to add
lower denture has some value for esthetics but more wax during the trv-in phase to preview
very little for mastication efficiency. This the patient’s facial symmetry before finishing
limitation is usually due to the fact that, after the prosthesis. These wax additions should be
a lateral glossectomy, a prosthesis has been passive, that is to say, they should not hinder
placed over the missing mandibular segment or impinge on any muscles in a way which
to obturate the resultant opening in the floor would tend to lift or unseat the denture.
of the mouth. Thus the patient has poor
tongue control, affecting the speech as. well as Superimposed Prosthesis (Fig. 9.18)
the lingual denture border length on the Congenital hereditary ectodermal dys-
resected side. plasia, which involves both maxilla and
Reshaping the acrylic teeth or changing the mandible, is rare. However, when it occurs, in
arrangement of the teeth can help in addition to the sparse hair, sunken eyes,

FIG. 9.16. A, preoperative view of intraoral tumor. B, postoperative view of marginal excision ot superior border
of mandible with the remaining molars crowned. C, superimposed denture in occlusion.
154 MAXILLOFACIAL PROSTHETICS

FIG. 9.17. A, partial resection of right edentulous mandible. B, complete maxillary and mandibular prostheses.
C, mandibular prosthesis in place. D, maxillary and mandibular prosthesis in occlusion. E, extraoral view of
patient without the prostheses. F, extraoral view of patient with the prostheses.
INTRAORAL PROSTHETICS 155

FIG. 9.18. A, typical clinical appearance of congenital hereditary ectodermal dysplasia. B, intraoral view,
showing missing teeth and peg-shaped teeth. C. mandibular cuspids thimble crowned and splinted. D. tissue side
of the superimposed prosthesis showing clip attachment. E. superimposed prosthesis inserted in the mouth. F,
extraoral view with the prosthesis.
156 MAXILLOFACIAL PROSTHETICS

mandible. These were thimble-crowned and


splinted with a Baker bar. Since radiographs
revealed only five permanent developing
teeth, the extensive treatment shown here
was considered necessary but temporary.
Superimposed or overlay dentures were
designed with a snap-on clip soldered to a
partial denture framework. At the request of
the patient and his parents, no attempt was
made to hide the gold crown thimbles of the
denture. The resultant overlay denture
snapped on the bar and gained tissue bearing
adhesion from the oral mucosal contact.
REFERENCES
1. Ackerman, A. J.: The prosthetic management of
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J. Prosth. Dent. 5: 413-432, 1955.
2. Adisman, I. K.: Removable partial dentures for
jaw defects of the maxilla and mandible. Dent.
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3. Adisman, I. K., and Birnbach, S.: Surgical pros
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8. Boucher, L. J.: Prosthetic restorations of a max
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466, 1970.
FIG. 9.19. A, anterior marginal excision of edentulous 11. Brown, K. E.: Fabrication of a hollow-bulb obtu
mandible. B, unconventional prosthesis with the rator. J. Prosth. Dent. 21: 97-103, 1969.
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esthetic result after insertion of prosthesis. (Courtesy of cial patients. J. Prosth. Dent. 17: 497-508, 1967.
Dr. J. Valiquette.) 13. Chalian, V. A.: Head and neck tumors and max
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there are always missing and pegshaped teeth School of Dentistry, Spring Issue, 1970.
15. Converse, J. J.: Maxillofacial deformities and
along with poor alveolar development.
maxillofacial prosthetics. J. Prosth. Dent. 13:
In the patient shown in Figure 9.18, the 571-583, 1963.
only teeth remaining at the age of 8 V2 years
were the deciduous cuspids in the
INTRAORAL PROSTHETICS 157

16. Curtis, T. A.: Treatment planning for intraoral bulb obturator for acquired palatal openings. J.
maxillofacial prosthetics for cancer patients. J. Prosth. Dent. 7: 126-134, 1957.
Prosth. Dent. 18: 70-76, 1967. 25. Riley, C.: Maxillofacial prosthetic rehabilitation
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Partial Prosthodontics. W. B. Saunders Com- 26. Roberts, A. C.: Obturators and Prostheses for
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19. Laney, W. R.: Maxillofacial prosthetics: intraoral orbit. J. Prosth. Dent. 13: 178-184, 1963.
defects. Mayo Clin. Proc. 39: 22-25, 1964. 28. Rosenthal, L. E.: The edentulous patient with
20. Lang, B. R., and Bruce, R. A.: Presurgical maxil- jaw defects. Dent. Clin. N. Amer. (Nov. 773- 779,
lectomy prosthesis. J. Prosth. Dent. 17: 613— 1964.
619, 1967. 29. Scannel, J. B.: Practical considerations in the
21. Lloyd, R. S., and Braund, R. R.: Maxillofacial dental treatment of patients with head and neck
prosthetic problems in patients with cancer. J. cancer. J. Prosth. Dent. 15: 764-769, 1965.
A. D. A. 35: 162-170, 1947. 30. Swoope, C. C.: Prosthetic management of re
22. Miglani, D. C., and Drane, J. B.: Maxillofacial sected edentulous mandibles. J. Prosth. Dent.
prosthesis and its role as a healing act. J. 21: 197-202, 1969.
Prosth. Dent. 9: 159-168, 1959. 31. Zarb, G. A.: The maxillary resection and its pros
23. Nadeau, J.: Special prosthesis. J. Prosth. Dent. thetic replacement. J. Prosth. Dent. 20: 268- 281,
20: 62-76, 1968. 1967.
24. Nififfer, T. J., and Shipron, T. H.: The hollow-
10
PERIODONTICS

Niles Hansen

The maintenance phase of the periodon- hygiene may be disturbed by the following: (a)
tium begins at birth and lasts as long as any tooth position, (b) retarded or incomplete
part of the natural dentition is present. Oral eruption, (c) malocclusion, (d) surgical
health depends largely upon the type of oral procedures, or (e) various types of removable
hygiene program that is followed. Methods appliances. Thus, the body may be called upon
should be based, first upon existing needs of to perform a major task in resisting
the individual patient, and second upon a periodontal disease.
consideration of conditions which are subject During the phases of change, the following
to change. program is indicated. First comes the
Periodontal problems involve inflammation, placement of ideal dental restorations, and it
and the prognosis, which must be determined should be noted that the well- formed, polished
prior to treatment planning, is based upon the alloy is much more conducive to tissue health
expected result of efforts to reduce than that seen in Figures 10.1 and 10.2.
inflammation. Second, a regular recall schedule should be
Tissue changes are basically atrophic or established based upon such criteria as (1)
hypertrophic. One may observe (1) redundant needs, dictated by type and number of
friable tissue with or without erythema, (2) appliances being worn, (2) the dentist’s ability
fibrotic hyperplastic tissue, or (3) recession of to instruct the patient, and (3) the patient’s
tissue. If inflammation is the sole pathologic ability to apply a sound home care program.
change, the prognosis is very favorable. When Gingivitis is the primary periodontal
inflammation is secondary, being problem, and it is most frequently caused by
superimposed on a systemic factor, the outlook local irritating factors. Control, in the presence
depends largely upon the degree of systemic of tissue-borne appliances, becomes a dual
control which can be attained. Patients with dentist-patient responsibility. In his design,
systemic conditions which of themselves the prosthodontist should use occlusal stops or
present no clinically detectable signs may rests wherever feasible. He can further relieve
represent an even more guarded prognosis and reline tooth-approximating surfaces of the
when the control of inflammatory processes is appliance with tissue-conditioning acrylics at
being considered. regular intervals. In addition, he should scale
The inflammatory changes in the maxil- at the frequency indicated by tissue response
lofacial patient are no less interesting. Sit- and reformation of plaque and calculus.
uations found in this patient are often subject Temporary appliances should be replaced by
to major changes in rather brief periods. The permanent prostheses as soon
natural physiologic means of
PERIODONTICS 159

to reproduce a more normal or more favorable


crown length and to create a more harmonious
tissue contour. If loss of bony support appears
imminent, further consideration must be
given to the usual factors of type, amount, and
location of remaining bone, degree of mobility,
availability of adequate splinting support,
strategic importance of the tooth, and the
ability of the operator.
The surgical procedures employed run the
ordinary range of periodontics. Radiosurgery
may be the treatment of choice for reducing
localized areas of soft tissue or around
individual teeth. It is also effective in reducing
palatal hyperplasia. Gingivo- plasty
procedures (Figs. 10.3 and 10.4)

FIG. 10.1. Alloy which has tarnished. Note roughened


surface and condition of marginal gingiva.
FIG. 10.2. Same case as in Fig. 10.1. Note improved
gingival response to smooth, highly polished
restoration.

as practicable. Patient responsibility must


FIG. 10.3. Pre-extraction and pre-gingival surgery.
always include removal of the appliance and
thorough rinsing of the mouth and appliance
after eating, proper brushing of the soft tissues
as well as tooth surfaces, and interdental
stimulation, using a lingual approach.
As the time approaches for the advent of a
more permanent dental situation, the
periodontal evaluation is a critical part of
treatment planning. In the presence of an
ideal oral hygiene maintenance program and
in the absence of systemic factors, no
progression to a state of periodontitis might be
expected. However, tooth position, eruption
pattern, or hypertrophy may be present, either
singly or in combination, as conditions
requiring surgical intervention. Surgical
procedures are designed FIG. 10.4. Typical appearance of gingival tissue after
gingivoplasty to obtain crown length.
160 MAXILLOFACIAL PROSTHETICS

may also be accomplished with any of the tions. This is particularly important in the
various gingivectomy knives, tissue nips, or case of the maxillofacial patient, who will
diamond stones. In the more complicated normally have few teeth to begin with. The
infrabony defects, various approaches from construction of self-cleansing dental
regeneration through medullary bone repair restorations is in itself the practice of per-
to osseous contour may be applied, depending iodontics.
upon needs, health, and operator ability. The earlier statement that methods of oral
Healing of the gingivectomy wound has hygiene must be adapted to the individual
been well described by numerous authors. patient applies with even greater
Although epithelization is complete in 14
days, it is well to consider healing in a broader
sense. At the end of 1 month, it has been
observed that tissues resembled alveolar
mucosa. Six months after surgery, there is a
gross morphologic appearance of attached
gingiva, but not until 1 year are the histologic
characteristics of long rete pegs, heavy
keratinization, and well-oriented fiber bundles
realized. Seemingly, therefore, the first
postoperative year is critical in controlling the
reshaping of tissues.
Postsurgical care may become a problem
when esthetic, functional, or retentional
requirements necessitate the use of a re-
movable appliance. In these situations,
recovery may be facilitated by the following.
A. Use of reline to adapt to new conditions.
B. When brushing is difficult, the tem-
porary use of an ointment (e.g., vancomycin).
C. Other ointments, such as Kenalog with
Orabase, or 3% Aureomycin ointment.
D. Mouth washes such as mild salt water
or My costatin suspension.
E. Carefully applied dentistry based upon
sound principles.
One of the most effective aids to tissue
recovery, however, is immediate and regular
(weekly when indicated) relief and reline of
the tissue surface of the appliance with a
tissue-conditioning material (Fig. 10.5). This
assures proper fit and proper adaptation to
the latest tissue condition, thus speeding
recovery.
Any program of oral hygiene is greatly
influenced by the quality of dental restora

FIG. 10.5. A, note palatal area of inflammation under


temporary appliance. B, applicance with tissue-
conditioning reline. C, 1 week after reline. Note
reduction of palatal inflammation.
PERIODONTICS 161

force to the maxillofacial patient. It is not blanching of the underlying tissue. While this
uncommon for the patient to present with a force is being maintained, the instrument is
normal mandibular arch opposing a mutilated rotated (if using rubber tip) or push-pulled
maxillary arch. Certainly the methods of care through the area for a definite time. It is often
must be taught in a different manner for each desirable to have the patient count in the
condition. Too often our concept of brushing initial days after instruction until a habit
and home care becomes stereotyped, and we pattern is formed. He should be urged not to
thus lose sight of what is to be accomplished. count the number of motions of the instrument
A good program of oral hygiene must encom- but to count time. In most patients, counting
pass tooth cleansing and tissue care and to 15 will take 5 seconds, which is enough time
stimulation, and neither of these conditions to spend on each interdental space daily.
can be met with a toothbrush alone. In addition to the use of the toothbrush and
The toothbrush should be of a medium to stimulator, other measures are often
soft texture. The head of the brush should be indicated. Dental floss, preferably of a non-
straight and approximately 1 inch long. It waxed type, is beneficial in cleansing the
should be applied in such a manner as to contact area. Again, the proper use must be
stimulate gingival tissue, encourage the knife- taught. The American Dental Association
like edge adaptation of marginal gingiva, and pamphlet entitled Effective Oral Hygiene1 is
cleanse the tooth surface. The series of events an invaluable reminder during this patient-
should take place in the order stated; and in learning phase.
the average situation with normal tooth align- Gauze, such as the Vk-inch width, can be
ment, a modified roll technique, from soft folded and applied distal to partial abutment
tissue to tooth substance, is recommended. areas in a shoeshine manner. Dental tape
Where there are overlapping or cratering should be applied under pontic areas of
defects, such as occur after necrotizing ul- bridges.
cerative gingivitis, the intracrevicular method Various forms of hydrotherapy are enjoying
may be more adaptable. a renewed popularity and are beneficial
Interdental stimulation is an essential around bar splints, banded situations, and
procedure in most mouths. Numerous devices hard-to-reach posterior areas. The Water-Pik
are available, but the aims and principles of is one such hydrotherapy device. This is a
application are identical. When properly used, forced, pulsating water jet adjustable to
these devices stimulate the terminal patient needs. A number of devices adaptable
circulation of gingival tissue, force removal of to bathroom fixtures are now available to
soft debris from the sulcus area, improve serve a similar purpose. A simple bulb syringe
keratinization, and provide some such as is used for irrigating the ear can be
interproximal tooth cleansing. While tooth applied in various situations.
brushing promotes proper marginal contour of It would be remiss not to mention that
gingival tissue, appropriate interdental considerable literature is now available
massage will promote the improved contour of concerning the electric toothbrush. The results
tissue sluiceways. There are three important of improved tissue tone resulting from
considerations in working toward these massage from this mode of home care have
objectives: (1) direction of application, (2) force been noted in many patients. Certainly, use of
of application, and (3) time of application. the electric toothbrush is to be encouraged, if
Any massaging device will accomplish not insisted upon, in situations which are
optimal results if the direction of application is considered critical.
at an angle to the contact area of teeth to Any program will be successful only to the
tissue. The stimulator must be applied with degree to which we are able to educate the
sufficient force to produce patient. Patient education becomes more
meaningful and cooperation more
162 MAXILLOFACIAL PROSTHETICS

complete if the patient becomes informed 2. Bass, C. C.: Optimum characteristics of tooth
concerning his periodontium. Let the patient brushes for personal oral hygiene. Dental Items
Interest 70: 697-718, 1948.
be aware that there is more than just a tooth
3. Buebe, F. E.: Gingival massage. J. Periodont. 19:
protruding through a hole in the gum. 66, 1948.
Illustrate for him the underlying, hidden 4. Chace, R.: The maintenance phase of periodontal
periodontium and its critical importance. It is therapy. J. Periodont. 22: 234, 1951.
then that home care suggestions become 5. Giblin, J. M., Levy, S., Staffileno, H., and Gar-
guilo, A. W.: Healing of re-entry wounds in dogs.
meaningful and self-care begins to have a J. Periodont. 37: 238-253, 1966.
purpose. 6. Goldman, H. M.: Periodontal Therapy, Ed. 3.
REFERENCES The C. V. Mosby Company, St. Louis, 1964.
1. American Academy of Periodontology: Effective Oral 7. Kronfeld, R.: Importance of normal and patho
logic tissue changes to the pyorrhea problem.
Hygiene, developed by the USAF School of
Dent. Cosmos. 73: 777-779, 1931.
Aerospace Medicine, Brooks Air Force Base,
8. Sorrin, S.: The Practice of Periodontia. McGraw-
Texas, 1969.
Hill Book Company Inc., New York, 1960.
11
SURGERY OF HEAD AND NECK CANCERS
Lewis W. Thompson and Raleigh E. Lingeman

Cancers in the head and neck vary from the cluding x-ray, laboratory studies, and, most
small basal cells, which are usually slow in important, biopsy to provide information on
their growth and destructive by local invasion, the specific tumor cell type with which he is
to the more aggressive tumors such as the dealing. In addition to being knowledgeable
melanoma which, in addition to its local about the anatomy, such as lymph drainage of
destruction, metastasizes early and widely. this region, the physician must be aware of
This chapter briefly discusses their surgical the natural history of the specific tumor,
management, emphasizing the application of including its response to current modalities of
prosthetics. treatment, including surgery, radiotherapy,
Head and neck cancers are extremely and chemotherapy (either individually or in
challenging both in their ablative care and in combination). Only after all this has been
the rehabilitation with either autogenous or considered should a treatment plan be out-
prosthetic materials. Occasionally, neither the lined and carried out.
ablative nor the rehabilitative aspect is as
Intraoral
rewarding as we would hope.
The first objective in head and neck cancer Lip. Cancer of the lip, especially of the
management is complete and permanent lower lip, is the most common malignancy of
eradication of the cancer, followed by the oral cavity. Etiologically, it is felt that
rehabilitation of the individual so that he can irritants such as solar rays play a part in the
return to society as a useful and participating increased incidence of lower lip versus upper
member. Again the team approach is all lip involvement.
important, with many specialists contributing, Epidermoid is the most common cell type,
including surgeon, radiotherapist, with basal cell occurring only when it arises
chemotherapist, prosthodontist, and many on the skin and involves the mucosa by
others. extension.
In dealing with cancer of this region, the Since these tumors are usually slow to
physician must individualize each patient’s metastasize, the prognosis is considerably
care and avoid stereotyped treatment. First, better than in other intraoral lesions. An
the patient’s general condition and the extent exception is cancer of the upper lip which,
of his disease must be evaluated completely, although it occurs less frequently, grows more
and in this the TNM (T, tumor; N, regional rapidly and has a greater tendency to
nodal metastases; M, distant metastases) metastasize than does cancer of the lower lip.
system of cancer staging is useful. Many tools Preauricular and anterior jugular chain is the
are available to aid the physician in his first route of spread with the upper
evaluation, in
163
164 MAXILLOFACIAL PROSTHETICS

lip lesions, while the lower lip lesions drain and/or borrowing tissue from the lower lip in
first to the submandibular nodes (Fig. 11. 1) . the form of an Abbe flap (Fig. 11.4). In total lip
Treatment depends on location and size of reconstruction, it is again preferable to use
the lesion. With lower lip lesions requiring local tissue rather than distant tissue pedicle
resection of one-third or less of the lip, a flaps.
“shield resection” and primary closure are Prosthetic replacement is rarely indicated
recommended (Fig. 11.2). When more than in lip reconstruction because of the mobility
one-third of the lip requires resection, usually needed in this area, which cannot be
it is preferable to advance lateral tissue adequately furnished with prosthetic devices.
mesially, as in the Bernard-Burrough A premalignant whitish discoloration
technique (Fig. 11.3). A radical neck dissection (leukoplakia) of lip mucous membranes is
is indicated when metastatic disease is occasionally seen. The vermilion surface is the
palpable in the neck. Upper lip resection most commonly involved area, and the
requires more extensive reconstructive problem can be simply dealt with by removing
procedures, including shifting lateral cheek the entire vermilion, then advancing mucosa
tissue mesially from the undersurface of the lip to resurface
the vermilion (Fig. 11.3).
Tongue. The second most common intraoral
cancer is cancer of the tongue. The etiology is
not known, but again irritants are suggested
as a contributing factor; these patients have a
higher incidence of poor dental hygiene plus
the use of alcohol and tobacco. Also, syphilis
has long been considered as a causative factor.
Again, the common cell type is epidermoid,
but the behavior and thus the prognosis vary
with the location. Lesions of the anterior third
of the tongue carry a better prognosis than the
more posterior ones and they do not
metastasize as readily. Lesions

FIG. 11.1. Lymphatic drainage of the head and neck


region. Left, facial skin; right, oral cavity.

FIG. 11.2. Carcinoma of the lip, small lesions. A, resection is outlined in the form of a shield. B, primary
closure demonstrating minimal deformity after one-third resection of the lip.
SURGERY OF HEAD AND NECK CANCERS 165

FIG. 11.3. Lip carcinoma. Resections of 35% or more of the lip require more than simple closure in their
reconstruction; in this case, a Bernard-Burrough technique was used. A lip shave was also performed on the left
side of the lower lip for precancerous changes.

of the middle and posterior thirds of the thetic hemimandible is something to be


tongue (Fig. 11.5) are more aggressive, with as considered (Fig. 17.10, Chapter 17). A good
high as 75% in some series having metastatic result with these depends upon a secure
neck involvement when first seen by a attachment at the autogenous-prosthetic
physician. The more posterior tumors extend union. A combination of K pins and a
submucously, frequently involving the floor of tantalum tray wired to both has given us the
the mouth, and laterally to the gingiva or best results. The success of such prosthetic
tonsillar pillar, depending on their location. implants has varied, because this is an area of
Lesions of the base of the tongue are considerable motion and is frequently
considered the most infiltrative and the traumatized.
“wildest” tumors of the oral cavity. When a large volume of intraoral tissue is
Surgical treatment for the small early resected, it is occasionally advantageous to
lesions of the anterior third is wide local use pedicle flap closure immediately (at the
excision with primary closure. Lesions of the time of ablative surgery), thus leaving the
middle third usually require in continuity remaining tongue free for better speech and
resection, including tongue (hemiglos- swallowing. If not done initially, this is a
sectomy), floor of the mouth, and ipsilat- eral consideration for a secondary procedure, with
radical neck dissection. Also, a hemi- an alternative method being to free those
mandibulectomy on the involved side is often tissues and accomplish split thickness skin
necessary. Occasionally, immediate grafting to the defect (Fig. 11.7). A prosthetic
mandibular reconstruction with rib grafts is stent of Kerr compound or COSOFT (Coe Lab,
possible, but more commonly the recon- Inc., Chicago, Illinois) is useful intraorally
struction is done secondarily. In this latter when dealing with such split thickness skin
situation, it is frequently advantageous to grafts.
retain soft tissue positioning, with K wires With large primary lesions, contralateral
bridging the mandibular gap (Fig. 11.6). In lymphatic spread is highly possible, thus
hemimandibular reconstruction, a rib from the requiring bilateral consideration. Lesions of
contralateral side furnishes satisfactory the posterior third or base of the tongue, as
external contour, but the procedure is mentioned earlier, are the “wildest” tumors
handicapped by varied amounts of absorption and usually present with lymph node
and the intraoral curvature makes it difficult, involvement. Surgical ablation requires
sometimes impossible, to construct a denture glossectomy, laryngectomy, and frequently
that fits. Thus, a pros bilateral neck dissection, and yet
166 MAXILLOFACIAL PROSTHETICS

the disease often recurs rapidly. The poor cers, again are usually epidermoid in type.
prognosis with any single mode of therapy has They are generally unilateral. When the
stimulated an interest in combinations of midline (anterior) is involved, bilateral neck
treatment: radiation and surgery; regional metastasis can occur (Fig. 11.8).
perfusion and surgery; systemic chemotherapy Surgical ablation consists of in continuity
with radiation, then surgery; and others. It is dissection of the floor with radical neck
too early to evaluate these approaches, but dissection and Often, because of close ap-
some such combinations may hold the promise proximation, hemimandibulectomy. The
of improved mortality. exception to this much surgery would be the
The tongue is affected by other types of very early small lesions whose ablation would
malignancy, such as sarcomas and lesions of consist of wide local excision with probable
the minor salivary glands, but these are split thickness skin graft closure. Lesions of
comparatively rare. this location are also being considered for
Floor of Mouth. These tumors, which combined treatments, and many centers are
account for approximately 159c of oral can using these treatment combinations.

FIG. 11.4. Extensive upper lip lesion. Reconstruction of such defects requires, in addition to tissue from the
lower lip, a mesial shift of cheek tissue; resection of a crescent-shaped area lateral to the nose allows tissue to be
brought mesially. (Courtesy of James E. Bennett, M.D.)
SURGERY OF HEAD AND NECK CANCERS 167

side of the neck which drains the primary


tumor site. Technically, several incisions have
been proposed to gain access to the neck. The
most commonly used was proposed by Hays
Martin4 and consists of connecting Y incisions
(Fig. 11.9). This incision, however, hak the
disadvantage of a vertical limb at right angles
to the normal skin folds, and thus it carries the
potential of scar contracture. In addition, there
are two areas of three-point approximation
(three flap tips) and thus a site of potential
wound breakdown which overlies a bared
carotid artery. Accordingly, many

FIG. 11.5. Carcinoma involving the right middle and


posterior thirds of the tongue.

FIG. 11.7. Tongue release. A split thickness skin


graft was used to line the floor of the mouth and under
the surface of the tongue.

FIG. 11.6. Temporary bridging of mandibular gap


with Kirshner wires retains soft tissue positioning
which is beneficial for later reconstruction.

Again, regarding reconstruction, the


decision is often between the distant flap
(initially or secondarily) and the secondary
release and split thickness skin graft, with
prosthetic stents playing a role. FIG. 11.8. Carcinoma involving the anterior floor of
The principle of a radical neck dissection is the mouth. This patient presented with bilateral neck
to remove the lymphatics on the note metastasis.
168 MAXILLOFACIAL PROSTHETICS

other incisions have been proposed, including proach is not difficult to work around, this
the McFee approach (Fig. 11.10), consisting of approach is good for nonirradiated as well as
parallel incisions without the central vertical irradiated necks, leaving a more acceptable
limb. This approach is especially useful in the scar.
irradiated neck because irradiation interferes In the classic radical neck dissection, tissue
with wound healing, thus increasing the removed for intraoral lesions includes all
chance of carotid exposure which may lead to superficial to the carotid and deep to the
blowout. Since the bridge of skin in the McFee platysma, anterior midline to trapezium,
ap- clavicle to mandible, including
sternocleidmastoid muscle, internal jugular,
and submaxillary gland (Fig. 11.11). Brachial
plexus, levator scapular muscle, and
scaleneous muscles, plus strap muscles,
constitute the residual floor (Fig.
10.12) . Modifications of this technique vary
with the individualization of the procedure.
Buccal Mucosa. These lesions account for
10 to 15% of oral cavity carcinomas. Intraoral
cancers are more common among older people,
and this location involves an even older group
on the average. Frequently with this lesion, a
history of tobacco chewing is elicited or the
presence of a precancerous lesion, leukoplakia
(Fig.
10.13) . There are basically two gross types of
epidermoid cancer: verrucous and ulcerative
or exophytic. The former is less invasive and
metastasizes much later, thus carrying the
best prognosis among intraoral cancers.
FIG. 11.9. Classic radical neck incision: Hays
Martin.

FIG. 11.10. McFee approach to radical neck dissection. This spares the central limb incision; thus, a biped- ical
central flap instead of unipedical flaps and three corner closures are used in an area where healing is less than
ideal.
SURGERY OF HEAD AND NECK CANCERS 169

FIG. 11.11. Anatomy of a radical neck dissection. A, subplatysmal skin flaps reflected, demonstrating the
underlying structures to be resected. B, superior extent of the dissection is the inferior border of mandible. The
mandibular branch of facial nerve is spared, while the anterior facial vessels are sacrificed.

FIG. 11.12. Anatomy of a radical neck dissection, continued. A, inferior margin of the dissection in the clavicle.
The jugular vein, along with the sternocleidomastoid muscle and accompanying lymphatics from the carotid sheath
to the platysmal muscle, made up the bulk of the resected specimen. B, floor of the dissection after a specimen is
removed, with remaining structures identified.

Surgical treatment varies with the type of lesions that lie close to the sulcus and extend
lesion. Wide resection and a split thickness so that ablative surgery requires maxillary or
skin graft to the defect are indicated in the mandibular resection, and the extensive
verrucous lesions. A radical excision is the lesions which require resection of the entire
treatment for the ulcerative type, plus cheek. The prosthetic management in both of
consideration of ipsilateral neck dissection. these categories is mentioned in other sections
Some feel that the latter should be reserved of this chapter.
until there is evidence of metastatic neck Alveolar Ridge—Gingivae. Approximately
nodes, especially if the lesion is limited to the 2% of oral cancers originate from the alveolar
cheek area and not the sulcus. The problem ridge. The lower ridge is involved four times
that the buccal mucosa lesion most commonly as often as the upper alveolar ridge. These
presents is local control. Notoriously, these lesions again are usually epidermoid in nature
patients have extensive atypical mucosa with but, in upper ridge involvement, minor
multicentric involvement. salivary gland tumors must be considered, as
The role of prosthetic rehabilitation in well as eroding maxillary antral carcinoma.
these lesions lies in two categories: those Primary alveolar ridge lesions metastasize
170 MAXILLOFACIAL PROSTHETICS

hand, soft palate carcinomas are usually


epidermoid and well-differentiated (Fig.
10.15) . The age group is older than for hard
palate tumors. Soft palate tumors metastasize
but usually late.
Surgical treatment of hard palate lesions is
wide excision, with neck dissection only when
nodes are involved. Soft palate carcinomas
have the best survival rate with a combination
of x-ray and surgery. Again, neck dissections
are reserved for those lesions with nodal
involvement.
Hard palate defects can be easily reha-
bilitated with an obturator denture, while soft
palate defects are more challenging for the
prosthodontist in that they require a speech
bulb type of obturator (Fig. 11.16) for
velopharyngeal closure to correct the resultant
FIG. 11.13. Intraoral carcinoma arising in an area of nasal speech.
leukoplakia. Tonsil. These lesions fall in the poor
prognostic category of the intraoral lesions.
Epidermoid carcinomas are usually highly
later than the previously mentioned intraoral
undifferentiated and, as in the case of lesions
lesions and thus have a better prognosis.
of the base of the tongue, a large percentage
Surgical treatment of lower alveolar ridge
have metastatic neck node involvement when
lesions is wide resection, either hem-
first seen by the physician. To date, the
imandibulectomy or sectional mandibulec-
recommended treatment is radiation with
tomy, depending on the extent and location of
neck dissection for the metastatic disease
the lesion. Radical neck dissection is indicated
when the primary is controlled, but again the
when neck nodes are involved. Radiation alone
outlook is grim. It is hoped that the future will
is rarely the treatment of choice because of the
be more promising, possibly through a
difficulty in eradicating tumor within bone
combination of modalities mentioned earlier
without damaging its host, the bone, which
in the chapter.
then leads to necrosis. Reconstruction of the
Larynx. Cancer of the larynx, together with
mandible follows the same sequence
cancer of the entire respiratory tract,
mentioned earlier: first, adequate soft tissue,
then autogenous or synthetic reconstruction.
In upper arch lesions, rehabilitation includes
fitting an intraoral prosthesis which, in
addition to supplying teeth, obturates the area
of resection.
Palate. This region must be divided into
hard and soft palate areas because of their
individuality. The hard palate lesions (Fig.
10.14) are rarely epidermoid in type unless
involved secondarily from antral lesions, but
are commonly mucous or minor salivary gland
in type. They occur in a younger age group
than most intraoral lesions and rarely
metastasize. On the other

FIG. 11.14. Mixed tumor of hard palate.


SURGERY OF HEAD AND NECK CANCERS 171

ness, but the first symptom is often a sen-


sation of vague discomfort as if something
were sticking in the throat, with later de-
velopment of dysphagia and referred pain to
the ear. Supraglottic carcinoma does not cause
hoarseness until the late stages of the disease
with invasion ‘of the glottic portion of the
larynx. Patients with cancer of the pyriform
fossa and postcricoid region usually complain
of persistent pain accompanied by progressive
dysphagia. Symptoms of subglottic
involvement are usually stridor and dyspnea,
although in many of these patients,
hoarseness will again be an early symptom.
Diagnosis depends upon thorough exam-
ination of the larynx and hypopharyngeal
regions by indirect laryngoscopy with the
mirror and direct laryngoscopy with the
laryngoscope. In most situations, diagnosis
can be made by mirror laryngoscopy, although
biopsy is usually done with direct
laryngoscopy.
FIG. 11.15. Epidermoid carcinoma of soft palate. This
The proven modalities of treatment are
lesion presented as an ulcer, in contrast to the lesion irradiation and surgery. Early lesions confined
shown in Fig. 11.14. to the vocal cord, with unimpaired motility of
the cord, may be treated by irradiation
has increased significantly during the past 10 utilizing cobalt 60 teletherapy, with excellent
years. The incidence of laryngeal cancer is results, in controlling the disease and
placed at 12 to 15%, with most of these tumors preserving the patient’s voice. For advanced
occurring in the male. Most of these tumors lesions of the glottis with fixation of one vocal
are epidermoid cancers but adenocarcinomas, cord, involvement of both vocal cords and
usually of the adeno- cystic type, have also extension of the
been encountered. Most of these tumors occur
during the fourth, fifth, and sixth decades of
life, with the majority in the 60-year-old
group. As with cancer of the respiratory tract,
excessive use of tobacco seems to be a factor.
Overindulgence in alcohol is also seen con-
sistently in patients with cancers of the
extrinsic larynx, such as the epiglottis, pyr-
iform fossa, and the postcricoid regions.
Patients with carcinoma of the larynx may
exhibit a variety of symptoms which lead them
to seek medical consultation. If the tumor
arises from the vocal cord, hoarseness always
occurs. Ocasionally the change in voice quality
is so subtle that the patient may allow it to go
without concern for prolonged periods. Tumors
of the su- praglottic region do not produce FIG. 11.16. Obturator denture with speech bulb: used
hoarse for reconstruction of hard and soft palate resection
defect.
172 MAXILLOFACIAL PROSTHETICS

tumor into the anterior commissure or been asked to prepare laryngeal stents both of
subglottic extension of the tumor require total the male and female size for use in
laryngectomy. If clinical evidence of reconstructing the glottis after crushing
metastasis to the cervical lymph nodes is injuries to the larynx. The stents are made
present, neck dissection is done in continuity from silastic and have been prepared from
with the laryngectomy. During the past 15 molds of the larynx taken from male and
years, conservative techniques have been female cadavers. Assistance is likewise needed
more widely used to conserve voice function. in the management of patients with
In addition to the use of laryngo- fissure and postcricoid and upper esophageal carcinomas.
cordectomy, supraglottic laryngectomy, We prefer a two-stage operation which is a
frontolateral laryngectomy, hemi- modification of the Wokey operation. After the
laryngectomy, and subtotal laryngectomy have ablation procedure has been carried out and a
become proven methods of controlling cancer pharyngostome and an esophagostome
in this area without sacrifice of the patient’s created, a polyvinyl chloride tube is used to
voice. Patients who have lost the function of connect the pharynx and esophagus for 3 to 6
speech by total laryngectomy are rehabilitated weeks before the second and final stage is
by training in esophageal speech and by use of done. This tube (Fig. 11.18) was designed by
the electronic artificial larynx. Also, in recent William Montgomery of Boston and can be
years use has been made of the Asai technique constructed by the maxillofacial prosthetic
which is simply a creation of an epi- thelia- department.
lined tube between the trachea and the The prognosis for the patient with carci-
pharynx to allow the patient to produce sound noma of the larynx depends on the extent and
on exhaling. These patients usually exhibit location of the primary lesion and the
excellent voice quality with no training being presence, of metastatic disease in the neck.
necessary, but the disadvantage is the Irradiation and the use of laryngofissure and
aspiration of saliva and, at times, food during cordectomy for small lesions of the mobile
eating. This procedure is reserved for patients vocal cord will produce about the same result,
who are unable to develop satisfactory an 80% 5-year survival. Laryngectomy for
esophageal speech or be rehabilitated with an glottic and subglottic cancers will produce
electronic artificial larynx. approximately a 70% 5- year cure rate.
There are only a few situations that require Supraglottic laryngectomy for cancer of the
the surgeon interested in laryngeal problems supraglottic structures will also provide about
to ask for assistance from members of the a 70% 5-year salvage. The poorest prognosis is
maxillofacial prosthetic service. Occasionally, with pyriform fossa carcinoma, for which the
contracture of the tracheal stoma requires the salvage overall is between 25 and 30% with
use of an acrylic or silastic button (Fig. 11.17), the total laryngectomy and neck dissection.
to prevent microstomia. The prosthodontist Bone and Odontogenic Tissues. Osteo-
has also

FIG. 11.17. Silastic button used on tracheal stomas to prevent contracture.


FIG. 11.18. Montgomery tube.
SURGERY OF HEAD AND NECK CANCERS 173

FIG. 11.19. Maxillary antral carcinoma. Physical Findings included: A, swollen right cheek, and B, hard palate
mass on the right.

sarcoma rarely involves the facial bones, but cystic defect with marked enlargement of the
in the small number of reported cases the jaw.
mandible is most commonly involved. This Treatment of the odontogenic neoplasms
very aggressive lesion carries a poor prognosis must be predicated upon the histologic
but is not quite as ruthless as those diagnosis as well as the clinical and radio-
osteosarcomas occurring elsewhere in the graphic findings. For example, the amelo-
body. It usually does not metastasize via the blastic fibroma, adenoameloblastoma, and the
lymphatics with neck node involvement but pigmented neuroectodermal tumor of infancy
distantly. Treatment consists of radical (melanotic progonoma) require only simple
mandibulectomy or maxillectomy with enucleation and curettage. On the other hand,
consideration of a heavy dose (7,000 to 10,000 the ameloblastoma and the calcifying
r) of postoperative x-ray. Because of the epithelial odontogenic tumor (Pindborg tumor)
aggressive nature of the lesion, the author require more vigorous surgical ablation, again
does not advocate immediate or early bony depending upon the clinical and radiographic
reconstruction. However, if the site is the findings. The authors advocate and practice
maxilla, intraoral prostheses are in order, aggressive curettage followed immediately by
initially to retain a split thickness skin graft, chip bone grafting into the defect in the early
followed after 4 to 6 weeks of healing with a cases with limited destruction. In recurrent or
permanent type of prosthesis containing teeth. extensive cases, a more radical approach with
The neoplasms of odontogenic origin wide segmental resection is preferred.
comprises a wide range of histologic types Paranasal Sinuses. This group is included
with corresponding differences in their clinical in the intraoral lesions because they
behavior and prognosis (see chapter 4). These occasionally present intraorally from erosion.
are benign neoplasms even though some types Their incidence has been reported to be as
such as the ameloblastoma may show high as 3% of all cancers of the upper
persistent local growth and invasion of the respiratory and gastrointestinal tracts. The
jaw bone, most commonly the mandible. In cell type is most commonly epidermoid,
this respect, the ameloblastoma simulates the varying from well-differentiated to highly
basal cell carcinoma in that it is locally undifferentiated. The less common cell types
destructive but does not metastasize except in include the cylindroma and the malignant
very rare instances. Radiographically, the lymphomas viz., reticulum cell sarcoma and
ameloblastoma may appear as a lymphosarcoma.
circumscribed radiolucency, often arising Symptoms, as in other cancers, usually
within the wall of a dentigerous cyst, or as a occur late. Often the lesion has become far
multilocular advanced, with loose upper teeth being the
174 MAXILLOFACIAL PROSTHETICS

presenting symptom; others present with pain ographic evidence of involvement of the base
over the cheeks, nasal obstruction, purulent of the skull, distant metastasis, or tumor
secretions, or ocular symptoms which occur whose cell type is the lymphoma group. The
when the floor of the orbit becomes involved surgical technique uses the Weber-Ferguson
(Fig. 11.19). skin approach (Fig. 11.20), followed by wide
The etiology is not known, but as many as osseous resection with osteotomes and/or new
20rr of these patients have long standing osseous power tools. The defect, including the
sinusitis or nasal polyposis. Papillary sinusitis inner surface of the cheeks, is lined with a
has long been considered a premalignant split thickness skin graft and obturated by a
disease similar to leukoplakia of the oral preoperatively constructed temporary dental
cavity. prosthesis. After a sufficient healing period (4
Because early diagnosis is extremely dif- to 8 weeks), a dental prosthesis is fitted which
ficult, these lesions carry a poor prognosis. includes an obturator for the maxillary
The combined approach of a full x-ray course antrum as well as the missing alveolar ridge
(6,000 r of cobalt), followed in 4 to 6 weeks by and palate, plus teeth (Fig. 17.19, Chapter
maxillectomy and orbital exenteration has 17). When the orbit is included in the
given the best survival rates. Surgery is specimen, an external pros-
contraindicated if there is radi

FIG. 11.20. Maxillectomy. A, Weber-Ferguson approach. B, specimen removed. C, closure incision hidden in
normal skin folds and lines. D, stippled area outlines the tissue removed.
SURGERY OF HEAD AND NECK CANCERS 175

TABLE 11.1. Classification of Parotid Tumors Differential points in the behavior of these
Percentage
Percentage
lesions are outlined in Table 11.2. If the deep
of
benign or
of lope is involved, the tumor may present as an
total
malignant intraoral lesion in the form of lateral wall
protrusion (Fig. 11.21). Preliminary incisional
Benign
Mixed 77 58 biopsy, generally speaking, is
Warthin’s (papillary cystade- 9 6 contraindicated", and needle aspiration
noma lymphomatosum) frequently does not furnish sufficient tissue
Oxyphilic adenoma 2 1.5 for diagnosis.
Chronic parotitis (Mikulicz’s 4 0.5
Treatment of the mixed tumor is superficial
disease)
lobectomy, sparing the facial nerve and not
Hemangioma 1 0.5
Cyst 4 3
interrupting the capsule, because if the latter
is broken, seeding occurs in the wound with
Lymphangioma (hygroma)
Neurofibroma recurrence and potential extensive
Neurilemoma involvement as serious as in some malignant
Lipoma lesions.
Hyperplastic lymph node The mucoepidermoid carcinoma (Fig. 11.22)
Malignant Low grade is the most common malignancy of the parotid
Mucoepidermoid gland. The well-differentiated form
25 6 (predominantly mucus-producing) destroys by
Adenocystic (cylindroma) 16 4
local invasion and rarely metastasizes. The
Acinar cell 9 2
superficial lobe is by far the most commonly
High grade Undifferentiated
involved, and treatment is lobectomy, with
18 4.5
Squamous cell 9 2.5 neck dissection only when neck nodes are
Sarcoma 4 1 involved with disease. The other low grade
Lymphosarcoma 10 2 malignancies are adenocys- tic carcinoma
Rhabdomyosarcoma (cylindroma) and acinar cell adenocarcinoma.
Malignant mixed Metastatic Their behavior and management are the same
squamous cell car- 6 2 as for the mucoepidermoid tumor (see also
cinoma Chapter 4).
Metastatic melanoma
3 1 The high grade malignant group includes
squamous and undifferentiated carcinomas as
thesis—orbit—is necessary which again can be well as miscellaneous types of
constructed approximately 8 weeks after adenocarcinoma. They are rarer but metas-
healing (all epithelial surfaces closed). tasize widely and rapidly; therefore, in

Extraoral
TABLE 11.2. Clinical differential characteristics of
Salivary Glands. The three major salivary
parotid tumors
glands are the parotid, submaxillary, and
Characteristics Benign Malignant
sublingual. Tumor involvement is most
common in the parotid and, because the facial Duration Long standing Recent origin
nerve and its branches course through the Rate of growth Very slow More rapid
gland, its involvement is potentially the most Size Large Smaller
serious. While 25% of the parotid tumors are Pain Absent Present 25%
malignant, the most common benign lesion, Facial palsy Absent Present 20%
Tenderness Infrequent Frequent and may
the mixed tumor (pleomorphic adenoma), has
be marked
a marked tendency to recur and can destroy by Consistency Stony hard
Rubber hard to
local invasion. Table 11.1 lists several types of soft
parotid neoplasms and other enlargements Attachments Movable Often fixed
and their occurrence rate. Regional lymph Not enlarged or If large, presump-
nodes unrelated tive diagnosis
176 MAXILLOFACIAL PROSTHETICS

the face destroy primarily by local invasion; if


medical care is sought early, the cure rate is
high. However, frequently these lesions are
allowed to progress before medical attention is
sought, and by then large amounts of tissue
have been destroyed which may include entire
regions—ear, nose, cheek, etc. (Fig. 17.5,
Chapter 17).
Surgical ablation of these lesions affords
the opportunity to examine resection margins
for adequate excision and, if necessary, wider
resection is performed at that time. These
tumors frequently manifest an iceberg
behavior in which the skin appearance does
not denote the true lateral and deep
FIG. 11.21. Tumor of the deep lobe of the parotid
expansion. The surgical plan calls for first
presenting intraorally as a lateral pharyngeal wall bulge.
eradicating the disease, with resection
margins somewhat greater in squamous cell
and inflammatory types of basal cell
addition to lobectomy, ipsilateral neck dis-
influenced by anatomic site, and then the best
section is indicated. Also, facial nerve resec-
possible functional and cosmetic repair. In
tion is frequently necessary. However, a nerve
recent years there has been an increased
graft, using the postauricular nerve if it is not interest in immediate repair not only to cover
involved, is often successful.
vital structures but also in severe deformities
Skin. The three chief skin cancers are basal
or functional disturb-
cell carcinoma, squamous cell carcinoma, and
malignant melanoma. Fortunately, the latter
is much less common, because it is
considerably more aggressive with early
lymphatic metastasis, as well as distant
dissemination via the blood stream. Squamous
cell cancer also has the capability of regional
node metastasis, but basal cell almost never
metastasizes.
Because these lesions are more common in
geographic areas where the sun is bright and
shines a lot and because they are usually seen
in fair-complexioned, lighthaired individuals,
their etiology is believed to be a combination
of hereditary predisposition and
environmental stimulus.
Clinically, basal cell carcinoma presents in
various types including cystic, cicatrical, and
papulo-pearly; however, the behavior of all
types is identical. Two precancerous lesions,
senile keratosis and x-ray dermatosis, are
thought by some to be the origin of the
majority of squamous cell cancers, but they
can arise de nouveau.
Basal cell and epidermoid carcinomas of FIG. 11.22. Mucoepidermoid carcinoma of parotid:
recurrence after initial conservative resection.
SURGERY OF HEAD AND NECK CANCERS 177

ances to restore the patient more quickly to an with the invasive lesions requiring a much
acceptable role in society, versus an earlier wider resection because of the potential lateral
school of thought which dictated a waiting lymphatic spread. The subject of node
period for possible recurrence before extensive dissection is a controversial one; however, the
reconstruction. balance of evidence favors removal of neck
Surgical reconstruction for the small le- nodes that drain the primary site in the
sions commonly requires simple closure. Other invasive type.
modalities include skin grafts (split or full
REFERENCES
thickness), island flaps, and advancement
flaps, with distant flaps being reserved for the 1. Chalian, V. A.: Head and neck tumors and maxillo
facial prosthetics. J. Kentucky Med. Ass. 65: 863-
more extensive defects. 866, 1967.
As mentioned earlier, the melanomas are a 2. Conley, J.: Concepts in Head and Neck Surgery.
different entity. The head and neck area has Georg Thieme, Stuttgart, 1970.
the highest incidence of melanoma and a 3. Jackson, C. L.: Evolution of surgical technique in
treatment of carcinomas of the larynx. Laryn-
better survival rate than other areas of the goscope 66: 1034-1041, 1956.
body. Histologically these lesions are classified 4. MacComb, W. S., and Fletcher, G. H.: Cancer of
into two groups: superficial melanoma, which the Head and Neck. The Williams & Wilkins
involves no more than the upper one-half of Company, Baltimore, 1967.
the dermis, and invasive melanoma. The 5. Martin, H. E.: Surgery of the Head and Neck Tu
mors. Hoeber Medical Division, Harper & Row,
former has a considerably better prognosis, Publishers, New York, 1957.
and treatment is less aggressive. The most 6. Ogura, J. H.: Supraglottic subtotal laryngectomy
important treatment is an adequate local and radical neck dissection for carcinomas of the
excision, epiglottis. Laryngoscope, 68: 983-1003, 1958.
12
RADIATION THERAPY IN CANCERS OF THE HEAD
AND NECK AREA
Ned B. Hornback

All malignant tumor cells of plants, lower and respond best to lower doses of irradiation.
animals, and man can be completely destroyed This increased sensitivity of immature and
by ionizing radiation. Unfortunately, the rapidly dividing cells to irradiation can also be
normal cells which surround the tumor cells seen in infants, in whom relatively small doses
are also susceptible to damage by this of irradiation can cause irreparable damage to
irradiation. However, most tumor cells are rapidly developing epiphyseal centers.
more sensitive to the damaging effects of Certain tumors are more readily destroyed
irradiation than are the surrounding normal by ionizing irradiation than are others. An
cellular tissues. It is this difference in important aspect of this radiosensitivity of
sensitivity response that permits the use of tumors is the type of tissue from which the
ionizing irradiation for the treatment of tumor arises. Tumors of germ cell origin
patients with malignant disease. (seminomas and dysgermi- nomas) are
How x- or gamma ray irradiation acts to extremely sensitive to irradiation, whereas
damage malignant cells is not completely most bone tumors, notably the osteogenic
understood. Several theories have been sarcomas, are very radioresistant, and only in
advanced as to how the radiation energy desperation does the radiation therapist
absorbed by the cell is converted into cellular undertake to treat them.
destruction. Proponents of the target theory There is considerable individual variation
say that a single sensitive area in the cell in tumor response, but the following is a list of
must be directly hit by an x-ray before death the common tumors and their relative
can occur. Others feel that radiochemical radiosensitivity.
toxins are released which are injurious to the
cells. Some propose that the cell dies because Highly sensitive
the proteins in the cell are split' following tumors Germ cell
irradiation, thereby increasing the osmotic neoplasms
tension of the cell and thus causing it to Dysgerminomas
absorb more body fluids until the cellular Seminomas Leukemic
infiltrates Sensitive
membrane finally ruptures. Whatever the
tumors
direct cause for injury to the cell, it can be Tumors of reticuloendothelial origin
observed clinically that tumors undergoing the Hodgkin’s lymphoma
greatest number of cellular divisions (e.g., Lymphosarcoma Reticulum
undifferentiated tumors) are the most sarcoma Giant follicular lymphoma
sensitive
RADIATION THERAPY 179

Lymphoma cutis then be given to the tumor without excessive


Multiple myeloma Tumors damage to the extremity.
of nervous system Other workers2"5, 7i 9- 12, 16, 19 have inves-
Neuroblastoma M tigated the use of certain chemicals, e.g., 5-
edulloblastoma fluorouracil, methotrexate, 5-bromo-
Retinoblastoma deoxyuridine, and actinomycin D, to enhance
Miscellaneous tumors
the effects of Irradiation on tumor cells.
Nephroblastoma (Wilms’ tumor)
Undifferentiated carcinomas
Results are encouraging, but extensive clinical
Lymphoepithelioma Moderately sensitive trials will be needed. As new
tumors Squamous cell carcinoma Basal cell chemotherapeutic potentiating drugs are
carcinoma Adenocarcinoma of uterus and developed and new treatment techniques are
breast Relatively radioresistant tumors perfected, the use of radiation therapy for the
Malignant melanoma Osteogenic sarcoma control of malignant disease will continue to
Adenocarcinoma (other than breast or expand.
uterus)
Teratoma Choice of Treatment: Surgery versus
Irradiation
While there are many times when a patient
Radiosensitivity must not be confused with could receive either irradiation or surgery,
radiocurability. Often the most sensitive there are also occasions when he could best be
tumors can be very aggressive and treated with surgery preceded by a dose of
metastasize widely and, while the tumor may irradiation. In such situations, the dose is
be controlled locally, the patient may later usually less than is given when one is
succumb to widespread metastatic disease. attempting to obtain a cure with irradiation
There has been considerable interest among alone. The purpose of preoperative irradiation
radiobiologists and radiotherapists in the is twofold: (1) to damage the most aggressive
possibility of increasing the sensitivity of the highly malignant peripheral tumor cells which
tumor to irradiation by various methods. would be most likely to be spread by the
Malignant tumors which have a good blood surgeon, and (2) to damage the “tumor bed,”
supply and are well oxygenated are more thereby making it more difficult for tumor
sensitive to irradiation than those with a poor cells left behind to become implanted in the
blood supply. Some radiotherapists feel that surgical field.
irradiating their patients in hyperbaric While each modality has both advantages
chambers, a procedure which increases the and disadvantages in the management of the
oxygen supply to the tumor, should improve patient with malignant disease, strong
the control rate of local tumors. Preliminary consideration should be given to carefully
results with this method have been administered radiation therapy alone. This is
encouraging.20 because it offers the overwhelming advantage
Suit and Lindbert18 have attempted to of preserving more of the patient’s normal
compensate for the difference in oxygen unaffected tissue, which must be removed in
tension of the hypoxic tumor as compared with all radical surgical operations. If there is a
the well-oxygenated normal tissue by placing recurrence following irradiation, often the
tourniquets on extremities and reducing the same radical surgical operation that was
blood supply to both the normal and tumor planned initially can be performed, provided
tissue. Since the blood supply to the tumor is that the patient is carefully observed after the
reduced less than it is to the normal tissue of radiotherapy so that a recurrence can be
the extremity, the relative lack of oxygen discovered early. On the other hand, if a
supply to the tumor is equalized. Larger radical surgery approach is used first and
irradiation doses can radiation is used in an attempt to control
recurrence, long-term control is usually
180 MAXILLOFACIAL PROSTHETICS

unsuccessful because of the disrupted blood approximately 0.5 cm below the surface of the
supply in the tissues and the resulting loss of patient, thus sparing the skin of the patient.
oxygen supply to the tumor. However, if a skin lesion is to be treated, a low
Some physicians have attempted to prove energy beam or soft x-ray is used so that the
that surgery is superior to irradiation, or vice surface receives the maximal dose and the
versa, by a statistical analysis of 5-year deeper structures are spared from high doses
survival rates. However, these reports are of irradiation. Since all of the above machines
frequently based on carefully selected groups produce a spectrum of low energy x-rays up to
of patients having a tremendous variability of their maximal energy, various filters of glass,
factors which undoubtedly influence the copper, tin, aluminum, etc., are used to
survival rate more than the type of treatment remove the softer x-rays and “harden” the
used. Age, medical condition of the patient, beam. The principal purpose of the filter is to
type and stage of tumor, cooperation of the remove the “soft” irradiations or lower
patient, resistance of the host, and energies produced, in order to obtain a proper
aggressiveness of the tumor are important depth of penetration of the' beam desired.
factors often ignored by the researcher. Very The other common form of radiation
few studies are available for review that production in radiation therapy is derived
accurately measure the control rate of surgery from a disintegrating radioactive nucleus, e.g.,
against the control rate of irradiation on cobalt-60. A cobalt machine is basically a lead
identical groups of patients with similar box which houses the decaying radioactive
tumors. This can be done only with a source. When the patient is to be treated, a
randomized group of patients, excluding all part of the lead box called the shutter is
factors except the type of treatment used.
removed, and the source is allowed to “see” the
The host’s own resistance to the tumor
area to be treated. Cobalt-60 is an excellent
undoubtedly represents the most important
source of radiation because of its pure energy,
factor in the successful management of the
releasing only two x-rays with an everage
cancer patient. Patients with malignancies
energy of 1.2 mev. At this energy level, the
rapidly spreading as a result of low host
maximal absorption of the beam is 0.5 cm
resistance present a distressing problem.
below the surface, permitting treatment of
Early death is the end result, regardless of the
deep- seated tumors in the body without
treatment method used.
burning the skin. It is basically a very simple
Methods of Irradiation Production therapy machine with a high degree of re-
External Irradiation. Two basic methods of liability and accuracy since it has a mono-
producing external irradiation energy are used energic beam and decays at a predictable rate
in radiotherapy: (1) converting electrical (x-ray machines have the distinct dis-
energy into x-rays, electrons, neutrons, or advantage of having a number of electrical
protons, and (2) using the gamma decay of and mechanical factors which can vary the
radioactive nuclei. The energy of the x-ray intensity and energy of the x-rays).
produced by an electrical current is directly Internal Irradiation. Certain malignant
dependent upon the amount of electrical tumors can best be treated by local im-
energy in kilovolts applied to the x-ray tube. plantation of radioactive sources of radium,
Thus, a 250-kv machine can produce x-rays cobalt, cesium, gold, radon, etc., directly into
with energies up to 250 kev. A 1 million-volt the tumor. Radium, cobalt, and cesium sources
machine can produce x-rays with energies up are removed from the patient at a prescribed
to 1,000,000 electron volts. The greater the time and may be used again in other patients.
energy of the x-ray beam, the deeper the Radioactive “seeds” of gold and radon are
penetration of the maximal dose or irradia- inserted into tumors and left in place
tion. A 2 million-volt x-ray unit will produce permanently. Internally placed radioactive
its maximal irradiation at a depth of sources of
RADIATION THERAPY 181

radium, cesium, and cobalt come in various treated with wide surgical excision of the
forms of needles, tubes, and plaques and are primary and a lymph node dissection
used primarily for curable lesions, since a whenever possible. Sanderman17 has shown
fairly accurate dosage may be calculated. Gold reason to believe that a course of preoperative
and radon seeds which measure approximately irradiation prior to surgical excision offers a
1 cm in length are difficult to place in the better chance for control of the malignant
exact position desired, thus making accurate melanoma than does surgery alone.
dosage calculations difficult, if not impossible. Hellriegel10 offers evidence that radiation
These permanently placed radioactive seeds therapy alone may be more effective than
are used primarily for palliation of enlarged surgery in managing malignant melanomas of
local tumor masses. the skin. His well-documented cases indicate
When internal radioactive sources, such as that there are challenging opportunities for
radium needles, are used by the therapist, the improvement in this usually depressing
overall dosage to the normal tissue condition. When age, medical condition, or
surrounding the tumor is considerably less extent of disease does not permit a wide
than with external therapy because of the surgical excision, irradiation certainly should
rapid fall-off of dosage rates surrounding the be strongly considered in an attempt to control
radioactive sources. local disease. Dosages must necessarily be in
Specific Areas in Head and Neck where the higher dosage range and approach
Irradiation Is Frequently Used to Treat tolerance of the normal surrounding tissue.
Cancer Basal Cell Carcinoma. Several different
clinical types of basal cell carcinomas are
Before undertaking treatment of any
recognized, and they appear to have the same
malignant lesion, the physician should learn
degree of radiosensitivity.
as much as possible about the patient. An
Ulcerative Basal Cell Carcinoma (Rodent
adequate history and a careful, complete
Ulcer). This common type of basal cell tumor is
physical examination are mandatory to
recognized by the flat ulceration surrounded
determine the general health of the patient
by pearly borders and the enlarged capillaries
and the extent of the tumor. A positive
leading into it.
histologic specimen is also required on all
Adenocystic Basal Cell Carcinoma. This
patients undergoing radiation therapy.
basal cell type is diagnosed clinically by its
Appropriate laboratory examinations and
tendency toward papule formation without
diagnostic x-rays should be obtained as
ulceration.
indicated prior to treatment. It would be
Morphea (or Serpiginous) Carcinoma. This
grossly unfair to the patient to treat a basal
lesion develops first as a flat type of neoplasm
cell lesion of the face and to permit a
with rolled up edges and later tends to heal
carcinoma of the breast, cervix, or bowel to go
centrally, forming a flat, atrophic, fibrous scar.
undetected.
Small basal cell lesions of the head and
Skin (Including Nose, Lip and Ear) neck which are freely movable can be removed
Malignant lesions of the skin of the head by simple local excision with an excellent
and neck are for the most part limited to cosmetic result. These small lesions can be
malignant melanomas, basal cell carcino: mas, adequately handled surgically or with
and squamous cell carcinomas, although other electrodissection and curettage. Certainly they
malignancies, e.g., lymphomas, mycosis can be effectively controlled with properly
fungoides, soft tissue sarcomas, and leukemic filtered low irradiation; however, it is
infiltrates, can occur in the head and neck questionable whether these relatively simple
area. lesions warrant the lengthened treatment
Malignant Melanomas. Malignant time necessary to obtain a satisfactory
melanomas have been considered by many to cosmetic result. They
be radioresistant tumors and are usually
182 MAXILLOFACIAL PROSTHETICS

can often be controlled with an excisional Moderate-sized lesion, 2 to 3 cm: 5000 rads
biopsy, and no further treatment is indicated. over 4 weeks, using treatment 3 to 5 times per
When basal cell lesions increase in size and week.
encroach upon vital cosmetic structures, such Larger lesion, over 3 cm: 6000 rads over 5
as eyelids, nose, ears, or lips, then one should weeks, using treatment 3 to 5 times per week.
strongly consider using protracted radiation Certain areas of the face are particularly
therapy because of the excellent cosmetic suited for irradiation. The cases shown in
result which can be obtained. Since these Figures 12.1 through 12.3 illustrate the
patients are best treated as out-patients, the excellent cosmetic results that can be obtained
expense to the patient is minimal. Control if proper fractionation is used.
rates for basal cell lesions are similar whether Squamous Cell Carcinoma of Skin. The
one uses radiation therapy or surgical excision ability of squamous cell skin lesions to
when results of comparable lesions are metastasize to local lymph nodes presents a
studied.8 special problem which is not seen with basal
Some clinicians have stated that most cell tumors. Not only must the clinician be
patients who have had radiation treatment for concerned about the local control of the tumor
malignancies will in time develop new cancers but he must carefully observe the patient for
in the irradiated areas. Experienced development of nodes prior to, during, and
radiotherapists who have carefully followed following treatments. Moss15 reports that in
their patients for many years find this to be an 365 cases the average incidence of metastasis
extremely rare possibility, and irradiation from squamous cell lesions of the skin
should never be withheld from the patient for (excluding lip) was 6.6%. Interestingly enough,
this reason. It is true that, while basal cell those skin lesions occurring about the ear had
lesions will develop near previously treated a high metastatic nodal rate of 15%, while
areas (as well as in other areas about the head those of the cheek had only a 4% metastatic
and neck that have not been exposed to rate. If the squamous cell lesion is treated
irradiation), the development of these new primarily with irradiation and neck nodes are
lesions reflects only the propensity of this either present or develop at a later date, these
individual to develop new lesions rather than are preferably handled by a neck dissection, as
the history of previous irradiation. When neck node metastases are difficult to treat
small basal cell lesions occur in essential with radiation therapy alone.
cosmetic areas, they can be successfully There is mounting evidence that neck
treated with a short treatment course, using a dissection, preceded by preoperative irra-
low kilovolt machine (120 to 140 kv). Larger diation, decreases local recurrence of tumor in
lesions require larger doses and a deeper form previously irradiated areas.11- 13 The primary
of irradiation, 250 to 500 kv. When larger lesion, however, may be successfully treated
doses of irradiation are given, it is important either by irradiation or surgical excision or a
to protract the course of irradiation combination of the two. The method selected
sufficiently to produce a satisfactory cosmetic depends upon various factors, such as extent
result. Although a wide variety of doses may of disease, presence of lymph node metastasis,
be used to treat basal cell lesions, the area involved, age and mental condition of the
following dosage and treatment time schedule patient, and availability of type of therapy to
currently being used at the Indiana University be used. There are certain contraindications to
Medical Center are considered adequate to treatment by irradiation, such as the
destroy the tumor, yet allow for regrowth of following: (1) tumor occurring near or in the
the unaffected normal skin. area of previous irradiation; (2) tumor
Small lesion, 1 to 2 cm: 4000 rads over 2 occurring in atrophic, poorly vascu-
weeks, using treatment 3 to 5 times per week.
RADIATION THERAPY 183

larized scar tissue; (3) a mentally disturbed,


uncooperative patient.
A small squamous cell lesion that can be
excised with adequate margins without
unduly deforming the patient certainly is a
candidate for surgery. If, however, excision of
the lesion means‘ removing vital cosmetic or
functional tissues, a procedure which in turn
requires extensive repair by plastic surgery,
then radiation therapy should be strongly
considered. The therapy must be done with
adequate margins, protraction of adequate
tumor doses, and protection of uninvolved
normal tissue. Large lesions which are
ulcerating and grossly infected appear to
respond much better if the infection is treated
with appropriate antibiotics at the time of
radiation therapy. Since the lesions are visible
and on the surface, the irradiation used is of
relatively low energy but will vary with the
depth of the lesion. Most squamous cell lesions
can be successfully controlled with 140-kv
superficial machines with proper filtration.
Lesions involving deeper structures similarly
require use of more penetrating forms of
irradiation in the range of 200 to 250 kv.
Again, as with basal cells, tumor dosage
depends somewhat on the size of the lesions,
but a dose of 6000 rads fractionated over 5
weeks appears to yield satisfactory cosmetic
results.
When squamous cell lesions overlie car-
tilage and bone with minimal or no gross
invasion of the structure, the risk of devel-
oping radiation chondronecrosis or osteo-
necrosis is extremely small if proper frac-
tionation of the total dose is employed.
However, if extensive destruction of cartilage
or bone is present, the patient usually does
very poorly and, while the tumor may be
controlled, painful chondronecrosis or
osteonecrosis often develops in later years.
FIG. 12.1. A 72-year-old white male had a 3- month
Preoperative irradiation followed by radical
history of a small ulcerated tumor of the nose. Biopsy
revealed basal cell carcinoma. A, the lesion prior to
surgery is preferable in extensive lesions
treatment. B, its behavior immediately following 6000 which have grossly destroyed bone and
rads delivered in 5 weeks, using 140-kv irradiation. C, cartilage. Preoperative irradiation doses from
there is no evidence of disease 3 years later. 2000 to 5000 rads over 1 to 5 weeks have been
successfully given without impairing wound
healing.
184 MAXILLOFACIAL PROSTHETICS

FIG. 12.2. A 56-year-old white male presented with a 6-month history of tumor of upper lid. Biopsy revealed
basal cell carcinoma involving tarsal plate. A, the lesion prior to treatment. B, stone moulage of the face for the
making of a lead protective mask. C, protective lead mask. D, the mask is dipped in wax to prevent possible
secondary electron contamination. E, the treatment set-up with protective eyeshield. F, a superficial 140-kv cone
is directed to the lesion. G, radiation reaction after the patient received 6000 rads in 5 weeks. H, there has been
no evidence of recurrence after 5 years. Note permanent epilation of hair. Vision has remained normal and equal
with untreated eye.

Keratoacanthoma (“Disappearing usually spontaneous regression of the lesion


Cancer”) (Fig. 12.4). Of all the skin tumors, occurs without treatment in 3 to 6 months.
keratoacanthoma is by far the most Treatment, if required, is surgical, and a
interesting. The diagnosis is made clinically simple excision of the lesion is all that is
by a careful history and physical examination. necessary. Indications for treatment are
The history is usually one of a rapidly limited to lesions that may encroach upon and
developing nodular skin lesion that increases destroy adjacent vital structures before
in size over a period of 3 or 4 days, then spontaneous remission occurs. There is no
becomes stable. It sometimes will ulcerate and reason to treat these lesions if the physician is
may become slightly larger over the next few willing to follow the patient carefully and to
months. Correct diagnosis by histology can be observe the lesion for changing growth
made only with a total excision of the lesion. A patterns.
biopsy of the lesion will appear as a well- Benign Lesions of Skin (Fig. 12.5).
differentiated squamous cell carcinoma, and Benign lesions of the head and neck area are
for the most part handled surgically.
RADIATION THERAPY 185

Only occasionally is it necessary to resort to to therapeutic doses of irradiation. Early


irradiation for the control of benign lesions. epiphyseal damage and closure, failure of
One indication for irradiation of a benign glandular development, sterilization, and
condition is seen in children in whom the cataract formation are only a few of the
tumor is growing rapidly and encroaching possible late manifestations of unnecessary
upon vital structures, with imminent childhood irradiation. There is also the rare
destruction of the organ or the individual. possibility that low kilovolt irradiation in
This condition can be seen in capillary childhood for a benign lesion may later lead to
hemangiomas of the head and neck in infancy, the development of skin cancer. This is
when the tumor may encroach upon the eye or extremely rare and unlikely if proper
may interfere with the sucking reflex or radiation doses are used, but nevertheless it
breathing of the infant. Parents are anxious to must be kept in mind.
have unsightly cavernous hemangiomas Lip. Basal cell lesions can originate in the
removed from the faces of their children; skin surrounding the lip and may invade the
however; experience has demonstrated that lip but, for the most part, carcinoma of the lip
most of the lesions regress spontaneously in is of squamous cell variety. Lymph node
early childhood. metastasis from squamous cell carcinoma of
Radiation to children should be avoided the lip has been variously reported as
whenever possible because of the marked occurring in from 6 to 15% of cases. 1,6 Lip
sensitivity of the rapid developing tissues cancers can be successfully treated with either
radiation or surgery,

FIG. 12.2, E to H.
186 MAXILLOFACIAL PROSTHETICS

FIG. 12.3. An 82-year-old white male had a 12-month history of an untreated sore on the lower lid. A the lesion
prior to treatment. B, the treatment shield. C, treatment position with protective shield. D, the tissue reaction is
seen immediately following administration of 6000 rads in 5 weeks, using a 140-kv machine in 15 treatments. E, 3
years after treatment, there is no evidence of recurrence. Vision is “better” in the treated eye.

and the smaller the tumor, the easier the increases in size beyond 1 to 2 cm and
control. Small lesions of the lip that can be occupies a larger portion of the lip, carefully
excised with a simple V-incision with ade- protracted radiation can produce excellent
quate margins can afford a good cosmetic cosmetic results with good longterm control
result. The procedure is simple, effective, and rates. The cases illustrated in Figures 12.6
relatively inexpensive. As the tumor through 12.8 indicate the ex
RADIATION THERAPY 187

cellent results that may be obtained with must be included to ensure that the entire
irradiation alone. lesion is in the field of irradiation. If the lesion
Since the radiation beam does not stop at recurs following an adequate dose of radiation,
the lip, care must be taken to protect the the recurrence will be seen at the periphery of
underlying structures: gums, teeth, tongue, the field, and this means that an inadequate
etc. Carefully constructed, comfortable lead port has been used to cover the original tumor.
protective devices can provide adequate The treatment schedule of 6000 rads in 5
protection. weeks produces excellent cosmetic results.
A fairly superficial type of irradiation is Treatment may be given daily or, if the
used in small lesions of the lip and, as the patient is traveling from some distance, 3
tumor increases in size and depth, deeper times a week.
forms of radiation are used. It is usually not
necessary to use a machine of any greater Oral Cavity
energy than 250 kv when dealing with Included in the discussion of cancer in the
carcinoma of the lip. oral cavity will be gingival cancer of both
Adequate margins around the tumor upper and lower gums, the anterior

FIG. 12.4. A 65-year-old white female with a history of a tumor mass above the upper lip developing rapidly
over 3 to 4 months. A clinical diagnosis of keratoacanthoma was made, and the patient was followed at monthly
intervals. Biopsy revealed well-differentiated squamous cell carcinoma. A, the lesion prior to treatment. (Note:
patient had basal cell carcinoma of nose removed surgically several years ago and, not surprisingly, refused all
further surgery to face.) B, the lesion 1 month later, no treatment. C, 3 months later, no treatment. D, there has
been complete regression of tumor at 9 months, and the patient has remained free of disease for 4 years.
188 MAXILLOFACIAL PROSTHETICS

FIG. 12.5. A 2-year-old female with a history of a rapidly increasing left orbital mass which was clinically
diagnosed as capillary hemangioma of left eyelid. A, the mass prior to treatment. B, the lesion is shown 2 weeks
following a single dose of 100 rads, using a 140-kv superficial machine.

FIG. 12.6. A 45-year-old white male presented with a 6-month history of a painless sore on the lip. Biopsy
revealed squamous cell carcinoma, well-differentiated. A, the'lesion prior to treatment. B, acrylic retractors to
expose the lesion for treatment. C, protective lead shields. D, the lip is seen 4 years and 8 months after treatment
using 250-kv irradiation, 15 treatments (6000 rads over 5 weeks).
RADIATION THERAPY 189

an adenocarcinoma developing from a


glandular structure. Sarcomas can develop in
oral cavity structures but are unusual.
Various techniques are available for the
treatment of cancer in the oral cavity, and the
radiation technique used depends upon the
location of the tumor. Lesions of the buccal
mucosa, the floor of the mouth, and the
anterior two-thirds of the tongue are in areas
which are well suited for a radium needle
implant, either alone or in combination with
external radiation therapy. Gingival lesions
involving either the upper or lower gingiva are
difficult to implant with radium because of the
close proximity of bone; these lesions are best
treated by either external therapy alone or, if
the lesion is small and accessible, an intraoral
cone can be used.
Very small lesions which can be completely
excised with minimal deformity can best be
treated with surgery alone. The only exception
would be those lesions that possess a high
degree of anaplastic activity. If transection of
the margin occurs in an attempt to excise the
lesion, follow-up treatment is, of course,
required. Transected tumors do very nicely
with a full course of radiation; they should be
treated soon after'the incision has healed and
before the tumor is allowed to grow.
As the size of the malignancy increases, it
becomes necessary for the patient to be
treated primarily by a modern radiothera-
peutic approach with a protracted course of
irradiation. Excellent cosmetic results can be
obtained with minimal discomfort to the
patient. Small lesions in the tongue, the floor
of the mouth, and the buccal mucosa can be
very successfully treated by a single plane
radium needle implant, which carries with it
low mortality and morbidity risks. In large
malignant tumors in these areas, external
FIG. 12.7. A 68-year-old white male was seen with an therapy is used first to shrink the tumor, and
exophytic lesion of the lower lip of 18-month duration. this treatment is followed by a radium needle
Biopsy revealed carcinoma of lower lip. A, the lesion implant. It has been our practice to treat
prior to treatment. B, the lesion 1 week after medium-sized lesions (3 to 5 cm) that have not
completion of irradiation using 6000 rads over 5 weeks, invaded the bone with doses of 3000 to 5000
250-kv irradiation. Note intraoral protective device. C,
rads tumor dose over approximately 3 to 5
the lip 4 years and 6 months after treatment.
weeks, using cobalt-60 external irradiation.
This is followed by a radium needle implant
two-thirds of the tongue, the floor of the delivering 3000 to 5000
mouth, and buccal mucosa. Most cancers in
the oral cavity are of the squamous cell
variety, and only occasionally does one see
190 MAXILLOFACIAL PROSTHETICS

rads given in 3 to 5 days. This has afforded handled by a neck dissection. If the primary
excellent cosmetic results with minimal remains controlled with radiation and the
amount of morbidity, and the recurrence rate neck node has completely disappeared,
is low if a good response is obtained initially elective neck dissection at this time is of
from the radiation. Gingival cancer, because of questionable value since it is extremely
its close proximity to bone, cannot be treated unlikely that a neck node will develop in a
with radium needle implant but can be previously radiated area where the primary is
handled with external cobalt-60 irradiation controlled.14 Exact dosages given to these oral
with special wedge techniques or with 250-kv cavity tumors are variable; however, a
intraoral cone techniques when possible. If the combined external irradiation and radium
tumor is of a relatively long-standing nature dose of 6000 to 8000 rads tumor dose is
and has grossly invaded bone with obvious usually required for complete control of the
bone destruction on the radiographs, these primary disease (Figs. 12.9 through 12.12).
lesions are best handled by a combined Complications of Irradiation: Prevention
approach of preoperative radiation followed by and Treatment
a surgical resection of the entire area. If high
Whenever an individual undergoes irra-
doses of radiation are given to the bone that
diation with an attempt at permanent control
has been previously infected or grossly
of carcinoma of the head and neck, normal
invaded with tumor, the risk of bone necrosis
tissue in the area of the tumor will, by
is high and, although the bone necrosis can be
necessity, be irradiated. Since normal tissue in
managed later by surgical resection, it is
different individuals has markedly different
probably best to remove the diseased bone as a
tolerance for similar doses of irradiation,
part of the initial form of therapy. Because
intensity of the symptoms varies. Fair-skinned
node disease is seen in approximately one-half
individuals with light reddish hair, who burn
of the patients with oral cavity cancer, we
easily in the sun, tend to have more reaction
routinely irradiate the first lymph node chain
to therapeutic doses of radiation than do dark-
draining the tumor area. Should an obvious
complexioned persons. Exceptions do occur as
node be present upon the beginning of
some acute reactions can be quite marked in
therapy, the neck is covered with a dose of
dark-skinned individuals without any
preoperative irradiation, and residual lymph
apparent excessive radiation exposure.
nodes are

FIG. 12.8. A 65-year-old white male had a 3-year history of a sore on the lower lip. Biopsy revealed a well-
differentiated squamous cell carcinoma. A, the lesion prior to treatment. B, the lip is shown 4Vt years after
treatment using 250-kv protracted irradiation. No evidence of disease on last visit.
RADIATION THERAPY 191

FIG. 12.9. A 56-year-old white female presented with FIG. 12.10. A 71-year-old white male with a history
an advanced squamous cell carcinoma of the anterior of a sore on the gum for the previous 6 months. Biopsy
two-thirds of tongue. There were no palpable lymph revealed a squamous cell carcinoma of retro- molar
nodes. A, the lesion prior to treatment. B, the tissue trigone area. A, the lesion prior to treatment. B, the
reaction is seen after 3500 rads over 3 weeks of Co-60 lesion after receiving 6000 rads of Co-60 in 6 weeks. C,
just prior to radium needle implant. C, the tongue 2Vi 2V% years after irradiation, there is no evidence of
years after treatment with radium needle implant. recurrence.
192 MAXILLOFACIAL PROSTHETICS

FIG. 12.11. A 67-year-old white male had an 8-month history of a lesion on the inside of the cheek. Biopsy
revealed a squamous cell carcinoma of the buccal cavity. A, the lesion prior to treatment. B, 6 years after radium
implant. No evidence of disease was seen.

FIG. 12.12. A 66-year-old white female presented with a 4-month history of a growth on the lower gingiva.
Clinical impression and biopsy revealed a verrucous type of squamous cell carcinoma, well differentiated. A, the
lesion prior to treatment. B, no evidence of disease 6 years after 3000 rads of Co-60 in 3 weeks and 2500 rads,
intraoral cone, 250 kv.

These acute reactions are dependent upon: (1) gree bum will heal with time, usually 30 to 60
the area irradiated, (2) the bulk of tissue days, and if proper protraction of the dosage is
irradiated, (3) the total dose time relationship, used, excellent cosmetic results can be
and (4) the type of irradiation used. expected.
When a patient is undergoing treatment of Irradiation of the oral cavity can produce
a skin lesion, the skin must of necessity be very distressing symptoms: soreness of the
treated in order to destroy the tumor. Therapy mucous membranes involved, dryness of the
of the tumor within the skin causes a marked mouth, and loss of taste. The greater the
reaction but surprisingly does not usually volume of irradiation, the more intense the
cause the patient any particular discomfort. reaction. It is, however, possible to treat small
This is presumably due to the temporary lesions of the oral cavity with an intraoral
interference with nerve endings in the area cone, with the patient experiencing nothing
during irradiation. This second de other than mild mucositis in the localized
tumor area. The
RADIATION THERAPY 193

acute mucositis reactions are often controlled spurs should be filed, and the gingiva over the
by good oral hygiene and salt and soda mouth mandible should be sutured.
washes, V2 teaspoon of each in a glass of warm All required dental work should be done
water every 3 to 4 hours. This appears to be prior to treatment. Healthy teeth that are in a
very soothing to most patients. good state of repair tolerate doses of radiation
Since the mouth is usually tender and sore without difficulty. The patient with teeth who
during radiation therapy, making eating has received heavy doses of radiation is
difficult, the patient can be expected to lose~5 advised to maintain excellent oral hygiene and
to 10 pounds of weight. This weight is usually to make frequent visits to the dentist for
regained upon recovery from the acute prophylactic maintenance of the teeth. If the
reactions of radiation. If swahowingjbecomes parotid glands have been irradiated,
painful, 0.5% Dyclone solution can be used 20 producing a dry mouth, it is especially
to 30 minutes before each meal. This has been important for the patient to maintain a proper
found effective in eliminating soreness of the diet, as well as to practice exceptional dental
mouth. prophylaxis. With the use of modern radiation
When large areas of the oral cavity are therapy, the incidence of bone necrosis is
treated which include the tongue or the extremely rare, and the incidence of bone
submandibular or parotid glands, dryness of necrosis in individuals having tumors not
the mouth and loss of taste can become quite involving the bone should be less than 1%.
marked. Taste usually returns to a fairly The therapist should make every effort to
normal state within 3 to 6 months following protect normal structures from receiving
irradiation. Dryness of the mouth may persist unnecessary doses of irradiation. It is of prime
for as long as 1 to 2 years. Permanent loss of importance, of course, that the tumor be
taste and permanent dryness of the mouth can treated to a full tumoricidal dose with
result from heavy doses of irradiation to large adequate margin of normal tissue; however,
volumes of tissue. Dryness of the mouth may protective lead devices often may be
be occasionally relieved by potassium-iodine constructed to shield normal tissue. Thickness
drops or by sucking on lemon drops to of the lead shields used will depend upon the
stimulate parotid or other salivary gland energy of the radiation used; for example, 11
activity. The mouth itself may be moistened by mm of lead are required to reduce cobalt
the use of various vegetable oils prior to meals. radiation by 50%. With low kilovolt levels, on
One of the most serious complications is the the other hand, thicknesses of 1 to 2 mm are
development of bone necrosis following heavy used to reduce the radiation by 50%. Various
doses of radiation. This rare complication is eye shields have been constructed to protect
found almost exclusively in patients withjjoor the cornea and lens during the radiation of
oral hvgieneJn whom the original tumor eyelids. During radiation of the lip, the teeth
presented withjnassive bone involvement prior and gums are protected by various forms of
to irradiation. The treatment is surgical, with lead shields. Many ingenious devices have
the use of appropriate antibiotics. “Radiation been used to protect the normal tissues of
necrosis” of the bone is probably a misnomer patients undergoing irradiation.
in that the damage in most, if not all,
Wound Healing
instances is a low grade osteomyelitis in an
area of bone whose resistance to bone infection One of the most talked about possible
has been weakened by the high doses of complications for the surgeon is the failure of
radiation required to cure the tumor. For this the wound to heal in a previously irradiated
reason, it is important to remove all infected field. Several factors are involved in slow
teeth prior to treatment. Bony wound healing following irradiation, including
total dosage, time over which doses are given,
and type of irradiation. One advantage of
supervoltage irradiation
194 MAXILLOFACIAL PROSTHETICS

is that the maximal dose can be delivered well were really believed that radiation causes
below the surface of the skin and thus not cancer, it would be difficult to get anybody in
interfere significantly with the skin for a routine posteroanterior and lateral chest
healing..Indeed, the skin itself may receive x-ray. Even the most ardent believers in
only 30 to 50% of the total amount of radiation radiation-induced cancer never hesitate to
dose, compared with the deeper structures. order diagnostic x-ray film on themselves on a
There are, of course, other factors which routine basis. It is known that, in a few
interfere with wound healing, since difficulty instances, it is possible to produce malignancy
in wound healing and fistula formation can be in radiated areas. In most such reports, the
seen in patients who have never received any patient has received low kilovol- tage doses of
radiation. The area of the surgical procedure, irradiation over long periods of time for benign
the nutritional status of the patient, the skill lesions. Since current irradiation of oral head
of the surgeon, and the area, size, and extent and neck lesions is almost exclusively limited
of tumor are all important factors in delayed to the cancer patient, different histologic cell
wound healing and fistula formation. When types induced by irradiation rarely if ever
preoperative irradiation is used on extensive occur. One should never hesitate to
head and neck lesions, healing of surgical recommend radiation therapy in head and
incisions has been found to be somewhat neck cancers because of the fear of developing
delayed, but in time it will take place. It must a second primary in the field of irradiation.
be remembered that the reason for giving the When one undertakes the therapy of a
radiation is not to delay wound healing but to malignancy, it is vitally important to consider
prevent the dissemination of tumor cells by the the patient rather than the tumor. The patient
surgeon and to render the tissue bed more must be aware of the disease, must be kept
informed of the treatment possibilities, and
resistant to tumor implantation. If this is to be
must be a part of the team of management of
accomplished, it is reasonable to expect that
his disease. It is the basic aim of therapy,
the normal tissue will also be affected, and
whether it be surgery or irradiation, to offer
delayed wound healing is a price that one must
the patient the best chance for control of the
pay. Delayed wound healing and fistula
disease with minimal discomfort, time, and
formation should not be a problem if proper
expense.
radiotherapy and the latest surgical skills are
judiciously applied. REFERENCES
1. Ashley, F. L., McConnell, D. V., Machida, R.,
Carcinogenesis of Irradiation Sterling, H. E., Galloway, D., and Grazer, F.:
Development of cancer from known doses of Carcinoma of the lip. Amer. J. Surg. 110: 549-
radiation is undoubtedly the most overstated 551, 1965.
2. Beckloff, G. L., and Lerner, H. J.: Concommit-
event in the field of medicine. Tumors
tant use of hydroxyurea and x-irradiation in
developing in an irradiated area are usually treatment of head and neck cancer. Int. Congr.
reported in the medical literature; however, Chemother. 5: 353-359, 1967.
the millions of people who have undergone 3. Berry, R. J.: Some observations in the combined
radiation therapy and have not developed any effects of x-rays and methotrexate on human
tumor cells in vitro with possible relevance to
cancer are not reported as it makes rather dull their most useful combination in radiotherapy.
reading. A new histologic tumor developing in Amer. J. Roentgen. 102: 509-518, 1968.
an irradiated area must be an extremely rare 4. Concannon, J. P., Summers, R. E., King, J.,
event. The type of radiation used, the energy of Tcherkow, G., Cole, C., and Rogow, E.: En-
hancement of x-ray effects on the small intes-
the beam, the area treated, and the disease
tinal epithelium of dogs by actinomycin-D. Amer.
treated are all factors to be considered in a J. Roentgen. 105: 126-136, 1969.
cause and effect approach. If it 5. D’Angio, L. J., Forber, S., and Maddock, C. L.:
Potentiation of x-ray effects of actinomycin-D.
Radiology 73: 175-177, 1959.
6. del Regato, J. A., and Sala, J. J.: The treatment
RADIATION THERAPY 195

of carcinoma of the lower lip. Radiology 73: 839 - 13. Millburn, L. F., and Hendrickson, F. R.: Initial
844, 1959. treatment of neck metastasis from squamous cell
7. Elkind, M. M., Moses, W. B., and Sutton-Gil- cancer. Radiology 89: 123-126, 1967.
bert, H.: Radiation response of mammalian cells 14. Million, R. R., Fletcher, G. H., and Jesse, R. H.,
grown in culture. VI. Protein, ANA and RNA Jr.: Evaluation of elective irradiation of the neck
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L.: The treatment of skin cancer, a statistical 15. Moss, W. T.: Therapeutic Radiology, Ed. 2, p.
study of 1,341 skin tumors comparing results 64. The C. V. Mosby Company, St. Louis, 1965.
obtained with irradiation, surgery and curettage 16. Richards, G. J., and Chambers, R. G.: Hydrox
followed by electro-dissection. Cancer 17: 35, yurea: a radiosensitizer in the treatment of
1964. neoplasms of the head and neck. Amer. J.
9. Friedman, M., and Daly, J. F.: Combined irra Roentgen. 105: 555-564, 1969.
diation and chemotherapy in treatment of 17. Sanderman, T. F.: The radical treatment of en
squamous cell carcinoma of head and neck. larged lymph nodes in malignant melanoma.
Amer. J. Roentgen. 90: 246-260, 1963. Amer. J. Roentgen. 97: 967-979, 1966.
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1168-1170, 1965.

/
13
DENTAL CARE OF HEAD AND NECK
CANCER PATIENTS RECEIVING
RADIATION THERAPY

Thomas E. Daly

The dentist’s role in the management of main concern, and the teeth and supporting
head and neck cancer patients should be to structures were considered only incidental to
work smoothly in a team approach with all the primary treatment. This held true whether
other clinicians involved in the total care of the initial treatment involved radiotherapy,
these patients. Beginning with early diagnosis surgery, or a combination approach.
and routing and continuing on through partial Prosthodontists and maxillofacial
or complete rehabilitation, the dentist has a prosthetists, along with certain other select
moral obligation to involve himself as dental groups, know the importance of
completely as is necessary for the long-range maintaining as many sound teeth as possible
well-being of any patient he is called upon to to serve as additional support for obturators,
see or who selects him. resection appliances, and other prostheses
Early diagnosis implies just that: early used in the treatment of head and neck cancer
lesions. Simpler treatment and healthier, patients. They also know the need for
happier patients are the end products of early removing grossly infected and nonrepairable
diagnosis, as are improvements in long-range teeth.
cure rates. Improving oral hygiene and performing
After a diagnosis of cancer is made, the operative procedures, particularly before
patient should be routed to the person or surgery, can be most helpful. The mouths of
center best equipped to handle his needs. head and neck cancer patients certainly need
Incorrect routing can result in delayed or no more irritation, for enough other sources of
inappropriate treatment. irritation are usually brought to light when a
For many years the oral surgeon, as a complete history of the patient is obtained.11
result of the rather dogmatic ideas that early In various cancer institutions or in hospitals
physicians held about the care of the teeth, with substantial numbers of cancer patients, a
was the only one involved with the dental partial mandibular or maxillary resection is
management of head and neck cancer patients. often performed on a patient who has not had
Later, maxillofacial prosthetists and general a dental prophylaxis beforehand. It then
prosthodontists gained recognition, yet care of becomes apparent that much infection and
the teeth and supporting structures was still inflammation could have been removed or
largely neglected. Tumor management was the partially eliminated prior to surgery. All

196
DENTAL CARE IN RADIATION THERAPY 197

surgical procedures around the gingivae,


teeth, tongue, or floor of the mouth would be
in a less infected field if a few visits for
prophylactic measures were made in advance.
Skin grafts to the floor of the mouth,
inferior surface of the tongue, or other areas of
the mouth take better when adjacent areas
are free of infection. Total or partial loss of
skin grafts because of infection can cause
prolonged hospitalization, pain, and more
extensive rehabilitation procedures. Surgical
procedures of the lip such as lip shaves, V
excision, and Esh- lander repairs heal far
better in the absence of infection. One needs
only to see a grossly infected postoperative lip
to appreciate the benefits of a thorough dental
prophylaxis before surgery.
Early articles dealing with management of
the head and neck cancer patient undergoing
radiotherapy have often been misleading.
They have led many dentists and physicians,
primarily radiotherapists or the occasional
radiologist who would treat a lesion, to believe FIG. 13.1. Nasopharynx field including parotid and
that the end product of aggressive radiation submaxillary gland irradiation.
therapy is a high percentage of bone and soft
tissue necrosis. The peculiar decay which is
commonly found after treatment of head and disagreement on some basic approaches to the
neck lesions was also thought to be an end problem. For example, some authors have said
product of aggressive radiation treatment. that extracting teeth prior to irradiation is no
Since the advent of cobalt therapy, the guarantee that osteitis and subsequent
electron beam, and other high energy ra- osteoradionecrosis will not develop16 (Figs.
diation procedures, cancer patients who would 13.5 and 13.6). It can even develop in
previously have been treated only by surgical edentulous patients following an unnoticed
procedures are being treated by radiotherapy minor trauma to the over- lying membrane
alone or by radiotherapy and surgery with resultant bone exposure and infection.3
combined9 (Fig. 13.1). As dosimetry, Other writers have advocated the
techniques, and equipment have improved, preirradiation extraction of teeth to prevent
interest in radiation therapy has increased. necrosis from occurring later. 5 Some
The defects caused by surgical intervention investigators hold a position somewhat in the
have decreased, and cosmetic results are middle, while still others admit that little is
better.14 known about which method is better. 14
For about the past quarter of a century, In addition, little has been done to alleviate
ideas on the management of a patient’s teeth the rampant postirradiation decay, and there
before and after radiation therapy have shown are many opinions on the best method of
little regard for dental hygiene or the overall reducing the high percentage of tooth decay
dental status of the patient (Figs. 13.2 to and amputation of the crowns of the teeth.
13.13). There has also been Other dental problems have more often than
not been treated by merely deferring definitive
treatment. Figures 13.1 through 13.13
illustrate var-
198 MAXILLOFACIAL PROSTHETICS

FIG. 13.2. A, patient with good dental condition prior to radiotherapy. B, lesion of same patient showing lower
left third molar that needs extraction. (Note: patient’s upper left third molar was also taken to keep it from ex -
truding downward.)

FIG. 13.3. A, patient showing fair dental condition, with teeth in direct field of irradiation being removed. B,
condition of ridges after primary closure 14 days from extraction: healing of extraction sites.
DENTAL CARE IN RADIATION THERAPY 199

ious situations encountered in connection with


radiation therapy.
From the dental and surgical standpoints,
the chief hazard in the management of the
head and neck cancer patient undergoing
radiation is of course necrosis, whether it be of
bone, soft tissue, or a combination of the two.
Postirradiation decay of the teeth is also a
matter of great concern (Fig. 13.7, A). Other
problems include sensitivity of the teeth,
trismus, infection, pain, and inability to wear
prostheses following irradiation.
These problems, their causes, and methods
to treat them are the subjects of the following
discussion.
FIG. 13.6. Advanced mandibular necrosis, showing root
sockets still present.
Bone Necrosis
Postirradiation necrosis, complete or marrow are facilitated by dividing them into two
partial, has been described since the early main groups.
days of radiotherapy. It is caused by im- 1) Quantitative changes, which comprise
pairment of the blood supply consequent to changes in the total content of cells in the
postirradiation endarteritis.6 marrow (e.g. expressed as the total number of
nucleated cells per mg. of marrow substance).
Stokke15 stated:
2) Qualitative changes, which can be subdivided
As a rule the biological effect of radiation given is into:
harmful. The nature and degree of the damage will, a) Changes in the mutual relation of the
however, depend on many factors such as the various types of marrow cells, and
radiation dose, the extent and localization of the b) Changes in the individual cell (e.g.
irradiated area, the mode of administration (e.g. the degenerative disturbances within the cell,
dose given in a single exposure, fractionated or changes in the mitotic rates, occurrence of
protracted), and the quality and penetrating power abnormal mitoses).
of the radiation. Reaction will also be influenced by
Histologic Damage
the age and nutritional and hormonal condition of
the irradiated animal or human. Whatever the source of the radiation,
Morphological changes in irradiated bone whether external or from internally deposited
isotopes, the general patterns of histo-
FIG. 13.7. A, x-rays of advanced radiation decay. B, Panorex of same patient in A, showing teeth after rehabil-
itation with amalgam restorations.

FIG. 13.8. Squeeze bottle applicators for dispensing FIG. 13.9. Material used for making fluoride carriers
fluoride into carrier: one red and one clear. Red bottle made to fit over stone model of patient’s dental arches.
has disclosing solution added to disclose plaque.
200
DENTAL CARE IN RADIATION THERAPY 201

logic change are remarkably similar in the now be viewed in the light of these known
'different species of experimental animals facts of histologic change. This is no longer
studied. bone which can function, repair, and me-
As evidence of histologic damage to bone, tabolize, as nonirradiated bone can do.
the following statement of criteria was Any surgical intervention will further tax
accepted by a panel of the International the already disturbed total healing process.
Atomic Energy Agency meeting in Vienna in Irradiated bone can no longer respond as does
1960: “(1) empty lacunae, (2) vessel injury, (3) normal bone to inflammation or infection.
development of irregular abnormal new bone, Repair processes are limited or absent as a
and (4) the appearance of varying degrees of result of cellular changes, and gross trauma or
fibrosis.”8 infection can precipitate intractable pain and
Management of bone necrosis should infection. Further management without
complete removal of the irradiated area of
bone becomes almost impossible.
At the University of Texas M. D. Anderson
Hospital and Tumor Institute and the
University of Texas Dental Branch at

FIG. 13.10. Fluoride squeezed into carrier and then


smoothed out with cotton-tipped applicator to coat
entire inner surface. FIG. 13.11. Upper carrier with fluoride in place.

FIG. 13.12. A, severe radiation decay, preoperative view. B, postoperative view, showing amalgam fillings.
202 MAXILLOFACIAL PROSTHETICS

from Holthusen7) show a correlation between


the number of cures and the number of
injuries produced by irradiation as the tumor
dose increases. The graphs hold much merit,
yet it should be noted that they are based on
the assumption that all factors are ‘'equal in a
given group of patients, with no predisposing
factors of trauma, poor nutritional status,
previous surgery, etc.
In reviewing Table 13.1, one might say

TABLE 13.1. Bone necrosis by dental groupings*

FIG. 13.13. Good-dental group 3 years following No. No. Bone Overall
Group patients Patients necrosis
bone necrosis bone
treatment yvitp. continued use of fluoride carriers. necrosis
c• 0‘
c* . :t V.
Ho^tom, a research study4
of bone necrosis Group I, 125 40.9 11 8.8 21.1
edentulous
and- other postirradiation complications- has-
Group II, 46 15 9 19.5 17.3
tbeen undertaken. Conservative management, poor
which includes minor oral surgery procedures Group III, 81 26.5 26 32 50
to remove sharp spicules and the use of
fair
antibiotics and zinc peroxide medicinal packs, Group IV, 53 17.6 6 11.3 11.5
has helped to maintain the long-term good
continuity of the maxilla and mandible; on the
other hand, traumatic intervention by means of Totals 305 52
major oral surgery or radical surgery has
* Includes all patients in the study (January 1, 1966
complicated the healing problems. If bone re-
through June 30, 1969).
moval is not taken to a clear margin, that is,
one not in the irradiated area, later surgical or
continued sequestration procedures have been
shown to be necessary.
Necrosis is more prevalent in patients who
have had oral surgery before radiation therapy
begins. Table 13.1 and Figure 13.14 indicate
that the least necrosis is seen in patients in
whom all teeth remain (the “good” group, as
against the edentulous group, in which all
teeth were removed before admission to the
hospital).
The dentally “fair” group (those with select
extractions in the field of irradiation) in Table
13.1 represents 50% of all bone necrosis seen,
yet it represents only 26.5% of all patients
included for study purposes. The dentally
“poor” group had all remaining teeth extracted.
They represent 15% of all patients and showed
17.3% of all necrosis. FIG. 13.14. Bone necrosis complication graph. Per-
The graphs in Figure 13.15 (adapted centage of patients with bone and/or, soft tissue ne-
crosis. Total of 305 patients (January 1, 1966, through
June 30, 1969).
DENTAL CARE IN RADIATION THERAPY 203

FIG. 13.15. A, curves of increasing percentage of tumor control, respectively, with skin damage and healing. B,
same curves in an unfavorable condition. (Courtesy of H. Holthusen 7.)

that an early necrosis state could be created had a neck dissection or other surgical
by the rather complicated surgical procedures procedure in that area?
required to extract some teeth prior to It is felt that long-range care of teeth would
irradiation. Time periods of waiting before be easier than management of necrosis. The
start would vary from 10 to 14 days and, in use of antibiotics,1 long-range oral hygiene
some instances, would run even longer. instructions, conservative dental treatment,
If this bone necrosis can be seen clinically, and eventual extraction of teeth as
one may ask whether it can be prevented by atraumatically as possible and only when all
reversing the causative factors. else fails, would prevent much of the necrosis
The degree of trauma necessary for the now seen.
removal of teeth, the amount of infection Before deciding to enter previously irra-
present, the number of days of healing prior to diated bone, whether for reasons of necrosis or
irradiation, and a multitude of known and for reasons of recurrence, residual disease, or
unknown factors must be considered. What is new primary, surgeons should bear in mind
the healing capacity of the individual? Is that intervention, exposure, and trauma will
diabetes or some other factor contributing to bring about additional problems to manage.
post-oral surgery problems? How many teeth However, procedures of this nature often are
are to be removed? What technique for necessary, and eventual sequelae must be
removal of these teeth is to be used? Has the expected.
patient An acceptable percentage of necrosis as
stated by Paterson and Fletcher12 for pri
204 MAXILLOFACIAL PROSTHETICS

mary treatments was set at 2 to 49c; these tions are partially eliminated,13 therefore
authors state that anything higher indicates a diminishing the capacity for natural flushing
failure in the therapeutic technique. If no of debris from the oral cavity. Saliva that is
other factor except tumor was considered, this normal in consistency and amount offers a
could be agreed upon, whereas therapeutic natural protection or barrier against much of
techniques might be the same and other the bacterial influx around the teeth and helps
factors, such as the oral surgery problems to prevent decay.2
previously discussed, could contribute to The direct effect of radiation on the teeth
necrosis. also results in various degrees of de-
Statements on the acceptable incidence of calcification. This phenomenon of direct
necrosis depend upon the site of the tumor and damage to the teeth is more vividly apparent
the philosophy of radicalism. The team of in patients who have had only a unilateral
surgeons and radiotherapists must decide on field of irradiation, in which one side was not
an acceptable percentage of necrosis to secure in the primary field. Teeth on the irradiated
the highest evidence of control of the lesion. side usually show more postirradiation
However, radiation radicalism has a point of damage.
diminishing return.6 These two factors—the loss in quantity and
Many persons have said that they want to viscosity of saliva and direct tooth
climb a mountain “because it is there.” Teeth destruction—should be viewed in the light of
should not be extracted merely because they the patient’s oral hygiene, his knowledge of
are present or because they may someday correct home care, and the amount and type of
create problems; likewise, the existence of tooth material remaining in the mouth.
bone necrosis is not reason enough for surgical Lesions of radiation decay are generally found
intervention. Conservatism in action is as on areas of cementum on the root surfaces
important as conservatism in thought. exposed through chronic periodontal disease
(Figs. 13.7, A and 13.12, A).
Teeth
The problems of postirradiation decay have Causative Factors of Radiation Decay
been present since the early days of
radiotherapy, and the belief that the decay Factors contributing to the evolution of
process would advance to complete ampu- radiation decay could be listed as follows.
tation of the clinical crowns of the teeth was, 1. Patient must have had radiation to teeth
for some, reason enough to extract the teeth and/or salivary glands.
prior to radiation therapy.3 2. Radiation must have been in a dose
In patients who receive cancerocidal doses significant enough to reduce normal activity of
to areas of the nasopharynx, oropharynx, and salivary glands or inhibit normal metabolism
oral cavity proper, the radiation is often given of the tooth.
by means of extraoral fields or portals of entry. 3. Teeth may or may not have been in the
The fields, by necessity in a great many cases, line of radiation.
have to pass through areas which include the 4. Fair to poor oral hygiene must be ex-
parotid, submaxillary, sublingual, and acces- hibited.
sory salivary glands. Parotid and submaxillary 5. Continuous plaque formation is present.
gland irradiation appears to be of great 6. Patient is unable to understand or
significance because of a decrease in amount perform home care correctly (e.g., because of
and consistency of the saliva. stroke, illiteracy, or amputation).
The consistency and amount of saliva are of 7. Condition of teeth prior to start of
great importance to the end production of radiation (high decay index, etc.).
radiation decay because serous por
DENTAL CARE IN RADIATION THERAPY 205

Corrective Measures
To eliminate or reduce this radiation decay,
the contributing factors must be dealt with.
1. Patient would still be irradiated in same
manner.
2. Radiation could perhaps be given in-
traorally instead of by lateral ports of entry.
3. Teeth in line of radiation perhaps could
be shielded as in the case of irradiation
directed to lips, buccal mucosa, etc., or
extracted, if teeth are in poor condition or have
much cementum exposure.
4. Fair and poor oral hygiene would ne-
cessitate immediate corrective oral hygiene
procedure or extraction of the teeth.
5. Plaque formations must be controlled by
mechanical, chemical, or other means (e.g.,
fluoride gels, good oral hygiene).
6. Patient’s inability to maintain good oral
hygiene must be corrected if possible.
7. Teeth severely involved with periodontal
problems should be removed and
other'procedures such as operative work
should be instituted to enhance the oral
hygiene.
Table 13.1 shows the percentage of patients
who have had teeth left in, and Table 13.2
shows the incidence of radiation decay in
control and study groups of patients in each of
the two groups with teeth remaining (fair and
good groups).
FIG. 13.16. Radiation decay study graph. Comparison
of control and treatment. Fluoride study, 134 patients
(January 1, 1966, through June 30, 1969).

TABLE 13.2. Radiation decay study by group* Control and Study


Patients in the fair and good groups have
Patients
Group Random Total no. No. patients
with radiation with been randomized to see whether the use of a
ized patients radiation
decay decay fluoride dental gel10 could reduce the
* P* incidence of this decay (Figs. 13.6 to 13.11).
Control 43 22 51 Table 13.2 and Figure 13.16 compare the
Group III
Fair Fluoride 38 10 26 results after 42 months of the study in those
Subtotal 81 32 who have had topical applications of fluoride
Group IV Control 26 13 50 and those who have not.
Good Fluoride 27 1 3 Other dental care in the fair and good
Subtotal 53 14
groups was the same, except for extractions in
the direct field of radiation for those in the
Total 134 46
fair group.
* Includes all patients in the study (January 1, 1966 Dental prophylaxes, brush training, res-
through June 30, 1969). torations, and generalized mouth care
206 MAXILLOFACIAL PROSTHETICS

were given to all patients in both groups, closing solution in gel. (Note: patients re-
whether in the fluoride or nonfluoride sec- ceiving no fluoride are instructed in the use of
tions. As Figure 13.16 indicates, when all disclosing tablets for their plaque
other factors were basically the same, the identification.)
fluoride appeared to have a significant bearing 12. Patient is given an adequate supply of
on the long-range health of teeth. fluoride dispensed in 2-oz squeeze bottles, and
Periodontal problems diminished in he is further instructed and followed at
severity in those who received topical ap- regular intervals.
plications of the fluoride, and general oral 13. Evaluation of dental status is stored on
health appeared better in practically all computer cards for later retrieval and review.
members of this fluoride group. * Patients who have undergone radiation
The technique employed at our institution therapy by means of previously described
for applying the 1% sodium fluoride gel is as lateral face ports often have extremely sen-
follows. sitive teeth. This sensitivity sets up a pro-
1. Impressions are made of upper and gressive drop in oral hygiene because of
lower arches in alginate impression material. inadequate brushing of these sensitive areas.
2. Stone casts are poured and trimmed, All patients do not experience this
each lower and upper being trimmed in a phenomenon, but when it is seen clinically, it
horseshoe shape. is quite dramatic.
3. The mouthguard material* is warmed in The response to the previously mentioned
boiling water until it is flexible and then topical applications of fluoride is dramatic, for
placed on the cast (Fig. 13.9). almost 95% of the patients studied thus far
4. The cast is put under vacuum, and the have had complete relief of sensitivity to hot,
material is compressed down over the cast. cold, and sweet foods and to brushing of the
5. Pressure is released and the material is teeth. The remaining patients find partial
allowed to cool. relief.
6. Material on the cast is marked with a The fluoride is applied to the teeth of these
felt pen to obtain an adequate margin (ap- patients with severe sensitivity in the same
proximately 3 mm beyond the junction of tooth manner that was outlined for the control of
and gingiva). radiation decay. It should be noted that all
7. Material is removed from the cast and patients with radiation decay do not
trimmed with scissors to the marked line. experience this sensitivity; in fact, it is often a
8. Right angles are smoothed with arbor painless, progressive type of decay process.
bands and then lightly fire-polished. Patients who have trismus as a result of
9. Fluoride carriers are returned to the fibrosis of muscles after radiation therapy can
mouth for fitting and any adjusting. be put on home exercises to increase their
10. Patient is instructed on the use of interarch space. In cases that are too severe
fluoride and reasons for the procedure: e.g., for this approach, mechanical appliances can
patient brushes and flosses completely before be constructed to put dynamic tension on
using carrier and then applies the gel to the these arches and muscles to stretch them to a
inside of the carrier, merely coating the more normal relationship. The fabrication of
surface, not filling it. The carrier is worn in these appliances is discussed in Chapters 6
place for 5 minutes in each arch (Figs. 13.10 and 7. Whatever the approach to this problem,
and 13.11). perseverance is the main thing, for dramatic
11. Patient is then instructed to brush off results are not achieved immediately. Patients
any remaining plaque disclosed by dis should be thoroughly instructed as to why this
condition has happened, the importance of
regaining lost space, and the end result if

* Stanguard, Stalite Inc., Hialeah; Florida 33013.


DENTAL CARE IN RADIATION THERAPY 207

the arches are allowed to further close down. REFERENCES


Infections in head and neck cancer patients 1. Anderson, W. A. D., editor: Pathology, Vol. II, p.
1290. The C. V. Mosby Company, St. Louis,
should be handled as in any other patients, 1966.
except that even more importance may be 2. Bunting, R. W.: Oral Hygiene, p. 107. Philadel
placed on keeping the irradiated patient free phia, Lea & Febiger, 1957.
of infection. 3. del Regato, J. A.: Discussion, radiation necrosis
of the mandible. Thirty-eighth Annual Meeting
Good oral hygiene is imperative, and
of the Radiological Society of North America,
antibiotics should be used when gross Cincinnati, Feb. 7-12, 1952. Radiology, 61: 785,
infection is present or when local control of 1953.
infection is impossible. Procedures such as 4. Drane, J. B.: Protocol, United States Public
incision and drainage should be performed Health Service Grant 4614.
5. Elzay, R. P., King, E. R., and Dittman, P.:
only when absolutely necessary. Dental prostheses and radiation to the jaws; a
Pain should be handled rather conserva- survey of prosthodontists and radiotherapists. J.
tively, with low grade analgesics and with the A. D. A. 4: 856-863, 1968.
removal of causative agents whenever 6. Fletcher, G. H., MacComb, W. S., and Shalek,
R. J.: Radiation Therapy in the Management of
possible. Severe pain usually needs immediate
Cancers of the Oral Cavity and Oropharynx, pp.
control, and narcotic analgesics or radical 22 and 26. Charles C Thomas, Publisher,
surgical or neurosurgical procedures will often Springfield, Illinois, 1962.
be necessary. 7. Holthusen, H.: Erfahrungen uber die
Prostheses after irradiation are not within Vertraglichkeitsgrenze fur Rontgenstrahlen und
deren Nutzan\vendung zur Verhutung von
the scope of this chapter but are reviewed Shaden. Strahlentherapie 57: 264, 1936.
elsewhere in this book, along with discussions 8. International Atomic Energy Agency: Radiation
of radiation shields and stents to shield Damage in Bone, ' STI/PUB/27, p. 10. Karntner
normal tissues and move them from the field Ring, Vienna 1, 1960.
9. James, A. G.: Cancer Prognosis Manual, p. 11.
of radiation (Chapter 15).
American Cancer Society, Columbus, January
Much progress has been made recently in 1967.
management of the dental problems of the 10. Keyes, P. H.: Research in dental caries.
head and neck cancer patient. However, more J. A. D. A. 76: 1370, 1968.
11. MacComb, W. S., and Fletcher, G. H.: Cancer of
practitioners must become involved, with a
the Head and Neck, p. 92. The Williams &
better understanding of this field. Additional Wilkins Company, Baltimore, 1967.
research in bone, saliva, teeth, prostheses, 12. Fletcher, G. H., MacComb, W. S., and Shalek,
radiation damage, healing, and other factors is R. J.: Radiation Therapy in the Management of
needed. Cancers of the Oral Cavity and Oropharynx, pp.
25, 26. Charles C Thomas, Publisher,
Springfield, Illinois, 1962.
Acknowledgments. This research was initially par- 13. Public Health Service Publication No. 1958:
tially sponsored and supported by the Cancer Control Report of a conference, Chicago, June 1968: Oral
Branch, Division of Chronic Diseases, United States Care for Oral Cancer Patients, p. 1-8.
Public Health Service Grant 4614, through the Uni- 14. Silverman, S., Jr., and Galenti, M.: Oral Cancer.
University of California, San Francisco Medical
versity of Texas Dental Branch at Houston and in
Center, 1970.
cooperation with The University of Texas M. D.
15. Stokke, T.: Bone Marrow Reaction to Local X-
Anderson Hospital and Tumor Institute at Houston. irradiation; An Experimental Study in Rats, pp.
Use of the Common Research Computer Facility, Texas 2 and 7. Norsk Hydro’s Institute for Cancer
Medical Center, was made available through United Research, Oslo, 1966.
States Public Health Service Grant FR-00254. 16. Wildermuth, O., and Cantril, S. T.: Radiation
necrosis of the mandible. Radiology 61: 771- 784,
1953.
14
ORAL SURGERY AND MAXILLOFACIAL
PROSTHETICS

Charles E. Hutton

As the skill and ingenuity of the pros- Fractures are generally classified as closed
thodontist increase, his relationship with the when there is no communication between the
oral surgeon becomes more intimate, and they fracture site and the outside, or open when
are able to combine their knowledge and there is a break in the over- lying skin or
experience to offer better service to patients mucous membrane.
who could not be treated as well by the Obviously, there is a much greater risk of
surgeon alone. contamination with the open fracture.
In order for two or more highly skilled Whenever a tooth is involved in a fracture site,
specialists to work together as a team, there this should be considered an open fracture,
must be a spirit of complete cooperation, and even through a gross mucous membrane
this condition exists only when each knows laceration may not be noticeable.
and appreciates the other’s problems, abilities, Fractures are further classified according
and limitations. A text such as this, therefore, to the nature of the break. A green-stick
is of extreme importance to the surgeon. fracture is one in which complete separation
Similarly, it must briefly review for the has not occurred; this is common in the more
maxillofacial prosthodontist some of the “elastic” bones of children and is often seen in
surgical problems with which he may be the condylar region of the mandible. An
working. impacted fracture occurs when the outside
force has driven the two fracture ends into one
Fractures of Jaws
another, and this is most commonly seen when
One common situation in which an oral an upward force is applied to the maxilla. A
surgeon needs the help of a prosthodontist is comminuted fracture is one involving multiple
in the design and fabrication of immobilization fragmentation, especially of the cortical plates.
appliances for fractures of the jaws. All degrees of comminutions may occur, and
Automobile accidents and fights are the more extensive they are, the more difficult
responsible for the vast majority of fractured the treatment problems. Extensive
jaws; however, trauma resulting from falls, comminution further indicates a more severe
industrial accidents, and sports also blow or more fragile bone structure, along
contributes. Fractures, especially of the with which there may be extensive soft tissue
mandible, also occur from extensive pathology damage and advanced age to complicate the
such as cysts, tumors, and infection. treatment plan.
Intentional surgical fractures are created for Whenever fractures of the mandible or
shortening or- lengthening the mandible or
maxilla.
208
ORAL SURGERY 209

maxilla are suspected, a careful history and The Le Fort I fracture is a low level hor-
examination are imperative. The patient’s izontal line involving the floor of the nose and
general condition, his past medical history, passing laterally below the zygoma (Fig. 14.2).
and the presence of other injuries will The Le Fort II is a pyramidal fracture
determine the treatment planning. Fractures involving the nasal bones and inferior orbital
of the jaws are surgical emergencies only when sinus (Fig. 14.3). The Le Fort III fracture
they contribute to airway obstructions and extends across the nasal bones, through the
severe hemorrhage. orbits, and above the zygomatic bones (Fig.
Oral and facial examinations may reveal 14.4).
more than the radiographic examination since These fractures may be unilateral or bi-
adequate films are sometimes difficult to lateral and are commonly combinations of this
obtain. classification.
The examiner focuses his attention on soft
tissue damage, areas of hemorrhage, Treatment of Fractures
hematoma and edema, displaced parts, Regardless of the etiology, type, or extent of
malocclusion, missing, luxated, or fractured the fracture, the basic treatment remains the
teeth, loss of function, pain, areas of same: reduction or realignment and
anesthesia, and the presence of foreign bodies. immobilization of the parts until healing
A complete radiographic examination of the occurs.
mandible should include posterior-anterior Since a cast cannot be applied to the jaws
projection, right and left lateral obliques of the as in the case of the arms or legs, we first turn
body and ramus and, if indicated, occlusal and to intraoral methods using the teeth as
submental vertex views. fixation and alignment guides. Since our most
Examination of the maxilla and other facial important goal is to restore function, we first
bones should include a posterior- anterior place the maxillary and mandibular teeth in
projection, lateral skull, Water’s view and, if their proper occlusal relationships and hold
indicated, occlusal and zygomatic arch views. them in that position until healing of the bone
Fractures of the mandible occur in multiple can support function.
form and bilaterally so often that one should In general, the simplest means of immo-
consider them as such until proven otherwise bilization that will produce the desired result
by an adequate radiographic survey. These is the best. When a reasonable complement of
fractures may involve the body, angle, sound teeth exists, immobilization is
condylar neck, ramus, symphysis, alveolar accomplished by the placement of wire loops or
processes and, rarely, the coronoid process. the wiring of standard fracture bars to the
The location and angulation of the fractures as upper and lower teeth and immobilization
they relate to the muscle pulls on the with intermaxillary traction (Figs. 14.5 and
mandible determine to a great extent how 14.6).
much displacement and disability will occur, There are many methods of applying wire
as well as the type of reduction necessary to loops to teeth, and the operator should know
realign and immobilize the fragments. their advantages and disadvantages; however,
Classically, fractures of the maxilla are it is best to develop skill with two or three
classified according to the level at which the methods and adapt them to particular
horizontal fracture line occurs. The alveolar situations, instead of trying to apply a
fracture, which involves a segment of alveolus multitude of different techniques.
and its contained teeth, may extend to the The simplest method uses single wire loops
sinus floor or nasal floor (Fig. 14.1). of 24 or 26 gauge stainless steel wire. The wire
is placed around the neck of the tooth twice,
drawn tightly, and twisted clockwise. Enough
twisted wire is left to
>

210 MAXILLOFACIAL PROSTHETICS

FIG. 14.1. Unilateral fracture of maxilla with midline palatal fracture, (upper left)
FIG. 14.2. Le Fort I fracture of maxilla, (upper right)
FIG. 14.3. Le Fort II fracture of maxilla, (lower left)
FIG. 14.4. Le Fort III fracture of maxilla, (lower right)

form a loop or rosette for the placement of an 24 or 26 gauge stainless steel wire in lengths
intermaxillary traction band (Fig. 14.7). This of 10 to 15 cm, an eyelet is formed in the
method is helpful when lone-standing teeth middle and twisted clockwise twice (Fig. 14.8).
are involved, or when intermaxillary wire The double wire is passed between two teeth
rather than elastic is to be used, in which case from buccal or labial to lingual, and one wire
the ends are left long enough so that maxillary is then passed around each tooth and brought
and mandibular wires can be twisted together. back to the buccal or labial. The posterior wire
The Ivy loop is one of the best and most is passed through the twist on its course for-
commonly used methods of obtaining loops. ward where it is twisted tightly with the
This technique uses two adjacent teeth, anterior wire. The system is then completely
provides two hooks for traction, is quickly tightened by placing a turn or two on the loop
applied and easily removed. Using (Fig. 14.9).
ORAL SURGERY 211

FIG. 14.5. Mandibular and maxillary arch bars with


intermaxillary traction fixation.

FIG. 14.6. Maxillary arch bar combined with mandibular labial-lingual splint for intermaxillary traction.
212 MAXILLOFACIAL PROSTHETICS

FIG. 14.7. Single wire loop for attachment of intermaxillary traction.

FIG. 14.8. Blair-Ivy loops for attachment of inter-


maxillary traction. FIG. 14.9. Completed Blair-Ivy loop.
ORAL SURGERY 213

FIG. 14.10. Classic arch bar attached to teeth with FIG. 14.11. Open reduction of fractured mandible by
individual wire ligatures. transosseous wire fixation.

to avoid trauma to the buccal tissues (Fig.


14.10).
When the appliances are in place, the
fractures are reduced by manipulating the
mandible into occlusion, and intermaxillary
traction is applied (Figs. 14.5 and 14.6).
When fixation by way of the teeth is not
possible, or when the fracture lies posterior to
the teeth and cannot be reduced by
manipulation, the next choice is open re-
duction. Direct reduction and fixation by
transosseous wire sutures or plates is used
and may or may not be combined with
intraoral fixation, depending on circum-
stances.
Although open reduction can be done
intraorally in selected cases, it is generally
accomplished under sterile conditions by way
FIG. 14.12. Open reduction with tantalum tray fixation of extraoral exposure. The fracture site is
to immobilize comminuted fragments.
surgically exposed, holes are drilled in each
fragment, and stainless steel wires are passed
through. The fracture is reduced by
manipulation and immobilized by tightening
The use of arch bars is the most common the transosseous wire sutures (Figs. 14.11 and
method of applying intermaxillary traction. It 14.12). The number and placement of the
affords much stability and flexibility and can wires are determined by the type and location
generally be used when multiple teeth are of the fracture.
usable. Several types of arch bars are Extraoral devices such as the Roger-
available. Anderson appliance may be used to advantage
The bar is cut to length and attached to the in selected cases involving problems of
teeth by means of 26 or 28 gauge wire placed immobilization. However, these methods are
around each appropriate tooth and twisted not in common use in private practice because
tightly with wire twisters or needle holders. of their inconvenience
The cut wire ends are bent inward
214 MAXILLOFACIAL PROSTHETICS

FIGS. 14.13-14.15. Extraoral pin fixation device for the immobilization of fragments of a mandibular fracture.

and appearance. The pins and appliances can Immobilization Appliances


be used on mandibular fractures (Figs. 14.13
to 14.15) or can be used to stabilize other The labiolingual splint is indicated when
facial fragments by being connected to plaster there are missing teeth, malocclusion, or
head caps or, in highly complicated cases, by mobile teeth, or when there is some danger of
being attached to halo head frames. overeruption of teeth because of the pressures
When standard methods of closed or open of ligatures or traction (Fig. 14.6). This type of
reductions are not possible (edentulous ridges, appliance is valuable in the postsurgical
extreme caries or periodontal disease, extreme immobilization of deformities, such as Class
malocclusion, alveolar fractures, etc.) or when III malocclusion, when it is necessary to open
they are contraindicated (anesthetic risks, a portion of the bite or compensate for
extensive comminutions or soft tissue damage, intraoral rehabilitative procedures to be done
etc.), ingenuity must be used in the fabrication later. Prefabricated splints are also necessary
of splints designed for the particular problems for the immobilization of the fragments in
at hand. maxillary osteotomies. These techniques are
discussed below.
ORAL SURGERY 215

FIG. 14.16. A, circumzygomatic wiring. B, nasal spine wiring. C, molar process wiring. D, infraorbital rim
wiring. E, lateral orbital rim wiring. F, circum-mandibular wiring.

A modification of this type of splint may be ative position. Since this may be a difficult
used when there is a tendency for a lateral problem, some leeway is desirable.
shift of the mandible which cannot be held These splints may be fixed by circumfer-
with ordinary appliances, as in the case of ential wires on the mandible and by various
hemimandibulectomy. means of cranial fixation on the maxilla (Fig.
The modified Gunning two-piece splint is 14.16). Chin straps or plaster head casts may
indicated when intraoral fixation is required be used when wiring is not desirable.
in the edentulous mouth. The patient’s When a simple circumferential fixation is
dentures may be used satisfactorily in these desirable but there is no need for mandibular
instances, but many times a denture does not immobilization, the lower splint may be
exist, has been lost in the accident, or is thinned and shortened to act simply as a ridge
broken beyond repair. A Gunning splint is support for the wires. If available, a lower
ideal when there is little or no displacement or denture is the ideal splint for this treatment.
in conjunction with open reductions. An When maxillary fixation is a problem
impression must be taken and models because of the lack of anchor points (e.g.,
prepared and, if there is displacement, the fractures of lateral orbits, malars, and zy-
models must be cut and approximated in the
anticipated postoper
216 MAXILLOFACIAL PROSTHETICS

FIGS. 14.17-14.19. A type of extraoral suspension to plaster head cap, using an intraoral appliance for an edentulous
maxilla. Traction may be applied in several directions and tension may be varied by adjustments in the rubber bands.

gomas), extraoral extensions of the intraoral transosseous wires impractical, and plates or
splint lend themselves to fine fixation and trays are indicated. Here again, custom
easy adjustment when attached to plaster fabrication is the answer since most standard
head caps or halo frames with traction (Figs. orthopedic appliances are too large, and each
14.17 to 14.19). fracture presents its own peculiar problems.
Occasionally, open reduction is the The U-shaped perforated plate molded to the
treatment of choice, but loss of bone or inferior border and fixed with wire
extensive comminutions render the usual
ORAL SURGERY 217

sutures will not only bridge the cap and There are occasions when prosthetic aids
stabilize the parts, but it also can act as a tray will improve esthetics but have no functional
to hold bone chips or grafts when indicated value, such as the building of a chin button
(Fig. 14.12). with metal mesh, tray, or plastics and the
recontouring of a malar process or zygoma.
The True Prosthesis Prostheses have proven more satisfactory than
The use of the true prosthesis, that is, a grafts in our experience, since there is less
true artificial replacement of missing tissues, susceptibility to infection and sloughing. Also,
is one of the most rapidly advancing fields in since a donor site for bone or cartilage is
medicine. Prostheses are being fabricated for eliminated, the additional surgery and trauma
the replacement of a single tooth or a complete are likewise eliminated.
complement of teeth, arms and legs, eyes, Many of these minor procedures can be
hemimaxillae and hemimandibles, cranial accomplished intraorally with local anesthesia
defects, and heart valves. There is little to on an out-patient basis.
surpass the feeling of accomplishment when a Any discussion such as this must not
functional and esthetic prosthesis has restored overlook a most important phase of maxil-
a patient to completeness. lofacial prosthetics: the construction of dental
When large mandibular defects result from prostheses.
radical surgery, extensive injuries, or The full mouth immediate denture is an
widespread infection, the prosthetic mandible extremely gratifying service which can be
is an excellent replacement. For small defects, offered through the combined efforts of the
when sound, functional bone remains both skilled prosthodontist and oral surgeon. These
proximal and distal to the defect, the ilium or patients maintain their natural vertical
rib graft remains the treatment of choice. dimension, they experience a minimal change
When the defect is extensive, however, or in lip drape, and they require little muscular
when the condylar portion is missing or readjustment since they do not experience the
severely displaced by muscle pull, the adjustment and readjustment that follow
prosthesis is the treatment of choice. removal of posterior teeth. In addition, healing
Through clinical measurement, radi- is rapid and usually without complication. For
ographic analysis, and sound clinical judg- the person whose work requires meeting the
ment, the prosthesis is sized, fashioned, and public, the entire transition from natural teeth
processed. to prosthetic teeth may require only 4 or 5
The bed is surgically prepared, the pros- days off from work (Figs. 14.22 to 14.26).
thesis is inserted, and any necessary ad-
justments made. Attachment to the bony Surgical Correction of Malocclusion
stump is usually accomplished by inserting The oral surgeon is frequently faced with
two pins or a wire loop into the medullary problems of bite correction after less than ideal
space and attaching a stabilizing tray to the results are obtained on complicated fractures
inferior border with wire sutures. The required and with the necessity of treating Class II and
period of immobilization will vary depending III and cleft palate malocclusion which cannot
upon the size of the prosthesis and the degree be satisfactorily corrected with orthodontics
of deviation prior to surgery. In general, the alone. Combinations of surgical procedures,
more stress that will immediately be placed orthodontic treatment, and fixed and
upon the area of attachment, the longer the removable appliances may be required, again
period of immobilization. In the case shown in calling for the close cooperation and teamwork
Figures 14.20 and 14.21, in which the mandi- of several specialties.
ble was replaced from left condyle to right The surgical correction of malocclusion is
mental foramen, the period of immobilization one of the most rapidly advancing fields
was 4 weeks.
218 MAXILLOFACIAL PROSTHETICS

FIG. 14.20.
Left mandibular implant. (Top)
FIG. 14.21.
Mandibular implant inserted in the fossa and immobilized with a tantalum tray to the remaining
healthy mandible. (Bottom)
ORAL SURGERY 219

n i A no .■ •i• postoperativelyJat time of suture removal.


FIG. 14.22. Preoperative view, showing gross H y
caries and malocclusion.

FIG. 14.23. Full dentures and clear acrylic guides.

of oral surgery. Although the notions are not


'new, recent advances in techniques have
opened the door for correction of almost all
severe mandibular and maxillary growth
deformities.
At this time, the most common deformity to
lend itself well to surgical correction is
mandibular prognathism. Many techniques
have been devised, but the most common is
the vertical ramus sliding osteotomy. In this
operation, the ramus is sectioned from the
sigmoid notch to a point near the angle by way
of a small incision below the inferior-posterior
border of the mandible. The mandible is
moved posteriorly to its new predetermined
relationship with the maxilla and immobi-
lized. The posterior fragment is then placed
laterally to the ramus and fixed with a
transosseous wire suture (Figs. 14.27 to
14.64).
FIG. 14.24. Dentures placed in operating room.
FIG. 14.27. Preoperative profile of surgical correction of
malocclusion utilizing labiolingual splint fixation
appliances and requiring only occlusal equilibration
following surgery.

220
FIG. 14.32. Postoperative profile, showing a virtual
absence of scar.

FIGS. 14.33-14.36. Partially endentulous patient requiring a multidisciplinary approach to full oral reha-
bilitation: preoperative views of Class HI facial appearance and severe malocclusion.
221
222 MAXILLOFACIAL PROSTHETICS

FIGS. 14.37 AND 14.38. Preoperative radiographs indicating only bicuspid occlusion.

FIGS. 14.39 AND 14.40. Postoperative radiographs illustrating a normal occlusal and skeletal relationship.
ORAL SURGERY 223

FIGS. 14.41 AND 14.42. Mounted study models indicating the proposed surgical changes on which the labio- lingual
appliances will be constructed.

FIGS. 14.43-14.45. Labiolingual splints in place following healing of the surgery sites.
224 MAXILLOFACIAL PROSTHETICS

FIGS. 14.46-14.50. Final reconstruction to include periodontal surgery, multiple full crown restorations, fixed bridges,
and removable partial dentures.
ORAL SURGERY 225

FIGS. 14.51-14.54. Completed full, balanced Class I occlusion and facial appearance.
226 MAXILLOFACIAL PROSTHETICS

FIGS. 14.55-14.57. Bilateral mandibular sliding osteotomy for correction of prognathism in the edentulous patient:
preoperative facial features and mandibular ridge showing pronounced Class III appearance.
ORAL SURGERY 227

FIGS. 14.60 AND 14.61. Postoperative radiographs indicating the new mandibular-maxillary relation. Note bilateral
mandibular circumferential wires and maxillary wires to the malar process and nasal spine used to maintain the intraoral
appliances.
228 MAXILLOFACIAL PROSTHETICS

FIG. 14.62. Postoperative ridge relations with fixation appliances in place.

FIG. 14.63. Profile 5 days postoperatively. (Left)


FIG. 14.64. Final complete dentures in place. (Right)
ORAL SURGERY 229

FIGS. 14.65 AND 14.66. Diagramatic illustration of the areas of bone cuts for the repositioning of the “premaxilla.”
Variation of these cuts can allow the anterior fragment to be moved in nearly any direction to correct a variety of anterior
maxillary deformities.

FIGS. 14.67 AND 14.68. Anterior maxillary protrusion preoperatively.

This procedure has many advantages, upward to the level of the nasal floor. This
including ease of operation, sterility of the procedure may involve the lateral wall of the
surgical field, good bony contact, maintenance maxillary sinus, but this has no clinical
of the mandibular arch length, repositioning significance. These cuts are then extended
of the masseter muscle, and posterior anteriorly well above the apices of the anterior
positioning of the coronoid process. teeth to the floor of the nose.
Similarly, many procedures have been Attention is then directed to the palatal
advocated for the repositioning of the maxilla bone where cuts are made through the plate of
which include either all or a portion of the bone transversely from right to left, thus
maxilla. However, the most widely indicated connecting the buccal cuts. This frees the
and executed procedure involves repositioning anterior maxilla except at the region of the
of the anterior maxilla from bicuspid to anterior nasal spine, where the separation is
bicuspid. Essentially the same procedure can judiciously made with a chisel. The fragment
be used with some modifications to reposition is then free to be moved to its predetermined
this fragment posteriorly, anteriorly, position.
superiorly, or interiorly. Accurate preoperative planning on models
Classically, the operation requires the loss is essential so that the width, angulation, and
of a bicuspid tooth on each side, but this may positioning of the cuts will meet the desired
vary according to the patient’s problem. Bone needs. In some instances, bone grafting will be
cuts are made, as predetermined on models in indicated if good bony contact does not result;
advance, through the buccal plates of bone in and, of course, adequate immobilization must
the bicuspid areas be obtained (Figs. 14.65 to 14.81).
230 MAXILLOFACIAL PROSTHETICS

FIGS. 14.69-14.71. Two-piece acrylic appliance for fixation of the anterior maxilla and protection of occlusion
during healing period. (Top)
FIG. 14.72. Postoperative relationship with appliance in place. (Bottom)

FIG. 14.73. Postoperative relationship with tempo-


rary partial denture being worn during the fabrication
of the final prosthesis.
ORAL SURGERY 231

FIG. 14.77. Bone cut at region of nasal spine to free the


“premaxilla.”

FIGS. 14.74 (Top) AND 14.75 (Bottom). A similar case,


showing right and left bone cuts in bicuspid regions.

FIG. 14.78. Repositioning of the free fragment, showing


a part of the horizontal cut going anterior to floor of nose.
FIG. 14.76. Position of transverse palatal bone cut.
232 MAXILLOFACIAL PROSTHETICS

FIGS. 14.79-14.81. One-piece fixation appliance. (Courtesy R. D. Lentz.)

Specialized Stents medications in place, and in protecting the


Thus far we have discussed the fixation tissues from external trauma.
appliances and the prostheses which are of a These appliances may have a variety of
relatively permanent nature. In oral surgery, designs and retention techniques, varying all
we have a further need for temporary the way from fabricated clasps to simple
appliances which may be useful for only a few splints held in place by biting pressures. In
days. These are the appliances used to control general, they should be simple and easy to
hemorrhage and to protect or support soft handle, and they should produce no trauma to
tissues. the surrounding tissues.
When extractions are necessary in severe Protective splints are also advisable in the
bleeders, such as the true hemophiliacs, every surgical treatment of large intraoral openings
adjunct for hemorrhage control is needed. and after the excision of large palatal tori.
Custom acrylic splints, fabricated before These appliances afford soft tissue support as
surgery and inserted at the time of extraction, well as protection from trauma during the
can be of immeasurable assistance. They aid initial healing process.
in maintaining constant pressure at the site, Mucobuccal fold extensions may require the
in keeping topical use of splints to hold the tissues in
ORAL SURGERY 233

their desired position until epithelization adjustments of occlusion. Bite-adjusting


occurs. Maxillary splints may afford their own appliances are strictly trial and error devices
retention; if not, immobilization to the malar and may be extremely critical, requiring great
process or transalveolar wires will maintain knowledge of functioning occlusion. After
them. Mandibular splints require establishing the proper relationships for each
circumferential fixation. particular problem, the dentist must then
Splints may also be fabricated to protect transfer this relationship from the trial and
tissues and hold medications in position after error appliance to a permanent denture,
tissue strippings for conditions such as bridge, or onlay appliance.
leukoplakia and fibromatosis and during the
REFERENCES
treatment of exposed bone from osteomyelitis,
1. Bell, W. H., Allessandra, P. A., and Condit, C. L.:
osteoradionecrosis, etc. Similar splints
Surgical-orthodontic correction of class II mal-
incorporating lead layers may be useful in occlusion. J. Oral Surg. 26: 265-272, 1968.
protecting teeth and alveolar ridges during 2. Guralnick, W. C.: Textbook of Oral Surgery. Lit
radiation procedures. tle, Brown and Company, Boston, 1968.
Skill in appliance design and fabrication is 3. Hooley, J. R.: Hospital Dentistry. Lea & Febiger,
Philadelphia, 1970.
also useful to the oral surgeon in treating 4. Kent, J., Reid, R., and Hinds, E.C.: Acrylic splints
temporomandibular joint problems. Patients for maxillary alveolar osteotomies. J. Oral Surg.
with temporomandibular joint symptoms are 27: 11-14, 1969.
frequently channeled to oral surgeons for 5. Rowe, N. L.; and Killey, H. C.: Fractures of Fa
cial Skeleton, Ed. 2. The Williams & Wilkins
diagnosis and treatment, but they are rarely
Company, Baltimore, 1968.
surgical problems. Occasionally, treatment 6. Kruger, G. 0.: Textbook of Oral Surgery, Ed. 3.
requires joint injections, systemic medication, The C. V. Mosby Company, St. Louis, 1968.
or immobilization; however, many of the 7. McDonald, R. E.: Dentistry for the Child and
symptoms may result from mechanical Adolescent. The C. V. Mosby Company, St. Louis,
1969.
imbalance of the masticatory system and
require intraoral
15
SPLINTS AND STENTS
Varoujan A. Chalian, Joe B. Drane, S. Miles Standish, and Luis
R. Guerra

Splints and stents are often used in head are made with irreversible hydrocolloid, and
and neck surgery, radiotherapy, oral surgery, the stone models are poured. The vertical and
periodontics, endodontics, and pedo- dontics. centric relations are then registered, the
They hold together the segments of fractures, models are mounte'd on an articulator, and
hold the skin grafts, and protect the healthy baseplates and interocclusal bite rims are
tissues while administering radiotherapy. In constructed for each arch. In the incisor areas,
addition, they are used to control possible spaces are created in the rims to facilitate
hemorrhage, to hold periodontal packing, to breathing, feeding, and possible
protect the denuded necks of teeth, to help in postanesthesia vomiting. At the occlusal
drainage of periodontal infections, and to surface, male and female buttons 3 to 5 mm
prevent the healing and accelerate the deep are created so that the two splints can be
eruption of unerupted teeth. They may be interlocked to maintain the proper centric.
adapted for use in special circumstances, such Two to four stainless steel bent wire hooks are
as in treatment of the physically handicapped. placed on both buccal flanges of the waxed-up
bases for future use in anchoring the
Splints
intermaxillary rubber bands. The waxed-up
Gunning Splint splints are invested, washed out, and packed
This prosthetic device is usually con- and cured in methyl methacrylate. After
structed for an edentulous mouth to hold curing, the splints are removed from the
together fractured segments of mandibular or flasks and trimmed. On both sides of the lower
maxillary bones and to immobilize the jaws in splint, two holes are drilled through the rim in
occlusion. In the one-piece Gunning splint, the first molar area to immobilize the splint
upper and lower baseplates are joined in a on the lower arch by circumferential wiring.
proper vertical and centric relation with a bite On both sides of the upper splint, two or three
rim (Fig. 15.1). This splint is immobilized by holes are drilled in the buccal flange for
an extraoral Barton bandage or an elastic chin possible use in immobilizing the upper splint
bandage. to any healthy facial bone that the surgeon
In the two-piece Gunning splint (Figs. 15.2 desires.
and 15.3), separate splints are constructed for The two-piece Gunning splint is then
the maxilla and the mandible, using the polished and fitted for final checking.
following technique. The impressions of
Modified Gunning Splint
edentulous maxilla and mandible
If the patient has complete maxillary and
mandibular dentures, the incisors can

234
SPLINTS AND STENTS 235

be removed and used as splints with the lower bases to immobilize the splints to the
addition of interdental wires. Three hooks are arches.
applied to anchor rubber bands, and buccal Another modified Gunning splint is made
holes are drilled in the upper and from fractured dentures. Figure 15.4, A shows
a fractured maxillary complete denture. In B,
the fragments of the denture have been
repaired and the incisors have been removed
in the upper and lower dentures. In C,
interdental Ivy loops have been placed and
twisted to form hooks for anchoring
intermaxillary rubber bands. Also, holes are
drilled for immobilization to one jaw. A
possible alternative is to imbed arch bars into
the facila aspect of the dentures (D).
Labiolingual Splint
Labiolingual splints are constructed for
dentulous or partially edentulous arches to aid
in reduction of fractures.
FIG. 15.1. One-piece Gunning splint.

FIG. 15.2. A, waxed-up bite rims mounted on the articulator. B, waxed-up splints, showing interocclusion buttons and
hooks. C, finished two-piece Gunning splint. D, two-piece Gunning splint interlocked.
236 MAXILLOFACIAL PROSTHETICS

FIG. 15.3. A, diagrammatic drawing of two-piece Gunning splint. B, two-piece Gunning splint in the mouth to
immobilize the jaws.

The splint consists of an acrylic band that another suitable area. Two buttons ap-
fits around the labial and lingual aspects of proximately 5 mm in diameter are added at
the teeth, leaving the occlusal surfaces of the the labial segment 3 mm away from the split
teeth uncovered. The continuity of the two line for use in tightening and immobilizing the
flanges is secured by a stainless steel wire splint to the arch with stainless steel wire.
bent to form hinges which are placed This type of splint is ideal for cases with
bilaterally behind the last posterior teeth. The exostosis, for there is no need of blocking out
labial flange is split into two sections from the the undercuts (Fig. 15.5).
midline or from If the fractured segments of the maxilla
SPLINTS AND STENTS 237

FIG. 15.4. A, fractured maxillary, complete denture. B, maxillary denture repaired and incisors removed. C, interdental
Ivy loops placed and the holes placed on the flanges for immobilization of splints. D, modified Gunning splint with arch
bars imbedded in the flange for intermaxillary fixation.

FIG. 15.5. A, labiolingual splint and mandibular cast with lingual exostoses. B, labiolingual splint seated over the
model.

or mandible are displaced, it is more difficult gual splint is constructed with labial hooks
to construct a labiolingual splint (Fig. 15.6). and anterior buttons for immobilization. In E,
The impressions of the jaws are made in the maxillary and mandibular labiolingual
irreversible hydrocolloid and poured in stone. splints are united in occlusion with
Then the cast showing the displaced intermaxillary rubber bands.
mandibular segments is sectioned and
Fenestrated Splint
recontoured, with the maxillary cast being
used as a guide. After recontouring, the This is a one-piece prosthetic device which
edentulous anterior ridge is smoothed with is contoured to fit a dentulous maxilla and
plaster and used as a master cast for mandible through fenestrations created for
construction of the labiolingual splint. In the occlusal surfaces of the teeth.
Figure 15.6, D, the labiolin
238 MAXILLOFACIAL PROSTHETICS

FIG. 15.6. A, master cast, showing displaced segments. B, cast is sectioned and recontoured. C, anterior ridge,
showing plaster retouching. D, labiolingual splint, showing the hooks and anterior buttons for immobilization. E,
maxillary and mandibular labiolingual splints seated over the models. F, diagrammatic drawing showing details
of construction of labiolingual splint.

These types of splints are used for short Kingsley Splint


permanent clinical crowns, for deciduous teeth
when no undercut is available for retention, The Kingsley splint, which is often con-
and for badly decayed teeth, as in structed for dentulous or edentulous patients,
postradiation caries (Fig. 15.7). covers the palate and the ridge. It
SPLINTS AND STENTS 239

consuming, plus expensive to the patient.


Chrome-cobalt aluminum and gold are
common metals used for construction of cast
metal splints (Fig. 15.9).

FIG. 15.7. A, mandibular and maxillary fenestrated


splint. B, fenestrated splint used for cleft palate child.
C, silicone fenestrated obturator used on heavily
radiated teeth.

has an anterior extension of metal rods


protruding bilaterally from the commissures
of the mouth. It is especially useful in raising
a fractured maxilla. This splint is immobilized
by an extraoral plaster headgear (Fig. 15.8).
Case Metal Splints
A cast metal prosthetic device is con-
structed when a long-term immobilization is
envisioned. This splint may be capped or left
open at the occlusal surface, or it may also be
FIG. 15.8. A, acrylic maxillary Kingsley splint. B, cast
hinged. Some of the disadvantages of cast
maxillary Kingsley splint. C, Kingsley splint inserted in
splints are that they are time
the mouth and secured with extraoral plaster headgear.
240 MAXILLOFACIAL PROSTHETICS

FIG. 15.9. A, cast metal splint used to immobilize the displaced fragments. B, cast metal splint used to hold the

fragments together to help the reduction. C, cast metal splint used in mandibular resection. D, anterior cast metal
splint for periodontics. E, anterior cast splint in place. (D and E, courtesy of Dr. H. Swenson.) F, cast metal splint
with hooks and lugs for interdental wiring. (Courtesy of Dr. D. Jordan.)

Stents these patients neglect their teeth because of a


Antihemorrhagic Stent fear of hemorrhage, they may later require
Control of postextraction bleeding in many surgical extractions. A prosthetic device
hemophiliac patients is of particular concern can be constructed with methyl methacrylate,
to the oral surgeon. Since many of lined with a hemostatic agent, and inserted in
the mouth
SPLINTS AND STENTS 241

immediately after surgery to control possible thesis is then prepared, with a bite rim over
bleeding. the extracted ridge containing the occlusal
Maxillary and mandibular impressions are imprint of the corresponding tooth of the
made in irreversible hydrocolloid, and the opposite arch (Fig. 15.10). After the extraction
casts are poured in stone. A wax inter- of each tooth, Hydrocast tissue treatment
occlusal centric relation is registered, and the material is placed on the socket area of the
casts are mounted on an articulator. The stent and‘gently inserted in the mouth. After
vertical dimension is increased by 1 mm. The the Hydrocast has set, the stent is removed
teeth to be extracted are removed and the and the excess material is trimmed. Partially
socket is prepared on the casts. A removable denatured gelatin and thrombin are placed in
baseplate type of pros the socket, and the

FIG. 15.10. A, mandibular and maxillary antihemorrhagic stents. B, extraction site of right maxillary first
molar. C, extraction site of left mandibular third molar. D, maxillary antihemorrhagic stent in place. E, man-
dibular antihemorrhagic stent in place.
242 MAXILLOFACIAL PROSTHETICS

FIG. 15.11. A, occlusal stent. B, intraoral view, showing greatly increased vertical overclosure. C, occlusal stent
with maxillary and mandibular views. D, occlusal stent in place. E, occlusion with improved vertical dimension.
(Courtesy of Dr. W. Schultz.) F, laminograph showing condylar position without (above) and with (below) the
occlusal stent.
SPLINTS AND STENTS 243

FIG. 15.11F
FIG. 15.12. A, stainless steel, metal plate in U shape with bilateral rods welded. B, stainless steel U-shaped
plate, showing added acrylic imprint of the occlusal anatomy of the teeth. C, lateral view of dynamic bite opener in
the mouth. D, frontal view of activated dynamic bite opener. E, pretreatment measurement of the opening of the
mouth. F, posttreatment measurement of the opening of the mouth.
244
SPLINTS AND STENTS 245

antihemorrhagic stent is reinserted in the ercise the temporomandibular joint or to open


mouth and allowed to remain for 5 to 7 days. and close the mouth (Fig. 15.12).
The stents are constructed of two stainless
Occlusal Stent steel metal plates 1.5 mm thick, which are cut
In the diagnosis of temporomandibular in a standard dental arch or U shape. To the
pain-dysfunction syndrome, it is essential to bilateral buccal surfaces of the metal plates,
evaluate the existing occlusion and to con- twP 10-gauge metal rods 14 to 16 inches long
struct a treatment device to change the ver- are welded. The plates are then perforated to
tical dimension. In doing so, the condylar head receive the occlusal acrylic stent.'The
is repositioned in the glenoid fossa, a measure maxillary and mandibular teeth are
which often relieves the acute symptoms (Fig. lubricated, and mixed auto- polymerizable
15.11). These occlusal stents or bite plates methyl methacrylate 3 mm thick is applied
may be adapted to either the mandibular or over the welded surfaces of the perforated
maxillary arch and may be of varied design. metal, carried to the mouth, and placed in
Regardless of their design or whether they are position. The occlusal surfaces register the
applied to the upper or lower arch, the imprint of the natural occlusal anatomy for
primary function of the occlusal stent is to retention and stabilization. Prior to complete
disengage the occlusion temporarily and to polymerization, the metal tray is removed, the
interrupt existing patterns of muscle function excess acrylic is trimmed, and the tray is rein-
which contribute to painful myospasm. serted in the mouth for complete polymeri-
To construct an occlusal stent, impressions zation. The procedure is repeated on the
of the maxilla and mandible are made with antagonist arch, and both rods are shaped for
irreversible hydrocolloid and poured in stone. comfortable passage past the commissures.
The interocclusal records are made for proper Next, the maxillary and mandibular stents are
mounting of the casts on an articulator. After constructed and inserted gently through the
the articulator is opened slightly for a new limited opening of the mouth to be seated over
vertical dimension, the upper or lower model the respective arches. Rubber bands are then
is used for waxing a baseplate type of applied on the bilateral maxillary and
appliance which extends to the occlusal mandibular rods to apply ascending and
surface and carries the imprint of the descending forces on the mandible to open the
antagonist arch. Clasps of wire are then bent mouth.
and adapted to the last teeth on the arch. This Drainage Stent
occlusal stent is processed in clear methyl
Although successful endodontic therapy
methacrylate and used as a trial appliance
depends on a number of rather exacting
prior to embarking on irreversible restorative
criteria, one condition which is often neglected
procedures.
is adequate drainage. The purpose of a
Dynamic Bite Opener (Trismus Stent, drainage stent is to allow the escape of blood
Temporomandibular Joint Exerciser) or other fluids. An impression of the maxilla is
made, and the fistula is reproduced in the
Various devices are used for mandibular stone cast. A 15-gauge polyethylene tube is
trismus, such as wooden or metal clothespins, inserted in the hole, and the labial aspect of
tongue blades, and mouth props. the cast is covered with two layers of baseplate
The dynamic bite opener is described here wax processed with methyl methacrylate,
as a modified Kingsley splint. It is a cured around the polyethylene tube, and
combination of maxillary and mandibular polished (Fig. 15.13). This type of drainage
occlusal stents with rod bows coming out from stent can be constructed on a pre-existing
the commissures of the mouth to ex partial or complete removable denture by
modifying the prosthesis in the appropriate
area to
246 MAXILLOFACIAL PROSTHETICS

FIG. 15.13. A, chronic lesion with labial fistula. B, labial stent inserted with opening. C, polyethylene tube
inserted in the stent. D, modification of pre-existing appliance.
SPLINTS AND STENTS 247

facilitate the securing of the drainage tube


(Fig. 15.13, D).
Pedodontic Stents
Unerupted teeth are surgically uncovered
to stimulate eruption. From the impression of
the arch the stone cast is made. A methyl
methacrylate stent is inserted in the mouth to
prevent the healing of uncovered tissue and to
facilitate eruption of the impacted tooth. (Fig.
15.14).
In children, permanent central incisors are
often knocked out or luxated by a sudden fall
or other accident. Immediate repositioning
and immobilizing in place is the main
treatment, along with a recommendation that
the patient avoid masticating or placing other
pressures on the teeth involved. Traumatized
teeth should be held in place with a
labiolingual stent or fenestrated stent as
described in the splint sections (Fig. 15.15).
I

Intraoral Stent for the Physically Handicapped


This interocclusal stent is designed for
aiding the patient in drinking and sucking in
nourishment. Study casts are made and
mounted on the articulator, using a wax bite
as a guide. The Vi-inch polyethylene tubing is
waxed into the center between the central
incisors. The tubing is cut 10 to 12 inches long
to allow for adjustability and patient freedom
during use (Fig. 15.16).
Interocclusal Stent for Typing, Writing, or
Painting
Study casts are made, and the models are
mounted on an articulator. The interocclusal
stent is waxed into its final form, and in the
center is embedded a metal plate of aluminum
to which a piece of aluminum tubing can be
attached. The interocclusal mouthpiece is
processed into acrylic resin, and when
polished it is reinserted into the patient’s
mouth. The tubing can then be bent and cut to
fit the patient’s needs. At the tube end
opposite the mouth, a rubber tip is placed for
use in turning pages and typing. It can be re-

FIG. 15.14. A, surgical exposure of left central in-


cisor to stimulate eruption. B, stent to prevent the
healing of the area. C, stent placed in the mouth.
248 MAXILLOFACIAL PROSTHETICS

FIG. 15.15. A, immediate repositioning of central incisor. B, fenestrated stent in place to hold the tooth.

FIG. 15.16. Stent for sucking and nourishment.

moved and fitted with a ballpoint pen or with


a paintbrush for art work (Fig. 15.17).
Stock or commercial stents have been made
to which can be added self-curing acrylic to
fabricate quickly a mouthpiece or interocclusal
stent.
Periodontal Stent
The periodontal stent is of labiolingual
design and is made prior to the surgery. It
holds the periodontal dressing in place during
the healing phase. In the fabrication phase,
the study cast is waxed up in the area of
contemplated surgery. If an edentulous area
exists, it can be used by embedding a wire
uniting the labiolingual waxed halves. The
stent, which is processed in clear or pink
acrylic, depends for retention upon tooth
undercuts and wiring of anterior buttons (Fig.
15.18).
Labial Periodontal Stent
Cosmetic results are often a disappointment FIG. 15.17. A, stent with rubber tip for typing. B,
after extensive periodontal surgery in stent with brush for painting. (A and B, courtesy of
Miss A. H. Slominski.)
SPLINTS AND STENTS 249

Often it is necessary to add soft wax, such


as periphery wax, to the lingual of the
patient’s anterior teeth before making the
impression. The area of the stent to be covered
will be from the distal of the second bicuspid
to the distal of the second bicuspid on the
opposite side. Consequently, an impression
from first molar to first molar is sufficient.

FIG. 15.18. A, preoperative view of mandibular arch.


B, extensive mandibular gingivectomy. C, la- biolingual
stent in place over periodontal packing.

the anterior of the mouth. For better patient


acceptance, a thin labial stent of gingival
tissue-toned and characterized acrylic can be
made to disguise the elongated crown-root FIG. 15.19. A, extensive gingivectomy of maxillary
appearance seen in a wide smile. Generally, anterior teeth. B, periodontal labial stent. C, perio-
only a maxillary stent is needed (Fig. 15.19). dontal labial stent in place as false gingiva. (Courtesy
of Dr. H. Swenson.)
250 MAXILLOFACIAL PROSTHETICS

On the stone cast, one thickness of beeswax for protection of the graft, immobilization of
or pink denture wax is adapted, carved, and the medicated dressing, and patient comfort
festooned as desired. Wax may be added if (Fig. 15.20).
more root anatomy is needed. The final waxed Study casts are made. The area of the
stent is processed and finished as with a surgery is outlined, and a quick-cure auto-
denture. It will snap into the labial undercuts polymerizing acrylic resin baseplate form is
of the patient, protect sensitive root areas, and made to cover the areas marked. With the
enhance the smile. deepening of the sulcus, the stent can be lined
at the time of surgery with a soft tissue liner
Stent for Use in Mucous Membrane Ad- or dental compound to cover and extend the
vancement or Skin Graft Protection baseplate border into the wound site. This is
worn until granulation and healing ensue
When an edentulous ridge is to be deepened without reattachment of the vestibule borders.
by vestibular surgery, the wound area must be The stent is cold-sterilized and inserted to
prevented from reattaching to the ridge during hold and protect the skin graft.
healing. When a skin graft is placed in a
vestibule, palate, or floor of the mouth, it is Mouth Protector
helpful to the patient and surgeon to cover it A mouth protector should be comfortable to
during the healing phase the patient, fit the arch well, have

FIG. 15.20. A, mandibular edentulous ridge, showing minimal sulcus. B, stent constructed for use in surgery. C,
stent lined with impression compound and wired in place. D, postoperative view of deepened sulcus.
SPLINTS AND STENTS 251

enough retention for stability, be easy to clean, the treatment process (Fig. 15.22); reposition
and durable enough to last if cared for by or protect by shielding undiseased tissue so as
means of a few simple rules. to remove it from the radiation field (Figs.
To construct a mouth protector, a good set 15.23 and 15.24); position the radiation beam
of alginate impressions is made and the stone in a given position (Fig. 15.25); carry
study casts are obtained. With few exceptions, radioactive material or dosimetric devices to a
such as a severely prognathic individual, only site (Fig. 15.26); recontour certain areas so
the maxillary cast will be used. This cast is that therapy can be simplified (Fig. 15.27).
trimmed closer to the middle of the In addition, the stent must be easily fab-
mucobuccal fold, and the palatal side is ricated and readily usable by the patient
trimmed until a fenestration occurs in the and/or radiotherapist. Since each stent must
deepest part of the palate. The outline of the meet the particular needs of the patient, it is
mouth protector is then penciled onto the difficult to explain in step-by- step fashion a
model. It is not necessary to carry this outline technique for construction of all such stents.
across the palate or to the deepest part of the However, certain generalizations can be
mucobuccal fold (Fig. 15.21). offered.
The cast is now ready to set in the middle of The material of choice for making im-
a perforated plate; which in turn is connected pressions is an irreversible hydrocolloid. This
to a vacuum hose. A sheet of vinyl resin is material is easy to manipulate, takes a
selected. This sheet is uniformly warmed by minimum of time, and is elastic enough to
any oven, burner, or hot plate until it is soft, allow for maximal comfort to the patient. The
flexible, and pliable. It is then centered over casts are best mounted on an articulator
the cast plate. The vacuum is turned on full which is versatile enough to allow at least
force and the acrylic sheet is sucked over all of unlimited vertical opening. At times the stent
the model boundaries. Newer factory- made can be constructed at the chair without the
vacuum molding machines are available need of making impressions and mounting the
(Omnivac) which can simplify this procedure. resultant casts on an articulator. This is done
Before the sheet completely cools, it is when the stent is of the simplest design or
advisable to trim the excess with shears. Next, when an emergency exists insofar as time is
the borders are smoothed and finished. concerned. For the most part, however, precise
Finally, the prosthesis is ready to try in the planning requires that the casts be mounted
mouth and make any final corrections. on an articulator in the laboratory. Further,
An oral mouth guard stent for protection of patients with large, painful lesions cannot
the teeth is recommended when: (1) an tolerate repeated trauma to the area. The
individual engages in contact sports; (2) possibility that the tumor may be spread by
maxillary anterior fixed bridgework or crowns injudicious manipulation should also be kept
are present and the patient is to enter surgery in mind.
under general anesthesia; (3) the patient The wax-up of the stent should be checked
engages in bruxism during the night; (4) an on the patient and corrections made prior to
adverse habit prevails which threatens the flasking and processing. In many cases, the
teeth periodontally; (5) the patient is a mouth stent need not be constructed of heat-curing
breather; (6) a periodontal pack needs to be acrylic, and the use of autopolymerizing
placed more securely. acrylic offers many advantages.
Because of its high density, availability,
Radiation Stents
and working properties, lead is the metal of
A radiation stent must perform the fol- choice for shielding purposes. However, its
lowing functions: position diseased tissues in a high melting point makes its use difficult at
given repeatable position throughout times, and low-fusing alloys are often
substituted. The thickness of metal
252 MAXILLOFACIAL PROSTHETICS

FIG. 15.21. A, outline of appliance is penciled on cast. B, cast is centered over the vacuum plate with the vinyl
sheet. C, borders are finished with torch flame. D, vinyl mouth protector ready to try. E, mouth protector being
inserting in the mouth. F, mouth protector inserted in the mouth.
FIG. 15.22. A, lesion on lateral border of the tongue (epidermoid carcinoma). B, stent in place. The device has a
flat surface at the level of the mandibular teeth connecting both sides of the arch. The tongue is thus forced into
the same position when the stent is in place.

FIG. 15.23. A, lesion of the upper lip (hemangioma). B, small device in which the anterior flange area has been
filled with lead to protect developing dentition. C, intraoral stent in position with strings taped securely to stent to
prevent displacement. D, extraoral stent in position. The lesion with adequate margin is thus isolated from the
developing dentition below by the intraoral stent, and the surrounding tissue is isolated by the extraoral stent.

253
FIG. 15.24. A, radiation fields for lesion of the lateral border of the tongue reconstructed on radiographs to
show the inclusion of the maxilla in the treatment area. B, the stent in position not only positions the tongue but
also removes the maxillae from the radiation field.

FIG. 15.25. A, stent with cone. Note the area for


seating on mandibular and maxillary ridges. B, view of
lesion (tongue) through the stent. C, patient during
therapy. Note that the stent is used to localize the cone.

254
FIG. 15.26. A, stent constructed to hold dosimetric devices for a patient who has undergone partial maxillary
resection. B, radiograph showing (1) the field and (2) wire loops in maxillary area to which are attached lithium
fluoride carriers. A similar device can be used as an applicator.

FIG. 15.27. A, large tumor of the lower lip (epidermoid carcinoma). There is limited opening into the oral cavity.
The lesion does not lie in one plane. B, radiation stent. The arms are extended but they are swung to the distal of
the appliance for insertion. The instrument at the top of the picture is engaged into the holes on the arms and the
arms are extended after the stent is seated. C, the stent at insertion. D, the overall effect of the stent is to flatten
the lip and cheek area to allow for simplified treatment. Note the fields outlined on the patient’s face.

255
256 MAXILLOFACIAL PROSTHETICS

required for adequate protection depends upon and Johnsoft, H. F.: Radium therapy appliance.
the type of radiation used and the “force” of the J. Prosth. Dent. 11: 1166-1169, 1961.
6. Drane, J. B.: Dental care of patients receiving
radiation. This phase of the stent construction radiation therapy. In Fletcher, G. H.: Textbook of
must be carried out with competent advice. In Radiotherapy, pp. 136-137. Lea & Fehiger,
a large treatment center, the physics Philadelphia, 1966.
department will be most helpful. Preliminary 7. Drane, J. B., and Rahn, A. 0.: Maxillofacial
studies using epoxy-lead combinations have prosthetics. In^MacComb, W. S., and Fletcher,
G. H.: Cancer of the Head and Neck, pp. 517-
not proved as successful as anticipated. This 537. Williams & Wilkins Company, Baltimore,
may be due in part to inexperience with the 1967.
working properties of the materials, as well as 8. Frazer-Moodie, W.: Mr. Gunning and his splint.
to an uneven distribution of metal in the epoxy Brit. J. Oral Surg. 7: 112-115, 1969.
9. George, W. A.: Prosthetic splints as an aid in the
resin. Further studies of these problems are treatment of hemophilia. J. Prosth. Dent. 11:
underway. Whenever lead or lead-containing 987-989, 1961.
alloys are used, the metals must be covered 10. Henry, P. J. and Barb, R. E.: Mouth protectors
with wax or acrylic resins. for use in general anesthesia. J. A. D. A. 68: 569-
Except for carriers, most stents are used for 570, 1964.
11. Hohlt, F.: Personal communication.
only a matter of minutes each day. Therefore, 12. Jerbi, F. C., et al.: Prostheses, stents and splints
they need not fit as accurately as some other for the oral cancer patient. In Oral Care for the
long-term prostheses. This in no way condones Oral Cancer Patient, Public Health Service Pub.
careless techniques but merely suggests that No. 1958, pp. 11-12.
13. Laney, W. R.: Role of the prosthodontist in a
the energy expended in constructing the stent medical institution. J. Oral Surg. 21: 15-20,
must be weighed against the realistic use of 1963.
the appliance. 14. Patterson, S. S.: Endodontic therapy: use of a
Carriers which will be worn for extended polyethylene tube and stent for drainage. J. A.
periods must be carefully constructed to D. A. 69: 710-714, 1964.
15. Rowe, N. L., and Killey, H. C.: Fractures of the
provide maximal patient comfort and to ensure Facial Skeleton. E. & S. Livingstone, Ltd.,
that the radioactive material is suitable Edinburgh, 1968.
positioned. These appliances must be checked 16. Rudd, K. D., Pedersen, R. E., Morrow, R. M.,
closely for proper fit before they are loaded and Green, A. E.: Maxillary appliance for con-
trolled radium needle placement. J. Prosth.
with radioactive material. Such devices can Dent. 16: 782, 1966.
vary in design from the simplest to the most 17. Sabin, H., and Saltzman, E.: Intraoral splints
complex, according to their use. for surgical fractures of the mandible. J. Prosth.
Dent. 23: 320-326, 1970.
REFERENCES 18. Santiago, A.: An intraoral stent for the direction
1. Adisman, K., and Birnbach, S.: Surgical pros of radiation therapy. J. Prosth. Dent. 15: 938-
thesis for reconstructive mandibular surgery. J. 944, 1965.
Prosth. Dent. 16: 988-991, 1966. 19. Santiago, A.: Use of intraoral prosthesis in radio
2. Boucher, L. J., and Moss, R. W.: Decompression therapy. Medical Record and Annals, 58: 3, 1965.
stents. J. Prosth. Dent. 14: 1163-1168, 1964. 20. Tapley, N., and Fletcher, G. H.: Radiation
3. Brown, K. E.: Dynamic opening device for man therapy with electron beam: current techniques.
dibular trismus. J. Prosth. Dent. 20: 438-442, Radiol. Clin. N. Amer. 2: August, 1969.
1968. 21. Valiquette, J.: The dentist’s involvement in radi
4. Delclos, L.: Radiotherapy for head and neck otherapy. Unpublished data, the University of
cancer. J. Prosth. Dent. 15: 157-167, 1965. Texas at Houston, 1969.
5. Dobson, D. P., Sowter, J. B., Webster, W. B., 22. Yaggi, H. K.: Appliance which holds radioactive
needles for treating oral malignancies. J. Prosth.
Dent. 9: 1060-1063, 1959.
16
NUTRITIONAL CONSIDERATIONS FOR
MAXILLOFACIAL PATIENTS
David K. Hennon, Marie Tchalian, and Vigen K. Babayan

A prime requisite for healing and recovery the actual operation. Often a discussion of the
after maxillofacial surgery is adequate surgical technique, appliances, and other
nutritional status of the patient. Yet in mechanical factors may overshadow the basic
surgery or in the fitting of prostheses for need for dietary counseling. While the patient
maxillofacial patients, the problem of pro- is hospitalized, his nutritional needs are
viding an adequate diet is complicated by the managed by the dietary staff. For this reason,
fact' that the basic masticatory apparatus may some surgeons believe that they need not
be functionally impaired (Fig. 16. 1). mention dietary factors and nutrition to their
In this chapter, no attempt is made to dis- patients. Yet these same patients must live
cuss normal nutrition or nutritional metab- with their nutritional problems after they go
olism since these topics are better covered in home. Therefore, modifications in diet and in-
textbooks on nutrition. Rather, practical structions for their use must be made prior to
dietary suggestions for the maxillofacial the patient’s dismissal from the hospital.
patient are offered, including the constituents The problem, then, is how to get the patient
of an adequate diet. to ingest an adequate quantity and quality of
In maxillofacial defects of the infant or nutrients in a form which is compatible with
young child, the pediatrician will be included the limitations imposed by the condition
in the surgical team, and nutritional present. This is a critical problem with
management will be his responsibility. Since complete immobilization of the jaws after
the primary concern in such defects as cleft lip mandibular resection or reduction of a fracture
and palate is to provide a functional route to which severely inhibits the normal ingestion of
receive nourishment, early closure of these food. The nutrient requirements for such a
defects by surgery or mechanical obturation is patient have increased because of the stress
desirable. When the child is able to eat imposed by the surgery, yet his ability to meet
reasonably well, nutritional management will the increased need is restricted.
be the same as for any other child.
Basic Diet
Patients with acquired defects generally
require the same nutritional management, but The basic dietary requirement for the
they may also require special considerations. surgical patient includes adequate amounts of
Dietary recommendations should be made protein, vitamins, and minerals. In addition,
early in treatment planning and preferably, in sufficient calories from
the case of surgery, tfefore

257
258 MAXILLOFACIAL PROSTHETICS

FIG. 16.1. A, patient following extensive resection of maxilla and facial soft tissue which creates a serious
problem in feeding. B, placement of denture-obturator and lower appliance allows patient to assume more normal
pattern of food intake. C, facial prosthesis aids in partially restoring integrity of oral cavity necessary to facilitate
swallowing. Illustrations are through courtesy of LTC John P. McCasland, Prosthodontic Service, Walter Reed
General Hospital, Washington, D. C.

carbohydrates and lipids are necessary to tamin supplementation, such as vitamin K, is


provide energy. While this appears to be a needed, it is recommended that this be
relatively simple matter, it is complicated by prescribed and administered in single
the patient’s food habits and his likes and preparations rather than in a multiple-vi-
dislikes, as well as by the necessity of having tamin supplement.
food of a certain consistency. Except for patients who may require
An increased vitamin intake may be specialized dietary management for conditions
desirable, especially if diet surveys have other than maxillofacial situations, “Food for
revealed a poor eating pattern prior to sur- Fitness, A Daily Food Guide,” Leaflet 424
gery, or if a condition exists which may impair published by the United States Department of
the utilization of vitamins; in this instance, Agriculture,7 should be adequate for dietary
the use of a vitamin supplement is practical counseling. A highly motivated patient could
and convenient. If special vi adapt the recom-
NUTRITIONAL CONSIDERATIONS 259

mendations in the guide to his own situation the patient has a pre-existing condition which
as far as likes and dislikes and consistency are requires a diet modification. For example, an
concerned. Briefly, the guide is organized into ulcer patient may be on a low residue diet; or
four major food groups with recommended an individual with hypertension may require
daily intakes listed for each group. sodium restriction. In such cases, cooperation
among members of the treatment team is
essential so that all aspects of the patient’s
Milk Group children, 3 to 4 cups; teenag-
problem are considered. The present
ers, 4 or more cups; adults, 2
or more cups
discussion, however, is mainly concerned with
Meat Group 1 or more servings: beef, veal, the patient’s diet at home where professional
pork, lamb, poultry, fish, eggs supervision is generally not available.
Vegetable-Fruit 4 or more servings; include A patient with severely impaired ability to
Group citrus fruit or other fruit or masticate, whatever the reason, will require a
vegetable important for vi- liquid diet. Those patients with limited
tamin C; a dark green or chewing function may require a combination
deep yellow vegetable for vi- liquid-soft diet. When the masticatory function
tamin A at least every other
is relatively unimpaired, a regular diet may be
day; other vegetables and
fruits, including potatoes
prescribed, following the plan of the Basic
4 or more servings of whole Four Food Groups. The most important
Bread-Cereal
Group grain, enriched, or restored element here, however, is the quality of the
products. regular diet in terms of protein, vitamins,
minerals, and calories.
Although not specified in the guide, butter, The liquid diet is perhaps the hardest to
margarine, other fats, oils, sugars, or plan because of the difficulty in providing
unenriched refined grain products will be used sufficient protein and calories in a form
in baked goods and mixed dishes or added to acceptable to the patient. The old standbys,
foods during preparation or at the table to milkshakes and eggnogs, soon lose their
round out meals and to satisfy the appetite. appeal. A food blender is often useful in
These “other” foods supply calories and can preparing foods for the liquid diet. With this
add to total nutrients in meals. apparatus, all types of liquid diets can be
Probably the most important consideration tried, and the variety is limited only by the
in the nutritional management of the surgical imagination. The patient should be
patient is to suggest dietary modifications encouraged to experiment with food com-
compatible with the condition present. During binations, for in this way he takes a part in his
the course of treatment, the consistency of the treatment planning and may be therefore
diet may require changes, but this should more conscientious in maintaining an
cause no undue difficulty if the patient has adequate nutrient intake.
been thoroughly counseled concerning his diet In some instances, a commercially available
and its importance to him. nutritional supplement may be prescribed to
In general, the types of diets that would most augment the diet. A list of some of these
often be used for the maxillofacial patient are supplements is shown in Table 16.1.
the liquid, mechanical, soft, and regular. In If a blender for preparing food is not
some instances, while the patient is available to the patient, an effective substitute
hospitalized, other means of nourishment may is strained infant foods. Many of these foods,
be necessary, such as intravenous or gavage especially some of the meats and fruits, are
feedings. These methods, however, are for quite flavorful. The meats can be thinned with
patients requiring special care and do not milk to make a broth, while the fruits and
represent the typical feeding situation at vegetables can be used as is or added to other
home. foods. To make
Other types of diets may be necessary if
260 MAXILLOFACIAL PROSTHETICS

TABLE 16.1. Proprietary food supplements Food Groups gives the patient a specific guide
to follow.
The Carnation Company
Carnation Instant Breakfast* Use of Proprietary Food Supplements
Carnation Slender* Occasionally it may be desirable to have the
D. M. Doyle Pharmaceutical Company patient use a commercially prepared food
Controlyte Dietene Meritene supplement, either as a supplemental feeding
Resource Baking Mix Fleet
or as a nutritionally complete meal. The
Company, Inc.
Provimalt
American Dental Association has classified
Lederle Laboratories Gevral Protein the following protein-vitamin-mineral food
Loma Linda Foods Soyalac supplements as acceptable.
Mead Johnson and Company Casec Nutrament (Mead Johnson Nutritionals, a
Portagen division of The Drackett Company).
Lonalac ProSobee Nutrament is stated to be a nutritionally
MCT Oil Protein Milk complete liquid food of which each 12.5 fluid
Nutrament* Sobee oz provide 375 calories with 25 grams of
Nutramigen Sustagen
protein, 11 grams of fat, and 44 grams of
carbohydrate, plus all known essential
vitamins and minerals.
Instant Nutrament (Mead Johnson Nu-
tritionals, a division of The Drackett
* All products except those marked (*) are fully Company). Instant Nutrament is stated to
described in the Physicians’ Desk Reference.5 consist of nonfat dry milk, sugar, corn syrup
solids, artificial flavor, and essential vitamins
foods more acceptable to adults, additional and minerals. Each packet contains
seasoning and spices may be used. Since some approximately 25% protein, 0.9% fat, and 65%
patients may rebel if told to use “baby foods,” carbohydrate, and provides 215 calories. When
mixed with 8 oz of milk as directed, each
artful counseling is necessary.
The soft diet allows more freedom in packet provides approximately 375 calories.
selecting food items and also is less monot- Carnation Instant Breakfast (The Car-
onous than the full liquid diet. While the nation Company). Carnation Instant
patient must judge for himself what foods can Breakfast is stated to consist of nonfat dry
be tolerated on the soft diet, a general milk, sugar, corn syrup solids, flavoring
suggestion is to avoid foods with hard, tough, agents, and essential vitamins and minerals.
or fibrous particles, such as chopped nuts, Each packet contains approximately 25%
hard bread crusts, celery, etc. Raw vegetables, protein, 1.8% fat, and 65% carbohydrate, and
nuts, and seeds are also avoided, not only provides approximately 130 calories. When
because of chewing difficulty but also because mixed with 8 oz of milk as directed, each
particles may become lodged under newly packet provides approximately 290 calories.
Carnation Slender (The Carnation
inserted appliances. Frying foods often results
in sharp, hard food particles, and this method Company). Carnation Slender is stated to
is not recommended. In general, though, the consist of nonfat dry milk, lactose, corn syrup
patient is best able to determine what foods he solids, flavoring agents, and essential
can tolerate, and some do remarkably well in vitamins and minerals. Some of the sucrose in
eating foods that are not normally considered this preparation has been replaced by sodium
saccharin. Each packet contains
for a soft diet.
The regular diet requires no special in- approximately 45% protein, 2.9% fat, and 34%
structions except to ensure the intake of a carbohydrate, and provides 63 calories. When
sufficient quantity of protein, calories, vi- mixed with 8 oz of milk
tamins, and minerals. The Basic Four
NUTRITIONAL CONSIDERATIONS 261

TABLE 16.2. Standard pureed gavage*

Approximate
Ingredients household Amount Calories Carbohydrate Protein Fat
measure

g g g

Baby veal 5'/3 oz 160 g 146 24.8 4.3


Baby peas 4'/2 oz 130 g 70 11.1 5.5 0.3
Baby peaches 41/2 oz 130 g 105 26.3 0.8 0.3
Skim milk powder 9 tbsp 70 g 254 36.6 25.1 0.7
Oil (corn, etc.) 2 tbsp 30 g 265 0.0 0.0 30.0
Dextrose 2 tbsp 30 g 110 30.0 0.0 0.0
(dark label Karo) Poly-Vi-
Sol 0.6 cc
(Mead Johnson)

Add water to make 1 quart 1000 cc 950 104.0 56.2 35.6


(unused portions must be refrigerated)

* Adapted from A Handbook for Writing Modified Diets. 3

TABLE 16.3. Standard milk-base gavage*

Approximate
Ingredients household Amount Calories Carbohydrate Protein Fat
measure

g g g

Homogenized milk 3% cup 900 CC 585 44.1 31.5 31.5


Skim milk powder 7 tbsp 50 g 182 26.2 18.0 0.4
Dextrose 4 tbsp 60 g 220 59.7 0.0 0.0
(dark label Karo) Poly-Vi-
Sol 0.6 cc
(Mead Johnson) Fer-In-Sol
0.6 cc
(Mead Johnson)

Water to make: 1 quart 1000 cc 987 130.0 49.5 31.9


(unused portions must be refrigerated)

* Adapted from A Handbook for Writing Modified Diets. 3

TABLE 16.4. High protein nourishment*

Approximate
Ingredient household Amount Calories Carbohydrate Protein Fat
measure
A g g g

Half and Half cream 3 oz 100 CC 134 4.6 3.2 11.7


Milk 2 cups 480 cc 317 23.5 16.8 17.8
Eggs 4 180 cc 293 1.6 23.2 20.7
Skim milk powder 21/2 cups 180 g 653 94.1 64.6 1.4
Dextrose 6 tbsp 90 g 330 89.6 0.0 0.0
(dark label Karo) Vanilla
extract 1 tbsp 1 tbsp

Total 1 quart 1000 cc 1727 213.4 107.8 51.6


(unused portions must be refrigerated)

* Adapted from A Handbook for Writing Modified Diets.3


262 MAXILLOFACIAL PROSTHETICS

as directed, each packet provides approxi- maximal protein and calories in a minimal
mately 225 calories. volume. Such a high protein-high calorie type
Meritene (D. M. Doyle Pharmaceutical of feeding that can be prepared at home is
Company, a division of the Dietene Company). shown in Table 16.4. One 8-oz glass of this
Meritene is stated to contain nonfat dry milk preparation will provide approximately 25
together with flavor and other additives to grams of protein and 425 calories. The usual
provide protein and essential vitamins and precautions regarding food handling and
minerals. More than 25% of the National preservation should be observed when these
Research Council’s recommendations for the feedings are prepared at home. In particular,
daily intake of nutrients are said to be raw eggs which are used in eggnogs or as a
provided by 1 oz of the supplement added to 8 major component in the high protein
oz of fluid milk. supplement should be fresh and clean with
Table 16.1 lists these and additional uncracked shells.
products which may be of value in the nu-
tritional management of the patient. REFERENCES
1. American Dental Association: Accepted Dental
Sometimes the use of proprietary food
Therapeutics, 1969/70, Ed. 33, Chicago, 1968.
supplements is not possible, as they may be 2. Composition of Foods, Agricultural Handbook No.
too expensive or not readily available to some 8, Agricultural Research Service, Washington, D.
patients. Table 16.2 illustrates a gavage C., revised December 1963.
feeding which is basically a normal diet in a 3. Department of Dietetics, Indiana University Med
ical Center: A Handbook for Writing Modified
pureed form, supplying about 1 cal per cc. It is Diets, revised 1969.
adequate in all nutrients if adequate calories 4. Nizel, A. E.: The Science of Nutrition and its
are supplied. It is helpful to mix the pureed Application to Clinical Dentistry, Ed. 2. W. B.
gavage in a blender, although hand mixing is Saunders Company, Philadelphia, 1966.
5. Physicians’ Desk Reference, Ed. 24, Medical Eco
satisfactory. Since the mixture settles upon
nomics, Inc., Oradell, N. J., 1970.
standing, it should be stirred or shaken before 6. Recommended Dietary Allowances—A Report of
use. the Food and Nutrition Board, National Research
As a maintenance or supplemental feeding, Council, Publication 1694, Ed. 7. National
a milk-base gavage can be used. Table 16.3 Academy of Sciences, Washington, D. C. 1968.
7. U. S. Department of Agriculture Leaflet 424,
lists the ingredients of a typical gavage. This Food for Fitness, A Daily Food Guide. Wash-
gavage is not as nutritionally complete as the ington, D. C., 1958.
pureed gavage, and therefore it should not be 8. Wohl, M. G., and Goodhart, R. S.: Modern Nu
used for long-term care. trition in Health and Disease, Ed. 4. Lea & Fe-
biger, Philadelphia, 1968.
Sometimes it is necessary to provide
17
PLASTIC SURGERY AND MAXILLOFACIAL
PROSTHETICS
Lewis W. Thompson

Plastic surgery has been defined as the would not be advisable, or for patients who
surgical correction of a deformity in order to refuse further surgery. Prosthetic replacement
improve appearance or function or both. is also beneficial in the case of malignancy
Prosthetics involves the use of nonviable when it is considered advantageous not to
material in order to improve appearance or reconstruct the area initially. Foreign
function or both. Thus there is a great deal of implants are contraindicated if autogenous
overlap between the two fields of maxillofacial material will correct the defect, if there has
prosthetics and plastic surgery. been recent bacterial infection, if there is
Prosthetics may be divided into two major excessive scar tissue or a history of radio-
categories: (1) external, involving those therapy, or if the patient is in poor systemic
materials which are partially or completely condition.
external to the body fluids and tissues, and (2) Scales has outlined the properties of an
internal, involving those materials which are ideal foreign implant material. This yardstick
implanted within living tissues. The second had not changed, and in the quest for the
category can be further divided into biologic “perfect” prosthetic implant, the material
grafts or artificial implants. Surgical implants, must meet following criteria.
whether biologic or artificial, are indicated for 1. It must not physically be modified by the
rebuilding contour and for providing struc- soft tissue.
tural support, temporary support, conduction 2. It must not be capable of inciting an
of fluid, or joint replacement. inflammatory or foreign body reaction.
Autogenous tissue has always been the best 3. It must not be capable of producing a
implant material because the body’s state of allergy or hypersensitivity.
mechanism for protecting itself against foreign 4. It must be chemically inert.
substances is so effective that very few 5. It must be noncarcinogenic.
materials have been found to be acceptable. 6. It must be capable of resisting strain.
However, there are times when autogenous 7. It must be capable of fabrication in the
material is not available or when it is form desired.
desirable to seek a substitute. For example, 8. It must be capable of sterilization.
substitutes might be considered desirable for In using artificial implant material, the
temporary use until autogenous tissue surgeon must use a bed where there is rich
reconstruction can be done, or for use in circulation in the tissue on all sides of the
elderly patients and those in poor general implant, and asepsis technique must be fol-
health when extensive single or multiple lowed. Exact fitting in the recipient site is
reconstructive procedures important: that is, there must be no undue
tension that interferes with blood or
263
264 MAXILLOFACIAL PROSTHETICS

lymph, and there must be no increase in the face. Etiology includes congenital,
pocket size to allow movement or leave space developmental, and acquired defects, the last
for hematoma. category usually being secondary to trauma or
Artificial materials which have been used tumor excision. Whatever the etiology,
successfully can be divided as follows: metals maxillofacial defects should be managed by a
(stainless steel and several types of vitallium), team approach, and each patient treated Lby
textiles (Teflon and Dacron), plastics (methyl the method best suited to his deformity,
methacrylate and polyurethane), and whether it is surgery, prosthetics, or a
elastomeres (silicones). combination of the two.
For external prostheses construction,
Nose
various materials are available, and these are
discussed in Chapter 6. Congenital deformities include complete
Maxillofacial deformities can be classified absence of the nose, which is rare; partial
according to etiology and regions of absence, which is frequently associated

FIG. 17.1. Congenital nasal defect. A and B, glabellar depression. C, utilizing a face moulage of the defect the
desired size and shaped implant is first molded in wax. D, from this wax model a reproduction is vulcanized in
Silastic. E, postoperative profile—inplant in place.
PROSTHETICS AND PLASTIC SURGERY 265

FIG. 17.2. Traumatic nasal defect. A, glabella-orbital region. B, C, and D, operative views—incision hidden in
eyebrow.

with midline clefts; and nasal deformities congenital deformities of the nose associated
associated with clefts of the primary palate, with clefts of the primary palate, many
which include alar cartilage hypoplasia and procedures have been described for the various
deformity. types of deformities requiring reconstruction.
Management of the cleft nose depends upon Detailed discussion of these procedures is not
the severity and location of the cleft. If it is within the scope of this chapter.
midline and minimal, elliptical excision of this There are various acquired defects sec-
central segment and approximation may be all ondary to trauma or excision of tumors. Small
that is necessary. In more severe forms, local defects can be managed very satisfactorily
tissues may have to be shifted to achieve the with split thickness or full thickness skin
desired result. Occasionally, it is grafts from areas of the body where the color
advantageous to perform more than soft tissue most closely matches that of the nose. In more
reconstruction, specifically in the patient with extensive defects, such as those involving not
hypertelorism where there is a marked central only skin and subcutaneous tissue but
bony excess, which should be dealt with first. cartilage, bone,
In
266 MAXILLOFACIAL PROSTHETICS

and/or mucosal lining, various reconstructive color match. In the female patient, this
methods are available, including the island forehead defect can be minimized with a hair
pedicle and composite grafts. Glabellar defects, style that partially or completely covers the
usually of the acquired type, can be corrected forehead.
with bone grafts, but form- fitted silastic In total nasal reconstruction, a support is
implants are very satisfactory (Figs. 17.1 and often needed to prevent contracture and
17.2). More common is the depressed dorsum collapse. The support can be achieved either
that requires augmenting which again can be initially, in a temporary or permanent fashion,
done with autogenous material (bone or or soon after the skin and soft tissue
cartilage) or silicones. reconstruction. It can be in the form of
When more than half the nose has been autogenous bone or prosthetic implants.
lost, usually through an acquired defect, Autogenous bone is available either from iliac
consideration should be given to sacrificing the crest or ribs, with the former being preferable
remaining nose prior to reconstruction. because it is cancellous bone and is easier to
However, if these remaining segments can all sculpture. Some have advocated the cantilever
be used, this is always advantageous. In total principle, but the author prefers an L-shaped
nasal loss, the most widely used source of strut because it adds support needed to
autogenous tissue is the forehead. The upper prevent fracturing, which is occasionally seen
arm flap was one of the first flaps used for with the cantilever method. The most
nasal reconstruction, and the acromiothoracic commonly used synthetic implant materials
region is another possibility; however, in both are Teflon and medical grade Silastic. Dacron
of these regions there is the disadvantage of a felt backing on the Silastic can be helpful in
difference in color and texture.of the tissue. stabilizing the prosthesis to the tissue. Silastic
The tissue is inelastic and has bulky implants available in varied sizes from the
subcutaneous tissue, whereas the texture of manufacturer, or it can be carved from a block
the forehead resembles that of the nose. A of the material to the desired size and shape.
scalp flap, using forehead tissue, has been Prosthetic reconstruction in partial loss of
popularized by Converse, but it has the the nose is a consideration (Figs. 17.3 and
disadvantage of creating a forehead defect. 17.4), but it has two disadvantages: color
This deformity can be minimized by using match and fixation. However, for total
thick split thickness skin grafts or a full thick- reconstruction, the prosthetic nose has certain
ness skin graft from nearby areas for better indications or advantages,

FIG. 17.3. Acquired full thickness “small” partial nasal loss. A and B, defect secondary to cancer resection. C,

prosthesis in place.
PROSTHETICS AND PLASTIC SURGERY 267

FIG. 17.4. Partial nasal loss. A, secondary to cancer resection. B and C, prosthesis in place. Glasses can be worn
to camouflage the prosthesis.

FIG. 17.5. Total nasal loss. A and B, epidermoid cancer requiring total nasal resection. C and E, total nasal
prosthesis for temporary rehabilitation. D, recurrent carcinoma demonstrating the advantage of a temporary
appliance over immediate reconstruction with autogenous tissue.
268 MAXILLOFACIAL PROSTHETICS

under the circumstances noted earlier. In total moulage and inset 12 hours later when it has
nasal loss, including the septum plus hardened (Fig. 17.8).
extension onto the cheeks as in some cancer Other congenital defects involving the
ablation (Fig. 17.5), reconstruction with mandible include first and second branchial
autogenous material is often less than ideal. arch syndrome, in which the mandibular
Other uses of prosthetic material in nasal defect varies from minimal underdevelopment
surgery include temporary stents around to absence of ascending ramus and condyle;
which split thickness skin grafts are wrapped, the glenoid fossa may also be underdeveloped
and nares stents for use after alar cartilage or absent. Hypoplastic deformities can be
work on the cleft lip nasal deformities (Fig. handled by
17.6). The latter can be fashioned and worn for
several months to retain position during the
healing period. These stents, of course, can be
removed for cleaning, then replaced.
Chin and Mandible
Congenital deformities include retrogna-
thia, micrognathia, prognathia, micro- genia,
and macrogenia. The extent of these
deformities is not fully realized until
mandibular growth is complete, at approx-
imately 14 to 16 years of age. With retro-
gnathia, prognathism, and micrognathia, the
treatment is often sliding osteotomy, and
various techniques have been described, be it
of the body or subcondylar or transverse FIG. 17.6. Nares stent. Worn to minimize postop-
ramus. An important component of erative contracture. The center is left open to permit
management is the occlusive dental problem breathing.
which can be corrected with the operative
procedure or managed with overlying
dentures. In macrognathia, the excess is
resected. Microgenia correction includes
augmentation of the mental symphysis, either
through an intraoral or submental incision,
with a variety of materials including onlay
bone graft, autogenous or homogenous
cartilage, Silastic, or Ivalon. Dacron felt
backing is a consideration for use with the
Silastic to facilitate stabilization;
prefabricated chin models are available in
varied sizes (Fig. 17.7). With large defects
requiring several onlays of autogenous
material, it is frequently advantageous to
perform a single operative procedure, using a
large block of Silastic formed or carved
preoperatively. Another method uses liquid
Silastic, which is poured in a preformed mold
made from a face
FIG. 17.7. Commercially available chin implants of
various sizes.
PROSTHETICS AND PLASTIC SURGERY 269

FIG. 17.8. Congenital defect—micrognathia. A, preoperative profile. B and C, silicone implant is fashioned on
preoperative facial moulage. (Courtesy of Dr. E. G. Zook.) D, postoperative profile.

grafting with either autogenous bone or reconstruction has been attempted with whole
preserved cartilage. The use of rib grafts, as or half joint transplants such as metatarsal-
advocated by Longacre, is a most common phalangeal and metatarsal alone. A
method. Frequently it is necessary to perform disadvantage of the joint transplants is that
bilateral grafting because of deviation of the these do not grow with the patient.
normal side to the abnormal, thus leaving the In ablative surgery of intraoral tumors,
normal side hypoplastic in appearance. When such as those involving the alveolar ridge or
prosthetic implant is elected, the medium floor of the mouth and extensive cancers of the
grade block Silastic can be carved to fit the de- tongue, it is often necessary to remove part of
fect, but again the preference is for a form- the mandible, sometimes half or more. In
fitting prosthesis molded from a face moulage these resections, the inferior margin can
(Fig. 17.9). Temporomandibular joint sometimes be left intact, which
270 MAXILLOFACIAL PROSTHETICS

FIG. 17.9. Unilateral mandibular hypoplasia. A, left mandibular hypoplasia. B, silicone implant seated on
preoperative facial moulage. C, postinsertion of implant.

FIG. 17.10. Acquired unilateral mandibular defect. A, right hemimandible and partial maxilla was resected for
extensive osteogenic sarcoma. B, extending from right hamimandibular implant hemimandi ± bular condyle to
symphysis. C and D, oral rehabilitation included complete upper and lower dental prosthesis. The lower has been
tolerated for 4 years now over the prosthetic hemimandible without difficulty.
PROSTHETICS AND PLASTIC SURGERY 271

improves the cosmetic appearance and fa-


cilitates the fitting of dentures. In recon-
struction of the hemimandibulectomy defects,
various methods are available, including iliac
crest bone and contralateral rib grafts, plus
prosthetic devices. Contralateral rib grafts for
hemimandibular reconstruction give a very
satisfactory external contour, but intraorally
the lack of angulation makes it difficult, if not
impossible, to fit a denture. Prosthetic hemi-
mandibles made of a variety of materials,
including Teflon, Silastic, and Morlex 50, have
been used satisfactorily, including the use of
dentures overlying these large pieces of
foreign material (Fig. 17.10); however,
conclusions cannot yet be drawn about their
long-term effectiveness because of the
relatively short period during which this FIG. 17.12. Mandibular reconstruction with rib graft.

technique has been used. Success of autogenous mandibular reconstruction


depends on immobilization which can be achieved with
tantalum at each anastomotic site.

When segments of the mandible are


missing either from ablative tumor surgery or
acquired defects such as shotgun injuries, they
can be reconstructed in various ways,
including use of K wires, with or without
skewered bone to bridge the defect either
temporarily or permanently, or other
prosthetic material such as tantalum (Fig.
17.11), with or without chips or segments of
bone within. Segments of autogenous bone can
be secured to anastomosing bone with trays of
tantalum (Fig. 17.12). In prosthetic
replacement, the critical point in technique is
secure attachment of nonvi- able material to
viable tissue (Fig. 17.13). An important
adjunct to all mandibular reconstructive
surgery is adequate initial immobilization:
utilizable techniques include interdental
wiring, intraoral prosthetic devices such as
Gunning splints, and extraoral traction
devices. Mandibular segments can also be
effectively immobilized by the use of a K wire
through the maxilla into the mandible.

Palate and Pharyngeal Wall


By far the most common congenital
FIG. 17.11.
Mandibular reconstruction with Tantalum
anomalies in this area are clefts of the sec-
tray. A, tray wired in place to restore anterior half of
mandible bilaterally. B, tray with Silastic filling ondary palate or cleft palates. Early in the
symphysis region.
272 MAXILLOFACIAL PROSTHETICS

FIG. 17.13. Acrylic mandibular replacement. A, prosthesis with embedded K wires and tantalum trays for
securement to the bone. B, tray in position to immobilize acrylic implant and remaining left mandible. After
placement, the wires are tightened securely. C, postoperative profile. D, preoperative profile.

management of these deformities, it is fre- built out, when indicated, by a variety of


quently advantageous to use prosthetic materials including autogenous materials
devices in the form of arch retainers or (bone, cartilage, or soft tissue such as a Hyne’s
expanders (Fig. 17.14). Later in the child’s pharyngoplasty) or synthetic materials such
life, obturators or speech bulbs can be used, as solid Silastic rubber, shredded Silastic 372,
but again the best approach is the use of coarse Silastic sponge, Silastic F-5792 RTV, or
autogenous material to correct these defects. injectable Teflon. Solid soft silicone rubber, in
The use of W expanders, orthodontic the experience of this investigator, has not
appliances for dental restoration, and been satisfactory because, in a high
dentures or prosthodontic devices for the percentage of cases, devices made of this
residual deformity points up the importance of material have eventually extruded.
the prosthodontist’s contribution in the Orbit
management of the cleft palate patient. The Congenital anomalies vary from hypoplasia
cleft lip and palate problem is discussed in of the bony orbit, particularly the superior,
detail in Chapter 21. lateral, and infraorbital rims, to marked
In cases of inadequate velopharyngeal hypoplasia with essentially nonex-
closure, whether due to a cleft palate or other
etiology, the pharyngeal wall can be
PROSTHETICS AND PLASTIC SURGERY 273

isting globes. The rim defect can be recon-


structed with onlay bone grafts or synthetic
materials such as Silastic, and the global
deficiency can be camouflaged with a
prosthesis after an adequate socket has been
constructed. It is essentially impossible to
reconstruct with autogenous material an
anatomic situation, either congenital or
acquired, in which there is a total loss of
upper and lower eyelids, along with the eye.
Thus the treatment of choice is an external
prosthesis, which includes the entire unit of
eyelids and globe, after the patient has
reached an age when this can be properly
cared for. Another congenital defect, Treacher-
Collins syndrome, has orbital anomalies in FIG. 17.15. Orbital floor augmentation. A sheet of
which bone, cartilage, or Silastic implants to reinforced silicone is used in the orbital floor of a facial
fracture case.
the infraorbital rim can be used to prevent the
antimongoloid slant of the palpebral fissure.
In these patients, eyelashes are frequently ophthalmos can be treated with fair success by
absent, and false eyelashes are suggested. In de-roofing the orbit.
Crouzon’s disease, also a congenital anomaly, The most common traumatic deformity of
ex- this region is the blow-out fracture of the
orbital floor, seen as an isolated defect or
associated with other facial fractures. Of the
various methods for management, the most
desirable is to locate the fragments, return
them to their respective positions, and retain
them with antral packing. Occasionally this is
not adequate, leaving the surgeon with the
choice of grafting autogenous bone from the
anterior maxillary wall or the iliac crest, or of
using a sheet of prosthetic material such as
silicon, Dacron, or Teflon (Fig. 17.15). This
augmentation has other benefits, as in the
badly traumatized floor in which there often
are varying degrees of postoperative
periorbital fat pad loss with subsequent drop
of the globe; this is corrected with the
appropriate thickness of synthetic sheeting. In
trauma cases in which a
dacryocystorhinostomy is necessary, fine
caliber Silastic tubing is useful; another
method uses a silk suture through the duct.
In the case of isolated global absence, most
commonly secondary to trauma or removal for
cancer, the defect is first filled with a
prosthetic conformer, then later with a
FIG. 17.14. Palate expander. A and B, the appliance prosthesis to match the good eye (Fig.
has an adjustable screw and is kept in place with 17.16) . When the entire unit, eyelids and
dental adhesives. globe, is removed for cancer, again the
274 MAXILLOFACIAL PROSTHETICS

FIG. 17.16. Orbital prosthesis. A, initially a conformer was used to occupy the space. B, later a globe prosthesis
was made to match the opposite eye.

FIG. 17.17. Total orbital prosthesis. A, left total maxillectomy including orbit exenteration was performed for
osteogenic sarcoma. B, external prosthesis in place. C, glasses are worn to help camouflage the prothesis.
(Courtesy of Dr. J. E. Bennett.)

treatment is total external prosthesis (Fig. as Silastic implants. Prosthetic materials are
17.17) . placed under the periosteum when feasible; if
not, they are placed immediately over the
Maxilla and Zygoma
periosteum, with fixation by wire. Working
Congenital defects in this region involve with synthetic material in these cases, one
bone and/or soft tissue and include such must note the areas which are deficient in soft
entities as Treacher-Collins syndrome, tissue and remember that they are potentially
Romberg’s disease, Crouzon’s disease, and poor areas for synthetic implant material.
Apert’s syndrome. These deformities can be Chips of Silastic 372 have also been used, as
improved surgically by autogenous bone grafts well as injectable Silastic S-5392. The latter is
or prosthetically with such materials currently
FIG. 17.18. Post-traumatic defect. A, right malar prominence and glabellar-frontal depression. B, silicone
implants are constructed preoperatively from his face moulage (implants are lying in place on the moulage).
(Courtesy of Dr. J. E. Bennett.)

FIG. 17.19. Total left maxillectomy. A, osteogenic sarcoma. B, maxillectomy defect. C and D, the defect is
corrected with oral prosthesis. In addition to teeth and alveolar ridge reconstruction, the prosthesis filled the
antral defect thus helped restore the contour of the cheek.
275
276 MAXILLOFACIAL PROSTHETICS

an experimental “drug,” and in the United


States today it is available only to specific
investigators. If one plans to use synthetic
material for the bulk of the bony defect
reconstruction, it is frequently advantageous
to perform the soft tissue reconstruction
before the prosthetic material is implanted.
The soft tissue reconstruction includes such
possibilities as free dermal fat grafts or
dermal fat grafts transferred via pedicle flaps.
Acquired defects in this area are usually
secondary to old facial fracture deformity, and
here again the treatment can be either bone
grafts or synthetic materials (Fig.
17.18) . In acquired defects secondary to
ablative cancer surgery, specifically in the
antral areas, prosthetic material is very
helpful temporarily in the form of obturators
to hold split thickness skin grafts and
remaining tissues in the normal position
during the healing phase; then later the
patient is fitted with obturator-dentures for
permanent use (Fig. 17.19).

FIG. 17.21. External ear framework. Prosthetic


(silicone) substitute for cartilage.

In acute facial bone fracture surgery,


specifically in the edentulous patient, pros-
thetic splints (Gunning) are frequently
necessary (Fig. 17.20).
Ear
Congenital deformities of the external ear
vary from the protruding ear to the microtic
ear. A varity of methods has been advocated
for repair of the former, with the basic
abnormality being the lack of anthelical fold.
For re-establishing this anthelical fold, the
author has preferred the technique described
by Mustarde plus crescent excision of the
appropriate amount of conchal cartilage where
indicated. The intermediate deformities in the
embryolog- ical evolutionary ladder, combining
protruding and microtic ear, leave the surgeon
with a technically challenging problem. •The
microtic deformity is not the cosmetic
FIG. 17.20. Gunning splint. Used for upper and
lower arch immobilization in an edentulous patient.
PROSTHETICS AND PLASTIC SURGERY 277

problem in girls that it is in boys because in is almost universally indicated, be it with


girls the hair style may provide partial autogenous tissues or prosthetic materials.
coverage; however, it is not implied that the In total ear reconstruction, such procedures
female should necessarily be denied the as the Tanzer multistage technique using
possibility of total ear reconstruction. In the autogenous material can be accomplished in
female it may not always be desirable to three to five operative procedures. Supporting
undertake the multistage reconstruction, but framework can be either costochondral
repositioning the lobes so that earrings can be cartilage, autogenous fibroe- lastic cartilage,
worn is advantageous. In the male patient, or a synthetic framework of medium grade
before some of the new hair styles were Silastic proposed by Cronin40 (Fig. 17.21).
introduced, the ears were very conspicuous Backing the Silastic framework with Dacron
appendages, and reconstruction helps with tissue

FIG. 17.22. Extensive lateral defect. A, epidermoid carcinoma. B, surgical ablation required temporal bone
resection. C, defect covered with split thickness skin graft. D, a large prosthesis including ear was fashioned to
cover the defect which is nicely camouflaged with hat and glasses.
278 MAXILLOFACIAL PROSTHETICS

immobilization. The microtic patient usually, areas can be constructed of synthetic material
has associated middle ear deformities. In with the helix made of autogenous tissue in the
bilateral deformities, it is advantageous to form of a pedicle graft from the supraclavicular
attempt repair of at least one middle ear. In or neck region. Contraindications for surgical
unilateral deformities, critical evaluation of reconstruction of external ears include old age,
mastoid and cochlea is important before poor health, malignancy that is questionably
deciding to attempt surgical correction. controlled, unwillingness of patient, lack of
Another possibility for their middle ear trained * surgeon, and inadequate autogenous
problems is the use of hearing aids. tissues. An example of this last is the burned
Acquired auricular deformities vary from patient who, in addition to losing his auricle, is
small defects secondary to trauma or tumor left with serious damage of the surrounding
resection, which can be managed by shifting tissues. Such deformities have been
local tissue, to large defects requiring reconstructed, but the results are not as
extensive reconstruction. In the latter desirable as one would like. It is frequently
category, prosthetic material can be used in advantageous to remove the small remnants of
part or totally (Fig. 17.22). In the smaller the ears, such as cartilage tags, and to use a
defects, conchal and anthelical total prosthetic external

FIG. 17.23. Total ear prosthesis. A, bilateral external ear defect secondary to burn. B, prosthetic external ears
in place. C and D, before external prosthesis ears could be fitted these soft tissue (no cartilage) remnants were
removed, leaving a surface on which a prosthesis could be worn.
PROSTHETICS AND PLASTIC SURGERY 279

FIG. 17.24. Posttraumatic skull defect. A, depressed left frontal area. B, x-ray demonstrating the underlying
bony defect. C, scalp flap was turned and bony defect filled with block of firm silicone rubber.

ear (Fig. 17.23). The advantages of the Skull


prosthetic ear include speed of reconstruction
and accuracy of matching the opposite ear in This discussion is limited to the forehead
size, shape, and position. The disadvantages region since this area is considered part of the
are basically three: (1) the patient’s face and thus in the category of maxillofacial
psychologic reaction, since the prosthetic ear defects. Forehead defects are more commonly
is not a living part of him, (2) the fact that the acquired than congenital and vary from minor
attachment is not always secure and may depressions, which can be nicely handled by
cause embarrassment when it is dislodged injecting sufficient material such as Silastic S-
(this situation is improving with the newer 5793 RTV or shredded Silastic 372, to larger
adhesives), and (3) the coloration of the defects, in which autogenous materials such
prosthesis, which doesn’t change as do the as rib or iliac crest bone grafts have been very
surrounding tissues or lose its tan. Also, this successful. In the field of prosthetic materials,
is not considered a suitable procedure in tantalum or stainless steel is the old standby.
individuals who are very active, such as the The metal serves as a strong protection for the
child before high school age and the active brain, but it has the disadvantage of heating
adult, although some authorities have debated up when the patient is in the hot sun. Another
this issue recently. material such as
280 MAXILLOFACIAL PROSTHETICS

FIG. 17.25. Total scalp avulsion. A and B, defect was first covered with split thickness skin graft. C, wig in
place.

methyl methacrylate can be catalyzed at the region. The most common etiologies are
time of surgery and poured into the defect; trauma and tumor resection (Fig. 17.25).
then, after a very rapid set-up, it is shaped
Miscellaneous
with power tools. This also is a very hard,
substantial material. Silicone, one of the more Other congenital deformities of the max-
recent materials used in this area, can be illofacial region include:
preshaped either by carving from a block or by Lateral and oblique facial clefts which are
form-shaping from a face mask (Fig. 17.24). managed very satisfactorily by shifting local
The advantages of prosthetic materials are tissues.
shorter operating time, the fact that there is Moebius syndrome is an interesting
no donor site and therefore more patient com- anomaly of bilateral seventh nerve loss with
fort, and the absence of absorption. no functioning muscle of facial expression.
For completeness, the use of wigs needs These patients can benefit from such
mentioning in the category of external procedures as dynamic masseter muscle
prostheses and in acquired defects of this transfer and slings.
Klippel-Feil syndrome, which involves
1

PROSTHETICS AND PLASTIC SURGERY 281

the neck with bilateral soft tissue neck webs, C. J.: An experimental study of silicone as a
can be corrected by shifting tissue in a Z- soft tissue substitute. Plast. Reconstr. Surg. 24:
600-608, 1959.
plasty manner. 12. Masson, J. K.: Relationship of surgery to pros
Fibrous displasia of the bones is an thetic reconstruction of maxillofacial area. Mayo
abnormality of the bone-forming mesenchyme Clin. Proc. 39: 20-22, 1964.
which is ordinarily self-limiting at maturation 13. Moore, A. M., and Brown, J. B.: Investigation of
polyvinyl compounds for use as subcutaneous
of the skeleton sometime during the teens.
prosthesis. Plast. Reconstr. Surg. 10: 453-459,
Treatment is cosmetic reduction of the 1952.
enlarged bone, and repeated procedures are 14. Rank, B. K.: The considered use of facial pros
often necessary. thesis. Brit. J. Plast. Surg. 6: 241-246, 1953-
Branchial cleft sinuses, cysts, and fistulas 1954.
15. Rubin, L. R., and Walden, R. H.: A seven year
are managed by excision after any evaluation of polyethylene in facial reconstruc-
inflammatory process has subsided. tive surgery. Plast. Reconstr. Surg. 16: 392- 407,
Macroglossia is a large tongue which may 1955.
alter mandibular growth as well as teeth 16. Rubin, L. R., Robertson, G. W., and Shapiro, R.
W.: Polyethylene in reconstructive surgery.
position; potentially it causes an enlarged
Plast. Reconstr. Surg. 3: 586-593, 1948.
mandible and a buck teeth effect. 17. Smith, W.: External facial prosthesis. In Gibson,
Management is excision of the excess. T.: Modern Trends in Plastic Surgery (first
series), p. 283. Butterworth and Company,
REFERENCES Washington, D. C., 1964.
General 18. Speirs, H. C., and Blocksma, R.: New implant
able silicone: an experimental evaluation of
1. Avons, M. S., Sabesin, S. M., and Smith, R. R.:
tissue response. Plast. Reconstr. Surg. 31: 166-
Experimental studies with Etheron sponge.
175, 1963.
Plast. Reconstr. Surg. 28: 72-80, 1961.
2. Barondes, R., Judge, W. D., Towne, C. B., and Nose
Baxter, M.: Silicones in medicine. Milit. Surgeon 19. Bulbulian, A. H.: Facila Prosthesis. W. B. Saun
106: 379-387, 1950. ders Company, Philadelphia, 1945.
3. Brown, J. B., Fryer, M. P., and Lu, M.: Poly 20. Chalian, V. A.: Maxillofacial Prosthesis. Univer
vinyl and silicone compounds as subcutaneous sity of Texas, Dental Branch, Houston, 1960.
prosthesis; laboratory and clinical investigation. 21. Pressman, J. J.: Nasal implants. Laryngoscope
A. M. A. Arch. Surg. 68: 744-751, 1954. 62: 582, 1952.
4. Brown, J. B., Fryer, M. P., and Ohlwiler, D. H.: Chin and Mandible
Study and use of synthetic materials such as 22. Brown, J. B., Fryer, M. P., Kollias, P., Ohlwiler,
silicones and Teflon as subcutaneous prosthesis. D. H., and Templeton, J. B.: Silicone and Teflon
Plast. Reconst. Surg. 26: 264-279, 1960. prosthesis, including full jaw substitution:
5. Brown, J. B., Fryer, M. P., Randall, P., and Lu, laboratory and clinic studies of Etheron. Ann.
M.: Silicones in plastic surgery. Plast. Reconstr. Surg. 157: 932-943, 1963.
Surg. 12: 374-376, 1953. 23. Byars, L. T.: Subperiosteal mandibular resection
6. Brown, J. B., Ohlwiler, D. H., and Fryer, M. P.: with internal bar fixation. Plast. Reconstr. Surg.
Investigation of the use of dimethyl siloxanes, 1: 236-239, 1946.
halogenated carbons and polyvinyl alcohol as 24. Conley, J. J.: The use of vitallium prosthesis and
subcutaneous prosthesis. Ann. Surg. 152: 534- implants in the reconstruction of the mandibular
547, 1960. arch. Plast. Reconstr. Surg. 8: 150-162, 1951.
7. Bulbulian, A. H.: Maxillofacial prosthetics, its 25. Freeman, B. S.: The use of vitallium plates to
origin and present status. Mayo Clin. Proc. 39: 3- maintain function following resection of the
17, 1964. mandible. Plast. Reconstr. Surg. 3: 73-78, 1948.
8. Faggella, R. M., Ott, B. S., and Murphy, W. M.: 26. Goodsell, J.: Tantalum in temporomandibular
The use of Marlex 50 in plastic and reconstruc- joint arthroplasty. J. Oral Surg. 16: 517-518,
tive surgery. I. Experimental observations. Plast. 1958.
Reconstr. Surg. 30: 247-253, 1962. 27. Kleitsch, W. P.: Vitallium reconstruction of a
9. Grindley, J. H., and Waugh, J. M.: Plastic hemimandible and temporomandibular joint.
sponge which acts a framework for living tissue Plast. Reconstr. Surg. 7: 244-253, 1951.
A. M. A. Arch. Surg. 63: 288-297, 1951. 28. Pennisi, V. R., Shapiro, R. L., Boucher, J. H.,
10. LeVeen, H. H., and Barberio, J. R.: Tissue reac Pickins, G. E., and Shadish, W. R.: Marlex 50
tion in plastics used in surgery, with special ref-
erence to Teflon. Ann. Surg. 129: 74-83, 1949.
11. Marzoni, F. A., Upchurch, S. E., and Lambert,
282 MAXILLOFACIAL PROSTHETICS

as a replacement for the mandibular condyle. total and subtotal reconstruction of the external
Plast. Reconstr. Surg. 34: 212-217, 1965. ear: preliminary report. Plast. Reconstr. Surg.
29. Robinson, M.: Silver implant in situ fifty-one 37: 399-405, 1966.
years after resection of mandible. J. A. M. A. 171: 41. Dunton, E. F., Blocker, T. G., Jr., Lewis, S. R.,
890, 1959. and Paderewski, J.: A compromise approach to
30. Winter, L., Lifton, J. C., and McQuillan, A. S.: total ear reconstruction. Plast. and Reconstr.
Embedment of a vitallium mandible prosthesis Surg. 34: 247-251, 1964.
as an integral part of the operation for removal 42. Fromm, B. E., Knutson, P. O., and Stenstrom,
of an adamantinoma. Amer. J. Surg. 69: 318- S. J.: Prosthetic ears—two methods of fixing to a
324, 1945. reconstructed auditory meatus. Plast. Reconstr.
Surg. 34: 252-260, 1964.
Palate and Pharyngeal Wall 43. Macomber, D. W.: Plastic mesh as a supporting
31. Blocksma, R.: Correction of velopharyngeal in medium in ear construction. Plast. Reconstr.
sufficiency by silastic pharyngeal implant. Plast. Surg. 25: 248-253, 1960.
Reconstr. Surg. 31: 268-274, 1963. 44. McCash, C. R.: Polyethylene tubing in ear recon
32. Blocksma, R.: Silicone implants for velopharyn struction. Brit. J. Plast. Surg. 10: 153-156, 1957-
geal insufficiency: a progress report. Cleft Palate 1958.
J. 1: 72-81, 1964. 45. McConnell, D. V., and Nixon, M.: A simplified
method for the construction of facial prosthesis.
33. Horton, C. E., Brauer, R. 0., and Cronin, T. D.:
Plast. Reconstr. Surg. 33: 278-287, 1964.
The prevention of maxillary collapse in congen-
46. Pennisi, V. R., Klabunde, E. H., McGregor, M.,
ital cleft lip and palate patients. Cleft Palate J.
O’Connor, G. B., Pierce, G. W., and Faggella, R.:
1: 25-30, 1964.
The use of Marlex 50 in plastic and recon-
Orbit structive surgery. I. Experimental observation.
Plast. Reconstr. Surg. 30: 247-253, 1962.
34. Bronberg, B. E., Rubin, L. R., and Walden, R. 47. Wellington, C.: Ear prosthesis in soft plastic.
H.: Implant reconstruction of the orbit. Amer. J. Brit. J. Plast. Surg. 9: 315-318, 1956-1957.
Surg. 100: 818-822, 1960.
Skull
35. Freeman, B. S.: The direct approach to acute
fractures of the zygomatic maxillary complex and 48. Burke, G. L.: The corrosion of metals in tissue:
immediate prosthetic replacement of the orbital and an introduction to tantalum. Canad. Med.
floor. Plast. Reconstr. Surg. 29: 587-595, 1962. Ass. J. 43: 125-128, 1940.
36. Lipshutz, H., and Ardizone, R.: The use of sili 49. Lockhart, W. S., Van Den Noort, G., Kimsey,
cone rubber in the immediate reconstruction of W. H., and Groff, R. A.: A comparison of tan-
fractures of the floor of the orbit. J. Trauma 3: talum and polyethylene for cranioplasty. J.
563-568, 1963. Neurosurg. 9: 254-257, 1952.
50. Pudenz, R. H.: The repair of cranial defects with
Maxilla and Zygoma tantalum: an experimental study. J. A. M. A.
37. Ashley, F. L., Rees, R. D., Ballantine, D. L., 121: 478-481, 1943.
Galloway, D., Machida, R., Grazer, F., Mc- 51. Scott, M., Wycis, H., and Murtagh, F.: Long
Connell, D. V., Edgington, T., and Kiskadden, term evaluation of stainless steel cranioplasty.
W.: An injection technique for the treatment of Surg. Gynec. Obstet. 115: 453-461, 1962.
facial hemiatrophy. Plast. Reconstr. Surg. 35: 52. Small, J. M., and Graham, A. P.: Acrylic resin
640-648, 1965. for the closure of skull defects; preliminary
38. Sofian, J.: Progress in nasal and chin augmenta report. Brit. J. Surg. 33: 106-113, 1945-1946.
tion. Plast. Reconstr. Surg. 37: 446-452, 1966. 53. White, J. C.: Late complications following cran
ioplasty with alloplastic plates. Ann. Surg. 128:
Ear 743-755, 1948.
39. Bulbulian, A. H., and Litzow, T. J.: Congenital 54. Wieford, B. C., and Gardner, W. J.: Tantalum
malformation of ear; prosthetic reconstruction in cranioplasty: a review of 106 cases in civilian
combination with a plastic surgical procedure. practice. J. Neurosurg. 6: 13-32, 1949.
Proc. Mayo Clin. 36: 429-438, 1961. 55. Woolf, J. I., and Walker, A. E.: Cranioplasty,
40. Cronin, T. D.: Use of a silastic framework for collective review. Int. Abstr. Surg. 81: 1-23, 1945.
18
EXTRAORAL PROSTHETICS
Varoujan A. Chalian, Joe B. Drane, Herbert H. Metz, A. C.
Roberts, and S. Miles Standish

GENERAL CONSIDERATIONS

Guidelines for Materials Making Impressions


Prosthetic restorations must meet certain Impressions must be carefully and gently
general requirements. The prosthodontist made, for these areas are very sensitive in an
strives for natural function and lifelike already sensitive patient. Yet the impression
appearance. His goal is an appliance which should be as accurate as possible to ensure a
can be easily and swiftly placed and held in well-fitting appliance. The casts made from
place comfortably and securely. He also wants the impressions should be carefully poured
it to retain its color quality and to be durable and reinforced so that all subsequent
and easy to clean. To accomplish these procedures will likewise be accurate to obtain
objectives, each patient must be treated the desired result. The material used in our
individually, for each presents unique procedures lends itself admirably to the
problems of adjustment and adaptability. intrinsic coloring procedure, making the color
The materials discussed in this chapter are more desirable than that obtained by extrinsic
polyvinyl resin, methyl methacrylate, procedures and noticeably more durable. The
Palamed, and silicone. reproduction of moles, freckles, and other skin
The ideal material for extraoral prostheses blemishes which may have been present on
should not irritate the surrounding tissues, the patient’s original skin makes for a more
yet it should be strong enough about the lifelike appearance, adding to the patient’s
periphery to endure. It should be translucent, satisfaction and adaptability.
lightweight, easy to process and easy to
Retention of Facial Prosthesis
manipulate prior to processing, and resistant
to various chemicals, such as ether and oils, Retention of the prosthesis depends upon
and to sunlight, heat, and cold. Although all of anatomic undercuts and such mechanical aids
these criteria have not yet been satisfied by as the surgical appliance adhesive cements,
any one material, laboratory and clinical re- fixation to eyeglasses, and pin fixation to
searchers are constantly making improve- upper dentures. Anatomic retention is
ments. acquired by extending

283
284 MAXILLOFACIAL PROSTHETICS

the .vinyl acrylic resin into natural undercuts Adhesive must be tacky before the prosthesis
in the patient’s defect. is placed.)
Of major importance in considering the To take care to look in one or more mirrors
source of retention is a careful study of the when placing the prosthesis. This will help the
patient’s history. For example, it is unwise to patient to place it in its correct relationship
attempt to use adhesive in the field of heavy with surrounding anatomic areas.
preoperative or postoperative irradiation. The To hold appliance in place with finger
radiated tissue in most instances becomes pressure for 5 minutes.
irritated by the cement and subsequently To check all edges by the use of the mirror
breaks down and heals quite poorly. For this for complete adaptation to all surfaces. The
reason, retention must be accomplished by surfaces of the prosthesis were made to fit the
means other than surgical appliance cement. supporting areas, so they should match
accurately.
Care of Facial Prosthesis To avoid too much exposure of the ap-
pliance to direct sunlight. Careful daily
Proper maintenance of the prosthesis is of cleansing will help prevent hardening of the
vital importance for hygienic and esthetic prosthesis caused by residues of nasal and
reasons. skin secretions.
The prosthesis should be removed at least The patient should remember at all times
once a day to be cleaned. The adhesive should that a prosthesis is exposed to conditions
be removed with a rolling motion of the ball of which will bring about changes in its basic
the finger or thumb in the direction of the color. The basic color of the surrounding areas
borders of the appliance. All surfaces of the may also change as a result of suntanning,
prosthesis should be free of all foreign exposure, illness, etc. In these cases, it may
substances, such as facial creams and become necessary to replace the prosthesis
cosmetics. The prosthesis should be washed with a color-corrected one. This would seem to
with a mild soap and a brush. (If the be a reasonable eventuality for the patient to
prosthesis includes an artificial eye, the expect, just as a denture may need adjustment
prosthesis and the eye should be cleaned because of alteration of its supporting
separately, the eye being handled and replaced structures from wear and constant handling.
with care. If the prosthesis includes a nose, the
patient should wipe well down into the Laboratory Facilities
opening with cotton or a swab where the brush Laboratory facilities required for maxil-
cannot reach.) lofacial prosthetic work do not differ greatly
The skin in contact with the prosthesis from those required for a conventional
should be thoroughly and gently cleaned. The prosthetic practice. There still exists a need
patient is carefully directed to remove and stop for the age-old plaster bin, and possibly a
wearing the prosthesis should any irritation larger quantity of plaster must be kept on
occur wherever the prosthesis contacts the hand than would be necessary in the ordinary
tissues and to see the prosthodontist as soon laboratory. Instead of enumerating every
as possible for treatment. small laboratory item which is needed to equip
The daily placement of the prosthesis will such a laboratory, this discussion is limited to
be successful if the patient follows the items essential to the fabrication of extraoral
directions given him, which are: prostheses.
To keep the supporting area clean, dry, and Aside from expendables (wax, investment,
free of oil. metal for mold construction, etc.) the main
To keep the prosthesis clean. laboratory equipment required is as follows.
To replace the prosthesis as directed. (If
adhesive is used, it should be used as spar-
ingly as possible and not too frequently.
EXTRAORAL PROSTHETICS 285

1. Double Boiler and Bunsen Burner with 10. Bench Lathe. This is used along with a
Tripod and Asbestos Pad. This equipment is variety of finishing stones, burs, and abrasive
used to prepare the reversible hydrocolloid materials to properly finish the functional
impression material used in taking the surfaces of the completed molds.
impression of the patient’s defect and in
Maxillofacial Prosthetics Studio
duplicating procedures for mold construction.
2. Large Investment Rings of Galvanized The studio suggested here would consist of
Sheet Metal (Various Sizes). These are used in two working areas 10 feet square designated
investing the wax models of the molds to be room 1 and room 2.
constructed. Room 1 {Fig. 18.1, A)
3. A Large Dry Heat Oven. This is em-
1. Padded Table. This table is used in
ployed to drive off moisture from the in-
obtaining the impression of the patient’s
vestment after wax elimination and to heat
defect. Generally speaking, an impression
the investment and ensure the proper thermal
made in the prone position captures the size
expansion prior to casting procedures.
and configuration of the defect to be restored
4. Square Jaw Pliers. These are used to
in its most natural and relaxed position. In
manipulate the molds.
rare instances, an impression made with the
5. Asbestos Gloves. These are essential in
head of the patient in a vertical rather than
permitting easy handling of the invested
horizontal position is more desirable, and this
models before, during, and after the actual
can be accomplished by using ‘a dental chair
casting of the molds.
with a headrest.
6. Cast Iron Melting Pot with Large Burner
2. Work Table on Wheels. This table can be
and Tripod. This set-up is used in melting the
rolled alongside the padded table during the
linotype metal and bringing it to the desirable
impression procedure. It may serve as a place
casting temperature prior to the pouring of the
for setting the impression material, the gauze
molds.
used for undercut packing, and prebent L-
7. Large Water Bath. This is necessary in
shaped paper clips. It is a great convenience
de-flasking the bench-cooled molds.
for the operator.
8. Hacksaw and Blades. This equipment is
3. Closet. This is used to store the patient’s
used to remove the metal sprues from the
coat or other clothing that must be removed
molds after casting.
while the impression is being taken. Drapes
9. Bench Vise. This is used to hold the
for covering the patient,
molds during sprue removal and finishing
procedures.

FIG. 18.1. Maxillofacial prosthetics studio. A, roo Chalian, i 1; B, room 2. (Reproduced with permission from .
V. A., Cunningham, D. C., and Drane, J. B., Prosth. Dent. 15: 570-576, 1965.)
286 MAXILLOFACIAL PROSTHETICS

towels, operating gowns, etc., are also stored is a pair of mirrors placed alongside the
here. patient on either wall. These mirrors, which
4. Shelves. Miscellaneous equipment used should measure approximately 24 by 30
in obtaining the impression is stored on inches, are mounted in such a way that the
shelves. This material may include extra lateral view of the patient is visible to the
plaster, paper clips, Vaseline, cotton gauze, operator at all times without necessitating
cotton applicators, cellophane tape, etc. These rotation ‘of the patient’s head or excessive
items may be transferred to the movable work motion on the part of the operator.
table as needed.
Lighting Criteria
Room 2 (Fig. 18.1, B) Lighting in all areas of the maxillofacial
1. Work Table. All work in room 2 revolves prosthetics studio should be designed for
around the centrally located work table. Here comfortable viewing. Excessively bright light
the clay model is sculptured and the final sources and reflecting surfaces that produce
vinyl resin prosthesis is painted. A table glare should be avoided.
measuring 60 by 20 inches is of adequate size. Since critical observation of skin, tissue, or
Below the table top is a partition to separate other material involves careful color definition,
the legs of the patient from those of the the light should permit optimal judgment of
operator during the modeling and painting the. true conditions.
operations. A pullout shelf is used to locate Daylight is desirable for evaluation of color
the electric hot plate which is used during the matching or color definition. However, since
painting procedure. there is some variation in the color quality of
2. Chairs. The chairs used should be daylight produced by direct sunlight, north
comfortable to both the patient and the sky, and overcast sky, a more exact definition
operator. The patient’s chair should be a of daylight color is needed as a standard
swivel armchair on casters, if possible, and comparison. It is therefore recommended that
should include a headrest. The operator works the Illuminating Engineering Society
more conveniently from a swivel chair on Standard daylight at 7400°K, which is widely
casters without arms. accepted in the United States, be adopted as
3. Mirrors. Of paramount importance, the reference lighting color.
especially during the modeling procedure,

PART 1. OCULAR PROSTHESIS

Dating from very early times in Egypt (i.e., and plica semilunaris. The margin of the
the Predynastic Period, before 3000 B. C.), eyelid consisted of a narrow rim of copper, and
simple inlaid eyes, consisting usually of white the wedge-shaped eyeball was cut out of
shell beads, have been found, and human opaque white quartz or white crystalline
figures bearing such eyes are to be seen in the limestone. The anterior surface was beau-
Cairo Museum. Predynastic art which still tifully polished and shaped to correspond with
remains all over Egypt shows that, even at the natural curvature of the sclera. The
this remote period, stone and shell could be craftsmanship was remarkable, although it
worked and that the art of glazing was must be remembered that these eyes were
already in existence. intended only for statues and mummies.
These early artificial eyes were very good Ambroi'se Pare (1510-1590), a Frenchman,
imitations of the natural organ, with such was the first to use both glass and porcelain
essential features as eyelids, sclera, cornea, eyes.
iris, pupil, and even the caruncle After Pare, the manufacture of artificial
EXTRAORAL PROSTHETICS 287

eyes became an active industry which pro- 7. The method is easy to teach; dental
vided a considerable stimulus to the glass- personnel can be trained in a relatively short
blowing art. At first Venice had the monopoly, time to undertake all phases of fabrication.
then the art spread to France and Bohemia. On the other hand, the glass eye has the
By 1835 artificial glass eyes were being disadvantage of being extremely fragile. A
produced on a large scale in Germany, which glass prosthesis will sometimes explode
continued as the center of production. During spontaneously in the eye socket and will
the two world wars, the supply of glass eyes require painstaking removal of the sharp
from Germany to the United States was fragments by an ophthalmologist (Fig. 18.2).
halted, and in 1943 the United States Army In addition, surface glass is affected when the
and Navy both undertook research to find a fluids of the socket cause an itching which
substitute. Attention was concentrated on may be extremely irritating to the socket
plastics, and the development of an acrylic eye membranes. Glass restorations are also
resulted. By 1945, the Army had 30 installa- difficult to fit properly in relation to defects
tions in operation, and thousands of artificial and variations, so that very often the
plastic eyes were being produced. Techniques prosthesis is far too small, giving the wearer
and materials were constantly improved, and the appearance of en- ophthalmos.
the plastic eyes proved far superior to glass Examination of Patient
eyes.
Examination of the anophthalmic socket
The plastic acrylic eye has the following
reveals a conjunctiva-covered posterior wall of
advantages.
triangular outline. It is surrounded by culs-de-
1. It provides freedom from fragility and
sac or fornices formed by the reflection of the
surface etching resulting from dissolution by
upper and lower lids. The most acute apex of
the socket secretions.
the triangular outline is directed at the nasal
2. Since the replacement is custom- made,
aspect and resolves itself into the medial
adjustability to size and form is more easily
canthus. In this region is found a reddish
accomplished to compensate for the socket
elevation, the lacrimal caruncle. The next
irregularities which are so frequently
most acute apex of the triangle is directed
observed.
superiorly. Between the two apices is a broad
3. Various other features can be adapted to
band, the Whitnall’s ligament, which is found
individual esthetic requirements, such as
occupying the region of the fornix. The most
limbus, depth of anterior chamber, corneal
rounded apex of the triangle is found in the
diameter, pupil, and episcleral and
inferior lateral position. The contour
conjunctival vessels. This is possible only
because of strictly anatomic assembly of parts
throughout.
4. There is an actual three-dimensional
effect in iris construction as a result of
suspension in clear resin of a perforated
transparent disc which has been painted on
both sides. This effect is enhanced by
placement of a jet-black pupil disc at some
distance posterior to the iris disc.
5. Prefabricated iris buttons can be
stocked, so that the operator knows at the
outset the exact color of the iris in the
completed prosthesis.
6. The plastic acrylic eye permits elimi-
nation of such time-consuming steps as
multiple mold construction and precision
grinding of the chamber angle.
FIG. 18.2. Glass eyes fractured.
288 MAXILLOFACIAL PROSTHETICS

and mobility of the posterior wall of the socket


are influenced by several factors.
Examination of Eye Socket
A knowledge of the anatomic features of the
eye socket is essential before proceeding with
the replacement. Inasmuch as eye sockets
present varying structural and functional
requirements, the existing muscle movements
should be studied. Also to be taken into
account are the type of operation by the
ophthalmic surgeon, enucleation or
evisceration, the question of whether an
implant sphere was imbedded at the time of
the operation and, if so, the type of sphere
used, gold or glass. The amount of orbital
adipose tissue present and the extent of
atrophy of muscle and other tissue incident to
the removal of the eye, as well as the contour
and tonus of the eyelids, should be
particularly evaluated at the time of
examination.
Technique
The fabrication of the plastic eye prosthesis
consists of eight steps: (1) painting of the iris
disc; (2) the iris button; (3) the wax form; (4)
molding; (5) the sclera; (6) veining technique;
(7) the conjuctiva; (8) polishing and fitting.
Precut ethyl cellulose transparent discs are
prepared in diameters of 11, 11.5, 12, and 12.5
FIG. 18.3. Precut ethyl cellulose disc.
mm (Fig. 18.3). The center of the disc is
punched out to form the pupillary aperture.
This aperture is approximately 3.5 mm in
diameter but may be increased with a round
file to the same size as the normal eye under
average conditions.
The colors used for the painting of the iris
disc are artist’s oil pigments of high quality.
The following shades are selected for color
permanence: titanium white, terre verte, ivory
black, yellow ochre, cerulean blue, burnt
umber, crimson red, and cadmium red (Fig.
18.4).
The iris of the proper diameter is grasped
with locking tweezers and placed in a holder
FIG. 18.4. Artist’s oil pigments.
until the oil pigments are blended. The normal
eye is studied, preferably under natural light.
Starting with the periphery of the iris, the color occurring within the limbus and is called
pigments are mixed to match. This is the first the background. The second zone is the
zone of collarette which occurs around the pupil and
continues on to the background. The disc is
turned over and the stroma
EXTRAORAL PROSTHETICS 289

color is applied; this third zone is radiating disc, causing a delamination or bleeding of the
and striated in structure and of a very delicate colors. The mix should be of a rubbery texture
design. and snap upon being pulled apart. The pastic
The fourth zone comprises the markings should not be kneaded between the fingers, as
and assumes a variety of shades ranging from doing so will pick up oils and dirt from the
lemon yellow to brown. Because the paints are skin which will be reflected in the finished
applied on both sides of the clear disc, this lens. The required amount of methyl
produces a true three-dimensional effect in methacrylate mix is placed in the openings for
subsequent processing. After painting, the balancing pur-
discs are placed in a suitable rack for drying
(Fig. 18.5). This requires 3 hours in an electric
drying oven at 70°C.
Iris Button or Corneal Lens
The painted iris disc in Figure 18.6 which
has been dried is now ready to be processed in
a set of stainless steel die plates especially FIG. 18.5. Enlarged model, showing four stages of
designed for this purpose (Fig. 18.7, A). These painting of iris disc. Left to right, background, collar-
plates consist of a template, a die, one pierced ette, stoma, markings, completed.
baffle, and two baffles. The template is
occluded with the baffle with the machined
side up, using a sheet of cellophane as a
separator. The painted iris disc is then placed
in the correct size aperture of the template,
care being taken to place the anterior surface
of the painted disc down. A small round disc of
vinyl acetate is placed over the pupillary
aperture of the painted disc to form the
illusion of the pupil. For the purpose of
making the corneal lens, 3 parts clear methyl
methacrylate are mixed with 1 part monomer.
An excess of monomer should be avoided, as it
will cause bubbles to form in the lens. It may
also attack the painted

FIG. 18.6. Painted iris disc.

FIG. 18.7. A, stainless steel die plates. B, buttons cured. C, stainless steel ball bearings.
290 MAXILLOFACIAL PROSTHETICS

poses. The die plates are then reassembled


upgn each other with sheets of cellophane
between the template, die, and baffle to act as
separators. The baffle is positioned over the
die plate, with the guidelines of each being
carefully observed. This is placed in a bench
press, and pressure is applied slowly and
gradually. When the die plates are compressed
sufficiently, they are removed with a
plexiglass scraper. Metal scrapers should be
avoided as they will scratch the stainless steel
dies. The template is then placed in its proper
position, and all parts of the dies are reassem-
bled and placed in a spring compress and the
FIG. 18.8. Conformers.
clamp is tightened. This is then placed in a
dry heat oven at 70°C for 3 hours. After
curing, the die is cooled and the buttons are
removed (Fig. 18.7, B).
Impression
There are two methods for fitting the
prosthesis to the socket. Dr. Victor Dietz is
responsible for the one most commonly used,
which is to make the scleral pattern from a
stainless steel ball bearing (Fig. 18.7, C). The
other method uses an alginate impression of
the contents of the enucleated socket. In this
case, the finished product is heavier and
therefore may cause a drooping of the lower
lid.
It is important for the surgeon to place a FIG. 18.9. A, wax pattern. B, wax assembly for try-
conformer in the socket after enucleation. This in. C, invested and covered with tin foil.
is most generally done at the time of surgery,
the only exception being when an unusual ligament; when the wax pattern has been
amount of hemorrhage occurs at the time of trimmed to shape and size as determined by
surgery. The conformer (Fig. 18.8), which is observation of the landmarks, it is then tried
made of clear acrylic, must be large enough to in the socket (Fig. 18.9, A). The center of the
support the lids and keep them from iris may then be marked on the wax with a
collapsing until the artificial eye is completed. suitable instrument. A small cone of soft green
A ball bearing is selected as the sphere to wax is placed on the back of the iris button.
make the scleral pattern. A horizontal The button is then placed securely on the hard
measurement of the eye socket determines the wax cup. Holding the button stem, the
size of the ball bearing to be selected. Hard operator tries the assembly in the socket and
baseplate wax is softened over the Bunsen makes such corrections as may be necessary to
flame and compressed over the ball bearing. bring the iris into proper alignment and
The wax cup is trimmed on its periphery to position with relation to the normal eye. A
the triangular outline of the posterior wall of special yellow high heat wax is used to build
the socket. It is extremely important to relieve up a smooth, spherical prosthesis. This is then
the wax adequately to compensate for the tried in the socket to check for optimal lid
Whitnall’s form, mobility, and iris line-up (Fig. 18.9, B).
EXTRAORAL PROSTHETICS 291

Flasking
Artificial stone is recommended for flasking
in order to avoid breakage or distortion. The
stem of the iris button is covered with tin foil,
and the wax form is invested in a HUE-LON
flask, with the anterior surface down in the
lower half of the flask, to the periphery of the
wax form. Petroleum is used as a separating
medium when the stone is hard, and the upper
half of the flask is filled with bubble-free
stone. After separation and the removal of the
wax, the iris button is carefully lifted out. The
entire mold is covered with tin foil, and the
iris button is replaced in the exact spot in the FIG. 18.10. Glass mortar (32 oz) and pestle.
mold. The case is then ready for packing (Fig.
18.9, C).
It is necessary to prepare the scleral
modifying and veining colors. A 32-oz glass
mortar and glass pestle are used to triturate
the ingredients (Fig. 18.10).
The following Windsor and Newton dry
powder colors are used (Fig. 18.11): cobalt
blue, burnt umber, yellow ochre, viridian,
ivory black, and cadmium red.
To each 150 mg of zinc oxide, 10 grams of
clear polymer (80 to 120 mesh) are triturated.
It is advisable to use quantities of 50 grams of
polymer.
The lakes are then compounded according FIG. 18.11. Dry powder colors.
to the following formula (Fig. 18.12).
To each 10 grams of white, add:
1. Brown: 75 mg of burnt umber plus 100 mg of
ivory black.
2. Yellow: 100 mg of yellow ochre plus 100 mg of
ivory black.
3. Green: 100 mg of viridian plus 100 mg of ivory
black.
4. Blue: 150 mg of cobalt blue plus 100 mg of
ivory black.
5. Black: 250 mg of ivory black.
From the lakes, the primary dilutions are
made for the scleral shades, using the
following formula:
1. Light brown: 125 mg of burnt umber plus 50 FIG. 18.12. The lakes.
mg of ivory black.
2. Light yellow: 150 mg of yellow ochre plus 50 4. Light gray: 200 mg of ivory black.
mg of ivory black. 5. Light green: 150 mg of viridian plus 50 mg of
3. Light blue: 200 mg of cobalt blue plus 50 mg ivory black.
of ivory black. 6. Dark brown: 125 mg of burnt umber plus 100
mg of ivory black.
7. Dark yellow: 150 mg of yellow ochre plus 100
mg of ivory black.
292 MAXILLOFACIAL PROSTHETICS

8. Dark green: 150 mg of viridian plus 100 mg of


ivory black.
9. Dark blue: 200 mg of cobalt blue plus 100 mg
of ivory black.
10. Dark gray: 350 mg of ivory black.
It is advisable to make a shade guide using
the above mixtures in order to match the
natural sclera more closely.
Packing
After the proper scleral shade has been
selected, the monomer is mixed with the
selected scleral shade (Fig. 18.13) in the ratio
of 1 to 3. When of proper consistency, the mix
is packed in the lower half of the flask with a
sheet of cellophane over this for trial packing.
The two halves are placed in a bench press,
and slight pressure is slowly applied until the
flask is closed completely. The flask is then
opened and the flash is removed, then the
flask closed and placed in a spring clamp. This
is placed in a dry heat oven at 100°C for 3
hours. After curing, the prosthesis is removed
from the flask. With mounted arbor bands, the
excess is removed and the
FIG. 18.13. Scleral shade guide.

FIG. 18.14. A, cured and polished. B, applying rayon threads. C, steps in veining technique. D, completed
acrylic eye.
EXTRAORAL PROSTHETICS 293

FIG. 18.16. A, without ocular prosthesis. B, with ocular prosthesis. C, conformer. D, suction cup in action to
remove ocular prosthesis. E, suction cup.

entire prosthesis is carefully smoothed. The Veining Technique


button stem is removed, and the area of the
limbus is given a soft natural line (Fig. 18.14, Red rayon threads are used for this purpose
A). All scratches are removed with pumice and (Fig. 18.14, B). The separated monofils are
tripoli on buff wheels and felt cones. A high tacked in place with a 5% solution of monomer
polish is not necessary at this stage. and polymer. The pattern of the natural eye is
followed by using the
294 MAXILLOFACIAL PROSTHETICS

pointed back of the 00 sable brush and surface. This is flasked with stone. The flask
pushing the fibers into the various designs is opened, and the wax is boiled out. Again
such as straight, tortuous, and sinuous or any both halves are covered with tin foil and
combination thereof (Fig. 18.14, C). Following packed with clear acrylic. Test packing is
this procedure, a 0 sable hair artist’s brush seldom necessary, and the case is cured at
and a 5% solution of monomer and polymer to 100°C for 3 hours.
which dry pigments have been added are used
to produce the characteristic pigmentations on Polishing and Fitting
the sclera, such as brown, yellow, green, or All rough areas are removed with fine
blue. The pigments are placed according to acrylic stones and polished. It is most im-
their appearance on the natural eye. Three portant to remove all scratches, as they would
coats of a 5% solution of clear monomer- be a source of irritation to the delicate mucous
polymer solution are painted over the veining membranes of the socket. A high luster is
and pigmented area. Each coat is allowed to advisable for comfort (Fig. 18.14, D). A drop of
dry for 4 or 5 minutes, then is placed in the mineral oil is placed on the forefinger and
oven at 72°C for 1 hour. distributed over both sides of the acrylic eye.
The patient is then shown how to insert and
Conjunctiva
remove the eye. Instructions are given on the
A wood applicator is attached to the back or care of the socket and the eye. Usually the
concave surface with sticky wax, and the restoration should be worn for 24 hours before
anterior or front surface is dipped into melted any alterations are made so that the orbital
baseplate wax to the periphery, thus providing tissues can adjust themselves (Figs. 18.15 and
a very thin, smooth 18.16).

PART 2. POLYVINYL RESIN IN FACIAL PROSTHETICS

Orbital Prosthesis prosthetics studio room 1, he lies on the


padded table with the defect of the eye facing
Making Impression up and parallel to the table and the head
In making an impression of an orbital draped with cotton towels to keep the
defect, maxillofacial prosthetics studio room 1 impression material from dripping where it is
is used, and the following instruments and not desired.
materials are needed. The eyebrows and eyelashes are coated
with Vaseline; the nostrils are packed with
Bunsen burner Cotton pliers Cotton wet gauze to prevent adherence and breakage
Double boiler applicators Alcohol torch
of impression material. The eyebrow and
Reversible hydrocol- Wax spatula no. 7 Wax
loid impression knife Kidney basin
supraorbital tissue of the defective eye are
material Plaster bowl Plaster retracted with Scotch tape, and the full width
Pan of cold water spatula Plaster of Paris of the face from 1 inch above the eyebrow to
Towels Plaster grinding for the upper lip line is boxed in with green
Gauze quick set-up Two boxing wax.
Scissors camel’s hair brushes The patient is instructed to close his
Cotton remaining eye and breathe through his mouth.
Scotch tape The impression material used at Indiana
Vaseline
University and University of Texas is re-
Green boxing wax
Paper clips opened
versible hydrocolloid which is 50% water and
into L shape 50% reversible hydrocolloid heated in a double
boiler to approximately 140° F. Stirring the
Procedure (Fig. 18.17). During the pa- mixture often until it is com-
tient’s first appointment in maxillofacial
EXTRAORAL PROSTHETICS 295

FIG. 18.17. A, preparation of Patient. B, the hydrocolloid impression material is painted on with a camel’s- hair
brush. C, prebent L-shaped paper clips are anchored in the hydrocolloid. D, plaster of Paris core. E, the
hydrocolloid impression is removed and inspected for artifacts. F, the master cast is compared with the patient’s
defect.

pletely dissolved, the operator then places the temperature before applying it over the skin.
pan of this thin paste in cold water to speed When the temperature is reached (110 to
up cooling. At this point it is necessary to stir 120°F) that is comfortable to the patient’s
the mixture continuously to prevent partial skin, the material is painted with a camel’s-
setting. The operator tests the material with hair brush, starting from undercuts and point
his little finger for proper of greatest depth to the entire surface
296 MAXILLOFACIAL PROSTHETICS

of the boxed-in area. This brushing process Procedure. Selection is made at the
is repeated until all undercuts are closed patient’s second appointment. The patient is
and the entire surface is covered with at seated in a swivel armchair across the table
least 3 mm of this material. from the operator. The eye to be chosen from
Prebent paper clips opened to an L the customized stock of acrylic resin eyes must
shape are dipped in this material and in- match the remaining eye. Details to be
serted in the hydrocolloid for the purpose considered are: whether left or right eye, size,
of reinforcement. Five minutes should be shape, color, and blood vessels. After selection
allowed for setting or until wires are firmly of the eye, the size and shape are easily
anchored. Then sufficient thickness of adapted to the orbital defect.
plaster of Paris with a mixture of grindings
for quick setting is poured in this prepared
area for a strong backing. Carving Clay Pattern
When the plaster of Paris is set, the op- The clay pattern is also carved during this
erator asks the patient to wrinkle his face; same second appointment. The following
then the operator frees and removes the instruments and materials are used.
impression from the patient’s face, care-
Pink wax Plaster knife
fully keeping in mind the location of un-
Alcohol torch Talcum powder
dercuts. Tin foil Vaseline
After removal, he checks the accuracy of Indelible pencil Toothbrush for stippling
the impression, places it in cool water to Wax spatula no. 7 Bo ley gauge
prevent the cracking of hydrocolloid under Modeling clay, soft Scalpel
the plaster’s heat, and sends it to the max- and hard Customized stock of
illofacial prosthetics laboratory for casting. Wooden modeling in- acrylic resin eyes Cotton
struments applicators Hollenback
Making Stone Cast Looped wire end model- carver no. 3
The stone cast is constructed in the ing instruments
maxillofacial prosthetics laboratory. The Curved scissors
Wax knife
following instruments and materials are
used. Procedure (Fig. 18.18, B-D). While
carving the clay pattern, it is important to
Plaster bowl
Wax keep in mind the individual structure of the
Plaster spatula
Wax spatula no. 7 eye and to personalize symmetrically the
Dental stone
Baseplate wax wrinkles and the opening of the eyelids and
Plaster knife
Hanau torch
Vibrator the shape of inner and outer corners of the eye.
Foil is molded in the defected area of the
Procedure. The dental stone is pre-
cast, and the cavity is built up with modeling
pared, poured slowly on the impression,
clay to face level. A Boley gauge is used to
and vibrated carefully to avoid bubbles.
measure the distance from the midline of the
Enough stone is added to properly cover bridge of the nose to the center of the pupil of
the impression. After V2 hour of setting,
the remaining eye. The same symmetrical
the impression is gently separated from the
measurement is used to centrally locate and
cast and trimmed and shaped to the de-
level the acrylic resin eye in the clay. The
sired form to set in vertical position. To
operator then applies a small amount of clay
assist the operator, the undesired under- around the eye and molds, shapes, and
cuts are closed with pink wax and the personalizes the wrinkles and opening
master cast is sent to maxillofacial pros-
according to the contour of the remaining eye.
thetics studio room 2 for modeling.
The pattern is repeatedly tried out on the
Selecting the Eye {Fig. 18.18) patient’s face with the aid of lateral mirrors
The eye is selected in maxillofacial pros- until the required result is obtained.
thetics studio room 2 from a customized Skin pores are made by pressing the sur-
stock of acrylic resin eyes.
EXTRAORAL PROSTHETICS 297

FIG. 18.18. A, the selection of the acrylic resin eye is made. B, a Boley gauge is used to center the pupil. C, the
carved clay pattern of the eye is seated on the master cast. D, the clay pattern is tried on the patient’s face. E, the
cast is outlined with an indelible pencil and boxed in. F, an alginate impression.
298 MAXILLOFACIAL PROSTHETICS

face lightly with a toothbursh. The margins of the setting time so that more working time
the clay pattern are trimmed and smoothed, will be available. As the material sets, prebent
and it is firmly set in correct position on the L-shaped paper clips must be inserted so that
master cast. The clay pattern of the eye is the impression is strengthened for the use of
then ready for construction of metallic molds. plaster of Paris (Fig. 18.18, F). After setting,
Constructing Metallic Molds the impression is removed from the master
The metallic molds (two pieces) are made in cast. Usually the clay pattern lifts off with the
the maxillofacial prosthetics laboratory. The alginate. The clay pattern is removed and
following instruments and materials are reseated on the cast (Fig. 18.19, A: 1).
needed. This alginate impression must be carefully
boxed with softened green boxing wax so as
not to distort the impression. It is then soaked
in water, and an average mixture of Gray
Indelible pencil Pink baseplate wax investment is prepared for a model not less
Green boxing wax, !/,6 Green boxing wax, lA
than 2 cm thick. It is advisable to make two
inch thick inch thick: three layers
Square red rope wax for main sprue Gray investment models before destroying the
Wax knife Red rope wax for vents clay pattern, one to be used in the event the
Wax spatula no. 7 Dry heat oven Sheet other is broken. Gray models should be
Alginate impression metal ring Linotype trimmed to the pencil line (Fig. 18.19, A: 2-4).
material metal Boil-out pot Impressions and Gray Stone Cast of Tissue-
Plaster bowl Asbestos gloves Iron pot side Mold; Double Impression taken (Fig.
Plaster spatula Square jaw pliers Gas- 18.19, B). In making the second metal mold,
Hydrocolloid impres- air torch Bench vise
an impression is taken of the defective side
sion material Hack saw and blades
with the eye in position.
Double boiler Vulcanite burs (assor-
Bunsen burner ted) Before placing the clay pattern in the cast,
Large pan of cold Hollenback carver Blue the operator cuts out clay in back of the eye-
water articulating paper to-eye periphery, leaving no undercuts. Then
Paper clip opened Yellow sticky wax with round bur no. 5 he establishes the
into L shape necessary keys parallel to the side angles to
Plaster of Paris prevent any positional loss if the eye is
Plaster grinding accidentally lifted. Next, sticky wax is applied
Separators: soap and to the center of the eye. The length of sticky
glycerin
wax is determined by the depth of the orbital
Gray investment
defect. Also, the remaining underportion of the
Procedure: Impression and Gray Stone eye is lubricated.
Cast of External Mold. In order to get the The floor of the orbital defect is also keyed
metal mold for making the permanent to prevent loss of eye position, and desired
prosthesis, a clay pattern must be properly undercuts for retention of the final prosthesis
seated in the cast so that the margins will not are penciled in. All areas above this outline
be damaged. The cast should be outlined with will be lubricated to prevent the edges of the
indelible pencil 1 cm away from the clay plaster core from sticking.
pattern, and the entire area is then boxed in A minimal amount of quick-setting plaster
with green boxing wax. This should be of Paris is placed within the eye periphery and
extended beyond the pencil marking (Fig. around the sticky wax, with an additional
18.18, E). Then the impression material is amount in the eye orbit. The clay pattern is
poured over the seated clay pattern for the then quickly and accurately placed on the
external metal mold for the prosthesis (tissue- master cast its original position. After the
side mold). plaster of Paris has set, the
The alginate impression material should be
used in proportions of 1 part powder to IV2
parts ice water in order to obtain a thinner
mix than for oral use and to delay
EXTRAORAL PROSTHETICS 299

clay is carefully removed with a wax knife. using a Hollenback carver, the operator
Care is taken to avoid displacing the acrylic carefully prepares an undercut necessary for
eye (Fig. 18.19, C). retention of the eye in the final prosthesis.
By holding the forefinger on the eye and

FIG. 18.19. A: 1, master cast; 2, Gray investment; 3, alginate impression; 4, trimmed cast. B: 1, master cast; 2,
back of modeled eye. C, eye positioned on master cast. D, the defect is boxed in and hydrocolloid is painted on for
the tissue-side mold impression. E: 1, master cast; 2, negative hydrocolloid impression; 3, Gray investment cast; 4,
positive alginate impression. F, waxed-up Gray investment casts with sprues and vent sprues.
300 MAXILLOFACIAL PROSTHETICS

Once more the outlined area is boxed in less than XA inch and not more than 1 inch
before taking hydrocolloid and alginate from the wall of the metal ring. The purpose of
impressions to get a negative investment this distance is to enable the gas- air flame to
model (Fig. 18.19, D-E). keep the metal reservoir in a molten state.
After the model has been soaked in water, After the position has been evaluated, the
all undercut areas and remaining portions are ring is half-filled with Gray investment, and
carefully painted with hydrocolloid material, the model is lowered into the desired position.
again at least 3 mm thick. Before setting, The ring is then filled with investment until
prebent L-shaped paper clips are placed for just the tips of the sprues and vents are
retaining the plaster backing. After setting, exposed. A minimal setting time of lA hour is
the negative impression is removed from the necessary before eliminating the wax in the
master model. The plastic eye pulled with the boil-out pot.
impression is gently removed and placed Elimination of Wax and Dryheating
aside. Investments (Fig. 18.20, B). At least 20
The negative hydrocolloid impression is minutes after the wax has been eliminated,
boxed with softened green wax. Glycerin the investment ring may be placed in the dry
separation is essential at this stage to prevent oven at 70°C. This temperature is required for
the two impression materials from adhering to a minimal period of 10 hours. Overnight
each other. heating at this temperature is desirable when
The previously mentioned proportion of possible.
alginate mixture can be used, with L- shaped Casting of Molds. The molds are made of
paper clips and plaster backing reinforcement linotype metal, which comes in ingots. The
for the positive impression. amount of metal to be used is determined by
After the termination of the necessary the size of the mold. It is always desirable to
setting time, the impressions are separated, and have an excess. The metal is melted in an iron
Gray investment is poured in the positive alginate pot over a Bunsen burner. Care should be
impression. After setting and separation, the Gray taken not to overheat the metal since this can
model is trimmed.to the desired outline. result in porosity (approximate melting
Waxing Up the Gray Cast Models (Fig. temperature, 500°F).
18.19 F). The two pieces of Gray investment After the hot investment rings have been
removed from the oven with asbestos gloves,
models are waxed with 3 mm of pink they should be placed on an asbestos pad.
baseplate wax, adding necessary sprues Ready molten metal is then poured in the
arid’vents as follows. The sprue is attached to investment (Fig. 18.20, C). A gas and air torch
the lowest portion of the model. If necessary, flame is used for at least 5 minutes to keep the
the model is tilted to cause the liquid metal to main sprue molten. The cooling period after
push trapped air ahead and out of vents which casting is about 30 minutes. The casting is
are placed at the highest point of the model. submerged in cold water to permit easy break-
A V-shaped groove is carved 5 mm from the out.
edge of the wax completely around the The metal molds are brush-cleaned with
periphery for the purpose of clamping the two water. The vents are completely removed, and
molds together. The name of the patient and the main sprue is cut off to a length of 2
the date of construction are carved on the inches, forming a handle (Fig. 18.20, D).
molds. The molds should fit together accurately; if
Investment of Wax Pattern (Fig. 18.20, A). not, high spots should be removed with
For investing purposes, inexpensive articulating paper and burs. The molds then
galvanized or sheet metal may be used as are ready for processing of the vinyl resin
rings. prosthesis.
The main or pouring sprue must be not
EXTRAORAL PROSTHETICS 301

FIG. 18.20. A, waxed-up Gray investment cast invested in the galvanized metal ring. B, investment rings in the
dry heat oven. C, pouring molten linotype metal into the investment. D, completed external and tissue- side metal
molds (closed and open views). E, vinyl resin being painted in the metal molds over a hot plate. F, filled metallic
molds are closed and the vinyl resin is cured in a dry heat oven.
302 MAXILLOFACIAL PROSTHETICS

Painting and Processing of Vinyl Resin over the defect and will not be outwardly
The vinyl resin is painted and processed visible. Care must be taken, however, to match
in maxillofacial prosthetics studio room 2. closely the desired color of the prosthesis near
The following instruments and materials the margins of the mold.
are required. Each layer of the vinyl resin is processed
for 1 minute in the oven until the desired
Dry heat oven thickness is obtained. Excess paste must be
Hot plate Plate glass base for
mixing pastes Metal pie removed from around the margin of the
Battery clamps
plate Linotype metal external and tissue-side molds so that the two
Timer
Camel’s-hair brushes, molds Asbestos gloves molds can be closed together and clamped.
assorted Cotton pliers Alcohol Before this closure is carried out, it is wise to
Flexible spatulas, as- lamp Wax spatula no. 7 paint a layer of the vinyl resin paste around
sorted Plaster knife Large pan the margins of the mold to form a seal and
Curved scissors, small of ice water Oil-soluble thus trap air between the external and tissue-
Clear vinyl resin paste dye Xylene Scalpel side layers.
Assorted vinyl resin Final Processing. Once the mold has been
bases closed and clamped with alligator- type
Assorted pigments of
battery clamps, it is placed in the oven for
vinyl resin paste
final vulcanization. This is easily
Procedure (Fig. 18.20, E). The patient’s accomplished by placing the mold in a metal
third and last appointment is in maxillofa- pie plate for more convenient manipulation
cial prosthetics studio room 2. The patient (Fig. 18.20, F). The mold is left in the oven at
is seated across from the operator. The 190°C for 10 to 15 minutes, depending on the
oven and hot plate are preheated to 190°C. size of the prosthesis. The mold is turned over
The color of vinyl resin paste is chosen by during the process so that each side is up for
premade samples for skin matching, and one-half of the total heating period. Excessive
the desired color of vinyl resin is then heating can produce bizarre color changes, and
mixed on a glass base. underheating results in an incompletely cured
Painting of External Mold. The mold is appliance.
heated for 3 to 5 minutes depending on After the heating of the mold is completed,
the size. After it is placed on the hot plate, it is removed from the oven and immersed in
a thin layer of clear vinyl resin is applied ice water. It should remain completely
with a camel’s-hair brush. A second thin submerged for 1 minute to ensure adequate
layer of tissue-matched vinyl resin is chilling of the metal before an attempt is made
added, and the pigments required to paint to remove the prosthesis (Fig. 18.21, A and B).
in the desired freckles or blood vessels are The two halves of the mold are separated by
also included in this layer. Each layer of using a plaster knife. The prosthesis is then
paste is processed in the oven for 1 min- removed and trimmed with curved scissors
ute, with care being taken to avoid over- and a hot no. 7 spatula.
cooking the vinyl resin paste. The operator Oil-soluble Dye Retouching. Required
continues to paint until the desired thick- tinting for shade discrepancies can be ac-
ness is obtained, making sure that the complished with xylene-soluble oil dyes (Fig.
margins are kept free of paste until he is 18.21, C). These are dispensed in the form of
ready to close the molds. powdered pigments and can be diluted with
Painting of Tissue-side Mold. The xylene when ready for use. These dyes are also
tissue-side mold is preheated for 3 to 5 of great value in characterization procedures
minutes in the dry heat oven at 190°C. for the addition of freckles, telangiectasia, etc.
The mold is then carried to the hot plate They are easily applied with a very tiny sable
for painting. It is not critical to match ex- or camel’s-hair brush.
actly the exterior color of the prosthesis
since this side will approximate the tissue
EXTRAORAL PROSTHETICS 303

FIG. 18.21. A, molds are chilled in cold water after the desired curing period. B, metallic molds are separated
and the eye prosthesis is removed. C, retouching of the eye prosthesis with xylene-soluble oil dyes. D, insertion of
eyelashes. E, anterior view of the orbital defect. F, the vinyl resin eye prosthesis fitted and cemented into position.
304 MAXILLOFACIAL PROSTHETICS

Insertion of Eyelashes. A ready supply of ancy between the natural and artificial eye
processed curved natural hairs (preferably less noticeable.
taken from a human arm) should be on hand The patient should be taught how to clean
for use as eyelashes. The materials used for the prosthesis (in warm water with a mild
this insertion are a broach holder and Y needle soap) and how to apply the surgical cement.
(this can be produced by removing the end of a The prosthesis should not be worn while
needle eye). sleeping, and thus bedtime is a convenient
With the prosthesis held under a magni- period for cleaning the prosthesis. On arising
fying glass and the hair held in the fork of the the next morning, the patient can then replace
Y needle, the eyelashes are placed in an it promptly.
upward position on the upper eyelid and in a
Nasal Prosthesis
downward position on the lower eyelid (Fig.
18.21, D). When the desired number of lashes
Impression of Nose Defect
have been thus placed, they are trimmed to
alternately long and short lengths to lend a The impression of the nose defect is made
natural appearance. in maxillofacial prosthetics studio room 1. The
Insertion of Acrylic Resin Eye. The eye is following instruments and
inserted into the vinyl resin portion of the materials are used.
prosthesis from the back side. It is usually Bunsen burner
Paper clips opened into
easier to insert the medial aspect of the eye, Double boiler
L shape Cotton pliers
then snap the lateral corner to place in the Reversible hydrocol-
loid impression Cotton applicators
thickened band of material which constitutes Alcohol torch Wax
material
the border of the opening. spatula Wax knife
Large pan of cold
Fitting Artificial (Vinyl Resin) Eye Prosthesis water Kidney basin Plaster
{Fig. 18.21, E and F). Towels bowl Plaster spatula
Gauze Plaster of Paris Plaster
After the acrylic resin eye is in place within grindings 2 camel’s-hair
Scissors
the vinyl resin prosthesis, it is ready for brushes
Cotton
placement in the orbital defect of the patient. Vaseline
A thin layer of surgical appliance cement is Green boxing wax
applied to the tissue surface of the prosthesis.
The upper brow is displaced superiorly and the
prosthesis is placed; the brow is then released Procedure. During this first appointment
and allowed to assume its natural position. for the patient, he is placed on the padded
The margins of the prosthesis should be table in a horizontal position to allow
pressed firmly into place to ensure proper relaxation of the tissue of the nasal defect.
adhesion of the cement. The eyebrows and eyelashes are coated
Instructions to Patient. Several things with Vaseline, the extreme undercuts are
are important with regard to patient edu- minimized with wet gauze packing, and the
cation. First of all, since the artificial eye does nostrils are packed to prevent adherence,
not track with the natural eye of the opposite seepage, and breakage of the impression
side, the patient should learn to turn his head material during the removal. The full width of
when changing his line of vision. By looking at the face from 1 inch above the eyebrow to the
all objects from a head-on view, he can upper lip line is boxed in with green boxing
maintain the most natural appearance. wax.
Wearing eyeglasses also enhances the natural The impression is made with the reversible
appearance of such a prosthesis by covering hydrocolloid impression material, a mixture of
the margins of the prosthesis, thus making the 50% water and 50% hydrocolloid. This
discrep material is prepared in a double boiler and
heated to approximately 140°F; it is then
cooled in cold water until the
EXTRAORAL PROSTHETICS 305

temperature becomes comfortable to the Procedure. This work is done during the
patient’s tissues (110°F). patient’s second appointment. While the
The defect is then painted with a min- operator carves the clay pattern of the nose, he
imum of 3 mm of this impression material, must keep in mind the goal of reproducing
and prebent L-shaped paper clips are skin texture and dominant wrinkles (Fig.
placed in the hydrocolloid before final set- 18.22, C).
ting. Quick-setting plaster of Paris backing A preoperative photograph of the patient
is added. and the observation and assistance of a close
The patient is then requested to wrinkle relative are very helpful in modeling the
the facial muscles to permit easy removal characterized nose.
of the impression. After removal, the im-
pression is immediately placed in cold Construction of Metallic Molds
water to prevent distortion caused by heat The metallic molds (two pieces) are con-
dissipation of the plaster backing. structed in the maxillofacial prosthetics
laboratory. Instruments and materials include
the following.
Making Master Cast (Maxillofacial Pros-
thetics Laboratory)
Indelible pencil Pink baseplate wax
The following instruments and materials Green boxing wax, l/6 Green boxing wax, lA
are needed. inch thick inch thick: three layers
Wax knife for main sprue
Plaster bowl
Wax spatula no. 7 Red rope wax for vents
Plaster spatula Wax Alginate impression Sheet metal ring Dry
Dental stone Wax spatula no. 7 material heat oven Boil-out pot
Plaster knife Pink baseplate wax Plaster bowl Linotype metal Iron pot
Vibrator Hanau torch Plaster spatula Asbestos gloves Square
Procedure (Fig. 18.22, A and B). Hydrocolloid impres- jaw pliers Gas-air torch
Dental stone is prepared, and poured sion material Bench vise Hack saw
slowly on the hydrocolloid impression, and Double boiler and blades Vulcanite
vibrated carefully to avoid bubble forma- Bunsen burner burs (assorted)
tion. When the stone has set, the cast is Large pan of cold Blue articulating paper
water Hollenback carver
trimmed as desired and all undesirable
Paper clips opened
undercuts are blocked out with pink wax
into L shape
preparatory to clay modeling. Plaster of Paris
Plaster grindings
Carving of Clay Pattern (Maxillofacial Separators: soap and
Prosthetics Studio Room 2) glycerin
Gray investment

This procedure requires the following Procedure: External Mold. The clay nose
instruments and materials. pattern is properly seated and sealed on the
master cast. An outline is drawn with indelible
Pink wax Looped wire end modeling pencil within 1 cm of the outside edge of the
Wax spatula no. 7 instruments Curve clay pattern, and the outlined area is boxed in
Wax knife scissors Toothbrush for with green boxing wax. An impression of the
Alcohol torch stippling Scalpel Plaster clay pattern is made with alginate material
Indelible pencil knife Cotton applicators
(ratio: 1 part powder to IV2 parts cold water).
Tin foil Hollenback carver no.
Prebent L-shaped paper clips are used for
Talcum powder 3
Vaseline Patient’s photograph
reinforcement, and quick-setting plaster is
Modeling clay, soft added for backing. The alginate impression is
and hard then separated from the master cast and
Modeling wooden in- placed in cool water.
struments
FIG. 18.22. A, extensive nasal defect. B, facial cast showing nasal defect. C, clay pattern of the nose seated over
the master cast. D, two metal molds separated, showing nasal prosthesis. E, nasal prosthesis cemented over the
defect. F, eyeglasses seated over the bridge of the nasal prosthesis.
306
EXTRAORAL PROSTHETICS 307

After boxing in the alginate impression The negative hydrocolloid impression is


with softened boxing wax, the operator separated from the master cast and boxed in
retraces the indelible pencil outline on the with softened green boxing wax.
impression. Next he pours Gray investment in Before making the positive impression, the
the alginate impression, separates the operator retraces the indelible pencil outline
investment model, and trims to the indelible and uses a thin film of glycerin solution to
outline. The investment model is waxed with ensure separation. Next, the operator makes a
three thicknesses of pink baseplate wax, and positive alginate impression of the negative
the main sprue (green boxing wax) is added at hydrocolloid impression (ratio: 1 part powder
the lowest point of the model. Red rope wax, V2 to IV2 parts cold water). Again, prebent L-
inch thick, is put in place, sprues are vented at shaped paper clips are used for reinforcement,
the highest points of the model, and a V- and quick-setting plaster is added for backing.
shaped groove is carved 5 mm from the edge of The positive alginate impression is sepa-
the entire model outline. The patient’s name rated from the negative hydrocolloid im-
and date of construction are then inscribed on pression, which is discarded. Next, the
the molds. positive alginate impression is boxed in with
After investing the waxed model in a sheet softened green boxing wax, and the indelible
metal ring with Gray investment, the operator pencil outline is retraced before the Gray
places the investment ring in the boil-out pot investment is poured in the positive alginate
for 20 minutes to eliminate wax. He then impression. The investment model is
places the investment ring in a dry heat oven separated and trimmed to the desired outline.
at 70°C for 10 hours (overnight is preferable). The Gray investment model is waxed with
Preparatory to casting the mold, linotype three thicknesses of pink baseplate wax.
ingots are melted, and the cast is poured with Three layers of green boxing wax, V2 by 3A
molten linotype metal and a gas-air torch. To inch, are added to the main sprue at the
prevent porosity in the metal mold, the main lowest point of the model. Red rope wax, !4
sprue is kept molten for about 5 minutes. The inch thick, is put in place, and the sprues are
poured mold is bench-cooled for 30 minutes vented at the highest point of the model. A V-
before being submerged in the water for shaped groove is carved 5 mm from the edge of
separation from the investment, which is done the entire model outline.
preparatory to grinding in with the tissue-side The operator invests the waxed model in a
mold. sheet metal ring with Gray investment and
Tissue-side Mold; Double Impression Taken. places the investment ring in a boil- out pot
The nose clay pattern is removed and the for 20 minutes to eliminate wax. He then
indelible pencil outline is retraced on the places the investment ring in a dry heat oven
master cast. To obtain the desired anatomic at 170°C for 10 hours (overnight is preferable).
retention, the operator removes unwanted Preparatory to casting, the linotype ingots are
block-out wax in the undercut areas. The melted, and the cast is poured with molten
outlined area is then boxed in with green linotype metal and a gas-air torch, with the
boxing wax. main sprue being kept molten for about 5
After painting the master cast with liquid minutes to prevent porosity.
soap as a separator, the operator makes an The poured mold is bench-cooled for 30
impression of the tissue side (defect side) with minutes before being submerged to separate
hydrocolloid material (ratio: 1 part the metal mold from the investment material.
hydrocolloid to 1 part water). Prebent L- Separation and grinding in are done with the
shaped paper clips are used for reinforcement, external mold for close approximation of the
and quick-setting plaster is added for backing. two molds.
308 MAXILLOFACIAL PROSTHETICS

Painting and Processing of Vinyl Resin Paste care must be taken to match closely the
This is done in maxillofacial prosthetics desired color near the margins of the mold.
studio room 2, and the following instruments Each layer of the paste is processed in the
and materials are needed. oven for 1 minute at 190°C. Again, the
operator keeps painting with the paste until
the desired thickness is obtained. He removes
Dry heat oven Plate glass base for excess paste from around the margin of the
Hot plate mixing pastes Metal pie external and tissue-side molds and, before
Battery clamps plate Linotype metal closing the molds, he paints the margins with
Timer molds Asbestos gloves fresh paste as a seal. The two molds are then
Camel’s-hair brushes, Pliers closed and clamped together.
assorted Alcohol lamp Wax
Final Processing. For easy manipulation,
Flexible spatulas, as- spatula no. 7 Plaster
knife Large pan of ice
the closed and clamped mold is placed in a
sorted
Curved scissors, small water Oil-soluble dyes metal pie plate. With the mold tissue side
Clear vinyl resin paste Scalpel down, the metal pie plate is then placed in the
Assorted vinyl resin dry oven at 190°C for 5 minutes (this keeps
bases the vinyl resin from being displaced from the
Assorted pigments of external mold). During the process, the molds
vinyl resin paste are turned over for another 5 minutes, with
the same 190°C temperature being
Procedure. For the patient’s third and last maintained until curing is complete. After the
appointment in maxillofacial prosthetics required processing time period, the molds are
studio room 2, he is seated on a swivel removed from the oven and submerged in a
armchair across from the operator. The oven pan of cold water for complete chilling. The
and electric hot plate are preheated to 190°C. two molds are separated with a plaster knife,
The color of the vinyl resin paste is chosen and the nose prosthesis is removed. The
from premade samples for skin matching, and operator then cuts out the nostrils, using a hot
the desired color of the vinyl resin is then no. 7 wax spatula or scalpel, and trims the
mixed on the glass base. edges with curved scissors (Fig. 18.22, D).
Painting of External Mold. The external Oil-soluble Dye Retouching. The nose
mold is heated for 3 to 5 minutes in the dry prosthesis is tinted to the desired color, and
oven at 190°C before being carried to the characterization is added with xylene- soluble
electric hot plate for painting. A very thin oil dyes.
layer of clear vinyl resin is painted on the
surface of the mold, and the second thin layer Fitting of Artificial (Vinyl Resin) Nasal
of the vinyl resin is added with tissue- Prosthesis
matched paste. If needed, freckles and blood The artificial nose is fitted and cemented to
vessels may be added with the different the patient’s defect (Fig. 18.22, E and F).
pigments of vinyl resin pastes. Each layer of
the paste is processed in the oven for 1 Auricular Prosthesis
The artificial ear must be a mirror- image
minute. The operator continues painting with
of the remaining natural ear, and for that
tissue-matched paste until the desired
reason the impression of the natural ear must
thickness is obtained. The margins are kept
be made along with that of the defective ear.
free of paste until it is time to close the molds.
To position the ear prosthesis, the operator
Painting of Tissue-side Mold. The tissue-
first uses an indelible pencil to draw a vertical
side mold is heated for 3 to 5 minutes in the
line from above the helix, through
dry oven at 190°C and then carried to the
electric hot plate for painting. Skin matching
of the vinyl resin paste is desirable but not
critical; however,
EXTRAORAL PROSTHETICS 309

the center of the external auditory meatus, meatus and beyond the tragus of the natural
and through and beyond the center of the lobe ear (Fig. 18.24, A and B). To coincide with the
of the natural ear (Fig. 18.23). He also draws natural ear, the same vertical and horizontal
a horizontal line from the helix through the lines are then drawn on the defective ear side.
center of the external auditory

FIG. 18.24. A, orientation lines. B, orientation lines. C: 1, impression of defect; 2, impression of opposite ear; 3,
stone cast of defect; 4, stone cast of opposite ear. D: 1, small strips of clay added on defective ear master cast; 2,
right ear modeled in clay; 3, stone cast of left natural ear.
310 MAXILLOFACIAL PROSTHETICS

Making Impression ear is made with a thin mixture of alginate


This is done in maxillofacial prosthetics (ratio: 1 part powder to IV2 parts cold water).
studio room 1, and instruments and materials Prebent L-shaped paper clips are used for
include the following. reinforcement, and quick-setting plaster of
Paris is added for backing. The operator
Bunsen burner Double Alginate impression removes the alginate impression, keeping in
boiler Reversible material mind the angle of undercuts, and places the
hydrocolloid impression Cotton applicators impression in a pan of cold water to prevent
material Alcohol torch Wax distortion.
Large pan of cold water spatula Wax knife
Towels Gauze Scissors Kidney basin Plaster
Making Stone Casts
Cotton Vaseline bowl Plaster spatula
Green boxing wax Paper Plaster of Paris Plaster The stone casts are made in the maxillo-
clips opened into L grindings 2 camel’s-hair facial prosthetics laboratory, with the fol-
shape Cotton pliers brushes Dental floss for lowing instruments and materials.
vertical and horizontal
tracings Indelible pencil Vibrator
Green boxing wax Wax
Plaster bowl Wax spatula no. 7
Plaster spatula Pink baseplate wax
Dental stone Hanau torch
Plaster knife
Procedure. The patient’s first appoint-
Procedure. Using an indelible pencil, the
ment is in maxillofacial prosthetics studio
operator outlines the outside edges of the
room 1.
hydrocolloid and alginate impression and
Impression of Defective Side (Fig. 18.24, C
retraces the vertical and horizontal lines on
1). The patient is placed on the padded table
both impressions for positioning purposes.
with the defective ear facing up, and the
Both impressions are boxed in with softened
external auditory tneatus is blocked in with
green boxing wax. After preparing an
wet cotton or gauze. All hair within the
adequate mixture of dental stone, the operator
impression area is coated with Vaseline. After
slowly pours the stone into the hydrocolloid
boxing in the defect area with green boxing
and alginate impressions. To avoid bubbles, he
wax, the operator makes an impression of the
vibrates the mix carefully. Then, after a 30-
area with green boxing wax, the operator
minute wait for setting, the hydrocolloid
makes an impression of the area by painting
impression is gently separated from the
on reversible hydrocolloid (ratio: 50%
master cast and the alginate impression is
hydrocolloid, 50% water). Prebent L-shaped
gently separated from the natural ear cast
paper clips are used for reinforcement, and
(Fig.
quick-setting plaster of Paris is added for
18.24, C: 3 and 4). The stone casts are
backing. The operator removes the
trimmed and shaped to the desired form, and
hydrocolloid impression, keeping in mind the
the undercuts on the master cast are closed
angle of existing undercuts to prevent tearing.
with pink baseplate wax.
He then places the impression in a pan of cold
water to prevent distortion.
Carving of Clay Pattern
Impression of Natural Ear (Fig. 18.24, C:
2). The patient is turned over so that the This is accomplished in maxillofacial
natural ear is up, and the external auditory prosthetics studio room 2. Instruments and
meatus is blocked in with wet cotton or gauze. materials include the following.
All hair within the impression area is coated
Pink baseplate wax Scalpel
with Vaseline, and the entire ear is boxed in
Was spatula no. 7 Plaster knife
with green boxing wax. An impression of the Wax knife Alcohol Cotton applicators
natural torch Indelible pencil Hollenback carver no.
3
EXTRAORAL PROSTHETICS 311

Tin foil Master cast Wooden Dry heat oven Blue articulating
Talcum powder modeling instruments Boil-out pot paper
Vaseline Stone cast of the nat Linotype metal Hollenback carver no. 3
Modeling clay, soft ural ear Iron pot Sticky wax
and hard
Toothbrush for stip- Procedure. Because of the multiple
pling undercuts of this clay pattern, the upper half of
Procedure (Fig. 18.24, D). The patient’s the external mold must be made in two
second appointment is in maxillofacial sections.
prosthetics studio room 2. While carving the Prior to making the impression of the clay
clay pattern, the operator should keep in mind pattern, the operator keys the master cast in a
the anatomic structure of the ear, taking the V shape in three areas: two on the anterior and
remaining ear as a guide. Tin foil is molded on one on the posterior edge. He then marks with
the defective ear area of the master cast, and indelible pencil the crest of the helix,
small strips of modeling clay are added one continuing posteriorly around the periphery to
upon the other until the height and contour of beneath the lobule. The outline is brought
the helix match those of the natural ear. Then within 1 cm of the outside edge of the clay
small pieces of clay are added to form the pattern.
helix, tragus, antitragus, cavum conchae, Posterior Section of External Mold (Fig.
cymba conchae, crus helicis, sca- pha, and lobe. 18.25, A: 1). The clay pattern is properly
After final shaping, the clay pattern is seated and sealed on the master cast. At the
characterized and smoothed. edge of the master cast, the posterior section of
The clay pattern of the ear is now tried on the clay pattern is boxed in from the anterior
the patient’s defect to make sure that it is a part of the helix to the lobule. The operator
reasonable mirror-image of the normal ear. then makes an alginate impression (ratio: 1
The proper placement, positioning, and any part powder to IV2 parts cold water) of the
esthetic corrections should be completed at posterior section. Prebent L-shaped paper clips
this time. are used for reinforcement, and quick-setting
plaster of Paris is added for backing. After
setting, the alginate is trimmed to the indelible
Construction of Metallic Molds (Three line on the crest of the helix. The alginate
Sections) impressions are keyed in a V shape in two
The metallic molds are constructed in the areas.
maxillofacial prosthetics laboratory. The Anterior Section of External Mold (Fig.
following instruments and materials are used. 18.25, A: 2). The remaining half of the master
cast is boxed in, and a film of glycerin is
painted on as a separator over the alginate
Indelible pencil Green Asbestos gloves impression in place on the master cast. The
boxing wax, '/l6 inch thick Double boiler operator makes an alginate impression (ratio: 1
Wax knife Wax spatula Bunsen burner
part powder to 1V2 parts cold water) of both the
no. 7 Alginate Pan of cold water
remaining portions of the master cast and the
impression material Paper clips opened
Plaster bowl Plaster into L shape posterior alginate impression in place on the
spatula Reversible Plaster of Paris cast. Prebent L-shaped paper clips are used for
hydrocolloid Plaster grindings reinforcement, and quick-setting plaster of
Boxing wax lA inch thick Separators: soap and Paris is added for backing. Both alginate
three layers for main glycerin impressions are carefully separated.
sprue Red rope wax for Gray investment Pouring of Gray Investment (Fig. 18.25, A: 3
vents Square jaw pliers and 4). The posterior section is poured as is,
Sheet metal ring Gas-air torch with the Gray investment on both surfaces and
Bench vise with the backing left
Hack saw and blades
Vulcanite burs (assor-
ted)
312 MAXILLOFACIAL PROSTHETICS

FIG. 18.25. A: 1, alginate impression, posterior section; 2, overall impression; 3, posterior Gray investment
section; 4, anterior Gray investment. B: 1, master cast; 2, negative impression; 3, refractory cast; 4, positive
impression. C, three Gray investment models waxed, with sprues and vents placed. D, closed mold with pros-
thesis.

exposed for separation. The anterior section is water). Prebent L-shaped paper clips are used
then poured with Gray investment, and the for reinforcement, and quick-setting plaster of
impressions are separated from the Gray Paris is added for backing. The two
models and trimmed to the outlined area. impressions are carefully separated, and the
Tissue-side Mold; Double Impressions (Fig. negative hydrocolloid impression is discarded.
18.25, B: 1-4). After the clay pattern has been The positive alginate impression is then
removed, the master cast is boxed in with poured in Gray investment, and the Gray
green boxing wax. The operator makes a model is separated and trimmed to the
negative hydrocolloid impression of the defect outlined area.
(ratio: 1 part hydrocolloid to 1 part water). Wax-up of Gray Investment Models (Fig.
Prebent L-shaped paper clips are used for 18.25, C). The three Gray investment models
reinforcement, and quick-setting plaster of are waxed with three thicknesses of baseplate
Paris is added for backing. Next, the operator wax. Main sprues, Vi by % inch, are added at
paints the negative hydrocolloid impression the lowest edge of the models. Vent sprues, V\
with a film of glycerin as a separator, and inch, are placed at the highest points of the
boxes in the negative hydrocolloid impression models. A V shaped groove is carved 5 mm
with softened green boxing wax. He then from the edge of the entire outline of each
makes the positive alginate impression (ratio: waxed-up model. The name of the patient and
1 part powder to IV2 parts cold the date of construction are then inscribed on
the anterior section of the external mold.
EXTRAORAL PROSTHETICS 313

Investing of Gray Investment Models. anterior sections are heated for 3 to 5 minutes
The three Gray investment models are in the dry oven at 190°C. Both molds are then
invested in separate rings. carried to the electric hot plate for painting. A
Wax Elimination and Dry-heating of very thin layer of clear vinyl resin is painted
Investment. The rings are placed in a boil- on the surface of the anterior section and on
out pot for 20 minutes to eliminate the the crest side of the posterior section. The
wax. They are then left in a dry heat oven posterior and the anterior sections are fitted
at 70°C for 10 hours (preferably overnight) together, and the second thin layer of the vinyl
Pouring of Metal Molds. After melting resin is added with tissue-matched paste. If
the linotype metal, the operator pours the necessary, freckles and blood vessels are added
casts with the metal, keeping the main with the different pigments of vinyl resin.
sprues molten with a gas air torch for about Each layer of the paste is processed in the
5 minutes to prevent porosity. The molds oven for 1 minute, and the operator continues
are bench-cooled for 30 minutes before to paint with tissue- matched paste until the
being submerged in the cold water for sep- desired thickness is obtained. The margins are
aration from the Gray investment. The kept free of paste until it is time to close the
three sections are then ground in for close molds.
fitting. Painting of Tissue-side Mold. The tissue-
side mold is heated for 3 to 5 minutes in the
Painting and Processing of Vinyl Resin dry oven at 190°C before being carried to the
Paste electric hot plate for painting. Skin matching
The vinyl resin paste is painted and of the vinyl resin is desirable but not critical.
processed in maxillofacial prosthetics Care must be taken to match closely the
studio room 2. The instruments and mate- desired color near the margins of the mold.
rials are as follows. Each layer of the paste is processed in the
oven for 1 minute at 190°C. The operator
Dry heat oven
continues to paint with the paste until the
Hot plate Plate glass base for
Battery clamps mixing pastes Metal pie desired thickness is obtained. Excess paste is
Timer plate Linotype metal removed from the margin of the posterior-
Camel’s-hair brushes, molds Asbestos gloves anterior and tissue-side molds and, before
assorted Pliers closing the sections of the mold, the operator
Flexible spatulas, as- Plaster knife Large pan paints the margins with fresh paste as a seal.
sorted of ice water Curved He then closes and clamps the three sections
Clear vinyl resin paste scissors, small Cherry of the mold together.
Assorted vinyl resin stones Oil-soluble dyes Final Processing {Fig. 18.25, D). For easy
bases Xylene
Assorted pigments of
manipulation, the operator places the closed
vinyl resin paste and clamped mold in a metal pie plate. The
metal pie plate with the mold is then placed in
Procedure. The patient’s third and last the dry oven at 190 °C for 5 to 7 minutes,
appointment is in maxillofacial prosthetics depending on the size. During the process, the
studio room 2. Again the patient is seated mold is turned over for another 5 to 7 minutes,
on the swivel armchair across from the with the temperature maintained at 190°C.
operator. The oven and the electric hot After the required processing time period, the
plate are preheated to 190°C, and the mold is removed from the oven and submerged
color of the vinyl resin is chosen from in the pan of cold water for complete chilling.
premade samples for skin matching. The The operator then separates the three sections
desired color of the vinyl resin is then of the mold with a plaster knife, removes the
mixed preparatory to painting. ear prosthesis,
Painting of Posterior and Anterior Sec-
tions of External Mold. The posterior and
314 MAXILLOFACIAL PROSTHETICS

FIG. 18.26. A, anterior view without prosthesis. B, posterior view without prosthesis. C, anterior view with
prosthesis. D, posterior view with prosthesis.

and trims the edges with curved scissors and Fitting Auricular Prosthesis
a cherry stone. A thin layer of surgical cement is applied to
Oil-soluble Dye Retouching. The ear the tissue surface of the ear prosthesis and
prosthesis is tinted to the desired color, and fitted over the defect (Fig. 18.26).
characterization is added with xylene- soluble
oil dyes.

PART 3: PALAMED IN FACIAL PROSTHETICS

The chemical composition of this material oratory pack (Fig. 18.27). The pack contains
is based on esters of acrylic and meth- acrylic base powders and stain concentrates, together
acid. The esters in the monomer state are in with solvent liquid for characterization of the
liquid form and convert into the polymeric finished prosthesis. A shade guide is provided
form on processing. Resilience of the processed in three basic skin color shades. Base shade
mass results from plasticization formed by a powders are numbered 20 Pale, 21 Medium,
special molecular structure. 24 Dark. Concentrate powders for blending
Palamed* is available complete in a lab are numbers 30 Brown, 40 Red, 50 Violet, and
60 Gray. Red fiber blood filaments are also
supplied.
* Kulzer and Company, Bad Homburg, West
Palamed has a chemical bond to hard
Germany.
EXTRAORAL PROSTHETICS 315

measure of liquid added and mixed for 2


minutes. Palamed has a tacky consistency
after the initial mix; to facilitate handling the
material, disposable surgeon’s gloves are worn.
After the material has been mixed, it will
become spongy in consistency and is ready for
packing. Cleanliness is essential, as the
material becomes soiled easily at this stage.
If the material is to assume its sponge
center and outer skin, it must expand (Fig.
18.29). To allow for this, the mold is packed to
only 90% of its volume. No trial closure is
required. When packing is completed, the flask
is placed in a spring clamp, immersed in
boiling water, and allowed to boil for 2 to 3
FIG. 18.27. Palamed laboratory pack.
hours according to the thickness of the
prosthesis.
acrylic. This enables the sections of a Palamed At the completion of the cure, the flask is
prosthesis to have supporting structures of allowed to cool slowly to achieve dimensional
hard acrylic. stability. For best results, the flask is left in
One of the main properties of this material the water bath to cool to room temperature.
is that is produces a soft, resilient skin with a The flask is opened and the prosthesis is
spongy central mass, which results in a de-flasked. This is a delicate procedure, as the
skinlike prosthesis that is light in weight. material will tear if roughly handled. To avoid
Manipulation of Palamed can be completed damage, the opened flask is immersed in warm
with normal dental laboratory apparatus. To water (45 °C) for 10 minutes. At this
obtain satisfactory results, weighing the temperature, the material becomes more
material is essential. The sculptured wax flexible and is easier to remove from the
prosthesis is weighed so as to achieve the plaster mass. In most cases, it is possible to
recommended liquid-to- powder ratio of 1.5:1, ease the prosthesis from the mold without
or 1.8:1. The more liquid used, the greater the damage to the
softness of the finished prosthesis. A
suggested weight ratio table is shown in
Figure 18.28.
Laboratory Technique WAX POWDER LIQUID POWDER LIQUID
g- g- ml. g- ml.
The wax prosthesis is flasked, the wax is
boiled out, and the flask is left to cool. The 1 0-6 0-3 0-6 0-4
mold material used is plaster of Paris, 2 1-2 0-7 M 0-7
3 1-8 I 1-6 10
modified with stone plaster as required.
4 2-4 1-3 2-2 1-4
Palamed should be packed only into a cold 5 30 1-7 2-7 1-8
mold. Plaster surfaces of the mold are coated 6 3-6 20 3-2 2-2
7 4-2 2-3 3-8 2-5
with a standard separating medium. The basic 8 4-8 2-6 4-3 30
skin shade is selected, using one or a 9 5-4 30 4-9 3-3
combination of the shade discs on the shade 10 60 3-3 5-4 3-6
20 12 6-6 10 8 7-2
card. To obtain the maximal simulation of the 30 18 10 16-2 10 8
patient’s skin shade, the discs are removed 40 24 13 21-6 14-4
50 30 16 5 27 0 180
from the card and held against the patient’s 60 36 20 32-4 21 6
skin. The color concentrates should also be 70 42 23 37-8 25-2
selected for blending the skin tone. 80 48 26 43-2 28-8
90 54 30 48-6 32-4
Weighed powder of the selected shade is 33 54 36
100 60
placed in a mixing bowl, and the correct
FIG. 18.28. Weight ratio table.
316 MAXILLOFACIAL PROSTHETICS

shields the coloring compounds from the


deteriorating effects of ultraviolet light.
Tinuvin P may be incorporated in the polymer
or it may be used in the acetone suspension
used for tinting the finished prosthesis.
Attraction to dirt is a problem with Pa-
lamed. This has particular importance in
relation to a patient’s employment. Patients
who work in contact with dust and dirt are
poor candidates for a prosthesis constructed of
Palamed. Magnified examination of the outer
skin reveals that the surface consists of pore-
like voids, consistent with expanded and
plasticized materials, which would account for
the material’s affinity to dirt as the pores fill
with debris and airborne dust. The use of
nonexpanding Palamed (Palamed B) has
FIG. 18.29. Sphere sectioned to illustrate sponge resulted in an improvement in some cases.
center and outer skin. Palamed has a unique resilience which
presents the difficulty of maintaining the
plaster. This is an advantage, since two or stability of form in a prosthesis. To overcome
more prostheses can be made for the patient. this problem, thin sections can be laminated
As soon as it has been removed from the using nylon net. The lamination is achieved by
plaster, the prosthesis is placed in cold water pressing Palamed into the nylon mesh, using
to chill the material preparatory to trimming two glass slabs separated by polyethylene
and finishing. Scissors, fine stones, and wet sheets (Fig. 18.30). This technique is useful in
sandpaper are used to finish the material. The reinforcing the margins of a prosthesis.
surface skin should not be broken during
finishing. A surface sheen is imparted by the
Case Reports
finishing process. This can be reduced by
dusting with powder. Case A: Ear. Schoolgirl, aged 12 (Fig.
18.31). Avulsion injury to right ear incurred
Characterization while riding a horse which bolted, throwing
Characterization of the prosthesis is the patient onto a gravel road. Her foot caught
completed by using Palamed paints made up in the stirrup and she was dragged some
in a 1% suspension of acetone. Concentrated distance on the right side of her face. The
characterization is achieved by use of the paint lower third of the ear re-
card, with acetone as the solvent. Mistakes
made during the extrinsic coloring can be
eradicated by a chloroform-soaked cotton wool
pellet. It is not advisable to repeat the
cleaning procedure too often since Palamed
becomes progressively more tacky with each
application.
The color stability of Palamed can be
improved considerably by adding 0.5%
‘Tinuvin P,’$ a new type of ultraviolet light
absorber for polymer materials which protects
the substrate from yellowing and

f Geigy Chemical Corporation. U. K. Ltd., Si- FIG. 18.30. Palamed reinforced by laminating with
monsway, Manchester. nylon mesh.
EXTRAORAL PROSTHETICS 317

FIG. 18.31. Case A, before (A) and after (B) fitting with prosthesis.

FIG. 18.32. Case B, before (A) and after (B) fitting with prosthesis.

mained intact. Following reparative surgery, Defect of left ear following surgery for a
the case was considered unsuitable for neurofibroma. Small remnants of the lobe
reconstructive surgery. A Palamed prosthesis remained. The external auditory meatus was
was constructed to restore retention. The unsatisfactory as a result of contraction. The
junction of the prosthesis and the remaining patient’s hearing was slightly impaired. A
ear was masked by a change of hair style. The Palamed prosthesis was constructed to cover
patient wears sunglasses and clip earrings the tissue remnants. Retention was achieved
without difficulty and is pleased with the with double-sided adhesive tape. The
cosmetic result. This patient has not returned prosthesis was light in weight and had a
for follow-up appointments. translucent appearance. The parents were
Case B: Ear. Boy, aged 12 (Fig. 18.32). very pleased with the result. Review
appointments showed that
318 MAXILLOFACIAL PROSTHETICS

FIG. 18.33. Case C, before (A) and after (B) fitting with prosthesis.

the child found difficulty in maintaining the defect and the nasal remnants, and the
prosthesis, although retention remained pendulous tissue was supported and con-
stable. The prosthesis was remade in Palamed tained. The restoration was retained by
because of damage caused by the patient spectacles. The prosthesis was worn for 18
wearing the prosthesis during sleep. After months. The defect was finally repaired by
further instructions to parents, the present forehead rhinoplasty and postnasal inlay.
prosthesis is now satisfactory. Throughout the period of wear, the prosthesis
Case C: Nose. Retired schoolteacher, aged remained resilient but with some color loss.
67 (Fig. 18.33). Extensive defect following The patient kept the prosthesis clean with a
excision of malignant melanoma. The excision detergent. Some staining of the prosthesis
included the tip of the nose and total right side occurred from cigarette smoke. This was easily
of nasal septum. The prosthesis was removed during the cleaning procedures. The
constructed of Palamed and methyl patient was pleased with the restoration and
methacrylate. A substructure of rigid material experienced no difficulty or discomfort caused
was covered with foamed Palamed. The by the prosthesis.
prosthesis covered both the

PART 4: METHYL METHACRYLATE IN FACIAL PROSTHETICS

The physical structure of methyl meth- For the most part, maintenance of methyl
acrylate allows for ease of cleaning, and its methacrylate prostheses involves removing
stability of form enables a restoration to be surface sheen caused by wear and cleaning.
worn for a considerable time before being Ultraviolet light absorption often causes a
remade. A prosthetic restoration which prosthesis to bleach, particularly if the patient
requires frequent renewal causes considerable spends much time outdoors. The discolored
inconvenience to the patient. The psychologic prosthesis is placed in a dyeing bath containing
effect of constant maintenance and renewal polymer dye dispersed in soap solution. The
also prevents him from feeling confident about prosthesis takes up the dye color by surface ab-
the prosthesis. These factors have prolonged sorption as a result of chemical reaction
the use of rigid prostheses. between dye and polymer. The color in-
EXTRAORAL PROSTHETICS 319

FIG. 18.34. Requirements for packing methyl methacrylate prostheses. A, acrylic paint suspension. B, con-
centrate acrylic stains. C, basic skin shade acrylic polymer. D, nylon flock.

tensity is controlled by immersion time and pressed basic skin dough according to the
dye concentration. above formula.
From the standard methyl methacrylate To simulate vascular areas, nylon filaments
denture-base resins, a satisfactory basic skin in shades of red, burgundy, and purple can be
shade can be achieved and varied to simulate used. Acrylic paints dispensed in methyl
skin tone characteristics with accuracy methacrylate monomer also reproduce skin
(Roberts and Penney, 1964). color accurately. The acrylic paints may be
4 ml of Stellon* pink
used in concentrated form to provide high
8 ml of Stellon veined color contrast and definition.
5 ml of Stellon clear
Laboratory Technique
4 ml of Stellon C. 2, light yellow 4 ml of
Stellon C. 4, dark yellow 2 ml of Stellon C. The packing of the material when used for
6, light gray 1 ml of Dentine stain, yellow facial prostheses generally follows standard
1 ml of Dentine stain, orange 1 ml of dental laboratory principles. The wax or clay
Dentine stain, gray 1 ml of Dentine stain, prosthesis is invested in the flask so as to
light brown All powders to be have the external surface presented for
incorporated together coloring during the packing stage.
A wide color variance and simulation of Following flasking, the wax is boiled out,
special skin tone characteristics may be the mold is cooled, and the separating medium
achieved with high concentrate acrylic is applied. Cold plaster molds must be used to
stains provide the maximal working time since the
intense red M. 709; intense red M. 708; intense red main color characteristics are achieved at the
M. 710; A. S. gray; A. S. yellow; A. S. ivory dense packing stage. The following materials and
white; A. S. blue; A. S. brown. instruments are set out for packing the
prosthesis (Fig. 18.34): acrylic concentrate
These are used at the packing stage for
stains, acrylic paint suspensions, colored
selective tinting on the surface of the
nylon filaments, a dish of monomer, small
paint brushes, mixing spatula, and cutting
instruments.
The technique requires a number of trial
* Amalgamated Dental Company Ltd., U. K.
$ Metrodent Ltd., Huddersfield, Yorkshire, Eng-
land.
320 MAXILLOFACIAL PROSTHETICS

closures. Polyethylene sheet has proved to be an acrylic blasting grade sand. An alternative
the most suitable means of separation. Basic method is to stipple the surface with a small
skin shade polymer is mixed with monomer round bur which has its shank bent. This
and allowed to attain a soft dough stage. The provides a vibrating effect on the acrylic
dough is packed into the mold, and the flask is surface. The disadvantage of the bur method
closed. When it is opened, the prosthesis will is that color characteristics may be ground off
be exposed external surface up. The flash is or reduced. This is less likely with
trimmed, the separating sheet is applied, and sandblasting.
the flask is closed. This procedure is repeated The fitting surface of a rigid acrylic
until the acrylic flash is reduced to a min- prosthesis must have a smooth, polished
imum. To provide the main color charac- surface. Polishing is difficult because of the
teristics, the concentrate stains are placed in geometry of the fitting surface. An acrylic
the appropriate areas of the prosthesis. The varnish which cross-links with the prosthesis
surface of the prosthesis is painted with acrylic is available. When it is painted on the
monomer to fuse the stains with the basic skin acrylic, a high gloss surface results.
shade. Blood vessels, if required, are
Characterization
simulated with the nylon filaments. A layer of
clear polymer is placed over the color, and The methyl methacrylate prosthesis is
monomer is again applied to wet the surface. tinted with acrylic paint suspensions. A
This clear layer tones down the color and seals Chinese writing brush permits fine stippling
the surface. A trial closure is again used to effects to be achieved. The most widely used
press in the surface color. Acrylic paint paint suspensions are red, blue, white, yellow,
suspensions are used to achieve any deep color and brown. A warm air blower will fix the
contrast and definition. To ensure accurate tints to the surface. Because of the accurate
color simulation from the material, the skin shade and characterization that can be
presence of the patient is required during the achieved at the packing stage, only minor
packing stage. The flask is held next to the tinting should be necessary.
patient’s face for prosthesis color reference. Autopolymerizing Acrylic
When an ear prosthesis is packed, a mix of
Cold-cure acrylic systems find many uses in
pink shade acrylic is packed into the helix
the construction of facial prostheses. A basic
area, followed by the main basic skin shade
skin shade can be formulated from standard
mass. The pink shade provides the color
dental cold-cure polymer, dentine shaders, and
contrast in the helix. A gradual shade
stains. The liquid used for this material is
differential must be achieved between the
dental cold- cure monomer.
helix and the body of the ear. Packing
completed, the closed flask is clamped and Autopolymerizing Acrylic Basic Skin Shade
polymerized. Conventional polymerization 25 ml: Pink
times are used: 20 ml: Clear
5 ml: Dentine light yellow 5 ml: Dentine dark
Wet heat: 65°C for 90 minutes, then 100°C for yellow 2 ml: Stainer gray 2 ml: Stainer yellow 2
30 minutes. ml: Stainer orange 2 ml: Stainer brown 1 ml:
Dry heat: 10 hours at 80°C. Stainer dark brown 1 ml: Ultraviolet light
absorber (Tinuwin P§) Nylon filaments (veins)
Following polymerization, the prosthesis is
de-flasked, and any flash or surface
imperfections are removed with stones or
rubber wheels. Areas of the prosthesis which
are to be bonded to spectacles are prepared. A
problem with methyl methacrylate prostheses
is surface sheen. This can be overcome by
sandblasting at 40 psi with

§ Geigy Chemical Corporation.


EXTRAORAL PROSTHETICS 321

This acrylic can be used to augment investment. Thin mixes of cold-cure acrylic are
margins of a rigid acrylic prosthesis when in painted on the surface of the duplicate model
position on the patient’s face. To protect the until the required thickness is achieved (Fig.
tissues from the heat of reaction during 18.36). Characterization of the prosthesis is
polymerization, a heat-barrier cream is completed with acrylic paints which are sealed
applied to the skin. A mix of cold-cure skin under a layer of clear cold-cure acrylic. When
shade acrylic is poured into a glass syringe the lamination process is completed, the
which is used to apply the acrylic in the areas soluble model is removed by boiling in water.
required (Fig. 18.35). Because of the thin If investment has been used, it can be easily
section of the cold-cure acrylic on the skin, the removed after soaking in water. This type of
patient experiences no discomfort during the thin-shell prosthesis has a translucent effect
polymerization time, which is accelerated by and is light in weight. If a prosthesis is to fit
body heat. over mobile tissue appendages, particularly in
When a thin-shell prosthesis is required, partial ear restorations, this cold- cure
the wax- or clay-sculptured prosthesis is lamination produces a close-fitting prosthesis
duplicated in a soluble plaster or casting which is difficult to achieve by other methods.

Case Reports
Case A: Nose. Male, aged 68 (Fig.
18.37) . Defect of the left side of nose fol-
lowing surgery to remove an extensive tumor.
The defect was contained in the midline of the
nose, presenting the problem of providing a
partial prosthesis. A thin methyl methacrylate
prosthesis was constructed and retained in
position by adhesive. Added mechanical
retention was achieved by a polyvinyl chloride-
covered wire loop which fitted around the colu-
FIG. 18.35. Self-cure acrylic applied to margins of
mella. A thin margin was obtained with
prosthesis.

FIG. 18.36. A, acrylic painted over duplicated model of soluble plaster. B, original model with sculptured
prosthesis.
322 MAXILLOFACIAL PROSTHETICS

FIG. 18.37. A, partial nasal defect, left side. B, methyl methacrylate nasal prosthesis seated over defect.

FIG. 18.38. A, traumatic sunken nasal bridge. B, full nasal prosthesis constructed of methyl methacrylate.
EXTRAORAL PROSTHETICS 323

FIG. 18.39. A, pathologic nasal defect due to lupus erythematosus. B, methyl methacrylate nasal prosthesis in
place.

self-cure acrylic of the same skin base color. Case C: Nose. Female, aged 78 (Fig.
The patient likes the prosthesis, and it 18.39) . Defect of nasal tip, ala, cartilage,
appears in good condition at review and columella as a result of lupus erythem-
appointments. atosus. The area was then disease-free, and
Case B: Nose. Female, aged 58 (Fig. the patient had worn a special silk adhesive
18.38) . Resorbed nasal bridge following a plaster for the past 20 years. However, this
blow across the face with a metal ruler at plaster had gone out of production, prompting
school. The incidence occurred when the the patient to seek advice. She was referred by
patient was 12 years old. No treatment was her own physician for an opinion on plastic
received because of the patient’s fear of surgery. Because of the age and prognosis of
surgery. The resulting defect has meant that the patient, a prosthesis was prescribed. A
the patient found great difficulty in wearing Palamed nose was constructed over the nasal
spectacles and is now very self- conscious remnants and retained in position by
about her undeveloped nose. In seeking a spectacles. The patient was pleased with the
means of retaining her spectacles, the optician result. The Palamed prosthesis remained
advised a prosthesis. To provide support and satisfactory for 18 months, when a new
contact, a rigid methyl methacrylate prosthesis was considered because of
prosthesis was constructed to cover the discoloration and loss of marginal contact. A
remaining nose structure and restore contour rigid methyl methacrylate prosthesis was
to the bridge. The prosthesis, in the form of a constructed. The patient was delighted with
thin shell, was fixed to the spectacles for the result, reporting that it was easy to
retention. The result was satisfactory; the maintain and comfortable to wear.
patient was very pleased and has obtained Case D: Eye and Orbit. Retired railway
employment. engineer, aged 69 (Fig. 18.40). Extensive
324 MAXILLOFACIAL PROSTHETICS

FIG. 18.40. A, extensive postsurgical defect of right facial region. B, two-piece obturator and mandibular com-
plete prosthesis and eye glasses to aid in retention of facial prosthesis. C, combination orbital and facial
prosthesis constructed in methyl methacrylate and seated over defect.

defect following excision of cancer of antrum weight of the previous restorations, which
and right cheek. The defect involved the total were combined with his upper denture by
orbit area extending down to the angle of the means of robust rods and tubes with addi-
mouth. The patient had worn a number of tional retention by spectacles attached at the
prostheses since his operation 12 years bridge of the nose. A new two-piece
previously. He had experienced headaches restoration was constructed of methyl
and facial pain caused by the methacrylate. The design concentrated on
EXTRAORAL PROSTHETICS 325

lightness in weight. The total external the patient’s spectacles which were not
prosthesis was formed to restore contour by attached to the prosthesis. The patient was
means of a cast chrome-cobalt stud. The plug delighted with the result and is able to wear
component of this stud was designed to the prosthesis for a full day without
connect to the socket section in the buccal discomfort or pain. He can easily assemble the
flange of the obturator denture. Further components of the prosthesis, and he has
stability was achieved by means of resumed his hobby of sailing.

PART 5: HEAT-VULCANIZING SILICONES FOR CONSTRUCTION OF


EXTRAORAL PROSTHESES

The term “silicone” covers many related produced by pigments at the surface of the
but different materials. They can vary con- skin, but by the color of blood and pigments
siderably in chemical and physical properties. within the tissues of the skin.
Some can be very reactive, but most are inert, A prosthetic restoration colored by the
like the original quartz. They come in many
forms, such as liquids, gels, greases,
defoamers, waxes, rubbers, resins, and
reactive chemicals. Each form has different
characteristics peculiar to its use. No silicone
occurs naturally; all are manmade.
Specifically for the construction of ex-
traoral prostheses, a stronger and more
translucent material has recently been
developed and is being used by a number of
prosthodontists. The Dow Corning Center for
Aid to Medical Research recently developed
the heat-vulcanizing “Clean Room” Silastic
MDX4-4514, MDX4-4515, and MDX4-4516 for
use in maxillofacial prosthetics. General
Electric also produces heat-vulcanizing
silicones for the same purposes.

Pigmenting and Coloring Heat-vulcanizing


Silicone
“Clean Room” heat-vulcanizing silicone
comes in a milky color. To be used for ex-
traoral prostheses, it should be colored to
match the skin; and there are two ways of
doing this: extrinsic and intrinsic. In extrinsic
coloring, the pigments in the form of paints or
dyes are applied directly to the surface of the
finished prosthesis. In intrinsic coloring, the
pigments are added directly to the silicone
prior to curing, and this produces a far more
satisfactory color and texture. In fact, the
intrinsic method of coloring is very similar to
FIG. 18.41. A, Sears portable wringer. B, stainless
nature’s way of imparting color to skin. Skin steel tube and Boston gear. C, Sears wringer with
color is not stainless steel tubes and gear ready to mill silicone.
MAXILLOFACIAL PROSTHETICS
326

FIG. 18.42. Diagrammatic drawing of metal jig to room three pieces of auricular metal mold while packing and
pressing silicone material.

agents on the properties of the finished rubber


parts, and do not contain so much filler or
additive material as to overpower the coloring
properties.
Pigments used with silicone rubber are
nearly always inorganic compounds such as
metallic oxides. Determining the concen-
tration of pigment needed to obtain the
desired color is primarily a trial-and-error
procedure.
A Sears portable wringer was altered for
this purpose (Fig. 18.41). The rubber rollers
were reduced to receive stainless steel tubes
1% inches, 1% inches, and 8V2 inches long. A
FIG. 18.43. Tattooing of silicone with tattooing Boston gear NB30B was placed on a roller
instrument. shaft adjacent to the motor to synchronize the
rollers and provide positive drive (Fig. 18.41,
intrinsic method will retain its color. Fur- B and C).
thermore, there is no risk of the pigments The pigment is placed in a small quantity
wearing off of the surface of the prosthesis. of silicone rubber and run through the mill
Almost any color is possible in silicone until it is thoroughly incorporated. The
rubber when the pigments used are heat- different color pigments are added until the
stable, do not react with vulcanizing desired skin tone is attained.
EXTRAORAL PROSTHETICS 327

FIG. 18.44. A, congenitally missing right ear with cartilaginous tag. B, surgical removal of the tag fo r better
shaping and fitting of the auricular prosthesis. C, three-piece metal mold in rectangular shape for easy pressing of
silicone. D, opened metal mold after curing the auricular prosthesis. E, silicone auricular prosthesis out of the
mold. F, flexibility of silicone material. G, silicone auricular prosthesis trimmed. H, silicone right auricular
prosthesis cemented over the defect.
328 MAXILLOFACIAL PROSTHETICS

FIG. 18.45. A, bilateral congenitally missing ear. B, silicone bilateral auricular prostheses cemented. Note the
hairdo of male patient to camouflage the margins of the prostheses.

Nylon flock is then applied to the tissue side 5. Barnhart, G. W.: A new material and technic in
of the mold to duplicate blood vessels, and the the art of somatoprosthesis. J. Dent. Res. 39:
836-844, 1960.
mold is then packed with pigmented silicone.
6. Beder, O. E.: Surgical and Maxillofacial Pros
Since the silicone should not be contaminated thesis. University of Washington Press, Seattle,
while being packed in the mold, the operator’s 1959.
hands should be clean or gloves should be 7. Braley, S.: Director, Dow Coming Center for Aid
used. The silicone is trial-packed and pressed. to Medical Research; personal communication.
8. Brown, K. E.: Fabrication of an ocular prosthesis.
Excess material is removed, and clamps are J. Prosth. Dent. 24: 225-235, 1970.
used to close the mold and to exert pressure 9. Bruce, G. M.: Ancient origins of artificial eye.
while it is being vulcanized in a dry heat oven Ann. Med. Hist. 2: 10-14, 1940.
at 170°C for approximately 20 minutes (Fig. 10. Bryan, P. L.: Consultant health care facilities;
personal communication.
18.42). After removal from the metal mold, the
11. Bulbulian, A. H.: Facial Prosthesis. W. B. Saun
prosthesis is checked on the patient, and ders Co., Philadelphia, 1945.
imperfections in the skin are duplicated by 12. Cantor, R., Curtis, T. A., and Rozen, R. D.: Pros
means of tattooing with water colors (Fig. thetic management of terminal cancer patients.
18.43). The prosthesis is then put back in the J. Prosth. Dent. 20: 361-366, 1968.
13. Cantor, R., and Hildestad, P.: A material for
dry heat oven at 50 °C and thoroughly dried. epithesis. Odont. T. 74: 32-40, 1966.
The silicone prosthesis is then ready for 14. Chalian, V. A.: Maxillofacial Prosthesis. Univer
placement on the patient. sity of Texas, Dental Branch, Houston, 1960.
A silicone adhesive is used for retaining the 15. Chalian, V. A., Cunningham, D. M., and Drane,
J. B.: Maxillofacial prosthetics departments in
prosthesis (Figs. 18.44 and 18.45). dental schools and medical centers. J. Prosth.
Dent. 15: 570-576, 1965.
REFERENCES 16. Chalian, V. A., and Thompson, L. W.: Prosthetic
1. Abrahamian, H. A.: Maxillofacial prosthetics: an Reconstruction of Facial Disfigurements: Pro-
introduction. Georgetown Dent. J. 31: 1-3, ceedings of the First International Symposium of
1964. Plastic and Reconstructive Surgery of the Face
2. Adisman, I. K.: Maxillofacial prosthesis. Int. Dent. and Neck, New York, 1970. Georg Thieme
J. 8: 30, 1958. Verlag, Stuttgart, in press.
3. Al-Qudsi, F. S.: Facial Prosthesis. Baghdad Uni 17. Clarke, C. D.: Facial and Body Prosthesis. C. V.
versity Press, Baghdad, 1968. Mosby Co., St. Louis, 1945.
4. Baker, L.: An artificial nose and palate. D. Cosmos 18. Dimitry, T. J.: Story of artificial eye. Eye, Ear,
47: 561-562, 1905. Nose, Throat Monthly 21: 270-274, 1941.
19. Firtell, D. H., and Bartlett, S. O.: Maxillofacial
prostheses: reproducible fabrication. J. Prosth.
Dent. 22: 247-252, 1969.
EXTRAORAL PROSTHETICS 329

20. Fonder, A. C.: Maxillofacial prosthetics. J. Prosth. 29. Nadeau, J.: Special prostheses. J. Prosth. Dent.
Dent. 21:310-314, 1969. 20: 62-76, 1968.
21. Fonseca, E. P.: The importance of form, charac 30. Prince, J. H.: Ocular Prosthesis. E. & S. Living
terization and retention in facial prosthesis. J. stone, Ltd., Edinburgh, 1946.
Prosth. Dent. 16: 338-343, 1966. 31. Riley, C.: Maxillofacial prosthetic rehabilitation
22. Hawkinson, R. T.: Development of skin surface of postoperative cancer patients. J. Prosth.
texture in maxillofacial prosthetics. J. Prosth. Dent.: 20: 352-360, 1968.
Dent. 15: 929-937, 1965. 32. Roberts, A. C.: Facial reconstruction by prosthetic
23. Helveston, E. M.: Assistant Professor of Ophthal means. Brit. J. Oral*Surg. 4: 157-182, 1966.
mology, Indiana University Medical School; 33. Roberts, A. C., and Penney, H. D.: An Advance
personal communication. in facial and body prosthesis material. Dent.
24. Kazanjian, V. H., and Converse, J. M.: The Surgi Pract. (Bristol) 15: 7-13, 1964.
cal Treatment of Facial Injuries, Ed. 2. The 34. Robinson, J. E.: Prosthetic treatment after surgi
Williams & Wilkins Co., Baltimore, 1959. cal removal of the maxilla and floor of the orbit.
25. Laney, W. R., Drane, J. B., and Rosenthal, L. E.: J. Prosth. Dent. 13: 178-184, 1963.
Educational status of maxillofacial prosthetics: 35. Robinson, J. E., Jr., and Niiranen, V. J. (Editors)
report of the Educational Survey Committee of Maxillofacial Prosthetics: Proceedings of an
the American Academy of Maxillofacial Interprofessional Conference, Washington, D.
Prosthetics. J. A. D. A. 73: 647-651, 1966. C., September, 1966. U. S. Public Health Service
26. Metz, H. H.: Maxillofacial prosthetic rehabilita Publication No. 1950, Washington, D. C., 1966.
tion after mouth and facial surgery. J. Prosth. 36. Schaaf, N. G.: Color characterizing silicone rubber
Dent. 14: 1169-1177, 1964. facial prostheses. J. Prosth. Dent. 24: 198-202,
27. Miglani, D. C., and Drane, J. B.: Maxillofacial 1970.
prosthesis and its use as a healing art. J. Prosth. 37. Tashma, J.: Coloring somatoprostheses. J. Prosth.
Dent. 9:159-168, 1959. Dent. 17: 303-305, 1967.
28. Nadeau, J.: Maxillofacial prosthesis with mag 38. Welden, R. B., and Niiranen, V. J.: Ocular pros
netic stabilizers. J. Prosth. Dent. 6: 114-119, thesis. J. Prosth. Dent. 6: 272-278, 1956.
1956.
19
CRANIAL AND FACIAL IMPLANTS
Varoujan A. Chalian, Joe B. Drane, Joseph C. Maroon,
Victor Matalon, and S. Miles Standish

Prerequisites of a successful implant are plant would best serve its purpose if it were
twofold. Both the implant and the tissue bed biodegradable in a predictable amount of time.
should have certain characteristics. The tissue This would allow it to act as a scaffold for the
bed should be free of infection, should be able body to build upon, and when it has served its
to be closed over the implant without purpose it can be resorbed and excreted. At
pressure, and should have an adequate blood present we have no material available which
supply. The last requirement basically negates will serve this function, and therefore a
placing an implant in irradiated tissue. biostable material is the one of choice.
Ideally, the implant would have the following 4. It must be strong enough to withstand
characteristics. stresses. The physiologic stresses of the body
1. It must be noncarcinogenic. Animal should not fatigue the implant and cause
experimentation has produced evidence that fracture.
physical rather than chemical factors are 5. It must be small enough to require a
responsible for the change from normal to minimum of tissue to cover. In both the
tumor cells in the implanted animal, the traumatic and the surgically created defect,
theory being that introducing a large expanse the amount of tissue for coverage of an implant
of implant material disturbs the electrostatic has been decreased or compromised. An
potential gradient in the prea of the interface. implant which accomplishes the necessary
Therefore the implant should have a contour and yet requires a minimum of tissue
configuration which allows for the fibrosing of for coverage would be the most desirable.
the tissue through it and thereby disturbs 6. It must be readily available and easy to
cellular function less. fabricate.
2. It must not cause excessive inflammation 7. It must be capable of being sterilized.
or foreign body reaction. A slight amount of Aseptic technique should be followed to
inflammatory process is desired. This serves prevent infection and subsequent compli-
two functions in the implant patient. First, it cations.
aids in fixating the implant in position, and At present, various metals and synthetic
second, it provides barriers to infection materials are used for implantation. The
spreading the length of the prosthesis. This is metals are tantalum, 18-8 stainless steel, and
best demonstrated by the migration of chrome cobalt alloys. Tantalum, which comes
implanted silicones which elicit no body in the form of sheets, wire, ribbon, and mesh,
defense reaction. has a long history of success in
3. It must be biostable. Ideally, an im

330
CRANIAL AND FACIAL IMPLANTS 331

implantation. Its value lies in the support of Modern techniques of cranioplasty were
structures or in wiring fragments together, developed in the late 19th century and, as
but it is not strong enough to bridge long, might be expected, autogenous grafts were
unsupported areas. employed. The dermatoperiosteal transposition
The 18-8 stainless steel (18% chromium, 8 flap of Muller-Konig and the osteoperiosteal
to 10% nickel, and 2 to 4% molybdenum) is an grafts of Durant in the 1890s are of special
Austenitic stainless steel and is the one used historical ‘significance. Extracranial sources of
most for implants. The chromium and nickel autogenous bone and cartilage for cranioplasty
are added to the standard iron and carbon to have included the tibia, ribs, iliac crest,
add strength and make the alloy more scapula, and sternum.
corrosion resistant. Handling of this type of Extensive trials with homogeneous (ca-
material necessitates specialized equipment to daver) grafts have been carried out, some with
attain the desired shapes. considerable success. But the fact that these
Chrome cobalt alloys are also well accepted are now rarely used attests to the general
by the body for implant and probably offer the dissatisfaction with this method. Similarly,
best opportunity for success. We have utilized heterogeneous bone grafts from dogs, eagles,
this material before in the fabricating of calves, sheep, oxen, and rabbits, and horns
partial dentures and therefore are familiar from buffalo, oxen, and elephants have all
with its handling. Most laboratories also have been, at times, enthusiastically reported; all,
the necessary equipment for processing it. however, are now primarily of historical in-
Among synthetic materials, methyl terest.
methacrylate, polyethylene, and silicone are The greatest progress in cranioplasty has
used the most because they do not cause body been made in the development and application
reactions and are easily manipulated in the of various plastic and metallic alloplastic
dental laboratory. materials, beginning at the turn of the
In the search for a suitable implant ma- century. Although gold plates were inserted
terial, grafts of an autogenous, homogenous, into skull defects as early as 1565, it was not
heterogeneous, and alloplastic nature have all until the 1930s and ’40s that the inert metals
been used. The Peruvians used pieces of were used, such as Vitallium, Ticonium,
animal shells and gourds to repair skull tantalum, and stainless steel.
defects. No less ingenious were the primitive The use of acrylic resins, specifically methyl
South Sea Islanders, who closed the scalp over methacrylate, has been the most significant
pieces of shells from the indigenous coconut. recent development in this field. By the
The bony proliferation observed around these separation of methyl methacrylate into liquid
and other materials used in the past, such as and powder polymers which could be mixed at
hard rubber, plaster of Paris, and gummed the time of surgery and fitted into any
cork, attests to the remarkable tolerance of appropriately prepared defect, the surgeon was
the body to implanted foreign objects. provided with an easy-to-use, nonreactive
material which gave excellent cosmetic results.
Cranioplasty
Of all the materials available for cranioplasty,
Cranioplasty, or the operative repair of a the autogenous split rib and iliac bone grafts
defect in the skull, has prodded the ingenuity and the alloplastic grafts of tantalum stainless
of medical practitioners for thousands of steel and methyl methacrylate are most
years. The potential danger and the generally used.
unsightliness of a pulsating and painful skull
Indications
defect were no less a problem of management
In the last 10 years, approximately 90
to the primitive shaman who employed special
cranioplasties have been performed at the
amulets and shells than it is for the modern
Indiana University Medical Center. Trauma,
surgeon with his alloys and plastics.
most often from high speed auto
332 MAXILLOFACIAL PROSTHETICS

collisions and blows to the head with sub- conform better to the desired contour. For any
sequent compound depressed skull fractures major reconstructive procedure, a plastic
and/or intracranial hematomas, was the cause surgeon and maxillofacial prosthetist should
of most of these skull defects. Additional be consulted.
sources included osteomyelitis of the skull, Since most of our experience has been with
either primary or following a previous methyl methacrylate and, to a lesser degree,
craniotomy, gunshot wounds, congenital split rib grafts and tantalum, the following
defects, and neoplasms of both cranial and comments deal primarily with these forms of
intracranial origin. cranioplasty.
Many authors formerly included epilepsy
Technique of Methyl Methacrylate Cranial
as an additional indication, particularly when
Implant
the attacks originated from the cortex
The skin incision is designed to allow
underlying the site of injury. It is now
complete exposure of the margins of the bone
generally agreed, however, that the cranial
defect. The bone edge is exposed and then,
defect, or repair thereof, is not likely to affect
with sharp dissection, a plane is developed
seizure activity.
between the dura and the frequently adherent
General indications for cranioplasty include
fibrous tissue immediately overlying the
the following: (1) pulsating and painful
defect. Care must be taken to avoid lacerating
defects; (2) danger of trauma at the site of the
the underlying dura and brain. Having thus
defect; (3) deforming and unsightly defects; (4)
completely exposed the defect, a periosteal
headache and other symptoms such as pain,
elevator is used to free the dura from the bone
apprehension, or tenderness at the site of a
edge circumferentially.
defect.
At this point, if the dura is full or tense, the
In all cases of penetrating craniocerebral
anesthesiologist is requested to hyperventilate
trauma, at least 6 months elapsed before
the patient to decrease intracranial pressure;
reoperation. Injuries involving the air sinuses
if the tension continues, a hypertonic agent
were delayed 9 to 12 months, and at least a
such as urea or mannitol is given
12-month delay was permitted in previously
intravenously.
infected cases. Cranioplasty was not
Next, the bone edge is freshened, rounded,
performed in the presence of wound
and slightly beveled with rongeurs. Some
contamination or if there was evidence of
surgeons prepare to remove the outer table of
acute or chronic infection. Cranioplasty in
adjacent bone with a high speed air drill to
children was delayed, when possible, until
provide a ledge for countersinking the plastic
after 5 years of age since there is relatively
plate. Others rongeur out inverted V-shaped
little additional skull growth after this period.
wedges of bone at several points and then
Cranioplasties before this age should be
mold the plastic into and under these defects
performed with autogenous bone when
to provide greater stability.
possible.
When this preparation has been completed,
In the one-stage method of cranioplasty,
the cranioplastic kit containing one vial of
methyl methacrylate has been used almost
sterile liquid monomer and one bottle of sterile
exclusively for both small and moderately
powdered polymer is opened. The powder and
large skull defects. Split rib grafts have
liquid are placed in a small sterile basin and
sometimes been used for large defects,
thoroughly mixed with a spatula (Fig. 19.1). It
especially those resulting from a wide
usually takes 5 to 6 minutes of stirring to
craniectomy performed for osteomyelitis, and
obtain a doughy mass of a consistency that can
also for reconstruction in the area of the
be conveniently molded.
frontal sinuses. One layer of cortical bone has
This is shaped with the hands to a size
been used to repair defects around the lateral
approximating the defect and to the thickness
margin of the orbit, with the graft obtained
of the surrounding bone. The plate is
from a curved area in the pelvis similar in
shape to that desired for the cranioplasty. This
type of bone graft may be bent considerably to
CRANIAL AND FACIAL IMPLANTS 333

used to trim rough and sharp edges and to


remove excess material. Stability is main-
tained with strategically placed wire sutures.
For greater stability as well as for cosmetic
purposes, wire may be used to bridge a defect
and may then be incorporated into the methyl
methacrylate plate when the acrylic is inserted
in its still pliable state (Fig. 19.2). This
technique is especially useful in reconstructing
a supraorbital ridge. An additional method of
securing a plate is to tie multiple wires
previously inserted through small twist- drill
holes at opposite sides of the skull defect
across the entire plate (Fig. 19.3). If desired,
acrylic plates may be reinforced with stainless
steel or radiolucent aluminum mesh.
The time required to mold and secure a
methyl methacrylate plate is approximately 20
to 25 minutes. Cosmetic results are usually
excellent and easy to achieve. The plate has
nearly the same density and strength as bone
and is transparent to x- rays; thus,
intracranial contrast procedures may be
carried out without obstruction or distortion.
Also, the material is inert and lacks the
physical effects that may be produced in metal
FIG. 19.1. A, preparation of methyl methacrylate.
plates by temperature change and electric
Container of sterile liquid monomer and powdered
phenomena.
polymer. B, liquid is poured into sterile basin con-
taining powder, and the contents are mixed until a
Split Rib Graft Cranioplasty
doughy consistency is obtained.
For larger defects, split rib grafts, with or
without periosteum, may prove satisfactory.
then inserted into the defect over moistened Portions of the ninth or tenth ribs are
cottonoids, previously placed to protect the generally used, with the incision beginning in
exposed dura, and molded either with the the posterior axillary line. After the proper
fingers or a small roller to conform to the length of rib has been resected, the piece is
exact contour of the defect. A thin flange of split longitudinally with a sharp, thin chisel.
acrylic around the periphery of the defect will The technique for exposing the skull defect
provide increased stability and also safety in and dura is the same as described above. In
that it prevents the implant from sinking into addition, part of the outer table of the skull is
underlying tissue as a result of external removed from opposite ends of the defect to
pressure. The plate is then removed, and final form a ledge into which the ends of the rib are
hardening occurs outside the skull. inserted. Fixation is obtained with wire
Many surgeons feel that a better fit is inserted through small holes drilled into the
obtained if the plate is not removed and final ledge and into the rib. The wound is closed in
hardening occurs in situ. In either case, a the usual manner. Some form of head
cooled Ringer’s or normal saline irrigant protection is recommended for several weeks
should be continuously directed onto the plate until stabilization occurs.
and surrounding tissue until the heat
generated by polymerization has been
dissipated. This takes from 7 to 9 minutes.
All rongeur and rasp or dental burs are
334 MAXILLOFACIAL PROSTHETICS

FIG. 19.2. A, skull defect following craniectomy for osteomyelitis. B, wire bridging the defect and incorporated
into methyl methacrylate plate. C, cosmetic result following cranioplasty.

FIG. 19.3. A, methyl methacrylate plate in place. B, plate secured with overlying wires placed through twist-drill
holes.
CRANIAL AND FACIAL IMPLANTS
336 MAXILLOFACIAL PROSTHETICS

FIG. 19.5. A, large frontotemporal skull defect. B, fashioned polyethylene plate. C, plate fitted into defect. D,
postoperative result after plate insertion. (Courtesy of Dr. Robert Polisar.)

Our results with split rib grafts in the few prosthetists in the development and use of
cases in which they were used generally have high density, high impact polyethylene in the
been quite satisfactory (Fig. 19.4). However, repair of skull defects. The material is
the necessity of a separate incision, the available in sheet form* and, with proper
occasional incomplete coverage of a defect, and compression molding, a very strong, stress-
the period required for stabilization are free product may be obtained. It is inert,
problems not encountered with the more lightweight, radiolucent, and easily trimmed
commonly used alloplastic grafts. at the time of surgery, and it may be used to
cover large skull defects with good cosmetic
Technique of Polyethylene Cranial Implant results (Fig. 19.5).
In the last few years, there has been a
progressive interest by maxillofacial
* Plaskon, AA60-003, Allied Chemical Corporation.
CRANIAL AND FACIAL IMPLANTS 337

The following steps are followed to obtain a border is marked with indelible pencil. At a
satisfactory prosthesis: (1) impression-taking margin of approximately 1 to 2 cm from the
with an alginate impression material, (2) penciled lines, the area is boxed in with boxing
modeling in stone, (3) patterning with wax, (4) wax. The impression is made by applying
flasking, (5) compression molding at irreversible hydrocolloid to the entire surface
approximately 300°F, (6) finishing, and (7) of the boxed-in area, the pre-bent paper clips -
cold sterilization. opened to an L shape are inserted in the
As with the various metals, considerable impression material for reinforcement. After
expertise and a familiarity with the physical setting of the irreversible hydrocolloid, quick-
properties of the material are necessary before setting plaster of Paris is added for backing.
consistently good results are obtained. When the plaster has set, the impression is
gently removed from the skull, the pencil line
Technique of Tantalum Cranial Implant (Fig. is reoutlined with indelible pencil, and dental
19.6, A to G). stone is then poured slowly into the
impression. Once the stone has set, the
To recontour the natural shape of the skull,
impression is separated from the moulage. At
it is important that the head be shaved before
this stage, the prosthodontist and neu-
the impression is made. The defect is palpated
rosurgeon study the moulage to determine
and the peripheral
whether an inlay or onlay implant should

FIG.19.6, A to G. A, cranial defect outlined with indelible pencil. B, defect boxed in with wax. C, irreversible
hydrocolloid used for impression and paper clips used for retention. D, plaster of Paris added for backing. E,
impression removed from the skull. F, impression is separated from moulage. G, tantalum implant pressed and
perforated.
338 MAXILLOFACIAL PROSTHETICS

FIG. 19.6, H to N. H, tantalum implant finished and ready for insertion. I, tissue bed ready to receive the
implant. J, tantalum implant placed and wired over the skull. K, preoperative cephalometric radiograph showing
cranial defect. L, postoperative cephalometric radiograph showing tantalum implant. M, preoperative view of
patient showing lateral defect. N, postoperative view of patient showing acceptable result.

be used. With an inlay implant, a shoulder After molding of the tantalum, it is perforated
rest is prepared around the defect at the by the use of round burs size 5 to 8 to allow
peripheral line approximately 1 mm deep to the connective tissue to penetrate the implant
compensate for the tissue overlying the defect. and neutralize its physical property, making it
The depressed area of the moulage is filled in a good conductor to heat and cold. After the
with modeling clay or plaster to bring the perforation, the implant is finished by rubber
contour out to normal. One baseplate points, polished, scrubbed, and immersed in
thickness of wax is applied to the pencil line hot nitric acid (69.5%) to eliminate contamina-
as a pattern to cut out the tantalum metal. tion (Fig. 19.6, H).
TTie retouched moulage is used as a die and, The tissue bed is prepared in the same
after the separating medium has been manner as described for methyl methacrylate
applied, a counter die is poured, using a thick (Fig. 19.6, I to N). The sterilized perforated
mix of artificial stone. After sufficient setting tantalum implant is then seated over the
time, the two halves of the mold are cranial defect and fixed with four to six
separated, the tantalum pattern is placed stainless steel wires to the surrounding skull.
between the dies, and the dies are inserted The wound is closed in
under the press.
CRANIAL AND FACIAL IMPLANTS 339

layers in the usual manner. Cosmetic results fering with proper breathing and speech.” 14
with this technique have been satisfactory. The functional problems are by far the
more life-threatening, but the psychosocial
Complications aspects of the deformity should not be
The most common complications of overlooked (Fig. 19.7, A). Functionally, the
cranioplasty include infection, instability of the problem of breathing4 becomes acute. With no
prosthesis, and erosion of the over- lying skin. anterior anchor for the tongue, it tends to fall
Additional complications include cerebrospinal back in the throat and occlude the opening. A
fluid leakage through a dural laceration, tracheotomy performed on this type of patient
epidural granuloma, or hematoma, and initially could save having to do it later under
pneumothorax following rib removal. If emergency conditions. The disruption of the
directly impacted, methyl methacrylate and delicate swallowing mechanism causes
polyethylene may shatter, but this is rarely a nutritional problems. Since the suprahyoid
problem. musculature is unanchored, it cannot institute
By delaying cranioplasty for the time the swallowing mechanism. Therefore a
intervals mentioned above, the necessity of nasogastric tube becomes necessary to sustain
removing a prosthesis because of infection the patient.
generally can be avoided. This section describes a method of reha-
Although a theoretical possibility, any bilitating the mandibular resection patient.
recognizable thermal damage to surrounding The literature records many efforts at
tissue from the heat of polymerization of repair of these defects. Implantable materials
methyl methacrylate is rare. In most cases, used have been gold, silver, gutta per- cha,
final hardening occurs in situ, and prolonged aluminum, bronze, steel, plastics, and
irrigation with cool saline solutions is used magnesium.
during this period. The initial efforts, prior to Lister’s work on
Mandibular Implants antiseptic surgical technique, were doomed to
failure regardless of the material used.
Introduction
Implantation of a metal was tantamount to
Loss of mandible continuity by trauma or sentencing the patient to infection and
surgery creates many problems. The hospital gangrene. Lister’s work prompted an
musculature involved in actuating the increased interest in implants but of a type to
mandible, being dependent upon fixation to a fixate fractures rather than to bridge an area.
rigid body, loses its dynamic balance and the The most interesting of these were
remnants operate as independent units. Repair investigations during the 1930s which
or replacement of the involved area is Ludwigson8 described as attempts to develop a
necessary to rebalance the musculature. biodegradable implant. Magnesium implants
Hemimandibulectomy patients normally were thought to be the answer, but unfor-
present less of a rehabilitative problem than tunately they were eliminated by the body too
patients in whom the anterior third of the rapidly to allow time for bony regeneration.
mandible has been removed. By use of The degeneration products created, namely
intraoral fixation at the time of surgery and hydrogen gas and magnesium salts, were also
intraoral guide planes postsurgically, the detrimental to the tissue.
hemimandibulectomy patient can be returned
Chrome Cobalt Mandibular Implant
to a functional state. Szko said, “Unlike
The implant proposed is a chrome cobalt
hemimandibulectomy, resection of the
circular mesh with a hollow lumen4 It
symphysis or a portion of the anterior third of
the mandible in the absence of prosthetic t Developed by Dr. G. Hahn at the Dallas Veterans
Administration Hospital.
measures will result in severe functional and
cosmetic deformity, inter
340 MAXILLOFACIAL PROSTHETICS

FIG. 19.7, A to G. A, postoperative mandibular defect. B, insertion of tube pedicle for creation of tissue bed.
Profile view of tube pedicle. C, frontal view of tube pedicle. D, full face view after insertion of prosthesis (note
apposition of lips). E, lateral view postoperatively. F, cephalometric radiograph of mandibular remnants. G,
panorex radiograph (note displacement of remnants medially and superiorly).

stimulates fibroblasts and allows for migration maintain the desired relationship of the
of them through and around it. It is not arches.
affected by body fluids and therefore will not Intraoral fixation should be accomplished
corrode. It can be made in a small size and prior to surgery, thereby obviating the need to
still retain enough strength to withstand the go into the mouth during surgery. This
body stresses, and it is capable of being eliminates the possibility of contamination of
sterilized. This chapter demonstrates the the surgical site, also. The incision for
fabrication method. placement of the implant should be made as
far as possible from the ultimate placement of
Surgical Considerations the prosthesis (Fig.
The prime requisite surgically is adequate 19.7, D and E). When sutured, this area will
tissue which has a good blood supply so that thereby be far enough away so that if the
coverage of the implant can be accomplished suture line breaks down, the entire procedure
without tension. This normally necessitates is not jeopardized. While the tissue is being
the migration of a tube pedicle to the deficient prepared to receive the implant, care must be
area (Fig. 19.7, B and C). If it is possible to taken to avoid perforation into the oral cavity.
fixate the remnants of the mandible in the
most ideal relationship to the maxilla, this
should be accomplished prior to insertion of Technique of Construction
the implant. This can be accomplished by arch To ascertain the size and location of the
bars and a bite wafer if enough teeth remain ascending rami, cephalometric and panoramic
to establish occlusion. If teeth are not present radiographs are taken (Fig. 19.7, F and G); the
but enough of the body of the mandible cephalometric gives a measurement of the
remains, a splint may be constructed to remnants and the pano-
CRANIAL AND FACIAL IMPLANTS 341

FIG. 19.7, H to 0. H, soft lead wire tracing of contour and plastic rod formed to corresponding contour. I, sleeve
portion of waxing. J, refractory model and waxed case. K, cast basket receptacle. L, fully waxed case in exploded
view. M, duplicating material and subsequent acrylic template of screw. N, casting tree of screws. 0, prosthesis in
exploded view prior to insertion.

ramie gives a fairly accurate indication of how of the mandibular implant. Using the x- ray
much they have been displaced medially and measurements of the rami and the contour
superiorly. An additional aid on the wire, a Vi-inch plastic rod is bent to contour
cephalometric x-ray would be the taping t>f a and cut off at the determined measurement
metal ruler, which has been notched every 5 (Fig. 19.7, H). This in turn is cut into sections
mm, onto the side of the patient’s face so that that will best allow for the anterior-posterior
an exact measurement can be made and and lateral adjustments of the finished
correlated by the ruler. product. These are duplicated in hydrocolloid§
The remnants of the mandible are pal- to produce a refractory model. H Both of these
pated, and their possible ultimate movement models are necessary because of the high heat
is determined. With the remnants returned as needed to melt surgical alloy Ticonium.
much as possible into normal position, a soft
lead wire is adapted into the desired contour
in relation to the rami. This gives a starting § Multi-gel, Ransom and Randolph.
point for the contour 11 Multi-vest, Ransom and Randolph (high heat
chrome investment).
342 MAXILLOFACIAL PROSTHETICS

Further refractory models are made for the Insertion into the tissues is accomplished
sleeve portion by taking the plastic rod and by fitting the basket receptacles to the bony
building out the portion destined to be the remnants and rotating the remaining portion
sleeve with a sheet of 24 gauge wax and a of the mandible to the most advantageous
sheet of 28 gauge wax over this (Fig. position. The other three pieces are then fitted
19.7, I). This allows for the sliding of one part in, and a contour that is compatible with the
in another. The basket portion for reception of remaining tissue is determined. All revisions
the remaining mandible is made on a of the prosthesis are made at this time. Care
previously prepared investment blank which should be taken to reduce the height of the
most closely simulates the width of. the sides of the basket receptacles to prevent their
remaining portion of the mandible (Fig. 19.7, J possible erosion into the oral cavity. All parts
and K). are then resterilized and inserted in the
The refractory models are then waxed up, determined contour. The basket portion is
using plastic patterns || of the desired mesh attached by means of the previously cast
size (Fig. 19.7, L). These are invested and cast screws. This can be accomplished by pre-
on a Ticomatic casting machine. Because of drilling holes into the mandible in the desired
the higher melting temperature of implant location, fitting the basket to the mandible,
Ticonium, the electric eye normally used on a and screwing the prosthesis to the remaining
Ticomatic machine must be blocked out and bone. The other pieces are then fitted into the
the procedure visually controlled. The castings previously determined contour, and screws are
are retrieved, and all of the investment mate- introduced to clinch the separate parts into
rial is cleaned off by use of a sandblaster with the rigid unit (Fig. 19.7, O). Care should be
100 pounds of air pressure. When the taken to place these screws in a location which
segments are clean, the sprues are cut off and would not interfere with any proposed future
the pieces are fitted together. All interferences intraoral appliance (Fig. 19.7, P and Q).
are relieved so that the parts can slide freely In closing the wound, the dead space
and be adjusted to any positions within the around the prosthesis can be reduced by
dimensions of the sleeve. All parts are then suturing the tissues directly to the prosthetic
electropolished so as to present the kindest mesh work. It is unnecessary to place a drain
surface possible to the tissues. into the wound, and a standard nonpressure
A sheet metal screw (wide threads) of the dressing can be placed over the suture line
proper size to clinch the inner portion to the when it has been closed. When fixation has
outer sleeve through the mesh is duplicated in been used, it should be left in place for
a room temperature-vulcanizing material.* ** approximately 10 days. After this period, the
Self-polymerizing acrylic is introduced into the fixation can be loosened for a longer period
duplication, and acrylic templates are made of each day until after 2 weeks all fixation has
the original screw (Fig. 19.7, M). These are been removed. The patient is treated basically
sprued on the head portion in a Christmas like a fracture patient in that a liquid diet is
tree arrangement for casting with the implant instituted initially, followed by a gradually
material (Fig. 19.7, N). The sprues are then tougher diet. The patient should be covered
cut off, and the screw heads are rounded and preoperatively and postoperatively with broad
slotted for receipt of a screwdriver. These are spectrum antibiotics to obviate any infection in
also electropolished. A screwdriver cast of the the area. Procedures described have been for
same implant material will eliminate the Ticonium surgical alloy (No. 25), but Vitallium
possibility of foreign body reaction to the is also used with great success, as evidenced
implantation of metal on the screws. by Dr. George Hahn’s series involving 15 pa-
tients. 4
This type of implant can also be used

|| Austenol MR-100 Flexseal plastic mesh pat-


terns.
** Silastic 502, Dow Corning, Midland, Michigan.
CRANIAL AND FACIAL IMPLANTS 343

FIG. 19.7, P to S. P, prosthesis in position in tube pedicle (note Ticonium screws to fixate separate portions of
prosthesis together). Q, panorex radiograph of implant in place (note placement of screws). R, lateral view fol-
lowing initial defatting procedure. S, full face view following initial defatting procedure.
344 MAXILLOFACIAL PROSTHETICS

FIG. 19.8, A to D. A, extraoral view of patient, showing slight deviation of the mandible toward resected left
side, creating facial asymmetry. B, lateral view showing left mandibular partial resection. C, Koragel mandibular
mold. D, model of wax mandible after removal from Koragel mold.

when the condyle head has been lost. By in place. Subsequent loss of the holding screws
following the contour of the mandible, as would be of no consequence. An added
determined by x-ray, the metallic mesh is advantage is the capability of repair if the
fabricated to extend to an area just short of prosthesis should fracture. Inserting a sleeve
the condylar fossa. A retentive cup with loops over the fractured portion and its fixation with
is fabricated for the end, and a clear methyl screws eliminates the need for complete
methacrylate condyle is processed upon it. removal. A point to be reemphasized is the use
Providing a hollow mesh rigid appliance to of surgical alloy (No. 25) Ticonium. Although
join the remains of the mandible is a partial denture Ticonium can be fabricated
satisfactory means of rehabilitating resection and the tissue will grow over it, it presents
patients (Fig. 19.7, R and S). Since the problems microscopically. The cells in contact
prosthesis is small in diameter and extremely with the metal are of an atypical structure,
strong, a minimum of tissue is needed to cover whereas those adjacent to the implant metal
it, and there is no flexing to produce pressure are normal in all measurable details.^ This
areas with subsequent breakdown. The mesh
construction allows for fibrosis of the tissues
around and through the prosthesis, thereby
Personal communication, Emil S. Griffiths,
fixating it Director of Research, Consolidated Metal Products, Inc.
CRANIAL AND FACIAL IMPLANTS 345

prosthesis is not the final answer for replacing wax pattern to the exact measurements as
lost portions of the mandible. Further previously recorded by direct measurement
research is being carried out and some very and by x-ray examination. The horizontal and
promising materials (titanium, Cero- sium) ascending rami were then reduced by
are on the horizon which may give a closer trimming the wax to avoid undue tension
approximation to the characteristics of bone. when the soft tissues were sutured over the
Combination of Methyl Methacrylate and implant. The coronoid process was trimmed
Perforated Tantalum Tray Mandibular and fenestrations were performed over the
Implant ascending ramus for the possible migration of
granulated tissues (Fig. 19.8, E). Two stainless
In the case illustrated here in Figure
steel wires of 0.045 gauge were inserted in the
19.8, an extraoral photograph and radi-
wax pattern as pins (Fig. 19.8, F). The finished
ograph of the patient’s mandible were taken
wax pattern was invested in a dental flask
from a distance of 72 inches to determine the
(Fig. 19.8, G), which was then packed with
remaining healthy mandible and the soft
clear methyl methacrylate, and the periphery
tissue contour (Fig. 19.8, A and B). To
of the implant was painted with tantalum
facilitate modeling of the missing part of the
powder for radiopacity (Fig. 19.8, H). Next, the
mandible, a standard Koragel mold was
implant was processed under pressure at a
prepared from an average mandible (Fig. 19.8,
temperature of 165°F for 12 hours and at
C). Molten wax was then poured into the
212°F for Vz hour. After curing, the implant
Koragel mold to cast a wax mandible (Fig.
was deflasked, cleaned, and polished.
19.8, D). The wax mandible was cut at the
A tantalum tray was constructed, using a
proposed site of transection, and the left angle
metal mold die-counter die of the inferior
of the mandible was precisely reproduced by
border of an average mandible from angle to
cutting the wax and altering the angle on the
angle to press the form of a sym-

FIG. 19.8, E to H. E, wax pattern trimmed and fenestrated. F, stainless steel wires (0.045 gauge) inserted in
the mandible wax pattern. G, mandible wax pattern flasked and ready for processing. H, tantalum powder
painted on clear methyl methacrylate for radiopacity.
3Bm
FIG. 19.8, I to 0. I, metal mold die-counter die of the inferior border of mandible from angle to angle. J, tantalum symphysis pressed in the metal mold. K, tantalum
sheet. L, perforated tantalum tray. M, assembled combination of mandibular implant of methyl methacrylate-stainless pins-perforated tantalum tray. N, tissue bed is
exposed to receive mandibular implant. O, mandibular implant inserted in the condylar fossa and wired to the mandible.
CRANIAL AND FACIAL IMPLANTS 347

FIG. 19.8, P to U. P, mandible is immobilized by Barton bandage. Q, postoperative lateral radiograph showing
the position of artificial mandible identified with radiopaque material. R, intraoral view of artificial ridge after 6
months. S, complete mandibular and maxillary dentures are inserted in the mouth. T, dentures in occlusion. U,
extraoral view of the patient after prosthetic reconstruction of the mandible to restore oral physiology and facial
symmetry.
348 MAXILLOFACIAL PROSTHETICS

FIG. 19.9, A to E. Diagrammatic drawing showing the application of perforated tantalum trays to the infraor-

bital rim, zygomatic-orbito-malar area, symphysis, angle of the mandible, and the chin area. (Courtesy of Drs. E.
C. Hinds and J. B. Drane.)

physis in tantalum. This was done to prepare Figure 19.8, R is an intraoral view of the
for splinting the implant to the remaining artificial ridge after 6 months; the ridge was
healthy mandible (Fig. 19.8, I to K). The then ready to serve as a saddle for a complete
tantalum tray was invested in dental stone mandibular denture. In Figure
and perforated at 5 mm intervals by round 19.8, S the complete maxillary and man-
burs numbers 5 to 8. Then the tray was dibular dentures are in the mouth. Figure
removed from the stone, finished with rubber 19.8, T shows the dentures in occlusion, and
wheels, polished, and placed in hot nitric acid Figure 19.8, U is a full face view of the patient
to eliminate foreign bodies (Fig. 19.8, L). after prosthetic reconstruction of the left
Figure 19.8, M shows a combination of mandible.
mandibular implant of methyl methacrylate,
stainless steel, and perforated tantalum tray Perforated Tantalum Implants for Recon-
assembled for final evaluation of size and struction of Facial Bones
shape. Perforated tantalum implants are often
In the mandibular reconstruction proce- used for reconstructing other defected facial
dure for the same patient, the tissue bed was bones, such as the infraorbital bone, the
first prepared to receive the implant (Fig. zygomatic-orbital-malar bone, the symphysis
19.8, N). The sterilized implant was inserted and associated mandibular defects (Fig. 19.9,
into the condylar fossa, with the anterior part A to E).
wired to the edge of the healthy mandible Figure 19.9, G shows a patient with left
with 26 gauge stainless steel wire (Fig. 19.8, infraorbital depressed bone. H is a postop-
0). The jaw was immobilized with a Barton erative view following reconstruction with a
bandage (Fig. perforated infraorbital tantalum tray. J shows
19.8, P). The postoperative radiograph in a defective left lateral inferior orbital margin
Figure 19.8, Q shows the location of the and zygoma. F and I are postoperative views
artificial mandible identified by radiopaque following reconstruction
material.
CRANIAL AND FACIAL IMPLANTS 349

FIG. 19.9, F to L. F, with left infraorbital bone defect. G, postoperative view following reconstruction with
tantalum tray. H, patient with left infraorbital and zygomatic bone defects. I, postoperative view following re-
construction with tantalum tray. J, postoperative radiography showing the tantalum tray. K, lateral radiograph
showing ankylosed left condylar head. L, postoperative view showing the perforated tantalum cap acting as a
pseudo joint.
A

with a perforated zygomatic-orbital tantalum the distal fragment by means of two trans-
implant. osseous stainless steel wire sutures.
In a case of temporomandibular joint
ankylosis after an automobile accident, the Silicone Implant for Reconstruction of Facial
ankylosis of the temporomandibular joint was Bones (Fig. 19.10)
corrected by means of subcondy- lar Silicone implants are used for reconstruc-
arthroplasty, with a perforated tantalum cap tion of the dorsum of the nose, the floor of the
being interposed between the distal and orbit, the malar bone, the forehead, and the
proximal segments (Fig. 19.9, K and L). The mandibular ridge. They are also
tantalum implant was secured to
350 MAXILLOFACIAL PROSTHETICS

FIG. 19.10. Silicone implant for reconstruction of malar bone and floor of orbit.

used to build out the retrognathic chin, and sulting from implanted plastics as possible
silicone ear armature is used to build the helix physical factors involved in tumor formation. J.
Theo. Biol. 17: 1-11, 1967.
of the ear. 7. Lang, B. R.: Constructing mandibular implants
When a silicone implant is used, it is during surgery. J. Prosth. Dent. 22: 360-366,
important that the implant material be 1969.
perforated or that dacron cloth be adhered to 8. Ludwigson, D. C.: Requirements for metallic
the device to provide tissue ingrowth which surgical implants and prosthetic devices. Metals
Engim Quart., August 1965.
will retain the prosthesis in place. 9. Reeves, D. L.: Cranioplasty. American Lecture
REFERENCES Series 39. American Lectures in Surgery. Charles
1. Brown, K. E.: Technique of splint contouring in C Thomas, Publisher, Springfield, 111., 1950.
resected edentulous mandibular reconstruction. 10. Reeves, D. L.: Neurological Surgery of Trauma,
J. Prosth. Dent. 21: 532-535, 1969. pp. 233-256. Office of The Surgeon General,
2. Cook, G. B., Walker, A. W., and Schewe, E. J.: Department of the Army, Washington, D. C.,
The Cerosium® mandibular prosthesis. Amer. J. 1965.
Surg. 110: 558-572, 1965. 11. Roberts, A. C.: A review of materials used for
3. Grant, F. C., and Norcross, N. C.: Repair of implantation in the human body. Bio-Med.
cranial defects by cranioplasty. Ann. Surg. 110: Engin., August, 397-401, 1966.
488-512, 1939. 12. Ross, P. J., and Jelsma, F.: Experiences with
4. Hahn, G. W.: Vitallium mesh mandibular pros acrylic plastic for cranioplasties. Amer. Surg. 26:
thesis. J. Prosth. Dent., July-August 1964. 519-524, 1960.
5. Korbicka, J., and Bechinie, E.: The carcinoge 13. Spence, W. T.: Form-fitting plastic cranioplasty.
nicity of fine Silon fabrics in animal experiment J. Neurosurg. 11: 219-225, 1954.
and the possibilities of using Silon in clinical 14. Szko, K.: The use of metal prostheses following
practice. Neoplasma (Bratisl.) 14: 537-550, 1967. anterior mandibulectomy and neck dissection for
6. Kordan, H. A.: Localized interfacial forces re carcinoma of the oral cavity. Amer. J. Surg. 104:
715-720, 1962.
20
PSYCHOSOCIAL AND ECONOMIC ASPECTS OF
MAXILLOFACIAL PATIENTS
Marvin O. Barnett and Varoujan A. Chalian

A little more than a century ago the great matic disfigurement, and disfigurement after
German surgeon, Dieffenbach, wrote of disease.
persons with facial disfigurement “ ... at the
sight of whom all men turn in disgust and Congenital Malformations
abhorrence and at whose presence children cry Congenital malformations are caused by
and dogs bark.” Despite the tremendous faulty development in prenatal life, and they
advances in social, medical, surgical, and vary in type and frequency. The most well-
prosthetic rehabilitation over the last 100 known congenital malformation of the face is
years, the plight of those with severe facial cleft lip with cleft palate, a condition that
disfigurement unfortunately has not changed occurs in about 1 out of 750 births in the
greatly since the statement was made. United States. Others are congenital absence
The term “facial disfigurement” is used to of the ear, which occurs in 1 in 20,000 births. A
designate an abnormality of the face that is fairly frequent condition that does not usually
sufficiently marked to set the individual aside manifest itself until adolescence is
from other members of society. There are malformation of the maxilla or mandible.
great variations in the degree of this Traumatic Disfigurement
disability. The disfigurement may be so slight
that it does not command undue attention Another major cause of facial disfigurement
from others. Even then, the psychologic is accidents. The National Safety Council has
wounds that show no scars may be so great estimated that in 1969,
that the disfigured person himself rejects 10.800.0 persons in the United States suf-
society under the mistaken notion that society fered nonfatal injuries requiring hospitaliza-
rejects him because of his disfigurement. On tion because of accidents and, of these,
the other hand, the degree of disfigurement 400.0 were left with permanent impair-
may be so gross that a person cannot appear ments.
in public without causing reactions ranging According to Reiss and Artz,7 6,800 deaths
from pity to horror from those who see him. occurred from burns in the United States in
For clarification, £he maxillofacial patient 1954. A conservative estimate is- that about
may be divided by etiology into three groups: 70,000 burned persons are hospitalized every
congenital malformations, trau year. Various developments in this age of
atomic energy and elec

351
352 MAXILLOFACIAL PROSTHETICS

tronics increase our risk of exposure to bums teristics and the social situation in which he
and particularly to severe burns that may is placed (Fig. 20.1).
result in death or disfigurement. Once the standards of normality and
abnormality are determined—in this case,
Disfigurement after Disease what constitutes an attractive face or an ugly
The third important cause of facial dis- one—we must recognize the importance of
figurement is disease. In the United States, visibility as it functions in the interaction
cancer is the most common disfiguring disease. between the disfigured individual and others.
In some countries, in certain areas of Europe One of the basic difficulties associated with
for example, lupus is a frequent cause, while facial deformity evolves from social perception,
leprosy and various tropical diseases are causes that is, the impression that a person creates
of disfigure- * ment in other parts of the world. because of his looks. We form impressions
The eradication of malignant tissue requires rapidly, and the impulsive rather than critical
removal by surgery or destruction by radiation, judgments which we are prone to make tend to
which frequently leaves the patient with severe operate adversely toward those whose faces
facial deformity. While life is preserved, severe are ugly or marred by some unsightly feature.
functional disability and gross facial Since such reactions are related to the primary
disfigurement are the aftermath of treatment. sense areas and are apparently devoid of
Patients must lead cloistered lives unless they reason, they may serve as barriers to the
can be rehabilitated. development of sympathetic social interaction.
The individual with an unfavorable physical
Psychosocial Aspects trait, therefore, may be the object of an imme-
Psychosocial factors play a primary role in diate negative reaction even though it may be
creating and complicating the problems of the followed by the recognition that his condition
facially deformed. Attitudes of a given society should have evoked sympathy. It is not
may determine not only what constitutes unusual to see horror or disgust reflected in
facial deformity but also to what extent an the expression of one who suddenly looks upon
individual with a facial deformity is to be a grossly disfigured person and to hear
accepted—or not accepted—as a member of seconds later such a remark as, “Oh, that poor
the group. Since social distinctions are based man.”
upon age, sex, race, physical normality, and Although a disfigured face may not nec-
attractiveness, a facial deformity is generally essarily be unsightly or difficult for others to
considered a handicap. This is not necessarily look at, it may serve as a misleading mask
because of any impairment of physical which not only blinds others to the play of
performance, as in the case of the blind, the subtle and meaningful expressions but also
amputee, or the paralytic, but mainly because conceals the real self behind the mask (Fig.
of the prejudice or disapproval which our 20.2). A facial paralysis which alters normal
society entertains for those with unsightly or expression may preclude objective judgments
abnormal faces. Such attitudes concerning of the real personality or may result in a
normality and abnormality may be as distorted image of it. Such is the mechanism
significant as any medical considerations of frequently found in the perceptual processes
health or disease. The problems of any facially whereby one feature unduly claims the
deformed person, then, are those of behavior observer’s attention, contributes
adjustment or maladjustment and, to un- disproportionately to the meaning aroused,
derstand them, we must study and evaluate and quite eclipses the evidence from
both his specific personality charac surrounding cues. It becomes what Allport1
terms an “anchorage point,” and from it no
judgment is allowed to drift.
PSYCHOSOCIAL AND ECONOMIC ASPECTS 353

FIG. 20.1. A, large facial defect. B, facial prosthesis in position. The patient’s morale was remarkably im-
proved, and she is accepted by her friends.

FIG. 20.2. A, exenteration of the orbit. B, silicone orbital prosthesis in place.

Since, then, the disfigured person cannot instances, they are assigned a marginal or
disguise his twisted face or the absence of an minority status, or both. Opportunities
ear but must go where all may see, his available to the nondisfigured are often denied
disfigurement is a visual stimulus to them; social participation, matters of
impressions and affective attitudes he is employment, prestige, role and status,
helpless to prevent. To complicate his situ- interpersonal relationships, personality
ation, there are the prevailing prejudices and organization, and a variety of cultural ac-
misunderstandings in our society concerning tivities are affected or altered in some way.
those who physically deviate from the so- The adjustment that such an individual will
called norm. More often than not, such make depends principally upon his particular
individuals discover that they are regarded as personality configuration and the socially and
social inferiors and, in some culturally defined at
354 MAXILLOFACIAL PROSTHETICS

titudes toward him—usually negative— which set apart from the group. Every culture has its
tend to control his social adjustment. own standards of attractiveness and, although
Social Forces Operating to Disadvantage of an infinite number of physical divergencies
Maxillofacial Patient are possible which meet the aesthetic
requirements, a certain conformity is
One of the many factors which tend to
demanded. Any striking deviation—a skin
operate to the disadvantage of the facially
color lighter or darker than that of the
deformed is the high social value we assign to
majority, eyes of a different “slant,” a
physical appeal. Television, movies,
distorted face—is usually enough to prevent
magazines, and other mass media constantly
an individual from being wholly accepted.
impress us with the importance of good looks
Since he looks different, it is often assumed
for marriage, jobs, and “success,” our national
that he must be different. This, in turn,
mania for preserving youthful appearance
frequently leads to his being treated as
long after youth has passed and, conversely,
different and, since “different” in this context
the social disdain for those who allow
all too often means inferior, the social distance
themselves to acquire facial blemishes or
between the individual and others is further
become bald or obese. So much emphasis is
widened. On his own part, the individual
placed upon first impressions that qualities of
tends to see himself as others do and may
character and mind seem negligible compared
develop a false image of himself; in any case,
to the importance of external appearance.
he is likely to feel more or less isolated. For
Physical attractiveness is regarded as an
most people, therefore, conformity to the
important ingredient of “success,” a saleable
physical standards of the society in which they
commodity. Obviously, this cultural bias is
live is something to be desired, and
detrimental to anyone whose face is disfig-
nonconformity is something to be avoided (Fig.
ured; it may turn a slight defect into a social
20.4).
and economic handicap (Fig. 20.3).
Even if we did not overemphasize ap-
pearance in our society, the facially deformed Genesis of Deformity
would still be confronted by the fact that A study of patients has revealed a huge
anyone who looks “different” is sensitivity to the differentials in attitudes
toward the genesis of deformity and the

FIG. 20.3. A, large forehead defect which handicapped the patient in social and business life. B, the forehead
defect is reconstructed by a polyvinyl resin prosthesis.
PSYCHOSOCIAL AND ECONOMIC ASPECTS 355

FIG. 20.4. A, nasal defect with flap-lip reconstruction. B, nasal prosthesis seated on the defect. C, glasses in
place to further stabilize and camouflage the nasal prosthesis.

symbolic meaning accorded it. Congenital as possible. Three years later, the mandible
deformities or those caused by or suggesting was restored by bone grafting, and the
disease are generally viewed in our society appliances which were temporarily used to
with disapproval. On the other hand, the hold her jaw and teeth in place left wires
saddlenose of a prize fighter or a wound protruding from her mouth. It was not only
incurred in war may not only be more difficult to speak and eat, but her appearance
acceptable in certain situations but may was more conspicuous than it had been
actually carry prestige value. If the deformity preoperatively. Despite this, however, the
suggests an origin which is socially not patient’s mental attitude changed
acceptable, the patient appears to be considerably, and^she even allowed herself to
influenced by it, as are the others to it. Many meet strangers, which she had formerly
patients are careful to draw the distinction avoided. She said, “I no longer feel self-
themselves as to how they acquired a conscious with people because now I am going
deformity in order to avoid the negative through the process of correction and know my
reactions they feel will be engendered. A face is going to be normal-looking soon. I
university instructor always made it a point to simply come out and explain that I was in an
explain that an accident had caused his accident and have had an operation to replace
recently acquired facial scars. Although no one my jawbone. Everyone accepts this and it is
had ever implied as much, he was afraid that perfectly easy. It is much better than ex-
people would think he was “an ex-convict or plaining that I had a tumor and going into the
led an immoral life.” details of that. Immediately after my jaw was
k
removed I told people that I had a tumor and I
Some patients learn through experience
that it is to their advantage to hide the real could see by their expressions that they felt
sorry and didn’t want to discuss it. They would
origin of the deformity rather than to tell the
change the subject immediately. When you
truth and become the object of pity or fear.
Because of an extensive tumor, a woman mention tumor, people think you have a
underwent resection of the right half of her cancer and will probably die of it. The word
‘cancer’ is like a death certificate. It is still not
mandible. This resulted in a deep indentation
of the side of her face. She not only grew discussed openly.”
For this patient, concealing the facts had
extremely self-conscious and depressed about
her appearance, but outside her job she obvious advantages. Even though the sur
avoided people as much
356 MAXILLOFACIAL PROSTHETICS

gical procedure made her deformity tem- comfort. Each patient made his own psy-
porarily more conspicuous, it enabled her to chologic adjustment to the situation. Some
give a socially acceptable explanation of her forms of adjustment were relatively adequate,
appearance and to feel that she could mingle others resulted in greater maladjustment, yet
with people rather than avoid them. In our all patients endeavored to lessen the tension
culture, wired teeth are not unusual, and by one method or another.
disfigurement by accident does not seem to There were those who tried to avoid dif-
produce the same emotional reaction that the ficult situations by withdrawal. Some
feared disease of cancer does. withdrew only from certain types of social
The widespread prejudice surrounding the activity; others sought as much seclusion as
facial cripple does indeed exert pressures that possible. Some patients became extremely
are difficult for him to cope with. While these aggressive in order to cope with unsatisfied
must not be minimized or passed over—on the needs and feelings of anxiety and insecurity.
contrary, they must be understood thoroughly The reaction of others was to blame external
if we are to help him adequately—it is of the factors, such as parents, environment, and
utmost importance that we relate them society, for their frustration and failure to
properly to any psychologic disturbances he succeed. Some patients used their deformities
may have. All too often these disturbances, as a defense against a hidden emotional
regardless of their etiology, are attributed disturbance.
directly to his deformity: “It is no wonder
when he has such a terrible handicap.”
Summary of Psychosocial Aspects
Conversely, if he achieves some success, people
are surprised he could do so: they anticipate As has been pointed out, the factors de-
personality difficulties that would preclude termining adjustment to facial deformity are
such achievement. These attitudes are not involved with the particular personality, in
confined to the uneducated but may be found particular situations, and with the
in upper social and educational brackets. sociocultural environment.
To counter the threats and social depri-
Types of Adjustment to Facial Deformities vations of their environment exacts from
Investigation at Indiana University Medical many patients a high psychologic cost.
Center and the University of Louisville Energies which might otherwise have been
Medical Complex revealed that each patient’s channeled into more positive aspects of
reaction and adjustment to his handicap were personality development are consumed by
unique and individual, dependent upon such wasteful preoccupation with the deformity,
factors as age at onset of the defect, parental vigilant anticipation of the reaction of others,
handling, personality structure, and duration and the building up of defense mechanisms to
of deformity. Those patients with noticeable relieve anxiety, all of which are detrimental to
defects did have in common many problems mental and emotional health.
which were the result of social factors
discussed in the preceding section. Difficulties Economic Considerations of Maxillofa-
most frequently complained of were those cial Patient
concerned with getting jobs, making friends,
opportunities for marriage, and discrimination It is necessary for one to realize the serv-
in general. Patients also said that staring, ices that are involved in the complete
remarks, and questions were the most treatment and rehabilitation of a facial defect.
frequent reactions to their deformities and The term generally consists of the following:
caused them extreme dis nursing service, social service, clerical
assistance, general practitioner, pediatrician,
plastic surgeon, radiologist,
PSYCHOSOCIAL AND ECONOMIC ASPECTS 357

psychologist or psychiatrist, general dentist, REFERENCES


orthodontist, maxillofacial prosthetist, oral 1. Allport, G. W.: Personality: A Psychological Inter
surgeon, speech therapist, and vocational pretation. Henry Holt, New York, 1937.
counselor. With such professional care 2. Baker, W. Y., and Smith, L. H.: Facial disfigure
ment and personality. J. A. M. A. 112: 301-304,
required, the maxillofacial patient is 1939.
presented with one hard-core problem: the 3. MacGregor, F. C.: Some psycho-social problems
need of money. associated with facial deformities. Amer. Sociol.
Fortunately, community agencies (Voca- Rev. 16: 629-638, 1951.
4. Mead, G. H.: Mind, Self and Society, Part III
tional Rehabilitation, Cancer Society, etc.) in University of Chicago Press, Chicago, 1934.
recent years have helped bridge the gap for 5. Perrin, F. A. C.: Physical attractiveness and re
these individuals. Able-bodied though most of pulsiveness. J. Exp. Psychol. 4: 203-217, 1921.
them are, as victims of prejudice, ridicule, 6. Preston, G. H.: The Substance of Mental Health.
Farrar & Rinehart, New York, 1943.
discrimination, and other indignities, they are 7. Reiss, E., and Artz, C. P.: Current status of re
in varying degrees psychologic, social, arid search in treatment of burns. Military Surgeon
economic cripples. 114: 187-190, 1954.
As one patient said of facial disfigurement: 8. Solomon, H. C.: Psychological implications of
cancer. Rocky Mountain Med. J. 44: 801-804,
“It’s not what it is—it’s what it does to you 1947.
that counts.”
21
CLEFT LIP AND CLEFT PALATE HABITATION
Varoujan A. Chalian, LaForrest D. Garner, Mohammed Mazaheri,
Robert J. Musselman, Morton S. Rosen, James C. Shanks, Paul E.
Starkey, Lewis W. Thompson, John M. Tondra, and Robert L. Wheeler

INTRODUCTION
The cleft lip and palate deformity is a variation of cleft lip presents with a Si-
congenital defect of the middle third of the monart’s band which is actually a partial
face, consisting of fissures of the upper lip fusion of the lip, usually at the base of the
and/or palate. nose. The remaining tissues of the phil- trum
Historically, clefts of the lip and palate and lip in the cleft area are open. In the
have had varied significance; in some tribes bilateral cleft lip situation, one side may be
they were regarded as marks of beauty, in completely cleft while the other side is
others as signs of supernatural ability. In incomplete. With clefts of the secondary
most cultures, however, they were regarded as palate, the same situation holds true, clefting
major, life-threatening abnormalities, and being either incomplete or complete. In the
infants with these defects were often not Stark classification, a cleft of the secondary
allowed to live. palate is not complete unless it extends to the
Numberous methods of classification (Fig. incisive foramen.' A rather common form of
21.1) have been proposed for these congenital incomplete cleft of the secondary palate is the
anomalies of the middle third of the face. The submucous cleft, in which the mucous
method proposed by Stark is the most widely membrane is intact on both the oral and nasal
used today, with that proposed by the Cleft surfaces, but there is failure of bone and
Palate Association next common in usage. muscle fusion in the midline. A popular
Stark’s method divides the middle third of the classification of a few years ago and one still
face into primary (anterior) and secondary used by some, is that of Veau: Type 1, defect of
(posterior) palates at the incisive foramen, vermilion or red portion of the lip; Type 2,
with the upper alveolar arch being a clefts which include the vermilion and a
component of the primary palate. Clefts of the portion of the lip musculature up to but not
primary palate can be either unilateral or including the floor of the nostril on the
bilateral and complete or incomplete, with affected side; Type 3, unilateral complete
varying degrees of incompleteness. An clefts involving the full
interesting
CLEFT LIP AND CLEFT PALATE 359

CLEFT PALATE trician, is usually the first to make the


ASSOCIATION
PRIMARY PALATE diagnosis and to discuss the deformity with
the parents. Referral of the infant to other
PRE PALATE SUBTOTAL UNILATERAL
members of the team is usually made by these
SUBTOTAL UNILATERAL professionals. In this early management stage,
PRE PALATE
it is essential that the general physical needs
PRE PALATE
TOTAL UNILATERAL *of the infant be attended to. The
otolaryngologist’s role is to prevent or treat
TOTAL BILATERAL
PRE PALATE those middle ear problems which are
SECONDARY PALATE
SUBTOTAL I
uniformly present in these children,
principally infections which may produce a
subsequent hearing loss.
TOTAL H
Since these defects commonly involve the
upper arch and result in dental problems such
as absence of teeth, supernumerary teeth, and
malposition of both bony arch and tooth
PALATE alignment, various dental specialists are
SECONDARY SUBTOTAL
(SUBMUCOUS) needed in their management, including the
PRIMARY AND SECONDARY
pedodontist, the orthodontist, and the
PRE PALATE TOTAL UNILATERAL HI
prosthodontist.
AND
PALATE
The primary function of the secondary
palate, specifically the soft palate, is adequate
TOTAL BILATERAL N
velopharyngeal closure for speech, which
PRE PALATE
AND
points out the importance of the speech
PALATE pathologist. The child psychiatrist or
psychologist is an important team member
FIG. 21.1. Classification of cleft lip and cleft palate. because these deformities always have
emotional and psychologic overtones. The
thickness of the lip typically accompanied by a social worker plays a vital part in working
marked deformity of the nose; Type 4, with the patient and his family to facilitate
bilateral clefts of the lip either partial, their adjustment to the typically long and
complete, or in combinations. complicated treatment program. Because the
The epidemiology, embryology, and management of these patients is long-term
pathogenesis of cleft lip and palate are and thereby expensive, the social worker is
presented in detail in Chapter 3. frequently called upon to help arrange
The patient with clefts of the primary and financial support from state and local
secondary palate presents a complex biologic, government or other agencies.
sociologic, and.psychologic problem, one whose The management of the cleft lip and palate
best management involves several disciplines. patient does not end with the initial repair of
The team approach is the only effective one, the primary defects. It is management
with the members usually including the extending into adulthood because of the
pediatrician, plastic surgeon, pedodontist, interplay of many factors of varying
otolaryngologist, orthodontist, speech consequence which present themselves
pathologist, prosthodontist, geneticist, between the time of initial repair and the time
pediatric psychiatrist, and social worker. A when full facial growth and emotional
brief discussion of each participant’s role on maturity have been attained. An attempt is
the cleft lip and palate team will be helpful in made in the ensuing pages to list, discuss, and
understanding the team function^ and needs. evaluate those important factors which relate
The pediatrician, along with the obste to the successful management of the cleft lip
and palate patient.
360 MAXILLOFACIAL PROSTHETICS

PART 1: DIAGNOSIS AND TREATMENT PLANNING

Congenital cleft can easily be diagnosed by form, and formation of the teeth should be
visual examination, with radiographic and included in this form. The shape of the arch
speech procedures supplying additional details (anteriorly, posteriorly, and laterally), the arch
concerning the deformity. relationship, tooth relationship, and type of
It is important that congenital clefts be malocclusion should also be included.
differentiated from acquired defects caused by Any dental caries, missing teeth, the
disease or injury. The patient’s medical history condition of gingival and periodontal tissue,
aids in the differentiation. any periapical lesions, and other information
The etiology and pathogenesis of cleft are of dental significance should also be recorded.
discussed in Chapter 3. A proper diagnosis of
the cleft type and its anatomic and functional Impressions for Study Casts
involvements depends largely upon the The dentist’s responsibility starts shortly
diagnostician’s knowledge of etiology and of after the birth of a child with a cleft. At this
the embryology, anatomy, and physiology of time, and semiannually until the child is 2
the area involved. The diagnostician should years old, the dentist makes impressions of
also have access to the various radiographic the infant’s maxillary and mandibular regions,
tools. and he also makes cephalometric and
Diagnostic and Examination Procedures photographic records. On the child’s second
Every patient with an oral cleft should be birthday and on each succeeding one, he
examined by surgical, medical, dental, and repeats the impressions and the radiographic
speech specialists. The following procedures and photographic records.
will facilitate the diagnosis: (1) case history Infant. Maxillary and mandibular im-
and recording of defect; (2) study casts and pression trays for infants are not manufac-
photographs; (3) various radiographic tured and must be constructed. The first step
procedures; (4) medical, surgical, speech, and is to adapt a piece of baseplate wax against
psychosocial recording. the maxillary or mandibular ridge. The wax is
Study casts and photographs, along with held with one finger and molded against the
various radiographic procedures, help the tissue with the other fingers. The wax pattern
dentist to study the growth and development obtained is invested and processed in acrylic
patterns of oral-facial-cranial structures and to resin. The procedure is repeated on different
observe the effects of surgical and orthopedic types of clefts until a sufficient number of
intervention upon the physiology and anatomy trays is obtained. Additional trays also can be
of the structures involved. constructed on the casts collected in the series.
Holes are drilled in the tray to provide
General Case History mechanical retention and escapeways for
A well-designed case history will provide all excess impression material. Additional re-
members of the team with the information tention is achieved by painting the internal
they need. This form should be limited to surface of the tray with an impression
general information about the cleft, history of adhesive.
cleft type, history of treatment, and the family An irreversible hydrocolloid material is
social and economic background. It is essential used for maxillary and mandibular impres-
that the information be arranged in concise sions. The amount of water used for these
form for rapid recording and extrapolation. impressions is five-sixths of that recommended
Dental History. All dental anomalies such as by the manufacturer, and water is
those involving number, shape,
CLEFT LIP AND CLEFT PALATE 361

issued at a temperature of 110°F in order to impression material. The procedure for


speed the setting of the material. removing the impression from the mouth must
The maxillary impression is made with the be modified according to the location of the
infant’s head tilted at a downward angle of 15 undercut.
degrees. The head is tilted slightly upward for Older Children and Adults. A stock tray
the mandibular impression. This position of adequate dimensions is selected. If a
makes it possible to maintain a direct view of registration of the entire cleft is desirable, the
the oral cavity at all times, and it directs the stock tray is modified with modeling
flow of the material toward the oropharyngeal compound extending posteriorly to the
space (Fig. 21.2). postpharyngeal wall (Fig. 21.3). This added
While the impression is being made, at section to the tray is underextended about 4 to
least four assistants should be available to (1) 5 mm in all directions, leaving an adequate
hold the infant’s head, (2) depress the tongue space for impression material.
and hold the suction, (3) hold the infant’s body The fast-setting, irreversible hydrocolloid is
and feet, and (4) mix the impression material. used for registering the preliminary im-
The infant is restrained in a receiving blanket. pression (Fig. 21.4). The following suggestions
Proper instruments should be available on should be kept in mind when the impression is
the bracket table to gain access to material made.
should it be displaced or lodged in the nasal 1. If the patient is a child, he should be
and oral pharynx. The tray should not be given the opportunity to see and examine the
overpacked with the impression material, nor tray; in some cases, he may be permitted to try
should too much force be applied in placing the tray in his mouth. He should be told that
the tray in position. The part of the tray that his cooperation is needed; otherwise, it will be
will be directly over an undercut should necessary to make several impressions. It is
contain less of the advisable to keep his mind occupied by talking
to him.

FIG. 21.2. A, the infant is positioned for face, maxillary, and mandibular impressions. B, an impression is made
of the face. C, the upper impression is in position in the mouth. D, the lower impression.
362 MAXILLOFACIAL PROSTHETICS

FIG. 21.3. A stock tray border, trimmed with molding compound and extended posteriorly with compound and
Adaptol, is used for making the preliminary impression.

FIG. 21.4. An alginate preliminary impression using the tray in Figure 21.3. Hard and soft palate cleft and
posterior pharyngeal wall have been registered.
CLEFT LIP AND CLEFT PALATE 363

2. The patient should have an early


morning appointment.
3. The patient should have an empty
stomach.
4. A topical anesthetic should be used on a
child who has a severe gagging reflex.
5. The tray should not be overloaded with
impression material. Excess material in the
nasopharynx will increase the difficulty of
removing the impression without a fracture.
6. All oral perforations should be packed
with gauze that has been saturated with
petroleum jelly.

Radiographs
As with the dental impression, cephalo-
metric data are recorded periodically. A
cineradiographic study with synchronized
sound of oral-pharyngeal structures in
function can help the dentist to evaluate
velopharyngeal function and tongue position
in postoperative and velopharyngeal-
incompetent individuals. A series of ceph-
alometric radiographs can also be of great
assistance. Sound spectrograms of speech are
used for comparative studies of speech
changes. A pressure and flow measuring
device permits the study of the relationship
between the nasal emission and speech
quality. The forms or charts for collecting data
from the various examinations are designed FIG. 21.5. A, the cephalometer used for an infant. B, a
for use with modern computers. sedated infant is on the table. The ear rods are carried
The technique employed in obtaining child to the external auditory meatuses, and the infant’s
and adult roetgenographic cephalometric data head is oriented in the Frankfort horizontal plane.
was described by Broadbent in 1931.2 Since
that time, many other investigators have
elaborated and added to this technique.
Numerous head-holding devices have been activities of nasal-pharnygeal dimension, lip
introduced to the profession. and tongue positions, etc.
The technique of infant cephalometry has Intraoral Radiographs. The intraoral
been described by Pruzanski and Lis 26 and by radiograph is used to determine the condition
Mazaheri and Sahni23 (Figs. 21.5 through of the teeth and surrounding structures. This
21.7). type of radiograph includes full mouth x-ray,
The roentgenographic cephalometer is an bite wings, and occlusal x- rays.
accurate and scientific instrument for Cineradiography. A cineradiographic
evaluating cranial-facial proportion and unit is used to record on film the function of
growth. Recently many investigators have the mandible, tongue, velum, and surrounding
used it for the evaluation of velopharyngeal tissue during phonation, blowing, and
relationship during various functional swallowing. The major components of the
cineradiographic structure are: a rotating
anode roentgenographic
364 MAXILLOFACIAL PROSTHETICS

FIG. 21.6. A, an x-ray tube mounted on the wall and a specially designed film holder enable a precise fixed-
distance radiograph of the maxillary anterior region to be made. In patients in whom the cleft involves the al -
veolar process, the bony relationship of the maxillary segments and changes in their behavior and position can be
accurately measured after surgical procedures to the lip and palate (with or without bone grafting). B, the occlusal
film is held in line with the source of the x-rays. C, the occlusal film is properly positioned. D, the occlusal
radiogram shows the position of the anterior teeth.

sound-on-film data at 24 frames per second,


and a timing device capable of accurately
recording exposure time to 0.001 second. A
specially designed cephalostat consisting of
ear rods and plastic forehead positioner
calibrated to orient the patient to his initial
position for subsequent studies can be used
(Fig. 21.8).
The distance between the roentgeno-
graphic tube and the intensifier tube is fixed.
The tubes are adjusted so that the central
rays of the roentgen tube will pass through
the patient and strike the center of the
receiving screen of the image intensifier. A
full-wave generator with an output-smoothing
FIG. 21.7. An adult cephalometric unit. device supplies the power for the rotating
roentgen tube. The generator has a stepless
tube with a 0.3-mm focal spot; a 9-inch image control of both kilovolts and milliamperes. The
intensifier tube with a light intensification sound-on- film recording apparatus is visually
factor of approximately 3600; an Auricon 16- monitored for recording all data presented by
mm motion picture camera with its optical the operator and/or patient. Settings of 65
system for recording
CLEFT LIP AND CLEFT PALATE 365

to 75 kv and 1.75 ma; with a 0.27-mm copper thropometric landmarks such as nasion, sells,
filter and a 0.5-mm aluminum filter, are used. basion, gamion, and anterior and posterior
Radiation dosage received by each subject, for nasal spines, etc., as well as many
30 seconds’ duration, averages 0.25 r. intermediate points, geometrically
Recording Analysis of Cephalometric determined, so there will be enough points to
and Cineradiographic Data. Analysis of describe adequately the bone and adjacent soft
skull shape by an electronic method has en- tissue outline. Figure 21.9 illustrates the 133
abled us to quantify and analyze our cepha- points on which is based our mathematical
lometric data with maximal accuracy and model of the skull.
minimal professional supervision. The fol- Step 3. The digitizing device which has
lowing is a brief description of the technique. been used to generate the coordinate points is
Step 1. Tracings of cephalometric generally known as OSCAR and is
roentgenogram are made by trained tech- manufactured by Benson-Lehner Corporation.
nicians with high reliability. With this device, two cross-hairs are
Step 2. To quantify this conventional positioned over the points on the
pattern before using it as a basis for cranial- mathematical model, and a recording knob is
facial analysis, a process known in the pressed when the point is to be recorded. The
computer world as digitizing is used. This potentiometer is a device which generates
method converts the cephalometric tracings recording voltages which are then passed
into a series of coordinates very much as in a through the analogue to the digital converter.
mapping program. After a number of This converter then operates an automatic
experiments and consultations, we select 136 IBM punch card machine which punches the
coordinate points to represent a description of coordinates on the standard IBM card (Fig.
the entire skull and soft tissue (Fig. 21.9). The 21.10).
numerical points include all of the Distances, angles, areas, and so on can be
conventional an- computed from the mathematical model very
neatly by developing suitable programs which
take the measurements of the various
coordinates from which the necessary
information can be derived. For instance, each
point of the mathematical model is described
by two coordinates, these being the distance
along an x-axis and the distance along the y-
axis. Hence, the distance of any point from the
origin becomes the length of the hypotenuse of
a right angle triangle and then can be com-
puted from the Pythagorean theorem.
Similarly, linear distance may be computed
between any two points on the mathematical
model. The data recorded on either a punch
card or magnetic tape is being programmed for
computer analysis. Frame-by-frame analysis
of cineradiographic film using the above
mentioned technique is useful in functional
FIG. 21.8. Cineradiographic unit records both
analysis of speech organs.
roentgenographic motion pictures and speech of the Laminography. Laminography has been
patient. This specially designed ceiling-mounted used for the study of cranial-facial growth and
apparatus supports the roentgen tube, cameras, radia- velophaiynx orifice size during a sustained
tion timer, and image intensifier, and reduces the soupd. Recently Mazaheri and
radiation to the patient while increasing picture screen
brilliance 3,600 times. The head-holder is attached to
the chair.
366 MAXILLOFACIAL PROSTHETICS

FIG. 21.9. This figure illustrates the digitizing of the cephalometric tracing. The 133 anatomic and geometrical
points are our mathematical model of the skull.

Biggerstaff17 introduced a sectional lami-


nograph for the study of the temperoman-
dibular joint (Fig. 21.11).
Pantomography. Panoramic x-rays have
been used for both the clinical diagnosis of the
oral-facial region and also for growth
appraisal of this area.

Photographs
Photographs are used for diagnosis,
teaching, and illustration of before and after
treatment. By precise orientation of the head,
FIG. 21.10. In the center is an OSCAR model F distortion and magnification are minimized;
scanning device. To the right is a decimal converter therefore, the photographs can be used for
which is used in conjunction with the OSCAR unit. On facial analysis. On an average, eight
the left is an IBM 026 cardpunch. The OSCAR unit
photographs are taken of each patient, to
records previously designated points from traced
cephalometric films as x-y coordinates. These coordi-
include extra- and intra-oral views, full face,
nates are produced as various voltage levels and are left and right profile, teeth in occlusion (in
automatically fed into a decimal converter. The con- infants, the maxillomandibular relationship),
verter then changes the voltage levels into integer left and right occlusion, anterior palate, and
numbers and feeds these numbers into a 026 card- posterior palate. If the patient is wearing a
punch which in turn produces a punched data card. The prosthetic speech appliance, anterior and
data obtained by this procedure could be used for posterior views of speech appliance are added
multiregression analyses of linear and angular to this list.
measurements.
CLEFT LIP AND CLEFT PALATE 367

Speech Recording The sonagraph, which has been used by many


Most patients have a disc, wire, and/or tape clinicians and researchers, is an instrument
recording. An infant’s babbling, crying and, which analyzes a complex signal as a function
later, speech should be part of the initial of both frequency and time. The resultant
diagnostic procedure. The periodic recording of portrayal, known as a sona- gram, displays
speech progress, along with various speech frequency along the vertical axis, time along
tests, is quite helpful to all speech and the horizontal axis, and intensity by the
nonspeech staff, as well as to the parents and darkness of the pattern. This type of
the patient. automatic analysis is very useful in giving a
Sound Spectrographic Recording clear and permanent picture of complex
This type of recording is helpful for initial signals that vary with time. The signal
diagnosis and follow-up of the patient. spectrum is scanned by either a 45- or 300-
cycle band-pass filter.

Fig. 21.11. A, the Franklin laminagraphic unit of the Lancaster Cleft Palate Clinic. Note (a) the custom
fabricated ear rods attached to the head-holding unit. B, an anterior-posterior view of a patient’s head positioned
in the Frankfort horizontal plane, with the ear rods and head-holding units in place.
368 MAXILLOFACIAL PROSTHETICS

The output of the analyzing filter is then oral and nasal pressures and flows. They all
recorded on dry facsimile paper that is fas- have advantages and disadvantages. When
tened around a drum rotating in synchron- used in combination with other diagnostic
ization with the magnetic recording disc (Figs. apparatus, however, this type of instrument
21.12 and 21.13). has a great value in cleft diagnosis (Fig.
A second type of analysis, known as a 21.14).
section, is displayed at the upper half of the
Otologic and Hearing Examination
sonagram. This auxiliary presentation with
the addition of the section micrometer A periodical otologic examination and
provides, at any preselected point in time, evaluation of patient acuity should be part of
portrayal of amplitude in the horizontal the patient’s record. Pure tone air-bone tests,
direction versus frequency in the vertical speech reception threshold, and discrimination
direction. The display is made on a uniform evaluations by voice are given in an
decibel scale with a range of 35 db. acoustically controlled chamber.
A .third type of portrayal, providing a Psychologic and Social Considerations
permanent record of the variation of average
amplitude versus time, was obtained by using Psychologic evaluations are -useful in
planning the individual patient’s treatment
the amplitude display unit. This display, using
program. For example, they can assist the
an amplitude scale that is logarithmic over a
social worker in his contacts with the parents.
24-db range, is produced on the top 1 V-i
Parents should be given the opportunity to
inches of the sonagram.
discuss the findings with the social worker
The fourth type of analysis, scale magni-
fication, is one in which any 10% portion of the and the psychologist in a joint conference.
Since more than 10% of the general
vertical frequency scale is expanded by a
population seeks help at some time in their
factor of 10. With the built-in calibrator, it is
lives for mental or emotional problems, it can
possible to obtain fine measurements of
be expected that a similar percentage of
frequency changes.
people with cleft palates will seek psychologic
help in the form of counseling or
Measurement of Nasal and Oral Pressure and
psychotherapy. Assistance in obtaining these
Flow
services should be made available to the
The measurement of oral and nasal
patient, perhaps through an appropriate
pressure and flow should be part of the initial
community agency.
diagnostic record. Several instruments are
Social service in a clinical setting should be
available commercially to record the
available to enable the patient to make full
use of medical, dental, and speech care, both
preventive and therapeutic, so that he can
achieve the fullest possible physical,
emotional, and social adjustment. Social
service is concerned with the following factors.
1. Evaluating financial ability in meeting
clinic care costs: determining eligibility for full
or partial assistance from public funds.
2. Relationships between the child, his
family, and the community.
3. The effect of a patient’s disability on the
family.

FIG. 21.12. Sound spectrograph with scale magnifier


and amplitude display.
CLEFT LIP AND CLEFT PALATE 369

FIG. 21.13. Series of sonagrams illustrating various portrayals obtained by sound spectrographic analyzer.

4. Family strength and ability to meet meet the social, psychologic, educational,
patient’s needs in order to maximize reha- recreational, and ancillary medical needs of
bilitation and prevent family disintegration. the patient.
5. Community resources designed to A social evaluation which is made by
examining social history data and intra-
370 MAXILLOFACIAL PROSTHETICS

undertaken. The analysis of longitudinal


maxillary and mandibular casts, cephalo-
metries, and radiographs has shown that two
major factors cause growth disturbances of
oral-facial regions in cleft individuals: (1) the
inherent potential for growth disturbance
present among cleft palate patients, and (2)
the trauma caused by surgical and orthopedic
intervention. Since the first factor can be
neither predicted nor reduced, all efforts have
been concentrated on minimizing growth dis-
turbances by performing surgery so as to
produce the least amount of trauma and scar
jFIG. 21.14. Several techniques are used to evaluate the
tissue. Longitudinal data obtained during the
velopharyngeal valving mechanism. An oral manometer past 6 years regarding the surgical closure of
measures the amount of air expelled from the mouth the cleft with a minimal amount of scar tissue
with the nostrils occluded and unoccluded. If less air is and trauma are very encouraging.
expelled when the nostrils are open than when blocked,
the air is leaking through the nose, an indication that
the velum is not valving properly. Indications for Prosthesis in Unoperated
Palates
family relationships helps to determine social Cleft palate surgery is not a stereotyped
casework goals. Social casework includes a exercise but a service demanding an as-
plan of action to help the patient and his sessment of all factors presented by each
family resolve problems in order to adjust to patient and a reparative surgical plan based
the present situation. The focus, timing, and on proven principles. Most cleft palates can be
extent of social casework are determined by reconstructed by surgery, enabling the patient
the medical-dental plan of treatment for which to develop acceptable velopharyngeal closure.
the medical staff carries ultimate There are apparently some situations in which
responsibility. Social casework is therefore a prosthesis is the physical restoration of
part of comprehensive medical-dental care. choice, and an opinion on this matter should
Through social service, the clinic team is be expressed by the group charged with the re-
aided in understanding the significance of habilitation of the cleft palate patient.
social, economic, and emotional factors in Many clefts of the hard palate can be closed
relation to patient disability treatment and by a vomer flap, and clefts of the soft palate
rehabilitation. can be closed by medial suture with good
anatomic and functional results. The wide
Treatment Planning cleft and the extremely short palate demand
The treatment program for a cleft palate further attention. Additional length may be
patient requires careful planning, as it should gained by a Dorrance7 or V-Y type of
take into account all factors involved in total retropositioning operation. The raw nasal
health care. The interest of the dentist and the surface may be covered with a skin graft,
physician in cranial- facial growth and nasal mucosa, or an island flap of palatal
behavior of soft and hard tissue, both before mucosa. The incompetent palatopharyngeal
and after surgery, has increased cooperation valve can be augmented by a pharyngeal flap,
between the surgeon and the dentist. As a either as a primary or secondary procedure.
result, a dental specialist has the opportunity The need for additional tissue in a wide cleft
to examine the cleft palate child and consult
with the surgeon, before any surgery is
CLEFT LIP AND CLEFT PALATE 371

can be satisfied by single or double regional repair may produce a low-vaulted palate. It
flaps. may be possible to close the soft palate with
In spite of the surgical advantages avail- the aid of local flaps and to restore the hard
able to the cleft palate patient, there has been palate with a prosthesis. A situation similar to
a need for cleft palate prostheses. The that once advocated by Gillies and Fry8 is
prosthodontist can assist both surgeon and created. The primary repair of the velum may
patient, and the mutual understanding among create a more favorable spatial arrangement
the specialists in a well- organized team is of for subsequent surgery on the hard palate.
great benefit to the patient. Some situations Neuromuscular Deficiency of Soft
indicating a prosthetic approach are discussed Palate and Pharynx. Repair of the palate
in the following paragraphs. would not be conducive to the development of
Wide Cleft with Deficient Soft Palate. good speech. It is difficult to create and
Some clefts of this type do not lend themselves maintain a pharyngeal flap large enough to
to surgical repair by means of local flaps. A produce competent palatopharyngeal valving
prosthesis is preferable to the more time- without obstructing the airway in the
consuming remote flaps in these situations. presence of a neurogenic deficiency of the
Many patients need a prosthesis to restore critical muscles. A pharyngeal flap serves best
missing dental units, and the distant tissue when surrounded by a dynamic musculature.
provides only a dynamic mass (Fig. 21.15). When this situation does not exist, the
Wide Cleft of Hard Palate. In bilateral pharyngeal section of a speech aid prosthesis
clefts, the vomer may be high and the cleft of may serve better to reduce nasality and nasal
the hard palate wide, so that surgical emission. The prosthesis can also act as a
physical therapy modality, providing a
resistive mass for the muscles to act against.
Should muscle function improve, definitive
surgical measures can then be contemplated.
Delayed Surgery. When surgery is de-
layed for medical reasons, or when the
surgeon prefers to repair the palate when the
patient is older, the cleft palate may be closed
temporarily with a prosthetic speech aid.
Expansion Prosthesis to Improve
Spatial Relations. An expansion prosthesis
may be used to restore and maintain more
normal spatial relations of the maxillary
segments prior to surgery. These segments
can be gradually separated by an expansion
prosthesis to create a space for the premaxilla
or to stabilize the parts in a normal position in
association with an autogenous bone graft. An
expansion or repositioning prosthesis, with or
without bone grafting, should be used in
selected cases. In most cleft lip and palate
patients, restoration of the anatomic
continuity of the labial muscle would mold the
segments into acceptable relationships to each
other and to the mandible.

FIG. 21.15. A, an adult patient with cleft of soft and


hard palate. B, speech appliance in position.
372 MAXILLOFACIAL PROSTHETICS

Combined Prosthesis and Orthodontic gradually reduced and eventually discarded as


Appliance. An orthodontic appliance may be muscle function improves. When the patient
combined with a prosthesis to move malposed presents a large velopharyngeal gap associated
teeth into a more favorable alignment. A with a neurogenic deficiency, the speech aid
prosthetic speech appliance could be designed prosthesis should be considered as a
for a patient receiving full band orthodontic permanent type of treatment.
treatment (Fig. 21.16). Surgical Failures. A prosthesis should be
Indications for Prosthesis in Operated Palates considered when a patient presents a low-
vaulted, heavily scarred, contracted palate, or
An Incompetent Palatopharyngeal one with large or multiple perforations (Fig.
Mechanism. If the clinical and cineradio- 21.17). Because of surgical progress in the last
graphic analyses suggest that the patient is 25 years, plastic surgeons today are not
close to functional closure, a prosthesis may confronted with many failures in cleft palate
serve as a physical therapy modality. The surgery. The surgeon can more accurately
pharyngeal section of the prosthesis may be predict the outcome of an operation, and he is
likely to avoid failure since alternatives are
available. Approximately 60% of all cleft
palate patients will need some type of
prosthesis by the age of 30.
Requirements of Speech Appliance
A. The prosthesis must be designed for the
individual patient in relation to his oral and
facial balance, masticatory function, and
speech.
B. Knowledge related to removable partial
and complete dentures should be used in
designing the maxillary part of the cleft palate
prosthesis. Preservation of the remaining
dentition and surrounding soft and hard tissue
in cleft palate patients is of utmost
importance. Improper design of the cleft palate
appliance can result in premature loss of both
hard and soft tissue, further complicating
prosthetic habili- tation.
C. The prosthetic speech appliance should
have more retention and support than most
other restorations. The crowning and splinting
of the abutment teeth in adult patients may
increase retention and support of the
prosthesis and may extend the life expectancy
of abutment teeth (Fig. 21.18).
D. Mouth preparations should be com-
pleted before making final impressions. When
lateral and vertical growth of the maxilla is
incomplete and partial eruption of the
deciduous and permanent teeth is
FIG. 21.16. A, a temporary prosthetic speech ap-
pliance designed not to interfere with the orthodontic
treatment while the patient is under active therapy. B,
the prosthesis in position. The retention is obtained by
placing the retainers above the molar buccal tubes.
CLEFT LIP AND CLEFT PALATE 373

FIG. 21.17. A, palatopharyngeal view of a patient with low-vaulted, heavily scarred, and perforated palate.
Nonfunctional pharyngeal flap has recently been inserted. B, prosthesis designed to close palatal perforation and
improve the velopharyngeal seal on the sides of the pharyngeal flap. C, the prosthesis in position.

evident, careful mouth preparations should be muscle activities or tongue movement during
made. To provide support for the prosthesis, swallowing and speech.
these preparations may include gin- I. The superior portion of the pharyngeal
givectomies to expose clinical crowns (to make section should be sloped laterally to eliminate
them usable) and the placement of coping on the collection of nasal secretions. The inferior
remaining teeth to prevent decalcification and portion of the pharyngeal section should be
caries. slightly concave to allow for freedom of tongue
E. Weight and size of the prosthetic speech movement.
appliance should be kept to a minimum. J. The location and the changes of the
F. Materials used should lend themselves speech bulb should include consideration of
easily to repair, extension, and reduction. the following factors.
G. Soft tissue displacement in velar and 1. The speech bulb should be positioned in
nasopharyngeal areas by the prosthesis should the location of greatest posterior pharyngeal
be avoided. and lateral pharyngeal wall activity, since
H. Velar and pharyngeal sections of the voice quality is judged best when the speech
prosthesis should never be displaced by lateral bulb is at these positions.
and posterior pharyngeal wall 2. The inferior-superior dimension and
weight of the speech bulb may be reduced
without apparent effect on nasal reso-
374 MAXILLOFACIAL PROSTHETICS

trolled, a prosthesis will require unusual care,


and frequent examinations are important.
5. Since the construction of a functional
prosthesis requires the services of a dentist
who has had training in cleft palate pros-
thodontics, it would be better to resort to
surgical ingenuity when experienced pros-
thodontic help is unavailable.
The edentulous condition is not a con-
traindication for a speech aid prosthesis.
REFERENCES
FIG.21.18. A patient with operated unilateral lip and 1. Biggerstaff, R. H., and Mazaheri, M.: Oral man
palate. Soft palate is scarred and short and lacks ifestations of the Ellis-van Creveld syndrome. J.
mobility. The maxillary arch was reconstructed, but a A. D. A. 5:1090-1095, 1968.
large oral-nasal fistula remains. A prosthetic speech 2. Broadbent, B. H.: A new x-ray technique and its
appliance was recommended for this patient. All application to orthodontia. Angle Orthodont.
maxillary teeth are crowned and splinted. 1(2): 45-66, 1931.
3. Cooper, H. K.: Cinefluorography with image in
tensification as an aid in treatment planning for
nance. (The lateral dimension of the bulb does some cleft lip and/or cleft palate cases. Amer. J.
not change significantly as the position is Orthodont. 42: 815-826, 1956.
4. Copper, H. K.: Recent trends in the manage
varied.) ment of the individual with oral-facial and
3. The speech bulb should be placed on or speech handicaps. Amer. J. Orthodont. 49: 683-
above the palatal plane when posterior and 700, 1963.
lateral pharyngeal wall activities are not 5. Cooper, H. K., Long, R. E., Cooper, J. A., Ma
present or when visual observation of the bulb zaheri, M., and Millard, R. T.: Psychological,
orthodontic, and prosthetic approaches in reha-
is not possible because of a long, soft palate. bilitation of the cleft palate patient. Dent. Clin.
4. The anterior tubercle of the atlas bone N. Amer. 381-393, 1960.
can be used as a reference point; however, the 6. Cronin, T. D.: Method of preventing raw area on
relative position of the tubercle of the atlas nasal surface of soft palate in pushback surgery.
Plast. Reconstr. Surg. 20: 474-484, 1957.
bone varies in different individuals, and the 7. Dorrance, G. M.: Lengthening of the soft palate
positions of the velopharyngeal structures in cleft palate operations. Ann. Surg. 82: 208,
change in relation to the tubercle as the 1925.
individual moves his head. Therefore, the atlas 8. Gillies, H. D., and Fry, W. K.: A new principle
in the surgical treatment of congenital cleft
bone is no longer used as the reference point
palate, and its mechanical counterpart. Brit.
for positioning of the pharyngeal section of the Med. J. 1: 335, 1921.
bulb. 9. Harkins, W. R.: Cleft palate prosthetics. In Gold
man, H. M., Forest, S. P., Byrd, D. L., and
Contraindications for Prosthesis McDonald, R. E.: Current Therapy in Dentistry,
Vol. II. The C. V. Mosby Company, St. Louis,
1. Surgical repair is feasible only when 1966.
surgical closure of the cleft will produce 10. Ivy, R. H.: Editorial: Some thoughts on posterior
anatomic and functional repair. pharyngeal flap surgery in the treatment of cleft
palate. Plast. Reconstr. Surg. 26: 417-420, 1960.
2. A mentally retarded patient is not a good 11. Lancaster Cleft Palate Clinic Booklet, revised
candidate for a prosthesis, since he is edition. Lancaster, Pa., 1968.
frequently not capable of giving his appliance 12. Limberg, A.: Neue Wege in der radikalen Urano-
the care it requires. plastik bei angeborene Apaltendeformationen:
Osteotomia interlaminaris and pterygomax-
3. A speech aid is not recommended for an illaris, resectio Margins Foraminis palatini und
uncooperative patient or for a child with neue Plattchennaht. Fissure osses occulta and
uncooperative parents. ihre Behandlung. Zbl. Chir. 54: 1745, 1927.
4. If caries is rampant and not con 13. Mazaheri, M.: Prosthetic treatment of closed ver-
CLEFT LIP AND CLEFT PALATE 375

tical dimension in the cleft palate patient. J. 21. Mazaheri, M., Millard, R. T., and Erickson, D.
Prosth. Dent. 11: 187-191, 1961. M.: Cineradiographic comparison of normal to
14. Mazaheri, M.: Indications and contraindications non-cleft subjects with velopharyngeal inade-
for prosthetic speech appliances in cleft palate. quacy. Cleft Palate J. 1: 199-209, 1964.
Plast. Reconstr. Surg. 30: 663-669, 1962. 22. Mazaheri, M., Nanda, S., and Sassouni, V.:
15. Mazaheri, M.: Prosthodontics in cleft palate Comparison of midfacial development of children
treatment and research. J. Prosth. Dent. 14: with clefts with their siblings. Cleft Palate J. 4:
1146-1162, 1964. 334-341, 1967. -
16. Mazaheri, M.: Cleft palate prosthetics. Curr. 23. Mazaheri, M., and Sahni, P. P.: Techniques of
Ther. Dent. 3: 315-334, 1968. cephalometry, photography and oral impressions
17. Mazaheri, M., and Biggerstaff, R. H.: Standard for infants. J. Prosth. Dent. 3: 315-323, 1969.
ized sectional laminographs of the temporo- 24. Millard, R. T.: Wide and/or short cleft palate,
mandibular joint. J. Prosth. Dent. 5: 489-496, Plast. Reconstr. Surg. 29: 40-57, 1962.
1967. 25. Mills, L. F., Niswander, J. D., Mazaheri, M., and
18. Mazaheri, M., Harding, R. L., and Ivy, R. H.: Brunelle, J. A.: Minor oral and facial defects in
The indication for a speech-aid prosthesis in cleft relatives of oral cleft patients. Angle Ortho- dont.
palate habilitation. Proceedings of the Third 38:199-204, 1968.
International Congress of Plastic Surgery, 26. Pruzansky, S., and Lis, E. F.: Cephalometric
Washington, D. C., October, 1963. Ex- cerpta roentgenography of infants: sedation, instru-
Medica International Congress, Series 66, mentation and research. Amer. J. Orthodont.
Amsterdam. 44:159-186, 1958.
19. Mazaheri, M., Harding, R. L., and Nanda, S.: 27. Stark, R. B., and DeHaan, C. R.: The addition
The effect of surgery on maxillary growth and of a pharyngeal flap to primary palatoplasty.
cleft width. Plast. Reconstr. Surg. 1: 22-30, 1967. Plast. Reconstr. Surg. 26: 378-387, 1960.
20. Mazaheri, M., and Hofmann, F. A.: Cineradiog 28. Veau, V., and Borel, S.: Division palatine; Anat-
raphy in prosthetic speech appliance construc- omie, Chirurgie, Phonetique. Masson et Cie.,
tion. J. Prost. Dent. 12: 571-575, 1962. Editeurs, Paris, 1931.

PART 2: SURGICAL MANAGEMENT OF THE CLEFT LIP AND CLEFT


PALATE

Clefts of Primary Palate alveolus develops with the lip embryologi-


Timing of Surgery cally so that the more extreme the lip de-
formity, the greater the bony defect and loss of
As in any purely elective operation, there is
normal dental arch. Early closure of the lip
always a difference of opinion as to the
has been imperative to permit early alignment
optimal time for surgical repair. Since there
of the bony arch. We feel that the early closure
are several schools of thought on the subject,
can accomplish this relationship and that it
we have established a group of arbitrary
can better the potential for growth and
criteria to determine, for practical purposes,
development of the bony components of the
the optimal time for surgery, in our
middle third of the face.
experience.
In recent years, the introduction of max-
1. The child must be free of any systemic
illary orthopedics has presented a substantial
t>r local disease which would contraindicate
argument for a change in procedure,
surgery.
permitting orthodontic manipulation of the
2. The child must have a minimal weight of
maxillary segments to improve bony position
7 pounds.
prior to surgical repair of the cleft lip.
3. The child must be in a weight- gaining
Maxillary position is of importance,
phase.
particularly in the wide cleft of the lip and
Consequently, this has placed most cleft lip
alveolus, where mechanical and technical
patients between 2 and 6 weeks of age at the
problems are encountered in the attempt to
time of the primary surgery. We have
repair the cleft surgically. In the more minor
recommended this time for surgery because of
clefts of the lip, the bony defect is a less
factors other than that of correcting the purely
significant factor technically in the
cosmetic deformity. The
376 MAXILLOFACIAL PROSTHETICS

closure of the lip. Consequently, in the past we The operative procedures on the primary
have deferred maxillary alignment by cleft lip may be performed under either local
mechanical means, if necessary, until a later or general anesthesia. When local anesthesia
date, usually SV2 to 5 years of age. is utilized, it appears to be best suited for
repair in infants under 1 month of age.
Surgical Procedures General ^anesthesia, generally administered
The history of cleft lip surgery is replete through intraoral insufflation or endotracheal
with numerous procedures which have been tube, has become more popular with the
initiated, forgotten, and revived. The major advent of modern improved types of general
historical factors involved in these numerous anesthesia. In all types of cleft lip repair, we
procedures, described by many people in many supplement the general anesthesia with local
lands, have resolved themselves into several infiltration of 1% Xylocaine with 1:100,000
major categories. The simple linear closures of Adrenalin. In order to minimize any possible
the lip were originally described by Rose of distortion resulting from the mechanical pres-
London and Thompson, then later modified by ence of the tube, we arrange to have the
Hage- dorn. The advocates of the triangular anesthetist at the left side of the table and the
flap looked upon Mirault as their champion, endotracheal tube taped to the midline of the
upon whose operation were based a great lower lip. We prefer to sit at the right side of
many of the lip repairs performed in this the table so that the view of the patient from
country prior to 1948. Mirault’s operation, as above and below is unobstructed, permitting
modified by Brown and McDowell, 7 was easier access to the intraoral aspect of the lip,
probably the most common operation as well as a better view of the symmetry of the
performed for the repair of the unilateral cleft nose and lip from below.
lip prior to the advent of the Le- Mesurier It is needless to mention the necessity for
repair.13’ 14 atraumatic technique during the course of the
The Tennison repair is another triangular operation. Atraumatic suture, with little or no
flap type of repair of a cleft lip, which was use of tissue forceps, is used routinely. We
developed during the popularity of the prefer skin hooks to tissue forceps which, even
LeMesurier repair in an attempt to preserve though delicate, do produce some tissue
more tissue and create better lip balance. A trauma. Small lip clamps are applied
number of the LeMesurier repairs developed bilaterally prior to the making of the incisions
increased length on the repaired side in the in order to minimize blood loss. We routinely
postoperative period. Modifications of these use methylene blue as the marking agent in
operations were developed by numerous order to determine the lines of our incisions.
plastic surgeons, among them Marcks 15 and Regardless of the technique or procedure
Bauer,3’ 4 whose procedures were further involved, there are a number of criteria which
varied by Randall, Haggarty, and Skoog.17 The are essential during the course of the repair
development of the Millard rotation-ad- which must be considered. Among these are
vancement procedure in 1955 attracted a approximation of all tissues with a minimum
considerable wave of popularity which seems of tension, accurate closure of the lip in layers,
to have persisted to the present time. and definite coaptation of the muscular is of
Consequently, the most popular operations both sides of the lip. Symmetry of the nostrils,
at the present time for the repair of the as far as possible, and careful alignment of the
unilateral cleft lip are the LeMesurier, vermilion border with adequate development
Tennison, Millard, and Mirault procedures. In of a buccal sulcus and advancement of the
order to point out the use and advantages of mucous membrane to produce normal eversion
the various types of procedure, these of the lower third of the lip are also important.
procedures are described and illustrated.
CLEFT LIP AND CLEFT PALATE 377

Prior to 1952, a major portion of the obtained considerable prominence in the


primary cleft lip repairs were done by the course of the last several years in that it has
Brown-McDowell modification of the Mir- ault developed the idea of rotation advancement of
lip repair (Fig. 21.19). This results in a the involved portion of the nose and lip, which
satisfactory lip in a large series of cases. In our appears to be more in keeping with their *
experience, however, the absence of the natural development embryologically. In most
Cupid’s bow and the mucocutaneous ridge is cases, the Millard procedure works extremely
almost universally apparent. The tendency for well in partial clefts of the lip. Some surgeons
the lip to appear thin and hypoplastic becomes are utilizing the Millard procedure for all
more obvious as the child grows older. types of cleft lip, whether partial or complete.
Consequently, this operation gave way in Many surgeons have difficulty in utilizing the
about 1952 to the Le- Mesurier-type Millard operation in the wide complete cleft in
technique. the lip because of the inability to rotate the
The LeMesurier operation (Fig. 21.20) flaps adequately to gain normal length of the
altered the geometry of the primary cleft lip involved portion of the lip. It has been our
repair by the development of a quadrilateral experience that the Millard procedure can be
flap in contradistinction to the triangular flap utilized for all types of lip defects and is used
of the Mirault. The advantages of the to its best advantage by one who has
LeMesurier lip repair were the alteration of experience with various other types of
the linear scar, addition of considerable tissue procedures, since much of the benefit of the
in the lower third of the lip to produce a operation depends upon previous experience in
marked fullness, and preservation of the the handling of tissue in this area.
normal vermilion mucocutaneous line. This
Bilateral Cleft Lip
also permitted the development of a minimum
of tension in closure of the severe cleft lip. One of the major problems in the treatment
The Tennison operation (Fig. 21.21), with of a bilateral cleft lip deformity is the
the insertion of the triangular flap rather that treatment of the prolabium and associated
the quadrilateral flap into the medial portion premaxilla. The premaxilla varies greatly in
of the lip, appears to have gained considerable size, shape, and position. The premaxilla
popularity, particularly among the younger usually contains the two central incisors but
surgeons. It discards a minimum of tissue and may contain other teeth as well. Various types
provides a satisfactory prominence of the of bilateral cleft deformities make it
lower third of the lip, preserving the Cupid’s impossible to standardize a procedure for
bow and a satisfactory mucocutaneous line. management.
The Millard operation (Fig. 21.22) has Resection or osteotomy of the vomer to
378 MAXILLOFACIAL PROSTHETICS

This two-stage technique (Figs. 21.24 and


21.25) involves closure of one side of the
bilateral cleft in the fashion similar to that
of a unilateral cleft, followed by closure of
the residual cleft in 2 to 3 months. Such
staging permits maximal salvage of avail-
able tissue. The technique utilizes a max-
imal amount of soft tissue available in re-
construction of the lip; at the same time, it
creates a buccal sulcus across the anterior
premaxilla, reducing the protruding pre-
maxilla as slowly and gently as possible, by
utilizing the function of the closed lip.
This operation is usually performed under
the same criteria as the unilateral cleft
procedure. We recommend the bilateral
FIG. 21.20. LeMesurier lip repair. This diagram Tennison approach to the closure, not only
illustrates the design of the flaps in a complete cleft of for giving additional length to both the
the lip, as modified by Bauer et al. 3- 4 to develop the prolabium and lateral lip flap, but also in
square flap closure. order to improve the appearance of the lip
by symmetrical philtral scars.
The premaxilla is not joined to the lat-
eral maxillary process at the initial sur-
gery. It is joined at the time of the cleft
palate repair which, in bilateral complete
clefts, is a two-stage procedure. The first
stage closes the anterior portion of the de-
fect by the vomer flap technique. The
completion of the muscle sling over the
premaxilla permits continued retroposi-
tioning of the premaxilla. Definitive posi-
tioning may require maxillary orthopedics,
as well as stabilization by subsequent bone
grafts.
Secondary Operations
FIG. 21.21. Tennison lip repair. Designed to use a
Residual Unilateral Cleft Lip De-
triangular flap, especially to utilize the maximal amount of
available tissue and to minimize abnormal lengthening of
formities. The better the primary cleft
the repaired side of the lip.

permit retropositioning of the premaxilla has


often been done at the time of the lip repair as
a preliminary procedure. This has, in the past,
led to maldevelopment of the middle third of
the maxilla, in our experience.
In order to minimize the multiple problems,
such as tight lip and unsatisfactory central FIG. 21.22. Millard lip repair. This diagram illus-
one-third in the repair of the bilateral cleft lip trates the position of incisions in the lip for rotation of
(Fig. 21.23), the one-stage repair of the the lip flaps to increase the length of the columella, as
deformity has been abandoned in favor of the well as to position the scar for simulating the philtral
two-stage procedure. line. Note absence of scar through the floor of the
nostril.
CLEFT LIP AND CLEFT PALATE 379

FIG. 21.23. Frequent result in one-stage repair of severe bilateral cleft lip deformity when associated with vomer
resection or osteotomy.

repair, the fewer secondary deformities ciated with secondary contracture. This
anticipated. Some residual deformity may be results in a tightness of the upper lip.
present, however, as a result of intrinsic Asymmetry of the nostrils, usually with
developmental errors as well as technical deviation of the septum and frequently with a
inadequacies. These deformities may be minor conspicuous scar, is often noted. A standard
enough to escape secondary repair or obvious secondary lip repair tends to correct all of
enough to require revision. Minor defects these in order, by means of scar revision,
associated with initial repair are inevitable. secondary rhinoplasty with submucous
We feel, however, that the so-called typical resection, and mucous membrane
cleft lip deformity, a notched lip with a poor advancement. In recent years, we have found
scar, has become less significant with that a routine Millard type of approach solves
improved primary repairs. One of the major many of the above problems in secondary lip
residual deformities is in the abnormal deformities. This seems to be especially true
development of the nose (Fig. 21.26). This when the nostril asymmetry is the major
problem is one of considerable severity, since problem associated with the short, notched lip.
it is progressive with growth and A major residual problem which should be
development. resolved is the large nasal-oral fistula
A common secondary lip deformity includes an resulting from a wide cleft involving the
inadequate buccal mucosa, asso
1

FIG. 21.24. The first stage of the bilateral cleft lip repair utilizes the maximal amount of tissue available. It lines
a portion of the prolabium to create a future buccal sulcus as well as to increase the possible development of the
vestigial columella.

FIG. 21.25. The second stage bilateral cleft lip repair is a procedure similar to that used in the first stage to
maintain symmetry. The mucosa lines the remainder of the prolabium, which makes up the central third of the
upper lip.

380
CLEFT LIP AND CLEFT PALATE 381

A residual irregularity of the exposed


mucosal portion of the lip can frequently be
improved by a standard lip shave procedure
for recontour of the vermilion (Fig. 21.27).
Residual Bilateral Cleft Lip Deformi-
ties. In most cases of bilateral cleft lip, there
is a congenital deficiency of the columella.
This defect requires a later operation, usually
at about 5 years of age, to reconstruct the
columella and to minimize the porcine type of
nose deformity. A modification of the Marcks
FIG. 21.26. Modified Erich procedure to create columellar lift (Fig. 21.28) is performed when
symmetry of the nose by correcting the nostril de- the lip is of adequate vertical length but has
formity. V to Y columellar incision is important to poor vertical or initial repair scars. This
lengthen the columella and to narrow it at its widest
permits utilization of the transverse fullness
portion in the base.
of the lip and revision of the scars in a single
procedure. The Cronin type (Fig. 21.29) of
columellar lift is utilized when the lip and
tissue of the floor of the nostrils are generally
satisfactory. The Barsky type (Fig. 21.30) of
columellar lift is very similar to the Cronin
except that it utilizes tissue from the upper
third of the lip. Thus, it is indicated when
there is excessive vertical length of the lip.
This permits reconstruction of the columella
and shortening of the vertical length of the lip
in the same procedure.
The one-stage bilateral cleft lip repair
frequently resulted in the loss of transverse
FIG. 21.27. Lip shave operation designed to improve the length of the lip because of a discarding of
appearance of an irregular or inadequate vermilion of the excess amounts of mucous membrane. This
upper lip secondary to previous scarring or excessive tightness of the soft tissue frequently fostered
thinning of lip. maldevelopment of the middle third
maxilla, a condition associated with loss of
support of the lip, nasal floor depression, and
muscle inadequacy of the upper portion of the
lip. Currently, we are treating this problem
with mucous membrane advancement and a
rotation of a muscle flap to the floor of the
nostril, as demonstrated in the diagram in
Figure 21.26. Ideally, this type of case should
merit a bone graft to correct the alveolar ridge
defect and stabilize the maxillary segments.
This would, of course, require previous ortho-
dontic alignment of the maxillary arch.
Occasionally it becomes necessary to use a
dental appliance to maintain a restored sulcus
FIG. 21.28. Columellar lift, modified Marcks pro-
following the release of the lip from its
cedure. This procedure, which is based on Marcks’
maxillary attachment, in order to improve the initial operation (A) and modified by Tondra, utilizes
appearance as well as the function of the lip. the scarred area of the upper lip, which facilitates
rotation of the alae into better position, at the same
time lengthening the columella.
382 MAXILLOFACIAL PROSTHETICS

as that performed prior to closure of the


palate) are losing interest.
Basically there are two indications for
delayed or secondary bone grafting: functional
and esthetic. The first is for stabilization of
the maxillary arch after arch alignment has
been achieved. The second is for correction of a
depressed alar base. The most practical source
of bone is the rib because of easy accessibility
and abundant supply. During the period of
graft healing, it is frequently beneficial to
maintain the position of the dental arch with
an intraoral appliance for a minimum of 3
months.
There is a variety of methods for bone-
grafting the maxillary arch. The method used
depends upon the nature of the defect and the
FIG. 21.29. Cronin operation is similar except that the desired accomplishment. Types include: inlay
flaps are developed in the floor of the nostrils instead of grafts, in which either bone chips or a block of
on the anterior surface of the lip. bone is placed between the ends of the
maxillary segments in order to establish bone
continuity; onlay grafts, in which segments of
bone span the defect; and a combination of
these two. The latter is our preference.

Clefts of Secondary Palate


Anatomically, the palate creates a me-
FIG. 21.30. Columellar lift, Barsky. Transverse flaps
chanical barrier between the oral pharynx and
designed from the upper portion of the lip, which
the nasal pharynx. The anterior portion of the
shortens the vertical height of the lip and elongates the
columella. palate is bony and fixed, whereas the posterior
half is muscular and labile. The muscular
portion of the palate changes size, shape, and
of the maxilla, which became more apparent
configuration
with increase in age and growth. We find this
problem fading with the increased use of the
two-stage lip repair. However, such defects
still are found. The Abbe lip switch operation
(Fig. 21.31) is used to furnish increased
transverse length, at the expense of the lower
lip.
Maxillary bone grafts, using split ribs, are
the treatment of choice for reconstruction of
the anterior maxilla when flattening or
FIG. 21.31. Abbe lip switch operation, utilizing tissues
retrusion is present.
of the redundant lower lip to increase the transverse
Bone Grafting. The timing, indications,
length of the upper lip when there is a deficiency of
and management of maxillary bone grafting tissue. Commonly used in secondary treatment of old
have been a controversial subject for several bilateral cleft lip repair done with loss of prolabium and
years. Now that sufficient time has elapsed for prolabial mucous membrane. The lower lip flap may
long-term evaluation, those proponents of also be V-shaped, depending on tissue need of upper lip.
early bone grafting (defined
CLEFT LIP AND CLEFT PALATE 383

with almost every conscious, as well as


unconscious, motion of the patient’s mus-
culature. This controls the amount of air and
sound which passes through the mouth as well
as the nose. Consequently, the palate is of
prime importance in the development of
normal speech. The primary purpose of
reconstructing the palate is to furnish the
mechanical as well as functional means to
develop normal speech.
A cleft palate has defects and deficiencies in
three dimensions. The failure of fusion in the
midline is the most obvious defect. The degree
of hypoplasia varies, becoming most marked
clinically in the partial clefts. The third
dimension of deficiency is in length. Failure of
the palate to reach the posterior pharynx at
the level of the atlas creates an inadequately
functioning palate and velopharyngeal insuffi-
ciency. Any surgical procedure which fails to
correct or restore both the mechanical and
functional aspects of the palate must be
considered inadequate, since both of these
aspects must be complete in order to furnish
the mechanism for normal speech. Submucous Clefts: generally, a V-Y
There are various schools of thought on the palatoplasty is indicated (Fig. 21.32).
subject of the time for repair of a primary Incomplete Cleft: Wardill V-Y palato-
palatal defect. We recommend primary repair plasty.
of the palate at approximately 18 months of Complete Clefts without Prepalatal
age, early in the development of definitive Tissue Involvement: generally our approach
speech, except in the case of bilateral complete has been the Wardill V-Y procedure, but the
cleft of the palate. For the latter, we von Langenbeck procedure (Fig. 21.33) is
recommend a two-stage procedure consisting acceptable.
of a vomer flap for reconstruction of the Complete Clefts with Primary Palatal
anterior or what would normally be the bony Involvement: V-Y palatoplasty, two- or four-
palate, along with stabilization of the flap (Fig. 21.34).
premaxilla at 12 to 15 months, followed by Wide Cleft and Bilateral Clefts: fre-
closure of the soft palate as a second stage quently it is advantageous to treat these
approximately 3 months later. This permits closures in two stages, using a vomer flap (Fig.
utilization of the maximal amount of tissue 21.35) for anterior closure at approximately 12
with the optimal opportunity for primary to 14 months of age, followed in 3 to 4 months
healing of the various areas. by the V-Y procedure as mentioned above.
There are numerous procedures designed
for repairing cleft palate deformities. This Secondary Procedures on Secondary Palate
variety is necessary because of the wide Approximately 15 to 20% (depending on the
variation in types of cleft palate deformities. series) of patients with clefts of the secondary
In our experience, the optimal surgical success palate will require secondary palatal
in closures of primary defects are as follows. procedures because of inadequate alveolar-
pharyngeal closure. This may be
384 MAXILLOFACIAL PROSTHETICS

FIG. 21.33. Von Langenbeck procedure for primary closure of cleft palate deformity.

former (lengthening the tissues in an anterior-


posterior direction) pushback in a V-Y fashion
and pushback with resurfacing the resulting
defect on the anterior nasal surface of the soft
palate either with an island flap, skin graft, or
superiorly based pharyngeal flap. The latter,
in addition to securing coverage and thus
preventing scar retraction, acts as an
obturator. Procedures for bringing the
posterior pharyngeal wall forward include
autogenous implants of cartilage or bone or
synthetic implants in the form of molded
silastic blocks or injection of synthetic
material to balloon out the tissue. The
posterior wall can be built out by the Hynes
procedure (Fig. 21.36), which creates an
anatomic Passa- vant’s ridge and is formed by
detaching the salpingopharyngeus muscle at
its distal attachment bilaterally and rotating
it 90 degrees to meet its fellow in a transverse
FIG. 21.34. Wardill four-flap palatoplasty.
direction at the level of the atlas.
Another method for creating adequate
due to scar contracture, poorly designed initial velopharyngeal closure is the Rosenthal
operative procedure with subsequent pharyngeal flap (Fig. 21.37), which utilizes the
inadequate palatal tissue in the anterior- posterior pharyngeal muscle based either
posterior direction, or slower growth of the superiorly or inferiorly, which is sutured to
middle third of the face. the soft palate. This creates an anatomic
The principle followed in correcting these obturator which minimizes the velopharyngeal
defects is to accomplish closure either by space and depends on lateral pharyngeal
moving the soft palatal tissue posteriorly for muscle motion for maximal success.
proper abutment against the posterior The decision as to 'which of these multiple
pharyngeal wall or by building out the procedures is to be used depends on the
posterior pharyngeal wall for contact with the individual patient situation, with
soft palate. Among the several procedures
described for achieving the
CLEFT LIP AND CLEFT PALATE 385

FIG. 21.35. Vomer flap repair for closure of anterior defect in bilateral cleft palate defect.

FIG. 21.36. Hynes pharyngoplasty. A, salpingopharyngeal muscle flap. B, salpingopharyngeal muscle crossed
on posterior pharyngeal wall C, sagittal view of crossed salpingopharyngeal muscle at level of atlas.

ELEVATION OF FLAP BASED


, AT LEVEL OF ATLAS

3 ATTACHMENT OF FLAP TO
PALATE WITH PALATE MUCOSAL
FLAP TO COVER RAW SURFACE
OF PHARYNGEAL FLAP

FIG. 21.37. Rosenthal flap, based superiorly for use in defects of less than 2 cm. POST., posterior.
386 MAXILLOFACIAL PROSTHETICS

many things to be considered, such as motion of skin from the nasal floor and alae. Plast.
Reconstr. Surg. 21: 417-426, 1958.
of the palate, condition of the palate in
10. Erich, J. B.: A technique for correcting a flat
relation to scarring, the velopharyngeal gap, nostril in a case of repaired harelip. Plast. Re-
and the age and mentality of the individual. constr. Surg. 12: 320-324, 1953.
11. Harkins, C. S.: Retropositioning of the premax
REFERENCES illa with the aid of an expansion prosthesis.
1. Adams, W. M., and Adams, L. H.: The misuse Plast. Reconstr. Surg. 22: 67-74, 1958.
of the prolabium in the repair of the bilateral 12. Hynes, W.: Pharyngoplasty by muscle transplan
cleft lip. Plast. Reconstr. Surg. 12: 225-232, 1953. tation. Brit. J. Plast. Surg. 3: 128-135, 1950.
2. Barsky, A. J.: Principles and Practice of Plastic 13. LeMesurier, A. B.: The treatment of complete
Surgery. The Williams & Wilkins Company, unilateral harelips. Surg. Gynec. Obstet. 95: 17-
Baltimore, 1950. 27, 1952.
3. Bauer, T. B., Trusler, H. M., and Glanz, S.: 14. LeMesurier, A. B.: The quadrilateral Mirault
Repair of the unilateral cleft lip. Plast. Reconstr. flap operation for harelips. Plast. Reconstr. Surg.
Surg. 11: 56-68, 1953. 16: 422-433, 1955.
4. Bauer, T. B., Trusler, H. M., and Tondra, J. 15. Marcks, K., Trevaskis, A., and Payne, M.: Elon
M.: Changing concepts in the management of gation of the columella by flap transfer and Z-
bilateral cleft lip deformities. Plast. Reconstr. plasty. Plast. Reconstr. Surg. 20: 466-470, 1957.
Surg. 24: 321-332, 1959. 16. Millard, D. R.: A reduced rotation in single hare
5. Brauer, R. O.: A comparison of the Tennison and lips. Amer. J. Surg. 95: 318-322, 1958.
LeMesurier lip repairs. Plast. Reconstr. Surg. 23: 17. Skoog, T.: A design for the repair of a unilateral
249-259, 1959. cleft lip. Amer. J. Surg. 95: 223-226, 1958.
6. Brauer, R. O., Cronin, T. D., and Reaves, E. L.: 18. Stark, R. B.: The pathogeneses of harelip and
Early maxillary orthopedics, orthodontia and cleft palate. Plast. Reconstr. Surg. 13: 20-39,
alveolar bone grafting in complete clefts of the 1954.
palate. Plast. Reconstr. Surg. 29: 625-641, 1962. 19. Tennison, C. W.: The repair of unilateral cleft lip
7. Brown, J. B., and McDowell, F.: Simplified de by the stencil method. Plast. Reconstr. Surg. 9:
sign for repair of single cleft lips. Surg. Gynec. 115-120, 1952.
Obstet. 80: 12-26, 1945. 20. Trusler, H. M., Bauer, T. B., and Tondra, J.
8. Converse, J. M.: Reconstructive Plastic Surgery. M.: The cleft lip-cleft palate problem. Plast.
W. B. Saunders Company, Philadelphia, 1964. Reconstr. Surg. 16: 174-188, 1955.
9. Cronin, T. 0.: Lengthening the columella by use 21. Trusler, H. M., and Glanz, S.: Secondary repair
of unilateral cleft lip deformity: square flap
technique. Plast. Reconstr. Surg. 10: 83-91, 1952.

PART 3: PEDODONTIC CARE FOR CHILDREN WITH CLEFT LIP AND


CLEFT PALATE

The pedodontist or general dentist is often imperfections inherent in the participation of


confronted with the parents of a child with a both specialist and parent, the dentist can
cleft lip and palate who want to know what to carry out a valuable and unique professional
do but are confused. The dentist cannot service. However, in his concern for parent
effectively involve the parent in the counseling, the pedodontist or general dentist
habilitation of the child unless he develops an must not overlook his important role in
understanding of the parent’s background. providing general dental care for children
With such an understanding, he can help the with cleft lip and palate. It is trite to state
parent anticipate and schedule the extended that good treatment requires proper diagnosis,
medical, dental, and speech therapy that are but these children have unique dental
required while minimizing the secondary conditions which the dentist must keep
handicaps in the area of personality uppermost in his mind during diagnosis and
development. By providing frequent, treatment planning.
consistent, and knowledgeable interpretations
Radiographic Findings
for the parents and child of the treatment
offered by all members of the professional Bailet and his associates1 have shown that
team and by realistically appraising the the dental development of children with cleft
difficulties and lip and palate may be delayed.
CLEFT LIP AND CLEFT PALATE 387

The dentist will need to evaluate dental include a Panorex or full intraoral series, bite-
development radiographically so that he can wing radiographs, and an occlusal radiograph
properly plan treatment such as space of the alveolar cleft. The occlusal radiograph
management which must be coordinated with provides a better view of all of the teeth in the
eruption. The parents should also be advised area of the cleft (Fig. 21.39).
concerning any delay in tooth eruption. Study models are of special importance in
Carr and Mink3 have indicated that ectopic the orthodontic evaluation of the child with
eruption of the maxillary 6-year molar is cleft lip and palate. Yet even dentists with
common in children with cleft palate. Any considerable clinical experience in treating
good pedodontic text will show several these children may forget that there are
techniques to treat this condition; however, usually nasal-oral fistulae just labial and just
radiographic diagnosis and early treatment lingual to the alveolar ridge in the area of the
are important to help reduce the amount of cleft (Fig. 21.40).
resorption of the second primary molar and to To prevent impression material from being
improve the prospects of guiding the 6-year forced into the nose through these fistulae, the
molar into a normal relationship. dentist must obturate them with a small piece
Primary and permanent lateral incisors of gauze. The saliva will hold the gauze in
may be congenitally absent. More commonly, place while the impression is being seated, or
however, there will be supernumerary teeth the gauze can be teased a short distance into
on the alveolar ridge or in the palate in the the fistula. The gauze will be removed with
area of the cleft (Fig. 21.38). This area of the the impression.
cleft of the alveolar ridge must be evaluated If some material is inadvertently forced
radiographically so that these conditions can into the nose and remains when the im-
be considered in treatment planning. pression is removed, the dentist may require
The radiographic examination should the assistance of the otolaryngologist to
remove the material.

FIG. 21.38. A primary supernumerary tooth has erupted into the palate in the area of the cleft. As is seen in
this close-up of the child shown in Figure 21.40, the supernumerary tooth may not completely erupt and may be
partially hidden by the gingival tissue in the area.
388 MAXILLOFACIAL PROSTHETICS

FIG. 21.39. Occlusal radiograph of the teeth in the area of the cleft. Teeth which are on the posterior side of the
cleft but appear to be lateral incisors are supernumerary teeth.

tional control drained by their previous


medical experiences, and they may whine and
sob during much of the dental appointment.
The fact is, however, that this sobbing may
help the child reduce his anxiety and prevent
him from building up any resentment toward
the dentist. These children are usually
observed to be friendly toward the dentist both
before and after dental treatment.
Because of the surgical repair of the cleft
lip, the tissue in the anterior maxillary
mucobuccal fold is tight and especially
sensitive and resistant to the penetration of
the needle and the deposition of the anesthetic
solution. Placing local anesthesia in this area
FIG. 21.40. Nasal-oral fistulae in a 5-year-old with a
may prove to be the most severe test of the
repaired Veau Type III cleft of the palate.
dentist’s ability to manage the child’s behavior
effectively.
Behavior Management After the topical anesthetic has been al-
During the collection of records and the lowed superficially to anesthetize the area, the
examination and treatment of the child with a dentist should deposit a small amount of
cleft lip and palate, the dentist must control anesthetic just below the epithelium. After 2
the child’s emotional adaptation to the dental or 3 minutes, this small amount will have
environment. Most children with clefts of the anesthetized the tissue and it will be less
lip or palate are reasonably mature in their painful to deposit the remainder of the
approach to dental treatment. However, anesthetic.
certain of these children seem to have had It must be remembered that the cleft has
most of their emo
CLEFT LIP AND CLEFT PALATE 389

interfered with the innervation of the teeth.


The anesthetic solution must be deposited on
the same side of the cleft as the teeth that are
to be treated.
If anesthesia of the lingual tissue is needed,
the needle can be passed through the
interdental papilla (Fig. 21.41). If the
anesthetic is deposited properly, the dentist
will see the lingual tissue blanch. This will
provide adequate anesthesia for the extraction
of a tooth and avoid a painful injection into the
scar tissue of the repaired cleft palate.
Most extractions in children with cleft lip
and palate are handled in exactly the same
FIG. 21.41. Demonstration of an injection through the
way as with other children. The exceptions are
interdental papilla to provide anesthesia of the lingual
supernumerary teeth that have erupted
gingival tissue.
lingually in the area of the cleft (Figs. 21.38
and 21.39) or teeth in the mobile premaxilla of
a Veau Type IV cleft palate. site may allow for the collapse of the posterior
When a supernumerary tooth positioned segments or may allow the nasal-oral fistula
lingually in the area of the cleft is to be in the area to become larger.
I
removed, it is usually necessary to supplement Stabilization of Posterior Segments
the labial anesthetic by depositing the solution
directly into the periodontal membrane of the If the dentist wishes to prevent collapse of
tooth to be extracted. This will allow for the the posterior segment subsequent to the
routine extraction of the tooth without pain to extraction of a tooth, surgical closure of the
the child. However, because of this problem cleft palate, or orthodontic repositioning of the
with anesthesia, it is frequently convenient to posterior segment, a simple transpalatal arch
have these teeth extracted under general should be placed (Fig. 21.42). If maxillary
anesthesia during a plastic surgery procedure. anterior teeth need to be replaced, a Hawley
The extraction of any tooth in the mobile type removable appliance can be used to
premaxilla in a Veau Type IV cleft palate stabilize the maxillary arch.
must be accomplished by using an elevation Preventive Care
technique in which the tooth is “wedged” out
Even more importantly than for the child
rather than pulled out with the application of
with a normal self-cleansing dentition, the
forceps. The premaxilla must be carefully
cleft palate child must be placed on an
stabilized with the fingers and thumb of the
extremely aggressive program of home care.
opposite hand. The consultation of an oral
Mink,13 Dixon,5 and Kraus et al.10 have
surgeon should be freely sought if any documented the fact, long recognized by
difficulty is anticipated.
clinicians, that children with cleft lip and
Before a supernumerary tooth is removed,
palate have numerous malformed and
the clinician must evaluate its usefulness in hypoplastic teeth (Fig. 21.43). These defects
maintaining the alveolar process and
provide many areas for plaque accumulation
preventing the collapse of the posterior
and cause a configuration of the oral cavity
segments. Pruzansky and Aduss15 state that that is not self-cleansing but in fact is often
“the bulbous and fully-toothed alveolar process
difficult to keep free of debris. Tote and
are an impediment to arch collapse.” Removal Sawinski18 and Tote et al.19 have
of a tooth in the cleft demonstrated that instruction in tooth
brushing using a disclosing tablet as a
teaching aid will produce a marked im-
390 MAXILLOFACIAL PROSTHETICS

FIG. 21.42. A transpalatal fixed holding appliance in a 3-year-old child with a repaired Veau Type III cleft of the

palate.

FIG. 21.43. An example of one type of hypoplastic defect found in the primary teeth of children with cleft lip
and palate.

provement in oral hygiene. Fodor and Ziegler7 Starkey17 has advocated a technique for the
studied the motivational effect of disclosing parent to use in brushing the preschool child’s
tablets and showed that they were the key teeth. The child stands in front of the parent
factor in improving oral hygiene in children. and leans back against her body. The parent
Any preventive program for children with cradles the child’s head in her left arm so that
cleft lip and palate must include instruction in her left hand is free to retract the lips while
the use of a disclosing tablet so that the child the right hand wields the brush (Fig. 21.44).
and parent will have a clear concept of the McClure12 and Kimmelman and Tassman9
areas of the teeth not being cleaned have shown that brushing performances for
adequately. children under 7 years of age are briefer, more
CLEFT LIP AND CLEFT PALATE 391

tion brush more efficiently than do preschool-


age children even when the children have
received instruction.
Parents of a preschool-age cleft palate child
should be taught by the dentist or his staff
how to brush their child’s teeth. The parents
should brush for the child until he is
motivated and has demonstrated his ability to
brush thoroughly for himself.
In addition, the patient should be taught
the proper use of dental floss. The floss must
pass through the contact points of all teeth
and then be drawn occlusally against the
proximal surfaces of both teeth involved in the
contact. The use of dental floss becomes an
important adjunct to cleaning the teeth, if all
possible debris is to be removed.
As with any patient, the dentist will need
to carry out a careful diagnosis of the child’s
present oral hygiene and dietary habits. He
will evaluate a dietary record and make
recommendations regarding the diet. The
topical application of fluoride is also a part of
the preventive program. Of great importance
is a regular evaluation of the patient’s
compliance with instructions on home care
and the frequent reinforcement of its
importance.
Jacobson and Rosenstein8 have noted the
difficulty that some children have in brushing
their maxillary anterior teeth because of the
interference of the tight upper lip. The plastic
surgeon will often surgically deepen the labial
sulcus in these children, and the dentist may
be called upon to construct an appliance to
hold the surgically created sulcus. Figure
21.45 illustrates a removable appliance used
to hold the surgically created sulcus. Porter-
field et al.14 advocate the use of a fixed
appliance attached to bands on the 6-year
molars with a labial arch wire.
The plastic surgeon may perform this
FIG. 21.44. Technique for brushing the preschool
child’s teeth: the parent cradles the child’s head with surgery for prosthetic reasons or for speech
the left arm as the fingers of the left hand retract the and esthetic reasons but, since an aggressive
lip and the right hand wields the brush. program in home oral hygiene will overcome
any interference from a tight lip, the sulcus
need not be deepened to improve hygiene
haphazard, and more erratic than in the case alone. However, the child must be directed
of older children. In addition, some children in and motivated to clean this area specifically.
the 3- to 5-year age group are unable to wield
the brush. McClure12 has also shown that
parents without instruc
392 MAXILLOFACIAL PROSTHETICS

FIG. 21.46. Illustration of the proper placement of a


lug on the labial of a stainless steel crown.

FIG. 21.45. A removable appliance with an area in


ated only by radiographic interpretation and
the maxillary anterior mucobuccal fold where com- clinical palpation, whereas the cast gold crown
pound was added in the operating room to help adaptation can be evaluated on the die. Unless
maintain a surgically deepened labial sulcus. there are some very serious economic
considerations, the cleft palate child should
receive a nearly ideal type of dental service.
Restorative Care Cast gold crowns can be successfully
Because of the hypoplastic defects, espe- constructed for most of these teeth needing
cially of the anterior teeth, few children with full coverage and will provide the maximum in
cleft lip and palate escape the need for self-cleansing qualities.
restorative dental care, no matter how Since some children must wear removable
aggressive the caries prevention program. The appliances such as speech bulbs or palatal
dentist must carefully explore every obturators which require efficient retention,
hypoplastic defect for caries. Also, every tooth the dentist should modify his steel crowns in
with an abnormal shape must be carefully these cases to include a labial or lingual lug
examined because caries may be present in (Fig. 21.46). This lug is made by soldering a
areas where it is not usually found. square wire in the midline one-third of the
Even if the hypoplastic defects are not labial or lingual surface of the crown. The
carious, the shape of the tooth and the solder is flowed over the occlusal surface of the
presence of hypoplasia must be considered in wire so that a guide plane is created to lift the
planning for their successful restoration. wrought clasp wire into the undercut when the
Because these hypoplastic defects often appliance is seated.
prevent the normal preparation of the tooth Of more immediate concern to the child in
for an amalgam restoration, stainless steel the mixed dentition is the esthetic restoration
crowns are often used. The use of cast gold of the hypoplastic maxillary anterior teeth.
crowns, even on the primary teeth, should also The acid etching technique advocated by
be considered. Doyle6 and by Easwell et al.11 can help to
The steel crowns are sometimes the only retain an acrylic tooth-colored restorative
full coverage possible on primary teeth in material in the hypoplastic defects. The
which almost all coronal tooth structure has preparation should include only the areas of
been lost. The crowns can be contoured so that hypoplasia, and the mechanical retention
they “snap” over the typically bulbous cervical should be minimal. This will serve adequately
third of the primary molar just occlusal to the as an intermediate restoration until a full
very constricted neck of the tooth. However, coverage restoration can be more
the adaptation of the metal at the cervical can advantageously placed.
be evalu-
CLEFT LIP AND CLEFT PALATE 393

REFERENCES 11. Laswell, H. R., Welk, D. A., and Regenos, J. W.:


Attachment of resin restorations to acid pre-
1. Bailet, H. L., Dozkos, J. D., and Swanson, L.
treated enamel. J. Amer. Dent. Ass. 85: 558,
T.: Dental development in children with cleft
1971.
palates. J. Dent. Res. 47: 664, 1968.
12. McClure, D. B.: A comparison of toothbrushing
2. Cahn, R. B.: Problems encountered in the treat
technics for the pre-school child. J. Dent. Child.
ment of clefts of the lip and the palate. Israel J.
33: 205-210, 1966.
Dent. Med. 18: 46, 1969.
13. Mink, J. R.: Relationship of hypoplastic teeth
3. Carr, G. E., and Mink, J. R.: Ectopic eruption of
and surgical trauma in cleft repair. J. Dent. Res.
the first permanent maxillary molar in cleft lip
38: 652, 1959.
and palate children. J. Dent. Child. 32: 179,
14. Porterfield, H. W., Haring, F., Kramer, R. N.,
1965.
and Kiehne, F.: Secondary mucous membrane
4. Crocker, E., and Crocker, C.: Some implications
advancement in bilateral cleft lip: a combined
of superstitions and folk beliefs for counseling
surgical-dental approach. Cleft Palate J. 7: 322,
parents of children with cleft lip and cleft palate.
1970.
Cleft Palate J. 7: 124, 1970.
15. Pruzansky, S., and Aduss, H.: Prevalence of arch
5. Dixon, D. A.: Defects of structure and formation
collapse and malocclusion in complete unilateral
of the teeth in persons with cleft palate and the
cleft lip and palate. Europ. Orthodont. Soc. Rep.
effect of reparative surgery on the dental tissue.
Cong. 365: 82, 1967.
Oral Surg. 25: 435, 1968.
16. Spriestersback, D. C.: Counseling parents of chil
6. Doyle, W. A.: Operative dentistry. In Goldman,
dren with cleft lips and palates. J. Chronic Dis.
H. M., Forrest, S. P., Byrd, D. L., and McDonald,
13: 244, 1961.
R. E.: Current Therapy in Dentistry. The C. V.
17. Starkey, P. E.: Instructions to parents for
Mosby Company, St. Louis, 1968.
brushing the child’s teeth. J. Dent. Child. 28: 42-
7. Fodor, J. R., and Ziegler, J. E.: A motivational
47, 1961.
study in dental health education. J. S. Calif.
18. Tote, P. D., and Sawinski, V. J.: Effective tooth-
Dent. Ass. 34: 203, 1966.
brushing requires instruction. J. Dent. Child. 34:
8. Jacobson, B. N., and Rosenstein, S. W.: The
296, 1967.
dentist and the cleft palate patient. Schweiz.
19. Tote, P. D., Sawinski, V. J., and Evans, C.: The
Mschr. Zahnheilk. 80: 507, 1970.
effects of instructed toothbrushing on the
9. Kimmelman, B., and Tassman, G. C.: Research
cleanliness of teeth and DMF: an eighteen month
in designs of children’s toothbrushes. J. Dent.
study. J. Oral. Ther. 3: 354, 1967.
Child. 27: 60-64, 1960.
20. Vincent, C. J.: The pedodontist in cleft palate
10. Kraus, B. S., Jordon, R. E., and Pruzansky, S.:
rehabilitation. Cleft Palate Bull. 10: 68, 1960.
Dental abnormalities in the deciduous and
permanent dentition of individuals with cleft lip
and palate. J. Dent. Res. 45: 1736, 1966.

PART 4: ORTHODONTIC TREATMENT FOR PATIENTS WITH CLEFT LIP


AND PALATE
Orthodontic treatment of the cleft lip and Each phase is discussed in detail with
palate patient depends upon a thorough illustrative cases.
knowledge of the problems associated with
Phase 1
growth, development, and tooth positions. For
this reason, the orthodontic treatment of the A large percentage of the patients born
cleft lip and palate patient is discussed in with clefts of the lip and palate have deviated
three phases. posterior as well as anterior segments. It has
Phase 1: early posterior segment alignment been reported that early segment alignment
following eruption of a full complement of will allow the maxillary halves to develop
deciduous molars, age 3 years to 5 years. normally even though a normal bony union is
Phase 2: posterior and anterior segment not present. This is the rationale for early
alignment in the early mixed dentition or late segment alignment or “maxillary orthopedics”
primary dentition, age 5 years to 7 years. as described by McNeil,4 Burston,3
Phase 3: complete orthodontic treatment. Rosenstein,6 and others. In many cleft lip and
palate rehabilitation centers, it is not feasible
to align maxillary segments in the newborn be
394 MAXILLOFACIAL PROSTHETICS

cause of problems involving transportation, tact with the cervical aspects of the teeth and
surgical management, and physical condition the bands for soldering purposes. After
of the patient. If the patient is subjected to adaptation, the appliance is finished and
cheiloplasty early in life and posterior segment cemented to prevent the occlusal forces and
collapse occurs later, the orthodontist is buccal wrap around musculature from tending
usually called on to reposition the posterior to collapse the segments to their
segments so that an alveolar bone graft may originaTpositions upon removal of the
be performed in the cleft site. retaining appliances.
The methods used by the author in repo- Unilateral activation of the W arch pro-
sitioning posterior segments in the 3- to 5- duces the type of tooth movement seen in the
year-old patient are: (a) fixed lingual arch (W schematic drawing of Figure 21.50. The buccal
arch) (Fig. 21.47), (b) removable lingual arch, segment on the nonactivated side is forced
and (c) split palate with jack- screw. distally when the appliance is seated with a
The fixed lingual arch, also known by the rotational point about the molar of the
term W arch, is suited for segment alignment activated side. Another side reaction is an
in cases of bilateral collapse of buccal expansive movement of the activated side with
segments with the long axis of the dental units flaring of the cuspid on the nonactivated side.
tipping lingually (Fig. 21.48). This type of The removable lingual arch is the second
problem may be corrected by tipping dental appliance of choice used in buccal segment
units and segments simultaneously (Fig. alignment. Its indications are: (a) bilateral
21.49). crossbites of buccal segments requiring bodily
The W arch consists of two molar bands movement of anchor teeth, and (b) control over
and a heavy lingual wire. The materials of axial inclinations of anchor teeth (Fig. 21.51).
choice are usually made of precious metals, The removable lingual arch is made of
e.g., Johnson oralium molar bands and stainless steel band material, either pinched
Paliney number 7 wire or 0.040-inch gold wire. bands from strip band material of
Johnson oralium bands which are slightly 0. 180- by 0.005- or 0.180- by 0.006-inch
larger than the second deciduous molars are bands or stainless steel seamless preformed
selected and annealed in a flame. They are bands. The bands are first adapted to the
then adapted to the molars with a band molar teeth with a band pusher and band
pusher and band biter. The best area for biter, then removed from the tooth with band-
pinching the band is on the mesiobuccal cusp removing pliers. Lingual arch sheaths are
or mesiolingual cusp with Howe pliers. After then positioned on the lingual aspects of each
the adaptation and pinching, the bands are molar band so that they are parallel in a
removed with band-removing pliers and the horizontal plane when the bands are properly
seams are fluxed with gold flux and flame- seated on the teeth and spot-welded. These
soldered before the bands are replaced on the sheaths are constructed to accept a piece of
teeth. A compound or alginate impression is 0.036- inch stainless steel wire bent double
taken, and the bands are removed and placed and shaped as a lingual arch. Following the
in the impression keyed by the extension of welding of the lingual sheaths on the lingual
the seam of the band material. surfaces of the bands, buccal tubes with slots
A model is poured in either plaster of Paris of 0.022 by 0.028 inches are placed on the
or dental cast stone and allowed to harden. buccal surfaces of the bands to receive a buccal
When the model has hardened, it is separated wire later in treatment. The bands which have
and a length of wire is decided upon and attachments permanently welded to them are
contoured to fit the palate and lingual aspects then cemented to the teeth. A piece of 0.036-
of the teeth. This is in the shape of a W since inch stainless steel wire is contoured similar
the wire is in con to
CLEFT LIP AND CLEFT PALATE 395

B-A AH)
FIG. 21.47.
Schematic occlusal view of W arch for bilateral expansion of maxillary arch. Areas of activation are
marked with an X.
FIG. 21.48. Frontal view schematically of maxillary first permanent molars. A, lingually tipped molars. B, corrected
axial inclinations.
FIG. 21.49. Frontal view schematically of maxillary first permanent molars being tipped from upright positions to
buccal flare.
FIG. 21.50. Occlusal view of lingual arch, illustrating unilateral activation of spring.
FIG. 21.51. Frontal schematic view, illustrating forces from removable lingual arch. Buccal force with buccal
torque to roots to effect bodily movement.

a W arch with two folded sections to fit the struction on the lingual arch, it is stress-
lingual sheaths on a previously taken study relieved in the oven at 850°F for at least 3
model. This wire may be designed in many minutes and cooled to room temperature. The
ways, depending upon the tooth movement lingual arch may be activated in the same
desired. Following the con way as the W arch, with two
396 MAXILLOFACIAL PROSTHETICS

additional activations of torque which can be The patient was 7 years 6 months old, with
placed in each molar for bodily expansion of a bilateral complete cleft of the lip and palate
molars if desired. Figure 21.51 shows the with the vomer attached and palatal fistulae
schematic representation of the removable bilaterally in the alveolar ridge area. The
lingual arch used to effect bodily expansion of premaxilla was mobile with permanent central
the molars. Expansion can be accomplished incisors rotated approximately 4&- degrees to
without changing axial inclinations if desired. each other. There was a left lateral
The axial inclinations can be changed by mandibular shift, giving the patient the
placing torque or twist in a buccolingual illusion of possessing a unilateral crossbite.
direction in that portion of the lingual arch The true centric, however, presented the
which inserts into the lingual sheaths. To mandible in an end-to-end relationship with a
reacti- ate the lingual arch, it is removed, acti- bilateral crossbite.
vated, and reinserted into the tubes. The treatment plan decided upon was as
The advantages of the removable lingual follows.
arch are listed above. The disadvantages are:
A_ A
(a) a large armamentarium of equipment is
necessary if seamless bands are to be used, (b) 1. Band 6/6 1/1 No treatment at this
/ / time
a spot welder is a must, and (c) more manual
2. Construct split
dexterity is required in adapting the wire and
palate
inserting it initially. 3. Labial arch wirp,
The third method of treatment to correctly 0.016 inch
align buccal segments is the split palate 4. Open coil to close
jackscrew appliance. Split palatal appliances space between
are indicated when the palatal shelves need 1/1
separation or when bodily movement of teeth /
associated with changes in palatal width is The appliance consisted of a split palate
necessary. Skeletal crossbites with posterior with a jackscrew, multibanding, and 0.008 by
teeth presenting normal axial inclinations 0.030-inch open coil spring to close
buccolingually can best be corrected by palatal diastemata. The forces being exerted were 120
splitting. to 150 grams or 4 to 5 ounces.
The split palate is constructed by adapting There are exceptions to any prescribed set
molar bands bilaterally and spotwelding treatment plan, and it might be in order to
horizontal lingual sheaths to the bands to discuss one such case. The second patient, a
receive 0.036-inch lingual arch wires. The male aged 2 years and 6 months, was seen in
lingual arch wire segments are embedded in the cleft lip and palate rehabilitation center of
the acrylic portion of the split palate. The the Indiana University Medical Center for
bands are replaced on the teeth, arch wires orthodontic intervention prior to surgical
are inserted in the sheaths, and an alginate closure of the lip. The patient clinically
impression is taken. The lingual arch wire is presented the following: a bilateral complete
removed from the band and placed in the cleft of the lip and palate with the vomer
alginate impression, and a model is poured unattached and premaxilla protruding and
with plaster or stone. This model is used for slightly rotated (Fig. 21.52). The left side of
the construction of the split palate. The jack- the lip had previously been closed. Treatment
screw with the split palate is removed from consisted of constructing an acrylic cap con-
the model after curing is complete, and the taining a contoured piece of 0.045-inch
appliance is trimmed and polished. stainless steel orthodontic wire which was
The following case history describes the use fitted labially and lingually to the premaxilla,
of the split palate in conjunction with a allowing the teeth to protrude through. An
multibanding technique in the early mixed occipital head cap was con-
dentition phase of treatment.
CLEFT LIP AND CLEFT PALATE 397

FIG. 21.52. A, profile of patient B. S., aged 2 years and 6 months, with bilateral complete cleft lip and palate
with one side of lip previously closed. Prior to orthodontic management and subsequent lip closure. B, frontal view
of patient B. S. prior to orthodontic management and subsequent lip closure.

FIG. 21.53. A, patient B. S. following retropositioning of premaxilla. B, appliances used to effect retroposi-
tioning of premaxilla.

structed and adjusted for comfort. Elastics Phase 2


were worn bilaterally delivering a pressure of The concepts of orthodontic treatment are
120 to 150 grams (4 to 5 ounces) continuously just as important in the mixed dentition stage
until satisfactory retropositioning of the of treatment as in the permanent dentition.
premaxilla was accomplished (Fig. 21.53, B). These concepts are good facial balance, dental
The results were gratifying since the harmony, stability, and maximal function.
premaxilla was retropositioned 8 mm along a Orthodontic treatment of cleft lip and
horizontal plane SN — 7 degrees to a point of palate patients in the mixed dentition has
approximation with the lateral aspects of the been discussed partially under the primary or
maxillary halves (Fig. 21.54, B). The plastic first phase of treatment. It consists of early
surgeons then performed lip surgery, and the segment alignment, both posterior and
first phase of orthodontic treatment was anterior, and correction of traumatic occlusion
accomplished (Fig. 21.55). of permanent anterior teeth.
398 MAXILLOFACIAL PROSTHETICS

FIG. 21.54. A, tracing of lateral cephalometric radiograph noting landmarks used. B, tracing showing segment
movement 4 in pre-surgical position.

Phase 3
Definitive tooth positions are essential for
complete rehabilitation of the cleft lip and
palate patient. The complexities of growth,
tooth eruption, tooth morphology, and jaw
position all play an ever-increasing role in the
treatment of the cleft lip and palate patient
with permanent teeth.
Malocclusions are found in nature in
several forms: (a) natural occlusions or Class I
arch length discrepancies, crossbites, or open
bites; (b) distal occlusions or Class II Division
I or Class II Division 2 malocclusion; (c)
mesioclusions or Class III malocclusions, and
other variations too numberous to mention.
The cleft lip and palate patient is not only
afflicted with the cleft defect but may also
have a skeletal or dental discrepancy. This
phase of the chapter deals with the open bite
problem, arch length inadequacy problem, and
narrow constricted palate. Three cases are
discussed in detail.
Patient 1 was a male aged 13 years and 3
FIG. 21.55. Surgical closure following retroposi-
months at the beginning of treatment.
tioning of premaxilla.
Clinically the patient presented with a
unilateral complete cleft of the left premaxilla
The author’s preference in correction of and maxilla as well as of the lip. The patient
rotated anterior teeth is the use of positive had an anterior crossbite of the left central
control over tooth movement with fixed incisor and essentially neutroclusion of the
appliances. For this reason, a multibanding buccal segments. There
technique is employed.
CLEFT LIP AND CLEFT PALATE 399

was an arch length inadequacy in his upper 1V-2 turns in the helix was soldered to the
jaw of 3 mm, not counting the missing left distal aspect of the arch wire and contoured to
permanent lateral incisor. There were many fit into the bracket of the rotated left central
rotations and abnormally positioned teeth in incisor. An open coil spring was compressed on
his maxillary arch. The patient had no the arm of the spring to move the central
apparent functional abnormalities or habits. distally along the arch wire. It was also
Cephalometrically, the patient showed an rotated at the same time. Otherwise, it would
essentially normal skeletal pattern. There become obstructed in its labial movement by
were no gross deviations from the mean for the right central incisor. Correcting the
his age group. rotation took 5 weeks.
The treatment plan called for banding all of No teeth were extracted in this case. The
the erupted permanent teeth in both upper results of 3 years of treatment and definitive
and lower jaws. The teeth which were banded prosthodontics can be seen in Figure 21.56.
were the molars and the permanent central The construction of the fixed bridge is
incisors. A stainless steel arch wire, 0.021 by discussed in Part 5.
0.025 inch, with a rotation spring of 0.018 by Patient 2 was a female aged 13 years and 6
0.022 inch with months with a bilateral complete cleft of the
lip, prepalate, and palate (Fig.

FIG. 21.56. A, frontal view of anterior occlusion prior to orthodontic management. B, frontal view of anterior
occlusion following orthodontic management. C, frontal view of anterior occlusion following prosthetic
management. D, occlusal view of three-unit fixed bridge consisting of a pin ledge crown on the central incisor and
partial veneer crown on the cuspid.
400
MAXILLOFACIAL PROSTHETICS
L.L. L.L.
Be fort* Abbe-Lip Afte; Abbe-Ll p
Switch Swi tch

FIG. 21.57. A, profile and frontal view of patient L. L., age 14 years and 6 months, with bilateral complete cleft lip and palate before Abbe lip switch.
B, profile and frontal view of L. L. after lip switch.
CLEFT LIP AND CLEFT PALATE 401

FIG. 21.58. Before and after orthodontic treatment, A, right lateral view. B, left lateral view. C, frontal
view. D, occlusal view of maxillary cast.

21.57). The face was concave with the upper Treatment Plan
lip retruded and flattened, and a tight cicatrix 1. An Abbe lip switch operation was
was found in the philtrum area resulting from performed to lengthen and loosen the upper
closure of the bilateral cleft lip defect lip.
surgically. The lower lip was full and slightly 2. An onlay bone graft of split rib was
protrusive in position. The midline was placed in the maxilla to give anterior support
acceptable since the premaxilla was mobile as to the upper lip and to stabilize the
a result of lack of soft tissue closure. premaxilla.
Cephalometrically, the maxilla was short 3. The dental arches were treated as fol-
in an A-P direction as evidenced by measuring lows.
anterior nasal spine to posterior nasal spine.
The mandible was large both in ramus height A A
and body length. Its relationship in an A-P
1. Band all posterior 1. Band all posterior
direction along a horizontal plane such as
teeth and do pre • teeth except first
Frankfort horizontal or occlusal plane was liminary bracket bicuspids and do
protrusive. The patient also had a longer than alignment preliminary
average total face. 2. Placement of bracket align
The dental pattern of the upper arch was buccal segments ment
constricted in the cuspid and bicuspid region. 3. Lingual arch 2. Extract both first
There was an asymmetry of the buccal 4. Maxillary expan bicuspids
segments toward the midline with a toe-in of sion 3. Buccal segments
the left buccal segments anteriorly. The 5. Band central inci placed in poste
sors rior teeth
central incisors were retruded to all horizontal
6. Flare and correct 4. Lingual arch
planes as seen cephalometrically and by
rotation 5. En masse tipping
viewing the right, left lateral, and frontal view 7. Finishing
of the articulated models. of the lower anterior
teeth 4 mm
6. Finishing
402 MAXILLOFACIAL PROSTHETICS

FIG. 21.59. A, final frontal view. B, final profile view. C, completed fixed bridge construction from maxillary
cuspid to cuspid. D, occlusal clinical view of fixed bridge cemented.

Final tooth alignment can be seen in third of the hard palate. There was a lack of
Figure 21.58, illustrating the before model (A) facial fullness in the middle one-third of the
and after model (B). The final profile and face as a result of multiple loss of maxillary
frontal views can be seen in Figure 21.58; C teeth (Fig. 21.60). To rehabilitate dental
and D. The final prosthesis was a six-unit esthetics, function, and stability, a partial'
anterior bridge from cuspid to cuspid in the denture was decided upon. The dental
maxillary arch, utilizing three-quarter crowns crossbite of the left maxillary cuspid and first
on the cuspids and full crowns made of premolar made the construction of the partial
porcelain fused to gold on the centrals and denture difficult because of the abnormal
lateral incisor pontics (Fig. 21.59). lateral forces which would be placed on the
Patient 3 was a 27-year-old female who had abutment teeth.
a repaired incomplete cleft of the palate An orthodontic appliance as seen in Figure
involving the soft palate and one- 21.61 was fabricated to move the cuspid out of
crossbite first, then reversed,
CLEFT LIP AND CLEFT PALATE 403

FIG. 21.60. A, frontal view before orthodontic and prosthetic management. B, frontal view after orthodontic
and prosthetic management.

FIG. 21.61. A, frontal view before orthodontic management. B, appliances used to effect change in tooth position
in maxilla.

FIG. 21.62. A, frontal view of occlusion after orthodontic treatment. B, prosthesis in place following orthodontic
treatment.
404 MAXILLOFACIAL PROSTHETICS

and the premolar was moved bucally before 3. Garner, L. D. An orthodontic approach to the
the construction of the partial. The orthodontic Veau type IV cleft lip and palate problem in the
preschool child. Cleft Palate J. 1: 82-87, 1964.
appliance was a removable lingual arch of 4. McNeil, C. K.: Oral and Facial Deformity. Sir
0.036-inch stainless steel with a 0.036-inch Isaac Pitman and Sons, Ltd., London, 1954.
stainless steel finger spring activated to flare 5. Ricketts, R. M.: Oral orthopedics for the cleft
the affected tooth. The clinical correction of the palate patient. Amer. J. Orthodont. 42: 401-408,
1956.
crossbite and subsequent partial denture can
6. Rosenstein, S. W.: Early orthodontic procedures
be seen in Figure 21.62, B. for cleft lip and palate individuals. Angle Ortho.
REFERENCES 33: 127, 1963.
1. B0hn, A.: Retention construction following Mr. 7. The team approach to cleft palate rehabilitation.
Harvold’s method of repositioning of the maxil- In Garner, L. D.: Dentistry for Adolescence, pp.
lary complex in cleft palate cases. Europ. 420-429. The C. V. Mosby Company, St. Louis,
Orthodont. Soc. Trans. 219-221, 1951. 1969.
2. Burston, W. R.: Early orthodontic treatment of 8. Tulley, W. J.: Late orthodontic treatment in a
cleft palate conditions. Dent. Pract. 9: 41, 1958. case of cleft palate. Brit. Soc. Orthodont. Trans.
78-80, 1950.

PART 5: PROSTHODONTIC REHABILITATION FOR CLEFT PALATE


PATIENTS

In cleft palate habilitation, the prostho- ness and have employed only early orthopedic
dontist has the same goals as any other techniques. Still others have employed neither
professional person working in this habili- technique.
tation area: (1) to improve appearance and (2) At birth, certain variables can exert a
to provide adequate function, including an profound influence on the results obtained
adequate speech mechanism. Prosthetic with these patients. Some of these variables
treatment of the cleft lip and palate condition are as follows (Fig. 21.64): (1) length of the
is so wide in scope that one might generalize minor segment; (2) position of the
by saying that it starts at birth and ends with
death. As an example of this, a marked
asymmetry of the dental arch is often seen in
the cleft palate newborn (Fig. 21.63) and,
unless this is corrected before surgery
commences, severe future problems can be
expected.
Maxillary Orthopedics
Since McNeil wrote of the pre-surgical
orthopedic treatment of the maxillary arch of
cleft lip and palate infants, approximately 20
years have elapsed. During those years,
treatment centers and private practitioners
around the world have experimented with and
modified the so-called McNeil technique. For
some persons, the idea of bone grafting the
cleft alveolus gradually became associated
with the early use of orthopedic appliances as
part of a dual treatment approach. Others,
however, have been convinced neither of the
need for early bone grafting nor of its effective
FIG. 21.63. Mother with cleft lip and palate holding

cleft child.
CLEFT LIP AND CLEFT PALATE 405

acrylic appliance is used. If it appears that the


arch is collapsed throughout its length, a
straight jackscrew appliance is used (Fig.
21.67). All appliances, whether active or
passive, are fabricated and inserted prior to
lip closure.
If the cleft configuration is wide or if the
segments appear in an ideal relationship, a

FIG. 21.64. Master casts showing maxillary segments


before and after early maxillary orthopedic treatment.

minor segment; (3) position of the anterior


portion of the greater segment or of the
premaxilla; (4) degree and location of the
apparent tissue deficiency; (5) area of coverage
or extension of the appliance; (6) growth KF, CP r # 16 00 <

potential of the patient; (7) appliance design: FIG. 21.65. Passive appliance (left) and active appliance
active or passive; (8) parent management of (right).
the child and appliance and degree of
cooperation.
In fact, however, these eight variables can
be reduced to four primary considerations:
configuration and extent of the cleft, growth
potential of the patient, parental cooperation,
and appliance design. As yet we have no
accurate means of assessing the growth
potential of the patients. Nor are there exact
means of determining in advance the degree of
parent cooperation that can be expected.
However, we can assess the configuration and
degree of the cleft arch with reasonable
accuracy and design our appliances according FIG. 21.66. Fan type of split acrylic appliance.
to prior clinical experience. Early orthopedic
treatment on any given patient should be un-
dertaken on the basis of a joint decision of the
surgeon, the orthodontist, and the
prosthodontist.
Our appliances are of two types (Fig.
21.65): the passive or holding type and the
active or expansion type. The type of appliance
to be placed will be determined by the
configuration of the cleft. Generally, if any
degree of collapse is manifested, an expansion
appliance is placed. If the collapse appears to
be primarily in the anterior region (Fig.
21.66), a fan type of split
FIG. 21.67. Jackscrew appliance.
406 MAXILLOFACIAL PROSTHETICS

holding appliance is used (Fig. 21.68). The


premaxillary molding can be controlled by the
amount of lingual support that the appliance
gives the premaxillary area. In cases of arch
collapse, surgical closure of the lip is delayed
until the expansion appliance has achieved an
ideal arch configuration. Cases presenting
initially with an ideal arch alignment or with
a wide cleft configuration are operated on as
soon as the holding appliance is placed (Fig.
21.69). In either situation, the age at which
the cleft lip is surgically closed ranges be-
tween 1 and 10 months. It should be stressed FIG. 21.70. A third holding appliance.
that the primary purpose of the appliance
prior to lip closure is not to proliferate tissue
or initiate growth but to guide the maxillary cally closed cleft lip, along with the appliance,
segments into proper spatial position with helps to create an ideal arch form (Fig. 21.70).
each other and with the mandibular arch. Success in achieving and maintaining a
After the maxillary appliance has the good arch alignment is considerably greater in
segments in good alignment, the plastic patients whose initial arch configuration is
surgeon restores lip continuity. The molding wide: that is, if the smaller segment (in the
pressure of the surgi- case of the unilateral complete cleft) or the
buccal segments (in the case of a bilateral
complete cleft) are positioned lateral to a
position that would constitute an ideal arch
configuration. The more lateral these
segments are to that ideal position, the
greater the chance of success in arriving at
and maintaining a good arch configuration.
On the other hand, when the initial arch
configuration demonstrates some degree of
collapse, even though the segments may be ex-
panded into an ideal relationship, the end
results often are less than satisfactory.
1-16-6o :-in_60 Perhaps the variables that permit arch col-
lapse, prenatally and before lip closure,
MM, CPI #1652 Lip Closure: 3-18-69'
BD: 10-20-68
continue to operate so as to compromise the
results of treatment.
FIG. 21.68. Holding appliance in position. A decrease in the size of the cleft is ap-
parent in over 90% of these patients. Although
the palatal appliance may stimulate growth in
some manner, the changes observed are
probably due primarily to the intrinsic growth
potential of the patient. Extraoral forces are
not needed to mold the greater segment into
an ideal configuration; instead, this is
accomplished by the forces of the surgically
united lip segments.
It has been observed clinically that the
forward growth of the lesser segment can
FIG. 21.69. Another holding appliance (used to prevent
collapse of segments).
CLEFT LIP AND CLEFT PALATE 407

displace the appliance anteriorly. A second (Fig. 21.71, A). Eruption of the teeth must not
observation has been that posterior growth of be impeded by the appliance. Therefore, if the
both greater and lesser segments occurs first deciduous molars erupt and displace the
independently of the appliances. Thus, a appliance, the chance for segment collapse is
patient who is wearing an appliance to good, unless proper adjustments are made in
maintain lateral dimension of the arches can the appliance (Fig. 21.71, B).
still manifest unimpeded growth in the Sometimes an appliance needs to be
anteroposterior dimension. These observations expanded on a child who has had poor
indicate that the growth potential is innate in segment position. If the parents activate the
the cleft individual and not initiated by the appliance without regard for fit, the expansion
presence of a maxillary positioning appliance. creates a dislodging force for which the
It must also be stated that, in cases of tissue parents compensate by adding more adhesive
apposition at the cleft site, there was no to the appliance. The parents may think the
coverage by the maxillary appliance because appliance is fitting and continue to expand it;
the appliance had been relieved in that area. however, at the next appointment the
One area of concern is the parental prosthodontist sees an appliance which is too
management of the child and the maxillary big for the segment relationships. The
appliance. Passive appliances need no appliance is then reduced to its original
parental control, but active appliances can position for a fresh start.
present problems because they must be Many children learn that removing the
activated by the parents to start the segments appliance attracts attention and they do so
moving. When the child has come home from frequently, thereby reducing its effectiveness.
the hospital after lip closure, the parents must Loss and breakage can also allow collapsing
see to- it that he wears the appliance at all changes to occur if the parents do not call
times. If the appliance is left out of the mouth immediately for an appointment to rectify the
after lip closure, lateral collapse of the problem. Some parents call 1 or 2 weeks later
segments can occur within 24 hours, creating to inform us of such a situation. The parents’
enough change so that inserting the appliance dental-cleft palate
after that time will not be effective because it I. Q. is a big factor in the degree of
no longer fits. Consequently, new models are urgency that they feel. They must be told
needed to make an appliance that will fit the repeatedly of the need for the child to wear the
collapsed arches. appliance at all times.
Another time of concern is the eruption of Sometimes there is parental concern
the maxillary first deciduous molars

FIG. 21.71. A, unrepaired cleft palate. B, adjusted appliance.


408 MAXILLOFACIAL PROSTHETICS

about pressure created by appliances. This


pressure is transient; once the appliance is
removed, the tissue returns to its normal
contour in just a few days.
Several salient points warrant re-emphasis
regarding infant appliances.
1. Active or holding appliances can achieve
and/or maintain ideal arch configurations in
patients with complete clefts of the lip and
palate.
2. Once the lip has been surgically closed,
the greatest tendency for additional collapse is
FIG. 21.72. Training appliance (left) used to promote
seen in those patients who presented initially
muscular activity, and temporary speech appliance (right).
with some degree of arch collapse.
3. Regardless of treatment techniques, a
considerably higher percentage of success is
achieved in patients whose initial arch anterior prosthesis which contours the upper
configurations are wide. lip and improves the anterior occlusion.
4. Studies attempting to relate arch form The first type is used for training, diag-
and occlusion in the permanent dentition to nosis, and as a temporary appliance. A
early treatment techniques must take into training appliance such as the prosthesis on
account the following factors. the left in Figure 21.72 is used to promote
A. The exact nature of the cleft condition, increased muscular activity so that the
including measures of cleft width. coordinated movement of the soft palate and
B. A quantification of the spatial rela- the posterior pharyngeal wall will achieve
tionships of the arch segments prior to velopharyngeal closure during speech. The
treatment. pharyngeal bulb is actually undersized to
C. An assessment of the growth potential promote activity of the muscles involved in
inherent in the particular categories of cases proper velopharyngeal closure.
being studied. If the appliance is to be used only as a
D. A profound awareness of growth and diagnostic tool and to aid in increasing muscle
development in the normal individual and in activity, the speech bulb is not as accurately
the cleft lip and palate types being studied, refined and does not achieve complete
and a recognition that homogeneity among efficiency during velopharyngeal closure. The
cleft lip and palate types may be the exception diagnostic appliance is also helpful in
rather than the rule. eliminating certain tongue habits which are
5. Parental cooperation is essential for undesirable.
successful treatment. The prosthesis on the right in Figure 21.72
6. Lip closure can increase deformation or is a temporary appliance which does
arch collapse unless controlled by appliances. accomplish valving, but it must be modified
This is an application of Wolffs law that from time to time because of changing
functional stresses shape bone. dentition and growth. Note that the speech
bulb lacks symmetry of design, for the reason
that the muscle activity in the nasopharynx is
Prosthetic Speech Appliances for Chil-
dren much greater on one side than on the other.
That is why a speech bulb can give a
Three types of speech aids can be con- physiologic evaluation of muscular activity in
structed for children: (1) an obturator with a the nasopharynx.
palatal-velar-pharyngeal portion, (2) a For children from 3 to 9 years of age, when
baseplate type which functions to obturate the possible, we construct stainless steel
palate and helps speech, and (3) an
CLEFT LIP AND CLEFT PALATE 409

crowns or bands on the second deciduous chanical challenge; it calls for a close adap-
maxillary molars and the deciduous maxillary tation of a firm surface to surfaces composed
cuspids (Fig. 21.73). To these crowns are of living hard and soft tissues varying in
soldered labial and buccal protuberances. consistency and mobility.
These protuberances act as retentive areas for In addition to the need for an intimate
the wrought wire clasps which are fabricated relationship between the pharyngeal bulb
with the speech appliance. prosthesis and living, moving tissues, there
must be a functioning peripheral valve with
Rationale for Pharyngeal Bulb
adjacent structures to prevent the escape of
The construction of a pharyngeal bulb air into the nose. However, the tissues should
prosthesis must be approached from a not be compressed, blanched, or impinged
physiologic viewpoint rather than a purely upon in order to achieve this result. Since the
mechanical one. Whatever the materials used structures surrounding the nasopharynx move
in obtaining the impression, the objective is during speech, the dynamics and details of
always the same. The completed bulb must these structures must determine the shape
have a surface with an individualized and configuration of the pharyngeal bulb.
configuration which will act within the The gross functional anatomy of the
nasopharynx to allow complete structures adjacent to the nasopharynx should
velopharyngeal closure during speech and yet be appraised in detail. Size, exact location,
present an open velopharyngeal port for and extent of movement of the following
breathing. This is not just a me- muscles should be visualized: (A) the levator
palati, (B) the palatopha- ryngeus and its
associated muscle, the sal- pingopharyngeus,
(C) the palatoglossus, (D) the superior
pharyngeal constrictor (Fig. 21.74, A) and its
specialized sphincter ring or Passavant’s ridge
(Fig.
21.74, B), (E) the tensor palati, and (F) the
musculus uvulae. The movement of these
muscle bundles should be observed and judged
as extensive, good, fair, trace, or none.
Construction of Bulb
The bulb section is fabricated in the pa-
tient’s mouth by starting with a small bulb
FIG. 21.73. Stainless steel crowns and bands used
for retention.

FIG. 21.74. A, anatomic features of nasopharynx. B, note Passavant’s ridge.


410 MAXILLOFACIAL PROSTHETICS

about the size of a pea (Fig. 21.75, A). With about 5 minutes to visit with his parents. The
each addition of compound (Fig. child and parents are encouraged to converse
21.75, B), the child is asked to bend his head so that the bulb becomes refined by muscle
down as far as he can. This action brings the trimming through use.
spinal column forward, causing the posterior After this, the appliance is removed and
pharyngeal wall to indent the posterior the necessary laboratory procedures are
surface of the impression. Since it is the performed to convert the compound bulb into
tubercle of the atlas which makes this deep a permanent one of acrylic (Fig.
indentation, the operator now has a means of 21.75, D).
orienting his placement of additional Figure 21.75, E shows the appliance in
impression material and the location that he place with high placement of the pharyngeal
wants for the bulb. bulb.
The child next moves his head from side to At the next appointment and at subsequent
side, which causes the palatopharyngeus ones, the same procedures are performed until
muscle to trim the anteriolateral aspect of the the patient can achieve complete
bulb. After this has been done several times, velopharyngeal closure and the resonance
the appliance is removed and studied for balance of the voice is within normal limits.
landmarks on the compound to determine The prosthodontist and probably the speech
where additional impression material is to be pathologist who is treating the patient often
added. Again, depending upon the patient’s hear the complaint, “My child speaks better
tolerance, the prosthodontist may decide to with this appliance out than with it in.” This
stop here or else to add more material to the is undoubtedly true because the child
present bulb. After enough material has been compensates for his speech defect and the
added, a thermoplastic wax is added to the appliance merely interferes with this
compound bulb, and the patient goes through compensation. Also, the preliminary bulb is
the same motions of moving the head down not meant to aid speech, and the parents
and side to side (Fig. 21.75, C). At this point, should be informed of this or else they will
the patient is dismissed for become discouraged during

FIG. 21.75. A to C, stages in construction of speech bulb. D, speech appliance in mouth. E, radiograph showing
level of speech bulb.
CLEFT LIP AND CLEFT PALATE 411

FIG. 21.76. A, scarred palate with fistula. B, hard palate obturator in mouth.

treatment. The preliminary bulb only helps to tioning well, a speech bulb is not indicated.
build up tolerance for the patient as he learns The usual retentive crowns are placed, the
to wear the speech appliance. maxillary impression is obtained, and the
Many parents want to know how large the hard palate is fabricated in about the same
bulb will be. The answer is that the bulb will way as the hard palate portion of a temporary
be large enough for the muscles of the throat speech appliance.
to function against. One point worth Figure 21.76, B shows the appliance in the
establishing with the parents is that the child mouth. Note the clasps superior to the
can wear the speech appliance very well and prominences on the retentive crowns and the
function adequately with it, but that the anterior finger springs to correct an anterior
parent could not wear one of these appliances crossbite.
and thus should not put himself in the child’s
Anterior Prosthesis
place. The child should be allowed to adjust as
he will to the appliance, but he should not be Mandibular prognathism is often seen at
given a basis for feelings of fear or defeat. ages 9 through 14 as a result of sudden
How long will it take? The prosthodontist growth of the mandible without comparable
can fabricate only as rapidly as the child will growth of the maxilla. If the surgeon does not
let him; and so actually no time can be wish to do a mandibular resection at this age,
designated because each child varies in this is an excellent time for the prosthodontist
adjusting to the appliance and tolerating it. to construct an anterior prosthesis which will
The parents must be urged to encourage and restore function to the mandibular dentition
compliment the child with the beginning and create a pleasing profile. This type of
appliance and not to harass or beat him into appliance will benefit the patient very much
wearing it. Any child can tolerate and adjust from a psychologic standpoint because it will
to a speech appliance well, but his success or give him renewed faith in himself and his ap-
failure depends more upon the parental pearance. It will also rebuild the needed arch
attitude than upon his own. The parents are form and supply tooth replacements for
often much more of a problem than the child. normal articulation and mastication.
A second type of appliance which is con- A 14-year-old boy presented with an
structed for children is the hard palate operated bilateral cleft of the lip and hard and
obturator (Fig. 21.76, A). This type is used soft palates together with a loss of the incisors
when a perforation exists in the hard palate in the premaxilla (Fig. 21.77, A). The middle
and the surgeon desires more growth of the third of the face had a dished- out appearance
child before surgical closure. In this type of as a result of lack of maxillary growth. The
case, since the soft palate has been surgically soft palate functions well during speech so
repaired and is func that a pharyngeal section
412 MAXILLOFACIAL PROSTHETICS

FIG. 21.77. A, repaired bilateral cleft lip with dished-out appearance in middle third of face. B and C, frontal and

palatal views of prosthesis. D, prosthesis in mouth.

is not needed on this patient’s appliance. A and F shows the two together. In G, the
frontal view of the appliance is shown in speech appliance and plumper are inserted in
Figure 21.77, B; Figure 21.77, C shows a the mouth. This case exemplifies a practical
palatal view. Note the presence of rugae to aid instance of cooperation between the surgeon,
the patient in tongue placement and orthodontist, and prosthodontist.
articulation. An anterior view, of the patient
Prostheses for Adults
is depicted in Figure 21.77, D.
At times, other procedures need to be Fixed Prosthesis
performed in conjunction with prosthetics. This type of repair becomes the treatment
Such a need was apparent in a 7-year-old boy of choice when the ridge defect is small. A
with an operated right unilateral cleft of the fixed appliance is preferable in all cases when
lip and alveolar ridge and an unoperated stability, longevity, comfort, and appropriate
complete cleft of the hard and soft palates hygiene can be accomplished. Often a separate
(Fig. 21.78, A). A speech appliance with a removable framework is necessary after the
pharyngeal bulb was indicated. In addition, anterior restoration is completed to cariy the
the surgeon felt that the upper lip was very bulb into the pharyngeal area.
tight and might be retarding maxillary growth A perennial problem facing the prostho-
(Fig. 21.78, B). He suggested the construction dontist is the stabilization of the mobile
of a plumper to stretch the upper lip. Figure premaxilla. This situation can be corrected by
21.78, C shows the speech appliance which constructing a fixed bridge from cuspid to
was constructed. In Figure 21.78, D the cuspid. The cuspid teeth which are stable and
appliance is in place in the mouth. The on either side of the free-
plumper which fastens to the appliance is
seen in E,
CLEFT LIP AND CLEFT PALATE 413

floating premaxilla and the remaining sound appliance was constructed to give adequate
teeth in the premaxilla are each reduced for velopharyngeal closure. Figure 21.79, B shows
placement of veneer crowns. After the crowns an intraoral view of the anterior fixed bridge
are constructed, an impression is made in and the prosthetic speech appliance
order to replace any missing teeth and to framework interlocking on the lingual aspect.
solder together the crowns into a fixed In C, the prosthetic speech appliance with a
appliance. This method allows the hollow bulb is shown, and the appliance with
prosthodontist to restore the integrity of the bulb in position is seen in D. E is a close-up of
maxillary dental arch and to provide the the anterior fixed bridge in place,
needed dental-facial esthetics, in addition to demonstrating facial esthetics and occlusion.
stabilizing the premaxilla for adequate dental The natural smile of the patient appears in F.
function.
A 28-year-old man presented with a freely Removable Prosthesis
mobile premaxilla and a foreshortened soft A removable prosthesis is preferred when
palate (Fig. 21.79, A). A fixed bridge was there is a large anterior ridge defect
constructed to connect the mobile premaxilla,
and a prosthetic speech

FIG. 21.78. A, intraoral view of unrepaired cleft of hard and soft palate. B, profile showing tight lip. C, tissue
side of temporary speech appliance. D, appliance in mouth. E, labial plumper. F, labial plumper and speech
appliance. G, speech appliance and plumper in mouth.
414 MAXILLOFACIAL PROSTHETICS

FIG. 21.79. A, mobile premaxilla. B, fixed bridge immobilizing premaxilla. C, speech appliance with hollow bulb.

D, appliance in mouth. E, fixed bridge in occlusion. F, esthetic result.

and/or the middle third of the face is de- 21.80, I). The occlusion is restored (Fig.
pressed. 21.80, J), middle face esthetics are achieved
These prostheses can be further categorized (Fig. 21.80, K), and it is hoped that a happy
into (1) snap-on type and (2) non snap-on type. patient results (Fig. 21.80, L).
Snap-on Prosthesis with No Speech Removable Partial Prosthesis with No
Bulb. Often, with a V-shaped ridge defect Speech Bulb. With a large ridge defect and
(Fig. 21.80, A and B), it may be necessary to extremely poor occlusion, more teeth may be
remove poorly shaped and poorly positioned salvaged to increase the retention and stability
teeth. These patients may be wearing a of the superimposed denture. This prosthesis
temporary acrylic appliance (Fig. 21.80, C). restores the vertical, facial, and occlusal
The abutment teeth need to be properly dimensions of the maxillofacial deformity.
prepared for full coverage (Fig. 21.80, D), In a patient with four maxillary molars, two
either with anatomically carved crowns or on each side, which maintained the vertical
thimble crowns and a Baker (Fig. 21.80, E), dimension of the face, a pharyngeal flap was
Dolder, or other type of bar splinting one side done to effect velopharyngeal closure (Fig.
with the other. 21.81, A and B). The maxillary molars were
A gold framework is designed and cast to crowned to prevent further decay and to give
overlay the bicuspids and clasp the molars; the maximal stability and retention to the anterior
clip attachment engages the anterior cross- prosthesis. Figure 21.81, C shows an intraoral
arch bar (Fig. 21.80, F and G. view of the prosthesis, D shows a front view,
Frequently, during the final prosthetic and E shows a front view in occlusion. In F and
construction phase, the existing acrylic partial G, the patient is seen in profile with- and
denture (Fig. 21.80, H) or a second temporary without the prosthesis. A front view of the
acrylic prosthesis must be modified. This snap- patient with the prosthesis is seen in H.
on prosthesis clasps the molars, overlays the Complete Superimposed Denture With
bicuspids with gold thimbles engaging No Speech Bulb. Another patient manifested
cemented gold thimbles, and clips to the normal mandibular arch devel
anterior bar (Fig.
CLEFT LIP AND CLEFT PALATE 415

opment, but the maxillary arch showed a lack all maxillary teeth (Fig. 21.82, C). Note the
of development (Fig. 21.82, A). Since the precision gold framework with clasps for
patient possessed adequate velopharyngeal retention and stability of the overlay denture
closure for normal speech, the major problem (Fig. 21.82, D). Intraoral views of the
was the vertical dimension of the face prosthesis in occlusion with the mandibular
resulting from overclosure (Fig. 21.82, B). Full teeth are seen in Figure 21.82, E. The overlay
gold crowns were placed on denturfe restores the vertical

FIG. 21.80. A and B, V-shaped ridge defect and ectopic erupted teeth. C, temporary appliance in mouth. D,
preparation of abutment teeth. E, teeth with crowns and thimble crown splinted with Baker bar. F, tissue side of
prosthesis with clip attachment. G, palatal view of prosthesis. H, old partial denture modified for interim use. I,
snap-on prosthesis in mouth. J, occlusion restored. K, patient without appliance. L, patient with appliance.
416 MAXILLOFACIAL PROSTHETICS

FIG. 21.81. A, maxillary molars maintaining vertical dimension. B, pharyngeal flap. C, intraoral view of

prosthesis. D, front view. E, front view in occlusion. F, patient without prosthesis. G, patient with prosthesis. H,
esthetic result.

dimension of the face and gives an ideal arch wire. Velar and pharyngeal portions, of course,
form to the maxillary arch with a full are overlaid with acrylic.
complement of teeth (Fig. 21.82, F and G). An attempt should be made to place the
Snap-on Prosthesis with Speech Bulb. pharyngeal section high so as to prevent
A modern, permanent adult speech appliance interference with tongue movement and also
has the palatal portion attached rigidly to the to keep the bulb small. This will result in a
velar portion. It accomplishes velopharyngeal bulb which weighs less but still uses the
valving by fitting into the nasopharynx and maximal activity of the pharyngeal
contacting its walls and the palatal tags musculature (Fig. 21.83, A). If the bulb is
during deglutition and phonation. Unlike the placed low, it might interfere with tongue
child’s temporary speech appliance, it involves movement during speech and swallowing.
only the permanent dentition, whereas the Certain modifications of the adult speech
child’s appliance involves the deciduous or appliance may be necessary, such a$ crowning
mixed dentition. Also, in the adult permanent and splinting of existing teeth prior to
appliance, the retentive clasps and velar and constructing the speech prosthesis (Fig. 21.83,
pharyngeal portions are fabricated in a precise B). However, with a short or unrepaired palate
gold casting; in the child’s appliance, they are and a speech impairment, the framework
constructed of wrought provides for the pharyngeal extension (Fig.
21.83, C and D).
CLEFT LIP AND CLEFT PALATE 417

This appliance snaps to the bar; overlays the not adequate for velopharyngeal closure. Note
bicuspids, which are out of occlusion, thus the configuration of the soft palate. A superior
gaining stabilization from them; and brings view of the speech appliance is seen in Figure
the anterior teeth forward to help correct the 21.84, B, and C shows the appliance in place
middle face concavity (Fig. 21.83, E). Figure with pharyngeal bulb. A cephalometric
21.83, F shows the mouth in occlusion. radiograph illustrates the location of the
Conventional Speech Prosthesis with pharyngeal bulb within the nasopharynx (Fig.
Bulb. Patients with a full complement of teeth 21.84, D).
may need only a framework clasping the Complete Superimposed Denture with
healthy abutment teeth. This framework Speech Bulb. Another type of prosthesis
carries the palatal, velar, and pharyngeal used by the cleft palate patient is the overlay
portions necessary for speech improvement. denture which may or may not have a
Figure 21.84, A shows an intraoral view of a pharyngeal bulb section. The teenage girl in
patient who presented with a left unilateral Figure 21.85, A presented with a loss of
cleft of the lip and hard and soft palates which vertical dimension and hypernasality with
had been closed surgically. The soft palate nasal emission. A paramount problem in this
length and movement were case was the dished-out appearance of the
middle third of the face (Fig. 21.85; B). Note
the con-

FIG. 21.82. A, underdeveloped maxillary arch. B, overclosure. C, teeth crowned for superimposed denture. D,
tissue side of superimposed denture. E, prosthesis in occlusion. F, restored vertical dimension. G, esthetic result.
418 MAXILLOFACIAL PROSTHETICS

FIG. 21.83. A, large cleft of unrepaired palate. B, crowns and thimble crowns splinted for snap-on prosthesis
with speech bulb. C, tissue side of speech appliance showing telescopic crowns and clip attachment. D, palatal
view of appliance. E, appliance in occlusion. F, esthetic result.
CLEFT LIP AND CLEFT PALATE 419

FIG. 21.84. A, inadequate closure of palate. Note full complement of maxillary teeth. B, tissue side of speech
prosthesis with pharyngeal bulb. C, prosthesis in mouth. D, radiograph showing level of bulb.

structed maxillary arch and the short soft the appliance to the nasal portion of the
palate with little or no mobility (Fig. 21.85; C). appliance.
The permanent upper anteriors were lost, and The appliance for this patient was made in
the remaining upper teeth were crowned to two sections so that the patient could insert
prevent them from decaying. In a case of this the nasal portion above the palatal shelves,
type, it is of cardinal importance to crown the using the. undercut created by the right and
teeth before covering them with the prosthetic left palatal bones. Proper use of these shelves
appliance. M gives additional stability and retention to the
Palatal, lateral, and interior views of the finished appliance.' The patient inserts the
appliance are in Figure 21.85, D, E, and F. nasal portion first. The posterior portion of
The speech appliance with pharyngeal bulb this section of the appliance is muscle-
inserted in the mouth is shown in G. A profile trimmed, as it would be for any speech bulb
view of the patient is shown in H. until proper air flow and resonance balance
Unconventional Speech Aid Pros- are obtained.
thesis. The inside of the appliance is shown in The patient then inserts the denture
Figure 21.86, A and B. Note the cast portion of his appliance. The nasal portion and
framework for clasping the two teeth and the the denture portion of the appliance interlock
gold post for attaching this part of by means of the gold button placed in the
denture (Fig. 21.86, C). The gold button
inserts into a soft acrylic area
420 MAXILLOFACIAL PROSTHETICS

FIG. 21.85. A, inadequate vertical dimension. B, dished-out middle third of face. C, postoperative scarring of
palatal tissue. D to F, palatal, lateral, and interior views of complete superimposed denture with speech bulb. G,
prosthesis in mouth. H, esthetic result.

which is elastic enough to allow the patient to edentulous maxilla and mandible. The cleft in
insert and disengage it at will. the maxilla was wide, and the patient was
The two parts of the appliance interlocked therefore a good candidate for the type of
are shown in Figure 21.86, D. E is an intraoral appliance to be described.
view of the appliance in place, and F is a full A nasopalatal portion and a denture por-
face view with the appliance in place. tion were constructed as previously discussed
Despite concentrated efforts to save every to use the undercut area created by the hard
tooth possible for the cleft palate patient, a palatal shelves.
small minority of these patients are As Figure 21.87, B shows, the patient
edentulous in the maxillary arch. Providing cannot disengage the nasal portion from the
stability and retention of the maxillary denture portion because the two parts are
denture alone presents enough problems for connected by a hinge (Fig. 21.87, C). The
such patients, and adding a speech bulb to the hinge allows the nasal portion to move only in
denture only compounds the problems. a superior-inferior direction (Fig. 21.87, D).
In addition to an unoperated cleft of the When the appliance is in place, close
hard and soft palates, the middle-aged woman approximation of the nasal portion and the
shown in Figure 21.87, A had an denture portion is maintained by attracting
magnets. One magnet is in the nasal portion
of the appliance,
CLEFT LIP AND CLEFT PALATE 421

and the other is in the denture portion. The stream and nasal resonance should be within
magnets maintain tight apposition of the two normal limits.
parts but also allow the patient to remove the The ultimate outcome of any speech
appliance without undue difficulty. The velar appliance will depend upon:
portion of the appliance has a muscle-trimmed A. The attitude and auditory acuity of the
bulb to give efficient velopharyngeal closure. patient.
Figure 21.87, E shows an intraoral view of the B. The patient’s ability to change and
appliance. create new motor skills needed for proper
As the prosthodontist works with the cleft utilization of a speech appliance.
palate patient, there are several fundamental C. The ability of the prosthodontist to
ideas to be kept in mind. create a speech appliance.
1. When impressions are made, the soft D. The ability of the speech pathologist to
palate and tissues of the nasopharynx must teach the patient how to use the speech
not be displaced by the impression materials. appliance.
2. The bulb and tailpiece (velar and Psychologic Considerations
pharyngeal section) of the prosthesis must not
be displaced by velar muscle movements or by The few remarks to be made regarding
psychologic problems in prosthetics are
tongue movements during speech and
swallowing. limited to patients requiring prosthetic speech
3. The nasopharyngeal tissues must be in appliances. There may be occasional cases of
contact with but must not be displaced by the fixed bridges or complete dentures in which
bulb of the appliance during speech and negative results are attributable to emotional
swallowing. problems, but most such problems are
associated with the placement of a prosthetic
4. When the pharyngeal section of the
prosthesis has been properly extended, the speech appliance.
patient should have no nasal emission during In children, the single greatest cause for
the failure to adjust to a speech appliance
speech, and his control of the air

FIG. 21.86. A, large cleft of hard and soft palate with remaining maxillary teeth. B, palatal portion of two- piece
unconventional speech aid prosthesis. C, palatal and nasal portions of appliance. Note central post for attachment
to nasal piece. D, assembled prosthesis. E, prosthesis in mouth. F, esthetic result.
422 MAXILLOFACIAL PROSTHETICS

FIG. 21.87. A, cleft of secondary palate on edentulous maxilla. B, patient inserting hinged appliance. C and D,
palatal and nasal portions of hinged speech appliance. E, appliance in mouth.

is the anxious parent. We have chosen the nostic implications as used by psychologists
term “anxiety” in discussing these parents or and psychiatrists, we use it only to identify
patients because it avoids the subjectivity of what would appear to be excessive and undue
terms such as “nervous” or “high- strung,” and tension on the part of the parents or patient in
because it avoids diagnostic labels such as the treatment situation. Although it may be
“emotionally disturbed,” “neurotic,” or even theoretically possible to have an excessively
“psychoneurotic.” Although the term “anxiety” anxious child patient with calm, composed,
does have diag and under
CLEFT LIP AND CLEFT PALATE 423

standing parents, we have found this to be lems in prosthetics are relatively easy to
true only in cases in which the child was manage as compared with the less frequent
brain-injured or mentally retarded, or pre- but considerably more complex psychologic
sented with primary psychopathology such as problems.
schizophrenia. Fortunately, such cases are The prosthetic speech appliance often is the
rare. key by which the door of normal life is opened.
Conversely, it is theoretically possible to When nature has provided insufficient tissue
find a well-adjusted child patient accompanied for successful surgical closure, the prosthesis
by parents with extremely high anxiety levels. becomes the method of choice. When surgery
This, however, is a most unlikely situation. is to be postponed through the speech
One thing is sure: the prosthodontist must readiness and development periods, a
attempt some assessment, by himself or with temporary speech appliance makes possible
consultative help, of the emotional stability of the acquisition of acceptable and even normal
the prospective patient and, particularly, his speech habits. Many cleft palate adults with
parents. Such judgments are considerably deficient maxillary development find that the
easier if the prosthodontist is associated with speech appliance combined with an antq^ rior
a cleft palate team, in which case he may seek stent and denture, along with the plastic
the opinions of other team members, particu- surgeon’s adjustments in the upper lip and
larly of the team psychologist or psychiatrist. nasal structure, enables them for the first
The prosthodontist who is not associated with time in their lives to speak intelligently, to eat
a cleft palate team may feel impelled to make normally, and to have an esthetically
a treatment decision based upon his subjective acceptable appearance.
impressions of the emotional stability- of
parents or patient. His situation is not at all REFERENCES
unlike that of plastic surgeons; who
1. Adisman, I. K.: Removable partial dentures
increasingly are learning the value of making for jaw defects of the maxilla and mandible.
or seeking such assessments before Dent. Clin. N. Amer. 849-870, 1962.
undertaking certain types of plastic 2. Adisman, I. K.: Cleft palate. M.S.D. thesis.
reconstructive surgery. New York University College of Dentistry
Library, New York.
Our final remarks have to do with an even 3. Aram, A., and Subtelny, J. D.: Velopharyn
more nebulous subject, “self-concept” or the geal function and cleft palate prosthesis. J.
“body image.” Occasionally patients have Prosth. Dent. 9: 149-158. 1959.
rejected the recommendation for a prosthetic 4. Boyle, H. H.: Design for Major Cleft Palate.
Staples Press, Ltd., London, 1957.
speech appliance or, after a time, have even
5. Bruno, S. A.: Prosthetic treatment of maxillo
rejected the appliance itself, since they have facial patients. J. Prosth. Dent. 17: 497- 508,
come to regard it as symbolic of a defect. Some 1967.
have stated quite frankly that the appliance 6. Cooper, H., Long, R.. Cooper, J., Mazaheri,
is, or would be, a constant reminder that they M., and Millard, R.: Psychological, orthodontic
and prosthetic approaches in rehabilitation of
were somehow inadequate or incomplete. cleft palate patient. Dent. Clin. N. Amer. 381-
Perhaps the best one can do in such cases is to 393, 1960.
try to anticipate these attitudes and to 7. Graham, M. D., Schweiger, J. W., and Olin,
institute as much guidance and counseling as W. H.: Hearing loss and ear disease in cleft
palate patients with obturators. Plast. Reconstr.
possible and as soon as possible. Such a course
Surg. 30: 348-358, 1962.
seems particularly suited to the parents of a 8. Gruber, H.: The role of the orthodontist on
young patient; however, considerable caution the cleft palate team in a military hospital.
is advisable in the case of the teenager or Plast. Reconstr. Surg. 38: 560-566, 1966.
young adult. In these cases, attempts to “talk 9. Harkins, C. S.: Principles of Cleft Palate
Prosthetics. Columbia University Press, New
them out of their attitudes” may only intensify York, 1960.
the problem. Anatomic and physiologic prob 10. Hubbard, W. B.: A cleft palate overdenture
appliance. J. Roy. Army Med. Corps 109: 162-
163, 1963.
424 MAXILLOFACIAL PROSTHETICS

11. Jordan, R., Kraus, B., and Neptune, C.: Den Pitman Publishing Company, London, 1954.
tal abnormalities associated with cleft lip and/or 17. Roberts, A. C.: Obturators and Prostheses for
cleft palate. Cleft Palate J., 3: 22-55, 1966. Cleft Palate. E & S. Livingstone, Ltd., London,
12. Lloyd, R., Pruzansky, S., and Subtelny, J. D.: 1965.
Prosthetic rehabilitation of cleft palate patient 18. Rosen, M. S.: Prosthetic speech appliance in
subsequent to multiple surgical and prosthetic rehabilitation of patients with cleft palate. J. A.
failures. J. Prosth. Dent. 7: 216- 230, 1957. D. A. 57: 203-210, 1958.
13. Mazaheri, M.: Prosthetic treatment of closed 19. Rosen, M. S.: Prosthetics for the cleft palate
vertical dimension in the cleft palate patient. J. patient. J. A. D. A. 60: 715-721, 1960.
Prosth. Dent. 11: 187-191, 1961. 20. Sharry, J. J.: Meatus obturator in particular
14. Mazaheri, M., and Hofmann, F. A.: Cinera and pharyngeal impressions in general. J.
diography in prosthetic speech appliance Prosth. Dent. 8: 893-896, 1958.
construction. J. Prosth. Dent. 12: 571-575, 1962. 21. Terkla, L. G., and Laney, W. R.: Partial Den
15. Mazaheri, M., and Millard, R.: Changes in tures. C. V. Mosby Company, St. Louis, 1963.
nasal resonance related to differences in location 22. Veau, V.: Division Palatine. Masson et Cie.,
of speech bulbs. Cleft Palate J. 2: 167-175, 1965. Paris, 1931.
16. McNeil, C. K.: Oral and Facial Deformity. 23. Warren, D.: A physiologic approach to cleft
palate prosthesis. J. Prosth. Dent. 15: 770- 778,
1965.

PART 6: DISORDERS OF SPEECH ASSOCIATED WITH MAXILLOFACIAL


DEFECTS

This portion of the chapter, dealing with broadly enough to include such factors as
speech, is addressed primarily to dentists. stress, rhythm, and vocal inflection (prosody).
Two prefatory comments are offered. First, the Speech is part of language, which is a broader
dentist is trained to use vision precisely, but system of symbols and signs representing
little attention is given to the development of objects, concepts, and thoughts.
discriminating hearing. In contrast, the The most common linguistic symbol is the
speech pathologist relies heavily on auditory word. A word may be exchanged between
skills. If the dentist is to study speech, he people on paper (writing, reading) or through
must cultivate his listening function. Second, the air (speaking, listening). The elements
the study of dental deviations, such as caries comprising the written word (letters) differ
and malocclusions, involves rather precise from those of the spoken word (speech sounds,
cause- and-effect thinking, whereas speech is called phonemes).
influenced by many variables. Moreover, the Telegraphy is an analogous communications
limits of minimal essential structures for good system. Clearly, each system requires an
speech are influenced by compensations in appropriate receiver, signals whose elements
using deviant structures to produce (dots and dashes, phonemes) have meaning by
acoustically acceptable speech. It would be a prior agreement to a code, plus a transmitter.
mistake to underestimate the power of a The analogy with telegraphy is used in
human being to compensate in speaking. discussing normal speech under the following
The present discussion includes a con- topics: the speech receptor, the speech signal,
sideration of normal speech, some speech and the speech transmitter.
disorders, and ways of correcting such dis-
Speech Receptor
orders.
The human ear has a remarkable capacity
Normal Speech to hear and to differentiate sounds differing
Speech is oral language, the expression of minutely in loudness (intensity) or in pitch
thoughts by means of sounds and words. At (frequency). It can hear frequencies ranging
the same time, speech may be defined from 30 to 16,000 Hz (Hertz, or cycles per
second) and intensi
CLEFT LIP AND CLEFT PALATE 425

ties extending up to 130 db (decibels).* To sounds (phonemes) differ. Speech sounds can
some 340,000 distinguishable pure tones be differentiated receptively on the basis of
differing in frequency or intensity could be acoustic properties (frequency and intensity).
added an unlimited number of complex tones They can also be differentiated on the basis of
or noises of differing quality.67 physical properties. Air molecules may be
The question remains, how does the ear’s moved by (1) a restricted air current (fioise) or
capacity to hear pure tones of precise (2) vibrated air (phonation). Speech sounds
frequency (pitch) and intensity (loudness) consist of one or both of these elements. One
compare with its ability to hear speech? In kind of speech sound consists primarily of
short, is the ear set on the right wave length to phon- ated sound, with relatively little flow of
be a speech receptor? air. Another type of speech sound has a flow of
Fortunately, the loudness and pitch air which, when restricted, i.e., placed under
properties of human speech lie well within the greater pressure, produced noises of. relatively
boundaries of the ear’s capacities to hear pure high frequencies. A third kind of sound
tones. Speech of varying intensity, ranging combines elements of these two classes, i.e.,
from a faint whisper (15 db) to average laryngeal phonation plus air flow. These three
conversation (about 67 db) to a loud shout (110 types of speech sounds are identified,
db), are all well within the range of hearing. respectively, as vowels, voiceless consonants,
The frequency characteristics of speech are and voiced consonants. The air-sound
contained within the range from 50 to 10,000 relationship of these three types of speech
Hz. The fundamental frequency of the sounds may be demonstrated by contrasting
speaking voice, produced in the larynx, lies the vowel sound ah ee (as in “I”), the voiceless
between 100 and 300 Hz. Although frequency consonant p (as in “pie”) and the voiced con-
characteristics of formants of speech sounds sonant b (as in “by”).2, 77
extend even higher,11 the critical frequencies The physical properties of speech sounds —
for hearing speech are from 500 to 2000 Hz. namely, phonated sound and air flow— are
Thus, the quietest level of intensity at which a related to acoustic characteristics of frequency
person can hear three pure tones, 500, 1000, and intensity. Vowel sounds (phonated with
and 2000 Hz, will coincide to a remarkable little air) tend to have lower frequencies and
degree with his ability to hear faint speech.10 higher intensities.11, 16 On the other hand, the
Such an assessment of auditory acuity does 10 voiceless consonants, p, t, k, f, th, s, sh, ch,
not measure the listener’s ability to wh, and h (not phonated but with noise pro-
discriminate between speech sounds or to duced by restricted air), tend to have higher
tolerate loud sounds. Although the listener frequencies and lower intensities. Fifteen
could be tested for each capacity—dis- voiced consonants tend to range between
crimination and tolerance—those functions are vowels and voiceless consonants.
presumed normal in the present discussion. In Each speech sound contains several
summary, the ear is viewed as well equipped overtones, in addition to the fundamental
to receive the speech signal. (laryngeal) frequency. Overtones consist of
frequencies which vary in intensity. A set of
Speech Signal frequency points of greater intensity
characterizes each sound. Thus, the 10 to 15
Just as letters used in writing and reading vowel sounds in English may be differentiated
differ in shape, so do speech on the basis of the relationship of overtones, or
formants, created as laryngeal sound vibrates
(resonates) in the pharyngeal and oral cavities.
Figure 21.88 was prepared from data11, 14
* The decibel is a ratio of two pressures or inten- which illustrate the relationships between
sities. Pressure is measured in dynes per square cen- different vowels
timeter. Intensity is measured in watts per square
centimeter. A sound of 130 db involves pressure
1,000,000 (and intensity 1,000,000,000,000) times
greater than the smallest sound that the ear can hear.
426 MAXILLOFACIAL PROSTHETICS

Front Back Speech Transmitter


Four interrelated systems are needed to
produce speech signals: one system for
250
M ee expelling air, another for vibrating air to
□= 00 produce voiced sound, a cavity system capable
1z
ih
00 of shaping voice by making some frequencies
03
E -
o stronger and some weaker, and a system of
500 A
eh aw
o
l_L_ restricting the flow of air/sound. These four
ae uh systems may be identified, respectively, as the
iz ah
human functions of respiration, phonation,
100 reso- nation, and articulation. Each function
0 ■1 __________ i __________________
4000 2000 1000 500 uses specific body structures. Thus, respiration
Second Formant - Hz
uses mouth, throat, trachea, lungs, and
21.88. Acoustic (formant frequency) and
FIG. muscles (such as the diaphragm, abdominal
physiologic (tongue position) correlates of vowel pro- muscles, rib-moving muscles), which can
duction. expand and contract the lungs. Phonation uses
cartilages and muscles of the larynx, especially
the vocal folds. Resonation uses the parts of
in terms of acoustic (first two formants) and
three cavities: pharyngeal, oral, and nasal. It
physiologic (tongue position within the mouth)
may be noted that a cavity, which is not a
factors.
structure itself, uses structures for its
Consonants may be divided further in
boundaries. The oral and nasal cavities
terms of their duration. Three voiceless
contain a common boundary, the palate.
sounds, p, t, and k, are termed stop-plosive as
Articulation uses the palate, tongue, lips, jaws,
air is dammed up and released, in contrast to
and teeth.t Because they are of particular
the other seven voiceless consonants which can
importance in this part of the chapter, the role
be prolonged. Similarly, three voiced
of the palate and the teeth are discussed
consonants, b, d, and g, are stopped, then
separately.
exploded.14
Role of Palate. As noted above, the palate
In summary, speech sounds may be ana-
serves two speech functions, resonation and
lyzed in terms of frequency, intensity, and
articulation. In resonation, it provides for the
duration. Such acoustic characteristics are
exclusion or inclusion (coupling) of the nasal
related to physical properties of sound res-
cavity as an echo chamber for phonated sound.
onation and air flow.
In articulation, it directs the air stream.
Although speech sounds are most readily
However, only three voiced consonants, m, n,
heard, they may be “seen.” Spectrographs
and ng, use the nasal cavity as resonator. For
record an inked plot of varying intensity for
all other consonants and/or vowels, 2 the palate
different frequencies. Although the
directs the air stream out of the mouth. Thus,
spectrographer may need as many as 21
for all but three phonemes, normal palatal
parameters of speech sounds in order to “read”
function precludes significant use of the nose
connected speech reliably,55 a spectrograph
either as a resonating echo chamber or as an
does provide a visual record of acoustic
air duct.
phenomena.11, 15
What manner of structure is the palate and
Exhaled air for speech may be measured in
how does it work? The palate is the
terms of volume, flow, and pressure.22’ 70’ 77
After leaving the throat (pharynx), air emerges
from the body via two cavities: oral (mouth) or
nasal (nose). To the extent that a speech signal
is not intelligible or acceptable, one must look t Although speech sounds may be analyzed as to
how (manner of articulation) as well as where (place of
to the transmitter as the reason for the faulty articulation) they are formed, the present discussion
signal. does not focus on the manner of articulation. See
Reference 51.
CLEFT LIP AND CLEFT PALATE 427

floor of the nose and, at the same time, the pharyngeal closure does not rely solely upon
ceiling or roof of the mouth. Architecturally, as this movement of the velum. There may be
shown in Figure 21.89, the palate may be simultaneous medial movement of the side
thought of as the wall and door separating one walls of the throat, as well as movement of the
room (the nose) from another room (the back wall of the throat toward the knuckling
mouth). Each room may be separated from, or velum.21 Thus, in the analogy of the fldor plan,
connected to, a hall (the throat), depending not only does the door swing across the top of
upon the location of a swinging door, the the hall, but the three other sides of the
velum or soft palate. That door, together with doorway move toward the door to contribute to
the tongue, may block the oral room, requiring closure.
the use of the nasal room. At other times, the Some degree of closure is present for
door may swing to block the entrance from the various activities: blowing through the mouth,
throat hall into the nose room. In effect, such swallowing, and making most speech sounds.
blocking includes three segments: the firm While air is being breathed in and out of the
wall, the moving door, and the doorway. lungs, the door may be in any position: closing
Anatomically, these segments correspond, off the nose room (breathing through the
respectively, to the hard palate, the soft mouth), closing off the mouth room (breathing
palate, and the velopharyngeal isthmus and through the nose), or ajar to some degree.
its borders. Clearly, the ability to close off the nose
The rest position of the palate is achieved room from the other rooms depends upon
when the soft palate, or velum, curves down in many factors: a palatal wall which is intact, a
an arc, approximately one- fifth of a circle, velar door which is both large and mobile, and
extending from the horizontal hard palate. a velopharyngeal doorway which is not too
Normally, the velum moves up and back large.
toward the back wall of the throat. This Role of Teeth. The teeth, anchored in the
movement is greatest in the middle third of jaws, are part of the articulatory mechanism.
the velum which seems to “knuckle” up and Although posterior teeth do not appear to
back.7 Often the posterior third of the velum contribute significantly to the articulation of
lies vertically along the back wall of the speech sounds, anterior teeth, especially
pharynx while the rest of the velum is incisors, can contribute,
horizontal. Velo

FIG. 21.89. Speech cavities and their separations.


428 MAXILLOFACIAL PROSTHETICS

XT'
pairs (one voiceless, one voiced) of sounds
produced at three different places in the
mouth. Acceptable s and z sounds appear to'
be made in either of two ways. A speaker may
use the longitudinal tongue furrow to channel
air against approximated incisal edges. This
method allows the tongue tip to touch lingual
surfaces of lower incisors, so long as upper and
lower incisal edges have a minimal (1 to 2 mm)
vertical (superior-inferior) gap and/or hori-
zontal (anterior-posterior) gap.
If either gap is appreciable (i.e., by anterior
open-bite, prognathism, or over-jet), the
speaker’s difficulty in constricting air flow
FIG. 21.90. Atypical s; lower lip against upper teeth may cause him to approximate upper incisors
constricts air flow. with the lower lip (Fig. 21.90) or to elevate the
tongue, with the tip contacting upper incisors,
alveolar ridge, or rugae. If the tongue does not
particularly for 10 specific consonants. They do
elevate sufficiently and merely reaches the
so essentially by constricting the flow of air
interdental space, the resulting sound tends
and sound. Flowing air, so constricted, creates
toward th, a frontal lisp. If the elevated tongue
a noise. Indeed, some sounds are termed
contact is too complete, air is forced around
“fricatives” to describe the friction-like way in
the sides of the tongue, causing a lateral lisp.
which they are produced. Flowing air is
Customarily, the elevated tongue position
restricted for / and v by placing the lip against
provides a midline triangular aperture
the incisors. One may note variations in the f
through which turbulent air/sound may
as different parts of the lower lip (vermilion
emerge. In the event of a large diastema, this
border, superior surface, medial aspect)
triangular escape route (and the tongue tip)
approximate the upper incisors. A similar
may be shifted slightly to the side (Fig. 21.91)
sound may be produced in the atypical manner
to allow air to bounce against the surface of a
of upper lip to lower incisors.
central incisor.
Two th sounds (as in “thin,” “then”) are the
result of air flow restricted by the tongue
against the incisal edge of upper and/or lower
incisors. The th sounds shift toward t and d as
air flow is increasingly constricted by abrupt
tongue-sealing against the lingual surface of
upper incisors, even if the tip is protruded
beyond the incisal edge. Although incisor
dentition generally is used in articulating
these four fricative consonants, the requisite
restriction of air need not rely on teeth, as evi-
denced by the edentulous person who uses the
gingiva and alveolar ridge or ridges for lip or
tongue contact to produce acoustically
acceptable, recognizable fricatives.
Six additional consonants contain friction-
like elements of hissing and hence are termed
sibilants. These six sounds include
FIG. 21.91. Atypical s; lateral shift of tongue directs
air against lingual surface of incisors.
CLEFT LIP AND CLEFT PALATE 429

Space vacated by a missing incisor may be be described by various terms: hypernasality,


filled by tongue margin. rhinolalia aperta (nose open), and excessive
The four sh-like sibilants, sh, zh, ch, and j, nasality.
involve retruding the tongue from the s and 2 Three consonants, m, n, and ng as in the
position. With adequate incisor approximation, word “morning,” demand nasal resonance and
the tongue tip may be free of any contact. If may be faulty if there is insufficient nasal
the incisor gap is appreciable, the requisite resonance. Other terms for this condition are
constriction may require contact of tongue hyponasality, rhinolalia clausa (nose closed),
borders and palate, except for midline opening. and denasality. The effect has been likened to
Normal speech may be identified in terms talking with a cold in the nose.
of acoustic and physical properties that Denasality will cause nasal consonants m,
correspond to physiologic factors, which may n, and ng to be changed in the direction of b, d,
vary. Although the boundaries of physiologic and g, respectively. At its worst, denasality
variation are somewhat imprecise, speech is will cause the sord “morning” to sound like
likely to become disordered when those “bordig,” will preclude breathing through the
boundaries are crossed. nose, and will render humming impossible
without occlusion of the nares.
Disorders of Speech
Articulation. A given speech sound may
Speech may be faulty in several ways. In be misarticulated in three ways: it may be
the present part of the chapter, disorders such distorted, yet recognizable as the intended
as stuttering, dysphasia, or dysphoniaij: are sound; it may be replaced by another speech
omitted in favor of disorders whose association sound; or it may be left out. Such a kind of
with maxillofacial defects is more clearly error (distortion, substitution, omission) does
established or presumed. not, per se, reveal the degree of error. In this
A maxillofacial defect may influence speech sense, there is a continuum of probabilities for
(1) by changing the resonance properties of the certain errors. At one end there are those
vocal tract through inappropriate coupling of errors, usually substitutions, which seldom
the nasal cavity, and/or (2) by changing the appear as articulatory deviations except as
capacity to impound, direct and constrict the associated with maxillofacial defects.
flow of air. Another way of designating the To the extent that air pressure is required
first of these problems is “disturbed nasal for articulation, e.g., of voiceless consonants,
balance.” any perforation in the seal of the vocal tract
Nasal Balance. The nasal balance may be may be expected to result in a distortion
upset in either direction, with too much or too caused by the escape of air. Nasal escape may
little resonance in the nose. When nasal result from a palatal fistula or marginal
resonance is too great, a speaker sounds as velopharyngeal closure. A larger opening, e.g.,
though he were “speaking through the nose.” an unoperated cleft palate or a hole in the
This voice quality may cheek, may cause the speaker to change his
release of air in terms of (1) force or air
pressure, or (2) constrictor site. Articulatory
force may be decreased or increased.
Decreased force of air release in articulation
t Palatal defects do not alter the basic pitch or
fundamental frequency of the voice. Moreover, palatal tends to minimize the impact of the perforate
defects do not change the loudness or intensity of vocal tract. Increased force of exhalation
laryngeal phonation (even though accompanying speech merely intensifies the air loss. Forcing more
may seem to be muffled or weak because of lowered air out quickly, when velopharyngeal closure
pressures of consonant articulation). However, among
persons whose palates have been defective, a greater
than average number do appear to be hoarse or breathy
to some degree,85 perhaps with vocal nodules as
concomitantly altered laryngeal structure. 40
430 MAXILLOFACIAL PROSTHETICS

is incomplete, results in a nasal snort. This the hose, not only will nozzle adjustments
sound of air driven from the nostrils may be prove ineffective, but effective adjustments
likened to the quick, nose-clearing snort of must be applied to the host between the faucet
exhalation ascribed to prize fighters. Although and the defective point of the hose. Such
the nasal snort may emerge during a plosive adjustments are likely to require kinking,
or sibilant, it is more apt to occur with a bending, or otherwise blocking the hose. After
fricative, e.g., /, v, th. the leak in the hose has been repaired, one
Substitutions with distinctive, unfamiliar must unlearn the previous habit of attempting
acoustic properties result from atypical to control the flow by kinking, bending, or
articulations. The person with a defective blocking the hose in order that nozzle
palate replaces the intended oral consonant adjustments now may be effective.
with a sound which is formed farther down the Apart from the unusual faults of articu-
respiratory tract. Ostensibly, the goal is to lation noted, the speaker may exhibit a full
constrict the air before it can be acted upon spectrum of more common errors, including
adversely by a defective palate. vowel distortions (“pop” for “pipe”), consonant
A glottal sound, used most frequently in distortions (“cah” for “car”), consonant
lieu of stop-plosives, p, b, t, d, k, g, results substitutions (“teef ’ for “teeth”), or, consonant
when the vocal folds are brought together and omissions (“bow” for “boat”). Such errors may
subjected to increased air pressure from the be demonstrated by the child who has had a
trachea below. As the vocal folds pull apart, palatal defect, not because of the palatal defect
air explodes from the glottis in a sound which but because he is a child.
resembles a slight cough.58
Testing for Speech Disorders
A pharyngeal sound, usually taking the
place of a sibilant consonant s, z, sh, zh, ch, j, Moll has pointed out66 that faulty artic-
is produced seemingly when some part of the ulation, as well as problems resulting from
back of the tongue approximates but does not disturbed nasal balance, are by definition
completely block the back wall of the throat. A problems only when perceived as such.
friction sound, somewhat like an h, results as Listener perception is not merely a bothersome
air is forced through the restricted corollary of disordered speech, it is a sine qua
passageway.47 non.
A palatal sound is a variant of the pha- With rare exceptions, in order for speech to
ryngeal. It also is most likely to appear for a be judged as faulty, it must sound faulty.
sibilant. The sound, formed when the back of Speech disorders are heard. Indeed, testing the
the tongue extends up toward the soft palate, speech of a person who has had (or may have
yields a fricative element which sounds like a had) a defective palate should involve listening
whispered he, such as begins the word “Hugh.” to his speech before looking at his palate.
Although these atypical errors of articu- Nasal Balance. A voice which sounds
lation may appear in the speech of a person disordered concerning the balance of nasal
who always has had a normal palate,58 the resonance may be tested further by using
increased likelihood of their existing in the specific speech sounds. It may be recalled that
speech of a person who has had a defective vowels are produced with resonated sound and
palate may be illuminated by the following little air flow. Vowel sounds such as ee and oo
analogy. The vocal tract may be likened to a are most suitable§ in
garden hose; so long as the hose is intact,
alterations of the nozzle at the end of the hose
determine how the water will emerge.
However, if there is a hole or a leak in the
middle of § Despite some indication that low vowel sounds,
such as ah, are more likely to be perceived as deviant in
cases of functional nasality, 34 high vowels are more
likely to be perceived as faulty in cases of organic
nasality.25' 43
CLEFT LIP AND CLEFT PALATE 431

testing for hypernasality. A nasal consonant not been able to measure nasality acousti-
such as m is most suitable in testing for cally.9 However, tests and tools do aid in
hyponasality. Thus the word “me” or “moo” assessing perceived nasal balance.
may be used to demonstrate both ample nasal Pinching and releasing nares together can
resonance (on m) and adequately delimited reveal changes in ee or oo which indicate cul-
nasal resonance (on ee or oo). The impression de-sac resonance of nasality, as well as
that the sound is coming through the nose may changes in a‘consonant (such as s) which
be corroborated in various ways: for example, indicate nasal emission. Instrumentation may
if the bridge of the nose is felt to vibrate be used to measure nasal emission more
unduly, or if the prolonged vowel changes precisely. 31- 70- 79- 82
when the nostrils are alternatively occluded Objective testing to understand perceived
(by pinching) and released. nasality may include radiographic42 or
Voiceless consonants, produced with more manometric procedures.84
air flow rather than resonated voice, manifest Articulation. Articulation which sounds
nasality as nasal emission of air rather than different from normal may be recorded with
as nasal resonance. Nasal emission is most phonetic symbols on paper, as well as
likely to emerge on voiceless consonants such electronically on tape, disc, or spectrogram. In
as s, /, or p. Such nasal emission may not be addition, the speaker’s potential sounds may
heard as readily as it is felt (by a finger held be tested by having him copy the exaggerated
across the upper lip under the nostrils) or seen yet accurate speech sounds produced by the
(as a force from the nostrils sufficient to cloud tester. The speaker may talk with his nostrils
a cold mirror, displace a feather, deflect a open as well as with his nostrils occluded, in
candle flame or, more precisely, appear as order to attribute faulty articulation to
oscillographic deviations actuated by strain velopharyngeal incompetence (improved with
gauges). nares occlusion) and/or mal-learning (not
Testing for nasal balance may begin and improved by occlusion).
end with a listener’s judgment as to whether a Speech may be disordered in how it looks
speech sample has too much or too little nasal as well as how it sounds. Nasal alae may be
resonance. Such testing may be made seen to wrinkle in a futile, grimacing attempt
somewhat more reliable by having the sample to close the nares during some speech sounds.
include connected speech as well as phrases In addition, a person who has had a palatal
and single words and sounds, by having defect is more likely to use the tongue in ways
several listeners, and by making judgments that look different, even if they sound all
along a scale of several degrees of impairment. right. In particular, n, t, d, and l may be
60- 64- 65 Thus far, there is no acceptable
articulated with a disproportionate use of
yardstick of nasality, such as a recording, tongue movement in a horizontal, as opposed
against which to match a sample. Thus it to a vertical, plane.37 In uttering n in a word
should not be'too surprising that listeners do such an “banana,” the tongue may be seen to
not agree completely on judgments of nasal- protrude even beyond the lips.
ity.4 The fact remains that nasality is best
determined by listener judgment, a test of Relating Disorders of Speech to Maxil-
perception. lofacial Defects
Objective corroboration may be sought with After disordered speech has been analyzed,
instruments which measure acoustic the maxillofacial defect must be identified
correlates of nasal resonance12- 30 and/or nasal before a causal relationship can be
established.
air pressure-flow. 79, 82 Thus far, instruments
Consequences of a maxillofacial defect will
such as the spectrograph have
vary considerably, according to
432 MAXILLOFACIAL PROSTHETICS

whether it emerged at birth (congenital) or damage to the central nervous system, e.g.,
after speech habits were established (ac- cerebral palsy,24 amyotrophic lateral sclerosis,
quired). Variation is particularly evident in poliomyelitis, myasthenia gravis, or myotonic
viewing disordered resonance as opposed to dystrophy.83 One other example of an acquired
disordered air flow. defect presumes a congenital defect as well.
Whereas a tonsillectomy and adenoidectomy
Congenital Defects usually result in hypernasality for 2 to 4 weeks
A cleft palate is the most frequent mani- only, the hypernasality may continue
festation of a congenital maxillofacial defect. In indefinitely if the preoperative palate had a
addition to an overt cleft, the child may be congenital shortness or submucous cleft.
born with a discrepancy in size of the palate: The fact that the defect is acquired implies
the hard palate may be too short, the soft a number of things. The presumption of prior
palate may be too short, or the velopharyngeal normalcy of structure (and resonance) implies
space may be too large.3 Determining the that normal articulatory gestures had been
discrepant length element may require special present to impound, direct, and constrict the
tests, such as lateral roentgen films. The child air stream. Thus, correcting the palatal defect
may be born with a palate which is intact and simultaneously restores order to articulation
long enough, yet poorly moving. Limited velar as well as to nasal balance.
mobility may be differentiated by the neu- If the palatal defect is not corrected,
rologist in terms of a supranuclear or in- consonant articulation is likely to become
franuclear lesion. disordered as a result of changes of force as
More frequently, a clinical judgment of the well as changes in constrictor site.
intactness, length, and mobility of the palate is In relating disordered speech to maxillo-
based upon visual evidence: peroral facial defects, additional information and
observation, lateral radiographic views (via caution may be needed. For example, excessive
static .roentogenographic fluoroscopic, nasality on low vowels (e.g., ah, aw, uh) but
cinefluoroscopic, or teleradiographic extensions not on high vowels (ee, oo) is characteristic of a
of vision) which relate the palate to the palate which is not defective but merely held
posterior pharyngeal wall. Of value also are down voluntarily, i.e., a functional disorder.86
tasks of velopharyngeal function, such as Moreover, atypically disordered articulation
blowing64- 65 and inhaling,8 as portrayed on a (e.g., glottal stop, nasal snort) in the absence of
manometric test. any demonstrable maxillofacial defect may
Acquired Maxillofacial Defects exist idiopathically. Thus, the glottal stops of
Cockney or urban speech do not imply velar
A maxillofacial defect may be created by
deficit. An idiopathic nasal snort of s or z may
design or by accident. If a portion of the
exist in the absence of hyperna- sality. It may
boundary of the oral cavity is malignant, the
be countered by occluding the nares, thereby
surgeon may need to excise tissue.il
inducing the speaker to lower the tongue from
Occasionally a palatal hole is created ad-
its palatal seal and to resume an oral release
ventitiously, when part of the mouth is pierced
of air.
or cut away by an object such as a stick.
Incidentally, the removal of the uvula— Correcting Disorders of Speech Asso-
through surgical act or accident— does not by ciated with Maxillofacial Defects
itself disorder speech or produce excessive use The correction of speech disorders asso-
of the nasal pathway.32 Occasionally a palatal ciated with palatal defects presumes the
defect emerges from attempt to correct the palatal defect itself. It is
1 Removal of part of the tongue, alveolus, or man- difficult to justify speech therapy with a person
dible, short of breeching the oral cavity, may be pre- whose palatal cleft is patent. On
sumed to affect articulation without affecting nasal
balance.
CLEFT LIP AND CLEFT PALATE 433

the other hand, the act of providing a cover for turate a space. In either case, the goal is to
the palatal cleft should not be equated with provide a substitute palate which, in con-
correcting the palatal defect or with correcting junction with adjacent structures, permits
associated speech disorders. satisfactory velopharyngeal function by
The correction of palatal defects involves providing both the inclusion and the exclusion
substitution and/or compensation for the of the nasal room as resonator and airway.
defective palate. Substitution results when Speech may be facilitated by the plastic
the surgeon uses a procedure to remove an surgeon or the maxillofacial prosthodontist in
obstacle in the nose, to close a hole in the various ways. Resonance and articulation may
palate, to add length to a palate, or otherwise be aided by creating a seal to combat any hole
to replace old structure with new by plastic or perforation in the oral cavity, i.e., cheek,
surgery. Substitution also results when the roof, or floor of the mouth. Nasal balance and
prosthodontist uses dental materials to mold a articulation may be aided by correcting flaws
structure by which to ob of palatal intactness, length, mobility.
Surgical

FIG. 21.92. Edentulous woman, 77 years old. A, palatal cleft. B, 45-year-old flanged black rubber obturator in
position. C, upper dentures and old obturator in place. D, lateral x-ray of new prosthesis, at rest.
434 MAXILLOFACIAL PROSTHETICS

FIG. 21.93. Girl, 16 years old, with cardiac problem. A, peroral view, overt cleft. B, peroral view, speech
prosthesis in mouth. C, lateral x-ray, at rest, with speech prosthesis in mouth. D, lateral x-ray, during ee, with
speech prosthesis in mouth.

corrections are considered in Part 2 of this rected by inserting a flanged acrylic button.
chapter. Prosthetic corrections are discussed Prosthetic correction of a velar defect may use
from the viewpoint of the speech pathologist. an anteriorally fixated base on which to
anchor a palatal lift18’ 20 or a speech bulb.
Prosthetic Correction Efficacy of such instruments for speech may be
demonstrated by tests of nasal balance, e.g.,
A small breach of palatal integrity (fistula or me, and ability to impound and release
hole in the hard palate) may be cor articulated air/sound orally.
CLEFT LIP AND CLEFT PALATE 435

A person may elect to use prosthetic rather seemingly complete obturation, the bulb
than surgical closure of an overt cleft. When permitted nasal breathing and uttering nasal
the 77-year-old woman illustrated in Figure consonants.
21.92 was 20 years old, a dentist fabricated a The man depicted in Figure 21.94 had a
flanged rubber plate which snapped into the maxillary resection for a tumor. The pros-
cleft margins. Persistent hypernasality, as thesis provided correction of the anterior and
well as pharyn- gealized k and g, may relate to lateral defects of the teeth and arch, as well as
the failure of the prosthesis to obturate her the correction of the resonance imbalance
velopharyngeal port. New dentures and a caused by the perforate maxilla.
speech bulb extend obturation posteriorally to The edentulous patient who acquired a
facilitate velopharyngeal closure. maxillary defect from surgical excision of a
The subject in Figure 21.93 is a 16-year- old carcinoma (Fig. 21.95) had sufficient retention
girl whose cardiac problem precluded surgical for dentures, in part because of the way in
management. The lateral radiograph suggests which his maxillary opening was obturated.
skeletal defects which include scoliosis. Her Because it was an anterior defect, nasality
prosthesis facilitated the gradual correction of after surgery was less than might be expected
articulation errors and reduction of for a defect of this size. Normal nasal balance
hypernasality. Despite and articulation accompanied insertion of the
prosthesis.

FIG. 21.94. Elderly man with acquired palatal defect, dentition present. A, before surgical excision of tumor. B,
postoperative maxillary defect. C, prosthesis to cover anterior defect involving left maxillary arch. D, prosthesis in
place.
436 MAXILLOFACIAL PROSTHETICS

An individual with an intact palate which


moves toward marginal velopharyngeal closure
may use a palatal lift as a training device.
Lifting the velum up and back seeks to
stimulate greater compensatory movement
mesially of lateral and posterior pharyngeal
\valls. An individual with an intact palate
which moves minimally (Fig. 2L96) may use a
palatal lift to obturate the velopharyngeal port
as much as possible, on the assumption that
minimal pharyngeal wall activity will be
evoked.
Prosthetic correction of anterior deviations
of occlusion may use artificial teeth and/or
acrylic covering of the hard palate. Speech is
more likely to be facilitated when there is
minimal vertical or horizontal discrepancy
between upper and .lower incisal edges in
centric, and limited spacing between teeth, to
facilitate sounds such as s. Palatal covering
should have minimal mass, i.e., acrylic should
not be too thick, yet countoured for tactile feed-
back during sounds involving elevation of the
tongue tip such as n, t, d, l. Such feedback may
be aided by distinguishing the midline of the
rugae and roughening, elevating, or recessing
the surface.
Compensatory Correction
Compensation may evolve when the nasal
room is used too much (hypernasality)—seldom
when the nasal room is used too little
(hyponasality). Compensation results when the
structural defect of the palate is so slight that
it can be overcome or offset by increased or
atypical function. Such a function may occur in
any of three structures surrounding the
velopharyngeal port: the velum, lateral
pharyngeal walls, or posterior pharyngeal wall.
In some instances, the velum compensates by
reaching superiorly more than posteriorally
(Fig. 21.97), or by extending its posterior third
horizontally rather than vertically. In some
instances, the lateral pharyngeal walls
compensate by moving medially to remarkable
degrees. 25, 74 In a few instances, the posterior
pharyngeal wall compensates by moving
anteriorally (Fig. 21.98) in a remarkable bulge,
FIG. 21.95. Man with acquired palatal defect, termed Pas- savant’s pad.0 ""
edentulous, 72 years old. A, after surgical excision of
maxillary lesion. B, tissue side of the obturator,
showing the hollow bulb. C, obturator inserted in
mouth.
FIG. 21.96. Intact palate with inadequate velar mobility. A, peroral view, at rest. B, lateral radiograph, at rest.
C, lateral radiograph, uttering ah. D, palatal lift prosthesis. E, peroral view, palatal lift in mouth. F, lateral
radiograph, palatal lift in place. (Courtesy of Dr. W. R. Laney.)

437
438 MAXILLOFACIAL PROSTHETICS

SHORT PALATE AT REST VP CONTACT - SUPERIOR >POSTERIOR


FIG. 21.97. Girl, 6 years old, velopharyngeal closure more superior than posterior. A, short palate at rest. B,
atypical closure during ee.

CONGENITALLY SHORT - AT REST PASSAVANT CUSHION, CONGENITALLY


SHORT PALATE - "EE"

FIG. 21.98. Girl, 12 years old, no overt cleft. A, lateral radiograph, at rest. B, lateral radiograph, during ee;
Passavant bulge almost reaches extended velum.

In addition to these physical actions, ond, increasing the pressure of consonant


compensation is facilitated by certain speech articulation, or modifying the position of the
modifications: raising the pitch, 27 talking tongue, pharynx, or larynx.66
faster than two syllables per sec Efforts to compensate for velopharyngeal
CLEFT LIP AND CLEFT PALATE 439

closure are best appreciated by recognizing 6. Calnan, J.: The error of Gustav Passavant.
that adequate compensation can develop Plastic Reconstr. Surg. 13: 275-289, 1954.
7. Calnan, J.: Palatopharyngeal incompetence in
within limits of physiologic gaps which are
speech. In Congenital Anomalies of the Face and
rather narrowly, if imprecisely, defined. At the Associated Structures, edited by S. Prun- zansky,
same time, even these limits may be violated, pp. 104-122. Springfield, 111., Charles C
with consequent hypernasality, under certain Thomas, Publisher, 1961.
conditions, such as fatigue at the end of the 8. Chase, R. A.: An objective evaluation of palato
pharyngeal competence. Plastic Reconstr. Surg.
day. 26: 23-39, 1960.
When efforts to compensate do not succeed 9. Curtis, J. F.: The acoustics of nasalized speech.
in reducing nasality (or when the standard of Cleft Palate J. 7: 380-396, 1970.
speech does not allow for any imperfection), 10. Davis, H.: Hearing and Deafness. Murray Hill
Books, New York, 1947.
substitution may be required.
11. Denes, P. B., and Pinson, E. N.: The Speech
Compensation and/or substitution are Chain, Bell Telephone Laboratories publication.
designed to correct problems of nasality. Such Waverly Press, Baltimore, 1963.
compensation or substitution facilitates, but 12. Dickson, D. R.: Acoustic study of nasality. J.
does not automatically provide for, the Speech Hear. Res. 5: 103-111, 1962.
13. Dickson, D. R.: A radiographic study of nasality.
correction of disorders of articulation. Such Cleft Palate J. 6: 160-165, 1969.
disorders are ameliorated by learning to use 14. Fairbanks, G.: Voice and Articulation Drillbook,
the habilitated speech equipment differently Ed. 2. Harper &. Brothers, New York, 1960.
for improved production of consonants. Old 15. Fant, G., Phonetics and speech research. In Re
search Potentials in Voice Physiology, edited by
patterns of articulation may need to be
D. W. Brewer, pp. 199-239. State University of
unlearned before new articulatory gestures New York, New York, 1964.
are learned. For example, if l were made with 16. Fletcher, H., Speech and Hearing in Communi
a back of tongue-velar contact, or if p were cation. D. Van Nostrand Company, New York,
made by the glottis, the short-stopping effect 1953.
17. Fujimura, O.: Spectra of nasalized vowels. In
of these gestures down in the speech tract Quarterly Progress Report 58, pp. 214-218.
would have to be eliminated to permit the Research Laboratory of Electronics, Massa-
appropriate oral gesture to have effect. Thus, chusetts Institute of Technology, Cambridge,
the surgeon and/or prosthodonist should not July 15, 1960.
18. Gibbons, P., and Bloomer, H.: A supportive-type
expect to achieve “good speech” by his
prosthetic speech Aid. J. Prosth. Dent. 8: 362-
intervention alone in all cases of maxillofacial 369, 1958.
defects. 19. Goetzinger, C. P., Embrey, J. E., Brooks, R.,
and Proud, G. O.: Auditory assessment of cleft
palate adults. Acta Otolaryng. (Stockholm) 52:
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440 MAXILLOFACIAL PROSTHETICS

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CLEFT LIP AND CLEFT PALATE 441

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J. D.: Palatal function and cleft palate speech. J. 103-113, 1966.
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70. Subtelny, J. D., McCormack, R. M., Curtin, J. flow technique for measuring velopharyngeal
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intraoral air pressure, nasal airflow— before and Palate J. 1: 52-71, 1964.
after pharyngeal flap surgery. Cleft Palate J. 7: 82. Warren, D. W., and Ryon, W. E.: Oral port con
68-90, 1970. striction, nasal resistance, and respiratory as-
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72. Subtelny, J. D., Sakuda, M., and Subtelny, J. 84. Weinberg, B., and Shanks, J. C.: The relation
D.: Prosthetic treatment for palatopharyngeal ship between three oral breath pressure ratios
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Cleft Palate J. 3: 130-158, 1966. with cleft palate. American Cleft Palate Asso-
73. Subtelny, J. D., and Subtelny, J. D.: Intelligi ciation meeting, Portland, Oregon, April, 1970.
bility and associated physiological factors of cleft 85. Westlake, H., and Rutherford, D.: Cleft Palate.
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75. Van Demark, D. R.: Misarticulations, and lis 29: 471-479, 1944.

*
:
*•

• .

.
|
Index

Abbe flap, 164 Amplitude display unit, 368 Anal


lip switch operation, 382, 400, 401 atresia, 30 Analgesics, 207
Accident, 351 automobile, 331-332, Anchorage point, 352 Anemia, 13, 17
349 Acid etching technique, 392 Anencephaly, 30 Anesthesia, 209,
Acinar cell adenoma, 74, 75 tumor, 376, 389 Anesthesiologist, 332
175 Ankylosis, 41 glossopalatine, 31
Acrocephalosyndactyly, 31, 41 Acrylic temporomandibular, joint, 349
acid, 314 Acrylic film, 102 resin, 8, 89, Anoxia, 35
90, 158, 360, 436 skin, 96, 101-104, 107 Anterior pituitary hormone, 43
skin coloring, 106 ACTH, 64 Antibiotics, 193, 202, 203, 207, 342
Actinomycin D, 179 Adamantinoma, 79 aureomycin, 160 mycostatin, 160
Adenoameloblastoma, 82, 173 vancomycin, 160 Antitragus, 27
Adenocarcinoma, 74, 75, 171, 179, 189 of Anxiety, 421-423 Apert’s syndrome,
acinar cell, 75, 175 ofbr_east, 179 274 Aplasia, 63, 65 Arch bar, 211,
of uterus, 179 , 213, 330 branchial, 26, 44 first, 41-
Adenocyst carcinoma. See Cylindroma 44, 268 second, 41, 44, 268 fixed
Adenocystic basal cell carcinoma, 75 lingual, 394 hyoid, 41 lingual, 394,
Adenoid cystic carcinoma, 75 395 mandibular, 39, 42, 161
Adenoidectomy, 431 Adenoma acinar maxillary, 161, 389 removable
cell, 74, 75 malignant pleomorphic, 75 lingual, 394 syndrome, 268 upper,
oxyphilic, 73, 75, 175 pleomorphic, 74-76, 359 W, 394, 395
175 sebaceous cell, 75 Adhesive, medical Arrhinencephaly, 35, 36
grade, 106, 129 Adrenalin, 35, 376 Arthritis, 13, 17
Agenesis, 42 Agnathia, 42, 64 Airbrush, rheumatoid, 42
106 Air flow in speech, 425 Airway Arthromyodysplasia congenita, 31
obstruction, 209 Alcohol, 70, 164, 171 Arthroplasty, subcondylar, 349
Articulation, 9, 426, 429, 431, 433
Alginate impression, 97, 100, 362 Alginic
consonant, 431 faulty, 430
acid, 114 Alloy, 159, 330, 331, 339
Articulator, 136 Asai technique, 172
Albumin, 339 mesh, 333
Ascher’s syndrome, 40 Atresia, 42
Alveolar ridge, cancer, 169
anal, 30
Ameloblastoma, 79-82, 173 pigmented,
Attachment, 127
83 pituitary, 64
Aureomycin, 160
American Dental Association, 2

443
444 INDEX

Austenol, 342 Automobile accident, Cancer


349 collision victim, 331-332 alveolar ridge, 169 cheek, 324
Avitaminosis, 35 disappearing, 184 epiglottis, 171
gingiva, 187, 190 glottis, 172
Bacteria on teeth, 204 Baker bar, 152, 156 head, 163-207 host resistance,
Balance, disturbed, 430 nasal, 429-433 180 larynx, 170, 171 lip, 163, 164
Bandage, Barton, 347, 348 Banding, 399 neck, 163-207 nose, 267 oral
Barsky operation, 382 Bar splint, arch, 211, cavity, 187 postcricoid region,
213, 330 Baker, 152, 156 transpalatal, 149 171 pyriform fossa, 171 salivary
Barton bandage, 347, 348 gland, 169 skin, 176 subglottis,
Basal cell carcinoma, 9, 14, 20, 67, 68, 75, 173, 176, 179, 172 survival rate, 180 tongue,
181, 183, 184, 187 Baseloid mixed tumor, 75 Basic four 164
food groups, 259, 260 Beard growth, 20 Bench vise, 285 Carcinoma, adenocystic, See Cylindroma basal cell, 9,
Benzoic acid, 93 Benzoyl peroxide, 93 Bernard- 14, 20, 67, 68, 75, 173, 176, 179, 181-184, 187 breast, 17
Burrough technique, 164-165 Betel nut chewing, 71 buccal mucosa, 71 ear, 277
Billiard ball, 89 Biopsy, 171 epidermoid, 67-69, 75, 170
Bite correction, 217, (See also Malclosure) wafer, 340 esophageal, 172 excision, 435
Blair-Ivy loop, 212 Blepharqchalasis, 40 Boiler, double, floor of mouth, 71 gingiva, 71
285 Bone displasia, 281 facial, 348-350 grafting, 382 head, 13 intraoral, 170 larynx,
necrosis, 190, 193, 199, 201, 202 172
reconstruction, 348-350 Brahe, lip, 68-70, 164, 185, 189, 255
Tycho, 1 Brain, 51 maxillary antral, 72, 169, 173
defect, 36, 37 '■ morphea, 181
Bread group, 259 Breathing, as a problem, 339 Bridge, mucoepidermoid, 75-78, 175, 176
402 neck, 13
Broadbent technique, 363 5-Bromodeoxyuridine, 179 nose, 267
Bronze, 339 oral cavity, 168
Brown-McDowell modification, 377 Bubble, 97 Buck palate, 72, 170, 171
teeth, 281 Bulb design, 134 pharyngeal, 409-411 parotid, 176
syringe, 161 Bulldog face, 42 Bunsen burner, 285 Burn, pyriform fossa, 172
351 on neck, 43 Burner, Bunsen, 285 large, 385 serpiginous, 181
Button, acrylic, 434 squamous cell, 176-181, 188-192
Butyl acrylate, terpolymer, 89, 96 supraglottid, 171 tongue, 70, 167,
253 ulcerative basal cell, 181
Calcium nitrate, 101 Calculus, 158 undifferentiated, 179 verrucous,
71
Cardiovascular disease, 13 Caries, 219
Carnation instant breakfast, 260 slender, 260 Carrier,
genetic, 34 Cast metal splint, 239-240 Cebocephaly, 36,
37 Cellulose nitrate, 89 Cephalization, 51
Cephalometer, roentgenographic, 363 Cephalometry,
363 data, 363
INDEX 445

in infants, 363 tracing, 366 Cereal group, 259 in Negroes, 28 epidemiology, 27-29 etiology, 32-
Cesium, 180, 181 Chamber, hyperbaric, 179 Cheek, 35 frequency of type, 29 media cleft, 36-39
cancer, 324 with hole, 429 Child psychiatrist, 359 pathogenesis, 29-32 prevalence, 27-32 sex ratio, 29
Chin, 268-271 congenital defect, 268 internal, 89 nose, 265
retrognathic, 350 Chinese, 89 palate, 5, 11, 23, 24, 25, 27, 41, 64, 66, 271-272, 375-
Chondronecrosis, radiation, 183 Chloroform, 92 377, 429, 432 classification, 358-359 diagnosis, 360
Choanal, primary, 24 Chrome-cobalt alloy, 330, examination, 360 habilitation, 358-423
331, 339 Chromosome, 36 13-15 (D) group, 36 management, 359 surgery, 370
Cineradiography, 363, 365 CL. See Cleft lip timing of surgery, 375-377 sinus, branchial, 281
CLP. See Cleft lip with cleft palate Clasp, cast, 122- uvula, 28, 29
126 cast circumferential, 124, 126 cast Roach- Cleidocranial dysostosis, 31 Climate, 35 Closure,
Akers, 125, 128 cast wrought circumferential, 124 primary, 164 velopharyngeal, 429 Clubfoot, 30, 31
cast wrought combination, 125 mandibular molar Coagulant, latex, 101 Cobalt irradiation, 174, 180, 189,
ring, 126 ring, 129 190 machine, 180 radioactive, 180 teletherapy, 171
Roach-Akers, 125, 128 stainless steel, 122 T-bar therapy, 197 Cocoa butter, 112 Color, normal skin, 103
cast circumferential, 126 Clay nose, 99 prosthesis, 103 Columellar lift, 382 Community
pattern, 296, 305, 310 sculpturing, 97 Cleavage, resources, 369 Compensation, 439 Conjunctiva, 293
prosencephalic, 35 Cleft, branchial, 26 complete, Consent form, 16 Consonant, 426 voiced, 425 voiceless,
open, 25 embryonic, 24 facial, 23, 25 425 Copolymerization, 89, 90 Cordectomy, 172 Cornea,
Cleft lip, 5, 23, 24, 27, 40, 65, 66, 376 * bilateral, 289 Correction,
377-381 diagnosis, 360 examination, 360 compensatory of speech, 436-439 prosthetic of
habilitation, 358-423 management, 359 / . speech, 434-436 Cortisone, 35, 64 Cosoft compound,
surgery, 376 165 Counselor, rehabilitation, 11 vocational, 11 CP.
Le Mesurier operation, 376 Millard operation, See Cleft palate Craniectomy for osteomyelitis, 334
376 Mirault operation, 376 simple line closure, Craniofacial dysostosis, 31 Craniopharyngioma,
376 unilateral, 378 with cleft palate, 11, 27, 351 congenital, 64 Cranioplasty, 331-339 complications,
age, maternal and paternal, 29 birth rank, 29 339 split rib graft, 333 Cranioshisis, 64
classifications, Craniosynostosis, 64 Craniotomy, 332 Cronin
by Cleft Palate Association, 358-359 by operation, 382 Crouzon’s disease, 66, 273, 274
Stark, 358-359 by Veau, 358-359 distribution,
geographical, 28-29 in Caucasians, 28 in
Japanese, 28 in Montana Indians, 28
446 INDEX

Crown, 122 Double boiler, 285


gold, 392 steel, Drainage, 207 Dryness of
392, 409 mouth, 193 Duration of
thimble, 128 speech, 426 Dyclone
Curettage, 173 solution, 193 Dynamic bite
Cycle per second (cps). See Hertz opener, 245
Cyclopia, 36, 37 Cylindroma, 75, 77, Dysgerminoma, 178
173, 175 Cyst, 26, 63, 175, 208, 281 Dysphagia, 171 *•
dentigerous, 80, 82, 173 multilocular, Dysplasia, chondroectodermal, 64 congenital, 64
173 odontogenic, 78-79 ectodermal, congenital, 155 monostotic fibrous,
Cystadenoma lymphomatosum, 73, 175 64 necrotic facial, 43 oculauriculovertebral, 31
papillary, 73 Dysostosis, cleidocranial, 31, 41, 42, 64 cranial,
64 craniofacial, 31, 66 mandibulofacial, 31, 39,
Dacron, 264, 268, 272 42-44, 66 orodigitofacial, 31 otomandibular, 43
Decalcification, 204 Decay, Dystrophy, congenital, 64
postirradiation, 197, 199, 204
radiation, 204, 205 Decibel, 425 Ear, 26, 27, 182, 276-279
Defect, acquired maxillofacial, 431 Ear, anatomy, 57-59
congenital, 332, 431 infrabony, 160 aplasia, 65 artificial, 3,
Deformity, 354 facial, 356 multiple, 308 burned, 278 canal, 98
65 nasal, 1 carcinoma, epidermoid, 277
Degeneration, congenitally malformed, 31, 44-46
63 Deglutition, cup, 46
133 Denasality, deformed, acquired, 278
429 Dental congenital, 31, 44-46 embryology,
floss, 161 25-27 epidermoid carcinoma, 277
history, 18 external, 27 internal, 26 lop, 45, 46
school, 5 stone, microtic, 276, 278 middle, 26-27
97 tape, 161 missing, 36, 65, 327, 328 natural,
Dentistry, 2, 360, 386 308, 424 prosthetic, 279
Denture, 1, 5, 122 protruding, 46, 276 reconstructed,
compound, 118 totally, 277-278 trauma, 278
placement, 219 temporary Ectoderm, 23, 26 Edema, 209
partial, 230 transitional, Eggnog, 259 Egypt, mummy, 1, 89
219 wired, 134 predynastic era, 286 Elastomer,
Depression, mental, 10 90, 264 Electron beam, 197 Ellis-
Diabetes, 13, 17, 34 Van Creveld syndrome, 64
Diamond stone, 160 Diet, Endocarditis, postirradiation, 199
basic, 257 counseling, 257 Endoderm, 26 Endodontics, 234
liquid, 259 for patient, Enucleation, 173, 290
257-262 Epidermoid carcinoma, 163-166, 255, 267, 277
Diorganopolysiloxane, 93 of ear, 277 of lower lip, 255 of nose, 267 of
Dipmolding, 101, 107 tongue, 253 Epiglottis, cancer, 171
Disease, genetic, 64
Disfigurement, after
disease, 351 congenital,
351 economic aspect, 351
facial, 351
psychological aspect, 351
traumatic aspect, 351
Displasia of bone, fibrous, 281
Dissection, anatomy, 169
bilateral of neck, 165 McFee,
168 radial of neck, 165
INDEX 447

formation, 194 palatal, 429, 434


Fixation, circumferential, 215
cranial, 215 maxillary, 215 pin, 214
wire, 213
Flap, double regional, 371 local,
371
pharyngeal, 370-373, 384, 385
scalp, 266 single regional, 371
triangular, 376 upper arm, 266
vomer, 370 Flasking, 291 Fluoride,
Epilepsy, 17, 332 Epithelium, 25 Erich technique, 200-202 dental gel, 205 sodium
381 Erythema, 158 Eshlander repair, 197 fluoride, 206 5-Fluorouracil, 179
Ethmocephaly, 36, 37 Ethyl cellulose, painting, 288 Foam, filler, 100, 105, 106
precut disc, 288 Ethylene, 90 derivatives, 90 polyurethane, 100 polyvinyl
Ethyl orthosilicate. See Tetraethyloxysilane chloride, 100 RTV-S 5370 (Dow
Exenteration, orbital, 130, 174 Eye, 25 Corning), 100 silicone, 100 Folic
acrylic, 287, 296, 304 advantages, 287 acid, 35 Food blender, 259 Food
fabrication, 288 fitting, 304 anatomy, 51-55 groups, basic four, 259-260 Food
artificial, 15 early, 286 bony orbit, 52-55 supplement, 260 Forceps damage
enucleation, 11 glass, 286, 287 inlaid, 286 porcelain, (at delivery), 42 Forebrain, 23, 25
286 socket, 288 Eyeball, missing, 65 Eyeglasses, 13 Foregut, 51 Forehead, 279 Foreign
Eyelash, 304 Eyelid, 54, 182 body, 209 Formaldehyde, 96
Formant, 425 Fossa, nasal, 98
Fabrication of prostheses, 96-107 of skin, 96-107 Fracture, alveolar, 209 bar, 209
Face, 1 bilateral, 209 closed, 208
Facial cleft, 5, 23, 280 lateral, 39 naso-ocular, 39-40 comminuted, 208 green stick, 208
oblique, 39 transverse, 39 Facial cripple, 356 impacted, 208 intentional surgical,
development, 23-25 fracture, 5 restoration, 4 208 jaw, 208-217 Le Fort I, 209 Le
Fauchard, Pierre, 1 Feeding by gavage, 259 Fort II, 209 Le Fort III, 209
intravenous, 259 Fenestrated splint, 237-239 Fetus, mandible, 208, 209, 214 maxilla,
deformed, 65 monster, 65 variant, 65 209 multiple, 208 surgical,
Fibroma, ameloblastic, 85, 173 central cementifying, intentional, 208 treatment, 209-217
84 odontogenic, 83 Fibromatosis, 233 Fibro- unilateral, 209 Franceschetti
odontoma, ameloblastic, 85 Fibrosis, 201 of muscle, syndrome, 67 Freckles, 283
206 Fibrin, 363 Frequency, acoustical, 425 critical,
First branchial arch syndrome, 43-45, 67 First 425 of speech, 425, 426 Fricative,
branchial cleft, 65 Fish, 51 Fissure, 63 Fistula, 26, 428 Fruit group, 259 Furrow,
281, 388 congenital, 31 embryologic, 39 Fusion, 24, 25
448 INDEX

Gag reflex, 21 Gamma decay, 180 ray, of neck, 185 of upper lip,
178 Gangrene, 339 Gap, mandibular, 253 Hematoma, 209
167 Gargoylism, 64 Gauze, 161 intracranial, 332
Gavage, 261 Gene, clefting, 34 German Hemiatrophy, facial, 46-47
measles, 64 Giant follicular Hemiglossectomy, 165
lymphoma, 178 Gingival cancer, 187, Hemignathia, 43
190 Gingivectomy, 249 healing, 160 Hemilaryngectomy, 172
knife, 160 Gingivitis, 158 necrotizing, Hemimandibulectomy, 165, 166, 170, 215, 271, 339
161 ulcerative, 161 Gingivoplasty, 159 Hemihypertrophy, congenital, 47 Hemophiliac, 240
Gland, 204 odontogenic, 11 parotid, 20, tooth extraction, 232 Hemorrhage, 209, 232 Hennig’s
73, 74, 197 salivary, 11, 73 compound, 89 Hertz, 424
submaxillary, 197 tissue, 11 High-protein nutrient, 261 Hoarseness, 171 Hodgkin’s
Glassblowing, 287 in Bohemia, 287 in lymphoma, 178 Holoprosencephaly, 25, 35-37 Hormone,
France, 287 in Germany, 287 in adrenal, 35 anterior pituitary, 43 cortisone, 35 Hospital
Venice, 287 Glazing, 286 Glossectomy, protocol, 8 service, 8 Humming, 429 Hurler’s disease,
165 Glossopalatine, ankylosis, 31 64 Hyatt, John Wesley, 89 Hyne’s pharyngoplasty, 272,
Glossoptosis, 25 Glottis, lesion, 171 384, 385 Hydrocolloid, irreversible, 120 reversible, 109,
Gloves, asbestos, 285 Glucose 112-115, 120, 285, 294, 295, 304, 341, 360
deprivation, 35 Gold, 89, 180, 181, 339 Hydrotherapy, 161 Hygiene, oral, 70, 390 Hygroma,
plate, 331
175 Hyoid, 26
Goldenhar’s syndrome, 44 Graft,
Hypernasality, 431, 436
cadaver, 331 homogeneous, 331
Hyperpigmentation, 20
heterogenous bone, 331
Hyperplasia, 63, 65 palatal, 159
osteoperiosteal, 331 Gray stone cast,
Hypertelorism, orbital, 34
298-301, 311, 312 Gunner with the
Hypertension, 259 Hypertrophy,
silver mask, 1, 89 Gunning splint, 234-
65 facial, 47
237, 271, 276 Gunshot wound, 332
Hyponasality. 429, 431, 436
Gutta percha, 339
Hypoplasia, 63-66 of bony orbit,
Hacksaw, 285 Hair 272 mandibular, 270
growth, 20 Hapsburg Hypophosphatasemia, 65
jaw, 42 Harelip. See Hypophosphatasia, 65
Cleft lip Hawley Hypotelorism, orbital, 36-38
appliance, 389 Head, 51 Hypothyroidism, congenital, 65
cancer, 163-177 Imbibition, 91 Immobilization,
formation, 51-52 209 Implant, aluminum, 339
surgery, 234 bronze, 339 chin, 268
Heart disease, congenital, 31 chrome—cobalt,
Hemangioendothelioma, infantile, 64 339 cranial, 2, 330-
Hemangioma, 64, 175 of eyelid, 188 of 350 facial, 330-350
head, 185 gutta percha, 339
magnesium, 339
mandibular, 218
material, 263
INDEX 449

perforated tray, 345 Laryngectomy, 165, 172


plastics, 339 silicone, 349 subtotal, 172 total, 172
silver, 339 steel, 339 Laryngofissure, 172
surgical, 263 tantalum, Laryngoscopy, 171 Larynx,
337, 338, 345 tray, artificial, 172 cancer, 170, 171
perforated, 345 Impression, Latex skin, coagulant, 101*
296, 298, 310 extraoral, uncured, 102 Lathe, 285 Lead,
108-111 facial, 108, 112- 256 mask, 184 shield, 109, 114
120 intraoral, 108 making, LeFort fracture, 209 Le Mesurier
283 material, 285 lip repair, 376-378 Leprosy, 352
technique, 108-120 tray, Lesion, benign lymphoepithelial, 75
360 Incision, 207 congenital, 63, 64 early, 196 of
Infant food, strained, 259 Infection, 199, 207, glottis, 171 head, 63 neck, 63 oral,
208, 330, 332, 339, 359 congenital, 64 11
Inflammation, 63, 350 palatal, 160 Insulin, 64 stromal tumor, 75 Leukoplakia,
Intensity of speech, 426 Intracrevicular 164, 168, 170, 174, 233 Levin tube,
method, 161 Irradiation, 197 cancer-producing, 133 Lip cancer, 68, 163, 164, 185
194 complication, 190-193 external, 180 carcinoma, 165 cleft. See Cleft lip
internal, 180 preoperative, 14, 179 versus congenital, 40 congenital double, 40-
surgery, 179 therapy, 171 Iris, 288-291 Ivalon, 41 lesion, 166 pits, 40
268 Ivory, 89 Ivy loop, 210 reconstruction, 164
shave, 197 sinus,
Jaw, 20 bone, 72 40
fracture, 208-217 Joint switch operation by Abbe, 382, 400, 401
symptom, 233 Lipoma, 175 Listener judgement, 431
temporomandibular, 41 Lister’s antiseptic surgery, 339 Lobectomy,
175 Lop ear, 45 Loudness, 425
K-wire, 271 Kelp, 114 Louis, Alphonse (Gunner with the silver mask), 89
Keracanthoma, 197 Keratinization, 161 Lung, 79
Keratoacanthoma, (disappearing cancer), 184 Lupus eythematosus, 323, 352 Lymphangioma, 64, 175
Keratosis, senile, 20 Lymph node, 20, 182 Lymphoepithelioma, 179
Kerr compound, 165 Lymphoma, 181 cutis, 179 malignant, 173
Kingsley splint, 1, 238-239 Lymphosarcoma, 173, 175, 178
Kirschner wire, 167
Klippel-Feil syndrome, 31, 280 Macrogenia, 268 Macroglossia, 281 Macrostomia, 24, 39
Koragel, 344 Malformation anencephaly, 30 anal atresia, 30 brain,
35 cleft lip, 30 cleft palate, 30
Labiolingual splint, 235-238 Lacuna, empty,
201 Lakes (paint), 291 Laminography, 365,
366 Franklin unit, 367 Language, 424 Larsen’s
syndrome, 31
450 INDEX

Malformation—continued Maxillofacial rehabilitation, 13


clubfoot, 30 congenital, 30, treatment, 13-22 McDowell. See Brown-
351 craniofacial, 36, 37 ear, McDowell McFee incision, 168 Measles,
351 German, 64 Meat group, 259
hydrocephalus, 30 mandible, Median cleft face syndrome, 25, 36-39
351 maxilla, 351 polydactyly, 30 Medulloblastoma, 179 Melanin, 67
prosencephalic cleavage, 35 spina Melanoma, 163, 177 malignant, 176,
bifida, 30 Malignancy, 263 oral, 179, 181, 318 metastatic, 175 palatal,
17 122
Malocclusion, 209, 398 class III Melting pot of cast iron, 285
(angle) dental, 42 surgical correction, Membrane, cellular, 178
217-231 Magnesium, 339 Magnet, Meritene, 262 Mesoderm, 23,
127, 131 26 Metabolism, inborn errors,
Mandible, 1, 4, 5, 25, 26, 40, 42, 64, 89, 170 aplasia, 64 Metal, 264
65 arch, 23-25 fracture, 199, 209 necrosis, 199 Metastasis, distant, 163
reconstruction, 271 replacement, 272 resection, 151- regional nodal, 164
154, 355 Mandibulectomy, 173 sectional, 170 Methacrylamide, 89
Mandibulofacial dysostosis, 31 Mannitol, 332 Methacrylic acid, 90, 314
Marcks procedure, 381 Mask, storage, 120 Methyl methacrylate, 86, 89, 91, 96, 179, 264, 280, 283,
Massaging device, 161 Masseter muscle transfer, 289, 318-325, 331-336, 339, 345, 346
280 Master stone model (mold, cast), 97-100, 139, case histories, 321-
305 Mastication, 133, 148 Mastoiditis, 42 Material, 325 Microcephaly, 36, 64
properties, 4 Maxilla, 1, 5, 25, 42, 89, 274-276 Microgenia, 268
fracture, 210, 236, 237 perforated, 435 repositioning, Micrognathia, 25, 31, 41, 64, 268, 269
229 resection of tumor, 435 Maxillary orthopedics, congenital, 64
375 Maxillectomy, 173, 174, 275 total, 275 Microsomia, hemifacial, 39, 43, 45
Maxillofacial deformity, acquired, 6 congenital, 5 Microstomia, 172 Microtia, 42, 45
developmental, 6, 23-47 hereditary, 23-47 Mikulicz’s disease, 75, 175 Milk group,
Maxillofacial diagnosis, 13-22 Maxillofacial 259 shake, 259
prosthesis, 1-12 auricular, 89 Chinese, 89 Egyptian Millard rotation advancement procedure, 376, 378
mummy, 89 evolution, 1-12 Mirault lip repair, 376-377 Brown-
material of fabrication, 89-107 McDowell modification, 377 Moebius
nasal, 89 syndrome, 280 Mold, casting, 300
ocular, 89 external, 298, 305, 308, 311 metallic,
practice, 2-5 298, 303, 305, 311, 313 painting, 302,
repair, 6 308, 313 .tissue-side, 298, 302, 307, 308,
scope, 1-12 312 Mole, 283 Mongolism, 34, 64
Maxillofacial prosthodontist, 2 Monster, fetal, 65 Morlex 50, 271
Morquio’s disease, 64 Moulage, 8, 108,
114, 120, 184 Mouse, 25 Ajax strain, 35
cleft lip with cleft palate, 35 Mouth
protector, 250-252 Mucosa, buccal, 20,
168 Mucositis, acute, 193 Multi-gel, 341
Multiple myeloma, 179 Multi-vest, 341
Mummy, Egyptian, 1
INDEX 451

Muscle, masseter, 39 tumor, 183


Myoepithelioma, 74 excision, 265
Mycosis fungoides, 181 Nostril, 24
Mycostatin, 160 Myxoma, Nucleus, radioactive, 180
odontogenic, 84 Nutrament, 260 instant,
260 Nutrition. See Diet

Nares, 98, 112 Nasal balance, 429- Obstetrician, 359


433 disturbed balance, 430 Obturator, 1, 5, 89, 133-148, 196, 272, 433
deformity, 322 fossae, 98 pressure denture, 170 palatal, 392
flow, 368 septum, 98 Nasality, speech bulb type, 170, 171
431, 439 Nasopharynx, 197 Neck Occlusion, 129 balanced class
anatomy, 20, 169 bilateral II, 225 final, 220
dissection, 165 cancer, 163-177 postoperative, 220
dissection, 164, 165, 182 McFee preoperative, 220
incision, 168 radial dissection, 167 Oculoauriculovertebral dysplasia, 31
surgery, 234 Necrosis, 63 of bone, Odontoma, ameloblastic, 84, 85
197 intrauterine facial, 43 of soft Oncocystoma, 75
tissue, 197 Neoplasia, 63 Ontogeny recapitulating phylogeny, 51
Neoplasm, 17, 332 glandular, 73 Oral cavity, primitive, 23 Oral facial digital
malignant, 8 odontogenic, 173 syndrome, 66 Oral health, 158 hygiene,
Nephroblastoma, 75, 179 Nerve, 158-161, 193, 196, 207 manometer, 370
cranial, 51 trigeminal, 46 pressure flow, 368 region, anatomy, 59-62
Neurofibromatosis, congenital, 64 surgery, 159, 196, 208 Orbit (eye), 272-274
Neurilemoma, 175 Neuroblastoma, bony, 52-55, 272 exenteration, 15, 18, 352
179 Neurocranium, 53 prosthesis, 274 Orifice, facial, 52
Neurofibroma, 175, 317 Noise, 425 Orodigitofacial dystosis, 31 Oropharynx, 21
Nose, 264-268 anatomy, 55-57 Orthodontic treatment for cleft lip and palate, 393-404
carcinoma, recurrent, 267 cavity, Orthopedics, maxillary, 375, 393, 404-408 OSCAR
55-57 clay, 99 scanning device, 366 unit, 366 Ossicle, 26 Ossification,
in cleft lip, 379 27 Ostectomy, 18 Osteitis, 197
cleft, 265 Osteochondrodystrophy, 64 Osteogenesis imperfecta, 64
congenital defect, 264 Osteomyelitis of skull, 193, 233, 332, 334
defect} acquired, 265 Osteonecrosis, 183 Osteoradionecrosis, 71, 197, 233
congenital, 7, 19, 264 Osteosarcoma, 173 Osteotomy, sliding, 226 of vomer,
glabellar, 266 377, 379 Otocephaly, 42 Otocyst, 26 Otolaryngologist,
impression of, 304 359 Oven, dry heat, 285, 290 Overtone, 425 Oxygen
deformity, 265 deprivation, 35 supply to tumor, 179 Oxygenation,
epidermoid cancer, 267 fetal, 35 Oxyphilic adenoma, 75
excision of tumor, 265
glabellar defect, 266
impression of defect, 304
loss, partial, 266-267
total, 267-268
reconstruction, total,
266 total reconstruction,
266 trauma, 265
452 INDEX

Pindborg tumor, 83, 173 Pipe smoking, 70


and cancer, 70 Pit, nasal, 23, 24 olfactory,
24 size, 24 Pitch, 425 Plaque, 158, 389
Plaskon, 336
Plaster band, orthopedic, 114, 117, 120 bin,
284
of Paris, 109, 113-116, 120, 284, 295, 296
soluble, 101, 102 Plastics, 90, 339
Packing, 292 Pain, 199, 207, 209 Paintbrush, 112, thermoset material, 90 Plastic surgery. See
113 Palamed, 283, 314-318 Palate 1, 21, 170, 271- Surgery Pliers, square jaw, 285 Polyacid, 91
272 carcinoma, epidermoid, 171 cleft, See Cleft esters, 91
palate embryology, 24 epidermoid carcinoma, 171 Polydactyly, 30, 31 Polyethylene, 331, 336
expander, 273 fistula, 434 fistulated, 429 hard, 25 Polymer, 89, 90 Polymerization, 91
lift, 434-437 melanoma, 122 primary, 24, 25 role in Polymethyl chloride, 90 Polymethyl
speech, 426-427 secondary, 25, 359 soft, 21, 25, 359 methacrylate, 89-92, 96 Polydimethyl
substitute, 433 Palatoplasty, 383, 384 siloxane, 93 Polyposis, nasal, 174
Pantomography, 366 Pantothenic acid, 35 Polysulfide rubber, 97, 141 Polyurethane
Papillary cystadenoma lymphomatosum, 73-75 foam, 100, 264 Polyvinyl acetate, 90
Pare, Ambroise, 1, 89, 286 Parotid gland, 193 chloride, 90, 100, 106, 172 resin, 283
carcinoma, 176 tumor, 73-77 Parotitis, chronic, 175 Potassium sulfate, 97 Pouch, endodermal
Passavant’s bulge, 438 pad, 436 pharyngeal, 26 Pregnancy, first trimester,
Patient education, 161 interview, 15 master file 31, 64 Premaxilla stabilization, 412
card, 14, 16 morale, 2, 133 record, 14 Primordium, facial, 24, 25 Process,
treatment consent form, 16 Pediatrician, 359 frontonasal, 23
Pedodontic treatment for cleft lip and palate, globular, 24

386-393
Pedodontist, 234, 386 Perception, social, 352 lateral nasal maxillary, 25 mandibular,
Peridontium, 158, 162 diseased, 158 23, 24 maxillary, 24, 25 median nasal, 24,
Periodontics, 158-162, 234 Periodontist, 11 25 Prognathism (Prognathia), 6, 43, 268
Peruvian, 33 edentulous, 226 mandibular, 42, 219, 411-
Pharyngoplasty, Hyne’s, 385 Pharynx, 26 412 Progonoma, melanotic, 83, 173
Phenylketonuria, 65 Philtrum-premaxilla anlage, Prophylaxis, dental, 193 Prosencephalic
36, 37 Phocomelia, 64 Phonation, 9, 425, 426 cleavage, 35 Prosencephalon, 23, 25
laryngeal, 425 of sound, 425 Phoneme, 424, 425 Prosthesis, 196 auricular, 308-314 cleft
Photography, 366 palate, 371 coloring, 103 contraindication,
Pierre Robin syndrome, 25, 31, 42, 66 374 expansion, 371 facial, 314-318, 353
Pigmentation, human skin, 94, 95, 103, 104 nasal, 304-308, 353 ocular, 11, 286-304
melanin, 67 spray dispersion, 95 synthetic mixture, orbital, 294-304, 353 palatal, 370
105 Pin fixation, 214 repositioning, 371 retention, 121-132
INDEX 453

silicone, 353 snap-on, 146-148 speech aid, Rest, occlusal, 124 Retention, anatomic, 121,
371 two-component, 106 Prosthetics, 129 extraoral, 129 mechanical, 121, 129
extraoral, 283-328 facial, 284, 294-328 Rethrognathism (Rethrognathia), 6, 40, 268
intraoral, 133-156 mandibular, 137, 148-156 maxillary, 66
maxillary, 133-148 maxillofacial, 208-233 Reticulum cell sarcoma, 146, 178
studio, 285-286, 294 Prosthodontics, 4, 399 Retinoblastoma, 179 *
American Board, 4 of cleft palate, 404-423 Retropositioning operation,
Prosthodontist, 9, 11, 13, 158, 208, 283, 371 Dorrance type, 370 of premaxilla, 398 V-Y
maxillofacial, 13 Protein, 128 Psychiatric type, 370 Rhabdosarcoma, 175 Rhinolalia
problem, 13 Psychiatrist, 10 Psychologist, 13, clausa (closed nose), 429 Rib graft, 269, 271
359 Pyriform fossa, cancer, 171 Riboflavin, 35
Robin Pierre Syndrome. See Pierre Robin
Radiation, 9 (See also Irradiation) Rodent ulcer, 67 Roentgen film, lateral, 431
conservatism, 204 damage, 207 Roger-Anderson appliance, 213 Romberg’s
of eyelid, 197 gamma-ray, 178 in disease, 46-47, 274 Rosenthal pharyngeal
children, 185 ionizing, 178 of lip, flap, 384, 385 RTV silicone rubber, 92-94, 97,
193 radicalism, 204 shield, 207 98 RTV-S 5370, 100 Rubber cement, 106
therapy, 196-207 therapy of natural, 90
cancer, 178-194 treatment, 170 room temperature vulcanized. See RTV
x-ray, 178 silicone, 89 Rubella, 64
Radiocurability, 179
Radiography, 21, 386, 388
cephalometric, 21 intraoral, 15,
363 tracing, 398
Radiosensitivity, 178, 179
Radiosurgery, 159
Radiotherapist, 9 Radiotherapy,
17, 198, 234 Radium, 9, 180, 181
needle, 2, 10, 189 Radon, 180, 181
Rathke’s pouch cyst, 64 Ray,
actinic of sun, 67 Realignment,
209 Reduction, open, 213, 216
Reflex, gagging, 363 Repair, 63 Saliva, 172, 204 quantity, 204 viscosity, 204
Resection, appliance, 196 Salivary gland cancer, 166 tumor, 73, 74
mandibular, 196, 339, 344, 355 Sarcoma, 86, 125, 166 osteogenic, 178, 270
maxillary, 196 vomer, 377, 379 reticulum cell, 146, 173 soft tissue, 181 Scale
Resin, 89, 90 Resonance, 9 magnification, 368 Scalp avulsion, 280
Resonation, 425, 426, 429, 433 Scoliosis, 435 “Seal” limb, 64 Seaweed, 114
nasal, 429 Respiration, 426 Second branchial arch syndrome, 43-45, 67
Section analysis, 368
“Seeds” radioactive, 180, 181
Seminoma, 178
Septum, nasal, 25
Shade of skin pigment, 94, 95
Shaman, 331
Sheet metal, galvanized, 285 Shelf force, 25
Shield, eye, 193 lead, 193 resection, 164
Sibilant, 428, 429
Silastic, 266, 268, 271-274, 325, 342 382, 93
399, 93 S 6508, 93 skin shade, 94
454 INDEX

Silicone, 92, 109, 114, 264, 272-276, 280, 283, 330, Sound spectrogram of speech, 363, 367
331 spectrograph, 369, 426 South Sea
ear, 350 islander, 331 Speech appliance, 372 for
foam filler, 100 children, 408-412 bulb, 171, 272, 374,
implant, 349 392, 434 cavity, 427 defect, 9 »
medical grade, 119 disorder, 429-439
prosthesis, 353 correction, 431-439
trial prosthesis, 99 esophageal, 172
Silicone rubber, 89, 96, 97 frequency, 425
heat vulcanized, 89, 93, 325-328 normal, 424-429
room temperature vulcanized, 89, 97, 114 palate, role of, 427
Silver, 89, 339 pathologist, 359, 424
mask, 1, 89 prosthesis, 371
teeth, 89 receptor, 424
Simmonart band, 358 recording, 367 signal,
Sinus, cervical, 26 425
paranasal, 173 Sinusitis, sound (phoneme), 424, 425
174 Sjoegren’s syndrome, substitution, 433, 439 teeth, role
75 Skin of, 427 therapist, 9, 13
acrylate, 96, 104, 105 transmitter, 426 Spina bifida, 30,
adnexa, 67 31 Splint, 211, 234-256 cast
basal cell carcinoma, 181 metal, 239-240 fenestrated, 237-
benign lesion, 184 blemish, 283 239 Gunning, 234-236 modified,
cancer, 67, 176 fabrication, 96-107 235 two-piece, 215 Kingsley, 238-
graft, 2, 15, 197 human, 104 239 labiolingual, 214, 223, 235-
reflectance curve, 105 lesion, 180 238 mandibular, 233 maxillary,
lymphoma, 181 malignant 233 protective, 232 Sponge, 89
melanoma, 181 pigment, 104 Stainless steel, 279 Stannous
shade, 94-96 octoate, 93 Stapes, 27
squamous carcinoma, 181 tone, Stark’s classification, 358-359 Steel
96 band, 122 orthodontic, 123 stainless,
translucency, 96 Skull, 279-280 264, 330, 331, 333, 339 Stent, 2, 8, 133,
compound fracture, 332, 335 234-256 antihemorrhagic, 240-245
defect, 336 forehead, 279 drainage, 245-247 interocclusal, 247
fracture, compound, 332, 335 intraoral, 247 labial, 246-249 laryngeal,
Sling, 280 Snap button, 131 172 nares, 268 occlusal, 242, 245
Snort, nasal, 430 Snuff, chewing, painting, 247, 248 pedodontic, 247
71 Social forces on patient, 354- peridontal, 248 radiation, 251, 254, 255
355 service, 368 worker, 11, 13, specialized, 232 temporary, 268 trismus,
359 Sodium fluoride, 206 Sodium 245 typing, 247, 248 writing, 247, 248
restriction, 259 Soft tissue Stethoscope, 20
reconstruction, 276 Solar ray, 163
Solvent, organic, 92 Sorption, 92
Sonagram, 367, 369 Sonagraph,
367 Sound, 424 glottal, 430
palatal, 430 pharyngeal, 430
vowel, 425

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