Extraoral Prosthesis Including Splints And Stents

EXTRAORAL PROSTHESIS INCLUDING SPLINTS AND STENTS

Introduction
Restoration of esthetics in the patient with gross defects of the face and head is
a valuable and dramatic service provided by the maxillo facial prosthodontist
The loss of any part of the face has dramatic influence on the psychology of
the patient. The restoration of these missing parts would not only rehabilitate these
individuals esthetically but also improve their quality of life.
The construction of facial prosthesis consists of 4 stages:
1. Moulage impression and working cast fabrication
2. Sculpting and formation of pattern
3. Mold fabrication
4. Processing of the prosthesis with intrinsic and extrinsic coloration
Moulage impression and working cast fabrication
Impression making – An impression has to be obtained to pour a working cast on
which the prosthesis pattern may be fabricated
Materials
 Impression plaster
 Reversible Hydrocolloid
 Irreversible Hydrocolloid
 Elastomeric impression materials
 Orthopedic plaster band
 Impression compound
Reversible Hydrocolloid
Advantages
 Good reproduction
 Can be applied in thin layers
 Large areas
Disadvantages
 Time consuming
 Relative increase in the temperature
 Material may tear and distort
 Extraoral Prosthesis Including Splints And Stents

Elastomeric impression materials

Advantages
 Excellent reproduction
 High tear resistance
 Good flow
Disadvantages
 Relatively short working time
 Difficult in mixing large quantity
Irreversible Hydrocolloid
 Most frequently used
 Readily available
 Inexpensive
 Long shelf life
 Good dental reproduction
 Satisfactory physical properly
Prolonged working time as mixing with cold water
Disadvantages
 Air entrapment
 Distortion
 Tearing
 Discomfort – (cold water)
Preparation of patient
Patients should be prepared physically and mentally
 Adequate drapes
 Block the deepest undercut with guaze
 Maintain airway using Straws
 Apply petroleum jelly to hair, etc
 Tell the patients about the procedure
 Constant reassurance
 Claustroprobia / achlupgobia
 Extraoral Prosthesis Including Splints And Stents

Position of the Patient

The patient should be either reclined in a dental chair or lying on a table with
his head elevated as this would aid in the gravity to stabilize material and relax the
muscle tone .
Procedure
 Drape the patient
 Hair can be protected by fastening towel around head, using a head cap and
applying petroleum jelly
 A Rim of boxing wax can be build around the face (area to be impressed) or a
custom barrier may be made of card board.
 . Cotton pellets are placed in the patients nose
 Allow the patient to practice breathing through the straws kept in the mouth
 when patient is breathing comfortably – Mix alginate
 Ratio – 1.25 to 1.5 times more amount of H2O
 Mechanical
 Mix
Hand
 Apply alginate over the skin using rounded spatula without any air entrapment
in a smooth thin layer
 Once the area is completely covered place a few paper clips gauze in to the
alginate to provide mechanical retention for the rigid plaster necessary for
removal of impression without distortion. Alginate adhesives may be used
after it has set.
 Mix fast setting plaster to a cake batter consistency and spread over the entire
impression surface to a thickness of a about 0.25mm
 Add little excess plaster to form 3 blocks or elevations.
 When the plaster has set sufficiently grasp impression on both sides and lift
gently. Instruct the patient to wriggle the face and release the breathing tube.
 Inspect the impression for voids and distortion
 Next step is to pour dental stone into the impression white dental stone is
preferred. The surface of the impression should be coated with about 0.25 inch
 Extraoral Prosthesis Including Splints And Stents

of vacuum spatulated stone and allowed to develop initial set. Then the
remaining thickness can be poured.
 Resultant working cast should be 1 inch thick anatomic surface of the mold.

Sculpture and Formation of the Prosthesis Pattern

Orbital prosthesis
 After the working cast has been trimmed, defect undercuts blocked out and
suitable separating media applied to the defect a sheet of pink baseplate wax is
softened and adapted to the orbital defect.
 This cup like pattern forms the basis for positioning the ocular section of the
prosthesis within the defect in the same frontal, saggital and horizontal planes
as the normal eye. This can be accomplished by placing the ocular section on a
stalk of soft wax in the wax cup.
 The entire assembly is placed in the defect and the ocular section manipulated
into the position that matches the normal gaze of the eye.
 During this procedure the patient is asked to stare directly at a point at eye
level 6 feet away with the head unsupported and in an upright position. After
proper positioning has been established the eyelid aperture is established by
softeneing and placing two small strips of wax .The shape of the eyelid should
reproduce the normal eye.
 Computer imaging can be used to establish the correct ocular positioning and
opening.
 Extraoral Prosthesis Including Splints And Stents

 Remaining contour of the prosthesis is obtained.The final surface texture is

obtained by carving the lines and wrinkles around the eye.
 After the completion of the finer details the sculpture is checked for fit and
direction of the gaze

IMPRESSION

MOULD FABRICATION

WAX PATTERN
Auricular prosthesis
 Extraoral Prosthesis Including Splints And Stents

 Sculpture of patterns for auricular prostheses can be difficult due to the

multiple convolutions and contours of the ear. In addition, the positioning of
the pattern is critical in relating it to the normal ear.
 Most individuals use a system of markings superiorly, inferiorly, anteriorly
and posteriorly at the time of making the impression. An ear-bow style of
face-bow may be helpful in locating the marks in the horizontal and vertical
planes. Marks are placed in the same positions around the normal ear using
water-soluble ink. The marks are reproduced in the impression material and
transferred to the resultant stone cast. A wax base is adapted to the cast of the
defect and a pattern is constructed that duplicates the patient's normal ear as
closely as possible.
 Patterns for auricular prostheses have been fabricated using laser
stereolithography and other CAD-CAM methods.
 If the ear defect is bilateral, a sibling or another individual of similar age and
build may be used as an ear model. Impressions are made of the model's ear
and poured in wax instead of stone. The resultant pattern is nearly complete
with some modifications to be made to suit the patient’s face.
 Some practitioners have developed a bank of models from previous patients.
Occasionally, a new patient presents with an ear similar to one in the bank,
and the pattern creation becomes much easier.
 An ingenious method for arriving at a basic framework for an ear sculpture
was developed by Dr Sarkis Isikhay. A wax cast of an impression of the
normal ear is sliced with a wax saw into 1-mm-thick sections. Each section is
reversed and placed on top of the previous section, resulting in a mirror image
of the original pattern .The edges are coalesced with a heated wax spatula and
the framework modified to reproduce tissue detail and original size.
Extraoral Prosthesis Including Splints And Stents
 Extraoral Prosthesis Including Splints And Stents

Nasal prosthesis
 Nasal prostheses allow for a great deal of artistic license in pattern
development. Unlike bilateral structures where one must strive to reproduce
every minute detail of contra lateral structures, the nose can be made to look
any way the patient desires.
 The easiest way to fabricate a nasal prosthesis pattern is to obtain an
impression from a sibling or other relative with a strong family resemblance
and pour the impression in soft sculpting wax
 The prosthesis pattern is built to the desired thickness in wax and sealed to the
master cast. A mix of dental stone is vibrated into the cavity between the
pattern and the master cast to provide for a hollow prosthesis, allowing for
decreased prosthesis weight and an airway. If the practitioner elects to sculpt a
nasal prosthesis pattern, the defect area of the working cast must be modified
with a stone or plaster block out to allow the final prosthesis to be hollow and
provide an airway.
 The internal and external margins of the prosthesis are determined and marked
on the cast. A pyramid-shaped block out is then built on the cast and trimmed
with a sharp scalpel to a configuration that will not interfere with pattern
sculpture
 The buildup is then coated with a suitable separating agent and the pattern wax
mixture is applied and built up to a rough contour. The rough pattern may then
be sculpted into the final form
 After skin texture is incorporated, the pattern may be tried on the patient to
verify fit and contour. The next step is fabrication of a mold to reproduce the
wax pattern in the selected prosthetic material.

Fabrication of the Mold

 Extraoral Prosthesis Including Splints And Stents

Based on the type of material we use for processing the prosthesis we can
decide upon the mold to be used. If we use auto polymerizing resin for the fabrication
of the prosthesis the mold may be made out of alginate. If the material of choice is
silicon then the mold needs to be fabricated in plaster.
Usually, the working cast is used as the tissue surface of the mold. Most small
defects, such as nasal, orbital, or auricular, may be flasked in a conventional denture
flask or Little Giant flask. In the case of large combination defects, freestanding stone
molds may be employed or large-diameter PVC pipe sections may be used as casings
for the molds.
In many cases, the master working cast is duplicated and the duplicate cast is
used for the mold construction, thus preserving the master cast for future use in case
of fracture of the mold.
When a polyurethane lining material is to be employed, a second duplicate
cast must be prepared to vacuum adapt the liner material. This cast must incorporate
nylon monofilament fibers to allow more efficient air transfer during the vacuum-
forming procedure. After the pattern has been sealed to the original or duplicate cast,
the pattern and cast are invested in the drag (base portion) of whatever mold.

Alter the stone flasking material has set in the tissue-surface half of the mold a
suitable separating medium is applied to the exposed stone surrounding the pattern.
Foil substitute is the separator of choice because it is least likely to contaminate the
platinum catalyst of the silicone prosthesis material. Then the cope or second part of
die mold carrier is placed into position and the second pour of the mold is made over
die drag, incorporating the pattern in the mold.
There are two exceptions to this procedure, the orbital prosthesis and the
auricular prosthesis. For the orbital prosthesis, an indexing method must be applied to
position the ocular segment of the prosthesis, now incorporated in the wax pattern,
back into the mold in its same orientation as in the pattern.
 Extraoral Prosthesis Including Splints And Stents

NASAL PROSTHESIS
Prior to investing the orbital prosthesis pattern, an index in the form of horizontal and
vertical pyramids is placed on the surface of the ocular segment with sticky wax. This
index is reproduced in the cope segment of the mold. The cope is carefully removed
from the drag to avoid damaging the indexing wax. Then the ocular segment is
removed from the wax pattern and duplicated using an alginate impression. The
duplicate ocular segment, including indexing wax, is poured in dental stone and
placed into the index indentations in the cope with cyanoacrylate adhesive. This
segment will form a pocket in the final silicone prosthesis for insertion of the ocular
segment of the prosthesis.

Due to the thin, convoluted nature of the auricular prosthesis and the large
undercut area behind the helix, it is necessary to construct a three-part mold to ensure
separation of the silicone prosthesis from the mold without tearing. Prior to investing
the cope, indentations are placed in the surface of the drag portion to ensure proper
placement of the second part of the three piece mold. Then a mixture of stone is
prepared and placed from the surface of the drag to the height of contour of the helix
around the entire posterior segment of the ear. After the stone has set, tin-foil
substitute is applied and the cope section of the mold is poured.
In most instances, the heat released from the setting reaction of the dental
stone will eliminate the need to boil out the wax pattern. As soon as the stone has set,
the cope and drag are carefully separated, and the softened wax pattern is removed
from the mold, leaving the mold surface relatively free of wax residue. Boiling water
and detergent are used to clean the mold cavity. The hot mold is then coated with tin-
foil substitute in preparation for placing the prosthesis material in the mold cavity.
Use of tin-foil substitute as the separator leaves a smooth, velvety finish on the
 Extraoral Prosthesis Including Splints And Stents

surface of the prosthesis. If a more distinct, shiny surface texture is desired, an acrylic
floor wax may be used to seal the mold surface. The resultant prosthesis will have a
shinier surface but may be more difficult to separate from the mold unless a silicone
mold release agent is used.
If the material of choice is autopolymerising resin then the pattern may be invested in
alginate.The advantage of this procedure is that the wax pattern may be retrieved
intact.

Processing of the Prosthesis Material with Intrinsic and Extrinsic

Coloration
Even when the contours of the prosthesis are not exact duplicates of the contra
lateral structures and the skin texture is not exactly reproduced, the prosthesis will
probably remain undetectable if the coloration is correct under most lighting
conditions.
Silicon
There are many methods for intrinsic and extrinsic coloration of silicone
materials Some individuals use micro air-spray techniques to color the surface of the
mold. Others use a brush-in technique or no distinctive intrinsic color, relying on
external colouring techniques only. Again, the method of coloring is largely at| the
discretion of the artist. .
The mold cavity is prepared by coating the external tissue surface area with a
thin coat of catalyzed uncolored silicone material (MDX 4-4210, Dow Corning,
Midland, MI; or A2186, Factor II, Lakeside, AZ). A commercial-grade hair dryer is
used to partially polymerize the first clear layer. Then characterization colors are
chosen and mixed with the silicone polymer and painted on the surface of the clear
layer. Colored rayon fibers may be sprinkled into the mold to simulate
microvasculature, but these fibers lose most of their color in less than 6 months and
are the least color stable of the pigments used to characterize prostheses.
If a urethane lining is to be used for the prosthesis, the urethane sheet is cut to
size and clamped into the frame of a vacuforming device. The sheet is cleaned with
reagent-grade acetone and allowed to dry for 20minutes. The urethane sheet is then
heated and vacuum adapted to the cast. One thin coat of 304 primer (Dow Corning) is
applied with a plastic-handled cotton-tip applicator and allowed to dry for 30 minutes.
 Extraoral Prosthesis Including Splints And Stents

A thin layer of A-320 bonding enhancer (Factor II) is then applied and allowed to dry
for 20 minutes. The mold is then packed with the silicone material of choice and
placed in a dry-heat oven at room temperature. The oven is brought to 150°F and held
for 90 minutes, then elevated to 200°F for an additional 20 minutes, removed from the
oven, and allowed to bench cool before opening.
After the mold surface is characterized by localized application of color, a
base color mixture of the silicone material is prepared to fill the mold cavity Although
dry earth pigments are the most colour stable, artist's oil pigments, rayon fibers, sil-
icone paste pigment, or liquid makeup can be used to provide color and kaolin powder
to provide opacity to the mixture. When a satisfactory base color has been mixed, the
silicone catalyst is added, and air may be removed from the mixture by placing the
container in a bell jar under vacuum
The colored, catalyzed, air-less silicone is then placed into the mold cavity,
taking care to allow the liquid to flow into all thin areas, particularly in the auricular
prosthesis mold .If both mold surfaces are concave, the concavities should both be
filled with silicone. If one surface is concave and the other convex, as in a nasal
prosthesis mold, only the concave mold surface must be filled with silicone. The two
pieces are reassembled and excess silicone is expressed using light pressure until
maximum mold closure is achieved. The mold is then clamped and placed into a dry-
heat oven at the manufacturer's prescribed polymerization time and temperature.
Residual silicone may be left on the external surface of the mold to test for
complete polymerization. Improperly polymerized silicone will remain sticky on the
surface. After the polymerization cycle is complete, the mold should be allowed to
cool to room temperature before removing the completed prosthesis. The residual
flash may be trimmed back to the margin with sharp scissors or a scalpel and finished
with an abrasive stone, The prosthesis should be cleaned with water and mild
detergent before placement on the patient.
Extrinsic coloration of the silicone prosthesis is difficult and should be
avoided if possible. If it is necessary to add color to the surface, silicon medical
adhesive Type A Dow Corning is a suitable carrier for the pigment. Pigment is mixed
with the silicon adhesive and applied to the surface of the prosthesis with a fingertip
in a patting motion. This allows a buildup of color intensity as needed, without
destroying surface texture. The adhesive begins to set on exposure to moisture in the
 Extraoral Prosthesis Including Splints And Stents

air, releasing acetic acid through evaporation. After the desired color is obtained,
damp gauze square is pressed into the added silicone adhesive. The gauze filaments
will assist in returning the desired surface texture and provide moisture to catalyze the
polymerization reaction. The process may be shortened by placing the prosthesis in a
microwave oven for 10 to 15 minutes.
Patients should be instructed in the use and care of the prosthesis, including
instruction on how to orient and place it, how to use adhesives, and how to maintain
both tissue and prosthesis hygiene. Additionally, patients should be advised that the
color match depends on the color of their tissues, which may be susceptible to the
seasons as well as activity level and environmental temperatures.
Acrylic
Autopolymerising resin may be used for the fabrication of the prosthesis. A mixture
of clear, pink and tooth coloured resin is used to form the polymer.The desired colour
is added to the monomer .The polymer is then added to the monomer and each time
the sample is tested against the patients skin to check for the colour matchThis
process is carried out till the desired colour match has been optained .Once the colour
has been confirmed the remaining polymer is added to the monomer and the resin is
poured into the alginate mold taking care to avoid any air entrapment.
After the resin has polymerized the prosthesis is retrieved from the mold and placed in
warm water to remove any residual monomer. The prosthesis is then trimmed and
finished.
Hence the fabrication of a facial prosthesis is as much as an art as it is a
science. The form colour and texture of the prosthesis must be as indiscernible as
possible.the rehabilitation efforts may be successful when the patient can appear in
public without fear of attracting unwanted attention.

FABRICATION OF CRANIAL PROSTHESIS

• Cranial defects may develop from various causes such as trauma, surgery,
congenital defects, or certain diseases.
• Such defects are treated with cranioplasty, which shields the underlying bone
tissue.
• It also aids in relieving pain and improving appearance, leading to improved
quality of life.
 Extraoral Prosthesis Including Splints And Stents

Indications for cranioplasty

• disfigurement and mechanical vulnerability.
• Small defects (2 to 3 cm in diameter), which are located immediately above
the orbital rim or at nasion, may require repair entirely for cosmetic reasons .
• Larger defects (8 to 10 cm in diameter) may require repair almost entirely for
brain protection.
• In some patients, who may be poor candidates for surgery, an external
prostheses can be fabricated as an integral component of a wig, thereby
providing some cosmesis and protection.

SELF CURE- Fabrication

• To develop an appropriate contour, the bony margins of the defect are
exposed.
• The monomer and polymer are mixed together and, when the’ resin becomes
doughy and looses its tackiness, it is applied to the defect and molded.
• In small defects, it can remain in place until polymerization is complete.
• Heat of polymerization is controlled with steady saline irrigations and moist
cottonoids.
• In larger defects, when the resin begins to harden and produce heat, it is
removed until polymerization is completed.
• Numerous perforations are drilled into the prosthesis prior to securing it into
position.
• Fibrous connective tissue proliferates through the holes, thereby enhancing
stability of the implant.
• In addition, fluid that may accumulate beneath the implant can pass to the
surface.
DISADVANTAGE
• The principle disadvantages of the direct application of autopolymerizing
acrylic resin are the heat of polymerization and the presence of free monomer.
• Residual liquid monomer has been implicated as the cause of local tissue
reactions, but, apparently, monomer toxicity is short lived.
Heat activated: Fabrication
 Extraoral Prosthesis Including Splints And Stents

• The scalp should be completely shaved for an impression for large cranial
defects.
• For smaller defects, a shaved border of 5 cm around the bony margin is
adequate.
• The outer bony margin is then palpated and outlined in indelible pencil on the
skin and impressions are made and cast is poured.

SPLINTS AND STENTS

Utilizing the knowledge of anatomy, physiology and dental materials, a dentist
can provide innovative prosthetic aids that will contribute to the total management of
the patient.
The prostheses to be discussed in the following seminar are examples of
adjunctive appliances that can be fabricated by the dental clinician to facilitate the
treatment and rehabilitation of patients with various functional and anatomical
deficiencies.
Types
 Radiation stents and splints
 Extraoral Prosthesis Including Splints And Stents

 Burn splints
 Occlusal splints
 Nasal stent
 Auditory stent
Radiation splints
Prosthetic devices frequently called stent, splints, carriers, or positioners can
be used to optimize the delivery of radiation while reducing the associated morbidity.
Shield.
This type of appliance positions the anatomical structures to be irradiated into
a predictable and repeatable position while displacing and/or shielding other normal
structures.
Positioner
This type of appliance will permit the radiation oncologist to correctly position
the radiation beam during the required multiple treatment sessions

Carrier
 This is a device which positions the radioactive sources into, or adjacent to the
tumour site.
 Many of the custom splints and stents actually incorporate several of the above
criteria into a single device.
Burn stents
 Management of burn patients not only depends on the area involved, but also
on the extent and severity of burns.
 Often rehabilitation will extend over a prolonged period of time, therefore the
patient requires extensive medical and psychological support from all
concerned.
 During the surgical and physical therapy phases, the maxillofacial
prosthodontist can make valuable contributions to patient care.
 Services that can be provided include the fabrication of the diagnostic cast of
the various areas of the body, to be utilized for the surgical reconstruction, as
well as prosthetic replacement of the missing facial structures.
 Extraoral Prosthesis Including Splints And Stents

 Extensive scar contracture occurs during the primary healing following burns
of the skin.
 Surgical reconstructive procedures include the releasing of the scar bands with
the placement of split thickness grafts. These grafts must be in close
approximation of the soft tissue bed if they are to survive.
 Appropriate adaptation and support will also minimize graft shrinkage.
 Support for the split thickness graft should be given for at least 6 months.
 Replacement of the skin of the anterior part of the neck present a difficult
problem
 Devices that are used to prevent the scar formation following the split
thickness graft are elastic bandages, sayer type , cervical wrap up collar
dressings and custom made leather molded splints.
 Custom splits are also used to minimize the hypertrophic scar formation, or to
flatten the scars already present.
Impressions are made with irreversible hydrocolloid.
 The impressions are made at the stage of the first dressing change.
 Petrolatum gauze should be place over the area of the skin graft to protect the
friable tissue.
 The impression should be well extended beyond all the margins of the graft.
 A double layer of modeling wax is applied to the inner surface of the cast to
provide space of the silicone rubber foam lining to be worn inside the splint.
 Auto polymerizing acrylic resin stent is formed over the relieved cast and it is
perforated to provide retention to the liner.
Silicone rubber is processed as a liner for the stent.
 The stent is secured with a 1 inch hook and loop tape. The patient is instructed
to wear the neck splint 24 hours a day and remove it only to change liners.
 At the end of 6 months the supported split thickness skin graft and normal
neck chin angle is established.
 Prosthesis for electric burns
 A burn at the oral commisures is the most common type of injury occurring in
children.
 As reported by Curtin et al the injury usually occurs due to biting or sucking at
the end of a charged electric cord, the ionic saliva completes the circuit.
 Extraoral Prosthesis Including Splints And Stents

 The localized tissues destruction and the subsequent perioral contracture may
result in microstomia, possibly leading to a functional and cosmetic deformity
of the oral commisure.
 Potential dental deformities are cross bite, crowding, retrution, palatal arch
contraction.
Contracture of the wound margins occurs only after 5 days of injury.
 The prompt application of the splint therapy before the start of wound
contracture minimizes post burn scarring and the development of microstomia.
 Oral device
 Reinberg proposed the fabrication of an extraoral device of the prevention of
microstomia.
 This prevention splint provides a dynamic force to counter the contracture.
 Softened wax is shaped to the uninvolved side of the cheek and commisure.
 A stone mold is made and the wax is eliminated, clear auto polymerizing
acrylic resin is cured for 20 minutes under 25 psi pressure.
 Rigid wire of 0.06 gauge of wire is attached to the end of the conformer, and is
bent for attachment of a headgear a strap.
 The second conformer is fabricated in the similar manner.
 Both conformer are attached to the orthodontic head gear cap which provides
traction.
 The splint is worn continuously for 4 to 6 months. An additional period of 4 to
6 months is recommended for night time wear.
 Intra oral device
 Ryan described the fabrication of the intraoral removable appliance.
 A millimeter ruler is used to measure the lips contour from the normal side to
the midline to determine where the tissues should be placed on the defect side.
 Stone cast are obtained and mounted to an articulator using inter occlusal wax
record.
 Two layers of base plate wax are adapted over the maxillary cast covering the
palate and the teeth to the level of the sulcus.
 The wax is warmed to index the occlusal surfaces of the mandibular teeth.
 Wax extensions are added to the wax covering adapted to the maxillary arch.
 Extraoral Prosthesis Including Splints And Stents

 These extensions are moulded to curve laterally and posteriorly to retract both
corners of the mouth.
 The internal contour of the extensions simulates the desired contour of the
healed tissue in clear acrylic resin.
 The prosthesis should be worn 24 hours a day for 6 to 8 months.
 It is removed for eating and cleaning of the teeth.
 Modification in contour and tension can be developed with soft wax, and then
duplicated with autopolymerizing resin, until optimal tissue contours are
achieved.
 A microstomia prevention appliance is available commercially.
Nasal stents
 These stents provide support for cartilage transplants during post surgical
healing for the correction of nasal deformities in cleft lip patients.
 Nasal stents also maintain the contour and minimize scar contracture
following skin grafting procedures to the nostrils
 The contracture of the scar tissue following facial burns can lead to
obliteration or severe narrowing of the nares.
 Nasal stents should be made as soon as possible to minimize this constriction
of the nostrils.
 If narrowing has already occurred, one method is the fabrication of a series of
nasal stents in increasing sizes to gradually enlarge the nasal passageways.
 Doran suggested the incorporation of an orthodontic jackscrew expander into
the lumen of the sectioned stent, and gradually activate until the desired
opening of the nares is obtained
 After desired expansion has been achieved, the sides of the stent are sealed,
and the stent was worn to maintain the nostril opening.
 If further corrective surgical procedures are contemplated, the acrylic resin
stent is used to support the split thickness skin graft.
Auditory inserts
 An auditory insert or custom ear plug, made of acrylic resin,
polyvinlychloride, or silicone rubber may be required as a stent during surgical
reconstruction of an ear.
 This also serves as a custom ear plug following mastoid surgery
 Extraoral Prosthesis Including Splints And Stents

 Impressions are made, by injecting the material into the auditory meatus as
well as into the convulsions of the pinna, if present.
 A mold is formed by suspending this impression in a plastic disposable cup
and then filled with rapid setting stone.
 After the stone has set initially the mold is scored lengthwise and split in half.
 It is lubricated with petrolatum and reassembled, secured with rubber bands
and filled with silicone or acrylic resin.
 Retaining substantial amount of the pinna helps in alignment, retention and
seal.
Trismus appliance
 Trismus can be severe following surgical procedures or radiation therapy to
the head and neck. Trismus occurs most frequently when surgery and /or the
fields of radiation involve the muscles of mastication or the
temporomandibular joint
 Several methods are used to counter act trismus and increase the interarch
space.
 Exercising the mandible during the immediate postsurgical period will tend to
minimize the formation of constricting scar tissue.
 Another method is using a threaded, tapered screw made of acrylic resin; the
patient places the screw between the posterior teeth and gradually turns to
wedge the teeth apart.
 This device can be fabricated with auto polymerizing acrylic resin.
 The threads are refined, and device is polished.

OCCLUSAL SPLINTS
INTRODUCTION:
The purpose of on occlusal treatment is to make the teeth confirm to a correct
skeleton related position of the condylar axis. The most common cause of masticatory
muscle pain is displacement of the mandible to a position dictated by maximum
intercuspation of the teeth. Displacement of the mandible always results in
displacement of condyle-disk assemblies, which in turn can lead to progressive
changes in condyle disk alignment.
 Extraoral Prosthesis Including Splints And Stents

The misalignment along with connective tissue changes that can occur within
the articular components, may make it difficult to determine the correct position for
condylar axis.
Injury to the intracapsular tissue may also make it difficult to ascertain the
physiologic seated position for the condyle. There are exceptions, but it is generally
improper treatment to directly alter an occlusion until it can be altered to confirm to a
condylar axis that has been verified as correct.
Occlusal splints provide an acceptable surface for reversible occlusal
treatment that can be altered as needed, to confirm with tentative treatment positions
for the condylar axis.

DEFINITION:
Occlusal splint or occlusal device – An removable artificial occlusal surface
used for diagnosis or therapy affecting the relationship of maxilla to the mandible. It
may be used for occlusal stabilization, for treatment of temporomandibular disorders
or prevent wear of the dentition.
Uses of Occlusal Appliances:
1. To temporarily provide a more orthopaedically stable joint.
2. Can also be used to introduce an optimum functional occlusion that reorganizes
the neuromuscular reflex activity which in turn reduces abnormal muscle activity
while encouraging more normal muscle function.
3. Protect teeth and supportive structures from abnormal forces that may create
breakdown or tooth wear.
4. Provide an acceptable surface for reversible occlusal treatment, that can be altered
as needed.
5. Can be used to help determine what is wrong or to help treat a specific
malrelationship that has been diagnosed.

TYPES OF OCCLUSAL SPLINT:

There are two types of occlusal splints. Regardless of the many different splint
designs, every occlusal splint can be classified as either,
1. Permissive splint
2. Directive splint
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1. Permissive splints are designed to unlock the occlusion to remove deviating tooth
inclines from contact. When this is accomplished, the neuromuscular reflex that
controls closure into maximum intercuspation is lost. The condyles are then allowed
to return to their correct seated position in centric relation if the condyle of the
articular components permits.

Because all corrective tooth inclines are either separated or covered with
smooth plastic, permissive splints allow the muscles to function according to their
own coordinated interactions; thus eliminating the cause and the effect of muscle in-
coordination. For this reason permissive splints are often referred as muscle
deprogrammers.
2. Directive splints are designed to position the mandible in a specific relationship to
the maxilla. Any splint with occlusal force that intercuspate is a directive splint
because the mandible is directed into the specific jaw to jaw relationship at which the
intercuspation of the teeth occurs.

The positioning of the mandible may also be accomplished by contacting

inclines against anterior teeth that direct the mandible in a particular position of
closure.
The sole purpose of directive splint is to position or align the condyle-disk
assemblies. Thus directive splints should be used only when a specifically directed
position of condyles is required. Contraindications for directive splints:
1. The condyle and the disk can be aligned correctly.
2. The correctly aligned condyle disk assembly can move to the most superior
position against the eminentia without derangement.
3. The disks can maintain their alignment with the condyles during function.
 Extraoral Prosthesis Including Splints And Stents

If the above conditions can be verified, it is an indication that the joints are
functioning in a physiologically acceptable relationship. There would be no need to
alter that relationship, and so there would be no reason for using any appliance that
directs the mandible away from that condylar axis.

APPLIANCES:
STABILIZATION APPLIANCE:

Also called muscle relaxation appliance as it is primarily used to reduce

muscle pain.
Description and treatment goals:-
Generally fabricated for maxillary arch and provides an optimal functional
occlusion for the patient. When the appliance is in place the condyles are in their most
musculoskeletal stable position at the time that the teeth are contacting evenly and
simultaneously.
Canine disocclusion of posterior teeth during eccentric movement is also
provided. The treatment goal of the stabilization appliance is to eliminate any
orthopaedic instability between the occlusal position and the joint position, thus
removing this instability as an etiologic factor in TMD.
Indications:-
a. Generally used to treat muscle hyperactivity, parafunctional habits like
bruxism.
b. For patients with local muscle soreness or chronic centrally mediated myalgia.
c. Helpful for patients experiencing retrodiscitis secondary to trauma. This
appliance can help reduce forces to damaged tissues, thus permitting more
efficient healing.
Simplified fabrication technique:-
The full arch hard acrylic stabilization appliance can be used in either arch, but
maxillary placement provides some advantages.
 Extraoral Prosthesis Including Splints And Stents

- The maxillary device is usually more stable and covers more tissue, which
makes it more retentive and less likely to break.
- It is also more versatile, allowing opposing contacts to be achieved in all
skeletal and molar relationship.
- The maxillary appliance provides increased stability, since all the mandibular
contacts are on flat surfaces. This may not be possible with mandibular device.
- Another advantage is the ability of certain features of the appliance to help
locate the musculoskeletal stable relationship of the condyles in the fossae.
FABRICATION TECHNIQUE:-
Fabrication of maxillary occlusal appliance
Maxillary alginate impression made

poured in gypsum product (die stone)

cast trimmed

2 mm sheet of biostar sheet adapted to cast with pressure or vacuum adapter

Outline of the appliance made at the level of interdental papilla on the buccal and
labial surface of teeth and cut off the cast with a separating disk

The adapted resin appliance is removed from the stone case

Excess resin is eliminated in the palatal area

The lingual border of the appliance extends 10-12mm from the gingival border of the
teeth throughout the lingual portion of the arch

The labial border of the appliance terminates between the incisal and middle thirds of
the anterior teeth.

A small amount of clear acrylic (self cure) is added to the occlusal surface of
the anterior portion of the appliance. This acts as an anterior stop. It is approximately
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4mm wide and should extend to the region where a mandibular central incisor will
contact.

ANTERIOR REPOSITIONING APPLIANCE:

Description and treatment goals:

It is an interocclusal device that encourages the mandible to assume a position

more anterior than the intercuspal position. Its goals is to provide a better condyle-
disk relationship in the fossae so that tissues have a better opportunity to adapt or
repair. It prevents the condyle form loading on the retrodiscal tissues. The reduction
of pressure behind the disk allows the synovial fluid to circulate better through the
joint spaces and aids the healing process. Once tissue adaptation has occurred, the
appliance is eliminated allowing the condyle to assume the musculoskeletal stable
position and painlessly function on the adaptive fibrous tissues.
The practicality of anterior repositioning splint is limited to those joints that
have not been damaged beyond their capacity for adaptive repair of connective
tissues.
Indications:
Primarily to treat disc derangement disorders. Patients with joint sounds can
sometimes be helped by it. Intermittent or chronic locking of the joint can also be
treated. Some inflammatory disorders are managed with this appliance, especially
when a slight anterior positioning of the condyles is more comfortable.
To use this appliance the disk must be capable of sliding movement. An
ankylosed joint will not respond to anterior repositioning splint therapy nor will a disk
that is too badly deformed.
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Fabrication Technique:
There are 3 basic requirements for an anterior repositioning splint.
1. The mandible must be directed by the splint to a position that aligns the condyle
with the disk.
2. The mandible must be prevented from closing or clenching distally to the position
of disk alignment.
3. Both anterior and posterior segments should share anchorage for directing the
mandible forward.
Like the stabilizing appliance, the ARS is a full arch hard acrylic device that
can be used in either arch. However the maxillary arch is preferred because a guiding
ramp can be more easily fabricated to direct the mandible into the desired forward
position. With a mandibular appliance the guiding ramp does not achieve this forward
position as easily, and thus the mandible is not controlled as well. In other words, the
patient can more easily position the mandible posteriorly with the mandibular
appliance.
Fabricating and fitting the appliance:-
- Initial steps similar to stabilization splint
- Anterior stop constructed on the appliance and fitted to the maxillary teeth.
SUPERIOR REPOSITIONING SPLINT:
After the condyle disk alignment and position have been determined by the
anterior repositioning splint, a superior repositioning splint should be worn to allow
complete reseating of the condyle disk assemblies up the eminence to the superior
craxis.
The purpose of anterior repositioning splint is fulfilled when the retrodiscal
tissues have healed sufficiently to regain a backward pull on the disk. However, either
the condyle or disk may have difficulty moving back to centric relation after being
held forward.
The purpose of superior repositioning splint is to eliminate the effect of
neuromuscular reflex that directs the mandible to close repetitively into maximum
intercuspation.
The goal is to true a skeletal relationship of the mandible to the maxilla and
not one that is influenced by MI of the teeth. The purpose of the superior
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repositioning splint is to establish the correct skeletal relationship before the correct
occlusal relationship is determined.
Fabrication Similar to stabilization splint:
ANTERIOR BITE PLANE:
Description and treatment goals:

The anterior bite plane is a hard acrylic appliance worn over the maxillary
teeth, providing contact with only the mandibular anterior teeth. It is primarily
intended to disengage the posterior teeth and thus eliminating their influence on the
function of the masticatory system.
It is a diagnostic splint. It is only worn for a day/two to verify that the TMJ are
comfortable and the disks stay aligned in function.
Indications:
- For treatment of muscle disorders related to orthopaedic instability or an acute
change in occlusal condition.
- Parafunctional activity may also be treated with it but only for a short periods.
Complication:
As the appliance covers only a portion of the arch, the unopposed posterior
teeth have the potential to supraerupt, if the appliance is used continuously over a
long period of time. When this occurs the appliance is removed, the anterior teeth no
longer contact and results in anterior open bite.
Anterior bite plane therapy must be closely monitored and used only for short
periods. The same treatment can be accomplished by stabilization splint and hence it’s
a better choice. There is no chance of supraeruption with it regardless of the length of
time the appliance is worn.
If the anterior bite plane causes increased discomfort, it indicates that an
intracapsular problem exists. Further diagnostic steps are needed to determine the
specific nature of problem. The anterior bite plane should be discontinued. If the
condyles can function with no discomfort, it will be evident in a short time.
POSTERIOR BITE PLANE:
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Description and treatment goals:

The posterior bite plane is usually fabricated for the mandibular teeth and
consists of areas of hard acrylic located over the area of posterior teeth and connected
by a cast metal lingual bar.
The treatment goals of the posterior bite plane are to achieve major alterations
in vertical dimension and mandibular positioning.
Indications:
- Advocated in case of severe loss of vertical dimension or when there is a need to
make major changes in anterior positioning of the mandible.
- The use of this device may be indicated for certain disc derangement disorders.
- The major concern surrounding this appliance is that it occludes with only part of
the dental arch and therefore allows potential supraeruption of the unopposed
teeth or intrusion of occluded teeth. So constant long term use is discouraged.
SOFT AND RESILIENT APPLIANCE:
Description and treatment goals:
The soft appliance is a device fabricated of resilient material that is usually
adapted to the maxillary teeth. Treatment goals are to achieve even and simultaneous
contact with the opposing teeth. In many instances this is difficult to accomplish
precisely, since most of the soft material do not adjust readily to the exact
requirements of the neuromuscular system.
Indications:
- Protective device for persons likely to receive trauma to their dental arches e.g.
athletic splint.
- For patients exhibiting high levels of clenching and bruxism, they help dissipate
some heavy loading forces encountered during parafunctional activity.
 Extraoral Prosthesis Including Splints And Stents

References:
1. Clinical Maxillofacial Prosthetics-Thomas .D.Taylor
2. Maxillofacial Prosthetics Multidisciplinary Practice- Chalian
3. Keith .F.Thomas
4. Colour characterization in silicon rubber facial prosthesis-
J.Prosthet.Dent.24:198-202 1970
5. Development of skin surface texture in maxillofacial prosthetics. J.Prosthet.
Dent.15:929-937 1965