223

Stents and Splints

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 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.

224 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.

225 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. 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.

226 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.

227 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.

228 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. 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.

229 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.

230 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 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

231 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.