HEALTH SCIENCES STANDARD HX00035491 Columbia ^nibergitp in tije Citp of i^eto gork . ^ . College of ^Ijpsiiciang anb burgeons; Reference Hitirarp Dental Fund Digitized by tine Internet Arciiive in 2010 witii funding from Columbia University Libraries http://www.archive.org/details/injuriesoffacejaOOmart INJURIES OF THE FACE AND JAW AND THEIR REPAIR INJURIES OF THE FACE AND JAW AND THEIR REPAIR AND THE TREATMENT OF FRACTURED JAWS BY P. MARTINIER PROFESSOR TO THE DENTAL SCHOOL OF PARIS, DENTIST TO THE SEINE ASYLUMS, HONORARY DIRECTOR OF THE DENTAL SCHOOL OF PARIS AND DR. G. LEMERLE PROFESSOR TO THE DENTAL SCHOOL OF PARIS, DENTIST TO THE HOSPITALS TRANSLATED BY H. LAWSON WHALE, M.D., F.R.C.S. CAPTAIN R.A.M.C, T. (FORMERLY CAPTAIN I. M.S.), THE ORAL DEPARTMENT, NO. S3 GENERAL HOSPITAL, B.E.F. ; VISITING SURGEON TO THE THROAT, NOSE, AND EAR DEPARTMENT, THE COUNTY OF LONDON WAR HOSPITAL, EPSOM ; LARYNGOLOGIST TO THE LONDON TEMPERANCE HOSPITAL, .-aND TO THE HAMPSTEAD GENERAL HOSPITAL \ NEW YORK WILLIAM WOOD AND COMPANY MDCCCCXVII 2.^ - 5 5" ^2-/ PRINTED IN GREAT BRITAIN TRANSLATOR'S FOREWORD It may be justly claimed that during the war no branch of surgery has emerged from oblivion and neglect to a position of insistent importance to a greater extent than facial restoration. The reasons for the former indifference are not far to seek. First, traumatic facial deformities were rare. Among non-traumatic causes, epithelioma is chiefly confined to the lips; syphilitic stigmata to the nasal bridge, and usually treated by paraffin. The ravages made by rodent ulcer and lupus are suitable rarely for plastic, although sometimes for prosthetic, correc- tion. Thus the field for plastic facial surgery was limited. And, secondly, the profession in Great Britain availed itself but little of such opportunities as offered. Anyone frankly adopting this branch as a speciality would likely have been classed with beauty specialists and other quacks. It would have been urged (and still is by inexperienced critics) that large facial gaps could only be treated by prosthesis, and should be passed on to the surgical instrument maker; that, as regards smaller wounds, anyone with the most modest surgical skill can sew up a face; and that since this is so, and the work neither vi TRANSLATOR'S FOREWORD involves serious surgical emergencies nor depends on a pathological basis, this branch can hardly be called true surgery — still less major surgery. I submit that, at any rate for gunshot injuries, this view is wrong. To undertake the correction of smashed faces and jaws, from the moment of their arrival from the firing-line until they are fully re- stored, will satiate even an ambitious surgical appetite with a diet of science flavoured with art. On any day the operator may be confronted with an emer- gency tracheotomy, a bullet to be removed from the prevertebral space, a carotid artery to be Hga- tured, accessory nasal sinuses (including frontal and sphenoidal) to be opened. The next day he may be busy with such delicate manipulations as raising the angle of a mouth, or with undertakings which must appeal to the spirit of a pioneer — for instance, moving large flaps, and grafting fat, cartilage, or bone. On the scientific side the facial surgeon is brought into contact with the modern scientific product of dental education, the oral surgeon; and with the physician and bacteriologist, witness the (alas ! too frequent) lung infections from septic mouths. And on the mechanical side he is in con- stant collaboration with expert dental mechanics, the admirable workmen who construct ingenious spHnts to build out lips, shape noses, and so on. Truly, there is much interesting country in this surgical no-man's-land, the face. The importance of temporary prosthesis is para- mount. Without its aid, it would be quite impossible TRANSLATOR'S FOREWORD vii to get the results we do. As to permanent pros- thesis, we at No. 83 General Hospital use it as little as possible. In a totally new nose (made from a rib cartilage and a forehead flap), invisible dilators may have to be worn in the nostrils, and removed daily for cleansing; a loss of tissue in a mandible, if unsuitable for a bone graft, requires a prosthesis; and often a gap in an alveolar margin has to be closed by a vulcanite denture bearing teeth. But — as is shown by our cases published elsewhere — we aim at building up the face from the patient's own tissues. The patient naturally prefers this. Only one has elected to go to England for a permanent mask prosthesis, rather than undergo a series of operations. Perhaps a few brief criticisms of the authors' views may be allowed. In m^^ experience, secondary hemorrhage is not so pleasantly rare as in theirs; but, as they say (p. 158), irrigation cannot be held responsible, ^^e^y frequent lavage is certainly neces- sary; at No. 83 it is performed hourly (p. 188). Boiled water (p. 323) is sufficient in many cases; but it should be under pressure, a forcible stream. Major Valadier devised an excellent apparatus in constant use here. A five-gallon petrol drum, movable on wheels, is fitted with an exit tube controlled by a stop-cock, and ending in a plated cannula. An entrance tube connects the drum with a bicycle pump, which provides the pressure. To prevent retrocession of the tongue (pp. 168, 191), I have never seen the necessity or advisability of viii TRANSLATOR'S FOREWORD the patient wearing a wire (attached to the jaw appHance and passing through the tongue). Any such arrangement is a constant source of shght pain, and encourages sepsis. Apropos of wiring the teeth of upper and lower jaws together, it is pointed out (p. 260) that this makes it difficult to feed the patient. I would add to this that, if he is to be shipped to England, it is also difficult for him to vomit if he feels seasick — an important detail. We share the authors' respect for teeth in the line of a fracture (p. 282). It is noticeable that they do not discuss grafts, either for nose or jaw. The suggestion that artificial substances should be used for filling the hollows left by frontal sinus operations (p. 229) is not likely to find general favour among rhinologists. It will hardly be beheved that the results are as good as those of, for instance, the radical method of Killian, whose " bridge " operation avoids any deformity. It will please many readers that the method of paraffin injection is damned with faint praise (p. 227). Indeed, for reasons familiar to rhinologists, this practice is, in Great Britain at any rate, not much followed now. Its dangers are out of aU proportion to the probability of a permanent good result. The authors' comments on total rhinoplasty (p. 234) seem unduly harsh; we have had very happy results. The section on prosthesis for the ear (p. 141) is scanty, which accords \\dth the lack of progress in this direction. The part devoted to laryngeal prosthesis (p. 107) is valuable as a lesson TRANSLATOR'S FOREWORD ix in mechanical ingenuity. But few surgeons of to-day feel any enthusiasm on the subject of artificial larynxes. After a total extirpation of the larynx the patient's mental condition is truly miserable. The keynote in the treatment of that ghastly afflic- tion, laryngeal carcinoma, is earlier diagnosis. Then, if operation be indicated, thyrotomy and submucous removal, or partial resection of the laryngeal box — with or without extirpation of lymphatic glands — is to-day admitted to be the procedure of choice. After operation, or in cases where this is contra- indicated, diathermy and radium are valuable allies. The section on fractures of the upper jaw (p. 330) is particularly clear and concise. In their introduction, the authors are to be con- gratulated on their frank admission that in the text they repeat themselves, and that they do not apologize for so doing. Such fundamental truths as, for in- stance, that an anatomically restored jaw is useless if physiologically damaged by malapposition of corresponding teeth well bear repetition. In conclusion, I should like to emphasize that facial work amply repays the trouble spent on it. Many of those maimed in this war w^ill require, on their discharge, to canvass for civil employment. Human nature always finds physical deformity repugnant, facial disfigurement especially so. And the sufferers are likely to be handicapped if their appearance is revolting. Their recognition of this fact largely accounts for their extraordinary patience in undergoing the repeated operations which are TRANSLATOR'S FOREWORD necessary. Their gratitude afterwards is good to see. It gives the surgeon real pleasure to note the pride with which, let us say, a man, who had lost his original nose, sneezes through a new one made out of his own iiesh and bone. Any who wish to verify this sensation of surgical satisfaction by undertaking similar work will find this book most useful. H. LAWSON WHALE, M.D., F.R.C.S., Capt. R A.M.C. (T.). No. 83 General Hospital, B.E.F. Sepiaih er, 1917. AUTHORS' PREFACE The manual which we issue to-day has no preten- sions to being a technical treatise on prosthetic restoration. We have merely endeavoured to sys- tematize the innumerable efforts at prosthetic restoration which have been made, especially during the last fifty years. Our principal aim, then, has been to point out the limitations of each of these, and to classify them. In fulfilling this object, we feel no misgivings on the score of having repeated ourselves. Any insistent repetitions will be forgiven us if we have succeeded in diminishing the regrettable confusion (which the practitioner too often en- counters) between methods sometimes strongly similar in appearance, but depending upon principles and general ideas which are essentially different. At the beginning of this manual it is our pleasant duty to salute the memory of our master, Claude Martin, who has always helped us in our written researches with a kindly and untiring supervision. The name of this genius among prosthesists dominates the restorative art which he practised. For out of fragmentary methods he has pieced together schemes such as that of immediate prosthesis. And he has xi xii AUTHORS' PREFACE helped to make surgical prosthesis an essentially French branch of our profession, and a branch of which the brilliance flashes through our land. We thank our confreres Fr. Martin, Pont, and Delair, from whom we have often received contributions, and who have allowed us to borrow extensively from their work. p. MARTINIER. G. LEMERLE. CONTENTS PAGE translator's foreword - - . - V authors' preface - - - - - xi CLASSIFICATION OF THE DIFFERENT METHODS OF RE- STORATION BY PROSTHESIS: EXTERNAL PROSTHESIS ; INTERNAL PROSTHESIS - - - . xvii PART I.— EXTERNAL PROSTHESIS SECTION I.— REMOTE OR LATE PROSTHESIS CHAPTER I. CHARACTERS OF CICATRICIAL TISSUE - - 3 II. BLOODLESS TREATMENT OF VICIOUS SCARS ; UPPER jaw; lower jaw; results of resections PER- FORMED ON THE LOWER JAW; REDUCTION OF NASAL DEFORMITIES - - - - 12 III. LATE prosthesis: late prosthesis OF the JAWS ; PROSTHESIS FOR THE SOFT PALATE AND HARD palate; PROSTHETIC INTERVENTION AFTER STA- PHYLORRHAPHY; OBTURATORS ENABLING NEWLY- BORN CHILDREN, AFFLICTED WITH LABIAL OR PALATAL FISSURES, TO BE SUCKLED; CONCLU- SIONS - - - - - -51 IV. LARYNGEAL PROSTHESIS: MICHAEL's ARTIFICIAL larynx; ARTIFICIAL LARYNX OF CL. MARTIN; DELAIr's APPARATUS - - - - 10/ V. LINGUAL PROSTHESIS : ARTIFICIAL TONGUE ; SHEATH FOR THE TONGUE - - - - 1 24 xiii xiv CONTENTS CHAPTER PAGE VI. NASAL PROSTHESIS- - - _ . 128 VII. AURICULAR PROSTHESIS - - - - I4I VIII. PROSTHESIS OF LIPS .... 142 IX. EXTENSIVE BUCCO-FACIAL RESTORATIONS - - 1 43 SECTION II.— IMMEDIATE PROSTHESIS I. IMMEDIATE PROVISIONAL PROSTHESIS APPLIED IN THE CASE OF SUBPERIOSTEAL RESECTIONS - 1 49 II. IMMEDIATE PROVISIONAL PROSTHESIS DESTINED TO OPPOSE CICATRICIAL RETRACTIONS - - I5I III. ACCIDENTS CONSECUTIVE TO RESECTIONS OF THE LOWER JAW NOT FOLLOWED BY PROSTHESIS - 1 52 IV. CONDITIONS WHICH MUST BE FULFILLED BY AN APPLIANCE OF IMMEDIATE PROSTHESIS - - 1 54 V. APPLIANCES OF IMMEDIATE PROSTHESIS FOR THE LOWER jaw: CONSTRUCTION OF APPLIANCES - 1 67 VI. APPLIANCES OF IMMEDIATE PROSTHESIS FOR THE UPPER jaw: generalities; description OF appliances; construction of appliances - 177 vii. placing the provisional appliance treat- ment placing the final appliance - 1 87 viii. conclusions ... - - 191 PART II.— INTERNAL PROSTHESIS SECTION I.— INTERNAL PROSTHESIS SECTION II.— INTERNAL PROSTHESIS PROPER I. TOLERANCE OF TISSUES TOWARDS FOREIGN BODIES: REACTIONS OF PERIOSTEUM AND BONE IN THE PRESENCE OF FOREIGN BODIES; REACTIONS OF THE TISSUES ACCORDING TO THE NATURE OF THE FOREIGN BODIES; TOLERANCE AS AFFECTED BY THE SHAPE OF THE FOREIGN BODY; TOLERANCE DEPENDING ON THE MOBILITY OF THE FOREIGN BODY ...... 213 CONTENTS XV CHAPTER PAGE II. THE VARIOUS MODES OF RETENTION OF APPLIANCES FOR INTERNAL PROSTHESIS, AND THEIR TOLER- ANCE BY BONY TISSUE . - - - 222 III. PLASTIC PROSTHESIS - - - - 22 7 IV. PRACTICAL CONCLUSIONS - - - - 229 V. RHINOPLASTY OVER A METAL APPLIANCE I GENER- ALITIES; CONSTRUCTION OF THE APPLIANCE; PLACING THE APPLIANCE; GOLDENSTEIN'S AP- PARATUS; THE ELEVATION OF COLLAPSED NOSES - 234 VI. CONSTRUCTION AND FITTING OF APPLIANCES FOR INTERNAL PROSTHESIS: GENERALITIES; INSTRU- MENTATION - - - - -239 PART III.— TREATMENT OF FRACTURED JAWS SECTION I.— FRACTURES OF THE MANDIBLE SIMPLE FRACTURES - - - - " -47 COMPOUND FRACTURES - - - . 248 I. SURGICAL METHODS: SUTURE OF BONE; LIGATURE OF BONE ------ 249 II, PROVISIONAL APPARATUS: BANDAGES; SLINGS; IN- TERDENTAL LIGATURES - - - - ^55 III. FRACTURE APPLIANCES proper: APPLIANCES FIXED WITHOUT PREVIOUSLY TAKING .\N IMPRESSION; APPLIANCES WHICH NECESSITATE THE TAKING OF AN IMPRESSION, AND MADE ON A CORRECTED MOULD APPLIANCES WITH A DOUBLE SPLINT, FOR TEETH AND CHIN: DESCRIPTION OF APPLI- ANCES; CRITICAL REVIEW OF THE DOUBLE SPLINT APPLIANCES MADE ACCORDING TO A CORRECTED MOULD OF THE DENTAL ARCH APPLIANCE CON- SISTING OF A DOUBLE DENTAL SPLINT, LOWER AND UPPER APPLIANCES WITH A SIMPLE DENTAL splint; CRITICISM OF APPLIANCES CONSISTING OF A SIMPLE SPLINT - - - - 26 1 xvi CONTENTS CHAPTER PAGE IV. TREATMENT OF FRACTURES OF THE MANDIBLE BY THE METHOD OF CL. MARTIN - - - 309 V. martin's modes of TREATMENT ACCORDING TO DIFFERENT TYPES OF FRACTURE - '3^5 VI. GENERAL CONCLUSIONS ON THE TREATMENT 0~ FRACTURES OF THE LOWER JAW - - 322 SECTION II.— TREATMENT OF FRACTURES OF THE UPPER JAW I. GENERALITIES ----- 330 II. TREATMENT OF PARTIAL ALVEOLAR FRACTURES - 332 III. TREATMENT OF INTERMAXILLARY DISRUPTIONS - S^S IV. TREATMENT OF THE HORIZONTAL FRACTURE OF - GUfiRIN - - - - - -334 V. TREATMENT OF CRANIO-FACIAL SEVERANCE - 342 CLASSIFICATION OF THE DIFFERENT METHODS OF RESTORATION BY PROSTHESIS The art of making artificial substitutes for any organs cut off, whether by an accident or by surgical procedures, constitutes the art of prosthesis. Ambroise Pare defined it more succinctly, in writing that it comprised all " methods and devices for supplying that which, from natural or accidental causes, is lacking."* The prosthetic method propounded by A. Pare is the oldest. It holds good to-da}^; and if in its tech- nique it has risen to an extraordinary perfection, nevertheless it still remains governed by the same general principles. The advent of the era of asepsis has allowed us to think out new prosthetic methods. These are still, at this day, in full growth; none of them has become final, but the unison which they have called forth between surgeon and prosthesist promises fair to be fertile of results. In the vast majority of cases the intervention of the prosthesist occurs a long time * Ambroise Pare, " CEuvres completes," Lyon, 1646, 23^= livre, p. 572. xvii xviii INJURIES OF THE FACE AND JAW after that of the surgeon. Nevertheless there are instances where the two procedures emerge into one single operation; and from this fact is derived a division which may serve as the basis of a classifica- tion of the various prosthetic methods. These latter may be drawn up into two great groups : External Prosthesis, when we are dealing with apparatus which remains in communication with space. Internal Prosthesis, when, allowing for the tolerance which the tissues, under certain conditions, display towards foreign bodies, {we make use of apparatus which has no communication with space. External prosthesis comprises remote and immediate pros- thesis. External Prosthesis. 1. Remote or Late Prosthesis occurs a certain time later than the operation or accident which has cut off the organ which it is proposed to replace, when the wound which was the outcome is entirely cica- trized. This process of cicatrization generally in- volves the formation of contractile fibrous bands which resist the application of a prosthetic apparatus. The reduction of the vicious scars constitutes the first step in any attempt at prosthetic restoration. Thus, the study of remote prosthesis includes the study of (i) methods for reducing scar tissue, (2) re- mote prosthetic methods proper. 2. Immediate Prosthesis has as its object the pre- vention, at the outset, of cicatricial contraction by RESTORATION BY PROSTHESIS ' xix the introduction into the tissues of an apparatus intended to replace the part of the skeleton which has been removed. This apparatus is essentially temporary; when, thanks to it, a correct healing has been obtained, it should be removed and give place to an apparatus which is late, final, and re- movable. Another plan of immediate prosthesis consists in introducing into the depth of the tissues apparatus intended as a temporary substitute for part of the skeleton after subperiosteal resection. This ap- paratus acts as a prop for periosteal flaps until these latter have given rise to an adequate regeneration of bone. Thus, immediate prosthesis comprises two methods quite distinct : {a) Immediate prosthesis intended to resist cica- tricial contraction (CI. Martin). (6) Immediate prosthesis intended to hold up peri- osteal flaps after subperiosteal resection (Michaels). Internal Prosthesis. Internal Prosthesis is designed to replace pieces of bony framework, or certain organs, by means of apparatus buried (in a final sense) in the depth of living tissues. It comprises two methods: I. Internal prosthesis intended to guide bony regeneration. This regeneration may occur because the resection was subperiosteal, or it may originate from a bone graft. In this case, contrary to what occurred in the above method — supra, 2 {h) — the XX ■ INIURIES OF THE FACE AND JAW i prop for the osseous formation is finally left in the I organism. 1 2. Internal prosthesis properly so called, consisting of an apparatus buried in the tissues and intended to be tolerated there permanently, wholly replacing in function the absent organ. . In relation to the surgical procedures first taken, internal prosthesis falls into the subdivisions of immediate and remote prosthesis. Such are the divisions which it seems to us logical to introduce into the study of the various prosthetic methods which we propose to examine according to this classification. We are, as a matter of fact, not discussing certain varieties of late prosthesis which are of interest to commercial circles. Internal prosthesis by injections of paraffin is a restoratory method which, since it does not belong to the dental speciality, we shall remove from our scheme of study. Let us, then, resume in the following way the classification of existing prosthetic methods.* * For everything concerning dental prosthesis, properly so called, the reader can refer to the " Manuel de Clinique de Prothese dentaire " of P. Martinier and G. Villain. Injuries of the Face and Jaw and their Repair FIRST PART EXTERNAL PROSTHESIS SECTION I REMOTE PROSTHESIS This is the oldest method. The type of this which is the simplest, and which, moreover, seems never to have emerged from the province of orthopaedic and surgical instrument makers, is the artificial limb fitted to a stump after an amputation. But, as applied to losses of tissue involving the face, remote prosthesis demands a special technique. This is connected with the technique of dental prosthesis, was evolved by dentists, and belongs exclusively to their department. Remote prosthesis of the lower jaw in particular constitutes a problem of singular complexity. In fact, after the removal of a part of the lower jaw, cicatricial contraction involves such extensive displacements that, until these latter have been reduced, one must not dream of making a prosthetic apparatus. INJURIES OF THE FACE AND JAW O I— I H < O H W H W en O PL. o o n3 ^ p o 03 +j C^'i< C rt o .^ -^.2 o o o u o o o --^ >; C!.t= > c c3 rt tfJ t/3 ^ C - ■ i: o o o u< v< w .ii a; ^ rf Sa ■" "o "" Ch . . 5>- •^ o rt >< o 4> -H O C4 to C^ < OS w H g^ 3 fe £ ac^ . M-. .is 4-> •- "^ ,/■■ ;2 ri ti c3 c c i: s ^ J? •^ ..-■ ■'^ TO -^7^ Vh ti (U ^ c3 •^ r! n^ 0, >, O >^ 2- g3 eye v- O P ■>^^ O 4J •'^ UH TO 01 O o . o -t-) oi >-• rt ac P- r/1 ^ CHARACTER OF CICATRICIAL TISSUE 3 Remote prosthesis of the face often falls into clearly cut steps: 1. Stage of reduction of scar tissue. 2. Stage of prosthesis proper. Dentists, well prepared for this task by their familiarity with the general principles of orthodontia which they apply every day, have managed to excel in this method of bucco-facial prosthetic restoration. CHAPTER I CHARACTER OF CICATRICIAL TISSUE The term "cicatrization" is given to the organic process tending to the production of a new tissue destined to close accidental or surgical solutions of continuity produced in the body. This tissue formed in this way is called a " cicatrix." The histological elements of a scar arise from the proliferation of histological elements which were there previously, and the two are always similar. The repair is usually provided by the connective tissue, but in the case of skin and mucous membranes epithelial tissue shares in the constitution of the cicatrix. We will consider cicatrization by first and by second intention. " Although the essential phenomena in the two cases are identical, the intervention of a new factor, suppuration, gives to the cicatrization of an infected wound some special characteristics."* * Francisque Martin, " Bloodless Treatment of Vicious Scars," These de Lyon, 1901. 4 INJURIES OF THE FACE AND JAW I. Cicatrization by First Intention. — When the hps of the wound are approximated, they are soon glued together, first by the blood poured out, later by serum which, exuded from neighbouring vessels, contains embryonic connective-tissue cells. This embryonic tissue is soon invaded by newly formed capillaries. According to Masse,* " The vessels of neighbouring parts of the new scar tissue produced show at first, at one point of their walls, some tiny bosses, which become changed into little processes, pointed at their end and enlarged at their base. "The parent vessel is usually a capillary with struc- tureless walls, with some fusiform cells at regular intervals. The new vessels which are produced are of the same nature ; tapering in shape, their walls are hyaline, the cells more numerous and especially more crowded. At first of a very small calibre, they can- not allow of the passage of corpuscles; only the blood-plasma can course through them. These tapering vessels become more and more prominent in the cicatricial tissue. Their increase in height goes hand in hand with an increase in width; mean- while they anastomose one with the other, and form loops which are at first permeable only to the plasma, later to blood-corpuscles. The first-formed loops soon give rise to other pointed branches, which in turn join to form secondar}^ loops; then a third, and so on." The capillaries emerging from one lip of the wound meet those of the opposite lip, and form an anasto- * Masse, " Cicatrization in Different Tissues," Montpellier, 1866. CHARACTER OF CICATRICIAL TISSUE 5 mosis which re-estabUshes the circulation from one edge of the wound to the other. These embryonic vessels take on progressively the characters of adult vessels; the same applies to the embryonic cells, which become adult connective- tissue cells. Later the cicatrix undergoes further modification, and at the end of its evolution it will consist of fibrous tissue. 2. Cicatrization by Second Intention. — When the lips of a wound have not been approximated, cica- trization is produced by means of a layer of fleshy buds covering the bottom of the wound. These fleshy buds form the granulation layer, of which the characters have been carefully described by the old- time surgeons. In fact, they represent the method of cicatrization natural to all infected wounds. It is on the surface of this granulation layer that the secretions are produced which constitute pus. This very surface is absorbent, witness the poisoning by sprinkling ulcerations with iodoform. Lastly, these fleshy buds have a power of contraction which gradually approximates the edges of the wound. " This approximation occurs especially when the wound is cleansed. At this time one observes the occurrence of a series of changes at the surface. The suppuration dries up, the fleshy buds take on a rich red colour, the edges of the wound contract and approach each other under the influence of the con- traction of the granular layer. On these edges appears a bluish border, originating in the healthy surrounding skin. This border approaches little by little the centre of the solution of continuity, the 6 INJURIES OF THE FACE AND JAW surface of which it gradually diminishes. This japan or varnish of epidermis gains ground from the peri- phery towards the centre incessantly, and soon the surface of the buds is epithelialized. The cicatriza- tion of the wound is complete. " In certain cases, the slight exudate which a wound in the process of cicatrization incessantly secretes hardens on the surface, and covers it with a dry scab, beneath which epithelialization proceeds just as when exposed to the air. This mode of healing, of which it has been proposed to make a separate variety termed ' cicatrization beneath a scab,' differs in no way in nature from cicatrization by second in- tention."* The granulation layer to which we just now referred is a soft tissue composed of round cells. Among these, certain cells are multinuclear; they are destined to die and form pus. In the neighbourhood of these multinuclear cells, which will be destroyed, are found numerous mononuclear cells, of which some are large and resemble epithelial cells. It is these epithelioid cells, according to Ziegler,t which give rise to granu- lation tissue. They are called "fibroblasts" or " fibroblastic cells," because they have the power of forming connective tissue. "The fibroblasts of most recent origin occur as round cells, but their shape is altered very soon; they put out processes which become gradually * Francisque Martin, " Bloodless Treatment of Vicious Scars," These de Lyon, 1901. f Ziegler, " Treatise of Pathological Anatomy," translated by Augier and Von Ermengen, 1892. CHARACTER OF CICATRICIAL TISSUE 7 lengthened. Thus cells are formed, some club- shaped, some fusiform; others, again, branched and united very irregularly by their branches. At the same time the number of large formative cells in- creases in such wise that at last they get the better of their small round neighbours, and group them- selves here and there in crowded masses; this occurs especially in the deeper parts of the fleshy buds. " A sufficient massing together of the formative cells inaugurates the development of the connective tissue, or intermediary fibrous tissue. This latter is formed partly at the immediate expense of the proto- plasm of the formative cells, partly at the expense of the homogeneous matrix, which, again, has previously been formed by the fibroblasts or formative cells. " In the former case [where the connective tissue is formed at the direct expense of the cell proto- plasm — Tr.] one can note the appearance, on the sides as well as at the ends of the formative cells, of fine fibrillar processes arising from neighbouring cells. The direction and mass of the bundles thus formed are independent of the original shape and situation of the cells which gave them origin ; usually the direction of the bundles is that of the greater diameter of these cells. When a sufficient number of fibrils has been produced, their formation ceases. The remains of nucleated protoplasm in the original cells become the fixed cells of the connective tissue, which remain attached to the surface of the bundles of fibrils. It is thus that the process comes to an end, and granulation tissue becomes a cicatrix."* * Francisque Martin, " Bloadless Tie.itmon': of tjVicious Scars," These de Lyon, 1901. 8 INJURIES OF THE FACE AND JAW 3. Epithelialization. — The newly formed epithelium which covers the superficial stratum of fleshy buds never arises from these; it is always traceable to neighbouring epidermal cells. This epithelialization can take place in three ways : {a) By sliding of epithelial cells from the periphery towards the centre. {b) By grafting of epithelial islands detached from the edges. (c) By cellular proliferation along the edges of the wound, thus tending to a progressive centripetal epithelialization. When the cicatrix is fully formed, it undergoes an evolution which may last from eighteen months to two years,* and during which the new tissue of which it is formed sufiers a series of changes. This cicatrix, now adult, will contain fibrous tissue and show a new structure and new physical properties. According to Francisque Martin, if one dissects and carefully examines a fully formed scar, one sees that it consists of — 1. A thin superficial membrane, sometimes rugous, more usually uniform and glossy; this, which is the newly formed epidermis, is dry, because no secretion appears to moisten it. 2. Deep to this epidermis is a special sort of tissue, of fibrous appearance, dense, resistant, pearly white, creaking under the scalpel. This is the fundamental part of the scar, or " inodular " tissue, which results from the cicatrization of the dermis. 3. In this dense non-porous tissue are formed * Dupuytren, " Cliniques Chirurgicales," iv. CHARACTER OF CICATRICIAL TISSUE g arterioles and venules in very small number and tightly bound down. " Inodular " tissue constitutes the fundamental element of adult scar tissue. Delpech has given it this name in contradistinction to young cicatricial tissue, which is, on the other hand, " nodular " tissue. " In the skin, a cicatrix consists of fibrous tissue, where fat -vesicles soon appear in the deep layers; but there are never as many fat-vesicles as in the normal condition, and the fibrous tissue found is always very dense. The dermis is produced in fibrous and elastic tissue, but glands are not repro- duced. The papillae are re-formed in the cases where they had, by their hypertrophy, made up the fleshy buds of the cicatricial tissue. In such a case the normal papillae of the skin, transformed into fleshy buds, return to their primitive condition; then some of the buds sink down, and the embryonic tissue becomes connective tissue. " But when the fleshy buds spring up from the deeper parts, and the papillae have been destroyed to a marked extent, they do not become entirely re-formed; and the cutaneous scar which results remains flat and depressed, or, on the other hand, prominent, if the exuberant granulations have not been restrained.* Our knowledge of the structure of the retractile scars which follow on union by second intention is less exact. On this point Fran- cisque Martin quotes in his thesis the following interesting remark of Paviot : ' It is easy to demon- strate that in the depth of connective tissue in * Cornil et Ranvier, " Manuel d' Histologic." lo INJURIES OF THE FACE AND JAW general elastic fibres and elastic granules are very rare if the tissue be a young one containing many round cells. And, on the other hand, when the number of round cells is less, when the connective- tissue fibres, increasingly full-grown and thick, appear in a similar kind of tissue, the elastic fibres and granules (as to the origin of which no one has been able to lay down anything beyond theories) increase proportionately in number. This is demonstrated daily by all histologists ; but the role of these elastic fibres, under the circumstances which we are study- ing, has never been laid down accurately.' " May we not suppose that it is to the trans- formation of the tissue to the inodular type, when the elastic elements appear, that a cicatrix owes the loss of its retractility ? Perhaps one may also infer that the extensibility of an inodular scar depends on the presence of the elastic elements. In support of the probable truth of this argument, one may cite a histological contrast easy to make, between a keloid scar which is still to a large extent nodular, and a linear fibrous scar robbed of all round cells and already rich in elastic elements." 4. Physical Characters of Cicatricial Tissue. — When it has lost its suppleness, cicatricial tissue possesses a good deal of toughness; its elasticity is nil, but it is noticeably extensible and capable of elongation under a slow and continuous pressure. It has no real retractility. Minervini* has shown experi- mentally that only the cellular tissue of a cicatrix * Minervini, " On the Retractile Power of Cutaneous Scars" (13'^ Congres Internat. de Medecine, Paris, 1910). CHARACTER OF CICATRICIAL TISSUE ii is retractile. A scar, once formed, does not retract. " Thus, we should speak, not of a retractile cicatrix, but of cicatricial retraction."* Francisque Martin thinks that the retractility of a cicatrix undergoing evolution depends upon the inflammatory process which accompanies cicatrization, and according to him there is a correlation between the duration of suppuration and the retractile power of a scar. A scar fully formed may be made supple and lengthened when it is made to undergo long and continuous pressure. " This relaxation and length- ening of scars is not invariable unless certain nutri- tional changes occur. But the exact nature of these changes, clinically obvious, are not known to us; and to arrive at final conclusions on this point a series of histological examinations bearing on scars before and after their lengthening will be required. "f Be this property what it may, it is thanks to it that vicious cicatrices may be corrected by the help of prosthetic treatment. In fact, consequent upon a prolonged suppuration, the scarring of a wound often produces bands and adhesions more or less extensive, which in turn entail a varying degree of functional incapacity of the affected part. These vicious scars necessitate surgical intervention, of which the results are often unreliable. Side by side with the surgical treatment, on the other hand, the bloodless treat- ment of the scars by prosthesis should have a place. ♦ Francisque INIartin, " Bloodless Treatment of Vicious Scars," These de Lyon, 1901. t Ibid. 12 INJURIES OF THE FACE AND JAW CHAPTER II THE BLOODLESS TREATMENT OF VICIOUS SCARS The bloodless treatment of vicious scars is wholly due to CI. Martin of Lyons. In 1900 he laid down the general principles of his method, as follows: "All patients on whom any part of the lower jaw has been resected, and to whom an immediate prosthesis has either not been applied or has remained an insufficient time, are as a rule invalids. The aesthetic changes and the functional troubles which they have to endure depend on one and the same cause — that is, the projection inwards of one or more bony fragments. These troubles comprise facial asymmetry, the sagging of skin not supported by a bony plate, the atresia of the mouth or forward projection of the tongue and the flow of saliva out- side, the lack of apposition of the dental arches, and the difficulties in mastication which result there- from. In the presence of such infirmities, I have asked myself if it is not possible to alleviate these patients. And therefore I have sought to correct the underlying lesion, on which the other evils depend — that is, the cicatricial retraction which produces the deviation of the bony fragments and the flatten- ing of the cheek on the side operated on. " In my earlier researches I had established an arrangement of apparatus which allows one to drag the bony extensions to their normal positions and keep them there, all the while leaving them free to BLOODLESS TREAT MENT OF VICIOUS SCARS 13 resume their functions. But, despite this correction, I had never been able to restore the buccal cavity to its original dimensions. I had, in fact, constantly to combat this unceasing and considerable force — the cicatricial retraction, which perpetually tends to spoil the result obtained. " These comparative failures had made it clear to me that I should not be able to achieve any unalter- able result without dealing with the scar itself. Thus, I have striven to alter it, to soften it, to make it extensible — in a word, to stretch it in such wise that the fragments could occupy their former position. " I have achieved this result by means of special apparatus to which I have given the name of heavy appliances or appliances for continuous pres- sure. The application of the method which I have just shown is not limited to the correction of deformities due to scars after resection of the jaw; it is a more general plan to which all de- formities due to scar tissue are amenable. The essential principles are frequent massage and con- tinuous pressure applied to the inodular tissue. But if, for resections of the jaw, the position of parts allows us to take advantage of gravity, this does not apply for other scars — for example, on the neck. One can then obtain continuous pressure by means of elastic traction apparatus, of which one can at will graduate the pressure."* " To sum up, the fundamental principle of the * Cl. Martin, " Methods of correcting Deformities due to Vicious Scars by Heavy Appliances or Appliances for Con- tinuous Pressure" (Cong, de Chir., Paris, 1900). 14 INJURIES OF THE FACE A ND JAW method which we advocate is the following: Bring to bear on the cicatricial tissue a slow and continuous action, which will coax it in the direction opposite to that of its retractility, and which can undo what this retractile force has done."* The means to which one can resort differ according to the form of the scar and the region affected. Annular scars can be stretched either by means of apparatus of soft elastic rubber or by spring ap- paratus. Linear scars may be stretched by con- tinuous pressure of heavy appliances or under the influence of traction apparatus. Traction and pres- sure are all the means generally used, whether we adopt heavy appliances, or elastic force as shown in the well-known plan of Fr. Martin (Figs, i and 2). But the mechanical treatment of vicious scars is governed by the following general rule : The reduction apparatus should act on the scars very gently, and never cause the patient the least pain. These appli- ances are as various as the deformities which they are destined to correct; so we shall limit ourselves, in this book, to describe only those which have been employed most often by CI. Martin at the level of the jaws. I. Upper Jaw. Resections of the maxilla often cause but little deformity in the region of the face. Nevertheless, the soft parts of the cheek may form deep adhesions which become irksome for the application of an * Fr. Martin, " Bloodless Treatment of Vicious Scars," These de Lyon, igoi. BLOODLESS TREATMENT OF VICIOUS SCARS 15 appliance for remote prosthesis. In such cases CI. Martin has used the following apparatus: A palatine piece covers the roof of the mouth, including the loss of substance left by the surgical intervention. It is fixed to the. teeth of the left maxilla, and on the right it is kept up, supported Figs, i and 2. — Traction Apparatus of Fr. Martin. by a spring taking its point d'appui from the lower jaw, like a denture. This principal piece bears two other accessory pieces. One is fixed without a joint on its upper surface near its posterior edge, and passes up to the top of the cavity to fit which it has been cast. The other is attached to the front part i6 INJURIES OF THE FACE AND JAW of the Upper surface, by a hinge joint placed a httle lower than the anterior border of the cavity. A spring placed horizontally on the former (posterior) of these accessory pieces plays on to the latter (anterior), which moves like a hinged shutter. This spring by its continuous pressure on the scar tissue gradually stretches it (Fig. 3).* We may equally well apply to the maxilla the Fig. 3. ^Apparatus for stretching after Resection of the Maxilla. (CI. Martin.) pressure produced in mastication, by fitting an apparatus of gradually increasing volume at the level of the scar tissue to be stretched. One of usf has used this plan successfully on a patient who had undergone resection of the left upper jaw. It was expedient, before fixing a final prosthesis on this patient, to force back the scar * CI. Martin, " jNIethods of correcting Deformities due to Vicious Scars by Heavy Appliances or Appliances for Con- tinuous Pressure " (Cong, de Chir., Paris, 1900). f Martinier, " Two Typical Cases of Restoration of the Maxillae" {Odontologie, 15 Mars, 1903, p. 225). Fig. 4. — :\Iodel in Plaster Cast of the First Impression. To the right of the figure, the perforation which makes the mouth communicate with the antrum and nasal fossae. (Martinier.) Fig. 5. — Model in Plaster Cast of the Last Impression,' after the Cicatrization of the Soft Parts and the Dilatation of the Scar Tissue. (Martinier.) 2 i8 INJURIES OF THE FACE AND JAW tissue which, in producing the classical deformities consecutive to total ablation of the maxilla, had invaded the operation cavity. The treatment is as follows: The plaster mould of the remaining moiety of the maxilla is taken, as well as of the mandible, and to initiate the slow stretching of the cicatricial bands one makes a provisional correcting appliance consisting of a metal framework composed thus: Fig 6. — The First or Provisional Appliance seen from its Upper Aspect. To the right of the figure the original skeletal part, to the left of the figure the part made of hard rubber destined to cover the palatal vault and close in the perforation. The outer part of the appliance may be fitted with a bed of gutta-percha to increase its 1. An external band encircling the dental arch and fitting the gum. 2. A beaten plate on what remain* of the palate, to which are soldered metal prolongations intended to give support to a piece of vulcanized rubber. This piece, forming a bridge above the hole in the BLOODLESS TREATMENT OF VICIOUS SCARS 19 palate, is an exact replica of a block of wax which has previously been fixed to the prolongations and tried in the mouth, with the idea of moulding the h?. ^^.^ Fig. 7. — The Same Appliance: Lateral View of Anterior Surface. The white part shows the added gutta-percha . scar tissue of that region which the apparatus is meant to stretch (Figs. 4 to 10). Fig. 8. — The First or Provisional AppHance, Lower Surface, with its Articulating Edge which will hnk up the Two Jaws. It has on its lower part an articulating border destined to re-establish the relations of the two 20 INJURIES OF THE FACE AND JAW jaws in the movements of occlusion and articulation (Fig. 8). The external band and palatine plate are joined Fig. 9. — The Same: Lateral View of Anterior Surface. one to the other by a series of hooks of platinized gold applied to the internal and external aspects of the teeth, and soldered only on the central side ^-4\j^Mii5»*5>^ Fig. 10. — The Second Apphance with its Final Metallic Skeletal Part, External Wing, and Special Hooks. through a very small part of their extent, so as to give them a very great elasticity (Fig. 10). The volume of the whole is increased by applying gutta-percha. If it be desired, one can eschew the use of gutta-percha, which has the disadvantage of. BLOODLESS TREATMENT OF VICIOUS SCARS 21 gradually softening in the mouth. The process consists in vulcanizing, at the time of making the apparatus, a series of small rubber plates, taking the external shape of the appliance at that part intended to stretch the cicatricial tissues. The superposition, one after the other, of the small plates in this way increases the pressure on the tissues to be stretched. Fig. II. — Lower Lingual Aspect of Final Appliance. These small plates may be fixed to the appliance by screws. One will take care beforehand to prevent the saliva soaking in, by plastering the inner side of the platelet and the corresponding part of the appli- ance with a solution of rubber in chloroform. Having obtained complete dilatation of the cicatricial mass, it only remains to make a final appliance carrying 22 INJURIES OF THE FACE AND JAW teeth articulating with those of the lower jaw. The arrangement with hooks which we have just described constitutes, in our opinion, the method of choice for fixing this sort of apparatus. The springs so con- stantly employed are very irksome to the patient, besides which, applied as they are and placed in contact with the surrounding tissues, they cannot fail to irritate these and retard a favourable result. At this stage certain considerations crop up on which we shall enlarge later. In a general way, it may be said that the primary apparatus to restore large losses of substance in the region of the upper jaw should be the lightest possible (hollow apparatus), to facilitate their retention. The same does not apply round about the lower jaw, where, on the contrary, heavy apparatus are indicated for the same reason. II. Lower Jaw. • The partial or total resections of the horizontal ramus of the lower jaw produce cicatricial deformities and displacements from contraction, which in most cases entail serious functional disabilities. Following on a partial resection of the jaw, one notices, in fact, that the cicatricial tissue forms a linear band between the ends of the two bones, and carries the remaining fragments inwards and back- wards. Mastication is impossible, since the teeth no longer articulate ; the Hps, lacking the support of the skeleton, allow the saliva to trickle out. For a long while we have sought to remedy these BLOODLESS TREATMENT OF VICIOUS SCARS 23 serious troubles resulting from resection of the lower jaw. Mursinna in Germany and Verhuylen at Antwerp made the first efforts. The appliance of Mursinna was an external one, and consisted simply of a sling, which hid the de- formity fairly well. A sponge placed inside absorbed the saliva. Verhuylen's apparatus replaced the whole jaw; it was actuated by a spring which kept the lower dental arch against the upper. To use it, the patient lowered with his hand the chin band containing the jaw, introduced his food, and released the catch. Afterwards Preterre constructed divers appliances which have alread}^ brought about excellent progress. Results of Resections performed upon the Lower Jaw. — Following on the resection, the jaw fragments become displaced, irresistibly .pulled by the cica- tricial retraction and the contraction of the muscles there inserted. The dental arches no longer corre- spond, and their movements sideways are very considerable. For instance, we often observe the front teeth of the left lower fragment articulating with the upper right molar teeth, the upper left teeth biting on the gums and on the lower part of the left cheek, thus giving rise to ulcerations in- tractable to all treatment. The cavity of the mouth is narrowed; the tongue, lacking its place in the mouth, is projected forwards. Under these condi- tions mastication is quite impossible, swallowing much hampered, and pronunciation unintelligible. Preterre, who during the Italian War had been able to observe these deformities in numerous 24 INJURIES OF THE FACE AND JAW cases, was anxious to remedy them so far as possible. So he waited until cicatrization was complete, and when he judged the time opportune, because there was no more deformity to fear from retraction of scar tissue, he took an impression and applied his apparatus. This apparatus consisted of a second artificial dental arch placed in front of the natural deviated arch, which it ensheathed, and from which it derived its support. The artificial denture articu- lated with the teeth of the upper jaw. The patient then had a lower jaw in two tiers, reminding one of a shark's. Preterre's appliance greatly facilitated mastication by giving a comparatively sturdy pomt d'appui to the teeth of the upper jaw, which thus could not impinge on the lower lips. But by its volume it still further narrows the buccal cavity, the tongue is still more cramped than before, pro- nunciation yet more faulty, swallowing nearly impossible. We can well realize what risky results late pros- thesis of the lower jaw gave, up to the time that the apparatus of CI. Martin — when he created his admirable method for bloodless correction of vicious scars — allowed of late corrections which it had been impossible to achieve before his time. To place an apparatus for late prosthesis of the lower jaw, it is necessary to reduce the cicatricial band in two directions. We must first carry the remaining fragments forwards and outwards until we re-estab- lish the interdental articulation; and then depress the cicatrix from above downwards, to hollow out of it in some way a bed receiving the prosthetic BLOODLESS TREATMENT OF VICIOUS SCARS 25 apparatus which shall re-establish the continuity of the mandibular arch. Appliances to pull on the Mandibular Fragments. — The aim of these is to carry the remaining segments of the jaws into a position of abduction until the interdental articulation is re-established. The majority of these appliances take their purchase from outside the mouth by the interposition of a Fig. 12. — ^ Apparatus to pull on the INIandibular Fragments. (CI. Martin.) casque encircling the head. CI. Martin has success fully employed an apparatus composed of the follow ing pieces (Fig. 12) : 1. A metal gutter encircling all the teeth of the remaining segment of the deviated jaw. In the incisive region is soldered a rod, bent into a semi- circle to allow free movement to the lower lip. This rod bears a hook at its end. 2. A metal band surrounds the head like a crown. On this crown is fixed, on the side opposite the 26 INJURIES OF THE FACE AND JAW resected part of the jaw, at the level of the temporal fossa, a second metal rod continued downwards for the length of the ascending ramus, and descending to the level of the mouth. It bears a ring at its end. 3. A strand of rubber, stretched between the ring of the temporal rod and the hook of the buccal rod, pulls the deviated segment outwards.* Frey, with a similar appliance, has published some excellent results. t Delair has made an apparatus based on the same principle, a spring acting on the dental arch and taking its point d'apptii from a casque. This ap- paratus consists essentially of a steel rod, of which one of the ends is fixed to a metal gutter covering the teeth of that bone segment which one wishes to reduce; the other end, rolled up on itself to form a closely coiled spiral spring, is held at the level of the occiput by a casque made of bands of aluminium, which encircle the head in different directions (Figs. 13 to 16). This spring, curved inwards in a half-circle to pass round the cheek, has then its fixed point at the occiput, and its movable point of action at the jaw which calls for reduction.}: Its action is powerful; it carries the jaw segment forwards and outwards, and quickly, in a few days, it re-establishes the inter- dental articulation, which is thereafter maintained. * Cl. Martin, " Treatise of Immediate Prosthesis." t Frey, " Gunshot Fracture of the Whole of One Ascending Ramus of the Lower Jaw: Prosthetic Treatment " (National Dental Congress, Cherbourg, 1905). + Delair, " Exhibition of an Apparatus for replacing the Jaw in Position " [Odontologie, 28 Fevr., 1906, p. 157). BLOODLESS TREATMENT OF VICIOUS SCARS 27 However, apparatus with casques are open to severa criticisms : Fig. 15. Fig. 16. Figs. 13 to 16. — Traction Apparatus of Delair. I. They are fatiguing for the patient; the spring passing between the lips near to the commissure 28 INJURIES OF THE FACE AND JAW provokes a flow of saliva difficult to prevent ; to wear the casque becomes quite distressing and even pain- ful; the projection of the spring at the level of the cheek and the occiput is very irksome when lying down; lastly, the appliance attracts attention to the patient who wears it, and prevents him from going out and attending to his work. 2. The apparatus is comparatively quite compli- cated to make, and the execution is not so simple as the idea. With these reservations, one must admit that Delair's appliance attains the end aimed at, and rapidly brings into abduction the cicatricial bands which follow a partial resection of the horizontal ramus of the lower jaw. Frey, having applied in one case the more simple elastic traction appliance of Martin, has obtained a very fine success. None the less, in his notes of the case, drawn up with extreme exactness, we observe the following remark: "At this time S fell ill with a serious pleuro-pneumonia, and all prosthetic interference was stopped. It is very probable that, despite antiseptic douches, the irritation of the mucosa provoked by our efforts allowed some patho- genic organisms to infect the respiratory passages. Moreover, the weather was warm, and S was tired by his casque and by the loss of saliva; for the strand of stretched elastic which attached the ap- paratus to the casque kept the mouth for ever open."* * Frey, " Remarks on Prosthesis of the Lower Jaw. Indi- cations for Immediate Prosthesis " {Revue de Stomatologie , Juin, 1903). BLOODLESS TREATMENT OF VICIOUS SCARS 29 We consider this quotation to be the best illustra- tion of the general criticisms which we have just been levelling. In taking stock of the disadvantages of appliances which take their point d'appui from a casque, one of us has been persuaded to make this point d'appid intrabuccal by the use of the following small appliance.* A capsule of stamped metal covers the premolars and first and second molars of the upper jaw on the side opposite the resection. This capsule, bearing at its posterior end and on its outer surface a hook opening backwards, is fixed on the teeth with cement like an ordinary metal crown. A similar capsule is sealed in the same way on to the deviated fragment of the lower arch, but it fits on to a group of teeth farther forward, maybe the canine and premolars. On the outer surface of its anterior end is soldered a hook opening forwards. An elastic band with a buttonhole at each end en- gages these hooks (Fig. 17). The fixed point d'appiii is formed by the upper jaw, and under the action of the traction produced by the rubber the mandible, displaced inwards and backwards, steadily corrects itself, and in a few weeks retakes its normal position. This little appli- ance, resembling those used by orthodontists, causes no fatigue to patients, and gives rise to none of the objections to which those which take an extrabuccal support from a metal casque are liable. It is ex- * Georges Lemerle, " Appliance of Reduction after Resec- tion of the Lower Jaw" {Le Lahoratoire, 2.Ci Janv., 1908, and Societe d'Odontologie, Juin, 1906). — Sebileaii and Lemerle. Soc. de Chir., 26 Dec, 1906. 30 INJURIES OF THE FACE AND JAW tremel}^ easy to make, and that is an interesting consideration. Whatever be the appHance used, the abduction of the fragments of a resected mandible is generally achieved easily. To depress the scar tissue from above downwards is beyond all comparison a more lengthy and difficult matter to negotiate satisfactorily. Apparatus for pulling down the Band of Scar Tissue. — The object of these is that, once the abduc- tion of the jaw segments is accomplished, they shall gradually depress the cicatrix, ultimately hollowing Fig. 17. — Reduction Apparatus of G. Lemerle. out of it, as it were, a cell to contain the final appli- ance of late prosthesis. Martin achieves this reduc- tion by the use of a slow and continuous pressure by heavy appliances fitted with pieces of tin. Since the originator of this plan demonstrated its use, there has been no alteration in this method; and this is the best evidence of its adequacy. Granted, fox" instance, a resection extending from the angle of the jaw to the vertical level of the pre- molars of the same side, Martin's appliance is built up as follows: After taking the impression of the remaining teeth, one fashions a piece of rubber BLOODLESS TREATMENT OF VICIOUS SCARS 3] taking its support from the latter. This piece ol rubber is prolonged backwards, making a narrow border as far as the position of the original angle of the jaw. After several days, when the patient is thoroughly accustomed to wearing this appliance, one adds a piece of tin extending the whole length of the cicatrix, and fitting on the lower border of the rubber — i.e., the, border in contact with the mucosa. The appliance is thus also lifted upwards (Figs. 18 and 19). At the end of five or six weeks, thanks to the weight of the tin slab and the pressure exercised by the teeth of the upper jaw during mastication, the upper rim of the appliance becomes lowered to the same level as the alveolar border of the opposite side. Then one adds another piece of tin, which causes a further sinking, later a third, and so on until the scar has completely yielded. The heavy apparatus, driving back the scar tissue, scoops out at the site of the original gingivo-buccal groove a hollow big enough to lodge a final appliance replacing the missing part of the jaw. One of us has used since 1898 an appliance of this kind which has given him the finest results. The patient had undergone operation for a sarcoma of the mandible. The re- section extended from the right lower canine to the condyle. The cicatricial bands were thick, under great tension, and pulled towards them the remaining part of the lower jaw, displacing the fragment in- wards. The apparatus was composed of — I. A platinum cage, which covered nearly every part of the fragment of the mandible; it extended 32 INJURIES OF THE FACE AND JAW downwards a long way, thus taking a firm support from the jaw, and not from the teeth, so that the Fig. i8. — Apparatus built up with all its Pieces. (Martin.) Figs. 19 and 21. — Pieces for expanding the Heavy Appliance of ^lartin, seen separately. latter were protected. To this cage were soldered two strong rods of German silver; the object of these BLOODLESS TREATMENT OF VICIOUS SCARS 33 was to bear a piece of brown rubber, with a shape and curve resembhng the mandible. This rubber itself rested on the cicatricial bands. The upper part of the rubber came in contact with the teeth of the corresponding maxilla, which provided the points of contact requisite to re-establish the articu- lation; the lower or basal portion and the inter- mediate part in the cheek were intended slowly to distend the cicatricial bands by progressive addition to the bulk of the appliance, and by the mechanical massage exercised by the apparatus on the tissues during the various movements of the jaw (Fig. 20). 2. An upper appliance in platinum, to which is soldered vertically on the right side another small platinum plate, almost rectangular in shape. This small plate on its buccal side glided on another, rubber plate, which in turn was fixed to the platinum cage by a screw. The two plates, mutually gliding on each other, were intended to prevent lateral movements, so that, during the motions of the lower jaw in opening the mouth, the portion of bone spared by the surgeon should be always kept in its normal position. On the left side a strong spiral spring, attached by means of spring-holders, was placed, to exercise a vertical pressure strong enough to stretch little by little the cicatricial bands. In proportion as the bands yielded and relaxed, one added to the lower and outer aspects of the appliance a thickness of gutta-percha; this was destined to be replaced by brown rubber at the time when the next apparatus, 34 INJURIES OF THE FACE AND JAW which was naturally more bulky, should be made. Fifteen days after the first apparatus had been placed in position, the spring was removed without any trouble, and the apparatus was well in place; the steady stretching of the cicatricial bands took place simply by adding to the volume of the apparatus. Several appliances of this sort should precede the final apparatus furnish'^d with teeth. In this final Fig. 20. — Appliance for Restoring the Lower Jaw. (Martinier. apparatus one replaces the brown rubber on the inner and outer surfaces by pink rubber; this is essential for aesthetic reasons. To sum up: Confronted with a patient who has undergone a partial or total resection of one or other jaw, the goal of prosthetic treatment should be — I. To re-establish the physiological functions of the jaws. IL To give to the face its normal appearance. I3L00DLESS TREATMENT OF VICIOUS SCARS 35 We can arrive at this goal by a survey of the two phases which we have described: 1. Phase of correction of scar tissue. 2. Phase of prosthesis proper. The first of these phases comprises the following procedures : {a) Taking a plaster impression. (6) Constructing the skeletal or basal part of the correcting appliance, of which the objects are — (i.) To assure its retention. (ii.) To resist the displacements of the fragments, (iii.) To stretch the cicatricial bands. 3. Trying the appliance in the mouth. Before doing so we shall have attached a mass of wax or composition, with the object of moulding the parts on which the appliance will rest and the parts with which it will be in contact. At the same time we shall instantly re-establish articulation with the teeth of the corresponding upper jaw. 4. Reproduction in rubber of the piece of wax or composition, or the casting in tin of this piece, according to the case. 5. Placing in position the first, provisional ap- paratus, and attentive watching of the tissues on which they rest or against which they press. 6. Any modification of the appliance. 7. Making successive provisional apparatus, and modifications brought to bear on these, if such be necessary. The second phase, referred to above as prosthesis proper, comprises: (a) The combined construction of the final appara- 36 INJURIES OF THE FACE AND JAW tus bearing artificial teeth, and the various parts of the apparatus, which should conform as far as possible to the lines of the face. [h) Placing the apparatus in the mouth and making the requisite final touches. To get a good result one needs time and patience. Fifteen days to a month are enough to obtain abduction of the deviated section of bone; but twelve to fifteen months are wanted to depress the cicatrix vertically and make it ready to accommodate a final prosthesis. That is why, whenever possible, one should make use of preoperative appliances. Preoperative Appliances. — When the application of an immediate prosthesis at the time of resection of the lower jaw is not indicated, or if we intend to fix there, subsequently, a late internal prosthesis, we must seek to prevent the inward and backward re- traction of the remaining fragment of the jaw. In other words, we strive at the outset to conserve for the remaining moiety its normal position; and we do not delay in resisting the effects of cicatricial contraction until these are obvious. Be it understood that these appliances for mini- mizing the retraction of the jaw can only be used where we are concerned with a resection which was partial, and where some of the jaw persists. When the surgeon has defined the extent of his operation, CI. Martin places on that bony segment which is fated to persist an appliance of vulcanized rubber which encloses the remaining teeth; to the latter it is fixed by screws, if it cannot grip sufficiently by itself. BLOODLESS TREATMENT OF VICIOUS SCARS 37 This appliance bears an -external lateral wing pointing upwards, controlled by a second wing which is part of a similar appliance attached to the upper Fig. 22.— Preoperative Prosthetic Appliance of CI. Martin: Upper Piece. jaw. The upper wing is on the inner side of the lower ; this helps the latter to resist the pull of the muscles on the remaining piece of the mandible and the retropulsion resulting from scar retraction.* Fig. 23. — Preoperative Prosthetic Appliance of CI. Martin: Lower Piece. ' When the wound has healed, CI. Martin finishes the work by pressing down the scar tissue by means of his heavy appliances, until he can re-establish the * It is of importance, for this purpose, that the surface of gliding of the wings should be in the form of a groove. • 38 INJURIES OF THE FACE AND JAW continuity of the jaw by means of a final prosthetic apparatus* (Fig. 24). One of us has on several occasions availed himself, in the clinic of his chief, M. Sebileau, of the following device by way of a preoperative appliance: some Fig. 24. — Final Prosthetic Apparatus showing the Purpose of the Wings. metal capsules sealed on to the teeth and joined by an elastic band, as described in a previous section. This scheme of prophylaxis against early deformi- ties following on resections of the mandible has always given the best results. We go so far as to * CI. Martin, " Preoperative Prosthesis " : Congres de Lyon Aout, igo6 {Laboratoire, i8 Nov., 1906). BLOODLESS TREATMENT OF VICIOUS SCARS 39 say that no resection of the mandible should be undertaken unless it is either followed by an im- mediate prosthesis or preceded by a preoperative appliance. One or other of these will serve the purpose of checking the immediate displacements following surgical intervention, and will afterwards allow of the use of a late external or internal pros- thesis. III. Reduction of Nasal Deformities. Deformities of the nose owe their origin to lesions of the skull bones consequent on either trauma, syphilis, or tuberculosis. The bony framework is sometimes merely deformed, sometimes has suffered a loss of substance more or less. The straightening of the nose may be effected by either a sudden or a gradual correction. I. Sudden Correction is especially indicated after fractures affecting the nasal skeleton. At an early moment the fracture is reduced. Thereafter a suit- able prosthetic appliance maintains the reduction. CI. Martin has designed, to effect this reduction, a surgical, forceps which greatly facilitates its per- formance.* Sudden correction has been used with equal success in some cases of nasal deformity due to vicious union of certain fractures or to specific lesions. In such cases the treatment is firstly surgical, then prosthetic. The surgical stage comprises the breaking down of * Congres dent, internat., Paris, 1900, 40 INJURIES OF THE FACE AND JAW cicatricial bands or the osteotomy of the nasal bones joined in a faulty position. The prosthetic stage consists in the application of an apparatus to hold the nose in a correct position. Sauer and Skogsborg in German}', and Aeyrapaa in Russia, have obtained by this method satisfactory results, following Kingsley, who since 1868 made experiments in this direction. But it is above all CI. Martin who extended this procedure to a large number of cases and systematized its technique. Once the scar tissue has been freed, the difficulty lies in finding a solid support for the apparatus which is to be kept there. The walls and borders of the nasal fossse only supply the most mediocre supports. The best is that which may be borrowed from an upper denture when a perforation of the palate coexists. When no such perforation exists, one can, as exemplified by Aeyrapaa, trephine the palatine vault to make a passage for a metalhc rod to sustain the apparatus which is to hold up the nose. We consider, with CI. Martin, that this is the best method for retention of these nasal correction appliances. The palatine perforation is not specially difficult to make, nor does it entail any functional disability for the patient. 2. Gradual Correction. — This is applicable to the majority of cases treated by the preceding method, but is particularly called for when the deformity concerns mainly the fleshy or cartilaginous parts of the nose. To raise a depressed and thickened septum, CI. Martin has thought out the following appliance: BLOODLESS TREATMENT OF VICIOUS SCARS 41 Two parallel sheets of hardened rubber are joined at their front part by a U-shaped spring. Their free ends are buried fore and aft in the nasal fossae on each side of the septum. At the front end of these plates are articulated two similar plates. These latter are movable in a vertical plane, and are lifted up in this direction by a spring placed near to their point of junction with the lower plates. This spring consists of an annealed gold wire, which can be bent to any desired shape. As CI. Martin puts it, the upper plates move on the lower like the blade of a pocket- knife in its handle. This appliance acts by taking its purchase from the two sides of the septum and the floor of the nasal fossae. The two lower plates, compressing the septum in the transverse plane, tend to diminish its thick- ness and lengthen it vertically. The upper plates, gently urged by the springs, lift up the whole front part of the nose. Thus, the combination of these two movements tends to give to the nose a more prominent and a narrower shape. To get satis- factory results, this apparatus should be continuously worn, and should not be removed except for just enough time to cleanse it. The force of the springs should be regulated so that their pressure never becomes painful. This type of appliance can be modified according to the variations of the cases, and CI. Martin has made several depending on this principle. He says: " For the twenty-five years that I have used them, I have obtained with these appli- ances some excellent results. None the less one can make two adverse criticisms: First, they act very 42 INJURIES OF THE FACE AND JAW slowly; secondly, the anterior spring is visible ex- ternally below the columella. This latter drawback is negligible in children and young people, and it is precisely in this category that I use this mode of correction for preference. Therefore I do not hesitate to recommend it, because I have got and am getting in my practice some fine results."* 3. Corrective Apparatus for the Nose.— These are intended to remedy congenital or acquired nasal deformities, when the bony and cartilaginous frame- work is still preserved. We can distinguish two sorts of apparatus : {a) Apparatus to dilate the nostrils and reshape the septum. (b) Apparatus to reshape flattened noses. {a) Dilators of the Nostrils. — CI. Martin has con- structed many appliances of this sort, consisting essentially of — Two vulcanized rubber plates which are placed in the nostrils on either side of the septum. An anterior spring which joins these two plates and holds them against the septum. Two other plates of hard rubber which glide on the first plates, imitating the move- ment of a knife-blade in its handle. By means of a spring these two plates are applied to the upper part of the nasal fossae, thus dilating the nostrils in the vertical direction, simultaneously raising the lobule and the soft parts (Fig. 26). To efiect a transverse widening of a nostril, CI. Martin applied an appliance consisting of two sheets of vulcanized rubber joined along one side by the * CI. Martin, " Rapport au Congres de Madrid," 1903, p. 31. BLOODLESS TREATMENT OF VICIOUS SCARS 43 same substance. One of these sheets rested against the septum, the other against the inner surface of the ala to be dilated. The appHance for straightening the septum comprises two upright plates of vulcanized rubber corresponding in size to the deviation, which are applied to each side of the septum by means of a spring placed in front. Fig. 25. — Continuous Pressure Apparatus. (Martin.) In these appliances the parts which have to exercise pressure on the mucosa are covered with rubber to guard against ulceration. {b) Apparatus to reshape Flattened Noses. — An attempt has been made to reshape saddle-back noses by means of rods of rolled metal, which fitted by one end on to the floor of the nasal fossae, and by the other propped up the nasal bones. No results were ob- 44 INJURIES OF THE FACE AND JAW tained; the rolled metal rod slipped down in the nasal fossa and ceased to act. * CI. Martin has invented an apparatus which is certain of achieving its purpose, is not cumbersome, allows of nasal breathing, and is hardly visible. It consists of — (i.) Two plates of vulcanized rubber to lie on the nasal floor and thus give a stable support to the spring. (ii.) A gold ware which follows the contours of the lower outline of the nostrils and unites the two plates. Fig. 26. — Nasal Dilator. (Martin.) to which it is attached by a hinge. The hinge gives a large range of movement to the plates, and allows them to lie snug against the nasal floor. This gold wire is barely visible, and may be made still less noticeable if covered with pink rubber. (iii.) Two springs of gold wire, varying in shape according to the point on which they are to act; these emerge from the upper surface of the intra- nasal plates, and end in — (iv.) Two tongues of hardened rubber, applied BLOODLESS TREATMENT OF VICIOUS SCARS 45 against the nasal vault, which they lift up and replace in its normal shape. The introduction of this apparatus is easy, and causes no annoyance when in place (Fig. 27). CI. Martin, for narrowing the root of a nose which is as wide above as below, uses an appliance which takes its support from the front part of the septum and the floor of the nasal fossae; by means of two springs and two small plates the arrangement pinches the upper and external part of the nose. Fir.. 27.— Appliance for Flattened Noses. (Martin.) The correction takes a long time; surgeon and patient must equip themselves with an enormous deal of patience. As a reward, we can promise the patient that if he wears the apparatus consistently success is certain. 4. Cicatricial Stenosis of thie Oro-Pharynx.* — CI. Martin has had occasion to apply his system of bloodless correction of cicatricial bands at the site of a cicatricial narrowing of the oro-pharynx. For * Cl. Martin, Congres de Madrid. 46 INJURIES OF THE FACE AND JAW this particular case he devised the following appara- tus, consisting of two parts: (i.) A palatine plate fixed in the usual way to the teeth, and completely covering the palate. Fig. 28. — Adhesions^of Palate Jand Pharyngeal Wall : Cast of the Mouth and Pharynx before Operation. (Delair.) (ii.) A dilating apparatus constituted by a spring screwed on to the middle of the plate. This spring is made of an annealed gold wire feebly stretched, and shaped like a compass of which the limbs, bent back in a curve, diverge. Their lower ends are prolonged BLOODLESS TREATMENT OF VICIOUS SCARS 47 into two semi-hard rubber balls. When the ap- paratus is in place, these balls press against the boundaries of the narrowed part, and the two branches of the spring cause the widening of the stenosis. Fig. 29. — Palatc-Pharyngeal Adhesions: Cast o^ the iMouth and Nose after Operation. (Delair.l^ 5. Palato-Pharyngeal Adhesions. — The same prin- ciples find a happy application for the correction of adhesions between palate and pharyngeal wall. Having freed the adhesion of the velum to the pharyngeal wall, one has to prevent any new ad- 48 ■INJURIES OF THE FACE AND JAW hesions from forming until the bleeding surfaces have completely healed, meanwhile keeping these apart. CI. Martin has obtained the best results with the following apparatus: A block of rubber in the shape of the pharynx is made by means of a mould taken from the cadaver. This block is kept in place by two prolongations entering the posterior nares, and ending in two rubber tubes which emerge from the > 11 •^; Fig. 30. — Palato-Pharyngeal Adhesions: Delair's Appliance, seen from Below, with the Carriage and the Dilators. nostrils. These facilitate easy retention of the whole arrangement. The wearing of this apparatus, for the whole period of cicatrization, enables one to prevent the formation of new adhesions. Delair* (Figs. 28 to 32) also has made an apparatus * Delair, "^Demonstration of a Child wearing a Dilator of the Naso-Pharynx : Delair's Plan to counteract Palato- haryngeal Adhesions " {Odontologie, 15 Juillet, 1909, p. 12). BLOODLESS TREATMENT OF VICIOVS SCAHS 49 to correct adhesions of the palate. It depends on a mechanism which is ingenious, but more comphcated than the pharyngeal separator of CI. Martin above described. Delair's apparatus comprises four pieces, as follows: I. A metallic palatine plate kept in place by rings fitted to the teeth. Fig. 31. — Delair's Appliance, seen from Above, with the Projection caused by the Upper Longitudinal Groove, in which glides the Safety- Screw. 2. In the centre of this plate a carriage; this is of gold, and consists of two pieces joined along their contiguous surfaces in an antero-posterior direction. 3. At the end of the carriage, two movable branches like the limbs of a compass, embracing the concavity of the velum and encircling the uvula to prevent any trauma of this latter. 4. The two movable branches are furnished at 4 50 INJURIES OF THE FACE AND JAW their ends with two prolongations of aluminium, destined to lie on the postero-superior aspect of the velum after it has been surgically freed. The several sections of this apparatus play one upon the other, and coax the velum free in various directions, with the help of elastic traction. A YiG. 2)Z. — Diagram to show the Details of Delair's Apparatus in Place. rubber ring connects the carriage of the palatine plate, producing a pull from above and behind; this, acting on the velum, prevents it from again touching the posterior pharyngeal wall. Some other rubber strands pull on the movable articulated branches of the carriage, making them diverge. This movement, LATE PROSTHESIS 51 occurring in a transverse plane, moves outwards the extreme borders of the newly formed velum, and prevents the raw edges from coming into mutual contact in the middle line. Delair's appliance has undoubtedly the advantage that, much lighter than Martin's and of very small bulk, it is much less irksome to him who wears it. Nevertheless, Martin's has one great merit, its simple construction; and for an apparatus essentially tem- porary, and which has to be worn only for a few weeks, this is an advantage not to be despised.* CHAPTER III LATE PROSTHESIS The Prosthetic Stage Proper. By " late prosthesis " is meant the prosthetic restora- tion of losses of substance due to accident or surgical interference, such restoration being performed at a smaller or greater interval after the complete healing of the soft parts. In the preceding chapter we saw that the retraction of scar tissue brings in its train divers deformities, and we have studied the methods used to rectify this. In the matter of late prosthesis, it is the stage of cicatricial contraction which beyond doubt offers the greatest difficulty. Late prosthesis proper — that is, the final appliance to remedy the loss of substance after obtaining correction of scar * Mixed velo-palatine prosthesis: surgical and prosthetic method. Vide Prosthetic Intervention after Staphylor- rhaphy, Chapter III. 52 INJURIES OF THE FACE AND JAW tissue — constitutes a very much easier phase of the restoration. We shall study in sequence late ap- paratus for restoration of the jaws, the soft and hard palates, the larynx, the bucco-facial region, the nose, and so on. I. Late Prosthesis of the Jaws. Apparatus and methods vary according to whether we are concerned with the upper or lower jaw. But we will now point out certain rules which must be kept. Impressions.— We take impressions in plaster for choice; plaster exerts but a moderate pressure on the tissues, and thus the replica which it provides is a faithful copy of the supporting tissues, cicatricial or otherwise, when these are at rest. W^e are often obliged to make a special impression tray for the case in hand. W'ith this idea we take, using an ordinary impression tray, a rough cast of the tissues which the appliance is ultimately to support. We cast this impression, and on the model thus obtained we make the impression tray either by stamping it on a sheet of German silver, or by making a tray in wax and substituting for it vulcanized rubber or aluminium cast in the wax. By means of this tray it becomes easy to bring the substance used for the impression in contact with all the tissues, exercising an equal"jif)ressure at all points. It is often necessary, in anfractuous cavities, to take the impression in several parts; this composite impression (see p. 183) gives, when it is assembled, the total impression. LATE PROSTHESIS .53 Apparatus. — The apparatus is furnished with teeth on the alveolar border. We employ for choice vulcanized rubber for making them. The base is made of undressed brown rubber, which is at the same time lighter and firmer; the gums in pink rubber ; and the backing or lingual cusp, if necessary, of white rubber. The base may equally well be made of cast aluminium, which is so well tolerated by mucous membranes. We more often use, for the bases in bulky appliances, soft rubber, which has the following advantages: 1. It causes no pain by pressure on the tissues which are in contact with it. 2. Its elasticity facilitates the removal of the appliances, and therefore their cleaning. 3. It does not lessen the humidity of neighbouring tissues. Hence its usefulness for prosthetic appli- ances in contact with the nasal mucosa. Apparatus used after resections of the mandible may con- veniently be massive; for by their weight they resist the cicatricial deformities of neighbouring tissues and facilitate the lowering of the jaw. For lower jaw appliances destined to replace large losses of substance, it is good to introduce into the rubber to be vulcanized, at the moment of packing, some fragments of rubber themselves previously vulcanized, or some pieces of tin, to get rid of the porosity caused by the unusual thickness of the part to be produced. It is by no means the same thing with the upper jaw appliances designed to remedy the functional troubles following a loss of substance after a surgical 54 INJURIES OF THE FACE AND JAW Operation, or resulting from congenital default. In such case lightness is a condition indispensable to success. These appliances are often bulky; to pre- serve the necessary size, all the while maintaining the lightness which is imperative, the thickest parts must be hollow. It has been suggested to incorporate in them a block of aluminium ; but this metal, howbeit light, is still too heavy, and the results have not been satisfactory. Another experiment has been the introduction of pieces of cork in the rubber, at the time of the packing of the apparatus. The. best plan is to leave a cavity in the centre of the thick parts of the contrivance. To get this result we avail ourselves of various processes : The appliance is flasked as usual. We cover with a sheet of rubber the deep part of the apparatus. In the hollow thus formed we pour a certain amount of plaster, representing what is to be the cavity. The plaster once hardened, and the seams loosened, we carry on the packing, as if we had to make a piece of an ordinary prosthesis. The block of plaster is thus included in the centre of the rubber. Geoff roy* has published an interesting process for obtaining extremely light apparatus. We cannot here describe the technical details. Enough to say that the hollow is obtained by means of two light boxes in stamped aluminium, and covered outside by rubber. They are exactly adapted by their borders, and united by the rubber which serves as their common envelope. * Geoffrov, " Hollow Appliances for Restorative Pros- thesis " {Odontologie, 30 Aout, 1906, p. 166). LATE PROSTHESIS 55 As a rule, prosthetic appliances come into contact with cicatricial tissue which is more fragile than normal tissues; so the appliance should not possess sharp angles, its rough points should be carefully rounded off. Moreover, as we have already pointed out, we prevent contusions and undue pressure on the tissues by using soft rubber for those points Fig. 2>2>- — Late Prosthesis for the Upper Jaw, as used bv Pont of Lyons. which have to be against them. Pont* has ex- hibited an entirely original apparatus for the restora- tion of the upper jaw (Figs. 33 and 34). * Pont, " General Considerations on Restorative Prosthesis for the Upper Jaw. Exhibition of a New Apphance " [Odontologie, v., 1903, p. 471). We must also call attention to an important memoir recounting seventeen cases of pros- thetic restoration after resection of the upper jaw. Vide Billing, "Von der Obsrkiefer Resektions Prothese," Stock- holm, 1 91 2; Isaac Marcus, editor. 56 INJURIES OF THE FACE AND JAW This apparatus consists of a hard vulcanized rubber palatine plate, supporting artificial teeth and resembling an ordinary denture. This plate is surmounted by a soft rubber pocket closely approach- ing to the shape of the maxilla or of the missing part. A gold tube, sunk into the palatine plate, puts this pocket into communication with the outer world. Fig. 34. — Late Prosthesis for the Upper Jaw : Pont of Lyons The inner end of the tube is closed by a valve, and the outer end by a pivot which supports one of the false teeth of the apparatus. When the patient wants to wear this arrangement, he has only to empty the pocket of air. It is easy to flatten the pocket and put the appliance in place. This done, the patient with a pear-shaped inflator refills the pocket with air, and it swells and hardens. LATE PROSTHESIS 57 In this way its retention is complete. The advantage of this apphance is its extreme lightness. Moreover, it can be used with effect for treating vicious scars. II. Prosthesis for Soft and Hard Palate. Perforations or losses of substance of the velum or hard palate may be congenital or acquired. In the latter case they occur most often from tertiary syphilis. The functional disabilities vary in degree with the amount of substance lost ; nasal speech may be noticed, and the escape of liquid, or occasionally solid food, from the nose. The patient experiences great difficulty in swallowing, above all of fluids; he throws back his head and drinks in tiny mouth- fuls. Nearly always phonation is heavily handi- capped, even to the point of being quite unintelligible. We cure these incapacities by methods surgical or prosthetic; the indications for these respective plans are drawn, as we shall see later, now from the age of the patient, now from the extent of the lesion. But the functional gain accruing is very variable, according to whether we are concerned with an acquired perforation or a congenital fissure. In the former the cure of speech is rapid, sometimes even immediate. Varying with the sort of case, a simple obturator plate or a flexible velum generally suffices to correct functional troubles perfectly. " This fact," says A. Martin, " is easily explained by the existence of previously educated muscles; and in these cases the imperfect speech depends rather on mechanical defects resulting from the lesion than on 58 INJURIES OF THE FACE AND JAW the abnormal play of the muscles. Thus, it suffices to re-establish these mechanical conditions in sup- pressing the communication between the mouth and the post -nasal space, for speech to redevelop as pure as of yore. " The treatment of congenital losses of substance Fig. t,^. — Cast of a Hare-Lip. (Deiair.) is different, and presents complex difficulties. To create anew the normal mechanical conditions never suffices to obtain a rapid and satisfactory functional result. The fact is that in these cases the chief impediment arises, not only from the actual loss of LATE PROSTHESIS 59 substance, but above all from the atrophy of muscles, and because their education has been nil or faulty. So far is this a truism that, even with a good appara- tus, we get an insignificant result as regards speech. " The prosthetic treatment should then always be followed by a period of re-education of speech, necessary to obtain a good final result, but which itself would not be enough."* Now, as we shall see later, this is a consideration often not fully realized. In the matter of congenital fissures of the velum, one cannot repeat too often that a long speech-training is indispensable. Ortho- phonia must be deemed the logical outcome of all efforts for restoration, surgical or prosthetic, and the majority of functional failures may be lain at the door of negligence of this paramount rule. There are two methods to cure clefts of the soft or hard palate: (i) surgical, (2) prosthetic. I. Surgical or Autoplastic Method. — We can only deal with this in passing. By two parallel incisions at the palatine cleft we can elevate the mucosa, and by sliding bring together the two flaps thus obtained. We thereafter freshen their edges, and suture them in the mid-line. When our object is to reconstruct the hard palate we use the term "uranoplasty"; when the soft palate is concerned it is a " staphylor- rhaphy." The immediate post -operative outcome is sometimes very pretty. But the functional results are not constant, because too often the surgeon neglects the observation and after-care of the velo- palatine scar tissue. We have seen in an earlier * CI. Martin, Cong. Madrid, p. 45. 6o INJURIES OF THE FACE AND JAW chapter that the character of scar tissue depends on its retractihty; but it is this very elasticity which enables it to elongate and soften easily by pressure or traction, gentle and continuous, or at any rate frequent. Later we shall see how systematic massage of the velum, after staphylorrhaphy, makes it supple and able to resist shortening. In certain cases, even to wear an appliance resembling an elastic ball for a brief space gives a fair amount of lengthening. 2. Prosthetic Method. — This comprises essentially two sorts of apparatus: artificial vela and obturators. The object of artificial vela is an anatomical restoration. The paramount end to he gained by obturators is a functional restoration, and, neglecting the reconstitution of the loss of substance, their only destiny is to correct its results by occluding the abnormal communication existing between the month and the naso-pharynx. Certain authors (CI. Martin, Delair, NormaiJ Kingsley) have sought to combine in one apparatus these different principles. Petronius in 1565 spoke of palatine obturators, and recommended wax, tow, sponge. Ambroise Pare described two sorts of obturators for fissures of the hard palate, consisting of a metal plate and a sponge. Fauchard combined obturators with dentures, and omitted the sponges hitherto employed. Bourdet noticed the tendency of acquired palatal fissures to close spontaneously, and invented a series of obturators consisting of a simple plate of gold, held by wires, and intended to encourage the reunion of the edges of the perforation. Delabarre in 1820 introduced into their construction a soft hinged velum. In 1823 Snell discovered one LATE PROSTHESIS 6i of the most important principles of this special prosthesis: to communicate to the artificial velum the movement of the remaining stumps of the palate. In 1840 Stearn made an obturator on this plan, and Schange in 1841 made the first model entirely in gold. Kingsley in 1864 constructed an artificial velum by means of two superposed sheets of soft rubber; the stumps of the velum fitted in between these, and communicated to them their mobility. Gariel in 1855 made an obturator in vulcanite having the form of a double shirt button. Preterre has made a large number of obturating arrangements and artificial vela, deriving his ideas from those of Stearn, carried out with greater simplicity.'''' After Preterre, the study of velo-palatine prosthesis came to a halt in France, although in Germany Suerson, then Brugger, gave it a great impetus. In these latter years, CI. Martin and Delair in France, and Calvin Case in the United States, have published important work on the question; and velo-palatine prosthesis seems now to be in good working order, at any rate as far as concerns its underlying principles. Prosthesis for the Hard Palate. — The disabilities resulting from losses of substance of the palatine vault are easily curable. It is sufficient, in order to cure the functional trouble, to fit an obturator con- sisting of a palatine plate which takes its point d'appui from the neighbouring teeth, and adapts itself exactly to the circumference of the perforation. This plaque may be of either metal or vulcanite. It must pass * Preterre, " Treatise of Congenital or Acquired Fissures of the Soft and Hard Palate," Paris, 1884. 62 INJURIES OF THE FACE AND JAW across the perforation like a bridge, without penetrating, because small losses of substance, notably of the ac- quired variety, tend to fill up spontaneously. The appliance must not hinder this tendency to repair. Contrivances which pass through the perforation and take their support from the floor of the nasal fossce are thus absolutely contra-indicated. Prosthesis for the Soft Palate. — When the lesion involves the velum, the difficulty is much greater than in the preceding case. To replace by a pros- thetic appliance a muscular and eminently mobile organ presents almost insurmountable difficulties. Hence the legion of contrivances suggested and the faulty results often achieved. The importance of an artificial velum varies according to the size of the fissure. The greater the breach, the more is it worth while to fill it up. Impression. — The material of choice is plaster; a special impression tray is useful. But it is often preferable to fashion it in the way already mentioned in the earlier book.* For it is rarely that impression trays when made have the desired measurements; this is especially true as regards the height of the palatine vault. We must make many trials until we succeed in getting the velum and the stumps of its pillars in a state of relaxation. In this case even more than in any other it is expedient, from the moment that the plaster is introduced into the mouth, to lower the patient's head, so that no plaster runs into his throat. In the event of requiring an im- * Vide p. Martinier and G. Villain, " Clinique de Prothese." LATE PROSTHESIS 63 pression of the edges of the perforation and the naso- pharynx, we take one impression (see p. 183) super- posed on the other ; or we can adopt the plan described apropos of the apparatus of Calvin Case. Contrivance of the Apparatus. — The apparatus is divided into two parts: one fixed, the other movable. The first or fixed part forms the base plate. It is rigid, extends along the surface of the palatine vault, and takes its point of attachment from the teeth by means of the various arrangements in practice for retention of apparatus. If we have a combined lesion of the soft and hard palates, it answers also as an obturator. This part may be in vulcanite or metal. It should be fitted as accurately as possible, so that the obturator may be very rigid. The second or movable part is as a rule in soft rubber, less often in hard rubber or metal. It plays the part of velum, and should have as far as possible the same relations and physiological movements as does the velum under normal conditions. It should fit on to the borders of the cleft, and follow smoothly whatever movements the stumps of the natural velum can impart to it. These two parts are united at the junction of the hard and soft palates by an articulation which dift'ers with the importance of the gap and the type of appliance used: sometimes there is no line of demarc- ation, but simply soft rubber succeeding hard; some- times there is a small hinge. This articulation must be very mobile and very delicate, so as to react to the least movement ; it must not become dirty, which would check the working of the appliance. Having 64 INJURIES OF THE FACE AND JAW framed these general laws, we will study a few of the best-known apparatus. Simple Appliance without a Hinge. — This apparatus consists of — • I. A palatine plate extending no farther than the level of the palate bones; it is sometimes of metal, usually of hard vulcanite, and is prolonged backwards in the direction of the velum in the form of a stanchion. Fig. 36. — Simple Appliance without a Hinge. (^lartinier.) '2. A plate of soft rubber corresponding to the loss of soft tissue in the hard and soft palates, and lying over the edges of this gap. The palatine and velo- palatine plates are continuous without the inter- position of a hinge or other joint. The hard part, which is continued into the centre of the soft rubber, acts as its guide, and keeps it along the borders of the perforation (Fig. 36). LATE PROSTHESIS 6$ The artificial velum so made has been adversely criticized in that it does not possess the desired mobility. When hrst inserted and the palate is in repose, it shuts off the cleft well; but in the move- ments of swallowing it lits badly and hampers the physiological work of neighbouring muscular struc- tures. After the lapse of some time the soft rubber becomes misshapen under the influence of this con- tinuous pressure, and ceases to tit even in repose. It hardens, and its mobility, never reliable, becomes still less. It cracks and becomes severed from the palatine plate at its point of union with the latter. Fig. 37. — Kingsley's Appliance. But above all we must indict this artificial velum of a faulty functional restoration; this, moreover, it shares more or less with all appliances which shut off the naso -pharynx only incompletely. Kingsley's Appliance. — This consists of — 1. A palatine plate of vulcanite or metal. 2. An artificial velum of soft rubber. 3. A hinge to join these two parts and assure free movement to the artificial velum (Fig. 37). This hinge does not put beyond doubt the close fitting of the remaining muscular parts. To it we must also add a spring which keeps it snug against 66 INJURIES OF THE FACE AND JAW the borders of the hole. This spring may be inferior - — i.e., buccal; in this case it consists of a sheet of flattened gold fixed to the base plate, playing on the velo-palatine part which it carries upwards in the movements of swallowing. Or, again, the spring may be superior — i.e., nasal — in which case it con- sists of a spiral spring, fixed in front to the base plate, and behind to the artificial velum, which it lifts upwards. Thus, it is certain that the latter maintains contact with what remains of the soft palate. A rubber ring can be substituted for the spiral spring, fixed in the same way. Appliance of Guerini of Naples,'^ — This consists of— 1. A palatine plate, preferably metallic. 2. An artificial velum in soft rubber. 3. A joint uniting these two parts. It is the latter (the joint) which gives originality to the arrangement. It comprises a series of small transverse plates joined by hinges, constituting in this way many small joints which give the obturator a great mobility on the palatine plate [a lobster-tailed joint — Tr.]. The pressure required to fit the appli- ance to the neighbouring parts during all their move- ments is provided by a small sheet of gold perpendi- cular to the segments of the lobster-tail, forming a spring. This small sheet is yielding enough to give way to movements of lowering, meanwhile carrying the velum upwards in movements of elevation (Fig. 38). * " New System of Obturator for the Soft Palate " (Con- gres dentaire international de Paris) . LATE PROSTHESIS 67 Martins Appliances — i. Appliance with Bags of Water. — Martin did not rest content with shutting off the buccal from the naso -pharyngeal cavities; in order to obtain a practically normal voice, he entirely Fig. s^. — ^Appliance of Giierini. replaced the lost substance. " The appliances which we use are of hard and soft rubber, which allows us to obtain an artificial velum having the free play of natural vela. Moreover — and herein lies the origin- ality of our system — we replace by hollow rubber bodies all the lost tissue, so as to give to the buccal 68 INJURIES OF THE FACE AND JAW and nasal cavities their natural form. This is, in fact, the only plan which enables us to obtain a correct pronunciation."* Consistent with this principle, Martin constructed some apparatus bearing at their posterior end globular masses of hollow soft rubber. If the vomer is partly missing, he replaces it in his obturator by a median Fig. 39. - — Martin's Appliance with Bags of Water. A, Upper bag of water; B, artificial velum; C, nasal prolongation. projection w^hich meets the remains of the natural vomer (Fig. 39). So as to give more mobility to the obturator, in order that it may be able to follow all the movements conveyed to it by the muscles, he partly fills with fluid the shallow cavity in the hollow soft rubber situated at the posterior part. He gives to this obturating part the shape of two bags joined by a constriction. The lower bag in front is continuous with the palatine plate of the apparatus, and its upper surface lies against the lower surface of the * Ci. ]^Iartin, " Concerning Immediate Prosthesis," Paris, 1889; Masson, editor. LATE PROSTHESIS 69 remaining parts of the velum. The upper and smaller ±)ag is placed in the nasal fossae, on the floor of which it rests by its inferior surface, overlapping a little the borders of the loss of tissue. The constricted part joining the two bags corresponds to the margin of the perforation, which are thus enclosed by the two valves {i.e., bags). The two bags are hollow, and communicate by an opening at the level of the constriction. This sub- divided cavity is partly filled with fluid. Under the influence of the muscular movements which com- press the lower bag its contained fluid is driven into the upper, which swells and presses the appliance snugly on the nasal floor. The apparatus in this way follows all the movements of the velum, and answers to every muscular impulse conveyed to it by the surrounding muscles. By altering the shape of the bags, we can divert the fluid into convenient channels, and thus obtain movements closely re- sembling those of the normal velum. 2. Trap-Door Obturators. — Meanwhile Martin, changing his point of view, has invented another obturator called a " trap-door," which is described in his own words as follows: " It consists primarily of a palatine piece in hard rubber, and a soft or hard velum joined together by a hinge (Figs. 40 and 41). " Above the velum the second part of the apparatus is fixed ; this is destined to fill up in part the pharyngeal cavity. It consists of three traps: one median and two lateral. The latter present, along their external borders, a gutter where the stumps of the velum -o INJURIES OF THE FACE AND JAW will lodge ; and the velum will communicate to these lateral traps their movement. In transverse section these traps are triangular, with the apex inwards; and the lower surface of one rests and glides on the upper surface of the other. The median valve also is triangular, in transverse section, the apex of the triangle pointing downwards, and fits into the angle fornned by the two lateral traps; its lateral aspects rest and move on their upper aspects. When the Figs. 40 and 41. — ^Martin's Trap-Door Obturator. Fig. 40. — Position of the Traps when the Pharyngeal Muscles are at Rest. Fig. 41. — The Same during the Contraction of the Pharyngeal Muscles. stumps of the soft palate contract, they compress the lateral traps, which glide one on the other by their inclined surfaces, pressing backwards and upwards the median trap, which becomes pushed against the posterior pharyngeal wall. During re- laxation the median trap descends by its own weight, opening out the lateral traps; these latter return to their position of rest, and the communication be LATE PROSTHESIS 71 tween the pharynx and nasal cavity is once more patent."* To make these hollow appliances, we construct a plaster model of the parts which are to be represented by hollow rubber — that is, the traps. We next cover all'aspects of the rubber with a suflhcient thick- ness of plaster, and vulcanize it. We take out the plaster by making a hole, which is forthwith tilled up again. Fi(i. 42. — Valve- Velum. Delairs Artificial Valve-Velum.'f — This contrivance is founded on the following postulates which Delair's exhaustive work has allowed him to formulate: 1. The basal or palatine part of an artificial velum should be of metal, to obtain a resonance superior to that given by vulcanized rubber. 2. The velum, whatever its shape, should be soft and supple. * CI. Martin, Cong, de Madrid, 1903, p. 54. t Delair, " Artificial Valve- Velum " (Cong. dent. nat. Ajaccio, OdontjL, Juillet, 1902, p. 59). — " On Velo-Palatine Prosthesis" {OdontoL, 1905, p. 143). — " New MethoJ of Re- storative Velo-Palatine Prosthesis " {OdontoL, 1901, p. ^j;}). 72 INJURIES OF THE FACE AND JAW 3. The velum should be united to the palatine plate by an absolutely mobile joint, so that the former may be able to follow, in their movements of elevation and depression, the stumps of the cleft velum and the faucial pillars. 4. The false velum should extend to beyond the limits of the anterior pillars, so as to close the pharyn- geal cavity, and thus reduce the resonance. The posterior margin of this velum should come into accurate contact with the cushion which is formed by the superior pharyngeal constrictor during swallowing and phonation. Delair's valve-velum is of soft rubber, with convex borders. It is attached to a fixed denture by a hinge. This velum passes up behind the posterior pillars, and ends in the form of an oval cupola, of which the flexible and thin borders tightly fit the contours of the pharynx. A sort of valve is thus produced, which checks the passage of air. When the soft rubber perishes, the valve can be changed. "To facilitate the elevation of the artificial velum, and allow it to follow the excursions of the natural one, a simple soft rubber washer serves as a spring. It is held b}^ a rod and ring at the top of the posterior part of the basal plate, and is caught on to a hook soldered to one of the two nuts which screw the velum to the movable posterior section of the appli- ance." To fashion his appliance, Delair simply took a mould of the upper jaw, not extending be^^ond the limits of the bony palate. After this mould he made the basal retention plate or denture. To construct I LATE PROSTHESIS 73 the mobile part — that is, the artificial velum and its valve destined to shut off the pharynx — the author preferred to rely on measurements. As a fact, the margins of the palatine gap and pillars have a divergence which varies consecutive to the state of rest or contraction of the residual stumps of soft palate. Now, the taking of the impression (which necessitates the use of cocaine) gives the position of the respective remnants of velum when in repose; and if a valve were constructed on these data it would be too small, in that the stumps in contracting increase the gape of the fissure margins. As a corollary to this, the final apparatus will shut off the pharynx only when in a state of rest ; this occlu- sion will become imperfect at the exact moment when the stumps contract. Delair accordingly took his measurements while allowing for the extreme gaping of the edges of the fissure, which he obtained by eliciting muscular contraction by tickling the mucosa. A certain number of special compasses thought, out by the author are requisite (Figs. 43 to 45), and enable us to obtain the following three measurements : I. Maximum width between the borders of the fissure. 1^. Maximum distance from the edges of the uvula to the posterior pharyngeal wall. 3. Distance between the lateral pharyngeal walls. Nevertheless, we ought not to make an appliance having these exact dimensions. In fact, if the notch of the velum at the level of the pillars measures exactly the same as the maximum distance between 74 INJURIES OF THE FACE AND JAW the stumps, there is a risk that the apphance will ulcerate the mucosa by friction. The velum, then, should be at this level about 3 mm. less than the hgure obtained by measuring. Likewise the valve YB Figs. 43 to 45. -Delair's Compasses for Bucco-Pharyngeal ^Measurements. should be, in the sagittal plane, about 2 mm. less than the figure obtained by measurement; for if the valve be as deep as the pharynx, the occlusion will be complete just as much in repose as during con- traction, and passage of air for respiration will become LATE PROSTHESIS 75 impossible. Lastly, if the breadth of the valve correspond to the transverse space between the lateral pharyngeal walls, the friction will prevent it from rising during contraction; hence the necessity of making it narrower by 3 mm. " To recapitulate," says Delair,"^ " in the case of a complete cleft, a plate denture, bridging the palatine fissure from one border to the other, will form a rigid obturator as far as the leyel of the aponeurotic part of the velum. It is exactly at this point, which corresponds to the anterior surface of the wisdom- teeth, that the mechanism of an artificial valve- velum should be fixed on to the denture. Then, given the width of any complete fissure whatsoever, we shall determine that of the artificial velum which we have in hand by adding 7 to 8 mm. to each margin, so as to insure absolute contact with the stumps during their maximum separation^that is, in swal- lowing, speaking, and singing. Its length will be less by i cm. We have studied mathematically the dimensions to be given to the two notches situated between velum and valve. Let us revert to this most important point, for on the perfect grasp of this depends success in many cases. "It is understood that the width of each notch should correspond to the thickness of the stump of the uvula, which it should cover. This thickness varies in different cases; its average is from 4 to 6 mm. Each notch should bestride, as it were, the cor- responding stump exactly at the point where the * Delair, " On Velo-Palatine Prosthesis " {Odontologie, 15 Fevr.. 1905. P- 151)- 76 INJURIES OF THE FACE AND JAW remnants of uvula and velum are continuous. As for the valve, let me recall in passing that its object is to shut off the naso -pharynx during swallowing as well as when speaking four-fifths of all spoken sounds. I have already given the reason wh}' it should be joined on to the artificial velum proper; I demon- strated its physiological role when, two years ago, Fig. 46. — Horizontal Section of a Cleft Palate. I exhibited several patients to whom it had been applied. " As regards its applicability, I repeat that, save only in the rare event of an extremely narrow fissure, it can always be used. " There is no precise anatomical ratio between the width and the depth of the space between the pharynx and the uvula stumps. As a fact, the tonsils are often a cause of stenosis of the cavity; b}' their size LATE PROSTHESIS 77 they sometimes push forward the anterior pillars, which enlarges the dimensions of the space to be filled. In other cases they are rudimentary, and this space is narrower. " The valve will always be oval, but not with a geometrical regularity. Its transverse diameter in front should be straight from one notch to the other; and its posterior border should have a slightly accentuated curve, so as to fit itself, inside the naso- phar^^nx, against the superior pharyngeal constrictor during its contraction." ' Delair has instituted a table showing the dimen- sions to give to the velum and valve after measuring the pharynx. He classified seven principal types corresponding to cases met with in practice. We think it right to publish this table, whose value in constituting a valve-velum is very great. As we see, according to this table of proportions, a valve- velum may easily be applied to fissures of from 20 to 30 mm. and more. Below these measurements Delair considers that staphylorrhaphy is indicated rather than prosthetic apparatus. The valve -velum should not be applied at once, for it will provoke reflex contraction of the pharynx. It is necessary to obtain previously a tolerance of the pharyngeal region when in contact with the foreign body which one wishef to place there. With this idea we first of all make the patient wear a basal plate, which meanwhile acts as an obturator in any case of cleft palate. When the patient is accustomed to use this piece we add a rubber tongue which acts as a sort of half 78 INJURIES OF THE FACE AND JAW velum. Some days later this demi- velum is replaced by an entire velum. Later we substitute a valve-velum. Latest of all and finally, when tolerance is perfect, we fit the complete and final apparatus. This education of the pharynx takes about three weeks (Delair). Measurements taken from Corresponding Nature. Measurements of Vela. r ^' ~:z ■^ S^' 1^ ^ ^ <^ <4i «s ->~. •^ "?s • S ^ „ •.^ .^ "^ ^