FOR A LADY OVER SIXTY YEARS OF AGE.

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palate on the median line, immediately behind the hard palate, as shown in Fig. 201. The opening was a single straight incision, which was subsequently enlarged by wearing a tent for a short time. There was no pain, and but little bleeding; and in a few days it was entirely healed. What complicated the case still further was the loss of all the teeth in the upper

jaw, an entire upper denture having been worn for years. The artificial palate was attached to such a denture, and instead of proving detrimental to the denture, it was an advantage, serving when in place to keep the back edge of the plate from the possibility of dropping. The marked improvement in articulation and the gratification of the patient were a sufficient justification for the partial undoing of such an admirable surgical operation.

CHAPTER XIII.

METHOD OF MAKING AN ARTIFICIAL PALATE.

THE success of these appliances depends very much upon the perfect accuracy of the model, as it is upon this that the parts are molded. It is essential that the entire border of the fissure, from the apex to the uvula, be perfectly represented in the model, as these parts are when in repose. It is also necessary that the model show definitely the form of the cavity above and on either side of the opening through the hard palate, since that part of the cavity is hidden from the eye. It is desirable, although it is not essential, that the posterior surface of the remnant of the soft palate be shown; but it is especially important that the anterior or under surface be represented with relaxed muscles and in perfect repose. All the author's experience makes this more and more imperative.

From an extended intercourse and correspondence with dentists, I am satisfied that the "taking of an impression of a cleft palate" is regarded as the most difficult step in the whole procedure of making artificial palates. While there is no more important step, there is no necessity for regarding it as of doubtful accomplishment. It need not be made a more formidable operation than most of the impressions for either full or partial sets of teeth; and in many instances I have found greater difficulty in obtaining a good impression of the lower jaw where there were straggling teeth than I have had in ordinary cases of fissured palate.

In cleft-palate cases it is not so much the skill required in

FORM OF A CLEFT PALATE WITH MUSCLES RELAXED. 289

introducing the impression material, as the knowledge of a correct impression when obtained. It is a common circumstance with the inexperienced to obtain an impression of all the parts in all their intricate detail, and which to their unpracticed eye is a model of perfection, but which is nevertheless useless. The only impression of a cleft palate which is serviceable in making such an artificial palate as will be of benefit to the patient, is one which represents perfectly the remnant of the velum in its relaxed or hanging position.

If the velum and uvula are pushed back by contact with the impression-cup, or with too stiff plaster or other unyielding material, an unpracticed eye may not be able to detect it either in the impression or in the resultant model; and an artificial velum adapted to such a model will fail to confer the benefit it otherwise should.

There is a common mistake made in accepting an impression which shows the sides of the fissure distorted by being drawn up by the levator muscles, and unless such error is detected it will surely lead to failure. If the operator is well

290 HOW TO OBTAIN AN IMPRESSION OF A CLEFT PALATE.

acquainted with the anatomy of the parts and the attachment and action of the levator muscles, there should be no hesitation in detecting the fault as soon as the impression is removed. If the operator is at all in doubt, let him study the parts closely before any effort is made to introduce material for the impression. Let him observe accurately the uniform line of the anterior surface of the velum, all the way from the junction with the hard palate to the divided uvula when the parts are in repose, and then become equally familiar with the change of form when they are in action.

Fig. 202 shows a fissured palate with the muscles relaxed and all the parts in repose. In many cases the first view obtained of the fissure will show the sides distorted, and it may be some minutes before they sink into repose; but more commonly they will appear in repose, and by touching but slightly with an instrument the action of the levatores will be seen catching the edges of the fissure a little more than half way up to the hard palate, and drawing them aside and upward like elbows akimbo. It is the skill used in not crowding back the soft parts when the material is introduced, and the ability to detect any adverse action of the levator muscles, that makes the getting of a correct impression of all congenital clefts as simple a matter as any important operation about the mouth.

HOW TO OBTAIN AN IMPRESSION OF A CLEFT PALATE.— With the requisite anatomical and physiological knowledge above indicated, the best method of procedure is as follows:

No special impression-cups are needed. The common britannia tray, of the uniform pattern for a full upper jaw, is the best thing I have yet used; and this is after repeated trials and experiments of every conceivable variety, with forms and cups made especially for the purpose and from a variety of materials. As the majority of cases will be where there are natural teeth in the jaw, the description of the process will recognize their presence.

NO SPECIAL TRAYS REQUIRED.

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Select from the various sizes of trays the one best adapted in size and form to cover all the teeth. Avoid its being unnecessarily large; to simply cover the teeth and rest steadily against them, without rocking, and with the handle in the center of the mouth, is sufficient. Place the tray in position against the teeth, and observe the fissured palate and uvula hanging beyond and below the posterior border of the cup. Add now an apron or extension to the back edge of the cup, made of sheet gutta-percha, wax, or any other convenient material, warming the edge of the cup and sticking it on. Let this apron come down just to the lower ends of the uvula, but on no account touch any of the soft tissues. Before any attempt is made to introduce the plaster, let the operator be sure that he has seen the tray in the position in which it will be when the impression is taken, and that the velum in its relaxed condition does not rest upon nor touch the apron of the tray. This will measurably guarantee success.

Secondly, let the morale of the performance, as described on page, be borne in mind. On no account is the patient to imbibe the idea that the operation is attended with any difficulty, or that any particular importance is or need be attached to the present manipulations. Should the patient become inquisitive or nervously apprehensive, divert his mind, as no magnified idea on his part of the importance of the procedure, nor any interested coöperation, is likely to be other than detrimental. With plaster of Paris prepared as described on page -, place on the tray a sufficient quantity to fill the roof of the mouth between the teeth, and extending down in a thin film, say a sixteenth to an eighth of an inch in thickness, over the apron. Make no calculation for an amount coming around outside the teeth, as that provided for the inner parts will generally be found quite sufficient to ooze out and cover the teeth. Neither need there be any provision made, where the fissure extends very far forward, for carrying plaster away up and getting an impression of the nares, vomer, and turbinated bones. Neither is it neces