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Prosthodontic Rehabilitation Of
Mandibulectomy Patients
Vinay Pavan Kumar K
2nd year P G student
Dept of Prosthodontics
AECS Maaruti College of Dental Sciences
Classification of
defects
Treatment
Surgical
Prosthodontic
Partially
edentulous
Completely
edentulous
Rehabilitation of
mandibulectomy
patients
Diagnostic
considerations
Classification of mandibular defects
Cantor and Curtis
 Class I -Radical
alveolectomy with
preservation of
mandibular continuity
 Class II - Lateral
resection of the
mandible distal to the
cuspid area
Firtell DN, Curtis TA, Removable partial denture design for the mandibular
resection patient, J Prosthet Dent 1982; 48(4):437- 443
 Class III - Lateral
resection of the mandible
to the midline
 Class IV - Lateral bone
graft and surgical
reconstruction
Firtell DN, Curtis TA, Removable partial denture design for the mandibular
resection patient, J Prosthet Dent 1982; 48(4):437- 443
 Class V - Anterior bone
graft and surgical
reconstruction
 Class VI - Anterior
mandibular resection
without surgical
reconstruction
Firtell DN, Curtis TA, Removable partial denture design for the mandibular
resection patient, J Prosthet Dent 1982; 48(4):437- 443
HCL (Boyd and colleagues classification)
 H - lateral defects of any length up to midline
including condyle
 C - defects involve central segment containing 4
incisors and 2 canines
 L - lateral defects excluding the condyle
 3 lower case letters describe soft tissue
component
 o – no skin or mucosa
 s – skin
 m – mucosa
 sm – skin and mucosa
Maurer et al, Scope and limitations of methods of mandibular reconstruction: a
long-term follow-up, Brit J Oral Maxillofacial Surgery 2010;28:100–104
Maurer et al, Scope and limitations of methods of mandibular reconstruction: a
long-term follow-up, Brit J Oral Maxillofacial Surgery 2010;28:100–104
Urken et al Classification
 Based on functional considerations caused by
detachment of different muscle groups and
difficulties with cosmetic restoration
 C – condyle
 R – ramus
 B – body
 S – total symphysis
 SH – hemi-symphysis
Mehta RP, Deschler DG, Mandibular Reconstruction in 2004: An Analysis of
Different Techniques, Current Opinion in Otolaryngology & Head and Neck
Surgery, 2004;12:288-293.
Mehta RP, Deschler DG, Mandibular Reconstruction in 2004: An Analysis of
Different Techniques, Current Opinion in Otolaryngology & Head and Neck
Surgery, 2004;12:288-293.
Goals of Mandibular Reconstruction
 Restore form and function
• Restore bony contour of native mandible
• Restoration of mastication
 Deglutition
 Articulation
 Maintainance of the airway
Diagnostic considerations
 Location and extent of the mandibular defect
 Presence of remaining teeth
 Degree of post mandibulectomy rotation and deviation
 Available mouth opening
 Functional limitation of the tongue
Location and extent of the mandibular
defect
 Loss of mandibular continuity/ without loss
 Radical alveolectomy
- Loss of vertical ridge height and vestibular depth
- Reduction in stability
Location of defect
 Farther anterior the defect the more the disfiguring
(facial appearance)and functional disability
 Anterior defects – symphyseal region – debilitating
functionally – muscle attachments
 Molar region defects – near normal mandibular function
Presence of remaining teeth
 Determines the prognosis of rehabilitative therapy
 Presence of teeth – better retention, stability and
support
 Mandibular incisors – abutments – indirect retention
Degree of post mandibulectomy rotation
and deviation
 Loss of mandibular continuity – deviation towards the
defect
 Vertical rotation of residual segment inferiorly
- suprahyoid muscles
- gravity
 Facial disfigurement, loss of occlusal contact, lack of saliva
control
Treatment for mandibular rotation and
deviation
 Restoration of continuity by osseous grafting
 Physical therapy – stretching exercises,
reposition training
Mandibular resection guidance prosthesis
- mandibular guide flange
- maxillary guidance ramp
Maxillary palatally positioned
guidance ramp
 When deviation is less severe
 Not indicated in edentulous patients – lateral
forces on complete dentures cannot be taken
up
Available mouth opening
 Trismus and scar/ fibrosis – post-
operatively
 Insert a stock mandibular impression tray
in the mouth
 Post surgical trismus - Stretching
exercises, moist heat and analgesics
Functional limitation of the tongue
 Wound closure limit tongue mobility
 Speech, swallowing, mastication and control of food
bolus and ability to control a removable prostheses
 Posterior resection of tongue more debilitating than
anterior tongue resection
Compromise of vestibular extensions
Implant rehabilitation
 Grafted bone limited- length, diameter and
number of implants less than ideal
 Bone plates and screws to be removed
Surgical Reconstruction
 The amount of remaining soft tissue
 The size, extent and prognosis of the tumor
requiring resection
 The age and general health of the patient
 Location of the resection
Surgical reconstruction
 Alloplastic implants
 Vascularized free tissue grafts
 Fibular Free Flap
 Scapular Free Flap
 Iliac Crest Free Flap
 Radial Forearm Free Flap
 Double Flap Reconstruction
Prosthodontic rehabilitation of partially
edentulous patients
 Lateral discontinuity defects
 Lateral defects with anterior teeth present
 Arc of closure – angular
Altered cast impressions
 Establish lingual extension of unresected side-
enhance stability and retention
 Coverage of buccal shelf on unresected side –
maximize support
 Extend impression into soft tissue on resected
side
 Mould the cheek and tongue from side to side
Clinical procedures
 Centric occlusion jaw relation record
 Records with soft wax and minimum pressure
 Force of contracture increases on unresected side –
resected side moves downward out of occlusion
 If severe trismus present – VD to be reduced to
facilitate insertion of bolus b/w teeth
Defects with mandibular continuity
 Anterior defects
 Patients with anterior inner table resections
 Anterior composite resections - mandibular
continuity is re-established by reconstructive
surgery
 patients have posterior teeth and extensive
anterior edentulous area – Kennedy class IV
partial denture
 Posterior occlusion rarely altered
Anterior defects
 Surgically restored anterior discontinuity defects –
occlusal abnormalities because of graft contracture ,
inaccurate positioning of the residual mandibular
segments.
 Prostheses – enhance esthetics, support for lower lip
and cheek, improved articulation of speech, control of
saliva
Implant retained prosthesis
 At least 10 mm of vertical bone
 Implants can be placed in residual bone or
free grafts
 Implants placed in the grafts 6- 9 months
later
 Removable overlay prosthesis preferred
for restoring the defects
Lateral defects
 Posterior dentition
remains on only one
side of the arch
 Conventional partial
denture
 Implant retained
Factors compromising function with
complete dentures
 Compromised retention, stability and support
 Reduced saliva output – radiation / excision
 Angular pathway of mandibular closure-
dislodge the denture
 Abnormal jaw relationships
 Neuromuscular imbalance
Impressions
 Preliminary impression - Maximum tissue coverage
 Retention – close adaptation of the prosthesis with the
bearing surface , extending lingual periphery maximally
in the unresected side.
 Polished surface accurately recorded – tongue retains
the denture
 Primary support area – buccal shelf on unresected side
 Functional impression of polished surfaces of
mandibular prosthesis
Centric registrations
 Maxilla – wax rim widened on unresected
side to account for the deviation of the
mandible
 Vertical dimension at rest difficult to
determine
 Evaluation of phonetics and closest speaking
space – best method for VD
Occlusal schemes
 Non anatomic posterior teeth
 Neutral zone
 Mandibular posterior teeth – unresected side – buccal to
crest of edentulous alveolus
 Resected side – lingual to crest of edentulous ridge
 Contour and support – lip and corner of the mouth –
thickening the denture flange below the crest of the ridge
 Mastication – non defect side
Processing, delivery and follow up
 Patients monitored closely during post
insertion period
 Use of prosthesis for mastication deferred
for a week
Implant retained and supported
overlay denture
 Osseointegrated implants – fabrication of well
retained and stable overlay prosthesis
 Minimum of 2 implants placed
 15 mm apart to accommodate retention bar
apparatus
Avinash C K A et al, Prosthetic management of partially resected dentulous
mandible, Indian J Dent Adv 2011; 3 (1): 750-753
References
 Beumer J, Curtis TA, Marunick MT, Maxillofacial
rehabilitation Prosthodontic and surgical
considerations,1st edition, lshiyaku Euro America
publications, St Louis, 1996, Pp 113- 224
 Taylor TT, Clinical maxillofacial prosthetics, 1st edition,
Quintessence Publications, Illinois, 2000,
Pp 155- 188
 Cantor R, Curtis TA, Prosthetic management of
edentulous mandibulectomy patients -part II, Clinical
procedures, J Prosthet Dent 1971;25:546-55
 Firtell DN, Curtis TA, Removable partial denture design
for the mandibular resection patient, J Prosthet Dent
1982; 48(4):437- 443
 Maurer et al, Scope and limitations of methods of
mandibular reconstruction: a long-term follow-up, Brit J
Oral Maxillofacial Surgery 2010;28:100–104
 Mehta RP, Deschler DG, Mandibular reconstruction in
2004: An analysis of different techniques, Current
Opinion in Otolaryngology & Head and Neck Surgery,
2004;12:288-293.

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Prosthodontic rehabilitation of mandibulectomy

  • 1. Prosthodontic Rehabilitation Of Mandibulectomy Patients Vinay Pavan Kumar K 2nd year P G student Dept of Prosthodontics AECS Maaruti College of Dental Sciences
  • 3. Classification of mandibular defects Cantor and Curtis  Class I -Radical alveolectomy with preservation of mandibular continuity  Class II - Lateral resection of the mandible distal to the cuspid area Firtell DN, Curtis TA, Removable partial denture design for the mandibular resection patient, J Prosthet Dent 1982; 48(4):437- 443
  • 4.  Class III - Lateral resection of the mandible to the midline  Class IV - Lateral bone graft and surgical reconstruction Firtell DN, Curtis TA, Removable partial denture design for the mandibular resection patient, J Prosthet Dent 1982; 48(4):437- 443
  • 5.  Class V - Anterior bone graft and surgical reconstruction  Class VI - Anterior mandibular resection without surgical reconstruction Firtell DN, Curtis TA, Removable partial denture design for the mandibular resection patient, J Prosthet Dent 1982; 48(4):437- 443
  • 6. HCL (Boyd and colleagues classification)  H - lateral defects of any length up to midline including condyle  C - defects involve central segment containing 4 incisors and 2 canines  L - lateral defects excluding the condyle  3 lower case letters describe soft tissue component  o – no skin or mucosa  s – skin  m – mucosa  sm – skin and mucosa Maurer et al, Scope and limitations of methods of mandibular reconstruction: a long-term follow-up, Brit J Oral Maxillofacial Surgery 2010;28:100–104
  • 7. Maurer et al, Scope and limitations of methods of mandibular reconstruction: a long-term follow-up, Brit J Oral Maxillofacial Surgery 2010;28:100–104
  • 8. Urken et al Classification  Based on functional considerations caused by detachment of different muscle groups and difficulties with cosmetic restoration  C – condyle  R – ramus  B – body  S – total symphysis  SH – hemi-symphysis Mehta RP, Deschler DG, Mandibular Reconstruction in 2004: An Analysis of Different Techniques, Current Opinion in Otolaryngology & Head and Neck Surgery, 2004;12:288-293.
  • 9. Mehta RP, Deschler DG, Mandibular Reconstruction in 2004: An Analysis of Different Techniques, Current Opinion in Otolaryngology & Head and Neck Surgery, 2004;12:288-293.
  • 10. Goals of Mandibular Reconstruction  Restore form and function • Restore bony contour of native mandible • Restoration of mastication  Deglutition  Articulation  Maintainance of the airway
  • 11. Diagnostic considerations  Location and extent of the mandibular defect  Presence of remaining teeth  Degree of post mandibulectomy rotation and deviation  Available mouth opening  Functional limitation of the tongue
  • 12. Location and extent of the mandibular defect  Loss of mandibular continuity/ without loss  Radical alveolectomy - Loss of vertical ridge height and vestibular depth - Reduction in stability
  • 13. Location of defect  Farther anterior the defect the more the disfiguring (facial appearance)and functional disability  Anterior defects – symphyseal region – debilitating functionally – muscle attachments  Molar region defects – near normal mandibular function
  • 14. Presence of remaining teeth  Determines the prognosis of rehabilitative therapy  Presence of teeth – better retention, stability and support  Mandibular incisors – abutments – indirect retention
  • 15. Degree of post mandibulectomy rotation and deviation  Loss of mandibular continuity – deviation towards the defect  Vertical rotation of residual segment inferiorly - suprahyoid muscles - gravity  Facial disfigurement, loss of occlusal contact, lack of saliva control
  • 16. Treatment for mandibular rotation and deviation  Restoration of continuity by osseous grafting  Physical therapy – stretching exercises, reposition training
  • 17. Mandibular resection guidance prosthesis - mandibular guide flange - maxillary guidance ramp
  • 18. Maxillary palatally positioned guidance ramp  When deviation is less severe  Not indicated in edentulous patients – lateral forces on complete dentures cannot be taken up
  • 19. Available mouth opening  Trismus and scar/ fibrosis – post- operatively  Insert a stock mandibular impression tray in the mouth  Post surgical trismus - Stretching exercises, moist heat and analgesics
  • 20. Functional limitation of the tongue  Wound closure limit tongue mobility  Speech, swallowing, mastication and control of food bolus and ability to control a removable prostheses  Posterior resection of tongue more debilitating than anterior tongue resection
  • 22. Implant rehabilitation  Grafted bone limited- length, diameter and number of implants less than ideal  Bone plates and screws to be removed
  • 23. Surgical Reconstruction  The amount of remaining soft tissue  The size, extent and prognosis of the tumor requiring resection  The age and general health of the patient  Location of the resection
  • 24. Surgical reconstruction  Alloplastic implants  Vascularized free tissue grafts  Fibular Free Flap  Scapular Free Flap  Iliac Crest Free Flap  Radial Forearm Free Flap  Double Flap Reconstruction
  • 25. Prosthodontic rehabilitation of partially edentulous patients  Lateral discontinuity defects  Lateral defects with anterior teeth present  Arc of closure – angular
  • 26. Altered cast impressions  Establish lingual extension of unresected side- enhance stability and retention  Coverage of buccal shelf on unresected side – maximize support  Extend impression into soft tissue on resected side  Mould the cheek and tongue from side to side
  • 27. Clinical procedures  Centric occlusion jaw relation record  Records with soft wax and minimum pressure  Force of contracture increases on unresected side – resected side moves downward out of occlusion  If severe trismus present – VD to be reduced to facilitate insertion of bolus b/w teeth
  • 28. Defects with mandibular continuity  Anterior defects  Patients with anterior inner table resections  Anterior composite resections - mandibular continuity is re-established by reconstructive surgery  patients have posterior teeth and extensive anterior edentulous area – Kennedy class IV partial denture  Posterior occlusion rarely altered
  • 29. Anterior defects  Surgically restored anterior discontinuity defects – occlusal abnormalities because of graft contracture , inaccurate positioning of the residual mandibular segments.  Prostheses – enhance esthetics, support for lower lip and cheek, improved articulation of speech, control of saliva
  • 30. Implant retained prosthesis  At least 10 mm of vertical bone  Implants can be placed in residual bone or free grafts  Implants placed in the grafts 6- 9 months later  Removable overlay prosthesis preferred for restoring the defects
  • 31. Lateral defects  Posterior dentition remains on only one side of the arch  Conventional partial denture  Implant retained
  • 32. Factors compromising function with complete dentures  Compromised retention, stability and support  Reduced saliva output – radiation / excision  Angular pathway of mandibular closure- dislodge the denture  Abnormal jaw relationships  Neuromuscular imbalance
  • 33. Impressions  Preliminary impression - Maximum tissue coverage  Retention – close adaptation of the prosthesis with the bearing surface , extending lingual periphery maximally in the unresected side.  Polished surface accurately recorded – tongue retains the denture  Primary support area – buccal shelf on unresected side  Functional impression of polished surfaces of mandibular prosthesis
  • 34. Centric registrations  Maxilla – wax rim widened on unresected side to account for the deviation of the mandible  Vertical dimension at rest difficult to determine  Evaluation of phonetics and closest speaking space – best method for VD
  • 35. Occlusal schemes  Non anatomic posterior teeth  Neutral zone  Mandibular posterior teeth – unresected side – buccal to crest of edentulous alveolus  Resected side – lingual to crest of edentulous ridge  Contour and support – lip and corner of the mouth – thickening the denture flange below the crest of the ridge  Mastication – non defect side
  • 36. Processing, delivery and follow up  Patients monitored closely during post insertion period  Use of prosthesis for mastication deferred for a week
  • 37. Implant retained and supported overlay denture  Osseointegrated implants – fabrication of well retained and stable overlay prosthesis  Minimum of 2 implants placed  15 mm apart to accommodate retention bar apparatus
  • 38. Avinash C K A et al, Prosthetic management of partially resected dentulous mandible, Indian J Dent Adv 2011; 3 (1): 750-753
  • 39. References  Beumer J, Curtis TA, Marunick MT, Maxillofacial rehabilitation Prosthodontic and surgical considerations,1st edition, lshiyaku Euro America publications, St Louis, 1996, Pp 113- 224  Taylor TT, Clinical maxillofacial prosthetics, 1st edition, Quintessence Publications, Illinois, 2000, Pp 155- 188  Cantor R, Curtis TA, Prosthetic management of edentulous mandibulectomy patients -part II, Clinical procedures, J Prosthet Dent 1971;25:546-55
  • 40.  Firtell DN, Curtis TA, Removable partial denture design for the mandibular resection patient, J Prosthet Dent 1982; 48(4):437- 443  Maurer et al, Scope and limitations of methods of mandibular reconstruction: a long-term follow-up, Brit J Oral Maxillofacial Surgery 2010;28:100–104  Mehta RP, Deschler DG, Mandibular reconstruction in 2004: An analysis of different techniques, Current Opinion in Otolaryngology & Head and Neck Surgery, 2004;12:288-293.

Editor's Notes

  1. Infr border of mand muscles of mastication r retained. Condyle ramus postr prtion of body of mand is removed. And fn of attached muscles has been lost. Deviation of mand toward the surgical side is seen Most of mand resection pts r found in this class
  2. 3- or even beyond. In addition to what is removed in class 2. anteriorportion of mandible is also resected 4-pt has a lateral resection and subsequent bone augmenation. Articulation with temporal bone has not been restored but there id less mand deviation
  3. 5- pt has mand resection which crosses the midline and articulation with the tnj has been maintained 6-similar to class 5 but the continuit has not been restored surgically
  4. Another classification to to categorise the defects in the mand and adj soft tissue
  5. H - hemimandibular continuity defect C- central continuity defect L lateral continuity defect
  6. Mand reconstruction shud allow for deglutition articulation and airway
  7. Resection of alveolar process without loss of continuiyt is less disfiguring when compared to with. Farther anterior the defect more disfiguring it will be. Anterior more debilitating cos of loss of key muscle attachments geniohyoid and genioglossus that ctrl tongue fn and mobility. Defects in molar region more easy to correct when compared to other regions.
  8. Particularly when the elevator muscles on the defect side remain intact In molar region only a linear graft will be reqd for the reconstruction when compared to the curved type of reconstruction reqd for the antr mandible
  9. Mans incisors cud serve as abutments where the canine tooth has been lost on the defect side
  10. This will help to limit the scar formation at the resection site
  11. These devices can be used when the residual mandible can be easily guided bck into its position either by the clinician or the pt. these can be used only when minimum force is reqd to guide the mand. If more force is reqd use a max casting with buccal bar against which mnad prostheses can slide, the max casting will splint and protect the surfaces of the maxillary teeth againt whicvh the guidance prostheses functions
  12. Are not indicated when dental Im plants are not used to stabilise the denture
  13. Many pts experience limited mouth opening following mandibulectomy sirgery. Excercises such as placing finger on mand and pull it downward. Excercises shud be started within 2 weeks preferably 1 week after surgery
  14. Wound closure mainlt done by suturing the remaining tissues of floor of mouth and tongu to the remining buccal tissues. We can chek the tongue mobility by asking the pt to lick the lips. Postr more debilitaiting than anterior cos of there can be loss of both motor and sensory ineervation in floor of mouth and base of tongue resections
  15. Prosthodontic rehabilitaion is closely dependent on vestibular extensions for proper retention suppotr stability and peripheral seal
  16. Volume of hgrafted bone available for placing the implants is limited. If bones and plates are present and they r in contact with the endosseous implants erosion can occur. When implant rehabilitaion of the bone grafted mateerial is done, the most common oprob which is seen is the excessive interarch space Becos of the limited width of the graft bone
  17. Becos after the primary resection may require soft tissue augmentatation Many small tumors can be immediaely reconstructed, malignant tumor wait for 1 yr.
  18. reconstruction can either be immediate or delayed. Alloplastic implants are titanium ss co cr. They r particularly useful for immediate separation and stabilisation of the residual fragmants. They can also be used in [pts who r not good candidates for bone grafts
  19. Arc of closure of mandible is more angular that vertical PROducing forces of occlusion that are entirely unilateral and on the non resected side
  20. After the cast partial framework is verified , an altered cast impression of the edentulous areas is obtained.
  21. In most cases this movement is accepted and no attempt is made to correct it.
  22. In case of lateral discontinuity defects. Complete dentures in thse pts is on;ly for esthetics
  23. Pt cud be manually placed into centric occlusion