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Prosthodontic Rehabilitation Of
Mandibulectomy Patients
Vinay Pavan Kumar K
2nd year P G student
Dept of Prosthodontics
AE...
Classification of
defects
Treatment
Surgical
Prosthodontic
Partially
edentulous
Completely
edentulous
Rehabilitation of
ma...
Classification of mandibular defects
Cantor and Curtis
 Class I -Radical
alveolectomy with
preservation of
mandibular con...
 Class III - Lateral
resection of the mandible
to the midline
 Class IV - Lateral bone
graft and surgical
reconstruction...
 Class V - Anterior bone
graft and surgical
reconstruction
 Class VI - Anterior
mandibular resection
without surgical
re...
HCL (Boyd and colleagues classification)
 H - lateral defects of any length up to midline
including condyle
 C - defects...
Maurer et al, Scope and limitations of methods of mandibular reconstruction: a
long-term follow-up, Brit J Oral Maxillofac...
Urken et al Classification
 Based on functional considerations caused by
detachment of different muscle groups and
diffic...
Mehta RP, Deschler DG, Mandibular Reconstruction in 2004: An Analysis of
Different Techniques, Current Opinion in Otolaryn...
Goals of Mandibular Reconstruction
 Restore form and function
• Restore bony contour of native mandible
• Restoration of ...
Diagnostic considerations
 Location and extent of the mandibular defect
 Presence of remaining teeth
 Degree of post ma...
Location and extent of the mandibular
defect
 Loss of mandibular continuity/ without loss
 Radical alveolectomy
- Loss o...
Location of defect
 Farther anterior the defect the more the disfiguring
(facial appearance)and functional disability
 A...
Presence of remaining teeth
 Determines the prognosis of rehabilitative therapy
 Presence of teeth – better retention, s...
Degree of post mandibulectomy rotation
and deviation
 Loss of mandibular continuity – deviation towards the
defect
 Vert...
Treatment for mandibular rotation and
deviation
 Restoration of continuity by osseous grafting
 Physical therapy – stret...
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 – late...
Available mouth opening
 Trismus and scar/ fibrosis – post-
operatively
 Insert a stock mandibular impression tray
in th...
Functional limitation of the tongue
 Wound closure limit tongue mobility
 Speech, swallowing, mastication and control of...
Compromise of vestibular extensions
Implant rehabilitation
 Grafted bone limited- length, diameter and
number of implants less than ideal
 Bone plates and s...
Surgical Reconstruction
 The amount of remaining soft tissue
 The size, extent and prognosis of the tumor
requiring rese...
Surgical reconstruction
 Alloplastic implants
 Vascularized free tissue grafts
 Fibular Free Flap
 Scapular Free Flap
...
Prosthodontic rehabilitation of partially
edentulous patients
 Lateral discontinuity defects
 Lateral defects with anter...
Altered cast impressions
 Establish lingual extension of unresected side-
enhance stability and retention
 Coverage of b...
Clinical procedures
 Centric occlusion jaw relation record
 Records with soft wax and minimum pressure
 Force of contra...
Defects with mandibular continuity
 Anterior defects
 Patients with anterior inner table resections
 Anterior composite...
Anterior defects
 Surgically restored anterior discontinuity defects –
occlusal abnormalities because of graft contractur...
Implant retained prosthesis
 At least 10 mm of vertical bone
 Implants can be placed in residual bone or
free grafts
 I...
Lateral defects
 Posterior dentition
remains on only one
side of the arch
 Conventional partial
denture
 Implant retain...
Factors compromising function with
complete dentures
 Compromised retention, stability and support
 Reduced saliva outpu...
Impressions
 Preliminary impression - Maximum tissue coverage
 Retention – close adaptation of the prosthesis with the
b...
Centric registrations
 Maxilla – wax rim widened on unresected
side to account for the deviation of the
mandible
 Vertic...
Occlusal schemes
 Non anatomic posterior teeth
 Neutral zone
 Mandibular posterior teeth – unresected side – buccal to
...
Processing, delivery and follow up
 Patients monitored closely during post
insertion period
 Use of prosthesis for masti...
Implant retained and supported
overlay denture
 Osseointegrated implants – fabrication of well
retained and stable overla...
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 ...
 Firtell DN, Curtis TA, Removable partial denture design
for the mandibular resection patient, J Prosthet Dent
1982; 48(4...
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Prosthodontic rehabilitation of mandibulectomy

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Prosthodontic rehabilitation of mandibulectomy patients
guiding flanges, palatal ramps, design

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Prosthodontic rehabilitation of mandibulectomy

  1. 1. Prosthodontic Rehabilitation Of Mandibulectomy Patients Vinay Pavan Kumar K 2nd year P G student Dept of Prosthodontics AECS Maaruti College of Dental Sciences
  2. 2. Classification of defects Treatment Surgical Prosthodontic Partially edentulous Completely edentulous Rehabilitation of mandibulectomy patients Diagnostic considerations
  3. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 16. Treatment for mandibular rotation and deviation  Restoration of continuity by osseous grafting  Physical therapy – stretching exercises, reposition training
  17. 17. Mandibular resection guidance prosthesis - mandibular guide flange - maxillary guidance ramp
  18. 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. 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. 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
  21. 21. Compromise of vestibular extensions
  22. 22. Implant rehabilitation  Grafted bone limited- length, diameter and number of implants less than ideal  Bone plates and screws to be removed
  23. 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. 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. 25. Prosthodontic rehabilitation of partially edentulous patients  Lateral discontinuity defects  Lateral defects with anterior teeth present  Arc of closure – angular
  26. 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. 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. 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. 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. 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. 31. Lateral defects  Posterior dentition remains on only one side of the arch  Conventional partial denture  Implant retained
  32. 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. 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. 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. 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. 36. Processing, delivery and follow up  Patients monitored closely during post insertion period  Use of prosthesis for mastication deferred for a week
  37. 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. 38. Avinash C K A et al, Prosthetic management of partially resected dentulous mandible, Indian J Dent Adv 2011; 3 (1): 750-753
  39. 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. 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.

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