• Mandible is a single bone that creates
• Peripheral boundaries of the floor of
• Facial form (Lower third of face)
• Disruption of the mandible has the
potential to disrupt any of these
Rehabilitation of mandibulectomy
patients should therefore consider both
form and function .
Surgical resection of tumor often
includes a partial mandibular
resection, a partial glossectomy, a
partial resection of the floor of the
mouth, and a radical neck dissection.
The extent of surgery and the effects of
radiation therapy and chemotherapy
determine the amount of
rehabilitation needed by a given
Oral reconstruction of the patient who
has a partially resected mandible is
one the most challenging procedures
confronting the maxillofacial
Acc to etiology - Laney(1979)
a) Anterior body
b) Lateral to
- Body only
- Body with
- Incomplete formation
- Incomplete ossification
as a result of postnatal insults
e.g.) trauma during birth,
Acc to amount of resection -
Laney• Continuity defect
- Inferior border and its
- No deviation
- Less facial disfigurement
- Occlusion rarely changed
- Can be :- anterior defect
• Discontinuity defect
- Complete segment of mandible from
alveolar crest to inferior border
- Mandible deviates to resected side
- Marked facial disfigurement
- Occlusion altered
- Can be :- lateral discontinuity defect
Acc to Cantor and Curtis (1971)
Radical alveolectomy with preservation of mandibular
- Portion of alveolar process and body of
- Lingual and buccal sulcus mucosa
- Portion of base of tongue and
- Lingual and inferior alveolar nerves
- Sublingual and Sub maxillary
- Sometimes anterior part of digastric
1. Least debilitating.
2. Can raise the floor of the mouth causing reduction in
3. Ability to shape and control the tongue may be lost
due to loss of some intrinsic muscles.
Class 2 :
Lateral resection of mandible distal to
- condyle, ramus and body of mandible distal to cuspid
- mylohyoid, hypoglossal,ant belly of digastric,
& palatoglossal muscles, most of intrinsic
- hypoglossal , lingual and inferior alv nerves
- adjacent buccal and lingual mucosa
1 Speech, swallowing, saliva control, manipulation of food impaired.
2. Facial disfigurement apparent
3. Disarticulation and loss of muscles of mastication will hampered
4. Taste ,sensory and motor losses more extensive as compared to
Lateral resection of the mandible to
all those described in class 2 in addition to the
anterior portion of the mandible,
genioglossus, remaining portion of
muscle with lingual and buccal mucosa.
1. Restricted tongue mobility due to loss of tip of tongue and
2. Speech, swallowing,saliva control and manipulation of food
3. Facial disfigurement is worse due to loss of anterior part of
4. Disarticulation and reduction in amount of basal bone
reduce prosthodontic prognosis.
Lateral bone graft & surgical
• Lateral bone and split thickness skin or
pedicle graft can be performed on patients
who have had:
- radical alveolectomies
- resection of mandible distal
with or without
• Three types of bone grafts are possible
1. Mandibular augmentation procedures.
2. Bone graft that connect a residual
condyle with the larger mandibular
Anterior bone graft &surgical
- anterior portion of the mandible
- large bilateral portions of mylohyoid,
genioglossus and anterior digastric muscles
- bilateral lingual and inferior alv nerves
- bilateral submaxillary and sublingual salivary
- mucosa of lower lip
- anterior floor of mouth
- ventral surface of tongue
The mucosa retained in the labial and buccal regions is sutured
residual stump of the tongue and a krischner wire is often
maintain the mandibular fragments .
It is similar to a class V patient, but
the continuity of the mandible has
not been restored surgically. Because
each lateral fragment moves
independently, the prognosis for a
removable prosthesis is poor and
fabrication is not recommended
With only one half or two thirds of the
mandible remaining, stability, support
and retention of the mandibular denture
Due to radiation therapy either prior to or
after surgery, the oral mucosa is
atrophic and fragile, predisposing to
soft tissue irritation and ulceration.
The reduction in saliva output, and the
thick mucinous nature of the saliva that
remains after therapeutic levels
radiation, impairs retention and
The angular pathway of mandibular
closure induces lateral forces upon the
dentures, which dislodge them.
The deviation of the mandible creates
abnormal jaw relationships. The
abnormal profile and position of the
mandible in relation to the maxilla
may prevent ideal placement of the
denture teeth over their supporting
The impairment of motor and/or
sensory control of the tongue, lip,
and cheek impairs the ability of the
Location & Extent of Mandibular
-Main problems – loss of vertical ridge
height and vestibular depth
-Vertical discrepancy is most important
when prosthesis supported by dental
implants is considered.
Marginal defects have better prognosis
than discontinuity defects.
The farther anterior the defect, the more
disfiguring and functionally
debilitating it is likely to be.
Reason: Loss of key muscle
geniohyoid) located in anterior
mandible that control tongue
function and mobility.
• Defects of the symphyseal region are
most debilitating and difficult to
• Greatest facial disfigurement.
• Surgical reconstruction necessary or
at least segmental stabilization
before prosthodontic treatment can be
Mandibulectomy defects in the molar
-well suited for surgical reconstruction
compared to anterior defects.
-If muscle attachments are intact – Good
-Near normal appearance and function is
2. Presence of remaining natural
Patients after mandibulectomy present with few or
remaining natural teeth.
-Pts with greatest risk of sq cell carcinoma are
users of tobacco and alcohol and lack good oral
-Strong relationship between tobacco & periodontal
-Teeth are usually extracted prior to radiotherapy to
prevent complications such as osteoradionecrosis.
Greater the number of teeth ,better the prognosis.
Remaining natural teeth in
linear relationship are unlikely
to provide adequate abutments
for prosthesis than teeth arranged
in two dimensions
A maxillary complete denture will
function well for a mandibulectomy
patient against a reconstructed
mandibular dentitionExceptions Collapse of residual proximal
mandibular stump against the posterior
maxillary alveolus prohibiting adequate
denture flange extension.
When a guide flange prosthesis is planned
for treatment of mandibular deviation .
Pressure from Guide flange can dislodge the
3.Degree of post mandibulectomy
rotation and deviation
Mandible deviates towards the defect and rotation
of mandibular occlusal plane inferiorly.
• During mandibular closure, mandible
rotates around occlusal contacts on
un-resected side, and remaining teeth
on resected side drop further out of
occlusion. This movement is called
FRONTAL PLANE ROTATION.
• Deviation: Due to
• Primarily due to loss of tissue involved in
Rotation: Due to
- Pull of the suprahyoid muscles on the residual
causing inferior displacement and rotation
fulcrum of the remaining condyle.
- Gravity. Loss of anchorage of elevator muscles.
• Facial disfigurement
• Loss of occlusal contact
• Prosthodontic prognosis in such patients can
be improved by early post resection physical
therapy to reposition the mandibular
fragment to a more normal position and to
minimize scar formation that will make
deviation more severe.
• Should be carried out as early as possible.
• After 6-8 weeks post operatively it will not
be as beneficial.
• Can be in the form of
1.Physical therapy carried out by the
Trismus –due to surgical trauma
Physical therapy should be started
Scar tissue formation will further reduce
Simple test to check mouth opening: Insert a
mandibular impression tray in the mouth.If
6.Functional limitation of
- Frequently the surgical wound is closed by
the remaining tissues of the floor of the mouth
tongue to the remaining buccal tissues.
This compromises: - Speech
- Control of food bolus
- Ability to control removable
- Lingual vestibuloplasty and skin or mucosal
be used to improve tongue mobility
Evaluation of tongue mobility
- In patients whom anterior resection has been done,
ability to lick the lips when the artificial prosthesis
In such cases consideration is given to lowering the
occlusal plane or arranging the teeth slightly
• Speech therapy
• Loss of innervation will compromise tongue function and
prognosis of prosthodontic rehabilitation.
If lingual nerve is sacrificed during resection, the tongue on
defect side will permanently remain without any feeling.
Loss of sensory capability:- Affects speech
Loss of sensory innervation of the buccal mucosa(long
7.Compromise of vestibular
Vestibular depth is critical for stability and
It is also critical when mandibular continuity is
restored with bone grafting and implants are
• Skin grafts are used for surgical reconstruction
either as lining for the surface of resected soft tissue
or as part of skin and connective tissue grafts such
as pedicle flaps, free flaps etc.
1. Effective load bearing tissue.
2. Can withstand pressure and chafing from
3. Protects underlying bone and connective tissue
well due to
rapid turnover of keratin producing cells.
1. No sensory innervations.
• Careful treatment planning is
required for patients with radiation
• Irradiated tissue is fragile ,sensitive
to manipulation, dessicated,slow to
heal, prone to infection and at risk of
10. Altered anatomic relationships
restoration of mandibular continuity
Reconstruction of anterior defects
Most difficult situation for grafting and frequently
results in a
graft that is deficient anteriorly.
- Results in a severe Class 2 like situation.
The prosthodontic difficulties seen in rehabilitating such
- Inability to provide proper lip support.
- Speech problems associated with mandibular
placed too far lingually.
- Inability to control food bolus due to lack of
- Excessive display of mandibular teeth due to patients
to maintain normal lip posture.
- Difficulty gaining adequate space for prosthesis
without encroaching on function of tongue.
- Misalignment of remaining un resected mandibular
and resultant relationship between maxillary and
Reconstruction of posterior defects
- More predictable from prosthodontic point of view as
to anterior defects.
- The mediolateral positon of the graft is frequently seen
11. Previous experience with
Indicator of how successful
rehabilitation will be, particularly
Relating surgical considerations to
Soft tissues are mainly used to reconstruct
They may be: - Skin graft
- Local flap
- Pedicle flap
- Micro vascular free flaps (MVFF)
Skin grafts are ideal for prosthetic reconstruction.
However when soft tissue bulk is required or
recipient bed is
previously irradiated micro vascular free flaps are
Previously soft tissue local flaps(mainly the residual
tongue sutured to the border of the defect) and
pedicle flaps (pectoralis muscle) were used.
MVFF have revolutionized the treatment of
Micro vascularized bone is mainly obtained from:
1.Fibula- most common
Soft tissue MVFF are obtained from
Mandibular mal position after bony
reconstructionMay be due to:
1. Minimal proximal mandible on the surgical side to attach the
2. Mandibular segments are not stabilized and maintained in
pre-operative relation to each other during grafting
3. Delayed reconstruction may not be able to overcome scar
4. The bone grafts used i.e the fibula and the iliac crest graft
some inherent problem.
(Lacks height compared to the residual mandible)
Maximum extension and tissue
coverage should be recorded with the
Irreversible hydrocolloid is used with
an altered/sectional stock tray.
Conventional border molding and
Master impression is used to achieve
better peripheral seal.
• Necessary due to loss of supporting bone ,unusual
intra-oral contours, gross mal position of occlusal
• Allow the determination of the relationship of the
final prosthesis periphery and the buccal or
lingual tooth position.
• Recording maxillo-mandibular relationship with
processed bases allow the clinician to evaluate
retention and stability proir to adding wax rims
• Significant loss of alveolar bone as well as rotation
and deviation of the mandible postoperatively make it
necessary for the record bases to be as stable as
possible during maxillo mandibular records.
• Extension beyond the periphery of the prosthesis may
required to support the lip. To add stability to the
prosthesis, occlusal contact may need to be
significantly buccal or
lingual to normal anatomic landmarks that usually
denote the occlusal table.
• Pts who have implant retained prosthesis should have
retentive elements incorporated in the processed
• Centric relation does not exist in
partially mandibulectomy patients
with discontinuity defects because
there is only one condyle to guide the
• Interestingly they do have
proprioception for a repeatable area
but not a repeatable point contact
when asked to open wide and close the
Record bases are constructed in the
usual way with the following
In the maxilla, the wax rim used to
record the centric occlusion
registration record is widened on the
un resected side towards the palatal
side in order to account for deviation
of the mandible.
• Vertical dimension of occlusion
is difficult to determine due to
mandibular deviation and
impaired motor and sensory
Traditional methods are
contraindicated hence VDO is
recorded with mandible closing
as much as possible.
VDO determination should rely on
lip competence, facial appearance
Centric occlusion registration is done
with wax, plaster or any other
The patient is instructed to move the
mandible as far as possible toward
the untreated side. Then patient was
asked to close with his own muscular
force when the mandible was
manually guided. This records a
functional maxillo mandibular
relationship which the patient can
Teeth selection and
arrangement• Artificial denture teeth of zero degree
cuspal angulations are selected and
arranged to achieve monoplane
occlusion and to allow for lateral
freedom of mandibular movements.
• With the lingual inclination of the
residual mandible, and with elevation
of the buccal shelf, placement of
posterior teeth to the buccal of the
residual alveolar ridge centers the
forces of occlusion more favorably
• After all the mandibular teeth and
the maxillary teeth have been
arranged, ramps are developed for the
maxillary prosthesis in base plate
wax. These ramps usually 5-10mm
wide and should provide 2-4mm
horizontal overlap with the
mandibular posterior teeth.
• Depending upon severity of deviation,
the ramp on the nonsurgical side
usually extends palatal to the
maxillary alveolar ridge, and the
ramp on the surgical side extends
• These patients have difficulty in
valving the tongue against the palate
for appropriate speech sounds and to
manipulate food bolus in mastication
• This is due to loss of tissue bulk and
motor movement of the tongue.
• This prostheses involves shaping the
contours of a palatal base plate, either
retained by maxillary dentition or
maxillary complete denture.
• In normal tongue-palate relationship,
the palate CUPS around the tongue at
rest and in function.
• Hence contours of palatal augmentation
prostheses should also CUP around the
• Repeated movements of tongue will allow
the clinician to add wax to the base plate to
establish occlusal contact.
• Thickness is increased until the tongue
contacts the palate in swallowing.
Cast partial denture
• Indicated for patients with marginal
• Ideal prosthesis bearing surface is
split thickness graft ; it is thin,
firmly attached to the mandible and
will not move with movement of
tongue , floor of mouth or cheek
Pick up impression or functional reline
Removable framework should follow
routine parameters of design related
to support, stability and retention.
patient resurfaced with skin
• Two part denture designed to engage and
utilize opposing proximal undercuts on
mesial and distal abutment teeth, which
will result in positive retention in both
vertical and lateral direction often without
incorporating a conventional clasp.
• Each part of the denture will therefore have
its individual path of insertion and once in
position the part will be maintained in
position by means of a locking bolt to form
a whole unit.
• The technical construction of such an
Methods to minimize
• Use of skin grafts and flaps for
• Inter maxillary fixation at time of
• Intense physiotherapy to minimize
• Aramany and Myers advocated the
use of inter maxillary fixation with
arch bars and elastics for 5-7 weeks
immediately after surgery.
• This type of fixation maintains the
residual mandible in the proper
maxillo mandibular position and
permits healing of the defect and the
associated scar formation with the
teeth in occlusion.
• If Inter maxillary fixation is
used in immediate post-
very little muscle retraining
may be needed.
• The degree of deviation seems
to be inversely proportional to
the length of time the
Gunning splints can be
used for IMF in edentulous
VACCUM FORMED PVC
• Following the removal of inter
maxillary fixation, early progression
to a more definitive appliance can be
facilitated by using an intermediate
Vacuum formed PVC appliance.
• Upper & Lower splints are fused
together in maximum inter cuspation
by interposing a further layer of the
• Jaw movements are thus gently
restrained and guided by the soft
plastic splint making it comfortable
for the patient to wear.
• The appliance may also be worn at
• This appliance has a relatively short
shelf life and needs to be replaced by a
more definitive acrylic or metal
appliance once the patient adapts to
On closure of jaws the lower teeth and
mandible are readily and easily guided
into the lower half of the splint by its
flanges and indentations into the correct
In discontinuity defects mandibular
guidance therapy can be instituted to
retrain the patient’s neuromuscular
system to provide an acceptable
maxillo-mandibular relationship of
the residual portion of the mandible
which permits occlusion of the
remaining natural teeth
1) Palatal based guidance prosthesis
• Maxillary inclined plane prosthesis.
• Positioning prosthesis with palatal
• Widened maxillary occlusal table
2) Mandibular based guidance
Maxillary inclined plane
prosthesis.• The prosthesis is retained using inter
proximal ball clasps or adam’s clasps.
• Mandibular closure results in the
progressive sliding of the remaining
mandibular teeth up the incline in a
superior and lateral direction until the
occlusal contact is reached.
Positioning prosthesis with palatal
• Patients who are able to use their pre
surgical inter cuspal position after
mandibular resection often complain
of inability to prevent the mandible
from deviating towards the defect
side during sleep.
• On awakening they have difficulty
reestablishing normal occlusal
• Flage extending from palate inferiorly into
the lingual vestibule between lateral border of
tongue & lingual surface of the mandible can
be formed in the mouth with auto
polymerizing acrylic resin.
• Prevent medial deviation of un resected
mandible even when the mouth is open.
• The flange should contact only the lingual
surfaces of mandibular teeth and it should
not impinge on the lingual mucosa of the
mandible throughout the opening and closing
Widened maxillary occlusal
• Patients who cannot attain the ideal
medio lateral position of the
remaining segment and an acceptable
occlusal contact of the teeth, in spite
of the use of various guidance
prostheses, a palatal ramp or a
widened maxillary occlusal table
using double row of teeth may be
• Provide a surface against which the
Palatal Ramp to widen
maxillary occlusal table
Twin occlusion to widen
maxillary occlusal table
Mandibular lateral guide flange
• Used in patients who can achieve
proper medio lateral position of the
mandible but cannot hold that
position for adequate mastication.
• The guide flange is attached to a cast
mandibular removable partial denture.
• It can be either molded in wax at the try-in
stage and processed in clear acrylic resin
or a heavy wire loop may be used.
• The guide flange is extended into
maxillary muco-buccal fold superiorly &
diagonally on non defect side without
reconstruction using osseo
• They provide stability and retention for the
• They allow the use of a fixed or removable
• It avoids the preparation of remaining teeth
• It avoids the problems of the tissue borne
• For many resection patients, usually
2 -3 properly positioned implants are
• Implants should not be placed close
to the border of the resected mandible
because the bone in this region may
be necrotic or poorly vascularized,
secondary to the previous surgical
Implants placed in the fibular
graft 6 months after
Unilateral partial denture
retained by ball
attachments on the implants
and one clasp on the
• Prosthodontic success in the
mandibular resection patient is
closely allied with the surgical
• MVFFs has revolutionized
reconstruction of the mandible and
contiguous oral structures.
• Prosthodontic modifications to
routine prosthodontic procedures are
necessary to compensate for deficits
that are not correctable with surgical
• The maintenance of facial form,
prevention of tethering of intraoral
tissues have greatly enhanced the
results obtained by prosthodontic
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patients with head and neck cancer J Prosthet
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maxillofacial patient J Prosthet Dent,1965;15:168-173
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mandibles J Prosthet Dent,1969;21:197-201
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mandibulectomy patients Part 1 J Prosthet Dent,1971;25:447-
455, Part 2 J Prosthet Dent,1971;25:547-555, Part 3 J
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mandibular resection J Prosthet Dent,1977;37:437-443
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mandibulectomies J Prosthet Dent,1982;48:178-183
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series,Vol 4 William R Laney
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