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

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. Classification of
defects
Treatment
Surgical
Prosthodontic
Partially
edentulous
Completely
edentulous
Rehabilitation of
mandibulectomy
patients
Diagnostic
considerations

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

21. Compromise of vestibular extensions

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.