Prosthodontic management of acquired defects of mandible123 /certified fixed orthodontic courses by Indian dental academy


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Prosthodontic management of acquired defects of mandible123 /certified fixed orthodontic courses by Indian dental academy

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education
  3. 3. Table of content  Introduction  Review of literature  Definitions  Classification of mandibular defects  Physiology of oral function following resection  Diagnostic Consideration for Prosthodontic rehabilitation
  4. 4.  Prosthodontic management Mandibular guidance prosthesis Partially edentulous patient Completely edentulous patient  Role of implants in rehabilitation  Summary  Conclusion
  5. 5. Introduction Management of malignant tumors involving the tongue, mandible, and adjacent structures represents a difficult challenge for both the reconstructive surgeon and prosthodontist. Rehabilitation is an essential phase of cancer care and should be considered from the time of diagnosis. Surgical resection often creates large defects accompanied by dysfunction,
  6. 6. and disfigurement while radiation therapy produces significant morbidity and unique tissue management problems. Speech, swallowing, control of saliva and mastication can be adversely affected. These cosmetic and functional impairments should be corrected or minimized, thereby allowing the patient to resume a normal working and social life.
  7. 7. Definitions
  8. 8.  mandibular resection: the surgical removal of a portion or all of the mandible and the related soft tissues called also mandibulectomy  mandibular resection prosthesis : a maxillofacial prosthesis used to maintain a functional position for the jaws (maxillae and mandible), improve speech and deglutition following trauma or/and surgery to the mandible or/and adjacent structures
  9. 9.  mandibular repositioning : guidance of the mandible to cause closure in a predetermined, altered position
  10. 10. Review of literature
  11. 11.  Prosthetic treatment of maxillofacial injuries  JPD 1955: Lt Colonel Edwin  Reviewed treatment of maxillofacial injuries. He stressed the need for efficiency and simplicity of appliances. He outlined several designs for various types of defects. The principles outlined by him are still followed.
  12. 12.  Prosthetic reconstruction of a resected mandible  JPD 1962: Adisman  Described a case report of management of a patient with resection of mandibular body from 1st molar of one side to other side, anterior 2/3 tongue and dorsum of tongue sutured to mucosa of lower lip.  Mandibular expansion with implant prosthesis and rehabilitation with RPD was done.
  13. 13.
  14. 14.
  15. 15.
  16. 16.  Use of a guide plane for maintaining the residual fragment in partial or hemimandibulectomy  JPD 1964: Robinson and Rubright  Described a simple guide plane from pre- surgical impression and designed to maintain a functional occlusal relationship as a postsurgical splint. Such a splint compensates for uncontrolled muscular contraction.
  17. 17.  Prosthetic mandible of resected edentulous mandible  JPD 1969: Swoope  He advocated the use of uncomplicated appliances for treatment of edentulous patient with partially resected mandible utilizing fundamental principles of denture construction. A ramp can be provided on maxillary denture to serve as training device for returning the mandible to a functional position.
  18. 18.  Prosthetic management of edentulous mandibulectomy patient   Cantor and curtis  JPD 1971  Part I : Anatomic, physiologic and psychologic consideration
  19. 19.  Presents physiologic consideration pertinent to mandibulectomy patients discussed in terms of functional adaptibility to surgical insult. Deglutition, speech, mandibular movement, mastication, respiration, salivary control and psychologic factors have been discussed. A classification for mandibulectomy patients has been suggested.
  20. 20.  Part II ; Clinical procedures  Describes prosthetic principle relevant to post- surgical conditions of radical mandibular surgery. It describes clinical procedure to treat the same. A clinical study of 30 mandibulectomy patients was undertaken to make an objective assessment of the procedures.
  21. 21.  Rehabilitating dentulous hemimandibulectomy patients  Moore and Mithchel : JPD 1976  Describes a technique that combines crowns with a maxillary prosthesis to guide a dentulous hemimandible into its most functional position after long term scarring and deviation to the affected surgical site.
  22. 22.
  23. 23.  Occlusal consideration for the partial hemimandibulectomy patients  Desjardin: JPD 1979  Described various occlusal consideration for continuity and discontinuity defects in edentulous and partially edentulous patients. The occlusal scheme varies from person to person. If the continuity of the mandible can be restored by secondary surgical management most of the problems of the discontinuity can be resolved.
  24. 24. Reduction of the median mandibulectomy with the fixed mandibular implant.  Goodwin et al : J oral max surg 1992 50(3):292-6  A technique is presented whereby a median mandibulectomy of an atrophic edentulous mandible is performed to gain access to an oropharyngeal tumor and is subsequently
  25. 25.  reapproximated with a four-pin FMI. The procedure allows reduction of the osteotomy site and provides intraoral implants that increase the stability and retentive properties of a mandibular prosthesis.
  26. 26. Titanium osseointegrated implants combined with hyperbaric oxygen therapy in previously irradiated mandibles Arcuri et al : JPD 1997;77:177-83  This report presents the preliminary results of placing 18 titanium screw implants into previously irradiated mandibles in conjunction with hyperbaric oxygen therapy. Results. Of the 18 implants placed, 17 (94%)
  27. 27.  were judged to be osseointegrated at the abutment. The use of implants in irradiated tissues may provide a means of enhancing prosthetic rehabilitation while reducing the risk of tissue trauma that may develop into osteoradionecrosis
  28. 28. Arrangement of artificial teeth in the neutral zone after surgical reconstruction of the mandible: A clinical report  Fukushima, sato et al: JPD 2002;88:125-7  This clinical report describes the fabrication of a fixed partial denture, supported and retained by implants, for a patient with unfavorable tongue movement caused by
  29. 29. movable grafted skin on the floor of the mouth after surgical reconstruction of the mandible. The neutral zone technique was used, and successful results were obtained.
  30. 30. Rehabilitation of an irradiated mandible after mandibular resection using implant/tooth-supported fixed prosthesis: A clinical report Levin et al :J P D 2004;91:310-4 The patient presented with an unstable removable partial denture compromised by mandibular resection. Previous irradiation of the mandible did not compromise the integration of
  31. 31. the implants, thus enabling a fixed rehabilitation. At first stage, a provisional implant-supported fixed partial denture that functioned as a positioning and guiding plane determined the intermaxillary relationship. The definitive metal ceramic restoration had the same interocclusal relationship established by the mandibular guidance device.
  32. 32. An implant-supported fixed prosthesis can provide an effective functional and predictable solution for patients undergoing mandibular resection and irradiation.
  33. 33. Classification of mandibular defects
  34. 34. Chalian (1985a)  Class I Resection of the ipsilateral condyle  Class II Resection of the ipsilateral condyle and ascending ramus  Class III Resection of the ipsilateral condyle and body to midsymphysis  Class IV Resection of the ipsilateral condyle to the contralateral body
  35. 35.  Class V Total mandibulectomy  Class VI Resection of the midsypmphysis  Class VII Segmental resection of the body  Class VIII Marginal or coronal resection of the body.
  36. 36. Urken et al. (1991) Urken classification of mandibular defects: C-condyle, R-ramus, B-body, SH-symphysis (half)
  37. 37. Cantor and Curtis  6 different categories based on extent of the defect and the method of restoration in edentulous patients.  Class I - Radical alveolectomy with preservation of mandibular continuity  Class II - Lateral resection of the mandible distal to the cuspid area  Class III - Lateral resection of the mandible to the midline
  38. 38.
  39. 39.
  40. 40.
  41. 41.
  42. 42.
  43. 43.
  44. 44.  Class IV - Lateral bone graft and surgical reconstruction  Class V - Anterior bone graft and surgical reconstruction  Class VI - Anterior mandibular resection without surgical reconstruction
  45. 45. Physiology of oral functions The nature and extent of disability depends on the  location and size of tumour  Impact of radiation/ chemotherapy  Structure and volume of tissue resected  Design of resection  Method of resection
  46. 46. Physiologic impairment  Deglutition  Speech  Mandibular movement  Salivary control  Psychologic factors
  47. 47. Deglutition  May be temporarily or permanently disrupted  Usually returns as swallowing is a primary function  It can be performed with minimal muscular function and even with loss of skeletal structures such as mandible and hyoid bone.  However tissue loss and reduced neuromuscular control of oral and laryngeal structures will restrict the anterior elevation of the floor of the mouth.
  48. 48. Dysfunction occurs due to  Dennervation  Scarring  Radiation fibrosis  Tongue resection  Discontinuity defect
  49. 49. Speech
  50. 50.  Speech distortion usually occurs in mandibulectomy patients due to impairment of the articulating mechanism or resonating chambers.  Reduction in tongue size or mobility  Displacement of mandibular fragment will cause asymmetric functioning of the tongue  Scarring of lower lip can interfere with sound production.
  51. 51. Mandibular movement and mastication  There is alteration and restriction of mandibular movement.  The remaining mandibular segment will retrude and deviate towards the surgical side at rest position. Upon opening the mouth this deviation will increase leading to angular pathway of opening and closing.
  52. 52.
  53. 53.
  54. 54.  Loss of proprioceptive sense of occlusion leads to uncoordinated less precise movements, loss of masticatory muscles on surgical side will result in significant rotation of mandible upon forceful closure.
  55. 55. Frontal plane rotation
  56. 56. Occlusal relationship
  57. 57. Saliva control Drooling can occur due to  Restricted tongue movement  Difficulty in swallowing  Absence of labial, buccal and lingual sulci  Scarring of orbicularis oris  Loss of sensory awareness
  58. 58.  Xerostomia  Reduced salivary flow which is thick and ropy.  Degeneration of salivary glands due to irradiation  Denture retention, tissue tolerance and taste adversely affected
  59. 59. Radiotherapy  Acute Sequelae  salivary gland pathoses  acute parotitis, irreversible changes (flow rates, compositional alterations)  oral mucositis  Infections of mucosa and periodontium  dysgeusia
  60. 60.  Chronic Sequelae  salivary gland pathoses  acute parotitis  irreversible changes (flow rates, compositional alterations)  dental alterations : rampant caries, demineralization  osteoradionecrosis
  61. 61.
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  63. 63.
  64. 64.
  65. 65. Psychologic factors  Distortion of self image  inablity to communicate,  shifting family and vocational roles require psychologic counseling
  66. 66. Diagnostic Consideration for Prosthodontic rehabilitation
  67. 67. Location and extent of mandibular defect  Continuity defect  Discontinuity defect
  68. 68. Continuity defect  Radical alveolectomy  Reduction in stability of prosthesis due to loss of vertical ridge height and vestibular depth.  Vertical discrepancy between level of residual osseous support an opposing dentition at the level of occlusal plane.
  69. 69.
  70. 70. Discontinuity defect  Rule of thumb: The further anterior the defect the more disfiguring and functionally debilitating it is likely to be.  Defects of symphyseal region always require surgical reconstruction before prosthodontic therapy can be effective.
  71. 71.
  72. 72.  Defects of posterior mandible can be restored to near normal mandibular mobility with immediate or delayed surgical reconstruction.
  73. 73. Presence of remaining natural teeth  Teeth are crucial to stability of prosthesis. Prognosis improves as no.. of teeth increase.  Teeth present bilaterally
  74. 74. Rotation and deviation of mandible  Deviation towards the defect side occurs due to loss of tissue and primary closure drawing the margins together.  Loss of continuity also results in inferior rotation of mandible
  75. 75.
  76. 76. Results of deviation and rotation are  Facial disfigurement  Loss of occlusal contact  Loss of ability to bring the lips together for salivary control.
  77. 77.
  78. 78. Mouth opening  Many patient experience limitation of mouth opening after mandibulectomy due to surgical trauma and scar formation  Sufficient mouth opening to allow dental access and making of impression is paramount.  Prevention of scar tissue formation by stretching exercise soon after surgery
  79. 79. Vestibular extension  Normal vestibule is important to alow for extension of flanges for maximum support , stability and perepheral seal asociated with retension.  Loss of vestibular depth adversely affects prognosis  Secondary surgery – vestibuloplasy must be done even if continuity of mandible exists.
  80. 80.
  81. 81. Tongue mobility  Frequently surgical wound is closed by suturing remaining tissue of floor of mouth or tongue to buccal tissue. This limits mobility of tongue.  Affects speech, swallowing, mastication, prosthesis control and control on food bolus.  Tongue mobility must be evaluated  Lingual vestibuloplasty, Speech therapy
  82. 82.
  83. 83. Prosthodontic management
  84. 84. Mandibular guidance prosthesis  Begins 2 weeks after surgery  Presence of teeth essential. Excessive lateral forces generated during guidance of mandible can dislodge complete denture.  Can be constructed on maxilla or mandible  Once acceptable occlusal relationship is attained guidance prosthesis can be discarded.
  85. 85.  1 Obtain maxillary and mandibular impression and pour the cast  2 Wax interocclusal record obtained by clinician by guiding mandible into best possible interocclusal relation  3 Cast mounted on articulator and studied  4 Occlusal equilibration done
  86. 86.  Diagnostic cast of mandible is surveyed and RPD design outlined.  Engage maximum no.. Of teeth. Guidance flange extended from continuous clasp on buccal aspect .  The guidance ramp must extend superiorly in a diagonal manner to allow for normal overlap of maxillary and mandibular teeth.
  87. 87.
  88. 88.  If an acrylic ramp is planned a retentive mesh must be placed extending from continuous buccal clasp on non-defect side.  To decide angulation of ramp a second wax record obtained with posterior teeth separated upto 3mm and mandible deflected maximum towards non-defect side is obtained and used to articulate cast.  Wax pattern of framework and flange s designed and casted
  89. 89.
  90. 90.  If acrylic ramp is planned, then autopolymerizing resin at dough stage is attached to retentive mesh placed in patients mouth and mandible guided repeatedly into desired position.  Resin manipulated to extend 7-10mm superiorly.  Prosthesis removed, allowed to polymerize, trimmed and polished.
  91. 91.  Resin ramp can be periodically assessed and adjusted unlike metal ramp
  92. 92.  Maxillary guidance ramp is made of acrylic.  The full palatal coverage prosthesis is constructed and tried in the mouth.  Autopolymerizing acrylic resin is added to palatal aspect along the lateral and anterior border on the non-defect side.  The prosthesis is replaced in mouth and mandible manipulated to desired position thus establishing a index in palate.
  93. 93.
  94. 94.  The movement is repeated several times until resin polymerizes .  Prosthesis is removed and polished.
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  99. 99. Thank you For more details please visit