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Prosthodontic rehabilitation of the mandibulectomy patient Prosthodontic rehabilitation of the mandibulectomy patient Presentation Transcript

  • PROSTHODONTICPROSTHODONTIC REHABILITATION OF THEREHABILITATION OF THE MANDIBULECTOMY PATIENTMANDIBULECTOMY PATIENT INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.comwww.indiandentalacademy.com
  • CONTENTSCONTENTS  INTRODUCTIONINTRODUCTION  CLASSIFICATION OF MANDIBULARCLASSIFICATION OF MANDIBULAR DEFECT.DEFECT.  DIAGNOSTIC CONSIDERATIONSDIAGNOSTIC CONSIDERATIONS  SURGICAL CONSIDERATIONSURGICAL CONSIDERATION  PROSTHETIC REHABILITATIONPROSTHETIC REHABILITATION  CONCLUSIONCONCLUSION  BIBLIOGRAPHYBIBLIOGRAPHY www.indiandentalacademy.comwww.indiandentalacademy.com
  • INTRODUCTIONINTRODUCTION  Muscles of mastication are bilaterally attachedMuscles of mastication are bilaterally attached to the mandible to generate a variety ofto the mandible to generate a variety of complex mandibular movements useful incomplex mandibular movements useful in speech, swallowing, mastication, andspeech, swallowing, mastication, and respiration. The mandible and the muscles ofrespiration. The mandible and the muscles of mastication also give form to the lower third ofmastication also give form to the lower third of the face. Disruption of the mandible has thethe face. Disruption of the mandible has the potential to disrupt any of these functions.potential to disrupt any of these functions. www.indiandentalacademy.comwww.indiandentalacademy.com
  • CLASSIFICATION OF THECLASSIFICATION OF THE MANIBULAR DEFECTMANIBULAR DEFECT  Congenital Defects ofCongenital Defects of the Mandiblethe Mandible  Acquired Defects of theAcquired Defects of the MandibleMandible -Continuity defect-Continuity defect --Discontinuity defectDiscontinuity defect www.indiandentalacademy.comwww.indiandentalacademy.com
  • Cantor and Curtis classificationCantor and Curtis classification  CLASS ICLASS I  CLASS IICLASS II -- Modification aModification a -- Modification bModification b -- Modification cModification c  CLASS IIICLASS III  CLASS IVCLASS IV  CLASS VCLASS V www.indiandentalacademy.comwww.indiandentalacademy.com
  • CLASS ICLASS I Marginal resection Continuity defect www.indiandentalacademy.comwww.indiandentalacademy.com
  • CLASS IICLASS II Segmental free end resection (discon-tinuity defect) that does not cross the midline. www.indiandentalacademy.comwww.indiandentalacademy.com
  •  Modification a:Modification a: Bilateral resectionBilateral resection posterior to the secondposterior to the second premolarpremolar www.indiandentalacademy.comwww.indiandentalacademy.com
  •  Modification b:Modification b: Unilateral resectionUnilateral resection posterior to the lateralposterior to the lateral incisorincisor www.indiandentalacademy.comwww.indiandentalacademy.com
  •  Modification c:Modification c: Bilateral resectionBilateral resection posterior to the lateralposterior to the lateral incisor on one side andincisor on one side and the second premolar onthe second premolar on the otherthe other www.indiandentalacademy.comwww.indiandentalacademy.com
  • CLASS IIICLASS III  Segmental free endSegmental free end resection upto or crossesresection upto or crosses the midlinethe midline www.indiandentalacademy.comwww.indiandentalacademy.com
  • CLASS IVCLASS IV  Includes class III defectIncludes class III defect with resection of thewith resection of the temperomandibulartemperomandibular jointjoint www.indiandentalacademy.comwww.indiandentalacademy.com
  • CLASS VCLASS V  Anterior boundedAnterior bounded resectionresection www.indiandentalacademy.comwww.indiandentalacademy.com
  • Predisposing factorsPredisposing factors  Ill fitting denturesIll fitting dentures  Palatal papillary hyperplasia.Palatal papillary hyperplasia.  AlcoholAlcohol  TobaccoTobacco  LeukoplakiaLeukoplakia  Oral lichen planusOral lichen planus  Carcinoma of tongueCarcinoma of tongue www.indiandentalacademy.comwww.indiandentalacademy.com
  • DIAGNOSTIC CONSIDERATIONSDIAGNOSTIC CONSIDERATIONS  Location and Extent of the Mandibular DefectLocation and Extent of the Mandibular Defect  Presence of Remaining Natural Teeth or Pre-Presence of Remaining Natural Teeth or Pre- existing Implantsexisting Implants  Degree of Postmandibulectomy Rotation andDegree of Postmandibulectomy Rotation and DeviationDeviation  Available Mouth OpeningAvailable Mouth Opening  Functional Limitation of the TongueFunctional Limitation of the Tongue www.indiandentalacademy.comwww.indiandentalacademy.com
  •  Compromise of Vestibular ExtensionsCompromise of Vestibular Extensions  Skin GraftingSkin Grafting  Radiation TherapyRadiation Therapy  Altered Anatomic Relationships FollowingAltered Anatomic Relationships Following Restoration of Mandibular ContinuityRestoration of Mandibular Continuity www.indiandentalacademy.comwww.indiandentalacademy.com
  • Location and Extent of theLocation and Extent of the Mandibular DefectMandibular Defect  Continuity orContinuity or discontinuity defect.discontinuity defect.  Size and location of theSize and location of the defect.defect. www.indiandentalacademy.comwww.indiandentalacademy.com
  • Presence of Remaining NaturalPresence of Remaining Natural Teeth or Pre-existing ImplantsTeeth or Pre-existing Implants  Teeth with poor diagnosis should be extractedTeeth with poor diagnosis should be extracted if radiation therapy is planned, to reduce theif radiation therapy is planned, to reduce the risk of future complication, particularlyrisk of future complication, particularly osteoradionecrosis.osteoradionecrosis.  Larger number of teeth , better design ofLarger number of teeth , better design of prostheses.prostheses. www.indiandentalacademy.comwww.indiandentalacademy.com
  •  When even one or twoWhen even one or two teeth remain in theteeth remain in the mandible, the patient ismandible, the patient is much more likely tomuch more likely to tolerate a removable,tolerate a removable, tissue-supportedtissue-supported prosthesis. The teeth areprosthesis. The teeth are crucial to the stability ofcrucial to the stability of the prosthesis.the prosthesis. www.indiandentalacademy.comwww.indiandentalacademy.com
  •  Teeth present on both sidesTeeth present on both sides of the midline permitof the midline permit greater prosthesis supportgreater prosthesis support because the problem ofbecause the problem of straight-line design can bestraight-line design can be avoided.avoided.  Mandibular incisors withMandibular incisors with adequate root support mayadequate root support may serve as abutments,serve as abutments, particularly where theparticularly where the canine on the side of thecanine on the side of the defect has been lost. Thisdefect has been lost. This also helps to give tripodalso helps to give tripod design and incorporatedesign and incorporate indirect retainers.indirect retainers.www.indiandentalacademy.comwww.indiandentalacademy.com
  •  A complete maxil-laryA complete maxil-lary denture will usuallydenture will usually function quite well against afunction quite well against a reconstructed mandibularreconstructed mandibular dentition; exceptionsdentition; exceptions include difficulty ininclude difficulty in fabrication of a maxillaryfabrication of a maxillary complete denture where thecomplete denture where the residual proxi-malresidual proxi-mal mandibular stump,mandibular stump, including the coronoidincluding the coronoid process.process. www.indiandentalacademy.comwww.indiandentalacademy.com
  • Degree of PostmandibulectomyDegree of Postmandibulectomy Rotation and DeviationRotation and Deviation  Mandibular deviation towardsMandibular deviation towards defect side occurs due to loss ofdefect side occurs due to loss of tissue involved in the surgicaltissue involved in the surgical resection. When mandible isresection. When mandible is drawn towards the defect fordrawn towards the defect for primary closure causes deviation.primary closure causes deviation.  Vertical rotation of residualVertical rotation of residual mandible in inferior directionmandible in inferior direction occurs due to.occurs due to. 1.1. The pull of the suprahyoidThe pull of the suprahyoid musculaturemusculature 2.2. Gravity.Gravity. www.indiandentalacademy.comwww.indiandentalacademy.com
  • Results of deviationResults of deviation  rotation of the mandiblerotation of the mandible  facial disfigurement,facial disfigurement,  loss of occlusal contact,loss of occlusal contact,  lips incompetence.lips incompetence.  Difficult in saliva controlDifficult in saliva control  swallowing process.swallowing process. www.indiandentalacademy.comwww.indiandentalacademy.com
  •  Treatment includes;Treatment includes; 1.1. Restoration of continuity through osseousRestoration of continuity through osseous graftinggrafting 2.2. Early post resection physical therapy.Early post resection physical therapy. 3.3. Use of mandibular resection guidanceUse of mandibular resection guidance prostheses.prostheses. 4.4. Maxillary guidance ramp.Maxillary guidance ramp. www.indiandentalacademy.comwww.indiandentalacademy.com
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  • Available Mouth OpeningAvailable Mouth Opening  Trismus due to fibrosis.Trismus due to fibrosis.  Test by inserting a tray .Test by inserting a tray .  Stretching exercises, moist heat, analgesics.Stretching exercises, moist heat, analgesics.  Tracheostomy may be necessary in severeTracheostomy may be necessary in severe cases.cases. www.indiandentalacademy.comwww.indiandentalacademy.com
  • Functional Limitation of the TongueFunctional Limitation of the Tongue  Impaired due to resection orImpaired due to resection or tethering.tethering.  Impair of functionImpair of function  Tethering is addressed by surgicalTethering is addressed by surgical release.release.  Resection is treated by palatal dropResection is treated by palatal drop or augmentation prosthesis.or augmentation prosthesis.  Test the mobility .Test the mobility .  Speech therapy.Speech therapy.  Loss of sensory and motorLoss of sensory and motor innervation.innervation. www.indiandentalacademy.comwww.indiandentalacademy.com
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  • Compromise of VestibularCompromise of Vestibular ExtensionsExtensions  Normal prostheses extension is required forNormal prostheses extension is required for peripheral seal.peripheral seal.  Referred for surgical revision/implant.Referred for surgical revision/implant.  Implant on normal ridge contour VsImplant on normal ridge contour Vs compromised vestibular extension.compromised vestibular extension.  peri-implant soft tissue inflammation.peri-implant soft tissue inflammation.  Provisional protective coverage.Provisional protective coverage. www.indiandentalacademy.comwww.indiandentalacademy.com
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  • Skin GraftingSkin Grafting  Skin graft vs fullSkin graft vs full thickness graft.thickness graft.  Problem placing implantProblem placing implant on these skin graft, is iton these skin graft, is it does not tolerate thedoes not tolerate the titanium surface in oraltitanium surface in oral environment.environment. MITCHELL advisedMITCHELL advised custom-fabricated goldcustom-fabricated gold alloy.alloy. www.indiandentalacademy.comwww.indiandentalacademy.com
  • Radiation TherapyRadiation Therapy  Tissues that have been radiated are fragile,Tissues that have been radiated are fragile, sensitive to manipulation, desiccated, slow tosensitive to manipulation, desiccated, slow to heal, prone to infection, and at risk for osteo-heal, prone to infection, and at risk for osteo- radionecrosis, particularly in the mandible.radionecrosis, particularly in the mandible. www.indiandentalacademy.comwww.indiandentalacademy.com
  • Altered Anatomic Relationships FollowingAltered Anatomic Relationships Following Restoration of Mandibular ContinuityRestoration of Mandibular Continuity  Grafting the anteriorGrafting the anterior mandible frequentlymandible frequently results in a graft that isresults in a graft that is deficient anteriorly.deficient anteriorly. www.indiandentalacademy.comwww.indiandentalacademy.com
  •  The clinical result is oneThe clinical result is one in which the maxillo-in which the maxillo- mandibular relationshipmandibular relationship is severely Class II andis severely Class II and with reduced likelihoodwith reduced likelihood of completelyof completely satisfactorysatisfactory prosthodonticprosthodontic rehabilitation.rehabilitation. www.indiandentalacademy.comwww.indiandentalacademy.com
  •  Reconstruction of posterior defectsReconstruction of posterior defects The mediolateral position of theThe mediolateral position of the graft is frequently seen to be lateralgraft is frequently seen to be lateral to the original position of theto the original position of the mandibular body. It results in amandibular body. It results in a prosthesis that must be built inprosthesis that must be built in crossbite to maintain the denturecrossbite to maintain the denture teeth over the supporting base ofteeth over the supporting base of the bone graft. When implants arethe bone graft. When implants are utilized, the implants requireutilized, the implants require extremely angled placement, andextremely angled placement, and the prosthesis they support maythe prosthesis they support may have to be cantilevered further tohave to be cantilevered further to the lingual to permit tooth contactthe lingual to permit tooth contact www.indiandentalacademy.comwww.indiandentalacademy.com
  • Interarch discrepencyInterarch discrepency  In lack of interarchIn lack of interarch spacespace 1.1. increasing the verticalincreasing the vertical dimension of occlusiondimension of occlusion within physiologicwithin physiologic limitslimits 2.2. surgical revision ofsurgical revision of hard and soft tissueshard and soft tissues www.indiandentalacademy.comwww.indiandentalacademy.com
  •  In increased interarchIn increased interarch spacespace - prosthesis is likely to- prosthesis is likely to generate torsional forcesgenerate torsional forces on the natural teethon the natural teeth - maximum use of all- maximum use of all remaining teeth as wellremaining teeth as well as maximum soft tissueas maximum soft tissue supportsupport www.indiandentalacademy.comwww.indiandentalacademy.com
  • Surgical ConsiderationsSurgical Considerations  Intermaxillary fixationIntermaxillary fixation  Resection guidance restorationsResection guidance restorations  Palatal Speech AidsPalatal Speech Aids  Maxillary guidance ramp.Maxillary guidance ramp. www.indiandentalacademy.comwww.indiandentalacademy.com
  •  Skin graft.Skin graft.  Local or pedicle graftLocal or pedicle graft  MVFFMVFF  The two primary sources of microvascularizedThe two primary sources of microvascularized bone for mandibular reconstruction are thebone for mandibular reconstruction are the fibula and iliac crest.fibula and iliac crest.  MVFFs from the forearm or the rectusMVFFs from the forearm or the rectus muscle.muscle. www.indiandentalacademy.comwww.indiandentalacademy.com
  • Intermaxillary fixationIntermaxillary fixation  This reduces theThis reduces the deviation associateddeviation associated with resection of thewith resection of the mandible if donemandible if done immediately using archimmediately using arch bars and elastics. This isbars and elastics. This is maintained for 5 – 7maintained for 5 – 7 weeks followingweeks following surgery.surgery. www.indiandentalacademy.comwww.indiandentalacademy.com
  • Palatal Speech AidsPalatal Speech Aids  Cantor et al (1996) stated that consonant sounds “Cantor et al (1996) stated that consonant sounds “kk”” andand “q”“q” required valving by the posterior part ofrequired valving by the posterior part of tongue with the posterior part of hard palate andtongue with the posterior part of hard palate and anterior portion of soft palate and these sounds wereanterior portion of soft palate and these sounds were particularly difficult for mandibulectomy patients. Heparticularly difficult for mandibulectomy patients. He reasoned that if palatal vault was loweredreasoned that if palatal vault was lowered prosthetically into space of donders to accommodateprosthetically into space of donders to accommodate for restricted tongue movements, speechfor restricted tongue movements, speech improvement might be noted.improvement might be noted. www.indiandentalacademy.comwww.indiandentalacademy.com
  • PROSTHETIC REHABILITATIONPROSTHETIC REHABILITATION OF DENTULOUS PATIENTSOF DENTULOUS PATIENTS  Design.Design. www.indiandentalacademy.comwww.indiandentalacademy.com
  • Lateral Discontinuity defectsLateral Discontinuity defects www.indiandentalacademy.comwww.indiandentalacademy.com
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  • DEFECTS WITH MANDIBULARDEFECTS WITH MANDIBULAR CONTINUITYCONTINUITY  Anterior DefectsAnterior Defects  Altered cast impressionAltered cast impression www.indiandentalacademy.comwww.indiandentalacademy.com
  •  Lateral continuousLateral continuous defectsdefects www.indiandentalacademy.comwww.indiandentalacademy.com
  • PROSTHETIC REHABILITATION ONPROSTHETIC REHABILITATION ON EDENTULOUS PATIENTSEDENTULOUS PATIENTS www.indiandentalacademy.comwww.indiandentalacademy.com
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  • LATERAL CONTINUITY DEFECTSLATERAL CONTINUITY DEFECTS www.indiandentalacademy.comwww.indiandentalacademy.com
  • CONCLUSIONCONCLUSION  Surgical and prosthodontic rehabilitation of theSurgical and prosthodontic rehabilitation of the mandibulectomy patient has the potential of beingmandibulectomy patient has the potential of being extremely gratifying to the clinician as well asextremely gratifying to the clinician as well as making an enormous impact on the quality of life formaking an enormous impact on the quality of life for the patient. At the same time, the complexities ofthe patient. At the same time, the complexities of dealing with the many factors involved in successfuldealing with the many factors involved in successful diagnosis and treatment planning of the patient with adiagnosis and treatment planning of the patient with a mandibular defect make the final outcome ofmandibular defect make the final outcome of treatment difficult to predict and often less thantreatment difficult to predict and often less than completely satisfactory. It is hoped that futurecompletely satisfactory. It is hoped that future developments will continue to improve outcomes ofdevelopments will continue to improve outcomes of postmandibulectomy treatment to further improve thepostmandibulectomy treatment to further improve the quality of life for patients requiring such treatment.quality of life for patients requiring such treatment.www.indiandentalacademy.comwww.indiandentalacademy.com
  • BIBLIOGRAPHYBIBLIOGRAPHY  Thomas D.Taylor: Clinical maxillofacialThomas D.Taylor: Clinical maxillofacial prosthetics.prosthetics.  Varoujan A.Chalian; MaxillofacialVaroujan A.Chalian; Maxillofacial prosthetics-Multidisciplinary practice.prosthetics-Multidisciplinary practice.  John Beumer- Maxillofacial Rehabilitation.John Beumer- Maxillofacial Rehabilitation.  Prosthetic rehabilitation of hemi-Prosthetic rehabilitation of hemi- mandibulectomy patient – JIPS;2006:6:1.mandibulectomy patient – JIPS;2006:6:1.www.indiandentalacademy.comwww.indiandentalacademy.com
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