prosthodontic management of acquired defects of mandible /certified fixed orthodontic courses by Indian dental academy

2,162 views

Published on



The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.


Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
00919248678078

0 Comments
6 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
2,162
On SlideShare
0
From Embeds
0
Number of Embeds
3
Actions
Shares
0
Downloads
0
Comments
0
Likes
6
Embeds 0
No embeds

No notes for slide

prosthodontic management of acquired defects of mandible /certified fixed orthodontic courses by Indian dental academy

  1. 1. PROSTHODONTIC MANAGEMENT OF ACQUIRED DEFECTS OF MANDIBLE www.indiandentalacademy.com
  2. 2. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  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 www.indiandentalacademy.com
  4. 4. • Prosthodontic management Mandibular guidance prosthesis Partially edentulous patient Completely edentulous patient • Role of implants in rehabilitation • Summary • Conclusion www.indiandentalacademy.com
  5. 5. Partially edentulous patient • Lateral discontinuity defect • Anterior continuity defect • Lateral continuity defect www.indiandentalacademy.com
  6. 6. Lateral discontinuity defect www.indiandentalacademy.com
  7. 7. Impression • Preliminary impression are made with modified stock tray. • Cast poured • Surveyed • RPD design www.indiandentalacademy.com
  8. 8. Partial denture design All principles of designing a conventional partial denture should be followed. • Major connector- rigid • Occlusal rest- direct forces along long axis • Direct retainer- engage several teeth www.indiandentalacademy.com
  9. 9. Factors To consider • Closure is angular rather than vertical • Forces of occlusion confined to unresected side • fulcrum line difficult to determine due to frontal plane rotation making it difficult to predict movement pattern of prosthesis during function www.indiandentalacademy.com
  10. 10. Forces of occlusion Frontal plane rotation www.indiandentalacademy.com
  11. 11. www.indiandentalacademy.com
  12. 12. www.indiandentalacademy.com
  13. 13. www.indiandentalacademy.com
  14. 14. • Once framework is fabricated it is tried in the patient’s mouth www.indiandentalacademy.com
  15. 15. Altered cast impression • Altered cast impression of edentulous area is taken • Special care on lingual extension of unresected side should be taken as it provides additional retention and stability • Maximum soft tissue coverage • Coverage of buccal shelf on unresected side is important www.indiandentalacademy.com
  16. 16. • On resected side tissue bed is unyielding hence to mold this area manipulate the cheek and ask patient to move tongue from side to side. • After altered cast impression is obtained, master cast is segmented. • Impression placed on the sectioned cast, boxed and poured www.indiandentalacademy.com
  17. 17. • Occlusal rim are made. • Jaw relation recorded by softening the wax and gently guiding the mandible. • Excessive force to be avoided www.indiandentalacademy.com
  18. 18. • Select teeth depending on opposing dentition • After jaw relation are verified at try-in, denture is acrylized • Partial denture is delivered www.indiandentalacademy.com
  19. 19. Defect with mandibular continuity maintained or reestablished www.indiandentalacademy.com
  20. 20. Anterior defect www.indiandentalacademy.com
  21. 21. • These patients have posterior teeth and extensive edentulous area anteriorly creating a kennedy classIV situation. • Normal mandibular movement pattern • Following bony recostruction vestibuloplasty are indicated www.indiandentalacademy.com
  22. 22. • Design must consider movement of anterior segment of prosthesis • Long mesial rest on 2nd molar provide indirect retention. • Care taken to relieve proximal plate and distal aspect of minor connector to allow for expected movement of prosthesis www.indiandentalacademy.com
  23. 23. www.indiandentalacademy.com
  24. 24. www.indiandentalacademy.com
  25. 25. • Conventional RPD enhance aesthetic and provide lip support leading to improved articulation of speech and salivary control • In small defects mastication is restored • In larger defects mastication is compromised because of length and movement of anterior edentulous span hence RPD serves mainly for lip support www.indiandentalacademy.com
  26. 26. Lateral defect www.indiandentalacademy.com
  27. 27. • Lateral defects in which posterior dentition remains only on one side are difficult to design. • Long lever arm and compromised tissue bed on resected side cause excessive movement of the prosthesis. www.indiandentalacademy.com
  28. 28. Favorable edentulous extension www.indiandentalacademy.com
  29. 29. Unfavorable edentulous extension www.indiandentalacademy.com
  30. 30. www.indiandentalacademy.com
  31. 31. www.indiandentalacademy.com
  32. 32. Completely edentulous patient Compromising factors • Stability, retention, support reduced due to resection • Radiotherapy makes mucosa fragile and atrophic • Reduced saliva with altered quality compromises retention www.indiandentalacademy.com
  33. 33. • Angular pathway of closure induces lateral forces on denture which tend to dislodge • Deviation creates abnormal jaw relation and teeth placement difficult • Impairment of motor and sensory function impair ability to control prosthesis. www.indiandentalacademy.com
  34. 34. • Primary impression made with irreversible hydrocolloid in a modified stock tray • Particular attention must be paid in recording areas posterior to the resection. www.indiandentalacademy.com
  35. 35. www.indiandentalacademy.com
  36. 36. Swallowing impression technique www.indiandentalacademy.com
  37. 37. www.indiandentalacademy.com
  38. 38. Area supported by bone and free of muscular activity drawn on diagnostic cast www.indiandentalacademy.com
  39. 39. • Perforated acrylic resin tray constructed on outlined area • Modeling compound stops placed on impression surface for stability and to provide space for impression material. • Two lateral columns that extend towards the maxillary ridge are formed on tray www.indiandentalacademy.com
  40. 40. www.indiandentalacademy.com
  41. 41. www.indiandentalacademy.com
  42. 42. www.indiandentalacademy.com
  43. 43. www.indiandentalacademy.com
  44. 44. www.indiandentalacademy.com
  45. 45. www.indiandentalacademy.com
  46. 46. www.indiandentalacademy.com
  47. 47. Conventional technique • Border molding and secondary impression can also be used www.indiandentalacademy.com
  48. 48. Maxillomandibular relation recording • Acrylic resin base fabricated on this cast indicates zone of neutralization • Wax occlusal rim placed within this zone • Maxillary rim adjusted for lip support and occlusal plane • Maxillary rim wider on unresected side to account for deviation of mandible www.indiandentalacademy.com
  49. 49. • Lower rim adjusted till a tentative occlusal vertical dmension has been established. • Vertical dimension of occlusion should be closed as much as possible in patient with reduced tongue bulk or mobility to allow tongue to interact with palatal structure • Mandible guided by clinician into unstrained repeatable position for centric registration • Maxillary ramp may be made at this stage www.indiandentalacademy.com
  50. 50. • Retention achieved by close adaptation of the prosthesis with bearing surface and maximal extension of lingual flange on unresected side as compatible with anatomical limitation • Support obtained from buccal shelf, crest of ridge retromolar pad and soft tissue bed posterior to resection www.indiandentalacademy.com
  51. 51. Teeth arrangement Non- anatomic teeth to be used • Abnormal jaw relation • Angular path of closure • Increased lateral stress • teeth arranged within the neutral zone www.indiandentalacademy.com
  52. 52. • Due to deviation and retrusion maxillary anterior teeth are placed lingual to and mandibular anterior teeth are paced labial to normal position. www.indiandentalacademy.com
  53. 53. Mandibular posterior teeth • Posterior teeth on unresected side placed buccal to crest of ridge. • With the lingual inclination of residual mandible and elevation of buccal shelf, placing posterior teeth buccaly centers he forces more favorably on supporting tissue and also is compatible with tongue position. www.indiandentalacademy.com
  54. 54. www.indiandentalacademy.com
  55. 55. On the resected side posterior teeth are placed lingual to the crest as • Lips and cheeks pulled medially due to scarring • To facilitate occlusal relationship with maxilla www.indiandentalacademy.com
  56. 56. Resected side, lingual placement of teeth Unresected side, buccal placement of teeth www.indiandentalacademy.com
  57. 57. Functionally generated palatal ramp • Soft occlusal wax is added on to the posterior and palatal surface of maxillary rim. • Mandible guided through opening and closing movement www.indiandentalacademy.com
  58. 58. www.indiandentalacademy.com
  59. 59. www.indiandentalacademy.com
  60. 60. www.indiandentalacademy.com
  61. 61. Maxillary posterior teeth • Maxillary posterior teeth are placed lingualy on unresected side and buccaly on resected side for favorable occlusal relation • Maxillary palatal ramp can be fabricated at this stage www.indiandentalacademy.com
  62. 62. www.indiandentalacademy.com
  63. 63. www.indiandentalacademy.com
  64. 64. • Following try- in prosthesis is processed in conventional manner. • At the time of insertion disclosing agent should be used to relieve area of excessive tissue displacement. www.indiandentalacademy.com
  65. 65. www.indiandentalacademy.com
  66. 66. www.indiandentalacademy.com
  67. 67. www.indiandentalacademy.com
  68. 68. www.indiandentalacademy.com
  69. 69. • “ Mastication is confined to non-defect side and bilateral occlusal contact serve more as stabilizing force. As muscles of mastication are no longer present on resected side bilateral balance of complete dentures during function in the classical sense is not possible.” Beumer www.indiandentalacademy.com
  70. 70. Role of Implants in rehabilitation www.indiandentalacademy.com
  71. 71. Application of implants has offered a major improvement in management of mandibular resection cases. By providing a foundation onto which fixed prosthodontic treatment is based or for retention of removable prosthesis, implants play a role in making rehabilitative efforts functional rather than mere aesthetic. www.indiandentalacademy.com
  72. 72. The patient receives a stable fixed prosthesis with an appropriate interocclusal relationship and occlusal scheme, predetermined by the guidance-positioning device. The fixed prosthesis resolves the problems, reduces mechanical irritation to the tongue and soft tissue, and allows sufficient space for the tongue for efficient mastication. www.indiandentalacademy.com
  73. 73. PERI-IMPLANT SOFT TISSUE CONSIDERATIONS • Implant abutments that traverse thick, movable, soft tissue beds before entering the oral cavity, frequently are plagued with soft tissue maintenance problems. The cause of these problems is often related to tissue movement, plaque accumulation, and ineffective oral hygiene efforts. • These factors can affect peri-implant health and possibly long-term retention of the implant. www.indiandentalacademy.com
  74. 74. www.indiandentalacademy.com
  75. 75. TIMING OF IMPLANT PLACEMENT Placement of osseointegrated implants at the time of surgical resection and osseous reconstruction has been reported and promoted on the basis of eliminating a separate surgical sitting, avoiding the need for hyperbaric oxygen, and reducing delays in prosthetic rehabilitation. However, this approach frequently results in compromised implant position and orientation limiting optimal prosthetic rehabilitation. www.indiandentalacademy.com
  76. 76. A better appreciation for tumor prognosis after definitive (permanent section) microscopic evaluation of surgical margins, neck node status lifestyle (alcohol, tobacco, other drug abuse) of the patient, and compliance for follow-up evaluations are all important factors to consider and are usually www.indiandentalacademy.com
  77. 77. more predictable and apparent when implant placement is performed in a delayed manner. Even if indicated, it would be imprudent from an oncologic standpoint to place implants when tumor prognosis is poor and risk for recurrence is high. www.indiandentalacademy.com
  78. 78. Osteoradionecrosis is the primary concern after invasive procedures, such as placement of endosseous implants in irradiated bone. Evidence suggests that placement of an endosseous dental implant into irradiated mandibles does not compromise implant integration nor reduce survival rate. www.indiandentalacademy.com
  79. 79. Implants placed in irradiated mandibles show a very high survival rate. Histologic examination confirms implant osseointegration in irradiated bone. A minimal interval of 9 to 12 months between radiotherapy and implant placement is recommended. www.indiandentalacademy.com
  80. 80. Implant supported overdenture www.indiandentalacademy.com
  81. 81. www.indiandentalacademy.com
  82. 82. www.indiandentalacademy.com
  83. 83. www.indiandentalacademy.com
  84. 84. www.indiandentalacademy.com
  85. 85. Implant supported removable partial denture www.indiandentalacademy.com
  86. 86. Arrangement of artificial teeth in the neutral zone after surgical reconstruction of the mandible www.indiandentalacademy.com
  87. 87. www.indiandentalacademy.com
  88. 88. www.indiandentalacademy.com
  89. 89. www.indiandentalacademy.com
  90. 90. www.indiandentalacademy.com
  91. 91. Summary • Rehabilitation of acquired mandibular defect is a challenging task. Several problems are encountered during the rehabilitation. www.indiandentalacademy.com
  92. 92. Physiologic impairment Degglutition Salivary control Speech Mandibular movement Psychologic factors www.indiandentalacademy.com
  93. 93. Diagnostic Consideration for Prosthodontic rehabilitation Location and extent of mandibular defect Presence of remaining natural teeth www.indiandentalacademy.com Rotation and deviation of mandible
  94. 94. • Often with lateral resection, frontal plane rotation, deviation to the resected side is seen. Hence guidance prosthesis is the starting point to rehabilitation. Once appropriate occlusal relationship can be achieved final removable or fixed prosthesis can be fabricated www.indiandentalacademy.com
  95. 95. Partially edentulous patient Lateral discontinuity defect Anterior continuity defect www.indiandentalacademy.com Lateral continuity defect
  96. 96. • For completely edentulous patient the swallowing technique for impression recording, to record neutral zone is recommended. Placement of teeth in neutral zone stabilizes the prosthesis. • Use of implants in management of these cases greatly enhances the functional outcome. The number, location and time of placement are important. www.indiandentalacademy.com
  97. 97. Conclusion Patients operated on for malignant tumors of the mandible, present a far more difficult rehabilitation problem, than those patients with maxillary defects. Recently, advances in the reconstruction of such defects by means of microvascular free flaps have allowed the maxillofacial prosthodontist to rehabilitate these patients more effectively. www.indiandentalacademy.com
  98. 98. With proper multidisciplinary pretreatment planning and postoperative treatment, osseointegrated implants can be strategically placed in those patients with a reconstructed mandible to restore occlusal and masticatory function while also achieving an acceptable esthetic. www.indiandentalacademy.com
  99. 99. Reference • Canter, R. and Curtis, T. A. Prosthetic management of the edentulous mandibulectomy patient. Part II Clinical procedures. J Prosthet Dent 25:546-555, 1971. • Canter, R. and Curtis, T. A. Prosthetic management of the edentulous mandibulectomy patient. Part III Clinical evaluation. J Prosthet Dent 25:670-678, 1971. • Curtis, T. A. and Canter, R. The forgotten patient in maxillofacial prosthetics. J Prosthet Dent 31:662-680, 1974. www.indiandentalacademy.com
  100. 100. • Firtell, D. N. and Curtis, T. A. Removable partial denture design for the mandibular resection patient. J Prosthet Dent 48:437-443, 1982. • Moore, D. J. and Mitchell, D. L. Rehabilitating dentulous hemimandibulectomy patients. J Prosthet Dent 35:202206, 1976. • Desjardins, R. P. Occlusal considerations for the partial mandibulectomy patient. J Prosthet Dent 41:308-315, 1979. • Beumer, J., III, Curtis, T. A. and Firtell, D. N. Maxillofacial Rehabilitation: Prosthetic and Surgical Considerations. C. V. Mosby, St. Louis, 1979 www.indiandentalacademy.com
  101. 101. • Prosthetic treatment of maxillofacial injuries • JPD 1955: Lt Colonel Edwin • Prosthetic reconstruction of a resected mandible JPD 1962: Adisman • Use of a guide plane for maintaining the residual fragment in partial or hemimandibulectomy JPD 1964: Robinson and Rubright • Prosthetic mandible of resected edentulous mandible JPD 1969: Swoope www.indiandentalacademy.com
  102. 102. • Rehabilitation of an irradiated mandible after mandibular resection using implant/toothsupported fixed prosthesis: a clinical report. BArak et al JPD 2004: 91:310 • Arrangement of artificial teeth in the neutral zone after surgical reconstruction of the mandible: A clinical report. Kokubo et al JPD 2002:88:125-7 • Titanium osseointegrated implants combined with hyperbaric oxygen therapy in previously irradiated mandibles. Arcuri et al JPD 1997;77:177-83 www.indiandentalacademy.com
  103. 103. • Functional criteria for mandibular implant placement post resection and reconstruction for cancer Marunik and Roumanas JPD 1999;82:107-13. • The fabrication of cast metal guidance flange prostheses for a patient with segmental mandibulectomy: A clinical report Aslan et al JPD 2005;93:217-20 • Clinical maxillofacial prosthetics: Thomas Taylor: quintessence pub. www.indiandentalacademy.com
  104. 104. Thank you www.indiandentalacademy.com Leader in continuing dental education www.indiandentalacademy.com

×