Prosthetic management of mandibulectomy and glossectomy pati/ orthodontic practice

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Prosthetic management of mandibulectomy and glossectomy pati/ orthodontic practice

  1. 1. PROSTHETIC MANAGEMENT OFPROSTHETIC MANAGEMENT OF MANDIBULECTOMY ANDMANDIBULECTOMY AND GLOSSECTOMY PATIENTSGLOSSECTOMY PATIENTS INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.comwww.indiandentalacademy.com
  2. 2. CONTENTSCONTENTS  INTRODUCTIONINTRODUCTION  PHYSIOLOGIC CONSIDERATIONSPHYSIOLOGIC CONSIDERATIONS  PSYCHOSOCIAL FACTORSPSYCHOSOCIAL FACTORS  CLASSIFICATION OF SURGICAL IMPAIRMENTSCLASSIFICATION OF SURGICAL IMPAIRMENTS  GUIDANCE RESTORATIONSGUIDANCE RESTORATIONS  SPEECH CONSIDERATIONSSPEECH CONSIDERATIONS  TONGUE PROSTHESISTONGUE PROSTHESIS  DESIGN CONSIDERATIONS TO VARIOUS RESECTED SITESDESIGN CONSIDERATIONS TO VARIOUS RESECTED SITES  CONLUSIONCONLUSION  REFERENCESREFERENCES www.indiandentalacademy.comwww.indiandentalacademy.com
  3. 3. INTRODUCTIONINTRODUCTION  One of the most consitently frustrating areas of maxillofacialOne of the most consitently frustrating areas of maxillofacial rehabilitation is the treatment of edentulous patients who haverehabilitation is the treatment of edentulous patients who have had radical cancer surgery of the tongue, floor of the mouth,had radical cancer surgery of the tongue, floor of the mouth, and mandible.and mandible.  The prosthetic prognosis is rarely good, and reconstructiveThe prosthetic prognosis is rarely good, and reconstructive procedures, even when indicated, usually donot significantlyprocedures, even when indicated, usually donot significantly improve the prosthetic potentialimprove the prosthetic potential  An understanding of post surgical anatomy and physiology isAn understanding of post surgical anatomy and physiology is an obvious prerequisite to the development of new prosthetican obvious prerequisite to the development of new prosthetic procedures for mandibulectomy patients.procedures for mandibulectomy patients. www.indiandentalacademy.comwww.indiandentalacademy.com
  4. 4. PHYSIOLOGICPHYSIOLOGIC CONSIDERATIONSCONSIDERATIONS General physiologic considerations pertinent to mandibulectomyGeneral physiologic considerations pertinent to mandibulectomy patients in terms of functional adapatability to surgical insultpatients in terms of functional adapatability to surgical insult are:are:  DeglutitionDeglutition  SpeechSpeech  Mandibular movement and masticationMandibular movement and mastication  Saliva controlSaliva control  RespirationRespiration www.indiandentalacademy.comwww.indiandentalacademy.com
  5. 5. DeglutitionDeglutition  Normal deglutition is a primary processNormal deglutition is a primary process  Postoperative swallowing can be temporarily or permanentlyPostoperative swallowing can be temporarily or permanently impaired.impaired.  Tissue loss or reduced muscular and neuromuscular control ofTissue loss or reduced muscular and neuromuscular control of oral and laryngeal structures will restrict the anterior elevationoral and laryngeal structures will restrict the anterior elevation of the floor of the mouth, hyoid bone, and larynx.of the floor of the mouth, hyoid bone, and larynx.  DysfunctionDysfunction occurs whenoccurs when 1. tongue immobility1. tongue immobility 2. denervation of glossopharyngeal, vagus and2. denervation of glossopharyngeal, vagus and superior laryngeal nervessuperior laryngeal nerves 3. scarring3. scarring 4. radiation fibrosis4. radiation fibrosis www.indiandentalacademy.comwww.indiandentalacademy.com
  6. 6. SpeechSpeech  Normal speech is a learned process, and is influenced byNormal speech is a learned process, and is influenced by vision, hearing, intelligence, motivation, and immitation.vision, hearing, intelligence, motivation, and immitation.  Kantner and West,Kantner and West, describe the components of speech asdescribe the components of speech as respiration, phonation, resonance, articulation, and neurologicrespiration, phonation, resonance, articulation, and neurologic integration.integration.  Speech distortion usually occurs in mandibulectomy patients bySpeech distortion usually occurs in mandibulectomy patients by impairment of the articulating mechanism and/or alteration ofimpairment of the articulating mechanism and/or alteration of the resonating chambers.the resonating chambers.  Speech can become hollow, flat and muffled.Speech can become hollow, flat and muffled.www.indiandentalacademy.comwww.indiandentalacademy.com
  7. 7. Mandibular movement and masticationMandibular movement and mastication  Normal mastication is a learned, volitional, and automaticNormal mastication is a learned, volitional, and automatic process giving rise to many individual variations.process giving rise to many individual variations.  The components of occlusion areThe components of occlusion are -Temporomandibular structures,-Temporomandibular structures, -The musculature which activates the masticatory apparatus,-The musculature which activates the masticatory apparatus, andand -The denture bearing tissues.-The denture bearing tissues.  All three components are radically altered by mandibularAll three components are radically altered by mandibular surgery.surgery. www.indiandentalacademy.comwww.indiandentalacademy.com
  8. 8. Mandibular movement and mastication…Mandibular movement and mastication…  In many instances, the patient can approximate theIn many instances, the patient can approximate the presurgical centric occlusal position, but restoration ofpresurgical centric occlusal position, but restoration of original occlusal dimension can interfere withoriginal occlusal dimension can interfere with compensatory speech and swallowing functions andcompensatory speech and swallowing functions and can diminish masticatory strengthcan diminish masticatory strength www.indiandentalacademy.comwww.indiandentalacademy.com
  9. 9. Saliva controlSaliva control  Drooling and other problems associated with changesDrooling and other problems associated with changes in salivary consistency and control compromise one ofin salivary consistency and control compromise one of the most debilitating postsurgical sequelae ofthe most debilitating postsurgical sequelae of mandibulectomy patientsmandibulectomy patients  Factors that impair the patients ability to control hisFactors that impair the patients ability to control his salivary secretions are:salivary secretions are: Restricted tongue movementsRestricted tongue movements Difficulties in swallowingDifficulties in swallowing The absence of labial, buccal, and lingual sulciThe absence of labial, buccal, and lingual sulci Scarring of the orbicularis orisScarring of the orbicularis oris Incision notching of the lower lip as well as loss ofIncision notching of the lower lip as well as loss of sensory awarenesssensory awarenesswww.indiandentalacademy.comwww.indiandentalacademy.com
  10. 10. Saliva control…Saliva control…  Mandibulectomy patients who have undergoneMandibulectomy patients who have undergone radiation therapy suffer from partial xerostomia andradiation therapy suffer from partial xerostomia and thick salivary secretions.thick salivary secretions.  The reduction in the amount of saliva present and itsThe reduction in the amount of saliva present and its characteristic sticky quality will adversly affect denturecharacteristic sticky quality will adversly affect denture retention, tissue tolerance, and taste.retention, tissue tolerance, and taste. www.indiandentalacademy.comwww.indiandentalacademy.com
  11. 11. RespirationRespiration  In order to maintain the airway following aIn order to maintain the airway following a mandibulectomy, muscular alterations are required tomandibulectomy, muscular alterations are required to compensate for postsurgical anatomical distortions.compensate for postsurgical anatomical distortions.  If laryngeal movements are severely restricted or if theIf laryngeal movements are severely restricted or if the larynx and hypopharynx are denervated, the lungs willlarynx and hypopharynx are denervated, the lungs will be unprotected from food and liquid.be unprotected from food and liquid. www.indiandentalacademy.comwww.indiandentalacademy.com
  12. 12. Respiration…Respiration…  In rare instances, the size of the fauces is surgicallyIn rare instances, the size of the fauces is surgically reduced to a point that compromises the oral cavityreduced to a point that compromises the oral cavity and a prosthesis can seriously impair oral patency,and a prosthesis can seriously impair oral patency, especially if there is partial obstruction of the nasalespecially if there is partial obstruction of the nasal cavities or nasopharynx.cavities or nasopharynx.  Patients who have had radiation therapy and surgeryPatients who have had radiation therapy and surgery are especially affected by oral tissue desiccation andare especially affected by oral tissue desiccation and experience great difficulty with oral breathing.experience great difficulty with oral breathing. www.indiandentalacademy.comwww.indiandentalacademy.com
  13. 13. PsychosocialPsychosocial factorsfactors  It is therapeutically unrealistic to discuss functional impairmentIt is therapeutically unrealistic to discuss functional impairment without making reference to thewithout making reference to the psychicpsychic andand socialsocial factorsfactors affecting the mandibulectomy patient.affecting the mandibulectomy patient.  Distortions in self – image, inability to communicate, andDistortions in self – image, inability to communicate, and shifting family and vocational roles require the reconstruction ofshifting family and vocational roles require the reconstruction of psychic systems to adequately handle the new internal andpsychic systems to adequately handle the new internal and external demands.external demands. www.indiandentalacademy.comwww.indiandentalacademy.com
  14. 14. Psychosocial factors…Psychosocial factors…  Severe anxiety, denial, depressive stupor, and diffuseSevere anxiety, denial, depressive stupor, and diffuse hostility are often present in mandibulectomy patientshostility are often present in mandibulectomy patients and overlay the symptoms of mild depression andand overlay the symptoms of mild depression and hysteria in relation to ordinary prosthetic treatment.hysteria in relation to ordinary prosthetic treatment.  Xerostomia, burning mouth, and dimunition of taste normallyXerostomia, burning mouth, and dimunition of taste normally ascribed to radiation therapy can be caused by depressionascribed to radiation therapy can be caused by depression www.indiandentalacademy.comwww.indiandentalacademy.com
  15. 15. Psychosocial factors…Psychosocial factors…  Acute depression is the most common psychologic symptom ofAcute depression is the most common psychologic symptom of the postsurgical cancer patient and is often disregarded duringthe postsurgical cancer patient and is often disregarded during treatment.treatment.  Genuinly successful prosthetic treatment requires the clinicalGenuinly successful prosthetic treatment requires the clinical understanding of these and other relevent psychosocial factors.understanding of these and other relevent psychosocial factors. www.indiandentalacademy.comwww.indiandentalacademy.com
  16. 16. Classification of surgical impairmentClassification of surgical impairment (Cantor and Curtis in 1971)(Cantor and Curtis in 1971)  The classification is based on theThe classification is based on the amount of mandible that has beenamount of mandible that has been resectedresected  The categories are as follows:The categories are as follows: Type 1 – Radical alveolectomy withType 1 – Radical alveolectomy with preservation of mandibularpreservation of mandibular continuitycontinuity Type 2 – Lateral resection of theType 2 – Lateral resection of the mandible distal to the cuspid.mandible distal to the cuspid. www.indiandentalacademy.comwww.indiandentalacademy.com
  17. 17. Classification…Classification… Type 3 – Lateral resection of theType 3 – Lateral resection of the mandible to the midlinemandible to the midline Type 4 – Lateral bone graft surgicalType 4 – Lateral bone graft surgical reconstructionreconstruction Type 5 – Anterior bone graft surgicalType 5 – Anterior bone graft surgical reconstructionreconstruction Type 6 – Resection of the anteriorType 6 – Resection of the anterior portion of the mandibleportion of the mandible without reconstructivewithout reconstructive surgery to unite the lateralsurgery to unite the lateral fragmentsfragments www.indiandentalacademy.comwww.indiandentalacademy.com
  18. 18. Beumer’s Classification (1979)Beumer’s Classification (1979) LateralDefects of the dentulous Patients Defects of edentulous Patients Lateral Discontinuity Defect Defects with Mandibular continuity Anterior defects Posterior defects Discontinuity Defects Anterior Border Defects www.indiandentalacademy.comwww.indiandentalacademy.com
  19. 19. ProstheticProsthetic RehabilitatinRehabilitatin According to Beumer Mandibulectomy patients areAccording to Beumer Mandibulectomy patients are treated by following stages:treated by following stages: 1. Reduction of mandibular deviation1. Reduction of mandibular deviation 2. Speech therapy, speech aids and tongue2. Speech therapy, speech aids and tongue prosthesisprosthesis 3. Actual prosthesis fabrication3. Actual prosthesis fabrication www.indiandentalacademy.comwww.indiandentalacademy.com
  20. 20. Reduction of Mandibular DeviationReduction of Mandibular Deviation Methods that will reduce mandibular deviation are:Methods that will reduce mandibular deviation are: 1.1. Intermaxillary fixationIntermaxillary fixation 2. Mandibular based guidance restorations2. Mandibular based guidance restorations 3. Palatally based guidance restorations3. Palatally based guidance restorations www.indiandentalacademy.comwww.indiandentalacademy.com
  21. 21. Intermaxillary FixationIntermaxillary Fixation  In dentulous patient’s intermaxillary fixation is done byIn dentulous patient’s intermaxillary fixation is done by using arch bars and elastics and maintained for 5 –using arch bars and elastics and maintained for 5 – 7wks.7wks.  In edentulous patient’s gunning splints are givenIn edentulous patient’s gunning splints are given  Guidance therapy is usually not required if the patientGuidance therapy is usually not required if the patient is treated with IMFis treated with IMF www.indiandentalacademy.comwww.indiandentalacademy.com
  22. 22. IMF…IMF…  It appears most useful in patient’s with resectionsIt appears most useful in patient’s with resections confined to the mandibleconfined to the mandible  The patients maintain proprioceptive sense ofThe patients maintain proprioceptive sense of occlusionocclusion  Severe mandibular deviation with extensive resectionsSevere mandibular deviation with extensive resections www.indiandentalacademy.comwww.indiandentalacademy.com
  23. 23. Mandibular based guidance restorationsMandibular based guidance restorations  Exercise program 2wks after surgeryExercise program 2wks after surgery  Following maximum opening, the mandible isFollowing maximum opening, the mandible is manipulated by grasping the chin and moving themanipulated by grasping the chin and moving the mandible away from the surgical side.mandible away from the surgical side.  There should be absence of primary woundThere should be absence of primary wound complicationscomplications  Most appropriate in dentulous patientsMost appropriate in dentulous patients www.indiandentalacademy.comwww.indiandentalacademy.com
  24. 24. Mandibular guidance therapy isMandibular guidance therapy is most successfulmost successful inin patients in whom resection involves only bonypatients in whom resection involves only bony structures with minimal sacrifice of tongue, floor of thestructures with minimal sacrifice of tongue, floor of the mouth and adjucent soft tissues.mouth and adjucent soft tissues. www.indiandentalacademy.comwww.indiandentalacademy.com
  25. 25. Guidance restorations…Guidance restorations…  Robinson and RubrightRobinson and Rubright in 1964in 1964 described adescribed a castcast mandibular guidancemandibular guidance restoration with a metal flange extendingrestoration with a metal flange extending on the nondefect side.on the nondefect side.  This restoration guides the mandible toThis restoration guides the mandible to an appropriate intercuspal positionan appropriate intercuspal position  Guidance ramp ofGuidance ramp of acrylic resinacrylic resin isis suggested if there is resistance insuggested if there is resistance in positioning the mandible.positioning the mandible. www.indiandentalacademy.comwww.indiandentalacademy.com
  26. 26. Guidance restorations…Guidance restorations…  Fabrication begins with formation of suitableFabrication begins with formation of suitable mandibular and maxillary casts.mandibular and maxillary casts.  A wax interocclusal record is obtained.A wax interocclusal record is obtained.  Partial denture framework design is madePartial denture framework design is made  The guidance ramp is usually designed to extend fromThe guidance ramp is usually designed to extend from a continuous clasp along the buccal surfaces of thea continuous clasp along the buccal surfaces of the bicuspids and molars.bicuspids and molars. www.indiandentalacademy.comwww.indiandentalacademy.com
  27. 27. Guidance restorations…Guidance restorations…  Incorporation of a maxillary framework with a buccalIncorporation of a maxillary framework with a buccal plate helps to prevent trauma.plate helps to prevent trauma.  A second wax record is obtained with the posteriorA second wax record is obtained with the posterior teeth separated approximately 3mm for the correctteeth separated approximately 3mm for the correct angulation of the mandibular guidance ramp.angulation of the mandibular guidance ramp.  The partial denture framework is fabricated followingThe partial denture framework is fabricated following customery prosthodontic guidelines.customery prosthodontic guidelines. www.indiandentalacademy.comwww.indiandentalacademy.com
  28. 28. Guidance restorations…Guidance restorations…  If the completed guidance ramp is to beIf the completed guidance ramp is to be formulated in acrylic resin,formulated in acrylic resin, autopolymerising material is added to theautopolymerising material is added to the prosthesis which is seated in the mouth.prosthesis which is seated in the mouth.  As the resin reaches dough stage, theAs the resin reaches dough stage, the mandible is manipulated into the desiredmandible is manipulated into the desired interocclusal relationship.interocclusal relationship.  The resin should be manipulated to extendThe resin should be manipulated to extend 7 to 10 mm superiorly. The prosthesis is7 to 10 mm superiorly. The prosthesis is removed from the mouth and the resin isremoved from the mouth and the resin is allowed to polymerize.allowed to polymerize. www.indiandentalacademy.comwww.indiandentalacademy.com
  29. 29. Palatally Based Guidance RestorationsPalatally Based Guidance Restorations  This is a guidance ramp and an indexThis is a guidance ramp and an index to a maxillary prosthesisto a maxillary prosthesis  Indicated for patients who has severeIndicated for patients who has severe deviation which preventsdeviation which prevents manipulation of mandible into anymanipulation of mandible into any form of acceptable contact.form of acceptable contact.  These maxillary prosthesis areThese maxillary prosthesis are usually constructed of acrylic resinusually constructed of acrylic resin with either cast or wrought wirewith either cast or wrought wire retainers.retainers. www.indiandentalacademy.comwww.indiandentalacademy.com
  30. 30. Guidance restorations…Guidance restorations…  The full palatal coverage prosthesis isThe full palatal coverage prosthesis is constructed following conventionalconstructed following conventional prosthodontic guidelines.prosthodontic guidelines.  A mix of autopolymerizing acrylic resin isA mix of autopolymerizing acrylic resin is prepared and added to the palatalprepared and added to the palatal prosthesis along the lateral and anteriorprosthesis along the lateral and anterior borders on the nondefect side.borders on the nondefect side.  The prosthesis is replaced in the mouth andThe prosthesis is replaced in the mouth and the mandible is manipulated to the desiredthe mandible is manipulated to the desired position, thus establishing an index in theposition, thus establishing an index in the palate.palate. www.indiandentalacademy.comwww.indiandentalacademy.com
  31. 31. Guidance restorations…Guidance restorations…  The patient should be able to close intoThe patient should be able to close into the index with appropriate manualthe index with appropriate manual manipulation of the mandible.manipulation of the mandible.  When the patient returns, the mandibleWhen the patient returns, the mandible will usually exhibit more movementwill usually exhibit more movement laterally toward the non surgical side,laterally toward the non surgical side, requiring adjustment of the palatal ramp.requiring adjustment of the palatal ramp.  If and when an acceptable intercuspalIf and when an acceptable intercuspal position is achieved, a cast mandibularposition is achieved, a cast mandibular guidance prosthesis may be necessary toguidance prosthesis may be necessary to maintain mandibular position.maintain mandibular position. www.indiandentalacademy.comwww.indiandentalacademy.com
  32. 32. Speech aids and Speech therapySpeech aids and Speech therapy  Misarticulation of speech sounds byMisarticulation of speech sounds by mandibular resections.mandibular resections.  Cantor et alCantor et al 1969, noted speech1969, noted speech improvement by lowering palatal vaultimprovement by lowering palatal vault prosthetically into the space of Donders toprosthetically into the space of Donders to accommodate for restricted tongueaccommodate for restricted tongue movements.movements.  The palate was lowered by means of aThe palate was lowered by means of a retainer for the dentulous patients and by aretainer for the dentulous patients and by a palatal acrylic resin extension onto thepalatal acrylic resin extension onto the upper denture for edentulous patients.upper denture for edentulous patients. www.indiandentalacademy.comwww.indiandentalacademy.com
  33. 33. Speech aids and Speech therapy…Speech aids and Speech therapy…  Speech therapy is most effective means of improvingSpeech therapy is most effective means of improving articulation in mandibulectomy patients.articulation in mandibulectomy patients.  Scott 1970, investigated the potential benefit ofScott 1970, investigated the potential benefit of intensive speech therapy for mandibulectomy patientsintensive speech therapy for mandibulectomy patients and concluded that:and concluded that: 11. Placement of a prosthesis, although. Placement of a prosthesis, although improves the quality of specific sounds, doesimproves the quality of specific sounds, does not improve discourse andnot improve discourse and 2. Intensive speech therapy improved speech2. Intensive speech therapy improved speech significantly for patients both with andsignificantly for patients both with and without prosthesis.without prosthesis. www.indiandentalacademy.comwww.indiandentalacademy.com
  34. 34. Tongue ProsthesisTongue Prosthesis  The loss of tongue impairs functions of stomatognathicThe loss of tongue impairs functions of stomatognathic systemsystem  Moore 1972, suggested that tongue prosthesisMoore 1972, suggested that tongue prosthesis provides articulation along with movements of theprovides articulation along with movements of the mandible and cheeks.mandible and cheeks.  Loss of tongue leads to difficulty in controlling salivaLoss of tongue leads to difficulty in controlling saliva and liquids.and liquids.  Pooling of the fluids in the altered floor of the mouthPooling of the fluids in the altered floor of the mouth stimulates cough reflex and/or leading to aspiration.stimulates cough reflex and/or leading to aspiration. www.indiandentalacademy.comwww.indiandentalacademy.com
  35. 35. Tongue Prosthesis…Tongue Prosthesis…  Impression is made with maxillaryImpression is made with maxillary stock tray which is built up andstock tray which is built up and extended with wax to include aextended with wax to include a major portion of the floor of themajor portion of the floor of the mouth.mouth.  Tongue prosthesis can be addedTongue prosthesis can be added to the removable partial denture.to the removable partial denture.  The retentive meshwork of theThe retentive meshwork of the framework is extended into theframework is extended into the defect to provide support for thedefect to provide support for the resin tongue prosthesis.resin tongue prosthesis. www.indiandentalacademy.comwww.indiandentalacademy.com
  36. 36. Tongue Prosthesis…Tongue Prosthesis…  The tentative contours of the prosthesis are developedThe tentative contours of the prosthesis are developed in wax and are evaluated intraorally prior toin wax and are evaluated intraorally prior to processing.processing.  The denture base is reevaluated with pressureThe denture base is reevaluated with pressure indicating paste to eliminate interferneces.indicating paste to eliminate interferneces.  In some patients speech can be improved by addingIn some patients speech can be improved by adding flexible tongue of silicone rubber to the mandibularflexible tongue of silicone rubber to the mandibular prosthesis.prosthesis. www.indiandentalacademy.comwww.indiandentalacademy.com
  37. 37. Silicone tongue prosthesisSilicone tongue prosthesis  This prosthesis is held in place by snap – ringThis prosthesis is held in place by snap – ring and undercut design in the mandibular dentureand undercut design in the mandibular denture base at the level of the occlusal table.base at the level of the occlusal table.  The tip of the tongue is flexible and elevated 2-The tip of the tongue is flexible and elevated 2- 3mm above the denture base.3mm above the denture base. www.indiandentalacademy.comwww.indiandentalacademy.com
  38. 38. Silicone tongue prosthesis…Silicone tongue prosthesis…  During closure into centric occlusion, theDuring closure into centric occlusion, the silicone rubber tip of the tongue prosthesissilicone rubber tip of the tongue prosthesis depresses, allowing for bilateral contact of thedepresses, allowing for bilateral contact of the posterior teeth.posterior teeth.  The surface of the tongue prosthesis is properlyThe surface of the tongue prosthesis is properly contoured.contoured. www.indiandentalacademy.comwww.indiandentalacademy.com
  39. 39. Tongue Prosthesis…Tongue Prosthesis…  Tongue prosthesis is suspended from the maxillaryTongue prosthesis is suspended from the maxillary complete denture.complete denture.  Impression wax is added to the maxillary denture.Impression wax is added to the maxillary denture.  During swallowing there should be maximum contactDuring swallowing there should be maximum contact with the floor of the mouth.with the floor of the mouth.  This prosthesis will assist in swallowing.This prosthesis will assist in swallowing. www.indiandentalacademy.comwww.indiandentalacademy.com
  40. 40. Prosthetic designs for dentulousProsthetic designs for dentulous patientspatients www.indiandentalacademy.comwww.indiandentalacademy.com
  41. 41. Lateral Discontinuity defects:Lateral Discontinuity defects: (Type 2&3)(Type 2&3)  Often resected in the region of second premolar andOften resected in the region of second premolar and first molar. If there are no other missing teeth in thefirst molar. If there are no other missing teeth in the arch, a prosthesis is usually not indicated.arch, a prosthesis is usually not indicated.  Framework design should be similar to a KennedyFramework design should be similar to a Kennedy class 2 design, with extension into the vestibularclass 2 design, with extension into the vestibular areas of the resection.areas of the resection.  The forces of occlusion are unilateral andThe forces of occlusion are unilateral and consequently the axis of rotation (fulcrum line) of theconsequently the axis of rotation (fulcrum line) of the partial denture deviates from the normpartial denture deviates from the norm www.indiandentalacademy.comwww.indiandentalacademy.com
  42. 42. Lateral Discontinuity defects:Lateral Discontinuity defects: (Type 2&3)…(Type 2&3)…  The choice of major connector dependsThe choice of major connector depends on the height of floor of the mouth.on the height of floor of the mouth.  Location of the minor connectors shouldLocation of the minor connectors should be physiologically determined tobe physiologically determined to minimize the stress on the abutmentminimize the stress on the abutment teeth.teeth.  Occlusal rests should be placed nearOcclusal rests should be placed near the defect.the defect.  Retention can be achieved through theRetention can be achieved through the use of various types of clasp assembliesuse of various types of clasp assemblies on the distal abutments.on the distal abutments. www.indiandentalacademy.comwww.indiandentalacademy.com
  43. 43. Lateral Discontinuity defects:Lateral Discontinuity defects: (Type 2&3)…(Type 2&3)…  Indirect retention can be derived from restsIndirect retention can be derived from rests prepared in the mesial fossae of the firstprepared in the mesial fossae of the first premolars and/or lingual surfaces of thepremolars and/or lingual surfaces of the canines.canines.  If posterior and anterior teeth are missing onIf posterior and anterior teeth are missing on the defect side, the remaining teeth on thethe defect side, the remaining teeth on the intact side of the arch are often present in aintact side of the arch are often present in a straight line configuration.straight line configuration.  Embrasure clasps may be used on theEmbrasure clasps may be used on the posterior teeth, with an infra-bulge retainerposterior teeth, with an infra-bulge retainer on the anterior abutment.on the anterior abutment.  Lingual retention and buccal reciprocationLingual retention and buccal reciprocation on the remaining posterior teeth should beon the remaining posterior teeth should be considered.considered. www.indiandentalacademy.comwww.indiandentalacademy.com
  44. 44. Lateral Discontinuity defects:Lateral Discontinuity defects: (Type 2&3)…(Type 2&3)…  If anterior and posterior teeth are missingIf anterior and posterior teeth are missing on the resected side and posterior teeth onon the resected side and posterior teeth on the unresected side, the prosthesis willthe unresected side, the prosthesis will have three denture base regions.have three denture base regions.  Rests should be placed on as many teethRests should be placed on as many teeth as possible, minor connectors should beas possible, minor connectors should be placed to enhance stability and wroughtplaced to enhance stability and wrought wire retainers are an acceptable alternativewire retainers are an acceptable alternative to the bar clasps.to the bar clasps.  Altered cast impressions can be used to getAltered cast impressions can be used to get the maximum soft tissue coverage.the maximum soft tissue coverage. www.indiandentalacademy.comwww.indiandentalacademy.com
  45. 45. Lateral Discontinuity defects:Lateral Discontinuity defects: (Type 2&3)…(Type 2&3)…  Maxillomandibular records are made with soft wax and aMaxillomandibular records are made with soft wax and a minimum of occlusal pressure.minimum of occlusal pressure.  Acrylic resin teeth are suggested with cusps approximatingAcrylic resin teeth are suggested with cusps approximating the angulation displayed by the opposing dentition.the angulation displayed by the opposing dentition.  When less than ideal occlusal relationships must be accepted,When less than ideal occlusal relationships must be accepted, it may be necessary to establish an occlusal ramp lingual toit may be necessary to establish an occlusal ramp lingual to the maxillary teeth on the unresected site.the maxillary teeth on the unresected site.  The partial denture prosthesis are delivered and adjusted inThe partial denture prosthesis are delivered and adjusted in the usual way.the usual way. www.indiandentalacademy.comwww.indiandentalacademy.com
  46. 46. Lateral Discontinuity defects:Lateral Discontinuity defects: (Type 2&3)…(Type 2&3)…  A type 3 resection produces a defect to the midline orA type 3 resection produces a defect to the midline or farther toward the intact side, leaving half or less offarther toward the intact side, leaving half or less of the mandible remaining.the mandible remaining.  The design of a framework for this situation would beThe design of a framework for this situation would be similar to the type 2 resection.similar to the type 2 resection.  In this resection there is a greater chance ofIn this resection there is a greater chance of prosthesis dislodgement caused by lack of supportprosthesis dislodgement caused by lack of support under anterior extension.under anterior extension. www.indiandentalacademy.comwww.indiandentalacademy.com
  47. 47. Defects with Mandibular ContinuityDefects with Mandibular Continuity www.indiandentalacademy.comwww.indiandentalacademy.com
  48. 48. Defects with mandibular continuityDefects with mandibular continuity Anterior defects (Type 5)Anterior defects (Type 5)  Patients with anterior inner tablePatients with anterior inner table resections and patients with anteriorresections and patients with anterior composite resections in whomcomposite resections in whom mandibular continuity has beenmandibular continuity has been reestablished by reconstructive surgery.reestablished by reconstructive surgery.  These patients display unusual softThese patients display unusual soft tissue configurations and compromisedtissue configurations and compromised bony support.bony support.  Prosthesis for these patients enhanceProsthesis for these patients enhance esthetics, speech and control of saliva.esthetics, speech and control of saliva. www.indiandentalacademy.comwww.indiandentalacademy.com
  49. 49. Defects with mandibular continuityDefects with mandibular continuity Anterior defects (Type 5)…Anterior defects (Type 5)…  The long mesial rests on the second molars provideThe long mesial rests on the second molars provide indirect retention.indirect retention.  Particular care should be taken to relieve the proximalParticular care should be taken to relieve the proximal plates and the distal aspect of the minor connectors.plates and the distal aspect of the minor connectors.  The edentulous areas are recorded with an alteredThe edentulous areas are recorded with an altered cast impression.cast impression.  Thermoplastic waxes are used to record movableThermoplastic waxes are used to record movable tissue beds.tissue beds. www.indiandentalacademy.comwww.indiandentalacademy.com
  50. 50. Defects with mandibular continuityDefects with mandibular continuity Anterior defects (Type 5)…Anterior defects (Type 5)…  At try-in esthetics, occlusion and speech should beAt try-in esthetics, occlusion and speech should be verified.verified.  Prosthesis is delivered with periodic monitoring.Prosthesis is delivered with periodic monitoring. www.indiandentalacademy.comwww.indiandentalacademy.com
  51. 51. Defects with mandibular continuityDefects with mandibular continuity Lateral defects (Type 1,4)Lateral defects (Type 1,4)  Inferior border of the mandible is intact,Inferior border of the mandible is intact, and normal movements can beand normal movements can be expected.expected.  The denture bearing area may beThe denture bearing area may be compromised because of closure of thecompromised because of closure of the defect using adjacent lining mucosa ordefect using adjacent lining mucosa or presence of split thickness skin graft.presence of split thickness skin graft.  If the defect is unilateral and posterior,If the defect is unilateral and posterior, the framework would be typical of athe framework would be typical of a Kennedy class 2 designKennedy class 2 design  When the marginal resection is in theWhen the marginal resection is in the anterior area, the design may be moreanterior area, the design may be more typical of a Kennedy class 4 design.typical of a Kennedy class 4 design. www.indiandentalacademy.comwww.indiandentalacademy.com
  52. 52. Defects with mandibular continuityDefects with mandibular continuity Lateral defects (Type 1,4)…Lateral defects (Type 1,4)…  Anterior marginal resections some times include partAnterior marginal resections some times include part of the anterior tongue and floor of the mouth.of the anterior tongue and floor of the mouth.  The remaining teeth often collapse lingually andThe remaining teeth often collapse lingually and necessitate labial bar as major connector.necessitate labial bar as major connector.  Capture of unique buccal, lingual and labial functionalCapture of unique buccal, lingual and labial functional contours in the final prosthesis can contributecontours in the final prosthesis can contribute significantly to stabilization of the prosthesis.significantly to stabilization of the prosthesis. www.indiandentalacademy.comwww.indiandentalacademy.com
  53. 53. Defects with mandibular continuityDefects with mandibular continuity Lateral defects (Type 1,4)…Lateral defects (Type 1,4)…  The extremely long lever arms and compromisedThe extremely long lever arms and compromised edentulous bearing surfaces contribute to excessiveedentulous bearing surfaces contribute to excessive movement of prosthesis during function.movement of prosthesis during function.  The ‘ribbon rest’ closely parallels the axis of rotation.The ‘ribbon rest’ closely parallels the axis of rotation. The anterior and posterior proximal plates move freelyThe anterior and posterior proximal plates move freely during function.during function.  The buccal retainer on the molar and the labialThe buccal retainer on the molar and the labial retainer on the cuspid are placed at the height ofretainer on the cuspid are placed at the height of contour.contour. www.indiandentalacademy.comwww.indiandentalacademy.com
  54. 54. Defects with mandibular continuityDefects with mandibular continuity Lateral defects (Type 1,4)…Lateral defects (Type 1,4)… The occlusion should be refined to achieve contact inThe occlusion should be refined to achieve contact in centric occlusion only and patient should be instructedcentric occlusion only and patient should be instructed to masticate on the side of the residual mandibularto masticate on the side of the residual mandibular dentition.dentition. www.indiandentalacademy.comwww.indiandentalacademy.com
  55. 55. Prosthetic Rehabilitation of EdentulousProsthetic Rehabilitation of Edentulous PatientsPatients www.indiandentalacademy.comwww.indiandentalacademy.com
  56. 56. Management of discontinuity defectsManagement of discontinuity defects  Complete dentures in these patients areComplete dentures in these patients are primarily for estheticsprimarily for esthetics  They improve lip and cheek contour andThey improve lip and cheek contour and replace missing teethreplace missing teeth www.indiandentalacademy.comwww.indiandentalacademy.com
  57. 57. Factors determining the prosthetic prognosis forFactors determining the prosthetic prognosis for complete dentures:complete dentures: 1.The prognosis is more favourable if the resection is limited to1.The prognosis is more favourable if the resection is limited to the cuspid region anteriorly.the cuspid region anteriorly. 2. If the motor and/or sensory control of the tongue has been2. If the motor and/or sensory control of the tongue has been significantly compromised by the resection, the prostheticsignificantly compromised by the resection, the prosthetic prognosis becomes extremely gaurded.prognosis becomes extremely gaurded. www.indiandentalacademy.comwww.indiandentalacademy.com
  58. 58. Factors determining the prosthetic prognosisFactors determining the prosthetic prognosis for complete dentures:for complete dentures: 3. Severe deviation of the mandible causes instability of3. Severe deviation of the mandible causes instability of the dentures.the dentures. 4. Post surgical lip posture and control, does have4. Post surgical lip posture and control, does have important prosthodontic implications.important prosthodontic implications. 5. Due to radiation therapy, there will be reduction in5. Due to radiation therapy, there will be reduction in salivary flow which leads to increased risk of mucosalsalivary flow which leads to increased risk of mucosal irritation and compromised peripheral seal.irritation and compromised peripheral seal. www.indiandentalacademy.comwww.indiandentalacademy.com
  59. 59. ImpressionsImpressions  Primary impressions made with irriversible hydrocolloid injectedPrimary impressions made with irriversible hydrocolloid injected with disposable syringe into areas of difficult access prior towith disposable syringe into areas of difficult access prior to seating the stock tray with impression material into position.seating the stock tray with impression material into position.  Master impression is made with conventional border mouldingMaster impression is made with conventional border moulding with modeling plastic to establish peripheral extensions whichwith modeling plastic to establish peripheral extensions which are refined with an elastic impression material.are refined with an elastic impression material.  Some clinicians advocate making a functional impression of theSome clinicians advocate making a functional impression of the polished surfaces of the mandibular prosthesispolished surfaces of the mandibular prosthesis www.indiandentalacademy.comwww.indiandentalacademy.com
  60. 60. Centric RegistrationCentric Registration  In the maxilla, the wax rim used to record the centric occlusionIn the maxilla, the wax rim used to record the centric occlusion registration record is widened on the unresected side in order toregistration record is widened on the unresected side in order to account for deviation of the mandible.account for deviation of the mandible.  Evaluation of phonetics and the closest speaking space areEvaluation of phonetics and the closest speaking space are best suited for the determination of vertical dimension of restbest suited for the determination of vertical dimension of rest and vertical dimension of occlusion.and vertical dimension of occlusion.  Centric occlusion registrations should be obtained with wax orCentric occlusion registrations should be obtained with wax or plaster.plaster.  The clinician should manipulate the mandible and place it in theThe clinician should manipulate the mandible and place it in the most advantageous position within the reach of the patient.most advantageous position within the reach of the patient. www.indiandentalacademy.comwww.indiandentalacademy.com
  61. 61. Occlusal Schemes and Lateral RegistrationsOcclusal Schemes and Lateral Registrations  SwoopSwoop 1969, suggested “non anatomic teeth” for patients with1969, suggested “non anatomic teeth” for patients with abnormal jaw relationships and angular path of closure.abnormal jaw relationships and angular path of closure.  ““Neutral Zone” identification facilitates positioning of theNeutral Zone” identification facilitates positioning of the mandibular teeth.mandibular teeth.  The wax rim is fabricated according to the neutral zone.The wax rim is fabricated according to the neutral zone.  Special attention should be paid to developing appropriateSpecial attention should be paid to developing appropriate contours of the rim in contact with the inside of the upper andcontours of the rim in contact with the inside of the upper and lower lip.lower lip. www.indiandentalacademy.comwww.indiandentalacademy.com
  62. 62. Occlusal Schemes and Lateral Registrations…Occlusal Schemes and Lateral Registrations…  After the wax rims have been altered and registrationsAfter the wax rims have been altered and registrations obtained, the maxillary and mandibular casts are mounted on aobtained, the maxillary and mandibular casts are mounted on a suitable articulator.suitable articulator.  It is advisable to place the maxillary anterior teeth lingual to,It is advisable to place the maxillary anterior teeth lingual to, and mandibular anterior teeth labial to, their accostemedand mandibular anterior teeth labial to, their accostemed position.position.  Lip tooth relationship can be improved if the vertical overlap isLip tooth relationship can be improved if the vertical overlap is increased so that the amount of tooth displayed and the smileincreased so that the amount of tooth displayed and the smile line are consistent with a more labial or normal position of theline are consistent with a more labial or normal position of the maxillary teeth.maxillary teeth. www.indiandentalacademy.comwww.indiandentalacademy.com
  63. 63. Occlusal Schemes and Lateral Registrations…Occlusal Schemes and Lateral Registrations…  Generally, in the mandible the posterior teeth on the unresectedGenerally, in the mandible the posterior teeth on the unresected side will be buccal to the crest of edentulous alveolus,side will be buccal to the crest of edentulous alveolus, especially in the bicuspid region.especially in the bicuspid region.  The posterior mandibular teeth on the surgical side usually areThe posterior mandibular teeth on the surgical side usually are placed lingual to the crest of the edentulous ridge.placed lingual to the crest of the edentulous ridge. www.indiandentalacademy.comwww.indiandentalacademy.com
  64. 64. Occlusal Schemes and Lateral Registrations…Occlusal Schemes and Lateral Registrations…  Contour and support for the corner of the mouth andContour and support for the corner of the mouth and the lip on the resected side are best accomplished bythe lip on the resected side are best accomplished by thickening the denture flange below the crest of thethickening the denture flange below the crest of the ridge.ridge.  After arranging all teeth in the maxillary prosthesis,After arranging all teeth in the maxillary prosthesis, ramps of 10mm wide and 3-4mm horizontal overlapramps of 10mm wide and 3-4mm horizontal overlap with the lower teeth should be provided.with the lower teeth should be provided. www.indiandentalacademy.comwww.indiandentalacademy.com
  65. 65. Occlusal Schemes and Lateral Registrations…Occlusal Schemes and Lateral Registrations…  After tooth arrangements have been finalized, the occlusalAfter tooth arrangements have been finalized, the occlusal contact of the mandibular teeth is checked with the maxillarycontact of the mandibular teeth is checked with the maxillary ramp.ramp.  The patient should be able to establish contact with rampsThe patient should be able to establish contact with ramps without guidance.without guidance.  After trial prosthesis have been perfected, they are processedAfter trial prosthesis have been perfected, they are processed following customery procedures.following customery procedures.  The use of the prosthesis for mastication should be defered forThe use of the prosthesis for mastication should be defered for atleast a weak. As the patient uses the prosthesis, someatleast a weak. As the patient uses the prosthesis, some adjustment of the ramps is usually necessary.adjustment of the ramps is usually necessary.www.indiandentalacademy.comwww.indiandentalacademy.com
  66. 66. Anterior Border DefectsAnterior Border Defects  The prognosis is usually favorableThe prognosis is usually favorable especially if a vestibuloplasty has beenespecially if a vestibuloplasty has been completed.completed.  The mandibular movements andThe mandibular movements and maxillomandibular relationships aremaxillomandibular relationships are usually within the normal limits for theseusually within the normal limits for these patients.patients.  Careful placement of the mandibularCareful placement of the mandibular anterior teeth and flange contour in thisanterior teeth and flange contour in this area is suggested.area is suggested. www.indiandentalacademy.comwww.indiandentalacademy.com
  67. 67. ConclusionConclusion  Design of removable partial dentures for patients who have hadDesign of removable partial dentures for patients who have had mandibular surgical resections varies from partial denturemandibular surgical resections varies from partial denture design for patients with intact mandibles.design for patients with intact mandibles.  The presence or absence of natural teeth in a resectedThe presence or absence of natural teeth in a resected mandible often determines the approach to prosthodonticmandible often determines the approach to prosthodontic rehabilitation.rehabilitation. www.indiandentalacademy.comwww.indiandentalacademy.com
  68. 68. ReferencesReferences 1.1. Maxillofacial rehabilitation – John BeumerMaxillofacial rehabilitation – John Beumer 2.2. McCracken’s Removable Partial Prosthodontics – 11McCracken’s Removable Partial Prosthodontics – 11thth EditionEdition 3.3. Prosthodontic management of edentulous mandibulectomyProsthodontic management of edentulous mandibulectomy patients (Part1&2)patients (Part1&2) JPD april 1971, Vol 25, No 4, Pgs 446 -457 and 546 -555JPD april 1971, Vol 25, No 4, Pgs 446 -457 and 546 -555 4.4. Removable partial denture design for the mandibularRemovable partial denture design for the mandibular resection patientresection patient JPD october 1982, Vol 48, No 4, Pgs 437 -443JPD october 1982, Vol 48, No 4, Pgs 437 -443 5.5. Prosthodontic management of postsurgical soft tissueProsthodontic management of postsurgical soft tissue deformities associated with marginal mandibulectomydeformities associated with marginal mandibulectomy JPD august 1982, Vol 48, No 2, Pgs 178 - 183JPD august 1982, Vol 48, No 2, Pgs 178 - 183 www.indiandentalacademy.comwww.indiandentalacademy.com
  69. 69. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.comwww.indiandentalacademy.com

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