Prosthetic management of mandibulectomy and glossectomy pati/ orthodontic practice

PROSTHETIC MANAGEMENT OFPROSTHETIC MANAGEMENT OF
MANDIBULECTOMY ANDMANDIBULECTOMY AND
GLOSSECTOMY PATIENTSGLOSSECTOMY PATIENTS
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com
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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

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.

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

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

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

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.

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

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

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.

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.

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.

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.

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

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.

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.

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

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

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

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

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

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

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

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.

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.

 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.

 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.

 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.

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

 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.

 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.

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.

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.

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.

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.

 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.

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.

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.

 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.

Prosthetic designs for dentulousProsthetic designs for dentulous
patientspatients

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

(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.

(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

(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.

(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.

(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.

Defects with Mandibular ContinuityDefects with Mandibular Continuity

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.

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

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.

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.

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.

 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

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.

Prosthetic Rehabilitation of EdentulousProsthetic Rehabilitation of Edentulous
PatientsPatients

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

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.

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.

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

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.

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.

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.

 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.

 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.

 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

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.

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.

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

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