Prosthodontic rehabilitation of the mandibulectomy patient

PROSTHODONTICPROSTHODONTIC
REHABILITATION OF THEREHABILITATION OF THE
MANDIBULECTOMY PATIENTMANDIBULECTOMY PATIENT
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com
www.indiandentalacademy.comwww.indiandentalacademy.com

CONTENTSCONTENTS
 INTRODUCTIONINTRODUCTION
 CLASSIFICATION OF MANDIBULARCLASSIFICATION OF MANDIBULAR
DEFECT.DEFECT.
 DIAGNOSTIC CONSIDERATIONSDIAGNOSTIC CONSIDERATIONS
 SURGICAL CONSIDERATIONSURGICAL CONSIDERATION
 PROSTHETIC REHABILITATIONPROSTHETIC REHABILITATION
 CONCLUSIONCONCLUSION
 BIBLIOGRAPHYBIBLIOGRAPHY

INTRODUCTIONINTRODUCTION
 Muscles of mastication are bilaterally attachedMuscles of mastication are bilaterally attached
to the mandible to generate a variety ofto the mandible to generate a variety of
complex mandibular movements useful incomplex mandibular movements useful in
speech, swallowing, mastication, andspeech, swallowing, mastication, and
respiration. The mandible and the muscles ofrespiration. The mandible and the muscles of
mastication also give form to the lower third ofmastication also give form to the lower third of
the face. Disruption of the mandible has thethe face. Disruption of the mandible has the
potential to disrupt any of these functions.potential to disrupt any of these functions.

CLASSIFICATION OF THECLASSIFICATION OF THE
MANIBULAR DEFECTMANIBULAR DEFECT
 Congenital Defects ofCongenital Defects of
the Mandiblethe Mandible
 Acquired Defects of theAcquired Defects of the
MandibleMandible
-Continuity defect-Continuity defect
--Discontinuity defectDiscontinuity defect

Cantor and Curtis classificationCantor and Curtis classification
 CLASS ICLASS I
 CLASS IICLASS II
-- Modification aModification a
-- Modification bModification b
-- Modification cModification c
 CLASS IIICLASS III
 CLASS IVCLASS IV
 CLASS VCLASS V

CLASS ICLASS I
Marginal resection
Continuity defect

CLASS IICLASS II
Segmental free end
resection (discon-tinuity
defect) that does not
cross the midline.

 Modification a:Modification a:
Bilateral resectionBilateral resection
posterior to the secondposterior to the second
premolarpremolar

 Modification b:Modification b:
Unilateral resectionUnilateral resection
posterior to the lateralposterior to the lateral
incisorincisor

 Modification c:Modification c:
Bilateral resectionBilateral resection
posterior to the lateralposterior to the lateral
incisor on one side andincisor on one side and
the second premolar onthe second premolar on
the otherthe other

CLASS IIICLASS III
 Segmental free endSegmental free end
resection upto or crossesresection upto or crosses
the midlinethe midline

CLASS IVCLASS IV
 Includes class III defectIncludes class III defect
with resection of thewith resection of the
temperomandibulartemperomandibular
jointjoint

CLASS VCLASS V
 Anterior boundedAnterior bounded
resectionresection

Predisposing factorsPredisposing factors
 Ill fitting denturesIll fitting dentures
 Palatal papillary hyperplasia.Palatal papillary hyperplasia.
 AlcoholAlcohol
 TobaccoTobacco
 LeukoplakiaLeukoplakia
 Oral lichen planusOral lichen planus
 Carcinoma of tongueCarcinoma of tongue

DIAGNOSTIC CONSIDERATIONSDIAGNOSTIC CONSIDERATIONS
 Location and Extent of the Mandibular DefectLocation and Extent of the Mandibular Defect
 Presence of Remaining Natural Teeth or Pre-Presence of Remaining Natural Teeth or Pre-
existing Implantsexisting Implants
 Degree of Postmandibulectomy Rotation andDegree of Postmandibulectomy Rotation and
DeviationDeviation
 Available Mouth OpeningAvailable Mouth Opening
 Functional Limitation of the TongueFunctional Limitation of the Tongue

 Compromise of Vestibular ExtensionsCompromise of Vestibular Extensions
 Skin GraftingSkin Grafting
 Radiation TherapyRadiation Therapy
 Altered Anatomic Relationships FollowingAltered Anatomic Relationships Following
Restoration of Mandibular ContinuityRestoration of Mandibular Continuity

Location and Extent of theLocation and Extent of the
Mandibular DefectMandibular Defect
 Continuity orContinuity or
discontinuity defect.discontinuity defect.
 Size and location of theSize and location of the
defect.defect.

Presence of Remaining NaturalPresence of Remaining Natural
Teeth or Pre-existing ImplantsTeeth or Pre-existing Implants
 Teeth with poor diagnosis should be extractedTeeth with poor diagnosis should be extracted
if radiation therapy is planned, to reduce theif radiation therapy is planned, to reduce the
risk of future complication, particularlyrisk of future complication, particularly
osteoradionecrosis.osteoradionecrosis.
 Larger number of teeth , better design ofLarger number of teeth , better design of
prostheses.prostheses.

 When even one or twoWhen even one or two
teeth remain in theteeth remain in the
mandible, the patient ismandible, the patient is
much more likely tomuch more likely to
tolerate a removable,tolerate a removable,
tissue-supportedtissue-supported
prosthesis. The teeth areprosthesis. The teeth are
crucial to the stability ofcrucial to the stability of
the prosthesis.the prosthesis.

 Teeth present on both sidesTeeth present on both sides
of the midline permitof the midline permit
greater prosthesis supportgreater prosthesis support
because the problem ofbecause the problem of
straight-line design can bestraight-line design can be
avoided.avoided.
 Mandibular incisors withMandibular incisors with
adequate root support mayadequate root support may
serve as abutments,serve as abutments,
particularly where theparticularly where the
canine on the side of thecanine on the side of the
defect has been lost. Thisdefect has been lost. This
also helps to give tripodalso helps to give tripod
design and incorporatedesign and incorporate
indirect retainers.indirect retainers.www.indiandentalacademy.comwww.indiandentalacademy.com

 A complete maxil-laryA complete maxil-lary
denture will usuallydenture will usually
function quite well against afunction quite well against a
reconstructed mandibularreconstructed mandibular
dentition; exceptionsdentition; exceptions
include difficulty ininclude difficulty in
fabrication of a maxillaryfabrication of a maxillary
complete denture where thecomplete denture where the
residual proxi-malresidual proxi-mal
mandibular stump,mandibular stump,
including the coronoidincluding the coronoid
process.process.

Degree of PostmandibulectomyDegree of Postmandibulectomy
Rotation and DeviationRotation and Deviation
 Mandibular deviation towardsMandibular deviation towards
defect side occurs due to loss ofdefect side occurs due to loss of
tissue involved in the surgicaltissue involved in the surgical
resection. When mandible isresection. When mandible is
drawn towards the defect fordrawn towards the defect for
primary closure causes deviation.primary closure causes deviation.
 Vertical rotation of residualVertical rotation of residual
mandible in inferior directionmandible in inferior direction
occurs due to.occurs due to.
1.1. The pull of the suprahyoidThe pull of the suprahyoid
musculaturemusculature
2.2. Gravity.Gravity.

Results of deviationResults of deviation
 rotation of the mandiblerotation of the mandible
 facial disfigurement,facial disfigurement,
 loss of occlusal contact,loss of occlusal contact,
 lips incompetence.lips incompetence.
 Difficult in saliva controlDifficult in saliva control
 swallowing process.swallowing process.

 Treatment includes;Treatment includes;
1.1. Restoration of continuity through osseousRestoration of continuity through osseous
graftinggrafting
2.2. Early post resection physical therapy.Early post resection physical therapy.
3.3. Use of mandibular resection guidanceUse of mandibular resection guidance
prostheses.prostheses.
4.4. Maxillary guidance ramp.Maxillary guidance ramp.

Available Mouth OpeningAvailable Mouth Opening
 Trismus due to fibrosis.Trismus due to fibrosis.
 Test by inserting a tray .Test by inserting a tray .
 Stretching exercises, moist heat, analgesics.Stretching exercises, moist heat, analgesics.
 Tracheostomy may be necessary in severeTracheostomy may be necessary in severe
cases.cases.

Functional Limitation of the TongueFunctional Limitation of the Tongue
 Impaired due to resection orImpaired due to resection or
tethering.tethering.
 Impair of functionImpair of function
 Tethering is addressed by surgicalTethering is addressed by surgical
release.release.
 Resection is treated by palatal dropResection is treated by palatal drop
or augmentation prosthesis.or augmentation prosthesis.
 Test the mobility .Test the mobility .
 Speech therapy.Speech therapy.
 Loss of sensory and motorLoss of sensory and motor
innervation.innervation.

Compromise of VestibularCompromise of Vestibular
ExtensionsExtensions
 Normal prostheses extension is required forNormal prostheses extension is required for
peripheral seal.peripheral seal.
 Referred for surgical revision/implant.Referred for surgical revision/implant.
 Implant on normal ridge contour VsImplant on normal ridge contour Vs
compromised vestibular extension.compromised vestibular extension.
 peri-implant soft tissue inflammation.peri-implant soft tissue inflammation.
 Provisional protective coverage.Provisional protective coverage.

Skin GraftingSkin Grafting
 Skin graft vs fullSkin graft vs full
thickness graft.thickness graft.
 Problem placing implantProblem placing implant
on these skin graft, is iton these skin graft, is it
does not tolerate thedoes not tolerate the
titanium surface in oraltitanium surface in oral
environment.environment.
MITCHELL advisedMITCHELL advised
custom-fabricated goldcustom-fabricated gold
alloy.alloy.

Radiation TherapyRadiation Therapy
 Tissues that have been radiated are fragile,Tissues that have been radiated are fragile,
sensitive to manipulation, desiccated, slow tosensitive to manipulation, desiccated, slow to
heal, prone to infection, and at risk for osteo-heal, prone to infection, and at risk for osteo-
radionecrosis, particularly in the mandible.radionecrosis, particularly in the mandible.

Altered Anatomic Relationships FollowingAltered Anatomic Relationships Following
Restoration of Mandibular ContinuityRestoration of Mandibular Continuity
 Grafting the anteriorGrafting the anterior
mandible frequentlymandible frequently
results in a graft that isresults in a graft that is
deficient anteriorly.deficient anteriorly.

 The clinical result is oneThe clinical result is one
in which the maxillo-in which the maxillo-
mandibular relationshipmandibular relationship
is severely Class II andis severely Class II and
with reduced likelihoodwith reduced likelihood
of completelyof completely
satisfactorysatisfactory
prosthodonticprosthodontic
rehabilitation.rehabilitation.

 Reconstruction of posterior defectsReconstruction of posterior defects
The mediolateral position of theThe mediolateral position of the
graft is frequently seen to be lateralgraft is frequently seen to be lateral
to the original position of theto the original position of the
mandibular body. It results in amandibular body. It results in a
prosthesis that must be built inprosthesis that must be built in
crossbite to maintain the denturecrossbite to maintain the denture
teeth over the supporting base ofteeth over the supporting base of
the bone graft. When implants arethe bone graft. When implants are
utilized, the implants requireutilized, the implants require
extremely angled placement, andextremely angled placement, and
the prosthesis they support maythe prosthesis they support may
have to be cantilevered further tohave to be cantilevered further to
the lingual to permit tooth contactthe lingual to permit tooth contact

Interarch discrepencyInterarch discrepency
 In lack of interarchIn lack of interarch
spacespace
1.1. increasing the verticalincreasing the vertical
dimension of occlusiondimension of occlusion
within physiologicwithin physiologic
limitslimits
2.2. surgical revision ofsurgical revision of
hard and soft tissueshard and soft tissues

 In increased interarchIn increased interarch
spacespace
- prosthesis is likely to- prosthesis is likely to
generate torsional forcesgenerate torsional forces
on the natural teethon the natural teeth
- maximum use of all- maximum use of all
remaining teeth as wellremaining teeth as well
as maximum soft tissueas maximum soft tissue
supportsupport

Surgical ConsiderationsSurgical Considerations
 Intermaxillary fixationIntermaxillary fixation
 Resection guidance restorationsResection guidance restorations
 Palatal Speech AidsPalatal Speech Aids
 Maxillary guidance ramp.Maxillary guidance ramp.

 Skin graft.Skin graft.
 Local or pedicle graftLocal or pedicle graft
 MVFFMVFF
 The two primary sources of microvascularizedThe two primary sources of microvascularized
bone for mandibular reconstruction are thebone for mandibular reconstruction are the
fibula and iliac crest.fibula and iliac crest.
 MVFFs from the forearm or the rectusMVFFs from the forearm or the rectus
muscle.muscle.

Intermaxillary fixationIntermaxillary fixation
 This reduces theThis reduces the
deviation associateddeviation associated
with resection of thewith resection of the
mandible if donemandible if done
immediately using archimmediately using arch
bars and elastics. This isbars and elastics. This is
maintained for 5 – 7maintained for 5 – 7
weeks followingweeks following
surgery.surgery.

Palatal Speech AidsPalatal Speech Aids
 Cantor et al (1996) stated that consonant sounds “Cantor et al (1996) stated that consonant sounds “kk””
andand “q”“q” required valving by the posterior part ofrequired valving by the posterior part of
tongue with the posterior part of hard palate andtongue with the posterior part of hard palate and
anterior portion of soft palate and these sounds wereanterior portion of soft palate and these sounds were
particularly difficult for mandibulectomy patients. Heparticularly difficult for mandibulectomy patients. He
reasoned that if palatal vault was loweredreasoned that if palatal vault was lowered
prosthetically into space of donders to accommodateprosthetically into space of donders to accommodate
for restricted tongue movements, speechfor restricted tongue movements, speech
improvement might be noted.improvement might be noted.

PROSTHETIC REHABILITATIONPROSTHETIC REHABILITATION
OF DENTULOUS PATIENTSOF DENTULOUS PATIENTS
 Design.Design.

Lateral Discontinuity defectsLateral Discontinuity defects

DEFECTS WITH MANDIBULARDEFECTS WITH MANDIBULAR
CONTINUITYCONTINUITY
 Anterior DefectsAnterior Defects
 Altered cast impressionAltered cast impression

 Lateral continuousLateral continuous
defectsdefects

PROSTHETIC REHABILITATION ONPROSTHETIC REHABILITATION ON
EDENTULOUS PATIENTSEDENTULOUS PATIENTS

LATERAL CONTINUITY DEFECTSLATERAL CONTINUITY DEFECTS

CONCLUSIONCONCLUSION
 Surgical and prosthodontic rehabilitation of theSurgical and prosthodontic rehabilitation of the
mandibulectomy patient has the potential of beingmandibulectomy patient has the potential of being
extremely gratifying to the clinician as well asextremely gratifying to the clinician as well as
making an enormous impact on the quality of life formaking an enormous impact on the quality of life for
the patient. At the same time, the complexities ofthe patient. At the same time, the complexities of
dealing with the many factors involved in successfuldealing with the many factors involved in successful
diagnosis and treatment planning of the patient with adiagnosis and treatment planning of the patient with a
mandibular defect make the final outcome ofmandibular defect make the final outcome of
treatment difficult to predict and often less thantreatment difficult to predict and often less than
completely satisfactory. It is hoped that futurecompletely satisfactory. It is hoped that future
developments will continue to improve outcomes ofdevelopments will continue to improve outcomes of
postmandibulectomy treatment to further improve thepostmandibulectomy treatment to further improve the
quality of life for patients requiring such treatment.quality of life for patients requiring such treatment.www.indiandentalacademy.comwww.indiandentalacademy.com

BIBLIOGRAPHYBIBLIOGRAPHY
 Thomas D.Taylor: Clinical maxillofacialThomas D.Taylor: Clinical maxillofacial
prosthetics.prosthetics.
 Varoujan A.Chalian; MaxillofacialVaroujan A.Chalian; Maxillofacial
prosthetics-Multidisciplinary practice.prosthetics-Multidisciplinary practice.
 John Beumer- Maxillofacial Rehabilitation.John Beumer- Maxillofacial Rehabilitation.
 Prosthetic rehabilitation of hemi-Prosthetic rehabilitation of hemi-
mandibulectomy patient – JIPS;2006:6:1.mandibulectomy patient – JIPS;2006:6:1.www.indiandentalacademy.comwww.indiandentalacademy.com

Prosthodontic rehabilitation of the mandibulectomy patient

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