MANAGEMENT OF AQUIRED MANDIBULAR DEFECT Dr. Dwij Kothari Darshan Dental College and Hospital, Udaipur

2. Presented by – Dr. Dwij Kothari
Darshan Dental College and Hospital

3. Contents
 Introduction
 Classification of mandibular defects
 Factors affecting treatment of mandibulectomy
patients
 Immediate vs Delayed reconstruction
 Relating surgical considerations in mandibulectomy
patients
 Prosthetic rehabilitation of mandibulectomy patients
 Mandibular guidance
 Intermaxillary fixation

4.  Resection guidance restoration
 Guidance prosthesis
 Speech aids and speech therapy
 Tongue prosthesis
 Prosthetic rehabilitation of dentulous patient
 Lateral discontinuity defect (class 2 & 3)
 Defects with mandibular continuity anterior defect
(class 5)
 Defects with mandibular continuity lateral defect
(class 1 & 4)

5.  Prosthetic rehabilitation of edentulous patient
 Management of discontinuity defect
 Factors determining prosthetic program for CD
 Impression
 Centric registration
 Occlusal schemes and lateral registration
 Anterior border defects
 Review of literature
 Summery and conclusion
 References

6. Introduction

7.  Mandible is a single bone that creates:
 Peripheral boundaries of the floor of the mouth
 Facial form
 Speech
 Swallowing
 Mastication
 Respiration
 Disruption of the mandible has the potential to
disrupt any of these.

8.  Rehabilitation of mandibulectomy patients should
therefore consider both form and function.

9.  Surgical resection of tumor often includes a partial
mandibulectomy resection, a partial glossectomy , a
partial resection of the floor of the mouth and a
radical neck dissection.
 The extent of surgery and effect of radiation therapy
and chemotherapy determine the amount of
rehabilitation needed to a patient.

13. Classification of mandibular defects
According to Laney(1979)
Based on etiology
1. Acquired: - Marginal
- Segmental :- a) Lateral to midline
- Body only
- Ramus- Body with disarticulation
b) Anterior body
- Subtotal
- Total

14. 2. Congenital
- Incomplete formation
- Incomplete ossification
i.e. hypoplasias, mandibulofacial dysostosis,etc
3. Developmental
as a result of postnatal insults
i.e. trauma during birth, surgery,etc

15. Based on amount of resection (Laney)
 Continuity defect
(marginal resection)
- Inferior border and its continuity
preserved
- No deviation
- Less facial disfigurement
- Occlusion rarely changed
- Can be :- anterior defect
posterior defect
 Discontinuity defect
(segmental resection)
- Complete segment - from alveolar
crest to inferior border removed
- Mandible deviates to resected side
- Marked facial disfigurement
- Occlusion altered
- Can be :- lateral discontinuity
defect
midline discontinuity
defect

16. According to Cantor and Curtis (1971)
Class 1 : Radical alveolectomy with preservation of
mandibular continuity

17. Tissues resected :
 Portion of alveolar process and body
of mandible
 Lingual and buccal sulcus mucosa
 Portion of base of tongue and
mylohyoid muscle
 Lingual and inferior alveolar nerves
 Sublingual and Submaxillary
salivary glands
 Sometimes anterior part of digastric
muscle

18. FEATURES:-
1. Least debilitating.
2. Sometimes resection of part of mylohyoid muscle and resultant scarring
can raise the floor of the mouth causing reduction in tongue mobility.
3. Ability to shape and control the tongue form may be lost due to loss of
some intrinsic muscles.
4. Resection of lingual and inf. alveolar nerves results in a loss of sensation
in the mucosa of cheek, alveolar process, lower lip and loss of taste on
anterior 2/3rd of the tongue.

19. Class 2 : Lateral resection of mandible distal to cuspid

20. Tissues resected:
 Condyle, ramus and body of mandible
distal to cuspid
 Mylohyoid, hypoglossal
 Pterygoid, masseter, external pterygoid,
 Palatoglossal muscles, most of intrinsic
muscles of tongue.
 Hypoglossal , lingual and inferior alveolar
nerves.
 Sublingual & Submaxillary salivary glands.
 Mucoperiosteum & adjacent buccal &
lingual sulcus mucosa

21. FEATURES:-
1. Speech, swallowing, saliva control, manipulation of food impaired.
2. Facial disfigurement apparent.
3. Disarticulation and loss of muscles of mastication will hamper
mandibular movements.
4. Taste, sensory and motor losses are more extensive as compared to class 1.

22. Class 3 - Lateral resection of the mandible to the midline

23. Tissues resected :
 All those described in class 2 in addition to the anterior portion of the
mandible, geniohyoid, genioglossus, remaining portion of mylohyoid
muscle with lingual and buccal mucosa.

24. FEATURES:-
1. Restricted tongue mobility due to loss of tip of tongue and
genioglossus muscle.
2. Speech, swallowing, saliva control and manipulation of food is severely
restricted.
3. Facial disfigurement is worse due to loss of anterior part of mandible.
4. Disarticulation and reduction in amount of basal bone reduce prosthodontic
prognosis.
5. Scarring of orbicularis oris can interfere with expression of emotion

25. Class 4: Lateral bone graft surgical reconstruction

26.  Lateral bone and split
thickness skin or pedicle graft
can be performed on patients
who have had:
- radical alveolectomies
- resection of mandible
distal to cuspid with or
without disarticulation.
-midline resections with or
without disarticulation.

27.  3 Types of bone grafts are possible:-
1. Mandibular augmentation procedures.
2. Bone graft that connect a residual condyle with the large
mandibular fragment.
3. Lateral bone grafts that extend from the mandibular
fragment into the defect area to establish a pseudo TMJ.

28. Class 5 :Anterior bone graft surgical reconstruction

29.  Tissues resected :
 anterior portion of the mandible
 large bilateral portions of mylohyoid,
geniohyoid
 genioglossus and anterior digastric muscles
 bilateral lingual and inferior alveolar nerves
 bilateral submaxillary and submandibular
salivary glands
 mucosa of lower lip
 anterior floor of the mouth
 ventral surface of the tongue

30.  The mucosa retained in the labial and buccal regions is sutured to the
residual stump of the tongue and a Kirschner wire is often positioned to
maintain the mandibular fragments .
 Bone graft and split thickness skin graft or pedicle graft procedures can
be used to restore anterior facial contour and bilateral mandibular
function.

31. Predisposing factors

32.  Dentures – Chronic irritation – epidermoid carcinoma
– squamous cell carcinoma
 Alcohol – squamous cell carcinoma in the floor of the
mouth – related to direct tissue contact or indirectly
with live cirrhosis and altered nutritional status
 Tobacco - cigarette , cigar, pipe , chewing tobacco
 Leukoplakia – white patch - can not be scraped off –
reversed by removing local irritants
 Oral lichen planus – recticular, plaque, and erosive
forms

33. Factors affecting treatment of
mandibulectomy patients

34. 1. Location and extent of mandibular defects
Radical alveolectomy
- Least debilitating.
- Main problems – loss of vertical ridge height and vestibular depth –
decreased stability for soft tissue-supported prosthesis as well as the loss
of load bearing tissues available for support.
- Vertical discrepancy most important when prosthesis supported by dental
implants are considered.

35. Discontinuity defects
RULE OF THUMB:-The further anterior the defect, the more
disfiguring and functionally debilitating
it is likely to be.
Osbon DB. Early treatment of soft tissue injuries of the face. J Oral Surg 1969;27:480–7.

36. - Most debilitating and difficult to treat.
- Greatest facial disfigurement.
- Surgical reconstruction necessary or at least segmental stabilization
before prosthodontic treatment can be initiated.
- Mandibulectomy defects of the molar region of the mandibular body are
more well suited for surgical reconstruction compared to anterior defects.
- If muscle attachments are intact – Good prognosis
Near normal appearance and function is achievable.
Defects of the symphyseal region

37. 2. Presence of remaining natural teeth/pre-existing
implants
Patients after mandibulectomy present with few or no
remaining natural teeth.
2 reasons:
1. Patients at greatest risk for squamous cell carcinoma - heavy
users of tobacco products and alcohol.
2. Teeth are usually extracted prior to radiotherapy to prevent
complications such as osteoradionecrosis.

38. Greater the number of teeth, better the prognosis
- Teeth present on both sides of the midline permit greater
prosthesis support since the problem of straight line design
can be avoided.
- Maximum number of abutment teeth should be
incorporated in the design of the prosthesis to maximize
stability and dissipate functional forces.

39. Ideal for rehabilitation

40.  A maxillary complete denture will function well for
mandibulectomy patient against a reconstructed mandibular
dentition
Exceptions:
 Collapse of residual proximal mandibular stump; coronoid
process against the posterior maxillary alveolus - prohibiting
adequate denture flange extension.
 When a guide flange prosthesis is planned to correct mandibular
deviation - pressure from the guide flange will tend to dislodge
the maxillary denture.

41. 3. Degree of post mandibulectomy rotation and deviation
- Loss of mandibular continuity causes deviation of the
remaining mandibular segment towards the defect and
rotation of mandibular occlusal plane inferiorly.
Deviation: Primarily due to loss of tissue involved in surgical
resection.

42. Rotation:- Due to
- Pull of the suprahyoid muscles on the residual mandibular
fragment causing inferior displacement and rotation around the
fulcrum of the remaining condyle.
- Gravity – Loss of anchorage of elevator muscles.
Sequelae:-
 Facial disfigurement
 Loss of occlusal contact
 Loss of ability to bring lips together for saliva control
& to initiate swallowing process

43.  Prosthodontic prognosis in such patients can be improved by
early post resection physical therapy to reposition the
mandibular fragment to a more normal position and to
minimize scar formation that will make deviation more
severe.
 Should be carried out as early as possible. After 6-8 weeks
post operatively it will not be as beneficial.
 Can be in the form of
1.Physical therapy carried out by the patient himself.
2.Mandibular resection guidance prosthesis

44. 4. Available mouth opening
- Trismus –due to surgical trauma
- Scar tissue formation will further reduce mouth opening.
- Physical therapy (Stretching exercise) should be started
immediately.
- Simple test to check mouth opening:
Insert a stock mandibular impression tray in the mouth.
If this cannot be accomplished, rehabilitation is unlikely to
occur.
- Surgery can be done to release scar tissue. However, not very
beneficial as it returns to the same in a short period of time.

45. 5. Functional limitation of the tongue
- Frequently the surgical wound is closed by suturing the
remaining tissues of the floor of the mouth or tongue to the
remaining buccal tissues.
This compromises: - Speech
- Swallowing
- Mastication
- Control of food bolus
- Ability to control removable prosthesis

46. - Lingual vestibuloplasty and skin or mucosal grafting can be
used to improve tongue mobility
- Evaluation of tongue mobility
- Patients in whom anterior resection has been done, ability to
lick the lips when the artificial prosthesis is placed in the
mouth may be difficult or impossible.
- In such cases consideration is given to lowering the anterior
occlusal plane or arranging the teeth slightly lingually.

47.  Loss of sensory innervation will compromise tongue function
and prognosis of prosthodontic rehabilitation.
If lingual nerve is sacrificed - tongue on the defect side will
permanently remain without any feeling.
Loss of sensory capability:- Affects speech
Mastication
Prosthesis control on defect side
Loss of sensory innervation of the buccal mucosa(long buccal
nerve) and lower lip(mental nerve) will reduce patient’s
ability to control food and saliva.

48. 6. Compromise of vestibular extensions
 Vestibular depth is critical for stability and peripheral seal.
 It is also critical when mandibular continuity is restored
with bone grafting and implants are considered.

49. 7. Skin grafting
 Skin grafts are used for surgical reconstruction either as lining for
the surface of resected soft tissue or as part of skin and connective
tissue grafts such as pedicle flaps, free flaps etc.
Advantages
1. Effective load bearing tissue.
2. Can withstand pressure from prosthesis.
3. Protects underlying bone and connective tissue well due to
rapid turnover of keratin producing cells.
Disadvantages
1. No sensory innervation.
2. Full thickness grafts may incorporate hair follicles.
3. Skin is not very compatible with titanium surface of implants.

50. 8. Radiation therapy
 Careful treatment planning is required for patients with
radiation therapy.
 Irradiated tissue is fragile, sensitive to manipulation,
dessicated, slow to heal, prone to infection and at risk of
osteoradionecrosis.

51. 9. Altered anatomic relationships following restoration
of mandibular continuity
 Reconstruction of anterior defects
- Most difficult situation for grafting
- Frequently results in a graft that is deficient anteriorly.
- Results in a severe Class II like situation.
The prosthodontic difficulties seen in rehabilitating such a patient are:-
- Inability to provide proper lower lip support for esthetics.
- Speech problems associated with mandibular dentition placed too
far lingually to allow normal articulation.

52. - Inability to control food bolus due to lack of motor function of
lips and muscles of the lower face.
- Excessive display of mandibular teeth due to patient’s inability
to maintain normal lower lip posture.
- Difficulty gaining adequate space for prosthesis placement
without encroaching on function of tongue.
- Misalignment of remaining unresected mandibular fragments
and resultant relationship between maxillary and mandibular
teeth.

53.  Reconstruction of posterior defects
- More predictable from prosthodontic point of view as compared
to anterior defects.
- The mediolateral position of the graft is frequently seen lateral to
the original position of the mandibular body.
- Thus the prosthesis must be built in cross bite to maintain the
denture teeth over the supporting base of the bone graft.

54. Angled dental implants- the prosthesis they support must be
cantilevered lingually to permit tooth contact.
Inadequate space after surgical
reconstruction- limits prosthesis
or implant placement.
Excessive space after surgical
reconstruction- problem to control
forces on remaining teeth or implants

55. Immediate vs delayed reconstruction
 Factors determining whether to reconstruct at the
time of tumor resection (immediate) or as a secondary
procedure (delayed).
 Amount and character of remaining soft tissue
 Anatomic location of the defect
 Size of bone defect
 General health of patient
 Prognosis for tumor control
 Experience of the surgeon

56.  Extensive soft tissue loss – require additional procedure
for soft tissue augmentation, thus precluding
immediate graft.
 If immediate reconstruction is desired but soft tissue
appear inadequate for proper watertight oral closure – a
forehead flap may be useful
 Flaps should be – broadly based, as thick as possible.

57.  The size, extent and prognosis of tumors requiring
resection are important factors.
 Relatively small defect – immediate reconsturction
 Spectrum malignant tumors requiring extensive hard
and soft tissue resection with a radical neck dissection –
immediate implant followed by delayed graft.
 Since tumor recurrences occur frequently within 1st year

58.  Medically compromised patients – observe the response
to primary surgery before subjecting to second
procedure
 Location of resection is another important factor
 Defects at symphysis require immediate stabilization,
or remaining mandibular fragments will colapse
medially and superiorly because of muscle pull and scar
contracture
 Immediate stabilization is less important in lateral
mandibular defects.

59. Relating surgical considerations to
prosthodontic treatment

60.  Marginal mandibulectomy:-
Soft tissues are mainly used to reconstruct marginal
mandibulectomies.
They may be: - Skin graft
- Local flap
- Pedicle flap
- Microvascular free flaps
(MVFF)
 Skin grafts serve as excellent prosthesis-bearing surfaces.
 However when soft tissue bulk is required or recipient bed is
previously irradiated - Microvascular free flaps are the
treatment of choice.

61.  Discontinuity mandibulectomy:-
- Previously soft tissue local flaps (mainly the residual tongue
sutured to the border of the defect) and pedicle flaps
(pectoralis muscle) were used.
- MVFF have revolutionized the treatment of discontinuity
defects.
- Microvascularized bone is mainly obtained from:
1.Fibula- most common
2.Iliac crest
- Soft tissue MVFF are obtained from:
1.Forearm
2.Rectus muscle

62. Mandibular malposition after bony reconstruction
 May be due to:
1. Minimal proximal mandible on the surgical
side to attach the bone graft.
2. Mandibular segments are not stabilized and
maintained in their pre-operative relation to
each other during grafting procedures.
3. Delayed reconstruction may not be able to
overcome scar tissue formation completely.

63. 4. The bone grafts used i.e the fibula and the iliac crest graft
have some inherent problems:
- Lacks height compared to the residual mandible
-Pyramidal in shape being narrower at the occlusal surface
-Fibula is grafted to restore inferior border of the mandible,
which is necessary to restore facial form. This tends to place
fibula buccally in the plane of the cheek.
-Since bone is placed buccally in the cheek, implants distal to
the premolar area cause constant soft tissue and infection
problems.

64. Prosthetic Rehabilitation of
mandibulectomy patients

65. Mandibular Guidance
 Loss of continuity of the mandible destroys the balance and
symmetry of mandibular function
 Leading to altered mandibular movements and deviation of
the residual fragment towards the surgical side.
 Methods to reduce mandibular deviation
 Intermaxillary fixation
 Use of mandibular based guidance restorations
 Use of palatally based guidance restorations

66. Intermaxillary Fixation
 One approach to reducing the deviation associated with
resection of the mandible
- use arch bars and elastics or wire in dentulous patients.
- “gunning splint” in edentulous patients.

67. Resection guidance restorations
 If intermaxillary fixation is not employed –
2weeks postsurgically, the patient should be placed on an
exercise program.
Following maximum opening, grasping the chin and
moving the mandible away from the surgical side.
 These movements tend to loosen scar contracture
reduce trismus, and improve maxillomandibular
relationships.

68.  If extensive resection and a considerable period of
time has elapsed, guidance procedures are much more
difficult and a compromised occlusal relationship may
result.
 For guidance prosthesis mandibular teeth must be
present.
 Once an acceptable occlusal relationship is
established, the guidance prosthesis may be discarded
or used occasionally to reinforce proprioceptive
mechanism.

69. Guidance prosthesis
 Robinson and Rubright described Mandibular
guidance prosthesis
 It consists of a RPD framework with a metal flange
extending 7 to 10 mm laterally and superiorly on the
buccal aspect of the bicuspids and molars on the
nondefect side.
 This flange engages the maxillary teeth during
mandibular closure.

70.  If the completed guidance ramp is to be
formulated in acrylic resin,
autopolymerizing material is added to the
prosthesis which is seated in the mouth.
 As the resin reaches dough stage, the
mandible is manipulated into the desired
interocclusal relationship.
 The resin should be manipulated to
extend 7 to 10 mm superiorly. The
prosthesis is removed from the mouth and
the resin is allowed to polymerize.

71.  Palatally based guidance restoration
 This is a guidance ramp and an index to a maxillary
prosthesis.
 Indicated for patients who has severe deviation
which prevents manipulation of mandible into any
form of acceptable contact.
 These maxillary prosthesis are usually constructed of
acrylic resin with either cast or wrought wire
retainers.

72.  The full palatal coverage prosthesis is constructed
following conventional prosthodontic guidelines.
 A mix of autopolymerizing acrylic resin is prepared and
added to the palatal prosthesis along the lateral and
anterior borders on the nondefect side.
 The prosthesis is replaced in the mouth and the
mandible is manipulated to the desired position, thus
establishing an index in the palate.

73.  The patient should be able to close into the index with
appropriate manual manipulation of the mandible.
 When the patient returns, the mandible will usually
exhibit more movement laterally toward the non
surgical side, requiring adjustment of the palatal ramp.
• If and when an acceptable intercuspal
position is achieved, a cast mandibular
guidance prosthesis may be necessary to
maintain mandibular position.

74. Speech aids and speech therapy
 Cantor et al 1969, noted speech improvement by lowering
palatal vault prosthetically into the space of Donders to
accommodate for restricted tongue movements.
 The palate was lowered by means of a retainer for the
dentulous patients and by a palatal acrylic resin extension
onto the upper denture for edentulous patients.
• Misarticulation of speech sounds by
mandibular resections.

75.  Scott 1970, investigated the potential benefit of intensive
speech therapy for mandibulectomy patients and
concluded that:
 Placement of a prosthesis, although improves the quality of
specific sounds, does not improve discourse and
 Intensive speech therapy improved speech significantly for
patients both with and without prosthesis.
• Speech therapy is most effective
means of improving articulation in
mandibulectomy.

76. Tongue prosthesis
 The loss of tongue impairs functions of stomatognathic
system.
 Moore 1972, suggested that tongue prosthesis provides
articulation along with movements of the mandible and
cheeks.
 Loss of tongue leads to difficulty in controlling saliva and
liquids.
 Pooling of the fluids in the altered floor of the mouth
stimulates cough reflex and/or leading to aspiration.

77. Prosthetic Rehabilitation of
Dentulous Patients

78. Lateral Discontinuity Defects
(Class 2 And 3)
 Often resected in the region of 2nd premolar and 1st
molar. If there are no other missing teeth in the arch, a
prosthesis is usually not indicated.
 Framework design should be similar to a Kennedy class
2 design, with extension into the vestibular areas of the
resection.

79.  The forces of occlusion are unilateral and consequently
the axis of rotation (fulcrum line) of the partial
denture deviates from the norm.

80.  Major connector – depends on the
height of floor of the mouth.
 Minor connector – minimize the
stress on abutment teeth.
 Occlusal rests – near the defect
 Retention – use of various types of
clasp assemblies on distal
abutments.

81.  If anterior and posterior teeth from resected side
missing and posterior teeth on unresected side are
missing, prosthesis have 3 denture base regions.
 Rests – on as many teeth as possible
 Minor connectors – enhance stability and wroght wire
retainers are acceptable alternative to bar clasps.
 Altered cast impression – used to get max. soft tissue
coverage.

82.  Maxillomandibular records – made with soft wax and
minimum occlusal pressure applied.
 Acrylic resin teeth
 When less than ideal occlusal relationships must be
accepted, it may be necessary to establish an occlusal
ramp lingual to maxillay teeth on the unresected site.

83.  Class 3 resection – defect to the midline or
farther toward the intact side, leaving half
or less of the mandible remaining.
 Design of framework – similar to type 2
resection
 In this resection – greater chance of
prosthesis dislodgement caused by lack of
support under anterior extension.

84. Defects With Mandibular Continuity
Anterior Defects (Class 5)
 Patients with anterior inner table resections and
patients with anterior composite resections in whom
mandibular continuity has been reestablished by
reconstructive surgery.
 These patients display unusual soft tissue
configurations and compromised bony support.
 Prosthesis for these patients enhance esthetics, speech
and control of saliva.

85.  Indirect retention – long
mesial rests on the 2nd Molars
 Minor connector – relieve
distal aspect and proximal
plates
 Edentulous areas are recorded
with an altered cast impression
 Thermoplastic waxes are used
to record movable tissue beds.

86.  Esthetics, occlusion and speech – verify at try-in stage
 Prosthesis is delivered with periodic monitoring.

87. Defects with Mandibular Continuity
Lateral Defects (Class 1, 4)
 Inferior border of the mandible is intact, and normal
movements can be expected.
 Compromised denture bearing area – because of closure
of the defect using adjacent lining mucosa or presence
of split thickness skin graft.
 If defect is unilateral and posterior – kennedy class 2
framework design
 If marginal resection in anterior area – kennedy class 4
framework design

88.  Anterior marginal resections some times include part
of the anterior tongue and floor of the mouth.
 The remaining teeth often collapse lingually and
necessitate labial bar as major connector.
 Buccal, lingual and labial functional contours – helps
in stabilization of the prosthesis.

89.  Extremely long lever arms & compromised edentulous
bearing surfaces contribute to excessive movement of
prosthesis during function.
 The ‘ribbon rest’ closely parallels the axis of rotation.
The anterior and posterior proximal plates move freely
during function.
 The buccal retainer on the molar and the labial
retainer on the cuspid are placed at the height of
contour.

90.  The occlusion should be refined to achieve contact in
centric occlusion only and patient should be
instructed to masticate on the side of the residual
mandibular dentition.

91. Prosthetic Rehabilitation of
Edentulous Patients

92. Management Of Discontinuity Defects
 Complete dentures in these patients are primarily for
esthetics.
 They improve lip and cheek contour and replace missing
teeth.

93. Factors Determining The Prosthetic
Prognosis For Complete Dentures
 The prognosis is more favourable if the resection is
limited to the cuspid region anteriorly.
 If the motor and/or sensory control of the tongue has
been significantly compromised by the resection, the
prosthetic prognosis becomes extremely guarded.
 Severe deviation of the mandible causes instability of
the dentures.

94.  Post surgical lip posture and control, does have
important prosthodontics implications.
 Due to radiation therapy, there will be reduction in
salivary flow which leads to increased risk of mucosal
irritation and compromised peripheral seal.

95. Impression
 Primary impression – irreversible hydrocolloid
impression material
 Final impression – border moulding with modeling
plastic and an elastic impression material
 Some clinicians advocate making a functional
impression of the polished surfaces of mandibular
prosthesis

96. Centric Registration
 In maxilla, wax rim used – widened on unresected side
in order to account for deviation of the mandible
 Determine VDO and VDR
 Centric occlusion registration – obtained with wax or
plaster
 The clinician should manipulate the mandible and
place it in the most advantageous position within the
reach of the patient.

97. Occlusal schemes and Lateral registrations
 Swoop 1969, suggested “non anatomic teeth” for
patients with abnormal jaw relationships and angular
path of closure.
 “Neutral Zone” identification facilitates positioning of
the mandibular teeth.
 The wax rim is fabricated according to the neutral
zone.

98.  Special attention should be paid of developing
appropriate contours of the rim in contact with the
inside of the upper and lower lip.
 After the wax rims have been altered and registations
obtained, the maxillary and mandibular casts are
mounted on a suitable articulator.

99.  It is advisable to place the maxillary anterior teeth
lingual to, and mandibular anterior teeth labial to,
their accustomed position.
 Lip tooth relationship can be improved if the vertical
overlap is increased so that the amount of tooth
displayed and the smile line are consistent with a more
labial or normal position of the maxillary teeth.

100.  Generally, in mandible the posterior teeth on the
unresected side will be buccal to the crest of
edentulous alveolus, especially in the bicuspid region.
 The posterior mandibular teeth on the surgical side
usually are placed lingual to the crest of the
edentulous ridge.

101.  Contour and support for the corner of the mouth and
the lop on the resected side are best accomplished by
thickening the denture flange below the crest of the
ridge.
 After arranging all teeth in the maxillary prosthesis,
ramps of 10mm wide and 3-4mm horizontal overlap
with the lower teeth should be provided.

102.  After tooth arrangements have been finalized, the occlusal
contact of the mandibular teeth is checked with the
maxillary ramp.
 The patient should be able to establish contact with ramps
without guidance.
 After trial prosthesis have been perfected, they are
processed following customary procedures.
 The use of prosthesis for mastication should be deferred
for at least a week. As the patient uses the prosthesis, some
adjustment of the ramps usually necessary.

103. Anterior Border Defects
 The prognosis is usually favorable especially if a
vestibuloplasty has been completed.
 The mandibular movements and maxillomandibular
relationships are usually within the normal limits for
these patients.
 Careful placement of the mandibular anterior teeth
and flange contour in this area is suggested.

104. Review of literature

105.  They supported this concept by quoting Fish (1933) who gave
this concept, and stressed on the importance of polished
surface for the retention and stability of the denture.
Shifman and Lepley(1982): Neutral zone or ‘denture
space’ concept for marginal mandibulectomy patients.

106.  In this method short and narrow artificial teeth which will
not interfere with the denture space were selected.
 They were arranged on the diagnostic cast; occlusion and
esthetics were verified clinically. This was done in self-cure
acrylic resin and space was present underneath the
occlusion for impression material. This prosthesis was
retained by simple Adams or embrasure claps.

107.  A functional impression of the defect side is made using
modelling compound for muscle trimming and is
completed with an impression wax.
 The released prosthesis is than cured and finished in the
usual manner.

108. Cantor and Curtis(1971): Swallowing technique
in edentulous patient
 A preliminary alginate impression of the mandibular
fragment is made in a modified stock tray.
 A narrow area, supported by bone and free of any muscular
activity, is drawn on the diagnostic cast and a perforated
acrylic resin custom tray is constructed that conforms to
this area.
 Two lateral columns that extend toward the maxillary ridge
are formed on the tray.

109.  Modeling compound “stops” are placed under the column
tray for stability and to provide space for the impression
material.
 Modeling compound is then added to the lateral columns
extending them superiorly until firm bilateral contact is
made with the maxilllary residual alveolar ridge.
 The vertical height of the columns should exceed the
postsurgical physiologic rest position by at least 2 to 3 mm.

110.  The lower part of the oral cavity is filled with an alginate
impression material that has been mixed with approximately
one third more water than is recommended by the
manufacture.
 The column tray is placed through the hydrocollooid material
until it is seated firmly on the alveolar mucosa.

111.  The mandible is then closed until the maxillary ridge rests
are properly seated, and the custom tray is securely in place
with the tongue resting between the columns on the tray.
 At this point, the patient begins to swallow, and between
each swallowing cycle, he puckers his lips.
 The patient continues these two motions until the alginate
material has set.

112. Swatantra agarwal, Praveen G, Samarth Kumar
agarwal and Sankalp sharma (2011), suggested Twin
Occlusion in which they did functional rehabilitation of
hemimandibulectomy patient, who had undergone
resection without reconstruction.

113. Maxillary arch representing
kennedy’s class I
Bite record

114. OPG reveals resection of mandible of left side
Intercuspation obtained by twin
occlusion on nonresected side

115. Mounted cast on articulator with
arrangement of teeth
Occlusal view of definitive prosthesis
placed in maxilla

116. Summary & Conclusion

117.  Management of mandibular defects is one of the most
challenging aspects of maxillo-facial prosthetics. These
defects affect not only function but also appearance and
thus the prosthodontists has to fulfill the dual
responsibility of restoring function and appearance.
 With the advent of advanced surgical and bone grafting
techniques, satisfactory prosthodontic prognosis can be
achieved for such patients. However there are still some
inherent problems in these procedures which have not
been completely overcome.

118.  On his part the prosthodontists should be able to
efficiently plane and execute treatment because the scope
of patients with mandibular defects may vary form the
completely edentulous patient to the patient with few teeth
remaining or patients requiring implant supported
prosthesis.

119. References
 John Beumer, Maxillofacial rehabilitation prosthodontic and surgical
reconstruction, 1st edition 1979
 Taylor TD, Clinical maxillofacial prosthetics, 1st edition 2000.
 William R Laney, Maxillofacial prosthetics, postgraduate dental hand
book series, Vol 4.
 Kenneth L Stewart, Clinical removable partial prosthodontics, 2nd
edition.
 Osbon DB. Early treatment of soft tissue injuries of the face. J Oral
Surg 1969;27:480–7.

120.  Cantor R and Curtis TA Prosthetic management of edentulous
mandibulectomy patients - Part 1. J Prosthet Dent, 1971; 25:447-455.
 Cantor R and Curtis TA Prosthetic management of edentulous
mandibulectomy patients - Part 2- J Prosthet Dent, 1971;25:547-555.
 Cantor R and Curtis TA Prosthetic management of edentulous
mandibulectomy patients - Part 3- J Prosthet Dent, 1971;25:671-678.
 Shifman A and Lepley JB Prosthodontic management of postsurgical
soft tissue deformities associated with marginal mandibulectomies. J
Prosthet Dent, 1982; 48:178-183.
 Swoope CC Prosthetic management of resected edentulous mandibles.
J Prosthet Dent, 1969; 21:197-201.

121.  Desjardins RP Occlusal considerations in partial mandibulectomy
patients . J Prosthet Dent, 1979; 41:308-311.
 Kelly EK Partial denture design applicable to the maxillofacial patient. J
Prosthet Dent, 1965; 15:168-173.
 Ackerman AJ The prosthodontic management of oral and facial defects
J Prosthet Dent, 1955; 5:413-432.
 Aramany MA and Myers EN Intermaxillary fixation following
mandibular resection. J Prosthet Dent, 1977; 37:437-443.
 Maxillofacial rehabilitation prosthodontic and surgical considerations,
John Beumer, Thomas A. Curtis & David N. Firtell; 1st edition 1979

122.  Scannell JB Practical considerations in dental treatment of patients
with head and neck cancer. J Prosthet Dent, 1965; 15:764-778.
 Schaff NG Oral reconstruction for edentulous patients after partial
mandibulectomies. J Prosthet Dent, 1976; 36:292-297.