Managment of hamimandibulectomy

Managment of hamimandibulectomy

1. Management of hemimandibulectomy in 21 century

2. C ontents Introduction • Challenge • Classification of mandibular defects • Complications • Factors affecting treatment of mandibulectomy patients • Prosthetic rehabilitation of mandibulectomy patients • Prosthetic rehabilitation of dentulous patient  • Prosthetic rehabilitation of edentulous patient • Conclusion • References 2

3. introduction 3

4. • Mandible is a single bone that creates Peripheral boundaries of the floor of mouth Facial form (Lower third of face) Speech Swallowing Mastication Respiration • Disruption of the mandible has the potential to disrupt any of these 4

5. 5

6. 6

7. 7

8. Classification of mandibular defects 8

9. Acc to etiology - Laney(1979) 9

10. 10 3 Developmental as a result of postnatal insults i.e. trauma during birth, surgery,etc

11. 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 11

12. Acc to Cantor and Curtis (1971)  Class 1 Radical alveolectomy with preservation of mandibular continuity 12

13. TISSUES RESECTED 13

14. FEATURES 14

15. Class 2 : Lateral resection of mandible distal to cuspid 15

16. TISSUE RESECTED 16

17. FEATURES 17

18. Class 3 Lateral resection of the mandible to midline 18

19. TISSUE RESECTED 19

20. FEATURES 20

21. Class 4 Lateral bone graft & surgical reconstruction 21

22.  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. 22

23.  3 Types of bone grafts are possible :- 23

24. Class 5 :Anterior bone graft surgical reconstruction 24

25. TISSUE RESECTED 25

26. The mucosa retained in the labial and buccal regions is sutured to the residual stump of the tongue and a krischner wire is often positioned to maintain the mandibular fragments . 26

27. Class 6 It is similar to a class V patient, but the continuity of the mandible has not been restored surgically. Because each lateral fragment moves independently, the prognosis for a removable prosthesis is poor and fabrication is not recommended 27

28. Complications 28 With only one half or two thirds of the mandible remaining, stability, support and retention of the mandibular denture are compromised. Due to radiation therapy either prior to or after surgery, the oral mucosa is atrophic and fragile, predisposing to soft tissue irritation and ulceration. The reduction in saliva output, and the thick mucinous nature of the saliva that remains after therapeutic levels radiation, impairs retention 

29. 29 The angular pathway of mandibular closure induces lateral forces upon the dentures, which dislodge them. The deviation of the mandible creates abnormal jaw relationships. The abnormal profile and position of the mandible in relation to the maxilla may prevent ideal placement of the denture teeth over their supporting structures. The impairment of motor and/or sensory control of the tongue, lip, and cheek impairs the ability of the

30. Factors affecting treatment of mandibulectomy patients 30

31. 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. 31

32. Discontinuity defects RULE OF THUMB:-The further anterior the defect, the more disfiguring and functionally debilitating it is likely to be 32

33. Defects of the symphyseal region 33

34. 2. Presence of remaining natural teeth/pre-existing implants Patients after mandibulectomy present with few or no remaining natural teeth. 2 reasons: 34

35. Greater the number of teeth, better the prognosis 35

36. 36 A maxillary complete denture will function well for mandibulectomy patient against a reconstructed mandibular dentition Exceptions:

37. 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 . 37 Deviation: Primarily due to loss of tissue involved in surgical resection.

38. 38 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:-

39. Can be in the form of 1.Physical therapy carried out by the patient himself. 2.Mandibular resection guidance prosthesis 39 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.

40. 4. Available mouth opening 40

41. 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 41

42.  Lingual vestibuloplasty and skin or mucosal grafting can be used to improve tongue mobility 42

43. 43

44. 6. Compromise of vestibular extensions   44

45. 45

46. 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. 46

47. 47

48. 8. Radiation therapy 48

49. 9. Altered anatomic relationships following restoration of mandibular continuity 49

50. 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 . Inability to control food bolus due to lack of motor function of lips and muscles of the lower face 50

51. - 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. 51

52.  Reconstruction of posterior defects 52

53. 53

54. Prosthetic Rehabilitation of mandibulectomy patients 54

55. 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 55

56. 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. 56

57. Resection guidance restorations 57

58. 58

59. Guidance prosthesis 59

60. 60

61. 61

62. Palatally based guidance restoration 62

63. 63

64. 64

65. 65

66. Prosthetic Rehabilitation of Dentulous Patients 66

67. Lateral Discontinuity Defects (Class 2 And 3) 67

68. 68

69. 69

70. 70

71. a- four implants have been placed. b to d – the milled bar enables fabrication of an overlay implant –supported prosthesis. e- panoramic radiograph of the implants and completed bar. f- tissue side of prosthesis the hader clips . g and h – prosthesis in position. The hypoglossal and lingual nerves are intact. Therefore, the patient is able to masticate on defected side. 71

72.  Class 3 resection 72

73. 73 Patient with a lateral tongue and mandibular discontinuity defect Maxillary RPD with palatal index Mandibular overlay rpd

74. 74 Mandibular and maxillary prosthesis in position Open position and closure with angular path

75. Defects With Mandibular Continuity Anterior Defects (Class 5) 75

76. 76

77. Esthetics , occlusion and speech – verify at try-in stage Prosthesis is delivered with periodic monitoring. 77

78. a- defect of the anterior mandible, re-constructed with a fibular free flap. Both posterior mandibular fragments are rotated medially. b & c RPD designed to engage lingual undercuts of the mandibular right molars. d – single retainer on the remaining left premolar . e- trial RPD 78

79. Defects with Mandibular Continuity Lateral Defects (Class 1, 4) 79

80. 80

81. 81

82. 82

83. 83

84. Prosthetic Rehabilitation of Edentulous Patients 84

85. Management Of Discontinuity Defects 85

86. Factors Determining The Prosthetic Prognosis For Complete Dentures 86

87. 87

88. 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 88

89. Cantor and Curtis(1971): Swallowing technique in edentulous patient 89 Cantor R and Curtis TA Prosthetic management of edentulous mandibulectomy patients - Part 2- J Prosthet Dent, 1971;25:547-555

90. 90

91. 91

92. 92

93. 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. 93

94. Occlusal schemes and Lateral registrations 94

95. 95

96. 96

97. 97

98. 98

99. 99

100. Prostheses for the mandibular discontinuity defect opposing a severely resorbed maxilla. a- Implants placed in opposing maxilla to prevent tipping and loss of retention of the maxillary denture during function b- overlay prosthesis c- prostheses inserted 100

101. 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. 101

102. Case report -1 A 32‑year‑old female patient. History- of a large swelling on the left side for 2 years which was later diagnosed as cemento ‑ossifying fibroma The defect was Class II according to Cantor and Curtis classification . On extraoral examination, there was severe deviation of the mandible toward left side and with facial asymmetry 102

103. Intraoral findings included missing lower left premolars and molars with mandibular second molar missing on the right side 103

104. (a) LIWA pattern on master cast. (b) metal framework on the mandibular cast. (c) try‑in in patient’s mouth with wax flange 104

105. (a) Labial view of the prosthesis inside the mouth. (b) frontal view of the patient with the prosthesis – smile 105 Choudhary S, Ram S, Kumar A. Prosthetic management of a hemi‑ mandibulectomy patient. Indian J Dent Sci 2018; 10:118-20.

106. Case report 2 A 29 yrs old male Chief complaint of missing teeth in lower left teeth region of the jaw. dental history revealed that a case of Ameloblastoma within the left mandible. The patient underwent an extensive resection of whole of left mandible before three years . 106 Narendra.R et al. Prosthodontic Rehabilitation of Cantor and Curtis Class III Mandibular Defect Using Cast Partial Denture :- A Case Report J. Pharm. Sci . & Res . Vol. 8(6), 2016, 461-463

107. Based on the clinical situation, a Cast partial removable partial denture was planned 107

108. After try in procedure processing of denture was done using Injection moulding technique. Finally trimmed and polished cast partial denture was inserted in the patients mouth 108

109. Summary & Conclusion 109

110. 110

111. 111

112. References 112

113.  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.  Cantor R and Curtis TA Prosthetic management of edentulous mandibulectomy patients - Part 1. J Prosthet Dent, 1971; 25:447-455 113

114.  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. 114

115.  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 115

116. 116 thanks!