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Removable Partial Denture Design for the Mandibulectomy Patients

Removable Partial Denture Design for the Mandibulectomy Patients

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Removable mandibular

David N. Firtell,
University of California,

partial denture design for the resection patient
D.D.S., M.A.,* and Thomas A. Curtis, D.D.S.**
School of Dentistry, San Francisco, Calif.

quamous cell carcinoma of the lateral border of the tongue and the floor of the mouth may be treated by a combination of surgery, radiation therapy, and chemotherapy. Surgical resection of this tumor often includes a partial mandibular resection, a partial glossectomy, a partial resection of the floor of the mouth, and a radical neck dissection. The extent of surgery and the effects of radiation therapy and chemotherapy determine the amount of rehabilitation needed by a given patient. Rehabilitation efforts may include secondary surgical management, prosthodontic treatment, speech therapy, and psychologic care. Acceptable fabrication and use of a prosthesis will be dependent on the coordinated efforts of the rehabilitative team as well as on the extent and location of the defect. The presence or absence of natural teeth in a resected mandible often determines the approach to prosthodontic rehabilitation. Several authors have described the rationale for the prosthodontic management of mandibular guidance, the need for altered palatal contours to accommodate restricted tongues, and the prosthodontic rehabilitation of edentulous mandibular resection patients.lm3 The literature, however, contains few references to the rehabilitation of partially edentulous mandibular resection patients.’ This article will discuss the design of removable prostheses for these patients based on a classification suggested by Cantor and Curtis.’ Cantor and Curtis classified edentulous mandibular resection patients by the amount of mandible that remains after resection and surgical reconstruction. Although the classification was suggested for edentulous patients, it is also applicable to partially edentulous patients. A review of this classification will aid in understanding the physiologic and treatment needs of patients with resected mandibles.
Presented Wash. *Professor **Associate before the Academy of Denture Prosthetics, Seattle,

S

REVIEW

OF CLASSIFICATlON

and Chairman, Removable Prosthodontics. Professor, Removable Prosthodontics.

The Class I mandibular resection patient has had a radical alveolar resection, but the continuity of the mandible has been preserved (Fig. 1, A). The inferior border of the mandible, the muscles of mastication, and most of the tongue and contiguous soft tissues have been retained. Scar contracture and wound closure limit the mobility of the tongue and Boor of the mouth. There may also be a sensory neural loss to regions supplied by branches of the mandibular and hypoglossal nerves if they have been resected or traumatized. A patient with a lateral discontinuity defect of the body of the mandible who subsequently has continuity restored with a bone graft is also considered in this classification. While Class I patients have some anatomic and functional limitations, most function well with removable partial dentures. In the Class II mandibular resection patient the total mandible has been resected distal to the canine (Fig. 1, B). The condyle, ramus, and posterior portion of the body of the mandible have been removed and the function of the attached muscles has been lost, resulting in deviation of the remaining mandible toward the surgical defect. A portion of the tongue has been resected or used for closure of the surgical wound. Loss of condylar control of the mandibie and muscular control of the tongue and mandible introduces major functional problems associated with speech, deglutition, and mastication. When compared to the Class I patient, the Class II patient experiences additional sensory neural loss and further impairment of degiutition, taste, and saliva control If the lesion invades the posterior tongue, surgical resection may require removal of the hypoglossal nerve. The reauhant loss of motor innervation further complicates oral physiologic functions as well as the mechanical control of a prosthesis. The largest number of mandibular resection patients can be found in this classification. The Class III mandibular resection patient has had the mandible resected to the midline or possibly beyond

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JOURNAL

OF PROSTHETIC

DENTISTRY

437

A v~tibuloplasty may also be needed to improve tongue movement and increasethe supporting area for a l~osthesis. total resection distal to cuspid. T. Edentulous mandibular resection patients are classified by remaining structures. 1971. B. total resection to midline or beyond.F :RTELL AND CURTIS Fig. D. (From Cantor. ClassIII. The Class V mandibular resecticuipatient has had an anterior resection that crosses e midline. the anterior portion of the mandible and its associated muscles are resected. ClassV. There is sufficient mandibular structure remaining to reestablishfunctional :ontinuity by placing an autogenousbone graft (Fig. speech. ClassI. but the tl bilateral temporomandibular art& ulation has been maintained. Part I: Anatc lmic. Articulation with the temporal bone has not been restored. J PROSTHET DENT 25446. C). ClassIV. A. D). physiologic. C. ClassII.) (Fig. 1. saliva control. In addition to the structures removed in the Class II patient.. and psychologic considerations. The ClassIV mandibular resectionpatient hashad a lateral resection and a subsequentbone augmentation to form a “pseudoarticulation” of bone and soft tissue in the region of the ascending ramus (Fig. 1. total resectionwith partial reconstructicIn. 1. 1. A. E). Even with bony augmentation many of the functional deficits associated with resectionsof the ant :rior portion of the 438 OCTOBER 1982 VOL JME 48 NUMBER 4 . causing increasedproblemswith mandibular deviation. and C utis. E. alveolar resection.and deglutition. R. but there is less mandibular deviation and more support for a prosthesis.: Prosthetic managementof edentulous mandibulectomy patients. total anterior resection reconstructed surgically. denture stability.

Arrows denote area of total mandibular resection. proper tissue support in the resectedregion may be compromised. (The functional concept of impressionmaking may be beneficial in someareas. The designof removable partial dentures for ClassI mandibular resectionpatients (Fig. Line A denotes primary fulcrum line around which prosthesis is expected to rotate. sidewithout severely compromisingesthetics. PROSTHESIS DESIGN CONSIDERATIONS The principles of partial denture design should be followed when planning a removable partial denture for the mandibular resection patient. somegeneral recommendations can be made.Minimal but effective retention is suggested because altered the mandibular function of these patients may encourage excessiveretentive forces that may exceed the physiologic limits of the supporting structures. and proximal plates for stability. However. Becauseeach lateral fragment moves independently. balanced hard and soft tissue support.the artificial teeth should be positioned to minimize occlusal forces on the resected Fig. Class I partially edentulous mandibular resection patients have adequate remaining structures for prosthesis support. Class II mandibular resection patients have diminished or no bony support on resected side. occlusal forces being directed along the long axis of the teeth. Multiple rests are indicated to increase support and distribute stress.) If possible.REMOVABLE PARTIAL DENTURE DESIGN Fig. 4. 2. lossof vestibular THE IOURNAL OF PROSTHETIC DENTISTRY 439 . secondary surgical procedures are often indicated to increasethe amount of mandible available for support and to mobilize a restricted tongue or lower lip. 2) should be similar to that for nonsurgical patients. The ClassVI mandibular resectionpatient is similar to a ClassV patient. 3. and an environment conducive to proper oral hygiene. redundant tissue. bracing and retentive elementswithin physiologic limits.guide planes. but the continuity of the mandible has not been restored surgically.’ and Kratochvil’ suggestthe need for rigid connectors. Altered cast impressionproceduresare essentialfor distal extension edentulousor surgically reducedridges. mandible remain. Although the application of theseprinciples in mandibular resection patients may vary due to the specificneedsof eachpatient. Line B denotesa secondary fulcrum line that becomesactive with excessiverotation. Henderson and SteffeJs Krol. Class II mandibular resection patients have proximal surface of last tooth on resectedside accessible for placement of a retentive arm. Scar bands. the prognosis for a removable prosthesis is poor and fabrication is not recommended. Fig. For successful prosthodontic rehabilitation.

. the length of the space and condition of the at utment teeth will determine the need for a fixed or rei novableprosthesis. for retention. 6.FIRTELL AND CURTIS Fig. Tooth-supported removable partia dentures do not require special design consideratio:ls.ound the fulcrum line connecting the most distal occlu! al rests bilaterally (Fig. 11). When a distal extension baseis required on the ncnresectedside. When a Class II mandibular resection patient has no teeth on resected side. the dista. Extending an occlusal rest to facial surface of abutment can provide a br. as occurs with many mandibular resection patient: (see Fig. depth. OCTOBER 1982 VOLUN E 4. surface of this abutment is accessiblein the mandibular resection patient. and an infrabulge area into which a retentive arm may be placed is often present. Proximal view of occlusal rest. Occlusal view of occlusal rest. A. First. Retentive arm can be placed on mesial surface of anterior abutment. 4). placing an I-bar retainer on the distal surfacc will provide a passive retentive arm in relation to :he primary fulcrum line when the distal extension denture base is depressed. -- Fig. The retainer on the defect side is comparable to the anterior c asp on the toothborne side of a Kennedy Class II *emovablepartial denture. and soft tissue attachments often prevent prosthesis extension and compromisethe occlusal scheme. but absenceof bony support prevents useof a prosthesisin the region (Fig.7 When by *The primary fulcrum which the prosthesis and axis are the center s of rotation around is expected to function iuring normal use. B. Class II mandibular resection patients have a distal extension space on the resected side.atochvil. 5). * Rest areas are rounded i:l all configurations to allow functional movements. If other modification spaces exist. This contour becomes more important when a tooth is tipped lingually. :cing component as suggested by Swenson and Terkla.This position for an I-ba:. the primary axis of rotation* centers a. Mesial rests are recommendedon the most distal abutments bilaterally with mii . primary fulcrum line fAJ passesthrough center of remaining teeth and rests.. Vestibuloplasty procedures may be indicated to increasesupport for the partial denture base.or connectorsand rests placed for proper bracing an1 reciprocation to prevent migration (Fig. However. The retentive arm on the defect I ide can be positioned to accomplish two objectives.9 NUMBER 4 . 5. 3). SI’ecial contours are necessary for occlusal rests when engaging proximal undercut. In both situations depressionof the distal extension base subjectsthe contrala era1 abutment to lateral torque. retainer allows function as suggested KroP and K .

7). Buccal view. When a Class II mandibular resection patient has no abutments on the resected side (Fig. Fig. The retentive arm is passive with rotation around the primary fulcrum line and active against occlusal displacement. The relief should be wide enough to allow cleaning with a small brush (Fig. Fig. 7. the prosthesis is displaced occlusally. B. 8. A. 9. there should be no contact with resin base to allow clasp flexibility and proper hygiene.EMOVABLE PARTIAL DENTURE DESIGN Fig. Class II mandibular resection patients with distal and anterior extensions will have a fulcrum line for distal extension CA’) and a different fulcrum line for anterior extension (AZ). 4). 8). The adjacent teeth resist distal forces on the anterior abutment. When a retentive arm is positioned on proximal surface of a tooth. Lingual view. the retentive arm becomes active. The replacement teeth contained in the anterior extension are positioned for THE JOURNAL OF PROSTHETIC DENTISTRY 441 . A Class II mandibular resection patient may have both a distal extension and an anterior extension (Fig. the primary fulcrum line is parallel or nearly parallel to the linear arrangement of the remaining teeth. To facilitate *?‘hr secondary fulcrum and axis are the centers of rotation around which the prosthesis may function under normal or abnormal use as movement of the prosthesis occurs and the fulcrum shifts. The distal retentive arm may force the tooth mesially. where the retentive tip cannot be placed on the distal surface. The distal extension should take precedenceas it is the primary functional area. the acrylic resin base in proximity to the abutment should be relieved. The retentive arm can be placed into the mesial undercut of the most anterior abutment with the same favorable functional result as placing the retentive arm into the distal undercut of the Class II distal extension design discussed previously. Class III mandibular resection patients have reduced bony support. flexion of the retentive arm and hygiene. but this force will be resisted by other teeth in the arch. Second. Retentive arms must be placed to reduce leverage around both fulcrums. 6). This is in contrast to the Kennedy Class II anterior abutment. on excessive rotation a secondary fulcrum* line becomes effective with the center of rotation on the defect side transfering to the retentive arm (Fig.

The replacement teeth are often position Ed for esthetics. esthetics with minimal function.: prosthesis. 9) is comparable to Class II mandibul u. The Class IV mandibular resectic n patient (Fig. The Class III mandibular resection patient (Fig. Note skin graft placed to release tongue and permit extension of prosthesis (arrows). and flexible retentive arms are placed into minimal undercuts on the lingual surface to reduce the leve ‘age created by the anterior extension. Class IV mandibular resection patients have had a bone graft. 5.ass II patient with both a distal extension base and ar anterior extension base. The mesial retentive arm would become active as the distal extension denture base was depressed. Posterior teeth are often present on both sides of the arch. but the undera t used should be as close as possible to the fulcrum line. Bilateral buccal and lingual occlusal rests and bracing elements establish a ful:rum line (A) and direct occlusal forces.resection patients whose abutments are present only on the nonresected side. The mesial undercut on the anterior abutment cannot be used in this situation as this retentive arm would be in direct conflict with rotation of the distal extension around the primary fulcrum line. 10.FIRTELL AND CURTIS Fig. which may be used for additional support. Fig.: amount of bony support available for the anterior extension. 12. Kratochvil’ refers to this extension as the “outrigger” because of the lack of bony suppor:. 10) is also similar to the Class II mandibular resection patient. This support should be recorded with fun ztional altered cast procedures so that both esthetics ar d function can be enhanced. The Class V mandibular resectior patient resembles a Kennedy Class IV removable part al denture patient because the resection crosses the :nidline. 11). which requires modification of rest configurations as suggested in Fig. there is increased support for a removabl. Unlike the Class III patien: . The design of the removable partial denture is similar to that described for the C. For these patients multiple occlusal rests are recommended. The remaining teeth often have a lingual inclination with little if any retentive undercut on the buccal surfaces. Bilateral lingual and buccal occlusal rests and bracing 442 OCTOBER 19132 VOLUME 48 NUMBER 4 . however. and speech in an area where there is mc cosal support only. Note lingual tipping of teeth. Class V mandibular resection patients have reduced support for placement of a prosthesis. The major difference is th. and the patient is cautioned to minimize anterior functional contacts. 11. but there is only a narrow area of bony idge available for support in the area of the defec (Fig. Fig. Retentive ilrms are placed on mesial surface of anterior abutmen s and are passive in function.

. THE JOURNAL OF PROSTHETIC DENTISTRY 443 .: Maxillary speech prostheses for mandibular surgical defects. C. A. Mosby Co. Keprmt DR. J. treatment. and Terkla.53. and psychologic considerations. 3... Louis. Part I: Retention T. M. In Beumer.S. Altug Kazanoglu. St. and Robert F.. A. G. T. J. N : &lraxillofacial Rehabilitation: Prosthodontic and Surgical Considerations. G.D.S.. A. J PROSTHET DEKT 22~2. The C. R. University of the Pacific. Retentive arms are placed on the mesial surface of the most anterior teeth. Jones. OP CALIFORNIA DEIVTISTRY 2. J PROSTHET DENT 14~992. 198 I.D. Part I: Anatomic. and A.ouis.sts to: N. and Edwin H. D. Mosby Co. h Beumer.’ are acceptable but require preparations that compromise tooth structure. The C. T. These retentive arms are passive when the prosthesis is placed in function and active when a dislodging force is applied to the prosthesis. Curtis. FIRTELI. I. MS. J. D.. Ribbon rests. The C.D. I). the basic concepts of support. REFERENCES 1. J.. St. D.. T. When the abutments have questionable periodontal support. Krol. Beumer III. F. Curtis. V.D. D.S. Louis. Cantor. Robinson.M. reyue. Suggestions for variations of design for different degrees of resections have been discussed. St.~ (Curtis. retention. Beumer. Ziegel.. CX 94143 ARTICLES TO APPEAR IN FUTURE ISSUES A contemporary review of the factors involved in complete denture retention. Jacobson. I. E. School of Dentistry. T.D. The extent of the surgical resection and the location and quality of the remaining structures will dictate the need to alter some basic principles of partial denture design.. S.: Sections on partial denture design. and Rubright.: Removable Partial Denture Design: Outline Syllabus. V. A. Mosby Co. sufficient tooth structure must be removed to permit adequate contour of rest seats and prevent fracture of the restoration. and Curtis. 1979. 6. November 1972. J PROSWET DENT 25~446. A. V. SUMMARY Design of removable partial dentures for patients who have had mandibular surgical resections varies from partial denture design for patients with intact mandibles. and Firtell. D.. suggested by Kratochvil. W.. Henderson.Sc. 1964.D. I&l. R. J.: Partial Denwrrs. 197 1. 1969.: McCracken’s Removable Partial Prosthodontics. St.$ and Vogel. and rehabilitation. L. 12). E. \‘. A qualitative A replacement comparison of various record base materials technique for a broken occlusal rest of silicone rubber prosthetic materials fabrication processing techniques John D. physiologic. V. Swenson. J. and stability should be fulfilled.. J. 1979. D. B.S.D. Even though the application of basic principles may vary in mandibular resection patients. T. J.: Maxillofacial Rehabilitation: Prosthodontic and Surgical Considerations. ed 6..M.REMOVABLE PARTIAL DENTURE DESIGN elements can establish a fulcrum line and direct occlusal forces in the long axis of abutment teeth (Fig. and Firtell. If a restoration must be placed under such an extensive rest. Louis. T. A. N. Cantor. and Curtis. Uimmsm Scfrtw~o~ SAN DAVID FRANUS~:O. Ph.. and Steffel.: Acquired defects of the mandible: Etiology. 5.. The C. Surface topography using conventional Keith Kent.: Prosthetic management of edentulous mandibulectomy patients. D.: Use of a guide plane for maintaining the residual fragment in partial or hrmimandibulectomy. and support. M. Mosby (h. ed 2. stability.. Smith. 1959. Kratochvil. the retentive arm may be replaced by a guide plane to increase stability in place of retention. 4. Shipp. D.D.

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