Prosthetic management of edentulous mandibulectomy

patients. Part I. Anatomic, physiologic, and

psychologic considerations

Robert Cantor, D.D.S., M.S.,* and Thomas A. Curtis, D.D.S.**

University of California, School of Dentistry, San Francisco, Calif.

0 ne of the most consistently frustrating areas of maxillofacial rehabilitation is

the treatment of edentulous patients who have had radical cancer surgery of the
tongue, floor of the mouth, and mandible. Mandibulectomy and commando pro-
cedures involve the extensive loss of tissuesand associated functions. The pros-
thetic prognosis is rarely good, and reconstructive surgical procedures, even when
indicated, usually do not significantly improve the prosthetic potential. In a recent
discussionof the follow-up role of prosthetics for ablative surgery of the head and
neck, Dr. John Conley stated, “Maxillofacial prosthetic treatment has been of
enormous benefit to most of my post-surgical patients. However, prosthetic treat-
ment of the edentulous mandibulectomy patient is usually unsuccessful.This is the
area in which research and new ideas are desperately needed.“l
Modern prosthetic treatment could not have evolved without the anatomic
and physiologic discussionsof Boucher,” Pendleton3 Silverman4 and others. For
example, MacMillin5 noted that textbook descriptions of muscular functioning
related to the mandible containing teeth are significantly different from the mus-
cular activity of the edentulous mandible. Similarly, available discussionsof mus-
cular activity pertinent to the edentulous mandible are not appropriate when de-
scribing the altered functions of the maxillofacial structures following radical
mandibular surgery.
An understanding of postsurgical anatomy and physiology is an obvious pre-
requisite to the development of new prosthetic procedures for mandibulectomy
patients. Only this understanding will permit functional utilization of these unusual
postoperative anatomic conditions.

Read before the American Academy of Maxillofacial Prosthetics, Oct., 1969, New York,
N. Y.
*Assistant Research Biologist and Co-Director, Maxillofacial Rehabilitation Clinic.
**Lecturer in Prosthetic Dentistry and Director, Maxillofacial Rehabilitation Clinic.

446
Vlhrne. 25 Prosthetic management of mandibulectomy patients 447
Number 4

An attempt was made by the Maxillofacial Rehabilitation Clinic at the Uni-

versity of California San Francisco Medical Center to investigate and describe
the altered dynamics of the postsurgical lower denture space, to formulate new
treatment concepts based on this inquiry, and to evaluate the effectiveness of
these new procedures. The results of this study will be presented in a 3 part
article. In Part I, the postsurgical physiology and anatomy related to deglutition,
speech, mandibular movements, mastication, saliva control, and respiration will
be discussed.A classification of mandibulectomy patients and some postsurgical
anatomic characteristics of each group will be presented.
Part II will present a step-by-step discussionof clinical procedures specifically
designed for the altered anatomic and physiologic conditions of mandibulectomy
patients, as well as the relevant prosthetic principles involved.
Part III will present a clinical research study of 30 mandibulectomy patients
for whom both the new prosthetic procedures and the more traditional or usual
denture techniques were used and compared.

GENERAL PHYSIOLOGIC CONSIDERATIONS

Swallowing, speech, mandibular movements, mastication, control of saliva,
respiration, and psychic functioning are adversely affected by radical mandibular
surgery. These dysfunctions radically alter the prosthetic prognosis. The degree
of impairment depends not only on the extent and type of surgery but also on
the specific vulnerability of each function. Both the adaptability of these functions
to surgical insult and the kind of impairment caused by various mandibular
surgical procedures will be discussed.

FUNCTIONAL ADAPTABILITY
Deglutition
Normal deglutition is a primary process. A bolus of food is carried through
the fauces and into the pharynx by the dorsum of the tongue. The nasopharynx
is closed by the soft palate, and the larynx is elevated. The soft palate, posterior
part of the tongue, gravity, and pharyngeal air pressure combine to force the
bolus of food into the dilated esophaLgus,and peristaltic contractions transfer it
to the stomach.
Postoperative swallowing can be temporarily or permanently impaired. How-
ever, since swallowing is a primary function and not easily disrupted, the ability
to swallow usually will return. Deglutition can be performed with a minimum of
tnuscular tissue and even with the loss of such skeletal structures as the mandible
and hyoid bone.s With an intact larynx, the voluntary closure of the glottis may be
learned. This action combined with a “gulp” movement bypassesmuch of the
oral and pharyngeal phasesof swallowing and throws the liquid into the esophageal
phase and the initiation of peristaltic action.7
However, tissuelossor reduced muscular and neuromuscular control of oral and
laryngeal structures will restrict the anterior elevation of the floor of the mouth,
hyoid bone, and larynx. Dysfunction occurs when ( 1) tongue immobility, (2)
denervation of the glossopharyngeal, vagus, and superior laryngeal nerves, (3)
scarring, or (4) radiation fibrosis prevents the patient from exerting sufficient
440 Cantor and Curtis J. Prosth. Dent.
April, 1971

pressure on the cricopharyngeal muscles to open the esophagus. Liquid and food
will then “pool” in the hypopharynx. The problem is compounded if the crico-
pharyngeal muscles are denervated or if the soft palate is impaired as a result of
an operation.

Speech
Normal speech is a learned process, and therefore it is influenced by vision,
hearing, intelligence, motivation, and imitation. A stream of air vibrates the vocal
folds and produces laryngeal sound waves. This sound takes on a characteristic
quality because of anatomic resonating chambers and is then broken up into
language sounds by the action of the tongue, lips, and cheeks. A high degree of
central nervous system development is essential to coordinate the complex neuro-
muscular patterns associated with speech production. Kantner and West8 de-
scribe the components of speech as respiration, phonation, resonance, articula-
tion, and neurologic integration. The function of speech is easily disturbed, and
any of these speech components can be affected. However, speech distortion
usually occurs in mandibulectomy patients by impairment of the articulating
mechanism and/or alteration of the resonating chambers.
The tongue is the main articulator-y organ in the production of speech, and
extremely rapid changes in position and morphology are required.s Postsurgical
reduction in tongue size and restricted mobility can prevent tongue-palate valving
and resultant speech distortions, although vowel sounds are usually unaffected.s
Anterior tongue restriction can cause distortion of consonants such as “d” or “t”,
while “g” and “k” will be adversely affected by posterior tongue restriction. Dis-
placement of a mandibular fragment will cause confluent asymmetric functioning
of the tongue affecting a variety of speech sounds. The corresponding displace-
ment, or scarring, of the lower lip can interfere with the production of sounds
such as “v” and “f.” Impairment of these articulating structures causes speech
distortions ranging from slight slurring to unintelligibility.
The resonating chambers include the pharynx and the oral cavity. Scarring,
compensatory overclosure of the mandibular fragment, and tissue loss resulting
in an undersized, misshapen,and immobile residual tongue combine to dramatical-
ly alter the form and resonating character of these spaces. Speech can become
hohow, flat, and muffled.

Mandibular movement and mastication

Normal mastication is a learned, volitional, and automatic process giving rise
to many individual variations. 4 Despite the degree of learned differentiation, this
function can often readjust following surgical insult. The literature is resplendent
with theories and discussionsof vertical dimension, centric relation, and mastica-
tory movements.lo-l2 However, this discussionwill be restricted to the characteris-
tics of mandibular functioning that influence postsurgical compensatory adjust-
ments.
The components of occlusion have been describedI as the temporomandibular
joint structures, the musculature which activates the masticatory apparatus, and
the denture-bearing tissues.All three components are radically altered by mandibu-
Volume 25 Prosthetic management of mandibulectomy patients 449
Number 4

1a.r surgery. Mandibular movements are partially controlled by the bilateral ac-
tion of the temporomandibular joints, and disarticulation of the joint on one
side will result in unilateral distortions. However, one advantageous characteristic
o:f the temporomandibular joints is that, when one joint is lost, the muscles of
the maxillofacial group can substitute for each other and maintain a functional
equilibrium.5 For example, the internal pterygoid and mylohyoid muscles pull
the resected mandible medially or toward the defect, but the temporal and masseter
muscles reciprocate in a superior and lateral direction. The ability of the muscles
of mastication to maintain a functional equilibrium following a mandibulectomy
can be easily overcome by scar contracture, and it is, therefore, important to
resist this scar displacement.
The muscles of mastication are normally in a state of equilibrium when the
opposing teeth are lightly touching. The centric occlusal position of the mandib-
ulectomy patient is medially displaced with a corresponding loss of vertical di-
mension. Masticatory force can be exerted along this deflected pathway, but
t:he patient is seldom capable of sufficiently coordinated muscular strength fol
normal mastication. In many instances, the patient can approximate the pre-
surgical centric occlusal position, but restoration of the original occlusal vertical
d.imension can interfere with compensatory speech and swallowing functions and
can diminish masticatory strength.

Saliva control
Drooling and other problems associated with changes in salivary consistency
a.nd control comprise one of the most debilitating postsurgical sequelae of man-
clibulectomy patients. These patients can suffer from too much or too little
saliva.
Drooling. Restricted tongue movements; difficulties in swallowing; the absence
of labial, buccal, and lingual sulci; scarring of the orbicularis oris; and incision
notching of the lower lip, as well as the loss of sensory awareness, will impair
the patient’s ability to control his salivary secretions. The role of hypersalivation
in the genesis of drooling is considered minimally significant by Smith and Goode”
when compared with failure to swallow salivary secretions or inability to retain
accumulated secretions within the mouth. However, insertion of the resection
prosthesis, or denture irritation, can produce excessive salivation. Although
this component is usually temporary, extreme drooling during the adjustment
period can demoralize the patient and permanently influence prosthetic trent-
ment.
Xerostomia. A large number of mandibulectomy patients who have undergone
radiation therapy suffer from partial xerostomia and thick salivary secretions.
When the salivary glands are included in the field of irradiation, varying degrees
of fibrosis, fatty degeneration, acinar atrophy (especially of the serous glands) , and
cellular necrosis take place. I5 The reduction in the amount of saliva present and
its characteristic sticky quality will adversely affect denture retention, tissue
tolerance, and taste. Fortunately, there is often some regeneration of salivary func-
tion, but chronic dryness of the oral mucous membranes influences prosthetic
therapy.
450 Cantor and Curtis J. Prosth. Dent.
April, 1971

Respiration
Respiration is, of course, a primary processthat involves the maxillofacial struc-
tures. These structures must maintain a patent airway and must alter the physical
properties of the inspired air to protect the sensitive lung tissues.The mandible and
associated structures must alter their relationships to the skull and cervical spine
in order to maintain patency during postural changes.4Continuous muscular ac-
tivity is required, and therefore, there is no consistent physiologic rest position.
This variability of respiratory rest position permits constant maintenance of an
optimal airway with minimal expenditure of energy.
In order to maintain the airway following a mandibulectomy, muscular altera-
tions are required to compensate for postsurgical anatomical distortions. If laryngeal
movements are severely restricted or if the larynx and hypopharynx are denervated,
the lungs will be unprotected from food and liquid. In rare instances, the size of
the fauces is surgically reduced to a point that compromises the oral airway. If
these anatomic conditions exist, a prosthesis can seriously impair oral patency,
especially if there is partial obstruction of the nasal cavities or nasopharynx. Pa-
tients who have had radiation therapy and surgery are especially affected by oral
tissue desiccation and experience great difficulty with oral breathing.

Psychosocial factors
It is therapeutically unrealistic to discussfunctional impairment without mak-
ing reference to the psychic and social factors affecting the mandibulectomy pa-
tient. These patients often describe the changes caused by radical surgery as the
termination of their “former life.” Distortions in self-image, inability to communi-
cate, and shifting family and vocational roles require the reconstruction of psychic
systems to adequately handle the new internal and external demands.
Social and behavioral compensationsare needed becauseof the frequent nega-
tive responsesencountered in social situations. These responsescan range from
staring and whispering to various forms of “social stereotyping.“ls* I7 The most
common stereotypic responseto the mandibulectomy patient is that of a “down-
and-out drunk.” Postsurgical speech slurring, depressive confusion, and rednessof
the facial tissuesdue to radiation can mimic the appearance of this well-known
social outcast, and many mandibulectomy patients must overcome these and
other initial negative impressions. Many other difficult social encounters can be
traced to the commonly held “contamination” fear of cancer and death. If the
mandibulectomy patient honestly answers questions concerning his appearance or
speech, the close identification with malignancy will often be so threatening to
the listener that the patient is repulsed and isolated. An emotionally stable person
could account for these negative responses,but the patient is also struggling with
many internal conflicts which minimize his objective perceptions.
Severe anxiety, denial, depressive stupor, and diffuse hostility are often present
in mandibulectomy patients and overlay the symptoms of mild depression and
hysteria in relation to ordinary prosthetic treatment as described by Ramsey.l*
Even xerostomia, “burning” mouth, and diminution of taste normally ascribed
to radiation therapy can be caused by depression.lg* 2o When the initial reaction
Valume 25 Prosthetic management of mandibulectomy patients 451
Number 4

of disbelief at the diagnosis of cancer dissipatesand the reality of death is ac-

cepted, the patient will usually respond with anger, rage, envy, and resentment.‘l
This anger is displaced in all directions and is projected into the environment
almost at random. Major treatment difficulties can arise if the clinician takes the
patient’s anger personally. Kfibler-Ross*l describesan alternative behavior to an,ger
a:; “bargaining.”
The psychodynamics of this emotional state are verbally characterized in the
following illustration : “I was unable to deny my illness and the strong likelihood
I will die; my anger was to no avail; however, if I am very nice and cooperative,
maybe fate will postpone the inevitable.” Desperation is well represented in the
patient who is overly eager to please.
Acute depression is the most common psychologic symptom of the postsurgical
cancer patient and is often disregarded during treatment. The spell of depression
usually results from a senseof great 10s~~’(the physical loss of a part of the jaw.
the financial loss of a business,and the psychic loss of self-esteemand authority‘ .
FLadoz3believes that, regardless of the nature of the loss, its extraordinary mean-
i-ng for the patient lies in the fact that terrible childhood experiences are evoked
and that at least a part of the depressedperson’s behavior can be described as a
display of helplessness,a cry for love, or a direct appeal for the security that has
been lost. Whitez4 adds that this reaction is complicated by the presence of hos-
tility toward those associated with the loss and also by the guilty fear that the
hostility itself has actually caused the loss. This type of patient has little desire
for rehabilitation or tolerance for demanding prosthetic procedures. Genuinely
successful prosthetic treatment requires the clinical understanding of these and
other relevant psychosocial factors,

CLASSIFICATION OF SURGICAL IMPAIRMENT

Previous investigators have referred to mandibulectomy patients as a single
igroup. However, it is obvious that the problems encountered by a patient who
has lost the anterior portion of his mandible are quite different from those follow-
:Lng disarticulation. In order to further discuss mandibulectomy patients and to
lrvaluate existing and new prosthetic techniques, it was deemed necessary to de-
,relop a classification system. Therefore, six postsurgical anatomic categories were
arbitrarily defined to help clarify future discussionsof these patients. As will be
noted, the classifications are based on the amount of the mandible that has been
resected or restored and are specific to edentulous patients. The categories are
as follows: Class I-radical alveolectomy with preservation of mandibular con-
tinuity; Class II-lateral resection of the mandible distal to the cuspid; Class
III--lateral resection of the mandibIe to the midline; Class IV-lateral bone graft
surgical reconstruction; CIass V-anterior bone graft surgical reconstruction; and
Class VI-resection of the anterior portion of the mandible without reconstruc-
tive surgery to unite the lateral fragments.
There are many postsurgical conditions that do not fit easily into these cate-
gories. This classification was determined by prosthetic, not surgical, considera-
tions, and the categories were limited for two reasons: to make it possible to
describe the general characteristics of each group and to evaluate prosthetic
452 Cantor and Curtis J. Prosth: Dent.
AprJ, 1971

Fig. 1. Class I. Radical mandibular alveolectomy.

procedures on a specific group basis. The first five groups seem appropriate for
these two tasks. Since patients in the Class VI category present very poor pros-
thetic prognoses, this group was not included in the study and will not be dis-
cussed. Concomitant radical neck dissections in conjunction with mandibular
resections are assumedin the following discussionswhich are based on commonly
accepted surgical procedures.25 The extent of surgery is decided by the type, size,
and location of the tumor, as well as the presence or absence of lymph node
involvement. Only those structures directly affecting the prosthetic prognosis
will be emphasized.

Class I
The tissuesresected on the affected side include these: a portion of the alveolar
process and body of the mandible; the mucoperiosteum of the mandible; the
lingual and buccal sulcus mucosa; a portion of the base of the tongue and
mylohyoid muscle; the lingual and inferior alveolar nerves; the sublingual and
submaxillary salivary glands; and, at times, the anterior part of the digastric
muscle (Fig. 1) ,
The structures that remain on the affected side are essentially normal and
include these: an intact lower border of the mandible; all primary and auxiliary
muscles of mastication; most of the tongue; and the mylohyoid muscle with the
exception of the scar tissue in the region of the resection.
Patients in this group function quite normally, although resection of a part
of the mylohyoid muscle and resultant scarring can interfere with raising the
floor of the mouth, and this often causes some reduction in tongue mobility.
The ability to shape and control tongue form can be impaired also by loss of
some of the intrinsic muscles. Resection of the lingual and inferior alveolar nerves
results in a loss of sensation in the mucosa of the cheek, alveolar process, lower
lip, and epithelium of the lower part of the face and loss of taste on the anterior
two thirds of the tongue. Motor control by the mylohyoid muscle can be irn-
paired, and motor function of the tongue is affected if the hypoglossal nerve is lost.
Volume 25 Prosthetic management of mandibulectomy patients 453
Number 4

Fig. 2. Class II. Lateral mandibular resection.

Clctss II

The tissues resected on the affected side include: the condyle, ramus, and
body of the mandible distal to the cuspid; the mylohyoid, hyoglossal, anterior
belly of the digastric, internal pterygoid, masseter, and external pterygoid muscles;
the pharyngoglossal and palatoglossal muscles when the tonsils are involved;
most of the intrinsic muscles of the tongue; the hypoglossal, lingual, and in-
ferior alveolar nerves; the sublingual and submaxillary salivary glands; and the
mucoperiosteum and adjacent buccal and lingual sulcus mucosa (Fig. 2).
The structures that remain on the affected side and comprise the boundaries
of the lower denture space include the following: the anterior part of the mandible;
the tip of the tongue; the anterior lingual sulcus; some of the intrinsic tongue
muscles; and the genioglossus and geniohyoid muscles. In some instances, it is
possible to leave the anterior two thirds of the tongue intact and to limit the
resection to the structures posterior to the mylohyoid muscle.
Patients in this group have multiple functional impairments. Disarticulation
and the loss of the muscles of mastication will result in distortions of mandibular
movements. Similar taste, sensory, and motor losses are found in the Class I
mandibulectomy patients, but these defects are more extensive. Speech, swallow-
ing, saliva control, and manipulation of food are all somewhat more impaired.
Facial disfigurement becomes apparent. Interference with swallowing can result
if a portion of the palatoglossus muscle remains active. This muscle will contract
during deglutition and reduce the opening into the pharynx. If the pyriform sinus
has been partially resected, the passageway into the hypopharynx is further re-
duced by the stump of the internal pterygoid muscle. The tongue is sutured to the
buccal mucosa on the defect side posterior to the cuspid, and muscular function
of the buccinator muscle is severely limited. However, the tip of the tongue does
remain for some control of saliva, manipulation of food, and speech.

CllUSS Ill
The resected tissues include all those described in the Class II category in
addition to the anterior portion of the mandible, the genioglossus muscle, the
454 Cantor and Curtis J. Prosth. Dent.
April, 1971

Fig. 3. Class III. Lateral mandibular resection (A) without hemiglossectomy, and (B) in
conjunction with hemiglossectomy.

Fig. 4. Class IV. Lateral bone and split-thickness skin graft.

geniohyoid muscle, and the remaining portion of the mylohyoid muscle with
adjacent lingual and buccal mucosa (Fig. 3). The tissuesremaining on the defect
side include the cheek mucosa, small portions of the palatogIossa1and internal
pterygoid muscles, and that portion of the tongue used to reform the floor of the
oral cavity by attaching it to the buccal mucosa. The lower denture space is
totally obliterated.
The loss of the tip of the tongue and genioglossusmuscle severely restricts
tongue mobility. A loss of tongue position also results, since this muscle keeps
the tongue from falling posteriorly. Speech, swallowing, saliva control and
manipulation of food are severely restricted in this group of patients. Facial dis-
figurement is also considerably worse because of the loss of the anterior part of
the mandible. Disarticulation and the reduction in the amount of basal bone
t’olumt 25 YroJthetic management of mandibulcc:tomy patients 455
h umbrr 4

further reduce the prosthetic prognosis. Scarring of the musculus orbicularis oris
c.an interfere with expressions of emotion and can also result in some slight articula-
tory distortions of speech.
There are instances when midline mandibular resections are performed with-
out removing the anterior part of the tongue (Fig. 3, A). When this occurs, the
functional impairment is substantially reduced, but the prosthetic prognosis remains
very poor due to the loss of so much bone.

Class IV
Lateral bone and split thickness skin or pedicle graft surgical procedures can
‘ae performed for patients who have had ( 1) radical alveolectomies, (2) resec-
tions of the mandible distal to the cuspid with or without disarticulation, and (3)
midline resections with or without disarticulation (Fig, 4). There are essentially
three types of bone grafts: mandibular augmentation procedures, bone grafts that
~connect a residual condyle with the larger mandibular fragment, and lateral bone
grafts that extend from the mandibular fragment into the defect area to establish
a pseudo temporomandibular joint. The prosthetic prognosis varies with each type
of reconstructive surgery. Alloplastic implant materials can be used, but prosthetic
treatment is rarely indicated for these patients; this group, therefore, will not be
discussed.
Patients who have been subjected to radical alveolectomies and secondary bone
augmentation procedures have essentially the same problems as do Class I mandib-
ulectomy patients or those who have had surgery for severe alveolar resorption.
Prosthetic treatment difficulties are less often encountered with this group of patients.
Bone grafts that connect a condylar fragment with the larger mandibular frag-
merrt permit the remaining maxillofacial structures to more easily control mandib-
ular movements. However, reduced condylar mobility, scar contracture, the loss
of muscles or muscle attachments, and the loss of muscular innervation can con-
tinue to cause restrictions of various functions.
A lateral bone graft that terminates in a fibrous tissue pseudo socket is com-
monly performed. Secondary split thickness skin grafts are used to extend the
lower denture space and to make the bone graft accessible for prosthetic utiliza-
tion. Following this reconstructive surgery, there is usually less unilateral action of
the mandibular fragment due to the passive resistance of the soft tissues in the
area of the bone graft. The floor of the mouth becomes wider, and the remaining
tissue bed often is stretched. It is sometimes possible to increase tongue mobility
by means of a split thickness, dermal, or pedicle graft. Tongue release procedures
are limited by the amount and posterior extension of the scar tissue present. The
shape and size of the surgically created sulcus depend on such factors as contrac-
tion of the skin graft, tissue reactions to radiation therapy, secondary infection, and
the size of the original sulcus. These patients will continue to experience deviation
of the mandible toward the defect side during opening movements and movement
toward a former centric relation during closing movements. Gravity and primary
scarring, as well as the excessive strength of the remaining muscles of mastication
that close the mandible, contribute to this tendency.
456 Cantor and Curtis J. Pro&h. Dent.
April, 1971

Fig. 5. Class V. Anterior bone and split-thickness skin graft.

Class V
Edentulous patients who have had anterior resections of the mandible have
two independent fragments or temporary intra-arch fixation and can rarely be
helped prosthetically. However, following anterior bone, skin, or pedicle grafting,
some prosthetic management is often feasible, and the primary and secondary
surgical procedures will, therefore, be discussed.
The tissues resected at the time of the original operation in&de: the anterior
portion of the mandible (usually from second bicuspid to second bicuspid) ; large
bilateral portions of the mylohyoid, geniohyoid, genioglossus, and the anterior
digastric muscles; bilateral lingual and inferior alveolar nerves; bilateral sub-
maxillary and submandibular salivary glands; and the mucosa of the lower lip,
anterior floor of the mouth, and the ventral surface of the tongue (Fig. 5). The
mucosa retained in the labial and buccal regions is sutured to the residual stump
of the tongue, and a Kirschner wire often is positioned to help maintain the
mandibular fragments.
Bone graft and split thickness skin, or pedicle, graft procedures can be used
to restore anterior facial contour and bilateral mandibular function. Preservation
of the hypoglossal nerve is critical, since tongue mobility is primarily achieved by
means of the intrinsic muscles of the tongue which project the stump forward and
laterally. Since the styloglossus, palatoglossal, and pharyngoglossal muscles are
present, it is possible for the tongue to bunch up and push in a posterior direction
to initiate deglutition and to produce guttural speech sounds. However, should the
hypoglossal nerve be lost bilaterally, this motor activity is severely limited. Ipsilateral
lower lip function is lost if the marginal mandibular branch of the facial nerve is
resected.

SUMMARY
Part I of this series of articles dealing with the prosthetic treatment of man-
dibulectomy patients presents some general physiologic considerations pertinent to
mandibulectomy patients discussed in terms of functional adaptability to surgical
insult, Deglutition, speech, mandibular movement and mastication, saliva control,
Volume 25 Prosthetic management of mandibulectomy patients 457
Number 4

respiration, and psychosocial factors are characterized. A classification of mandib-

,ulectomy patients is suggested, and the anatomic and physiologic oral conditions
of the patients in each group are described,
Part II will present a step-by-step discussion of clinical procedures specifically
designed for the anatomic and physiologic alterations of these patients.
Part III will present an evaluation of these suggested procedures by means of
a clinical research study of 30 mandibulectomy patients.

References
1. Conley, J.: The Role of Prosthetics in Ablative Surgery of the Head and Neck, Lecture
to the A.A.M.P., New York, N. Y., Oct., 1969.
2. Boucher, C. 0.: Impressions for Complete Dentures, J. Amer. Dent. Ass. 30: 14, 1944.
3. Pendleton, E. C.: Anatomy of the Face and Mouth From the Standpoint of the Denture
Prosthetist, J. Amer. Dent. Ass. 33: 219, 1946.
4. Silverman, S. I.: Denture Prosthesis and Functional Anatomy of the Maxillofacial Struc-
tures, J. PROSTH. DENT. 6: 305, 1956.
5. MacMillin, H. W.: Anatomy of the Throat, Mylohyoid Region and Mandible in Relation
to Mandibular Artificial Dentures, J. Amer. Dent. Ass. 23: 1435, 1937.
6. Silverman, S. I.: Oral Physiology, St. Louis, 1961, The C. V. Mosby Company.
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8. Kantner, C. F., and West, R.: Phonetics, New York, 1941, Harper & Brothers.
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theses for Mandibular Surgical Defects, J. PROSTH. DENT. 22: 253, 1969.
10. Granger, E. R.: Functional Relations of the Stomatognathic System, J. Amer. Dent. Ass.
48: 638, 1954.
11. Kurth, Cl. E.: Mandibular Movements and Articulator Occlusion, J. Amer. Dent. Ass. 39:
37, 1949.
12. Perry, H. T., and Harris, S. C.: Role of the Neuromuscular System in Functional Ac-
tivity of the Mandible, J. Amer. Dent. Ass. 48: 665, 1954.
13. Boucher, C. 0.: Occlusion in Prosthodontics, J. PROSTH. DENT. 3: 633, 1953.
14. Smith, R. A., and Goode, R. L.: Sialorrhea, Accepted for Publication, New Eng. J.
Med., 1970.
15. Silverman, S., and Galante, M.: Oral Cancer Monograph, San Francisco, 1966, Uni-
versity of California Medical Center Press.
16. McGregor, F. C., Abel, T. M., and Bryt, A.: Facial Deformities and Plastic Surgery-a
Psycho-social Study, Springfield, Ill., 1953, Charles C Thomas, Publisher.
17. Goffman, E.: Stigma, Englewood Cliis, N. J., 1963, Prentice-Hall, Inc.
18. Ramsey, W. 0.: The Relation of Emotional Factors to Prosthodontic Service, J, PROSTH.
DENT. 23: 4, 1970.
19. Busfield, B. L., and Wechsler, H.: Studies of Salivation in Depression, Arch. Gen.
Psychiat. 4: 10, 1961.
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