[Link].

in

CH AP T ER

Removable Partial Denture

Considerations in Maxillofacial
Prosthetics
CHAPTER OUTLINE MAXILLOFACIAL PROSTHETICS
Maxillofacial Prosthetics e preceding chapters have dealt with prosthesis consider-
Maxillofacial Classification ations for partially edentulous individuals. In these patients,
Timing of Dental and Maxillofacial Prosthetic Care the extent of loss includes teeth and a varying degree of
for Acquired Defects residual ridge bone, yet the remaining anatomy of the jaws
Preoperative and Intraoperative Care and adjacent regions is functionally and physically intact. For
Interim Care these patients, the major distinguishing feature that a ects
Potential Complications removable partial denture design is whether the prosthesis
Defect and Oral Hygiene will be tooth-supported or tooth- and tissue-supported.
Definitive Care e maxillofacial patient can experience unique altera-
Intraoral Prostheses: Design Considerations tions in the normal oral/craniofacial environment; these
Surgical Preservation for Prosthesis Benefit result from surgical resections (Figure 25-1), maxillofacial
Maxillary Defects trauma, congenital defects, developmental anomalies, or neu-
Mandibular Defects romuscular disease. In contrast to the above, when remov-
Mandibular Reconstruction—Bone Grafts able partial dentures are considered for these individuals, not
Maxillary Prostheses only are tooth and tissue support considerations important,
Obturator Prostheses but the design must also take into account what impact the
Speech Aid Prostheses altered environment will have on prosthesis support, stabil-
Palatal Lift Prostheses ity, and retention. In general, environmental changes reduce
Palatal Augmentation Prostheses the capacity for residual teeth and tissue to provide optimum
Mandibular Prostheses cross-arch support, stability, and retention.
Evolution of Mandibular Surgical Resection As a subspecialty of prosthodontics, maxillofacial pros-
Type I Resection thetics is concerned with the restoration and/or replacement
Type II Resection of the stomatognathic system and associated facial structures
Type III Resection with prostheses that may or may not be removed on a regu-
Type IV Resection lar or elective basis. is chapter discusses important back-
Type V Resection ground information related to maxillofacial prostheses and
Mandibular Guide Flange Prosthesis the principals involved in removable partial denture design
Jaw Relation Records for Mandibular Resection Patients for the maxillofacial patient.
Summary
Maxillofacial Classification
Patients can be categorized by maxillofacial defects that are
acquired, congenital, or developmental. Acquired defects
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316 Part III Maintenance

A B

Figure 25-1 A unilateral arrangement of maxillary teeth (A), no remaining horizontal hard palate, and a surgical defect, which includes
nasal and sinus cavities (B). This unique environment, which is the result of a surgical resection, requires careful application of removable
prosthodontic principles modified for maxillofacial needs.

replacement) or intraoral (involving the oral cavity); interim

(for short periods of time, o en perioperative) or de nitive
(more permanent); and treatment (used as a component of
management, such as a splint or stent) prostheses.

TIMING OF DENTAL AND MAXILLOFACIAL

PROSTHETIC CARE FOR ACQUIRED DEFECTS
Acquired defects are the most common maxillofacial defects
managed by using removable prostheses. A conceptual frame-
work for the timing of dental/oral care that best emphasizes
the initial important surgical requirements, followed later by
the important prosthetic requirements, is helpful to consider
regarding the coordination of care for patients with acquired
defects. Such a framework considers preoperative and intraop-
Figure 25-2 Large squamous cell carcinoma involving the erative interim care and de nitive care. Although it may seem
maxillary tuberosity region, which will result in an acquired defect unrelated initially, it is included in this discussion of removable
following surgical removal. partial dentures for maxillofacial applications because of the
important impact that decisions made at all stages of manage-
include those that are the result of trauma or of disease and ment can have on prosthesis function and patient outcomes.
its treatment. ese may include a so and/or hard palate
defect resulting from removal of a squamous cell carcinoma Preoperative and Intraoperative Care
of the region (Figure 25-2). Congenital defects are typically e planning of prosthetic treatment for acquired oral
craniofacial defects that are present from birth. e most defects should begin before surgery. For the patient facing
common of these include cle defects of the palate that may head and neck surgery, consideration should be given to
include the premaxillary alveolus. Developmental defects dental needs that will improve the immediate postopera-
are those defects that occur because of some genetic predis- tive course. Consequently, the prosthodontist who will help
position that is expressed during growth and development with management of the patient’s care should see the patient
(Figure 25-3). Such a classi cation order is helpful as patients before surgery (Figure 25-4). e dental objectives of the
within each category share similar characteristics (beyond preoperative and intraoperative care stages are to remove
those features speci cally related to the prosthesis design), potential dental postoperative complications, to plan for the
which become part of the total management plan. For exam- subsequent prosthetic treatment, and to make recommen-
ple, prosthetic management of an adult who has experienced dations for surgical site preparation that improve structural
a maxillectomy procedure can be quite di erent from man- integrity. Important patient bene ts of such a preoperative
agement of a patient with an unrepaired cle palate. consultation include the opportunity to develop the patient-
Another helpful way to classify maxillofacial patients clinician relationship, to discuss the functional de cits
is by the type of prosthesis under consideration. Conse- associated with the anticipated surgical procedure, and to
quently, prostheses are said to be extraoral (cranial or facial describe how and to what extent the stages of prosthetic
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Chapter 25 Removable Partial Denture Considerations in Maxillofacial Prosthetics 317

A B

Figure 25-3 A functional jaw position developed because of a combination of tooth loss and growth discrepancy. This developmen-
tal defect is illustrated by a protruded and over-closed mandibular position (A), which has created a significantly irregular maxillary
occlusal plane (B).

should be treated, as should any periodontal condition that

could potentially cause postoperative pain because of exces-
sive mobility or oral infection. Any tooth deemed nonre-
storable because of advanced caries or periodontal disease,
and not critical for temporary use during the interim care
period following temporary treatment, should be removed
before, or at the time of, surgical resection. Teeth that may
appear to have a limited long-term prognosis may signi -
cantly enhance prosthetic service during the initial postsur-
gical period and should be maintained until the initiation of
de nitive care.
Impressions are made of the maxillary and mandibular
arches to provide a record of existing conditions and occlusion
to allow fabrication of immediate or interim prostheses (Fig-
ure 25-5) and to assess the need for immediate and delayed
Figure 25-4 Presurgical presentation of a patient with a
modi cation of the teeth or adjacent structures to optimize
maxillary malignant melanoma. The benefits of having such a
prosthetic care. It is important at this stage to begin planning
visit before surgery are both psychological and functional. The
psychological benefits include the chance to discuss functional for the de nitive prosthesis because the greatest impact on the
deficits associated with the anticipated surgical procedure and to success of the maxillofacial prosthesis stems from the integ-
describe how and to what extent the stages of prosthetic manage- rity of the remaining teeth and surrounding structures.
ment will address them. The functional benefit from a prosthe-
sis standpoint is that strategically important teeth, for definitive Interim Care
and/or interim prosthesis use, can be discussed with the surgical e major emphasis during this stage of care is the surgi-
team and treatment planned for preservation. cal (and adjunctive) management needs of the patient. In
today’s environment of appropriately aggressive mandibular
management will address them. e bene t from a prosthe- surgical reconstruction, mandibular discontinuity defects
sis standpoint is that strategically important teeth, for de ni- are seldom a surgical outcome. When discontinuity defects
tive and/or interim prosthesis use, can be discussed with the in the mandible result following surgery, interim prosthetic
surgical team and treatment planned for preservation. care is not indicated and the discussion will be directed to
e immediate postoperative period will be signi cantly the maxillary defect.
challenging to the patient. If pre-existing dental disease is e typical maxillary acquired defect results in oral
severe enough to potentially create symptoms during the communication with the nose and/or maxillary sinus,
immediate postoperative period, treatment should be pro- although the composition of the surgical defect may vary
vided to remove such a complication. Large carious lesions, widely (Figure 25-6). is creates physiologic and func-
which could create pain, can be temporarily restored by end- tional de ciencies in mastication, deglutition, and speech.
odontic therapy if they o er some advantage for postopera- Such defects have a negative impact on the psychological
tive prosthetic function. Teeth exhibiting acute periodontal disposition of patients, especially if the defect also a ects
disease (such as acute necrotizing ulcerative gingivitis) cosmetic appearance. e major de ciencies directly
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318 Part III Maintenance

A B

Figure 25-5 A, A maxillary cast of the presurgical oral condition, which allows consultation with the surgeon regarding resection mar-
gins and the benefits of preservation of teeth. B, Another maxillary cast altered, following consultation with the head and neck surgeon,
to allow fabrication of a surgical stent. Perforations are made to allow fixation to the remaining teeth and to superior anatomic regions
with the use of wires.

A B

Figure 25-6 Maxillary defects. A, A resection that resulted in a small communication with the sinus, with some hard palate remaining,
and adjacent mucosa typical of the oral cavity. B, A resection that did not follow classic maxillectomy technique; however, the midline
resection was made through the socket of tooth #9, preserving its alveolar housing. C, A resection along the palatal midline that did
not preserve oral mucosa at the resection margin, which allows chronic ulceration at this point of prosthesis fulcrum. Notice the split-
thickness skin graft in the superior-lateral region. Engagement of this region can provide support to the obturator extension, minimizing
movement with function.
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Chapter 25 Removable Partial Denture Considerations in Maxillofacial Prosthetics 319

addressed by prosthetic management at this interim care to take nourishment by mouth without nasal re ux (allow-
time are deglutition and speech. is immediate postsurgi- ing for nasogastric tube removal) and to communicate with
cal time is very challenging for patients, and it is impor- family members are a signi cant component of early pros-
tant that they have been mentally prepared for it during the thetic management. How immediately such care should be
preoperative period. However, even with preliminary dis- provided depends on a number of factors.
cussion, the impact of the surgery is o en very distressing. A prosthesis can be provided at surgery (see Figure 25-5,
An initial focus on improvement in swallowing and speech B). Such a surgical obturator prosthesis is placed at the time
with the interim prosthesis can help boost the rehabilitation of surgical access closure and serves to control the surgical
process signi cantly. dressing and split-thickness skin gra during the immedi-
e patient is counseled that chewing on the defect side ate postsurgical period. Such prostheses are best stabilized
is not allowed because of its e ect on prosthesis movement. by appropriate wiring to remaining teeth or alveolar bone,
e objective of this interim obturator prosthesis is to sepa- or they may be suspended from superior skeletal struc-
rate the oral and nasal cavities by obturating the communi- tures. For some patients who have teeth remaining, such
cation. Such obturator prostheses most commonly refer to an immediate surgical prosthesis could be retained by
obturation of a hard palatal defect but conceptually can be wires in the prosthesis that engage undercuts on the teeth
considered the same for so palatal defects at this stage of and would be removable; however, the ability to control
management, because both attempt to arti cially block the the surgical dressing may be less predictable with such an
free transfer of speech sounds and foods/liquids between the approach. Immediate placement of a prosthesis has been
oral and nasal cavities. e advantages of having the ability suggested to improve patient acceptance of the surgical
defect, although no measure of this psychological impact
has been shown; this method o ers greater assurance of
adequate nourishment by mouth—potentially precluding
the use of a nasogastric tube.
It may be preferable to stabilize the surgical dressing by
suturing a sponge bolster to provide stabilization to the split-
thickness skin gra . Following the primary healing stage,
the sponge with packing (or the immediate prosthesis if
used) is removed by the surgeon and an interim obturator
prosthesis can be placed (Figure 25-7). For the patient who
has been provided with bolster obturation, the presurgical
prosthodontic evaluation is very important to ensure that the
patient is prepared for the transition from bolster to pros-
thesis, and to ensure that plans for the prosthesis are made,
especially if an interim prosthesis is to be fabricated. Interim
prostheses are wire-retained resin prostheses that generally
Figure 25-7 An interim obturator prosthesis fabricated of do not have teeth initially but may be modi ed with the
resin, retained by wires, and provided following surgical pack addition of teeth a er an initial period of accommodation
removal. (Figure 25-8).

A B

Figure 25-8 A-B, An interim obturator prosthesis fabricated of resin, retained by wires, and including artificial teeth for cosmesis
during an extended period of recovery. The superior and lateral surfaces may need modification to improve stability and retention as the
surgical site matures and allows more aggressive engagement.
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320 Part III Maintenance

When surgical defects become large, as in a near-total swallowing and speech. As was discussed previously, pros-
maxillectomy defect, prosthesis support, stability, and reten- thesis movement is dependent on the quality of the support-
tion are not likely to be satisfactory unless extension into the ing structures. Teeth o er the best support, followed by rm
defect can be accomplished. When teeth remain, the impact edentulous ridges, and lastly, surgical defect structures. e
of the defect size is somewhat lessened. But when the remain- tongue, opposing dentition, and cheek/lips place force on the
ing teeth are few or are located unilaterally in a straight line prosthesis that must be resisted over a large area to prevent
(see Figure 25-1), the mechanical advantage for prosthesis movement. Because the defect is least likely to be able to
stability is less. e ability of the defect tissue to o er the resist movement, the relative size and structural integrity of
needed mechanical characteristics to the interim prosthesis the defect compared with the remaining teeth and/or eden-
is unpredictable at best. It is this patient who bene ts the tulous ridge determine the potential prosthesis movement
most from a well-planned surgery that preserves oral and and most a ect the discomfort related to such movement.
defective anatomy to the advantage of the prosthesis. When teeth are available (and especially if located both
close to and far away from the defect), retention is enhanced
Potential Complications by engaging them with prosthetic clasps. Clasp retention is
e interim phase of prosthetic management can last for the most e cient means of e ectively resisting dislodgment.
3 months or more. e primary objective is to allow the e clasps will require periodic adjustment to maintain their
patient to pass from an active surgical (and adjunctive treat- e ectiveness, as the movement of the prosthesis exes the
ment) phase to an observational phase of management with clasps beyond their elastic recovery capacity. For edentu-
minimal complications. During the transition, the patient lous patients, because the surgical defect allows communi-
recovers from the systemic e ects of the treatment, deals cation between cavities, the tting surface of the prosthesis
with the psychological impact of the defect using his or her can no longer create a closed environment to develop a seal
own coping strategy, and becomes more aware of the func- for resisting dislodgment. Consequently, during the interim
tional de cits associated with the surgical defect(s). Mini- phase, when complete engagement of the defect is not pos-
mizing potential complications during the transition, which sible because of tissue sensitivity, the careful use of denture
includes preparing the patient for those anticipated to occur, adhesives is required to facilitate retention. e patient
facilitates the process for the patient and family. Common should be instructed that adhesives can alter the prosthesis
interim prosthetic complications are related to tissue trauma t and disrupt the close adaptation of the prosthesis to the
and the associated discomfort; inadequate retention (loose- remaining tissue. Used adhesive must be removed before
ness) of the maxillary prosthesis; incomplete obturation with new adhesive is reapplied, to maintain t and hygiene. Also
leakage of air, food, and liquid around the obturator portion related to retention is the inability to completely place the
of the prosthesis; and the tissue e ects of chemotherapy and prosthesis, which for maxillectomy patients can be due to
radiation therapy. contracture of the scar band. When the maxillary resection
Discomfort related to the use of interim prostheses can be leaves the cheek unsupported by bone, the prosthesis pro-
due to surgical wound healing dynamics, defect conditions, vides the necessary support for wound maturation. If the
mucosal e ects of adjunctive treatment, and/or prosthetic patient removes the interim obturator prosthesis for a period
t. Common areas of surgical wound pain include junctions su cient to allow contraction, the prosthesis will be more
of the oral and lip/cheek mucosa, especially at the anterior di cult to place. Once placed, however, the scar band will
alveolar region for maxillectomy patients. e lateral scar relax and subsequent removal and placement will be more
band produced when the skin gra heals to the oral mucosa easily accomplished. e discomfort associated with this
can be the site of discomfort in some patients. When a split- phenomenon is mostly due to patient anxiety and can be
thickness skin gra is not placed, discomfort caused by the e ectively addressed by reassuring the patient that this is an
prosthesis t within the defect can be a consistent and long- easily handled complication.
term problem. e hard palate surgical margin when not During the immediate postoperative healing stage, the
covered with surgically re ected oral mucosa most o en will surgical defect will undergo a change in dimension that
be covered by nasal epithelium, which is also very prone to a ects the prosthesis t and seal. If space is created with the
discomfort. Alveolar bone cuts that have not been rounded change, speech will be altered (increase in nasality) and nasal
will perforate the oral mucosa and will be painful whether re ux with swallowing will occur. e interim prosthesis
or not a prosthesis is worn. is is most frequently a nding is made of easily adjustable material to allow accommoda-
for mandibular resection superior alveolar margins when the tion for such changes. e most common manner of adjust-
reconstruction has restored the lower and labial contour to ment is through the use of temporary resilient denture lining
the mandible, but the intraoral mucosa at the superior sur- materials, which o er the ability to mold to the tissue directly
face is under tension because of a di erence in height. and reduce the mechanical e ects of movement by virtue
e prosthesis can create discomfort via excessive static of their viscoelastic nature. Leakage can occur quite easily
pressure from the internal surfaces or from overextension when swallowing unless the patient follows certain instruc-
into the vestibular tissue. e prosthesis can also create dis- tions. Because the prosthesis cannot o er a watertight seal
comfort caused by functional movement associated with that matches the presurgical state, patients will be instructed
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Chapter 25 Removable Partial Denture Considerations in Maxillofacial Prosthetics 321

not to swallow large quantities at one time, and to hold their

heads horizontal when swallowing. When the head posture
is forward, as when one is taking soup from a spoon, leak-
age easily occurs around the obturator component of a pros-
thesis. Another di cult condition that presents di culty in
controlling leakage on swallowing is the midline so palatal
resection. e functional movement of the remaining so
palate is o en very di cult to retain with a prosthesis. It is
also di cult to provide an adequate seal during the interim
prosthesis stage.
When combination treatment is prescribed for the
patient, it is commonly provided during the postsurgi-
cal phase, when the patient is using an interim prosthe-
sis. e major intraoral complication associated with both Figure 25-9 A definitive (left) and interim (right) obturator
prosthesis, contrasting the materials used and the obturator bulb
radiation therapy and chemotherapy, which a ects interim
contour. Clasp retention is more stabilizing with the definitive
prosthetic service, is mucositis. A careful balance between prosthesis because of the cast half-round clasp configuration,
comfort and adequate t for speech and swallowing needs the use of embrasure clasps, and the opportunity for guide-plane
must be determined with input from the patient. If pros- use. Also, because the surgical site is more mature, prosthesis
thesis adjustment can o er relief to ensure completion of extension into this region to augment support, stability, and re-
treatment and the patient understands the impact adjust- tention when necessary is possible.
ment may have on speech and swallowing, then it should
be accomplished.
e long-term e ects of radiation therapy, especially the need for and bene t of normal oral hygiene practices
radiation-induced xerostomia and capillary bed changes because of improved prosthesis t and tolerance. When teeth
(obliterative endarteritis) within the mandible, present a are remaining, it is important to the success of long-term
potentially signi cant threat to any remaining dentition prosthesis care to maintain a high level of oral hygiene. is
and to the development of osteoradionecrosis. During the is more critical for patients who exhibit xerostomia and have
interim prosthesis stage, the patient will begin to notice the increased risk of caries. For these patients, daily application
xerostomic e ects, which include development of thick, ropy of uoride in custom-formed carriers is prescribed along
saliva that makes swallowing more di cult, and an increase with frequent professional cleanings. e successful use of
in discomfort associated with removable prostheses. maxillofacial prostheses is enhanced greatly by the support
provided by natural teeth. Consequently, during the interim
Defect and Oral Hygiene prosthetic period, periodontal management procedures are
Following surgical pack removal, the defect site will mature begun in anticipation of the de nitive treatment to allow a
with time and exposure to the external environment. Initial smooth transition from the interim to de nitive prosthetic
loss of incompletely consolidated skin gra , mucous secre- stages.
tions mixed with blood, and residual food debris within
the cavity are common oral ndings for the patient with a Def initive Care
maxillary defect. ese cause concern for patients who are Surgical reconstruction for maxillofacial defects is an evolv-
unprepared and unfamiliar with these new oral ndings. As ing practice for head and neck cancer care. Prosthodontic
they become more familiar with the surgical defect, patients management for mandibular resection patients most com-
should be encouraged to clean the defect of food debris monly involves implant prostheses supported by a microvas-
and mucous secretions routinely. Defect hygiene will allow cular free ap. e evolution of similar techniques for the
quicker healing and will improve the ability to adequately surgical reconstruction of maxillary defects resulting in an
t a prosthesis. Common defect hygiene practices include implant-supported prosthesis is gaining in application.
(1) lavage procedures, which include rinsing of the defect When the active treatment phase has been completed
during normal showering, (2) rinsing of the defect using and no surgical reconstruction has been provided, de ni-
a bulb syringe or a modi ed oral irrigating device (modi- tive prosthetic management can be initiated for as long as it
ed to provide a multiple ori ce “shower” e ect), and (3) takes the defect tissue to mature su ciently to tolerate more
manual cleaning procedures, such as the use of a sponge- aggressive manipulation and obturation. is phase can
handled cleaning aid. Frequently, dried mucous secretions be considered a transition for the patient–physician rela-
are di cult to remove and require adequate hydration before tionship, in which the primary emphasis shi s from active
mechanical removal. treatment to observation. e primary emphasis from the
Following surgical pack removal, the patient may be reluc- patient’s standpoint shi s to prosthetic management, and
tant to begin oral hygiene practices because of oral discom- the goals and design of the prosthesis di er from those of
fort. As patients use the interim prosthesis, which requires the interim prosthesis (Figure 25-9). However, for some
daily removal and cleaning at a minimum, they will realize patients, more de nitive prostheses are delayed because of
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322 Part III Maintenance

general health concerns, questionable tumor prognosis or patients requiring replacement of missing teeth. e chal-
control, or failure of the patient to reach a level of oral and/ lenges faced in doing so for removable maxillofacial prosthe-
or defect hygiene that warrants more sophisticated treat- ses are quite di erent.
ment. Although this phase of management can be consid- Normal resistance to functional loads is achieved by the
ered elective, without de nitive prostheses, patients are not highly sophisticated periodontal attachment of the natural
a orded the opportunity for complete rehabilitation. It is dentition, which provides support and stability to teeth.
the extended use of temporary prostheses beyond their When the dentition is partially depleted and is replaced by
serviceable life span that has given a poor impression of prostheses that are tooth-supported, the support and stabil-
prosthetic service to many surgeons and patients. Every ity of the replacement teeth remain to be provided by the
opportunity should be provided to the patient for the most natural attachment. When tooth loss includes several poste-
complete rehabilitation possible, and this necessitates con- rior teeth, replacements are placed over the residual edentu-
sideration of more de nitive prostheses. lous ridge, and the prosthesis receives support and stability
From the previous discussion regarding removable from both teeth and mucosa. When all teeth are lost, support
prosthetic physiology, the inability of these static arti cial and stability are totally provided by the mucosa covering the
replacements to mimic their natural counterparts results residual edentulous ridges. Finally, when surgical removal of
in less than ideal functional measures. Factors related to tumors results in tooth and supporting structure loss, sup-
the structural integrity of the surgical defect and associated port and stability are provided by combinations of remain-
reconstructions as they a ect this already compromised ing teeth and/or residual ridges and areas within the surgical
functional capacity are important considerations, espe- defect. For partial and complete tissue-supported prostheses,
cially when few teeth remain. As was stated previously, the the mechanism of functional load support—as provided by
fact that control of removable maxillofacial prostheses has the mucosa—is unsuited to the task from a biological stand-
a large skilled performance requirement of patients suggests point. Given this understanding, when a maxillofacial pros-
that oral and defect structures adjacent to the prostheses are thesis is required to involve a surgical defect for support and
important for successful performance. is is crucial to an stability, it is obvious that the environment within the surgi-
understanding of the impact that postsurgical defect charac- cal defect is even less suited to the task.
teristics and so tissue reconstructions have on maxillofacial
prosthesis management. e reasons for this are twofold: (1) SURGICAL PRESERVATION FOR PROSTHESIS
the opportunity for maximal prosthetic bene t necessitates BENEFIT
consideration of surgical site characteristics that are separate
from classic tumor control approaches; and (2) the ability of Maxillary Defects
the patient to biomechanically control large removable pros- Surgical outcomes that in uence prosthesis success can be
theses following surgery may be notably hindered by surgi- considered as those that determine the number of maxil-
cal closure/reconstruction options. Surgical outcomes that lary structures removed (Figure 25-10) and/or those that
can improve prosthetic function without adversely a ecting a ect the structural integrity and quality of the defect. For
tumor control should be considered and will be described for surgical defects of the hard and/or so palate, the primary
the more common surgical defects and associated prostheses. prosthetic objectives include restoration of physical separa-
tion of the oral and nasal cavities in a manner that restores
mastication, deglutition, speech, and facial contour to as
INTRAORAL PROSTHESES: DESIGN
near a normal state as possible. Typical prostheses used to
CONSIDERATIONS
achieve these objectives include the obturator prosthesis
Maxillofacial prosthetics is largely a removable prosthetic (Figure 25-11, A and B), typically referring to prostheses
discipline, with the exception of dental implant–retained that obturate defects within the bony palate, and the speech
prostheses for some applications. For maxillofacial recon- aid prosthesis (see Figure 25-11, C and D), which typically
struction with removable partial denture prostheses, typical refers to prostheses that restore palatopharyngeal function
goals of treatment consist of a well-supported, stable, reten- for defects of the so palate.
tive prosthesis that is acceptable in appearance and exhib- Current preoperative diagnostic procedures have
its minimal movement under function, thereby preserving improved the ability to discern the location and regional
the maximum amount of supporting tissue. A strategy for bone involvement of tumors of the maxilla and associ-
achieving these goals includes maximum coverage of the ated paranasal sinuses. Relative to prosthetically important
edentulous ridge within the movement capacity of the mus- surgical modi cations, if it can be determined that tumor
cular attachments, maximum engagement of the remaining control does not require a classic radical maxillectomy
teeth to help control retention and movement under func- approach or that the inferior sinus oor, hard palate, and
tion, and placement of arti cial teeth to facilitate mainte- alveolus are uninvolved, preservation of as much hard palate
nance of this prescribed tooth-tissue contact during normal and alveolar bone and as many teeth as possible should be
functional contacts. Maintaining these basic concepts within considered. Tooth preservation has the greatest impact on
an otherwise normal anatomic environment (relative to food success because of its stabilizing e ect on prosthetic move-
control and deglutition) has provided reasonable success for ment. When teeth can be retained in the premaxilla for more
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Chapter 25 Removable Partial Denture Considerations in Maxillofacial Prosthetics 323

A B

Figure 25-10 A, A maxillary defect where a tooth distal to the resection was maintained. The tooth will significantly stabilize the
prosthesis by preventing movement of the obturator bulb into the defect at the distal resection margin. B, A maxillary defect that dem-
onstrates preservation of the anterior arch curvature, providing enhanced stability through a tripod effect. Also evident is the use of a
split-thickness skin graft in the superior-lateral region, which improves the opportunity for useful support.

A B

C D

Figure 25-11 A, Superior view of an obturator prosthesis demonstrating the cast framework, three posterior cast half-round clasps
and an anterior I-bar clasp, and a superior obturator surface contoured to encourage secretions to flow posteriorly. B, The same prosthe-
sis seated intraorally. C, A speech aid prosthesis with posterior retention and anterior indirect retention, and a resin speech bulb. D, The
same prosthesis showing bilateral embrasure clasps and obturation of the palatopharyngeal defect.

posterior tumors or in the posterior molar region for more for the average patient than a defect whereby preservation
anterior tumors, control of prosthesis movement is more of the premaxillary component was accomplished, inclu-
easily accomplished and prosthetic success can be consider- sion of the anterior premaxillary component should be an
ably improved (see Figure 25-10). Because the classic mid- individual decision based on tumor control, classic resection
line maxillectomy defect is signi cantly more debilitating technique.
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324 Part III Maintenance

For resections in patients with teeth, the tooth adjacent

to the defect is subjected to signi cant force from prosthe-
sis movement. When the surgical alveolar ostectomy cut is
planned, the resection should be made through the extrac-
tion site of the adjacent tooth to provide the most favorable
prognosis for this supportive tooth (see Figure 25-6). is
procedure ensures adequate alveolar support for the adjacent
tooth, which is a critical tooth for prosthesis success, and
improves the tooth’s prognosis for long-term survival. e
midline of the hard palate is a common area of removable
prosthesis pressure because of movement of the prosthesis
into the defect under functional forces of swallowing and
mastication. To provide the best surgical preparation for this
area, when the hard palate is resected, the vertical surface of
the bone cut should be covered with an advancement ap
of palatal mucosa, to provide a rm and resistant mucosal
covering to this region, where the prosthesis can notably act
as a fulcrum.
e so palate owes its normal function to the bilateral Figure 25-12 A maxillary obturator prosthesis demonstrat-
ing a distal extension, which engages a soft palatal remnant for
sling nature of the musculature, which provides the shape
added retention.
and movement capacity speci c for speech and degluti-
tion requirements. When this is altered because of surgery,
there appears to be a variable response in the ability to con- su cient access to the lateral-posterior region of the defect
tinue to provide palatopharyngeal competence based on to seal the defect at a minimum. In the edentulous patient,
the amount of continuous band of posterior tissue remain- for maximum ability to obturate a maxillary defect, access to
ing. O en, an insu cient band of palatal tissue fails to pro- the regions superior to the defect opening is required. Nasal
vide palatopharyngeal competence and hinders prosthetic turbinates and mucosal connections that do not allow full
management of the problem. To serve as a guide for deci- extension into the necessary retentive and supportive areas of
sion making in surgery, it has been suggested that if the the defect compromise function. e function of turbinates
required resection leaves less than one third of the poste- in the newly externalized environment is not bene cial for
rior aspect of the so palate, the entire so palate should breathed air humidi cation or warming and consequently
be removed. e exception to this would be the edentulous may not warrant preservation.
patient who is undergoing a radical maxillectomy. Without Surgical reconstruction of maxillary defects should be
teeth to provide the necessary retention for one side of a undertaken when restoration of the functional goals of
prosthesis, the patient bene ts from the ability to place the speech, deglutition, and mastication is better served by
prosthesis above the posterior so tissue band for retention such procedures. Surgical reconstruction of a maxillary
(Figure 25-12). hard palatal defect in a manner that provides separation
Preparation of the maxillary surgical site can improve of the oral and nasal cavities without consideration for
prosthesis tolerance through the use of a split-thickness skin oral space requirements for speech, or for the supportive
gra (see Figure 25-1). Lining the re ected cheek ap and requirements of replacement teeth, is not only incom-
posterior denuded structures with a gra improves tissue plete management but can preclude subsequent prosthetic
response by decreasing the pain associated with functional management. When surgical defects measure 3 cm or less
contact o en seen when this surface is le to heal second- and can be reconstructed to normal contours without
arily. If the posterior structures, pterygoid plates, or anterior compromising adjacent tissue function, surgical manage-
temporal bone can provide a rm supportive base for the ment is an appropriate consideration. Larger defects are
prosthesis, a skin gra covering is extremely helpful. Later- very di cult to surgically reconstruct and, without care-
ally, the junction of the skin and oral mucosa creates a scar ful planning for subsequent functional needs, could cre-
contracture, which provides a natural retentive region for the ate an environment incapable of supporting a prosthesis.
obturator portion of the prosthesis. Careful attention is given For partial so palatal reconstructions, it is very di cult
to this region in fabricating a prosthesis, to maximize sup- to provide functional tissue replacement without compro-
port, stability, and retention of the prosthesis. mising palatal function. In light of this unpredictability,
In general, the need to extend a prosthesis into the defect predictable prosthetic management of such defects is most
is greater for edentulous patients than patients with teeth. o en the treatment of choice.
When teeth remain, they are used to a greater extent to sta-
bilize and retain the obturator component of the prosthesis, Mandibular Defects
and the defect region is not required for such objectives. e functions of mastication, deglutition, speech, and oral
However, all patients with maxillary defects should have competence (saliva control) are made possible through
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Chapter 25 Removable Partial Denture Considerations in Maxillofacial Prosthetics 325

and cosmesis by the replacement of teeth. Achieving the

mastication goal requires an understanding that regardless
of the manner of prosthesis support (natural teeth, recon-
structed so tissue, or implants), the impact of the prosthetic
device on success is dependent on appropriate surgical man-
agement of both so tissue and bone.
Disease involving so tissue structures adjacent to and
enveloping the mandible necessitates consideration of a
mandibular resection to ensure control. When the so tis-
A sue disease is clearly separate from the mandible and does
not require bone removal, surgical defects involving these
structures should be surgically reconstructed and therefore
do not require prosthetic management. e exception to this
is the large tongue resection that may require augmentation
of the palatal contours to facilitate speech production. Such
a palatal augmentation prosthesis is most bene cial when
coordinated speech therapy can guide the optimal prosthe-
sis con guration. Other resections may appear to require
palatal augmentation for speech, yet the functional problem
is tongue immobility secondary to tension created by the
reconstructive tissue. Consideration should be given to so
tissue reconstructions that are of su cient size and mobil-
ity, are less prone to contracture tension, and can produce
a more normal alveololingual sulcus because these char-
acteristics have been shown to have a signi cant in uence
on tongue mobility. Other desirable characteristics, such
as sensation and lubrication, are also possible but necessi-
tate a choice of which one is most required given the goals
desired.
When tumors are primary to the mandible, as an amelo-
B blastoma is, or when they involve the mandible from adja-
cent regions, surgical resection of segments of the mandible
Figure 25-13 A, Marginal (left) and segmental (right) resec-
is required for tumor control. It may be di cult to always
tions of the mandible. When a segmental resection is not sta-
bilized with a reconstruction bar or bone graft, the continuity of
predict the functional de cit and the exact plan of recon-
the mandible is lost. Such a defect is a discontinuity defect of the struction because the surgeon determines the extent of the
mandible. B, When not stabilized, the discontinuous mandible resection based on presurgical and surgical ndings. How-
deviates toward the defect and presents significant problems ever, common anatomically based mandibular resections
with mastication restoration. include the lateral mandibular resection, the anterior man-
dibular resection, and the hemimandibular resection. From
the standpoint of the surviving mandibular resection patient,
coordinated e orts of separate anatomic regions, which the most signi cant decision regarding his or her manage-
include the oral sphincter, alveololingual and buccal sulci, ment is the decision to maintain mandibular continuity,
alveolar ridges, oor of the mouth, mobile tongue, base of which allows maintenance of position for adjacent intraoral
the tongue, tonsillar pillars, so palate, hard palate, and buc- and extraoral so tissue.
cal mucosa. e more regions that are involved in a surgical Surgical evolution of procedures that maintain continu-
procedure, the greater is the demand on surgical reconstruc- ity for the mandible has signi cantly improved the oppor-
tive e orts. When the mandible is also involved, the com- tunity for functional restoration of mastication, deglutition,
plexity of the reconstructive procedure is dependent on the and speech. e debilitating e ects of the discontinuity
location and amount of mandible to be included in the resec- defect include a signi cant cosmetic deformity to the lower
tion and the decision to maintain continuity with normal third of the face, decreased masticatory function secondary
mandibular position and contour (Figure 25-13). For disease to unilateral closure, compromised coordination of tongue
involving the functional anatomy around the mandible, sur- and teeth, altered speech ability, and impaired deglutition
gical outcomes that in uence prosthesis success are based (Figure 25-14). Given an appreciation of the decreased
on decisions to take mandibular portions or segments and performance seen with conventional mucosa-borne den-
decisions regarding reconstruction. e primary prosthetic ture prostheses, it should be obvious that masticatory reha-
objectives for mandibular defects are to restore mastication bilitation for the resection patient without mandibular
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326 Part III Maintenance

A B

Figure 25-14 A, A deviated mandibular position following segmental resection without reconstruction. The mandibular midline is left
of the maxillary midline by two teeth. B, With mandibular and maxillary prostheses in place, the patient closes to a functional position
that is unique to the unilateral closure pattern.

continuity is unpredictable at best and is never achieved Equally important to the functional outcome of mastication
for most patients. Even for patients with remaining teeth, was the development of the science and the clinical applica-
the altered mandibular position created in time presents tion of the osseointegration phenomenon in the area of den-
a signi cant functional and cosmetic handicap. From a tal implants.
prosthetic rehabilitation standpoint, the most signi cantly e ideal prosthetic characteristics of the replacement
handicapped postsurgical head and neck condition is the mandible include a stable union to proximal and distal seg-
discontinuous mandible. Consequently, such a postsurgical ments, restoration of contour to the lower third of the face,
condition should be the rare exception (typically because of a rounded ridge contour with attached mucosa of 2 to 3 mm
reconstruction plate failure) and should not be the planned thickness, and adjacent sulci providing free movement of
surgical outcome. buccal and lingual so tissues for food control. Regardless
e cosmetic deformity associated with mandibular resec- of the type of prosthesis to be used, the appropriate place-
tion is improved through the use of reconstruction plates to ment of the bone relative to the opposing arch is vital to the
maintain the presurgical contour to the lower jaw. is form intended functional use. If a removable prosthesis is planned
of mandibular contour and position maintenance should and is expected to cover the bone reconstruction, the con-
be considered the minimum standard of care for mandibu- tour of the developed ridge should provide a surface covered
lar resection patients from a functional standpoint. Use of with rm, thin so tissue, and a rounded superior contour
reconstruction plates can maintain cosmetic appearance with buccal and lingual slopes approaching parallel to each
and preserve the bilateral nature of mandibular movement. other and with su cient vestibular depth to provide hori-
However, the use of reconstruction plates alone precludes zontal stability. Such a ridge condition is the surgical analog
replacement of teeth in the region of resection. Prosthetic of a minimally resorbed edentulous ridge. With adequate
replacement of teeth cannot be provided for regions supe- cheek and tongue movement, this should provide a reason-
rior to the reconstruction bar because of the potential for able prognosis for prosthetic success, provided su cient
mucosal perforation and exposure of the bar from functional numbers of teeth remain on the nonresected side. For the
loading of the so tissue. From a masticatory function stand- optimum chance of prosthetic function, dental implants
point, this may not be a signi cant negative impact for some should be considered, and with su cient bulk of bone and
patients because of the maintenance of su cient numbers of the same characteristics listed for the removable prosthe-
occlusal contacts postsurgically. sis, the prognosis for success is the greatest. To reiterate, the
major determining factor for improved function will be the
Mandibular Reconstruction—Bone Grafts quality of the so tissue reconstruction.
e evolution of head and neck reconstructive surgery has e major complications seen with mandibular recon-
been dramatic over the past three decades. e vascular- struction are related to the bulk of the so tissue component
ized tissue options of the forehead and deltopectoral regions and lack of mobility of the tongue. When these factors are
gave way to the more popular pedicled myocutaneous aps controlled for, complications are caused most o en by bone
from the 1960s to the 1970s. By the 1980s, numerous osteo- placement and size. e common use of free aps, includ-
myocutaneous free- ap donor sites had been identi ed and ing bone from other regions of the body that do not possess
were being used for mandibular reconstruction and particu- the native mandibular shape, presents a signi cant degree of
late cancellous bone marrow in formed allogeneic frames. technical di culty associated with the procedure. e bula,
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Chapter 25 Removable Partial Denture Considerations in Maxillofacial Prosthetics 327

Vertical
displacement Long
radius sweep
Less

Greater

Short radius sweep

Given horizontal
A B flexure

C D

Figure 25-15 A, Coronal view of proposed maxillary resection. Bold lines designate typical area to be resected. B, Demonstrates the
value of lateral wall height in the design of a removable partial denture obturator. As the defect side of the prosthesis is displaced, the
lateral wall of the obturator will engage the scar band and aid in retaining the prosthesis. C, Coronal section with surgical obturator in
place. With the prosthesis in place, the relation of the scar band (arrow) to the lateral portion of the obturator can be seen. A buccal scar
band will develop at the height of the previous vestibule where the buccal mucosa and the skin graft in the surgical defect join. D, Axial
view of the resected area illustrates the defect. Dotted lines indicate areas available for intraoral retention.

which is a popular choice for mandibular replacement, pres- become a source of irritation if fulcrum-like action occurs
ents some challenges in meeting the ideal requirements with movement.
mentioned previously. Because of the straight nature of the
bone, it is easy to err in both horizontal and vertical position- MAXILLARY PROSTHESES
ing, especially for reconstructions that span to the midline.
Lingual positioning requires prosthetic placement at a posi- Obturator Prostheses
tion that may become functionally unstable over time. Such a e de ning characteristic of an obturator prosthesis is that
location requires implant positions that create a mechanical it serves to restore separation of the oral and adjacent cavities
cantilever that can be detrimental to the long-term success following surgical resection of tumors of the nasal and para-
of the implant-supported prosthesis. Posteriorly, the inability nasal regions (Figure 25-15). Aramany developed a classi -
to recreate the natural ascending curve of the mandible can cation for partially edentulous maxillectomy dental arches
restrict placement of teeth and preclude restoration of com- (Figure 25-16). e various defects resulting from resection
plete occlusion on the resected side. It is common to have a contain and are bounded by anatomic structures and an epi-
mismatch in height at the anterior junction of the gra with thelial lining (either transplanted skin and/or native mucosa)
the resident mandible. For implant-supported prostheses, that are quite di erent from normal partially edentulous arch
this area can present signi cant challenges in terms of ade- anatomic features. e expectation for this altered region
quate hygiene of the implants, and over time, this can com- to contribute signi cantly to prosthesis support, stability,
promise implant health. For removable prostheses, this can or retention is infrequently met. Consequently, prosthesis
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328 Part III Maintenance

I II III

IV V VI

Figure 25-16 Aramany’s classification for partially edentulous maxillectomy dental arches: Class I—midline resection. Class II—
unilateral resection. Class III—central resection. Class IV—bilateral anteroposterior resection. Class V—posterior resection. Class VI—
anterior resection.

A B

Figure 25-17 A, A maxillary obturator prosthesis in which remaining teeth provide significant stabilization to the obturator extension
because of their number and location, which allows cross-arch prosthesis engagement. B, Another obturator prosthesis, which benefits
from teeth in a linear arrangement and therefore does not have any cross-arch tooth stabilization. Obturator movement in B is likely to be
significantly greater than in A. The requirement for using the defect to provide support where possible is therefore greater in B than in A.

support and stabilization are largely dependent on the ability their arrangement becomes more linear (Figure 25-17).
to aggressively engage the remaining teeth and residual ridge is illustrates the importance of maintaining teeth when
structures. possible, which allows for greater prosthesis stabilization
In comparison with partially edentulous arches, the through direct tooth engagement and through cross-arch
movement potential for the prosthesis extension into the stabilization that increases with nonlinear tooth con gura-
defect can be signi cant. When engagement of the disto- tions (Figure 25-18).
buccal temporal bone is possible, upward movement of the To help control potential movement, various sugges-
obturator bulb can be greatly minimized. Movement poten- tions have been made relative to prosthesis design. e basic
tial increases as the remaining tooth number decreases and principle of placing support, stabilization, and retention
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Chapter 25 Removable Partial Denture Considerations in Maxillofacial Prosthetics 329

A B

Figure 25-18 A, Tooth arrangement that offers cross-arch stability (as in Figure 25-17, A) because of the arch curvature of the remain-
ing tooth distribution and the tripod effect it allows. B, More linear arrangement of teeth does not provide cross-arch stability and places
greater demand on the defect integrity for prosthesis performance.

immediately adjacent to and as far from the defect as pos- functional movement. Movement of the pharyngeal exten-
sible acts to distribute the tooth e ect on prosthesis perfor- sion imposed by the residual palatopharyngeal muscula-
mance to the greatest mechanical advantage. Because the ture is generally undesired and is a sign that modi cation
teeth adjacent to the anterior resection margin are o en is required. Common reasons for such movement include a
incisors, it may be necessary to consider splinting them to low position, causing tongue encroachment; superior exten-
improve the long-term prognosis. is region is critical for sion that does not account for head exure; or impression
prosthesis performance, and the requirement for a cingulum procedures that do not accurately record residual so palatal
rest and labial retention is o en di cult to optimize with- position or movement.
out crowns. Distally, it is o en necessary to incorporate an A pediatric speech aid is a temporary prosthesis used to
embrasure clasp to provide maximum retention and stabili- improve voice quality during the growing years. It is made
zation. Such a clasp assembly must have su cient room for of materials that are easily modi ed as growth or orthodon-
occlusal clearance, and it is not uncommon for the opposing tic treatment progresses. Because a speech aid has a signi -
occlusion to need adjustment to accommodate such a rest cant posterior extension into the pharyngeal region, torque
complex. When possible, the palatal surfaces of the maxillary is evident from the long moment arm. A basic principle of
teeth should be surveyed to determine whether guide-plane posterior retention with anterior indirect retention must be
surfaces can be produced to impart a stabilizing e ect. When applied to the design of such a maxillary prosthesis. Poste-
accomplished, the prosthesis bene ts from improved move- rior retention is gained by the use of wrought-wire clasps
ment resistance, and it does so with more teeth contributing around the most distal maxillary molars, whereas the ante-
to the e ect, thereby distributing the stress more appropri- rior extension of the prosthesis onto the hard palate provides
ately. Brown described how the vertical height of the lateral indirect retention. If clinical crown length and undercut are
portion of the obturator above the buccal scar band can con- adequate to provide retention, orthodontic bands with buc-
tribute to prosthesis movement control by helping to prevent cal tie wings can be used in conjunction with the wrought
vertical displacement (see Figure 25-15). wires. is design facilitates the maintenance of the pharyn-
geal part of the pediatric speech aid in the proper position in
Speech Aid Prostheses the palatopharyngeal opening.
e de ning characteristics of speech aid prostheses are that In the adult whose palatopharyngeal insu ciency is the
they are functionally shaped to the palatopharyngeal mus- result of a cle palate or palatal surgery, an adult speech aid
culature to restore or compensate for areas of the so palate prosthesis can be constructed of more de nitive materials
that are de cient because of surgery or congenital anomaly because growth changes will not have to be accommodated.
(see Figure 25-11). Such a prosthesis consists of a palatal If teeth are missing, the prosthesis will incorporate a reten-
component, which contacts the teeth to provide stability and tive partial denture framework. e basic design should
anchorage for retention; a palatal extension, which crosses the include posterior retention and anterior indirect retention.
residual so palate; and a pharyngeal component, which lls
the palatopharyngeal port during muscular function, serving Palatal Lift Prostheses
to restore the speech valve of the palatopharyngeal region. e de ning characteristic of a palatal li is that it positions
Because the typical speech aid prosthesis does not provide a accid so palate posteriorly and superiorly to narrow
tooth replacement, the patient should expect only minimum the palatopharyngeal opening for the purpose of improving
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330 Part III Maintenance

oral air pressure and therefore speech. Patients who exhibit

a structurally normal so palate and pharyngeal port can
demonstrate hypernasal speech caused by paralysis of the
regional musculature. is condition is referred to as palato-
pharyngeal incompetence because the failure lies in function,
not in anatomic de ciency. e paralysis can result from a
variety of neuromuscular conditions ( accid paralysis of the
so palate from closed head injuries, cerebral palsy, muscular I
dystrophy, or myasthenia gravis) that have varying clinical
courses. e palatal li prosthesis must physically position
the so palate to redirect air pressure orally. In placing the
so palate, any tissue resistance met acts as a dislodging force
on the prosthesis. is dislodging force must be resisted by
adequate direct and indirect retention.
To e ciently maintain prosthesis position, the dislodging
force is best resisted by bilateral direct retainers placed close
to the posterior li and anteriorly placed indirect retention.
Success with a palatal li prosthesis depends upon the pres- II III
ence of a number of maxillary posterior teeth, which can
provide retention for the prosthesis, coupled with an easily
placed accid so palate.

Palatal Augmentation Prostheses

When surgical resection involving the tongue and/or oor of
the mouth limits tongue mobility, it a ects both speech and
IV V
deglutition. With tongue mobility limitations, the contour of
the palate can be augmented by a prosthesis to modify the Figure 25-19 Cantor and Curtis classification of partial man-
space of Donder to allow food manipulation to be more eas- dibulectomy. (Redrawn from Cantor R, Curtis TA: Prosthetic man-
ily transferred posteriorly into the oropharynx. agement of edentulous mandibulectomy patients. I. Anatomic,
Prosthesis movement potential is low because the func- physiologic, and psychologic considerations, J Prosthet Dent
tional forces involved are those imparted by the tongue dur- 25:446-457, 1971.)
ing deglutition and speech, neither of which creates force
similar to mastication. It is common to use a diagnostic resin
augmentation prosthesis retained with wire clasps to plan the segment. Consequently, the function of the remaining
necessary contour needs. Once the appropriate palatal con- mandibular segment is severely compromised because of
tour has been determined, a de nitive augmentation pros- loss of coordinated bilateral muscular action functioning
thesis can be constructed of cast metal with appropriately across a bilateral joint. e resulting segmental movement
placed minor connectors for attaching the resin augmenta- is an uncoordinated action dictated by the remaining uni-
tion. Bilateral rests and direct retainers should be positioned lateral muscular activity within a surgical environment that
to facilitate the design for the acrylic retention because sta- changes with healing dynamics and patient rehabilitation
bility needs related to functional force are not a signi cant e orts. Successful removable prosthodontic intervention
design concern. for these situations necessitates a combination of clinician
knowledge of the functional movements of the remaining
MANDIBULAR PROSTHESES residual mandible and concerted e ort and persistence of
the patient.
Evolution of Mandibular Surgical Resection Historically, mandibular stabilization by bone grafts
When mandibular continuity is preserved, as in a marginal or reconstruction bars was not always a surgical goal.
resection (type I mandibular defect, see Figure 25-19), func- The major exception was the anterior defect (type V),
tion is least a ected and the major prosthesis concern is which was recognized to pose significant airway risks
related to the so tissue potential for support. With good if not managed. Currently, most lateral segmental man-
remaining dental support, near-normal function can o en dibulectomies are also reconstructed surgically. When the
be achieved with prosthodontic rehabilitation. mandible is not stabilized following resection and a dis-
Although it is not as common an outcome as in the past, continuity defect results, a mandibular resection prosthe-
when continuity of the mandible is lost because of a seg- sis should be provided to restore mastication within the
mental resection that was not reconstructed, the bilateral unique movement capabilities of the residual functioning
joint complex no longer controls the remaining mandibular mandible.
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Chapter 25 Removable Partial Denture Considerations in Maxillofacial Prosthetics 331

A B

C D

Figure 25-20 A type I resection of the anterior mandible. A, Bilateral molars remain to stabilize an anterior extension removable
partial denture. A split-thickness skin graft has been used to reconstruct the denture bearing area. B, The prosthesis showing cast clasps
and the anterior extension base. C, The prosthesis in place and covering the skin graft with a configuration produced through a corrective
cast impression technique. D, The resection prosthesis in occlusion. It is critical to have the remaining natural teeth occlude at the same
vertical dimension as the prosthetic teeth to ensure comfortable function.

Resection prostheses are those prostheses provided to by unique residual tissue characteristics and mandibular
patients who have acquired mandibular defects that result movement dynamics.
in loss of teeth and signi cant portions of the mandible.
Mandibular resection results in defects that may pre- Type I Resection
serve mandibular continuity or may result in discontinu- In a type I resection of the mandible, the inferior bor-
ity defects. ese are further subclassi ed by Cantor and der is intact and normal movements can be expected to
Curtis (Figure 25-19) and provide a meaningful foun- occur. e major di erence between this situation and
dation for a discussion of removable prosthesis design a typical edentulous span is the nature of the so tissue
considerations. foundation. For type I resections, the denture-bearing
e following discussion highlights design consid- area may be compromised by closure of the defect with
erations for the major defect classi cations outlined. A the use of adjacent lining mucosa (which can reduce the
common feature among all removable resection prosthe- bucco-lingual width), or by the presence of a split-thick-
ses is that all framework designs should be dictated by ness skin gra .
basic prosthodontic principles of design. ese include Ideally, one would like to see a rm, non-movable
broad stress distribution, cross-arch stabilization with tissue bed with normal buccal and lingual vestibular
use of a rigid major connector, stabilizing and retaining extension. If the defect is unilateral and posterior, the
components at locations within the arch to best mini- framework would be typical of a Kennedy Class II design,
mize dislodging functional forces, and replacement tooth taking into account whatever modi cation spaces may be
positions that optimize prosthesis stability and func- present. When the marginal resection is in the anterior
tional needs. Modi cations to these principles are deter- area, the design may be more typical of a Kennedy Class
mined on an individual basis and are greatly in uenced IV design (Figure 25-20).
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332 Part III Maintenance

A B

Figure 25-21 Type II resection and prosthesis. A, Clinical presentation of the mandibular right resection and missing mandibular
left molars. B, Resection prosthesis with a cast lingual plate major connector and wrought-wire clasps. C, Resection prosthesis in place
demonstrating the two-tooth extension on the defect side (patient’s right). (Courtesy of Dr. Ron Desjardins, Rochester, MN.)

Anterior marginal resections sometimes include part cheek to prevent food and saliva from collecting in the
of the anterior tongue and oor of the mouth. With loss region.
of normal tongue function, the remaining teeth are no Framework design should be similar to a Kennedy
longer retained in a neutral zone, and as a result, they Class II design, with extension into the vestibular areas
o en collapse lingually because of lip pressure. If this of the resection. is area would be considered nonfunc-
occurs, the use of a labial bar major connector may be tional and should not be required to support mastication.
necessary. It must be remembered that extension into the defect area
Corrected cast impression procedures provide a major can place signi cant stress on the remaining abutment
advantage for fabrication of removable partial dentures teeth; therefore, occlusal rests should be placed near the
in partial mandibulectomy patients. Capture of the defect, and an attempt should be made to gain tripod sup-
unique buccal, lingual, and labial functional contours in port from remaining teeth and tissue where possible.
the nal prosthesis can contribute signi cantly to sta- An example of a framework design for a type II man-
bilization of the prosthesis, especially in discontinuity dibular resection with missing molars on the nonsurgi-
defects. cal side is illustrated in Figure 25-21. e choice of major
connector depends on the height of the oor of the mouth
Type II Resection as it relates to the position of the attached gingival mar-
In the type II resection, the mandible is o en resected in gins during function. An extension base with arti cial
the region of the second premolar and rst molar. If no teeth can be used on the surgical side if space is avail-
other teeth in the arch are missing, a prosthesis usually able. e extent of this base is determined by a functional
is not indicated. In some situations, however, a prosthe- impression, and determination should be cautious of the
sis may have to be fabricated to support the buccal tis- potential for bone exposure at the superior margin of the
sue and to help ll the space between the tongue and the resection.
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Chapter 25 Removable Partial Denture Considerations in Maxillofacial Prosthetics 333

A B

C D

Figure 25-22 A, Frame design for type II resection, no teeth missing on the nonresected side. Note the provision for extension into
the resection space between tongue and cheek. B, Type II design with missing posterior teeth on the nonresected side. C, Type II design
with missing anterior teeth. D, Type II design with missing anterior and posterior teeth.

Retention can be achieved through the use of various path design may be used to engage the natural undercuts
types of clasp assemblies on the distal abutments. Indirect on the mesial proximal surfaces of the anterior abut-
retention can be derived from rests prepared in the mesial ments. Lingual retention with buccal reciprocation on
fossae of the rst premolars and/or the lingual surfaces of the remaining posterior teeth should be considered. e
the canines. Unlike the result in Figure 25-21, use of an longitudinal axis of rotation in this design should be con-
infrabulge retainer on the surgical side may be di cult sidered to be a straight line through the remaining teeth.
if a shallow vestibule results from surgical closure. e Depression of the prosthesis on the edentulous side will
locations of minor connectors should be physiologically have less of a chance to dislodge the prosthesis if retention
determined to minimize stress on the abutment teeth and is on the lingual surfaces than if on the buccal. Suggested
to enhance resistance to reasonable dislodging forces. framework designs for this patient group are illustrated in
Wrought-wire circumferential retainers are acceptable Figure 25-22.
alternatives. Physiologic relief of minor connectors is always rec-
In a type II mandibular resection, where posterior and ommended. When the remaining teeth are in a straight
anterior teeth are missing on the defect side, the remain- line, a Swing-Lock major connector design (Swing-Lock,
ing teeth on the intact side of the arch are o en present Inc., Milford, TX) may be used to take advantage of as
in a straight-line con guration. Embrasure clasps may be many buccal and/or labial undercuts as possible. Because
used on the posterior teeth, with an infrabulge retainer elderly patients o en complain of di culty manipulat-
on the anterior abutment. In some situations, a rotational ing Swing-Lock mechanisms, in straight-line situations it
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334 Part III Maintenance

If a type IV resection extends to the midline with

the extension of a graft into the defect area, but does
not include temporomandibular joint reconstruction
on the surgical side, the design will be similar to the
A type III resection with an extension base on the surgi-
cal side.
If the type IV resection extends beyond the midline,
R with less than half of the mandible remaining, the design
R will be similar to the type II resection that has an exten-
R
sion base into the surgical defect area.

R Type V Resection
In the type V resected mandible, when the anterior or
posterior denture-bearing area of the mandible has been
surgically reconstructed, the removable partial denture
Figure 25-23 Conventional clasping with the use of alternat- design is similar to the type I resection design.
ing buccal and lingual retention (arrows). e principal di erence between a type V resected
mandible and the intact mandible with the same tooth
loss pattern lies in the management of so tissue at the
gra site. For design purposes, one should consider the
may be possible to use alternate buccal and lingual reten- residual mandibles of the type I and V resections to be
tion e ectively (Figure 25-23). similar to nonsurgical mandibles with the same tooth-loss
In the type II resection with anterior and posterior pattern.
missing teeth on the resected side and posterior missing
teeth on the nonresected side, the prosthesis will have Mandibular Guide Flange Prosthesis
three denture base regions. is prosthesis may have a As was mentioned earlier, in a discontinuity defect, the
straight-line longitudinal axis of rotation, as previously movement of the residual mandibular segment is an
discussed. Rests should be placed on as many teeth as uncoordinated action dictated by two features unique to
possible, minor connectors should be placed to enhance the speci c defect and patient. e rst is the remaining
stability, and wrought-wire retainers represent an accept- unilateral muscular activity that will be speci c to the sur-
able alternative to the bar clasps. gical resection and that will have a characteristic resting
posture to the defect side with a diagonal movement on
Type III Resection “closure.” e second is that the surgical environment will
A type III resection (see Figure 25-19) produces a defect change as healing progresses, and patient e orts to train
to the midline or farther toward the intact side, leaving movement during this healing period will help maintain
half or less of the mandible remaining. both position and movement range. To facilitate training
e importance of retaining as many teeth as possible of the mandibular segment to maintain a more midline
in this situation cannot be overemphasized. e design of closure pattern, clinicians have used a guide ange pros-
a framework for this situation would be similar to the type thesis.
II resection. e longitudinal axis of rotation is again con- e mandibular guide ange prosthesis is used pri-
sidered to be a straight line through the remaining teeth. marily as an interim training device. When no miss-
is resection provides a greater chance of prosthesis dis- ing teeth are supplied, it may be considered a training
lodgment caused by lack of support under the anterior appliance rather than a prosthesis. is appliance is
extension. used in dentulous patients with non-reconstructed lat-
Alternating buccal and lingual retention in a rigid eral discontinuity defects who have severe deviation of
design or the Swing-Lock design should be considered. the mandible toward the surgical side and are unable to
achieve unassisted intercuspation on the nonsurgical
Type IV Resection side (Figure 25-24). Generally these patients have had a
A type IV resection (see Figure 25-19) would use the signi cant amount of so tissue removed along with the
same design concepts as type II or III resections with the resected mandibular segment and have attained surgical
corresponding edentulous areas. closure by suturing of the lateral surface of the tongue to
If the gra does not provide an articulation and the the buccal mucosa, which causes a deviation toward the
so tissue covering the gra is not rmly attached to the defect side. Scarring also occurs and is worse for patients
bone gra , the movement potential will be dictated by who have not been placed on an exercise program dur-
functional forces of movement coupled with so tissue ing the healing period. e guide ange prosthesis is
supportive capacities. designed to restrict the patient to vertical opening and
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Chapter 25 Removable Partial Denture Considerations in Maxillofacial Prosthetics 335

A B

C D

Figure 25-24 A mandibular guide flange prosthesis. A, Flange extension is incorporated into a mandibular type II resection prosthe-
sis using a resin extension. B, Resection prosthesis inserted. C, Opposing maxillary prosthesis designed to engage palatal surfaces of all
remaining teeth for maximal stability against flange-induced forces. D, Flange extending to the buccal region of the opposing prosthesis
and teeth. Upon closure, the flange will guide the mandible to maximum intercuspation, at which time the flange extension will reside in
the maxillary left buccal vestibule. (Courtesy of Dr. Ron Desjardins, Rochester, MN.)

closing movements into maximum occlusal contacts. the mandibular major connector by two generous inter-
Over time, this guided function should promote scar proximal minor connectors. As with the maxillary frame,
relaxation, allowing the patient to make unassisted mas- signi cant interproximal tooth structure must be cleared
ticatory contact. to provide the necessary bulk for the minor connec-
e components of the guide ange prosthesis include tors. e height of the guide ange is determined by the
the major and minor connectors needed to support, sta- depth of the buccal vestibule. A small hook is placed at
bilize, and retain the prosthesis and the guiding mecha- the middle of the top of the guide to prevent disengage-
nism. is may include a cast buccal guide bar and guide ment on wide opening. Because the mandibular segment
ange, or simply a resin ange, which engages the oppos- has a constant medial force, the ange acts as a powerful
ing arch buccal tooth surfaces. In either case, the oppos- lever with a strong lateral force on the teeth. erefore,
ing arch must provide a stable foundation to resist any extra rests and additional stabilization and retention on
forces needed to guide the deviated mandibular segment multiple teeth must be considered to prevent overstress-
into maximum occlusal contact. ing of individual teeth. Retention on the tooth adjacent to
e buccal guide bar is placed as close as possible to the the defect is critical for resistance to li ing of the frame.
buccal occlusal line angle of the remaining natural teeth to Lingual retention in the premolar area may be considered
allow maximum opening. e lateral position of the bar as an aid in resistance to displacement. When necessary,
must be adequate to prevent the guide from contacting missing teeth can be added to a guide ange prosthesis.
the buccal mucosa of the maxillary alveolus. e length Flange prostheses can be provisionally designed for mod-
of the bar should overlie the premolars and the rst molar i cation into de nitive removable partial dentures a er
where possible. Retention of the maxillary frame should guidance is no longer necessary. is is accomplished by
not be problematic because the force directed on the bar removal of the buccal ange and buccal guide bar com-
is in a palatal direction. e guide ange is attached to ponents a er the patient is able to make occlusal contacts
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336 Part III Maintenance

without use of the guide. However, many patients with medium at the preestablished occlusal vertical dimension,
mandibular resections have di culty making repeated which will be the occlusal contact position. If the surgical
occlusal contacts—a fact described in several studies. side is signi cantly de cient, an occlusion rim may have
Occlusal considerations in mandibulectomy patients have to be extended into the defect area to support the record-
been discussed extensively by Desjardins. ing medium. Head position is of extreme importance
Palatal occlusal ramps have been used to guide those during registration of jaw relation records. If the patient
patients with less severe deviation than those who require is in a semirecumbent position in the dental chair during
a guide ange into a more stable intercuspal contact the recording procedure, the mandible may be retracted
position. ese prostheses incorporate a palatal ramp and deviated toward the surgical side, preventing move-
that simulates the function of the guide ange prosthe- ment toward the intact side. To minimize this problem,
sis. is inclination of the palatal ramp is determined the recording should be made with the patient seated in a
by the severity of the deviation of the remaining man- normal upright postural position.
dible. Some patients have the ability to move laterally Most patients with lateral discontinuity defects can
into occlusion but have a tendency to close medially and make lateral movements toward the nonsurgical side,
palatally rather than close into an acceptable cuspal rela- even without the presence of a lateral pterygoid muscle
tionship. ese patients can bene t from a palatal ramp, functioning on the balancing (surgical) side. is is pos-
which can be functionally generated in wax at the try-in sible because of the compensatory e ects of the hori-
stage. is provides a platform for occlusal contact in the zontal bers of the temporalis and the lateral pterygoid
entire bucco-lingual range of movement. A supplemental muscle on the normal side, causing a rotational e ect on
row of prosthetic teeth may be arranged, then removed the remaining condyle.
at the boil out stage, and processed in pink acrylic resin
for esthetics. Patients who have experienced both smooth
and tooth-form ramps usually prefer the tooth form if the
SUMMARY
width is adequate.
Maxillofacial prosthetic treatment of the patient with an oral
defect is among the most challenging treatments in den-
JAW RELATION RECORDS FOR MANDIBULAR
tistry. Defects are highly individual and require the clini-
RESECTION PATIENTS
cian to call upon all knowledge and experience to fabricate
Interocclusal records must be made using verbal guidance a functional prosthesis. e basic principles and concepts
only for resection patients with discontinuity defects. A described throughout this text will help the clinician to suc-
hands-on approach, like that used for conventional eden- cessfully design maxillofacial removable partial dentures.
tulous jaw relation records, will lead to unnatural rota- e interested reader is encouraged to pursue maxillofacial
tion of the mandible and an inaccurate record. e patient texts for more information regarding prosthesis design for
should be instructed to move the mandible toward the this patient group.
nonsurgical side and close into a nonresistant recording