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Prosthodontic Rehabilitation of Acquired Mandibular Defects: A Non Surgical Treatment Approach.

Byline: Bilal Ahmed

Abstract

Prosthodontic rehabilitation of mandibulectomy defects is always a challenging clinical scenario. These defects pose a major anatomical physiological and psychological threat not only to the patients but to the entire family. A multidisciplinary team approach long term follow up and sympathetic attitude may help to bring these suffering patients back to normal life stream. Recent advancements in Dental Materials CAD CAM Laser Technology and Pre prosthetic surgical procedures like Osseo Integrated Implants have revolutionized the treatment approaches. However in certain clinical case scenarios Conventional Prosthodontic Principles are still the Gold Standards. This article reports the rehabilitation of a partial mandibulectomy patient following a conventional non surgical removable cast denture prosthodontics.Key words: Maxillofacial prosthodontics prosthodontic rehabilitation maxillofacial defects facial prosthesis.

Introduction

ehabilitation of mandibulectomy defects is always a challenging and controversial Prosthodontic clinical scenario. These defects either can be due to Congenital developmental anomalies or can be aquired due to trauma burns infections or surgical resections1. These defects pose a great loss to functional effeciency phonetics as well as facial profile of the affected subjects. Intra Orally these can lead to disturbed continuity of hard and soft tissues. Males are predominantly affected as they are relatively at greater risk of exposures to differentprofessional health hazards and traumatic incidents2.The clinical presentation usully depends on the etiology location and extent of the lesion. Surgical reconstruction with or without soft and/or hard tissue grafting procedures is the treatment of choice However in extensive defects where intimate closures are not possible a fixed or removable prosthesis may be the onlyoption possible depending upon the requirements.Rehabilitation of these patients after surgical resections of malignant lesions is one of the most difficult therapies of stomatognathic system. Significant deformation of tissues dysfunction of stomatognathic system with concurrent biological imbalance of the oral

cavity frequently affect the treatment strategies. Scars and contraction of oral crevice may cause serious psychological deficiencies that are another aspect of the treatment schedule3.These patients require a multidisciplinary teamapproach with thorough patient evluation and management protocols considering the functional and psychosocial requirements. A comprehensive long term treatment planning family and patient counselling and a sympathetic consideration can drammatically affect the treatment outcomes and these patients can become a usefull part of the society. Rehabilitation of these intra oral maxillo mandibular defects always pose clinical challenge to the prosthodontists as these clinical scenarios always present unpredictable treatment outcomes4.The primary objective of oral surgeons and prosthodontists is to eliminate disease and to improve the quality of life including the facial contours which influences the psychological condition of the patient. This report presents management of an intra oral mandibulectomy defect utilizing a conventionalremovable prosthodontic approach.

Case Report

A 42 years old male patient was refferred from the Oral Surgeon for the prosthodontic rehabilitation of anterior mandibulectomy along with the lost lower anterior dentition. This patient was presented with a four months history of mandibular surgical resection because of a large cystic lesion in the anterior body of the mandible. The records showed that the lesion incorporated the mandibular labial and buccal segments extending from tooth # 36 to tooth # 46 and resulted in a prominent swelling in the anterior lower half of the face. Oral surgeons resected the affected area along with the involved teeth however the lingual alveolar walls and the base of the mandible remained intact. There was no significant medical or family history. The patient attributed development of that cyst to faulty extraction of some lower tooth many years ago but there was no record available. Habitual history and drug history were also not associated.On extra oral examination lower one third of the face was prominently depressed specially on the left side. The lower lip was collapsed and unsupported. However morphological continuity of the lower border of the mandible was intact. All the mandibular movements were normal except the lower lip and adjacent soft tissues which were falling behind the upper dentition making an incompetent lip seal during functions.On intra oral examination upper arch was intact except for a broken dental root # 23. There was a big scarred defect in the anterior mandible area with no labial sulcus present. Anterior alveolar bone was severely compromised and only teeth present in the lower archwere # 37 38 47 48. There was a big open bite in theanterior region during occlusion. The alveolar bone in the lower premolar segments was intact and could be an ideal platform for differential support. The patient was suffering from compromised masticatory efficiency and phoneticsRediographic presentation revealed marked alveolar bone defect with intact cortical bases. The teeth present in the lower arch were healthy with sound divergent roots. There was a broken dental root # 23 with Preliminary impressions were recorded and study casts were surveyed and then articualted on a semi adjustable articulator. Different treatment options like osseointegrated implants bone grafting and conventional prosthodontic modalities were considered and presented to the patient. After a detailed discussion it was decided to rehabilitate this defect with a conservative cast partial removable prosthesis without implying any further surgical procedures.Routine prosthodontic procedures like mouthpreparations in the form of occlusal rests were done and a cast framework was tried in the patients mouth with retaining arms on lingual undercut areas of teeth # 37 47. After jaw relationing and tooth try in stages the functional impressions were done and altered casts were achieved.The final prosthesis was inserted within a week time and the patient was explained about the use and maintenance protocols (Figure-2 and 3). He was regularly followed up for any functional or occlusal discrepancies. He is happy and thankful to get his teeth and smiles back without any further aggressive surgery (Figure-4).

Discussion

In this study rehabilitation of a partial mandibulectomy patient following a conventional non surgical removable cast denture prosthodontics has been described. Restoration of extra and intra oral maxillofacial defects can be accomplished either surgically prosthetically or a combination of both. Prosthetic restoration is always attempted where surgical correction is not feasible. Pre surgical records like Mounted Casts photographs etc are extremely valuable in fabrication of prosthesis. There are undoubtedly great benefits of presurgical prosthodontic evaluation and fabrication of immediate surgical prosthesis5.The Prosthodontic end results mainly depend on the physical and mechanical properties and quality of materials used which includes Acrylic Resin Acrylic Co polymers Vinyl polymers Poly urethane elastomers Silicone Elasomers with cast or wrought metallic alloys. Acrylic Resins are widely used materials because they are cost effective easy to fabricate easily adjustable repairable and replaceable if required. Recently CAD CAM Technology is gaining popularity in the fabrication of Maxillo Facial Prosthesis but its use is limited due to its complexity Increased Cost and non availability at many centers in the under developed countries4.Biomechanical challenges in these maxillo facial prostheses are aided by Direct Retainers in the form of Clasp Assemblies Precision attachments Magnets Engaging soft and hard tissue undercuts Osseo Integrated Implant retained abutments or by the use of bio compatible adhesives. Hollow appliances help to reduce the weight of the obturator thus indirectly aid in the retention6.The difficulty in rehabilitation of these cases is a compromise between esthetics and functional efficiency7. This is important to restore the lost natural anatomy and morphology immediately or later after surgery for normal living and social acceptance among their peer group. The extensive prosthesis many a times result in gag reflexes but with reassuarance and standard precautions this can always be managed.These patients also suffer compromised adaptability to prosthodontic appliances because they have been reported to have reduced values of oral sterognostic abilities (OSA) and oral motor abilities (OMA). Thesesensory and motor sensations are compromised in mandibulectomy patients because of disturbed morphology of intra oral hard tissues that had to work as a platform against the sensory tongue8. The untreated cases suffered from compromised speech efficiency. However properly placed prosthesis with effectively sealed soft tissue margins can produce dramatic improvements9.Unfortunately this patient was refferred four months after the surgical resection so the benefits of earlier prosthodontic intervention was already lost. There were tight strictures on the affected side with collapsed profile. The patient also had to bear a difficult and problematic healing phase. However Prosthodontist Surgeons and patients jointly can overcome this problem. Our patient was happy with the restoration. He was quickly adapting to the prosthesis and its maintenance protocols.

References

1. The Academy of Prosthodontics Foundation. The glossary of Prosthodontic Terms. J Prosthet Dent 2005; 94:56.2. Ahmed B Hussain M Mehmood A Yazdanie N. Maxillofacial Rehabilitation of a large intra oral defect using Fixed Removable Prosthesis. J Coll Physicians Surg Pak 2011; 21:52-54.3. Ahmed B Mehmood A Hussain M Amin M Yazdanie N. Rehabilitation of nose using silicone based maxillofacial prosthesis. J Coll Physician Surg Pak 2010; 20(1):65-67.

4. Ahmed B Fateh A Yazdanie N. Rehabilitation of a large maxillofacial defect using acrylic resin prosthesis. J Coll Physicians Surg Pak 2011;21:254-6.

5. Turkaslan S Baykul T Aydin MA Ozarslan MM. Influence of immediate and permanent obturators on facial contours: A Case Series. Cases J 2009; 2:6.6. Kalavathy N Premnath K Jayanathi N Jadav V. Prosthetic rehabilitation of patient with ameloblastoma: A case report. JIPS 2011 (Epub ahead of Print).

7. Mehmood A Ahmed B Parveen N Yazdanie N. Oral health related quality of life in complete denture prosthodontics. Pak Oral Dent J 2009; 29:397-402.8. Ahmed B Hussain M Yazdanie N. Oral stereognostic ability: a test of oral perception. J Coll Physicians Surg Pak 2006;16:794-8.

9. Arigbede AO Dosumu OO Shaba OP Esan TA. Evaluation of speech in aptients with partial surgically acquired defects: pre and post prosthetic obturation. J Contemp Dent Pract 2006; 7:89-96.
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Article Details
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Author:Ahmed, Bilal
Publication:Pakistan Journal of Medical Research
Article Type:Report
Geographic Code:9PAKI
Date:Jun 30, 2014
Words:1623
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