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Conventional complete denture for a left segmental mandibulectomy patient: A clinical report
Available online at www.sciencedirect.com
Journal of Prosthodontic Research 54 (2010) 192–197 www.elsevier.com/locate/jpor
Case report
Conventional complete denture for a left segmental mandibulectomy patient: A clinical report Pravinkumar G. Patil MDS* Department of Prosthodontics, Government Dental College & Hospital, GMC Campus, Medical Square, Nagpur 440003, Maharashtra, India Received 19 May 2009; received in revised form 16 December 2009; accepted 22 December 2009 Available online 18 January 2010
Abstract Patient: A patient who had undergone left segmental mandibulectomy reconstructed with an autogenous bone graft presented with the chief complaint of difficulty in eating and speaking. Intraoral examination revealed thick, freely movable soft tissues with scar formation, loss of alveolar ridge, and obliteration of buccal and lingual sulcus in the entire left half of mandibular region. When given the options of pre-prosthetic surgery and dental implants, patient refused to undergo an additional surgery and requested a non-surgical treatment option. Consequently, conventional complete denture therapy modified by neutral zone technique was undertaken. Discussion: Prosthetic rehabilitation of this patient was challenging due to inadequate amount of supporting tissues on the defect side resulting from cancer surgery. The fabrication procedure of the denture was carefully modified to achieve retention and stability. Tissue surface of the denture was relined with resilient liner, polished surface contours and tooth positioning were recorded with neutral zone technique and occlusal surfaces were modified to achieve balanced occlusion. Conclusion: Conventional complete denture therapy with carefully recorded intaglio surface, cameo surface, and balanced occlusal surface can provide favorable retention and stability even though the denture bearing tissues are unfavorable especially in segmental mandibulectomy patients. # 2009 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved. Keywords: Mandibulectomy; Neutral zone; Complete denture
1. Introduction Neoplasms associated directly or indirectly with mandible usually require surgical removal of the lesion and extensive resection of the bone [1,2]. Smaller lesions removed without discontinuity of the bone are relatively simple to restore with prosthesis. Larger lesions that extend into floor of the mouth may be more difficult to restore with a prosthesis even though the continuity of mandible is maintained [3]. Success of the edentulous mandibular resection prosthesis is related directly to the amount of the remaining bone and soft tissues [4–7]. Segmental mandibulectomy results in special physiological and esthetic problems [8]. If the tongue is broadly resected or used for mandibular closure, valuable vestibule extension regions may be obliterated after surgery [9]. Frequently, the edentulous mandible requires reconstructive plastic surgery to create buccal or lingual sulcus depth to provide a favorable attached tissue foundation for good prognosis of complete denture therapy [10]. After * Tel.: +91 9923294699; fax: +91 7122743400. E-mail address: [email protected].
reconstructive surgery, implant-assisted overdentures may improve denture retention and stability. Most of the patients with malignant neoplasms undergo radiotherapy after resection surgery to limit the metastasis. Radiotherapy complications worsen the success of reconstructive surgical intervention as well as implant therapy [11,12]. Also most of the patients either become reluctant to undergo multiple surgical interventions or may not afford such treatment. Without pre-prosthetic reconstructive surgery, fabrication of a denture for the segmental mandibulectomy patients is challenging. This article describes fabrication of a conventional complete denture for a patient who had undergone left segmental mandibulectomy reconstructed with an autogenous bone graft. 2. Outline of the case 2.1. Patient examination, diagnosis and treatment planning A 69-year-old man was referred to the Department of Prosthodontics for prosthetic rehabilitation following a segmental mandibulectomy. A detailed case history revealed that
1883-1958/$ – see front matter # 2009 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved. doi:10.1016/j.jpor.2009.12.003
P.G. Patil / Journal of Prosthodontic Research 54 (2010) 192–197
193
Fig. 2. Mandibular preliminary impression.
The right second molar was drifted mesially to completely occupy the edentulous space of the first molar. A panoramic radiograph revealed mandibular reconstruction from symphysis to left angle by an autogenous fibular bone graft (Fig. 1C). An extraoral examination indicated facial asymmetry with slight deviation of mandible on right side because of over-correction of the defect. When given the option of implant supported prosthesis, patient refused an additional surgery and requested a noninvasive and economical treatment option. The option of vestibuloplasty of the left mandibular region, to create buccal and lingual sulci for the denture flanges, was also discarded on the same grounds. Therefore, it was decided to fabricate a conventional complete denture for this patient. 2.2. Fabrication of complete denture prosthesis
Fig. 1. (A) Intraoral view of patient with tongue in rest position. Note arrows indicating thick freely movable soft tissues. (B) Intraoral view of patient with tongue in functional position. Note loss of alveolar ridge on left side with vestibular obliteration. (C) Panoramic radiograph showing reconstructed left mandible with osseous graft.
the patient was diagnosed with squamous cell carcinoma of left buccal mucosa and had undergone partial glossectomy, segmental mandibulectomy and modified radical neck dissection 24 months back. The resultant defect was reconstructed with a free fibular autogenous bone graft. The patient received a postoperative course of total 7200 cGy external beam radiation for 6 months to limit neck metastasis. Intraoral examination revealed thick, freely movable soft tissues with scar formation, loss of alveolar ridge and obliteration of buccal and lingual sulci in the entire left half of mandibular region (Fig. 1A and B). A completely edentulous alveolar ridge was present on right half of the mandible. Maxillary right and left central incisors, right first molar and left first and second molars were missing.
A stainless steel stock edentulous tray (modified by trimming buccal flange of left half) and impression compound (Y-Dents impression compound; MDM Corporation, New Delhi, India) were used to record preliminary impression of the mandibular arch (Fig. 2). Maxillary impression was made with irreversible hydrocolloid (Dentalgin; Prime dental products, Mumbai, India). The impressions were poured with type III gypsum material (Kalstone; Kalabhai Karson Pvt. Ltd., Mumbai, India) and casts were retrieved. A mandibular custom tray was fabricated with autopolymerizing acrylic resin (DPI Cold Cure; Dental products of India, Mumbai, India) with spacer adapted only on right alveolar ridge. The borders of custom tray were adjusted to conform to the limiting structures with particular attention to the defect area. A sectional border molding procedure was performed starting with normal (right) side first, followed by the defect side. While recording the defect side, soft modeling compound (DPI Pinnacle; Dental products of India, Mumbai, India) was added to the tray borders and after tempering, the tray was positioned intraorally. Tissues in the defect area were recorded while the patient performed tongue movements, wide opening and closing movements and swallowing maneuvers. This procedure of recording the defect area was repeated 3–4 times till the maximum acceptable stability was achieved. A wash impression was made with zinc-oxide-eugenol impression paste (DPI
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P.G. Patil / Journal of Prosthodontic Research 54 (2010) 192–197
Fig. 3. Mandibular final impression.
Fig. 5. Teeth arranged in cross-bite to preserve neutral zone on right side. Note maxillary partial wax denture with two central incisors.
Fig. 4. Jaw relation with occlusal rim, shaped using neutral zone technique.
Impression paste, Dental products of India, Mumbai, India) (Fig. 3), and poured with type III gypsum material to make the master cast. Record base was made with wax-template technique using autopolymerizing acrylic resin [13]. The mandibular record base was evaluated intraorally for stability during functional movements. The shape of mandibular waxrim was modified using neutral zone technique [14,15]. The vertical and centric jaw relations were recorded (Fig. 4). The maxillary cast wasoriented on the semi-adjustable articulator (HanauH2; Teledyne Technologies, Los Angeles, Calif) using a face bow transfer and the jaw relations were transferred. The articulator was programmed using mean horizontal and lateral condylar inclinations (308 and 158, respectively). A semiadjustable articulator was used in this patient to simulate opening/closing arc of the mandible onto the articulator and to achieve balanced occlusion. A maxillary record base was fabricated using sprinkle-on technique and two acrylic resin central incisors (Acryrock; Ruthinium, Badia Polesine, Italy) were arranged. Anatomic acrylic resin denture teeth (Acryrock) were arranged on the mandibular record base and occlusion was developed as follows (Fig. 5). The occlusal surfaces of maxillary teeth were more palatal in position in relation to the mandibular occlusal rim, hence the right mandibular teeth were arranged in cross-bite. As
limited denture supporting area was available on left side, teeth arrangement was limited to premolars (which were mainly arranged to provide the balancing side contacts). Balanced occlusion was achieved on protrusive and right lateral excursive movements only, as the patient was presumed to masticate only on right side. The waxing and carving procedures of the mandibular trial denture were carried out. The waxed-up maxillary partial and mandibular complete dentures were tried in patient’s mouth and evaluated for denture stability, esthetics and occlusion during speech and eccentric jaw movements. Both the dentures were processed in heat polymerizing acrylic resin (Lucitone 199, Dentsply Intl) with the conventional technique (Fig. 6A and B) [16]. 2.3. Denture delivery and post-insertion care Occlusion of the denture at centric and eccentric positions was evaluated and adjusted intraorally. To improve the tissue contact, resilient liner (PermaSoft Denture Liner; Dentsply Austenal, York, PA) was used to reline the mandibular denture while keeping mandible into centric occlusion position (Fig. 6C). The sealer was applied once over the polymerized surface of the resilient liner to prevent water sorption by the liner and help in maintaining softness for longer period of time [17]. The dentures were delivered and post-insertion instructions were given (Fig. 7). Patient was recalled after 24 h for
P.G. Patil / Journal of Prosthodontic Research 54 (2010) 192–197
195
Fig. 7. Intraoral view of mandibular complete and maxillary partial denture.
satisfaction, patient was followed further at regular interval of 2 months, for initial 1 year. 3. Discussion
Fig. 6. (A) Polished surface of mandibular complete denture and maxillary partial denture. Note thin denture base with narrow occlusal table on left side of the mandibular denture. (B) Tissue surface of mandibular denture. Note lingual extension of denture base. (C) Mandibular denture base relined with resilient liner. Note glossy surface of sealer applied over the resilient liner.
necessary modifications. The patient was instructed to start eating a soft diet on the right side, after 15 days of denture delivery. The patient’s level of satisfaction was assessed according to the method described by Loney et al., after 1 month of denture use [18]. The patient was asked to rate his comfort in terms of a percentage to which he indicated about 90 percent of satisfaction level. The patient was pleased with the improved masticatory and esthetic outcome (Fig. 8A and B). To examine his adaptability to the dentures and level of
With the loss of buccal and lingual sulci and the presence of scar tissues, denture stability was extremely difficult to achieve in this patient. Displacement of the scar by the denture base and vice versa needed to be avoided. To achieve denture stability proper border extensions and impression surface, polished denture surface contours and harmonious occlusion were developed. In patients with unfavorable edentulous tissue support, the neutral zone technique is recommended to register the soft tissue contour and the denture polished surface [14,19]. The soft tissues that modulate the internal and external surfaces of the denture during neutral zone record influence stability of the dentures, and help determining the peripheral borders, tooth position, and external contours of the dentures [15]. The forces developed through muscular contraction during mastication, speaking and swallowing are directed against the dentures which either helps to stabilize or dislodge them [20,21]. The patient was instructed to masticate only on the non-resected side to avoid denture instability [22]. Occlusal ramps or platforms might be placed on the opposing maxillary prosthesis to guide the mandible into a more desirable maxillo-mandibular relationship and provide a broad area of occlusal contact [23]. Since the patient described in this report was able to close his mandible in a favorable maxillo-mandibular position; the occlusal ramp was not required. It may be necessary to accept an occlusion that is not bilaterally balanced in eccentric occluding positions for an edentulous resected maxilla or mandible [24]. In this patient the occlusal table on resected side extended upto the second premolar to provide balancing side contacts in right lateral excursive movements. The patient was instructed to avoid chewing from the left (defect) side. Changes in tissues beneath a maxillofacial prosthesis may be more rapid than those beneath a conventional complete denture prosthesis, therefore the occlusion and base adaptation were revaluated frequently [24]. Denture base adaptation was maintained by changing the resilient liner every year, along with sealer application to maintain softness of the liner [17].
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Fig. 8. (A) Extraoral view of the patient without prosthesis. (B) Extraoral view of the patient with prosthesis.
Maxillary partial denture replacing both missing central incisors was fabricated without clasps as retention was obtained by extending the acrylic extensions in palatal interdental areas. This type of tissue-borne acrylic partial denture festooned around the palatal gingival margins helps in prosthesis retention [25,26]. Although until now the patient has been allowed to wear a claspless maxillary partial denture, the necessity of clasps with rests should be also carefully considered in the future, in order to provide better bracing and support for the maxillary denture, if necessary. 4. Conclusion Though the denture bearing tissues were unfavorable, like in patients with segmental mandibulectomy; polished surface, occlusal surface and tissue surface were carefully modified to give favorable denture stability following neutral zone technique. Application of conventional prosthodontic principles along with patient cooperation can achieve long term success of prosthesis and predictable patient satisfaction in such compromised situations. References [1] Beumer III JB, Curtis TA, Firtell D. Maxillofacial rehabilitation: prosthodontic and surgical considerations. St. Louis: Mosby; 1979. p. 90–169. [2] Shafer WG, Hine MK, Levy BM, Tomich CE. A textbook of oral pathology, 4th ed., Philadelphia: WB Saunders; 1993. p. 86–229.
[3] Adisman IK. Prosthesis serviceability for acquired jaw defects. Dent Clin North Am 1990;34:265–84. [4] Cantor R, Curtis TA. Prosthetic managements of edentulous mandibulectomy patients. Part 1. Anatomic, physiologic and psychologic consideration. J Prosthet Dent 1971;25:446–57. [5] Taylor TD. Clinical maxillofacial prosthetics. Chicago: Quintessence; 2000. p. 171–188. [6] Desjardins RP. Occlusal considerations for the partial mandibulectomy patient. J Prosthet Dent 1979;41:308–15. [7] Cantor R, Curtis TA. Prosthetic management of edentulous mandibulectomy patients. II. Clinical procedures. J Prosthet Dent 1971;25: 546–55. [8] Prakash V. Prosthetic rehabilitation of edentulous mandibulectomy patient. A clinical report. Indian J Dent Res 2008;19:257–60. [9] Parel SM. Overdentures in the maxillofacial prosthetic practice. Part I: the cancer patient. J Prosthet Dent 1983;50:522–9. [10] Martin JW, Lemon JC, King GE. Maxillofacial restoration after tumor ablation. Clin Plast Surg 1994;21:87–96. [11] Werkmeister R, Szulczewski D, Walteros-Benz P, Joos U. Rehabilitation with dental implants of oral cancer patients. J Craniomaxillofac Surg 1999;27:38–41. [12] Roumanas ED, Nishimura RD, Davis BK, Beumer III J. Clinical evaluation of implants retaining edentulous maxillary obturator prosthesis. J Prosthet Dent 1997;77:184–90. [13] Zarb GA, Finer Y. Identification of shape and location of arch form: the occlusion rim and recording of trial denture base. In: Zarb GA, Bolender CL, Eckert SE, Fenton AH, Jacob RF, Merickske-Stern R, editors. Prosthodontic treatment for edentulous patients: complete dentures and implant supported prostheses. 12th ed., St. Louis: Mosby; 2005. p. 252– 67. [14] Beresin VE, Schiesser FJ. The neutral zone in complete dentures. J Prosthet Dent 1976;36:356–67.
P.G. Patil / Journal of Prosthodontic Research 54 (2010) 192–197 [15] Gahan MJ, Walmsley AD. The neutral zone impression revisited. Br Dent J 2005;198:269–72. [16] Morrow RM, Rudd KD, Rhoads JE. Dental laboratory procedures complete dentures, 2nd ed., St. Louis: Mosby; 1986. p. 312–338. [17] Kiat-Amnuay S, Gettleman L, Mekayarajjananonth T, Khan Z, Goldsmith JL. The influence of water storage on durometer hardness of 5 soft denture liners over time. J Prosthodont 2005;14:19–24. [18] Loney R. Diagnosing denture pain: principles and practice. J Can Dent Assoc 2006;72:137–41. [19] Fahmy FM, Kharat DU. A study of the importance of the neutral zone in complete dentures. J Prosthet Dent 1990;64:459–62. [20] Makzoume JE. Morphologic comparison of two neutral zone impression techniques: a pilot study. J Prosthet Dent 2004;92:563–8.
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[21] Wee AG, Cwynar RB, Cheng AC. Utilization of the neutral zone technique for a maxillofacial patient. J Prosthodont 2000;9:2–7. [22] Mou S, Chai T, Shiau Y, Wang J. Fabrication of conventional complete dentures for a left segmental mandibulectomy patient: a clinical report. J Prosthet Dent 2001;86:582–5. [23] Curtis TA, Cantor R. The forgotten patient in maxillofacial prosthetics. J Prosthet Dent 1974;31:662–80. [24] Principles, concepts, and practices in prosthodontics-1994. Academy of prosthodontics. J Prosthet Dent 1995;73:73–94. [25] Roberts DH. Fixed bridge prostheses, 2nd ed., Bristol: John Wright and Sons Ltd.; 1980. p. 7–29. [26] Grasso JE, Miller EL. Removable partial prosthodontics, 3rd ed., St. Louis: Mosby; 1991. p. 330–337.
Journal of Prosthodontic Research 54 (2010) 192–197 www.elsevier.com/locate/jpor
Case report
Conventional complete denture for a left segmental mandibulectomy patient: A clinical report Pravinkumar G. Patil MDS* Department of Prosthodontics, Government Dental College & Hospital, GMC Campus, Medical Square, Nagpur 440003, Maharashtra, India Received 19 May 2009; received in revised form 16 December 2009; accepted 22 December 2009 Available online 18 January 2010
Abstract Patient: A patient who had undergone left segmental mandibulectomy reconstructed with an autogenous bone graft presented with the chief complaint of difficulty in eating and speaking. Intraoral examination revealed thick, freely movable soft tissues with scar formation, loss of alveolar ridge, and obliteration of buccal and lingual sulcus in the entire left half of mandibular region. When given the options of pre-prosthetic surgery and dental implants, patient refused to undergo an additional surgery and requested a non-surgical treatment option. Consequently, conventional complete denture therapy modified by neutral zone technique was undertaken. Discussion: Prosthetic rehabilitation of this patient was challenging due to inadequate amount of supporting tissues on the defect side resulting from cancer surgery. The fabrication procedure of the denture was carefully modified to achieve retention and stability. Tissue surface of the denture was relined with resilient liner, polished surface contours and tooth positioning were recorded with neutral zone technique and occlusal surfaces were modified to achieve balanced occlusion. Conclusion: Conventional complete denture therapy with carefully recorded intaglio surface, cameo surface, and balanced occlusal surface can provide favorable retention and stability even though the denture bearing tissues are unfavorable especially in segmental mandibulectomy patients. # 2009 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved. Keywords: Mandibulectomy; Neutral zone; Complete denture
1. Introduction Neoplasms associated directly or indirectly with mandible usually require surgical removal of the lesion and extensive resection of the bone [1,2]. Smaller lesions removed without discontinuity of the bone are relatively simple to restore with prosthesis. Larger lesions that extend into floor of the mouth may be more difficult to restore with a prosthesis even though the continuity of mandible is maintained [3]. Success of the edentulous mandibular resection prosthesis is related directly to the amount of the remaining bone and soft tissues [4–7]. Segmental mandibulectomy results in special physiological and esthetic problems [8]. If the tongue is broadly resected or used for mandibular closure, valuable vestibule extension regions may be obliterated after surgery [9]. Frequently, the edentulous mandible requires reconstructive plastic surgery to create buccal or lingual sulcus depth to provide a favorable attached tissue foundation for good prognosis of complete denture therapy [10]. After * Tel.: +91 9923294699; fax: +91 7122743400. E-mail address: [email protected].
reconstructive surgery, implant-assisted overdentures may improve denture retention and stability. Most of the patients with malignant neoplasms undergo radiotherapy after resection surgery to limit the metastasis. Radiotherapy complications worsen the success of reconstructive surgical intervention as well as implant therapy [11,12]. Also most of the patients either become reluctant to undergo multiple surgical interventions or may not afford such treatment. Without pre-prosthetic reconstructive surgery, fabrication of a denture for the segmental mandibulectomy patients is challenging. This article describes fabrication of a conventional complete denture for a patient who had undergone left segmental mandibulectomy reconstructed with an autogenous bone graft. 2. Outline of the case 2.1. Patient examination, diagnosis and treatment planning A 69-year-old man was referred to the Department of Prosthodontics for prosthetic rehabilitation following a segmental mandibulectomy. A detailed case history revealed that
1883-1958/$ – see front matter # 2009 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved. doi:10.1016/j.jpor.2009.12.003
P.G. Patil / Journal of Prosthodontic Research 54 (2010) 192–197
193
Fig. 2. Mandibular preliminary impression.
The right second molar was drifted mesially to completely occupy the edentulous space of the first molar. A panoramic radiograph revealed mandibular reconstruction from symphysis to left angle by an autogenous fibular bone graft (Fig. 1C). An extraoral examination indicated facial asymmetry with slight deviation of mandible on right side because of over-correction of the defect. When given the option of implant supported prosthesis, patient refused an additional surgery and requested a noninvasive and economical treatment option. The option of vestibuloplasty of the left mandibular region, to create buccal and lingual sulci for the denture flanges, was also discarded on the same grounds. Therefore, it was decided to fabricate a conventional complete denture for this patient. 2.2. Fabrication of complete denture prosthesis
Fig. 1. (A) Intraoral view of patient with tongue in rest position. Note arrows indicating thick freely movable soft tissues. (B) Intraoral view of patient with tongue in functional position. Note loss of alveolar ridge on left side with vestibular obliteration. (C) Panoramic radiograph showing reconstructed left mandible with osseous graft.
the patient was diagnosed with squamous cell carcinoma of left buccal mucosa and had undergone partial glossectomy, segmental mandibulectomy and modified radical neck dissection 24 months back. The resultant defect was reconstructed with a free fibular autogenous bone graft. The patient received a postoperative course of total 7200 cGy external beam radiation for 6 months to limit neck metastasis. Intraoral examination revealed thick, freely movable soft tissues with scar formation, loss of alveolar ridge and obliteration of buccal and lingual sulci in the entire left half of mandibular region (Fig. 1A and B). A completely edentulous alveolar ridge was present on right half of the mandible. Maxillary right and left central incisors, right first molar and left first and second molars were missing.
A stainless steel stock edentulous tray (modified by trimming buccal flange of left half) and impression compound (Y-Dents impression compound; MDM Corporation, New Delhi, India) were used to record preliminary impression of the mandibular arch (Fig. 2). Maxillary impression was made with irreversible hydrocolloid (Dentalgin; Prime dental products, Mumbai, India). The impressions were poured with type III gypsum material (Kalstone; Kalabhai Karson Pvt. Ltd., Mumbai, India) and casts were retrieved. A mandibular custom tray was fabricated with autopolymerizing acrylic resin (DPI Cold Cure; Dental products of India, Mumbai, India) with spacer adapted only on right alveolar ridge. The borders of custom tray were adjusted to conform to the limiting structures with particular attention to the defect area. A sectional border molding procedure was performed starting with normal (right) side first, followed by the defect side. While recording the defect side, soft modeling compound (DPI Pinnacle; Dental products of India, Mumbai, India) was added to the tray borders and after tempering, the tray was positioned intraorally. Tissues in the defect area were recorded while the patient performed tongue movements, wide opening and closing movements and swallowing maneuvers. This procedure of recording the defect area was repeated 3–4 times till the maximum acceptable stability was achieved. A wash impression was made with zinc-oxide-eugenol impression paste (DPI
194
P.G. Patil / Journal of Prosthodontic Research 54 (2010) 192–197
Fig. 3. Mandibular final impression.
Fig. 5. Teeth arranged in cross-bite to preserve neutral zone on right side. Note maxillary partial wax denture with two central incisors.
Fig. 4. Jaw relation with occlusal rim, shaped using neutral zone technique.
Impression paste, Dental products of India, Mumbai, India) (Fig. 3), and poured with type III gypsum material to make the master cast. Record base was made with wax-template technique using autopolymerizing acrylic resin [13]. The mandibular record base was evaluated intraorally for stability during functional movements. The shape of mandibular waxrim was modified using neutral zone technique [14,15]. The vertical and centric jaw relations were recorded (Fig. 4). The maxillary cast wasoriented on the semi-adjustable articulator (HanauH2; Teledyne Technologies, Los Angeles, Calif) using a face bow transfer and the jaw relations were transferred. The articulator was programmed using mean horizontal and lateral condylar inclinations (308 and 158, respectively). A semiadjustable articulator was used in this patient to simulate opening/closing arc of the mandible onto the articulator and to achieve balanced occlusion. A maxillary record base was fabricated using sprinkle-on technique and two acrylic resin central incisors (Acryrock; Ruthinium, Badia Polesine, Italy) were arranged. Anatomic acrylic resin denture teeth (Acryrock) were arranged on the mandibular record base and occlusion was developed as follows (Fig. 5). The occlusal surfaces of maxillary teeth were more palatal in position in relation to the mandibular occlusal rim, hence the right mandibular teeth were arranged in cross-bite. As
limited denture supporting area was available on left side, teeth arrangement was limited to premolars (which were mainly arranged to provide the balancing side contacts). Balanced occlusion was achieved on protrusive and right lateral excursive movements only, as the patient was presumed to masticate only on right side. The waxing and carving procedures of the mandibular trial denture were carried out. The waxed-up maxillary partial and mandibular complete dentures were tried in patient’s mouth and evaluated for denture stability, esthetics and occlusion during speech and eccentric jaw movements. Both the dentures were processed in heat polymerizing acrylic resin (Lucitone 199, Dentsply Intl) with the conventional technique (Fig. 6A and B) [16]. 2.3. Denture delivery and post-insertion care Occlusion of the denture at centric and eccentric positions was evaluated and adjusted intraorally. To improve the tissue contact, resilient liner (PermaSoft Denture Liner; Dentsply Austenal, York, PA) was used to reline the mandibular denture while keeping mandible into centric occlusion position (Fig. 6C). The sealer was applied once over the polymerized surface of the resilient liner to prevent water sorption by the liner and help in maintaining softness for longer period of time [17]. The dentures were delivered and post-insertion instructions were given (Fig. 7). Patient was recalled after 24 h for
P.G. Patil / Journal of Prosthodontic Research 54 (2010) 192–197
195
Fig. 7. Intraoral view of mandibular complete and maxillary partial denture.
satisfaction, patient was followed further at regular interval of 2 months, for initial 1 year. 3. Discussion
Fig. 6. (A) Polished surface of mandibular complete denture and maxillary partial denture. Note thin denture base with narrow occlusal table on left side of the mandibular denture. (B) Tissue surface of mandibular denture. Note lingual extension of denture base. (C) Mandibular denture base relined with resilient liner. Note glossy surface of sealer applied over the resilient liner.
necessary modifications. The patient was instructed to start eating a soft diet on the right side, after 15 days of denture delivery. The patient’s level of satisfaction was assessed according to the method described by Loney et al., after 1 month of denture use [18]. The patient was asked to rate his comfort in terms of a percentage to which he indicated about 90 percent of satisfaction level. The patient was pleased with the improved masticatory and esthetic outcome (Fig. 8A and B). To examine his adaptability to the dentures and level of
With the loss of buccal and lingual sulci and the presence of scar tissues, denture stability was extremely difficult to achieve in this patient. Displacement of the scar by the denture base and vice versa needed to be avoided. To achieve denture stability proper border extensions and impression surface, polished denture surface contours and harmonious occlusion were developed. In patients with unfavorable edentulous tissue support, the neutral zone technique is recommended to register the soft tissue contour and the denture polished surface [14,19]. The soft tissues that modulate the internal and external surfaces of the denture during neutral zone record influence stability of the dentures, and help determining the peripheral borders, tooth position, and external contours of the dentures [15]. The forces developed through muscular contraction during mastication, speaking and swallowing are directed against the dentures which either helps to stabilize or dislodge them [20,21]. The patient was instructed to masticate only on the non-resected side to avoid denture instability [22]. Occlusal ramps or platforms might be placed on the opposing maxillary prosthesis to guide the mandible into a more desirable maxillo-mandibular relationship and provide a broad area of occlusal contact [23]. Since the patient described in this report was able to close his mandible in a favorable maxillo-mandibular position; the occlusal ramp was not required. It may be necessary to accept an occlusion that is not bilaterally balanced in eccentric occluding positions for an edentulous resected maxilla or mandible [24]. In this patient the occlusal table on resected side extended upto the second premolar to provide balancing side contacts in right lateral excursive movements. The patient was instructed to avoid chewing from the left (defect) side. Changes in tissues beneath a maxillofacial prosthesis may be more rapid than those beneath a conventional complete denture prosthesis, therefore the occlusion and base adaptation were revaluated frequently [24]. Denture base adaptation was maintained by changing the resilient liner every year, along with sealer application to maintain softness of the liner [17].
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P.G. Patil / Journal of Prosthodontic Research 54 (2010) 192–197
Fig. 8. (A) Extraoral view of the patient without prosthesis. (B) Extraoral view of the patient with prosthesis.
Maxillary partial denture replacing both missing central incisors was fabricated without clasps as retention was obtained by extending the acrylic extensions in palatal interdental areas. This type of tissue-borne acrylic partial denture festooned around the palatal gingival margins helps in prosthesis retention [25,26]. Although until now the patient has been allowed to wear a claspless maxillary partial denture, the necessity of clasps with rests should be also carefully considered in the future, in order to provide better bracing and support for the maxillary denture, if necessary. 4. Conclusion Though the denture bearing tissues were unfavorable, like in patients with segmental mandibulectomy; polished surface, occlusal surface and tissue surface were carefully modified to give favorable denture stability following neutral zone technique. Application of conventional prosthodontic principles along with patient cooperation can achieve long term success of prosthesis and predictable patient satisfaction in such compromised situations. References [1] Beumer III JB, Curtis TA, Firtell D. Maxillofacial rehabilitation: prosthodontic and surgical considerations. St. Louis: Mosby; 1979. p. 90–169. [2] Shafer WG, Hine MK, Levy BM, Tomich CE. A textbook of oral pathology, 4th ed., Philadelphia: WB Saunders; 1993. p. 86–229.
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