24 

CHAPTER

Removable Partial
Denture Considerations in
Maxillofacial Prosthetics

Chapter Outline Maxillofacial Prosthetics

Maxillofacial Prosthetics The preceding chapters have dealt with prosthesis consider-
Maxillofacial classification ations for partially edentulous individuals. In these patients,
Timing of Dental and Maxillofacial Prosthetic Care for the extent of loss includes teeth and a varying degree of
Acquired Defects residual ridge bone, yet the remaining anatomy of the jaws
Preoperative and intraoperative care and adjacent regions is functionally and physically intact.
Interim care For these patients, the major distinguishing feature that
Potential complications affects removable partial denture design is whether the
Defect and oral hygiene prosthesis will be tooth supported or tooth and tissue
Definitive care supported.
Intraoral Prostheses: Design Considerations The maxillofacial patient can experience unique altera-
Surgical Preservation for Prosthesis Benefit tions in the normal oral/craniofacial environment; these
Maxillary defects result from surgical resections (Figure 24-1), maxillofacial
Mandibular defects trauma, congenital defects, developmental anomalies, or
Mandibular reconstruction—bone grafts neuromuscular disease. In contrast to the above, when
Maxillary Prostheses removable partial dentures are considered for these indi-
Obturator prostheses viduals, not only are tooth and tissue support considerations
Speech aid prostheses important, but the design must also take into account what
Palatal lift prostheses impact the altered environment will have on prosthesis
Palatal augmentation prostheses support, stability, and retention. In general, environmental
Mandibular Prostheses changes reduce the capacity for residual teeth and tissue
Evolution of mandibular surgical resection to provide optimum cross-arch support, stability, and
Type I resection retention.
Type II resection As a subspecialty of prosthodontics, maxillofacial pros-
Type III resection thetics is concerned with the restoration and/or replacement
Type IV resection of the stomatognathic system and associated facial structures
Type V resection with prostheses that may or may not be removed on a regular
Mandibular guide flange prosthesis or elective basis. This chapter discusses important back-
Jaw Relation Records for Mandibular Resection Patients ground information related to maxillofacial prostheses and
Summary the principles involved in removable partial denture design
for the maxillofacial patient.

316
 Chapter 24  Removable Partial Denture Considerations in Maxillofacial Prosthetics 317

A B

Figure 24-1    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 remov-
able prosthodontic principles modified for maxillofacial needs.

rienced a maxillectomy procedure can be quite different

from management of a patient with an unrepaired cleft
palate.
Another helpful way to classify maxillofacial patients is
by the type of prosthesis under consideration. Consequently,
prostheses are said to be extraoral (cranial or facial replace-
ment) or intraoral (involving the oral cavity); interim (for
short periods of time, often perioperative) or definitive
(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
Figure 24-2    Large squamous cell carcinoma involving the Acquired defects are the most common maxillofacial defects
maxillary tuberosity region, which will result in an acquired defect managed by using removable prostheses. A conceptual
following surgical removal. framework for the timing of dental/oral care that best
emphasizes the initial important surgical requirements, fol-
lowed later by the important prosthetic requirements, is
helpful to consider regarding the coordination of care for
Maxillofacial Classification patients with acquired defects. Such a framework considers
Patients can be categorized by maxillofacial defects that are preoperative and intraoperative interim care and definitive
acquired, congenital, or developmental. Acquired defects care. Although it may seem unrelated initially, it is included
include those that are the result of trauma, or of disease and in this discussion of removable partial dentures for maxil-
its treatment. These may include a soft and/or hard palate lofacial applications because of the important impact that
defect resulting from removal of a squamous cell carcinoma decisions made at all stages of management can have on
of the region (Figure 24-2). Congenital defects are typically prosthesis function and patient outcomes.
craniofacial defects that are present from birth. The most
common of these include cleft defects of the palate that may Preoperative and Intraoperative Care
include the premaxillary alveolus. Developmental defects are The planning of prosthetic treatment for acquired oral
those defects that occur because of some genetic predisposi- defects should begin before surgery. For the patient facing
tion that is expressed during growth and development head and neck surgery, consideration should be given to
(Figure 24-3). Such a classification order is helpful as patients dental needs that will improve the immediate postoperative
within each category share similar characteristics (beyond course. Consequently, the prosthodontist who will help with
those features specifically related to the prosthesis design), management of the patient’s care should see the patient
which become part of the total management plan. For before surgery (Figure 24-4). The dental objectives of the
example, prosthetic management of an adult who has expe- preoperative and intraoperative care stages are to remove
 318 Part III  Maintenance

A B

Figure 24-3    A functional jaw position developed because of a combination of tooth loss and growth discrepancy. This developmental
defect is illustrated by a protruded and overclosed mandibular position (A), which has created a significantly irregular maxillary occlusal
plane (B).

The immediate postoperative period will be significantly

challenging to the patient. If preexisting dental disease is
severe enough to potentially create symptoms during the
immediate postoperative period, treatment should be pro-
vided to remove such a complication. Large carious lesions,
which could create pain, can be temporarily restored by
endodontic therapy if they offer some advantage for postop-
erative prosthetic function. Teeth exhibiting acute periodon-
tal disease (such as acute necrotizing ulcerative gingivitis)
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 nonrestor-
able because of advanced caries or periodontal disease, and
not critical for temporary use during the interim care period
Figure 24-4    Presurgical presentation of a patient with a max- following temporary treatment, should be removed before,
illary malignant melanoma. The benefits of having such a visit or at the time of, surgical resection. Teeth that may appear
before surgery are both psychological and functional. The psy- to have a limited long-term prognosis may significantly
chological benefits include the chance to discuss functional defi- enhance prosthetic service during the initial postsurgical
cits associated with the anticipated surgical procedure and to period and should be maintained until the initiation of
describe how and to what extent the stages of prosthetic manage- definitive care.
ment will address them. The functional benefit from a prosthesis Impressions are made of the maxillary and mandibular
standpoint is that strategically important teeth, for definitive arches to provide a record of existing conditions and occlu-
and/or interim prosthesis use, can be discussed with the surgical
sion to allow fabrication of immediate or interim prostheses
team and treatment planned for preservation.
(Figure 24-5) and to assess the need for immediate and
delayed modification of the teeth or adjacent structures to
potential dental postoperative complications, to plan for the optimize prosthetic care. It is important at this stage to begin
subsequent prosthetic treatment, and to make recommenda- planning for the definitive prosthesis because the greatest
tions for surgical site preparation that improve structural impact on the success of the maxillofacial prosthesis stems
integrity. Important patient benefits of such a preoperative from the integrity of the remaining teeth and surrounding
consultation include the opportunity to develop the patient- structures.
clinician relationship, to discuss the functional deficits
associated with the anticipated surgical procedure, and to Interim Care
describe how and to what extent the stages of prosthetic The major emphasis during this stage of care is the surgical
management will address them. The benefit from a prosthe- (and adjunctive) management needs of the patient. In
sis standpoint is that strategically important teeth, for defini- today’s environment of appropriately aggressive mandibular
tive and/or interim prosthesis use, can be discussed with the surgical reconstruction, mandibular discontinuity defects
surgical team and treatment planned for preservation. are seldom a surgical outcome. When discontinuity defects
 Chapter 24  Removable Partial Denture Considerations in Maxillofacial Prosthetics 319

A B

Figure 24-5    A, A maxillary cast of the presurgical oral condition, which allows consultation with the surgeon regarding resection
margins 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.

in the mandible result following surgery, interim prosthetic surgical dressing and split-thickness skin graft during the
care is not indicated and the discussion will be directed to immediate postsurgical period. Such prostheses are best sta-
the maxillary defect. bilized by appropriate wiring to remaining teeth or alveolar
The typical maxillary acquired defect results in oral com- bone, or they may be suspended from superior skeletal struc-
munication with the nose and/or maxillary sinus, although tures. For some patients who have teeth remaining, such an
the composition of the surgical defect may vary widely immediate surgical prosthesis could be retained by wires in
(Figure 24-6). This creates physiologic and functional defi- the prosthesis that engage undercuts on the teeth and would
ciencies in mastication, deglutition, and speech. Such defects be removable; however, the ability to control the surgical
have a negative impact on the psychological disposition of dressing may be less predictable with such an approach.
patients, especially if the defect also affects cosmetic appear- Immediate placement of a prosthesis has been suggested to
ance. The major deficiencies directly addressed by prosthetic improve patient acceptance of the surgical defect, although
management at this interim care time are deglutition and no measure of this psychological impact has been shown;
speech. This immediate postsurgical time is very challenging this method offers greater assurance of adequate nourish-
for patients, and it is important that they have been mentally ment by mouth—potentially precluding the use of a naso-
prepared for it during the preoperative period. However, gastric tube.
even with preliminary discussion, the impact of the surgery It may be preferable to stabilize the surgical dressing by
is often very distressing. An initial focus on improvement in suturing a sponge bolster to provide stabilization to the split-
swallowing and speech with the interim prosthesis can help thickness skin graft. Following the primary healing stage, the
boost the rehabilitation process significantly. sponge with packing (or the immediate prosthesis if used) is
The patient is counseled that chewing on the defect side removed by the surgeon and an interim obturator prosthesis
is not allowed because of its effect on prosthesis movement. can be placed (Figure 24-7). For the patient who has been
The objective of this interim obturator prosthesis is to sepa- provided with bolster obturation, the presurgical prosth-
rate the oral and nasal cavities by obturating the communi- odontic evaluation is very important to ensure that the
cation. Such obturator prostheses most commonly refer to patient is prepared for the transition from bolster to pros-
obturation of a hard palatal defect but conceptually can be thesis, and to ensure that plans for the prosthesis are made,
considered the same for soft palatal defects at this stage of especially if an interim prosthesis is to be fabricated. Interim
management, because both attempt to artificially block the prostheses are wire-retained resin prostheses that generally
free transfer of speech sounds and foods/liquids between the do not have teeth initially but may be modified with the
oral and nasal cavities. The advantages of having the ability addition of teeth after an initial period of accommodation
to take nourishment by mouth without nasal reflux (allow- (Figure 24-8).
ing for nasogastric tube removal) and to communicate with When surgical defects become large, as in a near-total
family members are a significant component of early pros- maxillectomy defect, prosthesis support, stability, and reten-
thetic management. How immediately such care should be tion are not likely to be satisfactory unless extension into the
provided depends on a number of factors. defect can be accomplished. When teeth remain, the impact
A prosthesis can be provided at surgery (see Figure of the defect size is somewhat lessened. But when the remain-
24-5B). Such a surgical obturator prosthesis is placed at the ing teeth are few or are located unilaterally in a straight line
time of surgical access closure and serves to control the (see Figure 24-1), the mechanical advantage for prosthesis
 320 Part III  Maintenance

A B

Figure 24-6    Maxillary defects. A, A resection that resulted in a small communication with the sinus, with some hard palate remain-
ing, 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.

stability is less. The ability of the defect tissue to offer the

needed mechanical characteristics to the interim prosthesis
is unpredictable at best. It is this patient who benefits the
most from a well-planned surgery that preserves oral and
defective anatomy to the advantage of the prosthesis.

Potential Complications
The interim phase of prosthetic management can last for
three or more months. The primary objective is to allow the
patient to pass from an active surgical (and adjunctive treat-
ment) phase to an observational phase of management with
minimal complications. During the transition, the patient
recovers from the systemic effects of the treatment, deals
with the psychological impact of the defect using his or her
Figure 24-7    An interim obturator prosthesis fabricated of own coping strategy, and becomes more aware of the func-
resin, retained by wires, and provided following surgical pack tional deficits associated with the surgical defect(s). Mini-
removal. mizing potential complications during the transition, which
 Chapter 24  Removable Partial Denture Considerations in Maxillofacial Prosthetics 321

A B

Figure 24-8    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.

includes preparing the patient for those anticipated to occur, tongue, opposing dentition, and cheek/lips place force on
facilitates the process for the patient and family. Common the prosthesis that must be resisted over a large area to
interim prosthetic complications are related to tissue trauma prevent movement. Because the defect is least likely to be
and the associated discomfort; inadequate retention (loose- able to resist movement, the relative size and structural
ness) of the maxillary prosthesis; incomplete obturation integrity of the defect compared with the remaining teeth
with leakage of air, food, and liquid around the obturator and/or edentulous ridge determine the potential prosthesis
portion of the prosthesis; and the tissue effects of chemo- movement and most affect the discomfort related to such
therapy and radiation therapy. movement.
Discomfort related to the use of interim prostheses can When teeth are available (and especially if located both
be due to surgical wound healing dynamics, defect condi- close to and far away from the defect), retention is enhanced
tions, mucosal effects of adjunctive treatment, and/or pros- by engaging them with prosthetic clasps. Clasp retention is
thetic fit. Common areas of surgical wound pain include the most efficient means of effectively resisting dislodgment.
junctions of the oral and lip/cheek mucosa, especially at The clasps will require periodic adjustment to maintain their
the anterior alveolar region for maxillectomy patients. The effectiveness as the movement of the prosthesis flexes the
lateral scar band produced when the skin graft heals to the clasps beyond their elastic recovery capacity. For edentulous
oral mucosa can be the site of discomfort in some patients. patients, because the surgical defect allows communication
When a split-thickness skin graft is not placed, discomfort between cavities, the fitting surface of the prosthesis can no
caused by the prosthesis fit within the defect can be a con- longer create a closed environment to develop a seal for
sistent and long-term problem. The hard palate surgical resisting dislodgment. Consequently, during the interim
margin when not covered with surgically reflected oral phase, when complete engagement of the defect is not pos-
mucosa most often will be covered by nasal epithelium, sible because of tissue sensitivity, the careful use of denture
which is also very prone to discomfort. Alveolar bone cuts adhesives is required to facilitate retention. The patient
that have not been rounded will perforate the oral mucosa should be instructed that adhesives can alter the prosthesis
and will be painful whether or not a prosthesis is worn. This fit and disrupt the close adaptation of the prosthesis to the
is most frequently a finding for mandibular resection supe- remaining tissue. Used adhesive must be removed before
rior alveolar margins when the reconstruction has restored new adhesive is reapplied, to maintain fit and hygiene. Also
the lower and labial contour to the mandible, but the intra- related to retention is the inability to completely place the
oral mucosa at the superior surface is under tension because prosthesis, which for maxillectomy patients can be due to
of a difference in height. contracture of the scar band. When the maxillary resection
The prosthesis can create discomfort via excessive static leaves the cheek unsupported by bone, the prosthesis pro-
pressure from the internal surfaces or from overextension vides the necessary support for wound maturation. If the
into the vestibular tissue. The prosthesis can also create dis- patient removes the interim obturator prosthesis for a period
comfort caused by functional movement associated with sufficient to allow contraction, the prosthesis will be more
swallowing and speech. As was discussed previously, pros- difficult to place. Once placed, however, the scar band will
thesis movement is dependent on the quality of the support- relax and subsequent removal and placement will be more
ing structures. Teeth offer the best support, followed by firm easily accomplished. The discomfort associated with this
edentulous ridges, and lastly, surgical defect structures. The phenomenon is mostly due to patient anxiety and can be
 322 Part III  Maintenance

effectively addressed by reassuring the patient that this is an become more familiar with the surgical defect, patients
easily handled complication. should be encouraged to clean the defect of food debris and
During the immediate postoperative healing stage, the mucous secretions routinely. Defect hygiene will allow
surgical defect will undergo a change in dimension that quicker healing and will improve the ability to adequately fit
affects the prosthesis fit and seal. If space is created with the a prosthesis. Common defect hygiene practices include (1)
change, speech will be altered (increase in nasality) and nasal lavage procedures, which include rinsing of the defect during
reflux with swallowing will occur. The interim prosthesis is normal showering, (2) rinsing of the defect using a bulb
made of easily adjustable material to allow accommodation syringe or a modified oral irrigating device (modified to
for such changes. The most common manner of adjustment provide a multiple orifice “shower” effect), and (3) manual
is through the use of temporary resilient denture lining cleaning procedures, such as the use of a sponge-handled
materials, which offer the ability to mold to the tissue directly cleaning aid. Frequently, dried mucous secretions are diffi-
and reduce the mechanical effects of movement by virtue of cult to remove and require adequate hydration before
their viscoelastic nature. Leakage can occur quite easily when mechanical removal.
swallowing unless the patient follows certain instructions. Following surgical pack removal, the patient may be
Because the prosthesis cannot offer a watertight seal that reluctant to begin oral hygiene practices because of oral dis-
matches the presurgical state, patients will be instructed not comfort. As patients use the interim prosthesis, which
to swallow large quantities at one time, and to hold their requires daily removal and cleaning at a minimum, they will
heads horizontal when swallowing. When the head posture realize the need for and benefit of normal oral hygiene prac-
is forward, as when one is taking soup from a spoon, leakage tices because of improved prosthesis fit and tolerance. When
easily occurs around the obturator component of a prosthe- teeth are remaining, it is important to the success of long-
sis. Another difficult condition that presents difficulty in term prosthesis care to maintain a high level of oral hygiene.
controlling leakage on swallowing is the midline soft palatal This is more critical for patients who exhibit xerostomia and
resection. The functional movement of the remaining soft have increased risk of caries. For these patients, daily appli-
palate is often very difficult to retain with a prosthesis. It is cation of fluoride in custom-formed carriers is prescribed
also difficult to provide an adequate seal during the interim along with frequent professional cleanings. The successful
prosthesis stage. use of maxillofacial prostheses is enhanced greatly by the
When combination treatment is prescribed for the support provided by natural teeth. Consequently, during the
patient, it is commonly provided during the postsurgical interim prosthetic period, periodontal management proce-
phase, when the patient is using an interim prosthesis. The dures are begun in anticipation of the definitive treatment
major intraoral complication associated with both radiation to allow a smooth transition from the interim to definitive
therapy and chemotherapy, which affects interim prosthetic prosthetic stages.
service, is mucositis. A careful balance between comfort and
adequate fit for speech and swallowing needs must be deter- Definitive Care
mined with input from the patient. If prosthesis adjustment When the active treatment phase has been completed, defin-
can offer relief to ensure completion of treatment and the itive prosthetic management can be initiated for as long as
patient understands the impact adjustment may have on it takes the defect tissue to mature sufficiently to tolerate
speech and swallowing, then it should be accomplished. more aggressive manipulation and obturation. This phase
The long-term effects of radiation therapy, especially can be considered a transition for the patient-physician rela-
radiation-induced xerostomia and capillary bed changes tionship, in which the primary emphasis shifts from active
(obliterative endarteritis) within the mandible, present a treatment to observation. The primary emphasis from the
potentially significant threat to any remaining dentition patient’s standpoint shifts to prosthetic management, and
and to the development of osteoradionecrosis. During the the goals and design of the prosthesis differ from those of
interim prosthesis stage, the patient will begin to notice the the interim prosthesis (Figure 24-9). However, for some
xerostomic effects, which include development of thick, patients, more definitive prostheses are delayed because of
ropy saliva that makes swallowing more difficult, and an general health concerns, questionable tumor prognosis or
increase in discomfort associated with removable control, or failure of the patient to reach a level of oral and/
prostheses. or defect hygiene that warrants more sophisticated treat-
ment. Although this phase of management can be consid-
Defect and Oral Hygiene ered elective, without definitive prostheses patients are not
Following surgical pack removal, the defect site will mature afforded the opportunity for complete rehabilitation. It is
with time and exposure to the external environment. Initial the extended use of temporary prostheses beyond their ser-
loss of incompletely consolidated skin graft, mucous secre- viceable life span that has given a poor impression of
tions mixed with blood, and residual food debris within the prosthetic service to many surgeons and patients. Every
cavity are common oral findings for the patient with a maxil- opportunity should be provided to the patient for the most
lary defect. These cause concern for patients who are unpre- complete rehabilitation possible, and this necessitates con-
pared and unfamiliar with these new oral findings. As they sideration of more definitive prostheses.
 Chapter 24  Removable Partial Denture Considerations in Maxillofacial Prosthetics 323

tive prosthesis that is acceptable in appearance and exhibits

minimal movement under function, thereby preserving the
maximum amount of supporting tissue. A strategy for
achieving these goals includes maximum coverage of the
edentulous ridge within the movement capacity of the mus-
cular attachments, maximum engagement of the remaining
teeth to help control retention and movement under func-
tion, and placement of artificial teeth to facilitate mainte-
nance of this prescribed tooth-tissue contact during normal
functional contacts. Maintaining these basic concepts within
an otherwise normal anatomic environment (relative to
food control and deglutition) has provided reasonable
Figure 24-9    A definitive (left) and interim (right) obturator
success for patients requiring replacement of missing teeth.
prosthesis contrasting the materials used and the obturator bulb The challenges faced in doing so for removable maxillofacial
contour. Clasp retention is more stabilizing with the definitive prostheses are quite different.
prosthesis because of the cast half-round clasp configuration, the Normal resistance to functional loads is achieved by the
use of embrasure clasps, and the opportunity for guide-plane highly sophisticated periodontal attachment of the natural
use. Also, because the surgical site is more mature, prosthesis dentition, which provides support and stability to teeth.
extension into this region to augment support, stability, and When the dentition is partially depleted and is replaced by
retention when necessary is possible. prostheses that are tooth supported, the support and stabil-
ity of the replacement teeth remain to be provided by the
natural attachment. When tooth loss includes several poste-
From the previous discussion regarding removable pros- rior teeth, replacements are placed over the residual edentu-
thetic physiology, the inability of these static artificial lous ridge, and the prosthesis receives support and stability
replacements to mimic their natural counterparts results in from both teeth and mucosa. When all teeth are lost, support
less than ideal functional measures. Factors related to the and stability are totally provided by the mucosa covering the
structural integrity of the surgical defect and associated residual edentulous ridges. Finally, when surgical removal of
reconstructions as they affect this already compromised tumors results in tooth and supporting structure loss,
functional capacity are important considerations, especially support and stability are provided by combinations of
when few teeth remain. As was stated previously, the fact remaining teeth and/or residual ridges and areas within the
that control of removable maxillofacial prostheses has a large surgical defect. For partial and complete tissue-supported
skilled performance requirement of patients suggests that prostheses, the mechanism of functional load support—as
oral and defect structures adjacent to the prostheses are provided by the mucosa—is unsuited to the task from a
important for successful performance. This is crucial to an biological standpoint. Given this understanding, when a
understanding of the impact that postsurgical defect charac- maxillofacial prosthesis is required to involve a surgical
teristics and soft tissue reconstructions have on maxillofacial defect for support and stability, it is obvious that the envi-
prosthesis management. The reasons for this are twofold: (1) ronment within the surgical defect is even less suited to the
the opportunity for maximal prosthetic benefit necessitates task.
consideration of surgical site characteristics that are separate
from classic tumor control approaches, and (2) the ability of
the patient to biomechanically control large removable pros- Surgical Preservation for
theses following surgery may be notably hindered by surgical Prosthesis Benefit
closure/reconstruction options. Surgical outcomes that can
improve prosthetic function without adversely affecting Maxillary Defects
tumor control should be considered and will be described Surgical outcomes that influence prosthesis success can be
for the more common surgical defects and associated considered as those that determine the number of maxillary
prostheses. structures removed (Figure 24-10) and/or those that affect
the structural integrity and quality of the defect. For surgical
defects of the hard and/or soft palate, the primary prosthetic
Intraoral Prostheses:
objectives include restoration of physical separation of the
Design Considerations
oral and nasal cavities in a manner that restores mastication,
Maxillofacial prosthetics is largely a removable prosthetic deglutition, speech, and facial contour to as near a normal
discipline, with the exception of dental implant–retained state as possible. Typical prostheses used to achieve these
prostheses for some applications. For maxillofacial recon- objectives include the obturator prosthesis (Figure 24-11A
struction with removable partial denture prostheses, typical and B), typically referring to prostheses that obturate defects
goals of treatment consist of a well-supported, stable, reten- within the bony palate, and the speech aid prosthesis (Figure
 324 Part III  Maintenance

A B

Figure 24-10    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 24-11    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 pros-
thesis 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.
 Chapter 24  Removable Partial Denture Considerations in Maxillofacial Prosthetics 325

24-11C and D), which typically refers to prostheses that exception to this would be the edentulous patient who is
restore palatopharyngeal function for defects of the soft undergoing a radical maxillectomy. Without teeth to provide
palate. the necessary retention for one side of a prosthesis, the
Current preoperative diagnostic procedures have patient benefits from the ability to place the prosthesis above
improved the ability to discern the location and regional the posterior soft tissue band for retention (Figure 24-12).
bone involvement of tumors of the maxilla and associated Preparation of the maxillary surgical site can improve
paranasal sinuses. Relative to prosthetically important surgi- prosthesis tolerance through the use of a split-thickness skin
cal modifications, if it can be determined that tumor control graft (see Figure 24-1). Lining the reflected cheek flap and
does not require a classic radical maxillectomy approach, or posterior denuded structures with a graft improves tissue
that the inferior sinus floor, hard palate, and alveolus are response by decreasing the pain associated with functional
uninvolved, preservation of as much hard palate and alveo- contact often seen when this surface is left to heal second-
lar bone and as many teeth as possible should be considered. arily. If the posterior structures, pterygoid plates, or anterior
Tooth preservation has the greatest impact on success temporal bone can provide a firm supportive base for the
because of its stabilizing effect on prosthetic movement. prosthesis, a skin graft covering is extremely helpful. Later-
When teeth can be retained in the premaxilla for more pos- ally, the junction of the skin and oral mucosa creates a scar
terior tumors, or in the posterior molar region for more contracture, which provides a natural retentive region for
anterior tumors, control of prosthesis movement is more the obturator portion of the prosthesis. Careful attention is
easily accomplished and prosthetic success can be consider- given to this region in fabricating a prosthesis, to maximize
ably improved (see Figure 24-10). Because the classic midline support, stability, and retention of the prosthesis.
maxillectomy defect is significantly more debilitating for the In general, the need to extend a prosthesis into the defect
average patient than a defect whereby preservation of the is greater for edentulous patients than patients with teeth.
premaxillary component was accomplished, inclusion of When teeth remain, they are used to a greater extent to
the anterior premaxillary component should be an individ- stabilize and retain the obturator component of the prosthe-
ual decision based on tumor control, classic resection sis, and the defect region is not required for such objectives.
technique. However, all patients with maxillary defects should have
For resections in patients with teeth, the tooth adjacent sufficient access to the lateral-posterior region of the defect
to the defect is subjected to significant force from prosthesis to seal the defect at a minimum. In the edentulous patient,
movement. When the surgical alveolar ostectomy cut is for maximum ability to obturate a maxillary defect, access
planned, the resection should be made through the extrac- to the regions superior to the defect opening is required.
tion site of the adjacent tooth to provide the most favorable Nasal turbinates and mucosal connections that do not allow
prognosis for this supportive tooth (see Figure 24-6). This full extension into the necessary retentive and supportive
procedure ensures adequate alveolar support for the adja- areas of the defect compromise function. The function of
cent tooth, which is a critical tooth for prosthesis success, turbinates in the newly externalized environment is not
and improves the tooth’s prognosis for long-term survival.
The midline of the hard palate is a common area of remov-
able prosthesis pressure because of movement of the pros-
thesis 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 flap
of palatal mucosa, to provide a firm and resistant mucosal
covering to this region, where the prosthesis can notably act
as a fulcrum.
The soft palate owes its normal function to the bilateral
sling nature of the musculature, which provides the shape
and movement capacity specific for speech and deglutition
requirements. When this is altered because of surgery, there
appears to be a variable response in the ability to continue
to provide palatopharyngeal competence based on the
amount of continuous band of posterior tissue remaining.
Often an insufficient band of palatal tissue fails to provide
palatopharyngeal competence and hinders prosthetic man-
agement of the problem. To serve as a guide for decision
making in surgery, it has been suggested that if the required Figure 24-12    A maxillary obturator prosthesis demonstrating
resection leaves less than one third of the posterior aspect of a distal extension, which engages a soft palatal remnant for
the soft palate, the entire soft palate should be removed. The added retention.
 326 Part III  Maintenance

beneficial for breathed air humidification or warming, and

consequently may not warrant preservation.
Surgical reconstruction of maxillary defects should be
undertaken when restoration of the functional goals of
speech, deglutition, and mastication is better served by such
procedures. Surgical reconstruction of a maxillary hard
palatal defect in a manner that provides separation of the
oral and nasal cavities without consideration for oral space
requirements for speech, or for the supportive requirements
of replacement teeth, is not only incomplete management A
but can preclude subsequent prosthetic management. When
surgical defects measure 3 cm or less and can be recon-
structed to normal contours without compromising adja-
cent tissue function, surgical management is an appropriate
consideration. Larger defects are very difficult to surgically
reconstruct and, without careful planning for subsequent
functional needs, could create an environment incapable of
supporting a prosthesis. For partial soft palatal reconstruc-
tions, it is very difficult to provide functional tissue replace-
ment without compromising palatal function. In light of this
unpredictability, predictable prosthetic management of such
defects is most often the treatment of choice.

Mandibular Defects
The functions of mastication, deglutition, speech, and oral
competence (saliva control) are made possible through
coordinated efforts of separate anatomic regions, which
include the oral sphincter, alveololingual and buccal sulci,
alveolar ridges, floor of the mouth, mobile tongue, base of
the tongue, tonsillar pillars, soft palate, hard palate, and
buccal mucosa. The more regions that are involved in a B
surgical procedure, the greater is the demand on surgical Figure 24-13    A, Marginal (left) and segmental (right) resec-
reconstructive efforts. When the mandible is also involved, tions of the mandible. When a segmental resection is not stabi-
the complexity of the reconstructive procedure is dependent lized with a reconstruction bar or bone graft, the continuity of
on the location and amount of mandible to be included in the mandible is lost. Such a defect is a discontinuity defect of
the resection and the decision to maintain continuity with the mandible. B, When not stabilized, the discontinuous man-
normal mandibular position and contour (Figure 24-13). dible deviates toward the defect and presents significant prob-
For disease involving the functional anatomy around the lems with mastication restoration.
mandible, surgical outcomes that influence prosthesis
success are based on decisions to take mandibular portions
or segments and decisions regarding reconstruction. The large tongue resection that may require augmentation of
primary prosthetic objectives for mandibular defects are to the palatal contours to facilitate speech production. Such a
restore mastication and cosmesis by the replacement of palatal augmentation prosthesis is most beneficial when
teeth. Achieving the mastication goal requires an under- coordinated speech therapy can guide the optimal prosthesis
standing that regardless of the manner of prosthesis support configuration. Other resections may appear to require
(natural teeth, reconstructed soft tissue, or implants), the palatal augmentation for speech, yet the functional problem
impact of the prosthetic device on success is dependent on is tongue immobility secondary to tension created by the
appropriate surgical management of both soft tissue and reconstructive tissue. Consideration should be given to soft
bone. tissue reconstructions that are of sufficient size and mobility,
Disease involving soft tissue structures adjacent to and are less prone to contracture tension, and can produce
enveloping the mandible necessitates consideration of a a more normal alveololingual sulcus because these charac-
mandibular resection to ensure control. When the soft tissue teristics have been shown to have a significant influence
disease is clearly separate from the mandible and does not on tongue mobility. Other desirable characteristics, such
require bone removal, surgical defects involving these struc- as sensation and lubrication, are also possible but necessitate
tures should be surgically reconstructed and therefore do not a choice of which one is most required given the goals
require prosthetic management. The exception to this is the desired.
 Chapter 24  Removable Partial Denture Considerations in Maxillofacial Prosthetics 327

When tumors are primary to the mandible, as an amelo- The cosmetic deformity associated with mandibular
blastoma is, or when they involve the mandible from adja- resection is improved through the use of reconstruction
cent regions, surgical resection of segments of the mandible plates to maintain the presurgical contour to the lower jaw.
is required for tumor control. It may be difficult to always This form of mandibular contour and position maintenance
predict the functional deficit and the exact plan of recon- should be considered the minimum standard of care for
struction because the surgeon determines the extent of the mandibular resection patients from a functional standpoint.
resection based on presurgical and surgical findings. Use of reconstruction plates can maintain cosmetic appear-
However, common anatomically based mandibular resec- ance and preserve the bilateral nature of mandibular move-
tions include the lateral mandibular resection, the anterior ment. However, the use of reconstruction plates alone
mandibular resection, and the hemimandibular resection. precludes replacement of teeth in the region of resection.
From the standpoint of the surviving mandibular resection Prosthetic replacement of teeth cannot be provided for
patient, the most significant decision regarding his or her regions superior to the reconstruction bar because of the
management is the decision to maintain mandibular conti- potential for mucosal perforation and exposure of the bar
nuity, which allows maintenance of position for adjacent from functional loading of the soft tissue. From a mastica-
intraoral and extraoral soft tissue. tory function standpoint, this may not be a significant nega-
Surgical evolution of procedures that maintain continuity tive impact for some patients because of the maintenance of
for the mandible has significantly improved the opportunity sufficient numbers of occlusal contacts postsurgically.
for functional restoration of mastication, deglutition, and
speech. The debilitating effects of the discontinuity defect Mandibular Reconstruction—Bone Grafts
include a significant cosmetic deformity to the lower third The evolution of head and neck reconstructive surgery has
of the face, decreased masticatory function secondary to uni- been dramatic over the past three decades. The vascularized
lateral closure, compromised coordination of tongue and tissue options of the forehead and deltopectoral regions gave
teeth, altered speech ability, and impaired deglutition (Figure way to the more popular pedicled myocutaneous flaps from
24-14). Given an appreciation of the decreased performance the 1960s to the 1970s. By the 1980s, numerous osteomyo-
seen with conventional mucosa-borne denture prostheses, it cutaneous free-flap donor sites had been identified and were
should be obvious that masticatory rehabilitation for the being used for mandibular reconstruction and particulate
resection patient without mandibular continuity is unpre- cancellous bone marrow in formed allogeneic frames.
dictable at best and is never achieved for most patients. Even Equally important to the functional outcome of mastication
for patients with remaining teeth, the altered mandibular was the development of the science and the clinical applica-
position created in time presents a significant functional and tion of the osseointegration phenomenon in the area of
cosmetic handicap. From a prosthetic rehabilitation stand- dental implants.
point, the most significantly handicapped postsurgical head The ideal prosthetic characteristics of the replacement
and neck condition is the discontinuous mandible. Conse- mandible include a stable union to proximal and distal seg-
quently, such a postsurgical condition should be the rare ments, restoration of contour to the lower third of the face,
exception (typically because of reconstruction plate failure) a rounded ridge contour with attached mucosa of 2 to 3 mm
and should not be the planned surgical outcome. thickness, and adjacent sulci providing free movement of

A B

Figure 24-14    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 posi-
tion that is unique to the unilateral closure pattern.
 328 Part III  Maintenance

buccal and lingual soft tissues for food control. Regardless nasal regions (Figure 24-15). Aramany developed a classifi-
of the type of prosthesis to be used, the appropriate place- cation for partially edentulous maxillectomy dental arches
ment of the bone relative to the opposing arch is vital to the (Figure 24-16). The various defects resulting from resection
intended functional use. If a removable prosthesis is planned contain and are bounded by anatomic structures and an
and is expected to cover the bone reconstruction, the contour epithelial lining (either transplanted skin and/or native
of the developed ridge should provide a surface covered with mucosa) that are quite different from normal partially eden-
firm, thin soft tissue, and a rounded superior contour with tulous arch anatomic features. The expectation for this
buccal and lingual slopes approaching parallel to each other altered region to contribute significantly to prosthesis
and with sufficient vestibular depth to provide horizontal support, stability, or retention is infrequently met. Conse-
stability. Such a ridge condition is the surgical analog of a quently, prosthesis support and stabilization are largely
minimally resorbed edentulous ridge. With adequate cheek dependent on the ability to aggressively engage the remain-
and tongue movement, this should provide a reasonable ing teeth and residual ridge structures.
prognosis for prosthetic success, provided sufficient numbers In comparison with partially edentulous arches, the
of teeth remain on the nonresected side. For the optimum movement potential for the prosthesis extension into the
chance of prosthetic function, dental implants should be defect can be significant. When engagement of the distobuc-
considered, and with sufficient bulk of bone and the same cal temporal bone is possible, upward movement of the
characteristics listed for the removable prosthesis, the prog- obturator bulb can be greatly minimized. Movement poten-
nosis for success is the greatest. To reiterate, the major deter- tial increases as the remaining tooth number decreases and
mining factor for improved function will be the quality of their arrangement becomes more linear (Figure 24-17). This
the soft tissue reconstruction. illustrates the importance of maintaining teeth when possi-
The major complications seen with mandibular recon- ble, which allows for greater prosthesis stabilization through
struction are related to the bulk of the soft tissue component direct tooth engagement and through cross-arch stabiliza-
and lack of mobility of the tongue. When these factors are tion that increases with nonlinear tooth configurations
controlled for, complications are caused most often by bone (Figure 24-18).
placement and size. The common use of free flaps, including To help control potential movement, various suggestions
bone from other regions of the body that do not possess the have been made relative to prosthesis design. The basic prin-
native mandibular shape, presents a significant degree of ciple of placing support, stabilization, and retention imme-
technical difficulty associated with the procedure. The fibula, diately adjacent to and as far from the defect as possible acts
which is a popular choice for mandibular replacement, pres- to distribute the tooth effect on prosthesis performance to
ents some challenges in meeting the ideal requirements the greatest mechanical advantage. Because the teeth adja-
mentioned previously. Because of the straight nature of the cent to the anterior resection margin are often incisors, it
bone, it is easy to err in both horizontal and vertical posi- may be necessary to consider splinting them to improve the
tioning, especially for reconstructions that span to the long-term prognosis. This region is critical for prosthesis
midline. Lingual positioning requires prosthetic placement performance, and the requirement for a cingulum rest and
at a position that may become functionally unstable over labial retention is often difficult to optimize without crowns.
time. Such a location requires implant positions that create Distally, it is often necessary to incorporate an embrasure
a mechanical cantilever that can be detrimental to the long- clasp to provide maximum retention and stabilization. Such
term success of the implant-supported prosthesis. Posteri- a clasp assembly must have sufficient room for occlusal
orly, the inability to re-create the natural ascending curve of clearance, and it is not uncommon for the opposing occlu-
the mandible can restrict placement of teeth and preclude sion to need adjustment to accommodate such a rest
restoration of complete occlusion on the resected side. It is complex. When possible, the palatal surfaces of the maxillary
common to have a mismatch in height at the anterior junc- teeth should be surveyed to determine whether guide-plane
tion of the graft with the resident mandible. For implant- surfaces can be produced to impart a stabilizing effect. When
supported prostheses, this area can present significant accomplished, the prosthesis benefits from improved move-
challenges in terms of adequate hygiene of the implants, and ment resistance, and it does so with more teeth contributing
over time, this can compromise implant health. For remov- to the effect, thereby distributing the stress more appropri-
able prostheses, this can become a source of irritation if ately. Brown described how the vertical height of the lateral
fulcrumlike action occurs with movement. portion of the obturator above the buccal scar band can
contribute to prosthesis movement control by helping to
prevent vertical displacement (see Figure 24-15).
Maxillary Prostheses
Speech Aid Prostheses
Obturator Prostheses The defining characteristics of speech aid prostheses are that
The defining characteristic of an obturator prosthesis is that they are functionally shaped to the palatopharyngeal mus-
it serves to restore separation of the oral and adjacent cavities culature to restore or compensate for areas of the soft palate
following surgical resection of tumors of the nasal and para- that are deficient because of surgery or congenital anomaly
 Chapter 24  Removable Partial Denture Considerations in Maxillofacial Prosthetics 329

Vertical
displacement Long
radius sweep
Less

Greater

Short radius sweep

Given horizontal
A B flexure

C D

Figure 24-15    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.

(see Figure 24-11). Such a prosthesis consists of a palatal A pediatric speech aid is a temporary prosthesis used to
component, which contacts the teeth to provide stability and improve voice quality during the growing years. It is made
anchorage for retention; a palatal extension, which crosses of materials that are easily modified as growth or orthodon-
the residual soft palate; and a pharyngeal component, which tic treatment progresses. Because a speech aid has a signifi-
fills the palatopharyngeal port during muscular function, cant posterior extension into the pharyngeal region, torque
serving to restore the speech valve of the palatopharyngeal is evident from the long moment arm. A basic principle of
region. posterior retention with anterior indirect retention must be
Because the typical speech aid prosthesis does not provide applied to the design of such a maxillary prosthesis. Poste-
tooth replacement, the patient should expect only minimum rior retention is gained by the use of wrought-wire clasps
functional movement. Movement of the pharyngeal exten- around the most distal maxillary molars, whereas the ante-
sion imposed by the residual palatopharyngeal musculature rior extension of the prosthesis onto the hard palate provides
is generally undesired and is a sign that modification is indirect retention. If clinical crown length and undercut are
required. Common reasons for such movement include a adequate to provide retention, orthodontic bands with
low position, causing tongue encroachment; superior exten- buccal tie wings can be used in conjunction with the wrought
sion that does not account for head flexure; or impression wires. This design facilitates the maintenance of the pharyn-
procedures that do not accurately record residual soft palatal geal part of the pediatric speech aid in the proper position
position or movement. in the palatopharyngeal opening.
 330 Part III  Maintenance

I II III

IV V VI

Figure 24-16    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 24-17    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.

In the adult whose palatopharyngeal insufficiency is the

result of a cleft palate or palatal surgery, an adult speech aid Palatal Lift Prostheses
prosthesis can be constructed of more definitive materials The defining characteristic of a palatal lift is that it positions
because growth changes will not have to be accommodated. a flaccid soft palate posteriorly and superiorly to narrow the
If teeth are missing, the prosthesis will incorporate a reten- palatopharyngeal opening for the purpose of improving oral
tive partial denture framework. The basic design should air pressure and therefore speech. Patients who exhibit a
include posterior retention and anterior indirect retention. structurally normal soft palate and pharyngeal port can
 Chapter 24  Removable Partial Denture Considerations in Maxillofacial Prosthetics 331

A B

Figure 24-18    A, Tooth arrangement that offers cross-arch stability (as in Figure 24-17, A) because of the arch curvature of the
remaining 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.

demonstrate hypernasal speech caused by paralysis of the mentation. Bilateral rests and direct retainers should be
regional musculature. This condition is referred to as pala- positioned to facilitate the design for the acrylic retention
topharyngeal incompetence because the failure lies in func- because stability needs related to functional force are not
tion, not in anatomic deficiency. The paralysis can result a significant design concern.
from a variety of neuromuscular conditions (flaccid paraly-
sis of the soft palate from closed head injuries, cerebral palsy,
Mandibular Prostheses
muscular dystrophy, or myasthenia gravis) that have varying
clinical courses. The palatal lift prosthesis must physically Resection prostheses are those prostheses provided to
position the soft palate to redirect air pressure orally. In patients who have acquired mandibular defects that result in
placing the soft palate, any tissue resistance met acts as a loss of teeth and significant portions of the mandible. Man-
dislodging force on the prosthesis. This dislodging force dibular resection results in defects that may preserve man-
must be resisted by adequate direct and indirect retention. dibular continuity or may result in discontinuity defects.
To efficiently maintain prosthesis position, the dislodging These are further subclassified by Cantor and Curtis (Figure
force is best resisted by bilateral direct retainers placed close 24-19) and provide a meaningful foundation for a discussion
to the posterior lift and anteriorly placed indirect retention. of removable prosthesis design considerations.
Success with a palatal lift prosthesis depends upon the pres-
ence of a number of maxillary posterior teeth, which can Evolution of Mandibular Surgical Resection
provide retention for the prosthesis, coupled with an easily When mandibular continuity is preserved, as in a marginal
placed flaccid soft palate. resection (type I mandibular defect, see Figure 24-19), func-
tion is least affected and the major prosthesis concern is
Palatal Augmentation Prostheses related to the soft tissue potential for support. With good
When surgical resection involving the tongue and/or floor remaining dental support, near-normal function can often
of the mouth limits tongue mobility, it affects both speech be achieved with prosthodontic rehabilitation.
and deglutition. With tongue mobility limitations, the Although it is not as common an outcome as in the past,
contour of the palate can be augmented by a prosthesis to when continuity of the mandible is lost because of a segmen-
modify the space of Donder to allow food manipulation to tal resection that was not reconstructed, the bilateral joint
be more easily transferred posteriorly into the oropharynx. complex no longer controls the remaining mandibular
Prosthesis movement potential is low because the func- segment. Consequently, the function of the remaining man-
tional forces involved are those imparted by the tongue dibular segment is severely compromised because of loss of
during deglutition and speech, neither of which creates force coordinated bilateral muscular action functioning across a
similar to mastication. It is common to use a diagnostic resin bilateral joint. The resulting segmental movement is an
augmentation prosthesis retained with wire clasps to plan uncoordinated action dictated by the remaining unilateral
the necessary contour needs. Once the appropriate palatal muscular activity within a surgical environment that changes
contour has been determined, a definitive augmentation with healing dynamics and patient rehabilitation efforts.
prosthesis can be constructed of cast metal with appropri- Successful removable prosthodontic intervention for these
ately placed minor connectors for attaching the resin aug- situations necessitates a combination of clinician knowledge
 332 Part III  Maintenance

Type I Resection
In a type I resection of the mandible, the inferior border is
intact and normal movements can be expected to occur. The
major difference between this situation and a typical eden-
tulous span is the nature of the soft tissue foundation. For
type I resections, the denture-bearing area may be compro-
I mised by closure of the defect with the use of adjacent lining
mucosa (which can reduce the bucco-lingual width), or by
the presence of a split-thickness skin graft.
Ideally, one would like to see a firm, nonmovable tissue
bed with normal buccal and lingual vestibular extension.
If the defect is unilateral and posterior, the framework
would be typical of a Kennedy Class II design, taking into
account whatever modification spaces may be present. When
the marginal resection is in the anterior area, the design
may be more typical of a Kennedy Class IV design (Figure
II III 24-20).
Anterior marginal resections sometimes include part of
the anterior tongue and floor of the mouth. With loss of
normal tongue function, the remaining teeth are no longer
retained in a neutral zone, and as a result, they often collapse
lingually because of lip pressure. If this occurs, the use of a
labial bar major connector may be necessary.
Corrected cast impression procedures provide a major
IV V
advantage for fabrication of removable partial dentures in
Figure 24-19    Cantor and Curtis classification of partial man- partial mandibulectomy patients. Capture of the unique
dibulectomy. (Redrawn from Cantor R, Curtis TA: J Prosthet Dent buccal, lingual, and labial functional contours in the final
25:446-457, 1971.) prosthesis can contribute significantly to stabilization of the
prosthesis, especially in discontinuity defects.

of the functional movements of the remaining residual man- Type II Resection

dible and concerted effort and persistence of the patient. In the type II resection, the mandible is often resected in the
Historically, mandibular stabilization by bone grafts or region of the second premolar and first molar. If no other
reconstruction bars was not always a surgical goal. The teeth in the arch are missing, a prosthesis usually is not
major exception was the anterior defect (type V), which was indicated. In some situations, however, a prosthesis may
recognized to pose significant airway risks if not managed. have to be fabricated to support the buccal tissue and to help
Currently, most lateral segmental mandibulectomies are also fill the space between the tongue and the cheek to prevent
reconstructed surgically. When the mandible is not stabi- food and saliva from collecting in the region.
lized following resection and a discontinuity defect results, Framework design should be similar to a Kennedy Class
a mandibular resection prosthesis should be provided to II design, with extension into the vestibular areas of the
restore mastication within the unique movement capabili- resection. This area would be considered nonfunctional and
ties of the residual functioning mandible. should not be required to support mastication. It must be
The following discussion highlights design considerations remembered that extension into the defect area can place
for the major defect classifications outlined. A common significant stress on the remaining abutment teeth; therefore
feature among all removable resection prostheses is that all occlusal rests should be placed near the defect, and an
framework designs should be dictated by basic prosthodon- attempt should be made to gain tripod support from remain-
tic principles of design. These include broad stress distribu- ing teeth and tissue where possible.
tion, cross-arch stabilization with use of a rigid major An example of a framework design for a type II mandibu-
connector, stabilizing and retaining components at locations lar resection with missing molars on the nonsurgical side is
within the arch to best minimize dislodging functional illustrated in Figure 24-21. The choice of major connector
forces, and replacement tooth positions that optimize pros- depends on the height of the floor of the mouth as it relates
thesis stability and functional needs. Modifications to these to the position of the attached gingival margins during func-
principles are determined on an individual basis and are tion. An extension base with artificial teeth can be used on
greatly influenced by unique residual tissue characteristics the surgical side if space is available. The extent of this base
and mandibular movement dynamics. is determined by a functional impression, and determina-
 Chapter 24  Removable Partial Denture Considerations in Maxillofacial Prosthetics 333

A B

C D

Figure 24-20    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 correc-
tive 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.

tion should be cautious of the potential for bone exposure mesial proximal surfaces of the anterior abutments. Lingual
at the superior margin of the resection. retention with buccal reciprocation on the remaining poste-
Retention can be achieved through the use of various rior teeth should be considered. The longitudinal axis of
types of clasp assemblies on the distal abutments. Indirect rotation in this design should be considered to be a straight
retention can be derived from rests prepared in the mesial line through the remaining teeth. Depression of the prosthe-
fossae of the first premolars and/or the lingual surfaces of sis on the edentulous side will have less of a chance to dis-
the canines. Unlike the result in Figure 24-21, use of an lodge the prosthesis if retention is on the lingual surfaces
infrabulge retainer on the surgical side may be difficult if a than if on the buccal. Suggested framework designs for this
shallow vestibule results from surgical closure. The locations patient group are illustrated in Figure 24-22.
of minor connectors should be physiologically determined Physiologic relief of minor connectors is always recom-
to minimize stress on the abutment teeth and to enhance mended. When the remaining teeth are in a straight line,
resistance to reasonable dislodging forces. Wrought-wire a Swing-Lock major connector design (Swing-Lock, Inc,
circumferential retainers are acceptable alternatives. Milford, TX) may be used to take advantage of as many
In a type II mandibular resection, where posterior and buccal and/or labial undercuts as possible. Because elderly
anterior teeth are missing on the defect side, the remaining patients often complain of difficulty manipulating Swing-
teeth on the intact side of the arch are often present in a Lock mechanisms, in straight-line situations it may be pos-
straight-line configuration. Embrasure clasps may be used sible to use alternate buccal and lingual retention effectively
on the posterior teeth, with an infrabulge retainer on the (Figure 24-23).
anterior abutment. In some situations, a rotational path In the type II resection with anterior and posterior
design may be used to engage the natural undercuts on the missing teeth on the resected side and posterior missing
 334 Part III  Maintenance

A B

Figure 24-21    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 Dr. Ron Desjardins, Rochester, MN.)

teeth on the nonresected side, the prosthesis will have three

denture base regions. This prosthesis may have a straight- Type IV Resection
line longitudinal axis of rotation, as previously discussed. A type IV resection (see Figure 24-19) would use the same
Rests should be placed on as many teeth as possible, minor design concepts as type II or III resections with the corre-
connectors should be placed to enhance stability, and sponding edentulous areas.
wrought-wire retainers represent an acceptable alternative to If the graft does not provide an articulation and the soft
the bar clasps. tissue covering the graft is not firmly attached to the bone
graft, the movement potential will be dictated by functional
forces of movement coupled with soft tissue supportive
Type III Resection capacities.
A type III resection (see Figure 24-19) produces a defect to If a type IV resection extends to the midline with the
the midline or farther toward the intact side, leaving half or extension of a graft into the defect area, but does not include
less of the mandible remaining. temporomandibular joint reconstruction on the surgical
The importance of retaining as many teeth as possible in side, the design will be similar to the type III resection with
this situation cannot be overemphasized. The design of a an extension base on the surgical side.
framework for this situation would be similar to the type II If the type IV resection extends beyond the midline, with
resection. The longitudinal axis of rotation is again consid- less than half of the mandible remaining, the design will be
ered to be a straight line through the remaining teeth. This similar to the type II resection that has an extension base
resection provides a greater chance of prosthesis dislodg- into the surgical defect area.
ment caused by lack of support under the anterior
extension. Type V Resection
Alternating buccal and lingual retention in a rigid design In the type V resected mandible, when the anterior or
or the Swing-Lock design should be considered. posterior denture-bearing area of the mandible has been
 Chapter 24  Removable Partial Denture Considerations in Maxillofacial Prosthetics 335

A B

C D

Figure 24-22    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.

surgically reconstructed, the removable partial denture

design is similar to the type I resection design.
The principal difference between a type V resected man-
dible and the intact mandible with the same tooth loss
pattern lies in the management of soft tissue at the graft site.
For design purposes, one should consider the residual man-
A dibles of the type I and V resections to be similar to nonsur-
gical mandibles with the same tooth-loss pattern.

Mandibular Guide Flange Prosthesis

R
R As was mentioned earlier, in a discontinuity defect, the
R movement of the residual mandibular segment is an unco-
ordinated action dictated by two features unique to the spe-
R cific defect and patient. The first is the remaining unilateral
muscular activity that will be specific to the surgical resec-
tion and that will have a characteristic resting posture to
the defect side with a diagonal movement on “closure.” The
Figure 24-23    Conventional clasping with the use of alternat- second is that the surgical environment will change as
ing buccal and lingual retention (arrows). healing progresses, and patient efforts to train movement
 336 Part III  Maintenance

during this healing period will help maintain both position ation, allowing the patient to make unassisted masticatory
and movement range. To facilitate training of the mandibu- contact.
lar segment to maintain a more midline closure pattern, The components of the guide flange prosthesis include
clinicians have used a guide flange prosthesis. the major and minor connectors needed to support, stabi-
The mandibular guide flange prosthesis is used primarily lize, and retain the prosthesis and the guiding mechanism.
as an interim training device. When no missing teeth are This may include a cast buccal guide bar and guide flange,
supplied, it may be considered a training appliance rather or simply a resin flange, which engages the opposing arch
than a prosthesis. This appliance is used in dentulous patients buccal tooth surfaces. In either case, the opposing arch must
with nonreconstructed lateral discontinuity defects who provide a stable foundation to resist any forces needed to
have severe deviation of the mandible toward the surgical guide the deviated mandibular segment into maximum
side and are unable to achieve unassisted intercuspation on occlusal contact.
the nonsurgical side (Figure 24-24). Generally these patients The buccal guide bar is placed as close as possible to the
have had a significant amount of soft tissue removed along buccal occlusal line angle of the remaining natural teeth to
with the resected mandibular segment and have attained allow maximum opening. The lateral position of the bar
surgical closure by suturing of the lateral surface of the must be adequate to prevent the guide from contacting the
tongue to the buccal mucosa, which causes a deviation buccal mucosa of the maxillary alveolus. The length of the
toward the defect side. Scarring also occurs and is worse bar should overlie the premolars and the first molar where
for patients who have not been placed on an exercise possible. Retention of the maxillary frame should not be
program during the healing period. The guide flange pros- problematic because the force directed on the bar is in a
thesis is designed to restrict the patient to vertical opening palatal direction. The guide flange is attached to the man-
and closing movements into maximum occlusal contacts. dibular major connector by two generous interproximal
Over time, this guided function should promote scar relax- minor connectors. As with the maxillary frame, significant

A B

C D

Figure 24-24    A mandibular guide flange prosthesis. A, Flange extension is incorporated into a mandibular type II resection prosthesis
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 Dr. Ron Desjardins, Rochester, MN.)
 Chapter 24  Removable Partial Denture Considerations in Maxillofacial Prosthetics 337

interproximal tooth structure must be cleared to provide the

Jaw Relation Records for Mandibular
necessary bulk for the minor connectors. The height of the
Resection Patients
guide flange is determined by the depth of the buccal vesti-
bule. A small hook is placed at the middle of the top of the Interocclusal records must be made using verbal guidance
guide to prevent disengagement on wide opening. Because only for resection patients with discontinuity defects. A
the mandibular segment has a constant medial force, the hands-on approach, like that used for conventional eden-
flange acts as a powerful lever with a strong lateral force on tulous jaw relation records, will lead to unnatural rotation
the teeth. Therefore extra rests and additional stabilization of the mandible and an inaccurate record. The patient
and retention on multiple teeth must be considered to should be instructed to move the mandible toward the non-
prevent overstressing of individual teeth. Retention on the surgical side and close into a nonresistant recording medium
tooth adjacent to the defect is critical for resistance to lifting at the preestablished occlusal vertical dimension, which
of the frame. Lingual retention in the premolar area may be will be the occlusal contact position. If the surgical side is
considered as an aid in resistance to displacement. When significantly deficient, an occlusion rim may have to be
necessary, missing teeth can be added to a guide flange pros- extended into the defect area to support the recording
thesis. Flange prostheses can be provisionally designed for medium. Head position is of extreme importance during
modification into definitive removable partial dentures after registration of jaw relation records. If the patient is in a
guidance is no longer necessary. This is accomplished by semirecumbent position in the dental chair during the
removal of the buccal flange and buccal guide bar compo- recording procedure, the mandible may be retracted and
nents after the patient is able to make occlusal contacts deviated toward the surgical side, preventing movement
without use of the guide. However, many patients with man- toward the intact side. To minimize this problem, the
dibular resections have difficulty making repeated occlusal recording should be made with the patient seated in a
contacts—a fact described in several studies. Occlusal con- normal upright postural position.
siderations in mandibulectomy patients have been discussed Most patients with lateral discontinuity defects can make
extensively by Desjardins. lateral movements toward the nonsurgical side, even without
Palatal occlusal ramps have been used to guide those the presence of a lateral pterygoid muscle functioning on the
patients with less severe deviation than those who require a balancing (surgical) side. This is possible because of the
guide flange into a more stable intercuspal contact position. compensatory effects of the horizontal fibers of the tempo-
These prostheses incorporate a palatal ramp that simulates ralis and the lateral pterygoid muscle on the normal side,
the function of the guide flange prosthesis. This inclination causing a rotational effect on the remaining condyle.
of the palatal ramp is determined by the severity of the devia-
tion of the remaining mandible. Some patients have the
Summary
ability to move laterally into occlusion but have a tendency
to close medially and palatally rather than close into an Maxillofacial prosthetic treatment of the patient with an oral
acceptable cuspal relationship. These patients can benefit defect is among the most challenging treatments in den-
from a palatal ramp, which can be functionally generated in tistry. Defects are highly individual and require the clinician
wax at the try-in stage. This provides a platform for occlusal to call upon all knowledge and experience to fabricate a
contact in the entire bucco-lingual range of movement. A functional prosthesis. The basic principles and concepts
supplemental row of prosthetic teeth may be arranged, then described throughout this text will help the clinician to suc-
removed at the boil out stage, and processed in pink acrylic cessfully design maxillofacial removable partial dentures.
resin for esthetics. Patients who have experienced both The interested reader is encouraged to pursue maxillofacial
smooth and tooth-form ramps usually prefer the tooth form texts for more information regarding prosthesis design for
if the width is adequate. this patient group.