Prosthetic Management

7/28/2019 Prosthetic Management

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Prosthetic management of edentulous mandibulectomypatients. Part I. Anatomic, physiologic, andpsychologic considerationsRobert Cantor, D.D.S., M.S.,* and Thomas A. Curtis, D.D.S.**University of California, School of Dentistry, San Francisco, Calif.

0 ne of the most consistently frustrating areas of maxillofacial rehabilitation isthe treatment of edentulous patients who have had radical cancer surgery of thetongue, floor of the mouth, and mandible. Mandibulectomy and commando pro-cedures involve the extensive loss of tissuesand associated functions. The pros-thetic prognosis is rarely good, and reconstructive surgical procedures, even whenindicated, usually do not significantly improve the prosthetic potential. In a recentdiscussionof the follow-up role of prosthetics for ablative surgery of the head andneck, Dr. John Conley stated, Maxillofacial prosthetic treatment has been ofenormous benefit to most of my post-surgical patients. However, prosthetic treat-ment of the edentulous mandibulectomy patient is usually unsuccessful.This is thearea in which research and new ideas are desperately needed.lModern prosthetic treatment could not have evolved without the anatomicand physiologic discussionsof Boucher, Pendleton3 Silverman4 and others. Forexample, MacMillin5 noted that textbook descriptions of muscular functioningrelated to the mandible containing teeth are significantly different from the mus-cular activity of the edentulous mandible. Similarly, available discussions f mus-cular activity pertinent to the edentulous mandible are not appropriate when de-scribing the altered functions of the maxillofacial structures following radicalmandibular surgery.An understanding of postsurgical anatomy and physiology is an obvious pre-requisite to the development of new prosthetic procedures for mandibulectomypatients. Only this understanding will permit functional utilization of these unusualpostoperative anatomic conditions.

Read before the American Academy of Maxillofacial Prosthe tics, Oct., 1969, New York,N. Y.

*Ass istant Research Biolog ist and Co-Director, Maxillofacial Rehab ilitation Clinic .**Lecturer in Prosthetic Dentistry and Director, Maxillofacial Rehab ilitation Clinic.

446


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Vlhrne. 25Number 4 Prosthetic management of mandibulectomy patients 447An attempt was made by the Maxillofacial Rehabilitation Clinic at the Uni-versity of California San Francisco Medical Center to investigate and describe

the altered dynamics of the postsurgical lower denture space, to formulate newtreatment concepts based on this inquiry, and to evaluate the effectiveness ofthese new procedures. The results of this study will be presented in a 3 partarticle. In Part I, the postsurgical physiology and anatomy related to deglutition,speech, mandibular movements, mastication, saliva control, and respiration willbe discussed.A classification of mandibulectomy patients and some postsurgicalanatomic characteristics of each group will be presented.Part II will present a step-by-step discussionof clinical procedures specificallydesigned for the altered anatomic and physiologic conditions of mandibulectomypatients, as well as the relevant prosthetic principles involved.

Part III will present a clinical research study of 30 mandibulectomy patientsfor whom both the new prosthetic procedures and the more traditional or usualdenture techniques were used and compared.GENERAL PHYSIOLOGIC CONSIDERATIONS

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

Normal deglutition is a primary process. A bolus of food is carried throughthe fauces and into the pharynx by the dorsum of the tongue. The nasopharynxis closed by the soft palate, and the larynx is elevated. The soft palate, posteriorpart of the tongue, gravity, and pharyngeal air pressure combine to force thebolus of food into the dilated esophaLgus, nd peristaltic contractions transfer itto the stomach.

Postoperative swallowing can be temporarily or permanently impaired. How-ever, since swallowing is a primary function and not easily disrupted, the abilityto swallow usually will return. Deglutition can be performed with a minimum oftnuscular tissue and even with the loss of such skeletal structures as the mandibleand hyoid bone.s With an intact larynx, the voluntary closure of the glottis may belearned. This action combined with a gulp movement bypassesmuch of theoral and pharyngeal phasesof swallowing and throws the liquid into the esophagealphase and the initiation of peristaltic action.7

However, tissue ossor reduced muscular and neuromuscular control of oral andlaryngeal structures will restrict the anterior elevation of the floor of the mouth,hyoid bone, and larynx. Dysfunction occurs when ( 1) tongue immobility, (2)denervation of the glossopharyngeal, vagus, and superior laryngeal nerves, (3)scarring, or (4) radiation fibrosis prevents the patient from exerting sufficient


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440 Cantor and Curtis J. Prosth. Dent.April, 1971pressure on the cricopharyngeal muscles to open the esophagus. Liquid and foodwill then pool in the hypopharynx. The problem is compounded if the crico-pharyngeal muscles are denervated or if the soft palate is impaired as a result ofan operation.Speech

Normal speech is a learned process, and therefore it is influenced by vision,hearing, intelligence, motivation, and imitation. A stream of air vibrates the vocalfolds and produces laryngeal sound waves. This sound takes on a characteristicquality because of anatomic resonating chambers and is then broken up intolanguage sounds by the action of the tongue, lips, and cheeks. A high degree ofcentral nervous system development is essential to coordinate the complex neuro-muscular patterns associated with speech production. Kantner and West8 de-scribe the components of speech as respiration, phonation, resonance, articula-tion, and neurologic integration. The function of speech is easily disturbed, andany of these speech components can be affected. However, speech distortionusually occurs in mandibulectomy patients by impairment of the articulatingmechanism and/or alteration of the resonating chambers.

The tongue is the main articulator-y organ in the production of speech, andextremely rapid changes in position and morphology are required.s Postsurgicalreduction in tongue size and restricted mobility can prevent tongue-palate valvingand resultant speech distortions, although vowel sounds are usually unaffected.sAnterior tongue restriction can cause distortion of consonants such as d or t,while g and k will be adversely affected by posterior tongue restriction. Dis-placement of a mandibular fragment will cause confluent asymmetric functioningof the tongue affecting a variety of speech sounds. The corresponding displace-ment, or scarring, of the lower lip can interfere with the production of soundssuch as v and f. Impairment of these articulating structures causes speechdistortions ranging from slight slurring to unintelligibility.The resonating chambers include the pharynx and the oral cavity. Scarring,compensatory overclosure of the mandibular fragment, and tissue loss resultingin an undersized, misshapen,and immobile residual tongue combine to dramatical-ly alter the form and resonating character of these spaces. Speech can becomehohow, flat, and muffled.Mandibular movement and mastication

Normal mastication is a learned, volitional, and automatic process giving riseto many individual variations. 4 Despite the degree of learned differentiation, thisfunction can often readjust following surgical insult. The literature is resplendentwith theories and discussionsof vertical dimension, centric relation, and mastica-tory movements.o-l2 However, this discussionwill be restricted to the characteris-tics of mandibular functioning that influence postsurgical compensatory adjust-ments.The components of occlusion have been describedI as the temporomandibularjoint structures, the musculature which activates the masticatory apparatus, andthe denture-bearing tissues.All three components are radically altered by mandibu-


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Volume 25Number 4 Prosthetic management of mandibulectomy patients 4491a.r surgery. Mandibular movements are partially controlled by the bilateral ac-tion of the temporomandibular joints, and disarticulation of the joint on oneside will result in unilateral distortions. However, one advantageous characteristico: f the temporomandibular joints is that, when one joint is lost, the muscles ofthe maxillofacial group can substitute for each other and maintain a functionalequilibrium.5 For example, the internal pterygoid and mylohyoid muscles pullthe resected mandible medially or toward the defect, but the temporal and massetermuscles reciprocate in a superior and lateral direction. The ability of the musclesof mastication to maintain a functional equilibrium following a mandibulectomycan be easily overcome by scar contracture, and it is, therefore, important toresist this scar displacement.

The muscles of mastication are normally in a state of equilibrium when theopposing teeth are lightly touching. The centric occlusal position of the mandib-ulectomy patient is medially displaced with a corresponding loss of vertical di-mension. Masticatory force can be exerted along this deflected pathway, butt:he patient is seldom capable of suf fic iently coordinated muscular strength folnormal mastication. In many instances, the patient can approximate the pre-surgical centric occlusal position, but restoration of the original occlusal verticald.imension can interfere with compensatory speech and swallowing functions andcan diminish masticatory strength.Saliva control

Drooling and other problems associated with changes in salivary consistencya.nd control comprise one of the most debilitating postsurgical sequelae o f man-clibulectomy patients. These patients can suffer from too much or too littlesaliva.

Drooling. Restricted tongue movements; diff icul ties in swallowing; the absenceof labial, buccal, and lingual sulci; scarring of the orbicularis oris; and incisionnotching of the lower lip, as well as the loss of sensory awareness, will impairthe patients ability to control his salivary secretions. The role of hypersalivationin the genesis of drooling is considered minimally significant by Smith and Goodewhen compared with failure to swallow salivary secretions or inability to retainaccumulated secretions within the mouth. However, insertion of the resectionprosthesis, or denture irritation, can produce excessive salivation. Althoughthis component is usually temporary, extreme drooling during the adjustmentperiod can demoralize the patient and permanently influence prosthetic trent-ment.

Xerostomia. A large number of mandibulectomy patients who have undergoneradiation therapy suffer from partial xerostomia and thick salivary secretions.When the salivary glands are included in the field of irradiation, varying degreesof fibrosis, fat ty degeneration, acinar atrophy (especially of the serous glands) , andcellular necrosis take place. I5 The reduction in the amount of saliva present andits characteristic sticky quality will adversely affect denture retention, tissuetolerance, and taste. Fortunately, there is often some regeneration of salivary func-tion, but chronic dryness of the oral mucous membranes influences prosthetictherapy.


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450 Cantor and Curtis J. Prosth. Dent.April, 1971Respiration

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

It is therapeutically unrealistic to discuss unctional impairment without mak-ing reference to the psychic and social factors affecting the mandibulectomy pa-tient. These patients often describe the changes caused by radical surgery as thetermination of their former life. Distortions in self-image, inability to communi-cate, and shifting family and vocational roles require the reconstruction of psychicsystems to adequately handle the new internal and external demands.Social and behavioral compensationsare needed becauseof the frequent nega-tive responsesencountered in social situations. These responsescan range fromstaring and whispering to various forms of social stereotyping.ls* I7 The mostcommon stereotypic response o the mandibulectomy patient is that of a down-and-out drunk. Postsurgical speech slurring, depressive confusion, and rednessofthe facial tissuesdue to radiation can mimic the appearance of this well-knownsocial outcast, and many mandibulectomy patients must overcome these andother initial negative impressions. Many other difficult social encounters can betraced to the commonly held contamination fear of cancer and death. If themandibulectomy patient honestly answers questions concerning his appearance orspeech, the close identification with malignancy will often be so threatening tothe listener that the patient is repulsed and isolated. An emotionally stable personcould account for these negative responses, ut the patient is also struggling withmany internal conflicts which minimize his objective perceptions.

Severe anxiety, denial, depressive stupor, and diffuse hostility are often presentin mandibulectomy patients and overlay the symptoms of mild depression andhysteria in relation to ordinary prosthetic treatment as described by Ramsey.l*Even xerostomia, burning mouth, and diminution of taste normally ascribedto radiation therapy can be caused by depression.g* 2o When the initial reaction


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Valume 25Number 4 Prosthetic management of mandibulectomy patients 451of disbelief at the diagnosis of cancer dissipatesand the reality of death is ac-cepted, the patient will usually respond with anger, rage, envy, and resentment.lThis anger is displaced in all directions and is projected into the environmentalmost at random. Major treatment difficulties can arise if the clinician takes thepatients anger personally. Kfibler-Ross*l describesan alternative behavior to an,gera:; bargaining.

The psychodynamics of this emotional state are verbally characterized in thefollowing illustration : I was unable to deny my illness and the strong likelihoodI will die; my anger was to no avail; however, if I am very nice and cooperative,maybe fate will postpone the inevitable. Desperation is well represented in thepatient who is overly eager to please.Acute depression s the most common psychologic symptom of the postsurgicalcancer patient and is often disregarded during treatment. The spell of depressionusually results from a senseof great 10s~~ the physical loss of a part of the jaw.the financial loss of a business,and the psychic loss of self-esteemand authority .FLadoz3believes that, regardless of the nature of the loss, its extraordinary mean-i-ng for the patient lies in the fact that terrible childhood experiences are evokedand that at least a part of the depressedpersons behavior can be described as adisplay of helplessness, cry for love, or a direct appeal for the security that hasbeen lost. Whitez4 adds that this reaction is complicated by the presence of hos-tility toward those associated with the loss and also by the guilty fear that thehostility itself has actually caused the loss. This type of patient has little desirefor rehabilitation or tolerance for demanding prosthetic procedures. Genuinelysuccessful prosthetic treatment requires the clinical understanding of these andother relevant psychosocial factors,CLASSIFICATION OF SURGICAL IMPAIRMENT

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


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452 Cantor and Curtis J. Prosth: Dent.AprJ, 1971

Fig. 1. Class I. Radical mandibular alveolectomy.

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

The tissues esected on the affected side include these: a portion of the alveolarprocess and body of the mandible; the mucoperiosteum of the mandible; thelingual and buccal sulcus mucosa; a portion of the base of the tongue andmylohyoid muscle; the lingual and inferior alveolar nerves; the sublingual andsubmaxillary salivary glands; and, at times, the anterior part of the digastricmuscle (Fig. 1) ,

The structures that remain on the affected side are essentially normal andinclude these: an intact lower border of the mandible; all primary and auxiliarymuscles of mastication; most of the tongue; and the mylohyoid muscle with theexception of the scar tissue in the region of the resection.

Patients in this group function quite normally, although resection of a partof the mylohyoid muscle and resultant scarring can interfere with raising thefloor of the mouth, and this often causes some reduction in tongue mobility.The ability to shape and control tongue form can be impaired also by loss ofsome of the intrinsic muscles. Resection of the lingual and inferior alveolar nervesresults in a loss of sensation in the mucosa of the cheek, alveolar process, lowerlip, and epithelium of the lower part of the face and loss of taste on the anteriortwo thirds of the tongue. Motor control by the mylohyoid muscle can be irn-paired, and motor function of the tongue is affected if the hypoglossal nerve is lost.


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Volume 25Number 4 Prosthetic management of mandibulectomy patients 453

Fig. 2. Class II. Lateral mandibular resection.

Clctss IIThe tissues resected on the affected side include: the condyle, ramus, and

body of the mandible distal to the cuspid; the mylohyoid, hyoglossal, anteriorbelly of the digastric, internal pterygoid, masseter, and external pterygoid muscles;the pharyngoglossal and palatoglossal muscles when the tonsils are involved;most of the intrinsic muscles o f the tongue; the hypoglossal, lingual, and in-ferior alveolar nerves; the sublingual and submaxillary salivary glands; and themucoperiosteum and adjacent buccal and lingual sulcus mucosa (Fig. 2).

The structures that remain on the affected side and comprise the boundariesof the lower denture space include the following: the anterior part of the mandible;the tip of the tongue; the anterior lingual sulcus; some of the intrinsic tonguemuscles; and the genioglossus and geniohyoid muscles. In some instances, it ispossible to leave the anterior two thirds of the tongue intact and to limit theresection to the structures posterior to the mylohyoid muscle.

Patients in this group have multiple functional impairments. Disarticulationand the loss of the muscles of mastication will result in distortions of mandibularmovements. Similar taste, sensory, and motor losses are found in the Class Imandibulectomy patients, but these defects are more extensive. Speech, swallow-ing, saliva control, and manipulation of food are all somewhat more impaired.Facial disfigurement becomes apparent. Interference with swallowing can resultif a portion of the palatoglossus muscle remains active. This muscle will contractduring deglutition and reduce the opening into the pharynx. I f the pyri form sinushas been partially resected, the passageway into the hypopharynx is further re-duced by the stump of the internal pterygoid muscle. The tongue is sutured to thebuccal mucosa on the defect side posterior to the cuspid, and muscular functionof the buccinator muscle is severely limited. However, the tip of the tongue doesremain for some control of saliva, manipulation of food, and speech.CllUSS Ill

The resected tissues include all those described in the Class II category inaddition to the anterior portion of the mandible, the genioglossus muscle, the


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454 Cantor and Curtis J. Prosth. Dent.April, 1971

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

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

geniohyoid muscle, and the remaining portion of the mylohyoid muscle withadjacent lingual and buccal mucosa (Fig. 3). The tissuesremaining on the defectside include the cheek mucosa, small portions of the palatogIossa1and internalpterygoid muscles, and that portion of the tongue used to reform the floor of theoral cavity by attaching it to the buccal mucosa. The lower denture space istotally obliterated.The loss of the tip of the tongue and genioglossusmuscle severely restrictstongue mobility. A loss of tongue position also results, since this muscle keepsthe tongue from falling posteriorly. Speech, swallowing, saliva control andmanipulation of food are severely restricted in this group of patients. Facial dis-figurement is also considerably worse because of the loss of the anterior part ofthe mandible. Disarticulation and the reduction in the amount of basal bone


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tolumt 25h umbrr 4 YroJthetic management of mandibulcc:tomy patients 455further reduce the prosthetic prognosis. Scarring of the musculus orbicularis orisc.an interfere with expressions of emotion and can also result in some slight articula-tory distortions of speech.

There are instances when midline mandibular resections are performed with-out removing the anterior part of the tongue (Fig. 3, A). When this occurs, thefunctional impairment is substantially reduced, but the prosthetic prognosis remainsvery poor due to the loss of so much bone.Class IV

Lateral bone and split thickness skin or pedicle graft surgical procedures canae performed for patients who have had ( 1) radical alveolectomies, (2) resec-tions of the mandible distal to the cuspid with or without disarticulation, and (3)midline resections with or without disarticulation (Fig, 4). There are essentiallythree types of bone graf ts: mandibular augmentation procedures, bone graf ts that~connect a residual condyle with the larger mandibular fragment, and lateral bonegrafts that extend from the mandibular fragment into the defect area to establisha pseudo temporomandibular joint. The prosthetic prognosis varies with each typeof reconstructive surgery. Alloplastic implant materials can be used, but prosthetictreatment is rarely indicated for these patients; this group, therefore, will not bediscussed.

Patients who have been subjected to radical alveolectomies and secondary boneaugmentation procedures have essentially the same problems as do Class I mandib-ulectomy patients or those who have had surgery for severe alveolar resorption.Prosthetic treatment diff iculties are less often encountered with this group of patients.

Bone graf ts that connect a condylar fragment with the larger mandibular frag-merrt permit the remaining maxillofacial structures to more easily control mandib-ular movements. However, reduced condylar mobil ity, scar contracture, the lossof muscles or muscle attachments, and the loss of muscular innervation can con-tinue to cause restrictions of various functions.

A lateral bone graft that terminates in a fibrous tissue pseudo socket is com-monly performed. Secondary split thickness skin grafts are used to extend thelower denture space and to make the bone graft accessible for prosthetic utiliza-tion. Following this reconstructive surgery, there is usually less unilateral action ofthe mandibular fragment due to the passive resistance of the soft tissues in thearea of the bone graft. The floor of the mouth becomes wider, and the remainingtissue bed often is stretched. It is sometimes possible to increase tongue mobili tyby means of a split thickness, dermal, or pedicle graf t. Tongue release proceduresare limited by the amount and posterior extension of the scar tissue present. Theshape and size of the surgically created sulcus depend on such factors as contrac-tion of the skin graf t, tissue reactions to radiation therapy, secondary infection, andthe size of the original sulcus. These patients will continue to experience deviationof the mandible toward the defect side during opening movements and movementtoward a former centric relation during closing movements. Gravity and primaryscarring, as well as the excessive strength of the remaining muscles of masticationthat close the mandible, contribute to this tendency.


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456 Cantor and Curtis J. Pro&h. Dent.April, 1971

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

Edentulous patients who have had anterior resections of the mandible havetwo independent fragments or temporary intra-arch fixation and can rarely behelped prosthetically. However, following anterior bone, skin, or pedicle grafting,some prosthetic management is often feasible, and the primary and secondarysurgical procedures will, therefore, be discussed.

The tissues resected at the time of the original operation in&de: the anteriorportion of the mandible (usually from second bicuspid to second bicuspid) ; largebilateral portions of the mylohyoid, geniohyoid, genioglossus, and the anteriordigastric muscles; bilateral lingual and inferior alveolar nerves; bilateral sub-maxillary and submandibular salivary glands; and the mucosa of the lower l ip,anterior floor of the mouth, and the ventral surface of the tongue (Fig. 5). Themucosa retained in the labial and buccal regions is sutured to the residual stumpof the tongue, and a Kirschner wire often is positioned to help maintain themandibular fragments.

Bone graft and split thickness skin, or pedicle, graft procedures can be usedto restore anterior facial contour and bilateral mandibular function. Preservationof the hypoglossal nerve is critical, since tongue mobility is primarily achieved bymeans of the intrinsic muscles of the tongue which project the stump forward andlaterally. Since the styloglossus, palatoglossal, and pharyngoglossal muscles arepresent, it is possible for the tongue to bunch up and push in a posterior directionto ini tia te deglutition and to produce guttural speech sounds. However, should thehypoglossal nerve be lost bilaterally, this motor activity is severely limited. Ipsilaterallower lip function is lost if the marginal mandibular branch of the facial nerve isresected.SUMMARYPart I of this series of articles dealing with the prosthetic treatment of man-dibulectomy patients presents some general physiologic considerations pertinent tomandibulectomy patients discussed in terms of functional adaptability to surgicalinsult, Deglutition, speech, mandibular movement and mastication, saliva control,


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Volume 25Number 4 Prosthetic management of mandibulectomy patients 457respiration, and psychosocial factors are characterized. A classification of mandib-,ulectomy patients is suggested, and the anatomic and physiologic oral conditionsof the patients in each group are described,Part II will present a step-by-step discussion o f clinical procedures specificallydesigned for the anatomic and physiologic alterations of these patients.

Part III will present an evaluation of these suggested procedures by means ofa clinical research study of 30 mandibulectomy patients.References

1. Conley, J.: The Role of Prosthetics in Ablative Surgery of the Head and Neck, Lectureto the A.A.M.P., New York, N. Y., Oct., 1969.2. Boucher, C. 0.: Impressions for Complete Dentures, J. Amer. Dent. Ass. 30: 14, 1944.

3. Pendleton, E. C.: Anatomy of the Face and Mouth From the Standpoint of the DentureProsthetist, J. Amer. Dent. Ass. 33: 219, 1946.4. Silverman, S. I.: Denture Prosthesis and Functional Anatomy of the Maxillofacial Struc-tures, J. PROSTH. DENT. 6: 305, 1956.

5. MacMillin, H. W.: Anatomy of the Throat, Mylohyoid Region and Mandible in Relationto Mandibular Artificial Dentures, J. Amer. Dent. Ass. 23: 1435, 1937.6. Silverman, S. I.: Oral Physiology, St. Louis, 1961, The C. V. Mosby Company.7. Dingman, D. L.: Post-Operative Management of the Severe Oral Cripple, Plast. Reconstr.

Surg. 45: 263, 1970.8. Kantner, C. F., and West, R.: Phonetics, New York, 1941, Harper & Brothers.9. Cantor, R., Curtis, T. A., Shipp, T., Beumer, J., and Vogel, B.: Maxillary Speech Pros-theses for Mandibular Surgical Defects, J. PROSTH. DENT. 22: 253, 1969.

10. Granger, E. R.: Functional Relations of the Stomatognathic System, J. Amer. Dent. Ass.48: 638, 1954.11. Kurth, Cl. E.: Mandibular Movements and Articulator Occlusion, J. Amer. Dent. Ass. 39:37, 1949.12. Perry, H. T., and Harris, S. C.: Role of the Neuromuscular System in Functional Ac-

tivi ty of the Mandible, J. Amer. Dent. Ass. 48: 665, 1954.13. Boucher, C. 0.: Occlusion in Prosthodontics, J. PROSTH. DENT. 3: 633, 1953.14. Smith, R. A., and Goode, R. L.: Sialorrhea, Accepted for Publication, New Eng. J.

Med., 1970.15. Silverman, S., and Galante, M.: Oral Cancer Monograph, San Francisco, 1966, Uni-versi ty of California Medical Center Press.16. McGregor, F. C., Abel, T. M., and Bryt, A.: Facial Deformities and Plastic Surgery-a

Psycho-social Study, Springfield, Ill. , 1953, Charles C Thomas, Publisher.17. Goffman, E.: Stigma, Englewood Cliis, N. J., 1963, Prentice-Hall, Inc.18. Ramsey, W. 0.: The Relation of Emotional Factors to Prosthodontic Service, J, PROSTH.DENT. 23: 4, 1970.19. Busfield, B. L., and Wechsler, H.: Studies of Salivation in Depression, Arch. Gen.Psychiat. 4: 10, 1961.

20. Ayd, F. J.: Recognizing the Depressed Patient, New York, 1961, Grune & Stratton, Inc.2 1. Kiibler-Ross, E.: On Death and Dying, London, 1969, The Macmillan Company.22. Wright, B.: Physical Disability-a Psychological Approach, New York, 1969, Harper &Row, Publishers.23. Rado, S.: Psychodynamics of Depression From the Etiological Point of View, Psychosom.

Med. 13: 51, 1951.24. White, R. W.: The Abnormal Personality, New York, 1964, The Ronald Press Company.25. Steadman, M. G.: Personal communication.

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