2011 Diagnosis and Treatment in Prosthodontics

......,.
,
Diagnosis and Treatment in Prosthodontics
Second Edition
DIAGNOSIS AND TREATMENT IN
PROSTHODONTICS Second Edition
Edited by
William R. laney, DMD, MS

Professor Emeritus
Department of Dental Specialties
Mayo Clinic College of Medicine
Rochester, Minnesota
Thomas J. Salinas, DDS

Associate Professor of Dentistry
Alan B. Carr, DMD, MS

Professor of Dentistry
Sreenivas Koka, DDS, MS, PhD

Professor of Dentistry
Steven E. Eckert, DDS, MS

Professor Emeritus
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Library of Congress Cataloging-in-Publication Data
Diagnosis and treatment in prosthcxlontics I ediled by William R. Laney ... (et ai.J. -· 2nd ed.
p.; em.
Rev. ed of: Diagnosis and treatment in prosthooontics I William R. L aney Joseph A. Gibilisco . 1983.
,
Includes bibl iographical references and index.

ISBN g78-0-86715-404-7 (hardcover)
1. Prosthodontics. I. Laney, William R., 1928· II. Laney, William R., 1928· Diagnosis and treatment in prosthodont ics.
[DNLM: 1. Prosthodontics--methods. 2. Oral Surgical Procedures,
Preprosll1etic--methods. WU 500)
RK651.D5 2011
617.6'9--dc22
2011006322
...
�
boolu
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Contributors
David J. Archibald, MD Brent E. Larson, DDS. MS
Resident Professor
Otolaryngology Department of Diagnostic/S urgical Orthodontics
Mayo Clinic College of Medi cine University of Minnesota
Rochester, Minnesota Minneapolis, Minnesota
Dusica Babovic-Vuksanovic, M D Charles L. Loprinzi, M D

Chair and Associate Professor Professor of Oncology
Department of Medical Genetics Mayo Clinic College of Medicine
Mayo Clinic College of MediCine Rochester, Minnesota
Rochester. Minnesota
David MacDonal d BDS. BSc(Hons). LLB(Hons). MSc.
,
Charles R. Carlson, PhD. MA. ABPP DDS(Edin). FDSRCPS (Giasg). DDRACA (UK), FRCD (Can)
Professor of Psychology and Dentistry Asso ciate Professor
College of Dentistry Faculty of DentiStry
University of Kentucky University of British Columbia
Lexington, Kentucky Vancouver, British Columbia
Canada
Alan B. Carr, DMO, MS
Professor of Dentistry Kevin I. Reid, DMD
Departmen t of Dental Specialties Assistant Professor of Dentistry
Mayo Clinic College of Medi ci ne Department of Dental Specialties
Rochester. Minnesota Mayo Clinic College of Medicine
Mijin Choi, DDS. MS
Clinical Assistant Professor Kevin L. Rieck, DDS. MD
Department of Prosthodontics Instructo r in Surgery
New York Universi ty College of Dentistry Section of Oral and Maxillofacial S urgery
New York, New York Mayo Clinic College of Medicine
Steven E. Eckert, DDS. MS
Professor Emeritus Jana M. Rieger, PhD
Department of Dental Specialties Associate Professor
Mayo Clinic College of Medicine Institute for Reconstructive Sciences in Medicine
Rochester. Minnesota Misericordia Community Hospital
Department of Speech and Language Pathology

Robert L. Foote M D,
and Audiology
Professor
Faculty of Rehabilitation Medi ci ne
Radiation Oncology
University of Alberta
Mayo Clinic College of Med icine
Edmonton Albert a
,
Canada
Jan L. Kasperbauer, MD
Professor of Oto laryngology
Associate Professor of Dentistry
Sreenivas Koka, Dos. MS PhD , Rochester, Minnesota
Professor o f Dentistry
D epartment of Dental S pecial ti es
John E. Schmidt, PhD
Assi stant Professor of Psychiatry
William R. Laney DMD. MS
,
Kostandinos Sideras, MD
Professor Emeritus
Assistant Professor of O ncology
IX
Preface
S ince publication of the first edition, many changes have occurred 8ectronic t echnology has provided for an improved diagnostic and
in the clinical practice of prosthodontics. While the human patient treatment-planning capability. Imaging techniques and equipment
and related oraVperioral problems remain physically unchanged. have evolved that provide more extensive and accurate information,
psychosocial attitudes toward dentistry and care deliverers have which assist the clinician in decsion
i making prior to and during
been altered as a result of shifts in societa l values and priorities. treatment. COmpared to two -dimensional or flat-screen ima ges,
An enlightened and enti tled generation now places more e mp hasis newer three-dimensional imaging and modeling have s ignificantly
on personal appearance, early relief from pain and inconvenience enhanced the planning and delivery of surgical r estorative treatmen t.
in a timel y manner, as well as cost and cost sharing by third p arty

- In response to these developments, this second edition r equired the
contributors. so lic itation of additional knowledge and expertise from experienced
Hard and soft tissue substance continues to be altered by disease prosthodontic specialists and competent representatives from re·
and traumatic injury with genetic overlay imposed occasionally by lated contributing disciplines. These relevant additions have provided
racial commingling and natural evolutionary processes. However, a n enhanced scope and depth of subject matter on topics pertinent
the clinical management of tooth and bone loss and acquired and to pr osthodontics.
congenital oral and peri oral defects has changed dramatically as a
result of improved technical and procedural modalities and materials.
The intro d uctiOn of BrAnemark's concept of osseointegration in Acknowledgments
North America in 1982. with its accompanying biocompatible
titanium hardware. has resulted in re ma rkable developments and The authors would like to acknowledge their colleagues in oral and
ap proaches to restorative treatment with versatility of application maxillofacial surgery, radiation oncology. and otolaryngolo gy/hea d
and predictable outcomes. and neck surgery for their dedication in helping compile the sub·
In addition to implant-support opportunities, probab ly more than ject matter. Additional thanks are extended to the secretarial support
any other phase of restorative dentistry, the advances in ceramic section o f the Department of Dental Sp ecialties at Mayo Clinic for
options and materials have contrib uted to satisfying pat ient demands helping wi1h portions of the manuscript. Further acknowledgments
for more esthetic treatment outcomes. These applications relate are extended to the authors wives and families for their understand·
'
primarily to fixed restoratio ns which now have more durability and a

, ing of the time needed to accomplish this important project.
more li felike appearance.
1
viii
Robert Stewart, ODS. MS Julian B. Woelfel, DDS
Clinical Assistant Professor of Dentistry Professor Emeritus
University of Detroit Mercy School of Dentistry
Detroit, Michigan The Ohio State University
Columbus. Ol1io
James M. Van Ess, oos. MD
Assistant Professor of Surgery John F. Wolfaardt , eos, MOent. PhD
Section of Oral and Maxillofacial Surgery Institute for Reconstructive Sciences in Medicine
Mayo Clinic College of Medicine Misericordia Community Hospital
Rochester, Minnesota Professor
Faculty of Medicine and Dentistry
Christopher F. Viozzi, DOS. MD
University o i Alberta
Assistant Professor of Surgery
Edmonton. Alberta
Section of Oral and Maxillofacial Surgery
Canada
Jonathan P. Wiens, oos. MSD

Clinical Associate Professor
School of Dentistry
University of Detroit Mercy
Detroit, Michigan
Table of Contents
Foreword by George A Zarb vii
Preface viii
Contributors ix
Basic Concepts of Genetics 1

1 Dusica Babovic-Vuksanovic
The Orthodontic-Prosthodontic Relationship 9

2 Brent E. Larson
History, Laboratory, and Examination 17

3 William R. Laney and Sreenivas Koka
Oral-Systemic Interactions 39
4 Sreenivas Koka, William R. Laney, and Thomas J. Salinas
Oral and Maxillofacial Radiology 51

5 David MacDonald
Psychologic Aspects of Diagnosis and Treatment in

6 Advanced Dental Care 71
John E. Schmidt and Charles R. Carlson
Temporomandibular Disorders and Orofacial Pain 83

7 Kevin I. Reid
Considerations in Treatment Planning 97

8 Alan B. Carr, Steven E. Eckert, and William R. Laney
Preprosthetic Surgery 115

9 Christopher F Viozzi
Bone Grafting and Ridge Augmentation Considerations Prior to

10 Endosseous Implant Reconstruction 129
James M. Van Ess and Kevin L. Rieck
Osseointegrated Implants and Implant Site Development 141
11 Kevin L. Rieck, Thomas J. Salinas, and James M. Van Ess
Surgical Defects of the Mandible and Maxilla 149

12 David J. Archibald and Jan L. Kasperbauer
Oral Complications of Chemotherapy and Radiation Therapy 163

13 Kostandinos Sideras, Charles L. Loprinzi, and Robert L. Foote
Radiation Therapy and Chemotherapy for Head and Neck

14 Cancer 183
Mijin Choi
Restoration of Congenital, Developmental, and Acquired Oral and

15 Perioral Defects 197
Thomas J. Salinas, Alan B. Carr, and William R. Laney
Contemporary Dental Materials and Their Application to

16 Prosthodontics 233
Thomas J. Salinas and Julian B. Woelfel
Diagnosis and Management of Inadequate Denture Prostheses 249

17 Steven E. Eckert
The Mutually Protective Complex: Occlusion and Fixed

18 Prosthodontics 263
Jonathan P. Wiens and Robert Stewart
Speech Pathology and Prosthodontic Applications 293

19 Thomas J. Salinas, William R. Laney, Jana M. Rieger, and John F. Wolfaardt
Management of Patients with New Prostheses 318

20 Steven E. Eckert
Index 333
Foreword
Twenty-eight years have elapsed since I came across the first edition it also preceded the osseointegration era; and the intervening
o f this superb text. I had al the time already made my personally years between the two editions were overtaken by the remarkable
decisive journeys to two renowned US institutions of graduate edu speed and excitement of the relevant scientific changes-biologic,
cation in my chosen field of interest. And just like many other would behavioral, social, technologic-that have now come to dominate
be clinical academics-both then and now-1 benefrted enormously the discipline.
from my extraordinary teachers' experience and their commitment The editors are therefore readily forgiven for making us wait so
to clinical excellence. However, my acquired and presumed ability long for this very welcome second editiOn. It significantly expands
to address the bigger picture of diagnosis as well as treatment in the original book's scope by its recruitment of those essential topics
the discipline of prosthodontics had to be acknowledged as an in sucl1 as genetics, adjunctive laborato1y examinations, psychologic
complete one. I had gradually realized that the rigor and focus that concerns, imaging techniques. etc, that have informed and revised
underscored the era's guidance in specialized dental education was the entire profession. It also makes it far clearer than ever before that
not automatically reconcilable with patients' systemic determinants the discipline has not only benefited from the infomnation explosion but
and individualized needs. Dental treatment planning tended to be that it has also convincingly embraced it. The net result is a renewed
overtly hegemonic because handicraft and anecdotal traditions in and elegant confimnation of the conviction that good prosthodontics
the discipline were dominant. Moreover. the additional objective of is simply not reducible to tidy formulas or rigidly ordered credos, that
treatment interventions t o restore orofacial function was rarely de i t demands scrupulous and eclectic observational skills, and that this
temnined by the exacting standards today's treatment outcome de approach remains a wise and essential strategy to avoid what might
mands. very well be unnecessary and misguided interventions.
It was inarguably an opportune time tor a text that sought to proVide This text makes a compelling case tor prosthodontics as a clinical
a synthesis of what was even more essential and comprehensive dental specialty in the best scholarly tradition. I cannot think of a
for optimal management of the prosthodontic patient. and this better one to make the profession appreciate what the discipline is
book's first edition addressed that big picture need in the scholarly really all about.
manner that admirably reflected the Mayo Clinic's distinguished
authorship pedigree. It quickly became a de rigeur assignment George A. Zarb
for graduate students in the specialty as well as new graduates Professor Emeritus, University of Toronto
who were considering prosthodontics as their career pursuit. But Editor-in-Chief. International Journal or Prosthodontics
vii
Chapter
Basic Concepts
of Genetics
Dusica Babovic-Vuksanovic, MD
T: e field of genetics has undergone rapid growth in recent

ears and greatly affected all areas of medicine. The compte
• Does this patient have a hereditary disorder?
o Does this patient have a simple condition or a complex disorder
on of the Human Genome Project. which identified the three underlying the symptoms?
billion base pairs of DNA that compose a human genome, was a o
Is there a need for evaluation of other family members?
landmark event of the end of the 20th century. Genetic information is • What is the risk that the patient's children or siblings will inheri t
now being incorporated into all areas of clinical medicine. changing the condition?
even basic concepts in evaluation of and therapy for patients. While • Could the disease be managed or stopped in its early stages i f a
science has yet to reach full comprehension of all gene functions and timely diagnosis is made?
protein interactions we remain optimistic that opportunities soon will
,
be developed to p redict. prevent, and cure human diseases through The answers to these questions can significantly affect a pa·
methods such as personal genetic fingerprinting and routine gene tient's life. For example. if a patient with Marian syndrome pres·
therapy. Staying up to date on recent genetic developments and ents with dental irregularities (eg, crowding) recognition of a gen·
,
applying this knowledge to patient care will become a necessary skill eralized connective tissue abnormality would typically lead to a
for most clinicians. series of p reventive measures including screening f o r aortic root
dilatation. In this patient, early diagnosis and appropriate treatment
might be life-saving. Another example is a patient with osteomata
of facial bones, dentigerous cysts, or supernumerary teeth-pos·
Genetics in Clinical Medicine sible signs of familial adenomatous polyposis. Early identification of
this hereditary disorder in the patient and his or her family would
The role or genetics in human disease is well-known. Some condi· lead to necessary surveillance for colon cancers or even preven·
lions are caused by single genes and inherited in a Mendelian pat· live colectomy, thereby transforming a uniformly malignant and le
tern; the diagnosis. risk assessment, and counseling for the family thal condition into a manageable one. The dental specialist often
are usually simple for these conditions. 1·2 In other cases, recognition may be the first t o see a patient with an unrecognized. complex
of an underlying genetic trail may be a challenge. and multidisci· medical problem; a high index of suspicion and appropriate refer·
plinary evaluations and complex diagnostic testing are often needed. rat may dramatically influence the well-being oi a patient and his or
Common quest1ons that general clinicians should ask include the her relatives.
following:
1
1 i B as ic Concepts of Gen eti cs
>
a J ) J
LEGEND
1(1 0 Healthy male
0 Healll>y female
) ) • Affected male
1·)t)) ((' )f
e Affected lemale
b () 1J Hete10zygote carri0< male
I 2 3 • 5 f) Hete10zygo1e carrier female
u (
0 Female carrier of X-linked
)f .
6
IJ
7
?I )) )) '
""'
-'W J(
eondrtion
8 9 10 II 12 X
'}
1(' 1( n i( l( u
.
13 14 IS 16 17 18
(J ) ('} •
;>
Ji Bt. ·-� u I
19 20 21 22 y
c • () )
Fig 1·1 A normal, male, G·banded kal)'otype. (Courtesy of Or Gopalrao Velagaleti, Ried Fig 1-2 Family trees demoostratill(J autosomal dominant (a), autosomal recessive (II).
Meyer. Daniel Kuffel. and Or Eric lhorland. Cytogenetic Laboratory, Mayo Clinic, Aoch· and X·finked (c) lraits.
ester, MN.)
drome), and some forms of ectodermal dysplasia. Disease expres

Inheritance Patterns sion may vary significantly in affected people even within the same
family, res ulti ng in different severity of disease in different individuals.
Despite the availability of many sophisticated diagnostic tests, basic Carriers of an autosomal dominant gene may not develop the p he ·
genetic prinCiples and the tra d�ional evaluation of the patient (medi· notyp e at all. because some genetic traits have reduced penetrance.
cal history, family h is tory and physical examination) remain essentia l.
, Alternatively, development of symptoms may be limited to late age,
Genes can be d ominant or recessive and are located on one of the as is seen in so me neurodegenerative disorders that manifest in
autosomes (chromosomes 1 thro ug h 22) or sex chromosomes (X adul thood (eg, Huntington disease. spinocerebellar ataxias , or Alz·
orY)'"' (Fig 1-1). heimer disease). This behavior sometimes may give the impression
Careful analy si s of the family tree often provides a clue t o t h e di ag· that the disease is skipping generatiOns.
no sis or suggests whether further investigation is warranted. When In contrast to autosomal dominant conditions, for which one
a genetic cause of the co ndit ion is unknown (le, diagnostic testing is abnormal gene (or allele) is sufficient to produce disease, autosomal
not available). the family analysis becomes the p rimary tool used in recessive conditions occur only in individual s who inherit two abnormal
g enet ic co u nseling. copies of a gene (FIQ 1-21:>). Usually. each parent iS a carrier of one
Autosomal dominant conditions are transmitted through multiple abnormal copy or the gene. but they are a y s mptomatic because they
generations of families. An affected individual has a 50% risk of also have a normal copy that prevents expression of the phenotype .
passing the abnormal gene to each of his or her children (Fig 1·2a). The aut oso mal recessive t rait is often suspected when a disease
Some examples of autosomal dominant conditions include Marian occurs in several siblings or in consanguineous families. The risk for
syndrome, von Hippel-lindau disease tuberous sclerosis, Gorlin
, carrier parents to have an affected child is 25% in e ach pregnancy.
syndro me, some chromosomal disorders (eg, velo-cardio-faeial syn- Examples of conditions that follow t his inheritance pattern include
Genetic Screening and Counseling J
'
Table 1-1
_
Inheritance pattern Example Recurrence risk" Sex differences
Autosomal dominant Most craniosynostoses Siblings: 50% None

Children: 50%
Autosomal recessive Most dysmo.phlc Siblings: 25% None

syndromes Chlldren: <5%
X-linked recessive Ducl1enne musctJiar Siblings Generally males affected and females
dystrophy Males: 50% alfectecl carriers'
Females: 50% carriers

Children: 100% females carriers
X-linked dominant Hypophosl)hatemic rickets Father is carrier Males usually more severely
affected'
Females: 100% affected
Males: not affected
Molller is carrier: 50% o f cl1iclren affected
MilochonClria! MELAS' Varial)le Transm,ssion mostly fhroogh females. ct1ildren

of both sexes affected•
MultifaCtOrial ISOlated defl lip with o r witl10vt Siblings: 1.2-s. 1% Slightly higher riSk to Children when mother
cleft palate is affected
Children: 1,7-5% (done parent affected)
Isolated clelt palate Siblings: 2-5%

Childr
en: 3-7% (Ifooe parn
e t affected)
1'he r<lk figU<es apply to siblnlgS Met children of an affeCted person.

'F<lmaiCSmght oo affecled. dueto the �1 ofskev.edXclvttnoscme.-..ctivatlcn.
'MElAS. mitochondrial encephatomyopathy, lactic acicJosiS. and stroke!lke et>isodes.
'Theexceptioo is leber oplicatrophy,>Mllch morese.€1llly aWects males.
cystic fibrosis, many inborn errors of metabolism, and some rare

syndromes for which the genetic etiology remains unknown.
Genetic Screening and
X-linked disorders are suspected in families with instances of Counseling
disease in male offspring or healthy (carrier) mothers (Fig 1-2c).
Genes on the X chromosome are usually recessive. and they tend After a clinical diagnosis is established, l h e patient's family history
to express mostly in males. who have only one X chromosome. is thoroughly reviewed to identify relatives at risk tor developing the
Examples of X-linked conditions include Fragile X syndrome. disease. The initiation of appropriate screening procedures for these
hemophilia, Duchenne muscular dystrophy, and certain forms of asymptomatic individuals often influences their prognosis and quality
ectodermal dysplasia. of life enormously. For example. a patient with dyskeratotic cysts of
The majority of human disorders are not caused by single the mandible or maxilla may have basal cell nevus syndrome (Gorlin
genes and do not express with an obvious pattern of inheritance. syndrome). If the diagnosis is supported by presence of basal cell
Multifactorial disorders result from a combination of hereditary and nevi, typical facial features, macrocephaly, skeletal anomalies, pal
environmental factors. Their complex etiology poses significant mar/plantar pits, or lamellar calcifications of the falx in the patient,
diagnostic and therapeutic challenges. Most birth defects (including confirmatory DNA testing from peripheral blood lymphocytes may
facial clefts), cardiovascular disorders. diabetes mellitus, and be performed to search for human patched gene disease-<:ausing
cancers are examples of multifactorial inheritance. While the etiology mutations.� By establishing the diagnosis of Gorlin syndrome and
for these cond�ions is only partially known, prediction of dis ease determining a DNA mutation in the patient, one would have a power
recurrence in family members is estimated Msed o n the empirical ful screening tool to detect family members at risk who would benefit
risks (Table 1 -1 ). Genetic research and association studies are from appropriate preventive measures (such as limited exposure to
currently focused on better comprehension of common multifactorial radiation and sun and suNeillance for basal cell carcinoma, hydro
disorders in an attempt to evaluate the contribution of various DNA cephalus. medulloblastoma. and development of jaw keratocysts).
polymorphisms to human disease development. Results from these For patients with a genetic disease or for parents with a cl1ild
studies may allow predictive testing of asymptomatic individuals and affected by a genetic condition, the estimated recurrence risk for
initiation of preventive measures, ultimately ushering in a new era of future pregnancies and the availability of preimplantation and prenatal
personalized genetic medicine in everyday clinical practice. diagnosis and therapy may inffuence their deciSions regarding family
3
1 i Basic Con ce pt s of Genet i cs
fig 1-3 A patient with van der Woude Fig 1-4 Fluorescent In situ hybndization (FISH) using probe Fig 1-5 Multicolor 11\Jorescence rn situ hybridizati()n (M·FISH)
syndrome. Note lower li p p�s. TUPLEI shows dele llon oo chromosome 22, cootirming the di· karyoi'Jpe of 47,XY,+r{8). The M·FISH identifies each cllromo·
agnosl s of velo-cardio-facial S'Jndrome. (Courtesy ol Or Gopalrao some by a unique color. Thus. tile unbalanced karyotype was
Velagaleti, Ried Mwer. Daniel Kuffel, and Or Eric Ttwland, Cyl()· identified by a nng composed of chromosome 8 material result·
.
genellc Lab<>ralofY, Mayo Clinic, Rochester, MN.) ing in par1ial trisomy lorchromosome 8. (CGurtesy ol Dr Gopalrao
Velagaleti. Ried Meyer, Daniel Kuffel. and Or Eric TllOfland, Cyto·
genetic Lab<>ratory. Mayo Clinic. Rochester. MN.)
pl anning . Ds
i t i nguishin g whether an isolated facial cleft in a patient Patients with craniofacial dysmorphism, systemic abnormalities
is a feature of van der Woude syndrome (resulting from a f amila
i l involving multiple organs, short stature, and cognitive deficits are
mutation in IRF-6 gene) changes the cleft recurrence risk in siblings often suspect for a chromosomal abnormality. A conventional
or in children of the affected individual from 3-4% Qn the case of cytogenetic study is an irreplaceable method to evaluate numeric and
isolated cleft) to up to 50% (in the case of van der Woude syndrome, structural chromosomal anomalies. High-resolution chromosome
which is autosomal dominant).'.., Therefore, a careful physical analysis using different banding methods (see Fig 1-1) det ects most
examination that reveals tower-l ip pits (Fig 1-3) and a positive chromosomal translocations. inversions. insertions, or deleti ons, but
family history in a patient with facial clefting may point t o a specific the resolution is limited to detection of changes up to 3-4 kb DNA
diagnosis and indicate additional testing. Once the path ogen ic Detection of any abnormality beyond this size requires more sensitive
mutation is identified in an affected family member, this information molecular analysis. One common molecular cytogenetic method is
can be used to screen other members of the family by using DNA fluorescence in situ hybridiZation (FISH). Tl,is technique relies on
technology on a single blood sample. Genetic counseling t o help the unique ability of a probe (a portion of single-stranded DNA)
interpret results from genetic tests and to determine appropriate t o anneal and hybridize with its complementary target sequence
preventive measures in these families is crucial. wherever it is located in the genome. The probe is conjugated with
a fluorescent label, allowing it to be visualized under ultraviolet light.
Different types of chromosome-specific probes are available for
Laboratory Methods Used in commercial purposes. SOme are specific for a particular region of
the chromosome (Fig 1-4), whereas otl,ers are used f or the entire
Genetic Testing chromosome, allowing painting of whole Chromosomes (Fig 1-5).

Such refined molecular cytogenetic methods have been an integral
Recent development of complex and powerful laboratory techniques part of di agn ostic evaluations to confirm common submicroscopic
has led to identification of the molecular basis for many conditions chromosomal abnormalities causing velo-cardio·faciaVDiGeorge
and great advancements in diagnostic testing.'"" syndrome, Williams syndrome, cri du chat syndrome. Wolf-
Laboratory Methods Used in Genetic Testing J
L ine 1 Line 2 Mlul
150 kb
I
�-
j150 kb
5'-ACGCGA-3'
100 kb -
i;
'- Mlul
i! ! 50kb
t j100 +50 kb
-
! I
5'-ACGCGT-3'
a b
Fig 1·6 (Left) Array c{)mparative genomic hybridization profile shOwing deletioo ol the Smitll·Magenis syndrome region on 17p11.2.
(Courtesy of Dr Eric Thorland, Cytogenetic Laboratory. Mayo Clinic, Rochester MN.)
,
Fig 1-7 (Top) Detec01 t1 1 of a single nucleotide change using Mlul enzyme digest. (a) Migration or DNA fragments after enzyme
digest1011 on gel electrophoresis. line 1: A single 150-kb fragment. Line 2: Two fragments, 100 kb and 50 kb. (b)Enzyme cut site and
DNA fragments alter digestion. Top: Enzyme Mlul did not cut. Bottom: The mutationA->T introduces a specific enzyme recognition
site and results in DNA cut into �·10 fragments.
Hirschhorn syndrome, Prader-Willi/Angelman syndrome, and others. pattern of inheritance, analysis of multiple DNA markers segregating
Despite an increase in available diagnostic methods, clinical obser disease may help predict whether the individual in question has
vations and judgment remain critical in selection of the appropriate inherited a disease-causing mutation.
test. Recently, clinicians started using the array comparative genomic In recent years, a growing number of mendelian disorders caused
hybridization(CGH) technique, also known as chromosomal by an alteration in a single gene have been identified. Detection
microarray analysis. which is a molecular-cytogenetic method for of genetic changes al the level of a single nucleotide (eg, in sickle
the analy sis of copy number changes (gainSIIosses) in the DNA. cell disease) requires much more sensitive molecular techniques
This method detects minute chromosomal abnormalities such that permit study of DNA itself. The invention o f polymerase chain
a s deletions or duplicatiOns at a much higher resolution level than reaction created revolutionary changes in DNA analysis. This simple
conventional cytogenetic methods (Rg 1-6) and includes analysis and rapid technique provides enormous amplification o f defined
for loci of most known microdeletion/duplicalion syndromes. The target DNA sequences. producing sufficient quantity for further
interpretation of this assay may be challenging because or numerous analysis. Sequencing can then be performed In a small amount of
benign polymorphic variants in DNA copy numbers in humans that e.xtracted DNA from a sample of peripheral blood (lymphocytes) or
can be confused for a disease-causing mutation. tn such cases, even from a single cell used for preimplantation genetic testing.
additiOnal testi ng of parents and other family members may be Another commonly used DNA method is the restriction-fragment
helpful to determine the importance of a DNA variant. polymorphism analysis. A specific single base-pair change is
Unkage analysis. an ind irect method with many limitations. was ident ified by using restriction enzymes that cut only a specific DNA
used frequently in the past for molecular genetic testing. This labor base sequence. Presence of a specific site can be determined
intensive technique requires studies on multiple family members based on DNA cleavage and can be observed by the altered mobility
and carries the possbility of diagnostic error resulting from rare
i of t ile DNA fragments on an electrophoretic field (Rg 1-7). Other
recombination events. Although its use has decreased drast ically in useful diagnostic molecular approaches take advantage of physical
recent years, it is still useful when direct molecular methods are not changes in DNA caused by sequence variations that change
possible. For example, in a pedigree with an autosomal dominant DNA electrophoretic mobility. Recently, development of improved
5
1 L Basic Concepts of Geneti cs
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Fig 1-8 Bidirectional se(luence ol a region ol
. . . . . . . exon 3 ol the cystic fibrosis transmembrane
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conductance regulator (CFTR) gene analyzer
I ...
'
.
with lhe software program Mutation Surveyor
. . . . . .. . . . . . . . . (SoftGeiletics). The top and oouom traces
. . . . (labeled 272305) are SeQuence traces from
� ·� ·"}it
. .
� 1\IV' a known negative control sample ll\at ls se
quenced with every run. The top trace repre
.. :.di:
. ., . .
sen!S the sequence of U1e sense strand (tlle
loiWard di re ction), and tile botlom trace is
. . .
• ' lOI • •
·
' the ants
i ense wand (reverse direction). The
.
· . .
. . ....
r11 1�; J
. . . . . . .. . se(luences below the top trace and above the
. . .. . .. ..
. . . . .
bottom trace are from a patient. The middle
. . .. . .. ..
. .. .. .. .. .
. two pallels are the net signal after subtract
, .
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ing the patient sample signal from the oontrol
·: �·A�
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sample signal. Note the hOmozygous G to T

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,
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change, which causes tlle normal glycine
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, fi oodon {GGA) to oode for a stop codon (fGA).
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. . This change is diagnostic of C)'Stic fibrosis in
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this Individual. (Courtesy of Or Edward High·
"' {\ IdA w 'VV
V .
smith. Cytogenetic laboratory, Mayo Clinic.
Rochester, MN )
technology for genomic sequencing has allowed analysis of large

DNA sequences in a very short time Fig ( 1·8), thereby creating a new
Clinical Genetics of Some
horizon in molecular testing. Disorders Seen in Prosthodontic
DNA testing is sometimes difficult for very large genes or for gen es
whose structure i s not enti rely known. In such cases. the analysis Practice
o f the altered protein product of a gene could lead to a diagnosis.
The protein of interest might be an enzyme whose activity can be
easily measured. This methodology is still prefe rred for identification Chromosomal trisomies, such as Ocwn syndrome (trisomy 21), Ed·
of a number of metabolic conditions, such as lysosomal storage wards syndrome (trisomy 18), and P atau syndrome (trisomy 13) are
disorders and glutaric aciduria type I. In other situations. the gene well-defined disorders caused by a chromosomal nondisjunction
.
product may not be an enzyme. but a change in the protein's weight that usually occurs In maternal meiotic divison
i .,..., Advanced ma
or an electrical change might be detected by elec trophoresis An i junction can
ternal age is a risk factor for such an event, but non ds
example of this is a protein assay used to identify defects in collagen affect any pregnancy. Various other structural chromos omal anoma
.
types 1 and 111. implicated in osteogenesis imp erte cta and a vascular lies can lead to an unbalanced karyotype (net g ain or loss of ge
form of Ehlers-Danlos syndrome, respectively• netic materi al) Children witl1 chromosomal anomalies usually have
Diagnostic laboratories use various methods to test different multiple dysm or phic features and some degree of cognitive deficit.
genes and gene products. Because of the rapid evolution of diag Some chromosomal abnormalities cause a consistent phenotype
nostic capabilities, selection of an optimal test for a patient might be that is e asily recognized. For example, velo-cardio-faciai/DiGeorge
a challenge. A useful Internet site where updated information may be syndrome . caused by deletion of chromosomal region 22q11.2 {see
obtained is GeneTests (http://www.genetests.org): the site is sup Fig 1-4), is characterized by a variable combination of birtl1 defects
ported by funding from tl1e National Institutes of Health and contains such as cleft lip and palate, congenital heart defects, craniofacial
a listing of genetic tests currently performed in most diagnostic and dysmorphism (Fig 1 -9). cervical spine anomalies, short stature, de·
research laboratori es in the United States and worldwide. velopmental delay. and psychi atric symptomatology at a later age. In
Clinical Genetics of Some Disorders Seen in Prosthodontic Practice J
Fig 1-9 (a and b) A patient with veto-cardio-tacial syndrome. Note

tacial cle!l, small palpebral fissures, wide nasal bridge, and !okled
over ear lobes.
addition, these patients may have medially displaced carotid arter commercially available in a few laboratores. In the more common
i
ies , which should be considered in surgeries involving the neck and Crouzon. Pfeiffer. Jackson-Weiss, and Apert syndromes, mutations
throat. They may be at risk for hypocalcemia in early life. Further are found in the gene coding for FGFR2. Less frequently, m utations
more, some of these patients have unrecognized submucosal cleft are observed in FGFR1 and FGFR3 in some cases of Crouzon and
palate, and the decision to perform adenoidectomy in these individu Pfeiffer syndromes. The mutations identified in FGFR2 are located
als should be made with caution. in exons 5 and 7 of the gene that encodes the immunoglobulin
Diagnosis of chromosomal diSorders is confirmed by chromosomal like chain Ill domain and the region linking immunoglobulin II and
analysis from peripheral leukocytes and. in case of microdeletions. by immuno globulin Ill ot the receptor, involved in receptor-ligand
a FISH test. In rare instances. the chromosomal anomaly can be seen binding. Mutations in the same gene (FGFR3) often result in
only in selected tissues (eg, fibroblasts). reflecting mosaic distribution different phenotypes, such as achondroplasia (mutation G380R),
of the abnormality. Patients with somatic mosaicism commonly have thanatophoric dysplasia, hypochondroplasia, nonsyndromic
an attenuated phenotype. Although this phenomenon is always coronal craniosynostosis. and Crouzon syndrome with acanthosis
postzygotic and the risk for a patient's sibli ngs is low, counseling for nigricans. Identical mutations therefore may be associated with
the recurrence risk in the patient's children is challenging. clinically distinct syndromes. Conversely, the same phenotype can
Because patients with chromosomal anomalies have complex result from mutati011s in different genes; one exam pl e is saethre
medical needs. the dental specialist might be involved in their Chotzen syndrome, which is caused by mutations in the gene
medical care as a part of the multidisciplinary team. It is important coding for FGFR2, FGFR3, and transcription !actor TWIST genes-"
to be aware that these patients may have a congenital heart defect Furthermore, the same gene defect can result in a highly variable
and need bacterial endocarditis prophylaxis.' They may have other phenotype even within the same family. Therefore, the clinically
undetected birth defects and may be at higher risk for perioperative distinct craniosynostotic syndromes are examples of the craniofacial
compl ications such as aspiration and poor wound healing. abnormalities spectrum and not distinct nosologiC entities.
Most craniosynostoses are caused by mutation s in one of Causative gene mutations are known for many other craniofacial
several genes that regulate growth and differentiation of the skeletal syndromes. such as Treacher Collins syndrome, with a gene TCOF1
system. The confusing clinical classification of different syndromes located on the long arm of chromosome 5.•2 The genetic etiology
that in clude craniosynostosis has been replaced in recent years of a number of craniofacial conditions (eg, Moebius syndrome,
by a molecular classification based on detection of specific gene hemifacial microsomia, or nevus sebaceous syndrome) is still
mutations.8 The disease genes id entified in craniosynostotic unknown. Most of these conditions probably result from single gene
syndromes are known either to regul ate transcription or to be mutations that remain to be discovered. The main strategy in current
required for signal transduction, and they play a central role in the management of these conditions includes careful clinical evaluation
development of the calvarial sutures.9·10 A mutation in the MSX2 and anticipatory guidance for early recognition an d prevention
gene was the first genetic detect identified in an autosomal dominant of complications known to be associated with these conditions
craniosynostosis type 2 (Boston type). DNA testing for common and genetic counseling based on empirical risks for recurrence in
mutations of fibroblast growth factor receptor (FGFR) genes is now family members.
7
1 i Basic Concepts of Genetics
Summary References
Improved understanding of genetic pathology and presymptomatic 1. MueiiGf' AF, Young 10. Emery's Elemoots o/ Medical Genetics, eel 9. London:
Churchill Uvingstone, 1995:45-66.
testing of individuals with nontreatabte conditions pose many ethi
2. Sack GH. Medical Genetics. New York: McGJaw-Hill. 1999:245-261.
cal issues and considerations." One can clearly see the benefits 3. Nussbaum AL. Mcinnes RR, Wolard HF. Thompson 8. Thompson Genetics m
of DNA testing for cancer-predisposing conditions, such as famil Medicine. ed 7. Philadelphia: Saunders. 2007.
ial adenomatous polyposis, where detection of gene carriers leads 4. Almoin DL. Connor JM, Pye<itt AE, Korl BR. Emety and A1moin's Pmc•ples
and Practice ol Medical Genetics, eelS. NewYol1<: Churchill Livingstone, 2007.
to life-saving procedures. In contrast, genetic testing for conditions
5. Klein AO, Oyl<as OJ. BaleAE. COnical testing for the nevoid basal cell carcinoma
with reduced penetrance, late onset, and lack of preventive mea syndrome In a DNA diagnostic labooltory. Genet Med 2005:7:611-619.
sures may b e outweighed by possible risks. A si milar dilemma exists 6. Byers PH. Disorders of COllagen biosyntheSis and stru ctu re. In: ScrivGf' CR.
Beaudet AL, Sly WS. et at (eds). The Metabolic and Molecular Bases of
tor predictive DNA testing in minors. Whether or not DNA testing is
lnl-.e�feO !llseas e. ed 8. New York: McGraw·H•II. 2001:5241-5285.
appropriate for an individual requires a long decision process and
7. BabOviC·Vuksanovic 0. Five things oculoplastiC surgeons Should knOw abOut
should involve a geneticist and genetic counselor, a social worker, medical genetics. Ophthal Plasl Recoostr Surg 2001;17:7-15.
and a psychiatrist or psychologist. Patient confidentiality, autonomy, 8. Dreyer SO. Zhou G. Lee B. The long and the short of It: DevelopmootaJ
genetics of the skeletal dysp!asias. Olin Genet 1998:54:464-473.
and insurability, and other factors such as possible employment dis·
9. MOUer U, Steinberger D. Kunze S. Molecular genetics of craniosynostotoc
crimination are of major importance in clinical genetics practice and syndromes. Graafes Arch Clin Exp Ophthalmo11997:235:545-550.
counseling. As clinicians, we need to remember the u
f ndamental 10. Bonaventure J. El Ghouzzi V. Molecular a nd cellUlar bases ot syndromlc cra
premise of OLir profession: Rrst do no harm. We should look forward niosynostoses. Expert Rev Mol Med 2003 Jat1 29;5(4):1-17.
11. Paznekas WA, Cunningham Ml. Howa rd TO. et al. Genetic het8fogeneity of
to scientific progress and ensure that medical and genetic discover
Saethre-Chotzen syndrome. due to TWIST and FGFA mutations. Am J Hum
ies are Incorporated into modern medicine in an ethical manner that Genet 19H8:62: t37()-t380.
serves the best interests of our patients. 12. Dixon MJ. Treache< Collis
n syndrome. Hum Molec Genet 1996:5 Spec
No:1391-1396.
13. He<nan<lez A. Evers SM. Functional Qei\Omics: CSnieal e«ect and the evolving
role of the surgeon. Arch Surg 1999;134:1209-1215.
Chapter
The Orthodontic
Prosthodontic Relationship
Brent E. Larson, oos. MS
rthodontc
i analysis and adjunctive orthodontic treatment
0
AP assessment
often can have a positive effect on the outcome of prosth·
odontic treatment. Cephalometric analysis. when used to The AP relationship of the maxilla and mandible can be evaluated
determine a patient's growth pattern or growth status, can help to best with a lateral cephalometric radiograph. If the lateral cep halo·
determine the best type of functional occlusal pattern or help t o iden· metric film is taken with the patient in natural head position, a vertical
tify when the patient has largely completed facial growth for timing line makes a simple reference (Fig 2·1 a). If there is doubt regard·
of implant placement. When clinicians understand how t o accurately ing the accuracy of the head position, a line perpendicular to the
assess growth patterns and apply appropriate procedures, the pre· Frankfort horizontal line makes a good approximation of vertical. The
prosthodontic use of orthodontics can lead to improved patient out· Frankfort horizontal line is detennined by a line that connects the
comes and simplify some otherwise complex restorative situations. upper border of the external auditory meatus (porion) to the lowest
point on the orbit of the eye (orbitale) (Fig 2·1b). The vertical line in
either instance should extend down from nasion, which generally is
the greatest bony concavity between the nose and forehead. The
Growth Pattern anterior extent of the maxilla {A-point) ideally should lie just in front
of the vertical reference line, and the most anterior point of the bony
chin (pogonion) should be about 4 mm behind this line.
Assessment If the maxilla deviates more than 2 mm from the vertical reference
line, or if the mandible is more than 3to 4 mm from the ideal position,
In the field of orthodontics, the growth pattern traditionally has been this indicates a skeletal pattern that may complicate restorative
detennined from lateral cephalometric films. Although complex treatment. The added complexity results from the oompensation
cephalometric analyses are numerous. a basic assessment may be in incisor position that is necessary to create a good functional
adequate to support restorative treatment planning. The restorative occlusion when there is an AP discrepancy of the maxilla and
clinician needs to know the general skeletal relationships in antero· mandible. For example, a retrusive mandible may require prcclined
posterior (AP), vertical, and transverse dimensions. If the simple mandibular incisors to compensate for its skeletal position. This
assessment methods listed below reveal a significant skeletal growth incisor position may be difficult to obtain with implant·supported
problem, it is advisable to consult with an orthodontist or other spe restorations because no bone is available in the desired implant site
cialist trained in more oomplex craniofacial assessment. t o support this tooth position.
9
2 i The Orthodontic-Prosthodontic Relationship
Fig 2-1 (a) lateral cephalometric film taken in natural

head pooi tlon. The horizontal 1qsual axis indicates that the
patient was looking in a mirror or at a distant horizon at
�·e leveL The vertical line descending from nasion acts
as a reference (see text). The anterior pan of the maxilla
(A·poln9 Ideally shOuld lie on ot just anterior to this line,
and the most anterior point of the chin (pogonion) should
be 2to 4 mrn behind this line. (b) Lateral cephalometric
film with the vertical reference line constructed as a
perpendicular to the Frankfort horizontal. This alternative
l'tlrtlcal reference fine is again dropped from nasion. and
the maxilla and mandible Should have the same relation·
Shi p to U1is line as descnbed in Fig 2·1a.
Fig 2-2 Vertical growth patterns. (a) In a normal veftlcalgrowth pattern, the mandibular plane extends just below the posterior cranium. (b) In a vertical excess growth pattern. the
mandiblllar plane extendS into the pooterior cranial vault. (c) In a vertical deficient grOW1h pattern, the mandibular plane extends well below the «ani al vault.
This simple skeletal AP assessment can be done with a straight the clinician visualize the midfacial plane. Ideally, the midlines of the
edge (eg, the edge of a piece of paper) oriented to the vertical ref maxillary and mandibular dentition should be aligned with the micl·
erence. It does not nequire complex instrumentation or extensive line of the face. and the chin should also coincide with this midfa·
knowledge to complete. cia! plane. If significant asymmetry is noted. a posterior-anterior (PA)
cephalogram can be taken to further visualize and quantify the de·
Vertical assessment v1ation. Transverse skeletal problems that affect the occlusion, such
as a narrow maxilla, often can be assessed from diagnostic casts.
A similar assessment can be made of vertical skeletal relation
ships using the mandibular plane angle as an indicator. The man Three-dimensional assessment methods
dibular plane (MPJ is simply a line tangent to the rower border of the
mandible. It can be estimated by placing a straightedge along the As helpful as conventional radiographic techniques can be in three·
lower border of the mandible. In a normal vertical pattern. as this dimensional (30) assessment of skeletal relationships, cone beam
line extends posteriorly it will pass just below the posterior cranium
, imaging may offer significant advantages, especially when planning
(Fig 2·2a). If this line intersect s or extends into the posterior cranium. complex interdisciplinary treatment that may involve implant place·
the patient has a more vertical growth pattern (Fig 2·2b). II the line is ment.' With cone beam imaging. one scan can yield an image vol·
far from touching the cranium and is almost parallel with a horizontal ume that can be used to produce a 30 rendering ot the complete fa·
reference, then the patient has a skeletal deep bite pattern (Fig 2·2c). cial skeleton and detailed information about the temporomandibular
joints and implant sites. These volumetric scans also can be used to
Transverse assessment construct virtual panoramic and cephalometric views without imag·
ing the patient repeatedly. Although better techniques to use these
The simplest assessment of transverse skeletal relationships is direct cone beam images for skeletal assessme nt are still being developed,
patient examination or review of a frontal photograph. Assessment the advantage of getting detailed information about many areas of
of asymmetry s the main goal of this frontal view. A piece of floss
i interest with a single scan makes this a valuable technique for pa
held down the middle of the patient's forehead and nose can help tients who need complex restorative treatment (Fig 2·3).
Growth Pattern j
� �
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1 1 1 \) \�
\ .'
1.:� \:'a ...

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.
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.
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\1 H
u �\)
Fig 2-3 Images from a single cone beam
scan include a 30 1oolume rendering (a), TMJ
sagitlal cuts (b), transverse cuts through a
possible implant plaoement area in the man
dible (c), a panoramic image (d), and a la!eml
cepllalometric image (e).
Impact of growth pattern on dental relationships Vertical discrepancies
i i A patient with skeletal vertical excess may have an anterior open

AP dscrepances
bite or elongated incisors with excessive gingival display. This vert.i
A Class II skeletal relationship can occur because of mandibular de cal excess pattern is often accompanied by some degree of man
ficiency, maxillary excess, or a combination of the two. A Class II re dibular retrusion because the mandible may be rotated downward
lationship i s found in approximately one in frve white people. Current and backward (see Fig 2-2b). A patient with vertical deficiency has
opinion is that the majority of Class II skeletal patterns are a result a tendency for an anterior deep bite malocclusion and is more likely
of mandibular deficiency. These patients tend to have a somewhat to demonstrate accelerated anterior tooth wear (see Fig 2-2c). The
narrowed maxillary arch form with maxillary incisors that are either
.
protrusive (division 1 relationsllip) or upright (division 2 rel ationship)
The mandibular incisors are typically proclined in a position that at
bite force exerted by patients with this skeletal pattern is typically
greater than normal, which may be a consideration in the selection
of restorative procedures or materials.
tempts to compensate for the increased overjet (Fig 2-4).
A Class Ill skeletal relationship is the result of a retrusive maxilla, Occlusal relationships
a prognathic mandible, or some combination of the two. This
relationship occurs more frequently in Asian populations. and it is Deviations in skeletal or occlusal relationships complicate the devel
only seen in about 1o/o of the white population. The transverse and opment of ideal occlusal characteristics. The dental compensation
incisal changes for Class Ill patients are opposite of those seen that occurs in cases of skeletal discrepancies makes it more dif·
i
in Class II patients: The maxillary posterior teeth tip facially. the ficult to obtain axial loading of posterior teeth. Vert cal discrepancies
maxillary incisors tip anteriorly, and the mandibular incisors remain can also affect the lateral occlusal guidance scheme. The occlusal
upright. The lateral cephalometric image in Fig 2-5 is an example guidance of individuals with long lower faces and vertical excess
of a Class Ill patient with a combination of maxillary deficiency and (Frankf011-mandibular plane angle is greater than 24 degrees) tends
mandibular excess. to be associated with group function, whereas the occlusal guidance
11
2 iThe Ort hodontic-Prosthodontic Relationship
( (( B
Fig 2-4 Lateral cephalometric film of a patiem with a Fig 2-5 Lateral ce1>halometnc film ol a Class 111 skeletal Fig 2-6 The envelope of discrepancy. The dM< tooth out
skeletal Class II relationsh ip and vertical excess. The c�in pattern. The chin is seV�Jral millimeters in front of the o rela tive
line represents tile Weal maxillary molar posilio
is more lhallt 0 mm behind lhe vertical reference line, and Vllr1ical reference line. The vertical proportions are near to the mandibular arclt The small black dot is the Weal
!he mandibular plane extends into the posterior crnnium. normal because the mandibular plane extends slightly mesiolingual cusp Up position. The various enlarging en
below the posleriQr cranium. velopes represent the magnitude of discrepancy that
can be correcte d by various treatment modalities: occlu·
sal adjustm ent (A): restora tive treatment {B); orthodon·
tic treatment in a nongrowing Individual (q; orthodontic
trea tment in a growing individual {0); and combined
orthodontic and orthognatllic surgical treatment (E).
of those with short lower faces and vertical deficiency (Frankfort

mandibular plane angle is less than 24 degrees) tends t o be as
Growth Status
sociated with canine guidance.� The importance of this relationship
becomes obvious if one attempts to create a pure canine guidance Assessment of growth status has tong been an important element i n
scheme in a patient with vertical excess. In many such cases, it is orthodontic treatment planning. In addition to helping identify wheth
nearly impossibl e to acl1ieve the canine guidance without violating er growth modification usin g functional app liances is a reasonable
reasonable esthetic guidelines for the length of canines. treatment option, this assessment can also determine when growth
has largely been co mple ted so that orthognathic surgery can be per
Alteration of occlusal relationships formed. Growth changes have been shown to make up a large part
of most orthodontic treatment changes in adolescents; therefore,
The degree to which occlusal rel ati onships must be altered to awareness of the growth status is essential to estimate the p rob able
achieve specific treatment goals determines whether these goals success of treatment. It has also been discovered that g rowt h does
can be met by nestorative care atone or whether adjunctive orth not actually stop after adolescence but continues to a certain extent
odontic or orthognathic surgical treatment will be needed. Proffit has th roug h out life. If this late growth is accompanied by vertical alveolar
described the concept or the "envelope of d iscrepancy." which he growth, implant-supported restorations can be left be hin d like an an
uses to determine whether a desired chan ge could be accomp lished kylosed tooth,• which explains why assessment of growth status is
by orthodontics alone, by orthodontics with growth modification in so important for proper timing of implant placement. Implants placed
a growing indivi dual or by orthodontics plus orthognathic surgery.3
, prior to the cessation of adol esce nt growth can become Similarly
This concept can be expanded to include prosthodontic treatment displaced from the occlusal plane and end up neither esthetic n or
as welt. Figure 2-6 shows the envelope of diScrepancy for a maxillary fun ctio nal .•
first molar in the AP and transverse dimensions. The treatment limits
shown may vary depending on the patient's periodontal health and
level of cooperation, the skill and experience of the practitioner, and Method of growth status determination
other individual factors. The goal is not so much to provide specific
millimetric g ui delines as it is to provide a reasonable thought pro cess Although age guidelines can be used to help with timing of implant
for the practitioner to consider the magni tud e of changes that are placement. individual variation from age norms can be significant.
required and to avoid embarking on a treatmen t plan that has little or Tracking standing-height changes to assess the completion of statu
no chance of success. rat growth is more specific to an indM du al but is stil l limited b y the
Adjunctive Orthodontic Procedures to Support Prosthodontic Treatment J
100%
Orthodontics
Outcome
0%
Case type
Fig 2-7 Two sequenta i l cephalometric tracings super Fig 2·8 Representation of the need for botll orthodontic and prosthodoutic treatment in many cases to reacll an
Imposed on the anterior cr anial base. In this patient. the ideal 0\Jl�'Oille. The dotled line represents aJl individual case requiring mosUy restorative therapy. but adjunctive
significantchange noted at thechin indicatestllatgrowthis ortllodontlcs allows optimal treatment to be obtained.
not yet COOJplete.
variable correlation between statural growth and jaw growth. To find Molar uprighting
ff vertical jaw growth is completed or slowed to an adult level, it is
recommended to measure the growth changes on a lateral cephalo The loss of a molar or premolar can result in the mesial tipping of the
gram. If two sequential lateral cephalograms taken at least 6 months tooth posterior t o the space. Uprighting the molar prior to tooth re
apart can be superimposed with no observable vertical change, then placement can allow more physiologic axial loading of the posterior
it is reasonable to proceed with implant placement with the expec teeth and create the space for a property sized tooth replacement.
tation that significant flrrther growth is unlikely. The vertiCal change Allhough often referred to a s simple or limited tooth movement,
can be assessed by tracing the cranial base structures, maxilla, and most molar uprighting is mechanically extrusive. If this extrusive
mandible on the two images and superimposing the tracings on the component is not property controlled, the tooth can become quite
cranial base structures, which should reveal any change in vertical mobile and uncomfortable as it is subjected to premature tooth con
growth at the chin. If significant growth is still occurring (Rg 2-7), an tact. Care also must be t aken t o use an adequate number of teeth
additional radiograph could be taken in 6 to 12 months and a new for anchorage in order to ensure that unwanted movement of other
superimposillon done. This procedure can be repeated until no sig teeth does not occur during the uprighting process. If tooth-only
nificant change is observed. anchorage i s used, it is typical t o include teeth through the canine in
the anchorage unit and to use a bonded canine-to-canine retainer to
maintain cross-arch control.
Adjunctive Orthodontic Root uprighting adjacent to implant site
Procedures to Support
One of the most common preprosthodontic ortl1odontic goals is
Prosthodontic Treatment t o move tooth roots away from implant sites to avoid root damage
during implant placement. Experience has shown that it is quite a
challenge to maintain ideal root position after adolescent orthodontic
Orthodontic and prosthodontic procedures can be quite comple treatment until the patient's growth status allows implant placement.
mentary when dealing with a patient in need of extensive restoration. Umited orthodontic readjustments are often necessary to create ad
Unlike the orthodontist, the restorative clinician is adept at altering equate space for the implant (Fig 2·g). The etiology of changes in
tooth size, shape. and color. Conversely, the orthodontist i s capable o
r ot position during the retention period is not well understood, but
of changing tooth position and adjusting the position of the gingi these changes happen frequently enough to suggest a reevaluai
t on
val margin, procedures the restorative dentist is less able to directly o f root position if more than 2 years have passed since orthodontic
address. Some complex cases can be treated successfully by the treatment was completed.
orthodontist Of' restorative dentist alone, but many require varying
contributions from each for success (Fig 2-8).
13
2 LThe Orthodontic-Prosthodontic Relationship
Fig 2·9 {a) Root posltions adjacent to the planned implant site during orthodontic treatment. (b) Position of the same roots at U1e oomp!etion of Ofthodontics. (c)The same roots
2 I& years later, when the patient was ready fOf implant placement Note the appment relapse of root position during the retention period.
Bolton anterior six

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Maxillary anterior six total (mm)
fig 2·1o The tirstpremolar in this patient was moved mesialo/ to oonsolidate U1e space i n Fig 2-11 Ideal relationship between the sums of the widths of the six maxillary anterior
the seoond J)lemolar posiUon.This movement allowed for maximum function and esthetics teeth and the six mandibtllar anterior teeth. A total mandibular anterior tooth width of
in the restorative phase,wtlich would have been diflicutt without tooth movement 38.5 mm (redline) would require a total maxillaly anterior tooth width of 49.7 mm.
Consolidation of space Creation of space for the replacement of

congenitally missing teeth
Missing teeth, whether congenital or resulting from caries or trauma,
often allow adjacent teeth t o drift and rotate so that simple tooth re·
placement is not possible. Basic orthodontic treatment can prepare The creation of additlonal space for optimal replacement of congeni·
the space for placement of restorations with esthetic tooth size and tally missing teeth can be a challenge. In the anterior area, � can be
optimal function. These tooth movements may be done with simple helpf ul to calculate the anticipated size of the restoration to provide
appliances or, if appropriate for the patient, lnvisalign aligners. In the a goal for any orthodontic procedures initiated to create the space.
restorative situation in Fig 2-10, where space remained mesial and This can be done with the Bolton Tooth Size Ratio. which is an ideal
distal to a maxillary first premolar, orthodontic movement ot the pre ratio of maxillary anterior tooth width to mandibular anterior tooth
molar into its proper position allowed placement of an ideally sized width.• The graph in Fig 2-11 shows this ratio, and the patient in Fig
pontic to maximize function and esthetics. 2·12 demonstrates how to use this ratio clinically. The ideal size of
the missing maxillary left lateral incisor and the diminutive maxillary
Adjunctive Orthodontic Procedures to Support Prosthodontic Tre atment j
Fig 2-12 (a)The total width of tl'le six mandibular anterior

teeth was 34.8 mm. Using the chart In Fig 2-11. the to
tal width ol the maxillary arch was then determined to be
45 mm. (OJTherefore, the missing lateral and peg·Shaped
laternf each Should be about 6.5 mm wide lor proper tootll
size balance with tile mandibular teetll. The results of
tills tooth size applicato
i n are seen in tile liniShed case
(see fig 2-16).
Fig 2-13 The resuHs of orthodontic leveling of the occlu·

sal plane to allow restoration of the missing mandibular
first molar. The reverse articulation of the lateral incisor (<!}
was corrected and interdigitation improved (b).
right lateral incisor is determined by measuring the total size of the structure is impossible. Orthodontic intrusion allows the interincisal
six mandibular anterior teeth. using this sum to determine the ideal space t o be reestablished so that the restoration can be completed.
sum of the six maxillary anterior teeth and then calculating what size This is a difficult and complex tooth movement t o complete and nor
maxillary lateral incisors are necessary. In this case, the ideal size is mally requires comprehensive orthodontic treatment with fixed ap
calCulated as 6.5 m m which is then created orthodontically. The
, pliances to achieve the desired results. Patients with severe attrition
definitive restoration shows the balance that proper tooth size can of the anterior teeth are not good candidates for lnvisaDgn treatment
create both esthetically and functionally. because the intrusive and extrusive tooth movements required are dif
ficult to achieve with this appliance.
Leveling of the occlusal plane
Temporary anchorage devices or other

When several teeth are missing and some posterior teeth are left
skeletal anchorage
unopposed, an irregular occlusal plane may develop. When this oc
curs, preprosthodontic correction of the occlusal plane can create a
much more desirable restorative situation. Leveling the occlusal plane Temporary anchorage devices (TAOs), also known as miniscrews or
orthodontically reduces the need to extract hypererupted teeth or microimplants. are a relatively new treatment option that allow pure
treat them endodontically so the crown can be reduced suffiCiently. skeletal anchorage to support tooth movement' TADs essentially
The patient in Frg 2-13 presented with a highly irregular occlusal plane are small, threaded screws placed in the patient s bone to seNe as
'
prior to treatment. Orthodontic leveling and space consolidation al anchors for tooth movement. TAOs often are placed interdentally
lowed easier restoration without loss of add�ional tooth structure. into fixed gingival tissue (Fig 2-14). Similar skeletal anchorage also
can be provided by small palatal implants or miniplates. One particu
lar advantage of skeletal anchorage for adjunctive tooth movement
is that it can mi ni mize the orthodontic appliances needed to support
Intrusion of worn anterior teeth to allow space
a particular tooth movement. For example, if a patient requires intru
for restoration sion o f a maxillary molar to allow implant placement in the posterior
portion of the mandible, a TAD placed between the maxillary first and
In patients with severe attrition of the anerior teeth, passive eruption
t second molars can intrude the molar and provide the vertical space
frequently occurs to the point that replacement of the missing tooth necessary for restoration (Rg 2-15).
15
2 LThe Orthodontic-Prosthodontic Relationship
Fig 2-15 A TAO placed be·

tween the llrst and second mo·
lar roots to support intrusion o l
the maxillary second molar. The
implant below could not be re·
Fig 2-14 TAOs placed bilaterally stored until the maxmary molar
dislal to the maxillary canines to wasintruded. A transpatatal arch
allow protract ion o f the poste· was used to prevent Ut e maxil·

rior Ieeth without retraction ol the 1ary molar fr om Upping facially as
maxillary incisors. it intruded.
Fig 2-16 Collaborative treatment ol a woman with a congenilally absent maxHJary Jell lateral incisor aJtd a diminutive maxillary right lateral Incisor. (a) Initial anterior photo.
(b) End ol orthodontic phase. (c) Retention of ortltodontic treatment until growth is complete lor Implant placement. (d and e) Definitive implant restoration and porcelain veneer.
(Q Postoperative smile.
TAOs can be placed easily and rapidly by the orthodontist. oral

surgeon, or periodontist. Often, only topical anesthesia is required
References
for placement, and usually no anesthesia is necessary for rem oval .
1. Peck JN, Conte GJ. RadiologiC techntques using CBCT and 3·0 treatment
The success r ateofTADs is higher in the maxilla than in the mandible planning for Implant placement. J Cafif Dent Assoc 2008;36:287-290,292-
and h igher in older individuals compared to younger patients, but 294,296-297.
overall about 75% to 85% of TAOs remain in place to complete the 2. DiPietro GJ. A study of OCC lusion as related to the Frankfort ·mand.bUiar plane
angle. J Prosthet Dent 1977:38:452-458.
tooth movement th at is desired.8
3. Proffit WR, FlfJids HW, Sarver OM. ContemporatY Ort110donti<:s, ed 4.
Sl Louis: M osby. 2007:690.
4. BemrudJP. SchatzJP. Chtistou P. Belser u, Kiliaridis s. Long·termll€01icalchanges
ol the af\terlor rnaxilaly teeth �1t to s!ngle implants i n yco.tng and rnatcre
Summary adults. A rel/05peclivest\Jdy. J Cln Pooodont012004;31:1024-t028.
5. Thilande< B. Oclman J, Lekholm U. Orthodontic aspects of ttle use of
oral omplants in adOlescents: A 1 0-yaar follow up study. Eur J 01'1h0d
-
Optimal prosthodontic treatment can be facilitated by awareness of 2001:23:715-731.

orthodontic analyses and adjunctive orthodontic techniques. Only 6. Bolton WA Disharmony in tooth size and its relatiOn to the analysis and
treatment of malocclusion. Angle Orthod 1g58;28:113-130.
th rough application of these principles can predictable and success
7. Leung MT. Lee TC. Rabie AB. Wong RW. Use of minlscrewsaocJ miniplates in
ful results be obtained in individuals with complex restorative needs. Ol'lhOdontics. J Oral MaJ<JIIofac Surg 2008;66:1461-1466.
Patients can benefit from proper orthodontic·prosthodontic collabo· 8. Chen YJ, Chang HH, Huang CY. Hung HC, La.i EH, Yao CC. A retrospective
ration that results in the desired outcome-a beautiful, functional analysiis of the failure rate of three dlffe.ent orthodontic skeletal anchorage
ss
y tems. CUn Oraltmplants Res 2007:18:768-775.
smile (Fig 2·16).
Chapter
History, Laboratory,
and Examination
William R. Laney, oMo, MS
Sreenivas Koka, oos. MS. PhD
The art of history taking lies in the ability to subtly direct the con
History versation witll the patient. As the patient inteNiew progresses and
information is accumulated, insight into the patient s problems is
'
The prosth odontist who expects to excel in hospital- or office-based gained, which helps the clinician to guide the inteNiew to the most
practice appreciates the necessity for a complete history of the pa pertinent and useful topics. If the pati ent's medical history is contrib
tient. The evotLrtion of prosthodontics in recent decades has resulted Lrtory, sensitive, or complex. it is essential that tile clinician document
in renewed respect for the art and science of consultation and his the details of the contributing factors of the history in the patient's
tory taking. The prosthodontist must be concerned with the patient's permanent dental record. Precisely obtained and well-recorded his
mental and physical state and must evaluate the patient's ability to tory data may prove useful to the dentist and the patient in the case
adapt to what is often a major pllysical and psychologic change. Ob of litigation or other situations where written evidence is required.
taining a patient's history and conducting a physical examination are Recording the history can be the first step in resolving a patient's
prerequisites to establishing a diagnosis, finalizing a treatment plan, problem. Careful interpretation of the patient's history laboratory
,
and implementing the treatment. These data accu mulating activities

- data. and physical findings is essential for successful treatment of
involve documenting the patient's symptoms and signs. Symptoms such problems as temporomandibular joint disorders (TMDs). dif
are subjective manifestations of a disorder or disease state related ficult restorative conditions. and atypical face pain. Furthermore. a
by the patient in the history-taking process. and signs are outward detailed record of family his tory and an understanding of genetic
manifestations of a disorder or disease state 111at are obseNed by influences on development of the craniofacial stru cture are i mportant
the clinician or patient and described In the patient record for future it a patient presents to the prosthodontist with a congenital defect.
review. The signs that become apparent during the physical exami An array of mechanisms currently is used to record the patient
nation process often can be quantified or qualified and may suggest history, but the move to electronic patient records portends a di mi n
the need to obtain adjunctive data through laboratory analyses, im ished role for paper forms. Regardless of the method used, the style
aging studies. or other forms of testing. of documentation must accommodate patient individuality, because
Current prosthodonlic practice has evolved to em phas iZe patient a universal system o f symbols and checkboxes is not satisfactory
mediated needs from a variety of vantage points. Prost11odontists to document a patient's subjective description of symptoms and
today are more aware of tile com plex behavioral differences among the events associated with them. However. the use of health inven
patients and the need to identify key attributes of patient personality, tory questionnaires may be indicated for some patients particularly
,
Additionally, the interplay between medical and dental practitioners those entering a practice for the first time. No mechanical or elec
continues to s trengthen as a mutual appreciation fosters commu tronic devices are usually necessary to interpret the questionnaire re
nication. The costs of prosthodontic care along with government sponses. Whether a questionnaire designed for the specific practice
or third-party reimbursement practices have also enhanced some or a standard instrument SliCh as the Cornell Medical Index (CMI} is
forms of dental practice while li miting others. The net result is that used, analysis of a patient's responses, combined with a more de
the "best" treatment plan for a specific patient depends on many tailed history and examination, usually identifies at least 95% of the
factors, some of which are beyond the control of the prost hodontis t. diagnostic areas o r systems in which disease might be found. Other
17
3 i History, Laboratory, and Examination
commonly used questionnaires include that designed by Bolender the head, across the midline to the left shoulder. and down to the left
et al and the Minnesota Multiphasic Personality Inventory (MMPI), fingertips or the limbs of the left side is not of organic origin.
which can provide adjunctive information concerning the patient's
emotional status.1·2 Characteristics of pain
The patient should understand why the questionnaire is used and
why responses are evaluated as they are. The interview is to be con This category probably represents the most significant area of history
ducted privately, and questions related to previous illnesses, surger taking. Neuralgias, neuropathies. odontalgias. pain associated with
ies, hospitalizations, family problems. or personal habits should be other neurologic diseases. and psychogenic problems are all entities
limited. The interview process. particularty in a prosthodontic prac with particular pain patterns that are vital to understanding the prob
tice, is an essential time for the patient to establish a healthy attitude lem, and they must be recorded. Each descriptive entity (see chapter
toward the clinician who may be preparing t o undertake a major 7) usually fits a highly subjective set of circumstances that should be
rehabilitation or restoration of a gross disfigurement or malfunction. skillfully extracted from the patient's memory and analyzed in detail.
Once the history is taken. the final review can be compared to Remissions. if any, are particularly useful in distinguishing between
analysis of a narrative that permits logical reflection on the recorded organic and nonorganic pain. Whereas patients who describe a reac
facts. The facts of lhis narrative should be arranged in a seql•ence tion to a psychogenic disorder usually report that they are never with
that allows this analysis to lead to tentative diagnoses: (1) initial on out distress or discomfo1t, patients with organic disease usually de
set of complaint; (2) anatomical location of the problem; (3) charac scribe occasional remission from their pain. For example, one of the
teristics of pain: (4) factors that aggravate or relieve the problem: and most characteristic entities associated with trigeminal neuralgia is the
(5) previous consultations, diagnoses. and treatments. occurrence of several remissions, occasionally lasting many years.
Factors that aggravate or relieve pain

Guidelines for logical sequence of history
The goal at this point in the history taking is to determine whether cer·
Initial onset tain factors increase or decrease the degree of distress. For example,
fatigue and tension usually increase pain from organic disease. The
The first known occurrence of the patient's complaint should be the rational patient recognizes and describes situations that modulate the
first recorded tact. In an attempt to emphasize the significance or degree of distress. In contrast, patients with psychogeniC problems
this event, pain of recent origin following a known surgical or re often deny that either tension or stress is a factor and may feel that
storative procedure often suggests organic distress such as postin the examining clinician is accusing them of being tense or neurotic.
fection. posttraumatic, or postoperative neuropathy or neuritis. It is Mandibular excursions, talking, and swallowing also are important
helpful to recognize that postsurgical pain often produces distress contributors to the amount of pain the patient may experience.
for many years. If a patient is seen early in the course or the distress If compounds as mild as nonsteroidal anti-inflammatory drugs
and if a diagnosis of nerve injury is established. the patient will likely (NSAIDs) give relief, then the examining clinician may believe that an
obtain relief much sooner. inflammatory condition exists, such as those associated with many
If the initial onset is unknown to the patient. but the pain is de musculoskeletal disorders or TMJ arthralgias. It is important to rec
scribed as brief. sharp, and lancinating. the practitioner should begin ognize that the agents that give relief often suggest a general idea
to suspect pulpal neuri t is or neuralgia, even at this earty stage in of the nature of the patient's illness. Should these agents provide
the history-taking procedure. If the initial onset is accompanied by significant relief, usage should be continued.
a constant, burning dry mouth sensation, the historymay indicate
a previous traumatic emotional experience. which is often linked Previous consultations, diagnoses, and treatments
with burning mouth syndrome; however. it also may indicate a post
menopausal state. discomfort secondary to medications prescribed The history should include the various types of medical an d dental
for other medical disorders. or some other organic problem. practitioners that the patient may have consulted. It is advisable to
itemize the active treatments that the patient has undergone, includ·
Anatomical location of pain ing the types of prostheses. splints, medications, and so forth. This
part of the history is particularly significant should a similar course of
The site or course of pain must be described and carefully recorded. treatment again be considered. It is important to know what degree
It is essential to recognize that organic pain usually follows its ana of success the patient has experienced previously. Utile is gained
tomical pathway (ie, pain originating in the third division of the right by repeating a procedure tl1at has failed previously, unless misman
fifth cranial nerve does not radiate to the third division of the left agement (eg. improper dosage or type of medication or inadequate
nerve). On the other hand, pain that originates in the right temporo design of a prosthesis) is known to have been a factor.
mandibular joi nt (TMJ) and then radiates t o the top of the right side of
Laboratory Data J
Table 3-1 [(Complete blood count procedures and ranges

Procedure Male Femal e
Whi te bloo d c
ell s 4.8-10.8 4.8- 1 0.8
(II'\Ousands/IJL)
Red blood cells 4.2-5.4 4.2-5.4
(millions/J.ll)
Hemoglobin (gldl) 14.<H8.0 12.CH6.0

Hematocrit (%) 42.()-52.0 37.()-47.0
Platelets (lhOusends/J.JL) 14()-440 140-440
The attitude of the examining clinician has much to do with the information about three types of blood cells: (7) white blood cells
future well-being of the patient. A curt pronouncement that "there (WBCs). (2) red blood cells (RBCs). and (3) platelets. These blood
is nothing wrong with you" can be distressing and damaging to the cells are made in the bone marrow. the spongy tissue filling the cen
patient. However, this information can be presented to the patient ter of bones. Bone marrow in the skull, sternum (breast bone), ribs,
in a reassuring manner if it i s explained that careful examination has vertebral column {backbone), and pelvis produces these blood cells.
not revealed any evidence of serious disease. The clinician's recogni A CBC includes five measures: (1) WBC concentration (thousands
tion of the patient's difficulties and an assurance that assistance will per microliter I�L] of blood), (2) ABC concentration (millions per �L of
continue to be provided gives great comfort. Clinicians, in turn, are blood), {3) hemoglobin (grams per deciliter [dl] of blood), {4) hema
allowed the privilege of periodic reexamination of the patient, with tocrit (percentage of RBCs in relation to total blood volume), and (5)
the result that a previously undetected circumstance subsequently platelet count (thousands per IJL of blood). The normal ranges (with
may be recognized and treated property. sex differences, if any) are presented in Table 3-1 .
Beyond these fiVe measures, further sophisticated analysis of WBC
types results in a WBC differential, which deduces the percentage
of each of the five types of WBCs included in the total WBC count.
Laboratory Data Convention also requires calculation of an absolute number of each
cell type found in 1 IJL, which represents a percentage of the normal
It is always necessary to record pertinent laboratory reports or oth total WBC range of 4,800 to 10,800 cells/IJL. Neutrophils, basophils,
er aids such as diagnostic casts. histologic specimens, diagnostic and eosinophils are collectively referred to as granulocytes because
images including interpretation (if available), and all other medical of granules in their cytoplasm, and lymphocytes and monocytes are
reports !hat the patient may have. If additional information from re collectively referred to as agranulocytes. Normal ranges for these cell
ferring dentists or physicians is available through correspondence, it types can be found in Table 3-2.
becomes an integral part of the patient's history. Patients witl1 an immune system disorder or a suppressed immune
Although the prosthodontist may not routinely order laboratory system as a result of chemotherapy have signii
f cantly lowered WBC
tests, it is important that the clinician have a working knowledge counts, rendering them prone to infection and sepsis. In this situa
of laboratory data. This information assists in disease differentiation tion, the oncologist may delay the next phase of chemotherapy until
and determination of definitive diagnoses and provides parameters the patient's WBC is sufficiently recovered. Rather t11an use the WBC
tor treatment planning and management. The provision o f laboratory count to assess U1e patient's status, the oncologist will use the abso
data has become a highly sophisticated and automated process. lute neutrophil count (ANC) a s a measure of infection-fighting WBCs.
Many basic tests. such as complete blood counts with differential (Neutrophlls make up the large majority of the granulocyte popula
and metabolic tests, have established normal reference ranges to tion, so some clinicians use the term absolute granulocyte count
assist the clinician in identifiCation of outlying data points. [AGC).) To calculate the ANC, the clinician must know the number
o f WBCs and the percentage of mature neutrophils, referred to as
polys, and immature neutrophils, referred to as bands. Then, the
Complete blood count with differential number of WBCs is multiplied b y the percentage of polys and bands.
For example, if the number of WBCs is 400, the percentage of
A complete blood count (CBC)-also known as a full blood count. polys is 10% (0.10), and the percentage of bands is 5% (0.05), the
full blood exam, or blood panel-is derived from a serum sample ANC is calculated as follows:
typically collected in a tube treated with ethylenediaminetetraacetic
acid to prevent clot1ing. The objective of this examination is to gather 400 X (0.10 + 0.05):400 X 0.15:60
19
Absolute value
Cell type Normal range {% } in cells/IJL
Nevtroph\ls 4 5-75 2.200-8 . 1 00
Basophils 0-2 0-200
EOSinoptlls 0-5 0-500
Lymphocytes 20-45 960-4.860
Monocytes 1-10 100-1. 000
The normal neutrophil range is 2,500 to 7,000. When the neu International normalized ratio
trophil count falls to below 1 ,000, the risk of infection is moderately
increased; when it falls below 500, the risk of infection is seriously in The international normalized ratio (INR) was developed to improve
creased. This condition is referred to as neutropena
i . Although some standardized assessment of clotting capability because the amount
variability is present, a general guideline for halting chemotherapy is of tissue factor added during PT testing can vary significantly as a
an ANC o f less than 1,500. result of manufacturer or batch differences. Each manufacturer pro
vicles an International Sensitivity Index (lSI} for any tissue factor it
produces. The INR is then c alcu lated as the ratio of the patient's PT
Hemostasis and coagulation studies to a normal (control) sample raised t o the power of the lSI value for
the control sample used:
The aging population that constitutes a significant portion of a
prosthodontic practice may have medical conditions (eg, thrombo· I NR = (PT test .;- PT nomnaij181
embolism, stroke, or atrial fibrillation} that require anticoagulant ther
apy with a vitamin K antagonist such as warlarin (Coumadin !Bristol· For patients needing anticoagulant therapy, an INR of 2.0 to 3.0 i s
Myers SquibbD. Other medical conditions that affect clotting include considered des irable, although if an artificial heart valve is present,
liver disease, uremia, some cancers, bone marrow disorders, and an INR of 2.5 to 3.5 is recommended.3 Most patients on anticoagu
vitamin K deficiency. One outcome of anticoagulant therapy may be lant therapy undergo routine testing, olten weekly, to detemnine their
a higher risk of unwanted hemorrhage after dental surgical proce INR and many are well aware of their test results. For those who are
dures such as extractions or implant placement. Certain standard unaware, their physician should be contacted before dental surgery
measures of coagulation potential are used by physicians and den is begun. In general, Wahl recommends that dental surgery not be
tists to ascetiain whether dental surgery is contraindicated for an performed if the most recent INR is above 4.0.� In circumstances
individual patient. requiring the modification of anticoagulant therapy, warfarin, which
has a half-lite of about 36 hours, should be discontinued for at least
Prothrombin time 2 days for an effect to be observed. It may be necessary to repeal

INR testing at this time to ensure that the INR has dropped (indica\
The prothrombin time (Pl) test measures the time it takes tor blood ing a shorter clotting lime).
plasma to Clot and is a measure of lhe extrinsic pathway of clotting.
Therefore, PT measures the activity of factors II, V, VII, X, and fibrino
gen. After plasma has been separated from blood, tissue factor (also Comprehensive metabolic panel
known as factor Ill or thromboplastin), typically derived from an ani·
mal source. is added and the time for clotting measured. Although A comprehensive metabolic panel (CMP) consists of 14 specific
there is laboratory-to-laboratory variability, a normal PT is considered tests that are often ordered as a group. These provide an overview of
t o be 12 to 15 seconds. kidney functton, electrolyte and acid-base balance. and blood sugar,
calcium, and blood protein levels. Significant abnormalities in the val·
ues for any of these tests may indicate that a fundamental metabolic
concern needs to be addressed. The CMP provides a screening tool
to assess organ functiOn and other conditions such as diabetes, liver
disease, and kidney disease. The normal ranges for each measure
are presented in Table 3·3.
J
Laboratory Data
Table 3-3 I: Normal ranges for laboratory values

Ana lyle Age/sex Reference range
Albumin (9/dl) 3.5- 4 .8
Alkalne
i phosphatase 0..1 y 5()-38()
(ALP) (lUll) 1-5y 85-320
5-10y 110-350
1()-16 y 85-3a0
16-18y 65-225
>18y 25-100
Alanine arninotransferase (All) (lUll) Male 1()-45
Female 7-35
Aspartate aminotranslerose Male 12-38
(A$1) (IU/� Female 8-34
i irubin, total (mgid L)

Bl 0..1 d < 6.0
1-2d "8.0
2-5d < 12.0
5 d-1 100 < 10.0
> 1 100 0.2-1.3

Calcu
i m (cal (mgidL) 0..10d 7.6-10.4
10d-24 100 9.0..11.0

24 mo-12 y 8.8-10.8
> 12y 8.4-10.2
Carbondioxide (CO,) (mmolll) 22-32
Chloride (C� (mmot/L) 98-107
Creatinine (mgid� Male 0.7-1.3
Female 0.15-1.1
Glucose (mgi<IL) 0-1 mo 45-90

>1 mo 65-110
Potassium (K) (mmOVL) 0..12 mo 3.5-6.0
> 12 mo 3.5-5.0
Protein. total (g/dL) 6.o-8.0
SOdu
i m (Na) (miOOIIL) 135-14 4
Urea ntrogen
i (UN) (mgldL) Q-7d 3-12
>7d 8-20
21
3 History, Laboratory, and Examination
spected for ulceratrons, crusts. fissures, or other surface changes.

No physical examtnati on IS complete without digrtal palpatron. Lat
eral surfaces of Ihe face and temporal areas are palpated as the pa
tient opens and closes the mouth to ascertain the extent of lemporal.
pterygoid, and masseteric function. Asking lhe patient to purse the
lips gives an indication of the perioral muscular vigor and integr ity. To
assess the smoothness and range of motion of the TMJs, the clini
cian should place t he Index fingers bilaterally over the preauricular
areas as the palient opens from a closed position and moves the
mandible anteropostenorly and laterally. Tenderness, onep1tus, and
deviation are noted. The condyles can be further examined by plac
ing the fiOQBf wi thin the external auditory meatus and palpat.ng the
Cervical lymph nodes anterior wan below the tragus. This examination often can suggest
potential problems 1n record•ng rnaxillomandibular relations.
Thyroid gland examined
lnspecllng the neck and cerv�cal lymp h nodes is an Important part
of the extraoral examination of the head and neck and logically fol
lows digital palpation {Rg 3- 1). A suggested routine includes pal
Fig 3·1 Left, Bimanual palpalioo of the neck should include examination of the cervical
lymph nodes. Right, Clinician should palpale along the larynx tor Immobility and enlarge pation for enlarged nodes In the jugular chain and in the parotid.
men! Examination of the U1yroid glancl includes palpatioll olllle lobe, which Is facilitated submandibular, and submaxillary groups.
by !laving the patient swallow to e!evale the gland.
Salivary glands
The lateral structures of the face and the penrnand!bular area are
best examined wrth bimanual manipulation {Fig 3-2). Nodular or
Physical Examination indurated surfaces 1n the V1Cin1ty of the mandtbufar angle are sug
gestive of parotid leSions. Lesions deep in the cheek are difficult to
The face and mouth are relatively s.mple to examtne because their detect: therefore, careful palpation of the buccal mucosa and skin.
component structure s are readily accessible to visual inspect ion , by means of a forefinger placed intraorally and the opposite hand
digital palpation, percuss1on, and radiographic record1ng. Any ap placed extraorally, should be a routine procedure. Obviously, the
proach to the actual examination should be systematic and routine purpose of the examination is to distinguish the normal from the
for each examining cli n ician. Printed forms may be helpful to record abnormal. The parotid duct {Stensen's duel) i s usually clearly iden
findings because they provide an ouUine that minimizes oversight tifiable in trao r a lly, and manipulation of the gland should elicit a flow
and encourages thoroughness. of watery ftuid. Diagnostically, it is advantageous to locate nodes or
The common tendency when conducting an i ni tia l examination is swelling relative to the musculature of the area. Circumscrrbed Ia·
to proceed with the intraoral phase without givi ng much consider sions are readily movable whereas inflamed tissues or structures ag
ation to the body as a whole. In preliminary deliberato
i ns, an astute gressively 1nvolved by neoplastiC disease are relatively fixed. The pa
observer notes the patiSnt's relative body proportiOnS. weight. pos tient may provide subjecllve Information by reacting to patnful st1mu�
ture, gait, degree of functional coordination, and any obvious abner· or by failing to respond to palpation ol the tissue. Pain 1s usuaJy an
malit1es or deform1Ues. A closer look at the head and neck should early indiCation of Inflammation. but 1t is also associated with tater
reveal signifiCant aspects of facial compositiOn. asyrTllmelries, sk1n stages of malgnant diSease.
texture, complexion, expression in the eyes, breathing, functional The submandibular gland is readily identified by intraoral and ex
habits of teeth clenching . twti ching, and other neuromuscular invol· traoral palpation. It can be examined by gently rolling the glandular
un tary manipulations. substance belween the fingers, and its patency can be noted by the
salivary flow. Irregular or firm structures within the duct or possible at·
a
t ched lymph nodes should be examined. Inflammation, purulence, a
Extraoral examination hard mass within the duct, and pa in suggest the presence of a salivary
stone (calcification) and the need for further eval uat i on by Imaging.
Regardless of the examination seque nce . the perioral structures A quantitative and qualitative evaluation of the saliva is very Im
should be assessed first. A general evaluation is made of the fa· portant t o prognos1s, partiCularly for the patient with complete den·
ciaJ contours and support provided by the denlillon. Characteristcs
i tures. Salivary flow from the parotid duct is primarily serous, the flow
such as abnormal swellings. deformities, tes.ons. discolorahons. and from the sublingual and submandibular glands is mixed ITlUCillOUS·
general bony contours are noted. The tips, ears. and nose are in- serous, and the products o f the palatine glands are purely mUCinous.
Physical Examination j
Fig 3-2 (a) lntra01a1 and exuooral palpation of the salivary glands torpatMiogic change.
The tollSillar area should also be inspected visually. (b) SubmaxiUary gland examinalioo
with bimanual digital palpatioo. (Courtesy of Dr Dan E. Tolnl<!n, Rochester, MN.)
A copious amount of serous saliva adversely affects the retention of cus or on the inferior surface of the mandible. Bimanual palpation of
a complete denture by disrupting the border seal. Studies and clini the floor of the mouth and inferior mandibular surface is performed
cal evidence suggest that the more viscous secretion of the palatine to assess contours, determine displaceability, and ascertain soft tis
glands plays a positive role in the retention of a denture:' Although sue attachments.
assessment of the character of saliva i s an important factor in esti Further examination of the tongue is facilitated by asking the
mating denture retention, the role of saliva in oral hygiene and the patient to protrude the tongue and move it from side to side in a
protection of mucosal surfaces beneath a prosthesis should not be sweeping motion. Umitation, deviation, or asymmetry of motion may
overlooked. indicate neurologic deficit. disease. or the effects of medications.
The chemistry and sufficient buffering capacity of saliva are also The base of the tongue is palpated by passing a finger posterior·
vital to protect the natural dentition from caries lesions. Either a ly over the dorsal surface to detect abnomnal masses, induration.
change in the chemistry of saliva that diminishes the buffering ca or roughness. The tonsillar pharyngeal and nasopharyngeal areas
-
p acity or a diminution in salivary volume will increase the risk for car also should be observed with a m outh or laryngeal mirror (Fig 3-4).
ies (see chapter 4 for further discussion of hyposalivation). Tongue blade inspection provides the opportunity for a superficial
view of readily apparent structures, but it cannot provide visualization
of structures out of the direct vision of the clinician.
Intraoral examination The examination then moves t o the mouth and lips. With the man
dible at r est a superficial evaluation of the vertical dimension of rest
.
The oral cavity is further examined by ins pecting the tongue and the is begun. Facial measurements can be made repeatedly with the
floor of the mouth. Removal of Ill-fitting removable prostheses may mandble at rest and the teeth in maximal intercuspation to provide
i
be necessary to facilitate the next phase of the examination. The an estimate of interocclusal rest distance and a prelim inary idea as to
patient is asked to place the tip of the tongue against the hard palate whether the vertical dimension of occlusion (VDO) is physiologically
to expose the ventral surface of the tongue anteriorly and the floor appropriate. Phonetic tests also may be helpful to determine the
of the mouth (Fig 3·3). Of particular interest is the distance between appropriateness of the VDO. An appraisal of the esthetic appear
the floor o f the moulh and the inferior surface of the tongue in thiS ance of the natural or artificial dentition follows. Size. shape. color.
extreme position, in addition to any abnormalities in the lingual sui- and arrangement of teeth relative to the lips and the entire face are
23
3 i History, Laboratory , and Examination
Fig 3-3 (a) Floor of the mouth, anterior lingual sulcus depth, mucosal appearance, salivary gland orifices, and frenum attacllmenl are observed wiHt the tongue
blade. (b) Palpation ollhe floor or the mouth includes salivary glands and base of the tongue. These sllould be inspec ted for asymmetry, i ndurat on or granularity.
i ,
Fig 3·4 Let� Mirror examination of lhe tonsillar-pha�;ngeal area.

Contact between the mirror and Ute soft palate should be avoided
while tile mirror Is pressed on the tongue to force rellex contraction
of the uvula and contraction or U1e OlopharyngeaJ muscles. These
contractions facilitate Inspection or tile sort palate and posterior
and lateral p11aryngeal walls. Phonation of "ah" aids in obse!Va·
tion of palatal function and palatopharyngeal con1petence. Right.
With longue protMed. a mirror is introduced in an inverte<J position
to viSualize tonsillar pillars. epiglottis . vallecula. and larynx. A topical
anesthetic may be required to prevent gagging; the mirror should
be warmed to prevent IO!)ging.
important and frequently known collectively as the esthetic compo· the patient may have about their quality and the patient s attitude '
sition. The size of the oral aperture affects the dtsplay of denti1ion toward previous prosthodontic services. General factors that are Im
and is considered in treatment planning and physical management. portant to review at this time include retention . s tabilit y vertical and ,
Particularly im p ortant is the size of the mouth opening relative to the horizontal aspects of occlusion. base extension. border width. and
arch size and area to be covered by a removable denture. placement, In addition to the physical qualities and condition of the
Next, the clinician observes the entire dentition. The general state denture prostheses. A more detailed examination probably is best
of the patient's oral hygiene and the quality and quantity of dental deferred until additional records are available.
restorat ions provides insight into the concern the patient has for his Tissue morphology and response to exis t ing prost11eses are seen
or her oral health. Functional habits should be apparent from observ· after removal of the prostheses. II a peculiar prosthetic design, soft
ing wear facets. attritional recontouring. and areas of erosion. tissue or bony configuration. bizarre dentitiOn or tooth alignment,
Removable prostheses may have been the precipitating factor for morphology lesions or recent operation seems to complicate re·
, .
the examination, so concern (but not excessive attention) is focused moval, it is p rudent to ask the patient to perform this task. An unnec
o n the prostheses the mselves. Preoccupation with the mechanics essary injury t o the patient at this sitting may have an adverse effect
of restorations at this time can reinforce both preconceived notions on his or her openness to future treatment options.
Fig 3·5 (a) Advanced attrllion is seen In this pa·

li en l, whose vertical stops (b) arise mainly in the
anlenOf Ieeth.
The natural dentition Dentition in function

The horizontal relationship of the mandible to the maxil la and all
Examination of the remaining natural teeth initiates the assessment functional occlusal contacts should be visualized. It is Important to
of any or all oral structures that could contribute to the support of a distinguish between mandibula r closure of the transverse horizon·
prosthetic restoration. An established routine prompts the dentist to tal axis. whi ch leads to centric relation. and habitual closure. which
observe and collate the following characteristics of the teeth: implies maximum interdigitation of the natural teeth (centric oc·
elusion). In general, diagnostic mounting should be made using a
• Number • Crown-root ratio centric relation recording, although it is acknowledged that there is
• Color • Caries incidence significant variability in how cent ric relation is defined, determined,
• Accretions • Morphology and recorded. Clinical experience increases one's proficiency in the
• Al ignmen t • Fracture functional analysis of mandibular movements. After reviewing their
• Location in the arch • Erosion own experiences and the studies reported in tl1e literature. Zarb et al
• Individual position • Attri tion suggested that the influence of tooth loss on the functional chewing
• Mobility • Interproxim al contact cycle persists only if the neuromuscular basis is altered beyond the
• Migration • Restorative potenti al adaptive capacity?-� They further noted that the range of an indi·
vidual's adaptive capacity is considerable both in pathophysiologic
The vitality of each tooth should be tested. Special consideration extent and in the duration of change. An assessment of mandibular
must be given to those teeth that have served as abutments for fixed function is aided by obseNation of natural wear patterns on the oc·
or removable prostheses. clusal and incisal surfaces of the natural or artificial teeth. A simple
Characteristics, locations and the extent of caries lesions are not·
, classification that may be hel p ful at !his stage of the examination
ed. The clinician should be able to distinguish typical dental caries categorizes mandibular movements as cyclic, vertical, o r bruxing.
from the lesions commonly associated with irradiati on of the oral and Evidence of cyclic pattems of wear includes smooth surfaces
perioral structures. The quality and quantity of dental restorations on marginal ridges, inclined planes. flattened triangular ridges, and
should be evaluated and recorded. widened fossae with moderate to minimal cuspal wear. More tooth
Assessment of the periodontium involves inspection oi the mor· surfaces appear to be in contact during protrusive and lateral excur·
ti s and physiologic response of the gingival
phologic characterisc sions than perhaps might have been at an earlier age or examina·
tissues. Factors such as texture, form, color, depth o f the gingival lion. Except for vertical mastication, a general reduction in incisal
sulcus or periodontal pocket (probing depths), presence of exudate. guidance and cuspaf inclination can be noted with increasing age.
and susceptibility to hemorrhage are noted. Clinical findings should Vertical mastication results in alterations to the teeth that are char·
be necorded on paper or electronic media and should become part acteristic of shearing action: relatively steep, sharp cusps; exces·
of the patient's permanent dental record. sive wear on the buccal or labial cuspal inclines and surfaces of the
After the teeth have been examined individually, a critical evalua· mandibular teeth; and excessive wear on the lingual inclines of the
tion must be made of both the stat ic dentition as a unit within each maxillary teeth. A relati vel y steep incisal guidance, provided by an
arch and the functional i nterocclu sal relationships. The location of exaggerated vertical overlap of lhe anterior teeth wilhout horizontal
edentulous spaces throughout the arches is significant. Whereas the i n, usually characterizes the dentition of the patient with
compensato
clinical appraisal of occlusal re!ations!1ips is fundamental to any oral a predominantly vertical masticatory stroke. Mamelons may remain
examination, additional findings may become evident from an evalu· on nonfunctional incisors. Migration or flaring of the anterior teeth
ation of diagnostic casts mounted on an articulator because they and possibly the premolars also may be observed. Advanced attri·
allow more adequate viewing of the arches and occlusion from the lion from a strong vertical stroke is seen in Fig 3·5.
lingual/palatal aspect.
25
3 iHistory, Laboratory, and Examination
and t heir ability to respond to prosthetic stress (see chapter 4). If

teeth were removed in an uncomplicated surgical procedure as a
consequence of dental caries. the bone probably has been spared,
and the initial denture base support can be expected to be optimal.
For patients who have previously worn removable dentures, the
potential support for complete dentures can be evaluated by obser
vation of the tissues' respons e to the stress imposed b y the remov·
able prostheses. Dia gnostic casts and radiog rap hs may provide in
dices of the response to previous prosthetic stress and t herefore are
i nvaluabl e in determining the appropriateness of a complete denture.
Fig 3-6 Advanced occlusal wear approximating a reverse curve. The clinician must rely more heavily on tile result s of the physical ex
am in a tion and on h is or her clinical judgment it (1) th e patient's his to·
ry is unavailable, meager. or unreliable; (2) preextraction records are
missing; or (3) t he patient has not had experience with a prosthesis.
The documented success o f endosseous implant-supported
The teeth of the pati ent who habituall y bruxes or whose masticatory prost heses has permitted clinicians to offer patients this alternative.
pattern is a wide, flat arc appear flattened on the occlusal or incisal Implant -supported prostheses overcome compromises in alveol ar
surfaces (Fig 3·6). There may be e vidence of an anti-Monson or re· support by providing rigid bone-implant anchorage to either add sta·
verse curve within the arch. The occlusal table generally appears wid bility to a removable prosthesis or support a fixed dental prosthesis
ened and the incisal edges beveled. Dentinal exposure is common, (see chapter 8).
and in extreme cases. the crown may be worn to the g in g ival line .
All mandibular movement patterns cannot be eas ily categorized. Arch size and oral aperture
The relationship of muscles, joi nts. teeth, and ligaments in their neu If a significant discrepancy exists between the size of the opening
romuscular interplay vary somewhat according to the existin g Angle into the oral cav ity and the maxillary or mandibular arch size and
classification. The function of teeth as groups to provide protection shape, fabrication of the prosthesis and its use b y the patient ar e
or bet ter distribution of occlusal stresses has received considerable complicated. Impression proced ures , records of maxillomandibu
attention. Beyron categorized mandibular movement patterns as lar relationships, and arrangement of t eeth are particular1y difficult
(7) multid i rectional gliding movements, (2) predomi nantly bilateral if the opening of the m outh is restricted in relation t o the size of the
movements, (3) predom inantly sagittal movements, and (4) predomi denture foundation to be covered. Such conditions are frequen tly
nantly unilateral movemen ts.' The interested reader is encouraged to encountered in p atients who have been treated surgically tor the
review Beyron's work in more detail. removal of malignant lesions, burns, traumatic injury, or congenital
t on of the soft tissues comprising the
Visual and dig ital examinai mallormation. Dermatologc manifestations of systemic disease,
i
lips. tongue, floor of the mouth. labial and b uccal surfaces, alveo such as those seen in scleroderma, also pose limitations to ph ys ical
lar rd
i g e, mucosal surtace, gingivae, palate, and oropharynx should management. Scarring not on l y reduces the size of the open ing but
proceed in orderly sequence. Configuration. texture. color, position, also renders the tissues stiff and unyielding to manipulation. When
function, and health of these structures should be noted and sign ifi such conditions are present, the us e of topical lubricants, less bulky
cant find ings recorded. re tracting instruments. and illumination adjuncts such as a headlight
should be considered. In planning treatment for patients with small
The edentulous mouth or restricted mouth op enings, premedication or sedation, longer ap·
pointments, staged clinical procedures. and fee alterations are fac
The approach to examinato
i n of the edentulous or potentially eden tors for eval uat on.
i
tulous mouth varies according t o the previous prosthetic experiences

of the pat e
i nt . If the patient has not worn prostheses before and the Ridge form
deci so
i n to remove all rema ining teeth is contemplated, it is impor A s ystematc
i examination of the edentulous oral cavity generally be
tant to be aware of th e primary precipitating rationale for extraction. gins with the residual bony ridges. Ridge form is characterized b y its
Periodontal etiology for tooth loss implies the existence of a chronic cross secti onal contour as a whole arch and traditionally is catego·
-
pathologic state involving both soft and hard t issues. Bone loss at· rized as U-shaped. V-shaped, or flat Typical maxillary ridge palatal
tributable to p eriodontal disease naturally reduces the potential ridge configurations are illustrated in Fig 3-7. Although the size or amount
structure available for support of dentures. Furthermore, clinical ex of alveolar ridge available to support a prosthesis is important, the
perience seems to ind icate that prosthetic stresses applied to sup maxillary form and �s rel at ion ship to hard palatal structure are even
porting tissues that were previously periodontally involved are not more cr itical.
well received, and loss of support can be expected at a more rapid A U-shaped ridge in either arch is generally the most favorable
rate. certain systemic diseases may weaken the support structures form for supporting a denture because it provides a broad base t o
fig 3-7 Left, V.Shaped maxillary ridge with essentially no hard palate; not conducive to d evelopment of good stability and retention of a oomptete dooture. Middle, U-shaped maxillary
ridge w1th horizo ntal support; favorable for suJ)JJOil and retention. Right, Torus palatinus is a oom pliCating factor in development of gOod retention and stability because th1s structure
usually is oovered by only a thin mucoperiosteum. (Reprinted from laney and GonzaleZ' with permission.)
Fig 3·8 A thin, sharp mandibular ridge is often a source of discomfort in Fig 3·9 Combination syndrome Is exemp lified In the clinical presentation
the edentulous patient of this patient. Note the atrophic nature ol the maxillary anterior residual
alveolar ridge, bulbous encroacl�ng maxillary tuberosities, and supra
erupted mandibular anterior teeth.
resist occlusal stresses and parallel sides that enhance adhesion and to the "down and out• progreSSion of bone loss in the mandibular
resistance to d ispl acement and encourage border seaL Excessive ridge. Maxillomandibular relationships thus normally progress to re
bulk associated with this ridge form can create problems in esthetics. verse articulation {crossbite) situations that complicate the distribu
insertion. and removal. It also may limit space needed for mechanical tion of prosthetic stress to the basal support. Factors responsible for
arrangement of the teeth in an optimally functional alignment. ridge resorption are numerous and varied, bu their detailed evalu
t
The V-shaped ridge has a narrow crest that cannot absorb mas ation is not within the scope of this text. However. certain pertinent
ticatory stresses wi thout irritation and discomfort. It is less favorable observations must be considered in planning treatment and there·
for retention because of its sloping sides and its tendency to be lore are covered elsewhere in this text.
come narrow and develop fibrous tissue with denture wear. As the Ridge resorption clinically ranges trom minimal to extreme. Gener
surface area decreases. the adhesion provided by close adaptation ally, mandibular resorption i s more prevalent than maxillary resorp
and retention. as encouraged by an effective border seal, is more tion. and the degree of deformity and complexity of restoration are
difficult to maintain. The thin, sharp mandibular ridge presents one more severe in the mandibular arch. The pattern and rate of resorp
of the most difficult problems for prosthetic management (Fig 3-8). tion vary depending on systemic and local influences. A general
Without implant placement or other forms of protection through re vertical loss ot alveolar bone over the entire ridge can occur when
distribution of stresses or the use of resilient base materials. the thin all natural teeth are lost simultaneously or within a relatively short
ridge is usually a constant source of pain and discomfort for the pa time, wi1h or without follow-up prosthetic experience. Patients who
tient. The large maxillary V-shaped ridge com monly associated with retain mandibular anterior teeth for a significant period after toss of
a high, tapering palatal vault. often seen in the congenital cleft palate posterior teeth often present with a ridge configuration that exhibits
patient, offers some primary prosthetic support but usually little op two vertical levels after the removal of the remaining natural teeth
portunity for retention and stability. (Fig 3-9). It the mandibular anterior teeth have supported a remov
The flat residual ridge is that most frequently seen by prosthoclon able partial denture worn opposite an edentulous maxillary ridge and
tists and is the most difficult for restoraUon. The nomnal pattern ot al complete denture. one can expect to see more loss of the anterior
veolar bony resorption in the maxillary ridge is "up and in," compared maxillary bony ridge relative to its posterior quadrants because of the
27
3 i History, Laboratory, and Exam ination
Ag 3-10 (a) Bulbous maxillary ridge that is supported by a knife-edge residual alveolar ridge. (Repnnted lrom laney Fig 3-11 Ungual tOri evident in a patienl presenting lor
and Gonzalez$ with permission.) !b)Opposing undercul maxillary tuberosities require surgical re<JU(;lion or use of reslient
i treatment
llanges when prominent canine eminences complrcate insertion and removal of the p10slhesis.
unfavorable distribution of functional stress and the changes in sup Physical examination ot the ridge form includes an evaluation ot
port of the prosthesis. This condifion has been called combination the bony support available for the contemplated prosthesis and its
syndrome by some authors."''0 potential ior retention and stability, development of a desirable oc
Maxillary resorption can progress posteriorly to the noor of the clusal scheme, and esthetic arrangement of teeth.
maxillary sinus and anteriorly to involve the anterior nasal spine.
Loss of the mandibular alveolar ridge may result in dehiscence of P a la te
the mandibular canal and an actual inverted configuration, with the Palatal configuration is interrelated with maxillary ridge form to the
external oblique and mylohyoid ridges a s buccal and lingual liori • extent that one may be a disadvantage to the other. Bony morpho!·
zontal landma�s. respectively. Anteriorly. the genial tubercle areas ogy that may be desirable from the denture-bearing viewpoint can
become more prominent a s resorption increases. Complaints of be compromised by the soft tissue covering. To enhance retention
ridge soreness and pain, with eventual paresthesia of the lip, illus and stab ility of a prosthesis, the prosthodontist's goal is to balance
trate other complications of resorption. These effects are frequently three static surfaces of the denture base (ie, the impression surface,
compounded either by the accumulation of redundant soft tissues the depressed surface tor palatal relief, and the raised surface tor the
that replace lost bone or by t he development of mobile soft tissues posterior palatal sea� against one dynamic tissue surface .
that extend from the buccal mucosa to the floor of the mouth over The palatal bone has a periosteal attachment and mucosal cover
the mandibular ridge crest. ing with underlying connective and glandular tissue elements. Palpa
The bulbous ridge has a configuration that is the reverse of the tion normally reveals firm and dense tissues of limited elasticity over
V-shape. It is thinner at its base than at the crest and is usually con t he anterior part of the hard palale, where the rugae appear as ir
sidered undercut This type of ridge is unfavorable for deve lopin g regular elevations. The anterior palatine foramen, landma�ed by the
a border seal because base relief must be provided for comfort incisive papilla. lies on the anterior part of the median palatine suture.
able seating of the prosthesis8 (Fig 3-1 Oa). Ordinarily, the mandibular Traumatic forces applied t o this area may induce paresthesia. pain,
ridge would appear bulbous only in the anterior region. and in the or a local burning sensation because the nasopalatine vessels and
maxillary arch, the entire ridge could be involved because of exag nerves underlie the mucosa near the papilla.
gerated tuberosity and canine eminences (Fig 3·1 Ob). In its anteroposterior extent, the median palatine suture can vary
Variations within these typical ridge forms can occur. Exostoses from a middle depression to an extensively undercut torus palatinus.
may be evident in the palatal vault o r laterally o n the ridge. or lingual The suture i s usually covered by the relatively thin mucoperiosteum.
tori may be evident in the mandibular arch (Fig 3-11). Irregular bony Removal of bulbous. pedunculated, and undercut palatal tori should
resorption or retained roots cause sharp spicules or prominences be considered in the edentulous patient to enhance adaptation and
on the ridge crest. Retained impacted teeth can produce transient stability of the dentLire base.
variations in ridge contour. Unopposed natural teeth often extrude Lateral to the midline and posteriorly, the thickness of the submu·
along with accompanying bone, which. if lett alter extraction, can cosa in the palate increases. Fat cells are profusely interspersed in
produce an undesirable obstruction. A Rared or extremely bulky an· the superficial tissues between the deep layers o f the mucosa and
terior ridge segment with opposing posterior undercuts complicates the palatine glands. Pend leton s uggested that the palatine glands
the esthetic arrangement of artificial teeth and the insertion and re may contribute to the mechanical function of adipose tissue. "·'2
moval of the prosthesis. They also may act a s a buffer to the forces transmitted to the denser
Maxilla
Tongue /
\ )r
� (
o'
,___ }(_
I
'
,_,
'
v }
3 1'- 2
)
Fig 3-12 House classification or soft palate as Class 1, Class 2, or crass 3 accordill!l Fig 3-13 Lateral Ulroat form according to Neil." Class designation is related to anterior
to angle made v.ith hard palate.13 extent or retromylohyoid curtain and its relationship to bony mandible. Class 1: posterioc
relationship; Class Ill: anterior relationship with less opportunity lor denture base exten
sion; Class II: anything In between.
tissues of the residual ridges and midpalatal suture by the denture. is prominent. the mucOSal covering can be easily irr�ated by overex
The anterior palatine neNes and descending palatine vessels leave tension of the denture.
the greater palatine foramina at the posterolateral angles of the hard
palate. If the residual ridge has been badly resorbed lor an extended Soft palat e
period, there may be dehiscence or the canal and superficial loca The soft palate is covered by a nonkeratinized epithelium with sub
tion of these structures in their anterior course. occasionall y, spiny jacent laminar propria and loosely arranged submucosa that contain
processes of bone develop near these foramina and require surgical mucous glands. The form of the soft palate is classified according to
removal or a planned relief area in the denture base. the angle of its rest drape from the hard palate (Fig 3-12). A Class 1
Oversimplification in classifying palatal throat forms can lead to palate has a gradual inferior slope with less active movement at the
an assumption that soft palate function is hingelike. However, a junction of the hard and soft palates and therefore can be covered
wide range of three-dimensional functional movements is actu b y a denture beyond the junction to enhance extension and seal.
ally involved in speech and deglutition. Movement of the soft palate The Class 2 palate has a more acute drape and is more active than
at the vibrating line in the midline involves a thin, firm, tendonlike the Class 1 palate but generally demonstrates less movement than
band-the palatine aponeurosis, which supports the palatal mus the crass 3 palate, which drops abruptly from the hard palate. '3 Den
cles. strengthens the palate, and attaches anterior1y to the poste ture base impingement on a Class 3 palate can lead to soreness,
rior border of the horizontal plate of palatine bone. In essence. the loss of border seal. and gagging.
posterior border of a maxillary complete denture is supported by the
palatine aponeurosis. Lateral throat form
The pterygomaxilfary (hamular) notch is formed by the pterygoid Neil described a so-called soft-palate configuration th roat form,.
hamulus, the pyramidal process or the palatine bone, and the maxi!· but distinguished this category from lateral throat form. He defined
lary tuberosity. This trough is one in a series of border landmarks for lateral throat form as the contour of the hard lingual surtace of the
the establishment of a definite periphery for the complete denture. mandibular ridge in the molar area and the velum-like tissue distal to
It contains collagenous tissue, and displaceability of the soft tissues the mylohyoid ridge in the retromylohyoid fossa as it functions under
in the notch can be related to the influence of the attachment of the the influence of the tongue (Fig 3-13). Lateral throat form is classified
pterygomandibular raphe on the maxillary tuberosity. Also active in according to the extent of anterior movement of the retromylohyoid
this area is the tendon of the tensor veil palatini, which is protected curtain as the tongue is extended anteriorly beyond t11e vermilion
by a bursa as it rounds the hook of the hamulus. When the hamulus border of the lower lip. With the index finger passively contacting
29
3 i Hi story, Laboratory, and Examination
Fi g 3-14 Orthognathic or Angle Class II maxillomandibu!ar relationship anteroposteri Fig 3-15 Prognatllic or Angle Class Ill maxilornandlbular relationship anteroposteriorty
ony. Normal posterior relationship. and laterally.
A •
Fig 3-16 Reverse articulation (crossblte) A relationship, In which anterior ridge relation· Fig 3-17 Reverse articulation (crossbite) B relationship with n()(OJal·position ridge re·
ships are oormal and crossbite is seen poster iorly. A-anteri()(; P-p os lerior. lationslllp and crossbite seen anteriony. This combination is rarely seoo.
the curved wall of mucosa in the retromo lar fossa with the tongue • NormaVAngle Class 1: anterior segment of the mandibular ridge
at rest, the patient is instructed to protrude the tongue. If the lateral is directly below or slightly posterior to the maxillary anterior ridge
throat form changes oonfigurat ion so as to place heavy pressure segment
on the finger. pushing i t anteriorly completely out of the retromolar • Orthognathic/Angle Class II: anterior segment of the mandibular
fossa, i t is known as a Class Ill. If the pressure exerted on the fin ridge is posterior to its normal position relative to the maxillary an·
ger is mi ni mal or if no pressure is exerted, the lateral throat form is terior ridge segment (Fig 3-14)
deemed to be a Class I. Any position of the tissues between these • Prognathic/Angle Class Ill: anterior segment of the mandibular
extremes Is a Class II lateral throat form. Observation and notation of ridge is anterior and lateral to its normal position relative to the
this phenomenon are important to ascertain the opportunity for den maxillary anterior ridge segment (Fig 3-15)
ture base extension in the area. Based on a study of 100 edentulous • Reverse articulation A (crossbite A): anterior ridge relationship is
patients, Huang et al'5 reported that 70% of those examined had a normal. but posterior ridge relationship is prognat hic (Fig 3-16)
Class I throat form. 25% had a Class II tl1roat form, and 5% had a • Reverse articulation 8 (crossblte 8): posterior ridge relationship is
Class Ill throat form. They recommended the use of an imp lant depth normal, but anterior ridge relation is prognathic (Fig 3-17)
gauge both to determine the length of lateral throat form and to aid
in custom impression-tray fabrication. A critical evaluation ot arch alignment and the inter a rch ridge
relationships is necessary to formulate a treatment approach that
Maxillomandibular relationship enhances the strengths and minimizes t11e weaknesses of the struc·
Smith described ridge relationship as the anteroposterior position of
ture under consider ation . Factors such as tray selection, impreSSion
the mandibular residual ridge relative to the maxillary residual ridge techniques, tooth form and position, division of lnterarch space, oc
when the jaws are in centric relation and separated by the distance clusal scheme, and base materials are some of the interrelated as
they will be separated by the prostheses.'6 These relationships in the pects of this observation.
edentulous patient may be categorized as follows:
Physical Examination
Fig 3-18 (a) Coofiguratioos of tongue position according to Wright et al.16 (b) Normal tongue position. (c) Retracled
Class I tongue position.
Fig 3-19 Toogue thrust encountered in mandibular pro·

trusioll of this partially edentulous patient.
Tongue I retracted tongue is pulled backward so that the entire floor of the
The morphology and physiology of the tongue are noteworthy in mouth is pulled down and exposed extending to the molar region.
the examination process because this organ is directly related to The lateral tongue borders do not contact the occlusal surfaces of
successful experiences with removable dental prostheses. Smith the teeth, and the apex is withdrawn into the floor of the mouth. The
described two anatomical tongue types'": (1) long, narrow, and ta Class II retracted tongue is pulled backward and upward, and its
pered: and (2) short. broad. and thick. Although the first type is less musculature i s tensely contracted. The tongue apex i s drawn into
problematic for taking the impression, the lack of physical bulk ren the body, which gives a square appearance, and the lateral borders
ders the tapering tongue less effective in contributing to the devel are well above the occlusal surfaces of the posterior teeth. Conse
opment and m<l!Otenance of a lingual border seal for the mandibular quently, the floor of the mouth is also raised and tensed.
denture. The thick, broad tongue fills more of the space in the floor of ObseNations of tongue position should be made early in the ex
the mouth and therefore provides a positive contact surface for the amination with the patient's mouth opened only wide enough to ac
lingual denture ftange and a better border seal. However, its morpho cept food. A normal tongue position enhances retention and stability
logic characteristics complicate impression procedures and render of maxillary and mandibular dentures whereas a retracted tongue
it more susceptible lo irritation and occlusal trauma from the teelh. results in looseness and instability of mandibular prostheses. Smith
The posture and function of the tongue are directly related to its et al obseNed that dentures move due to forces from the tongue
anatomical configuration. Wright et at studied tongue positions and and perioral musculature during mastication of food at least as much
their effect on the stability of the mandibular denture." Their inves as they d o from the forces applied to the prosthesis through the
tigations revealed that 75% of an patients obseNed have a normal food bolus.'" Strength of the tongue therefore can be a positive or
tongue position in which the tongue completely fills the ftoor of the negative factor in denture experience, depending on how the patient
mouth: has a dorsal surface that is round. smooth, and free of mus uses it. ObseNation and clinical data indicate that when the patient
cular contractions: and has lateral borders that rest on the incisal becomes edentulous, the tongue becomes stronger, and its strength
edges of the mandibular anterior teeth or the anterior edentulous may contribute 25% to 50% of the force of mandibular closure.'9
ridge crest (Rg 3·18a). Size or activity o f the tongue does not affect Passive anterior carriage of the tongue assists stability and retention
this positional relationship, which remains the same from the dentu of a mandibular prosthesis and usually is an advantage. However,
lous to the edentulous state. habitual tongue thrust is detrimental to prosthetic stability and actu
Retracted tongue positions are found in 25% of patients" and ally encourages mandibular protrusion to the extent that balanced
may be classified as Class I or 11 (Figs 3- 18b and 3-18c). The Class occlusion and articulation are difficult to maintain (Fig 3-19).
31
Fig 3-20 (a and D) Sigrllfi cant anatomical areas in lhe maxil

lary arch to consider n i assessing !he potential for retention and
stability: in ciSive papilla and rugae (I). median palatal raphe (2).
lateral hard palate and tuberosity (3), zygomatic arch (4), residual
ridge {5), palatal configuration (6), and hard-sol\ plate junction
and function (7).
Posture and carriage of ttle tongue also are related to maxilloman lion of the masticatory mucosa with an instrument or a finger should
dibular positional relationships. The patient with a retrognathic man indicate to the prosthodontist the degree of stability that might be
dible generally carries the mandible in an anterior position to facilitate expected for the prosthesis. in addition to the capacity of the soft
mastication, speech, and closure of the lips. The tongue of a prog tissues lor adaptation to the prosthesis. To compare the degree or
nathic patient usually fills the floor of the mouth but is somewhat less displacement seen in the mucosa. it i s convenient to use the follow·
active because it has a more favorable position for mastication and ing simple classification suggested by House":
speech. Desjardins has suggested that the positional relationship of
the tongue to the mandible is an environmental factor that affects the • Type 7: tissue can be displaced approximately 2 mm; cushionlike,
patient's ability to wear and use complete dentures.20 yet will not permit gross positional displacement
Since the tongue is endowed with the most sophisticated percep • Type 2a: tissue thinner than 2 mm, usually unyielding, often atro
tive threshold of all body musculature and functions with a wide range phic with smooth surface; poor for developing good adhesion and
of precise and rapid motions, it must be respected and accommodat border sea
ed adequately in the prosthesis design. Although the tongue can be • Type 2b: tissue thicker than 2 mm and easily displaced; poor
trained to posture and performance that is advantageous for denture stress-bearing potential: usually occurs as ffabby redundancy in
retention, the process is usually slow and requires patient concentra regions of excessive bone resorption under ill-fitting or malaligned
tion and perseverance. Poor tongue habits and undue preoccupation prostheses; also may appear as anteroposterior folds over re
with position usually result in an unsucce ssful denture experience. sorbed posterior ridges or on fibrous ridges where bony resorption
has occurred laterally
Mucosa • Type 3: excessively flabby to the degree that surgiCal excision is
Lining and enveloping the bony structure of the jaws are soft tissues indicated
with specifiC morphologic and physiologic characteristics, tradition
ally subdivided into masticatory, lining, and specialized mucosa.'' An orderly examination of the masticatory mucosa allows the clini
The roles served by these tissues in the design and fabrication cian to determine the potential retention and stability of a prosthe
of denture prostheses are altered from those intended by nature. sis• The following critical areas for comparison in the maxillary arch
Furthermore, when surgical intervention is used to improve pros are identified in Rg 3-20:
thesis-bearing areas through transplants. implants. or other simi lar
procedures, the subsequent response or the residual tissues to the • Incisive papilla and rugae: prominence or papilla and rugae. loca
stresses imposed may be somewhat unpredictable. tion of papilla relative to ridge crest. sensitivity. and pathology
• Median palatal raphe: configuration width and length of promi
,
Masticatory (support) mucosa The masticatory mucosa covers nence. and thickness of mucosal covering relative t o ridge crest
the alveolar ridges. the attached gingiva, and the hard palate. Be • Lateral hard palate and tuberosity: displaceability of mucosa and
cause it normally is exposed to the mechanical forces of mastication subadjacent tissues, presence of bony projections along palatine
and manipulation of the food bo lus. it is generally keratinized and canal or atrophied palates, tuberosity composition, tuberosity con
has a metabolic pattern similar to that of gingival tissue.'" Where it figuration laterally and vertically. and pterygomaxillary notch dis
appears, the masticatory mucosa also has a characteristic thick placeability
ness. degree of keratiniza tiOn, density, lamina propria firmness. and • Zygomatic arch: width. incline. prominence of bony arch, and dis
immovable attachment t o underlying structures. In the posterolateral placeability of mucosal covering relative to that of the residual ridge
aspecls of the hard palate, a thicker submucosa with compartments and median palatal raphe
o f adipose and glandular tissue links the lamina propria to perioste • Residualridge: type of mucosal covering and its relationship to that
um. In the gingiva. a well-defined submucosal layer is absent. Palpa- of other identified areas
Fig 3·21 raalldb)Anatomical structures or Importance

in the mandibular arch: residual ridge and frena {1),
buccal shelf (2), retromolar pad (3). mylohyoid ridge {4),
and genial tubercle and anterior floor of mouth (5).
Fig 3·22 Frena presentation in an edentulous p atient. Note the approxi

mate insertion or Irena to crest of the residual alveolar ri(!ge.
Evaluation of the mandibular masticatory mucosa should parallel because it selVes as the direct border-tissue contact for most re
that of the maxilla, with special attention t o the relationship of the movable prostheses. The vestibule, vestibular fornix, or sulcus is that
following mucosal coverings (Fig 3-21 }: space in the oral cavity created by reflection of the soft tissues from
the alveolar ridge to blend with the lips and cheeks. The reflection
• Residual ridge: type of mucosal covering and its relationship to that is known as the mucobuccal fold or mucolabial fold. The mucous
of the alveolar mucosa. buccal shelf configuration and extension. membrane covering the periphery of the alveolar ridge is loosely at
retromolar pad. and genial tubercle width and prominence tached to the underlying structures. providing mobility and reSilience.
• Mylohyoid ridge: prominence of the ridge medially, relationship to The mucous membrane on the outer surface o f the fold is closely
the residual ridge crest, relationship t o the masticatory mucosa of attached to the musculature of the cheek and lips.
the residual ridge. presence or absence of longitudinal tissue folds. In the floor of the mouth, the mucous membrane is thin and loosely
and functional position of these tissues attached to the underlying structures to accommodate the tongue.
• Retromolar pad: prominence, displaceabilti y, and relationship to The sublingual mucosa is fixed to the alveolar ridge at the lingual
pterygomandibular raphe and residual ridge and its mucosal cov mucogingival line. It covers the sulcus and sublingual glands, and it
ering reflects into the ventral surface of the tongue. In the sublingual fossa,
• Buccal shelf: mucosal covering and lateral prominence of the ex the sublingual glands lie just beneath the mucosa, and although it is
tarnal oblique ridge and buccinator and masseter muscle influence resilient in the network of adipose and glandular tissue, it can inter
• Genial tubercle: mucosal covering and its relationship to the con fere with the pl acement of a denture flange.
tiguous tissues of the floor of the mouth and ridge crest Folds of mucous membranes known as frena create areas of re
sistance and prominence within the vestibular areas (Fig 3-22). Con
Not t o be confused with the mylohyoid ridge is a residual promi sisting primarily of connective tissue but no muscle, the frena of the
nent bony area sometimes left as the lingual portion of the second maxillaJy arch usually are located bilaterally in the premolar areas
or third molar alveolus after extr action. The mucosa covering these and in the laba
i l midline. The pterygomandibular raphe attachment
endoalveolar crests or lingual tuberosities is usually attached and to the maxillary tuberosity often acts as a frenum when attached
firm. high on the ridge. In the mandibular arch, frena ane found bilaterally
in the premolar areas and at the midline on both the labial and lingual
Lining m u c o s a The lining mucosa provides a protective covering aspects of the ri dge. These structures do not tolerate constant direct
tor the oral cavity. It i s particularly important to the prosthodontist pressure without undergoing pathologic change.
33
3 i Hi story, Laboratory, and Examinat ion
come.23 To that extent, examination of patients contemplating dental

implant therapy is justifiably less focused on typical diagnostic and
treatment -planning proc edures. In these patients, the clinical exami
nation should pay particular attention to ridge morphology, interocclu
sal relationships. paraf unctional occlusal habits. location of available
bone to house implant bodies at optimal angulation and position rela·
tive to the alveolar ridge and gingival crests esthetic considerations
.
that mighl necessitate gingival recontouring, and the psychologic pro

fil e of the patient. which is often overlooked but crucial to success.
The radiographic examination is a crucial tool t o identify the location
and v olume of calcified tissue. The results of this examination guide the
clinician's and patient s decisions regarding the need for preprosthetic
'
au gmentation of potential implant osteotomy sites. For experienced

s urgeons. a two-dimensional image such as a panoramic radiograph
Fig 3-23 Mapping of oral ana perioral areas that perceive vanous taste sensations.
will suffiCe for most situations, and additional information such as that
(ReJ)nnte<l from Heftl<in" with permission.)
available from cone beam computed tomography (CBCT) can be
sought in atypical situations. Inexperienced surgeons may opt for en
Because of t he structural and functional versatility of their lining hanced imaging more frequently until they are comfortable with using
mucosa, most border tissues can be lightly placed to create a seal
" " only a panoramic radiograph. At this time, routine use of CBCT cannot
that aids In the retention of a complete denture. When functional be justified because there are no data to support better outcomes for
space and appearance permit, inc reased width of the denture flange patients who undergo this imaging process, which involves increased
enhances the border seaL costs and radiation exposure.
A variety o f bone and soft tissue Classification systems are available
Sp e cial ize d mucosa Another type of oral mucosa is the highly for use in dental implant therapy.:•4l The proponents of these systems
specialized covering of the dorsal and lateral surfaces of the tongue. seek to improve communication. education, treatment. and outcomes
Its characteristics are somewhat dissimilar between the body and through their use. However. no single system for either bone or soft
base of the tongue. The anterior two-thirds of the to ngue morpho ti ssue has gained widespread acceptance. presumably because each
logically makes up the structure's body, and the posterior one-third system is based more upon clinical presentation at a single point in
is known as the base. On the surface of t he tongue body are filiform time and does not affor d sufficient consideration to the biologic pro
and fungifOfm papillae. The latter contain a few taste buds, but the 8 cesses at play nor the prognosis of any given classification. Regard·
to 1 0 large circumvallate papillae that border the posterior extent of less, as basic communication tools, cl assificati on systems are us eful .
the tongue body contain numerous taste buds. Laterally, the tongue Examples of bone classification systems for bone volum e and quality
body contains foliate papillae that also include taste buds in their are described in later portions of t his text (see chapters 9-12).
folds. Over the surface of the tongue base are rounded prominences
of lymph tissue that collectively make up the lingual tonsiL Taste
buds also are located on the posterior surface of the epiglottis. on
the hard and soft palates, and the mucosal surfaces of o ther areas Taste
in the oral cavity and pharynx (Rg 3·23).
Taste buds are composed of so t o 150 taste receptOf cells that are
Implant therapy clustered together. The taste cells in a taste b ud are intimat ely inter·
Over the past 20 years. certain fundamental beliefs regarding implant woven wit h dendritic sensory nerves that transmit taste signals to the
therapy have changed in the lace of compelling clinical evidence. For i er
brain. The function of taste cells and nerves can change under dff
example. techniques such as implant placement at the same time as ent conditions (eg, medication, aging) and should be considered a
extraction and immediate loading have been sh own to produce excel physiologic function that has natural variabil ity. Taste, the sensation
lent clinical outcomes, yet these concepts were considered high risk caused by contact of Ofopharynx with a substance, should be distin·
when first proposed. In a dditio n . long-term clinical results with other guis he d from flavor, which is the mixed sensation of taste and smell .
wise untreated commercially pure titanium-surfaced implants at ad There are five types of taste recognized by humans: (1) sweet. (2)
modem BrAnernark indicated a higher risk of implant failure in certain sal ty, (3) sour, (4) bil1er. and (5) umami (savory). Many chemicals are
situations. In particular, these situations included placement of maxil involved in the expression of t hese individual taste sensations. Taste
lary implants. implants placed in smokers Of diabetic patients, or use sensation is further affected by thermal stimulation of the tongue;
of impl ants less than 10 mm i n length. Recent evidence with surface therefore, foods of different tempefatures also affect taste sensa·
treated implants, however, indicates t hat many of tile deficiencies lion. Studies of the detection and recognition thresholds lor tile fiVe
presented by the clinical situations described above have been over- modalities o f taste have determined that these are defined by taste
Informed Consent J
buds on the tongue, palate, and pharynx of normal subjects. These low-grade adenocarcinoma) and l y mphomas (especially in the base
anatomical areas are served by tile trigemi nal facial, glossopharyn
, of the tongue and lymph tiss ue in the floor of the mouth).
geal, and vagus nerves such that particular taste functions are not Oral cancer affects approximately 35,000 Americans every year
specific for particular cranial nerves. Each taste modality is appreci and kills approximately 8,000 (2008 esti mate). Collectively, the vari
ated di fferently on the tongue, palate, and pharynx: Sensitivity for ous forms affect men more frequently than women in a ratio that is
salty and sweet is greatest on the tongue and sensitivity for sour
, slightly greater than 2:1. This ratio is noteworthy because the ratio in
and bitter tastes is greatest on the palate. In humans. approximately 2002 was 6:1, wl1ich indicates that oral cancer incidence in women is
one in four individuals (women more often than men) is hypersensi rising at a disturbing rate and may reflect the increased percentage of
tive to bitter tastes, a condition that may be the result of an increased women using tobacco products. Worldwide. approximately 400,000
number of fungiform papillae. cases of oral cancer were diagnosed in 2007, making it the sixth most
Alteration of taste sensation is sometimes a complaint of denture common cancer."' The accessibility of the oral cavity should make
wearers, but the rofe of prostheses as the initiating factor of such a identification and treatment of premalignant and malignant lesions
change is not entirely substantiated. Henkin and Christiansen found easier compared to many other cancers. but patients' tack of regular
that persons wearing complete maxillary dentures had significant el attendance at dental exams means that lesions often progress in size
evation of taste threshold for bitter and sour.31 A similar phenomenon and consequence before detection. Many orophal)lngeal cancers are
was observed in subjects whose palatal region had been anesthetized. Stage Ill or Stage IV (fNM classification) at the time of diagnosis. As
Each pat ient perceived each of the taste modalities but reported some a resuH, the 5-year prognosis of those diagnosed with oropharyngeal
diminution in perception of taste after the pro sthesis was in place. cancer is less than 50%. Oropharyngeal cancer claims more lives than
In contrast. a different study of ta ste among wearers of complete either melanoma o r cervical cancer, for which screening mechanisms
dentures noted that taste perception was slightly enhanced.32 It was are more prevalent, accepted, and thorough.
postulated that dentures actually helped lo confine taste modalities Alcohol and tobacco use are the main risk !actors for oral cancer.
to taste receptors whereas without dentures the same tast e solu However, a significant proportion (25%) of oropharyngeal cancers
tions were spread and diluted. An i nvestigation of the influence of occur in patients with no known risk factors, which supports the no
palatal topography suggested that neither contour nor denture base lion that other mechanisms of oroph ary ngeal cancer development
material significantly affected the ability of denture wearers to per must exist. Recent research suggests a role for the human papilloma
ceive the taste of solutions at room tem perature. virus (HP\1). HPV-16 and HPV-18. which are two forms strongly as
Hyposmia refers to an abnormally decreased sensitivity to odors. sociated with cervical cancer, are specifically implicated in oropha·
Patients with this condition demonstrate increased detection and l)lngeal cancer development.
retention thresholds for sour and bitter tastes. They typically have Ear1y lesions and premalignant lesions are often dif
f icult to identify
high arched palates. Henkin and Christiansen speculated that taste because only subtle changes to the mucosa may be evident. Le
deficiencies observed in patients with Turner syndrome or faci al hy sions presen t initially as either leukoplakia or eryth roptaki a and prog
popla si a may be the res ult o f a similar anatomical abnormality of the ress to nonhealing ulcerations. In advanced stages other sequelae
.
palate that has altered the taste buds, the neural structures of the manifest such as bleeding, loosening of teeth. difficulty wearing re
palate. or both."' Patients with palatal defects resulting from surgical movable dental prostheses, dysphagia, dysarthria, or development
maxillectomy often report loss of taste sensation, and many demon of neck masses. Leukoplakia and erythroplakia can be observed for
strate hyposmia. After prosthetic restoration of the defect, detection a short time to see if resolution occurs; if it does not, biopsy should
and recogniti on thresholds for sour and bitter have been found to be be considered so that appropriate diagnosis-driven t herapy can be
significantly elevated when the prosthesis is in place. The studies of initiated. The use of oral cancer diagnostic tools as an alternative
Henkin and Christians en are important in that they cite the signifi to biopsy has g row n in recent years, with two main forms of detec
cance of the palate. pharynx. and tongue in taste discrimination."'.:l3 tion currently available. The first, used for some years. are systems
If tongue action against the palate does affect perception of taste, based on oral cytology or toluidine blue dye. The second form relies
then any prosthesis, prosthetic design, or morphologic or functi onal on light detection of muc osal abnormalities. Fur ther refinements in
disability will be a factor in the total restoration process. these systems will permit enhanced specificity and sensitivity. For an
excellent review of currently available oral cancer diagnosis screen
ing tools, the reader is referred to Lingen et al.35
Malignant and
Premalignant Lesions
Informed Consent
More than 90% of oropharyngeal (oral cavity and oropharynx} can
cers are or al squamous cell carcinomas (OSCCs). Other types of The legal and ethical issues pertaining to informed consent have
cancers that have primary sites in the oropharynx are salivary gland evolved over the past decades as society has moved toward ensur
carcinomas (adenoid cystic, mucoepidermoid, and polymorphous ing that each patient has the right t o determine what happens to
35
3 iHistory, Laboratory, and Examination
his or her body and that a patient is entitled to be informed of the and that documentation attesting to these procedures is made in the
risks of treatment and any alternative treatments. Initially. consent patient's medical record.
procedures and consent forms were used manly for surgical pro
i
cedures; today informed consent is deemed appropriate for all ir

,
reversible procedures and tor those that involve any risk to a patient.
even if they are noninvasive. One exception to the informed con Summary
sent doctrine is the provision of emergency care in instances where
the circumstances dictate. In 1972, an important decision from the The review of a patient's medical history iS essential for complement
United States Court of Appeals for the District of Columbia Circuit ing a comprehensive physical exan1ination to accurately determine
reinforced a patient·s right to determine his or her treatment and held a diagnOSis. The pat ient may be additionally evaluated by means of
that health care providers must inform each patient of all risks that laboratory and other tests that serve to augment information in de·
might influence that patient's decision to choose a specific treatment termining a diagnosis. Other pertinent steps of performing a detailed
ptan .36 31 Two caveats. stated in the same decision. were that (1) re
· and thorough examination also serve to record along with the history
mote risks that a typical patient would not consider anyway need not a series of symptoms and signs leading to deduction of accurate
be disclosed. and (2) risks that would already be known to the aver and comprehensive diagnoses . Additional consideration is given to
age person also need not be disclosed. Unfortunately, informed con discussion of consent t o treatment or informed consent. Additional
sent standards are defined In the United States by each state, and discussion should focus on the appropriate level of understanding
there is some degree of variability even as it pertains to the question of the patient. Through these carefully executed steps, the clinician
of whether written or verbal consent is sufficient. Prosthodontists are can perform shared decision making with the patient for appropriate
obligate d to know the legal requirements of the state(s) in which they treatment paths.
are practicing and are advised to practice in concordance with the
Amercan Dental Association's Code of Professional Conduct. which
i
states that dentists should inform patients about their treatment in a

way that allows the patient to be involved in the treatment decision, References
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Oral tmptants Res 2 005: 16:639-644.
37
Chapter
Oral- Systemic Interactions

Sreenivas Koka, oos. MS. PhD
William R. Laney, oMD. Ms
nderstanding the relationship between the oral cavity and (Wickham striae) t hat form u sually a result of the coalesc�nce
U
are
the rest of the human body is a c hallenge for both clinicians of small papules. The bands often give the appearance of a lattice
and scientists. Recent advances in research on ora l system
- on oral mucosa, sometimes referred to as reticular lichen planus
ic links have drawn dentists and physicians together in a manner (Fig 4-1 ). Annular or plaque·like patterns also may be observed in
that will only improve the ability of these health care professionals to the patient. These three forms are ostensibly variations of the same
setVe each patient's best interests. Oral-systemic links are often re manifest ati on. OLP may also present in an erosive form that usually
ciprocal (ie, some systemic conditions have oral manifestations. and affects the gingivae and in cl udes erythematous or ulcerated lesions.
some oral conditions have systemi c manifestations). However, oral OLP can be misdiagnosed on occasions when ot11er causes are
c ond itions with systemic mani festat ions are poorly u nd erstood . This mis sed. Allergic contact stomatitis, certain drvg interactions, and
chapter describes those conditions and the effects of pharmacologic graft-versus-host disease may all result in lesions that are similar
therapy on the ora l cavity emphasizing conditions and manifesta
, in appearance to OLP. A thorough assessment of the patient's
tions that are pertinent to the practice of prosthodontics. medical history and a histopathologic evaluation can help to form
the correct diagnosis and allow for assessment of malignancy, which
is uncommon in the reticular, annular, or plaque like forms.
-
Oral Manifestations of Systemic Corticosteroids, retinoids, and calcineurin inhibitors are most
commonly used in medical treatment of OLP.2.3 Short courses of
Conditions corticosteroids (oral or sys temi c) appear to h elp with resolution
of severe u lcerative or recalcitrant OLP. However, long-term
use of systemic steroids is associated with Side effects including
Mucosal conditions hypertension . diabetes mellitus. loss of bone mineral density. cataract
formation, gastric ulceration, and development of oral candidiasis.
Vesiculoerosive conditions Retinoids are effective in minimizing the effects of OLP but less so
than corticosteroids. These dr ug s also come with side effects, the
The most common vesicLlloerosive conditions (VECs) are oral lichen most serious of which is teratogenic potential, which contraindicates
planus (OLP), mucous membrane pemphigoicJ (MMP), and erythema their use in women of childbearing age. Calcineurin inhibi tors
multiforme (EM). These conditions are similar in that all three are in (cyclosporine, tacrolimus, and pimecrollnus) have been studied less
flammatory lesions. possibly of an autoimmune nature. that do not than corticosteroids and retinoids but can markedly help patients
appear t o have easily determined or consistent etiologies. with OLP. In rare instances, side effects may inciude the developm ent
OLP has been reported to occur in 0.5% to 2.2% of the population. of mal ig nancy a lthough this remains controversiat.•·5 Phototherapy
.
ll typically presents in patients between 30 and 60 years of age. with using ultraviolet light irradiation is another possible treatment option
a predilection toward women.' The bilaterally symmetric white bands for OLP. alth oug l, data describing its benefits are not plentiful and
39
4 L Oral-Systemic Interactions
Fig 4-1 H)1JEir1rophic lichen plaM ideflt�ied in IJuccal m�. Fig 4-2 E!yt/lema multitorme identified in tile lips (a) and wrist (11) ol a patient after administration ol olfend1ng
pharmaceutical agenL
indicate it may have potential for malignant transformation in the area patients with severe cases. Regardless of severity, excellent oral
treated. hygiene is highly recommended to remove any inflammatory agents.
When the clinical presentation is not sufficient lor conclusive EM may affect skin or mucous membranes. In contrast to OLP,
diagnosis. biopsy and histopathologic evaluation should be EM typically presents in a younger age group (20 to 40 years
considered."·' Topical corticosteroids are the first form of treatment old) and may also be observed in children. The conditton is often
to be employed, and systemic corticosteroids should be considered recurrent. Clinically, in the oral cavity, EM appears as widespread and
for severe OLP Retinoids and calcineurin should be used as second· diffuse ulcerations that are difficult to differentiate from pemphigoictl
line treatments. Patients also should be informed that diet may play a pemphigus. These lesions have an acute onset and are typically
role i n OLP and that foods and liquids that are spicy or have strong found in the anterior portion oi the mouth and on the lips11 (Fig 4·2).
artificial flavoring are best avoided. EM oral lesions present concurrently will1 skin lesions.
MMP is a benign condition characterized by separation of The clinical presentation of the minor form of EM includes mild,
epithelium from connective tissue. It often manifests as mucosal exanthematous lesions limited to oral mucosal Involvement. EM
blistering or ulceration, which may result in scarring.a When oral MMP major, which involves skin lesions and multiple mucosal sites,
presents, it is usually painful. Given its autoimmune etiology, the eventually may progress t o Stevens-Johnson syndrome, which
condition can episodically appear over the years. In some patients. usually presents as a fulminant and severe blistering condition
however. oral MMP occurs regularly and can be a significant burden involving the skin extensively. Symmetric rashes present on the
to endure. Antibodies to proteins (possibly taminin and BP180) arms and legs and often have an "iris" or "target" appearance.
involved in maintaining ttw integrity of the epithelium-connective Typical rashes are less than 3 em in diameter, have a round shape
tissue junction are implicated. and there does appear to be some wit h a reasonably well-described edge, and show two concentric
evidence that the greater the concentration of the autoantibodies in rings around the center disc. In EM major and Stevens-Johnson
these sites. the worse the ensuing ulceration. The prevalence of MMP syndrome, the skin lesions are noticeably raised and palpable.12 EM
is reported to be 0.002% to 0.005% annually, with a 2:1 predilection major also involves multiple mucous membrane sites, including the
for females. It primarily presents in individuals who are middle-aged oral. esophageal. ocular. laryngeal. and genital mucosae.
or older.• The lesions may be initially painful and become fluid filled. Understanding the etiology of EM is challenging; a number of
When the blisters break open, the area remains painful during the bacterial, fungal, viral, and pharmacologic agents appear to induce
slow healing process (3 to 6 weeks). Sloughing tissue during oral the expression of antigens t o which the body reacts. Herpes simplex
hygiene procedures is not uncommon. and clinicians actually may virus Is of particular concern because it has been implicated in up to
apply pressure to induce epithelial sloughing (Nikolsky sign) so as to 70% of recurrent cases. Therefore, management of EM is focused
diagnose MMP. on determining the precipitating agent. If a viral etiology is suspected,
As with other autoimmune conditions. corticosteroid use is antiviral medications can be considered, and antibiotics may be
often the first line of therapy.'" Fortunately, many patients are not considered if a bacterial etiology is suspected. No specific treatment
significantly affect ed by oral MMP. Those who develop a tolerance is available for the EM itself, although, as with OLP, steroids and
to the pain may not need corticosteroid therapy and consequently retinoids have been used with nonspecific results.13
can avoid its side effects. When therapy is indicated, use of The prosthodontist should play an active role in educating patients
corticosteroids in periodic bursts should be considered. Retinoids about ways to minimize the occurrence or severity of vesiculoerosive
have also been used, along with intravenous immunoglobulin. for conditions. Care mus t be taken when handling the oral tissues .
Oral Manifestations of System ic Conditions J
Poorly contoured sharp restorations, rough prostheses, and ill-fitting it.'" BMS also can be Oow rate;
associated with reduced salivary
prostheses may all contribute t o the condition. A tissue-supported therefore, the resulting xerostomia may need treatment. However,
prosthesis may be a challenge because pressure on the mucosa because xerostomia also can cause a burning sensation, the ques
may initiate or exacerbate these conditions. Therefore, whenever tion of which condition was the predecessor is an important one to
possible, prostheses that are not tissue supported (eg, tooth- or resolve. A diagnosis of BMS is made when other causes have been
implant-supported prostheses) are highly desirable. excluded, which is significant because BMS has an average duration
of 2 t o 3 years.
Systemic lupus erythematosus BMS may be divided Into primary BMS and secondary BMS
based upon associated etiologies. Primary BMS includes idiopathic,
Systemic lupus erythematosus (SLE) is a multisystem condition that nonneuropathio BMS, and secondary BMS, or burning mouth
has musculoskeletal, hematologic, integumentary, and serologic in sensations, results from organic and therapeutic factcrs such as oral
volvement." Patients suffer periods of activity and remission. Ad· cavity disorders. systemic disorders. nutritional imbalances, drug
vanced SLE may appear similar t o Sj6gren syndrome. and the asso interactions, or neurologic/psychiatric variations.'9 BMS can also be
ciated xerostomia will have dental implications. Females are affected classified by its frequency of presentation:
far more than males. with some reports suggesting a 10:1 predilec
tion.'"-'611 is theorized that SLE represents an autoimmune condition • Type 1 BMS is defined as daily occurring symptoms that do not
that develops as a result of the formation of immunoglobulin G and manifest upon awakening but develop during the day.
immunoglobulin M immune complexes, and it is often categorized • Type 2 BMS refers to daily occurring symptoms that are present
as a type Ill hypersensitivity reaction. The effects can be generalized all day.
or organ-specific; kidneys. lungs, and joints are often affected. The • Type 3 BMS refers t o intermittent symptoms with pain-free
etiology of SLE may be partially genetic, with environmental stimuli inteNals.
such as medications, infection (eg, Epstein-Barr virus). and sunlight
as possible triggers.'7 Oral lesions such as desquamative gingivitis In general, nonpsychiatric factors are linked with Type 1 BMS, and
or erosive mucosal lesions have been reported in up to 40% of pa psychiatric factors are linked to Type 2 BMS. BMS is considered
tients. The histology of the oral lesions i s similar t o those of EM or to have one or more of four possible etiologies: local oral factors,
OLP in that bandlike subepithelial inflammation is present. In SLE systemic factors, psychogenic, and idiopathic.
biopsy specimens. the use o f immunoffuorescent staining technique Given the potentially multifactorial etiology of BMS and the
will often show the immunoglobulin and complement deposition possibility that a psychiatric component exists, treatment relies on
along the basement membrane. a thorough examination and history.20 Interestingly, use of hormone
Susceptibility to infection is common among SLE patients, so replacement therapy has not proven unequivocally effective, despite
clinicians should closely monitor their patients for craniofacial the susceptibility of postmenopausal women to developing BMS.
infections. In addition, because SLE patients are vulnerable to stroke, Some studies have suggested use of antidepressants and selective
many are placed on blood-thinning medications. which would affect serotonin reuptake inhibitors for those patients with psychiatric
surgical management. Patients on dialysis also may require modified factors. The analgesic effects of these medications may be more
scheduling after the dentist consults with the patient's physician. beneficial than their antidepressant activity. In addition. some
antidepressants exacerbate xerostomia. Benzodiazepines (eg,
Burning mouth syndrome clonazepam) and gabapentinoids (eg. gabapentin and pegabalin),
which may interrupt the neuropathogenesis of BMS, also are
Historically, burning mouth syndrome (BMS) has been considered a reported to be effective in some patients with BMS. Regardless,
nonneuropathic cond�ion with an intraoral localization. usually unac many BMS patients struggle with the condition and do not find
companied by mucosal lesions or other clinical signs of organic dis· effective treatment. Newer medications may prove to be effective
ease. More recently, however. it has been proposed that idiopathic with fewer side effects.
BMS may have a neuropathic pathogenesis. In general, patients de
scribe a co nstant, intense pain, with a sensation of being scalded, Pregnancy
that frequently affects the lips, palate. and tongue. '6 The condition
manifests in females at a ratio of 7:1 and appears to be particularly Pregnancy gingivitis21 is inflammation ot the gingiva (typically ante
prevalent in postmenopausal women. Thus, the mean age of BMS riorly) that is obseNed in up to 75% of pregnant women. Tissues
patients is between 55 and 60 years old. BMS can be characterized are erythematous, edematous, hyperplastic, and especially prone to
by both presence of sensory symptoms (burning pain, dysesthe hemorrhage upon the slight€st contact. It is postulated that poor
sia) and absence of sensory symptoms (loss of taste. paresthesia). oral hygiene accentuates the conditio!l, which is a product of the
Therefore, BMS is distinct from the aforementioned VECs in that it is pregnancy, by promoting inflam mation. The histologic appearance
not considered an autoimmune disorder. and no specific histologic of the gingival tissues shows altered vascular networks with capillary
pattern can be identified in the mucosa of patients suffering from beds opened up and an inffammatory cell infiltrate.22 As a result of
41
4 i Oral-Systemic Interactions
these findings, it is reasonable to conclude that pregnancy affects disease. a dental examination and aggressive treatment of poten
the vascularity of the gingiva and the immune response t o bacterial tially susceptible teeth and tissues may be warranted t o prevent the
challenge. Interestingly, this condition is not always painful. need for treatment later in the course of the disease under more
Pregnancy tumor is another benign hyperplastic gingival condnion adverse conditions.
seen during the second and third months of pregnancy.231ts location.
typically between anterior maxillary teeth. and its purplish color make Huntington disease
it more noticeable than pregnancy gingivitis. Histologically, it appears
to be very similar to a pyogenic granuloma in that it includes immature Huntington disease. which typically presents in 30- to 40-year-old
vascular granulation tissue along with neutrophils. lymphocytes. and age groups. is associated with choreatic movements and dementia.
plasma cells." As wiU1 pregnancy gingivitis, pregnancy tumor is The disease has a well-described genetic etiology and results from
often painless and seems more common in women with poor oral an autosomal dominant mutation on the short arm of ch romosome
hygiene. 1-lowever. hygiene alone does not explain the presence 4. Oral dyskinesias associated with the disease include speech prob
of these lesions in the anterior area of the mouth. where hygiene lems, swallowing difficulties. and grimacing. The excessive head and
is typically better. Fortunately. the lesions often resolve once the mouth movements are a challenge in dental care. and sedation may
pregnancy i s over. be considered to assist in patient management. As with patients af
fected by Parkinson disease. edentulous patients may warrant treat
ment with implant-supported restorations.
Dyskinesias
Tourette syndrome
Dyskinesias. or movement disorders. can profoundly affect oral
health as modifying factors within the oral cavity that can inhib1t pro Typically manifesting in childhood or young adulthood. Tourette syn
vision of dental care.25 Although it may be assumed that the chal drome is characterized by facial tics. multiple dyskinetic events, and
lenge of dyskinesias lies in excess movement. some dyskinesias vocal sounds. Patients with Touretle syndrome may use inappropri
involve diminished movement. Dyskinesias are best managed by an ate language as a consequence of this condition.Tourette sufferers
interdisciplinary team of medical and dental specialists who work often engage in self-mutilation of oral tissues; biting of the tongue.
together to ensure optimum health lor each patient. lips. or cheek may be obse1ved in these patients. In addition. hy
posalivation and xerostomia are side effects o f some of the drugs
Oral dyskinesias prescribed for Touretle sufferers, such as haloperidol.

Patients with Tourette syndrome are particularly sensitive to stress.
Lobbezoo and Naeije26 suggest that oral dyskinesias be divided and dental visits may exacerbate their condition. Helpful measures
into orofacial dyskinesias and oromandibular dyskinesias. Orofacial include short appointments. a calm and soothing atmosphere. and
dyskinesias are made up of involuntary movements of the face, lip, some early appointments lhat involve only consultation activities
tongue. and jaw. They can be a result of psychiatric conditions. an where the patient and practitioner can develop a rapport. If complex
overdose of dopan1ine drugs, or chronic use of antipsychotic medi restorative treatment is necessary, sedation can be used after
cations. Oromandibular dyskinesias consist of involuntary and ex consultation with U1e patient's other health care providers.
cessive contractions of lip, tongue. and jaw musculature. Antipsy
chotic medications or loss of basal ganglia control in the thalamus
and brain stem are postulated to be causative agents for oroman Bone conditions
dibular dyskinesias. Removable prostheses or trauma experienced
during dental treatment also may be precipitating factors for either Osteoporosis
fom1 of oral dyskinesia. The use of implant-supported restorations
may be beneficial to some edentulous patients whh this condition. The loss of bone density (osteoporosis) at nonoral sites vulnerable to
fracture (eg. hip, wrist, spine. heel) has led to the question of whether
Parkinson disease oral bones are also compromised. At present. a diagnosis of os
teoporosis i s made after comparison o f an individual's bone mineral
The challenges facing the patient with Parkinson disease are pre density (spine and hip are the most common sites analyzed) to a
dominantly twofold. The tremors. hypokinesia, and muscular ri reference value of typical bone density in a normal 30- to 40-year
gidity often seen in these patients present physical challenges to old population. If the individual's bone mineral density is 2.5 or more
the provision of dental care. A patient with Parkinson disease also standard deviations below the reference mean. the World Health
may present with a number of oral manifestations such as xerosto Organization guidelines support a diagnosis of osteoporosis. Bone
mia, burning mouth, mucositis, drooling, and difficulties with swal mineral density is but one surrogate for bone quality, however; new
lowing and speaking. Many patients find optimum oral hygiene a fracture risk guidelines reconcile other surrogates to provide better
challenge to maintain. As such. they are at increased risk for car prediction of fracture risk"'·20 (FRAX analysis).
ies and periodontal disease. For patients in the earty stages of the
Oral Manifestations of Syste mic Conditions J
Fig 4-3 (<��large osteonecroitcleslon o lll'.axllla In a pallenl

receiving zolelldrolc acid to oontrol multiple myeloma. (IJ)
Small lesion of mandible associated with adminlstmtion of
bispllospllOn ales to oon1101 bony metastasis.
The main implications for the restorative clinician involve peri in the jaws and angiogenesis that precludes the osseous healing
odontal disease progression and dental implant survival because pattern.3' Furthermore, there is evidence that t he risk of developing
both are affected by bone quality. lhene is growing evidence that bisphosphonate-associated ONJ increases not only with dosage
osteoporosis may be a risk !actor lor periodontal disease because but also with duration or bisphosphonate therapy. Occasionally,
patients with low bone mineral density or a diagnosis of osteoporosis ONJ can develop spontaneously or following trauma to sites of
tend to have more advanced periodontal disease (as measured by poor blood supply, such as tori or the mylohyoid ridge. To date, an
clinical attachment loss) and a greater incidence of tooth loss.29·30 increased risk of develop ing ONJ or dental implant failure has not
ll is still unknown whether this effect of the osteoporotic condition been reported in patients receiving bisphosphonate therapy and
crosses socioeconomic strata. dental implant treatment. Until a better appreciation grows for the
A recent publicat ion b y Holahan et aP' provides the broadest incidence of ONJ in bisphosphonate-directed care for osteoporosis.
analysis yet of tl1e effect of systemic bone mineral density on dental patients who are taking bisphosphonates should be informed that
implant survival. The data support previously published smaller they are at risk (albeit very low) for developing ONJ after any dental
studiesn.33 that showed neither low bone mineral density nor a surgery, including dental implant placement.'la Particular attention
diagnosis of osteoporosis as a risk factor for dental implant survival. should be paid to the duration of bisphosphonate exposure.
Therefore, given the available evidence, a diagnosis of osteoporosis Rgure 4-3 shows osteonecrotic lesions in the maxilla and mandible.
is not a contraindication to dental implant therapy.
Salivary dysfunction
Osteonecrosis of the jaw
In 2005, Ruggiero et aJ described 63 cases of osteonecrosis of Saliva has an important role in many key physiologic functions.
the jaw (ONJ) associated with intravenously or orally administered Saliva supports food intake and digestion of starch (amylase) and
bisphosphonates."' Patients who had received hi gh doses of lipids Qipase). Dur ing digestion, saliva dissolves food to promote
bisphosphonates wene at greatest risk tor developing bone necrosis optimum taste perception. Saliva's role in protecting the oral cavity
at surgical sites. such as those at risk for skeletal-related events or structures is well understood. Through its rinsing and Uushing acti v
bone pain secondary to multiple myeloma; those with breast cancer. ity and lhe presence of immunoglobulins. tysozymes. peroxidases,
lung cancer, and prostate cancer; and those who had undergone and histatins, saliva protects the dentition and periodontium against
dental surgery. Some similarities exist b etween the clinical presenta infection. Saliva is also necessary for speech, s wallowing and main
,
tions of ONJ and osteoradionecrosis (see chapter 14). The American tenance of taste receptors.30
Association of Oral and Maxillofac al Surgeons"" and the American
i Salivary gland dysfunction may result in hypersalivation or
Society of Bone and Mineral Research"' agree that ONJ is clinically hyposalivation. The former condition, which is less studied. is assoc
defined as bone that is exposed for longer than 8 weeks in someone iated with specific neurologic disorders such as Parkinson disease
with a history of bisphosphonate use. and amyotrophic lateral sclerosis (ALS) and with developmental
In patients receiving lower doses of bisphosphonate, such as conditions such as Down syndrome, autism, and cerebral palsy. tn
those being treated for osteoporosis or osteopenia. the incidence some instances, excess saliva Is a result of swallowing difficulties
of ONJ appears to be extremely low. Since 2005, many additional and not actually incneased saliva production.
published cases confirm the condition of bisphosphonate Hyposalivation. defined as an unstimulated whole salivary flow rate
associated ONJ as a likely result of suppnession of bone turnover of less than 0.10 to 0.16 mUmin collected for 5 to 15 minutes. refers
43
to diminished salivary flow."'·" Tl1e condition is not synonymous complain of xerostomia, which is confirmed by objective measure
with xerostomia. which represents a patient's subjectiVe feeling of ments that demonstrate reduced unstimulated whole saliva produc
oral dryness. Although hyposafivation and xerostomia may occur tion:•• Because approximately 30% of those with SLE develop sec
simultaneously, either can occur without the other. In the authors' ondary SS, this condition is observed often.60 Other conditions such
experience, some patients who complain of dry mou th appear t o have as primary biliary cirrhosis and sarcoidosis also may be associated
reasonable volume of saliva, whereas others who seem t o have little with secondary SS and hyposalivation. although the pathophysiol
saliva may not complain of being xerostomic. However, if salivary flow ogy is unclear.
is reduced below 50% of its normal rate, patients generally perceive Similar to SS. patients with human immunodeficiency virus exhibit
a dry mouth and are therefore xerostomic. UHimately. changes in the clear lymphocyte infiltration of salivary gland tissue. which leads
volume or composition of saliva leave patients vulnerable to a variety to hyposalivation and gland enlargement, especially of the parotid
of oral consequences, including dry or cracked lips; angular cheilitis tissues.
of the lips; dry, dirty, or coarse tongue; erythematous tongue; dental
erosions; oral candidiasis; oral ulcers; caries lesions; dysphagia; Radiation-induced hyposalivation
and difficulty wearing removable prostheses. The prosthodontist is
challenged to help patients manage such conditions that affect oral Radiation therapy is routinely employed to treat head and neck can·
health and quality of life. Hyposalivation resulting from medications cer, and the salivary glands are usually exposed to the effects of
will be discussed later In this chapter. radiation if they lie in the radiation field or cannot be appropriately
Certain systemic conditions predispose patients to hyposalivation shielded.5' Of the three main pairs of salivary glands, the parotid
or xerostomia; this area of study is reviewed in excellent detail by glands are the most sensitive to radiation. Dysfunction of the glands
von Bultzingslowen et al.'" Because data on the volume and quality is likely caused b y one or more of three reasons: (1) damage to
of saliva in patients with diabetes mellitus are inconclusive to date, the gland vasculature. (2) death of parenchymal tissue, or (3)
an association between this condition and salivary gland dysfunction diminished neural signaling. Effects are dose dependent, and, unfor
has not been established. One group of systemic conditions that has tunately, the doses needed for therapeutic effect (50 to 70 Gy) are
been proven t o affect salivary flow, however, is chronic inflammatory greater than the doses that induce salivary gland dysfunction� (more
rheumatic diseases. than 40 Gy). Use of intensity-modulated radiation therapy (IMRT) can
reduce the detrimental effects of radiation on parotid gland tissues.
Inflammatory rheumatic diseases However. the submandibular or sublingual glands do not benefit
from IMRT.
Sjogren syndrome
Sj6gren syndrome (SS) is an autoimmune inflammatory connective
tissue condition that predominantly affects women between the Dental conditions
ages of 30 and 50 years."" Along with salivary gland dysfunction, lac
rimal gland dysfunction is also seen, which results in keratoconjunc Eating disorders
tivitis sicca. Normal glandular function appears to be disrupted by
excess lymphocyte infiltration. The parotid or submandibular glands Approximately 8% to 10% of females in the United States suffer from
may become enlarged, and systemically, malaise and arthralgia may an eating disorder of some kind. Two serious eating disorders have
ensue....·•• Patients with primary SS, characterized as only salivary dental management implications: anorexia nervosa (AN) and bulimia
gland and lacrimal gland invol vement, are at greater risk for develop nervosa (BN). Prevalences of AN in 1.0% of adolescent girls (0.5%
ment of autoimmune thyroiditis, non-Hodgkin lymphoma. hepatitis, to 3. 7% of all females) and 2% to 3% in young women have been
interstHial nephritis, and lung disease. Those with secondary SS, reported, and an socioeconomic classes are affected.53 The preva
which is primary S S plus another autoimmune rheumatic disease. lence of AN in young men i s also rising, albeit at a lower rate than
may also suffer from connective tissue disorders such as rheumatoid in young women. Unfortunately, in most Western industrialized cui·
arthritis (RAJ or lupus erythematosus. Given the clinical and histo tures, the incidence of both of these conditions is increasing. Eating
pathologic descriptions o f SS, diagnosis often involves the assess disorders represent a manifestation of psychiatric suffering and a
ment of dry mouth. dry eyes. saliva secretion rates. tear secretion struggle to achieve a physical appearance resembling the patient's
rates, biopsy of glandular tissue for determination of lymphocyte concept of an ideal body shape. Inner conflicts resulting from lack
infiltration, and autoantibody testing."8 Quality of life is significantly of self-esteem, dislike of body appearance. and the relationship of
affected for patients with Sjogren syndrome.'' these to diet create a circle of guilt and obsession.&-� Regardless of
sex. sufferers of eating disorders often look upon their behavior as a
Other conditions sign ot tremendous self-discipline and may feel almost heroic a s they
Other inflammatory rheumatic conditions also may involve hyposafi lose weight and suppress appetite.
vation. Approximately 30% of RA sufferers also have SS. although For a diagnosis of AN, the patient's symptoms must conform to
the hyposafivation seen in some RA patients seems to occur even if the guidelines set out in the DSM-tV-T R (the American Psychiatric
secondary SS is not present:'8 More than 75% of patients with SLE Association's Diagnostic and Statistical Manual of Mental Disorders
Oral Manifestations of Systemic Conditions J
N, Text Revision).55 AN is considered to be present if the following 5. Absence of anorexia. A cycle of bingeing and purging is not con
four criteria are met: sidered BN if it occurs during an episode of AN. Instead, the pa
tient is S8Jd to have binge/purge type anorexia.
1. Weight loss. Pat ients with AN experience a weight loss of at least
15% of normal body weight based on age and height. In other The oral manifestations of AN and BN fall into two categories.56
words, body weight is less than 85% of what medical authorities The first category relates t o oral changes as a result of malnutrition.
consider a minimum normal weigh t. 8-group vitam in defiCiency is associated with decreased epithe
2. Fear of weight gain. Patients display an intense fear or gaining lial regeneration and neuropathy related to glossiti s. Furthermore, a
weight and worry incessantly about becoming fat. This fear per burning mouth sensation may be described by some malnourished
sists even after severe weight loss. patients, although it should be recognized that burning mouth syn
3. Distorted body image. An anorexic patient's image of the ideal drome has a multifaceted etiology. Other consequences of chronic
body is profoundly disturbed. Even after severe weight loss, these malnutrition include bilateral parotid gland enlargement and sial
patients see themselves as ·rat." Body image abnormally influenc adenosis. The second category of oral manifestation is dental ero
e s his or her sense of self-worth. This distorted body image leaves sion. Typical vulnerable sites are the palatal surfaces o f anterior and
patients unable to realistically evaluate weight loss. As such they . posterior teeth and in the frequent purger soft tissues (eg. loss or
, .
will often deny the seriousness of weight loss, even i n the face of tongue papillae or mucosal reddening). Any dental restorations pres
starvation. ent will remain unaffected while tooth structure around the restora
4. Amenorrhea. Amenorrhea must be present for a diagnosis of AN tions erodes. Further loss of tooth structure may be inhibited by the
in females. Amenorrhea is defined as a cessation of menses for use o f 1 .1% neutral sodium fluoride. Placement of full-coverage den
at least three menstrual cycles. An inadequate diet and malnutri tal restorations may have advantages for patients with BN because
tion cause a drop in bloodborne sex hormones, resulting in the they prevent further erosion of tooth structure. Stimulation of salivary
cessation or menstruation. Long-term amenorrhea causes hor flow using sugar-free chewing gum also may be beneficial. However,
mone imbalances that increase the risk of osteoporosis in female sucl1 treatments are predominantly palliative for the effects of BN,
patients with AN. and referral to a medical practitioner is vital to ensure that patients
with AN or BN receive the appropriate psychiatric care.
The signs and symptoms of AN are usually obvious. Malnutrition .
especially lack or protein absorption as a result of prolonged lack or Gastroesophageal reflux disease
carbohydrate ingestion, causes multisystem effects. The weight loss
observed in AN precedes amenorrhea in most (but not all) sufferers. Gastroesophageal reflux disease (GERD) affects approximately 35%
In patients who experience extreme weight loss, ventricular tachy to 40% of adults in the United States. The most common complaint
cardia and sudden death may result from electrolyte imbalance. is heartburn, but the condition has a wide range of manifestations,
The DSM-IV-TR also provides criteria by which a diagnosis of BN including laryngitis, asthma. cough, and chest pain, all of which
is made. Duration and frequency of the bingeing and purging cycle result from acidic stomach contents entering the esophagus and
are important factors for diagnosis. as is t he patient's attitude toward lungs. The lower esophageal sphincter pressure. the motility of the
weight loss and body image. In all, five cri teria must be met before a esophageal body and the stomach, the composition of the reflux
diagnosis of BN is considered: material, and the sensitivity of the esophageal mucosa to the re
flux material are important factors involved in the pathogenesis of
1. Binge eating. The DSM-IV-TR defines bingeing associated with disease-related symptoms and lesions. The most useful tool for
BN as eating withi n a specific time period an amount of food sig diagnosis of GERD is 24-hour monitoring of esophageal pH via a
nificantly greater than that expected of normal eating habits. catheter passed through the nose to a point approx imately 2 inches
2. Purging. Purging is defined as recurrent, inappropriate compensating superior to the lower esophageal sphincter. Many clinicians make a
behavior to prevent weight gain after episodes or bingeing. Purging diagnosis of GERD if the pH drops below 4.0 for at least 4% of the
behaviors associated with BN include self-induced vomiting misuse, 24-hour monitoring period.01-M
of laxatives diuretic use, enemas, fasUng, and excessive exercise.
, A recent systematic review58 demonstrated a strong association
3. Frequency and duration. For a diagnosis of BN, episodes of between GERD and dental erosion. with the lingual and palatal
bingeing and purgi ng must occur at least twice a week for 3 con surfaces of teeth most often involved. In some instances, the tongue
secutive months. may act to protect lingual surfaces by pushing acidic fluid onto
4. Body image and we g
i h t loss attitudes. Patients with BN,Iike those the labial surfaces of teeth. Teeth with significant lingual or palatal
with AN, have an excessive fear of weight gain and self-evaluate erosion may become progressively thin and take on a y ellowish
almost completely in terms of body image and weight loss. A pa appearance. Anterior teeth with thin incisal edges also may be prone
tient with BN h as an unrealistic image of hi s or her ideal weig ht, to chipping. Posterior teeth may have occlusal "cupping" where
usually well below the healthy minimum required for the individu dentin dissolution occurs more rapidly than enamel dissolution, and
al's age, sex. and height . dental restorations may protrude from the rest of the tooth surface,
as seen in AN and BN. Some pa t ients' dentition may compensate lor
45
4 LOral-Systemic In teractions
Fig 4·4 Multiple views of a patient witl1 a form or amelogenesis imperfecta. (a)Anterior view. (b) Occlusal view of the mandible. (c) Occlusal view or the maxilla.
loss of tooth structure by eruption or other forms of tooth movement, who treats a patient with AI must first recognize the condition and
predisposing these patients to maloccluSions or toss of vertical determine if full-coverage restorations that extend to (presumably)
dimension of occlusion. Interestingly, the acidic environment may normal cementum are warranted.
prevent activity of cariogenic bacteria; patients with GERD appear Dentinogenesis imperfecta (01)-an autosomal dominant
to have a tower rate of caries lesions than the general population. hereditary condition in which dentin formation is ab normal
Management of dental erosion result ing from GERD may take can be subdivided into three types60: (1) type I is associated with
the form of noninvasive treatment aimed at increasing salivary flow, osteogenesis impertecta (01); (2) type II i s not associated with 01;
which would buHer the eHects of tow pH and wash away the acidic and (3} type Ill is associated with the Brandywine triracial isolate
fluid. Treatment may also include use of topical fluoride (neutral and large pulp chambers. tn types 11 and Ill, mutation of the dentin
pH), placement of Simple restorations, or even lull-mouth fixed sialophosphoprotein gene on chromosome 4 has been implicated.
prosthodontic rehabilitation (with or without orthodontic therapy) to Type I Of with concurre nt Of is a mutation of the collagen 1 gene
protect tooth structure and correct malocclusion. As with many other that res ults in abnormal dentin formation. Regardless of the Dl type,
medical conditions that have oral manifestations, patients suspected teeth have a blue-gray or yellow-brown opalescent appearance.
of having GERD should be referred to their physicians to determine Although ena01et forms normally in Dt patents,
i the tack of sound
if the GERD is still active or if it occurred in the past. Treatment for structural support renders the enamel prone to fracture, which
active GERD Sihoutd follow phySician recomme ndation s. results in the ma�ormed dentin wearing rapidly, sometimes to the
point where teeth are worn down to the soft tissue crest of the
Dental malformations alveolar ridge. In types I and If, dentin deposition is often excessive
and results in obliterated pulps, whereas in type Ill pulp chambers
Tooth development is a well-choreographed series of genetic events are larger than normaL It is a challenge to restore teeth that are
that ensunes apprepriate interactions between epithelial and mesenchy so structurally compro mised . Because the rapid tooth wear is
mal tissues. Research from the past 20 years attempts to understand difficult to prevent. placement of dental restorations may not have a
the regulation of the genes involved in tooth development, and the re good prognosis.
sutts of this work may create opportunities for successful manufactured
tooth regeneration. TI1e genes that are known to influence tooth forma
tion and development are well reviewed by Hu and Simmer.50 Other systemic conditions with oral effects
Amelogenesis imperfecta (AI) is a diverse group of dental mat
formations resulting from aberrant activity of genes responsible Diabetes mellitus
tor enamel rormati0n.00 Figure 4-4 shows the anterior and occlusal
views of a patient with AI. To date, four genes have been implicated Diabetes mellitus is o ne of the world s most insidious diseases.
'
in AI: amelogenin (the principal extracellular matrix protein in enamel). About 5% of annual global deaths can be attributed to diabetes.
enamefin, KLK4. and MMP20. Witkop6' proposed four subclasses of Life expectancy for a 40-year-old male diagnosed with diabetes is
Al based upon phenotype: {1) type I refers to hypoplastic AI; (2) type decreased by 12 years. Life expectancy for a 40 year otd female - -
If refers to hypomature enamel ("snow-capped" teeth are an example diagnosed with diabetes is reduced by t4 years. Unfortunately, the
of type If At); (3) type Ill refers to hypocalcified enamel; and (4) type prevalence of diabetes is increasing throughout the world; the World
IV refers to hypomature-hypoplastic enamel with taurodontism. Healt11 Organization reports that 220 million people suffer from di·
Regardless of the type of AI, enamel is structurally compromised, abetes around the world and that 1.1 m•llion people died from it
and its fragility manifests as enamel fracture or accelerated enamel in 2005.e2
wear. Teeth may appear yellow or brown if underlying dentin is visible. Type 1 diabetes (formerly insulin-dependent diabetes) manifests
and patients may complain of hypersensitivity. The prosthodontist in approximately 5% of diabetes sufferers and represents insulin
Oral Manifestations of Systemic Conditions J
deficiency. Disease onset often occurs in adolescence or young widened palpebral fissures, effects of GERD, thickened periodontal
adulthood. Type 2 di abetes manifests in approximately 85% to 90% ligaments, blunted mandibular angles, a mouselike face (resulting
of people with diabetes and represents a combination of insulin from atrophy of nasal alae), and in many chronic situations , limited
resistance and reduced insulin secretion. The other 5% to 10% of mouth opening that is related to microstomia, thereby limiting oral
diabetes cases result from other inherited or acquired causes sucl' cavity access.'" Dental m anage ment may involve keeping the
a s gene tic mutations intertering with beta cell function, pancreatic envi ronment warm for the patient prone to vascul ar spasms and
disease, acromegaly, Cushing syndrome, and pheochromocytoma, using oxygen for patients whose pulmonary func tion is reduc ed .
among others.
Diabetes is diagnosed after two atypical plasma glucose values Amyotrophic lateral sclerosis
are recorded on different days. The American Diabetes Association
currently states that a fasting glucose of at least 126 mg/dL or a ALS is a progressively degener ative neuromuscular d se
i ase that has
random glucose or post-oral glucose challenge level of a t least no known c ur e. In the United States. the disease gained attention
200 mg/dl meets criteria for diabetes. Measurement of serum after t he famous baseball player Lou Gehrig succumbed t o ALS in
hemoglobin A1c (HbA 1 c) levels is a quick way to ascertain the level 1941. In some circles, the disease is kno wn as Lou Ge/Jrig's disease.
of glyce mic control in a p atie nt with d iabetes.63 HbA1 c represents It is estimated that approximately 30,000 individua ls in the United
the amount of glycosylated hemoglobin and offers a guide to the States are afflicted with ALS at any one time, and approxi ma tely
degree of control within the prece ding 3 months. HbA1c levels 5,000 new cases are diagnosed each year.<» The disease presents
should not be used to diagnose diabetes but rather to mo nitor the more frequ entl y in men than in women and usually is diagnosed be·
level of glycemic controt.64 tween t he ages of 40 and 60. The tack of cure is especiall y daunt·
Diabetes has high mortality and morbidity rates because of ing considering that the mean survival time pos tdag i nos is is 3 to 5
complications resulting !rom vascular disease. Microvascular ye ars."' Many ALS patients suffer from depression as the disease
complicati ons result in retinopathy, nephropathy, and neuropathy. advances. The etiology of ALS is poorly understood although a.
Macrovascular complications lead to coronary artery dis ease , gen etic link is proposed in about 10% of ALS cases. Other work
peripheral vascul ar disease. and cerebrovascular disease. suggests tha t smoking and history of hea d trauma may be li nked
Acute systemic complications of diabetes include hyperosmolar to development of ALS. Medical management of ALS offers few op
hyperglycemia, in fection. and diabetic ketoacidosis. Patients with tions. Only one medication riluzole. is cleared by the Federal Drug
,
diabetes are at greater risk for xerostomia. candid iasis. gingivitis, Administration for ALS.
periodontitis, oral lichen planus, and oral cancer.65 Smoking The med ication is an i nh ibitor of gl utamin e release, which is impli·
exacerbates the effect of diabetes on periodontitis. Additionally, cated in the motor neuron degeneration seen in ALS. Unfortunately,
some evidence indicates that periodontitis may predispose patients riluzole only modestly affects progression of the disease_>o Ultimately,
to worsening diabetes and increased mortality.00 However, it is the inability to respire as diaphragm and intercostal muscle fUnction
s till unknown whether specific oral hygiene interventions lead to is lost leads to death. unless the patient choose s to have a trache
improved diabetic control and fewer consequences of diabetes. ostomy performed. Regardless. a time comes when the patient is to·
tally dependent for all basic needs. communiCation becomes limited
Scleroderma or nonexistent, and palliative care is the remaining focus."
Sensory neurons are unaffected in ALS. whereas motor neurons
Progressive systemic sclerosis (PSS) is a chronic autoimmune con in the later al tracts of the spinal cord slowly sclerose leading to
,
dition that often manifests first as scleroderma. Scleroderma is char progressive muscle weakness that culminates in loss of all motor
acterized by progressive increases in the production of type I and function. EMG studies demonstrate fibrillations that correlate with
type Ill collagen that result in tissue fibrosis. Concurrently, increased denervation and the muscle wasting that occurs because of atrophy
levels of amorphous ground substance are deposited in connective of affe cted muscles. In addition, magnetic resonance imaging, nerve
tissues. Changes in the walls of microvasculature often occur, lead con duction studies, nerve b1opsy, serum studies (elevated creatine
i ng to thi ckeni ng and smaller lumen size. phosphokinase may be seen in ALS patients), and myelography
PSS can be classified into localized sclerosis and systemic also may be pertormed. However. a diagnoSis of ALS is normally
sclerosis."' The latter is ofte n one of five conditions seen in patients made after other neurologic conditions such as mul tiple sclerosis
with CREST syndrome (a combination of calcinoSis cutis, Raynaud's and rad icutopathy have been ruled out.
p he nome non , esophageal dysmotility [GERD]. sclerodac tyly, and ALS has two main oral manifestations of which p racti tio ners should
telangiectasias). Life-threatening renal dis ease develops in 10% to be aware. Degenerative changes occur in the anterior horn cells
15% of patients with PSS, and pulmonary disease often becomes o f the spinal cord that contain motor nuclei of brain stem, notably
debilitating as fibrosis affects pulmonary tissues. PSS, CREST, and cranial nerves VII (facial} and XII (hypoglossal}. Consequently, ALS
scleroderma usually present between 30 and 50 years of age and patients have altere d facial expressions and impaired swallowing
are seen in women four times as often as in men. capability. Further progression of the disease leads to aspiration and
Orofacial manifestations in the patient with PSS or scleroderma dysphagia resuHing from loss of motor function in muscles that make
include xeropthalmia, xerostomia (due to fibrosis of salivary gla nds) , up the pharynx, palate, tongue, and neck.
47
4 iOral-Systemic Interactions
Periodontal disease with gastric ulcers, hypertension, or asthma. Randomized controlled

trials (RCTs) demonstrate that pilocarpine helps patients find relief
Research on the role of periodontal disease in systemic function has from xerostomia. Current guidelines recommend a 5-mg dose taken
focused on cardiovascular disease (atherosclerosis and thrombosis) orally three times a day for patients with primary or secondary SS or
and pregnancy in an attempt t o uncover a strong association be those suffering from radiation-induced xerostomian Higher doses
tween periodontal disease and both of these conditions. Regretta (up to 10 mg) may be used, ff necessary. although new formulations
bly, the degree of association has proven difficult to define as studies may increase the effectiveness of the medication.
with contrasting results have yielded a data set that is far from com Cevimeline hydrochloride, a derivative or acetylcholine and a
pelling in establi shing a sound link. The number of confounding vari muscarinic agonist, has been shown in RCTs to reduce xerostomia
ables in cardiovascular disease and pregnancy makes the exact role and hyposativation.78 Side effects include increased muscle tone and
of periodontal disease difficult to identify, and additional variations in molil� of the Gl tract and increased actiwy of pancreatic, gastric,
the definitions of periodontal disease add to the confusion.7�·73 and sweat glands. The current recommended dose is 30 mg to be
taken orally three times a day for patients with primary or secondary
ss.•>
Pharmacologic Interactions in Interferon-a iS a cytokine with a wide range of systemic effects

that particularly affect the immune system. RCTs appear to have
the Oral Cavity reached a reasonable consensus that interferon-a improves patients'
subjective assessment of xerostomia; however, conflicting data have
been published regarding benefits on reducing hyposalivation.42
Medications inducing hyposalivation Current dosage recommendations for patients with primary SS who
are looking for relief from xerostomia are 150 IU of interferon-alpha
A dry mouth seem s to be one of the most common side effects to be taken in lozenge form three times a day.
of medication use; over 400 medications depress function of the
salivary glands.m� Different medications induce hyposalivation by
different mechanisms that interfere with parasympathetic signaling. Drug-induced intrinsic discoloration of teeth
Some do this by inhib�ing adrenergic neuroeffector junction activ
ity, others by lowering central connection activity of the autonomic Teeth are especially prone to drug-induced changes from birth to
nervous system, and still others through anticholinergic effects. approximately 8 years old. Effects of drugs on tooth development
The clinician must stay aware of new and existing medications and include discoloration that can be difficult to reverse by noninvasive
possible medication interactions. Currently, the following families of means such as vital bleaching.70 Depending on the teeth and tissues
medications have representatives that interfere with salivary gland affected, direct or indirect restorations may be necessary.
function: antidepressants, antihistamines. antihypertensives, anti
psychotics. antiarrhythmics. anticonvulsants . diuretics. antiparkin
Fluoride
sonians, antiemetics, antiarthritics, anJHnflammatones, and anx
iolytics. In addition, chemotherapy can lead to hyposalivation and Optimum fluoride intake results in esthetically unaffected teeth that
changes in the quality of the saliva produced. Fortunately, in most are relatively resistant to the formation of caries lesions because of
patients, salivary function returns to normal or close to normal after improved enamel strength. However, excess fluoride exposure dur·
chemotherapy ends. unless doses were exceedingly high or pro ing tooth development leads to hypomineralized enamel and chang·
longed use occurred. es in appearance lhat range from small white flecks at cusp tips lo
larger opaque areas t o darkly stained pitted areas.
Medications to treat hyposalivation and its Tetracycline

effects Mothers who take tetracycline (or a derivative) during the second
or tl1ird trimesters of pregnancy may have children whose teeth are
Pilocarpine is a muscarinic-stimulating cholinergic agonist with para significantly discolored and which appear initially as yellow and then
sympathomimetic properties, nesulting in increased muscle tone turn to gray or gray-brown over time. Parents should avoid giving
o f various tissues o f the gastrointestinal (GQ tract. As a mimic of tetracycline to children under the age of 8 years to prevent disco!·
acetylcholine, pilocarpine stimulates secretion from the salivary and oration of the permanent dentition. Tetracycline or oxytetracycline
lacrimal glands.'e Patients should be monitored for sweating or Gl leads to yellow teeth, whereas chlortetracycline produces gray
disturbances, and the drug should not be administered t o patients brown teeth.'6
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42. von BG!tzingsloweo 1, Sollecito TP, Fox PC. et al. Salivary dysfunctiOn as· 69. Hoffman JJ. Toward a bette < understanc!lng of amyotrophic lateral scl<lrOSis.
sociated with systemic diseases: Systernati<; review at1d clinical manage· Home Haalthe Nurse 2008:26:337-342.
ment recornmendallons. Oral Surg Oral Med Oral Pathol Oral Radlol Ended 70. M�ier RG, M�chell JD, Lyon M, Moore DH. Riluzole lor amyotrophic lateral
2007;103(suppi):S57.e1-1 5. sclerosis (ALS)/motor neuron dJSease (MND). Cochrane Database Syst Rev
43. Mathews SA. Kurian ST. Scofield RH. Otal manifestations of SjOgren's syn· 2007;(1):C0001447.
drome. J Dent Res 2008;87:308-318. 71. Radunovlc A. Mitsumoto H, Leigh PN. Clinical care of patients w11h amyo·
44. Mignogna MD, Fedele S, Lo Russo L, Lo Muzio L, Wolff A. Sj()gren's syn· trophic late<al scle<OSis. Lancet Neuro1 2007;6:9t3-92S.
drome: The diagnostic potential ot early oral manifestations prece<:!01g hy· 72. Koo LC. Polson AM. Kang T. Associations between periodontal diseases and
posalivationtxerostomia. J Orar Pathol Med 2005;34: t-6. systemic diseases: A review of the inte<·relationships and interactions with dia·
45. Mes e H. Matuso R. Salivary secretion. taste and hyposalivation. JOralRehabll betes, reS!Jiratory diseases, cardiovascular diseases and osteoporosis. Public
2007;34:71t-723. Health 2008; 122:417-433.
46. Mavraganl CP. Moutsopoulos NM. Moutsopoutos HM. T h e management of 73. Wuliams RC. Barnett AH. Claffey N. et al. The potential impact of peri·
SjOgren's syndrome. Nat Cin Pract RMumatol 2006:2:252-261. odontal disease on general health: A consensus view. Curr Med Res ()pin
47. Stewart CM, Berg KM. Cha S, Reeves WH. Salivary dysfunction and quality 2006;24:1635-1643.
of ife in Sj()gren's Syndrome: A clitical oral·Systemc connection. JAm Dent 74. Moore PA. Guggenhe,me< J. Mecication·induce<:l hyJ)OSalv i ao
it n: Etiology. eli·
Assoc 2008: 139:291-299. agnosis, and treatment. Compend Conlin Educ Dent 2008:29:50-55.
48. Hetenius LM. Oral and salivary parameters in pal ients with rheumatic diseases. 75. Gupta A. Epste•n JB, SroUSS< H. Hyposalwatio!1 111 aklierly patients. J Can Dent
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Acta Ooontol Scand 2005;63:284-293. Assoc 2006:72:841-846.
49. Sen-Aryeh H. Wnole saliva In systemic lupus erythematosus patients. Oral 76. 8er1< l. Systemic pilocarp111 e for treatment of xerostomia. Expert Opin Drug
Surg Oral Med Oral Pathol 1993:75:696-699. Metab Toxicol 2008;4:1333-1340.
50. Fox AI. SjOgren's syndrome in dennatology. Clin De<matol2006;24:393-413. 77. Nusair S, Rubinow A. The use ol oral pilocarpine in xerostomia and SjOgren's
51. Chambers MS. Rosenthal Dl, Weber AS. Radiation-induced xe<ostomia. Head syndrome. Semin Arthritis Rheum t 999:28:360-367.
Neck 2007;29:58-63. 78. Atkinso11 JC, Grisius M. Massey W. Salivary hypofunction and xerostom.a:
52. Shil:>oski CH, Hodgson TA. Ship JA, Schiedt M. Management ot salivary hy· Diagnosis alld treatment. Dent Clin No<th Am 2005;49:309-326.
pofunction during and alte< radiotherapy. Oral Surg Oral Med Oral Pathol Oral 79. Tredwin CJ, Scully C, Bagan-Sebastian JV. DnJQ·induced disorde<s of teeth. J
Radio! EndOd 2007:103(suppQ:S66.e1-19. Dent Res 2005:84:596-602.
53. Aranha AC. Eduardo Cde P. Cordas TA. Eating discrders. Part!: PsychiatriC 80. McKenna BE. Ul!ney PJ. Kennedy JD, Bateson J. Minocycline-induoed stain·
diagnosis and dental implications. J Contemp Dent Pract 2008;9(6): 73-81. ing of 11'18 adult pennane11t oontition: A reVIew of the literature and report of a
54. National Institute of Mental Health. Eating Disor®rs: Booklet Online Resource. case. De<1t UPdate 1999;26:t6G-t62.
http://www.nimh.nih.(IIOV/healtl\lpubllcations!eattng·discrders. Accessed 3 81. sanchez AR. Rogers AS 3rd, She<•dan PJ. Tetracyclineand other tetracyc�ne·
Dec 2010. derivative staining of the teeth and oral cavity. lnt J Derrnatol 2004;43:709-
55. American Psychiatric Association. Diagnostic and Statistical Manual ol Man 715.
tal Disorde<s IV, Text Revision. Washington, DC: AmeriCan Psychiatric Pes r s, 82. LaPorta VN. Nll<itakis NG. Sindler AJ, Reynolds MA. Minocycline-associated
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manifestations of eai
t ng disorders: A critical review. Oral Dis 2008;14:479- 83. Treiste< NS. Mag�ick D. woo SB. Oral m ucosal pigmentation secondary to
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Surg Oral Me<:!Oral Pathol Oral Radio! Ended 2004;97:718-725.
50 1
Chapter
Oral and Maxillofacial

Radiology
David MacDonald, sos. BSc(Hons), LLB(Hons), MSc, DDS(Edin),
FDSRCPS(Giasg), DDRRCR(UK), FRCO(Gan)
n medicine diagnostic images are almost invariably read by spe of digital imaging is only seen if the clinician abandons the slower 0·
I cialist radiologists and not the medical practitioners themselves.

In dentistry, on the other hand, almost every clinician serves as
his or her own radiologist. Dental curricula devote significant time
speed film (still used In about 60% of North American dental offices)
in favor of the faster E· and F-speed films. However, integration of
digital radiology with a digitized oral health record system offers clear
and resources to diagnostic radiology, in contrast to most medical advantages: It streamlines office procedures. enhances efficiency of
curricula. The role of the prosthodontist as diagnostic radiologist is image management, and minimizes errors, reducing the risk of legal
crucial because of an restorative specialists. the prosthodontist is the liability.
specialist most likely to be attending the older patient, who will thus
be more likely to present with a higher burden of significant disease.
This chapter addresses developments that specifically affect the Digital dental radiography
prosthodontist as radiologist and require a deeper understanding of
computed tomography (CT} and magnetic resonance imaging (MRI). Solid-state and phosphor plate are two separate digital tec hnolo·
While the descriptions here focus on imaging for tumors or tumor gies (Fig 5·1 a). The solid-state technology is still largely represented
like lesions, prosthodontists are likely to see a variety of radiopaque by the charge-coupled device (CCO) (Fig 5·1 b). The more current
and radiolucent lesions in their patients. Differential diagnoses for devices using this technology were last objectively reviewed by
these lesions are discussed elsewhere.' Farman and Farman in 2005.3 The CCO has now been joined by
Although oral and maxillofacial r adiology (OMFR) has evolved complementary metal-oxide-semiconductor (CMOS). Both ceo
considerably in recent years, the essential principles of ALARA (as and CMOS result in an immediate image. This differs from the pho·
low as reasonably achievable [radiation dose]) remain.2 The most tostimulable storage phosphor (PSP) system (also known as SPS or
significant developments in OMFR are digital radiography and cone PIP), which requires scanning of the detector before the captured
beam computed tomography (CBCT). These are accompanied by latent image can be displayed. To minimize degradation of the fm·
the more mundane but nevertheless essential developments in im· age. it should be scanned in a dim room as soon as possible after
age display and data storage. the detector has been exposed.' Therefore, a separate room akin to
the dark room is still required. PSP detectors should be considered
semidisposable t o ensure that a legally adequate standard of image
quality is maintained; as few as 50 uses can damage the PSP detec·
Image Capture tor enough that it should be replaced.5 Many clinicians may find that
CCD/CMOS and PSP technologies complement each other. The
In spite of the considerable pace of digitization, properly exposed instant image created by CCD/CMOS technology is invaluable tor
and developed dental film, viewed on a standard illuminated viewer endodontic or other chairside procedures, which need almost real
under reduced ambient light, remains the gok! standard for image time imaging. The more flexible PSP detector (which is as flexible
quality. The reduction in radiation dose that is advertised as a benefit as film) can be used in situations in which the bulkier CCD/CMOS
51
5 i Oral and Maxillofacial Radiology
Fig 5·1 Digital deotaltadiogral)hy. (a) PSP plate s in siZes from tile left. ooclusal, 2. 1. and o. Thly must be scanned Fig 5·2 Thtee monitOIS displaying the same image. The
bef01e !lleir laten t 1mages can be disolayed. (b) ceo in sizes 1 and 2 compated with a s1ze 2 PSP. Tile leads connect the two to the left are medical-grade self·calibmting mono·
detectors to the computer wlllch immediately dlsolays the image.
, chromatic moJlit()(s for plimary diagnosis of clinical im·
ages. The one on U1e 1ight is a standard color monitor for
chairside use that acts as a quick reference for Images
previously read. The monochromatic monit or on tile far
lelt is a 3-megapixel (MP} monitor that displays each pixel
captured by the detectot. This is optimal lot the display of
entire panotamic r adiographic images. The ambe i n t light·
ing in this photograph is much brighter than that used for
primary diagnosis, so as to enhance the pnotography.
detector is difficult to use (eg, patients with limited opening or shal radiologists, should use similar facilities. The best medical grayscale
low palates). PSPs are better for vertical bitewings. Detectors for oc monitors, although more expensive than commercial monitors. cost
clusal projections are generally only available as PSPs (see Fig 5·1 a). the same as or less than a no. 2 size ceo detector (about the same
size as a standard periapical film) (see Fig 5-1). These medical·grade
di agnostic or primary-read monitors are technologically complex.
Digital panoramic radiography They not only display images with the optimal spatial resolution and
contrast resolution with high brightness but also may self-calibrate.
Panoramic radiography has also been transformed by digitization. The displayed image should represent all the data captured by
In some units, film has been replaced with a similarly sized sheet of the detector. Ideally. the image should display each pixel captured
PSP, which is scanned and displayed on the monitor. Other pan by the detector on the monitor display (1:1 display) to optimize the
oramic units use solid-state detectors that display the image instant detector's spatial resolution. However, it is very unlikely that many
ly. Mischkowski et af found that in a comparison between a newer monitors currently found in dental offices (almost all are COTS)
cone beam device and a digital panoramic x-ray untt, the former display at this ratio. Therefore, information contained within the
performed better in the diagnosis of specific lesions and the tatter detector image may not be displayed on the monit or. Haak et al
displayed better image quality in rts oveNiew of the jaws.• reported that ratios of 1:1 and 2:1 were significantly better than a
ratio of 7:1 for detection of proximal caries.' In a comparison of a
standard desktop wit h a dedicated medical monitor, Gutierrez et al
found that the standard desktop display was clearly inadequate for
Image Display diagnostic radiology.e
The grayscale standard display function (GSDF) is based on a
phenomenon called human contrast sensitivity, which takes the
Monitors human eye's nonlinear perception into account. Because the human
eye sees relatively small ch an ges more easily in brighter areas than
In medicine, diagnostic images are read by radiologists on medical in darker areas. the GSOF adjusts the brightness so that all areas are
grade diagnostic grayscale monitors under reduced ambient lighting equally perceptible.•
(Fig 5-2). The radiologists then produce a report that accompanies In addition to the spatial resolution, the contrast resolution should
the images so that referring clinicians, using a point-of-care monitor be considered. Although monitors used for medical diagnosis use
(almost always a commercial off-the sh elf - [COTS) model, which can 12-bit grayscale deplh, if the computer runs on an operating system
have a color display), can use tl1e report as a guide while review such as Windows, images only resolve 10 8-bit depth (or the 256
ing the images. II follows that dentists. who are generally t heir own levels of gray used by ordinary monttors). This can be improved
Methods of Conveying Electronic Information J
to 10-bit grayscale depth (1024 levels of gray) by an application the workstation). The format must be protected from unauthorized
program interface (API). but because this requires customization alteration, toss. damage. or any other event tl1at might make the
of the software, H generally is only applied when mammography content inaccessible. Many jurisdictions require thai digital clinical
is required. Neve1iheless, mammography faces the similar high data be backed up to a remote server. T h e advantage of this is that
spatial resolution-low contrast resolution challenge that clinicians the records are preserved if the office is destroyed, whiCh allows
encounter in caries diagnosis. But whereas the former is concerned clinicians to quickly retrieve the data and resume management of
with finding radiopacities in radiolucent soft tissue, the latter is patients at an alternative venue.
concerned with observing radiolucencies in the highly mineralized Although not much of an issue for a single practitioner. image
enamel and dentin. The medical monitors require the 12·bit depth storage may present a challenge for a large group practice that uses
for accurate self-calibration, which i s performed to Digital Imaging CBCT data for i mplants and orthodontic cephalometry. Intraoral
and Communications in Medicine (DICOM) standards. images account for only hundreds of bytes of storage and panoramic
Self-calibration of the monitor's brightness (luminance) ensures radiographs only a few thousand. Nevertheless. the massive image
that every image the clinician reviews is of optimal quality. Medical· files required for CBCT data quickly exl1aust even a very generous
grade monitors are exceptionally bright, optimally about 500 candela storage capacity.
(candles) per square meter (cd/m'). All monitors fade with time, so Compression of image files is an alternative to increased s torage.
this se�-calibration ensures optimal and standardized brightness Two systems are used for compression: lossless (without loss of data)
until the backlight brightness falls below the threshold and needs and lossy Qrrevocable loss of data). Although Eraso et at's reported
replacing. that foss of image quality is not a factor unless the file size is reduced
to 4% or less, Fidler et al,who systematically reviewed the literature
on lossy compression, reported that the amount of Information
Ambient lighting lost is difficult t o express and standardize.16 Therefore, until lossy
compression has been definitively tested. all data contained in a
Reduced ambient lighting (illuminance) essentially goes in tandem clinical image file must be preserved.
with monitor brightness. Recommendations for reduced ambient The format of the image at the time of creation remains the
lighting in diagnostic reading stations for radiographs are 2 to 10 original.'7 Therefore, scanning a film, even on a medical-grade
lux (lx: the unit for illuminance). in contrast to 200 to 250 lx in clini· scanner. creates only a copy; the film is the original image and must
cat viewing stations in hospitals. '0 The evidence for the need for re· be retained for as tong as that jurisdiction requires. Si milarly, digital
duced ambient lighting in dentistry is provided by Haak et at." They images remain originals even if they are printed onto the appropriate
found that differences in monochromatic intensity were detected quality paper or transparencies by medical-grade printers; these
significantly earlier if the ambient lighting was reduced (70 lx versus printouts are just copies. It follows that any modification of the
the 1000 lx recommended for the dental operatory). Although both original image can only ever be an edition of the original, which must
monitors used in the study did not reach the National ElectriCal Man remain unaltered.
ufacturers Association's standards for DICOM. the flat· screen liquid
c•ystat display (LCD) monitor performed bener than the cathode ray
(CAD monitor in the dental operatory. probably because the
tube
flat-screen monitor was brighter. CRT and LCD monitors function
Methods of Conveying
equally well, provided they comply with DtCOM standards.'2 Electronic Information
Teteradiology is defined as the format transmission of images within a
Storage and Compression of secure local area network (LAN) and not as transmission by ordinary
email. The application of teteradiology in clinical practiCe has been
Images accelerated by Picture Archiving and CommuniCation Systems and

OICOM and eliminates the need for physical transport of informa
Adopting digital technology does not alleviate the problem of long· tion through printed transparencies, DVDs, or COs. Email transmis·
term storage of all analog films. The length of time that records sions are not secure. however, and t11e attached images cannot be
must be retained varies by jurisdiction. A recent publication ad considered diagnostic. particularly if they were lossy compressed.
dressed some o f the legal issues that may affect recent advances Teleradiotogy currently lacks standards for an interoperable. man
in OMFR.,._,, ufacturer-independent protocol for security.•• Strategies to achieve
Fundamentally, electronic dental-record storage must accurately this have recently been overviewed. '9 Therefore, in the absence of
preserve the original content of the record (eg, text. image. or format teleradiology. it is preferable to download data onto a OVD or
chart) and the identity of visual display.•• The record must include CO for medicolegal reasons because this format then includes all the
complete information about the creation or any modification of the original digital data generated during the examination (conventional
record (author, date, time. and exact source of the record, suct1 as digital radiology. CT. or MRI) rather than selected and manipulated
53
5 iOral and Maxillofacial Radiology
Fi g 5·3 The components ol the computed tomography unit.

(a) Tile ganuy, containing the x·ray tube and detectors, and
the table upco which the patient lies and is progressively
advanCed through the ganUy. (b) The operator console is
located in a room adjacent to the unit. A lead glass window
allows the operator full view of the patient and unit during
exposure. (Reprinted from MacOooald·Jankowski and Ul0
wit ll pennissiOfl.)
images printed on transparencies. The data on the DVD/CD can be The display is a digital Image reconstructed by the computer as
downloaded by the clinician to be reconstructed according to clini· pixels (picture elements), which represent a 30 block of tissue. The
cat requirements. However. proper reconstn.1ction of the data does voxel is the pixel size multiplied by the slice thickness (voxet length
require appropriate software. varies from 1 to 20 mm). Each pixel is assigned a CT number (see
later) representing tissue density. This density is proportional to the
degree to which the material within the voxel has attenuated the
x-ray beam. The resultant attenuation coefficient of a particular voxel
Advanced Imaging in reflects the mean of an tissues within it. the proportion of hard and
Prosthodontic Practice soft tissues to air, and the voxel length (slice thickness).
Formerly, clinicians relied on the cl inical examination and convention

al radiology to assess and diagnose lesions affecting the jawbones. SpCT
Unfortunately, conventional radiology generally yields images that
lack the sensitivity to reveal small changes in the bone. Conventional SpCT is also known as helical or volume acquisition CT (HCT and
radiology also presents all structures wit!1in a three· dimensional (3D) VCT, respectively). SpCT requires that the patient be moved through
volume of bone only as a two-dimensional (20) image. These handi· the aperture of the gantry during the generation of x-rays by the ro
caps have been addressed both by spiral computed tomography tating x-ray head (Fig 5·4). creating a helix or spiral o f data.
(SpCT) and now by CBCT. MRI also contributes to diagnosis. es Clinicians viewing SpCT should understand the terms bone
pecially in cases of temporomandibular joint (TMJ) dysfunction. AI· window, soft tissue window, windo w width fNW), window level
though the principles and roles of CT (including CBCT) and MRI have (WL). and pitch. Bone and soft tissue windows and their widths
.
already been addressed."' ., the essential elements and functions and levels are expressed in Hounsfield units (HU). which are also
will be introduced in the following text. called CT numbers. Tl1ese range from -1,024 HU. repnesenting air
(fixed point), to 0 HU. representing water (fixed point). to 3,071 HU.
representing dense metal. Bone and soft tissue windows (Fig 5·5)
are two of the three standard windows for viewing the data captured
Basic construction and principles of computed
by CT; the third window i s the air window, which generally is used in
tomography cardiothoracic medicine. Each window optimizes viewing of tissue
types by appropriately adjusting the WL and WW For face and jaw
.
The CT unit has three main components (Fig 5·3): (1) t he gantry or lesions, the soft tissue window is close to that of water (0 HU), the
framework (which may be angled up to 30 degrees), (2) the patient WL i s40 to 60 HU, and the WW is 250 HU . The bone windows for
table (or bed or couch) that moves the patient through the aperture such lesions are WL of 250 to 500 HU and WW o f 1,000 to 2,000
in the gantry, and (3) the control console in an adjacent room that HU or higher.
is shielded from x·rays. The operator views the patient and CT unit Pitch is the tightness of the helix and represents the spatial
througl1 a lead glass window during t he exposure. resolution in the patient's long axis that would be visible on
Advanced Imaging in Prosthodontic Practice j
Fig 5-4 Spiral comP\Ited tomogravllY. tn spiral Fig 5·5 Soft !issue and bone windows ol a patient with maxillary fibrous dysplasia. (a) The soli
computed tomography (SpCn. U1e rotating X·ray tube tissue window displays cell·rich structures such as the muscles, skin, salivary glands. spinal column,
describes a spiral as it exposes the pa11ent whose bed and blood vessels as gray structures. The fatty subC\ftaneous !issues and fascia appear almost as
continuously moves through the gantry. (Reprinted black as the ai r f illed pharynx and mastoid air cells. The bony structures appear as homogenous
-
from MacOonald·Jankowsl<i and ll20 with permission.) white areas. /b) The bone window displays the bony structures in such detail that trabeculae can be
discerned. The bony structures appear slighU y smaller ihan they did in Ihe soft tissue window. The
bone window displays soft tissue, but fat appears as a lighter gray shape in comparison to other
structures. Note that the dysplastic lesion appears almost fully calcified on the soft tissue window.
but the bone window displays variable radiodensities wllhin the lesion. (Reprinted from MacOonald·
Jankowski and LP"with pennisslon.)
Fig 5·6 SpCT achieves 3D roconstruction by dividing the voxel into cuberilles, each Fig 5·7 Tne postoperat1ve 3D reconstruction of this mandible allows a complete
with the same attenuation coefficient as the ortginat voxel. (ReprintM fron1 MacOonald· evaluation for definitive restoration. (Reprinted from MacDonald-Jankowski and li20with
JankOWSki and Ljl!)with permission.) permission.)
reconstruction. The string of data for a given data volume is longer of pixels is greatest. Only those cuberilles that represent the surface
for a pitch of 2:1 than for a pitch of 3:1: therefore, the total radiation of the object of interest are projected onto the monitor. The 30 re·
dose to the patient will be higher, although the detail will be better constructions can then be rotated to display the reconstruction from
when viewed on thin reconstructed sfices. For severe facial trauma, any point of view (Fig 5·7).
a 1 : 1 pitch is best.
Limitations of SpCT
Three-dimensional reformatting
Each original voxel is divided into cubes called cuberilles. Each cu Reduced resolution in all planes except the axial plane
berille has the same mean attenuation coefficient of the original voxel Mulliplanar reformatting (MPR), especially in the coronal plane, is
(Rg 5·6). The need tor this interpolation ariSes because the original inadequate lor the assessment of severe facial trauma primarily ori
voxef's spatial resolution is best in the axial plane, where the density ented in the axial (xy) plane because the spatial resolution is great est
55
Fig 5·8 The 30 reconstruction of 11\is assault victim displays the comp!eXlty of the
i njuries, particularly of the midface, prior to surgc
i al reconstruction. (Reprinted from
MacDooald·Jankowski and Lf"'with permission.)
in the axial plane.242• Hoeffner et al suggested that specific protocols (or dual modalrty) positron emission tomography/computed tomog
are required for obtaining coronal MPR of data acquired axtally.26 raphy (PET/Cl) suggests t11at i t has a higher sensitivity and pos�ive
predictive value than CT for detection of primary tumors in patients
Streak artifacts with cervical metastases.32 The use of the coronal plane is helpful to
Although streak artifacts can degrade lhe SpCT image as they do in investigate the base of the skull, orbital floor, palate, paranasal si·
most other imaging modalities, this can be reduced by metal artifact nuses, and small tumors that cross the midline of the tongue base.?S
reduction software. Naranjo et al display such a strategy.27 Baum et
al suggested that a s11ort additional spiral parallel to the body ot the Fractures
mandible reduces artifacts behind the dental arch and improves the Maxillofacial fractures are common, and because of the already
overall diagnostic quality of the resulting image.:re oomplicated anatomy in !his region, it can be difficult to interpret
multiple fractures. which present as overlapping densities in con·
Low sensitivity for identification of small tumors ventional radiologY33 (Rg 5-8). Conventional radiology should be acl·
Although SpCT has a high specificity for metastatic lesions.29 it has a equate to demonstrate simple superficial fractures such as those
low sensrtivity because necrosis, Which is pathognom•c for metasta of the nose, zygomatic arch, ar1d body of the mandible. However,
sis, is rarely visible in small lesions. Therefore. the sensitivity of SpCT many patients wilh complex maxillofacial fractures may benefit from
is optimal only tor larger lesions with an attendant poorer prognosis. the short scan time of SpCT, especially those patients with muttiple
trauma and possible damaged organs that were not yet fully sta
Indications for SpCT bilized.34 In a review of panoramic radiographic and SpCT images
of 217 patients."" it was found that SpCT identified more fractures,
Although SpCT has been almost oompletely displaced by CBCT tor particularly those of the angle, ramus. and condylar neck. tl1an the
the presurgical imaging ot osseointegrated implants, SpCT is still panoramic images. Multiplanar CT reconstruction oould be useful to
essential to accurately stage carcinomas and to evaluate oomplex evaluate the feasibility of lag screw osteosynthesis in the fractured
fractures. CT hss also enhanced our understanding of other lesions condyle.36
by allowing the display of features that are difficult to identify in con
ventional radiOgraphy. Such features include the complex admixture Other functions of SpCT
of ossecus and soft tissues in fibrous dysplasia"' (see Rg 5·5) and the
peripheral location of septae in odontogenic myxoma." which appear Image-guided surgery
otherwise con1pletely translesional on conventional ractiograpl1s. The envelope for successful placement of an implant that meets
a patient's esthetic, phonetic, and functional needs is already very
Malignancy oonstrained. When anaton1ical factors are added. the challenge is
Although CT and MRI are widely used for imaging the prirnary neo even greater because of the proximity of the resorbed edentulous
plasm and cervical lymph nodes. because both modalities 11ave lim alveolus to the inferior dental neiVe, the maxillary antrum, or the
ited accuracy in identifying metatasis, ultrasound-guided fine-needle sublingual fossa. Placement of an implant into the submandibu
aspiration cytology is more retiable."'The initial report on the fused lar space may rupture the lingual artery, provoking potentially fife·
Advanced Imaging in Prosthodontic Practice J
Fig 5·9 Color-coded 30 reformatting displays the Fig 5·10 This virtual antroscopy from the Navigator function displays a 30 reconstructlon of a lesion ariSing
exten t of the amelOblastoma (red) within tlle mandible. trom U1e roof of Ule maxillary antrum. (Reprinted from Macoooatd-Jankowski and U"' wiUl permission.)
It has per10raled !he alveolar bone In twO places (red).
This image was produced by pulling out the neoplasm
from one recons�uction and tl\en placing it within a
second recons�ction of the facial skeleton. (Reprinted
from MacOona.fd-Jankowski and Ul& with permission.)
threatening events.3'·38 A stent used during th e imaging, incorpo volume rendering with surface rendering for 20 patients found that
rating radiopaque markers to facilitate subsequent location, can be the former allowed better visualization than the la tter•� Volume ren
readily transformed into a s urgical guide that optimizes the use of dering was also more sensitive for the diagnosis of maxillofacial le·
cross-sectional images. Such images have been recommended in sions, particular1y those that were primarily intraosseous.
a position paper by the American Academy of Oral and Maxillofacial
Radiology.311 Color-coded 3D reformatting
COlor-coded 3D reformatting may be done for extensive lesions by
Determination of bone mineral density and volume ascribing a separat e color t o the lesion, the bone and adjacent soft
,
Determination of bone mineral density (BMD) is a central activity in tissues:• This has been applied to an ameloblastoma in Fig 5·9.
the diagnosis of osteoporosis that can be accomplished with SpC T.
AHhough dual energy x-ray absorptiometry (DXA) of the lumbar spine Navigator
and the hip is the standard, this method can result in false positives The Navigator function in SpCT allows perspeci
t ve volume render
for halt of all patients.•" The OSTEODENT p ro ject has indicated that ing. With this function, preoperative virtual endoscopy ol the maxi!·
cortical porosity is a poor predictor of osteoporosis and that only lofacial region can be performed to evaluate the surface contours
those patients wnh a mandibular cortical width (MCW) of less th an of ant ral lesions (Fig 5·1 0), define vascular lesions and examine the
,
3 mm Should be referred lor furttler investigation •' Nevertheless. pharynx and larynx.''
diagnosis of osteoporosis based on MCW may include just as many
false posnvi e s •o
. Compute r -aid ed design/computer-aided ma nufac t u re
BMD is a poor predictor of osteoporosis because it is both unit Computer-aided design/computer-aided manufacture (CAD/CAM)
and operator sensitive, and it does not consider the bone volume, tech nology can be ad opted in any hospital tor daily use. In one ex
which can be measured with more reliable results by quantitative ample, a Ho ng Kong group used a four-stage process to produce
computed tomography:'2 Nevertheless, evidence that tra-becular a quantitative osteotomy simulation that could predict postoperative
bone density measu rements (measured in HU) vary by site confirms appearance with photoreal istic quality."ll CAD/CAM can generate 3D
the importance of a site-specific evaluation prior t o implant models by laser or by milling.
placement.<3 A significant relationship has been reported between
HU and subjectively evaluated type 4 bone.+<
CBCT
Volume rendering
Volume rendering is a technique that uses the concept of opacity to Although it cannot be denied that SpCT has completely transformed
quickly reconstr uct a 3D volume acquired on CT or MRI. The end medical imaging, CBCT has more specifically transformed maxillo·
result is similar to a virtual anatomical dissection and can assist in facial imaging. CBCT uses a cone-shaped beam of x-ray photon s
surgical planning for a particular patient. One study that compared rather than the fan-shaped beam used by SpCT (Fig 5-11). This cone
57
Fig 5-11 The cone beam of CBCT examin�

a 30 region within a 360-degree rotation:
ir
most scans. however, requ e only a 270·
degree rotation. (Reprinted from MacOooald·
Jankowski and Orpe" with pennission.)
Fig 5-12 Display of the panoramic (a), coronal (b), and 3D (c) CBCT reconstructions
of a lymphoma 11ithin the maxilla. This lesion has perf01ated the floor of the antrum
and Is growing along the antral floor. It has also substantially eroded the alveolar
bone associated with the first and second molars; this Is clearly displayed in Ule
30 reconstruction. The unit used was an iCAT with a 0.2-mm mn i imum voxel size.
(Reprinted from MacOonald-Jankowski and DrpeV with permission.)
Fig 5·14 CBCT reconstructs 30 im·

ages by generaling cuberilles directly.
each witll fis own alle!luation coefficient.
Fig 5-13 Display of the coronal (a) and 30 (b)CBCT reconstructions of a torus palatinus This allows 3D reconstructions with bet·
and bilateral exostoses on the palatal aspect oltlle maxillarJ tuberosities. The metallic ter resolution in lhe z plane in addition
artifact observed on tile coronal reconstruction, at the level of tile restored last molar to the axial (xy) plane. SpCT, excepting
in (b.)was minimized in the 30 reconstruction by excluding moot of the crowns: hence the most modern 256 MOCT units. can
the pu lp chambers rattler than occlusal surtaces are visible in lhis reconstruction. Some only produce cuberilles secondarily from
residual metallic artifact is observed as whfte streaks on both exostoses. The unit used voxels (see Fig 5·6). (Reprinted from
was an iCATwnh a 0.2-mm minimum voxel size. (Reprinted from MacDonald·Jankowski MacDonald-Jankowskl and Orpe2' with
and Orpe" with permission.) pennission.)
beam can be round or rectangular. In contrast to the multiple rota created for preoperative assessment of implant placement. Altl1ough
tions required by SpCT. CBCT requires a single 360-degree rotation the panoramic reconstruction from CBCT data, unlike a conventional
(some units require only a 180- to 220-degree arc). Furthemnore. as panoramic radiograph, is dimensionally stable and free of second·
the CBCT exposes a smaller portion of the patient, it generally has ary artifacts, these attributes should not be used solely as reasons
a smaller footprint, similar to that of a panoramic radiographic unit, tor replacing the lower-radiation-dose-imparti ng conventional pan·
and it can be installed in the dental office. TI1is makes access to it oramic radiography with CBCT. Figures 5-12 and 5-13 display the
easier and cheaper than SpCT. but such a cheap and ready access 20 and 30 reconstructions of a case of lymphoma and a case of a
may result in CBCT investigations that do not have clear clinical in torus palatinus and exostoses. respectively.
dications. Nevertl1eless. such unnecessary radiation exPosures con·
tribute t o the radiation dose tl1e patients receive and increase their B e t t e r spatial resolution
risk o f suffering radiation-induced disease, such as cancer. Recently, CBCT not only displays superior spatial resolution of high-contrast
both the American Academy of Oral and Maxillofacial Radiology and structures such as teeth and bone but also shows superior spatial
the European Academy or Dental and Maxillofacial Radiology have resolution in all planes at a reduced radiation dose. Whereas the best
issued guidelines tor the use of CBCT in dentistry..,g.so size for the most modern SpCT (the 256-muttidetector CT (MOC1)
unit) is 0.35 mm, the best spatial resolution of CBCT is 0.076-mm
Advantages of CBCT minimum voxel size.
The advantages of CBCT over SpCT include better spatial resolu Better 30 reconstruction
tion, shorter scan time, lower radiation dose, smaller footprint, and CBCT reconstructs 30 images by generating cuberilles directly, each
lower cost. In addition to p roducing 30 images, CBCT can produce with its own attenuation coefficient (Fig 5-14). This allows 30 recon
20 images similar to panoramic and cross-sectional reconstructions structions with better spatial resolution in the patient's long axis and in
581
fig 5-15 (a} The ProMax 3D CBCT unit installed in the gantry that once housed the
ProMax digital panoramic ra<Jiographic unit. The patient's posture and positioning within
the CBCT would be similar to that Of an ordina1y panoramic radiograph. TI1e operator
exposes tile patient lrom an adjoining room that has been appropriately shielded by
lead-lined walls and a lead gl<iss window. As with any radiographic exposure. the patient
and the unit must be inlull view ot Ule operator. who is seen seated in tile adjacent room.
It is crucial to Obse!Ve the patient and gantry Ulroughoot the enUre exposure In case the
exposure needs to be terminated. (l>JTil!l touch-screen control panel enhances inlection
cootrol, and its !unctions are generally sell-explanatory.
the axial plane. Except for the most modem 256 MDCT units. SpCT in the emergency or o per ating room. was comparable to conventional
can only produce cuberilles secondarily from voxels (see Fig 5-6). ra d iograph s. The NewTom imparted tv·Jice the dose of the Siremobil
Most CBCT units use flat panel detectors constructed of amorphous scanner. In contrast, the radiation dose to the parotid gland from con
silicon rather than the image intensifiers frequently used in SpCT that ventional panoram ic radiography was higher than the dose from either
often produce geometric distortion.s' In addition, flat panel detectors CBCT unit.57
have a better signal-to-noise ratio (SNR) and better spatial resolution. 10 The lower radiation dose of CBCT i s partially related to the short
Although many recon str uct ion algorithms tor CBCT have not yet exposure ime
t ; most units make a single rotation of 360 degrees.
achieved the performance observed in the best multislice Sp CT This short scanning tirne minimizes risk of movement artifacts. It has
scanners, research continues t o improve the quality of CBCT software been reported that the smaller effective dose inherent to CBCT can
and related technology.� be further reduced to avoid the thyroid and the cervical spine if lead
Some CBCT units have more than one field of view (FOV). FOVs shielding is used.sa
vary markedly between the different makes of CBCT scanners. Radiation dose varies substanti ally depending on the unit, FOV,
AlthOugh a larger FOV provides surgeons and orthodontists with a and technical factors. The effective does (1:,007) for a large FOV
3D reconstruction of the whole maxillofacial complex, which optimizes CBCT investigation ranged from 68 to 1,073 mi cro Sieverts (JJSv). for
planning for orthognathic surgery. it includes structures normally a medium FOV CBCT from 69 to 560 �Sv. and for a medium FOV
outside the usual area of dlagnoslic interest. The larger FOVs are also MDCT it was 860 1-1Sv.
likely to be accompanied by a lower spatial re solution. If the FOV is found to be too small, overlapping FOVs can be
combined ("stitching'), which is what the ProMax 3D (Pianmeca)
Better bone imaging, but p oorer soft tissue imaging does. Each additional exposure proportionally increases the effec t ive
Although CBCT is very good tor intrinsically high-contrast stnuctures dose. Therefore. if a particular FOV is chosen for the appropriate
such as bone, its use of 12 to 14-bit technology versus the 16- spatial resolution, the operator should keep in mind that the higher the
to 24-bit technology used in SpCT means that useful information spatial resolution, the higher the radiation dose imparted to the patient.
cannot b e obtained about soft tissue quality.53 However. because Ultimately, it is t he operator's responsibility to ensure that all area s
the most common indication for CBCT is preo perati ve implant-site captured, particularly those extragnathic areas, have been reported
ev aluation, lack of a soft tissue image will have little impact on treat appropriately. This burden has been addressed by the manufacturers,
ment planning. The main features pertinent to implant assessment who have built a wide range of CBCT units only with small and
are bone thickness. depth, and quality. medium-sized FOVs that allow the investigation to be confined solely
to the jaws with the very minimal inclusion of extragnathic structures.
Lower radiation dose The last are the proper interpretive remit of the radiologist. This point
The International Commission on Radiological Protection (ICRP) 2007 will be further discussed later.
app ortion s a higher effective dose to oral stnuctures than ICRP 1990
because the salivary glands have been included as a weighted tis Accuracy of measurements
sue.... This has resuned in an upward reassessment of fatal cancer Although CBCT images underestimate the real distance between
risk from oral and maxillofacial radiographic examinations. The 2007 skull sites, differences are only significant tor th e skull base."' Dis
effective dose (E2()0,) calculations were tound to be 224% to 235% tances are reliable for linear measurements of other stnuctures more
greater than those calculated according to t he 1990 formula (E,mJ.66 closely associated with dental and maxillof ac ial imaging. One study
In addition to the wide range in radiation dose delivered by eight found that all CBCT linear measurements of the TMJs of dry human
different CBCT units,s. the exposure parameters can be a du
j sted skull s were accurate whereas conventional cephalograms displayed
according to the diagnostic task.56 The CBCT radiation dose to the some error.60 Other research has concluded that CBCT images are
e y e was only one-third of that tor SpCT. The dose from t he Sire geometrically correct, with minimal distortion of axial images.s1·""
mobil lso-C (Siemens), a mobile version of CBCT technology for use
59
Smaller footprint and familiar use have been produced by specialist radiologic centers and evaluated
Almost all CBCT units use panoramic radiographic-style gantries and reported by radiologists before transmission. However, because
(Fig 5-15a). Not only i s such a setup familiar to clinicians and their CBCT units now can be placed within a dental office, the burden
patients but also the foo tprint is smaller and units can be installed
, to evaluate extragnathic areas has shifted t o clinicians without the
in most rooms. Furthermore. CBCT units are becoming more user benem of a separate radiologi st report. Therefore. clinicians should
friendly (Fig 5-15b). be cautious of using CBCT and assessing data �hout assistance
of a radiologist.'"' Failure to consider the whole image could result in
missed neoplasms and missed atherosclerosis. Because the cost to
Potential uses for CBCT
treat end-stage disease in the hospital is five times the cost to treat
non-end-stage disease in the community, earlier diagnosis and care
Preoperat i ve implant-site assessment
can result in decreased mor1ality and health care costs. 10
Prior to the advent of CBCT. CT imaging was appreciated for its val
ue in preoperative implant-site assessment, but its use was restrict
ed to patients needing multiple implants because only then could the Image quality of CBCT versus conventional
diagnostic benefit offset the radiation dose imparted. CBCT is easy radiography
t o use and produces a 3D image volume t11at can be reformatted
by the treating surgeon using appropriate software.63 Preoperative Conventional intraoral radiography, whether analog or digital. pro
evaluation for implant placement constitutes a majority of referrals vides better spatial resolution that allows review of details such a s
for CBCT. Multiple studies support the use of CBCT for t he assess ground glass and peau d'orange (orange peel) appearance of bone.
ment of alveolar bone grafting before and after placement of dental the poorly defined margins associated with fibrous dysplasia, and
implants or orthodontic treatment of teeth adjacent to clefts."'·60"' the fine cortices of other lesions. In contrast, t he CBCT's pano ramic
Hamada et al also reported that 3D CBCT displayed the integrity of reconstruction is superior to that of a conventional panoramic radio
the bone adjacent t o the subsequent implant.64 graph because it displays no superimposed secondary images and
CBCT produces high-quality diagnostic images of the TMJs at a is geometrically more accurate. One major disadvantage of CBCT is
lower radiation dose than sper.os Images can be used in simulations the streaking artifacts caused by metal restorations (see Fig 5-13a).
of condylar growlh, bone formation. and orthognathic surgery.""
Cevldanes et al suggest that 3D colored displacement mapping Spat i al reso luti on
could be applied to determine bone remodeling following surgery.61 The best spatial resolution currently achievable in CBCT is 0.076-
mm voxel size. which t ranslates into 6.61ine-pairs per millimeter. This
3D cephalometry is substantially less than the spatial resolution available in conven
Although 3D cephalometric images can be reconstructed from tional radiography (parti cularly intraoral images), vvhich is necessary
SpCT data CBCT imparts less radiation and is more convenient for
,
to detect early dental caries and those features that indicate other
the patient. Its vertical scanning position creates a view of the soft early disease.
tissue mask of the patient in the upright pos�ion....
Contrast resolution
As mentioned earlier, the main disadvantage of CBCT is its dynamiC
Restrictions of CBCT range of contrast. Although this has been increased from 8-bit to
14-bit depth. it is still insufficient to display contrast within soft tissue.
Contrast media SpCT, which does display such contrast. ranges from 16-bit (for the
Due to CBCT's inl1erently poorer soft tissue imaging, definitive as economy model) to 24·bit (in a top-end model). Nevertheless. the
sessment of malignant or locally invasive lesions such as amelo narrow dynamic range of CBCT is not a problem because it is mostly
blastomas and odontogenic myxomas requires delivery of an in used for preoperative implant planning, which is primarily concerned
travenous contrast medium while the patient is supine. Therefore, with bone quality and quantity.
because dental CBCTs other than the NewTom scan patients in a
ve11ical position, t hey are unsuitable for the intravenous delivery of
contrast to the patient. MRI
Anatomy and pathology beyond the face and jaws MRI is the first-choice imaging method for a number of lesions af
In most jurisdictions. it is a medicolegal requirement that clinicians fecting the face and jaws because of its ability to distinguish soft
should be able to evaluate everything that i s displayed on the CT im tissue lesions from adjacent healthy tissue. MRI already plays an im
age, even if it extends outside the area of their interest. TI1e common portant role in the evaluation and diagnosi s of TMJ disorders and
and impo11ant lesions occurring within the base of the skull and the neoplasms of the face and jaws. However, CT remains the primary
neck have already been addressed elsewhere.1 Oral and maxillofacial cross-sectional modality tor the majority of cases. This is because
surgeons have previously used SpCT images which by necessity
. CT offers better evaluation o f cortical bone, a shorter scanning time,
60 1
and less susceptibility to motion artifacts.71 New users of MRI im Disadvantages of MAl
ages. especially those already familiar with CT images, must address
a steep learning curve (eg, bone appears black, and fat appears very Even when produced by the same manufacturer, each magnet has
bright). its own idiosyncrasies that uniquely affect the images produced.
Although the MRI scanner bears a physical resemblance to a CT Therefore. unlike CT scans. if a patient is reassessed on a different
scanner (see Fig 5-3a), the two imaging modalities are completely MRI scanner, � is unlikely that the images will be identical. Very few
different. MRI does not use ionizing radiation but rather a radiowave studies have compared the results derived from different scanners.'"
·dialogue· with the patient's tissues and lesion. Its efficacy as a Air and bone have fewer protons and give virtually no signal. so
clinical imaging modality is based primarily upon the proton-rich they appear as black on the scan. This is problematic for images
nature of h uma ns : our tissues are composed of between 70% and of the air-filled maxillary antrum, which is normally separated from
90% water which is concentrated hydrogen nuclei
, or protons. A its thin bony walls by a thin antral mucosa but may not always be
strong magnetic field is used to excite the hydrogen nuclei and then obvious. depending on the thinness of the mucosa and spatial
measure how long it takes them to return to their resting energy resolution of the MRI scanner.
st a tes." Disease or injury can drastically change the amount of Like any other type of medical imaging, movement has a
water within a tissue. so MRI is very sensitive to this'• deleterious effect on t he resulting images. This issue is significant,
considering the relatively long scanning times; A routine MRI
Components of the MAl suite scanning session can take 30 to 40 minutes, unlike the CT session
which takes only 10 to 15 minutes." While CT scans produce
The MRI suite has three components: the magnet room, technical an entire volume data that can be manipulated to produce bone
room. and console room. The magnet room contains the magnet and soft tissue windows in variable widths, MRI has to scan each
and radiofrequency (RF) coils. It is enclosed in a Faraday cage, sequence separately. Therefore T1-weighted (anatomy) scans and
which prevents the radiofrequencies arising outside the magnet T2·weighted (pathology) scans may not necessarily correspond
from interfering with those generated by the magnet. This cage is an exactly because of some movement between each sequence.
AF-shielded enclosure made of copper, aluminum, or steel sheets
and includes a door and windows made of special wire-embedded Artifacts
glass. The door should be closed at all times during each sequence. Two types of artifacts may be produced in MRI scans of dental struc·
All equipment present or entering the magnet room must be MR safe tures70: (1) those that result from patient motion. and (2) those that
or MR conditional (see next page for explanation). result from discrepancies in the magnetic field caused by magnet
susceptibility effects. Patient motion seldom causes artifacts when
Magnet the pa tient has been proper1y instructed and is comfortably posi
The magnet is the main component of the MAl scanner. Most mag· tioned.
nets currently in clinical use are within the midrange of 0.5 t o 1.5 tesla Susceptibility artifacts presenting as geometric d istortio ns are
(f: a measure of magnetic field strength). Although this is considered caused by air/tissue or bone/tissue artifacts or by ferromagnetic
the optimal range, some studies have displayed very good images metals. The fo m1 er is more likely to be a problem in high-field scanners
created on a 0.2-T scanner.13·'" The patient or part to be imaged is (those operating above 1.5 l), but certain strategies can minimize
placed wt
i hin a tunnel. Magnets of less than 0.5 T generally do not this effect."' The latter artifacts usually appear as localized areas of
have to have a tunnel and are open. 75 The SNR is proportional to the signal blackout adjacent to the metal structure. although orthodontic
field strength: TI1e higher the field strength, the greater the SNR.76 bands may cause severe geometric distortion. Concerns that the
MAl image may have been distorted can be checked by using
RF Coil SPAMM (spatial modulation of magnetization). which can provide a
The RF coil is made up of two separate coils: one to transmit the qualitative estimate of the accuracy of the MRI when planning dental
RF pulse to the patient's tissues and lesion and one to receive the implants.80
MR signal from the patient's tissues and lesion. The RF coil's shape
and size are appropriate to the part of the body to be investigated. Dangers
There is a range of coils for nearly every part of the body, including Although. unlike CT. MRI does not use ionizing radiation,8' safety is
the TMJ.72 Selectio n of the appropriate coil is paramount to achieve still a consideration. The dangers. in decreasing order of importance,
a high spatial resolution. are the magnet. RF exposure. and acoustic noise.
The magnetic field strength is an important factor in image quality. While MRI is not invasive. there are risks. To date. there have been
In dentistry, low field strength reduces metal artifacts, which is often at least 13 reported deaths due to MAl accident�: 10 people with
more importantn Kakimoto et al reported that whereas MRI scans pacemakers died during sequences. and 3 patients died after entry
were unaffected by metal artifacts, the artifacts rendered the CT into the magnet core, where they were struck by ferrous equipment,
images of the same patients useless for two of their study's nine including an oxygen cylinder.71To minimize such events , the Amer ican
patients.'• College of Radiology reissued the ACR Guidance Document forSafe
61
5 i Or al and Maxillofacial Radiology
Fig 5·16 T1-weigh ted scan. The subCutaneous fat and parapharyngeal fat appear Fig 5·17 T2·1W!ighted scan of the same section displayed in f'19 5·16. This scan
white (bright, or hyperintense), whereas the other soft tissues display a range of accenttlates water-rich tiSStJes, which include most lesions. and renders them
grays, from WilY light (hypointensel to lflose represented by sl<clctal muscle and lfle hype!intense. In some cases. it may be dff i icult to differentiate these areas from
pleomorplli c adenoma Qsointense). The black a1eas represent air-filled spaces, bene. fat, which is alSo hypertntense oo T2 -weighted scans. Fr�enlly, the fat signal Is
or blood vesselS comaining fast-Oowing blood. (Reprimed from MacOonald·Jankowsl<i" suppressed oo T2-weighted scans to further accentuate the walef-contai ning features.
with permission.) StJCh as the nasal and antra.! mucosa and salivary pleomorphic adenoma. This image
displays fat suppression. (Reprinted from MacOonald·Jankowski" with pefmission.)
MRPractices i n 2007. Applianc es are labeled MRsafe (square label}. (Fig 5-17). T2 · weighte d images are also called water images.'2 T2-
MR conditional (triangular label indicating safe up to 1 .5 T) and MR weighted images are useful for detecting infection, hemorrhage, and
unsafe (round label with a circle·st ash deSign}.83 neopla sms .75 A T2- weigh t ed image takes longer to acquire than a
T1-weighted ima ge, requir ing a long TE (greater than 75 ms) and a
Essential MRI jargon tong TR (less than 1500 ms}.72
Anhough many other sequences have g eneri c names, most use
In addition to T1-weighted and T2-weighted. t he prosthodontist the name or acronym created by the man ufacturer of t he unit.
workin g wi1h MRI is likely to see references t o intensity, fat suppres·
sion. and gadolinium. It is important to understand these terms to Hyperintensity, hypointensity, and isointensity
make best use of the re port and its accompanying images . Hyperintensity can be used to describe a bright structure (eg, fat
in T1-weighted and T2-weighled sc ans and most cysts and neo
T1-weighted plasms in T2-weighted images). Hypointensity descri bes structures,
T1-weighted scans are often known as anatomy scans because both in T1-weighted and T2-weighted scans, with dense calcified
their images display excellent contrast and most clearly show the tissues (including calcified lesion s } and fast-flowing blood. lsointen·
boundaries between different t i ssues (Fig 5 16). These boundaries
· sity is associated wi1h skeletal muscle in T1·weighted scans" (see
are made obvious by the fat-filled fascial pla nes, so T1·weighted Fig 5·16).
images are also termed fat images.72 Tt weighte d scans have been
·
ap plied to t he TMJ to determine the position of the articular disc. For Fa t su ppression
a T1-weighted image, a TE (echo d elay time) of less t han 40 ms and Fat normally appears as hyperintense on T1 -weight e d and T2·
a short TR (re petition time) of l ess than 750 ms ar e required. '2 weighted scans. Unlortunately, particularly in T2·weighted scans.
most lesions (neoplastic. cystic, and inflammatory} are also hyperin·
T2-weighted tense. Therefore, to i den t f
i y these lesions, the hype rint ense fat s ig·
T2-weighted images are oFten termed pathology scans because col· nat must be suppressed (Fg
i 5·18}. When contrast media is used
lections of abnormal fluid are bright against the darker normal tissue in T1 · weight ed scans, fat suppression i s required to detect subtle
Fig 5-18 n -welghted gadolinium-enhanced Images ol an advanced squamous Fig 5·19 Fat-suppressed Tl-vreighted and T2-welghted images o l a 7-year·o!d
cell carcinoma oltlle tongue. The hype�i nte n sity ol fat In both images has not been will1 pamtess pr()(Jressive sublingual swel ling. A dermOid cyst is situated beneath the
tat SIJIJI)ressed. (a) A coronal Tl-weighted scan soow·s the bilateral lesiOn panially geni()(Jiossus but above the hyOglossus. Other differential diagnoses were thyroglossal
obtllra ling the oropharynx and Invading the submandibular space. The center of this cysts and cystic hygroma. (a) Gadolinium-enha nced and lat-suwressed coronal T t
lesion is not very hyperintense because it is relatively unenhanced and is as isointense lveighted Image shows gadolinium -enhanced blood vessels in the capSIJie a round tile
as the skeletal muscle. {b) An axial Tl·weighted scan shows the lesion t o have superior aspect o fthe cyst.The normally hyperintense signal ofthe subcutaneous fat has
extensively invaded the lateral pharyngeal space an(! obturated the ipsilateral vallecula. been suppressed (compare with Rg 5-18}. (b) A fat-suppressed corooa l T2 1velghted
·
(Reprinted from MacOonald·Jankowski" witl1 permission.) ima ge shows the hyperintense Signal completely occupying lhe hypointense structure
observed on the T1-weighted scan. The bilateral leardrop-shape(l structures are the
sativa-tilled sulci of lho floor of the mouth. (Reprinted from MacOonald·JankovJSki et
ar3 with permission.)
Fig 5·20 A patient v�lh sublingual swelling and occasional mild pain lor 4 to 5 years
was diagnosed with neuroma. {a) Gadolinium·enhanced ar1d fat-suppressed axial T1·
weighted image shows the ringlike enhancement of peripheral blood vessels. (b) The
fal-suwressed axial T2-weighled image shows lllat the entire lesion is hyperintense.
Most lesions are water rich and awear hyperintense on T2-weighted scans. (Reprinted
from MacDonald·Jankowski et al23wilh permission.)
lesions that normally occur within fat-filled structures such as bone Contrast media
marrow. Figure 5-19 displays T1-weighted and T2-weighted images Contrast media enhance blood vessels and vascularized tissues
that have both had t he hyperintense signal of the subcutaneous fat (Figs 5-20 to 5-22). To det ermine whether enhancement has oc
suppressed. Another reason lor fat suppressio n is that a very hyper curred, the contrast images (usually T1 -weighte d with gadol ini um)
intense fat signa l can create an artifact a few pixels away from i ts are compared with the previo u s noncontrast images. Gadolinium,
real posi tion (this artifact is called the chemical shift), which may be the most widely used contrast media in MRI. is used to enhance T1-
clinically significant (eg. a hyperintense signal coming from bone weighted signals in tissues. It accumulates in richly vascular lesions,
marrow suggesting that H has been infilt rated wit h an adjacent oral such as most neoplasms and causes them t o become hyperintense
,
cancer).72·"'The most frequently encountered fat-suppression strat (Figs 5-22a. 5-23a, and 5-24a). It has recently been shown to in·
egy is •tat satu ration . " Anotl1er relatively frequently encountered duce nephrogenic systemic fibrosis, which may rapidly progress to
s trategy is short T1 inversion recovery (STIR). wheelchair depende nce in many, intractable pain syndrome in oth ·
ers, and even death occasionally.1l4-&JAfter gadolinium is injected into
the body. H is ra pi dly distributed in the blood and graduall y excreted
by the kidneys over 24 hours.
63
5 i Oral and Maxillof acial R adiology
Fig 5·21 New, enlarged jugulodigastlic node atter partial glosscctomy tor squamous Fig 5·22 Painless, gradually expanoing sweUing ollhe left parotid gland. Needle biopsy
cell carcinoma. (a) GadOlinium-enhanced and fat-suppressed coronal Tl-weighted Showed a pleomorphic salivary adenoma. (a)Gadolinlum-entlanced and fat-suppressed
image shows the gadolinium (l1yperintense) ringlike enhancement or the jugulodigastnc axial Tl-weighted image higlllights tile blood vessels within tnis neO()Iasm. (b) The fat
node. suggesting central necrosis indicative 01 metastasis. (b) The tat-suppressed suppressed coronal T2-weighted image Shows t h e blood vessel-filled component of
COfonal T2-weighted image confirms hyperintense signal from the area of central tllis lesion that conlributes to its hyperintensity. (Reprinted from MacDonald-Jankowski
necrosis, which has been defined by fat suppression. (Reprinted from MacDonald et atn with permission.)
JankowSki et a� wiUl pemlission.)
Uses for MRI in OMFR pat ients.9' Notwithstanding these encouraging results, it is recom·
mended that the radiologist be consulted before such patients are
Although many reports focus on MRI of the face and ;aws (mostly for referred because implants do interfere with i mage quality in many
TMJ disorders). the complex and evolving nature of MRJ means that units. The presence of implants should be cleany mentioned in the
sufficient data are not yet available to draw clear conclusions: this referral letter. and the patient should be told to report these to the
was recently confirmed by a systematic review on TMJs."' MAl staff pr io r to the procedure. Magnetically retained prostheses
can cause severe artifacts if not removed, �n and the long-term in
Visualization of the soft tissue (lesion)-bone interface duction o f magnetism within implants remains unknown.
In additi on to reconstruction in any plane and the complete absence
of ioniZing rada
i tion, the contrast i n an MR I image optimizes the dis TMJ im agi ng
play of soft tissues and their precise relationship to the bone. making Conventional radiography i s of limited value in most cases of TMJ
MAt the imaging modality of choice for this purpose. CBCT and the disorder because rt displays only the bony structures that can also
bone window of high-spatial resolution SpCT. on the other hand, are be displayed by CT (see Fig 5-23a) and MRI (see Figs 5·23b and
best t o determine the effects of disease o n bone (eg, erosion). The 5·23c). Furthermore, it displays the changes brought by the disease
soft tissue window of SpCT, in which the bone "blooms• and thus progression, such as osteophytes, and thus reflects the disease his
appears much thicker and obscures the soft t issue-bone interface tory rather than the current com plaint. Although recently MRI was
(see Fig 5-5), Is less useful. The soft tissue-bone interface in MRI can cautiously identified as the best modality for temporomandibular
cause geometric distortion, but if MAl is used with a certain protocol, disorders, in the absence of high-quality stud ies on its diagnostic
this distortion is negligible." efficacy, there is no clear evidence for when it should be used.93
Generally, only T 1 weighted scans of the TMJ are used, particularly
-
Implant d entis try to determine the position of the articular disc."" An imaging protocol
Before the impact of CBCT cou ld be fully appreciated, the role of and categories and distributions of TMJ disc position in the mouth
MAl in implant dentistry was reviewed and found t o be safe for pre closed position have been defined.95 Joint effusion, which is an
operative implant-site assessment''" However, grade 4 titani um im excess of fluid in the joint space (see Fig 5-23c), may be associated
plants (used in dental implants) were found to be particularly MRI with oint
j pain and inflammatory changes"" and is not displayed
unsafe in 7.0-T MAJ.69 Safety aspects of almost every kind of non· by T1 -weighted scans: indeed. it is not even readily displayed by
dental implant have been researched,00 but this does not appear to T2-weighled scans. To display a ioint effusion, fat suppression
have been done for dental implants. Sawyer-Glover and Shellock is necessary, which reduces the scanning time and the risk of
state that forces u p to 1.5 T will not move or dislodge dental im movement artifacts. Joint effusion can occur in association with
plants, which indicates that MAis less than 1.5 T are safe for those marrow edema and osteonecrosis.
Fig 5·23 A painful joint displays effusioo

on a fat-suppressed T2·wcightcd scan as a
hyperintense area. (a) Exquisite bone detail
is obvioos o n this CT booe window. The soft
tissue is a uniform gray, punctuated only
by the air-filled external acoustic meatus.
(b) The Tl·weighted scan shows the very
hypointense condylar and glenoid cortices
and external acoustic meatus. The partially
displaced disc is otseNed as a hypolntense
structure above the condylar head and
the lsointense lateral ptel)'gold muscle. (c)
Fat-suppressed T2-weighted Image shows
thai the relatively hyperintense condylar
marrow is now hypolntense. (Reprln ted
from MacDonald·Jankowski et al23 with
•
permission.)
•
• •
Fig 5·24 (a) The rat-suppressed T2·weighted scan displays squamous cell carcinoma
'•
•
X ,
f
.,.,
.
�
'"
•,,
?J
of the toogu c more prominently than that displayed in a T1·wcighted scan enhanced '
�)
•• • •
b y gadolinium and fat supprcss1on. The gadolinium-enhanced. fat-suppressed, coronal

T1-1veightcd image shows gadolinium-enhanced blood vessels at the pcrlpllel)' of the
lesion. (b)Fat-suppressed coronaiT2·•.veighted image d e monstrates howfat suppression
I t\•
-
accentuates the water-rich neoplasm. (Reprinted from MacDonald·Jankowski et al" .. '•
with permission.)
Facial pain infrequently the primary mode of diagnosis, it is an inval uable tool to
A routine MAl should be considered for all trigeminal neural gia (TN) help the c li nician stage the lesion and determine the optimal course
pati ents.96This suggestion is supported by Tanaka et at, who report· of treatment.'00 Nevertheless. spatial resolution could be a limiting
ed that the majority of 150 patients with TN had neurovascular com· factor. Ozturk et al reported that neither CT nor MRI was useful for
pressiOn or the nerve root in the cerebellopontine angle cistem.9' Six T1 tumors but both were better fo r T2 to T4 tumors.'"'
patients in their series 11ad brain tumors. As sec appears on a T1-weighted scan as isointense, it is
A functional MRI technique called blood oxygen level dependent difficult to distinguish from adjacent skeletal muscle. particularly in
(BOLD) may improve the understanding of central nervous system the tongue (see Ft g 5·18). then gadolinium-enhanced T1·weighted
sites involved in pain trans mission and processing. oo BOLD takes images can display the lingual lesion (see Figs 5·18 and 5·24a).
advantage of the differing magnetic susceptibilities of fully oxygenated On a T2·weighted scan. SCC is hyperintense and can be readily
hemoglobin and deoxyhemoglobin as they alter T2·weighted decay distinguished without fat suppression because !he tongue, which
and allows location of distinct areas of the brain activated during is a muscular structure, contains tittle fat (see Fig 5·24b). Hsu et al
del ivery of pa i nfu l stimuli. maintain that direct laryngoscopy is the most accurate method to
evaluate the mucosal suriace of the aerodigestive tract.'�
Facial swellings Although MRI dsi plays contrast e n hancement better than CT. this
MAl {1 .5 T) is sufficiently accurate to diagnose or exclude some neo· may be nullified by movement artifacts produced during the longer
plasms.O'l MRI also seems to be effective in the diagnoSis of inflam· scanning time.'03 One pilot study reported on perfusion CT, which
matory disease, including infections. may offer better detection of primary and recurrent SCC.'""
Malignancies Involvement of adjacent bone Bolzoni et at reporte<l that in a

Diagnosis and preoperative as sessment Despite many series o f MRis of 43 patients with SCC befo re mandibulectomy,
advances In the understand ing of head and neck cancer, the 16 patients (2 of whom were false posi tives) displayed mandibular
survival rates are still poor. This is mostly because patients tend to involvement. 10' Although the MRis of the remaining 27 patients
present with advanced disease {see Fig 5·18). Most head and neck displayed cortical integrity, one mandible was found to have become
mali g nancies are associated with squamous cell ca rcin oma (SCC), microscopically involved.
pred o minantly of the mouth and pharynx. Although imaging is
65
5 iOral and Maxillofacial Radiology
}· l
•(,.
.
,I �
lj/''• ;-t
�I�\"_0
,
'I �
I .)� '
Fig 5-25 An indurated ulcer 0.5 em in dmmeter is observed on the floor of the mouth.
\ X t
The jugulodigaslric lymph node and those adjacent to the submandibular gland are
displayed. Because these nodes are oval shaped and the shortest diameter is less than
1 em. they may be reactive rather than neoplastic. (a) Fat-suppressed aXial T2-weighted
and (b) fat-suppressed coronal T2·welghted images. (Reprinted from MacDonald·
b • Jankowski e t al" with permission.)
The specificity of MRI for cortical invasion is significantly lower Other important lesions of the face and jaws
than for CT."' Most of the false positives seen in MRis may be a result Ameloblastomas presenting as a unilocular radiolucency are mosl
of the chemical shift artifact of the bone marrow fat. STIR has been likely to be unicystic. but some are of the solid type that invariably re
recommended to display bone marrow invasion as a hyperintense quire resection. 1"'·'"" One histopathologic review of MRI appearanc
signal'"' es of 1o ameloblastomas suggested that solid and cystic portions
When used to determine the involvement of the mandibular canal. can be differentiated, particularly by gadolinium. "0 An ameloblastic
MRI is significantly inferior to CT because the intensities of the tumor carcinoma metastasizing not only to the lung but also to the skull can
and surrounding inflammation appear similar. This em phasizes the be seen on MRI and PET/CT."1
continued need to use CT in conjunction with MRI for patients with The signal intensity of lesions on T1-weighted and T2-weighted
head and neck cancer.8-' MRI images is dependent upon a number of factors, such as the
amount of bone trabeculae and degree of cellularity.112 Rbrous
Assessment o f regional lymph nodes Metastasis to the regional dysplasia and ossifying fibroma both show an intermediate signal
lymph nodes i s common. Management of almost all cases must o n T1-weighted scans and a hypointense signal on T2-weighted
therefore include these nodes, even if lymph node involvement IS not scans."3 The hypointensity on T2-weighted images i s caused by
apparent clinically,211 because the risk of occult metastasis is high in numerous bony trabeculae.'" Fibrous dysplasia in �s early stages
oral. pharyngeal. and nasopharyngeal cancers.10• may show areas of T2-weighted hyperintensity that may correlate
Key indicators of metastasis include an increase in nodal size. with bone resorption. 113 Intravenous contrast produces a moderately
a more rounded shape. and central necrosis that appears as a enhanced signal for ossifying fibroma. which is often identified as
prominent ring, which is enhanced by gadolinium on a T1-weighted fibrous clysplasia. Although fibrous dysplasia and ossifying fibroma
scan (see Rg 5·21}. Unfortunately, these changes are rarely observed can be mistaken for meningioma on MRI. 1 13 MRI offers greater
in small nodes. Therefore, ultrasound-guided fine-needle aspiration specificity in cases with neurovascular and ocular involvement."•
cytology is recommended.106 A neoplastic node is more likely to be
round, with a diameter of at least 1 em; a reactive or inflammatory Vascular lesions Congenital vascular lesions of the head and neck
I$
node is more likely to be ovoid. with a diameter that may be less than have been classified as hemangiomas and vascular malformations.1
1 em (Fig 5·25}. The hemangioma, usually not present at birth, proliferates during life
and involutes, whereas l11e vascular malformation, always present
Assessment of deeply placed o r invading cancers Laryngeal at birth. never prolfferates and never involutes. High-flow vascular
and pharyngeal sees extend deep into tissues, including malformations give a hypointense signal on T1-weighted and T2·
submucosal extension beyond the obvious primary mucosal lesion, weighted scans!' Of the nine patients studied by Kakimoto et al,
and cannot be assessed accurately by endoscopy. Therefore. CT ei ght were evaluated using fat -suppressed gadolinium-enhanced
and MRi are required for proper staging."'" M RI scans, which increase tumor contrast and thereby allow easy
detection of vascular lesions (Rg 5-26a}.117 Add�ionally, although
Posttreatment i ma g ing Because MAl's vaunted ability to phleboliths were best detected on CT. in two patients the CT images
differentiate tumors is compromised by edema after radiotherapy, were degraded by metal artifacts from dental restorations.
SpCT is better at displaying posttreatment tissue changes and A combination of 3D FASE (fast asymmetric spin echo) and T2·
tumor recurrences.107 weighted scans with 30 ultrafast spin echo sequences display the
References J
Fig 5-26 Hemangioma of the rongue. The labial lesion had already been rrealed by
laser. (a) The fal·suppressed axial T2·weighted image shows the hemangioma as a
clearly defined hyperintense signal. (b) The magnefic resonance angiography image of
the facial ar tery shows a dilated facial arteryand sup erior labial bra nch.The inferior labial
branch is not visible bacause o f previous laser treatmenl. (Reprinted from MacDonald·
Jankowski eta!"' with permission.)
30 structure of hemangiomas and the feeding arteries without using

contrast media."8 Figure 5-26b displays MR angiography.
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75. Gray CF. Redpath TW, Smilll F, Staff RT. Advanced imaging: Magnetic reso· 101. Ozturk M, Yor\Jim� I, Guney E. 01.can N. Masses or ihe tongue and
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S. CT and MR rmaging features of oral and maxillofacial hemangioma and 103. Rumbold! Z. Day TA. Michel M. Imaging of oral cavity cancer. Oral Ortool
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112. Jee WH. Ohor KH. ChOe BY. PM< JM. Shinn KS. Fibrous dysplas.a: M R 120. MIUer n, RandOlph DA Jr. Staron RB, Feldman F, Cush1n S. Fat-suppressed
rmagng characteristics with radiopathologc correiahon. Am J Roentgenol MRI ot musculoskeletal infection: Fast T2·v>f8ighted techruques versus
1996;167:1523-1527. gadolinium-enhanced Tl-welghted �nages. Skeletal Racfiol 1997:26:
113. Wenig BM, Mafee MF. Gho$11 L. Fibto-osseous. osseous. and candeginous 654-658.
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114. Khanna JN. Andrade NN. Giant OSSifying fibroma. Case report on a birnaxil 122. Morimoto Y, Haou M. Tomoyose T, et al. Dynamic magnetic resonance
laJy presentat ion. 1nt J Oral M axillofac Surg 1992:21:233-235. sialographry as a new diagnost ic technique lor patients with Sjogren's syn·
115. Rical de P. Horswell 68. Craniofacial fibrous dysplasia ot the Ironto-orbital drome. Ofal Dis 2006:12:408-414.
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S. CT and MR imagong features of oral and maxrtlof acaal hemangioma and of the unsttmUtated whole salrva tlow rate and salivary gland srze estimat·
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118. Tanaka T. MorimOlo Y. Takano H. et al. Three-dimensional ldentilication 2006;5 1:345-349.
of hemangiomas and feeding arteris
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combined phase-contrast MR angiography and Fast asymmetric s;>in· agement of obstmctive salivary gland diseas e. De11t Update 2006;33:28-30.
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100o609-613.
119. Klto S. Morimoto Y, TanakaT, et al. Utility of dilfusioo·wei!)hted images using
fast asymmetric Sllin·echo sequences tor detectiOn ol abscess formation rn
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2006;101 :231-238.
Chapter
Psychologic Aspects of
Diagnosis and Treatment in
Advanced Dental Care
John E. Schmidt, Pho
Cha r les R. Carlson, Pho. MA. ABPP
3. The dualistic nature of the biomedical model, which separated

The Role of Psychology in function of the body from function of the mind. In Engel's opin·
Advanced Dental Care ion. this view encouraged clinicians to focus on the biology of the
body without taking into consideration the concurrent mental and
An understanding of how anxiety or other psychologic issues may emotional functionality.2
compl icate dental treatment is important when considering the ben
efits of long-term. consistent dental care. Comprehensive and ef This last criticism is particularly pertinent to this chapter.
fective treatment, regardless of the specialty or practice. suggests Psychologic processes may affect patients' perceptions and
consideration of the whole person beyond just the phySical aspects. interpretations of physical symptoms or the effectiveness of
This evolving notion of comprehensive care began w�h the concep treatments. Social systems (eg, cultural norms or socioeconomic
tion of the biopsychosocial model developed by Dr Engel,' who be status) may affect the patient's actions and treatment options. To
lieved that, to understand a patient's suffering and ensure that the focus on a specific biologic condition or treatment without considering
patient feels understood, one must attend to the biologic, psycho the patient through the framework of the biopsychosocial model falls
logic, and social dimensions of illness and care. Engel was a critic well short of providing comprehensive and empathic care. Research
of the medical field's narrow biomedical approach to research and i n the area of psychosomatics has consistently shown how the
treatment, which often regarded patients as objects. He considered integration of physical disease and emotional state affects treatment
three characteristics of the contemporary medical philosophy to be of the suffering person.
mainly responsible for the dehumanizing of care: This chapter focuses on the psychology of dental patients from
two perspectives: (I) patients seen in general practice and (2)
1. The reductionist nature of medical thinking, which basically ig more complex patients, such as those seen in prosthodontics
nored anything that could not be verified and explained using cel and orofacial pain clinics. It is important for clinicians to have an
lular or molecular processes. The standard biomedical model of awareness of psychologic status and comorbidity in their patients
care essentially neglected the human dimension of suffering. and to understand that patients struggling with psychologic
2. The lack of understanding or consideration of the influence of conditions such as depression and anxiety may require additional
the observer on the observed. In caring for patients, Engel felt attention, assessment, and follow-up. Standardized psychologic
that one cannot assume a stance of pure objectivity because it is assessments focus on typical areas of difficulty for these patients
impossible to interact with or observe a system without disturbing and allow clinicians to formulate a comprehensive treatment plan
that system in some way. based on all aspects of patient function. Depending on the outcome
71
6 iPsychologic Aspects of Diagnosis and Treatment in Advanced Dental Care
of these assessments. several treatment options are available that in greater detai l later in this chapter. The use of relaxation
have shown much success tor advanced dental care patients with strategies for patients struggling with treatment-related anxiety
psychologic issues. Althoug h these behavioral strategies are ideal has demonstrated benefits in a number ot studies.'•·•6 The
for patients with orofacial pain, this information should prove helpful basic premise is that by engaging in a relaxation protocol. the
tor any dental patient struggling with psychologic distress. anxiety-prone patient creates balance in the autonomic nervous
system. This dampens sympat11etic activity associated with the
anxiety-induced emotional and physiologic arousal, otherwise
Treatment-Related Dental known as the fig/Jt or flight response.

3. Distraction. im agery, and visualizato
i n: Distraction is an often
Anxiety overlooked yet simple way to reduce anxiety. Ustening to a
por table music device when in the dental chair has demonstrated
Perhaps the most common psychologic issue many dental practitio greater efficacy in reducing anxiety compared to controls.••
ners encounter in daily practice is treatment-related anxiety. In fact. More advanced distraction techniques include imagery and
dental anxiety is so prevalent that many practitioners have become visualization. In these self-regulatory strategies, the patient uses
quite adept at identifying, addressing, and reducing mild fear of den a practiced script to mentally reduce the situational fear. Several
i logic
tal treatment and specific dental phobias in patients.3 Epidemo studies in the dental literature have shown that guided imagery
data suggest dental anxiety is quite peNasive, affecting 18% to 20% and suggestion can reduce anxiety, increase tolerance of dental
of the US population.•.s Dental anxiety is potentially a public health procedures. and speed the healing process. •G.IT
concern because treatment-related anxiety can deter patients from 4. Medication: Medication and sedation are also options for
pursuing adequate dental care in a timely manner. When the patient treatment-related fear and anxiety and have proven to be
does eventually seek treatment, the necessary procedures are more quite effective in some cases.'"''• However, pharmacologic
urgent. costly, distressing to the patient. and challenging to the prac approaches are considered short-term solutions to a chronic
titioner. problem.
Dental anxiety is a complex problem with a known variety of
etiologic factors.6 It may be specific to dental treatment, or it may A multidimensional approach is often the most effective because
be a more generalized anxiety problem triggered by dental treatment it uses a variety of inteNentions and strategies to reduce anxiety
and other medical situations. Precipitating factors can range and tear. Patients may find that in addition to other behavioral and
from an early !earful dental treatment exPerience to a history of pharmacologic techniques, a single brief therapy session focused
childhood traumatic experiences that precede a pe!Vasive anxiety on reducing anxiety and fear i s beneficial. This approach has proven
disorder.6·1 Regardless of the etiology, the clinician who has a set of helpful in a variety of phobic conditions such as arachnophobiaro
techniques or approaches readily available to help reduce treatmen t and dental phobia.v In a recent study comparing pat ients treated
related anxiety will have a more relaxed patient and a less stressful with medication, patients treated with one session of psychologic
treatment session. The following are common techniques that have therapy, and a control group that received no treatment before oral
demonstrated efficacy in reducing dental treatme nt -related anxiety: surgery . both treatment groups demonstrated signifiCantly less
anxiety about surgery compared to the control group.22 However,
1. Communication betweenpractitionerandpatient: latrosedation. the reduction in anxiety was short-lived in the medication group,
as described more than 40 years ago by Friedman. is still whereas the therapy group maintained reduced treatment-related
relevant in the care of the anxious dental patient.8 latrosedation anxiety at a posttreatment follow-up.
is a method of calming the patient through verbal and
nonverbal communication by the provider. In this approach.
a comprehen sive inteNiew is paramount to establish an open
and trusting relationship between the patient and provider
Psychologic Factors in
and to better understand the specifics of the patient's fear. Orofacial Pain
More recent research has shown that a focus on reducing
treatment-related anxiety through communication and Patients with orofacial pain are a particularly challenging popula
building rapport consi stently enhances patient comfort and tion from both dental and psychoiogic treatment perspectives.
treatment effectiveness.""" Trust between the practitioner and Orofacial pain includes a broad group of conditions categorized as
patient positively affects short-term and long-term treatment temporomandibular disorders (TMDs). n1ese conditions are quite
outcomes. '�'3 common and occur primarily in YOllng and middle-aged women.23
2. Relaxation: To reduce anxiety. relaxation from a psychologic i logic study. 5.3% of the US population reported
In a recent epidemo
symptom management perspective consists of activity experiencing some form of TMD pain.2' Other prevalence studies
designed t o achieve a quiet body and mind. Therapeutic have placed the incidence of TMD even hgher, at about 12%.u
i
relaxation is a form of self-regulation. which will be discussed

Psychologic Factors in Orofacial Pain J
Orofacial pain conditions may arise after injury to the tempor muscle pain conditions. Higher levels of psychologic dysfunction
omandibular joint (fMJ) or a s a result of chronic parafunctional ac in muscle pain conditions among orofacial pain diagnoses have
tivities such as bruxism. Habitual tensing of the jaw musculature been demonstrated in several studie s.:!to-38 One of these focused on
also may initiat e a TMD or exacerbate an already existing TMD. Co differences between patients diagnosed with masticatory muscle
morbid conditions are extremely common in patients wit h oro-facial pain and patients with intracapsular pain, within various behavioral
pain, who often present with medical complaints such as diagnoses and psychosocial domains."" Although no significant differences
of interstitial cystitis, fibromyalgia. or gastroesophageal reflux dis were reported in pain severity or duration, those with masticatory
ease.'621 Because comorbid conditiOns suggest broad physiologic pain reported more symptoms or depression, anxiety, and sleep
dysfunction, they hint at the complexity of orofacial pain conditions. dysfunction, in addito
i n to a higher number of traumatic stressors. tn
Patients with orofacial pain are a diagnostic challenge, and general, chronic orofaciat pain is an emotionally and physically taxing
they often suffer from multiple TMD conditions simultaneously. For condition regardless of the specific diagnosis.
example, a typical patient may experience an early disc derangement
disorder with associated pain. The pain and discomfort lead to
secondary muscular contractions that attempt to reduce painful Orofacial pain, stress, and emotional distress
movements. a s described by Lund.28 If prolonged, the init a
i l disc
disorder can lead to a chronic masticatory muscle pain problem. Emotional distress is a nonspecific term used to denote a significant
Dia gnoses and treatment choices for these patients are complicated psychologic disturbance. This can take the form of symptoms of
by the interrelationships that may exist among orofacial pain depression, anxiety, or increased irritability and moodiness. Emo
conditions.29 tional distress may be a consequence of the pain, related to the
Often. orofacial pain conditions are chronic; their negative effects limitations the pain imposes on the patient's life, or a combination
on many aspects of patients' daily lives include reduced social thereof. Regardless of the source, emotional distress is an important
activities, disruption of personal relationships , difficulties with and all-too-com mon !actor in the ctiagnosis and treatment consider
activities of daily living. and problems with employment. Significant ations for these patients.2<1·39 Perhaps the most important (yet least
psychologic distress often develops as the orofaciat pain condition considered) aspect of emotional distress is the deleterious effects it
worsens and become chronic or an already present psychologic can have on many systems of the body.
problem becomes exacerbated by the orofacial pain conditiOn. In Physiologic effects and changes associated with stress and the
recognition of the complex association between the physical disorder emotional effects of pain are widespread. The body responds to
and psychologic response, the dual-axis model was developed by an acute stressor with physiologic changes designed to help the
Dworkin:)() and Okeson.29 In this model, the problematic biologic individual cope. During an a cute stress response, the body is more
components are included on Axis I, and the associated psychologic alert and ready to escape or defend to protect bodily integrity.
responses or comorbidities are included on Axis II. Application of Mental concentration is more focused, and reaction time, strength,
i nos ti c and treatment-planning tool gives the
this model as a dag and agility are increased. The stress-response system includes the
clinician a broader understanding of the multiple difficulties that hypothalamic-pituitary-adrenal axis and the sympathetic-adrenal
patients with orofacial pain experience. It also distinguishes the medullary axis. When these systems are triggered by a stressor,
physiologic aspects of an orofacial pain condition from the subjective corticotropin-releasing hormone is released in the hypothalamus.
nature of p ain perception and its impact on psychologic and social This hormone triggers the release of adrenocorticotropin from
fu nctioning.3' Because successful management of orofacial pain the pituitary gland, which activates the ad renal glands. The
conditions requires a multifaceted therapeutic approach, the dual adrenals release epinephrine, norepinephrine, and cortisol. These
axis model can help the practitiOner maintain awareness of specific compounds help the body successfully respond to a threat by
psychologic conditions and how they affect treatment outcomes for increasing blood pressure and heart rate. diverting blood to muscles,
these challenging patients. and speeding reaction time. Cortisol releases glucose from bodily
Research investigating comorbid psychologic status has shown reserves to provide easily convertibl e fuel to muscles and the brain.
that psychologic disturbance is a common occurrence among In an acute stress response, cortisol exerts a feedback loop that
patients with orofacial pain. Studies that compared orofacial pain dampens the stress response after the trigger has been resolved by
patients w�h pain-free controls found that the patients with pain stopping the production of corticotropin-releasing hormone in the
consistently reported greater sympt om s of depression, anxiety, hypothalamus.40·"
and emotional distress.32.33 In a study by Korszun et at. 29% of Chronic activation of the stress-response systems. which
patients met criteria for Diagnostic and Statistical Manual of Mental likely occurs with chronic orofaciat pain, can result in long-term
Disorders (DSM) IV-TR d iagnosis of a major depressive disorder.30"" adverse physiologic and health effects.�43 Prolonged secretion of
However, among orofacial pain cond�ions, psychologic distress is glucocorticoids associated with chronic stress results in hypertension,
more com monly found in those patients diagnosed with a Research d am age to muscle tissue, and inhibition of inflammatory responses.••
Diagnostic Criteria for Temporomandibular Disorders (ROC!TMD) Recent research has demonstrated the deleterious effects chronic
Axis I TMD diagnosis.3S The ROC Axis I diagnoses include primary stress can have on wound heating'5·''6 and has provided evidence
73
6 i Psychologic Aspects of Diagnosis and Treatment in Advanced Dental Care
of the association between chronic stress and cardiovascular

Box 6·1 Symptoms of a major depressive disorder
disease. osteoporosis. arthritis, type 2 diabetes. and functional
decline•l These findings are particularly salient for patients with
1. For a rnajor depressive episode, a person must have experienced at
chronic orofacial pain as they struggle t o manage pain severity and
least fiVe of the fine symptoms below for the same 2 weeks or more.
other functional symptoms. The association between symptoms of ror most of the time almost eve<y day, and thiS si a change from his/
depression and the physiologic markers of chronic stress response her prior level of functioning. One or the symptoms must be either (II)
depressed mood. or (b) lOss ollnterest.
is robust'' and suggests that depressive symptomatology, so often
a.Depressed mood (lor ch1ldren and adolesCents, this may be
present in patients suffering from chronic pain. can have significant imt ble
a mood)
long-term oonsequences on physical health and emotional b. A significantly reduced level ol interest or pleasure in most or
afl activities
well being .
c. A considerable loss or 9311'1 of weight (eg, 5% or more change of
-
weoght in a month when not dieting): this may also be an roease

or decrease in appetite: lor children. they may nto gain an expected
Depression amount of weight
d. DiffiCulty fallng or staying asleep (insomnia), or steeping more than
usual (hypersomnia)
Given the prevalence of depressive symptomatology in patients with e. Behavior that is agtated or slowed down (thts change shOUld be
noticeable to othets)
orofacial pain and other advanced dental conditions.48 it is important
f. Feeling fatigued, or diminished energy
tor the clinician to have a sound understanding of the symptoms and g. Thoughts of o,vorthlessness or extreme guih
diagnostic criteria of major depression. Knowledge of and ability to h. Reduced ability to think, concentrate. or make decisions
i. Frequent thoughts of death or suicide (with or withoui a specifiC
identify these symptoms will enable the practitioner to take appropri·
plan). or attempt ot SUICide
ate steps to ensure comprehensive care is in place for the patient. 2. TI1e person's symptoms do not indicate a mixed episode (maniC and
Specific symptoms of a major depressive disorder from the OSM·IV depressive).
3. The person's symptoms are a cause of great distress or difficulty 1n
TR are summarized i n Box 6·1."'
ft.,ct!Onlng at Mme. work, or o111er Important Sff',as.
Knowledge of the symptoms and characteristics commonly found 4. The person's symptoms are not caused by substance usa (eg, alcohol.
in ch ronic orofaoial pain patients reveals why depressive symptoms drugs. medlc<ltoi n) or a medical disoreler.
5. The person's symptoms arenot theresult ornormal griefor berea��emeot
are so common in this population. Depressed affect exacerbates
over the death of a loved one.
pain perception. and pain perception intensifies negative affect and 6. Symptoms oontinue for more than 2 months. or they lnc:Ude great
depressive symptomatology through catastrophizing and cog nitive difficulty n Junctioning. frequent lhoughts or worthlessness. thooghts or
suicide. symptoms Ihat are psychOtic. or behavior that Is $lowed down
distortions.'" The pain perceptiorKlepression association may
(psychomotor retardaion t ).
result from social and interpersonal effects of the chronic pain
condition. Chronic pain patients generally are more socially isolated, (Repmted from the American Psychiatnc Associabon'" wnh permission.)
have difficulty focusing on tasks requiring mental effort, have more
sleep dysfunction and daytime fatigue, and have negative self·
perceptions.'"' In dental care, the most significant effect of depression
is lack ol regular oral hygiene and minimal pursuit of treatment.
Depressed patients may be uncooperative and irritable, be reticent
and withdrawn. or 11ave numerous unwarranted complaints during patients. In addition, possible medication interactions should be
a viSit. Additionally, depression may adversely affect adherence to carefully reviewed. TCAs. for example, can adversely int er act with
postoperative instructions."' some local anesthetics, resulting in an increase in systolic blood
The standard treatment for depresSion is antidepressant medication pressure and possible cardiac dysrhythmias.63 A detailed review of
and concurrent cogn�ive-behavioral therapy. This bimodal approach antidepressant medications and dental implications is available."
has proven effective for managing depressive symptomatology in
many different clinical populations. Antidepressant medications are
grouped into four main families and include (1) selective serotonin Anxiety
reuptake inhibitors (SSRis), such as citalopram (Celexa [Forest
Pharmaceuticalsl) and Huoxetine (Prozac [Eli UllylJ; (2} tricyclic Anxiety symptoms can ooexist w�h depression, or they can present
antidep ressants (TCAs). such as amitriptyline and nortriptyline; (3) as stand-alone symptoms. A patient may experience phobic anxiety
monoamine oxidase inhibitors (MAOis) such as phenelzine (Nardi! to dental treatment in particular. or the anxiety problem may be more
[Pfizer]); and (4} atypical antidepressants such as bupropion generalized or caused by a traumatic experience. The primary differ
(Wellbutrin [GiaxoSmithKiine)), mirtazapine (Remeron [Schering ence between a phobic anxiety condition like dental phobia and a
Piough)). and venlafaxine (Effexor [Pfizer)).52 Regardless of the more generalized anxiety disorder is the impact on normal function
medication, the practitioner should be aware of the possible side ing. The phobic reaction is specific to a trigger, such as dental treat·
effects, specifically potential orofacial reactions. For example. TCA ment or even more specifically to the sound of a dental drill,' where
use is associated with xerostomia, which affects up to 50% of as symptoms i n other anxiety disorders are broader and can affect
normal functioning in a variety of ways. Regardless of the source or

trigger, anxiety symptoms can greatly interfere with consistent dental
Box 6-2 I Symptoms of GAD
care and treatment of orofacial pain05
1. Excesswe anxiety and worry (apprehenSive expectation). occuning
In patients presenting for dental treatment, generalized anxiety
more days than not fO< at least 6 monl!ls. aboUl a number of events or
disorder (GAD) and post-traumatic stress disorder (PTSD) are activities (sUCh as health 0< employment).
the most commonly encountered anxiety disorders?� GAD is 2. The person finds ij diffocun to COI1trol the worry.
3. n�e anxiety and worry �re associated >Mth Ulree (or mote) of the
characterized by persistent, excessive, and often unrealistic worry
follOWlflQ six Symptoms (with at Jeast some symptoms l)fesent fO< more
about everyday things. Individuals with this disorder report that the days than not for the past 6 monthS: )
worry is beyond their control, and they often expect the worst in a. Restlessness Of feelfng keyed up or on edge
b. Easily fa!Jgoed
any situation. The exaggerated and unrelenting worry often centers
c. Dilfocutty concentratlf)Q or mrnd go;ng blank
on issues of health, family, finances, or employment. The wony can d. Irritability
interfere with all aspects of daily living. The prevalence of GAD in e. Muscle tensiOn
f. Sleep cfJSturbance (difficulty falling Of stayfng asleep: Of restless,
the US population is approximately 3%, with a lifetime prevalence
unsalisfyilg sleep)
rate of 5%. Approximately two·thirds of those with GAD are women. 4. The anxiety. worry. or physocal symptoms cause clinically S<Qnificant
Specific symptoms of GAD a s found in the DSM N-TR are listed in diStress or impairment In social. occupational. or olhe< impenant areas
of functioning.
Box 6·2.s•
5.The person's symptomsare not caused by substance use (eg. alCOhol,
In patients with orofacial pain, the nociceptive component of drugs. medicatio n) 01' a medical disorder.
the pain experience is often the source of anxiety. Anticipation of
(Reprinted from the American Psychiatric As$0Ciation" with poon1ssion.)
increased pain exacerbates fear and anxiety and leads to avoidance
of previously normal activities. This becomes a pattern in which
fear of movement and fear of reinjuring the site of pain predict
functional limitations."" A diagnosis of GAD or other anxiety disorder.
when comorbid to a primary TMD or other dental disorder. also
raises concern regarding parafunction. Parafunction is defined as Behavioral treatments for anxiety disorders can effectively reduce
movement or use of a body part that is considered outside of normal symptoms. promote normal daily function, and improve overall
functioning and that may lead to abnormal wearing and breaking quality of life. Cognitive-behavioral therapy is the primary choice for
down of associated tissues and structure. Anxiety, regardless of the quick and effective change. The cognitive component of this therapy
trigger, may cause an increase in oral parafunctional activity (eg. helps the patient identify and change the thinking patterns thai
clenching of the jaw muscles o r bruxism),51 which can affect resting suppon the emotional aspect of anxiety. The behavioral component
muscle activity and result in fatigued masticatory musculature and helps the patient identify and change the physical reactions to the
increased pain.?9 Anxiety disorders such as GAD are often reported fear-inducing stimuli. Homework is a standard part of cognitive·
in patients sufferin g from muscle disorders.58 behavioral therapy and may include tasks such as keeping a daily
Uke depressive disorders. treatment for GAD and other anxiety mood record or identifying cognitive distortions. Details and benefits
disorders is most effective when approached from pharmacologic and of cognitive-behavioral therapy are discussed in more detail later in
behavioral perspectives simultaneously. Treatment choices depend this chapter.
on the specific problems and personal preferences of the patient.
Medications for anxiety problems are not a cure but keep symptoms
under control while the patient participates in therapy. The principal Traumatic stressors and PTSD
medications used for anxiety disorders include antidepressants.
antianxiety drugs. and beta-blockers to control some of the physical Several recent studies have investigated the prevalence of trauma!·
symptoms. Antianxiety medications include benzodiazepines such ic stressors and severity of PTSD crit eria in patients with orofacial
a s ctonazepam (Kionopin [Roche)), torazepam (Ativan [Baxter)). pain and TMDs.G0-<3 In one study, 50.3% of patients with TMD (n =
and alprazolam (Xanax [Pfizer]). Tl1ese medications are generally 600) reported having experienced at least one traumatic stressor.
prescribed for short periods of time because of possible dependency Surprisingly, the most often reported stressors in this study did not
concerns. Newer antianxiety medications such as buspirone (Bus par involve direct personal physical injury but loss of a spouse or loved
[Bristol-Myers SquibbJ) have demonstrated effectiveness in treating one.6' This suggests that TMD patients may lack adequate skills to
GAD and comorbid symptoms of depression."' These medications cope with the emotional distress triggered by a significant stressor,
also reduce the noxious nociceptive effect of pain by decreasing providing further evidence of the association between psychologic
associated pain-related emotional distress. Drowsiness and fatigue disturbance and chronic pain. The prevalence of clinically significant
are the most commonly reported side effects of these medications. PTSD symptomatology is also high among TMD patients. In a recent
Beta-blockers are used to treat cardiovascular conditions and can sample o l709 patients with heterogenous RDC!fMD classifications,
reduce some of the physical symptoms experienced with an anxiety 14.7% met diagnostic criteria for a diagnosis of PTSD.6' These find·
disorder such as situational tachycardia and hypertension. ings suggest that traumatic experiences may significantly influence
75
6 i Psyc holog ic Aspects of Di a gnosis and Treatment in Advanced Dental C a re
mental health and physical symptoms. Given the p revalence or trau '
Box 6·3 Diagnostic criteria for PTSD
ma and PTSD among TMD patients, the dental practitioner should
have a clear understanding or d iagnostic cr�eria tor PTSD34 (B ox
1. The person has been exposed to a traumatic event in which botl1 of the
6-3).
following were present:
Recent research investigating the underlying mechanisms and a. The person expelienQed, wnn<lS$00. orW<lS confronted with an event
factors of PTSO suggests a frequent inability to inhibit autonomic o r events that InVOlVed actual or threatened death or serious injury, or
a threat to the physical integi
r ty ot sell or Others
respo nse. Two studies compared PTSD patients with age· and sex
b. The person's response Involved intense fear. helplessness. or hoiYOr
matched controls on autonomic response at rest. during a st ressor. 2. The trauma tc i event IS persistently reexpe<ieoced in one (or more) of
and postst ressor.04...The pattern of autonomic response in the PTSO the following ways:
a. Recurre�1t and intrusiVe d�tressing recol!eclions ol the event
participants showed significant sympathetic activation across study
b. Recurrent dstrewng dreams of tile event
periods, but the control group showed minimal sympathetic arousal c. Acting Of feeling as if the traumatic event were recurring (includes
durin g the baseline and poststressor periods and high sympathetic a sense of reliving the el<l)erience. illusions. 1-.allucinatiOns, and
associative flashback episodes)
activity during the stressor period. The results suggest that responses
d. Intense �ychologic distress at exposureto internal or external cues
of the control group to the stressor represent a typical autonomic that symbolize or resemble an aspect ol the traumatic event
reaction in nontraumatized individuals. In contrast. the responses e. PhysiologiC reactMty on exPOSUre to iClternal or extemal cues that
symbolize or resemble an aspect of the traumatic event
of the PTSD patients d emon strate diminished inhibitory control that
3. Persistent avoidance of st�mJii associatedwith the trauma and numbing
results in a continuous state of autonomic arousal in either a res tfu l of general responsiveness, as indicated by three (0( more) of the
or distressing situation. This rigidity of autonomic activity may reflect following:
a. Effons ro avoid thOughts. feelings. or conversations associated with
the constant state of hyperactivation that is one of the hallmarks of
the lrauma
PTSD symptomatology. A recent study of a sample of ROC/TMD b. Efforts to aVOi<:l activitieS. !)laces. or people that arouse recollections
Axis I masticatory myalgia patients.. revealed results similar to those of the trauma
c. Inability to recall an important aspect <>I the lrauma
reported by previous stud ies and suggests the combination of pain
d. M811<edly dimini shed o1terest or participation rn signlflcant actlvitres
and lack of inhibitory control may contribute to the chronicity and e. Feeling of detachment or estrangemen t from others
psychologic distress in orofacial pain patients. r. Restricted range or affect {eg, \lnable t o have loving reehngs)
g. sense or a foreshortened future (eg. does not expect to have a
camer, maiTiage, ohidren. or a normal life span)
4. Persistent symptoms of lncfeased arousal {not present before the
Personality factors lf8J.Jma), as indicated by two {or more) of the foUowing:
a. Difficutty falli ng or slaying asleep
b. trfaability or outburs tsof anger
The int erest in personality characteristics and chronic pain-emo· c. Difficuhy concentratiOQ
tional distress-somatic complaints has waxed and waned over the d. Hypervigilance
e. Exaggerated startle response
past several decades. The develop ment of the Five-Factor Model
(FFM) of personality structure by Costa and McCrae has fostered (Reprinted from the Ame<ican Psychiatric Association" with permission.)
more interest in the area of personality assessment a s comp lemen

tary to comprehensive diagnoses and treatment planning. The FFM
is a leading theory or personality organization that assesses five ma
jor domains of perso na lity: (1) o penness . (2) conscientiousn ess (3)
,
extraversion, (4) agreeabl eness, and (5) neurotic ism . The Revised
NEO Personality Inventory (NEO PI·R) and NEO Five-Factor Inven
tory {NEO·FFI} were developed based on these five personality lac·
tors.67•69 The NEO PI-R is a 240-item questionnaire that assesses the only the neuroticism or extraversion subscales of the NEO PI-R and
live factors and parses out each factor into facet scores that provide NEO·FFI in chronic pain research but have also found that these
more detailed information on personality structure. The NEO-FFI two personality factors are associated with pain coping or pain
assesses the five factors only and is thus a shorter questionnaire at behaviors.'0·71
60 items. These studies suggest that i t may be clini ncall y useful to include an
Application of the FFM t o p a tients with chronic pain is surprisingly assessment of normal personality structure during multidimensional
limited. One of the first studies in t he pain literature assessing evaluation when planning treatment for chronic pain. However, the
personality characteristics in patients with chronic pain showed utility of personality assessment with the NEO-FFI or other instrument
significant correlations between neuroticism and extraversion traits based on the FFM in treatment plan nin g lor orofa cia l pain and TMD
and perceptions of pain suffering , illness behavior, and cognitive patients has not been studied. Further clarification of the relati ons hip
processing of p ain .69 Therefore, personality characteristics may between personality traits and the experience of chron ic orofacial
influence cognitive processing of the impact and meaning of chronic pain may enable clinicians to tailor pain management programs
pain an d thus may have a moderating influence on successful t o individual patient personality characteristics, possibly improving
management of pain and pain behaviors. Other studies have used long-term pain management outcomes.
Fatigue and sleep disturbances psychologic status, medication regimen, and whether the patient is
able to proVide a valid consent ior treatment.'"
Fatigue and sleep disturbances are other factors of interest in the Bipolar disorder is not as chronically debilitating a disease as
assessment of and treatment planning tor orotac i al patient popula schizophrenia: however, if not well-managed, it can lead t o long-term
tions. These patients often report high levels of fatigue and dysfunc disability and disruption of social and occupational respon Sibilities .
tional sleep patterns compared to pain-free controls.61l.12 It is likely A diagnosis of bipolar disorder, formerly known as manic-depressive
that fatigue and poor sleep contribute to the physical symptoms, disorder, is made when an individual experiences recurrent episodes
subjective pain experience. and psychologic distress. However. the of depressed and elated moods. During the elated or manic phase,
specific contributions of sleep dysfunc1ion and fatigue to poor func the individual appears euphoric, unusually cheertut, acts grandiose,
tioning are not well understood. More research is needed in these and often engages in risky behavior patterns. He or she may
areas to better understand the associations among sleep, fatigue, abuse substances, go on shopping binges, or engage in sex with
and the chronicity and distress experienced by orofacial pain and multiple partners. Sleep is minimal during the manic phase. The
TMD patients. individual presents with pressured speech and is often disruptive
and domineering in social situations. During the depressed phase,
the individual reports feeling sad, helpless. and a lack of desire to
Serious psychopathology engage in enjoyable actiVities. Feelings of guilt and thoughts of
suicide are common. Physical symptoms during this phase Include
Although the incidence of serious psychopathology in the general difficulties with sleep (sleeping too much or very little): altered eating
population is relatively small, practitioners should be cognizant of the habits. with a significant increase or decrease in body weight; and
signs and symptoms of this group of disorders in order to proVide extreme fatigue and lethargy. This disease is prevalent in 1.6% of the
adequate treatment and useful advice to the patient or caregivers. US population, and it is the sixth leading cause of disability daims.77
These conditions include DSM-IV-TR Axis I mood disorders such as There are three main types of bipolar disorder:
schizophrenia spectrum disorders and bipolar disorders.
Schizophrenia occurs in 1% to 1.5% of the US population and I. i lar I dsor
Bpo i der: The individual vvith thi s disorder has had at
is largely connected to genetic factors.13 Schizophrenia occurs least one episode of mania with or without a previous episode of
in types or forms. with paranoid schizophrenia being the most depression.
common. Other types include disorganized, catatonic, and residual i order: This is diagnosed when there is a t least one
2. Bipolar II ds
forms of the disease. Men and women are equally affected, and episode of depression and one episode of hypomania, which is a
it often manifests when the individual is a young adult. Common milder form of mania that lasts only a few days.
symptoms include (1) distorted perceptions of reality that often 3. Cyclothymic disorder: This is a milder form of bipolar disorder.
lead the individual to feel frightened, anxious. and confused: (2) Cyclothymic disorder includes mood swings, but the highs and
hallucinations and illusions, which are sensory perceptions that lows are not as severe as in a type I or type II bipolar disorder.34
occur without connection to an appropriate source (eg, hearing
voices when no one is nearby); and (3) delusions, which are false Patients with bipolar symptoms who undergo dental treatment
personal beliefs not explained by reason or usual cultural concepts. may be uncooperative, irritable, and have many complaints that are
Other characteristics of schizophrenic patients include disordered inconsistent with diagnostic evaluation. As with the schizophrenic
thinking, which may prevent the patient from focusing or paying patient discussed above, communication with the patient and the
attention, and flat or blunted affect, which refers to the reduction in patient's caregiver or psychiatrist is paramount.'• There is also
emotional expressiveness through diminished facial expressions and a strong association between the depressed phase of bipolar
speaking in a monotone voice." disorder and periodontal disease. which suggests decline and
In the past 10 years, major improvements have been seen in the neglect of dental hygiene. During manic episodes. bipolar patients
pharmacologic management of schizophrenia symptoms. Although may be overzealous with dental care and cause cervical abrasion
medications have a significant impact on the quality of life tor these or mucosal or gingival lacerations.19 Medications used to manage
patients, one side effect is profound hyposalivation, which results in bipolar symptoms (such as lithium) often result in reduced salivary
an extremely high incidence ot periodontal disease.,., to flow, leading to rapid dental deterioration. mucosal dryness, and
Instead of spending the majority of their lives within the confines dysphagia...,..,
oi a mental institution as they once did, many people with Patients with serious psychopathology are difficult to treat
schizophrenia now live within the community in group homes. regardless of the present behavioral management issues. The
Therefore, general dental practitioners are now much more likely to practitioner must be prepared 10 address the specific problems and
care for this population. Perhaps the most important consideration challenges unique t o this population. A thorough medical history
in management of a scllizophrenic patient is communication. and communication with mental health providers foster a productive
Patients will often tell their dentists of their diseases. The practitioner therapeutic relationship between the patient and dental practitioner.
should also consult with the patient's psychiatrist to ctiscuss current
77
Assessment of Psychologic Depression
Status Of the several standard brief assessments available t o measure se

verity of depressive symptomatology, the most commonly used is
A biopsychosocial approach to orofacial pain and TMD diagno the BDI and the updated 801-11.90·•1 The BDI-11 is a 21-item self-report
sis and treatment requires a comprehensive assessment across measure designed to assess specific symptoms common among
multiple domains of functioning. Chronic pain and other complex people with depression; i l takes only 5 to 10 minutes to complete.
chronic conditions have affective. cognitive, behavioral. social. and The BDI·II has been extensively tested for content validity, concur
sensory aspects."' Development of a diagnosis and an effective rent validity; and construct validity. The 801-11 content validity was es
treatment plan requires a comprehensive evaluation of the specif tablished by a consensus among clinicians about depressive symp
ic symptoms experienced by each patient in all of these domains. toms displayed by psychiatric patients. Many studies have shown
These symptoms may affect how a patient adapts and responds to concurrent validity between the BDI-11 and such measures of de·
a chronic condition. Multidimensional assessment addresses many pression as the Hamilton Depression Rating Scale (HAM-D) and the
areas that traditional medical or dental assessments do not. such as MMPI-2 scale. n1e BOI-11 is copyright controlled, ancl the publisher
social environment. energy level, exercise. affect. psychopathology, charges a fee for its use.
and personality characteristicsM Another widely used depression inventory is the Center for
Assessment of overall psychologic functioning can be com Epidemiological Studies Depression Scale (CES-0).92 This measure
pleted with a variety of standard measures. For many years. is a 20-item assessment of depressive symptoms that is in the public
the gold standard was the Minnesota Multiphasic Personality domain and free to use. The CES-0 has been consistently used to
lnventory-2 (MMPI-2). MMPI-2 assessment is useful to screen for assess current depressive symptoms in many dif f erent groups of
psychopathology in certain patients with chronic pain, to examine psychiatric and medical patients. The only significant criticism of the
the psychologic effects of comorbid medical conditions."'' and to CES-D is that no items on the measure assess suicide ideation. Other
predict treatment outcomes in chronic pain patients.a�·86 However, brief public domain inventories of depression include the Patient
assesm
s ent with a standard measure like the MMPI-2 should be Health Ouestionnaire-9 (PHQ-9) and the HAM·D.9a.ll<1 The HAM·D is
completed by a practitioner trained in the interpretation of this designed to be administered orally to the patient by proper1y trained
measure. which is not feasible for most standard clinics. The personnel, which makes it a useful measure when reading ability is
MMPI-2 is lengthy, with more than 550 questions; this is hardly questionable.
appealing to clinicians already considering a lengthy assessment
package and initial diagnostic evaluation.
A commonly used alternative assessment is the Symptom Anxiety
Checklist-90-R (SCL-90-R).8' The SCL-90-R is a 90-item multi·
dimensional self-report measure of psychologic functioning scored Although several well-established brief measures of anxiety are avail
on a five-point scale o f distress (0 through 4). The dimensions on able. the two most widely used in primary care and general clini·
the SCL-90-R are somatization, obsessive-compulsive behavior. cal settings are the Beck Anxiety Inventory (BAI) and the State-Trait
interpersonal sensitivity. depression. anxiety, hostility, phobic anxiety, Anxiety Inventory (STAI). The BAl. developed by the same doctor
paranoid ideation, and psychoticism. A global severity index is who developed the 801 and BDI-11, is a 21-item self-report measure
also available, which provides a single quantitative value of overall of current anxiety symptoms.9s It was designed to assess anxiety
psychologic functioning. Test-retest reliabimies range from r= 0.78 based on the OSM-111-R criteria for generalized anxiety disorder and
to r = 0.90 for nonpatient samples, and internal consistencies panic disorder. Many studies have used the BAI, and its validity and
range irom o.77 to 0.90. The SCL-90-R has been extensively reli ability have been well-established in a variety of psychiatric and
used in research focused o n psychologic characteristics in TMD medical populations. The STAI is the most widely used measure of
populations.""·"'.$" The short form of the SCL- 90-R. known as the anxiety."" It provides state and trait anxiety assessments. each with
Brief Symptom Inventory (BSI), is a 53-item measure rated on the a 20-item scale. The state anxiety scale assesses current symptoms
same five-point scale as the SCL-90-R that assesses the same nine that may be temporary. and the trait anxiety scale assesses long·
symptom dimensions.89 The primary benefit of a comprehensive self standing anxiety symptoms. To assess anxiety associated specifi·
report measure like the SCL-90-R or BSI is the amount of information cally with chronic pain. the Pain Anxiety Symptoms Scale (PASS) is
gained with a single assessment tool. The drawbacks are the fee an appropriate measure.•' The PASS is a 40-item scale that provides
that is involved with the use of these assessments and the lack of scores in four domains: (1) fearful appraisals of pain, (2) pain-related
more specific symptomatic information that can be obtained from cognitive anxiety. (3) escape avoidance behavior. and (4) pain-related
single-construct measures like the Beck DepresSion Inventory (BDI). physiologic anxiety. It has demonstrated good reliability and validity in
heterogenous samples of chronic pain patients.
Behavioral Treatment Strategies J
PTSD and trauma 5-point Ukert scale from 0 (not at all) to 4 (extremely). The MFSI
is an effective way to predict the presence and magnitude of self·
Given the high prevalenc e of traumatic stressors and PTSD symp reported fatigue in orofacial pain pa tients."' The FSI is a much briefer
t omat olo gy repOrted in pa t ients with TMD and orofacial pain,o'·62 assessment of f atig ue consisting of 13 items that focus on {1) the
.
clinical assessment of these experiences and symptoms i s strongly degree to which fatigue interferes wtth quality of lif e, (2) frequency of
suggested. The Post Traumatic Stress Disorder Checklist-Civilian fatigue, and (3) severtty of fa tigue .
Version (PCL-C) is the most commonly used and well-validated
assessment tor trauma expesure and PTSD ... The PCL-C is a
self-repOrt measure used to assess the incidence or significant life
stressors and prevalence of PTSD symptomatology. Patients first Behavioral Treatment Strategies
look at a list and id entify significant stressors the y may have expe
rienced (eg, military combat. violent attack, incarceration, natural or The goal of behavioral treatment is to return p atients to normal func
manmade disaster. severe auto accident, sudden injury/seri ous ac tioning as q uickly as possible. The complex nature of TMD and oro
c ident observed someone hurt or killed). They then select the most
. facial disorders requires systematic application of multidisci plinary
signifi c ant stressor and note the date of occurrence. Next they an strategies. supervised bya primary care provider. for the most effec
swer 17 symptom-related questions by noting how much they have tive management. In keeping with the framework of the biopsycho·
be en bothered b y each symptom in the last month. The PCL-C pro social model of Engel. treatments should address the biologic (eg,
vides a total score as well as three subscale scores (reexperiencin g , oral appliances), psychologic (eg. depression or anxiety). and social
avoid a nce/numbing , and arousal) based on the DSM-IV-TR criteria (eg, daily functioning) components of functioning in a coo rdinated
tor PTSD diagn os i s (see Box 6- 3). The PCL-C has demonS1rated ef manner. Regardless of the primary focus of treatment. s trategies
ficac y in the screening or PTSD in orotacial pain patJents .62>19 should be based on studies that used randomized clinical trials to
establ ish treatm ent efficacy. Throughout the course of therapy, the
st a nd ardized assessments discussed earlier should be used to de
Sleep dysfunction and fatigue termine treatment benefit and trajectory of improvement.
In addition to measuring psychologic char ac teristics and trauma

related distress, a comprehensive assessment should also measure Cognitive-behavioral therapy
physiologic variables known to be associated with treatment effec
tiveness. As discussed above, sleep dysfunction and fatigue are sig Cognitive behavioral therapy focuses on building awareness of the
nifiCantly associated with psychologic and phys i ologic dysfunction in connection between thoug ht processes. emotional t rigg ers . and be
orofacial pain and TMD p atie nts . The Pittsburgh Sleep Quality Index havioral response patterns. The goal is to foster change in thinking
(PSQI) is th e gold standard for assessing sleep dysfuncti on 'co The
. by identifying distorted cognitive patterns or beli efs (eg, "my pain will
PSOI is a 1 2 item measure of overall sleep quality that provides one
- never get better") and behaviors (eg, "every time t visit wi th friends,
compos ite score comprising seven subscale scores. The subscales my p ain gets worse so t don't socialize") and working toward more
,
include sleep quality. sleep latency. sleep duratiOn sleep efficiency.

, positive and adaptive cogniti ons and behavioral respenses."'' Dis
sleep disturbances, use of sleep medicatiOn. and daytime dysfunc torted cognitive patterns can develop as a result of chronic pain and
tion. The PSQI has exhibited test-ret est reliability and good overall can contribute to the maintenance of the pain condition. The s ki lls
internal consistency. and it provides a valid and reliable assessment and techniques involved in applying cogntt ive-behavioral therapy re
of overall sleep qu ality and disturbance.'oo.•o• quire a s ignific ant amount of training and experience. Patients should
Fatigue can be assessed by a variety of di ffe rent standardized be referred to specialists for this approach: however. understanding
measures. The most widely used measures of fatigue include the the concept of this therapy helps the clinician offer informed treat
Multidimensional Fatigue Symptom Inventory (MFSI)""' and th e ment options to patients.
F atigue Symptom Inventory (FSI).u» Both ot these measures were
developed to assess fatigue in p atients underg oing treatment for
cancer. Since conceptualization, the measures have been adapted Physical self-regulation
and s uc cessfully used in a variety of clinical and research applications
across medical settings. The MFSI is a 30-i tem measure deSigned Physical self-regulation refers to a systematic program designed
to identify five racers of fatigue:(7) global experience. (2) somatic to reduce physiologic activation through the use of diaphragmatic
symptoms, (3) cognitive sympto ms. (4) affective symptoms, and (5) breathing training, proprioceptive awareness training (postural re
behavioral symptoms. Patients are asked lo rate each statement laxation: recognition and contol
r of parafunctional tooth contact,
ac co rding to how true it has been over the past 7 days along a clenching, and grinding: and gentle stretching), sleep hygiene,
79
fluid intake. nutrition, and exercise management.'05 The interven and foster more control over these systems. A recent comprehensive
tion is presented in two 50-minute training sessions. This program review of biofeedback treatments for TMD patients is available.111
has demonstrated significant reduction in pain severity and interler
ence from pain. Patients have also experienced an increase in incisal
opening and perceptual control. These benefits were maintained at
a 26-week posttreatment evaluation. Summary
Relaxation strategies Understanding of the psychologic characteristics seen in den

tal practice as described in this chapter is important for success·
Relaxation strategies can be as simple as resting the body in a re fltl patient management. The practitioner may find It challenging to
laxed position for brief periods throughout the day. A brief introduc maintain awareness of all aspects of the biopsychosocial model in
tion, explanation. and practice with the patient may be all that are daily general practice and thus should have the skills necessary to
required to foster incorporation of relaxation into the daily routine. develop a comprehensive treatment plan encompassing a multidi
For those patients who struggle with learning and using relaxation mensional approach. Access to and a professional relationship with
as a therapeutic strategy, more extensive training may be required. a mental health provider experienced in clinical health psychology
From a therapeutic perspective, relaxation is defined as engaging or orofacial pain management is highly beneficial t o comprehensive
in an activity of a calming nature that reduces physical activity and quality care.
mental activity and quiets the mind and body. Techniques that
trigger the relaxation response include passive muscle relaxation.
yoga, and meditation.'06 As a sell-regulatory strategy, relaxation
fosters an increase in overall system dynamics through reduction References
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4. Klepac RK. Fear and avoidance of dental treatment in adults. Ann Behav Med
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5 . Gatchel RJ, Ingersoll BD. Bowman L. Robertson MC, Walker C. The preva·
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Biofeedback training
t9e3:107 :609-6t0 .
6. Beggren U, Meynert G. Denal
t fear and avoidance: causes, symptoms. and
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began in the 1960s and 1970s with the development of psycho
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2004;196: 101-107.
vide information on a variety of bodily functions such as sweat gland
10. Dally YM, Crawford AN, HumphriS G, Lennon MA. Factors affecting dental
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1992: 19:307-309.
cian attaches muscle sensors to the areas of concern: the patient
12. Sondell K, S&Jerfetdt B, Palmqvist S. Underlying dimensions of vc r!Jal com·
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Standard biofeedback protocols require several practice sessions
14. HainS¥.-orth JM, Moss H. Fairtlrother KJ. Relaxation and complementary ther·
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patient become more aware of the muscle activity and mechanics
801
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Chapter
Temporomandibular
Disorders and Orofacial Pain
Kevin I. Reid, oMo
Epidemiology Temporomandibular Disorders
Ororacial pain is common. and most instances can be attributed The abbreviation TMD represents a constellation of painful symp·
to toothaches o r other minor dental diseases.' Among the chronic toms in the jaw muscles and temporomandibular joints (TMJs). The
orofacial pain conditions, temporomandibular disorders (TMDs) are term TMJ does not represent a diagnostic entity. For example, a
the most prevalent, affecting approximately 2.2 or every 100 per patient may have osteoarthritis in the TMJ or a nonreducing disc
sons and seen primarily in women between the ages of 35 and 45 displacement with arthralgia. Use o f the term reduction refers to the
years.2.3 By comparison, large population-based studies at the Mayo position of the cartilaginous disc within the TMJ. Reducing disc dis
Clinic in Rochester. Minnesota. determined the incidence of trigemi placement refers to a disc that i s displaced while at rest but returns
i and glossopharyngeal neuralgia to be 3 to 5 onsets
nal neuralga to normal position in the course of opening the mouth. Thus, a re
per year per 100,000 population and 0.7 per 100,000 per year. re ducing disc displacement occurs when, during the course of open·
spectively.'·' Similar incidence rates have been reported for burning ing lhe mouth, lhe mandibular condyle encounters the posterior as·
mouth syndrome.' Because of the incidence rate of TMDs,� they are pact of the articular disc and then slips under the disc, creating the
probably the most frequently encountered chronic facial pain condi "click" most often associated w"h disc displacements. Nonreducing
tion in a general clinical setting. disc displacement connotes a situation in which the articular ele
The personal, social, and economic effects of orofaeial pain ap ments are out of their normal relationships and remain anatomically
pear to be si m ilar to those of back pain and headache.2 These con deranged throughout the range of motion of the mandible; thus. the
ditions are a source of worry, sleep disturbance, and absence from translation of the mandibular condyle down the articular eminence is
work• Painful TMD sy mptoms fluctuate over time' and are self-lim obslrucled by t he displaced disc. The condyle does not slip under
iting, often resolving after the age of 45 years.' LeResche et al8 dis the disc as it does in a reducing disc displacement.
covered what might be an exception to this pattern when they found Patients with TMDs commonly complain of pain in the muscles of
that hormone replacement therapy increases the prevalence of TMD mastication, most frequently the masseter and lemporal muscles.
by 30%. A recent publication from the International Association for Most TMD pain is localized to the jaw musculature, and a small er
the Study of Pain provides a comprehensive review of the epidemiol number of patients have a diagnosis of TMJ pain.'0·" When
ogy of pain disorders, including all orofacial pain conditions.• the clinician either hears or feels a click o r pop in lhe TMJ. the
83
7 iTemporomandibular Disorders and Orof acial Pain
Rg 7·1 The normal anatomy of tile TMJ (a) is compareo to a disc displacement Fig 7-2 (a) Magnetic resooance maging (MRI) shows a nonnat TMJ In a nor·
I
w1th reduction (b) and w1th0u1 reduction (c). The m ost common cfinieat finaing mal position of me a rticular disc (large white arrow) ana presence ol intact
asscclateo with a displacement with reduction Is the sound of a "click" In lhe cortical bone (small white arrow). (l>J MAl shows that a nonreoucing disc dis·
allected joint. A reduced range of motion with absence of clicl<ing is the most placement {farge white arrow) and degenerative joint changes are most e•i·
common finaing In a disc displacement witllout reduction. Variations ol U1ese dent in tile loss of Integrity of lhe cortical bone and reducion ol joint space
t
llndings are common, and pain may or may not be pre.sent in each. (smalt wflitearrOIY).
assumption may be that this anatomical derangement is the source Classification

of the patient's discomfort. In fact, TMJ noises are common and
rarely associated with pain .12 I t is helpful to ask the patient if the joint Although many attempts have been ma de to classify TMDs accord·
i in the focal preauricular area o verlyin g
noise i s associated with pan ing to symptoms," none of the classifications is currently based on
the TMJ. The presence of a clicking sound in the TMJ is generally etiology because the causes of TMDs have not been established.
not ascribed an etiologic role in the pat ien t s pain complaint unless
' As a consequence, diagnoses and treatments are not standar dized
focal preauricular pain occur s with the clicking. Normal TMJ anatomy but generally conform to t he particular theory the clinician espouses
and disc displacements with and without reduction are illustrated with respect to causation. To address this problem. a major effort
i
isplacemen t w ith re duction usually p resents clincally
in Fig 7·1. A d t o validate diagnostic criteria began in 1992 and holds p r omi se f or
with clicking o f the affected side and possibly decreased range of standardizing diagnostiC criteria.'' The criteria, entitled the Research
motion and pain, although neither may occur. The previous absence Diagnostic Criteria for Temporomandibular Disorders (RDCffMO),
of clickin g and a decreased range of motion often characterize a provide specific gui delines for standard ized clinical examination and
nonreducing disc displacement. Pain may or may not be present. rely on algorithms to assign Axis 1 and Axis 11 diagnoses that corre
Figure 7·2 compares normal TMJ anatomy with a nonreducing disc spond t o the cl in ical and psychologic status of patients, respectively.
displacement that displays features of degenerative joint changes, Axis II disorders are similar to those that occur in pa tients with head·
including loss of joint space and osteophytic cortical bone changes . ache and back pa in . which cause intrusions into their o ccupational,
Temporomandibular Disorders J
Group Disorder
Group I Muscle disorders
Ia Myofascial pain
lb Myofascial pain With imited opening
Group II Disc displacements
lla Disc displacement wi1h reduction

lib Disc displacement >'lilhout teO.ICiion, with limited opening
lie Disc �twilhout reduelbn, wilhoul imlled apering
Group 111 Arthralgia, arthritis, arthrosis
Ilia Arltvalgia
illb Os!eoarlhriliS of the TMJ Fig 7-3 Passive stletch or the mandible. This techniQue allows the cfinieian to gently
provoke the mandillle to adeQuately assess range of molion capability and to altempt
lllc Osteoarthrosls of the TMJ
to clinically reproduce the patienrs pain complan
i t.
recreational. and social activities.'3 Thus. the clinician may approach least 5 mm more than the unassisted opening. ,. Muscle pain as a
this aspect of patient evaluation and treatment in accordance with result of myofascial pain is most frequently (1) bilateral, (2) felt in the
other methods used to diagnose. refer. and treat patients who have masseter muscles, and (3) aggravated by routine jaw use, such as
chronic pain. Axis II disorders are no\ discussed in detail in this chap talking or chewing. The pain tends to occur on a constant and daily
ter but have been reviewed elsewhere." A comprehensive presenta basis wit h fluctuating intensity. Axis !-related pain is often associated
tion of the ROC. published by the Interna tional RDCITMD Consor with "trigger points, " anecdotally described in the literature for
tium Network. is available for review online. '6 decades as "hyperirritable'' areas of tenderness within taut bands of
Axis I disorders are categorized based on the presence of muscle.•• Specific trigger p0lnts may refer pain in specific patterns
symptoms in the masticatory muscles. TMJs, or both'·' (Table 7-1). througl10ut the head, although this widely held assumption has not
These symptoms are often accompanied by reduced range of been subjected to rigorous scientific validation. Clinical experience
mandib ular motion, earache, neck pain, and lension-lype headaches. verifies that patients do have lower pain thresholds in response
In addilion. patients may report tooth pain in the absen ce of dental t o palp at ion: however. the exact nature of trigger points has not
disease or a sense thai their teeth do not come together properly. been established. Axis I, Group I TMDs have been compared with
fibromyafgia, and although more studies are needed to clarify the
Axis /, Group I disorders etiologies of thes e clinical entities. some infomnation suggests that
these syndromes share potentially Important characteristics."
The Axis I. Group I disorders (see Table 7-1) refer \o pain in \he jaw Tooth clenching and grinding (bruxism) may contribute to jaw
musculature that may be accompanied by a limited range of mo muscle pain.•&-21> Sleep-related brux sm is neurologically mediated�'
i
tion of \he mandible.« These muscle disorders are based on \he and may occur independent of st ress, which l1as been the
presence of persistent pain, usually characterized as a background predominant (but invalidated) explan ation lor bruxism for decades.
ache while at rest. during function. or both. Pain is often diffuse and When pain from bruxism does occur, muscle soreness after exercise
located in the masseter. temporal. and p te rygoid muscles. Normal is the likely explanation. as it develops over a period of hours and
ran ge of motion is g en erally 40 mm in the vertical plane" and can diminishes slowly.n lnterocclusal devices may be the treatment
be increased by passively stretching the mandible. The technique of choice,>• but many other treatments have been proposed; a
t o meas ure range of motion is simple (Fig 7-3). This should be per recent article provides a thorough review of these.2' One study
formed for every patien t with a suspected TMD. that compared tl1e effect of parafunctional habits (eg, bruxism) on
Umited motion in a patie nt with a muscle dis order is defined as patients with TMDs and on asymptomatic controls determined that
unassisted opening of tess than 40 mm and assisted opening of at more sadness, increased stress. and jaw behaViors/habit s that
85
7 i Tempor o mandibu lar Disorders and Orofacial Pain
Table 7-2 lP. i. �gnostic·criteria for intraarticular temporomandibular disorders
10 without reduction 10 without reduction

Normal 10 with reduction
(acute) (chronic)
History None None Positive his tory of mand. bular Po Sitive history ofTMJ noise
limitation
Exam 1. NO recll)fOCal Click 1. Reciprocal CliCk or POPPI"9 t. NO reciProcal CliCk 1 . No reciprocal click
2. No coarse crepitus Jl(esent 2. No ooarse crepitus 2. Coarse crepitus or joint sound
3. Passive stretch > 40 mm 2. No coarse crepitus 3. Maximum opening < 35 mm other than 1
4. Lateral movements;, 7 mm 3. Passive stretd1 ;, 35 mm 4. Pass111e stretch < 40 mm
5. If S·cUNe deviation is presen t, 5. Conllalateral movement< 7mm
then joint must be silent 6. No S-cuNe deviation
10-intraart iculaf d isorder. (Adapted fromMderson et at �1
increased muscle tenSion were good predictors of jaw pain."' As tors,31 recognizing that chronic temporomandibular pain. like other
with TMDs in general. the cause of Axis I disorders is not known musculoskeletal pain syndromes. is frequently identified as a persis
but has often been attributed to malocclusion, a hypothesis that tent dull ache'" that i s aggravated by use of the jaw.
contemporary standards of investigation have not supported.2<>-211 The clinician should ask a standard series of questions to begin
to rule out TMD. A jaw disability checklist may be a helpful tool
Axis /, Groups II and J/1 disorders (Box 7-1 ).1'1 Oth er questions that may assist the c linician include
the following:
Axis I. Groups 11 and 111 disorders are related to alteration of soft
tiSSLte anatomy within the TMJ or degenerative joint changes (see 1. Are you able to open your mouth as well as you think you
Table 7-1 ). The cardinal signs of internal anatomical alterations of should be able to?
soft tissue in the TMJs include decreased range of mandibular mo 2. Do you feel your bite has changed?
tion and joint noises w�h mouth opening and closing. Patients may 3. Does your jaw make clicking, grating, or grinding sounds? If so,
report prominent clicking or grinding sounds with jaw use. These is this noise accompanied by pain?
disorders may not necessarily be associated with pain. so it should 4. Does your jaw lock or catch?
not always be assumed that a patient's clicking TMJ is the source of 5. Have you been told or are you aware of clenching or grinding
pain. Symptoms of mandibular dysfunction may also include "catch your teeth while awake or sleeping?
ing" or locking of tile jaw. Clinicall y reliable criteria (Table 7-2) al
low the clinician to determine the anatomical status of a par ticular It any of these questions is answered in the affirmative, the
TMJ with a great degree of accuracy.29 These clinical criteria do not developing differential diagnosis then should include TMD. A
make reference to pain, which may or may not be present in any of complete history and clinical examination may then follow, uSing
these diagnostic scenarios. The clinical reliability of the criteria was criteria presented in the RDC.15 Stohler provides a treatment
tested against radiographic findings, which are not predictive of pain algorithm based on responses to the Graded Chronic Pain Scale, a
in TMDs. 30 The methods of esta blishing a diagnosis depend in part seven-item questionnaire assessing pain intensity and impact of pain
on accurate assessment of range of motion (see Rg 7-3). on usual activities.:!$
Clinical history of TMD Examination
Diagnosis of TMDs is contingent both on obtaining a comprehensive The examination should include palpation of the preauricular (TMJ)
history and, t o a lesser extent, on physical examination findings and areas and the masseter muscles in addition to the anterior, middle,
reproductions of the patient's pain comp la int. It is crucial to ask the and posterior areas of the temporal muscles. Although much has
patient to highlight the area of discomfort by pointing with one finger been published to guide clinicians in this technique, no universal
rather than fanning the entire hand over the face. which precludes technique has emerged as the gold standard."" One useful tech
the ability to attempt to locate the site of discomfort. It is equally nique is to palpate the muscles of mastication and the preauricular
important to present the patient with a choice ot verbal pain descrip- regions with a moderate amount of pressLtre while asking the patient
861
��;l:i��onsiderations for determining the probability

Tabl e 7_3
What activities does your present jaw probl&m Considerations High Low
prevent or llmft yoo from doin g?
Pain Constant ache/tightness Sharp, electric, burning. paroxysmal,
o Chewing
interm»tent, spontaneous pain
o Drinl<ing Sharp pa1n with jaw use
Sharp pa.n with jaw use
o Exercising
o Eating hard foods Muscles Masticatory muscles or TMJ Site not necessarily in muscles or TMJs
o Eating soft foods
Jaw use Aggravated by jaw use No definitive change with jaw use
0 Smiling/laughing
o Sexual activity Clinical Pain reproduced \v»h palpatlon May be associated wah paresthesia,
0 Cleaning teeth or face Reduced range of mandibolar motion dysesthesia, or other neurologic signs
0 Yawning
Painful clicks or grinding in TMJs
0 SWaUowlng
Jaw catclles or lockS
0 Talking
o Keeping yoor usual facial appearance AssoCiated ear, neck, tension-type
headaches
to indicate if the stimulus is painfuL For example, While palpating preauricular pain is shown in Fig 7-2b. This patient's pain intensity
the masseter. the clinician may ask the patient. "Is this pressure or was constant. increased with any jaw movement, and often triggered
pain?" During palpation, the examiner should apply light pressure a severe tension-type headache. However, MRI lor diagnosis of
with the pad of the index finger over the TMJ. Excessive pressure TMD is not reliable••: MRI studies have shown that the prevalence
may inadvertently displace the articular disc, thereby invalidating the of disc displacement in the general population may be as h igh as
examination. The goals of palpation are to replicate the patient's pain one-third.",·••
and to detect anatomical alterations within the joint that may oth Several dia9nostic aids have flourished over the decades,
erwise manifest clinically as clicking, popping, or crepitus, thereby including "bioelectric diagnosis," thermography, jaw tracking, and
indicating altered anatomy, bony degeneration, or both.2Q Sensitiv Doppler ultrasonographic auscultation f
o the T MJ. These and other
ity and specificity of intraoral digital palpation are low and palpation diagnostic aids claiming to lead to mo re precise diagnosis and
should not be solely relied upon to generate diagnosis35·"" Methods treatment have been subjected to rigorous scientific review. Results
recommended by the ROC" have demonstrated reliability and may consistently show the general lack of sensitivity and specificity of
serve as a guide for obtaining history and clinical data.3T.36 tllese techniques."'""' No scientifically reliable evidence currently
Asking the pat1ent to move t he mandible in lateral and protrusive exists that supports the use of these methods over a standard
directions while light manual resistance is applied against the history and clinical examination; therefore, the patient-absorbed
mandible often is helpful in reproducing the chief complaint. Detailed costs for such methods appear to be unnecessary.
instructions for this technique have been published."" In addition, Clinical considerations that may assist the clinician in determining
anecdotal information suggests that TMJ pain is aggravated when the probability of a diagnosis of TMD are shown in Table 7-3. A
patients are asked to clench maximally with their posterior teeth high degree of probability may warrant steps to address pain and
against several tongue depressors. Clenching against the tongue dysfunction prior to prosthodontic treatment. Alternatively, referral
depressors on the right may produce pain in the left preauricular area to a specialist with o
frmal training and expertise in diagnosis and
if the left TMJ is painful. Although this is not a validated indicator of treatment of TMDs may be appropriate.
TMJ pa thology it is an anecdotal clinical tool that may be beneficial.
, Pain within the masticatory system may be a TMD. but in several
Imaging modalities for the assessment of TMDs typically include published cases, TMD pain was mimicked by more sinister disease
(1) panoramic radiography, which allows the clinician to rule out processes lor which proper treatment was delayed :••
bony and odontogenic abnormalities; (2) MRI, which may assist in
the diagnosis of Axis I , Group II disorders; and (3) plain or computed Etiology
tomography (Cl), which may help rule out degenerative changes
associated with Axis I, Group Ill disorders. In cases of suspected Many hypot11eses regarding the etiology of Axis I disorders have
neoplasia or osteomyelitis, or in some complex cases involving any been proposed."' Despite a lack of strong scientific evidenoe to sup
of the arthritides. bone scintigraphy may be indicated'0 An MRI of port their validity, many of these theories persist among groups of
a nonreducing disc displacement in a patient with severe and focal clinicians and serve as the basis for therapies that are often invasive,
87
7 i Temporomandibular Disorders and Orofacial Pain
expensive. and, in some cases, harmful. These hypotheses include, recommendations are based. Treatment plans shOuld be formulated
for example, speculation about the cause-and-effect relationship be· with an understanding that TMDs are generally self-limiting and that
tween malocclusion and TMDs (reviewed by Greene49 and Lunds'), over time the painful symptoms of TMD gradually diminish' This in
tor which there is scant evidence by contemporary standards of sci· formation should influence clinicians t o offer supportive and palliative
entific investigation. The occlusal etiology hypothesis has nourished treatments that have tow associated risk, are supported by resuHs
despite abundant contradictory evidence.""-:za The widespread prac· o f well-designed clinical trials, and are relatively inexpensive to the
tice of occlusal alteration by orthodontic, prosthodontic, and surgical patient. A rational approach to treatment based on available science
means to treat TMD persists despite the lack of evidence to warrant is the standard among many academic and informed clinical com
this approach over less invasive means."" Volumes of evidence have munities.'-'• This approach is reflected in the consensus reached
demonstrated that TMDs are self-limiting, that painful symptoms by a multidisciplinary group or scientists and clinicians who nearly
fluctuate, and that simple, noninvasive methods can effectively man· 20 years ago were commissioned t o review the literature on TMDs
age symptoms of TMDs.'·"-52-56 and make recommendations regarding etiology, diagnosis. and
In past decade, academic, clinical, and scientific communities treatment.18
have escalated exploration of the pathophysiology of pain, including Common treatments that meet the criteria mentioned above
ororacial pain. in animal and human s�1bjects. These efforts may include the cautious use of interocclusal spJints'•·n and education or
contribute greatly t o the understanding o f TMD pain and the counseling regarding self-management of TMDs.78 Research into the
development of valid diagnostic tools and treatments. Examples efficacy of other treatments for TMD pain, such as physical therapy,
of this work include study of central nervous system plasticity and trigger point injections, and pharmacotherapy, is voluminous but
sensory processing within the medullary dorsal hom.se muscle limited in scope and often lacking in scientific rigor79; however,
pathophysiolog�·'8 (reviewed by Svensson and Graven-Nielsen''). significant improvement in the quality of these investigations has
and Ihe influence of endogenous inflammatory mediators and opioid been seen over tl1e last several years.90 Other treatments currently in
systems.68 Other work includes investigation or the psychophysics vogue include compounded topical medicaments•• and injection of
of experimentally induced pain.s?M N-methyl-0-aspartate (NMDA) botulinum toxin,ll2 neither of which is supported by controlled clinical
receptor physiology,60 modulation of sensory input in the trigeminal trials. However, these methods are frequently used and are generally
sensory complex,6' and brain imaging.ill> In addition, researchers considered within the scope of conservative and reversible methods
are studying pain and illness behavior.63 the effect of pain on motor of pain relief. although their long-term effectiveness remains to be
behavior,••.,;: and endocrinologic influences on TMD pain.$1;66 studied.
Investigators have uncovered links between serum serotonin levels Outcome studies clearly show that a combination of splint
and masticatory myalgia6' and have shown that patients with use. biofeedback. and stress management is superior to each of
TMD have a generalized sensitivity to evoked stimuli compared these alone and results in long-term therapeutic results.'• Several
with controls.68 A recent investigation revealed that patients with studies have produced results supportive of splint use, but the
masticatory myofascial pain who received repetitive noxious digital mechanism of the splints' action is not understood and may
stimulation demonstrated more pronounced temporal summation of have a nonspecific effect.'•·n Splints are often used t o counteract
pain and greater after-sensations of pain in comparison to controls ... the presumed damage caused by clenching and grinding teeth
which supports the hypothesis that TMD pain is likely centrally while awake or asleep. Hatl<away"" has suggested that control
mediated or amplified. Comprehensive reviews of the mechanisms of clenching while awake should be focused on eliminating the
involved in orofacial pain and treatment approaChes. based on habit of bruxism. rather than solely addressing stress reduction.
scientific and clinical evidence gathered from contemporary Sleep-related bruxism is attributable to neurologically mediated
standards of investigation. have recently been published. providing rhythmic masticatory movements assOCiated with isolated changes
invaluable resources for practitioners.'o-n in electroencephalography and either preceded or followed by
increases in cardiac rate."' Though sleep-related bruxism may or
may not be associated with pain,.. protection of dentition with splints
Treatment (mouthguards, appliances) is often warranted. Splints have been
shown to effectively diminish pain associated with sleep-related
Ideally, treatment should be based on an understanding of the etiol bruxism, but they may cause gross and unnecessary alterations in
ogy and the results of controlled clinical trials and outcome stud· patients' ocdusions, and thus should be monitored by a dentist who
ies. Because the etiology or Axis I disorders is not understood. the is familiar with their effects.
dinician should consider treatment that is palliative, reversible, and Pharmacotherapy has been shown to reduce the effects of
evidence based.73 Ethical standards compel the clinician at least to steep-related bruxism, but not without potential concerns lor long
inform the patient when suggested treatments do not meet these term side effects of medication use.86 In assessing the possibility
criteria. Ethical standards, specifically the fundamental principle that steep-related bruxism is a contributing factor in TMD pain, the
of respect for patient autonomy/' also require clinicians to inform clinician should consider that those patients using selective serotonin
patients about the degree of scientific integrity on which treatment reuptake inhibitors may be at risk for developing bruxism-induced jaw
88 1
pain."'Although medications for TMD are widely used, the literature

provides only limited guidance regarding pharmacologic treatment
Box 7·2 [:Initia l treatment of JMDs:-
of TMOs.88 Tricyclic preparations have been administered to treat
Oral habits and diet
many oU1er pain conditions119 and may be considered in some cases
• Avoidclenching and grinding teeth in daytime
of TMD pain management88 Gabapentin was shown to be more • Restrict diet to those foods that do not aggravate pain
effective than placebo in treating masticatory myalgia and thus may • Avoid chewing gum. biting on pens or pencils, etc
• AVOitJ r'IOOessential use ot Jaw lor extended Pe<IOds (Singing, PlaYing
be appropriate in some refractory cases.110 Other medications that
musical instrument. etc)
clinicians may prescribe are nonsteroidal anti-inflammatory drugs,""
muscle relaxants, and short-term treatment with corticosteroids Medications
• Nonsteroidal anli·•nflammatory drugs at regular l nteNals (eg, f!folery 4
or benzodiazepines. However, the clinician should be aware that
to 6 hOurs)
female patients with various orofacial pain diagnoses tend to present • 01/ler analgesic preparations (eg, tramaclol. opioid analgesics)
with significantly more neurologic, gastrointestinal, pulmonary, • Clonazepam 0.5 mg 2 hS (at bedtime) o t reduce SleeP·related bnOOsm
• Nortriptyline or amitriptyline (usuaUy 10 mg. tilrated to effect or
dermatofogic, and other conditions compared to asymptomatic
target dose)
controls, perhaps complicating treatment options and outcome.•• • Muscle relaXants (eg, metaxalone. bacrolen, tizanldile)
More work is needed 10 understand the genetic and molecular events • Botulinum toxin injectiOn
• Medrol Dosepak (metl))llprednisolone)
that result in chronic pain and how contemporary pharmacology can
affect these actions.e& Physical modalities
The literature on TMO indicates that psychologic factors are • Application ol moist heat Of ice
• Short-term use of alhletic mouth9uard
associated with TMD and influence treatment outcome.92m Thus,
the clinician may wish to assess the pa tient's experiences with Psychologc i support/intervention
depression, anxiety, or both, which may affect the patient's response • Referral to mental health professional specializing in pain disorders
to the usual treatments. Standard psychologic assessment similar

to that for other pain conditions is warranted in some. but not all,
patients with TMD. The Graded Chronic Pain Scale9" can help the
clinician make the decision to refer a patient to a mental health
professional. Other standard psychometric batteries that may be
used are reviewed in numerous pain textbooks.95 Cervical spinal pain and TMDs
Alter establishing a tentative diagnosis of a TMO, the clinician may
wish to refer the patient to a specialist with formal postgraduate Case series have shown that patients who have TMO also report
training in orofacial pain. Initial treatment options are outlined cervical spinal pain.•oo One study found a much greater prevalence
in Box 7·2. of cervical spinal pain among those with TMO than in those without
TMo.•o• Another study that examined the prevalence of signs and
symptoms of cervical spinal discrders in patients with TMD observed
Aural symptoms and TMDs that patients with a primarily muscular component to their TMOs
(Axis I, Group I) had pain and dysfunction of the cervical spine more
Patients with TMDs often report symptoms that warrant evaluation frequenHy than those with a primarily joint-related TM0.102 No differ
by an otolaryngologist. A recent study that compared 432 patients ences were found in upper cervical extension, neck flexion, or shoul·
without TMO and 344 patients with TMO found that aural symp der girdle function. however. The concluSion was that orthopedic
toms occurred in 59% of those with TMD but in only 29% of those tests of the cervical spine are of little benefrt to differentiate patients
without TM0.116 Symptoms of otalgia. tinnitus. vertigo. and per with cervical spinal disorder from those with TMD. The same authors
ceived hearing Joss were strongly associated with TMD. Although also investigated the prevalence of signs and symptoms of TMD in
numerous investigators have speculated about the cause of this patients with cervical spinal disorders.""' Their findings suggested
long-observed symptom comorbidity, a cause-and-effect relation that the prevalence of TMD in patients with cervical spinal disoders
r
ship has not been firmly established.••.oo Nevertheless, reports is not greater than that seen in the general adult population. Several
indicate that treatment o f TMO relieves certain aural symptoms. studies have examined possible relationships between head pes·
Surgical99 and nonsurgical97 treatments are reportedly effective in lure and TMO, with conflicting results. In the most comprehensive
treating tinnitus. vertigo. dizziness. subjective hearing loss. and study to date, no relationship was found between an anterior head
sensations of ear fullness and pressure. However, the small num position and TMD.'"'
ber of these reports. the variable study design, and, in most cases, The literature i s replete with efforts to establish a relationship
the absence of control subjects merits caution in prescribing TMO between whiplash injunes and TMDs. For example, patients who
treatment for patients with aural symptoms. had experienced whiplash reported more TMJ pain, more jaw
muscle pain. and loss of range of mandibular motion and stated
greater intent t o seek treatment for a TM0.'05 Ferrari and Leonard.'"'
89
�� - Litigation and TMDs

Box 7 -3 am l)leJang uage f
S
1 o r., htrgatlon f)Ur f)oses i .
------�---------
As mentioned above, although there appears to be a h igher preva

Sample language providing histo rical information and cl i nical
lence of cervical neck pain in patients with TMDs, the influence of
findings of a pa t ie nt in li t igat ion .
whiplash on development of TMD is not clear.101
Ms Mary Accide nt was evaluated in th is office for complainls Patients who present with symptoms of TMD after motor vehicle
related to jaw pain and clicking on August 17, 2008. accidents (MVAsl have significantly more orofacial pain complaints
Ms Accident reported that she was invol ved in a motor vehicle compared with non-MVA patients with TMD. Upon MRI examination,
accident on June 10. 2008, during which she was a belted driver
patients in MVA-related litigation were found to have a higher
and was rear-end ed by another vehicle traveling at a speed of
approximately 25 miles per hour. Ms Accident reports that shortly incidence of nonreducing disc displacement than the nonlitigating
after the accident. she developed neck pain and was diagnosed group,1o7 though it cannot be determined from t hese data if those
with whiplash at a local urgent treatment center. Two days after the disc displacements were present prior to the MVA. This conclusion
accident, she noticed jaw pain, an inabi trty to open her mouth as also should include consideration that MRI is not a gold standard to
usual, and some painful clicking in her leftjaw.
determine the presence or degree of disc displacemen " t
Ms Accident Indicated that she had never ha<l jaw pain or- simil ar
symptoms prio r t o the acci<lent as described above. When compared to patients who are not in litigation. those
After comprehensive history and examination, it is my opinion who are in litigation tend to have an increased number of clinically
that she is suffering from masticatory myofascial pain and left identified painful anatomical sites but no differences in overall clinical
temporomandibular joint disc displacement with re duction, with findings.'"" It has been shown that the number of sites painful to
arthralgia and reduced range ot motion.
palpation In patients with TMD rises significantly with patients'
Recommended treatment plan consists of the use of an
interocclusal a ppliance physical therapy, behavior modification to
,
tendency to somatization.109•1 '0 While this should not imply a direct
reduce aggravating behaviors and activities, and judicio us use of correlation, It is of particula r interest when considering that patients
analgesic medications. i n litigation do not respond a s well to usual treatments and have
much more widespread and prolonged pain than those who are
not in l�igat io n -'07 Thus, it appears that trauma from MVAs, when
Sample language responding to a request to detennine whether
t he accident in question was the cause of the patient's pain.
accompanied by litigation, is associated with more complaints of
pain that lasts longer and iS more difficult to treat. Patients who
Ms Acci<lent reported to me that she had never experienced the present with post -MVA symptoms of TMD should be informed of
symptoms I outlined prior t o the motor vehicle accident of June these well-established relationships and counseled so that realistic
1 O, 2008. The dental and medical records that I have reviewed
expectations for treatment outcomes m ay be establiShed.
corroborate this history. I have no information that would lead me to
challenge Ms Accident's claim that symptoms began shortly after
Trauma or litigation should not influence evaluation or treatment
the accide nt. recommendations other than counseling patients with regard
Thus. based on Ms Accident's reported history, the symptoms to outcome expectations as noted above. In many cases, the
about which she complains began shortly after the accident of temporal relationship between MVA and onset of symptoms may
June 10, 2008.
be justifiably cited. but the literature currently provides neither
established pathophysiologic evidence nor universal understanding
of how a whiplash injury may result in TMD symptoms. Given the
lack of a n established relationship between T MD onset and whiplash
i njuri es, in addition to the wide variety of symptoms that may be
influenced by litigation and even country of origin,'""' it is prudent to
refrain from speculation and to prepare reports based on historical
information provided by patients and clinical findings in the course of
interaction with legal and insurance representatives. An example of
however, concluded that studies to date have not provided sufficient correspondence between dentist and legal counsel is provided for
evidence to support a conclusive cause-and-effect relationship review (Box 7-3).
between TMJ injury and whiplash. At a later date, depending on the status of litigation, the dentist
Although the pathophysiologic relationsh ip between TMD and may be asked to determine to a reasonable degree of medical
cervical spinal pain has not been established. it is reasonable certainty whether the stated accident in the case is responsible for
to consider whether comorbid neck and jaw pain results from the symptoms the patient is experiencing that were outlined in the
convergence or sensory information in the medullary dorsal 11om previous letter. A suggested response is offered (Box 7-3).
from orofacial and cervical receptors-" Multidisciplinary treatment for The treatin g dentist cannot be expected to formulate hypotheses
patients with TMD and cervical spinal pain may involve the patient's about what occurs in a motor vehicle accident and should not be
physician and a physiatrist or physical therapist. in addition to the drawn to speculation about what may or may not have occurred
treating dentist.
Prosthodontics and TMDs J
given the array of possibilities influenced by speed, position of The clinician shollld be aware of the natural progression of
occupants. engagement of air bags. and other variables."' TMJ degenerative joint disease because the degeneration and
remodeling of the TMJs may affect occlusal stability over time.""
This is particularly true of any of the systemic arthmides. such as
rheumatoid arthritis, a disease which regularly affects the TMJs.11e
Prosthodontics and TMDs
Alteration of the TMJ anatomy, including disc displacements and Prosthodontic case example
bony degeneration. may influence occlusal stability. Thus, prior to
prosthodontic treatment, it is prudent to provide clinical and radio· A 44-year-old woman presented for periodontal and prosthodon·
graphic evaluation of the TMJs. tic consultations for possible implant placement and prosthodontic
Most TMJ derangements are stable and do not progress to more restoration. Her chief complaint was difficulty chewing because of
advanced stages. However, in light of the considerable time and longstanding partial edentulism in areas o f teeth nos. 28 through 31
expense invested in prosthodontic rehabilitation, it is recommended (mandibular right premolars and molars).
that the prosthodontist discuss the possibility that alteration of the There were no clinical, radiographic, or medical contraindications
TMJs may occur subsequent to treatment and that this may negatively to implant p lacement. The patient's oral hygiene was impeccable,
affect the stabil�y of occlusal relationships. This discussion should with no evidence of periodontal disease. Her Class I occlusion was
be part of an informed consent process wherein patients are made in a good state of repair with several posterior amalgam restorations.
as aware as possible of th e potential outcomes associated with their History was positive for past and current preauricular pain on
particular clinical situations. Predicting eventual instability of occlusal a constant and daily basis. The pain was described as an aching
relationships as a consequence ot alteration of TMJ anatomy is sensation that became sharp when the patient ate meats or raw
difficult. It is possible to assess the degree of active degeneration vegetables. Repetitive chewing (eg, eating popcorn or chewing gum)
of TMJs in those whose clinical and radiographic examination exacerbated the baseline pain, rated as four out of ten on average,
demonstrates arthritic degeneration.' '2 By definition, any internal with ten being "the worst pain imaginable" and zero being ''no pain."
derangement of one or both TMJs. including cartilaginous and bony The patient reported that dental appointments were often difficult for
degeneration. imposes instability on the masticatory system and her because "I can't open my mouth very wide." She recalled that her
may significantly alter outcomes of prosthetically aided occlusion. jaw previously clicked and !hat several years ago it abruptly stopped
If clini cal examination reveals crepitus and radiographic evidence clicking, at which time she had onset of severe preauricular pain and
of bony alterations of the condyle or articular eminence, the following decreased ability t o open her mouth. Although the range of motion
steps may be considered prior to prosthetic treatment: resolved over the years, the pain remained (although decreased in
intensiy
t ), and she now experienced a "grinding sound" in her ears.
1. CT scan of temporomandibular joints. CT scans of TMJs When asked about !he stability of her occlusion, she responded,
provide a detailed examination o f the TMJ anatomy, allowing "My bite changes an the time; I never know wl1ere t o rest my teeth."
the prosthodontist to more accurately assess the degree of A panoramic radiograph suggested degenerative changes in both
degeneration of the affected joints. However, these do not mandibl!lar condyles. A CT scan of the TMJs (Fig 7·4) revealed
allow the clinician to predict whether the degeneration is active. diminished TMJ space, bilateral flattening of mandibular condyles,
To assess the extent of active metabolic degeneration, bone and irregulariy
t of cortical bone with osteophytes and subcondytar
scintigraphy is recommended .113 cysts primarily on the left.
2. Technetium Tc 99m bone scan. To assess the extent of Clinical examination revealed an active range of mandibular motion
active metabolic degeneration, a Tc 99m bone scan may be of 35 mm in the vertical plane and a passive stretch of 42 mm. Both
requested."·1 If uptake is identified in TMJs, it may be prudent focal preauricular areas were tender to palpation and t o provocation
to postpone prosthetic treatment until a later Tc 99m bone tests. such as moving the mandible against resistance. Crepitus was
scan reveals quiescence. If treatment proceeds in actively detected in the left TMJ, and a click was apparent in the right TMJ.
degenerating joints, occlusal stability certainly cannot be This patient's primary concern was partial edentulism. However,
prediCted and treatment failure may occur. concerns regarding the status of her TMJs resulted in the deciSion
3. Diagnostic stabilization appliance. The use of a stab lization to delay implant placement and seek an orofacial pain consultation.
i
appliance, adjusted In normal intercuspal position (ie, without Recommendations from the orofacial pain consultant included
guided manipulation o f mandible), may be beneficial to monitor measures to address pain. In addition, a technetium Tc 99m bone
occlusal changes over time. Initial adjustment of the appliance scan revealed high uptake in the left TMJ. with very little uptake in
should include even and simultaneous bilateral contacts of the the right. Implant placement was delayed until a repeat bone scan
posterior occlusion. The appliance may then be monitored to was performed 1 year late. This revealed significantly reduced
reveal changes in occlusal contacts. In combination with Tc uptake, suggesting that the metabolic activity associated with the
99m bone scans, this represents an invaluable clinical toot. degenerative process was quiescent at least temporarily. The dentist
91
7 iTemporomandibular Di sorders and Orofac ial Pain
Truelove et al'22 randomly assigned patients with myofascial pain

or painful TMJ disc displacements with reduction into one of three
groups. Group I received "dentist-prescribed, conservative and
reversible self-care strategies that required the dentist to follow
a standardized treatment checklist that identified all treatment
recommendations Oaw relaxation, reduction of parafunction, thermal
packs. NSAIOs, passive opening stretches, and suggestions abou1
stress reduction)." Group II received the same standard instruction
as Group I but also was fitted tor a dentist-prescribed, maxillary
acryfic resin heat -processed stabilization appliance created in a
dental laboratory. Group Ill received the same instructions as Groups
I and II and used a viny1 athletic mouthguard of a soft thermoplastic
material fabricated chairside with clinician supervision and direction.
All groups improved over the 12 months of the study. Self·
reported pain scores and muscle and joint palpation scores did not
Fig 7-4 BHateral CT scan of TMJs reveals loss of jointspace. osteophyte formation, and
subc011dylar cyst formalion. most notabl e on left. differ among the three groups, indicating that self-care strategies
alone or in combination wit11 appliances were as effective as the use
of appliances alone.
Carlson et al'2� randomly assigned groups of patients with
myofascial pain to physical self-regulation (PSR). which involves
suggested to the pe riodontist and prosthodontist that the patient training in breathing, postural relaxation, and propriocept ive
be counseled to understand that although the bone scan revealed reeducation, or standard dental care (SOC). which consists of patient
little current activity. there may be an unpredictable recurrence of education about self-care and use of a stabilization appliance. A
degenerative activity resulting in alteration of prosthodontically blinded examiner assessed patients at 6 and 26 weeks posttreatment.
established occlusion . It was highly recommended that the Although both groups improved at 6 weeks, the PSR group reported
periodontist and prosthodontist highlight that conversation in the significantly less pain and a better range of mandibular motion at the
dental record for future reference, if necessary. s ent than the soc group . This study supports the
26-week assesm
Prior to any prosthetic rehabilitation, the prosthodontist should implementation of physical self-care techniques.
establish t he status of the TMJs. If there are degenerative changes, or Thus, a formalized self-care education program is as effective as
even if the patient has a disc displacement with or without reduction, the standard appliances that can be used. These studies collectively
it is prudent to enter these data into the medical record and to reveal that appliances may be superfluous in the treatment of patients
undertake and record a conversation with the patient informing him with TMDs, whi ch is especially compelling when considering that
or her that unpnedictable changes may occur as a result of articular these appliances' mechanism of action still is n ot understood.77 '2•
pathology. Thus. patients may consent to treatment after they have
been made fully aware of the possible outcomes that could negate
therapeutic occlusal gains from prosthetic rehabilitation.
Summary
Orofacial pain is relatively common, and TMDs encompass the
Self-Care majority of these cases. Diagnosis is assigned to a specifi c criteria
based on signs and symptoms and Is critical to offeri ng appropri·
Treatments for TMOs are diverse and often reflect a particular clini ate treatment. Because the etiology of TMDs is poorly understood,
cian's background and biases. Although no standard of care has recommendations f o r treatment are suggested to be reversible, pal
been univers ally endorsed by the dental field, a large number of clini liative , and evidence based. Some studies show that self-care mo
cians treat patients with oral splint appllances and other noninvasive dalities are as effective as appliance therapy, further emphasizing
means.117·"8 Some evidence has shown that combinations of treat that the use of appliances is also poorly understood. Many TMD pa·
ments are helpful,' '9 but there is also compelling evidence to indicate tients require prosthodontic treatment to stabilize their occlusion and
that TMDs are self-limiti ng' and that. over time, symptoms are likely should be evaluated by advanced radiologic imaging to ascertain
to resolve spontaneously. '20 However, convincing information indi the stability of the TMJ complex. Although most TMJ derangements
cates that self-care is an effective method t o address TMD pain.m are stable, the patient should then be counselled as to the potential
need for f urther treatment if the disorder precipitates any change.
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lhe ce!VIcal spine In tempo romandibtJlar and ce<Vical spine diSOrders. JOml 116. Voog U. Alstergren P, 8iasson S, Lebur E, Kallikorm R. Kopp S. Progres
R ehab<t 1996;23:742-750. SIOn otradiographiC changes in the temporom andibular jOints o f pattents with
103. de Wijer A, Steenks M, Bosman F, Helders P, Faber J. Symptoms of the rheumatoid arthn ti s lf1 relation to rnftammato<Y markers and mediators on tile
stomatognathlc system in temporomandlb<�lar and ceMCal spine disorders. blood. Acta Odontot $¢and 2004;62:7-13.
J Oral Rehabl l 1996;23:733-4t. tl7. Ekberg E. \fallon D. Nilner M. Occlusal appliance therapy in patients with tem
104. V<sscher C. Ce<Vical Spinal Pain in Chronic Cr aniomandtbttlar Pain Patients: porom andibtAar disorders. A double·blind controlled study in a short·term
Recognnion, Prevalence. and RiSk Indicators [thesis). Amsterdam: Untversity perspective. Acta OdontOf Scand 1998;56:'122-128.
Of Amsterdam, 2000. t t8. Feine J. WI(!
me r C. LLrnd J. Physicat tllerapy: A cri t que. Oral Surg Oral Med
i
105. Kmm E. The incidence o f TMJ dysfunction in patients who have suf· Oral Pathol Dial RadiO! Endod t997;83:t2 3-127.
fared a cervical whiplaSh injury following a tratif c accident. J Orofac Pain 1 19. Sh8(ma <1 J. Turk D. Nonpharrnacotogic approacheS to the management
19 9 3;7 :209- 21 3. or mycfascial tempo<omandibutar CliSOrders. Cw Pail Headache Rep
106. Ferrar1 A, Leonard M. Whiplash and temporomandibtttar disorders: A critic al 200t;5:421-431.
review. JAm Dent Assoc 1998:129:1739-t745. t20. Whitney C, Von t<orff M. Regression to the mean in treated versus untreated
107. Grushl<a M. Ching V. Epstein J. Gorsky M. Radiographic and clinical fea· chronic pain. Pa1n 1992:50:281-285.
tures of temporomand•bttlar dysfunction in patients foflowi"9 indirect trauma: 12t. Dworkin SF. Huggins KH. Wilson L. et al. A randomized clinlcal tnal using re·
A retrospective study. Oral Surg Oral Med Oral Pathol Oral Radio! Ended search diagnostic crtteria for temporomandibular diSOrders-Axis II t o target
2007;104:772-780. cfinic cases for a taJored se�-care TMO treatment program. J Orotac i
Pan
108. Burgess J, Dworkin S.utigation and post-traumatic TMD: How patients re 200 2:t6:48-£3.
port t reatment outcome. JAm Dent Asscc 1993;t24:105-t l0. t22. Truelove E. Huggins K, Mane! L. Dworkin S. The efficacy of tradrtional, low·
109. Sherman J, LeResclle L, Huggins K, Mane! L. Sage J. Dworl<in S. There cost and nonsplint tllerapies lor temporomandibular disorder: A random ized
lationship of somatization end depression to experimental pai'l response contrOlled trial. JAm Dent Assoc 2006 : t 37: t099-1t07.
<n women with temporomandibular Clisorders. Psychosom Med 2004:66: t23. Gartson C, Bertrand P. Etrieh A. Maxwell A, Bll'lon A. Physical sell-regula·
852-860. lion training for the management of temporomandibular disorders. J Orofac
11o. Ohr bach R. Dwo<kin s. Five-year outcomes in TMD: Reiationsnip of Pain 200t1
: 5:47-55.
Changes h1 pain to Changes in physical anCI psychological variables. Pair\ 124. Kreiner M , Betancor E. Clark G. Occlusal stabilization appliances. Evidence
1998;74;3t5-326. of !heir effiCacy. JAm Dent Asscc 200t :132:770-777.
95
Chapter
Considerations in
Treatment Planning
Alan B. Carr, oMo, MS
Steven E. Eckert, oos, MS
William R. Laney, oMo. Ms
c inician who ignores any facet of treatment planning for the estimated length of time necessary to accomplish this treatment.
A
l
edenlt )lous or pa!tially edentulous patient invnes treatment The other category defines the treatment plan as either a list of the
ailure. In the absence of acute disease, the individual pre work proposed based on the complete examination or the intended
senting for prosthodontic services may be "normal" yet exhibit ab· sequence of procedures for the treatment of a patient. It may be
normal features. For instance, the patient may indicate good general important to consider the nature of what is being treated to fully
health but have missing teeth. altered function or speech, compro understand the process called treatment planning.
mised appearance, or poor sell-esteem. Some degree or physi There are limitations inherent in the term treatment because of the
cal, functional, or psychologic abnormalities may affect the patient finality that is suggested. For a disease or condition that is curable or
as well. reversible (ie, the patient can be returned to a state or completeness
An assessment of the patient with missing teeth should include and health), a single treatment episode may be sufficient. However, if
more than physical characteristics. The clinician must understand the disease or condition is neither reversible nor curable but requires
the individual's existing physical conditions. in addition to how his processes to facilitate the patient's coping, management of the
o r her psychologic/emotional makeup relates t o the reason f o r situation over time. or the alleviation of pain. treatment is not a single
seeking care. These characteristics, when recognized and placed episode and periodic reassessments are part ol that management.
within the historical context of the patient's oral health history, help Given that partial and complete edentulism aie chronic conditions
the clinician fully comprehend the patient's immediate and long that cannot be reversed to an original state and must be managed
term needs. By identifying which of the related factors are most over time, the initial goal of treatment planning should be to determine
important to the management of a particular patient and by applying the best management plan for the patient.
clinical knowledge and skills, the clinician can create and execute an
effective treatment plan.
Personal Factors
Planning Treatment Versus Management or a patient embodies more than physical replacement
Management of a missing anatomical part of the body. When management takes

into consideration the various functional and social roles that teeth
Although there is no consensus among medical or dental fields. play in a patient's lrre. and how replacement affects those roles, this
definitions of treatment plan generally belong to one of two major process is called rehabilitation.
categories: One suggests that a treatment plan is a written docu The historical context o f the patient's main concern illustrates
ment that outlines the progression of therapy and contains vaii patient-specific expectations and responses to previous Ca!e.
ous components that include the main presenting problem. a list of Patients presenting for a first prosthesis w11o have no previous
goals for treatment, techniques to accomplish these goals, and an prosthodontic experience have only natural teeth as a reference tor
97
8 iConsiderations in Treatment Planning
comparison. This context is very different from that of a patient who It is the patient's rote to (1) identify his or her desired level of
has an extensive prosthodontic care history. Interventions tor those involvement in the process; (2) express understanding of the
patients with a history of prosthodontic treatment should take into information provided, especially of the different treatment options
consideration the effects of this previous treatment at the tooth· and the relative outcome differences between those options; and (3)
tissue and functional-esthetiC levels to formulate a more realistic determine his or her preference(s) for a specifiC outcome in order to
context for patient expectations. assist in selection of an option.
In prosthodontics, patients with similar tooth loss distributions and Providers routinely make these types of decisions. However, a
prostheses may have had completely different experiences. This can decision-making process that directly involves the patient presents
be quite confusing to the less experienced provider. and certain a new set of circumstances. Patients do not make such decisions
categories of prostheses bring even greater variability. The principles frequently, and most decisions are made with little preparation
outlining the processes of patient habituation to prosthetic devices or repetition. Consequently, patients cannot acquire a stable
are not clearly delineated. However, understanding the unique understanding of the key elements of the decision and may feel
combination of a patient s habituation facility and prior experiences
' overwhelmed. The way the options are outlined. Including the
is key in defining management features that lead to a favorable language used to describe possible outcomes, has a profound
outcome. influence on how patients frame such decisions and make their final
decision. Consequently, i t is critically important that patients be given
relevant. accurate information in a form that positively Influences
Outcome-guided planning their preferences.
The most successful providers maintain a sensitivity to each
Treatment-planning efforts that are largely guided by patients' desired patient's level of desire to share in the decision. They also
results are referred to as patient-based outcomes. These desires are communicate the best evidence that reflects their practice
usually heavily influenced by previous negative experience, which may outcomes, take measures to ensure that the patient understands
involve natural teeth or a fabricated prosthesis. Because the patient's what is communicated. and agree with t11e patient on a decision that
natural Ieeth were likely unhealthy and the prosthesis was likely unf is the best for this patient given the specifiC circumstances. Because
avorable, the patient's experience was likely compromised. any educational interaction must consider differences in learning
When expectations are discussed. patient education is important levels, decision aids can be used to benefit some patients.
to (1) identity the etiology of a negative experience, {2) place the The deciSion that best serves an individual often depends largely on
context of expectation within that experience and judge how it was the patient's preferences and values. Therefore. the treatment that is
influenced by oral conditions, and (3) subsequently identity realistic best tor one patient may not be best tor another in exactly the same
expectations based on the various management options available. situation. Yet the shared decision-making process influences individual
For health care-management issues where available treatment outcomes; it has been demonstrated that active participation of
options offer different outcomes (ie, tong-term management patients in this process correlates with improved qualiy
t of life.
differences). it is important to help patients understand those
differences and identity which characteristics best meet their
preferences and values. In this process. information and decision
making are shared because future provider-patient interaction is Physical Factors
determined by the choice that best fits patient needs. A shared
decision-making model emphasizes the important role o f each party The contents of the oral cavity cannot be disassociated from the
in making such care deciSions. remainder of the body in treatment planning. Metabolic processes
affected by disease can involve and precipitate changes in the oral
caviy
t . Many of these entities and manifestations are described in
Shared decision making chapter 4 and must be considered, along with local factors, in the
development of a treatment plan because the ultimate success of
The three major components in decision making are {1) what options the restoration is dependent on the health and maintenance of bone,
are available. {2) what is the likely outcome of each option, and (3) teeth, and soft tissue for structural support.
what is the value of each outcome to the decision maker. The pro· Historically, prosthodontic treatment planning has focused heavily
vider and the patient each have a role in such an interaction. on the evaluation of physical features of the oral cavity and the
It is the provider's role to (1) identify what level of involvement the quality of support offered by prosthetic solutions. This evaluation
patient deSires in this decisiOn. {2) give reliable information at the has been divided into tooth considerations, which typically require a
outset of this potential long-term relationship, (3) clearly articulate fixed solution, or tooth-tissue and tissue considerations, which result
the different outcomes for each option, and (4) provide maintenance in removable solutions. This continuum, from tooth to tooth-tissue
expectations for continued management of tooth loss in light o f the to tissue, highlights the suppo11 differences between structures
patient's risk level. involved. Support characteristics vary from that which feels most
Physical Factors J
Fig 8-1 Of the available supporting Ussues ror a removable Fig 8-2 (a and b) Bone index areas indicate whether bone would respond favorably to torces applied to lhese
par1lat dentUJe, lhe mandibular left canine and mandibular supporting tissues.
r igh t lirst and second premolars are considered for
abutment support.
natural to a patient habituated to natural teeth to that which is least bony metabolism over a prolonged period are more likely to wear
like natural teeth and highly variable i n support capacity. This focus on an oral prosthesis successlully. Clinical experience has shown that
support quality is important, and it must be recognized that patient structures unused for long periods (eg, nonfunctional teeth, bone,
responses to each type of support may be inconsistent , especially or soft tissues) USlJally respond poor1y t o sudden or sustained
as the support becomes more tissuelike and less toothlike. functional loading.
Clinical evidence of bone maintenance may be observed in areas
previously st ressed by a prosthesis or forces transmitted through
Bone natural dentition over a known period. In addition, radiographic
examination of the physical contour and quantity or bone in localized
Clinical factors related to the resorption of bone are numerous and ridge areas in tl�e arch or adjacent t o stressed teeth can be used to
varied. Atwood' categorized these factors as anatomical, meta predict the quality of bone support (Figs 8-1 and 8-2). These index
i , functional, and prosthetic. Anatomical factors refer to the
bolc areas are vital in treatment planning because they show the need
size. shape. and density of ridges; the thickness and character of for abutment splinting, reduction of the occlusal table, preprosthetic
the mucosal coverin g; the ridge relationships; and the number and surgical provision to increase usable base surface area, or removal
depth of alveoli. MetaboliC factors include the multiple nutritional. of teeth.�-3 However. the reliability of the radiograph as an infallible
honmonal, and other factors that influence the relative cellular activ medium to evaluate the quality of bony support is questionable for
ity of the bone-fonming cells (osteoblasts) and the bone-resorbing the following reasons2:
cells (osteoclasis). Functional factors include the frequency, inten
sity, duration, and direction of force applied to bone, all of which are • Degree of calcification is not a dependable measure of bone stabil·
translated into cellular activity and result in bone formation or bone ity or of bone ability to withstand added functional demands.
resorption, depending on the patient s resistance to these factors
' . • Appearance of bone density varies with radiographic technique;
Prosthetic factors refer to the many techniques. materials, principles. thus, the density as portrayed is an uncertain measure in bone
concepts, and practices that are incorporated into the prosthesis. evaluation.
Thus, when planning a pa1tial denture for the patient who has • Relative density may vary among patients whose bone stability
remaining natural teeth. among which are potential abutments with has been proven through adequate base support over many years
less-than-normal bony support. the clinician should observe the without resorptive changes.
bone loss and consider the reason tor its occurrence to ascertain
the phase of deterioration and wMtl'ler the process may be A review of the anatomical, metabolic, functional, and prosthetic
reversed by prosthetic or other means. There is a tendency to select factors that 11ave contributed to the state of the bony support as tM
patients for treatment, propose solutions for clinical problems, and clinician finds i t upon examination should provide helpful information
prognosticate restoration success solely in terms of the amount of for treat ment planning. Historically, preprosthetic vestibuloplasty
available bony support. A large U·shaped ridge or ridge segment is with split-thickness skin graft may 11ave been appropriate for a
generally desirable, but the most critical factor in the longevity of a previously stressed or unavailable bony ridge supporting a complete
removable prosthesis is the abmty of the bone to resist the forces denture. However. current bone-conserving endosseous implant
of functional loading and to maintain a state or equilibrium. Patients treatment modalities that are less invasive may now be the choice of
who can maintain the regenerative and degenerative processes of intervention for the same clinical condition.
99
8 i Considerations in Treatment Planning
Obviously, not all deteriorated mout11s can be restored satisfactorily resorption and (2) to develop a technique that arrests the resorptive
with surgical or prosthetic procedures. A basic challenge to all mechanism. Accomplishment of these goats relies upon the
clinicians who Fabricate oral prostheses is the predictability of clinician's ability to identify the nature of local control factors affecting
response by the bony foundation to prosthetic stress. Can one bone remodeling.
preoperatively identi fy the patients with physiologic resistance for Current practices in prosthodontics have not resolved the problem
lasting support? Clinical judgment acquired from experience is often o f the maintenance of residual bone. Therefore, new approaches
the significant factor in detem1ining the ultimate level of professional must be continually sought to accomplish this end while known
success. factors are examined and reevaluated. Until it is possible to build
A 1972 workshop on complete denture occlusion included a better bone. we must do all we can to conserve it (see chapter 10 on
study of residual (alveolar) bone. Tl1e following information from the bone grafting). In the meantime, If changes occur in the bone base
final report of this workshop is pertinent t o the current knowledge of on which occlusion relies, then the occlusion of the entire denture
residual bone as it applies to removable prostheses.' must change.
Control factors
Teeth
Numerous suggested control factors at the genetic, systemic, and
local levels influence modeling and remodeling behavior. It appears A thorough evaluation of all structures that could contribute sup·
from available evidence regarding loss of residual bone after tooth port to a prosthesis must include natural teeth, because the final
removal and insertion of dentures that most factors are local control treatment and prost11etic choice are influenced by their number,
mechanisms. However, this does not preclude the possible effects alignment. location in the arch. individual position. mobility. vitality,
of systemic and genetic factors. crown-to-root ratio, root size and shape, susceptibility to caries,
Some or the local control mechanisms that have been investigated pathologic involvement. and morphology. One of the most important
include biomechanical factors, neurotrophic factors, vascular observations affecting treatment planning involves the condition of
mechanisms, chalones (local hormones), enzymes, pH, bioelectric the occlusal plane of the remaining natural teeth. A harmonious oc
potential, gas tension. temperature, and nerve and neuromuscular clusal scheme seldom can be achieved if compromised by extruded,
reflexes. badly tipped. or malaligned teeth. It may be possible to recontour or
With respect to complete denture prosthodontics. little is known realign such units by selectv
i e grinding, restor ation with full crowns.
about how this wide variety of local control mechanisms may cause or orthodontic guidance. If not. crown reduction or removal of one or
reduction of residual bone. more teeth is indicated for purely mechanical reasons. When a fixed
or removable partial denture opposes a complete denture. restora·
Prosthetic factors tions for the partially edentulous arch should not be completed until
the desired plane of occlusion tor the complete denture has been
The development and maintenance of the alveolar process are di established (Rg 8-3).
rectly related to the eruption and presence of the dentition. The oc
clusal pressures are translated into forces expressed through the Distribution
periodontal ligament. Proprioceptive and biomechanical stimuli may
be instrumental in the maintenance of the alveolar process. Classifications of partial dentures have been proposed by many au·
Two concepts have been advanced concerning the question thors and are generally based on the location of edentulous areas
of whether toss of residual bone is inevitable. One contends that within the arch.3·� The location. type, and length ol the edentulous
when the teeth are lost. there is a variable progressive residual bone span are all important when considering prosthesis design. A fixed
toss. The remodeling is regarded as a direct consequence of the partial denture is preferable to a removable one when loss of a single
elimination of the functional demands imposed by the teeth through tooth or two adjacent teeth has created a space bounded by clini
the periodontal ligament. According to this concept, the resorption cally adequate abutments. If edentulous areas are longer, multiple
of the ridge is a typical phenomenon, and lack of resorption abutments are usually necessary to support fixed restorations.
represents an atyptcal condition. The other concept maintains that Abutment alignment may contraindicate fixed partial dentures,
residual bone toss i s not a necessary consequence of tooth removal. particularly in a square or ovoid arch in which canines are among
The variable rate o f bone loss is dependent upon a series of poorly the missing teeth. Unilaterally missing lateral incisors. central
understood factors. incisors, and canines create a situation that contraindicates a fixed
A prosthesis introduces alien forces into the oral cavity and partial prosthesis. Tylman suggested that a fixed prosthesis in
creates a functional situation for tl1e residual bone that is totally such a case probably would fail because (1) the curvature of the
contradictory to that encountered in jaws bearing teeth. The goals restoration produces a destructive leverage on the abutments; (2)
for the prosthodontist are (1) t o determine the mechanisms by which the two terminal abutments adjacent t o the edentulous area are
the forces transmitted through the prosthesis are translated into not suffiCiently strong; and (3) the wisdom of involving five teeth
100 1
Physical Factors j
Fig 8-3 (a andb)The occlusal plane isestablished prior to treatment for removable partial deniiJfes.
Fig 8-5 (a and b) Canine abtJtments splinted with

Rg 8-4 Multiple abutmeniS must be considered lor a fixed restoration when the resistance arm is
1 O·gauge round gold bar.
lengthened, as in a more tapered arch. Note the heavy black line connecting the dotted canines and
shorter lever arm (a) In a llatler arch curve, compared to U1e llgllter line connecting canines in solid
outline and the addhional lrM!r leogtll (b) in a more curved arch.
t o replace three missing teeth is questionable. '0 The same general edentulous span is not badly resorbed and is well healed, perhaps
objections to a fixed prosthesis prevail with unilaterally missing undercut, and not overly prominent, a fixed partial denture with
canines. adjacent lateral incisors, and first premolars or unilaterally pon ti c replacement is generally indicated in either arch.
mi ssing canines and first and second premolars. Whereas these However. a removable restoration is preferable if the edentulous
considerations are usually applicable to either arch lor the described area is badly resorbed in relation to abutment hei ght if large frena
,
situations, exceptions may occur when the opposing occlusion is are disadvantageously located, or if the need exists for significant
provided by a removable partial denture. when the spans are short. alteration of the position of tooth replacements. alignment, and
o r when the abutments are exceptionally strong. base contour for esthetic reasons or for the jaw relationsl1ip. A
The stress imposed on a canine-to-canine anterior lixed partial fixed anterior restoration that acoommodates the latter conditions
prosthesis is related to ridge curvature. The farther the pontics uses the bar-type splint (Fig 8·5) advocated by Dolder," Vig. '2 and
deviate from a straight line through the canine abutments. the others.5·"·" This combination provides a definite rest seat and an
longer the operative lever arm (Fig 8-4). When the length or the lever effective Indirect retainer for the anterior base of the removable
arm is multiplied by the force applied to the incisal edges, tipping partial denture when the rulcrum line is somewhat posterior to the
stresses can be estimated and tolerance can be projected. When bar. The r,xed bar also seNes as an effective and inexpensive cross
no intermediary toot11 is available as an abutment in the curved arch splint for less·than-opti mal abutments.
anterior arch, it is advisable to use the first premolars bilaterally lor Anterior concentration of occlusal function and stress from the
add�ional support. premolar region invite problems. Although the use or a removable
The type of restoration for anterior teeth is often based on the partial denture alone to replace molars may be contraindicated. it
presence of distal edentulous areas. When anterior and posterior could be considered when bilateral posterior edentulous areas are
edentulous areas are interrupted by natural teeth, anteroposterior short and the premolars are located at least midway between the
rotary movement of a removable partial denture around the temporomandibular articulation end guidances and the incisors.
i ntermediary abutments is often difficult to control. Consequently, If occlusal runction is primarily anterior in any type of prosthetic
a combination of fixed and removable p artial prostheses may be restoration. loss of posterior support results in decreased
desirable within the same arch. If the residual ridge of the anterior masticatory efficiency because of a diminished occlusal table and
101
reduced vertical dimension of occlusion. This loss o f support also excellent alternative solutions to fixed partial prostheses that would
can create temporomandibular joint (TMJ) disturbances from neuro otherwise require tooth preparation and pontic replacements.
muscular imbalance and distortion of mandibular posture. Natural Potential implant sites with inadequate bone quantity or configuration
premolar occlusions have been shown to be comparable to complete can frequently be improved with bone substitutes and regenerative
dentures in masticatory efficiency.'5 Because molar loss results in growth factors.
approximately a 75o/o reduction in chewing efficiency, a removable Management of an isolated secon d premolar presents a perplexing
partial denture is indicated when there is adequate abutment therapeutic situation because its use as a terminal abutment for a
support. The presence o f fewer than lour symmetric occlusal units distal-extension removable partial denture is questionable. When
may be an indication t o increase masticatory efficiency.'" the first premolar is missing. the second premolar is best stabilized
In addition to restoration of occlusal function. molar replacements with a fixed restoration using the canine and isolated premolar as
are necessary for good articulation in speaking. Precise speech abutment teeth. In this manner. fixed and removable prostheses
sounds are dependent on the placement of the tongue and on the are used a s restorations of choice in the same arch to counteract
controlled delivery of a developed air stream through the oral cavity. undesirable lining and rotary torquing forces on the Isolated tooth.
Badly resorbed edentulous areas disrupt the normal flow of air and The development of more sophisticated endodontic and periodontal
encourage an abnormal posture or placement of the tongue with concepts and techniques means that teeth previously considered
resultant "slushy" speech. The need to replace single missing molars for removal can now be saved. However, after treatment. a need
may be questioned because of the inherent difficulty in stabilizing a often rises for positive stabilization through direct splinting of groups
unilateral, distal extension-based partial prosthesis. Replacement of of teeth. Four basic splinting procedures have been proposed.2'-211
second molars primarily to prevent continued eruption of opposing They include the vertical parallel pin, vertical nonparallel, horizontal
molars may be accomplished with cantilever extensions from double parallel, and horizontal nonparallel systems. Although each system
abutments, if necessary. Aside from preventing the extrusion of has particular advantages, disadvantages, and applications, the
unopposed teeth, control of the overdevelopment of soft or hard general concept has been proven. When properly applied with
tissues in the maxillary tuberosity region may be an indication for good clinical judgment, effective stabilization with pin splinting has
unilateral or bilateral replacement of maxillary molars. provided a good prognosis for questionable teeth. Additional time,
expense. and service from the clinic and laboratory are significant
Stabilization factors when considering the use of these techniques.
When restorative treatment is planned for patients with missing Condition of abutment teeth
teeth, replacements are necessary to restore a pleasing appearance.
prevent extrusion of opposing teeth. prevent drifting or tipping. and Regardless of the number of remaining teeth. their physical status
provide support for teeth bounding the edentulous area by splinting is a n important consideration when planning treatment. In young
either within the arch or with a cross-arch segment. A fixed partial patients. large pulp chambers preclude the use of cast retainers to
denture within an arch segment stabilizes teeth primarily against me support fixed restorations because tooth preparation would be com·
siodistal movement: situations involving several abutments in both promised. In mouths in which canes lesions are rampant or previous
anterior and posterior segments require splinting to resist lateral treatment has necessitated pulp capping or root canal therapy, the
movements as well. When well designed. fabricated. and supported prognosis for use of such teeth for prosthesis abutments must be
by properly prepared abutment teeth, a removable partial denture somewhat guarded (Fig 8-6). This is not to say that devitalized teeth,
also can be an effective splinting mechanism. Its stabilizing influence properly treated and maintained, are contraindicated as abutments.
is enhanced if intracoronal attachments are used to direct principal However, the patient must be cautioned that longevity of a restora
stresses toward the long axes of the teeth. Although some pros tion supported by a nonvital tooth or teeth may be less than optimal,
thesis movement will occur. the primary objective is to control such and planning should include the use of muttipte abutment teeth and
movement and to confine it as much as possible to one plane. provisions tor revision of the prosthesis or design of alternate resto
Teeth weakened by periodontal disease frequently have long rations in the event of abutment breakdown or loss.
clinical crowns and lend themselves to alleration or preparation Root anatomy is also a concern in selection of prosthesis
for the effective use of positive guiding planes. When distributed abutments. Larger roots are better for support and distribution
throughout the arch with mesial. distal. and lingual guiding plane of stress. The canines and molars with multiple root s provide the
surfaces. teeth that are property prepared and cared for can be best mechanical advantage for support, compared to mandibular
stabilized with a removable prosthesis and made satisfactorily premolars with thin, tapered roots: incisors with rounded roots:
functional." Other types of removable splints have been proposed molars with fused roots; and any teeth with roots resected or
and used successfully.•e-ro reduced as a consequence of surgery.
Endosseous implants are the preferred treatment option for Root configuration naturally provides resistance to force,
many of these clinical situations. When bone quantity and quality depending on the location of the tooth within the arch.'0 Maxillary
are adequate in isolated edentulous spaces, implants can provide incisor roots are pyramidal and provide optimal periodontal
1021
Physical Factors J
Fig 8-6 (a) Patient pre$enting with several nonvilal, heavily restored abutment teeth. (b) Restornlion with unsplinted Rg S-7 Patient p�esenting vmh a combination of peliodontal
full·oove�age restorations and Implant-supported fixed partial denture.lndMdual prosthetic units increase the chances asease andocclusal trauma.
of long-term survival of endodontically treated teeth.
attachment on the lingual. mesial. and distal surfaces to resist tor definitive periodontal care and home care. nme must be given
lingual and distal stresses. Mandibular incisor roots are flattened for the patient to respond to education and treatment before
on the mesial and distal surfaces and provide resistance to lateral prosthodontic procedures are initiated. In situations in which only lip
forces in a closed arch. Tl1e tripod effect created by the roots or service is given to the importance of demonstrating understanding
maxillary molars enhances stability and resistance to lateral forces: and care. all too often the patient will continue poor hygiene habits
mesial and distal stresses are resisted by the buccal root surfaces, that contribute to the ultimate failure of the prosthetic restoration,
and the lingual root counteracts buccolingual stress. Canine roots despite the clinician's best intentions and efforts.
have advantageous lenglll, with mesial and distal surface widths to The decision to retain or remove periodontally involved teeth is often
withstand strong forces generated at the arch corners. Mandibular difficu�. It such teeth ane a vehicle for prognessive bone loss and Chronic
root contours generally reflect the same natural adaptive design. soft tissue disease in the patient under routine care, the irreversible
Regardless or these compensatory root features, loss of teeth and nature of the process must be considered before all support or the
f
excessive forces from poorly designed restorations can produce eventual nestoration is lost. Ante's law is frequently cited as a reliable
stresses that exceed the physiologic limits of tolerance and result in guide to assess the periodontal potential of abutment teeth for a fixed
failure of the restoration. proslhesis.28 It states that '1he combined pericemental area ot the
The use of periodontally weakened teeth as abutments is often abutment teeth should be equal to or greater in pericemental area than
debated, but an extensive discussion is outside the scope of this the tooth or teeth to be neplaced." According to Smith.29 the accepted
text. However, the health of the periodontium is important because and desired crown-to-root ratio for fixed prosthesis abutments is 1 :1.5
the presence of periodontal disease imp lies the need for removal of i nches in linear measurement. A tendency prevails to devalue these
local irritants and occlusal discrepancies. both of which precipitate criteria in the fabrication of removable partial dentures because it is
chronic inf lammatory processes and loss of bone. Swoope has difficult to estimate the role of the base in overall support, and the
summarized the significant factors that affect the prognosis of consequences of abutment loss are less complicated. However, such
periodontal therapy and thus the possibility of using periodontally thinking only contributes to the erroneous concept that the removable
diseased teeth for prosthesis support.26 These include {1) the extent partial dentune is an interim prosthesis to be used until the patient
or disease Invo lvement : (2} duration and progression: (3} causative reaChes an edentulous state.
factors including occlusion, bone level. pocket depth, and furcation It either arch has the potential to become edentulous. an over
involvement; (4) complexity of the prosthesis required; and (5) the denture is a possible indication. particularly if the ar ch is opposed
patient's attitude, cooperation, ability, and determination to provide by a complete complement of natural teeth. Whereas morphologic,
horne care. The pertinent clinical signs of trauma from occlusion physiologic, and psychologic conditions suggest a poor prognosis tor
and inflammation ane (1) thickening of the periodontal ligament, (2) complete dentures, the overdenture may be a satisfactory alternative
excessive tooth mobility, (3) angular (vertical) bone destruction, {4) restoration that meets t11e criteria of a particular1y difficult situation.
intrabony pockets and craters, (5) f urcation involvement, and (6) The mandibular arch is commonly considered as an overdenture
pathologic migration of the maxillary anterior teeth27 (Fig 8-7). recipient because of its smaller basal seat potential and propensity
Regardless of etiology, if the pathologic process can be arrested for resorption. When an adverse anterior guidance relationship is
and controlled, well-occluded restorations can b e fabricated to precipitated by esthetic requirements, it can be advantageous to
provide satisfactory function. A patient's motivation to retain natural retain some maxillary teeth to support an overdenture. '3
teeth is usually reflected in cooperative efforts to Improve mediocre When all dental restorative treatment possibilities have been
oral hygiene or sustain good oral hygiene after receiving instructions considered, resulted in failure, or been found impractical for any
103
8 i C onsiderat i ons in Treatment Planning
reason. the deciSion to render the patient edentulous must be Unless this variation is compensated for in prosthesis design and
faced. The best complete dentures are still poor substitutes for the fabrication. comfort and satisfactory function are rarely achieved.
natural dentition, and the patient must be aware of this reality before Health of the soft tissues is clinicaUy indicated by changes in color,
submitting t o removal of the remaining teeth. However. deterioration surface texture, configuration. displaceability, and volume. Ostlund
of the natural dentition and supporting structures may provide no studied 291 bi opsy specimens of palatal mucosa from lhe posterior
alternative. Grossly malpositioned and misaligned teeth. further palatal seal area to ascertain the microscopic changes produced
compromised by an unfavorable maxillomandibular relationship and by wearing a complete denture.'2 Although the mucosa appeared
tooth-jaw disproportions, may need to be sacrificed if it is determined normal clinically, there was a decrease in thickness and ultimate
that they are untreatable by orthodontic or surgical procedures. When disappearance of the homy layer of epithelium with subsequent
an esthetic appearance and acceptable function are unattainable parakeratosis after a denture had been worn approx imately 6 months.
with remaining natural teeth. the choice of restoration is simplified. Cellular changes consisted o f an {1) initial thinning of the stratum
However, the solution is not universally well accommodated by all corneum and later parakeratosis, which i s usually more prominent in
patients. Continuing regressive changes in the remaining supporting females; (2) early increase in mitosis which diminishes as the extent
.
structures necessitate regular care t o maintain a healthy prosthesis of injury progresses; and (3) increased volume attributable t o edema.
support relationsh ip. Because mitotic activity is low in mucosa undergoing even severe
The application of osseointegrated endosseous implants for the change over a period of years. the incidence of malignant change
support of complete dentures has been shown to be both versatile is low. These histologic phenomena commonly occur in mucosa
and predictable.30·� Implants in the canine positions standing atone supporting a reasonably well·fitting prosthesis.
or with bar attachments, particularly in an edentulous mandibular Kapur and Shklar"'l observed a smaller group of bi opsy specimens
arch. can provide adequate support for removable overdentures than Ostlund."" but specimens 11ad been taken from the ridge
when the patient has financial limitations. Four implants placed crest before and 3 months after dentures were worn. The results
in a quadrilateral configuration can provide excellent cross-arch demonstrated excellent tissue response with the development of an
support to retain complete fixed or removable restorations in either obvious. well-formed stratum corneum. The authors postulated that
edentulous arch in selected patients. differences in findings compared with Ostlund's might be attributed
to the site of biopsy and t o relative stresses imposed on each
site. It is generally believed that a well-adapted denture stimulates
Soft tissues rather than irritates the supporting mucosa. However, lhe first sign
of residual ridge destruction under ill-fitting dentures is often the

In reference to removable dentures, clinicians often tell patients, deformed and traumatized overlying soft tissues.3' More significant
"Mother Nature never intended for your oral tissues to be covered epithelial changes may follow, such as excessive k-eratinization,
or stressed by plastic dentures." It this is used as an excuse to edema, fibrosis. and sclerosis associated with scarring; connective
replace a removable denture with poorly conceived and fabri tissue inflammation; glandular congestion; and atrophy.
cated restorations, the patient will likely not listen. However, when Excessively thick mucosa covering the residual ridge permits an
presented before treatment in an attempt to educate the patient undesirable amount of prosthesis movement and becomes a source
about the deficiencies of removable oral prostheses, the phrase has of chronic irritation. This situation isoften seen in the maxilla. particularly
more impact. in an edentulous anterior maxillary residual ridge opposed by natural
mandibular anterior teeth. When occlusal function is concentrated
Characteristics and responses in the anterior segment of a complete denture, bone is lost from
the resultant trauma, and redundant soft tissue accumulates loca.lly
Physically, the soft tissues overlying the bony structure of the jaws in response to the chronic irritation produced by the now-unstable
are the weakest prosthesis-supporting elements. However. they prosthesis. In addition to the mobile soft tissue mass, commonly
play a significant role in the patient's perception, the retention and associated with the rotation of the maxillary denture upward and
stability of removable prostheses. and the comfort of the pros anteriorly, a thicker tayer of fibrous tissue overlying the tu berosities
theses. A slight placement border of soft tissues surrounding develops to fill the interfacial void created by the downward posterior
complete dentures permits the development of a peripheral seal. movement of the prosthesis. This phenomenon iS observed almost
A masticatory mu cosal thickness of approximately 2 mm cushions routinely in patients without ma ndibular posterior restorations or
the denture base seat and buffers the impact of forces transmitted with poorly adapted bilateral distal extensi on partial dentures in
, -
to the bony support during function. Furthermore, mucosa with this infraocclusion. Extremely hypermobite soft tissue accumulation
approximate thickness provides a flrm seat that enhances resistance over the entire maxillary residual ridge, almost a s if t o replace it,
to denture movement in the horizontal plane. Thus. soft tissues may be encountered in patients with severe atrophy of the bony
provide protection, comfort, and some degree of efficiency for the ridg e This is found often in clinical situations in Wl1ich a complete
.
patient who must wear a prosthesis. Unfortunately, ridge mucosa natural mandibular dentition opposes an edentulous maxillary ridge
seldom has uniform thickness. consistency, and displaceability. supporting a complete denture (Fig 8-8).
1041
Physical Factors j
Fig 8·8 Edentulous maxillary anterior alv€()1uswilll h)-permoblle soft tissue (a)characleristically found io patients Fig 8·9 Papillomatous lesion olllle palate from continuous
wnh maoolbular anterior dentition {1!). denture wear.
Inflammatory papillary hyperplasia of the palatal mucosa i s a Innervation and perception

relatively common finding beneath maxillary complete dentures
(Fig 8·9). The lesion is best observed after washing and drying the The role of innervation in supportive soft tissue is especially i mpor
mucosa with an air stream. Although papillary hyperplasia can occur tant for the person who wears complete dentures. Aside from the
with clinically satisfactory prostheses, the condition usually develops receptors that detect painful stimllli, other discriminatory structures
in patients with less-than-desirable oral hygiene wearing poorly filling in the oral soft tissues affect the patient's abiliTy to wear and manipu·
and occluded prostheses, often with excessive palatal relief. The late a prosthesis. A study of 109 sections of gingiva and edentulous
basic biologic process seems to be inflammation caused by chronic mucosa found that organized nerve endings per unit area were more
exceSSive retention of food debris and stagnant oral secretions.35 numerous in women and older persons than in men and young per·
A study of 226 denture-wearing patients revealed an incidence sons.-<61n both the maxillary and mandibular arches. neural richness
of papillary hyperplasia in 11% of the group and demonstrated a decreased from the incisor t o the molar region. It was postulated
dramatic correlation between the lesion and continuous denture that removal of teeth does not appreciably alter the innervation of
wear (day and night).:le oral mucosa, but a prosthesis could be a stimulus to altered neural
Papillary lesions seldom subside completely without treatment. anatomy. The quality of fit of a soft tissue-supported prosthesis
Tissue rest. massage. and medication reduce the inflammation. seems to be related to its ability to stimulate or Significantly alter the
but the papillary projections generally persist even though they may neural innervation.
shrink. Bolender et al37 reported that fabrication of new dentures The proprioceptive role of the periodontal ligament in mandibular
does not substantially change the lesions, but surgical removal of posture is important for optimal function and protection of teeth,
the lesion with a high· frequency cutting current followed b y new TMJs, and surrounding soft tissues. The ligament contains deep
dentures is effective in its eradication. pressure nerve endings in close proximity to an individual tooth that
Significant comfort and functional problems also arise in patients moves und.er stress, a llowing the force on the tooth to be sensed.
with extremely atrophic masticatory and lining mucosa. Unfortunately, Patients with dentures do not detect small masticatory forces well
these problems are seen most often in the elderly or senile patient because any force applied is distributed over a large area of suppor1
tor whom little can be done. Whereas surgical correction or injection instead. Manly et al'' postulated that the sensory discrimination
of sclerosing agents may be effective in managing hyperrnobile of denture patients is not seriously im paired when the forces and
soft tissue excesses,38·:» the treatment alternatives for atrophic soft movements involved are of the magnitude commonly used in
tissues are rtmited. Resilient denture liners,"" cast metal bases,""'"-'3 mastication. However, when these patients encounter smaller forces
and surface tension-reducing films applied to denture surfaces"·•• or movements such as changes in texture, sensory discrimination is
have been used successfully in selected patients. However. atrophic less effective. A study of occlusal tact11e sense in denture wearers
mucosa that i s thin, taut. friable. painfu l, and relatively avascular reported that the sensory threshold for the detection of bodies
remains a challenge for the prosthodontist to use as an effective, placed between the occlusal surfaces of soft tissue-supported
comfortable support for a removable prosthesis. It is easily abused, dentures was approximately six times that of natural teeth.•8 Those
responds poorly to irritation or injury, and lacks lhe resilience of with natural teeth were able to detect tinfoil from 0.008 to 0.03 mm
normal masticatory mucosa. thicl<. but the mean sensory threshold was 0. 18 mm for denture
wearers, with a range of 0.03 to 0.60 mm.
105
Fig 8-10 An Implant-retai ned overderture caB improv e

compromised denture-bearing areas (a) aBd advanced mandibular
residual ridge resorptioo (b). Note the ball ab\Jtments (c) and
i ntaglio surface (d)ol the overdenture prosthesis.
Sensory cues in eating seem to be vibratory or auditory. Because tions of dental implants, this approach was far more predictable. tn
a prosthesis is separated from bone by mucosa, the transmitted early descriptions, these implants demonstrated a success rate of
stimuli must travel through tissue much thicker than the 0.33 mm or 90% in the mandible and approximately 81% in the maxilla at up to
less that surrounds a root encased in bone. Thus, the patient with 15 years posttreatment.53
dentures i s probably handicapped by mechanical coupling between Since the early reports, sCientists and clinicians further refined the
the teeth and sensory elements that is inadequate tor the det ection process, which now exhibits a 5-year survival rate in e)(cess of 95%
of vibration or sounds.., As a result. the denture wearer's enjoyment in either jaw. This high survival rate led many clinicians to consider
of food is diminished. A diet for such patients logically would include this treatment modality as a new potential specialty of dentistry-a
foods with striking di fferences in crispness and texture. specialty devoted not to the management of a disease state but the
Brill et al'9·50 studied the role of touch receptors in the oral mucosa study of a device. This specialty is known as implant dentistry.
and their relationship to denture retention. Patients with dentures lost In contemporary dentistry, dental implants provide augmented
control or their prostheses when surface anesthesia was applied to retention, support. and stability to dental prostheses. They do not
the oral mucosa. Subsequent investigations supported the concept eliminate the need for appropri ate treatment planning, but they act
that exteroceptors of the oral mucosa influence the purposive as auxiliary devices to improve the anatomical, physiologi c. and
behavior of the muscles of the cheeks. lips. and tongue and thus psychologic prognoses of edentulous patients.
affect denture retention. Unquestionably , that intangible ability When patients present with partial or complete edentulism,
known as coordination is a primary factor in the edentulous patieni's the clini cian must consider the chief complaint of the patient and
success or failure with complete dentures. Because coordination how it relates to the clinician's ability t o address those complaints.
is closely related to neural perception, the soft tissues of the oral Patients normally identify concerns related to comfort, function, or
mucosa play a significant rote in the denture experience. One of the esthetics. Depending on the anatomy of the residual ridges and
challenges of treatment planning is to determine a patient's level of potential abutment teeth, clinicians may or may not b e able t o meet
coordination before rendering the mouth edentul ous. the specific demands of the patient.
Endosseous implants may be used for a variety of treatment options.
Implants are used individually to support overdentures (Fig 8·1 0),
Endosseous implants in combination with other implants to support partial fixed dental
prostheses (Fig 8-11), or in combination with other implants to
Although dental implants have been used in many forms tor centu support complete fi)(ed dental prostheses (Fig 8·12).
ries. objective outcomes in the form of defined clinical and histologic Implants can provide retention to removable complete dental
terms and the rigor of epidemiologic review was not demonstrated prostheses; tor example, overdentures use one or more implants
until more recently.•• In the mid-1960s. a new concept called osseo with some type of nonrigid connection to retain the denture. The
integration was introduced,52 which implied a direct union between mechanical connection can provide greater retention than a mucosal
living bone and an alloplastic implant. In contrast to previous genera- seal could provide i n a traditional complete denture. In situations
106 1
Physical Factors j
Fig 8-11 Adolescent paent treated tor awlsio� of

ti
mandibular anterior teeth. (a) Immediate posttraumatic

panoramic radiograph. (b) Posttreatment paooramic
radiograph. (c) Metal-ceramic implant-supported fiXed
partial dennrre used to treat partial eden
t fism. (d) The
u
prosthesis, once secured allows access ior hygiene.
,
Fig 8-12 Patient treated for a variant or ectodem1ar

dysplasia. (81 Clin cal pretreatment view. (b) Paooramic
i
pretreatmenl radiograph. (c) Elective edentuk1tion with

placement or extended-length ano elldOSseous root-form
Implants. (d and e) Fixed acryliC reSin-metal prosl/leses
designed as screw-retained restorations.
in which partially tissue-supported overdentures are designed, it is When a sufficient number ol •mplants can be connected, it is
critical that the implant provide retention only. If the implant is required possible to use implants to provide all aspects of retention. support,
t o provide vertical support for the prost hesis or lateral stability For and stability for a prosthesis . In this situation, a complete or partial
the prosthesis, the implant could become overloaded, which would fixed dental prosthesis is fabricated with direct connections to the
result in implant fracture o r loss of osseolntegration. When a partial endosseous Implants. The clini cian should detem1ine the appr opriate
tissue-supported overdenture is considered. the clinician must number and location of implants that will meet the mechanical needs
carefully evaluate all the factors that affect a traditional denture and of the prosthess . The patient may also have esthetic concerns, in
i
manage them to ensure long-term survival of the implant retentive which case the underlying bone volume must be sufficient t o allow
element and t11e dental prosthesis. implant placement in areas that are favorable for esthetic support of
107
8 i Conside rations in Treatment Planning
the prosthesiS. If the existing bone volume is not enough it must be

, surfaces that were used in earlier implant research. A"hough surface
augmented to allow implant placement in these critical areas. analysis values are similar to turned implant surfaces, these surfaces
When planning fixed dental prostheses in an esthetic area. do not appear to surmount a soft tissue response upon becoming
clinicians must have a thorough understanding of factors related to exposed. Long-tenn implications of these newer surfaces are simply
lip support, biomechanical considerations. available dental materials. unknown at present (Fig 8-14).
and long-term performance of endosseovs implants. The connection of endosseous implants to natural teeth is an area
Regarding biornecllanical factors related to endosseous implants, of controversy in implant dentistry. Early endosseous implant designs
clinicians must understand the number of implants necessary to included components to allow micromotion between the rigidly
support a prosthesis and how the distribution of these implants fixated implant and the prosthesis connected to it. Biomechanical
relates to potential forces that the implants must withstand. Scientific studies suggest tll a t tl1e abutment and prosthetic components
research has demonstrated that four implants in the maxilla and three connected to an endosseous implant have sufficient mobility to allow
implants in the mandible, if distributed ideally. can successfully retain connection between tooth a nd implant.""·"' A number of single-arm
fixed prostheses ... However. these studies also point out that this clinical case series have demonstrated adverse effects when teeth
number of implants leaves no margin for error because the implants are connected to endosseous implants. and it appears that the
need to be distributed ideally and adverse bone response around consensus favors implant connection to implants rather than implant
any individual implant covld jeopardize the long-term success of the connection to natural teeth.<l!i.ee
prosthesis. Most clinicians elect to place more than the minimum Although the earliest descriptions of implant-supported
number of implants to support fixed dental prostheses. An ideal prostheses used the implants only as support in mechanisms for
distribution or implants also eliminates the need for cantilevers. fixed complete dentures. it is now clear that implants are routinely
Although cantilevered designs have been described in the implant used as support for fixed partial dentures as well. Implants provide
literature and have shown long-term success. it is biomechanically support when distal extension is needed or when the potential
advantageous to avoid them if possible..s.!o6 primary abutment teeth are not ideal for traditional tooth-supported
Endosseous implants exhibit virtually no mobility within the fixed partial dentures. Teeth may not be ideal retainers because they
supporting bone. This relative rigidity is favorable for most dental may be unrestored and in no need of restorations, or they may be so
materials. especially ceramics. Prostheses need to fit intimately to the heavily restored that the likelihood of long-term clinical performance
un derlying implants to avoid stress at the implant-prosthetic interface. from these teeth is low. Endosseous implants therefore offer the
If clinicians elect to use cemented restorations, the cement may act clinician the advantage of absolute retention, support, and stability
as a stress-relieving agent; whereas screw-retained restorations for fixed partial dentures without involving any of the adjacent natural
include no stress-relieving agent and therefore depend upon intimacy teeth.
of fit. Scientific research in implant dentistry has failed to identify any Because endosseous implants are not subject to caries lesions,
specific occlusal material that consistently demonstrates improved they may be an ideal solution in patients with high caries susceptibility
.
performance over any other material.'' Consecuentfy, the interest in Ukewise, because endosseous implants are not supported in the
ceramic materials on endosseous Implants continues to Increase. bone by Ihe traditional periodontal mechanism. they are not subject
All-ceramic materials are particularly appealing because of their low to periodontitis; however, endosseous implants may be subject to
cost. high rigidity, and obvious esthetic advantages: however. their peri-implant mucositis or peri-implantitis. The exact mechanisms for
primary drawback i s an inability to correct for slight discrepanci es in these two processes remain unclear.
fit. When metal-ceramic prostheses demonstrate slight misfits, the Endosseous implants may be the only restoration option that
clinician or laboratory technicians can simply section the prosthesis meets the demands of the patient. When patients request fixed
and laser weld or solder it to establish an improved fit to the dental prostheses and lack strategically positioned natural teeth with
underlying implants. This is not possible with all-ceramic materials reasonable long-term prognoses, endosseous implants may provide
and is perhaps the reason they have not bean universally adopted the support for the requested prosthesis.
in implant dentistry, although there is currently much interest in their Some patients may have a number of clinical options to achieve
use. With considerable research, these materials could become the their desired treatment goals. When considering how endosseous
future of implant-supported prostheses'"""" (Fig 8-13). implants factor into the treatment-planning decisions of the patient,
Long-term success of dental implants has been documented the clinician is cautioned not to make implants the sole supporting
by a number of independent investigators, and short-term research mechanism for every dental prosthesis but to carefully choose
has so tar shown newer implant surfaces to be superior to older implants that allow substantial improvement toward the long-term
ones.&2 Most contemporary implants exhibit microtextured surfaces performance of the dental prosthesis.
that may be more plaque adherent than some of the polished metal
1081
Physical Factors j
Fig 8-13 Edentulous patient ptaM€<1 !()( treatment with implant-supported fixed
restorations. (a 10 c) Panoramic radiograph and wee-dimensional planning computed
tomography (CT) using surgical navigation. (4/AII�eramie restoration 1\ith a zirconium
oxide lramewolk and individually pressed zirconia crowns. (e) Occlusal view of final
restorations. (Q Radiographic appearance of rehabilitation. (Reprinted from Gutierrez·
Riera et a�· with pennission.)
Fig 8·14 Pert-implant bone lOsswith concurrent soft tssi ue mi�tion.

Despite the recession of the softtissues to the level of the moderately
rougheood surlace, minimal soft tissue inflammation Is apparent.
109
8 L Consi derations in Treatment Pl anni ng
Fig 8-15 (a to c) Mounted diagnostic casts on a semiadjustable articulator display interocclusat relationships.
Fisat). To provide an accurate record of maxillomandibutar relat ion

ships, diagnostic casts should be mounted on a semi ad j ustable ar
ticulator with accurate interocc lusal centric relation records made from
the cli nician s material of choice (Rg 8-15).
'
If the casts are ar1iculated for selective grinding prior to occlusal

adj ustment or for prewaxing to determine a desirable occlusal scheme
for proposed restorations. a facebow transfer along with records of
eccentric relation and centric relation should be made for articulator
adjustment. When the planned oral rehabilitation is extensive, a
pantographic recording of mandibular movements may provide more
sophisticated information for transfer to a fully adj ustable articulator.
Recently, computerized axiographic recording has been used to
show more detailed three-dimenSional movement of the mandible
to determine immediate Side shift. surtrusion. and detrusion of the
mandibular condyle. This is 11etpful to program semiadjustable and fully
Fig 8-16 A computerized axiograph recording Ulree-dimenslonal movement of
adjlrstable artiCulators used for cornprellensive rellabilijations in which
the mandible. The record ing can assist with programmi ng semiadjustable or tully
multiple restorations reestab6sh occlusal relationships (Fig 8-16).
adjustable articulators.
Mounted diagnostic casts are an immediate source of information
for evaluation of the following factors<S8:
• Occlusal relationship (interarch and interdental)

Bony protuberances that affect p r osthesis design
Diagnostic Casts •
• Soft tissue irregularities

• Tooth form and stnucu t re and the need for restoration or alteration
Diagnostic casts are prepared from accurate impressions made of • Tooth POSition (inclination. rotation, extrusion. spacing, and es
dental stone and can provide a permanent record of the configura thetic considerations)
t i on, distribution. and interrelationship of soft t issues teeth, and st atic
, • Maxillomandibular relationship and indications for changing the
mandibular position for study and treatment planning. They are a vertical and horizontal dimensions of occlusion
valuable addition t o the accumulation of diagnostic information. Neat, • Fee requirements for proposed design and fabrication of the resto
trimmed, defect-free diagnostic casts assist in provider-patient com rations under consideration
munication in planned treatment presentations and can be a moll
vating factor in the patient's acceptance of the proposed restorative I n addition to the aforementioned factors, diagnostic casts include
plan.6' Because casts provide necessary clinical and laboratOly data . other benefits. Casts are valuable visual aids for patient education,
a s do radiographs. biopsy specimens, blood tests, and urinalysis, a interdisciplinary professional or technical consultations, comparative
c01nmensurate fee for service should be charged and justified as the studies . and actual dinical procedures. Furthermore, as lasting
situation may warr ant Casts may be hand-related or affixed without
. records, diagnostic casts provide useful preoperative informatioo
permanent mounting to a device such as the Galetti ar1icufator (Setvis and are reliable for legal purposes.
110 1
Cytologic Examination and Clinical Staging Procedures J
Cytologic Examination and

Clinical Staging Procedures
Cytologic examination
II is the prosthodontist's responSibility in any examination and treat

ment-planning procedure to inspect thoroughly, by whatever means
necessary, the oral hard and soft tissues to ascertain the state of
their normalcy. The use of oral exfoliative cytology a s an effective
diagnostic technique for the detection of oral cancer has been con
troversial and much investigated since it was first used for the earty
discovery and treatment of cancer of the uterine cervix. Though cy
tologic diagnosis of pharyngeal cancer was attempted in 1860.69 Fig 8·17 Olmgren's line or maligr.ancy plane.
more recent work developed the smear procedure used in the di
agnosis of nasopharyngeal lesions.199 Conclusions from acceptable reported from different sources'5 The extent of prosthodontic restor
clinical studies state that (1) the results were excellent; (2) the pro· ative procedures and the time involved may be determined partially b y
cedure is not a substitute for biopsy; (3) the technique is a valuable this preliminary assessment. Thus, it i s important that the prosthodon·
adjunct. and positive results demand thai a source be sought: {4) a tist understand the systems used for clinical staging to communicate
knowledge of normal cytology is essential; (5) strict attention must adequately with medical colleagues and patients.
be paid to detail; and (6) the cytologist must be experienced in order Currently used systems of staging involve {1) diagnostic
to evaluate the oral smear. categorization of the lesion and extent of involvement. (2) surgical
A property obtained, fiXed, and interpreted oral smear will give a findings, and (3) histopathologic findings. These factors are used
positive result for clinically obvious carcinoma.70 Various methods as separate criteria or in various combinations, depending on the
and instruments have been suggested for obtaining an adequate procedures and personnel at the particular institutions involved.
specimen tor examination." Among these are cotton-tipped stick One system of grading carcinomas based on cell differentiation was
applicators (either dry or mOistened with normal saline). tongue developed in 1915.'" pubfished in 1920, and revised in 1925 on the
blades (either smooth or rough edged), a metal/plastic instrument, basis of experience as follows:
and a metal dental cement spatula. After analyzing the smears of
346 patients, Staats and Goldsby reported that the dental spatula o Grade 1: Cell differentiation or self-control ranges from 100% to
consistently provided the best sample of cells for examination." 75%; undifferentiation ranges from 0% to 25%
In routine examinations. the oral smear remains a questionable o Grade II: Cell differentiation or self-control ranges from 75% to
entity for detecting subtle tissue changes. Cytologic examination 50%; undifferentiation ranges from 25% to 50%
of benign lesions has not proved to be a signifiCant diagnostic o Grade /11: Cell differentiation or self-control ranges from 50% to
aid.72 Premalignant lesions such as leukoplakia also are not reliable 25%; undifferentiation ranges from 50% to 75%
for cytologic diagnosis.'�,. Thus, oral cytology, although never a o Grade IV: Cell di fferentiation or self-control ranges from 25% to
substitute f o r biopsy. is best used a s an adjunct to the diagnosis of 0%: undifferentiation ranges from 75% to 100%
visible oral lesions. It is a valuable diagnostic technique for follow
up examinations of treated patients and in cases of questionable As the grade category increases. so does the malignancy of
negative biopsies or sites inaccessible for biopsy. the neoplasm. With experience from surgical findings. this histo·
pathologic classification is a relatively simple and effective device for
staging. However, different tumor types (eg, eprthelial or connective
Clinical staging tissue) respond differently to certain forms of treatment, thus making
a clasSification o f this type more complex.
In patients with head and neck cancer, successful rehabilitation, in In 1933, Chngren proposed a classification incorporating the
cluding the prosthetic restoration of acquired oral and perioral defects. position of the tumor, the histopathologic findings, and the presence
is related to a lundamental knowledge of malignant disease and the or absence of metastasis.17 Tumors occurring anteriorly and inferiorly
prognosis of various forms of treatment. The American Joint Commit· to a line (malignancy plane) passing from the inner canthi downward
tee for Cancer Staging and End-Results Reporting (AJC) stated that and backward t o the mandibular angles are generally considered
the purpose of assessing the extent of disease before undertaking more benign and responsive to successful therapy. Those that are
treatment in each case or cancer is twofold: (1) selection of the most posterior to and superior t o the line have an early effect on structures,
appropriate treatment and 2
{ ) meaningful comparison of end results rendering prognosis less favorable (Fig 8-17). Subdivisions of these
111
8 iConsiderations in Treatment Planning
categories include medial and lateral designations: the lateral is an additional dimension to the treatment-planning process through
generally considered more favorable than the medial for successful their supportive and retentive roles in prosthodontic treatment. Their
therapy because of lymph drainage and potential metastasis. Thus, predictable survival is advar1tageous in areas or tooth and alveolar
Ohngren classified maxillary tumors accordi ng to their degree loss. Finally, clinical staging procedures for head and neck cancer of
of maJtgnancy: fer a perspective on treatment planning for patients who have over
come their disease. It should be realized that treatment planning is
I. Superior-Posterior-Medial (most malignant) an individualized composition tailored to the specific needs of each
II. Superior-Posterior-Lateral {malignancy about same as in I because patient and may be variable and best matched by an intom1ed. care
location of S-P-L is above the malignancy plane) or Anterior-Infe ful, and shared decision-making process.
rior-Lateral (location is balanced by ear1ier metastasis in the retro
mandibular nodes of A-1-L below the plane)
Ill. Anterior-Inferior-Medial (least malignant)
References
In Ohngren's classification, metastasis is indicated as"+" and the
absence of malignancy i s indicated as "0." Tl1e hiStologic degree 1.Atwood D. Some chnical factors rel{lte<l to rate of resorption of residual ridges.
J Prosthet Dent 1962;12:44 t-450.
of malignancy is classified as M1, M2, o r M3; tumors classified as
2. Applega te o. An evalu<�tion of the support for the removable partial Clenl\lfe. J
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Incorporating elements of the aforementioned systems. a more 4. Lang B. Kelsey CC (eds). lntemational WorkshOp on Complete Dentvre O<::clu·
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sophisticated staging system for primary lesions o f the oral cavity has
5. Augsburger R. The Gilmore attachment. J Prosthet Dent 1966;16:1090-1102.
been developed by the American Joint Committee on Cancef (AJCC) 6. Beokeu LThe influence of saddle classrflcatio n on the de&gn of partial remov·
in conjunction with the International Union Against Cancer (UICC). able rest orations. J Prosthet Dent 1953:3:�16.
7. CummerW. Partial denture seMCe.ln: Anthony L (ed). Ametican Textbook of
These committees have agreed to use a tumor-node-metastasis
Prosthebc Dentistry. Phrladelphia: Lea and Febiger, 1942:670-840.
system (TNM) to designate the primary lesions and the extent of
8. Kennedy E. Partial dentvre construction. Dent Items Interest 1925;47:23-35.
involvement. The general rules for staging with this system are based 9. Sl<inoer C. A classrfrcation ol removable par'tial dentures based upon the prin·
on (1) the anatomical extent of disease before any definitive therapy ciples of anatomy and phy siology. J Prosthet Dent 1959;9:240-246.
10. Tytman S. Theory and PracticeofCrown and Bridge Pr'osthesis. e<l3. S1 Louis:
has been rendered; (2) careful visual and digital clinical examination
Mosby. 1954.
of the oral cavity and the neck: and (3) surgical and pathologic 1 t. Dolder E. The oar jOin! mandibular denture. J Prosthef Den1196 t;1 t :689-707.
findings, which are not mandatory but may be valuable if available. 12. Vl(l A. Splinting bars and maxilary indirect retainers for removable partial den·
In the TNM system, the oral cavity is considered one anatomical area tures. J Prosthet Dent 1963; 13:125-129.
13. Btewe< A, MorrowR. Overdentures. St. Louis: Mosby. 1975.
extending from the lips t o and including the soft palate, uvula, and
14. Pour\d E. Cross arch sp6nting \IS premature extractions. J Pr'osthe! Dent
base of the tongue. Examinations in search of distant metastases 1966;16:1058-1008.
are left to the judgment of the clinician, and although confirmation by 15. Yurkstas A. The effect of miSsing teeU1 on masticat ory performance and
biopsy is desirable, it is not required (see chapter 14). efficrency. J Prosthet Dent 1954;4:120-123.
16. Kayser A. Shortened dental arches and oral function. J Oral Rehabil
The TNM staging system is becoming more widespread
1981;8:457-462.
and provides a universal vehicle for communication among all 17. Rud<:lK, O'Leary T. Stabilizing periodootally weakened teeth by usrng guide
professionals who may be involved in the treatment of patients with plane removable partial dentures: A preliminary report. J Prosthet Dent
cancer of the head and neck. 1966;16:721-727.
18. Overby G. Esthetic spl.nting ol mobile per'iodontally Involved teeth by vertical
pinning. J Proslhet Dent 1961;1 I: 112-118.
19. Overby G. Fixed-removable splinting techniques u1 periOdontics. Dent Clif1
Nortl1 Am 1964:197-211.
Summary 20. Simmons J. Swing-lock stabilization and retention: A preliminaryclinical report.
Tex Dent J 1963:81:10-12.
21. Sanell C. Feldman A. Horlzon1al pin Slll•nt for lower anterior teeth. J Prosthet
Patients presenting for prosthodontic treatment should be assessed Dent 1962:12:138-156.
for management versus treatment because tooth loss is a chronic :22. Sanell C. Mann A, Courtade G. The use of pins i n restorative dentistry. Part Ill.
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disease state that sometimes can be managed more effectively than
23. Mann A. Courtade G. Sanell C. The use of pl'ls In restorative dentistry. Part
treated definitively. Patients should be educated about their primary I. Parallel pin er tention obtained wijhovt using paralleling devices . J Pr'osthet
needs and the tradeoffs associated with treatment. In these cases, Dent 1965;15:502-516.
the approach of shared decision making between clinician and pa 24. Courtade G, Sanell c. Mann A. The use ot pins in restorative dentistry. Pan It
Pa�a!tel;ng inswment s. J Pros!het Dent 1965; 15:691-703.
tient should take place to make clear the progression of treatment
25. Courtade G. Methods for pin spinting the lower anterior te eth. Dent Clin North
with predictable outcomes. The patient's anatomy, bone, and soft Am 1g7o: 14:3-17.
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27. Ghckman 1. The s.gnificance of trauma from ocdusion .., periodontal disease: 55. Aparido C. Rangert B. Sennerby L. lmmedlate/earty loading of dental im
A new coocept. CDC CurrOent Comment 1969;1:25-28. plants: A report from the Sociedad Espanola <:te lmplantes World Congress
28. Ante I. The fundamental p<inciple of abutments. Micll State Dent Soc Butl consensus meehng in Barcelona, Spain, 2002. Clin Implant Dent Relat Res
1926:8:14-23. 2003;5:57-60.
29. Smijh G. Objectives of a fixed partial denture. J Prosthet Dent 1961;1 t: 56. Aparido C. Ouauani W, Garcia R, Arevalo X, Muela R, Fortes V.A prospective
463-473. dir>ical study on titanium implants in lhe zygomatic arch for prosthetic reha
30. Brlinemarl< Pl. Hansson 80. Ar:Jell R. et al. Osseointegrated implants in the bilitao ti n of the atrophic eclenlulous maxila with a follow-up of 6 mon tt\S 10 5
treatment or the edentulous jaw. Expetience from a IO·year period. Scand J years. Clin Implant Dent Relat Ras 2006;8:114-122.
Plast Reconstr Surg Suppl1977;16:1-t32. 57. carlsson GE. Dental occi.Jsion: Modern concepts and their application ln lm·
31. Branemark P. TI1e Osseointegration Book: From calvarium to calcaneus. Chi plant prosthodontics. Odontology 2009:97:8-1 7.
cago: Oui'ltessenoe. 2005. 58. Wolfart s. Eschbach s, Scherrer s. Kern M. Cli1ical outcome or three-unit
32. Ostlund S. The effect of oomplete dentures on the gum tissues:A histological lithium-disilicate glass-ceramic fixed dental prostheses: Up to 8 years results.
and histopathological investigation. Acta OdontOI Scand 1958;16: 1-41. Dent Mater 2009;25:863-71.
33. Kapur K. Shklar G. The effect of complete dentures on alveolar muoosa. J 59. Sailer I. Feher A. Riser F, Gauckler W. Luthy H. Hammer1e CH. Five-year clini
Prostl1et Dent 1963:13: t030-1007. cal results of Ztrt:OI'IIa frameworks for posterior fixed partial <:tentures. lnt J
34. Lytle R. Soft tissue displacement beneath removable partial and OCJ<J>Plete Prosthodont 2007;20:383-388.
dentures. J Prosthet Dent 1962: 12:34-43. 60. Blatz MB, Sadan A, Martin J. Lang B. In vitro evalualion of h s ear bond
35. Fisher A. Rashd i P. Inflammatory papillary hyperplasia 01 the palatal mu oosa. strengths ol res>n to densely-sintered high-purity 2irconium-oxi(Je ce
Oral Surg 1952;5: t91-198. ramic aHer tong-term storage and thermal cycling. J Prosthet Dent
36. Lambson G. Papilary hyperplasia of the palate. J Prosthel Dent t966:16: 2004;91:356-362.
63 6-6 45 . 6L Gutrerrez-Riera JJ. Flores AR, R•vera FZ. Salinas TJ. Endosseous implant
37. Bolender CL. Swenson RD. Yamane G . Evaluation of treatment ot inflamma rehabiMation of edentulism using high·strength ceramics and component
tory papillary hyperplasia of the palate. J Prosthet Dent 1965;15:1013-1022. prost11esis design. In: Duarte S Jr (ed). ODT 2010. 01icago: Quintessence.
36. Desjardins R. TOimarl 0. Etiology and management of hypem10bile mucosa 2010:11-30.
overlying the residual alveolar ridge. JProsthet Dent t974;32:619-38. 62. Balshe AA. Ecke<1 SE, Koka s. Assad DA, WeaverAL The effects o f smoking
39. Lask1n D. A SClerosing procedure for hypermobile edentulous ndges. J Pros on the survival of smooth· and rough -surface dental implants.lnt J Oral Maxa
that Dent 1970:23:274-278. lofac Implants 2008:23:1117-1122.
40. Laney W. Processed res�ient denture liners. Dent Clin North Am 1970:14: 63. Rangert B. Gunne J. Glantz PO. Svensson A. Vertical load cfrstribution on a
531-551. three-unit prosthesiS supported by a nat ural tooth and a single BrAnemark
�1. Campbell 0. The casl-aitJminum base denture. J Am Dent Assoc implant. An in vivo study. Clin Oral Implants Res 1995:6:40-46.
1936;23: 1264-1270. 64. Undh T, Dahlgren S. Gunnarsson K. et al. Tooth-implant supported fixed pros
42. Lunc:J®ist D. An a1um1num aloy as a denture-base materiaL J Prosthet Dent lhe$9s: A retrospective multicenter study. lnt J Prosthodont 2001; 14:321-328.
1963;13:102-t10. 65. Block MS. Lirette D. Gardine< D, et al. Prospective evaluation of implants con
43. Swartz w. Retention forces with different denture base materials. J Prosthet nected to teeth. fnt J Oral Maxillofac Implants 2002;17:473-487.
Dent t966; 16:458-463. 66. Chee ww, Mordohai N. Tooth·to-implant connectlOil: A systematic review ot
44. Boucher W, EPinger C. Lutes M, Hickey JC. The effects of a microlaye< of the lherature and a case report utilizing a new connection deSign. Clin Implant
silica on the retention of mandibular complete dentures. J Prosthel Dent Dent Relat Res 2009. Feb t3JEpub ahead of print).
t968;19:581-586. 67. ThOmpson E. Constructing and using diagnostic models. Dent Cln North Am
45. O'Brien W, Ryge G. Wenability of poly-(methylmethacrylate} treated with sili 1963:67-84.
con tetrachlo<ide. J Prosthet Dent 1965:15:671. 68. Laney w. Cnlical aspects of re movable pa11ial dentlO'e service. I n: Goldman
46. Desjardins R, W..,kelmann R. Gonzalez J. Comparison of nerve endings In H. Forrest S. Byrd 0 (eds). Current Therapy In Oenlistry. St LouiS: lviosby,
normal gingiva wlth those 1n mucosa covering edentulous alveolar ridges. J 1968:287-304.
Dent Res 1971;50:867-879. 69. Se!bach GJ. von Hamm E. The dinlcal valve of oral cytoiogy. Acta Cytol
47. Manly R, Pfalfman C. Lathrop 0. Oral sensory thresholds of persons with t 9 6 3 ; 7:337-345.
natural and artificial dentitrons. J Dent Res 1952;31 :305-312. 70. Rob1nson H. Oral exfoliative cytology: A reinforcement of diagnosis, not a di
48. Siirila H, Laine P. OcctJsal tactile threshold in dentur e wearers. Acta Odonlol vin ing rod. CDC Ourr Dent Comment 1 969; 1:22-24.
Scand 1969;27:19 3-t97. 7 t . Staats OJ, GOldsby JW. Graphic comparison of ;ntraoral exfoliative cytology
49. Bril N. Reflexes. registrations. and prosthetic therapy. J Prosthet Dent technics. ActaCytot 1963;7:107-ttO.
1957:7:341-360. 72. Silvem1an SJ. Becks H. Farber S. The diagnostic value of intraoral cytology. J
50. Bnl N. Tryde G, Sohubeler S. The role of exteroceptors in dentlO'e retention. J Dent Res 1958:37: t95-205.
Proslhet Dent t959;9:761 - 768. 73. Montgomery P. \1()1'1 Haam E. A study of the extol�tive cytology of orat leuko
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Synergies in Surgery. Prosthodontrcs. Biomate<iaiS. Chicago: Quintessence. 74. Umiker W, Lampe I, Rapp R. Oral smears 1n U\E> diagnosis of carcrnoma and
2008. premalignant lesions. Oral Surg t 960: t3:897-907.
52. Brfu1emarkP1. Adell R. Breine U. Hansson BO. Undstrom J, Ohlsson A. Intra 75. Greene FL. Page OL. Fleming I D. et aJ (eds). AJCC cancer Staging lvla�al. ed
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Plast Reoonstr Surg 1969;3:81-100. 76. BrodersA. The grading of carcinoma. Mrnn Med t925:8:726-730.
53. A<:tell R, Lekholm U, Rockier B . Brlinemark Pl. A 15-year study of osseo 77. Chngren L. Malignant tu mour s of tl1e mexilloethmoidal region. Acta Oto!aryn
Integrated implants in the treatment of the edentulous jaw. lnt J Oral Surg go1 SupPI (Stockh) 1933;19:79-112.
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54. Malo P. de Araujo Nobre M, Range<1 B. Short implants placed one-stage In
maxi lae and mandibles: A retrospective clinical study wllh 1 to 9 years of
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113
Chapter
Preprosthetic Surgery
Christopher F. Viozzi, DDS. Mo
reprosthetic surgery has enjoyed an enviable poSition in generation ago. However. these techniques are just as important
P the long histories of oral and maxillofacial surgery and

prosthodontics. Traditionally. preprosthetic surgery was char
acterized as the preparation of the oral cavity's soft and hard tissues
today as ever in the treatment of patients in whom they are indicated.
Despite the increased use of endosseous implant therapy, these
procedures remain relevant to and important for the ultimate benefit
t o receive complete denture prostheses. Over the years, and in the of completely edentulous and partially edentulous patients.
face of changing patterns of oral disease and loss of dentition. this
field of surgery and dentistry has changed, culminating recently in
the use of preprosthetic surgery as an integral part of the treatment
for implant prosthodontics. Although a number of traditional tech
Biologic and Functional Effects
niques are infrequently utilized as primary treatment today, the goal of Edentulism
of preprosthetic surgery remains the same now as it was many years
ago: to establish a suttable environment for the reception of a dental Tooth loss begins a process in which resorption of bone proceeds
prosthesis while maintaining the overall health of the patient's hard predictably. The placement of a prosthesis may affect that process
and soft tissues. This environment allows a prosthetic reconstruction significantly. The mandible tends to be affected with these resorp·
that provides function, preseNes oral health, and fulfills the esthetic live processes to a significantly greater degree than the maxilla for a
requirements of the patient and provider. variety o f reasons, including its overall functional surface area and Its
Surgical preparation of the oral cavtty for prostheses can be muscle attachments.1
characterized as either a primary or a secondary procedure. These The degree and rate of bone loss over time can also be affected
procedures can be further subdivided into those that address by general overall health, systemic factors such as osteoporosis and
soft tissues, those that address hard tissues, or a combination. renal dysfunction, local factors such as changes in the vascularity of
Regardless of the desired outcome, there remains a great the bone and soft tissues. and the use of certain medications such
necessity for communication and collaborative care between as bisphosphonates. Although the pattern of bone loss seems to be
the prosthodontist and the oral and maxillofacial surgeon. This is fairly prediCtable, the rate at which it occurs is quite variable among
essential in Ieday's practice, because changing disease patterns individuals. The duration of edentulism seems to correlate well with
have decreased the overall rate of partial and complete edentulism, the amount of resorption present.
resulting in contemporary providers who have far less experience Cawood and Howell described the pattern of resorption and
with preprosthetic surgery compared with their counterparts a bone loss in their classic articleZ: these relationships are shown in
115
9 i Preprosthetic Surgery
��'I\
J
IJ\ d j
S mm ISm
cn
\ 1\. \ \ \ � · -
lrciMJoramoo
;r 0
"'
i 10
I> n20
IOmmOrnm fY v VI
�
II "
GreaiUl).lllltinleklfiiiMn
c
I �r.)!j�.�.:j.j
a!
O
IO
IOIMI mm II
O
" " y 1'1
• • IV v " VI
Fig 9-1 (8) Maxillary hOrizontal measurements. Classiticatlon of anterior Fig 9-2 Modified cawood and Hol'tell classification of resorption. The micker line Illustrates tile
(b) and posterior (c) maxillary alvooJar ridge. (Modified Jrom cawood and amount of attached mucosa. which decreases with progressive resorpoti n. (Modified 1ron1 cawood
Howell' v�th permssi ion.) a;1<1 Howelf2wilh permiSsion.)
Rgs 9-1 and 9-2. The pattem of bon e loss has a significant impact implant placement; and (4) sati s factory resolution of esthetic,
o n treatment planning for reconstructive and rehabi litativ e oral speech. and masticato ry requirements.3 Although satisfying all of
surgery and prosthetic procedures. The overall objee1ives of these these requirements can be a signilicant challenge, an orderly history
procedures should i ncl u de th e following : and physical examination. development of a problem list. and a
goal-oriented rehabilitative treatment plan should allow the clinician
• 8imination of pathology to meet these objectives in the majority of patients. At all times ,
• Rehabilitation of infected or inflamed tissue r priate,
attention toward patients' overall systemic health is app o
• Reestablishment of maxillomandibular relationships in all spatial especially because many are elderly. Their cognitive status must also
dim ensi on s be assessed to ascertain whether they can reasonably be expected
• Preservation or alveolar ridge dimensions conducive to prosthetic to cooperate with the treatment plan and properly maintain and use
restoration the prosthetic restorations over time.
• Achievem ent of keratinized tissue coverage over load-bearing
areas
• Relief of bony and soft tissue undercuts
• Establishment or proper vestibular depth Primary Surgery
• Relocation of muscle attachments to allow for prosthesis flange
extension, if necessary
Simple extractions and alveoloplasty
Also important are the (1) establishment o f proper notching of
the posterior maxillary and palatal vault proportions; (2) prevention The removal of teeth in a patient who will have dental reconstruc
of pathologic fractures of the atrophic mandible; (3) preparation of tion is clearly a preprosthetic procedure. It is important for the oral
the alveolar ridge by grafting or other procedures for subsequent surgeon to consider this concept, so that this treatment does not
116 1
Primary Surgery J
a
�
a
� ......_
c d c d
Fig 9-3 Simple alveoloplasty. (a) Isolated, supererupted molar Fi g 9-4 AnteriOf maxtllary alveoloplasty after mulliple extractions. (a) labial bony
and ouUine of gi n gival inc isions. (b) Tooth remo-ted and soft tissue alveolar promine nce before extraction. (b) Mucaperiosteat llap reflected labially just
wedges excised. (C) Reduction of bony alveolai CJest completed. (d) beyond bony labial prominence, reduction of labial plate. and lnterradicular bony crest
Woolld sutured. (shadedarea representsbone removed). (c)Anterior view ol completed a!veoloplasly. (d)
Woo lld closed with suture placed across interradlcular crest.
compromise the definitive reconstruction. Even in cases of simple in infection rates. Once the tissues have been reflected, retractors
extractions. the concept that the eventual prosthetic treatment has a should be placed in an atraumatic way. without multiple removals
surgical component should not be lost on the operator. and insertions. Incisions should be made in positions that will not
Alveoloplasty is the contouring of the edentulous ridges to receive eventually overlie a bony cavity to prevent dehiscence. Avoidance
a prosthesis. It has been advocated in some form since the middle of unnecessa1y and overly aggressive periosteal manipulation and
of the 19th century and has been refined over the years. In its original musGte stripping is important.
form, alveoloplasty was performed by the surgeon or prosthodontist Alveoloplasty i s nearly always required to some degree after
on casts from which immediate prostheses were fabricated. This multiple extractions and occasionally after single extractions. tn
procedure often took a fairly aggressive approach: much o f the labial single extraction alveoloplasty, the mesial and distal aspects o f the
alveolus in the maxilla or mandible was removed. Undercuts were alveolus frequently require reduction because of bone morphology
eliminated, and the height of the alveolus was made uniform. The in the interproximal region. Access often can be obtained without
cast surgery was then dupliCated on the patient. While this probably a separate incision by simply elevating a small cuff of soft tissue
made insertion of the prosthesis more predictable, it may not have around the socket. The collar of bone, part.icularly on the mesial and
served the tong-term needs o f the patient in terms of bone quantity. distal aspects. usually can be reduced easily with rotary o r hand
Currently, radical atveoplasty Is to be avoided and a conservative instrumentation through a minimal flap (Fig 9-3). In cases of multiple
approach is appropriate. extractions. a flap is developed that is adequate lor v isualization at
Any operation to redefine the contours of the maxillary and least 1 em past the proximal and distal extent of extractions.
mandibular alveoli will result in postoperative bone resorption or Multiple instruments can be used, including hand files and rongeurs
remodeling. However, surgical procedures must allow o
f r proper use or rotary instruments. Undercuts and sharp locations are removed
of a prost11esis. The primary goal is to provide optimal ridge contour to provide a relatively unifom1 bone height. It is not necessary to
with a secondary goal of preserving osseous tissues. A broad aggressively remove bone to create "ideal" osseous anatomy.
alveolar ridge distributes forces well. The structures themselves Debridement of the extraction sockets to remove granulation tissue
are dynamic and are influenced by multiple stimuli that change the or abscess cavities, copious irrigation with sterile saline, and careful
form over time. Although this discussion focuses on the osseous reapproximation or the tissue margins allow eventual healing with
treatment. soft tissue principles should not be ignored. adequate ridge fom1 (Rg 9-4).
When estabfishing a soft tissue flap, certain basic surgical principles Radical alveoloplasty has been recommended in the past for the
should be followed. The development of an adequately sized flap treatment of severe maxillomandibular alveolar relationship problems,
for proper visualization and access is one of these principles. Short elimination of severe undercuts. eradication of neoplasm. or as a
incisions often are more traumatized by the retraction process, precursor t o radiotherapy. Currently. it is exceedingly rare that these
leading t o greater edema, more patient discomfort. and an increase situations are addressed with radical alveoloplasty. Maxillomandibular
117
because of access issues and because of the risk or bleeding and

hematoma formation in the floor of the mouth.
Palatal tori can range from small, incipient sessile growths to very
bulbous, multilobulated lesions that fill the bulk of the palatal vault.
Removal of palatal tori is not difficult and begins with reasonable
access. A variety of incisions can be used for access to tori,
all of which have broad-based designs. It is important that t he
mucoperiosteal flap be developed beyond the margin or the torus to
allow placement of protective retractors into the area where tile torus
a meets the native palatal bone. This protects the fragile tissues from
injury during removal (Rg 9-5).
A variety of techniques have been used to remove the bone. One
method calls for scoring the torus and then using osteotomes for
removal, but this risks unpredictable fracture of the palatal bone.
Rotary instrumentation ls usually the most successful way to remove
these outgrowths. Attention must be directed toward inadvertent
nasal cavity perforation and creation of an oronasal fistula. A palatal
splint should always be used to support the soft tissues of the palate
against the basal palatal bone to prevent hematoma formation
and to improve patient comfort. A splint also can serve as a guide
c d to determine the adequacy of osseous recontouring. Finally. if an
inadvertent nasal perforation occurs. a splint is important to support
Fig 9·5 (a) Preoperative view of a maxil!ruy tows with the midline Incision indicated
healing and prevent an oronasal fistula.
(dashed line). (I!) Removal of sa1\Ciioned elements ol tile torus with an osteotome. C)
(
Removal of posterior maxillary and mandibular bony exostoses also
Rnal smootlling of irregulartties wllh a rotary bur. (d) FinaJ ctosure.
is problematic, a s they may occur in a large variety of morphologic
sizes and shapes. Surgical removal should display careful attention
toward avoidance of injury to the thin overlying mucosa.
relationship problems can be more reasonably addressed with Maxillary labial frenectomy
orthognathicsurgery, withouttheprophylacticremovalofdentitionprior
to radiotherapy. The labial frenum exists as a confluence of muscle attachments and
It is frequently the case. and patients should be advised. that mucosa onto the labial aspect of the midline maxillaryalveolus. In den
removal of multiple teefh with concurrent alveoloplasty results in tulous patients, the frenum can cause periodontal compromise by pull·
an osseous wound of significant length. This has the potential to ing the maxillary gingiva away from the central incisors. It becomes a
form secondary areas of tissue irritation from bony protuberances problem in the edentulous patient who has had progressive loss of
created during the healing process. Secondary or spot alveoloplasty alveolar height because it gradually approximates the alveolar crest.
is appropriate after a suitable 2- t o 3-month period of healing and A maxillary prosthesis placed in a patient with a prominent maxillary
can be done In most cases very judiciously and easily. labial frenum is fraught with the potential for irritation a n d seal loss from
movement of the prosthesis ffange.
The simplest procedure to exCise a maxillary labial frenum is to place
Removal of tori and exostoses straight or curved hemostats on the frenum at the level of the mucosa
and excise below them to the level of muscle. A diamond-shaped
Tori are abnormal growths of histologically normal bone that tend wound results. After hemostasis is obtained, the lateral aspects of the
to project into the floor of mouth or hard palate. They are common. wound can be undermined with tenotomy scissors. The mdsection
affecting up to 14% of the edentulous population. Interestingly, 28% of the wound initially is closed by passing a suture through the lateral
oi patients have both palatal and mandibular tori.• aspect of the mucosal margin. The suture should grasp the periosteum
The problem with these structures is twofold: (1) The overlying in the midline and then pass back through the opposite mucosal
mucosa is quite thin. especially at the apex, and easily traumatized: margin. As the su ure is tightened, the tiSSLIS is inverted into the depth
t
and (2) the tori can create instability in the prosthesis. Tori are best o f the wound and a neovestibule is created. The superior and inferior
treated surgically by removal with rotary instrumentation to restore sections of the wound are then closed. Carbon dioxide (COJ laser
normal anatomy. The removal of mandibular tori can be difficult excision or radiofrequency ablation unrts also can be used for excision.
118 1
Primary Surgery J
/
1'
c a
Fig 9·6 Hyperplastic reviSion of superior labial frenum. (a) Preoperative appearance of Fig 9-7 Z plasly correction or hyperplastic maxillary labial frenum. (a) Z incision: long
-
frenum with a broad base to lip. Incision outlilled. (b) Vertical incision after submucosal bar (2 to 3) parallel to and Uuough long axis of frenum. Unes 1-2 and 3-4 are eQual In
dissection assuming, under tension. a diamond-shaped configuration. (c) Fibrous le ngUt (b}TransposHioo of mucosal llaps 1-2-3 and 2-3-4 completed.
frenum and submucosal tiSStle excised. Traosfixing suture placed from one mucosal
wound edge through the perlilsteum of the nasal spine and exiting through the opposite
mucosal margin. This suture is tied i nttially. (d) Placement of additional sutures to
close the wound.
The instrumentation used is less important than the operator's attention frenum. Hemostasis is achieved, the lateral aspects of the wound
to detail, although some reports suggest the laser exciSion may have are undermined. and the wound is closed. At all times attention .
some advantages in terms of postoperative discomfort' (FIQ 9-6). must be directed toward prevention of injury to the surrounding
The Z-plasty technique rearranges the hyperplastic maxilla1y labial vital structures, including the submandibular duct. lingual nerve
frenum, thereby lengthening the tissues. This can be combined with branches, and genioglossus muscle. A floor-of-mouth hematoma is
an excisionaltechnique. Some relapse is expected with all o f these a possible complication of this type of excision and must be dealt
techniques. The degree ot relapse depends to a certain extent on with aggressively it i t occurs.
the thickness of the tissues and the ability o f the clinician to create a
neovestib ule as described above (Fig 9· 7).
.
Buccal and muscular frenectomies
Lingual frenectomy The premolar labial areas of the maxilla and mandible are frequently
noted t o have muscular insertions. These occasionally can cause
The lingual frenum rarely interferes with use of a prosthesis and prosthetic problems related to dysfunction or di slodgement . Sur·
therefore is not generally a preprosthetic concern. However, it fre gical removal involves a transverse incision through the frenum to
quently causes problems with tongue protrusion and can be a so· the pe1·iosteum. which creates a di amond s haped wound that can
-
cial embarrassment. mostly for younger patients. but also tor some be closed longitudinally. If the muscle attachment is fairly high on
adults. Ungual frenectomy is readily accomplished by a number of the alveolus. a transverse incision can then expose the muscle.
means including excision, laser ablation . radiofrequency excision. The muscle can be detached just above the periosteum and resu·
and tissue rearrangement (eg. Z-plasty). lured higher in the vestibule. The total submucosal vestlbuloplasty,
In its simplest form, the frenectorny can be accomplished by described later, is an extension of thi s type o f procedure tor a
providing suitable infiltration anesthesia, followed by lysis o t the broader muscle attachment.
119
9 i Preprosthet ic Surgery
a
l'-
b
il �
L.1
a b
Tongue
,
c d e
Fig 9·1o Submucosal vestibuloplasty. (a) Midllne incision through mucosa only !rom
lip to attached alveolar mucosa. (OJ Blunt submucosal dissectiOn d1rected toward
zygomatic-maxillary buttress. (CJ Cross sectOn
i representing the two tunnels created
d by submucosal and supraperiosleal dissection planes. (d)Appearance of cross section
alter muscles and connective tissue are excised lrom periosteum and septum between
4 tunnel s has been removed. (e)Superior reposito
i ning of vestibular depth and fixation ol
mucosa to alveolar periosteum with surgical splint secured with ciret1mpa1ata1 sutures.
3
2
Revision of scar contractures of the vestibule

Fig 9-8 Mandibular vestibular revision wilh free oolatal mucosal grahs. (ill Incisions
Many procedure s can result in scar contracture within the vestibular
outlined at donor site. Mucosa is lett intact over midline, which hastens healing
and reduces morbidity. (b) Two palatal grafts. (c) Lowllf vestibule compromised by tissues. Very small areas of contracture can be treated si milan y to
alveolar booe reSO(j)tion and high muscle attachments. (d) Placement and sutwing o l the revision of frenal attachments described above, but these tend
grafts alter supraf)e(iosteaJ disseclioo. (e) Cross section of graft ed slle with fiXatiOn
of grail by means of surgical splint: periosteum (1), palatal graft (2). splint (3).
circummandibular suture (4).
to undergo frequent relapse. For larger wounds, excision with recon·
·
struction techniques such as palatal mucosal or spl il thickness skin
grafts may provide a better result (Figs 9·8 and 9-9).
Ridge extension procedures
In the maxilla, the submucosal vestibuloplasty can gain ridge exten

sion in cases where bony resorption is mild to moderate but soft tis
sue attachments preclude adequate retention. Care must be taken

to avoid upper lip distortion; therefore, adequate lip length must be
present to perform this procedure. Local anesthesia is used in a tu
mescent technique to allow hemostasis and proper visualization of
c
t he tissue layers. A midline vertical incision is made in the labial mu
cosa, and two separate levels of dissection proceed laterally one
supraperiosteal and one supramuscular. The inteNening muscle is
.
Fig 9·9 Mandibular vestibular exta1sioo and tov1ering ol floor of mouth with split
i kness skin graft (a) Cross section of body of mandibl e with incision sites marked
thc excised through the small incision, creating an area in which the peri·
(arrows). (b) Refleclion of buccal and lingual mucosal flaps showing supraperiosteal osteum is immediately subjacent to the oral mucosa without inter
dissection with detachment ot buccinator (1) and mylohyoid muscles (2 and 3) and vening muscle attachments.• The wound is then closed so that the
placement of inframandibular han1mock sutures (4) to engage mucosa. mylohyoid. and oral mucosa adheres directly to the periosteum and possi bly gains
buccinator musCles. When suture is li ghtened and lied, mucosal flaps and muscles are
some vertical increase in sulcus depth (Fig 9-10). It is important that
fiXed at a more inferior position. (c) Adaptation and fixation of skin graft to mandibular
periosteal su�ace with a splint: periosteum (1), skin grall (2), splint suture (3), and the prosthesis be inserted then to keep the mucosa elevated until it
circummandibular suture (4). adheres. The prosthesis should be fixed to the maxilla with palatal
120 1
Secondary Surgery J
a
I!! b
1 1
b
c a
Fig 9-1 1 Maxillary veslibuloplasty with Skin graft (buccal Inlay technique). (a) Cross Fig 9-12 Up switch vestibuloplasty performed with a catheter secured with
section of maxilla showing diminished ves�bular depth and incision sites (aqows). {b) transcutaneous sutures extraorally (a) and intraorally (b) to auow preservation of U1e
Relfection of mucosal lfaps and su praperiosteal dissection of muscle attachments and disseclion 3Jld maintenance ol alveolar height. The arrow in (b) indicales the free edge
submuoosal tissue. (c)Skin gfaft in place and sutwed to mucosa ofcheekand alveolus ( 1): of the vestibuloplasty dissection. Healing by secondary Intention is the anliclpaled mode
grall adapted and fixed to periosleLITl by surgical splint !2). 1Y11ieh has accentuated rolled of tissue coverage. (Modified from Beime' with permission.)
peripll€ry to create an illlaid epiU1elial pocket: splint Is fixed vAth circumpalatal sutures (3).
screws or transpalatal suspension wires and removed 10 to 14 days proceeds. Insertion of the prosthesis at the end of the operation aids
postoperatively (Fig 9-1 1). in hemostasis and, in cases where the prosthesis fits well. seems to
Placement of a prosthesis as a surgical stent to maintain tissue decrease pain, particularly in the maxilla. Unfortunately, poor1y fitting
in its reoriented positions is very important. Alternative techniques immediate dentures can have the opposite effect.
can include the placement of a large, red rubber catheter in the Ideally, the patient will have close postoperative follow-up by both
mandibular vestibule, secured with percutaneous sutures to a bolster the surgeon and prosthodontist. The surgeon must instruct the
dressing on the skin of the chin (Fig 9-12). The stent i s then left in patient to keep the dentures in place at all times for the first 3 to
place for 1 0 days to keep the mobilized tissue margins in place. In 5 days after surgery, with the exception of frequent short removals
any event, a fair1y high degree of relapse should be anticipated. and to irrigate the oral cavity. Reinsertion within 15 minutes allows the
overcorrection should be the rule at the initial surgery. prosthesis to be placed before edema causes difficulties. The
prosthodontist should expect to see the patient shortly after surgery
to evaluate the fit and occlusion and adjust as necessary. Soft relines
Immediate denture considerations may be necessary early on after insertion. Although the immediate
provisional prosthesis can be helpful in terms of pain management,
The placement of an immediate prosthesis can b e a great advantage surgical guidance. patient comfort, and immediate social function.
to the patient. Many patients feel this is an absolute requirement these advantages must be weighed against the additional time and
given today's society; they will not present in public without some expense for the patient.
form of dentition. In addition to the social advantages, immediate
insertion also provides certain surgical benefits. It is important that
the patient realize that immediate prostheses are not necessarily
permanent units: many of these dentures are merely interim pros Secondary Surgery
theses. Failure to advise the patient about this can easily lead to
misunderstandings.
Diagnostic casts should be used to determine the need for or extent Removal of papillary hyperplasia of the palate
of osseous recontouring. ConseNatism should be the rule because
secondary procedures may be required subsequently. The denture Papillary hyperplasia of the palate i s a common, benign condition
or a clear acrylic resin stent can be an excellent guide to the surgeon that presents as a reddened, cobblestoned, or velvety appearance
for appropriate removal of undercuts and protuberances a s surgery of the palate in patients who typically wear their maxillary prosthesis
121
9 iPreprosthetic Sur gery
a b a b
Fig 9-13 (a) liP switch vestibuloptasty with sup raperosteal dissection (arrow). (b)
l Fig 9-14 Up swit cll vestibuloplasty with subpetiosteal reflection (arrow) and
Suturing of the free edge of the flap to lhe new depUi of U1e vestibule. (Modified from traJ1SposiUon (a) to the adjacentlree mucosal flap to increase the depth ol the vestibule
Beirne' wi th permission.) {b). (Modified from Beirne' wllll permission.)
constantly. The condition is strongly associated with Candida infec Ridge extension procedures
t ion. Treatment of the patient with antifungal medica tions such as
fluconazole and treatment of the prosthesis, which may require dilute Ridge -extens ion procedures have a common goal of incre asing the
hyp och lorite solution or possibly replacement of the denture. can amount of hard tissue available for prosthesis stabUity by altering
eradicate this pro blem It is essential to instruct the patient regard
. the anato mical positions of the attach ing soft tissues and muscles.
ing the importance of nightly removal o f the prosthesis and proper The decision to use the following procedures is predicated on the
hygien e measures. In more severe cases and in those patie nts who presence of at least a minimal amount of basal alveolar bone; a lack
have funga l eti ology, removal of the hyperplasia by rotary instrumen thereof is an indication to consider bony augmentation of t11e alveo·
t a tion radiofrequency exci sion or ablation. or laser ablation may be
, Ius (generally combined with soft tissue revision). However, because
necessary. If this is done. preservation of the periosteal tissues is o f the increased use of endosseous implants, ridge extension proce
very i mportant to allow for healing without scar formation. dures are now less frequently used.
In the maxilla without adequate fip height, a true vestibuloplasty
can be done. In this procedure. local infiltration is performed, and an
Removal of epulis fissurata incision is made at the junction of the attached and loose mucosa.
A su praperiost eal dissection proceeds superi orly in the maxilla and
Epulis fissurata, or tubular growths of fibrous enlarged tissue, are inferiorly in the mandible until a vestibul e of suitable depth IS noted .
most common in the labial mandibular vestibule but can be seen The edge of the flap is sutured to the depth of the neovestibule (Rg
elsewhere. They are associated with ill-frtting mandibular prostheses. 9·13).
In some cases. the lesions can be massive and may be used by pa The decision of whether t o graft mucosa or allow secondary
tients to create rete ntion. Chronic denture movement and Candida epithelialization of the wound is unclear. The use of split-thickness
infection are suspected etiologies. There is also anecdotal evidence skin grafts, as described in t he early 1900s by Esser,• or palatal
that females are more commonly affected than mates. mucosal grafts, as described by Hall in 1970.'0 seems to decrease
Treatment involves supraperiosteal excision with prima ry repair, or the tendency to relapse but increases donor site morbidity. The
possible split-thickness skin or muco sal grafting for larger epulides. palatal graft donor site morbidity can be lessened by providing a
The procedure can be done with scalpel excision, C02 lase r or . surgical stent and by preserving the midline maxillary mucosa to
radiofrequency techniques. In a study of 20 patients who were avoid completely stripping the palate. Some permanent scarring
treated with C02 laser without closure or grafting and allowed to is inevitable with the harvest of a split-thickness graft of skin. The
heal by secondary intention, the authors reported good results with , ju dicio us choice of donor site can avo i d this problem. For instance.
partial reepithelialization within 14 days and comple te healing within a split-thickness graft irom areas such as the inner upper arm,
4 weeks.8 Prosthesis replacement is nearly always needed because where many patients have redundant skin, can be harvest ed . The
the patients often have undergone multiple adjustments (by clinician recipien t site can then l:>e excised in a fusiform manner and primarily
or self) in an effort to create a proper fit. Fungal infecti on treatment is closed with an actual improvement in skin tension and contours.
as described above. The same procedure can be done in the inguina l area in some
patients (Fig 9-14).
122 1
Secondary Surgery j
Fig 9-15 A oertotome insti\Jment (a) severs tile

periodontal ligament (b).
A common problem in the mandible involves a lack of lingual glasses. All of these suffered from problems such as migration, lack
vestibular depth because of high musde attachments, sometimes of bone formation, and lack of resorbabilily. thereby precluding later
combined with labial vestibular depth problem s . The labial problems implant placement.
are trE'.ated as described above, but the lingual attachments of the With an increased emphasis on eventual implant treatment, the
genial muscles and mylohyoid must be lysed and lowel'ed. An inCision preservation of alveolar bone at the time of tooth removal has been
can be placed at the junction of the attached and loose mucosa on increasingly emphasized. Conservative surgical techniques using
the lingual of the mandible. Dissection at a suprapenosteallevel allows periotomes and immediate grafting of extraction sockets have recent ly
access to t he muscles and othel' structures (eg, sublingual glands) in received more attention.
t h e floor of the mouth. Once these tissues are bluntly dissected free, the Periotomes are instruments with a flat, thin blade that can be
soft tissue flaps are inverted into the depth of the neovestibules on the inserted longitudinany along the tooth root to sever the periodontal
labial and lingual aspects. A variety of techniques can be used to keep ligament attachments between bone and thus facil tating
root,
i
the flaps in place. including placement of a prosthesis with extended atraumatic extraction and preservation of alveolar conto ur. In practice,
flange that is wired in place with circummandJbular wiring technique. severing the coronal one-third of these attachments is generally
Another o ption is transmandibular suturing followed by placement of sufficient to allow delivery of the root because more than one-half of
a large, red rubber catheter in the labial and lingual vestibule, secured the supporting fibers have been severed due to the conical shape of
to the skin with transcutaneous bolsters such as dental cotton rolls. the roots (Fig 9-15).
Because dental implants have decreased the use of mandJbular Immediate extraction site grafting involves careful. atraumatic
vestibuloplasty procedures. extension of flanges into the lingual a nd surgical extraction with pr eservation of soft tissue integrity. The socket
labial tissues is rarely needed. I f they are need ed. the lingual muscle is debrided gently of any granulation tissue. and gentle curettage of
insertions from the genial muscles and mylohyoid or the labial muscle the socket walls can proceed. AggreSSive curettage is not appropri ate.
insertions can be lowered at the supraperiosteal level and the areas Del'nineralized, freeze-dried human bone or bovine bone products are
grafted and prosthetically supported until healed. From a surgical placed into the socket, and a collagen membrane or collagen socket
management standpoint, it is critical to expect signifiCant floor-of plug is placed t o ccntain the graft. Immediate provisional placement
mouth edema and to prevent hematomas that could lead to airway can also help contain the graft, and an ovate pontic design helps the
compromise. Perioperative glucocorticoids are used routinely in tissue to heal in a manner conducive t o eventual good esthetics.•'
these patients.
Ridge augmentation procedures

Ridge preservation procedures
The aforementioned ridge extension procedures are only useful in
The original concept behind ridge preservation was preparation for patients in whom the bone quantity and quality are sufficient t o ere·
complete denture prostheses. A multitude of alloplastic materials were ate adequate load-bearing surfaces once soft tissue problems are
tried, including hydroxyapatite, tricatcium phosphate, and bioactive corrected. When bone quantity and quality are inadequate, recon·
123
9 L Preprosthetic Surgery
Fig 9-16 MandiOOiaf recoostruction due to se>$e mandibular atroph.y (a) Preoperntive patient presentatloo. (Ill lntraot'al
surgical view o l pilot osteotomies lor Implant placement. (c) lntrOOt"al view or Implants placed supracrestally Ill alklw grafting
wiUt autogenoos bone. (dj Panoramic radiograph or posiOperatillll reconsbuctiOn. (e) lntraotal V!m•1 o l prosthetic rehabllitati011.
(f) Postoperative f)lesentation.
Fig 9-17 Cadaveric mandible tray

ri gidly fixed to an atrophic mandible
witlt autogenoos cancellous bOne
sandwiched between native and
cadaveric booe. Note that bur holes
have been created to facilitate the
rcvascularizatlon ol the graft.
struction can be perform ed to replace deficient osseous tissue. All fixation techniques proved problematic. Immediate endosseous im
procedures are pnedicated on relatively normal positions of the basal plant placement with autogenous graft placement seems to provide
bone in the maxilla and mandible. Craniofacial defonmities that ren a more predictable result.
der this relato
i nsl1ip grossly abnormal at baseline are accentuated Onlay grafting with autogenous bone can be done transorally or
by the resorptive process of bone loss and, although well tolerated ttansoeNically. Cutaneous incision placement has a lower incidence
in dentulous patients, may be poorly tolerated in the presence of of infection and graft loss. A variati on on this t echnique is credited
lost dentition. to Marx et al, who described a tent-pole technique of placing
multiple implants in the atrophic mandible via a submental 1ncision
Mandibular procedures and packing cancellous cellular marrow from the hip combined
with platelet-rich plasma into the defect. The implants support the
A number of mandibular techniques have been described. Onlay overlying periosteum. thereby promoting less resor ption of the graft
grafting with alloplastic or autogenous tissues to increase ridge itself" (Fig 9-16).
height was f requently used in the past. but long-term results proved Quinn et al described inferior border grafting of the edentulous
poor because of resorption of grafts from soft tissue (particularly mandible, which uses a transceNicaJ approach to place a hollowed·
periosteal) contraction o r m igration of the materials. The wire osteo out cadaveric man d ibl e filled with autogenous cancellous marrow
synthesis involved in t hi s procedure prior to the use of rigid internal at t he Inferior border'3 (Fig 9-17). Following consolidation, implants
124 1
Secondary Surgery J
•
•
•
•
•
.
' .._______
a a b
:-::-=-="�::':�dJ
·-
--- - · ---
.,
.....__,
Fig 9-18 (a) Sinus elevation procedure with an inward uap door lracture ol lateral Fig 9-19 Maxillal)' ridge augmentation w!U1 lnter·posltiOflal mac crest block graft. (a)
sinus wall (arrow). (b) Gfalt material Is placed on the 11001 ol Ule sinus (arrows). The Le Fort I maxilla!)' osteotomy wiUl graft irlte�posilion (1). Cortical surface of graft (2) is
sinus linng
i should not be perforated during the elevation o f the bone. (Modified lrom positioned toward nasal lloor. Fixation is accomplished with transosseous wires and
Beime' wilh permisslon.) surgical splint secured by skeletal fixation (3). b
{ )Atrophic maxilla!)' ridge (solid n
il e) and
result after augmentatiOfl (dc«ed line). As a resull of the deCrease in interarctl distance,
the mandible no longer autorotaled (so/KIIine) and assumed normal posture (dottedline).
(Modified from Beirne' with permission.)
are placed through the native mandible into the grafted area. This In the posterior maxilla. extensive pneumatization of the maxilla can
procedure strengthens the edentulous mandible considerably with encroach on the alveolus. rendering implant placement impossible
the significant addition of bone in the atrophic saddle regions. The without sinus grafts. Sinus grafts are performed through a lateral
one disadvantage of this technique is that the graft does not replace bony window created lransorally. Every attempt is made to presetve
the lost alveolus at the superior border of the mandible but instead the integrity of the sinus membrane, and it is elevated, sometimes
adds bone at the inferiOr border, and the increased interalveotar along with the bony window, to torm a pocket in the base ot the
freeway space does not Change. Even so, this technique seems sinus where grafting can be performed. The procedure creates a very
t o work very well in selected patients and has a low incidence of favorable site for grafting that is highly vascular and well ccntainecf.
problems. Many materials have been advocated for use in the sinus. including
A number of osteotomy techniques have been described in autogenous bone. allografts, xenografts. alloplasts, and recombinant
which the atrophic mandib le is sectioned and the segments are bone morphogenetic protein products.I$ All ot these materials have
positioned in such a way that the overall bony height i s increased. been reported to carry high success rates, making their selection
These osteotomized segments are pedicled on the periosteum to somewhat contusing. After grafting, immediate placement ot
maintain viability. Issues have included problems with maintenance implants is possible if a minimal amount of vertical bone is present to
of vitality of the segments because of minimal blood supply and affow initial stable placement, LJSually at least 4 to 5 mm between the
neurosensory disturbances; therefore, these procedures are very alveolar crest and the base of the sinus7 (Fig g-18).
rarely performed today. lnterpositional iliac crest placement via le Fort I osteotomy is useful
in patients with severe alveolar atrophy who have a reasonable palatal
Maxillary procedures vault. This procedure is more complicated but allows simultaneous
correction of not only the vertical problems but anteroposterior and
In the maxilla, the decision to augment the bony skeleton is more transverse issues as well. Again, some controversy exists regarding
complicated. Onlay grafts secured by implants at the initial surgery whetl1er to place implants immediately or during a second surgery.
or rigidly fixated with screws or plates to allow secondary implant There is always some element ot skeletal relapse. and placement
placement can work well in the patient with alveolar ridge atrophy during a second surgery typically allows more accurate positioning
and shallow palatal depth.'5 There is some ccntroversy regarding of the implants (Fig 9-19).
whether the implants themselves should be used to secure the graft
for tong-term success.••·"
125
9 LPreprosthetic Surgery
Fig 9-20 TranslOCation of alveolar vOlume witliOIJt bone grafting.

(a) Initial presentation of patient with large mandibular alveolar
defect (b) Reflection of tissue revealing extent of hard tissue
defect (c) Application of distraction device with osteotomies.
(d and e) Full range of d istraction device and closure ol mucosa
fYI/er the device witll distraction actiVator access.
Alveolar distraction osteogenesis is similar to that seen in normal nondistracted bone subjected to
implant placement.'9 Typically, implants can be placed at the time
Alveolar distraction osteogenesis has gained popularity recently as of distractor removal, thereby requiring no additional surgeries
an excellent alternative to the techniques described above. This pro· beyond what would be needed normally. A number of manufacturers
cedure has a number of advantages. the most important of which produce a wide variety of distractors that can be chosen based on
is that it does not require a donor site with the attendant morbid· the size and geometry of the defect.
ity. Unlike the other augmentation procedures described. this i s not
constrained by a lack of available soft tissue or by the memory of
the soft tissue envelope. which leads to pressure on the grafts and
at least partial resorption. The distraction process gradually creates Orthognathic Surgery
more soft tissue, thereby addressing the soft tissue matter in a pre
dictable manner. The treatment of the edentulous or partially edentulous patient with
The basic surgical technique involves the creation of a transport abnormal craniofacial relationships is complicated by the "preresorp·
disc of bone that remains attached on at least one surface to lion• maJpoSitioning of the bones. If the prosthodontist determines
vascular periosteum. A suitable distractOi' i s chosen based on the that these structures will compromise the prosthetic result, orlhog·
size of the defect and secured. After a 5· to 7·day latency period, nathic surgery should at least be contemplated to correct this prob·
activation of the distractor at a rate of 1.0 mm per day is performed. !em. This is often a major undertaking. and the patient's ability to
The rhytl1m can be once per day or more frequently. as studies have undergo such a procedure should be thoroughly evaluated.
not clearly shown differences in outcome with different distraction PrediCtable surgical maneuvers are available to the surgeon
rhythms. Once adequate positioning Is noted, the distraction is to correct anteroposterior, transverse, or vertical problems, or
stopped and the appliance maintained for 6 to 8 weeks to allow for combinations of these problems. In the maxilla, the Le Fort I
consolidation of regenerated tissue. Then the appliance is removed osteotomy with or without segmentation and with or without bone
and the implants are placed (Fig 9·20). grafts typically can address most issues. Segmental osteotomies
The regenerate bo ne is highly vascular, allowing predictable occasionally can be added to the maxillary procedures if indicated,
osseointegration of Implants. Peri-implant bone loss over time but maintenance of vascularity complicates these. In the mandible,
1261
References J
a number of procedures are typically employed, with the bilateral goals. Soft tissue and bony procedures have an essential place in
sagittal split ramus osteotomy the most frequently used. Other this treatment sequencing. More specifically, there are instances
options include vertical ramus osteotomies and C or L os teotomies. in which soft and hard tissues should be manipulated to provtde
Close cooperation between the prosthodontist and surgeon a sound and conditioned foundation for continued prosthodontic
beginning in the treatment-planning phase is critical. The goals of the treatment. In the last several decades, these procedures have been
prosthodontist must be clearly communicated to the surgeon, and reduced in number because of the prevalence of dental-implant
the surgeon must be able to surgiCally deliver a result that benefits treatment. Nevertheless. the clinician should become familiar with
the prosthodontist's treatment. Presurgical treatment planning must these procedures because they may be preparatory for prosthodon·
involve cast surgery to accurately quantify the amount of spatial tic treatment. regardless of the modality chosen. Furthermore. many
change desired by the prosthodontist. It is then the surgeon's duty of the bony-based procedures provide an augmentative role in opti·
to determine if those movements are feasible. The use of the casts mizing the outcome of repositioning and offer a more robust founda·
to fabricate intraoperative surgical guide stents is mandatory. lion for prosthodontic treatment. The next few chapters outline more
In the maxilla. a typical surgical correction of the severely atrophic specific applications such as bone grafting and implant site develop·
max.illa begins with a low incision near the reflection of the attached ment to provide this valuable service.
and loose mucosa. Higher inCisions are likely to encounter the piriform
region of the nose and risk causing injury to the nasal mucosa. The
maxillary bone quality is often quite poor. Careful technique is used
to create an osteotomy that w.ill allow gentle downfracture. Once References
the maxilla is disarticulated, the tissues can be gently stretched.
The maxilla can be segmented, if needed. to increase posterior 1. Tallgren A. The conhnuing reduction of the re sidual alveolar ridges i n complete
denture wearers: A mixed·lotli)tudinal study covering 25 years . 1972. J Pros-
space between the left and right sides, but this increases the risk of
1M! Denl 2000:89:427-435.
devascularization. i n oftheeden!Uiousjaws. lnl J Oral Maxa·
2. Cawood Jl, Howell AA. A classifocalo
In cases of vertical insufficiency, an interpositional bone graft is lofac Surg 1988:17:232-236.
harvested from the ilium and secured in a sandwich osteotomy, 3. Starshak T. Oral analon't)' and pllysiology. In: S t a r s h a k T, Saunoers B (eels).
Pteprostheic Oral and Maxillofacial Su rgery. StLouiS: Mosby, 1980:5-28.
t
with the cortical surface of the graft facing the nasal cavity to allow
4. AI Quran FA, AI·Owairi ZN. Torusp alat n
i u s and t()(uS m and ibularis in edentu·
revascularization of the cancellous side from the distal segment. The lous patients. J Comemp Cool P r a c l 2006:7:112-119.
guide splint is then inserted and the maxilla appropriately positioned 5. Haytac MC, Ozcelil< 0. Evalualion of patiem p ercept ions a tf e< frenectomy
by gently seating the condyles into the fossae. Internal vertical operations: A oomparlSOI) of carbon dioxide lasar and scalpel techniques. J
Perioctonto12006:77:181 5-1819.
reference marks can help to determine the appropriate vertical
6. Wesstlerg GA. Schendel SA. E p k e< BN. Modified maXJIIary submucosal ves·
position for the fragment. Stabilization has been accomplished tibuloplasty. lnt J Oral Surg 1980:9:7 4 -78.
with different techniques, including wire suspension t o the piriform 7 . Beirne OR . Osseointegrated implanl systems. In: Peterson W. tnoresano AT,
Marcianl RD. Roser SM (eelS). Principleso l Oral ano MaXIllofacial Surgery, vol
and zygomatic buttress that plates the fragments in place. In these
2. Phriade!phia: Lippincou Williams & Wilkins, 1992:1146.
cases, however. it can be difficult to find adequate bone quantity to 8. Keng SB. L.oh HS. The treatment of epuis fissuratum of the oral cavily by CO
place internal fixation devices. 2 1aser surgery. J Clift Laser Me<! Surg 1992:10:303-306.
The surgiCal splint is usually left in place for 6 weeks, after which 9. Esser JF. Studei s in l)laslic surgery ol the lace: 1. use or sl<in f rom Ihe neck 10
replace race defects. 11. Plas t i c oper alions aboul the mouth. Ill. The epidermc
time it is removed and a soft reline performed. It is wise to avoid
inlay. Ann Surg 1917;65:297-315.
placing a defini1ive functional prosthesis for at least 4 to 6 months. 10. Hall HO, O'Sieen AN. Freegralts Of palat al mucosa i n mandiOOia.r vestibulo·
Today, many patients eventually have implants placed for the plasty. J Oral Surg 1970;28:566-574.
retention of a fixed prosthesis. Implant placement should be delayed 11. Sclar AG. Preserving alveolar ridge anatoml' following toolh removal tn con·
junclion with tmmedlale imlap nt placement. The Bio·Col techn ique . Atlas Oral
until complete consolidation of the graft has occurred. which takes 6
Maxrllofac Surg Clin North Atn 1999;7:39-59.
months or more. particularly in older patients. 12. Marx RE, Shellenberger T, Wimsatt J. Correa P. Severely resorbed mandible:
Results are generally good, with one recent study showing survival Predictable reconslruction wilh soft !issue matrix expansion (lent pole) gr afts.
rates of 94% for implants placed in this type of reconstruction at an J Oral Maxillolac Surg 2002;60:678-888.
13. Quinn PO, Kent K, MacAiee KA 2nd. R econstructing theatrophic mandible
average of 45 months after prosthetic loading.ro Implant success
with n f ior bofder grafling and i mp lants; A preliminary report.lnt J Oral M axii
i er
rates of 83% at the same time interval suggest that peri-implant !O f a c 1mp1an1s 1992:7:87-93.
bone loss can be a problem in this con st ruct.2' 14. Miloro M. QuiM PO. Ptevenlion olrecurrenl palhologie fracture oil he atrop hic
mandibleusing <1ferior border grafling; Reportof two cases. J Oral Maxillofa c
Sutg 1994;52:414-420.
15. Keller EE. Totman DE. Eckel'l S. Surgical·proslhodonti c rec()nstruclion of ad·
vMCed maxilruy bone C<Jmpromlse with au1ogenous onlay block bonegrat f s
Summary andosseornlegrated endosseous tmplant s : A 12-year studyof 32 consecutive
palienls. lnl J Oral Maxii!Ofa c lmplanls 1999;1 4 :197-209.
16. Ver�ren Jl. Wismeijer 0, van Waas MA. One-slep rooonstruclion of the
Dentoalveolar surgery in preparation for prosthodontics is a primary severely resorbed mand•ble with onlay bone grafts and endosteal implants. A
step after diagnosis and treatment planning have arrived at specific 5-year follow-up. lnl J Oral MaxAiofac Surg 1996;25;112-115.
127
17. NystrOm E, Al\lqVIst J. Kahnberg KE. RosenquiSt JB. Autogenous onlay bOne 20. Beltrao GC. cJe Abreu AT, Ber.rao RG. Finco NF. Lateral cephalometric ta·
grafts fixed with screw implants for the treatment of severnly resorbed max· diograph for the p!anmng of maxiUary implant reconstruction. Dentomaxil!ofac
illae. Radiographic evaluation of preoperative bone dinensions, postopera Radioi2007:36:45-SO.
tive bone ioSS. a<1d changes in soh-tissue pro1ile. lnt J Oral Maxillofac Surg 21. Chiapasco M, Brusati R. Rench! P. Le Fort I osteotomy with ihterposnional
1996:25:351-359. bone grafts and delayed oral implants for the rehabil�a tioo of extremely atro·
18. Browaeys H. Bouvry P. DeBruyn H. A literature review on biomaterials o> sinus phied maxiiae: A 1-9-year clinical follow-up study on humans. Clin Oral lm·
augmentation procedures. C'n Implant Dent Relat Res 2007:9: 166-177. plants Res 2007: t8:74-85.
19. Perez-Sayans M, Fernandez·Gonzalez B. Somoza·Martin M, Gandara·Rey
JM. Garcia-Garcia A. Peri·onplanl bOne resop
r lion around implants plaCed in
atveolnr bone subjected to distraction osteogeoesis. J Oral MaxiiiOfac Surg
2008;66:787-790.
1281
Chapter
Bone Grafting and Ridge

Augmentation Considerations
Prior to Endosseous
Implant Reconstruction
James M. Van Ess, oos. Mo
Kevin L. Rieck, oos. Mo
number of factors must be considered during the initial plan the residual ridge is able to accept an implant without the need for
ning and treatment phases of endosseous Implant recon further grafting. Thickness of the overlying soft tissue may hinder
truction of the partially or completely edentulous patient. the assessment and must also be ccnsidered during the planning
When modern endosseous implants originally were developed. there stage. An alveolar ridge with thin overlying tiSSlle potentially may
were absolute and relative contraindications to placing implants in allow for easier surgical planning and implant placement ccmpared
certain pati ents. ' Although some of these contraindications may still to an alveolar ridge with thick overlying tissue. Excessively thick or
be valid ccncerns, many have since been shown to be less relevant hyperplastic tissue may camouflage an underlying ridge that is found
to treatment outcomes and are unjustified However, two factors that
. to lack adequate bone volume upon exposure. In addition, ridge form
all restorative dentists and surgeons need to ccnsider when treat may be less than ideal in terms of the definitive re storation even if
,
ment planning for implant placement are (1) the overall quality of an implant can still be surgically placed. Historically, surgeons have
bone and (2) the overall quantity or volume of bone. This chapter placed implants in areas of greatest bone volume, and restorative
focuses on the appropriate bone volume requirements for implant dentists were left to restore the implant in a less-than-ideal position.
placement and reviews various grafting and ridge augme ntati on op AlthOugh the panoramic radiograph continues to be the
tions and techniques that clinicians may consider. gold standard for evaluation, three dimensional
- (30) ccmputed
During the clinical and radiographic evaluation of the patient. tomography (Cl) scanning is becoming more readily available
the restorative dentist and surgeon need to first establish whether for better assessment and treatment planning This noninvasive
.
129
10 L Bone Grafting and Ridge Augmentation Considerations Prior to Endosseous Implant Reconstruction
Fig 10·1 CT (a) and 30 (I!) St.aMing technologtes provide a better assessment ol im· Fig 10·2 (aandb).AWmPiiate inte rdental spaceevaluation should take into consideration
plant proximity to vital structures and keatment plaiUling in areas of OOITlpromised bone the size of the implant the periodontal ligament space, and the need lor a minimum of
,
quantity and anatomy. 1.0 to 1.5 mm of circumlerential bone around the implant follovi.ng placement
Fig 1 0·3 The position of vital structures such as the IAN.IIs anterior loop relative to the mental foramen. and
pneumatizationof the maxillary sinuses should beassessed to determine Implant tenglll, diameter, or possi ble
neeo lor future graiting.
technology allows clinicians to view bone volume and vital structures Implant (4 rnrn) + periodontal ligament (0.25 rnm x 2 sides) +
such as the floor of the maxillary sinuses and the position of the bone (1.0 to 1.5 rnrn x 2 Sides)= 4.0 mm + 0.5 mm + 2.0 to 3.0 mm
inferior alveclar nerves relative to implant size, surgical position, and = 6.5 to 7.5 mm interdental space required
best placement for p rosthetic rehabilitation (Fig 10·1).
When considering the buccolingual or buccopalatal dimension,
the amount of buccal plate bone overlying the implant following
Implant and Bone Volume placement should be at least 0.5 mm. There ideally should also be
1.0 mm of lingual plate bone present. Vital structures should be noted
Considerations and evaluated during treatment planni ng and radiographic review

to assist in selection of the appropriate implant length or diameter.
When considering bone volume and whether or not an implant can Maxillary implants should ideally be 1.0 mm from lhe maxillary sinus
be placed. the clinician must consider the size, shape, and position floor and nasal ftoor, 2.0 mm above the inferior alveolar neurovascular
of any defect. i n addition to the function that the patient wishes to bundle. and 5.0 mm anterior to the mental foramen. This last factor
achieve. Implants should be positioned to retain a minimum of 1 .0 to is especially important because the inferior alveolar nerve (IAN) often
1.5 mm of circumferential bone around the entire implant following loops forward an average of 3.0 mm prior to exiting the mental
placement. In a typical dental defect, when an implant is to be placed foramen. Therefore, clinical and radio graphic evaluation of the IAN
between two adjacent teeth. the average periodontal ligament space and mental foramen before implant placement is critical (Fig 10-3).
of 0.25 mm must also be considered. To determine the proper inter· The length of a mandibular implant should measure at or 1.0 mm
dental distance, this value should be doubled and then added to the a.bove the inferior border of the mandible.
implant diameter plus the minimum circumferential bone desired (Fig When bone volume is slightly deficient and implant length extends
10·2). For example, if t11e dentist and surgecn plan to place a 4·rnm slightly beyond the inferior border ol the mandible, floor of the nose,
implant, a total of 6.5 to 7.5 mm between the two adjacent teeth is or floor of the maxillary sinus, i t is usually of little consequence.
required. This formula is illustrated by the following equation: The implant often will tent the associated periosteum, and bone
130 1
Bone Grafting Options j
Box 10-1 ��R p _
.
.
Mechanical Biologic
• Years ol denture wear • Bone quality Group 1.- Minor ridge I'G(nodeling
• Nocturnal denture wear - Osteopo<osls Gro11p 2: Sharp atrophic residual ridge
• Parafunc1ional haO!ts - Systemic disease Gro11p 3: Basal bone ridge
• Closure ol bite -Vascular supply Gro11p 4: Reso<ption of basal bone
-Diet
Anatomical
• Sex
• Bone quantity and torm befO<e
-Female preva�e
extraC1ion
deposition is likely to occur without the need for further bone grafting. These may include but are not limited to (1) age and health of the
When other dimensional criteria cannot be met, an implant with a patient, (2) donor site characteristics. (3) risk of nonunion. (4) biologic
smaller diameter or shorter length or bone augmentation should be insult to patient, (5) morbidity level of the procedure, (6) weakened
considered. donor sites. (7) potential risks and complications from the harvest
site, and (8) the patient's desires•
Ridge Resorption and Atrophy

Bone Grafting Options
Following a prolonged intetval between tooth loss and implant
reconstruction in completely or partially edentulous patients, the al· Various grafting techniques can be performed, in the outpatient or
veolar ridge usually undergoes significant resorption_ This continu inpatient setting, that will provide adequate bone volume for suc
ous process invariably affects edentulous ridges because bone is cessful implant reconstruction. The gold standard and most widely
a dynamic rather than static tissue.2 Consequently, it responds to used technique is autologous bone harvesting and graftin g_ Autolo·
a variety of intrinsic and extrinsic factors. A typical example of this gous bone is considered the most successful and predictable graft
is the resorption that occurs in response to ill-fitting dentures or re ing material,• primarily because of its osteogenic, ost eocondu ctive,
movable partial dentures: but other, more subtle factors, such as osteoinductive, and nonimmunogenic properties. With autologous
metabolic conditions, may also play a role (Box 1 0·1 ). Resorption grafts. the bone healing time, implant placement, and subsequent
progresses at varying rates among individuals. Typically, women ex prosthetic loading can occur will1in 5 to 6 months of surgery. Con
perience quicker initial resorption than men. Following tooth extrac versely, with nonautologous grafts. the recovery and loading period
tion and an initial healing phase. significant resorption occurs during may be as long as 8 to 12 months.7 Descriptions of different aug
the first 6 t o 18 months and then tapers off over time. Women and mentation techniques using various autologous donor sites follow.
men demonstrate similar long-term bone-loss patterns."" which are
often superior-palatal in the m axilla and inferior-lingual in the man
dible (Box 10-2). This bone loss may be minimal or advance to the Bone graft healing
level of basal bone, which must be considered when planning for ap
propriate placement of implants or potential need for bone grafting. Prior to reviewing bone grafting and augmentation options. a thor
Unfortunately, after careful evaluation and treatment planning, ough understanding of bone healing is desirable because it directly
bone volume may still be found inadequate for implant placement relates to the appropriate choice of graft for specific patients. In gen·
In this case, some form of bone augmentation and grafting should eral. successful bone graft healing and formation are a function of
be considered and pertormed. The morphology of the bony defect is the degree to which the graft stimulates osteogenesis. osteocon
an important factor in the method chosen for augmentation and can duction, osteoinduction, and incorporation.
be readily assessed clinically and radiographically.4 Even though the Osteogenesis is the formation of new bone from osteoprogenitor
volume of bone required and the nature of the defect often dictate cells, which can develop spontaneously or be transplanted.
harvest-site location and technique. other factors also should be Osteogenesis usually is associated with aulogenous grafts but
considered when selecting graft type and potential harvest Sites. may also apply to fresh froz.en allografts. Osteoconduction is the
131
10 LBone Grafting and Ridge Augmentation Considerations Prior to Endosseous Implant Reconstruction
Fig 10·4 Preoperative (a) and POStoperative ttJ)panoramic

radiographs demonstrating a maxillary sinus elevation
graft using allogeneic freeze-dried bone and imme<iate
implant placement.
Fig 10·5 (a and b) A left maxillary sinus elevation

graft using a combination of heterogenous bovine
bone, allogeneic demineraliZed bone. and autologous
particulate bone.
formation of new bone resulting from the differentiation of cells from are more readily available in demineralized allografts than in mineral·
the recipient bed and the ingrowth of 11ost cells along and into a ized allografts 9 Unfortllnately, allogeneic grafts do not prov d
. i e any
grafted or biologic alloplastic framework. Osteoinduction i s the osteogenesis because there are no viable cells within the graft itself.
formation of new bone by the differentiation of mese nchymal cells The risk for transmission of ine
f ctious disease is slight and even less
,
from the recipient bed into osteoblasts. It i s often associated with so in demineralized grafts. Demineralized grafts are often an excel·
bone-inductive proteins such as bone morphogenetic protein (BMP) lent option f or maxillary sinus elevation pr ocedures, for patients who
or platelet-derived growth facto r. Incorporation is the process by prefer to avoid a secondary surgical site. or for combination with
which the gralt mater ial and host site tissue are united and by which another graft to capture bone volume (Rg 10·4).
cells are mixed.
The origin of a bone graft affects its subsequent potential to
induce an immunologic response or one of these four bone healing Heterogenous bone grafts
r sponse usually dictates the type
functions; therefore, the desired e
of graft used. The graft types can be classified as autogenous, Heterogenous bone g rafts are also known as xen ografts or het·
allogeneic, heterogenous, al/oplastic, or a combination of these.• erografts. These grafts are transferred from one species to an·
other species. An example is the use of treated anorganic bovine
bone in humans to graft small alveolar defects or to perform sinus
Allogeneic bone grafts augmentation. Although used less frequently than in the past, Bio
Oss (Geistlich), Osteograf/N (Denlsply Friadent), and Pepgen P-15
Allogeneic bone grafts are also known as allografts or homologous (Dentsply Friadent) are still popular among a number of surgeons. 1o
grafts. This is a graft that is taken from another individual within the The most obvious d isadvantage is t he potential immu nologic anti·
same species. Although the material can be fresh frozen bone, it is genicity differences betw een the different species, which can be re·
often processed in one of several ways to minimize the recipient s ' duced by removing the organic component of bone. 1 1 Like allografts,
potential immunologic reaction t o and rejection of the graft. Pro· these grafts are osteoconductive and do not provide any osteogenic
cessing may take the form of demineralization, deproteinization, or or osteoinductive function. The advantages of these grafts are simi·
lyophilization (f reeze drying) of the bone. The adva ntage of this graft lar to allografts: There is no sur gical donor site and associated mer·
type is that there is no morbidity from a secondary donor site. It pro· bidity, and large amounts of graft material of various particle szes are i
vides a matrix for osteoinduction and osteoconduction and contalns availabl e This type of graft may be used alone or in combination with
.
BMPs, which can stimulate precursor cells. Although the amount of other graft materials (Fig 1 0·5).
BMPs has been known to be reduced in allogenec grafts, BMPs
i
1321
Bone Harvest Sites j
Alloplastic grafts
Bone Harvest Sites
Alloplastic grafts are primarily inorganic, biologically inert materials
used in implant placement and ridge augmentation procedures. There are many considerations when choosing a harvest site for
They are blocompatible and enhance bone formation by osteocon bone grafting. The surgeon must consider donor sites based on the
duction. Alloplastic grafts do not provide osteogenesis and are not following factors'·':
osteoinductive. They are often used in combination with other grafts
to enhance the other grafts or provide volume. Hydroxyapatite (HA). • Defect size. shape, and amount of autogenous bone required
the most common bone substitute used. is a calcium phosphate ce • Mo rbidity and risks of the harvesting procedure
ramic and the major inorganic mineral component of bone. It is avail • Need for particulate or block bone
able in block or particulate forms. Tricalcium phosphate (a calcium • Proximity of recipient site to potential donor site
phosphate ceramic) and bioactive glass (a polycrystalline ceramic) • Patient desires
are two other examples of alloplasts used. The resorption rate varies
for each material and often is a consideration when choosing what Local grafts from intraoralsitesare convenient sources for autogenous
to use tor various grafting purposes. Unfortunately. augmentation bone harvesting and often provide adequate bone tor small defects
procedures with HA have experienced complications and disadvan spanning one to two tooth sites. The mandibular syrnphysis/chin,
tages including soft tissue dehiscence and ulceration, HA exposure ramus, external oblique ridge, tori, and coronoid processes can be
and migration of particles, and paresthesia or dysesthesia.12 harvested. Maxillary harvesting from tuberostlies. exostoses, buttress
regions, or even a palatine torus may be feasible. Distant grafts from
extraoral sites such as the anterior or posterior iliac crest, anterior tibia,
Autogenous bone grafts fibula, ribs. or cranium are also options when a significant amount of
bone is required or a combination of bone and soft tissue is required.
An autogenous bone graft Is bone harvested from another site of the
same individual in whom it is t o be grafted. These are also known
a s autografts or autologous grafts. As previously mentioned, autog Intraoral harvest sites
enous grafts tend to be the ideal bone graft material. They have os
teoconductive and osteoinduclive properties and induce osteogen Mandibular symphysis/chin graft
esis at the recipient bed. Incorporation of the bone during the initial
phase of bone healing is also superior because of the intimate con The mandibular symphysis provides easy access to conicocancel
tact between the recipient bed and viable donor bone. The other ad lous blocks of good bone quantity with minimal morbidity in cases
vantage of autogenous grafts is that the bone is the individual's own, requiring reconstruction of small or medium defects.•,;.•& An incision
and immunologic rejection and transmission of disease is minimized. is made approximately 5 mm below the mucogingival margin in the
The primary disadvantage of autogenous grafts i s that the bone has anterior mandibular vestibule, anterior and inferior to the incisors.
to b e harvested from a second surgical site and transferred to the A mucoperiosteal flap is developed t o expose the anterior man
recipient site. This often adds morbidity to the procedure in terms of dible and identify and protect the mental nerves. Approximately
recovery and postoperative signs and symptoms. It also increases 5 to 1 0 ml of bone can be harvested from this site and used to
the length and cost of the procedure. restore deficiencies of up to four teeth that require augmentation in
Autogenous grafts can be further classifie d based on donor both height and widlh 17 (Fig 1 0-6). Both blocks and trephine cores
sites and the compostlion of the bone from those sites; these ol various thicknesses can be harvested based on detecl require
include cortical. cancellous. corticocancellous, and pedicle or free ments. Although the volume of bone obtained is usually greater
composite grafts. Cortical grafts are primarily dense. solid blocks of than that obtained from the ramus. the major disadvantage is in
cortical bone that provide superior structural properties that are a sufficient bone volume tor large defects. Mental and incisal nerve
result of the highest concentration of BMP. Cancellous bone grafts, paresthesia, potential injury to tooth roots, chin ptosis secondary
on the other hand, are particulate in nature and are composed of to insufficient resuspension of the mentalis muscle, and wound de·
medullary bone. which has the highest concentration of osteogenic hiscence are potential complications.
cells. Cancellous bone grafts revascularize more rapidly than cortical
bone grafts. The time required for revascularization can range from 2 Mandibular ramus graft
weeks for cancellous bone grafts to 2 months in purely cortical bone
grafts. Corticocancellous grafts subsequently combine the benefits Similar to mandibular symphysis grafts, mandibular ramus grafts
o f cortical and cancellous bone grafts. 13 Composite grafts provide provide 5 to 10 ml ol bone to augment small to medium defects
not only t11e benefit of an immediate vascularized blood supply but (Rg 10-7). They are easily obtained via an intraoral approach. Ac
also the transfer of soft tissue along with bone. This is advantageous cess and harvesting is obtained through an inc1sion over the external
when the defect comprises both soft tissue and bone deficiency. oblique ridge in the area of the third molar. A mucoperiosteal flap
133
10 LBone G rafting a n d R i dge Au gme n ta tion Considerations Prior to Endosseous Implant Reconstruction
Fig 10-6 (a to d) Autogenous bone graft haiVcstillQ from tile

chin. This area can provide excellent corticocancellous blocl<
grofts or trephined cores that can be placed in a bone mill for
partci ulate graftillg.
Fig 1 0·7 (a to d)Harvesting an Intraoral monocorticocarocello!Js ramus block grall can yield bone volllmes ol 5 to 10 ml.
along the ascending ramus is elevated, where a monocortical block osity region) and the bone is usually cancellous a nd particulate in
3 to 4 mm thick by 10 mm• can often be harves ted from the lateral n ature. These other sites are often indicated when minimal bone is
cortex. In contrast to the s ymphysis graft . the bone type i s p rima ri l y req ui red or when the graft is to be co mbined with another material,
cortical in nature but exhib its minimal resorption (0% to 25%) and such as an allograft or xenograft. Harvest ing from these si tes also
maintai n s its dense quality.• II i s often used as an onl ay graft to re may be an a djunct to another procedure such as rem oving third
capture alveolar width deficiencies (Fig 10·8), but in instances where molars or reducing tori. The bone can be used in i nstances of sock·
the ramus is wide, it may also be used to recapture vertical height et preservation, grafting of two· or three-wall periodontal defects,
deficiency. Although the IAN may be at risk during harvesti ng de· grafti ng of exposed implant threads, or combination grafts for sin us
elevations. Harvesti ng usu ally has ve1y low morbidity, and the bone
,
creased sensation. postoperative edema, pai n and wound dehis·,
cence are tess common compared with symphysis harvesti ng .'·'" often incorporates we ll to the recipient si te .
Other intraoral donor sites

Extraoral harvest sites
A number of other intraoral sites also can be used to obtain bone, in·
dueling the coronoid process (Fig 10·9). mandibular external oblique Anterior and posterior iliac crests
ridge (Fig 10·1 0), maxillary and mandibular tori and exostoses (Fig
1 0·11), maxillary tuberosities (Fig 10·12), and even the buttress or Both the anterior and posterior iliac crests provide excel·
zygomas. Bone volume is often limited (2 ml i n the max il lary tuber· lent sources for large volumes of bone needed to reconstruct a
1
34 1
Fig 10-8 (a to c)Autogenous corticocancellous ramus block graft applied to a thmugh-and-through defect thai resulted from a longstanding abscessed maxillary left lateral inc1sor .
(d) Imp lant reconswclion and hea«ng abutment placement 6 months later.
Fig 10·9 (a to d)intraoral hamsling of a hypertrophic coronoid process tor grafting at Fig 10-10 (a and b) Autogenous particulate bone harvesting of the mandibular
the maxillary light lateral incisor. external oblique ridge.
Fig 10.11 (a to d) H,11Vesting of mandibular tori lor autogonous grafting of the nght maxillary sinus floor. Borle was milled and then grafted in particulate IOI'Il1 in conjunction with an implanL
Fig 1 0·12 {a to c) HarveSiing 01 autogenous tuberosity IXllle, 1vtllch will

be used In oomllinaiont with allogeneic demineratized bone lor maxilary
sinus elevation grafting.
135
10 LBone Grafting and Ridge Augmentation Considerations Prior to Endosseous Implant Reconstruction
Fig 10·13 (<1 to c)AIJtogenous anterior Iliac crest corticocancenous J blOC!< gralt to a mandibular site that Is vertically and llilnzontally deficient.
Fig 10·14 (a to c)Anterior iliac crest corticocancellous block gra ft to the maxilla and subsequent implant placementS montllS later.
Fig 10·15 (a to c) Patient with severe maxillary atrophy from a pcMy lilting and unstable subperiosteal i mplant. Full-arch reconstruction of the maxilla was performed with anterior
iliac ccrticocancellous blOC!< grafting and immedlate implant placement.
vast array of defects and deformities prior to implant placement can be performed on the anterior crest. Although l1arvesting can be
(Figs 10·13 to 10·15). These procedures may range from recon· performed as an ambulatOry in-office procedure,'9 it is often done
struction of alveolar vertical and width deficiencies and cleft defects in the hospital setting under general anesthesia. This also depends
to full-arch reconstruction and maxillary sinus-floor augmentation. on whether a closed technique with trephining can be used or an
Both sites provide cortical cancellous, and corticocancellous grafts
, open technique Is necessary to harvest corticocancellous blocks .
in excess of 50 mL. On average, the posterior iliac crest provides In any case, either harvesting technique is not without significant
roughly double the bone volume (75 to 140 ml) that the anterior iliac moribidfty or compl cations compared to intraoral harvesting. When
i .
crest can provide (50 to 70 ml) (Fig 1 0·16). comparing posterior and anterior ilium harvesting, a prospective
The main advantage of the anterior harvest i s that the patient can study by Marx and Morales found the posterior approach to be
remain supine, in contrast to tM posterior harvest where the patient associated with fewer com pl ications and less morbidity than the
is required to be prone. In addition either a lateral or medial approach
, anterior approach.20 However, in both instances, gait disturibances,
1361
Fig 1 0-16 (a to c) Ha rvesting

rrom the anterio r and posterior
iliac crests can provide excellent
volumes ol autogenous cancellous
and corticocancellous bone that
can be used to reconstruct large
defects.
Fig 10-17 Proximal tibia bone

harvesUng (a) can produce up to 40
ml or cancellous bone (b). GT
Gerdy's tubercle, U1e lateral tibial
plateau aM preferred harveting sne.
(a. Repnnted frool Marx and Stevel\1'
with permission.)
sensory loss. postoperative pain, hematomas, seromas, fractures corticocancellous blocks are not indicated and in situations requiring
of the ilium, skin scars. infection. and prolonged hospitalization are large volumes of bone.
among the documented complications.
Cranium
Proximal tibia
Cranial or calvarial bone harvesting can provide up to 20 to 40 ml of
The proximal tibia can be an excellent donor site that provides an cortical block bone for grafting. Cancellous bone can be harvested
abundant amount of cancellous bone with little morbidity. Harvesting but i n much smaller volume than thai whiCh can be obtained from the
can be done in a relatively quick and easy outpatient setting under ilium. The largest volume of cancellous bone is found along the su
local or intravenous sedation (Rg 1 0-17). Typical bone volume har perior aspect of the parietal eminence. As a result, the cortical cranial
vested can be upwards of 40 ml. The incidence of complications for bone is more ideal for veneer grafting and has an advantage of being
tibia grafts ranges from 1.3% to 3.8%. which is favorable when com close to the recipient site. Cranial bone being of intramembranous
pared to iliac crest complications, which range from 8.6% to 9.2%.22 origin. the healing time for this kind of graft is often shorter. with signifi
Tibia grafts are contraindicated in children and growing adolescents cantly less graft resorption than graft material from other donor sites.
and in the presence of infection. arthritis, or metabolic or metastatic Furthermore. small incisions within the hairline are easily hidden. and
bone disease. Patients who have undergone recent knee surgery patient recovery is fairly rapid. The disadvantages are that a general
or those with a history of knee trauma are also poor candidates. anesthetic is often required, there is less cancellous bone available,
A proximal tibia graft is ideal for sinus elevation procedures when and the possibility of injury to cranial contents always exists.
137
10 L Bone Grafting and Ridge Augmentation Considerations Prior to Endosseous Implant Reconstruction
Fig 10·18 (a and b) Vascularized composite fibula grail

used for reconslruclion of a large posllraumalic defeGI ollhe
mandible. II provides excellent contour and bone �lume for
ummate implant and prosthetic reconstruction.
Fig 10·19 (.1 to d) Distractlofl osteogenesis provides an

alternative to bone grafting by providing an Increase in both
soft tissue as well as bone volume via a distroctlon deviCe.
Composite Autogenous Grafts Distraction Osteogenesis
Composite autogenous gralls involve the transfer of both soft tissue Distraction osteogenesis is the biologic process of new bone for·
and osseous tissue. They can be in the form of a pedicled composite mation between bone segments that are gradually separated by in·
graft or a microvascular free composite graft. The vascularized fibula cremenlal traction. It is based on the Law of Tension-Stress, which
graft is a commonly pertomned procedure that provides an excellent states that tension forces stimulate osteogenesis. This treatment
volume of bone and associated soft tissue for large discontinuity modality has become a possible alternative to grafting (Fig 10·19).
defects. There is potentially 22 to 25 em of bone length available for It also allows for an increase in soft tissue and bone volume be·
grafting. After the vasculature off the primary vessels is pertorated. cause the clinician has the opportunity to control the rhythm and
a number of osteotomies can be performed to contour and recon· rate of a distractor placed across an osteotomy site. With this ap·
struct defects to a more anatomical and esthetically pleasing form proach, farge amounts of bone o
f r future implant placement can be
(Fig 1 0·18). created without the need for additional grafting. The primary disad·
vantages are length of treatment, patient compliance, and device
complications.
138 1
References J
6. Herlord A. Reoonsltuctlon of alveolar detects prior to implant placement. Se·

Summary !acted Read1ngs Oral Maxilofac Surg 2003;11(6).
7. Fugazzotto PA. Treatment oplions fO< augmentation of the poslenO< maxilla.
lfl';)lant Dent 2000;9:281-287.
When implant reconstruction is considered. both bone quality and
8. Ellis E. Biology of bone grafling: An ove<view. Selected Readings Oral Ma><ll
quantity need to be considered during the ear1y stages of treatment lofac Surg 1992;2(1):1-15.
planning. Bone quality can be a limiting factor in implant placement, 9. Becker W, Uri st MR, Tuci<er LM, Becker BE. Ochsenbein C. Human deminer
and deficient bone quantity or poor location of bone can potentially ali2ed ftee2e-dried bone: Inadequate induced bone f<ll'malion in athymic mice.
A preliminary repo11. J Periodonlol 1995;66:822-828.
inhibH the placement of implants or result in unsatisfactory lreatment
10. Fur usawa T. Mizunuma K. Osteocon<)uctive prope<ties and efficacy or resorb
outcomes. Implants consistently have a high rate of success with allle lliOactive gl ass as bone grafting mat&flal. Implant Dent 1997;6:93-101.
and without bone grafting and provide a superior restorative option 11. Bell WH. Use or heterogenous bone in oral surgery. J Oral Surg Anesth Hosp
Dent Serv 1961;19:459-474.
to patients whh missing teeth. The restorative dentist. surgeon. and
12. Kent JN, Anger IM. Ouim JH, Guerra LA. HydJOxytapatite alveolar ridge re·
patient must work together to consider the risks, benefits. and al·
CO<>struction: Clinical experiences. oomplications. and technical modifications.
ternatives of all available graft types to reestablish appropriate bone J Oral Maxillofac Surg 1986;44:37-49.
volume before final implant placement. Autologous bone grafting re 13. Reddy LV. Potaczek I<K. Office-based autogenous b<Jne graft harvesting o
l r
denlalrmplants. Selected Readings Oral Maxfllofac Surg 2008;16{1).
mains the gold standard and continues to be the most predictable
14. B"''·ne PJ. Herlord AS. An algorithm for reconstruction or alveolar defects
and most successful grafting material in the surgeon's armamen befO<e implant pl acement. Oral Maxillofac Surg Clln Nol1h Am 2001;13:
tarium. However, many factors should be considered in selection of 533-54 1.
a donor site and the most appropriate grafting technique. Functional 15. Montazem A, Valauri D\1, SI-Hdaire H, Buchbinder D. The mandibular symphy
sis as a donor site in maxdlofacial bone grafting: A quantative anatomic study.
and esthetic compromise can and should be eliminated by appropri·
J Oral Maxiuorac Surg 2000;58:136lH371.
ate augmentation of the alveolar ridge prior to implant placement. 16. Zeiter OJ, Ries Wl. Sanders JJ. TI1e use or a bOne blOCk rrom tile Chi n tor
With the techniques and materials currently available, bone deficien alveolar ridge augmentation. lnt J Periodooic
t s Restorative Dent 2000:20:
cies should not hinder consideration of a patient for implant recon 618-827.
17. Misch Cl'JI. Misch CE. Resnik RR. Ismail YH. Reconsti\Jclion of mruollary alveo
struction.
lar defects with mandibular symphysrs grafts for dental implants: A prelim,nary
procedural report. lnt J Oral Maxdlofac Implants 1992:7:3 6()..36.6
18. Clave<o J. Lundgren S. Ramus 0< chin gralts for maxillary SJ�s inlay and local
onlay augmentation: Comparison of donor sile morbidity and complications.
References Clln Implant Dent Relal Res 2003;5:154- 160.

19. Freilich MM, Sandor GK. Amb<llatory in-office anterior iiac crest bone harvest
UlQ. Oral Surg Oral Med Oral PathoiOral Ra(fi ol Endod 2006;101:291-298.
1. Kwon PH. LasKin D. Clinician's Manual or Oral and MaxJliofac.al Surgery. Chi 20. Marx RE, Morales MJ. Motbidity from bone harvest in major jaw reconsti\Jc·
cago: Quintessence. 1991:390. li n: A randomized lrial comparing the lateral anteOO.-and posterior approach·
o
2. Caywood Jl, Howell RA. A classmcatlon ot edentulous !(IWS. fnl J Oral Maxil es t o the ilu m. J Oral Maxii!Oiac Surg 1988:48:196- 203.
lotac Surg 1988;17:232-236. 21. Marx RE, Stevens MR. Atlas or Oral and ExtroraJ Bone Harvesting. Chicago:
3. Ket1l JN. Fingll( I, Quinn J. GU!l(ra L Hydroxylapatite alveolar ridge reconstruc Ointessence, 2010.
hon: Clinicalexperiences, complications and technique modificatiOns. J Olal 22. O'Keerre AM. Riemer BL. Butterfield SL. Harvesti ng or autogenovs cancel
Maxillofac Surg 1986;44:37-49. lous IX>ne graft from the proxlmallib.al metaphysis. A revie\v of 230 cases. J
4, Mi sch CM. Comparison of intraoral donor sites for onlay grafting prior to im Orthop Trauma 1991 ;5:469-474,
plant placemenl. lnt J Oral Maxillotac Implants 1997:12:767-776.
5. Burchard\ H. Biolcgy of b<Jne lransplantation. Orthop Clin North Am
1987;18: 187-196.
139
Chapter
Osseointegrated Implants and

Implant Site Development
Kevin L. Rieck, DDS, MD
James M. Van Ess, DDs. MD
he use of osseointegrated implants has become routine within cal guides to be used for precise surgical navigation in esthetically
T contemporary oral and maxillofacial surgery practice. However.

in the early part of the 20th century, implant dentistry was not
looked upon as a proven technique that could be commonly em
difficult regions. These guides facilitate more accurate placement of
implants with maximum engagement in available bone. This tech
nique can promote greater initial implant stability with better potential
ployed. Early studies found that most metals that came into contact for immediate loading,' but protocols lor this treatment and outcome
with bodily fluids underwent an electrolytic reaction. It soon was dis assessment have yet to be validated.
covered that inert metals such as titanium, tantalum, and nickel chro Contemporary surgical techniques to place endosseous implants
mium were relatively well tolerated.' Subsequent work by Formiggini and the ancillary procedures associated with implant surgery have
and Chercheve. although somewhat problematic. demonstrated supplanted previous surgical methods for preprosthetic surgery. It is
progress in the rehabilitation of complete and partial edentulism2·3 rare in current practice for historically common preprosthetic proce
Shortly thereafter, Bnmemark, while performing studies on wound dures such a s vestibuloplasty or visor osteotomies to be employed.
healing, made a serendipitous discovery of the effect of bone growth Today's surgical approaches can place implants in virtually any pa
against titanium. This discove1y gave rise to the concept of osseo tient under any circumstances. However, clinicians should keep in
i tegration, a term proposed by the investigator.'.; With subsequent
n mind that the loss of teeth also generally includes loss of the as
investigation. osseointegrated implants became a useful application sociated hard and soft tissues. These changes can complicate the
for edentulous patients because they demonstrated significant suc planned or desired position of single or multiple implants and associ
cess over tong-term follow-up.• ated prosthetic rehabilitation.
The vast knowledge and experience gained in the last 40 years in Many surgeons refer to the cadre of possible procedures to im
the field of implant dentistry have resulted in significant advances for prove the location of planned implants as site deve/opmenr. While i t
patients afflicted with partial and complete edentulism. Titanium and is imperative to consider site development as requisite for tong-term
titanium alloy surface treatments and loading protocols have evolved success in esthetically critical areas, i t is impossible to succinctly
within the last decade to allow implant -supported prostheses to be summarize in this chapter an of the techniques available to accom
loaded at an earlier stage. In particular. the anterior mandible has plish definitive site develo pment.
been successfully treated using immediate-loading protocols, al As one examines a potential implant surgical site, multiple issues
though the rate of long-term success lor this procedure has not yet must be resolved before the implant can be placed. It is understood
been established. The predictability o f various types o f bone also that a comprehensive health l1istory and exam are prerequisites.
has been enhanced and redefined to allow immediate loading with Very few contraindications to implant placement exiSt. HistoriC'.al con
provisional or definitive prostheses. traindications included diabetes. smoking, infectious diseases such
Because of the increased predictability of osseointegration. im· as human immunodeficiency virus. and trank allergy to titanium.
mediate loading has become a more accessible treatment option. Excluding the patient with documented allergies and those with
despite the serious challenges in areas where esthetic demands uncontrolled medical conditions or unrealistic expectations. viltU·
are high. The introduction of three-dimenSional (3D} imaging tech ally any other patient can undergo implant surgery. Unfortunately, the
niques has allowed greater opportunity for computer-assisted surgi- potential for success diminishes when one considers the requirements
141
�� LOsseointegrated Implants and Implant Site Development
___..._ - �
Fig 11-1 Traumatic loss of alVeolus and se\1\!ralteeth

by oarasymphyseal fracture. (a)Preoperati\1\! sitvation.
(b) Placement of two osseointegrated implants wtth
screw-retaineo metal-ceramic prosthesis to replace
hara and soft tissues. (c)Incisal view. (d) Up Oynamics
with prosthesis.
fOf site development in preparatiOn for implants. Minor local procedures curs within 6 mont hs after the extraction of anterior teeth.M This
are often inconsequential adjuncts for patients, but major procedures type of resorption results in compromised restorative solutions
such as onlay bone grafting from the iliac crest or elsewhere must be when either conventional or implant-supported restorations are
carefully planned and executed only in medically stable patients. considered. Similar resorption also occu rs in posterior quadrants;
however, the esthetic concerns in these locations are not nearly
as dem anding on the restor ative clinician in most situations. To
optimize the anterior esthetics lor implant restorations. a 30 ap
Partial Edentulism proach should be taken. paying attention to ideal implant position
and size and ultimate ly the ideal location lor the definiti ve crown. '0
Surgical and prosthodontic management o f the partially edentu If ideal dimensions are not present preoperatively or at the time of
lous maxilla or mandible accounts for the greatest proportion of implant placement, vari ous grafting or augmentation techniques
patients evaluated lor endosseous Implants. Each partially eden are Incorporated to achieve the des ired result.
tulous site has unique clinical aspects that must be co nsidered Recently. clinic ans have recognized that results are compromised
i
when treatment planning for an impl ant-retained restoration. The when extraction sites are allowed to heal without any intervention in
overall goal of site development in these patients is to emulate the postoperative period. Most o f the partially and completely eden·
the ideal preextraction clinical scenario fn terms of tooth position tulous patients who present clinically have existed in that state lor
and preservation of associated periodontal tissues. The challenge some time and exhibit the associated hard and soft tissue deficien
is that te eth are rarely lost without concomitant damage to the cies previously discussed. When the clinician i s planning an extrac
underlying bone or local soft tissues (Fig 11-1) . This can result tion and restoration with an implant, maintenance of a s much of
from periodontal disease, endodontic issues that cause infection the alveolus and socket as possible is desired. Bone preservation
or chronic apical pathology, or traumatic exodontia. These factors can also be helpful to prepare sites lor fixed non-implant-SLipported
compromise the site for eventual implant placement and also af prosthodontics because retention of contours similar to any adjacent
fect the choice of which restoration is appropriate. A discussion natural dentition aids in esthetics. To maintain anatomical volume,
on whether to use removable, fixed, or implant-supported res various materials have been suggested and used as a means to fill in
torations to manage single or multiple edentulous sites through the socket postextraction. The term ridge preseNation has become
out the maxilla or mandible is beyond the focus of this chapter. synonymous with t11ese techniques and associated material applica
Several methods are available to manage the sequelae of dental tions. Grafting materials such as autogenous bone, allogeneic bone,
extractions in preparation for restorative treatment. xenogenei c bone, and various synthetics are available to assist with
Tooth extraction is an extremely common dental procedure. Ex this process (see chapter 10).
traction sites usually heal uneventfully, with bony regeneration of Placement of grafts necessitates some isolation of the grafted site
the socket within the alveolus. However. even in the most ideal from direct exposure to the oral environment. Primary soft tissue clo·
situations. the heights of the healed alveolus and associated soft sure is possible with the advancement of local tissue flaps or wider
tissues are generally less than their original position in both the undermining of the local soft tissue. However, such approaches can
coronal-apical and buccolingual dimensions. Studies suggest impair the local blood supply and ultimately affect the outcome or graft
that as much as 3 to 4 m m of ridge resorption and remodeling oc- incorpOfation or ot11er aspects of the stte. To circumvent this compro-
1421
Parta
i l Edentulism j
-
�- '
--
--
Fig 11-2 (a and b) An rhBMP-2 product in lhe form of a

rolfagen·soaked sponge. (c)Autogenous bone is used as a
matrix for tile rhBMP·2 sponge. (rf) Recipient sne of maxiI·
lary sinus. (e) Grafted maxilla witll rhBMP-2/booe mixture.
(Q Immediate postoperali'll! panoramic radiograph. (g)
Panoramic radiograph 6 mootlls post-Implant placement.
mise membranes can be incorporated in a manner that follows the

, using these materials. Patients play a vital role in this de cis ion
principles of guided tissue re generation . It has been documented that making process: nonautogenous graft materials must be com
barrier membranes overlying extraction sites allow for maximum bony pared to autogenous bone or tis sue grafts in terms of usefulness
regeneration and decrease the overall loss of bone.M Sclar has taken and the morb idity of harvestin g the autograft.
this concept further with a procedure he developed known as the Bio The associated risks, benefits, and alternatives of using any of
Col teclmiqve. Thi s procedure involVes the use of Bio-Oss (Geistlich), these materials alone or in combination must be reviewed. Often,
a d eproteinized natural cancellous bone mineral, and ConaPiug (In nonautogenous bone grafts are preferred over autogenous grafts,
tegra), a resorbable collagen dressing material, placed over the graft particularly in situations in which particulate grafting is commonly
and then separated further from the oral cavny by the application of employed (eg. socket preservation and sinus augmentation) . Autog·
lsodent (81man International) t o the surface." M ovate pontic placed enous grafts typically require approximately 4 months to incorpo·
over the necently grafte d site can assiSt with maturaton
i and retention rate in the host tissue bed. and allogeneic alloplastic, or xenogeneic
,
of the ada
j cent soft tissues. Simultaneous implant placement in con grafts generally require addition al time to heal-up to several months
junction with this technique can result in success rates approaching longer. This timi ng can affect the choice of graft and needs to be
99% and optimal local esthetics.'2 These principles can be applied to considered when making the decision to place impl ants into grafted
all extraction sites, assuming the site has been created atraumatically sites at the time of extraction or later.
and has an adequate volume of bone to retain the graft. Relatively new to the surgical armamentarium tor grafting purposes
Every clinician has a treatment algorithm , whether written or is InFuse (Medtronic Sofamor Danek), a recombinant human bone
mental. that is followed when evaluating grafting options for ex morphogenetic pro tein 2 (r hBMP-2) that has been cleared by the US
traction sites and other defects. This should include the opera Food and Drug Admins
i tration for socket preservation and sinus aug·
tive and recovery time required for extractions or extractions with mentation in addition to select orthopedic applications . This protein,
,
grafting and should consider the variation in graft incorporation used to generate de novo bone,'3 has unique handling characteristics
times based on specific materials and host factors. A myriad of and a feaming curve in �s use related to the biologic response one
graft materials exist. and the specific application of each material sees clinically. It can be used as a stand-alone product, eliminating
has inherent advantages and disadvantages. Differences in incor the need for autogenous donor harvesting and morbidity and !he po
po r ation time. rate or amount of incorporation. load-bearing lim tential risks associated with the allogeneic, alloptastic, or xenogeneiC
its, and material costs are b u l a few of the considerations wh en products (Fig 11-2).
143
� �LOsseointegrated Implants and Impla nt Site Develop ment
Fig 11·3 (a) Missing celltralinclsor with associated facial

cortical plate defect. (b) Implant placement leaves a thin
margrn of bone at incisal aspetl (c) Placement of hydroxy·
apaHte parti<:u!ate graft (d) After soft tissue has developed
and the implant is uncovered, the alveolus presents wtth
.
adequate width for an esthetic and symmetric definitive

prosthetic result (e). (Courtesy ol Dr Michael S. Block,
Metairie, LA.)
compared to particulate grafts, which may be acted upon by shear

Hard Tissue Defects ing forces in the oral cavity, resulting in possible poor incorporation.
Particulate grafts are available as mineralized, demineralized, cancel
An understanding of l h e general nature of hard tissue defects, par lo us or cortical forms (Fig 11·3.
)
ticularly size. location. adjacent structures and the anticipated type Xenografts and alloplasts are available as particulate bene regen
,
of restoration to be placed, helps the clinician to determine the type eration produ cts for use in alveolar socket grafting and sinus aug
,
of grafting that is approp riate. As noted previously, host factors, pa mentation procedures. The Bio-Col technique uses Bio-Oss (min
tient desires, procedural morbidity, financial limitations. and clinician eralized bovine bene) a s a xenograft to perform site preservation or
experience are just a few issues that influence the development of to augment hard tissues around implants as needed.12 Several non
the definitive treatment plan. autogenous graft materials are associated with ridge preservation
The gold standard for bene grafting materials in the oral and max and implant placement, but xenografts are recommended because
illofacial region, particularly the oral cavity, is autogenous bone. It of their ability to maintain volume and their slower resorption rate. ••
is osteoconductive. osteoinductive, osteogenic, and nonimmuno Guided tissue regeneration principles often include placement of a
genlc. As mentioned earlier, autogenous bone harvested as a free membrane over the particulate graft. This p rocedu re helps to retain
graft typically incorporates into the recipient site in approximately 4 the graft, to allow soft tissue epithelialization. and to minimize altera
months, whereas nonautogenous grafts of various types typically tion of the adjacent soft tissues.
take up to 8 to 12 months t o Incorporate. Often, autogenous and Bony defects in the jaws can affect only alveolar bone or extend
nonautogenous bene are combined for site development for os apically t o basal bone. Resorption in the posterior maxilla typically
seous defects. This combination allows the desirable properties of includes loss of alveolar bone in conjunction with enlargement of the
each mat erial to work to the patient's advantage and can aid in the maxillary sinus. Bone resorption in the anterior area can lead to sig
overall outcome by adding bulk and reducing donor site morbidity. nii
f cant defects, and the residual ridge or basal bone can essentially
Graft options consist of block-form segments of bone or corti· encroach upon the piriform rim of the nasal cavity. Significant bone
cal deproteinized segments processed into fine particulate pieces loss in the mandible increases the proximity of the underlying inferior
of various sizes. Cancellous bone is provided as a particulate graiL alveolar neurovascular bundle to the residual alveolar crest. Bone
The type and form of graft to use depend on a number of factors but resorbs not only coronoapicalty in the maxilla and mandible but also
initially are determined by the size of the defect being corrected or buccolingually. Various methods to determine the extent of existing
augmented. Im mobility of the graft is important to allow lor vascular bone loss are readily available to the contemporary clinician.
ingrowth and incorporation to the host tissue bed. Immobilization In addition to a thorough clinical exam, standard intraoral and
is easier to control with block autografts secured by rigid fixation panoramic radiographs are indicated. 3D imaging with standard
144 1
Soft Tissue Defects j
c omputed tomography (Cl) or cone beam CT techniques offers the When performing these procedures in esthetic areas. the surg eon
clinician the most information regarding the type and volume of de must attempt to blend these grafts with the adjacent tissues in terms
fect present. Some software adaptations of these systems can help of color, bulk, and shape. Three key principles must be followed to
the clinician determine the actual volume of graft material needed, maximize success with soft tissue grafting procedures:
based on radiographic interpretation algorithms. Bone-sounding
techniques also can be performed to assist the surgeon in establish 1. The recipient bed must be hemostatic and uniform in its surface.
ing the exact location of the bone, the extent of the d efec t and the
, 2. The surgeon must plan for immobilization and adequate vascular·
volume and type of overlying soft tissue. Knowledge of the tissue ity of the graft
type can be valuable when considering the needs for grafting and 3. The graft itself should be of sufficient size when harvested to allow
soft tissue adaptation over the graft, In addition t o whether any ancil for the correction of the defect and any loss of graft volume during
lary soft tissue grafting is anticipated. incorporat ion at the site.•s
Cortical blocks are also available from a bone bank and frequently
consist of portions of donor iliac crest. These blocks can be shaped The graft of clloice used for these procedures is a subepithelial
and secured to the recipient sites in much the same fast1ion that connective tissue graft. This can be used in a number of ways to
autogenous grafts are placed and secured. As mentioned earlier. provide ad ded volume or improved tissue quality, and it can take the
these grafts require a few more months for incorporation or remodel form of a pedicled or free graft. One of the simplest soft t ssue
i aug·
ing when compared to their autogenous counterparts of equal size. mentation procedures used in association with endosseous implant
The addrtion of ri18MP-2 to the grafting armamentarium of sur placement is the palatal roll t echnique . This technique, primarily used
geons signaled a new era when it was put into widespread clini in the anterior esthetic area, consists of making a palatal epithelial
cal use for maxillofacial applications in March 2007. At some point. incision and then undermining the epithelium, thereby exposing the
it may si gnificantly supplant traditional bone grafting . The BMP connective tissue. The connec tive tissue is then incised at its deep
impregnated collagen sponges placed into the maxillary sinus or aspect and rolled under the facial or buccal flap to provide added
alveolar sockets become bone over approximately 6 months (see bulk in the desired location. The epithelium is closed wrth minimal
Rg 11·2). Implant placement can then be pelion11ed.•s Grafted sites impact or insult to the donor site.
can have either a hard or softer bony feet to them when implants Free connective tissue graft t ransfer is also routinely used. The
are initially placed, but after additional implant integration, continued recommended location lor harvest is the palatal tissue in the premo·
consolidation and formation of autogenous bone is seen in response tar region (Fig 11·4). Single-incision and dual-incision technique s and
to the BMP. Other techniques such as ridge splitting and distraction "open" or "closed" methods are all options in harvesting procedures,
osteogenesis are used periodically to provide additional augmenta each with respective advantages and disadvantages. Regardless of
tion or correction to underlying bone deficiencies in preparation for the tec hnique used, the surgeon attempts to obtain a graft of uni
eventual implant placement. form tl1ickness that closely duplicates the size of the defect being
modified. Usually, tissue in this area is approximately 4 m m thick and
may include a small epithelial component at its margin and some fat
in addition to the connective tissue component.
Soft Tissue Defects The recipient site is prepared in a split-thickness fashion before
the graft is harvested. Careful preparatioll of the recipient bed allows
The soft tissue environment surrounding endosseous implants plays for an excellent dual blood supply lor the free graft. A broad-based
a vital role similar t o bone regarding the eventuat long-ten11 success flap is also helpful to ensure adequate blood supply and health of
of implant reconstructions. Defects or deficiencies in oral mucosa, the graft. Nourishment of t he graft is initially osmotic in natl're, but
particularly the attached gingival epithelium. must generally be cor vascularization of the graft occurs over the ensuing few weeks.
rected to ensure hemidesmosomat attachment of the junctional Once t11e recipient site has been prepared, moistened gauze is
epithelium to the implant surface, thereby creating a healthy bio applied to the area. and the surgeon addresses the donor site. The
logic implant-bone-soft tissue interface. The soft tissue can be easily open technique mentioned earlier involves a releasing incision for
conceptualized as deficient, acceptable, or excessive. Management improved access. This can result in some potential vascular com
essentially involves erther the addition to or modification of t he local promise of the recipient site and thus the graft, but it has many ad·
tissue or selective reduction of tissue in areas of excess. Usually, vantages over the closed technique in regard to actually placing and
the primary focus in discussion of soft tiss ue management for site securing a graft. Grafts can be harvested in a full-thickness fashion
development, implant placement, and improvement otthe tissue is from the palate and subsequently de-epithelialized as necessary;
additive grafting procedures. The g old standard in these techniques however, this practice may present greater morbidity to the patient.
involves reallocation or rearrangement of host tissue to an adjacent Full-thickness grafts are often used to treat mucogingivat d efects
or distant site in the oral cavity. The goal of grafting procedures is to and to provide epithelialized mucosa around dental implants. Palatal
create an ideal implant-soft tissue interface to maximize long-term stents may be beneficial as a protective dressing in the recovery
success of the implant and definitive restoration. period regardless of the type of graft harvested.
145
�� L Osseointegrated Implants and Implant Site Development
Fig 1 1·4 (a) An implant placed tor a single missing too1l1 i s uncovered. !he treatment plan calls tor a subepitnetial connective tissue graft. (IJ) Fcil template used for sizing donor
tissue. Donor tissue Is harvested with a double-blade scalpel (C) and men siZed to the foil template (d). (e and Q Grafl immobilization techniQue places suture through subepithelial
pOCket in necipient s�e. (g) Definitive prosthetic result shOWing tissue symmetry. (Coortesy of Or MichaelS. Block, Metairie. LA.)
The use of loc al vascularized soft tissue flaps has been described
and popularized by Sclar as a means to incorporate a lar g e volume
Summary
o f soft tissue augment ati on in esthetic areas with a single surgical
procedure. '6 As its name implies the vascularized interpositionat
, Con tempor ary surgical and p ro s th odontic practitioners possess the
periosteal-connective tissue Hap is harvested from the vascular requisi te knowledge. techniques and skill to address the many dif
,
plexus between the periosteal and connective tissue layers, which ficult clinical scenarios presented. There i s a sound biologic basis
are supplied by the greater palatine artery as it approaches the in for the soft and hard tissue augmentation procedures routinely em
cisive foramen. The procedure offers many advantages to the sur ployed to develop potential implant surgical sites into ideal locations
geon. Including the ability to perform simultaneous hard and soft tor long-term success of implants and prostheses.
tissue augmentations, but it can be technique sensitive.
Nonautogenous soft tissue grafts can be used in many of the
same ways as subepithelial and epithelial grafts. The material most
frequently used for this purpose is Allo Derm (LifeCell), an acellular References
dermal matrix. This material is produced from donated human skin
that is processed in a prop rietary fashion to remove the epidermal 1. Venable C. Sluck W, Beach A. The effecls on booe ollhe presence of metals:
based upen electrOlySiS, expetimental study. Ann Surg1937:105:917-938.
components and re tain the intact dermis. It retains the physical
2. Formiggini MS. Prostheses fixed in edentulous moulhs by means o f direct endo·
properties of the dermis but eliminates the antigenicity associated maxillary infibutations (in Spanish!. An Esp Odontoestomatol1955;14:675-683.
with donor grafts. AlloDerm has a tong history of successful use as a 3. Chercheve R. Cri tical studies of implarualon
i methods pn Frenc111. Rev Fr Odon·
tostomatol1965;12:1302-1319.
graft material t hroughou t the body. Its use in conjunc ti on with dental
4. BrAnemark Pl. Adell R, Breine U. Hansson 80. Undstrom J, Ohlsson A. lnlm·
implants to provide an increased keratinized band of tissue has been
os.�eous anchorage ofcJental prostheses. I. Experimental studies. Scand J Plast
advocated and shown to reduce inflammation secondary to plaque Reconstr Surg1969:3:81-tOO.
accumulation, when compared to sites with less attached mucosa.17 5. Adell R, Hansson 80, Brllnemark Pl. Breine U. lnira·osseous anchorage of
dental prostheses. II. Review of cliniCal approaches. Scand J Plas1 Recoostt
Surg 1970:4:t9-34.
1461
References J
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trealmell l or the eden!ulous jaw. Experience from a 10-year period. Scand lhetic implantlherapy. J Ofal Mrudlofac Surg 00
2 4:62(9 suppl2):�105.
J Plast Reconstr Sutg 1977;16:1-132. 13. Boyne PJ. Malx RE. Nevins M. el al. A feasibility study evaluating rhBMP·21
7. Nickenig HJ, Eilner S. Reliability of implant placement aHer virtual planning of absorbable collagen sponge lor maxillary sinus floor augmenlation. In! J Peri
Implant postttons using cone beam CT data and surgical (guide) ternplales. odonlics Res1oralive Dent !997;17:11-25.
J Craniomaxillofac Surg 2007;35:207-211. 14. Block MS. Jackson WC. Technoques !Of grafting !he extraotion sile on prepara·
8. Leckovlc V. Kenney EB, Weinlaender M, et al. A bone regenerative approach on
il lor dental omplant placement. Atlas Oral Maxmolac Surg Cin North Am
10 alveolar ridge maintenance follOWing tooth extractloo. Repo11 ol 10 cases. 2006;14:1-25.
J Penodonlol 1997;68:563-570. 15. Block MS, Achong R. Bone morphogenetic protein lor sinus augmentatoon.
9. Leckovic V. Camargo PM. Klokkevotd PR. et al. Preservation of 31veolar Atlas Oral Maxillofac s,"g Cll'l North Am 2006;14;99-t05.
bone in extraction sockels using bioabS0<1)able memblanes. J PeriO<IOI'l!Ol 16. Sclar AG. Soft Tissue �d Esthetic Considerations in Implant Ther"J)y. Chi·
1998;69: 1044-1049. cago: Quintessence.2003.
10. Buser D. Martin W, Belser UC. Optimizing esthelics for implant rest(J(ations in 17. Park JB. Increasing lhe widlll of keca!inized mucosa a�ound endosseous im·
the anterior maxilla; Anatomic and surgical considerations. lnt J Oral Max�lofac plant usl'lg acellular dermal matrix allogl1!ft. Implant Dent 2006:15:275-281.
Implants 2004;19(suppg:43-61.
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Soft lrssue Esthetic Procedures fO< Tee!h and Implants. Philadelphia: Saun
ders. 1999:39-59.
147
Chapter
Surgical Defects of the

Mandible and Maxilla
David J. Archibald, MD
Jan L. Kasperbauer, MD
ariety of problems that affect lhe bones of the jaws and

ce (eg. neoplasms. trauma, or complicaions from other
Etiology
t
ocedures) may require surgical resection, which frequently
results in bone and soft tissue defects. When treatment planning.
the surgeon must consider not only resection but reconstruction as Disease entities
well. Successful management should provide the patient with an es
thetically acceptable appearance; a high level of deglutition, swallow. Odontogenic tumors
and speech function: and a satisfactory resolution of the underlying
process. T h e treatment plan for resection must take into account the Tooth formation is typically complete by 18 years of age. However,
a.ggressiveness of the disease process: Benign conditions should be remnants of odontogenic tissue can be found in the hard and soft
treated with close margins, while aggressive malignancies require tissues of the head and neck in patients of any age. When located
wider margins. Reconstructive considerations include donor site in the periodontal ligament. they are called epithelial rests of Malas
availability and morbidity, role and function of the graft, patient age, sez; when found in the gingiva, they are called rests ofSerres. These
and clinician ability. Patient expectations can be managed with thor trapped odontogenic epithelial rests are thought to be the source or
ough education regarding the impact of resection and reconstruc many odontogenic tumors. Tumors also may originate in reduced
tion on speech, chewing, and swallowing. A multidisciplinary team enamel epithelium of the tooth crown, the enamel organ. dental pa·
that includes surgical specialists. dental specialists, and speech pa pilla, and the dental sac. Odontogenic tumors are a diverse group
thologists is essential to optimize outcomes. that, when advanced, may require significant mandibular resection.
149
�2 i Surgi c al Defects of the Mandible and Maxilla
Fig 12-1 Computed tomography (Cl) scan witll axial (a)

and coronal (b) views of a 65-year-old woman wilh recurrent
maxilla!)' ameloblastoma. The lesion is visible as a soft
tissue density occupying U1e light maxillal)' smus region wilh
posterior and anterior extensioo and some erosloo or tile
zygomatic arch.
Lesions range !rom benign proliferations to malignant neoplasms ca expansion, although most tumors are found incidentally on a routine
pa ble of metastatic spread. Primary odontogenic tumors are com imaging study. The histo pathology of these tumors is unque and i
monly classified as epithelial, mesenchymal, or mixed tumors. includes sheets of polyhedral epithelial cells. abundant cytoplasm
that may stain positive for amyloid, and concentric calcium deposits
Epithelial t u mors within the amyloid material. The tumors are slow growing, with less
Ameloblastomas Ameloblastomas are benign neoplasms that invasive potential than ameloblastomas, and the overall recurrence
stem from the epHhelia involved in the formation of teeth such as
. rate is less than 20%.
odontogeniC rests, enamel, and the lining of odontogenic cysts.
These tumors are slow growing, can produce significant deformity, Adenomatoid odontogenic tumors Adenomatoid odontogenic
and may recur if treatment is conservative. They most commonly oc tumors are lesions that contain ductlike structures and behave clini
cur in the fourth and fifth decades of life , and they are chiefly found cally more like a hamartoma or odontogenic cyst than a ne oplasm .
in the molar region of the mandibl e with only 15% occurring in the
, They are typically found in patients younger than 20 years and are
maxilla usually in the molar or antral region (Rg 12-1). Lesions are
, more prevalent in women than in men . Patients generally present
typically asymptomatic and are found incidentally on imaging studies with a painless swelling. Most lesions occur in the anterior maxilla
o r in patients being evaluated for malocclusion. and are associated with the crowns of impacted teeth . but there
Amefoblastomas are typically divide d into central and perip heral hav e been rare reported cases of extraosseous lesions. Radiologi·
(extraosseous) lesions. The central tumors can be further subdivided cally; they typically appear unilocular and radiolucent; hi stologically,
into biologic subtypes: solid, cystic, malignant. and ameloblastic they appear contained within a cystic structure that resembles the
carcinon1a. Cystic ameloblastomas occur in a slightly younger enamel organ. Because of the encapsulated and noninvasive nature
population compared with other ameloblastomas. They account for of these tumors. treatment typically Involves enucleation; recurrence
10% to 15% of all central ameloblastomas and are often treated is rare.
with curettage only, with a 1 0% to 20% re currence rate. Central
solid tumors. in contrast. have a recurrence rate greater than 50% Squamous odontogenic tumors Squamous odontogenic tumors
if treated with curettage only so recommended treatment includes
, are neoplasms that involve the alveolar process and are thought to
resection with 1-cm margins.•-a develo p from the rests of Malassez. They are often associated with
the roots of teeth. Although the mandible and maxilla are affected
Calcifyin g epithelial odontogenic tumors Calcifying epithelial equally, the anterior maxilla and posterior mandible are more likely
odontogenic tumors. also known as Pindborg tumors share many
, regions. Patients are usually asymp tomatic and can be affected at
clinical features of arneloblastomas bu1 differ microscopically and various ages, but the average age of onset is 40 years. Rad ographi i
radi ographically Which dental remnant cells give rise to these neo
. cally, the lesion appears well circumscribed. Squamous odontogenic
plasms is unknown, although dental lamina remnants and the str a tumors do have invasive capacHy but infrequently recur after curet
tum intermedium of the enamel organ have been proposed as the tage or excision.
source. These tumors affect patients over a very broad age range.
although the average age of onset is 40 years. They occur in the Clear cell odontogenic tumors Clear cell odontogenic tumors
mandible twice as frequently as in the maxilla, and p eripheral tumors are rare neoplasms with an unknown etiology. though their typical lo·
are rarely reported. Approximately half of the tumors are associ at ed cation and histology suggest an odontogenic source. These tumors
with an impacted tooth. Patients usually present clinically with jaw are usually seen in women older than 60 years. They are poorly cir-
1501
Etiology J
cumscribed and locally aggressive. Histologically. t11ese lesions are

composed of sheets with clear cytoplasm. Metastases to the lungs
and regional lymph nodes have been reported.
Mesenchymal tumors
Odo n to g e n ic myxomas The odontogenic myxoma is a benign
tumor that arises from the periodontal ligament. dental follicle. or
dental papilla. It usually occurs in the second and third decades of
life, and the mandible is slightly more commonty affected than the
maxilla. It frequently is associated with missing or impacted teeth.
This neoplasm behaves aggressively, eroding cortical bone, a n d may
involve the maxillary sinus. Treatment of choice is en bloc resection
with 1-cm margins.
Fig 12·2 Tl·weighted magnetic resonance imaging (MRI) ol a 61-year·old wo,nan
Central odontogenic fibromas The central odontogenic fibroma with a 2.6-cm osteosarcoma erOding into tlle hard palate. nasal septum, and anterior
is a rare lesion seen in all age groups and found in both the maxilla maxillary ridge.
and mandible. It is composed of connective tissue, resembles a den

tal follicle, ar1d occurs around the etowns of unerupted teeth. This
stow-growing tumor is rarely painful. Enucleation i s the treatment of
choice. and there have been few clinical cases of recurrence. Recurrences are rare. although ametobtastic fibrosarcoma has been
documented a s arising from recurrent ameloblastic fibroma.
Cementoblastomas The cementobtastoma i s a rare, benign neo
plasm originating from cementoblasts. II usually occurs in the sec Odontomas Odontomas are fully differentiated mixed tumors com
ond and third decades of life and is more frequently seen in the posed of enamel and dentin, and they can be regarded as ham·
mandible than in the maxilla. The tumors may cause cortical expan artemas rather than neoplasms. They may occur as numerous
siOn and tow-grade pain. Because of their close association with the rudimentary teeth, In which case they are classified as compound
tooth root. the tooth usually is sacrificed during resection, along with odontomas; or they may appear as ar1 unstructured collection, in
some surrounding bone. Recurrences have not been reported. which case they are labeled complex odontomas. They are the most
common odontogenic tumors. Most are discovered in the second
Periapical cementoosseous dysplasias Periapical cemento· decade of life, and the maxilla is slightly more commonly affected
osseous dysplasia arises from the periodontal ligament and contains than the mandible. Clinically, these may appear as a retained primary
fibrous tissue, cementum, and bone. Chronic inflammatory cells may tooth. an impacted tooth, or alveolar swelling. Patients are generally
also be seen. As the name implies. the lesion represents a dysplastic asymptomatic. Odontomas have limited growth, though complex
process rather than a neoplasm. This tumor has a predilection for odontomas may reach a significant size. Enucleation is the treatment
women, predominantly black women, older than 20 years. Multiple of choice, and recurrences are rare. ,...,
asymptomatic lesions are usually present, involving the mandibular In the majority of cases, the associated mucosal resection is not
incisor root apices. Because most patients are asymptomatic, this a major element in tumor control but may impact the reconstructive
condition is usually discovered on routine imaging studies. No treat needs. Malignant odontogenic tumors are fortunately rare: these
ment is reQuired because the teeth remain vital with this disease include ameloblastic sarcomas and squamous cell cancers
process. originating from dental appendages.
Mixed tumors Osteosarcomas

Ameloblastic fibromas and ameloblastic fibroodontomas
Amelobtastic fibroma and ametoblastic fibroodontoma are benign Approximately 10% of all osteosarcomas involve the head and neck
mixed odontogenic tumors that share similar clinical and biologic area, with the mandible most frequently affected, followed by the
features. They occur predominantly in children and young adults. maxilla (Fig 12-2). The skull base is much less commonly involved.
with a mean age of 12 years. The mandible is affected more Ire· Osteosarcomas in the head and neck typically occur in the third
Quentty than the maxilla. Tumors may be unilocular or multilocular and fourth decades of life, in contrast to osteosarcoma of the long
and are often associated with the crown of an impacted tooth. The bones, which is most common in the second decade of life. Paget
tumor mass is composed primarily of myxoid connective tissue sur disease and priOr radiation therapy to head and neck sites are two
rounded by a fibrous capsule. Because of these tumors' encapsula risk factors for the development of osteosarcomas later in life, which
tion and lack of invasive capacity, treatment is typically conservative. are termed secondary osteosarcomas. Neoadjuvant chemotherapy
151
�2 i Surgical Defects of the Mandible and Maxilla
derived from the oral mucosa may involve the mandible and maxilla
by various routes, including (1) direct invasion, (2) perineural spread,
(3) extenSion along tooth roots. or (4) origination in epithelium adja·
cent to tooth roots.' Direct invasion from the oral mucosa is the most
common type of involvement, with the earliest stage being periOsteal
invasion (Fig 12-3). Wih
t advanced disease, cortical erosion can oc·
cur and may result in pathologic fractures of Lhe mandible. Maxillary
alveolar cancer and hard palate cancer are relatively rare but may
have a female predilection.• sec with extracapsular spread that di·
rectty invades the mandible may metastasize to lymph nodes adja·
cent to the mandible, primarily the perivascular lymph nodes in the
submandibular triangle.
Maxillary sinus mucosa also can l)e a source of sec and adeno·
carcinoma, which typically generate few symptoms until advanced.
Clinicians who manage these neoplasms should consider that
lymphatic metastasis also may be present.
Salivary gland malignancies

The proximity of salivary gland tissue to the mandible in the fo011
o f oral minor salivary glands, sublingual glands. the submandibu
lar gland. and the parotid gland occaSionally results in malignan·
des with mandibular or maxillary involvement. The most common
intraoral salivary gland malignancy is the adenoid cystic carcinoma
Fig 12-3 Auorodeoxygtuco�ilron emission tomography/computed tomography
(previously known as the cylindroma). Although other mucosal ma
(FDG-PET/CT) scan •.>ith CT fusiofl of a 65-year-old man with squamoos cell carcinoma
of the light postelior ton gue and lloor of mouth with mandibular involvem ent. lignancies are graded on 5-year survival rates, adenoid cystic carci·
nomas have a 15-year survival rate approaching 25%.9 Because of
these tumors' aggressive nature and propensity to have perineural
spread and skip lesions. they are treated with aggressive resection
(at least 3-cm margins) and postoperative radiotherapy. Distant me
tastasis tends to occur late to the lungs or brain, with mu�ifocal-type
round soft tissue densities. However, like the odontogenic tumor,
these tend to grow slowly, allowing patients to live many years after
their appearance.
has become the standard treatment for osteosarcomas of the long
bones, with significant improvement in survival rates, although data Advanced skin cancers
to support this approach for lesions in the head and neck are not Direct extension or nodal metastasis from skin cancers of various
robust.' Surgery remains the primary mode of therapy for osteosar types (eg, squamous cell cancer. basal cell cancer. and melanoma)
comas of the head and neck. Treatment modalities used for osteo may invade mandibular and maxillary periostea, erode cortical
sarcomas of the limbs, sucl1 as neoadjuvant chemotherapy followed bone, extend into bone by perineural extension, and directly invade
by surgery, have been applied to patients with head and neck lesions through cortical bone. In this unusual situation, the jaw involvement
without clear evidence of benefit. The presence of viable tumor in the may be secondary and can be the primary reconstructive challenge
postresection pathology specimen delenmines the need for further (Rg 12-4).
chemotherapy. Other forms of sarcomas (eg, chondrosarcomas. fi
brosarcomas, and synovial sarcomas) involve both the maxilla and Metastases (prostate, breast, co l o n, renal cell, a n d
mandible but are much less common than osteosarcomas.• thyroid cancer)
Primary malignancies can metastasize to the maxilla and mandible.
Secondary involvement by malignancy In this instance. knowledge of the patient's prognosis sMutd be
matched with the symptoms when attempting to establish a treat
ment plan. The most common site of metastasis is the molar region
Mucosal squamous cell cancers of the mandible.
Oral cancer is the sixth most common cancer worldwide, with a
widely varied geographic incidence influenced by lifestyle, genetic,
and demographic factors.6 Mucosal squamous cell carcinoma (SCC)
1521
Etiology J
Trauma
Avulsive trauma and complex craniofacial gunshot wounds may gen

erate significant hard and soft tissue deficits. In gunshot wounds, the
velocity and Si4e of the projectiles determine the type and magnitude
of bone and soft tissue defect. For example, close-range shotgun
blasts and high-velocity projectiles may generate sizable bone and
soft tissue defects. Initial management is directed toward acute con
cerns related to airway patency, respiration, and circulatory status.
When the wound is self-inflicted, psychologic assessment and man
agement of mental illness is integrated into the care of the patient.
The defects associated with these injuries may disrupt bone, soft
tissue, mucosa. nerves, and vasculature. Motor vehicle-associated
injuries may also result in significant damage to the mandible, but
they rarely generate bone deficits. Free tissue transfer allows recon
Fig 12-4 Photograph (a) and ruoal CT scan {b) ol an 87-year·old woman wtth an
struction of large bone deficits and soft tissue loss.•• advanced squamous cell carcinoma involving the mental skin with bony destruction of
the body of the mandible around the symphysis and mvaslon of the musculatt�e of the
anterior lloor of the mouth.
Osteonecrosis
Osteonecrosis of the mandible and maxilla can be attributed pri

marily to radiation therapy (brachytherapy or external beam) and
bisphosphonate therapy, which is a more recently recognized fac
tor. Irradiation may produce areas of avascular bone necrosis when
the high linear energy transfer from radiotherapy lyses populations
of stem cells, endosteal osteoblasts, and vascular endothelial cells. resorption. pathologic fracture), the avascular mandibular bone
If this necrosis fails to heal over 3 months � is termed osteoradio
, needs to be removed. The effects of the radiation create the need
necros is. The extent of bone necrosis varies and can range from for resection and reconstruction with vascularized tissue to replace
superticial. small areas of exposed bone to large. bilateral areas of the necrotic bone and augment mucosa and soft tissue. When
infected, painful, exposed bone with orocutaneous fistulae, inferior patients are at a stage that requires resection and vascularized bone
border resorption, and possibly pathologic fracture. Osteoradione· reconstruction, hyperbaric oxygen is not necessary.••
crosis reportedly occurs in 5% to 15% of patients undergoing radia Osteonecrosis as a complication of bisphosphonate therapy
tion that includes the mandible in treatment fields, and it may de was noted as early as 2003.•s Bisphosphonates are prescribed
velop in cases in which the primary tumor does not have mandibular (1) to stabilize bone loss in osteoporosis, (2) to stabilize bone
invasion (eg, oropharyngeal carcinoma)." The maxilla is affected lesions in metastatic cancer (such as breast and prostate), (3) to
much tess frequently than the mandible. Three mechanisms have treat bone resorption defects in multiple myeloma, and (4} as an
been proposed as responsible for the radiation effect on bone that adjunct in severe hypercalcemia. The medication has two effects
causes osteoradionecrosis: (1) endarteritis, (2) decreased osteoclast that likely cause osteonecrosis: (1) cessation of bone remodeling
viability, and (3) fibroblast apoptosis." Risk factors associated with and bone turnover by the basic osteoclast-inhibiting effect and (2)
osteoradionecrosis include the volume of bone in the radiation field, inhibition of capillary neoangiogenesis. The rich blood supply and
the dose of radiation, dental inflammation, and dental extractions. rapid bone turnover rate in the jaws contribute to the concentration
Prior to the advent of vascularized bone reconstruction, Marx'2 of bisphosphonates in the mandible and maxilla. Other factors
developed a classification of osteoradionecrosis based on the degree that contribute to the exclusive occurrence of bisphosphonate
of bone involvement and response to hyperbaric oxygen therapy osteonecrosis in the mandible and maxilla may include the presence
(HBO). However, a recent randomized, double-blind, placebo· of teeth, which require daily bone remodeling, and dental-associated
controlled study failed to identity any benefit of HBO for quicker chronic inflammation. The major� of these cases can be managed
recovery, slower progression of disease, or pain relief.'3 In spite of this conservatively.'"
information, the first line of treatment generally involves conservative Some advanced cases of bisphosphonate osteonecrosis, similar
efforts that include antibiotiC therapy, prednisone. debridement. to osteoradionecrosis, present with orocutaneous fistulae, pathologic
and hyperbaric oxygen. When these efforts fail to resolve the pain, fractures, and large areas of exposed bone, but they are not well
ulceratiOn, and infection, or when patients present with advanced served by conservative management. I n these situations, resection
stage osteoradionecrosis (orocutaneous fistulae, inferior border and vascularized bone reconstruction are reasonaJ)Ie."
153
�2 i Surgical Defects of the Mandible and Maxilla
Fig 12-5 (a} Panoramic radiograph ol a patient with advanced squamO\Is cell carcinoma with mandibular involvement tha t Fig 12·6 Axial CT scan of a 61-year-old
is difficult to assess secondary to superimposi1i011 of the cervical spine. (b)Axial CT scan of the same patient shows obvious woman with a S<ltJamous cell carcinoma
symphyseal mandibular destruction bY the tumor. inV()Ivlng the left oral cavity and mandible. rhls
scan reveals significant erosion In t h e left body
of the mandi ble.
Osteomyelitis occasionally results in painful nonhealing necrotic nerve provides insight to maxillary tumor extension. In patients with
bone. When intravenous antibiotics and c onservative debridement advanced maxillary tumors. nasal and orbital extension must be
have failed, resection and reconstruction may become necessary. considered, whiCh could potentially result in diplopia. epiphora, nasal
obstruction. rhinorrhea, or epistaxis. Physical examination in patients
with malignant lesions must include palpation of the neck to identify
metastatic cervical adenopathy.
Evaluation Radiographic evaluation is a key element in the preoperative
evaluation of the mandible and maxilla. Unfortunately, no single
A preoperative determinat ion of the extent of a tumor or trauma imaging study can predict mandibular invasion with a high level of
should g uide the initial resection o r management. This requ1res inte accuracy. This issue has generated studies that support a variety of
gration of a careful history, in addition to physical and radiographic algorithms proposed to guide resecti on. '8 These algorithms attempt
examinations. The patient should be asked about the following: to integrate information from the clinical examination. selected
radiographic examinations. and importantly, frozen section histology,
• Risk factors tor mal ignancy (eg, alcohol or tobacco use, family his that is requ ired to help prevent overtreatment and undertreatment.
tory of disorders associated with mandibular tumors) Unfortunately, most investigations do not include frozen section
• Comort:>idities that could increase anesthetic risks and affect sur evaluation in the algorithm.
vival Commonly used imaging studies incl ude standard radiographs (eg,
• Famil y hist ory of disease that could influence the diagnosis panoramic radiographs and periapical films), CT imaging, and MRI.
• C linical sym ptoms that may help cl arify the diagnosis or extent of A panoramic radiograph remains a useful and inexpensive method
the disease to document bone characteristics of the mandible. Limitations in the
accur acy of this image include the superimposition of the cervical spine
In the mandible, deep-ear or retroorbital pain would suggest In the interforaminal area and a required 30% to 50% bone loss before
peri neural spread along the first division of the fifth cranial nerve. lesions can be detected (Fig 12·5). CT imaging with special formats
In the maxilla, perineural spread along the infraorbital nerve and its attempts to overcome some of the limitations of the radiograph but is
branches may generate retr oorbit al pain. The soft tissue examination complcated
i by artifacts from metalNc dental restorations and difficulty
for the mandible should include bimanual palpation of tumor borders in assessing changes relative to inflammati on and asymmetric tooth
and assessment of mucosal integrity, friability, and sensory (focusing roots'9 (Rg 12-6). Routne
i CT imaging with contrast p rov ides insight
on lingual. inferior alveolar, and mental nerves) and m otor (hypoglossal toward soft tissue extenSion and nodal involvement. MRI is more
and facial nerves) integri ty . Similarly, the level of function of the sensitive in the detection of perineural spread marrow involvement
. ,
anterior superior alveolar nerve, posterior alveolar nerve, and palatine and soft tissue extension; however. it is limited in differentiating
1
541
Treatment J
marrow fat from tumor and inflammation and is more time-consuming extent or perineural spread is difficult to assess radiologically and
than other modalities. The lengthy process may not be tolerated by clin ically. Frozen section analysis or the inferior alveolar nerve and
claustrophobiC patients. and patient motion may degrade the Quality mental nerve may provide some guidance to resection. In general,
of the image. PET/CT fuses the spectrographic data from C18-labeled perineural spread requires a segmental rnandibulectorny.
glucose uptake with CT imaging but unfortunately cannot differentiate Osteotomies are performed with the goal of providing adequate
tumors from inflammation. Thus. evaluation of mandibular invasion margins for tumor ablation while preserving adjacent viable dentition.
remains a challenge. The final decision on the extent of mandibular Preservation of the periosteal and mandibular blood supply is
resection can be estimated radiologically, but in the authors' opinion. especially imponant in patients who have undergone prior radiation
it should be modified based on intraoperative findings and frozen because they are at increased risk for small vessel fibrosis. Minimal
section histology. cauterization and low settings decrease thermal damage . During
In contrast to the mandible, radiologic evaluation of bone invasion bone incision and hole drilling. copious irrigation and careful control
of the maxilla is relatively straightforward because of the thin bone. of the powered instrumentation should minimize heat and prevent
Orbital, perineural. pterygoid, and cutaneous invasion are key dental injury.
factors in surgical planning. Ophthalmologic evaluation is essential
tor patients with advanced maxillary tumors when orbital extension Transoral resection
is suggested clinically or radiologiCally.
Access to and resection of the mandible can be accomplished tran
sorally in certain patients with appropriate tumor histology, location,
and mandibular mobility. Protection and retraction of the lips are the
Treatment initial steps. followed by isolation or retraction of the tongue and
buccal mucosa. if necessary. Mucosal incisions that extend to the
planned Sites of bone removal allow the use of powered instrumen
Resection of the mandible tation to complete the planned osteotomies. The adjacent vascula·
ture and nerves (eg, the facial artery and vein; the marginal branch of
A variety of incisions can be used in resection of the mandible, the facial nerve; the lingual, hypoglossal, inferior alveolar, and mental
influenced by the extent o f soft tissue tumor involvement, extent nerves; and the vessels of the floor of the mouth) must be controlled
o f mandibular involvement, and area of access reQuired for recon or protected. The surface area of resected mucosa and the integrity
struction. The key anatomical units that must be managed during a of the residual mandible determine the need for stabilization, aug
mandibulectomy include the residual dentition, adjacent motor and mentation. or reconstruction.
sensory nerves. adjacent arteries and veins, and adjacent muscles
and bone. Transcervical resection
Mucosally based cancers with extension to the periosteum may
be managed in several ways. If the malignancy exhibits minimal To avoid an incision that divides the lip. a skin incision paralleling the
surface-area involvement, a frozen section that suggests contact inferior border of the mandible (located several centimeters inferior
but not penetration through the periosteum may indicate that the to the lower border) can be connected to a mucosal incision in the
bone does not require treatment. In patients who have surlace areas labial/buccal vestibule (visor ftap). This approach can provide wide
of tumor contact with the periosteum greater than 1 em, the authors access to the rnandib!e, floor of the mouth, and tongue for resec
prefer bone removal by application of a bur to the cortex or rim tion and reconstruction. A carefully placed and closed incision that
mandibulectomy. Any radiologic evidence ol cortical erosion would divides the lip in the midline routinely heals well unless the lip pre
indicate a need for at least a rim mandibulectomy. Involvement of viously has undergone irradiation. The increased access facilitates
the cancellous portion of the mandible should result in a segmental placement of microvascular free grafts when significant mucosal re
mandibulectomy. The challenge in this situation is to resect sufficient section and reconstruction are required.20
bone to cure the malignancy yet preserve enough normal tissue to
facilitate reconstruction. Frozen section analysis of calcified tissue Segmental versus marginal mandibulectomy
is challenging and further complicates treatment. As discussed
earlier, radiologic studies are helpful but lack specificity. MRI may Marginal mandibulectomy is defined as subtotal removal of a length
be helpful to assess tumor extension within the mandible. Based on o f the mandible. A sagittal marginal mandibulectomy preserves ei
radiologic studies, at feast 1 ern of normal bone is removed beyond tl1er the lingual or buccal cortex. A rim marginal rnandibulectorny
the expected leading edge of a malignant tL1mor. results in resection o f a portion of the height of the mandible. In a
Perineural spread of a tumor along the osseous course of the segmental mandibulectorny, the full height of the mandible is re
inferior alveolar nerve should be a consideration in the case of moved for a given length. The type of procedure performed must
mental skin anesthesia, significant deep pain. and tumors that be appropriate to the nature of mandibular involvement and the
demonstrate significant bone invasion radiologically or clinically. The extent of the diseaset> (Fig 12·7).
155
�2 i Surgic al Defects of the Mandible and Maxilla
the mandible, the radiologic assessm ent of bone involvement is less

challenging and resection of bone margins is more straightforward.
Perineural spread must be considered during resection of maxillary
malignancies, and the branches of Vz (maxillary division of the
tri geminal nerve) must be eval uated clinically and radiologically. MRI
is typically more sensitive in the identification of perineural invasion
ar1d soft tissue/muscle extension. Bone characteristics ar1d invasion
are more accurately imaged on CT. allowing for better evaluation. ln
cases of advanced tumors, both modalities are often useful. Frozen
section analysis confirms perineural spread and guides the extent of
re section. Because of the proximity of the inferior alveolar nerve to
the floor of the orbi t, perineural spread may requi re resection of the
floor of the orbit.
The locations of osteotomies are planned to provide adequate
resection margins and preserve uninvolved dentition, mucosa. and
soft tissue. During the procedure, use of powered instrumentation
with copious irrigation minimizes bone injury and facilitates
preservation of adjacent alveolar bone ar1d dentition.
Fig 12-7 Intraoperative photograph of a patientundergoing segmental mandillulectomy
and neck dissection tor treatment of a squamous cell carcinoma involving me mandible.
Transoral resection
Tumors that primarily involve the inferior portion of the maxilla are
ve1y amenable t o transoral resection. provided Significant trismus is
not present. It is relatively straightforward to circumferentially incise
mucosa and follow with appropriate osteotomies. Special consid
Resection of the maxilla eration and effort is required when the tumor ext ends toward the
pterygoid plates and musculature or involves the primary palate. In
Resection of the maxilla can b e perlormed transorally or via a variety volvement of the pterygoid region may require additional resection
of approaches that address the level of soft tissue involvement, tu extending into the infratemporal fossa and parapharyngeal space,
mor extension to adjacent structures, and chosen method of recon prompting pterygoid osteotomies and pterygoid muscle resection.
struction or rehabilitation. The primary focus is on adequate resec Osteotomies of the primary palate must address the bone thickness
tion of the tumor and management of adjacent structures (eg. orbit, along t he piriform aperture and the potential extension into the nasal
pterygomaxillary space, nasal cavity), which are more complex than floor.
those in the mandible. Because of these structures, t11e tumor is
less accessible to palpation. and no t infrequently the goal of a 1-cm Facial degloving
margin is compromised, primarily when the tumor approximates the
orbit. In addition, the surgeon should recognize that the maxillary Greater access t o the face of the maxilla, nasal cavity, and floor of
artery is less accessible than the mandibular vascula ture and may the orbit can be gained by extending a buccogingival incision across
only be controlled after specimen removal. the midline with connection to the nasal cavity along the piriform
Mucosally based lesions require resection of sufficient tissue aperture. With skin and soft tissue retraction. the entire maxilla can
to provide an approximate 1-cm negative margin. Frozen section be accessed. This method avoids a facial incision, but access to
ar1alysis of the peripheral and deep margins assists in determining and control of the Mterior superior maxilla and anterior orbit may be
the extent of mucosa and bone resection required, respectively. suboptimal.
Si mil ar to the mandible. i f the tumor extends to but not through the
periosteum, bone removal is nol required unless there is a large Lateral rhinotomy
surface area o f periosteal contact that would challenge the accuracy
of frozen section.ln this case, resectio n of bone sl1ould b e considered. An incision placed along the junction of the nose and cheek com
When maxillary alveolar bone is sufficiently robust, partial-thiCkness bined with an incision that divides the upper lip provides excellent
resection may be accomplished without communication t o the access to the maxilla, nasal cavity, and orbit. In addition, when
maxillary sinus. This would be unlikely in edentulous patients, except reconstruction involves tissue transfer, the greater access facili
in the area of the primary palate. ln general. communication with the ta tes graft placement When healed, the incision is quite acceptable
maxillary sinus should be anticipated, and the surgical plan must because of the placement at the junction of cosmetic subun t s of
i
include a contingency to addness the antral opening. In contrast to the face.
156 1
Reconstruction J
Weber-Ferguson incision donor site for transposition has a significant component from the
buccal surface. scarring may limit mandibular opening. In contrast
In cases of tumor extenSion toward or into the lat eral anterior or to other transposition naps, palatal transposition naps provide sig
bit and zygoma. greater access for resection is gained through an nificant thickness, and the donor site fills significantly by secondary
incision along the eyelid (Weber-Ferguson incision). This inciSion is intention healing. Similar to advancement flaps, prosthetic fabrica
placed in the location comm only used for blepharoplasty and is con tion and fitting can be considered in approximately 4 t o 6 weeks,
nected t o the soft tissue dissection over the maxilla and the lateral depending on the complexity of the defect and mucosal recovery in
rhinotomy inc ision. the donor site.
Skin grafting
Reconstruction
Skin grafting for reconstruction has limited applications to mandibu
Reconstructive efforts must give primary consideration t o the res lar defects because cortical bone does not provide a sufficient capil
toration and maintenance of functiOn while minimizing donor site lary bed lor the skin graft. Intact periosteum and cancellous bone are
morbidity. Occasionally, situations arise in which reconstruction of a suitable sites for skin graft reconstruction but may lack resistance to
d efect should be avoided and the wound is allowed to fill with granu trauma. Reconstruction o f maxillary defects has traditionally involved
lation tissue and mucosa from adjacent epithelium For example, an
. skin grafting on the anterior, lateral, and posterior surfaces of the
elderly patient wit h significant coronary artery disease presents with defect, with the skin graft held in place by a pack supported with a
recurrent carcinoma of the mandibular alveolus. She underwent pri· provisional maxillary prosthesis or bolstering sutures. The skin graft
or surgery for an oral carcinoma with postoperative chemoradiation typically establishes vascular connections wit11 the underlying capil
therapy, completed 4 years ago. In this case. resection of the tumor laries by postoperative day 5, prompting pack removal and for ma
and underlying bone may be all that is feasible. tion of a temporary obturator 5 t o 7 days after resection and graft
One would expect scar contracture and subsequent restriction of ing. This reconstruction is very effective and well tolerated in lateral
motion to negatively impact mastication swallowing, and speech.
, and posterior maxillary defects. The scar or fibrotic band junction
Most often. however. reconstruction of jaw d efects preserves func between the labial or buccal mucosa and recipient site may serve
tiOn and may involve simple mucosal advancement closure, trans as additional support for the obturator. Extended defects increase
position flaps, skin grafting, and regional flaps; or it may escalate to the size and weight of the obturator. The contour and integrity of
microvascular tree-flap reconstruction. These techniques also may the opposing primary and secondary palate affect the success of
be combined with pro sthetic rehabilitation. obturation. Trismus in the patient and li m ited manual dexterity in the
clinician must be considered with this type of reconstruction.
Mucosal advancement flaps

Regional flaps
In instances of limited bone and mucosal resection. closure may be
accomplished by approximatiOn of m ucosa alone. In previously irra Two regional flaps based on the facial artery. the submental artery
diated patients, tissues must be handled with care because of de island flap and platysma flap. provide small volumes of vascularized
creased vascular supply, risk of wound breakdown, and subsequent skin, fat, and superficial fascia, wl1icl1 can be helpful in resurfacing
potential development of osteoradiOnecrosis. Loss of vertical bone defects on the floor of the mouth and mandibular alveolus. Large
height and blunting of the labial and lingual sulci can create challenges surface defects over the mandible or maxilla with involvement of ad
for dental rehabilitatiOn. In most cases, oral prostheses can be planned jacent tongue and buccal mucosa are generally not well served by
and fabricated or modified 4 to 6 weeks after the resection. secondary-intention healing or reconstruction with a skin graft. Re
gional flaps that have been employed in the past include forehead,
temporalis, pectoralis, and trapezius myocutaneous flaps. Each of
Transposition flaps t hese options has l imitatiOns, and they mostly l1ave been replaced b y
microvascular flaps, especially when vascular ized bone is required.
When transoral resection yields sufficient residual bone with a Forehead flaps cause a significant cosmetic change at the donor
mucosal defect that cannot be closed primarily, transposition site (altered forehead contour). Another challenge of using the
flaps of adjacent mucosa (eg, tongue floor of the mouth, buccal or
, forehead flap or the temporalis flap is the restricted entry into the
palatal mucosa) may be em ployed. In general, the blood supply is oral cavity in the zygomatic region and the increased bulk/fullness of
robust in nonirradiated individuals, and successful closure can be the cheek that results. The superficial temporal vessels supply this
expected. The resultant alteration in the sulci is greater compared flap and may be compromised by a neck dissection, in which case
to other techniques and may challenge oral rehabilitation. If the the flap should be delayed.
157
1 2l Surgical Defects o f the Mandible and Maxilla
tl
Fig 12-8 Intraoperative photograph of a fibular ostcocutanooos Fig 12-9 Intraoperative photographsof a fibular osteocutaneous microvasa1tar free flap after osteotomies
miClovascular free flap donor har�est site. have been pertormed. fixated with locking plates to recontour the new mandible (a)lor reconstrucffon of a
large left mandibuloclomy defect (b).
Perhaps a more rational application of flaps. based on the Microvascular free flaps
temporal artery distribution, is the application of osseofascial or
os teofasciocutaneous flaps for maxillwy reconstruc tion 22
. From a surgical perspective, management of mandibular and maxillary
Trapezius and pectoralis flaps are options for reconstruction of defects has been revolutioniZed by microvascular free tissue transfer
defects of the tongue. floor of the mouth. and cheek areas. but it is of bone, fascia, muscle, and skin. Although microvascular free-flap
a challenge for these flaps to reach maxillary defects based on their reconstruction is time-consuming, Simultaneous flap harvest du1ing
vascular pedicles (transverse cervical artery and pectoral branch tumor resection helps to maximize time efficiency. The head and neck
o f the thoracoacromial artery respectively). Shoulder dysfunction
. have ample recipient vessels of suitable size for microvascular recon
results from the use of the trapezius muscle, b ut the pectoralis major struction. The most commonly used arteries are the facial and other
myocutaneous flap is generally well tolerated. The thickness of the branches of the external carotid, such as the superior thyroid artery.
muscle, fat, and skin of a myocutaneous flap may provide excess Full-thickness (segmental) mandibular defects are ideally managed
bulk and limit tissue mobility. Some of the thickness resolves as the with placement of robustly vascular bone grafts. Repair also requires
muscle atrophies. A thinner flap can be fashioned by using only soft tiss�'e that can replace intraoral mucosa. skin. or both. Alt11ough
the muscle, but obtaining a watertight closure is more challenging. the rib, metatarsal, humerus, and clavicle have all been used to
In addition, these flaps do not provide reliably vasculariZed bone reconstruct the mandible, the most commonly used donor sites
for reconstruction of the mandible o r maxilla capable of tolerating include the fibula, iliac crest. scapula, and radius. Selection of the
radiation or implant placement. Placement of a metallic plate and donor site is influenced by the nature o f the defect. Each donor site
coverage with a myocutaneous flap is not tolerated when the has advantages and disadvantages in the types of tissue available
defect involves the anterior mandible. Lateral detects treated in this and other characteristics of the donor site location.
manner may remain covered, but plate fracture may result from the T11e first microvascular bone transfer was performed in 1975 by
forces applied during mastication. Successful bone reconstruction Taylor, whO used a vascularized segment of the fibula for treatment of
can b e obtained with application of cancellous bone grafts placed a defect of the tibia.Zl Hidalgo expanded the utility of the fibular flap
in metallic trays or fixed to a metallic bar if well-vascularized tissue when he performed the first mandibular reconstruction in 1989, uSing
is covering the area and if a watertight closure is maintained to osteotomies to mimic the shape of almost an entire mandible." The
prevent sali vary contamination. When vascularized bone is required fibular flap has since proven to be a valuable method for mandible
for reconstruction, microvascular free flaps are the best choice . reconstruction. especially for extenSiVe defects.
In most individuals. the fibula is the most commonly used donor
s�e for primwy recons truction of mandibular defects (Fig t 2-8). II can
provide up to 25 ern of bicortical bone, and because of its excellent
periosteal blood supply, it can tolerate multiple osteotomies (Fig 12·9).
Fibular bone also Is strong enough to support osseointegrated
158 1
Reconstruction j
Fig 12-10 (a andb) Pootop erativc photographs of a patient wnh a squamoos cell carcinoma of the mandible t en 1 year a«erfibolar microvascular reconstruction
al<
of his mandibular defect. {c) Intraoral postoperative photograph showing well·heafed skin after the fibular osteocutaneous microvascular reconstruction of the
retromolar trigone.
endosseous implants; however, its height may be a limitation in this or later. The need for postoperative adjuvant therapy also must
regard?$ To overcome this limitation, Jones introduced the possibility be considered in the timing of dental rehabilitation because of the
ot folding two osteotomized bone segments.26 Reported donor site significant mucositis that may develop.
morbidity after a fibular free flap is minimat2'-29 (Rg 12-10).
The iliac crest also has excellent bone quality but is hampered
to some degree by pedicle length, soft tissue bulk, and contour or Primary reconstruction of the maxilla
osteotomy limitations.
The scapular flap has less robust bone quality and quantity and is Tumors that require maxillary resection may create detects ot the
therefore less suitable for mandibular reconstruction. The scapular maxilla. palate. orbit, or adjacent soft tissue. Such defects can lead
region does have a pedicle distribution thai allows separation of the to significant sequelae such as hypernasality of speech, difficulty
cutaneous and bone elements, facilitating resurfacing of multiple with mastication, swallowing difficulty (food and liquid may be forced
surfaces. This i s ideal for maxillectomy defects that may require out the nasal cavity), sinusitis, and facial disf!Qurement. Goals of
reconstruction o f the oral. nasal. and cutaneous surtaces.30 The maxilla1y reconstruction include the following3':
primary disadvantage of this donor site is the additional surgical time
required to shift the patient's position during the operation. • Obliterating a maxillary defect
Tile radial forearm free flap can be harvested with a portion of • Obtaining a healed wound
the radius. Approximately one-hall the circumference of the radius • Separating tlle oral cavity from the sinonasal cavity
is included, and the residual radius shoul.d be supported wrth metal • Supporting the orbit or filling the orbital cavity in cases of exentera·
plating to prevent fracture. In mandibular reconstruction, the bone lion
is emphasized because it provides a structure to maintain the • Restoring palatal competence and function
mandibular arch, supports the dental restoration, and prevents • Restoring facial contours
distortion of facial symmetry. The maxilla, in contrast, can be • Recreating functional dentition
reconstructed with soft tissue only, and dental restorations can be
supported by the contralateral maxilla. Local soft tissue flaps can be used in reconstruction of small de·
Often. the microvascular free-flap reconstruction is one step in feels of the clleek, upper lip. palate. and nasal cavity. Pedicled fore·
the rehabilitation process for a patient. Revision ot skin or muscle head and temporalis muscle flaps have been used lor larger midface
bulk may be required, and dental restoration may occur at that time detects but are often limited by the length of the vascular pedicle
159
1 2l Surgical Defects o f the Mandible and Maxilla
Fig 12-11 Intraoperative photograplls of a 61-I'Car-ol d woman Ulldergoing cenlral maxillectomy (a) a nd radial foreann microvaswlar reconstruction of
her palatal defect (bandc) after treatment for an osteosarcoma invading the hard palate, nasal septum, and anterior maxillary lidge.
and the amount of soft tissue available to fill the defect."' In the past with a thorougll clinical exan1ination, is key in assessment of the
20 years, myocutaneous free flaps have been used to reconstruct patient's potential tor competent function postrehabilitation (see
maxillary defects. Latissimus dorsi, rectus abdominis, and radial chapter 15). Ancillary support for the conclusiOI'lS gained through
forearm myocutaneous tree flaps have been described as success clinical examination should b e provided by cinematic ftuoroscopy in
ful techniques to obtain a sealed palate and a satisfactory esthetic the form of a modified barium swallow. Assuming this assessment
result"" (Fig 12·11). demonstrates that lhe patient has a competent swallowing reflex,
Soft tissue reconstruc tion typically is reserved for patients who it may be appropriate to consider fabrication or a bone-anchored
have residual dentition adequate tor mastication. In patients who prosthesis (see chapter 19). Osseointegrated endosseous implants
lack this dentition, osseocutaneous free· flap reconstruction is an are a tremendous development that are truly state-of-the-art for
option. This procedure has been described using the scapula. patients who require prosthetic replacement of portions of the
fibula, and iliac crest, all of which potentially have sufficient bone mandible or maxilla. The timing of implant placement for dental
stock to support osseointegrated en dosseous imp!ants.34 No single restoration should be individualz
i ed, with consideration given to
technique is sufficient to reconstruct the great diversity of maxillary prognosis, age, patient motivation, and cost.
detects, and thus the approach to reconstruction must be planned
based on the bony and soft tissue needs or the specific defect and
the avail able prosthodontic support.
Patient Education
Patient education is a key element of management throughout re·

Rehabilitation construction and rehabilitation of maxillary and mandibular defects.
Treatments in these regions have a significant effect on facial ap
Satisfactory orat function following traumatic or surgical defects of pearance. speech, mastication, and swallowing. Therefore. it is es
the mandible and maxilla requ1res maintenance of the mandibular sential to initially prepare the patient for the complexity and risks of
opening. Scarring in the buccal region or fibrosis in the pterygoid surgery and later continue education throughout the recovery and
and temporalis muscles can significantly limit opening and limit pros rehabilitation.
thesis use. Early in the postoperative period, patient instruction on
range of motion is required and should be stressed throughout the
course of adjuvant therapy. Sensory deficits decrease over time, and
eventually sensation can be detected in flaps without sensory nerve Summary
reconstruction.
The previous part of this chapter elaborated on surgical techniques Team management of maxillary and mandibular tumors and defects
tor disease control and anatomical reoonstruction. However. has progressively improved patients' quality of life. However. in ad·
the complex multifunctional aspects of deglutition, speech, and vanced cases, the current reconstructive options are not sufficient
mastication are dependent not only upon an appropriate physical to restore normal appearance and function. Translational research
restoration of resected anatomy but also upon neurophysiologic should generate new options to overcome some of the limitations
competence of the structures involved. Baseline assessment of of current reconstructive techniques and offer new therapeutics that
the patient's ability to swallow and speak intelligibly, established may obviate the need for surgical resection.
160 1
References
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34. T McrovascUartree llap raconstructMt op·
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161
Chapter
Oral Complications of
Chemotherapy and
Radiation Therapy
Kostandinos Sideras, MD
Charl es L. Loprinzi, MD
Robert L. Foote, MD
T: e oral cavity i s a common site for chemotherapy-induced

nd ra
cfiat ion in duced toxic ity. Manifestations of this toxici1y
-
Pathophysiology of Mucosal
Injury
.
nclude alimentary tract mucositis; secondary infectious com
plications induced by bacteria. fung i and vinJses: and graft-versus
.
host diseas e in patients receiving allogeneic bone marrow t rans

It is currently accepted that the process of mucosal inju ry. and sub
plants. Although alimentary tract mucositis can involve the entire
sequent healing, is not limited to the epithelium but involves all lay
gastrointestinal tract,' it most frequently manifests in the oral cavity
ers of the mucosa. including the extracellul ar matrix. A five- stage
as ulc eratio n , pain, and bleeding. Mucositis leads to significant pa
process has been postulated to e xplai n t11e complex molecular, cel
t ient morbidity and decline in quality of life and limits the use of addi
lular, and histologic events associated with chemotherapy-induced
tional chemotherapeutic treatment. Moreover, the economic burden
m ucosal injury':
o f this frequent oncologic complication is considerable!., This chap
ter discusses the e tiology incidence. risk factors, pre ven tio n, and
,
1. Initiation pl1ase: Oxi da tive stress related to che mo therapy is

treatment of oral toxic effects of standard chemotherapy, intensive
though t to be responsible for the first phase of mucosal inj ury.
myeloablative chemotherapy, and radiat io n therapy. The prevention
2. Upregulation and message generation phase: The second phase
and treatment of graft-versus-host disease are beyond the scope of
involves the upregulation of transcnption factors and t h e genera
this chapter.
lion of messenger signals. In this stage, upregulation of nuclear
factor "� (NF-�<P) is thought to play a central role in the subse
quent upregulation of multiple proinflammatory cytokines (eg, tu
mor necrosis factor-a [TNF-a]. interteukin-1 [:l(IL-1 p]. and IL-6).
NF-K(:\ is also thought to upregulate cyclooxygenase-2 (COX-2),
whiCh in turn is implicated in the upregulation of matrix metal
loproteinase.� The sphingomyelinase and ceramide pathways, fi
bronectin breakup, and macrophage activa tion are other complex
events that lead to further mucosal injury and apoptosis.
163
�3 i Oral Complications of Chem o ther ap y and Radiation Therapy
0
� High
-�
u
�
100%
E
� 80%
a
"
80%
!
u
«)%
0
�
�
20%
·c
�
�
"' Standard c h em oth erap y
ti LOw Fig 13-1 Risk of mucositis according 1o type ol cancer thernpy. MTX-Methotrexatc:
Kavdbine Do x orubici n l S.Fli/ Cisplatin/MTXI MD-CT
Docetaxe H ().. RT
Getncitibine Paolitaxel Cydo(lhOStlh&mkle (EMf) C�C) MO-CT (EMT)--moderate-do$6 chemotherapy (extra-myetoablative therapy); HO·RT
(HN�ligh-dose radiotherapy (head and neck cancer). {M001fied from PeterS(IIl' with
Treatment
permission.)
3. Signaling and amplification phase: The third phase of muco

sal injury involves additional signaling and amplification of the
Oral Complications of
above-mentioned pathways, leading to generation of additional Chemotherapy Including
proinflammatory cytokines. The biologically altered mucosa still
appears anatomically intact. Myeloablative Chemotherapy
4. Ulceration phase: The fourth phase consists of the symptomatic
phase of mucositis, involving mucosal ulceration. pain. and bleed
ing. Bacterial superinfection and reduction in salivary gland func Incidence and risk factors
tion can complicate and amplify the mucosal injury at this stage.
5. Healing phase: The iff th and final phase involves the healing of the The degree of mucosal injury is significantly affected by the type of
mucosa, which dep ends on angiogenesis and increased biologic chemotherapeutic agents used, the specific dose, the route and fre
activity in the extracellular matrix. In patients undergOing myeloab quency of administration, and whether the chemotherapy is given as
Iative chemotherapy, the healing phase may not begin llntil leuko monot11erapy or in combinato
i n with other agents and modalities of
cyte recovery. treatment (Fig 13-1 ).
Ant i metabolites (eg, methotrexate and 5-FU [fluorouracil]),
It is important to understand that these phases do not necessarily antitumor antibiotics (eg. doxorubicin). platinum agents (eg. cisplatin),
follow a linear progression but may occur simultaneously at different purine analogs (eg, cytarabine), and topoisomerase inhibitors (eg,
locations.• etoposide) are especially associated with mucositis. Methotrexate
Multiple scales to assess mucositis exist in clinical practice. and etoposide are secreted into the saliva. enhancing mucosal
Although these scales differ in the level of objective and subjective toxicity. lrinotecan. ahhough notorious for causing gastrointestinal
information used, patient-provided data offer the same conclusions mucositis in the form of diarrhea, has limited oral toxicity.
as clinician-determined data.6 The World Health Organization (WHO) 5-FU-induced mucositis is usuallyfirst noticed from 3 to 7 days after
and National Cancer Institute Common Toxicity Criteria (NCI-CTC) initiation of therapy. Severity peaks at 7 to 12 days and diminishes at
scales are most commonly used. These combine information from about 2 to 3 weeks (Fig 13-2). In patients undergoing myeloablative
the patient's signs and symptoms and reported functional status and chemotherapy tor hematologic malignancies. mucositis severity can
ability to eat:' peak up to 18 days after initiation of therapy.'
164 1
Oral Complications of Chemotherapy Including Myeloablative Chemotherapy J
80
Fig 13-2 Percentages ot patients with mucositis tor 30 days after initiation ot 5·Fu
Dased chemotherapy. These data come from two sequential randomized tliatsJ030:
One compared 30 minutes of ()(at ccyotherapy (•l with a control groUJ) (,\).and one 0 5 10 15 20 25 30
compared 30 minutes of ccyotherapy (v) with 60 minutes of cryotherapy (•). (Mo<l�ied Oayotcycte
from Peterson• with permission.)
Chemotherapy for the treatment of solid tumors leads to Prevention of chemotherapy-induced oral
the development of mucositis in 5% t o 40% ot p at ients 5% to .
complications
15% of whom develop grade 3 or 4 mucositis.8 Many modern
treatment approaches are frequently more toxic because of their
aggressiveness.• 5-FU is the most commonly used drug to treat Effective prevention of chemotherapy-induced oral complica tions
gastrointestinal malignanCies. Although it has long been believed that would allow for an improved quality of life for patients receiving che
continuous administration of 5-FU carries a higher risk of mucositis motherapy and a reduction of the rate of life-threatening infections
compared to bolus administration of 5-FU. a meta-analysis of trials that may originate in the oral mucosa. Theoretically, this could im
failed to s uppo rt this association.'0 prove the effectiveness of antineoplastic therapy by preventing treat·
When myeloablative chemotherapy is used, the incidence of ment modifications during subsequent cycles of chemotherapy and
mucositis increases to 70% to 100%, 21% to 67% of which is grade permitting more dose-intensive therapies. Several different methods
3 or 4 mucositis.'·" This appears to be especially true for induction have been proposed to prevent chemotherapy-induced oral com
regimens containing high-dose melphalan.' When chemotherapy is plications.
combined with radiation therapy to treat cancer of the head and
neck, the mucositis rate approaches 90% to 100% of patients. 43% Oral hygiene
of which is grade 3 o r 4 mucositis.'2
The rote of age and gender in the development of mucositis has AHhough generally there is insufficient evidence to suggest any one
not yet been clearly defined.13 There is also conflicting evidence on approach, there is enough collective evidence to recommend that
whether the type of bone marrow transplant (autologous versus patients receiving chemotl1erapy for solid tumors initiate a com·
allogeneic) or the use of total body irradiation in the conditioning prehensive oral care protocol.•• Multiple oral care protocols have
regimen is related to the risk of mucositis'3 On the other hand, demonstrated feasibility and tolerability, and some have shown a
poor oral hygiene. dental caries, periodontal disease, and high titers reduction in the severity of mucositis and an improvement in the
of herpes simplex virus (HSV} and positive oultures tor Candida patient's ability t o cope with symptoms.•• Such oral care protocols
tropicalis are generally considered risk factors.'3 are usually implemented by nursing, dental, or other staff and involve
Interpersonal variability in the development of mucositis has been various degrees of patient education. Protocols can include den
obseNed tor years, and this may be because of the differences in tal consultations and screening for caries lesions: basic oral care
metabolism of the chemotherapeutic drugs from person to person. with toothbrushing, Hassing, and frequent rinsing; regular inspection
A prime example is the drug methotrexate, which results in a of the oral cavity: and avoidance of substances such as tobacco,
much higher incidence of mucositis in patients who are unable to alcohol, hard-consistency foods, and spices.'6·" The cross study-
metabolize this drug.'" differences seen in the two similar treatment trials in Rg 13-2 may be
165
�3 i Or al Complications of Chemotherap y and Radiation Therapy
related to the use or nurse-directed oral care reco mmendati ons in ganan. a naturally occurring peptide with a broad antimicrobial
the second study. which were not used in tt1e first study. Because of spectrum. has also failed to show benefit." One small placebo·
the tow-grade chronic inflammation present in diseased periodontal controlled randomized trial has shown benefit ror the prophylactic
supporting tissues, tooth extraction prior to chemotherapy may also use of topical povidone-iodine. but further study is needed before
be a consideraton.
i 1e this agent is accepted for cl ni cal
i use.25 In addition , data are not
C urre ntl y there is a wide heterogeneity in the approach to mucositis
, convincing for s ystemic antibacterial proph yl axis and thus systemic
,
prevention in the United States. and multiple oral care protoco ls are antimicrobials are not recommended at this lime for the prevention
available. This indicates the need for a more standardized approach. ot mucositis22.2u•
including the institution of multidisciplinary teams. 19·20 Reactivation of HSV can be a significant complication in patients
Guidelines drafted by th e Centers tor Disease Control and receiving myetoablative chemotherapy. HSV frequently presents
Preventi on (CDC). Infectious Diseases Society of America (IDSA), and with regional and localized oral ulceration. Although high titers of
American Society for Blood and Marrow Transplantation (ASBM1) HSV and posi tive ou«ures for C tropica/is have been reported as
recommend a thorough dental ev a luation for myeloablat ive chemo i nifiCant risk factors tor the development of mucositis. the role of
sg
therapy candidates. with appropriate indicated treatment. before HSV is considered to be marginal , and routine surveillance cultures
initiation of any c onditi onin g regime n. This incl udes ap pro pr ia te of oral tissues are not recommended '5"" However, HSV infect ion
.
treatment of caries lesions. proper fitting of dentaJ prostheses. and should be suspected if mucositis persists or appears to worsen 2
extraction of periodontally compromised teeth. These interventions or more weeks posttransplantation. The CDC, tDSA, and ASBMT
ideally should be performed 10 to 14 days prior to any conditioning guidelines recomme nd testing fo
r serum anti-HSV immunoglobulin
therapy. During therapy, oral hygiene should be maintained with G prior to bone marrow transplan t. Prophylactic treatment with
rinses four to six times a day using s te rile water. normal saline. or acyclovir is recommended only tor seropositive allogeneic stem cell
sodium bicarbonate solutions. Patients should brush their teeth at re cipients until engraftment, until mucositis resolves, or up t o 30 days
least twice daily witll a soft or uttrasoft toothb rush or a foam swab. after the start of treatment. Prolonged treatment can be considered
Use of toothpaste is optional, and daily dental flossing should be for patients with frequent recurrent HSV infections. Seropostlive
done only by patients experienced in the technique if it can be done
, autologous stem cell reci-pients also may be treated if signifiCant
without trauma. In addition. patients need a relatively normal platelet mucositis is expected from the conditioning regimen. Vatacyctovir
count to floss without inducing bleeding. Orthodontic appliances and f oscarnet are not recommended for this indication.2•
and space maintainers can be removed during therapy, although Although antifungal medications are currently not recommended
they can be used during the initial conditioning phase if good tissue for the prophylaxis o f oral candidiasis in patients receiving chemo
integrit y and satisfactory daily oral hy giene is mai ntained.'-1 therapy. there is evidence to suggest that proph ylactic antifungal
medications that are gastroint estinally absorbable or p a rtia lly
Antimicrobial agents absorbable reduce the rate of oral candidiasis.3•
In the past. microorganisms were hypothesized to play a central role Cryotherapy

in the pathogenesis of mucositis. This is no longer thought to be
true, partly because topical and systemic antibiotics have thus far
failed to significantly affect the incidence and severity of mucositis. 5-FU-based chemotherapy
As a result, they are currently not recommended for routine use.22 A North Central Cancer Treatment Group (NCCTG) randomized cli
One explanation may be their general failure to significantly eradicate nical trial demonstrated t11at oral cryotherapy can inhibit the devel
mi crobes from the oral cavitf3 or the possibility that alterations in the opment of bolus 5-FU-induced mucositis.32 This finding has been
microbial flora by antimicrobial age nts might make no difference in independently validated by other investigators.� It is hypothesized
mucositis .».2< Another explanati on is that microorganisms may play that cryotherapy works by causing local vasoconstriction during pe·
a more complex or more minor rote in t he pathogenesis of muc ositis riods of peak 5-FU blood concentration, thus decreasing the delivery
than initially thought. It is currently suggested that instead of being of 5-FU to the oral m ucosa. ill this t herap y, the patient is asked to
involved in the initiation phase they probably intensify the inflamma
. suck on crushed ice starting 5 minutes prior to 5-FU administration
tory process associated with the later phases of mucosal injury.•·22 and continuing for a total of 30 minutes. Oral cryotherapy las ting
Nevertheless, there does appear to be an association between the longer than 60 minutes does not appear to provide any additiona l
severity o f mucositis and th e incidence of sepsis and other infec benefit in this se tting.3e
tions. suggesting that microbes use th e alread y damaged mucosa
as a portal of entry and therefore increase the risk of infectious com Eda t rexa te
plicati o ns. Four sm a ll nonrandomized phase I and II trials have used 20 to 30
Of all the antiseptic agents, chlorhexidine gluconate has been min utes of oral cryotherapy for prevention of mucositis in patients re·
most extensively studied in multiple randomized trials. Because ceiving edatrexate, a methotrexate analog with improved preclinical
of mixed fi ndings. its regular use is not recommended.•s.�.,. lse- antitumor activity. Three out of the four trials have shown g ood toler-
166 1
Oral Complications of Chemotherapy Including Myeloablative Chemotherapy J
ability of edatrexate when used with oral cryotherapy,37"""' and one Amino acids
study showed high toxicity desp ite this preventative strategy.40 Cur
rent guidelines recommend cryolherapy as an attempl to decrease Glutamine is a nitrogen-rich nonessential amino acid with critical
mucositis in patients treated with bolus edatrexate.15 roles in nucleotide synthesis. muscle function. and overall metabolic
homeostasis. During periods of stress. it becomes a conditionally
High-dose melphalan essential amino acid, and its stores can be significantly depleted, as
Several small prospective nonrandomized sludi e s in patients re is the case in patients with cancer.50 Multiple trials have attempted to
ce iving high-dose melphalan therapy have tested the efficacy of investigate the potential benefits of different glutamine preparations
oral cryotherapy. Grade 3 mucositis developed in up to 11% of througl1 both the parenteral and oral routes, with mixed results.50.6'
patienls treated with o ral cryotherapy, al1hough mucositis was Glutamine has been administered parenterally a s part of total paren
observed in over 70% of historical controls patients..,'"'5 In the teral nutrition or in intravenous infusions mixed with normal saline. I t
only randomized placebo-controlled study. which used room has also been administered as oral supplements and as swish-and
temperature normal saline as placebo, 40 patients were treated swallow mouthrinse preparations. Overall, these trials have been
with cryotherapy or placebo for 30 minutes before and 6 hours after small and rather inconclusive.
chemotherapy with high-dose melphalan. Grade 3 mucositis was Recent data have emerged regarding Saforis (MGI Pharma). an
experienced in 14% of patients receiving cryotherapy versus 74% of oral suspension of L-glutamine with an enhanced delivery system.
patients receiving normal saline.46 Although the need for prolonged In one trial, 326 patients with breast cancer who developed grade
cryotherapy is questionable, considering patient noncompliance and 2 or higher mucositis during the first cycle of treatment with an
the likely equivalent efficacy of shorter administration, cryotherapy anthracydine-based regimen were treated with Saforis. Concurrent
appears to be a promising strategy to lower the risk of mucositis in with their nex1 chemotherapy clos e . patients were given 2.5 g per 5
patients receiving high-dose melphalan therapy, and it is currently ml orally 3 times per day for at least 14 days. which they swished for
recommended in this setting." This evidence points to a possil)le 30 seconds and swallowed. Compared with a placebo control group.
role for cryotherapy in more diverse settings than previously thought. the results showed an 11% reduction in the incidence of grade 2
or higher mucositis in the subsequent cycle of chemotherapy (50%
Antioxidants, anticholinergics, and coating agents to 39%; P = .03). Patients who were treated with Saforis also saw
a reduction in subsequent severity of mucositis.� In another trial,
InsuffiCient evidence exists regarding the effectiveness of antioxidant 197 patients undergoing bone marrow transplant who were treated
compounds 11ke tretinoin and vitamin E in preventing oral mucositis with glutamine via the swish-and-swallow method for 14 days had
in patients receiving chemotherapy." A small randomized trial of zinc a significant reduction in the severity and duration of mucositis.
sulfate reported a statistically significant benefit in preventing severe This was true for the autologous transplant recipients but not for
mucositis, but more investigation is warranted before this agent can the patients receiving allogeneic transplants.53 Although glutamine is
be accepted into standard practice.•• Insufficient evidence also ex not yet officially recommended for the prevention of chemotherapy
ists to support the prophylactic use of propanthefine. an anticholiner induced oral mucositis. results of several studies are promising and,
gic drug that is though! to reduce the amount of etoposide secreted il subsequent data are confirmatory. recommendations may change.
in the saliva."" Sucralfate, a coating agent, has received mixed re
sults in studies and therefore is not currently recommended for the Growth factors
prevention of oral mucositis.�·26
Growth factors. whether administered systemically or topically, may
Anti-inflammatory agents help prevent oral mucositis because of their potential to improve
healing. Although the use of granulocyte colony-stimulating factor
Because inflammatory mediators appear to play a central role in the (G-CSF) and granulocyte macrophage colony-sti mulating factor
development of mucositis, the use of anti-inflammatory agents has (GM-CSF) has been associated with reduced incidence or mucosi
been proposed as a preventive method. However, cytokine inhibitors tis in certain randomized trials. the data are inconclusive. A recent
and anti-inflammatory agents have not yet proven effiCacious. meta-analysis found that systemic growth factors were beneficial for
Pentoxify11ine, a TNF-a and IL-2 inhibitor. is not recommended prophylactic treatment. but topical preparations were not.l<l How
in either the standard chemotherapy or bone marrow transplant ever. these results were largely based on one strongly positive study;
s etting.'"" Benzydamine mouthrinse has been approved to treat fLJrther evidence is therefore n eeded.,.
radiation-induced mucositis in Europe and Canada and is currently Topical keratinocyte growth factor (KGF). which is secreted b y
being tested in the United States. '5.<9 However. evidence regarding injured mucosal epithelium. may !lave a more localized healing effect
its use in prevention of chemotherapy-induced mucositis is weak. in the oral cavity. On e such preparation. palifermin, was recently
and it is currently not recommended in this selting.zo cleared by the US Food and Drug Administration (FDA) for use in
preventing myeloablalive chemotherapy-induced mucositis. The
recommendation was based on a randomized study of 212 patients
167
�3 i Or al Complications of Chemotherapy and Radiation Therapy
who received intravenous palifermin or placebo for 3 consecutive the study was not conclusive, and further investigation is under·
days immediately before the ini tiation o f conditioning therapy. Grade way. Finally. a double-blind. randomized. placebo-controlled trial of
3 or 4 mucositis developed in 63% of patients in the palifermin chamomile mouthrinse has also fail ed to shOw benefit.�·2G
group and 98% of patients in the placebo group.» Palifermin has
shown benefit in at least two more trials. In a series of 59 patients Conclusions regarding prevention
undergoing hematopoietic stem cell transplantation, 13% of patients
receiving palifermin developed severe mucositis compared to 48% The importance of instituting oral hygiene protocols in p atients re·
o f patients who received standard care."' ceiving chemotherapy is well established. Cryotherapy is the most
Palifermin was also tested in 64 patients with colorectal cancer conventional and simplest preventive method. at least for 5-FLJ
who received 5-FU-based chemotherapy. Again, a signficant
i based bolus therapy, and appears to have implications for other
i score was seen: 29% o f patients
reduction in severe mucosits chemotherapeutic regimens such as edatrexate and high-dose
receiving palifermin developed severe mucositis compared to 61 o/o melphalan therapy. The rote of topical or systemic antibiotics is not
of those who received a placebo.51 Although apparentty effective, yet established. Glutamine supplementation in the form of AES-15
palifermin is an expensive option for mucositis prevention at this (Saforis) has recently shown promise as a potentially effective agent.
point. In addition, because oral cryotherapy was not administered to Palifermin, a KGF preparation. has been cleared by the FDA tor LISe
the patients who received 5-FU-based chemotherapy or the patients with high-dose chemotherapeu1ic regimens that are associated with
who received high-dose melphalan therapy in these studies, it would high rates of mucositis. Palifermin has shown promise in other set·
be interesting t o examine how palifermin would fare in comparison tings as well. Low-level laser therapy has shown promise bu1 is lim·
to oral cryotherapy. ited to centers able to support its use.
Low-levellaser therapy
Treatment of chemotherapy-induced oral
There is accumulating evidence that low-level laser therapy may
promote healing and reduction of pain in patients at risk for oral mu
mucositis
cositis.ss.s9 However, the expense, the need for specialized training
and equipment. and the diffiCulty in interpreting and comparing the Despite a plethora of prescr ibed remedies. scant information is avail ·
results from various trials limit the widespread applicability of this able regarding the effective treatment of chemotherapy-induced
approach at this time. AlthO ugh no guidelines regarding this thera· mucositis. Hence. initial treatment of established mucositis varies sig
py exist as of yet, low-level laser therapy is considered standard in nificantly among institu1ions, and different providers often prescribe
some treatment centers.00 Further investigation with large phase Ill, remedies based on their individual experiences and preferences.'9
randomized, placebo-controlled clinical trials is encouraged.'s For Among these many proposed treatments are various mouthrinses,
centers able to support the necessary technology and tra ining. this costing agents, topical anesthetics or analgesics, anti-infla mmatory
approach is recommended in an attempt t o reduce the oral mucosi· agents. systemic narcotics. and topical and systemic growth lac·
i h myeloablative chemotherapy.
tis associated wt tors.15 These treatments are aimed at promoting the healing of the
injured oral mucosa. thus limiting the severity and duration of ulcer
Other interventions ations and palliating the symptoms of oral mucositis.

General recommendations frequently given to the p atients with
Other protocols include the prophylactic use of mouthrinses such established mucositis include the avoidance of spicy, coarse, hot,
a s normal saline, sodium bicarbonate solutions. and other mixtures. cold, or acidic foods or liquids, and all medications or beverages
Although there i s insufficient evidence t o support their use. these containing alcohol. Soft. moist foods and nonalcoholic beverages
mixtures constitute parts of various standard oral care prot ocols. are encouraged. The treating physician s11ould take care not to lose
However, evidence does Show that alcohol-containing rinses tend to sight of the othe r important means of support for the cancer patient
wors en the symptoms of mucositis and therefore should be avoided. with mucositis: Proper hydrat ion . nutrition, infection surveillance,
In a d oub le-blin d controlled trial in patients undergoing bone marrow and psychologic support can all significantly affect the patient's well·
transplantation, a neutral supersaturated calcium phosphate rinse being and quality of life.
(Caphoso1 [EUSA Pharma]) given in conjunction with fluoride was
shown to have greater benefits than fluoride rinses alone.00 Allopuri Mouthrinses
nol mouthrinses, despite constituting "standard clinical practice" at
some institutions in the early 1990s, are cur rently not recommended For p atients with established mucositis. one of the first therapeutic
because at least two randomized clinical trials have convincingly measures frequently recommended is to r inse the mouth every 2 to
shown no benefit.25.<11.e2 A homeopathic remedy tested as a mouth· 4 hours with a salt and baking soda solution (Y.! tsp salt plus Y.! tsp
rinse in a randomized placebo-controlled trial of 32 pediatric patients baking soda in an 8-oz glass of warm water). This IS often soothing
undergoing stem cell transplantation showed a statistically signifi and is thought to be deansing. Some centers use baking soda alone
cant reduction in the incidence and severity of mucositis. However . because the addition of salt is thought to b e too drying to the mu·
1681
Oral Complications of Radiation Therapy J
cosa. In one multicenter study, 200 patients receiving standard che recommended. Antibiotics or antifungal medications should be given
motherapy who followed a carefully planned oral hygiene protocol to patients with evidence of infection. Various palliative mouthrinses
(PRO-SELF) were randomized to one of three different mouthrinses: freQuenHy containing combinations of diphenhydramine. viscous
salt and baking soda, chlorhexidine, or •magic mouthwash" (lido lidocaine. magnesium hydroxide/aluminum hydroxide, nystatin, and
caine, Benadryl [McNeii-PPC], and Maalox [NovartisJ). No significant corticosteroids are widely used in clinical practice based on provider
differences were observed among the three regimens in the time it preference and experience. The efficacy of these mouthrinses has
took to soothe the signs and symptoms of mucositis, but the salt not been adeQuately evaluated to date, although salt and baking
and soda solution was the least costly."' soda mouthrinses appear to be the most economic solution.
Mouthrinses. often referred to a s magic mouthwash or miracle
mouthwash, are usually topical preparations of analgesic. anesthetic,
and coating agents, the composition of which varies across
institutions. The most common ingredients are diphenhydramine.
Oral Complications of Radiation
viscous lidocaine, magnesium hydroxide/aluminum hydroxide, Therapy
nystatin, and corticosteroids."" Other ingredients may include
benzocaine. milk of magnesia, chlorhexidine, kaolin. and pectin.·�
Despite their widespread use, the general lack of evidence supporting Mucositis
the efficacy and tolerability of these mouthrinses does not allow any
of these preparations to be included in current formal guidelines.'5 Etiology
Further study of these palliative mixtures is strongly encouraged,
given their overall availability, ease of administration. freQuent use. The most troublesome acute reaction for patients receiving radiation
and low cost. therapy to the cral cavity is radiation-induced mucositis. Acute mu·
Chlorhexidine mouthrinses are not recommended because studies cositis results from the loss of squamous epithelial cells as a result
have failed to support their use for the treatment of established of the sterilization of mucosal stem cells and the inhibition of transit
mucositis.•> Coating agents such as sucralfate also have failed to cell proliferation. This leads to a gradual linear decrease in epithe·
show any benefit for the treatment of established chemotherapy lial cell numbers. As radiation therapy continues, a steady state be·
induced mucositis when tested in small randomized trials.65 tween mucosal cell death and mucosal cell regeneration may occur
because the surviving cells increase cell production rates. Usually,
Anti-inflammatory agents however, cell regeneration cannot keep u p with cell death, and partial
or complete denudation develops. This presents as patchy or conflu·
Anti-inflammatory agents in general have not been established as an ent pseudomembranous mucositis. Healing eventually occurs when
effective treatment for chemotherapy-induced mucositis.eo> cells regenerate from the surviving mucosal stem cells. The loss of
the epithelial barrier exacerbates insults from physical. chemical, and
Growth factors microbial agents. It has been reported that the oropharyngeal flora
may contribute to radiation therapy-induced mucositis. However,
It is hypothesized that GM-CSF, whether used topically as a mouth which flora i s involved. and which step in the mucositis process may
rinse or systemically, may stimulate proliferation of endothelial cells be prevented by elimination of the offending flora, remains unknown.
and promote keratinocyte growth, thus enhancing recovery from orat One hypothesis is that endotoxins produced by gram-negative bacilli
mucositis. However, studies have been limited and of poor meth are potent mediators of the inflammatory process.
odologic Quality.65•67 Because the oral mucosa has a relatively high turnover rate, it
changes early during a course of fractionated external beam radiation
Systemic analgesics therapy. At tractions of 2 Gy per day, 5 days per week. mucosal
erythema is typically noted within the first week or two of trea tment.
Oral mucositis pain can be severe and can significantly interfere with By approximately 2 to 3 weeks after the start of treatment, the
the Quality of life of patients receiving chemotherapy. Management erythematous mucosa develops small whitish-yellow patches called
should follow the same aggressive guidelines used to treat general patchy pseudomembranou s mucositis. These pseudomembranes
pain in patients with cancer."" The use of patient-controlled anesthe represent collections or dead surface epithelial cells, fibrin, and
sia to treat mucositis pain is effective and well established. especially polymorphonuclear leukocytes on a mOist background. Tl1is acute
in the hematopoietic stem cell transplantation se1ting.15 reaction is typically accompanied by oral discomfort. In many
patients, the patchy mucositis becomes confluent by the third
Conclusions regarding treatment methods or iourth week o f radiation therapy and can be associated with
significant pain.
Overall, evidence is lacking regarding the effica cy o f various agents The severity of mucositis is related to the daily dose of radiation
in treatment of established mucositis. Systemic analgesic therapy therapy, the total cumulative dose, the volume of irradiated tissue,
o f mucositis pain with narco tic medications is well established and and the use of concurrent radiation-senSitiZing or mucositis-Inducing
169
�3 i Oral Complications of Chemotherapy and Radiation Therapy
Chemotherapeutic agents. At fractions of 1.7 Gy to 1.8 Gy per day, Prevention and treatment
5 days per week. the maximum reaction is typically intense erythema
with occasional patChy mucositis. In this situation, cell death and In light of the serious deleterious effects that radiation-induced oral
repopulation of epithelial stem cells are in near equilibrium. If the daily mucositis may have on a patient's well-being and the potential loss
dose is increased to 2 Gy or more, cell death exceeds the prol ferative of tumor control that may result from an interruption or prolongation
i
capacity of the epithelial stem cells. and almost all patients will have o f treatment because of mucositis, measures for preventing muco·
confluent mucositis b y the third week of radiation therapy. This sitis are being investigated. Benzydamine hydrochloride 0.15% oral
happens in cases with a large volume of tissue to be treated (eg, rinse. a nonsteroidal drug that possesses analgesic, anesthetic. anti·
the entire oral cavity) and altered fractionation schedules, which may inflammatory, and antimicrobial properties, is effective, safe, and well
involve hypertractionation (1 .1 Gy to 1.5 Gy twice a day) or accelerated tolerated for prophylactic treatment of radiation-induced oral mu·
fractionation (1.6 Gy two or three times a day or concomitant boost cositis.•vo Nonetheless, benzydamine is not cleared for this use in
with 1.8 Gy in the morning and 1.5 Gy in the afternoon). the United States because the data are not conVincing regarding
Mucositis first appears and is often most severe on the mucosa of its benefit and because some of the studies investigating it used an
the soft palate, tonsillar pillars, buccal mucosa. lateral border of the alcohol-based control arm (which should cause toxicity in patients
tongue, and pharyngeal walls. The hard palate. gingival ridges. and geuing radiation therapy) as opposed to a placebo.
dorsum of the tongue are less frequently involved during a course of Several controlled clinical trials have evaluated combinations
radiation therapy or, alternatively, only after very high doses or when of relatively nonabsorbable antibiotics (tobramycin, polymyxin E,
administered with concurrent radiation-sensitizing chemotherapy. and amphotericin 8; or bacitracin. clotrimazole. and gentamicin
In patients with metallic dental restorations, promi-nent mucositis or iseganan) for patients undergoing radiation therapy to the oral
frequently develops on the adjacent buccal mucosa. the adjacent cavity.•9•7'"79 These trials generally do not provide conVincing data
lateral border of the tongue, or both as a result of back-scattering of of sufficient clinical magnitude to recommend use of antimicrobial
low-energy electrons. mouthrinses (chlorhexidine or benzydanline). antibiotic lozenges, or
Symptoms of oral discomfort are usually at their most intense 3 to antibiotic paste as part of standard practice. For a critical review, the
4 weeks into the course of radiation therapy. Thereafter, symptoms reader is referred to an article b y Sutherland and Browman.eo
usually plateau and may even diminish in patients treated with The inability to control mucositis-related pain can frustrate the
radiation therapy atone. even if treatment is continued. After external patient and the treating physician. Substances that have been
beam radiation therapy, the mucous membranes normally heal evaluated with mixed results include the following"'""":
within 4 to 6 weeks, although occasionally a patient may require up
to 12 weeks or even several months. The latter is particularly true of • Viscous lidocaine with 1% cocaine
patients treated with concurrent radiation-sensitizing chemotherapy. • Dyclonine hydrochloride 1.0%
The mucositis produced b y an interstitial radioactive implant • Mixture of kaolin-pectin solution, diphenhydranline, and saline
typically appears 7 to 10 days alter removal and peaks approximately • Morphine
2 weeks alter removal. The mucositis generally heals b y 6 weeks • Tricyclic antidepressants
after removal. unless the implanted volum e was large, in which case • Mucosa-adhesive water-soluble polymer film containing topical
complete healing may require several months. anesthetics and antibiotics
Radiation-induced oral mucositis canresult in intense pain. which may • Oral aloe vera
substantially limit adequate hydration and nutrition, prevent proper oral • Capsaicin lozenges
hygiene, serve as a portal for infection, and affect speech. All t11ese • Sodium-sucrose-octasulfate mouthrinse
effects can significantly intertere with the general well-being of the
patient and may tempt the treating physician to interrupt the course Janjan et al8' reported improved pain management in patients
of treatment to permit resolution of the acute symptoms. At times, the undergoing radiation therapy for head and neck cancer when they
treatment may be discontinued altogether before a potentially curative received daily nursing intervention consisting of instructions on the
regimen of radiation therapy can be fully delivered. use of mouthrinses and a three-step analgesic protocol consisting of
Clinical and radiobiologic evidence shows that the protraction acetanlinophen, acetaminophen with codeine suspension, and liquid
of overall treatment time adversely influences the radiocurability of morphine for relief of mild. moderate, and severe pain, respectively.
certain human tumors. particularly squamous cell carcinomas of the The prescribed analgesic regime n was promptly changed when
head and neck region. The additional dose needed t o compensate each patient's symptoms changed. Patients who had the nurSing
for a protracted course of radiation therapy has been attributed t o an intervention reported fewer days of moderate and severe pain; had
accelerated tumor clonogenic growth rate. Randomized clinical trials less pain throughout the day; and noted less disturbance in sleep,
have demonstrated improved local control and survival when a"ered food intake, and energy level. Dally review of a symptom survey by a
fractionation schemes that deliver conventional or higher doses of radiation oncology nurse, combined with a well-defined strategy for
radiation therapy are used over a shorter-than-conventional period.69 mouth care and analgesics. appeared to improve pain management
Therefore, a break in radiation therapy because of mucositis may of radiation-induced oropharyngeal mucositis because of prompt at
lead to treatment failure. tention to patient needs.
170 1
Fig 13-3 TOillJue depressing stent used during treatment of carcinoma on the base
of the tongue.
Many narcotic pain medications come in a liquid formulation Other preliminary studies have investigated Ule direct application
that is relatively easy to swallow or can be administered through a of a prostaglandin E2 gel.""' the use of oral glutarnine.'03 and daily
feeding tube. Fentanyl patches are also very effective for patients use of subcutaneous GM-CSF.�� Results of pilot studies suggested
who cannot swallow. A topical morphine mouthrinse may be a that GM-CSF may be quite effective in the prevention and treatnlent
more effective treatment for mucositis pain than the more common of radiation-induced oral mucositis.Ill>Ia& However, prospective
magic mouthwash"" (eg, lidocaine, diphenhydramine, magnesium randomized clinical trials have revealed no definite evidence that
aluminum hydroxide). subcutaneously administered GM-CSF reduces the severity of
Additional interventions to prevent or minimize radiation-induced radiation-induced mucositis.1"'·"0 On the other hand. some early
mucositis have been evaluated. One such intervention involves the animal and human data suggest that. in addition to its role in
use of a sucralfate suspension, an agent that appears to provide chemotherapy-induced mucositis, KGF also may be efficacious in
a protective barrier and may have a cytoprotective effect. The the prevention and treatment of radiation-induced mucosttis.<»·"'-"3
latter may be mediated through prostaglandin release. resulting in A multicenter study of intravenous palitermin to reduce mucositis in
increased mucosal blood flow. mucus production, mitotic activity, patients with head and neck cancer receiving chemoradiotherapy is
and a suriace migration of cells. However, results from small being conducted by the Radiation Therapy Oncology Group (RTOG).
double-blind, placebo-controlled. randomized prospective trials The radioprotector amifostine has been evaluated as a means of
are contradictory.- Thus, tile randomized trials of sucralfate as preventing radiation-induced acute mucositis. One small randomized
treatment for mucoSitis do not establish a role lor sucralfate in clinical clinical trial reported that amifostine reduced the severity of acute
practice. mucositis.'" Unfortunately, larger randomized trials evaluating intra
Another intervenllon consists of painting the buccal mucosa with venous or subcutaneous amifostine in patients receiving radiation
a 2% silver nitrate solution for several days before radiation therapy. therapy alone or combined with chemotherapy have revealed con
Maciejewski et al96 reported that this intervention stimulated normal flicting results.1"""" Nausea, vomiting, hypotension, allergic re
mucosa repopulation during radiation therapy, which produced a actions. and injection-site reactions are common side effects of this
significantly less severe mucosal reaction and faster mucosal healing drug. These side effects may be reduced by rapid intravenous push,
after completion of radiation therapy. Low-level laser therapy may optimal hydration of the patient, premedication with antiernetics, and
also activate epithelial healing. A phase Ill, randomized, placebo subcutaneous administration. However. in addition to questionable
controlled trial to evaluate the efficacy of low-level helium-neon efficacy and significant toxicity, amifostine is associated with re
laser in the prevention of radiation-induced mucositis demonstrated markably increased costs."0 In total. present data are insufficient to
significant reduction in severity and duration of oral mucositis recommend amifostine at the dosage required t o prevent mucositis
associated with radiation therapy, even when combined with associated with radiation therapy. 1•1
chemotherapy.•' Astute treatment planning for radiation therapy can limit the volume
A double-blind, placebo-controlled, randomized trial of treatment of no1111al tissues irradiated and thereby reduce the severity of normal
with 40 mg of prednisone daily beginning on the eighth day of an tissue reactions. Methods t o reduce these reactions in patients with
accelerated course of radiation therapy did not show a reduction in head and neck cancer Include (1) computed tomography-based
the intensity or duration of mucositis. However, a trend was observed target delineation. (2) intensity-modulated radiation therapy (IMRT),
that favored the role of prednisone in shorter treatment interruptions and (3) custom-made intraoral stents (Fig 13-3) designed to exclude
and a significant reduction in overall treatment time.98 Zinc sulfate, uninvolved tissues from the treatment portals or shield tissues within
ct-tocopherol. and intravenous �-alanyl-�-glutamine have been the treatment area."a·'22·'23 Patients with primary cancers of the oral
found to be effective in decreasing the severity of radiation-induced cavity, oropharynx, paranasal sinuses, and salivary glands are the
mucositis and oral discomfort in placebo-controlled prospective best candidates for the use of intraoral devices. Posi1ional stents
tri als.'800·'00 In an uncontrolled evaluation. orgotein. a copper-zinc can effectively exclude the tongue and floor of the mouth when hard
superoxide dismutase. demonstrated reduced severity of acute palate, nasal cavity. and paranasal sinus malignancies are being
radiation-induced mucositis.'"' These unique approaches to the treated. COnversely, they can be used to exclude the palatal mucosa
problem of acute mucositis deserve further study. during treatment of the tongue or floor of the mouth. Shielding stents
171
�3 iOral Complications of Chemotherapy and Radiation Therapy
made with a lead alloy have been found to provide protection for the first 1 or 2 weeks of treatment. Not only is the quantity of saliva
uninvolved ccntralateral muccsa in treatment of well-lateralized reduced, but its composition and physical properties are changed
tumors or the oral cavity, parotid gland, lip, and skin or the cheek. as well. Drastic reductions in basel ine and reflex production of
Gauze packed between metallic restorations and buccal mucosa alkaline and watery secretions of serous acini often persist after the
can reduce scatter radiation. Radiation dose can al so be minimized ccmpletion of radiation therapy. Without appropriate management,
when treatment plans involve electron-beam. three-dimensional this problem can lead t o progressive deterioration of the teeth,
conformal. multibeam, wedged-pair, or oblique radiation therapy. muccsa, gingiva, and mandible.
Standard measures to prevent and treat radiation-induced The acute response of serous salivary glands to radiation has been
muccsttis in patients often include aggressive, meticulous oral shown to result from interphase death of the reproductive stem cells
hygiene. This consists of brushing after each meal with a soft and damage t o the fibrovascular stroma. A progressive reduction in
toothbrush and baking soda toothpaste and rinsing the mouth salivary flow rates, pH, and secretory immunoglobulin A has been
every 2 hours throughout the day with a half-strength hydrogen demonstrated with increasing doses of radiation therapy. In parotid
peroxide or alkaline solution. Patients should be instructed t o avoid glands that receive less than 1.000 cGy; 90% continue to secrete
irritating or abrasive substances such as cc mmercial toothpastes measurable quantities of saliva after stimulation. This decreases t o
and mou!hrinses; tobacco: alcoholic beverages; extremely hot or 50% after administration o f 3.000 cGy. 19% after 5,000 cGy, and
cold foods or beverages; very spicy foods; acidic foods (eg, citrus 0% after 7,000 cGy. In g4% of patients receiving doses of less than
fruits and their juices); and foods that are hard and coarse (eg, raw 5,200 cGy, secretion quantities may reccver beginning 2 months
vegetables, pretzels. potato chips, crackers. and crusty bread). after treatment, wtth ccntinual improvement of the salivary flow for
When disccmfort develops. topical anesthetic agents can be used. up to 18 months. Doses that exceed 6.400 cGy cause irreversibly
As the pain progresses. use or systemic analgesics, including depressed parotid function in the majority of glands. Patients
acetaminophen with codeine suspension or oral morphine sulfate receiving doses ot more than 6,400 cGy to one gland may have
elixir, may beccme necessary. Suspensions are preferred over elixirs only slight dryness; 11owever. patients with both glands irradiated
because they are formulated without alcohol. Daily intervention by a will have severe problems with salivary flow and discomfort from
radiation therapy nurse or physician, with prompt increases in doses dryness. Exclusion of more than 50% of both parotid glands from
of syst emic analgesics as necessary, appears t o result in improved the direct radiation beam can prevent severe dryness when the rest
pain control. improved sense of well-being, and less weight loss.87 of the major salivary glands are included in the lield. There is a linear
The muccsa o f patients undergoing radiation therapy t o the oral correlation between postradiotherapy salivary flow ratio and parotid
cavity should be examined at least once a week. and antibiotic gland dose (5% loss ol function per 1 Gy of mean dose) as well as a
or antifungal medications should be prescribed i f infections are strong parotid volume dependency.'26 Because there is no threshold
documented. Clotrimazole lozenges. one dissolved in the mouth five dose, radiation treatment planning should attempt to achieve as low
times a day for 14 days, generally work well to treat oral candidiasis. a mean parotid dose as possible. A mean dose below 39 G y has a
However, i f Significant mucoSitis, altered taste. or xerostomia has oomplication probability of 50%. Recovery of parotid function can
developed. nystatin oral suspension or fluconazole in tablet or be evaluated at 6 months . 1 year. and 5 years after completion of
liquid form is often effective and better tolerated than lozenges. radiation therapy. '27·'26
Fluconazole is more effective than nystatin, but to prevent drug It has been suggested that a mean parotid gland dose of 26 Gy
resistant infections, it may need to l)e given at a higher dose or for or less should be a planning goal if most gland function needs t o
an extended period in patients receiving combined chemotherapy be preserved.'26 ·'29 Using the normal tissue complication probability
and radiation therapy.'"'·'�• model, studies found that the dose/volume/function relationships
in the parotid glands are characterized by (1) dose and volume
thresholds. (2) steep dose/response/function relationships when the
Xerostomia thresholds are reached, and (3) a maximum volume dependence
parameter. Chao et al';n observed a correlation between mean
Etiology parotid dose and t h e fractional reduction of stimulated salivary

output a t 6 months alter the ccmpletion of radiation therapy. They
The major salivary glands (parotid, submandibular, and sublingual) also noted that responses t o quality-of-life questions on eating
produce up to 80% of total salivary secretions. The rest of the saliva and speaking functions were significantly affected by stimulated or
is produced by minor glands scattered thro ughout the oral cavity. It is unstimulated salivary now at 6 months. Based on these findings,
estimated that the sublingual glands contribute only 2% to 5% of the sparing the parotid glands should translate into objective and
salivary flow rate. Submandibular glands seem to be as important as subjective improvement of xerostomia and quality of life in patients
or more important than parotid glands in the resting state, although wit h head and neck cancer receiving radiation therapy. Eisbruch e t
parotid glands beccme the main contributors under stimulation. a1m found that the degree o f xerostomia was related to the degree
When areas undergoing radiation therapy include the major salivary of xerostomia experienced before radiation therapy, the time since
glands. many patients experience dryness of the oral muccsa during radiation therapy, and the mean close to the major salivary glands
1721
(most notably the submandibular gland) and oral cav ty. This would butter, broth, mayonnaise, yogurt, or salad dressing. Dunk1ng bread
i
suggest that radiation exposure of the oral mucosa and its minor and other baked foods in milk or other liquids makes them easier to
salivary glands should be minimized as an important goal in treatment swallow. Some patients may find a pureed diet or a full-liquid diet
planning to reduce the severity of radiation-induced xerostomia. easier to swallow than solid foods. Addition of a liquid high-protein
supplement will help ensure that patients are getting enough protein
Prevention and treatment and calories. Hot. spicy, or acidic foods may b e irritating and should
be eaten with caution. For some patients, a vaporizer or humidifier
Treatment of radiation-induced xerostomia includes the avoidance of in the room or at the bedside helps alleviate the discomfort of
any drugs that may also decrease the flow of saliva and contribute xerostomia. Frequent oral rinses with an alkaline solution may help
to patient discomfort. These drugs may include anorectic agents, restore the sense of taste, moisten the mouth, and promote better
anticholinergics, antidepressants, antihistamines, antihypertensives, hygiene.
antipsycholics. antiparkinsonian agents, diuretics. caffeine, nicotine. Two large randomized, double-blind. placebo-controlled. multi·
hypnot ics and sedatives. Patients should be advised to take fre
. center clinical trials have documented the efficacy of oral pilocarpine
quent sips ot water and suck on ice chips. Because chewing stimu (5 mg given orally three times a day) in improving salivary flow. mouth
lates the now of saliva, patients with reSidual sal ivary function may be comfort. and ability to speak: relieving oral dryness; and reducing
helped by eating foods such as carrots or cele•y o r by chewing sug the need for oral comfort agents after head and neck irradiation.
arless or xylitol-containing gum. Patients with xerostom i a are highly Adverse reactions are minimal, the most common being mild to
susceptible to caries lesions and should not use sugar-containing moderate sweating, which is related to dose. Best resu�s may
o r acidic foods or beverages to stimulate salivary flow. Commercial require continuous treatment for more than 8 weeks.I3S·�>' Most
nonprescription solutions used to lubricate the oral tissues may be patients reported significant relief of symptoms of xerostomia and
the only effective treatment lor patients without functioning salivary improvement in quality of life that did not appear to be dependent
gland parenchyma or tor those whose salivary glands do not re on previous radiotherapy dose/volume parameters. These reports
spond to stimulation. Virtually all lubricants can provide some short suggest that oral pilocarpine acts primarily by stimulating ectopic
term relief for patients with xerostomia. Some studies have indicated salivary glands and can be beneficial for a large range of patients
that salivary substitutes containing carboxymethyl cellulose or hy with xerostomia. Topical pilocarpine adminis tration has shown
droxymethyl cellulose are more effective in relieving dryness than results similar to those achieved with systemic treatment but with
water-based or glycerin-based solutions. Some patients prefer mu· improved patient toterance.138
copolysaccharide solutions. Xialine (ACTA), a xanthan gum-based One small retrospective trial and two small double-blind. placebo
saliva substitute, has been shown to be no better than placebo in controlled. randomized Wals suggested that pilocarpine (5 mg given
decreasing the effects of xerostom a,
i althOugh Xialine may be able to orally tour times a day), started the day before or on the same day
reduce problems with speech and senses that are attributable to dry as radiation therapy, given concurrently with radiation therapy, and
mouth.131 After review of patient-completed xerostomia inventories continued for 3 months after radiation therapy results in a lower
,
and unstimulated and stimulated salivary flow rates. various reports frequency of oral symptoms and xerostomia dur ing and after
have suggested that acupuncture can reduce symptoms ot xerosto· treatment. It may not be necessary to continue pilocarpine after 3
mia and improve salivary flow rates.131·'3' monthS to maintain the benefits.,,_,.. However, two large placebo
For the treatment of established radiation-induced xerostomia. the controlled clinical trials conducted by Princess Margaret Hospital
following medicaments are recommended: and the RTOG failed to confirm these initial findings and did not
demonstrate any reduction in the incidence or severity of radiation
• Pilocarpine 5 mg. given orally three to four times a day, up to 10 mg induced xero sto mi a with prophylactic use ot pilocarpine 3 days
three times a day maximum; or as an alternative. cevimeline HCI before radiation therapy, during radiation therapy, and for 3 months
30 mg. given orally three times a day after completion ot radiation therapy. "2·"3
• Artificial saliva (eg, Mouthkote [Parnell], Xerolube [Colgate], MoiStir Amifostine appears to protect the sal vary glands from the effects of
i
[Kingswood Laboratories]) radiation therapy and may be helpful to prevent or minimize the effects
• Biotene products (eg, gum, toothpaste, mouthrinse) (GiaxoSmith· of xerostomia and loss of taste.""""6 ."9·1""·145 Several non-placebo·
Kline) controlled cflnical trials reported significant reduction in the severity of
acute and chronic radiation-induced xerostomia with prophylactic use
Xerostomia primarily affects mastication and oral manipulation o f amifostine. 114"1161'·1 1•• Based on local or regional control and overall
of dry, absorbent food material. Initiation and duration of the survival, there was no evidence that amifostine interfered with the
pharyngeal swallow do not appear to be affected. Patients with antitumor effects of radiation therapy. Jellema et a1 compared patients
severe xerostomia may be helped by eating soft, bland foods, who received no amifostine t o those who received it three or five times
including cool or cold foods with a high liquid content such as ice weekly. The incidence of grade 2 or greater late xerostomia differed
cream, popsicles, puddings, watermelon, and grapes. Solid foods Significantly at 6 months (74% for no amifostine, 67% for three times
can be made easier to swallow by adding gravies, sauces, melted weekly, 52% for five times weekly) but not thereafter. Patient-rated
173
xerostomia was more severe in the patients not receMng amifostine, situation have been mixed, with those of the largest placebo
and no difference was seen between those who received doses three controlled trial being negat ive. However, based on results of clinical
or five times weekly. Nausea and emesis were common side effects, trials, amifostine has been cleared by the FDA in the adjuvan t set
with 28o/o of patients discontinuing the amifostine before the end of ting as an agent that can attenuate the development of xerostomia.
radiotherapy. ••• Subcutaneous admi nistration of amifostine may be Nonetheless, the inconvenience and toxicity of this drug therapy
as effective as intravenous administration, with less severe nausea, limit its use in some practices. IMRT may preserve salivary flow and
vomiting, and hypotension but more frequent cutaneous toxicity."6 improve quality of life in patients with early-stage nasopharyngeal
Incidence o f grade 2 or higher xerostomia continued to decrease while carcinoma.
unstimulated and stimulated saliva production continued to increase
at 12, 18, and 24 months posttreatment in the patients not receiving
amifostine. In addition while the mean overall scores for the patient
,
Dental caries
benefit questionnaire improved signifiCantly for those taking amifostine
at 12 months, there were no further significant Improvements at Etiology
18 or 24 months.••• A placebo controlled phase Ill trial failed to
-
confirm the radioprotective benefit of amifostine on salivary function Patients undergoing radiation therapy to the oral cavity have an in
following chemoradiotherapy. "8 Xerostomia self-report quest creased incidence of caries b ecause of an insufficient quantity of
ionnaire scores are a more accurate reflection of the severity of saliva to cleanse the teeth and changes in the quality of the saliva.
xerostomia because physician-assessed scores underestimate the These factors promote colonization of the oral cavity by a more car
severity of xerostomia. 1'17 A small randomized trial demonstrated that iogenic flora. In addition. the discomfort associated with xerostomia
amifostine may prevent deterioration o f dental health."8 The use of and persistent mliCOsitls may result in poor oral hygiene with infre
amifostine may be considered to decrease the incidence or acute quent brushing, flossing, and oral rinsing. Some patients may alter
and late xerostomia in patients undergoing fractionated radiation their diets to include sugar-containing drinks and soft foods in an
therapy in head and neck regions that include the salivary glands."' effort to alleviate the effects of xerostomia. Rampant caries involVing
Amifostine has been cleared by the FDA for use in the postoperative all tooth surfaces (including the cervical portion) can result after just
adjuvant setting . a few months of xerostomia.
In selected patients with cancers in the oropharynx. hypopharynx.
or larynx. it has been reported that surgical transfer of a sub Prevention and treatment
mandibular gland into the submental space can be successfully
accomplished."9 If patients reql.lire postoperative radiation therapy, To prevent the development of dental caries (which may necessitate
the submandibular gland can more readily be excluded from the extraction or resuH in soft tissue necrosis. bone exposure. or osteo
irradiated volume, thus preserving some saliva production. However, radionecrosis (ORN]) after a course of radiation therapy, all patients
this process requires validation by controlled cl inical trials. should undergo a thorough dental evaluation before treatment. Un
Three-dimensional conformal radiotherapy and IMRT have been salvageable teeth should be extracted. with an alveolectomy and
shown in prospective uncontrolled and controlled phase 111 clini cal primary wound closure to follow. Patients should have a thorough
trials to preserve parotid salivary ftow and improve quality of life dental prophylaxis. including scaling. root planing, curettage. and
!<l.�>•
by reducing the radiation dose t o the parotid glands.'"·'2!1.•30.o polishing. Restorative dental procedures should be performed for
Altered fractionation radiation therapy schedule s may also help to salvageable teeth. A preventive regimen should be initiated, includ
preserve salivary function. The function o f parotid glands in patients ing plaque removal w�h dental floss and thorough instructions for
treated with three different radiation therapy schedules was evaluated effective toothbrushing. Custom-made fluoride carriers should
9 or more months after completion of treatment.'"" Twelve parotid be fabricated. and a neutral 1.1 o/o sodium fluoride gel should be
glands that had received conventionally fractionated radiotherapy in applied to the teeth after breakfast and before bedtime for a
a dose of 60 Gy to 66 Gy showed a mean percentage flow of 20o/o period of 2 weeks, beginning as soon as possible after the initia
and a significant decrease in saliva pH. Six glands that had received tion of radiation therapy. This subsequently may be reduced to one
continuous hyperfractionated accelerated radiation therapy showed bedtime application for 1 month and then twice-weekly fluoride ap
mean percentage Haws of 65%. with only slight and insignifiCant plications indefinitely. However, some patients may require twice
decreases in saliva pH. These resuHs were attributed t o the lower daily application for the rest of their lives. The dosage of the fluoride
dose per fraction used. with subsequent greater repair of sublethal should be modified according to the patient's history of dental caries
damage between treatmen t fractions. and oral hygiene performance. Patients should also use a calcium
phosphate remineralizing rinse immediately alter fluoride applica
Conclusions regarding prevention and treatment tions. Combined fluoride and calcium formulations are available.
The dental evaluation should also include an assessment of
Prevention of radiation-induced xerostomia has been actively stud dentures for edentulous patients, and ill-fitting dentures should b e
ied in the recent past. Results from the use of pilocarpine in this corrected. Patients should be discouraged from wearing dentures
174 1
until the mucosa is completely healed from the acute effects of Treatment
radiation therapy (usually about 3 months).
After radiation therapy, patients should be seen every 3 months If recurrent cancer is not clinically suspected, biopsy should be
for frequent dental checkups. There is no concern regarding the avoided because this may enlarge the area o f necrosis. Topical an
additional radiographic exposure of dental films because the dose is esthetics can relieve the discomfort associated with soft tissue ne·
insignificant compared to the therapeutic dose given for the cancer crosis and allow the patient to eat normally. Antibiotics often provide
therapy. Nearly all routine dental procedures can be performed pain relief. particularly when the ulceration is deep and infected. It is
without unusual precautions after a COllrse of radiation therapy. essential that the patient discontinue the use of alcohol and tobac
The exceptions are radical periocfontal treatment, orthodontics. co. If the area of necrosis is traumatized by dentures, the dentures
and extractions, which may lead to ORN if not done with special should not be worn until healing is complete.
consideration. Some institutions favor the use of hyperbaric oxygen More than 90% of soft tissue necroses will heal with conservative
before extraction.'53 Primary closure of the wound should be carried treatment, although in some instances. it may lake many months.
out over a smooth bony surface so that no sharp spicules or ridges A small trial (consisting of 12 patients with 15 sites of late radiation
are lett beneath the mucosa, which gives the extraction site a better necrosis of the soft tissues) has been conducted to evaluate the
chance of complete healing without the development of necrosis. effect of pentoxifylline on healing radiation necrosis. The average
When extreme root sensitivity occurs after radiation therapy, brush duration of necrosis before treatment with pentoxifylline was 30.5
ing fluoride onto the exposed root surface and using specially weeks. With the institution of pentoxifylline (400 mg given orally three
formulated, commercially available oo
t thpas te appears to decrease times a day), 13 of 15 necroses healed completely and 1 partially
the sensitivity to some extent. healed after an average of 9 weeks from the start of treatment. All
patients experienced pain relief.'"' Additional case reports and small
clinical trials have suggested that !he combination of pentoxiMiine,
Soft tissue and bone necrosis tocopherol, and clodronate may be beneficial in preventing and
healing severe ORN, radiation-induced trismus, radiation-induced
Etiology ulcerated fibrosis, soft tissue necrosis, and mucosal necrosis.•s5->et

These results support further study of pentoxifylline in patients in
The soft tissue necrosis of oral cavity mucosa that occurs after high whom soft tissue necrosis develops after a course of radiation
doses of radiation therapy may be at1ributed to the obliteration of therapy.
small blood vessels or to severe mucositis with ulceration. Irradiated Most bone exposures will heal spontaneously after conservative
epithelium is thinner than normal and appears pale and atrophic. It treatment. Although small areas of bone exposure Qess than
also has telangiectatic vessels. The irradiated mucosa is more sus 1 em) generally heal spontaneously after a periocf of weeks
ceptible to mechanical injury and to the noxious effects of alcohol to months, larger areas of bone exposure may persist and result
and tobacco. Soft tissue necrosis usually begins with breakdown of in bone necrosis, followed by sequestration. If the bone is rough
damaged mucosa. resulting in a small ulcer. Most soft tissue necro or protrudes above the level of the gingiva. an oral surgeon may
ses occur within 2 years after radiation therapy. Occurrence after this remove it to promote healing. An oral surgeon can also perform local
time is generally preceded by mucosal trauma. The risk of soft tis debridement of mocferate- sized necrosis, if indicated. Patients who
sue necrosis increases with larger fraction sizes, higher total doses, wear dentures should refrain from using them or have them modi·
larger volumes of irradiated mucosa, and the use of an interstitial lied to provide relief over the site of exposure. Pain is not a common
implant. symptom; if present, it can usually be controlled with analgesics or
The mandible and maxilla will tolerate rather high doses of a local anesthetic applied with a cotton-tipped applicator, if needed.
radiation therapy without serious problems, as long as the tissues Antibiotics frequently reduce infection and discomfort within a few
overlying the bone remain intact. If sott tissue necrosis develops in days but should be continued for 2 l o 3 weeks. Hyperbaric oxygen,
the mucosa overlying the mandible or maxilla. the underlying bone along with antibiotic therapy and local debridement, may help
may become exposed. This can lead t o serious injury, resulting promote healing. Mandibular resection should be reserved as the
in ORN. Patients at highest risk for ORN appear to be those with last resort for the patient with intractable pain, recurrence of severe
tumors involving the gingiva or bone; those who continue to smoke infections, fracture. or trismus.
or drink after radiation therapy; and those who receive high doses Most bone problems develop within 3 to 12 months after radia·
o f radiation therapy, large treatment volumes. large fraction sizes. lion therapy. but some risk persists for many years, especially if
or interstitial implants. Compared with the maxilla, the gingiva of the the patient undergoes dental extractions. Necrosis is most likely
mandible has a rather tenuous blood supply, placing the mandible at to occur after extraction of mandibular teeth, although this is
greater risk of exposure and necrosis. If exposed. necrotic bone may infrequent i f special precautions are taken. TI1e edentulous patient
become infected. The necrotic process may then extend to involve has a lower overall risk for bone necrosis compared with the
adjacent bone for a considerable distance. Severe necrosis can then dentulous patient.
develop and lead to orocutaneous fistulae and pathologic fractures.
175
�3 i Oral Complications of Chemotherapy and Radiation Thera py
Taste alterations Malignancy
Loss of taste occurs rapidly and early in the course of radiation ther The carcinogenic effect of ionizing radiation 11as long been recog·
a py to the oral cavity. Most patients report that the sense of taste nized. The latent inteNaJ between radiation therapy and the develop·
is essentially nonexistent by the third or fourth week of treat ment . ment of cancer varies from several to many years. Kogelnik et al'64
After the completion o f radiation therapy, most patients report some reviewed the charts of 1, 163 patients from the MD Anderson Can
t aste improvement within 1 to 2 months. Full recovery of taste usu cer Center who had suNived a minimum of 5 years after treatment
ally requires 2 to 4 months. In some patients. taste never returns for head and neck cancer without recurrence. Follow-up for these
to normal, at least in part because of xerostomia. Allhough some patients ranged from 7.5 to 25.5 years. Patients were treated with
studies have suggested that zinc therapy may be useful in improv surgery alone (n = 337) or radiation therapy with or without surgery
ing taste acuity. a randomized clinical trial did not show any benefit (n = 826}. For these respe ctive groups, the inc i den c es of new can·
for zinc over a placebo.•03 Amifostine may protect against taste loss cers in the primary tumor site (1.8% vs 2.7%}. within the immediate
caused by irradiation. "4•11• vicinity of the primary tumor (4.2% vs 3.1 %}, or at sites remote from
the primary tumor but still within the oral cavity or pharynx (4.7% vs
5. 7%) were very similar. It was concluded that moderate-dose or
Trismus hig h- dose radiation therapy did not produce any new squamous cell
carcinomas of the mucous membranes. Similar findings have been
Etiology reported elsewhere.•65.•60

The rarity of radiatiOn-induced sarcomas, the long latent period
Causes of trismus include (1) fibrosis of the mas ticatory musculature before their deve opment,
l and the difficulty of obtaining reliable
after high-dose radiatiOn therapy to the oral cavity or oropharynx (2)
, long-term follow-up data make the task of estimating tl1e true risk of
surgical scarring. and (3) advanced carcinomas involving the ptery this problem difficult. However. most series include 1 or 2 cases of
goid or masseter musculature. The temporomandibular joint (fMJ} radiation-induced bone sarcoma per 1 ,000 5-year survivors. If one
is relatiVely resistant to ankylosis caused by radiation therapy, but were to assum e malignant in duction in 1 patient of every 500 long·
the risk of injury increases if the joint is invaded by tumor. The use term suNivors and an estimated 5-year suNival rate of 40% for all
of large daily treatment fractions also appears t o increase the risk of patients with head and neck cancer who received radiation therapy,
trismus. it is calculated that 1 case would be induced per 1 ,250 patients
treated. A review of lhe Mayo Clinic experience showed no difference
Prevention and treatment in suNival between patients with ra diation-indu ced sarcomas of the
mandible or maxilla and those with non-radiation-induced sarcomas
High-energy x-ray beams and sophisticated multiple-field tech of the same site (45% 5-year overall suNivaQ.
niques should be used whenever possible to reduce the total dose Because some patients with radiation-Induced osteogenic
of radiation to the TMJ and the muscles of masti cation. Patients sarcomas of the mandible or maxilla can be cured. the risk of death
treated with both surgery and radiation therapy have a greater risk from a radiation-indu ced sarcoma after a course of radiation therapy
for trismus than patients treated with just one modality. For these is minimal and is very similar to the risk of death a patient accepts
high-risk patients and those in who m trismus has developed before when undergoing chemotherapy, general anesthesia. general
treat ment daily jaw-stretching exercises may increase the interarch
, surgery. or major head and neck cancer surgery.
or interincisor distance. A number of devices can be used, includ An association also has been noted between radiation therapy and
ing commercially available jaw-stretching tools and less-expensive thyroid tumors. The latent period is usually I 0 to 30 years. Almost
stacked tongue blades, tapered corks. or clothespins. These devices all reported cases have followed low doses of radiation therapy
are inserted between the teeth to increase the interincisor distance (from less than 6 cGy t o 1 ,500 cGy), well below the doses used for
until gradual increases are encountered. The exercises should be squamous cell carcinomas of the head and neck. In contrast, doses
done for 4 minutes four times daily. Additio nal tongue blades can greater than 2,000 cGy to 3,000 cGy are associated with a very low
be added or a thicker aspect of the cork can be placed between risk of induction of thyroid neoplasia. This is likely because higher
the teeth every few days t o increase the interincisor distance and doses of radiation t11erapy either completely destroy follicular celts or
stretch the muscles of mastication. The rate of advancement should at least render the survivi11g cells incapable of division. Not all thyroid
be approximately 1 mm every other day and should be monitored to neoplasms that deveOP l after radiation therapy are malignant. and
ensure the distance approaches an amount that permits adequate many of the malignant neoplasms that do develop (papillary and
hygiene measures and reasonable bolus manipulation. Any sudden follicular carcinomas} are readily curable with surgery. Thus, the
degree ot restri ction In mandibular opening is suspici ous for recur risk of radiation-induced carcinoma should not be a major factor in
rence or other infratemporal fossa disease. determining treatment approaches for the typical patient with head
and neck cancer.
176 1
Oral Complications of Radiation Therapy j
Fig 13-4 Tongue depressing stent for balloon catheter. {a) Wax template is fitted to
determine opening and fit to teeth. (b) Maxillary defect is susceptible to mocosltls at
the air-tissue Interface. (c) Wax pattern ol the stent shows where the balloon catheter
would enter. (d) Wax pattem before processing to acrylic resin. (e) Completed stent and
balloon catheter.
Prevention and treatment of radiation-induced ticiently to the target volume. Historically, this was alded by the use
of positioning devices such as stents and shields. The trend toward
oral complications
using computed imaging and IMRT for treatment of head and neck
cancer has somewhat decreased the need for shielding devices.
Need for guidelines However. the use of tissue bolus materials and positioning devices is
still required to make the treatment effective.
Investigators surveyed Dutch radiation therapy centers that per The target tissue may involve a relatively superficial area, or it may
form irradiation of patients with head and neck cancer to determ•ne be more centrally and deeply located. As such, the treatment beams
which prevention and treatment regimens are used for oral sequelae may be projected from multiple directions to mini mize dose to tt1e
resulting from head and neck radiotherapy. •e7 Survey questions in superficial areas of the skin and vital structures such as the spinal
cluded queries about screening, care before and during radiation cord. Movable structures such as the tongue and mandible may b e
therapy, care during postradiation therapy, and the composition of positioned outside o f the treatment field by the use of a positioning
the dental team who evaluated and treated the patients undergoing stent (Rg 13-4). These stents often depress both the tongue and
radiation therapy. Unfortunately, these investigators found a great mandible away from the treatment area to minimize the exposure in
diversity among the institutes' approaches to prevention and treat the treatment area and decrease the risk or incidence of radiation
ment of oral sequelae in patients with head and neck cancer. Dis induced mucositis. Further incorporation of gold seed markers
turbing findings included a lack of well-defined guidelines in many is useful to ensure reproducible treatment orientation between
centers. absence of a dental team at some centers. absence of an treatment sessions.
oral hygienist on some dental teams, and the observation that many Superficial lesions requiring radiotherapy can be most efficiently
patients were not referred to the dental team in a timely manner. The treated by incorporating the use of a tissue bolus material to allow
development of a general standard protocol for the pev
r ention of optimal location of the beam energy at the surface. Often, these
oral complications was recommended tor all head and neck cancer materials are made of either wax or acrylic resin, permitting delivery
radiation therapy centers.•EB of a focalized and effective dose to the treatment area (Fig 13·5).
Similar deficiencies are likely present at head and neck cancer Shielding devices can be made o t prevent the radiation from af
radiotherapy centers within the United States. It is strongly recom fecting tissues behind the prop osed target tissue . These devices
mended that dedicated teams be assembled to administer aggres often are made primarily of acrylic resin surrounding a central core
sive care to pati ents receiving radi ation therapy to the oral mucosa. of a shielding alloy such as Wood's metal (Fig 13-6). It is critical that
These teams should institute preventive measures and treat symp the thickness of acrylic resin be proportional to the planned energy of
toms as early as possible. the beam. Acrylic resin tt1at sufficiently surrounds \118 alloy minimizes
scatter, thereby preventing fonnation of mucositis. Energies used to
Stents, shields, carriers, and positioning devices treat head and neck tumors are approximately 6-MV photons. and
require at least 7 mm of acrylic resin around the alloy to absorb scatter.
One goal of radiation therapy of head and neck tumors is to confine Brachytherapy is also used occasionally to treat specific areas
the treatment to only the area planned for treatment. This minimizes ot t118 head and neck and recurrent lesions. Often. radioisotopes
the side effects noted earlier and allows treatment to be directed ef- are used. which emit gamma radiation from their radioactive decay
177
1 3lOral Comp lic ations of Chemotherapy and Radiation Therapy
Fig 13·5 (a) Bolus of wax used to contrOl deptll of

treatment of supe11icial skin lesion of face. The tub
Ing is used for airway exchange. {band c) CT image
shOwing lhe wax bolus alongsi�e lhe skin.
Fig 13·6 (a)A wax template is to be

created for a shield:ng slenl !hal "nil
prolect the longue and other struc
tures behind the target tissues of
basal cell carcinoma of the upper Up.
(b) Steo t fabnca"on on casts of max
lila and mandible. {c) Wood·s metal i s
pouree into the stent. (d)Resolution of
lesion after 3 weeks of treatmeol wilh
stent in place.
Fig 13·7 (a} Brachytherapy using ce·
slum in tile catheter for treatment of in

Fig 13-8 (a) Trealment of scalp angiosar
lranasal Kaposi sarcoma. (I>) Computed
coma. (IIJ Catneter cap used for ra�ioactive
vault for delivel)' of ra�ioactive isotope.
isotope delivery.
(c) Acrylic resin slenl wilh catheter re·
ceptacle.
and can be pl aced a t a specified proximit y to the tumor bed for invasive in nature. Recent large-scale trials have d emonstrated that
a specific dose based on timed exposure. Positioning stents are chemotherapy and r adiotherapy in conjunction wi th tumor-ablative
helpful to direct the spatial location of these point sources for surgery are more effective i n controlling disease than surgery and ra
repeated exposures. The stents configure the uninvolved tissue at diotherap y atone. Because of the trends in using this combined ther
a specific distance from the target tissue and can be automatically apy and contemporary chemotherapeutic agents. the sequelae of
loaded from a computed vault that contains the radioactive source common side effects precipitate often within this patient population.
(Figs 13-7 and 13·8). Several approaches t o h an dling this complex array of treatments
and their associated side effects have been presented as guide
lines. As continued development of radiot herapy techniques move
forward, these sequelae may continue to change in their frequency
Summary of occurrence. The goal of disease control with these mod alities is
state oi the art and should be approached with the knowledge of
Combined-modality therapy of head and neck cancers or cancers management of their accompanying complications.
of other origin is effective in con t rolling tumors that are advanced or
1781
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1821
Chapter
Radiation Therapy and

Chemotherapy for Head
and Neck Cancer
Mijin Choi, oos. Ms
Epidemiology and Survival Rate \E_,stim�S�d )!�d.�9 new cancer cases

Table 14_1
;by sex in the United States, 2010
The American Cancer Society estimated that approxmate ly 1.5 i

Type Men (789,620) Women (739,9401
million new cases of cancer would be diagnosed in 201 0.' Among Prostate 28%
these new estimated cancer cases, oral cavity and oropharyngeal
lung and b<'oc'IChus 15% 14%
cancers accou nt for 36.540 (25.420 men and 11,120 women)
Colon an<! rectl•m 9% 10%
cases. ll was predicted that approximately 7,880 of these patients
(5,430 men and 2,450 women) would die of t hese cancers in 2008' Urinary bla<IOO< 7%
(Table 14-1). Noo·Hodgl<fn 1ymp110ma 5% 4%
Cancers in the oral cavity most commonly occur in the tongue Melanoma ol skin 5% 4%
(approximately 20% to 25% of all cases). The incidence rate for
Kidney and renal peMs 4% 3%
malignancies in the floor of the mouth, lips, and minor salivary
Oral cavity 3%
glands ranges from 1 0% to 15%? Oropharyngeal cancers are most
commonly found in middle-aged and Older individuals and affect leukanla $%
more men than women. Recently. however. a disturbing number of Pancreas 3%

i
these oral cancer malignanc es have been documented in younger Boeasl 28%
adults. The difference in the male-to-female ratio has also become
Uterine corpus 6%
less pronounced over the past half century. possibly because
Tl'lyTOid 5%
women have gradually more equally exposed themselves to known
oral carcinogens such as tobacco and alcohol. Ov.lJy 3%
Despite the accessibility of the oral cavity to direct examination, (A

clapt
e<f om the Ameolcan cancer Societf with permission,)
ff
these malignancies are often not detected until a late stage. As a result.
183
� 41Radiation Thera py and Chemotherapy for Head and Neck Cancer
Table 14-3 [..General definitiOI'!S of,;TNM. sta ging system

'··� � � 0-� �
Primary t um or
Site White Black Absolute difference (T) Definition
All sites 67 57 TX Primary tumor cannot be assessed

10
Breast {female) 90 78 12 TO NO evi<!ence of primary tumor
ColOn 66 55 11 T'tS carcinoma rn Situ
Esophagus 18 11 7 T1, T2, T3, T4 lncreasmg si�eorlocalextent ofthe primary tumQr. defined
vnae< SPecifr c Site
Leukemia 51 40 11
T4a' ModeratelYadvanced tumor
Non-Hodgkin 55 56 9
lymphoma T4b' Very advanced tlmO<
Oral cavity 62 41 21
Regional lymph nodes (N)
Prostate 99 95 4
NX Regional lymph nodes cannot be assessed
Rectum 66 58 8
NO No regionallympl1 nodes metastasis
Urina!y bladder 81 65 16
N1. N2, N3 Increasing involvement of regional lymph noc1es
Uterine cervix 74 66 8
Distant metastasis (M)t
Uter ine corpus 66 61 25
MX Q;stant metastasis cannot be assessed
·s-year relatwe survival rates base<! on car�e« patrents diagnosed from 1996 to
2003 and followed th-ough 2004. (Reprinted from the NatJOnal Canoer fflstitute' with MO No distant metastasis
pe<miSSIOrl.)
Mi Q;stam metastasis
' P..- seventh ec

tionAK;C
l TNM SIBQflg system. T4 llJnOr'S larger than 4 em.
•
'N01e: MetaslaSis 'anyl ym ph node orh er than regional isclassilled as a disl&ll merasf<ISis.
"
(AdaPted Iron• ltle AmencanJoot Com m�tee on Camer'wilh permsslon.)
the survival rate for oral cancer has remained essentially unchanged T 4b (very advanced), based on the involvement of vital structures,
over the past three decades.• The ov erall S-year relative survival rate of which should help surgeons determine the suitabili ty for surgical
oral cancer between 1999 and 2005 was 61% (Table 14-2). resection.6·7·'0 In addition, reporting of prognostic factors such as
the primary site: tumor thickness: human paplllomavirus (HPV)
status; node siz e. location. level. and entracapsular spread were
recommended." Staging criteria for mucosal melanoma of the head
Staging and neck was created to classify this rare and aggressive tumor'�
(Table 14-6).
The tumor-node-metastasis (TNM) system is the method of staging
oral carcinomas (Tables 14-3 and 14-4). T describes the extent of
the primary tumor: N describes the absence or pr esence and extent
of regional lymph node metastasis; and M describes the absence or Radiation Therapy
presence of distant metastasis.'
In the United States, the American Joint Committee on Cancer
(AJCC) established the TNM system, based on the tumor Principles
anatomy, to aid with selection of treatment and determination of
prognosis . • Because head and neck cancers tend to involve multiple In management of head and neck cancer. surgery, radiation therapy,
anatomical sites. this staging system was found to be defiCient, and chemotherapy are the most frequently used treatment modali
especially for Stage IV cancers, which account for about 75% of ties. l11e primary goal of radiation t11erapy is the local regio n al sup
patients with squamous cell carcinoma of the head and neck . 7.ll pression of cancer with preservation of the structure and function of
Further advances in understanding the genetic and molecular normal tissue.'2 Radiation therapy may be used alone but i s often
mechanisms of cancer have made modification of the existing combined with s urgery or chemotherapy to increase the effective·
TNM staging system, and better prognostic accuracy, possible ness of each treatment modality.'" Radiation therapy alone is best
(Table 14-5). In the seventh edition of the AJCC Cancer Staging suited for the cure ot early stage tumors. incl uding early squamous
-
Manual, T 4 tumors were divided into T 4a (moderately advanced) or cell carcinomas of the head and neck. The most advantageous com-
184 1
Radiation Therapy J
Table 14_4
jT staging for tumors of the lip, oral cavity,
_ Table 14_6
I!AJCC staging for head and neck
,and oropharynx ,'mucosal;melanoma
1
Stage Description Stage Description
T3 Mucosel disease
TX Primal)' tumor cannot be assessed
No ev.oonce ol pmnatv tumor

T4a Moderately advanced: soft tissue. cartiage, bone. skin
TO
ros Caronoma 1n situ

T4b Very advanced: brain dvra. skull base. lower cranial
neNeS. mastiCator space, carotid artel)'. prevettebral
Tl Tumor 2 em or less in greatesl dimension gpace, mediastinum
T2 Tumor more than 2 em but less lhan 4 em ill greatest Nx Cannot be assessed
dimension
NO Negative
T3 Tumor more !han 4 em in greatest dimension
Nl Regional LN+
T4a
Stage T N M
Lip Tumor invades through cortical bone, inferior alveolaJ
Slage Ill T3 NO MO
nerve. lloor ot mouth. 0< Skin or lace (eg. chin or nose)
Oral cavity Tumor Invades �ent structures (eg. through Slage IVa T4a NO MO
cortical bone, 1nto deep extmsiC muscle of lhe T3-T4 Nl MO
tongue !genioglossus. hyoglossUs, palatogossus. and
StageNb T4b AnyN MO
stytoglossusj, maxilal)'sinus. skin of face)
Stage IVc AnyT AnyN Ml
O!ophai)'OX Tumor invades the larynx, deep/extrinsic muscle of
t ngue. medial pterygoid. haJd palate. or mandible
o
T4b
4Jandoral cavity Tumor invades masticator gpace, ptel)'goOd plates. o<

skull base or encases 1nterna1 carotid ariel)'
Orophai)'OX Tumor invad es laleral ptetygOid mus cle. pte l)'goid pla t es,
lateral nascl)har)'II X , 0< sku ll base 0< enca se s ca r
o tic:l artery bination of these therapies or singl e therapy is detennined based on
the site of the cancer and the stage (extent) of the disease. Other
factors that influence the selection of optimal treatment regimen(s)
include the following":
T abl e 14-5 ��-�

A
f
JCCSt!!_gi�g
_..A_
� _ -�""�
.neck cancers
•
•
Age
Comorbidity
• Occupation
Stage T N M
• Preference and compliance
StageD Tis NO MO • Quality of life fo!lowing treatment
Stage 1 Tl NO MO • Availability of expertise in radiation therapy
Stage II T2 NO
• Histologic features of the malignancy
MO
• History of a previous malignant lesion in the head and neck area
Stage 111 T3 NO MO
T1 Nl MO
Current primary radiation treatment modalities include external
T2 Nl MO beam radiation therapy (EBRT) and brachytherapy.
T3 Nl MO
Stage IVa T4a NO MO

Clinical applications
T4a N1 MO
T1 N2 MO
EBRT
T2 N2 MO
T3
A l i near accelerator is most commonly used for external beam radia
N2 MO
tion treatments. It uses microwave technology and can deliVer a uni
StageNb T4a N2 MO
fonn dose of hi gh e nergy x-ray beams while spari ng the surrounding
-
T4b AnyN MO normal tissu e. Typically, the treatments are giVen using a technique
AnyT N3 MO known as fractionation once a day, 5 days a week, for 6 to 7 weeks.
This technique delivers a large dose of radiation in smaller units in
StageNc AnyT AnyN Ml
a given treatment period, about 2 Gy per daily fraction. The smaller
(Aclapte<J from U1e Amettcan Joint Comm•ttee on Cancer< with ce•m•ssion.) units of radiation allow healthy cells to recover and repair the damaged
185
� 41 Radiation Thera py and Chemotherapy for Head and Neck Cancer
cells. Fractionation results in a differential effect between tumor cells

and those of normal tissue because a greater number of tumor cells
are killed with each successive dose. The total radiation dose deliv
Early acute side effects Late long-term side effects
ered with conventional fractionation is 66 Gy to 70 Gy. This is often the
• Swalling • Telangiectasia
maximum amount that can be delivered to tissues. Other fractionation • Decreased saJMl production • ThrombOsis
techniques for radiation therapy include accelerated fractionation. hy • Change i n quality of saliva • Xerostomia
perfractionation, and concomitant boost fractionation. • Fungal infections • Scatring trismus
• Altered taste sensation • Impaired bone remodeling ability
Accelerated fractionatiOn or hypertractionation techniques involve
• Oral mucositis • Impaired he<l\ing abiHty
twice-daily doses of radiation. These approaches are genera lly used
• Trlsmll$ • If salivary lunctton is no1
for large, unresectable tumors. Accelerated fractionation maintains recO\Iered, increased risk f()(
the dose given per fraction but reduces overall treatment duration caries, periodontal diseases.
and !ungual Infections
to 4 to 6 weeks.'" This technique delivers two doses of 1.2 Gy per
fraction to the targeted area. In hyperfractionatiOI\ an increased dose
is given over the same period. These altered fractionation techniques 1. High-dose-rate {HDR) brachytherapy
have been shown to improve control of locally advanced squamous 2. Low-dose-rate {LOR) brach ytherapy
cell carcinoma of the head and neck.'8 However, the side effects from 3. Pulsed-dose-rate (POR) brachytherapy
these therapies are severe. Concomitant boost fractionation involves
hyperfractionation and accelerated fractionation, 10 beginning with HDR brachytl1erapy can be a treatment option for patients who are
conventional fractionation {1.8-Gy daily fractions that total 72 Gy) not candidates for surgery or EBRT.25 In HOR b rachytherapy, hollow
and adding a second daily fraction of 1.5 Gy to a smaller field on the catheters are placed into or around the tumor in the operating room,
last 12 days of the radiation therapy.10 usually under general anesthesia. The actual therapy i s initiated
A linear accelerator is also used for intensity-modulated radiation when the catheters are connected to a radiation treatment unit."9
therapy {IMRT). IMRT uses computer-controlled x-ray accelerators LOR brachytherapy also requires placement of thin, hollow,
to deliver precise radiation doses to specific areas within the plastic tubes into and around Ihe tum or. Unlike HOR brachytherapy,
tumor. 17 When planning for IMRT, three-dimensional (30) computed these tubes are loaded with tiny radioactive pellets (called seeds)
tomography (CT) images of the patient and computerized dose that remain in place for a few days to treat tumor cells. The patient
calculations are combined to determine the dose-intensity patiern. stays in the hospital during the treatmen t. As a precaution during the
The planned radiation dose conforms to the 30 shape of the tumor therapy. the length of time that visitors. nurses. and other caregivers
by controlling the intensity of the radiation beam. This allows a can spend with the patient is limited .32.33
higher-intensity radiation beam to focus directly on the targeted POR brachytherapy is a new treatment modality that combines
tumor region. The ability of this technique to safely deliver higher HOR and LOR brachytherapy.31•33 This technique is rarely used in the
and more effective radiatoi n doses results in fewer side effects when treatment of head and neck cancers.
compared to conventional radiotherapy. IMRT consequently reduces
toxicity for critical organs such as the parotid gland. spinal cord,
brain stem. and optic nerves."-22 IMRT also spares SLlperficial skin Side effects of radiation therapy
su rfaces and mucosa from common side effects, such as mucositis
and dermatitis. seen with conventional EBRT. The oral complica1i0ns induced by radiation therapy can be catego
A newer treatment approach in radiation therapy, combinatiOn rized into early acute side effects and late long-term side effects {Box
therapy, entails the concomitant administration or radiation and 14-1).1n most cases, side effects or radiation therapy do not appear
chemotherapeutic agents such as 5-0uorouracil {5-FU) and until after several weeks of treatment. During the early phase of treat
cisplatin."" Tl1e side effects from this combination therapy are also ment, patients notice minimal loss of saliva and changes in taste.
more severe and frequent compared to conventional radiotherapy. The salivary g lands. mucosal membranes. jaw muscles. and bOne
Combination therapy is discussed in more depth later in this chapter. are directly affected during the therapy. As a result of head and neck
radiation, patients often experience significant loss of saliva (xero
Brachytherapy stomia), ulceration of the oral mucosa (mucositis). and fibrosis of the
muscles of mastication (trismus)."""
Brachytherapy. also called internal radiation and interstitial radiatO
i n Exposure to radiation therapy places patients at high risk lor
therapy, requires insertion of radioactive sources or implants directly developing fungal infections. Xerostomia can further exacerbate
into a tumor.2""17 This type of treatment is usually recommended for the risk for candida colonization. The decreased saliva production
first presentation lesions, local recurrences, or second primary tu also can lead to periodontal disease. rampant dental caries. and
mors.2Wl Brachytherapy permits the delivery of a higher radiation other oral fungal and bacterial infections. l$.39 Radiation therapy also
dose to the tumor while sparing surrounding normal tissues.31 At may cause changes in the composition of saliva due to alterations
present. three types of brachytherapy are used: in secretory immunoglobulin A production, pH. lactoferrin. and
1861
Radiation Therapy j
Grade 0: No aal mucositis

Gracie 1: Erythema and soreness
Gracie 2: Ulce<s. able to eat solids
Gracie 3: Ulcers. reqwes liQuid diet (becauseof mucositis)
Grade 4: Ulcers. alimentation not possible (because of
mucositis}
Fig 14-1 Oral mlJCQ5itis induced

by radiation therapy. (a) Oral mu·
cosltis on the ventral side of the
tongue (arrow). (b and c) Oral mu·
cositis on the hard and soft palates
(arrows). (Courtesy of DrAlexander
Kerr and Or Joan A. Phelan, New
York. NY.)
Fig 14·2 ORN Induced by radiation therapy. (8} PallO(amic

radiogfapll prior to radiation therapy. (b) Post-radiation therapl;
P,'lllO(amic radiograph showing ORN. (Courtesy of Dr Kenneth
S. Kurtz. NewYork. NY.)
bicarbonate concentrations. These changes in the characteristics shown that a r adiati on dose of less than 26 Gy to the parotid glands
of sativa, in addition to decreased salivary flow, further affect its may prevent permanent damage to salivary glands.'5 However, when
buffering ability against caries. Increased cariogenic flora such as total radiation doses are greater than 50 Gy, irreversible damage to
Streptococcus mutans and Lactobacillus have been reported.*"'- salivary glands may occur with xerostomia.43 In addition to xerosto
mia, hyposalivation can lead to dysphagia (swal l owng difficulty),
i
Oral mucositis dysgeusia (chewing and speaking difficulty), hyposalivation-related

dental caries, per iodontal disease, and oral fungal infections.,._.,
Oral mucositis is the most common s ide effect of radiation therapy,
and clinical symptoms usually develop by t11e third week of radia· Osteoradionecrosis
tion therapy or chemotherapy""·'3 (Fig 14-1 a). Oral mucositis begins
as erythema and then progresses to include erosion, ulcerations. Osteoradionecrosis (ORN) is a long-tem1. irreversible oral compli·
and swe lling that ca n be covered by a white fibrinous pseudomem cation that results from hypovascularization in irradiated hard and
brane''·"" (Figs 14-1 b and 14·1 c). Signs and symptoms typically per soft tissues. In the majority of cases, ORN occurs in the mandible,
sist for 6 to 8 weeks with g radual resolution.3M• In some cases, the where bone density is high with poor vascularization (Fig 14·2). The
symptoms of oral mucositis can last for several months. Although causes of ORN include dental and periodontal disease, tooth extrac
many scales that measure the severity ot oral mucositis are available, tion before or after radiation, poor oral hygiene. and irritation from ill ·
the World Health Organization scale is most widely used because it fitting denture prostheses. 54
..' Katsura et at s howed that continued
is easy t o use in clinical practice" (Box 14·2). smoking and alcohol consumption after radiation therapy, combined
with poor ora l hygiene, are sg n ificant nsk
i factors and critical ac
Hyposalivation celeration factors for ORN after conventional external radi othera py.58
The radiatio n dose, dose rate, modality, fraction size, radiation field
Depending on the amount of radiation dose delivered to the s al ivary size, and tumor location are key considerations when determi ni ng
glands , hypos aliva ti on can be t ransient or permanent. II has been the treatment strategies lor this compromised oral state."""' The risk
187
� 41 Radiation Therapy and Chemotherapy for Head and Neck Cancer
for ORN increases with dose volumes greater than 50 Gy. Thorn et
;11'1 Chem i and regimens
al reported ORN o ccurrence when the radiation doses were greater
.
., bl e 14..7
.a - : -erapeut c agents
..-..:oth
� usedinhead and neck cancer therapy
• ..
than 65 Gy.112
Agents/regimens
(mechanism of action) Dosage
Cisplatln (alkylallng agent) 75 or tOO mg;orl' every 3 to 4 weeks
Chemotherapy CispJatin (alkyla!ing agent) 75 or 100 mglm' eve<v 3to 4 weeks
5·1tuorour a;cl (5·FU: antmetabolite) 5·FU: 1000 mg/nl'/qd continuous

Cisplatin (alkylating agent) Infusion for 5 <Jays; cispla!ln: 75 or
100 rngtm'
Principles
Docataxel (microtubule targeting) Docetaxet: 75 or 100 mg/m'; 5-FU:
5·FU (antimetabolite) t000 mgtm'/d corl!inuous infusion
Chemotherapy is used to treat malignancies and to palliate symp· for 4 days
toms In patients w ith disseminated cancer when the potential ben· Cart>oplat;l (alkylaling agent) AUC 1.5 weekly
efits of treatment exceed the side effects. It is also used to treat
Paclrtaxel (microtubule targeting) Paclilaxet: 45 mgfm' weekly:
asymptomatic patients when canc er is aggressive and treatable. Cart>oplatin (alkylating agent) carboplatin; AUC 6 fNe<y 3 weeks
Chemotherapeutic agents are contraindicated (1) when the patient Paclrtaxet (microtubule targeting) Paclrtaxet: 200 mg/m' fWe<y 3 weeks;
is not likely to survive longer even if tumor shrinkage is accomplished MethOtrexate (antimetabolite) methotrexate: 40 mgtm'weekly:
Docetaxet (microtubule targeting) docetaxel: 3<>-35 mg/m' weekly,
and (2) when the patient i s symptomatic with slow-growing, incur·
or
75 or 1 00 mgtm• every 3 weeks
able tumors.
Cetuximab (EGFR inhibitor) 250 mg/m' weekly
Cytotoxic agents used in chemotherapy c a n be categorized by
osage b y plotting
their activities in the cell generation cycle. Many chemotherapeutic AU C - a(ea undet the C U Ml, which is u sed t
o calculate ca
rboplatin d
a concentratiOO agaio\SI bme: EGFR- epic!ermal g owth
the carbOI)Iatin plaSm r factor
agents are phase-specific agents, designed to destroy tumor cells roceptor.
at specific phases of the cell cycle. Other agents destroy tumor cells
without discrm
i inating involvement in specific cell cycles; therefore,
r categorized as phase-nonspecific agents.
they ae
Clinical applications Combination therapy
The most commonly used cytotoxic agents to treat head and neck Combination therapy refers to combining chemotherapy with radia
cancers are alky1ating agents, antibiotics, and antimetabolites. Alkyl· tion therapy or surgery. The categories of combination therapy ap·
ating agents include c isplatn
i and carboplatin;G3 bleomycin and dau· preaches include the following:
norubicin are examples of antibiotic agents: and methotrexate and
fluorouracil are forms of antimetabol ites . Paclitaxel and docet axel are • Induction chemotherapy
microtubule-targeting agents. and cetuximab. an epidermal growth • Con current chemotherapy and radiation therapy Qncluding hyper·
factor receptor inhibitor, is one of the agents recently cleared by the fractionated radiation with chemotherapy)
US Food and Drug Administrat ion (FDA) that are used in treatment of • Postoperative chemoradiation therapy
locally advanced disease. :M Each o f these agents can be used alone • Adjuvant chemotherapy
or in combination with one another. Although the rate of response
to the therapy is largely influenced by the amount of previous treat· Induction chemotherapy consists of se veral courses of chemo·
ment. the tumor burden, and the patient's performance status, 15o/o therapy before surgery or radiation therapy. Concurrent combination
to 30% of patients usually showed quick responses when these therapy involves the administration of chemotherapy and radiation
agents were used alone. The combination of cisplatin and fluoro· therapy during the same treatment period. Postoperative chemo
uracil is a widely used combination regimen and has been shown radiation therapy is indicated for (1) T3 or T 4 lesions, (2) tumors with
to significantly enhance patients' response rates.2' A detailed list of positive surgical margins. (3) perineural invasion, (4) lymphovascular
chemotherapeutic agents and regimens used to treat head and neck invasion. (5) multiple positive lymph nodes, or (6) extracapsular
cancers is shown in Table 14·7.27 extension." Adjuvant chemotherapy is initiated after the tumors
Most chemotherapies used in head and neck cancer are targeted are resected. TM goal of this treatment approach is to increase the
at solid tumors. Oral side effects in patients undergoing treatment of local-regional control of locally advanced head and neck squamous
hematogenous malignancies can be more severe: This therapy often cell carcinomas. Two different tumoricidal agents are used to reduce
includes transplantation or replacement of bone marrow. the incidence of distant metastases through amplification of the
effects of radiation ther apy.••.llS
188 1
Dental Management of Oral Complications
--------�-
Drugs used•ncombinationtherapyn"ldudemelhotrexate.hydroxyurea,
bleomycin. Cisplatin or cartx>plabn, 5-FU. miomya
t n. gemdtabine,
Dental Management of Oral
taxanes, and others." These drugs are usually paied 1111th conveniOnal
t Complications
or atered fractionatiOI'l (hyperlractionatiOn, accelerated fractionation)
radiatJon therapy.• Currently. the most Widely used chemoradiotherapy
regimen in clnical practJce � three OOU"SeS of Cisplatil fNer'/ 3 In many cases. oral complications ansing from head and neck can
weeks COI'lCUfleltl IIIIth conventiOnal racJiaiiOI'l therapy.a oer therapy can be effectively controlled through preventiVe man
These concurrent therapeutic approaches demonstrate effective agement. A consultation With a dental team pnor to the iniia
t lion
ness in treatJnQ unresectable rumors. nasopharyngeal cancer. larynx of radi ation therapy or chemoradiotherapy is cruc1al for succeslsfu
cancer, and hlgh-risk postoperative patients... The overall 5-year management of patients undergo1ng these treatments.
survival rate of locally advanced tumors has shown 1mprovement by

5% to 8% with the combinatiOn therapeutic approach. According to
Pre-radiation therapy considerations
CorvO, the overall survival rate after conventiOnal radiation therapy
can be imp roved either by concomitant chernoradiotherapy or hyper
The pr etreatment clinical examination should consist or a complete
fractiOnated radiation therapy with Increased total dose . However.
accelerated fract ionation radiation therapy seems to have smaller radiographic exam•nation. i nclud in g panoram•c radiograph, to de
benefits in overall suNival'·' termine periodontal status and the presence or any periapical pa
thology or signs of tumor invasion. It Is crucial to consult with the
pati ent's medical oncologist and radiation oncologist regarding the
Side effects of chemotherapy type(s) an d total dose or radiation therapy, duration of treatment.
and extent or treatment fields to assess the potential for side effects
Pat i ents undergoing chemotherapy are subjected to compromised

from the therapy. In addition, lull-mouth prophylaxis or scaling and
rcot planing, restoratiOn or caries lesions, evaluation of any exi sting
immune responses and decrea sed platelet counts. Platel et counts of
less than 20,000 Increase the n sks for prolonged and sp ontaneous prosthesis for proper fit. emphasis on oral hyg•ene, and 1nstruc1Jon
bleeding. Therefore, it is advisable to replace floss and toothbrushes on nutritional intake should be planned as necessary.
with gauze or soft sponges to clean teeth and gingiva." ' Mucosal
side effects from chemotherapy are generally acute in nature and
Preradiation extractions
heal well once the therap y IS completed. However, patients are still at
high risk lor developing caries lesions and other oral 1nlections dur
ing the therapy.118 Other toxicii19S from chemotherapy include neu
Nonrestorable caries lesions, moderate to severe periodontal dis
ropathy, hearing loss, kidney failure. and bone marrow suppreSSIOfl. ease. and periapical pathology can lead to ORN 1n irradl8ted tis
sues.5758·"73 In most studi9S, performing dental extractions after
radiation therapy was shOwn t o Jncfease rates of ORN... Therefore,
Chemotherapy-induced oral mucositis
pati e nts with risk factors should be carefully evaluated for extractiOn
Chemotherapy-induced oral mucositis IS known to be more acute prior 10 radiation therapy.•• -
compared to radiation-IndUCed mucositis. Approximately 5 to 8 days One of the critical considerations in plann�ng preradiation dental
following Initiation of chemotherapy, erythema, edema, and ulcer extraction is the t1rr.e 1nterval between the ext ractiOns and the
ation begin to occur... Nonkeratinized t1ssues are Involved with this beginning of rad iation therapy. Enough hrr.e should be given for
condition, and the symptoms usually last lor about 7 t o 1o days. The sufficient healing without any compromise or tumor control...""'"
incidence of oral mucositis In pat.ents with solid tumors undergoing From 1976 to 2003, stud1es recommended postextraction healing
chemotherapy can approach 37% dunng cycles. '0 The severity or periods prior to radiation therap y that ranged from 10 to 32 days,
with the incidence of OAN as low as 2.6%.'9"-- A min i mum of
mucositis is related to age, diagnosis of the patient. level or oral hy
giene during t her apy, genetic factors, and dose of chemothera py.eu1 1 0 to14 days should be allowed lor healing before radiation therapy
Patients who develop oral mucositis during chemotherapy are also is begun.
at hi gher risk of contracting other infections.
Radiation- and chemotherapy-induced

Chemotherapy-induced hyposalivation
xerostomia
The reducti on in salivary gland function as a result of chemotherapeu
tic agents may be transient. It is reported that approximately 40% of The primary management or xerostomia (hyposalivation) 1s frequent
patients who are undergoing chemotherapy experience xerostomia. sipping of wat e r. In add itio n, frequent rinsi ng, espec•ally after each
The symptoms of hyposalivation are usually short-term. and complete meal. is recommended to clean and buffer the oral !Issues. Use of
recovery is expected within 2 to 8 weeks following chemotherapy."l sugarless gum or candy t o strmulate salivary flow IS suggested . Pa-
189
14 Radiation Therapy and Chemotherapy for Head and Neck Cancer
llents may also use artifiCial safiV8, but these products are only to be ' Suggested therapies for r adiation-induced
used as short-tenn p alli ative measures. Box 14-3 ll"c.
oral mucos111s
. .
Two drugs suggested fo r the prevention of hyposalivation

during radiat1on th erapy are amifostine (Ethyol (Medlmmune)), a Mucosal covering agents Topical anesthetics'
radi opro tector and pilocarpine (Salagen (MGI PharmaJ). A daity dose
• 2% Or 4% VISCOUS lldocaM1a
,
• Milk of magnesia (MaalOX)'

of 200 mgfm? of amifostine given in tra veno usly 15 to 30 minu tes
• Olphenhydram1no liquid • Benzydamine hydroci'IIQ(ido
before irradia ti on has been shown to h elp reduce the incidence of
(Benadl)'t (McNeii-PPCD.' (Tantum (Elder PharmaceoticaiD
xerostomia without com pro misn g tumor control.a:! Amifostine has a
i
12.5 mg/5 ml
• 0.5% doxep<n suspensiOn.
protective effect upon salivary tissue and may be contraindicated in
0.5% compounded
patient s wllh a h story of salivary gland tumors, 1n whom tumoncidal
i
doses of radiation therapy are intentional. Pilocarpine Is the only

·15--00 ml by moultl lour tJneS a day as needed.
FDA-cleared drug for radatior1-111duced hyposalNallon. It is usually '5-10 rrL. nnse lor leu lt>MI ITWI,Iourtmes a day.
given in doses of 5 to 10 mg three t o four times per day. The effects '5 rrL. mse for less 111M 1 mn. lour1.-nes a dayas needed.
of pilocarpine 1n preseNin g salivary gland funciOI'I
t are shown to be
limited to parotid glands. Fewer oalr complai nts have been reported
with the use of pilocarpine compared to amifostine.-
General oral care In structi ons for patients with symptoms of
hyposalivation should include the following: Several st u dies have evaluated th e use of cryotherapy, or
the cooling of the mouth using ice cubes, for prevention or orat
• Metic ul ous oral hygiene mucosit is.""""' The rati onale behind this approach was based on
• Fluoride such as PreviDent 5000 Plus (Colgate- Palmolive) the local vasoconstrictive effects of th e ice. which reduced the
• C hl orhexid1 ne gluconat e 0.12% r inse to decrease the chance of chemot he rapeutc drug delivery to oral mucosa. Meta-analyses
i
oral infection by Mahood et al and Cascinu et al showed significant prevenllve

effects with cryotherapy. · The MASCC!lSOO guide�nes
recommend the use of cryotherapy for patients receiving bolus
Radiation- and chemotherapy-induced oral dOses of 5-FU. melphalan. and edatrexate.99
mucositis
Oral infections
The main focus in management of oral mucosibs is pain control.•'·""
Pain makes dally routines such as food intake and oral hygiene care
Fungal infections
difficu l t and diminishes overall quality ollife. II severe mucositis is ex
pec ted placement of a gastrostomy tLibe shoul d be considered to
. Nystatin rinses are the most widely used treatment for oral fllngat
avoid compromiSe in nutritional Intake. Compared to chemotherapy infections. However. th e high sucrose content in nystatin is a major
i appears to
induced oral mucositis, radiation-induced oral mucosits concern 1n dentulous patients With decreased salivary flow because
have more permanent effects that require long-term nsk management. it can promot e dental canes. Therefore. proper oral hygiene should
Topcal mouthrinses that contain an anesthetic such as 2% be reinforced when the medication is given. When more severe ora l
VISCOUS lidocaine are among the most oommonly used pain fungal infectiOOS are oblserved. a systemic antifungal mediCation
management pod r ucts. Mixtures of lidocaine and equal volumes such as fluconazole (Oiftucan (PflzerD or amphotericin B is recom·
of mucosal covering agents such as diphehnyda r mine liquid and mended. al toug
h h amphoter1on B potentially may cause 11 11 er toxiC
Maalox (Novart1s Consumer Health) or Kaopectate (Chattem) have ityThe use of toPICal antifun gal medications should also be consid
.
been recommended" (Box 14-3). The Mucositis Study Group of ered. A summary of recommended anllfungal medications is l1sted
the Multinational Assoc1at1on of Support1ve Care in Cancer and the in Box 14·4.3911 is i mportan t to note that concurrent use of nystabn
International Society for Oral Oncology (MASCC/ISOO) opposes the and chlorl1exidil1e is contraindicated because chlorhexidine binds to
use of sucralfate (top ical mucosal bloadherent agent) to manag e pain nystatin. resutling in ineffective drug acti on 39 .
in oral mucositis based on lack of efficacy. despite its wide use.9'm

The efficacy of 0. 12% c hl or hexidine as a preventive in terven ti on Bacterial infections
for oral mucositis-induced microbial infection is Inconclusive to
date. Most rad iati on oncologists recommend using a baking soda Prior to planning treatment strategies for clinical symptoms that may
mouthnnse to preven t secondary nfecb on exacerbated by radiCition
i
be of bacterial origin, the clinician must determine the etiOlogy of
mucositis. Oral rinses containing alcohol and hydrogen peroxide symptoms such as swethng, dental pain, and purulent diSCharge,
are not recommended because of their imtabng effects on oral which may be the result of pulpal or periodontal infections.• Ac
mucosa.• Swelling associated with oral mUCOSitiS IS managed with curate diagnoses of these dinicat symptoms are criical
t because the
nonsteroi dal anti Inflamma tory agents or steroids.
-
190
Dental Management of Oral Complications J
I men t and prophylaxis of

Antifungal therapies for oral fungal infections T r
e at
Box 14_4 -��·
i
..
..,..-
. _
associated with cancer therapy Table 14·8 rp es simplex virus in
hel"l -·
�r�rec
·'-
..rud
-�11:.-
"""' 'JI:I�"' ..:;;.ent
esc�, ';;I
�
�immunocompromised patients
Systemic agents Topical agents
Drug Prophy l axis Treatment
• Fluconazole (O>fiucoo), • Nystal!n suspensiOO. 100.000 U/ml
1 00 mg; 1 tab once Oral acyclovir 4()()..000 mg. three 400 mg. three times a
a day • Nystabn cream or ootment, 100.000 ti-nes a day day for 10 days or longer
U/g; apply to denture surfaces three
• Amphotericin B, 0.1 limes a day Oral valacyclovir 500-1.000 mg. two 5CJ0.1.000 mg. two
mg/ml (compounoed); times a day times a day for 10 days
• Ctotrimazole cream. 1%: apply to or longer
5 mL. rinse for about 1
min. then expectorate denture sur1aces three times a day
Oral tamciclovlr 500-1,000 mg, two 5 00 mg, two times a day
the excess. three times • Ctotrimazole troches. 10 mg; dissolve ttnes a day or 10 (l
f a ys o r longe r
a day
Tn mouth, live times a day for 14 days
• Ketoconazole. 200 mg: 1 or 2 tabs

by mouth lour limes a day
• Chlortlexidlne rinse. o. t 2%: 5-10
ml, rinse for less than 1 min, then in Table 14-8. Although acyclovir is the most common therapy for
expectorate the excess. three times recrudescent HSV. valacyclovir and lamciclovir are widely used
a day
alternatives.
Osteoradionecrosis
i nflammatory responses during myelosuppression may not follow
the traditional clinical signs of an infection and often result in an ex
The reported risk of ORN resuhing from postradiation dental extrac
aggerated inflammatory response.
tion varies from 0% t o 45%.O>.sz.•os •oo Fifty percent of all ORN cases
Treatment of bacterial infections of pulpal or periodontal origin
can be attributed to tooth extractions. Therefore, prevention of ORN
should include elimination or the source of the infection and
should be i nitiated prior to radiation therapy, as discussed earlier.
appropriate antimicrobial therapy. When extraction, incision
Postradiation prevention of ORN focuses on close follow-up proto·
and drainage, or scaling and curettage are under consideration
col. In the presence of ORN, conservative debridement of seques
to eradicate infections, a platelet count of 50,000 per cm3 is
tra combined with irrigation and peritreatment antibiotic therapy is
recommended. However, in patients with lower platelet counts,
recommended.'"'
when the benefits of removing the source o f an infection outweigh
Hyperbaric oxygen (HBO) therapy is considered an adjunctive
the risk of potential prolonged bleeding, platelet transfusions should
therapy in the prevention or treatment of ORN. It i s thought to work
be planned with the treating oncologist to control bleeding.
by enhancing microvascularity of irradiated bone and decreasing
tissue hypoxia through improved oxygen tension. thereby increasing
Viral infections osteoclastic and fibroblastic activity....�..'0&-"2 HBO therapy has
been shown to induce osteoblast apoptosis and cause cell-cycle
The most common viral infections observed in cancer patients are arrest. However. its positive effect on either normal or irradiated
due to Herpesvirus. Among these wuses, herpes simplex virus type tissue remains controversial.'2·''' The general recommendation is 20
1 (HSV-1) , herpes simplex virus type 2 (HSV-2). varicella-zoster virus preoperati ve "dives" of 100% oxygen at 2.0 to 2.4 atm. for 90 to 120
0/ZV), and Epstein-Barr virus (EBV) are frequently associated with minutes for each session. followed by 1 0 dives postoperatively.'09"0
head and neck cancer patients. Although the majority of the popula· The use of antibiotiCs is also considered to be another adjwant
tion has been exposed to HSV-1. only 1% of those exposed develop therapy for prevention of postradiation ORN.'1 However. further
primary herpetic gingivostomat�ls.>o.> The virus can be reactivated well-controlled studies are required to assess the positive benefits of
when a pat ient is in an immunocompromised state during cancer HBO therapy and antibiotics in preventing ORN.
therapy, developing into recrudescent HSV. VZ:V and EBV also may
be reactivated in myetosuppressed patients, lead ing to herpes zoster
and oral hairy leukoplakia (OHL), respectively.'"' A !issue biopsy is in Trismus
dicated for correct diagnosis of OHL because these lesions cannot be
wiped away. This condition is self-limiting and requires no treatment."" Trismus is one of the Side effects of radiation therapy that results
Recurrent HSV lesions may appear on any mucosal surface, from scarring in the muscles of masticati on. This condition renders
keratinized or nonkeratinized. and may potentially be life threatening. the patient unable to fully open the mouth. T h e progression or Iris ·
Therefore. antiviral prophylaxis is an integral part of the standard care mus can be prevented by jaw-opening exercises. Wooden tongue
tor many cancer therapy protocols.'00·•0< Treatment and prophylaxis blades are the easiest tool for p atients to use when performing these
of HSV lesions in patients who are immunocompromised are listed exercises. Patients are instructed to gently stretch the jaw by gradu-
191
� 41Radiation Therapy and Chemotherapy for Head and Neck Cancer
When managing patients who are about to undergo IV bisphos

phonate therapy or asymptomatic patients already treated with
bisphosphonates, the primary strategy for the prevention of BRONJ
should involve careful assessment of risk factors. Some of the lo
cal risk factors for patients receiving IV bisphosphonates are extrac
tions, dental implant placement. periapical surgery. and periodontal
surgery involving osseous surgery. It has been shown that dentoal
veolar surgery increases development of ONJ at least seven times
more than patients without the surgery.'""'"" Therefore, patients us
ing bisphosphonates should be informed of risks such as compro
misecl healing and should be advised to consider alternatives. For
those who are yet to initiate bisphosphonate treatment, extraction
Fig 14-3 Osteonecrosis of the ;aw.
of nonrestorable teeth shOtlld be considered. Other elective den
toalveolar surgery should also be completed and allowed to heal
adequately, if systemic conditions permit.',
alty increasing the number of tongue blades in a stack placed be For patients who already developed ONJ, oral antimicrobial rinses
tween the canines or molars. Generally, it is recommended to do suc11 as 0.12% chlorhexidine with systemic antibiotic therapy are in
the jaw-opening exercises 20 t o 25 limes a day for 2 minutes at a dicated. Sharp bony edges and loose sequestra should be removed
time. Another commercial device such as TheraBite (Atos Medical) without compromising surrounding normal tissues. Although there is
or custom-fabricated acrylic corkscrew-shaped device (Skiar Instru no evidence that discontinuation of the bisphosphonate will improve
ments) may also be used. the clinical condition, careful consideration should be given in con
sultation with the treating physician and the patient.
Special Considerations Dental implants after cancer therapy
Studies on survival rates of dental implants associated with radiation

Osteonecrosis of the jaw therapy have been controversial and inconclusive t o date.'23"125 The
main concerns with patients exposed to radiation therapy stem from
Osteonecrosis of the jaw (ONJ) or bispiJOsphonate-re/ated osteone their compromised wound-healing ability a s a result of hypovascu
crosis of the jaw (BRONJ) is defined as exposed necrotic bone in the larization of irradiated tissues that have been exposed to radiation
maxillofacial region that fails to heal after 6 t o 8 weeks in patients with greater than 60 Gy.86-'00· '�121 When the radiation field is involved in
no history of craniofacial radiation who are undergoing intravenous the area of potential implant sites, it is imperative to gather a history
(IV) bisphosphonate U1erapy for car1eer or for ostecporosis"3·"' (Rg of radiation therapy that includes (1) total dose of radiation, (2) mode
14·3). Oral bisphosphonates are usually used to treat osteopenia, of radiation therapy, (3) extent of irradiated field, (4) length of time
Paget's disease of bone, and osteogenesis impertecta.'t$ The most since the therapy, and (5) history of patient's wound-healing capacity
common IV bisphosphonates used in reducing hypercalcemia and after radiation therapy, if available. The information should be criti
in advanced cancer therapy include pamidronate (Aredia [Novarlis]) cally evaluated prior t o considering dental implant therapy.
and zoledronic acid (Zometa [Novartis]). The half-life of bisphospho
nates is approximately 10 years, and long-term use of this drug can
cause significant drug accumulation within bone. However. the de
tails of etiology of ONJ from bisphosphonate therapy have not been Summary
established.
The cumulative incidence of BRONJ based on the available data Incidence rates of head and neck cancers continue to increase. Ear
range from 0.8% to 12%."�'ro It has been shown that the risk of ly detection is the key factor affecting survival rate and selection of
BRONJ is significantly higher in patients receiving IV bisphospho treatment modalities. Treatment regimens involving radiation thera
nates as opposed to oral bisphosphonates. Also, long-term expo py, chemotherapy, surgical resection, or a combination of these can
sure to bisphosphonates appears to increase the risk of BRONJ. give shor1- and long-term side effects. The side effects from these
The American Association of Oral and Maxillofacial Surgeons con treatments affect patient comfort and function as well as prosthesis
cluded that patients with less than 3 years of oral bisphosphonate and restoration designs. Therefore, careful planning of the overall
therapy have no clinical risk factors and that no alteration or delay rehabilitation process at li1e initial phase of treatment is essential in
in the planned surgery is necessary, based on experience with 50 improving the quality of life for patients.
115
patients.
1921
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64. Brlzel OM. Esclarnado R. Concurr en t chemorad!Otherapy for locally advanced. Manage 2006:32:27-37.
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2004, Nrm Or teans. LAJ. J Clin Oncot 2004:22:488. 9 1 . Dodd MJ. Miaskowskl C. Greenspan D, e1 aJ. Rao:flatton-1nduced mucosnis:
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100. Young SK, Rowe NH, Buchanan Rl\. A clinical study for lhe cont«ll of fa 753-761.
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1976;41:498-507. lion of Oral and Maxiiofadal Surgeons position paper on biSPhO$i)honate
101. Woo SB. Challacombe SJ. Management or recurrent oral herpes simplex in· retated osteonecrosis of the jaws. J Oral Maxi!lofac Sorg 2007:65:389-376.
fections. OralSurg Oral Med Oral Pathol Oral Radio! Ended 2007:103{suppl 1t6. Dune BG. Katz M. Crowley J. Osteonecrosis of the jaw and bisphospho
12):e1-e18. nates. N EngI J Med 2005;353:99-102.
102. Schubert MM, Peterson DE. Floumoy N. Meyers JD. Truelove El. Oral and 117. Barruas A, Kaslrihs E, Bamia C, et al. OsteonecrosiS of the jaw 1n cancer after
pharyngeal herpes simplex vlnJS infection after allogeneic bone marrow treatment with bisphosphonates: tncidenGe and riSk factors. J Clin Oncol
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103. Redding SW. luce EB, Boren MW. Oral herpes simplex virus 111fection in Jaw In patients with multiple myeloma treated with bisphosphOOates: Evi
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1990;69:578-580. 2006;91 :96&-971.
104. Angarone M, lson MG. Prevention and earty treatment of opportunistic viral 119. Pozzi s. Marcheselh R. Sacehi S, et al. Bisphospl10nate-associated osteo
Infections 01 patients Wltl1 leukemia and aiJ09eneic stem cell transplantation necroSis or the jaw: A review Of 35 ca.ses and an evaluation of its freQuency in
recipients. J Natl Gompr cane Netw 2008:6: t91-20t. multiple myeloma patients. Leuk Lymphoma 2007;48:56-54.
105. Heriot JC. Bone MC. Ibrahim E. castro JR. Systematic dental management 120. Zavras AI. Zhu S. BisphosphOnates are aSSOCiated with increasea risk for jav.•
1nhead and neck irradiation. lnt J Radiat Oncol Blot Phys 1981:7:1()25-1029. surgery in medical claims data: Is � osteonecrosis? J Oral Maxillofac SL"9
106. Marx RE. Johnson RP. Studies in the rad•obio!ogy or osteora<f10<>ecros1s 2006:64:917-923.
and their chrncal significance. Oral Surg Oral Med Oral Pathol 1987;64: 121. Badros A. We�kel D, Salama A, et al. Osteonecrosis of the jaw 1n mul·
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107. Marunick M, Mille< R, Gordon S. Recent repotts link blsphosphonates use to 945-952.
osteonecrosis. Today's FDA 2006:18(3):2&-31. t22. Van Poznak C. EstiloC. Osteonecrosis or the jaw in cancer patients receiving
108. Miller EC, Ve<goTJ Jr. Feldman MI. Dental management of l:>atients undergo IV bisphosohonates. Oncology 2006:20:1 053-1062.
Ing radiation therapy tor cancer of the head and neck. Compend Cootln Educ 12 3. Moy PK, Me<ina D. Shetly v. Agt1alooTL Denlat lmplant failure rates and as
Dent 1981 :2:350-356. sociated (1$1< factors. tnt J Oral Maxiilofac Implants 2005:20:569-577.
109. Miller EH, Quinn AI. Demal considerations In the management o f head and 124. Nelson K, HebererS. Glatzer C. Survival analysis and clinical evaluation of
neck cancer patients. Ototaryngol Ctin North Am 2006:39:3t9-329. Implant-retained prostheses 01 oral cancer resection patients over a mean
110. Chavez JA, Adkinson CD. Adjunctiv e hypelba!iC oxygen in irradiated patients rotlow·up period of tO years. J Prosthet Dent 2007:98:405-410.
requiting dental extractions: Outcomes and complications.J Oral Maxillolac 125. Yerit KC, Posch M, Seemann M, et al. Implant survival In mandibles of 1rtadi·
Sorg 2001 ;59:51&-522. t ed oral cancer patients. Oin Oral hnptants Res 2006;17:337-344.
a
111. Sennett MH, Feldmeier J. Hampson N. Smee R. Milross C. Hype<banc OX· 126. Marx RE. Morales MJ. The use of 1mplants in the reconstrucbon of oral can·
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feclolpostoperativeradiotherapyonthefunctionalresultofimplantsptaceddur
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195
Chapter
Restoration of Congenital,
Developmental, and Acquired
Oral and Perioral Defects
Alan B. Carr, DMD. MS
Wi ll iam R. Laney, DMD, MS
appropriate disciplines to provide input vital to the success of opti

Etiology mal treatment sequencing.
Acquired defects of the oral and perioral region can have multiple
Congenital defects of the oral and perioral region may be the re etiologies related to benign and malignant diseases of ectodennal,
sult of a single or multiple components of congenital syndromes. mesodem1a1. or endodermal primordia. Precipitating factors for neo
Some defects are related to lack of embryonic development of a plastic disease include viruses, environmental factors, carcinogens,
specific arch or stem from another syndrome, whereby muttiple and genetic predisposition. Other causes of these defects may
anomalies constitute the particular syndrome. Defects often as be residual effects of adjunctive treatment for obstructive sleep
sociated with congenital malfonnations include cleft lip. cleft apnea. osteoradionecrosis, osteomyelitis, or refractory mycotic
palate, or cleft lip and palate; partial or complete anodontia; or infections. Trauma iS another source of anatomical defects of the
amelogenesis lmperfecta (Fig 15-1) or dentinogenesis imperfecta. oral and perioral region and may have devastating effects on the
All of these may occur as isolated defects or may be a component delicate physiologic processes of swallowing, mastication, speech,
of systemic manifestations of syndromes such as trisomy 21 , facial expression, sight, taste, olfaction, hearing, and balance. Exter
Goldenhar syndrome. Gardner syndrome. ectodermal dysplasia. nal trauma is often implicated in interference of these processes, but
Treacher Collins syndrome, or Pierre Robin syndrome. Many of these endogenous trauma such as chronic gastroesophageal reflux can
syndromes can significantly affect treatment plans for patients, as result in significant loss of tooth structure and associated findings,
other related manifestations may have preclusions to care. Never suc11 as laryngeal edema and chronic coughing.
theless. management of these patients requires expertise from all
197
15 Re s torati o n of Con geni tal, Developmental, and Acquired Oral and Perioral Defects
Fig 15-1 Patieot diagnosed mth amelogenesis ompe!fecta on most posterior teeth _( a � ) Preoperative Clinical Situation. Treatment to include rest001toons lor the most IJ()Slenor
1/
teeth 10 mandible. (c)Posttreatment wm of max111a. (rf! Centnc occlusion of pabent w
i Cipated treatment of antenor teeth.
th an�
Patients with congemtat maHormations should also be managed

Multidisciplinary Care by a similar treatment team consisting of surgical, orthodontic,
pediatric. genetic, prosthodontic. and psychologic specialists to
For both the health care provider and the patient, optimal manage coordinate interdisciplinary care that is often staged depending
ment occurs through the coordinated efforts of a multidisciplinary on anatomical and physiologic development. Such a group of
team. Because of the complexity or tt1e IL•nctional deficits associ physicians/dentists and allied health care specialists is often known
ated with removal of some head and neck tumors and the involved as a craniofacial treatment team and can provide collective input tor
adjacent tissues, congenital anomalies, and traumatically induced strategies and spec1fic stages of intervention.
deficits, sur gical management may not be adequate as a sole re The knowledgeable surgeon who provides head and neck cancer
constructive procedure. For tumors tl1at involve regions of anatomy management services understands the need for the support of a
with different but coordinated functions. or tor defects t hat involve dental colleague to maximiZe treatment efforts. Many well-meaning
large areas. surgical replacement of pert1nent anato my using the general dentists have helped in these challenging endeavors;
best available methods is often less than ideal and less predictable however. the interaction has too often been less than Ideal because
than prosthetic managemant. Challenges for the surgeon include (1) of the limited training and expert•se of the dentiSt. Unfortunately, in
recogniZing the surgiCal reconstructive limits for complex defects: these situations. the surgeon is forced to offer more surgery when
(2) l.ll1detstanding when prostheses can provide a better functional adequate prosthodontic support is not available. MaXJllofaaal
and cosme itc result compared to the surgical optJons; (3) being prosthetics. a subdiscipline of prosthodontics. is the branch of
aware of when prostheses are required 1n coordinatOn
i wrth surgical dentistry concerned With the restoration and replacemen t of funct100
reconstruction; and (4) deSigning and prCMdlflg a surgical Sti e that and esthetics of the stomatognathc and cran10facoal structures that
alows optJmal prosthetic useful ness. have been affected by dosease. •ntury. surgery, or congenital defect.
Pat100t s affliCted With head and neck cancer or ben.gn diseases The maxillofacial prosthodontist is a VItal resource for total head and
that are treated aggressively should have a d1agnosic
t sequence neck patient manag ement 5efVIC9 and IS the best qualified to prO\IIde
that can start w•th a head and neck surgeon and progress to a the prosthetic support to the surgeon. The patient w1th an acqUifed
maxollofacial prosthodontist. oral and maxillofacial surgeon. radiation defect is best served by the coordinated efforts of the surgeon and
oncolog1st. med�cal oncologist. nutn•o
t nlst. and speech therapist. maxiRofaCial prosthodontist. Consequently. determination of the
Anticipation of resecbon for malignant disease in these cases is following aspects of prosthetic care should simplify the coordination
best approached wrth a comprehen si ve treatment plan that involves of treatment tor patients with acquired defects:
interaction among all of these subspeciallles.
Acquired defiCiencies of the maxilla often are treated best with • Degree to which prosthetic reconstruction can approach pre
surgery and prosthodontics Outcomes for these patients are fairty
.
surgical function
predictable, and coordinated efforts usually produce favorable results. • Timing of prosthetic care, with examples based on prostheses
Acquired defects of the mandible. however, require a more In-depth tor the most common head and neck surgical defects
interaction among all appropriate subspecialties because limitations • Surgical outcomes that can improve prosthetic success for differ
in function and cosmetics usually follow tumor ablative surgery. Often, ent regions
secondary tumor control is instituted because or considerations for • Helpfulness of osseointegrated implants for the patient with
combined therapy, which may include some aspect of radiation or acquired de fects
chemotherapy. In these circumstances. treatment objectives should
be clearly stated and efforts tor subsequent rehabllitat•on should
.
It may be appropriate to first review normal function as a baseline
also be planned to address di fficulties in function and cosmetics. for goal setting to atta•n the presurg1cal function of mastication.
deglutition. and speech.
198
Normal Functional Parameters J
changed.' This reliability o f masticatory efficiency is not seen across

Normal Functional Parameters populations o f patients with an identical number of occluding teeth.
Performance measures reveal a great deal of functional variability
Because patients tend to present with a variety of presurgical intra among patients with similar numbers of contacting teeth and an
oral conditions. their basis for comparison is their previous unique even greater variability within populations with increasing degrees
oral/dental experience. A knowledge of the many objective and o f edentulism.
subjective measures of oral function assists in the development of Occlusal contact area is highly correlated with masticatory
realistic goals and expectations tor the patient with an acquired performance'"' Therefore, the loss or molars, which provide more
defect. Functional impairment following surgery most often relates opportunities f o r contacting surfaces because of their increased
to mastication, swallowing, and speech; while cosmetic impairment size, would be expected to have a greater effect on performance.
resulting from intraoral defects most often is characterized by disfig This has been demonstrated in individuals with missing molars who
urement of the lower one-third of the face. require a greater number of chewing strokes and retain a greater
mean particle size before swallowing.8 The point at which an
individual is prepared to swallow the food bolus is another measure
of performance and i s described as the swallowing threshold.
Physiologic aspects of mastication and
Superior masticatory ability, which is highly correlated with occlusal
deglutition contact area also achieves greater food reduction at the swallowing
,
threshold. Conversely, a diminished ability to chew is reflected in

Though considered separate functional acts. mastication as part of larger particles at the swallowing threshold.
the feeding continuum precedes the activity of deglutition and is not Individuals with a shortened dental arch may have occlusal forces
an end in itself. The interaction of the two distinct but coordinated similar t o those with a complete complement of natural teeth, bu1
aspects of feeding suggests that some judgment of mastication their chewing efficiency can be greatly reduced.• Patients who 11ave
termination or completeness precedes the initiation of deglutition. undergone prosthetic replacement of teeth often demonstrate less
Although the mastication-deglutition sequence is obvious. the inter function that that experienced with a complete natural dentition
action of the two functions is not widely understood and underlies state. Functional measures are closest to the natural state when
some of the subtle but important functional deficits inherent in the restorations are fixed partial dentures (FPDs) rigidly supported by
head and neck cancer patient following surgery. teeth or implants. Function is reduced somewhat when restorations
Mastication involves two discrete but well-synchronized activities: are removable and supported by teeth, reduced further when
(1) subdivision of food by applied force and (2) selective manipulation restorations are removable and supported by teeth and edentulous
by the tongue and cheeks to sort out coarse particles and bring ridges, and lowest when restorations are removable and supported
them to the occlusal surfaces of teeth for further breakdown.' The on edentulous ridges alone.'o 11
initial subdivision or comminution phase involves the processes of Subjective measures of oral function provide information as to
selection. which is the chance that a particle is placed between the the level of concordance between objective measures o f patients'
teeth in position to be broken. and breakage. which is the degree oral function and their subjective perceptions. It has been shown
o f fragmentation of a particle once selected! The size, shape, that subjective measures or masticatory ability are often overrated
and texture of the food particles provide the sensory input that compared to functional tests and that for complete denture wearers,
influences the configuration and area of each chewing stroke. In the subjective criteria may be preferred when monitoring care'2
efficient mastication, the larger particles are selectively reduced in The l�erature also suggests that removable partial dentures (RPDs)
size more rapidly than fine particles.3 The process of mastication is are frequently described by patients as adding very little benefit
therefore greatly influenced by factors that affect the physical ability compared to no prostheses'3; however. this observation most
to reduce the food bolus and to monitor the reduction process by likely i s related to the lack of maintenance of the occluding tooth
neurosensory means. relationships••.•• and highlights the limitations of this prosthesis type
for patients who may be noncompliant with follow-up visits.
Food reduction
Monitoring of food reduction
Masticatory efficiency describes an index of food reduction, or the
ability to reduce food to a certain size in a given time frame.' It has Food reduction also is influenced by the patient's ability to monitor
been shown that there is a strong correlation between masticatory the mastication process. which is required to determine the point at
efficiency and the number of occluding teeth in dentulous individu· which deglutition should be initiated. As mentioned earlier, the size,
als, which would suggest variability of particle selection related to shape, and texture of food are monitored during mastication to allow
contacting teeth.5 The reliability of this process is demonstrated modification in mandibular movement for efficient food reduction. In
in the duplication of masticatory efficiency test results in the same dentulous individuals given food particles of varying size and con
individual over time when the number of contacting teeth 11as not centration suspended i n yogurt, increased concentrations and par-
199
151 Restoration of Congenital, Developmental, and Acquired Oral and Perioral Defects
D---+-- 2
1
l-----\- 3
Fig 15-2 Phases of swallowing: oral phase (1), pharyngeal phase (2). and Fig 15-3 Cephalometric radi ograph. (.1)Soft palate at rest. tf])Patieflt phonating "ah" to dem·
esophageal phase (3). onstrate palatopharyngeal incompetence.
ticle size required more time to prepare tor swallowing's (ie, greater Though surgical management can affect all phases of the swallowing
swallowing threshold). These findings suggest that the oral mucose mechanism, prosthetic management is chiefly con-earned with
may have a critical proprioceptive role in detecting characteristics components of the oral and pharyngeal phases related to structural
necessary for efficient mastication. integrity: the tongue. the hard palate, and the soft palate-pharyngeal
If afferent sensory input is necessary lor efficient mastication, this functional unit commonly referred to as the palatopharyngeal complex.
might help explain why patients with complete dentures (which cover Objective measures of normal swallowing, such as videoffuoroscopie
so much mucosa) exhibit much lower scores of oral function. Could studies. provide an understanding of the timing and coordination of
an understanding of the under1ying reasons for this reduced functional tongue loading and movement, nasopharyngeal closure, pharyngeal
capacity have any bearing on maxillofacial deficits following head clearance, airway protection, and upper esophageal opening.?.O
and neck surgery? One study addressed whether reduced sensory Prosthetic management only directly affects the first three measures.
input affects masticatory efficiency by anesthetizing the oral mucosa The tongue exhibits a highly complex capacity for motion. Its
of dentulous individuals and measuring masticatory effiCiency." arrangement of muscles with external attachments allows a wide
Individuals who normally required approximately 20 chewing strokes range of movement around the oral cavity, and its internal or intrinsic
to prepare food for swallowing required approximately 40 chewing attachments allow task-specific shape modifications. Studies of the
strokes for the same task following unilateral anesthesia. These surface motion of the tongue during swallowing reveal perimeter
dentulous individuals, who normally were more selective of coarse contact with the alveolar ridge and a central groove that exhibits
particles for rapid reduction characteristic of efficient mastication. centripetal and centrifugal motion.20 Such motions in combination
demonstrated a more random reduction of food particles similar to with the pharyngeal walls create an oropharyngeal chamber that
that seen in patients with complete dentures. An increased number expels its contents into the hypopharynx. The o
t ngue i s able to
ot chewing strokes as a compensatory measure in mastication is modulate its propulsive force based on bolus viscosity and volume.
common in complete denture patients. and as with the measure of The modulation capacity of the anterior two-thirds of the tongue
occlusal force. mastication is widely variable among patients with exceeds that o f the posterior base of the tongue.�1 Consequently,
both satisfactory and unsatisfactory prostheses.10•18 The relationship the functions of the tongue in swallowing include mainly bolus
between decreased sensation and functional performance may help propulsion but also bolus containmeflt and volume accommodation.
partly t o explain the reduced lunctional scores of patients following Because closure includes portions of the palate and pharynx, it is
intraoral resections and reconstructions. and it could fuel increased frequently referred to as palatopharyngeal closure. When the food
interest in sensate flaps for oral reconstructions.10 bolus is propelled into the pharynx, stimulation of the surrounding
mucosa of the anterior tonsillar pillars initiates involuntary pharyn
geal contractions. These begin with palatal elevation in coordination
Swallowing with pharyngeal wall movement, hyoid bone elevation. and epiglot
tis closure of the airway with opening of the pharyngoesophageal
There are three phases of swallowing: (1) the oral phase. which sphincter (cricopharyngeal muscle). These events in the human
includes mastication; (2) the pharyngeal phase. which starts invol are impressively consistent. The components of major Interest tor
untarily once the bolus approaches the palatoglossal arch; and (3) prosthodontics are the soft palate and pharyngeal wall movement.
the esophageal phase, which starts at the stricture of the cricopha The posmon and movements of the soft palate vary with age; at
ryngeal muscle (Fig 15-2). closure, it is characteristically above the level of the palatal plane in
the adult (Fig 15-3).
200 1
Normal Functional Parameters J
The pattern of movement varies between men and women; men all l evel s, the nasal cavities, and the oral cavity. For the mucosa
show a g reater portion of palate in contact, less length, and a higher lined pharyngeal chamber. changes in the static dimensions or the
point of contact with the posterior pharyngeal wall.M Pharyngeal wall opportunit y for dynamic movement that influences resonance will
movement is less predictable relative to the posterior wall compared not be improved with prosthesis use.
to t he lateral walls and the soft palate. Posterior wall movement The soft palate serves to couple and uncouple the oral and
has been demonstrated in patients in whom compensatory anterior nasal cavities for selective production of consonant phonemes
movement may provide a functional benefit because of long (see chapter 19). Its valve!ike function helps to di rect the air st ream
term sructur al inadequacy (eg, cleft palate). The resulting anterior
t as needed, and, as such. it controls use of the different resonant
bulge has been called Passavant's ridge or Passavant's cushion.>> chambers of the upper airway. The soft palate's control of the airway
Lateral pharyngeal wall movement contributes significantly to also i s important to the articulatory function of speech because
palatopharyngeal closure for both swallowing and speech. The it allows creation of the oral articulatory valves. Altered function
level of movement is greatest at the region of the palatal plane. o f the soft palate consequently impacts both articulation and
making transoral inspection of this movement difficult. The character resonance. One study has shown that when resections are limited
oi movement Is sphincteric in nature and is not always bilaterally to the anterior portion of the soft palate, prosthetic treatment has
symmetric. Approximately 1 em contacts the soft palate." and sufficed to maintain 1hese functions (and surgical reconstruction
contact at the midline occurs in va1ying lengths depending on is not indicated; more extensive resections of the pos terior
}
whether the swallow is a reflex or dry swallow. The musculature pharyngeal wall were rehabilrtated equally successfully with surgery
responsible for this pharyngeal wall movement has been debated, and prosthetics.:te The challenge for prosthetic management is to
but current research supports the idea that the function is related determ ine the altered soft palatal and surrounding pharyngeal wall
to bilateral superior pharyngeal constrictor, levator veli palatini, and movement and the associated p alatopharyngeal incompetency and
possibly the salpingopharyngeus muscles. to place a static palatal obturator component of a prosthesis within
this region to artificially redirect the air stream for optimal articulation.
Succe.ssful management of soft palatal defects with such speech
Speech aid prostheses is best determined through coordinated speech
intelligibility testing by a speech pathologist.
Speech is a learned !unction that utilizes the structural anatomy Surgical management of tumors involving the tongue affects the
intended for the more basic functions of respiratiOn and deglutition. arti cul atory function of this highly specialized organ. The extrinsic
Multiple components are required for successful speech, including muscles chiefly provide a stable postural background from which the
respiration, phonation. resonation. articulation, neurologic integra intrinsic muscles cont rol fine. discrete movements associated with
tion. and the ability t o hear sounds. The utility of speech lies in the speech. It has been demonstrated that the articulatory movements
ability to communicate; therefore, the most useful objective measure of the tongue apex are more active in consonant production, and
of speech is speech intelligibility. the body of the tongue is active in both consonant and vowel
Surgical management of head and neck tumors can result in production.2' Speech function in a group of 11 patients who had
acquired speech disorders such as (1) impaired articulation. (2) resection of tumors greater than 1 em involving the tongue base,
reduced speech intelligibility (3) altered oral and nasal resonance.
, tonsillar pillar, and mandible (with primary closure) was compared
(4) impaired voice quality, (5) changes in speech rates and pros with speech function in another group of patients who had anterior
ody, and (6) reductions in global speech prof iciency.25 Surgical tongue resections. Speech performance was better in the tongue
reconstructions for tongue, floor-of-mouth, and mandibular tumors base resection group.:>a The maintenance of anterio r tongue mobility
can also alter speech through their effects on the mobility of the was the important finding and suggests that efforts to minimize the
tongue. mandible. and lips. Reconstruction of pharyngeal areas postsurgical impact on tongue mobility are warranted.
with tissue that does not allow dynamic movement and is bulkier For useful production of consonants in speech, the tongue must
than the original tissue may also alter the resonance of speech. be able to contact variable regions of the maxilla, teeth. and posSibly
Prosthodontic management mainly addresses the resonation and the lips. Surgical defects that result in hindered movement can be
articulation deficits created by the tumor treatment. compensated for by artificial lowering of the maxilla or palate to
The acquired defects that most frequently affect speech are the altered functional level of the tongue in an attempt to improve
resections of the tongue. fioor of mouth, retromolar trigone, mandible. consonant production. For total glossectomy defects, prostheses
and the hard and soft pal ates. Defects that create communication can be provided to statically fill the space in the floor of the mouth to
between separate caVities (maxillary or soft palate defects} or detects facilitate deglutition and speech. The success of such prostheses ior
that are large and significantly increase the size of a cavity can alter both functions is largely dependent on the mobility of the mandible
speech resonance. This quality of speech is derived from the airway and whether the base of the tongue was preserved. It is possible that
chambers above the level of the larynx thai include the pharynx at each function will require different static forms for optimal results.
201
II Ill IV v
Fig 15·4 Classificalioo ol congenilal cleft lip and p alale. Class 1: lip only; C lass II: soft palate: Class Ill: soli and hard palate: Cl ass IV: unilateral complele clef! lip and palate: Class v·
bilateral complete cleft lip and palale. (Reprinted from Terkla and laney"' with pemnission.)
or unattempted surgical management. Additionally, nasoalveolar

Cleft Lip and Palate molding may be offered as an adjunct to early intervention in some
team approaches.
Cleft lip, with and without cleft palate. and isolated cleft palate are The literature reveals a lack of an accepted universal clinical
serious birth defects that affect approximately 1 in every 600 new protocol to guide management of this patient population.32 Because
born babies worldwide."" The incidence of cleft lip/palate by race is of this situation, tl,e prosthodontist should consider the management
2.1 per 1.000 in Asians, 1 per 1.000 in whites, and 0.41 per 1,000 options that can be provided tO this patient population and work
in blacks. Isolated cleft palate is less variable. presenting a fairly con within the team approach to support the overall management needs.
stant ratio of 0.45 to 0.5 per 1,000 births. It is common for patients
with clefts to exhibit other congenital anomalies: 7% to 13% of those
with isolated clefts and 11% to 14% of those with cleft lip/palate are Historical and background considerations
additionally affected. There are several classifications of cleft lip and
palate combinations (Fig 15·4). Early descriptions of surgical closure techniques were followed
Clefts often !lave pathologic consequences. such as nutritional by considerations of the influence of operative closure on palatal
deficiencies. resulting from impaired feeding, reduced hearing function and subsequent anatomical development. The concern re
from recurrent ear infections, abnormal speecl, development, and garding the influence of the surgical wound on motor control in soft
diminished facial growth related to surgical interventions. Although palatal speech movements in the developing child, in addition to its
the bony defect is a critical focus of surgical intetvention, the muscular influence on nasomaxillary growth, has been at the heart of tech·
and soft tissue pathology have the greatest impact on the functionat nique refinements. This evolution is reflected in the statement that
result of management. The region is a complex arrangement of six "the challenge in the art of modern palatoplasty is no longer suc
muscles, three of which are critical to palatopharyngeal function: cessful closure of the cleft palate but an optimal speech outcome
the uvula, the levator veli palatini, and the superior pharyngeal without compromising maxillofacial growth."33 T his evolution of treat·
constrictor. In a cleft palate, the muscle considered most significant ment goals has aroused controversies related to speech and maxil·
to palatopharyngeal competence is the levator veli palatini. lofacial growth that dispute the effectiveness of numerous treatment
protocols. Developments in prosthodontic management can also be
seen in the impact of alveolar bone grafting techniques in the mixed
Management dentition. This option has also allowed arch discontinuity t o be re
stored at a time when orthodontic movement can potentiallyobviate

Management of cleft lip or palate is a multidisciplinary team effort the need for prosthodontic intervention in select situations."'
that requires coordinated care initiated soon after birth, continu
ing throughout subsequent years3' In the past. the proslhodontic
contribution to the team occurred at earlier stages of care than is Multidisciplinary intervention
generally the current practice. This change is largely a result of more
acceptable surgical options that are now available to address basic A World Health Organization (WHO) report on the global impact of
speech and swallow needs of the developing infant and child. craniofacial anomalies (CFA) proposed that treatment of CFA has not
Currently, prosthodonUc managem�t includes consideration benefited from contemporary health technology assessment; conse·
for restoration of missing teeth within tl,e anterolateral alveolus or quentty, optimal management cannot be universally defined for even
prostheses to provide palatopharyngeal closure for unsuccessful the most common conditions. For each of the many subgroups of
202 1
Cleft Lip and Palate j
.......
Fig 15·5 (a)A 12-year-old gi� with cleft palate. (b) Intraoral defect. (c) Base prosthesis processed witll wire extension. (<QTracing of defect with mooeling plastic compound. (e) Final
tracing with mouth temperature wax. (f)Radiographic verificatioo willl pharyngeal extension adjacent to level of alias. (g) Intraoral view with seated interim prostllesis.
Fig 15·6 (a to C) Adu lt with unilateral Cleft lip/cleft palate restored willl RPO-based prosthesis willl palatal and pharyngeal obturators.
CFA, th e attainment of homogenous samples of adequate siZe fo r of patients for whom prosthodontic services are indicated has dimin·
randomized trials and long terrn follow up presents a formidable chat·
- - ished sig nif icantly The prosthodontist now appears to be involved
.
lenge.:!O Where care is available, multiple providers are necessary for mainly in the later phase of active treatment, when fixed and re·
appropriate management.36 movabl e prostheses are needed to definitively restore missing teeth,
A major contribution of orthodontics is its ability to limit facial stabilize aligned arch segments, restore occlusal function. provide
growth distortion with the use of corrective orthodontic alveolar facial support and dlmension, and assist in speech (Fig 15·5).
ridge positioning and toot h movement (see chapter 2). As previously The changing role of the prosthodontist does not imply that his or
stated, the benefit of alveo l ar bone grafts during the mixed dentition her services are no longer needed in the early phases of treat ment.
stage is t hat they allow the opportunity to position adjacen t teeth Because some situations exist in which prosthodontic services may
within the graft for optimal esthetics and function.31 be indicated early, active p articipati on in the group decision-making
With the establishment of cleft palate teams and centers, the eli· process is encour aged . Most pat ients with cleft palate require some
nical management of large numbers of patients led to the accum type of prosthesis. Mazaheri has estimated that in app roxi mately
ulation of data that suggest the merit of staged treatment initiated 95% of the patients in whom a cleft involves the alveolar ridge, either
soon after birth Earlier surgical and orthodontic intervention for most
. a fixed or a removable prosthesis will be needed.36 It has also been
patients has resulted in less complex problems in the adolescent and suggested that abo ut 60% of all cleft palate patients need some type
adult years. Because of the better results achieved thro ugh earlier of prosthesis by the age of 30 years.
treatment. the rol e of the prosthodontist in the multidisciplinary team Other than tooth-supported restorations, th e most common pros·
has changed somewhat in recent years. The need for fabrica tion thesis required for t11e patient with cleft palate is an RPD (Fig 15·6).
of obturators, replacement of missing teeth, and speech-bulb stim In patients with distorted jaw relationships, closed vertical dimension
ulators in preschool children with clefts continues. but t he volume of occlusion (VOO), com plic ated occlusal or esthetic problems. or
203
the need for bulky extensions or �llers in the prosthesis, the clasp assist with columella formation and ideal segmental poSJtioning,O\> The
type partial denture i s frequently the basic prosthetic unit. More than procedure may be staged, (lepending on the problems antiCipated
one prosthetic need usually can be met by the RPD. The application in closure, q�1ality and quantity of soft tissue available, and expected
of basic principles, concepts, and practices to the prosthodontic results. An alternative approach is to perform primary closure to include
management of these patients is a s important as it is for any other operation on the soft palate and a pharyngeal flap in one procedure.
patient without a congenital defect. Especially Important are the pre When the hard palate cleft is wide, closure of the soft palate alone
ventive aspects of prosthesis design that allow functional stresses to may be indicated, and if insufficient palatal length is anticipated, a
be distributed to those structures best able to withstand them most prosthesis is used to obturate the hard palate defect and provide
effectively with prolonged use. speech assistance in the palatopharyngeal region. Shoud l it be
determined that a palatal operation has resulted in palatopharyngeal
incompetence, an obturator may be the adjunctive or transitional
Prosthodontic management treatment or choice during the phase from 18 to 36 months.
In the management of the patient wilh cleft palate, the prosthodon Child phase
tist may be enlisted to provide indicated services at various intervals.
Specific requirements for management are determined by the de At approximately 3 years of age, the average child should be able
velopmental stage of the patient and the nature and extent of the to understand and cooperate to the extent that indicated active
abnormality being treated. Representative chronologie modes of treatment can begin. Usually, the primary dentition has erupted and
treatment and their rationale should be provided to the patient. and a definitive occlusal relationship has been established by this age.
it should be explained that basic approaches to care can be modi Most patients with complete cleft palates will require orthodontic
fied to more extensive problems as they occur. treatment, which may have been started already if the maxillary
orthopedics concept has not been espoused.
Infant phase Primary objectives for a prosthesis at this stage include the re·
placement of missing teeth, retention of arch alignment, and speech
The early afignment of malposed maxillary arch segments is benefi assistance through the closure of nasoal veolopalatal fistulae and the
cial for surgical closure. Positioning devices for the anterior maxil use or a pharyngeal obturator. To satisfy these objectives. the typi·
lary region are generally used to deliver a slight predetermined force cal prosthesis consists of anterior. palatal, and pharyngeal sec ti ons.
for movement. The infant. who lacks teeth for retention and sup Primary teeth seldom have natural contours that are conducive to
port, must be kept under observation t o ensure that the prosthesis the retention and stability of an obturator prosthesis. Thus, it is usu·
remains in the intended position and is performing the desired func ally necessary t o place orthodontic bands vJith attached tubes or
tion. As growth begins to accelerate after the first 4 to 6 weeks of lugs, cast or preformed crowns, direct bonded plastic brackets, or
life, a more aggressive force can be imposed to direct movement of overcontour restorations on teeth that are essential for support and
the segments. retention of the prosthesis. The pharyngeal obturator component is
Use of the prosthesis is continued until the lip can be surgically most often developed following fabrication of a stable palatal base. It
closed. usually 6 to 12 weeks after birth. After the lip operation. is molded with plastic compound on an extension placed within the
continued use of the prosthesis may be indicated for segmental anticipated pharyngeal space. Molding to functional head positions
retention or feeding assistance. When teeth begin to erupt, problems of forward and lateral flexure and having the patient repeatedly and
in adaptation and stabilization become more frequent and use of the forcefully phonate "ah" helps attain an appropriate shape (see Rg
prosthesis may be discontinued. Further prosthodontic intervention 15-5). In this phase, the trajectory is also dependent upon several
probably is unnecessary until primary dentition is more complete and factors, including the palatal plane and atlas tubercle (Rg 15-7).
the child is cooperative enough to understand and undergo further Successful pharyngeal obturator design and function include the
intraoral procedures. following features:
A management decision is necessary when the speech process
has developed enough for the prosthodontist to assess the level of • Lightweight and minimal in bulk to reduce stress on supporting
palatopharyngeal competence. Even though it is possible to fabricate structures
and place an obturator as early as 18 months of age, litile benefrt is • Hygienic design without much surface detail that could encour
likely. and other management problems may be created if the child age adhesion of food debris and secretions or cause irritation
cannot understand the treatment rationale. The speech pathologist • Optimal size and shape for intended function without impinge
plays an important role in collective judgments as to the type and ment on resting tissues
timing of prosthetic or surgical inteNention during this early period. • Noninterference in mastication, deglutition, or tongue function
To permit undisturbed growth, surgical closure of lhe cleft palate during speech
usually is delayed until the child is about 18 months of age. During this • Easily revised. repaired. or remade
time. it may also be preferable to consider nasoalveolar molding to
2041
Cleft Lip and Palate j
b d
Fig 15-7 (a) Level of palatophaf)'ngeal closure related to antelior tuMrcle. (Modified from Aram and Subtefny>? with perm1ssion.) (/))Level of clOSure in relation lo palatal plane.
Distance difference between (a) and (b) suggests tllat the palatal plane is a more reliable guide. (c and d) Note the change in palatopharyngeal closure pattern between the young
patient (c)and adult patlem (d) because or sl<eletaf growth and soft lissue function.
Fig 15-8 {a lo d)Adult with bilateral cleft palate restored with telesCOpic cto1•ms. bar attachment, and overlay prosthesis.
Once the palatal section of the prosthesis is processed and ciency mostly occurs in the anterior part of the maxilla, which may
fimshed, it is adjusted in the mouth for comfort and fit. If this is the also exhibit horizontal deficiency. lntertooth dimensions are narrower
patient's first prosthesis experience, a short period of use without the from the premolars anteriorly, compared to patients without clefts.
obturator may be desirable to accustom the patient to the feel and Orientation of the plane of occlusion may be distorted and requires
manipulation of the prosthesis. scrutiny in the reestablishment of an effective occlusal scheme.
If a child with a cleft palate is wearing an obturator, the parents Patients who have had orthodontic treatment probably have Md the
should be told that the device will need to be revised or remade as mandibular plane leveled, but the resultant orientation height may
primary teeth are replaced by permanent dentition and as growth be disadvantageous in the distribution of stress to the weaker arch.
continues. Whereas standard treatment-planning processes require mounted
diagnostic casts only, judgments related t o plane manage111e nt must
Adult phase be made with the patient while he or she i s seen in the clinical setting.
The determination o f how VDO is to be restored sometimes
The goals of treating adult patients with cleft palate are the same requires the collective judgments or the orthodontist, oral surgeon,
as those for any prosthodontic patient: intelligible speech, functional and prosthodontist. In the adult patient, surgical orthodontiCs may
occlusion. and an acceptable cosmetic relationship. The mainte· be effecti ve in reducing gross vertical discrepancies rapidly before
nance of healthy natural teeth is critical to the success of any fixed definitive restorations are placed. If surgical treatment or orthodontics
o r removable partial prosthesis. Because the remaining teeth usu is contraindicated, the prosthetic restoration of this dimension
ally must resist more stress, wide distribution of forces is important. depends on the remaining teeth {number, location, support, effective
Therefore, the simpler the prosthesis design, the easier it will be for crown-to-root ratio, mobility, and vitality) and on dental hygiene.
the prosthodontist to maintain and for the patient to care for and Restoration of VDO by means of cast-crown restorations and fixed
manipulate. prostheses is preferable to extensive removable overlays. However,
Certain concerns more common to adults with cleft palate are if the crown-to-root ratio becomes unfavorable in the process, a
important to consider. removable prosthesis is indicated.
Cleft palate patients who commonly require overlay prosthe
Dimensional distortions ses (Fig 15-8) include those with (1) a resected or ftoating maxil
voo is reflective of overclosure and Ms been described as the result lary anterior region, (2) lip collapse, (3) numerous missing teeth and
of an intrinsic tissue deficiency in all patients with clefts. The defi- occlusal relapse, or (4) large anterior interarch distances. VDO is not
205
Fig 15·9 (a) Isolated cleft palate In the adull patient. (II) CompOnent prosthesiS used to treat Fig 15-10 The ctass1c submu-cosal cleft showing the 0\lllrt signs of abnormal
patient Note lndlrect retention provided by major 00<1nector. muscle poslbon: bilid uvula (1), furrow along mdi line o1 soli palate (2), notch in
po5teli0f margin of hard palate (3), and illSeltion of levator and othe r palatal
muscles mto hard palate insteadof forming a sling across mid,ne (4). (Reprinted
from Kaplan"' vAitl permlsslon.)
a significant factor in management of the edentulous patient, but the

amount of dimension to restore at any one time becomes a problem.
Acquired Functional Deficits
However, the rest oration of VDO generally decreases as a factor as Resembling Congenital
the p atient ages and loses neuromuscular coordination.
Deficiencies
Retention a n d stability
Because prostheses for the adult patient with cleft palate are oom
monly more extensive t han conventional denture prostheses, their A typical congenital oral defect such as cleft palate exhibits abnormal
retention and stability create additional problems. The maxillary morphologic structures that result in compromised function. OU1er
prosthesis is of particular concern because it addresses the major conditions created by disease or trauma become evident becau se
d efect. Teeth and bone are the natural supporting structures used o f foss of neuromuscular control. These oommonly affect the speech
for retent on and stability of a prosthesis; theri quality and quantity
i process; despite normal development of the related palatopharyngeal
usually determine ll<e effectiveness of the prosthesis. If arch alignment anatomy, trauma t o the central nervous system, muscular dystro·
is favorable. ed entulous spaces are few and short, additional bulk phies, or neuromuscular deficiencies can adversely affect its coordi·
is not needed for lip or facial support, and a pharyngeal obturator is nated action.
not needed for speech. then FPDs are the restorations of choice to Perioral examination occasionally reveals no overt palat al cleft. yet
rep lace missing teeth and to restore occlusal function. Impl ant con the soft palate appears 10 be limited in function. Further examination
sideration following bone augmentation, if needed may be indicated
, may suggest a submucosal cleft, whic h contains inadequate bone
and obviates the historical approach of cross-arch fixed prostheses. structure accompanied by muscle compromise that impairs palatal
When the patient with cleft palate is partially edentulous and must function (Fig 15-10).
wear an RPD, it is possible to provide a pharyngeal obturator, addi· Disso lution of muscle can result from pathologiC involvement of
tiona! bulk for facial or lip support. or more latitude in the p lacement the central nervous system. peripheral nerves, or the muscles them
of artificial teeth. However. ll1e opportunity to add these features is selves. Thus. disease entities may be categorized as myelopathic.
compromised somewhat when numerous anterior teeth are missing, neurotrophic , or myopathic. Dystrophy results when the primary path·
the anterior maxillary region has been resected or maxillary under·
, ologic factor is an inherer<t disability in the muscle itself. Muscle atrophy
development has resu lted in infraclusion. The retention of maxillary is a oommon sequela of distant disease of the central nervous system.
anterior teeth becomes more significant in such situations because Dystrophy and atrophy are not usually considered neuromuscular
oi the value of these teeth in providing not only direct support and disorders. Because myelopathic disease is arbitrarily limited to
retention but also indirect retention as a stabilizing mechanism (Fig involvement of the final common-path cell within the cer<trat nervous
15·9). When a pharyngeal obt urator is a part of t he maxillary pros· system, disorders of this type may be combined with neurotrophic
thesis an additional lever
. arm is introduced p osterior to the active disorders, which i mply a neuromuscular disability that originates in
s upport . A counteractive ant erior stop is thus desirable to reduce alteration of the final oommon-path cell o r its peripheral extension.
sagittal rotary movement of the prosthesis. The disability-producing diseases that oommonly affect palata·
pharyngeal structures include bulbar pol o
i myelitis (viraQ, di phtheria
2061
Acquired Functional Deficits Resembling Congenital Deficiencies J
-Palatal plane •
ta Ia
Fi g 15·11 Diagram of p alatal lift retainc<l by
extensive engagement of <le11tal undilrcuts to
provide e:evaUOfl o f palate to a position that
ensures palatopharyngeal competence. (a) Palt a e
at rest. (b) Palatal posijiOfl With lift. (Reprinted from
a b
Gonzalez and Aronson" With permissiOfl.)
Fi g 15·12 Bulbar paralysis of soft palate. Lateral cephalomelric radiographs depict oropharyngeal configur ation at rest (a). at opening (b). and with palatal lift appliance in position
(c). (d) Soft palate a t rest. (e) Prost hesis in place resulting in approximation of soft palate Ia pl1aryngeal wall.
(bacterial). amyotrophic lateral sclerosis (ALS), and myasthenia basic speech-producing components (ie, respiratory muscles,
gravis. Although the incidence of poliomyelitis has been reduced larynx, palate. pharynx, tongue, and lips) it is not surprising that
,
significantly by preventive measures. the afflicted patient can suffer respiration, phonation. and articulation are influenced adversely.
paralysis of the respiratory muscles and palate. Similarly. dipht heri a The prosthodonlic approach to the management of patients with
occurs infrequently, but a large study showed that many patients these afflictions primarily involves support for the weakened palate.43
experienced some paralysis.'' In its mildest form, t11e paralysis is us When the palate is elevated to the position achieved during optimal
ually limi ted to the palate. normal function and held there. improved speech can be expected.
Among the chronic myelopathic atrophi es is ALS, which is closely The prosthetic device used to provide this support is known as
related to progressive muscular atrophy. In contrast t o the latter, ALS a palatal/itt.

begin s later in life and is fatal. The etiologic factor for this disease is It has been suggested that the objectives for use of a prosthesis
obscure, but it inita
i lly manifests as a spastic paralysis that results differ depending on the clinical situation. For the patient with palatal
from bi later al atrophy of the pyramidal tracts. Both flaccid and spastic incompetency, the goal is stimulat i on of muscle activity by prosthetic
paralysis can affect the soft palate and precipitat e deterioration in therapy; for the patient with palatopharyngeal insufficiency. the goal
speech inte lligibili ty. should be the development of muscle strengt h by placement of
Myasthenia gravis is a condition invo lv1ng an abnormal fatigability a prosthesis." Usually, consideration of the use of a palatal lift is
or weakness of muscles. Approx imately 50% of cases result from advisable as soon as poss ib le after the traumatic inCident or after
a beni gn tumor of the thymus (th ymoma). The malfunction occurs diagnosi s of the disease process involved The longer the delay, the
.
in response to an interference with the transmission of i mpulses more likely the palate will lose its resilience and begin t o atrophy.
across the neuromuscular junction. Although not totally successful,
modes of treatment include the temporary use of parasympathetic
stimulators, such as neostigmine (Prostigmin [Valeantj), or surgical Fabrication of palatal lift
removal of the tl1ymus.
Other postnatal causes of palatopharyngeal insufficiency can be Because oi the active force continuously applied on the soft pal·
attributed to trauma to the brain or cerebrovascular accidents. The ate by a palatal lift, to be effective, the prosthesis carrying the lift
degree of paresis is variable, and the return of function in response must be a s rigid as possible. with sufficient retention to offset the
to stimulation by a prosthesis can be limi ted if the trauma has been constar1t dislodging force. Such stability requires the presence of
extensive. enough healthy natural teeth to provide the necessary support and
The speech sequelae of neuro logi cally induced palatopharyn resistance to the unfavorable stresses imposed on the dentition.
geal insufficiency usually include nasal emission. hypernasality. Prosthesis design must provide for the wide distribution or these
and misarticulation . 42 When neurologic disease has affecte d the stresses and maximum retenti on (Fig s 15·11 and 15·12).
207
The basic prosthesis has a palatal section retained by the natural Maxillofacial surgery presurgical considerations
teeth and a pharyngeal extension designed to support lhe ineffective
palate in an atraumatic manner. In the young patient, stainless steel Consultation and history
wire is used for clasp retainers, which are connected by a full palatal
acrylic-resin base. Primary teeth or partially erupted permanent The assembly of a treatment team is an essential strategy when
teeth will need adjunctive orthodontic bands with tubes or lugs, treating patients with maxil lofacial prostheses. Along with the head
directly bonded attachments, or temporary crowns to provide the and neck surgeon, radiation oncologist, medical oncologist, oral and
positive retentive contours needed. Fully erupted permanent teeth maxillofacial surgeon. speech therapist. and nutrition specialist, the
in reasonably good alignment and occlusion are used to support maxillofacial prosthodontist makes a unique contribution in the for
more definitive type cast-metal frames or bases that carry the lilt. mation of a definitive rehabilitative treatment plan. A review of a pa·
Such construction is more rigid with less bulk. and longer service tienrs medical history, expectations, and overall psychologic outlook
usually can be expected. However, appropriate tooth preparation is are indispensable pieces of infom1ation to help formulate this plan.
mandatory to provide embrasure and rest clearance for the frame Medical history taking and physical examination are two vital com·
without causing hyperocclusion or creating the need to reduce metal ponents of information gatheri11g. An assessment of the patient's
bulk and theretore strength. chief complaint initiates a series of questions that will help ascertain
The pharyngeal extension from the palatal section is similar in de the patient's subjective intormation. Collecting information pertaining
sign and location t o that used for a congenital cleft. A wire or cast to the patient's medical history, past surgical history, social history,
metal loop or grid is directed posteriorly along the palatal plane to current medications. allergies. and review of systems constructs
carry the impression and tina! fabrication materials. Location of the a background of vital statistics to guide the physical examination.
extension is determined by clinical assessment ot (1) palatal tengt11 A tho rough head and neck examination is then used to develop a
and width, (2) residual function, (3) resilience of the soft palate, (4) comprehensive and multifaceted treatment plan.
depth ot the nasopharynx, and (5) rest angle of the soft palate. When
the desired degree of lift has been ascertained, the cast on which the Examination
palatal section is to be fabricated is trimmed to accommodate the
position of the lift (see Fig 15-10). The examination of the patient after a thorough history taking and re
Materials and methods used in the development of the lift view of systems should begin with an in-depth review of the patient's
impression are the same as for the pharyngeal obturator. As noted, soft tissues. The dental components of a comprehensive examina·
the palatal plane provides general guidance tor the height of the lift. lion have been discussed previously (see chapter 3), but key areas
The palatal extension must be broad enough to prevent injury yet of the head and neck evaluation for these specifiC types of patients
clear the bilateral hamular processes just posterior to the hard palate. will be emphasized.
The soft palate is suppler in the midline because of the underlying The patient's mandibular range of motion can be assessed by
muscular configuration, s o diSplacement is more readily achieved in measuring interincisal distance, which often indicates the degree of any
that region. Borders o f the lift must be rounded to minimize trauma encroachment of tumors upon the infratemporal fossa. trismus related
to soft tissue, and the inferior surface should be slightly concave to to radiation sclerosis, or dysfunction of the temporomandibular joint.
avoid creating excessive interference with the tongue. This can be repeated at each recall visit to monitor for recurrences;
A palatal lift may be ineffective in sttuations in which the palate is any sudden restriction in opening may be suspect.
too short or the nasopharynx too long to achieve palatopharyngeal Examination of soft tissues of the head and neck should begin
competence. When these conditions exist, a lift -obturator comb with the lower lip, ventral and lateral surfaces of the tongue, and
ination should be considered. The lift portion of the prosthesis is floor of the mouth because squamous cell carcinomas most com·
located along the palatal plane in such a way that the pharyngeal monty affect these areas. Up competency (seal) is an integral part of
obtu rator extension will be positioned at the point of maximum swallowing and should be noted upon presentation because it fre
muscular contraction on the posterior pharyngeal wall. In pa ti ents quently becomes a consideration for resective surgery involving any
with a potential for therapeutic muscular response, the combination adjacent area of the lip. Involvement of the tongue and floor of the
may then stimulate velopharyngeal development and pharyngeal mouth with neoplasia is most problematic because their removal sig·
construction. It has been suggested that the palatal lift is more nificantly debilitates speech and swallowing (Fig 15-13). Elevation of
effective for patients wit11 palatal incompetence but no Involvement the soft palate upon phonation should be symmetr c and complete
i
o f other oropharyngeal musculature. The lift-obturator combination to its lull extent relative to the pharyngeal wall. Upon swallowing, the
may be more successful in patients with palatopharyngeal in larynx should elevate within 2 to 3 seconds.
sufficiency and minor speech articulatory di sorders. The anterior and posterior triangles of the neck should be exam·
Regular follow-up appointments are necessary t o maintain fit ined to reveal any lymphadenopathy. The consistency of nodal ex
and function of the prosthesis. In selected instances, the elevation pansion is also important: Supple and somewhat elastic quality is
process may need t o be staged rather than attempted immediately. relatively normal whereas a rigid and noticeably inflexible quality may
Should the patient find it difficult to tolerate the prosthesis initially, be a concern. A study by Lindberg at at•• found that malignant tu
short periods of use can be tried whh intervening periods of rest. mors of the soft palate, tonsil, and base of the tongue have a predi·
2081
Acquired Functional Deficits Resembling Congenital Deficiencies j
Fig 15·13 (a}T1NOMO squamous cell carcinoma of tlle right lateral border of the tongue will result in someglossal disability related to speech and swaltowing. (b)T4NOMO squamous
cell carcinoma of the kil'ler lip necessitating resection. This will result in significant functJOnal deficits of SPeech and swallowing. (C) Large erythroplakla, confirmed as squamous
cell carcinoma. and associated leukOPlakia of lip will necessitate resection that affects lip seal and functional mobWiy of upper lip. (d) Large souamous cell ca rcinoma necessitates
resection of greater than half of the hard palate and some soft palate. affecting supiJQI1ing tissues that would stabilize an obttJrator prosthesis.
• Consult with patlel>t to discuss anticipated postsurgical

I illv,lairment and manner of prostheSis management
I II
• Determine potential ror dental complications and prescribe
I I
I the required treatment
I
I • Plan subSeQuent prosthetic treatment based on records
I (diagnostic casts and radiographs)
v I SCM
I • Make recommendations for surgical site preparalioo to
I
optimize prosthetic management
Fig 15·14 Lymphnodercgionsoftheneck. Fig 15-15 Bidigltal palpation of SCM to discern

melastatlc nodes in le'!els II, Ill. aM IV first-echelon
nodal drainage areas.
lection for metastasis to the neck consistent with tumors originating in-depth oral examination indicates strategic teeth to be retained
in Waldeyer's ring. The neck is subdivided into six regions based on and used for postoperative rehabilitation. Identification of caries
the level of nodal drainage. a system commonly used and endorsed and periodontal disease is an additional focus o f this examination
by the American Academy of Otolaryngology-Head and Neck Sur· procedure. If needed, it may be appropriate to obtain a full-mouth
gery"' (Rg 15-14). These nodal metastases can be found in levels periapical dental radiographic series. Periodontal probing, occlusal
II, Ill, and IV or adjacent to the sternocleidomastoid muscle (SCM). analysis, and specific restorative charting should complete the
Nodal expansion to the floor of the mouth or tongue has a tendency dental assessment.
to metastasize to subtriangle I. and nasopharyngeal tumors tend to Depending on what is planned for patients, it may be appropriate
metastasize to posterior triangle o r region V. A helpful examination to make diagnostic impresSions for the fabrication of surgical
technique is to ask the patient t o push the tip of the tongue to the prostheses. Clinical photographs can document the dynamic nature
palate, which distends the floor of the mouth for examination of the of perioral musculature, lip relation l o teeth upon smiling, and tooth·
submental and submandibular regions. Bimanual palpation is also to-tooth relationships. Patients for who m maxillectomy procedures,
helpful to discern nodal enlargement when the neck is large or previ soft palate resection, or glossectomy is planned can benefit from
ously dissected (Fig 15-15). Nodal expansion that is greater than 3 having preoperative impressions made to fabricate surgical or interim
to 6 em should be noted and communicated to the treatment team. prostheses (Box 15-1 ). Incipient or recurrent dental caries may need
Specific tumor assessment may disclose encroachment of the attention and should be treated prior to surgery or other proposed
tumor on vital structures such as the base of the tongue. body of the treatment. Transitional treatment with glass-ionomer restorative or
mandible, or anterior tonsillar pillar. In U1ese cases, it may be found intermediate restorative material is often appropriate for patients
that neuropraxia. limited motion. or dysphagia may mannest as a with a high caries index. Preventive periodontal debridement can be
resutt of tumor invasion. These specific findings should be recorded performed prior to surgical treatment because this will facilitate soft
prior to surgery, radiotherapy. or treatment with chemotherapeutic tissue healing during convalescence.
agents because their presence will be important in postoperative Staging of cancers of the oral cavity is important in communication
or posttreatment assessment. The above strategies are employed among health care professionals and for classification of treatment
mainly for patients who have been referred for maxillofacial prosthetic needs based on the stage of the disease. The TNM (tumor-node
evaluation. metastasis) classification system is discussed in detail in chapter 14
A panoramic screening radiograph should be requisite in addition (see Table 14·3).
to complete comprehensive examination for these patients. An
209
151Restoration of Congenital, Developmental, and Acquired Oral and Perioral Defects
Timing of dental and maxillofacial Interim care

prosthetic care
The major emphasis during the interim stage of care is on the surgi
cal (and adjunctive) management needs of the patient. Considering
A conceptual model for the timing of dentaVoral care that best em current trends of appropriately aggressive mandibular surgical re
phasizes the primary surgical requirements and the subsequent constructions. mandibular discontinuity defects are seldom a surgi
prosthetic considerations is helpful for the coordination of care. Such cal outcome. Consequently, interim care for mandibular defects is
a S1rategy considers preoperative and intraoperative care. interim not commonty indicated, and the following Information applies to
care, and definitive care. maxillary defects (Box 15-2).
The usual maxillectomy defect creates oronasal communication,
Preoperative and intraoperative care which produces physiologic deficiencies in mastication, deglutition,
and speech. Such defects have a negative impact on the psychologiC
The planning of prosthetiC treatment for acquired oral defects should disposition of patients, especially if the defect also affects cosmetic
begin prior to surgery. For the patient facing head and neck surgery, appearance. The major deficiencies directly addressed by prosthetic
the focus should be on dental treatment that will improve the imme management at this juncture are deglutition and speech. Patients
diate postoperative course. Consequently, the prosthodontist who are counseled to avoid chewing on the defect side because of the
will manage the patient's care should see the patient prior to surgery. effect on prosthesis movement. The objective of the immediate
The dental objectives of the preoperative-intraoperative care stage prostheSis is to separate the oral and nasal cavities to enhance or
are to remove potential dental postoperative complications. plan allow communication. Such obturator prostheses are designed to
for subsequent prosthetic treatment, and make recommendations Close a hard palatal defect but can be considered for soft palatal
for surgical site preparation to improve structural integrity. A signifi defects at this stage of management, as a prosthesis in either location
cant benefit of this preoperative consultation is the opportunity to attempts to artificially block the tree transfer of speech sounds and
discuss the functional defiCits associated with the anticipated surgi foods or liquids between the oral and nasal cavities. The ability to take
cal procedure and how the stages of prosthetic management will nourishment by mouth without nasal reflux, avoiding the need for a
address them. nasogastric tube. and the abilrty to communicate with family men1bers
Tile immediate postoperative period will be significantly challenging are significant advantages of eariy prosthetic management. The timing
to the palient. II preexisting dental disease is severe enough to of such care depends on a number of factors.
potentially create symptoms during the immediate postoperative A split-thickness skin graft is recommended at surgery to provide
period, treatment should be provided to remove these potential stable, keratinized tissue that lines the maxillectomy defect and cre
complications. large caries lesions that could become symptomatic ates some support and retention for the indicated prosthesis. The
can be temporarily restored, and endodontic therapy instituted, development of a skin-mucosal scar junction also can aid with toler
if treatment offers some advantage to postoperative prosthetic ance and retention of the prosthesis. Uning the reflected cheek flap
function. Teeth that exhibit acute periodontal disease (such as acute and posterior denuded structures with a graft improves the tissue
necrotizing ulcerative gingivitis) should be treated, as s11ould any response by decreasing the pain associated with t11e functional con
periodontal condition that could potentially cause postoperative pain tact often seen when this surface is left t o heal secondarily. If the
or complications related to excessive mobility or disease extension. posterior structures, pterygoid plates, or anterior temporal bone can
Any tooth deemed nonrestorable because of advanced caries or provide a supportive base for the prosthesis, a skin graft covering is
periodontal disease and not critical for temporary use during the extremely helpful. laterally, the junction of the skin and oral mucosa
interim care period following temporary treatment is indicated for creates a scar contracture, wl1ich provides a natural retentive entity
removal at the time or resective surgery. Teeth that appear t o have for the obturator portion of the prosthesis. Careful attention is given
a limited long-term prognosis may significantly enhance prosthetic to this region when fabricating prostheses to maximize the support,
service during the initial postsurgical period and should be maintained stability, and retention of the prostheSis (Fig 15-16).
until definitive care Is ini tiated. The surgical prosthesis is placed at the time of surgical access
Impressions are made of the maxillary and mandibular arches to closure. It serves to control the surgical dressing and split-thickness
(1) provide a record of existing cor1ditions and occlus ion, (2) facilitate skin graft and minimize hematoma formation during the immediate
fabrication of immediate or interim prostheses, and (3) assess the postsurgical period. Such prostheses are best stabilized by
need tor immediate and delayed modification of the teeth or adjacent appropriately wiring them to remaining teeth or alveolar bone or
structures to optimize prosthetic care. It is important at this stage by suspen ding them from superior skeletal structures. Alternative
t o begin planning for the definitive prosthesis because the greatest stabilization for edentulous patients can be achieved with several
impact on the success of the maxill ofaCial prostheSis stems from the 2.7 x 10-mm screws. For some patients with remaining teeth, the
integrity of the surrounding stnuctures.<a ideal immediate surgical prosthesis would be removable and could
be retained by wires in the prosthesis that engage undercuts on
the teeth; however, the ability to control the surgical dressing may
210 1
Box 15-2 �Interim prosthetic trea�ment
Mandibular defects
Interim treatment not usually Indicated
Maxilla!)' defects
Goal$
• Obturate surgiCal defect

• Improve speech and deg1ulltion
Instructions
• Head level when swallowing

• No Chewing on defect side
• Looseness, leakage, or discomfort require follow-up
Cotr>p/iC811ons
• Loss oJ seal ((:(eates nasal speech and leakage of loodliq
l uids)
• lack of retention or looseness
• lnabitity to place prosthesis because of contracture Of lateral scar band
• Discomfort caused by mucosills (radiolhefapy o r chemotherapy). pros
thesis pressu re. too-aggressive defect cleafling
Fig 15-16 (a) Web<lr-Ferguson incisioo used to approach resection of mucoepidermoid carcinoma of light side of 1naxilla. (b) Surgical prosthesis to stabilize surgical p acl<ing
material. (c) Surgical prosthesis secured by circumdental wire ligatures. Note splil thidlness skin graft to lateral aspect of cheek. (d) SUrgical prosthesis removed at tO days and
·
transitioned to interim prosthesis 1\ith soft acrylic resin. (Courtesy of Or James C. lemon, Lubbock, TX.)
be less predictable with thiS approach. Immediate placement of a obturate the defect and serve satisfactorily du ring the healing stage.
prosthesis can 1mprove patient acceptance of the surgical defect Oneadvant age of using an existing prosthesis is t hat accommodation
(though no measure of this psychologic impact has been proven) is less challenging to the patient because the existing prosthesis
and offers greater assurance of adeQuate oral intake, potentially has contours that match the presurgical state. When an ed entulous
precluding the use of a nasogast ric tube. patient has no pros t hesis or the existing prosthesis is unaccept able ,
It may be preferable t o stabilize the surgical dressing and split it will be necessary to make an impression following surgical-pack
thickness skin graft by suturing a sponge bolster at the grafting removal to fabricate an interim obturator prosthesis. For dentulous
site. Following the primary healing stage, the sponge and packing patients, an interim prosthesis is mad e from the preoperative cast,
(or the immediate or adapted prosthesiS, if used) are removed by which is altered with input from the surgeon regarding potential
the surgeon, and an interim obturator prosthesis can b e placed. defect margins and the location of remaining teeth and incorporates
For the patient who has been provided with bolster obturation, the retaining clasps for stability.
presurgical prosthodontic evaluation is very i mportant to ensure Subsequent addition of a resilient liner t o the prosthesis portion
that both the patient is prepared for the transition from bolster to adjacent to the defect provides obturation that is tolerable for the
prosthesis and that plans are ready for the prosthesis, especially if surgical wound. As the defect margins and lining tissue mature,
an interim prosthesis is to be fabricated. the defect can be filled further for maxi mum seal and benefit.
For edentulous patients with acceptable maxil lary complete Alternatively, an intraoperative impression can be made upon pack
dentures. the existing prosthesis can be modified to adeQuately removal to facilitate fabrication of an interim prosthesis.
211
15L Restorati on of Congenital, Developmental, and Acquired Oral and Perioral Defects
Fig 15·17 (a) T4NOMO squamous cell

carcinoma of leh side of maxilla necessitating
surgical removal. (b) Surgical prosthesis
fabricated with anticipated stabilization with
palatal SCiew. (c) Resected turnOf illustrating
size of defect. (d) Weber-Ferguson exposure
illustrating left infrastructure maxillectomy.
(e) Surgical obturator prosthesis secured to
stabil ize packing material. (Courtesy of Or
Jack W. Marlin, Houston, TX.)
When surgical defects become large, as in a near-total maxillecto age of air, food, and liquid around the obturator portion of t he prosthe
my defect, p rosthesis support. stability, and retention are not likely to sis: and (4) the tissue effects of chemotherapy and radiation therapy.
be satisfactory unless the prosthesis can extend into the defect (Fig Discomfort related to the useof interim prostheses can be related to
15-17). The impact of defect size is somewhat reduced when teet h surgical wound healing dynamics. defect conditions, mucosal effects
remain, but when the remaining teeth are few or located in a straight of adjunctive treatment. and prosthesis fit. Common areas of surgical
line, the mechanical advantage for prosthesis stability is diminished. wound pain include iunctions of oral and lip/cheek mucosa, especially
The ability of the defect tissues to offer the needed mechanical sup at the anterior alveolar region for maxillectomy patients. The lateral
port and retention characteristics to the interim prosthesis i s unpre· scar band produced when the skin graft heals to the oral mucosa
dictable at best. Patients with large defects benefit the most from can also cause discomfort in some patients. When a split-thickness
a surgeon who understands which prosthetic features proVide the skin graft iS not placed, discomfort related to prosthesis fit and
most advantageous structural integrity to various surgical defects. mucosal shrinkage within the defect can be a conSistent and long
With this understanding, the surgeon and prosthodontist must eva!· term problem. The hard palate surgical margin, when not covered with
uate these patients' potential for immediate surgical reconstruction surgically reflected oral mucosa. often is covered by nasal epithelium,
that includes implant placement.••.so which is also very prone to trauma and discomfort. Alveolar bone
cuts that have not been no''nded will perforate the oral mucosa and
Potential complications cause pain regardless o f whether a prosthesis iS worn. This is most
The interim phase of prosthetic management can last ior 3 months or frequently found in mandibular resection superior alveolar margins
-
longer. The primary objective is to allow the patient to pass, with mini after the reconstruction has restored the lower and labial contours
mal complicato
i ns, from an active surgical (and adjunctive treatment) to the mandible but the intraoral mucosa at the superior surface
phase to an observational phase o f management. Duling the transi is under tension caused by a difference in height. Excessive static
tion, the patient recovers from the systemic effects of the treatment, pressure from the internal prosthesis surfaces or overextension into
manages the psychologic impact of the defect wit h indMduaJ coping the vestibular tissues can cause discomfort. Discomfort also can arise
strategies, and becomes more aware of the functional defiCits asso fnom prosthesis movement associated wti h swallowing and speech.
ciated with tt1e surgical defect(s). Minimizing potential complications Often the functional dynamics change as soft palatal tissue heals,
during the transition includes preparing the patient for anticipated is requiring changes In configuration o f the obturator.
sues and facUitates the rehabilitative process for the patient and femily. Prosthesis movement depends on the qu ality of the supporting
Common interim prosthetic compli cations may result from (1) tissue structures. Teeth oHer the best support followed by firm edentulous
,
trauma and associated d iscomfort: (2) inadequate retention (loose ridges, and lastly the surgical defect structures. The tongue. opposing
ness) of the maxillary prosthesis; (3) incomp lete obturation with leak- dentition. and cheeks or lip s exert forces on the prosthesis that must
212 1
Fig 15-18 Maxillary defect 10 days a«er surgical-pack removal. Patient is instructed
on !\lice-daily irrigation with syringe using san and soda solution.
be resisted over a large area to prevent movement. Because the applied, permitting tissue adaptation and reducing the mechanical
defect is least fikely to be able to resist movement, its relative size and effects of movement by virtue of their viscoelastic nature. Because
structural integrity compared to the remaining teeth and edentulous the prosthesis cannot offer a watertight seal that matches the
ridge determine the potential prosthesis movement and have the prestJrgical state. patients should be instructed not to swallow
biggest influence on the discomfort related with such movement. large quantities at one time and to hold the head horizontal when
When teeth are available, prosthesis retention is enhanced by swallowing. When the head posture is forward, as in taking soup from
engaging them with clasps and rests. Tooth-clasp retention is a spoon. leakage easily occurs around the obturator component of
the most efficient means to effectively resist dislodgement. The a prosthesi s . Another complication experienced during swallowing
clasps require periodic adjustment t o maintain their effectiveness is leakage; this can occur in patients who have undergone midline
because the movement of the prosthesis flexes the clasps beyond soft palatal resection, which often involves removal of the posterior
their elastic recovery capacity. For edentulous patients, because nasal spine. Functional movement of the remaining soft palate often
the surgical defect allows communication between cavities, the creates challenges in prosthesis adaptation and the provision of an
basal seat of the prosthesis can no longer develop a seal to resist adequate seal during the interim prosthesis stage.
dislodgement. In these situations, it may be warranted to place
endossecus dental implants t o improve retention and stability (see Defect and oral hygiene
Use ofendosseous implants, below). During the interim phase, when Following surgical-pack removal, the healing defect site matures
complete engagement of the defect is not possi ble because of tissue with time and exposure to the external environment. Initial loss of an
sensitivity, the judicious use of denture adhesives may be required to incompletely consolidated skin graft. mucous secretions mixed with
facilitate retention. The patient should be instructed that adhesives blood, and residual food debris within the cavity are common oral
can after the prosthesis fit and disrupt the close adaptation of the findings for the patient with a maxillary detect (Fig 15·18).
prosthesis to the remaining tissues. Also. used adhesive must be These findings cause concern for patients who are unprepared for
removed before reapplying new adhesive to maintain fit and hygiene. these new oral developments. As they become more familiar with
The inability to completely place the prosthests can also affect the surgical detect, they should be encouraged to clean the defect
retention; for maxillectomy patients, this may result from contracture of food debris and mucous secretions routinely. Defect hygiene
of the scar band. When the cheek remains unsupported by bone allows more timely healing and more adequate fit of a prosthesis.
following the maxillary resection, the prosthesis provides the One common defect hygiene practice is lavage procedures. which
necessary support for wound maturation. If the patient removes include ri nsing of the defect during normal showering with a bulb
the interim obturator prosthesis for a period sufficient to allow syringe or with a modified oral irrigating device (modified to provide a
contraction, the prosthesis will be more dif
f icult to remove and reseal. multiple-orifice "shower" effect). Also common are manual cleaning
However. once the prosthesis is placed, the scar band will relax, procedures using lubricated Q-tips or a s ponge handled cleaning
-
and subsequent removal and placement are easier. The discomfort aid. Frequently, dried mucous secretions are difficult to remove
associated with this phenomenon is mostly related to patient anxiety and require adequate hydration with physiologic saline or a 50/50
and can be effectively addressed by reassuring the patient that this mixture of hydrogen peroxide and water before mechanical removal.
is an easily handled complication. Following surgical-pack removal, patients who experience dis
During the immedtate postoperative healing stage, the surgical comfort may be reluctant to begin oral hygiene practices. As they
defect undergoes a change in dimension that affects the prosthesis use the interim prosthesis, which requires a minimum of daily removal
fit and seal. If the change creates space. speech increases in nasality and cleaning, they will realize the benefitofnormal oral hygienepractices
and nasal reflux occurs with swallowing. The interim prosthesis is because of Improved prosthesis fit and tolerance. It is important to the
made of easily adjustable material to allow accommodation for such success of long-term prosthetic care to maintain a high level of oral
changes. The most common mode of adjustment is through the hygiene for remaini ng teeth. This iS more critical lor patients who exh
ibit
use of temporary, resilient denture·lining materials that flow when xerostomia and have an increased risk for caries. For these patients,
213
a daily application of fluoride in custom-formed carriers is prescribed soft !issue inflammatio n. The timing of implant placement relative
along with frequent professional cleanings. Stannous fluoride is to the primary surgery-radiation combination protocols is under
highly efficient in prevention of incipient and recurrent caries.5'-<13 continual investigation. Because bone exhibits a response to radiation
Occasionally some patients treated with head and neck irradiatio n
, damage that is delayed by 2 to 3 months, current reports suggest
cannot tolerate the acidic nature of a 0.4% fluoride gel. In these cases. either taking advantage of this interim time for implant placement or
1% neutral sodium fluoride is an acceptable alternative. The use of delaying placement until approximately a year or more after treatment.
maxillofacial prostheses is much more successful when supported Although � has been shown that HBO has a positive effect on soft
by natural teeth. COnsequently, during the interim prosthetic period, tissu es, it is unproven whether implant survival is long term."
periodontal management procedures are begun in anticipation of The use of osseointegrated implants in osteomyocutaneous flaps
definitive treatment so as t o allow a smooth transition from the interim has been valuable in provid1ng patients with stable maxillofacial
to definitive prosthetic stage. prostheses. However, implants still demonstrate varying degrees
of success.ss even in this compromised population of p at ients.
Combi n at io n ther apy Additional controlled cl inical trials and resultant data should reveal
Combination treatment, when indicated, is commonly provided the effectiveness of HBO in such patients.
during the p ostsurgical phase when the patient is using an inter i m
prost hesi s. The major intraoral complication asscciated with both Considerations for support, sta bi lit y and retention
,
radiation therapy and chemotherapy that impacts interim prosthetic In most situations, maxillofacial prostheses address compromised
service is mucositis. A careful balance between c omfort and ade opportunities for support and stability. Even in the most ideal cir
quate fit for speech and swallowing must be determined with input cumstances. prosthesis adaptation to the underlying tissues can
from the patient. Prosthesis adjustment shOuld only be done if it can be problematic. It has been advocated that processed acrylic resin
offer enough relief to ensure completion of treatment and if the pa bases be used to achieve accurate interocclusat records. The pro·
tient understands the impact adjustment may have on speech and cessing technique reduces the contraction of acrylic resin polymers
swallowin g. To maintan proper nu trit ion during convalescence. it is
i and leads t o greater occlusal accuracy upon processing.-·
important for patients with maxillary defects to continue to wear their Other procedures to obtain an accurate prosthesis fit Include
obturator. Palliative management of mucositis can be accom plished compression moldin g of acryl ic resin and injection molding, the latter
by using salt and soda rinses. topical anesthetics. and mucosal sta of which can (1) improve the level of fit and adaptation of processed
bilizers. acrylic resin bases to t he underlying stone cast and ultimately to
The long term effects of radiation therapy, especially radiation
- underl)�ng tissues62·63 and (2) create fewer dimensional changes and
induced xerostomia and capillary bed changes (obliterative i g techniques.64£6
occlusal change co mpared t o compression moldn
endarteritis) within the mandi ble . present a pot entially significant making it the m ore favorable technique currently (see chap ter 16).
threat to any remaining dentition and are a risk factor for the As with other modes of therapy, regular care and discretionary
development of osteoradion ecrosis Durin g the interim prosthesis
. follow-up are suggested .
stage. the patient will begin t o notice the xerostomic effects of

therapy, including thiCk. ropy saliva that makes swallowing more Use of endosseous implants The common use of intraoral
difficult and an increase in discomfort from the removable prosthesis. mucosa l tissues to support removable dental prostheses has often
Although variable, many patients start to experience this within the resvlted in limited restoration of function compared to the completely
second and third week of t umoricidal doses of radiation therapy. dentulous mouth. When bone-anchored implants are substituted tor
When the patient has been exposed to adjunctive radiation therapy, mucosal support, performance measures resemble those of a more
the recipient bone undergoes diminished healing potential resulting completely restored condition (Fig 15-19).
from t he damage to normal tissue and sublethal cellular damage. Part of the success o f bone-anchored prostheses is related to
This leads to progressive obliterative endarteritis with resultant tissue reduced res orpt ion of the residual ridge, co mmonly seen in patient
ischemia and fibrosis. A higher implan t failure rate is directly related populations who wear conventional removable prostheses. For
to the reduced capacity of the bone to primarily heal and remodel pat ients requiring conventional prosthetic restorations, those with
under functional loads. This finding has been reported for intraoral the most depleted dentitions benefit significantly from the use of
and extraoral maxillofacial implant use.•s It has also been reported endosseous implants. For patients with acquired defects of the
that the use of hyperbaric oxygen (HBO) treatment. originally provided oral cavity, implants provide retention and support for prostheses
for osteoradionecrosis patients. provides a protective effect against that are sign ificantly compromised because of a qualitatively and
the diminished healing rate of irradiated bone.56 A course of HBO quantita t ively diminished supportive foundation. The patie nt with an
treatment is indicated for patients who require reconstructions within acquired defect benefits the most from the use of dental implants
tissue that has received a dose of radiation greater than 5,000 cGy because the improvement in prosthetic support frees the adjacent
because this is the only means of developing capillary angiogenesis tissues, which are frequently reconstructed structures, from the
and fibroplasia within that tissue.56 HBO re duces the incidence of responsibility of controlling rem ovable prosthesis movem ent.
-
complications associated with implant use, such as implant loss and
214 1
Acquired Functional Deficits Resembling Congenital Deficiencies
Fig 15·19 (a) Osteom)•ocutaneous rtap

and implant-supported fixed prosthesis. (b)
Postoperative 11anoramlcradiograph.(Cour1-
esy ol Dr Kev10 L. Rieck. Rochester. MN.)
Typically, the stnuctures that provide the pmwy support for a

prosthesis are remainirg teeth, hard palate, and the residual ridge .,
edentulous areas. To properly assess the strengths of each structure,
it iS first 1mportant to visualize the basic arch shape, the fulcnum hne
around which the prosthesis will rrtOVB, and the ability to develop
indirect and direct retention. In ideal circumstances, removal of a
malignant lesion with a surgiCal technique that pemnits conseNation
of the maxillary anterior region provides the optimal anatomical
configuration for prosthesis design. If a maxillectomy hes been
periorrned on an arch with tapered configuration, indirect retention
usually is tess effective than it is in arches that are square or ovoid.
The shape and size of the hard palate are also important
components of the prosthesis design and control applied stresses
(FtgS 15-21 and 15-22). A flat palatal configLKation cneates a
circumstance in which control of prosthesis movement is prOVided
Fig 15·20 Booodanes o1 !ypleall113l011ectomy ca'llty. almost exclusively by the tooth surfaces ergaged by the pnosthesiS.
Maxillary defects afford d•minished opportunity to resist the rotary
movement when the obturator 1s in function. If the remain1ng teeth
have short clinical crowns. the stabilizing effect is less because
Implant use to support and retain typical max•llo fac•al prostheses the teeth are required to provide more direct resistance to such
In the nonirraeliated mandible and maxilla has revealed cumulative movement. Whereas a V·shaped palatal vault may be more resistant
success rates similar to those for convenhonal prostheses sup to rotary movement. it contributes less to prosthesis retention
ported by implants: approximately 75% for the maxilla and 90% because the minimal palatal surface more nearty parallels the path of
for the mandible, regardless of placement in nonvascular or placement and removal of the prosthesis. AU-shaped palatal vault
revascutarized lree bone grafts.ae Similarly, the success rates for provides the most desirable configuration to control and counteract
extraora11mplants neveal some location-specific effects: the temporal prosthesis movement. This shape not only provides a broader
region demonstrates the highest success (95%}. followed by the surface tor retention but also plays a more active role in distnbutoo
base of the nose/maxilla (90%) and the tromal bone of the orbital rim of stress by protect•rg the denhtion and its supportrng complex. In
(77%). While data continue to accumulate and exact success rates most of these cases. complete coverage of the hard palate With
vary between reports. the opportunity to provide a management acrylic nesin or cast-metal bases 1s desirable. Additional factors that
procedure that, at worst, has an 8 in 10 chance of success 1s a should be considered •n prosthesis design involve the onentat1on
favorable risk for the benefit derived. and inclination of the remainirg maxillary teeth.
Maxillary posterior teeth naturally have a buccal incl•nation
Aspects of Prosthesis Design and provide opposing buccal undercuts for prosthesis retention.
Maxillary defects Anato mical stnuctures that usually can augment Resection of one side of the maxilla can significantly reduce the
retention and stab•llty In additton to the natural denlittOn include the effectiveness of the remaining buccal undercuts and usually requires
(1) rim of the soft palate, (2) anterior wall of the temporal bone in the more aggressive engagement of the available retenlive areas. The
infratemporal fossa, (3) mucosal band of scar tissue o n the internal natural inclination of the max1ilary posteriOr teeU1 often does not
surface of the cheek, (4) anterior nasal spine, and (5) floor of the pemnit the use of the palatal surlaoes as retentive undercuts (F.gs
nose above the hard palate (Ftg 15·20). These structures can be 15·23 and 15·24). If the posterior ctinical crowns are suffiCiently
evaluated and detern11ned tor each clinical situation 111 the 0\/el'all long. their palatal surlaces often can be prepated as guodJOg
treatment ptarnrg. planes to assist 1n control of prosthesiS movement and retention.
215
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'
'
'
� :
.. / Flat
"--.
-./ ..
·
-
.
.
' -
' ·
:
Fig 15·21 Top row: Location of fulcrum line diagon ally across arch that provides Fig 15·22 Pala lal shape and Size inlluence the retention and stability ol maxillary
some indirect retention In canine region opposite the defect area. Bottom row: llldirect obturator.
retentioo opportunity is lost when anterior maxillary region is not intact.
Clasp
Fig 15·23 Buccal inclination ol maxillary posterior teeth minimize s advantageous Fig 15-24 Cast illustrating applicati:>n
use of lingual surfaces for reciprocation and stabilization. Aggressive engagement of of the design soom1 in Fig 15· 23.
buocal retentive areas can be achieved with the use of buccal bar and combinations of
circumferenit al and bar c1asps (dotted line).
If the remai ning clinical crowns are short, elective crown ing of the easily irritated and the mucosa is quite sensitive. with an elaborate
remaining posterior teeth pellTlils fabrication of parallel surfaces blood supply that does not withstand physical force well.
and palatal undercuts. In some cases. it may be advantageous to Plans for stable prostheses in edentulous patients emphasize
splint the remaining teeth With multiple cast restorations. Additional the limitation of support, retention. and stability. In these situations,
strategies incorporate the use of a swing-lock mechanism which . engagement of all areas i s critical to provide a stable prosthesis.
should have soft tissue clearances that do not impede the path of A classic discussion of design principles proposed by Brown
insertion of the major oonnector. claims t11at the obturator is designed to create a buttresslike action
Although st rategically located, the nasal septum is a poor stress to develop the lateral peripheral contou� (Fig 15-25). This places
bearing area and should not be engaged by the prosthesis. It is the lateral border high and as far away from the retentive axis as pos-
2161
Fig 15·25 A cross section show1ng the variation in vertical displacement created with a
given amount of lateral wall llexure when different peripheral obturat01 desigos are put
to use. (Reprinted from Brown" with permission.)
sible. A skin graft is often placed to line the cheek flap. The band of ot these prostheses without monitoring can become problematic,
scar tissue that re sults from the skin-mucosal suture line is useful to and many of these patients may be better served by microvascular
support the o bt urat or laterally and to provide a border seal through reconstruction.
a broad obturator-soft tissue interface. However, in time, the scar
tissue usually softens, stretches, and becomes less supportive with Definitive procedures and pr inci ple s of design After treatment
continued use. plannin g and mouth preparation have been completed, the actrve
Another area of potential engagement incorporates the remaining p hase of clinical prosthodontic treatment can begin. Stock pertorat·
soft p alate to provide support and a border seal to r the o bt urator ed metal trays are usually he lpf ul to obtain preliminary impressions of
posteriorly. Extensions from the ob tu rato r over the rim of remain ing both arches. In dividualized trays of autopolyrnerizing or light-curing
soft palate assist in retenti o n and stability, t he reby preventing resin can be fabricated on the resultant preliminary casts. A hand le
regurgitation of food and ftuid over the obturator. These extensions can be inco r porate d to allow resemblance of an occlusion rim fo r
also ensure integrity of the palatopharyngeal mechanism for speech. lip support in reference to the facial midline and for the inter pu pi llary
The re maini ng soft palate is especially useful in edentulous patients line. This procedure aids in fabrication of a master cast that is poured
for retent ion and stabilization. II it becomes necessary to resect and trimmed in the correct orientation. Trays should be f abr icat ed
the sort palate entirely for disease control the surgeon might be
, over a wax shim of suffiCient thickness t o provide adequate space
prompted to elevate a flap and transpose it across the defect at for impression material. It i s desirabl e t o leave a portion of the shim
the approximate level of the jun ct ion of the hard and soft palate. In in the tray to serve as a stop while molding the border. However. the
either case, it is desirable t o extend the obt urator far enough into the wax should be cu t back sufficiently to permit application of com
defect or the oropharynx to provide contact through the entire range pound or other thermoplastic material to the borders without fusing
of motion of the soft palate and associated pharyngeal muscles. t o the wax spacer.
Other design features to promo te prosthesis retention and st abil ty i Border molding is of primary importance, and developmen t
include (1) maximum extension of the denture base. (2) max imu m of an acceptable obturator pros thesis impression is as critical as
border thickness compatible with an estl1etic appearance and for a conventional complete denture. Border molding often allows
mandibular function, {3) good adaptation of the load-bearing surface engage ment of areas that cannot be directly extended by a rigid
of the prosthesis base. and (4) external contours that enhance the tray. Every attempt should be made t o establish an effective border
seal of the prosthe sis. seal with a well-adapted tray with meticulous border molding. The
In patie nt s who have undergone a bi late ral total maxillectomy, width of the seal or tissue co nta ct area depends on (1) the amount
engagement of the aforementioned structures is not possible, and of functional movement of the border tissues at the p rosthesis
other means of retention should be used. Facial seal may be the intertaoe and (2) the displ aceabil ity of the tissues being recorded
only conventional means of prosthesis retention available. Many in the impression. The contact area i s generally more extensive in
attemp ts have been made over the years to engage the remaining the lateral region or the cheek. Thickne ss of the molding material
maxillary cavity. Removable devices that use coil-spring or flat· depends on the amount needed to provide the desired facial
spring mechanisms,ea a movable section that engages the anterior support. It is not adVisable to make this determination with a on e ·
nasal spine. a posterior portion that engages the soft palate or step impresSion technique.
posterior nasal spine, and opposing magnets have been proposed If some or all of the soft palate has been removed, development of
and used with some degree of success.,. However. long-term use the posterior section of the obturator is similar to that u se d with cleft
217
15L Rest oration of Congenital, Developmental, and Acquired Oral and Perioral Defects
Fig 15·26 (a to c)AIIered cast

wilh intraoral tracing ot defect.
made with Korecta wax no. 4
(0-R Mine�. and balance ol
cast secured With irregularities
toallow acr,'lic resinprocessing
oo corrected cast.
Fig 15·27 (a) Maxillary detect restored with auxiliary osseointcgrate<J lmp!ant suJli)OII. (I)) Fabrication or bar atl<lchment based oo tlial wax tooth arrangement and preservatiOn w�h
full<:tional matrix. (C) Designing bar attachment for hygiene Clearance with proximal brushes. (d) In traoral view ol bar attachmenl
palate prostheses. Frequently the superior pharyngeal constrictor

, sian material from being extruded into the void under the pressure
muscle bulges forward, forming Passavant's ridge in a compensatory of impression seating. This is especially important when using algi·
manner that provides a landmark for obturator placement in this nate because the material is weak and easily torn when removing
area. Movement of the lateral wall of the pharynx during function the impression. Detail of the defect area is of secondary importance
also assists development of the pharyngeal portion o f the obturator. when recording the defect using plastic materials. Modeling com·
Obturator development in these areas must not obstruct the orifice pound. high· temperature waxes, and mouth temperatune wax are
o f the eustachian tube. Superior extension of the obturato r into the acceptable materials for the altered cast technique in obturator-seal
defect is determined primarily by the border seal and by the quality development. Trial additions with the material can be accomplished
of resonance desired during the patient's speech patterns. This can upon insertion and removal of the cast f rame processed acrylic·
or
often be a trial-and-error process that usually is not completed until resin base. As wnh the altered cast procedure for RPDs (Fig 15-26),
the restoration is finalized because thickness ol the obturator is a the completed obturator impression has the extension and shape
related factor. However, the superior surface extension should be of the desired definitive prosthesis, avoiding the need for numerous
estimated as carefully as possible because or practical factors in adjustments in the pos tinsertion period.
limitation ol the mandibular opening. The borders of custom trays For those p atients whose dentition has been partially restored
should be at least 2 to 3 m m thick t o provide an adequate surface with osseointegrated implants, it is possible t o create a design that
over which the impression material can flow to produce proper permijs retention, stability, and some degree of stress relief. A bar
border t11ickness, appropriate border seal, and compatible function. attachment is often useful when splinting multiple implants that po
When natural teeth remain, it is appropriate to use the altered· tentially have differences in their long-axis parallelism (Fig 15·27).
cast procedure to provide a more accurate obturator prosthesis Alternatively, an implant-supported fixed partial prosthesis design
whose path of insertion and removal is consistent with that of the with conventional clasping can also be used for simpler design and
cast framework. follow-up. If feasible, placement of one or two implants In the detect
If a cast framework is made, it may be preferable t o create a cus· site �nfraorbital rim, zygoma, or sphenoid bone) may be especially
tom base into the defect and arrange artificial teeth in wax, with useful in regards to support and lim itati on of rotation occurring
subsequent impressions of the defect. Typically, the final impres under function. More recently, image-guided surgery has made
sions are made with rubber base, polyether, or vinyl polysiloxane these procedures more feasible and minimizes complications when
materials. While the impression is made. it may be practical to pack placing implants in anato mically restrictive areas.
small defects or tissue perforations with cotton to prevent impres-
2181
Fig 15-28 (a andb)Processed record base

with attachments made to verity esthetics
and phonetics. (c) Postoperaiv
t e view of the
palient (same patient treated in Fig 15·171.
Fig 15·29 (a) Large maxillary obturator prosthesis designed to leave

superior surtace hollow. {b) ainicaJ view of prosU1esis stabilized by bracing
and reciprocation.
Recording jaw relationships and tooth arrangement Fabrica· tages to using a hollow obturator have been studied and are based
tion of stable bases to necord maxillomandibular relationships is as primarily on weight and resonance7l).72 (Fig t 5·29). Although many
important in the creation of an obturator prosthesis as with any re· techniques use a sea led lid for a closed, hollow prosthesis. these
i . Wax occl us ion rims can be affixed to the base
movab le prosthess may leak and create hygiene issues for the patient. Therefore,
i n the usual manner, and the continuity of the palatal contour in the it may be prefe rab le for larger defects to use an open design for
defect area is provided with baseplate wax, leaving the obturator their superior prosthesis surface because in many cases, it is not a
hollow (Fig 15·28). When n atu ra l teeth remain, the metal framework critically functioning surface for intermediate-sized prostheses. The
is used to carry and stabilize the base an d obturator extension. o pening should be at least 2 em t o allow easier access for daily
f icult i n eden tul ous patients,
Determination of th e VDO ca n be dif cleaning and removal of collected secretions and food debris. For
es pec ially in those with maxillary resections who commonly have patients in whom grafted zygomatiC tissue, maxillary sinus walls,
asymmetric lip posture. VDO can initially be esta b lis h ed with the ar or other superiorly based features are Llsed fo r support, it may be
rangement of prosthetic anterior teeth. preferable to have a closed or partially open prosthesis design.
With the understanding that the prosthesis will settle i nto the This provides a superi or area of support wh i le the integrity of the
defect when i n function and perhaps sag at rest, estab lis hm ent of prosthesis is ma intained through selective closed des ign.
an occlusal plane should parallel the i nterpupi l lary line and Camper's
plane. Stability of the base is essential; processed bases or cast· Definitive care
m eta l frames are the best choices to retain stability and obta in
accurate interocclusal records. Definitive prosthetic management can be ini ti ated when the active
After tooth arrangement has been comp leted and accepted treatment phase has been completed and the defect tissue has
clinically, the prostl1esis can be processed by a number of methods. matured suffic ie ntly to tolerate more aggressive manipulation and
Compression molding is one of t he most common methods lor obturation. This phase can be con sidered transitional for the patient·
polymethyl methacrylate process ing. This i s a relatively predictable doctor relationship because the primary emphasis shifts from active
technology, but more recent ly injecti on molding has been used (see treatment to obseNati on and ma inte nance. For some patients, de·
chapter 16 for a di sc ussion of the advantages or Injection molding). finitive prostheses may be delayed because of general health con·
Regardless of t he technique chosen, it is most important t o achieve cerns, questionable t um or prognosis or control, or w he n the pat ient
complete and thorough processing of the material by a staged has fai led to reach a level of oral/defect hygiene that warrant s more
temperature cure. Complete polymerization is more a function of sophisticated treatment. Though this phase of manage ment can be
length of the cure process. consid ened elective. without definitive prostheses, patients are not
It may be preferable to process larger obturators with a hollow afforded the opportunity for complete rehabilitatio n. The extended
design, necessitating forethought in planning the process. Advan· use o f temporary prostheses beyond their serviceable life span has
219
given a poor impression of prosthodontic service to many surgeons is the opportunity to educate patients when their expectations are
and patients. Every opportunity should be provided to the patient for unrealistic." After developing protocols for management of common
the most complete rehabilitation possible. and !his requires planning reconstruction options, the surgeon-maxillofacial prosthodontist
for more definitive prostheses. team can share in patient education needs as they arise.
The real challenges for the surgeon who treats patients with head The inability of a static artificial replacement to mimic its natural
and neck cancer are control of local neck, and metastatic disease,
, counterpart results in less-than-ideal function. The effects of factors
but the surviving patient (and the resection patient with benign related to the structural integrity of the surgical defect and associated
disease) should have every reasonable opportunity for complete restorations on an already-compro mised functional capacity are
rehabilitation. There appears to be some confusion in the literature important. Control of removable maxillofacial prost11eses requires
as to what constitutes functional rehabilitation. It is possible that skilled performance on the part of patients, which suggests that
the terminology has not kept pace with the evolution of surgical healthy oral and defect structures adjacent to the prostheses are
reconstructive techniques that now allow a broad range of functional important for successful outcomes.eoThis is crucial to understand how
outcomes to be considered true functional rehabilitation."' It is true the postsurgical defect characteristics and soft tissue reconstruction
that more complex and aggressive operations have not sl,own a affect maxillofacial prosthesis management. The opportunity to
statistically significant change in survival rates.'• However, the achieve maximum prosthetic benefit requires consideration of
outcome of these procedures as they have evolved is not a positive surgical site characteristics (tripodization, tissue support, retention
effect on survival Itself but on improved quality of survival. If surgical opportunities) that are separate from classic tumor control
reconstruction i s to be planned in the interests of the individual approaches. The ability of the patient to biomechanically control
patient. there should be a complete understanding of the defects large removable prostheses following surgery may be significantly
involved and the magnitude or the disability associated wi1h the hindered by surgical closure/reconstruction options. Surgical
ablative surgery, and the rehabilitative efforts should be measured.'5 outcomes that can improve prosthetic function without adversely
An important factor in the development of the treatment plan is the affecting tumor control should be considered; the following sections
cost effectiveness, and the challenge is to develop reliable and valid describe approaches for the more common surgical defects and
means to measure the functional and psychosocial outcomes of associated prostheses.
various treatment options for mandibular resection management.
A disabling surgical result is very important in consideration of Maxillary defects
individual patient decisions for reconstruction. The magnitude of Surgical outcomes that influence prosthetic success include those
the disability is a patient-specific, patient -perceived factor that is that affect the amount of maxillary structures removed and those that
determined when comparing potential results with the presurgical affect the structural integrity and quality of the defect. For surgical
functional condition. Consequently, the patient has a role in the defects of the hard and soft palates. the primary prosthetic objective
process of reconstruction-outcome assessment, which is the truest is restoration of the physical separation of the oral and nasal cavities
measure of treatment success, and should be a part of the planning to effectively return mastication. deglutition, speech, and facial con
process for maximum patient benefit. It is important to realize that tour to as near a normal state as possible. The typical prostheses
in the reconstruction decision-making process, there may be a used to achieve these objectives include the obturator prosthesis
lack or concordance between the patient and surgeon regarding (ie. prosthesis that obturates defects within the bony palate) and the
expectations and outcomes.78 Such a problem is common in health speech-aid prosthesis (ie, prosthesis tl1at restores palatopharyngeal
care and is critical to understand for outcome measures that have a function for defects of the soft palate) (Fig 15-30).
strong psychosocial component. Current preoperative diagnostic procedures have improved the
In this region of the body, which is vital to the patient's social ability to discern the location and regional bone involvement of tu
interaction. it is important that the patient completely understand the mors of the maxilla and associated paranasal sinuses. Regarding
impairment and subsequent disability associated with the surgical prosthetically important surgical modifications, if it can be deter
resection and surgical or prosthetic reconstl\lctions. Often, it is mined that tumor control does not require a classic radical maxil
already difficult t o precisely describe the anatomical involvement of lectomy approach or that the inferior sinus flcor, hard palate, and
the disease presurgically and the degree of disability associated with alveolus are uninvolved, preservation of as much hard palate, alveo·
subsequent treatment. Complicating this discussion is the difficulty lar bone. and teeth as possible should be considered. Tooth preser
in patient-provider interaction because of the psychologic burden of vation has the greatest impact on success because of the ability of
the subject of cancer. Although it has been shown that tong-term teeth to stabilize prosthesis movement. When teeth can be retained
survivors {between 2 and 6 years) of composite head and neck in the maxillary anterior region during treatment ol more posterior
resections still experience severe psychosocial distress,77 presurgical tumors or in the molar region for more anterior tumors, prosthesis
counsehng regarding treatment and its sequelae has a positive effect movement can be more easily controlled, thereby improving pros
on psychosocial outcome.'6 Discussing patient expectations and thetic success. Because the classic midline maxillectomy defect is
goals is a criical step for clinical dectsions in which preferences play
t significantly more debilitating for the average patient compared to
a role.10 An added benefit to this type of patient -provider interaction a defect in which preservation of the anterior maxillary region was
2201
Fig 15-30 (a)Oefillitive obturator prosthesis using a cast lramewQr1< base

wtth wrought·wire claSIJS. (b) Pharyngeal obturator replacing the resected
soft palate, aiding in veloplwyngeal function.
possible, salvage of the anterior component should be an individual benefit from the placement of the prosthesiS extension above the
decision based on tumor control (see Fig 15-21). posterior soft tissue band for retention.
For resections in dentulous patients, the tooth adjacent to the In general, the need to extend prostheses into the defect is
defect is subjected to significant force from prosthesis movement. greater lor edentulous patients than for patients with teeth because
When the surgical alveolar ostectomy cut is planned, the resection defect configuration is not as much of a factor when teeth remain
should be made through the extraction site of the adjacent tooth to stabilize and retain the obturator component of the prosthesis.
to provide the most favorable prognosis for the potential prosthesis However, all patients with maxillary defects should have access to
abutment. This procedure ensures adequate alveolar support for the posterolateral region of the defect sufficient to maximally seal
the adjacent tooth, which is usually a critical unit for prosthesis the defect. For maximum ability t o obturate a maxillary defect in the
success and improves the tooth'S prognosis for long-term survival. edentulous patient, there must be access to the regions superior to
The midline of the hard palate is a common area for pressure on the the defect opening. Nasal concha and respiratOry epithelium-lined
removable prosthesis that results from the rotational movement of surfaces that do not allow adequate extension into the necessary
the prosthesis into the defect under functional forces of swallowing retentive and supportive areas of the defect can compromise
and mastication. To provide the best surgical preparation for this function. The function of nasal concha in the newly externalized
area when the hard palate is resected, the vertical surface of the environment is not beneficial to breathed air humidification or
bone cut should be covered with an advancement flap of palatal warming and consequently may not warrant preservation.
mucosa to provide a firm and resistant mucosal covering for this Surgical reconstruction of maxillary defects should be undertaken
region during function.8' Additionally, removal of the inferior concha. in situations where it would aid in the restoration of speech,
vomer. and in some cases the nasal septum may be necessary to deglutition, and mastication. Successful algorithms have been
create comfortable optimal obturation. developed based on functional criteria.'9.eo.oo However, these
The soft palate owes its normal function to the bilateral sling patients may not be candidates for such procedures or have the
configuration of the musculature, which provides the shape and availability and expertise of a surgical reconstructive team. Surgical
movement capacity necessary for speech and deglutition. When this reconstruction of a maxillary hard palatal defect in a manner
configuration is altered by surgery, there appears to be a variable that provides separation of the oral and nasal cavities without
response in continued palatopharyngeal competence based on the consideration tor oral space requirements to,· speech or for the sup·
amount of continuous band ol posterior tissue that remains. When portive requirements of replacement teeth is not only incomplete
the posterior nasal spine, the soft palatal aponeurosis. and pterygoid management but can grossly preclude subsequent prosthetic
hamulus are resected. the procedure especially tends to create management. When surgical defects are 3 em or less and can be
altered range of motion o f the soft palate. Patients may complain of reconstructed t o nonmal contours without compromising adjacent
difficulty hearing or eustachian tube dysfunction when the pterygoid tissue function. surgical management with local or regional flaps is
hamuli are involved in the resection.••83 Pressure-equalizing tubes usually an appropriate consideration. Larger defects are very difficult
may resolve this problem. An insufficient band of palatal tissue often to surgically reconstruct; without careful planning for subsequent
fails to provide palatopharyngeal competence and compromises functional needs, the reconstruction could create an environment
prosthetic resolution. To guide decision making during surgery, it has incapable of supporting a prosthesis. For partial soft palatal defect
been suggested that if the required resection leaves less than one reconstructions, it is very difficult to provide for functional tissue
third of the posterior aspect of the soft palate, the entire soft palate replacement without compromising palatal function. In light o f this
should be removed.84 The exception to this would be the edentulous unpredictability, the prosthetic management of such defects is most
patient who is undergoing a radical maxillectomy. Without teeth to often the preferred treatment.
provide the necessary retention for a prosthesis, the patient could
221
Fig 15-31 (a) Patient treated for squamous cell carcinoma of the right side ollhe tongue that invaded the right mandibular body. Treatment consisted of right composite resection
wnh reconstruction of the defect using a vasculartzed fibular graft and four endosseous implants. (b) Fixed prosthetic reconstruction using screw-retained fixed partial denture. (c)
Oental occlusion restored to aid in masti<:allon. (Counesy of Or Eugene Keller, Rochester, MN.)
M a ndi bl e t o ng u e de fect s
- and mobility, (2) a re less prone to contracture tension. and (3) can
The functions of mastication, deglutition, speech, and oral com produce a more normal lingual sulcus. These characteristics have
petence (saliva controij are possible through coordinated efforts of been shown to have a significant effect on tongue mobility.� Other
separate anatomical regions including the oral sphincter, lingual and desirable characteristics, such as sensation and lubrication, are also
buccal sulci, alveolar ridges, floor of the mouth, mobile tongue. base possible but require a choice as to which is most necessary based
of the tongue. tonsillar pillars, soft palate. hard palate, and buccal on treatment goals.•a
mucosa.a• Tile more regions involve<! in a surgical procedure. the If it can be determined that the mant1ible is not involved or is min
greater the demand on the surgical reconstructive efforts. When imally involve<!. mandibular preservation options. which have been
the mandible is also involved, the complexity of the reconstructive shown to greatly benefit functional outcomes, can be employed.00
proce<!ure depends on the location and amount of mandible to be Knowledge of the mechanism by which soft tissue disease
included in the resection and whether continuity with normal man involves the mandible has given rise to a rationale for preservation
dibular position and contour is possible. When disease involves the techniques.9' Also, the increased popularity of the mandibular oste
functional anatomy around the mandible, surgical outcomes that af otomy, or mandibular swing. to provide access to tumors that neveat
fect prosthetic success are based on the decision to remove man grossly normal tissue between the tumor and bone has provided an
dibular portions and on the planned reconstruction. The primary option for segmental resection of the lateral mandible. which has
prosthetic objective for mandibular defects is to restore mastica been commonly used for access. Given the functional morbidity
tion by the replacement of teeth. Achieving this goal requires an of segmental resection compared to the opportun ity to preserve
understanding that. regardless of the manner of prosthesis support mandibular continuity, the decision to remove segments of the
(natural teeth, reconstructed soft tissue, or implants), a prosthetic mandible should be based on tumor control and patient survival. not
outcome depends on the appropriate surgical management of soft the nee<! tor access.
tissue and bone (Fig 15-31 ). Surgical outcomes of mandibular osteotomy that may affect
Disease that involves soft tissue structures adjacent t o and pr osthetic management relate to fixation placement. For edentulous
enveloping the mandible requires consideration for mandibular patients who will need mucosa-supported complete dentures,
resection to ensure control. When diseased soft tissue is clearly internal rigid fixation should be place<! below the level of the anterior
separate from the mandible and does not require bone removal. labial vestibule extension of the prosthesis. This can be accomplishe<!
surgical defects involving these structures should b e surgically b y using the mental foramen as a guide and placing the foxation just
reconstructe<! and therefore do not require prosthetic management. below a line joining the bilateral foramina. Additional consideration
The exception to this is the large tongue resection, which may is needed in pat ients who have undergone vestibuloplasty and for
require augmentation of palatal contours to facilitate speech placement of split-thickness skin grafts when maximum extension
production. A palatal augmentation prosthesis is most beneficial tor the prosthesis is to be provided. A skin graft can b e especially
when coordinated speech therapy can assist in determining the useful to preserve vestibular extension during oral surgical dissection.
optimal prosthesis contiguration.88 The patient should also be Recogntlion of the pattern of tumor invasion and spread within the
assured that a palatal augmentation prosthesis i s beneficial for l:>oth mandible has le<! to a better understanding ot how best to apply an
speech and swallowing.a� When total glossectomies are planned. other mandible preservation procedure called the rim resection.951!6
use of a mandibular tongue prosthesis has been well c!Qcumente<! For the mandibular rim resection, the optimal surgical outcome for
a s providing some element of speech and swallowing.00·9' Other prosthesis use would be soft tissue reconstruction that provides a
resections may appear to require palatal augmentation tor speech. firm, thin attachment to the remaining bone and exhibits a smooth,
yet the functional problem is tongue immobility secondary to inve<1e<l U-shape<! surface contour (Rg 15-32). This surgical resu� of
tension created by the reconstructed tissue. Consideration should fers the best opportunity for prosthodontic options, including remov
be given to son tissue reconstructions that (1) are of sufficient size able prostheses or implant-supporte<! prostheses.
Fig 15·32 (a) Mural ameiOblasloma ol me left Side of

the mandible. (b) Re$0Ctlon of me mandible by marginal
mandibulectomy. (C) Clinical appearance after reseclion.
(d) Marginal mandibulectomy ol left alveolus restored
with removable prosthesis.
Fig 15·33 (a) Patient resected for mandibular squamous cell carcinoma with a Fig 15·34 (a) Mandibular resectioo patient, nonreconstructed, with closure assisted by
nonreconstructed defect. {b)Panoramic radiograph of patient showing proximal segme nt a maxillary guide-plane pr05thesis. {b) Closure into maximal intercuspation with midlme
and distal segment displaced. deviation still evident.
If an implant-supported prosthesis is planned. the prognosis is allows adjacent Intraoral and extraoral sort tissues to retain their
improved when mu�iple implants 10 mm or longer can be placed. positions.
Because these preservation procedures maintain the original Reconstruction decisions that require mandibular discontinuity
maxilfomandibular relationship, they allow the opportunity to replace without reconstruction should be considered a rare exception rather
the missing dentition in an anatomically useful position . The chal lenge than the preferred treatment choice. From a prosthetic rehabilrtation
to maintain these relationships and provide reconstruction of the perspective. the most significantly handicapped postsurgical head
adjacent soft tissues in a manner that allows separate but coordinated and neck condition is the discontinuous mandible.07 Mandibular
function of pt))ISiologie and anatomical components occurs when discontinuity results in significant cosmetic deformity to the lower
mandibular segmental resection is necessary for tumor control. one-third of the face, impaired masticatory function secondary to
When tumors are primary to the mandible, such as an unilateral closure and compromised coordination of the tongue and
ameloblastoma. or involve the mandible from adjacent regions, teeth, altered speech ability, and impaired deglutition (see Fig 15·31) .
surgical resection of mandibular segments is required for tumor Evolution of surgical prooedures that maintain mandibular continu·
control. It may be difficult to predict the functional deficit and the ity have significantly improved the chances for functional restoration
exact plan of reconstruction because the surgeon determines the of mastication. deglutition. and speech. Given the decreased per·
extent of the resection based on presurgical and surgical findings. fomnance seen with conventional mucosa-supported denture pros
Common anatomically based mandibular resections include the theses, masticatory rehabilitation for the resection patient without
lateral mandibular resection, the anterior mandibular resection, and mandibular continuity is unpredictable at best and never achieved
the hemimandibular resection. From the perspective of the surviving for most patients. Even for patients with remaining teeth. the altered
mandibular resection patient, the most significant decision in the mandibular position that develops over time presents a signifiCant
treatment plan is whether to maintain mandibular continuity, which functional and cosmetic handicap (Figs 15·33 and 15-34).
223
15L Re sto ration of Congenital, Developmental, and Acquired Oral and Perioral Defects
Fig 15·35 (a) Patient resected for osteosarcoma of the anterior mandible and reconstructed with vascu la(Jzed fibular flap. (b) Endo.sseous implantS placed into flap. (c) Radiograph
after placement. {d)Attachmllllt mechanism and tissue view just subsequent to reconstructioo. (Courtesy of Dr Rhonda Jacob, Houstoo, TX.)
Fig 15·36 (a) Patiellt seen preoperatively with squamous cea carcmoma of the alveolar ridge. fJJ) Paooramic radiograph post-marginal mandibulectomy; the decision was made to
rehabilit ate with an endosseous implant-supported fixed prosthesis. (cand d) Clinical and radiographic views of rehabilitation.
Mandibular defects Thus. after reconstruction. the tongue and mandible function in a
Segmental resection of the mandible results in significant disability more normal manner. and the patient is better able t o manage and
and is best treated by surgical reconstruction. This reconstruction control fluids.
may be alloptastic or autogenous. and several options are available When the mandible is reconstructed with bone and endosseous
to replace the missing tissue. Decision factors include the (1) extent implants. it may become necessary to create a sulcus that borders
and location of the resected bone, (2) extent of soft tissue excision, the grafted bone. This is particularly true when a glossal disability
(3) presence or absence of a skin or mucosal defec (4) p resence t. remains and a toss of lip support necessitates fabrication of an over·
or absence of a periosteal envelope, and (5) the need for contour denture prosthesis (Fig 15·35).
restoration and arch stabilization. Historically, discontinuous man Patients who have mandibular resections must be further as·
dibles l1ave not been rou1inely reconstructed. and many of the po· sessed for swallowing function. A modified barium swallow and a
sitional discrepancies seen cont ributed to cosmetic and functional cineradiograpllic fluorescence study can indicate the level of bolus
debilitation. Many patients who are not candidates for microvascular cont rol from the oral cavity to the esophagus. In many reconstruction
reconstruction can be restored with compensatory-type mandibu· patients, oral sensation is diminished because of denervation of the
tar resection prostheses. The process of this kind of restoration has microvascular graft or prosthesis coverage: this can lead to altered
been described in detai l by several au1hors.97..,. sensations and poor bolus control. It is imparative that the patient
Patients who require se gment al resections of the anterior unde rs tand that purely mechanical reconstruction does not ensure
mandible rather than complete replacement of the mandible pose com petency in swallowing function. The multidisciplinary treatment
one of the more diffteult restorative problems. If it is possible to team members should emphasize thi s qualifier prior to any planned
attempt restoration of postsurgical mandibular function approaching therapy. With this knowledge, pat ients can more easily accept the
normalcy, a primary bone graft or aJioplastic implant should be used outcome of collaborative work among these specialists. Marginal
t o maintain continuity. The main problems associated with anterior mandibulectomy patients who have remaining t eeth can be treated
segmental resection are pooling of saliva and drooling. Perhaps more either with a cast-frame RPO or an implant-supported restoration
than any other factor, these annoying conditions prompt the patient (F.g 15·36). Prosthesis design for edentulous patients can be a fixed
t o insist on early restoration of mandibular continuity. Restored or removable restoration with a design that simlllates a clasSic tis
i y of the lip and resuspension of the hyoid bone can often
mobilt sue-integrated prosthesis. Scar tissue created in the lower lip and
position the larynx anteriorly and superiorly and reduce the possibil y it floor of the mouth often necessitates a removable p rosthesis design
of aspiration. This is known as laryngeal suspension and can be to facilitate hygiene and ease of long-term management .
used in some cases in which chronic aspiration is pro bl em atic .00 '
224 1
Fig 15·37 Compress1on recoostruction plates used to

a
reduce the fibular man dibular juncon
- ti .
Fig 15-38 (a) Posterolateral resectiOn of the mand1ble showing a tendency for residual segments to
assume the medial posito
i n. (b) Midline and floor of the mouth mandibular resection precipitates med!111
an<J superior mrgration of segments.
Mandibular reconstruction a significant negative factor for some patients because sufficient
The evolution of head and neck reconstructive surgery has been numbers of occlusal contacts can be maintained postsurgically. Plate
dramatic over the past three decades. The option to use vascular· and soft tissue reconstruction versus more aggressive techniques
ized tissues from the forehead and deltopectoral regions gave way are important planning considerations.
to the more popular pedicled myocutaneous flaps performed in the
1960s and 1970s. By the 1980s, microvascular anastomosis had Immediate versus delayed reconstruction The reconstruc·
developed extensively,'01 and numerous osteomyocutaneous free live effort for any mandibular segmental resection should include
flap donor sites were identified and used for mandibular reconstruc at minimum immediate stabilization that allows maximum tongue
tion.'"'-'04 In addition, particulate cancellous bone marrow (PCBM) mobility. This approach facilitates secondary reconstructive ef
in formed allogeneic frames was used.'o� Equally important to the forts by reducing the negative outcomes of fibrosis and oontrac·
functional outcome of mastication was the development of the sci ture seen when no stabilization is provided.'08 The decision of
ence and clinical appfication of the osseointegration phenomenon in whether t o reconstruct immediately or at a delayed time depends
implant dentistry.00 '00 on whether immediate or delayed use of bone is more desirable. In
making this decision, it is important to consider the functional re
Reconstruction plates The cosmetic deformity assOCiated with quirement of dental prostheses given the extent of the surgery and
mandibular resection is improved through the use of reconstruction the remaining teeth. If a lateral resection (Fig 15-38) leaves sufficient
plates, which maintain the presurgical contour of the mandible.•or teeth for functional benefit, the patient may be best seNed with
The most commonly found prosthetic devices currently used in no prosthesis or additional intervention, especially if a significant
mandibular reconstruction are the transosteal bone plate systems. medical risk exists. The number of teeth required for acceptable
These plating systems are slightly different from their orthopedic function varies for each patient. The patient with a full complement
counterparts in that they permit immediate functional loading re o f teeth on the nonresected side of the mandible and an optimally
quirements for mastication (Fig 15-37). Often, the screws used for preseNed occlusion through the oontralateraf canine or premolar
the immobilization traverse both cortices and may apply a degree of region may be a candidate for no prosthesis. However, patients
compression upon tightening. with a conservative lateral resection (especially edentulous patients)
From a functional standpoint, this form of mandibular contour and may have varying levels of ability to function with a mandibular re·
position maintenance should be considered the minimum standard of movable resection prosthesis. For these patients. strong consider
care for mandibular resection patients. Use of reconstruction plates ation s11ould be given to bone reconstruction and possible secondary
can maintain cosmetic appearance and preserve the bilateral nature preprosthetic surgery of the reconstructed region. Optimal pertor·
of mandibular movement. However. reconstruction plates alone mance results from the use of endosseous implants for complete
preclude replacement of teeth in the region of resection. Prosthetic support (totally implant-supported) or assisted support Qmplant
replacement of teeth cannot be provided for regions superior to the tissue-supported) of the prostheses.
reconstruction bar because of the potential for mucosal perforation When the decision is made to proceed with the surgical recon·
and exposure or the bar after the soft tissue undergoes functional struction that provides the best chance for dental reconstruction fol·
ioading. When considering masticatory function, this may not be lowing mandibular resection. bone is a necessary component of the
225
15L Restoration of Congenital, Developmental, and Acquired Oral and Perioral Defects
Fig 15-39 (a) Pedunculated erythroplaJOC lesiOn in the midline of the ma ndible (I)) Lateral lesion contiguous as leukoplal<ia and diagnosed as invasive SQu amou s cellcan:inoma. (c)
.
Panoramic radiograph showing dissolution olllona ootwoon mandibular indsors alld associated periodontal defects in adjacent dentition. (d) Resoc�on specimen shoWing invasion
of lesion to lingual aspect. (e) Fibular osteomyocutaneous flap used to restore the mandibuk1r discontinuity defect. (f) Plating of fibular segment to residual mandible. {Coortesy of
Drs William Lydian and Perry Johnson. Omaha. NE.)
reconstruction (Fig 15-39). The most significant factor in reconstruc PCBM w�h allogeneic frames and free revascularized bone and
tive outcomes is the size of the soft tissue defect and the degree to composite grafts are currently most common. An important adjunctive
which the replacement soft tissue can match the presurgical func therapy in the postradiatiOn patient is HBO to reduce complications
tional characteristics Attention to this factor in the reconstructive
. and improve the healing dynamics associated wnh the soft tissue
effort increases the likelihood that a patient can (1) receive a stable environment, the graft bone, and dental implants. Replacement bone
bone replacement; (2) be provided with a well-supported. stable, size, shape, and positiOn, in addi tiOn to the type of prosthesis planned,
and retentive prosthesis for a mandible that exhibits adequate func all affect the potential for prost het ic care after succesfs ul graft transfer,
tional movement capability; and (3) use the cheek and tongue to stabilization, and union.
manipulate food or liquids in a coordinated fashion for mastication. The ideal prosthetic characteristics of the mandibular restoration
Given t hi s understanding . the following discussion of mandibular are shown in Table 15-1. Regardless of the type of prosthesi s to be
bone reconstruction does not guarantee intact neurosensory feed used, the appropriate placement of bone relative to the opposing
back for the complex pattern of mastication, and patients should arch is vital t o the intended funcllonal use. If a removable prosthesis
always be counseled to this end. is planned to cover the bone reconstruction. the contour of the
The literature provides numerous d escriptions of the surgical developed ridge should provide (7) a surface covered with firm, thin
options for mandibular hard and soft tissue reconstruction.'""·"0 A soft tissue; (2} a rounded superior contour with parallel buccal and
significant concern exists regarding the cost benefit of such procedures lingual slopes; and (3) sufficient vestibular depth to provide horizontal
as well. '<18."1•1 '�Options for mandibular replacement include PCBM in stability. A ridge in this condition is the surgical analog of a minimally
an allogeneic frame shaped to the contour of the replaced anatomy.'06 resorbed edentulous ridge accompanied by adequate cheek and
nonvascularized free bone grafts, pedicled osteocutaneous flaps, and tongue movement and should provide a reasonable prognosis for
free revascularized bone and composite grafts.""'" The proponents prosthetic success provided a sufficient number of teeth remain on
of each technique make their selection based on reconstruction the nonresected side. For optimal occlusal function. dental implants
timing needs, morbidity associated with the donor site, and potential should be considered. With adequate bone volume and the ideal
for perioperative and postoperative complications. or these options. ridge contour. the prognosis for success is optimal.
226 1
prosthesis does not address any paralytic effect on the lower eyelid or
Ideal dental prosthetic characteris
Table 15_1 clleek. It is also unable to mimic the dynamic movement of a normal
tics of a mandibular reconstruction
commissure and requires considerable patient accommodation. The
F act or s Characteristics
management of unintelligible speech is add ressed elsew here, but
Spatial relations/lip to:
the clin1cian should note that the social impact of speech carries a
Remaining mandible ContiniJO<.Is at superior anef lntenO< boroers with
cosmetic characteristic that needs to be appreciated in restoration
the proximaVdistat segments of native mandible
of detects.
Facial contour Restores presurgical external contour to the lower
one·thif'(l of the face
Complications The major complications seen with mandibular re
Maxllary teeth:
HoAZontal concem Positioned beneath the opposing teeth to allow constructions often result from excessive bulk or the soft tissue com
functional placement of the replacement teeth ponent and lack of tongue mobility. When these factors are controlled,
Maxillary teeth: complications are mostly the result of bone placement and size. Free
Vertical concern Prollldes a mln>mtXO of 1O·mm sa p c.ng between fla ps that include bone from other regions of the body in a shape other
111e sofl ts
i s ue covering the bone and IJle OPPOSing
than the native shape of the mandible introduce a significant degree of
OCClusion (not the opposing ridge)
technical difficulty to the reconstructive procedure. The fibula, which
Size and shaPe:
is a popular choice for mandibular replacement, presents some c11al·
Intraoral form Exhibits a rounded superior surfaoe With nearly
lenges in meeting tile ideal requirements as listed in Table 15-1 .116
parallel buccal and lnguaJ surfaces at least 1 em n
height from vestibule Because of the straight configuration of the bone. it is easy to err
Bulk Provides a minmum bulk for Implants of 10 mm in in b oth the horizontal and vertical positioning, especially for recon
width and 15 mm In height structions that extend to the midline. Lingual positioning requires im
Soft tissue relatlonshl/)s: plant positions that create a mechanical cantilever detrimental to tile
Separate movement Provides a 10.mm vestibular depth and distension long-term success of the implant -supported prosthes is .
that allows independent movement of the cheek In the posterior regions, the inab ility to re-create the natural
and toogue relative to the mandible
ascending curve of the mandible can restrict placement of teeth and
Ridge cove<lng rPolll(l es sof1 ti ssue tha t rs firm (attached t o the preclude restoration o f complete occlusion on the resected side. It
bone) and less than 3 mm thiC k to covertl'le bone
is common to have a mismatch in height at the anterior junction
of the graft with the resd
i ual mandible. For implant-supported
prostheses. this area can present significant challenges to adequate
implant hygiene, and with time, it can compromise implant health.
For removable prostheses. the irregularity can become a source of
irritation if it acts as a fulcrum during function. The size of the fibula
Cosmetic impact of intraoral acquired defects Sur gical man may be a concern, as it i s understood that implant geometry may
agement of intraoral or perioral tumors that require removal of por· be a factor in predicting success. Because implant failure can occur
tions of the facial skeleton can cause disfi gurement of the face. with inadequate length or wi dth, an increase in arch height and width
The most common disfiguring procedure involves resection of can predict a significant improvement in implant survival."7
the mandible with no reconstruction or with reconstruction that There may be a tendency to place dental implants at the time
alters t he contours of the lower one-third of the face. The past of immediate reconstruction. When radiation therapy is planned
decade has seen increased attention directed to the cosmetic in t11e postsurgical period, a delay in implant placement following
impact of resective surgery of the head and neck region. and this a course of HBO improves the chance tor implant survival and
has resulted in the current minimal reconstructive standard that reduces the potential for development of osteoradionecrosis in the
mandibular resections use the prosthetic plate described earlier."' native mandible. Tll9 maxil lofaca
i l prosthodontist is able to provide the
Other forms of cosmetic incapacity that are not classified as most useful input regarding the placement of implants following a
deformities include drooling, oral incompetence, facial paralysis , survey of the relationships provided by the bone reconstruction.
artd unintelligible speech. Drooling and oral incom petence are Although immediate placement can be accomplished, it has olten
associated with similar deficits such as (1) impaired m andib ular lip resulted in dental implant positions that are not useful for prosthetic
sensation and posture; (2) a decreased labial and l ingual sulcus support.""
reflection that does not encourage posterior flow of saliva and An inability of the fibula graft to integrate with the remaining man
liquids in the diet; and (3) a decreased ability to approximate and dible segment can also be particularly troublesome in reestablish·
seal the lips during swallowing. These de fici ts are not typically ing continuity. Grafting procedures have been helpful. but skeletal
managed with prostheses. Unilateral facial paralysis, which results immobilization has proven to be optimal to obtain callus formation.
in an inferi or position of the oral commissure, has been treated with Occasionally, the implants themselves can be used along with cast
,
the use of a li p-supportive prosthesis that simply attempts to place splints, as a stabilization device to obtain the formation of new bone
the commissure in a bilaterally appropriate position.115 However, this (Rg 15·40).
227
151 R e st orati on of Congenital, D evelop mental, and Acquired Oral and Perioral Defects
Fig 15-40 (a) Pal10famic radiograph of patient treated

with resection of osteosarcoma and reco1lStruclion with
vascularized fibula g1alt not forming a union (anew). (b)
Treatment with endosseous implants in both segments for
munobilizaton
i in conjunction vAth maxlllomandibular l lxatlon
.
(c) Panoramic radiograph shows removal of hardware and

Joss or one Implant. (d) Occlusal radiograph shows resolution
of discontinUity affer 6 months. (e) Delinitive prosthodonlic
restoration. (Courtesy or Dr Michael Miloro, Cllicago, ll.)
Surveillance be suspected, and any white or red lesions can potentially indicate
carcinoma or carcinoma in situ. As many as 44% of white lesions on
It is i mperative that pat ients who have undergone treat ment for head the floor of the mouth may constitute a carcinoma."0 The likelihood
and neck cancer be thoroughly examined at each visit. One of the of red lesi on s masquerading as carcin o ma is as high as 90%.'2<1 De·
greatest advantages of the use of removable prostheses for patients spite abstinence from the use of tobacco and alcohol a patient's .
with maxillofaCial defects is the opportunity to thoroughly and sys past exposure to these substances always remains a c onoern for
tematically evaluate previous surgical sites for recurrent disease. Per the develo pment of second primary tumors.
chapter 1 2, squa mous cell carcnomas are commonly followed for
i
long-term survival, and 5-year disease-free observation periods ap

pear to yield the likelihood of long-term cure. Although the concept
of field cancerization has been proposed as an explanation for the Summary
develo pment of second primary tu mOfs, surgical reconstruction may
occur for maxillary resections with the assu mption that recurrent dis This chapter has attempted to describe the functional and cosmetic
ease is unlikely. Other tumor types, such as adenoid cystic carcinoma aspects of maxillofacial prosthetic management of acquired and
(cylindroma), may require a more extended period of follow up, whc
- i h congenital defects in light of th e realistic function provided by remov
may extend fOf years before elective bone grafting or implant place able prostheses. The goal was to facilitate the decision-making pro·
ment can be contemplated. A frank and open discussion between oess for c ombined surgical and prosthetic management of pati ents
surgeon, patient. and prosthodontist should take plaoe prior to any with acquired or congenital defects of the head and neck.
consideration of elective reconstructive procedures. As functional impairment is often a result of common surgical
procedures, a description or prosthesis goats and limitati ons has
been provided to help the clinician understand the expectations for
Recall examinations prosthetic reconstruction. Also, the timing of prosthetic management
was discussed, as well as the types of common prostheses
At each subse quent visit, a thorough examination should be per associated with the stages of prosthetic management.
formed including radiograph ic and clinical surveys that can be com· Surgical management of disease in this highly complex region
pared to baseline information. Vital information such as interinciSal of the body usually is followed by surgical reconstruction that uses
o pen ing tooth mobility, swallowing times, neck mobility, and other
, tissues lacking the task-specific functional capacity of that which was
basic dental parameters should be recorded and evaluated for any removed. The subsequent physical and psychosocial adaptation
sudden changes. Any changes in oral mucosa should be monitored during recovery can oHen place a significant burden on the p atient.
closely, documented by photography, and com mun icated to the pa Prostheses, which in conventional dental use are less tha n ideal
tient's head and neck surgeon. Recurrent path ology sh ould always for restoration of normal oral function, are most favorable to restore
2281
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8:303-308.
231
Chapter
Contemporary Dental
Materials and Their
Application to Prosthodontics
Thomas J. Salinas, ODS
Julia n B. Woelfel, ODS
ental materials have undergone significant development over

History of Restorative Materials
D the last several decades. To satisfy the demand for esthetic
and functional restorations, development of materials with
improved physical properties and esthetic appeal has provided th e Historically, complete dentures had to be carved from materials such
impetus for the current availability and variety of products. Many of as coconut shell hippopotamus tusk, ox femur, o r a hard fruitwood
,
the innovations realized have occurred in the areas of polymers, cer such as teak by direct observation of contours. In Poland in 1711,
amics, and alloy systems. Purman made the first recorded impressions of the jaw using bees
Much of this development in ceramic materials has manifested as wax. His cast was also made of wax, probably to serve as a model
increased strength, improved esthetic quality, and new technology for fitting by the bone or ivory craftsmen. In Germany in 1756, Pfaff
used to manufacture these materials. Application of computer-aided formed the first plaster cast. described "taking the bite," and made
design and computer-assisted manufacture (CAD/CAM) technology and used the first recorded articulato r. Having a working model was
has allowed homogenous ceramic materials to be manufactured a tremendous advance in dentistry and made i t possible for gold
within the dimensions and tolerances indicated for tooth- and denture bases to be swaged {Bou rdet, France, 1757) and porcelain
implant-supported restorations. Composite resin polymers also dentures to be molded or fused {Delabarre, France. 1800). Tin (Hud
have evolved beyond their original formulations to demonstrate son, United States, 1820) with silver or gold plating (Royce, England,
increased resistance to abrasion and improved esthetic properties. 1836) and a form of gutta-percha were tried without much s uccess
Although alloy systems have remained largely unchanged over the as d enture bases prior t o the introduction of hard rubber (vulcanite)
last several decades. changing patient preferences have required by Evans in 1851 in England.
alteration of these materials for more specialized applications. The The process for making vulcanite was patented by Nelson
process of microtexturing titanium for increased bioactivity during Goodyear of the United States in 1851. This was the most readily
the osseointegration process has markedly changed manufacturing acceptable and cost -effective way to produce a denture base for
trends over the last 1 0 years. A newer method of fabricating res the next 80 years until the introduction of pelymethyl methacrylate
torations is computer numeric controlled {CNC) machining, which (PMMA) resin. The principal shortcomings of vulcanite as a denture
offers an unparalleled level of fit and biocompatibility. Nobl e alloys base material were its poor esthetic p roperties its lack of ab rasion
,
have also been continually used. despite the increases in their costs resistance. and the difficulty encountered in repairing or rebasing
in recent years. Bectroformed copings for porcelain-fused-to-metal prostheses. Although vulcanite was dimensionally stable and had
restorations have gained a wide degree of acceptance because of adequate strengt11, the material was somewhat porous, which
their minimal spatial requirements and tissue-compatible color. caused a slight fouling of the denture base.
233
�6 i Contemporary Dental Materials and Their Application to Prosthodontics
In 1936, the dental profession welcomed the introduction of

acrylic resin. For the next 6 years, both vulcanite and acrylic resin
Polymers
were used for denture bases. with acrylic resin eventually replacing
hard rubber. By 1942, acrylic resin was considered the best available Polymeric restorative materials originated with the development of
denture base material.' Even though hundreds of industrial plastics silicate cements in the late 1800s. After lhe introduction of PMMA to
have been developed since that time, including acrylic copolymers dentistry in the early 1930s, acrylic resin was used in the 1940s for
(eg, Luxene 44) and a polystyrene (eg, Jectron), none have had as the restoration of some teeth. Although this material was relatively
good a combination or favorable physical properties as acrylic resins. easy to use. it exhibited high shrinkage upon polymerization, signifi
Acrylic copolymers and polystyrene have a greater flexural strength cant wear, and eventual discoloration. In the 1 g6os. composite resin
than acrylic resin, but midline fractures of maxillary dentures occur was introduced t o dentistry. This material combined ease of place
more frequently with polystyrene bases. Neither vinyl acrylics nor ment with significantly improved esthetics. At the time o f its introduc
polystyrenes reproduce surlace detail as accurately as acrylic resins. tion, the polymer matrix most commonly was composed of bisphe
Of the 58 desirable qualities proposed by a special workshop of nol glycidyt methacrylate (bis-GMA). The filler was primarily quartz
the former Academy of Denture Prosthetics. acrylic resin mel 47 of particles, which seemed to reduce the amount of contraction upon
these requirements': however, it fails in such areas as instantaneous polymerization and impart some level or translucency and strength.
temperature conductivity, wettable surlace, easy sterilization. The main disadvantages of composite resins are their tendency
resistance to abrasion and stain, choice of hardness or softness, to absorb some degree of water and their rate of wear. Three
fracture resistance. and a few others. mechanisms contribute to the degradation of composite resin:
Although acrylic resin is commonly used today for fabrication of
complete dentures. other materials occasionally are used to meet 1. Two-body wear occurs when two bodies Slide against each other.
requirements of the clinician who wishes to provide patients with an During this type of movement. compression and tension develop
individualized prosthesis. TI1ese materials can be classified into five at the surlace at variable and critical levels. creating cracks per·
categories: (1) metals. (2) plastics other than acrylic resin, (3) acrylic pendicular to the direction of sliding. In this circumstance, the
resins, (4) porcelains, and (5) resilient liners. affected material chips and results in material loss.
The use of metal in a denture base has certain advantages 2. Three-body wear is seen as the removal of material through abra·
over plastic materials. A few of these advantages include thermal sion by a small hard particle of grit caught between two rubbing
conductivity, decreased bulk with increased strength. and dimen surtaces. Three-body wear i s often cited as the most common
sional stability. The high cost, weight, inability to be rebased, and reason for composite resin wear, but filler particles from the com
poor esthetic qualities are the main disadvantages. Although it is posite resin can contribute t o this type or wear a s well.
unable t o be relined and adjusted, a gold base for fabrication of 3. Corrosive wear is a combination of chemical degradalion. lwo
the mandibular denture may be advantageous because the mass body wear, and three-body wear. Chemical degradation of com·
is more lhan double that of an acrylic resin base. Other metals posite resin occurs between the filler particles in the organic rna·
such as aluminum and chrome have been used. but they are trix as a result of the dissolution of the organic silane coupling
disadvantageous because of the above-identified factors. agent. The subsequent loss of filler particles contributes further
Although pocelain
r was used as a denture base material in the to three-body wear.
19th century, it demonstrates considerable volumetric shrinkage
(approximately 30% to 35%). This trait, along with its weight liability Other mechanisms of loss of the organic matrix can include an
and fragility, makes porcelain impractical for use considering the incomplete cure or loss of the matrix througl1 solvency by alcohol
other materials available today. or high-velocity liquids.3 The size or the particles and their tendency
Nylon is an unsatisfactoJy denture base material because of its to prematurely separate !rom the organic matrix also can contribute
inability to resist the oral environment. As it absorbs moisture. the to wear. This phenomenon was fairly common in the earlier versions
material tends to swell excessively and discolor after only 6 months or composite resins. Subsequent generations of composite resins
of service. Polyamide material is also unsatisfactory when used as were developed with progressively smaller sizes of filler particles
a denture base material. Epoxy has a high rate of water sorplion to withsland significant loading. This led to an improvemenl of
a s well, with accompanying dimensional change. Polycarbonate esthetics and increased the resistance to wear. resulting in greater
material has also been used, but it shows a similar degree of color stability. Modern versions of composite resins are designed to
distortion from water sorption, higl1er ilexibility, low hardness. and be used in a variety or clinical situations.
less adhesion to acrylic resin teeth. With the advent of composile resin bonding to tooth structure in
the 1 g6Qs by Bowen and Buonocore,<·� it became apparent this was
a promising area for improvements. Adhesion to tooth structure is
a multifactorial process that involves consideration of the types of
conditioning agents used to bond the materials and the types of
exposed tissues that participate in the bonding. Bonding to enamel is
234
1
Polymers J
ll_p!rth<l_l!. �� nd t.PJ>Iications of

Table 16_1
[ �
various composite resin fillers
Class Particle size Application
Microfiled composite 0.0 1-Q. 1 21J(n Prima ri ly lor anterior teelh

res<ls
Hybrid oomposile 0.6-t.Opm Suitable for anterior or

resins posterior teeth
Microhybrid compos- 0.04-1 .0 pm U!Wers<ll esthetiCs. wear

ite resins rSS�Stance
Nanofiled composite 2{}-75 nm U<Wersal esthetics.

res<ls smooth wear
Rg 16-1 Schematic representmion or aontin oondlng interface. (Modified from Van

-
Meerlleek ct al•witll permission.)
relatively predictable because this tissue is primarily organic crystals simple restorations. Where significant dentinal exposure presents �self
composed of 95% hydroxyapatite, 4% water, and less than 1 o/o tor adhesive luting, it may be appropriate to use a fourth-generation,
collagen. It was found that etc hing enamel with an excess o f 30% three-step bonding process (eg. monolithic all-ceramic restorations
phosphoric acid would lead to a distinct etch pattern and cneate and other critical bond procedures that involve significant dentinal
an increased surface area for bonding composite resin and other exposure).
restorative materials. The predictability of bonding to enamel has
decreased the risk of secondary caries, postoperative sensitivity, and
marginal leakage present with other restorative materials. Bonding Composite resins
to dentin is considerably more complex and requires extensive
knowledge of contemporary bonding agents. Unlike enamel. Small -particle composite resins contain coarse particles that are typ
dentin is composed of 45% hydroxyapatite, 25% water, and 30% ically 0.5 to 3.0 1.1m in diameter. These filler particles occupy about
inorganic matrix. Ultrastructure characteristics of freshly cut dentin 60% to 77% of a composite by volume; as filler b y weight the per ,
were described by Van Meerbeek with decalcified dentin and a loose centage is higher (70% to 90%). Otten. the filler is a conglome r ation
collagen fibrillar network impregnated with reference resin" (Fig 16-1). of different sizes of particles, which tends to create more efficient
With a compnehension or the characteristics of dentin , the packing (see Table 16-1).
rationales lor use of successive gene r ations of resin bonding tor Microfilled composite resins contain colloidal silica particles that are
denti n are clear. Freshly cut dentin has a charac teristic surface just
- 0 . 0 1 to 0.12 pm in diameter. The loading of filler particles tends to be
after preparation . A bond to this tissue can be obtained by conditioning about 30% to 55% by volume, or similar amounts by weight. Often,
the surface, priming with an appropriate hydrophflic primer, and then large oligomers are added to make these compositions workable in a
applying bonding resin. The compoSite restorative material can then dinical environment. However, the filler content may be increased and
be bonded onto this activated surface. The resin bond to dentin has properties improved by selectively abrading polymerized microfilled
a strength of between 20 and 35 megapascals (MPa)! This is highly composites into smaller constituents {1 0 to 20 1.1m in diameter) and
variable depending on the cfinician's skill level and adherence to using these particles along w•th colloidal silica.
bonding procedure because many of these bonding procedures are Hybrid composite resins include both colloidal and fine particles
quite technique sensitive. Fourth-generation bonding agents that rely as filler. Collod
i al particles can supplement the matrix interspersed
on specific etch. prime. and bond procedures are still widely used. among the fine particles . ultimately creating a filler content of
The advantage of using a fourth-generation bonding procedure is that approximately 65% by volume. Hybrid composites have been very
high bond strengths to dentin can be obtained. The disadvantage is popular because of their resistance to mechanical abrasion.
that this procedure is time-consuming and has potential to overetch Microhybrid composite resins are composed of microfillers and
the dentin and create postoperative sensitivity. Two-step procedures ultrafine glass particles. They offer maxim um solid particle loading
invoMng either a fifth-generation or sixth-generation bonding agent due to ther reduced fill and particle-size variance (0.04 to 1 .0 pm).
i
use weaker acids for etching and are less technique sensitive to the These can be used in anterior or posterior applications and offer
variations in dentin moisture content. One-step procedures appear to both increased resistance to wear and esthetic appeal.a
be less technique sensitive and save time, but they yield significantly Nanofilled composite resins are a subgroup of microhybrid
reduced bond strengths . Applications of these self-etching materials composites with small particles prepared using nanotechnology.
appear to be in the early stages of development and may be used for These particles t ypically range from 20 to 75 nm , depending on the
235
intended shade and translucency needed. These particles can be Acrylic resins
partially coalesced or concentrated as small nuggets that act as
silanated fillers. These materials typically take on a smooth surface Shortly after acrylic resin was Introduced in 1936, it became widely
during polishing procedures or simulated clinical wear. They create used because of the relative ease with which it could be manipulated
a natural blend with virgin tooth structure and create more esthetic and because of its excellent esthetic properties. During early use,
realism in anterior areas without compromising physical properties. many acrylic resin dentures were improperly processed or only par·
Nanofilled composite resins can be used further for lamination tialty cured. Eventually, adequate research was performed to define
over removable or fixed restorations fused to titanium or noble standards related to proper manipulation and processing.
alloys. Their ease of repair, est11etic appeal. and compatibility of Since these standards were developed, there has been a low
wear against opposing surfaces make them very popular for these incidence of PMMA resin allergy.9 The incide n c e of acrylic resin
applications. The latest advancement in polymerization o f these allergy is relatively rare when associated with contact dem1atitis.
materials is the light-emitting diode {LED). Some of the laboratory Usually. any inflammation occurs beneath only a portion of the
commercial units used to polymerize these materials have also used denture, and the remaining part of the involved mucous mem-brane
a vacuum concurrently with multiple sources of light to result in a {eg, cheek, tongue. opposing arch) appears normal although it
relatively dense cure. also contacts the same acrylic resin. All acrylic resin denture bases
The polymerization shrinkage seen with the nanofilled composite contain 0.2% to 0.5% residual monomer after processing {slightly
resins can generate stresses of approxlmately 18 MPa in the more with autopolymerizing compared with heat-curing resin). The
prosthetic or tooth interface. Because shrinkage often is a function maximum recommended level for residual methyl methacrylate
of the amount of polymer in the matrix. the calculated amount can monomer approaches 2.3%. which is mandated as an American
be variable and dependent upon the type of composite material. Dental Association {ADA) specification number 12. However,
Microfilled composite resins can demonstrate polymerization studies have shown tl1at. over 2 to 3 weeks. residual monomer,
shrinkage between 2% and 4%. in contrast to line-particle materials, continues t o polymerize (or migrate through the surface of the
which exhibit shrinkage between 1.0% and 1.7%. Strategies t o avoid prosthesis and evaporate), reducing residual monomer content to
shrinkage include adding incremental amounts of composite material, below 0.5%.'0 Various investigators and pathologists agree that it
varying the light intensity during the polymerization, and formulating is difficult to relate denture stomatitis or allergic contact dermatitis
the bulk of the prosthesis by a laboratory procedure before luting it to to residual acrylic monomer. Most denture stomatitis is caused by
place. Regardless of the approach used. the degree o f conversion to trauma from poorly adapted denture bases, secondary Candida
completely polymerized material typically approaches between 60% infections. or a combination of both.
and 75% at best.8 To optimize the amount and extent of cure, the Several significant improvements have been incorporated into
tip of the light source can be placed within 2 mm of the surface. the acrylic resins over the years to make them more versatile. In a
amount of material to be cured at one time should not be more than recent comparison of approximately etght contemporary heat·
2.5 mm, and the exposure time can be increased for darker shades polymerized acrylic resins, those having the lowest percentage of
or more opaque materials. residual monomer content {0.2% or less) also demonstrated the
Some contemporary strategies to decrease the amount of wear highest flexural strength {73.5 MPa or more)." Most modern acrylic
are targeted at developing filler particles that are more resistant to resins contain a cross-linking agent in the monomer such as glycol
the effects of two-body and lhree·body wear. Zirconium silicate has dimethacrylate. Other additions such as plasticizer agents augment
been recently developed as a micro
fi ll er particle with increased wear the resiliency of the acrylic resin upon impact. Dibutyl pthalate is a
resistance. This product shows promise for use in full-coverage commonly used plasticizer added to acrylic resins that does not enter
provisional and definitive restoratiOns. Urethane dimethacrylate polymerization but interferes with t11e interaction between polymer
{UDMA) is another contemporary material designed for use in the molecules. This makes the polymer softer than parent polymer and
fabrication of provisional denture record bases. occlusal splints. results in a softer, more resilient acrylic resin. Addition of other esters
and definitive prosthesis material. Although somewhat viscous. this suc11 as butyl or octyt methacrylate can plasticiZe PMMA. This type
material has been developed for specific application using minimal o f internal plastiCizer tends to be contained within its own structure
processing techniques with a direct-cast application technique. and is not leached out in oral environments but remains stable.
Often, a heated and desiccated master cast is used t o adapt the Introduction of autopolymerizing acrylic resin was significant
base portion of prostheses. because it (1) improved dimensional accuracy; (2) simplified repair,
Additional development of these materials allows them to be used use. and impression tray fabrication; and (3) allowed expedient
with thermal adaptation in the fabrication of patterns to be used in fabrication of orthodontic and provisional prostheses. Dentures made
casting, CAM. or fabrication of provisional restorations. Although with autopolymerizing acrylic resin have given long-term satisfaction.
these patterns are promising. further development of image Other advances soon occurred with the introduction of nuid resins,
acquisition technolog for single· and mulliple·toolh restorations which received wide attention. When the polymer is mixed with the
y
continues to occur and may negate the need for laboratory monomer, the ffuid resin brieny assumes a nonviscous state, which
generated patterns with a specific configuration and design. allows it to be poured rapidty into any mold configuration. This
2361
Resilient Liners J
Clinical applications
Because of the above-described dimensional change associated

with PMMA resin polymerization. adaptation of the intaglio surface of
removable prostheses may exert uneven pressure across mucosal
surfaces. To ensure uniform pressure distribution, it has been sug
gested that a technique incorporating a processed acryliC resin den
ture base be used. Additionally, if the acrylic resin is allowed to con
tract gradual ly greater occlusal accuracy occur s upon p rocessing.
.
Brewer and Langer suggested this technique t o improve the clinical

Fig 16-2 Diatolic recesses included in anten1>r teeth for added stabilization.
performance of complete denture s"·'&; Jacob and Yen extended the
technique to maxillofacial patients some time later.'Q
As mentioned previously, other efforts to obtain accurately fitting
prostheses have been focused at specific processing techniques.
cuts in half the time required for !tasking, processing, and finishing The classic use of compression molding to process acrylic resin has
compared to conventional techniques. One reqllirement when using been universal throughout the last 70 years. Recently, it has been
this technique is t o create diatoric recesses in the denture teeth shown that injection-molding techniques can improve the level of
(Fig 16-2) and then use a special bonding agent (a solution of 50% fit and adaptation of acrylic resin to the underlying stone cast. This
CH,CI) and cold-curing monomer for 4 t o 7 minutes. Otherwise, technique allows less dimensional change upon processing, thereby
porcelain teeth should be used because achieving a chemical improving adaptation of tl1e denture base to the underlying tissues.
bond with denture teeth is unattainable. Conventional compression Assuming that linear dimensional change of acryliC resin approximates
molding with heat-curing acrylic resin is the most popular method to 6% and accuracy of most elastomeric impression materials is quite
fabricate complete dent ures. It requires minimal time and equipment, high.• the biggest discrepancy in the patient-laboratory sequence
and with proper training, it results in predictable outcomes. Injection appears to be in acrylic resin processing. Although the accuracy of
molding of heat-cured acrylic resin was introd uced by Pryor'2 and compression molding versus injection molding has been disputed
was gradually revised t o allow a greater degree of adaptation and over the years, the most recent data indicate that injection molding
occlusal accuracy."·•• is favorable over compression molding. •:1.>0 Additionally, residual
High coeffiCients o f thermal expansion (CTEs) are inherent with monomer content is said t o be similar to that of compressi on-molding
heat-cured acrylic resin and are responsible for internal stresses in techniques. which may be related more to the length of processing
the processed denture base.'6 These stresses are greater than those time rather than the technique.2' Fabrication of clear acrylic resin
encountered with room temperaturer-cured resins. Because the bases allows further assessment of the set of the base that covers
resin has a high CTE (about 10 times that of investing stone), it tends tissues or implant substructures. Ught-cured UDMA bases can
to shrink at a more rapid rate than the investment. A partial release expedite the processing time and result in more intimate adaptation.
of these internal stresses in a denture occurs when it is removed UOMA shows higher transvers e strengths than conventional heat
from its gypsum cast: it may be observed as a small but uniform processed acrylic resins.""
shrinkage of about 0.5% (0.2 mm) or less across the molars and
flanges, followed by a slight increase in saliva production during the
next few weeks of wear.
Generally, after about 2 months of wear, the dimensions of an Resilient Liners
acrylic resin denture approximate those of the original impression
o f the mouth. Specli ically, after 2 months of use, a heat-cured Resilient liners may be used in certain prosthodontic applications
prosthesis is about 0.2% undersized, and a cold-cured denture is and are typically indicated in patients with a spinous submucosal
about 0. 1% oversized At this time, the aerylic resin would have
. alveolar process, sizable opposable undercuts in soft tissue, psy
reached equilibrium with water and should remain dimensionally chogenic pain. or parafunction. These materials can be bonded with
stable almost indefinitely. newly polymerized acrylic resi n but tend to degrade once placed in
Rebasing a denture involves removing all of the acryliC resin the oral environment.
except a strip holding the Ieeth so that the rebased denture will Other materials have been used chairside to permit temporary
be essentially a unit of new material. If the residual acrylic is highly conditioning of soft tissues. The shortcomings of silicone elastomers
primed with monomer and care is taken to create a butl-joint finish are evident after several years' use, as the surface becomes a
line. the possibility of an unsightly junction line between new and old nidus for growth of microorganisms, particularly fungal organisms.
resins is greatly reduced. This technique also permits the external Several methods have been used to combat this issue. including
surface of the denture to be recontoured so that the thickness of the incorporating zinc compounds into the rubber during processing
palate and flanges s uniform.
i and soaking the prosthesis in diluted quaternary ammonium salt
237
�6 i Conte mporary Dental Materials and Their Application to Prosthodontics
Fi g 16-3 (il)Aiuminurn oxide abrasion of titanium framework planned for resin veneering. {b) Framework coated wilh silica abrasive {note bluish hue after Rocatec (3M ESPE)
treatmen Q. (c) Framework veneered with biS-GMA-llased opaQuer ready lor resin processing or lamin ation.
solutions (1:750) for 6 hours once a week.23 Soft lining materials for of the liner preserves its integrity during use. Because these materials
dentures should exhibit the following f ea tures : have a significant microroughness, they are susceptible to bacterial
and fungal colonization and m aterial breakdown.25 The effects
• Low solubility and sorption in saliva or cleaning by quaternary ammonium compounds, effervescent
• Adhesion and compatibility with the denture base t ablets in soluti on . and hot water appear to degrade these materials,
• Abilit y to maintain softness and resiliency particularly RlV si lico nes .2Jl Despite these outcomes, patients
• Minima l to no di mensional change during processing should be diligent in cleaning the underside of these liners using
• Easy to clean and adjust room temperature water and a mild detergent.
• Stable color
• Tasteless and odorless
Ideally, these materials would also discourag e the growth of

Resin Bonding to Prosthetic
microorganisms. Materials
Acrylic soft liners can have plast icizer that i s either bound or
unbound to the acrylic. Bound plasticizers generally extend the life Polymerization of resins inevitably results in contraction shrinkage
of a finer but are difficuH to produce. Because the plasticiZer has a and often creates a microgap when applied to metal surfaces, tooth
lower rate or cure than the acrylic monomer. the result forms a phase structure, or ceramic. This gap is often at least 50 to 75 f.lm and
separation that leads t o a tendency for water to absorb where there con tributes to bacterial contamination, delamination. and chronic
is more plasticizer, and the balance of the material distorts because of staining of the prosthetic veneering mater a
l. Bonding to both metal
i
the osmotic pressure created. Even with carefully formulated products, and ceramic can be problematic unless specific approaches are un
the majority of plasticizer s have been removed from production. dertaken to eliminate the inherent gap associated with resin-to-metal
Other types of plasticized acrylics are based on copolymer beads bonding. Application of free silica and silane coupling can help to
that consist principally of ethyl methacrylate . The plastiCiZer is usually eliminate this problem. H istOrical approaches to this have included
contained within the monomer as a large pthalate ester, which enters pyrolytic application of silica or tribochemical application in conjunc
the beads as the monomer polymerizes. This interrupts a free path or tion with organosilane coupling applicatton.2'·:1b Pyrolytic application
cross-linking between polymer chains. making the resin somewhat is particularly suitable for nonprecious or palladium-based alloys29;
soft at mouth temperature yet rigid below room temperature. Because however, this is more problematic because of the elevated tempera
of these problems, soft acrylic liners have poor resilience and deform ture and stresses generated in the alloy. Tribochemical application of
after long-term exposure to water. silica is a more practical approach because it can be easily applied
Silicone soft liners can be characterized as room temperature in the la.boratory or even intraorally to improve the resin-to-metal""
vulca nizing (RlV) and heat temperature vulcanizing (HlV). H'fV or the resin-to-ceramic bond." When used with dental alloys, l he
silicones possess a siloxane methacrylate that polymerizes against application of silica has been especially useful for resin -to-metal ad
simultaneous-curing methacrylate resin. In contrast , R'fV silicones hesion32 (Fig 16-3). Phosphate monomers have also been success
have a cross-linking system similar to those used in impression ful in enh ancing the resin-to-metal bond33 and have been included
materials, which are characteristically weak and insuffici ent for long in some resin cements applied intraorally. An additional benefit of
term use. One strategy to maintain the material's resiliency is to applying opaquing material is that the underlying framework of the
apply a sealer mon thly.24 HlV silicone liners must be designed with restoration is less apparent when the acrylic resin is less than several
sufficient thickness for resiliency and ca reful attention to preservation milli meters thick.
of the material's adherence to the denture base. Strategic placement
2381
Elastomers for Facial Prostheses J
Fig 16·4 (a) Tissue-integrated prosthesis and fabrication second·

ary to facial uauma. {b) Bar attae11ment used for retention, sup
ported by three implants placed into mastoid process ot temporal
bone. (C) Reverse of prosthesis diSPlaying acrylic resin keeper 1•Ath
three clip attaclm
l ents.
common practice.35 n1e use of a polyurethane liner also facilitates

Elastomers for Facial Prostheses clear1ing ar1d removal of adhesi ve; howeve,r this material has fallen
out of favor as more contemporary silicone materials do not readily
Facial prostheses historically have incorporated a wide variety o1 ma bond to polyurethane surfaces. In 1992, a widesp read survey on
terials. Those used within the last 50 years include chlorinated poly the use of facial elastomers found that silicone MDX4-421 0 (Dow
ethylene. polyurethane. acrylic resins. polyvinyl chloride. and silicone Coming) was the most commonly employed material,36 and the
elastomers, which are most common. Some years ago, Lewis and major i ty of those used were RTV materials. At the time of the survey,
Castleberry proposed ideal characterist ics of a facial elastomer"": A-2186 (Factor II) was the second most commonly used elastomer;
by some estimates, it appears that it is the most commonly used
1. The material should be easily reproduced and inexpensively fab- today, perhaps because it is relatively inexpenSive. A-2186 is not
ricated. considered as color stable as MDX4-4210, and many of its other
2. The material should be solvent free with appropriate viscosity. physical properties are also inferior.
3. It should have minim al to no shrinkage upon polymerization. Extrinsic coloration has been commonly applied with a slurry of
4. The material should be of sufficient viscosi ty to prevent settling silicone in some form o f solvent made of aromatic hydrocarbons
of the colorant components (10,000 to 75,000 centipoise). like xylene, cyclohexane. or trichloroethane. These slurries can be
5. The conversion of liquid to rubber should occur at room tem hypersaturated with artist's oil-based p igments or dry earth pigments
perature or at a temperature low enougll to permit the use and consisting of metal oxides. A subtle layering technique is often used
reuse of easily fab ricated molds such as gypsum. to impart varied shading of the base elastomer color. As with other
6. The prosthesis should be easily removable from the mold and restorative materials, surface staining is not sufficient to impart a
require no further treatment. realistic perception of human tissues. Therefore layering by intrinsic
,
7. The material must accept intrinsic and extrinsic coloration. coloration is commonly suggested to impart realism by permitting
8. The tear strength of the material should be above 30 to 100 psi . translucency and depth of color. Despite the method arld elastomer
9. The tensile strength of the material should be between 1,000 used, color change is inevitable3' Even with specific additives
and 2,000 psi . targeted at shielding a prosthesis from the effects of ultraviolet light,
10. The coefficient of friction. hardness, and water sorption should elastomers still change color with long-term exposure.38
define the feel of the material. Attachment mechanisms of facial prost11eses can include
11. The surface tension should be low enough to accept adhesives conventional retention with medical grade adhesives. eyeglasses,
yet high enough to allow their removal with soap and water. or segmental retention for a combination defect using magnets
from an intraoral component. Attachment by tissue integrat ed
-
Because the goal of a maxillofacial prosthesis is to seal and prosthesis (Implant-supported and Implant-retained) technology is
become invisible at the defect margins, tear strength of the elastomer another method that has led to a significant improvement in quality
is a significant consideration. Many adhesively retained prostheses of life for these patients (Fig 16·4). However, this technology often
are made with extremely thin margins, requiring extra strength in necessitates fabrication of an internal scaffold made of acrylic
these areas. Some of the early silicone elastomers had insufficient resin to provide an atlachment receptacle, which requires bonding
resistance 10 tearing to provide long-teml service, and reinforcement silicone to acrylic resin. Numerous chemical primers readily facilitate
with more tear-resistarll materials such as polyurethane became this mechanism via microtexturing with airborne-particle abrasion.
239
� 6iContemporary Dental Materials and Their Application to Prosthodontics
Polycarboxylate cements were developed as an attempt to combine

the strengths of zinc phosphate cement with the biocompatibility
Ceme nt Composition o f zinc oxid�ugenol cement. They consist primarily of zinc oxide,
aluminum oxide, and small amounts of stannous or other fluoride,
Phosphate Zinc phosphate. zioc s!llcophosphate
with polyacrytic acid as a liquid component. These cements have a
Phenolate Zinc oXIde-eugenol. calcium hydroxide salicylate gel-like consistency and flow differently than other types of cements.
As with zinc phosphate. they are somewhat soluble in oral fluids yet
Polycartx>xylate Zinc potycartx>xylate, glass 10nomer have good biocompatibility and cause minimal movement of fluid
down the dentinal tubules. They bond ionically with tooth structure,
Resin Acfylic, O.methacrytate. adhesive (4-METAJ
provided the surfaces are clean, and also bond to a variety of
Resin·modified alloys. Similarly, glass-ionomer cement development culminated in
HybrK!Ionomers
glass ionomers
a combination of silicate and polyacrylic acid, which led to a more
translucent and stronger material. Aluminum fluorosilicate glass and
50% aqueous solution of polyacrylic itacon ic acid are frequently
used for this material. Upon mixing, these acids react with the glass
particles and use the calcium and aluminum ions to cross-link the
polyacid molecule initially into a gel form.
Cements Glass-ionomer cements. similar to polycarboxylate compounds,
bond well to enamel. dentin, and alloys. These cements are susceptible
Cements used for luting must resist dissolution and fluids In the oral to moisture breakdown in the early phases of setting, Which can be
environment in addition to compression, shear. and tension. Ade prevented by varnish application. Postoperative sensitivity has been
quate time for manipulation should be allowed for the ingredients to reported with these materials and occurs mostly because of the
dispense because most of these cements consist of a powder and protracted low pH associated with the effects of ions leached from
liquid. The prototypes of cements used in the earliest part of the 20th the material, dehydrated dentin, and microleakage. Compressive
century included zinc oxide-eugenol, zinc phosphate. and silicate strengths of glass-ionomer cements are between 90 and 140 MPa.
glass phosphoric acid. Although used successfully, these cements Hybrid ionomer cements are essentially modified glass
were replaced by more contemporary developments In the ear1y ionomer cements with the add�ion of water-soluble polymers and
1970s. Significant research has accompanied the development of methacrylate-based monomers. The strategy behind fortification of
cements over the last several decades. Based on this research, five these cements is the ability to proceed with the acid-base reaction
basic types of cements can be classified according to their matrix along with the potential to light cure the methacrylate component.
fonning elements• (Table 16-2). A high early strength and resistance to aqueous breakdown are
Zinc phosphate and zinc silicophosphate cements have been significant advantages of these cements. As with glass-ionomer
used for many years and often are considered the gold standard cements, fluoride is released in the early phases of placement. The
in comparison to more contemporary cements. Unfortunately, addition of resin particles in the cement leads to a greater resistance
these cements have an initially high acidic quality. making them less against solubil�y in oral fluids. Although the compression strength
desirable with respect to pulpal sensitivity. is comparable, these cements have higher flexural strengths in
Phenolate-based cements such as zinc oxide-eugenol and comparison to glass-ionomer cements because of their resin
calcium hydroxide are primarily indicated for provisional cementation content. Setting expansion and absorption of water are common
of crowns and fixed partial dentures (FPDs) or liners in deep and detrimental to their use in all-ceramic restorations.
cavity preparations. Although the product of zinc oxide in eugenol Polymer cements are mostly based on methacrylate systems and
appears to form a stable compound, the cement is quite soluble in the materials most resistant to dissolution by oral ftuids. Many of
oral fluids. It has a low compressive strength (7 to 40 MPa) and a these cements are dimethacrylate (bis-GMA)-based components,
very low tensile strength. The biggest advantage of t he cement is adhesive compounds with 4-META (4·methacryloxyethyl trimellitate
its soothing and obtundent effect upon the dental pulp. Polymer anhydride) bonding capabilities, or fluid bis-GMA-based materials.
reinforced versions of the cement have been cited to be more Their chemistry is very similar t o that of the polymers presented
resistant to dissolution by oral fluids but appear to be essentially ear lier in this chapter. The main difference of these cements is the
the same. Calcium hydroxide chelate cements are also phenolate techniqlle required in bonding sequences and what they offer in
derivatives and are conglomerates of calcium hydroxide, zinc oxide, support of single-phase ceramics. Clinical guidelines for their use can
and zinc salts, along with calcium sulfate and titanium dioxide, which range from securing full-coverage restorations on short preparations
chelate similar t o the zinc oxide-eugenol reaction. These materials t o bonding veneers and ot11er all-ceramic restorations.39 Meticulous
facilitate formation of a dentin bridge when used for pulp capping. attention to detail in bonding sequences and isolation are more
Additionally, they protect the pulp by neutralizing and preventing the critical for polymer cements because their long-tenn use can be
passage of acid and act as a barrier for other irritating agents. critical to the success of the restoration they support.
240 1
Ceramics J
/<» 0 O/
0 0 0
00 0 0
0
0
0 0 Oo
0
0
0 •
Fig 16·5 (if) Porcelain·fused·to-metal fixed partial denture with porcelain buccal bull margi ns, {b) Clinical appearance of pros Fig 16·6 Schematic diagram of dispersion
thesis with optimal esthetic appearance. strengthening whereby the dispersion of
particles throughout U1e matrix discourages
miclocrack propagation.
Because of this slight difference in CTE, upon cooling, the metal

Ceramics oontracts slightly more than the porcelain pl acing it under compres
.
sion and thereby increasing its adhesion. This results in tremendous

The use of ceramics can be traced back as early as 4000 BC in resistance to propagation fracture by impact-force application. Al
Sumeria. Formulations of ceramics specific to dentistry began with though present·day modifications of porcelain and alloy systems
developments in the 1850s, and progress continued with the use of have optimized the strength of porcelain-fused-to-metal restora
porcelain jacket crowns by Land in 1907 '0 tions. the translucency of t hese materials often make the restoration
The constituents of dental porcelain include quartz, feldspar, appear less than natural. Modifications of metal-ceramic frameworks
kaolin. and vanous oxides t o simulate the colors of tooth structure. have been introduced to facilitate further light-transmission proper
Quartz forms a skeleton for the strength of dental porcelain. Feldspar t ies. Reducing the framework on the buccal aspect in exchange for
forms leucite crystals and a glassy phase noted for its translucent greater porcelain marginal material has fed to greater esthetic appeal
effects. Kaolin (4%) is a binder and helps create structure with unfired of the porcelain-fused-to-metal restoration'2 (Fig 16·5).
porcelain; it also is an inl1erent component for opacity. Alumina is The goal of achieving true light transmission through the restoration
added at a 10% volume to increase strength. Potassium oxlde is is better achieved with all-ceramic restorations. The major classes
also included at approxi mately 7% to 1 0%. Sodium oxide iS included of dental ceramics include primarily glass-based, reinforced glass
at 5% to increase the CTE. Calcium oxide (1 %) is also added to based. and polycrystalline materials."" Currently, a monolithic
increase the CTE. structure or a polycrystalline core with a glass-based veneer is the
The support of porcelain with metal initially met witll difficulty predominant variation in the use of all-ceramic restorations. The
resulting from the inherent difference between the high CTE of metal early use of feldspathic porcelain alone as a rest orative material was
and the relatively tow CTE of porcelain. This challooge was overcome fraught with problems, and reinforced porcelains were developed
through the work o f Weinstein et al, who used gold alloys as direct and became popular in the 1960s...
, Although possessing nearly
support for dental porcelain.•• The trouble ari sing from the different double the strength of conventional feldspathic porcelain, reinforced
CTEs of metal and porcelain was resolved by decreasing that of porcelain restorations required bonding to improve their resistance to
metal and increasing that of porcelain. The application of porcelain fracture. A popular method for the reinforcement of porcelain is known
to metal can be explained by tl1e various factors o f bonding involved: as dispersion strengthening (Fig 16-6). Dispersion strengthening
increases the resistance to fracture through the inclusion of ceramic
• Van der Waals force particles. These inclusions discourage microcracK propagation by
• Mechanical bonding intertering with the crack formation itself.
• Chemical or ionic bonding Many different substances have been used to accomplish this,
• Compressive f orces such as alumina and, more recently, leucite. The original formulation
resulted in an alumina-porcelain core that increased the strength
Of these, a slight disparity in the CTE between the metal and the by approximately 40%. Successive layers of porcelain included a
porcelain means that compressive forces are the most influential dentinal layer, which is approximately 15% alumina. and an enamel
factor in lhe bonding process. The opti mal difference i n the CTE layer. which iS 5% alumina. Although somewhat stronger than
between porcelain and alloy should approximate (0.5 " tQ·•;•qs
241
16 L Contemporary Dental Materials and Their Application t o Prosthodontics
Fig 16-7 (illVeneer preparation. (b) Feldspathic veneer bonded 1•Ath resin luting. Fig 16-8 (a) Maxillary and mandibular prosUJeSes composed or zirconium oxide
lramew01k veneered With gingiva- and loolh·colored porcelain. (b) Intaglio surtace of
mandibular proslhesis.
Fig 16-9 (a)Rrstgenerationofaluminum oxide

abutments wnh gold abutment screw. (b) Ra·
diograph of abutment showing altered coronal
surtace and relative radiodensity. (c) Clinical re·
suit of all-wamic reconstruction using layered
alumina for replacement of the maxillary right
central inCisor.
conventional feldspalhic porcelain. the opacity of the material made zirconium oxide cores (Fig 16-8). glazing these materials decreases
it difficult to achieve the desired esthetics. their opacity:•9
More recent formulations of porcelain have included leucite for Although somewhat laborious, the technique to create a layered
dispersion strengthening. Which significantly improved translucency. high-strength all-ceramic system significantly improved esthetics
Contemporary porcelains can be produced by thermoplastic pres and resistance to fracture without the need for bonding. Later
sing using a lost wax technique. Since this is a largely feldspathic developments in CAD/CAM allowed a more rapid production of
compound, i t can be etched and bonded to place, resulting in the core portion of the system with ceramic material that is densely
superior optical qualities with sufficient functional strength. Multiple sintered as opposed t o glass infiltrated.50 The use of alumina offers
firings allow further leucite crystal formation, increasing final strengths a core strength of approximately 600 MPa whereas that of zirconia
to 160 to 180 MPa.•• However, monolithic systems have been is approximately 1.000 MPa. The use of lithium disilicate as a core
criticized because of their high abrasion potential against enamel, material has also been a significant improvement for layered all
attributed directly to the crystalline leucite content of these systems. ceramic restorations. Although not as fracture resistant as other
Bonding these materials results in significant improvement of their high-strength ceramics, these single-unit restorations have a high
long-term success through thermal cycling, hydrolytic degradation, survival rate When properly used, according to a 5-year study.$! When
and cyclic fatigue.·10Adhesion or monolithic and other ceramic systems the core material is used as a monolithic material, it demonstrates a
is largely due to silanation, craCk bridging,47 and micromechanical comparable high survival rate.
texturing techniques. Adhesion is accomplished through etching W�h the use of alum inum oxide in all-ceramic restorations,
and bonding of bis-GMA resin-based systems to calcified tissues it was realized that this material may be uniquely suited as an
(Fig 16-7). Glass-based restorations should be bonded but are esthetic alternative for abutment material in osseointegrated implant
less sensitive t o the effects of dislodgement. Attempts to use glass restorations.�·53 The first generation of aluminum oxide abutments
ionomers with these restorations have resulted in delayed expansion was supplied in a prefabricated form that had to be prepared and
and subsequent restorative failure. It is postulated that imbibition of customized for each case (Fig 16-g), The potential for microcracks
water by the glass-ionomer matr x potentiates this mode of failure. and overreduction was soon evident and sparked interest in a
i
Layered ceramics are considered an improvement in potential prepared, prefabricated form or one produced by CAM.
strength compared to the limitations of monolithic systems. Sadoun Technical ceramics such as alumina or zirconia are often
experienced a significant breakthrough in layered ceramic systems produced b y a sintering process. This involves condensation of
in 1988.'8 His technique used what is known a s slip casting to allow the ceramic particles into a specific prefabricated shape bound
a sintered ceramic to be infiltrated by glass. With the exception of together by an alcohol. The mass is then allowed to harden and
242 1
Metal Alloys J
desicca te produci ng a green-state object well su i ted for m achining

.
without producing cracks or other defects. The machining process

typically produces a mechanical equivalent that is slightl y oversized
to accommodate for sintering shrinkage. The object is then sintered
at very high temperatures to produce a dense ceramic material;
for zirconia, this is 13so•c. One advantage of CAM of presintered
green-state material is that it allows production o f custom abutments
that are virtually free of defects.
Aluminum oxide and titanium have been shown to have hemi
desmosomal attachment in animal studies, indicating a possible
clinical benefit."' With the Introduction or zirconium dioxide, or
Strain
zirconia (Zr02), the use of alu mi na and high-stress applications of
abutments declined. Zirconia is a promising material in all-ceramic
restorations and can exist in three forms: cubic, tetragonal. or Fig 16·1o Slress-strain curve for behavior of metal.
monoclinic. The ability of zirconia to resist fracture is dependent

upon its crystalline phase: The monoclinic form is the weakest of the centered cubic crystal. Titanium assumes more of the hexagonal
three; the resistance of tetragonal zirconia is considerable, but it has close-packed array, in which the atoms are equidistant from each
a tendency to revert to the monoclinic form at room temperature. other in a horizontal plane but not in the vertical plane.
T o help retai n its tetragonal structure. yttrium can be added to the Generally, metals that have high dens i ties are associated with
ceramic. close-proximity a1-rangement o f the atomic centers Within the
Although many forms of zirconia exist. yttrium-stabilized tetragonal crystal. Other prop ert i es such as reflectance or visible light stem
zirconia polycrystal (YTZP) currently is the preferred material for from the ability of the outer electrons to absorb and retransmit lght.
i
abutments in high-stress situations where strength is needed and The mobility of the outer or val ence electrons also contributes to
for placement in the esthetiC zone as a foundation for multiunit all· their electroconductivity and thermal condliCtivity. Because many
ceramic restorations. Another property unique to YTZP is that of metals have a relative freedom of the valence electrons. the energy
phase transfor mation , where crack propagation initiates formation required for the electrons to release may be relatively high or low,
o f \he monoclinic form in an attempt to discourage fracture. This which translates to a high or low corrosi on resistance. respectively.
somewhat unique feature of the monoclinic form causes it to expand The number or valence electrons also contributes to and influences
by approx imately 4o/o adjacent t o a crack, making this material the melting point or the alloy. For instance, an increased number of
questionable for clinical application. valence electrons makes the covalent bonding more difficult to break
The use of YrZP i n multiunit posterior restorations has been and requires greater heat energy. This is characteristic ot metals that
reviewed with scruti ny and has shown significant problems with ionize to 2 or 3 (eg, Ni2-, Cu�·. Fe3•).
chipping and delamination on tooth-supported abutments......, These Physical properties or metals are often dependent upon the
issues occur predominantly over pont ic-abutment connections, orientation they assume within a gi ven structure ot alloy. Stress·
where even heat distribution during ceramic tiring becomes difficult to strain curves are commonly used to plot the properties of metals (Fig
achieve. Because this material is quite insulative, porcelain lamination 16-t 0). The amount or stress applied to a metal is usually measured
is unpredictable. Future efforts are to be focused on improving the either in MPa or pounds per square inch (psij on the y axis. The x-axis
-
bond between veneering porcelain and zirconi um oxide. of this graph represents strain, a dimensionless factor. indicated by
a percent change or difference. The first departure from the slope

of t11e initial stress applicati on is conside red the proportional limit
or point A The proportional limit signifies the greatest stress that a
Metal Alloys material will sustain without a deviation from the proportionality of
stress to strain. The second point, B. is considered the yield strength
Alloys play a nu mber of important roles in dentistry, whether they and is defined as the stress at which the material exhibits a specified
are used in instruments to prepare teeth or manipulate soft tissues. limiting deviati on from proportionality of stress to strain. The accepted
restorations to replace missing tooth structure, or dental laboratory amount of p ermanent deformation that materials undergo is usually
applications. At least two-thirds of the periodic table of the elements 0.2%, often called 0.2% offs et. Poi nt C, or ultimate tensile strength,
are metals that can occur in pure form. combined with each other, or is defined as the maximum wess that a material can withstand
as an oxide. Pure metals exist in a crystalline form and occupy posi· before failure in tension. This property is especially useful because i t
tions that are characteri sti c based on their atomic configurati ons . indicates the point of failure when a material is placed into intraoral
Of the many crystalli ne forms, \he t hree most common are body· function. Fracture strength, or point D, identifies the stress point at
centered cubic, face-centered cubic, and hexagonal close-packed which the material may not necessarily fracture but may elongate
cell. Most alloys of cobalt, nickel. gold, and palladium form the face- excessively.
243
From a molten state, metals cool into clusters of atoms. which Nobility indicates the resistance to corrosion and relative inertness
coalesce to form nuclei. These nuclei remain stable and coalesce in the oral environment, whicl1 i s an important consideratiOn when
to form a grain structure. Although CryStals are rarely found within selecting an alloy. Hardness value may be of Interest when wear
metals used in dentistry. they are randomly oriented within the grain against antagonist materials is a concern. The yield strength deter
structure. The size of the grains may dictate ceJtain properties. mines a material's resistance and capacity for load bearing. which
including yield strength, ductility, and ultimately, plastic deformation. is particularly important for fixed partial dentures in any form. The
Smaller-grain structures may have a beneficial effect on cast alloys elongation is indicative of how partial or full-coverage restorations
because they generally raise the yield stress. Increase the ductility. may be burnished: it is also somewhat indicative of the ability to
and raise the ultimate tensile strength. Certain alloys such as bend or readapt wire clasps. For instance, elongation factors greater
ruthenium, iridium. and rhodium melt at a temperature markedly than 6% are needed for proper adaptation of wrought-wire clasps
higher than that of traditional dental alloys. Addition of U1ese metals used for removable partial dentures.58 Fusion temperature of the
allows them to act as centers of nucleation and create fine-grained alloy should be significantly greater than the fusion temperature of
structures, which ere more resistant to applied forces. These fine porcelain to avoid sag during firing cycles.
grained metals strengthen the alloy by resisting dislocation of the Noble metals have been particularly useful for restorations used in
atoms through a mechanism whereby alloy atoms slide over each the oral cavity because they (1) are resistant to corrosion. (2) have a
other. Processes tl1at resist dislocation movement tend to harden a high degree of wear compatibility when opposing natural dentition,
metal, increase its yield strength, and decrease its ductility. (3) can be made resistant to deformatiOn when combined with
One method for hardening metal is known as work hardening other metals. (4) can have a high degree of elongation. if necessary,
or cold working, which includes changing metal configuration by and (5) are relatively easy to cast and finish with the simplest of
hammering, pulling, cold rolling. or bending. These processes create technology and equipment. They have been successfully used
many dislocations and p revent the metal from deforming further for many years but have a high cost. which has limited their use
because the crystal is more distorted and will not allow further recently. Palladium combined with copper and silver has been a very
dislocations to form. Another process for hardening metals includes popular alloy, particularly for porcelain-fused-to-metal applications.
precipitation hardening, whereby a finely dispersed cluster of atoms Palladium-copper-gallium also has been a desirable alloy because it
is precipitated from a quench-cooled solid solution. In addition, a has a yield strength considerably higher than most other noble alloys
heat treatment often used to increase resistance of gold alloys can (900 MPa). Silver is especially beneficial because it increases the
be used to harden metals. In this method. copper and gold atoms CTE of palladium to a desirable level for porcelains that have higher
are reheated and tend to separate on alternate planes of the crystal CTEs. However, it has been noted occasionally that ion exchange
lattice in an ordered pattern. With this organization, the metal tends between the porcelain and sHver in the alloy has resulted in greenish
to be more resistant to dislocation. increaSing its yield stress. Heat discoloration of the porcelain.59 Colloidal coating gold agents can
treatment also tends to increase the alloy's corrosion resistance by be used on the surface of the alloy to stop diffusion of corrosion
allowing the atoms to reach a galvanic equilibrium, which often products. but they interfere with the surface oxidation necessary
occurs when an alloy such as palladium-copper-gallium is rapidly for the porcelain bond. Although a good alternative to gold alloys,
cooled and a galvanic cell is created between the center of a grain palladium-Silver alloy has fallen out of favor.
and grain boundary.'' Base metal alloy development was predicated on the costly nature
Noble metals include alloys consisting o f gold. palladium. platinum. of noble and high noble alloys. The most desirable properties include
silver, and other metals used in minor proportions. The composition ot high yield stress. high elastic modulus. and high surface hardness.
these alloys alone makes them resistant to corrosion and interaction Burnishability of the metal is less than desirable because these
with acids. fn combination with copper and other alloys. noble metals alloys are commonly used for high casting accuracy and extended
can be made resistant to deformatiOn in varying proportions. fixed partial denture design. Tl1ese alloys reproduce marginal and
It is not within t11e scope of this chapter to give specific indications. surface features in sharp detail, making their use in cross-sectional
but a basic list of material propeJties and points o f comparison to connections highly desirable. Unfortunately. base metal alloys
look tor when selecting an alloy includes the o
f llowing: display co nSide rably more contraction shrinkage (2.7%) compared
to noble alloys (1.25% to 1.7%), which necessitates compensation
• Noble metal content: the percentage of eight noble metals typi during casting and fabrication techniques. Nickel-chromium alloys
cally used in dental alloys ere the most extensively used products in this category: their
• Hardness: usually indicated by VHN (Vickers hardness number). casting ability and porcelain application are comparable to many
which measures the resistance to indentation other conventional alloys. Although titanium i s often classified under
• Yield strength: a measure of the stress needed to plastically base metals, it is highly bi ocompalible and is occasionally used for
deform an alloy removable partial dentures, implant abutments, implants, and other
• Bongation: the percentage of permanent deformation a metal prosthetic restorative components.
undergoes when brought to its fracture point
• Fusion temperature: the temperature achieved when an alloy
separates under its own weight from melting
244 1
Metal A lloys J
[IFiexu�al strength of various titanium convert titanium to a beta form. The pure-beta fom1ation usually de
Table 16•3 !a
lloys composes into the alpha-beta fom1 and creates a relatively stable
Yield strength' Tensile strength' compound. The alpha-beta alloy of Ti-6AI-4V (6% aluminum and 4%
Material
(MPa) (MPa) vanadium) often is increased in strength by solution treatm ent.
Titanium, as i t is often referred to. consists of either 99% pure
cpTIGrade1 172 241
titanium (known also as commercially pure titanium (cpTi). available
cpTIGrade2 276 345
in four grades) or alloys of titanium chosen lor their resistance to
cpTi Grade 3 379 448 deformation (Table 16-3). The most common titanium alloy used in
cpTi Grade 4 483 552 dentistry is titanium-aluminum-vanadium. which i s also used in the
897 aerospace industry and has been shown to be highly resilient, tough,
Ti·6AI·4V 828
and resistant t o permanent deformation. Ti-6AI-4V alloy is especially
American Society lorTestb>g and Mate<ials (ASTM International StaJldards)
preferred for the production of implant restorative components.
•
r The stress at which the material is changed i'l shape to perrnatl&nt induced strail.
• Tile maxim<1m st<esslllat a mate<ial can whhstancl befo<e raillJI'e in tension. Trace elements of carbon. oxygen. nitrogen. and iron are found in
cpTi in varying proportions and allow increased yield strength. The
unique ability of titanium to create passivation (the ability to rorm a
surface oxide and therefore resist corrosion) makes it suitable for
the oral environment and biocompatible with many different tissues.
The kinetics of cells play an important role when titanium is a
substrate for osse ointegration. A cascade of events follows lm·
plantation of titanium into bone as its surface promotes cellular
Cobalt-chrome alloys adhesion by deposition of protein and other cell mediators unique
to titanium.(!<) Titanium in the wrought 10011 is often 25% stronger
Cobalt-chrome alloys are mainly comprised of approximately 60o/o than the commercially available machined fom1. The use of cpTi for
cobalt and 30% chromium. The addition of chromium creates a re casting in the dental laboratory is quite problematic because of its
sistance to corrosion of the metal and adds, along with other minor propensity to develop an oxide on the surface. Titanium casting is
elements, a signilicant degree of stiffness. The stiffness or cast base done in an inert or argon environment to allow defect-free surface
metal alloys is almost twice that of gold alloys and is especially appli formation. Even with specialized casting equipment. this can still be
cable in fabrication of removable and fixed partial dentures. The high problematic; therefore, the use or titanium and casting procedures
stiffness allows these alloys to resist heat treatment and to be used is not common.••
in a very thin configuration witl1out compromised structural integrity.
However, adjustments to the cast clasp assemblies for removable
partial dentures can be difficult because of the low elongation inher Alloy allergies
ent w�h these alloys. In areas of high stress or where considerable
support is afforded by soft tissues. a combination clasp made of a The allergenic potential of alloys has come under scru tiny in recent
more flexible material (wrought platinum-gold·palladium wire) should years because it is well recognized that nickel is a common aller
be used instead. Chromium alloys can be significantly corroded by gen."' Nickel is identii
f ed as a culprit of contact dem1atitis in as many
cleaning procedures using over-the-counter hypochlorite, so an al· as t 2% to 38% of cases.�5 Because of its hardness and desirable
ternative cleansing method using liquid-based hand soap or effer properties. it is often used in jewelry for earrin gs and in other skin·
vescent tablets should be used. piercing ornaments. Cross-reactivity of nickel with other metals such
as copper. palladium. and cobalt appears to beT-cell mediated and
resembles similar immunochemical mechanisms."" Some lichenoid
Titanium alloys lesions occurring in the oral cavity appear to be associated with
metals tl1at predispose hosts to immune reactions."'·€8 Titanium and
Titanium may assume one of three microscopic forms: a. a·fl, or j3. titanium alloys have also been occasionally identified as potential al·
Certain elements will predispose titanium to form one of these micro lergens. The incidence of this is less than 0.6% but may be a poten·
structures. Addilions of aluminum or oxygen transform titanium into tial cause or disintegration. persistent peri-imptantitis. or unexplained
an alpha phase. which makes the metal stable at a higher tempera peri-implant bone loss.'"' Although dermal-patch testing is the most
ture. Alpha titanium cannot be llardened by heat treatment but can common and most predictable method to evaluate patients with
be annealed or softened by cold working. Alpha titanium can also be suspected metal hypersensitivity. other methods sucll as MELISA
welded because it does not respond to heat treatment. Alpha-beta (memory lymphocyte immunostimulation assay) can be used as a
alloys can be strengthened by heat treatment. which i s usually fol screening device.7° Certain alloys such as nickel and beryllium have
lowed by quenching in water, oil, or other solutions. Other elements also been implicated in carcinogenesis when in the context of oc
such as vanadium. molybdenum. chromium. and copper affect and cupational exposure.11•73
245
16 L Contemporary Dental Materials and Their Application t o Prosthodontics
Fig 16·11 (a) Scanning of acrylic reSin pattern for creatioo of

lhree-dimenSiOOal file. (b) CNC-mllled titanium framev.'Oik. (c)
Radiographic assesm s ent of trial fiillg
tt wilh Sheffield test.
Fig 16·12 Osseolntegrated tooth replacement uSing copy mill ing techniQue. (a) Preol)erative patient presentatloo with periOOOiltally hopeless teelh. (b) Occlusal view of cast aher
removal of teeth and replacement wllh fiVe osseointegrated implants and zircolliu m oxi(le abutments. (C) Clinical appointment to verffy position of abutment margins and centric jaw
registratioo. d)( Light-curing composite resin frame indexed in the device readied for computer-assisted copy milling ol presintered zirconia. (e)Sintered lramev.oorl<s juxtaposed with
the matrix lor porcelain lamination. (f) Occlusal viev1 of finished restoratioos. (g}Apjl€arance after cementatioo of restorations with simulated porcelain gingiva. (111Anal esthetic resull
relatiVe to lip line.
Computer Numeric Controlled instrumentation change. A numb er of these operations can be com
pleted in an around-the-clock sequence and therefore can create a
Machining number of prostheses in a very short period of time.

CNC mi lling isespecially useful when a hOmogenous material is used
CNC machining is a relatively new technique for manufacturing cus for a portion o f a restoration. For example, a metallic framework used
tom dental restorations. However, it has been used for many years fo r an implant restoration can be made in a single phase, bypassing the
in the fabrication of machined parts with prefabricated specifications. fitting difficuhies associated with casting. In comparison to traditional
Most of these machines are computer-controlled vertical milling de casting methods this method resuHs in a significantly improved fit,
.
vices that have the ability to move vertically along the z-axis. This extra potentially reducing mechanical complications"" (Rg 16-11). Other
degree of freedom penni\s additional applications such as creation applications uniquelysuited t o r this process include milling high-strength
of relief sculptures. The most advanced CNC milling machine, the ceramics in a slightly oversized fashion in the presintered state to create
five-axis machine, adds two axes to the three normal axes (x-axis. accurate single-tooth restoration copings. In this way, the matea
ri l is
y-axis, z-axis). The fourth axis ofho rizontal milling machines is a c-axis accurately fitted by a computer-machined process and results in a
or q-axis that al lows the mount ed workpiece to be rotated to permit more homogenous state. A three-dimensional file can be created by
asymmetric and eccentric turning. The fifth axis (b·axis) controls the traditional production of a resin pattern. followed by touch or optical
tilt o f the tool itself. When all these axes are used in synergy, extremely scanning to acquire the th ree-dimensional information. which is then
complicated geometries, even those associated with human anatomy, stored in a specific fom1at. Alternatively, this information can b ecreated
can b e made with relative ease. Because of th e complexity in pro by custom and preset parameters in specific software. Current ly, three
gram ming such geometries. live-axis mill ing machines are almost al· dimensional infonnation is programmed into binary code for m il ling.
ways program med with CAM. One major advantage to using CNC i s Other m ethods that perform touch scanning simultaneously with the
that operator intervention is efiminated, allowing the code to program milling process are known as copy milffng techniques. These also can
the operation through various drilling sequences and stop only for a n be faci6\a\ed by CAM (Fig 16-12).
2461
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layer of resin 1\Jting agent on the biaxial flexure strength of lwo all-ceramic 63. Shaikh WA. Sha'l<h sw. AJiecgies in India: An analysis of 3389 patients
systems. J Proslhel Dent 2005:93:459-466. allendlng an allergy Clinic in Mumba•. lncia. J lnCiian Med Assoc 2008:
47. Rosenstiel SF Gupta PK, Van de< Sl\.lys RA. Zimmennan MH. Strength of a
. 106:220.
dental glass-ceramic aHer surface coating. Dem Mate r 1993;9:274-279. 64. Pratt MD, Belsi to DV. Deleo VA, et al. North Ame<ican Contact Oermati·
48. TyszbtaH>adoun M Prwentor]. A neo"' a'! C l)(amic system. French paten! IJS Group patch-teSt results. 2001-2002 study period. Dermatitis 2004:15:
4,772,436. 2 0 Sep t988. 176-183.
<�9. Heffernan MJ, Aquilino SA. Diaz-Arnold AM. Haselton DR. Stanlord CM. Var 65. Akhtar N, Rashid MM. 01owdhul)' AO. All E, Chowdhury AM. Patch test for
gas MA. Relative tra�cency of six all-ce<amic systems. Part II: Core and the detection of contact allergens. Mymensingh Med J 2004;13:181-184.
veneer materials. J Prosthel Dent 2002:88:10-IS. 66. WoM S. Hemmer W. Focke M. Gotz M. Jarlsch R. Copper allergy revisited. J
50. Andersson M, Oden A A new all-ceramic crown. A dense-sintered, high-purity Am Acad Oermatol 2001:45:863-870.
alumina coping \Mth porcelai n. Acta Odontol Scand 1993;51 :5�4. 67. Drtnchova D, Kapralova S. Tochy M, et al. Oral l ichenoi d lesions and allergy to
51. Marquardt P. Strub JR. Survival rates of IPS empress 2 an-ceramic crowns and dental materials. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub
fixed partial dentures: Resuhs of a 5-year prospective clinical study. Quintes 2007; 15t:333-339.
sence lnt 2006;37: 253-259. 68. Mizoguchi S. Setoyama M, Kanzal<i T. Linear lichen planus in the region of the
52. lngbec A. Prestipino v. New ted1nology. 2. High-strength ceramic abutment· mandibiJia r neNe caused bY an allergy to patiad lltm i1 dental metals. Derma
provides eslhetie. fl•n ctiOnal alll)(native. Dent tmptanrot Update 1991:2:82-83. tOlogy 1998:196:268-270.
53. tngbe< A, PreStipino V. H•gh·strength ceramic aootment provides esthetic, 69. Sicilia A. Cuesta s. Coma G. et al. ntanrum allergy in dental mptant pa
fvnctior1at alternative.Oent lmplantol Update 1991:2:70-72. lieots : A cHnical study on 1500 consecutive patients. Cin Oral Implants Res
54. Abrahamsson I, Berglundh T. Glantz PO. Lindhe J. The mucosal attachment 2008:19:823-835.
at diffecent abutments. An experimental study In dogs. J Cfin Peciodontol 70. Valentine·Thon E, Mulle< K. Guzzi G. Kreisel S. Ohnsorge P. Sandkamp M.
1998;25:721-727. LTT-MELISA is clinically rel evatlt for detecting and mon�oring metal sensitivity.
55. Sa;ier I, Feher A, Filser F. Gaucl<ler U. Luthy H, Hammerle CH. Five-year cflni Neuro End ocri nol Lett 2000:27(suppl1): 17-24.
cal restjts of z•rconl8 frameworl<s for posterior fixed partial dentures. lnt J 7 1 . lu H. Shl X. Costa M. Huang C. GarcinogMic effect of nickel compounds. Mol
Prosthodont 2007;20:383-388. Cell Biochem 2005;279:45-67.
56. Raigrodski AJ. Chiche GJ. Polil<et N. et al. The efficacy of postenor three-unit 72. Kasprzak KS, Sundecman FIN Jr. Salnlkow K. Nfcl<el carcinogenesis. Mutat
zirconium-oxide-based ceramic fixed partial dental prostheses: A prospective Res 2003:533:67-97.
clinical pilot study. J Prosthet Dent 2006:96:237-244. 73. Snow ET. Metal catcinogenesis: Mecharistic implicabons. Pharmacal Thee
57. U D. Brantley WA, Mitchell JC. Daehn GS. Monaghan P, Papazoglou E. Fa 1992:53:31-65.
tigue studies of high-palladium de.1tal casting alloys: Pall 1. Fatigue limits and 74. OrtO<p A. Jfll11t T. Chn<:a l experiMces or computer numeriC oontrot-mnled
fracture Characteristics. J Mater Sci Mate< Med 2002:13:36 t -367. titanium trameworl<s supported by implants in the edentli!Ous jaw: A 5-year
58. Carr A, Brown 0, McGivney G. McCracken's Removable Partial Prosthodon prospective study. Clin Implant DMt Relat Res 2004;6:199-209.
tics. St Louis: MOSbY. 2005. 75. Ortorp A. Jemt T. BacK T. Jalevik T. Comparisons ol preciSi0<1 of fil betwaef1
59. Blanco-Dalmau L Preventing green <liScoloration of porcelain bal<ed over cast and CNC-miRed titanium implant tramewO<l<s lor the edentulous man
silve<·palladium alloys. J Proslhet Dent 1983:50:865. dible. tnt J Prosthodont 2003;16:194-200.
2481
Chapter
Diagnosis and Management

of Inadequate Denture
Prostheses
Steven E. Eckert, DDS. Ms
lthough patients may offer a variety of reasons for seeking relevant to their concerns. uaimately, careful and specific questions
A tooth replacement with dental prostheses, these descriptions

generally fall into a few concise categories. Actual or per
ceived shortcomings assoctated with comfort, function, or esthetics
will identi fy problems within the broad categories of comfort, func
tion, and estheti.s. The clinician should determine the ti meline of the
r
patient's complaints and the magnitude of the concerns.

may prompt patients to request replacement prostheses. If a patient identifies problems that occur only during eating, this
Once teeth have been replaced. experience suggests that the suggests different concerns than those of patients who describe
majority of p atient s express satisfaction with dental prostheses. problems that arise during smiling, laughing, or yawning. Whereas
However, satisfaction may diminish over time, and patients may seek the former suggests occlusion as a proble m , the latter occur during
repair or replacement of their prostheses. Complaints may be rel ated extreme move ments , which can identify problems with border
to (1) def c i cies in the existing prostheses . (2) chang es in the
i en extension or adaptation of the denture to the under lying tissue.
underlying anatomical structures that have caused t he prostheses Once the nature of the problem is understood. a c linical evaluation
to act as a cofactor in futther deterioration of the tissues. or (3) must be made. Although n is tempting t o focus immediately on the
unrealislic patient expectations for adequate prostheses. factors that were identified in t he patient interview, the clinician is
Inadequacies in prostheses may be linked to poor fft. improper cautioned not to overlook other factors that could be revealed wi1h a
prosthetic design discrepancies in occlusion, or lack of adaptati on
, carefu l examination. This examination needs to include inspection of
to the underlying tissues. This chapter reviews the diagno st ic factors the existing prostheses. anatomical assessment, and evaluation of
that contribute to these causes of denture inadequacy. i ities of the patient.
physiologic actv
Clinical evaluation of dentures and supporting

Ill-Fitting Dentures
structures
Patient comments must be considered carefully when there is a com
plaint about a new denture. The clinician should question the patient Dental prostheses exhibit three distinc t surfaces that all contribute
directly to obtain loiS or 11er opinion of the experienced pro blems. to the perfom�ance of the denture: (1) intaglio, (2) occlusal, and (3)
Patients often provide lengthy and rambling descriptions of prob polished surfaces. Considering the amount of time spent making
lems, but it is important to keep them focused on the issues that are denture impressions, the clinician may assume that the intaglio or
249
�7 i Diagnosis and Managemen t of Inadeq uate De ntu re Pros t hes es
Fig 17·1 Pressure indicator paste reveals appl ied pres·

-
sure to primary stress·bealing areas of maxntary complete
denture tissue surfaces.
tissue surface of the denture is the most critical surface affecting force to the lingual aspect of the anterior teeth determines retention
denture success. However. the occl u sal surface of the denture and in the poster i or lingual aspects of the denture. and application of a
the ass ociated occlusal scheme are essential to the performance of superiorl y directed force in the anterior region assists in determination
the prosthesis during masticatory function. and the contours of the of retention by the sublingual border.
polished surfaces provide crucial stability for the denture. Low-fusing wax or modeling compound may be applied on a trial
The character of the soft and hard tissues also contributes basis to suspected areas of underextension. If material additions
to t he retention and stability of the denture. Movable soft tissue demonstrate enhancement of de nture retention, this indicates that
provides limited support when compared with fir m tissue. However, improvements can be made .
nonresilient soft tissue may diminish the retention of the denture.
Inadequate residual ridge height cou ld affect denture stability.
To evaluate the evenness of support, disclosing material is applied
Adverse tissue responses to recently made
to the intaglio surface of the exi sting denture. The denture then may
dentures
be seated with firm finger pressure over the posterior teeth. Once
the dentures are removed. the patte rn of pressure·indicator pas te
should reveal firm contact In the primary supporting areas of the The response of soft tissues to denture use can be varied. Careful
residual ridges, the hard palate in the maxillary denture, and the assessment may lead to i dentifi cation of the s ource of irri tati on.
buccal shelf and ridge crests of the mandibular denture (Fig 17 1 ). · Ulcerations in the vestibular area are usually caused by
It is important t o avoid occlusal force during this analysis because overextension of the denture tfange. The l oca tion of the ulcerated
occlusal contact of the denture could induce adverse forces tissue can be identified with a marking pencil and transferred to the
secondary to discrepancies in the occlusion, leading to erroneous denture. The ink transfers from the mucosa t o the dentu re allowing ,
conclusions regarding the supporting structures. Further evaluation the pressure poi nt on the denture to be relieved. Resolution of
of s upport can be acco mplis hed by applying pressure to the ulceratiOn should occur quickly.
dentures alternately on the right and left poste ior occlusal surfaces.
r Localized inflammatiOn may be cau sed by pressure from the
The denture should not exhibit appreciable movement if the support denture base on the soft tissue, usually as a result of errors in
is adequate. Resil ient tissue will cause the denture to move when the impression technique. This may be identified with disclosing
this pressure is applied. paste. Inflammation limited specifically to the residual ri dge crest
The stabil ity of the denture is evaluated by grasping the denture may indicate occlusal prematurity, excessive vertical dimension,
and attempting to rotate or displace it laterally. The amount of or bruxism. Generalized inflammation in previously healthy tissue
movement must be considered relative to the shape and character is uncommon with re cently made dentures. Should it occur, the
of the underlying structures. Highly movable tissue could also clinician may consider the possibility or dental·material allergies,
contribute to a lack of stability. i nadequ ate denture processing resulting in residual free monomer.
Application of force to the anterior lingual aspeci of maxillary or ill health or severe nutritional deficiencies in the patient.
denture teeth assists in evaluating the efficien cy of the posterior Patients may state that the dentures c ontact more firmly on one
palatal sea t . Similarly, application of force in a buccal direction to the side than the other and that the retention of the denture diminishes
lingual aspect o f the posterior teeth demonstrates the effectiveness as the day progresses. If the pati en t has a tendency toward bruxism
of the border seat. In the mandibular arch, appl ication of anterior or clenching. minor inaccu racies in the occlusiOn could cause this
250 1
Ill-Fitting Dentures J
reduced retention. If an occlusal discrepancy is severe, the patient 24 hours per day Should be educated regarding the adverse effects
will likely complain of diminished retention during chew ing. of this denture-use pattern. Treatment o f papillary hyperplasia may
Petechial hemorrhage coveri ng a relatively large area may involve tissue massage by finger pressure or with a soft toothbrush.
d emonstrate gross tissue displac e ment during the impression The judicious use of tissue conditioning material in dentures can
-
taking procedures. This i s usually associated with general instability be beneficial, but these materials must be replaced frequently to
of the denture. ensure that they maintain positive stimulation of the tissue. Failure
of the lesion to demonstrate resolution after implementation of
the aforementioned treatments may indiCate the need tor further
investigation. If microscopic assessment and culturing for Candida
Adverse tissue responses to dentures used for
albicans demonstrate the presence or this fungu s appropriate
.
more than 1 year prescriptions for antifungal medication should be provided. Surgical
resection of papillary hyperplasia is rarely indicated because
Lack of retention elimination of Inflammation is the primary treatment goal and,

even if resection is accomplished, spontaneous recurrence is not
The patient generally experiences a gradual loss of retention over uncommon.
the first few months after placement of new dentures. but this is Chronic overextension of the denture borders could result in
usually followed by an indefinite period of adequate retention. Most ulceration and subsequent healing with scarring. This condition
patients are able t o remove dentures with minimal effort as they learn is unlikely to be reversible and ultimately may interfere with
to intentionally break the border seal. Patients also learn to manage establishment of an adequate border seal because the scar tissue
denture function as their muscular coordination and physiologic ad lacks elasti city.
aptation to the dentures improve over lime. When patients cannot The supporting tissues can become distorted from overuse of
adapt to a well-made denture. it is unlike ly that relines. rebases, or dentures. Lytle described the need for daily denture removal to allow
treatment to address the tissue surface of the denture will provide tissue rebound.2 The removal of dentures also is critical before new
long-lasting improvement. denture impressions can be made. Although it is unclear whether
ill fitting dentures cause resorption of suppor ting bone, i t may be
-
assumed that resorption accelerates as bone responds to stress

Other adverse tissue responses
and inftammati on.3 In addition. bone is responsive to a number of
Localized tissue responses such as inflammation are likely to be systemic factors that further contribute to the reso ption process.
r
attributed t o the same concerns of border overextension and pre The local environment can contribute to bone loss, especially when
mature occlusion described previously. Generalized inflammatory remainin g mandibular anterior teeth oppose a maxillary denture
response could be the result of a gross lack of adaptation of the and cause excessive force on the anterior maxilla, producing
denture. poor occlus on bacterial or fungal infections. generalized
i . secondary resorption in that area. When the loss ot posterior
debilitation resulting from disease processes , or severe nutritional occlusion is associated with downgrowth of the tuberosity, fibrous
defi ciencies. hyperplasia of the anterior maxilla, papillary hyperp lasia, extrusion
Hyperkeratosis is a reaction to external inritation. When hyper of the mandibular anterior teeth, and the use of a mandibular distal
keratosis is observed, the source of irritation should be eliminated extension removable partial denture base, the t erm combination
and the affected tissue observed to ensure that the lesion resolVes. syndrome is often applied. •
Lack of resolution following appropriate adjustment and an adequate
healing time indicates the need for tissue biopsy.
Hyperplastic tissue responses, such a s the development o f epulis Occlusal considerations
fissurata at the depth of the vestibule. are generally associated with
overextension of the denture border. Correction of the overextended Occlusal force causes a denture to intrude into the supporting tis
border may result in spontaneous remission, but these lesions sues.5 This phenomenon i s simply the result of tissue res ilience. Dur
sometimes require stimulation through finger massage or excision if ing the denture fabrication process, maxillomandibular registrations
resolution does not occur. may be established using forces that mimic occlusal force or minimal
Inflammatory papillary hyperplasia may be observed in the palate of stress. Advocates of the use of minimal stress during the recordi ng
d e nture wearers.' Identification of papillary hyperplasia often requires o f maxillomandibular relationships suggest that this is the only realis
application of a stream of air to the palate to separate the matted tic way to achieve a repeatable recording. In addition, occlusal rela·
papillae. The eti ology of this lesion is unclear. It is not uncommon tionships established using heavy force d uring prosthesis fabrication
to observe papillary hyperplasia in patients who exhibit prolonged subsequently can be evaluated only with application of excessive
wear of ill-fitting dentures. Patients should be questioned regarding forces. This procedure could cause the denture to move on the un
patterns of denture use, and those who describe wearing dentures derly ing tissue, causing further deterioration of the underlying bone.
251
� 7iDiagnosis and Management of Inadequate Denture Prostheses
Over
COrrect -1--"m\ Under
extension -f-7/:iff-Jh extension
extension -1-..;;;;,•!N/.
a c
Fig 17-2 (a) Cross seclioo of prope�y exfclldcd fi.1Jlge, which fills the vestibule but does not have a labial flare. {b)Overextended flange 1•rith labial or buccal flare.The border should
terminate where the nare begins. (c) Underextended flanges are usually sharper or, if of proper thickness, lack tissue detail. The vestibule is not filled by the llafl9e When the lip is at
rest. resu lting in decreased retention. (1\dapted from Laney and Gibiliseo" with permission.)
and presence or absence of connective tissue rugae. If these issues

Inadequate Denture Design can be addressed without compromising the design principles for
denture fabrication, accommodation in the design is indicated. Con
Experienced clinicians understand that a number of different design versely. if the changes create dentures that are outside the normal
features can be compatible wit11 prosthetic success in some pa parameters of denture fabrication. they should not be made. The
tients. Some factors represent philosophic differences in design of main concerns of the patient should be identii
f ed before treatment
the prosthesis while others are clearly inadequate features to which is initiated, when the clinician can explain the limitations of potential
the patients have adapted. These features may include (1) overex accommodations rather than waiting for the final stages of treatment
tended or underextended flanges, (2) dentures with anatomical or to make excuses for an inability to meet the patient's demands.
nonanatomical teeth, (3) dentures without full occlusal balance. and
(4) dentures without relief. Although patients may be able to use Inadequate preparation
dentures that fail to comp ly with appropriate design principles. this
does not suggest that design is irrelevant; instead, this is testimony Failure of the denture to cover the retromolar pad usually indicates
to the adaptability of patients to prostheses. As described earlier, an insufficient maxillornandibular space caused by lack of attention
many inadequacies can and do lead to adverse tissue responses. to excessively large maxillary tuberosities. Similarly. underextension
Conversely, some patients experience a lack of success with well of the denture Hanges could occur when extensive or deep under
designed and well-fabricated dentures. This i s genera.lly observed cuts are not addressed in the initial preparatory phases.
in those who do not learn to manage the dentures. Contact of the
buccal mucosa and tongue against the polished surfaces of the
denture i s important to achieve stability and retention of the dentures. Denture extension
To a great extent, denture management is a learned behavior that
can be affected by a number of psychosocial and physiologic factors The clinician should be familiar with the appearance of a property
of the patient. A patient's age, emotional state, motivation to wear extended denture. Whereas overextended dentures tend t o be Hared
dentures. physical condition, tissue resilience, and the amount of in a reverse fashion o n the labial or buccal su1iaces. underextended
residual ridge all can affect the ability to succeed with dentures. dentures may exhibit sharp areas at the borders (Rg 17-2). Appro
Although appropriate denture design may overcome some of prtate extension is associated with rounded borders. Border tissue
these issues, it i s rare that design alone can solve all problems. For can occupy three possible positions: (1) with the facial and lingual
a prosthesis t o be successful. many of these factors need t o be musculature at rest, (2) with the musculature activated to elevate
addressed and improved as much as possible prtor to treatment. (maxillary) or depress (mandibular) the border tissues, and (3) with
the perioral musculature forcefully contracted. Because most func
tional movements oe. speaking. swallowing, and moister1ing the
Related factors that lead to faulty design lips) are not extreme in nature, the dentllre borders should provide
a seal when the tissues are at rest or nearly at rest. If border tissues
Patient demands are recorded while the lips are pursed or contracted forcefully, the
denture will lack border seal during function.
Unfortunately, many faulty designs are dictated by the demands of The properly extended denture gently seats its flanges into
the patient. The cliniCian generally attempts to accommodate pa the patient's border tissues. If insertion of the denture results in
tient concerns regarding esthetics. bulk of denture base material, disptacemer1t of the border tissues, the denture is overextended; if
2521
Inadequate Denture Design j
there is space between the denture border and the tissue reflection, extends more than 2 to 3 mm beyond these should be suspect for
the denture is underextended. The potential posterior palatal seal overextension.
is evaluated by tracing the area with an indelible pencil.6 A mirror is
used to identify the pterygomaxillary space, and the remainder of Mandibular denture
the posterior aspect of the denture iS determined by identification
of the vibrating line. The posterior portion of the maxillary denture Labial a n d buccal borders As in the maxillary denture, the man
must extend over displaceable tissue of the soft palate but must dibular labial border should not change directions from vertical to
not overextend onto movable palatal tissue because the seal will be horizontal. When this occurs. overextension is likely.
easily lost. The external oblique ridge is an important anatomical landmark
Ungual extensions of the mandibular denture are checked i n a tor the buccal border of the mandibular denture. Overextension is
different manner. Extreme tongue movement cannot be accom probable when the denture extends beyond this ridge. On occasion,
modated, but the patient should be capable of making side-to the depth of the vestibule may allow the border to extend over the
side movements with the tip of the tongue without dislodging the external oblique ridge. In this case, careful evaluation of the tissue
denture. Denture extension is best evaluated by extending the labial renection can determine whether the correct anatomical relationship
or buccal tissues to break the peripheral seal or by asking the patient exists.
t o elevate the tongue to determine whether this action disrupts the
peripheral seal. If either activity dislodges the denture, the cause Retromolar border If the retromolar pad has been recorded in a
should be identified and the local areas of overextension adjusted relatively undisturbed manner, direction of the surface outline should
appropriately. change from predominantly horizontal to predominantly vertical. The
denture should not extend beyond this directional change.
Characteristics of overextension
Posterior lingual border An extension beyond a straight line or
When considering the different areas of denture borders, it is pos slightly convex line that connects the distal border of the retromolar
sible to identify characteristics that suggest overextension. Following pad and the deepest part of the retromylohyoid fossa is likely indica·
are characteristics of overextension for each border segment. tive of overextension.•
M axi llary denture Retromylohyoid em i nen ce The denture borders should not ex·
tend inferior to tile retromylohyoid eminence. If the denture or im
Labial and b u c ca l borders If the tissue-surface contour of the pression outline flares medially beyond tile fossa and beneath the
denture flange changes from vertical to horizontal, overextension is tongue, overextension is present.
probable. Frenum notches will be present, but the tissue surface will
have a labial or buccal flare in these areas when overextended. A Mylohyoid border When viewed from the lingual aspect, the out
border may extend onto the zygomatic process, which may not be line from the retromylohyoid eminence to tile premylohyoid eminence
inappropriate. should be relatively straight. On oocasion. this border demonstrates
Depending on the patient's specific anatomy, a definite notch or a gentle convexity, but it rarely dips inferiorly because the mylohyoid
flattening is usually found at the denture border that opposes the muscle passes medially and anteriorly. The properly formed mylohy
anterior surface of the medial pterygoid m uscle. In the presence of oid border should exhibit an S-shaped lingual border.
overextension, this landmark will not be recorded clearly because
the pterygomaxillary space will be larger in the denture impression Premylohyoid eminence This landmark is usually recorded quite
compared to the clinical examination. clearly. The anterior portion of the mylohyoid muscle is inferior to the
sublingual gland, and the posterior border of the gland often causes
Posterior palatal border At the pterygomaxillary space or hamular a soft tissue depression in this area. This landmark may be obscured
notch, the border should terminate in the most superior portion of if overextension is present in adjacent areas.
each space. When overextension occurs, the record of the ptery
gomaxillary space is clearly anterior t o the posterior border of the Sublingual borde r It is difficult to characterize changes to the bor
impression or denture. der direction of the denture in the sublingual area. Overextension
Overextension in the midline is often more difficult to recognize.' o f this area may be identified by retracting the labial border and
Extension posterior to a straight line joining the two pteryg omaxillary observing superior movements of the denture. which may indicate
spaces is usually indicative of overextension. The fovea palatinae overextension. The lingual frenum is usually recorded on the tissue
are recognizable landmarks. However, while these landmarks are surface of the denture. The border should extend to the point of in
constant, their relationship to t11e vibrating line is not. Normally, sertion of the frenum. If the frenum is displaced vertically, the border
these are found w�hin the denture outline within a few millimeters should be reduced until there is no record o f this tissue surface of
of tile posterior portion of the maxillary denture. A denture that the denture.
253
�7 i Diag nosis and Management of Inadequate Denture Prostheses
Characteristics of underextension Su bling ual border When the dent ure is underextended. the sub·
lingual frenum is not present, even if a prominent frenum presents .
Because underextension does not reveal anatomical structures, it is This area may be evaluated clinically, as de scribed in the section on
often difficult to ident ify an underextended denture border upon vi overextensiOn.
sual exam ination . There are no landmarks that clearly identify under
extension. The clinician should consider underextension when the Border thickness
landmarks described previously are clearly lacking in an impression
or in the denture. Border thickness should be determined by the impression. It is crit i ·
cal that this thick ness not be altered during the denture fabrication
Maxillary denture process because the border molding process establishes the appro
-
priate thickness. Border thickness has no definitive limits, although

Labial and bu cca l borders If the denture impression or a denture some generalizations may be made. Thicker borders may be neces
is underextended, the labial and buccal frena cannot be identified.

sary a nterior l y for lip support and esthetics. Normally, in patients with
In addition, denture borders are not rounded, nor does the denture severe residual ridge resorption. borders are thicker. Conversely, in
periphery demonstrat e specific anatomical structures. Posterior to those with large. unresorbed ridges. borders are generally thinner.•
the tuberosity, the pterygomaxillary space and associated notch that
are caused by the anterior border of the medial pterygoid muscle are Maxillary denture
not recorded. Average thickness tor the borders should be approximately 3 mm tor
the labial border, 3 to 8 mm for the buccal border, and approximately
Posterior palatal border If the distal upward curve of the tuberos 2 mm tor the palatal border. The frenal areas are usually thinner than
ity is missing, this border is likely to be underextended. Underexten the adjacent borders.
sion should also be suspected if there are no recognizable contours
that extend to the notch, if the border curves severely in the center M a ndibular den ture
of the palate, or if the fovea palatinae are not reoorded. Average thickness of the labial and buccal borders is appr oximat ely
3 mm , and the retromolar pad is approximately 2 m m thick. The
Mandibular denture mylohyoid region is general ly 3 mm in thickness, and the sublingual
borders are more variable.
Labial a n d buccal borders As described with the maxillary den Sharp denture borders frequently cause ir ritation even if the border
ture, the absence of clearly delineated frena in the presenc e of sharp, is extended correctly. However, adjustment of a sharp denture
nonrounded borders can indicate underextenSion. In the buccal shelf border may result in a denture with deficient retention because the
area. underextension may be indicated by absence of a horizontal border is now underextended.
c ontour that is medial to the extemal ob lique ridge. Tl)in denture borders may not provide sufficient strength to the
denture. thereby making it more susceptible to fracture. Thickness
Retromolar border The ent ire retromolar pad should be v sibl e of tM denture borders also should be conSidered for lip support
from base to apex. Occasi onall y, a triangular area may be recorded du ring the impr e ssion making phase. TI)in borders or borders that
i
just anterior t o the retromolar pad, but termination of the denture in were reduced during the technical phases of denture fabrication may
this area represents underextension. provide inadequate d enture esthetics.
Thick borders caused by overextension of the denture impresSion
Posterior lingual b order A mesial or anterior slope to the posterior may lead to inadequate denture retention during physiologic move
lingual border as it progresses from the retromolar pad to retromy ments. Excessive thickness of t he denture in the posterior palatal
lohyoid fossa is characteristic of underextension. Failure to demon bord er area may lead to gagging and general discomfort. Excessive
strate a specific eminence on the denture or in the impression also is thickness of the distal l ateral portion of the maxillary buccal borders
indicative of underextension. ooutd lead to interference with the coronoid process o f the mandible,
and excessive thickness of the man dibular borders in the mylohy
Myl ohyo id border Absence of an S-shaped curve at the lingual oid region could cause irritation throu gh interference with tongue
border in the mylohyoid region is characteristic of an underextension function.
in the area.
External denture contours

Premylohyoi d eminence This landmark is absent if the denture is
underextended and also may be absent if the mylohyoid muscle is As des cribed previously, there are three general denture surfaces
displaced laterally, thereby eliminat ing the S s haped oontour of the
- that need to be properly adapted to the patient's anatomical struc
lingual border. tures and phySiologic actions. The intaglio or tissue surface of the
denture i s established in tl)e impression phases of t reatment. An-
2
1
54
terior occlusal surfaces must be arranged appropriately to provide Li ng u al contours The posterior lingual c ontours should be rela·
adequate lip support and allow proper speech. The poste1ior teeth lively straight occlusogingivally, with only slight ooncavity to allow
are arranged in relation to anatomical structures such as the retro tongue space. This concavity should be no deeper than the lingual
molar pad and residual ridges while also being positioned to avoid surface of posterior t e eth.
imping em e n t on the muscu lar structures of the buccal and lingual
structures. Finall y, the polished surface, or externa l contours, of the
denture should be in harmony with buccal and li ngual anatomical Tooth position and esthetics
structures and should exhibit contou rs that allow surrounding mus
cular s tructu res to maintain the dentures in position.• The inter rela tionshi p of tooth position and the final es th etic qualities
of the denture cannot be overemphasized. Tooth position depends
Maxillary denture on the appropriate identification of t he correct vertical and horizontal
position of the jaws. Factors that affect correct determi nati on of the
Labial and buccal contours Superior to the gingival m argin should centric relation posit i on {horizontal relation) and vertical dimension of
be a generally convex, broad gingival roll of the denture base. Con occlusion (VDO. vertical relation) must be carefully considered.
tours should reflect a gradual gingival roll. and effort should be made
to avoid excessive bulk in this area, wh ich would create an unnatural Maxillary anterior tooth position
appearance and may interfere with function. Pronounced interdental
groove s should be avoided. Stippling of the denture may be provided The maxi llary anterior teeth should be at an app ropri ate angle to
to avoid a glossy appearance, but a stippled surface is not accepted provide adequate lip support and compensate for residual ridge
by all patients. resorption. Patients with retrognathic jaw relationships typically have
a m ore vertical Inclination of the long axis of the maxillary anterior
Palatal c o ntou r Palatal contour should resemble that of the natu teeth and may actually demonstrate a lingual inclination of these
ral palate. In cases of severe residual r idge resorption, the anterior teeth. TI1e amount of residual ridge resorption may be assessed
portion of the denture palate may become nearly vertical, possi by evaluauon of the incisive papilla, wh ich is typically located 5 to
bly requiring an increase in the t hickness of the anterior portion of 7 mm posterior to the labial contour of the residual ridge. If the
the palate. Appli cati on of impression waxes to the anterior palatal incisive papilla is nearer to the l abial oontour, the teeth likely need to
aspect of the maxil la1y denture may faci litate the physiologic form be arranged further to the labial to establish proper esthetics. The
ation of this palatal contour. Overcontour or tlndercontour of this clinician is cautioned not to place the teeth too far labially because
portion of the denture could result in speech problems because ltlis could result in excessive lev erage forces in the anterior maxilla
t he tongue must adapt to the palate to produce many speech and cause instability of the base. The goal of tooth arrangement is
sounds. Duplication of the connective tissue rugae is optional. to place the teeth as close as possible to their natural positions.
Many clinici ans report this as a clinically effective aid in speech pro Although some patients may request exce ssive labial tooth position
duction, but others have described it as a confounding factor for for esthetics. this is unlikely to provide the expected improvements
appropriate speech .''·'2 New denture wearers probably adap t better in upper lip support.
to the establishment of rugae in the denture: experienced denture
wearers who have not l1ad this feature in previous dentures generally Guides for maxillary anterior tooth posit ion
do not tolerate these structures. Maxillary incisors will gently contact the wetfdry line of the lower lip
when f and v sounds are pronounced. When a pa tien t pronounces
Mand ibu la r dent ure the letter s, the mandible moves to its most forward speaking
position. which generally pl aces th e mandibular incisor ap·
Labial and buccal contours As with th e maxillary denture, a slight pro x imately 1 mm lingual and inferior to the li ngual edge of the
gingival convexity on the labial aspect of the m andibula r denture is maxillary incisor. If the teeth are property positioned, mandibular
appropriate. Excessive co ncavity is not desirable because it results incisors will art1culate just below and behind the maxillary central
in food im paction and difliculty in man ipulation of the facial surfac incisal edges when speaking the s sound. According t o Pound,
es of the denture. Efforts to compensate for skeletal abnormalities however, t his guideline results in errors almost 50% of the time
re sulting in a Class Ill skeletal relationship, or for severe m andibular when patients exhibit a Class II jaw relationship.• In contrast, Class I
residual resorption that establishes a pseudo-Class Ill relationship. or Class 111 jaw re lationship errors are observed 5% and 2% of
may place the mandibular teeth toward the lingual aspect of the the time. respectively. When pronouncing the f sound. incisal edges
anterior portion of the mandibular denture. Each sit u ation needs to of the maxillary central incisors arti c ulate with the inner curvatu re
be considered carefully in e stabls
i hing the labial oontour to avoid of the lower lip where the horizontal portion of the lip joins with
creation of an excessive concavity. the vertical portion.
255
1 7 Diagnosis and Manage ment of Inadequate Denture Prostheses
Relationship of the incisors to the incisive papilla this situation. the occlusal plane appears to be superior to the com
The labial surface of the maxillary central incisor should be posi i
m ssure oi the tip. ThiS can adversely affect the stabiliy
t of the man
tiOiled approximately 5 to 7 mm anteriOr to the center of the incisive dibular denture because the pat•ent cannot man1putate the tongue
pap�Ja. This measurement iS established through evaluation of the and manage the food bolus appropnately. This can be evaluated by
natural dentrtion. In pauents with residual ndge resorptiOn, the Inci con1panson of the level of the mandibular premolars' occlusal sur
sive papilla changes its location relatiVe to the antenor teeth and be face and the location of the commtSSUres when the teeth are slightly
comes a less reliable predictor for tooth placement. A less dogmatiC separated.
approach should be conSldered. with placement of the labial surface
of the inciSors no less than 5 mm and no more than 10 mm labial to Too far inferior
the center of the •nc•s.ve papilla. The mandibular antenor teeth may not be visible dunng speech
if they are arranged too inferior1y. Some conditions may cause the
Common errors in maxillary anterior prosthetic tooth clinician to reduce the amount of vertical ovel1ap o l the anterior
position teeth. thereby positioning the mandibular anterior teeth Inferior to
the position that would have been assu med by the natural dentition.
Teeth t o o far inferior and anterior The patient and his or her If this approach is used, the anterior teeth w1ll be less visible than
friends and relatives will generally describe tooth placement too far normal.
inferi or and anterior as a "toothy" appearance. In addition to the un
e sthetic appearance. th1s tooth arrangement may lead to instability of Axial in clin ation
the maxillary denture. Speech may tack precision and be described The axial inclination of the mandibular Incisors varies depending on
as "slushy" when making the s sound. which occurs because the the facial profile. A straight profile should display a slightly la bi al incli·
pati en t is unable to place t11e tongue in a positi on that confin es the nation, a convex facial profile should display a definite labial inclina
stream of air that forms the s sound.,; tion, and a concave facial profile should present a long axis that is
vertical or slightly inclined toward the lingual.
Teeth too far superior and anterior This situation causes insuf
ficient display of the prosthetic teeth, and the lip exhibrts too much Posterior tooth position
fullness. It is not uncommon for the patient to experience this prob
len1 when natural teeth are present in the mandibular arch and the Orientation of the occlusal plane and the arch form of the anterior
clinician attempts to reduce the amount of vertiCal overlap of the teeth influences the location of the poster1or teeth. The occlusogln
anterior teeth Careful consideratiOn of the s sound may be valuable
.
gival position of the premolars is 1nftuer1ced pr•mar•ly by the orienta
in recogniZll1g th1s condition. tion of the anterior occlusal plane, and the arch form 1nftuences the
buccollllgu al tooth positiOn in the premolar regiOn.
Teeth too far inferior and anterior Although teeth can be placed
too far inferior and anterior an the normal {orthiOgnathic) relationship, Orientation of the posterior occlusal plane
it is more common wtt h retrognathlc J<lW relationships. This problem A ine extended from the occlusal plane should 1ntercept the retro
occurs when the cliniCian attempts to place the teeth 11110 an orthog molar pad at its midpoint. Proper onentat10n depends on the proper
nathi c relatiOnship desprte a patiElnt's retrognathic jaw relationship positioning of the anterior teeth. The occlusal plane should run ap
or when arrang1ng teeth on the residual ndge. This error is more proximately parallel to the residual ridge planes.
common when the patient exhibits moderate to severe residual ridge
resorption. Buccolingual tooth position
The central fossa o f the mandibular posterior teeth should generally
be located over the crest of the residual ndge, and the alignment of
Mandibular anterior tooth position
the teeth should follow the contour of the arch. This position may
Too far anterior be altered in consideration of interarch retat1onsh•ps. The m axillary
In general, the mandibular anterior teeth should not be anterior to posterior teeth are usua lly buccal to the ridge crest, but no portion of
the labial border of the mandibular denture; instead, they should be the toot11 st1 ould be buccal to the denture border.
parallel to the facial profile of this area. If the teeth are too far anterior,
the retention of the mandibular denture is adversely affected. This is I mp rop er occlu sa l plane pos i tion
exacerbated by situations in which the patient exhibits active men Wright et al described the imp011ance of pl acing the mandibular pre·
talis musculature. molars near the level of the commissures of the lip when the teeth
are slightly separated.8 Sufficient tongue space to prevent an ad
Too far superior verse effect of the denture on the funct1on and position of the tongue
When the mandibul ar anterior teeth are positioned too supenor1y. the has been emphasized. Either o f these factors could affect th e stabil
patient exhibits a large display of the mand•butar anterior teeth. In ity of the mandibular denture.
256
If the occlusal plane is too higl\ the patient will complain of denture teeth should be moved buccaJiy. On occasion, an exception
difficulty in management of t he iood bolus. This may occur because may be made in tooth position, with the seoond molar positioned so
of an inabmty to re ach the buccal vesti bul e with the tong ue . Food that the buccal cusp is o v er the residual ridge crest. This normally
may become trapped in the buccal vestibule and cannot be cle ared , does n ot create tongue crowding and may he lp prevent the patient
commonly resulting in instability of the denture. The relationship from cheek b iti n g.
between the occlusal plane and the lip commissures should be
evalu ated because this will reveal imprope r tooth p os itio ning to the Reverse artic ulation relationships
clinician. Ultimately, the latera l borders of the tongue at rest will be The mandibular posterior teeth are arranged a s described previOus
below the occlusal plane if the teeth are arranged too high. ly, with the central fossae slightly buccal to the crest of the residual
lithe occlusal plane is arranged too low, the patient may experience ridge. Often, cl inic ans are reluctant to posi iOn posterior teeth in
i t
difficulty with estheti cs speech, and mastication. Prominent display

, anything other than a normal relationship, Therefore, maxillary teeth
of maxillary premolars that are too low can cause esthetic problems. genera lly are positioned with a buccal h orizontal overtap. However,
In addition, maxillary anterior teeth that are too prominent during at times the maxillomandibular ridge rela tio nship creates a situation
function may be associated with an excessive display of denture in which the maxillary teeth are too fa r buccal to allow the teeth to
base material. The mandibular an teri or teelh will pro bably not show, be medial to the b ucca l aspect o f the maxillary d en tu re. In these
and the patient may oomplain that ot hers are not aware that the situations, a reverse articulation relationship is indi cated, and it may
mandibular prosthesis is being used. The patient may find it diffi cult be prudent to conSider the use of cuspless teeth to s implify arrange
to speak if the teeth are positioned too low: for example, a lisp ment of the p oste rior teeth .
occurs because the tongue is f orced between the teeth on the
s sounds. An occlusal plane that is too low may not have much Distal extent of the pos t eri or t eet h
effect o n mastication unless there i s an unfavorable maxillary ridge, Because placement of teeth on the sloping ridge anterior to the ret·
in which case instability of the maxillary denture occurs secondary romolar pad i s d etrimental t o the sability of the mandibular denture,
t
to increased leverage forces when the mandible moves to lateral suc11 an arrangement of pros thetic teeth should be avoided. The
excursi ons . re sidual ridge may present with long posterior slopes beginning in
The determination of the VDO infl uenc es the location o f the the premolar region. Should this be encountered, some of the stope
occlusal plane. When the VDO is too great, the occlusal plane is may need to be covered, but the terminal portion of the tooth ar
i . Conversely, if the VDO is insuffc
often located too hgh i ient. the rangemen t should be s hort of the retromolar pad.
occlusal plane is located too low.
Posterior tooth form
I mpr o p er buccol ing u al tooth posit i on Successful dentures can be fabricated u sin g cusped or c usple ss
The proper buccotin gual position of the posterior teeth is deter teeth. Cuspless teeth could be co nt r ai ndicated in patients for whom
mined relative to the position of t he mandibular residual ridge. In the appearance of the maxill ary premolars is a prime conSideration.
general. the central fossae of the mandibular second premolar and In addition, if cuspless teeth are to oppose partial dentures or the
molars should be over the ridge crest. Mas ti catory performance may natural dentition, their use may not be advisa ble because it could
be red uced" if the teeth are moved 4 mm or more buccal to this oompromise occlusal function.
relationship. The normal resorptive pattern in the mandibular arch Cuspless teeth demonstrate definite advantages in three situations:
occurs more rapidly on the buccal pla te but because the basal bone
,
in the mandible is not immediately beneath the residual ridge, the 1. Patients with retrognathia exhibit a large range of anteroposterior
crest of the ridge appears to move buccally with excesSive e
r si dual func ti on. The mandible commonly is positioned an terior to cen
ridge resorption. Considering this resorptive pattern, it is recom tric relation. Closure tends to be anterior to centric relation. and
mended th at the posterior teeth be positioned no more than 1 t o 2 patients exhibit a cons istent pattern of horizontal movement. Be·
mm buccal to the position described above. The exception occurs if cause the patien t cannot be fo rced to function in a retruded posi
t he tongue is unusually large. tion, i t seems prudent to create an occ lusal scheme that allows a
The lingual limit for the p os terio r teeth is the retromolar pad. No range of horizontal contact. If cuspless Ieeth are used, transition
part of the tooth should be placed lingual to the pad. If the teeth from the horizontal overlap of the anterior teeth to the more nor
are posi ti oned too far lingua l, the prosthetic teeth intertere with mal posterior overlap can be accommodated more easily without
t ongue function. A ling ual position could enhance mandibular interference from cusps.
denture stability, but this situation must be balanced against the 2. Pati ents with extensive residual ridge resorption may benefit from
size of the tongue. A tongue that is too confined will be forced into cuspless teeth because these teeth assist in the retention of the
a re trude d position, thereby reducing oontrol of t h e mandibular denture. Dentures with cusped teeth placed in these patients of·
denture. The s i t uati on should be carefully oonsidered in the wax ten become dis lodged.
trial den ture phase of denture fabrication. In this phase, the patient 3. Patients with prognathic mandibles may benefrt from a reverse
should be asked to swallow and then slowly open t he mouth to arti c ulat ion relationship, which is much easier to develop using
observe restriction of the tongue. If 1he tongue is restricted. the cuspless teeth.
257
�7 i Diagnosis and Management of Inadequate Denture Prostheses
Fig 17·3 Resilient liners used In mandlbular Ql/llrdenture toadd retentive features and
oomtort lor underlying muoosa.
Vertical dimension the acrylic resin posterior teeth results in premature anterior occlu·
sal contact. Premature occlusal contact in the anterior region may
Although much research has been focused on VDO. there contin ·
cause more rapid deterioration of the underlying residual ridge.
ues to be no definitive method to establish the correct VDO. The
most common methods involve the use of rest position as a guide
based upon the assumption that the appropriate VDO is 1 to 3 mm Base materials
less than the vertical dimension of rest." Other methods include ob·
servation of phonetics the
, closest speaking space, swallowing of Metal bases
s aliva, facial profile, neuromuscular perception, and evaluation of the
interocclusal space. Given the lack of a definnive method it seems , For some patients, metal bases seem to be more comfortable than
appropriate for the clinician to utilize multiple methods to determine acrylic resin denture bases. Many clinicians assume that metal bas·
and confinn the VDO. es fit the underlying tissue more accurately, but this has not been
It cannot be assumed that every patient should possess the routinely confirmed in scientific evaluations. Should metal bases be
same interocclusal distance. Phonetic tests to determine closest used the residual ridge should be quite stable because adjustment
,
speaking space may be most helpful t o individualize the amount of a metal denture base is limited. Less lateral denture base distor·
of interocclusal distance tor each patient. It may be advisable to lion occurs when a metal base is used. Metal denture bases are not
provide more interocclusal distance for more elderly patients or for amenable to routine and si mple relining or rebasin g procedures.
patients who exhibit compromised muscular coordinat on. i
Relining
Palatal relief It is pr udent to avoid the use of denture bases that cannot be relined.
The exception to this would be the rare situation in which the ridges
Arbitrary placement of standard relief in the midpalatal reg on is poor
i are so stable that changes in the residual ridge archi tecture are not
practice. Individual palatal relief in the areas of a prominent incisive anticipated.
papilla or nonresilient tissue may be indicated but it should not be
,
a routine procedure. Indiscriminate use of palatal relief could lead to Resilient denture bases
the development of papillary hyperplasia. A mor e prudent approach
is to use pressure-indicator paste t o demonstrate areas where relief Resilient denture bases have been proposed for patients who exhibit
is needed after denture fabrication.' intolerance to hard denture liners (Fig 17·3). Unfortunately, no per
Denture material should be carefully selected, with consideration manent resilient liners have been developed for routine clinical use.
of the needs and demands of the patient. It is crucial that patients Should a resilient denll1re base be considered, the clinician must
be provided with materials that do not elicit hypersensitivity reactions provide at least 2 mm of thickness to ensure a therapeu tic benefit.
and that provide functional and esthetic sclutions to meet their needs. Adjustment of resilient liners is difficult because these materials are
not easily modified with traditional r otary instr uments .
The maintenance of resilient liners is difficu lt. Because there

Tooth materials is no chemical bond between the acrylic resin denture base and
resilient liner. it is likely that the liner will separate from the denture
Porcelain materials should not be occluded against gold or the natu base over t ime. When this occurs. it is not unusual for the liner
ral dentition. Similarly, occlusion of porcelain denture teeth against material to discolor and for fungus or bacteria to invade at the
acrylic resin denture teeth results in rapid wear of the resin teeth. interface. Traditional effervescent denture cleansers may damage
Porcelain anterior teeth occasionally are used wnh acrylic resin pos· resilient liners and should be avoided. For conventional acrylic resin
terior teeth. This situation is ill advised because the greater wear of dentures, patients should be instructed to soak the denture for 30
2581
Inadequate Design of Removable Partial DenturesJ
Fig 17·4 (a)This rigi d cast cirC�Jmferential Clasp was not functoi nally designed and
caused periodontal trauma and tooth mobility. {b) Radiographic evidence of thickening
of periodontal ligament space, a sign of trauma. This is pa�icula�y likely to ocCIJr where
lhe crown-to-root ratio is relatively high.
minutes each day in a solution of 2 teaspoons of water softener and Signs of injury from removable partial dentures
1 teaspoon of chloride bleach in 8 ounces of water. After the denture
iS removed from the soaking solution. it should be thoroughly Tooth mobility
brushed and rinsed in water. Resilient liners are not harmed by
vigorous brushing. but hard acrylic resin is susceptible to abrasion. Mobility is generally recognized as evidence of trauma to the tooth.
For this reason, vigorous brusl1ing should be confined to the resilient However. in the absence of plaque and associated marginal inflam
material. mation, mobility does not appear to exacerbate periodontal disease.
Resilient liners are indicated for patients with thin or friable oral When mobility is encountered, the clinician is advised to evaluate the
mucosa that covers the residual ridge crest or with bony prominences mobility of other teeth in tl�e arch.
such as mandibular tori. Before resilient liners are used, the patient Poor clas p design also can induce tooth mobility. The use of
should demonstrate an inability to function with conventional hard cast circumferential Clasps on an abutment tooth adjacent to distal
denture bases. extension removable partial dentures is an ill-conceived approach
The use of resilient liners in patients with extensive bony undercuts (Fig 17 4)
· . When this clasp design is used. excessive force is
should be considered only if surgical resection is not possible. transferred to the abutment tooth. The situation is exacerbated
Parafunctional habits such as brtJXing or clenching could result in by residual ridge resorption in the posterior edentulous regio n that
soreness of the residual ridges, so resilient denture liners may be of occurs without readaptation of the removable partial denture base.
some benefit for the patient with these habits. Prematu re occlusal contacts transmitted directly to the abutment
Resilient liners have been advocated for p atients who have teeth or indirectly through the removable partial denture base
received therapeutic radiation to the jaws. These liners may be of extension can result in excessive application of force, leading to
some benefit for patients with radiation tissue damage, but the mobility of the abutment teeth. Failure lo provide full peripheral base
dinician s11ould be cautioned that improper utilization of resilient extension could result in greater vertical movement of the distal
liners could damage the oral mucosa. Likewise, resilient liners in extension denture base, with commensurate increases in forces oo
these patients require more frequent reassessment and replacement the abutment teeth.
to ensure patient safety and comfort. Tooth mobility also may occur if primary abutment teeth for the
removable partial denture already exhibit loss of bone support.
When these teeth are subjected t o the additional stress associated
with being an abutment. the mobility pattern may be exaggerated.
Inadequate Design of Retentive clasps should be opposed by bracing or reciprocal
Removable Partial Dentures arms. If t11is is not the case. the tooth is subjected to deleterious
forces every time the remova bl e p rosthesis is inserted or removed: a
It is not unusual forthe clinician to delegate virtually all responsibility for reciprocating arm prevents this. An occlusal rest should direct forces
the design and fabrication of a removable partial denture to the den down the long axis of the tooth. If the occlusal rest is not properly
tal laboratory technician. Unfortunately, the technician is not routinely designed, forces could be applied in a nonaxial direction and exert
trained in oral medicine and is therefore unable to create designs that further trauma on the tooth.
are unlikely to induce dental pathosis. In additioo, when the dental
laboratory technician is faced with inadequate occlusal rest prepara ·
Adverse periodontal response

tion. there is no opportunity for compensat
on
i through design.
Gingival inflamm ato
i n may occur if the components of the removable
partial denture impinge on the soft tissue. This commonly occurs
when guiding planes have been improperly designed and extend to
the gingival margin or when infrabulge clasps compress the facial
gingival tissue.
259
�7 i Di agnosis and Management of Inadequate Denture Prosthe ses
vertical Moderate Extteme
a b a b c
Fig 17-5 Occlusal rests: improperty prepared (a) and properly Fig 17-6 Slope of lingual alveolar bone should be OOilSidercd when detennining
prepared (b) rests to resist horizontal and vertical forces on thicl<ness of relief !()( rn<ljor connector for a mandibular removabl e partial denture. (a)
mandibular premolar. {Modified from Terkla and laney" wilh Vertical slope with minimal relief (30 ga). (b) Moderate slope with moderate relief {28
permission.) ga). (c) Extteme sl ope with heavy relief (26 ga). (Adapted from Laney and Gibilisco< whh
permission.)
A negative soft tissue reaction may result when a removable Currently, most removable partial denture frameworks are
parttal denture acts as a food trap. In addition, poor oral hygiene can fabricated from base metal alloys. Because these alloys possess
accentuate the situation. Pl aque accumulation often is increased more strength in comparison to traditional type IV gold alloy frames.
beneath the components of a removable partial denture because it is possibl e t o fabricate frames that are thinner and less obvious t o
those components interfere with the natural cleansing actions of the the patient. The use of broad, thin midpalatal major connectors i n
tongue and lhe facial musculature. the maxillary arch has increased in popularity because these are less
Occlusal rests are used to prevent tissueward movement of the intrusi ve on nom1al speech production. However, in rare instances.
removable partial denture. If occlllsal rests are not provided , or it may b e necessary to consider a posterior palatal connector or
if the rest is improperly designed or fractures under function, the double· bar connector to prevent flexure of posterior edentulous
partial denture is prone to settling, which can result in dehiscence or quadrants.
fenestration of the tissue covering the root'5 (Fig 17-5). Ac1ylic resin major connectors should be used only for provisional
prostheses. The lower strengt11 o f acrylic resin in contrast to base
metal alloys makes it unsuitable a s a major connector tor a definitive
Errors in removable partial denture design prosthesis .
Major connectors Minor connectors
Major connectors should be rigid during function. In the mandibular Excessive blockout of proximal surfaces on the master cast mini
arch, it is not uncommon for the major connector to be t oo small in mizes the effectiveness of guiding planes in controlling the path of
cross -sectional area. This results in ffexion. which transm its exce s insertion and removal. The guiding pl ane may not be covered with
sive forces to the abutment teeth. The maxillary arch usually does metal if the clinician attempts to make the metal less conspicuous. If
not have this problem because the major connector in t11e maxilla is the guiding planes are not contacted by metal. appropriate blockout
generally larger compared to that in the mandible. would not be effective. In addition. it is possible thai inadequate ex
Placement of the major connector too close to the gingival margin tension of the guiding planes could result in food impaction.
can result in gingival inflammation. which may lead to gingival The minor connector should not be placed on prominent contours
hyperplasia. Soft tissue stimulation also as reduced during function. of the teeth or tissue because it may interfere with movement of the
The sup erior portion of the lingual bar should extend no less than 3 tongue or lips and become an annoyance to the pat i ent (Fig 17-7).
mm from the gingval margin.
i These components should join the major connector at right angles.
Given the complications observed with the use of a lingual bar, it
is not uncommon for clinicians to overutilize the lingual plate major Rests
connector. Althougl1 the lingual plate resists flexion. it covers the
gingival tissues. thereby resulting in a loss of stim ulation during Failure to provide rests that adequately support a removable partial
function. In addition, inadequate relief can cause encroachment of denture can result In migration of the prosthesis toward the soft tis
the major connector on the oral mucosa (Fig 17 6
) - . sue. Although it is not necessary to have rests on each clasp , there
2601
Inadequate Design of Removable Partial Dentures J
Fig 17-7 The minor cconector to this indirect retainer is imprope�y placed on U1e
lingual prominence of the mandibular right first premolar. Poor clasp design required
replacement of the minor connector on gingival prominence in the area where It will
interfere wllll tongue function not sufficiently rigid and may also trap food.
should be an adequate number of rests to resist settling of the pros Stress management for removable partial
thesis. Rests must be designed with an adequate bulk of metal at
dentures
the junction of the rest and the minor connector to prevent fractures
or bends.
Stress management is critical for all removable partial dentures bu1
is particularly applicable when distal-extension removable partial
Clasps
denture designs are considered. Tl1e soft tissue beneath the distal
Partial dentures that combine tooth and tissue support exhibit extension base does not provide the magnitude of support that is
movement secondary to the differential resilience of teeth and tis provided by the clasped abu1ment teeth. If design of the remov
sue. Movement occurs as rotation around a fulcrum line and must able partial denture does not control these differential stresses, the
be anticipated in design of the prosthesis to minimize stress on the residual ridges or the abutment teeth could be loaded beyond their
abutment teeth. Clasps should be designed to disengage or to read capacity to withstand stress without injury.
ily flex out of undercuts when rotation occurs around the fulcrum. A Three basic approaches to stress management have been
variety of designs have been proposed to address these concerns. described":
The mesial t-bar combined wijh a mesial occlusal rest will disengage
when posterior forces are applied to the denture base. Wrought· 1. Physiologic or functional basing: An effort is made t o equalize the
wire clasps will exhibit increased flexibility under posterior functional support contributed by the residual ridge and the teeth by some
toad. A study by Kapur et aJ demonstrated no significant difference fonm of physiologic basing.
in abutment tooth performance relative t o ctasp design.'" 2. Broad stress distribution: Stresses are distributed over multiple
The retentive clasp arm and bracing anm should contact the tooth teeth to avoid excessive stress on any individual tooth.
simultaneously. If the retentive arm contacts tl1e abutment first, 3. Stress breakers: This method relieves the stress on the abutment
excessive force results on the abutment tooth. Ideally, the bracing teeth by using movable connectors between the retainers and the
arm and guiding planes provide support during insertion and removal denture base. which transmits more stress to the residual ridges.
of the prosthesis. If the bracing anm is fabricated as a suprabulge
bracing arm and only contacts the tooth when the prosthesis is fully All three approaches to stress management have merits. The
seated, it will not counteract the forces exerted by the retentive clasp clinician should select the features that provide maximum benefit for
during insertion. the specific patient. remembering that each patient's circumstances
are unique. In certain situations. the teeth may provide superior
Denture base support to the soft tissues. but in other circumstances. the tissues
could provide superior support to the teeth. In some situations, both
The acrylic resin denture base must be sufficiently large to retain may be capable or compromised relative to support. When tooth
the denture teeth on the removable partial denture. The base should support is adequate and satisfactory residual ridges exist. functional
provide support but may not provide border seal or lateral stab basing by impression technique may be beneficiaL Conversely, when
Ility, which are provided by the remaining natural teeth. In a tooth abu1ment teeth have lost bone support, wide stress distribution can
supported removable partial denture, the base should not extend protect all the remaining teeth. If periodontal support for the teet11 is
into tissue undercuts unless required for esthetic reasons. Denture diminished while residual ridge support is strong, the stress-breaking
base extension should mimic that of a complete denture, with the concept may be indicated. It is incumbent upon the clinician not
exception of the lingual border of the mandibular removable partial to embrace one philosophy for all patients but instead consider
denture. The retromylohyoid fossa need not b e included: the under the individual patient's circumstances and apply the appropriate
cuts in this area would likely interfere wijh the path of insertion. treatment approach for that patient.
261
�7 i Diagnosis and Management of Inadequate Denture Prostheses
5. Arstad T. The ReSille.1Cy o f the Edentulous Alveolar Ridges. OSlO: OslO

Summary Universily Press, 1959.
6. Laney WR. Glbllosco JA. Diagnosis and Treatment In Prosthodontics. Phila
delphia: Lea and Febiger. 1983.
Patients treated for complete or partial edentulism with complete or
7. Laney W. Gonzales J. The maxiBary denture: tts palatal relief and posterror
partial removable prostheses have requirements for function, com palatal seal. JAm Dent Assoc 1967:75:1182-1187.
fort, and esthetics. There are many parameters that comprise dental 8. Wright C. Sw&tU w. Godwin w. Mandibular DentureStallilrty: A New Concept.
Ann Arbot, Ml: The Overbeck Company, t961.
prostheses' acceptabi lity to the p ati ent . The reader is encouraged to
9. Pound E. Personalized Denture Procedures: Dentist's Manual. Anaheim:
look for signs and symptoms that may indicate the need for trouble
Oenar. 1973.
shooting of a speci fic inadequacy related to prosthesi s design. It is 10. Palmer JM. SINCtucal changes for speech improvement in complete upper
hoped that the patient's existing anatomy will b e best preserved by denture fabrication. J Prosthet Dent 1979:41:507-510.
11. U J. Zhang F. Chen Y, Wang G. Subjective e'laluation of acoustic changes
paying specific attention to the previously mentioned factors.
befO<e and alter restoratt011 wit h complete denture Un Chinese]. Shanghai J
Stoma1ol2003:12:247-249.
12. Pound E. Esthetics and phonetiCS in ful denture construction. J Ca!W Dent
Assoc 195();26:179-185.
References 13. Kapur K. Seman S. Mas1ieat0f)' pe<lonnance and efficiency in denture
weare<s. J Prosthet De nt 2006;95:407-411,
14. �191' C. Hickey J. Zarb G. P rosthO<IOntic Treatment for Edentulous

1. Lambson G, Anderson R. Palatal paptllaf)' hyperplas<a. J Prosthet Dent Patients. eo 7. StLouis: Mosby. 1975.
1967:18:528-533.
15. Terl<la LG. Laney WR. Partial Dentures. eel 3, S1 Louis: Mosby. t96'3.
2. lytle R. TI1e management of abused oral tissues i n complete dentt.re
16. Kapur KK. Deupree R. Dent RJ. Hasse AL A rarldomited clinical trial of
construction. J Prosthet Dent 1957:7:27-42.
two baSic removable partial denture deSigns. Part I. Coropa<lSOn of frve·year
3. McLean F. Uris! M. Bone: Fundamentals of the Physiology of Skeletal Tossves, s uccess rates and periodontal heaiU1. J Prosthet Dent 1!194:72:268-282.
e<l3. C ihcago: UniverSity of ChiCago Press, 1968. 17. Salinas TJ. Treatment of edentul:sm: Optimizing outcomes with tissue man.
4. Saundefs T. Gillis A Jr. Desjardins A. The maxilla')' complete denture oppos•
agement and impresSion techniques. J Prosthodont 2009:18:97-106.
log the bilateral Clistal extension partial denture: Treatment oonsiderations.
J Prosthet Dent 1979;41 :124-28.
2621
Chapter
The Mutually Protective

Complex: Occlusion and
Fixed Prosthodontics
Jonathan P. Wiens, DDS. MSD
Robert Stewart. DDS. Ms
T: e notion o f a mutually protective complex (MPC) between

he dentition and the encompassing host tissues is significant.
Normative Values of the MPC
The penetration or hard ectodermal tissues through soft tis
sue and their placement within a ligamentous-osseous mesodermal
base is a unique phenomenon. The biologic attachment and survival Stomatognathic function
of these joined but differentially derived cell types are challenged by
a pathogenic, abrasive, and addle environment, along with tempera Masticatory patterns
ture variances and dynamic vector interarch loading forces. As such,
the MPC concept implies a synergy between the attributes of the The most critical aspect of the MPC i s maintenance of stomatog·
dentition, periodontium, and combined stomatognathic system to nathic function, which includes respiration, mastication. deglutition,
sustain the patient's oral homeostasis. phonation-articulation, and esthetics. For example, to achieve satis
The epitome of the MPC concept may be characterized by the factory masticatory function, assessment of bolus size and its level
seminal development of osseointegration, whereby a prosthodontic of comminution is required before it reaches the swallowing thresh·
replacement is solely supported and retained by afloplastic titanium old before deglutition.
root analogs with a direct and viable attachment to structured liv Stomatognathic function begins with the scissortike cutting action
ing bone. Conversely, the placement of synthetic materials into the of the incisors and the gripping-separating action of the canines and
oral environment has been found to cause periodontal inflammation, premolars. followed by trituration b y the molars t o comminute food
antigenic-allergic reactions, infections, tissue necrosis, or dysplastic substances. Reaching the swallowing threshold requires that !his
processes.'·2 process occur in a synchronized and progressive manner. In adults,
Reestablishment of the MPC after prosthodontic treatment re the initial teardrop-shaped chewing cycle starts with an inferior
quires that the restoration's anatomical form and chemical properties mandibular vertical opening. followed by anterior positioning during
not challenge the host's biologic stabiliy
t . Simultaneously, tlie resto closure as the incisal edges approximate and slide past each other
ration's structural integrity must w�hstand a hostile oral environment. (incising) from infer ior to superior, cutting the food in the process.
Therefore . effective treatment requires knowledge of the normative The chewing patterns of the posterior teeth begin in much the same
values, recognition of altered conditions, and an understanding of manner. but. on closure, the mandible moves more laterally, ap
the intrinsic and extrinsic factors for success that are involved in the proximating the mandibular buccal cusps toward the central fossa
restorative procedures. of the maxillary buccal cusps, comminuting the bolus.3 While teeth
263
18 i The Mutually Protective Complex: Occlusion and Fixed Prosthodontics
.....
Fig 18-1 Ahlgren found lhat 98% of lhe patieniS wilh a normal occ lusion open al the Fig 18-2 Vertical axis rotates in the horizontal plane. llotizonlal axis rotates In U1e
median plane or slightly to llle contralateral side and c!ose to the side of lhe bolus (types sagittal plane, and sagittal axis rotates in lhe Ironia! plane. (Reprinted from Craddock el
f. II, Ill).' Pal,enls wilh malocclusions llad signifiCant irregutarilies in lhe ChiMing cycle al' with pennission.)
during llOth opening and closing cycles relative to the bolus.
penetrate the bolus during mastication, not all opposing teeth con are programmed for sequential and repetitive cycles and depend
tact completely or simultaneously. The posterior teeth are separated on the position of the incisal edges and cusp-fossa relationships
during incising, but during trituration the anterior and posterior teeth and their proprioceptive responses. As such. it may be desirable
on lhe nonworking side generally do not contact. This obsentation to have specific tooth shapes (cusps, fossae, ridges. and grooves)
may change depending on the properties of the food, nature of the that contact during certain mandibular movements so as to enhance
chewing stroke (ie, the desired function of incision versus trituration), mastication. Also important is the lac!< of tooth contact, or perhaps
and the dynamic spatial relationships of the opposing teeth. The the controlled approximation of near contact. that allows the freedom
combined alignment of the dentition and temporomandibular joint to perform other necessary functions without overloading any one
(TMJ) morphology, together with the neuromusculatol)' influence, component. The anatomical and physiologic tooth forms investing
determine these movements. A disturbance of any of these factors, periodontal tissues and encompassing mandibular movements and
such as malocclusion. may alter the chewing pattern• (Fig 18-1). their respective functions have been studied in depth• (Rg 18-2).
Biomechanics
Teeth and the periodontium
The mandible functions as a Class Ill lever system during mastica
tion, with the elevator muscles (effort) positioned between the joints Morphogenic expression of the intrinsic genetiC code creates an an
(fulcrum) and the denti1ion (work-resistance).5 As a result. the forces atomiCal tooth form and supporting structure that vary from tooth to
weaken as the effective resistance arm lengthens. Therefore. the tooth. These structural forms may vary among ethnicities. but all are
distant forces during incising are less than the proximal forces dur subject to alterations over time because of extrinsic factors. Each
ing trituration. To be effective, these dynamics require narrow incisal developing tooth form seNeS a specific purpose and function within
edges to increase the penetration forces, in contrast to the broader. the dynamics of mandibular movements.
multiple-cusp form of the molars required to withstand the increased
forces. The anatomical crown forms and corresponding root shapes Crown
are an apparent example of form following function.
The leverage concept is often illustrated with the mandible in pure The incisal edges and occlusal surfaces of teeth are positioned su
rotation. as seen in a sagittal view. when in reality the advancing perior to the long axis of the root. which is also aligned along the
or translating condyle changes the effective effort arm length. arc of closure and the perpendicular tangent
to the Monson CUNe
During trituration, the laterotrusive working condyle generally pivots t o resist occlusal forces. Each anatomical crown fonn has a slight
while the mediotrusive translating nonworking condyle seNes as a rise in contour that has been suggested to protect the periodontium
secondary fulcrum or protective bracing point that improves overall from the traumatic potential of food that passes by during each mas
stability. This system is further sophisticated by the synchronous ticatory cycle. Proximal tooth contacts prevent food impaction and
roles of the elevator and depressor muscles that may function in a have buccolingual embrasures that offer similar protection by allow
synergistic manner or as an antagonistic tether. ing food t o escape. Concavities below the proximal contacts allow
Mandibular movement patterns change subtly during this pro the presence and protection of the interdental papillae. The incisal
gression irom mastication to deglutition. Not only do they vary edge dimensions, compared to the width of the posterior occlusal
depending on the type or consistency of the food and its location on table, are designed to provide the appropriate force tor mastica
the occlusal table, but they also vary between the various occlusal tion within the limitations of a suitable supporting root structure and
classifications. The stereotactic approximations of the cutting edges its respective position within the arch. The lingual fossa of maxi!-
2641
Normative Values of the MPC I
Fig 18-3 (a) Loss of interdental papilla and giogivitis formation around a provisional crOI'nl, secondary to overcontoured restoration and inadequate 01al hygiene, as visualized by
disclosing solution {b). Patients must institute adequate oral hygiene belore, duriog, and after treatment. Topical agents such as chlorhexidine or peroxide gels may be beneficial. The
noncompliant patient may not be a sunable candidate tor treatment without adequate 01a1 hygiene and presents a guarded prognosis. (c)Tissue lnflammabon Is beginning to reSQ!ve
alter placement of a properly contoured provisional crown and Institution of oral hygiene measures.
lary inci s ors and lingual inclines of maxillary canines serve as guides Periodontium
for the opposing teeth as they gli de toward complete tooth contact
o r maximal intercuspation (MI). Buccal and lingual co ntours are bi The marginal gingiva surrounds the teeth. The interdental papi!!ae
planar. particularly on the centric holding cusps. to confine occlusal that occupy the gingival embrasure-interproximal space are usually
forces along the long axis. Contacts on inclined planes increase the pyramidal but may be "col shaped" because of proximal contact. The
potentially damaging horizontal force vectors, which require meth marginal gingiva is supported and stabilize d by the gingival fibers and
ods of control such as posterior centric holding cusps. longer/mul is continuous with the attached gingiva. which is firm and bound to
tiple root forms. and tooth guidance using a less destructive lever the underlying periosteum. The attached gingiva extends to the rel
age system. Multicusp p ost erior teeth interdigitate when teeth reach atively loose and movable areolar mucosa, ca!!ed th e mucogingival
the occlusal interface and bypass each other without tooth contact junction. The periodontal ligament (POL) consists of collageno us fibers
during the various eccentric excursio ns. that connect the cementum of the tooth to the alveolar bone and are
oriented in a suspensory manner more suited tor vertical rather than
Root horizontal forces. The POL als o contains proprioceptive innervation

to allow for the differentiation of spatial jaw r elationshi ps and reflexive
The undulating cervical line, or cementoenamel junction height actions dur ing occlusal overtoad. It has been suggested that normal
(CEJ), measures 3.5 mm anteri orly and 0 m m posterior1y. 7 The CEJ occlusal forces generated during mastication and deg lutit ion are ap
designates the beginning of the anato mic al root and o
f rms a mid proximat el y 40% of the maximum occlusal force." In addition to the
tooth constriction that serves as a protective niche to harbor the POL fibers. gingival fibers tl1at radiate outward or are circumf er ential
bi ologic soft tissue attachment and interdental papillae. The peri attac11 the teeth to the adjacent gingival tissue.
cemental tooth area varies with the number of roots and correlates The marginal gingiva typically follows the CEJ. The marginal
to the potential functional loads experienced anteriorly to p osteri orly. attached gingival architecture has been classified as having a thick
or thin biotype and is either scalloped or ftat. The scalloped, thin
Pulp chamber biotype is less resistant to traumatic injury and may not recover as
easily from mechanical intrusions as the thick biotype. The biologic
The pulp chamber contains neurovascular elements that provide the attachment of the marginal gingiva has been measured midfacia!!y
nourishment and sensory innervation tor repair and protection of the with a mean sul cular depth of 0.69 mm epithelial attachment of
,
odontoblasts. Of critical importance is the preservation of pulp vital 0.97 m m and connec tive tissue-to-bone depth of
, 1.07 mm, for a
ity during restorative procedures . which potentia!!y present a number total d entogingival complex of 2.73 mm.12 Kois and Tarnow have
of thermal and chemical irritants.s9 The general shape of the pulp found greater measurements of 4.0 to 4.5 mm interdenta!!y.'3·" The
chamber follows the external contour s of the tooth. Detailed mea interdental p apilla typica!!y measures more than half of the clinical
surements of the distance from external tooth surface to pulp cham cr own length for maxillary incisors and tends to parallel the CEJ, but
ber have been made to estimate the available depth for adequate this depends on crestal bone levels and the presence of periodontal
physical and esth et ic properties of restorative materials.10 Pati ent disease. Maintenance of the interdental papi!!a fo!!owing dentai pro
age and the presence of prio r caries lesions or restorations play a cedures is of great importance, particularly in esthetic areas (Fig
role in the development of secondary and reparative dentin and may 18-3). Whe n the distance from the interproxim al contact area to the
create g reat er dimensional space over tim e. crest of the bene is 5 mm or less, the interdental papilla will likely
regenerate. Based on these observations a minimum of 3 to 5 mm
.
of supercrestal tooth structure should be obtained by surgical crown
265
18 iThe Mutually Protective Complex: Occlusion and Fixed Prosthodontics
lengthening, if necessary.,.., However, when the interradicular tooth other eccentric movements. These refined recordings allowed a
distance is greater than 2.4 mm, the interdental papilla may not closer match of cast articulations to the clinical situation and were
regenerate, which may require a more conservalive restorative or ullimately used to prescribe an individualized occlusal scheme and
crown-lengthening approach.'a.'9 Gingival biotype, scalloped gingival morphology for each patient.2"'�
margin. adjacent root proximity, and location of the crestal bone. in Posselt investigated lhe full range of border movements of the
addition t o possible crown-lengthening procedures or orthodontic mandible and called it the envelope ofmotion.""The three-dimensional
extrusion, should be considered to enhance the dentogingival (30) shape is fusiform longitudinally and rhomboid in cross section.
esthetics and health.20 All of the mandibular movements necessary for function are
contained within this envelope (Fig 18-4). The most superior border
is truncated because of the presence of the dentilion. The anterior
Mandibular movements and occlusal positions (protrusive) and posterior (retrusive) border movements are flanked
by right and left lateral maximum movements o f approximately 8
The specific proprioceptive telemetry of mandibular movements and 10 mm. respectively. All four movements converge inferiorly,
depends on their impending function and the skeletal and dental and the apex represents the most open and translated condylar
relationships. The presence of the dentition when the teeth are in position, which Is approximately 45 mm long interincisally (40 to 60
contact predominantly guides the anterior aspect of mandibular mm range). The intraborder movements, below the superior aspect,
movement, and the condylar determinants guide the posterior as· are free of tooth contact. These movements are under the control
peel. Von Spee was one of the first investigators t o recognize that of the neuromusculature and influenced by the condylar fossae
mandibular movements were determined by the configuration of morphology and the contiguous craniomandibular ligaments during
the TMJs and occlusal anatomy when in intimate contact in a extreme mandibular positions. Several useful landmarks denote the
harmonious fashion!' While there are both condylar and tooth positional aspects of the envelope of motion along with anterior.
guidances, all mandibular movements are under voluntary neuro· posterior. and vertical occlusal determinants.
muscular control and the involuntary responses to signals derived
from the information-gathering proprioceptors, mechanoreceptors,
and reflexive nocioceptors. Tooth-mediated controls are obviously Mandibular eccentricity
lacking when the dentition is absent. This condition leaves the re·
maining reftexive complements within the muscles. joints. ligaments. Posterior determinants
skin, and mucosa to fill the responsibility. It is important to recognize
that tooth anatomy and tooth position both influence and are influ Christensen first reported on the separation of posterior teeth as
enced by these interactions during functions such as mastication a direct result of the condylar inclination path during protrusive
and phonetic articulation. movement.J> This phenomenon is the result o f the horizontal con·
Historically, the ability to scientifically analyze and replicate any dylar inclination as viewed in the sagittal plane (anteroposterior)
semblance of mandibular movements required reliable anatomical during protrusion.'2 Posselt noted that the average value of the adult
points of reference. the spat ial orientation of dental casts. and condylar path is 8 to 10 mm long, wiih an inclination that is approxi·
methods to track dynamic jaw positions. A connection between live mately 33 degrees relative to the occlusal plane and 43 degrees rela
function and the articulator, to accurately record and systematically tive to the Frankfort horizontal plane (represented in profile by a line
duplicate anatomical points and arcs of physiologic movemenl, from the lowest point on the margin of lhe orbit to the highest point
has been attempted for more than 200 years.:l?·�·· Bonwill arbitrarily on the margin of the auditory meatus).30
oriented the mandibular cast using a concept of an equilateral Bennett noted a similar relationship of the posterior teeth during
triangle, based on a 1 OO·mm intercondylar width and from the lateral jaw movements,32 which was denoted as the Bennett angle.
condyles to the median incisor point.25 Balkwill further improved This is formed between the sagittal plane and the average path of
mandibular cast orientation by using a sagittal angulation alignment the advancing condyle, as viewed in the l1orizontal plane during lat ·
of approximately 26: 4 degrees from the mandibular occlusal plane eral mandibular movements.'3 The mediotrusive movement repre
to the condyles.26 The vertex of the Balkwill angle may be visualized senls the pathway of the orbiting or nonworking condyle in lateral ex·
as an extended line t o the scribed midpoint on the anterior guide pin cursions while laterotrusive movement represents the working or piv
of many articulators. The Bonwill articulator had a O·degree condylar oting condyle. The Bennett angle is approximately 10 to 15 degrees
inclination. whereas Balkwill and others developed articulators with medial from straight protrusive movements. The resultant lateral shift,
sloped condylar inclinations to better simulate condylar pathways. or Bennett movement, may be temporally progressive o r immediate
Snow created a fascia facebow to depict the relationship of the in nature. Posselt indicates that the Bennett movement. which is ex
maxillary cast paralleling the Camper base plane as an anatomical pressed by the translation of the working/rotating condyle, may range
third point of reference on an articulator that better accommodated from 0 to 1.5 mm.30 While the Bennett movement is visualized at the
the physical variations of each patient.27 Subsequently, Harlan and working condyle, it is the result of the combined immediate translation
McCollum attached the Snow facebow to the mandible and recorded of the nonworking condyle and the working condyle excursions.
centers of rotation such as the transverse 11oriZontal axis (THA) and
2661
• 2
..
Right left
border border co
•
•
�
eLL
�a ·
"
'a
•
a • ...
I> c MP
Fig 18-4 Posselt's ellVelope of motloo. (a) Sagittal view (fusiform shape). C�e11tric occlusion; Ml-maximal interCtJspation; R-rest po siion; EE-e<Jge-to-edge pro1rosive
t
position; MP-most protruded position ; Mo-most �n position. Note that CO is inferior to Ml but superior toR. The centric relation arc represents pure rotation as determined by
the transverse horizontal aXis. The translatloo arc represents the b<xlily movement as the colldyles travel down the eminence to MO. The dolledlilles represent superimposed incisors
with movement from EE to Ml during incising. (b) Frontal view (shield Shape). RL-right laterotrus!on; LL-teft lateratrus!an. Nate that ZOM 1 signilies righVlett laterotrusian, the
junction or 1 and 2 represents the greatest ver1ical magnitude of canine guidance or group functioo, and zone 2 is beyond the functional range of disocclusloo and may represent
other posterior tooth contacts including working/balancing contacts. The dolled line represents the SltperimPOSCd right maxillary and mandibular canines in right closing (chewing
stroke). (c) Horizon tal view [rhomboid Shape). RL- mos t right taterotrusion; LL-most le ft latcrotrusion. The tracing or the border movements in the horizontal plane appears as a
rhomboid shape with right and left laterotrusloo movements appearing as a Gothic arch shape. Note !hat Ml i s anterior to CO and represents an intraborder position in this illustration.
Table 18-1
[[
Parameter Cusp height/angle Ridge/groove direction
Increase vertical incisal or canine guidance Increase posterior cusp height No change
tncrease honzontal indsal or canine guidance Decrease posterior cusp herght No change
lnct'ease horizontal condyiar inclination Ina-ease posterior cusp height No change
Decrease maxillary palatal and mandibular buccal Mandibular pathWays more distal; maxillary pathways
Increase Benneu angle
cusp heights mediolaterally more mesial
Widen fossae and decrease maxilla!y buCCal and Change co;relates or is inftoenced by pathWay or
lnct'ease Benneu movement
mandibular lingual ctJsp heights mediolaterally worl<ing corldyte
Mandibular pathWays more distal: maxillary pathways
Increase intEl<'Conc:IYiar width No change
more mesal
i
Increase posterior oedUsal plane l'lelgt1t Decrease posterior cusp height No change
Increase cwve of Spee Decrease posterior cusp height No change
The Christensen phenomenon (horizontal condylar inclination), The Bennett angle. or lateral condylar mo vement . is steeper than
along with the Bennett angle and movement, has a significant im the horizo nt al condylar inclination (protrusive angle), and the differ
pact on t he height and location or cusps, ridges, and grooves of the ence between the two is referred to as the Rscher angle. This angle
posterior teeth. It should be recognized that the acts of inciSing or is formed by the intersection of the protrusive and nonworking-side
trituration. or the functional envelope, o nly represeflt approximately con dylar paths as viewed in the sagittal plane.'3·33·"' The difference
one-third of the initial condylar pathways. Areas beyond edge-to allows the presence of a greater mediolateral cusp height anatomy
edge contact are outside or Functional mandibular movements but from central fossa to cusp tip, and it may lessen the potential to r
may be within the range of parafunctional movements {Table 18·1). damaging horizontal tooth contacts during lateral excursions. The
267
1 8iThe Mutually Protective Complex: Occlusion and Fixed Prosthodontics
Fig 18·5 Occlusal pathways. (a) Maxillary posterior segment; {b) mandibular posterior THE Af\JICUIBTION QUINT RIIIIOlf'H L.HANA\J.
segment Th e red dot represents llle palatal cusp of the maxillary first molar as it
occludes the oentral fossa of the mandibular first molar. The blue dot represents the
midbuccal cusp of tile mandibular molar as it occlude s Into the central fossa of the Fig 18·6 tlanau quint. (Repnnted from Hanau" with permiSSion.)
maxillary fltSt molar. The pathways between llle blue arrow (working} and red arroiV
(n onworking) represent llle functional envelope. The black arrow (protrusive pathway)
lies in between.
benefit gained is the added insurance against deflective contacts creases or decreases in the intercondylar width expand or retract the
or destructive processes in lateral excursions. or more specifically, fan, respectively. Greater anterior guidance and condylar inclinations
the mediotrusive or balancing pat11way. For example, if the Fischer increase the vertical aspects while immediate Bennett movements
angle were 0 degrees (mediOtrusive and protruSiVe angle similar in shorten or flatten the cusps. Therefore. the occlusal interface topog
the sagittal plane), then the topography of the posterior central fossa raphy reflects the posterior determinants in add�ion to the anterior
and incline toward the cusp tips would be required to be flatter me determinants and defines the parameters within which the chewing
diolaterally. This causes slightly shorter cusp heights and results in cycle functions (Fig 18-5).
a Hattened mediolateral occlusal plane (curve of Wilson) and less
prominent antel'oposterior occlusal plane (curve of Spee). As a re Anterior determinants
sult, a deflective balancing contact would be most evident on the
buccal incline of the mesiolingual cusp of the maxillary first molar The separation or disocclusion of posterior teeth during protrusion
when it meets the lingual incline of the mandibular buccal cusp on noted by Christensen3' occurred at a time when much importance
the nonworking side. was placed on a balanced articulation (BA) occlusal scheme. BA is
An immediate Bennett movement would essentially have the the bilateral and simultaneous anterior and posterior occlusal contact
same inHuence but would also include increased tooth contact be o f teeth in centric and eccentric positions. Attempts to approach BA
tween the lingual incline or the maxillary buccal cusp and the buccal occlusal schemes from a scientific perspective or discovery led to a
aspects of the mandibular buccal cusp on the working side. Hobo period of p rescriptive geometry and engineered formulations••-"'""'
noted variations in the movement of the working condyle that ap· A significant development was the Hanau quint, or five determinants
peared to be related to the nature of the canine guidance.35 A weak of occlusion"' (Fig 18·6), which was simpfified by Thielemann's alge
correlation appears to exist between the Bennett angle (nonworking braic equation311.39:
condylar path) and the contralateral canine lingual incline guidance.
Balanced condy e
l ar guidanc x inc isal guidance
Anterior and lateral guidance is generally greater than the respective ""
-'
condylar guidance in the dentate patient.

articulation = c:
:-us
-
:
- :p-an
::-
-:
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of
orientation articulation
Variations in the intercondylar width and in the tooth's distance
from the centers of rotation have an additional impact on cvspal Using this equation, steep condylar and incisal guidance require
pathways that do not contact, the ridges. and groove direction. a higher cusp-angle form, accentuated compensating curve, or el
These variations follow a fan-shaped pattern. with the changes in evation of the occlusal plane in order to achieve BA. Conceptually,
the Gothic arch pathways of mediotrusion and laterotrusion. and the equatiOn may also be used in reverse to predict the lack of tooth
with protrusion and lateroprotrusion interspersed. The area between when gliding tooth contacts are not desired.
the pathways represents the potential areas of tooth contact. In·
2681
Fig 18·7 Oevelopmeflt of progressive disoo:lusion. (a) Patient had severely wom teeth
from bruxism. resulting In a loss or vertical dimension of occlusion (VDO) and loss of anterior
guldaoce. Extensive crown-lengthening pr�oures were performed to achieve adequate tooth
preparations. (b) Because o l the severe bruxism habit and maxillomandibular relationship, only
minimal anterior guidanoo oould be deveiOj)C(! resulting in a group function in laterotrtlsioo
, Fig 18·8 The potential for wear of the restorative material is greater in this
The potential for develop ing aberrant mediotruslve tooth contacts ever time Is greater patient. The clinician should anticipate occlusal wear and lherefl)(e plan or
in this patient and may result In deflectioo on mandibular closure. The posteriOf condylar develop a progresslve disocclusion that allows gliding tooth contacts durtng
determinants will have greater inHuenoo on proximal restorations and 111 this situation require eccentric taw movements. It IS also tecOfnmended that an occlusal device be
shol termed1olateral and anterO(JOSiertor cusp heights. Therefore. recording and replicating the placed to reduoe the fracrure and wear potential. with penodic recall to mon itor
coodylar determinants is crt i ical in the occlusal scheme envisiooed. any occlusal changes.
Granger believed that BA maintained the dentition in a state of CG or GF.•• The restoration of worn denti t ion must take all of t hese
functional equilibrium.·�·" The method to achieve SA required re obseNations into consideration to develop a mutually protective oc
cording the patient's condylar guidance and the clinician's deter clusion. Allowances lor the inevitable wear of the restored dentition
mination of the appropriate incisal guidance (IG). and then selecting a are indiCated and should be incorporated into the design of contigu
cusp angle, plane of orientation, and compensating curve to achieve ous tooth fomns. Considerations include (7) material selection, (2)
t he desired tooth contacts. The primary purpose of BA was to achieve the development of a planned progressive disocclusion from anter ior
cross-arch gliding tooth contacts t o stabilize removable dental pros to poster ior (if an terior disocclusion is subsequently lost because of
theses for the edentulous patient. Capturing the precise condylar wear). (3) p at ien t education, and (4) an occlusal device to reduce the
guidance, cont!QIIing the other four detemninants, and reproduci ng effects of parafunctiOn. Elimination of posterior deflective contacts
these determinants on a patient analog 1nstrument became a scen
i ce requires that the restored IG be greater than t he horizontal condylar
unto itself. Thielemann·s formula was a mathematic approach to SA inclination (see Rgs 18-7 and 18·8).
calculations that could project the amount of tooth ntact based on
co However, � is not acceptable to merely create steep IG w�h im
the selected paramet ers. However. li mitat ions were found when these mediate disocclusion, which may be traumatic. Steep IG schemes
principles were appl ied to the natural dentition. can resuh in worn, mobile, malposed natural teeth; exposure of re·
Schuyler questioned the presence o f balan ci ng contacts in nat ural storative materials to excessive yield-strength forces; or the need for
dentitiOn because they appeared to be a cause of TMJ dysfunc high-resistance and retentive tooth preparations. Determination of
tion, periodontal involvement. and excessive wear.•• Shupe e t al the restored incisor length and thc i kness and t he Ml contact position
found less muscle activity generated in a canine guidance (CG) ver is critical. F urther refinement is needed between these two determi·
sus group function (GF) guidance, based o n an electrom yogr aphic nations to properly develop the maxillary lingual fossa, which should
(EMG) st udy of n ine subjects:>;) Williamson and Lundquist observed iculator s anterior guide
be concave and n ot linear. The use of an art '
decreased EMG activity of the masseter and temporalis muscles table may result in a flat-plane lingual fossa. The lingual fossa's con
when anterior guidance was developed on an occlusal device, thus cavity and resultant guidance must be more progressive in design to
eliminating posterior tooth contact.'' Reversal of the process led to accommodate mandibular movements that occur between edge-to·
an Increase in muscle groups and aci t vity when the anterior guid edge contact a nd the MI. Mandibular movements that occur during
ance was eliminated and posterior tooth contact was made. Both t on must also be contact free and unrestricted. The
speech produci
studies suggest that canine guidance causes less wear on posterior l ingua l fossa should nol be convex, which can happen after selecting
t eeth and less stress on the TMJs because of r educed muscle activ an incre ased VDO level that compromises incisal coupling. Contem·
ity. Goldstein reported a more favorable periodontal ind ex with ca· plation of the occlusal scheme under development should include
nine-protected articulation after evaluation o f 100 pa tients with either the Influence of vertical determinan1s.
269
Vertical determinants Desjardins noted that the PRP and VDO are difficult mandibular
positions to evaluate.6• Methods t o determine rest position are to
The physiologic rest position (PRP) is the mandibular position as some extent unscientific or lack specific reliability. Therefore, their
sumed when the head is in an upright position, the elevator and determination should not be confined to a single technique or con·
depressor muscle groups are in equilibrium in to ni c contraction, and sideration.61·03 Similarly, the VDO may be represented by a variable
the condyles are in a neutral, unstrained position. '3 The VDO is lo range but has inviolate endpoints controlled by other influencing
cated superior to the PRP by approximately 2 to 4 mm. This space factors. The importance in determining an appropriate VDO can·
between PRP and V DO is known as the interocclusal distance or not be overstated. Its relationship to CR is critical because it
rest space. The PRP is typically anterior and inferior to centric rela becomes the preliminary level from which an occlusal scheme and
tion (CR) and varies in its distance and position relative to the VDO, Ml are developed. When the patient with a malocclusion is to be
CR. and skeletal retationsl1ip. Absence of the VDO in the edentulous restored, the arbitrary selection of an increased or decreased oc·
patient poses concerns in determining the most suitable occlusal clusal plane or VDO for prosthodontic convenience affects the incisal
position as a result of the loss of the dentition an d compromised coupling effect and may result in tooth Intrusion and extrusion."'..e7
proprioception.•• Additionally, changes to the anterior guidance require concomitant
Physical methods to assess VDO include symmetry of facial changes to the occlusal plane and resultant cusp angle to eliminate
thirds, preextraction records, measurement of the current dentition/ deflective occlusal contacts or for the creation of gliding tooth con·
prostheses, parallel ridge relations, and maxillomandibular incisal tacts. Methods to transfer anterior ooctusal guidance to the articula·
edge relationships. '1 Physiologic assessment includes measure tor may include recording the IG a s determined or established by
ment of the PRP through evaluation of phonetics, esthetics. swal provisional restorations or wax reference crowns that are confimled
lowing, myotactic contraction, reftexive stretch. and patient comfort. intraorafly. 68
Head position, muscle fatigue, skeletal relationship, and resorp
tive changes can influence muscle tone and therefore affect PRP
measurements. Niswonger evaluated 200 dentulous patients and Anatomical planes and centers of rotation
observed that 87% had a mean interocclusal distance of 4/$2 inches
or 3.2 mm. with a range of '/32 to "/32 inches.48 A subsequent study A variety of methods to record CR and border movements to rep·
o f 200 dentulous patients with advanced attrition and apparent loss licate a patient's jaw movements have been developed over time.
of voo found similar measurements, suggesting that the rest posi· They include positiOnal interocclusal records. leaf gauges. jigs.
lion reflected changes in the VDO and underwent muscle foreshor graphic stylus recordings, stereomolded TMJ and IG analogs. com·
tening.<9 Swerdlow evaluated 40 patients radiographically before puter-aided design/computer-assisted manufacture {CAD/CAM)
and after extraction and noted a slight increase in VDO, followed by imagery, and electronic tracking devices such as the Denar Cadiax
a subsequent decrease after 6 months. He also noted that interoc Com pact 2 System (Whip Mix). Maxillomandibular recordings may
clusal distance was greater with phonetic (3.7 mm) versus swallow· be transferred to a patient analog instrument for cast articulation, oc·
ing (2.6 mm) testing methods."' clusal analysis. ancl fabrication of indirect dental restorations. Proper
The interincisal relationship can assist in establishing the anterior recording of movements and adjustments using patient analog in·
reference point of the VDO. This dimension is measured through struments requires a basic understanding of the rotational centers,
phonetics ar1d the evaluation of the interooclusal distar1ce from rest arcs, and planes involved.
position to mandibular incisal contact into the lingual cingulum area Physiologically, the occlusal plane (1) may bisect the available
of the maxillary incisors. The approximation of incisal edges during distance between ridges; (2} may be aligned wih
t the postural position
speech testing, such as the closest speaking space, and facial-tooth and lateral borders of the tongue, buccinator, and glossal muscular
esthetic profiling are also necessary. During sibilant production. the activity: and (3) must allow the tongue to retrieve food from the
space between the anterior teeth should provide 1 to 2 mm of clear buccal sulcus and create intelligib le speech. The anterior occlusal or
ance for proper articulation. The contact-free mandibular movement incisal plane affects esthetiCs, the incisor-lower lip line relationship,
is usually in an anterior-inferior direction.�' the need for lip support, phonetics, and maxillomandibular skeletal
Patients with excessive VDO or excessive incisor overlap are un configuration. Anteroposterior plane discrepancies also may be ac·
able to place the tip of the tongue between the incisors when testing companied by transverse occlusal planes tl1at are neither congruent
lingual-dental sibilant phonetic combinations such as "these shoes." nor consistent.
An increased VDO that violates the PRP can result in excessive tooth
contact, pain, fracture. and intrusion. A decreased VDO may affect Points of reference
mastication efficiency as the Ml closure passes beyond the function
al muscle-length range, resulting in the lack of phonetic clarity. ather The third point of reference. such as the orbitale e
r lative to the orien
extreme position may create symptoms of muscle fatigue. Therefore, tation of facebow records, is a readily discernable anatomical land·
care must be exercised in detem1ination of VDO and should attempt mark. Gonzalez and others determined the third point of reference in
to correlate with the dynamic interincisal relationship. facebow articulator mountings was incorrect.""·" They observed that
270 1
the transverse THA was lower than \he orbitale and that the Frank spatial relationship between the maxilla and the THA and thus offers
fort horizontal plane and Camper base plane were not truly parallel a more precise transfer to an articulator. The benefits are threefold:
to the natural horizontal plane (NHP). The "errant" third point of ref
erence was believed to be a factor in the development of aberrant 1. The arc of closure and excursive pathways are likely to be more
tooth contacts. particularly in lateral excursions or in visualization of accurate on the articulator, thereby lessening inaccuracies at the
the occlusal planes of articulated casts. Methods to create a more occlusal interface.
COf'rect alignment with the NHP and to enhance the accuracy of arbi 2. lnterocclusal CR records may be made at a slightly increased ver
trary THA have been suggested-'2 Because the condylar inclination is tical dimension and transferred to the articulator.
maintained on the upper member of arcon instruments. the condyfar 3. Slight alterations o f the VDO on the articulator in the dental labo·
determinants should remain mOf'e constant relative to the third point ratory should be representative of similar changes in the patient.
of reference, thus minimizing potential error.73 It should be noted that
nonarcon instruments may not accept some eccentric interocclusal Eccentric records may be made with maxillomandibular static in·
records. unlike arcon instruments. Lack of the Fischer angle element terocclusal records or by dynamic pantographic tracings or elec
in most semiadjustable articulatOf's may result in shorter balancing tronic tracking devices that allow the articulator's condylar elements
cusp contacts in lateral excursions or the restOf'ation. thus further mini to be geometrically aligned to the patient's anatomical occlusal de·
mizing this potential error for nonbalanced articulation. terminants.
The observation of the condylar inclination, as numerically denoted The articulator is more frequently used because of the simplicity
in degrees on an articulator, is influenced by the selected third point with which artlitrary or average-value THAs are located and trans
of reference. The QuickMount Facebow (Whip Mix) uses a nasion ferred by an ear facebow or by average condylar element values.
projection to assist in determination of the third point of reference The arbitrary facebow method has been found to be anterior-inferior
(orbitale), and the Hanau Springbow (Whip Mix) uses the orbitale as but usually within 5 mm of the kinematic THA. These approximate
the third point of reference. The Denar Slidematic Facebow (Whip determinations may create occlusal interface errors in the range of
Mix) reference point is 43 mm above the incisal edge, superior to 0.2 m m at the second molar.19-S3 One study found closer THA ap·
the Camper base plane but Inferior to the orbitale. The relative posi proximations,ao• and other authors oppose the concept of pure rotary
tions of casts within the members of these articulators reveal subtle motion used to represent the constantly changing curvilinear contour
differences. The use of the nasion point and axis-ortlitale plane may of the condyle against the articular eminence.85.&; Superior-anterior
result in a more severe anteroposterior cant appearance of the oc THA deviations produce greater occlusal discrepancies compared
clusal plane in QuickMount and Hanau mountings. Interestingly, the with inferior-posterior THA deviations."'
Denar anterior reference point extended t o the axis point is nearly Semiadjustable articulators that accept positional records can
identical to the NHP when the patient stands. which tends to raise only provide endpoint information, in contrast t o a fully adjustable
the anterior aspect of the occlusal plane. instrument. Those incremental point pathways may be concave,
Regardless of the articulator used, the condylar inclination should convex. or a temporal combination of the two and not linear.sa A
correlate with the occlusal plane and the selected third point of refer fully adjustable articulator offers the best oppOf'tunity to replicate the
ence. Mountings with a steeper occlusal plane may reflect steeper patient's mandibular movements. which permits better-designed
condylar-inclination measurements yet remain relatively consistent restorations, probably with fewer chairside adjustments. However,
with each other. Procequral consistency by the operator may allow simulation of excursive tooth contacts on an articulator is only an
discernment of modifications in the methodology needed during approximation ol dynamic occlusal relationships.89 The concept that
treatment. It may be necessary to make adjustments in the articula the patient is the ultimate articulator illustrates that a technique to
tor settings Of' values and variations in recording methods. based on fabricate dental restorations that require zero adjustments is yet to
correction of positive errors (increased contact or higher cusps) or be designed.
negative errors (lack oi contact, shorter cusps). A s such, the clinician The semiadjustable articulator may lack other features. such as the
should understand the nuances of the instrumentation used relative Fischer angle, immediate sideshift, or variable intercondylar width.
to the clinical situation.14·'a Nonarcon articulators usually do not accept lateral interocclusal re·
cords and rely upon formulation averages to determine the Bennett
Adjustable articulators and equivalency angle. Unear or flat anterior guide tables or condylar elements may
further hamper the restorations' contOllr by overcontouring (positive
Restorations fabricated indirectly reQuire methods to capture the error) or undercontouring (negative error) influences of the occlusal
3D form of the prepared teeth and dynamic maxillomandibular re interface. However, these observations should not curtail the use of
lationships of the dental analogs (casts). These records allow the a conventional semiadjustable articulator nor lessen its merit as a
development of proper tooth contours and occlusal anatomy. An patient analog or the critical role it plays in the laboratory. They do
articulator can provide a significant reduction of treatment time and require that the clinician maintain an open mind when using a semi
facilitate the completion of indirect restorations in tl1e patient's ab adjustable articulator to overcome the limitations of any mechanical
sence. The kinematic facebow method is able to record the correct instrumentation. The clinician must determine what is expected of
271
1 8iT h e Mutually Protective Comple x : Occlusion and Fixed Prosthodontics
I
l �_rji. �!:'L�t()_r 1!ttriE!J!�.!U!.��-t l!!!i_r r.e_�I?.� £1!Ye_;
_
Table 18-2
;I -
uses
Attribute Concept
Capable or receiving transler or 3D position or maxilla Spatial orientation of casts fo r a•c o

r ciOSUfe and lor esthetic
and mandible relative toa n anatomical plane or reference assessment
Capable of receMng THA recordings with rotary movement CR. centric occlusion (CO). MI. ridge and groove direction
or condylar element and variable intercondylar distance O<
I
ver tical axes
Capable of receiving lateral and protr\Jsive recordings for Horizontal condylar incl•nation, Bennett angle and Bennett
unilateral and b�ateraltmnslatory movement ofcondylar movement, ridge and groove direction, cusp height
t
element. Coodytar elements can undergo 30 modifica ions
to match paUent's mandibular
movements
Anle<io< gvida pin and table that are alte<able to correlate to Maintains VOO. MI. lntercuspal contact area with anerable
patient's IG a nteriO< guidance
a ble upper and lOwe< membels to securely hOld

Pt>ysieatly st Maintain C<lsts in same position repeatedly and over time
maxmary and mandibular casts
the proposed restoration, identify situations in which the occlusal in With current technology that visually quantifies the location and tim
terface needs alteration. and select the proper articulator to achieve ing of occlusal contacts. creates virtual dental casts. and digitally re
the desired resul t"" (see Table 18-2). These fundamentals require cords the pathways ofTMJs, it is probable that present use of physical
developmen1 of an appropriate MPC diagnosis and treatment plan. artiCulators will give way to use of the virtual articulator. Future fixed
prosthodontic reconstruct1ons may involve digital records of the con
Virtual dental articulation dylar pathways: digital records of the IG, lengths, and VDO from either
an occlusal guard or provisional crowns made with CAD/CAM: imag
The combination of computer-aided registration of occlusion. digi ing of all the preparations in one or both arches; and instant program
tally recorded condylar pathways, and virtual dental casts, all im ming of a virtual articulator. Definitive CAD/CAM restoratiOns could
ported t o a virtual articulator to fabricate CAD/CAM restorations, then be fabricated without the traditional technique, time, and materi
may become the new norm. Digital imaging systems currently offer als that are currently common. Most of the elements to this end are
functions that va�y from scanning full or parti al dental stone casts already in practice or in progress.
to directly obtaining intraoral data. Scanning dental stone casts is
possible using any one of several commercially available laser opti
cal scanners. Many o f these scanners a�e made to archive dental
casts. Recording images directly from the mouth to create virtual Diagnosis
dental casts is an available fealure in scanner systems such as the
Cadent iTero (Cadent). OrthoCAD (Cadent), Lava (3M ESPE). and MPC synergy may be reduced by the loss of teeth, periodontium.
the newly introduced ILUMA (IMTEC) and CEREC Bluecam (Sirona). and supporting alveolar bone through accident, disease. or lack of
The Cadent iTero has a Class C laser camera; Lava and CEREC devefoprnent througll disturbances in growth, genetic alterations,
use LED-based images; and ILUMA is a cone beam computed to and tumor development. These alterations affect physiologic func
mography (CBCl)-based system. CBCT technology Ms seen im t i on and ultimately homeostasis. Tooth loss accompanied by un
mense manufacturer interest for surgical diagnostics and planning, treated malocclusions is commonly seen in prosthodontic practice.
orthodontic appliCations. and prosthodontic applications. Advance Tooth attrition. fraclures. and noncaries lesions associated with the
ments in imaging software continue to address problems such as behavioral and destructive influences of bruxism or secondary to
patient movement during imaging and metallic scatter in formation erosion from gastroesophageal reflux disease (GERD) or bulimia are
o f full-arch digHallmpressions. The capability of CBCT technology in also frequent occurrences. Prosthodontic techniques and materials
fabrication of dental restorations, combined with CAD/CAM, is likely selec1ed to restore MPC are only effective when an appropriate di
in development. agnosis is made. Unstable TMJs and aberrant occlusal relationships
can create complexities in selecting 1he most favorable Ml position.
2721
Diagnosis J
Diagnoses should include observations of inappropriate tooth con correction of malposed teeth and disparate arches is sometimes
tours. excessive structural tooth loss, periodontal or endodontic dis possible. However. attempts to make absolute corrections are usu·
ease. tooth malpositions and accompanying discrepant arches. and ally not made without compromise. Assessment of the patient's
temporomandibular disorders (TMDs). The degree of prosthodontic skeletal growth patterns and resultant tooth positions, along with
difficulty may be correlated to the Prosthodontic Diagnostic Index'" contemplation of the possible correction, must occur prior to the
initiation of treatment.95 A planned diagnostic phase with provi
sional restorations often is beneficial. It is important to visualize the
Alterations in growth and development normal axial inclination of the dentition and its spatial relationship
within the arch and between the arches. The axial inclinations, edge
The anatomical growth and development of the craniofacial struc to-edge incisal contact. and the mandibular incisal edge position
tures vary and as a result affect tooth positions and eventually tooth at Ml upon the lingual surface of the maxillary counterpart require
shape. Variable 3D positioning of the TMJs relative to the develop careful consideration. Critical to this end, the appropriate incisal
mental growth and position of the maxilla and mandible creates a coupling must be reestablished during prosthodontic reconstruction
dynamic relationship of the occlusal plane and tooth positions.•• The for the development of an appropriate posterior occlusal scheme.
final occlusal configuration will either become physiologic within the Advance recognition of the maxillomandibular relationship or skeletal
patient's adaptive capacity or will become predisposed to prema abnormalities may serve as prognostic predictors tor dentulous and
ture and destructive tooth wear, with progressive loss of the MPC. edentulous patients and therefore allow better patient care.
The resultant lack of occlusal stability may lead to tooth migration
and further occlusal abnormalities. Cephalometric analysis. with the
recording made in GR and at the appropriate VDO, can be used Alterations of tooth structure
to assess soft tissue, skeletal, and dental variables. Women display
greater maxillary incisal edge length. Older adult patients general The loss of tooth structure may result from demineralization caused
ly display less maxillary incisal e dge. possibly because of a longer by caries or from chemical erosion induced by acid reflux or acidic
upper lip and tooth wear, and more of the mandibular incisors.93 food.96 Frictional tooth loss may result from attrition by parafunction
Tooth migration, wear, and extrusion and splaying as a result of loss or from abrasive food substances.Abrasion also may be caused by
of posterior occlusal support or periodontal involvement therefore imp roper toothbrushing or incompatible restorative materials. Mac
affect the occlusal interface. rotrauma can lead to a variety of acute tooth fractures. and repetitive
Orthodontic treatment. combined with orthognathic or prostho microtrauma to the occlusal surface as a result of lateral or paralunc
dontic realignment of discordant arches (see chapter 2). may cor tional occlusal forces has been suggested to generate chronic flex
rect many malocclusions and provide the opportuni1y for normal ural compression-tension mode abtractions that are propagated to
physiologic activity and appropriate tooth contact/wear to develop.•• distant sites such as the cervical aspect of the tooth.91 Other i nves·
Unfort unately patients who require prosthodontic care often pres
, tigators have not found a correlation between occlusal wear and the
ent with an untreated malocclusion accompanied by terminal health formation of noncaries cervical lesions.96·'00 Additional risk factors for
of the dentition. The esthetic losses incurred as the result of under high occlusal wear include bruxism. loss of molar contact. and edge·
lying malocclusion may be the primary initiating factor for the patient to-edge incisal relations; i n addition, mates generally show more oc
seeking treatment. Therefore. recognition of the preexisting anatomi· clusal wear than women. •O• TI1ese various modali ties of tooth wear
cal facial. skeletal. and dental relationships will assist in proper treat are in stark contrast to age-appropriate or "normal" expected tooth
ment planning to reestablish the patient's MPC occlusion. However, wear over a lifetime. The differential diagnosis of noncaries cervical
the prosthodontic realignment of the maxillomandibular relationship lesions and loss of tooth struclure prior to treatment is important.
and the patient's concept of ideal tooth positions must be tempered The combined or sequential development of stress. friction. and cor
by the physical variations and physiologic limitations of the patient's rosion lesions should be understood because it may influence the
growth and development. outcome of a chosen treatment.'02
The extent of tooth wear depends on the abrasiveness and pH of
Prosthodontic impact the diet and the frequency, magnitude, and direction of tooth con
tact or "angle of attack" relative to the interincisal angle and c hewing
Orthodontic treatment typically is completed on the growing patient. cycle'03 (Table 18·3). Of importance relative to wear are the IG pa·
which may facilitate the correction of underlying malocclusions and rameters and materials used to restore teeth.IG includes the (1) hori
possibly redirect developmental growth. While an adult or nongrow zontal and vertical overlap, (2) amount and location of the contact,
ing patient may undergo orthodontic treatment. corrections obtained (3) angle of contact. (4) incisal level compared to the posterior occlu
to enhance the prosthodontic outcome may be limited or require sal plane level, and the (5) corresponding labiolingual curve of each
supplemental orthognathic surgery. Tooth malposition in a patient arch. •o• For example. the alignment of the dentition in the patient
with an under lying malocclusion is often the tipping point in the with a Class II, Division 2 malocclusion is predisposed to anterior
decision to extract an otherwise restorable tooth. The prosthodontic tooth wear, and the patient with a Class II, Division 1 malocclusion,
273
Table 18-3 l c l ass,

i ti c at i o n ottootti'ioss/�ear·
----------------------------------------------
Etiology Process Location Features Notes
Bruxism At trl1ion Anterior more than posteriol' LOS$ o l too th st ruct u e

r is
prog oes- Worn surf8ces coincide: 00/�nce<f w�r.
sivety grea ter toward t11e anterior d1Je to w11ich may be locaiZed; Class 11
unfavorable changes possibly created occ�ion may Pfedispose the patlsnlto
by deflective occlusal contacts abnoonal wear pattems
GERD/bulima
i Erosion Anterior more than postenor Maxollary hngual from free g11gival margin Island restorahons necessary; worn
to incisal and palatal aspect of posterior surfaces do not coinclde: lncr�sed
tooth; tongue shields mandbular frequency ot young females woth bulimia
anteriOJ' teeth
Carbonated EroSion Posterior ffiOJ'e than antefior CUppjnglctatering with sharp enamel Island restorations necessary: worn
soft drinks edges; mandibular first molar ocdusal surfaces do not coincide
(acidic) Involvement IS most C()J'nmon
Fruit muD1ng Erosion Pos terior more than anterior Maxilary and mandibul3r teeth WOJ'n Abraded enamel edQ0S penpheral t o cuPS!
{acidic) equally: cupping and cratering craters will match
TOOthpaSte/ Abrasion Facial/buccal surface of mancfi. Lossof enamel surface details; cervical Denuded areasand restorations may have
toothbrush bular canine and p<emolars dentin notched apiCal to enamel polished appearance: confiomed by 1n
predominate Vllro tests
Blomechanlcal Abfraction Cervica1 aspects of teetn Loss of enamel witn chipped/ Microfracture of enamel rods, dentin, and
overload delaminated appearanoa opposite cementum
area of occlusal overload
Harsh diet or Abrasion Posterior more than anterior MaxiDary and mandibular teeth wom Advanced �bnOrrnal wear facets coincide
eno.ironment equa!ly due to d>el oonsistlng of hard or
abrasive substances or dusty
enVJronment
Amelogenesis Genetic Generalized occl.Jsal wear with Accele<ated wear due to hypoplastic, Thinner and softer enamel and dentin that
imperfect a CleaVIng of friable enamel from l1ypocaJCifted. hypomatured enamel: are prone to caries
the dentin enamel is discolored
Other Vari able Location-specific wear Unique lo the situation Unglazed or abrnsive porcelain: pipe
smol<ing; lemon SJ.Jcking
open b ite or reverse articulation is predisposed to posterior wear.

, enamel wear compared to polished ceramics that contain minimal
Additionally, bruxism and the physical properties of the materials at to no leucite . ' '0 and an acidic environment may further result in dis ·
the occlusal interface, such as porcelain opposing enamel. acceler solution of K,O.
ate the wear rate.•os Wear of enamel that opposes metal occurs by
plastic deformation whereas
. wear of ceramic materials occurs by Acquired Ml
the loss of the surface glaze and seq ue
ial microfractures. '06 Sliding
nt
wear can result from adhesive wear of similar materials or from sub· It is common to observe acquired Ml anterior or lal9fal to CO. along
surface fatigue, leading to delamination that is common in the enam with deflective tooth contacts greater than 2 mm. during centric and
el-dentinal complex.107 Wear also may happen when an abrasive eccentric movements in the worn dentition. As the coronal aspect of
diet or substance is introduced. creating two-body or three-body the tooth form recedes, the function of the tooth and the dynamics
wear. This Is made progressively worse when saliva is not sufficient of no rmal muscle activity may change. Muscle splinting, habitual an·
to act as a lubricant. Two-body wea r studies that mimic parafunc terior mandibular posturing, and the reduced PAP accompany these
tion may result in greater wear. '06 The concept of three-body wear is observations. possibly resulting in tooth migration or unusual wear
relevant when dissimilar materials are i ntroduced opposite enamel. patterns and unstable acquired Ml positions.
It has been establiShed that gold alloys have a wear facto r si milar to In patients with a nonuniform Ml without periodontal factors. the
enamel , whereas porcelain i s known to cause g reater enamel wear, assessment of tooth mobility be a meaningful observation. In·
can
which may be related to loss of the surface glaze and fracture tough struments that can provide o bjective and quantifiable measurements
ness rathe r than the material s hardness.100·'09 Moreover, the pres
' have been developed to detect tooth mobility (Periotest IMedizintech
ence of leucite in the glazed ceramic resto ration may result in more nik Gulden)) and uneven occlusal contact(T-Scan Ill (TekscanJ)."'-117
2741
Diagnosis J
The use or full-arch pressure sensors that allow chairside computer The loss of posterior occlusal support and VDO places additional
analysis has been made possible by the T-Scan Ill. This system forces on the anterior teeth. This causes tooth migration. loss of
allows the clinician to determine locations and timing or deflective labial bone, diastema formation, splaying, altered IG. abnormal wear
occlusal contacts instantly and to review eccentric tooth contacts. patterns, passive eruption, and the muscle splinting that seems to
Objective graphic data on a chairside computer monitor document occur with TMDs in some patients. Patients with severe attrition or
and aid in intraoral adjustments. Clinicians should keep in mind the missing teeth will likely require restoration of the collapsed VDO.
limitations of any device, the level of difficulty in interpretation of the However, some patients may require surgical or prosthodontic re
results, and the derived treatment directives. Clinical assessment of duction or an excessive voo t o an appropriate level. An increased
discomfort or signs of fremitus, unexpected wear or tooth migration. VDO may be the result of tooth extrusion. open bite, vertical maxil·
or periodontal changes may have low specificity but high sensitivity lary excess, or lack of a patent nasal airway. Restoration of the MPC
and therefore may be diagnostically more reliable. may require orthognathic realignment of the arches or extraction of
Patients with developmental growth disorders or acquired de teeth that interfere with the occlusal plane.
flective occlusal tooth contacts may be predisposed to develop The loss of any tooth in the partially dentulous patient usually leads
abnormal wear of any one component over time. As a result, the to a milieu of interarch and intra-arch integrity issues resulting from
orthodontic stability. endodontic/periodontal health. and tooth adjacent teeth that drift into the space created by the missing tooth.
restorability may become compromised. Isometric clenching typical The dentition continues t o erupt beyond the occlusal plane in the
ly occurs In Ml, whereas bruxism involves more CR-Iateroprotrusive absence of opposing occlusal forces. Subsequent tooth malposi
movements, as evidenced by congruent or matching tooth wear pat tions may affect periodontal health because of the loss of protec
terns. These meaningless mouth movements more closely resemble tive proximal contacts, creation of angular periodontal attachment
articulator movements, in contrast to masticatory movements. defects. and nonaxial loading. Retention of malposed teeth may
In these situations, the patient may remain symptomless while require the apical reestablishment of the biologic attachment through
attempting to adapt. sometimes despite obvious signs of ongo crown-lengthening procedures and possible therapeutic endodontic
ing destructive processes and gradual degradation of MPC.113 The therapy to address physical proximity and requirements of restor
extremely worn dentition may exhibit aspects of a balanced arti ative materials.
culation but lack the necessary components to maintain a stable In addition, it is common to observe altered Ml pos'r t ions caused
MPC occlusion. It is believed that the posterior contacts of the by deflective tooth contacts that shift mandibular closure. These ac
dentitiOn o n the mediotrusive or nonwori<ingfbatancing side are quired positions d isrupt the proprioceptive control and the otherwise
potentially harmful in the dentulous patient. These contacts may in harmonious gliding eccentric tooth contacts."• Anterior pasturing
terfere with the progressive anterior disocclusion. deplete the centric of the mandible may lead to foreshortening of the lateral pterygoid
holding cusps, and accelerate the toss of Ml and VDO. Balancing muscle through continuous contraction and may result in changes
and cross-articulating contacts increase proximal and distractive within the articular disc complex. This c-reates difficulties in deter
forces to the condyle, possibly interfering with the intimate contact mining the original CR position. Placement of an occlusal splint to
with the articular disc and eminence. These findings may indicate the create passivity may eliminate the proprioceptive input from the
need for intervention. acquired Ml position. leading to a stable and repeatable CO position.
CR as a repeatable reference position is the integral position from
which an occlusal scheme may be developed. Other positional ref
Alterations of arch integrity erence points are arbitrary, inconsistent. or are missing because
of aberrant acquired positions. likewise, the occlusal int erface refer
Tooth toss may result from avulsions. fractures. periodontic or end ence points may have been removed in the course of tooth preparation
odontic disease. or caries that renders a tooth nonrestorable. The for crowns or fixed partial dentures. Advanced tooth wear. tooth loss,
types and incidence of cracks that lead to tooth loss have been and acquired mandibular positions may disguise a pre-existing under
related to the presence of Class I or II intracoronal restorations. ex lying skeletal malocclusion. Therefore. it is important for the prosth
cursive interference, parafunction. and age. 114 The loss of a tooth odontist to consider obtaining cephalometric analyses and diagnostic
and its periodontal connection also includes the potential loss of wax-ups of the projected changes and verify the proposed chang·
the alveolar bone. Alveolar bone growth factors begin as the tooth es through reversible procedures, whenever possible, before def
erupts and are mediated during eruption by the periodontal ligament initive treatment is begun. The diagnosis must include an analysis of
tension and functional loading. As these elements are lost when a the patient's CR. co. MI. PRP. VDO. and gliding disocclusion factors
tooth is lost, subsequent reduction of alveolar bone occurs over time to restore the MPC. While the diagnostic findings and attempts to
because the disuse atrophy alters the physical form of the alveolar restore them may be approached from a mechanical engineering per
ridge horizontally and vertically. Maintenance of the residual ridge spective. the definitive restoration of an MPC ultimately demands that
ultimately depends on the atraumatic nature of tooth removal and all factors be biologically, functionally, and esthetically acceptable.'•e
alveolus preservation, the proximity and health of the adjacent teeth,
and the patient's systemic health.
275
Parafunction logic tooth wear from each component and creating a synergistic
stability.
Mandibular movements during bruxism. associated with stressed Alterations of the controllable occlusal determinants. such as the
individuals, are different than those obseiVed during chewing. Rather Ml position, may be indicated depending on the health status of
than intermittent in duration, light in magnitude, and vertical. man· the TMJ or skeletal malocclusions. Discordant skeletal and dental
dibular movements during bruxism are prolonged, excessive. and components in the horizontal plane may require an in tercuspal con·
some times horizontal.117 Chewing motions are t ypically well within tact area (also known as long centric) approach in tre atment plan·
the border movements. but bruxin g movements challenge the di l· ning. A determi nation must be made regarding the required number
lerence between CO and Ml and test the limits of the envelope of of occ luding dental units needed to establish a stable occlusion.'"'
motion -"&."9 The incorpora tion of a shortened dental arch construct may be
Disocclusion time refers to the time in which posterior teeth sepa· appropriate in certain situations. 12"'12<! However, any attempt to
rate during mandibular movement and the length of time that the restore the occlusion will be short-lived without the correction or
elevator muscles contract. Kerstein compared the disocclusion time mitigation of the underlying etiology or casual factors in the develop·
of 49 patients with chronic myofascial pain dysfunction (MPO) to a ment of tooth wear or loss. Reduction of lateral stresses and hyper·
contr ol group, with consideration or sex and Angle classilieati ons.1:>o fl1nction is paramount and should be mo n itored by assessing tooth
The results indicated that patients with MPO had longer dlsoc· fremitus. mobility, wear, and migrat i on resulting in open proximal
elusion times, followed by pat ients with open bite Class II malocclu·
, contacts. The presence of a forgiving proprioceptive neuromuscular
sions. Class Ill malocclusions. and finally Class I malocclusions. No capacity does not eliminate the need for accurate treatment.
significant differences were f ou nd between men and women. It was
suggested that the patients with MPD had chroniC ischemia and
muscle dysfunction; meanwhile. patients with a malocclusion lacked
the anterior gllidance necessary to reduce elevator muscle activity, Restorations and Treatment
yet they may remain within their physiologic tolerance. Yang e t al
demonstrated that posterior movement of the mandible during lat • The historical development of gold alloys that were compatible with
eral translation correlated wit h internal derangements of the TMJ'2' various ceramic materials led to the advent of all-ceramic resto·
The notation of clinical obseiVations in a pantogram is helpful to rations. These expanded the scope of care and treatment refine·
monitor the pat ient s range of motion and provides a chronology that
' me nt for fixed prosthodontics. All-ceramic materials ushered in new
helps track periodic changes or restrictions in the range of move· requirements of materials science, accompanied by caveats of bio
ment over time. which may reflect underlying skeletal or neuromu s· logic safety and tissue compatibility as t he prosthodontic restoration
cular disorder s . Chapter 7 provid es more detail. became a biomimetic and effective functional replacement. Severely
worn and frail teeth benefited from full-coverage or partial-coverage
Occlusal stability restorations that re st ored the axial and occlusal forms of the teeth ,
resulting in greater tooth longevity and improved esthetic s.
To verilY the feas ibility of restoring the occlusi on at an increased VDO.
placement of an occlusal device Is still a warranted clinical proce
d ure prior to embarking upon any irreversible change in the patient's Fixed prosthodontic outcomes
occlusal scheme.m Alterations in VOO and the subsequent superior
or infer ior rotation of the mandible to achieve an acceptable Ml must Although the clinical successes in fixed prosthodontics are well
be carefully pertormed in any patient. Accurate pretreatment records docu mented multiple outcome studies note cli ni cal complications.
,
are necessary. which may allow reapproximation of the original VDO/ A longitudinal study of 515 metal-ceramic fixed dental prostheses
Ml in the event of adverse signs or symptoms. Ot.her con siderati on s (FOPs) found an overall success rate of ge% at 5 years. 87% at 10
include the esthetics. phone ti cs and peri odontavend odontic health,
, years. and 85% at 15 years. In this study, 60% of the prostheses
in addition to creation of adequate dimensional space for the physi· were three-unit FOPs, and 40% were FOPs of four units or more.127
cal integrity needs of the potential restorative materials. Modes of failure were tooth fracture (38%), periodontal breakdown
The unimate goal of this procedure is t o provide a stable occlusion (27%), loss of retention (13%), and caries (t 1 o/o).'2ll A literature search
to main tain the VOO during Ml and to create appropriate harmonious by Goodacre et at to identify FOP outcome studies included the inci·
gliding tooth contacts or anterior guidance d uring eccentric move dence of complications in addition to clinical data regarding success
ments that do not cause deflection of the mandible or excessive and failure.120 The nature and frequency of clinical complications var
stress to the dentition, muscles, or joints. An MPC occlusion requires ied between restora tion types: all-ceramic crowns (8%). posts and
the establishment of a stable Ml at an appropriate VDO begi nning at cores (10%), conventional crowns (11%), resin-bonded prostheses
CR, which can be established by neuromuscular release. Guidance (26%), and conventional FOPs (27%). Some failure data (eg, bent
from the anterior teeth should prevent defle ctive posterior tooth con· or broken posts) did not meet t he inclusion criteria that would allow
tacts and allow freed om in eccentric movements, reduci n g pat ho· consistent reporting. The three most common complicati ons seen in
2761
Restorations and TreatmentJ
Fig 18·9 (a and b) The ubiquitous porcelain·fused·to·metal crown has proven to be

durable and useful in restoring posterior occlusion where increased mastiCatory focces
are anticipated. Beveled margins allow extension Into the gingival sulcus when cervical
caries may be present and have the potential for intrusion into the biologic width if
formed from metal and opaceous porcelain.
FOPs were caries {18% of abutments}, endodontic problems {11% The ADA has classified type Ill alloys for fixed prosthodontic use in
of abutments}, and foss o f retention (7% of prostheses). which the occlusal surface will be restored. The goal is to use non·
In another study. Curtis et aJ noted that 82% of patients reported corrosive and biologically inert materials that have a hardness similar
no discomfort from a loose retainer, and 41% of patients were un to enamel and can withstand occlusal forces without deforming or
aware that the FOP retainer was loose.'"' The authors found that fracturing.
50% of the abutments under loose retainers had decay, and they In general, the alloy's Vickers hardness should not exceed that o f
could reoement 64% of those FDPs that were retrieved without in· enamel. which is 340 kg/mm'. It should be recognized that increased
ddent. It is unknown whether the underlying cause of the loose re· hardness does not immediately imply greater wear, as noted earlier
tainer Qack of retention. occlusal overload, etc} was eliminated or in the section on modes of wear. A tensile strength above 300 MPa
corrected, which could necessitate subsequent or periodic rece and elongation of 12% are necessary to avoid fracture of alloys used
mentation or remake. Reduction of clinical complicatiOns that could in FOPs. The addition of copper improves the strength and hardness,
affect the selection of restorative materials should be planned based whereas silver may assist in reducing the melting temperature.
on the diagnostic findings, the clinician's tooth preparation, and The demand for esthetic solutions. along with the successful bond·
prosthesis design parameters. ing of porcelain to a metal substrate, led to advances in FDP treatment
options. The alloy chosen for the application of porcelain must have a
higher melting point (above so•q compared to the fusiOn temperature
Selection of restorative materials of the ceramic to avoid deformatiOn of the metal coping/framework.
The noble metal alloys allow copings to be made 0.5 mm thick, which
Metal-ceramic improves the esthetic qualities of the veneering porcelain.

Innovative techniques have been developed to create thinner
Gold alloys combine strength, modulus. corrosion resistance. wear gold copings that are only 0.3 mm thick, allowing more conservative
resistance, and biologic compatibility. The American Dental Associa preparations, potential for better porcelain depth for esthetics, and a
tion (ADA) divides metal castings into three groups based o n weight desirable soft tissue biologic response. These methods include the
percentage composition'3': traditional lost-wax technique for cast gold, electroforming. and sin
tared-infused gold-platinum-palladium aggregate copings. The gold
1. The high noble (HN) metal alloys must contain at least 60% of a color imparts warmer porcelain shades and can block out undesir
combination of gold, palladium. and platinum. with gold making able discolorations in the tooth preparation. However, opacity is still
up 40%. required, and the softer gold coping derives much of its strength from
2. Titanium and titanium alloys must contain at least 85% titanium. the tooth preparation internally and from the overlying ceramic exter
3. The noble (N) metal alloys must contain at least 25% of a com· nally. The ceramic may have a greater susceptibility to stains. resulting
bination of gold, palladium, and platinum, without any minimum in delamination of the porcelain from the coping under tension. Metal
required gold percentage. copings must provide adequate strength to support a porcelain over
4. The predominantly base (PB) metal alloys contain less than 25% lay no more than 2 mm thick. Additionally, they will always have dif·
of any combination of gold. palladium. and platinum, without fur ficulty with light transmission. the potential for metal iOn discoloration,
ther specification on composition. and patient-reported sensitivities to the metal used (Fig 18·9).
277
1 8 The Mutually Protective Complex: Occlusion and Fixed Prosthodontics
a li c
Fig 18·1o (a to c)AJI·ceramc crowns are best suiled for anterior leelh because they allow imprO'Ied eslhelics, light ltansnussi<Jn thro!J!jllhe tooth-rootjunction, and ellminao \J n of
subgongival metal and opaceous porce!am.A 360-llegree shoulder ol un form domensoon and stable fruodatian are necessary to SUilPOfllhe all-ceramic cro.·.n. EsthebC aD-ceramc
cro.oms may ha1oe SUPfagrngNal mar� and avOid entering the g.rlgiVal sulcus. t11us iffilli'O'Nl!l the oppor1\Jnlly lor peOodontal heailh. All-<:eramiC crowns may be mono!tm: or
bila)'efed &layered ceramics may potenllali'/ fracture in the outer fetdspathoc porcelam from a harder rnternal core SltUCIIJ'e. in conltast to a monoli1hic cerarrnc thai has unrform
Pfoperlies lhroughouL The mode of fracture differs tor each.
All-ceramic live removal of the filler particle allows the micromechanical bond·
ing of the crown to the composite resin-cement interface. Glassy
The aforementioned limitations have ted to the development of all · ceramics are subject to crack propagation and stress corrosron in
ceramrc systems that have accuracy of fit and strength approaching the presence of water and saliva, possi bly leading to fractures. The
that of the time· tested metal-ceramic crowns. Research has been frequency of fractures in all- ceramic crowns. often found in the inter·
concentrated on increasing the crystalline content with matenals proximal regions and espeoally 1n the molar regions, may make the
such as mtea (Dicor), lellcr
te (IPS Empress). lithrum disilicate (IPS full ca s t-metal or metal- ceramic crown the preferred restoratoon on
e.max). hydroxyapatrte (Cerapearl), and glass-infiltrated oxides (In· the mo4ar regron because of its abli ity to withstand rncreased forces
Geram). Accompanying the change in the crystallnei content were (Frg 18-10).
methods to process the an-ceramic sys tem s including castable (Di·
, Polycrystalline ceramrcs do not have glassy components. They
cor). rnfillrated powder/slurry slip casting (ln-Ceram), p ressable (IPS are more opaque and much tougher and stronger compared to
Empress and e .max) and CAD/CAM machinable
. (CEREC, Lava, glassy ceramics because their densely packed atoms allow th inner
Procera). These new systems result in a monolithic restoration or a copings. Polycrystalli ne ceramics m ay be used a s c rown copings to
coping that may be overlaid with fe!dspathc
i or fluoroapatite porce which veneering feldspathic ceramics are added to obtain tho de·
lain to achieve the desired anatomical form. All-ceramic crowns offer sired esthetics. Appropriately matched feldsp athic veneering porce·
the best opportunity to achieve the desrred esthetics because they la in may be applied to an al u mi na or zrconi a coping in similar fashion
i
eliminate the metal coping and light tran smission. They also benefit to a metal coping wrthout opaceous porcelain, but it may be com·
from the presence of glazed porcelain wllhin the gingival sulcus and promised by a coping that is opaceous or does not allow light trans
reduced thermal transmission t o the tooth. mission. Advances in transformation-toughened yttrium-stabilized
Kelly has diVIded the spectrum of all-ceramcs rnto three groups: tetragonal zirconia polycrystal (YTZP) have 111Cteased 1ts physical
(1J predonmantly gassy materials. (2} partrcle-filled glass-ceram properties by gMng 11 the ability t o change its state from monocliniC
ics, and (3} polycrystalhne ceramics.taz '33 Glasses mimre the optr· at room temperature to tetragonal, which allows 1! to expand and
cal qualitres of enamel and dentin. They are derived from feldspar. squeeze a crack closed. The use of ceramics for mu�iunll FDPs IS
cons1strng of s1hca and alumina, which are resrstant to devrlrifrcation currently being studied as a replacement for the conventional metal
or crystallization. Partrcle-filled glass ceramics become more of a substructure. Further Investigation is needed regarding the effective
composite resin with the introduction of crystalline leucita. The addi· bond strength between the veneering porcelain and coping because
tion of �0 (11%) and subsequent heat treatments (70r:l' to 1200"C) o f the need to match the feldspathic CTE with the minimal CTE of
fom1 leucite. which i n turn increases the coefficient of thermal ex· zirconia as well as reports of increased veneer-chipping frequenc y in
pansion (CTE) to greater than the casting alloy for greate r compres comparison to monolithic crow n s.
sion bonding.'34 The add ition of leucite and aluminum oxide to some Ceramics are susceptible to surface flaws from machining. ad·
of the all-c eramic restorations causes drspersion strengthening by justmenls, alumina particle abrasion, and the presence of Griffith
preventrng crack propagation, thus allowing elimination of the metal flaws."' Multilayer ceramrcs and thin monolithic ceramics tend to
oop<ng.'""'''" However. aluminum oxide may increase the opacity. f(l(I'Tl radial cracks at the cement rnterface as a result of accumulated
Besides maintairung the refractive index of feldspar. the leuc1te com damage. Monol1thic all-ceramic crowns tend to form surface Hertz·
ponent may be removed by acid on the intagliO SU!face. The setae- ian cone cracks that propagate and accelerate with the presence of
2781
Restorations and Treatment J
- -
Table 18-4 9��!1!i� sy�!e_�s_.
Trade name
Material Composition (manufacturer) Process Usage
Estheuc ceramics (veneering and other)
Predom inantly glass-ceramic- Silica or quartz (SiOJ. aliJmi- Alpha, VM7, Mark II (Vita): Powder condensing. vacuum Veneer of ceramic substruc
leldspathic glass num oxide !AI,OJ. boric oxide AllCeram (OeguOent) firing tures, inlays, ontays, veneers
(B,O). potash (K,C03), soda
(Na.O). and metal oxideS
Moderately filled glass- Feldspathic glass wrth VMK-95, Omega 900. Vita Powder condensing, vacuum Veneerof metal subslrUC1ures.
cerumic-leldspathic glass the addition or 17%-25% Response (Vita); Ceramco II. firing inlays, onlays, veneers
leucrte (KAISi,O.J Cernmco 3 (Dentsply): IPS
d. SIGN (lvoclarVtva(lent):
Avant6 (Pentron Ceramics):
Renex (Wieland)
Hlgl>ly fifledglass·cemmic-feldsparhic glass (subs/ti.Jcture)

Feldspathic glass 40%-50% leucite (KAISi.,Oj: Empress. ProCAO (lvoclar Leuc�e: injected/pressed ce- Le<.Jclle: inlays, onlays.
-55% aluminum oxide fAtp) Vivadanl): OPC {Pentron ramie; aluminum oxide: milled veneers. singJe-urlt crowns:
Ceramics); F10esse All-Ceram- aluminum oxide: single-unit
I c (Dentsply); Vrtadur N (Vrta} crowns
Alumina 70% aluminum oxide (AI,O,) ln-Ceram Alumina (Vita) Slip casting, infused with low Smgle-unl! crowns, anterior
viSCOSity glass, overlaid with three-unit FOP
feldspathic porcelaO'l
Aluminoborosi!icate (AIBSiO,) -50% aluminum oxide (AI,O,): ln-Ceram Zirconia (Vita) Slip casting, miled Single-untt crowns, three-unit
Zirconium oxide (ZrO,) FOP
Modified feldspatl'tic glass -70% lithium disilicate Empress 2. e. max PresstCAD Heat-pressed Single-untt crowns. anterior
(U,Si,OJ {lvoclar Vwadent): G3 (Pentron lhree-uni1 FOP
Ceramics)
Po/yc(ystalfine ceramics (core/substructure)
Aluminum oxide < 0.5% dopants Procera (Nobel Biocare) Copy-milled encl sintered Single-un1t crowns
aconia 3%-5% ytllfum oxide f:(,O) Proceta{Nobel Biocare); Copy-milled, sinterect; green Single-unit crowns. three- or
Cercon (Dentsply): LaVa (3M/ milled. sintered; sinteredl four..,nit FOP
ESPE); Evetest ZH (KaVo); milled: miaed
Denzir (Decim):
DC Zircon (OCS)
moisture. The progression of a fracture from the flexural inner surface ramie restorations to dentin and enamel have enabled widespread
to the outer surface indicates a prevalent fracture mode and requires use of ceramic materials. The advantages of CAD/CAM technol·
crown replacement.'38 Consideration should be given to the appro ogy over hand·crafled restorations are (1) speed. (2) comparable
priate tooth preparation, such as adequate occlusal reduction or the accuracy of fit and occlusion. (3) negligible differences in quality,
development of a definitive resistance form on the lingual aspects of (4} a shorter second appointment tor the patient, (5) reduced cost
maxillary and mandibular teeth that can withstand gliding disocclu of restoration fabrication, and (6) the convenience of eliminating im
i n forces. All-ceramic restorations require that the clinician match
so pressions and provisional restorations. Umitations of these systems
the materials. processing methods, and cementation or bonding include the (1) initial cost of the system. (2) current material limita
procedures to the dinical situation.'39 Transformation-toughened o
it ns to several ceramic families and composite resins. (3) current
zirconia may evolve to become the most successful system. but inability to create definitive FPDs. and (4) the requirement that full·arch
techniques to maintain the veneering porcelain must be improved.''"0 single-unit treatment still use stone dental casts and articulators.
Ceramic systems will continue to evolve as the science. technology, CEREC (Sirena) and E4D Dentist (040 Technologies) are currently
and manufacturing capabilities develop and make relatively new sys the only chairside CAD/CAM systems. The CEREC system was the
tems obsolete (Table 18-4). first CAD/CAM device on the market. This system uses an infrared
scanner or LED camera 10 optically capture as much as possible of
CAD/CAM dental restorations the full dental arch. The tooth preparation and occlusal registration
are imaged. and th e restoration is designed on the computer and
Chairside CAD/CAM single-unit restorations have been a part of clini then milled from any number of ceramic materials withil) one patient
cal dentistry since 1985. Advancements in techniques to bond ce- visit. lntracoronal and extracoronal restorations are currently milled
279
1 8l The Mutually Protectiv e Complex: Occlusion an d Fixed Prosthodontics
Fig 18-11 CAD/CAM crown. (a} Fractured alloy restoration. (b)Tooth prepared fora CAD/CAM onlay. (c)Digital Image of prepared
too th and restoration. (d) Ceramic block in milling machine. (e) Completed milled restoration. (/)Cemented CAD/CAM restoration.
from ceramic material blocks from Vident. lvoclar Vivadent, and 3M tis.··�·45 Access for oral hygiene that includes nat buccolingual
gingivi
ESPE. Offsite mill ing is possible by emailing the images to a par contours, open embrasures, location of proximal c ontacts toward
ticipating local dental laboratory (CEREC C onnect). The E4D Dentist the occlusaVincisal one-tnird, and crown contours that follow the
system is a newer system thai also allows creation of direct and root form is important to maintain a healt hy gingival attachment .
indirect s ingle un it intfacoronal and extracoronal restorations using
- The preparation depth to achieve the material's best properties
a d igital laser camera. The restorations are designed chairside and must take into consideration the overall tooth size, pulp chamber
are milled chairside or offsite by local laboratories (E40 Studo). The i morphology, and undulating root form with cervical constrictions.
associated milling unit is paired with the ceramic blocks from lvocl ar Underprepar at ion may result in overcontourin g and overprepara
.
and 3M. tion may encroach upon the vital endodontic and gin gival tissues.
The LAVA Cha irsde
i Oral Scanner (3M ESPE) uses 3D video imag Varying clinical situations and anatomical s izes influence treatment
ing to fabricate a virtual or m illed dental cast offs ite. M il led zirconia pla nni ng. For examp le the maxillary l ateral in cisors and mandibular
,
singl e unit copings or FOP frameworks are made from the virtual
- incisors are of small dimension and therefore benefit from the place
cast, and milled casts can be used for traditional restorations in the ment of all ceram ic crowns because the required depth for prepara
-
dental laborat ory (Fig 18-11). tion reduction is less. In cont rast the increased loading potential in
,
posterior molar regions may require metal occlusal surfaces that are
more resilient and not prone to brittle mater ial fracture. The extension
Tooth preparation parameters of crown margins into the gingival sulcus of perodont a ily involved i
teeth with sign ilicant gingival attachment loss may result in pulpal
Contours and tooth reduction encroachment, requiring that endodontic therapy be performed
before preparation. The initial incorporation of cervical chamfer or
The contours of ful l-coverage re s torations play a s upport ive role in shoulder aspects of the periodontal preparation is often eliminated
establish ing a favorable periodo ntal environment. The gingival p ro because the cervical constriction creates a knife-edged margin that
tection theory suggests that crown contours should be designed to restricts the use to metal or metal-ceram ic restorations. The loca
p rotect the g ingiva from mechanical injury but allow gingival stimula tion of supragingival margins may redu ce the potential for pulpal and
tion and have self-cleansing contours.••• However, the cervical bulge gingival encroachm ent in these situations while achieving adequate
that was designed t o be protective has been shown to increase retention and resistance form, assuming caries is controlled and
plaque , resultin g in inflammation because it fa ls to provide p ath
i structural tooth defects a re absent .
ways for food deflection. and mastication does not remove plaque Restorative materials must be affixed in such a manner as to not
l margins of teeth.'" Although systemic factors play a
at the g ingiva become dislodged under normal masticatory functions that include
rote, bacterial plaque has been est ablished as the primary cause of comp ressive, t ensile and tang ential shear forces. While all forces
,
Restorations and Treatment J
Fig 18·12 Toot h prepa1allon u sing depth cuts to create unllorm reduction. After vertical Fig 18·13 Two-plane 1educlion. (a and II}Tooth preparation must tollow normal tooth
and hOrizontal depth cuts have been made, U1e g1idS are connected by etimlnallon of the contours to achieve un!lorm reductiOn aoo appr()jlriate restoraion contours. T his aspect
t
IslandS of tooth structure. Is pronounced in the maxdlcuy arch-labial surtace and on the centlic holding cusps
of lhe maxillary palatal cusps and mandibular buccal cusps. Failure to Include a two·
plane !Eduction typically resul ts In o•1ercontoured crowns. visualilaUon ol opaceous
porcelain or undef!>Jing tooth co101. or a general 1educlion 111 lhe ideal physical and
eslMtic properties.
play an integral role. more applicable are those shear forces that preparation with rounded line angles and shallow occlusal form to
may be more tangential or horizontal in nature. The general retention facilitate oopy milling CAD/CAM procedures is prescribed. Greater
and resistance form of anterior teeth i s different than that or posterior interproximal and lingual reduction is needed for all-ceramic crowns
teeth. Shear forces during anterior disocclusion or posterior work· compared to porcelain·fused·to·gold crowns. All-ceramic crowns
ing and nonworking contacts. in contrast to forces during vertical are less forgiving and should not be used with nonideal tooth prepa·
chewing, place further unique demands upon any restoration. The rations"' (Figs 18·12 and 18·13).
dynamics of the food bolus or the presence of parafune1ional habits
adds other variables to the complex equation. Margin location and the biologic attachment
The restorative material selected must be o f a specific dimension
to achieve suitable and efficacious physical properties. It is gener· The margin of the cast restoration is susceptible to biologic and
ally accepted that tooth preparation includes considerations for the mechanical failure. Compared to subgingival margins. supragingival
pulpal and periodontal tissue health. along with adequate retention finish lines challenge the gingival health less and offer lhe potential
and resistance form. that must l)e weighed against the esthetic and for the luting agent to bond to enamel. However, the placement of
physical properties of the restorative material chosen. The uniform crown margins subgingivally may be required in the following cir·
reduction and depth of the preparation must not exceed the toter· cumstances: (1) to achieve adequate occlusal-cervical dimension;
ance of the vital pulp, and the crown margin should not interfere (2) to extend beyond caries or noncaries lesions; (3) to correct tooth
with the biologic attachment of the periodontium. Additionally, du· size/position discrepancies; (4) to achieve appropriate esthetics; and
at-plane or multiplane reduction must achieve the proper physical (5) to achieve adequate ferrule effect for endodontically treated teeth
properties, esthetic qualities. and defined occlusal anatomy with ade or teeth with large foundation restorations. Defective subgingival
quate thiCkness to accommodate wear over time withOut restoration margins are more difficult to detect. Cooper et al have reported that
failure. acceptable clinically detectable supragingival margins ranged from 2
Full cast crowns reqllire the least amount of reduction: 1.0 to 1.5 to 51 j.Jm. and subgingival margins were 34 io 119 1Jm.'48 Marginal
mm occlusally and 0.5 to 0.8 mm axially, with 0.3-mm chamfer fin· openings directly relate to cement dissolution. plaque accumulation,
ish lines. ,.6 Metal-ceramic crowns and most all-ceramic crowns re and subsequent bacterial invasion followed by caries formation. Ra·
quire greater occlusal redue1ion of 2.0 to 2.5 mm. Metal-ceramic diographs improve the diagnostic sensitivity for interproximal caries,
crowns require 1.5 to 1.7 mm axially on the facial/buccal aspects but clinical examination is more reliable in the diagnosis of second·
to develop acceptable color. translucency, and tooth morphology. ary caries in crowned teeth. "9 Although caries is a host·mediated
Nonbonded all-ceramic crowns require an axial reduction depth of response. proper marginal fit is important to reduce its likelihood.
approximately 1.0 mm because they do not include the metal cop· Methods to improve marginal adaptation include venting and ce·
ing or extra thickness of the opaque layer. yet they require the pres· ment spacing that improves crown sealing.'00 Parallel preparations
enoe of a definitive shoulder preparation for support of the porcelain. and multiple-abutment FOPs reduce crown seating due to viscosity
In contrast, bonded ceramic restoratiOns require less bulk because and hydraulic pressure of the cement. It has been suggested that
they gain strength from the underlying tooth structure. Alumina and knife-edged and bevel margins have better adaption through a slip·
zirconia copings provide even greater strength and do not rely on joint fitting of the surfaces. However. distortion fll)m porcelain firing
bonding to achieve adequate fracture resistance. A uniform chamfer is greater on thinner sections of the cast.'�' Preparations that allow
281
adequate bulk for metal and porcelain with rounded line angles will trolled porcelain shrinkage t o maintain appropriate intimate fit. The
show the least amount of stress concentration. 152•15·' greatest shrinkage occurs at the place oi greatest porcelain bulk and
Crown margin placement has included the idea of prevention by lack of sufficient supporting metal, which is often a t the labial margin
extension into the •cartes-free zone• of the gingival sulcus at various midpointm (Figs 18-14 and 18-15).
depths. Plaque formation and inflammation occur more frequently
in teeth with subgingival margins compared to those with supra Retention and resistance form
gingival margins.154"1"' Iatrogenic gingivitis, gingival recesSion, and
crestal bone loss ensue when subgingival restorations approximate Adequate retention and resistance form are required to prevent
the biologic attachment, but they are less likely when the placement crowns or FOPs from becoming uncemented. The primary factors
is greater than 0.4 mm coronal to the biologic attachment'01·'e;.."'a for crown retention and resistance are parallelism and length of the
Other concepts of margin location include maintaining the crown axial walls and surface area.1 1' The ability of the prepared tooth to
margin distance of 4.0 mm from the crestal bone and limiting the in retain a crown i s often related to the diametrically opposed angles of
tracrevicular margin to 0.5 mm apical to the free gingival margin. 16'·168 the prepared axial walls, or total (combined) occlusal convergence
Knoernschild and Campbell noted that mean attachment loss in (TOC). Some investigators have recommended a 2· to 6-degree ta
crowned teeth was similar to loss observed with control teeth""'; per as ideal. but a 10- to 20-degree TOC Qe. a 5- to 10-degree
therefore, periodontal inflammation may be related t o factors other taper) is a realistic goal and often the clinical result with a favor
than crown restoration qualities and biomaterial properties. able outcome. "2-11>The preparation of posterior teeth often results
Crown-lengthening procedures should be planned to achieve in a greater TOC compared to anterior teeth and may exceed 20
adequate tooth preparation dimensions and gingival health when degrees.'76 Methods to tessen overtapering include depth cuts,
anatomical conditions permit. Crown lengthening reestablishes the axial reduction before the occluSal reduction. correction of tipped
biologic attachment more apically and also may improve the gingi proximal contacts of adjacent teeth, and two-eye assessment as
val arcl1itecture to allow a more ideal crown preparation. However, opposed to one-eye a ssessment to evaluate axial inclination. These
caution must b e exercised in patients with thin or highly scalloped methods allow a better visual and mental perception of the overall
gingival types or when the adjacent tooth-root proximity and furca taper during the preparation process. Other methods include pedo
tion height pertain to the location of the crown margin placement. dontic handpieces, shorter burs, and bite blocks for patients who
Preparation of the crown margin or finish line may include a cham have a limited opening.
fer or shOulder with or without a bevel, a slanted shoulder, and some Resistance to tipping or rotation around a specii
f c point is actually
times a knife edge. In general, all margin types are able to achieve re more important than retention.m-"'' Assessment of the resistance
liable marginal adaptations. The selection of a finish-line form should form requires the examination of the TOC to the cervical dimensi on.
be based on the esthetic requirements, the need for prevention by Lewis and Owen analyzed the on/off nature o f resistance form by
extension, adjacent tooth-root proximity type of crown or materials
, comparing the preparation taper to base width.u•o They found that
selected, and the ability or preferences of the clinician. Knife-edged the resistive sections of a preparation wall are all points above the
margins are encountered on periodontally involved teeth and may midintersection point as determined by the perpendicular line from
be difficult to ascertain in the impression or laboratory compared to the center of rotation on the opposing margin. In a somewhat similar
other margin forms. The beveled margin may add to the occlusal approach, Zuckerman used a boundary circle centered at the base
gingival dimension, thereby increasing the resistance form. However, of the preparation and a radius of one half of the base. 1�1 Zuckerman
-
this necessit ates the presence of metal and opaque porcela in in the found that preparations with a TOC of 22 degrees can have resis
gingival sulcus, which may increase the bulk and roughness with tance form because of the amount of tooth structure that remains
added potential for biologic imp ingement and plaque accumulation. above the boundary circle.
Highly scalloped knife-edged and beveled designs with thin metal The conclusion that can be dr awn is that teeth with shorter
margin s have the potential lor deformation during porcelain firing preparations or teeth Will, wider bas es (molars) require less taper
and metal display through translucent or thin gingival margins. Metal to achieve adequate retention and resistance form. Tapers exceed
margins may be polished and burnished in the laboratory t o reduce ing 20 degrees may have inadequate retentive form, but they may
marginal gaps, but this is done with the risk of foreshortening the achieve adequate resistance form when more than a 4:10 height
crown margin's length. to-base ratio exists.'61'83 The greater buccolingual dimensions of
Uke the metal-ceramic beveled margins, slanted shoulders of 60 molars result in a less favorable ratio compared to anterior teeth and
d egrees w�h disappearing margins terminate with three different ma premolars. Therefore. because molars tend to be shorter and wider,
terials into the gingival sulcus, resulting in a similar gingival response. it is recommended that a 4-mm occlu sal cervical preparation height
Shoulder m a rg ins of 90 degrees are perhaps the easiest to capture be maintained. In contrast. anterior teeth and premolars. prepared
clinically with impression materials or optical scanners. They also are with less taper, may permit a minimum of 3-mm occlusal cervical
the easiest to visualize in the laboratory, may allow the developm ent dimension and still have some degree of resistance form.
of a more natural emergence profile, and are required for nonbonded The circumferential form of the prepared tooth also plays a role
all-ceramic crowns. However, they al so require adequate occlusal in the dislodgement resistance. Teeth that are not round or oval but
cervical tooth dimension l o r retention and resistance form and con- have a triangular. square, rectangular. or rhomboid shape inherently
Restorations and Treatment j
Fig 18-14 (a) All-ce ramic crovm margi n Crwm margin prepared at the free gi ngiva
.
withoot inju ry to the gingival attachment. Note how the unHor m two-plane reductions have
achieved adequate shoulder depth to support the porcelain. Appropriate lnterocclusal
c!earance is created to allow adequate thickness of porcelain during centric and eccentric
ocdusal poSitions.jb) GingiVal displacement. Alter placement o l gingival displacement media, Fig 18-15 Supmgingival margin. Prepared abutment for an FDP with adequate
the prepared mar gins may be r elined . as they now are easily visualized and recorded by an retenllOnand resistance 101m. This patiellt's peliodOntal disease has been treated.
etastomefic impression mat81ial or optical scan . and a grngival graft has been placed to establish a zone of attached grngiva. Note
that the gingival sulcus was avoided. which led to a suprag1ngival margin in a
Cfllically compromised periodontal condition followi ng an attaclled muoosal graiL
Staini ng is due to use of Peridex (3M ESPE).
.
...
.
..
··
.
'.
.. .
,
•
.•.
.
.... .
. .
·�··.
a A 0 b A
Fig 18-16 Retention and resistance torm. (a) To evaluate the resistive zone of preparation, Lewis and Owen sllovled that all points occlusal to the point of intersection (point E)
between a p erpeodicuta r line from an oppoSing margin and ll1e side of preparation have resistance form. and all points gingival to this intersection do not.•e<> PointE is a tangent pomt.
and the segment f·rom E to s has resistance rorm: tne section !rom A t o E doeS not. vertical proiected hei ght ol EB is called res1stwe 11eigt1t (RH), and vertical projected heigh t of EA
rs called nonresistwe /Ieight (NRHj. RA-fesistar'lce area. (b) Zuckoonan showed that a circle centered on base of a prepar ation wltll a radius equal to one-hall of the base intersects
the side or preparation at a tangent point."' Pomt E mar1<s the intersection be!lveen the Zuckerman circle and the Lewis and Owen perpendicular (Reprinted from Cameron et al'e<>
.
w1th permissi on.) (candd) Minimal tooth convergence. Minimal interproximal and lingual axial wall heights require the placement of an interproximal groove to reduce Upping forces
and improve resistance form.
have an antirotational rorm.'"' Those prepared teeth that are cylindri form. Surgical procedures to lengthen the available clinical crown
cal in nature may require auxiliary axial grooves or boxes or the main· should be considered when the prosthodontist is confronted with
tenance ol rounded corners to achieve the ideal antirotational resis inadequate tooth form to retain a crown. Additionally, therapeutc
i
tance form. Shorter teeth, such as mandibular molars, will benefit devitalization may be indicated to allow the placement of cast post
from proximal grooves to resist buccolingual forces.'86 Molars that and core foundations of adequate size to retain the crown. The post
are tipped mesially have a short distal wall and lack resistance form does not reinforce the pulpless tooth and may actually weaken the
even when prepared with the smallest taper. The resistance form root."'·'"' The purpose of the post is to retain the core, which in turn
benefits from the placement of buccal and lingual axial grooves.'"" retains the crown. Post IMgths that are equal to or greater than the
Surface irregularities should be smoothed and line angles should be crown height (to reduce tipping-bending and pull-out forces) and
rounded to facilitate laboratory procedures and overall frt. Boxes. maintain 4 to 5 mm of endodontic apical seal (where 95% of the lat·
grooves, and pinholes generally are limited to metal o r metal-ceram era! canals are found) have been shown to provide greater longevity,
ic crowns and not used for an-ceramic crowns because they may with a failure rate of 2.5%.'9'·"'2 Posts may be parallel or tapered to
limit the resistance form. Uneven opposing margins also reduce the follow the root form. Custom tapered posts may be associated with
resistance form and may necessitate localized crown lengthening to wedge stress: parallel posts risk root perforation because oi the in·
extend the margin apieally'8' (Fi g 18-16). creased tooth preparation apically in narrow root forms. o r they may
lack adaptation o r proximity in coronal aspects of the prepared post
Restoration of endodontically treated teeth space. Therefore. both forms may risk root fracture.•ro-:go
Parallel or tapered posts may be cemented or bonded with a pas·
Tooth preparations must have restorations thal provide an adequate sive fit or engage the intraradicular walls in screwlike fashion, which
foundation to protect the pulp chamber and allow proper axial wall may lead to an internal strain fracture related to increased lateral
283
1 8l The Mutually Protective Complex: Occlusion and Fixed Prosthodontics
Fig 18-17 Post and core !allure. (a andb) lack of ferrule led to !he abut ment resin Fig 18-18 Post and core preparation. (ill Removal ol all caries dentin, unsupported
core fracture, recurrent caries, and ullimale failure ol tlle FOP. Minimal ferrule effect may tcolh structure, and endodontic filling material while maintaining an apical seal of at
lead to mechanical fracture ol!he core !rom the post and dislodgement diKing incsing least 4 to 5 mm is necessary to achieve an adequate foundation for a cast post and oore
tor this endodontically \feated tootn (maxillary right canine). (b) n1e development of a
i ,
bruxism, or lateral guidance chewing The use of compos�e resin 001es may become
.
problematic as a resull of hydrolysis, causing dimensional changes and bacterial horizontal or flat wrtace creates support lor the core and reduces lhe wedging effect ol
infiltration. Extension ol lhe crown margin Into the gingival sulcus may be necessary to a tape red post Adequate toolh structure remains to allow a ferrule effect of more than
achieve adequate retention, and crown�engU1ening procedll{es should be considered.A 1.5 mm to achieve greatllf resistance form lor ll1e cast post and core.
guarded prognosis is likely, and otller alternative lfeatment plans Should be considered
including implant placement or removable dental prostheses.
Fig 18-19 Cast post with ceramic. Fel<lspathic porcelain

!used to a l);llladium·s11ver post (a) allows the use of a
pressed ceramic crown to reduce the gray Shadow that
shows lhrough ltlc \fanslucent crown (b). (c) A less
translucent ingot may be selected, but the shadow may
remain in radicular areas because ligllt transmission Is
impeded by ltle cast·metal post.
loading in nonvital t eeth. Other prefab riCated post designs are avail incorporates complete encirclement with 1.5 to 2.0 mm of prepared
able as tooth-colored carbon fiber with a parallel or tapered design. sound tooth structure.189 Consideration for orthodontic extrusion or
Prefabricated posts require the abi lity to bond or mechanically inter crow n lengthening may be needed if inadequate tooth structure re
lock with the cone. This is a critical point because if the core sepa mains to achieve an adequate ferrule. A fiberotomy during or gingi
rates from the post , tile crown ret aner will fail. Silica coating and si voplasty following these procedures may be considered based on
lanization may assist with the bonding of compOSite resin to Zirconia
i
desired gingival architecture and height (Figs 18-17 to 18-19).

posts.'96 Prefabricated posts may be the best option when the ma
jority of coronal tooth structure remains and the core requirement s
are minimal. However, the use of resin materials as a core foundation FOP design parameters
material may be contraindicated because o f the hydrophilic absorp
tion of moisture from dentinal t ubules or sa liva. This process results Support
in dimensional changes of the core with the potential to affect crown
fit and allow bacterial ingrowth.'"' The crown-to-root ratio and bone indices are often empirically used to
Recent development of a combination of zirconium oxide posts assess the ability of any tooth to serve as an abutment for a fixed or
and pressed ceramic cores may provide a better bond between the removable prosthesis.'�.o· Greater crown-to-root ratios approaching
core and post materials wllh adequate fracture resistance and im
, 2:1 are preferred for abutment teeth. Ratios approaching 1:1 may be
proved light transmission fo
r all ceramic crowns.•llti·199 It has been
- considered for removable dental prostheses, when the forces of the
reported that alteration of the Zirco nium oxide posts with diamo nds opposing occlusion may be fewer.m= Ante suggested that the total
reduces fracture resistance; conversely, air abrasion with alumina pericemental area of the abutment teeth for FOPs should equal or ex
particles may increas e the fracture resistance .""' ceed that of the teeth to be replaced.""' The implication was that abut
Irrespective of which post and core system is selected, the suc ment teeth with compromised periodontal support may contraindiCate
cess of the restoration largely depends on the development of ad fixed prosthodontic treatment. The role of occlusion in the stability of
equate retention and resistance form, thus requiring a ferrule prepa FOPs with reduced periodontal tissue support was investlgated by
ration. The preparation of a ferrule on sound tooth structure lessens Nyman et al.:>OS The authors followed 20 pat ients who had advanced
the bending moment at the post-core junction, reducing the pos periodontal breakdown and tooth loss over a 6ye - ar period. The suc
sibilit y of post fracture or loosening. Improved resistance to post cessful outcome of fixed prosthodontic treatment, whiCh exceeded
deformation or crown dislodgement occurs when a ferrule effect Ante's recommendations, was surmised to be t he result of treatment
2841
Restorations and TreatmentJ
Fig 18·20 Il ls paramount to select appropriate tooth abutments to support llle FOP Fig 18·21 Path of Insertion. (a) Prepared abutme nt teeth must have a common path
and maintain control of tooth preparation reduction, retention, and resistance form. Also of Insertion. Combination s of anterior and posterior abutments often have incon!Jn<
ent
important is preservation of sof t ussue health lor a successful treatment outcome (see axial alignments. In addition. pal)ents with an excessive curve of Spee potentially have
Table 18·1). Applying Ante's gu idelines to this patiel1t. the pericemental area of the abutment Ieeth and interproximal contacts that intenere with the path or insertion.
abutmems can be calculated by adding the centra l incisor and canine (176 + 270 = which may compromise toolh preparation resistance lorm. endanger the pulp health.
446 mm�. The total exceeds the pericemental area of a lateral incisor. If an FOP were to and compromise the adequacy of the proximal contact. (b) Nonrigid connectors may be
span from second molar to caniooto replace the missing premolars and first molar, the indicated in these situations but require appropriate tooth reduction to accommodale
pericemental area of the abutrnllilts would equal700 mm> compared to the 850 mm1 of the pattem. a height of at least 3 mm lor adequate resistance form, and appropliate
lhe replacement teeth. Ante's guidelines In the Iauer scenario suggest thai the abutment buccotlngt.al size. Nonrigid connectors also may be ind icated with long FOP spans. pier
suPJ)Oif for the FOP is inadequate. abutments. and d issimilar occlusal loads.
of the diseased periodontal tissues and establishment of a stable The TOC of prepared abutment teeth for FOPs represents the
occlusion in the intercuspal position. Patients were restored using composite of retention and resistance forms. The TOCs of prepared
cross-arch splinting, supragingival crown margins, open gingival em abutment teeth must be congruent with each other and with the
brasures, cantilevered pontics, and a balanced articulation between adjacenl proximal contacts. The taper of one aspect of an abut·
a retruded contact position and habitual intercu spation. The authors ment tooth may contrast with another abutment tooth. Therefore,
concluded that bone destroyed by per1odontal disease will not regen· one axial wall may have a common path of insertion while another
erate spontaneously, but bone loss r elated to occlusal trauma is a may not. which interferes with the seating of the FDP. Any proximal
reversible process once the trauma is eliminated (Fig 18·20). or buccolingual grooves or boxes, in similar fashion. must follow the
same path of insertion for the entire prosthesis (Rg 18·21).
Path of insertion
Pontic design
Abutment teeth prepared for FOPs tend to need great er taper t o per
mit a uniform path of insertion. Proximal contacts of adjacent teeth The placement of an FOP involves the replacement of a missing
may influence the prepared tape,r as seen when there is an exces tooth by a pontic. The genetic coding of the attached gingiva and
sive c urve of Spee or when teeth adjacent to the abutments are alveolar bone may allow tor an esthetic and biomimetic replace·
tipped because of the missing tooth so that he crown margin is be ment. However, pontics typically are not osseoinductive and do not
t
neath the proximal contact and interferes with the path of insertion. encourage bone growth. Soft tissue reactions around pontics are
The proximal contact wall should be corrected in lhese situations; well known and include inflammatory reactions related to plaque ac
otherwise, the resultant contact area will be restricted t o the occlusal cumulation or food impaction resulting from the presence of trap
level or will have a frank open contact that allows food impaction. angles. The pontic form must be es theti cally, phonetically, and hy·
Correction of the proximal contact also allows the abutment tooth to gienically designed. Several pontic forms may be considered that
be prepared with less taper. have advantages and disadvantages depending on the replacemenl
Mobile FDPs likely result from cement infidelily and recurrent car tooth's position in the arch. Pontic designs include the denture base
ies from nonresistant molar preparation forms. Other contributors to or lull ridge lap. the ridge lap. th e modified ridge lap, the ovate. and
complications with FOPs include a tack of adequate ferrule design or the sanitary pontic.:.J8.2o7
proper post and core design, fractured roots, and endodontic failure Alveolar ridge deficiencies and phonetics are best accommodated
and periodontal attachment loss as a resull of excessive tangen by full ridge lap ponlics. Although lhese satisfy the esthetic and pho·
tial forces (eg, from disocclusion or balancing contacts and bruxism netic requirements. the denture base and ridge lap designs severely
forces t hat exceed the retention and resistance form of the crown limit oral hygiene because of the co ncave pontic form al the ridge,
preparation). resulting in inflammation. The convex sanitary pontic, which lacks
tissue contact. has been primarily used in the posterior mandible
285
Table 18-5 U�Pon t i c form
Pont i c Attribute s Location
Anterio r Posteri or An ter io r Posterior

maxilla maxilla mandible mandible
Full ridge lap' Coocave fcrm allows ndge adapta iO t n but not
adequate hygiene: results In tissue Inflammation
Modiroed ridge lap Convex apiCal form touches sort !iSsue: more
X X "
esthetic and perm�s hygiene
Spherical no noge Convex apical f<><m that doas not tQUCh soft tssu
i e,
contact (sanitary) allowlog easier accessfor hygiene
Ova.te Convex apical f<><m that allows better emergence

X X
profiles, esthe«cs. and phoneic
t s: permits hy grene
• n because it sevetely limi ts oral h

The full ri dge nap Is not applicable In any loca«o yg iene.sd
Fig 18-22 Modified ridge lap pontic design. (a)The patient is missing the maxillary left
central incioor with both vertical and horizontal bone loss. A porcelain·fused-to·melal
FOP spans from the left central incisor to rigllt canine. (b) Because of the deficient ridge
fOffil, an ovate JXllltic could not be developed, and a modified ridge lap design was
chosen. Adequate embrasures are required to preserve the health of the interdenlal
papfllae yet shoul d eliminate excessive space and esthetic toss. Rigid connect01s are
Indicated when minimal space exists. The canine was included In the overall design
because U1e SUPIJO!l lrom the lateral incisor was minimal COIISidertng the impendin g
function.
where access to hygiene is more difficult and esthetic or phonetic mucosal health.a" All pontics require smooth surfaces and properly
requirements are less demanding.209-2'0 Modified ridge lap designs sized connectors for tissue health. Reduction of the buccolingual
improve upon both designs. The modified ridge lap is more convex, dimension o f posterior pontics is not desirable because of the re·
with a passive pinpoint contact that allows better hygiene: however, duced connector strength and the creation of trap angles that may
this feature was developed at the expense of esthetics, phonetics. allow the ingress of food during mastication (Table 18-5 and Rgs
and occasionally the occlusion if the cingulum was eliminated.>"'·"' 18·22 to 18·24).
The ovate pontic allows a more natural emergence profile and
convex surface for hygiene that can maintain soft tissue 11ealth when Connector design
adequate alveolar ridge form remains. The ovate pontic was first
described in 19<33; because of its convex form, it allowed appropri The physical properties of FOP connectors are often evaluated using
ate hygiene and could fulfill the esthetic and phonetic requirements beam physics to compare flexure. In g eneral, defiection of a beam
when designed corre ctly.212 The method to determine the appropri (1) increases as the cube of �s length. (2) is inversely proportional to
ate contour for this pontic first involves probing the depth location its width, and (3) is inversely proportional to the cube of its height.>"
of alveolar crestal bone. Greater soft tissue depths require a slight The connectors must oblige the interdental papillae and occlusal re
pressure and deeper pontic fom1 for greater tissue support and to quirements and pem1it adequate hygiene. Tl1e fracture resistance
achieve an ideal emergence profile, which should begin more than 1 of FDPs is related to the span length and the size, shape, and posi·
mm from the underlying bone.2'3 The use of a convex ovate pontic lion of the connectors. Soldered connectors must be of appropri
design that is smooth and highly glazed is not typically associated ate size to have adequate properties and may at times be stronger
with clinical signs of inflammation when proper oral hygiene is fol when designed as cast connectors, in contrast to being soldered
lowed. However, this pontic design is associated with a thinner kera interproximally or soldered at the pontic midpoint as opposed to a
tin layer and changes in the composition of the subjacent connective smaller proximal area.
tissue, along with a slight increase in inflammatory cells.206 The use of segmented FDPs with semirigid connectors can allow
Investigations of soft tissue reactions to different pontic materi noncongruent TOC paths of insertion between abutments, which
als such as porcelain. composite resin. and metallic alloys reveal may facilitate the development of better individual retention and
no differences in regard to the amount of plaque accumulation and resistance form. Tooth preparation requirements include adequate
2861
Restorations and Treatment j
a b
Fig 18-23 Ovate pontic destgn. (a) M ovate pontic design was created using Fig 18-24 The saMary pontic. (a and b) The sanitary POntiC is convex or <Wate in
electrosurgery followed by placement of a propel!y sllaped provisional prosthesis. Note contour but typically does not touch the soH tissue. It is best used In ll1e posterior
healthy kera�nized gingiva beneath the pontic space. (b)Arl all·ceramic FOP was placed mand ible where hygiene is more difficult or where physical space is limited, allowing
from the maxillary right canine to central incsor
i and from the maxillary left central better mechanical preperties to be developed in the FOP desig n. T h e connectors may be
incisor to canine 10 replace congenitally missing lateral incisors. cast with the brazing occurring throughout the pontic to allow greater bulk of material
for increased bending resistance of the connectors.
F ig 18-25 fractured connector. Note the FOP that spans from maxillary right central Fig 16-26 A zircoola FOP fra mewor1\ with 3-mm diamete r connector design.
inci sor to left canine. Patient was a severe bruxer, resulting in multiple retainer Connectllr must accommodate the interdental papilla and incsai l embrasure and must
perforations and tooth migration. The apposing occlusion and anatomical limilatiOIIS b e of adequate size to resist fracture. Precise treatment cast records are critical for
prevented adeQuate dimensions for the r etainer thickness arl(l connector. 1ead1ng to these restOC'ations because they cannot be sectioneo and brazed like metal frameworl<s.
connector failure. Alternative treatment plans. inc luding dental impllints. should be
considered Other optioiiS include use of materials with a higher modulus of elasticity
.
(greater stiffness) or a cast segmented connector frt adequate space permits) instead of
a brazed connection. It may also be possible to provide freedom !rom centric occlusion,
modify the opposing occlusion, or prescribe an occlusal device for bruxism with patient
instruction.
space intracoronally and occlusal-gingivally for the placement of a The metal-ceramic FOP has served as the standard to which oth
matrix, which also must have a common path of insertion with the er materials and techniques are compared. Metal-free FOPs have
segmented abutment. Abut ment preference for the matrix is given made strides in recent years in fit and physical properties.''6 The
to the tooth with the greatest resistance and retention form, which most common mode of failure for an all-ceramic FOP is fracture of
is usually the more anterior toot11. In contrast to matrix placement, the connectors, with 70% to 78% of cracks originating from the in
the patrix should be placed on the pontic segment and crown re terface between the core and the ceramics at the gingival embra
tainer with the least retention and resistance form. such as the mo sure.'" Campbell and Sozio investigated FOP fractures in vitro and
lar retainer. Therefore. if t he retainer separates from the weakest found that whereas metal-ceramic fractures develop first at the in
member, it would be clinically retrievable and may be easily rece taglio surface of the pontic, ceramic FOPs develop vertical fractures
mented before caries can develop, with less likelihood of the patient at the connectors.''8 In general, the brittle ceramic connectors must
being unaware of the problem. Other considerations for connec be of greater size to resist fracture. As a result, all-ceramic FOPs
tors are copings placed on the molar and cemented wi\11 a stronger are generally restricted to premolar regions. where the connector
luting agent, followed by a second retainer luted with provisional surface areas may be larger, to better resist fracture. Restricted inter
cement. and alternative implant treatment modalities (Figs 18-25 occlusal distances. mobile teeth, and parafunctional habits will chal
and 18-26}. lenge any FOP construction and especially all-ceramic FOPs.
287
1 8l The Mutually Protective Com plex: Occlusion and Fixed Prosthodontics
(' mplex FOP. (a andb)Pretre<�tment photos of a patient whh dig(ldontia wearing a maxiltaJy removable patlial denMe with mandibUlar FOP ma(le 40 yeatS earlier.
Fig t8-Z7 .,o
The patient requested an FOP afternalive but declined imptanVgralting surgel)' and a removable dental prosthesis. Maxil81)'central incisors and molars remain; lateral Incisors
are ca11tile\1lred pootics. (c) The stlghtJy �popiaStic aNOOiar(ldges wefe the re&At oftack of toolh development . The patient deClined augmentatiOn beea\Js e of a tow snile tine
that would 110t afleet lheesthetiC outcome. IUallde}AC<ytic resin cOllings place<J over the central incisors and gold COllings on lhe motars serve as a jig to laeititate recording or
centnc ooclllSlOO and the correct \'1!!1JCal max41omandibular relationship lor repetition on an articulator. M occlu sal device can help achieve a neuromllScutar release to verify
tros repeatable posotion before de flllitive treatment is begun. (Itoi) Gold copings on the mc4ars and the use ofsemirigid mat1ix and patnx connectors we<e IOCOrporated into
the FOP deSi gn . TI>e posterior segments were cemented ••th proviSional cement over the permat�ently cemented molar gold copings. This approoch attows retrieval ol
the segments for receme11tatio11, if needed. Use of an occlusal device and tong-te<m maintenance requirements mtJSt be understood by the patient and recognized by the
clinician. 0 too) Completed FOP treatment nastored with Ml at CR. Anterior guidance was established to allow posterior separation during protruSiOn. madlotrusiOn, and
laterotrusion. Mandibular FOP consisted of three-un� and four-unit restorations with rigid connectO<S because of the Shorter span.
Complex FOP designs The repetitive combination of alternating directional forces eventually
may reduce the fidelity of the luting agent and shorten its longevity.
The three-unit FOP may be the simplest design when controlled When the canine is missing. group function concepts or a shared
loading is confined to the posterior or anterior regions. Multiple abut uniform disocclusion on the abutment teeth should be considered to
ments and tooth replacements reduce the prognosis. FOP designs avoid unnecessarily increasing tangential loading. Moreover, close
(Fig 18-27) that include the canine as a primary abutment and are inspection must be done for possible cross-arch balancing contacts
accompanied by localized loading, such as in canine disocclusion, related to the reduced vertical dynamics of the prescribed disocclu·
inherently impart simultaneous compressive and tensile forces on sion. The concept of incorporating a progressive disocclusion de
the abutments during functional loading and cross-arch unloading. scribed earlier in this chapter is worth considering.
288 1
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ion
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Chapter
Speech Pathology and

Prosthodontic Applications
Thomas J. Salinas DDS ,
William R. Laney, DMD. MS

Jana M. Rieger, PhD
John F. Wolfaardt, sos. MDe"1. PhO
subtle ideas. Sentences aregenerated t o achieve self-expression

Generation of Speech and self-realization and to ma nipulat e the behavior of others. The
neuro logically intact person possesses an auditory retention span
The oral and laryngeal apparatus, altho ugll fu ndamentally respon adequate to receive competing incoming auditory and vi sual signals,
sible for the functions of mastication, de glutit ion and protectio n
, to arrange them hierarchically, and to respond to them different ially
of the lungs from invasion by foreign o bjects is also a speech
, in a decoding process. An appropriate response to these sounds is
mechanism. Highly skilled activi tie s desi gned tor comm unicalio n selected from the many possibil�ies, and it is then encoded in the
have been added to those that are more instinctual. conventional symbols of language: ultimately. the child speaks.
Several basic processes are involved in communication. two
of which primarily, but not exclusiv ely involve lhe prosthodonst.
, ti
A revie w of these basic processes provides a perspective for the Motor processes
expected level of the prosthodont ist's interest.
Respiration provides the raw material for speech. In respiration,
expi ratory muscles produce an exhaled air stream. The inspiratory·
Symbolization expiratory cycle of vegetative breathing is altered d urin g speech,
with prolongation of the expiratory portion. In phonation. t he b"9ath
A fundament al component of human interaction is the symbol sys stream sets into vibration the approxi mated vocal folds or the
tem (language) adopted by society for exchange of ideas. The child larynx, and a complex tone is generate d which at its most basic is
.
is surrounded by noises that he or sh e le arns to recognize as words a meaningless squawk. Interspersed between the voice tones are
tor certain sensations. perceptions. concepts, objects. desires, emo voiceless segments of the breath stream emitted between abducted
tions, and needs; we say that the words come to have meaning for vor.al cords.
him or her. Eventually, the child learns to translate experiences into This breath stream. w it h periodic and aperiodic components. must
words, as he or s he acquires and continually adds to a vocab ulary be shaped and modified through additional processes of resonance
of words that are recognized and some of which are used. The child and articulation. Resonance refers to the selective amplification of
also becomes adept at applying the battery of rule s (morphology the voiced tone; the pharynx. oral cav�. and nasal cavity serve as
syntax) that govern alteration of these word s and their co mbinations resonators that reinforce certain components of the tone and sup·
to fOml sentence s and to express increasingly complicated and press others. If the nasal cavities are coupled to other cavities, a
293
19 i Speech Pathology and Prosthodontic Applications
distinctive nasal tone results The constrictor muscles of the phar

. Although the work or the p rosthodontist may extend to other
ynx and the levator muscle of the soft palate (velum) work together aspects of the communication process, it relates primarily to the
to couple and uncouple these resonance chambers. Alterations in processes of articulation and resonance. These processes are closely
the resonance characteristics of the oral i
cav
ty are accomplished related, the difference being mostly an artifact of the words used to
by varied positions of the tongue and mandible and by altera describe them. Vowel articulation is accom plished by alterations in
tions of the orifice through mandibular adjustments and changes the character of the oral cavity as a resonator; articulation o f the nasal
in lip opening. Ultimately, the breath stream is shaped into sounds consonants requires nasal resonance; and improper coupling of the
(articulation) througl1 impedances produced by the various articu nasal resonance cavities to the oral cavity leads to distortion of the
lators (ie. tongue, teeth, and lips). Rapidly sequenced sounds are so-called pressure con sonants. The prosthodontist inffuences 1118
grouped Into words strung together in characteristic patterns of role dentition plays In valving, and restorative work can compensate
phrasing at different rates of speed and with rhythms characteristic for inadequate function of the palatopharyngeal valve.
of the dialect being spoken. The term prosody embraces all those
variations in time, pitch, and loudness that accomplish emphasis
and lend interest to speech. Compensatory mechanisms
Impairment o f language processing unrelated to sensory loss
or mental retardation is termed aphasia. Motor speech problems Certain relationships are expected between structure and function
caused by lesions of the central or peripheral nervous system are and between abnom1ality and dysfunction; that is, certain con
collectively known as dysarthria. The term dysphonia is applied to sequences can be assumed to result from certain causes. But one
all types or impairment of phonation, both organic and nonorganic. is continually confronted with the fact that even a major physical
An articulatory problem without apparent neurologic basis is called deviation does not always result in a significant speech deviation.
dis/alia. Delay in acquisition of communication skills is called speech Observation of a wide spectrum of anatomical variation and behav·
and language retardation. ioral adjustment reveals an impressive adaptability or the human or
ganism to adversity. Compensatory mechanisms help the individual
to accommodate seemingly insurmountable obstacles surprisingly
Valving function well. Speech is possible even in cases of congenital aglossia'·2 and
surgical excision of large portions of the tongue.H Children may lack
Speech production can be considered. in Simplest terms. as the in maxillary incisors yet fail to misartieulate those sounds whose pro·
fluence of a serie s or musculoskeletal valves on the breath stream. duction is ordinarily considered dependent on dental impedance of
The vocal folds, or glottal valve, constitute the first series of valves. the breath stream.8 Patients with open palatal clefts may occlude the
The adduction of these folds permits the production of a voiced ceft
l by means of unusual degrees of oral activity and extraordinary
tone, and their abduction permits uninterrupted or voiceless pas tongue movements and yet manage to produce consonants with an
sage of air. The muscles of the soft palate and the pharynx constitute acceptable degree o f oral breath pressure.
the palatopharyngeal valve. which couples or uncouples the nasal When the s tructure or function of oral mechanisms is impaired b y
c avities. The tongue contacts different parts of the oral cavity to pro· orofacial abnomnalities. it is unsafe t o draw a one-to-one relationship
duce dff
i erent vatving effects: and assume that what appears to be an adequate cause will indeed
result in the expected speech problem. Undoubtedly, an explanation
• The back of the tongue touches the soft palate to produce a tin exists for any such unexpected lack of consequence. but present
guovelar valve. knowledge may not clarify the exact nature of the compensatory
• The blade of the tongue rises to contact the hard palate, creating mechanism.
a linguopalatal v alve .
• The tip of the tongue rises to touch the alveolar ridge, constituting
a linguoalveolar valve.
• The tip of the tongue, when it protrudes between and touches the Sounds of Speech
teeth, creates a linguodental valve.
Language's smallest units of speech sounds, not carrying mean ·
The lips function in two valving activities: The maxillary incisors ing themselves, are combined to form the smallest meaningful units
and tl18 lower lip fomn a labiodental valve, and the lips work together of words (in linguistiC terminology. morphemes). General American
to form a labial valve. The various valves interrupt, impede, and English 11as approximately 45 different speech sounds. No two peo·
constrict the air stream in many ways to produce the complete pie produce a given sound in exactly the same way or with the identi·
repertoire of speech sounds. Impairment of function of any of the cal acoustic effect, and a given speaker varies in product i on of one
valves may lead to a communication disorder, the severity of which sound to another. Nevertheless, all or these variable productions of a
depends on the degree of uncompensated alterations in speech that sound (called allophones ) are recognized as variants of that sound,
attract attention and are evaluated negatively by listeners . and they are appropriately grouped into a family, called a phoneme.
2941
Classification of Consonantsj
Table 19-1 \Vowelsound s

-------
\ -
- Table 19-3 lfConsonants
Phonetic symbol Key word Phonetic symbol Key word
Iii tll!l.n /rnl mum
/II tin In/ l)OOQ
lei late fl)l siog
/r.J ten /pi QOQ
Ia!/ tan lbl !llll
IN tQn
IV !OI
Ia! !IPOil
ldl de�
/,/ turn
/kl c.oo!s
I'iN moth!lr
IQt lg! gag
Ia!
lot da:tln Iff !luff
lol tQte /VI �1¥8
/u/ b!l.QK tel l!link
lui moo n 101 the<e
lsi §i!UC9
lzl �oos
IV sousu
1"!/ meaaure
ltf/ £llurm
Table 19-2 I Diphthongs lr!!J fudge
Phonetic symbol Key word /hi heort
{aut Jr/ !ed
l ao/ IV !IJJ
lou/ /hw/ !OOlere
le1/ Av/ Jti'(lat
ool
t lj/ �s
It is more appropriate, then. to say tl1at in General American English, 3. Consonants generally are phonemes characterized by consider
there are approximately 45 d fferent phonemes.
i able impedance of the breath stream and used adjacent to vowels
Thephonemes of Engl sh can be divided into tour groups: vowels,
i and diphthongs to build syllables. The symbOls and ide tifyingn
diphthongs. consonants, and combinations: keywords of 25 consonants are listed in Table 19-3.
4. A combination is a blend of consonants and/or vowels articulated
1 . Vowels are open-voiced sounds, or sounds that involve vibration in such quick succession that they are identified as a single pho·
of the vocal cords and are relatively unimpeded by the oral valves neme, although the blend can be separated into two component
in their egress. Vowels may constitute a syllable or serve as the sounds. A combination in General American English is /ju/ as in
nucleus of a syllable. Whereas in written General American Eng theword�y.
lish. six symbols are used to represent vowel entities (a, e, 1. o,
u, and sometimes y). these symbols can be pronounced in more
than six ways and therefore require additional symbolization. Table
19-1 shows common vowel s in General American Engl sh . each
i
Classification of Consonants
represented by a symbol in the International Phonetic Alphabet
(IPA) and illustrated in a word. The prosthodontist is concerned primaril y with consonants. whose
2. Diphthongs are blends of two vowels spoken within a single syl distinctive identity is created by differential impedance of the breath
lable without interruption of phonation. The diphthongs are con stream, including impedance introduced by the teeth. PrOduction
n
sidered si gle phonemes, and although each can be separated of the vowels and diphthongs is seldom a problem in patients with
phonetically into two parts, the two vowels are spoken in quick whom the prosthodontist usually works, but the production of con
succession. Table 19-2 lists frve common diphthongs of General sonants may be significantly influenced by orofacial anomalies, so
American English. their classification and manner of generation are important to un
derstand.
295
Methods used to study consonant production locus, nature, and degree of constriction determine the distinc
tive features of each sound. The nine fricative sounds are /f/,
Cephalometric radiographs have been used to show the ver1ical lvl. lei, 16/, lsi, !zl, IJI, 131, and /h/. The term sibilant sometimes
and ant eroposterior relationships of the various articulators dur is applied t o any s·like sound. The sounds usually referred to as
ing the production of consonants and sustained vowels....'' Even sibilants are /s/. tzl.IJI, and /3/. Misarticulation of the sibilants is
more informative are cinefluorographic films. Because cinefluor known as lisping or sigmatism.
ography does not require the static conditions necessary in single 4. The affricates (alSo called affricatives) are combinations of two
exposure procedures. it can utilize connected speech samples consonants produced in quick succession without interruption
rather than only sustained sounds, and it provides more than one of the breath stream. Although these can be dissected into their
cross-sectional time sample during speech sounds. Thus, move· component parts, they usually are considered phonemically to
ments as well a s static positions may be studied.'z be consonant elements. If the plosive IV is exploded through
Palatography is a technique used to study tongue contact with the constriction characteristic of the fricative /fl. the affricate
the alveolar ridge and palate during the production of phonemes ltJI results. If the plosive /d/ i s exploded through the constriction
or syllables. A thin acrylic resin or other dental baseplate material characteristic of the fricative /y, the affricate /cty is produced.
is shaped to the contours of a hard palate through the use of a 5. The glides (/hw/ . /w/, and /j!} involve relatively little impedance
dental cast. The lingual surtace of this false palate is dusted with of the air stream. Their distinctive characteristic is that they vary
powder and inserted in the mouth; as the speaker produces the acoustically and physiologically within their duration.
desired phoneme, the tongue erases the powder from the area of 6. The semivowels (/r/ and /II) involve the least impedance of the
contact. '3 A new technique of continuous palatography does for breath stream. They are vowel-like in their manner of production
palatography"·" what cinefluorography does for the cephalometric and their perception.
radiograph by permitting multiple measurements representative of
continuous speech. Transducers are embedded in a plastic artifi· The phonemes classified as nasals and semivowets are some·
cia! palate with electrodes that protrude less than 1 mm from the times called liquids. Consonants that can readily be prolonged are
surface. Each electrode functions on contact with the tongue. The called continuants. Thus the nasals, fricatives, and semivowels are
resulting signal is carried by insulated copper wires through a poly· considered continuants; the plosives. affricates. and glides are not
ethylene tube to an amplifier. then t o a readout unit. which is an included in this classification.
analog diagram of the palate with lights mounted in positions that
correspond to the electrodes in the plastic palate. Motion pictures
are made of the readout panel during speech, and frame-by-frame Classification according to laryngeal action
analysis of tongue movements can be made.
The sound spectrograph (sonograph, s pectrometer) provides In the production of some consonants, the air stream passes through
another type of analysis. uw It graphically portrays the regions of the larynx without activating the abducted vocal cords. Thus. the
energy concentration characteristic of the various phonemes spo· aperiodic sounds subsequently produced by impedance within the
ken during 2.5 seconds of continuous speech. oral cav�y are called voiceless (also called unvoiced or surd). Most
of these phonemes have a voiced periodic counterpart produced
similar to impedance within the oral cavity but characterized by a
Classification by manner of production voiced tone brought about by vibration of the adducied vocal folds.
These phonemes are called voiced (sonant). The pairs of voiceless
Six groups of English consonants can be differentiated according to and vo ced phonemes are called cognate pairs (Table 19·4). The
i
the manner in which they are produced. voiceless /h/ and the voiced !mi. In!. If)/, /1/, /r/. and /j/ have no
cognates.
1. The three nasals Vml, /n/, and lr)l') are distinguished from the rest
of the consonants in that their production rnvolves the coupling
of the nasal cavities as resonators. The emission of each sound Classification by pressure characteristics
is nasal. When the nasal cavities are blocked. the nasal sounds
are produced denasally (hyponasally). The resulting speech com Consonants vary in the amount of intraoral breath pressure required
monly is described as "talking with a stuffy nose: for their correct production.'&'9 The consonants that require the
2. The second group o f six consonants, the plosives or stop most pressure are the affricates. fricatives, and plosives; therefore,
plosives, requires a complete stoppage of the air stream, a build· they are known as pressure consonants. Continuants require sig
up of pressure, and a sudden release and explosion of the breath. nificantly more pressure than noncontinuants. and voiceless conso·
The sounds are /p/, /b/, IV, ld/, lkl, and /g/. nants require more pressure than their voice cognates.
3. The fricatives involve less complete stoppage of the breath stream
but sufficient constriction of it that a friction sound results. The
2961
Classification of Consonants j
Table 19-4 Cognate pairs of phonemes

Voiceless Voiced
Plo$ivoo
Ipi lbl
lV ldl
lkl !gl
Fricatives
Ill lvl
Ia/ /0/
Is/ lzl
Glides
lhwl lwl
Affricates
I!JI lay
Fig 19-1 Frootal lriew of articulatioo of labiodefllals Ill Fig 19-2 frontal view ot articulation of linguodentals /a/ Fig 19-3 Frontal view of articulalion of llnguoalveolar p!o·
and lvl. and /0/. sives and nasai/V,/dl, and In/.
Classification by place of production Linguodental consonants
This method of classification of consonants is probably most mean The fricatives /e/ and !of are producec by forcing the breath stream
ingful to the prosthodontist because it highlights those consonants through the constriction produced when the tip of the tongue is pro·
most affected by dental conditions. For this reason, the various sub trudec between maxillary and mandibular incisors (Fig 19-2); the
groups, each with its distinctive features, are illustrated separately. tongue and maxillary incisors touch or are approximated. The pho·
The frontal view of the mouth during phoneme production is shown name lei is voiceless, and /o/ is voiced. The voiced phoneme is pro
in each figure to convey useful i nformation . The figures presented duced with more force than the voiceless one. For the oral emission
in this chapter represent abstractions of the articulatory act, which oi these pressure co nsonants, the palatopharyngeal valve is closed.
may vary widely from speaker to speaker and from production to
production of the same phoneme by the same speaker. At best. Linguoalveolar consonants
these figures constitute an average representation of the process of
phoneme articulation. The 10 linguoalveolar consonants are divided into five groups, orga·
nized by distinctive place and manner of production:
Labiodental consonants
1. Tile consonants IV, lei/, and /n/ have a common articulatory posi·
The fricatives Iff and /v/ are produced by forcing the breath stream tioning, although two are plosives and one is nasal. In all three. the
through the contact made by the maxillary inciSors with the lower lip tip of the tongue contacts the alveolar ridge, with the sides of the
(Fig 1 g .1). In the case of If!, the breath stream is voiceless; in tile case tongue in tight contact with the teeth and gingivae (Fig 19-3). In
of /v/, the breath stream is voiced. To accomplish the oral emission the case of IV and /d/, the palatopharyngeal valve is closed. and
of these pressure consonants. the palatopharyngeal valve is closed. impounded breath pressure is suddenly exploded orally. In the
case of /n/, the palatopharyngeal valve is open, and the voiced
breath stream is emitted nasally.
297
2. The linguoalveolar fricatives lsi and fzl result from the formation 2. The consonant /j/ is a voiced linguopalatal glide. It is initiated with
of a narrow midline groove of the tongue through which air iS di· the tongue raised toward the front of the hard palate, but in the
rected against the incisal edge of the teeth (Fig 19-4). The lat course ot the sound's production, the tongue moves to a posi
eral margins of the tongue contact the teeth and gingivae, and tion appropriate tor the articulation of the following phoneme (Fig
the blade of the tongue nearly touches the alveolar ridge. The 1g·9). The palatophal)'ngeal valve is closed and the teeth are
palatopharyngeal valve is closed so that the air stream for these nearly in contact.
continuants can b e emitted orally. Some speakers place the tip
of the tongue behind the maxillary teeth, and others place the tip Linguovelar consonants
of the tongue behind the mandibular teeth. The position of the
tongue tip is less important than the constriction of the air stream The so-called back consonants or gutturals lk/, /g/, and /f)/ are pro
b y the narrow groove and its impedance by the alveolar ridge and duced by contact of the middle of the tongue with the soft palate (Fig
the teeth. The breath stream is unvoiced for /s/ but voiced and 19-t0). In the case of the plosives /k/ and /g/, the palatopharyngeal
expelled somewhat Jess forcefully for lzl. valve is closed as pressure builds up behind the linguovelar contact
3. The fricatives If/ and I'!) are produced similarly to lsi and /zl. except and releases. tn the case of the nasal /f)/. the palatophal)'ngeal valve
that the tongue groove is broader than in lsi and lzl (Fig 19-5). is open and the voiced air stream is nasally resonated.
While the lateral edges of tile tongue contact teeth and gingivae,
the tip and blade of the tongue approximate the alveolar ridge. In Bilabial consonants
some speakers, the tongue is more posterior and approximates the
front of the palate rather than the alveolar ridge. Because of this, tn the five bilabial consonants, the distinctive valving involves the lips.
these phonemes are sometimes included in the linguopalatal group Three of these involve lip closure, and two involve lip rounding:
discussed subsequently. The palatopharyngeal valve is closed so
that air can be directed forcefully between the nearly closed teeth. 1. For /p/, /b/, and lml, intraoral breath pressure is impounded
The lips are often rounded and protruded. The breath stream for behind closed lips (Fig t g-11). For production of the plosives /p/
production of If/ is voiceless, and it is voiced for /sf. and /b/, the palatopharyngeal valve is closed and the impounded
4. The phonemes /tf/ and ld:J are linguoalveolar affricates; when the air pressure is suddenly exploded orally. For production of the
point of contact is slightly more posterior, they are linguopalatal. nasal /m/, the palatopharyngeal valve is open and the voiced air
The tongue is placed tor the production of the plosives IV and ld!, stream is resonated nasally.
but the air is exploded lhrough the constriction characteristic of 2. The consonants /hw/ and /w/ are bilabial glides. They require
the fricatives If! and 1?/ (Fig 19-6). The palatopharyngeal valve is rounding of the lips, which subsequently move to the appropriate
closed to accomplish the pressure required for the combination of position for the following phoneme (Fig 1g-12). The palatopha·
a forceful plosive and a prolonged fricative. The air stream in /tf/ is ryngeal valve is closed. The voiceless lllw/ has a mild fricative
voiceless, and it is voiced tor /ri!J. component; its cognate is the voiced /w/.
5. The consonant /1/ is a voiced semivowel. The tip of the tongue is
in contact with the alveolar ridge, the lateral margins of the tongue Glottal consonants
being towered so that the airstream flows laterally on either side of
the contact (Fig 19· 7). Hence the phoneme i s sometimes called a 1\vo consonants in which the constriction is at the level of the glottis
lateral. TI1e palatopharyngeal valve is closed during its production. (space between the vocal folds) are !hi and /o/:
If the tip of the tongue is positioned posteriorly with more palatal
than alveolar contact. val)'ing degrees of so-called dark IV are 1. The Ill/ sound is an unvoiced fricative produced by the turbulence
produced. created when the breath stream passes between the partially ap
proximated vocal folds. Part of the friction probably i s created
Linguopalatal consonants when the air strikes the surfaces of the pharynx and oral cavity.
TI1e palatophal)'ngeal valve is typically closed. Tongue and lip po
Two consonants are produced by lingual approximation t o some sitions d o not influence the character of the phoneme.
portion of the palate posterior to the alveolar ridge: 2. The consonant /o/ is a glottal plosive produced by sudden imped
ance and release of the breath stream at the glottis. It is com
1. The consonant /r/ is a voiced semivowel. Typically, the sides of monly produced by infants but not retained in the normal General
the tongue touch the maxillary teeth (Fig 19·8). The tip of the American English repertoire of phonemes. Patients with palato
tongue often is pointed to an immediately postdental area, but at pharyngeal incompetence often resort to this glottal plosive as a
other times, the tongue blade is arched highest toward the palate substitute for plosive valving within the oral cavity, which requires
while the tip points down. Phonemes adjacent to /r/ in speech will competence of the palatophal)'ngeal valve.20
determine the contour of the tongue and the portion of it that is
highest. TI1e palatopharyngeal valve i s closed.
298 1
Relationship of Dental Conditions to Articulation Problems j
Fig 19-4 Frontal view of articulation of linguoalveofar Fig 19-5 Frontal view of articulation ol llnguoalvoolar Fig 19·6 Frontal view of articulation ol linguoalveolar af ·
fricatives Is/ and lzl. lrlcaUves If! and 1?}. fricates ltfl and ld?J.
Fig 19·7 Frontal view of articulation of linguoalveolaf Fig 19·8 Frontal view of articulation of liflguopalatal Fig 19-9 Frontal view ol articulation or llnguopalatal glide
semivowel/If. semivowellr/. lj/.
Fig 19-1o Frontal view of articulation of linguovelar plo Fig 19-11 Frontal view of articulation of bilabial ptosives Fig 19-12 Frontal view ol articulation of bilabial glides
sives and nasal/k/, /gl, and /rJ/. lp/, lbl, and lrnl. lhw/ and lwl.
conclude from group data that severe dental devialions are more
Relationship of Dental likely to cause speech problems.
Conditions to Articulation In a study of the relat ionship between speech and occlusion in
410 university students, Fymbo found ma oclc usions
l i n 87% of 111
Problems students with defective speech , 62% of 199 students with average
speech, and 35% of 100 st udents with superior speech.2' The 35
superior speakers with malocclusion showed no ill effects from the
Although some practitioners and writers have stated that certain malocclusion. Based on these obsen�ations , Fymbo concluded
dental conditions definitely cause certain predictable speech de that severity of the speech defect varies directly with the severity of
fects , studies of groups with abnormal dental conditions or disor the dental anomaly. Fairbanks and Untner compared 30 university
ders of articulation have failed to confinn a one-to-one relationship students who had superior consonant articulation with 30 students
between a given dental condition and any given speech defect. who demonstrated inferior consonant articulation.�• One of their
However. i n certain individuals. the presence of a dental abnonnality conclusions was that the students with inferior articulation also tended
is causally related t o an articulat on problem. It is also possible t o
i to present with a significantly higher number of dental deviations.
299
19 i Speech Pathology and Prosthodontic A ppl i c ations
Effect of malocclusion a constriction with the ha rd palate and alveolar ridge. The major
difference between the normal speakers and the defective speakers
Although dental conditions apparently had little deleterious effect on with malocclu sion was round in the anteroposterior posi tion of the
the average and superior speakers. Fymbo's report of the differential tongue t ip in relation to the mandibular incisors: Normal speakers
incidence of malocclusion among d efec ve . average. and superio r
ti posi tioned the tip slightly posterior to the mandibular incisors; those
speakers is of interest. Fymbo called attention to the importance of with defective speech protruded the tongue t ip significantl y beyond
abnormal vertical relationships of the aw
j s. s pecif ical ly open bite and the mandibular incisors and approach ed the lingual surfaces of the
close bite conditions21 (close bite refers to a sm all interarch distance protruding maxillary Incs
i ors. The groups did not differ with regard
or critical incisal gui dance). Only 29% of the patients with close t o the degree of constriction effected between the midline of the
bite and 21% of those with open bite had satisfactory or superior tongue and the pal at e.2�
speech. Similarly Fairbanks and Lintner found a higher incidence
,
of open bite and close bite among speakers with inferior consonant
articulation.22 Ope n bite likely is a more important contributor to the Effect of intactness of the dental incisal edge
significant difference compared to close bite.
Of 78 children receiving therapy because of faulty p rod uction Data vary concerning the importance of the completeness and
of sibilants, Wolf found that 74% had malocclusion and 26% had alignment of the dental incisal edge against which the constricted
normal occlusion.23 In 28% of the children who had maloc clusi on, air str eem is directed in articulation of sibilants. Based on his group
a direct relation ship was established between the malocclusion and of college students, Fymbo concluded that edentulous spaces are
t he articulation defect. An additional 26% of those with malocclusion strong etiologic factors in defect ive speech produ ct ion especially
.
showed a secondary or possible relationship. However, the remaining when they are found among the six maxillary anterior teeth.2' A sig
c hildren de monstrated no appa rent relationship between their nificantly higher number of mi ssing teeth were found in the group
spee ch problems and malocclusion. Anterior open bite. prot rusion of w ith more defective s pee ch . He felt that the spacing of t h e teeth
the maxilla with open bite, and protru sio n of the mandible with open affected speech competency as well. Wolf ment ions widely spaced
bite were all fou nd to be potential causes of articulation problems. incisors or canines as a potential cause of sibilant-articulation dif·
In a s tudy of 76 school children ages 8 through 12 years who were ficulty.23
ident i fied as having a significant open bite. 45% were judged to Snow st udied the speech of 498 first-grade students to determine
have an interdental lisp (tongue tip protruding between maxillary the effect of missing or grossly abnormal maxillary incisors on
and mandibul ar incisors in production of /s/) s uff iciently obvious to the articulation of lsi, lzl. /fl. /v/, lei. and /0/.5 Of these children,
warrant speech the ra py?' 314 had abnormal or missing maxill ary incisors. A sig nificantly
Data con cerning other types of malocclusion yield somewhat less larger proportion of the children w ith mi ss ing or abnormal incisors
clear-cut conclusions. In addition to the aforementioned conditions, misarticulated the phonemes compared to children with nor mal
Wolf lists protrusion of the maxilla with in creased h orizontal overlap dentition. However, most of the children with abnormal or missi ng
and protrusion of the mandibl e with reversed overlap as potential incisors stiD articulated the phonemes correctly. and some of the
causes of articulation problems."' However, Fairbanks and Lintner children without dental abnormality misarticutated them. She
fo und that an atypical anteroposterior relationship of the maxillary concluded that alt11ough defective incisors g ene rally do not interfere
and mandibular anterior teeth (increased horizontal overlap or with correct articulation, for some ch ildren. the condit i on of the
reversed overlap conditions) did not different iate inferior from maxillary incisors may be a critical factor in its development.
supe rior articulators.22 Based o n a study of 81 adolescents. Subtelny In a cephalometric study. Weinberg compared three groups of
e t al conclu ded that some speakers with horizontal overlap may 13 children: The first group exhibited complete dentitions. normal
adjust to it in such a way as t o produce defective sibilant sounds?5 occlusions. and correct production of lsi; the second group exhibited
They studied 30 patients with nor mal occlusion and speech and missing maxillary central incisors, normal molar relationships, and
51 patie nt s with Class II, Division 1 malocclusion (mandibular cor rect production of /s/; and the third group exhibited missing
retrusion associated wi1h protr ud ing incisors) rn whom the degree maxilla1y central incisors, normal molar relationships, and defective
of maxill ary dental horizontal overlap beyo nd the mandibular incisors production of /sl.""' In the latter two groups, those with defective
exceeded 6 mm. Of t he 51 patients. 31 had normal speech and production of Is! were found t o elevate and protrude the tongue tip;
20 had defective speech. Through cephalometric methods, the those with correct production of lsi did not.
manners of production of /sl were studied. In the speakers with In their study of college-age superior and inferior articulators.
normal occlusion, the incisors were round to assume an edge Fairbanks and Lintner found that the anterior teeth of p atien ts from
to-edge relationship, acco mpl ished by a sligh t protrusion of the each group did not differ significant ly in the total number of slight
mandible. The tongue tip was ch aracteristically posterior to the or appreciable deviations from nor mal in terms of alignment or
mandibular incisors, with a vertical position that varied as it formed existence ot diastemas.n
300 1
Palatopharyngeal Incompetence and Its Prosthetic Management J
Conditions probably unrelated to articulation • Pa tients with cleft of the lip only or of the lip and alveolar process:
problems 4.5% (closely resembles that of pati ents without any cleft)
• Pati ents with cleft lip and palate: 42.6% (maxillary second premolar
most frequently missing)
No avai labl e data support the idea that a lat eral open bite is related • Patients with posterior cleft palate only: 32.3% (mandibul ar second
t o arti culation problems. Another common notion i s that the height premolar most frequently missing)
and width of the palate are directly related t o defective articulation.
Fymbo felt thai either an unusually high or low palate could be re· Dental malformations (fissural teeth) took the place of maxillary
lated to faulty production of Is! and /z/.2' However, Fairbanks and lateral incisors in the cleft area. regardless of cleft type, in 75.6% of
Untner found that the width and height of the dental arch and hard cases with primary dentition and 44.3% with permanent dentition.
palate were not decisive factors in their groups of super ior a nd infe · A fissural tooth developed more often on the distal side of the cleft,
rior articulators.n usually medial or lingual to the canine.
Dental conditions in cleft lip and palate

Speech considerations in fabrication of
Certain dental abnormalities can b e expected to occur in p atient s

prostheses
who present with a cleft of the lip, alveolar ridge, palate, or any com
bination of these. Such abnormalities may contribute to articulatory In the preparation of partial dentures to restore edentulous areas
problems that are associated with speech difficulties resulting from and provide an incisal edge for the impedance of the air stream in
palatopharyngeal in competence. speech, consideration should be given to how pl acement of material
The nature of dental abnormalities in 10 fetuses and 105 indi· behind the maxillary incisors, which reduces space in the oral cavity,
viduals with cleft tip or cleft palate was reported by Jordan et al,2' affects speech. Patients with dentures usually become aware of how
who compared maxilla1y and mandibular dental casts of these they produce sounds and may have some acoustic distortion of sibi·
individuals with those obtained from 87 pat ients with nonnal cleft lants and possibly other linguoalveolar phonemes. Tench observed
and palate. All fet uses and 54.3% of t he persons with postnatal oleft that people with small tongues rarely have difficulty with dentures,
palate had dental abnormalities (missing teeth 25.7%; thick curved
, , but those with broad tongues and tongues that almost completely
maxillary incisors, 23.5%; peg-shaped incisors. 11%: exaggerated fill the oral cavity experience speech difficulty."' Guiding principles in
mamelons, 5.9%: reduced hypocone, 5.1 %; supernumerary teeth, preparation of conventional prostheses should be to keep the thick·
4.4%; missing hypocone, 4.4%: malformed mandibular primary ness of the material behind the maxillary incisors t o a minimum and
first molars 3.7%; and malformed mandibular premolars, 3.7%), in
, provide a well defined alveolar process centrally.
-
contrast to only 14.9% of lhe patients without cleft lip/palate. The A prosthesis may help to preserve the maxillary arch form in
investigators concluded that individuals with a cleft who present with children with clefts of the lip and alveolar process. The use of acrylic
dental abnormalities are likely to have multiple abnormalities: The resin prostheses inserted immediately after repair of a cleft Up in
fetuses with cleft p al ate had an average of 3 abnormal iti es, and the newborns has been described.30·3' The prosthesis is fabricated with
patients with postnatal cleft and some dental abnormality had an projections into the cleft area t o prevent the possibility o f collapse of
average of 2.4 abnormalities. The presence or absence of dental the cleft space while allowing palatal growth. Good preservation of
abnormalities was not related to type of cleft in the post natal patients. alveolar ridge contour has been reported with this method.
These findings would appear to Indicate that the specific area
affected by the cleft Oip alone: palate alone: or alveolus with lip,
palate, or both) does not necessarily influence the presence or
absence of dental abnormalities. The presence of a cleft rather ,
Palatopharyngeal Incompetence
than its location, is significantly involved with the appearance of and Its Prosthetic Management
morphologic abnormalities.27
Bohn reported additional findings from two studies of abnormal The muscles constituting the palatopharyngeal (velopharyngeal)
d ent al conditions and 339 patients with various types of clefts.2• valve seNe to uncouple the nasal cavities from the rest of the speech
Permanent dentition failed t o develop (agenesis) in only 10% of apparatus. On contraction the levator veli palatini and the constric·
.
patients presenting with cleft of the Up alone. In patients In whom the tor muscles of the pharynx, innervated by the 1Oth cranial nerve,
alveolar process and lip were involved, agenesis of primary dentition close the lumen that connects the oropharynx and the nasopharynx.
in the cleft area was found in 14.3%, and agenesis of permanent The soft palat e moves backward and upward t o contact the back
dentition was found in 45.5%. Incidence of missing teeth outside the wall of the pharynx, and the constrictor muscles move mesially. Un·
cleft area in the permanent dentition was reported as follows: der n orm al anatomical and p hysiolog ic conditions. there is little or no
anterior movement of the posterior pharyngeal wall. However under ,
301
certain abnormal conditions, a bulge in the back wall, designated The fact that cavity relationships are abnormal and do not permit
Passavant's ridge. appears inconsistently and contributes t o clo competent palatopharyngeal valving may not be evident at the onset
sure.32 Spriestersbach reported observation or Passavant's ridge in of speech or even for years thereafter. Many cases or congenitally
approximately one-third of persons with cleft palate and concluded short palate, congenitally deep pharynx, and submucosal cleft go
that h only develops when greater restriction of the lumen of the unrecognized because hypertrophied adenoids fill space in the na
pharynx in the region of the velopharyngeal port is neededo:J (see sopl1arynx and provide a surface against which the inadequate pala
chapter 15). tal musculature makes contact. The abnormality may be discovered
Sphincteric closure of the palatopharyngeal port confines the only after adenoidectomy, as speech deteriorates.""-"'
breath stream and its resonance to the oral cavity and oropharynx.
allowing buildup of intraoral breath pressure to the degree necessary
for correct consonant articulation. This makes oral rather than nasal Results
emission of air possible and prevents nasal resonance. Opening of
the valve allows production of In! and /fJ/, the nasal consonants: Palatopharyngeal incompetence leads to the following three primary
however, even when the valve is open, desired nasal resonance may speech consequences:
not be attained if the nasal cavities are occluded by hypertrophied
adenoid tissue. polyps, a deviated septum, a retropharyngeal tumor, 1. Hypernasality, a voice-quality abnormality resuijing from excessive
or rhinitis. nasal resonance, is a logical consequence of coupling with an
extra resonator. Correlations of 0.60 to 0.78 between the mea
sured degree of palatopharyngeal closure and listener judgments
Causes of hyper nasality have been reported."
2. Often associated with hypernasality is the noise created by flow of
Several conditions can cause failure of valve closure, resulting in air through the nares during articulation, or nasal emission of air.
palatopharyngeal incompetence: 3. Because the production of many consonants requires the buildup
of substantial intraoral breath pressure and oral impedance of the
• Neurologic disease may weaken or paralyze the muscles involved. breath stream, it is expected that an impairment of palatopharyn
For example. in lower motor neuron diseases such as bulbar polio geal valving that allows even minimal egress of air into the nasal
myelitis, other neurotropic virus diseases. and myasthenia gravis. cavities would result in a distortion of articulation.••
the muscles are flaccid and closure is not complete. In bilateral
upper motor neuron diseases that result in spasticity of the mus Shelton et al studied 6 patients with palatal inadequacies, 24
cles and slowness and limitation of movement, valving may not be patients with surgically repaired cleft palates, and 1 0 patients with
possible at the rate necessary for rapid speech, so closure is not normal palates, and concluded that gaps between the soft palate
accomplished. and the pharyngeal wall smaller or larger than 2.0 mm may have a
• A congenital cleft of the palate permits free egress of air from the deleterious effect on articulation:" Speakers with palatopharyngeal
oral cavity into the nasal cavity. Even after primary surgical repair incompetence have the most difficulty in articulating affricates.
of a cleft, the palate may be immobile or too short t o permit com fricatives, and plosives (the pressure consonants), and relatively less
plete closure."' difficulty with glides and semivowels."''"'� Voiceless consonants are
• If no palatal cleft is evident, there may be a submucosal cleft with more frequently misarticulated than their voiced cognates. Omission
inadequate bony structure and abnormal muscle fiber relationships of phonemes is more frequent than their substitution or distortion,
that impair closure. especially when the consonant occurs as part or a consonant
• Several abnormalities of cavity relationships can lead to palatopha cluster. Patients with cleft palate only have been found to have more
ryngeal dysfunction in the absence of a clert.:JS·36 The soft palate articulatiOn difficulties compared t o patients with both cleft lip and
may be congenitally short, with a normal-dimenSion hard palate palate:�_.,->2
and pharynx. The hard and soft palates may be of normal length These patterns of articulation error are related directly to an
but associated with an excessively deep pharynx. Alternatively, the inability to generate sufficient intraoral breath pressure. A significant
hard and soft palates may be short and the nasopharynx of normal correlation has been found between articulation skill and measures
depth; or the hard palate may be short, the nasopharynx unusually of intraoral breath pressure.•9.s:� In a study of 84 children with
deep, and the soft palate of normal length. congenital clefts of the lip and palate or of the palate only, Pitzner
• Surgical resection of oral structures for treatment of cancer or trau and Morris concluded that children with adequate intraoral breath
matic injury may result in continuity of oral and nasal cavities. pressure showed, as a group, articulation skills comparable to
• Additional special cases have included (1) basilar skull deformities those of children with normal lips and palates.6' The only exception
with associ ated congenital shortening of the soft palate'!' and (2) occurred in the productiOn of fricatives, which may be explained by
cases of congenital lymphangioma with fixation of the soft palate.38 problems with dentition.
A 1 0-year survey of 1 ,061 persons with clefts of the lip and palate alization of palatopharyngeal valving. It has been used in the clinical
in various stages of treatment indicated that 16.5% of the patients evaluation of closure and closure potential and in the evaluation of
presented with an articulation defect. 21.5% displayed hypernasality, surgical management of palatal problems.os.(6 The instrument can be
and an additional 27.6% presented with both... Delayed speech coupled to a video recording system to display the palatopharyngeal
was reported in 1.1 %, a percentage slightly higher than one would activity t o the speaker. The visual feedback thus provided has been
expect in the general population.•H• Others have reported that, as successfully used in therapy designed to help patients approximate
a group, children with cleft palates are impaired in certain aspects closure."'
of language development. Such impairment may be related more to
psychosocial factors than to palatopharyngeal incompetence and its Speech examination and articulation test
consequences.� The incidence or other voice disorders, stuttering,
cerebral-palsied speech, bilingualism, and cluttering was essentially The speech examination and articulation test may b e the most use·
the same as that found in the general population. ful evaluation procedure. The clinician notes the degree of hyperna
sality and the emission of air through the nose during speech. The
number and type of articulation errors are noted. Of particular inter
Evaluation of palatopharyngeal competence est is the patient's ability to produce pressure consonants. which
may be measured specifically through the Iowa Pressure Articula·
A variety of procedures are available to critically evaluate the com lion Test.eaos Performance on this test has been found to predict
petence of the palatopharyngeal valve. Each procedure contributes the need for secondary management after primary repair of a cleft.'0
some facet of information that is useful for decision making con It is useful to note whether the patient substitutes the glottal
cerning physical management and the Institution of remediation.63 plosive hi for the usual plosives20 and whether he or she produces
However, the most important and useful information is obtained by a pharyngeal fricative in place of a nonnal lsi and /z/.''7-''·" Such
conducting a thorough physical examination. compensatory errors often are made by pat ients who cannot
accomplish normal impedance of the breath stream intraorally.
Peroral viewing The examiner may perform a stimulation test, asking the patient
to reproduce the phonemes produced in error: when the patient
An obvious but relatively unsatisfactory evaluation procedure is per listens closely and tries hard. he or she may be able to produce
oral viewing (ie, looking directly into the mouth). The limited infor some of them correctly. thus providing some indication or the
mation one can gain includes (1) the amount o f palatal tissue, (2) potential for palatopharyngeal closure during the production of
its asymmetry or distortion by scar tissue. (3) its motility in cenain consonants under optimal conditions. The examiner then compares
speech and nonspeech activities, (4) the extent of mesial movement the production of phonemes and single words with articulation heard
of the lateral walls of the pharynx, and (5) the amount of elevation during conversation; the patient may be able to extend a special
and posterior retraction of the soft palate Unfortunately, such infor
. effort and accomplish palatopharyngeal closure for brief periods. but
mation is limited because the movement that can be observed is re the more taxing demands of contextual speech demonstrate any
stricted to that obtained during prolongation of a low vowel such as inadequacy of palatopharyngeal valving.
Ia/, an activity only remotely related to contextual speech. Informa Speech test data provide what may be considered criterion
tion about the briskness of the pharyngeal reftex reveals little about measures of palatopharyngeal competence. The following proce
how the valve works during speech. Peroral viewing does not permit dures are essentially supplementary to the speech examination
one to detem1ine accurately the crucial area of contact between the and enhance understanding o f the dynamics behind the speech
soft palate and the pharyngeal wall, nor can the extent or firmness of performance. They help to explain what is heard and why it is heard.
the contact be discerned. One cannot be sure about the presence
or importance of such compensatory phenomena as movements of Observation of behavior
the posterior wall of the pharynx (appearance of Passavant's ridge)
during speech or adenoid tissue that would cause palatopharyngeal Behavior of the patient during speech and certain nonspeech ac
contact at an atypical point. tivities should be observed. One may note facial grimaces during
speech production, particularly contraction of the alae of the nose,
Oral panendoscope which usually indicate an attempted compensation for palatopha·

ryngeal incompetence. When one suspects palatopharyngeal in·
The oral panendoscope allows direct viewing of the critical portion competence and yet fails to note hypernasal speech, nasal emis·
of the palatopharyngeal mechanism. which peroral viewing fails to sion, or poor articulation of pressure consonants, one should test
provide.ll<l This is a tubular optical device with integral illumination for freedom of the nasal airway. The discovery of some type of nasal
and a lens system that, when placed in the mouth, allows direct visu- obstruction may explain why the expected signs are absent.
303
Measurement of intraoral breath pressure Measurement of oral and nasal airflow
The ability to impound intraoral breath pressure can be measured Measurement of oral and nasal airflow is a useful supplement to
with several types of instruments, the most common of which is measurements of intraoral breath pressure. Similar to the instrumen
the oral manometer."" Oral air pressure is measured in ounces per tation described above, the technique involves {1) face masks to
square inch above amb
ient pressure. TI1e breath pressure impound trap the total airflow, (2) a flowmeter t o act as a s811sing instrument,
ed intraorally with the nostrils occluded is compared with the pres (3) a pressure transducer {4) a voltage amplifier, and (5) a readou1
.
sure impounded with nostrils open. The former value can be taken system. Using a respirometer, a face mask, a mouth mask, and a
as the maximum because nasal leak is obviated. Any discrepancy pneumotachograph for the flowmeter. Hardy and Arkebauer mea
between this value and the value obtained with nostrils open can sured the air expired from the mouth only and the air expired from
be attributed to nasal teak. A convenient clinical measure is the ratio both the mouth and the nose when 32 nomnal children counted and
between these two values. Equal values with the nostrils open repeated nonsense syllables.'" They concluded that respirometric
and occluded give a ratio of 1 :1, indicating that the patient has quotients are capable of differentiating between speech activities
palatopharyngeal competence for this activity. Impounding tess in with minimal differences in degree of palatopharyngeal closure. A
traoral breath pressure w it h the nostrils open compared to nostrils warm-wire flowmeter or nasal anemometer has been reported to
occluded yields a ratio of tess than 1:1 and indicates nasal escape. quantity certain rapidly changing characteristics of nasal leakage
When blowing into the oral manometer, some patients may produce in palatopharyngeal incompetence.I!0.6• Warren has questioned the
erroneously high pressures by closing off the nasopharynx with usefulness of the nasal anemometer because of lack of linearity
tongue-palate valving. To counteract this situation. the bleed valve in measurem811t through the entire range of incompetence."' and
of the oral manometer should be left open, which immediately ex Hardy has indicated preference for the pneumotachograph over the
hausts the small amount of air trapped in the oral cavity. The blowing warm-wire anemometer because of its lower cost and its ability to
task then requires a continuous flow of air through the mouth and detect inspiratory and expiratory ai rflow n Holle
i n has also reviewed
provides a true measurement of the amount of nasal escap e.7s Of the uses of these and other instruments M
the varied breath-pressure ratios that might be derived from the use Techniques for combining measurements of intraoral breath
of an oral manometer, positive readings (based on blowing rather pressure and nasal airflow have been described"" and applied78
than sucking) with the bleed open have been found to relate best to evaluate palatopharyngeal function in dysarthric children with
to measures ot articulation skilt.'6 although negative readings have cerebral patsy. who repeated syllables at prescribed rates and
been reported to relate better to judgments of hypernasality.'5 Posi produced sequences of changing syllables at conversational rates.
tive pressure ratios of 0.90:1 or better usually reflect adequate func Simultaneous oscillographic recordings of the speech signal, nasal
tioning for articulation of the palatopharyngeal valve, and ratios of airflow rate, and intraoral breath pressure clearly display relationships
0.89:1 and lower are associated with significant impairment of ar between palatopharyngeal dysfunction and speech characteristics.
t iculatio n skills.•9 Tile technique has been used to evaluate the effect of prosthetic
Other types of instruments have been used to measure intraoral appliances on speech.""
breath pressure in addition to the kind of pressure just described.
U-tube manomet81s filled with liquid have been used to measure Measurement of hypernasality
intraoral breath pressure produced by maximal exp iratory effort.
A spirometer can be used to compare two maximal expiratory Objective measures of the degree of hypernasality are possible
efforts, one with nostrils open and one with nostrils occluded.42 A through the use of other instrumental techniques t11at are not so
wet spirometer, another vol ume measuring instrument, can be used generally available or so conveniently applied as the foregoing pro
similarly: If the vital capacity measure produced with the nostrils cedures . A nasality meter has been descnbed that makes use ot
open is tess than the measure produced with the nostrils occluded, phase relationships in the frequency spectrum of the speech wave
it is assumed that the resistance produced by the spirometer to define degrees ot nasal resonance.tlG The speech spectrograph
caused a significant portion of the expired air t o be forced through has been applied t o study alterations in the nom1al regions of energy
an incompetent velopharyngeal port wh811 the patient's nostrils were concentration brought about by nasal resonance.••.as Tonar is an
open.77 other instrument that scans nasal and oral ou1put. g911erates nasal
Techniques also have been devised to measure intraoral breath to-oral acoustic ratios, and teeds them to a nasality-rating meter for
pressure during speech production,.,·"' Instrumentation involves (1) con ti nuous display as one speaks. '0·� Fletcher has reported the use
a polyethylene tub e positioned along the buccogingival sulcus, the of tonar tor t he clinical reduction of hypernasality.""
open end of which is oriented perpendicularly to the flow of air in the
oral pharynx; (2) a pressure transducer that converts pressure into Lateral radiographs
a voltage; (3) amplifiers to increase that voltage; and (4) a readout
system. Lateral radiogra phs of the head can be used to detem1ine the verti
cal and anteroposterior relationships of the soft palate and the pos-
3041
Fig 19-13 lateral radiographs of the head. (a) Speech structtlres at rest. (b) Same patient producing Ia/ without palatopharyngeal closure. (c) Same patient producing lsi with
adequate palatopharyngeal closure. (Reprinted from Litzow and DarleY"' with peonission.}
terior pharyngeal wall during the production of sustained vowels or used to study palatopharyngeal closure. Analysis can be made
consonants. However, such images do not Indicate medial-lateral of several anatomical planes. witl1 each exposure made during
relationships of the structures_ Ordinarily, at least three views are ob production of a sustained phoneme and lasting for 1 or 2 seconds.ow
tained: (1) with speech structures at rest, (2) during phon ation of Ia/ This procedure has been used to investigate the degree and level of
or /u/, and (3) during articulation of a voiceless continuant consonant lateral pharyngeal wall movement during palatopharyngeal valvin g.90
such as /s/. Clinical experience has shown that some patients attain
palatopharyngeal closure on the vowel but not on the consonant, Cineradiography
and others attain closure on the consonant but not on the vowel
(Fig 19-13). Because the aoequacy of pharyngeal closure on sustained pho
Still radiographs reveal whether the patient can at t ain closure nemes may be different from the closure demonstrated in contextual
duri ng the brief articulation of an isolated phoneme_ Measurements speech. cineradiograpllic films of palatopharyngeal valving are used
can be made of the distance. if any between the palate and posterior
. to supplement cephalometric images. Movements of the valving
pharyngeal wall or of the extent o f contact between them if closure mechanism can be analyzed in terms of flexibility of the velum. the
is attained. height of its elevation. the extent of its contact with the posterior wall,
ObseNation of sustained sounds may provide some information and the significance of any adenoid mass and of the appearance of
on the potential of a patient to achieve closure under optimal Passavant's ridge in accomplishing closure. In addition, the films are
conditions; however, there is currently no evidence to indicate that able to capture the complex relationshi ps among all these vari ables
this potential, when exhibited only on sustained sounds, is a valid during the articulation of phonemes in rapid or slow succession. I t
predictor of the potential for achieving closure during speech "' . is possible to measure. on individual frames. the amount of palato
Tomography, a still radiographic procedure tha t provides a cross pharyngeal opening during the production of acceptable and unac
section of st ructures rather than a projection of all planes, can be ceptable speech. One also can study general clinical aspects of per-
305
19 i
Speech Pathology and Prosthodontic Applications
formance or have the films undergo vigorous quantitative analysis. Pulsed ultrasound
The cor relat ion between measures of palatopharyngeal opening
made from still radiographs and those made from cineradiographic Variations in the positiOn of a point o n the lateral pharyngeal wall
films is approximately 0.70."' Lubker and Morris reported that relative to the external neck wall can be monitored by time-motion
mean differences between the two types of measurements were display of pulsed ultrasound. The technique has been used to eval
not significant for Is! but were significant for /u/. If only one single uate lateral pharyngeal wall motion in normal speakers and those
exposure film is to be used for estimating vetopharyngeal opening with cleft palate, and it can provide useful information about hard
during cinefluorography, sustained /sf seems the best choice. to-study mesial movements of the palatopharyngeal valve without
Blackfield et al studied the relationships between cinefluorographic introducing extraneous devices into the vocal tract or exposing it to
film measurements from productiOn of seven phonemes.� radiation.•Oil-lOS
measurements made on lateral head films during production of Ia/
and !if. measurements of nasal air escape using the McKesson Other procedures for evaluation
Scott Vital Capacity Analyzer, and ratings of speech adequacy. They
found a strong positive correlation between the measurements of Cine magnetic resonance imaging and fiberoptic endoscopy also
speech adequacy but failed to find similar correlations when they have been used tor evaluation of speech. but they are more corn
used measurements taken from cephalometric film. They attributed monty used with patients manifesting dysphagia.'0'·"0 A sensory
this failure to inaccuracies of the single-lilm technique. In patients component used with fibero ptics, known as a FEEST {fiberoptic en
with obvious palatopharyngeal incompetence {wide opening). doscopic evaluation of swallowing with sensory testing). can indicate
the error was small, but in patients with a good range of palatal more detalled information.110 It is also used in the study of the effects
motion, agreement between cinefluorographic and cephalometric o f gastroesophageal reflux o n the larynx and swallowing function.
measurements was poor. This testing method creates an air- pulse stimulus of mechanorecep
Cineftuoroscopic and, more recently, videofluoroscopic techniques tors within the larynx.
using image intensification allow muttiple-view analysis ol palatopha Any of the previously described procedures may be used to assess
ryngeal function. Lateral, frontal, and base projections together permit a patient's palatopharyngeal competence and to predict the need
study of the truly sphincteric nature of palatopharyngeal closure.96·9' for prosthodontic or surgical management. Some measures clearly
These projections have revealed distinctive patterns of valving in provide more critical informatiOn than others. Studies have shown that
normal and deviant speech and nonspeech activti ies.&e-"» to be exact in description and prediction, several procedures should
Cinefluorographic techniques involving 360-degree rotation around be used jointly. A composite measure that embraces contributions
a patient have been developed.'"' RotatiOnal cineftuorography permits from the speech examinatiOn, oral examination. observation of
analysis of speech physiology from different horizontal and vertical the patient's behavior, pressure and airflow measu rements. and
angles and allows the separation of objects, providing a sense of radiographic studies will increase the reliability of judgment and
depth perception ordinarily supplied by stereoscopy. The rotational accuracy o f prediction. 1"·"�
technique enables the velum to be studied from one lateral view. such
as seen at a 90-degree rotation, or at multiple angles to separate the
right and left sides.'0' It has been used to study obturator prostheses Indications for prosthetic management
in cleft palate subjects.
In some cases. the speech aid rnay be seen in contact with the The two main approaches to the correctiOn of conditions that cause
posterior and lateral pharyngeal wall when viewed from one lateral palatopharyngeal incompetence are (1) restoration of physical conti
position. but no contact may be observed o n the other side after the nuity of surfaces that separate oral and nasal cavities and (2) provi
unit is rotated through an angle of 270 degrees.'"' sion of a mechanism that allows intermittent opening and closing of
Swallowing, blowing, sucking, and gagging also have been the valve separating the cavities. Surgery has been the traditional
suggested for use in cinefluorographic evaluation of palatopharyngeal treatment for primary closure of a congenital palatal cleft. When
function. However, they are not as valid of predictors a s speech.91 primary surgical repair has not resulted in palatopharyngeal com
For example, closure is usually obtained during swallowing, even in petence, various secondary surgical procedures have been used.
individuals who cannot achieve closure for speech. Also, whereas Lengthening of an active velum to permit normal palatopharyngeal
the tip of the uvula makes contact with the pharyngeal wall during valving is the goal of some of these procedures. Ho wever, some
swallowing, it has been consistently observed that the middle third procedures. such as the pharyngeal flap, have a different purpose
of the velum, rather than the tip, makes contact with the posterior of providing a kind of living obturation of the area. These procedures
pharyngeal wall during valving for speech. have been applied to noncleft conditions such as velar weakness
or paralysis caused by neurologic disease. Prosthetic management
with a pharyngeal obturator has been applied in primary closure of
a congenital cleft to treat acquired incompetence resulting from sur
gical removal of cancerous tissue. This also has been successful
3061
in the secondary treat ment of incompetence after primary surgical ultimately discarded after the development of adequate speech.116
repair. The obturator has been used as a complement to surgical In less dramat ic cases. a degree of pharyngeal constriction may be
treatment. often in an attempt to predict the outcome ol secondary developed so that a surgical procedure such as a pharyngeal nap
surgical management of the palate. may be more successful. Blakeley further suggests that obturators
With regard to primary management ot an open congenital cleft. are initially more successful than pharyngeal naps in achieving
the following conditions indicate that a prosthetic approach would normal air pressure for speech117; therefore, they can be beneficial in
be preferable to a surgical approach113: disrupting habitual patterns of abnormal speech.
As reported. it may be possible gradually to reduce the size of
• A cleft of both soft and hard palates is so wide that available local the obturator. "6 Weiss described the variables related to success
tissues are insufficient for repair. in reducing and uHimately discarding the obturator in 20 patients'18
• A cleft of the hard palate i s so wide that local tissue is inadequate He suggested an objective procedure involving p ressure-indicator
for its repair, even though the soft palate might be closed surgically. paste to combat perceived hypernasality during reduction of the
• Surgery is contraindicated for medical reasons (eg, a blood dys pharyngeal segments of prostheses."9 Mathewson suggested the
crasia). use of micronized barium in fabrication of the prosthesis, which
• Surgery must be delayed for medical or other reasons, and interim renders it radiopaque, to facilitate study of obturator position during
management is necessary. an obturator-reduction program.120 However, a deliberate program
of obturator reduction has not proved to be an effective means of
Prosthetic management is indicated in patients who have already developing posterior pharyngeal wall movement. 121.122
had primary repair of the palate and in p atients exhibiting the follow
ing palatopharyngeal problems:
Nasopharyngoscopy in palatopharyngeal
• The surgically repaired velum remains too short. tense. scarred. or
immobile to accomplish closure, and its surg ical retropositioning is
prosthetic rehabilitation
judged to be of little value.
• The palate is perforated and further surgical management is judged Disruption of the palatomaxillary complex may have significant
inadvisable. adverse consequences for speech and swallowing. Surgical re·
• Palatal perforation has resulted from removal of a neoplastic lesion. cons truction of the palatomaxillary structures may be delayed,
contraindicated, or undesired by the patient. In these circumstanc
Conditions are plentiful in which either a prosthetic or a surgical es. palatopharyngeal dysfunction may be addressed with prosthetic
approach would be equally effiCacious. In these situations. rehabilitation. 123 which may involve fabrication of prostheses to sup
consideration must be given t o such matters as the ability and port or replace the function of the soft palate. In the latter case,
willin gness of the family and patient to undergo the expensive where pharyngeal muscular activity exists, the prosthesis also serves
and time-consuming preparatory orthodontic treatment. dental to engage this muscular activity t o optimize pharyngeal closure while
restorations, and repeated adjustments of retention devices and maintaining a nasal airway. Prosthetic rehabilitation of structures in·
obturator fabrication. The clinician should be reasonably sure of volving the soft palate and pharynx presents a particular challenge
patient and family compliance over an extended time. If a child because these structures compose a dynamic three-dimensional
has an intellectual disability, the possibility of cooperation and space that is out of the line of sight from the oral cavit y.
careful treatment of the prosthesis would be questionable. and The functional challenge presented by prosthetic rehabilitation
prosthetic management might be judged inappropriate. If a patient of the soft palate has been confirmed in studies that have shown
has anodontia or rampant caries. prosthetic management might be that speech was compromised to a greater degree when the
contraindicated. resection involved the soft palate.113•12" Authors have long debated
A prosthesis as a complement to surgery should be considered. the landmarks to use as reference points for positioning the
Use of an interim prosthesis as a diagnostic aid or predictor has been inferior and superior margins of a pharyngeal obturator.12!.-'so The
reported.35."'·ns Because surgical outcomes with regard to speech literature has suggested optimal vertical dimension for a pharyngeal
are sometimes questionable and surgical procedures are essentially obturator and the plane of closure. The palatal plane and level of the
irreversible, the clinician may elect to use a reversible technique such anterior tubercle of C1 have both been suggested as landmarks for
a s the fabrication of an interim prosthesis and prescribe speech positioning a pharyngeal obturator. More recent research has shown
therapy to evaluate the patient's potential for improved closure that the level of positioning of a prosthesis or the degree to which a
and speech. The interim prostheSis may introduce resistance pharyngeal obturator contacts the postero i r pharyngeal wall has no
against which the pharyngeal constrictor can function and lead direct relation to functio nal speech results.121 Moreover, it has been
to the compensatory i ge. Blakeley
development of Passavant's rd demonstrated that velopharyngeal muscular activity is variable within
described a patient with a prosthesis in whom so much pharyngeal individuals who exhibit different patterns of closure during different
activity developed that the obturator was first reduced in size and f unctions. 13,_,33
307
Fig 19-14 A flexible nasendoscope attached to a light source. This arrangement allows Fig 19-15 A flexible nasendoscope attached to a digital system tllat allows visualiZation
only one obseNer and no sound recording. ot U1e image on a monitor and digital sound recording with the image. The image and
sound can be reviewed by multiple individuals at any lime.
Passavant's ridge has been suggested as a landmark for • It is an excellent patient education tool that helps patients under
prosthesis positioning. but it is unreliable because it is not present stand the structural and functional challenges posed by their con
in many individuals with normal anatomical structures, it may occur dition.
only in a portion of disordered speakers, and when present it may be
positioned higher or lower than the functional muscular level. The NPS procedure is typically performed with a 3-mm flexible
Based on the above information, the clinical notion of designing fiberoptic endoscope attached to a light source (Fig 19-14). In this
prostheses for the soft palate or pharyngeal space using a commonty simplest of arrangements, visualization is through the nasendoscope
applied set of landmarks is not possible because of the variability eyepiece, but only one individual can observe at a time. Attaching
i n velopharyngeal function. This variability occur s regardless of the nasendoscope to a monitor allows for mulliple observers. A more
sex and patterns of closure. 131•133•13' Historically, the fabrication of sophisticated approach i s to use a system tl1at allows for a monitor
prostheses in the palatopharyngeal area has been undertaken as a and a digital recording (Fig 19-15) so that video and audio may be
blind procedure. recorded and then viewed at a later time for treatment planning or
Placement of a prosthesis in the palatopharyngeal area requires assessment of progress of care. The images provide the clinical
that the procedure make optimum use of available muscular team with the ability to visualize the area of interest before, during,
activity, whiCh requires visualization of the area under treatment. and after treatment (Figs 19·16 to 19·18).
Visualization of the nasopharynx is well achieved with the addition In a retrospective ar1alysis of speecl1 data, five patients of varying
o f nasopharyngoscopy (NPS) to the prosthetic treatment protocol. age and etiology were assessed before treatment and after prosthetic
The treatment process should involve a speech pathologist and may intervention. 13!. Treatment involved use of conventional functional
include the use of aeromechanical and acoustic speech techniques impression techniques. After prosthetic intervention. NPS was used
to assess the adequacy of prosthetic intervention. 135 NPS is used to assess the treatment and modify the prosthesis accordingly.
to visualize the palatopharyngeal port during assessment and Nasaliy
t and velopharyngeal opening outcome measurements were
treatment. The use of NPS in the management of palatopharyngeal assessed at intervals throughout the stages of care. Perceptual
functional or structural defects is thought essential for the following assessment of speech samples also was done. Although all patients
reasons: initially treated with a conventional approach showed improved
speech. they all were found to have nasality ar1d velopharyngeaJ
• It provides direct visualization of the nasopharynx. oropharynx, and orifice area values that were not within nom1al limits. After NPS
residual pharyngeal functional muscular activity. was used to revise the pharyngeal impression, both nasality and
• It allows prosthetic treatment t o be designed to address diagnostic velopharyngeal orifice area measurements returned to within normal
findings. This also allows treatment to be selected with regard to limits. likewise. NPS allowed a return to norn1a1 resonance balance
surgical or prosthetic options and the likelihood of failure of pros of perceptual judgment of speech.
thetic treatment. The use of NPS as a clinical tool requires training and education
• It allows the clinician to monitor treatment outcomes over time and in nasendoscopy and in the interpretation of structures and
to assess wl1en and how to modify the prosthesis. functions being visualized. With the appropriate background,
• Visualization of the treatment area enhances communication be the prosthodontist can incorporate this technology into a routine
tween the prosthodontist. speech pathologist. surgeon. and dental treatment armamentarium to provide care for palatopl1aryngeal
technologist team. functional and structural defects.
308 1
Rg 19-16 NPS Image of closure of two pharyngeal ports. The images show haw sub· Fig 19-17 The NPS image shows a Fig 19-18 NPS i mage of a compleled
stantlaUy difterent the patterns of closure are between tl1e h•IO individuals. (<1) Circular functional impression for a pharyngeal phaJ)'Ilgeal obturalor providillQ an ap
pattern of closure. (b) Corooat pattern of closure. obturator. leakage !rom the anterolateral proprtate approximation ol tl1e wan of the
pharyngeal area is evidef1t, which will need pharynx.
to be addressed in tl1e Impression. Identify
ing this aJea ol nasal escape could no! be
achieved without NPS visualizalion.
Effect of prosthodontic management on ObseiVations of speech produced with the open nasopharynx
were paired with those from an obturated nasopharynx. Speech
speech
quality and intelligibility were significantly improved by obturation,
although normal intelligibility and quality generally were not obtained.
Studies have consistently shown that satisfactory speech can be In a cephalometric analysis comparing what were judged to be
attained through a program of prosthodontic management in pa successful and unsuccessful speakers, it was found that the
tients with palatopharyngeal incompetence. rn a longitudinal study unsuccessful speakers had significantly longer and less mobile soft
(for periods up to 10 years) of 163 patients ages 6 to 78 years,'36 all palates; in such cases. the carrier and pharyngeal obturator were
patients (74 with clefts of the secondary palate only. 86 with clefts located at rower levels within the oral and oropharyngeal cavities,
of hard and soft palates, and 3 with congenitally short palates) ini and obturation frequently was obseiVed t o be deficient in the lateral
tially displayed palatopharyngeal incompetence and the expected aspect. Obturation was found to be most adequate and speech
speech difficulties. In 151 of the patients (92.6%), palatopharyngeal most satisfactory in subjects who had exceedingly short soft palates.
incompetence was corrected. In 53 patients, the obturator had to Arndt et al studied the effect of obturation without remedial
be reduced a short time after placement because of the develop speech training on the speech of 11 adults with congenital palatal
ment of increased pharyngeal constriction. Similarly, adjustments clefts and 10 adults with acquired palatopharyngeal incompetence
were needed after initial placement of the prostheses in 150 pa related to either bulbar poliomyelitis or surgical resection of hard or
tients (92%) because of increased muscle activity. Of the 12 patients soft palates d u e t o cancer.'39 Articulation and hypernasality were
who failed to achieve palatopharyngeal competence, 6 rejected the judged in speech samples produced with and without the obturators.
prosthesis and 6 failed to adjust satisfactorily to the prosthesis be Both groups demonstrated significantly improved articulation and
cause of tolerance problems that were not solved. In 147 patients significantly reduced hypernasality with the obturators. Tl1e authors
(90.2%), hypernasality and nasal emission were corrected. Speech concluded that whereas the patients with acquired palatopharyngeal
problems persisted in 66 patients; these were functional articulatory incompetence demonstrated more acceptable voice quality,
and voice disorders for which they were receiving therapy. It was the patients with congenital palatal clefts demonstrated better
believed that all but 12 of the patients had mechanisms adequate articulation.
to achieve defect-free speech. There were no reports of obstruc Rolnick and Hoops studied the speech of 20 patients who had
tion of the eustachian tubes, presence of carcinogenic irritants, or used oral prostheses designed to improve speech tor periods
evidence ot infectious processes or breathing complications related varying from 10 months t o 20 years (mean, 11 years).139 Eleven of
to these speech appliances. This potential for immediate adjustment the patients had surgically induced palatal defects resulting from
of resonance balance without significant complications is a major oral carcinoma; the other 9 patients had congenital cleft palate.
benefit of the prosthetic approach to correcting speech problems. Comparisons of speech with and without prostheses pointed
although tolerance problems sometimes require modification of the Clearly to the efficacy of the prostheses as speech aids. Without
appliances. them, plosive duration, degree of hypernasality, and impairment of
Subtelny et al analyzed the results of prost11odontic treatment of intelligibility were all significantly increased.
23 patients with pal atal cleft with palatopharyngeal incompetence.'3'
309
with age, and ct1anges in the site of velopl1aryngeal Closure were

Special Considerations in observed relative to age. Whereas the soft palate most frequently
Prosthesis Fabrication approximated the superior or superior-posterior aspects o f the

nasopharynx in the younger age groups, the soft palate almost
always contacted the posterior pharyngeal wall during phonation in
Age of patient the older age groups. The transition was particularly noticeable in
the 9-to-11-year age group. This transition occurs because the soft
Harkins et al'.oo have indicated that a functional prosthesis can be
palate is closer to the cranial base and root of the nasopharynx at
fabricated for children as young as 2.5 years. Use of a prosthesis at
an early age, and as the child ages, the vertical distance between
such an early age aUows surgery to be delayed, if necessary. Some
the hard palate and cranial base Increases and the soft palate
clinicians have applied prostheses prior to the eruption of primary
establishes a nearly vertical relationship with the skull base; these
teeth to facilitate nursing.1" 1" Rubezhova reported on the use of
growth factors allow for increased velar movement. which results in
a "floating" ooturator in 211 children who were 1 day old, indicat
the soft palate approximating the posterior pharyngeal wall rather
ing that use ol such an instrument in nursing aids in the restoration
than the superior·posterior aspect of the nasopharynx.
of this vital function in children.143 Similarl y, Epstein fitted obturator
It was also round that the middle one-third of the velum is the
prostheses in 27g children with cleft palate when they were 3 or
portion that makes contact with the pharyngeal wall: the uvula was
4 days old.,.. The prostheses reduced the tendency to colds and
not observed t o contribute to palatopharyngeal closure. The authors
otitis, made feeding easier. improved sucking function, and reduced
reported that velopharyngeal closure is closely related to the palatal
hospitalization lime for the infants.
plane.126 In the 4-to-8-year age group, the palatal plane was slightly
Whenever prostheses are fitted at such early ages. particular
above the midpoint of vetopharyngeal closure; however. in the older
attention must be given to alteration of the design of the prosthesis
age groups, this midpoint was above the palatal plane. This transition
and its pharyngeal portion because the cavity contours alter with
occurs around 12 years of age, afte r which little functional change
growth. Cephalograms taken longitudinally on 96 children at ages 6.
occurs. Therefore, the obturator can best assist velopharyngeal
9, and 12 years have shown significant changes In the dimensions of
closure (and aid speech) if its pharyngeal extension is above the
air space because of changing bony relationships and the alteration
palatal plane. If it i s placed below the palatal plane, the prosthesis
o f soft tissue contours. ,..
may be ineffective in assisting velopharyngeal closure.
A similar finding was reported by Falter and Shelton in a study
of 19 children with cleft palates from 7 to 13 years old, all wearing
obturators. 147 Children with obturators that extended high into the
Obturator placement for optimal speech
nasopharynx tended to have better articulation scores compared
improvement with those whose obturators were positioned lower. The authors
concluded that the bulb of the obturator should not only contact
It has been suggested that in the fabrication of the prosthesis. the the lateral pharyngeal wall but also be positioned just high enough
obturator be adjusted until the patient is able to produce a strong to contact the posterior pharyngeal wa n and take advantage of its
/p/, a sustained fricative 111 or /s/ without nasal emission. and an movement.
adequate nasal /m/. "8 Hyponasality refers to insufficient nasal res This study did not find a significant correlation between adequacy
onance in production of the nasal consonants so that non-nasal of articulation and the extent of contact between the obturator and the
substitutions are made lor them (/Jad lor mad, doe lor no, and sig lor posterior pl1aryngeal wall; patients with greater contact did not have
sing). This is an indication that the palatopharyngeal lumen has been better articulation than those with less contact. Similarly, a significant
overobturated and that intermittent valving action is no longer pos correlation was not found between adequacy of articulation and size
sible. As the obturator is adjusted on successive visits, more detailed of the obturator. The significant factor with regard to improvement of
articulation tes ting is desirable until optimal pos itioning and size of speech was the position of t11e obturator.
the obturator have been determined. Further data were provided in a study by Mazaheri and Millard on
Failure of prostheses to improve speech may be attributed to the effect of placement of the pharyngeal portion of the prosthesis
improp er positioning of the pharyngeal section of the prosthesis, on speech. 126 They studied 10 patients witl1 unoperated cleft palate
a problem studied by Aram and Subtelny.12-> Using cephalometric (ages 15 to 20 years) whose speech was judged to be acceptable
films. they studied the area of closure demonstrated in 90 children with the use of a prosthesis. Three positions of the obturator were
and young adults, 15 in each of 6 age groups (4 to 5 years, 6 to 8 tried-high, medium, and tow-corresponding to locations above ,
years. 9 to 11 years, 12 to 14 years, 15 to 17 years, and 19 to 20 on, and below the area of posterior pharyngeal wall activity. After
years old). In all instances, they found that the soft palate moved in each placement, the subjects were allowed 5 weeks t o adjust.
an upward and backward direction to create closure. However, the Speech samples then were recorded and judged lor hypernasality,
degree of velar movement from rest to closure was found to increase and spectrographic analysis o f vowels was made. Voice quality was
310 1
Special Considerations in Prosthesis Fabrication J
judged to be best when the obturator was positioned on the area these patients , 19 had weakness or paralysis of the velum from
of posterior pharyngeal wall activity. tt was found that the inferior neurologic disease. Of these19, 1 0 had upper motor neuron system
superior dimension of the obturator could be reduced to a quarter damage (6 from traumati c causes. 3 from cerebrovascular accidents,
of its original size without apparent effect on nasal resonance, 1 from degenerative central nervous system disease), 5 had lower
which confirmed the finding of Falter and Shelton'.&a that extent of motor neuron disease/flaccid paralySIS (3 from myasthenia gravis. 1
contact and obturator size are not important determinants of speech from bulbar poliomyelitis 1 from diphtheria), and 4 had combined
,
adequacy. spastic and flaccid paralysis of the velum (from amyotrophic lateral
Shelton et al studied 19 subjects (9 with surgically operated sclerosis). The other 16 patients had palatopharyngeal deficiencies
cleft palates, 9 with open unoperated clefts, and 1 with untreated resulting from a short soft palate or a deep nasopl1arynx : in 7 ot
submucosal deft) in whom the obturator SiZe was systematically t hese, hypernasality and nasal emission were noted only after
reduced by small increments three times, spaced so as to allow adenoidectomy. All patients had the typical speech problems seen
each subject to compensate between adjustm ents.>22 llley found in palatopharyngeal incompetence.
no significant differences between articulation scores before and Two of prostheses were used: (1) a two-part prosthesis
types
alter reduction and no differences in the number of sibilant or plosive with a retentive portion supported by the maxillary teeth or
errors They postulated that closure is more critical for the acquisition
. removable denture and a lift portion to elevate the soft palate and
of articulation than for its maintenance: bulb reduction might im pair (2) a prosthesis used mostly for those with short palates or deep
articulation development in younger patients or in pate
i nts who nasopharynx, with a pharyngeal piece added to the lift portion to
d emonstrate great numbers of articulation errors. 122 elevate the soft palate and close the palatopharyngeal space. In all
patients, the prosthesis was fitted so as to elevate the soft palate to
Contact with lateral walls the level of the palatal plane or to place the pharyngeal portion just
above the median tubercle of the atlas. Speech evaluations, made
Closure must be attained not only in the anteroposterior dimension longitudinally. indicated large to moderate reductions in hypernasality
but also In the lateral dimension. Cephalometric and cin efluoro and nasal emission and increased speech intelligibility. In four
graphic films reveal whether the obturator contacts the sphincter patients , follow-up studies showed improved palatopharyngeal
mechanism superiorly and posteriorly, but they do not show the ade efficiency w�h the prosthesis removed, indicating that better closure
quacy of the obturator's contact with the lateral aspec ts of the naso was perhaps a result of the stimulation of the musculature provided
pharynx. For this reason. rotational cinefluorography and air pressure by the prosthesis. In no patient was the patatal lilt dislodged by any
and airflow studies are helpful to determine whether the obturator is residual palatopharyngeal movement, and no inflammation of the
adequate in its lateral extension. mucosa of the soft palate or alteration in tooth position was noted.
In the Mazaheri and Millard study,>2G the lateral dimension of the Contraindications to the use of a palatal lift include (1J inability to
obturator in the various conditions (above, on, and below the area attain adequate retention, (2) presence of a spastic or stiff soft palate
of posterior pharyngeal wall activity) did not change significantly as that does not tolerate elevation, and (3) lack of cooperation on the
the position varied. This finding was contrary to the hypothesis of the part of the patient.
inv estigators that the lateral dimension of the nasopharynx wo utd be Hardy et al compared the use of the p alatal lift in 11 children with
less at the level where the posterior and lateral pharyngeal wall activ cerebral palsy to the results obtained with pharyngeal flap s urgery
ity takes place. compared t o above or below it. in 6 c hildren with cerebral palsy.85 Of the 6 chldren treated surgi
i
cally only 3 made suffiCient speech gains to justify considering the

,
procedure a success; prosthetic management of t 0 of the 11 chil
Palatal lift dren was judged to be successful. Anticipated difficulty i n tolerati ng

the lift because of increased gag reflex was not experienced. Even
In patients with weak or paralyzed soft palates related to neurologic though some of the children displayed gross invol untary head move
disease or in patients with su rgically repaired clefts where a fairly long ments, the prosthesis did not irr itate the posterior pharyngeal wall
soft palate remains essentially nonfunctional for closure, a conven during head flexion; nor were any instances noted of inflam mation
tional obturator prosthesis may be difficult to fabricate because of or necrosis of the soft tissue on the inferior velar surface. Improved
the palatal tissue under and behind which the prostl1esis must pass functioning of the palatopharyngeal valve was noted in one patient
to b e effective. In such cases. a palatal lift has been found to be ef after he had worn the palatal lilt for a time. Based on these results,
fective (see chapter 15). Gibbons and Bloomer first reported the use prosthetic management of palatal paresis in children with cerebral
of such a prosthesis in an adult patient with flaccid velar paralysis palsy is the procedure of choice. Not only is there no surgical risk to
resulting from bulbar poliomyelitis.'43 The lift elevated the velum and the ch ild, but there appears to be a greater probability or success
reduced the palatopha1yngeal space, resulting in improved speech. with the prosthetic program compared with the surgica.l procedure.et.
Gonzalez and Aronson studied the use of palatal lifts in the
treatment of 35 patients ranging in age from 4 to 72 years."' Of
311
Table 19-5 [-
1 Developmental sequence of speech1. production of the phonemes is again possible when the permanent
dentition erupts.
Age of child Consonants correctly used in words
The developmental sequence of articulation is paralleled in the
3to4 /mi. /p/, lbl. /wl, {hi
development o f skill in the use of other features of language.
4 !05 In!. /V,Idl, lf}l.lkl, lgl,ljl
Children advance in orderly increments of language skills such as
5to6 Iff. M,lsl,lzJ
6to 7 /j/, ly, !II. !a/.101 (1) length of utterance, (2) number of words they understand (recog
7 to 8 /rl, lhwl, Is!, /zJ nition vocabulary), (3) number of different words they use (vocabulary
of use). (4) grammatic complexity of their sentence structures. (5)
accuracy of syntax. (6) fluency and spontaneity of oral expression,
and (7) social use of speech to influence listeners' opinions and
actions.
Factors Related to the

Intelligence
Development of Speech Skills
The child's intelligence plays an important role in the rate of mastery
The ability of the child t o communicate depends on more than the of speech and language skills. The intellectually disabled are typically
condition of the speech structures. Important internal and environ delayed in their first use of words and sentences. They present more
mental variables profoundly influence a child's learning and use of than the average number of articulation errors. most prominently
speech. One must appreciate the patient's social and family history omissions of phonemes. Complete speechlessness can be attrib
in addition to medical history to visualize the dynamic relationships uted to mental deficiency only in extreme cases152•153 (ie, 10 range
between these elements and plan a remedial program comprehen of 10 to 25). Mutism is usually attributable to autism or, in an older
sive enough to meet the patient's needs. child who once spoke but stopped speaking, to hysteria. Altl•ough
the level of proficiency in speech and language ultimately attained
by intellectually disabled children is below that of normal children. all
except those with extremely low intelligence demonstrate growth in
Developmental sequence of speech-sound
these skills.
mastery
The child is not born able to produce the entire repertoire of pho Hearing loss
nemes; the infant has a meager repertoire to which he or she gradually
adds. The average child can produce 27 diffe rent phonemes by 2.5 Children who are deaf or profoundly hard of hearing display colos
years of age.'"" Mastery of the use of these phonemes in words takes sal delays in acquisition of a symbol system and development of
longer. Cross-sectional studies of children generally a gree that the de intelligible speech. Children whose loss of hearing is less severe
velopmental sequence is somewhat as shown in Table 19-5.1"'·1•1 develop a symbol system but miss ce1tain crucial features of the
The rate at which children master phonemes varies greatly. By 3 speech around them and display difficulty in reproducing it. Because
years of age, some children correctly articulate all of the consonants children who are hard of hearing can monitor their performance to
and all of the vowels (vowels are typically mastered by all children some degree, they produce voice and speech patterns less bizarre
early and without much difficulty). Other children do not master all of than !hose of deaf children. Their communication may be lacking
the consonants until they attain the age of 8 years or perhaps even in vocal melody. and they may demonstrate articulatory distortions,
later. Girls typically master phonemes in context somewhat earlier particularly of phonemes with high-irequency components (ie. frica
than boys. tives and affricates). Also. they may omit final phonemes and may
No single general principle appears to adequately account for have trouble monitoring the intensity of their speech.
the developmental sequence of speech. Among the factors that The incidence of hearing loss is higher in children with cleft palate
probably play a role in determining this sequence are (1) frequency of compared to the general population.154 Incidence of pathologic
occurrence of the phonemes in the child's environment, (2) visibility conditions of the middle ear also i s higher than in the general
of the phonemes, (3) their auditory distinctiveness, (4) their phonetic population. 1*1$7 Hearing loss occurs more frequently in children
power. (5) the distinctive tac1ile and proprioceptive characteristics of with cleft palate only than in cl1itdren with clefts of both lip and
their production. (6) the complexity of muscular adjustment required palate. 1011 One cannot make a general statement about the incidence
for their production, and (7) the child's changing dental status. With of hearing toss within the cleft palate population because research
regard to the last factor, although children typically master lsi and data indicate that it varies widely with the age of the group tested.
lzl between the ages of 5 and 6 years. these sounds often become Spriestersbach et al reported that the hearing acuity of children with
distorted when maxillary anterior primary teeth are lost. Correct cleft palate varies a s a function of age.158 Children who were 6 years
3121
Factors Related to the Development of Speech Skills J
or older when they were tested had Significantly smaller incidence severe picture of communication disturbance. Their motor difficulties
and magnnude of toss than did children tested before 6 years of are often complicated by hearing loss.
age. The research of Goetzinger et at suggested that adults with Some patients who do not show the weakness, slowness. or
cleft palate do not display more hearing problems than the general incoordination that causes dysarthria nevertheless may demonstrate
adult population. •so unusually poor motor-speech performance. Such difficulty in per
Some clinicians believe that t11e manner in which cleft palate is fomling skilled motor acts voluntarily is termed apraxia. 162 A patient
managed bears an important relationship to the incidence of hearing with oral apraxia is unable to follow instructions to wiggle or pro
toss. Masters et at studied a group of 172 patients."'" They reported trude and retract the tongue, to whistle, to blow. to click the teeth,
that patients wnh prosthetically repaired clefts had the highest t o click the tongue, or to cough. Associated with this, or sometimes
incidence of hearing toss, and they attributed this hearing toss to the occurring independently, is apraxia of speech, demonstrated by
prosthodontist's inability to fabricate an adequate prosthesis prior difficulty in producing phonemic units of speech. The patient cannot
to 2 years of age and the failure of the prosthesis to restore palatal understand where to place the tongue to produce a given phoneme
musculature function. or how to execute a sequence of movements to produce a word.
They considered the preservation of nom1al physiology of the
eustachian tube and middle ear to be essential. However, their
data did not take into account the age of the children at the time Specific language disability
they were tested. Spriestersbacll et al also found that the incidence
of hearing loss was greater in children treated prosthetically than Some children display difficulty in understanding and using language
in children with surgically repaired clefts, but the degree of loss even though testing reveals no hearing loss. motor defect, intellec
between the two groups was not significantly different. 1"' Because tual impairment, or emotional disturbance. Such difficulty in handling
of these findings, they doubted that the higher incidence of hearing the symbol system is designated specific language disability (devel
loss in subjects wearing obturators could be explained on the basis opmental aphasia or congenital aphasia). It is presumed that such
of poorly functioning palatal musculature. cllildren have tl1is difficulty because of bilateral cerebral lesions or
In another study by Graham et al,161 54 patients were examined defective crucial neural substrate for language. Such children may
before and after placement of an obturator: no ear infections express themselves with gestures and indicate considerable under
developed after initial placement of the obturator. and no patients standing of their environment, but they are unable to understand the
showed an increase in hearing toss after obturator use. It was significance of what is said to them or. in milder cases. give the ap
concluded that an obturator can b e wom with no adverse effect pearance of mishearing words in a way similar to the hard of hearing.
on the otologic condition of the palatal cleft patient Patients in this Less severe degrees or specific language disability may account for
study had received otologic care from infancy, and obturators were some of the persistent articulation and syntactic problems displayed
not fabricated before these children were 4 years of age. by some children. Examination with the Illinois Test o f Psycholinguistic
Abilities may indicate that a child has particular difficulty in the
sequencing and recall of series of auditory units. '60 Although the
Impairment of motor control child may be able to discriminate between and produce individual
sounds. he or she may be unable to blend sequences of sounds
Children with cerebral palsy and patients with neuromuscular impair and recognize what words they compose. Sentences generated are
ment may display, as a part of their motor difficulties. i mpairment of often syntactically primitive and reveal a disability in incorporation
control of the speech apparatus with resulting dysarthria. •e. Motor of implicit syntactic rules from the surrounding auditory language
impairment may range from minimal weakness or incoordination to environment. The specific reading disability known as dyslexia falls
complete paralysis or severe incoordination: consequently, speech within the general category of specific language disability.•G<
problems range in severity from mild interferences to complete lack
of speech. Patients with spastic cerebral palsy (bilateral involve
ment of corticobulbar fiber tracts) present a pseudobulbar palsy in Psychosocial factors
which they are unable to move their tongues easily in all directions
or quickly make lip and palatopharyngeal adjustments. Vowels may The family constitutes a primary influence in the child's develop
be distorted, consonants may be produced imprecisely, voice quality ment. The number of people in the family, the relative position of
may be harsh or breathy, loudness may be poorly controlled, and hy the child in the family, and the socioeconomic status of the family
pernasality may be evident. Patients with extrapyramidal movement all undoubtedly have some impact on acquisition of speech. Inves
disorders (eg, athetosis. chorea, dystonia) present more inconsistent tigations indicate a kind of hierarchy with regard to rate of language
phonatory and articulatory aberrations, with distortion varying from acquisition16,.'67: Only cllildren are usually most accelerated, children
moment to moment as slow or sudden involuntary movements inter of single births who have siblings are somewhat slower, and children
fere with finer voluntary movements of speech production. Children of multiple births are typically even slower. Children deprived of fam
with athetoid cerebral palsy caused by kernicterus display the most ily experiences because they live in orphanages have been shown
313
to be even slower than those of multiple births in acquisition of lan

guage skills. and they display more speech problems than children
Summary
who live with families. l<!ll,1oo
Children from families representing higher socioeconomic status Development of speecl1 has specific timing and order of skill acquisi·
have been recognized as linguistically accelerated over children from tion. The development of speech patterns of the English language
lower socioeconomic levels. Many factors are implied in the term has a number of factors that nurture these skills. Congenital diseas·
socioeconomic status: es also influence the development of these skills and may be variable
depending on the abnormality present. Nevertheless, the preceding
• Economic stability of the family information is geared toward recognizing speech development pat·
• Education level of the parents terns and also providing comprehensive treatment team support for
• Amount of leisure time those patients requiring advanced prosthodontic care.
• Type and variety of recreational outlets available
• Abundance of educationally stimulating materials in the home
• Variety of stimulating experiences to which the child is exposed
• Parents' sophistication regarding child-rearing practicas References
• Quality of the speech models heard by the children
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a meager background of exposure to language rather than the
5. Massengftl RJ. Maxwell S. Pickrell K. An ana lySis or artJCUiation rolloWtOg par11a1
learning of two languages per se."o.171 Certainly, the amount and
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1971;36:101-114.
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16. Lehiste I. Some Acovstie Characteristics ot DySarthriC Speech. Saset, Swit·
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OiSOld f950:15:207-210.
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23. Woll I. Relaion ol malocclusion to Slgmatism. Am J Dis Child 1937:54:
t
decision making regarding further physical management. 52<H;28.
3141
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u
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l
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i
os: Some clinical and research
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317
Chapter
Management of Patients
w-ith New- Prostheses
Steven E. Eckert, oos. MS
I ough clinicians may follow all the appropriate procedures Achievement of treatment objectives requires a thorough exam
provide adequate dental prostheses, in some situations. ination and diagnosis and cooperation on the part of the patient to
tients may not be satisfied with their restorations. Prob provide a realistic set of desired outcomes. Failure on the part of
lems may manifest during the insertion or postinsertion phase and the clinician to appreciate the patient's desires before initiation of
may require acknowledgment of one of three factors in prosthodon treatment could condemn all efforts to failure.
tic care: (1) that certain inherent patient-related or technical prob
lems may be beyond the control of the clinician: (2) that the insertion
and adjustment phases of prosthodontics are much a part of the
Prosthodontic Intervention
as
total treatment as the making of impressions or recording of maxi!·

lomandibular relationships; and (3) that the clinician must have the
knowledge, judgment, and honesty to distinguish between technical Conditioning of the hard and soft tissues of the mouth to a state
difficulties and difficulties secondary to patients' subjective concerns. of health is mandatory prior to the fabrication of dental prostheses'
This chapter discusses the management of problems that arise (Rg 20-1). Should prostheses be fabricated on injured or diseased
from the placement and adjustment phases of new prostheses for tissues, they will only perpetuate the previous disease state. Con
edentulous patients. partially dentulous patients. and patients with versely, placement of a prosthesis on healthy tissue ensures adapta
congenital and acquired oral defects. tion that minimizes or eliminates tissue changes that would require
subsequent alteration of the prosthesis during the adjustment phase
of treatment. This will likely result in a more satisfied patient.
Physical conditioning may involve (1) the repeated use of resilient
Objectives of Treatment tissue-conditioning materials, (2) use o f an interim prosthesis, (3)
adjustment and correction of ill-fitting dentures. and (4} physiologic
The objectives o f prosthodontic treatment are threefold: (7) resto st imulation of the tissues and joints.2 Systemic measures include the
ration of mastication, deglutition, and speech; (2) provision of an establlshment of adequate medical control of pathologic processes
esthetic restoration that is comfortable for the patient: and (3) pres and appropriate nutrition for the patient.3
ervation of the remaining structures. In most situations, these objec A combination of oral and written instructions should be provided.
tives can be achieved with appropriate prosthodontic procedures. These instructions should illustrate anticipated problems and
However, it is the subjective assessment of the patient that ultimately demonstrate corrective methods that may help the patient adapt
determines whether the objective concerns have been achieved. more easily to the dental prosthesis.
319
20L Managemen t of Patients with New Prostheses
Fig 20-1 (a} Palieot presenting with painful oral mucosa b eneath impfan1-retained denture base. (b) Alter 2 days of tissue conditiooing. (c) Alter 7 days of tissue conditiooing.
(Reprtnted from Salinas· wiUl pennissioo.)
Fig 20-2 laboratory remount

ol maxillary and mandibular
oomplete dentures to correct
101 prooessing errors.
Fig 20-3 (a andb) Protrusive relationship with balanced articulation.
marginal ridges should b e deepened. This procedure is repeated until

Insertion Phase of Complete the anterior guide pin touches the anterior guide table:'
Dentures On the working or functional side. balance is established by

reducing the inner inclines of the nonworking cusps. On the balancing
or nonfunctioning side, the contacts appear between the inner inclines
Laboratory procedures of the working cusps. The clinician must decide whether to reduce
the mandibular buccal o r maxillary palatal inner incline. The decision
After the dental prostheses have been processed but before their i s based on the adjustment that provides the least alteration in
removal from the master cast, they should be ret urned to the treating anatomical form relative to the adjacent teeth while m aint aining forces
c linician for occlusal c orrection of processing error (Fig 20-2). In thi s as close to the long axis of teeth as possible.
process. prostheses are remounted on the articulator and selective In protrusion. contacts are balanced by bringing the incisors into
grinding is perfomned to es tabli sh a bilateral balanced occlusion. For an end-to-end relationship (Fig 20-3). Me sial facing inclines of the
a partially edentulous patient. the occlusal scheme s hould be com mandibular posterior teeth and distal facing inc lines of the maxillary
patib le with the existing occlusal condition and functional demands posterior teeth present as the interfering contacts. Should the anterior
of the patient. The primary objective is to establish an occlusion that teeth not be in contact, the aforementioned contacts should be
provides stability o
f r the prostheses. adjusted until the anterior teeth achieve the end-to-end relationship.
When the occlusion for complete dentures is adjusted. the goal Throughout the occlusal adjustment it i s critical that the clinician
,
is to provide a broad area of tooth contact. In a normal Class I jaw maintain the estab lished VDO. When in doubt, it is better to adjust
relationship , the buccal cusps of the mandibular teeth and lingual nonworking cusps rather than working cusps because this provides
cusps of the maxillary teeth (working cusps) provide stops lor the a broader area of contact that stabmzes the denture in functional
vertical dim ension of occlusion (VDO) i n centric relation (CR) that movement s .
should be maintained; otherwise, the VDO wou ld be reduced. After the occlusion has been adjusted, the final st ep is to use
During processing. dimensional changes in the acrylic resin and the abrasive paste between the maxillary and mandibular prostheses.
changes in position of the teeth combine t o manifest a s an increased Cautious movement of t ile upper member of the articulator from
VDO. This increased dimension must b e eliminated through occlusal centric to eccentric positions and then back to centric permit s
adjustment. smoother eccentric movements. The established VDO mus t be
If the working cusps described above are premature in centric and maintained.
eccentric movements. they should be reduced. However. if the vertical If nonanatomical posterior teeth are used in the restoration. it iS not
holding cusps are premature only in centric movements, the fossae or always possible to obtain complete occlusal balance in all eccentric
320 1
Insertion Phase of Complete Dentures J
Fig 20-5 Awlitation of pressure·

Fig 20-4 Facebow preser.oa· Indicator paste reveals excessive
lion index to allow a clinical pres&,re on tile lingual side of tile
remounllng. if desired. resklual alveolar ridge.
positions. Instead, i t may be possible to establish a modified balance After the new denture is inserted, it should be examined in the
with the anterior teeth in an edge-to-edge relationsh ip and the mouth to evaluate border extension e
r tention. and occlusion . At t he
.
terminal molar creating protrusive balance using a balancing ramp. same time, the patient should be reminded of the prognosis that had
Once occlusal adjustment has been refined, a plaster occlusal been discussed earlier in the treatment. Disclosing wax may be used
index of the maxillary denture is made before removing it from the t o evaluate the extension of the borders and determine whether they
articulator (Rg 20·4). This process eliminates the need for a new are appropriate. Tile contours of the borders should be compatible
facebow transfer should a c l inical remount be necessary. with the vestibular space• Borders should allow movement of the
If fixed or removable partial prostheses are fabricated, a similar frena and accommodate the hamular process. The denture should be
selective grinding process can be followed, without the use of stable when the patient is speaking and swallowing. Overextension,
abrasive paste. because bilateral balance i s not the treatment underextension, and interference with movable tissues should be
objective. Deflective balancing side contacts o n the natural teeth corrected at this stage.
could be Injuriou s to those teeth. It is often too difficult to establish The tissue surface of the prosthesis should be evaluated for
perfect harmony in bilateral balance when natural teeth only are potential pressure areas or for undesirable undercuts. When the
present. denture i s placed in the mouth wi1h even bilateral p ressure toward the
After refinement, the removable prostheses can be removed tissue surface, pressure-indicator paste should verify that there are
from the articulator and the cast. The contour of the polished no distinct areas of pressure (Rg 20-5). If such areas are identified.
surface of the prostheSis is verified by the clinician and adjusted relief should be provided by grinding the pressure area with a carbide
a s needed. Surface contours of the prosthesis should follow a bur and then smoothing it with a rubber wheel.
con struct ed surface created by either a neutral-zone technique or If fixed prostheses are being inserted, it is important to evaluate
that produced from adjacent structures of the cheek and tongue.56 the interproximal contacts to ensure that contact exists, but not
Up on completion of these procedures, the prostheses are returned so mucl1 that the restoration needs to be wedged into position,
to the laboratory for finishing and polishing; care is taken to maintain which would limit the patient's ability to floss between teeth. The
appropriate border extensions and width. restoration's marginal adaptation should be evaluated to ensure
marginal closure. which, once the restoration is luted , prevents
marginal leakage and reduces the likelihood of development of
Clinical procedures caries lesions at the crown margin . Contours of the crown margin
should be shaped to prevent gingival irritation that could lead to
The patient who has been carefully educated and motivated dur periodontal breakdown. There should be sufficient embrasure space
ing the prosthesis fabricatiOn process should understand what to to prevent gi ngival impingement, but not so much that unesthetic
expect from the prosthesis. Likewise, the patient should understand black triangles are created where the interdental papillae do not meet
the requirements for proper care of the mouth and the prosthesis. the gingival aspect of the embrasure. In some instances, provisional
This is an ideal time to review the recommendations for the patient cementation of the prosthesis may allow clinical assessment to
and the maintenance procedures for dental prostheses. ensure that the restoration meets the demands of the clinician and
At the insertiOn stage, three surfaces of the denture or dental patient.
prosthesis should be inspected: (1) the tissue surface (mtaglio) . (2) the
polished surface, and (3) the occlusal surface. The remainder of the
denture should be inspected for imperfections as well: The denture Occlusal discrepancies
b orders should be checked for proper length, thickness, and contour,
and the border should be round and smooth. If complete dentures are It is often difficu� to detect occlusal discrepancies intraorally in com·
being inserted, it is adVantageous ij the patient has not worn an old plete dentures because the dentures may exhibit slight movement
prosthesis immediately prior to insertion of the new prostheses. on the underlying soft tissue. The variability in resiliency between the
321
20 i Management of Patients with New Prostheses
Fig 20-6 (aand b) Clinical remounting IJ(OCedure to correct for processing errors.
intraoral tissues can slightly displace the prosthesis. Patients may Articulating paper is valuable if the prostheses are stable and the
not be able to identify slight discrepancies in occlusal contact: how supporting structures firm. The clinician should make every effort to
ever, when occlusal discrepancies are eliminated. patients do seem introduce the articulating paper or ribbon bilaterally; if it is applied to
to be able to recognize this improvement. only one side, the patient tends to deviate the mandible toward that
It may be prudent for the clinician to assume that all prostheses side. Articulating paper or ribbon is best applied when the tooth or
include occlusal discrepancies. Such occlusal disharmonies can prosthetic suriaces are relatively dry.
occur as a result of (1) undetected errors in registration ol the Occlusal indicator waxes have an adhesive surface that should
maxillomandibular relationship records, (2) errors in mounting the be placed onto the teeth. Once occlusal contact is established. any
casts on the articulator, (3) poorly adapted or unstable denture bases, penetrations tllrough the wax may be marked with a lead pencil or
(4) changes in the supporting structures sinoe the impressions were adjusted directry. Errors in CR are most easily identified with this
made, (5) repositioning of mobile teeth, or (6) release of stress in the method. Errors 111 eccentric contact are more difficult to discern.
acrylic resin of the denture bases after prooessing.
Undetected errors may be caused by (1) splinting action of the R e m o u n t method
muscles, (2) interferenoe of the denture bases, (3) differences in When more obvious or gross occlusal interierences are round, it
the physical characteristics of the recording media, (4) excessive is more appropriate to perform a clinical remount. An interocclu
pressure exerted by the patient during the CR recording, (5) failure sal registration of the prostheses slightly out of occlusion can be
of the patient to understand and follow instructions, or (6) failure of established with a variety of different materials including wax, zinc
the clinician to record and transfer relationships to the articulator. oxide-eugenol paste, plaster, or elastomeric bite registration materi
When mounting the casts on the articulator, it is important that bases als. Once the record is obtained, the dentures are replaced on the
be properly seated. Improper seating of the occlusion rim, denture articulator and remounting prooedures are initiated.
base, or interocclusal records may lead to incorrect orientation of The advantages of the clinical remount are that occlusal adjustment
the casts in the horizontal or vertical dimensions. Should the cast on the articulator requires no patient cooperation. visibility is
be disturbed during the mounting p rooes.s the position of the casts improved, a stable working foundation is established. and a dry field
may be altered, resulting in occlusal disharmony. is present to facilitate the identification of occlusal interterences.
The remount method may require that the patient wear the denture
Correction of occlusal discrepancies for a time to allow the denture base to settle onto the underlying oral
mucosa. This also assists in recovery of the acrylic resin denture
Although the prosthesis is remounted after processing, this labora base from minor prooessing changes.
tory remount procedure is only as accurate as the instrument that
was used, the records that were obtained, and the mounting proce
dures done before prooessing. It is distinctly possible that occlusal Instructions for patients
discrepancies may remain. This should be assessed at the insertion
visit through intraoral evaluation or clinical remount.' Ongoing care for patients with dental prostheses is a conoern for
the treating clinician. Patients must be made aware of tlleir respon
Intraoral assessment sibility toward the maintenance of their oral health and their pros
Intraoral correction of occlusal discrepancies should only be per theses. The clinician must allow sufficient time to provide detailed
formed when lhe discrepancies are minor. Discrepancies can be instructions to the patient regarding required maintenance. While the
assese
s d using articulating paper, shim stock, central bearing points, clinician adjusts, finishes. and polishes the denture, the patient is
intraoral waxes, or electronic devices such as the T-Scan (fekscan). generally attentive to the instructions provided. However, once the
Regardless of the method used to define the discrepancy, t11e clinician denture is inserted, the patient may become preoccupied with the fit
must still exhibit the appropriate adjustment techniques to eliminate of the denture to the tissues, functional aspects of the denture, and
any identified occlusal errors (Fig 20-6). the esthetic outcomes of the prosthesis, and may not be receptive
to further instructions.
Insertion Phase of Complete Dentures J
It may be prudent to physically demonstrate the use of dental

OearMr or Mrs
hygiene products intraorally to ensure that the patient has a thor
______
1am enCO\irage<l t:>y me ovtcome we nave acnleve<J mn ough understanding of the technique. Oral lavage using mouth
completioo ol trQatmenl by yo�< new proothesis/psos<h<lOO$.
r inse may be encouraged in the edentulous patient to ensure the
The <es)laccmeol <>I oral lon:to()n by a Pf(l$1he$$ IS rather removal of residual particles of food. Removal of food debriS and
comple<anddependson a numbe<ollaclors. NeverUleless. U>e
stains from all aspects of the prosthesis should be emphasized.
0ta1 environment changes continuously through .J lifetime, Md
you shOlAd expecl 10 see some of these changes assc:x>a!ed • Removal at night. Patients should be encouraged to remove their
with tho na tu ral process of +.vearing dental prosthesos. Some
prostheses at night. Whereas parafunctiOnal movements are often
or ll1ese changesallen seen may lncb.Jde but are not tmiled 10:
the cause for increased resorption of the supporting structures. the
•W<wor !he <lenlut<> IOOih ·S<l«lness be<lealh the limitation of these po tential habits is sufficient to justify removal of
·Ctlan9es in the !Jite prostheses
·Occasto naJ lract.vre vr.ctar ·loosenong oltne Pf(l$1hll$0$ the prostheses while sleeping. Patients who follow the advice re
runc1100 -Moor oolor changes or me
garding prosthetic removal often relate that the prosthesis adapts
prooth<lses
to the oral tissue more favorably in the morning. This may indicate
Regular #ollow·up Dllows us to anticipate these changes and
tissue rebound when the prosthesis is out of !he mouth.
1r11ervet'le Bflll'<lpnalely. lt ISsugg ested thatyou"""' ouroffice al
leas! aoouallyso that wecan monilorth""" changesar >d render • Learning to eat. It may be beneficial for the clinician t o provide guid
services that may b<l noocred <lurng !his time. We ate always ance to the patient relative t o diet selection during the early peri
avaiable to anS\•IOf Questions concetnlng t(eatment needs. anct
wo encoorage you to 1>e an aelive pert ol yo"' own orar he.>MI ods of prosthetic use. Because the general proprioception of the
care.
oral cavity is altered with the insertion of a prosthesis, the pat ient
Since<ely you<s in heallh, may become aware of significant changes in the oral environment.
Dr _____
Even those patients who have worn prostheses previously may
experience a totally different set of sensations. Patients first need
to accept the feel of the prosthesis and learn to speak with the
Fig 20-7 A letter given to paijents at the conclusion ot their treatment verifies what prosthesis before complicating matters through the introduction of
treatment has boon rendered and also sets the stage to assist the patients ill under food. Initially, patients should follow a well-balanced semisolid diet,
stall(ling their nood to follow up for servicing needs. A sample letter Is shown. eaten slowly in small portions, until they become competent in the
feel of the prostheses. Gradual increases in the consistency and
It is best to make InstructiOns clear. brief. and direct. Lenglhy size of the portions can be made a s the patients gain confidence
instructions will only serve to fatigue the patient and will likely be in their ability to control their new prostheses.
forgotten. Instructions should concentrate on the following basic • Settling of a prosthesis. The patient should never leave the office
factors: with the new denture without an appointment for reassessm ent
the next day. Because the prosthesis rests on soft tissues that ex
• Temporary nature of prostheses. All treatment in dent istry and hibit varying degrees of resiliency it is highly likely that the dentures
,
medicine is temporary in nature. Patients need to be aware that will settle during the early phases of prost hetic use. Functional use
the prosthesis that is inserted today will not be expected to fit the of the prosthesis allows more settling in some areas than in others.
same way next month or next year. Normal physiologic aging, Given this situation, it is likely that localized irritation and occlu
changes in the oral cavity, and changes in the supporting tissues sal discrepancies may develcp . After prosthetic insertion. ongong i
affect the adaptation of the denture to the underlying tissue. Like adjustm ents are needed to correct the problems associated with
wis e erosion of the prosthetic materials will result in changes in
, settlin g o f the denture. The patient should be aware that early cor
tooth contact. rection of these problems prevents development of more serious
• Oral hygiene. Care oi the mouth and the prosthesi s is critical to problems.
prevent future disease. Patients will quickly understand that dental
prostheses complicate oral hygiene. When patients eat. food par Although the clinician is primarily responsible for educating the
ticles accumulate adjacent to dental prostheses. Although proper patient, much of the teaching duty may be delegated to auxiliary
design of the prosthesis may diminish this complication, it is un personnel. The dental hygienist or dental assistant can give basic
likely t o eliminate it. Patients need to be aware that it is critical that i nstructions to the patients . and i t may be that patients accept this
they remove and clean their dental prostheses after each meal. information more easily from them. Audiovisual material may be of
Proper method oi insenion and removal of the prosthesis should value to the patient. as are various pamphlets. textbook s. and other
be demonstrated 1o the patient, who must then demonstrate to printed material. Questions should be solicited from the patient
the clinician the ability to perform these tasks. throughout the insertiOn and immediate po st in sertion periOds. The
• Patient care. The patient should be instructed in the proper care clinician should be engaged in definitive answers to any questions
of the mouth and the prosthesis and should be given the neces posed by the p atient. It is appropriate to give the patient written
sary materials and supplies o
t accomplish these tasks. Care of the instructions regarding the use and maintenance of dental prostheses
remaining teeth and periodontal tissues should be demonstrated. (Rg 20-7).
323
20 Management of Patients with New Prost hese s
--�-----
support to the corners ot the mouth d the patient's goal s

i to eliminate
Postinsertion Phase folds and wrinkles. Attempts to "plump· the lips and cheeks with a
prosthesiS are unlikely to prove succes.sful Conversely, these efforts
Patient car e after insert1011 of the prosthesis is part of the total t o pbump tissue may distort the corners of the mouth, whiCh creates
prosthodonbc treatment. Appointments should be arranged accord an unnatural appearance of the 6p and 1nterferes With the stabll ty i
ingly. Sufficient time should be avatlable to diagnose and correct tis and retention of the prostheses. It iS best to recognize these esthelle
sue 1mtation and ocdusal dtSCrepanoes and to revtew posMsertion concerns before treatment is initl3ted because Ill many lllStances,
instnJctions. Patients W1U appr9CI3te the clll1icl3n's commitment to the only solution iS cosmetiC surgicalltlterven l()l).
t
ongOltlg car e and their well-being. demonstrated by a wilbngness Prevention of esthet1c complaints such as fullness under the nose,
to spend the time necessary to address all concerns regarding the concave upper lrp, excessNe visib1hty of the teeth or denture base,
prosthesis. and the artifiCial look o f the prosthesis are best addressed during
Patients should be adVIsed of the reasons behind allowi ng denture fabrication. Patl9flts and clinci ians should both participate
adjustment to the prostheses. They should understand that the actively in arriving at an acceptable cosmetic result.' If it Is not
prosthesis must be worn f or at least 1 hour to allow the denture to possible to satisfy the patient during the wax trial stage, it is not
settle before postinsertion care is sought. Patients should understand possible to satisfy that patient by transforming the wax trial denture
that the denture cannot be thoroughly evaluated it it has been kept in i resin denture. In soma instances, it may be necessary
into an acrylc
a pocket rather than remain1ng in the mouth before a postinsertion to terminate treatment at the wax tri al denture stage rather than
and adtustment appointment. In the event of soreness, the patient proceed to the fabrication ot a definitive prosthesis only to have the
shOllld understand that acljusunent cM reduce pressure in the area patient dissatisfied with the results.
o t soreness. but elim inatiOn of all sensation would likely occur only if
the denture is overadtusted.
Phonetics
Major Problems with New It is not uncommon for speech to be altered temporarily following the
insertion of new prostheses. Patients need to be couns eled regard
Prostheses ing the adaptability of the tongue. They may benefit from read1ng
aloud for a few minutes every day until they become more proficen i t
Diagnosis and treatment of post1nsert1on problems generally tnclude in the use of their valving mechaniSms of speech. It dtfflCulties do not
the evaluation of tour major areas of concern: esthetics, phonetcs
i ,
disappear. reassesn sme t of the occlusal scheme should be consid
tissue irritation. and loss ot retentiOn and stabili ty. The successful ered. Improper placement ot the teeth 111the vertical, honzontal, and
correction ot these problems depends on the clinician·s abirlty t o de frontal planes usually contnbutes to speech changes that the patient
termine their causes. m date. Minor speech imperfections might be related
cannot accomo
to excessive flow o f saliva. large tongue. contour or thickness ot the
palate, or any cornblnation of these factors.
Esthetics
The excessive flow o t saliva is seen more frequently 111 the new
denture wearer. This generally is expla1ned as a toreign-bocly re
Esthetic acceptance of the prosthesis provides strong psychologic action that usually subsides 1n a relatrvely short time. If the tongue
sup port for the patient dunng the adJUStment periOd. The clinician is large, adequate space must be provided within the dental arch to
should be cautious of patients who deemphasize the esthetic as allow for its movement dunng physiologiC function while permitting it
pects of the1r prostheses because it is unreasonable to expect pa to serve as a primary stabilizing lnnuence of the complete maxillary
tients to be devoid of vanity. Consequently, the clinician m ust be denture. If the artificial teeth have been property placed In an
reacly and abl e to address esthetiC concerns. adequate ccclusal scheme, the contour of t11e palatal denture base
Patients who are displeased with the appearance of a prosthesis should be likewise adequate. Thickness of 111e palatal denture base
may complain about it in rather vague or uncertain terms. Frequently, should be limited to that which Is required to prevent fracture of the
the patients are unable to describe specific problem areas, although denture (1.5 to 2 mm).
they obviously have concerns. One common complaint is the failure
of the prosthesis to eliminate all the folds and wrinkles around the
lips and mouth. The clinician can do much to restore or improve Tissue irritation
the appearance ot the mouth an d face, but there are some signs
of aging that cannot be addressed through dental prostheses. The The specific location of irritated tissue, t1me of Its development and
,
lablal ffange should be carefully contoured and the prosthetic teeth clin ical features of the involved regio n are Important factors in diag
appropriately positioned to establish an acceptable appearance of nosing the cause of the irritation. The cli ni cian must always be aware
tip support in the area of the philtrum. Uttle can be done to prOvide that a sore spot may be far removed from the causative agent. Mere
324
Major Problems with New Prostheses J
Fig 20-8 (a and b) Patient presenling with residual lidge

soreness 011 the ri g ht side as a result of not wearing a man
dibular removable partial <fenture to balance the maxillary

denture.
removal of denture base substance in the area of irritation may give may be the result of fungal infections within the oral cavity, primarily
only temporary relief and could result in soreness elsewhere or in from Candida albicans, and may be definitively diagnosed through
diminished retention and stability of the prosthesis. microscopic confirmation of the presence of fungus using potassium
Overextension, trauma resulting from faulty occlusion, pressure hydroXide (KOH) staining or culturing.
from the denture base. and abrasion of tissues caused by prosthetic Once the diagnosis is established and causative agents are
movement are the most frequently cited causes or irritation. defined, addressing the source or irritation to achieve its resolution
The lesion caused by overextension is found in the vestibule and usually is a simple matter. Clinicians may provide relief to the tissue.
appears as a cut or break in the alveolar mucosa. Lesions caused occlusal, or polished surface of the prosthesiS to address many of
by movement, trauma, and pressure are most often found on the the discrepancies . In some instances, the remake of prostheses may
masticatory mucosa and appear as localized areas of hyperemia be required if simple modification is insufficient t o address the cause.
or ulcerations. Hyperocclusion generally manifests as localized or Irritation on the crest ol the residual ridges may be caused by the
diffuse redness on the residual ridges. following:
A vari ety of other factors can lead to irritation or the denture
bearing areas. Ge neralized irritation of the denture-bearing area may • Bone spicules rrom previous extractions
be caused by the following: • Deflective occlusal contacts (Rg 20-8)
• Irregularities on the denture surface or on the crest of the residual
• Increased VD O ridge
• Occlusal disharmony between centric occlusion (CO) and maximal • Pressure from the denture base
intercuspation (MI)
• Occlusal interferences and eccentric positions Each of these factors has a slightly different clinical presentation.
• Bruxism or clenching Bone spicules are identified as small openings or lesions in the
• Xerostomia soft tissue with a hard, loose center. Deflective occlusal contacts
• T issue reactions to denture matelial or denture cleaner are generally identified as a redness or ulceration of the soft tissue
• Poor oral hygiene near the contact itself. Deflective contacts are corrected by occlusal
• Unfavorable denture-bearing tissues adjustment, which generally requires remount o f the dentures on an
• Dentune stomatitis a.rticulator in CR. The clinician identifies and removes the deflective
contacts through selective grinding. Irregulariti es on the denture
The differential diagnosis tor the cause of denture irritation is often surface can be identified through visual or tactile means: irregularities
based on clinical observation. Clicking of the teeth when the patient in the underl ying soft tissue. which often go unnoticed through visual
is talking may indicate an increased VDO. Shifting of the mandibular inspection can be identified thr ough palpation. Discrepancies within
,
denture anteriorly upon closure indicates disharmony between CO the denture are easily removed. but alterations in the contour of the
and MI. Lack of occlusal balance in eccentric movements may residual alveolar ridge may require alveoloplasty.
indicate the presence of interferences. Bruxism or clenching may Irritation near the vestibules may be caused by overextension of
be recognized through the rapid development o r wear racets on a denture border or by sharp or unpolished denture borders. These
the denture teeth. Xerostomia is identified by generalized dryness lesions generally appear as defined cuts in the alveolar mucosa.
of the oral mucosa that may be accompanied by a sticky mucosal Offending areas may be verified through the use of p ressure indicator
-
surface upon dig�al examination. If generalized irritation disappears paste or disclosing wax and may be corrected through appropriate
after a 24-hour period of no denture usage, an allergic reaction to adjustment of the borders followed by polishing of the adjusted or
the denture base or the denture cleaner should be suspected. In rough areas.
this case, skin-patch testing may be indicated. Denture stomatitis
325
20 i Management of Patients with New Prostheses
Tongue, cheek, or lip biting are also causes of irritation and may
result from the following:
• Decreased VDO
• Insufficient horizontal overlap of teeth
• Improper anteroposterior or buccolingual position of posterior teeth
• Insufficient posterior clearance of denture bases
• Lack of muscle tone
• Poor location of occlusal plane
• Neurologic problems
Fig 20·9 Mouth temperature wax used to develop functional posterior palatal seal.
Observation of the patient during speech may demonstrate

excessive maxillomandibular space. End-to-end relationships seal may be corrected by providing extension into these areas with
of the buccal cusps of posterior teeth may indicate insufficient new border seals. Mouth temperature wax may be useful to develop
horizontal overlap. Tooth arrangement should not encroach upon the proper extensions and appropriate border seals (Fig 20-9}.
tissue adjacent to the retromolar pad or the maxillary tuberosity. When the maxillary denture drops during speaking, the patient
The dorsal surlace of the tongue should be 1.5 to 2 mm above the should be evaluated for discrepancies in tl1e occlusion, lack of
plane of occlusion. When any of these situations is encountered, posterior palatal seal, or underextension or overextension of
rearrang ement of the prosthetic teeth is necessary. the borders. Occlusal discrepancies. such as interferences in
Irritation in the maxillary tuberosijy region is usually caused by centric or eccentric contacts and an Increased VDO with occlusal
bilateral undercuts, overextension o f the denture border. or dimensional contact in protrusion. could cause dentures to become dislodged.
changes of the maxillary denture during processing. Of these potential If the discrepancy is related to an increase in the VOO beyond
causes. the presence of bilateral undercuts is most commonly physiologic limits, the denture will likely need to be remade. Loss
encountered. However, if the lesion is located at the pterygomaxillary o f retention associated with any inadequate posterior palatal seal
space area. the cause is usually overextension. Pressure-indicator may b e corrected through the use of mouth temperature wax on the
paste generally identifies this problem. which can be eliminated posterior palatal seal area to confinn the need for augmentation. If
through appropriate relief of the overextended denture. If dimensional this is successful, autopolymerizing resin may be used to replace the
changes are significant. the prosthesis should be remade. mouth temperature wax.
Irrit ation on the median raphe may be related to loss of support from Overextension o f borders is characterized by dislodgement of the
the primary stress-bearing areas, insufficient relief, or excessive incisal denture when the lips or cheeks are physically displaced. If this is
contact in CR. If discomfort appears several days after insertion of encountered, the denture must be carefully adjusted at the denture
the denture. it is usually the result of loss of support from the primary borders. Conversely, if the denture is underextended, correction
stress-bearing areas. However, i f discomfort appears within 24 to 48 wax may be used to identify the short flange, which can then be
hours after denture insertion. it is likely the result of inadequate relief corrected through the use of autopofymerizing resin. If discrepancies
during processing. When the denture rotates around the midline. the are too great. it may be necessary to relieve all borders, repeat
lack of relief is verified. Excessive incisal contacts are identified through border molding, and perlorm a rebase procedure.
forward and upward movement of the maxillary denture in CO. When dentures are displaced during function, the clinician must
determine whether this is related to occlusion or the patient's inability
to manage the food bolus. Occlusal discrepancies. particularly the
Loss of denture retention and stability lack ol balanced occlusion. can lead to dislodgement of the denture
in function. 11 i s possible that selective grinding on the working Side
If the denture drops when the mouth is open wide. as in yawning, the of dentures that have been remounted on an articulator may allow
patient should be evaluated for the following: the balancing contacts to be reestablished. However, if the tooth
arrangement was insufficient, some of the prosthetic teeth may
• Occlusal contacts that could interrupt the border seal need to b e replaced on the contralateral side or the denture may
• Underextension of the posterior border need to be remade. Patients may respond to instructions to take
• Overextension in the labial, buccal. or p terygomaxillar y space smaller bites of food and to attempt to chew bilaterally to stabilize
• Lack of posterior palatal seal the denture during mastication.
Occasionally, patients may experience inability to maintain denture
Treatment tor any of these problems demands appropriate retention when laughing or whistling. Either of these activities could
diagnosis. If the occlusion interrupts the border seal , then equilibration result in denture dislodgement. particularly if the dentures are
of the remounted dentures should effectively address this problem. overextended in the labial flange areas or if the patient has excessive
Underextension of the posterior border or lack of posterior palatal muscular activity in any of the flange areas. When this complaint
3261
Removable Partial Dentures and Related Problems J
is described by the patient, the clinician should carefully assess all

denture flanges with an anticipation of overextension.
Removable Partial Dentures and
Some patients experience adequate denture retention initially, Related Problems
followed by a dramatic reduction in denture retention. If this occurs.
the clinician should suspect changes in the characteristics of the
patient's saliva. It may be necessary to have the patient rinse the oral Many of the difficulties that patients experience with new complete
cavity more frequently or use artifiCial saliva, which may provide an dentures are also encountered with removable partial dentures. This
improved viscosity for denture retention. is particularly true when removable partial dentures are primarily
Most of the previous problems apply to the maxillary denture, tissue supported but also when teeth and mucosa participate in re
but it is also possible for patients to experience difficulty with tention. support, and stability of the removable partial denture.
retention of the mandibular denture. As mentioned previously, the Generalized irritation beneath the denture base may be caused by
clinician should always consider occlusal discrepancies and the one or more of the following factors:
influence that such discrepancies could have on denture retention.
Other factors that may contribute to inadequate retention of the • Excessive soft tissue displacement during the impression-making
mandibular denture include the positions of the teeth relative to the procedures
surrounding musculature and the contours of the polished surfaces • Incorrect orientation of the denture base and removable partial
of the denture. The labial surface of the mandibular denture should denture framework
be carefully inspected to ensure that there is no overextension in • Excessive soft tissue compression during the recording of maxi!·
the area of the genioglossus, mylohyoid, or retromylohyoid fossa. tomandibular relationship records
Any overextension that is encountered should be carefully corrected.
The contours of the polished surface of the denture should be If the occlusal rests fail to seat fully when the denture base
flat or slightly concave. When patients have severe residual ridge is seated. the clinician should suspect excessive soft tissue
resorption, it may be beneficial for the clinician to accentuate the displacement during the impression-making phase. Improper
concavity on the polished surface of the denture and then use mouth orientation of the denture base to the metal framework may occur
temperature wax on that surface to allow physiologic molding of during the altered cast procedures or during processing of the
the polished surfaces by the buccal and lingual musculature. This denture base. When excessive soft tissue compression occurs
physiologic molding may improve overall retention of the denture. during maxillomandibular relationship record making, the clinician
but the clinician is cautioned that mouth temperature wax does not may observe simultaneous seating of the frame and the base, but
move rapidly. Tl1erefore, such molding may require extended contact the prosthetic teeth are likely in hyperooclusion. Failure of the frame
between the oral structures and the mouth temperature wax. and base to seat simultaneously could be corrected by relief of the
Mandibular dentures depend on patient coordination and tissue surface of the denture, followed by relining procedures (Fig
compliance lor satisfactory clinical performance. Patients with 20·1 0). Hyperocclusion secondary to exceSSive pressure during
deficient anatomy. such as a retracted tongue. may benefit from maxillomandibular relationship record making may be corrected
exercises that could improve tongue movement and coordination. through occlusal adjustment intraorally or on the articulator.
Some exercises that may prove beneficial are described below: Localized irritation beneath the denture base is caused by excessive
tissue displacement during impression-making procedures or lack
• Thrust the tongue out and in as rapidly as possible. The tongue should of gingival reliel. Pressure-indicator paste can be used to reveal
move 4 to 8 mm beyond the lower lip during these movements. differences in the relative resiliency of tissue beneath the denture
• Extend the tongue to the top of the lower lip and move it Sideways base, which indicate the need for c linical adjustment in these areas .
rapidly. Failure to provide relief for the gingiva may lead to pinching of the
• Thrust the tongue out a s far as possible. then pull it back quickly. gingiva adjacent to the denture base. This situation can be corrected
• Say "eee yuh." The full benefit of the exercise can best be attained by appropriate adjustment of the denture base.
by saying eee in a high pitch and then following this with •·yuh"
·' " A number of tissue irritations related to the metal framework may
in a normal pitch. be caused by the following:
• Concentrate on carrying the tongue forward behind the mandibular
anterior teeth (for Class II patients). • Pressure from metal framework
• Lack of relief beneath the metal frame
Although the exercises are not terribly complicated, the patient may • Location of major connector
find them awkward at first. The patient should perform the exercises • Excessive beading of framework
twice daily for approximately 5 minutes with the mandibular denture • Distortion of frame
removed. The initial response may be soreness of the tongue, but
this should disappear after a short period of time. Generally, the Pressure beneath the metal framework may be identified
patient will notice improvement in the coordination and general througl1 the use of pressure-indicator paste. Typically, relief should
movement of the tongue within 3 to 4 weeks. be provided in fabrication of the metal framework for the gingival
327
20 i Manag emen t o f Patients with New Prostheses
Fig 20-1 o (a) Patient pre�nting with occlusal insta

bility related lo advanced residual ridge resorption
addressed by refining both prosH1eses. (IJ) Adequate
occlusal relief was available with design of the frame·
WOik.
sulcus. for nonyielding mucosa such as that found over tori, and tor closer to the survey line_ In some instances. it may be necessary to
sublingual slopes that deviate from vertical. Adjustment of the metal replace the retentive arm with a wrought -wire clasp. Tooth movement
framework may be provided. but the magnitude or adjustment is may occur between impression-making procedures and prosthesis
quite limited. Major connector design should avoid encroachment insertion. Unfortunately, this situation can only be addressed by
upon functional musculature or Irena. Major connectors that are remaking the metal framework. Failure of the removable partial
placed too close to gingival margins will pemnt
i accumulation of denture to seat fully may be caused by acrylic resin or metal
food adjacent to the remaining teeth and could result in gingival or impingement on the natural teeth. This situation should be easily
periodontal compliCations. When encountered. overextended major identified with disclosing wax or pressure-indicator paste and can be
connectors may be shortened in the areas of t1ssue ulceration. If addressed with simple adjustment of the prosthesis.
major connectors are less than 4 rnrn from the gingival margin,
they must be narrowed to provide self-cleansing areas. or the
partial denture framework may need to be remade. Remake is also
necessary should adjustment result in a flexible metal framework.
Complications of Obturator
When excessive beading is encountered, it can be corrected through Prostheses
selective adjustment.
It is not unusual for the patient to encounter tooth pain or mobility Obturator prostheses exhibit many of the same compliCations seen
following placement of a removable partial denture. The potential with removable partial dentures. However, some unique complica
causes for this include the following: tions need to be considered.g
Difficulties with proper speech are sometimes encountered with
• Pulpi tis obturator prostheses (see chaptef 19). These may be caused
• Return of function of the tooth that had previously been nonfunc- by insufficient obturation, excessive obturation, or resonance or
tional articulation errors. Speech difficulties generally are more common
• Traumat1c occlusion in patients with congenital defects. Insufficient obturation initially
• Bruxing o r clenching habits should be identified througll nasal emission of air, which causes
• Rigid retainer hypernasatity. Increased obturation of the defect can correct this.
• Tooth movement Should modification be delayed, patients may exhibit muscular
• Failure of partial denture to seat fully activity in the infratemporal area to compensate tor the tack of defect
obturation. Excessive obturation can be detected by the hollow
Occlusal and parti al denture stress on a tooth that has been out hyponasal quality of speech and by difficulty with nasal breathing.
of occlusal function for an extended period may make the tooth Thi s may be corrected through judicious reduction of the size
sensitive to percussion. In many instances, pulpitis is reversible; o f the obturator. Patients with large oral or perioral defects may
however. if the tooth remains symptomatic, endodontic therapy may experience resonating sound or voice quality because the volume
be necessary. Deflective occlusal contacts related to the abutment o f air may be dissimilar after obturation. Although it may be possible
tooth. partial denture frame, or the prosthetic teeth may be detected to alter the superior surface of the obturator prosthesis to improve
by visual examination, articulating paper. or occlusal indicator resonant sounds. this issue is sometimes secondary to the need
wax. Occlusal adjustment should be perfomned to address these for appropriate insertion and drainage requirements of the obturator
discrepancies. prosthesis. Articulation errors may be identified through subjective
If excessive pressure is needed to place or remove a removable analysis of speech, but these are best evaluated and treated by a
partial denture, it may be indicative of excessive rigidity of the direct speech pathologist who can address the articulation concerns with
retainers. This situation can be addressed through the tapering of a variety of therapeutic methods. •o
the retentive clasp arms or by careful movement of the retentive tip
3281
Fixed Dental Prostheses J
Fig 20·11 (a and b) Patient presenting with slight initation of soft tissues after post Fig 20·12 (a)Full veneer preparation orone nonvital and twovltalteedt {b)Subsequent
surgical changes. restoration wil h all-ceramiC restorations.
Table 20·1
Factors requiring intervention

l,.Common
"L!:
. .-'--'-�-.o;
,- �;;.. "comp lications ofnewprostheses and their short-term andlong-term "solutions:
·�-r·,.�.=-:!<"�-�
� ---��-�
Sho rt-term
.F--
- ..,.,._�-.·�
� ..
�.�_
...-.,
,.-.-.-��-.;."""
·�·..:
�:�:.:.. • -:--
-=�-- �<e
_.:::o
· ··�-��1-=--"
Long-term
�·-�;
" ••-�··2;··� -�-.JI
Staln11g utrasonic debridement/poishinQ Modilicahon of diet
Repeated fracture of denture base Repair and rea�ss occlusal factors Redesign with reinforcement or modify supporting tisS\Jes
Worn teeth Lamination of teet11 with composite resk1 Repi<leement of prosthetic teeth
Inflamed soit tissues Determine cause and adjust tissue condition or �ne Monrtor progress and determone repeated need tor recall
and inteovootion
Uns!al:lle denrure base Reassess adaptation and positionally reline Regular recall examination with or v�thout inteNention
Cl\ronic OllnCJI(Ja onrection Routine care fo< infections With anllfungal agent: Cl!S1nrection
o r prosthesis
Determine un<Jerlying contributing !actors and ln teovooe as
necessary
Patients may experience occasional passage of food a nd liqu ids could result in tissue ulceration or excessive secretions of the
above the obturator prosthesis. This situation may develop secondary respiratory mucosa. The clinician is advised to eliminate all contact
to a lack of peripheral seal of the obturator portion of the prosthesis. between the prosthesis and the turtinates, nasal mucosa. or orbital
Normally, this lack of seal can be evaluated visually. In addition, in contents (Fig 20-11).
some instances, the musculature of the soft palate may return to its
presurgical level, which could reduce contact between the muscular
structure and the obturator prosthesis. Either of these situations
coufd be treated through the addition of mouth temperature wax Fixed Dental Prostheses
to the periphery of the prosthesis. Once the seal is reestablished
and confirmed, autopolymerizing resin may be applied to replace Dental prostheses may be rigidly connected to teeth or dental implants.
the mouth temperature wax. Patients who complain or passage o f Each approach carries unique potential complications and demands
fluids or food should be observed while drinking water to ensure that specific considerations regarding long-term maintenance (Table 20-1).
the patient's head position facilitates swallowing. Patients should When prostheses are connected to natural teeth, a number of
be instructed to hold the head level or even to tip it posteriorly to short-term and long-term complications may be observed. Short
encourage the passage of food into the oropharynx. term complications generally relate to the health of the dental
Irritation beneath the obturator portion of the prosthesis may be pulp. occlusal scheme. and gingivalfperiodontal health. Long-term
caused by impingement of the prosthesis on either t11e static or considerations include all the short-term factors plus biologic and
movable tissues. Impingement on the static tissues can be easily biomechanicat complications that may occur over time.
identified vvith pressure-indicator paste, and the prosthesis can be Tooth preparation for full or partial veneer crowns causes trauma
adjusted acco rdingly. 11 impingement occurs on movable tissue, to the pulp or the tooth (Fig 20·12). In most instances, this results in
pressure-Indicator paste still may be beneficial, but the clinician transient irritation known as reversible pulpitis, which may manifest as
is encouraged to respond to patients' complaints of difficul!y with thermal or osmotic sensitivity. The health status of the pulp may be
head movement, mandibular movement, o r swallowing activities. assessed through vitality testing, although such test results are not
Impingement of the obturator prosthesis o n the respiratory mucosa entirely reliable and may not predict lhe future course of pulpal hE>..alth.
329
20 i Manag ement o f Patients with New Prostheses
Fig 20-13 (a) Metal-ceramic failure requiring refabrication

ol this implant restoration. (b) Failure of zirconia frameworl<
beneath all-ceramic crown. requiring refabrication.
When tooth sensitivity is not progressive in nature, the ex or partial veneer crowns. Chronic occlusal irregulariti es could lead
pectation is that i t will gradually subside. Should discomfort t o adaptive mobility of the teeth. In the absence of plaque, mobility
remain or progressively increase in severity, root canal therapy is unlikely to cause attachm ent toss; however patients may be
may be indicated. In some instances. it is possible that an occlusal
,
concerned by the mobility pattern. Appropriate occlusal adjustment

prematurity or interference could propagate thermal or osmotic may effectively limit or eliminate tooth mobility, unless the mobility is
sensitivity. Most modern occlusal tl1eories call for forces down the primarily the result of bone loss.
long axis of posterior teeth when the jaws are in CR or Ml without Restorative luting agents may gradually dissolve over time or may
posterior tooth contact in lateral excursions. Articulating paper respond adversely to repeated high compressive loading. Crowns
may be useful to identify premature contacts, which can then be that become dislodged but are otherwise intact may simply be luted
eliminated through selective grinding of the restoration. Scientific to the tooth preparation once again. A crown that is damaged during
literature demonstrates that the gingival and periodontal response to dislodgement may require refabr cation (Rg 20-13).
i
dental restorations should be maintainable if the patient follows good Biomechanical complications in the form of catastrophic material
oral hygiene practices. failure, material wear, or material fracture are possible long-tem1
At times. chronic adverse soft tissue responses to full veneer complications. All are likely to requi r e refabrication of restorations.
crowns are observed. This may occur secondary to allergies to When prostheses are retained by dental implants, the biologic
the dental materials, rncomplete debridement of dental cement, or risk of dental caries is eliminated. Because there is no periodontal
violation of the biologic width. Because most dental materials are supporting mechanism, periodontitis cannot exist around dental
hypoallergenic in nature. it is unlikely that the clinician needs to implants either. However. peri-implantitis and peri-implant mucositis
routinely perform patch tests on patients prior to the placement of have been described as similar processes to traditional periodontal
restorations. However. when chronic soft tissue irritation is observed disease. Whereas peri implan tHis results in loss of supporting bone
structure, peri-implant mucositis is a soft tissue reaction without
-
subsequent to placement of a restoration. it may b e prudent for the

clinician to consider such patch testing. If 1116 patient tests positive associated bone loss. It is to the patient's advantage to receive
for allergic reaction, the only solution is to remake the restoration. instructions in oral hygiene and t o maintain meticulous oral hygiene
Ukewise, if the patient experiences a biologic width violation causing practices.
chronic gingival inflammation. the clinician should remake the Soft ti ssue recession adjacent to an endosseou s implant could
restoration after periodontal crown lengthening is performed. expose the supporting implants to the oral cavity. Because most
One of the most common reasons for failure o f fixed dental modern implants have a microscopic roughness to their surfaces. it
prostheses is dental caries'' When crowns are fabricated for is possible that the surfaces could be plaque adherent and lead to
patients. it is imperative that the clinician advise the patient of the further tissue breakdown. From a cosmetic standpoint, the exposure
risk of dental caries and the need for ongoing maintenance. All of a metal implant within the esthetic zone is unacceptable. A variety
patients should be advised to practice routine oral hygiene that of connective tissue and bone grafting procedures have been
includes toothbrushing after each meal and before bedtime in proposed to resolve this issue, but the long-term efficacy of these
addition to dally flossing. Patients who exhibit a high risk for dental procedures remains unknown.
caries should consider caries prevention protocols that may involve Biomechanical complications related to fracture of dental materials
the use of (1) fluori de-contain ing toothpaste , (2) fluoride gels, (3) are more likely to occur with implant-supported restorations
fluoride varnish, (4) remineralizing so!Lrtions, (5) cl11orhexidine rinses. because these restorations have virtually no mobility within bone.
(6) xylitol-containing chewing gum after meals, and (7) even topical Consequently, the implant-supported restorations are subjected to
iodine (betadine) solutions t o reduce the bacterial flora implicated in higher impact forces, which could cause fracture ofmany of the brittle
development of caries. These preventive mechanisms also reduce ceramic materials. Should these restorations be screw retained, it is
the risk o f periodontal disease. Advances in periodontal therapy allow possible that simple laboratory repairs may be provided. However. if
effective maintenance o l the periodontal health around teeth with full prostheses are cement retained, simple repairs are not likely.
330 1
References J
Summary References
Dental prostheses are mechanical devices that must func 1. Salinas TJ. Treatment of eden!Uiism: Optimrzing outcomes witn �ssue man·
agement and impression techniques. J Prosthocklnt2009:18:97-105.
tion in the complex physiologic region of the oral cavity. It is easy
2. Lytle RB. The fnl!nagement of abused oral tissues in complete dent ure con·
to understand why patients experience difficulty in adapting to such structioo. J Prosthet Df>.nt 1957:7:27-42.
intraoral devices. Despite the cautious and exacting processes 3. Boos RH. Prepar&tion and conefitiooing of patJents fOf prosthe1iC treatme<1t.
undertaken by clinicians. problems may still arise. J P rosthe1 Dent 1959:9:4-tO.

4. Zarb G. Bolender C (eds). Prosthodontic Treatment for Edentulous Patients.
Meticulous attention to detail during the insertion and maintenance
ed t2. S t Loois: Mosby. 2004.
procedures improves the likelihood of clinical success. Even so. the 5. Murphy WM. The neutral zone and lhe polished surfaces of full dentures. Dent
clinician needs to respond appropriately to clinical complications Pract Dent Rec 1966;16:244-248.
as they arise. In addition, clinicians must be able to communicate 6. Beresin VE. Schiesser FJ. The neutral zone in complete dentures. J Proslhet
Dent 1976:36:35thl67.
patients' responsibilities regarding the successful utilization of 7. Kingery RH. The postinsertion phaSe of denture treatment. Dent Clin North
dental prostheses. Prosthetic success is, to a great extent, a Am 1960(Juty):343-358.
patient-mediated endeavor. Patients who lack desire. motivation. or 8. Pound E. Pe<sonalized Dentute Procedures: Dentist's Manual. Anahem: De·
nar, 1973.
dexterity to appropriately utilize and maintain their dental prostheses
i T, Marunick M (eds). Maxillofacial Rehabilitahon: Proslh
9. Beumer J 3rd. C urts
are likely condemned to failure. Although the discussion of patient ooonitc and Sur9ical Considerations. Tokyo: lshryaKu EuroAmerica, 1997.
commitment begins at the initial patient presentation, these 10. Petkel J (ed). Physiology ofSpeech Productioo: Resutts and Implications of a
discussions never truly end. Even upon completion of all technical Ouant�ative Cineradiographic Study. Cambridge, MA: MIT Press. 1969.
11. Pjetursson BE. Tan K. Lang NP. Brllgger U. Egger M, Zwahlen M. A sys·
procedures, patients should still be reminded that they are the most
tematic r�' 04 the &•rvival and oomplicalion rates or fixed pallial dentures
critical factors toward future success. (FPDs) after an obsEiJVation period of at leas t 5 year s. Oin Oral Implants Res
2004: 15:667-676.
331
Index
Page numbers followed by •r denote figures; "t• tables: and ''b. boxes
A American Joint Committee on Cancer staging, Bisphosphonates

Absolute granulocyte count. 19 184, 185t description of. 43
Absolute neutrophil count, 1g Amifostine. 171.173-174,176.190 half-life ot. 192
Abutments Amino acids. 167 osteonecrosis caused by, 153, 192
aluminum oxide, 242f Amyotrophic lateral scl erosis. 47. 207 BlOod oxygen level dependent, 65
canines as, 1 01f Anatomical p lanes 270-272
. Body image distortions. 45
conditoon of, 102-104 Anchorage. temparary devices for. 15-16. 161 BOlton Tooth Size Ratio. 14, 15f
fixed dental prosthesis support, 285f Anorexia neNosa. 44-45 Bone
fixed partial dentures affected by alignment MteriOr maxillary alVeoloplasty, 1171 controt factors that affect, 99
of, 100 Anterior palatine foramen. 28 necrosis of. 175
fixed prosthetic, 103 Anterior teeth prosthetic factors. 99
periodontally weakened, 103 intrusioo or, 15 remodeling of, gg
pier. 289 mandibular. 1 07f resorption of. 99, 115
restoration of. 1031 maxillary, 255-256 treatment·planning considerations, 99-100
nppect.289 restorations for. 101 volume of. for implants. 130-131

total occlusal convergence f or. 285 Ante's law. 103 Bone grafts
Accelerated fractionaiOn,
t 185 Antlcholinerglcs, 167 allogeneic. 132,1321
Acquired defects Anticoagulant therapy. 20 altoptastic, 133

congenital deficiencies. 206-228 Antidepressants, 74 aLrtogenous.133, 1341. 143-144
cosmetic impact of, 227 Antifungal medications, 190. 191b cancellous. 133. 144
etiOlogy or. 197 Antl innammatory agents. 167

- cortical. 133. 145
multidisciplinary care for. 198 Antioxidants, 167 corticocanceRous, 133
palatal fift for. 207-208 Anxiety description of, 131

Acrylic resins, 234.236-237. 260. 301 assessment of. 78 fibular, 158-159
Adenoid cystic carcinoma. 152 dental,72 hafVest sites for
Adenomatoid odo ntogenic tumors, 150 gooeralized anxiety disorder. 74-75 corono id process. 134. 135f
Adjwant chemotherapy, 188 medications lor, 75 cranium. 137
Affncates, 296 Aphasia. 294 extraoral. 134. 136f,136-137
Agranulocytes, 19 Apraxia. speech,313 Iliac crest, 134, 136-137, 136f-137f. 159
All·ceramic restorations, 242,276, 278-27 9, Articulating paper, 322 tntraoral, 133-134, 1341
279t, 283f Articulation. See Speech. mandibular external oblique ridge, 134,
Allergies. 245 A rticulato r s.270-272, 2721 1351

Allogeneic bone grafts. 132. 1321 Artifacts. 56, 62 mandibular ramus, 133-134. 1351
Alloplastic bone grafts, t 33 Atypical antidepressants. 74 mandibular sympl1ysis 133, 1341

,
Alloys, 245, 245t Autogenous bone grafts. 133. 1341, 143-144 mandibular tori. 134. 1351
Aluminum oxide. 2421, 242-243. 279t Autopolymerizing acly!ic resin. 236 maxillary t uberosities. 134. 1351
AJveolai ridge Autos()(I)BI dominant cooditions. 2, 3t proximal tibia, 137, 137f
augmentation of, 123-127 Autoomals recessive conditions. 3t healing, 131-132

distractioo osteogenesis of, 126-127, 1271 heterogenous. 132,132f
extension procedures f()(, 120-123 B nonautogenous, 143-144
mandible. See Mandibular ridge. Bacterial infections. 190-191 summary of. 139
ma>olla. See Maxmary ridge. Balanced articulation occlusal scheme, 267-268 Bone index areas. 99t
i for deficiency o1, 285

pantes Barrier membranes; 143 Bone mineral density. 57
preservation of, 123,142 Bar-type splint. 1 01 Bone morphogenetic proteins, 132
prosthesis effects on, 3251 Beck Anxiety Inventory. 78 Bone sarcomas. 176
residual, 131 Bennett angle, 266-268 Booe-anchored prostheses. 214
resorption of, 26, 99, 131, 1311, 142, 255, Bennett movement, 266-288 Border mo lding,217
257.328 B enzydamine hydroc�ride. 167, 170 Brachytherapy. 177-178 . 186

Alveoloplasty, 116-118.1171 B �a ba
i l consooants. 298. 2991 Brief Symptom Inventory, 78
Ameloblastic fibromas, 151 Binge eating, 45 Bruxism. 85. 86-89, 274t
Ameloblastic fibroodontomas. 151 Bio·Col technique. 143-144 Buccal frenectomy, 119
Ameloblastoma. 571,88, 150. 2231 Biofeedback training.80 Bul imi a nervosa, 44-45
Amelogenesis m
i perlecta. 46. 46f. 198f. 274t Biopsychosocial model. 71 Burning mouth syndron1e, 41
Amenorrhea,45 BipOlar disorder.7i
333
i Index
c riSk factors for, t64-165 Cone beam computed tomography
Calcifying epithelial odontogenic tumors. 1 5 0 trea�ent or. 168-169 accuracy of. 59
Calcineurin inhibitors. 39 Chlorhex.idine mouthrinses, 169, 190 advantages of, 58-60
CalCium hydroxide chelate cemen1s. 240 Chrislensen phenomen on, 267 contrast media for, 80
Calvarial bone harvesting. 1 37 Chromosomal disorders, 6-7 contrast resolulion of, 80
Cancenous bene grafts. 133. 1 4 4 Chromosomal microarray analysis. 5 convenlional radiography versus, 60
Cancer. S e e Head and neck cancer; Squamous Chromosome analysis. 4 description of, 10, t l f , 34, 272
cell carcinoma. Cinefluoroscopy, 306 flllld of view. 59
Carcinoma. See SQuamous cen carcinOma. Cineradiograplhy, 305-306 implant site assessmenls using, 60
C aries. 1 74-1 75, 330 Clagps, 259, 2591. 261 principles of, 58
Cas1s, diagnoslic, 110. 1101. 121 Class II skeletal relationship, 11, 12f radiation dose usmg. 59
Cawood ru1d Howell classifiCation, 1161 Class 111 skeletal relationship, 11. 121 restrictions or. 60
Cemenloblastomas, 151 Clear cell odontogenic IUmors, 150-151 spatial resolulion or, 58, 60
Cemenloenamel junction height. 265 Cleft lip a11d palate spiral computed lomography versus. 58-60
Cements. 240, 240t bilateral, 205f 30 reconstruction uses of. 581. 58-59
Center lor Epidemiological Studies Depression Classification of, 2021 Congen�al defects
Scale, 78 hearing lOss and. 312 clef! lip and palate. See Clell lip and palate.
Centers of rotation, 270-272 historical considerations. 202 etiology of. 197
Central odontogenic fibromas. 151 incidence of. 202 muttidisciplin<�ry care for. 198
Centric relation, 270, 275 management of, 202 Congen�ally missing teelh, 14-15
Cephalon1etric analysis. 9, 13f mullid•sciplinary inlervention for. 202-204. 203f Connective !issue graft. 145, 1461
Cephalometric radiographs. 296 pata1op11aryngeal incompeta.1ce secondary to, Connectors, 260, 2601. 288-287. 2871
Ceramics, 241 f, 241-243. 276, 278-279. 2791 302 Consonants. 20i. 295-298. 2971. 2991
Cerebral palsy. 3 1 3 pha1yngeal obturator for, 204-206 Continuants. 296
CEREC system, 279-280 prostheses for, 203 Conlours. of restorations, 254-255, 280-281
Cervical lymph nodes. 22, 221 prosthodont•c management of. 204-206 Contrast media
Cervical spine pain, 89-90 removable partial dentures for. 2031 cone beam computed tomography use of. 60
Charge-coupled dev•ce. 51 , 52f speech abnormalities secondary to. 301 magnetic resonance imaging use of. 63.
Chemical shifl, 63 surgi<'.al repair or, 306 63f-64f
Chemotherapy verttcal dimension or occlusion in, 205 Copy milling techniques. 246. 246f
adjuvant, 188 Clinicalslag ing,ltt-112 Cornell Medical ln<:Jex. t7
agents of. 188 Close bite. 300 Cortical grafls, 133. 145
clinicalapplications or. 188 Coagulation tesls, 20 Cortlccn

ca cellous grafts, 133
hypoSalivation caused by. 189 Coball-chrome allOys, 245 Corticosteroids, 39-40
induction. 188 CoeffiCients of thermal expansion. 237 . 241. 278 Cortisol, 73
•nlections caused by. 1�191 Cognitive-behavioral therapy, 75, 79 Craniofaciallrea�ent team, 198
mucosilis caused by. See Chemolherapy- Cold working, 244 Craniosynostoses, 7
induced mucosi�s. Color-coded 3D reformatting, 57 Cranium, 137
myeloablative. 165 Combination syndrome, 27f 28 , CREST syndrome, 47
principles of, 188 Comparative genomic hybri<fozation, 5, 51 Crossbite, 30, 301
radiation lherapy combined wilh, 188-189 Complementary metal-oxide-semiconductor. 51 Crown (anatomicaQ. 264-265
regimens or, 188 Complete blood oounl with difterential. 19-20, 191 Crown (resloratlon)
side effects or, 189 Composite autogenous grafts, 138 all-ceramic. 278f. 28t
white blood cell counts affecled by. 1 9 Composite grafts, 133 computer·aided design/computer-aided manLJ·
Chemotherapy-induced mucositis Composite resins, 234-236, 235t facture, 280f
amino acids for. 167 Comprehensive metabolic pane!, 20. 211 fuR C8St, 281
anti·i'lflammalory agents for, 1 67 Computed tomograplhy lengthening procedures, 281, 283
antimicrobial agents for. 188 cone beam. See Cone beam computed tomo· marg1n preparations. 281
cryclherapy for, 168-168, 190 graphy. metal-ceramic, 281
dietary recommendalioos, 188 equipment used in. 54, 541 porcelain·fused-lo·metal. 277
growth factors for, 167-169 magnetic resonance imaging versus, 61 relention and resislanCe form. 281-282
incidence of. 164-165 principles of. 54 Crown-to-root ratio, 284
low·levellaser therapy for. 168 spiral. See Spiral computed tomography. Cryotherapy. 1 6 8 - t 88, 1 90
melphalan for, 167 temporomandibular joint. 91, 921 C T numbers, 54
mouthnnses for. 188-169 Computer numeric conlrOIIed machining. 233. Cuberilles. 55, 551. 80
oral hygiene lor, 165-166 246, 2461 Cylindroma. 152
pain associated with. 169 Computer-aided design/computer-aided Cystic ameloblastomas. 150
palhophysiology of. 163-164, 164f manufacture. 57. 270. 279-280 Cytologic examination. 1 1 1
prevention or. 165-168 Condylar inClination, 27t
334 1
Index J
D supporting structure evaluations, 249-250 EnvelOpe of discrepancy. 12
Deglut�ion, 199-200 Denture base Envelope of motion, 286, 267f
DeluSiOrlS, 77 imtation beneath. 327 Epithelial rests of Malassez. 149-150
Dental anxiety. 72 materials for, 258-259 Epithelial tumors. 150-151
Dental caries. 174-175, 330 Denture design Inadequacies, 252-259 Epstein-Barr virus, t 91
Dental erosion. 45 contributing factors. 252 Epulis fissurata, 122
Dental malfOimations, 46. 461 dental materials, 258 Erythema muUff01me, 40, 401
Dental materials extension-related, 252-255 Erythroplakia. 35
acrylic resins, 234. 236-237, 260 overextension, 252-253, 325 Esthetic composaion, 2 4
advances in, 233 palatal re6ef. 258 Exostoses, 118
cemenis, 240, 240 t removable partial dentures, 259-261 External beam radiation therapy. 185-186
ceramcs. 2411, 241-243. 276, 278-279. 279t tooth position. 255-257 Extraoral examinahon. 22. 221-231
composite resins, 234-236. 235t underextension, 254
elastomers, 239 vertical di mensi on of occlusion, 258 F

fracture or. 330 Depression, 74, 74b. 78 Facebow. 271, 321f
history of, 233-234 Depth cuts, 2811 Facial degloving. 156
metal alloys, 234, 2431, 243-24 5 , 277 Diabetes mellitus, 48-47 Facial pain. 65
metal-<:eramic, 277, 277f DiagnosJC
r casts, ItO, 1101. 121 Facial paralysis, 227
nylon, 234 Dibut)'l phthalate. 236 Faraday cage, 61
polymers, 234-237 DigHat dental radiography, 51-52, 52f Fatimages,62
porcelain, 234 Digital panoramiC radiography. 52 Fat suppression, 62-63, 631
recommendatiorlS for, 258 Diphthongs 2g5, 295t
.
Fatigue. 77, 79
resilient liners, 237-238. 258f Disc displacement. 83 Fatigue Symptom Inventory, 79
selection or. 27 7-280 Disocclusion time. 276 FEEST,306
loolll preparation parameters for, 280-284 Dispersion strengthen<ng, 241, 241 f Fibroblast growth factor receptor genes. 7
Dentinogenesis imperfecta. 46 Distraction. 72 Fibrous dysplasia. 66
Dentin-resin bonding, 235 Oistlaelionosteogenesis, t28-t27. 1271, 138,1391 Fibular grafts, 138f, 158-15g, 227
Denti tior>. See alSo Teeth. DNA testing, 6 Fight or Hight response 72 .
examination or, 25-26 Down syndr o me. 6 Filiform papillae. 34

in function. 25-26 Drooling, 227. 324 Fischer angle. 267
Denture(s). See also Prostheses. Dry mouth, 48 Five.·Factor Model, 76
adverse tissve responses to, 250-251 Dual energy x-ray absorptiometry, 57 Fixed dental P<'OStheses
border thiCkness o1. 254 Dysarthria. 2g4, 313 abutment support for. 265f
eating with, 323 DyskeratotiC cysts, 3 complex, 288-289. 2881
extension of. 252- 253 Dyskinesias, 42 complications associated with. 27&-277. 285,
external contours of, 254-255 Dyslafia, 294 329-330
fixed partial. See Fixed partial dentures. Dysphonia, 294 dental caries effect on, 330
ill-fitting . See Ill-fitting dentures. design of, 284-289
immediate, 121 E metal-ceramic. 287
inadequate design of. See Demure design in· Eating disorders, 44-45 outoomes of, 276
adequacies. Ectodermal dysplasia, 1071 path of insertion, 285, 2851
insertion ol, 320-323 Edatrexate. 166-167 pontiC, 285-286. 286f, 286t
intagli o surface of, 249-250 Edeniulism, 115-116, 142-143 support for. 284-285. 2651
lOss of reteo1tion and stabaity. 326-327 Edentulous mouth, 28-34 zirconia framework, 2871
mandibular. See Mandibular denture. Edwards syndrome,6 Fixed partial dentures
maxllary. See Maxillary denture. Elastomers. 239 abutment al,gnment effects on. 1 0 0
nighttime removal or. 323 Electromyography, 80 ceramics for, 278
occlusal discrepancies during insertion of, Electrophoretic fe
i ld. 5 implant-supported, 218
321-322 Emotional d istress. 73-74 porcelain-fused-to-metal. 2411
occlusal force effects on, 251 Enamel wear, 274 tooth stabilization using. 102
overdentures. 1061 Endoalveolar crests,33 Axed prosthodontics. 278-277
pa«ent instnJCtions regarding, 322--:323, 3231 Endodontically treated teeth, 283-284. 284f Flowmeter, 304
postinsertion phase of. 324 Endosseous implants Fluconazole, 190
in radiat
o
i n therapy patients, 1 74-175 biomechanical factors related to, t 08 Fluorescence in situ hybridiZation, 4. 41
rebasing of, 237 descnptlon of. 128 Fluoride, 48
remounting of. 322 hard tissue defects, 144-145 5·Ruorouracil, 164-166, 1651
removable partial. See Removable partial history of. 106 Food reduction, 199-200
denture. mandibular reconstruction use of,224 Forehead tlaps, 157, 15 9
retention of , 326-327 paroal edentulism treated with, 142-143 Fovea palatinae, 253
soft lining materials for, 238 soft tissue recession adjacent to, 330 Fractionation, 185
tooth stabilization using, 101 Fracture stren gth, 243
335
i Index
Fractures, 56, 56f recall examinations for, 228 lmplant(s)

Frankfort horizontal line. 9 reconstrvclion after. See M andibular recon· bone and soft tissue classification systems, 34
Frena. 33, 331 struction; Maxillolacial prostheses. bone volume for, 130-131
Fren ectomy, f 18-119, 119! sites of. 183 computed tomography before, 1301
Fricatives, 296-299, 297t, 299f staging of, 184, 1841-1851 cone beam computed tomography used lor
Functional rehabil�ation. 220 surveiDance fo r, 228 site assess ment. 60
Fungal infections, 190. 191b survival rate for. 183. 184t �osseous. See Endosseous implants.
Fungiform papillae. 34 TNMstagingof. 184,184t-185t failure of, 34
He d
a and neck tumors. 201 fixed restorations supported with, 109f
G Hear ing loss, 312-313 functions of, 106
Gado linium, 63 Heat temperature vulCanizing silicone, 238 history of, 141
Gastroesophageal reflux ctisease, 45-46 Hemangiomas,66, 67f imrnediate placemenlof,34, 121.126,141,227
Generalized anxiety disorder. 74-75 Hemoglobin A1c. 47 in terstitial radiOactive. 170

Genetic counse5ng, 3-4 Hemostasis tests. 20 long·term success of. 106
Genetic screening, 3-4 Her pes simplex virus, 166, 1g1, 1 911 magnetic resonance imaging uses for. 64
Genetic testing, 4-6, 4f-5f Heterogenous bone grafts, 132. 1321 maxillary, 130
Genetics. 1-3 High·dcse·rate brachytherapy. 186 osseointegrated. See Osseointegrated
Ger�ial tubercle, 28, 33 History taking, 17-19 implants.
Gingiva. 259. 265 Hounsfield untts. 54 postradiation therapy, 192, 227
Ging1vitis. 41-42. 265f Human contrast sensitivity. 52 root uprighting adjacent to site of, 13. 14f
Gtass·1oncmer cements, 240 Human papilloma virus. 35 site development or. 141
Glassy ceramics. 278. 279t Huntington d•sease. 42 spiral computed tomography used during
Glottal consonants, 298 Hybrid composite resins. 235. 235t placement of. 56-57
Glutamine. 167-168 Hybrid ionomer cements. 240 treatment planning tor. 128
Gorlin syndrome, 3 Hydroxyapatite. 133 Implant dentistry. 106
Grafts Hyperbaric oxygen therapy, 153. 191, 214. 226 lmplant·reta1ned overdenture. 106f
barrier membranes with. 143 Hypertractionation, 185 lmplant·supponed fixed partial dentures, 218,
bon e. See Bone grafts. Hyperintensity, 62 330
composite autogenous. 138 Hyperkeratosis, 251 Incisal edge Intactness, 300
connective tissue. 145. 146f HypemasaBty, 302, 304 Incisive papiRa, 32, 256
skin. See Skin grafts. Hypersalivation. 43, 324 Induction chemotherapy, 188
GranulOcyte colony-stimulating factor. 167 Hypointensity, 62 Infections
GranulOcyte macrophage colony· stimulating Hyponasality, 310 bacterial, 190-191
factor, 167, 111 Hyposalivation. See also Xerostomia. fun gal, 190, 191b
Granulocytes, 19 chemotherapy-induced. 189 magnetic resonance imaging of. 67
Grayscal e standard display function, 52 descripti on of, 43-44, 48 viral, 1 91
Growth factors, 167-169 radiation therapy-induced, 187 Inferior alveolar nerve, 130, 1301
Growth pattem Hyposmia, 35 Inflammatory papiDary hyperplasia, 105, 251
alterations in, 273 Inflammatory meumatic diseases, 44
s ent of, 9. 101

anteroposteriOr assesm I Informed consent. 35-36
assessment of. �10. 1Of Inheritance patterns, 2-3

latrosedation, 72
dental relationships affected by. 11-12 Intaglio surface, 24g-250, 254-255
Iliac ccest
three--dimensional assessm ent of, 10, 11 f lntenstty-modulated radiation therapy, 44, 186
anterior. 134. 136
transverse assessment of, 10 Interdental distance. 1 30
oone grah harvesting of. 134, 136-137.
vertical assessment of. 10. 101 Interdental papillae. 265, 2651
136f-137f 15g .
Growth status. 12-13 ln1erferon·n, 4 8

interposiliOnalllloCk gran or. 126. 1261, 128
Guided 1magery, 72 lnterincisal space, 15
lll·fitting dentures
International normalized ratio, 20
1
Guided tissue regeneration, 143-144 adverse tissu e responses. 25o-251
lnterocclusal distance. 270
clinical eva lua1on of. 24�250
H laCk of retention, 251
lnterpositi:lnaliliac crest blOCk graft, 126, 1261. 128
tnterslllial radioactive implant. 170
304
HalluciJlations, 77 occlu sion, 251
Intraoral breath pressu re
Hanau Quint, 268, 268f supporting structure evaluations, 24�250
,
32.
Intraoral examination
Hard palate. 215, 229 Images
dentition, 25-26
lateral throat form.
Head and neck cancer capturing of. 51-52
29f. 29-30
chemotherapy for. See Chemotherapy. compression ol, 53
mandibular ridge, 26-28
mucosa. See Mucosa.
descripion
t or. 192 display of. 521, 52-53
disabiity concenns. 220 storage of, 53
oral caVIty. 23. 24f
epidemiology of, 183t, 183-184 transmiS sion or. 53-54
palate, 28-30, 2 9!. See also Hard palate: Soft
metastasis contrOl, 220 fmmediatedenture. 121
palate.
radiation therapy lor. See Radiation therapy. Immediate loading, 141
tongue, 23, 311. 31-32
336 1
Index J
Iowa Pressure Articulation Test. 303 hypointensity, 62 reconstruction of. See MandibLdar
lsointens�y. 62 implant uses of, 64 reconstn;ction.
infections, 67 rehabilitation after. 160
J isointensity. 62 resection of. See Mandibular resection.
Jaw. osteonecrosis of, 43. 153 192 ,
malignancies evaluated with, 65-66 trauma-related. 153
Jugulodigastric node, 64f oral and maxillofacial uses o f , 64-67 treatment of. 155. 1561
risks associated with, 61-62 Mandibular denture. See alSo Denture(s).
sialography 67 anterior tooth positi on in, 256
K
,
temporomandibular di s orders 87 border t hickness of. 254

Ka,yotype.
,
2f
temporomandibular joint on, 64, 651, 84f external contours of. 255
Keratlnocyte growth factor, 167, 171
terminology assoca i ted with, 62-63 insertion of , 320..323
T1-wei9hted, 62 , 621-631. 66 ooctusat plane considerations, 256-25 7
L
T2-weighted. 62. 621-631, 66 overextension of. 253
Labiodental consonan1s, 297, 2g7f
vascular lesions. 66-67. 671 patient factors that affect. 327
Laboratory tests
Major depressive disorder, 74. 74b posterior tooth position in. 256-257
coagulation studies, 20
Malignancies. See also Head an d neck cancer. underextension or. 254
complete blood co unt with differential, 19t,
magnetic reSOrlance imaging or. 65-66 Mandibular discontinuity. 223
19-20
oral involvement of, 1 52 Mandibular incisors. 256
comprehensive metabolic panel, 20, 21t
spiral computed tomography imagong of, 56 Mandibular inferior border grafting, 125f
hemostasis, 20
Malignant lesions, 35 Mandibular plane, 1 0
intematiorlal normalized r atio . 20
Malnutrition, 45 Mandibutarramus graft, 133-134. 1351
prothromb in time. 20
Malocclusions. 273. 299-300 Mar>dibular reconstn;ction
Lateral cephalometric radiograph, 9, 1Of
Mametons. 25 complications of. 227. 2281
Lateral condylar movement, 267
Mandible delayed. 226-228
Lateral rhinotomy. 156
atrophy or. 1 24f immediate, 226-228
Lateral tnroat form. 29f. 29-30
biomechanics of. 264 intraoral acquired defects. 227
LAVA Chairside Oral Scanne r. 280
bonY defects in, 144 maxillotaciaJ prostheses fo r. 2221-223f, 222-224
Law of Tension-stress 138 .
eccen trici ty of, 266-270 microvascular flaps for, 15 8f. 158-159

Leuci te, 242. 274
envelope of motion, 286, 267f mucosal adVancement flaps lor, 157
LeukoPlakia. 35
examination of. 86-87 particulate cancellous bone marrow for.
lingual frenectomy. 119
masticatory function of. 264 225 226
-
lingual tori. 26. 28f

maxilla and, anteroposterior as�nent ol. 9, 1 Of plates f or, 225. 2251
linguoatveolar consorlants, 297f, 297-298, 299f
movement patterns of, 26, 264, 286 prostheses for, 226, 226t
linguodentat consonants, 297. 297f
osteotomy resectioning of, 125, 155 re<Jionalllaps for, 157-158
linguopalatal consonants. 296, 2991
pas Sflle stretch of, 85f skin graft1ngfor. 157
l..inguovelar consonants, 298, 299 1
radiation therapy tolerance of, 175 transposition naps tor, 157
Lining mucosa, 33-34
recons truction of. See Mandibular Mandibular resection
linkage analysis, 5
reconstruction. defects secondaly to, 224
lip swftch vestibuloplasty, 1 2 1 l
rim resection. 222 mandibular defects treated wfth, 125. 155,
uquids. 296
scft tissue examinato
i n of, 154 223f, 229
Litigation. 90-91
squamous ceo carcinoma of, 65. 2231 posterOlateral, 2251
Long centric , 276
Mandible-tongue defects, 222-223, 2221-2231 swallowing assessments alter. 224
Lossless file system. 53
Mandibular arch Mandibular ndge. See also Alveolar ridge.
Lossy file system. 53
alte<ations of. 275-276 augmentation of. 124f. 124-125
Lou Gehrig's disease, 47
size of. 26 external oblique, bone g rafting of. 134, 135f
Low·dose-rate braehytherapy, 186
Mandibular defects form of. 26-2 7. 27f
Low-levellaser therapy, 168. 1 71
catc�ying epithelial odontogenic tumors, 150 loss of. 28
description of, 149 resorption of. 26. 99
M etythroptakic leSIOn, 2261 U-shaped. 26-27
Magnet, 61 etiology of, 149-154 V-shaped. 26-27
Magn et1 c resonance imaging Mandibular symphysis, 1 33. 1341
evaluation or. 154-155
art�acts associated with, 62
full-thickness. 158 Mandibular vestibuloplasty. 123
blood oxygen level dependent. 65 imaging of. 154-155 Mandibulectorny, 155. 1561
comp uted tomography versus, 61 Intraoral acquired, 227 Manometer . 304
contrast media used in, 63, 63f-64f mesenchymal tumors, 151 Marian syndrome. 1
descrip1ion or. 60-61 mixed tumors. 151 Marginat9ingiva. 265
disadvantages of, 61-62
odontogenic tumors. 149-151 Marginal mandibutectomy, 155
equipment fo r, 61 osteonecrosis. 43. 153 Margi11s. 281, 2631
fast asymmetric spin echo. 86 patient education about. 160 Masticato
i n. 199-200. 263-264
rat suppressoon, 62-63. 63f
radiographic evaluation or. 154 Masticato,y mucosa. 32-33. 32f-33f
hyf)E!fintensity, 62 Masticato,y muscl es. 86
337
i Index
Masticatory pain, 73, 88 interim care for, 210-212, 21 1b Mucous membrane pemphigoid, 39-40
Maxilla Intraoperative care for, 210 Multicolor fluorescence in situ hybridization, 41
atrophy of, 136f jaw relationships, 219 Multidimensional Fatigue Symptom InventOry, 79
edentulous, 1051 mandible·tongue detects treated wit11, 222- Multidisclp6nary team, 149
hOrizontal measurements or. 1161 223. 222f-223f Multifactorial disorders. 3. 3t
mandible and, ante<'oposterior assessment of, mandibUlar defects treated with. 224 Multiplanar refO<matting. 55-56
9, tOt maxillary detects treated w�h. 220-221, 2211 Mutually protective complex
pneumatization or, 125 obturator, 216. 219 characteristics of. 263
primary reconst<uction or. 159-160 oral hygiene for. 213-214 factors that affect. 272-273
radiation tl'le<'apy tolerance of, 175 preoperative care for. 21 0 normative values of, 263-272
resectlon of. 156-157 summary of. 228-229 prosthodontic techniQues for restoration of,
resorption of. 28, 144 timing of, 210-226 272-273
squamous cell carcinoma of. 2121 tooth arrangement. 219 stomatognathie function, 263-264
Maxillary antral leSions. 57. 57f z•roonium oxide framewotl< for. 2421 Myastherua gravis, 207
Maxillary arch. 32f Maxillofacial prosthodontics, 198 Mylohyoid ridge, 33
Maxillary detects Maxillofacial surgery, 208-209 Myofascial pain, 85, 276
ameloblastoma, 150f Maxillomandibular recordings, 270
description or. 149 Maxillomandib\Jiar relationships N
etiology of, 14�154 classification of, 30, 30f Nanofllled con1posite resins. 235t, 235-236
evaluation of. 154-155 description of. 27 Nasal airflow measurements. 304
imaging of, 154-155 Maximal intercuspation. 265, 274-276 Nasopharyngeal area. 23
miXed tumors t 51, Median palatal raphe, 32 Nasopharyngoscopy, 307...00 8. 3081-309i
osteonecrosis, 43, 153 Mesenchymal tumors, 151 NeCk
osteosarcomas. 151, 1511 Metal alloys. 234, 243f, 243-245. 277 lymph nooe of, 2091
patient education about. 160 Metal-ceramic materials palpation of. 221. 209f
radiographic evaluation of, 154 description of, 2 77, 2771 Neuroma, 631
reconstructJon of, 159-160. 220-221 failure of. 3301 Neutropenia, 20
rehabilitation after, 160 fil<ed dental prosthesis fabricated from, 287 Neutrophils, 19-20
resection of. 156-157 Metastases. 152 Noble metals, 244, 277
l!auma-related, 153 Microlilled composite resins, 235, 235t Nonaulogenous bone grafts. 143-144
treatment of, 156-157 Microhybrid composite resins, 235, 2351 Nonreducing disc displacement. 83
Maxillary denture. See also Denture(s). Microvascular flaps. 158f. 158-15g Nuclear factor kB, 163
anterior tooth position in, 255-256 Minnesota MlAtiphasic Personality lnventory-2, 78 Nylon, 234
border thickness of, 254 MitochOndrial pattern, 3t
0
external contours of, 255 Mixed tumors, 151
tnsertion of. 320-323 Molar uplighting. 13
Obturators. 204-206. 216. 306.328-329
overextension or. 253 MoMors, 52f, 52-53
Occlusal contact areas. 199
underextens10n of, 254 Monoamine oxidase inhibRors. 74
Occlusal cupping, 45
Maxillary fibrous dysplasia. 551 Motor vef11cle accidents. 90, 153
OccluSal plane, 15. 1011. 256, 270
Maxillary Incisors. 255-256 Mouthrinses
Occlusal relationships
Maxillary labial frenectomy, 118-119, 119! benzydamine hydrochloride, 167, 170
alteration of, 12
Maxillary ridge. See also Alveolar ridge. chlorhexidine. 169, 190
growlh pattern effect on, 11-12
augmentation of. 125-126.1261 mucositis prevention and treatment using.
Occlusal rests. 260, 2601. 327
bulbous. 28, 28f 168-169. 190
Ooctusat wear. 2 5. 261, 2691, 273-274
Maxillary stnus Mucobuccal told. 33
flap, 133
Occlusion
elevation procedure Mucoperiosteal
antenor determinants of. 267-268. 2671-2681
allogeneic bone graft for, 132. 132f Mucosa
balanced articulation scherne, 267-266.
Illustration ol, 1261 lining. 33-34
2671-2681
mucosel squamous cell carcinoma ol. 152 mas1•catory. 32-33. 32f-33f
determinants of, 266-268. 267t. 2681
Maxillary tuberosities, 134, 135f, 326 specialized, 34
discrepancies in, 321-322. 326
Mucosal advancement flaps, 157
and, 266
Maxillary vestib!Joptasty, 1211
mandibular movements
Maxillectomy, 2151. 220 Mucosal squamous cell carcinoma. 152
posterior determinants ot. 266-268. 267t, 2681
stability of, 276
Maxitloiacial fractures. 56. 56f Mucositis
Maxilloiacial prostheses chemotherapy-induced. See Chemotherapy-
vertical determinants of, 270. See also Vertical
combination therapy for. 2 14 induced mucOSitis.
dimension of occlusion.
complications of, 212-213 dietary recommendations, 168, 172
OdontogeniC myxomas. 151
defects, 213-214 oral hygiene for. 165-166, 172
OdontogeniC tumors, 149-15 t
defll'litive care, 219-220 patn management. 190
Odontomas. 151
design of, 215-220 radiation-induced. See Radiation therapy,
Ohngren's classilication, 112
hard palate considerations, 215 mucositis caused by.
338 1
IndexJ
6hngren's line, 111f Outcome·guided treatment planning. 98 Palau syndrome, 6
Onlay grafting, 124-125 Ova te pon�c. 286, 2871 Patchy pseudomembranous muoos�is. 169
Oral ancl maxillofacial radiology Overdentures. 106f Patient-based outcomes. 98
ambient lighbng during, 53 Ove.exte�slon of dentures. 252-253. 325 Pectoralis Hap. 158
description of. 51 Overtaperi ng, 281 Pentoxifylline, 167. 175
digtal dental radiography, 51-52. 52f Periapical cementoosseous dysplasia, 151
di(jtal panoramic radiography, 52 p Pen·implant bone loss. 1091
images. See Images. Pain PeriOdontal disease, 48. 1031
Oral aperture, 26 aggravating factors. 18 Periodontal ligament, 105, 265
Oral cancer. 35 characteristics or. 18 Periodontitis, 4 7
Oral candidiasis, 172 h1story taking. t 8 Periodontium, 25. 265-266
Oral cai/Uy examinatiOfl, 23. 241 management ol, in radiation therapy, 170-171 Periotome, 123. 1231
Oral defects mucositis·related, 169 Peroral viev�ng. or palatopharyngeal valve. 303
acquired orofacial. See Orofacial pain. Personality. 76
congenital deficiencies. 206-228 Pain Anxiety Symptoms Scale, 78 Pharyngeal obturator, 204-206. 216, 306
cosmetic i mpact of. 227 Palatal lilt, 207-208, 311 Pharyngeal wall movement. 201
etiology or. 1g7 Palatal mucosa Phenolate·based cements. 240
multidisciplinary care for, 198 d escriptio n of, 105 Phob<a, 72
pal<ltal lifl for. 207-208 grafts of, 120, 1201 PhOfla�on. 293
con genita l Palatal refief. 258 Phonemes, 295, 298, 303
Cleft lip and pala te. See Cleft lip and palate. Palatal stents, 145 Phosp hate monomers. 238
etiology or. 197 Palatal tori. 28. 118 Photostimulable storage phospl10r system. 51. 521
mul11disciplinary care for, 198 Palate Phototherapy, 39-40
max�lofacial pros theses for. See Maxillofacial augmentation prosthesis far. 222 Physical examination
prostheses. deft. See Cleff ip and palate. extraoral, 22, 221-231
Oral hygiene examination of, 28-30, 29f intraoral. See Intraoral examinati on.
dentures, 323 hafd, 32, 215, 229 salivary glands, 22. 231
maxillofacial prostheses. 213-214 papilary hyperplasia in, 121-122 Physical seff·regulation. 79-80, 92
mucOSiti s managed with, 165-166, 172 soft. See Soft palate. Physiologic rest position, 270
Oral lichen planus. 39-40. 40r Palatine aponeurosis. 2g PictureArchiving and Communication Systems. 53
Oral squamous cell carc<nomas, 35 Palatography, 296 Pier abut ments. 289
Oo
r facial dyskinesias. 42 Palatopharyngeal closure Pilocarpine, 48, 173
Orofacial pain description o l , 2<>0-201, 205f Pindbor9 tumors. 150
anxiety associated witl1, 75 muscles tnvolved in, 301 Pitch, 54
b<QPsychosocial approach to, 78 Palatopharyngeal competence Pittsburgh Sleep Quality Index, 79
emotional distress and, 73-74 description ol, 221 Plasticizers. 238
epidemiology or. 83 evaluation of, 303-306 PolycryStalline ceramics. 278
psychologic disturoances with, 73 lateral radiographs of. 304-305 Polymerization shrinkage, 236, 238
psychologic factors in, 72-77 Palatopharyngeal incompetence P�. 234-237
stress and, 73-74 causes of, 302 Polymethyl methacrylate. 233. 236
Oromandibular dyskinesias, 42 Cleft tip and palate as cause ol. 302 POfltics. 285-286, 286f, 286t
Orthognathic surgery, 127-128 description or. 301-302 P()(celain·tused·to·metal restorations
Osseointegrated implants prosthetic management of ClOWn, 2771
hard t1ssue defects. 144-145 fabrication coosiderations, 310-311 fiXed part<al denture, 241f
maxfilary defect treated wit h, 2181 indications for. 306-307 Posrtioning stents, 178, 1781
overview or. 141-142 nasopharyngoscopy in. 307-308.3081-3091 Post and core, 283-284, 2841
Osseointegration. tOO,141 speech effects. 309 Posterior edentulous areas. 10 1
OsteocOflduction. 131-132 speech effects, 302 Posterior teeth
Osteogenesis, 131 Palatopharyngeal insufficiency, 207 chewing patterns of. 263
Ostea<ncluction, 132 Panendoscope, 303 mandibular, 258-257
Osteomata, 1 Papilary hyperplasia. 121-122. 251 maxillary. 2161
Osteomyelnis. 154 Parafunctional habits, 85. 276. See alSo Bruxism. Posttraumatic stress disorder. 75-76, 76b, 79
Osteomyocutaneous flaps. 214, 215f Parap11aryngeal fat. 621 Precipftation hardening, 244
Osteooecrosis or the jaw, 43, 153. 192 Parasymphyseallracture, 1421 Pregnancy gingivftiS. 41-d2
OsteoporoSis, 42-43, 57 Parkinson disease, 4 2 Pregnancy tumor, 42
Osteoradionecrosis, 153, 175, 1871. 188-189, 191 Parotid duct, 22 Premafignant lesions. 35
Osteosarcomas. 151, 1511. 176 Parotid gland. 64f, 172 Premylohycld eminence. 253-254
Osteotomy, mandibular Partial edentulism, 142-143,275 Preprosthetic surgery
prosthetic management after, 222 Particulate cancellous bone marrow, 225-226 alveoloplasty, 116-118, 1171
resectionilg uses of, 125, 155 Passavant's ridge, 201. 308 buocaJ lrenectomy. 119
339
i Index
description of. 115 Radiation therapy Removable partial dentures

max>lary labial frenectomy, 118-119. 119f bone sarcomas caused by, 176 base of.261.327
ridge procedures. See Alveolar ridge. brachytherapy, 177-178.186 clasps, 259. 259f, 261
scar oontractures in vestibule treated wll.h. 120. chemotherapy combined with. 188-189 cleft lip and palate, 2031
1201 dental extractions before, 189 design inadequacies and errors, 259-261
simple extracti ons. 115-118 external beam, 185-186 gingival inflammation caused by, 25g
Preprosthetic vestibuloplasty. 9 9 implant therapy after. 192.227 inju ry caused by. 269-260
Progressive dlsooclus ion , 288 intensity-modulated, 186 1118j0r connectors.260. 260f
Progressive systemic scle(osis, 47 mucositis caused by in maxillofacial defect patients, 228
Proportional limit, 243 description of. 187f minor connectors, 260.2611
Prostheses. See also Denture(s). dietary recommendations. 172 occtusal rests. 260, 2601
age of patient and.310 etiology of. 169-17 in posterior edentulous areas. 101
0
esthetic considerations, 324 low-level laser therapy for. 171 problems assoc<ated with. 327-328
fabrication considerations, 310-311 oral hygiene for. 172 rests, 260-261, 2601
fixed dental.See Fixed dental proslheses. pain associated with, 17(}.171 ridge resorption and, 131
insertion of. 320-323 patchy pseudomembranous. 169 splinting use of. 101
1rritallon caused by. 324-326 prevention of. 170-172 stress management for. 261
maxillofacial. See Maxillofacial prostheses. severity factors. 169-170 bssue Irritation caused by.327
palatal tift. 311 treatment of. 17(}.172. 190. 190b tooth mobility, 259
phonetics affected by, 324 oral complications of tooth-supported, 261
postinsertion phase ot. 324 bone necrosis. 175 Resection
problems with. 324-327. 3291 dental caries, 17 4-175 mandibular. See Mandibular resection.
speech affected by. 301, 324 infections. 190-19 t maxillary. 155-157
taste sensation alterations caused by. 35 malignancies, 176 Resilient liners. 237-238, 2581
tissue response to, 24, 324-326 management of, 189-192 Resin bonding
Prosthodontics mucositis. See RadiatiOn therapy.mucositis to dentin. 235
case example of, 16f, 91-92 caused by. to prosthetic materoals, 238
cleft lip and palate managed wnh. 204-206 osteoradionecrosis. 153.175. 187f, 188- Resonance.293-294
malaligned teeth treated with. 273 189. 191 Restspace.270
objectives of.319 prevention of, 177-178 Restorations.See also Denture(s); Prostheses.
orthodontic procedures to support, 13-16 soft tissue necrosis 175 biologic attachment of, 281-282
outcomes of, 275-277 taste alterations. 176 con tours of. 254-255. 290-281
,
speech effects of, 309 treatment of, 177-178 endodontically tteated teeth, 283-284, 2841
temporomandibular disorders and, 91-92 ltismus, 176, 191-192 margin location. 281-282
Ussue conditioning for.319, 3201 xerostomia. 172-174. 186, 189-190.214 retention and resistance form of. 282-283
Prothromb1n time, 20 pa�n management during, 170-171 toott> preparation parameters for, 280-284
Proximal tibia, 137. 137f positioning stents. 178 178f Restorative materials. See Dental materials.
Psychologic factors pretreatment considerations, 189 Reslfiction-fragment polymorphism analysis.5
,
anxiety. See Anxiety. principles of, 184-185 Rests of Serres, 149

assessment of.78-80 salivary glands affected by, 172, 186 Reticular lichen planus, 39, 401
behavioral treatments for, 79-80 shielding stents. 177. 178f Retinoids, 3 g
bipolar disorder, 77 side effects of, 186-188 Retrognathia, 257
depression, 74, 74 b. 7 8 thyroid tumors and, 176 Retron1olar
pad, 33
fatigue, 77. 79 tongue depressing stents.171. 1711. 177. 177f Retromy!ohyo1d eminence, 253
in orofacial pain, 72-77 lJeatm ent planning for, 171 Retroorib�al pa1n. 154
posttraumatic stress disorder. 75-76, 76b. 79 wortd Health Organization scale for. 187b Reversible putpitis.329
role ot, 71-72 Radiation-Induced hyposalivalion. 44 Revised NEO Personalny Inventory. 76
schizophrenia, 7 7 Radical alveoloplasty, 117 rihBMP-2, 143f, 145
sleep disturibances. 77, 7g Radiofrequency COlis, 61 Rheumatoid arthritis. 44
temporomandibular disorders, 89 Radiography Ridge.See Alveolar ridge: Mandibular ridge:
treatment-related 8J1xiety. 72 cone beam computed tomography versus. 60 Maxillary ridge.
Pterygomandibular raphe. 33 digital dental, 51-52, 52f Ridge lap pontic. 285-286. 286f
Plel)lgomaxillary notch. 29 digital panoramic. 52 Rim resection. 222
Pulp chamber, 265 mandibular clefects evalUated with, 154 Room temperatl.l'e vulcanizing silicone. 238
Pulpal health, 329 maxillary defects evaluated with, 154 Root
Pulsed uhrasound. 306 Ret>asing, 237 anatomy of. 102. 265
Pulsed-dose-rate brachytherapy, 186 Reducing disc displacement.83-84 configuration of, 102-103
Regional flaps, 157-158
R Regionallymp11 nodes. 66, 66f 5
Radial forearm free flap, 159 Rehabilitation. 97, 160 Saliva
Relaxation. 72.80 flow of, 22-23
34 1
0
IndexJ
functions of, 43 incisal edge intactness effect on. 300 Stress (emotion), 73-74
Salivary glands inteligence effects on, 312 Stress (mechanical). 261
amaostine effects on, 173-17 4 ma locclusion effects on, 300 Subepithelial oonnective tissue graft, 145, 146f
dysfunction ol, 43-44 motor processes involved in, 293-294 Subgingival margins. 281
maHgnancies of, 152 obturator placement for optimal improvement Submandibular gland, 22
neoplasms of, 67 of, 310-31 1, 328 Submaxillary gland, 231
parotid gland, 641, 172 palatopharyngeal incompetence effects on, 302 Submucosal cleft, 2061
physical examination of, 22-23. 231 pt1ysi0logy or. 201 Submucosal vestibulopl asty, t20. 1211
radiation thei'apy effects on, 172 prosthesis effects on, 301, 324 Sucralfate, 171
Sanitary pontic, 2871 prosthodont!c tteatment effects on, 309 Supragingival margin, 2831
Schizophrenia, 77 psychosocial factOfS that affect, 313-314 Swallowing. 2001. 20G-201, 208, 224
Scleroderma, 47 socioeconomic status effects on, 314 Swallowing threshold, t99
Segmental mandibulectomy, t55, t561 sounds of. 294-295. 2951 Symbolization. 293
SelectiVe serotonin reuptal<e inhibrtors. 74 symbolization, 293 Symptom Checklist-90. 78
Semiadjustable articulators. 27t testing of. 303-306 Systemic conditions
Shared decision making, 98 vatving luncfion involved in, 294 amyotrophic lateral sclerosis, 47
Shielding stents. 171-t72. 177, 1781 Speech therapy. 314 anorexia nervosa. 44-45
Sialography, 67 Spiral computed tomography bulimia nervosa, 44-45
Silicone soft liners. 238 bone mineoal density detenninations, 57 burning mouth syndrome, 41
S1mp1e extractiOns, 116-118 cOlor-coded 30 reformatting, 57 dental malformations. 46
Sinus elevation cone beam computed tomography versus. diabetes mellhus. 46-47
allogeneic bone graft for. t 32 . 1321 58-60 dyskineslas. 42
proce<ture 104', 126f definition of, 54 eatu1g disorders, 44-45
Sj6gren syndrome, 4 t 44 • functions of, 56-57 gastroesophageal reflux disease. 45-46
Skeletal anchO<age, 15-t6. 16f imp!ant placement uses of. 56-57 Huntington disease. 42
Skin cancets. 152 indications For. 56 mucous membrane pemphigoid. 39-40
Skin grafts limitations of, 55-56 oral liChen planus, 39-40
mandibular reconstl\lction uses of. 157 low sensitivity of, 56 osteonecrosis of the jaw. 43, 153. 192
spit-thickness, 120. 120f, 122. 145, 21o-211 Navigator function in, 5 7, 57f osteoporosis, 42-43. 57
Sleep principles of. 551 Parkinson disease, 42
bruxism during. 85. 88-89 streak artaacts associated whh. 56 scleroderma, 47
disturbances of. 77. 79 three-dimensional reformatting, 55. 551 Sj6gren syndrome, 41, 44
Soft palate volume rendering uses or, 57 systemic lupus erythematosus. 41, 44
anatomy of, 29 Spirometer, 304 Tourette syndrome, 42
bulbar paralysis of, 2071 Splints, 88 vesiculoerosive conditions. 39-41
classification of. 29 , 291 Split-thickness skin grafts. 120. 1201. 122. 145, System1c lupus erythematosus, 41, 44
congen ita l shortening of, 302 21Q-211
musculature of, 22t, 294 Squamous cell carcinoma T
in swaRowing, 200, 2001 C04'nputed tomography of, 1541 Taste
Soft tissue(s) follow· up for, 228 description of, 34-35
characteristics of, 104-105 laryngeal, 66 radiation therapy-induOed alterati0f1S to, 176
conditioning of, 319, 3201 magnetic resonance imaging of, 65 Taste buds. 34f. 34-35
defects of, 145-146 mandibular involvement of, 65, 223f Technetium 99m bone scan. 9 1
hypoplastic, 129 of maxilla, 2 1 2 1 Teeth
innervation in, 105-106 mucosal, 152 anterior. See Mtenor teeth.
necrosis of, 175 pharyngeal. 66 crown of, 264-265
pontic effects on. 286 radiograph of, 154f d•Stribution. 1OQ-102
reconstruction of, 160 tongue, 152f, 2091 dl\lg-induOed intrinsic discolOration of, 46-49
responses of, 104-105, 286 Staging loss of, 272-273, 275
Soft tissue nap, 117 American JQjnt Committee on cancer, 184, 185t posterior. See Posterior teeth.
Space Clinical, 111-1t2 preparation parameters for. 28o-284
consolidation of. 14. t4f head and neck cancer. 184, 184H85t pulp chamber of, 265
creation of. 14-15 TNM. 112.184. 1841-185! stabilization of, 102
Specific language disability, 313 Stannous fluO<ide, 214 structural alterations. 273-275
Speech State·Trait Anxiety Inventory. 78 wear of, 2691, 273-274
cleft lip and palate effects on. 301 Stensen's duct, 22 Teteradiology, 53
C04'npensatory mechanisms involved in. 294 Sternocleidomastoid, 209 Temporalis flap, 157, 159
consonants of, 201, 295-298, 2971. 299f Stevens-Johnson syndrome, 40 Temporary anchorage devices. 15-16, 16f
dental oonditions that affect, 299-301 Stomatognathic function, 263-264 Temporomandibular disorders
development of, 3t 2 t, 312-314 Strain, 243, 2431 aural symptoms. 8g
hearing loss effects on. 312-313 Streak artifacts, 56 Axis I, Group t, 85-86, 851
341
i Index
Axis I, Groups II and Ill. 86 Tori v

cervical spine pain and, 89-90 definition of, 118 van der Woude syndrome. 41
classification of, 84-86 lingual. 28, 281 Velo-cardio-facial syndrome, &-7, 7f
clinical history of,8 6 mandibular. 134. 1351 Velopharyngeal closure,310
diagnosis of,86t-87t, 87 maxillary. 118, 1181 Veneers,2421. 3291. 329-330
epidemiology of, 83 palatal,28, 118 Vert1cal dimension of occlusion
etiology of. 87-88 removal of, 118 assessment ot, 270
examination of. 86-87 Tolal occlusal convergence, 281, 285 in cleft lip and palate, 205
imaging of,87 Tourette syndrome, 42 description of. 23. 270 320
,
incidence of. 72 Transcervical resection, of mandible, 155 establishing of, 258

litigation and. 9(}-91 Transoral resection, 155-156 toss of. 275
magnetic resonance imaging of. 87 TranspoMion Raps, 157 occlusal plane localion, 257
motor vehicle acc,dents as cause of. 90 Trapezius flap. 158 restoration of , 205. 276
pain associated with. 83-84 Trauma Vertical excess,11
prevalence of. 83 mandibular and max�lary defects caused by, i53 Vertical insufficiency,128
prosthodontics and, 91-92 occlusal, 103f Vertical mastication, 25
psychologic factors associated with. 8 9 Treacher Coltms syndrome. 7 Vesiculoerosive conditions, 39-41
sell-care tor. 92 Treatment planning Vickers hardness. 277
splints for. 88 bone. 99-100 Viral infections, 191
summary of,92 implants. 129 Virtual articulation. 272
treatment of. 86-89,89t management versus. 97 Volume rencleling, 57
Temporomandibular JOint outcome-gu1ded. 98 Vowels,295
anatomy of. 84f oveNiew of, 98-99 V-shaped mandibular ridge, 26-27. 215
computed tomography of. 91. 921 personal factors. 97-98
effuSton of. 64,65f shared decision making, 98
w
magnetic resonance unaging of. 84, 65f, 841 teeth, tCl0-104
Warfarin. 20
orofacial pain after injury to, 73 Tncalcium phosphate. 133
Wear. 25. 26f, 269f,273-27 4
Tetracycline. 48 Tricyclic antide pressants. 74
Weber-Ferguson incision. 157, 211f
Therapeutic relaxation, 72 Trigeminal neuralgia, 65
White blood ce3s, 19,20t
Three-dimensional cephalometry, 60 Trismus, 176,191-192
Wickham striae, 39
Thyroid tumors, 176 Trisomies. 6
Work hardening, 244
Titanium alloys. 243, 245, 245t Tumors
TNM staging, 112, 184,1841-1851 epithelial, 15o-151
X
Tomography mesenchymal, 151
Xenografts. 132. 144
com puted. See Computed tomography. mixed, 151
Xerostomia, 172-174. 186, 189-190,325
palatopharyngeal competence evaluations, 305 odontogenic, 149-151
X-tinked disorders. 3. 3t
Tongue pregnancy, 42
defects of, 222-223, 222f-223f r d, 176
lllyoi
examination of, 23,311.31-32 Turner syndrome, 35
v
hemangioma of. 67f T1-wetghted images. 62, 62f-631. 66 Yttrium-stabilized tetragonal zirconia POlvciYstaJ.
papillae on. 34 T2·weighted Images, 62,621-631, 66 243,278
resection of, 229

retracted position of 31 .
u z
squamous cell carcinoma of, 1521. 2091 Ultimate tensile strength. 243 Zinc phOsphate cement, 240
in swallowing,200 Unintelligible speech, 227 Zinc sil!cophosphate cement. 240
taste buds on,34-35, 341 Urethane dlmelhaC()IIate,236 Z-plasty technique. 119.1 19f
Tongue depressing stents. t 71. 171f. t77. 177f U s haped mandibular ndge. 2&-27. 99, 215
-
Zygomatic arch,32
Tonsillar-pharyngeal area, 23, 241
Tooth extractions
description of, 142
preradiation therapy, 189
3421

2011 Diagnosis and Treatment in Prosthodontics

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2011 Diagnosis and Treatment in Prosthodontics

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......,.

William R. laney, DMD, MS

Thomas J. Salinas, DDS

Alan B. Carr, DMD, MS

Sreenivas Koka, DDS, MS, PhD

Steven E. Eckert, DDS, MS

Quintessence Publishing Co, Inc

Includes bibl iographical references and index.

© 2011 Quintessence Publis h ing Co, Inc

Quintessence Publ ishi ng Co, Inc

Editor: Leah Huffman

Dusica Babovic-Vuksanovic, M D Charles L. Loprinzi, M D

Department of Speech and Language Pathology

in a timel y manner, as well as cost and cost sharing by third p arty

primarily to fixed restoratio ns which now have more durability and a

Jonathan P. Wiens, oos. MSD

Basic Concepts of Genetics 1

The Orthodontic-Prosthodontic Relationship 9

History, Laboratory, and Examination 17

Oral and Maxillofacial Radiology 51

Psychologic Aspects of Diagnosis and Treatment in

Temporomandibular Disorders and Orofacial Pain 83

Considerations in Treatment Planning 97

Preprosthetic Surgery 115

Bone Grafting and Ridge Augmentation Considerations Prior to

Surgical Defects of the Mandible and Maxilla 149

Oral Complications of Chemotherapy and Radiation Therapy 163

Radiation Therapy and Chemotherapy for Head and Neck

Restoration of Congenital, Developmental, and Acquired Oral and

Contemporary Dental Materials and Their Application to

Diagnosis and Management of Inadequate Denture Prostheses 249

The Mutually Protective Complex: Occlusion and Fixed

Speech Pathology and Prosthodontic Applications 293

Management of Patients with New Prostheses 318

T: e field of genetics has undergone rapid growth in recent

drome), and some forms of ectodermal dysplasia. Disease expres­

Inheritance pattern Example Recurrence risk" Sex differences

Autosomal dominant Most craniosynostoses Siblings: 50% None

Autosomal recessive Most dysmo.phlc Siblings: 25% None

Females: 50% carriers

MilochonClria! MELAS' Varial)le Transm,ssion mostly fhroogh females. ct1ildren

Isolated clelt palate Siblings: 2-5%

1'he r<lk figU<es apply to siblnlgS Met children of an affeCted person.

cystic fibrosis, many inborn errors of metabolism, and some rare

Genetic Testing chromosome, allowing painting of whole Chromosomes (Fig 1-5).

L ine 1 Line 2 Mlul

sample signal. Note the hOmozygous G to T

technology for genomic sequencing has allowed analysis of large

Fig 1-9 (a and b) A patient with veto-cardio-tacial syndrome. Note

Fig 2-1 (a) lateral cephalometric film taken in natural

1.:� \:'a ...

Impact of growth pattern on dental relationships Vertical discrepancies

i i A patient with skeletal vertical excess may have an anterior open

of those with short lower faces and vertical deficiency (Frankfort­

Adjunctive Orthodontic Root uprighting adjacent to implant site

Bolton anterior six

Consolidation of space Creation of space for the replacement of

Fig 2-12 (a)The total width of tl'le six mandibular anterior

Fig 2-13 The resuHs of orthodontic leveling of the occlu·

Leveling of the occlusal plane

Temporary anchorage devices or other

Fig 2-15 A TAO placed be·

allow protract ion o f the poste· was used to prevent Ut e maxil·

TAOs can be placed easily and rapidly by the orthodontist. oral

drome), and some forms of ectodermal dysplasia. Disease expres

of those with short lower faces and vertical deficiency (Frankfort

Fig 3-20 (a and D) Sigrllfi cant anatomical areas in lhe maxil

Fig 3·22 Frena presentation in an edentulous p atient. Note the approxi

that mighl necessitate gingival recontouring, and the psychologic pro

cedures; today informed consent is deemed appropriate for all ir

Formerly, clinicians relied on the cl inical examination and convention

more interest in the area of personality assessment a s comp lemen

Status Of the several standard brief assessments available t o measure se

In addition to measuring psychologic char ac teristics and trauma