Prosthodontic consideration in the treatment of patients with

maxill.ary and mandibular deficiencies

Alan EIickey, DMD,a and Thomas J. Vergo, Jr., DDSb
Maine Medical Center, Portland, Maine, and Tufts University, School of Dental Medicine,
Boston, Mass.

Despite advancements in surgical osteotomy repositioning procedures for congeni-

tal and developmental intermaxillary deficiencies, prosthetic rehabilitation remains
a viable alternative in some patients. In developing a treatment plan, the advan-
tages and disadvantages of both surgical and prosthetic rehabilitation must be
weighed. The interdisciplinary team approach is best for treatment planning. The
treatment options are presented with a variety of treatment philosophies. Maxillo-
facial surgical and/or prosthetic treatments must be carefully coordinated to
ensure the best results for patients with moderate to severe “jaw” discrepancies. (J
PROSTHET DENT 1991;66:645-9.)

A dvances in surgical techniques and acceptance of

the team approach have made surgical repositioning of the
maxillae and the mandible (osteotomy procedures) routine
oral and maxillofacial pr0cedures.l Improvements in vari-
ous diagnostic tools, transplant and implant technology,
and microvascular surgical procedures assure the surgeon
more predictability, safer procedures, and more conserva-
tive approaches to correction of maxillary and mandibular
deficiencies.” Despite these significant surgical advance-
ments, prosthodontic intervention as a primary treatment
or adjunctive treatment to surgery and orthodontics should
not be overlooked.
Patients with moderate-to-severe skeletal discrepancies
of the maxillae and/or the mandible, regardless of the eti-
ologic factors of their deformities, require a complete and
coordinated diagnostic workup and treatment plan repre-
sentative of the whole team’s expertise. In addition to
medical colleagues, the team usually consists of an oral and
maxillofacial surgeon, a prosthodontist, an orthodontist,
and a restorative or pediatric dentist (Fig. 1). Paraprofes-
sional team members such as a social worker, a psycholo-
gist, and a speech pathologist will assure optimum treat-
ment with long-term functional and psychologic results.
This article addresses the role of prosthodontic rehabil-
itation of selected patients as an alternative to surgical
procedures or as an adjunctive treatment to orthognathic
surgery. The patients chosen were representative of the Fig. 1. A, Thirteen-year-old girl with repaired cleft pal-
various options available to the team and the patient in ate demonstrating arch collapse, inadequate vertical di-
correcting intermaxillary discrepancies. mension of occlusion, poor facial support, and poor esthet-
ics. Attempts to improve intraoral situation failed with
orthodontics because of lack of patient complicance and
desire for no surgery; B, A maxillofacial overdenture using
aActive Staff and Private practice, Maine Medical Center.
bProfessor, Restorative Dentistry Department, and Division Head, existing dentition for support (without endodontic treat-
Maxillofacial Prosthetic Section, Tufts University, School of ment) was used successfully to obtain correct vertical
Dental Medicine. dimension of occlusion, improved mastication, facial sup-
1011124046 port, and esthetics.

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PROSTHODONTIC CONSIDERATIONS

Patients sustaining severe facial trauma, as seen after a

As in all aspects of medical and dental treatment, an in- motor vehicle accident, can have residual malalignment of
depth evaluation and diagnosis is paramount to developing the maxillae and mandible. If plastic and/or maxillofacial
a predictable, successful, and long-term result. A complete and oral surgical reconstruction cannot be done, prosthetic
systemic medical examination and a full series of head and intervention in the form of modified removable prostheses
neck radiographs, full mouth radiographs, panoramic ra- can stabilize the patient’s oral functions and appearance.
diographs, and cepholometric radiographs should be eval-
uated. Mounted diagnostic casts in habitual and most DISCUSSION
retruded mandibular positions with associated model sur- Often the poor esthetic appearance that can accompany
gery are diagnostic procedures that should be performed. major discrepancies between the maxillae and the mandi-
Intraoral and extraoral photographs should be made to ble can have a negative psychologic effect. Poor self-image,
evaluate the facial structures of all patients. peer pressure, and job related discrimination have been
The special relationship of the maxillae and the mandi- directly related to the psychosocial scarring that these pa-
ble to the overall configuration of the facial structures and tients may experience.2-7 Positive emotional support may
to each other must be examined. If a moderate-to-severe be gained by providing expedient prosthetic treatment
discrepancy exists between the maxillae and the mandible to manage the orofacial defects. Often prosthetic interven-
that cannot be managed with orthodontic and/or orthog- tion can be accomplished rapidly and painlessly so as to
nathic surgical treatment, correction of the intermaxillary minimize the onset of emotional and psychologic eompli-
relationship may require alternative treatment. cations.
When the mandible is in a favorable position relative to Intraoral prostheses can improve extraoral facial con-
the skeletal structures of the head and neck region, max- tours by providing support for the perioral soft tissues.
illary prosthetic intervention should be considered as a Such prostheses can also be used as surgical stents if plas-
possible alternative. Arch discrepancy often has an associ- tic surgical procedures are indicated. Patients with ac-
ated decrease in the vertical dimension of occlusion. If in- quired or congenitally related defects of the maxillae may
adequate radiographic and clinical analyses are performed, require prosthetic treatment involving obturators, speech
this type of relationship may be misdiagnosed as an Angle bulbs, and/or a palatal lift prosthesis. In this situation,
classIII relationship. In actuality, the maxillae are retruded surgical treatment would be contraindicated. If extensive
superiorly and posteriorly, creating a pseudo Angle classIII long-term surgical procedures with questionable prognosis
arch relationship as the mandible closes upward and are proposed, the patient may benefit by altering the
forward to achieve maximum intercuspation. The analysis treatment plan to a less complicated one using prosthetic
of the cephalometric radiographic tracings at the correct rehabilitation. This treatment may be more cost-effective
vertical dimension of occlusion should determine which with a decrease in hospitalization resulting in minimal dis-
arch is actually affected so that the correct treatment mo- ruption of the patient’s lifestyle. Rising medical costs and
dality is selected (Fig. 2). personal financial considerations often play an important
Medical factors can play a significant role in selection of role in developing a quality treatment plan.
the ideal treatment. Cardiac complications, emphysema, In making the decision as to the prosthetic treatment re-
blood dyscrasias, and other systemic conditions may result quired to correct the maxillary and mandibular discrep-
in high risk to the patient, contradicting a general anes- ancy in a given patient, the disadvantages as well as the
thetic and surgical procedures. The young, healthy patient advantages of prosthodontic treatment must be eonsid-
who has the potential for continued facial growth may re- ered. If the maxillae and mandible are not in a favorable
quire prosthetic intervention as an interim treatment until relationship, although good prosthetic and esthetic results
growth has stabilized, allowing a more favorable and pre- can be obtained, unfavorable stresses can be placed on the
dictable surgical result to be achieved (Fig. 3). remaining dentition and residual alveolar ridges that may
Prosthetic habilitation as an alternative to surgical pro- accelerate bone resorption. Meticulous prosthodontic tech-
cedures for repaired unilateral or bilateral cleft lips and niques and diligent patient follow-up assure continued tis-
palates may be indicated in selected patients. Closure of sue stability and adaptation as well as harmonious occlu-
the lip and the hard and/or soft palate by the surgeon may sion. If unfavorable tissue contours cannot be ideally cor-
restrict growth of the maxillary complex due to scarring or rected with surgery, a removable prosthesis may need to be
contracture of the surgical sites. Again, prosthetic inter- used instead of a less stable fixed prosthesis. Prosthetic re-
vention may be the treatment of choice to restore the ver- habilitation in combination with or instead of surgical pro-
tical dimension of occlusion and facial contours as well as cedures based on the team’s recommendations can be suc-
the oral functions of speech, swallowing, and chewing. Or- cessful on selected patients.
thognathic surgical intervention may present a risk in the
CONCLUSIONS
cleft lip and palate patient, affecting the velopharyngeal
closure with resultant distortion of resonance contributing A philosophic discussion of the treatment options avail-
to hypernasality (Fig. 4). able to the health profession team for patients with mod-

THE JOURNAL OF PROSTHETIC DENTISTRY

 Fig. 4. A, Bilateral cleft lip and palate. Premaxilla surgically removed at age 3 months
resulted in large oronasal defect and poor lip closure. B, Constriction of maxillae due to
bilateral cleft and removal of premaxilla. C, Intraoral overdenture prosthesis with obtu-
rator and bifid speech bulbs. D, Final esthetic result before surgical reconstruction of up-
per lip. Overdenture acts as template to which plastic surgeon can reconstruct upper lip.
Patient was so pleased with esthetic results with overdenture that he refused lip surgery.

erate-to-severe misalignment of the maxillae and/or the 2. MacGregor FC. Source psychosocial problems associated with facial
deformities. Am Sot Rev 1951;16:629.
mandible has been presented. Patients’ individual needs
3. Meiloo JAM. The fate of one’s face. Psych& Q 1956;30:31.
must be evaluated and diagnosed, treatment planned, and 4. Clifford E. Psvchosocial asuects of orofacial anomalies: soecialties in
rehabilitation accomplished on a select basis. Combining or search of data in orofacial anomalies, clinical and research implications.
Proceedings of Conference-ASHA Reports 8. Washington, 19’73.
substituting surgical and prosthetic intervention on the 5. Bershield E, Walster E. Beauty and the best. Psychology Today 1982;
basis of anatomic, psychologic, functional, and financial 5:10, 42, 74, 94.
status of the patient must be considered. Maxillofacial 6. MacGregor FC. Social and psychological implications of dentofacial
disfigurement. Angle Orthod 1970;40:231.
surgical and/or prosthetic treatment procedures should be 7. MacGregor FC, Abel T, Bryt A, et al. Facial deformities and plastic
closely coordinated so that the best result can be provided surgery: apsychosocialstudy. Springfield, Ill.: Charles C. Thomas, 1953.
to the patient.
Reprintrequeststo:
DR. THOMAS J. VERGO, JR.
REFERENCES
TUFTS UNIVERSITY SCHOOL OF DENTAL MEDICINE
1. Bell WH, Profitt WR, White RP. Surgical correction of dentofacial de- ONE KNEELAND ST.
formities. vol I and II, Philadelphia: WB Saunders Co., 1980;443-843. BOSTON, MA 02111

THE JOURNAL OF PROSTHETIC DENTISTRY 649

ing denture is relieved to provi e a ~~~~j~~~ of I to 15 mm
space for the new resh3 The c tinges that occur during the
roeessing of the reline resirn could result in the need for
djustments the tissue surface or to alterations of the
occlrnsion of complete denture upon insertion.
This ~~~est~~at~~~ compares the dimensional change at
the diatokmcal flanges of processed simulated denture
bases after relining with three resins.

A metal die sj~~~~at~~g a maxillary edentukms arch (Fig.

1) was used to construct 30 simulated denture bases 1.5 to
2 mn thick from a high hpact denture base resin (hci-