A fi

pati

Santosh Nelogi,

aReader, Department of Prosthetic DbProfessor, Department of ProstheticcLecturer, Department of ProstheticdPostgraduate student, Department

Nelogi et al

xed guide flange appliance for

ents after a hemimandibulectomy

MDS,a Ramesh Chowdhary, MDS,b

Maheshwari Ambi, BDS,c and Prachi Kothari, MDSd

KLE VK Institute of Dental Science, Karnataka, India; S. NijalingappaInstitute of Dental Sciences, Gulbarga, India

Oral carcinoma destroys structures, including the maxilla and mandible, which often require surgical management andrehabilitation. Poor tissue support after mandibular reconstruction in patients with hemimandibular defects hinders thereconstruction of functional and stable mandibular guide flange prostheses. The fabrication and use of a fixed guide flangeprosthesis for rehabilitating patients with hemimandibular defects is described. The device permitted the use of the sameprosthesis for both the functional and mechanical correction of mandibular deviation and is indicated where the fabricationof other appliances is contraindicated because of the compromised oral and physical state of the patient. (J Prosthet Dent2013;110:429-432)

Oral cancer is the eighth mostcommon carcinoma worldwide,1-5 de-stroys tissue, which often requires resec-tion involving themandible,maxilla,floorof the mouth, and tongue, and whichmay adversely affect an individual’smental health.6-9 After mandibularresection, patients experience the lossof a proprioceptive sense of occlusionand the absence of the muscles ofmastication on the surgical side, result-ing in significant rotation of the man-dible upon closure, with the mandibledeviating toward the surgical side(medial).7,8,10-12

Treatment of the deviated mandiblestarts with early corrective mandibularmovement therapy, including physi-otherapeutic stretching exercises.7,13,14

Various designs of prostheses used toguide the mandible into centric oc-clusion have been described.7-22 Aremovable guide flange prosthesiscannot be retained intraorally if onlya few teeth remain in the sectionedmandible. Retention can be furthercompromised by radiation and surgicalscarring, which limits mouth opening

entistry, KDentistry

Dentistry,of Prosthe

and functional vestibule depth suchthat placement and removal of theguide flange prosthesis is impossiblefor the patient,13 leading to furtherocclusion problems.13,7,20 Therefore, toovercome the problems of the remov-able design, a fixed prosthesis thatwould prevent scar contraction bykeeping muscles in the stressed condi-tion and at the same time providecorrective and masticatory functionsis indicated.10,11 A technique using afixed mandibular guide flange appli-ance has been designed for the pros-thetic management of patients after ahemimandibulectomy.

TECHNIQUE

1. Make maxillary and segmentedmandibular impressions in elastomericimpression material (Aquasil UltraSoft Putty; Aquasil Ultra LV Wash;Dentsply Intl) andpour casts with Type IIIdental stone (Kalastone; Kalabahi PvtLtd).

2. Articulate the maxillary andmandibular casts at a reasonable centric

LE VK Institute of Dental Science., S. Nijalingappa Institute of Dental Sciences.KLE VK Institute of Dental Science.tic Dentistry, KLE VK Institute of Dental Scienc

relationship with occlusion recordingwax (Dental Wax; Carmel Group Inc).

3. Place orthodontic tooth separa-tors (Elástico Separador; Dental MorelliLtd) interdentally around one of themandibular posterior teeth so as tocreate interdental space.

4. Adapt the prefabricated ortho-dontic molar band (3M Unitek) of theproposed tooth size on the preparedmandibular cast (Fig. 1).

5. Bend a wrought wire (KC Smithand Co) 1 mm thick and 5 cm long inthe shape of a U (with right anglebends) with a tube 10 mm in lengthoccupying the base of the U, whichfreely rotates around the wire (Fig. 2).

6. Adjust the height of the U-sha-ped loop with a tube on a mountedmandibular cast with a preadjustedband in such a manner that the tubewill be placed horizontally at the levelof the buccal surface of maxillaryposterior teeth when the teeth are inarticulation. After confirming the po-sition, solder a U-shaped loop (Den-taurum Dental Technology) to thepreadjusted band (Figs. 3, 4).

e.

1 Mandibular cast with molar band adapted to preparedtooth.

2 U loop with tube.

3 U loop soldered to preadjusted band.

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7. Further adjust the band witha soldered U-shaped loop with thetube positioned medially and laterallydepending on the extent of the mandib-ular deviation (Fig. 4).

The Journal of Prosthetic Dentis

8. Sterilize the appliance with dryheat before cementing it to the pre-pared site.

9. Remove the separators placed inthe patient’s mouth and place the

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molar band with the U loop and eval-uate for efficacy. Any adjustment inangulation (medially, laterally) of theU-shaped loop in relation to the molarband is done at this stage so thatit guides the mandible in centricocclusion with less strain on the patient(Figs. 5, 6).10. Once the fit and function of

the appliance are confirmed with theleast possible strain on the patient,cement it to the proposed tooth. Thedesign of the fixed guide flange witha U-shaped loop is adjusted in sucha way that it will not traumatize themaxillary teeth and gingiva duringfunction (Fig. 7).

DISCUSSION

The mandibular guide flange pros-thesis is commonly used and has beenthe subject of many studies.7,12-20

Sahin et al18 and Chalian et al19

advocated the fabrication of a castmetal guidance prosthesis with sup-porting and retentive flanges for a pa-tient after a mandibulectomy. Theauthors claimed that the patient wasable to achieve a functional intercuspalposition after the insertion of theprosthesis but that mastication waslimited to vertical movement only. Joshiet al20 described the fabrication of amandibular guide flange prosthesis andsuggested that a removable prosthesiswas an effective alternative for mostpatients with mandibular defects,considering the poor prognosis, diffi-culty in deciding on the use of theimplant, and economic feasibility. Theprosthesis described by Koumjian andFirtell21 was modified with a Herbstappliance; the disadvantage of thistechnique was the occasional separa-tion of the tube and plunger atmaximum jaw opening. Prencipe et al22

described a technique by simply insert-ing and removing the guide flange.

The fixed guide flange appliancementioned here consists of a molarband with a U loop, which is cementedto the tooth. The U loop of the fixedguide flange extends superiorly anddiagonally along the buccal surface of

Nelogi et al

4 Fixed appliance guide flange.

5 Occlusal view of cemented fixed guide flange.

6 Fixed guide flange showing position and level of loop attime of articulation.

November 2013 431

the maxillary premolar and molar teeth.The stainless steel tube at the base ofthe U loop glides the mandible intocentric occlusion, thereby reducing

Nelogi et al

mandibular deviation and allowingfor the normal vertical and horizontaloverlap of the remaining dentition(Figs. 6, 7).

The fixed guide flange presentedhere prevents the deviation of themandible toward the surgical side andserves to minimize radiation scarring bykeeping the tissue in a stressed condi-tion; stretching the tissues during heal-ing minimizes the amount of scarringwithin the area.7,14

The proposed fixed guide flangeis recommended for those patientswith significant mandibular resection(Fig. 8) who have limited mouthopening ability resulting from tissuescarring and who lack the motor skillsto manage a removable prosthesis(Fig. 9).

The technique is proposed onlywhen the remaining teeth are peri-odontally sound enough to bear theangular pull of muscles and masti-catory forces. The fixed guide flangeprosthesis proposed is functional, aes-thetic, comfortable, and easy to fabri-cate and repair; it also allows betterhygiene maintenance.

After the placement of a fixedmandibular guide flange prosthesis,the patient must be evaluated for anystrain or pain in the temporoman-dibular joints and muscles every 6hours for the first 72 hours aftercementation. The patient is furtherrecalled after 6, 12, and 28 days toevaluate the efficacy of the fixed guideflange appliance and to ensure thatno misalignment or migration of themaxillary tooth/teeth adjacent to theloop has occurred in the remainingdentition.

SUMMARY

The proposed guide flange is asimple alternative to the existingremovable mandibular guide flangeprosthesis. The guide flange consists ofa molar band with a U loop, which iscemented to one of the mandibularteeth. Disadvantages include the pos-sible migration of maxillary teeth adja-cent to the loop. Further researchshould focus on determining the influ-ence of the fixed guide flange on themaxillary teeth and on any long-termadverse effects of its use.

7 Definitive intraoral result.

8 Panoramic radiographic view showing mandibular discontinuity defect.

9 Intraoral view showing mandibular deviation towardresected side.

432 Volume 110 Issue 5

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11. Curtis DA, Plesh O, Miller AJ, Curtis TA,Sharma A, Sehweitzer RL, et al.A comparison of masticatory function withor without reconstruction of the mandible.Head Neck 1997;19:287-96.

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13. Schneider RL, Taylor TD. Mandibular resec-tion guidance prostheses: a literature review.J Prosthet Dent 1986;55:84-6.

14. Robinson JE, Rubright WC. Use of a guideplane for maintaining the residual fragmentin partial or hemimandibulectomy. J ProsthetDent 1964;14:992-9.

15. Moore DJ, Mitchell DL. Rehabilitatingdentulous hemimandibulectomy patients.J Prosthet Dent 1976;35:202-6.

16. Fattore L,Marchmont-RobinsonH, Crinzi RA,Edmonds DC. Use of a two-piece Gunningsplint as a mandibular guide appliance for apatient treated for ameloblastoma. Oral Sur-gery Oral Med Oral Pathol 1988;66:662-5.

17. Hasanreisoglu U, Uçtasli S, Gurbuz A.Mandibular guidance prosthesis followingresection procedures: three case reports. Eur JProsthodont Restor Dent 1992;1:69-72.

18. SahinN, Hekimo�gluC, Aslan Y. The fabricationof cast metal guidance flange prostheses fora patient with segmental mandibulectomy: aclinical report. J ProsthetDent2005;93:217-20.

19. Chalian VA, Drane JB, Standish SM. Maxil-lofacial prosthetics multidisciplinary practice.Baltimore: Williams & Wilkins; 1972. p. 148.

20. Joshi PR, Saini GS, Shetty P, Bhat SG. Pros-thetic rehabilitation following segmentalmandibulectomy. J Ind Prosthodont Soc2008;8:108-11.

21. Koumjian JH, Firtell DN. An appliance tocorrect mandibular deviation in a dentulouspatient with a discontinuity defect. J ProsthetDent 1992;67:833-4.

22. Prencipe MA, Durval E, De Salvador A,Tatini C, Roberto B. Removable partialprosthesis (RPP) with acrylic resin flange forthe mandibular guidance therapy.J Maxillofac Oral Surg 2009;8:19-21.

Corresponding author:Dr Santosh NelogiHouse #1, l.i.g. Phase IIIAdarsh Nagar, Gulbarga, KarnatkaINDIAE-mail: santrodent@rediffmail.com

Copyright ª 2013 by the Editorial Council forThe Journal of Prosthetic Dentistry.

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