Prosthetic Management of PartiallyResected Dentulous Mandible

Anulekha Avinash C K 1, Kiran Kumar T2, Naveen Raj T3

Department of Prosthodontics and Implantology,Kamineni Institute of Dental Sciences,Narketpally.

Email for correspondence:avinash_tejaswi@yahoo.co.in

ABSTRACT

In the area of head and neck tumors it is oftennecessary to perform radical surgery to eradicate thedisease completely. Very often unsightly andincapacitating defects of the face and oral cavity areleft as a result of such treatment. It is inconceivablethat the treatment ends with the elimination of thedisease. The correction of these defects should alwaysbe accompanied by this rehabilitation so as to makethem socially acceptable as before. These may betreated by the plastic surgeon, the prosthodontist, orboth.

KEY WORDS:

Mandibular guidance therapy, Guide flangeprosthesis, hemimandibulectomy

INTRODUCTION

The surgical treatment of tumors of the lower jawquite frequently necessitates the removal of a portionof the mandible, resulting in the loss of normalrelationship of the remaining portion of the mandible

to the upper jaw. There is a cosmetic deformity, dueto the remaining fragment turning inward andbackward, in addition to that caused by the tissue lossresulting from the removal of the tumor1 . There aretwo main problems in these cases, the restoration offunction to the remaining segment of the mandibleand cosmetic improvement. The restoration of themasticatory function is most important. Cosmeticimprovement is secondarily addressed. The mostconsistently frustrating areas of maxillofacialrehabilitation is the treatment of dentulous patientswho have had radical surgery of the floor of themouth and mandible2. Mandibulectomy andcommando procedures involve the extensive loss oftissues and associated functions. The prostheticprognosis is rarely good, and reconstructive surgicalprocedures, even when indicated, usually do notsignificantly improve the prosthetic potentialsufficient to restore the patient’s face to the normalfacial contour due to the great amount of tissue lossand formation of cicatricial tissue. The possibility ofpressure necrosis in these regions requires therestoration of facial contour to be limited to thecondition as found3 . This article aims in prostheticmanagement of hemimandibulectomy patients to

Article InfoReceived: July 12, 2011Review Completed: August, 14, 2011Accepted: September, 15, 2011Available Online: January, 2012© NAD, 2012 - All rights reserved

CASE REPORT

ABSTRACT:

In the area of head and neck tumors it is often necessary toperform radical surgery to eradicate the disease completely. Veryoften unsightly and incapacitating defects of the face and oralcavity are left as a result of such treatment. It is inconceivablethat the treatment ends with the elimination of the disease. Thecorrection of these defects should always be accompanied bythis rehabilitation so as to make them socially acceptable asbefore. These may be treated by the plastic surgeon, theprosthodontist, or both.

Key words: Mandibular guidance therapy, Guide flange prosthesis,hemimandibulectomy

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reposition of the mandible in correct anatomicallocation and to enhance the patients confidence byimproving the esthetics and function.

CASE REPORT

A 32 year old female reported to the Departmentof Prosthetic Dentistry with a chief complain ofdifficulty in mastication and speech. She had aunilateral discontinuity mandibular defect on theright side due to surgery for ameloblastoma. Thesurgery was performed 2 year back andreconstruction was done with muscle graft. Nointermaxillary fixation was applied at the time ofsurgery.

Extra oral examination showed facial asymmetrywith mandibular deviation to the right side. Clinicalexamination revealed severe deviation of themandible towards the resected side, with lack ofproper contact between the maxillary and themandibular teeth. Intra oral examination showedmissing teeth 42,43, 44, 45, 46, 47(Fig-1) and 48 andorthopantomogram for the same (Fig 2) .

Through clinical evaluation, it was noted that thepatient’s mandible could be manually placed into thecentric occlusion without excessive force. Mandibularbased acrylic resection prosthesis with a buccalguiding flange was planned. A maxillary andmandibular final impression was made by usingelastomeric impression. [Fig3]. The master casts werepoured with Type III dental stone.

A maxillomandibular record was made bymanually assisting the mandible into the centricocclusion( Fig 4). The maxillary and mandibular castwas mounted on a three point articulator(Fig 5).

The mandibular resection prosthesis wasfabricated on the defect (right) side. The design [Fig6] included the guidance flange on the buccal andthe supporting flange on the lingual at the nondefect left side. The retention was provided by theinterdental clasp, engaging the premolars and themolars. The guide flange extended superiorly anddiagonally on the buccal surface of the molars andthe premolars, allowing the normal horizontal andvertical overlap of the left maxillary teeth. The guideflange was sufficiently blocked out, so that it would

not traumatize the left maxillary teeth and thegingiva when the patient closed her mouth. Amonoplane occlusal scheme was provided on theright side with the absence of all unwanted occlusalinterferences, this provided esthetic and functionalbenefit to the patient with minimal harm. Theprosthesis was finished, evaluated and insertedintraorally.

The guide flange provided a mechanical systemwhich prevented the mandible from turning towardsthe resected side ( Fig 7) . The patient was advised touse the guide flange device throughout the day,except at night and during meals.

Physiotherapy was suggested to assist thepatient in improving the symmetrical arc of closureand in finding the centric occlusion position withoutguiding the mandible manually. The exerciseconsisted of the simple opening and closing of themandible with and without the appliance. Thesemovements tend to loosen scar contracture, reducetrismus and reprogram the remaining musculatureto close the mandible into the centric occlusion.When prosthetic therapy is combined with a wellorganized exercise program, improved results can beachieved.

Three days after insertion of the prosthesis, thepatient was able to achieve a functional intercuspalposition without manual manipulation. After oneweek, the patient was evaluated for the insertion ofthe interim removable partial denture. The interimremovable partial denture was fabricated for thepatient with heat cure acrylic by utilizing the wroughtwire clasp and by engaging the premolars and themolars to get retention. This prosthesis helped herto get accustomed to close the mandible into thecorrect intercuspal position without the use of anyexternal aid [Fig8 and 9]. Guidance prosthesis andinterim removable partial denture serve as trainingappliances till a cast partial denture can be fabricatedfor the patient. In this case report the patient was heldunder observation till an acceptablemaxillomandibular relationship was achieved so asto further plan for a definitive prosthesis. The patientwas comfortable with esthetic and function providedby the interim prosthesis.

Prosthetic Management of Partially Resected Dentulous Mandible Anulekha Avinash C K, et, al.

Indian J Dent Adv 2011; 3 Suppl 1: 750-753

DISCUSSION

Rehabilitation is an essential phase of cancer careand should be considered from the time of diagnosisin a complete and comprehensive treatment plan.The primary objective of rehabilitation is therestoration of appearance and function. Mandibularresection, as a consequence of surgical treatment ofthe tumour, will clinically result in facial asymmetryand malocclusion4. The residual mandible deviatesmedially and superiorly and it will be more or lessevident, depending on the location and theextension of the resection, the amount of soft tissueand innervations which are involved and thepresence of the remaining natural teeth. A correctivedevice named ‘Guide Flange prosthesis’ is indicatedto limit that clinical manifestation and to restoremandibular function5. The basic design of the guideflange prostheses will depend greatly on post-operative findings, as there are no type of appliancesthat will serve for every patient. However there arefundamental principles for the construction of afunctional appliance: Every patient should maintainfunctional occlusion for mastication, and this maybeaccomplished by a guide plane6 .Dorsey J. Moore etal. (1976)7 described a technique which combinescrowns with a maxillary prosthesis to guide themandible into a functional occlusion.

This clinical report illustrates the prostheticmanagement of a patient who underwentmandibular resection due to surgery forameloblastoma. The literature shows various typesof cast metal guidance prostheses which are effectivein managing the mandibular deviation5. In this casereport it was planned to fabricate an interim acrylicguiding flange to achieve an stable and anacceptable maxillomandibular relationship for thepatients before proceeding with definitive prosthesis.This simple acrylic guiding flange was not only costeffective for managing mandibular deviation but alsorestore the patient esthetic and function to the greatextent. Nonanatomic acrylic resin posterior teeth areused to minimize lateral stress which would tend todisplace the mandibular appliance.3 In this casereport monoplane occlusal scheme was provided torestore the function with minimal ill effects. SinceMohamed A. Aramany et al. (1977)8 reported patients

Prosthetic Management of Partially Resected Dentulous Mandible Anulekha Avinash C K, et, al.

who were treated by the use of immediateintermaxillary fixation after segmental resection ofthe mandible to eradicate cancerous lesions. Theyclaimed that the use of intermaxillary fixation duringthe first postoperative weeks reduces the degree ofdeviation.

A classification of mandibular defects has beendescribed by Cantor and Curtis. Although theclassification system is suggested primarily foredentulous patients, it is also applicable to partiallyedentulous patients9.

CLASSIFICATION OF MANDIBULAR DEFECTS 9 :-(FIG-9)

Class I: Mandibular resection involving alveolar defectwith preservation of mandibular continuity.

Class II: Resection defects involve loss of Mandibularcontinuity distal to the canine area.

Class III: Resection defect involves loss up to themandibular midline region.

Class IV: Resection defect involves the lateral aspectof the mandible, but are augmented to maintainpseudoarticulation of bone and soft tissues in theregion of the ascendin ramus.

Class V: Resection defect involves the symphysis andparasymphysis region only, augmented to

Preserve bilateral temporomandibular articulations.

Class VI: Similar to class V, except that the Mandibularcontinuity is not restored.

CONCLUSION

The mandibular guidance therapy is mostsuccessful in patients whose resection involves onlybony structures with minimal loss of soft tissue andno radical neck dissection or radiation therapy.Therefore the patients who are treated for any tumorsare generally are ideal candidates for the use of amandibular guidance therapy. For better results, theprosthetic management should be combined withan exercise program10.

REFRENCES1. Cantor R, Curtis TA. Prosthetic management of edentulous

mandibulectomy patients. Part I. Anatomic, physiologic andpsycho logic considerations. J Prosthet dent 1971; 25:446-458.

Indian J Dent Adv 2011; 3 Suppl 1: 750-753

Fig 1: Pre-operative intraoral view showingmandibular deviation towards resected side.

Fig 2: Ortho pantamogram view showingresected mandible on right side

Fig 3: Impression made using elastomericimpression.

Fig 4 : Maxillomandibular Relationship Fig 5: maxillary and mandibular cast weremounted on a three point articulator

Fig 6: Design of Guide Flange Prosthesis a :guiding flange, b: support flange c: prosthesis

Fig 7: Intraoral view of the patient with theGuide flange prosthesis

Fig 8 : Pre treatmentfrontal view

Fig 9: Post treatmentfrontal view

Fig10: Cantor and Curtisclassification of mandibular defects.

Prosthetic Management of Partially Resected Dentulous Mandible Anulekha Avinash C K, et, al.

2. Cantor R, Curtis TA. Prosthetic management of edentulousmandibulectomy patients. Part II. Clinical procedures. JProsthet dent 1971 ;25:546-556.

3. Swoope CC.Prosthetic management of resectededentulous mandibles. J Prosthet dent. 1969;21:257-262.

4. Scannell BJ. Practical considerations in the dentaltreatment of patients with head and neck. J Prosthet dent1965 ;15:764-771.

5. Ackerman JA, The prosthetic management of oral and facialdefects following cancer surgery. J Prosthet dent 1955;5:413-430.

6. Hasanreisoglu U, Uçtasli S, Gurbuz A. Mandibular guidance

prosthesis following resection procedures: Three casereports. Eur J Prosthodont Rest Dent 1992;1:69-72.

7. Ronald P. Desjardins. Maxillofacial prosthetics.temporomandibular joint dental implants. J Prosthet dent1979;41:308-316.

8. Aramany MA, Myers NE. Intermaxillary fixation followingmandibular resection. J Prosthet dent 1977;37:337-345.

9. Shetty P, Baliga M, Rodrigues S, Dixit S. Prostheticmanagement following mandibular resection: Aclinicalreport J Nepal Dent Assoc 2009;10(1):57-60.

10. Cantor R, Curtis TA. Prosthetic management of edentulousmandibulectomy patients. Part III. Clinical evaluation. JProsthet dent 1971 ;25:608-618.

Indian J Dent Adv 2011; 3 Suppl 1: 750-753