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 Table of Contents  
CASE REPORT
Year : 2023  |  Volume : 15  |  Issue : 1  |  Page : 57-60

Regaining mandibular position after hemimandibulectomy using ancillary maxillofacial prosthesis


1 Department of Prosthodontics, SRM Dental College, Chennai, Tamil Nadu, India
2 Department of Prosthodontics, Tamil Nadu Government Dental College, Chennai, Tamil Nadu, India

Date of Submission22-Mar-2022
Date of Decision07-Jun-2022
Date of Acceptance18-Jun-2022
Date of Web Publication29-Dec-2022

Correspondence Address:
Ahila S Chidembaranathan
Department of Prosthodontics, SRM Dental College, Ramapuram, Chennai - 600 089, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jorr.jorr_10_22

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  Abstract 


Fracture of any part of the mandible leads to deviation of the remaining portion of the mandible toward the fracture site and alteration of the biting surface of the teeth. Surgical resection of the mandible more commonly affects physiological, psychological, and esthetic effects of an individual. In such kind of patient, a buccal-based guidance appliance had an effective role in reducing or correcting the deviation of the mandible. This case report describes the prosthetic rehabilitation of resected mandible on the right side, and the deviation was corrected using guide flange ancillary maxillofacial prosthesis with a novel design. The guide flange prosthesis along with regular exercise minimizes the deviation of the mandible which further improves the masticatory efficiency and quality of life.

Keywords: Ameloblastoma, guide flange, hemimandibulectomy, maxillofacial prosthesis


How to cite this article:
Chidembaranathan AS, Thulasingam C. Regaining mandibular position after hemimandibulectomy using ancillary maxillofacial prosthesis. J Oral Res Rev 2023;15:57-60

How to cite this URL:
Chidembaranathan AS, Thulasingam C. Regaining mandibular position after hemimandibulectomy using ancillary maxillofacial prosthesis. J Oral Res Rev [serial online] 2023 [cited 2023 Jan 31];15:57-60. Available from: https://www.jorr.org/text.asp?2023/15/1/57/365911




  Introduction Top


Mandible is the only movable bone in the craniofacial region that forms the lower boundaries of the face, which aids in phonetics, esthetics, swallowing, mastication, and respiration. The most prevalent epithelial origin tumors in the oral cavity are ameloblastoma, which can be excised surgically along with the part of the mandible to prevent recurrence of the tumor.[1] The patients have altered speech, trouble in deglutition, less governance on the secretions of saliva, and disfigurement after surgery.[2]

After surgery, the healthy mandibular fragments hand down; hence, stabilization or rehabilitation of the defects can be done instantly after surgery or postponed until healing is completed.[3],[4] The goal of instant reconstruction of the mandible is to retain the facial symmetry, position of dental arches with teeth, stable occlusion, and masticatory function.[5],[6] Prosthetic rehabilitation following hemimandibulectomy is the most challenging and demanding procedure because the site, extent of resection, and loss of continuity markedly influence the masticatory function.[7],[8]

Achieving the normal maxillomandibular relations is clogged by extensive jaw resection, postsurgical complications, and radiation therapy. The mandibular guidance appliance and palatal-based guidance have an effective role in reducing the mandibular deviation.[9],[10] Guide flange prosthesis (GFP) is an ancillary dental prosthesis intended for the correction of mediolateral position of the mandible.[11] This clinical report describes early reestablishment of the mandibular position after postsurgical hemimandibulectomy of the right side of the mandible using guide flange ancillary maxillofacial prosthesis with a novel design.


  Case Report Top


A 45-year-old male patient referred to the Department of Prosthodontics, Tamil Nadu Government Dental College and Hospital, Chennai, with the complaints of deflection of the mandible toward the right side, drooping saliva through right-side corner of the mouth, and difficulty in chewing after excision of the mandible on the right side along with cheek muscles [Figure 1].
Figure 1: Mandibular deviation postoperative

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The previous records showed that the patient had ameloblastoma on the ramus of right side of mandible. On extraoral examination, midline shift and shifting of the mandible towards the right side while opening of the mouth and the mouth opening was about 15 mm. The resected area of the cheek was replaced with anterolateral thigh flap. Intraoral examination showed partially edentulous area in relation to 26 which is classified as Kennedy's Class III without occlusal contact. The defect was diagnosed as Cantor and Curtis Class III which denotes excision of the mandible from midline without surgical reconstruction, and the tag of muscles of suprahyoid on the residual mandibular fragment leads to inferior displacement.[12],[13] Intermaxillary fixation was given 1 month after surgical resection to reduce the severity of deviation and facilitate muscular revamping in the maxillofacial region.[14] It was found out that the patient was trained to bring the mandible in occlusion manually when the patient was unable to detain it consistently. The planned treatment was mandibular guide flange with a novel simple design in the early phase to correct deviation of mandible, followed by definitive partial denture prosthesis. The treatment was begun after briefly explained about the procedures, and the novel design of the ancillary prosthesis and procedure started after obtaining the informed consent from the patient and family members.

Procedure

A sectional plastic tray was used to make alginate (Zelgan Plus Alginate Impression Material (Dentsply, International, Inc., New York, USA) impression of the maxillary and mandibular arch [Figure 2] The impressions of the maxilla and mandible were filled with Type III gypsum product (Golden Stone, Golden Stone Ramaraju Traders, Chennai, Tamil Nadu). Bite registration was done while the mandible was moved away from resected site by manually guiding the mandible to centric occlusion with modeling wax (Hindustan Dental Products, Hyderabad, India). Then, the record was transferred to a mean value articulator. A 19-gauge rounded stainless steel orthodontic wire (KC Smith and Co, Monmouth, UK) was folded to fabricate guiding flange prosthesis and three 21-gauge wires crosses the teeth from buccal to lingual side canine, premolar, and molar area for retention purpose [Figure 3]. The buccal and lingual flanges were waxed up with modeling wax (Hindustan dental products, Hyderabad, India), and the projection of the wire was contacted the middle portion of the buccal surface of the left side maxillary second premolar and first molar teeth. Based on the amount of deviation and mouth opening, a mandibular guide flange prosthesis (GFP) was using autopolymerized polymethylmethacrylate resin (PMMA) resin (Dentsply India (DPI) Cold Cure pink; Dental products of India). Then, the initial stability and retention of guide flange prosthesis (GFP) were verified clinically; then, acrylic resin was added gradually onto the guide flange until there was smooth movement of the mandible to proper relation and delivering minimum force to maxillary teeth. After finishing and polishing of the prosthesis, it was inserted and the midline and occlusion were checked clinically [Figure 4]. The patient was advised to wear the GFP all over the day except at night and during meals. Physiotherapy was advised to minimize trismus and scar contraction and facilitate occlusion. Then, the patient was evaluated after ever month to check the deflection of mandible. The patient slowly intended to bring himself to the original position after 3 months of regular exercise with the prosthesis.
Figure 2: Maxillary and mandibular arch sectional impression

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Figure 3: Guide flange prosthesis

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Figure 4: Guide flange prosthesis placed on the mandible

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  Discussion Top


Fracture of the mandible causes discontinuity and deviation of the remaining mandible along with the excised part and alteration of occlusal plane on the fracture side, due to the muscular pull of mylohyoid, geniohyoid, stylohyoid, and digastric on the residual mandibular fragment.[15]

The objective of rehabilitation after hemimandibulectomy is helping the rest of the mandible to bring back to centric relation;[3] hence, the patient can repeat the hinge movements of mandible to achieve a functional occlusal relation.[16] The starting time of the treatment has a major role in success of mandibular resection cases. The correction of deviation after completion of 6–8 weeks is very difficult due to scar contraction.[13] Hence, the patient is advised to go for physiotherapy.[17],[18] This case report describes restoring of function after hemimandibulectomy with a novel GFP. The guide flange aids to minimize deflection of mandible and promote function and esthetics. This mode of treatment is helpful in patient's excision involves only bony structures, with less soft tissues.

A vertical projection from the guide flange prosthesis contacts the buccal surface of the opposing maxillary teeth.[12] The wire loop of GFP was localized to two premolars and a first molar to avoid the dislodging forces in the lingual crescent area. Although the lingual flange was short, it is enough to stabilize the guidance flange prosthesis (GFP). The authors did not notice any significant teeth movement after 3 months. Support for the guidance flange prosthesis (GFP) was obtained from the interalveolar ridge area with retentive wire incorporated into the prosthesis. The buccal and lingual flanges can be brought nearer by bending the occlusal cross-over wire to improve the retention. The limitation of the design is that it may change in shape due to the pull of the mandible force in the initial period of training.


  Conclusion Top


The current design of customized guide flange prosthesis is convenient, simple, efficient, and easy to fabricate which reduces the mandibular deviation and enhances chewing efficiency during the healing phase of mandibular resection.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Aramany MA, Myers EN. Intermaxillary fixation following mandibular resection. J Prosthet Dent 1977;37:437-44.  Back to cited text no. 1
    
2.
Desjardins RP. Early rehabilitative management of the hemi-mandibulectomy patient. J Prosthet Dent 1977;38:308-11.  Back to cited text no. 2
    
3.
Adekeye EO. Reconstruction of mandibular defect by autogenous bone grafts: A review of 37 cases. J Oral Surg 1978;36:125-30.  Back to cited text no. 3
    
4.
Schrag C, Chang YM, Tsai CY, Wei FC. Complete rehabilitation of the mandible following segmental resection. J Surg Oncol 2006;94:538-45.  Back to cited text no. 4
    
5.
Olson ML, Shedd DP. Disability and rehabilitation in head and neck cancer patients after treatment. Head Neck Surg 1978;1:52-8.  Back to cited text no. 5
    
6.
Curtis DA, Plesh O, Miller AJ, Curtis TA, Sharma A, Schweitzer R, et al. A comparison of masticatory function in patients with or without reconstruction of the mandible. Head Neck 1997;19:287-96.  Back to cited text no. 6
    
7.
Mou SH, Chai T, Shiau YY, Wang JS. Fabrication of conventional complete dentures for a left segmental mandibulectomy patient: A clinical report. J Prosthet Dent 2001;86:582-5.  Back to cited text no. 7
    
8.
Banerjee R, Banerjee S. Guiding flange prosthesis for a patient with a hemimandibulectomy defect: A clinical report. J Clin Diagn Res 2010;4:234753.  Back to cited text no. 8
    
9.
Nelogi S, Chowdhary R, Ambi M, Kothari P.A fixed guide flange appliance for patients after a hemi-mandibulectomy. J Prosthet Dent 2013;110:42932.  Back to cited text no. 9
    
10.
Sahu SK. Mandibular guide flange prosthesis following mandibular resection: A clinical report. J Clin Diagn Res 2010;4:326670.  Back to cited text no. 10
    
11.
Desjardins RP. Relating examination findings to treatment procedures. In: Laney WR, editor. Maxillofacial Prosthetics. Littleton: PSG Publishing; 1979. p. 69-114.  Back to cited text no. 11
    
12.
Beumer J, Curtis T, Marunick MT. Maxillofacial Rehabilitation: Prosthodontic and Surgical Consideration. 3rd ed. St. Louis: Ishiyaku Euro America; 1996. p. 184-8.  Back to cited text no. 12
    
13.
Santosh N, Ramesh C, Maheshwari A, Prachi K. A Fixed Guide flange appliance for patients after a hemi-mandibulectomy. J Prosthet Dent 2013;110:429-32.  Back to cited text no. 13
    
14.
Anyanechi CE, Saheeb BD. Prevention of collapse of the contralateral half of the mandible after hemi-mandibulectomy: Our experience in a low-resource center. J Orofac Sci 2017;9:106-10.  Back to cited text no. 14
  [Full text]  
15.
Taylor TD. Diagnostic considerations for prosthodontics rehabilitation of the mandibulectomy patient. In: Taylor TD, editor. Clinical Maxillofacial Prosthetics. Chicago: Quintessence Publishing; 2000. p. 15570.  Back to cited text no. 15
    
16.
Desjardins RP. Occlusal considerations for the partial mandibulectomy patient. J Prosthet Dent 1979;41:308-15.  Back to cited text no. 16
    
17.
Sahin N, Hekimoğlu C, Aslan Y. The fabrication of cast metal guidance flange prostheses for a patient with segmental mandibulectomy: A clinical report. J Prosthet Dent 2005;93:217-20.  Back to cited text no. 17
    
18.
Lingeshwar D, Appadurai R, Swedheni U, Padmaja C. Prosthodontic management of hemi-mandibulectomy patients to restore form and function – A case series. World J Clin Cases 2017;5:384-9.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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