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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 4  |  Issue : 2  |  Page : 103-106

Customizing guidance flange prosthesis for management of segmental mandibulectomy


1 Department of Prosthodontics, Sinhgad Dental College and Hospital, Pune, Maharashtra, India
2 Clove Dental Amar Colony, New Delhi, India

Date of Web Publication11-Dec-2015

Correspondence Address:
Bhushan Satish Gaikwad
E/602 Nancy Lake Homes, Opposite Bharati Vidyapeeth, Katraj, Pune - 411 046, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-4696.171547

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  Abstract 

Treatment of benign and malignant tumors may involve surgical resection of the mandible, which may be segmental or hemisectioned. The prosthetic rehabilitation of resected mandible becomes difficult when preprosthetic planning is not considered. Preprosthetic plastic surgery and/or implant assisted overdenture may enhance the prosthetic rehabilitation of edentulous patients who have undergone resection of the mandible. Due to medical conditions, unwillingness for additional surgery or economical restraints, the treatment is limited to guidance flange prosthesis. The guidance flange prosthesis helps in directing the deviating mandible to improve form and function. This case report describes a procedure for fabricating customized guiding flange prosthesis to rehabilitate edentulous segmental mandibulectomy.

Keywords: Customized flange, denture prosthesis, guiding flange, hemimandibulectony, segmental resection


How to cite this article:
Gaikwad BS, Badgujar MS. Customizing guidance flange prosthesis for management of segmental mandibulectomy. J Dent Allied Sci 2015;4:103-6

How to cite this URL:
Gaikwad BS, Badgujar MS. Customizing guidance flange prosthesis for management of segmental mandibulectomy. J Dent Allied Sci [serial online] 2015 [cited 2019 Aug 24];4:103-6. Available from: http://www.jdas.in/text.asp?2015/4/2/103/171547


  Introduction Top


Treatment of a surgically resected mandible involves rehabilitation of form and function. Rehabilitation of the defect becomes difficult when preprosthetic planning is not considered. Mandibular discontinuity results in medial deviation of the residual jaw segment. [1] The list of dysfunctions also includes compromised esthetics, difficulty in mastication, swallowing, speech, mandibular movements, control of saliva, psychic function, and respiration. [2] The degree of deviation and prognosis of edentulous mandibular guidance prosthesis depends on the amount of remaining bone and soft tissue. [3],[4],[5],[6]

Reconstructive plastic surgery and/or implant assisted prosthesis must be considered to provide a favorable attached tissue foundation and improve prosthetic rehabilitation. [7],[8],[9] Due to patients financial limitations, the reconstructive surgical procedure and or implant assisted prosthetic rehabilitative procedures are usually rejected. Without preprosthetic planning, the treatment of surgically resected mandible is invariably restricted to guidance prosthesis.

Guidance prostheses that help in the correction of mandibular deviation are of two types:

  1. Mandibular based guidance prostheses (or guiding flange prostheses) (GFP) and
  2. Palatally based guidance prostheses (or palatal ramp prostheses). [10],[11]


In the present case report, an alternative procedure has been described to fabricate a functionally customized GFP in an edentulous patient with Class II mandibular resection. [3]


  Case Report Top


A 65-year-old man reported to the Department of Prosthodontics in SMBT Dental College and Hospital, Sangamner, Maharashtra, India. The patient's chief complaints were missing teeth and inability to chew food. On taking the history of previous procedures, it was revealed that surgical resection was done in the lower right jaw region 6 years back. The patient was edentulous before the surgery.

Intraoral examination revealed an edentulous maxilla and mandible having a high well-rounded residual alveolar ridge (RAR) [Figure 1]. Discontinuity of the mandibular jaw was observed in the lower right posterior region, extending from the right cuspid region to condyle [Figure 1]. According to Cantor and Curtis, the defect may be classified as Class II. [3] Mild deviation of the mandible toward the right side with minimum soft tissue contractures and complete healing was observed. Considering that the RAR of the maxilla and mandible were well-formed, fabrication of maxillary complete denture and mandibular GFP were decided.
Figure 1: Intraoral photograph

Click here to view


Treatment phase

  1. Maxillary and mandibular impressions were made, and master cast was obtained.
  2. Maxillary and mandibular record bases were fabricated followed by the fabrication of wax occlusal rims along the crest of RAR for both arches.
  3. Maxillary wax occlusion rim was adjusted for visibility, and the occlusion plane was made parallel to the Camper's line (ala-tragus line).
  4. Orientation relation was recorded using a face bow (HANAU Spring Bow, Whip Mix, USA) followed by establishing vertical dimension and recording centric maxillomandibular relation (MMR) and transferred to semi-adjustable articulator (HANAU Wide-Vue Arcon Articulator, Whip Mix, USA).
  5. Centric MMR was recorded by manual manipulation of the mandible. The maxillary and mandibular wax occlusal rims were observed to ensure that the buccal surfaces were flushed and occlusal surfaces made uniform contact. The jaw was manipulated to achieve a hinging motion.
  6. Artificial teeth arrangement was done with the central groove of the teeth falling on the crest of RAR.
  7. Modeling wax was adapted on buccal surfaces of the left maxillary premolars and molars. Autopolymerizing acrylic resin was adapted on the modeling wax and fused to the mandibular record base forming a guiding flange.
  8. Maxillary and mandibular waxed up trial dentures were inserted, and occlusion was evaluated.
  9. Following the verification of waxed up trial dentures, modeling wax was removed from the guiding flange, and a layer of carding wax was adapted.
  10. The patient was guided in centric occlusion and instructed to open the mouth and stop, after which the jaw was guided back in centric occlusion.
  11. The procedure was repeated 2-3 times acquiring a satisfactory grooving carved pattern over the carding wax. The maxillary premolars and molars carved out the carding wax during jaw opening movement, creating a pathway for guiding the jaw in centric occlusion.
  12. Die stone was poured over carding wax to fabricate an index to facilitate reproduction of the grooving pattern on the final prosthesis.
  13. Two orthodontic wires were bent at both the ends to form loops. One looped end was embedded in die stone that would form the index.
  14. The other looped end will get incorporated in plaster during the flasking procedure while processing. After dewaxing procedure, the index will be retained in the counter flask with the help of the looped wires [Figure 2].
    Figure 2: Die stone index with orthodontic wires and customized guiding flange

    Click here to view
  15. The maxillary complete denture and mandibular GFP were waxed up and were processed conventionally.
  16. During finishing and polishing, care was exercised to preserve the grooving pattern on guiding flange, and polishing was done to achieve a flawless surface.
  17. The smooth surface of the guiding flange provided unhindered gliding of maxillary artificial premolars and molars, effectively correcting deviation of the residual mandibular segment.
  18. Insertion of maxillary complete denture and mandibular GFP were done [Figure 3].
    Figure 3: Prosthesis in function

    Click here to view
  19. The patient was recalled periodically to keep a follow-up and rectification of problems.



  Discussion Top


Rehabilitation of a resected edentulous mandible is a difficult task when compared to the rehabilitation of a dentulous jaw. In the presence of teeth, the cast partial prosthesis is able to obtain retention by engaging the undercuts on the teeth. In an edentulous situation, the prosthesis solely relies on RAR and factors responsible for the success of a complete denture.

The deviation of mandible toward surgical side occurs due to loss of tissue continuity inherent to surgical resection. [3] It is desired that the surgical reconstruction should be performed immediately following resective procedure of the jaw. The reconstructive procedure helps in improving masticatory function and corrects facial symmetry to some extent, most importantly; the procedure limits the deviation of the residual segment toward the resected side.

To minimize the deviation of the residual mandibular segment, guidance therapy should be initiated promptly to re-establish the correct path of closure. [10] Guidance prosthesis has been fabricated for dentulous, partially edentulous, and also for edentulous conditions. Two types of guidance prostheses could be considered, a palatally based or palatal ramp prosthesis and mandibular based or GFP. When the residual mandibular segment closes, the palatal ramp guides the jaw by providing an inclined plane on which the mandibular teeth slide into occlusion with the maxillary teeth. Whereas in GFP, the buccal surface and the cusps of maxillary teeth make contact with the flange which generates a pulling force on the mandible guiding the jaw in desired relation. [10] In the presence of a greater degree of deviation, palatal ramp prosthesis is opted, whereas if the deviation is not severe, a GFP is preferred.

Customized guiding flange prosthesis was attempted in a patient with resected mandible that was classified as Class II. [3] Mastication was the primary concern of the patient. The patient did not have major facial asymmetry and was not concerned with esthetics. The patient had reported in an edentulous state with good RAR height and width in both the jaws. Due to well-formed mandibular RAR, the prognosis of the mandibular prosthesis was predicted favorable. Conventional complete denture with guiding flange was planned; therefore, functionally customized guiding flange was fabricated to rectify mandibular deviation.

Usually, the GFP is modified in a chair side situation and is re-lined by autopolymerizing acrylic resin making the procedure more or less arbitrary. In the present case, the entire prosthesis was fabricated in heat-polymerized acrylic resin. Fabricating the prosthesis in heat-polymerized acrylic resin has greater advantages as compared to autopolymerized acrylic resin such as better finish, greater physical and mechanical properties, and minimum residual monomer in comparison to autopolymerized acrylic resin.

The described procedure does not require an additional appointment, as the guiding flange is recorded during the try-in of waxed up prosthesis. The procedure demands patients' cooperation while recording the path of deviation.

Customized guiding flange precisely directed the deviating residual mandibular segment in centric occlusion and provided a psychological comfort to the patient during various functional movements. The primary need of mastication was satisfied, and an improvement in the speech was also observed that was appreciated by the patient as well.


  Conclusion Top


This case report describes an alternative procedure for rehabilitation of the unfortunate patient, undergone segmental resection of the mandible. The procedure described here aims at improving the GFP treatment and also limits the number of appointments, as that of conventional complete denture treatment. However, preprosthetic planning should always be considered before surgical resection of the mandible.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Beumer J 3 rd , Curtis TA, Marunick MT. Maxillofacial Rehabilitation: Prosthodontics and Surgical Consideration. St. Louis: Ishiyaku Euro America; 1996. p. 184-8.  Back to cited text no. 1
    
2.
Buemer J, Curtis T, Firtell D. Maxillofacial Rehabilitation. St. Louis: Mosby; 1979. p. 90-169.  Back to cited text no. 2
    
3.
Cantor R, Curtis TA. Prosthetic management of edentulous mandibulectomy patients. I. Anatomic, physiologic, and psychologic considerations. J Prosthet Dent 1971;25:446-57.  Back to cited text no. 3
    
4.
Taylor TD. Clinical Maxillofacial Prosthetics. Chicago: Quintessence; 2000. p. 171-88.  Back to cited text no. 4
    
5.
Desjardins RP. Occlusal considerations for the partial mandibulectomy patient. J Prosthet Dent 1979;41:308-15.  Back to cited text no. 5
[PUBMED]    
6.
Cantor R, Curtis TA. Prosthetic management of edentulous mandibulectomy patients. II. Clinical procedures. J Prosthet Dent 1971;25:546-55.  Back to cited text no. 6
    
7.
Martin JW, Lemon JC, King GE. Maxillofacial restoration after tumor ablation. Clin Plast Surg 1994;21:87-96.  Back to cited text no. 7
    
8.
Marunick M, Mathog RH, Boyd SB. Functional outcome of an implant-retained edentulous mandibular resection prosthesis: A clinical report. J Prosthet Dent 1995;74:441-5.  Back to cited text no. 8
    
9.
Oelgiesser D, Levin L, Barak S, Schwartz-Arad D. Rehabilitation of an irradiated mandible after mandibular resection using implant/tooth-supported fixed prosthesis: A clinical report. J Prosthet Dent 2004;91:310-4.  Back to cited text no. 9
    
10.
Prencipe MA, Durval E, De Salvador A, Tatini C, Roberto B. Removable Partial Prosthesis (RPP) with acrylic resin flange for the mandibular guidance therapy. J Maxillofac Oral Surg 2009; 8:19-21.  Back to cited text no. 10
    
11.
Beumer J III, Marunick M, Silverman S Jr, Garrett N, Rieger J, Abemayor E, et al. Rehabilitation of tongue and mandibular defects. In Beumer J III, Marunick MT, Esposito SJ (eds): Maxillofacial Rehabilitation: Prosthodontic and Surgical Management of Cancer-Related, Acquired, and Congenital Defects of the Head and Neck (ed 3). Carol Stream, IL, Quintessence, 2011, p. 61-154.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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Abstract
Introduction
Case Report
Discussion
Conclusion
References
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