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					              Journal of Nepal Dental Association (2011), Vol. 12, No. 1, Jan.-Jun., 58-60


                                                                                                             Case Note

Prosthetic  rehabilitation   of    edentulous                                                            segmental
mandibulectomy patient: A case report
Bhat AM1, D Krishna Prasad2, Gupta H3, Hegde R4
Professor, 2Professor and Head of the Department, 3Post Graduate Student, 4Reader, Department of Prosthodontics, A. B. Shetty
1


Memorial Institute of Dental Sciences, Mangalore




    Abstract:
    An understanding of postsurgical anatomy and physiology is an obvious prerequisite to the development of new
    prosthetic procedures for mandibulectomy patients. Loss of the potential basal seat area, atrophic and fragile
    oral mucosa, reduction in salivary output, angular pathway of mandibular closure, deviation of the mandible and
    impairment of the motor and sensory control of the tongue, lips and cheeks make the fabrication of a prosthesis
    difficult in these situations. Several prosthetic options include sectional prosthesis, use of palatal ramp, setting
    double rows of teeth on the unresected side in maxilla and use of functional chew in technique. This article
    describes the use of two rows of maxillary posterior teeth on the unresected side in a patient who had undergone
    segmental mandibulectomy. The inner row helped in restoring the function whereas the outer row helped in
    restoring the cheek support and esthetics.

    Key words: Segmental mandibulectomy, Double rows of teeth


Introduction                                                        Class VI: Similar to class V, except that the mandibular
One of the most consistently difficult areas of maxillofacial        continuity is not restored.
rehabilitation is the treatment of edentulous patients
who have had a radical cancer surgery of the tongue,                Schaaf2 in 1976 outlined various factors to be considered
floor of the mouth and mandible. Only a complete                     in partial mandibulectomy patient who are also completely
understanding will permit functional utilization of these           edentulous. These are amount of mandible remaining,
unusual postoperative anatomic conditions1.                         amount of deviation, remaining kinesthetic sense and
                                                                    control, actual present ridge relationship, nature of
Cantor and Curtis1 (1971) devised a prosthetic                      denture bearing areas, status of the patient’s disease,
classification that is as follows:                                   type of the treatment patient has received, preoperative
Class I: Mandibular resection involving alveolar defect             success with complete dentures and overall vigor of the
with preservation of mandibular continuity                          patient.
Class II: Resection defects involve loss of mandibular
continuity distal to the canine area                                Both mandibulectomy and Commando’s procedure
Class III: Resection defect involves loss up to the                 involve an extensive loss of tissues and associated
mandibular midline region.                                          function. The most significant difficulty encountered is
Class IV: Resection defect involves the lateral aspect              mandibular deviation towards the defective side. The
of the mandible, but are augmented to maintain                      greater the loss of tissues, greater will be the deviation
pseudoarticulation of bone and soft tissues in the region           of the mandible to the resected side, thus compromising
of the ascending ramus.                                             the prognosis of the prosthetic rehabilitation to a greater
Class V: Resection defect involves the symphysis and                extent. Apart from deviation, other dysfunctions in such
parasymphysis region only, augmented to preserve                    patients are observed in swallowing, speech, control of
bilateral temporomandibular articulations.                          saliva, mandibular movements, mastication, respiration
                                                                    and psychic functioning3.

Correspondence
Dr. Himanshu Gupta, Senior Lecturer, Department of Prosthodontics, Sardar Patel Post Graduate Institute of Dental and Medical
Sciences, Rai Baraeli Road, Lucknow, (U.P). E-mail: himanshumds@gmail.com


J. Nepal Dent. Assoc. (2011), Vol. 12, No. 1                   58
Treatment options are varied and several authors have               unresected side were planned.
taken different approaches in these situations. Swoope4
described the use of palatal ramp prosthesis to correct             Primary impressions were made using alginate
deviation. However he believed in sectional mandibular              (Neocolloid, Dentsply) with stock trays. Lower stock
complete dentures and said that nothing is gained by                tray was modified with modeling wax on the left side.
extension onto the movable and unsupported tissues                  Custom trays were fabricated using self cure resin (DPI-
of the surgical site. Schaaf2 and Rosenthal5 suggested              RR, Mumbai, India). Border moulding and secondary
setting of double rows of maxillary teeth on the unresected         impression were made with greenstick compound and
side. The inner row helped in restoring the function                zinc oxide eugenol impression paste for maxillary arch
whereas the outer row helped in restoring the cheek                 while putty consistency (Zetaplus, Zhermac Clinical,
support and enhancing the esthetics. The variations in              Italy) and light body condensation silicone (Oranwash
closure of the jaws is observed in this technique on right          L, Zhermac Clinical, Italy) was used for mandibular arch
and left side and then a central and relaxed position               (Fig. 1) and cast poured in dental stone (Fig. 2).
is recorded. Another technique by Cantor and Curtis6
involved functional chew in of the maxillary posterior              Self cure resin record bases were made and occlusion
wax blocks while lower denture in mouth.                            rims fabricated. Additional block of wax was put in
                                                                    maxillary posterior unresected segment to support the
Case report                                                         lower wax rim while the patient closes. Wax rims were
A 48 yr old male patient reported to the Department                 then adjusted until a tentative vertical jaw relation was
of Prosthodontics, A.B. Shetty Memorial Institute of                established. A face bow transfer was done and the
Dental Sciences, Mangalore after surgery and radiation              maxillary cast mounted on Girrbachs (Artex) non arcon
for squammous cell carcinoma involving left alveolus.               semi adjustable articulator. For horizontal registration,
Segmental mandibulectomy and supraomohyoid                          patient was made to bring his mandible to unresected
neck dissection were performed six months back.                     side as far as possible without causing pain. The wax
Reconstruction was done using pectoralis major                      was softened and the position was sealed. The lower
myocutaneous flap. Over 1 1/2 months back he                         cast was mounted in this secured relation.
underwent post operative radiotherapy. This patient falls
under class II of Cantor and Curtis classification.                  Teeth arrangement was done while arranging two rows
                                                                    of teeth (Acry rock, Ruthinium, Valsad, India) in the
Clinical examination revealed total edentulousness and              maxillary posterior unresected side. Try in of the waxed
missing left mandible from canine region onwards. There             up denture was done and evaluated for esthetics,
was severe mandibular deviation towards the resected                speech, occlusion and vertical dimension. The dentures
side. As the patient was made to bring the mandible                 were then characterized, processed and occlusion
towards the right side, he complained of moderate pain              was adjusted (Fig 3). After finishing and polishing, the
in the right temporomandibular joint area. A decision was           prosthesis was inserted into the patient’s mouth. Any
then made to fabricate the complete denture prosthesis              occlusal interferences in normal range of movements
in repeatable and relaxed position. As the deviation was            were checked and corrected. Routine postinsertion
marked, two rows of maxillary posterior teeth on the                instructions were given to the patient




Fig 1: Mandibular secondary impression             Fig 2: Mandibular master cast                   Fig 3: Processed    complete
                                                                                                          dentures




                                                              59                     J. Nepal Dent. Assoc. (2011), Vol. 12, No. 1
Fig 4: Occlusion on the resected side          Fig 5: Occlusion on the unresected side      Fig 6: Before         Fig 7: After
                                                                                                   prosthesis            prosthesis
                                                                                                   insertion             insertion



Discussion
Four most important factors that effect rehabilitation                 accordance with Desjardins8, who stated that this easily
in mandibulectomy as listed by Cantor and Curtis are                   attainable maxillomandibular relationship may be more
location and extent of surgery, effect of radiation therapy,           conducive in achieving the goal of mandibular stability in
the presence or absence of teeth and psychosocial                      the mandibular denture.
factors7. Boucher stated that the amount of biting force
tolerated by a denture is directly proportional to the size            To conclude, in this segmental mandibulectomy case,
of tissue bearing area. Since mandibulectomy patients                  successful rehabilitation has been achieved by the use
have markedly reduced masticatory strength and little                  of two rows of maxillary posterior teeth on the unresected
hard and soft tissue support, it is important to record and            side and this can be considered as a viable treatment
utilize as broad a denture base area as possible6.                     option for these type of cases.

In many dentulous mandibulectomy patients, the guide                   References
flange is used as a training prosthesis, and its continued              1.   Cantor R, Curtis TA. Prosthetic management of edentulous
use can lead to eventual mandibular control without                         mandibulectomy patients. Part 1. Anatomic, physiologic
the prosthesis. However, patients who are edentulous                        and psychologic consideration. J Prosthet Dent 1971;25:
in the maxilla or mandible or both usually cannot be                        446-57.
considered for such a prosthesis because extreme                       2.   Scaaf NG. Oral construction for edentulous patients after
mediolateral forces placed on the prosthesis may                            partial mandibulectomies. J Prosthet Dent 1976;36:292-7.
prevent maintenance of border seal and lead to denture                 3.   Beumer J, Curtis T, Firtell D editors. Maxillofacial
instability8.                                                               rehabilitation. St. Louis: Mosby; 1979. p. 90-169.
                                                                       4.   Swoope CC. Prosthetic management of resected
In this case, two rows of maxillary posterior teeth                         edentulous mandible. J Prosthet Dent 1969;21:197-202
were arranged on the unresected side. This treatment                   5.   Rosenthal LC. The edentulous patient with jaw defects.
modality is in accordance to case reports by Schaff2                        Dent Clin North Am 964; 8:773-9.
and Rosenthal5. Desjardins8 also observed that in
                                                                       6.   Cantor R, Curtis TA. Prosthetic management of edentulous
edentulous patients and in patients who cannot attain                       mandibulectomy patients: Part II, Clinical procedures. J
the ideal mediolateral relation of the remaining segment,                   Prosthet Dent 1971; 25:546-55.
a maxillary table can provide a surface against which the
                                                                       7.   Curtis TA, Cantor R.The forgotten patient in maxillofacial
natural or artificial teeth of the mandible can occlude.                     prosthetics. J Prosthet Dent 1974; 31: 662-79.
                                                                       8.   Desjardins RP. Occlusal considerations for the partial
Also in this case, considerations were given to
                                                                            mandibulectomy patient. J Prosthet Dent 1979; 41:308-
acceptance of an easily achievable maxillomandibular
                                                                            15.
relationship rather than a strained one. This is in




J. Nepal Dent. Assoc. (2011), Vol. 12, No. 1                    60

				
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