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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 7  |  Issue : 4  |  Page : 115-118

Prosthodontic rehabilitation of an edentulous hemimandibulectomy patient


1 Senior Lecturer, Department of Prosthodontics, Dr. G. D. Pol Foundation's, Yerala Medical Trust's Dental College and Hospital, Navi Mumbai, Maharashtra, India
2 Professor and Head, Department of Prosthodontics, Dr. G. D. Pol Foundation's, Yerala Medical Trust's Dental College and Hospital, Navi Mumbai, Maharashtra, India
3 Reader, Department of Prosthodontics, Dr. G. D. Pol Foundation's, Yerala Medical Trust's Dental College and Hospital, Navi Mumbai, Maharashtra, India
4 Consultant Oral and Maxillofacial Surgeon, Baba Jeevan Singhji Memorial Medical Centre, Gurudwara Sri Dashmesh Darbar, Guru Teg Bahadur Nagar, Mumbai, Maharashtra, India

Date of Submission17-Oct-2020
Date of Acceptance09-Nov-2020
Date of Web Publication29-Dec-2020

Correspondence Address:
Dr. Saumil Chetan Sampat
103/104, Cairo CHS, Skyline Oasis, Premier Road, Ghatkopar (West), Mumbai - 400 086, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpcdr.ijpcdr_44_20

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  Abstract 


Edentulous patients with lateral discontinuity defects of the mandible pose a challenge for the prosthodontist. With variable degrees of bony and soft-tissue resection, the prosthodontic prognosis is dependent on a number of complex factors. Complete dentures in such patients are primarily given for improvement of esthetics. In a selected few patients, however, such prosthesis may improve speech and masticatory function. This case report describes the use of two rows of nonanatomic teeth (in the maxillary denture) on the unresected side to broaden the occlusal table, thus fulfilling the patient's needs and requirements.

Keywords: Hemimandibulectomy, prosthodontic, rehabilitation, squamous cell carcinoma, two rows of nonanatomic teeth


How to cite this article:
Sampat SC, Saloni M, Parmeet B, Vinay D, Amol D. Prosthodontic rehabilitation of an edentulous hemimandibulectomy patient. Int J Prev Clin Dent Res 2020;7:115-8

How to cite this URL:
Sampat SC, Saloni M, Parmeet B, Vinay D, Amol D. Prosthodontic rehabilitation of an edentulous hemimandibulectomy patient. Int J Prev Clin Dent Res [serial online] 2020 [cited 2021 Jan 24];7:115-8. Available from: https://www.ijpcdr.org/text.asp?2020/7/4/115/305291




  Introduction Top


Squamous cell carcinoma is by far the most common histology found for tumors of the oral cavity. Oral subsites that may be the locus for primary tumors include the oral tongue, floor of the mouth, retromolar trigone, upper and lower gingiva, hard palate, buccal mucosa, and the oral lips. Advanced local disease and lymph node metastasis are associated with poor prognosis, which is reflected in the current American Joint Committee on Cancer (AJCC) staging system.[1] Lymph node metastases are present in approximately 45% of patients diagnosed with oral squamous cell carcinoma, and the presence of lymph node disease decreases the patient's survival by approximately 50%. The mainstay of treatment for these patients is surgical resection, neck dissection, and postoperative radiation treatment directed at the primary site of disease and the draining nodal basins in the neck. Segmental resection of the mandible results in considerable physiological and esthetic problems, especially if condylectomy has been performed. Following such a surgical procedure, the remaining mandibular segment is often retruded and deviated toward the surgical side.[2] The severity of deviation is further complicated by scar contracture, muscle imbalance secondary to motor control deficits, and the type of wound closure employed. Apart from mandibular deviation, associated dysfunctions may include trismus, inadequate salivary quantity and quality, compromised health of oral mucous membrane, and aberrant jaw relationships. Complete dentures in such patients thus serve primarily to improve esthetics and lip and cheek contours and replace missing teeth. While few authors[3],[4],[5] have rehabilitated edentulous hemimandibulectomy patients with maxillary palatal ramps on unresected side, some have used modified palatal ramps using twin rows of teeth.[6],[7],[8] However, most of these case reports in the literature deal with partially edentulous patients and very few[9],[10],[11] are related to completely edentulous patients. We, the authors, present a case of rehabilitation of an edentulous hemimandibulectomy patient by utilizing twin rows of maxillary posterior teeth on the untreated side.


  Case Report Top


A 75-year-old male patient referred to the private practice with the chief complaint of difficulty in chewing food due to the deviation of jaw and missing teeth and wanted replacement of teeth. The patient gave a history of supari chewing for 20 years, 8–10 times/day. The patient was diagnosed with early squamous cell carcinoma involving left buccal mucosa and mandibular alveolus; the lesion was about 2 to 3 cm and with a lymphadenopathy involving the left submandibular lymph nodes. According to the AJCC tumor staging guidelines,[1] the lesion was staged as Stage II; thus, left-side hemimandibulectomy with modified radicular neck dissection was performed and the defect was reconstructed by using pectoralis major myocutaneous flap 6 months ago. Radiation therapy was completed a month before. Extraoral examination [Figure 1] revealed facial asymmetry, deviated lower third of the face, decreased mouth opening, significant deviation of the mandible to the left side on mouth opening, left corner of mouth drooping downward, angular cheilitis, and left condyle and ramus absent on palpation. Intraoral examination revealed left mandibular defect distal to lateral incisor, surgical skin graft seen on resected side, edentulous right side, and edentulous upper jaw. An orthopantomogram [Figure 2] revealed resection of the mandible distal to the lower left lateral incisior involving the ramus, coronoid process, and condyle. This represented Class II type of resection according to the Cantor and Curtis classification.[12] Maxillary preliminary impression was made using medium fusing impression compound (Aslate, Asian Acrylates, Mumbai, Maharashtra, India), while mandibular impression was made with irreversible hydrocolloid (Tropicalgin, Zhermack SpA, Italy) using a stock metal nonperforated tray. Casts were prepared with dental plaster (Kaldent, Kalabhai Karson Pvt Ltd., Mumbai, Maharashtra, India) and acrylic resin (DPI® RR Cold Cure, Dental Products of India, Mumbai, Maharashtra, India) impression trays were constructed. The tray was border molded with modeling plastic (DPI® Tracing stick, Dental products of India, Mumbai, Maharashtra, India), taking care to avoid over extensions. Final impressions were made with light-body vinyl polysiloxane (Flexceed, GC, India). Final casts were poured with Type III dental stone (Kalstone, Kalabhai Karson Pvt. Ltd., Mumbai, Maharashtra, India). Record bases were made with self-cure acrylic (DPI®RR Cold Cure, Dental Products of India, Mumbai, Maharashtra, India) using the sprinkle-on technique. Wax rims (Modelling wax-Regular, Maarc, Shiva Products, Mumbai, Maharashtra, India) were adjusted until a tentative occlusal vertical dimension was established. The patient's tactile sense and sense of comfort were used to determine the vertical dimension of occlusion. The patient was advised to move the mandible as far as possible to the untreated side manually and then gently close the jaw into position to record a functional maxillomandibular relationship.[3],[13] Maxillary cast was mounted using facebow record (Hanau Spring bow; Whip-Mix Corporation, Louisville, KY, USA) on a semi-adjustable articulator (Hanau Wide-Vue; Whip-Mix Corporation, Louisville, KY, USA) and mandibular with reference to the recorded jaw relation. The teeth were arranged in the usual manner; semi-anatomic posterior teeth (Acry Rock, Ruthinium Dental Products (P) Ltd., India) were used. Two rows of maxillary posterior teeth were arranged on the unaffected side. Occlusal surfaces of these teeth were ground to provide freedom of movement in the lateral direction. A wax setup was tried in the mouth and was checked for esthetics, phonetics, vertical dimension, and occlusion. The trial dentures were waxed, processed, and remounted and the occlusion was refined. Any interference that may hamper freedom of movement was checked and removed before denture insertion. The dentures were evaluated intraorally and the mandible was manipulated to the static centric position area. Any interference in normal movements was corrected. The patient was given routine postinsertion instructions along with a denture maintenance kit (Replay Denture Kit, ICPA Health Products Ltd., Mumbai, Maharashtra, India) and was motivated to make efforts to learn to adapt to the new dentures [Figure 3]. Simple exercises such as repeated opening and closing of mandible were suggested to the patient to better adapt to the new dentures. This helped the patient to learn to manipulate the lower denture into the proper position. Initially, retention of the dentures, especially of the lower one, was a problem, but this improved with constant use. Recall checkup was done at regular intervals and within a week; the patient expressed satisfaction in mastication and phonetics [Figure 4].
Figure 1: Frontal view showing mandibular deviation toward the resected side

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Figure 2: Orthopantomogram showing the resected mandible

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Figure 3: Finished dentures

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Figure 4: Frontal view showing restored vertical dimension and acceptable post denture insertion aesthetics

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  Discussion Top


The prosthetic rehabilitation of edentulous patients with lateral discontinuity defects is challenging.[2] Most often, the results obtained in improving the “quality of life” of these patients are far from satisfactory. While guide flange appliance[2],[7],[8] can be successfully used in dentulous patients, they cannot be used in edentulous patients. The basic objective in rehabilitation of such cases should be retraining the remaining mandibular muscles to stabilize the mandibular denture by providing an acceptable maxilla–mandibular relationship of the remaining portion of the mandible with repeated occlusal approximation in restoring occlusal function. In the present case, the final contours of the mandibular denture were obtained by recording the maximum depth of the lingual sulcus of the resected side using a close fitting custom tray and meticulous border molding procedure. Recording the maxilla–mandibular relation was a challenge in this particular case, as no single static point of closure was obtained. Thus, developing occlusion in such cases necessitates the use of semi-anatomic teeth. Some authors[3],[5] have suggested the use of ramps on the maxillary teeth. These ramps should be approximately 5–10 mm wide depending on the extent of the mandibular deviation. In the present case, an attempt has been made to modify the ramp by providing twin rows of teeth on the uninvolved side of the maxillary denture to provide freedom in movement of the mandible at the established vertical dimension. Providing two rows of teeth on the unresected side of the maxillary denture helped in providing a broader occlusal table.[6],[7],[8],[9],[13],[14] Semi-anatomic teeth were used for esthetics, while occlusal grinding was done to provide freedom in lateral movements. This helped in minimizing lateral stresses that would otherwise have displaced the mandibular prosthesis. The teeth slide over one another down the incline formed by the second row of teeth and into a functional occlusal position. The inner row of teeth helped in restoring masticatory function, while the outer row of teeth provided esthetics and cheek fullness.


  Conclusion Top


The rehabilitation of an edentulous hemimandibulectomy patient with a removable prosthesis can have several shortcomings. Steps further from the conventional principles of complete denture prosthodontics need to be applied for rehabilitation for such patients. Developing a broad occlusal table in the maxillary arch on the unaffected side will help to position the residual fragment into the correct sagittal relationship, enhance the stability of the dentures, and thus, improve masticatory ability. Surgical reconstruction by implants and grafts of various types is the ideal treatment when feasible. However, it is not always feasible in every patient, and alternative prosthodontic approaches need to be resorted to.

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.
Amin MB, Edge SB, Greene FL, Byrd DR, Brookland RK, Washington MK, et al., editors. AJCC Cancer Staging Manual. 8th ed. New York: Springer; 2017.  Back to cited text no. 1
    
2.
Beumer J, Marunick MT, Esposito SJ. Maxillofacial Rehabilitation. 3rd ed. USA: Quintessence; 2011. p. 87-9, 118-20.  Back to cited text no. 2
    
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Swoope CC. Prosthetic management of resected edentulous mandibles. J Prosthet Dent 1969;21:197-202.  Back to cited text no. 3
    
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Schaaf NG. Oral reconstruction for edentulous patients after partial mandibulectomies. J Prosthet Dent 1976;36:292-7.  Back to cited text no. 4
    
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Prakash V. Prosthetic rehabilitation of edentulous mandibulectomy patient: A clinical report. Indian J Dent Res 2008;19:257-60.  Back to cited text no. 6
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Koralakunte PR, Shamnur SN, Iynalli RV, Shivmurthy S. Prosthetic management of hemimandibulectomy patient with guiding plane and twin occlusion prosthesis. J Nat Sci Biol Med 2015;6:449-53.  Back to cited text no. 7
    
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Marathe AS, Kshirsagar PS. A systematic approach in rehabilitation of hemimandibulectomy: A case report. J Indian Prosthodont Soc 2016;16:208-12.  Back to cited text no. 8
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Agarwal S, Praveen G, Agarwal SK, Sharma S. Twin occlusion: A solution to rehabilitate hemimandibulectomy patient A case report. J Indian Prosthodont Soc 2011;11:254-7.  Back to cited text no. 9
    
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Rosenthal LC. The edentulous patient with jaw defects. Dent Clin North Am 964;8:773-9.  Back to cited text no. 10
    
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Ufuk H, Sadullah U, Ayhan G. Mandibular guidance prosthesis followingresection procedures: Three case reports. Eur J Prosthodont Rest Dent 1992;1:69-72.  Back to cited text no. 11
    
12.
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. 12
    
13.
Desjardins RP. Occlusal considerations for the partial mandibulectomy patient. J Prosthet Dent 1979;41:308-15.  Back to cited text no. 13
    
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Sahu KS, Motwani BK, Dani A. Prosthetic rehabilitation of edentulous hemimandibulectomy patient: A case report. Clin Case Rep 2017;5:1739-42.  Back to cited text no. 14
    


    Figures

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



 

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