Year : 2008 | Volume
: 19 | Issue : 3 | Page : 257--260
Prosthetic rehabilitation of edentulous mandibulectomy patient: A clinical report
Department of Prosthodontics, Manipal College of Dental Sciences, MAHE University, Manipal, India
Department of Prosthodontics, Manipal College of Dental Sciences, MAHE University, Manipal
Segmental resection of the mandible commonly results in deviation of the mandible to the defective side. The amount of deviation depends on the amount of hard and soft tissue involvement, the method of surgical site closure, the degree of impaired tongue function, the number of remaining teeth and the extent of loss of sensory and motor innervations. Prosthodontic treatment along with physical therapy may be useful in reducing mandibular deviation and improving masticatory efficiency. This clinical report describes the use of two rows of nonanatomic teeth on the unresected side. This provided a broader occlusal table and improved masticatory efficiency in our edentulous madibulectomy patient.
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Prakash V. Prosthetic rehabilitation of edentulous mandibulectomy patient: A clinical report.Indian J Dent Res 2008;19:257-260
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Prakash V. Prosthetic rehabilitation of edentulous mandibulectomy patient: A clinical report. Indian J Dent Res [serial online] 2008 [cited 2020 Feb 29 ];19:257-260
Available from: http://www.ijdr.in/text.asp?2008/19/3/257/42961
One of the most challenging and demanding maxillofacial endeavors is the construction of functional, complete dentures for the edentulous patient who has undergone a mandibular resection. Segmental resection of the mandible results in special physiological and esthetic problems, especially if condylectomy has been performed. The most significant difficulty encountered is mandibular deviation towards the defective side. , There are multifactorial causes for the deviation including the extent of osseous and soft tissue involvement, the loss of sensory and motor innervations, the type of wound closure and certain additional forms of treatment that the patient might have received.
Both mandibulectomy and commando procedure involve an extensive loss of tissues and associated function.  The greater the loss of tissues, greater will be the deviation of the mandible to the resected side, thus compromising the prognosis of the prosthetic rehabilitation to a greater extent. Apart from deviation, other dysfunctions in such patients are observed in swallowing, speech, control of saliva, mandibular movements, mastication, respiration and psychic functioning.  This type of dysfunction radically alters the prosthetic prognosis. The degree of impairment depends not only on the extent and type of surgery, but also on specific vulnerability of each function. Based on the nature of resection, Cantor and Curtis (1971) devised a prosthetic classification that is as follows: 
Class I - Radical alveolectomy with preservation of mandibular continuity
Class II - Lateral resection of the mandible distal to the cuspid
Class III - Lateral resection of the mandible and maxilla
Class IV - Lateral bone graft surgical reconstruction
Class V - Anterior bone graft surgical reconstruction
Class VI - Resection of the anterior portion of the mandible without reconstructive surgery to unite the lateral fragments
There are several unfavorable, physical limitations when rehabilitating completely edentulous patients with resected mandibles. ,, This include resected skin grafts, scar tissue and deviation of the resected mandibles, limited coordinative ability, resorbed ridges and limited posterior throat form due to obliteration by the grafts. One of the basic objectives in rehabilitation is to retrain the muscles for mandibular denture control and repeated occlusal approximation.
A treatment option available for the treatment of edentulous patients to achieve optimal function is a palatal ramp on the maxillary denture as described by Swoope.  Rosenthal suggested two rows of maxillary posterior teeth on the unresected side. , Two cases , have been reported in literature where two rows of teeth were used to rehabilitate the edentulous hemi-mandibulectomy patient. In the past, artificial temporo-mandibular joints have been used to rehabilitate the edentulous patient, but they are not in use anymore.  Another technique uses two positional records: one in a deviated position and the other in the functional position. The occlusion is cleared between these positions to provide a range of possible occlusal contacts. This article describes the use of two rows of maxillary teeth on the unresected side in a patient who had undergone partial mandibulectomy.
A 74 year-old, completely edentulous, male patient was referred to the Department of Prosthodontics in Manipal College of Dental Sciences, Manipal. He complained of difficulty in eating and speaking. The patient's history indicated that he had a tobacco-chewing habit since 40 years and was a chronic alcoholic since 12 years. He was diagnosed with squamous cell carcinoma of the right buccal mucosa (T 4 , N 0 , and M 0 ) about two years back.
His medical history revealed that he had undergone an extensive resection of the mandible distal to the right lower canine region, together with radical neck dissection and a bite commando operation about 20 months ago. The reconstruction had been done with a pectoralis major myocutaneous flap and he had had postoperative radiotherapy for six months. An extraoral examination showed an asymmetrical face, concave profile and an ovoid face [Figure 1]. There was deviation of the mandible to the right side. Right-side facial paralysis was noted because of resection of the facial nerve during Commando operation. On palpation, the ridge on the right lower site was found to be present only till the first premolar region. The flap extended and filled the space posterior to this region [Figure 2]. An ortho-pantomogram (OPG) revealed resection of the mandible distal to the lower canine involving the ramus, coronoid process and condyle [Figure 3]. This represented class II type of resection according to the Cantor and Curtis classification.
Preliminary impressions were made with irreversible hydrocolloid using polycarbonate trays (Superform trays, Vannini Dental Industry, Italy). Casts were prepared and acrylic resin impression trays were constructed. The tray was border-molded with modeling plastic (DPI Tracing stick, Dental products of India, Mumbai, India), taking care to avoid overextention.  Final impressions were made with medium-body vinyl polysiloxane (Reprosil, Dentsply/ Caulk, Milford, DE). This impression material was chosen to produce minimal tissue displacement. Master casts were poured with Type III dental stone (DPI, Mumbai, India). Stabilized record bases were made with self-cure acrylic (DPI, Mumbai, India) using the sprinkle-on technique. Wax rims were adjusted until a tentative occlusal vertical dimension was established. Face bow transfer was made to orient the maxillary cast to the semi-adjustable articulator (Whip-Mix corp; Louisville, Ky). The patient was asked to move his mandible as far possible to the untreated side and then, gently lower his jaw into position to record a functional maxillomandibular relationship. , The lower rim was mounted using standard horizontal and lateral condylar inclination values (30° and 0° respectively). 
The teeth were arranged in the usual manner; semi-anatomic posterior teeth (Lactodent, Pyrax polymers, Roorkee, India) were used. Two rows of maxillary posterior teeth were arranged on the unaffected side. Occlusal surfaces of these teeth were ground so as to provide freedom of movement in the lateral direction. A Monson curve was incorporated so as to orient the mandibular segment by deflecting it outwards. A wax set-up was tried in the mouth and was checked for esthetics, phonetics, occlusal vertical dimension and occlusion [Figure 4]. A posterior palatal seal was recorded in the usual manner and the dentures were waxed, processed and remounted and the occlusion was refined. Freedom of movement and lack of cuspal intercuspation was checked before denture insertion. The dentures were evaluated intraorally and the mandible was manipulated to the static centric position area [Figure 5], [Figure 6]. Any interference in normal movements was corrected. The dentures were removed, repolished and then reinserted. The patient was given routine postinsertion instructions and was motivated to make efforts to learn to adapt to the new dentures. Simple exercises were suggested to the patient such as repeated opening and closing of mandible. This helped the patient 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. Within a week, the patient expressed satisfaction in mastication and phonetics [Figure 7].
Successful rehabilitation of edentulous mandibulectomy patients is more difficult than that of a dentulous patient. Sharry  described the difficulties encountered as:
Limited coverage and retentionGrossly impaired relation of the mandible to the maxillaLimited movement of the mandible
Loss of facial structures and sensory and motor innervation complicates the control factor and together with the reduced denture base, contributes to a difficult complete-denture situation. The maxillo-mandibular relation cannot be recorded with any degree of accuracy in a deviated position so that a satisfactory occlusion is difficult to achieve. The occlusion is usually developed in the static centric position area. ,, This position is achieved by the patient comfortably though it is not truly repeatable as a centric relation.
Providing two rows of teeth on the unresected side of the maxillary denture helped in providing a broader occlusal table. , 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 helped in restoring the function whereas the outer row helped in supporting the cheeks and enhancing the esthetics. The semi-anatomic teeth with minimal occlusal grinding helped in controlling the deviation better than a plane acrylic palatal ramp would have. Lateral forces were minimized and the stability of the denture was improved.
As described in this report, the two rows of teeth on the unresected side definitely improved patient mastication and reduced the deviation of the mandible to a certain extent. The vertical dimension of the occlusion was reestablished and proper lip contour, fullness and support was restored. Simple exercises with the prosthetic treatment helped the patient to achieve stabilizing occlusal contact and hence, an increased masticatory efficiency. The patient has been followed up for eight months now. He has expressed satisfaction with the mastication and esthetic outcome.
Certain basic principles of construction of conventional dentures should be modified for mandibular resection patients because of many restrictive physical factors. In edentulous patients, a broad occlusal table developed 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. The philosophical approach to the treatment and rehabilitation of edentulous patients with resected mandibles is not in concentrating on what has been sacrificed in the eradication of the disease, but rather in taking full advantage of the remaining structures.
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