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 Table of Contents  
Year : 2022  |  Volume : 14  |  Issue : 1  |  Page : 28-31

Prosthodontic rehabilitation using balancing ramp-guided flexible prosthesis in a squamous cell carcinoma patient treated with hemimandibulectomy

Department of Prosthodontics, Post Graduate Institute of Dental Sciences, Pt. B.D Sharma University of Health Sciences, Rohtak, Haryana, India

Date of Submission23-Aug-2020
Date of Decision26-Dec-2020
Date of Acceptance24-Jan-2021
Date of Web Publication31-Dec-2021

Correspondence Address:
Prachi Jain
Department of Prosthodontics, Post Graduate Institute of Dental Sciences, Pt. B.D Sharma University of Health Sciences, Rohtak - 124 001, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJDS.IJDS_144_20

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Loss of any anatomical structure leads to functional insufficiency and psychological trauma. Malignant neoplasms of mandible are often surgically treated by hemimandibulectomy which greatly affects the function postoperatively. The amount of dysfunction depends upon the size of resected segment, effect on tongue, number of remaining teeth, and the extent of loss of sensory and motor innervations. This clinical report describes the prosthodontic management of a squamous cell carcinoma patient treated with hemimandibulectomy and rehabilitated using balancing ramp-guided flexible prosthesis to accommodate mandibular deviation and limited mouth opening.

Keywords: Balancing ramp, guided flexible prosthesis, hemimandibulectomy, limited mouth opening, mandibular deviation

How to cite this article:
Rathee M, Jain P, Shetye AG, Alam M. Prosthodontic rehabilitation using balancing ramp-guided flexible prosthesis in a squamous cell carcinoma patient treated with hemimandibulectomy. Indian J Dent Sci 2022;14:28-31

How to cite this URL:
Rathee M, Jain P, Shetye AG, Alam M. Prosthodontic rehabilitation using balancing ramp-guided flexible prosthesis in a squamous cell carcinoma patient treated with hemimandibulectomy. Indian J Dent Sci [serial online] 2022 [cited 2022 Jul 4];14:28-31. Available from: http://www.ijds.in/text.asp?2022/14/1/28/334517

  Introduction Top

Oral rehabilitation after surgical treatment of neoplasia affecting the oral region is desirable but challenging.[1] Malignant tumors of the mandible are surgically treated by hemimandibulectomy which adversely affects speech and mastication.[2] The postsurgical mandibular discontinuity results in deviation toward the defect side and rotation of the mandibular occlusal plane inferiorly due to muscle pull and scar contracture. This leads to facial disfigurement, deranged occlusal contact of teeth, lip incompetency for saliva control, and difficulty in initiating swallowing.[3]

Cantor and Curtis gave a classification of mandibular defects for edentulous patients which can also be utilized for dentulous individuals.[4] The presence or absence of natural teeth in a resected mandible is the key factor in determining the prosthetic approach. The basic objective in rehabilitation of a discontinuity defect of the mandible is retraining the remaining mandibular muscles to provide an acceptable maxillomandibular relationship.[5]

This clinical report describes the prosthodontic management of a squamous cell carcinoma patient treated with hemimandibulectomy rehabilitated using balancing ramp-guided flexible prosthesis to accommodate mandibular deviation and limited mouth opening.

  Case Report Top

A 63-year-old-male reported to the department of prosthodontics with the chief complaint of difficulty in eating, missing teeth, and unsatisfactory facial appearance [Figure 1]a. The patient was a treated case of squamous cell carcinoma that affected the right buccal mucosa and mandibular alveolus, for which he had undergone hemimandibulectomy 3 months back.
Figure 1: (a) Preoperative intraoral view, (b) Eagle eye view, (c) Orthopantomogram showing resected mandible

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Extraorally, there was facial asymmetry with facial midline deviated to the right in the lower facial third [Figure 1]b. The mouth opening was restricted and was observed to be 25 mm (two-finger width) in the midline [Figure 2]. Intraorally, the body of the mandible was missing from the right side. Only the anteriors and first premolar were present in the mandibular arch. Maxillary arch was partially edentulous with few remaining teeth and root pieces. Hair growth was observed on the skin graft on the right buccal mucosa. The mandibular buccal sulcus was obliterated and interridge distance was markedly reduced. Orthopantomogram showed the resected mandible and the remaining teeth [Figure 1]c. On the basis of clinical and radiographic examination, the mandibular defect was diagnosed as Cantor and Curtis Class II that is lateral resection of the mandible distal to the cuspid.
Figure 2: Limited mouth opening: (a) 25-mm interincisal opening, (b) Two-finger opening

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There was marked mandibular deviation with severe scar contracture greatly restricting the mandibular movement. The jaw approximation against the maxillary arch through assisted mandible guidance could not be achieved. Thus, a guided prosthesis with a modified design that involved balancing ramps to guide the patient to bring the mandible into intercuspal position was planned.

Clinical procedure

The patient had limited mouth opening which posed difficulty in the use of impression tray. Thus, it was planned to use sectional trays modified with impression compound (Y-Dents impression compound; MDM Corporation, New Delhi, India) [Figure 3]a. The maxillary and mandibular impressions were made using irreversible hydrocolloid impression material (DPI Algitex Alginate powder, Mumbai, India) [Figure 3]b and were poured with type III dental stone (Kaldent; Kalabhai Karson Private Limited, Mumbai, India) to obtain the working model. The denture base was fabricated using an autopolymerizing acrylic resin (DPI-RR Cold Cure, Dental Products of India, Mumbai, India).
Figure 3: (a) Modified sectional trays, (b) Irreversible hydrocolloid impression

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The residual ridge was severely atrophied on the defect side. The conventional material (modeling wax) used for fabrication of occlusal rims was avoided in the present case. Instead, occlusal rims were made using McCord and Tyson admix technique prepared by mixing impression compound and green stick (DPI Pinnacle Tracing Sticks, Dental Products of India, Mumbai, India) in a ratio of 3:7 parts. The functional neutral zone was recorded instead of using anatomic averages. Neutral zone is the potential space between the lips and cheeks on one side and the tongue on the other, where the forces between the tongue and cheeks or lips are equal and hence artificial teeth were placed in neutral zone. The patient was instructed to perform all muscle functions such as sucking, swallowing, and producing exaggerated “EEE” and “OOO” sounds. The neutral zone in the present case was found to be markedly deviated lingually. Interocclusal records on the unaffected side were made using modeling wax.

The maxillomandibular relation was recorded and mounted on the articulator. Putty index using addition silicone putty (Zhermack Elite P and P Putty Addition Silicone, Badia Polesine, Italy) was made over the recorded neutral zone and modeling wax (Rolex, Modeling Wax, New Delhi, India) was poured into it. Teeth arrangement was done with anatomic acrylic resin teeth (Premadent Teeth Set, New Delhi, India). Balancing ramps inclined lingually were made on the defect side in maxillary and mandibular arches with the aim to provide a masticatory stop to minimize deviation during intercuspation. It was planned not to provide artificial teeth on the defect side in both the arches due to shift of neutral zone too far lingually, reduced inter ridge space, and absence of bony support in the mandibular arch. The functional and speech evaluation was carried out at the try-in appointment [Figure 4]a. The denture was processed using flexible denture base material (iFlex, TCS Dental, California, USA) with acetal resin clasps placed on teeth adjoining the edentulous areas for improved retention and esthetics [Figure 4]b. The denture was then finished and polished [Figure 5]a.
Figure 4: (a) Try-in done, (b) Final prosthesis in situ

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Figure 5: (a) Balancing ramp-guided flexible partial denture, (b) Postoperative frontal profile view

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During insertion appointment, the denture was inspected for border extensions, occlusal interferences, and phonetics. The patient's speech improved significantly with this guidance prosthesis and the patient was able to close his mandible into intercuspation without deviation [Figure 5]b. The flexible denture base material helped the patient to comfortably adapt onto the resected side. The patient was scheduled for regular follow-up after 24 h, 1 week, and 3 months. The patient expressed improvement in mastication as well as in appearance.

  Discussion Top

The prosthetic prognosis of a resected mandible is multifactorial influenced by the site and extent of surgery, presence or absence of teeth, and psychological impact.[6] Limited mouth opening and mandibular deviation is the most often encountered challenge to functional rehabilitation. Mandibular deviation caused due to discontinuity defect is mainly occurred by uncompromised influence of contralateral musculature, particularly internal pterygoid muscle and pull from contraction of cicatricial tissue on resected side.[2] Various prostheses have been reported in the literature to reduce or eliminate the mandibular deviation such as maxillomandibular fixation, implant-supported prosthesis, removable mandibular guide flange prosthesis, and palatal-based guidance restoration.[5],[6],[7] However, in the present case, removable guidance prosthesis was chosen due to deviation of neutral zone, obliteration of the buccal sulcus, reduced interridge space, and limited mouth opening.

Modified impression technique was followed. The steps of making occlusal rims to record maxillomandibular relation were also modified to suit the anatomy of denture foundation. Flexible denture material was used for the definitive prosthesis fabrication as it is a monomer-free thermoplastic dental polymer with low flexural modulus and better patient acceptance.[8] The reduced number of patient visits and ease of adjustability are other added advantages of this material. The flexible denture can be considered for its simplicity, cost-effectiveness, and economy of finance in time.

The prosthetic design in the present case consisted of balancing ramps or guide plane on the resected side which directed the mandibular teeth into intercuspation during closure. In all cases, every effort should be made to re-establish a favorable distribution of force to stabilize the prosthesis during mastication and function.[9] The guide plane in the present case aided in the faciolingual repositioning of the residual mandible. Thus, this prosthetic appliance was useful in achieving improvements in mandibular deviation and occlusal equilibrium.

  Conclusion Top

The postsurgical rehabilitation of a hemimandibulectomy patient is challenging if not addressed through surgical reconstruction. Hence, a customized prosthetic design is required for a favorable outcome. In the present case, the treatment plan was customized from the beginning through culmination. Due to limited mouth opening, the options remained minimal and focused on the comfort and functional efficiency of the patient. The impression procedure, maxillomandibular jaw relation recording, denture base material selection, and design of the guidance prosthesis involved planning and execution customized for the patient and resulted in prosthesis with a satisfactory outcome, however, the surgical treatment option remains the preferred biological substitute.

Ethical clearance

The authors declare that a written and signed consent to publish the information from the patient was obtained prior to submission.

Declaration of patient consent

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

Financial support and sponsorship

This was a self-funded study.

Conflicts of interest

There are no conflicts of interest.

  References Top

Petrovic I, Rosen EB, Matros E, Huryn JM, Shah JP. Oral rehabilitation of the cancer patient: A formidable challenge. J Surg Oncol 2018;117:1729-35.  Back to cited text no. 1
Nair SJ, Aparna IN, Dhanasekar B, Prabhu N. Prosthetic rehabilitation of hemimandibulectomy defect with removable partial denture prosthesis using an attachment-retained guiding flange. Contemp Clin Dent 2018;9:120-22.  Back to cited text no. 2
[PUBMED]  [Full text]  
Lingeshwar D, Appadurai R, Sswedheni U, Padmaja C. Prosthodontic management of hemimandibulectomy patients to restore form and function-A case series. World J Clin Cases 2017;5:384-9.  Back to cited text no. 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. 4
Desjardins RP. Occlusal considerations for the partial mandibulectomy patient. J Prosthet Dent 1979;41:308-15.  Back to cited text no. 5
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. 6
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. 7
Yunus N, Rashid AA, Azmi LL, Abu-Hassan MI. Some flexural properties of a nylon denture base polymer. J Oral Rehabil 2005;32:65-71.  Back to cited text no. 8
Bhochhibhoya A, Shakya P, Mathema S, Maskey B. Simplified technique for the prosthodontic rehabilitation of a patient with a segmental mandibulectomy with a hollow cast partial dental prosthesis: A clinical report. J Prosthet Dent 2016;116:144-6.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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