WJ CC World Journal of

Clinical Cases
Submit a Manuscript: http://www.f6publishing.com World J Clin Cases 2017 October 16; 5(10): 384-389

DOI: 10.12998/wjcc.v5.i10.384 ISSN 2307-8960 (online)

CASE REPORT

Prosthodontic management of hemimandibulectomy

patients to restore form and function - A case series

Deenadayalan Lingeshwar, Rajendran Appadurai, Ujjayanthi Sswedheni, Challa Padmaja

Deenadayalan Lingeshwar, Rajendran Appadurai, Ujjayanthi Abstract

Sswedheni, Challa Padmaja, Government Royapettah Hospital,
Chennai 600014, India Surgical resection of mandible owing to benign, malignant
neoplasm, osteoradionecrosis is common. The resection
Author contributions: All authors equally contributed to the can be total or segmental depending on the lesion. Loss
treatment and writing case report. of mandibular continuity causes deviation of remaining
mandibular segment towards the resected side and
Institutional review board statement: This case report was rotation inferiorly due to muscle pull and scar contracture
exempt from the Institutional Review Board standards at Govern­
affecting mastication and esthetics. Surgical reconstruction
ment Royapettah hospital, Chennai, India.
may not be always possible. Prosthetic rehabilitation plays
Informed consent statement: A letter of permission had been a major role in these patients. This case series describes
obtained from the patients no matter if the article appears in the different types of guiding flange (GF) prosthesis with
published or in the online journal. modifications for three hemimandibulectomy patients at
different time interval after surgery. The article details
Conflict-of-interest statement: There is no conflict of interest GF prosthesis combined with physiotherapy to correct
or financial interests, direct or indirect, that exist or may be deviation of mandible thereby improving mastication,
perceived to exist for individual contributors in connection with esthetics and speech and thus enhancing the quality of
the content of this paper.
life.
Open-Access: This article is an open-access article which was
selected by an in-house editor and fully peer-reviewed by external Key words: Hemimandibulectomy; Mandibular deviation;
reviewers. It is distributed in accordance with the Creative Guiding flange prosthesis; Palatal ramp
Commons Attribution Non Commercial (CC BY-NC 4.0) license,
which permits others to distribute, remix, adapt, build upon this © The Author(s) 2017. Published by Baishideng Publishing
work non-commercially, and license their derivative works on Group Inc. All rights reserved.
different terms, provided the original work is properly cited and
the use is non-commercial. See: http://creativecommons.org/ Core tip: Mandible is a significant structure in lower
licenses/by-nc/4.0/
third of face constituting to esthetics and functions like
Manuscript source: Unsolicited manuscript speech, swallowing and mastication. Surgical resection
owing to various reasons disrupts these functions. Both
Correspondence to: Dr. Deenadayalan Lingeshwar, Assistant form and function should be considered in rehabilitating
Professor, Government Royapettah Hospital, Westcott Road, hemimandibulectomy patients. This article describes
Opposite YMCA Ground, Chennai 600014, prosthetic rehabilitation that comprises of different types
India. grhdentalpublications@gmail.com of guiding flange prosthesis with modifications for three
Telephone: +91-74-18314035 hemimandibulectomy patients at different time interval
after surgery.
Received: May 23, 2017
Peer-review started: May 24, 2017
First decision: July 11, 2017
Revised: July 27, 2017 Lingeshwar D, Appadurai R, Sswedheni U, Padmaja C. Pros­thodontic
Accepted: August 2, 2017 management of hemimandibulectomy patients to restore form and
Article in press: August 3, 2017 function - A case series. World J Clin Cases 2017; 5(10): 384-389
Published online: October 16, 2017 Available from: URL: http://www.wjgnet.com/2307-8960/full/v5/

WJCC|www.wjgnet.com 384 October 16, 2017|Volume 5|Issue 10|

 Lingeshwar D et al . Restoration of function for hemimandibulectomy patients

i10/384.htm DOI: http://dx.doi.org/10.12998/wjcc.v5.i10.384

INTRODUCTION
Mandible is a significant structure in lower third of face
constituting to function and esthetics. It is a single bone
that creates peripheral boundaries of the floor of the
mouth, facial form (lower third), speech, swallowing,
mastication and respiration. Disruption of mandible due
to trauma, surgical resection for benign and malignant
neoplasm disrupts any of these functions. Both form
and function should be considered in rehabilitating Figure 1 Midline shift and loss of occlusal contact.
hemimandibulectomy patients. Loss of mandibular
continuity causes deviation of the remaining mandibular
segments towards the defect and rotation of the
Retentive partes (Clasp)
mandibular occlusal plane inferiorly due to muscle pull
and scar contracture. Mandibulectomy with radical
neck dissection increases this deviation. This results in
facial disfigurement, loss of occlusal contact, in many
cases, loss of lip competency for saliva control and
[1]
to initiate the swallowing process . Literature shows
techniques to correct mandibular deviation that can
vary from intermaxillary fixation with elastics, palatal or
mandibular guiding flange (GF) prosthesis anchored on
[2]
natural teeth or the dental flange . The GF is probably
the simplest and most useful in maintaining position
[3]
of the remaining jaw . This article describes different Figure 2 Mandibular guiding flange prosthesis.
types of GF prosthesis with modifications for three
hemimandibulectomy patients at different time interval
after surgery. Type Ⅲ Dental stone (Goldstone, mfg. by ASIAN
CHEMICALS). Interocclusal record was made with
modelling wax (the Hindustan dental products) by
CASE REPORT asking the patient to move the mandible away from
Case report 1 resected site as far as possible and manually guiding
A 36 years old male patient was referred to the hospital the mandible to centric occlusion. This record was
with the history of carcinoma left buccal mucosa transferred to a mean value articulator. Three clasps
for which he underwent hemimandibulectomy and were made using 21 gauge wire - “C” clasp on canine
modified radical neck dissection one month back and and premolar; adams clasp on molar for retention
reconstructed with pectoralis major myocutaneous purpose. Considering the amount of deviation and
flap. Patient complained of difficulty in mastication and reduced mouth opening, mandibular GF prosthesis was
speech. fabricated on the nondefect side using autopolymerising
Extra oral examination revealed facial asymmetry acrylic resin (DPI Cold Cure pink; Dental products of
and deviation of mandible towards the resected site India). After applying sufficient separating medium,
and the deviation increased on opening the mouth. the resin was added on buccal and lingual aspect of
The mouth opening was reduced to 25 mm. Intra oral nondefect side of mandible and on the buccal side the
examination revealed partially edentulous mandible extension was till the maxillary buccal vestibule. The
and loss of occlusal contact (Figure 1).The mandibular prosthesis was tried in patient mouth and checked for
defect was classified as Cantor and Curtis Class Ⅱ that is retention and stability. It was trimmed and adjusted so
[4]
lateral resection of the mandible distal to cuspid . It was that the mandible is guided to centric occlusion without
noted that mandible can be guided to centric occlusion delivering excessive force to maxillary teeth. Acrylic
manually but the patient could not achieve this position resin was added little by little to the guide flange until
consistently on his own. So the treatment objective was there was smooth guidance of the mandible to proper
to correct the deviation of mandible and to restore proper occlusion without any interference. The prosthesis
occlusion for mastication. was finished and polished (Figure 2). After insertion
Impressions were made with modified stainless of the prosthesis, midline coincided and occlusion was
steel stock tray and irreversible hydrocolloid (Tropicalgin, achieved (Figure 3). The patient was advised to use
IDS DENMED Pvt. Ltd.) followed by pouring cast with the GF throughout the day except at night and during

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 Deenadayalan L et al . Restoration of function for hemimandibulectomy patients

Figure 3 Correction of deviation after insertion of the prosthesis. Figure 5 Occlusion contacts established with prosthesis.

Extension to
prevent supra
Occlusion eruption
stabilization

Flange

Figure 4 Palatal guiding flange prosthesis. Figure 6 Palatal guiding flange prosthesis with functionally generated
acrylic occlusal table on non-resected site and stabilization ramp for
resected side.
meals. Physiotherapy exercises were also insisted. It
included maximum mouth opening and grasping the
chin to move the mandible away from surgical side. This this position consistently. Since mouth opening was
will help in reducing trismus, minimize scar contracture normal compared to previous case, an acrylic GF on
[1]
and improve occlusion . Review after a month, there maxilla was planned as interim prosthesis.
was trivial reduction in the deviation. Hence, palatal GF Impression, cast, interocclusal record and articulation
prosthesis was made which wouldn’t affect esthetics. were made following the same procedure as in case
report 1. Palatal GF prosthesis was planned for this
case considering the stability of prosthesis, esthetics,
Case report 2
A 49 years old male patient presented to the hospital occlusion and downward rotation of mandible. The guide
with the complaint of difficulty in mastication and flange extended till the lingual sulcus on the nondefect
facial disfigurement for the past three years owing to side. The prosthesis was tried in patient mouth. The
carcinoma left buccal mucosa for which he underwent inclination of the guide flange was adjusted until it
composite resection of mandible and reconstructed guided the mandible to centric occlusion (Figure 4). But
with Pectoralis major myocutaneous flap following as both maxillary and mandibular teeth were attrited,
preoperative chemotherapy and radiotherapy. On clinical functional cusps were worn out. The mandibular teeth
examination, there was deviation of remaining mandible glided beyond centric occlusion. To prevent this and to
towards the resected site and also downward rotation train the patient in centric occlusion, the acrylic resin
of mandible. It was noted that intermaxillary fixation was extended on the palatal cusps of maxillary teeth. A
was not done at the time of surgery. The mandibular functionally generated path was recorded and an occlusal
defect was classified as Cantor and Curtis type Ⅲ .
[4] table was fabricated accordingly so as to stabilize the
Since it was resected till the midline the deviation and occlusion. The occlusal table was also extended on the
downward rotation of mandible was more due to loss maxillary teeth of defect side to prevent supraeruption
of muscular support. The mouth opening was 35 mm. as there were no opposing teeth (Figures 5 and 6). The
Intra oral examination revealed generalized attrition, patient was recalled after a month for review.
supraeruption and partially edentulous mandible.
Patient was able to bring remaining mandible to centric Case report 3
occlusion with guidance and he was not able to achieve A 35 years old male patient came to the hospital with

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 Deenadayalan L et al . Restoration of function for hemimandibulectomy patients

Figure 8 Mandibular first molar contacting the palatal ramp that guides
the mandible to occlusion.

an inferior direction is caused by the pull of suprahyoid

musculature and gravity due to loss of anchorage of
[1]
elevator muscles . The pathway of closure in a lateral
resection of mandible starts from its medial, retruded
position and closes in an upward diagonal manner into
an occlusion which may or may not correspond with
[6]
the patient’s preoperative occlusion . The amount
of deviation and downward rotation depends on the
extent of tissue loss. The more the mandible remaining,
Figure 7 Note the midline before and after insertion of the prosthesis. the better is the prosthetic prognosis. Retention of
[4]
mandibular cuspids is especially beneficial .
the history of hemimandibulectomy and left maxillary The basic objective in rehabilitation is retraining the
alveolectomy reconstructed with masseter flap done remaining mandibular muscles to provide an acceptable
two weeks ago owing to carcinoma left buccal mucosa. maxillo-mandibular relationship of the remaining
[7]
Mouth opening was noted as 30 mm. It was noted that portion of the mandible . This would permit occlusion of
the deviation of mandible towards the resected side was remaining natural teeth or control of residual edentulous
minimum as the surgery was done only two weeks ago. segments to provide for the reasonable placement and
[7]
If intervention with the GF was not done at this time, acceptable occlusion of the artificial teeth . There are
the deviation would worsen on healing process and four significant factors that affect rehabilitation: The
scar formation. The procedure of impression making, location and extent of surgery, the effect of radiation
cast, interocclusal record and articulation as in case therapy, the presence or absence of teeth and the
[6]
report 1 was done. As the deviation was minimum, psychological aspect .
palatal GF prosthesis was planned for this case. As The time of initiation of the treatment is the key
opposing teeth were present in the mandibular arch, to success for restoring the form and function. The
the risk of supraeruption is nil. The prosthesis extended deviation after hemimandibulectomy will be difficult to
till the lingual sulcus on palatal non resected side. The correct after the healing phase of 6 to 8 wk due to scar
prosthesis was tried in patient mouth and trimmed contracture and the muscles adapting to this cicatricial
[1]
accordingly (Figure 7). The patient was able to guide tissue . Patients usually have trismus following the
the mandible into pre-existing occlusion (Figure 8). surgery which will be a challenge for making an im­
The patient was advised to wear the flange at all times pression of maxilla and mandible. Hence preoperative
except while eating and during nights and was asked to casts should be advocated for all patients so that
review after one week. exact maxillo-mandibular relationship can be obtained
postoperatively. Intermaxillary fixation can be advocated
at time of surgery but for dressings and irrigation, it
DISCUSSION would be more advantageous to enable the patient to
Segmental resection of mandible results in deviation open and close the mouth. Temporary retainers can be
of remaining segment towards the resected side made preoperatively so that it can immediately placed
[8]
due to uncompensated influence of contralateral after surgery . Robinson stated that temporary acrylic
[5]
musculature, particularly the internal pterygoid muscle. GF can be inserted on the third postoperative day . In
If this influence is uncompensated, the contraction the above cases intermaxillary fixation was not done at
of cicatricial tissue will fix the residual fragment in its the time of surgery and preoperative impressions were
[5]
deviated position . The rotation of residual mandible in not made as they were referred only after surgery.

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 Deenadayalan L et al . Restoration of function for hemimandibulectomy patients

Table 1 Protocol for guiding flange

Based on time of referral

1 Before surgery - 1 wk post-surgery Intermaxillary fixation done with elastics
2 1 wk post-surgery - 1 mo GF prosthesis and Physiotherapy
3 1 mo - 1 yr Active physiotherapy, Counseling followed by GF prosthesis
4 > 1 yr Surgical intervention
Based on amount of tissue resected
1 Amount of hard and soft tissue Directly influences success and difficulty in rehabilitation
2 Segmental resection of mandible distal to Maxillary or Mandibular GF
cuspid
2 Segmental resection of mandible that Maxillary GF is the choice as the loss of mandibular canine results
involves canine in more downward rotation of mandible and the mandibular GF
might not be stable
Types of prosthesis
1 Acrylic GF Immediately after surgery and as training prosthesis
2 Definitive Cast metal GF One year after training prosthesis

Modifications
1 To prevent supraeruption Occlusal table on Maxillary teeth on defect side
2 To stabilize occlusion Functionally generated occlusal table on Maxillary teeth on
nondefect side
Intervention Prognosis
1 From the time of planning and surgery Better
2 Long time interval after surgery Guarded

GF: Guiding flange.

Physiotherapy is recommended to reduce trismus deviation was trivial in the third patient as he reported
and to loosen scar contracture. Without this, masticatory one week following surgery, maxillary GF was given.
ability may decrease and lateral movement toward the In the second case report, the downward rotation of
[9]
nonresected side may not be possible . It must be mandible was significant as the resection involved
started two weeks postoperatively. Patient is asked to mandibular canine. For this case, maxillary GF was
gently push the mandible away from the defect toward given with functionally generated occlusal table on non-
more normal position. While holding mandible in position, defect side. For all the three patients, physiotherapy was
the patient should open the mouth as wide as possible to insisted along with the insertion of GF. The patients had
[1,4]
stretch the musculature at the resection site . In all the pain only due to scar contractures and deviation leading
three cases, physiotherapy was insisted. to pain on mandibular movements. This was addressed
Various literature shows different techniques for by correcting the deviation, and trying to maintain a
managing the deviation that include cast metal guidance stable occlusion. Guideline for GF is listed in Table 1.
prosthesis which is more technique sensitive, time Rehabilitation is an essential phase of cancer care
consuming, expensive and require more number of and should be considered from the time of diagnosis in a
patient visits. Acrylic GF is comparatively simple in design, complete and comprehensive treatment plan. The primary
cost effective, less patient visit and more importantly the objective is restoration of function and ap­pearance.
[10]
ease of adjustability . GF prosthesis serves both the purpose. This article
A common complaint without such an appliance is pain gives a comprehensive explanation about rehabilitation
in the remaining temperomandibular joint which results procedures carried out for three patients who were
[8]
from the abnormal position of the condyle . Definitive surgically treated for carcinoma with hemimandibulectomy
treatment of these patients takes at least a year from the and neck dissection.
date of surgery as definitive treatment requires complete
healing and no recurrence of cancer. Till then the acrylic GF COMMENTS
COMMENTS
prosthesis can be used as a training device for mandibular
movements and to avoid further compilations. Case characteristics 
All three cases complained of difficulty in mastication and facial disfigurement
In the cases presented above, acrylic GF was used as
following hemimandibulectomy reconstructed with flap.
a training prosthesis. Out of three patients, one patient
was referred immediately after surgery, one patient five
Clinical diagnosis
years after surgery and other patient one month after
All three cases showed deviation of mandible towards the resected site, los of
surgery. In the first and third case report, resection was lip competency and occlusal contact and reduced mouth opening.
distal to canine. The amount of deviation was more in
the first patient as the patient reported one month after Treatment
surgery, mandibular GF was given for a period of three Guiding flange (GF) prosthesis to correct deviation of mandible and to stablise
weeks later replaced with maxillary GF. The amount of occlusion enhancing mastication and esthetics.

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 Deenadayalan L et al . Restoration of function for hemimandibulectomy patients

Term explanation Chicago: Quintessence publishing, 2000: 155-170

GF prosthesis guides the remaining mandible to proper and stable occlusion 2 Schneider RL, Taylor TD. Mandibular resection guidance prostheses:
and trains the mandibular movements after hemimandibulectomy. a literature review. J Prosthet Dent 1986; 55: 84-86 [PMID: 3511245
DOI: 10.1016/0022-3913(86)90080-6]
3 Edgerton M, Pyott J. Surgery and prosthesis in Jaw reconstruction. J
Experiences and lessons Prosthet Dent 1954; 4: 257-262 [DOI: 10.1016/0022-3913(54)90103-1]
The time of initiation of treatment is the key to success. A common complaint 4 Beumer J, Curtis T, Marunick MT. Maxillofacial rehabilitation:
without such prosthesis is pain in temperomandibular joint. This GF prosthesis Prosthodontic and surgical consideration Ishiyaku Euro America. 3rd
alleviates pain and can be used as training device for mandibular movements edition. St. Luis, 1996: 184-188
after surgery. 5 Robinson JE, Rubright WC. Use of guide plane for maintain the
residual fragment in partial or hemimandibulectomy. J Prosthet Dent
1964; 14: 992-999 [DOI: 10.1016/0022-3913(64)90032-0]
Peer-review 6 Curtis TA, Cantor R. The forgotten patient in maxillofacial
This is a well written manuscript exposing the experience of the authors in such
prosthetics. J Prosthet Dent 1974; 31: 662-680 [PMID: 4524862 DOI:
particular field. 10.1016/0022-3913(74)90122-X]
7 Desjardins RP. Occlusal considerations for the partial
mandibulectomy patient. J Prosthet Dent 1979; 41: 308-315 [PMID:
ACKNOWLEDGMENTS 368320 DOI: 10.1016/0022-3913(79)90014-3]
8 Ackerman AJ. The prosthetic management of oral and facial defects
We thank the Department of surgical oncology, Govern­
following cancer surgery. J Prosthet Dent 1955; 5: 413-432 [DOI:
ment Royapettah hospital, Chennai, India and the 10.1016/0022-3913(55)90050-0]
Department of Plastic surgery, Rajiv Gandhi Government 9 Sahin N, Hekimoğlu C, Aslan Y. The fabrication of cast
General hospital, Chennai, India for their valuable support. metal guidance flange prostheses for a patient with segmental
mandibulectomy: a clinical report. J Prosthet Dent 2005; 93: 217-220
[PMID: 15775921 DOI: 10.1016/j.prosdent.2004.12.007]
10 Kar S, Tripathi A, Madhok R. Treatment outcome with guiding flange
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1 Taylor TD. Diagnostic considerations for Prosthodontic rehabilitation patients. Ann Maxillofac Surg 2015; 5: 266-270 [PMID: 26981486
of the mandibulectomy patient. In: Clinical Maxillofacial Prosthetics, DOI: 10.4103/2231-0746.175750]

P- Reviewer: Alimehmeti RH, Fourtounas C, Wang F S- Editor: Ji FF

L- Editor: A E- Editor: Lu YJ

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