INDIAN DENTAL JOURNAL

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1 REHABILITATION OF A COMPOSITE MAXILLA-MANDIBULAR RESECTION PATIENT BY GUIDE FLANGE AND OBTURATOR PROSTHESIS Dr. Shefali Goel 1 Dr. Neetu Singh 2 Dr. Balendra Pratap Singh 3 Dr. Pooran Chand 4 1, 2 Junior Resident, Department of Prosthodontics, King George s Medical University, UP, Lucknow, India 3 Associate Professor, Department of Prosthodontics, King George s Medical University, UP, Lucknow, India 4 Professor and Head, Department of Prosthodontics, King George s Medical University, UP, Lucknow, India Address for Correspondence: Dr. Balendra Pratap Singh, Deptt. of Prosthodontics, KGMU, Lucknow. balendrapratapsingh@kgmcindia.edu ABSTRACT Composite resection is a resection of a tumour with bone, adjacent soft tissue and contiguous lymph channels. It is commonly used as a surgical intervention for malignant Lesion. Such an intervention can lead to creation of communication between oral cavity, nasal cavity or antral cavity and/or mandibular discontinuity. This is followed by difficulties in performing normal functions such mastication, swallowing and speaking. Therefore early prosthodontic rehabilitation with the help of guide flange prosthesis and maxillary obturator is necessary. This article describes the early prosthodontic management of a patient who had underwent a composite resection with left modified radical neck dissection (MRND)-II reconstructed with an autogenous pectoralis major myocutaneous (PMMC) flap. KEYWORDS: Composite Resection, Guide Flange Prosthesis, Maxillary Obturator, Squamous Cell Carcinoma I NTRODUCTION - Squamous cell carcinoma (SCC) of the oral cavity accounts for 4% of malignancies in men and 2% of malignancies in women, and is responsible for 3% of all cancer deaths. 1 Gingival and alveolar ridge carcinomas usually are painless and most frequently arise from keratinized mucosa on a posterior mandibular site. 2 Tobacco chewing has been shown a strong association with SCC. Surgical intervention is its main management. But the situation becomes more challenging when due to disease severity both surgical removal of the affected side mandible along with some part of maxilla is done. This clinical condition forced patients to face the dual problem of inability to chew and swallow food along with nasal regurgitation which in long term predisposes to infections, inadequate nutrition etc. Patient aesthetics is also compromised due to cosmetic disfigurement. Therefore prosthodontic rehabilitation of the dual defect is done with the combined approach of the obturator prosthesis and guide flange prosthesis which restores the missing structures and acts as a barrier between the communications among the various cavities. Various authors have indicated various prosthesis for hemimandibulectomy in the literature like Robinson et al 3 - cast mandibular resection restoration, Hasanreisoglu et al 4 - palatal guide ramps mandibular guide flange prostheses, Beumer et al 5 -guidance ramp(cast metal/acrylic resin), Prencipe MA et al 6 - mandibular prosthesis with precision attachments. 46

2 Reestablishment of an acceptable repeatable occlusion by mandibular muscle training is the main rehabilitation objective. An obturator (Latin: obturare, to stop up) is a prosthesis that occludes an opening in the roof of the mouth, as a result of a partial or total removal of the maxilla. 7 Guide flange prosthesis (GFP) is a mandibular conventional prosthesis designed for the patient who can achieve an appropriate mediolateral position of the mandible but repetition of the position is inconsistent for adequate mastication. 8 This case report describes early prosthodontic management of a patient who has undergone a composite resection with left modified radical neck dissection (MRND)-II reconstructed with an autogenous pectoralis major myocutaneous (PMMC). Modified guide flange prosthesis(gfp) and the maxillary obturator were fabricated to treat the patient. CASE REPORT A 41 year old female was advised to visit the Department of Prosthodontics for prosthetic rehabilitation. A detailed case history revealed that the patient was diagnosed with SCC of left buccal mucosa one year back with extension to alveolus of maxilla and mandible and soft palate. Therefore she underwent composite resection with left MRND-II followed by reconstruction with Pectoralis major myocutaneous flap (PMMC). Hemimandibulectomy (from the left condyle to the left parasymphyseal region) was performed in the patient. Patient was also treated with CO60 EBRT radiotherapy at dosage of 66 Gy. On examination, Maxillary arch had missing teeth from maxillary left incisor to molar with hard palate defect on left side (Figure 1). Patient had Aramany class II maxillectomy defect.7 The area starting from the left lower bicuspid up to the left condyle was excised and there was obliteration of sulcus on the affected side (Figure 2). Patient had Cantor and Curtis Class II mandibular defect.8 Gross asymmetry of the face was found with restriction of the mouth opening to 25 mm. 17 mm deviation of the mandible from the midline toward the left side was seen. (Figure 3) Patient was a tobacco chewer since 10 years. Oral hygiene was poor with generalized stains, inflammation and recession of gingiva. PROCEDURE Irreversible hydrocolloid (algitex DPI) with stainless steel stock edentulous tray was used to record the preliminary impression of the maxillary and mandibular arch which were poured with Type III gypsum material (Dental Stone, Kalabhai) to obtain the cast. Modified guide flange prosthesis was fabricated by the use of a 19 gauge hard, stainless steel orthodontic wire. Prosthesis included a guidance flange on the buccal side and the supporting flange on the lingual side. To provide retention wire was adapted extending from the lingual surface of 43 and 44 interdentally extending occlusally up to the buccal surface of maxillary posteriors forming a loop and terminating on lingual surface of 46 by forming a U clasp. The guide flange was extended superiorly and diagonally on the buccal surface of the molars and the premolars, allowing the normal horizontal and vertical overlap of the maxillary teeth. By selective trimming of the teeth and clasp contacting surface or by addition of the auto-polymerizing clear acrylic resin flange inclination was adjusted. The flange orientation was kept slightly outwards towards buccal to accommodate clasps and achieve unhindered occlusion. Adjustment of flange height was done in such a way that smooth, unhindered mandibular movements are reproduced by 47

3 the mandibular guide plane prosthesis. The mandibular guide-flange was waxed-up with modelling wax (Modelling wax; DPI) and subsequently acrylized (Figure 4) with clear heat-polymerized acrylic resin (DPI Heat cure clear). A 19 gauge hard, round, stainless steel orthodontic wire was manipulated to fabricate C clasp on left upper central incisor, 2 pinhead clasps mesially and distally on the right upper second premolar and Adam s clasp on right upper first molar of the maxillary cast. A modelling wax (single thickness) was adapted on the maxillary cast covering entire hard palate and subsequently acrylized into the heatpolymerized clear acrylic resin to make the maxillary obturator. (Figure5) The prosthesis was delivered and postinsertion instructions were given. The patient follow up was done at the regular interval of two months for next 1 year. The patient stated that he was satisfied with prosthesis and was able to communicate and masticate with less mandibular deviation. (Figure 6A to 6C) DISCUSSION Mandibular guide plane prosthesis helps in alleviation of plethora like speech impairment, inability to swallow, dribbling of saliva, uncoordinated mandibular movements, cosmetic disfigurement etc which are caused due to mandibular discontinuity. Therefore to reduce postsurgical deviation following surgery immediate intermaxillary fixation which is maintained for 5-7 weeks is needed followed by commencement of exercise therapy in the 1st week post surgery9-12 after which mandibular guide plane prosthesis is fabricated. Prosthetic rehabilitation in form of mandibular guidance prosthesis can be of two types.13 Palatal based guidance prosthesis like maxillary inclined plane prosthesis, positioning prosthesis with palatal flange, widened maxillary occlusal table or palatal ramp or mandibular based guidance prosthesis like mandibular lateral/ oblique guide flange prosthesis. The major indication for palatal based guidance prosthesis is when an acceptable occlusal contact of the teeth cannot be attained due to inability to achieve the ideal mediolateral position of the remaining segment by the patient. Since the patient is able to achieve proper mediolateral position of the mandible but cannot hold that position for adequate mastication a mandibular guide flange is indicated. Use of prosthesis can commence as early as one week postsurgery and continues till the mediolateral position can be successfully reproduced by the patient. Definitive obturator is fabricated once the surgical site has healed. It acts as a barrier which helps to improve speech, prevent nasal communication and consequently improves mastication. It is fabricated by acrylic resin and retention can be improved by incorporation of cast partial retentive elements for which teeth are needed to be modified. CONCLUTIONS Early prosthodontic rehabilitation of composite maxilla-mandibular defect is a must to successfully rehabilitate the patient and abate the consequences of the surgical intervention. 48

4 Figure 1: Maxillary and Mandibular Arch Figure 2: Post-Operative Panoramic Radiograph Figure 3: Maximum Mouth Opening and Lateral Deviation Figure 4: Guide Flange Prosthesis Figure 5: Maxillary Obturator Figure 6: a) Occlusion Without GFP b) Prosthesis Guided Occlusion c) Four Months Postoperative With Prosthesis 49

5 REFERENCES 1. Kramer D., Durham J. S., Jackson S., Brookes J. Management of the neck in NO Squamous cell carcinoma of the oral cavity. The Journal of Otolaryngology, 2001; 30: Tajima Y., Shionoya N., Fujita K, Utsumi N. Epidermoid carcinoma originating from the gingival sulcus. Oral Oncol, Eur J. Cancer, 1993; 29: Robinson JE, Rubright W.C. Use of a guide plane for maintaining the residual fragment in partial or hemimandibulectomy. J Prosthet Dent 1964;14: Hasanreisoglu U, Uçtasli S, Gurbuz A. Mandibular guidance prosthesis following resection procedures: Three case reports. Eur J Prosthodont Rest Dent 1992;1: Beumer. J III, Curtis T.A, Marunick MT. Maxillofacial Rehabilitation. Prosthodontic and surgical consideration. St. Louis :Ishiyaku. Euro America p Prencipe MA, Durval E, De Salvador A, Tatini C, Branchi Roberto. Removable Partial Prosthesis (RPP) with acrylic resin flange for the mandibular guidance therapy. J Maxillofac Oral Surg. 2009;8: Chalian VA, Drane JB, Standish SM. Multidisciplinary practice. Baltimore: The Williams and Wilkins Co; Maxillofacial prosthetics; pp Desjardins RP. Relating examination findings to treatment procedures. In: Laney WR. Maxillofacial prosthetics. Littleton; PSG Publishing; P Martin JW, Shupe RJ, Jacob EF, King GE. Mandibular positioning prosthesis for the partially resected mandibulectomy patient. J Prosthet Dent1976;35: Taylor TD. Diagnostic considerations for prosthodontic rehabilitation of the mandibulectomy patient. In: Taylor TD, editor. Clinical maxillofacial prosthetics.chicago; Quintessence Publishing; P Shafer WG, Hine MK, Levy BM, Tomich CE. A text book of oral pathology. 4th ed Philadelphia: WB Saunders1993;2: Olson ML, Shedd DP. Disability and rehabilitation in head and neck cancer patients after treatment. Head Neck Surg 1978; 1: Beumer J, Curtis TA, Firtell DN: Maxillofacial rehabilitation:prosthodontics and Surgical Considerations. St Louis,1979,The CV Mosby Co: