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Abstract: Mandible is the vital element of the stomatognathic system. Various muscles attachment stabilize the mandible alongside a range of forces. The mandible is the most common site for the intraoral tumors. Benign or malignant tumors are accountable for diverse surgical treatment like marginal, segmental, hemi, subtotal, or total mandibulectomy depending upon the site and size of the tumor in the mandible. Ameloblastoma is a most common odontogenic epithelium benign tumor of the mandible. Loss of the continuity of the mandible by virtue of surgical resection disturbed the balance and the symmetry of mandibular function, leading to altered mandibular movements and disparity of the residual fragment towards the surgical side. In the following case a heat cure acrylic guiding ramp prosthesis was given to a patient who encountered a hemi section of the mandible, for the treatment for Ameloblastoma.
1 2 Poonam R. Kulkarni, Rahul S. Kulkarni1.M.D.S. (Senior Lecturer), Department of Prosthodontics, Sri Aurobindo College of Dentistry and PG Institute, Indore - 453555, Madhya Pradesh, India.2M.D.S. (Senior Lecturer), Department of Prosthodontics, Index Institute of Dental Sciences, Index City, Indore -452001, Madhya Pradesh, India.
GUIDING RAMP - AN UPHOLDING
APPLIANCE
FOR HEMIMANDIBULECTOMY PATIENT
Keywords :Guiding ramp, Ameloblastoma, Hemimandibulectomy, Divergence of mandible, Kennedy class II
Source of support : NilConflict of interest: None
Journal of Dental Sciences
University
University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 114
University J Dent Scie 2016; No. 2, Vol. 2
Case Report
Introduction:
A ramp or guide plane palatal to maxillary teeth that go down
against the non resected side of mandible facilitates patient to
achieve unswerving closure to an intercuspal position. A
breach in the continuity of mandible after resection
annihilates balance and symmetry which leads to changed
mandibular movements and deviation of the residual
fragment towards the defective side. This would obstruct the
aesthetic and psychological placate along with masticatory 1function . In the present case heat cure acrylic resin guiding
ramp prosthesis was given to a hemimandibulectomy patient
for preventing the deviation of the mandible.
Case report:
A 41 year old male patient reported to the Department of
Prosthodontics with a chief complaint of difficulty in
mastication since 7 months. His medical history revealed that
he was diagnosed for ameloblastoma on the right side of the
mandible, for which he had undergone extensive resection of
the entire mandible on right side 2 years back. An extra oral
examination showed asymmetrical face [Figure-1]. There
was deviation of the mandible to the right side (resected side)
[Figure-2]. Past dental history revealed extraction of
periodontally weakened maxillary teeth from 13 to 17.
Intraoral examination revealed maxillary kennedy's class II
partially edentulous arch with missing teeth from 13 to17 and
on palpation, the absence of mandibular ridge from right
lateral incisor region posteriorly with missing teeth 42 to 47
[Figure-3, 4]. Clinical examination of the surgical wound
closure showed consolidated cicatricial tissues, the remaining
natural teeth in both arches were attrited with slight loss of
periodontal support [Figure-4].
Figure-1: Extra-oral view
University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 115
University J Dent Scie 2016; No. 2, Vol. 2
Figure-2: Intra-oral view (deviation of the
mandible on right side on closing of the mouth)
Figure-3: Intra-oral view (maxillary arch)
Figure-4: Intra-oral view (mandibular arch)
Treatment procedure:
Maxillary and mandibular preliminary impressions were
made with irreversible hydrocolloid impression material
(Zelgan2002, Dentsply, Gurgoan, India) using stock trays
[Figure-5]and casts were poured with type III gypsum
product (Kalabhai Pvt Ltd, New Delhi, India). On the
maxillary cast a custom tray was fabricated with self-cure
acrylic resin (RR, Dentsply, India). Border molding was
carried out and final impression was made with zinc oxide
eugenol impression paste (DPI, Mumbai, India). Alginate tray
adhesive (Fix Adhesive, Dentsply, USA) was applied to
custom tray and a pick up impression was made with stock
tray. Impressions were poured with type III gypsum product
to obtain a master cast. Denture base was fabricated and wax
occlusal rim in edentulous area of maxillary cast following
the arch form was made and a wax bite was also made palatal
to maxillary posterior teeth opposite to the edentulous area
[ F i g u r e - 6 ] . D u r i n g r e c o r d i n g o f f u n c t i o n a l
maxillomandibular relations patient was guided to move his
mandible as far as possible to the unaffected side and then
gently close his mandibular jaw into position to record the
indentation of the mandibular posterior teeth of unaffected
side against the palatal maxillary wax bite. After articulation,
during the selection and the setting of the teeth rules of
aesthetics were born in mind and anatomic teeth (Premadent,
New Delhi, India) were selected and arranged in the posterior
edentulous region of maxilla. Waxed up denture with guiding
ramp was tried and checked for retention, stability, comfort,
and aesthetic. As the patient's cause of concern was the ability
of the guiding ramp to retain the mandible in maximum
intercuspation position on unaffected side of the mouth so, the
denture teeth with guiding ramp was re-checked and
corrections were made accordingly on the unaffected side.
For retention purpose, a 22 gauge orthodontic wire was used
for maxillary prosthesis that followed the contour of buccal
teeth surfaces below the height of contour. Denture was
processed with heat-cure acrylic resin (RR, Dentsply, India)
[Figure-7]. After processing, finished and polished denture
with guiding ramp was inserted in the patient's mouth [Figure-
8, 9]. Necessary instructions were given on technique of
placement, removal, and maintenance of the prosthesis. Post-
insertion follow-up and patient care was carried out at the
regular intervals of time.
Figure-5: Maxillary and mandibular irreversible
hydrocolloid (alginate) impression
University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 116
University J Dent Scie 2016; No. 2, Vol. 2
Figure-6: Final waxed up denture with guiding
ramp
Figure-7: Final removable partial denture with
guiding ramp
Figure-8: Final prosthesis in patient's mouth
Figure-9: Teeth in the occlusion after placement of
prosthesis with guiding ramp in the mouth.
Discussion:
The hemimandibulectomy patient is difficult to manage
because the prosthodontists are restricted in their abilities to
provide a reasonable and practical occlusal scheme.
Nevertheless, these patients need the ultimate clinical and 2psychological support of the prosthodontists . The timing of
the maxillofacial prosthodontist's initial contact with these
patients before surgery is very essential for proper
examination, planning and implementation so that the
training prosthesis can be inserted at the time of surgery or
shortly later to prevent muscle imbalance from pulling the
mandible to an eccentric position and decrease the effect of 3pull from the contraction of the cicatricial tissue .
The reasons for segmented resected mandible are 4,5,6,7multifactorial with several collateral problems which alter
3,7,8prosthetic prognosis . However, the four significant factors
that affect the amount of prosthetic rehabilitation include the
site and extent of surgery, the effect of radiation, presence or 9absence of teeth and psychological impact . The basic
objective of rehabilitation is 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 2approximation in restoring occlusal function . Many patients
need the additional support of a maxillary inclined plane
prosthesis to assist muscle retraining as fabricated in the
present case that acts as guiding or training device. The
retraining of the residual mandibular muscles would permit
occlusion of remaining natural teeth or control of residual
edentulous segments to provide for the reasonable placement 2and acceptable occlusion of the artificial teeth .
Literature review advocates fabrication of guide flange or
palatal ramp prosthesis for such patients to prevent deviation
of the mandible and to improve masticatory function and
aesthetics. Guide flange therapy is most successful in patients
where resection involves only bony structures with minimal
sacrifice of tongue, floor of the mouth, and adjacent soft 6,10tissue . Hence we fabricated a conventional maxillary
removable partial prosthesis with guiding ramp. After
insertion of the prosthesis the patient could intercuspate
University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 117
University J Dent Scie 2016; No. 2, Vol. 2
mandibular teeth properly [ Figure-9] due to guiding ramp.
The patient was kept on 1 month recall. After 1 month the
patient reported an increase in masticatory efficiency and
seemed happy with the treatment.
Conclusion:
The requirement for early consultation with the maxillofacial
prosthodontist has been emphasized in rehabilitation of
mandibulectomy patients. A multidisciplinary team come up
to before, during and after surgery for improved
prosthodontic treatment result is important by the side of early
guidance therapy, individualized physiotherapy and patient
mutual aid. The present article describes the fabrication of a
maxillary guiding ramp to guide the segmented mandible into
its most satisfactory functional position after long-standing
scarring and mandibular deviation to the affected side. The
optimistic mind-set of the patient towards the treatment with
supported physiotherapy led to triumph over the limitations of
prosthetic rehabilitation giving satisfactory results.
Acknowledgement:
Authors are thankful to the Department of Prosthodontics,
Government Dental College and Hospital, Ahmedabad -
380016, Gujarat, India.
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CORRESPONDING AUTHOR:
Dr. Poonam R. Kulkarni
Postal address: 8-A, Krishi Vihar Colony, Near Tilak Nagar,
Indore- 452001, M.P.
E mail: [email protected]
Mobile no: 07024765475