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

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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

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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

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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: poonamrahulkulkarni@gmail.com

Mobile no: 07024765475