A fixed guide flange appliance for

patients after a hemimandibulectomy

Santosh Nelogi, MDS,
a
Ramesh Chowdhary, MDS,
b
Maheshwari Ambi, BDS,
c
and Prachi Kothari, MDS
d
KLE VK Institute of Dental Science, Karnataka, India; S. Nijalingappa
Institute of Dental Sciences, Gulbarga, India
Oral carcinoma destroys structures, including the maxilla and mandible, which often require surgical management and
rehabilitation. Poor tissue support after mandibular reconstruction in patients with hemimandibular defects hinders the
reconstruction of functional and stable mandibular guide ange prostheses. The fabrication and use of a xed guide ange
prosthesis for rehabilitating patients with hemimandibular defects is described. The device permitted the use of the same
prosthesis for both the functional and mechanical correction of mandibular deviation and is indicated where the fabrication
of other appliances is contraindicated because of the compromised oral and physical state of the patient. (J Prosthet Dent
2013;110:429-432)
Oral cancer is the eighth most
common carcinoma worldwide,
1-5
de-
stroys tissue, which often requires resec-
tioninvolving the mandible, maxilla, oor
of the mouth, and tongue, and which
may adversely affect an individuals
mental health.
6-9
After mandibular
resection, patients experience the loss
of a proprioceptive sense of occlusion
and the absence of the muscles of
mastication on the surgical side, result-
ing in signicant rotation of the man-
dible upon closure, with the mandible
deviating toward the surgical side
(medial).
7,8,10-12
Treatment of the deviated mandible
starts with early corrective mandibular
movement therapy, including physi-
otherapeutic stretching exercises.
7,13,14
Various designs of prostheses used to
guide the mandible into centric oc-
clusion have been described.
7-22
A
removable guide ange prosthesis
cannot be retained intraorally if only
a few teeth remain in the sectioned
mandible. Retention can be further
compromised by radiation and surgical
scarring, which limits mouth opening
and functional vestibule depth such
that placement and removal of the
guide ange prosthesis is impossible
for the patient,
13
leading to further
occlusion problems.
13,7,20
Therefore, to
overcome the problems of the remov-
able design, a xed prosthesis that
would prevent scar contraction by
keeping muscles in the stressed condi-
tion and at the same time provide
corrective and masticatory functions
is indicated.
10,11
A technique using a
xed mandibular guide ange appli-
ance has been designed for the pros-
thetic management of patients after a
hemimandibulectomy.
TECHNIQUE
1. Make maxillary and segmented
mandibular impressions in elastomeric
impression material (Aquasil Ultra
Soft Putty; Aquasil Ultra LV Wash;
Dentsply Intl) andpour casts withType III
dental stone (Kalastone; Kalabahi Pvt
Ltd).
2. Articulate the maxillary and
mandibular casts at a reasonable centric
relationship with occlusion recording
wax (Dental Wax; Carmel Group Inc).
3. Place orthodontic tooth separa-
tors (Elstico Separador; Dental Morelli
Ltd) interdentally around one of the
mandibular posterior teeth so as to
create interdental space.
4. Adapt the prefabricated ortho-
dontic molar band (3M Unitek) of the
proposed tooth size on the prepared
mandibular cast (Fig. 1).
5. Bend a wrought wire (KC Smith
and Co) 1 mm thick and 5 cm long in
the shape of a U (with right angle
bends) with a tube 10 mm in length
occupying the base of the U, which
freely rotates around the wire (Fig. 2).
6. Adjust the height of the U-sha-
ped loop with a tube on a mounted
mandibular cast with a preadjusted
band in such a manner that the tube
will be placed horizontally at the level
of the buccal surface of maxillary
posterior teeth when the teeth are in
articulation. After conrming the po-
sition, solder a U-shaped loop (Den-
taurum Dental Technology) to the
preadjusted band (Figs. 3, 4).
a
Reader, Department of Prosthetic Dentistry, KLE VK Institute of Dental Science.
b
Professor, Department of Prosthetic Dentistry, S. Nijalingappa Institute of Dental Sciences.
c
Lecturer, Department of Prosthetic Dentistry, KLE VK Institute of Dental Science.
d
Postgraduate student, Department of Prosthetic Dentistry, KLE VK Institute of Dental Science.
Nelogi et al
7. Further adjust the band with
a soldered U-shaped loop with the
tube positioned medially and laterally
depending on the extent of the mandib-
ular deviation (Fig. 4).
8. Sterilize the appliance with dry
heat before cementing it to the pre-
pared site.
9. Remove the separators placed in
the patients mouth and place the
molar band with the U loop and eval-
uate for efcacy. Any adjustment in
angulation (medially, laterally) of the
U-shaped loop in relation to the molar
band is done at this stage so that
it guides the mandible in centric
occlusion with less strain on the patient
(Figs. 5, 6).
10. Once the t and function of
the appliance are conrmed with the
least possible strain on the patient,
cement it to the proposed tooth. The
design of the xed guide ange with
a U-shaped loop is adjusted in such
a way that it will not traumatize the
maxillary teeth and gingiva during
function (Fig. 7).
DISCUSSION
The mandibular guide ange pros-
thesis is commonly used and has been
the subject of many studies.
7,12-20
Sahin et al
18
and Chalian et al
19
advocated the fabrication of a cast
metal guidance prosthesis with sup-
porting and retentive anges for a pa-
tient after a mandibulectomy. The
authors claimed that the patient was
able to achieve a functional intercuspal
position after the insertion of the
prosthesis but that mastication was
limited to vertical movement only. Joshi
et al
20
described the fabrication of a
mandibular guide ange prosthesis and
suggested that a removable prosthesis
was an effective alternative for most
patients with mandibular defects,
considering the poor prognosis, dif-
culty in deciding on the use of the
implant, and economic feasibility. The
prosthesis described by Koumjian and
Firtell
21
was modied with a Herbst
appliance; the disadvantage of this
technique was the occasional separa-
tion of the tube and plunger at
maximum jaw opening. Prencipe et al
22
described a technique by simply insert-
ing and removing the guide ange.
The xed guide ange appliance
mentioned here consists of a molar
band with a U loop, which is cemented
to the tooth. The U loop of the xed
guide ange extends superiorly and
diagonally along the buccal surface of
1 Mandibular cast with molar band adapted to prepared
tooth.
2 U loop with tube.
3 U loop soldered to preadjusted band.
430 Volume 110 Issue 5
The Journal of Prosthetic Dentistry Nelogi et al
the maxillary premolar and molar teeth.
The stainless steel tube at the base of
the U loop glides the mandible into
centric occlusion, thereby reducing
mandibular deviation and allowing
for the normal vertical and horizontal
overlap of the remaining dentition
(Figs. 6, 7).
The xed guide ange presented
here prevents the deviation of the
mandible toward the surgical side and
serves to minimize radiation scarring by
keeping the tissue in a stressed condi-
tion; stretching the tissues during heal-
ing minimizes the amount of scarring
within the area.
7,14
The proposed xed guide ange
is recommended for those patients
with signicant mandibular resection
(Fig. 8) who have limited mouth
opening ability resulting from tissue
scarring and who lack the motor skills
to manage a removable prosthesis
(Fig. 9).
The technique is proposed only
when the remaining teeth are peri-
odontally sound enough to bear the
angular pull of muscles and masti-
catory forces. The xed guide ange
prosthesis proposed is functional, aes-
thetic, comfortable, and easy to fabri-
cate and repair; it also allows better
hygiene maintenance.
After the placement of a xed
mandibular guide ange prosthesis,
the patient must be evaluated for any
strain or pain in the temporoman-
dibular joints and muscles every 6
hours for the rst 72 hours after
cementation. The patient is further
recalled after 6, 12, and 28 days to
evaluate the efcacy of the xed guide
ange appliance and to ensure that
no misalignment or migration of the
maxillary tooth/teeth adjacent to the
loop has occurred in the remaining
dentition.
SUMMARY
The proposed guide ange is a
simple alternative to the existing
removable mandibular guide ange
prosthesis. The guide ange consists of
a molar band with a U loop, which is
cemented to one of the mandibular
teeth. Disadvantages include the pos-
sible migration of maxillary teeth adja-
cent to the loop. Further research
should focus on determining the inu-
ence of the xed guide ange on the
maxillary teeth and on any long-term
adverse effects of its use.
4 Fixed appliance guide ange.
5 Occlusal view of cemented xed guide ange.
6 Fixed guide ange showing position and level of loop at
time of articulation.
November 2013 431
Nelogi et al
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Corresponding author:
Dr Santosh Nelogi
House #1, l.i.g. Phase III
Adarsh Nagar, Gulbarga, Karnatka
INDIA
E-mail: santrodent@rediffmail.com
Copyright 2013 by the Editorial Council for
The Journal of Prosthetic Dentistry.
7 Denitive intraoral result.
8 Panoramic radiographic view showing mandibular discontinuity defect.
9 Intraoral view showing mandibular deviation toward
resected side.
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The Journal of Prosthetic Dentistry Nelogi et al