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SRM University Journal of Dental Sciences Volume 2, Issue 4, October - December 2011

Case report

Training Flange Appliance after Hemi-mandibulectomy - A case report

M Satish1, Nirmala Pasam 2
1
Department of Oral and Maxillofacial Surgery, Sri Sai Dental College, Srikakulam
2
Department of Prosthodontics, Gitam Dental College, Visakhapatnam

Address for correspondence Abstract

Dr M Satish Loss of continuity of the mandible destroys the balance of the
50-50-33/1, lower face and leads to decreased mandibular function. This is
TPT colony, due to deviation of the residual segment towards the surgical
Visakhapatnam, site, which causes difficulty in mastication due to
Andhra Pradesh, India. disoccclusion, facial disfigurement, swallowing and speech.A
E-mail: msatishb4u@yahoo.co.in 62 year old male patient with hemimandibulectomy done on the
right side of the face reported to our clinic for prosthetic
rehabilitation of the deviated mandible due to difficulty in
mastication, speech and swallowing.A simple training flange
appliance was given for a period of 4months, so that the
residual mandible can be easily repositioned into proper
alignment followed by a permanent prosthesis. This case report
explains the treatment that has been done for a patient with
deviation of the mandible after hemimandibulectomy.
Key Words: Hemimandibulectomy; training flange appliance

Introduction A 62year old male patient with hemimandibulectomy done

Discontinuity of the mandible after surgical resection or
trauma destroys the balance and symmetry of mandibular
function, which leads to altered mandibular movements and
deviation of the residual segment towards the defect side.1
The reasons for deviation are multifactoral and include:
a) The location and extent of the resection
b) The amount of soft tissue involvement
c) The degree to which innervation has been
involved
d) Presence of remaining natural teeth
e) How much tightly the surgeon closed the wound.
on the right side of the face reported to our clinic for prosthetic
rehabilitation of the deviated mandible. Patient's chief
complaint was difficulty in mastication due to deviation of the
mandible towards the defective side thus causing
disoccclusion of the teeth on the normal side. Patient also
complained of difficulty in speech and swallowing. (Figure 1)
History
Patient had undergone surgical resection of the mandible on
the right side of the mandible due to malignant lesion 9
months back. Patient had undergone radiation therapy
postoperatively.

Thus the various debilitating consequences that have On Examination

observed are:
Extra-oral examination
 Disoccclusion
Facial asymmetry due to depression on the right side
 Disoriented masticatory cycle
Deviation of the mandible towards the right
 Facial disfigurement
Scar tissue on the right side of the face
 Distorted speech and salivation problems

Intra-oral examination
This paper explains the treatment that has been done for a
Maxillary arch shows intact dentition.Mandible has been
patient w ith deviation of the mandible after
resected distal to the second premolar on the right side
hemimandibulectomy.

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Training Flange Appliance after Hemi-mandibulectomy - A case report M Satish et al

showing CLASS 2 defect with intact dentition on the normal
side.
There is a deviation of the mandible towards the defective
side thus disoccclusion of the teeth on the normal side. The
amount of deviation was 4 to 5mm approximately from the
midline towards the defect side. Patient was unable to take the
mandible to occlude with the maxilla. (Figure 2)
Diagnosis
Full mouth radiographs were taken to know the amount of
hard tissue that is left intact and to see the amount of bone that
has been resected.
Impressions were made with irreversible hydrocolloid
impression material to make the diagnostic casts. Diagnostic
casts were mounted on an articulator.
Treatment
The basic objective in rehabilitation is retraining the
remaining mandibular muscles to provide an acceptable
maxilla-mandibular relationship for the remaining portion of
the mandible. The retraining of the residual remaining
mandible is to achieve an acceptable occlusion.
deviation. An ideal result was achieved when the patient was
able to repeatedly approximate the maxillary and mandibular
teeth without the use of the training flange appliance.2
Physiotherapy was suggested to assist the patient in
improving the symmetrical arc of closure and finding centric
occlusion position without guiding the mandible manually.
The exercise consisted of simple opening and closing of the
mandible with or without the appliance. When the prosthetic
therapy combined with a well-organized exercise regimen,
improved results were achieved within a short span of time.
After a period of four months, a removable partial denture
was given to the patient for the missing teeth with minimal
deflective contacts in centric and eccentric position (Figure
5).
Oral hygiene instructions were given. Patient was referred to
the Department of Periodonotics and Conservative dentistry
for the oral prophylaxis and restorations.

The patient was evaluated for the fabrication of a training

flange appliance.

Treatment plan with its prognosis was presented to the patient

and was accepted by the patient.

A maxillary training flange was fabricated using a clear self-

cure acrylic resin. The appliance was retained by two Adam's
clasps on either side of molars and two on either side of the
premolars. An inclined platform was fabricated palatal to the
Figure 1: Deviated mandible
posterior teeth in the maxillary arch on the normal side, which
slopes occlusally away from the natural teeth. (Figure 3)

Appliance was checked in the patient's mouth for the

progressive sliding of the remaining mandibular teeth up the
incline until the occlusal contact reached by checking high
points with articulating paper.

After the patient had worn the training flange appliance for a
period of three and a half months, he was pleased that more
teeth contacted on the left side i.e. normal side and he was able
to chew food better. (Figure 4)

The attainment of occlusal contacts was achieved over

varying time intervals depending on the extent of the Figure 2: Disocclusion on the normal side

353 Streamdent, 2(4), 2011

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Training Flange Appliance after Hemi-mandibulectomy - A case report
Figure 3: Training Flange Appliance
Figure 4: Occlusion on the normal side
Figure 5: Post operative view
Discussion
The patient who undergone mandibular resection are left with
multiple physiologic and cosmetic deficiencies, including
inability to masticate in an acceptable or efficient manner.
Streamdent, 2(4), 2011
M Satish et al
One of the primary goal of treatment is the restoration of
acceptable occlusal function by retraining the patient's
neuromuscular system.
Various treatment options available are3
1. Use of skin grafts and flaps for wound closure
2. Intermaxillary fixation at the time of surgery
3. Guidance restorations
4. Physiotherapy to decrease the fibrosis.
Use of skin grafts or flaps may reduce deviation caused by
primary closure. Grafting also improves postoperative tongue
mobility and benefits mastication, saliva control, deglutition
and speech.
Aramany and Myers- advocated Inter-maxillary fixation 5-
7weeks immediately after surgery. There is evidence to
indicate that Intermaxillary fixation limits the postoperative
mandibular deviation. The degree of deviation is inversely
proportional to the length of time the mandible is fixed.4
Mc Casland suggested use of straight opening and closing
exercises to train the neuromuscular system to avoid
deviation of the mandible.
Beumer et al suggested exercise program for 2 weeks post
surgically along with guidance appliance. Exercise consists
of the patient grasping the chin and moving the mandible
away from the surgical side5. The internal pterygoid and
mylohyoid muscles pull the resected mandible medially or
towards the defect, but the temporal and masseter
reciprocates in a superior and lateral direction. The ability of
the masticatory muscles to maintain a functional equilibrium
following mandibulectomy can be easily overcome by scar
contraction, and it is, therefore important to resist this scar
displacement.
The guidance appliances that can be used are:
 Palatal ramp
 Positioning prosthesis
 Herbst appliance
 Guide plane splints
The palatal ramp directs the mandibular teeth into the
intercuspal position on closing by the addition of acrylic resin
to form a ramp or guide plane palatal to the maxillary arch that
oppose the non resected portion of the mandible.
A positioning prosthesis can be made by extending a palatal
flange inferiorly onto the lingual vestibule between the lateral
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Training Flange Appliance after Hemi-mandibulectomy - A case report
border of the tongue and lingual surface of the mandible. This
flange can be formed in the mouth with auto polymerizing
acrylic resin.
Herbst appliance is compared to an artificial joint working
between maxilla and mandible. This is a telescopic
mechanism attached to orthodontic bands to keep the position
of the mandible stable.
Adisman fabricated guide plane splints as preoperative
Intermaxillary prostheses. This removable appliance is made
up of cast metal with an acrylic resin or heavy wire loops that
extend into the mucobuccal fold.
The discontinuity defect creates a much greater occlusal
discrepancy thus, the basic objective is to achieve an occlusal
scheme with multiple occlusal contacts in centric position.
Long centric or group function occlusion on the working side
can be incorporated in the partially edentulous mouth that
may generate least stress to the remaining structures. Vertical
dimension of occlusion can be slightly decreased in an
attempt to decrease occlusal force. Balanced occlusion in all
eccentric positions increases the denture stability in
completely edentulous patients. Patients with little maxillary
or mandibular support benefit from non anatomic teeth.
Lowering the occlusal plane permits easier stress distribution
and control of food on occlusal plane.
Advantages of guiding flange appliance
 Realignment of the residual mandible to occlude with the
opposing maxillary dentition
 Improved mastication
 Improved speech and swallowing
 Ease of fabrication and economical
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M Satish et al
Conclusion
A comfortable mandibular alignment is not always
maintainable in the restoration of the patients with partially
resected mandible. Training flange appliance, can be a useful
adjunct to preserve the mandibular function after partial
mandibulectomy procedures and to minimize associated
complications like mastication, speech and swallowing as…
“Every human has the Divine right to look human”.
References
1. Robert.L.Schneider, Thomas .D. Taylor, Mandibular
resection guidance prostheses: A literature review.
J.Prosthet.Dent.1986;55(1):84-86.
2. Ronald. P. Desjardins, Occlusal considerations for the
partial mandibulectomy patient. J. Prosthet. Dent.
1979;41(3):308-315.
3. Jack.W.Martin, Ronald.J.Shupe, Ehonda. F. Jacob,
Gordon.E.King. Mandibular positioning prosthesis for
the partially resected mandibulectomy patient. J.
Prosthet.Dent. 1976;35:202
4. Aramany MA, Myers EN: Intermaxillary fixation
following mandibular resection. J. Prosthet. Dent.
1977;37:437.
5. Beumer. J.Curtis. TA, Firtell DN: Maxillofacial
Rehabilitation: Prosthodontic and surgical
considerartions.
Streamdent, 2(4), 2011