DOI: 10.7860/JCDR/2023/63264.

18175
Case Report

Oral Rehabilitation of Segmental

Dentistry Section
Mandibulectomy with Extensive
Fibrosis- A Daunting Obstacle for
the Maxillofacial Prosthodontist
Raisa Natasha Chodankar1, Aditya Acharya2, Raghunath Patil3

ABSTRACT
The fifth most frequent malignancy worldwide is head and neck cancer. Following surgical removal of lesions of the oral cavity,
mandibular resection can result in undesirable effects, such as altered mandibular movements, disfigurement, dysphagia, impaired
speech, and deviation of the mandible in the direction of the resected site. After a marginal or segmental mandibulectomy,
prompt rehabilitation is preferred since aesthetic and functional deficiencies impair a patient’s quality of life. The contribution of
maxillofacial prosthodontists safeguards the prosthetic viability, driven by a prosthetic proposed plan. Maxillofacial prosthodontists
should be included from the start, and they play a crucial and directing role in this procedure. The present case report specifies
the treatment of a 52-year-old male patient with extensive fibrosis who had a reduced mouth opening as a result of right-side
segmental mandibulectomy. The mandible was difficult to manipulate into occlusion due to considerable fibrosis that had formed
over time, thus a guiding flange prosthesis was not employed in the present case. To address the patient’s inability to chew food, a
double occlusion table was designed using the remaining maxillary teeth. A 3-month follow-up was performed, as well as the Oral
Health Impact Profile-14 (OHIP-14) was done prior to and following the treatment.

Keywords: Dental prosthesis design, Head and neck oncology, Mandibular defects,
­Maxillofacial prosthesis, Oral health-related quality of life

CASE REPORT
A 52-year-old male patient reported to the Department of
Prosthodontics, Crown and Bridges with the chief complaint
of inability to chew food since four years. The patient’s prior
interventional history reveals that mandibulectomy was done
following squamous cell carcinoma of the right buccal mucosa and
alveolus five years ago. Following surgical intervention, the patient
did not receive any prosthodontic rehabilitative care. Patient gave
history of radiotherapy three and half years ago.
A clinical examination revealed the right mandibular portion missing
and extraoral facial asymmetry. Deviation of the mandible was
towards the right side [Table/Fig-1a-c]. Orthopantomography was [Table/Fig-2]: Preoperative orthopantomogram.
used for diagnostic imaging, this illustrated that the right mandibular
body was absent, and teeth present were 21-28, 33-37, 42-43
[Table/Fig-2]. Due to the sharp pain of varying intensity, the patient
endured extraction of 21,22,42,43,44 by a nearby dentist. On
intraoral examination, drooling of saliva and a restricted mouth
opening of 3.5 cm was observed [Table/Fig-3a-c].
[Table/Fig-3]: (a-c) Intraoral photographs of the patient showing drooling of saliva
Postsurgical rehabilitation was not received by the patient, this and restricted mouth opening.
resulted in the ramus segment migrating superiorly and medially
and fibrosing, with limited mouth opening, making impressions a difficult process, and hampered the treatment prognosis. No details
of the surgical procedure were available with the patient.
A guide flange prosthesis was not used in this particular case
because the mandible was difficult to manipulate into occlusion
due to extensive fibrosis that had developed over time. To resolve
the patient’s inability to chew food, a double occlusion table was
designed with the help of the remaining maxillary teeth.
A stock tray was used to make an impression using irreversible
hydrocolloid impression material (Tropicalgin Zhermack alginate
powder) which was then followed by the fabrication of a custom
tray using tray compound, a wash impression using vinyl poly
[Table/Fig-1]: a-c) Preprosthodontic treatment extraoral photographs. siloxane impression material light body (Express 3M ESPE) was
12 Journal of Clinical and Diagnostic Research. 2023 Jul, Vol-17(7): ZD12-ZD14
www.jcdr.net Raisa Natasha Chodankar et al., A Daunting Obstacle for the Maxillofacial Prosthodontist

made. A palatal plate made of chemically-cured polymethyl Post-

methacrylate (DPI, Mumbai) was used to record the Functionally Pretreatment treatment
Dimensions Question response response
Generated Pathway (FGP) [1]. The patient was instructed to close
into centric occlusion. Modelling wax (Prevest Denpro) was used to Have you had trouble pronouncing
any words because of problems with 4 2
record indentations made by the patient’s mandibular teeth [Table/ Domain 1: your teeth, mouth, or dentures?
Fig-4a]. The patient was then instructed to open the jaws and Functional
Limitation Have you felt that your sense of taste
try to move it laterally as much as possible, due to the restricted has worsened because of problems 4 1
movement of jaw only about 2-3 mm of lateral movement were with your teeth, mouth, or dentures?
recorded. Before going in for definitive records, this was repeated. Have you had painful aching in your
3 0
Cast was poured using dental stone (Kalabhai, Mumbai) by the mouth?
Domain 2:
indentations produced in wax [Table/Fig-4b]. Casts were mounted Physical pain Have you found it uncomfortable to
on 3-point mean value articulator and a row of semi-anatomic eat any foods because of problems 4 1
with your teeth, mouth, or dentures?
maxillary posterior teeth on the untreated side of the maxillary
Have you been self-conscious
denture was arranged [Table/Fig-4c]. After trial, it was processed
because of your teeth, mouth, or 3 1
using chemically-cured polymethylmethacrylate and insertion was Domain 3: dentures?
done. No treatment was done on untreated side due to restriction Psychological
discomfort Have you felt tense because of
in mouth opening [Table/Fig-5a]. problems with your teeth, mouth, or 4 2
dentures?
At the follow-up after three months the patient reported improvement
in chewing efficiency and overall satisfactory experience [Table/Fig- Has your diet been unsatisfactory
because of problems with your teeth, 4 2
5b,c]. The pre and post-treatment responses to OHIP-14 [2] were Domain 4: mouth, or dentures?
recorded [Table/Fig-6]. Physical
disability Have you had to interrupt meals
because of problems with your teeth, 4 1
mouth, or dentures?
Have you found it difficult to relax
because of problems with your teeth, 4 2
Domain 5: mouth, or dentures?
Psychological
disability Have you been a bit embarrassed
because of problems with your teeth, 4 1
mouth, or dentures?
Have you been a bit irritable with
other people because of problems 3 1
Domain with your teeth, mouth, or dentures?
[Table/Fig-4]: a) Functionally Generated Pathway (FGP) registration using modelling 6: Social
disability Have you had difficulty doing your
wax; b) model fabricated in dental stone using the FGP; c) semi-anatomical teeth
usual jobs because of problems with 3 1
arrangement done on the palatal aspect.
your teeth, mouth, denture?
Have you felt that life in general was
less satisfying because of problems 4 1
Domain 7: with your teeth, mouth, dentures?
Handicap Have you been totally unable to
function because of problems with 4 2
your teeth, mouth, dentures?
[Table/Fig-6]: Oral Health Impact Profile-14 (OHIP-14). Pretreatment and three
months post-treatment patient.
*The responses were recorded on a 5-point Likert scale (0-never; 1-hardly ever, 2- occasionally,
3- fairly often, and 4- very often)
[Table/Fig-5]: a) Postprosthodontic rehabilitation shows the achieved intercuspation;
b,c) Postoperative extraoral photographs at three months follow-up.
Different surgical treatment approaches, such as a marginal,
DISCUSSION segmental, hemi, subtotal, or total mandibulectomy, are used,
Mandibular continuity defects may result from the removal of benign depending on the location and size of the tumour in the mandible
or malignant tumours infections, or trauma [3]. The fifth most frequent [8]. Immediate reconstruction is generally advised following
malignancy worldwide is head and neck cancer [4]. Following surgical the removal of a mandibular segment in order to enhance facial
removal of lesions of the oral cavity, mandibular resection can result symmetry and masticatory function. More than 50% of patients with
reconstructed head and neck cancer still reported experiencing
in undesirable effects, such as altered mandibular movements,
impaired mastication, despite recent advances in reconstructive
disfigurement, dysphagia, impaired speech and articulation, and
surgery and prosthodontic rehabilitation procedures [8]. Re-
deviation of the mandible in the direction of the resected site [5].
educating muscles to establish a desirable occlusal relationship is
Loss of continuity results in rotation of the mandibular occlusal plane
the fundamental goal of rehabilitation. Depending on the type and
downward and deflection of the remaining segment(s) toward the
extent of the mandibular deficiencies, a number of different, such
defect. Because of the muscular imbalance caused by the unilateral
as implant-supported prostheses or guide flange prostheses have
muscle removal, the maxillomandibular relation is changed, resulting been recommended for the correction of mandibular deviation.
in fewer tooth-to-tooth contacts after a segmental mandibulectomy Koralakunte PR et al., corrected the mandibular deviation, and
procedure [5,6]. After a marginal or segmental mandibulectomy, restored the maxillomandibular relationship by a functional training
prompt rehabilitation is preferred since aesthetic and functional device called a maxillary guided hollow inclined plane with twin
deficiencies might impair a patient’s quality of life [7]. occlusion acrylic prosthesis was designed [9]. Agarwal S et al.,
For mandibular reconstruction, free bone grafts, vascularised flaps, fabricated a maxillary removable partial prosthesis with two rows
alloplastic implants can all be used in conjunction with soft-tissue-free of teeth-twinned occlusion on the unresected side in the maxillary
flaps [5]. This report describes the fabrication of a maxillary occlusal edentulous arch [10].
table prosthesis for the management of postsurgical malocclusion In the present case, the patient reported at a quite later stage
in the case of limited mouth opening in a mandibulectomy patient and due to extensive fibrosis, the mediolateral movement of the
without reconstruction. mandible was not possible. Due to this, the occlusal relationship
Journal of Clinical and Diagnostic Research. 2023 Jul, Vol-17(7): ZD12-ZD14 13
 Raisa Natasha Chodankar et al., A Daunting Obstacle for the Maxillofacial Prosthodontist www.jcdr.net

of the teeth was not maintained and hence the inability to chew intraoral rehabilitation. Maximising dental rehabilitation dramatically
was encountered. The addition of teeth on the palatal aspect of the enhances oral health-related quality of life, oral diet success, and
unaffected maxillary arch gave a broad occlusal table by means of oral functioning.
which the remaining mandibular natural teeth could occlude and
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PARTICULARS OF CONTRIBUTORS:
1. Postgraduate Student, Department of Prosthodontics Crown and Bridge, KAHER, KLE VK Institute of Dental Sciences, Belagavi, Karnataka, India.
2. Reader, Department of Prosthodontics Crown and Bridge, KAHER, KLE VK Institute of Dental Sciences, Belagavi, Karnataka, India.
3. Professor, Department of Prosthodontics Crown and Bridge, KAHER, KLE VK Institute of Dental Sciences, Belagavi, Karnataka, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: PLAGIARISM CHECKING METHODS: [Jain H et al.] Etymology: Author Origin
Raisa Natasha Chodankar, • Plagiarism X-checker: Feb 21, 2022
JNMC Campus, Belagavi-590010, Karnataka, India. • Manual Googling: Apr 19, 2023 Emendations: 7
E-mail: [email protected] • iThenticate Software: May 24, 2023 (16%)

Author declaration: Date of Submission: Feb 08, 2023

• Financial or Other Competing Interests: None Date of Peer Review: Mar 29, 2023
• Was informed consent obtained from the subjects involved in the study? Yes Date of Acceptance: May 31, 2023
• For any images presented appropriate consent has been obtained from the subjects. Yes Date of Publishing: Jul 01, 2023

14 Journal of Clinical and Diagnostic Research. 2023 Jul, Vol-17(7): ZD12-ZD14