The surgical resection of the malignant tumors invading mandible often leads to complex clinical scenario. Disabilities resulting from the lateral resection lead to severe mandibular dysfunction than the radicular surgeries. Swallowing, speech, mandibular movements, mastication, control of saliva, respiration, and psychic functioning are adversely affected by mandibular resection.¹,²,³,⁴,⁵,⁶,⁷

Rehabilitation of such patients requires meticulous treatment planning with fabrication of interim guide flange prosthesis to reduce mandibular deviation followed by a well designed definitive prosthesis. The clinical objectives for such patients includes (1) to record the teeth and myodynamics of remaining postsurgical tissues, (2) to reduce the deviation of the mandible and minimize the resistance from postsurgical tissue scarring, (3) to record the unilateral movements of the remaining mandible in relation to maxilla to establish occlusion.⁸

A number of treatment modalities are suggested which includes intermaxillary fixation,⁹ maxillary retained palatal guidance prosthesis, mandibular retained guidance prosthesis,¹⁰,¹¹ implant supported mandibular prosthesis,⁶,¹²,¹³ if there is sufficient available bone. However, if there is only soft tissue reconstruction, the prosthesis relies mainly on the remaining teeth for the support.

A male patient aged about 47 years was referred to the Department of Prosthodontics, Maratha Mandal's NGH Institute of Dental Sciences and Research Centre, Belgaum with a chief complaint of deviation of the mandible. A thorough case history revealed that the patient had undergone segmental mandibular resection from the left condyle to the parasymphyseal region affected by squamous cell carcinoma a year ago. Orthopantomogram revealed discontinuity in the left mandible with loss of left condylar and coronoid process, ramus, angle of the mandible, premolars, and molars. Intraoral examination revealed free fibula graft showing satisfactory healing with obliteration of buccal and lingual sulci. Anterior open-bite was observed because of the frontal rotation of the mandible. There was marked deviation of the mandible toward the defect side Figure 1. The patient was not able to hold the mandible in stable occlusal position. There was no history of inter-maxillary fixation. It was classified as Class II according to the recent classification given by Brown.¹⁴ The treatment plan for this patient was mainly aimed at reduction of mandibular deviation by giving guidance prosthesis with correction of open bite and to achieve stable occlusion.Figure 1

Pretreatment view.

Patients with mandibular resections shows excessive morbidity and such patients should be intervened at an early stage to achieve favorable prognosis. The success of prosthetic rehabilitation depends on size and extension of the defect, myodynamics of the soft tissue, propioception of the patient, number of remaining teeth for the support, extent of mouth opening, and severity of mandibular deviation.⁵ After surgical resection, if the wound is closed primarily without reconstruction, the mandible retrudes and deviates more severely toward the defect side.¹,⁴,¹¹ The mandibular resection closed by free grafts shows lesser mandibular deviation. The loss of muscles of mastication and neuromuscular reflex on the defect side results in frontal rotation of the remaining mandible and the entire envelop of motion is seen towards defect side which results in loss of occlusal contact.⁴ Comprehensive therapy includes muscle reprogramming exercises along with the guidance prosthesis.¹¹ Many authors have advocated the use of intermaxillary fixation immediate postoperatively. Aramany and Myers⁹ have reported that intermaxillary fixation done during the first 6 postoperative weeks will reduce the degree of deviation. Sahin et al.¹¹ advocated the fabrication of cast metal guidance prostheses with supporting flanges for reducing the mandibular deviation and maintaining the cheek and the tongue out of the path of closure in segmental resections. In this patient, as there was no bone reconstruction of the resected area, the support for any sort of removable prosthesis was poor and as the patient was more concerned about esthetics and mastication, a fixed prosthesis was planned on the mandibular teeth with the correction of open bite. The attachments were placed on the fixed partial denture of the mandibular teeth. The retention of the guide flange was much improved because of the attachments and patient was able to hold the mandible in stable occlusion. The muscles were reprogrammed and the myotonicity of mandibular musculature was well considered. The patient was followed up for 2 years. Since the guide flange was made removable, the patient was more comfortable, and the flange could be removed as and when required without any inference during mastication.

A simple and innovative way of customizing the access postattachments to retain mandibular guide flange has been presented. It is cost-effective and can be easily fabricated. There is psychological benefit for the patient with enhanced retention of guide flange prosthesis. It also helps in reducing mandibular deviation effectively and achieving stable occlusion.

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Conflicts of interest

The authors of this manuscript declare that they have no conflicts of interest, real or perceived, financial or nonfinancial in this article.