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Clinical Series

Mandibular guidance prosthesis: Conventional and

innovative approach: A case series
Ranjoy Hazra, Ayush Srivastava, Dinesh Kumar
Department of Prosthodontics and Crown and Bridge, Army Dental Center (Research and Referral), New Delhi, India

Abstract Surgical resection of the lower jaw due to the presence of a benign or malignant tumor is the most
frequent cause of mandibular deviation. Location and extent of the tumor decide the surgical modality of
mandibulectomy to be performed. The clinician must wait for an adequate span of time for completion
of the healing and acceptance of the osseous graft before considering a definitive prosthesis. During the
inceptive healing period, prosthodontic intervention is of utmost priority for preventing the mandibular
deviation. A corrective appliance termed “guide flange prosthesis (GFP)” is indicated to limit this clinical
manifestation. The basic intention of rehabilitation is to train the mandibular muscles and to re‑establish
an acceptable occlusal relationship so that the patient can adequately control the opening and closing
movements. This case series describes early prosthodontic management of three patients who had undergone
hemimandibulectomy, with different techniques of fabrication of a GFP. The three techniques described
consist of two conventional methods of fabrication while the third technique is a new innovative approach.

Keywords: Deviation of mandible, guide flange prosthesis, hemimandibulectomy, mandibular guidance

therapy

Address for correspondence: Dr. Ranjoy Hazra, Department of Prosthodontics and Crown and Bridge, Army Dental Center (Research and Referral),
New Delhi ‑ 110 010, India.
E‑mail: [email protected]
Submitted: 10‑Jan‑2021, Revised: 30-Mar-2021, Accepted: 03‑Apr‑2021, Published: 28-Apr-2021

INTRODUCTION continuity is usually not as debilitating as a resection

that includes mandibular continuity.[2] Loss of continuity
Benign or malignant neoplasms which are associated causes deviation of remaining segment(s) toward the
with the lower jaw usually require surgical excision of defect and rotation of the mandibular occlusal plane
the pathologic lesion and extensive resection of the downwards. After a segmental mandibulectomy surgery,
lower jaw.[1,2] Mandibular resection following surgical masticatory function is compromised because of
treatment for neoplastic lesions of the oral cavity leads muscular imbalance due to unilateral muscle removal,
to numerous complications including altered mandibular altered maxillomandibular relationship, and decreased
movements, disfigurement, difficulty in swallowing, tooth‑to‑tooth contacts. Although immediate mandibular
impaired speech and articulation, and deviation of the reconstruction aims to restore facial symmetry, arch
mandible toward the resected site. The resection of a alignment, and stable occlusion, masticatory function
portion of the mandible without loss of mandibular
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DOI: How to cite this article: Hazra R, Srivastava A, Kumar D. Mandibular

10.4103/jips.jips_12_21 guidance prosthesis: Conventional and innovative approach: A case series.
J Indian Prosthodont Soc 2021;21:208-14.

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Hazra, et al.: Mandibular guidance prosthesis

usually remains compromised.[3,4] Loss of the proprioceptive • A 0.7 mm wire was adapted onto the mandibular cast
sense of occlusion following mandibular resection leads on the fourth quadrant to form the framework of the
to the uncoordinated movements of the mandible. The prosthesis
basic rehabilitation goal is to re‑educate muscles to • Autopolymerizing polymethylmethacrylate (DPI Clear;
re‑establish an acceptable occlusal relationship. Guide Dental Products of India, Mumbai) was adapted over
flange prosthesis (GFP) is a mandibular conventional the wire framework which was subsequently removed,
prosthesis designed for those patients who are able to finished, and polished [Figure 3]
achieve an appropriate mediolateral maximum intercuspal • The Guide Flange was inserted and the patient was
position of the mandible without much effort but are trained to achieve full closure [Figure 4] He was
unable to repeat this position consistently for adequate instructed to wear it in all times other than having
mastication and also to limit further deviation.[5] food and 2 months follow‑up showed signs of a
satisfactory resolution of the deviation without the
Cantor and Curtis have classified the mandibular defects guiding prosthesis.
into six categories.[6]
• Class I: Mandibular resection involving alveolar defect Case 2
with preservation of mandibular continuity In our 2nd case, A 47‑year‑old serving soldier reported to
• Class II: Resection defects involve loss of mandibular the Department of Prosthodontics, he underwent partial
continuity distal to the canine area resection of the mandible due to squamous cell carcinoma
• Class III: Resection defect involves loss up to the of the floor of the mouth on the left side.
mandibular midline region
• Class IV: Resection defect involves the lateral aspect On examination, the patient had an 8.5 mm deviation of
of the mandible, but is augmented to maintain pseudo the mandible and toward the left side from the midline with
articulation of the bone and soft tissues in the region a mouth opening of 22 mm [Figure 5]. The defect did not
of the ascending ramus cross the midline and hence could be classified as Cantor
• Class V: Resection defect involves the symphysis and and Curtis classification‑II. The patient was unable to
parasymphysis region only, augmented to preserve approximate his teeth for chewing food and had difficulty
bilateral temporomandibular articulations in swallowing.
• Class VI: Similar to class V, except that the mandibular • Primary impressions were made in irreversible
hydrocolloid (Zelgan 2002; Dentsply, Delhi) casts were
continuity is not restored.
made in Type III dental stone (Kalstone; Kalabhai
CASE REPORTS Karson, Mumbai)
• Recording of a tentative maximal intercuspation
Case 1 position in the bite registration silicone and casts are
In our 1st case, A 43‑year‑old jawan reported to the mounted in the same relation
department of prosthodontics after he underwent partial • A complete palatal coverage prosthesis is constructed
resection of the mandible due to squamous cell carcinoma first by autopolymerizing acrylic resin (DPI Clear;
in the floor of the mouth on the left side. Dental Products of India, Mumbai). Adams and
embrasure Clasps were placed bilaterally for
On examination, the patient had a 5.7 mm deviation of retention. Moreover, then it is fitted and adjusted
mandible toward the left side from the midline with a mouth in the mouth. The prosthesis is removed and a
opening of 25 mm [Figure 1]. The defect did not cross the modeling wax ramp is prepared and added to the
midline and hence could be classified as Cantor and Curtis desired position. The mandible is manipulated
classification‑II. The patient was unable to approximate laterally toward the desired position and the occlusal
his teeth during mastication and speech with associative contact noted and the mandible is manipulated
symptoms of drooling of saliva and halitosis. to get a definite pathway or trail on the palatal
• Primary impressions were made in irreversible ramp [Figure 6]
hydrocolloid (Zelgan 2002; Dentsply, Delhi) and casts • Then, the prosthesis is constructed in heat cure
were made in Type III dental stone.(Kalstone; Kalabhai Polymethylmethacrylate resin (DPI Heat Cure; Dental
Karson, Mumbai) Products of India, Mumbai). in the conventional
• Recording of a tentative maximal intercuspation method [Figure 7]
position and casts are mounted in the same • The patient was recalled and trained and the finished
relation [Figure 2] maxillary prosthesis was inserted [Figure 8 and 9]
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Hazra, et al.: Mandibular guidance prosthesis

Figure 1: Preoperative deviation Figure 2: Wire components in casts mounted in tentative maximal
intercuspation

Figure 3: Finished prosthesis

Figure 4: Postoperative intraoral and extraoral view

Figure 5: Preoperative deviation

• Three months postinsertion follow‑up showed signs Figure 6: Occlusal registration in wax palatal ramp
of a satisfactory resolution of the deviation.
A 48‑year‑old man reported to the department of
Case 3 prosthodontics, after he underwent hemimandibulectomy
In our 3rd case, a new innovative variant of the GFP was subsequent to squamous cell carcinoma of the left
designed in our department. alveolus.
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Hazra, et al.: Mandibular guidance prosthesis

Figure 7: Finished prosthesis Figure 8: Postoperative intraoral view

Figure 9: Postoperative occlusion

On examination, patient had an 11 mm deviation of the Figure 10: Preoperative deviation

mandible toward the left side from the midline had a
mouth opening of 18 mm [Figure 10] Patient was unable This was then trimmed to be kept from the mesial
to approximate his teeth for chewing food and had severe of the canine to the distal of the second molar and
cosmetic disfigurement. equigingivally. Holes were made on the buccal surface
• First, a corkscrew was given to the patient for 2 weeks of the adapted sheet to increase the mechanical
to improve the mouth opening and facilitate prosthesis retention with acrylic. This was placed on the mounted
fabrication cast and articulator was closed. Clear auto polymerizing
• Primary impressions were made in irreversible acrylic (DPI Clear; Dental Products of India, Mumbai)
hydrocolloid (Zelgan 2002; Dentsply, Delhi) and casts was adapted and builded up on the buccal surface of
were made in Type III dental stone (Kalstone; Kalabhai the vacuum sheet and superiorly till the gingival level
Karson, Mumbai) of the maxillary occluding teeth [Figures 13]
• Recording of a tentative maximal intercuspation • The prosthesis was then finished, adjusted, and polished
position in the bite registration silicone and casts were following which the patient was trained in inserting and
mounted in the same relation removal the prosthesis and was instructed in wearing it
at all times other than eating [Figures 14 and 15]
• A sandwich foil vacuum for med sheet
• Postinsertion 3 month follow‑up showed signs of a
(Durasoft PD 1.8 mm × 125 mm; SCHEU, Germany)
satisfactory resolution of the deviation.
with a 0.8 mm hard and a 1 mm soft side was adapted
over the mandibular cast in a thermoplastic Biostar press DISCUSSION
machine. The soft side was toward the tooth surface.
The hard side of the sandwich foil has a property of Depending upon the location and extent of the tumor
chemically bonding to acrylic [Figures 11 and 12]. in the mandible, various surgical treatment modalities
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Hazra, et al.: Mandibular guidance prosthesis

Figure 12: Adapted Durasoft sheet

Figure 11: Sandwich foil vaccum formed sheet

Figure 14: Finished prosthesis

patients still report with impaired mastication.[7] Recent

advancements in facial reconstructive surgery and
osseointegrated endosseous dental implants provide
a treatment modality that may adequately rehabilitate
oral cancer patients so that they can return to a healthy,
productive life.[8]
Figure 13: Acrylic flange added after mounting in tentative
intercuspation
Although dental implants are the definitive solution
for replacing the missing teeth for reconstructed
mandibulectomy patients, the clinicians must wait for
extensive period of time for completion of healing. During
this period early prosthodontic intervention by guide flange
serves the purpose of reducing the mandibular deviation,
preventing extrusion of the maxillary teeth, and improving
the masticatory efficiency.

Figure 15: Postoperative intraoral view The GFP can be regarded as a training type of prosthesis.
If the patient can successfully repeat the position, the GFP
such as marginal, segmental, hemi, subtotal, or can often be discontinued. Some patients, however, may
total mandibulectomy are undertaken. [2] Mandibular have to continue indefinitely, and the stress generated to
deviation toward the defect side occurs primarily the remaining teeth must then be carefully monitored. All
because of the loss of tissue involved in the surgery.[1] of our cases reported in this article required short‑term
When a segment of the mandible is removed, immediate therapy and so there were less chances of damaging forces
reconstruction is usually recommended to improve in the opposing teeth and hence no stabilization appliance
both facial symmetr y and masticator y function. was planned.
Although techniques for reconstructive surgery and
prosthodontic rehabilitation have improved, more The earlier the mandibular guidance therapy is initiated in
than 50% of reconstructed head‑and‑neck cancer the course of treatment the more successful the patients
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Hazra, et al.: Mandibular guidance prosthesis

definitive occlusal relationship is restored.[1] The basic • It is much more compact than the other conventional
rehabilitation objective, in this case, was to re‑educate designs.
mandibular muscles to re‑establish an acceptable occlusal
relationship and to restore the mastication.[2] The most The success of mandibular guidance therapy varies and
common treatment modalities for such patients are depends on the nature of the surgical defect, the early initiation
maxilla mandibular fixation, implant‑supported prosthesis, of guidance therapy, patient cooperation, and other factors.[2]
removable mandibular GFP, and palatal‑based guidance Patients with extensive posterior base of the tongue lesions
restorations.[1] that have resulted in significant soft‑tissue resection and have
required radiation therapy are frequently unable to achieve
This mandibular guidance prosthesis consists of a useful intercuspal relationships. Mandibular guidance therapy
removable partial denture framework with a flange is most successful in patients in whom the resection involves
extending 7–10 mm laterally and superiorly on the buccal only bony structures with minimal adjacent soft tissues.
aspect of the premolars and molars on the nondefect side.[1]
This flange engages the maxillary teeth during mandibular The absence of a radical neck dissection and radiation
closure, thereby directing the lower jaw to an appropriate therapy also improves the prognosis for mandibular
intercuspal position. guidance therapy.

While in the palatal‑based guide flange the index should CONCLUSION

not extend below the level of the upper teeth.[9] If it does,
Every patient should maintain centric occlusion for
it may interfere with speech, deglutition, and other oral
mastication, and this may be accomplished by a GFP.
functions requiring tongue movements. In selected patients
When an acceptable intercuspal position is achieved,
with limited tongue motion, this observance may not be
occlusal equilibration is generally necessary to maintain the
necessary.
mandibular position. The patient should be informed that,
The guidance flange may be constructed of cast as mandibular deviation is reduced, the facial disfigurement
chrome‑cobalt metal or acrylic resin. The material of choice on the defect side will be aggravated because the deviation
will depend on the existing occlusal relationship of the of the mandible toward the surgical side will tend to
patient and the need for adjustment. All of our cases were camouflage the defect. Ensuing the resection, restoration
rehabilitated with acrylic resin GFP as all were planned to of function is routinely not possible and prolonged
be used for a shorter duration of time and needed frequent disfigurement is unavoidable, but providing a guide flange
adjustment. initially followed by prosthetic rehabilitation, functions
such as speech and mastication can be restored to normal
Compared to the conventional GFP, the innovative physiological limits with the slightest disfigurement.
technique has the following advantages:
Declaration of patient consent
• It tends to induce lesser orthodontic forces so a
The authors certify that they have obtained all appropriate
maxillary framework is not usually necessary for
patient consent forms. In the form, the legal guardian
protection
has given his consent for images and other clinical
• The discomfort caused by the wire components
information to be reported in the journal. The guardian
repeatedly interfering on the occlusal table and risk
understands that names and initials will not be published
of wire breakage is eliminated in this design
and due efforts will be made to conceal identity, but
• It is an entirely tooth‑supported prosthesis, not
anonymity cannot be guaranteed.
placing any additional pressure on the gingiva and
abrading it, especially in cases with thin friable Financial support and sponsorship
mucosa Nil.
• The fabrication of the new design was lesser technique
sensitive and same‑day insertion of the prosthesis was Conflicts of interest
done There are no conflicts of interest.
• It was a much easier learning curve for the patient to
insert and remove the prosthesis as the indentations REFERENCES
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