Dubey PK1, Sethuraman R2
1Dr Pavan Kumar Dubey, Consultant Prosthodontist,The Dental Evolution, Varanasi, Uttar Pradesh, 2Dr Rajesh Sethuraman , Professor, Department of Prosthodontics, K.M. Shah Dental College, Vadodara, Gujarat, India.
Address for correspondence: 1Dr Pavan Kumar Dubey, Email: drpavan26@gmail.com
Abstract
Patients who have undergone mandibular resection are generally co-operative and philosophical in respect to their conditions. The prosthodontic prognosis is dependent on a number of complex factors. The extent of bony and soft tissue resection has significant impact. Patients with lateral discontinuity defects of the mandible have little hope of achieving pre-surgical levels of masticatory efficiency, however certain measures can be sought off to minimize the post surgical deviation. In this case report an effort has been made by incorporating the gunning’s splint with modified mechanism of interlocking in the form of mandibular discontinuity prosthesis with an intent to minimize the post surgical deviation
Keywords: Edentulous, Resection prosthesis, Stabilization
Manuscript received: 17th Aug 2015, Reviewed: 27th Aug 2015
Author Corrected: 7th sept 2015, Accepted for Publication: 16th Sept 2015
Introduction
In lateral discontinuity mandibulectomy defects the arc of closure is angular rather than vertical , there is unilateral condensation of forces exclusively on the unresected side. Also, because of rotation of the mandible in the frontal plane , the resected side drops down out of occlusion and hence location of fulcrum line is also not easy .Use of mesial, occlusal rest on the distal abutment tooth, placing the retainers at the height of contour, or by using retainers with with adequate flexibility , will prevent excessive forces being transferred on the abutment teeth[1].
Terminologies
Marginal mandibulectomy- implies that a margin of bone is resected but the continuity of the mandible is maintained [2].
Discontinuity mandibulectomy- a discontinuity resection of the mandible indicates that a portion of the mandible is resected, and the condyle to condyle continuity of the mandible is disrupted [2].
Gunning’s splint –a device fabricated from casts of edentulous maxillary and mandibular arches to aid in reduction and fixation of a fracture [3].
It is so named on the name of English born American dentist Thomas Brian Gunning, 1813-1889 after his work on the fabrication of above mentioned prosthesis. His initial work described 4 types of splints used in the treatment of jaw fractures (1866-67), which allowed openings for saliva flow, nourishment and speech [3].
It holds together fractured segments of bones and immobilizes the jaws. In an edentulous patient no hard tissues will be available for stabilization and retention of splints. The retention is mainly obtained by wiring to underlying bony tissues. A gunning splint can be a one piece or a two piece gunning splint. A two piece gunning splint is used on an edentulous jaw to maintain centric or vertical relationship for immobilization and inter maxillary fixation [4].
Evaluating factors for constructing prosthesis for mandibulectomy patients: Norman G Schaff [5] has described following factors for evaluating mandibulectomy patients before constructing prosthesis.
i) Pre-operative success with complete denturs
ii) Over-all vigor of the patient.
iii) Patient awareness of present oral status and limitations
iv) Amount of residual mandible
v) Amount of deviation
vi) Remaining kinesthetic sense and control
vii) Actual present ridge relationship
viii) Nature of denture bearing area
ix) Type of treatment patient has received
x) Status of the patient’s disease.
Case Rreport
A 56 year old edentulous female patient was referred from department of oral surgery, K.M. Shah dental college, Vadodara. She had to undergo for hemi-mandibulectomy. Since all the teeth in the maxillary and mandibular arches were periodontaly compromised and were indicated for extraction. Therefore it was decided to fabricate a splint before the surgery and utilize the splints to immobilize mandible at the time of surgery itself to optimize the mandibular deviation after surgery.
After examination, preliminary impression of maxillary and mandibular arch was made with alginate impression material. Final casts were fabricated. Next day a jaw relation procedure was performed and vertical and centric relation were registered & transferred to an articulator. The teeth were removed from the cast. In order to prevent any kind of movement between maxillary and mandibular splint a locking mechanism was introduced. Male projections (tungsten carbide burs) about 3 mm are made on occlusal surface of one acrylic rim for anchorage by self-cure to grooves (Females) on the other acrylic rim during fixation. Wire hooks were embedded in the buccal flange and used for inter maxillary fixation. Holes were made in buccal flange for wiring the upper splint to extra cranial headgear and for circumferential wiring of lower splint in area of first molar. The rim was finished, polished. The splint was finished and was fixed in Oral Surgery department. Lower member was attached to mandible by circum mandibular wiring and upper member fixed to extra cranial headgear through wires. Upper and lower splints were attached by ligature wires for immobilization.
The Technique
Fig. 1 Fig.2
Steps 1 - After examination, preliminary impression of maxillary and mandibular arch was made with alginate impression material and Jaw Relation Procedure Was Performed
Fig. 3
Step 2 – The teeth were removed from the mounted cast
Fig. 4 (A) Fig 4 (B)
Step 3- Wire hooks were embedded in the buccal flange and used for inter maxillary fixati
Fig. 5 Fig .6
Step- 4 - A locking mechanism was introduced. Male projections (tungsten carbide burs) about 3 mm are made on occlusal surface of one acrylic rim for anchorage by self-cure to grooves (Females) on the other acrylic rim during fixation
Fig. 7
Discussion
The sole purpose for modification in the fabrication of gunning’s splint pre-operatively is to ensure the correct maxillo-mandibular relation [6] at which the prosthesis would be placed post-operatively. It is well documented that the muscle pull of unaffected site is so strong that it requires Intermaxillary fixation which might not be possible post operatively. Similarly, Fracture of edentulous maxillary and mandibular arches in an elderly patient pose serious challenge for achieving the stabilization. Surgical intervention using miniplate osteosyntesis may not be practical approach. Therefore, interdisciplinary approach including a prosthodontist and a surgeon is required where gunning splints may overcome the problem.
Conclusion
The prosthetic prognosis of removable prosthesis for patients with resections of the tongue and the mandible is quite variable. Following resection of the mandible, besides the progression of healing, the primary determinant for fabrication of a definitive prosthesis is related to occlusion. Before beginning with the fabrication of a definitive prosthesis the prosthodontist must ensure that all conventional restorative procedures are complete and an acceptable occlusion is achieved.
Funding: Nil, Conflict of interest: None initiated.
Permission from IRB: Yes
References
1. Frank J. Kratochvil. Influence of occlusal rest position and clasp design on movement of abutment teeth. J Prosthet Dent. 1961; 13:114-121.
2. Zarb, Hobrick, Eckert, Jacob, Fenton, Finer, Chang, Koka. Prothodontic treatment for edentulous patients. Elsevier; 13th edition: 377.
3. The glossary of prosthodontic terms.J Prosthet dent. 2005 july ; 94(1): 42. [PubMed]
4. Fraser-Moodie W. Mr. Gunning and his splint. Br J Oral Surg. 1969 Nov; 7(2):112-5. [PubMed]
5. Norman G Schaff. Oral reconstruction for edentulous patients after partial mandibulectomies.J Prosthet Dent. 1976 ; 36( 3): 292–297. [PubMed]
6. Sheldon Winkler : Essentials of complete denture prosthodontics.AITBS Publishers: 2nd Edition:83. [PubMed]
How to cite this article?
Dubey PK, Sethuraman R. Modified pre-surgical technique for optimizing the mandibular deviation using gunning’s splint as discontinuity mandibulectomy prosthesis: A Case Report. Int J Med Res Rev 2015;3(8):902-905. doi:10.17511/ijmrr.2015.i8.154.