|LETTER TO THE EDITOR
|Year : 2015 | Volume
| Issue : 3 | Page : 405-407
Rehabilitative management of segmental mandibulectomy patient
R Vivek1, A Singh1, TP Chaturvedi2
1 Department of Prosthodontics, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
2 Department of Orthodontics, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
|Date of Web Publication||18-Feb-2016|
Department of Prosthodontics, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Vivek R, Singh A, Chaturvedi T P. Rehabilitative management of segmental mandibulectomy patient. Indian J Cancer 2015;52:405-7
Ameloblastoma are benign epithelial neoplasms and representing about 10% of odontogenic tumors. These neoplasms develop from various sources of odontogenic epithelium, including dental follicular lining, epithelial lining and exhibit locally aggressive behavior. Approximately, 50% of ameloblastoma arise from epithelial lining of the dentigerous cyst and are called mural ameloblastoma. Treatment of ameloblastoma depends on the extent of tumor infiltration through the cyst wall and into the surrounding bone. Aggressive resection has been advocated for management of ameloblastoma of the maxillofacial region.
A 28-year-old male patient reported with the chief complaint of swelling in left posterior region of the lower jaw since 2 months. Dental history indicated gradual increase in swelling size with occasional pain. On extra oral examination, paresthesia of the lower lip, facial asymmetry, diffuse swelling on left angle and body of mandible was found. Swelling was non-tender, soft to hard in consistency, no rise in local temperature and lymph nodes were non-palpable. Intraoral examination revealed expansion of the cortical plate in the region of 35, 36, 37 [Figure 1]. Grade III mobility in relation to 35, 36 and grade II with respect to 37 were other findings recorded. On radiographic examination, computed tomography scan, axial view confirmed expansion of buccal and lingual cortical plate [Figure 2]. Treatment was initiated with extraction of 35 and 36 and incisional biopsy of tissue was obtained from the socket of 36. The lesion was diagnosed as mural ameloblastoma of the mandible extending from apices of 33 to distal of 38. Surgical treatment plan included segmental mandibulectomy followed by reconstruction with iliac crest bone graft.
Surgery was completed with resection of the affected segment of the jaw [Figure 3] followed by the placement of the iliac crest graft fixed with titanium reconstruction plate. Tumor-free margins were confirmed by pathological studies; therefore follow-up radiation therapy was not indicated. Post-surgical healing was uneventful and 6 month follow-up was done. After complete healing, patient was recalled and thorough pre-prosthetic intraoral [Figure 4] and radiographic assessment was done and conventional cast partial denture was planned due to patient's financial restriction for implant therapy [Figure 5]. Intraoral examination revealed thick, freely movable soft-tissues with scar formation, loss of the alveolar ridge and obliteration of buccal and lingual sulci in the segmented half of the mandibular region.
Prosthetic phase of the patient was initiated by making impressions of upper and lower arch using irreversible hydrocolloid [Figure 6] (Neocolloid, Zhermach, Rovigo, Italy). Cast was poured in dental stone (Kalstone; Kalabhai Karson Pvt. Ltd., Mumbai, India). Surveying and designing was done and required mouth preparations were completed. Final impression (Reprosil, Dentsply/Caulk, Milford, DE) [Figure 7] and cast duplication (Begoform, Bego, Germany) were carried out followed by designing with pattern wax on the master cast. Casting of the metal framework was done in co-cr alloy (CoCr Model Casting Alloy; Degussa Dental, Hanau, Germany). After finishing of the framework, intraoral try-in was done and minor adjustments were made [Figure 8]. Later, jaw relation followed by teeth setting on the affected side was completed. When the partial denture try-in appointment was satisfactory [Figure 9], packing and curing of the denture was done in the conventional manner. After required finishing and polishing, intraoral placement of cast partial denture was done [Figure 10]. The cast partial denture was delivered and post-insertion instructions were given. Patient was recalled after 24 h for minor adjustments. Follow-up at regular interval of 2 months for initial 1 year was done.
Ameloblastoma in the mandible can progress to great size and cause facial asymmetry, displacement of teeth, loose teeth, malocclusion and pathologic fractures. Even though some authors advocate a more conservative approach such as enucleation and curettage of this tumor, a large lesion with erosion of the mandibular cortex certainly requires a more aggressive approach for complete removal of the tumor. Four donor sites i.e., fibula, iliac crest, radial forearm and scapula have become the primary sources of vascularized bone and soft-tissue for the oral reconstruction. Type III resection  produces a defect to the midline or farther towards the intact side, leaving half or less of the mandible remaining. An implant-supported fixed prosthesis or removable cast partial dentures are the two main treatment options to restore partially edentulous arches in patients who had undergone mandibular resection. The present case was challenging due to patient's unwillingness for surgical intervention with implant placement, due to financial constraints. To achieve denture stability proper border extensions and impression surface, polished denture surface contours and harmonious occlusion were developed. The forces developed through muscular contraction during mastication, speaking and swallowing are directed against the dentures, which either helps to stabilize or dislodge them. Patient was instructed to masticate only on the non-resected side to avoid denture instability. Changes in tissues beneath a maxillofacial prosthesis may be more rapid than those beneath conventional complete denture prosthesis; therefore, the occlusion and base adaptation were revaluated frequently.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]