Fabrication of functional complete dentures for edentulous patients who have undergone hemimandibulectomy is a very arduous and demanding endeavor. The most challenging situation encountered during this procedure is the deviation of the mandible to the resected side. The deviation of the mandible to the resected side is directly proportional to the loss of tissues in the area hemi-mandibulectomy has been performed. In cases with Cantor and Curtis classes II, III, IV, and V, guide flange prosthesis would be a treatment modality. For guide flange prosthesis to be effective, the sufficient number of posterior teeth that are periodontally sound should be present in the opposite arch. In patients where reconstruction is not done after resection of the mandible, scar tissue formation occurs over a period of time that stiffens the tissues and worsens prosthetic rehabilitation, leading to compromised treatment planning.

1. Twin-occlusion Prosthesis in a Class III
Hemimandibulectomy Patient
Nishu priya
1st year PGT
Department of Prosthodontics and Crown & Bridge
Coutinho CA, Hegde D, Vijayalakshmi CR, et al. Twin-occlusion Prosthesis in a Class III
Hemimandibulectomy Patient. Int J Prosthodont Restor Dent 2020;10(1):35–38.
Journal Club

2.  Fabrication of functional complete dentures for edentulous patients
who have undergone hemimandibulectomy is a very arduous and
demanding endeavor.
 The most challenging situation encountered during this procedure is
the deviation of the mandible to the resected side. The deviation of
the mandible to the resected side is directly proportional to the loss
of tissues in the area hemi-mandibulectomy has been performed.
Introduction

3. Class I - Radical alveolectomy with preservation of
mandibular continuity
Class II - Lateral resection of the mandible distal to
the canine area
Class III - Resection of the mandible to the midline
Class IV - Lateral resections surgically
reconstructed with bone grafts
Class V - Anterior mandibular defects with bone
graft reconstruction
Class VI - Anterior mandibular defects without
surgical reconstruction
Cantor and Curtis classification for
mandibulectomy

4. Prosthetic treatments available
Swoop proposed the use of a
Palatal Ramp
Rosenthal suggested the use
of twin occlusion
Mathew and Thomas delivered a
Guiding Flange prosthesis
Ruby et al. fabricated complete denture
using dynamic functional impression
technique and using neutral zone

5.  In cases with Cantor and Curtis classes II, III, IV, and V, guide flange
prosthesis would be a treatment modality. For guide flange prosthesis to
be effective, the sufficient number of posterior teeth that are
periodontally sound should be present in the opposite arch.
 In patients where reconstruction is not done after resection of the
mandible, scar tissue formation occurs over a period of time that stiffens
the tissues and worsens prosthetic rehabilitation, leading to
compromised treatment planning.

6. This case report describes prosthodontic management of a patient
who has undergone hemimandibulectomy and was rehabilitated
with complete dentures using two rows of maxillary posterior
teeth on unresected side.

7. A 74-year-old male patient reported to the department of prosthodontics with the chief
complaint of difficulty in eating and poor appearance and wanted replacement of teeth.
 History: habit of tobacco chewing for 10 years and was diagnosed with early
squamous cell carcinoma involving left mandibular alveolus. Left-side
hemimandibulectomy was performed 1 year ago; no reconstruction was done, which
resulted in greater deviation owing to the scar tissue formed over a period of time.
 Extraoral examination: showed facial asymmetry in the lower third of the face,
decreased mouth opening, significant deviation of mandible to left side of mouth
opening, and drooping of the corner of the mouth which was more prominent on the
left side.
Case description

8. Intraoral examination: edentulous maxillary and
mandibular arches with a left mandibular defect
from the midline. Ridges were smooth, round,
well-keratinized mucosa with sufficient height
and width for support.
The case was diagnosed as Cantor and Curtis
Class III mandibular defect based on clinical and
radiographic examination.

9. Preliminary impressions
were made with irreversible
hydrocolloid material using
stock trays and casts were
poured with type II dental
plaster.
On the maxillary and
mandibular casts, a custom
tray was fabricated with
self-cure acrylic resin and
border molding was
performed.
Final impressions were
made with zinc oxide
eugenol impression paste.
Denture bases were
fabricated and wax occlusal
rims were made.
Clinical procedure

10.  A functional occlusal record was obtained in wax placed lingual to the
maxillary posterior occlusal rim on the opposite side of the defect region
and used as an index to arrange the palatal row of the teeth.
 The patient’s tactile sense was used to assess the vertical dimension of
occlusion.
 The patient was advised to move his mandible as far as possible toward
the resected side and then gently close his mandibular jaw into the
position to record a functional maxillo-mandibular relationship.

11.  After articulation, two sets of non-anatomic teeth were selected.
 Two rows of teeth were arranged in the posterior region of edentulous
maxilla on the unaffected side.
 First row of teeth were arranged as per contour of the patients ridge and the
other set were arranged palatal to the first row in the maxillary arch on
which the mandibular teeth would occlude.

12.  The teeth arrangement in the mandible would have ended at 32 region and as
this would lead to an abrupt termination of the denture, three teeth were added
to that region for esthetic purpose and were in mild contact.
 Arrangement was verified while trying for esthetics, phonetics. and occlusion.

13.  The processed dentures were evaluated intra-orally for occlusal adjustments
and border overextension.
 Post-insertion instructions were given to the patient and was advised not to
masticate on the defect side.
 He was instructed to do mouth opening and closing exercises to improve the
neuromuscular coordination.

14.  The patient was periodically followed up after 1 day, 1 week, 1 month, and 3
months. Initially the patient experienced difficulty in using the denture but over
the period of time he showed improvement in mastication and phonetics, and
by 3 months he was satisfied functionally and psychologically.

15.  Greater the tissue loss, greater will be the mandibular deviation to the resected side,
thereby compromising the prognosis of the treatment.
 Resected mandible along with tissue loss causes rotation of the mandibular plane on the
defect side.
 The suprahyoid muscle pull causes inferior displacement and rotation of the condyle,
thereby causing an anterior open bite.
 According to Beumer et al., it was suggested that following maximum opening, the
patient is asked to manipulate the mandible by grasping the chin and moving the
mandible away from the surgical side.
 These movements tend to loosen scar contracture and improve maxillo-mandibular
relationships.
Discussion

16.  Dentulous patients can be retrained to achieve acceptable maxillo-mandibular
relationship with the help of appliance like guide plane. However, it cannot be
used in edentulous patients. Hence, these patients cannot achieve adequate
maxillo-mandibular relationship.
 In this case report, the definitive treatment to meet the functional and esthetic
requirements of the edentulous hemi-mandibulectomy patient would have
been an implant-supported prosthesis.
 But since the patient had restrictions to undergo another surgery owing to
financial constraints, an acrylic complete denture with twin occlusion was
given.
Approach

17.  Reconstruction and rehabilitation of a completely edentulous patient with
hemimandibulectomy defects poses a special clinical challenge.
 The treatment modality using a twin-occlusion complete denture to the
patient gave a significant improvement in mastication, speech, and
esthetics.
Conclusion

18. Twin-occlusion prosthesis: A glimmer of
hope for hemimandibulectomy patient
Ritu Sharma, Akanksha Sharma, Bhanu Pratap Verma, Sameep Singh,
Satyavir Singh; Indian J Dent Sci 2019;11:61-4.

19.  A 62-year-old male patient reported to the department of
prosthodontics with a chief complaint of difficulty in chewing
food for 2 months.
 History : tobacco chewer, 10–12 packets per day for 36 years.
He was diagnosed for SCC on the left side of the mandible,
for which he had undergone extensive resection of the entire
mandible on the left side with part of the anterior mandible
on the right side 6 years back.
 Examination: An extraoral examination showed
asymmetrical face and a convex profile. There was deviation
of the mandible to the left side that is toward the resected
side.
Case report

20. Preliminary impressions of maxillary and
mandibular arches
Intraoral view

21. Custom tray fabrication Border moulded tray Final impression

22. Secondary casts Maxillo-mandibular
relationship

23. Final prosthesis
Intraoral view post
insertion

24.  The basic objective of rehabilitation is training the remaining mandibular muscles to stabilize the
mandibular denture by providing an acceptable maxillary–mandibular relationship.
 Literature review advocates fabrication of guide flange or palatal ramp prosthesis for such
patients to prevent deviation of the mandible and to improve masticatory function and esthetics.
 Since a considerable period of time had elapsed after the surgical procedure, scar tissue
formation had occurred and guidance prosthesis was not possible. Thus, a prosthesis was
fabricated with an arrangement of two rows of teeth because the patient could not close his
mouth in proper intercuspation and hence could not masticate.
 After insertion of the prosthesis, the patient could intercuspate mandibular teeth properly due to
twin maxillary occlusal table. After 1 week, the patient reported an increase in masticatory
efficiency.
Approach

25. A hemimandibulectomy can have many debilitating consequences, such as
disturbed occlusion, a disoriented masticatory cycle, facial disfigurement,
distorted speech, and salivation problems. Guide flange prosthesis is the
most common treatment option in such cases, but in cases where a
sufficient number of teeth are not present and where deviation is massive,
providing twin occlusion rehabilitates the patient functionally.
Conclusion

26. Twin Occlusion Prosthesis: Management
of Hemimandibulectomy Patient
Dhaniram Talukder, Pankaj Datta, Anupama Raheja, Bharti Dua; Indian Journal
of Dental Education; Volume 10; Number 4, October-December 2017

27.  A 31 year old male patient was reported to Inderprastha
Dental College and Hospital, Ghaziabad, Uttar Pradesh, with
a chief complaint of difficulty in chewing.
 History: history tobacco chewing since 6-7 years. He was
diagnosed for squamous cell carcinoma on the right side of
the mandible, for which he had undergone extensive
resection of the mandible on right side up to the canine
region, 1 year back.
 Extra oral examination: showed asymmetrical face, and a
convex profile. There was deviation of the mandible to the
right side.
Case description

28.  Intraoral examination: maxillary
arch had all teeth present and
mandible was resected on right
side up to the canine region.
 The condition was a Class III Cantor
and Curtis hemimandibulectomy
classification.

29. Primary impression

30. Fabrication of occlusal
block with Adam’s clasp
Final twin occlusal
prosthesis
Post- operative
intraoral view

31. Approach
 In this case the guidance prosthesis was not planned because a time
period of around 1 year had elapsed and scar tissue formation had
occurred.
 Twin occlusion was provided because the patient could not occlude on
the natural teeth.

32.  Since most patients undergoing hemimandibulectomies
are from less socioeconomic favored population, the
recent and better treatment options such as implant and
bone grafting are not feasible.
 Twin occlusion enables the patient to masticate
appropriately, to lead a healthy, good quality of life. It
helps patient to deal with the physical and psychological
disabilities
Conclusion

33. Prosthetic rehabilitation of partially resected
edentulous mandible using twin-occlusion- A
case report
Amarjeet Gambhir ; Prosthetic Rehabilitation of Partially Resected
Edentulous Mandible Using Twin-Occlusion- A Case Report. Journal of
Dental Science Research Review & Reports. 2020; SRC/JDSR-105.

34.  A 70 year old female patient reported to the Department of Prosthodontics
with a chief complaint of difficulty in mastication & speech since last six
months.
 History: she was diagnosed with squamous cell carcinoma of the right side of
the mandible, for which she had undergone extensive resection on the
entire posterior region of the mandible four years back.
 Extra oral examination: an asymmetrical face with deviation of the mandible
to the resected side. On palpation, the mandibular ridge on the right side
was found to be present only till premolar region.
Clinical description

35.  Intra oral examination: resection
of mandible distal to the right first
premolar involving the ramus,
coronoid process & condyle (Class
II defect). The patient had
completely edentulous maxillary
and mandibular arches with
significant deviation of resected
mandible to the right side.

36. Primary and secondary casts

38.  Acquired mandibular defects present many changes to
the extra- and intra-oral environment, which make it
difficult to provide adequate retention, support, and
stability for the prostheses. The present case report
describes the successful prosthetic rehabilitation of an
edentulous mandibulectomy patient using two rows of
non-anatomic teeth. The incorporation of twin-
occlusion on the unresected side of the maxillary
prosthesis helped in achieving a satisfactory aesthetic
and functional outcome of treatment.
Conclusion

39. A systematic approach in rehabilitation of
hemimandibulectomy: A case report
Marathe AS, Kshirsagar PS. A systematic approach in rehabilitation of
hemimandibulectomy: A case report. J Indian Prosthodont Soc
2016;16:208-12

40. A 44-year-old female patient reported to the Department of Prosthodontics with the
chief complaint of difficulty in chewing food due to the deviation of jaw, missing teeth,
and wanted replacement of teeth.
 History: history of areca nut chewing since 20 years. The patient was diagnosed with
early squamous cell carcinoma involving left buccal mucosa and mandibular alveolus
and thus left side hemimandibulectomy was performed 6 months ago.
 Extraoral examination: revealed facial asymmetry, deviated lower third of face,
decreased mouth opening, significant deviation of mandible to left side on mouth
opening, left corner of mouth drooping downward, angular cheilitis, and left condyle
and ramus absent on palpation.
Case presentation

41.  The case was diagnosed as Cantor and Curtis
Class II mandibular defect.
 Treatment plan decided was mandibular guide
flange prosthesis to aid in correction of
mandibular deviation, followed by a definitive
prosthesis of a maxillary cast partial denture
with double row of teeth on non-resected side
and a mandibular cast partial denture retained
by precision attachments with a buccal guiding
flange.
Intraoral examination: left mandibular defect distal to
lateral incisor, surgical skin graft seen on resected
side. Maxillary and mandibular arches were partially
edentulous. Root pieces were present in the 46, 47
region.

42. • The patient was advised to
move the mandible as far as
possible to the untreated
side manually and then
gently close the jaw into
position to record a
functional
maxillomandibular
relationship.
• The prosthesis was
designed with a buccal
guiding flange.
• The patient wore the
guiding flange for 4 months
followed by extraction of
root pieces.

43. The definitive prosthesis was
then fabricated consisting
of maxillary and mandibular
cast partial denture.

44. • Patient wore the denture for 10 days to acclimatize and the guiding flange was cut off.
• Significant reduction in mandibular deviation was observed and maximum
intercuspation could be achieved due to the guidance from the twin row of teeth.
• The palatal row of teeth provided favorable occlusal relationship, and the buccal row
of teeth supported the cheeks.

45.  Guide flange prosthesis is most
common treatment modality.
 However, in cases where sufficient
numbers of abutment teeth are not
present and where deviation is
massive, providing twin occlusion
rehabilitates the patient functionally.

46.  Hemimandibulectomy patients are the difficult patient to manage because
prosthodontist is limited in their ability to provide a reasonable and occlusal
scheme, these patients are best treated with uncomplicated prosthesis.
 The patients who have undergone mandibular resection without surgical
reconstruction, the prognosis is poor and the rehabilitation is difficult because
of deviation and rotation of mandible and restricted mouth opening. Guide
flange prosthesis is most commonly used mode of prosthetic rehabilitation to
guide the mandible in occlusion but in patients with difficult manipulation and
severe deviation of mandible, it is not indicated. Dual occlusion prosthesis is a
viable alternative to achieve functional rehabilitation in these patients.
Conclusion

47. References
 Coutinho CA, Hegde D, Vijayalakshmi CR, et al. Twin-occlusion Prosthesis in a
Class III Hemimandibulectomy Patient. Int J Prosthodont Restor Dent
2020;10(1):35–38.
 Ritu Sharma, Akanksha Sharma, Bhanu Pratap Verma, Sameep Singh, Satyavir
Singh; Indian J Dent Sci 2019;11:61-4.
 Dhaniram Talukder, Pankaj Datta, Anupama Raheja, Bharti Dua; Indian Journal of
Dental Education; Volume 10; Number 4, October-December 2017
 Amarjeet Gambhir ; Prosthetic Rehabilitation of Partially Resected Edentulous
Mandible Using Twin-Occlusion- A Case Report. Journal of Dental Science
Research Review & Reports. SRC/JDSR-105.
 Marathe AS, Kshirsagar PS. A systematic approach in rehabilitation of
hemimandibulectomy: A case report. J Indian Prosthodont Soc 2016;16:208-12