Intermaxillary fixation following mandibular resection

MAXILLOFACIAL PROSTHETICS TEMPOROMANDIBULAR JOINT DENTAL IMPLANTS I.

KENNETH

ADISMAN,

LOUIS

Intermaxillary

J.

Section editors

BOUCHER,

fixation

following

mandibular

resection Mohamed

A.

Aramany,

Eye and Ear Hospital

D.D.S., of

Pittsburgh

M.S.,*

and

Eugene

and University

N. of

Myers,

Pittsburgh,

M.D.**

Pittsburgh,

Pa.

R

adical surgery for cancer of the oral cavity frequently requires resection involving the mandible, floor of the mouth, tongue, and soft palate. This extensive loss of tissues often results in impaired function in mastication, deglutition, and speech, compounded in some instances with drooling.‘+ Mandibular deviation due to discontinuity of the mandibular arch, scarring, and altered muscle function will result in facial asymmetry and malocclusion (Figs. 1 and 2), preventing the patient from chewing normally or having a normal appearance. Normal occlusion in which the posterior natural teeth interdigitate is lost; and the teeth on the remaining mandibular segment will occlude lingual to the maxillary teeth. The residual mandibular segment on the unoperated side deviates medially and superiorly in the edentulous patient making construction of dentures difficult. Marginal resection of the mandible denotes the loss of alveolar bone sparing the inferior border (Figs. 3 and 4) ; whereas, the term “segmental resection” refers to the loss of continuity of the body or ramus of the mandible (Figs. 5 and 6). In contrast to segmental resection, marginal resection does not result in malocclusion. The best method of rehabilitation is to restore the continuity of the mandible either by autogenous bone graft or by use of alloplastic material, which will facilitate the intraoral prosthetic reconstruction.4 This would be inadvisable at the time of surgical resection since either contamination of the operative area with saliva or poor healing of irradiated tissues would result. Presented

before

Supported

in

the

*Professor Regional Center

of

**Professor of Pittsburgh;

and Chief,

part

by

American

Academy

of

National

Cancer

Institute

Prosthodontics, for Maxillofacial Chairman, Department

School of Dental Rehabilitation.

Maxillofacial Contract Medicine,

Department of Otolaryngology, of Otolaryngology, Eye and

Prosthetics,

Lake

Geneva,

wis.

NIH-NCI-55184-05. University

Ear

of Pittsburgh;

School of Medicine, Hospital.

Director, University

437

Fig.

1. Facial

Fig. tient

2. Intraoral in Fig. 1.

asymmetry view

due indicates

Fig. 3. Surgical specimen the floor of the mouth. Fig. The

to segmental the

degree

of a marginal

resection

resection

4. Split-thickness skin graft used to repair body of the mandible remained intact.

FUNCTIONAL

of the mandible.

of deviation

of the mandibular

of the mandible the

defect

created

position

of the

to eradicate by

pa-

carcinoma

the marginal

of

resection.

IMPAIRMENT

Impairment of function in patients undergoing mandibulectomy varies in degree according to (1) the extent of the surgical resection, (2) the structures involved, (3) the complexity of the rehabilitative procedures, and (4) the patient’s motivation. The speech problem may be related to a soft-palate defect, scarring of oral structures, and/or restriction of tongue mobility, affecting the various mechanisms essential for both articulation and voice quality. Mastication and deglutition are impaired as a result of alteration in temporomandibular joint function and disruption of the neuromuscular system, controlling the masticatory apparatus and the swallowing act. Restricted tongue mobility, difficulty in swallowing, absence of the vestibular sulcus, scarring or paralysis of the lower lip, as well as loss of sensory awareness impair the patient’s ability to control salivary secretion, leading to drooling. The prosthetic rehabilitation is complicated by loss of parts of the denture-bearing areas, mandibular deviation, and loss of occlusal contact with the opposing teeth. RATIONALE The most difficult problem faced in intraoral who have had segmental resection of the mandible

prosthetic restoration is the reestablishment

for patients of the man-

Volume Number

31 4

Intermaxillary

Fig. 5. Surgical mucosa.

The

Fig. 6. Patient’s

specimen obtained by segmental segment includes the lateral part profile

shows

the effect

fixation

after

mandibular

resection

439

resection to eradicate carcinoma of the buccal of the tongue and a part of the mandible.

of segmental

resection

of the mandible.

dibular position in relation to the maxillary arch. The mandible tends to deviate medially and superiorly to a greater degree in the edentulous patient than in the patient who has natural posterior teeth in good occlusion. It is generally accepted that there are fewer problems with the rehabilitation of partially edentulous patients than with those who are completely edentulous. Preservation of the preoperative occlusal alignment of the remaining mandibular structure is a logical goal for the rehabilitation of these patients. The Head and Neck Team of the Department of Otolaryngology, University of Pittsburgh, Eye and Ear Hospital, embarked on a project to reduce the degree of deviation for both dentulous and edentulous patients by immediate immobilization of the mandible following segmental resection. Diagnostic records obtained for each patient prior to surgery include dental casts and jaw relation records, The interdigitation of the natural teeth was accepted as centric position for the dentulous patients. The edentulous patients’ own dentures were used for the construction of modified Gunning splints.5 For the edentulous patients who did not have dentures, a modified complete denture technique was used to construct surgical splints. In this latter group, it was expected that more postoperative problems would be encountered if the patient had an unfavorable attitude toward dentures. SURGICAL

PROCEDURE

The group was homogenous in that all patients had cancer and resections were performed for the purpose of eradicating this disease. The lesions included in the treatment of this group were squamous-cell and mucoepidermoid carcinomas, occurring primarily in the retromolar trigone, the posterior aspect of the lower gum, and the posterior aspect of the tongue and tonsillar area. All but two of these patients were treated by primary surgery. Some underwent resection of their primary tumors and segmental mandibulectomy continuous with

440

Aramany

and

Fig. into

7. A 3 cm. exophytic the tonsillar fossa.

Fig.

8. Patient’s

dentures

J. Prosthet. Dent. April, 1977

Myers

squamous-cell utilized

to fabricate

carcinoma modified

on the right Gunning

side splints

of the from

tongue clear

extending

acrylic

resin.

radical neck dissections. There were several patients who had localized resections combined with upper-neck dissection. Sufficient tissue remained to effect a primary closure in approximately half the patients in this group. All but three of the remaining patients required reconstruction with a deltopectoral flap to provide adequate epithelial lining for the oral cavity. NO major difficulties in healing were encountered in this group. No forehead flaps or tongue flaps were needed. Split-thickness skin grafts were used in three patients. For two patients, radiation therapy was not successful. These patients had a three-dimensional excision of the cancer in continuity with upper-neck dissection and partial mandibulectomy. Rehabilitation of the resected site was accomplished with a split-thickness skin graft. There were no difficulties with healing in these patients. After the surgical defect had been closed primarily or after reconstruction, attention was turned to the restoration of the occlusion. For the dentulous patients, maxillary and mandibular arch bars were simply wired into place. Several of these patients were partially edentulous, so partial splints were constructed and wired into place to provide added stability. In the edentulous group of patients, the splints were wired after the surgical defect had been closed or after reconstruction. The maxillary component was suspended from the zygomatic arches and the nasal spine, and circumferential wiring was used for the mandibular splint. Intermaxillary wiring or elastics were utilized for immobilization. Fixation was accomplished during the night with elastics, and the elastics were removed during the day. This resulted in less patient discomfort and faster return of the function of swallowing. It also permitted easy access for (1) inspection of the intraoral wound, (2) removal of the surgical packing from the grafted areas, and (3) better oral hygiene. PROTOCOL

FOR TREATMENT

A 63-year-old man was referred in October, 1974, for treatment of a tongue lesion. He had first noticed this lesion 4 months earlier. He reported that the lesion

7iziKr”4’

Intermaxillary

fixation

after

mandibular

resection

441

resection

of the

“_---. Fig. 9. The lesion.

maxillary

and mandibular

surgical

splints

Fig. 10. Intermaxillary wiring maintains the proper period of healing. Elastics are used to accomplish this

are wired mandibular purpose.

in place relation

after

during

the

initial

responded to antibiotic therapy at first, but then it recurred. He complained of a 40 pound weight loss. The diagnosis established by biopsy specified a squamous-cell carcinoma of the right lateral aspect of the tongue (Fig. 7). The surgical treatment was planned to include partial glossectomy, partial segmental mandibular resection, and right radical neck dissection. Immediate intermaxillary fixation of the remaining mandibular fragment to the maxillae with a modified Gunning splint was planned at the time of the resection. The patient’s dentures were utilized to construct modified Gunning splints (Fig. 8). The splints were tried in the patient’s mouth before surgery. The maxillary splints were suspended from the zygomatic arches and the nasal spine after resection of the lesion. Circumferential wiring was used to retain the splint on the mandibular arch (Fig. 9). The intermaxillary fixation was completed, and then the facial flap was repositioned and sutured in layers. The maxillary fixation (Fig. 10) was maintained for 6 weeks, after which the splints were removed, relined with a resilient liner,* and then reinserted. The patient was instructed to keep the surgical splints in the oral cavity until new dentures were fabricated (Figs. 11 and 12). The facial symmetry was maintained in spite of the segmental resection (Figs. 13 through 15). The patient’s original dentures were modified by grinding the mandibular denture to fit the residual mandibular segment. The patient was able to achieve closure in centric occlusion. The patient used the modified denture for 1 year, during which few adjustments were performed. The neutral-zone concept, as suggested by Cantor and Curtis,3 was followed 1 year later in making new complete maxillary and sectional lower dentures (Figs. 16 and 17) . DISCUSSION Forty-five patients were treated by use of mandibular resection during the past 2f/2 years. The types of surgical interventions for this population varied and were *Soft

Oryl,

Teledyne

Dental,

Elk Grove

Village,

III.

442

Aramany

Fig. 11. The wiring the jaw relationship Fig.

12. The

Fig.

relined

J. Yrosthet.

and Myers

April,

is removed and until a definitive surgical

13. A Panorex

splints

radiograph

the splint relined and reinserted. prosthesis is fabricated. with

the

showing

jaws

in closed

the extent

The

patient

Dent. 1977

can maintain

position.

of the

segmental

resection.

carried out by different surgeons. Various surgical reconstructive procedures were used. It was noted that the degree of mandibular deviation was greater in the edentulous population than in the partially edentulous patients. The reason for this may be the effect of the intercuspation of the remaining dentition which reinforces the memory of the mandibular position through the proprioceptive nerve endings in the periodontal membrane of the remaining natural teeth. The construction of dentures for the edentulous patients is very difficult due to the deviation of the remaining mandible. The greater the deviation, the more difficult the prosthetic rehabilitation. A protocol for the immobilization of the remaining mandibular segment evolved from these observations and was instituted for both edentulous and partially edentulous patients. Over the past 20 months, 14 patients were treated by use of this protocol (eight were completely edentulous and six were partially edentulous). The immobilization of the mandible was maintained for a period of 5 to 7 weeks. Elastics were applied only at night by the nurses or by the patient’s relatives if the patient had left the hospital. The degree of deviation observed after use of wiring was much less than the deviation observed in the patient who never had intermaxillary wiring. All of the patients maintained the centric relationship of the remaining dentition, or that of the

“N”l5K;

u

Fig.

“4’

14. The

Intermaxillary

patient

exhibits

Fig. 15. As the mandible evident.

mandibular

approaches

fixation

deviation the occlusal

Fig.

16. Intraoral

view

of the deviation

of the

Fig.

17. Intraoral

view

of the dentures

in centric

after

mandibular

on extreme vertical

mandible

resection

443

opening.

position,

on opening

the symmetry

of the face is

the mouth.

occlusion.

original dentures, after the treatment. Two of the edentulous patients could not maintain the exact occlusal relationship, and a ramp was constructed on the maxillary denture to guide the mandible into position. Among the six partially edentulous patients who went through the protocol, one showed jaw deviation. For this patient, a guide flange was placed on the mandibular denture to maintain the intercuspal relationship. After using the guide flange for a period of time, the patient was able to wear his original removable partial denture without the guide flange. The philosophy for the treatment of edentulous patients experiencing mandibular resection is to provide intermaxillary wire fixation irnmediately after surgery and to maintain the fixation during the night for a period of 7 weeks. An interim prosthesis is then immediately supplied to the patient until the definitive prosthesis can be constructed. If the patient deviates from the centric relation, flat-plane teeth with a guiding ramp are used, providing a starting contact point and permitting the teeth to slide into the centric position. Immediately after the surgery, the partially edentulous patients are treated with

444

Aramany

and Myers

.I. Prosthet. Dent. April, 1977

intermaxillary wiring utilizing arch bars and elastics or wires. The patient is encouraged to use his mandible as soon as possible. If any deviation in the original position is noted, a guide flange is inserted until the patient can return to the intercuspal position. The guide flange may be used again after a period of a few months if the same deviation recurs. When possible, intermaxillary fixation will alleviate the problem of deviation, but it is not as ideal as the restoration of the continuity of the mandible, which would be the best type of rehabilitation. SUMMARY This report concerns 14 patients who were treated by use of immediate intermaxillary fixation after segmental resection of the mandible to eradicate cancerous lesions. Mandibular resection usually produces problems in surgical and prosthetic reconstruction. The use of intermaxillary fixation during the first 6 postoperative weeks will reduce the degree of deviation. In mandibular resection for edentulous patients, the original dentures were used postoperatively with slight modification or no modification at all. With fixation and encouragement of early functional movement of the mandible, the dentulous patients showed a lesser degree of deviation. Some of the patients of the latter group used guide flange prostheses during the postoperative period to return the mandible to the centric position. Edentulous patients who deviated slightly were fitted with a maxillary ramp which guided the mandibular segment, after the initial contact, into the proper centric relation. References 1.

2. 3. 4.

5.

Cantor, R., and Curtis,

T. A.: Prosthetic Management of Edentulous Mandibulectomy Patients. Part I. Anatomic and Physiologic Considerations, J. PROSTHET. DENT. 25: 446-457, 1971. Cantor, R., and Curtis, T. A.: Prosthetic Management of Edentulous Mandibulectomy Patients. Part II. Clinical Considerations, J. PROSTHET. DENT. 25: 546-655, 1971. Cantor, R., and Curtis, T. A.: Prosthetic Management of Edentulous Mandibulectomy Patients. Part III. Clinical Evaluation, J. PROSTHET. DENT. 25: 670-678, 1971. Aramany, M. A.: Replacement of Missing or Defective Organs, in Sassouni, V., and Sotereanos, G. : Diagnosis and Treatment of Dentofacial Abnormalities, Springfield, 1974, Charles C Thomas Publisher. Aramany, M. A.: New Trends in Construction of Splints, J. PROSTHET. DENT. 23: 88-95, 1970. EYE AND EAR HOSPITAL 230 LOTHROP ST. PITTSBURGH, PA. 15213