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CASE REPORT
Year : 2012  |  Volume : 1  |  Issue : 2  |  Page : 134-136

Treatment of unilateral bifid condyle resection using a maxillary guidance ramp: A clinical report


Department of Prosthodontics, SIBAR Institute of Dental Sciences, Guntur, India

Date of Web Publication11-Jul-2012

Correspondence Address:
Durga Prasad Tadi
Senior Lecturer, Department of Prosthodontics, Sibar Institute of Dental Sciences, Takkellapadu, Guntur - 522509
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-8632.98372

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  Abstract 

When the condyle is lost, guidance therapy may be required to achieve an improved alignment and function. To achieve an optimum occlusion, maxillary fixation or usage of either palatal guiding ramps or mandibular guiding ramps are generally the treatment of choice. The present case with a bifid condyle resection discusses about achieving an acceptable maxillomandibular relation within a period of 6 months, using a maxillary guidance ramp.

Keywords: Malocclusion, mandibular deviation, maxillary guidance ramp


How to cite this article:
Tadi DP, Sandeep C, Krishna Babu PJ, Mohan TK. Treatment of unilateral bifid condyle resection using a maxillary guidance ramp: A clinical report. J NTR Univ Health Sci 2012;1:134-6

How to cite this URL:
Tadi DP, Sandeep C, Krishna Babu PJ, Mohan TK. Treatment of unilateral bifid condyle resection using a maxillary guidance ramp: A clinical report. J NTR Univ Health Sci [serial online] 2012 [cited 2019 Nov 18];1:134-6. Available from: http://www.jdrntruhs.org/text.asp?2012/1/2/134/98372


  Introduction Top


Loss of continuity of the mandible destroys the balance of the lower half of the face, leading to the deviation of the residual segment towards the resected side. Decreased masticatory function is directly related to the extent of mandibular resection and continuity loss. A mandibular guidance therapy should be initiated at an early stage in the course of the treatment. Prosthetic modalities like intermaxillary fixation, maxillary or mandibular restorations will reduce the mandibular deviation. [1],[2],[3],[4] This article presents a means to achieve an intermaxillary relation using maxillary guidance ramp prosthesis in a patient with a resected bifid condyle.


  Case Report Top


A 20-year-old male patient reported to the Department of Prosthodontics, Sibar Institute of Dental Sciences, Guntur, India with a chief complaint of difficulty in mastication and speech along with an unesthetical jaw deviation to right side. Patient also gave a history of resected bifid condyle. Upon extra-oral examination, there was typical facial asymmetry with considerable subsidence on the cheek and lips as a result of mandibular deviation to the right side [Figure 1]a and b. On intra-oral examination, all the teeth but for third molars have erupted, and there was no midline coincidence of the maxillary with the mandibular dentition. The mandibular arch was deviated to right side and in maximum intercuspation cross-bite relation of the posterior teeth on the resected side with no occlusal contacts on the unresected side was noted [Figure 1]c. It was noted that the patient's mandible could be manually placed into centric occlusion without excessive force. Sufficient alveolingual sulcus was noted in the left lower region for the fabrication of maxillary flange prosthesis on left side.
Figure 1: (a,b) Typical facial asymmetry (c) Deviation of mandible with noticeable cross-bite on resected site and malocclusion on unresected site

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Maxillary and mandibular impressions were made using irreversible hydrocolloid impression material (Algitex, Dental Products of India, Mumbai) in stock perforated dentulous trays, and type IV gypsum product (Ultrarock, Kalabhai Karson Pvt. Ltd., Mumbai) was used to pour the casts. Adams clasp were made on right and left maxillary 1 st molars using 21 gauge wires. 2 mm thickness modeling wax sheet (Hindustan Dental Products, Hyderabad) was adapted to fabricate heat cute clear acrylic denture base in a conventional way. [5]

The denture base was finished, polished tried in the patient's mouth for proper fit. Half a sheet of modeling wax was rolled and placed on the left side of the denture base like a ramp laterally along the medial aspects of the maxillary posterior teeth [Figure 2]a. Now, the mandible was guided towards its centric relation using Dawson's bilateral manipulation several times, thereby establishing the guiding contours of the left mandibular teeth on the wax ramp. [6],[7] The index was checked for any discrepancies, and the indexed prosthesis was removed along with the denture base, flasked and packed using the heat cure pink acrylic for differentiation from clear acrylic denture base and processed. Thus, palatal ramp was custom fabricated [Figure 2]b.
Figure 2: (a) Prosthesis showing customized maxillary guiding ramp (b) Intraoral picture showing try in of ramp

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The prosthesis was finished, polished, and inserted in the patient's mouth. The patient was trained in guiding the mandible along the ramp. Post-insertion instructions were given, and monthly recall was advised for next 6 months. After 6 months, the facial symmetry was noted [Figure 3]a and intra-orally inter midline relations were coinciding with proper occlusal contacts on both resected and unresected side, even without the prosthesis. Minimal occlusal correction (enameloplasty) was carried out to achieve maximum intercuspation [Figure 3]b. Further, the patient was advised to discontinue the prosthesis.
Figure 3: (a) Intraoral picture showing prosthesis after six months follow-up (b) Ideal centric occlusion achieved without prosthesis

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  Discussion Top


In condylectomy patients, there is loss of equilibrium; therefore, the mandible generally deviates towards to the resected side. This leads to loss of facial symmetry on the resected side and cross-bite occlusion on the unresected side. To establish facial symmetry and to achieve maximum intercuspation in centric relation, the mandible can be guided using a ramp placed either in maxillary arch on the unresected side or resected side in the mandibular arch, on the availability of space foe the ramp in the opposing arch.

This design of the prosthesis was chosen due to adequate available alveololingual space in left region. Usually, in desected or resected condylar conditions, there is permanent deviation of mandible toward the resected side, so the patient will be advised to wear the fabricated prosthesis throughout life, but in our present case with bifid condyle resection situation, the aim of the prosthesis fabrication was to train the muscles to achieve equilibrium so that the remaining condyle on the resected side can be guided into corresponding glenoid fossa, thereby achieving good centric occlusion within a period of 6 months. [8],[9],[10]


  Conclusion Top


Facial asymmetry and cross-bite occlusion is a complex situation, generally seen in mandibular discontinuity situations. As presented in this clinical situation, the use of maxillary ramp prosthesis will achieve the desired effective guidance and reprogramming of the mandibular movements aiding the patient to have a better occlusion and esthetics.

 
  References Top

1.Beumer J III, Curtis TA, Marunick MT. Maxillofacial rehabilitation: Prosthodontic and surgical consideration. St. Louis: Ishiyaku EuroAmerica; 1996. p. 184-8.  Back to cited text no. 1
    
2.Schneider R, Taylor TD. Mandibular resection guidance prostheses: A literature review. J Prosthet Dent 1986;55:84-6.  Back to cited text no. 2
    
3.Schaaf NG. Oral reconstruction for edentulous patients after partial mandibulectomies. J Prosthet Dent 1976;36:292-7.  Back to cited text no. 3
[PUBMED]    
4.Swoope CC. Prosthetic management of resected edentulous mandibles. J Prosthet Dent 1969;21:197-202.  Back to cited text no. 4
[PUBMED]    
5.Carr AB, McGivney GP, Brown DT. McCracken's removable partial prosthodontics. 11th ed. St. Louis: Elsevier/Mosby; 2005. p. 344-50.  Back to cited text no. 5
    
6.Dawson PE. Evaluation, diagnosis and treatment of occlusal problems. St Louis: CV Mobsy Co; 1961. p. 48-79.  Back to cited text no. 6
    
7.Ozcelik TB, Pektas ZO. Management of chronic unilateral temporomandibular joint dislocation with a mandibular guidance prosthesis: A clinical report. J Prosthet Dent 2008;99:95-100.  Back to cited text no. 7
[PUBMED]  [FULLTEXT]  
8.Kurtulmus H, Kumbuloglu O, Saygi T, User A. Management of lateral mandibular discontinuity by maxillary guidance. Br J Oral Maxillofac Surg 2008;46:123-5. Epub 2006 Nov 13.  Back to cited text no. 8
    
9.Sxahin N, Hekimoðlu C, Aslan Y. The fabrication of cast metal guidance flange prostheses for a patient with segmental mandibulectomy:A clinical report. J Prosthet Dent 2005;93:217-20.  Back to cited text no. 9
    
10.Robinson JE, Rubright WC. Use of a guide plane for maintaining the residual fragment in partial or hemi-mandibulectomy. J Prosthet Dent 1964;14:992-9.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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   Abstract
  Introduction
  Case Report
  Discussion
  Conclusion
   References
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