Case Report

Twin Neutrocentric Concept of Occlusion – A Glimmer of Hope

for Rehabilitating a Partially Resected Edentulous Mandible
Kritika Rajan, Ishan Roy Choudhury*, Debabrata Biswas, Adrija Saha
Department of Prosthodontics and Crown and Bridge, Dr. R. Ahmed Dental College and Hospital, Kolkata, West Bengal, India.

Abstract
Oral cancer is the sixth most common type of cancer in India and oral squamous cell carcinoma dominates all the oral cancer cases with
potentially malignant disorders. Consumption of tobacco including smokeless tobacco, betel-nut chewing, excessive alcohol consumption,
unhygienic oral condition, and sustained viral infections are some of the risk factors for the incidence of oral cancer. Lack of knowledge
increases the mortality rate of any form of cancer. Surgical resection of the tumor produces various problems such as mandibular deviation
due to formation of scar tissue and decreased mouth opening due to trismus. Functional rehabilitation is hampered due to denture instability
which is a major disadvantage in such cases. This article highlights the functional rehabilitation of a hemi-mandibulectomy patient who has
undergone resection without reconstruction followed by radiotherapy with a denture having twin neutrocentric concept of occlusion.

Keywords: Cantor and curtis, Mandibular resection, Neutrocentric occlusal scheme, Oral squamous cell carcinoma, Twin occlusion.

Introduction Various limitations to radiotherapy are[2]

Oral rehabilitation of a patient who has a partially resected 1. The oral mucosa becomes atrophic and fragile, predisposing
mandible is one of the most challenging procedures confronting to soft-tissue irritation and ulceration,
the maxillofacial prosthodontist. The situation becomes further 2. The reduced salivary output, and the thick mucinous
complicated due to the therapeutic radiation which results nature of the saliva that remains after therapeutic levels of
in atrophic oral mucosa and reduced mouth opening due to radiation, impairs retention, and compromises lubrication
formation of scar tissue. Surgical resection of tumor often of the denture-mucosal interface.
includes a partial mandibular resection, partial glossectomy, Both these limitations produce prosthodontic complications
resection of the floor of the mouth, and radical neck dissection. such as[3]
The extent of surgery and the effects of radiation therapy 1. Loss of mandibular continuity causes deviation of the
determine the amount of rehabilitation needed by a given remaining mandibular segment toward the defect and
patient.[1] rotation of mandibular occlusal plane inferiorly,
While rehabilitating completely edentulous hemi- Rotation is due to:
mandibulectomy patient, there are various limitations due to • Pull of the suprahyoid muscles on the residual
surgery and radiotherapy. mandibular fragment causing inferior displacement and
rotation around the fulcrum of the remaining condyle,
Limitations due to surgery include the following[2] • Gravity, and
1. Scar tissue formation,
• Loss of anchorage of elevator muscles.
2. Deviation of resected mandible due to loss of tissue during
surgical resection, Address for correspondence: Dr. Ishan Roy Choudhury,
3. Limited co-coordinative ability, Department of Prosthodontics and Crown and Bridge, Dr. R. Ahmed Dental
4. Limited posterior throat form due to obliteration by the College and Hospital, Kolkata, West Bengal, India.
grafts, and Email: ishanr3@[Link]
5. With only one-half or two-thirds of the mandible remaining, Received: Jul. 01, 2024; Accepted: Jul. 30, 2024; Published: Aug. 12, 2024
stability, support, and retention of the mandibular denture
are compromised. This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
Access this article online remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
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Website:
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How to cite this article: Rajan K, Choudhury IS, Biswas D, Saha A. Twin
DOI: Neutrocentric Concept of Occlusion – A Glimmer of Hope for Rehabilitating
[Link] a Partially Resected Edentulous Mandible. J Res Adv Dent 2024;15(6):1-4.

© 2024 Journal of Research and Advancement in Dentistry 1

 Rajan K, et al.: Rehabilitation in a Case of Hemi-Mandibulectomy using Twin Neutrocentric Occlusal Concept

Sequelae: Extraoral examination revealed an asymmetrical face, a

• Facial disfigurement, deviated mandible toward right side and a convex facial profile.
• Loss of occlusal contact, and On intraoral examination, it was found that, in the maxillary
• Loss of ability to bring lips together for saliva control arch, all remaining tooth posterior to both canines were missing
and to initiate swallowing process. and the mandibular arch was completely edentulous.
2. The angular pathway of mandibular closure induces
Treatment plan
lateral forces on the dentures, which dislodge them,
A maxillary removable partial denture with twin row of teeth
3. The deviation of the mandible creates abnormal jaw
along with a monoplane occlusion and sectional mandibular
relationships. The abnormal profile and position of the
denture was the treatment of choice to rehabilitate the patient.
mandible in relation to the maxilla may prevent the ideal
placement of the denture teeth over their supporting Clinical and laboratory procedure
structures, Fabrication of the maxillary removable partial denture and
4. The impairment of motor and/or sensory control of the sectional mandibular complete denture
tongue, lip, and cheek impairs the ability of the patient to Initially, a primary impression was recorded in irreversible
control the prosthesis during function. hydrocolloid impression material (Figure 2a). After border
molding, final impressions were made using zinc oxide eugenol
Prosthodontic prognosis in segmental resection patients
impression material and master cast was poured (Figure 2b).
causes the following[4] Record bases for bite registration were prepared on stone master
1. Decreased mouth opening due to trismus due to surgical cast (Figure 3a). The patient’s tactile sense or sense of comfort
trauma. was used to assess the vertical dimension of occlusion. The
2. Formation of scar tissue further reducing mouth opening. patient was instructed to move his mandible as far as possible
Prosthodontic prognosis in such patients can be improved to the unaffected side and then gently close his mandible to
by early post-resection physical therapy record a functional maxilla-mandibular relationship. The casts
1. To reposition the mandibular segment to a more normal were, then, mounted on a free plane articulator.
position, and
2. To minimize scar formation that could make deviation
more severe.
This must be carried out as early as possible and can be in the
form of physical therapy carried out by the patient himself
or by providing a mandibular resection guidance prosthesis.
Obtaining stability in dentures is another challenge due to
the differences between natural and artificial teeth such as
thickness, rigidity, and site of the attaching membranes,
especially in such cases where the remaining denture bearing
area in inadequate.
Figure 1: Panoramic radiograph revealing Class III Cantor and curtis
To obtain maximum stability in the prosthesis, M. M. De Van mandibular defect
in 1954 proposed the concept “Neutrocentric Occlusion.”
This concept revolves around the neutralization of the cuspal
inclines and centralization of forces which act on the denture
bearing area during centric relation by incorporating various
factors that aid in better stability in the dentures.[5]

Case Report a
A 55-year-old male patient reported to the department
of prosthodontics with a chief complaint of difficulty in
chewing food and facial disfigurement. The patient’s medical
history revealed that he was diagnosed with squamous cell
carcinoma on the right side of the mandible, for which
he had undergone resection of the mandible 1 year ago
following which he underwent radiotherapy. Panoramic
radiograph revealed mandibular resection from the midline b
till the condyle (Class III Cantor and Curtis classification) Figure 2: (a) Maxillary and mandibular primary impression made and
(Figure 1). (b) mandibular secondary impression

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 Rajan K, et al.: Rehabilitation in a Case of Hemi-Mandibulectomy using Twin Neutrocentric Occlusal Concept

Arrangement of twin row of teeth in neutrocentric

occlusal concept
Accordingly, teeth size selection was carried out, teeth
arrangements were done using zero-degree posterior teeth.
Two rows of maxillary posterior teeth were arranged on the
unaffected side. First row of teeth was arranged as per the
anatomic guideline of the contour of the patient’s ridge. Second
row of teeth were arranged palatal to the first row which a
intercuspated with the mandibular teeth. A wax trial was done
in the mouth and was checked for esthetics, phonetics, vertical
dimension, and occlusion (Figure 3b and c).
Finishing and polishing of denture
The dentures were, then, processed with heat polymerized
acrylic resin. After proper finishing and polishing, dentures
were inserted into the patient’s mouth and evaluated for
b c
esthetics and function (Figure 4a). Minor adjustments were
made on the dentures and it was again polished. Finally, Figure 3: (a) Twin row of occlusal wax rims made on maxillary and
there was freedom of mandibular movement without any mandibular cast, (b) diagrammatic representation of principles of
interferences, as well as broad and long occlusal contact neutrocentric occlusion, and (c) first row of teeth arranged as per the
anatomic guideline of the contour of the patient’s ridge. Second row
(Figure 4b).
of teeth arranged palatal to the first row which intercuspated with the
Denture insertion and delivery mandibular teeth
The patient was given post-insertion instructions and was
motivated to make efforts to learn to adapt to the new dentures.
Simple exercises were suggested to the patient such as repeated
opening and closing of mandible.

Discussion
This article highlights the functional rehabilitation of hemi-
mandibulectomy patient who has undergone resection without
reconstruction followed by radiotherapy using two concepts
which are: a
a. Incorporating twin row of teeth
b. Using neutrocentric concept of occlusion.
Rosenthal had described a technique employing a twin/second
row of maxillary posterior teeth on the untreated side of the
maxillary denture. The teeth slide over one another, down the b
incline formed by the second row of teeth, and into a functional Figure 4: (a) Polished dentures and (b) intraoral photographs of prosthesis
occlusal position.[6] The palatal row of teeth intercuspated with
the remaining mandibular teeth and the buccal row of teeth neutrocentric concept, and thus, these improved the
supported the cheeks. masticatory ability.
In the neutron-centric concept of occlusion, the teeth are not
inclined to form compensatory curves. In the mediolateral Conclusion
direction, the teeth are set with no medial and lateral A functional and esthetic rehabilitation of patient with
inclination. Thus, this concept of occlusion eliminates any marked alveolar ridge deformity is a valuable service
anteroposterior or mediolateral inclines of the teeth and provided to the patient. In the present case, the twin neutron-
directs the forces of occlusion to the posterior teeth. The centric occlusal scheme provided good stability to the
occlusal plane is parallel to the mean plane of the denture denture which, further, improved the function and esthetics
foundation.[7,8] of the patient.
After incorporating these two concepts, the patient could
intercuspate the mandibular teeth properly due to twin References
maxillary occlusal table and experienced enhanced stability 1. Swoope CC. Prosthetic management of resected edentulous mandible.
of the dentures due to teeth arrangement following the J Prosthet Dent 1969;21:197-202.

Journal of Research and Advancement in Dentistry ¦ Volume 15 ¦ Issue 6 ¦ Nov-Dec 2024 3

 Rajan K, et al.: Rehabilitation in a Case of Hemi-Mandibulectomy using Twin Neutrocentric Occlusal Concept

2. Watson RM, Welfare RD, Islami A. The difficulties of prosthetic stability. J Am Dent Assoc 1954;48:165-9.
management of Edentulous cases with hemi-mandibulectomy following 6. Rosenthal LE. The edentulous patient with jaw defects. Dent Clin North
cancer treatment. J Oral Rehabil 1984;11:201-14. Am 1964;80:773-9.
3. Kenneth FB. Complete denture treatment in patients with resected 7. Anand V, Manoharan PS. Neutrocentric a forgotten concept-a case
mandible. J Prosthet Dent 1969;21:443-7. report. Acta Sci Dent Sci 2020;4:11-4.
4. Desjardins RP. Occlusal considerations for the partial mandibulectomy 8. Rangarajan V, Yogesh PB, Gajapathi B, Ibrahim MM, Kumar RG,
patient. J Prosthet Dent 1979;41:308-15. Karthik M. Concepts of occlusion in prosthodontics: A literature review,
5. DeVan MM. The concept of neutrocentric occlusion as related to denture part II. J Indian Prosthodont Soc 2016;16:8-14.

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