1. Palatal resections - Alterations at surgery
to enhance the prosthetic prognosis
John Beumer III, DDS,MS
Division of Advanced Prosthodontics
UCLA School of Dentistry
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2. Maxillary Defects – Prosthodontic
Challenges
Dentulous patients
v Restorethe partition between the oral and
nasal cavities
Restore palatal contours
v Replace needed dentition
v Provide retention, stability, support for the
partial denture-obturator prosthesis
v Create partial denture designs that do not
stress abutment teeth beyond their
physiologic tolerance

3. Maxillary Defects – Prosthodontic
Challenges
Edentulous patients
v Restore partition between the nasal and
oral cavities
v Restore palatal contours
v Replace the necessary dentition
v Provide retention, stability, and support for
the complete denture - obturator prosthesis
To meet these challenges we need the help and
cooperation of our surgical oncology colleagues.

4. Maxillary Defects – Prosthodontic
Challenges
Edentulous patients
v Restore partition between the nasal and
oral cavities
v Restore palatal contours
v Replace the necessary dentition
v Provide retention, stability, and support for
the complete denture - obturator prosthesis
The surgeon can help by creating an accessible, skin
lined defect that can be used to help retain, stabilized,
and support the future obturator prosthesis.

5. Alterations at Surgery to Enhance the
Prosthetic Prognosis
v Skin grafting the defect
v Maintain access to the defect
v Salvaging the premaxillary segment
v Soft palate resection and velopharyngeal function
v Retention of key teeth
v Use of palatal mucosa
v Placement of osseointegrated implants

6. Skin Grafting - Advantages
v In radical maxillectomy defects skin grafting the
inside of the cheek flap creates a divergent lateral
wall which when engaged by the obturator
prosthesis, facilitates retention.
v The scar band at the skin graft mucosal junction
creates an undercut superior to this junction .
Engagement of this undercut with the obturator
prosthesis facilitates retention on the defect side.
v A skin lined cheek flap is more flexible than one
that epithelializes spontaneously and can be more
effectively displaced by the prosthesis allowing for
the development of better midfacial contours on the
defect side.
v Skin lined defects provide keratinized surfaces in
the defect that can be engaged more aggressively
with the prosthesis thereby improving stability,
retention and support for the obturator prosthesis.

7. Skin grafting
Note the undercut just superior to the skin graft mucosal
junction (arrows). In addition, the lateral walls of these
skin lined defects diverge superiorly and if properly
engaged, retention of the obturator prosthesis is
significantly enhanced.

8. Skin grafting vs spontaneous epithelialization
Note the difference between these two defects. The defect on the left
is lined with skin and can be aggressively engaged prosthodontically
enhancing stability, retention and support. The defect on the right is
lined with poorly keratinized squamous epithelium and respiratory
epithelium. Neither of these epithelial surfaces are suited to resist the
abrasion associated with the use of an obturator prosthesis.

9. Skin grafting vs spontaneous epithelialization
Both these patients had similar resections. In one a skin
graft was used to line the defect. In the other, the wound
was allowed to epithelialize spontaneously.
The skin lined defect can be used to help support, stabilize,
and retain the obturator prosthesis whereas the defect
without skin lining cannot be so utilized .

10. Skin grafting vs spontaneous epithelialization
Although large, such defects can be restored prosthodontically if
skin lined. In this patient there were soft tissue undercuts
bilaterally and these were engaged by using a two piece
prosthesis providing the patient with a well retained obturator
prosthesis. Speech and swallowing were fully restored but
mastication was still severely compromised.

11. Total palatectomy defects
Two piece obturator
prosthesis
This type of prosthesis is
effective in restoring speech
and swallowing but
mastication will be severely

12. Skin grafting vs spontaneous epithelialization
Total palatectomy defects
This defect was not lined with skin and has undergone
contraction. Unfortunately, it is not restorable using
prosthodontic means.

13. Skin grafts vs secondary epithelialization
Even though these patients are edentulous their defects are
relatively easy to obturate because the defects are lined with
skin. Properly engaging the lateral wall of the defect and the
undercut just superior to the skin graft mucosal junction will
greatly facilitate the retention and stability of the obturator
prosthesis.

14. Skin grafting vs spontaneous epithelialization
v Grafting this defect prevented undesirable contraction of the
upper lip and it retains much of its original flexibility.
The result: A properly extended obturator prosthesis
will restore the contours of the upper lip.

15. Anterior defects
Skin lined defects vs defects which are allowed
to granulate and epithelialize spontaneously
Advantages of skin lined anterior defects
a) Improved support provided by the defect
b) Less contraction of the lip
c) More control over the lip contours with the obturator
prosthesis

16. Skin graft vs Secondary Epithelialization
This wound was closed primarily and the
raw tissue surfaces were not skin grafted.
Result: The upper lip contracted and normal lip contours could
not be restored with the labial flange of the prosthesis.

17. Anterior defects
a b
v An attempt was made to close this defect
primarily.
v Note scarring and lip retraction that results.

18. Skin grafts vs spontaneous epithelialization
Note the poor quality tissues in the defect. Defects such as
these are difficult to restore because the defect can not be
properly engaged with the obturator extension.
Result: The retention and stability of the prosthesis is
compromised.

19. Skin grafts vs secondary epithelialization
The skin graft placed into this defect sloughed and the wound epithelialized
with poorly keratinized epithelium and respiratory epithelium. This type of
mucosal lining does not tolerate well the abrasion associated with the wear
of an obturator prosthesis. In addition, because of contraction of the defect
and the lack of a skin graft mucosal junction there are no undercuts to
engage.
Result: Retention and stability are compromised.

20. Access to the defect
Large defects should not be closed surgically and
access to the defect should be maintained.
An attempt was made to close this defect primarily. This defect
can be obturated but the forces of gravity and the long lever arm
of the prosthesis will place great stress and strain on the abutment
teeth which could lead to their premature loss.

21. Access to the defect must be maintained
In this patient the middle turbinates were retained. They
subsequently became edematous and extended down into the
oral cavity, distorted the palatal contours of the obturator
prosthesis, violating the tongue space. They were
subsequently removed.

22. Access to the defect must be maintained
These defects were closed with soft tissue flaps. Note the
distortion of the palatal contours and the elimination of the
tongue space. These patients could not be fitted with a
prosthesis. They were unable to masticate and their
speech articulation was severely compromised.

23. Access to the defect
This defect was closed with a radial forearm free flap. Note the
distortion of the palatal contours and the compromise of the
tongue space. Absent the retentive contribution of the defect, the
partial denture restoring the posterior dentition delivers clinically
significant stress to the abutment teeth.

24. Access to the defect
Result:
Over time the teeth retaining this partial denture and obturator
may be lost prematurely.
In addition, the patient complained about the accumulation of
secretions in the nasal cavity on the defect side.

25. Access to the defect
Problems as a result of these mucous accumulations:
a) Local infections.
b) A very strong and unpleasant odor emanating from the nasal
passages on the defect side.

26. A
Retention of the premaxilla:
Advantages-Edentulous
Patients
v Improved support because of
increased palatal shelf surface
area B
v Improved stability
v Additional implant sites
In patient “B” only a small portion of the premaxilla on the defect side was
retained, but as a result significant amounts of palatal shelf were saved
leading to increased support for the obturator prosthesis.

27. Retention of the premaxilla: Advantages-
Edentulous Patients
v In this patient sufficient bone remained to permit the
placement of three implants.

28. Retention of the premaxilla
Retaining the premaxilla on the
defect side allows for more
favorable partial denture designs.
Rests can be positioned so that
occlusal forces can
be directed
along the long
axis of the
abutment
teeth.

29. Retention of the premaxillary segment
When the premaxillary segment has been completely
removed, support is significantly compromised and the
partial denture framework will expose the remaining teeth
to clinically significant lateral forces.

30. Retention of the premaxilla
v Implant sites
The best implant site in the upper jaw is the premaxilla. In most
maxillectomy patients, 2-4 implants can be placed in this region.
The more of the premaxilla available for implant placement the
more favorable the implant distribution pattern (A-P spread).

31. Retention of key abutment teeth
Abutment teeth adjacent to the defect are subjected to the
greatest stress and bony cuts through the alveolus next to these
teeth should be interproximal rather than intraseptal
In this patient the transalveolar bony cut was properly made.
The result: This abutment tooth is circumscribed by alveolar
bone, making it a suitable partial denture abutment.

32. Retention of key abutment teeth
In these three patients bony cuts through the alveolus
were made too close to the roots of teeth. The result:
These teeth are of limited value as partial denture
abutments for the obturator prosthesis.

33. Soft palate resection and velopharyngeal
closure
v Middle third of the soft palate is responsible for palatal
elevation (levator veli palatini) during velopharyngeal
closure.
v In partially edentulous patients when teeth can effectively
retain the obturator prosthesis, when the middle third is
resected for tumor control the remaining posterior third
should also be resected. This will insure appropriate access
to the residual velopharyngeal musculature.
v In edentulous patients, when difficulty with retention is
anticipated, these nonfunctional posterior one third remnants
are retained to facilitate retention.

34. Soft palate resection and velopharyngeal closure
Remnants of the levator are generally
present and functional after complete
removal of the soft palate. These muscle
remnants are imbedded within the lateral
wall of the pharynx and their contracture
plus contraction of the superior
constrictor comprise the residual
velopharyngeal mechanism.
In order for the obturator to restore
speech to normal the obturator
extension must interact with this
residual musculature in a precise
manner. Retaining nonfunctional soft
palate remnants may make it difficult
to achieve this precise interaction.

35. Soft palate resection
The posterior one third of the soft palate was retained in both
these patients. This strip of mucosa is nonfunctional and
prevents proper extension an precise placement of an obturator
prosthesis into the residual, still functional velopharyngeal
mechanism.
Result: Speech will be hypernasal.

36. Soft palate resection and velopharyngeal closure
l In edentulous patients the needs of retention outweigh the
needs of precise velopharyngeal closure
Extension onto the
nasal side of the
residual soft palate
In this patient the soft palate remnant was retained because it
can be used to aid retention of the obturator prosthesis.

37. Palatal mucosa The palatal margin of the defect
is a fulcrum around which the
prosthesis rotates, particularly in
edentulous patients. When
possible this bony margin should
be covered with palatal mucosa
as was done in these two
patients.
Bony cut
Palatal
incision

38. Placement of osseointegrated implants
immediately following resection of the tumor
Considered:
vIn edentulous patients
vWhen the prognosis for the remaining dentition
is poor

39. Placement of osseointegrated implants
immediately following resection of the tumor
in patients to receive postoperative radiation
v Inpatients scheduled to receive postoperative radiation
therapy the dose enhancement effect at the bone
implant interface is outweighed by the bone anchorage
achieved during the 6 week postoperative period prior
to commencement of radiation therapy.

40. Rehabilitation – Surgery vs Prosthodontics
Arguments in favor of prosthodontic rehabilitation
v It is more cost effective
v The open defect can be monitored for tumor recurrence
v Bulky flaps distort palatal contours and reduce the tongue
space compromising speech articulation and control of the
bolus during mastication.
v Palatal contours and speech articulation are best restored
with an obturator prosthesis
v Mucous tends to accumulate on the nasal side of the flap
causing unpleasant odors and local infections
v Partial denture designs and stresses on abutment teeth
v Inability to use the defect to facilitate retention on the side of the
defect results in additional stresses on the residual dentition leading
to premature loss of abutment teeth.

41. Surgery vs Prosthodontics (cont’d)
Small defects in dentulous patients
Small defects, secondary to
removal of benign tumors, such as
this one, can be closed without
distorting palatal contours.
This patient played a reed
instrument and although her
speech was normal, she could
not play effectively with an
obturator prosthesis. The
tumor was benign, a suitable
followup period had elapsed,
and so the defect was closed
with local flaps.
Note: A partial denture was still needed to restore
the missing molar dentition.

42. Surgery vs Prosthodontics
Large defects are best restored
prosthodontically
This defect was closed with a radial forearm flap. A
prosthesis was still necessary for esthetics, lip
support, and to prevent supereruption of the opposing
mandibular dentition. Without, the benefit of the
retentive qualities of the defect however, the
abutment teeth, particularly the cuspid may be
exposed to forces beyond the physiologic limits of
the periodontal ligament.
Following reconstruction the patient complained of a foul odor coming from the
sinus. Exam revealed significant accumulations of dried mucous on the sinus
side of the flap which could not be easily removed by the patient.

43. Surgery vs Prosthodontics
l This large maxillectomy - orbital exenteration defect was
restored with radial forearm flap combined with an orbital
prosthesis and a maxillary obturator prosthesis. Note
that the maxillary defect was not obliterated by the
flap. The obturator prosthesis replaces the missing
teeth, and restores palatal contours. Speech articulation
is normal and hypernasality is eliminated.

44. Surgery vs Prosthodontics
v Selected maxillary defects can be effectively
reconstructed with vascularized free flaps.
v This technique is generally best suited for
secondary reconstruction after the patient is proven
to be free of disease.
v The defect must be of sufficient size because the
vascularization of small free flaps with bone grafts
of less than 2 cm is not predictable

45. Surgery vs Prosthodontics
a b c
d e g
h a. Surgical defect. b and c. Drill guide secured,
implant sites prepared and osteotomies completed.
d and e. Graft secured in position. f and g.
Occlusion of fixed partial denture. Note palatal
contours are near normal.
Courtesy Dr. D. Rohner and Dr. H. Reintsema

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