Prosthetic management of glossectomy/ orthodontic continuing education


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Prosthetic management of glossectomy/ orthodontic continuing education

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  3. 3. CONTENTSCONTENTS • Introduction • Functions of tongue • Pathology • Prosthodontic treatment of total glossectomy • Prosthodontic treatment of partial glossectomy • Review of literature • Conclusion • References
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  5. 5. INTRODUCTIONINTRODUCTION • Approx 5% of all cancers occur in the mouth. • Carcinoma of the tongue is the second most common oral cancer. • Posterior lateral borders of the tongue are the most frequent sites of cancer of the tongue ( British Postgraduate Medical Federation, 1988)
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  9. 9. FUNCTIONS OF TONGUEFUNCTIONS OF TONGUE MASTICATION:- • Defined as the act of chewing foods. • It represents the initial stage of digestion, when the food is broken down into particle sizes for ease of swallowing. • The tongue has a complex role in mastication. • It directly crushes the food against the rugae of the hard palate & it aids repositioning of food bolus onto the occlusal surfaces after each chewing stroke.
  10. 10. SWALLOWING:- • Swallowing is a series of coordinated muscular contractions that moves a bolus of food from the oral cavity through the oesophagus to the stomach. • It occurs in three stages:- – Stage I : Oral stage – Voluntary stage. – Stage II : Pharyngeal stage – Involuntary (reflex) stage. – Stage III : Oesophageal stage – Involuntary (reflex) stage.
  11. 11. ORAL STAGE:- • The tongue forms a bolus of masticated food & places it between the hard palate & the dorsum of the tongue. • The presence of bolus on mucosa of the palate initiates a reflex wave of contraction in the tongue. • Elevation of the tongue with the counteraction of the soft palate depression, pushes the food into the oropharynx.
  12. 12. PHARYNGEAL STAGE:- • Once the tongue releases the bolus into the pharynx, a paristaltic wave caused by the contraction of the pharyngeal constrictor muscles carries it down to the oesophagus. • It is estimated that these two stages last for about 1min.
  13. 13. OESOPHAGEAL STAGE:- • This consists of passing of the bolus through the length of the oesophagus & into the stomach. • Paristaltic waves carry the bolus down to the oesophagus which takes 6- 7secs. • This stage of swallowing is not related to the tongue function but after the initiation of swallowing the tongue aids in debridement of food in the buccal vestibule & the floor of the mouth. • These functions occur in coordination with the musculature of cheek & lips.
  14. 14. • McConnel et al (1988) described swallowing as a pressure-generation mechanism powered by a two- pump system. • These two pumps are the I. oropharyngeal propulsion pump (OPP) and II. the hypo pharyngeal suction pump (HSP). • The significance of normal tongue mobility for normal deglutition to take place is that any condition that affects the anterior two thirds of the tongue will necessarily affect the OPP and that any problems affecting the base of the tongue will alter HSP.
  15. 15. SPEECH:- • Speech occurs when a volume of air is forced from the lungs by the diaphragm through the larynx & oral cavity. • Controlled contraction & relaxation of vocal cords create a sound with the desired pitch. • Once the pitch is produced, the precise form assumed by the mouth determines the exact articulation of the sound. ARTICULATION OF SOUND:- • Important sound formed by the lips are letters “m, b & p”. • Teeth are important in saying “s ” sound. • The tongue & the palate are especially important in forming “d ” sound. The tip of the tongue reaches up to touch the palate directly behind the incisors.
  16. 16. • A combination of anatomic structures can also be used to form many sounds. • The tongue touches the maxillary incisors to form “th ” sound. • The lower lip touches the incisal edges of maxillary teeth to form “f & v ” sounds. • The posterior of the tongue rises to touch the soft palate to produce “k or g ” sound.
  17. 17. PATHOLOGYPATHOLOGY • More than 90% of the malignant tumors of the tongue are epidermoid carcinomas occuring on either the anterior 2/3rd or the posterior 1/3rd of the organ. • The remainder includes occasional verrucous carcinomas & adenocarcinomas arising in the minor salivary glands of the tongue. SQUAMOUS CELL CARCINOMA OF THE TONGUE:- • It is the most common single site, intraoral carcinoma & occurs about as frequently as lip cancer. • Approx. 60% of the lesions arise from the ant.2/3rd of the tongue & the remainder are from the base.
  18. 18. • The carcinoma of the dorsum of the tongue is a rare lesion & usually arises because of chronic mucosal abnormality such as atrophic glossitis, lichenoid change or leukoplakia. • The majority of the tongue carcinomas occur on the lateral borders of the ant.2/3rd & the ventral surface of the tongue. • Clinically, the carcinoma of the tongue is detected as either an ulcer or an exophytic lesion. • Local pain, pain on swallowing & lump in the neck are more common presenting complaints for anterior & posterior carcinomas.
  19. 19. ETIOLOGY:- • The etiology of lingual carcinoma is not clearly established. • Lingual carcinoma is traditionally associated with:- – Syphilis. – Sepsis – Alcohol – Tobacco – Infection with candida albicans – Dietary deficiency(iron deficiency)
  20. 20. PROSTHODONTIC TREATMENT OF TOTALPROSTHODONTIC TREATMENT OF TOTAL GLOSSECTOMYGLOSSECTOMY • Total glossectomy creates a large oral cavity with loss of oral communication & pooling of saliva & liquids. • These liquids seep around the epiglottis, leading to aspiration. • Surgical closure of laryngeal opening may reduce the incidence of aspiration & aid the patient in swallowing liquids.
  21. 21. • Major goals in prosthodontic rehabilitation of total glossectomy patient with surgical reconstruction are:- 1) Reduce the size of oral cavity, which improves resonance & minimizes the degree of pooling saliva. 2) Direct the food bolous into the oropharynx with the aid of a trough carved into the dorsum of the tongue prosthesis. 3) Protect the underlying fragile mucosa if the skin flaps were not used. 4) Develop surface contact with the surrounding structures during speech & swallowing. 5) Improve appearance & psychosocial adjustment.
  22. 22. • Success of rehabilitation depends on:- - Patient motivation - Anatomic factors(such as presence or absence of teeth) - Associated morbidity of surrounding structures, including mandibulectomy, palatectomy, & radiation therapy.
  23. 23. Construction of Mandibular Total Tongue Prosthesis - A thorough clinical & radiographic examination should always precede the initiation of active treatment. - Efforts should be made to restore carious lesions & to eradicate or bring under control all dental & periodontal disease present. - Preliminary impression is made by seating the patient in upright position & properly draped. - Care should be taken that the impression material does not flow into the hypopharynx.
  24. 24. - A stock plastic maxillary tray of proper size be selected to register the entire floor of the mouth. - Utility wax is added to the posterior edge & the vault of the tray to confine the hydrocolloid material & to prevent it from flowing towards the patients throat. - The modified tray should be tried in the patients mouth for proper fit & comfort. - The tray is loaded with quick setting irreversible hydrocolloid & is positioned intra-orally, after setting of the material tray is removed, inspected & poured in artificial stone.
  25. 25. - Preliminary cast is surveyed & mouth preparation is done. - Final impression is made & the cast is poured. - All undesirable undercuts are blocked out & the area of the floor of the mouth is relieved with atleast two thickness of base plate wax before duplicating the master cast.
  26. 26. - Wax pattern of the glossectomy framework is finished, sprued, invested, cast in chrome cobalt alloy & polished. - Care should be taken to ensure that the retentive meshwork does not touch the floor of the mouth during any functional movement.
  27. 27. - A layer of sticky wax is luted to the retentive meshwork of the RPD framework, which is covered with a layer of mouth temperature softening wax & then placed in the patient’s mouth. - The patient is asked to pronounce sounds like “eeee” & do movements such as opening & closing & attempting to swallow. - After every 10 min. the wax tracing is inspected & more wax is added to ensure passive contact with the floor of the mouth during functional movements.
  28. 28. - After complete tracing of the floor of the mouth, the framework is invested in the cope(base portion) of a maxillary denture flask with wax impression facing downward into the cope. - A mushroom like projection is waxed to the oral surface of the framework to retain the oral portion of the tongue prosthesis. - The investment procedure is completed & acrylized in heat cure resin. - After finishing & polishing prosthesis is tried in the patient’s mouth.
  29. 29. - Three prosthetic tongues are advised :- 1. Speech, 2. swallowing & 3. one for both speech & swallowing.
  30. 30. PROSTHETIC TONGUE FOR SPEECH:- - This prosthesis should have an anterior elevation to facilitate articulation of the anterior linguoalveolar sounds “t & d”. - The posterior elevation aids in articulation of posterior linguoalveolar sounds “g & k.” - To create elevations, gray stick compound is luted to the anterior & posterior portion & patient is asked to occlude the teeth. - Contact should be evident in both the areas of the compound. - Both the elevations are reduced to 2-3 mm & a layer of mouth temperature wax is flowed onto the surface.
  31. 31. - The patient is asked to repeat “t, d, g & k” & attempt swallowing. - Wax surface is examined for the glossiness, indicating proper contact with the palatal tissue. - Prosthesis is cured in clear heat cure acrylic resin & finished & polished.
  32. 32. PROSTHETIC TONGUE FOR SWALLOWING:-PROSTHETIC TONGUE FOR SWALLOWING:- - The prosthesis is waxed in the form of a sloping trough base in the posterior respect to help guide the food bolus into the oropharynx. - It is then processed in the denture base acrylic resin. - This tongue prosthesis is attached via retentive button to the base of the prosthesis.
  33. 33. PROSTHETIC TONGUE FOR BOTH SPEECH & SWALLOWING:- - A heavy mix tissue-conditioning material is added to the base & the patient is asked to move the mandible while pronouncing the same words. - A trough like groove is created in the posterior middle aspect of the traced tongue. - Patient is tested for speech & swallowing by small sips of water. - Tissue conditioning material is removed & duplicated in silicon with appropriate intrinsic coloration & attached mechanically on the mushroom like projection on the acrylic base.
  34. 34. • Cotert H.S & Aras E. (1999) reported a case of a tongue prosthesis for a total glossectomy patient in a complete denture wearer. Procedure:- - A set of upper & lower dentures were constructed. - Artificial teeth with zero degree inclined flat cusps were used with a linear occlusal relation sliding anteroposteriorly. - The patient was allowed to adapt to the prosthesis for 2 weeks. - A dome shaped prosthetic tongue was carved in a pink setup wax. - Approx. 4mm space was provided between a prosthetic tongue & a palatal vault. - A “food guiding groove” was carved on both sides of the prosthetic tongue, 1mm below the occlusal plane & increasing in width anteroposteriorly. - Approx. 2mm of pink wax was added to the palatal vault of the upper denture to improve voice & speech. - Patient was asked to read a word list containing vowels & consonants in different placements during the forming & refinement of the wax surfaces.
  35. 35. Three different articulation areas were constructed between the prosthetic tongue & palatal vault for speech improvement. • Anterior articulation was designed to produce hard palato-lingual (linguo- alveolar) fricatives(s, z, sh) & performed in the most anterior position of the mandible. • A narrow groove was carved in the midline of the anterior portion of the upper denture to improve the voicing of these phonemes.
  36. 36. • Middle articulation was designed to produce hard palato-lingual plosives (t, d) affricatives (c, ch) & nasal (n) consonants. • Posterior articulation was designed to produce soft palato-lingual plosive(k, g) & nasal (ng) consonants. • Posterior contact was performed between the summit of the dome of the prosthetic tongue & the posterior palatal region.
  37. 37. • Bredfeldt G.W.(1992) reported a prosthetic restoration of an edentulous patient with a total glossectomy. • For good hygiene maintenance a removable soft acrylic tongue prosthesis was attached to the mandibular denture.
  38. 38. • Gillis R. & Leonard R.J.(1983) – reported a prosthetic treatment for speech & swallowing in patients with total glossectomy. Prosthesis Construction:- • The patient’s remaining mandibular teeth were prepared for the placement of a cast-chrome-cobalt framework. • Red impression compound was used to mold the floor-of-the-mouth portion of the prosthesis, which was extended posteriorly to the epiglottis & slightly beyond the epiglottis on the right posterior aspect. • The impression compound was slightly relieved, & a rubber elastomer impression was made. • The resulting “altered cast” was invested, & the dorsal portion was waxed arbitrarily.
  39. 39. • Five methyl methacrylate resin buttons were placed on the dorsal surface of the finished floor-of-the-mouth portion of the prosthesis to retain the upper portion still to be fabricated. • The patient was allowed to wear the prosthesis base for several days. • Tongue portions of the prosthesis were then designed with the intent of determining a particular shape that would best facilitate speech. •The completed prosthesis was worn by the patient for several weeks to assure good adaptation. Inferior view Superior
  41. 41. • Necessary when patient experiences difficulty in speaking &/or managing a food bolus. • Function of augmentation prosthesis – to fill the volume deficiency between the remaining tongue, mandible & the palate. • Choice between a mandibular or a palatal augmentation prosthesis depends upon – availability of abutment teeth, the extent & site of the tongue deficiency, & patient acceptance.
  42. 42. • Mandibular Augmentation Procedure:-Mandibular Augmentation Procedure:- - After constructing a conventional or interim mandibular removable complete or partial denture, a thick mix of tissue – conditioning material is added to the lingual flange in the area of the tongue deficiency. - Prosthesis with the tissue – conditioning material is inserted into the patient’s mouth, & the patient is instructed to swallow, open & close, & pronounce certain phonemes depending on the site of resection.
  43. 43. - Anterior resection situations require use of consonant sounds – t & d posterior defects require glottal stop execution – k & g sounds. - After tissue – conditioning material has set, a plaster matrix is made of the tissue – conditioner impression & the soft liner material is eliminated. - The augmented part of the prosthesis is processed with autopolymerized acrylic resin, & the prosthesis is finished & polished.
  44. 44. - For edentulous patients, mandibular final impression is made utilizing the neutral zone technique & the denture is processed accordingly.
  45. 45. • Palatal Augmentation Procedure:-Palatal Augmentation Procedure:- - In dentate or partially edentulous patients, a maxillary framework is designed following conventional prosthodontic techniques with an added midpalatal meshwork to retain the augmentation portion of the prosthesis. - Functional molding of the augmentation portion of the prosthesis is done & anterior tongue position consonants are emphasized.
  46. 46. - In edentulous patients, conventional maxillary & mandibular complete dentures are fabricated & used for 2 weeks. - Maxillary denture is augmented to compensate for the tongue deficiency. - A thick mix of tissue-conditioning material is added to the palatal portion of the maxillary denture & the patient is instructed to swallow & to pronounce certain phonemes, depending upon the location of the deficiency.
  47. 47. - A plaster matrix is fabricated & the tissue-conditioning material is replaced with autopolymerized acrylic resin. - Denture is inserted in patient’s mouth & again tested for speech & swallowing. - Further modified as reline/rebase procedures. - If palatal augmentation is large, then the prosthesis should be made hollow to reduce weight.
  48. 48. • Meyer J.B. et al (1990) reported the fabrication of a light cured interim palatal augmentation prosthesis. Procedure:- • A wire clasp-retained acrylic resin baseplate was made with maximum palatal coverage & clinically adjusted. • During insertion appointment a small amount of uncured acrylic resin was added to the posterior half of the baseplate. • The patient was asked to repeat the linguo-alveolar sounds & swallow. • The reshaped addition was polymerized with the light curing unit. • Incremental addition of resin was continued until linguo-palatal contact was adequate to produce a swallowing reflex.
  49. 49. • Lehman W.L. et al (1966) – reported a prosthetic treatment following complete glossectomy. Intraoral structures following complete glossectomy An acrylic resin mantle was attached to the lower denture & contoured to inter-change with the palate of the maxillary denture. The lower denture & extension were shaped to allow freedom for left & right lateral mandibular
  50. 50. A space was created between the mandibular mantle & the palate. This was designed to aid in shunting the food toward the right & left occlusal tables. The mantle was extended to the posterior border of the lingual flanges, completely closing in the tongue space.
  51. 51. • In severe cases in which lesions involve middle 1/3rd of the tongue require a continuity resection including tongue, floor of the mouth & ipsilateral radial neck dissection. Also a hemimandibulectomy on the involved site. • A combination of palatal augmentation prosthesis & a guiding flange prosthesis may be require to maintain the symmetry of face & to keep the oral cavity in proper allignment so that, speech can be produced most effectively.
  52. 52. • Perhaps the most difficult patient to treat functionally is the patient with a tumor in the base of the tongue who receives a partial glossectomy, partial mandibulectomy, & partial palatectomy. • Problems may include effecting & controlling swallowing, drooling, nasal regurgitation of food, aspiration, poor articulation, loss of speech intelligibility, loss of facial symmetry & depression. • It is necessary to provide oranasal separation through palatal speech prosthesis, palatal augmentation prosthesis & a guiding flange prosthesis.
  53. 53. • The guidance ramp may be incorporated into a palatal-drop prosthesis in cases of partial glossectomy with limited residual tongue mobility. • Such a prosthesis serves dual purposes of mandibular guidance & residual tongue articulation. • Neither mandibular guidance prosthesis nor palatal guidance ramps are indicated for the edentulous patients without the use of dental implants to stabilize the dentures. Maxillary guidance ramp
  54. 54. REVIEW OF LITERATUREREVIEW OF LITERATURE • Taicher S. & Bergen S.F.(1981) – constructed a maxillary polydimethylsiloxane glossal prostheses for a glossectomy patient. They used polydimethylsiloxane in combination with acrylic resin for the restoration of an artificial tongue. The material used was pliable & simulated the texture of the natural tongue. They stated, that attaching the tongue prosthesis to the maxillary prosthesis has several advantages. In most patients, the mandible is either small or nonexistent & does not offer good support for a prosthesis. The maxillae, have a large stable bearing area which can support a denture & so, it is logical to try to use the bearing area to support a glossal prosthesis.
  55. 55. • Leonard R.J. & Gillis R.(1990) – conducted a study on the differential effects of speech prostheses in glossectomized patients. 5 patients representing different categories of glossal resection were fitted with prostheses specially designed to improve speech. Speech recordings with & without the prosthesis were made & subjected to a variety of analyses. They concluded, - Firstly, the use of prostheses improved speech in the 5 subjects & the improvements were apparent to differing extents. - Secondly, just as speech is differentially affected by extent & location of oropharyngeal resection, so it may be differentially affected by the introduction of a prosthesis.
  56. 56. CONCLUSION • Glossectomy prosthesis fabrication is an extremely challenging facet of maxillofacial prosthodontics. • The expectations of the patient and the uninitiated speech therapist or pathologist are rarely met, and the frustration level of the prosthodontist can be very high indeed. • Realistic expectations only come with experience, but with experience, the fabrication of glossectomy prostheses can be very gratifying
  58. 58. REFERENCES • Chalian VA :- “Maxillofacial prosthetics”, 1972. • Gillis R.E. – “Prosthetic treatment for speech & swallowing in patients with total glossectomy.” JPD 1983:57;808-814. • Lehman W.L. – “Prosthetic treatment following complete glossectomy.” JPD 1966:16;344-350. • Leonard R.J. – “Differential effects of speech prostheses in glossectomized patient.” JPD 1990:64;701-708. • Meyer J.B. – “Light cured interim palatal augmentation prosthesis- A clinical report.” JPD 1990:63;1-3. • Taicher S.T. – “Maxillary polydimethylsiloxane glossal prosthesis.” JPD 1981:48;71-77. • Taylor TD :- “Clinical maxillofacial prosthetics”,1st edition 2000.
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