Tumors of the palate can cause defects requiring resection. Epidermoid carcinomas arising from the paranasal sinuses or palate often require radical maxillectomy, sometimes with orbital exenteration. Pleomorphic adenomas are usually removed with palatectomy. Adenoid cystic carcinomas are aggressive and require extensive resection. Traumatic defects have irregular shapes and scarring, making prosthetic restoration difficult. Fungal infections like mucormycosis in immunosuppressed patients can cause extensive necrosis requiring wide resection. Bisphosphonate use can cause localized osteonecrosis defects.

1. 10. Etiology of Palatal Defects
John Beumer III, DDS,MS
Distinguished professor emeritus
UCLA School of Dentistry
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2. Table of Contents
 Tumors of the region
Epidermoid
Salivary gland
Mesenchymal
 Traumatic defects
 Fungal infections
 Osteonecrosis secondary to
bisphosphonates
 Prolonged cocaine use

3. Tumors of the Region:
Resection and the resultant defects
 Maxillofacial Prosthodontists need to be familiar
with the types of surgical resections used to
remove various types of tumors found in the
upper jaw and paranasal sinuses. Why?
 Advantages:
• He/she can better interact with the surgeon
• The prosthodontist needs to become familiar with the
methods of treatment so that he/she can better
prepare the patient to deal with the limits of oral
function and morbidities imposed by the surgery and
adjunctive therapies such as radiation therapy or
chemoRT.

4. Tumors of the Region:
Epidermoid
 Sinus
 Palatal
Salivary gland
 Benign
 Malignant
Mesenchymal
 Benign
 Malignant

5. Methods of Resection
Palatectomy
 Performed transorally. Mucosal incisions are outlined to provide 5-10 mm
of normal tissue around the tumor.
 Bony cuts are made with a power saw or an osteotome. The bony edges
are covered with residual mucosa and periosteum if available.
 Split thickness skin grafts are used to line selected raw tissue surfaces of
the defect.
Radical maxillectomy
 Skin incisions (Weber-Fergusson) are used to expose the maxilla to be
resected.
 Oral mucosal incisions are made through the palate and the buccal
vestibule.
 Bony cuts are made through the palate, alveolar ridge, lateral nasal
bones, floor of the orbit, malar eminence, pterygoid plates and zygomatic
arch.
 After the remaining soft tissues are detached and removed with the
specimen, the raw tissues of the defect are lined with a split thickness
skin graft. The skin incision is then closed.

6. Methods of resection
Radical Maxillectomy
 A typical resection and defect is shown.
Note that the defect is lined with skin. This
type of defect is a favorable one because
the defect can be used to facilitate the
retention, stability and support of the partial
denture with obturator.
obturator
In this patient an orbital
exenteration was also performed.
performed

7. Palatectomy
 These defects are generally quite small
compared to radical maxillectomy defects and
usually the paranasal sinus partitions are still
intact.
 Dentate patients with such defects are
relatively easy to restore if suitable numbers
of teeth are present and the defect does not
extend into the movable portion of the soft
palate.
 Edentulous patients with such defects are
more difficult to restore because the defect
cannot be engaged as aggressively compared
to a skin lined radical maxillectomy defect,
resulting in compromised retention. Such
patients stand to benefit from the placement of
osseointegrated implants.

8. Epidermoid carcinomas
 Tumors arising from the paranasal sinuses
 Tumors arising from the palatal epithelium

9. Epidermoid carcinomas arising from
the paranasal sinuses
Initial signs and symptoms:
 Nasal congestion
 Nasal infection and bleeding
 Loosening of teeth and other oral signs
 Proptosis and swelling around the eye and cheek

10. Epidermoid carcinomas arising from
the paranasal sinuses
Roentgenographic
analysis reveal soft
tissue masses filling
the sinus with
advanced lesions
demonstrating erosion
of the bony walls of the
antrum (arrows).

11. Epidermoid carcinomas arising from
the paranasal sinuses
In both these patients the first signs that brought
the tumor to the attention of the patient was palatal
swelling and loosening of teeth.

12.  In these three patients, swelling of the cheek
and eye region first brought the attention of
the patient to the tumor.

13.  Epidermoid carcinoma arising from the
paranasal sinuses
These tumors generally require radical maxillectomy sometimes
accompanied by an orbital exenteration for tumor removal. Many
patients also receive postoperative radiation. Metastasis to the neck is
rare and so prophylactic neck dissections are generally not performed.

14. Epidermoid carcinomas arising from
the paranasal sinuses
Defects secondary to radical
maxillectomy can be rather
large and disfiguring and
fabrication of the prosthetic
restoration can be quite
challenging particularly in the
edentulous patient.
Osseointegrated implants
are strongly recommended
in these situations.

15. Epidermoid carcinomas arising from the
palatal mucosa
These tumors tend to stay localized and generally
can be removed with partial palatectomy transorally.
The defects created are smaller than those created
with radical maxillectomy and less disfiguring.
Prosthodontic restoration of these types of defects is relatively simple
particularly when key teeth are still present. If teeth are not present
implants can be placed to retain and stabilize the prosthesis.

16. Salivary gland tumors
 Benign
 Pleomorphic adenoma
Most arise from the minor
salivary glands at the junction
of the hard and soft palate.
They stay localized but require
resection with a healthy
margin of normal tissue
around the tumor. A
palatectomy performed
transorally is usually sufficient
for removal.

17. Pleomorphic adenoma
Even large pleomorphic adenomas such as this can be
removed transorally with a partial palatectomy. Prosthetic
obturation is relatively straight forward as long as healthy teeth
or bone sites for implants remain.

18. Pleomorphic adenoma
The surgical defects created are usually confined to
the junction of the hard and soft palate.
Prosthetic obturation is
easily accomplished.
Occasionally when the
defect extends onto the
middle third of the soft
palate, leakage of fluids
during swallowing may
occur sporadically.

19. Salivary gland tumors
 Malignant
 Adenoid cystic carcinoma
These are slow growing but locally aggressive
malignant tumors that tend to spread along
peripheral nerves and perivascular sheaths. They
require very aggressive local resections.

20. Adenoid cystic
carcinoma
Aggressive resections are
required for cure. Note how
much of the hard palate has been
removed in this resection.
This combination of hard palate
- soft palate defect however is
easily obturated prosthetically
providing a levator veli
palatini remnant is present
on the side opposite the tumor
resection and teeth or implants
are available to retain the
prosthesis.

21. Adenoid cystic carcinoma
Note the recurrence (arrow). This is a common occurrence and
patients with adenoidcystic carcinoma often require additional
resections. Fortunately however, it is a slow growing neoplasm
that remains localized in most patients.

22. Mucoepidermoid carcinomas
 High grade
 Intermediate grade
 Low grade
Resection of high grade tumors is aggressive often
requiring a Weber-Fergusson incision while most low
grade tumors can be removed transorally.
transorally

23. Mesenchymal Tumors
 Lymphosarcomas
 Chondrosarcomas
 Osteosarcomas
This patient presented with an osteosarcoma of the hard palate. Note that
the tumor has invaded into the floor of the nose and the maxillary sinus
(arrow). A transoral partial palatectomy was performed and the defect
obturated prosthetically.
prosthetically

24. Mesenchymal Tumors
This patient presented
with an extensive
osteosarcoma. A radical
maxillectomy and an
orbital exenteration was
required for tumor
removal. The prognosis
for such an advanced
neoplasm is very poor.

25. Other phenomenon causing
maxillary defects
 Trauma
 Aspergillosis
 Mucormycosis
 Osteonecrosis secondary
to use of bisphosphonates

26. Traumatic Defects
A traumatic defect secondary to a gunshot wound
Note the poor quality mucosa lining the
defect, its irregular shape and the scarring of
tissues adjacent to the defect. Only the
maxillary second molar remains.

27. Traumatic Defects
A traumatic defect secondary to self
inflicted gunshot wound
Note the poor quality mucosa lining the defect, its irregular
shape and the scarring of tissues adjacent to the defect.
The residual maxillary segments are displaced and the
mandibular fragments are misaligned.

28. Traumatic Defects
These defects are more difficult to
restore prosthodontically. Why ?
 Poor quality mucosa lines the defect
 Defects are irregular in size and shape
 Scarring of tissues adjacent to the defect
 Residual maxillary segments may be displaced
 Misalignment of the mandibular dentition complicate the
occlusal relationships

29. Other phenomenon causing maxillary defects
Mucormycosis and aspergillosis
These are fungal infections that occur in chronically immuno-
suppressed patients and those with uncontrolled diabetes. The
organisms cause ascending venous thrombosis resulting in
necrosis of the involved structures.

30. Mucormycosis and aspergillosis
Immediately postoperative
Treatment requires extensive
resection combined with
systemic antifungal therapy.
The defects cannot be
successfully skin grafted and
may be difficult to restore
because of scar contraction
and the poor quality of the
epithelium lining the defect.
4 months postoperative

31. Mucormycosis and aspergillosis
This patient required removal of the
orbital contents to control the infection
resulting in facial disfigurement.

32. Cocaine use

33. BRONJ
Most of the defects associated with
bisphosphonate use are localized as seen
here.

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