Abdulrahman, A Almalki
| Abdulrahman, A Almalki |
Abdulrahman A Almalki, Brian Myung Chang
Oral and Maxillofacial Surgery, University of Pennsylvania Dental Medicine
Introduction
The posterior lateral border of the tongue is one of the most common sites for oral carcinomas. The treatment of choice for such lesions is surgical therapy in combination with radiotherapy and chemotherapy. [1] Post-treatment, impairment of mastication, deglutition, and speech depending on the extent of surgical resection and partial or complete glossectomy with or without mandibulectomy. Tumor location in the anterior tongue has the biggest impact on articulation quality, whereas tumor in the tongue base has the biggest impact on swallowing. [2] It is a very challenging situation for a maxillofacial prosthodontist to rehabilitate such patients. Palatal augmentation prosthesis (PAP) has been used successfully to allow reshaping the hard and/or soft palate to improve tongue/palate contact during speech and swallowing. [3] This could be a removable partial denture or complete denture prosthesis. The thickness of the PAP will have a substantial effect on the phonetics and swallowing pattern of the patient. In depth knowledge of production of different sounds can be used as a diagnostic aid in understanding the compensatory articulation used by glossectomy patients and in determining the thickness of the PAP.
Methods
A 76 year old male reported to the Graduated Prosthodontics Clinic with chief complaints of difficulty in swallowing and impaired speech due to partial resection of the tongue. Three years back, the patient was diagnosed with squamous cell carcinoma involving the left lateral border of the tongue and floor of the mouth with negative margin in the posterior two third of the tongue. The patient underwent posterior two third glossectomy. The patient had diabetes for the last 5 years and was controlled by medication. Extraoral examination indicated that there was little collapse of soft tissue on the right cheek and the right side of the neck. The patient had limited mouth opening (40 mm). Intraoral examination depicted that the lingual sulcus was completely obliterated on the resected side. The patient was partially edentulous in resected side with few teeth missing in the maxillary arch, and inadequate articulation with deviation of the mandibular arch toward the resected side (left side) with significant horizontal overlap. Existing teeth had inadequate direct restorations, wear, and abrasion. The treatment plan thus included fabricating of surveyed crowns followed by fabrication of PAP with oral surface being contoured by functional palatal impression technique using functional wax on the oral surface and reproducing the same in the final prosthesis.
Results
Clinical steps: 1) Surveyed crowns were fabricated using metal ceramic restorations for teeth #’s 5,6,7,8,9,10,11,12,13,25,26,27,28,29,30,31 with metal collar design (figure-2). 2) After final surveying the crowns and cementation. (Figure-3). 3) Primary impressions were made, and custom trays were fabricated, and border molding with final impression were made using polyvinyl siloxane. 4) Maxillomandibular mandibular relationship records were made, and master casts were mounted to fabricate cast metal framework (figure-4). 5) Teeth set-up were completed and try-in was done (figure-5). 6) Palatal modification was performed with wax using a brush on the oral side of the hollow prosthesis, and the patient was instructed to functionally manipulate the wax by the floor of the mouth by repeating the linguovelar sounds /k/, /kh/, /g/, and /gh/ for the posterior palatal tracing. This sounds enabled the tongue to articulate with the different positions on the palate. For tracing the swallowing patterns, the patient was asked to swallow saliva multiple times. Phonetics was checked again, and finally, a proper balance was achieved between speech and swallowing tracings. 7) Prosthesis was finally processed with the heat cure acrylic resin. A smooth palate without rugae was preferred by the patient for easier removal of food during eating (figure-6). 8) The prosthesis was delivered to the patient and follow ups were done after 24 h and 1 week. After 1 week, speech therapy and oral exercises were initiated to improve the efficiency of the prosthesis. The patient was asked to suck the saliva forcibly inside the pharynx to improve the swallowing abilities. He was also asked to do exercises involving muscles of cheeks, lips, and floor of mouth such as blowing and sucking exercises to improve articulation during speech. (figure-7).
Conclusion
A PAP can help patients treated for head & neck cancer patients to more precisely articulated velar consonants and can benefit oral transport.