Glossectomy

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PROSTHETIC REHABILITATION

FOLLOWING PARTIAL AND

TOTAL GLOSSECTOMY

Rohan Grover

JR II


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Introduction

Approx 5% of all cancers occur in the oral cavity.

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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FUNCTIONS AFFECTED BY GLOSSECTOMY

Speech difficulties.

Deglutition difficulties.

Difficulties in mastication and foodbolus management.

Difficulties in saliva management.


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Prosthodontic Treatment of

Total Glossectomy Tongue defects due to tumor removal can result

in eithertotal or partial glossectomy.

A total glossectomy will create a large oral cavityand pooling of saliva and liquids. These liquids

can seep around the epiglotis, leading to

aspiration.


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With present knowledge, it is impossible torecreate the original function of the mobiletongue either surgically or prosthetically. It is,however, possible to improve function andesthetics for these patients.


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The major goals in prosthodontic

rehabilitation of the total glossectomy

patient without surgical reconstruction

are to (Cantor et al, 1969):

1. Reduce the size of the oral cavity, whichimproves resonance and minimizes the degreeof pooling of saliva.

2. Direct the food bolus into the oropharynx withthe aid of a trough carved into the dorsum of thetongue prosthesis.


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3. Protect the underlying fragile mucosa if skinflaps were not used.

4. Develop surface contact with thesurrounding structures during speech andswallowing.

5. Improve appearanceand psychosocialadjustment.


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The success of prosthodontic rehabilitationdepends primarily on

patient motivation,

anatomic factors (such as the presence or absenceof teeth),

associated morbidity of the surroundingstructures, including mandibulectomy,palatectomy, and radiation therapy to theseareas.


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In total glossectomy, the mandibular tongueprosthesis is the treatment of choice (Moore,1972).

However, in a situation involving an edentulouspatient and an irradiated, resorbed mandibularridge or a patient with a very mutilated

dentition, a palatal augmentation prosthesisshould be considered.


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Construction of a Mandibular

Total Tongue Prosthesis

For preliminary impressions, the patientshould be seated in an upright position.

It is critical for the safety of the patient toensure that impression material does not

flow into the hypopharynx.

For this reason, the dental assistant must

accompany with a high-speed suction.


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A stock maxillary tray of proper size shouldbe selected.

The maxillary tray is necessary to register theentire floor of the mouth.


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Utility wax is added to the posterior edge and

the vault of the tray to confine the hydrocolloid

material and to prevent it from flowing toward

the patient's throat.

Modified stock tray is tried in the patients mouth

for fit and comfort


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Preliminary impression of the mandibular arch

and the floor of the mouth following total

glossectomy


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Master cast

after block-out

Refractorycast


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Completed wax pattern Spruing of the total

glossectomy framework


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Finished chrome-cobalt framework on the master

cast


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The framework is tried in the patient's mouth

using rouge and chloroform or similardisclosing media to ensure complete andpassive seating on the teeth


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Care should be taken to ensure that theretentive meshwork does not touch the floorof the mouth during any functional

movement.

If it does, it should be cut and soldered in amore Occlusal position or the frameworkremade at a higher level.


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Mouth temperature wax is placed on the retentive

meshwork


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The patient is asked to perform functionalmovements with the floor of the mouth such

as attempting to pronounce various soundslike ee, opening and closing, and attemptingto swallow

Iowa-wax impression of the floor of the

mouth


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The wax tracing is inspected and more wax isadded to ensure passive contact with the floor ofthe mouth during functional movements.

A mushroom like projection is waxed to the oralsurface of the framework to retain the oral

portion of the tongue prosthesis.


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Acrylic resin base with a

retentive mushroom extensionfitted on the cast

Maxillary & mandibular casts

showing that the framework

and the mushroom retentive

extension do not interfere with

the opposing arch


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It has been suggested that three prosthetictongues be made: one for speech

one for swallowing one for both speech and swallowing

(Moore, 1972; Myers and Sun, 1996)


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The prosthetic tongue for speech should have an

anterior elevation to facilitate articulation of theanterior linguoalveolar sounds t and d.

It should also have a posterior elevation to aid inthe articulation of the glottal stops or posteriorlinguoalveolar sounds g and k.

Both elevations help to shape the oral cavity,thus improving vowel production in general.


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Mandibular tongue prosthesis for speech. It is

made of clear acrylic and has anterior and

posterior elevations


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To create these elevations, green stickcompound is luted to the anterior portion of the

framework and the patient is asked to occludethe teeth.

Compound is then added to the posterior portion

of the framework and the patient is asked againto occlude the teeth.

Contact with the palate should be evident in

both areas of compound. Both anterior andposterior elevations are reduced 2 to 3 mm and alayer of Iowa wax is flowed onto the surface.


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The patient is asked to repeat t, d, k, g andattempt swallowing.

The wax surface is then examined. It should beglossy, indicating that contact with the palataltissue has been made.

If compound is showing through, it should bereduced with a sharp knife and a new layer ofIowa wax added.


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The patient should repeat the mandibularmovements to pronounce t, d, k, g.

These tracings should be performed in the

presence of a speech pathologist when possible.

After satisfactory production of these sounds,

the tongue prosthesis for speech is processed inclear heat-cured acrylic resin, highly polished,then tried in the patient's mouth


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Mandibular tongue prosthesis for speech


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The prosthetic tongue for swallowing iswaxed in the form of a sloping trough like

base in the posterior aspect to help guide thefood bolus into the oropharynx. It is thenprocessed in denture-base acrylic resin.


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In some instances, the mandibular tongue-prosthesis can be constructed to include both

features of swallowing and speech in a highlymotivated patient.

The framework with the processed acrylic-resinbase that contains the oral "mushroom

projection" is used for this purpose.


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A heavy mix of tissue-conditioning material isadded to the base and the patient is asked to

move the mandible while pronouncing t, d, k,g as the material sets.

Add or remove material during this procedure

until the desired sounds are attained.


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Tissue conditioner material is being used during

tracing of the mandibular prosthesis


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After final tracing, the artificial tongue is snapped

off its acrylic resin base before processing with

silicone material


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The tissue conditioner tracing is thenremoved and duplicated in silicone with

appropriate intrinsic coloration and attachedmechanically on the mushroom likeprojection of the acrylic resin base.


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Silicone tongue prosthesis for both speech and

swallowing

Case Reports


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Glenn Bregeldt . Tongue Prosthesis for Total Gloss ectomy Pat ient.

J Prosth od 1992;1:131-133.

Case Reports

Case Reports


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J Prosth od 1992;1:131-133.

Mandibular denture showing elliptical acrylic

retention button and posterior platforms for posterior

support of the tongue prosthesis.

Case Reports

Case Reports


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J Prosth od 1992;1:131-133.

Final tongue prosthesis with mandibular denture.

Case Reports

Case Reports


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J Prosth od 1992;1:131-133.

Tongue prosthesis attached to mandibular denture

Case Reports

Case Reports


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J Prosth od 1992;1:131-133.

Completed soft acrylic tongue prosthesis that is

attached to the mandibular denture but removablefor hygiene

Case Reports


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Prosthetic Treatment of

Partial Glossectomy

It has been demonstrated that removal of lessthan 50% of the tongue may result in only minorfunctional impairment and, consequently,prosthodontic intervention is not required

(Aramany et al., 1982).

However, in cases where a patient has had apartial glossectomy and a partial

mandibulectomy, there is a greater need for aglossectomy prosthesis.


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Prosthodontic treatment for partial glossectomy isnecessary when the patient experiences difficulty inspeaking and/or managing a food bolus.

When indicated, either the palatal augmentationprosthesis or a mandibular augmentation prosthesis maybe fabricated.

The function of the augmentation prosthesis is to fill thevolume deficiency between the remaining tongue andthe mandible and the palate


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The choice between a mandibular and apalatal augmentation prosthesis dependsupon the availability of abutment teeth, the

extent and site of the tongue deficiency, andpatient acceptance.


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Mandibular Augmentation

Procedure After constructing a conventional or interim mandibular

removable complete or partial denture, a thick mix oftissue-conditioning material is added to the lingualflange in the area of the tongue deficiency.

The prosthesis with the tissue conditioner is insertedinto the patient's mouth, and the patient is instructed toswallow, open and close, and pronounce certain

phonemes depending on the site of the resection.


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Mandibular lingual augmentation tracing in tissue-

conditioning material is added to the mandibular

temporary RPD


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Completed mandibular lingual augmentation

prosthesis


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Mandibular lingual augmentation prosthesis in

mouth


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Anterior resection situations require

the use of consonant sounds such as

t and d.

Posterior defects require glottal stop

execution such as k and g sounds.


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After the tissue-conditioning material has set, aplaster matrix is made of the tissue-conditionerimpression and the soft liner material iseliminated.

The augmented part of the prosthesis isprocessed with autopolymerized acrylic resin.


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For an edentulous patient, the mandibularfinal impression is made utilizing the neutralzone technique and the denture is processed

accordingly .


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Mandibular neutral zone impression to generate

the lingual augmentation prosthesis


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Finished complete denture with the lingual flange

augmented towards the tongue defect


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Palatal Augmentation

Prosthesis


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A, Schematic illustration of functional contacts occurring between tongue and palate in

non-glossectomy subject.

B, Illustrates lowering of palatal vault in glossectomy patient with palatal augmentation

prosthesis allowing for functional contact between residual or reconstructed tongueand prosthesis.


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Palatal Augmentation Prosthesis


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Palatal Augmentation Prosthesis

In dentate or partially dentate patients, a

maxillary framework is designed followingconventional prosthodontic techniques with anadded mid-palatal meshwork to retain the

augmentation portion of the prosthesis.

Functional molding of the augmentation portion

of the prosthesis is done in a similar manner tothe partially edentulous mandibular total

glossectomy prosthesis however, anterior

tongue position consonants are emphasized.


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Tissue conditioning

palatal

augmentation

prosthesis after

tracing &

immediately before

duplication into

silicone


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Final & disassembled palatal augmentation

prosthesis


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In the edentulous patient, conventionalmaxillary and mandibular complete denturesare fabricated and used for a brief time

(usually 2 weeks) before the maxillarydenture is augmented to compensate forthe tongue deficiency.


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A thick mix of tissue-conditioning material isadded to the palatal portion of the maxillary

denture.

While the material is still moldable, the patient is

instructed to swallow and to pronounce certain

phonemes, depending upon the location of thedeficiency.


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Tracing of the palatal augmentation in maxillary

complete denture for a patient with partial

glossectomy


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Finished palatal augmentation added to complete

denture for a partial glossectomy patient


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Conclusion

Glossectomy prosthesis fabrication is an extremelychallenging facet of maxillofacial prosthodontics.

The expectations of the patient and the speech

therapist or pathologist are rarely met, and thefrustration level of the prosthodontist can be veryhigh indeed.

Realistic expectations only come with experience,and with experience, the fabrication of

glossectomyprostheses can be very gratifying .


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References

Clinical Maxillofacial Prosthetics Thomas D.Taylor

Maxillofacial Prosthetics - WR Laney.

Maxillofacial Prosthetics : Multidisciplinary

Practice Chalian, Drane & Standish..


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References

The efficacy of palatal augmentation prostheses for speechand swallowing in patients undergoing glossectomy: A reviewof the literature. J Prosthet Dent 2004;91:67-74.

Prosthetic management of a total glossectomy defect

after free flap reconstruction in an edentulous patient: Aclinical report. J Prosthet Dent 2003; 89:119-22.

Neutral zone approach for denture fabrication for a partialglossectomy patient: A clinical report. J Prosthet Dent

2000;84:390-3.

References


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Immediate rehabilitation after total glossectomy: Aclinical report. JPD 1993;462-63.

Armany M, Downs J, Beery Q et al. Prosthodonticrehablitation for glossectomy patinet. J Prosthet Dent1982;48:78.

Cantor R, Curtis T, Shipp T et al. Maxillary prosthesis for

mandibular surgical defects. J Prosthet Dnet1969;22:253.

Moore D. Glossectomy rehabilitation by mandibulartongue prosthesis. J Prosthet Dent 1972;28:429.

Luciello F, Vergo T, Schaff N. Prosthodontic and speechrehabilitation after partial and complete glossectomy. JProsthet Dent 1980;43:204.


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