Prosthodontic Management of Total and Partial Glossectomy

MANAGEMENT OFMANAGEMENT OF
TOTAL AND PARTIAL GLOSSECTOMYTOTAL AND PARTIAL GLOSSECTOMY
PATIENTPATIENT
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

CONTENTSCONTENTS
• Introduction
• Functions of tongue
• Pathology
• Prosthodontic treatment of total glossectomy
• Prosthodontic treatment of partial glossectomy
• Review of literature
• Conclusion
• References

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)

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.

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.

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.

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.

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.

• 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.

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.

• 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.

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.

• 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.

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)

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.

• 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.

• 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.

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.

- 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.

- 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.

- 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.

- 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.

- 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.

- Three prosthetic tongues are advised :-
1. Speech,
2. swallowing &
3. one for both speech & swallowing.

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.

- 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.

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.

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.

• 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.

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.

• 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.

• 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.

• 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.

• 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 viewwww.indiandentalacademy.com

PROSTHETIC TREATMENT OF PARTIALPROSTHETIC TREATMENT OF PARTIAL
GLOSSECTOMYGLOSSECTOMY

• 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.

• 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.

- 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.

- For edentulous patients, mandibular final impression is made utilizing the
neutral zone technique & the denture is processed accordingly.

• 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.

- 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.

- 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.

• 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.

• 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
movements.www.indiandentalacademy.com

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.

• 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.

• 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.

• 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

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.

• 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.

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

• WHEN ALL IS LOST FUTURE STILL
REMAINS

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.

Prosthodontic Management of Total and Partial Glossectomy

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