CLINICAL REPORT

Soft obturator prosthesis for postoperative soft palate

carcinoma: A clinical report
Tomohisa Ohno, DDS, PhD,a Kyoko Hojo, SLP, PhD,b and Ichiro Fujishima, MD, PhDc

Oral cancer is often treated by ABSTRACT

surgery. A substantial loss of
An intraoral prosthesis with a soft flexible obturator was provided for a patient with a soft palate
oral tissue occurs after surgery, perforation after surgical and chemoradiotherapy treatments of a soft palate tumor. An obturator
which may result in dysphagia composed of movable and flexible silicone was attached to a structure similar to a palatal lift; it was
and dysarthria.1 Hypernasality therefore able to move according to the movement of the soft palate, which was confirmed by
and reflux of food from the endoscopic examination. The application of this prosthesis resulted in complete disappearance of
oral cavity to the nasal cavity hypernasality and food reflux, and the patient was able to eat without particular limitation during
becomes a significant issue in daytime wearing. This type of prosthesis represents a potential prosthetic approach to a soft palate
nasal-oral fistula. (J Prosthet Dent 2017;-:---)
patients with cancer of the
2
palate. To compensate for the substantial oral tissue
squamous cell carcinoma (T1N0M0). The patient had
defect, oral prostheses can be provided. These include
been aware of the soft palate tumor 3 years previously
obturators, speech aids, and speech valves, which can
and had visited an otolaryngologist at the local general
compensate for the substantial loss of the hard and soft
hospital, where a soft palate squamous cell carcinoma
palates.2,3 For the maxilla, most of these prostheses are
was diagnosed. Laser ablation under general anesthesia
fabricated from rigid dental materials such as metal and
was performed a month later, followed by radiation
acrylic resin.4-6 However, because the soft palate moves
therapy 2 months after surgery. A total of 56 Gy was
during articulation and swallowing, soft palate stimula-
irradiated, and the lesion disappeared. However, the soft
tion increases with a rigid appliance. For a prosthesis that
palate tumor recurred after 2 years. Laser ablation
contacts the soft palate, an alternative is needed. Sato
was therefore performed, again under general
et al7 and Spratley et al8 reported a palatal lift prosthesis
anesthesia, in addition to chemotherapy with cisplatin
with a movable lift composed of wire and rigid acrylic
and 5-fluorouracil. As a result, although the tumor dis-
resin. However, these are elaborate prostheses that take
appeared, perforation was observed in the soft palate,
time to fabricate. Shimodaira et al9 presented a slightly
resulting in a nasal-oral fistula. Implementing fistula
flexible silicone obturator made for the soft palate, but it
closure as an additional surgery did not result in
had limited mobility. The present clinical report describes
adequate closure. The patient then consulted a dentist for
a patient with a nasal-oral fistula after surgery of the soft
prosthodontic treatment 6 months after the second
palate, who was treated with a soft, movable, and flexible
otolaryngologic surgery.
obturator prosthesis.
The patient’s level of consciousness was clear
(Glasgow Coma Scale E1V1M1), and her dentition was
CLINICAL REPORT
intact. Fistula formation of approximately 8 mm in
A 64-year-old woman presented to Seirei Mikatahara diameter was observed in the left soft palate near the
General Hospital with a history of left soft palate hard palate, and there was hypernasality (Fig. 1). No

a
Senior investigator, Center for Development of Advanced Medicine for Dental and Oral Diseases, Japanese National Center for Geriatrics and Gerontology, Obu, Japan.
b
Section Chief, Department of Rehabilitation Medicine, Hamamatsu City Rehabilitation Hospital, Hamamatsu, Japan.
c
Hospital Director, Department of Rehabilitation Medicine, Hamamatsu City Rehabilitation Hospital, Hamamatsu, Japan.

THE JOURNAL OF PROSTHETIC DENTISTRY 1

2 Volume
Figure 1. Oral cavity showing oral-nasal fistula.
Figure 3. Prosthesis with soft obturator.
problems were noted with the movement and length of
the soft palate, and there was no elevation failure or
deviation. Endoscopic examination showed considerable
food reflux, especially water, from the oral cavity to the
nasal cavity through the fistula (Fig. 2). Therefore, the
patient had frequently to interrupt her food intake.
To physically occlude the fistula in the soft palate, an
obturator-type prosthesis was fabricated (Fig. 3). It con-
sisted of a palatal plate, 4 wire clasps, and a flexible
structure similar to a palatal lift, composed of soft silicone
(Sofreliner Medium Soft; Tokuyama Dental Corp), which
adhered to the acrylic resin palatal plate with a bonding
agent and several retention holes. Since part of the fistula
was in the soft palate and mobile, the obturator also
needed to have mobility. Therefore, the fabrication
method for a palatal lift prosthesis with a soft movable
and flexible lift was used as previously reported.10
An impression was made to include the defective part
of the soft palate, and a prosthesis was fabricated on the
definitive cast. To make an impression of the fistula, a
combination impression of putty and injection types
THE JOURNAL OF PROSTHETIC DENTISTRY
- Issue -
Figure 2. Endoscopy showing reflux of green tea through fistula. View
from nasal cavity.
Figure 4. Endoscopy from nasal side showing soft palate with obturator.
Saliva around obturator flowed before insertion of obturator.
(Exafine putty type, Examixfine injection type; GC Dental
Products) was used. Because of the difficulty and risk of
making an impression of a small fistula and the potential
for the impression material to dislodge, a silicone
impression material was used. Furthermore, the
impression was made by adjusting the amount so that
only a small amount of material flowed through the fis-
tula into the nasal cavity side of the soft palate. The
prosthesis was designed to clasp the maxillary left and
right first molar and the left and right first premolars. A
resin baseplate covered the posterior portion of the hard
palate. A structure similar to a palatal lift was added to
close the fistula of the soft palate. An obturator
Ohno et al
- 2017
Figure 5. Positional relationship between soft palate and obturator.
composed of silicone (Sofreliner Medium Soft; Tokuyama
Dental Corp) was attached to the lift. The obturator was
designed to enter the nostril slightly through the fistula
from the oral cavity (Figs. 4, 5). Therefore, the obturator
was able to move approximately 5 to 6 mm according to
the movement of the soft palate.
The application of this prosthesis resulted in the
complete disappearance of hypernasal speech and food
reflux. The subject was able to eat without particular
limitation during daytime wearing.
DISCUSSION
This clinical report describes a patient with a nasal-oral
fistula after surgery of the soft palate, who received a
soft obturator prosthesis to improve hypernasality and
dysphagia. The obturator was composed of a soft silicone
and had mobility. The desired effect was achieved clini-
cally and was confirmed by endoscopic examination.
Endoscopic examination was useful, and the effect of the
prosthesis was visually understood.11 A seal of the fistula
by the obturator was clearly observed through endo-
scopic examination (Fig. 2). In this patient, no problem
was observed with the movement and length of the soft
palate, and the hypernasality and oral-to-nasal reflux
was completely prevented by sealing only the fistula.
The movement of the soft palate during swallowing
and articulation is complex. The prosthesis should be
designed so that it does not disturb the movement of the
soft palate, unlike speech aids and speech bulbs that use
rigid acrylic resin or wire for the soft palate region.7-9
Although few prostheses with flexibility have been
described, silicone appears to be a suitable material for
fabricating prostheses for the soft palate.
Silicone, however, does deteriorate and needs to be
replaced periodically. Therefore, long-term follow-up is
Ohno et al
3
needed to evaluate for deterioration, such as debonding
of the extension from the main acrylic resin palatal plate.
In addition, since the fistula region of this patient was a
relatively closed hard palate with a small amount of
movement, the same effect might have been obtained if a
rigid resin had been used; however, ulceration might
have occurred. Although the fistula in this patient was
present in the soft palate closer to the hard palate, this
type of prosthesis may be more effective for patients with
a fistula closer to the caudal side.
SUMMARY
An intraoral prosthesis with a soft movable and flexible
obturator was provided for a patient with a soft palate
perforation after surgery and chemoradiotherapy for a
soft palate tumor. The application of this prosthesis
completely prevented hypernasality, and reflux of food
from the oral cavity to the nasal cavity. This type of
prosthesis therefore represents a prosthetic approach to
the treatment of a soft palate nasal-oral fistula.
REFERENCES
1. Olson ML, Shedd DP. Disability and rehabilitation in head and neck cancer
patients after treatment. Head Neck Surg 1978;1:52-8.
2. Barata LF, De Carvalho GB, Carrara-de Angelis E, De Faria JC, Kowalski LP.
Swallowing, speech and quality of life in patients undergoing resection of soft
palate. Eur Arch Otorhinolaryngol 2013;270:305-12.
3. Kornblith AB, Zlotolow IM, Gooen J, Huryn JM, Lerner T, Strong EW, et al.
Quality of life of maxillectomy patients using an obturator prosthesis. Head
Neck 1996;18:323-34.
4. Mishra N, Chand P, Singh RD. Two-piece denture-obturator prosthesis for a
patient with severe trismus: a new approach. J Indian Prosthodont Soc
2010;10:246-8.
5. Shyammohan A, Sreenivasulu D. Speech therapy with obturator. J Indian
Prosthodont Soc 2010;10:197-9.
6. Yalug S, Yazicioglu H. An alternative approach to fabricating a meatus
obturator prosthesis. J Oral Sci 2003;45:43-5.
7. Sato Y, Sato M, Yoshida K, Tsuru H. Palatal lift prostheses for edentulous
patients. J Prosthet Dent 1987;58:206-10.
8. Spratley MH, Chenerey HJ, Murdoch BE. A different design of palatal lift
appliance: review and case reports. Aust Dent J 1988;33:491-5.
9. Shimodaira K, Yoshida H, Mizukami M, Funakubo T. Obturator prosthesis
conforming to movement of the soft palate: a clinical report. J Prosthet Dent
1994;71:547-51.
10. Ohno T, Katagiri N, Fujishima I. Palatal lift prosthesis for bolus transport in a
patient with dysphagia: a clinical report. J Prosthet Dent 20 February 2017.
doi: 10.1016/j.jpor.2017.01.006. [Epub ahead of print.]
11. Amin BM, Aras MA, Chitre V, Rajagopal P. The role of nasendoscopy in the
fabrication of a palatopharyngeal obturator: a case report. J Clin Diagn Res
2014;8:12-4.
Corresponding author:
Dr Tomohisa Ohno
Center for Development of Advanced Medicine for Dental and Oral Diseases
Japanese National Center for Geriatrics and Gerontology
7-430 Morioka-cho
Obu-city, Aichi 474-8511
JAPAN
Email: tomohisa@ncgg.go.jp
Copyright © 2017 by the Editorial Council for The Journal of Prosthetic Dentistry.
THE JOURNAL OF PROSTHETIC DENTISTRY