PALATAL

AUGMENTATION
PROSTHESIS
1
INTRODUCTION
◦ Swallowing function, in humans, is very complex.

◦ Swallowing plays, not only an important role in food digestion, but also a
major role in preventing the entrance of food and/or other materials into the
lower respiratory tract.

◦ To achieve this, precise coordination is necessary between breathing and

swallowing since the pharynx serves as a common pathway for both respiration
and digestion.

2
 The physical and gustative
properties of the bolus

masticatory and swallowing

central pattern generators (CPGs)

swallow threshold is crossed and

the bolus passes from the mouth.

◦ Tongue movements play an important role in wide range of functional and

developmental fields, including craniofacial development, mastication,
swallowing, texture appreciation, dysphagia and phonetics.
3
◦ The anterior two thirds of the tongue is critical at the initial phase of deglutition,
while the posterior one third plays an important role in generating negative
pressure to push the bolus of food down the alimentary canal.

4
◦ Hiroshi Saito and Ichizoh Itoh conducted a study on the function of the intrinsic
muscles of the tongue by studying the three-dimensional architecture of the
longitudinal muscle.

◦ In the longitudinal muscle of the tongue, muscle bundles running in the

anteroposterior direction were arranged at regular intervals.

◦ The transverse and vertical muscles of the tongue entered this mesh-like structure
of muscle bundles of the longitudinal muscle as flat muscle bundles.

5
 The transverse and vertical muscles showed no ramification in the center of the
tongue, where there is no longitudinal muscle.

◦ These results suggest that the three intrinsic muscles of the tongue are
interlaced with one another and are bound tightly in the longitudinal muscle.

◦ This structure may enable the dorsum of the tongue to harden for pressing food
during mastication and shifting the food posteriorly for swallowing.

Hiroshi Saito and Ichizoh Itoh ,Three-dimensional architecture of the intrinsic tongue muscles, particularly
the longitudinal muscle, by the chemical-maceration method. Anatomical Science International (2003) 78,
168–176
6
◦ In 1990, Dodds et al., using sagittal and coronal views of the oral cavity noted
that during the oral phase of swallowing, the bolus is located within a spoon-
like depression of the mid-tongue.

◦ Concurrently the posterior tongue is elevated and a seal is formed with the soft
palate to prevent premature entry of the bolus into the unprepared pharynx.

◦ The anterior two-thirds of the tongue now elevates and rolls back posteriorly in
a piston like manner, effectively forcing the bolus into the oropharynx. This
study was purely descriptive of tongue shape and bolus position.

7
◦ JA Kieser, MG Farland, H Jack, M Farella, Y Wang, O Rohrle has conducted a
study on the role of oral soft tissues in swallowing function and tongue
pressure, thus uncovered highly variable individual pressure patterns during
swallowing, which can nonetheless be divided into four stages:

70kpa Preparatory Primary Propulsive Intermediate Terminal

(1)preparation and containment of the
bolus;
(2) primary pressure wave;
(3) intermediate pressure gradient from
25kpa
the anterior and lateral margins of the
tongue towards the midline, followed by a
sequential, secondary rostro-caudal
midline pressure wave; and
(4) terminal return to pre-swallowing
Anterior Posterior Right Posterior left posterior
midpalatine Right Anterior Left Anterior
pressure.
JA Kieser, MG Farland, H Jack, M Farella, Y Wang, O Rohrle The role of oral soft tissues in swallowing function: what
8
can tongue pressure tell us? Australian Dental Journal 2014; 59:(1 Suppl): 155–161
◦ Disruption of normal swallowing, referred to as dysphagia, is frequently
associated with neurological disorders such as cerebrovascular accidents,
cerebral palsy and Parkinson’s disease.

◦ Dysphagia can prove fatal and often requires extensive rehabilitation.

◦ Dysphagia is a common occurrence in patients with tongue cancer, and its

treatment has been demonstrated to have significant influence on the function
of the tongue during swallowing. In addition, there are consequences on the
physical and mental condition of patients and it reduces their quality of life.

9
◦ Patients with oral and oropharyngeal cancer are usually treated with surgery,
radiotherapy, and chemotherapy, administered alone or in combination.

◦ The main post-radiotherapy sequelae are mucositis, xerostomia, dysgeusia,

hoarseness, fibrosis and osteonecrosis. Difficulties with speech, mastication
and swallowing are also produced.

◦ Chemotherapeutic agents for head and neck cancer (HNC) can impact the
ability of patients to swallow thus causing nutritional problems.

10
◦ Complete or partial glossectomy results in morbidity related to speech and
deglutition, due to altered residual tongue volume and mobility.
◦ The treatment options may include:
Modified dental prosthesis
Speech therapy
Oral exercises.
◦ Several types of prosthesis have been described to improve speech and
swallowing in glossectomized patient. Their main function is to reshape the
oral cavity, or to reduce its size, so that residual tongue can function more
effectively in its oropharyngeal environment.

11
PALATAL AUGMENTATION PROSTHESIS
◦ A removable maxillofacial prosthesis that alters the hard and/ or soft palate’ s
topographical form adjacent to the tongue; it allows reshaping of the hard
palate to improve tongue/ palate contact during speech and swallowing to
compensate for impaired tongue mobility as a result of surgery, trauma, or
neurological or motor deficits. (GPT-9)

12
◦ ADVANTAGES:
◦ PAP are used to model and lower the palatal vault to offer new contact for the
remaining portion of the resected tongue. Thus, the patients can performed the
functions of swallowing and speech.
◦ Thus decreases dysphagia and dysarthria.

◦ DISADVANTAGES:
◦ Palatal augmentation prosthesis is bulky and often difficult to adjust.

13
Case report: 01

Prosthodontic rehabilitation of completely edentulous patient

with partial glossectomy

◦ A 65-year-old male patient reported with the chief complaint of difficulty in

chewing due to missing teeth in upper and lower arches and impaired speech
due to partial resection of the tongue along the left lateral border following the
surgery.

◦ The patient had been diagnosed with squamous cell carcinoma involving the
left lateral border of the tongue 2 years back. The patient had type II diabetes
since last 20 years and was under medication.

14
GENERAL EXAMINATION:

◦ Collapse of lip and cheek on the left side of the face, due to lack of support of
the musculature.

INTRAORAL EXAMINATION:

◦ The tongue was compromised with resected left lateral border, flaccid, with
altered posture, and restricted movements.

15
Maxillary arch with well-developed residual alveolar ridge and mandibular arch
with severely resorbed residual alveolar ridge. The lingual sulcus was almost
completely lost on the resected side.

◦ The floor of the mouth was also compromised with musculature partially
covering the mandibular residual alveolar ridge on the left posterior region.
16
◦ The treatment plan included maxillary and mandibular complete dentures,
using a special impression technique for mandibular arch and modified
occlusal scheme.

◦ The mandibular metal stock tray was beaded using impression compound and
was extended properly for recording the residual alveolar ridge and associated
tissues, and then tray was loaded with an admix of impression compound and
tracing compound in ratio of 3:7.

◦ Lingualized occlusion.

17
Palatal augmentation of maxillary denture
◦ The maxillary denture was modified after acrylization by palatal augmentation.
◦ Functional palatal impression technique was followed, whereby modelling
compound was softened and added to the maxillary denture on the left side.

18
◦ The patient was instructed to functionally manipulate the modelling compound
with the tongue by repeating the lingual alveolar sounds /k/and/g/for the
posterior palatal tracing, and the lingual alveolar sounds/t/and/d/for the anterior
palatal tracing.

◦ This enabled the tongue to make palatal articulations.

◦ Additional compound was added to the anterior palatal region, allowing the
mandibular anterior teeth to indent into the compound.

19
◦ This resulted in a significant improvement for the fricative and affricative
(hard) palatal lingual sounds /s/sh/z/zh/.

◦ For tracing the swallowing patterns, patient was asked to swallow blenderized,
soft diet. A proper balance was made between speech and swallowing tracings,
making sure that none of them is restricted.

◦ The patient was able to communicate and swallow effectively. The entire
traced area is processed with heat cure acrylic resin.

Garg A. Prosthodontic rehabilitation of completely edentulous patient with

partial glossectomy. J Indian Prosthodont Soc 2016;16:204-7.
20
◦ Case report- 02
◦ Palatal Drop Augmentation and Tongue Prosthesis: A case
report.

◦ A 31 year old male patient was operated for gunshot

trauma in body of mandible followed by reconstruction and
now reported for prosthetic rehabilitation.

◦ To improve swallowing by creating negative pressure,

tongue and palatal drop prosthesis can be fabricated.

◦ Clasps were given on 35 and 47 and 36 was replaced with

denture tooth. Tongue prosthesis sculpted in wax attached
to wire clasp retained lower base plate.
21
PALATAL DROP AUGMENTATION PROSTHESIS:
◦ Self cure acrylic resin is poured in upper cast to form base
plate.

◦ Wire clasps were given on upper premolars 15 and 25 and

palatal drop was sculpted in pink baseplate wax.

◦ At the wax try in appointment swallowing, speech,

mastication were checked.

◦ Patient was asked to repeat linguoalveolar sounds e, g, k for

posterior palatal tracing and t, d for anterior palatal tracing.

22
◦ Pressure indicating paste was used between two prosthesis. Tongue
prosthesis in place patient found immediate improvement in resonance and
quality of his voice.
◦ Wax tracing was inspected and wax adjusted to ensure passive contact with
the floor of mouth during functional movements. Areas of contact between
two prosthesis were glossy indicating contact was made.

MOLD PREPARATION:

◦ Silicon prosthesis of tongue and palatal augmentation prosthesis were

packed in two piece flasks.
◦ Flasking

23
◦ Epicon 5 was applied with brush to promote bonding of acrylic to silicon.
◦ Obturasil 40 was injected in thin layers around lower base plate and on upper
mold.
◦ After polymerisation prosthesis were deflasked from molds.
◦ Both the palatal drop and tongue prosthesis allowed the patient to increase the
capacity to swallow and reduce the space but the speech could not be restored
to full extent.

◦ Dr. Nafij Bin Jamayet et al, Palatal Drop Augmentation and Tongue Prosthesis:
A case report. City Dent. Coll. J Volume-10, Number-1, January-2013
24
Case report: 03
Different Techniques for Palatal Augmentation in Partially Glossectomized
Patients. A Report of Two Cases
◦ A 31-year-old Chinese male reported to the department
for maxillary and mandibular complete dentures.
◦ The patient was operated on the right side border of the
tongue to eradicate a squamous cell carcinoma(SCC)
lump.
◦ He underwent hemiglossectomy with right radical and
left functional neck dissection and reconstruction with
radial forearm flap about 2 years back.

25
◦ The denture was issued and patient was instructed to
use it for 1-2 weeks before palatal augmentation was
done.
◦ Functional impression technique with tissue
conditioning material was added layer by layer to
the palatal part of the denture and the patient was
asked to swallow several times and pronounce some
letters or phonemes (T, and D).
◦ Tissue conditioning material was replaced with heat
polymerized acrylic resin.

26
27
◦ A 72-year-old Chinese man complaints regarding the inability to masticate the
food, speech problems, xerostomia, and swallowing difficulty.

Extra oral examination: symmetrical face with postsurgical scarring on the

neck.
◦ The lips were competent.
◦ The skeletal profile was class I.
◦ The maximum mouth opening was normal.

28
Intraoral examination:
◦ The maxillary arch was Class III Kennedy classification with two modifications.
◦ Mandibular arch was Class II with one modification.

◦ During the issuing time of dentures, a palatal augmentation was done for the
maxillary denture using a layer after layer of softened modeling wax until the
patient experienced ease in swallowing using water for testing.

◦ A hallow augmentation palate was constructed to reduce the weight of the denture.

◦ Abdulhadi LM (2012) Different Techniques for Palatal Augmentation in Partially Glossectomized

Patients. A Report of Two Cases. Scientific reports. Vol. 1(8); 391, 2012.

29
Case report: 04
◦ Effects of palatal augmentation prosthesis in oropharyngeal dysphagia in Chilean
patients with tongue cancer: Case report
◦ A 61-year-old man had been diagnosed with squamous cell carcinoma (SCC) of
the base of the tongue (T3N2cMO).
◦ Surgery with bilateral neck dissection was performed, followed by Radiotherapy
and Chemotherapy.
◦ Xerostomia, trismus, dysphonia and osteomyelitis were post treatment
complications.

30
◦ Intraoral examination : Partially edentulous non-denture wearer.
◦ In the swallowing evaluation,
a mild degree of oropharyngeal dysphagia (OPD),
movement of neck when swallowing, nasal regurgitation,
escape of food out the mouth, increased oral transit times,
presence of cough, as well as liquid and paste oral and pharyngeal
residues.

◦ PAP and RPD were fabricated.

Ana María Contreras, Alejandra Martínez, Ricardo Alarcón, Vinka Devcic, Alfonso Catalán. Effects of
palatal augmentation prosthesis in oropharyngeal dysphagia in Chilean patients with tongue cancer: Cases
report.

31
CONCLUSION:
Palatal Augmentation prosthesis is beneficial for the rehabilitation after
glossectomy of patients with head and neck cancer.
Its use enables patients to perform compensatory movements of the tongue in
relation to the surrounding structures, movements that are essential for
articulation and the oral preparatory and oral phases of deglutition.
The prosthesis is an important aid for articulatory and deglutatory rehabilitation,
a continuous process that requires the combined efforts of the speech and
swallowing pathologist, the prosthodontist, and the nutritionist, as well as the
surgeon.

32
REFERENCES:
◦ Hiroshi Saito and Ichizoh Itoh ,Three-dimensional architecture of the intrinsic tongue muscles,
particularly the longitudinal muscle, by the chemical-maceration method. Anatomical Science
International (2003) 78, 168–176
◦ JA Kieser, MG Farland, H Jack, M Farella, Y Wang, O Rohrle The role of oral soft tissues in swallowing
function: what can tongue pressure tell us? Australian Dental Journal 2014; 59:(1 Suppl): 155–161
◦ Garg A. Prosthodontic rehabilitation of completely edentulous patient with partial glossectomy. J Indian
Prosthodont Soc 2016;16:204-7.
◦ Dr. Nafij Bin Jamayet et al, Palatal Drop Augmentation and Tongue Prosthesis: A case report. City Dent.
Coll. J Volume-10, Number-1, January-2013
◦ Abdulhadi LM (2012) Different Techniques for Palatal Augmentation in Partially Glossectomized
Patients. A Report of Two Cases. Scientific reports. Vol. 1(8); 391, 2012.
◦ Ana María Contreras, Alejandra Martínez, Ricardo Alarcón, Vinka Devcic, Alfonso Catalán. Effects of
palatal augmentation prosthesis in oropharyngeal dysphagia in Chilean patients with tongue cancer:
Cases report.

33
34