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Soft obturator prosthesis for postoperative soft palate carcinoma: A clinical report
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 hypernasality and food reflux, and the patient was able to eat without particular limitation during oral cavity to the nasal cavity daytime wearing. This type of prosthesis represents a potential prosthetic approach to a soft palate becomes a significant issue in 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 stimulairradiated, 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 disresin. 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 diameter was observed in the left soft palate near the A 64-year-old woman presented to Seirei Mikatahara hard palate, and there was hypernasality (Fig. 1). No General Hospital with a history of left soft palate
a
Senior investigator, Center for Development of Advanced Medicine for Dental and Oral Diseases, Japanese National Center for Geriatrics and Gerontology, Obu, Japan. 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. b
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Figure 1. Oral cavity showing oral-nasal fistula. Figure 2. Endoscopy showing reflux of green tea through fistula. View from nasal cavity.
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 consisted 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
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 fistula 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
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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 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 clinically 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 endoscopic 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
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: [email protected] Copyright © 2017 by the Editorial Council for The Journal of Prosthetic Dentistry.
THE JOURNAL OF PROSTHETIC DENTISTRY
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 hypernasality and food reflux, and the patient was able to eat without particular limitation during oral cavity to the nasal cavity daytime wearing. This type of prosthesis represents a potential prosthetic approach to a soft palate becomes a significant issue in 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 stimulairradiated, 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 disresin. 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 diameter was observed in the left soft palate near the A 64-year-old woman presented to Seirei Mikatahara hard palate, and there was hypernasality (Fig. 1). No General Hospital with a history of left soft palate
a
Senior investigator, Center for Development of Advanced Medicine for Dental and Oral Diseases, Japanese National Center for Geriatrics and Gerontology, Obu, Japan. 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. b
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Figure 1. Oral cavity showing oral-nasal fistula. Figure 2. Endoscopy showing reflux of green tea through fistula. View from nasal cavity.
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 consisted 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
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 fistula 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
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 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 clinically 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 endoscopic 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
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: [email protected] Copyright © 2017 by the Editorial Council for The Journal of Prosthetic Dentistry.
THE JOURNAL OF PROSTHETIC DENTISTRY