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Prosthetic management of a total glossectomy defect after free flapreconstruction in an edentulous patient: A clinical report

Mark A. Pigno, DDS,a and Jeff J. Funk, BS, CDTb

The University of Texas Health Science Center at San Antonio, San Antonio, Texas

Total glossectomy with surgical reconstruction can result in a significantly altered mandibular archanatomy. In edentulous patients, lingual vestibules along with the mandibular alveolar ridge can be

obliterated. With the absence of lower anterior dentition, support of the lower lip is lost and tractionfrom surgical closure can cause the lower lip to collapse into the oral cavity. This report describes the

prosthetic treatment of an edentulous total glossectomy patient with an unconventional custom im-

pression procedure to develop and record proper lower lip and cheek support. It also discusses some

issues involved in the prosthetic management of the total glossectomy patient. (J Prosthet Dent 2003;

89:119-22.)

Oncologic management of advanced carcinoma ofthe tongue is a difficult medical problem that can create

serious treatment dilemmas.1 A total glossectomy withits associated morbidity may sometimes be the treat-ment of choice. Often criticized as a treatment optionbecause of the severe functional sequela, advances inreconstruction and rehabilitation techniques have im-proved functional outcomes in patients undergoing to-tal glossectomy.1-9 Contemporary surgical reconstruc-tion of total glossectomy defects usually involvesplacement of a musculocutaneous, microvascular freeflap to close the defect.8,9 Introduction of bulk into theflap to create a neotongue has been advocated by somesurgeons in an attempt to improve postoperative speech

and swallowing.8,9 Although flap placement is an effective method of

defect closure and may assist in postoperative speech andswallowing, it can obliterate the mandibular lingual ves-tibule and, possibly, most of the mandibular alveolarridge. In addition, if a patient undergoing glossectomyis edentulous or has missing mandibular anterior denti-tion, lower lip support can be significantly compro-mised. The lower lip can be tethered or collapsed intothe oral cavity, compounding postoperative problemswith appearance, speech, or lip competence. Prostheticmanagement of patients undergoing total glossectomy

with a collapsed lower lip and obliterated mandibularridge anatomy may require an unconventional customimpression procedure to accurately record the properlower lip and cheek position. Although several reports inthe literature describe prosthetic management of thepatient undergoing total glossectomy,10-21 few refer-ences describe prosthetic treatment of a patient aftercontemporary microvascular free flap surgical recon-struction of a total glossectomy defect.13,22 This clinical

report describes the prosthetic management of an eden-tulous patient who underwent a total glossectomy fol-

lowed by surgical reconstruction of the defect with amicrovascular free flap.

CLINICAL REPORT

A 57-year-old white man was referred to the maxillo-facial prosthetics clinic at The University of TexasHealth Science Center at San Antonio by his head andneck surgeon for evaluation concerning prosthetic treat-ment. He had a history of squamous cell carcinoma ofthe left base of the tongue that was classified as aT4N2M0 tumor by use of the tumor/lymph node/me-

tastases (TNM) classification system.23

The tumor wasinitially treated with a combination of chemotherapyand radiotherapy. After this initial treatment, the patientunderwent a total glossectomy without laryngectomyand bilateral modified neck dissections to remove theresidual tumor. The resulting defect was immediatelyreconstructed with a rectus abdominus microvascularfree flap. The rectus abdominus has a reduced musclecomponent and tendinous inscriptions that provide animproved purchase for suturing, which makes it a pre-ferred donor site for reconstruction of total glossectomydefects.9

The patient was totally edentulous. The resection andfree flap reconstruction had obliterated his mandibularridge and buccal/lingual vestibules (Fig. 1). The floor ofhis mouth was flattened with minimum bulk introducedfor creation of a neotongue. The reconstruction greatlyreduced his oropharyngeal opening. His lower lip col-lapsed back into the oral cavity, due to lack of supportand traction on the lower lip originating from surgicalclosure of the defect (Fig. 2). Speech was categorized asintelligible with careful listening by use of a previouslyintroduced speech rating scale.5 With an adaptive swal-low routine, the patient could slowly swallow a liquid orsemiliquid diet without aspiration with his head tiltedback. His reduced oropharyngeal opening decreased

aAssociate Professor and Director, Maxillofacial Prosthetics TertiaryCare Center, Department of Prosthodontics.

bMaxillofacial Prosthetics Technician and Manager, Dental SchoolLaboratory Services.

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swallowing speed, and his diet was supplemented with agastrostomy tube. He was undergoing therapy for im-provement of speech and swallowing before being seenfor prosthetic treatment. The patients chief complaintwas that the collapsed lower lip negatively affected hisfacial appearance and compromised his lip competence.

He was extremely motivated concerning prosthetictreatment. The planned treatment was fabrication of amandibular prosthesis and palatal augmentation pros-thesis. The mandibular prosthesis will be referred to as amandibular resection prosthesis, because the prosthesisserved to compensate for changes in the mandibulararch after resection of soft tissue intimately associatedwith the mandible.

Preliminary and final impressions were made of themaxillary arch with conventional prosthodontic proce-dures. Because of altered anatomy and the need to cap-ture the proper lower lip and cheek position, a prelimi-nary impression for fabrication of the mandibular

resection prosthesis was made with an interim soft liningmaterial (Tru-Soft; Harry J Bosworth Co, Skokie, Ill.)mixed to a thick consistency and adapted to the intraoralmandibular defect with gloved fingers lubricated withpetroleum jelly (Figs. 3 and 4). Placement in this man-ner allowed control of lip and cheek position. The pre-

liminary impression was made so that it was the approx-imate size and shape desired for the final mandibularprosthesis. A cast was poured with the preliminary im-pression, and a custom tray was fabricated that extendedonto the mucosal surfaces of the lower lip and cheekareas. Afinal impression was made with the custom trayusing light-bodied polysulfide impression material(Light-Bodied Permlastic; Kerr Corp, Orange, Calif.)(Fig. 5). The master cast was poured capturing the po-sition of the mucosal surfaces of the lower lip andcheeks. A processed trial base was fabricated for the glos-sectomy defect, and jaw relation records were made. Thevertical dimension of occlusion for the prosthetic treat-

Fig. 1. Intraoral view of free flap reconstructed glossectomydefect.

Fig. 2. Facial profile view of patient shows collapsed lowerlip.

Fig. 3. Manipulation of soft liner preliminary mandibularimpression in mouth to establish acceptable lower lip andcheek support.

Fig. 4. Soft liner preliminary impression of glossectomy de-fect.

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ment was reduced to minimize interference with adaptivespeech and swallowing patterns that the patient had devel-oped with flap-to-palate contact before prosthetic treat-ment. Because the mandibular ridge was obliterated, thedenture teeth for the mandibular prosthesis were arrangedon the processed trial base with the lower lip and cheekpositions recorded on the processed trial base, the recov-ered mandibular master cast, and the opposing maxillaryarch as guides (Fig. 6). It was particularly important toarrange the anterior mandibular denture teeth so thatproper lip support was established. A monoplane occlusalscheme was used to minimize lateral forces on the mandib-ular prosthesis during jaw movement.24,25

The palatal augmentation was developed onto themaxillary prosthesis at the wax try-in appointment afterapproval of esthetics and verification of the jaw relationrecords. The lingual contours of the mandibular pros-thesis were developed to guide liquid and semiliquidmaterial into the oropharyngeal opening (Fig. 7). Thepalatal augmentation prosthesis and mandibular resec-

tion prosthesis were completed and delivered. The pa-tient was very pleased with the esthetic improvementresulting from the lower lip support provided by themandibular prosthesis (Fig. 8). At the 1-week follow-upappointment, the patient requested removal of much ofthe palatal augmentation, because he stated it reducedthe volume of liquids that he was capable of holding inhis oral cavity and interfered with his adaptive swallowroutine. Reduction of the augmentation did not com-pletely resolve the patients swallowing problem, and hepreferred to remove the maxillary and mandibular pros-theses to swallow his liquid and semiliquid oral diet. Hewas able to maintain an adequate oral diet, and the gas-trostomy tube was removed. After 6 months of speechtherapy, his speech improved to being intelligible butnoticeably in error.5

SUMMARY

Particular consideration should be given to the pa-tients chief complaints when planning treatment for the

Fig. 5. Final impression of glossectomy defect records ac-ceptable lower lip and cheek support.

Fig. 6. Lateral view of tooth arrangement on articulator.

Fig. 7. Occlusal view of completed mandibular resectionprosthesis.

Fig. 8. Facial profile view of patient shows reestablishedlower lip support.

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glossectomy patient. A patient may best be able to ac-commodate to some dysfunction without prostheticsupport while desiring prosthetic treatment to help im-prove or correct other specific problems. The prostheticmanagement of an edentulous, microvascular free flapreconstructed, total glossectomy patient is described in

this report. The patients chief complaint of inadequatelower lip support was addressed with the use of a customimpression procedure to establish acceptable lower lipand cheek support in the final prosthesis.

REFERENCES

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Otolaryngol Head Neck Surg 1991;117:512-5.2. Krespi YP, Sisson GA. Reconstruction after total or subtotal glossectomy.

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TL, et al. Adaptive mechanisms of speech and swallowing after combinedjaw and tongue reconstruction in long-term survivors. Am J Surg 1987;

154:419-22.6. Sultan MR, Coleman JJ 3rd. Oncologic and functional considerations of

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9. Urken ML, Moscoso JF, Lawson W, Biller HF. A systematic approach tofunctional reconstruction of the oral cavity following partial and totalglossectomy. Arch Otolaryngol Head Neck Surg 1994;120:589-601.

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22. Beumer J, Marunick MT, Curtis TA, Roumanas E. Acquired defects of themandible: etiology, treatment, and rehabilitation. In: Beumer J, Curtis TA,

Marunick MT, editors. Maxillofacial rehabilitation: prosthodontic andsurgical considerations. Palmer, PA: Medico Dental Media InternationalInc.; 1996. p. 113-223.

23. American Joint Committee on Cancer. AJCC cancer staging manual. 5thed. Philadelphia: Lippincott-Raven Publishers; 1998. p. 31-9.

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on denture base deformation. J Prosthet Dent 1966;16:34-43.

Reprint requests to:DR MARK A PIGNO

THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT SAN ANTONIO

DEPARTMENT OF PROSTHODONTICS-7912

7703 FLOYD CURL DR

SAN ANTONIO, TX 78229-3900FAX: (210) 567-6758

E-MAIL: pigno@uthscsa.edu

Copyright 2003 by The Editorial Council of The Journal of Prosthetic

Dentistry.0022-3913/2003/$30.00 0

doi:10.1067/mpr.2003.22

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