DOI: 10.7860/JCDR/2016/15868.

7184
Review Article

Rehabilitation of Glossectomy
Dentistry Section

Cases with Tongue Prosthesis:

A Literature Review
Muthu kumar Balasubramaniam1, Ahila Singaravel Chidambaranathan2, Gokul Shanmugam3, rajdeep tah4

ABSTRACT
Tongue is the only movable muscular organ without any bone in the human body. It has very important role in perception of taste and
sensations like touch, pressure, heat and cold. The purpose of the article is to review various types of tongue prosthesis and their clinical
applications. This review helps the clinician to choose the appropriate type of tongue prosthesis for different clinical situations, retention
of tongue prosthesis and material selection for each type of prosthesis. A broad search of published literature was performed using the
keyword glossectomy, glossal prosthesis and tongue prosthesis from 1980 to 2014 in Medline, Google scholar, internet and text book.
This review gives basic knowledge of glossal prosthesis and selection of the same for various clinical conditions.

Keywords: Glossal prosthesis, Palatal augmentation prosthesis, Speech appliance

Introduction production. It also restricts air flow to produce consonants such as

Patient’s whose floor of the mouth has been resected usually k,g,t,d,s and z [3].
undergo immediate reconstruction with local flap, skin graft, distant
flap or micro vascular free tissue transfer. Although the shape of Tongue Size
the tongue can be more or less built. Its movement is restricted Classification according to House [6]
by defects of the body or frenum, attachment of the flap, residual Class 1: Normal in size, development, and function. Sufficient teeth
tongue or postoperative scar ring. Each of these restrictions results are present to maintain normal form and function.
in dysfunction of mastication, deglutition and speech [1]. Class 2: Teeth have been absent long enough to permit a change
Mastication aids by directly crushing the food against the rugae of in the form and function of the tongue.
the hard palate. The muscles of the cheek and tongue control the Class 3: Excessively large tongue, all teeth have been absent for an
food bolus by repositioning it onto the occlusal surfaces after each extended period of time, allowing for abnormal development of the
chewing stroke, after that, saliva mixes into the bolus [2]. Sensory size of the tongue. Improper denture contour sometimes can lead
nerve endings in the tongue help distinguish the texture and to development of a class 3 tongue.
consistency of the food. When the bolus is ready for swallowing,
the tongue helps in debridement of food in the buccal vestibule and
Tongue Position
the floor of the mouth [3].
Swallowing is composed of three stages: oral, pharyngeal and Classification according to Wright [6]
oesophageal. The oral phase is under voluntary neuromuscular Normal: The tongue fills the floor of the mouth and is confined
control and the later two phases are under involuntary neuromuscular within the mandibular teeth. The lateral borders rest on the occlusal
control [4]. During the oral phase of deglutition, the tongue gathers surfaces of the posterior teeth and the apex rests on the incisal
food into a bolus and positions the bolus between the dorsum of edges of the anterior teeth.
the tongue and the hard palate. As the middle tongue and palate Class 1: Retracted: The tongue is retracted. The floor of the mouth
contacts, the soft palate elevates in combination with the lateral is pulled downward and is exposed back to the molar area. The
and posterior pharyngeal walls forming a closed seal between the lateral borders are raised above the occlusal plane and the apex is
oral and nasal cavity. Thus for deglutition, the anterior two thirds pulled down into the floor of the mouth.
of the tongue is critical at the initial phase of deglutition, while the
Class 2: Retracted: The tongue is very tense and pulled backward
posterior one third plays an important role in generating negative
and upward. The apex is pulled back into the body of the tongue and
pressure to push the bolus of food down the alimentary canal [5].
it almost disappears. The lateral borders rest above the mandibular
In the subsequent pharyngeal stage, as the bolus moves inferiorly occlusal plane. The floor of the mouth is raised and tense.
from the base of the tongue, continual palatopharyngeal closure
Class 3: When tongue is low in relation to mandibular ridge crest
prevents food from the entering the nasopharynx. Next, elevation of
or retarded in relation to anterior ridge, retention of the mandibular
the larynx towards the base of the tongue is accomplished by the
denture will be poor.
suprahyoid musculature. This is followed by closure of the larynx by
inferoposterior rotation of the epiglottis. This is a laryngopharyngeal
protective mechanism to prevent aspiration during swallowing.
Investigation
Articulatory function after glossectomy has been evaluated by means
A finite period of apnea must necessarily take place with each
of dynamic palatography. The dynamic palatograph is an electronic
swallow. Relating deglutition to respiration, deglutition most often
apparatus that generate a visual display of constantly changing
occurs during expiration and includes a period of apnea ranging
linguo-palatal sounds as a function of time using an artificial palatal
from 0.3- 2.5 seconds [4].
plate with affixed electrodes. Palatography can examine whether
The tongue is the major component modulating air to create tongue contacts the palate or not at measuring point [7]. The glossal
speech. The tongue shapes the oral and pharyngeal cavity for vowel sounds which are one of the misheard sounds in glossectomy
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patients categorised into three types by type of articulation, stop

plosive, affricate and fricative. These sounds cannot be evaluated
by observing simply whether not the tongue contacts the palate.
Therefore, to assist with the rehabilitation of glossectomy patients,
it is necessary to evaluate objectively the degree of linguo-palatal
contact [8].
Wax trial and patient’s speech was assessed with the help of Dr.
Speech Software Version 4 (Tiger DRS, Inc., Seattle). This software
allows the user to record, analyze and display the acoustic signals.
The programme will automatically compute statistical information [Table/Fig-4]: Partial denture with
[Table/Fig-3]: Guiding flange. palatal augmentation prosthesis.
and plot a voice profile from sustained vowel and continuous
speech. This is an objective, non-invasive method to evaluate
production. The tongue for swallowing is made with a trough in the
acoustic signals [9].
posterior aspect to guide the food bolus into the oro-pharynx [10].
Defect Classification with Treatment Option
3. Partially edentulous with partial glossectomy
Tongue (glossal) defects can be classified into partial or total.
Factors influencing the prognosis of restoring the tongue with
involving anterior part of the tongue.
Treatment: Maxillary partial denture with palatal augmentation [12].
prosthesis depend upon the presence or absence of teeth and
the type of procedure that is combined with the glossectomy (e.g.,
mandibulectomy, palatectomy, radiation therapy). Patients with 4. Dentulous patient with segmental resection of
partial glossectomy (i.e., < 50% of tongue removed) suffer minimal mandible and resection of lateral part of the tongue.
functional impairment and require no prosthesis. Removal of more Treatment: Maxillary partial denture with palatal augmentation
than 50% of the tongue requires rehabilitation with either palatal prosthesis and mandibular cast partial denture obturating the defect
or lingual augmentation prosthesis. Total glossectomy create a with a guiding flange [Table/Fig-3,4]. The guidance flange for the
large oral cavity, loss of speech, and pooling of saliva and liquid. mandibular framework was designed to extend upto the non-defect
Patients with a total glossectomy require a total glossal prosthesis. side [13].
In dentulous patients, the glossal prosthesis can be attached to the Types of tongue prosthesis based upon the function
mandibular teeth through a lower partial denture [2]. A. Single piece tongue
On reviewing the literature, the following various clinical scenarios 1. Tongue prosthesis for swallowing.
were identified and treated with different types of tongue prosthesis.
2. Tongue prosthesis for speech.

1. Completely edentulous with total glossectomy [10] In edentulous patients, tongue prosthesis can be retained to either
Treatment: Mandibular denture lingual flange extending over the floor a mandibular or maxillary denture. Common problems associated
of the mouth with a mushroom with tongue prosthesis include lack of salivary control and loss of
shaped button attached to it on ability to maneuver food from the buccal vestibule. Therefore, it is
which, the silicon tongue can best to fabricate two prosthetic tongues, one for swallowing and 1
be placed [Table/Fig-1]. After a for speech [14].
total glossectomy the floor of A typical prosthetic tongue for speech is flat with wide anterior
the mouth becomes concave. elevation, which aids in articulation of linguo-alveolar sounds
Two prosthetic tongues can be (e.g., /t/, /d/). It also has a posterior elevation, which aids in
made, one for phonetics and the production of posterior linguo-
other for swallowing. The tongue alveolar sounds (e.g., /k/, /g/)
made for phonetics is somewhat and helps to shape the oral
flat, with a slightly wide anterior [Table/Fig-1]: Tongue prosthesis for cavity for improved vowel
elevation to aid in articulation of swallowing. productions [14].
linguo-alveolar sounds `t` and `d` The tongue prosthesis made
and to aid in shaping the oral cavity for improved vowel production. for swallowing had a trough in
The tongue for swallowing is made with a trough in the posterior its posterior slope to guide the [Table/Fig-5]: Tip of the tongue pros­
aspect to guide the food bolus entery into the oropharynx. food bolus into the oropharynx. thesis (silicone).
A speech pathologist and a
2. Completely edentulous with total glossectomy and dietitian should monitor the
hemi-mandibulectomy. patients who have had a glossectomy [14] [Table/Fig-5].
Treatment 1: Mandible is reconstructed with bone graft and B. Two piece tongue
rehabilitated with implant retained
Impressions are made with alginate using a maxillary tray for
overdenture is made with tongue
mandibular arch in order to record the floor of the mouth properly.
prosthesis [11]. [Table/Fig-2].
The base of the mandibular denture extends over the floor of the
Treatment 2: Maxillary complete
denture and mandibular complete
denture with guiding flange which
will close the defect [Table/Fig-3].
Loss of continuity of the mandible
affects the balance of the lower
face and leads to deviation of
the residual segment toward the
resected side to aid in shaping [Table/Fig-2]: Tongue prosthesis for
speech. [Table/Fig-6]: Mushroom type retention; [Table/Fig-7]: Tongue prosthesis.
the oral cavity for improved vowel

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Silicone
Long chain molecules composed of alternating chain of silicone and
oxygen atoms. The extraordinary properties of silicones are due
to the special characteristics of the silicon oxygen bonds in their
backbone. Because the silicon oxygen bond is much stronger than
the carbon-carbon bond of organic polymers, silicones make better
electric insulators and are more resistant to oxidation. Two types of
silicone are RTV and HTV (According to vulcanising temperature)
[Table/Fig-8]: Maxillary denture with palatal augmentation prosthesis; [18].
[Table/Fig-9]: Mandibular denture with wax pattern.
RTV – Silicone (Silastic 382, Silastic 399)
mouth. A “mushroom like” button is made on the mandibular They set by condensation polymerisation in which stannous
prosthesis so that a silicone tongue can be placed over it [10] octate is the catalyst; Ortho-alkyl Silicate is cross linking agent.
[Table/Fig-6,7]. The advantages are, allows intrinsic colouration, easy handling,
C. Prosthesis Attached to Maxillary Denture-Palatal Augmentation quick processing, good thermal and colour stability and inert. The
Prosthesis disadvantages are they have weak edge strength, zipper effect,
The Palatal Augmentation Prosthesis (PAP) has been defined by the poor tear strength, high specific gravity, stiff, poor wettability [19].
Glossary of Prosthodontic Terms as a palatal prosthesis that allows
reshaping of the hard palate to improve tongue/palate contact Silicone (MDX 4-4210)
during speech and swallowing because of impaired tongue mobility Most commonly used material for maxillofacial prosthesis. It
as a result of surgery, trauma, or neurologic/motor deficits [15]. The requires heat for vulcanization. It is highly viscous, white and
palatal augmentation prosthesis is used to restore impaired speech opaque. It is available as one or two component in which platinum
and swallowing in glossectomy [Table/Fig-8] patients by artificially salts (for addition polymerisation) and Hydro-methylsiloxane for
lowering the palatal vault to provide contact between the remaining cross-linking. It requires advanced equipment for processing and
tongue and the palatal contours [15]. The function of the residual it has better physical properties. It exhibits improved qualities
tongue is recorded with softened modeling compound. The patient relating to colouration and edge strength, not heavily filled, making
is asked to repeat the linguo-velar sounds and the linguo-alveolar. it translucent, increased elongation and resistant to tear. Surface
The compound gets moulded accordingly and then the denture is characterization can be achieved with pigments immersed in a silicon
processed. Modification if acceptable speech articulation is attained adhesive. Superior cosmetic results are achieved with this material.
for most elements of speech except the linguo-alveolar fricatives The advantages are excellent thermal stability, colour stablity with
`s` and `t`, for which another modification can be done. A narrow, UV, superior strength, biologically inert, polychromatic and it has
sharp groove carved in the midline of the palatal prosthesis can, by good tear strength. The disadvantages are low edge strength, poor
directing the air stream, improve the production of these sounds wettability, low elasticity, require two roll milling machine for intrinsic
[16]. colouring and metal molds for processing. Also, extrinsic colouring
is difficult [20].
Techniques [17] The material used to fabricate tongue prosthesis is silicone
Wax up for the tongue prosthesis was done on the auto-polymerized which. has several advantages. (i) single component, (ii) ready to
acrylic resin record bases, which was done like the shape of a tongue use, (iii) eliminating mixing errors, (iv) easy processing, (v) can be
that conforms to oral cavity dimensions with rounded edges [Table/ polymerized simultaneously with acrylic, (vi) stands the influences of
Fig-9]. The tongue tip was arched downwards to approximately a oral environment without deterioration, (vii) non-irritant (viii) odourless
15-degree angle, and the entire pattern was then arched slightly and tasteless [2].
to form the highest point at the anterior one third of the tongue.
Wax pattern was then folded to form a wide central V-shaped angle Discussion
(approximately 160 degrees). The thickness of the wax was reduced Tongue is the major articulator during the production of all
4 to 5mm at the base and the posterior two thirds of the tongue. phonemes except bilabial, labio-dentals and glottal sounds. Tongue
movements modify the shape of the oral cavity and change the
Materials Used for Tongue Prosthesis resonance characteristics that produce different consonants [2]. The
coordination of the muscle and nerve is impaired in glossectomy
Acrylic Resin patients even after reconstruction by flap [21].
Polymethylmethacrylate (PMMA) resin is the material of choice in When a patient undergoes a partial on total glossectomy, the ability
the past. It is easy to work with acrylic resin and it is, hygienic, to masticate, swallow and formulate vowels and consonants for
durable and easily matches to skin colour. It has many advantages speech sounds is dramatically altered. The size, location and extent
like, intrinsic and extrinsic colouration can be done easily with of the defect affect the degree of disability to swallow or speak. The
acrylic resin. Strength of this is material is high compared to areas of surgical resection that affects function of the tongue include
silicone. Alterations can be easily done and compatible with most removal of the anterior tip of the tongue, lateral (partial) glossectomy,
adhesive systems, heat PMMA preferred over the auto polymerizing removal of the base of the tongue and total glossectomy [22]. Moore
PMMA (Presence of free toxic tertiary amines). The colour stability (1972) suggested that tongue prosthesis as the treatment of choice
when exposed to UV light is better in heat polymerized resin. in total glossectomy. This approach seldom restores the function of
Also, it remains serviceable for up to two years. Surface colour speech and small; it is mostly cosmesis [23].
applications can be easily done and lasts for longer periods. It has
Artificial tongue prosthesis may be either hard or resilient acrylic
some disadvantages like rigidity, cannot be used in movable tissue
which is attached to the lower denture base, which covers the
beds which leads to local discomfort and exposure of margins and
alveolar ridge as well as floor of the mouth. The artificial tongue is
high thermal conductivity which may precipitate discomfort in cold
designed such a way that the dorsum of the anterior two third of
climates. Duplication of the prostheses is not possible because
the tongue conforms to the anterior part of the palate and comes in
removal of prosthesis is possible only after destruction of the mold
contact with the palate when the teeth are brought into occlusion.
[18].
The posterior one third of the tongue is designed to act as a funnel,

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PARTICULARS OF CONTRIBUTORS:
1. Professor and Head of Deptartment, Deptartment of Prosthodontics, SRM Dental College, Ramapuram, Chennai, India.
2. Reader, Deptartment of Prosthodontics, SRM Dental College, Ramapuram, Chennai, India.
3. Post Graduate Student, Deptartment of Prosthodontics, SRM Dental College, Ramapuram, Chennai, India.
4. Post Graduate Student, SRM Dental College, Ramapuram, Chennai, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Ahila Singaravel Chidambaranathan,
Date of Submission: Jul 23, 2015
Reader, SRM Dental College, Ramapuram, Chennai-89, India.
Date of Peer Review: Aug 05, 2015
E-mail: [email protected]
Date of Acceptance: Oct 27, 2015
Financial OR OTHER COMPETING INTERESTS: None. Date of Publishing: Feb 01, 2016

4 Journal of Clinical and Diagnostic Research. 2016 Feb, Vol-10(2): ZE01-ZE04