Palatal Lift Prosthesis - Surgical Alternatives To Palatal Lift Prostheses

Surgical Alternatives To Palatal Lift Prostheses

Several scenarios serve to contraindicate the fabrication of palatal lift prostheses or discourage their use. The physical management of palatopharyngeal incompetence by way of a palatal lift prosthesis might not be well tolerated by patients with strong gag reflexes. Edentulous patients or partially edentulous patients without a sufficient number of dental abutments cannot predictably retain palatal lift prostheses. Dentoalveolar growth and development, pediatric dental exfoliation, and exodontia secondary to periodontitis, carious lesions, other pathoses, or trauma can necessitate the fabrication of successive palatal lift prostheses that may be deemed too costly and/or time consuming. As such, surgical tactics aimed at mitigating palatopharyngeal incompetence can be employed as a substitute to its prosthetic management. Conversely, prosthetic palatopharyngeal incompetence management can offer a favorable substitute to surgical management when surgical contraindications are encountered.

Pharyngeal Flap Surgery

The superiorly based or inferiorly based pharyngeal flap surgical procedure offers an alternative to the fabrication of a palatal lift prosthesis. A pharyngeal flap surgery unites the posterior pharyngeal wall and the soft palate to definitively occlude the midsagittal aspect of the palatopharyngeal port while bilaterally maintaining patencies between the nasopharynx and oropharynx to facilitate nasal respiration and resonance during the production of nasal phonemes. Since surgical management generally eliminates the need for a palatal lift prosthesis and its incumbent disadvantages, the pharyngeal flap surgical procedure is often favored as a first option for addressing palatopharyngeal incompetence. Nevertheless, patients with minimal lateral pharyngeal wall adduction may be incapable of closing their surgically preserved palatopharyngeal ports following a pharyngeal flap surgical procedure. Such patients can suffer from residual palatopharyngeal incompetence that could necessitate the fabrication of palatal lift prostheses that occlude the offending nasopharyngeal ports.

Contraindications to pharyngeal flap surgical procedures, thus, include nominal measures of lateral pharyngeal wall adduction. Patients whose lateral pharyngeal walls negligibly adduct necessitate pharyngeal flaps that are wider in a mediolateral direction than patients with dramatic lateral pharyngeal wall adduction. As such, midsagittal pharyngeal flaps designed to be wide enough to mitigate palatopharyngeal incompetence in patients with minimal lateral pharyngeal wall adduction run the risk of being so wide they fail to allow the preservation of bilateral palatopharyngeal ports large enough to safeguard the capacity for nasal respiration. Patients with diminutive bilateral palatopharyngeal ports can postoperatively suffer from obstructive sleep apnea. With this in mind, pharyngeal flap surgical candidates should undertake a preoperative nasoendoscopic examination by an otolaryngologist, plastic surgeon, or speech language pathologist to assess the degree of lateral pharyngeal wall adduction. A preoperative assessment of such adduction can serve as a surgical guide to how wide a pharyngeal flap must be to be efficacious. Nasoendoscopic evaluations prior to surgery can also diminish the possibility of iatrogenically precipitating obstructive sleep apnea.

Additionally, aberrant pharyngeal vascular anatomy can serve as a contraindication to the pharyngeal flap surgical procedure. Internal carotid arteries within the pharyngeal walls can take an atypical medial course through the posterior aspect of the pharyngeal wall, particularly in patients with velocardiofacial syndrome. Since such anomalies raise the risk of dangerous intraoperative hemorrhaging, contrast enhanced computed tomography and/or magnetic resonance angiography should be obtained in the interest of evaluating pharyngeal vascular anatomy prior to a pharyngeal flap surgical procedure.

Pharyngoplasty

In contrast to the pharyngeal flap surgical procedure that optimally serves patients with ample lateral pharyngeal wall adduction, the pharyngoplasty represents a surgical technique more suitable for patients with soft palatal elevation that is unaccompanied by enough lateral pharyngeal wall adduction to affect palatopharyngeal closure. During a pharyngoplasty, incisions are made into the lateral and posterior pharyngeal walls in an effort to elevate strips of native tissue away from its normal position. These elevated tissues are called flaps and remain pedicled to their native pharyngeal structures as a means of maintaining their blood flow. The flaps are strategically sutured into recipient sites where they provide postoperative tissue volume in areas of the lateral oropharynx and nasopharynx believed not to preoperatively adduct enough to realize palatopharyngeal closure. Pharyngoplasty contraindications and complications are not unlike those considered when preparing for pharyngeal flap surgical procedures. Vascular anatomy must be preoperatively assessed and the provision of lateral pharyngeal wall bulkiness carries the risk of inducing obstructive sleep apnea.