ISSN eissn Case Report Case of making maxillary palatal augmentation complete denture

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1 ISSN eissn Case Report Case of making maxillary palatal augmentation complete denture for patient with dysphagia after partial glossectomy Hyung-Seok Kim, Ji-Young Park, Sun-Young Yim, Yu-Ri Heo, Mee-Kyoung Son* Department of Prosthodontics, College of Dentistry, Chosun University, Gwangju, Republic of Korea If complication arises after glossectomy which leads to trouble in forming food bolus or transfer of the food, it is possible that either food bolus may block the airway or dysphagia may occur as the food bolus goes down into the airway. To solve the issue, palatal augmentation prosthesis could be used. In this case, the patient with an oral cancer is having difficulties swallowing food after glossectomy. Through taking impressions of polishing surface of his denture referring his tongue movement, the complete denture for the upper jaw was created using the concept of palatal augmentation prosthesis. This new upper denture increases the palataltongue contact pressure, allowing the patient to perform better swallowing and better pronunciation. (J Dent Rehabil Appl Sci 2018;34(3):239-45) Key words: glossectomy; dysphagia; swallowing disorder; palatal augmentation prosthesis 서론 전체암발생빈도의약 3-4% 를차지하는구강암중설암은약 45% 로가장높은빈도를차지하고 대연령의남성에서주로호발한다. 1 설암은혀와근접한경부림프절 level I, II, III 에주로전이된다고알려져있으며, 이를제거하기위해선택적경부청소술 (selective neck dissection, SND) 중하나인상견갑설골근경부청소술 (supraomohyoid neck dissection, SOND) 이가장흔하게시행되고있다. 2 설암이발생된경우, 부분혹은완전혀절제술 (partial or total glossectomy) 을시행하게되고, 이로인해환자는연하, 발음, 저작기능에장애를겪게된다. 3-5 연하는구강단계, 인두단계, 식도단계의 3단계로이루어진다. 그중첫번째단계인구강단계에서혀는볼과함께작용하여식괴를치아의교합면에위치하도록하여 저작에도움이되게할뿐만아니라, 구개와접촉하여식괴를삼키기쉬운형태로만들고후방으로이동시키는역할을한다. 혀의전방 2/3 부위는연하의초기단계에서중요한반면, 후방 1/3 부위는식괴를식도로밀어서내려보내기위한압력을형성하는데중요한역할을한다. 4 만약혀의부분또는완전절제술로인해식괴의형성이나이동에장애가생기는경우, 음식섭취가어렵거나식괴가기도를막기도하고기도를통해폐로흡인될수도있는연하장애 ( 연하곤란, 삼킴장애 ) 가발생할수있다. 특히노인환자에서는노화또는영양결핍에의하여연하와관련된목주위근육의부피나근력감소를동반하는경우가빈번하며혀의힘또한감소되어있으므로 70세이상에서연하장애의빈도가높게나타나고있다. 이러한상황에더하여환자가무치악으로저작기능이소실되고구강암등으로인해혀절제술이시행되었다면저작및연하장애로인한심각한문제에당면하게된다. 6,7 *Correspondence to: Mee-Kyoung Son Professor, Department of Prosthodontics, College of Dentistry, Chosun University 303, Philmoon-daero, Dong-gu, Gwangju, 61452, Republic of Korea Tel: , Fax: , son0513@chosun.ac.kr Received: June 18, 2018/Last Revision: July 12, 2018/Accepted: July 27, 2018 Copyright 2018 The Korean Academy of Stomatognathic Function and Occlusion. cc It is identical to Creative Commons Non-Commercial License. 239

혀의기능운동을인기한상악의연마면인상을채득하여, 구개증대보철개념을활용한상악총의치를제작하였으며, 구개-혀접촉압력이증가되어연하및발음에양호한결과를얻었기에보고하고자한다. 증례보고 만 69세의남자환자가음식을삼키기힘들고치아가상실된부분을보철수복하고싶다는주소로내원하였다.

2 Kim HS, Park JY, Yim SY, Heo YR, Son MK 연하장애는식괴의기도폐쇄로인한질식뿐아니라침이나음식이기도를통해폐로넘어감으로써흡인성폐렴의원인이되며, 이로인해노인환자는사망에이르게될수도있다. 7 따라서, 이러한경우도움을주는장치가필요한데, 이를위해혀의가동범위가적거나혀절제술로인해혀가구개에접촉하지않은환자에서발음이나저작, 연하에도움을주는장치를구개증대보철물 (PAP; Palatal Augmentation Prosthesis) 이라고부른다. 8 본증례의환자는구강암으로혀의좌측부분절제술후음식을삼키기어렵다는주소로내원하였다. 혀의기능운동을인기한상악의연마면인상을채득하여, 구개증대보철개념을활용한상악총의치를제작하였으며, 구개-혀접촉압력이증가되어연하및발음에양호한결과를얻었기에보고하고자한다. 증례보고 만 69세의남자환자가음식을삼키기힘들고치아가상실된부분을보철수복하고싶다는주소로내원하였다. 환자는 15년전설암으로인해좌측혀부분절제술 (left partial glossectomy) 과하악골부분절제술 (partial mandibulectomy), 상견갑설골근경부청소술 (supraomohyoid neck dissection, SOND) 후전측대퇴피판 (anterolateral thigh flap) 및전완피판 (forearm flap) 을이용해재건하는치료를받은병력이있다. 초진시환자 는상악임시의치를장착중이셨으며구내검사및방사선사진판독을시행한결과, 좌측하악골부분절제부위의각화조직과좌측혀부위의반흔조직이관찰되었고 #33,47는이차우식, #34는잔존치근및우식, #44 는심한우식상태였다 (Fig. 1). 임플란트를이용한보철수복은치료계획을위한상담시원치않았으나, 추후임플란트를이용한보철수복을하더라도입천장을덮는의치가기능적으로필요한것으로보여상하악가철성의치로수복하기로하였다. 연하시부분절제된혀가구개측에잘접촉하지않아발음과연하의문제가발생하고있으므로, 상악은구개증대보철물의형태를갖는총의치를제작하기로계획하였고하악은 #33,34,44,46 발거후 #43-45 surveyed crown 및가철성국소의치를제작하기로계획하였다. 또한좌측의의치상은반흔조직의전방까지만조직피개하도록계획하였다. 통상적인방법으로의치를제작하는과정중, 하악 surveyed crown 수복후기능인상채득과정에서는좌측은반흔조직의전방까지만조직을피개할계획으로 #35부위까지만기능인상채득을시행하였다. 납의치시적후혀운동을인기하기위하여상악연마면인상채득을시행하였다. 조직조정재 (Tempo, Lang Dental, Wheeling, USA) 를구개측연마면에적용하여구강내시적후, 연하운동및 ㅌ, ㄷ, ㅋ, ㄱ 발음을유도하여혀의기능운동을인기하였다 (Fig. 2, 3). 3 A B C D Fig. 1. Initial intraoral photographs. (A) Occlusal view of maxillary arch, (B) Frontal view of maxillary & mandibular arch, (C) Occlusal view of mandibular arch, (D) A panoramic radiography. A B C Fig. 2. (A) Master cast, (B) Wax denture, (C) Wax denture try in. 240 J Dent Rehabil Appl Sci 2018;34(3):239-45

Case of making maxillary palatal augmentation complete denture for patient with dysphagia after

(A) Application of tissue conditioner before polished surface impression, (B) After polished

(A) Upper wax denture after trimming tissue conditioner, (B, C) Occlusal & rear view of cured upper

Fig. 6. A tongue pressure-measuring device (JMS tongue pressure measurement devicetm).

구개-혀 압력 측정을 위해, 연하 시 혀가 구개에 접촉할 때 JMS 혀 압 력 측정기(JMS Co. Ltd, Hiroshima, Japan)로 최대 혀 압 력을 측정하였다(Fig.

3 Case of making maxillary palatal augmentation complete denture for patient with dysphagia after partial glossectomy A B Fig. 3. (A) Application of tissue conditioner before polished surface impression, (B) After polished surface impression. A B C Fig. 4. (A) Upper wax denture after trimming tissue conditioner, (B, C) Occlusal & rear view of cured upper complete denture with polished surface impression technique. Fig. 5. Upper & lower denture delivery. Fig. 6. A tongue pressure-measuring device (JMS tongue pressure measurement devicetm). 이후 통상적인 방법으로 의치 제작을 완성하여 구강 내에 장착하였고, 원활한 사용여부 체크를 위해 구개-혀 압력 측정 및 발음을 평가하였다(Fig. 4, 5). 구개-혀 압력 측정을 위해, 연하 시 혀가 구개에 접촉할 때 JMS 혀 압 력 측정기(JMS Co. Ltd, Hiroshima, Japan)로 최대 혀 압 력을 측정하였다(Fig. 6, 7). 개선된 정도를 평가하기 위해 무치악 상태와 납의치 시적 시(연마면 인상 전), 의치 장 착 직후, 의치 장착 2주 후에 각각 2번씩 측정하여 평균 을 계산하였다(Table 1). 연마면 인상 전 납의치 시적 시 보다 의치 장착 후의 구개-혀 압력이 평균 kpa 만큼 증가되었음이 관찰되었다. J Dent Rehabil Appl Sci 2018;34(3): Fig. 7. The tongue pressure test. 241

4 Kim HS, Park JY, Yim SY, Heo YR, Son MK Table 1. Result of the tongue pressure test Measurement period Primary measurement (kpa) Secondary measurement (kpa) Mean (kpa) Edentulous state Wax denture try-in before polished surface impression Immediately after denture delivery weeks after denture delivery 고찰 급격한노인인구비율의증가에따라우리나라는 2026 년에는만 65세이상의노인인구가총인구의 20% 이상을차지하는초고령사회로진입할것으로예측되고있다. 6 다른나라와비교하여매우빠른초고령화로진입하고있으며빠르게발달된의학기술덕분에수명이증가되어자연스레노인의건강및삶의질등에관심이급격하게증가되어왔다. 6 특히식생활은삶과직접적으로연관되며노인에게연하장애는흔히일어날수있는데, 이러한연하장애는영양결핍및질식이나흡인성폐렴의원인이되며질식으로인한갑작스런죽음에이르게될수도있다. 7,8 연하장애의원인은다양하지만, 치과에서흔히관찰되는연하장애의원인으로는부분또는완전혀절제술과혀근육약화에따른혀의움직임제한이있다. 9 설암으로인해부분혀절제술을시행하였거나, 노화에의한혀의움직임제한등이있는환자에서혀가구개에접촉할수있도록하는구개증대보철물 (PAP) 의제작을통해연하장애를해결할수있다고보고되고있다. 9 Toyoshita 등 10 은상악총의치환자 10명을대상으로의치상구개부위두께가 1.4 mm와 2.8 mm인두개의의치를각각착용하게한후연하시혀의움직임및소리를측정하여연하능력을평가하였고, 구개부위가두꺼운의치상에서혀압력이더커서연하작용에더유리함을보고하였다. Marunick와 Tselios 5 는혀절제술후연하장애가있는환자들을구개증대보철물로수복한여러연구들을조사한결과, 총 42명중 36명에서연하장애가개선된것을확인할수있었다. 물론각각의연구들의환자개개인의다양성이존재하는데다혀절제술과정에따른장애의정도가분류되지않았고측정방법이표준화된것도아니지만, 대부분의연구들에의해구개증대보철물이연하장애를개선시킬수있다는점이긍정적으로평가되어왔다 Ohno 등 11,12 은설하신경이손상되어연하장애가있는환자들에서조직조정재를사용하여연하하는동안혀기능운동을인기하여구개증대보철물을제작하였고, Abdulhadi 13 는우측혀부분절제된환자에서통상적인방법으로완성된의치에구개증대를위해조직조정재로기능인상채득하여추후아크릴릭레진으로교체하였다. 본증례의환자는혀의좌측부분절제술로혀의움직임이저하되어있고상악의오랜기간임시의치상태로인해연하에어려움이있었다. 따라서상악무치악치료를위한총의치제작시, 혀의움직임을인기한연마면인상을채득하여구개증대보철물을제작하고자하였다. 연마면인상채득할때먼저연하운동을유도하여혀의움직임을인기한후, ㅌ, ㄷ 발음을통해혀전방부위기능인상을, ㅋ, ㄱ 발음을통해혀후방부위기능인상을각각채득하였다. 3 일반적인환자와혀절제술환자의상악연마면인상을비교한결과, 일반적인환자에서는전반적으로구개전방및측방부위인상재의두께가매우얇았고구개중앙에서부터후방부위로갈수록인상재가더많이남아있었다. 연하시구개전방과측방부위에서혀가긴밀하게접촉하면서인상재를구개중앙및후방부위로이동시킨것으로보인다. Ono 등 15 은평균 28세의정상인 10 명을대상으로연하시혀압력패턴을분석하였는데, 혀는구개전방부위에가장먼저접촉했을뿐만아니라가장오랫동안접촉했었던반면에, 구개후방부위에는마지막에접촉했고가장짧은시간동안만접촉했다. 연하시구개에혀가접촉하는순서는구개전방 - 구개측방 - 구개중앙 - 구개후방순이었고, 구개전방부위에서최대혀압력이가장높게나타났으며구개후방부위에서가장작게나타났다. 이측정결과는일반적인환자의상악연마면인상형태와유사한양상을보인다. 반면에혀절제술환자의경우접촉압력의저하로인상재의두께 242 J Dent Rehabil Appl Sci 2018;34(3):239-45

Case of making maxillary palatal augmentation complete denture for patient with dysphagia after partial glossectomy A B Fig. 8. Upper wax denture after polished surface impression.

5 Case of making maxillary palatal augmentation complete denture for patient with dysphagia after partial glossectomy A B Fig. 8. Upper wax denture after polished surface impression. (A) Normal patient without dysphagia, (B) Patient with partial glossectomy. 가구개전방및측방부위를포함하여전반적으로두껍게나타났으며, 좌측혀부분절제에의한좌측구개-혀압력감소로인해좌측측방부위인상재가두꺼워서좌우가크게불균형한양상으로나타났다 (Fig. 8). Ono 등 15 의연구에따르면연하시정상인의최대혀압력의평균은구개부위별로 kpa사이에분포하였는데, 본증례환자의연마면인상후의구개-혀압력측정값 ( kpa) 이정상인의수치와근접한결과를보였다. 연마면인상을채득한최종의치를장착한초기에는두껍고, 불규칙한표면의구개부로인한불편감을호소하였으나, 약 4주경과후에는특별한불편감을나타내지않았다. 연마면인상채득후, 구개-혀압력이증가하였으며, 환자는연하및발음에대해보철물장착전또는연마면인상전보다개선되었다고평가하였으며만족하였다. 결론 혀절제술로인해혀의형태가비정상적인경우에구개-혀압력이감소하여연하장애가발생할수있다. 혀가구개에접촉하도록하게하는구개증대보철물은이러한연하장애를개선시키는데사용될수있다. 악성종양으로인한기능적인문제를갖는이같은환자외에도노화에의한구강및구강주위근력의저하로연하장애를경험하는노인환자들이증가하고있다. 따라서, 노인환자맞춤형보철치료, 즉단순히구강의해부학적형태를수복하는보철치료보다는구강기능재활과회복을고려한보철물의제작으로치료패러다임의변화가필요할것이다. J Dent Rehabil Appl Sci 2018;34(3): ORCID Hyung-Seok Kim Ji-Young Park Sun-Young Yim Yu-Ri Heo Mee-Kyoung Son References 1. Choi SW. Clinical diagnosis of oral cancer. J Korean Dent Assoc 2011;49: Joo YH, Sun DI, Shin JH, Shin JH, Lee CH, Cho SH, Kim MS. The results of treatment in clinical NO oral tongue cancer. Korean J Otorhinolaryngol Head Neck Surg 2007;50: Yoon JY, Lee SH, Lee JY, Oh NS. Prosthetic rehabilitation for a glossectomy patient - a clinical report. J Korean Acad Prosthodont 2013;51: Balasubramaniam MK, Chidambaranathan AS, Shanmugam G, Tah R. Rehabilitation of glossectomy cases with tongue prosthesis: a literature review. J Clin Diagn Res 2016;10:ZE01-ZE Marunick M, Tselios N. The efficacy of palatal augmentation prostheses for speech and swallowing in patients undergoing glossectomy: a review of the literature. J Prosthet Dent 2004;91: Kwag JM, Park II, Son MK. Suggestion for understanding and activation of the nursing home dentist 243

6 Kim HS, Park JY, Yim SY, Heo YR, Son MK system. Oral Biol Res 2017;41: Sakai K, Nakayama E, Tohara H, Kodama K, Takehisa T, Takehisa Y, Ueda K. Relationship between tongue strength, lip strength, and nutrition-related sarcopenia in older rehabilitation inpatients: a crosssectional study. Clin Interv Aging 2017;12: Sura L, Madhavan A, Carnaby G, Crary MA. Dysphagia in the elderly: management and nutritional considerations. Clin Interv Aging 2012;7: The glossary of prosthodontic terms. J Prosthet Dent 2017;117:e1-e Toyoshita Y, Koshino H, Hirai T, Matsumi T. Effect of wearing a palatal plate on swallowing function. J Prosthodontic Res 2009;53: Ohno T, Fujishima I. Palatal and lingual augmentation prosthesis for patients with dysphagia and functional problems: a clinical report. J Prosthet Dent 2017;117: Ohno T, Ohno R, Fujishima I. Effect of palatal augmentation prosthesis on pharyngeal manometric pressure in a patient with functional dysphagia: a case report. J Prosthodont Res 2017;61: Abdulhadi LM. Different techniques for palatal augmentation in partially glossectomized patients. A report of two cases. Open Access Scientific Reports 2012;1: Robbins KT, Bowman JB, Jacob RF. Postglossectomy deglutitory and articulatory rehabilitation with palatal augmentation prostheses. Arch Otolaryngol Head Neck Surg 1987;113: Ono T, Hori K, Nokubi T. Pattern of tongue pressure on hard palate during swallowing. Dysphagia 2004;19: J Dent Rehabil Appl Sci 2018;34(3):239-45

7 Case Report 부분혀절제술로인해연하장애가있는환자에서상악구개증대총의치제작증례 김형석, 박지영, 임선영, 허유리, 손미경 * 조선대학교치과대학치과보철학교실 만약혀절제술로인해식괴의형성및이동에장애가생기는경우, 식괴가기도를막거나기도로흡인되는연하장애가발생할수있으며, 이런경우에구개증대보철물은도움이될수있다. 구강암으로인해부분혀절제술을받은후음식물을삼키기어렵다는주소로내원한환자에게혀의기능운동을인기한상악의연마면인상채득을통해구개증대보철개념을활용한상악총의치를제작하여, 구개-혀접촉압력을증가시켜서연하및발음에양호한결과를얻을수있었다. ( 구강회복응용과학지 2018;34(3):239-45) 주요어 : 혀절제술 ; 연하곤란 ; 삼킴장애 ; 구개증대보철물 * 교신저자 : 손미경 (61452) 광주광역시동구필문대로 303 조선대학교치과대학치과보철학교실 Tel: Fax: son0513@chosun.ac.kr 접수일 : 2018 년 6 월 18 일 수정일 : 2018 년 7 월 12 일 채택일 : 2018 년 7 월 27 일 245

ISSN eissn Case Report Neutral zone approach and external impression for rehabilitati

ISSN eissn Case Report Neutral zone approach and external impression for rehabilitati https://doi.org/10.14368/jdras.2018.34.3.218 ISSN 2384-4353 eissn 2384-4272 ase Report Neutral zone approach and external impression for rehabilitation of macroglossia: a case report Hyeon Kang, Nu-Ri