C L IN IC A L
REPORT
S ubm ucosal palatal sw ellings cause problem s in diagnosis and in surgical m anagem ent. D iagnostic m ethods include visualization, palpation, aspiration, radiography, and histologic exam ination. If the lesion requires surgical intervention, an acrylic splint should usually be used postoperatively to prevent com plications and to facilitate healing.
Surgical treatment of submucosal tumors of the hard palate William R. Woods, DDS James L. Andrews, DDS Bruce F. Barker, DDS, Kansas City, Mo H i H H i
T he m ost com m on tum ors o f the hard palate are pleom orphic adenom as (mixed salivary gland tum or), adenoid cystic carcinom as, and mucoepiderm oid carcinom as. Pleom orphic adenom as ac count for 75% of all benign tum ors o f the hard p alate.1,2 T he palate is also the intraoral site of predilection for adenoid cystic carcinom a and m ucoepiderm oid carcinom a.25 T hese tum ors usually have sim ilar sym ptom s and clinical ap pearance. T he main sym ptom is a painless swell ing.6 T he duration o f sym ptom s for salivary gland carcinom as of the palate averages 29 m onths, in com parison to years for all other salivary tu m o rs.7 Inability to w ear a dental prosthesis may be the m ajor sign. T he m ucosa overlying the tum or usually appears norm al but, in som e cases, there is a bluish discoloration.8 T he lesions are usually not ulcerated unless they are traum atized, which helps to distinguish them from epithelial lesions. G enerally, there is no invasion o f bone, but pressure from the enlarging m ass may cause re sorption of underlying b o n e.1,2 H ow ever, adenoid cystic carcinom a may involve bone and cause pain.2 1028 ■ JADA, Vol. 96, June 1978
W e believe that local excision with an adequate margin o f clinically norm al tissue of 5 mm to 1 cm, depending on clinical judgm ent, is the initial sur gical procedure. If the histopathologic exam ina tion shows a marginal section free o f pleom orphic adenom a or with w ell-differentiated m uco epiderm oid, then the initial surgical procedure is adequate. H ow ever, surgery should be reinsti tuted if a tum or is discovered in any m argins of the surgical specim en. M oreover, if the lesion is an adenoid cystic carcinom a, it justifies special p ro cedures, including an en bloc resection o f the maxilla and, possibly, dissection o f the neck. T he adenoid cystic carcinom a of the palate is an aggressive, potentially lethal tum or. T he prog nosis for high-grade m ucoepiderm oid carcinom a is poor also, and adequate treatm ent usually in volves m ore radical procedures.9
Report of cases Case 1
A 47-year-old white wom an was referred to the oral surgery clinic because a painless swelling in
C L IN IC A L
REPORT
Fig 2 ■ Palatal sp lin t in place postoperatively (case 1).
Fig 1 ■ S urgical defect shows no erosion of palatal bone (case 1).
the palate prevented her from wearing her partial denture; she had had the swelling for 18 months. Intraoral exam ination show ed a raised, bluish m ass approxim ately 7 mm in diam eter in the left palatal vault opposite the first m olar. T he mass was firm and slightly depressible, but produced no blanching or m ucous exudate with pressure. T eeth w ere vital and not displaced. Radiographic studies disclosed normal structures with no bony invasion o f the m axillary sinus. T he medical his tory w as noncontributory and results of a physical exam ination were within norm al limits. N o lym phadenopathy was present. T he initial differential diagnosis included pleom orphic adenom a, m ucoepiderm oid car cinom a, adenoid cystic carcinom a, and m ucous retention cyst. Im pressions were taken to con struct a palatal splint for an excisional biopsy of the tum or mass.
■ Surgical procedure: A nesthesia was induced locally with 2% lidocaine hydrochloride and epinephrine, 1:100,000. A scalpel was used to in cise the tissue to the bone surrounding the m ass with a 5-mm margin o f clinically normal tissue.. T he entire section o f tissue, including the perios teum , was rem oved; no defect or erosion of palatal bone was seen (Fig 1). T he m oderate am ount o f hem orrhage was controlled with local pressure. An anodyne dressing o f zinc oxide and eugenol was placed into the defect and the palatal splint was wired into place (Fig 2). ■ Pathological exam ination: T he specim en was im m ersed in Form alin; it consisted of an ellipse of grayish-w hite, soft tissue m easuring 1.5x1.2 cm. T he central portion was slightly raised and bluish. T he specim en was bisected longitudinally and was totally em bedded. M icroscopic exam ination disclosed strips of m ucosa covered with intact squam ous epithelium with no atypia. T he underlying connective tissue had several m ucous m inor salivary glands as well
THE AUTHORS
Dr. W oods is senior resident, departm ent of oral and m axillofacial surgery, University o f Missouri-Kansas City School of D entistry at Trum an M edical C enter, 2301 Holmes St, Kansas City, Mo 64108. Dr. Andrew s is chairm an, de partm ent of oral surgery, and Dr. Barker Is assistant profes sor, departm ent oral pathology, University of MissouriKansas City School of Dentistry. Address requests fo r re prin ts to Dr. Woods. WOODS
ANDREWS
BARKER
W oods— Andrews— Barker: SUBMUCOSAL TUMORS ■ 1029
C L IN IC A L
REPORT
Fig 4 ■ H igh-pow er view shows p o rtio n of cyst wall and adjacent hyalinized strom a. Note focal mural plaques of clear cells and epiderm oid cells (case 1).
Fig 3 ■ Low -pow er view of intact surface m ucosa w ith cystic saliv ary tum or in subm ucosa (case 1).
as a cystic salivary tum or. T he tum or was charac terized by an irregular serpentine cavity lined with mainly cuboidal or epiderm oid cells with scat tered m ucous cells and clear cells (Fig 3). Large, mural plaques of sim ilar cells partially obliterated the lumen (Fig 4). All sections showed that the tum or cells were confined within the luminal area. A focally dense, hyalinized zone was seen im m ediately adjacent to the lining cells. T here was relative uniform ity o f nuclear morphology. The rem ainder of the tissue showed scattered chronic inflammation including chronic sialadenitis. The deep and lateral margins were free of tum or. The diagnosis was low-grade m ucoepiderm oid car cinoma.
Fig 5 ■ Four-week postoperative photograph shows norm al mu cosa w ith epithelial scarring (case 1).
■ Postoperative course: T he palatal splint and the dressing were rem oved after seven days. N orm al granulation tissue was forming and the splint was replaced with a new dressing and reexam ined until reepithelization was com plete. A fter four w eeks, the operative site contained normal m ucosa with epithelial scarring (Fig 5). T he patient is being followed up on a regular basis; there was no evidence o f recurrence 32. m onths postoperatively. Case 2
A 20-year-old black man was adm itted to the hos pital for treatm ent of a leg w ound. Routine physi cal exam ination disclosed a swelling on the right side of the palate. T he patient was referred to the oral surgery service for diagnosis and treatm ent of the palatal swelling. Intraoral exam ination showed a raised mass on the right side of the palate, extending from the prem olar area anteriorly onto the soft palate post1030 ■ JADA, Vol. 96, June 1978
Fig 6 ■ M irro r image shows raised palatal mass w ith normalappearing m ucosa (case 2).
eriorly. T he m ass did not cross the midline. The covering m ucosa appeared normal (Fig 6). Palpa tion showed a firm, nonm ovable, nontender, well-circum scribed, subm ucosal mass. N o thrill
C L IN IC A L
was noted and no teeth were displaced. T he nasal floor was not elevated. The patient said that the m ass had been present for approxim ately two years. G row th was fairly rapid during the first year, but the m ass had not increased during the past 12 m onths. T he area was asym ptom atic throughout the two years. Studies included radiographs, vitality testing of the teeth, and aspiration o f the m ass. Radiographic studies included periapical, panoram ic, occlusal, and stereographic W aters views. All radiographs w ere norm al except for the occlusal view, which show ed a radiolucency o f the right side of the hard palate in the region of the mass. N o involvem ent o f the maxillary sinus was seen. A spiration o f the m ass produced no fluid. V ital ity testing of the teeth in the area showed normal responses. It was decided that the m ass was a neoplasm , and a palatal splint was constructed from a stone model for insertion at the time of surgery. ■ Surgical procedure: G eneral anesthesia was induced via a nasoendotracheal route through the left nostril, and w as supplem ented by local infil tration o f lidocaine hydrochloride, 2%, and epinephrine, 1:100,000, for hem ostasis. The tissue surrounding the lesion was incised to the bone with a scalpel, including a 5-mm margin of clinically normal m ucosa surrounding the m ass. T he lesion was separated from the palatal bone with blunt and sharp dissection. T he entire block of tissue containing the lesion was removed (Fig 7). M oderate hem orrhage was encountered in dissection o f the soft palate and was controlled by ligation o f vessels and electrocoagulation. Inspection o f the surgical defect showed no erosion of the palatal bone, but showed no perfo ration into the m axillary sinus or nasal cavity. The anterior palatine nerve and greater palatine ves sels had been served at the exits from the canal. A large vulcanite bur was used to rem ove 1 mm of bone from the eroded palatal bone adjacent to the lesion to eradicate any tum or cells that could have rem ained after rem oval of the lesion. A periodon tal pack was mixed and placed into the surgical defect. T he preform ed acrylic splint was placed over the defect and wired to the teeth to hold it in place. N o attem pt at prim ary closure was made. ■ Pathological exam ination: On gross exam ina tion, the specim en was an ellipse of palatal m u cosa, 4 .5 x 3 cm in dim ension, containing a wellcircum scribed, circular m ass. M icroscopic ex
REPORT
am ination disclosed a nodular salivary gland tum or lying slightly beneath the epithelium . The tum or had a sharp, well-circum scribed border with tum or cells confined within that area (Fig 8). T he tum or w as characterized by a proliferation of ductal elem ents with abundant strom a. The strom a generally had a loose, mesenchym al-like character but, in focal areas, had a more hyalin ized and som etim es cartilaginous appearance. T he deep and lateral margins were free of tum or. T he diagnosis w as benign mixed tum or of salivary origin (pleom orphic adenom a). ■ P ostoperative course: T he postoperative course was uncom plicated with little pain or dis com fort. O n the fourth postoperative day, the splint was rem oved. T he periodontal pack was rem oved from the defect, afresh pack was placed, and the splint was reinserted. A fter approxi-
Fig 7 ■ Intact surgical specim en w ith w ell-circum scribed lesion (case 2).
Fig 8 ■ Low -pow er view shows nodular, w ell-circum scribed saliv ary gland tu m o r lying beneath epithelium (case 2). W oods— Andrew s— Barker: SUBMUCOSAL TUMORS ■ 1031
C L IN IC A L
REPORT
extent of the tum or, for incision lines, and for fabrication of a surgical splint. D uplicate casts made from the m aster cast should be recontoured to restore normal palatal anatom y before con struction o f the splint. A surgical sedative dressing should be used under the splint to cover the surgical defect. T he cem ent is mixed in the operating room and placed betw een the splint and the defect on insertion of the appliance. If the patient has teeth, the splint is held in place by ligation to the teeth with interden tal wires o r clasps. If the patient is edentulous, either circum zygom atic wires or pins can be used to hold the splint in place.
Fig 9 ■ Three-week postoperative photograph shows normal
Summary
reepithelialization (case 2).
mately ten days, the exposed bone was covered with granulation tissue and only the palatal splint was used to cover the area until reepithelialization was com plete (Fig 9). T he patient was followed up for two years postoperatively with no evidence of recurrence.
Discussion Subm ucosal tum ors of m inor salivary gland origin are com m only found on the palate. T hese include pleom orphic adenom as, adenoid cystic car cinom as, and m ucoepiderm oid carcinom as. A com m on site of origin is the posterior part o f the hard palate, betw een the midline and alveolus, at its junction with soft palate. W ide surgical exci sion of the tum ors in this area is the preferred treatm ent, as m inor salivary gland tum ors are ex ceedingly likely to recur. A fter the tum or is excised, a large area of palatal bone or soft palatal m usculature may be denuded and com plete closure of the surgical de fect is difficult, if not im possible. W hen primary closure cannot be obtained, healing by secondary intention m ust occur. C overing the surgically created defect with a palatal splint that holds sur gical cem ent against the exposed connective tis sues provides hem ostasis, prevents form ation of hem atom as, allows the patient to eat and function w ithout pain, and minimizes the passage o f fluids into the nose if there is oronasal com m unication. Preoperative im pressions of the palate should be taken. A cast is then provided for study of the 1032 ■ JADA, Vol. 96, June 1978
Tw o cases have been presented to illustrate the principles o f total excisional biopsy for palatal tum ors and the postoperative m anagem ent o f the resulting defect with the use of palatal splints. Total excisional biopsy is curative for benign tum ors and for some malignant-grade tum ors, and is the preferred m ethod o f treatm ent when possi ble. Total excision o f the lesion with adequate m argins negates the possibility o f seeding the tum or into surrounding tissue or of leaving be hind residual tum or.
The authors thank Mrs. E. B. Cook fo r her assistance w ith this paper. 1. Pinto, R.S.; Kelly, D.E.; and Ajax, G.E. R adiologic features of benign pleo m orphic adenom a of the hard palate. Oral Surg 39:976 June 1975. 2. C haudhry, A.P.; Vickers, R.A.; and G orlin, R.J. Intraoral m inor salivary gland tum ors: an analysis of 1,414 cases. Oral Surg 14:1194 Oct 1961. 3. Luna, M.A.; Stimson, P.G.; and B ardwil, J.M. M inor salivary gland tum ors o f the oral cavity. A review of 68 cases. Oral Surg 25:71 Jan 1968. 4. Eversole, L.R. M ucoepiderm oid carcinom a: review of 815 re ported cases. J Oral Surg 28:490 July 1970. 5. Crocker, D.J.; Cavalaris, C.J.; and Finch, R. Intraoral m inor salivary gland tum ors. Report of 38 cases. Oral Surg 29:60 Jan 1970. 6. B ardw ill, J.M., and others. Report of one-hundred tum ors of the m ino r salivary glands. Am J Surg 112:493 Oct 1966. 7. W alker, W.E.: Rosenfeld, L.; and Hartmann, W.H. Salivary gland carcinom a of the palate. Oral Surg 33:936 Dec 1975. 8. Melrose, R.J.; Abrams, A.M.; Howell, F.V. M ucoepiderm oid tum ors o f the intraoral m ino r salivary glands: a clin ico p a th o lo g ic study of 54 cases. J Oral Path 2:314, 1973. 9. Eversole, L.R.; Rovin, S.; and Sabes, W.R. M ucoepiderm oid carcinom a of m inor salivary glands: report of 17 cases w ith fo llo w up. J Oral Surg 30:107 Feb 1972.
REPORT
S ubm ucosal palatal sw ellings cause problem s in diagnosis and in surgical m anagem ent. D iagnostic m ethods include visualization, palpation, aspiration, radiography, and histologic exam ination. If the lesion requires surgical intervention, an acrylic splint should usually be used postoperatively to prevent com plications and to facilitate healing.
Surgical treatment of submucosal tumors of the hard palate William R. Woods, DDS James L. Andrews, DDS Bruce F. Barker, DDS, Kansas City, Mo H i H H i
T he m ost com m on tum ors o f the hard palate are pleom orphic adenom as (mixed salivary gland tum or), adenoid cystic carcinom as, and mucoepiderm oid carcinom as. Pleom orphic adenom as ac count for 75% of all benign tum ors o f the hard p alate.1,2 T he palate is also the intraoral site of predilection for adenoid cystic carcinom a and m ucoepiderm oid carcinom a.25 T hese tum ors usually have sim ilar sym ptom s and clinical ap pearance. T he main sym ptom is a painless swell ing.6 T he duration o f sym ptom s for salivary gland carcinom as of the palate averages 29 m onths, in com parison to years for all other salivary tu m o rs.7 Inability to w ear a dental prosthesis may be the m ajor sign. T he m ucosa overlying the tum or usually appears norm al but, in som e cases, there is a bluish discoloration.8 T he lesions are usually not ulcerated unless they are traum atized, which helps to distinguish them from epithelial lesions. G enerally, there is no invasion o f bone, but pressure from the enlarging m ass may cause re sorption of underlying b o n e.1,2 H ow ever, adenoid cystic carcinom a may involve bone and cause pain.2 1028 ■ JADA, Vol. 96, June 1978
W e believe that local excision with an adequate margin o f clinically norm al tissue of 5 mm to 1 cm, depending on clinical judgm ent, is the initial sur gical procedure. If the histopathologic exam ina tion shows a marginal section free o f pleom orphic adenom a or with w ell-differentiated m uco epiderm oid, then the initial surgical procedure is adequate. H ow ever, surgery should be reinsti tuted if a tum or is discovered in any m argins of the surgical specim en. M oreover, if the lesion is an adenoid cystic carcinom a, it justifies special p ro cedures, including an en bloc resection o f the maxilla and, possibly, dissection o f the neck. T he adenoid cystic carcinom a of the palate is an aggressive, potentially lethal tum or. T he prog nosis for high-grade m ucoepiderm oid carcinom a is poor also, and adequate treatm ent usually in volves m ore radical procedures.9
Report of cases Case 1
A 47-year-old white wom an was referred to the oral surgery clinic because a painless swelling in
C L IN IC A L
REPORT
Fig 2 ■ Palatal sp lin t in place postoperatively (case 1).
Fig 1 ■ S urgical defect shows no erosion of palatal bone (case 1).
the palate prevented her from wearing her partial denture; she had had the swelling for 18 months. Intraoral exam ination show ed a raised, bluish m ass approxim ately 7 mm in diam eter in the left palatal vault opposite the first m olar. T he mass was firm and slightly depressible, but produced no blanching or m ucous exudate with pressure. T eeth w ere vital and not displaced. Radiographic studies disclosed normal structures with no bony invasion o f the m axillary sinus. T he medical his tory w as noncontributory and results of a physical exam ination were within norm al limits. N o lym phadenopathy was present. T he initial differential diagnosis included pleom orphic adenom a, m ucoepiderm oid car cinom a, adenoid cystic carcinom a, and m ucous retention cyst. Im pressions were taken to con struct a palatal splint for an excisional biopsy of the tum or mass.
■ Surgical procedure: A nesthesia was induced locally with 2% lidocaine hydrochloride and epinephrine, 1:100,000. A scalpel was used to in cise the tissue to the bone surrounding the m ass with a 5-mm margin o f clinically normal tissue.. T he entire section o f tissue, including the perios teum , was rem oved; no defect or erosion of palatal bone was seen (Fig 1). T he m oderate am ount o f hem orrhage was controlled with local pressure. An anodyne dressing o f zinc oxide and eugenol was placed into the defect and the palatal splint was wired into place (Fig 2). ■ Pathological exam ination: T he specim en was im m ersed in Form alin; it consisted of an ellipse of grayish-w hite, soft tissue m easuring 1.5x1.2 cm. T he central portion was slightly raised and bluish. T he specim en was bisected longitudinally and was totally em bedded. M icroscopic exam ination disclosed strips of m ucosa covered with intact squam ous epithelium with no atypia. T he underlying connective tissue had several m ucous m inor salivary glands as well
THE AUTHORS
Dr. W oods is senior resident, departm ent of oral and m axillofacial surgery, University o f Missouri-Kansas City School of D entistry at Trum an M edical C enter, 2301 Holmes St, Kansas City, Mo 64108. Dr. Andrew s is chairm an, de partm ent of oral surgery, and Dr. Barker Is assistant profes sor, departm ent oral pathology, University of MissouriKansas City School of Dentistry. Address requests fo r re prin ts to Dr. Woods. WOODS
ANDREWS
BARKER
W oods— Andrews— Barker: SUBMUCOSAL TUMORS ■ 1029
C L IN IC A L
REPORT
Fig 4 ■ H igh-pow er view shows p o rtio n of cyst wall and adjacent hyalinized strom a. Note focal mural plaques of clear cells and epiderm oid cells (case 1).
Fig 3 ■ Low -pow er view of intact surface m ucosa w ith cystic saliv ary tum or in subm ucosa (case 1).
as a cystic salivary tum or. T he tum or was charac terized by an irregular serpentine cavity lined with mainly cuboidal or epiderm oid cells with scat tered m ucous cells and clear cells (Fig 3). Large, mural plaques of sim ilar cells partially obliterated the lumen (Fig 4). All sections showed that the tum or cells were confined within the luminal area. A focally dense, hyalinized zone was seen im m ediately adjacent to the lining cells. T here was relative uniform ity o f nuclear morphology. The rem ainder of the tissue showed scattered chronic inflammation including chronic sialadenitis. The deep and lateral margins were free of tum or. The diagnosis was low-grade m ucoepiderm oid car cinoma.
Fig 5 ■ Four-week postoperative photograph shows norm al mu cosa w ith epithelial scarring (case 1).
■ Postoperative course: T he palatal splint and the dressing were rem oved after seven days. N orm al granulation tissue was forming and the splint was replaced with a new dressing and reexam ined until reepithelization was com plete. A fter four w eeks, the operative site contained normal m ucosa with epithelial scarring (Fig 5). T he patient is being followed up on a regular basis; there was no evidence o f recurrence 32. m onths postoperatively. Case 2
A 20-year-old black man was adm itted to the hos pital for treatm ent of a leg w ound. Routine physi cal exam ination disclosed a swelling on the right side of the palate. T he patient was referred to the oral surgery service for diagnosis and treatm ent of the palatal swelling. Intraoral exam ination showed a raised mass on the right side of the palate, extending from the prem olar area anteriorly onto the soft palate post1030 ■ JADA, Vol. 96, June 1978
Fig 6 ■ M irro r image shows raised palatal mass w ith normalappearing m ucosa (case 2).
eriorly. T he m ass did not cross the midline. The covering m ucosa appeared normal (Fig 6). Palpa tion showed a firm, nonm ovable, nontender, well-circum scribed, subm ucosal mass. N o thrill
C L IN IC A L
was noted and no teeth were displaced. T he nasal floor was not elevated. The patient said that the m ass had been present for approxim ately two years. G row th was fairly rapid during the first year, but the m ass had not increased during the past 12 m onths. T he area was asym ptom atic throughout the two years. Studies included radiographs, vitality testing of the teeth, and aspiration o f the m ass. Radiographic studies included periapical, panoram ic, occlusal, and stereographic W aters views. All radiographs w ere norm al except for the occlusal view, which show ed a radiolucency o f the right side of the hard palate in the region of the mass. N o involvem ent o f the maxillary sinus was seen. A spiration o f the m ass produced no fluid. V ital ity testing of the teeth in the area showed normal responses. It was decided that the m ass was a neoplasm , and a palatal splint was constructed from a stone model for insertion at the time of surgery. ■ Surgical procedure: G eneral anesthesia was induced via a nasoendotracheal route through the left nostril, and w as supplem ented by local infil tration o f lidocaine hydrochloride, 2%, and epinephrine, 1:100,000, for hem ostasis. The tissue surrounding the lesion was incised to the bone with a scalpel, including a 5-mm margin of clinically normal m ucosa surrounding the m ass. T he lesion was separated from the palatal bone with blunt and sharp dissection. T he entire block of tissue containing the lesion was removed (Fig 7). M oderate hem orrhage was encountered in dissection o f the soft palate and was controlled by ligation o f vessels and electrocoagulation. Inspection o f the surgical defect showed no erosion of the palatal bone, but showed no perfo ration into the m axillary sinus or nasal cavity. The anterior palatine nerve and greater palatine ves sels had been served at the exits from the canal. A large vulcanite bur was used to rem ove 1 mm of bone from the eroded palatal bone adjacent to the lesion to eradicate any tum or cells that could have rem ained after rem oval of the lesion. A periodon tal pack was mixed and placed into the surgical defect. T he preform ed acrylic splint was placed over the defect and wired to the teeth to hold it in place. N o attem pt at prim ary closure was made. ■ Pathological exam ination: On gross exam ina tion, the specim en was an ellipse of palatal m u cosa, 4 .5 x 3 cm in dim ension, containing a wellcircum scribed, circular m ass. M icroscopic ex
REPORT
am ination disclosed a nodular salivary gland tum or lying slightly beneath the epithelium . The tum or had a sharp, well-circum scribed border with tum or cells confined within that area (Fig 8). T he tum or w as characterized by a proliferation of ductal elem ents with abundant strom a. The strom a generally had a loose, mesenchym al-like character but, in focal areas, had a more hyalin ized and som etim es cartilaginous appearance. T he deep and lateral margins were free of tum or. T he diagnosis w as benign mixed tum or of salivary origin (pleom orphic adenom a). ■ P ostoperative course: T he postoperative course was uncom plicated with little pain or dis com fort. O n the fourth postoperative day, the splint was rem oved. T he periodontal pack was rem oved from the defect, afresh pack was placed, and the splint was reinserted. A fter approxi-
Fig 7 ■ Intact surgical specim en w ith w ell-circum scribed lesion (case 2).
Fig 8 ■ Low -pow er view shows nodular, w ell-circum scribed saliv ary gland tu m o r lying beneath epithelium (case 2). W oods— Andrew s— Barker: SUBMUCOSAL TUMORS ■ 1031
C L IN IC A L
REPORT
extent of the tum or, for incision lines, and for fabrication of a surgical splint. D uplicate casts made from the m aster cast should be recontoured to restore normal palatal anatom y before con struction o f the splint. A surgical sedative dressing should be used under the splint to cover the surgical defect. T he cem ent is mixed in the operating room and placed betw een the splint and the defect on insertion of the appliance. If the patient has teeth, the splint is held in place by ligation to the teeth with interden tal wires o r clasps. If the patient is edentulous, either circum zygom atic wires or pins can be used to hold the splint in place.
Fig 9 ■ Three-week postoperative photograph shows normal
Summary
reepithelialization (case 2).
mately ten days, the exposed bone was covered with granulation tissue and only the palatal splint was used to cover the area until reepithelialization was com plete (Fig 9). T he patient was followed up for two years postoperatively with no evidence of recurrence.
Discussion Subm ucosal tum ors of m inor salivary gland origin are com m only found on the palate. T hese include pleom orphic adenom as, adenoid cystic car cinom as, and m ucoepiderm oid carcinom as. A com m on site of origin is the posterior part o f the hard palate, betw een the midline and alveolus, at its junction with soft palate. W ide surgical exci sion of the tum ors in this area is the preferred treatm ent, as m inor salivary gland tum ors are ex ceedingly likely to recur. A fter the tum or is excised, a large area of palatal bone or soft palatal m usculature may be denuded and com plete closure of the surgical de fect is difficult, if not im possible. W hen primary closure cannot be obtained, healing by secondary intention m ust occur. C overing the surgically created defect with a palatal splint that holds sur gical cem ent against the exposed connective tis sues provides hem ostasis, prevents form ation of hem atom as, allows the patient to eat and function w ithout pain, and minimizes the passage o f fluids into the nose if there is oronasal com m unication. Preoperative im pressions of the palate should be taken. A cast is then provided for study of the 1032 ■ JADA, Vol. 96, June 1978
Tw o cases have been presented to illustrate the principles o f total excisional biopsy for palatal tum ors and the postoperative m anagem ent o f the resulting defect with the use of palatal splints. Total excisional biopsy is curative for benign tum ors and for some malignant-grade tum ors, and is the preferred m ethod o f treatm ent when possi ble. Total excision o f the lesion with adequate m argins negates the possibility o f seeding the tum or into surrounding tissue or of leaving be hind residual tum or.
The authors thank Mrs. E. B. Cook fo r her assistance w ith this paper. 1. Pinto, R.S.; Kelly, D.E.; and Ajax, G.E. R adiologic features of benign pleo m orphic adenom a of the hard palate. Oral Surg 39:976 June 1975. 2. C haudhry, A.P.; Vickers, R.A.; and G orlin, R.J. Intraoral m inor salivary gland tum ors: an analysis of 1,414 cases. Oral Surg 14:1194 Oct 1961. 3. Luna, M.A.; Stimson, P.G.; and B ardwil, J.M. M inor salivary gland tum ors o f the oral cavity. A review of 68 cases. Oral Surg 25:71 Jan 1968. 4. Eversole, L.R. M ucoepiderm oid carcinom a: review of 815 re ported cases. J Oral Surg 28:490 July 1970. 5. Crocker, D.J.; Cavalaris, C.J.; and Finch, R. Intraoral m inor salivary gland tum ors. Report of 38 cases. Oral Surg 29:60 Jan 1970. 6. B ardw ill, J.M., and others. Report of one-hundred tum ors of the m ino r salivary glands. Am J Surg 112:493 Oct 1966. 7. W alker, W.E.: Rosenfeld, L.; and Hartmann, W.H. Salivary gland carcinom a of the palate. Oral Surg 33:936 Dec 1975. 8. Melrose, R.J.; Abrams, A.M.; Howell, F.V. M ucoepiderm oid tum ors o f the intraoral m ino r salivary glands: a clin ico p a th o lo g ic study of 54 cases. J Oral Path 2:314, 1973. 9. Eversole, L.R.; Rovin, S.; and Sabes, W.R. M ucoepiderm oid carcinom a of m inor salivary glands: report of 17 cases w ith fo llo w up. J Oral Surg 30:107 Feb 1972.
