JDSOR
10.5005/jp-journals-10039-1170
CASE REPORT
Palatal Perforation: Case Report and Literature Review
1
Archana Chaurasia, 2Ramkant Dandriyal, 3Shazia Safi, 4Vishakha Lal
ABSTRACT
Palatal perforation is a breach in the palatal vault leading to an
abnormal epithelized track between the nasal and oral cavity,
associated with nasal regurgitation of fluid, food lodgment in the
defect, hypernasality of voice, besides the risk of nasal infection
resulting from food lodgment. It is a rare condition encountered in
routine dental practice. It is well understood that palatal perfora-
tion can be a difficult diagnostic dilemma. Collagen membrane
used in our study is found to be an effective dressing material
for faster uneventful healing of palatal perforation.
Keywords: Collagen membrane, Palatal perforation, Suction
cups.
How to cite this article: Chaurasia A, Dandriyal R, Safi S, Lal V.
Palatal Perforation: Case Report and Literature Review. J Dent
Sci Oral Rehab 2017;8(3):113-116.
Source of support: Nil
Conflict of interest: None
INTRODUCTION
The palate is an integral part of the oral cavity constitut-
ing various types of tissue that give rise to different types
of pathological conditions. Perforation is a hole or break
between two epithelial surfaces commonly between a
hollow viscus and the skin (external fistula) or between
two hollow viscera (internal fistula), lined with granula-
tion tissue, which is subsequently epithelialized.1 Palatal
perforation is also known as oronasal communication
or oronasal fistula. By definition, it is an internal fistula
represented by an abnormal epithelialized track com-
municating between the nasal and oral cavity.
There are various etiological factors for palatal perfo-
rations discussed in various literature, which can occur
alone or in combination.2-4
Developmental: During the sixth week of prenatal
period, the nasal cavity is separated from the oral cavity,
anteriorly by premaxilla and maxilla, and posteriorly
by the horizontal plate of Palatine bone. Failure of this
1
Senior Lecturer, 2Professor, 3,4Postgraduate Student
1-4
Department of Oral and Maxillofacial Surgery, Institute of
Dental Sciences, Bareilly, Uttar Pradesh, India
Corresponding Author: Archana Chaurasia, Senior Lecturer
Department of Oral and Maxilofacial Surgery, Institute of Dental
Sciences, Bareilly, Uttar Pradesh, India, Phone: +919451260999
e-mail: drarchanachaurasia@gmail.com
Journal of Dental Sciences and Oral Rehabilitation, July-September 2017;8(3):113-116
Palatal Perforation: Case Report and Literature Review
integration results in cleft palate. Alteration in the normal
fusion process, defect in the regional vascular supply, a
mechanical alteration in tongue size can lead to perfo-
ration. During pregnancy, mother-to-fetus transfer of
substances, such as alcohol, drugs or toxins or infections,
cigarette smoking, folic acid deficiency, corticosteroid use,
and anticonvulsant therapy are some causative agents for
this abnormality.
Drug related: Palatal perforation due to drug abuse like
cocaine, heroin, or narcotics is a well-known situation in
adults. Cocaine is an alkaloid extract derived from the
Erythroxylum coca plant. Its unique vasoconstrictive
properties led to its use as an anesthetic, but if overused,
the intense vasoconstriction leads to ischemia of affected
tissues, which can progress to necrosis and then perfora-
tion.5 The nasal septum is eroded and eventually disinte-
grates with the collapse of the internal support structure.
The area of damage extends to causing perforation of the
hard and/or soft palate.
Trauma: Sometimes, an elderly edentulous denture
wearer complains of a perforation in his/her palate. Due
to bone resorption, a previously impacted canine may
emerge in the form of a palatal perforation. Sometimes,
following a tooth extraction, an oroantral fistula remains.
Other procedures such as sagittal palatal fracture occur-
ring with a palate alveolar fracture or with a comminuted
Lefort fracture may sequestrate leading to late post trau-
matic period, forceful slipping of extraction instruments
(straight elevator and chisel) during upper posterior teeth
removal and this can lead to perforation.
Infections: There are some infections resulting in
palatal perforation seen in tuberculosis, tertiary syphi-
lis, leprosy, rhinoscleroderma, naso-oral blastomycosis,
leishmaniasis, actinomycosis, histoplasmosis, coccidio-
mycosis, and diphtheria.
Neoplastic: Tumors involving maxilla and other
anatomically related structures may require surgical
management and resection of the involved area, result-
ing in palatal perforation. Besides developmental cysts
like nasopalatine duct cyst, median palatal cyst, globu-
lomaxillary cyst, nasoalveolar cyst, and odontogenic
cystlike periapical cysts presence, when also treated by
enucleation and curettage may destroy the bony floor of
the nasal cavity and lead to oronasal fistula.1
Maxillary tumors are usually handled surgically,
either by conservative approach in localized lesions or
by a wide or radical approach in more aggressive lesions,
113
Archana Chaurasia et al
which includes maxillectomy, a process of partial or total
removal of maxilla in a patient suffering from benign
or malignant neoplasm.6 The resultant surgical defect
often includes part of the hard and soft palate, which
results in an oroantral and/or oronasal communication.7
Rehabilitation can be accomplished either surgically or
prosthetically.
Autoimmune: There are some autoimmune diseases
that result in palatal perforation, such as lupus ery-
thematous, sarcoidosis, Crohn’s disease, and Wegener
granulomatosis.
Idiopathic: Lethal midline granuloma is a disease entity
associated with the destruction of the nasal septum,
hard palate, lateral nasal walls, paranasal sinuses, skin
of the face, orbit, and nasopharynx by an inflammatory
infiltrate with atypical lymphocytes and histiocytic cells,
ulcerative necrotizing lesion with a strong inflammatory
component, angiocentric and angiodestructive, leading
to the destruction of structures and frequently to bone
sequestration, which causes perforation.
Others: Rhinolithiasis—Exogenous (such as grains,
small stone fragments, plastic parts, seeds, insects, glass,
wood, and others) or endogenous (dry secretion, clots,
cell lysis products, mucosa necrosis, and tooth fragments)
products may act as foreign bodies8 and lodge into nasal
cavity, resulting in an uncommon disease, which may
present asymptomatically showing characteristic pres-
ence of mineralized tumor,9 large enough to cause nasal
septum perforation or deviation, oroantral and orona-
sal fistula, chronic sinusitis, and destruction of lateral
nasal wall.10 Usual symptoms are progressive unilateral
nasal obstruction, rhinorrhea (usually purulent and fetid),
cacosmia, and epistaxis with headache, facial pain, and
epiphora seen less commonly.
The presence of maxillary sinusitis, epithelialization
of the fistula tract, osteitis, or osteomyelitis on fistula
margins, a foreign body, dental cysts, a dental apical
Fig. 1: Hole in the palate
114
abscess, or tumors prevent spontaneous healing and
result in perforation of palate.
Based on size, it can be categorized into three types:
small (<2 mm), medium (3–5 mm), and large (>5 mm).11
Hypernasality of voice due to audible nasal air escape
during speech, nasal regurgitation of fluids, food lodg-
ment into nasal cavity with risk of rhinitis and tonsillitis,
it is most commonly observed on the junction between
soft and hard palate.
CASE REPORT
A 54-year-old female visited our Department of Oral and
Maxillofacial surgery with a chief complaint of hole in
upper jaw since 7 to 8 months, which is slowly increasing
in size. She further gave a history of nasal regurgitation
of fluid, food lodgment in the defect, and hypernasality
of voice. She is wearing the suction cup denture for the
entire day and night, and has been removing it only for
cleaning from the last 4 to 5 years. The patient also reveals
that she is under medication for tuberculosis since last
1 month and gave no history of any drug allergy.
On examination, intraorally it showed two oval-
shaped holes present in the midline of the hard palate.
One was approximately 0.3 mm in dimension and another
was 0.6 mm in dimension (Fig. 1). On palpation, margins
were nontender. All surrounding tissues appeared normal
in color and texture. When the patient was asked to
gargle water, it escaped through her nose. No extraoral
abnormality was observed, and regional lymph nodes
were not palpable. Maxillary occlusal radiograph showed
radiolucency in the center of the hard palate. For the
measurement of the radiolucency, computed tomography
(CT) scan was done, and the measurement was 1.00 cm
in greatest dimension (Fig. 2). The patient was advised
to discontinue the denture immediately, and the surgery
closure was planned.
Fig. 2: Computed tomography scan showing palatal perforation

Fig. 3: Suturing of the palatal perforation using collagen membrane
The surgical closure of palatal perforation was
planned under general anesthesia. It was induced by
nasotracheal intubation. Patient was placed in the supine
position and neck extension achieved by keeping a pillow
under the shoulder. Local anesthesia with adrenaline was
injected around the lesion for hemostasis. The margins of
the fistula were excised to remove the epithelial lining.
Collagen membrane was used for the closure of the defect
using 3-0 Vicryl sutures (Fig. 3).
Before surgery, primary impression was taken and
acrylic plate was fabricated on the cast. The perforation
was blocked in the cast by wax to prevent unwanted
extension inside the defect. This plate was given to the
patient immediately after surgery.
One week postoperative review showed that the
defect area healed without infection, dehiscence, and was
covered with normal fibrin. Fifteen days after surgery, the
wound in the defect area healed well. After 2 months of
the surgery, the patient was referred to prosthodontics
for fabrication of new denture (Fig. 4).
DISCUSSION
The palatal perforation closure techniques are much
studied in the patients with the history of previous
surgeries and cleft palate. The management of palatal
perforation caused by suction cup begins with educat-
ing the patient about the ill effects of continuous use
of suction cup denture.12 These perforations are due to
continuous negative pressure from the vacuum, which
results in resorption of the underlying bone and atro-
phies the mucosa beneath the suction cups inserted into
the tissue surface of upper complete dentures.13 This
device is not advisable according to academic recom-
mendations, but it is used by nondentist denturists,
who traditionally fabricate complete dentures without
scientific knowledge.
Journal of Dental Sciences and Oral Rehabilitation, July-September 2017;8(3):113-116
JDSOR
Palatal Perforation: Case Report and Literature Review
Fig. 4: Postoperative 2-month follow-up
Palatal perforation beneath the suction cup under the
maxillary upper denture is a challenge for reconstruction.
Closures of palatal perforation are difficult because of the
stiffness of palatal mucosa and further complicated by the
nonavailability of adequate tissue for tension-free closure.12
No single procedure can be satisfactory for all types of
palatal perforation. The choice of operating technique
depends on the site and size of the defect and age of the
patient. Depending on the size of the defect, there are various
flaps available to close the defect. Palatal flap, nasolabial flap,
buccal pad of fat, and tongue flap are the locoregional flaps
that can be used to close the fistula. Among the distant flaps
that can be used are myofascial flaps, forehead flaps, etc.
Collagen can be used as an alternative to the above-
mentioned graft materials to cover the intraoral surgical
defects. As there is a large body of evidence that collagen
is a common denominator in all stages of wound healing,
it serves as the key extracellular component for repair and
remodeling.14 Unique features of collagen membranes
include guiding function, chemotactic property, hemo-
static property, and resistance to masticatory forces for
sufficient time and allowing granulation tissue to form.15
CONCLUSION
This to conclude that the use of collagen membrane
showed accelerated healing process. This may be
explained through the formation of a gelatinized coagu-
lum containing abundant amounts of fibrinogen and
fibronectin, which have high concentrations of chemoat-
tractants and growth factors that help in deposition and
organization of freshly formed fibers. Granulation tissue
facilitates migration of fibroblasts into the wound bed.16-18
Collagen appears to be biocompatible, has no signifi-
cant immune rejection, and is with biodegradable char-
acteristics. None of the cases showed adverse or allergic
reactions to the collagen, proving its safety as a biological
dressing material.19-21
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Archana Chaurasia et al
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