This action might not be possible to undo. Are you sure you want to continue?
ALI ARAM, D.M.D.,"
FUNCTION AND CLEFT PALATE PROS
have made remarkable contributions toward fulfilling the communicative needs of cleft palate individuals. This has been accomplished by the construction and placement of prosthetic appliances. Techniques and designs for prosthetic construction to improve speech potential have been described and discussed in dental literature.lS4 Basically, these prosthetic “aids to speech” serve to obturate any opening or cleft of the palate and frequently carry an extension into the pharynx designed to improve or supplement velopharyngeal valving. An understanding of normal velopharyngeal function and an appreciation of the consequences of abnormal function seem to be prerequisite to any meaningful discussion of data relating to cleft palate prosthesis. During speech, the soft palate normally elevates and retracts to contact pharyngeal structures which are constricting simultaneously. The synergistic behavior of the velar and pharyngeal musculature creates a sphincteric type of constriction, commonly called a velopharyngeal closure. Adequate velopharyngeal closure prevents the passage of air from the oropharFunctional valving cannot be attained ynx into the nasopharynx during function. if a soft palate is short, limited in mobility, or cleft. As a consequence, air and sound energy are transmitted into and through the nasal cavity during speech. This results in an unpleasant nasal quality in speech and in a reduction of intraoral breath pressure. Because of this, some speech sounds cannot be produced and become dis:orted as well as weakened. A prosthesis with a pharyngeal extension may be constructed for such patients so that adequate valving for speech purposes can be ieveloped. The pharyngeal extension, usually constructed of acrylic resin, must conform :o the dimension, shape, and position of the velopharyngeal opening which exists luring function. It must be designed so that there is a close approximation of the ‘unctioning musculature around the acrylic resin section during speech and degluti.ion. Therefore, the proper positioning of the pharyngeal section is critical to jrosthetic success.
This investigation was supported in part by a research grant, D-553, from the National nstitute of Dental Research of the National Institutes of Health, United States Public Health ervice. Received for publication March 28, 1958. *Orthodontic Department.
NTERESTED, WELL-INFORMED, AND RESOURCEFUL dentists
In a few roentgenograms.10 56.97 4.01 6.60 2.80 3. or placement.33 -0. those which do not improve speech potential appreciably. 90 subjects. METHOD OF STUDY For the purpose of this study. the x-ray registrations are comparable from one functional position to the next and permit qualitative as well as quantitative analyses.85 4. commonly result from pharyngeal sections which are inappropriate in size.70 6.42 2.150 ARAM AND SUBTELNY J. with the mandible at rest position.07 2. Three lateral cephalometric Lateral headplates were secured roentgenograms were made of each individual.36 2. ranging from 4 to 20 years in age.5-17 years of age). Fifteen individuals were included in each age group.30 2.-Feb.) 4-5 6-8 9-11 12-14 IS-17 . Group V (1. and Group VI (18-20 years of age). the approximate level of velopharyngeal closure was investigated.38 9. Group II (6-8 years of age).50 6. From the composite tracing.92 2.93 60. Group IV (12-14 years of age).78 * =t + * * * 2.20 6.47 7. Specifically. This study of normal velopharyngeal function was undertaken in an effort to acquire some useful information relative to the positioning of a prosthetic pharyngeal extension. 1959 Prosthetic failures. They were divided into six age groups : Group I (4-5 years of age). that is. a tracing of the headplate with the teeth in occlusion was made for the purpose of comparison and as a guide for outlining the soft palate and related structures.37 55.) ANTERIORTUBERCLE 0 FATLAS TOMID-POINT OF CLosURE(MM. The two tracings of the same subject were superimposed on the palatal plane (a line drawn from the anterior nasal spine to the posterior nasal spine of the hard palate). TABLE I. Den.18-20 44. . and a composite tracing was made. Pros.77 2. The position of the subject’s head relative to the source of x-rays and the degree of magnification are controlled carefully. the possibility of changes in the level of closure.25 4.50 5. Jan.99 51. with the teeth in occlusion. and with the subject phonating “00” as in “food.83 44.” The cephalometric technique5 permits the stabilization of the subject’s head within a specially designed headholder.01 5.49 2.03 2.21 The roentgenograms obtained while the subject was at “rest” and during the phonation of “00” were studied and traced.. various linear and angular measurements were made.00 2.50 * * * * f * 8.06 -1.32 8. incident to growth.38 4. With the realization that speech aids are designed for children as well as adults. Group III (9-11 years of age). were studied. Thereby.78 5. MEAN MEASUREMENTSIN DIFFERENTAGEGROUPS GROUP AGE RANGE IN YEARS SOFT PALATE MOVEMENTIN DEGREES IL PALATAL PLANE TO MID-POINT OF CLOSURE (MM.87 * * f * * f- 3. were evaluated. shape. where the entire configuration of the soft palate at rest was not clearly visible.
Right. the soft palate moved in an upward and backward direction to create a closure (Fig. In all instances. I. Tracings of cephalometric *oentgenograms depict the upward and backward movement of the soft palate (stippled area) iuring phonation. The graph shows the average degree of movement for each age group. The position of the soft palate during phonation was defined by a line drawn from the posterior nasal spine to the mid-point of velopharyngeal closure.--Soft palate at rest and during velopharyngeal closure. The degree of velar movement from rest to closure was found to increase with increment in age (Table I).-A tracing of a cephalometric roentgenogram illustrates the method of measuring the degree of soft palate movement. 2.D CLEFT PAL.51 SOFT PALATE The position of the soft palate at rest was defined by a line drawn from the posterior nasal spine of the hard palate to the tip of the uvula. . The degree of movement was determined by measuring the angle formed between these two lines. rest to closure.” Fig.\‘olun1e 9 A-umber 1 \~H~OI’IIARYNGEAL MOVEMENT FCNCTIOK A. phonation “00.4TIS PROSTHESES 1. rest. In other words. Means for the degree of soft palate movement from rest to closure were established for each age group. 1) . closure. Left.h. the soit palate moved a greater amount in older age groups in order to contact the superior Fig.
Not only did the site of velopharyngeal closure change with increment of age. Den.-Feb. The soft palate most frequently approximated the superior and/or the superior-posterior aspects of the nasopharynx in the younger age groups. The site of closure age levels. At an early age. 3). adenoid tissue is no longer evident. the soft palate is closer to the base of the cranium and the underlying soft tissue forming the roof of the nasopharynx.. Fig. The transition was particularly noticeable in the 9. In the older age groups. Thereafter. during phonation is different at different SITE AND SPAN OF CLOSURE Examination of the cephalometric headplates obtained during the phonation of “00” revealed that there was a change in the site of velopharyngeal closure relative to age. Jan. the soft palate in function approximates the posterior pharyngeal wall rather than the superior-posterior aspect of the nasopharynx. it would seem that the soft palate could approximate the superior and/or the superiorposterior aspect of the nasopharynx with a lesser degree of elevation at an early age. Therefore.-Soft palate at Closure. the soft palate almost always contacted the posterior pharyngeal wall during phonation (Fig. There is an increased vertical distance between the hard palate and the base of the cranium. 2). It seems logical that the site of closure should change with increment in age. Pros. These factors increase the dimensions through which velar movement occurs. In the older age groups.6 At the same time.to ICyear age group (Fig. The mean established for the degree of movement was the same for the first two age groups (4-8 years of age).152 ARAM AND SUBTELNY J. but the amount of velar tissue effecting the closure was also observed to change with . 3. a mass of adenoid tissue is frequently present. This tissue serves effectively to bring the roof of the nasopharynx closer to the level of the soft palate. 1959 and/or the posterior pharyngeal wall. the degree of soft palate movement increased continuously until seventeen years of age. In the last group (18-20 years of age). As a result.to 1l-year age group. the movement of the soft palate decreased somewhat to the approximate degree of movement defined for the 12. and the soft palate is observed to assume a more nearly vertical relationship to the base of the skull.
3).6 mm. In order to do this. On lateral cephalometric roentgenograms. the uvula of the soft palate does not contribute appreciably to effecting a velopharyngeal closure during speech function. 4. both of which could result from increased pharyngeal dimensions incident with growth. the significant observation is that this change is almost equal to a 50 per cent reduction in vertical extent of closure. the linear span of the soft palate tissue contacting pharyngeal tissue during phonation was measured. It has been reported that during functional valving of the velopharyngeal port. in the first age group to 4. the reduction in average span or vertical extent of closure represents only 4 mm. Normally.-A tracing of a cephalometric roentgenogram illustrates the method of measuring in The graph shows the average millimeters from the palatal plane to the mid-point of closure. in the last age group. The vertical span of soft palate tissue effecting the velopharyngeal closure in the mid-sagittal plane of the head was found to decrease from an average of 8. However. Fig. However.4 mm. and this was observed in only 3 of the 90 subjects studied. the changes in site of closure have been described relative to the pharynx. in the older age groups.7 This statement is supported by the present data and appears to be especially applicable to the younger age groups. This apparent change is compatible with the decrease in the span of closure. Point contact between velum and pharynx was not found during velopharyngeal closure in any of the subjects studied. position of the mid-point of closure to the palatal plane for each age group. As the figures indicate. In order to quantitate this observation. The minimum span of soft tissue contact was 1 mm. the middle third of the soft palate contacts the pharyngeal wall.. it seemed that the more distal portion of the middle third of the velum was most functional in effecting the closure. the vertical distance from the palatal plane to the mid-point of closure was measured (Fig.Volume 9 Number 1 VELOPHARYNGEAL FUNCTION AND CLEFT I’ALATE PROSTHESI3 1s3 age. 4). The fact that the pharynx itself goes through morphologic alterations suggests that the level or site of closure might well be evaluated in reference to the palatal plane. Incident with growth. the uvula generally is not found to be in contact with pharyngeal tissues during function (Fig. .
the myodynamics of the velopharyngeal region can best be considered in reference to the palatal plane. Jan. As a corollary. the mid-point of the velopharyngeal closure was closely related to the level of the hard palate. Specifically. but was found to be comparatively stable as well. The means ranged from 2 mm. Pros. For this reason. the mid-point of velopharyngeal closure was slightly below the level of the palatal plane from 4 to 8 years of age. some muscular components of the velum insert into the pharynx. To a great extent. The level of velopharyngeal function is related frequently to the anterior tubercle of the first cervical vertebra.-F&. Although the average degree of soft palate movement during phonation increased with increment in age. 7). In addition. In addition. From these measurements. 1959 The level of velopharyngeal closure was found to be closely related to the palatal plane. They provide some quantitative information relative to tl normal function of the soft palate and the relationship of this tissue to contiguou structures. the vertical distance between the mid-point of closure and the most prominent point of the anterior tubercle of the first cervical vertebra was found to increase with age. it was consistently above the level of the palatal plane. it was slightly below . In all age groups. in the older age groups (Table I). There are several reasons why velopharyngeal function should be considered in reference to the palatal plane. Den.to 11-year age group to 3 mm. The resulting measurements showed much more variability than was observed when closure was related to the palatal plane. Thereafter. these factors may account for the finding that there is less variability in defining the level of velopharyngeal closure when it is located in reference to the palatal plane. in relation to the palatal plane. the means revealed that the mid-point of closure was always above the level of the anterior tubercle of the atlas (Fig. the soft palate is a contiguous structure with some of its muscular components inserting as well as taking origin on the hard palate and its attached aponeurosis. Because of this anatomic and physiologic inter-relationship. Primarily.. the findings relate directly to the functional level for the placement of the pharyngeal section of the prostheses. in the 9. the mean established for the mid-point of closure in reference to the palatal plane was not only consistently above the level of the palatal plane.8 This may account for the increase in vertical distance between the level of velopharyngeal closure and the tubercle of the atlas. the vertical distance between the mid-point of closure and the most prominent point of the anterior tubercle of the atlas was measured for each age group. CLINICAL IMPLICATIONS These findings may be helpful in diagnosis and treatment planning for cleft palate individuals. it can be postulated that a mature level of velopharyngeal closure. On the average. the anterior tubercle of the atlas drops in vertical relationship to the base of the skull at a faster rate than does the hard palate with increment in age. On the average. Such information appears to have considerable clinical application in regard to the construction of cleft palate prostheses. is attained by approximately 12 years of age and that little change occurs in the level of function thereafter. After 9 years of age.154 ARAM AND SUBTELNY J.
Air and sound energy can pass readily from the oral pharynx into the nasopharynx during function. phonating “00.” The pharyngeal section does not aid velopharyngeal tion. Fig. Note that the pharyngeal contacts the posterior pharyngeal wall above the level of a Passavant’s pad.-A tracing of a cephalometric roentgenogram of an individual with an adequate cleft of the speech appliance.-A tracing of a mid-sagittal lammagraph of an individual with an inadequate speech function during phonaaid phonating “00.5 Fig. The pharyngeal section is above the palatal plane.Volume 9 Number 1 VELOPHARYNGEAL FUNCTION AND CLEFT PALATE PROSTHESES 1 5. 5. . 6.” The prosthesis passes through an unoperated section palate.
1959 the level of the hard palate until 8 years of age and. i. ‘I. The pharyngeal extension should be placed as nearly as possible within the region of muscle function. posterior. However. and lateral aspects of the pharyngeal section. functional valving must be attained on the anterior. 6). or surgically closed. Jan:Feb. the extension should follow the oral contour of the resting soft palate and then project upward and backward to reach the desired level within the nasopharynx (Fig. 8). but short. If the soft palate is completely cleft. 2 The present data show that this would be a poor landmark for guidance in the construction and placement of the pharyngeal sections (Fig. the prosthesis can easily extend through the opening of the cleft to the desired level (Fig. thereafter. The lateral walls of the nasopharynx usually move medially during velo- . of velopharyngeal closure relative to the anterior Many dentists have attempted to approximate pharyngeal tissue overlying the anterior tubercle of the first cervical vertebra on the basis that this area was that of maximum pharyngeal constriction.156 ARAM AND SUBTELNY J. Den. This normative data indicates that the projected level of the hard palate should serve advantageously as a “guidepost” in approximating the region of muscular function during speech.-The average level of the mid-point tubercle of the first cervical vertebra.. it may obturate the cleft. If the pharyngeal extension of the prosthesis is above the palatal plane in the region of muscular function. 5). If it is much below this level. Fig. The pharyngeal section must be properly designed once the desired level is reached. There are differences in the degree and location of pharyngeal movement as well as in velar activity which may make it necessary to modify the shape and placement of the pharyngeal section. consistently above it. It must be recognized that individual asymmetries in pharyngeal function exist. but remain ineffectual in assisting velopharyngeal function (Fig. the nasopharynx. it can serve best as an adequate speech aid (Fig. Pros. 5). 7). If the soft palate is intact..e. The acrylic resin section must contact the posterior pharyngeal wall and be contacted by the muscles of the lateral aspects of the nasopharynx as well as the soft palate during function.
in addition to the muscular forces exerted upon the pharyngeal section. The prosthetic extension first projects downward to accommodate the Boft palate at rest. In older age groups. the dentist must clasp dental units for the anchorage of a prosthesis which extends posteriorly into the nasopharynx. the muscles of the lateral walls of the nasopharynx will not contact it. It seems important that the dentist should strive to keep the mass of the pharyngeal section to an absolute minimum in size and yet sufficiently bulky to function properly. and an opening between the oral and nasopharynx will exist. could advantageously aid in preserving the health of the supporting structures of the dentition. Thus. 8. it was observed that the span of soft palate tissue contacting the posterior pharyngeal wall during velopharyngeal closure was not great.Volume 9 Number 1 VELOPHARYNGEAL FUNCTION AND CLEFT PALATE PROSTHESES I. For stability. the supporting structures of the teeth may be damaged. Eventually. when the soft palate normally contacts the posterior pharyngeal wall. On the lateral cephalometric roentgenograms. Unnecessary bulk. This consideration Fig. This will defeat the purpose of the prosthesis. the pharyngeal prosthesis does not necessarily have to extend all the way to the superior aspect of the nasopharynx.57 pharyngeal function. the stability of the “speech aid” may be lost. If the acrylic resin section is not adequate in its lateral extension. The dentist must examine the lateral extension of the pharyngeal prosthesis carefully. will increase “leverage” stresses placed upon the clasped teeth. . It then projects toward the cranium to carry the pharyngeal section into the nasopharyngeal region.-A tracing of a cephalometric roentgenogram on an individual with a surgically repaired cleft palate. With an unfavorable alteration in the supporting structures of the teeth utilized for anchorage. and it is a potential source of failure. The subject was phonating “00” during the roentgenographic procedure. it would seem that the pharyngeal section of a prosthesis would not have to contact the posterior pharyngeal wall over a very large vertical area. for it is overlooked frequently.
1951. REFERENCES 1. PROS.. Subtelny. 1931. 1954. J. it remains the only hope for an adequate speech rehabilitation of an individual with a cleft of the palate. Angle Orthodont. Prosthetic Treatment. PROS.: Fundamental Principles of Orofacial Prosthetic Therapy in Congenital Cleft Palate. R..D. D. 2. ROCHESTER 8. It should behoove the dentist to use all possible measures to construct an adequate speech aid. Baden. King. T. 3. J. E. 6. : Movements of the Soft Palate. Jan. Pruzansky. 1957. Ei9V&.: A New X-Ray Technique and Its Application to Orthodontia. PROS. This can be accomplished only with a careful diagnosis and careful appliance construction. Den. Plastic Surg.DEN. 5:286. J.. 5. 800 MAIN ST. Surg. Brit.A. strengthened with the knowledge of the correct position of the individual parts for proper function. J. 7:216. 8. Angle Orthodont. C.158 ARAM AND SUBTELNY J. Plastic & Reconstruct. S. Malson. Calnan. DEN. 4:568.-Feb. S.. S.DEN. 1957. 7.: Prosthetic Rehabilitation of a Cleft Palate Patient Subsequent to Multiple Surgical and Prosthetic Failures. 22:23.: A Roentgenographic Study of Pharyngeal Growth. E. Y. H.: Nonobstructing Prosthetic Speech Aid During Growth and Orthodontic Treatment. In many instances. Harkins. S. 1957.: Role of the Prosthodontist in the Rehabilitation of Cleft Palate Patients. 1:45. . 43:29. J. and Subtelny. 19:49. 1953. D. Lloyd. J. Part II. Broadbent. 4. J. 7:403. S. J. 1959 The prosthodontist is called upon frequently to construct a “speech aid” when all other therapeutic procedures have failed. N. The normative data presented may be helpful in indicating the proper position for the pharyngeal section of a speech appliance.A.: A Cephalometric Study of the Growth of the Soft Palate. R. Pros.