Palatal Lift Prosthesis for

the Treatment of Velopharyngeal 40

Incompetency and Insufficiency

Mohammed Mazaheri

40.1 Treatment, Methodology,
and Results in Patients with
Velopharyngeal Inadequacy
Before getting into methodology of treatment of
patients with velopharyngeal inadequacy, who
require prosthetic velar elevation and velopha-
ryngeal stimulation, let us outline the Lancaster
Cleft Palate Clinic’s present concept of treatment
for patients with various types of velopharyngeal
incompetency.
From 1984 to 1992, a total of 431 patients
were referred to the Lancaster Cleft Palate Clinic
with congenital or acquired velopharyngeal
incompetency (VPI) (Table 40.1). This popula-
tion consisted of 230 males and 201 females with
a mean age of 11.26 years. Note the breakdown
in the type of velopharyngeal incompetency. Two
hundred seventy-one patients (63 %) demon-
strated congenital velopharyngeal incompetency
without submucous cleft; 86 (20 %) had VPI with
a submucous cleft; 68 (16 %) had VPI related to
trauma; and 6 (1 %) had VPI as a result of dis-
eases such as myasthenia gravis, stroke, polio,
and other neurological disorders.
Each patient was examined and evaluated by a
plastic surgeon, prosthodontist, and speech-
language pathologist with a combined experience
M. Mazaheri, MDD, DDS, M.Sc.
Professor of Surgery Pennsylvania State University,
Hershey Medical Center, Past Medical and Dental
Director, Lancaster Cleft Palate Clinic,
223 North Lime Street, Lancaster, PA, 17602, USA
e-mail: dr.momaz@gmail.com
Table 40.1 Number of patients and type of velopharyn-
geal incompetency (VPI)
Number of patients
Male 230 (53 %)
Female 201 (47 %)
Type of velopharyngeal Incompetence
No cleft 271 (63 %)
Submucous cleft 86 (20 %)
From trauma 68 (16 %)
From disease 6 (1 %)
of 110 years. A questionnaire was designed for
data acquisition and long-term follow-up of these
patients (Table 40.2).
40.1.1 The Referral
It is interesting to note that 256 patients (59 %)
were referred by speech-language pathologists
(Table 40.3), indicating that velopharyngeal
incompetency is not recognized at an early
age and that the diagnosis is frequently made
when the patient starts school. The number of
physician referrals was 96 (22 %). The remain-
ing referrals (19 %) came from rehabilitation
counselors, dentists, rehabilitation centers, and
families.
Please note that 104 patients (25 %) had had
their tonsils and adenoids removed in order to
eliminate or remedy the velopharyngeal incom-
petency (Table 40.4). This, of course, causes an
increase in hypernasality for the VPI patient.

S. Berkowitz (ed.), Cleft Lip and Palate, 839

DOI 10.1007/978-3-642-30770-6_40, © Springer-Verlag Berlin Heidelberg 2013
840 M. Mazaheri

Table 40.2 Questionnaire designed to record appropriate information on patients for the study
1. Patient number ______________________________________________________________________________
2. Patient name ________________________________________________________________________________
3. Patient address ______________________________________________________________________________
4. Birth date _________________________________________ 5. Sex ________ Race:
______________________________
6. Referral source ______________________________________________________________________________
7. Chief complaint _____________________________________________________________________________
8. Specific diagnosis:
Congenital VPI, no cleft __________
VPI with cleft __________
VPI with submucous cleft __________
VPI from trauma __________
VPI from cancer __________
VPI with other diseases __________
Iatrogenic VPI __________
Other unclassifiable __________
9. Diagnostic data available
Cephs __________
Lateral only __________
Lateral and AP __________
At ages ___________________________
No cephs _________________ Tracings
Cineradiographs
Yes _________ at ages ___________________________
No _________
Recordings
Yes _________ at ages ___________________________
No _________
Dental models
Yes _________ at ages ___________________________
No _________
Growth analysis
Yes _________ No _________
Sonograms
Yes _________ No _________
Audiology examination
Yes _________ at ages ___________________________
No _________
Surgical records
Yes _________ No _________
10. Other conditions (short narrative or diagnostic classification)
Dental health: _______________________________________________________________________________
Orthodontic: ________________________________________________________________________________
Audiology, otology: __________________________________________________________________________
Allergies: __________________________________________________________________________________
Smoking habits:
No _________ Yes _________ Pack/day
Tonsils and adenoids removed:
Yes _________ age _________
No _________
40 Palatal Lift Prosthesis for the Treatment of Velopharyngeal Incompetency and Insufficiency 841

Table 40.2 (continued)

11. When was VPI first noticed:
Age of onset __________
Circumstance __________
Who first noted VPI __________
12. VIP treatment history
Speech therapy ______________________________ No. of sessions ___________________________________
Surgery (flap) _______________________________ Type of flap ______________________________________
Surgeon ____________________________________ Hospital ________________________________________
Other surgery _______________________________ Procedure _______________________________________
Surgeon ____________________________________ Hospital ________________________________________
Prosthesis __________________________________ Type of prosthesis _________________________________
Prosthodontist _______________________________ Hospital/clinic ___________________________________
13. Sequence of treatment (if multiple procedures)
Speech therapy only __________
Flap and speech __________
Flap only __________
Lift and speech __________
Lift only __________
Speech and flap __________
Speech and lift __________
Flap and lift __________
Lift and flap __________
Three procedures sequence:
1. _______________________ 2. _______________________ 3. _______________________
14. Evaluation of result (speech)
Date of last follow-up __________
Acceptable __________
Not acceptable __________
Acceptable but can improve __________
Not acceptable but can improve __________
No improvement likely __________
Should recall patient __________
15. Recommendations
Today’s date ____________________________ Preparer’s signature ____________________________

Table 40.3 Referral source for VPI patients Table 40.4 Status of tonsils and adenoids of VPI
pallechts
No. Percent of
Source of referrals sample (%) No. Percent of
Speech pathologist 256 59 Status of adenoids of cases sample (%)
Physician/surgeon 98 23 In 100 23
RN (nurse) 23 5 Out 104 24
Dentist 12 3 In/out (to insert 14 3
PDH/BVR 23 5 pharyngeal flap)
Rehabilitation center 1 0.5 No information available 213 50
Social worker 2 0.5
Family 18 4
842 M. Mazaheri

Table 40.5 Treatment methodology for patients with VPI Table 40.6 Status of patients who received palatal Lifts
No. Percentage of Status No. of patients
Treatment of cases sample (%) Palatal lift appliance removed 3
Speech only 126 29 for pharyngeal flap
Pharyngeal flap 122 28 Pharyngeal flap patients 13
Pharyngeal flap 55 13 received appliances
recommended Lift removed later 5
Palatal lift 74 17 Combined appliance removed 5
Palatal lift removed 8 2 later
after stimulation Still wearing palatal lift 5
Palatal lift 15 3 Combined appliance still 1
recommended being worn
Pharyngeal flap – 16 4
palatal lift
Palata lift – pharyn- 12 4 Table 40.7 Summary of use of prostheses and pharyn-
geal flap geal flaps
Palatal lift Combined appliance
Pathology N In Out In Out
In addition to oral examination, nasal endos- Congenital
copy, and individual judgment, all patients had PF-PL 9 4 5 0 0
two cephalometric radiographs taken, one with PF-COMB 3 0 0 1 2
the soft palate at rest and the second during pro- PL-PF 3 0 3 0 0
longed phonation of the vowel “E.” Twenty-five Trauma
percent of the subjects had cineradiographic PF-PL 1 1 0 0 0
studies of the velopharyngeal region to observe Totals
continuous phonation. Applianee 6 5 0 1 0
in
Applianee 10 0 8 0 2
out
40.1.2 Results of Treatment
Note: PF pharyngeal flap, PL palatal lift prosthesis, COMB
combination prosthesis
According to nasal endoscopic evaluation, radio-
graphic analysis, and listener judgments, 126
(29 %) of the patients demonstrated inconsistent Thirteen of the subjects with congenital VPI who
or borderline velopharyngeal dysfunction were treated with a pharyngeal flap continued to
(Table 40.5). The team decided that each subject exhibit a significant to moderate amount of hyper-
was to be referred to a speech-language patholo- nasal resonance and nasal emission (Tables 40.6
gist with instructions to have a review by the team and 40.7). Palatal lifts or combination prostheses
in 1 year if the condition persisted. Further evalu- were constructed for these patients. Five of these
ation of these patients after 1 year revealed that patients had the palatal lifts removed, and two had
the hypernasality or nasal emission had subsided, their combination appliance removed after 1 year
and none required further treatment. because the prostheses had resulted in their develop-
It was recommended that 177 patients (41 %) ing adequate posterior and lateral pharyngeal wall
have pharyngeal flap surgery. In 122 patients activity, and the patients were judged to have satis-
(mean age, 10 years), the surgical procedure con- factory voice quality without the appliances. Five of
sisted of a superiorly based flap performed by our the patients with a lift and one with a combination
staff plastic surgeon. The remaining 55 subjects appliance continued wearing their prostheses
were referred to the plastic surgeon of their choice because of consistent nasal emission and lack of
for a pharyngeal flap with instructions to return to response to the prosthetic stimulation. One patient
the clinic after insertion of the flap for further with VPI as a result of trauma who had pharyngeal
evaluation. flap surgery continued wearing his combination
40 Palatal Lift Prosthesis for the Treatment of Velopharyngeal Incompetency and Insufficiency 843

Table 40.8 Summary of Palatal lift Coinhination

status of palatal lift and Etiology N In position Removed In position Removed
combination prostheses used
for VPI of various etiologies Congenital 61 13 21 23 4
Trauma 19 11 4 1 3
Disease 9 3 3 3 0
Totals 89 27+ 28 = (55) 27+ 7 = (34)
Note: Of the 35 appliances that were removed, 3 were removed due to patient rejec-
tion and 32 were removed after increased velopharyngeal function and satisfactory
speech quality were achieved

prosthesis. The remaining patients with pharyngeal
flaps were judged to have acceptable speech quality
by the three team members. Further tests for nasal
and oral pressure (cul-de-sac shifting, listening tube,
nasal endoscopy, and oral manometer) substantiated
the clinical finding.
Eighty-nine of the subjects were fitted with a
palatal lift or combination prosthesis (Table 40.8).
Sixty-one of the patients with congenital VPI
(mean age, 11 years) had a palatal lift or combi-
nation appliance. At the time of this study, 13 of
the patients with a palatal lift were still wearing
their prostheses and 21 had gained adequate
muscle activity so that the prostheses were
removed. Twenty-three of the 61 patients were
still wearing a combination lift, and 4 gained
adequate tissue stimulation, so the prosthesis was
discarded.
Of the 19 patients with traumatic VPI (mean
age, 21 years), 11 had their prostheses still in
position, 4 were removed, 1 had his combination
in position, and 3 had rejected the combination
prosthesis because of difficulty of adjustment,
more difficulty swallowing, or lack of patient
motivation and/or cooperation.
Of the 9 patients with VPI as a result of vari-
ous neurological diseases, 3 have a palatal lift in
position, 3 appliances have been removed, and 3
have a combination appliance still in position.
Fifteen additional patients were recommended
for palatal lift prostheses, but the subjects or sub-
jects’ families elected not to have any form of
treatment. Six-month follow-up revealed that the
patients or the parents were satisfied with the
patient’s speech as it was. It was recommended to
five patients that their palatal lift be removed in
favor of a pharyngeal flap performed by a plastic
surgeon in the patient’s hometown. There was no
follow-up at the Clinic for these patients after the
insertion of the flap.
40.1.3 Summary
Analysis of the 35 patients whose appliances were
removed revealed that 3 patients rejected the pros-
thesis within 6 months. Of the remaining 32
patients, 3 appliances were removed to insert a
superiorly based pharyngeal flap, and 29 were
removed when the patient demonstrated voice
quality without the appliance that was judged to be
satisfactory. Hypernasality was no longer a concern
to these patients. The judges found this to be
accurate.
In our population, use of the palatal lift or
combination appliance for patients with traumatic
VPI resulted in more acceptable speech perfor-
mance than with velopharyngeal flap.
40.1.4 Conclusion
It is interesting to note that a majority of the
patients referred to the Lancaster Cleft Palate
Clinic for velopharyngeal incompetency were
referred by speech-language pathologists. It was
also interesting to note that a significant number
of patients had had their tonsils and adenoids
removed to remedy their hypernasality.
We have found that patients with a gap of
more than 12 mm between the soft palate and
posterior pharyngeal wall respond more favorably
to physical therapy with a palatal lift or combina-
tion prosthesis prior to a pharyngeal flap than
patients who have a pharyngeal flap as the initial
mode of treatment.
844
Two of the subjects with complete paralysis
of the soft palate as a result of traumatic injury
had pharyngeal flaps performed by non-team
member plastic surgeons; neither of these sur-
geries produced an acceptable speech quality
result.
It is also interesting to note that a majority
of the patients were diagnosed as having
velopharyngeal incompetency after the age of
5. The studies show that the younger patients
responded much more favorably to our treat-
ment modalities (pharyngeal flap, palatal lift)
than older patients. Therefore, it behooves us
to diagnose cases at earlier ages and undertake
the required treatment as early as possible.
40.2 Palatal Lift Prostheses
for the Treatment of Patients
Requiring Velar Elevation,
Velopharyngeal Stimulation,
and Velopharyngeal
Obturation
40.2.1 Symptoms
Hypernasality or nasal emission and decreased
speech intelligibility occur as a result of several
organic conditions (e.g., congenital or acquired
cleft of the palate, congenital short soft palate or
palatal paresis or velopharyngeal insufficiency,
velar paralysis or velopharyngeal incompetency,
abnormal nasal pharyngeal size, and hypernasality
occurring after the removal of the tonsils and
adenoids).
40.2.2 Etiology
The etiological factors contributing to the devel-
opment of these organic conditions can be
classified into two major categories:
1. Prenatal
(a) Cleft of the palate
(b) Short soft palate
(c) Abnormal nasal pharyngeal size
(d) Abnormal velopharyngeal neuromuscular
development
M. Mazaheri
2. Postnatal
• Partial or completely paralyzed velum as a
result of central or peripheral nervous sys-
tem damage (e.g., a patient with myasthe-
nia gravis, bulbar polio, traumatic brain
injuries, cerebral vascular accidents, degen-
erative central nervous system diseases,
and amyotrophic lateral sclerosis).
40.2.3 Speech Characteristics
Speech characteristics common in both types of
patients with velopharyngeal incompetency and
velopharyngeal insufficiency are:
1. Hypernasality
2. Nasal emission
3. Decreased intelligibility of speech due to weak
consonant production
The patient with velopharyngeal insufficiency
often develops glottal stop substitution as a result
of compensation for production of pressure con-
sonants. The patient with neurological diseases
resulting in a full or partial paralysis of lips,
tongue, larynx, or respiratory musculatures often
develops an abnormal articulatory pattern and
diminution of breath pressure, which causes a
reduction of oral pressure and flow.
40.2.4 Methods of Treatment
The closure and obturation of palatal clefts and
defects for patients with congenital and acquired
clefts have been reported. Early humans used stone,
wood, gum, cotton, and other foreign bodies to
obturate the palatal opening. In recent years, sev-
eral methods have been advocated for satisfying
the main objective of socially acceptable speech
for these patients. Among these concepts are:
1. Traditional speech treatment, such as active
lip, tongue, and palate exercises for the stimu-
lation and physical therapy of musculatures
(myofunctional therapy), designed to effect
reduction in hypernasality.
2. Surgical methods designed to reduce the
velopharyngeal gap or lumen, employing velar
lengthening procedures, velopharyngeal flaps,
implants (cartilage, bone, silicone, Teflon®),
and combinations of several methods.
40 Palatal Lift Prosthesis for the Treatment of Velopharyngeal Incompetency and Insufficiency
Fig. 40.1 (a) Patient with palatopharyngeal insufficiency.
The treatment procedure is the stimulation of the soft pal-
ate by a palatal lift prosthesis followed by pharyngeal flap
3. Faradization and electrical vibration massage
to stimulate palatal function.
4. Prosthetics designed to elevate and stimulate
the soft palate in patients with velopharyngeal
incompetency or to elevate, stimulate, and
obturate the velopharyngeal lumen in patients
with velopharyngeal insufficiency.
As previously stated, two prosthodontic pro-
cedures are available to us in the treatment of
patients with velopharyngeal inadequacies:
1. Lift type
2. Combination of lift and bulb
The lift type of prosthesis is used to elevate the
soft palate to the maximum position attained during
normal speech and deglutition. The reduction in size
of the velopharyngeal gap and lumen will decrease
nasal air flow, increase oral pressure for consonant
articulation, and improve voice quality. The lift may
845
surgery. (b) View of palatal lift prosthesis in position. (c)
Palatal view of the lift prosthesis
also act as a physical modality for stimulation of
velar and pharyngeal musculatures and elimination
of the occurrence of velar disuse atrophy (Figs. 40.1,
40.2, 40.3, 40.4, 40.5, and 40.6).
The combined lift/bulb prosthesis should be
the method of choice when the soft palate is
insufficient for the proper velopharyngeal clo-
sure. The combined lift/bulb prosthesis is used to
elevate the soft palate, obturate the gap, and stim-
ulate velopharyngeal development and pharyn-
geal constriction (Figs. 40.7 and 40.8).
40.2.5 Prerequisites of Lift
and Combination Prostheses
1. The maxillary portion of the prosthesis is desi-
gned to achieve optimal retention and stability.
846 M. Mazaheri

Fig. 40.2 (a) Lateral radiograph of patient in Fig. 18.1 demonstrates the palatopharyngeal relationship prior to elevation
and stimulation. (b) Height of velar elevation during the sound “E.” (c) Tracing of the cephalogram in a

Fig. 40.3 (a) Radiographic view of the palatal lift pros- surgery was done after 14 months of soft palatal stimula-
thesis of patient in Fig. 18.2 in position. Note the degree tion, after which the lift prosthesis could be discarded. (c)
of palatal elevation. (b) Increased mobility of the soft pal- Cephalometric tracing of the palatal lift prosthesis and the
ate after 1 year of prosthetic stimulation. Pharyngeal flap degree of velar elevation accomplished by the lift
40 Palatal Lift Prosthesis for the Treatment of Velopharyngeal Incompetency and Insufficiency 847

Fig. 40.4 Top left: Patient with palatopharyngeal incom- soft palate elevation after 6 months of prosthetic velar
petency in which the soft palate is paralyzed as a result of stimulation. Bottom right: Oral and palatal view of the lift
neurologic involvement after an accidental head injury. prosthesis
Top right: Palatal lift in position. Bottom left: Increased

Fig. 40.5 (a) Lateral radiograph of the patient in Fig. 11 months of stimulation and speech therapy patient is
18.4 prior to stimulation saying “E.” (b) The palatal lift saying “E.” Note the substantial increase in the velar
prosthesis in position elevating the soft palate. (c) Note elevation
the increase in the degree of palatal elevation. After
848 M. Mazaheri

Fig. 40.6 (a) Tracing of a lateral cephalogram of the patient in Fig. 18.5 prior to soft palate stimulation by a palatal lift
prosthesis. (b) Tracing of the palatal lift prosthesis and elevated soft palate

Fig. 40.7 (a) Patient with a palatopharyngeal tion in position. The uvula was displaced by the prosthesis
insufficiency in which the soft palate is short and has lim- without causing any irritation. (c) Palatal view of the
ited mobility. (b) Combination palatal lift pharyngeal sec- prosthesis
40 Palatal Lift Prosthesis for the Treatment of Velopharyngeal Incompetency and Insufficiency 849

Fig. 40.8 (a) Lateral radiograph demonstrating short soft combined palatal lift/pharyngeal section prosthesis in
palate and large nasopharynx. (b) Tracing of the lateral position
cephalogram of the patient in Fig. 18.7. (c) Tracing of the

2. The lift portion should be placed so that velar
elevation occurs in the area where normal
velopharyngeal closure takes place.
3. Elevation of the velum should be gradual
so that the velum becomes less resistant to
displacement.
4. The pharyngeal section should be placed in the
area where posterior and lateral pharyngeal con-
striction takes place so that it increases the change
of further stimulation and muscle activation.
5. The reduction of pharyngeal section, when
indicated, should be gradual.
6. Speech therapy, such as active lip, tongue, and
palatal exercises and placement, should be
properly instituted in conjunction with the
construction and insertion of the prosthesis.
40.2.6 Objectives in Making Prosthetic
Lift and Combination Services
1. Reduce hypernasality and nasal air escape by
velar elevation
2. Reduce the degree of disuse atrophy
3. Increase velopharyngeal function by constant
and continuous stimulation
4. Increase neuromuscular response by gentle
stimulation and speech exercises
40.2.6.1 Results of Using Lift and
Combination Prostheses
Methods of Evaluation
1. Speech testing procedures
2. Nasal endoscopy
850
3. Radiographic evaluation (e.g., cineradiogra-
phy, cephalometrics, sectional laminography,
or tomography)
4. Oral nasal air pressure and air flow assessing
devices
5. Electronic instrumentation such as Tonar and
sonograph
The optimal result depends on the type of oral
pharyngeal involvement. If the neurological disor-
der is more localized to the velopharyngeal region,
and the patient has few or no speech articulatory
disorders, the prosthetic result is optimal. Patients
with muscle paralysis of the tongue, lips, larynx,
and respiratory organs usually respond less favor-
ably to prosthetic care. Their phonatory and artic-
ulatory disorders usually remain after the prosthetic
treatment. These patients often require more inten-
sive and coordinated myofunctional therapy.
Patients’ tolerance and acceptance of pros-
thetic treatment vary. Some patients have less
difficulty than others, becoming accustomed to
the palatal and velopharyngeal coverage and
decreased oral pharyngeal space and volume.
We have also noted variations in muscle
response to mechanical stimulation. The velum
of the same patient, shortly after placement of the
lift, becomes more active, and after 6 months to
1 year, prosthetic stimulation and support can be
discarded. Whether the increased velar elevation
is the result of prosthetic stimulation or neuro-
musculature recovery is difficult to assess.
However, we can state that, in our experience,
similar patients who received speech therapy as
the only mode of velopharyngeal stimulation
demonstrated less functional recovery over the
same period of time than patients where the pros-
theses were employed (see Figs. 40.6 and 40.7).
In our series of patients, we have found
more marked nasal pharyngeal than velar
musculature response to the prosthetic stimulation.
With the velopharyngeal bulb, the patient often
develops compensatory muscular constriction,
requiring frequent reduction in the size of the
pharyngeal bulb. In some patients, complete
elimination of the bulb was accomplished. We
could safely state that the reason for the varia-
tion in the degree of response observed in
patients with velar incompetency and patients
with velopharyngeal insufficiency is that we
M. Mazaheri
have two separate phenomena to consider. For
one patient, we are trying to stimulate muscle
activity by prosthetic physical therapy; for the
other patient, we are attempting to create mus-
cle build-up or constriction as a result of pros-
thetic placement.
40.3 Summary
1. Velar elevation should be gradual in order to
put less pressure on the teeth retaining the
prosthesis and to reduce the possibility of
mucosal irritation.
2. Prosthetic stimulation should be initiated as
soon as velar paralysis is noted, to reduce the
occurrence of velar disuse atrophy.
3. The palatal lift prosthesis is used as a tempo-
rary or permanent measure for the correction
of velar incompetency. As soon as adequate
elevation occurs, the prosthesis is discarded.
Otherwise, the patient could wear the prosthe-
sis as a permanent supportive device.
4. Construction of the combination lift/bulb pros-
thesis requires a program of gradual velar eleva-
tion and molding of the pharyngeal bulb to
reduce the gag reflexes and increase velopharyn-
geal adaptation to the prosthesis. After initial
placement, modification of the velopharyngeal
section becomes less troublesome to the patient.
5. Speech and myofunctional therapy should be
instituted in conjunction with the prosthetic
treatment.
6. Prosthetic lift and combination prostheses are
more effective for patients with less severe
neurological impairment and speech articula-
tory errors.
7. The prosthetic lift has been more effective for
patients with velar incompetency without
involvement of other oral pharyngeal muscu-
latures, whereas the combination type has
been more effective for patients with velopha-
ryngeal insufficiency without marked speech
articulatory disorders.
Several questions require further
investigation.
1. What is the relationship between the palatal
stimulation and degree of neuromuscular
function and recovery?
40 Palatal Lift Prosthesis for the Treatment of Velopharyngeal Incompetency and Insufficiency 851

2. What is the relationship between stimulation 4. What is the degree of stability of velopha-
and degree of occurrence of disuse atrophy? ryngeal function and constriction after stimu-
3. What is the relationship between pharyngeal lation?
stimulation and muscle constriction?