Khe Hở Môi Và Vòm Miệng: Chẩn Đoán Và Quản Lý Điều Trị (Cleft Lip and Palate)

806
J.E. Riski
soft palate of the cleft palate-only group and in
the growth in depth of the nasopharynx of the
bilateral cleft lip/palate group. Based on the pres-
ent cephalometric data, it was impossible to pre-
dict at an early age those cleft lip and/or palate
patients who will later require management of
velopharyngeal incompetence.
Other investigators have demonstrated that a
careful speech analysis has important predictive
value of future velopharyngeal competence. Van
Demark and his colleagues produced a number of
investigations in the 1970s that valuated the pre-
dictive value of the articulation test. Van Demark
and Morris ( 1977 ) studied the articulation test
scores for 278 subjects with cleft palate and com-
pared the results with the normative data of the
Iowa Pressure Articulation Test (IPAT) and the
Templin-Darley Screening test of Articulation. In
addition, the predictive value of the IPAT in rela-
tion to the need for secondary management was
examined. Examination of the data concerning
“risk rates” indicates that the IPAT is very useful
in predicting the need for secondary management.
Subjects who obtained scores of zero on the IPAT
at four and one-half years of age had a 96 % risk
of requiring secondary palatal management.
In 1975, Van Demark et al. ( 1975 ) evaluated
the articulation scores, lateral x-rays, and clinical
judgments of velopharyngeal competency of 75
subjects in order to determine their predictive
value. Each of the measures resulted in at least
90 % appropriate predictions. However, the com-
bination of articulation score and lateral x-ray
rating appeared to be the best predictor for this
particular sample in that subsequent treatment
was correctly predicted for 96 % of the subjects.
38.4
Predicting Future Speech
Pro fi ciency
A single type of cleft palate does not result in a
homogeneous population. Clefts of the same type
(e.g., unilateral cleft of the lip palate) will have
very different outcomes. Some children will
develop normal speech following surgical repair
of the cleft with very little other intervention. Do
they have more of a chance of velopharyngeal
competence, better hearing acuity, and a dental
arch more conducive to normal speech? Other
children develop speech and language more
slowly and are ushered into early intervention
programs. We still have no way of identifying
which children are going to require extensive
behavioral intervention without continually mon-
itoring speech development and careful evalua-
tion of speech and velopharyngeal function.
Although gender is not a signi fi cant variable
in the outcome of surgery, it appears to be an
important variable in the development of speech
pro fi ciency. Hardin et al. ( 1990 ) examined the
relative contribution of clinical data obtained
during speech examinations at age 4 years and at
each subsequent age through 13 years. The pur-
pose was to evaluate the ability of data from
4 years of age to predict pro fi ciency at age
14 years. All children had unilateral cleft of the
lip and palate. Sixteen independent variables
used in the analysis at age 4 years included 4 non-
speech variables (gender, type and age of primary
surgery, and pharyngeal fl ap surgery) and 12
speech measures obtained from speech examina-
tion. In subsequent analyses at ages 5 through
13 years, the rate of change between adjacent age
levels for each of the 12 speech measures was
also included for 28 independent variables. The
results of the investigation indicated that a large
percentage of the variance in judged speech
pro fi ciency at age 14 years could be accounted
for, using clinical data obtained for speech exam-
inations at ages 4 through 13 years. Regression
analyses were performed for the total group of
subjects at ages 4 through 13 years. The most
ef fi cient set of predictors accounted for 50–75 %
of the variance in the dependent variable. The
variable of gender was identi fi ed as the single
most important predictor in nine of the ten regres-
sion analyses alone, accounting for at least 40 %
of the variance in judged speech pro fi ciency.
When the regression analyses were performed
separately for males and females, approximately
50–80 % of the variance was accounted for in
judged speech pro fi ciency for males and 50–90 %
for females using one, two, or three of the inde-
pendent variables. The most ef fi cient set of pre-
dictors varied across age levels for both groups.

807
38 Speech, Language, and Velopharyngeal Dysfunction
In addition, these predictors differed between
males and females.
38.5
Articulation Development
and the Age at Palatoplasty
A goal of cleft palate habilitation is the develop-
ment of normal articulation. Factors that contrib-
ute to or interfere with normal development have
been studied for some time. The child’s age at the
initial palate closure and type of cleft have been
obvious factors to evaluate.
Just as early palate closure seems to lead to
better palate function, so does it appear to lead to
better articulation. Hardin et al. ( 1990 ) studied 48
children at 6 years of age and later in adoles-
cence. Their results suggested the importance of
establishing velopharyngeal competence by
6 years of age since resonance and articulation
de fi cits maintained some stability after that age.
O’Gara et al. ( 1994 ) evaluated the speech
development of 23 children with one syndrome
unilateral cleft of the lip and palate from 5 to
35 months of age. The infants who had earlier
palatal repair produced signi fi cantly higher per-
centages of oral stops (i.e., /p/, /b/, /t/) after
12 months of age than infants with later palatal
repair, although there was no signi fi cant differ-
ence in mean frequency use of oral fricatives (i.e.,
/s/, /f/) up to 3 years of age. The results of this
investigation support the earlier fi nding by Van
Demark and Morris ( 1977 ) that the use of the oral
stops sounds /p/ and /b/ is a good early indicator
of velopharyngeal competence.
The severity of the cleft appears to in fl uence
the number of misarticulations. Riski and DeLong
( 1984 ) studied the articulation of a group of chil-
dren longitudinally from 3 to 8 years of age. They
reported that the number of misarticulations on
an articulation screening test increased with
severity of the cleft. That is, children with bilat-
eral cleft lip and palate had more articulation
errors than children with unilateral cleft lip and
palate, who had more misarticulations than chil-
dren with isolated cleft palate. As might be
expected, children who also required a pharyngo-
plasty had more articulation errors than children
who did not require a pharyngoplasty but had the
same type of cleft.
The results of this investigation were sup-
ported by a later study of Finnish-speaking chil-
dren (Laitinen et al. 1998 ) . Those results
demonstrated that the occurrence, severity, and
number of errors of all studied sounds separately
or grouped increased with the severity of the
cleft, being constantly greatest in the BCLP group
and lowest in the CL (A) group. Further, the boys
tended to have more problems than girls in pro-
ducing the studied sounds correctly.
38.6
The Stability
of Velopharyngeal
Functioning over Time
Despite the effort to create velopharyngeal com-
petence with primary palatoplasty, there is evi-
dence that velopharyngeal competence is not
stable and may change throughout the life of a
child VanDemark and Morris ( 1983 ) . The roles
of adenoid size and adenoid involution have been
the focus of several investigations.
Gereau and Shprintzen ( 1988 ) evaluated the
relative size of the adenoids relative to the suc-
cess or failure of primary palatoplasty. They stud-
ied velopharyngeal valving in 850 children with
nonsyndromic clefts, 138 children with syndro-
mic clefts, and a group of children without clefts.
They evaluated speech relative to adenoid size.
Their data suggested a strong positive correlation
between the incidence of hypernasal resonance
post palatoplasty and relative adenoid size in the
children with cleft palate. Velopharyngeal clo-
sure was observed consistently at the adenoids in
all groups of children studied.
The importance of the adenoids in velopha-
ryngeal closure was evaluated by Mason and
Warren ( 1980 ) . Speci fi cally, they evaluated the
phenomenon of gradual development of hyperna-
sality as a result of adenoidal involution. They
reported that hypernasality developed in two
patients from a sample of 122 with repaired cleft
palate. They identi fi ed three patterns of velopha-
ryngeal closure against the adenoid mass from
lateral radiographs.

808
J.E. Riski
One small-sample-size study does not support
the contribution of adenoid involution to devel-
oping velopharyngeal incompetence in children
with cleft palate. Van Demark et al. ( 1988 ) com-
pared longitudinally perceptual ratings of articu-
lation defectiveness, nasality, and velopharyngeal
competency in 13 subjects who required second-
ary palatal management after age 10 with a sec-
ond group who did not require a pharyngoplasty.
Perceptual data when examined longitudinally
did not adequately discriminate between subjects
who at one time achieved velopharyngeal closure
but who ultimately required secondary manage-
ment and those patients who needed no further
treatment. A decrease in articulation scores and
an increase in severity of nasality and articulation
defectiveness over time indicate that patients are
at risk for secondary management. Evaluation of
lateral x-rays indicated that (1) those in the group
who required secondary operations demonstrated
more variability in velopharyngeal closure than
those in the comparison group, who required no
secondary operations, and (2) adenoidal involu-
tion did not appear to be a signi fi cant factor.
Morris et al. ( 1990 ) evaluated the role of
hypertrophied adenoids and any role they might
have in maintaining velopharyngeal competence.
Thirty-nine subjects were selected from a large
longitudinal study based on availability of lateral
still x-ray fi lms taken in series from 5 to 16 years
of age. Ratings of velar-pharyngeal contact and
ratings of adenoid size were obtained from the
fi lms. The obtained data indicated the expected
decrease in adenoid size. All patients maintained
velopharyngeal competence during the period of
study. However, three of the 39 subjects were
judged to show loss of such contact during the
period of study and an additional four had sur-
gery for velopharyngeal incompetence after the
completion of the study. All seven appeared to
show signi fi cant deterioration of velopharyngeal
status in middle or late adolescence.
In a larger study of 121 children born with
cleft (lip) palate, Riski et al. ( 1996 ) evaluated
velopharyngeal competence relative to adenoid
involution. They reported that 11/121 (9.1 %)
developed velopharyngeal incompetence with
adenoid involution. Velopharyngeal function was
evaluated with clinical and instrumental tools.
Each of the 121 children initially demonstrated
velopharyngeal closure characterized by the
absence of any nasal air escape or hypernasality.
However, at an average age of 5.7 years, nasal air
escape was fi rst detected. Lateral radiographs
were taken at that time to monitor adenoid size.
At an average age of 8.6 years, the adenoids had
involuted 4.64 mm, leading to signi fi cant velopha-
ryngeal incompetence requiring management.
The importance of the adenoid mass for
velopharyngeal competence in children with cleft
palate was also highlighted in a longitudinal
study reported by Haapanen et al. ( 1993 ) . They
evaluated two groups of children with cleft pal-
ate. One group of 24 children had an adenoidec-
tomy at the time of palatoplasty, and a second
group of 25 children with cleft palate did not have
an adenoidectomy. They found that hypernasality
and nasal air escape occurred signi fi cantly more
frequently in the group of children who had an
adenoidectomy than in the group of children who
did not. The groups did not differ when it came to
articulation errors associated with velopharyn-
geal insuf fi ciency.
38.7
Age at Pharyngoplasty
Given that 20 % of children will demonstrate
velopharyngeal incompetence following palato-
plasty, considerable effort has been expended to
identify the ideal age for secondary cleft palate
management. Many authors of studies of pharyn-
goplasties have commented on the most appro-
priate age for intervention. Most have reported
better results in younger patients. An early study
by Moll et al. ( 1963 ) found better results in
patients younger than 15 years of age. Leanderson
et al. ( 1974 ) evaluated the results of secondary
management by pharyngeal fl ap in 124 patients
with cleft palate. They reported the best results
between 5 and 6 years of age. They observed
continued speech improvements for several years
after surgery in young patients. No improvement
was found in older (over 25 years) patients.
Riski ( 1979 ) reported on longitudinal data of
speech sound acquisition and resonance in 52

809
38 Speech, Language, and Velopharyngeal Dysfunction
children who had had pharyngeal fl aps for velopha-
ryngeal incompetency. These data were compared
to similar data for a group of 48 children with cleft
palates who had not required secondary manage-
ment. Comparisons were made also between the
pre- and postsurgical performance of the group
who had had pharyngeal fl aps. Further compari-
sons were made between children who had second-
ary surgery before 6 years and after 6 years of age.
Development of acceptable resonance and articula-
tion patterns was slower in children who required
pharyngeal fl aps compared to those who did not.
Further analysis showed that the post-pharyngeal
fl ap group demonstrated acceleration in the acqui-
sition of acceptable sound production in the year
immediately following surgery. The data suggested
that children who had fl aps before 6 years of age
made faster gains in the development of articula-
tion and acceptable resonance than did children
who were treated after the age of 6 years.
Van Demark and Hammerquist ( 1978 )
observed a trend for poorer articulation when a
pharyngeal fl ap was done after 10 years of age.
Surprisingly, when studied at 10 years of age,
children with pharyngeal fl aps done earlier than
5 years of age had poorer velopharyngeal compe-
tence ratings than children with pharyngeal fl aps
done later than 5 years of age. They concluded
that the optimal time for pharyngeal fl ap was
between 4 and 10 years of age.
Seyfer et al. ( 1988 ) reported the results of supe-
riorly based pharyngeal fl aps in 39 patients. All 11
(100 %) patients under 6 years of age improved.
The average improvement was 1.1 on a 3-point
scale. In contrast, 74 % of the 28 patients over
6 years of age improved by 1.4 on the same 3-point
scale. The difference was not statistically signi fi cant,
however; in addition, no signi fi cant difference was
observed between the improvement for children
less than 2 years old (including primary pharyngeal
fl aps) and those over 2 years old.
Van Demark and Hardin ( 1985 ) evaluated 129
patients with pharyngeal fl aps. Articulation
improved 15 % postoperatively and was only
90 % correct by 16 years of age. That is, speech
was not normal in the oldest group studied.
Although articulation ratings were better for
patients receiving fl aps earlier than 4 years of age
or between 4 and 5 years of age, there was no
difference in nasality when patients receiving fl aps
early and late were compared. They concluded
that age at which pharyngeal fl ap surgery was per-
formed was not critical in speech outcome.
A large series of children who had a sphincter
pharyngoplasty was studied by Riski et al. ( 1992 )
using aerodynamic and imaging data. In this series,
109 of 139 patients demonstrated resolution of VPI.
Sixteen of the initial failures were revised. The revi-
sion was successful in eight of 16, yielding an over-
all success rate of 117 of 139 (84.2 %).
Additional analysis of the series demonstrated
that patients with mild hypernasality (90.38 %)
were treated more successfully than those with
severe hypernasality (71.26 %). Preoperative
velopharyngeal ori fi ce area, estimated by aerody-
namic testing, in fl uenced surgical outcome to
some degree. The 64 patients with normal post-
operative resonance demonstrated a preoperative
gap of 9.9 mm 2 ; the 11 hypernasal patients had a
larger preoperative gap of 12.2 mm 2 , and the four
hyponasal patients had a much smaller preopera-
tive gap of 5.0 mm 2 .
Age was a more signi fi cant determinant of
outcome than was size of velopharyngeal gap.
Sixty children under age 12 had a success rate of
84 % and a preoperative area of 9.6 mm 2 . Twenty
patients over 12 years had a success rate of only
55 % and a similar preoperative ori fi ce area of
10.9 mm 2 . A closer analysis of the age informa-
tion revealed that the rate of complete success
when VPI is managed before 6 years of age is
90.9 %. The success rate falls to 73.9 % between
6 and 12 years, 70.0 % between 12 and 18 years,
and to 47.0 % after 18 years.
Finally Losken et al. ( 2003 ) found no statisti-
cal difference in the average age at initial sphinc-
ter pharyngoplasty in patients who required a
revision (6.8 years + 4.48) compared to those who
did not require revision (7.4 years + 4.4).
38.8
The Adult Patient
Although VPI is usually diagnosed and treated in
childhood, it is not uncommon for adults to pres-
ent for management. Younger and Dickson ( 1985 )

810
J.E. Riski
treated eight adults with residual VPI following
cleft palate repair as children. A superiorly based
pharyngeal fl ap was used in each case. They
reported “signi fi cant subjective and objective
improvement,” although they reported no data.
A more controlled study was reported by Hall
et al. ( 1991 ) . Twenty adult patients received a
superiorly based pharyngeal fl ap. The authors
reported normal resonance in 15 patients, hypo-
nasality in three, and residual hypernasality in
two. The heterogeneity of the sample made con-
clusions dif fi cult. Of the 20 patients, 13 had unre-
paired clefts, two had speech bulbs, and one had
a failed pharyngeal fl ap.
38.9
Primary Versus Secondary
Pharyngoplasty
Several studies have been reported of pharyngo-
plasty used during primary repair of the palate.
The pharyngeal fl ap is advocated to provide addi-
tional tissue when the palatal cleft is extremely
wide (Hardin et al. 1986 ) . Both the pharyngeal fl ap
(Dalston and Stuteville 1975 ) and the sphincter
pharyngoplasty (Riski et al. 1987 ) have been used
at the time of primary palatal closure in an attempt
to increase velopharyngeal competence. Both pro-
cedures have a higher rate of success than a palato-
plasty alone. An inferiorly based fl ap combined
with a palatoplasty has been shown to eliminate
hypernasality in 94 % of patients (Dalston and
Stuteville 1975 ) . A sphincter pharyngoplasty com-
bined with a palatoplasty has been shown to have
a 100 % success rate (Riski et al. 1987 ) . Controversy
still exists about using any secondary procedure
with primary palatoplasty, because only 20–30 %
of patients will eventually require pharyngoplasty
and because of the potential obstruction. The abil-
ity to predict which infants will eventually require
a pharyngoplasty appears to be poor. One surgeon
attempted to identify infants who would eventu-
ally need a pharyngoplasty by visual inspection of
the nasopharynx at the time of palatoplasty. Sixteen
of these children were later evaluated. The pharyn-
goplasty appeared necessary in only 50 % (Riski
et al. 1987 ) . The remaining children achieved clo-
sure above the pharyngoplasty at the adenoids.
38.10 Speech Therapy
Our ability to evaluate velopharyngeal function is
much more exact than our ability to treat velopha-
ryngeal dysfunction and associated misarticula-
tions with speech therapy. Many procedures have
been proposed for treating velopharyngeal dys-
function, but there is little evidence that any of
these techniques actually improves velopharyngeal
function (Ruscello 1989 ) . Currently, there seems to
be a proliferation of oral motor exercises without
any evidence supporting these procedures. Evidence
from the literature suggests that nonspeech, oral
motor exercises have little basis in fact. Oral motor
exercises isolate oral movements by manipulating
the oral structures either manually or with instru-
ments such as toothbrushes. In contrast, speech is a
coordinated process incorporating coordinated
movements of respiration, laryngeal, velopharyn-
geal, and oral articulatory gestures. Proponents of
oral motor exercises often proposed that nonspeech
oral movements must develop before learning
speech oral movements. Research suggests how-
ever that they develop in parallel.
Moore and colleagues have published a num-
ber of investigations evaluating whether speech
emerges from earlier-appearing oral motor behav-
iors. Moore and Ruark ( 1996 ) designed an inves-
tigation to quantify the coordinative organization
of mandibular muscles in toddlers during speech
and nonspeech behaviors. Seven 15-month-olds
were observed during spontaneous production of
chewing, sucking, babbling, and speech. They
found that mandibular coordination across these
behaviors was quite different from that observed
for other behaviors, even in the earliest stages of
true word production. Production of true words
was predominantly characterized by relatively
stronger coupling among all mandibular muscles
compared to earlier emerging chewing and suck-
ing. Variegated babbling exhibited stronger cou-
pling than reduplicated babbling, as well as
chewing and sucking. They concluded that their
fi ndings did not support the suggestion that
speech coordination emerges from earlier-ap-
pearing oral motor behaviors. Further, they con-
cluded that the fi nding of coupled activation
among mandibular antagonists during speech

811
38 Speech, Language, and Velopharyngeal Dysfunction
paralleled earlier comparisons of adult speech
and nonspeech behaviors.
In a follow-up investigation, Ruark and Moore
( 1997 ) reported on an investigation that was
designed to quantify the coordinative organiza-
tion of lip muscle activity of 2-year-old children
during speech and nonspeech behaviors. They
recorded electromyographic (EMG) activity from
the right upper and lower lip activity of seven
2-year-old children during productions of chew-
ing, syllable repetition, lip protrusion, and speech
(repeated two-word utterances) tasks. Task com-
parisons revealed that the coordinative organiza-
tion of upper and lower lip activity is task speci fi c;
different coordinative strategies are employed for
different tasks. They concluded that the fi nding
of coordinative elements of the perioral system
of 2-year-olds is task speci fi c and extends the
results of previous studies of adults and chil-
dren, where task-speci fi c coordinative strategies
were employed by the mandibular and perioral.
Further, they concluded that the task-dependent
coordination of the perioral system of 2-year-olds
supports the notion that developing speech and
earlier-developing oromotor behaviors (i.e., suck-
ing, chewing) are mediated by different control
mechanisms.
Parallel to the fi ndings of parallel mechanisms
for speech and nonspeech production is the report
from Benson et al. ( 2001 ) , who found a parallel
rather than serial model of auditory speech and
nonspeech perception. They identi fi ed candidate
brain regions constituting a neural network for
preattentive phonetic perception with MRI and
multivariate multiple regression of imaging data.
They used stimuli that were contrasted along
speech/nonspeech, acoustic, or phonetic com-
plexity (three levels each) and natural/synthetic
dimensions. They found that seven distributed
brain regions’ activity correlated with speech and
speech complexity dimensions, including fi ve
left-sided foci [posterior superior temporal gyrus
(STG), angular gyrus, ventral occipitotemporal
cortex, inferior/posterior supramarginal gyrus,
and middle frontal gyrus (MFG)] and two right-
sided foci (posterior STG and anterior insula). In
contrast, only the left MFG discriminated natural
and synthetic speech. They concluded that the
data supported a parallel rather than serial model
of auditory speech and nonspeech perception.
A place for isolated oral motor exercises has
yet to be de fi ned. There is the potential that mal-
adaptive speech habits will continue and become
more ingrained as ineffective and unproven exer-
cises continue.
Continuous positive airway pressure (CPAP)
therapy can be used to reduce hypernasality by
elevating the air pressure in the nasal cavities dur-
ing speech (Kuehn 1991 ) . The purpose of this
study was to determine whether increased intrana-
sal air pressure loads the major muscle of velopha-
ryngeal closure, the levator veli palatini. Nine
subjects, four with cleft palate and fi ve without
cleft palate, were studied. Electromyographic
activity was measured from the levator veli pala-
tini muscle with several levels of air pressure
delivered to the nasal cavities using a commer-
cially available CPAP instrument. It was found
that levator veli palatini activity was signi fi cantly
greater for the positive air pressure conditions
than for the atmospheric pressure conditions for
both subject groups. This indicates that the levator
veli palatini muscle acts against the resistive load
produced by the increased intranasal air pressure.
The results support the use of CPAP therapy as a
method of resistance exercise for strengthening
velopharyngeal closure muscles.
Very few studies have evaluated speech ther-
apy treatment strategies for a child with cleft pal-
ate. Pamploma et al. ( 1999 ) compared the amount
of speech therapy time required to correct com-
pensatory articulation for two types of speech
therapy. One group was treated with a phonologic-
based intervention, and the second modality was
treated with an articulatory or phonetic approach.
Twenty-nine patients ranging from 3 to 7 years
were treated. Fifteen patients were included in
the fi rst group (control) and received articulatory
therapy, and 14 patients were included in the
second group (active) and received phonologic
therapy. The median age of each group was simi-
lar; that of the control group was 54 months old,
and that of the active group was 55.50 months
old. The speech pathologist in charge of the
speech therapy was the same in all cases. A blind
procedure was utilized whereby each patient was

812
J.E. Riski
evaluated independently by two speech patholo-
gists every 3 months until both examiners were
convinced that compensatory articulation had
been completely corrected.
The mean total time of speech therapy required
for the normalization of speech in the two groups
of patients was compared. The mean total time
of therapy was 30.07 months in the control
group and 14.50 months in the active group.
A Student’s t -test demonstrated that the total time
of therapy was signi fi cantly reduced ( P < 0.001)
when a phonological intervention was utilized.
38.11 Role of Parents in Speech
Therapy
The child developing speech and language might
have a parent who is actively involved in provid-
ing speech and language stimulation or one who
is passive. The evidence from studies of speech
and language intervention is clear that the child
with active parent participation develops better
language skills. Studies of children with cleft lip/
palate as well as other disabilities demonstrate
that it is paramount that clinicians incorporate the
parent as an active participant in speech therapy
and speech and language stimulation.
Pamplona and Ysunza ( 2000 ) and Pamplona
et al. ( 1996 ) investigated whether including the
mother as an active participant in speech therapy
sessions would improve the language develop-
ment of children with cleft palate who also had
additional language delays. One group was treated
by the speech pathologist alone (control group),
and a second group was treated by the speech
pathologist but was also accompanied by their
mothers (experimental group). Both groups were
evaluated before and after treatment to evaluate
the advance of each group. The patients accompa-
nied by their mothers had signi fi cantly better lan-
guage skills compared with patients treated
without their mothers. They concluded that the
results supported the statement that language
development is related to mother-child mode of
daily life interaction in children with cleft palate.
Additional support and evidence for parent
involvement comes from Broen et al. ( 1998 ) .
They described the changes in a 3-year-old child’s
production of speech during a period of diagnos-
tic therapy and the changes that occurred follow-
ing the fi tting of a speech prosthesis. The child’s
mother served as the primary intervener, guided
by a speech-language pathologist. The mother
was able to change the child’s speech so that
more of her productions were at a correct place of
articulation. After structural management, nasal
and glottalized productions disappeared from the
child’s speech, but glottal stops did not.
Support for the importance of parent partici-
pation is also found in investigations of children
with other disorders. Janjua et al. ( 2002 ) evalu-
ated language development in severe and pro-
found hearing-impaired children and the type of
parental interactions. They found that children
who were directly involved in an activity with
their parents develop better language, as were
children who performed the task after their par-
ents demonstrated it to them. The authors recom-
mended that parents encourage child participation
and use more contingent and child-centered inter-
action. In addition, they found no signi fi cant dif-
ferences between oral and bilingual families in
terms of quality of interaction.
Girolametto et al. ( 2002 ) studied 10 English-
speaking mother-child dyads and 10 Italian-
speaking mother-child dyads. All 20 children
were late talkers who showed delays in expressive
vocabulary development but age-appropriate cog-
nitive and receptive language skills. The authors
found some cultural differences in language learn-
ing and concluded that their results support the
use of language interventions based on increasing
maternal responsiveness for these children at the
one-word stage of language development.
38.12 Language Development
and Learning
The school-aged child with a cleft palate presents
the clinician with unique considerations beyond
articulation
and
velopharyngeal
function.
Evidence fi rst surfaced in the 1970s that children
with cleft palate might have educational prob-
lems that separate them from children without

813
38 Speech, Language, and Velopharyngeal Dysfunction
clefts. Richman ( 1976 ) evaluated 44 cleft lip and
palate/palate-only children who were individu-
ally matched with 44 normal school children on
the basis of sex, age, grade, intelligence, and
socioeconomic status. All children received
behavioral ratings by classroom teachers, and
achievement test scores were obtained. The chil-
dren with cleft palate were rated by teachers as
displaying signi fi cantly greater inhibition of
impulse (internalizing behavior). Further, the
children with clefts also scored signi fi cantly
lower on overall basic skills achievement tests.
At that time, Richman suggested that cleft chil-
dren might be responding to the social-behavioral
environment, which may include negative social
responses from others.
Later, Richman ( 1980 ) examined patterns of
cognitive ability in 57 cleft lip and palate children
with verbal de fi cits, but without general intellec-
tual impairment. He was attempting to answer
the question of whether the verbal disability dis-
played by these children was related primarily to
a speci fi c verbal expression de fi cit or a more gen-
eral symbolic mediation problem. Two groups of
children were identi fi ed based on performance on
cognitive tasks which required verbal mediation
strategies without requiring vocal responses. The
children with only a verbal expression problem
performed signi fi cantly better on tasks requiring
categorization and associative reasoning, although
there were few apparent differences on memory
items. Those children with a verbal expression
de fi cit displayed both an underlying symbolic
mediation de fi ciency and learning disabilities.
There was a higher proportion of cleft palate-
only children in the more severe group.
Richman and Eliason ( 1984 ) reviewed the
research on intelligence, achievement, behavior,
and personality of children with cleft lip and pal-
ate. Studies of intellectual functioning demon-
strated that the general intelligence of cleft
populations is relatively normally distributed
with group mean IQ scores within the average
range. There is some suggestion of a higher fre-
quency of depressed verbal intellectual function-
ing relative to visual-motor intelligence. Factors
that appear to affect IQ levels are presence of
other congenital anomalies, speech and hearing
de fi ciency, and low-incidence cleft type by sex
occurrences. There is evidence that a high per-
centage of cleft children are underachievers.
Personality and behavioral studies do not suggest
signi fi cant psychopathology, although there is
evidence of behavioral inhibition, concern regard-
ing appearance, and decreased expectations by
teachers and parents.
Richman and his colleagues fi rst delineated
speci fi c reading and learning disabilities in chil-
dren with isolated clefts. Richman and Eliason
( 1982 ) studied children with cleft lip and palate
and cleft palate only. Both groups presented with
reading disability and were matched for intelli-
gence, age, sex, and reading level. The two groups
were compared on reading and neuropsychologi-
cal test variables. Subjects included 14 males and
10 females of each cleft type ranging in age from
8 to 13 years. The results showed a signi fi cant
difference between groups on most language
measures and differences in reading comprehen-
sion and type of reading errors. These results
suggested that children with cleft palate only
constitute a language-disorder group with more
severe reading disabilities. Children with cleft lip
and palate are more likely to have verbal expres-
sive de fi cits and milder reading problems, possi-
bly related to peripheral speech mechanisms.
Richman et al. ( 1988 ) were then able to delin-
eate the incidence of reading disabilities in chil-
dren with isolated cleft palate. They examined
172 elementary school children with cleft lip and
palate (CLP) or cleft palate only (CPO).
Approximately 35 % of the sample displayed a
moderate degree of reading disability, and 17 %
of the group exhibited severe reading disability.
Reading disability was more prevalent at younger
ages, presumably because of peripheral speech
de fi cits. For older children, those with CLP dis-
played an incidence of reading disability similar
to the general population (9 %). However, chil-
dren with CPO exhibited a much higher rate of
reading disability (33 %). There was no differ-
ence between genders in the prevalence of read-
ing disability in this sample. This study supported
their earlier research that suggested children with
CPO may be more likely to experience general
language disorders leading to long-term reading

814
J.E. Riski
disabilities. Children with CLP appear to mani-
fest reading problems that tend to resolve with
increased age.
Investigations that are more recent have high-
lighted the elevated incidence of learning dis-
abilities in children with clefts, especially those
with isolated cleft palate. Broder et al. ( 1998 )
examined the prevalence of learning disability
(LD), level of school achievement, and preva-
lence of grade retention by type of cleft and gen-
der at two craniofacial centers. They studied 84
consecutively evaluated patients from one center who
were matched by cleft type, age, and gender with
84 patients evaluated at a second center. They
found that 46 % of subjects with cleft had LD,
47 % had de fi cient educational progress, and
27 % had repeated a grade (excluding kindergar-
ten) in school. Males with cleft palate only (CPO)
had a signi fi cantly higher rate of LD than any
other subject group. Males with CPO and females
with CLP were more likely to repeat a grade in
school than were females with CPO and males
with CLP. They concluded that children with
cleft are at risk for learning disability, low school
achievement, and grade retention.
These investigations have prompted a series
of studies looking at preschool children. Scherer
and D’Antonio ( 1995 ) used a parent question-
naire as a component for screening early lan-
guage development of children 16–30 months
of age with cleft lip and palate. Thirty nonsyn-
dromic children with cleft lip and palate and 30
children without clefts received the MacArthur
Communicative Development Inventory: Toddler
(CDI: Toddler), administered by a pediatrician.
In addition, a speech-language screening was
performed by a speech-language pathologist.
Results of the two assessments indicated that the
CDI: Toddler was a valid screener of language
development compared to a comprehensive
speech-language screening. They reported dif-
ferences between the cleft and noncleft groups
and found evidence of delays in expressive lan-
guage development in the children with cleft lip
and palate.
The source of language-learning disabilities
was investigated by Ceponiene et al. ( 1999 ) .
They investigated persistence of auditory short-term
memory (STM) that is implicitly involved in
language-speci fi c perception in children with clefts,
grouped using fi ne-graded cleft classi fi cation.
Cortical evoked potentials were recorded in 78
children with nonsyndromic oral clefts and in
32 healthy peers. A mismatch negativity (MMN)
potential that indexes preattentive detection of
change in auditory input was obtained in response
to tone sounds. In order to test durability of short-
term memory traces, sounds were presented with
three stimulation rates. With slowest stimulation,
MMN amplitudes were reduced in cleft children
compared to the healthy peers ( P < 0.00065). Only
cleft lip children did not signi fi cantly differ from
controls. Among isolated palatal clefts, the more
posteriorly delimited the cleft was, the smaller
was the amplitude of MMN. MMNs of smallest
amplitudes were obtained in the subgroup of com-
plete unilateral cleft of lip and palate. The authors
concluded that the reduced MMN amplitudes
found in cleft children imply de fi ciency in audi-
tory STM trace maintenance. This dysfunction is
likely to contribute to their language and learning
disabilities. The MMN diminution with shorter/
more posterior clefts suggests that differences in
auditory cortex function are one of the underly-
ing mechanisms of the cleft type-malcognition
association.
In a follow-up study, Ceponiene et al. ( 2000 )
investigated preattentive auditory discrimination,
reporting that it plays a signi fi cant role in lan-
guage acquisition and usage. They evaluated
infants with different cleft types. A mismatch
negativity (MMN) component of brain evoked
potentials, which indexes preconscious sound
discrimination, and brain responses to rare sine-
wave tones were recorded in 12 healthy infants
and 32 infants with oral clefts at the ages of 0 and
6 months. Infants with clefts were subdivided
into two categories: those with cleft lip and palate
(CLP) ( n = 11 at birth, n = 6 at the age of 6 months)
and those with cleft palate only (CPO) ( n = 17 at
birth, n = 8 at the age of 6 months). At both ages,
brain responses to rare sounds tended to be
smaller in both cleft subgroups than in healthy
peers. However, in the latency range of 300–
500 ms, the MMN was signi fi cantly smaller in
infants with CPO. In infants with CLP, the MMN

815
38 Speech, Language, and Velopharyngeal Dysfunction
was comparable to that of healthy infants.
Differences in auditory discrimination between
infants with CLP and CPO, as re fl ected by MMN,
were detectable at birth and persisted into later
infancy. This pattern parallels known behavioral
differences between children with these cleft
types. The authors concluded that brain responses
to rare sounds, in contrast, had no differentiative
power with respect to the cleft type.
38.13 Preschool and School-Aged
Investigations
Several investigators have evaluated language
functions in infants, preschool, and school-aged
children. Neiman and Savage ( 1997 ) obtained
reports from caregivers to describe the develop-
mental status of infants and toddlers with clefts.
They studied 186 infants and toddlers with cleft
lip, cleft palate, and cleft lip/palate, using the
Kent Infant Developmental Scale and the
Minnesota Child Development Inventory, both
caregiver reports. Reports were obtained at one
of the following age categories: 5, 13, 25, and
36 months. Data were analyzed in separate two-
between ANOVAs (age × cleft type) for each
developmental domain according to developmen-
tal assessment measure. Further, results were
examined relative to the normative sample.
Lower-motor and self-help developmental
quotients were lower at 5 months compared to
the 13-month-old level. The 5-month-old infants
with cleft exhibited “at-risk/delayed” develop-
ment on the motor, self-help, and cognitive
domains compared to the normative sample.
Infants at 13 and 25 months were within normal
limits in all developmental domains, with the
exception of the 13-month-old infants with cleft
palate, who demonstrate “at-risk” development
in the motor domain. Toddlers with cleft palate
exhibit “at-risk/delayed” development in the
expressive language domain at 36 months.
Early delays were also reported by Broen et al.
( 1998 ) . They studied the early cognitive and lin-
guistic development of 29 children with cleft pal-
ate compared to that of 29 children without clefts.
Measures included the mental scale of the Bayley
Scales of Infant Development, the Minnesota Child
Development Inventory, mean length of utterance,
and words acquired by 24 months. Children with
cleft palate, although well within the normal range,
performed signi fi cantly below the children in the
noncleft group on the mental scale of the Bayley
Scales of Infant Development, some subscales
of the Minnesota Child Development Inventory,
and words acquired by 24 months. Differences
observed in the cognitive development of chil-
dren with and without cleft palate were verbal as
opposed to nonverbal (i.e., linguistic in nature) and
were related to hearing status at 12 months and
velopharyngeal adequacy.
Chapman et al. ( 1998 ) examined the conversa-
tional skills of preschool and school-age children
with cleft lip and palate during interactions with
unfamiliar adults. Standardized measures of
speech and language were administered, and rat-
ings of resonance were obtained. Comparisons
were made between the children with cleft lip
and palate and their same-age peers on measures
of conversational participation and a standard-
ized test of pragmatic skills. Twenty children
with unilateral cleft lip and palate (10 preschool-
ers and 10 school-age children) and 20 noncleft
peers were matched for gender, age, and socio-
economic status.
Paired t-tests revealed no signi fi cant differences
between the preschool and school-age children
with cleft lip and palate and their noncleft peers in
level of conversational participation. However,
individual child comparisons revealed less asser-
tive pro fi les of conversational participation for
50 % of the preschool and 20 % of the school-age
children with cleft lip and palate. The investigators
concluded that children with cleft lip and palate
may show a less assertive style of conversational
participation, at least during the preschool years.
Therefore, craniofacial team evaluations should
include examination of conversational compe-
tency, particularly for children who are demon-
strating dif fi culty with other aspects of speech,
language, or social development.
The work of Speltz and colleagues suggests
that the differences between cleft lip/palate and
cleft palate-only children may not be revealed
until preschool or school age. Speltz et al. ( 2000 )

816
J.E. Riski
used cognitive and psychomotor tasks to evaluate
29 infants with cleft lip and palate (CLP), 28
infants with cleft palate only (CPO), and a demo-
graphically matched comparison (COMP) group
of 69 infants. The children were studied at ages 3,
12, and 24 months. The purpose was to examine
predictors of cognitive status at age 24 months in
the cleft group. Infants were administered the
Bayley Scales of Infant Development (BSID),
mother-infant interactions were observed, and
medical records were reviewed. The CLP and
CPO groups scored lower than the COMP group
on the BSID, but did not differ from one another.
Cleft group infants scored lower than COMP
group infants on BSID items assessing nonverbal
and expressive language skills. Quality of mater-
nal interaction predicted the 2-year mental devel-
opment index (MDI) scores of infants with clefts.
They concluded that infants with clefts show rela-
tive de fi cits in cognitive and psychomotor devel-
opment and that cognitive de fi cits are apparent in
nonverbal as well as verbal areas of performance.
38.14 Velo-Cardio-Facial Syndrome
Velo-Cardio-Facial Syndrome (VCFS) was fi rst
described by Shprintzen et al. in 1978 Shprintzen
et al. 1978 . They described a pattern of similari-
ties among 12 patients including overt or submu-
cous clefts of the secondary palate, ventricular
septal defects, typical facies, and learning dis-
abilities. We have since learned that both
DiGeorge syndrome and VCFS have a micro-
scopic deletion of chromosome 22q11.2. Treating
the speech, language, and velopharyngeal dys-
function in these patients present us with special
challenges beyond those of patients with clefts
and are considered separately.
Golding-Kushner et al. ( 1985 ) fi rst described
a rather distinctive pattern of language disorders
and personality characteristics when they
described language, academic, and psychological
pro fi les of 26 patients with velo-cardio-facial
syndrome. The characteristics continued through
the course of development from initial language
acquisition through childhood and adolescence.
Gerdes et al. ( 1999 ) suggested that the global
delays and the variations in intelligence found are
directly associated with the 22q11.2 deletion and
are not explained by physical anomalies such as
palatal defects or cardiac defects, or therapeutic
interventions such as cardiac surgery. They
reported that all of the children had late onset of
verbal speech and behavioral disorders, including
disinhibition and attention disorders. They
strongly encourage early intervention services
beginning in infancy to address the delays in
gross motor skills, speech and language, and
global developmental delays.
The observations of Gerdes et al. ( 1999 ) were
supported by Scherer et al. ( 1999 ) . They described
the speech and language development of four
children with VCFS studied longitudinally from
6 to 30 months of age and compared their per-
formance with three groups of children: (1) nor-
mally developing children, (2) children with cleft
lip and palate, and (3) children with isolated cleft
palate. The data demonstrated that young children
with VCFS show a receptive-expressive language
impairment from the onset of language. Further,
speech and expressive language development
were severely delayed beyond a level predicted by
their other developmental or receptive language
performance. The children with VCFS showed
severe limitations in speech sound inventories and
early vocabulary development that far exceeded
those shown by the children with cleft lip and
palate and children with isolated cleft palate. The
authors concluded that young children with VCFS
emerge from a critical speech and language-learn-
ing period with severe limitations in their commu-
nicative abilities. They recommended additional
studies to describe the later course of these early
speech and language impairments and to explore
the relationship to learning disabilities described
for older children with VCFS.
More recently Murphy et al. ( 1998 ) investi-
gated the presence of 22q11.2 deletion in indi-
viduals with learning disabilities. They evaluated
265 people with learning disability residing in
two learning disability hospitals in South Wales.
Individuals were selected for inclusion if they
ful fi lled any of the following criteria: psychotic
disorder (schizophrenia or affective disorder),

817
38 Speech, Language, and Velopharyngeal Dysfunction
family history of psychotic disorder, cleft palate
and/or lip, congenital heart disease, broadly
de fi ned facial dysmorphism, or a history of
hypocalcaemia. Fluorescence in situ hybridiza-
tion studies were performed on 74 selected indi-
viduals. Cytogenetic analysis revealed that two
individuals demonstrated a previously undetected
chromosome 22qII deletion. A third person dem-
onstrated a previously undetected cytogenetically
visible deletion on chromosome 15. The authors
concluded that VCFS appears to be etiologically
signi fi cant in a proportion of individuals with
idiopathic learning disability, especially in those
where psychosis is associated with mild learning
disability. They suggested that clinicians should
consider a chromosome 22qII deletion in people
who meet the selection criteria.
Citing the paucity of investigations evaluating
education interventions, Kok and Solman ( 1995 )
reported their investigation of interactive computer-
based instruction on the development of reading,
language, spelling, and number skills. They
recorded any positive effects of computer-based
instruction on students’ self-esteem, motivation,
and competence in computer operational skills.
They reported that the students were enthusiastic
about the system, developed an interest in reading,
and transferred remedial instruction to classroom
performance. Comparison of pre- and posttest
results indicated signi fi cant improvement in read-
ing ability as measured using Neale Analysis.
Later, Scherer et al. ( 2001 ) described commu-
nication pro fi les in children with VCFS compared
with children with Down syndrome. Four chil-
dren with VCFS and four children with Down
syndrome underwent cognitive and speech and
language assessment. Communication pro fi les
of children with Down syndrome showed a
fl at pro fi le, indicating all measures were simi-
lar and delayed relative to chronological age.
Children with VCFS showed vocabulary, pat-
tern of sound types, and mean babbling length
below cognitive and other language ages. The
authors concluded that communication pro fi les
of children with VCFS differed qualitatively
and quantitatively from those of children with
Down syndrome and supported the hypothesis
that some children with VCFS present with a
pro fi le of communication impairment that may
be distinctive to the syndrome.
The source of the learning dif fi culties and
speech and language was investigated by Cheour
et al. ( 1997 ) . They evaluated the duration of audi-
tory sensory memory, which is of central impor-
tance to speech perception and understanding.
They used mismatch negativity (MMN), an atten-
tion-independent event-related potential which
provides an objective electrical index of auditory
sensory memory. They reported that the duration
of this memory span is considerably shorter in
6–10-year-old children with VCFS than in healthy
controls. They concluded that the language-
related problems encountered in children suffer-
ing from VCFS are likely to be caused also by
central nervous system (CNS) dysfunctions.
38.15 Summary
Individuals with cleft palate face many obstacles
to normal speech and language throughout their
life. One of the fi rst challenges is to identify
knowledgeable and skilled caregivers. Although
clefting is a frequent birth defect, it is a low-
incident disorder among pediatric disorders. This
can limit the number of training programs and
thus the number of treatment centers with skilled
caregivers. Further, noncleft hypernasality is
labeled a “voice disorder”. This delays efforts
to refer children with noncleft hypernasality to
craniofacial teams for appropriate assessment
and management. Considerable effort is needed
to educate caregivers (especially speech- language
pathologists, otolaryngologists, and pediatri-
cians) that these types of problems are best evalu-
ated and managed by craniofacial teams.
As clinicians, we are unable to predict, at the
time of palatoplasty, those infants who will need
secondary palatal management. Further, velopha-
ryngeal function can be unstable in some children.
As the child grows, the nasopharyngeal dimensions
can become compromised as craniofacial structures
grow and adenoids involute. This can lead to com-
promise of velopharyngeal function over the life of
a child. Careful monitoring of emerging speech and
velopharyngeal function remains paramount to early

818
J.E. Riski
identi fi cation of VPI and appropriate management.
Earlier identi fi cation and management results in
more successful outcomes.
The development of a single standard of treat-
ment has been elusive. Speech-language patholo-
gists are challenged to institute therapy regimens
that are evidenced-based. There does not seem to
be any evidence supporting oral motor exercises
that isolate oral movements from other vocal tract
structures used in speech. However, velopharyn-
geal exercise using CPAP and speech therapy
with a phonologic approach hold some promise.
Finally, infants and children with clefts are
known to have language and learning dif fi culties.
Evaluation of emerging language in infants and
language/learning skills in school-age children is
indispensable. Programs that include a strong
parental involvement seem to demonstrate more
success than programs that do not.
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821
S. Berkowitz (ed.), Cleft Lip and Palate,
DOI 10.1007/978-3-642-30770-6_39, © Springer-Verlag Berlin Heidelberg 2013
39
Cleft lip and palate habilitation began as an indi-
vidual enterprise. The development of knowledge
of the nature of the defect and of the remedial
measures that were helpful in allowing these
patients to achieve more normal participation in
community life attracted additional specialists to
aid in their habilitation. The need for communi-
cation and understanding among these interested
disciplines has stimulated a rapid growth of cleft
palate teams during the past 15 years. The need
for this concerted effort is real. The specialists
comprising the cleft palate teams differ in their
training and experience, which has led to the
development of different treatment philosophies.
In our group, the surgeon plays a dominant
role (Cooper et al. 1960 ) , because we believe that
the reconstruction of a cleft palate is primarily a
surgical challenge and an area where competent
surgeons are capable of offering even more ser-
vices to patients with cleft lip and palate than are
universally practiced. Along with this philoso-
phy, we maintain that a group enterprise by pro-
fessionals is necessary in a complete habilitation
program. In many areas of the world, trained per-
sonnel are not available to assist the cleft palate
patient in all of his or her needs, and the surgeon
has been forced to devise ingenious and occa-
sionally extensive surgical procedures.
Cleft palate surgery is not a stereotyped exer-
cise, but rather a service demanding an assess-
ment of all the factors presented by each patient
and a reparative surgical plan based on proven
principles. The majority of cleft palates can be
reconstructed by trained surgeons to enable the
patient to develop acceptable speech.
Many clefts of the hard palate can be closed by
a vomer fl ap (Ivy 1960 ; Mazaheri 1962, 1964,
1973, 1976, 1977 ; Mazaheri and Hofmann 1962,
1965, 1969 ; Mazaheri 1961, 1970 ; Mazaheri et al.
1963, 1964, 1967, 1988, 1993 ; Millard 1962,
1966 ; Stark and DeHaan 1960 ; Veau and Borel
1931 ; Fauchard 1746 ; Grabb et al. 1971 ) , and
clefts of the soft palate can be closed by median
suture with a good anatomical and functional
result. The wide cleft and the short palate demand
additional attention. Additional length may be
gained by the Dorrance or a V-Y type retroposi-
tioning operation. The raw nasal surface may be
covered with a skin graft (Giles and Fry 1921 ) or
nasal mucosa (Dorrance 1925 ; Cronin 1957 ) or an
island fl ap of palatal mucosa (Millard 1962, 1966 ) .
The incompetent palatopharyngeal valve can be
augmented by a pharyngeal fl ap, either as a pri-
mary (Grabb et al. 1971 ) or secondary procedure.
The need for additional tissue in a wide cleft can
be satis fi ed by single or double regional fl aps.
Associated with these surgical advantages
now available to the cleft palate patient, there has
also been a need for cleft palate prostheses. The
trained prosthodontist has methods at his com-
mand to assist both the surgeon and the patient.
Mutual understanding and restraint develop
Prosthetic Speech Appliances
for Patients with Cleft Palate
Mohammed Mazaheri
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

822
M. Mazaheri
among the specialists in a well-organized team to
the bene fi t of the patient.
Since the early sixteenth century, dentists have
been making appliances designed to close defects
in the hard palate (Fig. 39.1 ). Like their predeces-
sors, prosthodontists today are also vitally inter-
ested in helping the individual with an oral cleft.
The prosthetic speech appliances they make are
recommended as a preliminary or secondary
treatment for many patients with cleft palate. The
terms “obturator” and “speech appliance” will
both be used in this chapter. They are frequently
used synonymously, but it has become the custom
to apply the term “obturator” to a device used in
Fig. 39.1 Designs by
Fauchard showing early
obturators employed for
palatal defects (From
Fauchard 1746 . Reprinted
in Grabb et al. 1971 )

823
39 Prosthetic Speech Appliances for Patients with Cleft Palate
treating acquired defects and “speech appliance”
to one employed in treating congenital clefts.
The design and construction of speech appli-
ances and obturators have changed much in the last
20 years, mainly due to improved materials and
methods. We have, for example, better wax, acryl-
ics, and impression materials and superior stone and
plaster for the investment process. We also have
bene fi ted from improved diagnostic tools for evalu-
ating the results of prosthetic treatment. Greater
coordination of interdisciplinary team efforts has
helped establish a more ideal prosthetic concept,
one that ensures that fi xed or removable partial den-
ture prostheses are managed so as to preserve the
integrity of all remaining teeth and the surrounding
soft and hard oropharyngeal structures.
The decision for prosthetic rehabilitation is
made based on the individual patients’ needs,
motivation for improvement, and availability of the
suggested rehabilitative program. Approximately,
50 % of all patients with cleft lip and palate will
need some type of fi xed or removable prosthesis
by 30 years of age.
As our knowledge and experience in the cleft
palate fi eld increased, those of us responsible
for providing prosthetic care recognized the
importance of establishing a better prosthodon-
tic concept and principles regarding treatment.
In rendering these patients the best service, we
should fi rst follow all the rules and principles
governing the fi xed and removable partial den-
ture prosthesis and, secondly, should remove any
fear of causing harm because of existing ana-
tomic, functional, and physiologic deviation.
39.1
Diagnosis and Treatment
Planning
In treating people whose oral-facial handicaps affect
speech, the best results are achieved when the diag-
nosis and treatment are carried out by a group of
clinicians who represent the various interested spe-
cialities and work together as a team rather than
independently performing a series of procedures.
In diagnosis and treatment planning, full con-
sideration should be given to (1) the type and
width of the cleft; (2) the position and relation of
the maxillary segments to each other in unilateral
and bilateral clefts; (3) the form and lateral and
anteroposterior dimensions of the maxillary arch;
(4) the length, thickness, and mobility of the soft
palate; (5) the perforations remaining in the hard
and soft palate area and labial sulcus after sur-
gery; (6) the posterior and lateral pharyngeal wall
movement and the size of the nasopharynx; (7) a
loose premaxilla; (8) the number of missing teeth;
(9) malformed and malposed teeth; (10) partially
erupted teeth; (11) teeth in the line of the cleft;
(12) constricted maxillae; (13) the condition of
the tonsils and adenoids; and (14) growth and
development of the child. The patient’s articula-
tion, voice quality, hearing acuity, mental attitude,
and general health also must be considered.
Socially acceptable speech cannot be produced
without proper velopharyngeal valving. Therefore,
surgical closure of the palate without due consid-
eration of the depth of the nasopharynx and the
length and function of the velum during phona-
tion cannot satisfy this objective. Better under-
standing of the nature of the cleft, anatomy, and
the physiology of the area involved would elimi-
nate many of these dif fi culties. The results of sur-
gical treatment of cleft palates should be evaluated
with the aid of cineradiographic studies, nasal
endoscopy, serial cephalometrics, maxillary and
mandibular casts, speech recordings made before
and after surgery, sound spectrographic analysis,
measurements of nasal and oral air pressure and
fl ow, and speech and audiometric evaluations.
All members of the team should be thoroughly
familiar with the problem at hand. Often, the best
result is not achieved when the knowledge of the
specialists is not all encompassing (Cronin 1957 ) .
The total habilitation and rehabilitation in the
fi eld of oral, facial, and speech impairment is
achieved only when the following objectives are
kept in mind: (l) socially acceptable speech, (2)
restoration of the masticating apparatus, (3) aes-
thetic facial and dental harmony, and (4) psycho-
logic adjustment of the patient to the condition.
Use of a speech appliance simply as a last
resort is poor procedure. Its use must be clearly
indicated by the oral conditions. For example, the
indications for a prosthesis are clearly de fi ned for
a patient who has undergone a series of unsuc-
cessful palatal operations. There is no magic in a
prosthetic speech aid. However, there are some

824
M. Mazaheri
patients for whom a prosthesis seems to be the
only means of improving speech. In such situa-
tions, it fi lls a de fi nite need. A prosthetic speech
aid should be used for palatal conditions where it
is indicated, just as the pharyngeal fl ap operation
should be used only where it is indicated.
39.2
Treatment Planning
Treatment programs for cleft palate patients require
careful planning and should include all factors
involved in total health care. The interest of the
dentist and physician in craniofacial growth and
behavior of soft and hard tissues, both before and
after surgery, has increased cooperation between
surgeons and dentists. As a result, a dental special-
ist has the opportunity to examine the cleft palate
child, with the surgeon, before any surgery is
undertaken. Analysis of longitudinal maxillary and
mandibular casts, cephalometrics, and radiographs
has shown that two major factors cause growth dis-
turbances of oral-facial regions in individuals with
clefts: fi rst, the inherent potential for growth dis-
turbance present among cleft palate patients and,
second, the trauma caused by surgical and orthope-
dic intervention. Because the fi rst factor can be
neither predicted nor reduced, efforts have been
directed toward minimizing growth disturbance by
performing surgery with the least amount of trauma
and scar tissue. Longitudinal data obtained during
the past 4 years regarding the surgical closure of
the cleft with minimum amount of scar tissue and
trauma are very encouraging (Millard 1966 ) .
39.3
Requirements of a Speech
Appliance
1. The prosthesis must be designed for the indi-
vidual patient in relation to his oral and facial
balance, masticatory function, and speech.
2. Knowledge related to removable partial and
complete dentures should be used in designing
the maxillary part of the cleft palate prosthe-
sis. Preservation of remaining dentition and
surrounding soft and hard tissue in cleft palate
patients is of utmost importance. Improperly
designed cleft palate appliances can result in
premature loss of both hard and soft tissue,
further complicating prosthetic habilitation.
3. The prosthetic speech appliance should have
more retention and support than most other res-
torations. The crowning and splinting of the
abutment teeth in adult patients may increase
retention and support of the prosthesis and may
extend the life expectancy of abutment teeth.
4. Mouth preparations should be completed before
making fi nal impressions. In cases where lateral
and vertical growth of the maxilla is incomplete
and partial eruption of the deciduous and per-
manent teeth is evident, careful mouth prepara-
tions should be made. To provide support of the
prosthesis, these preparations may include gin-
givectomies to expose clinical crowns (to make
them usable) and the placement of copings on
remaining teeth to prevent decalci fi cation and
caries. Osseointegrated implants have been a
great help in gaining adequate retention for the
prosthesis.
5. The weight and size of the prosthetic speech
appliance should be kept to a minimum.
6. The materials used should lend themselves
easily to repair, extension, and reduction.
7. Soft tissue displacement in the velar and
nasopharyngeal areas by the prosthesis
should be avoided.
8. The velar and pharyngeal sections of the
prosthesis should never be displaced by
movements of the lateral and posterior pha-
ryngeal wall muscles or the tongue during
swallowing and speech.
9. The superior portion of the pharyngeal sec-
tion should be sloped laterally to eliminate
the collection of nasal secretions. The infe-
rior portion of the pharyngeal section should
be slightly concave to allow freedom of
tongue movement.
10. The location and the changes of the speech
bulb should include consideration of the fol-
lowing factors:
(a) The speech bulb should be positioned in
the location of greatest posterior and lat-
eral pharyngeal wall activity, because
voice quality is judged best when the
speech bulb is at these positions.

825
39 Prosthetic Speech Appliances for Patients with Cleft Palate
(b) The inferior-superior dimension and
weight of the speech bulb may be reduced
without apparent effect on nasal reso-
nance. (The lateral dimension of the bulb
does not change signi fi cantly as the posi-
tion is varied.) (Fig. 39.2 )
(c) The speech bulb should be placed on or
above the palatal plane in cases where
posterior and lateral pharyngeal wall
activities are not present or where visual
observation of the bulb is not possible,
due to a long, soft palate (Fig. 39.3 ).
(d) The anterior tubercle of the atlas bone can
be used as a reference point; however,
investigation has shown that the relative
position of the tubercle of the atlas bone
Fig. 39.2 As a result of our studies, we have concluded
that the inferior-superior dimensions of the speech bulb do
not have a signi fi cant effect on speech quality as long as
the bulb is properly placed to facilitate good velopharyn-
geal closure. This dimension was reduced to one-quarter
of its original size, as shown in cast made during fi tting for
one patient, without apparent effect on nasal resonance
Original bulb
N
ANS
pp
High blub
Medium bulb
Low bulb
Appliance
p
Fig. 39.3 Superimposed tracing of the original speech
bulb and various experimental speech bulbs. The palatal
plane was used as a plane of reference along with poste-
rior pharyngeal wall activity, muscle bulge, or Passavant’s
pad. The posterior nasal spine ( PNS ), absent in cleft palate
subjects, is called posterior palatal point ( Ppp ) and repre-
sents the most posterior point of the remnants of the pala-
tal shelves as shown in the lateral cephalometric fi lm.
Median position was judged best

826
M. Mazaheri
varies in different individuals and that the
positions of the velopharyngeal structures
change in relation to the tubercle as the
individual moves his or her head.
Therefore, the atlas bone is no longer used
as the reference point for positioning of
the pharyngeal section of the bulb.
39.4
Indications for Prostheses
in Unoperated Palates
Cleft palate surgery is not a stereotyped exercise,
but rather a service that demands an assessment of
all factors presented by each patient and a repara-
tive surgical plan based on proven principles. The
majority of cleft palates can be reconstructed by
surgery, enabling the patient to develop accept-
able velopharyngeal closure. However, in some
situations, a prosthesis is the physical restoration
of choice. This decision should be made by the
group charged with the habilitation of the cleft
palate patient.
Many clefts of the hard palate can be closed by
a vomer fl ap (Mazaheri 1973 ; Veau and Borel
1931 ) and clefts of the soft palate by median
suture with good anatomic and functional result.
The wide cleft and the short palate demand fur-
ther attention. Additional length may be gained
by a Dorrance or V-Y type retropositioning
operation. The raw nasal surface may be cov-
ered with a skin graft, nasal mucosa, or an
island fl ap of palatal mucosa (Cronin 1957 ;
Giles and Fry 1921 ; Veau and Borel 1931 ) . The
incompetent palatopharyngeal valve can be
augmented by a pharyngeal fl ap, as either a pri-
mary or secondary procedure (Grabb et al.
1971 ) . The need for additional tissue in a wide
cleft can be satis fi ed by single or double regional
fl aps.
Despite the surgical advances available to
the cleft palate patient, a need remains for
cleft palate prostheses. The prosthodontist can
assist both the surgeon and patient, and the
mutual understanding among the specialists
in a well- organized team is of great bene fi t to
the patient. Some situations indicating a pros-
thetic approach are discussed in the following
paragraphs.
39.4.1 A Wide Cleft with a De fi cient
Soft Palate
Some clefts of this type do not lend themselves to
a surgical repair by means of local fl aps. A pros-
thesis is preferable to the more time-consuming
remote fl aps in these situations. Many patients
need a prosthesis to restore missing dental units,
and the distant tissue provides only a dynamic
mass (Figs. 39.4 and 39.5 ).
a
b
Fig. 39.4 ( a ) An edentulous patient with an unoperated
cleft of the soft and hard palate that affects the retention
and support of the prosthesis. At no time should a patient
with a cleft, especially an unoperated cleft, be rendered
edentulous. ( b ) The completed prosthetic speech appli-
ance in position

827
39 Prosthetic Speech Appliances for Patients with Cleft Palate
39.4.2 A Wide Cleft of the Hard Palate
In bilateral clefts, the vomer may be high and the
cleft of the hard palate wide so that a surgical
repair may produce a low-vaulted palate. It may
be possible to close the soft palate with the aid of
local fl aps and to restore the hard palate with a
prosthesis. A situation similar to that once advo-
cated by Gillies and Fry (Limberg 1927 ) is cre-
ated: the primary repair of the velum may create
a more favorable spatial arrangement for subse-
quent surgery on the hard palate.
39.4.3 Neuromuscular De fi ciency
of the Soft Palate and Pharynx
Repair of the palate would not be conducive to
the development of good speech. It is dif fi cult to
create and maintain a pharyngeal fl ap large
enough to produce competent palatopharyngeal
valving without obstructing the airway in the
presence of a neurogenic de fi ciency of the critical
muscles. A pharyngeal fl ap serves best when sur-
rounded by dynamic musculature. When this sit-
uation does not exist, the pharyngeal section of a
a
c
b
Fig. 39.5 ( a ) Patient at the age of 16 years with a very
wide cleft of the soft and hard palate. ( b ) Prosthetic
speech aid in position. Note that the pharyngeal section
of the speech aid is placed directly over the posterior and
lateral pharyngeal wall muscle activities. ( c ) Oral view of
prosthetic speech aid. The utilization of second bicuspids
and fi rst and second molars for retention and support will
prevent this prosthesis from dislodging into the nasal
cavity during swallowing and speaking

828
M. Mazaheri
speech-aid prosthesis may serve better to reduce
nasality and nasal emission. The prosthesis can
also act as a physical therapy modality, providing
a resistive mass for the muscles to act against.
Should muscle function improve, de fi nitive sur-
gical measures can then be contemplated.
39.4.4 Delayed Surgery
When surgery is delayed for medical reasons,
or when the surgeon prefers to repair the palate
when the patient is older, the cleft palate may be
temporarily closed with a prosthetic speech aid
(Fig. 39.6 ).
39.4.5 Expansion Prosthesis to Improve
Spatial Relations
An expansion prosthesis may be used to restore
and maintain more normal spatial relations of the
maxillary segments prior to surgery. These seg-
ments can be gradually separated by an expan-
sion prosthesis to create a space for the premaxilla
or to stabilize the parts in a normal position in
association with an autogenous bone graft. The
use of an expansion or repositioning prosthesis,
with or without bone grafting, is appropriate for
selected cases. In the majority of cleft lip and pal-
ate patients, restoration of the anatomic continu-
ity of the labial muscle would mold the segments
into acceptable relationships to each other and to
the mandible.
39.4.6 Combined Prosthesis
and Orthodontic Appliance
An orthodontic appliance may be combined with
a prosthesis to move malposed teeth into a more
favorable alignment. A prosthetic speech appli-
ance, such as the one illustrated in Fig. 39.7 ,
could be designed for a patient receiving full-
band orthodontic treatment.
39.5
Indications for a Prosthesis
in Operated Palates
39.5.1 Incompetent Palatopharyngeal
Mechanisms
If clinical, nasal endoscopic, and cineradio-
graphic analyses suggest that the patient is near
a functional closure, a prosthesis may serve as
a physical therapy modality. The pharyngeal
section of the prosthesis is gradually reduced as
a
b
Fig. 39.6 ( a ) A four and half-year-old girl with a rather
wide cleft of the soft and hard palate. We elected to fi t her
with a prosthesis and to delay the palatal surgery until a
later age. ( b ) The prosthetic speech aid in position. She
tolerated the prosthesis, and the speech signi fi cantly
improved within a 6-month period

829
39 Prosthetic Speech Appliances for Patients with Cleft Palate
muscle function improves, and the prosthesis is
eventually discarded. When the patient presents
a large velopharyngeal gap associated with a
neurogenic de fi ciency, the speech-aid prosthesis
should be considered as a permanent treatment.
39.5.2 Surgical Failures
A prosthesis should be considered when a
patient presents a low-vaulted, heavily scarred,
and contracted palate or a palate with large or
multiple perforations (Fig. 39.8 ). Because of the
surgical progress in the last 25 years, plastic sur-
geons today are not confronted with many fail-
ures in cleft palate surgery. Trained surgeons
can now predict with greater accuracy the pos-
sible success of an operation, and are likely to
avoid failure because other alternatives are
available. Approximately 50 % of all cleft
palate patients will need some type of prosthesis
by the age of 30.
39.6
Contraindications
for a Prosthesis
1. Surgical repair is feasible only when surgical
closure of the cleft will produce anatomic and
functional repair.
2. Patients with mental retardation are not good
candidates for prostheses, because they fre-
quently are not capable of giving the appliance
the care it requires.
3. A speech aid is not recommended for an unco-
operative patient or for a child with uncoop-
erative parents.
4. If caries are rampant and not controlled, a
prosthesis will require unusual care, and
frequent examinations are important.
a
c
b
Fig. 39.7 ( a , b ) A temporary prosthetic speech appliance
was designed not to interfere with orthodontic treatment
while the patient was under active therapy. ( a ) View of the
palate without prosthesis. ( b ) The prosthesis in position.
Retention is obtained by placing the retainers above the
molar buccal tubes. ( c ) View of the prosthesis after 1 year of
velopharyngeal and lateral pharyngeal wall activity, result-
ing in acceptable speech. Prosthesis was then discarded

830
M. Mazaheri
5. The edentulous condition is not a contraindi-
cation for a speech-aid prosthesis.
6. Because the construction of a functional
prosthesis requires the services of a dentist
who has had training in cleft palate prostho-
dontics, it would be better to resort to surgical
ingenuity when experienced prosthodontic
help is not available.
39.7
Constructing Prosthetic
Speech Appliances
For patients with deciduous, mixed, or permanent
dentitions that are not fully erupted, all three sec-
tions of the prosthetic speech appliance are made
of acrylic resin, and wrought wire retainers are
used (Fig. 39.9 ). In patients whose permanent
teeth are fully erupted, the anterior section of the
prosthetic speech appliance should be made of
cast metal or a combination of cast metal and
acrylic resin (Fig. 39.10 ).
39.7.1 Preliminary Impression
A stock tray of adequate dimensions is selected.
If a registration of the entire cleft is desirable,
the stock tray is modi fi ed with modeling
compound extending posteriorly to the postpha-
ryngeal wall. The added section is underextended
about 4–5 mm in all directions, leaving adequate
space for impression material. Fast-setting,
irreversible hydrocolloid is used for registering
a
b
Fig. 39.8 ( a , b ) Two patients with heavily scarred palates and perforations: surgical failures
Fig. 39.9 A temporary
acrylic resin speech
appliance with wrought wire
clasps and full palatal
coverage designed for a
4-year-old child

831
39 Prosthetic Speech Appliances for Patients with Cleft Palate
the preliminary impression. The following sug-
gestions should be kept in mind when the pre-
liminary impression is made:
1. If the patient is a child, he or she should be
given the opportunity to examine the tray; in
some cases, the child may be permitted to try
the tray in his mouth. Children should be told
that their cooperation is needed; otherwise, it
will be necessary to make several impressions.
Talking to children throughout the procedure
is helpful.
2. The patient should have an early morning
appointment.
3. The patient should have an empty stomach.
4. A topical anesthetic should be used on a child
who has a severe gag re fl ex.
5. The tray should not be overloaded with
impression material. Excess material in the
nasopharynx will increase the dif fi culty of
removing the impression without a fracture
(see Fig. 39.14 ).
6. All oral perforations should be packed with
gauze that has been saturated with petroleum
jelly.
39.7.2 Preparation of the Deciduous
Teeth for Retention
Most deciduous teeth do not have suf fi cient
undercut for retention of the prosthesis. However,
a small amount of bilateral undercut can give
adequate retention. The following recommenda-
tions will help to produce adequate retention:
1. Carefully extend the clasp arms into inter-
proximal areas of the teeth.
2. Insert, if necessary, serrated platinum pins into
the buccal surface of deciduous molars to cre-
ate an arti fi cial undercut for the clasp.
3. Place bands with soldered retention lugs on
the teeth.
4. Use chrome-cobalt crowns with retention lugs
for teeth with extensive carious lesions or
areas of decalci fi cation.
After the clasp design has been determined on
the diagnostic casts and the teeth have been pre-
pared for retention, the fi nal impression is made.
If adequate retention is not available in the
permanent dentition, crowning of the molars
might be desirable to provide proper retentive
areas (Figs. 39.11 and 39.12 ).
Fig. 39.10 A permanent cast gold speech appliance with
partial palatal coverage for an adult with no missing teeth
a
b
Fig. 39.11 ( a , b ) Crowning and splinting of the abut-
ment teeth will increase the retention and support of the
prosthesis and the life expectancy of the abutment teeth.
( a ) Patient before dental restoration. ( b ) After restoration
with prosthesis in position

832
M. Mazaheri
39.7.3 Final Impression
An acrylic resin tray is constructed over the
diagnostic cast (Fig. 39.13 ). The patient is pre-
pared in the same manner as for the preliminary
impression, and the fi nal impression is then made
with an irreversible hydrocolloid impression
material (Fig. 39.14 ). The master cast is made of
dental stone.
39.7.4 Jaw Relation Records
Jaw relation records such as vertical dimension,
centric relation, and protrusive relation are made
and used in the adjustment of the articulator.
39.8
Design and Construction
of the Prosthesis
The master casts are surveyed and the prosthesis
is designed (Fig. 39.15 ). For patients with
severely constricted maxillary and mandibular
Fig. 39.12 Patient with wide cleft of the hard and soft
palate treated with prosthetic speech appliance
Fig. 39.13 An acrylic tray is made over the diagnostic
cast and the border trimmed with green modeling
compound
Fig. 39.14 The fi nal impression is made with alginate
material. Note the extent of the registration of the cleft
Fig. 39.15 Cast gold framework. The prosthetic speech
appliance requires more retention and support; therefore,
all the remaining maxillary teeth of this patient have been
used for this purpose. The posterior extension of the
framework reinforces the tailpiece and the speech bulb

833
39 Prosthetic Speech Appliances for Patients with Cleft Palate
arches, teeth are arranged outside the remaining
natural teeth to establish the proper esthetics and
occlusion.
The prosthetic speech appliance is constructed
in three sections. The design of the anterior por-
tion is similar to that of a partial or complete den-
ture. After this section is completed, the patient is
instructed to wear it for at least 1 week. The
length of this adjustment period depends on
the ability of the patient to adapt to this part of the
prosthesis. The construction of the middle part,
the tailpiece, or velar section varies for operated
and nonoperated clefts.
In unoperated clefts with the maxillary pros-
thesis in position, the extent of the tailpiece over
the margin of the cleft is marked on the posterior
part of the appliance. The tailpiece extends poste-
riorly to the anterior extent of the uvula.
In operated palates that are short and require
a prosthesis, the position of the tailpiece is
marked on the posterior margin of the prosthesis.
The tailpiece extends approximately 3 mm behind
the posterior margin of the soft palate. The width
of the tailpiece is approximately 5 mm, and its
reinforced thickness is about l.5 mm.
39.8.1 Construction of Velar Section
A piece of shellac baseplate material of the
required width and length is used as a tray. It is
securely attached to the posterior part of the
prosthesis with about 2-mm relief. This assem-
blage is examined in the patient’s mouth for
proper extension. The tissue side of the tray is
fi lled with zinc oxide and eugenol impression
paste, and the appliance is inserted into the
mouth. The patient is instructed to hold his or
her head in a vertical position to prevent escape
of the impression material into the nasophar-
ynx. The head is held in this position for 1 min,
then the patient is instructed to swallow a little
water so that the muscular movement of the soft
palate will be registered in the impression. After
the material has hardened, the prosthesis is
removed from the mouth, and the tailpiece is
processed with self-curing acrylic resin. The
denture portion with the fi nished tailpiece is
placed in the mouth for testing. Swallowing of
small amounts of water will stimulate muscle
action along the lateral edge of the velar sec-
tion. If the velar section is overextended later-
ally, undue muscle displacement and eventual
tissue soreness will occur.
39.8.2 Construction of Pharyngeal
Section or Speech Bulb
Two holes are drilled in the posterior part of the
tailpiece. A piece of separating wire is drawn
through the holes to form a loop that extends
superoposteriorly beyond the superior part of
the tailpiece. The ends of the wire are twisted
together inferiorly (oral side) and secured to the
appliance by sticky wax (Fig. 39.16 ). The wire
loop that is extended into the nasal pharyngeal
area is manipulated into an oval form, and the
appliance is inserted into the mouth (Fig. 39.17 ).
The patient is asked to swallow, and the wire is
adjusted so that it will not contact the pharyngeal
walls at any time. Posterior and lateral pharyn-
geal wall activity can be stimulated by spraying
those tissues with water. The desired position of
the wire is in the area of the maximum poste-
rior and lateral pharyngeal constriction. Green
modeling compound is added around the wire
loop to reinforce it and its attachment to the
tailpiece (Fig. 39.18 ). The appliance is inserted
into the patient’s mouth, and he is asked to swal-
low a little water. Adaptol, softened in water
at 150–160 °F for 4–5 min, is added over the
green compound, and the appliance is inserted
into the mouth. Again the patient is instructed to
swallow a little water to produce muscle activ-
ity, and thus, the impression material is molded
(Fig. 39.19 ).
The prosthesis is reinserted a number of times,
and the patient is instructed to swallow each time
when additions of Adaptol are made to the mass
on the wire loop. These steps are repeated until a
functional impression of the lateral and posterior
pharyngeal walls is made (Fig. 39.20 ). The
impression material is then molded by instructing
the patient to place his chin against his chest and
move his head from side to side. In the rest posi-
tion, he swallows water and talks to allow further
molding of the impression material by muscular

834
M. Mazaheri
activity. If the mass is overextended, the patient
will feel it during these actions. The overextended
bulb impression is easily adjusted by reheating
the bulb on the exterior surface and reinserting it
into the patient’s mouth. While the material is
soft, the patient is instructed to produce the
desired muscular activities. The completed
speech bulb impression is chilled thoroughly in
ice water. To check the position of the bulb, water
is injected again, and the position of the bulb is
examined in the mouth for its relation to the pos-
terior and lateral pharyngeal wall activities.
A spray of water onto the tissue will again stimu-
late these activities. In unoperated clefts, muscle
function along the speech bulb during swallow-
ing can be observed directly when the mouth is
wide open and water is being injected onto the
a
b
Fig. 39.16 ( a ) The location of the two holes drilled on the tailpiece. ( b ) View of the wire formed in a loop, extending
superoposteriorly into the nasal pharynx
Fig. 39.17 Wire loop is attached to the tailpiece, inserted
into the mouth of patient seen in Fig. 39.12, and checked
to see that it does not contact posterior and lateral pharyn-
geal walls during swallowing
Fig. 39.18 Modeling compound is added around the
wire loop to reinforce the wire and its attachment to the
tailpiece

835
39 Prosthetic Speech Appliances for Patients with Cleft Palate
tissues. When the posterior pharyngeal wall
activity is not present, or direct visualization is
not possible due to the length of the soft palate, a
lateral cephalometric radiograph will reveal the
position of the bulb in relation to the nasopharyn-
geal structures. In such cases, the bulb is placed
in the area of the palatal plane. When the bulb
form has been perfected, the bulb and tailpiece
are processed onto the denture portion of the
appliance. A heat-cured acrylic resin is used for
making these parts.
For patients with unusually sensitive posterior
and lateral pharyngeal walls (e.g., when the gag
re fl ex is easily triggered), the making of a fi nal
impression for the speech bulb on the initial try is
delayed until the patient is properly prepared for
the impression. In such cases, it is helpful to con-
struct an underextended bulb in self-curing
acrylic resin, and to allow the patient to become
adjusted to this small bulb for 2 or 3 weeks. After
the patient has become accustomed to the under-
sized bulb, a fi nal impression is made by adding
Adaptol to the bulb, following the procedures
previously outlined. The fi nal impression of the
speech bulb is processed in a heat-curing type of
acrylic resin (Figs. 39.21 and 39.22 ).
To prevent the patient from swallowing the
bulb in case the tailpiece is fractured, the appli-
ance should be reinforced by incorporating a
piece of No. 11 gauge half-round wire in the
anterior body of the appliance and extending the
wire into the bulb. If the anterior part of the appli-
ance is made of cast metal, the frame should be
extended posteriorly to strengthen the velar and
pharyngeal section (see Fig. 39.15 ).
Fig. 39.19 Adaptol, softened by heating to 150–160 °F,
is added over the green compound, and appliance is
inserted into the mouth of the patient, Fig. 17.12 . Note the
displacement of the material after patient has swallowed
some water and rotated the head to each side and down
a
b
Fig. 39.20 ( a ) Functional registration of the velopharyn-
geal region using Adaptol. The gradual addition of
Adaptol and patient swallowing water and moving the
head down and to the sides will give the functional impres-
sion of the velopharyngeal region. If any gagging re fl ex is
present, then underextended pharyngeal section is pro-
cessed using an autopolymer. A week or two later, the
pharyngeal section is modi fi ed for addition of the Adaptol.
When the desired speech result is obtained and the patient
does not show any gagging re fl ex, the speech bulb is heat-
processed. ( b ) More Adaptol is gradually added, and the
appliance is inserted until a functional impression of the
area has been obtained. In most patients, the speech bulb
does not contact the throat wall while the surrounding tis-
sues are at rest

836
M. Mazaheri
39.8.3 Insertion of the Appliance
The fi nished speech appliance is inserted into the
mouth and examined for muscle adaptation to the
speech bulb during swallowing and phonation,
excessive pressure against the posterior and
lateral walls of the pharynx, stability of the
appliance during function, and improvement of
the quality of the voice.
39.8.4 Position of Speech Bulb
For most patients, when the bulb is positioned too
far inferiorly, the pharyngeal section has the fol-
lowing undesirable effects:
1. It has a tendency to be displaced by the dorsal
part of the tongue during tongue movements.
2. It fails to relate to the normal region for mak-
ing adequate velopharyngeal closure.
3. It has a detrimental acoustical effect on the
quality of the voice. (Caution should be exer-
cised to avoid blocking or extending the
speech bulb into the eustachian tube.)
39.9
Summary
The prosthetic treatment of certain patients with
cleft palate is an important part of the multidisci-
plinary approach to solving the many problems
related to total health.
Some of the cleft palate patients for whom
speech aids can be made include those with a wide
cleft of the palate with a de fi ciency of the soft pal-
ate, a wide cleft of the hard palate with a high
vomer, a neuromuscular de fi cit (a sphincteric
velopharyngeal action may not be attained even
with a pharyngoplasty if the de fi cit is marked),
and surgical failures.
I strongly object to the use of remote extraoral
fl aps in cleft palate surgery because a prosthesis
seems to be more appropriate. The possibility of
cancer being related to such a prosthesis is quite
remote, and there has been no evidence of
increased hearing loss in patients wearing a pros-
thesis. A prosthesis should not be used in a patient
not competent to care for it or maintain proper
hygiene.
A prosthodontist engaged in treating patients
with oral, facial, and speech de fi cits should be
thoroughly familiar with the anatomic and physi-
ologic deviations of the region involved and with
Fig. 39.21 Processed speech bulb in position, patient
from Fig. 39.12
Fig. 39.22 The nasal and lateral sides of the speech bulb,
tailpiece, and a portion of the palatal area of the anterior
section are placed in dental stone. These parts of the appli-
ance are made of acrylic resin

837
39 Prosthetic Speech Appliances for Patients with Cleft Palate
the basic principles involved in prosthetic
dentistry. He should always be willing to acquire
further knowledge in this fi eld.
References
Cooper HK, Long RE, Cooper JA, Mazaheri M, Millard
RT (1960) Psychological, orthodontic, and prosthetic
approaches in rehabilitation of the cleft palate patient.
Dent Clin North Am 381–393
Cronin TD (1957) Method of preventing raw area on nasal
surface of soft palate in pushback surgery. Plast
Reconstr Surg 20:474–484
Dorrance GM (1925) Lengthening of the soft palate in
cleft palate operations. Ann Surg 82:208
Fauchard P (1746) Le Chirurgien Densiste, ou Traite des
Dents, 2nd edn. J. Mariette, Paris, p 305
Giles HD, Fry WK (1921) A new principle in the surgical
treatment of congenital cleft palate, and its mechanical
counterpart. Br Med J 1:335
Grabb WC, Rosenstein SW, Bzoch KR (eds) (1971) Cleft
lip and palate. Little, Brown, Boston
Ivy RH (1960) Editorial. Some thoughts on posterior pha-
ryngeal fl ap surgery in the treatment of cleft palate.
Plast Reconstr Surg 26:417–420
Limberg A (1927) Neue Wege in der radikalen
Uranoplastik bei angeborene Spaltendeformationen:
osteotomia interlaminaris and pterygomaxillaris, resec-
tio margins foraminis palatini und neue Plattchennaht.
Fissure osses occulta and ihre Behandlung. Zbl Chir
54:1745
Mazaheri M (1961) Prosthetic treatment of closed vertical
dimension in the cleft palate patient. J Prosthet Dent
11:187–191
Mazaheri M (1962) Indications and contraindications for
prosthetic speech appliances in cleft palate. Plast
Reconstr Surg 30:663–669
Mazaheri J (1964) Prosthodontics in cleft palate treatment
and research. J Prosthet Dent 14:1146–1162
Mazaheri M (1970) Speci fi c dental responsibilities in the
cleft palate team and coordinating of dental care: long-
term planning. Cleft Palate J 7(2):459–464
Mazaheri M (1973) Correction of palatal defects: a prost-
hodontist’s viewpoint. J Oral Surg 31:913–917
Mazaheri M (1976) Prosthodontic aspects of palatal ele-
vation and palatopharyngeal stimulation. J Prosthet
Dent 35:319–326
Mazaheri M (1977) Longitudinal analysis of growth of
the soft palate and nasal pharynx from six months to
six years. Cleft Palate J 14(1):52–62
Mazaheri M, Athanasiou AE, Zarrinnia K (1988) Dental
arch dimensions in patients with a unilateral cleft lip
and palate. Cleft Palate J 25:139–145
Mazaheri M, Hofmann FA (1962) Cineradiography in
prosthetic speech appliance construction. J Prosthet
Dent 12:571–575
Mazaheri M, Millard RT (1965) Changes in nasal reso-
nance related to differences in location and dimension
of speech bulbs. Cleft Palate J 2:167
Mazaheri M, Sahni PO (1969) Techniques of cephalome-
try, photography and oral impressions for infants.
J Prosthet Dent 3:315
Mazaheri M, Harding RL, Ivy RH (1963) The indication
for a speech-aid prosthesis in cleft palate habilitation.
Excerpta Medica international congress series no. 66,
proceedings of the third international congress of plas-
tic surgery. Washington, DC, 1963
Mazaheri M, Millard RT, Erickson DM (1964) Cineradio-
graphic comparison of normal to non-cleft subjects with
velopharyngeal inadequacy. Cleft Palate J 1:199–209
Mazaheri MS, Nanda S, Sassouni V (1967) Comparison
of midfacial development of children with clefts and
their siblings. Cleft Palate J 4:334
Mazaheri M, Athanasiou AE, Long RE Jr, Kolokitha OG
(1993) Evaluation of maxillary dental arch form in
unilateral clefts of lip, alveolus, and palate from one
month to four years. Cleft Palate Craniofac J 30(1):
90–93
Millard DR (1962) Wide and/or short cleft palate. Plast
Reconstr Surg 29:40
Millard DR Jr (1966) A new use of the island fl ap in wide
palate clefts. Plast Reconstr Surg 38:330
Stark RB, DeHaan CR (1960) The addition of a pharyn-
geal fl ap to primary palatoplasty. Plast Reconstr Surg
26:378–387
Veau V, Borel S (1931) Division palatine; anatomie, chir-
urgie, phonetique. Masson and Cie, Paris

839
S. Berkowitz (ed.), Cleft Lip and Palate,
DOI 10.1007/978-3-642-30770-6_40, © Springer-Verlag Berlin Heidelberg 2013
40
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
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.
Palatal Lift Prosthesis for
the Treatment of Velopharyngeal
Incompetency and Insuf fi ciency
Mohammed Mazaheri
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 %)

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. Speci fi c 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 unclassi fi able __________
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 classi fi cation)
Dental health: _______________________________________________________________________________
Orthodontic: ________________________________________________________________________________
Audiology, otology: __________________________________________________________________________
Allergies: __________________________________________________________________________________
Smoking habits:
No _________ Yes _________ Pack/day
Tonsils and adenoids removed:
Yes _________ age _________
No _________

841
40 Palatal Lift Prosthesis for the Treatment of Velopharyngeal Incompetency and Insufficiency
Table 40.2 (continued)
11. When was VPI fi rst noticed:
Age of onset __________
Circumstance __________
Who fi rst noted VPI __________
12. VIP treatment history
Speech therapy ______________________________ No. of sessions ___________________________________
Surgery ( fl ap) _______________________________ Type of fl ap ______________________________________
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 fl ap __________
Speech and lift __________
Flap and lift __________
Lift and fl ap __________
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
Source
No.
of referrals
Percent of
sample (%)
Speech pathologist
256
59
Physician/surgeon
98
23
RN (nurse)
23
5
Dentist
12
3
PDH/BVR
23
5
Rehabilitation center
1
0.5
Social worker
2
0.5
Family
18
4
Table 40.4 Status of tonsils and adenoids of VPI
pallechts
Status of adenoids
No.
of cases
Percent of
sample (%)
In
100
23
Out
104
24
In/out (to insert
pharyngeal fl ap)
14
3
No information available 213
50

842
M. Mazaheri
In addition to oral examination, nasal endos-
copy, and individual judgment, all patients had
two cephalometric radiographs taken, one with
the soft palate at rest and the second during pro-
longed phonation of the vowel “E.” Twenty- fi ve
percent of the subjects had cineradiographic
studies of the velopharyngeal region to observe
continuous phonation.
40.1.2 Results of Treatment
According to nasal endoscopic evaluation, radio-
graphic analysis, and listener judgments, 126
(29 %) of the patients demonstrated inconsistent
or
borderline
velopharyngeal
dysfunction
(Table 40.5 ). The team decided that each subject
was to be referred to a speech-language patholo-
gist with instructions to have a review by the team
in 1 year if the condition persisted. Further evalu-
ation of these patients after 1 year revealed that
the hypernasality or nasal emission had subsided,
and none required further treatment.
It was recommended that 177 patients (41 %)
have pharyngeal fl ap surgery. In 122 patients
(mean age, 10 years), the surgical procedure con-
sisted of a superiorly based fl ap performed by our
staff plastic surgeon. The remaining 55 subjects
were referred to the plastic surgeon of their choice
for a pharyngeal fl ap with instructions to return to
the clinic after insertion of the fl ap for further
evaluation.
Thirteen of the subjects with congenital VPI who
were treated with a pharyngeal fl ap continued to
exhibit a signi fi cant to moderate amount of hyper-
nasal resonance and nasal emission (Tables 40.6
and 40.7 ). Palatal lifts or combination prostheses
were constructed for these patients. Five of these
patients had the palatal lifts removed, and two had
their combination appliance removed after 1 year
because the prostheses had resulted in their develop-
ing adequate posterior and lateral pharyngeal wall
activity, and the patients were judged to have satis-
factory voice quality without the appliances. Five of
the patients with a lift and one with a combination
appliance continued wearing their prostheses
because of consistent nasal emission and lack of
response to the prosthetic stimulation. One patient
with VPI as a result of trauma who had pharyngeal
fl ap surgery continued wearing his combination
Table 40.5 Treatment methodology for patients with VPI
Treatment
No.
of cases
Percentage of
sample (%)
Speech only
126
29
Pharyngeal fl ap
122
28
Pharyngeal fl ap
recommended
55
13
Palatal lift
74
17
Palatal lift removed
after stimulation
8
2
Palatal lift
recommended
15
3
Pharyngeal fl ap –
palatal lift
16
4
Palata lift – pharyn-
geal fl ap
12
4
Table 40.6 Status of patients who received palatal Lifts
Status
No. of patients
Palatal lift appliance removed
for pharyngeal fl ap
3
Pharyngeal fl ap patients
received appliances
13
Lift removed later
5
Combined appliance removed
later
5
Still wearing palatal lift
5
Combined appliance still
being worn
1
Table 40.7 Summary of use of prostheses and pharyn-
geal fl aps
Pathology
N
Palatal lift Combined appliance
In
Out In
Out
Congenital
PF-PL
9
4
5
0
0
PF-COMB
3
0
0
1
2
PL-PF
3
0
3
0
0
Trauma
PF-PL
1
1
0
0
0
Totals
Applianee
in
6
5
0
1
0
Applianee
out
10
0
8
0
2
Note: PF pharyngeal fl ap, PL palatal lift prosthesis, COMB
combination prosthesis

843
40 Palatal Lift Prosthesis for the Treatment of Velopharyngeal Incompetency and Insufficiency
prosthesis. The remaining patients with pharyngeal
fl aps 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 fi nding.
Eighty-nine of the subjects were fi tted 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 dif fi culty of adjustment,
more dif fi culty 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 satis fi ed with the
patient’s speech as it was. It was recommended to
fi ve patients that their palatal lift be removed in
favor of a pharyngeal fl ap 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 fl ap.
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 fl ap, 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 fl ap.
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 signi fi cant 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 fl ap than
patients who have a pharyngeal fl ap as the initial
mode of treatment.
Etiology
N
Palatal lift
Coinhination
In position
Removed
In position
Removed
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
Table 40.8 Summary of
status of palatal lift and
combination prostheses used
for VPI of various etiologies

844
M. Mazaheri
Two of the subjects with complete paralysis
of the soft palate as a result of traumatic injury
had pharyngeal fl aps 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 fl ap, 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 insuf fi ciency,
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
classi fi ed 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
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 insuf fi ciency are:
1. Hypernasality
2. Nasal emission
3. Decreased intelligibility of speech due to weak
consonant production
The patient with velopharyngeal insuf fi ciency
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 fl ow.
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 fl aps,
implants (cartilage, bone, silicone, Te fl on ® ),
and combinations of several methods.

845
40 Palatal Lift Prosthesis for the Treatment of Velopharyngeal Incompetency and Insufficiency
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 insuf fi ciency.
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 fl ow, increase oral pressure for consonant
articulation, and improve voice quality. The lift may
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
insuf fi cient 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.
Fig. 40.1 ( a ) Patient with palatopharyngeal insuf fi ciency.
The treatment procedure is the stimulation of the soft pal-
ate by a palatal lift prosthesis followed by pharyngeal fl ap
surgery. ( b ) View of palatal lift prosthesis in position. ( c )
Palatal view of the lift prosthesis

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-
thesis of patient in Fig. 18.2 in position. Note the degree
of palatal elevation. ( b ) Increased mobility of the soft pal-
ate after 1 year of prosthetic stimulation. Pharyngeal fl ap
surgery was done after 14 months of soft palatal stimula-
tion, after which the lift prosthesis could be discarded. ( c )
Cephalometric tracing of the palatal lift prosthesis and the
degree of velar elevation accomplished by the lift

847
40 Palatal Lift Prosthesis for the Treatment of Velopharyngeal Incompetency and Insufficiency
Fig. 40.4 Top left : Patient with palatopharyngeal incom-
petency in which the soft palate is paralyzed as a result of
neurologic involvement after an accidental head injury.
Top right : Palatal lift in position. Bottom left : Increased
soft palate elevation after 6 months of prosthetic velar
stimulation. Bottom right : Oral and palatal view of the lift
prosthesis
Fig. 40.5 ( a ) Lateral radiograph of the patient in Fig.
18.4 prior to stimulation saying “E.” ( b ) The palatal lift
prosthesis in position elevating the soft palate. ( c ) Note
the increase in the degree of palatal elevation. After
11 months of stimulation and speech therapy patient is
saying “E.” Note the substantial increase in the velar
elevation

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
insuf fi ciency in which the soft palate is short and has lim-
ited mobility. ( b ) Combination palatal lift pharyngeal sec-
tion in position. The uvula was displaced by the prosthesis
without causing any irritation. ( c ) Palatal view of the
prosthesis

849
40 Palatal Lift Prosthesis for the Treatment of Velopharyngeal Incompetency and Insufficiency
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
Fig. 40.8 ( a ) Lateral radiograph demonstrating short soft
palate and large nasopharynx. ( b ) Tracing of the lateral
cephalogram of the patient in Fig. 18.7 . ( c ) Tracing of the
combined palatal lift/pharyngeal section prosthesis in
position

850
M. Mazaheri
3. Radiographic evaluation (e.g., cineradiogra-
phy, cephalometrics, sectional laminography,
or tomography)
4. Oral nasal air pressure and air fl ow 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
dif fi culty 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 dif fi cult 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 insuf fi ciency is that we
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 re fl exes and increase velopharyn-
geal adaptation to the prosthesis. After initial
placement, modi fi cation 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 insuf fi ciency 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?

851
40 Palatal Lift Prosthesis for the Treatment of Velopharyngeal Incompetency and Insufficiency
2. What is the relationship between stimulation
and degree of occurrence of disuse atrophy?
3. What is the relationship between pharyngeal
stimulation and muscle constriction?
4. What is the degree of stability of velopha-
ryngeal function and constriction after stimu-
lation?

Part XIV
Third World Cleft Treatment

855
S. Berkowitz (ed.), Cleft Lip and Palate,
DOI 10.1007/978-3-642-30770-6_41, © Springer-Verlag Berlin Heidelberg 2013
41
Abbreviations
Cleft palate may occur in isolation (CP) or in
conjunction with cleft lip (CLP) and sometimes
as a component of a syndrome.
OFC
Orofacial cleft
PSO
Pre-surgical orthopaedics
CL
Cleft lip
CP
Isolated cleft palate
CLP
Cleft lip and palate
sP
Soft palate
hP
Hard palate
Ant
Anterior
IVV
Intravelar veloplasty
MCC Maternal care coordination
ANC
Antenatal care
ORL
Otorhinolaryngology
41.1
Introduction
Orofacial clefts (OFCs), which include cleft lip
(CL), cleft palate (CP) and cleft lip with cleft palate
(CLP), can impair the development of teeth,
speech, hearing and feeding capability in isolation
or combination. These defects create physical and
emotional stress for infants, children and their
families. At other times, there are multi-system
and complex anatomical, physiological and psy-
chosocial problems which are taken into consider-
ation in optimal care delivery (Sitversen et al.
2008 ) . For many reasons, the protocol of care for
these patients has attracted lingering debates
worldwide (Malcolm and Richard 2000 ) . Although
the timely receipt of primary cleft surgery is essen-
tial to the medical and psychosocial well-being of
these patients (Bokhout et al. 1997 ; Strauss 1999 ;
Riski 2002 ; Benedict and Farel 2003 ) , services
and treatment delivery can vary, depending on
severity of the defect, presence of associated syn-
dromes or other birth defect(s) and the child’s age
and rate of development (Nackashi et al. 2002 ) .
Despite these variations, some general helpful
recommendations exist (Nackashi et al. 2002 ;
Lynch and Karnell 2003 ) .
The initial evaluation of an infant with OFC is
recommended within the fi rst few days of life, and
subsequent evaluations should be scheduled at
regular intervals, depending on cleft severity, pres-
ence of associated deformities and the child’s age.
The ideal timing and method of CLP repair
remain an enigma, despite many studies, surveys and
reports in the literature (Agrawal and Panda 2011 ;
Cleft Palate Treatment
in Developing Countries of Africa
Fadekemi O. Oginni and Wasiu L. Adeyemo
F. O. Oginni , BChD (Ife), FMCDS (Nig), FWACS (*)
Department of Oral and Maxillofacial Surgery,
Faculty of Dentistry , College of Health Sciences,
Obafemi Awolowo University ,
Ile-Ife , Osun State 220005 , Nigeria
e-mail: torera5265@yahoo.com
W. L. Adeyemo , BDS (Ib), FMCDS (Nig),
FWACS, Ph.D., Cologne, FICS
Department of Oral and Maxillofacial Surgery,
Faculty of Dental Sciences, College of Medicine ,
University of Lagos , PMB 12003 Lagos , Nigeria
e-mail: lanreadeyemo@yahoo.com

856
F.O. Oginni and W.L. Adeyemo
Shaw et al. 2001 ) . It varies from place to place and
with different patient types.
Basically, the controversy is focused on early
palatoplasty for improved speech development
versus delayed palatal closure with minimal dis-
turbance to facial growth (Ysunza et al. 2010 ) .
Some investigators believe that early hard palate
closure is advisable (Semb 1991 ; Noverraz et al.
1993 ) , whereas others believe that delaying hard
palate closure would result in a more favourable
growth of the maxilla (Hotz and Gnoinski 1976,
1979 ; Freide et al. 1987 ) .
For children with OFC, timely primary cleft sur-
gery was de fi ned as surgery within 18 months of
life. For infants with CL, it was de fi ned as surgery
within the fi rst 6 months of life, and for infants with
CP with or without CL, surgery within 18 months
of life (American Cleft Palate-Craniofacial
Association 1993 ) . Timeliness in surgery is a prod-
uct of multiple factors which appear to differ from
place to place and from time to time. Different cen-
tres and practitioners tend to adopt and advocate
protocols that suit their prevailing circumstance(s).
The situation in the developing world could be
tagged peculiar for a number of reasons. These
include fi nancial constraints, limited facilities
and personnel, low level of awareness about cleft
care and poor health-seeking behaviours.
Others factors affecting timeliness in surgery are:
Maternal care coordination ( MCC )/ Antenatal
care ( ANC ). Children whose mothers received
MCC/ANC are more likely to get informed
about availability and places where cleft sur-
gery are available than those children whose
mothers received no such care or counsel
(Cassel et al. 2009 ) .
Residence . Those living in the urban or semi-
urban locations are more likely to receive
timely cleft surgery than children living in
rural settings (Cassel et al. 2009 ) .
Racial / ethnic factors . Multiracial studies have
found differences in the access to care indicat-
ing racial/ethnic and geographic differences in
the receipt of timely primary cleft surgery
among children with OFC. Lack of access to
care was noted especially among Black/non-
Hispanic and Hispanic individuals (Ronsaville
and Hakim 2000 ; Fiscella et al. 2002 ; Buescher
et al. 2003 ; National Institute for Health Care
Management Foundation 2007 ) .
Available services . Differences in the types of
services and treatment offered by the various
craniofacial centres and teams can also affect
the timeliness of services (Strauss 2002 ) . Some
craniofacial teams provide evaluation and qual-
ity assurance only, while craniofacial centres
usually provide more direct services and treat-
ment. Craniofacial centres and teams vary in
their capacity to treat patients with clefts and or
other craniofacial conditions (Strauss 2002 ;
American Cleft Palate-Craniofacial Association,
Cleft Palate Foundation 2005–2006 ) .
Parental perception . Parental perception of
need and cleft severity may delay surgery.
Cleft lip defects are readily apparent at birth,
and parents usually understand the need for
surgical intervention. Isolated cleft palate may
however go unnoticed for sometime and
untreated for a relatively longer time even in
the presence of speech impairment.
Income group . Children born into higher income
(Figs. 41.2 , 41.3 , 41.4 and 41.5 ) group homes
have a greater tendency to receive timely care
(Porter fi eld and McBride 2007 ) . Coincidentally,
this group has ready access to ANC and the
associated strong referral network which assist
them in accessing resources. Furthermore, this
link ensures delivery of appropriate services and
continuity of care.
Children with OFC who bene fi ted from refer-
ral to services (especially to craniofacial centres
and teams) were signi fi cantly associated with
areas of residence, cleft type, presence of other
birth defects, presence of other malformations in
the family and receipt of MCC services in a series
of studies (White 1981 ; Williams and Sandy
2003 ; Cassell et al. 2007 ) .
Untreated cases however have been associated
with some rare forms of clefts that are compara-
bly minor (e.g. bi fi d uvula or submucous CP) for
which surgery may never be needed (Gosain et al.
1999 ; Sperber 2002 ) .
Other factors, such as fi nancial and non -
fi nancial barriers , can impede receipt of timely
cleft surgery among this population. Financial
barriers are widely present in most developing

857
41 Cleft Palate Treatment in Developing Countries of Africa
countries where majority of patients cannot afford
to pay for treatment. Non- fi nancial barriers
include health policies, service organizations and
unavailability of effective referral systems (i.e.
craniofacial centres and other specialized ser-
vices and care providers) (Rosenbach et al. 1999 ;
Newacheck et al. 2000 ; Betz et al. 2004 ) .
Personal barriers , such as ignorance about
available supports and the extent of support as
well as inability to navigate the healthcare system
effectively (St Clair et al. 1990 ) and religious and
cultural beliefs (Oginni et al. 2010 ) , are real.
41.2
Considerations for Age
in Palatoplasty
The primary goal in timing of CP surgery is to
provide adequate palatal function for the devel-
opment of normal speech without interfering
signi fi cantly with the maxillary growth. Soft pal-
ate surgery aims at velopharyngeal competence,
while normal facial growth and dentition are the
goals of hard palate repair.
Although a controversial subject, early closure
of the lip and palate is believed to impart greatly
to early speech function and learning, whereas
delayed closure favours growth of the maxilla
(Rohrich et al. 2000 ) .
The age at which palatal closure is performed
is usually the surgeon’s choice and a compromise
between the need for normal growth and normal
speech. Arguments for and against the delayed
hard palate closure often revolve around the
“trade-off” between the inhibitory effects of early
palate repair on growth versus the increased bur-
den of additional treatment, which may be neces-
sary as a result of delaying palate repair
(Robertson 1986 ; Peterson-Falzone 1996 ) .
In the early days, closure of the hard palate
after eruption of the secondary dentition was con-
sidered a prerequisite for undisturbed maxillary
growth (Hagemann 1941 ; Schweckendick 1951 ) .
Later, the focus of treatment shifted toward con-
sideration of speech development.
Early repair of the soft palate was recommended
to prevent speech disturbances in patients with
delayed hard palate closure. The philosophy of
repairing the soft palate for speech requirements
but delaying the hard palate repair to reduce growth
inhibition was introduced by Gillies and Kesley
Fry ( 1921 ) . This was later introduced into clinical
practice by Schweckendiek who delayed palate
repair into the adolescent years (Schweckendick
and Doz 1978 ) . This method has since undergone
further modi fi cations by Robertson and Jolleys
( 1968 ) , Hotz et al. ( 1978 ) and Malek et al. ( 1986 ) .
Studies on growth of the facial skeleton have
identi fi ed the second postnatal year as the period
of active growth and suggested that palatal surgery
performed at the age of 1 year might disturb the
growth of the maxilla more than those performed
at about 2 years. Similarly, the Oxford cleft palate
study and others (Rohrich and Byrd 1990 ; Rohrich
et al. 1996, 2000 ; Noverraz et al. 1993 ) suggest
that we may consider hard palate surgeries done in
children under 12 months as early and those done
at or beyond 48 months late.
Although, varying degrees of intrinsic maxil-
lary growth de fi ciencies are common fi ndings in
the facial skeleton of individuals with clefts
(Yoshida et al. 1992 ; Berkowitz et al. 2005 ) . The
preoperative morphology in the cleft child is said
to explain half of the occlusal morphologies and
variations in occlusal development and maxillary
inter-canine width (Friede et al. 1988 ) . The inher-
ent growth impairment observed may be exacer-
bated by surgical technique, surgeon’s skill (Ross
1987b ) and timing of surgery.
Proponents
of
neonatal
cleft
surgery
(Hodgkinson et al. 2005 ) believe that with it,
healing is better, parents obtain some psychologi-
cal relief and the child has minimal cognitive
development effect (McHeik and Levard 2006 ;
Galineir et al. 2008 ; Murray et al. 2008 ) . On the
other hand, it is plagued with greater risks
(Hodgkinson et al. 2005 ) , more so for the palate.
Considering that early palatal repair (prior to 1
year of age) is desirable for excellent speech
results (Ross 1987c ) , this protocol was embraced
by some centres. A few of them performed simul-
taneous lip and hard palate repair at the age of
4–5 months (Ross 1987c ) , only to be abandoned
soon due to the associated poor growth and
restricted midfacial development (Friede and
Lilja 1994 ; Melissaratou and Friede 2002 ) .