Dr. Anita Gala, Dr. Janani Iyer, Dr. Swapnali Mhatre
Private Dental Practitioner, Prosthodontist, Mumbai
Department of Prosthodontics, Crown & Bridge, M.G.M Dental College and Hospital, Navi Mumbai
Department of Prosthodontics, Crown & Bridge, B V P Dental College and Hospital, Navi Mumbai
A pharyngeal obturator prosthesis can be used for several objectives in patients with congenital and acquired soft palate defects. Most pharyngeal obturators are used to separate the nasopharynx and oropharynx during speech and deglutition. The prosthesis consists of partial or complete denture base and a pharyngeal extension that will not only physically modify the pharyngeal airway but also provide an object against which the surrounding muscle can function to provide a seal between oropharynx and nasopharynx. In this case report, patient had congenital hard and soft palate defect due to cleft palate. His chief complaint was phonation and to attain a close to normal speech. He was treated with horizontal type speech bulb obturator. The speech was evaluated with the Dr. Speech software. The obturator was very effective in refinement of speech.
Citations : Gala A, Iyer J, Mhatre S. Rehabilitation of Cleft Palate Patient with Horizontal Pharyngeal Obturator and Speech Bulb - A Case Report. J Prosthodont Dent Mater 2021;2(1): 70-74.
Speech is learning process and develops over an extended period. Most master the normal articulation of speech by 6 years of age, whereas some requires an additional year for maturation of speech. Speech is easily disturbed by congenital malformations and ablative surgery. A cleft palate by definition is (a congenital tissue or) elongated opening in the soft and/or hard palate. It may be congenital or acquired. The basic disability of the cleft palate is that the individual is unable to close the nasopharynx from the oropharynx. In the normal individuals this closure is effected by the complete hard palate and by the raising of the soft palate into intimate contact with the posterior and lateral pharyngeal walls. This airtight separation of the two cavities is essential for the functions of swallowing and speech.
CLASSIFICATION OF CLEFT PALATE [VEAUS 1931]:
Class I - Clefts involving soft palate only.
Class II - Clefts involving soft and hard palates but not the alveolus.
Class III - Clefts involving the soft and hard palates and continuing through the alveolus on one side of the pre-maxillary area.
Class IV - Clefts involving soft and hard palates and continuing through the alveolus on both side leaving a free pre-maxilla.
Types of obturator:
1. Hinged obturator or Artificial Velum
2. Fixed or horizontal obturator :
3. Meatus obturator
Fixed or horizontal obturator:
In 1868 Suersen first published and Fitzgibbon reported on its usefulness in 1920’s. The obturator is placed in a fixed position within the pharynx at the site of maximum muscle activity or approximately at the level of the palatal plane.
During physiologic function, the obturator is contacted by the posterior pharyngeal wall and the lateral pharyngeal musculature, creating a separation between the oropharynx and nasopharynx.
CASE REPORT :
A 28-year-old male patient referred to department of prosthodontics with the chief complaint of difficulty in eating food, drinking water because of aspiration and problem with phonetics. Patient was more concerned about his speech because of poor communication. According to past medical history patient had congenital cleft lip and palate. He was operated for cleft lip correction surgery in childhood. Intra-oral examination revealed Veau’s class III cleft palate (fig.1). The surrounding area appeared to be normal with no evidence of infection. All the teeth were present with malformed 22 and 23. Since the patient was not ready for surgical correction, after clinical evaluation it was decided to fabricate Horizontal speech bulb obturator.
Dentulous impression tray size-3 was selected. Impression was made with the help of irreversible hydrocolloid impression material (fig.2). Cast was obtained after pouring with stone.
Fabrication of oral section of prosthesis
Four wrought wire clasp (19 gauge) were fabricated and positioned in such a way that two were on first premolars, another two were on first molars and retentive loop was fabricated with 21 gauge wire to support impression material. It extended from posterior part of obturator plate into palatopharyngeal defect area without compressing soft tissue. Oral section was fabricated with heat cure acrylic resin of a 2mm uniform thickness.
Recording an impression for pharyngeal section
Low fusing Impression compound was softened, kneaded and placed over the wire loop and inserted in the patient’s mouth to make the horizontal plane location of the obturator
- By asking the patient to tilt the head so that his chin rests on his chest,
- By asking him to swallow so that the inferior border of the obturator is in contact with the tongue during swallowing and simulating normal physiological movements
- By tilting or flexing the neck side-to-side and then swallowing.
Excess material was removed from the superior aspect until patient was able to breathe comfortably, peripheries of compound were trimmed and new material added and inserted in patient’s mouth. Patient was instructed to do the head movements again as mentioned above and the prosthesis removed from the mouth and inspected for continuous smooth margin all over the peripheries. These procedures were repeated until continuous margins obtained. If patient had difficulty in breathing, lateral surfaces of the compound was trimmed and tissues were recorded without pressure. The low fusing impression compound records the entire length of soft palate and makes contact with the posterior pharyngeal wall.
Speech analysis was done using Dr. Speech Software Version 4 (Tiger DRS, Inc., Seattle) by qualified speech pathologist to determine the adequacy of the impression. And impression was modified to get the best results. This software allows the user to record, analyze and display the acoustic signals. The program will automatically compute statistical information and plot a voice profile from sustained vowel and continuous speech. This is an objective, non-invasive method to evaluate acoustic signals. The voice sample was recorded through a hi-fidelity unidirectional condenser microphone. Each recording was done at mouth-to-microphone distance of 3 inches. Dr. Speech software program analyzed the following voice parameters, fundamental frequency (Hz), frequency range (Hz), intensity [(dB)-decibel], maximum phonation time (MPT) seconds, perturbation parameters such as jitter (pitch perturbation) and shimmer (amplitude perturbation). (fig.5&6).
Acrylisation of pharyngeal section
Then the second piece was beaded and boxed. Master cast made and second piece processed with self-cure resin attached to the first piece and prosthesis is delivered to the patient. (fig.7 &8).
Patient was also advised to continue with the speech therapy with the prosthesis to get more effective refinement of speech.
The horizontal (fixed) pharyngeal obturator is the most common type of pharyngeal obturator in use today and is the most effective in refinement of speech for many patients. It provides more physiologic separation between the oral and nasal structures and is in a region of muscle activity; therefore, speech therapy is effective in refinement of speech.
The Pros of Prostheses: It can provide adequate VP closure for speech, flexibility of additions/reductions to achieve optimal speech outcome, non-permanent and temporary, provides diagnostic information re: effect of VPC on speech, may “train out” and avoid need for surgery, may increase probability that surgery will be successful - adjunct to surgery.
The Cons of Prostheses: Reduction programs are time consuming and may not be ultimately successful, prostheses may need frequent adjustment for adequate retention, and replacement of lost or broken prostheses.
It was evident that the horizontal (fixed) pharyngeal obturator was effective in refinement of speech and comfort for the patient. Evaluation of speech by software was very helpful in improving the impression to get the best result. Also, along with the prosthesis taking speech therapy is very helpful in further refinement of speech.
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