Speech-aid prostheses for neurogenic velopharyngeal incompetence
Identifieur interne : 003F54 ( Istex/Corpus ); précédent : 003F53; suivant : 003F55Speech-aid prostheses for neurogenic velopharyngeal incompetence
Auteurs : Arie Shifman ; Yehuda Finkelstein ; Ariela Nachmani ; Dov OphirSource :
- The Journal of Prosthetic Dentistry [ 0022-3913 ] ; 2000.
English descriptors
- KwdEn :
- Autopolymerizing acrylic resin, Aviv university, Cerebral palsy, Chaim sheba, Clear acrylic resin, Cleft, Cleft palate, Cleft palate craniofac, Closure, Closure pattern, Contingent noncompliance, Continuous speech, Coronal, Dent, Dental medicine, Dentistry, Dysarthric patient, Effective nasopharyngeal obturation, Effective treatment approach, Extension wires, Family members, Final prosthesis, Hypernasality, Incompetence, Incompetent patients, Insufficiency, Intelligibility, Intermediate closure, Kfar saba, Labial errors, Maxillary, Maxillary section, Maxillofacial prosthetics, Maximal closure, Medial movement, Meir hospital, Mild hypernasality, Mild velar movement coronal, Multiview videofluoroscopy, Nasal emission, Nasal resonance, Nasopharyngeal, Nasopharyngeal obturation, Nasopharyngeal section, Nasopharyngeal sections, Nasopharyngoscopic control, Neck surgery, Oral view, Palatal, Palatal dimple, Palatal elevation, Palate, Palate surgery unit, Peroral examination, Pharyngeal, Pharyngeal walls, Plast reconstr surg, Plps, Portal area, Posterior border, Posterior pharyngeal wall, Prosthesis, Prosthet, Prosthet dent, Prosthetic, Prosthetic dentistry, Prosthetic management, Prosthetic treatment, Retentive loop, Sackler school, Shifman, Shutter sign, Soft palate, Speech intelligibility, Speech production, Speech therapy, Superior view, Surg, Surgical treatment, Valving mechanism, Velocardiofacial syndrome, Velopharyngeal, Velopharyngeal closure, Velopharyngeal incompetence, Velopharyngeal insufficiency, Videonasopharyngoscopic examinations, Weak pressure consonants.
- Teeft :
- Autopolymerizing acrylic resin, Aviv university, Cerebral palsy, Chaim sheba, Clear acrylic resin, Cleft, Cleft palate, Cleft palate craniofac, Closure, Closure pattern, Contingent noncompliance, Continuous speech, Coronal, Dent, Dental medicine, Dentistry, Dysarthric patient, Effective nasopharyngeal obturation, Effective treatment approach, Extension wires, Family members, Final prosthesis, Hypernasality, Incompetence, Incompetent patients, Insufficiency, Intelligibility, Intermediate closure, Kfar saba, Labial errors, Maxillary, Maxillary section, Maxillofacial prosthetics, Maximal closure, Medial movement, Meir hospital, Mild hypernasality, Mild velar movement coronal, Multiview videofluoroscopy, Nasal emission, Nasal resonance, Nasopharyngeal, Nasopharyngeal obturation, Nasopharyngeal section, Nasopharyngeal sections, Nasopharyngoscopic control, Neck surgery, Oral view, Palatal, Palatal dimple, Palatal elevation, Palate, Palate surgery unit, Peroral examination, Pharyngeal, Pharyngeal walls, Plast reconstr surg, Plps, Portal area, Posterior border, Posterior pharyngeal wall, Prosthesis, Prosthet, Prosthet dent, Prosthetic, Prosthetic dentistry, Prosthetic management, Prosthetic treatment, Retentive loop, Sackler school, Shifman, Shutter sign, Soft palate, Speech intelligibility, Speech production, Speech therapy, Superior view, Surg, Surgical treatment, Valving mechanism, Velocardiofacial syndrome, Velopharyngeal, Velopharyngeal closure, Velopharyngeal incompetence, Velopharyngeal insufficiency, Videonasopharyngoscopic examinations, Weak pressure consonants.
Abstract
Abstract: Statement Of Problem. When surgical treatment is not considered an option, prosthetic management of velopharyngeal insufficiency is carried out by means of a speech-aid prosthesis, whereas velopharyngeal incompetence is traditionally managed by a palatal lift prosthesis. Varying degrees of treatment success have been attributed to palatal lift prostheses. Purpose. This study introduces the use of nasopharyngeal obturation instead of palatal elevation for the management of velopharyngeal incompetence. Methods. Seven patients afflicted by neurogenic velopharyngeal incompetence were treated with wire-extension speech-aid prostheses constructed to circumvent the dysfunctional soft palate. The shape of the nasopharyngeal section was functionally molded in speech and swallowing and controlled by video-nasopharyngoscopic examinations. Results. Effective nasopharyngeal obturation with notable improved speech was achieved in all patients. Even though all patients ultimately tolerated the prostheses well, 2 patients denied any improvement in speech with the finalized prostheses. Conclusion. Wire-extension speech-aid prostheses used by the patients were an effective treatment approach for velopharyngeal incompetence. Nasopharyngoscopic control is mandatory for maximizing the effect of velopharyngeal closure around the nasopharyngeal section of the prosthesis in function, yet it allows free nasal breathing. Velopharyngeally incompetent patients should be carefully tailored for prosthetic treatment because of contingent noncompliance. (J Prosthet Dent 2000;83:99-106.)
Url:
DOI: 10.1016/S0022-3913(00)70094-1
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ISTEX:7FF63C7ABB94612A2F2F97963139FCDD85DAEF6BLe document en format XML
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Ariela" uniqKey="Nachmani A" first="Ariela" last="Nachmani">Ariela Nachmani</name><affiliation><mods:affiliation>Speech-Language Pathologist, Department of Otolaryngology, Head and Neck Surgery, Meir Hospital, Kfar Saba</mods:affiliation></affiliation></author><author><name sortKey="Ophir, Dov" sort="Ophir, Dov" uniqKey="Ophir D" first="Dov" last="Ophir">Dov Ophir</name><affiliation><mods:affiliation>Chief, Department of Otolaryngology, Head and Neck Surgery, Meir Hospital, Kfar Saba; and Clinical Associate Professor, Sackler School of Medicine, Tel Aviv University</mods:affiliation></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">ISTEX</idno><idno type="RBID">ISTEX:7FF63C7ABB94612A2F2F97963139FCDD85DAEF6B</idno><date when="2000" year="2000">2000</date><idno type="doi">10.1016/S0022-3913(00)70094-1</idno><idno type="url">https://api.istex.fr/document/7FF63C7ABB94612A2F2F97963139FCDD85DAEF6B/fulltext/pdf</idno><idno 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when="2000">2000</date><biblScope unit="volume">83</biblScope><biblScope unit="issue">1</biblScope><biblScope unit="page" from="99">99</biblScope><biblScope unit="page" to="106">106</biblScope></imprint><idno type="ISSN">0022-3913</idno></series></biblStruct></sourceDesc><seriesStmt><idno type="ISSN">0022-3913</idno></seriesStmt></fileDesc><profileDesc><textClass><keywords scheme="KwdEn" xml:lang="en"><term>Autopolymerizing acrylic resin</term><term>Aviv university</term><term>Cerebral palsy</term><term>Chaim sheba</term><term>Clear acrylic resin</term><term>Cleft</term><term>Cleft palate</term><term>Cleft palate craniofac</term><term>Closure</term><term>Closure pattern</term><term>Contingent noncompliance</term><term>Continuous speech</term><term>Coronal</term><term>Dent</term><term>Dental medicine</term><term>Dentistry</term><term>Dysarthric patient</term><term>Effective nasopharyngeal obturation</term><term>Effective treatment approach</term><term>Extension wires</term><term>Family members</term><term>Final prosthesis</term><term>Hypernasality</term><term>Incompetence</term><term>Incompetent patients</term><term>Insufficiency</term><term>Intelligibility</term><term>Intermediate closure</term><term>Kfar saba</term><term>Labial errors</term><term>Maxillary</term><term>Maxillary section</term><term>Maxillofacial prosthetics</term><term>Maximal closure</term><term>Medial movement</term><term>Meir hospital</term><term>Mild hypernasality</term><term>Mild velar movement coronal</term><term>Multiview videofluoroscopy</term><term>Nasal emission</term><term>Nasal resonance</term><term>Nasopharyngeal</term><term>Nasopharyngeal obturation</term><term>Nasopharyngeal section</term><term>Nasopharyngeal sections</term><term>Nasopharyngoscopic control</term><term>Neck surgery</term><term>Oral view</term><term>Palatal</term><term>Palatal dimple</term><term>Palatal elevation</term><term>Palate</term><term>Palate surgery unit</term><term>Peroral 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consonants</term></keywords><keywords scheme="Teeft" xml:lang="en"><term>Autopolymerizing acrylic resin</term><term>Aviv university</term><term>Cerebral palsy</term><term>Chaim sheba</term><term>Clear acrylic resin</term><term>Cleft</term><term>Cleft palate</term><term>Cleft palate craniofac</term><term>Closure</term><term>Closure pattern</term><term>Contingent noncompliance</term><term>Continuous speech</term><term>Coronal</term><term>Dent</term><term>Dental medicine</term><term>Dentistry</term><term>Dysarthric patient</term><term>Effective nasopharyngeal obturation</term><term>Effective treatment approach</term><term>Extension wires</term><term>Family members</term><term>Final prosthesis</term><term>Hypernasality</term><term>Incompetence</term><term>Incompetent patients</term><term>Insufficiency</term><term>Intelligibility</term><term>Intermediate closure</term><term>Kfar saba</term><term>Labial errors</term><term>Maxillary</term><term>Maxillary section</term><term>Maxillofacial 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management</term><term>Prosthetic treatment</term><term>Retentive loop</term><term>Sackler school</term><term>Shifman</term><term>Shutter sign</term><term>Soft palate</term><term>Speech intelligibility</term><term>Speech production</term><term>Speech therapy</term><term>Superior view</term><term>Surg</term><term>Surgical treatment</term><term>Valving mechanism</term><term>Velocardiofacial syndrome</term><term>Velopharyngeal</term><term>Velopharyngeal closure</term><term>Velopharyngeal incompetence</term><term>Velopharyngeal insufficiency</term><term>Videonasopharyngoscopic examinations</term><term>Weak pressure consonants</term></keywords></textClass><langUsage><language ident="en">en</language></langUsage></profileDesc></teiHeader><front><div type="abstract" xml:lang="en">Abstract: Statement Of Problem. When surgical treatment is not considered an option, prosthetic management of velopharyngeal insufficiency is carried out by means of a speech-aid prosthesis, whereas velopharyngeal incompetence is traditionally managed by a palatal lift prosthesis. Varying degrees of treatment success have been attributed to palatal lift prostheses. Purpose. This study introduces the use of nasopharyngeal obturation instead of palatal elevation for the management of velopharyngeal incompetence. Methods. Seven patients afflicted by neurogenic velopharyngeal incompetence were treated with wire-extension speech-aid prostheses constructed to circumvent the dysfunctional soft palate. The shape of the nasopharyngeal section was functionally molded in speech and swallowing and controlled by video-nasopharyngoscopic examinations. Results. Effective nasopharyngeal obturation with notable improved speech was achieved in all patients. Even though all patients ultimately tolerated the prostheses well, 2 patients denied any improvement in speech with the finalized prostheses. Conclusion. Wire-extension speech-aid prostheses used by the patients were an effective treatment approach for velopharyngeal incompetence. Nasopharyngoscopic control is mandatory for maximizing the effect of velopharyngeal closure around the nasopharyngeal section of the prosthesis in function, yet it allows free nasal breathing. Velopharyngeally incompetent patients should be carefully tailored for prosthetic treatment because of contingent noncompliance. 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and Senior Clinical Lecturer, Department of Oral Rehabilitation, School of Dental Medicine, Tel Aviv University</json:string></affiliations></json:item><json:item><name>Yehuda Finkelstein MD</name><affiliations><json:string>Chief, Palate Surgery Unit, Department of Otolaryngology, Head and Neck Surgery, Meir Hospital; and Senior Lecturer, Sackler School of Medicine, Tel Aviv University</json:string></affiliations></json:item><json:item><name>Ariela Nachmani MA</name><affiliations><json:string>Speech-Language Pathologist, Department of Otolaryngology, Head and Neck Surgery, Meir Hospital, Kfar Saba</json:string></affiliations></json:item><json:item><name>Dov Ophir MD</name><affiliations><json:string>Chief, Department of Otolaryngology, Head and Neck Surgery, Meir Hospital, Kfar Saba; and Clinical Associate Professor, Sackler School of Medicine, Tel Aviv University</json:string></affiliations></json:item></author><arkIstex>ark:/67375/6H6-BM9VZDN4-C</arkIstex><language><json:string>eng</json:string></language><originalGenre><json:string>Full-length article</json:string></originalGenre><abstract>Abstract: Statement Of Problem. When surgical treatment is not considered an option, prosthetic management of velopharyngeal insufficiency is carried out by means of a speech-aid prosthesis, whereas velopharyngeal incompetence is traditionally managed by a palatal lift prosthesis. Varying degrees of treatment success have been attributed to palatal lift prostheses. Purpose. This study introduces the use of nasopharyngeal obturation instead of palatal elevation for the management of velopharyngeal incompetence. Methods. Seven patients afflicted by neurogenic velopharyngeal incompetence were treated with wire-extension speech-aid prostheses constructed to circumvent the dysfunctional soft palate. The shape of the nasopharyngeal section was functionally molded in speech and swallowing and controlled by video-nasopharyngoscopic examinations. Results. Effective nasopharyngeal obturation with notable improved speech was achieved in all patients. Even though all patients ultimately tolerated the prostheses well, 2 patients denied any improvement in speech with the finalized prostheses. Conclusion. Wire-extension speech-aid prostheses used by the patients were an effective treatment approach for velopharyngeal incompetence. Nasopharyngoscopic control is mandatory for maximizing the effect of velopharyngeal closure around the nasopharyngeal section of the prosthesis in function, yet it allows free nasal breathing. Velopharyngeally incompetent patients should be carefully tailored for prosthetic treatment because of contingent noncompliance. (J Prosthet Dent 2000;83:99-106.)</abstract><qualityIndicators><score>9.216</score><pdfWordCount>4816</pdfWordCount><pdfCharCount>32212</pdfCharCount><pdfVersion>1.3</pdfVersion><pdfPageCount>8</pdfPageCount><pdfPageSize>612 x 792 pts (letter)</pdfPageSize><refBibsNative>true</refBibsNative><abstractWordCount>200</abstractWordCount><abstractCharCount>1591</abstractCharCount><keywordCount>0</keywordCount></qualityIndicators><title>Speech-aid prostheses for neurogenic velopharyngeal incompetence</title><pmid><json:string>10633028</json:string></pmid><pii><json:string>S0022-3913(00)70094-1</json:string></pii><genre><json:string>research-article</json:string></genre><serie><title>J Prosthet Dent</title><language><json:string>unknown</json:string></language><volume>81</volume><pages><first>41</first><last>110</last></pages></serie><host><title>The Journal of Prosthetic Dentistry</title><language><json:string>unknown</json:string></language><publicationDate>2000</publicationDate><issn><json:string>0022-3913</json:string></issn><pii><json:string>S0022-3913(05)X7072-X</json:string></pii><volume>83</volume><issue>1</issue><pages><first>99</first><last>106</last></pages><genre><json:string>journal</json:string></genre></host><namedEntities><unitex><date><json:string>2000</json:string><json:string>1997</json:string></date><geogName></geogName><orgName><json:string>Chaim Sheba Medical Center</json:string><json:string>Department of Oral Rehabilitation, School of Dental Medicine, Tel Aviv University</json:string><json:string>Shure Bros Inc</json:string><json:string>GC Corp, Tokyo, Japan</json:string><json:string>Department of Otolaryngology, Head and Neck</json:string><json:string>Department of Otolaryngology-Head and Neck</json:string><json:string>Meir Hospital, Sapir Medical Center, Kfar Saba</json:string><json:string>Tel Aviv University</json:string><json:string>Meir Hospital, Kfar Saba</json:string><json:string>Sony Corp, Tokyo, Japan</json:string><json:string>Israel Statement</json:string></orgName><orgName_funder></orgName_funder><orgName_provider></orgName_provider><persName><json:string>Unit</json:string><json:string>Dov Ophir</json:string><json:string>Yehuda Finkelstein</json:string><json:string>I. Characteristics</json:string><json:string>Meir Hospital</json:string><json:string>Ariela Nachmani</json:string><json:string>Patient</json:string><json:string>AL Table</json:string></persName><placeName><json:string>Malta</json:string></placeName><ref_url></ref_url><ref_bibl><json:string>Wolfaardt et al</json:string><json:string>Witt et al</json:string></ref_bibl><bibl></bibl></unitex></namedEntities><ark><json:string>ark:/67375/6H6-BM9VZDN4-C</json:string></ark><categories><wos><json:string>1 - science</json:string><json:string>2 - dentistry, oral surgery & medicine</json:string></wos><scienceMetrix><json:string>1 - health sciences</json:string><json:string>2 - clinical medicine</json:string><json:string>3 - dentistry</json:string></scienceMetrix><scopus><json:string>1 - Health Sciences</json:string><json:string>2 - Dentistry</json:string><json:string>3 - Oral Surgery</json:string></scopus><inist><json:string>1 - sciences appliquees, technologies et medecines</json:string><json:string>2 - sciences biologiques et medicales</json:string><json:string>3 - sciences medicales</json:string><json:string>4 - otorhinolaryngologie. stomatologie</json:string></inist></categories><publicationDate>2000</publicationDate><copyrightDate>2000</copyrightDate><doi><json:string>10.1016/S0022-3913(00)70094-1</json:string></doi><id>7FF63C7ABB94612A2F2F97963139FCDD85DAEF6B</id><score>1</score><fulltext><json:item><extension>pdf</extension><original>true</original><mimetype>application/pdf</mimetype><uri>https://api.istex.fr/document/7FF63C7ABB94612A2F2F97963139FCDD85DAEF6B/fulltext/pdf</uri></json:item><json:item><extension>zip</extension><original>false</original><mimetype>application/zip</mimetype><uri>https://api.istex.fr/document/7FF63C7ABB94612A2F2F97963139FCDD85DAEF6B/fulltext/zip</uri></json:item><istex:fulltextTEI uri="https://api.istex.fr/document/7FF63C7ABB94612A2F2F97963139FCDD85DAEF6B/fulltext/tei"><teiHeader><fileDesc><titleStmt><title level="a" type="main" xml:lang="en">Speech-aid prostheses for neurogenic velopharyngeal incompetence</title></titleStmt><publicationStmt><authority>ISTEX</authority><publisher>ELSEVIER</publisher><availability><p>©2000 Editorial Council of The Journal of Prosthetic Dentistry.</p></availability><date>2000</date></publicationStmt><notesStmt><note>Reprint requests to: DR ARIE SHIFMAN, POB 1031, PETACH TIKVA 49110, ISRAEL, FAX: (972)3-9317548, E-MAIL: yehudaf@ultinet.co.il</note><note>0022-3913/2000/$12.00 + 0. 10/1/102829</note><note type="content">Table I: Characteristics of VP incompetent patients</note><note type="content">Table II: Pretreatment speech evaluation and treatment outcome</note></notesStmt><sourceDesc><biblStruct type="inbook"><analytic><title level="a" type="main" xml:lang="en">Speech-aid prostheses for neurogenic velopharyngeal incompetence</title><author xml:id="author-0000"><persName><forename type="first">Arie</forename><surname>Shifman</surname></persName><roleName type="degree">DMD</roleName><affiliation>Chief, Maxillofacial Prosthetic Unit, Chaim Sheba Medical Center; and Senior Clinical Lecturer, Department of Oral Rehabilitation, School of Dental Medicine, Tel Aviv University</affiliation></author><author xml:id="author-0001"><persName><forename type="first">Yehuda</forename><surname>Finkelstein</surname></persName><roleName type="degree">MD</roleName><affiliation>Chief, Palate Surgery Unit, Department of Otolaryngology, Head and Neck Surgery, Meir Hospital; and Senior Lecturer, Sackler School of Medicine, Tel Aviv University</affiliation></author><author xml:id="author-0002"><persName><forename type="first">Ariela</forename><surname>Nachmani</surname></persName><roleName type="degree">MA</roleName><affiliation>Speech-Language Pathologist, Department of Otolaryngology, Head and Neck Surgery, Meir Hospital, Kfar Saba</affiliation></author><author xml:id="author-0003"><persName><forename type="first">Dov</forename><surname>Ophir</surname></persName><roleName type="degree">MD</roleName><affiliation>Chief, Department of Otolaryngology, Head and Neck Surgery, Meir Hospital, Kfar Saba; and Clinical Associate Professor, Sackler School of Medicine, Tel Aviv University</affiliation></author><idno type="istex">7FF63C7ABB94612A2F2F97963139FCDD85DAEF6B</idno><idno type="DOI">10.1016/S0022-3913(00)70094-1</idno><idno type="PII">S0022-3913(00)70094-1</idno></analytic><monogr><title level="j">The Journal of Prosthetic Dentistry</title><title level="j" type="abbrev">YMPR</title><idno type="pISSN">0022-3913</idno><idno type="PII">S0022-3913(05)X7072-X</idno><imprint><publisher>ELSEVIER</publisher><date type="published" when="2000"></date><biblScope unit="volume">83</biblScope><biblScope unit="issue">1</biblScope><biblScope unit="page" from="99">99</biblScope><biblScope unit="page" to="106">106</biblScope></imprint></monogr></biblStruct></sourceDesc></fileDesc><profileDesc><creation><date>2000</date></creation><langUsage><language ident="en">en</language></langUsage><abstract xml:lang="en"><p>Statement Of Problem. When surgical treatment is not considered an option, prosthetic management of velopharyngeal insufficiency is carried out by means of a speech-aid prosthesis, whereas velopharyngeal incompetence is traditionally managed by a palatal lift prosthesis. Varying degrees of treatment success have been attributed to palatal lift prostheses. Purpose. This study introduces the use of nasopharyngeal obturation instead of palatal elevation for the management of velopharyngeal incompetence. Methods. Seven patients afflicted by neurogenic velopharyngeal incompetence were treated with wire-extension speech-aid prostheses constructed to circumvent the dysfunctional soft palate. The shape of the nasopharyngeal section was functionally molded in speech and swallowing and controlled by video-nasopharyngoscopic examinations. Results. Effective nasopharyngeal obturation with notable improved speech was achieved in all patients. Even though all patients ultimately tolerated the prostheses well, 2 patients denied any improvement in speech with the finalized prostheses. Conclusion. Wire-extension speech-aid prostheses used by the patients were an effective treatment approach for velopharyngeal incompetence. Nasopharyngoscopic control is mandatory for maximizing the effect of velopharyngeal closure around the nasopharyngeal section of the prosthesis in function, yet it allows free nasal breathing. Velopharyngeally incompetent patients should be carefully tailored for prosthetic treatment because of contingent noncompliance. (J Prosthet Dent 2000;83:99-106.)</p></abstract></profileDesc><revisionDesc><change when="2000">Published</change></revisionDesc></teiHeader></istex:fulltextTEI><json:item><extension>txt</extension><original>false</original><mimetype>text/plain</mimetype><uri>https://api.istex.fr/document/7FF63C7ABB94612A2F2F97963139FCDD85DAEF6B/fulltext/txt</uri></json:item></fulltext><metadata><istex:metadataXml wicri:clean="Elsevier doc found" wicri:toSee="Elsevier, no converted or simple article"><istex:xmlDeclaration>version="1.0" encoding="utf-8"</istex:xmlDeclaration><istex:docType PUBLIC="-//ES//DTD journal article DTD version 5.0.1//EN//XML" URI="art501.dtd" name="istex:docType"><istex:entity SYSTEM="gr1" NDATA="IMAGE" name="gr1"></istex:entity><istex:entity SYSTEM="gr2" NDATA="IMAGE" name="gr2"></istex:entity><istex:entity SYSTEM="gr3" NDATA="IMAGE" name="gr3"></istex:entity><istex:entity SYSTEM="gr4" NDATA="IMAGE" name="gr4"></istex:entity></istex:docType><istex:document><article docsubtype="fla" xml:lang="en"><item-info><jid>YMPR</jid><aid>102829</aid><ce:pii>S0022-3913(00)70094-1</ce:pii><ce:doi>10.1016/S0022-3913(00)70094-1</ce:doi><ce:copyright type="other" year="2000">Editorial Council of The Journal of Prosthetic Dentistry.</ce:copyright></item-info><ce:floats><ce:table id="tab1" colsep="0" rowsep="0" frame="topbot"><ce:label>Table I</ce:label><ce:caption><ce:simple-para>Characteristics of VP incompetent patients</ce:simple-para></ce:caption><tgroup cols="5"><colspec colname="col1" colsep="0"></colspec><colspec colname="col2" colsep="0"></colspec><colspec colname="col3" colsep="0"></colspec><colspec colname="col4" colsep="0"></colspec><colspec colname="col5" colsep="0"></colspec><thead><row><entry>Patient number</entry><entry align="center">Patient name</entry><entry align="center">Age (y)</entry><entry align="center">Gender</entry><entry align="center">Cause</entry></row></thead><tbody><row><entry>1</entry><entry align="center">SZ</entry><entry align="center">11</entry><entry align="center">Male</entry><entry align="center">Open head injury</entry></row><row><entry>2</entry><entry align="center">SN</entry><entry align="center">25</entry><entry align="center">Male</entry><entry align="center">Closed head injury</entry></row><row><entry>3</entry><entry align="center">BT</entry><entry align="center">25</entry><entry align="center">Male</entry><entry align="center">Neurosurgery: Astrocytoma</entry></row><row><entry>4</entry><entry align="center">HY</entry><entry align="center">64</entry><entry align="center">Male</entry><entry align="center">Rec. cerebrovascular accident</entry></row><row><entry></entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry><entry align="center">Bilateral central VII nerve paralysis</entry></row><row><entry>5</entry><entry align="center">DS</entry><entry align="center">47</entry><entry align="center">Male</entry><entry align="center">Amyotrophic lateral sclerosis</entry></row><row><entry>6</entry><entry align="center">MG</entry><entry align="center">43</entry><entry align="center">Male</entry><entry align="center">Excision of cervical Schwanoma</entry></row><row><entry></entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry><entry align="center">Right X, IX nerves paralysis</entry></row><row><entry></entry><entry align="center"></entry><entry align="center"></entry><entry align="center"></entry><entry align="center">(Right velopharyngeal and vocal cord paralysis)</entry></row><row><entry>7</entry><entry align="center">ST</entry><entry align="center">21</entry><entry align="center">Female</entry><entry align="center">Dystonia</entry></row></tbody></tgroup></ce:table><ce:table id="tab2" colsep="0" rowsep="0" frame="topbot"><ce:label>Table II</ce:label><ce:caption><ce:simple-para>Pretreatment speech evaluation and treatment outcome</ce:simple-para></ce:caption><tgroup cols="9"><colspec colname="col1" colsep="0"></colspec><colspec colname="col2" colsep="0"></colspec><colspec colname="col3" colsep="0"></colspec><colspec colname="col4" colsep="0"></colspec><colspec colname="col5" colsep="0"></colspec><colspec colname="col6" colsep="0"></colspec><colspec colname="col7" colsep="0"></colspec><colspec colname="col8" colsep="0"></colspec><colspec colname="col9" colsep="0"></colspec><thead><row><entry morerows="1">Patient no.</entry><entry morerows="1" align="center">VP closure pattern and gap</entry><entry namest="col3" nameend="col5" align="center">Preprosthetic speech evaluation</entry><entry colname="col6" morerows="1" align="center">No. of visits*</entry><entry namest="col7" nameend="col9" align="center">Postprosthetic speech evaluation</entry></row><row><entry colname="col3" align="center">Hypernasality</entry><entry align="center">Dysarthria</entry><entry align="center">Intelligibility</entry><entry colname="col7" align="center">Hypernasality</entry><entry align="center">Intelligibility</entry><entry align="center">Overall improvement</entry></row></thead><tbody><row><entry>1</entry><entry align="center">Coronal and mild velar movement</entry><entry align="center">Severe</entry><entry align="center">+ Red. loud.</entry><entry align="center">Markedly reduced</entry><entry align="center">9</entry><entry align="center">Normal</entry><entry align="center">Mildly reduced</entry><entry align="center">Marked</entry></row><row><entry>2</entry><entry align="center">Coronal and mild velar movement</entry><entry align="center">Severe</entry><entry align="center">+</entry><entry align="center">Moderately reduced</entry><entry align="center">9</entry><entry align="center">Normal</entry><entry align="center">Normal</entry><entry align="center">Marked</entry></row><row><entry>3</entry><entry align="center">Coronal and mild velar movement</entry><entry align="center">Severe</entry><entry align="center">+</entry><entry align="center">Markedly reduced</entry><entry align="center">8</entry><entry align="center">Mild</entry><entry align="center">Mildly reduced</entry><entry align="center">Marked</entry></row><row><entry>4</entry><entry align="center">Coronal and mild velar movement</entry><entry align="center">Severe</entry><entry align="center">+ Red. loud.</entry><entry align="center">Markedly reduced</entry><entry align="center">11</entry><entry align="center">Normal</entry><entry align="center">Mildly reduced</entry><entry align="center">Marked</entry></row><row><entry>5</entry><entry align="center">Complete paralysis</entry><entry align="center">Severe</entry><entry align="center">+ Red. loud.</entry><entry align="center">Markedly reduced</entry><entry align="center">13</entry><entry align="center">Mild</entry><entry align="center">Moderately reduced</entry><entry align="center">Moderate</entry></row><row><entry>6</entry><entry align="center">CMLW and gap in the right portal area</entry><entry align="center">Moderate</entry><entry align="center">– Dysphonia</entry><entry align="center">Mildly reduced</entry><entry align="center">9</entry><entry align="center">Normal</entry><entry align="center">Normal</entry><entry align="center">Marked</entry></row><row><entry>7</entry><entry align="center">Coronal and central symmetrical gap</entry><entry align="center">Moderate</entry><entry align="center">+</entry><entry align="center">Markedly reduced</entry><entry align="center">10</entry><entry align="center">Mild</entry><entry align="center">Moderately reduced</entry><entry align="center">Slight</entry></row><row><entry namest="col1" nameend="col9">*Preprosthetic, prosthetic fitting, and postprosthetic evaluation visits.</entry></row></tbody></tgroup><ce:legend><ce:simple-para><ce:italic>CMLW</ce:italic> = Coronal with marked medial movement of the lateral pharyngeal walls.</ce:simple-para><ce:simple-para><ce:italic>Red. loud.</ce:italic> = Reduced loudness.</ce:simple-para></ce:legend></ce:table></ce:floats><head><ce:article-footnote><ce:label>☆</ce:label><ce:note-para>Reprint requests to: DR ARIE SHIFMAN, POB 1031, PETACH TIKVA 49110, ISRAEL, FAX: (972)3-9317548, <ce:inter-ref xlink:href="mailto:yehudaf@ultinet.co.il">E-MAIL: yehudaf@ultinet.co.il</ce:inter-ref></ce:note-para></ce:article-footnote><ce:article-footnote><ce:label>☆☆</ce:label><ce:note-para>0022-3913/2000/$12.00 + 0. <ce:bold>10/1/102829</ce:bold></ce:note-para></ce:article-footnote><ce:title>Speech-aid prostheses for neurogenic velopharyngeal incompetence</ce:title><ce:presented>Presented at the biannual meeting of the International College of Prosthodontists, Sliema, Malta, October 1997; and at the annual meeting of the American Academy of Maxillofacial Prosthetics, Orlando, Fla., November 1997.</ce:presented><ce:author-group><ce:author><ce:given-name>Arie</ce:given-name><ce:surname>Shifman</ce:surname><ce:degrees>DMD</ce:degrees><ce:cross-ref refid="aff2"><ce:sup>a</ce:sup></ce:cross-ref></ce:author><ce:author><ce:given-name>Yehuda</ce:given-name><ce:surname>Finkelstein</ce:surname><ce:degrees>MD</ce:degrees><ce:cross-ref refid="aff3"><ce:sup>b</ce:sup></ce:cross-ref></ce:author><ce:author><ce:given-name>Ariela</ce:given-name><ce:surname>Nachmani</ce:surname><ce:degrees>MA</ce:degrees><ce:cross-ref refid="aff4"><ce:sup>c</ce:sup></ce:cross-ref></ce:author><ce:author><ce:given-name>Dov</ce:given-name><ce:surname>Ophir</ce:surname><ce:degrees>MD</ce:degrees><ce:cross-ref refid="aff5"><ce:sup>d</ce:sup></ce:cross-ref></ce:author><ce:affiliation><ce:textfn>Maurice and Gabriela Goldschleger School of Dental Medicine, and Chaim Sheba Medical Center, Tel-Hashomer; Meir Hospital, Sapir Medical Center, Kfar Saba; and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel</ce:textfn></ce:affiliation><ce:affiliation id="aff2"><ce:label>a</ce:label><ce:textfn>Chief, Maxillofacial Prosthetic Unit, Chaim Sheba Medical Center; and Senior Clinical Lecturer, Department of Oral Rehabilitation, School of Dental Medicine, Tel Aviv University</ce:textfn></ce:affiliation><ce:affiliation id="aff3"><ce:label>b</ce:label><ce:textfn>Chief, Palate Surgery Unit, Department of Otolaryngology, Head and Neck Surgery, Meir Hospital; and Senior Lecturer, Sackler School of Medicine, Tel Aviv University</ce:textfn></ce:affiliation><ce:affiliation id="aff4"><ce:label>c</ce:label><ce:textfn>Speech-Language Pathologist, Department of Otolaryngology, Head and Neck Surgery, Meir Hospital, Kfar Saba</ce:textfn></ce:affiliation><ce:affiliation id="aff5"><ce:label>d</ce:label><ce:textfn>Chief, Department of Otolaryngology, Head and Neck Surgery, Meir Hospital, Kfar Saba; and Clinical Associate Professor, Sackler School of Medicine, Tel Aviv University</ce:textfn></ce:affiliation></ce:author-group><ce:abstract><ce:section-title>Abstract</ce:section-title><ce:abstract-sec><ce:simple-para><ce:bold>Statement Of Problem.</ce:bold> When surgical treatment is not considered an option, prosthetic management of velopharyngeal insufficiency is carried out by means of a speech-aid prosthesis, whereas velopharyngeal incompetence is traditionally managed by a palatal lift prosthesis. Varying degrees of treatment success have been attributed to palatal lift prostheses. <ce:bold>Purpose.</ce:bold> This study introduces the use of nasopharyngeal obturation instead of palatal elevation for the management of velopharyngeal incompetence. <ce:bold>Methods.</ce:bold> Seven patients afflicted by neurogenic velopharyngeal incompetence were treated with wire-extension speech-aid prostheses constructed to circumvent the dysfunctional soft palate. The shape of the nasopharyngeal section was functionally molded in speech and swallowing and controlled by video-nasopharyngoscopic examinations. <ce:bold>Results.</ce:bold> Effective nasopharyngeal obturation with notable improved speech was achieved in all patients. Even though all patients ultimately tolerated the prostheses well, 2 patients denied any improvement in speech with the finalized prostheses. <ce:bold>Conclusion.</ce:bold> Wire-extension speech-aid prostheses used by the patients were an effective treatment approach for velopharyngeal incompetence. Nasopharyngoscopic control is mandatory for maximizing the effect of velopharyngeal closure around the nasopharyngeal section of the prosthesis in function, yet it allows free nasal breathing. Velopharyngeally incompetent patients should be carefully tailored for prosthetic treatment because of contingent noncompliance. (J Prosthet Dent 2000;83:99-106.)</ce:simple-para></ce:abstract-sec></ce:abstract></head><body><ce:sections><ce:para><ce:display><ce:textbox><ce:textbox-body><ce:sections><ce:para><ce:italic>The results of this study indicated that nasopharyngeal obturation by speech-aid prostheses, in conjunction with speech-language therapy, was useful for the correction of velopharyngeal incompetence.</ce:italic></ce:para></ce:sections></ce:textbox-body></ce:textbox></ce:display></ce:para><ce:para>The palatopharyngeal or velopharyngeal (VP) valving mechanism regulates resonation and speech utterance and partakes in nonspeech oral activities such as swallowing, blowing, sucking, and whistling.<ce:cross-refs refid="bib1 bib2"><ce:sup>1,2</ce:sup></ce:cross-refs> VP dysfunction implies the presence of hypernasality, inappropriate nasal escape, and decreased air pressure during the production of oral speech sounds (weak pressure consonants). Compensatory articulations in the form of secondary glottal, lingual, and labial errors are often present.<ce:cross-refs refid="bib1 bib2"><ce:sup>1,2</ce:sup></ce:cross-refs></ce:para><ce:para>As VP dysfunction may be congenital, developmental, or acquired, it may affect all age groups. It may occur either as VP insufficiency or as VP incompetence. VP insufficiency denotes speech and resonance aberrations related to a congenital or acquired anatomic defect of the soft palate that makes the VP sphincter incomplete such as that which occurs in cleft palate or post resection of a palatal tumor. By contrast, VP incompetence denotes dysfunction of an anatomically intact VP that occurs in patients with neuromuscular disorders, or mislearning.<ce:cross-refs refid="bib3 bib4"><ce:sup>3,4</ce:sup></ce:cross-refs></ce:para><ce:para>Neuromuscular impairment of the VP can be related to various etiologic factors: (1) traumatic brain injuries, cerebrovascular accidents or postneurosurgical treatment of brain/meningeal tumors; (2) central or peripheral degenerative or metabolic diseases of the nervous system such as: multiple sclerosis, parkinsonism, bulbar poliomyelitis, cerebral palsy, amyotrophic lateral sclerosis, dystonia, and myasthenia gravis; (3) muscle or connective tissue disease, for instance, myotonic dystrophy or mixed connective tissue disorder. Other conditions linked to incompetence of an apparently intact VP sphincter are behavioral mislearning,<ce:cross-ref refid="bib2"><ce:sup>2</ce:sup></ce:cross-ref> tonsillar upper poles hypertrophy,<ce:cross-ref refid="bib5"><ce:sup>5</ce:sup></ce:cross-ref> hypotonic (dyskinetic) VP,<ce:cross-ref refid="bib6"><ce:sup>6</ce:sup></ce:cross-ref> and overly stressed VP (wind instrument playing).<ce:cross-ref refid="bib7"><ce:sup>7</ce:sup></ce:cross-ref> Surgery is considered the preferred treatment for speech correction in patients affected by VP dysfunction. However, this treatment is not possible or practical for numerous clinical situations such as (1) advanced cardiovascular or neurologic diseases (cerebral palsy, postcerebrovascular accidents); (2) biomechanical limitations for surgery (cervical spine deformities, limitation of mandibular opening or microstomia); (3) anomalous medial deviation of the internal carotid arteries, which may be revealed nasopharyngoscopically by pulsations appearing in the pharyngeal walls and can be completely revealed by MRI or spiral computed tomography with carotid angiography (this phenomenon commonly occurs in the Velocardiofacial syndrome)<ce:cross-refs refid="bib8 bib9"><ce:sup>8,9</ce:sup></ce:cross-refs>; (4) presence or risk of obstructive sleep apnea; and (5) patients refusing surgery because of psychologic reasons (fear) or economic restraints.</ce:para><ce:para>For patients who cannot receive surgical treatment, prosthetic treatment combined with speech therapy is the treatment of choice. Prosthetic management of VP insufficiency is carried out by means of speech-aid prostheses (SAPs), whereas VP incompetence is treated with palatal lift prostheses (PLPs).<ce:cross-ref refid="bib10"><ce:sup>10</ce:sup></ce:cross-ref> The functional component of the SAP is a nasopharyngeal section (“speech bulb”) that is shaped to conform to the activity of the VP during speech and swallowing, whereas PLP reduces hypernasality by approximating the incompetent soft palate to the posterior pharyngeal wall.</ce:para><ce:para>The purpose of this study is to assess the feasibility of using an alternative type of SAP for the management of VP incompetence.</ce:para><ce:section><ce:section-title>MATERIAL AND METHODS</ce:section-title><ce:para>Patients were recruited from consecutive patients attending the Palate Surgery Unit of the Department of Otolaryngology-Head and Neck Surgery, Meir Hospital, Sapir Medical Center, Kfar Saba, or at the private practice of the second author during the years 1994-1997. These patients underwent a complete ear-nose-throat examination, including assessment of speech, video-nasopharyngoscopy and multiview videofluoroscopy. Their medical background was gleaned from hospital records. Patients in whom surgery could not be considered were also examined by a maxillofacial prosthodontist and by a speech-language pathologist. After team members concluded that the patient could markedly benefit from the prosthetic treatment, patients were offered speech-aid prostheses. Only those patients with VP incompetence, who had completed the prosthodontic treatment that was controlled by video-nasopharyngoscopic examinations, were selected.</ce:para><ce:section><ce:section-title>Speech examination</ce:section-title><ce:para>Judgments were made after listening to connected free speech, including loud reading tasks, counting from 1 to 10, and naming the days of the week. In addition, repetition tasks include samples of a number of pressure consonants (p/b/d/t/s/z/sh/ts) in consonant/vowel sequences, of meaningful Hebrew words and sentences. Vowels nasality test was performed by having the patient repeat pronouncing sequences of /i-a/ and /u-i/, while the diagnostician alternately closed the patient’s nostrils by digital pinching and re-opened them by releasing the nostrils. Resonance during occlusion and unocclusion was compared. From the data collected, judgments and rates of the following were made: (1) intelligibility — normal, mildly reduced, moderately reduced, or markedly reduced; (2) phonation — normal, reduced loudness, tendency to higher pitch, or dysphonia; (3) resonance and nasal emission, which included normal resonance, inconsistent hypernasality, namely, oral responses produced, but accompanied by occasional nasalization in connected speech, mild hypernasality, namely, increased nasal quality and inconsistent nasal emission, moderate hypernasality, namely, consistent nasality, which is greater in degree than mild hypernasality, consistent nasal emission and weak pressure consonants, or severe hypernasality, namely, marked nasal resonance, consistent nasal emission, weak pressure consonants, and persistent nasal substitutions. This speech evaluation process was repeated for all patients wearing the final prosthesis.</ce:para><ce:para>On peroral examination, the palatal dimple was observed during phonation. Normally, a midline dimple is present at the junction of the middle and posterior third of the soft palate during “ah” or “eh.”<ce:cross-ref refid="bib11"><ce:sup>11</ce:sup></ce:cross-ref> Shutter sign was also searched, and consisted of up and down movement of the posterior pharyngeal wall, which indicates formation of Passavant’s ridge on the higher plane.<ce:cross-ref refid="bib11"><ce:sup>11</ce:sup></ce:cross-ref></ce:para></ce:section><ce:section><ce:section-title>Video-nasopharyngoscopic and multiview videofluoroscopic examinations</ce:section-title><ce:para>A video-nasopharyngoscopic examination of the VP valve under topical anesthesia was performed using an Olympus ENF-P2 flexible nasopharyngoscope and rigid telescope 30 degrees (Storz Hopkins) when possible. The examination was recorded by a Sony SVO 1500P videotape recorder (Sony Corp, Tokyo, Japan). An external microphone (SHURE SM-11, Shure Bros Inc, Evanston, Ill.) was used to record the acoustic signal on the videotape. The examination includes the full depth of the pharynx, with special attention to the medial movement of the lateral and posterior walls of VP valve, during closure in speech.<ce:cross-refs refid="bib12 bib13 bib14"><ce:sup>12-14</ce:sup></ce:cross-refs> In addition, a multiview videofluoroscopic examination was performed, so as to characterize the relative contribution of the pharyngeal walls to the closure pattern.<ce:cross-refs refid="bib12 bib13 bib14 bib15 bib16"><ce:sup>12-16</ce:sup></ce:cross-refs> On the basis of both examinations, patients were categorized according to the VP closure pattern namely coronal, circular type with or without Passavant’s ridge or sagittal.<ce:cross-refs refid="bib12 bib13 bib14 bib15 bib16"><ce:sup>12-16</ce:sup></ce:cross-refs> Each type of the VP closure pattern was classified as symmetric or asymmetric. The symmetric gap in VP closure was noted as central small or central large. The asymmetric gap was noted as central or located in right or left portal area.</ce:para></ce:section><ce:section><ce:section-title>Speech-aid prostheses</ce:section-title><ce:para>All patients were provided with a wire-extension SAP that consisted of a conventional maxillary section and a nasopharyngeal section that was connected to it with 1-curved (Fig. 1) or 2-curved stainless steel 0.9-mm wires (Figs. 2 and 3).
<ce:display><ce:figure id="fig1"><ce:label>Fig. 1</ce:label><ce:caption><ce:simple-para><ce:bold>A,</ce:bold> Superior view of final speech-aid prosthesis of patient no. 3. Maxillary and nasopharyngeal sections connected to it with 1-curved stainless steel wire. <ce:bold>B,</ce:bold> Oral view of prosthesis in patient’s mouth with 1 wire passing on right side of uvula.</ce:simple-para></ce:caption> <ce:link locator="gr1"></ce:link></ce:figure></ce:display><ce:display><ce:figure id="fig2"><ce:label>Fig. 2</ce:label><ce:caption><ce:simple-para><ce:bold>A,</ce:bold> Superior view of final 2-wired speech-aid prosthesis of patient no. 1. <ce:bold>B,</ce:bold> Oral view of prosthesis in patient’s mouth. Extension wires passing on both sides of uvula.</ce:simple-para></ce:caption> <ce:link locator="gr2"></ce:link></ce:figure></ce:display><ce:display><ce:figure id="fig3"><ce:label>Fig. 3</ce:label><ce:caption><ce:simple-para>Superior view of final 2-wired speech-aid prosthesis of patient no. 6. Nasopharyngeal section is made of autopolymerizing acrylic resin.</ce:simple-para></ce:caption> <ce:link locator="gr3"></ce:link></ce:figure></ce:display>Initially, a SAP with 1 extension wire<ce:cross-ref refid="bib2"><ce:sup>2</ce:sup></ce:cross-ref> was provided for 1 patient (no. 3). Subsequently, it seemed safer to provide all the consecutive patients with SAPs consisting of 2 extension wires. These wires made only a light contact with the vault of the soft palate at rest and circumvented the soft palate by passing through the notches on each side of the base of the uvula (<ce:cross-refs refid="fig1 fig2">Figs. 1, <ce:italic>B</ce:italic> and 2, <ce:italic>B</ce:italic></ce:cross-refs> ). The patients underwent video-nasopharyngoscopic examinations before, occasionally during the stage of final impressions, and after delivery of the prosthesis (Fig. 4).
<ce:display><ce:figure><ce:label>Fig. 4</ce:label><ce:caption><ce:simple-para>Endoscopic view (flexible endoscope) of paretic VP valve of patient no. 3. <ce:bold>A,</ce:bold> At rest; <ce:bold>B,</ce:bold> intermediate closure during continuous speech; <ce:bold>C,</ce:bold> during maximal closure. Prosthesis in place: <ce:bold>D,</ce:bold> at rest; <ce:bold>E,</ce:bold> intermediate closure during continuous speech; <ce:bold>F,</ce:bold> during maximal closure.</ce:simple-para></ce:caption> <ce:link locator="gr4"></ce:link></ce:figure></ce:display>Patients were advised that after completion of the prosthetic phase, speech therapy was a must for achieving the best functional result.</ce:para></ce:section><ce:section><ce:section-title>Prosthetic procedure</ce:section-title><ce:para>For any SAP, the wire-extension prosthesis was fabricated in successive stages to enhance patient adjustment to, and acceptance of, the prosthesis. Patients and their family members were told the nature of the procedure and the ubiquitous appearance of a gag reflex as a natural protective reaction to intraoral stimuli. Preimpression topical anesthetic agents were rarely needed.</ce:para><ce:para>A stone cast was made from an irreversible hydrocolloid impression and used to fabricate the maxillary section from clear heat-polymerizing acrylic resin with retentive clasps. This device was delivered to the patient. The wire-extension and the nasopharyngeal sections were fabricated after a period of at least 2 to 3 weeks of the patient wearing and adjusting to the maxillary section. A portion of curved 0.9-mm stainless steel wire of approximately 10 cm was bent in an acute angle at a point of 15 mm from the cut end of the wire. Measures were taken to reduce internal stresses within the wires. When the appropriate angle was not initially attained, the wire was discarded and replaced by a new section of a wire. Furthermore, the wire was bent in the same plane, but in an opposite direction of the curvature of the wire coil.</ce:para><ce:para>Bending of the wires was done gradually with an orthodontic 3-prone plier. The wire was held by a hemostat, and the bent short section was passed through the right uvular notch of the soft palate at rest, so that it was localized freely in the nasopharynx. While being held by the hemostat, the remainder of the wire was adjusted to conform to the vault of the soft palate at a point 5 mm away from the posterior border of the maxillary section that was placed in the mouth. The wire was then cut, and its end bent in a form of retentive loop. The retentive loop was then connected to the posterior border of the maxillary section by autopolymerizing acrylic resin. Further adjustments were made to the wire so that it was touched lightly by the resting soft palate.</ce:para><ce:para>A second wire was similarly bent parallel to the first wire and adjusted to pass through the left uvular notch and connected to the maxillary section. Both ends of the 2 wires were then bent and connected with a minimal amount of autopolymerizing acrylic resin to serve as a tray for the nasopharyngeal impression. A functional impression was made with a thermoplastic material (impression compound, Kerr/Sybron, Romulus, Mich.). This impression was then replaced in the office, by a polishable, quick-setting autopolymerizing acrylic resin (Unifast, GC Corp, Tokyo, Japan) (<ce:cross-ref refid="fig3">Fig. 3</ce:cross-ref>), or by clear heat-polymerizing acrylic resin in the laboratory (<ce:cross-refs refid="fig1 fig2">Figs. 1, <ce:italic>A</ce:italic> and 2, <ce:italic>A</ce:italic></ce:cross-refs> ). The device was delivered to the patient for an additional adjustment period of 2 to 3 weeks.</ce:para><ce:para>The nasopharyngeal section was subsequently enlarged in a similar manner with the aid of fluid wax impression (Korecta-wax, extra soft No. 4, D-R Miner Dental, Concord, Calif.). Occasionally, the procedure had to be repeated a number of times before attaining its final form, especially in patients who had a wide VP gap. At this stage, the properly constructed device eliminated nasal emission during speech production, yet left free nasal breathing. Our experience showed that it was impossible to achieve this goal without nasopharyngoscopic control, whereby the nasopharyngeal section was inspected to conform to the various VP activities and modified accordingly by slight addition or removal of the obturative material.<ce:cross-refs refid="bib15 bib16"><ce:sup>15,16</ce:sup></ce:cross-refs> As wearing of the prosthesis may improve VP function,<ce:cross-refs refid="bib2 bib17 bib18 bib19"><ce:sup>2,17-19</ce:sup></ce:cross-refs> patients were followed for several weeks, and reevaluated with video-nasopharyngoscopic control for possible VP stimulation. When VP function improved, appropriate modifications of the nasopharyngeal section were made. Patients were instructed and constantly motivated in proper handling and cleaning of the prosthesis.</ce:para></ce:section><ce:section><ce:section-title>Postprosthesis evaluation</ce:section-title><ce:para>Speech evaluation and video-nasopharyngoscopy were performed with and without the SAP in the mouth. Recordings of the patients’ speech were compared between the initial examination and at this follow-up stage. Patients were then referred to speech-language therapy and reexamined after treatment. There was a mean duration of 3 months between fitting of the prosthesis and the final postprosthesis evaluation of the patients. Judgments of changes in speech were made on the basis of actual clinical observations and review of the recordings. The initial and subsequent changes in speech, including both hypernasality and intelligibility, were noted as: none, slight, moderate, or marked.</ce:para></ce:section></ce:section><ce:section><ce:section-title>RESULTS</ce:section-title><ce:para>Seven patients between the ages of 11 to 64 years were assigned for this study (Table I).
<ce:float-anchor refid="tab1"></ce:float-anchor>The time elapsed from presentation of the patients’ symptoms and their first examination was 3 months to 1 year (mean 9 months). The patients greatly differed in cause and clinical expression (<ce:cross-ref refid="tab1">Table I</ce:cross-ref>). They were all affected by intelligibly impaired hypernasal speech (Table II) as a consequence of various neurologic deficiencies and therefore made more effort in speech production, causing muscle fatigue.
<ce:float-anchor refid="tab2"></ce:float-anchor>Besides VP incompetence, 6 patients also suffered with dysarthria, which further reduced speech intelligibility (<ce:cross-ref refid="tab2">Table II</ce:cross-ref>).</ce:para><ce:para>The youngest patient (no. 1) presented maladaptive articulation in the form of secondary glottal, lingual, and labial errors as well. Other speech alterations were present, such as impaired labial function because of bilateral central facial nerve paralysis (no. 4) and breathy dysphonia because of unilateral glottal paralysis partially compensated by the contralateral vocal cord (no. 6). In addition to these findings, on otolaryngologic examination, the palatal dimple was observed in 1 patient (no. 7), appeared momentarily in 4 patients (nos. 1-4), deviated to the left in 1 patient (no. 6), and was absent in 1 patient (no. 5). Shutter sign was negative in all patients. On video-nasopharyngoscopy and multiview videofluoroscopy, a small gap in the portal area was found in 1 patient (no. 6), central, wide, and symmetric in 1 patient (no. 7), wide in 4 patients (nos. 1-4) and complete VP paralysis in 1 patient (no. 5) (<ce:cross-ref refid="tab2">Table II</ce:cross-ref>).</ce:para><ce:para>All patients adjusted to the SAP favorably, though some experienced great difficulty during the process of adaptation. Molding of the nasopharyngeal section of the SAP under video-nasopharyngoscopic control resulted in free nasal breathing and minimized patients’ discomfort. In addition to complete elimination of nasal emission and nasal resonance, considerable improvements in speech intelligibility and reduced patients’ fatigue were noted (<ce:cross-ref refid="tab2">Table II</ce:cross-ref>). In 6 of the 7 patients (excluding no. 6), in addition to dysarthria, a slurred speech emerged and compensatory articulation appeared in 1 patient (no. 1). Therefore, speech therapy was advocated for these patients. However, 2 patients (nos. 4 and 5), concomitant with their close family members, denied any improvements in speech. These patients refused further speech therapy and ultimately discontinued the use of SAP.</ce:para><ce:para>Three patients with VP paresis (nos. 1, 2, and 7) showed VP stimulation with enhanced velar and lateral pharyngeal walls movement. In these patients, a progressive speech bulb reduction with video-nasopharyngoscopic control was performed. In no patient were wires fractured, fatigued, or disconnected.</ce:para></ce:section><ce:section><ce:section-title>DISCUSSION</ce:section-title><ce:para>PLP is a device reserved for patients with adequate palatal tissue but with poor control of coordination and timing of VP movements. Thus, PLP is currently considered as the only effective type of prosthesis for the management of VP incompetence.<ce:cross-ref refid="bib10"><ce:sup>10</ce:sup></ce:cross-ref> Gibbons and Bloomer<ce:cross-ref refid="bib20"><ce:sup>20</ce:sup></ce:cross-ref> were the first to use a PLP with the objectives of (1) a reduction of VP lumen to decrease hypernasality and oral pressure for consonants; (2) preservation of an airway for comfortable nasal breathing; (3) avoidance of undue stress on the supporting teeth as the device resists the natural elasticity and weight of the soft palate in elevation; and (4) absence of injury to the soft palate as a result of pressure from supporting palatal section.<ce:cross-ref refid="bib20"><ce:sup>20</ce:sup></ce:cross-ref> Use of PLP in patients with VP incompetence has since been advocated by many clinicians.<ce:cross-refs refid="bib21 bib22 bib23 bib24 bib25 bib26 bib27 bib28 bib29 bib30 bib31 bib32 bib33 bib34"><ce:sup>21-34</ce:sup></ce:cross-refs> Turner and Williams<ce:cross-ref refid="bib32"><ce:sup>32</ce:sup></ce:cross-ref> suggest the use of multiview videofluoroscopy and nasopharyngoscopy to achieve maximum benefit from PLPs. Although clinical studies report improvement of speech intelligibility after the use of PLPs in groups of patients affected by VP incompetence,<ce:cross-refs refid="bib24 bib25 bib26"><ce:sup>24-26</ce:sup></ce:cross-refs> optimum speech achievements can infrequently be attained in these patients.<ce:cross-refs refid="bib24 bib26 bib30 bib34"><ce:sup>24,26,30,34</ce:sup></ce:cross-refs></ce:para><ce:para>The objectives addressed by Gibbons and Bloomer,<ce:cross-ref refid="bib20"><ce:sup>20</ce:sup></ce:cross-ref> can rarely be fulfilled to obtain optimal results. Modern imaging modalities, such as nasopharyngoscopy and multiview fluoroscopy, have demonstrated that medial movements of the pharyngeal musculature involved in VP closure occur at the level of the hard palate or even higher, at the level of the torus tubarius and therefore above the level which the soft palate can normally be elevated by the PLPs. Furthermore, PLPs cannot accommodate the individual variety of normal VP closure patterns, such as coronal, circular, circular with Passavant’s ridge, or sagittal. Overzealous elevation of the soft palate may result in soreness, loss of retention of the prosthesis or interference in free nasal respiration due to the reduction in cross sectional area of the VP isthmus. Mazaheri and Mazaheri<ce:cross-ref refid="bib28"><ce:sup>28</ce:sup></ce:cross-ref> proposed that PLPs also stimulated the soft palate muscles and eliminated palatal disuse atrophy. In 32 patients treated with PLP, Wolfaardt et al<ce:cross-ref refid="bib33"><ce:sup>33</ce:sup></ce:cross-ref> found that 21 patients (66%) appeared to have benefited from the use of the prostheses. Of these 21 patients, 14 went through a wear-reduction program and successfully eliminated the prosthesis. However, no details of the characteristics of this patient population were given. A recent report by Witt et al<ce:cross-ref refid="bib34"><ce:sup>34</ce:sup></ce:cross-ref> indicates that although PLPs may improve articulation performance in most patients, postintervention gap of the VP remained unchanged. These authors conclude that their study neither supports the concept that PLPs alter the neuromuscular patterning of the VP, nor provides objective documentation of the feasibility of prosthetic reduction for weaning.<ce:cross-ref refid="bib34"><ce:sup>34</ce:sup></ce:cross-ref> SAP has been proven capable to enhance VP function,<ce:cross-refs refid="bib2 bib17 bib18 bib19"><ce:sup>2,17-19</ce:sup></ce:cross-refs> whereas VP stimulation by PLP is questionable.<ce:cross-ref refid="bib34"><ce:sup>34</ce:sup></ce:cross-ref> The use of PLP as the principal prosthetic treatment available for VP incompetence is challenged in this article. In the current work, the progressive reduction of the weight of the bulb reduces its lever action and, thus, creates stable prostheses. In contrast, the high lever action of the PLP, which highly supports the velum, may create less stable prostheses. Thus, an additional advantage of the wire-extension SAP is that there is no need for heavy retention for the maxillary section as is the case in PLPs.<ce:cross-ref refid="bib31"><ce:sup>31</ce:sup></ce:cross-ref> Therefore, it can also effectively be used in children with partially erupted or deciduous dentition.</ce:para><ce:para>The wire-extension SAP is a device originally described as a temporary pediatric SAP for the management of VP incompetence.<ce:cross-ref refid="bib2"><ce:sup>2</ce:sup></ce:cross-ref> We have successfully extended the use of this type of device to adult patients. Design of wire-extension SAPs seems to be a major improvement in the management of VP incompetence compared with PLPs. Use of palatal wire-extension facilitates access to the nasopharynx without impeding the uvula even in the presence of a long, dysfunctional soft palate. Effective nasopharyngeal obturation can thus be achieved. The nasopharyngeal section of the prosthesis can be molded or adjusted to conform to a variety of VP functions and adaptations with the aid of nasopharngoscopy. The fixed type of SAP has a long history of clinical use and success for the management of VP insufficiency.<ce:cross-refs refid="bib1 bib35"><ce:sup>1,35</ce:sup></ce:cross-refs> In 1 patient (no. 3), only one wire extension was used, in accordance with the original description<ce:cross-ref refid="bib2"><ce:sup>2</ce:sup></ce:cross-ref> (<ce:cross-ref refid="fig1">Fig. 1</ce:cross-ref>). Although this type of wire-extension SAP may be less objectionable to the patient, it should be handled with extreme care to avoid risk of bending the wire and injury to the patient. However, clinical procedures for wire-extension SAPs fabrication are cumbersome. The most difficult and time-consuming phase of the procedure is to carefully adapt the extension wire to conform to the passive soft palate. This is accomplished by trial-and-error with short reinsertions of the device.</ce:para><ce:para>The wire-extension SAP described in this article should not be confused with a prosthesis intended for palatal stimulation.<ce:cross-refs refid="bib36 bib37 bib38"><ce:sup>36-38</ce:sup></ce:cross-refs> Although palatal wire extensions are similar in both types of prostheses, the latter is a special palatal training device in which a nasopharyngeal section is constructed only to resist the upward movements of the soft palate and not intended to obturate the VP lumen.<ce:cross-refs refid="bib36 bib37 bib38"><ce:sup>36-38</ce:sup></ce:cross-refs> Improved palatal activity is claimed to be gained by the isometric movement of a dysfunctional soft palate against a dorsally placed mechanical hindrance. However, this approach disregards the critical role of the pharyngeal walls in normal and in abnormal VP function. As shown in this article, one cannot overemphasize the importance of careful patient selection for SAPs used to correct VP incompetence. Many reasons can be attributed to patient’s noncompliance. None of the patients with neurogenic afflictions showed pure VP incompetence. Dysarthria, as well as developmental, behavioral, and cognitive impairments were present in this group of patients (<ce:cross-ref refid="tab2">Table II</ce:cross-ref>). In our experience, as well as in a previous report,<ce:cross-ref refid="bib26"><ce:sup>26</ce:sup></ce:cross-ref> the corrected VP incompetence permits the dysarthric patient to attain normal speech and it may allow him to increase his speech intelligibility. Our study comprises a small group of VP incompetent patients and was not intended to be a randomly controlled clinical trial. Nevertheless, the study showed that wire-extension SAP can be favorably used in VP incompetent patients with marked improvement in speech in all patients.</ce:para><ce:para>There are many impediments for conducting a prospective clinical research that strives to compare the efficacy of PLPs versus wire-extension SAPs. Two approaches may be adopted for such a comparison: (1) intersubject; or (2) intrasubject. The first research option requires large and homogenous patient populations having VP incompetence, and that its individuals will be randomly assigned to 1 of these 2 modes of treatment. Our patient group, as with other PLP studies, comprised a heterogeneous patient population in terms of age, cause of VP incompetence, and clinical manifestations (<ce:cross-ref refid="tab2">Table II</ce:cross-ref>). The second research option in which patients will alternatively be given both types of devices, seems to be easier to manage. However, it may involve many problems such as patient noncompliance or treatments that cannot be matched. Intolerance or noncompliance to removable prostheses is a problem often encountered in prosthodontic practice. In addition, substantial improvements in speech are regularly expected only after the SAP is finalized and combined with speech therapy. Furthermore, improvement of speech is not normally perceived by the patient himself or occasionally even by family members tuned to his unintelligible speech.<ce:cross-refs refid="bib39 bib40"><ce:sup>39,40</ce:sup></ce:cross-refs> For these reasons, VP incompetent patients may show lower readiness for prosthetic treatment than patients with VP insufficiency. These factors further increase the likelihood of noncompliance with the use of two consecutive SAPs. Also, wearing of any SAP may provoke VP stimulation.<ce:cross-refs refid="bib2 bib17 bib18 bib19"><ce:sup>2,17-19</ce:sup></ce:cross-refs> The elimination of the SAP may lead to unpredictable vanishing of VP stimulation and may, thus, induce unequal starting points for the 2 modes of treatment. Finally, it seems unethical if we subject compromised patients to difficult reverse treatments only for the sake of clinical research.</ce:para><ce:para>Despite the considerable improvement in speech noted in our patients, 2 patients (nos. 4 and 5), concomitant with their close family members, denied these improvements in speech. It is well known that the patients and the persons with a high level of familiarity with them may be insensitive to speech changes.<ce:cross-ref refid="bib39"><ce:sup>39</ce:sup></ce:cross-ref> Their ability to discriminate speech alterations in less familiar speakers is probably better.<ce:cross-ref refid="bib40"><ce:sup>40</ce:sup></ce:cross-ref> However, it was our impression that one of these patients (no. 4) discontinued treatment because he was motivated by secondary gain.</ce:para></ce:section><ce:section><ce:section-title>CONCLUSIONS</ce:section-title><ce:para>The wire-extension speech-aid prostheses seem to be an effective treatment approach for patients suffering with velopharyngeal incompetence who cannot be surgically treated. 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and Senior Clinical Lecturer, Department of Oral Rehabilitation, School of Dental Medicine, Tel Aviv University</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Yehuda</namePart><namePart type="family">Finkelstein</namePart><namePart type="termsOfAddress">MD</namePart><affiliation>Chief, Palate Surgery Unit, Department of Otolaryngology, Head and Neck Surgery, Meir Hospital; and Senior Lecturer, Sackler School of Medicine, Tel Aviv University</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Ariela</namePart><namePart type="family">Nachmani</namePart><namePart type="termsOfAddress">MA</namePart><affiliation>Speech-Language Pathologist, Department of Otolaryngology, Head and Neck Surgery, Meir Hospital, Kfar Saba</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Dov</namePart><namePart type="family">Ophir</namePart><namePart type="termsOfAddress">MD</namePart><affiliation>Chief, Department of Otolaryngology, Head and Neck Surgery, Meir Hospital, Kfar Saba; and Clinical Associate Professor, Sackler School of Medicine, Tel Aviv University</affiliation><role><roleTerm type="text">author</roleTerm></role></name><typeOfResource>text</typeOfResource><genre type="research-article" displayLabel="Full-length article" authority="ISTEX" authorityURI="https://content-type.data.istex.fr" valueURI="https://content-type.data.istex.fr/ark:/67375/XTP-1JC4F85T-7">research-article</genre><originInfo><publisher>ELSEVIER</publisher><dateIssued encoding="w3cdtf">2000</dateIssued><copyrightDate encoding="w3cdtf">2000</copyrightDate></originInfo><language><languageTerm type="code" authority="iso639-2b">eng</languageTerm><languageTerm type="code" authority="rfc3066">en</languageTerm></language><abstract lang="en">Abstract: Statement Of Problem. When surgical treatment is not considered an option, prosthetic management of velopharyngeal insufficiency is carried out by means of a speech-aid prosthesis, whereas velopharyngeal incompetence is traditionally managed by a palatal lift prosthesis. Varying degrees of treatment success have been attributed to palatal lift prostheses. Purpose. This study introduces the use of nasopharyngeal obturation instead of palatal elevation for the management of velopharyngeal incompetence. Methods. Seven patients afflicted by neurogenic velopharyngeal incompetence were treated with wire-extension speech-aid prostheses constructed to circumvent the dysfunctional soft palate. The shape of the nasopharyngeal section was functionally molded in speech and swallowing and controlled by video-nasopharyngoscopic examinations. Results. Effective nasopharyngeal obturation with notable improved speech was achieved in all patients. Even though all patients ultimately tolerated the prostheses well, 2 patients denied any improvement in speech with the finalized prostheses. Conclusion. Wire-extension speech-aid prostheses used by the patients were an effective treatment approach for velopharyngeal incompetence. Nasopharyngoscopic control is mandatory for maximizing the effect of velopharyngeal closure around the nasopharyngeal section of the prosthesis in function, yet it allows free nasal breathing. Velopharyngeally incompetent patients should be carefully tailored for prosthetic treatment because of contingent noncompliance. (J Prosthet Dent 2000;83:99-106.)</abstract><note>Reprint requests to: DR ARIE SHIFMAN, POB 1031, PETACH TIKVA 49110, ISRAEL, FAX: (972)3-9317548, E-MAIL: yehudaf@ultinet.co.il</note><note>0022-3913/2000/$12.00 + 0. 10/1/102829</note><note type="content">Table I: Characteristics of VP incompetent patients</note><note type="content">Table II: Pretreatment speech evaluation and treatment outcome</note><relatedItem type="host"><titleInfo><title>The Journal of Prosthetic Dentistry</title></titleInfo><titleInfo type="abbreviated"><title>YMPR</title></titleInfo><genre type="journal" authority="ISTEX" authorityURI="https://publication-type.data.istex.fr" valueURI="https://publication-type.data.istex.fr/ark:/67375/JMC-0GLKJH51-B">journal</genre><originInfo><publisher>ELSEVIER</publisher><dateIssued encoding="w3cdtf">200001</dateIssued></originInfo><identifier type="ISSN">0022-3913</identifier><identifier type="PII">S0022-3913(05)X7072-X</identifier><part><date>200001</date><detail type="volume"><number>83</number><caption>vol.</caption></detail><detail type="issue"><number>1</number><caption>no.</caption></detail><extent unit="issue-pages"><start>1</start><end>126</end></extent><extent unit="pages"><start>99</start><end>106</end></extent></part></relatedItem><identifier type="istex">7FF63C7ABB94612A2F2F97963139FCDD85DAEF6B</identifier><identifier type="ark">ark:/67375/6H6-BM9VZDN4-C</identifier><identifier type="DOI">10.1016/S0022-3913(00)70094-1</identifier><identifier type="PII">S0022-3913(00)70094-1</identifier><accessCondition type="use and reproduction" contentType="copyright">©2000 Editorial Council of The Journal of Prosthetic Dentistry.</accessCondition><recordInfo><recordContentSource authority="ISTEX" authorityURI="https://loaded-corpus.data.istex.fr" valueURI="https://loaded-corpus.data.istex.fr/ark:/67375/XBH-HKKZVM7B-M">elsevier</recordContentSource><recordOrigin>Editorial Council of The Journal of Prosthetic Dentistry., ©2000</recordOrigin></recordInfo></mods><json:item><extension>json</extension><original>false</original><mimetype>application/json</mimetype><uri>https://api.istex.fr/document/7FF63C7ABB94612A2F2F97963139FCDD85DAEF6B/metadata/json</uri></json:item></metadata></istex></record>Pour manipuler ce document sous Unix (Dilib)
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