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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 9  |  Issue : 3  |  Page : 125-129

Prosthetics and speech therapy in patients with a high-Arched palate


1 Department of Prosthodontics, DY Patil University School of Dentistry, Navi Mumbai, Maharashtra, India
2 Department of Prosthodontics, Dr. Swarup's Multispeciality Dentistry, Mumbai, Maharashtra, India

Date of Submission10-Sep-2019
Date of Acceptance18-Nov-2019
Date of Web Publication20-Dec-2019

Correspondence Address:
Dr. Shilpi Sanghvi
Department of Prosthodontics, DY Patil University School of Dentistry, DY Patil University, Dr. DY Patil Vidyanagar, Sector 7, Nerul, Navi Mumbai - 400 706, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_38_19

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   Abstract 


The prosthodontic rehabilitation of patients postcleft palate repair is an important part of the multidisciplinary approach to solving the many problems related to total health. One such problem is speech difficulties and articulation errors. High-arched palate associated with cleft palate repair affects phonation and articulation by affecting the approximation of its surface with the tongue. This results in unintelligible and hypernasal sound production. Palatogram is a fairly simple, yet highly efficacious clinical technique for the assessment of palatal contours, to improve the existent speech deficiencies of affected sounds. This case report demonstrates a multidisciplinary treatment approach to successfully improve the intelligibility of speech by fabrication of a speech appliance by making a palatogram and customizing the palatal contours.

Keywords: Cleft palate repair, high-arched palate, multidisciplinary approach, palatogram, speech


How to cite this article:
Sanghvi S, Mistry G, Rathod AM, Swarup N. Prosthetics and speech therapy in patients with a high-Arched palate. J Interdiscip Dentistry 2019;9:125-9

How to cite this URL:
Sanghvi S, Mistry G, Rathod AM, Swarup N. Prosthetics and speech therapy in patients with a high-Arched palate. J Interdiscip Dentistry [serial online] 2019 [cited 2020 Sep 19];9:125-9. Available from: http://www.jidonline.com/text.asp?2019/9/3/125/273660




   Clinical Relevance to Interdisciplinary Dentistry Top


  • Post cleft palate repair, patients are handled by both dental and medical professionals
  • Cleft palate repair invariably is associated with growth restrictions, leading to articulation problems and. hypernasality
  • Role of Orthodontists- maxillary expansion and occlusal correction
  • Role of Prosthodontists- Speech appliance to establish contact between the tongue and palate
  • - Speech pathologists and language therapists work in conjunction with the dental specialists



   Introduction Top


Speech is a complex physiological phenomenon resulting from respiratory, laryngeal, and resonator system interactions.[1] It is an important function of the stomatognathic system which uses the oral cavity as an instrument. Teeth, alveolar ridge, and palate are static components of speech, whereas tongue, lips, and velum are dynamic components.[2] The tongue is the principal articulator of the consonants which contacts specific areas of the teeth, alveolar ridge, and hard palate. For this reason, the consonant sounds are of the greatest interest to the prosthodontist.[3],[4] These sounds are classified according to the anatomic parts involved in their formation: (1) palatolingual – formed by tongue and hard or soft palate, (2) linguodental – tongue and teeth, (3) labiodental – lips and teeth, and (4) bilabial – lips[5] [Table 1].[6] Any palatal deformity can affect the production of consonant sounds. Cleft lip and palate individuals exhibit dental, skeletal, aesthetic, and functional discrepancies involving a constricted upper dental arch and a deep palatal vault because of scar tissue that develops over the denuded palatal bone remaining after palatoplasty.[4],[5],[6],[7],[8] Lubit[9] studied that individuals with high or narrow palates more commonly have articulatory disorders and a hypernasal speech because of less available space for the tongue movements required for appropriate articulation.

A multidisciplinary treatment approach is required to treat such cases, where speech pathologists and therapists, orthodontists, prosthodontists, and oral surgeons work together as a team.
Table 1: Specific speech sounds with stimulus sentences


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In this case report, we as prosthodontists have utilized a palatogram to diagnose, record, and establish tongue contact position and reproduce functional palatal contours for satisfactory articulation.[4],[10]


   Case Report Top


An 18-year-old male patient was referred to the Department of Prosthodontics from the Department of Speech and Language Pathology with a complaint of unsatisfactory levels of pronunciation and speech. He described his speech as “excessively nasal” with distortion of the s, z, sh, ch, and t sounds. On eliciting dental history, he revealed getting operated for surgical correction of cleft palate and tongue-tie as a child. Following which, as per protocol, he was undergoing speech therapy. However, he continued to have speech problems relating to pronunciation and nasality. On intraoral examination, it was revealed that the patient had a deep palatal vault. The cleft palate scar was distinctly visible, so was the tongue-tie. After a thorough sequential diagnosis, and excluding a possible oronasal communication, it was concluded that a constricted maxilla with a high-arched palate [Figure 1] along with a relapse in tongue-tie was the cause of this speech difficulty.
Figure 1: High--arched palate, with a constricted maxilla. Cleft palate scar seen in the midline

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This case report narrates a technique of applying palatogram as a practical implication for customizing the palatal contour of a maxillary speech appliance to improve the speech quality.

Step 1 was correction of tongue-tie [Figure 2]. The patient was referred to the Department of Oral and Maxillofacial Surgery for frenulectomy to release the tongue-tie using a soft-tissue diode laser to increase the freedom of movement of tongue.[11]
Figure 2: Frenulectomy performed using a soft-tissue diode laser

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Step 2 was construction of a self-cure acrylic plate [Figure 3]. Clear self-cure acrylic was adapted onto the cast. Adam's clasps on molar teeth were used for retention. Modeling wax was adapted on the plate. Rugae were designed and carved in wax.
Figure 3: Maxillary acrylic palatal plate constructed and rugae designed and carved out in wax

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Step 3 included the application of recording medium. The palatal surface of the plate was dried thoroughly before dusting gypsum product (plaster of Paris) and the excess powder shaken off.

Step 4 was insertion of coated maxillary plate. The patient was trained to pronounce the sound and open the mouth without contacting the palate again. Touching dusted plate with the fingers during insertion was avoided.

Step 5 involved pronunciation of linguopalatal and linguoalveolar consonant sounds and recording palatograms. The patient was instructed to articulate various consonant sounds – s, sh, ch, n, t, k, and g. The patient was trained to use vowel “O” with the consonant to be studied, even though the combination was not a word, i.e., to study k-ko, ch-cho, and sh–sho, according to Allen's protocol where “O” is the only vowel where the tongue does not make any contact with palate, thereby avoiding multiple recordings of tongue to palate.[12] The patient was asked to repeat the desired sound only two consecutive times by making definite palatal contact, but avoiding contact after opening the mouth. Then, the plate was carefully removed. An audio was recorded for each sound [Audio 1].



Palatogram recordings using English and Hindi consonants:[3],[4],[13]

  • “S” sound using word So-So/Somvaar [Figure 4]
  • “Sh” sound using word Show/Shobha [Figure 5]
  • “Ch” sound using word Choke/Chor [Figure 6]
  • “N” sound using word No
  • “T” sound using word Tom/Toto
  • “K and G” sound using word Coke/King/Coma/Gulab [Figure 7].
Figure 4: Palatogram for “S” sound

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Figure 5: Palatogram for “SH” sound

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Figure 6: Palatogram for “CH” sound

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Figure 7: Palatogram for “K/G” sounds

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Step 6 was the valuation of recordings. The contact areas (areas where the recording medium has been wiped away) were outlined for easier identification and correction. Palatogram so obtained was compared for reference with definite patterns of every sound.[3] Undercontoured regions (lesser wiped off) were corrected by adding wax and rerecording. Overcontoured regions (greater smudges) were corrected by removing wax and rerecording.

Each individual produces a similar palatogram for a given sound. However, there are certain unique characteristics for that particular person because of variations in shape and size of tongue and palatal vault arch form.

Step 7 was the processing of the customized acrylic plate [Figure 8]. The waxed acrylic plate was processed with pink heat-cured acrylic resin, following the routine steps of denture fabrication, finishing, and polishing.
Figure 8: Maxillary palatal speech appliance fabricated using pink heat-cured acrylic resin

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Step 8 involved rechecking the tongue contact with the palate [Figure 9] and [Figure 10]. Reevaluation of the intelligibility of s, sh, ch, k, and t sounds with the customized speech appliance was carried out. Audio recordings were repeated 1 month after delivery of the appliance [Audio 2].
Figure 9: Tongue position and proximity to the palate before frenulectomy and receiving the palatal plate

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Figure 10: Approximation of the tongue with the palate improved after receiving the palatal speech appliance

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   Discussion Top


Speech difficulties as sequelae of cleft palate repair, owing to the resultant constricted high-arched palate, are generally a deep-rooted problem. Dental and medical specialists should make collective efforts to provide prudent treatment to enhance an individual's personality. Hence, a prosthodontist plays a pivotal role in understanding the basic mechanisms involved in the various speech pathologies and provide rehabilitative treatment to such patients.

Unblemished phonetics necessitates the tongue to seal the posterior palatal surface and direct a flow of air anteriorly, against an alveolopalatal prominence, beginning at the premolars, which becomes progressively thicker around molars.[3] This prominence is excessive in majority of cleft palate repair cases.[8] Tanaka[14] inferred that palatal contours being crucial for the pronunciation of “S,” “SH,” and “CH” sounds were not found to be accurate in majority of constricted maxilla cases. Premature contact due to excessive thickness in anterior area can result in the “T” sounding like a “D.”

“A palatogram is an easy, effective, inexpensive technique of assessment and verification of palatal contours to improve and correct the existing speech deficiencies of affected sound.”[3] It is a static record of tongue and palatal contours during sound articulation, which can be diagnostically used as a simple test for phonetics evaluation.[4] Various indicator mediums could be used “ occlude aerosol, pressure-indicating paste, gothic arch-tracing ink, food coloring, etc.

In this case report, a palatal plate was fabricated to compensate for the increased depth of the palatal vault and to establish contact between the tongue and palate to improve articulation. The plate was incorporated with rugae designs to increase air turbulence and tactile sensitivity, thereby increasing phonetic adaptation, sound quality, and intelligibility.[14] Highly satisfactory results were obtained, and the patient was asked to follow-up initially after 1 month and later every 3 months.

However, a more definitive treatment for the patient would be orthodontic intervention using maxillary expansion and myofunctional therapy to retrain and strengthen the tongue. Surgical correction of the palate would be the last option for correction of speech.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Petrovic-Lazic M, Jovanovic N, Kulic M, Babac S, Jurisic V. Acoustic and perceptual characteristics of the voice in patients with vocal polyps after surgery and voice therapy. J Voice 2015;29:241-6.  Back to cited text no. 1
    
2.
Adaki R, Meshram S, Adaki S. Acoustic analysis and speech intelligibility in patients wearing conventional dentures and rugae incorporated dentures. J Indian Prosthodont Soc 2013;13:413-20.  Back to cited text no. 2
    
3.
Farley DW, Jones JD, Cronin RJ. Palatogram assessment of maxillary complete dentures. J Prosthodont 1998;7:84-90.  Back to cited text no. 3
    
4.
Kong HJ, Hansen CA. Customizing palatal contours of a denture to improve speech intelligibility. J Prosthet Dent 2008;99:243-8.  Back to cited text no. 4
    
5.
Landa JS. Practical Full Denture Prosthesis. London: Dental Items of Interest Publishing Co.; 1954. p. 311-29.  Back to cited text no. 5
    
6.
Jain AR, Venkat Prasad MK, Ariga P. Palatogram revisited. Contemp Clin Dent 2014;5:138-41.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Von den Hoff J, Maltha JC, Kuijpers-Jagtman AM. Palatal wound healing: The effects of scarring on growth. In: Berkowitz S, editor. Cleft lip and Palate. Diagnosis and Management. 2nd ed. Berlin: Springer Verlag; 2006. p. 301-13.  Back to cited text no. 7
    
8.
Peterson-Falzone SJ, Hardin-Jones MA, Karnell MP. Cleft Palate Speech. 3rd ed. St. Louis, MO: Mosby, Inc.; 2001.  Back to cited text no. 8
    
9.
Lubit EC. The relationship of malocclusion and faulty speech articulation. J Oral Med 1967;22:47-55.  Back to cited text no. 9
    
10.
The glossary of prosthodontic terms. J Prosthet Dent 2005;94:10-92.  Back to cited text no. 10
    
11.
Morosolli AR, Veeck EB, Niccoli-Filho W, Gomes MF, das Graças V Goulart M. Healing process after surgical treatment with scalpel, electrocautery and laser radiation: histomorphologic and histomorphometric analysis. Lasers Med Sci 2010;25:93-100.  Back to cited text no. 11
    
12.
Allen LB. Improved phonetics in denture construction. J Prosthet Dent 1958;8:753-63.  Back to cited text no. 12
    
13.
Rothman R. Phonetics considerations in denture prosthesis. J Prosthet Dent 1961;11:21423.  Back to cited text no. 13
    
14.
Tanaka H. Speech patterns of edentulous patients and morphology of the palate in relation to phonetics. J Prosthet Dent 1973;29:16-28.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
 
 
    Tables

  [Table 1]



 

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