Prosthetics and speech therapy in patients with a high-Arched palate
Shilpi Sanghvi1, Gaurang Mistry1, Asha M Rathod1, Naina Swarup2 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 Submission
10-Sep-2019
Date of Acceptance
18-Nov-2019
Date of Web Publication
20-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
Source of Support: None, Conflict of Interest: None
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DOI: 10.4103/jid.jid_38_19
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.
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 2023 Jun 10];9:125-9. Available from: https://www.jidonline.com/text.asp?2019/9/3/125/273660
Clinical Relevance to Interdisciplinary Dentistry
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
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
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
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
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
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
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]
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.
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
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.
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