Management of the Soft Palate Defect

Defects of the soft palate may present as perplexing problems to the clinician. One of the
difficulties is a lack of universal terminology. Without accepted terminology it is
impossible to adopt a method of communication that allows universal understanding of
specific clinical findings. Poor communication hampers discussions among the surgical
and rehabilitative teams.

The term velum is often used interchangeably with the preferred soft palate. Such
an interchange of terms is incorrect as the term velum refers to a covering or veil while
the soft palate is actually a complex neuromuscular aponeurosis. Although the muscular
activity of the soft palate provides function, it is also evident that a complex feedback
system of afferent and efferent neural connections is required to control physiologic
movement. Likewise, tissue bulk, in the form of connective tissue and epithelium, is
required to provide contact with the pharyngeal walls during function.

Abnormalities of the soft palate can occur in different ways. The resultant deficiencies
are usually grouped into congenital, acquired or developmental defects depending upon
the etiology. In the congenital cleft palate the embryological development of the hard
and /or soft palate is interrupted. Surgical resection of neoplastic disease can alter the
continuity the soft palate resulting in an acquired defect. Diminished capacity of the soft
palate to respond to functional demands may be the result of muscular or neurologic
diseases.

Beyond etiology, defects are also classified according to the anatomy and physiology of
the structures. These classifications identify the degree and type of palatopharyngeal
closure. The resultant diagnosis often determines the course of treatment. When some
or all of the anatomical structure of the soft palate is absent, the term palatopharyngeal
insufficiency applies. When the soft palate is of adequate dimensions but lacks
movement because of disease or trauma affecting the muscular and/or neurologic
capacity the term palatopharyngeal incompetence applies. The term palatopharyngeal
Soft Palate Defects 2

inadequacy includes incompetence and/or insufficiency but may also suggest a reduction
or absence of pharyngeal wall activity.

Absence or loss of some or all of the soft palate results in insufficient structure or altered
function of the remaining structure to provide closure with the pharynx (Fig. 1). In this
situation an obturator prosthesis is designed to close the opening between the residual
hard and/or soft palate and the pharynx. A pharyngeal obturator prostheses, which
may also be called a speech aid prosthesis, extends beyond the residual soft palate to
create separation between the oropharynx and nasopharynx. It provides a fixed structure
against which the pharyngeal muscles can function to affect palatopharyneal closure. A
meatus obturator is designed to close the posterior nasal choanae through a vertical
extension from the distal aspect of the maxillary prosthesis. This obturator design may
be indicated when the entire soft palate has been lost (Fig. 2). Such a design will reduce
leverage factors on the prosthesis but will not permit function of the pharyngeal muscles
against it. The meatus oburator is often thought to be mechanical while the fixed
pharyngeal obturator is thought to be more physiologic. The hinged pharyngeal oburator
is not often referred to in recent times because of the mechanics involved in its
fabrication.

The soft palate normally serves to establish a separation between the oral and nasal
cavities. The soft palate moves in response to physiologic demands of speech,
deglutition and respiration. The movement of the soft palate is a coordinated activity that
results in varying degrees of closure between the soft palate and the pharyngeal walls
during breathing, speaking and swallowing. At some times there may be complete
closure while at other times there may be varying degrees of opening. When it occurs,
palatopharyngeal inadequacy results in physical and psychosocial concerns for the
patient. The objectives of prosthetic intervention are to prevent food and fluid
regurgitation and to improve speech intelligibility. The prosthesis will include both a
pharyngeal and a palatal section. Pharyngeal extensions add bulk, weight and leverage
thus generating stress to the supporting structures of the mouth through the palatal section
of the prosthesis.
Soft Palate Defects 3

The greater the defect, the larger the obturator portion of the prosthesis will be. Although
larger prostheses create more weight, thereby negatively impacting prosthesis retention,
there are times when a smaller defect may be more problematic. Unilateral soft palate
defects are more difficult to obturate because the function of the residual soft palate does
not provide closure on the nondefect side and it can be difficult to extend the obturator
around or over the residual tissue (Fig 3). The configuration of the residual soft palate
may complicate the prosthetic situation if the residual soft palate drapes towards the base
of the tongue. In classic prosthodontic literature, House 1provides three classifications of
soft palates. In his description of complete denture therapy, the most favorable
orientation of the soft palate occurs when this structure extends horizontally from the
hard palate and the least favorable condition exists when the soft palate is nearly
perpendicular to the plane of the hard palate. It is easier to lift and/or obturate
incompetent soft palates that are more horizontal.

Design of the prosthesis must apply the basic principles of support, retention and stability
so as to minimize the stress generated to the structures of the mouth. Remaining natural
teeth, residual ridges, endosseous implants, hard palate and residual soft palate will all
contribute to the support, retention and stability of the prosthesis from either a positive or
negative standpoint. All of these entities need to be considered in detail before prosthetic
intervention is undertaken. The location of the fulcrum line, retentive undercuts and
potential for indirect retention will be important factors in determining the prognosis.

In general, the prosthesis will have a fulcrum line near the defect area. If natural teeth or
implants are present to provide retention and support for the prosthesis, the fulcrum line
will pass between the most posterior occlusal rests on each side of the arch. Retentive
clasps placed into undercuts adjacent to the defect will resist the downward displacement
of the prosthesis due to the effects of gravity. Occlusal rests on the opposite side of the
fulcrum line from the defect will act as indirect retainers. Long guide planes on the
natural teeth will also assist in prevention of rotational dislodgment of the prosthesis.
Soft Palate Defects 4

When natural teeth or implants are not present, retention of the prosthesis is problematic.
Large, parallel sided residual ridges may be sufficient to retain the prosthesis particularly
if the superior aspect of the residual soft palate can be engaged. A square arch form may
provide improved retention and indirect retention to the prosthesis. Regardless of the
anatomic situation, every effort should be made to develop a border seal as with a
conventional complete denture. In most situations, a denture adhesive may be of benefit
towards use of the prosthesis because the obturator portion will tend to dislodge a
prosthesis that does not have positive retention opportunities.

Palatopharyngeal incompetence may be related to degenerative disease, cerebrovascular

accidents or trauma. When palatopharyngeal incompetence is encountered, rehabilitative
efforts are designed to elevate the soft palate. A palatal lift prosthesis is used to raise
the soft palate to the level of the hard palate (Fig. 4). This elevation places the junction
of the middle and posterior thirds of the soft palate in close proximity to the posterior
pharyngeal wall creating a muscular seal that prevents nasal regurgitation of fluid and
food during deglutition. The prosthesis also prevents the escape of air into the nose when
speaking. Because this prosthesis provides a mechanical rather than a functional closure
of the palatopharyneal valve, the ideal closure that prevents the passage of air and/or food
and liquids will also result in an inability to breath through the nose. Reduction of the
prosthesis to allow nasal breathing may be needed. It must be remembered that a palatal
lift prosthesis only addresses palatopharyngeal closure. The physiologic acts of speaking
and swallowing are dependent upon the coordinated function of many other oral and
pharyngeal muscle groups which may also be affected in palatopharyngeal incompetence.
The prosthesis may stimulate a return of muscular function in some patients but,
depending upon the etiology, others may experience little or no improvement.

Type of prosthesis

The defect etiology usually determines the type of prosthesis that is needed. Before
treatment is initiated the natural course of existing disease or the stage of rehabilitation
Soft Palate Defects 5

should be considered. In many instances it will be unwise to proceed immediately to a

definitive prosthesis. An interim prosthesis is indicated if the long term disease prognosis
is guarded or if the natural progression of disease or rehabilitation will demand frequent
modifications of the prosthesis.

In many situations it may be possible to use diagnostic interim prostheses to determine

the ability to tolerate a definitive prosthesis. Sometimes the diagnostic prosthesis may
take the place of definitive care; this is particularly true when frequent modifications of
the prosthesis are needed.

Technical Considerations For The Pharyngeal Obturator/Speech

Aid Prosthesis

The pharyngeal obturator prosthesis does not displace the soft palate but replaces missing
portions of the soft palate (Fig. 5). Therefore, a pharyngeal obturator prosthesis has less
active displacement force upon it than does a palatal lift prosthesis. Despite the lack of
active displacement forces, this prosthesis continues to generate stress to the palatal
portion of the prosthesis due to the forces of gravity. For this reason the principles of
retention and stability outlined for the palatal lift prosthesis should still be applied.

The obturator section of this prosthesis is formed after the oral portion of the prosthesis is
made. In some patients it may be more convenient to develop the obturator portion once
the framework of the oral section is completed but before full completion of the oral
portion. A retentive loop is extended posteriorly from the palatal portion of the
prosthesis to facilitate placement and retention of impression material in the pharynx.

Modeling compound is added to the retentive loop until it contacts the posterior and
lateral pharyngeal walls. Border molding is achieved by adding and removing modeling
compound in the posterior and lateral pharyngeal areas. After the warmed modeling
Soft Palate Defects 6

compound addition is inserted the patient is instructed to flex the neck fully to achieve
contact of the chin to the chest. This movement will establish contact of the posterior
aspect of the obturator with the soft tissue covering the dorsal tubercle of the atlas.
Lateral aspects of the obturator are formed by rotation and flexion of the neck to achieve
chin contact with the right and left shoulder respectively. Once contact is present around
the lateral and posterior borders of the modeling compound obturator, there should be
absence of air and liquid flow from the oral to the nasal cavities (Fig. 6). After slight
(0.5-1.0 mm) reduction of the compound, mouth temperature wax is adapted to the
modeling compound. The material remains in place for 7-10 minutes and the previous
neck flexion and rotary flexion movements are repeated (Fig. 7). Difficulties in nasal
breathing may necessitate reduction of the lateral aspects of the obturator until breathing
is unstrained. Such a reduction of the prosthesis may result in a return of some degree of
hypernasality.

The inferior portion of the obturator is maintained parallel with the horizontal hard palate
if possible (Fig. 8). This level will prevent the tongue from dislodging the prosthesis
during deglutition. After completion of the impression, standard dental laboratory
procedures are used to transform this portion of the prosthesis into acrylic resin.

Technical considerations with the Meatus Obturator

The meatus obturator should be considered when the posterior extension of a fixed
obturator prosthesis is likely to result in prosthesis displacement. 2 The meatus obturator
projects vertically at the posterior aspect of the prosthesis to obturate the posterior nasal
choanae (Fig. 9). Because the vertical extension is closer to the palatal portion of the
prosthesis there is less torque placed on the palatal portion thus decreasing the tendency
for dislodgement. This prosthesis is most applicable to the fully edentulous patient who
has undergone a total soft palate resection. 3 Since the posterior and lateral pharyngeal
walls cannot function against a meatus obturatur, speech will tend to be hyponasal. With
ideal obturation there will be absence of nasal breathing.
Soft Palate Defects 7

As with the other prosthetic designs the oral portion of this prosthesis is fabricated to full
extension in an effort to maximize retention, support and stability. The vertical portion of
the prosthesis is made in modeling compound. The prosthesis is inserted with a
rotational path, first seating the vertical extension to the posterior choanae and then
seating the oral portion of the prosthesis. Once the vertical extension is formed in
modeling compound, mouth temperature wax is used to refine adaptation to the posterior
choanae.

Once the meatus extension is processed onto the denture it is necessary to provide for
nasal breathing (Fig. 10). One hole should be placed through each side of the prosthesis
so that breathing is possible through each nares. Use the smallest opening possible at the
best angle to prevent nasal regurgitation.

Technical Considerations for The Palatal Lift Prosthesis

The soft palate extension of the palatal lift prosthesis is designed to elevate an immobile
soft palate to the approximate level of the palatal plane (Fig. 11). 4 5 6 The posterior target
of the elevation is the dorsal tubercle of the first cervical vertebrae (atlas). The ease of
elevation is dependent upon the elasticity, fibrosis and muscular activity of the soft
palate.

When elevated, the soft palate will tend to displace the palatal lift and this displacement
must be resisted by the retentive components of the prosthesis (Fig. 12).7 The retentive
clasps must be rigid and placed as close as possible to the obturator portion of the
prosthesis. Occlusal (cingulum, incisal) rests will resist displacement of the prosthesis
towards the tissue but it is the retentive aspect of occlusal rests (indirect retainers) that
are most critical in this prosthesis. The further away from the fulcrum line the more
effective the occlusal rests will be as indirect retainers. Parallel guide planes may also
resist rotational displacement of a palatal lift prosthesis if there is sufficient clinical
crown length.
Soft Palate Defects 8

When natural teeth are absent, retention of the prosthesis is severely compromised. In the
absence of favorable anatomy, it may be impossible to use a palatal lift prosthesis unless
dental implants can be placed as denture adhesive is usually not sufficient to counteract
the displacement forces of the soft palate. When reduced denture retention is anticipated
it may be prudent to first fabricate a conventional prosthesis and then gradually add to the
posterior aspect of the prosthesis while attempting to minimize the amount of elevation.

The lift section of a palatal lift prosthesis is formed after the oral portion of the prosthesis
is completed. A retentive loop is extended posteriorly from the palatal portion of the
prosthesis to facilitate placement and retention of impression material to raise the soft
palate.

Modeling compound is added to the retentive loop until the soft palate contacts the
posterior and lateral pharyngeal walls. Initially, it will be necessary to manually hold this
material in place until hardened as the soft palate will displace it easily. Once the basic
extension has been established, border molding is achieved by adding and removing
modeling compound in the posterior and lateral pharyngeal areas. After the warmed
modeling compound addition is inserted the patient is instructed to flex the neck fully to
achieve contact of the chin to the chest. This movement will establish contact of the
middle third of the soft palate with the soft tissue covering the dorsal tubercle of the atlas.
Lateral aspects of the lift are formed by rotation and flexion of the neck to achieve chin
contact with the right and left shoulder respectively. A dull appearance of the modeling
compound ensures tissue contact. Once contact of the soft palate with the pharyngeal
walls is present, nasal breathing will not be possible. After slight (0.5-1.0 mm) reduction
of the compound, mouth temperature wax is adapted to the modeling compound. The
material remains in place for 7-10 minutes and the previous neck flexion and rotary
flexion movements are repeated. Once the lift has been added to the palatal portion of
the prosthesis, difficulties in nasal breathing may necessitate reduction of the lateral
aspects of the lift until breathing is unstrained. Such a reduction of the prosthesis may
result in a return of some degree of hypernasality.
Soft Palate Defects 9

Flaccid soft palates can be elevated easily with little counter force that would tend to
dislodge the prosthesis. Taut soft palates that resist elevation compromise potential
success of this type of prosthesis. Increased force used to elevate a taut soft palate may
generate soreness or ulceration or result in dislodgement of the prosthesis. In these
situations, it will be necessary to compromise on the level of elevation and focus on
lateral extension of the prosthesis to attempt adequate closure at a lower level in the
oropharynx.

Evaluation of Effectiveness of Treatment

When treatment is complete the patient will have palatopharyngeal closure during speech

and deglutition while unimpeded nasal breathing will still be possible. Effectiveness of

treatment with a palatal lift or a pharyngeal obturator prosthesis may be evaluated

through subjective or objective methods.

Speech evaluation will determine the presence of nasality. Following treatment patients

may experience hypernasal speech if the oropharyngeal contact is ineffective. If

oropharyngeal contact is excessive the patient may experience hyponasal speech.

Trained observers of nasality are often able to describe the quality of pharyngeal closure

through speech alone. 89 The less experienced or skilled observer may benefit from the

input of a speech pathologist or therapist in assessing the patient.

Patient reports of food or fluid regurgitation may indicate inadequate pharyngeal closure.

Evidence of excessive closure would be an inability to achieve nasal breathing. Effective

Soft Palate Defects 10

closure of the oropharynx may require modifications to the palatal lift or the pharyngeal

obturator to achieve the balance between inadequate and excessive closure.

Objective methods for evaluation of oropharyngeal closure involve direct visualization,

indirect visualization, and measurement of air pressure differentials. Direct visualization

may be performed through the use of a nasal endoscope. This fiber optic scope is used to

determine the presence or absence of oropharyngeal closure. 1011 Indirect methods of

visualization involve the use of radio-opaque fluids and cineradiography to assess fluid

regurgitation. 12131415 Air pressure in the oral and nasal cavities can be assessed to

determine the presence of closure.1617

Objective methods of assessment require the use of testing armamentarium that may

interfere with test results. In addition the proper use of testing equipment demands time

to establish skills while the improper use of equipment could prove dangerous to the

patient. 11 Conversely, subjective testing may not be of sufficient sensitivity to discern the

borderline air or fluid emissions. Neither approach is perfect. Experience of the clinician

may be the most appropriate method to determine the most favorable test for the patient

in question.

Summary

As with all phases of prosthodontics, there can be considerable difference in soft palate
defects from one patient to another. The goal of this chapter was to outline the basic
types of soft palate defect and to offer basic suggestions in their management with
obturator or lift prostheses. There are many techniques that would lend themselves to
development of acceptable obturator prostheses. It is important that the clinician become
Soft Palate Defects 11

familiar with a technique with which he/she is comfortable and can master. Application
of that technique to the variations in soft palate defects should not be that difficult. It
must always be remembered, and the patient must be so counseled in advance of
treatment, that the prosthodontist cannot restore the intricate neuromuscular structure
that is the soft palate. The clinician can only try to provide an alternative means for
oropharyngeal function. How successful that alternative is will be dependent on the
patients ability to accept the defect and to adapt to an alternative environment.
Soft Palate Defects 12

Legends

Figure 1. Residual soft palate defect following surgical management of cleft hard and
soft palate.
Figure 2. Surgical loss of soft palate in edentulous patient.
Figure 3. Partial surgical removal of soft palate leaves remaining right segment which
only functions minimally and does not aid in palatopharyngeal closure.

Figure 4. (A) Nonfunctioning soft palate without defect. (B) Nonfunctioning soft palate
radiographically. (C) Palatal lift prosthesis in place which elevates soft palate so that it
makes contact with pharyngeal wall.
Figure 5. Soft palate obturator will separate oral from nasal pharynx but not lift scarred
soft palate in repaired clefts.
Figure 6. Once framework for oral portion of the prosthesis is completed, impression of
obturator portion of the prosthesis is made with impression materials attached to a
retentive loop cast to the framework. Modeling plastic is border molded to conform to
the motions of the patient.
Figure 7. Completed obturator impression made in mouth temperature wax.
Figure 8. Tongue surface of the obturator portion of the prosthesis should not encroach
on tongue space any more than necessary for reasonable strength of materials.
Figure 9. Meatus obturator extends vertically into the defect as opposed to being
horizontally suspended between the oral and nasal pharynx.
Figure 10. (A) Openings placed through meatus obturator to allow for nasal breathing.
(B) Meatus obturator in place.
Figure 11. Palatal lift prosthesis elevates soft palate to provide palatopharyngeal closure.
Figure 12. Not relationship of direct and indirect retainers to the fulcrum line. The
further forward the indirect retention, the better the resistance to dislodgement.
Soft Palate Defects 13

Objective Design Feature Result

Support Occlusal rests Rests on natural teeth limit movement
towards tissue
Major connector Contact of major connector with tissue
decreases movement
Hard and soft tissue Contact between denture base and
underlying tissue

Retention Retentive clasps Undercuts on primary retainers

engaged by clasps
Skin graft Junction of skin graft and host tissue
creates retentive interface
Residual ridges Residual ridges and hard palate
provide retention in edentulous
patients
Indirect retention Occlusal rests on opposite side of
fulcrum line interfere with rotation of
the prosthesis away from tissue
Endosseous implants Direct retention of prosthesis

Stability Minor connectors Minor connectors prevent lateral
motion of prosthesis
Denture flanges Contact of flanges with residual ridges
diminishes motion
Soft Palate Defects 14

Appelby RC, Ludwig TF: Patient evaluation for complete detnure therapy. J Pros Dent 24:11-17,
1970.
Beder OE, Canell JA, Tomlinson J: The palatal elevator button. J Prosthet Dent 20:182-188,
August 1968.
Blackfield HM, Miller ER, Owsley JQ, Lawson LI: Cinefluorographic evaluation of patients with
velopharyngeal dysfunction in the absence of overt cleft palate. J Plast Reconstruct Surg 30:441-
451, 1962.
Conley SF, Gosain AK, Marks SM, Larson DL: Identification and assessment of velopharyngeal
inadequacy. Am J Otolaryngol 18(1):38-46 1997
Gonzalez JB, Aronson AE: Palatal lift prosthesis for the treatment of anatomic and neurologic
palatopharyngeal insufficiency. Cleft Palate J 7:91-104, january 1970
Kipfmueller LJ, Lang BR: Treating velopharyngeal inadequacies with a palatal lift prosthesis. J
Prosthet Dent 27:63-72, January 1972.
Marshall RC, Jones RN: Effects of a palatal lift prosthesis upon the speech intelligibility of a
dysarthric patient. J Prosthet Dent 25:327, 1971.
Mazaheri M, Hoffman FA: Cineradiography in prosthetic speech appliance construction. J
Prosthet Dent 12:571-575, May-June 1962.
Mazaheri M, Mazaheri E: Prosthodontic aspects of palatal elevation and palatopharyngeal
stimulation. J Prosthet Dent 35:319-326, 1976.
Mazaheri M, Millard RT, Erickson DM: Cineradiographic comparison of normal to noncleft
subjects with velopharyngeal inadequacy. Cleft Palate J 1:199, 1964.
Millard RT: Changes in nasal resonance related to differences in location and dimension of
speech bulbs. Cleft Palate J 2:167-175, 1965.
Morr KE, Warren DW, Dalston RM, Smith LR: Screening of velopharyngeal inadequacy by
differential pressure measurements.Cleft Palate J 26(1):42-5,1989
Pownell PH, Minoli JJ, Rohrich RJ: Diagnostic nasal endoscopy .Plast Reconstr Surg 99(5):1451-
8, 1997
Sharry JJ: Meatus obturator in cleft palate prosthesis. Oral Surg, Oral Med, Oral Path 7:852-855,
1955.
Taylor TD, Desjardins RP: Construction of the meatus-type obturator; its advantages and
disadvantages. J Prosthet Dent 49:80-84, January 1983.
Warren DW, Hoffman FA: A cineradiographic study of velopharyngeal closure. J Plast
Reconstruct Surg 28:656, December 1961.
Warren DW: Perci: a method for rating palatal efficiency.Cleft Palate J 1979 Jul;16(3):279-85
Soft Palate Defects 15

1
Appelby RC, Ludwig TF: Patient evaluation for complete detnure therapy. J Pros Dent 24:11-17, 1970.
2
Sharry JJ: Meatus obturator in cleft palate prosthesis. Oral Surg, Oral Med, Oral Path 7:852-855, 1955.
3
Taylor TD, Desjardins RP: Construction of the meatus-type obturator; its advantages and disadvantages. J
Prosthet Dent 49:80-84, January 1983.
4
Gonzalez JB, Aronson AE: Palatal lift prosthesis for the treatment of anatomic and neurologic
palatopharyngeal insufficiency. Cleft Palate J 7:91-104, january 1970
5
Beder OE, Canell JA, Tomlinson J: The palatal elevator button. J Prosthet Dent 20:182-188, August 1968.
6
Kipfmueller LJ, Lang BR: Treating velopharyngeal inadequacies with a palatal lift prosthesis. J Prosthet
Dent 27:63-72, January 1972.
7
Mazaheri M, Mazaheri E: Prosthodontic aspects of palatal elevation and palatopharyngeal stimulation. J
Prosthet Dent 35:319-326, 1976.
8
Millard RT: Changes in nasal resonance related to differences in location and dimension of speech bulbs.
Cleft Palate J 2:167-175, 1965.
9
Marshall RC, Jones RN: Effects of a palatal lift prosthesis upon the speech intelligibility of a dysarthric
patient. J Prosthet Dent 25:327, 1971.
10
Conley SF, Gosain AK, Marks SM, Larson DL: Identification and assessment of velopharyngeal
inadequacy. Am J Otolaryngol 18(1):38-46 1997
11
Pownell PH, Minoli JJ, Rohrich RJ: Diagnostic nasal endoscopy .Plast Reconstr Surg 99(5):1451-8, 1997
12
Warren DW, Hoffman FA: A cineradiographic study of velopharyngeal closure. J Plast Reconstruct Surg
28:656, December 1961.
13
Mazaheri M, Hoffman FA: Cineradiography in prosthetic speech appliance
construction. J Prosthet Dent 12:571-575, May-June 1962.
14
Blackfield HM, Miller ER, Owsley JQ, Lawson LI: Cinefluorographic evaluation of patients with
velopharyngeal dysfunction in the absence of overt cleft palate. J Plast Reconstruct Surg 30:441-451, 1962.
15
Mazaheri M, Millard RT, Erickson DM: Cineradiographic comparison of normal to noncleft subjects
with velopharyngeal inadequacy. Cleft Palate J 1:199, 1964.
16
Warren DW: Perci: a method for rating palatal efficiency.Cleft Palate J 1979 Jul;16(3):279-85
17
Morr KE, Warren DW, Dalston RM, Smith LR: Screening of velopharyngeal inadequacy by differential
pressure measurements.Cleft Palate J 26(1):42-5,1989