Prosthetic Management

of Soft Palate Defects

PRESENTED BY
DR. PIYUSH DONGRE
2ND YEAR PGT, DEPT OF PROSTHODONTICS.

GUIDED BY
: PROF(DR.) T.K. GIRI
PROF(DR.) SUGATA MUKHERJEE
DR. R.AHMED DENTAL COLLEGE AND HOSPITAL,
KOLKATA.
Contents
 Introduction
 Classification
 Anatomy
 Physiologic considerations
 Management
 Technical considerations
 Conclusion
 Introduction
 Defects of the soft palate may present as perplexing
problems to the clinician.

 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.
 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
 The objectives of prosthetic intervention are to prevent food
and fluid regurgitation and to improve speech intelligibility
 Classification
 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.
Anatomy of the soft palate and pharynx

IT IS MOVEABLE MUSCULAR FOLD SUSPENDED FROM POSTERIOR

BORDER OF HARD PALATE.

HAS NO BONY SKELETON.

IT SEPARATES THE NASOPHARYNX FROM THE OROPHARYNX

SURFACES
1. The anterior (oral) surface- is concave and is marked by median raphe.
2. The posterior surface- is convex , and is continuous superiorly with the
floor of the nasal cavity. 
Borders
1. The superior border –is attached to the posterior border of the
hardpalate ,blending on each side with the pharynx.
2. The inferior border- is free and bounds the pharyngeal isthmus. From its
middle, there hangs a conical projection , called uvula.
• The velopharyngeal port is defined
anteriorly by the soft palate, or
velum, laterally by the lateral
pharyngeal walls, and posteriorly
by the posterior pharyngeal wall.

• Closure of the velopharynx during

speech is a voluntary action that is
mediated by the motor cortex and
that requires the coordinated action
of the velopharyngeal musculature.
• The muscles of the soft palate
include the levator veli palatini, the
tensor veli palatini, the
palatoglossus, the
palatopharyngeus, and the
musculus uvulae
 The levator takes its origin from the petrous portion of
the temporal bone and from the medial aspect of the
eustachian tube. Insert into the palatal aponeurosis and
decussating with the levator fibers from the opposite side.
 Contraction of the muscular sling formed by the
paired levators is the primary mechanism for velar
elevation and closure of the velopharyngeal port.
 The musculus uvulae is a paired intrinsic muscle that
likely contributes to velopharyngeal closure both by
adding bulk to the dorsal surface of the velum and by
contributing to velar stretch.
 It is usually absent in patients with overt and
submucosal clefts of the palate.
 The superior pharyngeal constrictor is a
broad, thin muscle that takes origin from
the velum, the medial pterygoid, and the
pterygomandibular raphe, inserting into
the median pharyngeal raphe along with
the constrictor muscle fibers from the
opposite side.
 Contraction of the superior constrictor
may contribute to velopharyngeal closure
by effecting medial movement of the
lateral walls and anterior movement of
the posterior wall of the velopharynx.
 The anatomy of the superior constrictor
and its contribution to velopharyngeal
closure, however, are highly variable.
Physiologic considerations


SPEECH

 PALATOPHARYNGEAL
FUNCTION
 Speech
 Speech is a learned process that makes use of anatomic
structures designed primarily for respiration and
deglutition.
 The production of speech requires the selective
modification and control of outgoing airstream. The
source of power or air pressure resides within the
respiratory apparatus.
 Most girls master the normal articulation of speech by
6½ years of age , whereas boys take another 1 year of
maturation.
 The source of air pressure is within the
INTRODUCTIO

respiratory apparatus. Phonation is
provided by the varying tensions, vibratory N
cycles, and intricate coordination of vocal
folds of the larynx. The pharynx, oral and
nasal cavity act as the resonating chambers
that provide amplification and resonation
to the voice.
Speech and maxillofacial prosthetics
 Of the six components of speech, resonance and
articulation are most readily influenced by
maxillofacial prosthodontic rehabilitation.
 Patients with acquired defects or congenital
malformation of soft palate may exhibit excessive nasal
resonance because they are unable to control and divert
sufficient airflow into the oral cavity without surgical
and / or prosthodontic intervention.
 Degree of palatopharyngeal closure, tongue position and
structural resistance within nasal cavity influence oral-
nasal resonance balance.
 Resonance disturbances manifest as excessive nasal
resonance ( hypernasality, nasality , rhinolalia aperta ) or
insufficient nasal resonance ( hyponasality, denasality,
rhinolalia clausa ).
 With hypernasality excessive air escapes into the nasal
cavity and the patient sounds as though he is speaking
through his nose.
 Patients with hyponasality exhibits insufficient airflow
through the nasal compartments.
 Prosthodontist is challenged to avoid hypernasality and
yet maintain patency for breathing and nasal consonant
sounds [ /m/ , /n/ ,/ng/ ] .
 Speech Phonemes
 American English contains 44 different speech sounds or
phonemes that are classified as
1. Vowels
2. Voiceless consonants
3. Voiced consonants.
 Vowels are formed primarily with phonated sound with little
flow of air ( ↓ frequency, ↑ intensity ) e.g
/a/, /e/ ,/ i/ , /o/, /u/ .
 Voiceless consonants such as /p/, /t/, /f/ , /s/, are formed with
a column of air( laryngeal phonation) when restricted. ( ↑
frequency, ↓ intensity ).
 Voiced consonants such as /b/ , /d/, /g / combine
laryngeal phonation plus airflow with variable
frequencies and intensities.

 All vowels and most consonant sounds use the oral

pharynx and oral cavity as primary resonating chambers.

 However, there are three nasal consonants /m/, /n/, /ng/

that use the nasal cavity as primary resonating chamber.
PALATOPHARYNGEAL FUNCTION
 The palatopharynx is a precisely coordinated valve
formed by several muscle groups.
 At rest the soft palate drapes downwards so that the
oral pharynx and nasopharynx are open and coupled
to allow for normal breathing through nasal passages.
 When palatopharyngeal closure is required, the
middle one third of the soft palate arcs backward to
contact the posterior pharyngeal wall at or above the
level of the palatal plane.
 The lateral pharyngeal walls move medially and
posteriorly to contact the margins of the soft palate at or
slightly below the level of torus tubarius ( medial bulging
of the pharyngeal terminus of eustachian tube )
 Posterior pharyngeal wall may move anteriorly to
facilitate contact with elevated soft palate. The level of
posterior wall contact is also corresponds with the level
of anterior tubercle of atlas ( 1st cervical vertebra).
 Complete palatopharyngeal closure is required for normal
deglutition and production of speech sounds . For nasal
consonants, the palatopharyngeal port will be open in
varying degrees.
 Palatopharyngeal closure is
slightly below the level of the
palatal plane up to 8 years of age
and is consistently above the level
of the palatal plane thereafter.
Ref : JPD 1959

 The pattern of soft palate

movement varies between men
and women.
Ref :cleft palate journal 1970
 Skolnick et al. and Croft et al. have
described three basic patterns of
velopharyngeal closure observed in
normal subjects
 (1) coronal, in which closure is
primarily by velar elevation.
 sagittal, in which closure is primarily
by medial movement of the lateral
pharyngeal walls and the velum
contacts the lateral walls rather than
the posterior wall.
 circular in which medial movement of
the lateral pharyngeal walls
contributes to velopharyngeal closure
in near- equal proportion to the
velum.

 Of these, the coronal pattern of

closure is observed most commonly
in both normal individuals and in
patients with VPD.
Palatopharyngeal disorders may be
broadly classified based on physiology
and structural integrity into
palatopharyngeal incompetence,
palatopharyngeal insufficiency and
palatopharyngeal inadequacy.
 Palatopharyngeal insufficiency
When some or all of the anatomical structure of the soft
palate is absent. Patients with congenital and
developmental aberration and acquired soft palate
defects fall into this classification.

 Palatopharyngeal incompetence
When the soft palate is of adequate dimensions but lacks
movement because of disease or trauma affecting the
muscular and/or neurologic capacity. Patients with
bulbar poliomyelitis, myasthenia gravis , CVA are
included in this category.
 Inability of an
anatomically intact
soft palate to
contribute to a
functional
velopharyngeal
closure usually due
to disease of a
neurogenic or
Velopharyngeal muscular nature or
incompetence traumatic injuries.
Velopharyngeal insufficiency When some or all of the anatomic
structure of the soft palate is
absent but movement of remaining
tissues is within physiologic limits,
such as congenital cleft palate,
short soft palate (due to congenital
or postsurgical scarring of the soft
palate), and acquired palatal clefts
Such patient will exhibit

Impaired speech intelligibility

 Seepage of nasal secretions into the oral cavity
 Fluid and food regurgitation.
 Problems in deglutition and resonance, articulation disturbance
Difficulty in swallowing and hyper nasality are also eminent.

Treatment can be done through surgery, prosthesis, speech therapy, or a combination

of them all, depending on the case.
Management

• Surgical treatment
1. Posterior pharyngeal flap
2. Sphincter pharyngoplasty
3. Posterior pharyngeal wall augmentation
4. Furlow double opposing Z-Palatoplasty
1. Non-Surgical treatment
1. Prosthetic treatment
 Behavioural speech therapy
Prosthodontic Rehabilitation
 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 .
 In this situation an obturator
prosthesis is designed to close
the opening between the
residual hard and/or soft palate
and the pharynx.
 Obturator designs

Palatopharyngeal insufficiency

1. Pharyngeal obturator prostheses/ Speech aid prosthesis.

a. Fixed type
b. Hinged type
2. Meatus Obturator

 Palatopharyngeal incompetence

Palatal lift prosthesis

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.
 Therefore, a pharyngeal obturator prosthesis has less active displacement force
upon it than does a palatal lift prosthesis.
 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.
 High fusing compound is added to the
retentive loop without contacting the
walls of the defect.
 Low fusing compound is added incrementally to
border mold the pharyngeal space.

 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
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.

 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
 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 . 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.

 Superior portion of the

completed obturator
prosthesis is slightly convex
in shape and highly polished
• Patient’s ability to suck from a glass of water, and
water not coming from his nose.
• Patient’s ability to breathe and swallow with ease.
• A marked improvement in speech. With the patient
able to articulate plosive sounds such as b and p.
• And by verifying the prosthesis with the
cephaloradiographs.
• Over extended prosthesis – chance of gagging
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 (Sharry 1955).

 Themeatus obturator projects vertically at the posterior

aspect of the prosthesis to obturate the posterior nasal
choanae. 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
( Taylor and desjardins 1983).
 Since the posterior and lateral pharyngeal walls cannot
function against a meatus obturator, speech will tend to
be hyponasal. With ideal obturation there will be absence
of nasal breathing.
 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.
 The impression for meatus
obturator will often show the
imprint of turbinates, vomer, and
orifice of the eustachian tube. The
latter should be cut away.
 Once the meatus extension is
processed onto the denture it is
necessary to provide for nasal
breathing . One hole (2 to 5 mm )
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
and slope downwards towards
pharynx to allow drainage posteriorly.

 The meatus obturator should be reduced anteriorly and posteriorly ( 5 mm in

thickness) as much as possible in order to lighten the appliance. Once should
test the voice quality periodically while trimming, lest the obturating effect be lost.
LIMITATIONS OF MEATUS OBTURATOR
A. The Hinge obturator moves with the soft palate
B. The Fixed obturator is directed toward or slightly above passavant’s pad
C. The Meatus obturator is directed at approximately 90° to the long axis of palate
 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
 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
 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, shaped, flamed to
create a smooth surface and then
chilled before placing it into the
mouth.
 The chilled compound is carried to the
mouth and seated and allowed to wear
for several minutes.
 Small additions are made to compound
posteriorly until the soft palate is brought
into light contact with posterior
pharyngeal wall.
 At this stage space will remain between
the soft palate and the lateral pharyngeal
walls.
 Following each addition patient is asked
to breathe through nose and attempt
speech.
 Enlargement of the lift ceases when the
speech professional is satisfied with the
result.
 difficulties in nasal breathing
may necessitate reduction of the
lateral aspects of the lift until
breathing is unstrained.
 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 patient is
asked to speak, swallow water, and move the head in all
directions.
 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.
 Subjective 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.
 Patient reports of food or fluid regurgitation
may indicate inadequate pharyngeal closure.
Evidence of excessive closure would be an
inability to achieve nasal breathing.
 Objective methods
 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.
 Indirect methods of visualization involve the use of
radio-opaque fluids and cineradiography to assess fluid
regurgitation.
 Air pressure in the oral and nasal cavities can be
assessed to determine the presence of closure.
• To achieve movement of soft
palate, incorporation of
muscle function in the
prosthesis by using polymer
based artificial muscle fiber
and rejuvenation of muscle
function by the use of
actuator.
Conclusion
 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
patient’s ability to accept the defect and to adapt to an alternative
environment.
References
 Maxillofacial rehabilitation; Curtis
 Maxillofacial Prosthetics multidisciplinary practise ;
Challian
 Maxillofacial Prosthetics; Laney
 Clinical maxillofacial prosthetics ; Taylor
 Complete denture prosthodontics ; Sharry
 Journal of prosthetic dentistry
 Cleft palate journal
 Internet source
Thank you