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CASE REPORT
Year : 2011  |  Volume : 29  |  Issue : 6  |  Page : 70-73
 

Clinical application of palatal lift appliance in velopharyngeal incompetence


Department of Orthodontics, Government Dental College and Hospital, Chennai, India

Date of Web Publication12-Dec-2011

Correspondence Address:
S Premkumar
B3, Block 2, Jain Ashraya Phase III, 31, Arcot Road, Virugambakkam, Chennai - 600 092
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.90746

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   Abstract 

The presence of nasal air leak in cleft palate patients with velopharyngeal incompetence leads to characteristic nasal snort. The efficacy of the palatal lift appliance in patients with adequate velopharyngeal tissue with incompetence was tested. Speech quality improved after the wearing of palatal lift appliance. Palatal lift appliances are simple and efficient in reducing the nasal air leak. Ongoing speech therapy is necessary and advised for patients receiving palatal lift.


Keywords: Palatal lift appliance, speech and cleft, velopharyngeal incompetence


How to cite this article:
Premkumar S. Clinical application of palatal lift appliance in velopharyngeal incompetence. J Indian Soc Pedod Prev Dent 2011;29, Suppl S1:70-3

How to cite this URL:
Premkumar S. Clinical application of palatal lift appliance in velopharyngeal incompetence. J Indian Soc Pedod Prev Dent [serial online] 2011 [cited 2019 Dec 10];29, Suppl S1:70-3. Available from: http://www.jisppd.com/text.asp?2011/29/6/70/90746



   Introduction Top


Velopharynx is a muscular valve located between the nasal and oral cavity. It consists of lateral and posterior pharyngeal walls and soft palate. Velopharynx is associated with control of passage of air during speech. Velopharyngeal dysfunction occurs when the valve is unable to perform its own closing. This dysfunction could result from two main reasons: (i) due to lack of tissue, which is called as velopharyngeal insufficiency, and (ii) due to lack of proper movement called as velopharyngeal incompetence. Velopharyngeal dysfunctions jeopardize the individual's communication skill as the speech becomes completely atypical. The constant communication between the oral and nasal cavities affects speech comprehension, produces hypernasality, compensatory articulation and nasal air emission.

Cleft palate patients are often candidates with velopharyngeal incompetence which leads to dysfunction and characteristic nasal snort. With the evolution of treatment concepts, treatment of cleft palate patients with velopharyngeal incompetency by palatal lift appliance has become a part of the current trend for the rehabilitation of velopharyngeal dysfunction. [1] Many publications about the effectiveness of palatal lift prosthesis have been published. [2] The failure of soft palate to elevate during speech results in air leak [Figure 1].
Figure 1: Mechanism of nasal air leak in velopharyngeal incompetence

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Based on this, an attempt was made to evaluate the orthodontic treatment for velopharyngeal incompetence by palatal lift appliance in a patient with adequate velopharyngeal tissue.

Palatal lift appliance

Palatal lift appliances act by lifting the soft palate upward and backward. When the soft palate is moved superiorly and posteriorly, the paired superior constrictor walls move medially to contract and press into the lateral portion of the elevated soft palate, thus effecting a proper velopharyngeal closure.


   Case Report Top


A 9-year-old female patient reported with the complaint of hypernasality and disarticulation. History revealed she was operated for cleft lip and palate earlier. Clinical examination revealed she had sufficient palatopharyngeal tissues with only velopharyngeal incompetence. Palatal lift appliance was chosen as the treatment for correcting her speech problem.

Fabrication of the palatal lift appliance

For the purpose of easy comprehension, the fabrication of palatal lift appliance can be studied under four stages given below.

Stage 1

Subsequent to clinical examination, recording of preliminary impression with irreversible hydrocolloid is done and a primary cast is prepared from it [Figure 2]. A custom tray is processed after adapting wax spacer [Figure 3] to the primary model. With the help of the custom tray [Figure 4], a precise impression with adequate extension to the soft palate is recorded.
Figure 2: Primary cast

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Figure 3: Wax spacer adapted before processing of custom tray

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Figure 4: Processed custom tray

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Stage 2

The second step in the fabrication is the processing of acrylic framework with posterior wire extension [Figure 5]. A primary requirement for successful palatal lift is retention. Abutment teeth should be strategically located to give maximum advantage to the lift. Posterior teeth act as the best abutment because they are closer to the cantilever extension. Additional retention is obtained by giving a southend clasp for the maxillary central incisors. The wire framework or retentive loop for the lift should extend 2 cm posterior to the fovea palatine. This length will provide adequate support for lift molding. The loop should be on the same plane as the hard palate. It should be in contact with and slightly displacing the soft palate [Figure 6].
Figure 5: Acrylic framework with wire extension

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Figure 6: Wire extension displacing the soft palate

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Stage 3

This stage consists of the generation of the palatal lift. The oral portion of the appliance with loop is tried in and adjusted as necessary to ensure complete seating.

Modeling compound is applied to the loop, shaped, flamed to create a smooth surface and then chilled before placing it into the mouth. If softened compound is placed in the mouth, the soft palate will displace it downward and the lift action will not occur.

Displacement of the soft palate is the primary goal of the procedure and can be accomplished with hardened compound only. Small additions are made to the compound posteriorly until the soft palate is brought into light contact with posterior pharyngeal walls. Following each addition, the patient is asked to breathe through nose. Speech drills that require the creation of intra-oral air pressure are very effective in determining the reduction in hypernasality. B and p are plosive sounds requiring intra-oral pressure. A simple clinical test to find out the reduction of nasal air leak is done. The patient is asked to blow air out with the mouth closed. Operator has to keep his finger below the nostrils of the patient to check for nasal air leak. A satisfactory lift generation will completely eliminate nasal air leak [Figure 7].
Figure 7: Completed lift generation

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Stage 4

Following lift generation session, the lift portion of the appliance is replicated in acrylic resin. Appliance is carefully trimmed and polished to ensure that there are no residual rough or sharp edges that might lacerate the distended soft palate [Figure 8].
Figure 8: Processed palatal lift appliance

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Appliance insertion and instruction

During the insertion of appliance [Figure 9], the effectiveness in reducing the nasal air leak and lift generation are checked again. Patients are seen within 2 or 3 days after delivery of the palatal lift. Usually the lift appliance should be worn constantly during waking hours. Wearing the appliance during sleep is not recommended. This allows the mucosa of the palate to recover from the coverage and pressure caused by the lift. Some patients might complain of loss of taste as nasal air flow is necessary for olfactory portion of taste.
Figure 9: Palatal lift appliance in position

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Evaluation of outcome

A lateral cephalogram was taken after insertion of the palatal lift appliance and assessed for palatal lift [Figure 10]. A definite lift generation was evident from the radiograph. The patient was referred to speech therapist for assessment of speech. Speech assessment showed marked reduction in hypernasality and increased coordination of speech 3 months after treatment. A nasal emission test was also conducted, which showed the absence of nasal air leak.
Figure 10: Lateral cephalometric radiograph of the patient with the palatal lift appliance in position

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   Conclusion Top


The objective of providing a palatal lift appliance for the patient is to obtain velopharyngeal closure by displacing the soft palate to the level of normal palate closure at the level of palatal plane. Once the soft palate gets lifted, the residual muscle activity in the pharyngeal walls will cause a reduction in size of the palatopharyngeal opening with decrease in nasality. [3] Palatal lift appliances are simple and efficient in achieving the above-mentioned objective.

Ongoing speech therapy is necessary and advised for patients receiving palatal lift appliance.

 
   References Top

1.Beery Q, Rood S, Schramm V. Pharyngeal wall motion in cleft palate adults. Cleft Palate J 1983;20:7.  Back to cited text no. 1
    
2.Kipfmueller L, Lang B. Treating velopharyngeal inadequacies with a palatal lift prosthesis. J Prosthet Dent 1972;27:63.  Back to cited text no. 2
    
3.Schaefer KS, Taylor TD. Clinical application of palatal lift. In: Thomas D, editor. Maxillofacial prosthetics. Chicago: Taylor Quintessence Publishing Co, Inc; 2000. p. 133-42  Back to cited text no. 3
    


    Figures

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


This article has been cited by
1 Prosthetic rehabilitation of a child with velopharyngeal dysfunction A case report
Neha Sikka,Reeta Jain,Ashutosh Kaushik,Reena Rani
Journal of Oral Biology and Craniofacial Research. 2014;
[Pubmed] | [DOI]
2 Management of obstructive sleep apnea with a palatal lift prosthesis
Gaurav Bhalla,Deeksha Arya,Pooran Chand,Kamleshwar Singh,Shuchi Tripathi
international journal of stomatology & occlusion medicine. 2013; 6(3): 101
[Pubmed] | [DOI]



 

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