PROSTHETIC REHABILITATION OF

VELOPHARYNGEAL DEFECTS
PRESENTER: Dr.P.VIVEK SHANKAR (PG III YEAR)

Dr.B.MUTHUKUMAR, MDS GUIDED BY

HOD AND PROFESSOR Dr.K.MURUGESAN., MDS, PROFESSOR
Dr.PETER JOHN., MDS, READER
DEPARTMENT OF PROSTHODONTICS

SRM DENTAL COLLEGE AND HOSPITAL, RAMAPURAM

CONTENTS

 INTRODUCTION
 VELOPHARYNX
 DEFECTS
 CLASSIFICATION
 PROSTHETIC REHABILITATION
 TOTAL DEFECTS
 PARTIAL DEFECTS
 SPECIAL OBTURATORS
 - PALATAL LIFT PROSTHESIS
 - MEATAL OBTURATOR.
 SUMMARY
 REFERENCES
MAXILLOFACIAL PROSTHETICS

 any prosthesis used to replace part or all of any stomatognathic and/or craniofacial
structures.,.

The Glossary of Prosthodontic terms, 8th edition. J Pros Dent. 2005;94(1):10- 92.
VELOPHARNYX - ANATOMY

VELOPHARYNX - VELUM – Soft Palate, PHARYNX – REGION OF PHARYNX

Ali Aram. Velopharyngeal function and cleft palate prosthesis. J Pros. Dent. 1959; 9: 149
VELOPHARYNGEAL MECHANISM

Ali Aram. Velopharyngeal function and cleft palate prosthesis. J Pros. Dent. 1959; 9: 149
VELOPHARYNGEAL DEFECTS

 Congenital malformations (such as cleft palate)

 Developmental aberrations (such as a short hard or soft palate, or a
deep nasopharynx).
 Acquired neurological deficits
 Surgical resection of neo-plastic disease

Beumer J, Curtis A, Marunick MT. Maxillofacial rehabilitation: Prosthodontic and surgical

considerations. St Louis: Ishiyaku Euro-America; 1996; 285-329.
VELOPHARYNGEAL CORRECTION

VPI

SURGICAL PROSTHETIC
 CLASSIFICATION

 Palatal insufficiency

 Palatal incompetency

Beumer J, Curtis A, Marunick MT. Maxillofacial rehabilitation: Prosthodontic and surgical considerations. St
Louis: Ishiyaku Euro-America; 1996; 285-329.
PALATAL INSUFFICIENCY

 Palatal insufficiency refers to patients with inadequate length of the

hard and/or soft palate which affect velopharyngeal closure, but
with movement of the remaining tissues within normal physiological
limits.
 PALATAL INCOMPETENCY
 Palatal incompetence refers to patients with essentially
normal velopharyngeal structures, but in whom the intact
mechanism is unable to affect velopharyngeal closure.

 It is seen in patients with neurological diseases such as

myastenia gravis or neurological deficits which are
secondary to cerebrovascular accidents or closed head
injuries.

 In velopharyngeal incompetence or insufficiency, the

posterior wall movement or passavant ridge is more, which
help in obtaining a velopharnygeal seal. Passavant ridge is
associated only with a circular type of closure
PROSTHODONTIC REHABILITATION
 A prosthesis which is placed following resection of portions of the bony
maxillae and adjacent structures is basically a covering prosthesis which re-
establishes the oral-nasal partition.

 Obturator prosthesis which is fabricated for patients with velopharyngeal

defects varies with the location and nature of the defect or deficiency.

Beumer J, Curtis A, Marunick MT. Maxillofacial rehabilitation: Prosthodontic and surgical

considerations. St Louis: Ishiyaku Euro-America; 1996; 285-329.
OBJECTIVES

 To provide the capability for the control of nasal emission during

speech.

 To prevent the leakage of material into the nasal passage during

deglutition.

 If soft tissues which are peripheral to the defect do not display

some movement, speech will not be normal with prosthetic
obturator prosthesis.

 Movement of the lateral and posterior walls and movement of

the residual soft palate are essential for rehabilitation
PROSTHETIC REHABILITATION

 (1) Obturator/speech aid prosthesis

 (2) Palatal lift
 (3) Combination of all of the above

 Alternatively, a speech aid prosthesis is used to restore a soft palate

defect or a dynamic defect in order to separate the oropharynx
from the nasopharynx
 When the velum is inadequate and the ratio of the velar length to
nasopharyngeal depth is excessive, the obturator, in combination
with the speech aid prosthesis, substitutes for this tissue deficiency
IMMEDIATE SURGICAL OBTURATOR

 Immediate surgical obturation is most useful in dentulous patients,

where the entire soft palate has to be resected.
 The principle advantage of using immediate surgical obturators for
soft palate defects is support and retention of the surgical packing.
 FABRICATION
• Immediate surgical obturators are constructed presurgically. An extended impression of
the soft palate is obtained.

• After the cast is retrieved, it is altered to correspond to the proposed defect. The superior-
interior level of the obturator is determined by the plane of the hard palate.

• The cast is altered to extend the palatal plane within 2 to 3 mm of the estimated position
of the posterior pharyngeal wall. The width of the obturator is determined by the width of
the soft palate.

• Approximately 7 to 10 days post surgically, the prosthesis is removed along with the
surgical packing and it is placed again after corrections are made.
DISADVANTAGES
 Firstly, the drape of the intact soft palate precludes from obtaining an impression of
the nasopharynx, where the normal velopharyngeal closure occurs and where the
surgical obturator should be located.
 Secondly, functional movements of the velopharyngeal mechanism cannot be
recorded either prior to or during surgery.
 Thirdly, the pharyngeal tissues which are peripheral to the defect will usually exhibit
little movement during function in the immediate postoperative period.
 Fourthly, the extent of tumours in this region is more difficult to visualize; hence, it is
more difficult to delineate the surgical margins presurgically
 DELAYED SURGICAL OBTURATOR

 In edentulous patients, or in patients with limited medial or lateral

posterior border resections, a delayed obturation may be the
treatment of choice.
 In edentulous or partially edentulous patients, consideration should
be given to attachment of the delayed surgical obturator to the
existing maxillary complete or partial denture
DEFINITIVE OBTURATION

 DENTULOUS PATIENT – RPD FRAMEWORK – RETAINS OBTURATOR

 The obturator should be rigid. Therefore, it does not attempt to duplicate the
movements of the soft palate. It is a fixed platform of acrylic resin, which provides
surface contact for the remaining musculature of the velopharyngeal mechanism
during function.
 If the lateral and posterior pharyngeal walls exhibit normal movement, a space
will exist between these structures and the obturator when these tissues are at rest.
This space permits breathing through the nasal cavity.
Following guidelines should be considered for
location of the obturator segment of the
prosthesis:
• The obturator for an adult patient should be located in the
nasopharynx, at the level of normal velopharyngeal closure.
• The inferior margin of the obturator should not extend
beyond the lower level of muscular activity which is exhibited
by the residual velopharyngeal complex
• The superior margin of the obturator should not extend
above the level of muscular activity.
• The inferior extension of the obturator will usually be an
extension of the palatal plane, and it will be extended to
posterior pharyngeal wall.
Walter studied the pharyngeal activity in cleft palate
subjects. He stated that
• Patterns of attempted palatopharyngeal closure during speech in
unrepaired cleft palate patients are complex and variable.
• The presence of the obturator has a marked effect on the
pattern of activity.
• Obturators should be molded to speech function and not
swallowing. Since the swallowing closure has more forceful
pressure activity, the obturator which is molded to swallowing
activity will be too small to give a palatopharyngeal seal during
speech.

Walter. Palatopharyngeal activity in cleft palate subjects. J Pros Dent. 1990; 63: 187.
OBTURATORS FOR TOTAL SOFT
PALATE DEFECTS
 Construction of obturators for soft palate deficiencies begins with
the fabrication of the conventional prosthesis.
FABRICATION
 RPD Frameworks
 Impressions:
 Irreversible hydrocolloid with a stock tray
 Extend tray and impression into the defect
 • Attempt to record as much of the defect as is reasonable with this impression.
 • This will greatly facilitate the fabrication of the altered cast tray extension.
 RPD Designs Unique features:
 a) Forces of gravity
 b) Long lever arms
 c) Retentive loop must extend into the defect.
 The effect of the obturator extension will be most significant for patients with Kennedy
Class I or Class II partial dentures
 Indirect retention is key to counteracting the long lever arms and the forces of gravity.
 Altered cast impression trays
 Characteristics:
 Made of tray resin for easy adjustability during molding of the obturator.
There should be 2-3 mm of space between the tray extension and adjacent
tissues at maximum contracture of the residual velopharyngeal musculature.
Disclosing wax is useful in checking tray extension.
 BORDER MOLDING

 The defect is functionally molded with a low fusing dental

compound and refined with a thermoplastic wax.
 Maneuvers used to trim the bulb
 • Flexure of the neck combined with rotation of the head
 • Speech – primarily plosive sounds
 • Swallowing
 Dry swallowing results in a more forceful contraction of the
velopharyngeal musculature and should not be used to refine
the bulb.
 Otherwise the bulb will be underextended.
Begin by adding compound to the anterior portion of the defect before
progressing to the lateral and posterior areas. The activated pharyngeal
musculature will displace the excess compound superiorly and inferiorly.
Compound that extends above or below the area of the
velopharyngeal mechanism should be trimmed away. The oral side of
the obturator must be concave and the nasal side should be convex.
The range of movement represents the potential space between the obturator
and the adjacent tissues at rest.

If these tissues are immobile or if the obturator extends above the area of
movement, the prosthesis has the potential to compromise the patency of the
nasal airway . In such circumstances speech cannot be restored to normal. At
best a balance between hypernasality and hyponasality is achieved.
COMPOUND CUT-BACK
The compound is cut back 1-2 mm prior to adding the thermoplastic wax. Iowa
wax is added to the surface of the compound The wax is tempered and
placed intraorally. The pattern is molded functionally by having the patient
speak and swallow as previously.
CORRECTED IMPRESSION

Border molding is completed by having the

patient wear the wax- compound obturator for
at least two hours in order to ensure that the
impression is not overextended.

Note that in (A) the velopharyngeal

musculature is in full contracture while in (B) it is
NOT
COMPLETED IMPRESSION

• Wax pattern in passive contact with the

velopharyngeal complex during functional
contraction.

• No compound is exposed.

• Concave tongue surface.

• Convex nasal surface.

• Wax pattern does not extend beyond the

zone of function.

• In most patients the height of the pharyngeal

extension does not exceed 10-15mm
BOXING OF IMPRESSIONS
PROCESSING
INSERTION

Extensions are verified using

- Pressure indicating paste

- Disclosing wax
SOFT PALATE OBTURATORS

• Oral side is concave

• Nasal side is convex
• All surfaces are highly polished
OBTURATOR REDUCTION AND
COMPENSATORY MOVEMENT
 Some clinicians have reported increased lateral wall movement following
reduction of the obturator prosthesis to the point in some patients where the
prosthesis could be removed altogether (Weis CE, 1971).
 These results have been questioned and have not been reproduced by others.
We have observed changes in obturator size and shape during years of use but
not to the point where it was possible to remove the appliance and maintain
velopharyngeal closure.
 Both obturators were made for the same patient, but 7 years apart.
Note that the lateral wall extension of the prosthesis on the left
(arrows) is greater than that on the right.
 SIZE AND POSITION OF OBTURATOR
 If the obturator is positioned correctly at the level of greatest lateral and
posterior pharyngeal wall movement, a superior extension of approx. 10mm is
adequate.

 Overextension – placed too high – occlusion of nasopharynx – difficulty with

nasal breathing and hyponasal speech.

 Under extension – Tongue function will be disrupted and gagging.

Beumer J, Curtis A, Marunick MT. Maxillofacial rehabilitation: Prosthodontic and surgical considerations. St
Louis: Ishiyaku Euro-America; 1996; 285-329.
 SPEECH EVALUATION FOLLOWING
OBTURATOR PLACEMENT
 Assistance of speech pathologist.
 Cleft palate patients – Speech therapy.
 Acquired defects – Do not require.

 METHODS FOR EVALUATION:

 1. Multiview videofluoroscopy
 2. Nasal endoscopy
 3. Pressure airflow aerodynamic assessment
equipment
 TEST SENTENCES FOR EVALUATION

Chierici G, Lawson L. Clinical speech considerations in prosthodontics: perspectives of the prosthodontist and speech pathologist. J
Prosthet Dent. 1973 Jan;29(1):29-39
OBTURATOR FOR POSTERIOR
BORDER DEFECTS

Median Lateral
posterior posterior
border defects border defects.
METHODS

 Two approaches to cross the residual soft palate

 1. Record the soft palate at rest. After the soft palate is
circumvented, the obturator is extended superiorly behind the soft
palate to the proper level for obturation.

 2. Displace the residual soft palate superiorly with the soft palate
extension in order to place the obturator in the proper area in the
nasopharynx. This is known as Palatal lift prosthesis.
MEDIAN POSTERIOR BORDER
DEFECTS
 Preliminary impression – residual SP plus defect posterior to the SP.

 Basic prosthesis completed.

 Wire loop attached to RPD or CD prosthesis to secure the obturator.

 Loop should be adjusted such that 1mm of space exists between

wire retention and soft palate at rest.
LATERAL POSTERIOR BORDER
DEFECTS
 Record the tissues surrounding the defect during function.

 Adequate movement of the residual velopharyngeal mechanism is

needed to control nasal air flow.

 Generally the lateral extensions of the obturator are reduced

gradually until nasal breathing is acceptable.
IMPLANT RETAINED SOFT PALATE
OBTURATORS
 WHY?

 Retention
 Precision of placement of the obturator prosthesis
2 implants in premaxillary segment in cuspids –
When PPS not compromised.

4 or more implants – When the defect

compromises the PPS.
FACEBOW TRANSFER, JAW RELATION, TRY IN, INSERTION
HOLLOW OBTURATOR
 The weight of the prosthesis is reduced, making it more comfortable
and efficient.
 The lightness of the prosthesis changes one of the fundamental
problems of retention and it increases physiologic function

Nidiffer, Shipman. Hollow bulb obturator for acquired palatal openings. J Pros Dent. 1957; 7: 126.
SPECIAL OBTURATORS
 PALATAL LIFT PROSTHESIS

First reported by Gibbons and Bloomer. This type of prosthesis is

especially useful for patients with velopharyngeal
incompetence.

The objective is to displace the soft palate to the level of normal

palatal elevation, thus enabling closure by pharyngeal wall
action.

If the length of the wall is insufficient to effect closure after

maximal displacement, the addition of an obturator behind the
displaced soft palate may be necessary.

Thomas D Taylor. Clinical management of soft palate defect patient in Clinical Maxillofacial
Prosthetics. 121-32.
ADVANTAGES

• The gag response is minimized due to the superior position and the sustained
pressure of the lift portion of the prosthesis against the soft palate.

• The physiology of the tongue is not compromised due to the superior position of
the palatal extension.

• The access to the nasopharynx for the obturator (if necessary) is facilitated.

• The lift portion may be developed sequentially, to aid patient adaptation to the
prosthesis

Leo J Kipfmueller, Brien R Lang. Treating velopharyngeal inadequacies with a palatal lift prosthesis.
J Pros Dent. 1972; 27(1): 63-72.
CONTRAINDICATIONS

• If adequate retention is not available for basic prosthesis.

• If the palate is not displaceable.
• If the patient is uncooperative

Leo J Kipfmueller, Brien R Lang. Treating velopharyngeal inadequacies with a palatal lift
prosthesis. J Pros Dent. 1972; 27(1): 63-72.
 In deciding between a palatal lift and an obturator, one should remember
that a palatal lift is best when the soft palate is of normal length for closure of
the oropharyngeal portal but has inadequate muscle function to elevate the
soft palate to close the portal.

 In addition, if there is a space behind the elevated soft palate after placing
a palatal lift, obturation of some sort will be required, whether it is a
combination of a lift/obturator, speech bulb, meatal prosthesis or any
combination of these.
SPEECH AID PROSTHESIS
(PHARYNGEAL OBTURATOR)

Gibbons Bloomer designed and evaluated a speech

aid prosthesis. This was constructed for a patient with
bulbospinal poliomyelitis which resulted in palatal
paralysis.

This appliance would elevate the palate to a position

which approximated that of normal retraction, thereby
narrowing the lumen of the palatopharyngeal valve.

Gibbons Bloomer. A supportive type prosthetic speech aid. J Pros Dent. 1958;
8: 362
MEATAL OBTURATOR

• Extends upto the nasal meatus

• Establishes closure with nasal structures at a level
posterior and superior to posterior border of hard
palate
• The closure is established against the conchae
and roof of nasal cavity
• It separates oral and nasal cavities
• Indicated in patients with extensive soft palate
defects.
• The meatal obturator itself is static in nature, despite it correcting a dynamic,
complex deficiency.
• Usually, it extends cephalad from the junction of the hard and soft palate in an
oblique orientation in order to rest against the turbinates and the superior aspect
of the nasal cavity.
• The disadvantage of this type of prosthesis is that it tends to make the patient’s
speech hyponasal, which can be altered by creating holes in the prosthesis
 SUMMARY

A properly designed and extended obturator prosthesis for a soft palate

defect should provide the patient with perfect speech if a segment of the
velopharyngeal musculature remains.
REFERENCES

 [1] The Glossary of Prosthodontic terms, 8th edition. J Pros Dent. 2005;94(1):10-
92.
 [2] Sprintzen RJ, Bardach J. Cleft palate speech management. St Louis: CV
Mosby; 1995; 263-7.
 [3] Beumer J, Curtis A, Marunick MT. Maxillofacial rehabilitation: Prosthodontic
and surgical considerations. St Louis: Ishiyaku Euro-America; 1996; 285-329.
 [4] Agrawal KK, Singh BP, Chand P, Patel C. Impact of delayed prosthetic
treatment of velopharyngeal insufficiency on quality of life. Indian J Dent Res.
2011; 22: 356-8.
 [5] Ali Aram. Velopharyngeal function and cleft palate prosthesis. J Pros. Dent.
1959; 9: 149.
REFERENCES

 6] Subtelny JD, Sakuda M, Subtelny JD. Prosthetic Treatment for Palatopharyngeal

 Incompetence: Research and Clinical Implications. Cleft Palate J. 1966; 4: 130-
 58.
 [7] Leo J Kipfmueller, Brien R Lang. Treating velopharyngeal inadequacies with a
 palatal lift prosthesis. J Pros Dent. 1972; 27(1): 63-72.
 [8] Falter Jane W, Shelton RL. Jr. Bulb Fitting and Placement in Prosthetic Treatment
 of Cleft Palate, Cleft Palate J. 1964; 1: 441-7.
 [9] Walter. Palatopharyngeal activity in cleft palate subjects. J Pros Dent. 1990; 63:
 187.
 [10] Jacob King. Indirect retainers in soft palate obturator design. J Pros Dent. 1990;
 63: 311.
REFERENCES

 [11] Gardner, et al. Swing lock design considerations for obturator frameworks. J
 Pros Dent. 1995; 74: 503.
 [12] Gregory, et al. Prosthodontic principles in the framework design of maxillary
 obturator prosthesis. J Pros Dent. 2005; 93: 405.
 [13] SH Tuma, G Pekkam, HO Gumus, A Aktas. Prosthetic rehabilitation of
 velopharnygeal insuffiency: Pharnygeal obturator prosthesis with different
 retention mechanism. Euro J Dent. 2010; 4(1): 81-7.
 [14] Nidiffer, Shipman. Hollow bulb obturator for acquired palatal openings. J
Pros
 Dent. 1957; 7: 126.
 [15] Alex Fox. Prosthetic correction of severe acquired cleft palate. J Pros Dent.
 1958; 8: 542
REFERENCES

 [16] Buckner. Construction of a denture with hollow obturator, lid,

and soft acrylic lining. J Pros Dent. 1974; 31: 95.
 [17] Victor et al. A simplified method for making a hollow obturator.
J Pros Dent. 1976; 36: 580.
 [18] Schneider. Method of fabricating a hollow obturator. J Pros
Dent. 1978; 40: 351.
 [19] Thomas D Taylor. Clinical management of soft palate defect
patient in Clinical Maxillofacial Prosthetics. 121-32.
 [20] Thomas D Taylor. Clinical application of palatal lift patient in
Clinical Maxillofacial Prosthetics. 133-44.
THANK YOU