Egészségügy | Fogászat » John Walter - Obturators for cleft palate and other speech appliances

0ROSTHETIC$ENTISTRY *OHN $ 7ALTER /BTURATORS FOR #LEFT 0ALATE AND OTHER 3PEECH !PPLIANCES !BSTRACT !N OUTLINE IS GIVEN OF PALATO PHARYNGEAL FUNCTION IN THE CLEFT PALATE PATIENT AND HOW IT MAY BE EXPECTED TO VARY FROM THAT OF THE NON CLEFT SUBJECT 4HE PROCEDURE OF OBTURATOR MOULDING IS DESCRIBED AND THE FUNCTIONING OF PALATAL TRAINING APPLIANCES AND PALATAL SUPPORTS EXPLAINED #LINICAL 2ELEVANCE 4HE ARTICLE IS OF RELEVANCE FOR $0S PARTICULARLY THOSE WITH AN INTEREST IN PROSTHETIC DENTISTRY JUNIOR HOSPITAL STAFF AND 3P2S IN 2ESTORATIVE $ENTISTRY $ENT 5PDATE     ENERICALLY THE TERM OBTURATOR TENDS TO BE USED TOO WIDELY )T IS SIMPLY A DEVICE TO OBLITERATE A CAVITY !LTHOUGH MOST OBTURATORS ARE ATTACHED TO A DENTURE THE TWO COMPONENTS SHOULD BE DESIGNED AS SEPARATE ENTITIES THAT ARE TO BE UNITED THE OPERATOR IS THEN LESS LIKELY TO ADOPT METHODS THAT WILL PRODUCE A COMPROMISED OUTCOME ! SPEECH BULB IS THAT PART OF AN OBTURATOR THAT LIES IN THE NASO PHARYNX THE FORM

AND POSITION OF WHICH CONTROLS NASAL AIR FLOW AND BALANCES THE NASAL QUALITY OF THE VOICE 4HERE ARE ALSO SOME OTHER SIMPLE APPLIANCES THAT A SPEECH AND LANGUAGE THERAPIST OR A GERIATRICIAN MAY REQUEST THE DENTIST TO PROVIDE 4HESE ARE NOT OBTURATORS BUT ARE INCLUDED IN THIS ARTICLE AS THEIR USE RELATES TO SOFT PALATE FUNCTION AND REFLECTS THE DEVELOPING ROLE OF THE PROSTHODONTIST !DVANCES IN THE UNDERSTANDING * $ 7ALTER "$3 $$3 &$3 2#3%D %MERITUS 2EADER IN 0ROSTHETIC $ENTISTRY $EPARTMENT OF 0ROSTHODONTICS &LOOR  UYS 4OWER +4 $ENTAL )NSTITUTE ,ONDON 3% 24 AND ,OCUM #ONSULTANT 3TOKE -ANDEVILLE (OSPITAL -AY  OF THE MECHANISMS DISRUPTED BY CONGENITAL CLEFT PALATE AND IN THE PROVISION OF INTEGRATED CARE HAVE ALTERED THE ROLE OF THE PROSTHESIS IN TREATING THE CONDITION /VER  YEARS AGO ILLIES AND &RY REALIZED THAT CLEFT PALATE INVOLVED MORE THAN JUST THE FAILURE OF EMBRYOLOGICAL PROCESSES TO UNITE AND THAT THERE WAS ALSO A DEFICIENCY OF TISSUE 4HUS THE

FORCED APPOSITION OF THE REMAINING SEGMENTS FOLLOWED BY INAPPROPRIATE SURGERY WOULD PRODUCE A MAXILLARY ARCH DEFICIENT IN BOTH HORIZONTAL DIMENSIONS AND RESTRICT THE DOWNWARD AND FORWARD GROWTH OF THE MIDDLE THIRD OF THE FACE 4HE SOLUTION OFFERED BY ILLIES AND &RY WAS A COMBINATION OF SURGERY TO REPAIR THE SOFT PALATE AND THE PROVISION OF A PROSTHESIS TO CLOSE THE REMAINING HARD PALATE DEFECT 5P TO  YEARS AGO AND WHERE A CLEFT LIP WAS ALSO PRESENT IT WAS NOT UNUSUAL FOR THE LIP TO BE CLOSED BUT FOR THE HARD AND SOFT PALATES TO BE LEFT WITHOUT SURGICAL INTERVENTION AND FOR A PROSTHESIS TO BE MADE 7HETHER THIS WAS OWING TO PRE .(3 ECONOMIC CIRCUMSTANCES OR A REALIZATION THAT FURTHER SURGERY MIGHT HAVE GREATER LONG TERM DEBILITATING RATHER THAN BENEFICIAL POTENTIAL IS A MATTER OF CONJECTURE #ERTAINLY THE MORE ELDERLY CLEFT PATIENT WHO IS NOW EDENTULOUS AND WHO HAS NEVER UNDERGONE SURGERY IS FAR EASIER TO PROVIDE WITH A SATISFACTORY PROSTHESIS THAN ONE WHO UNDERWENT INAPPROPRIATE

SURGERY THAT DEFORMED THE MAXILLARY ARCH AND WHICH IN ADDITION MOST LIKELY BROKE DOWN PARTIALLY 4HE PROSTHODONTIST MAY BE CALLED UPON LESS FREQUENTLY FOR THE PROVISION OF TRADITIONAL PROSTHESES BUT THE DIVERSITY IN THE NATURE OF THE PROSTHESES AND APPLIANCES REQUESTED CONTINUES TO BROADEN !S REQUIREMENTS BECOME MORE INDIVIDUALIZED IT IS IMPORTANT TO WORK FROM AN UNDERSTANDING OF BASIC PRINCIPLES RATHER THAN ROTE STAGES OF CONSTRUCTION 0ALATO PHARYNGEAL FUNCTION 4HIS TERM RELATES TO THE CO ORDINATED MOVEMENT OF THE SOFT PALATE AND THE LATERAL AND POSTERIOR NASO PHARYNGEAL WALLS WHICH IS SO IMPORTANT IN SPEECH AND THE INITIATION OF SWALLOWING 4HE OLD NAME FOR THE SOFT PALATE WAS VELUM AND SO THE SYNONYM @VELO PHARYNGEAL FUNCTION MAY ALSO BE ENCOUNTERED ! CLEFT SOFT PALATE IS NOT SIMPLY A DIVIDED ANATOMICALLY @NORMAL PALATE MOST OF THE FIBRES THAT WOULD BE INSERTED INTO THE APONEUROSIS HAVE TO FIND ALTERNATIVE ECTOPIC INSERTIONS 4HUS PALATOPHARYNGEUS PALATOGLOSSUS AND LEVATOR

PALATI FIBRES ARE ATTACHED TO THE POSTERIOR ASPECT OF THE RESIDUAL HARD PALATE INSERTIONS THAT EXTEND FORWARD ALONG THE MARGINS OF THE CLEFT PALATAL SHELF TO FORM THE @CLEFT MUSCLE OF 6EAU AND ARE IMPORTANT IN $ENTAL5PDATE  0ROSTHETIC$ENTISTRY DESIGNING RETENTION INTO ANY CLEFT PROSTHESIS &IGURE   0ALATOPHARYNGEUS TENSOR AND LEVATOR PALATI FIBRES ALSO APPROACH THE BORDERS OF THE SOFT PALATE CLEFT RADIALLY AND WILL THUS WIDEN THE CLEFT ON CONTRACTION !S THREE OF THE FOUR MUSCLES MENTIONED THUS FAR HAVE AN ASSOCIATION WITH THE NASO PHARYNX AS WELL AS THE PALATE IT CAN BE SEEN THAT THE POTENTIAL FOR PALATO PHARYNGEAL DYSFUNCTION IN THE CLEFT PALATE SUBJECT IS CONSIDERABLE 4HE MOST WIDELY APPRECIATED FEATURE OF THE CLEFT PALATO PHARYNGEAL MECHANISM IS 0ASSAVANTS RIDGE FIRST DESCRIBED IN  0ASSAVANT BELIEVED THAT THIS RIDGE OR PAD TO BE SEEN STANDING OUT FROM THE LATERAL AND POSTERIOR PHARYNGEAL WALLS IN A CLEFT PALATE SUBJECT WAS PART OF THE NORMAL MECHANISM

REVEALED BY THE PRESENCE OF THE CLEFT &IGURE   (E ATTRIBUTED THE PHENOMENON TO THE CONTRACTION OF SUPERIOR CONSTRICTOR FIBRES WHICH TRIGGERED A LENGTHY DEBATE IN THE TH CENTURY ERMAN LITERATURE WITH THE &IGURE  !N OBTURATOR MOULDING SHOWING THE RETENTIVE GROOVE DEVELOPED BY THE @CLEFT MUSCLE OF 6EAU AROUND THE BORDER OF THE HARD PALATE CLEFT &IGURE  4HE POSITION OF 0ASSAVANTS RIDGE "" AND ITS RELATIONSHIP WITH THE %USTACHIAN TUBE ! IS DEMONSTRATED IN THIS PATIENT WITH AN EXTENSIVE SURGICAL DEFECT OF THE PALATE  $ENTAL5PDATE A B &IGURE  A 4HE POSTERIOR PHARYNGEAL WALL WITH THE PROMINENCE OF THE ANTERIOR TUBERCLE OF # ENCIRCLED B ! LATERAL SKULL RADIOGRAPH SHOWING THE OUTLINED OBTURATOR OPPOSITE THE ANTERIOR TUBERCLE OF # PROPONENTS OF PALATOPHARYNGEUS FIBRES AS THE CAUSAL MECHANISM -ODERN ELECTRO MYOGRAPHIC RESEARCH SUGGESTS THAT THE LATTER IS THE MORE LIKELY CASE 0ASSAVANT RIDGE FORMATION IS MANIFEST IN APPROXIMATELY  OF

UNREPAIRED CLEFT PALATE SUBJECTS AS AGAINST  OF NON CLEFT INDIVIDUALS 4HUS THE RIDGE IS PROBABLY RELATED TO A VARIATION IN THE PALATO PHARYNGEAL MECHANISM MORE COMMONLY FOUND IN CLEFT SUBJECTS BY VIRTUE OF THE DISRUPTED ANATOMY REATER DETAIL OF THE PALATO PHARYNGEAL MECHANISM IN CLEFT PALATE SUBJECTS AND AN INTRODUCTION TO THE RELEVANT RESEARCH MAY BE FOUND ELSEWHERE  BUT FROM THE PRACTICAL POINT OF VIEW IN FORMING A SUCCESSFUL SPEECH BULB IT IS NECESSARY TO HAVE AN APPRECIATION OF THE PATTERNS OF PALATO PHARYNGEAL ACTIVITY AND THE LEVEL AT WHICH THIS MUSCULAR ACTIVITY TAKES PLACE 4HERE ARE TWO PRINCIPAL PATTERNS OF ATTEMPTED PALATO PHARYNGEAL CLOSURE IDENTIFIED ENDOSCOPICALLY SO FAR AS PHARYNGEAL WALL MOVEMENT IS CONCERNED 7ITH BOTH THE SOFT PALATE IS DRAWN SUPERIORLY AND POSTERIORLY BUT IN ONE THE POSTERIOR AND LATERAL PHARYNGEAL WALLS FORM A 0ASSAVANT RIDGE WHILST IN THE SECOND THERE IS NARROWING OF THE PHARYNX DUE TO MEDIAL MOVEMENT OF THE LATERAL WALLS 7ITHIN THESE TWO

CLASSES THERE IS CONSIDERABLE VARIATION IN THE DETAIL OF THE MOVEMENT AND IN THE DEGREE OF ACTIVITY ESPECIALLY IN THE PRODUCTION OF SPEECH SOUNDS PHONEMES  )NDIVIDUALS WHO CAN DEMONSTRATE RIDGE FORMATION DONT NECESSARILY DO SO ON ALL ANTICIPATED OCCASIONS 4HE IMPORTANT FEATURE TO BEAR IN MIND WHEN MOULDING THE SPEECH BULB IS THAT MUSCULAR ACTIVITY DURING SWALLOWING IS RELATIVELY SLOW AND FORCEFUL COMPARED TO THE RAPID AND SLIGHT PHARYNGEAL MOVEMENTS ASSOCIATED WITH SPEECH 4HIS BEING THE CASE A SPEECH BULB MOULDED ENTIRELY BY SWALLOWING ACTIVITY WILL BE TOO SMALL TO BE EFFECTIVE &OR MAXIMUM EFFICIENCY THE BULB HAS TO BE OF THE SMALLEST BULK AND POSITIONED TO TAKE MAXIMUM ADVANTAGE OF NASO PHARYNGEAL WALL MOVEMENT 0ASSAVANTS RIDGE FORMS ON THE POSTERIOR PHARYNGEAL WALL ACROSS THE ANTERIOR TUBERCLE OF THE FIRST CERVICAL VERTEBRA # &IGURE  A AND B  ,ATERALLY THE RIDGE EXTENDS AROUND TO LIE JUST BELOW THE INFERIOR MARGIN OF THE OPENING OF THE %USTACHIAN TUBE

&IGURE  AND THIS IN TURN IS AT THE SAME HORIZONTAL LEVEL AS THE POSTERIOR MARGIN OF THE RESIDUAL HARD PALATE )N NON RIDGE ATTEMPTED CLOSURE PATTERNS THE LEVATOR PALATI MUSCLES ARE PRIME AGENTS IN THE MEDIAL MOVEMENT OF THE LATERAL PHARYNGEAL WALLS AND ENTER THE NASO PHARYNX ACROSS THE FLOOR OF THE %USTACHIAN TUBES ON EITHER SIDE 4HUS WHICHEVER PATTERN OF ATTEMPTED NASO PHARYNGEAL CLOSURE WE ARE DEALING WITH IT IS APPARENT THAT THE LEVEL AT WHICH THE PROSTHESIS HAS TO BE MOULDED IS REPRESENTED BY A PLANE DEFINED BY THE POSTERIOR MARGIN OF THE RESIDUAL HARD PALATE THE INFERIOR MARGINS OF THE %USTACHIAN TUBES AND THE ANTERIOR TUBERCLE OF THE FIRST CERVICAL VERTEBRA -AY  0ROSTHETIC$ENTISTRY /BTURATOR FORMING &IGURE  !N IMPRESSION INCLUDING GAUZE IMPREGNATED WITH SOFT PARAFFIN USED TO PREVENT ZINC OXIDE AND EUGENOL PASTE PASSING INTO THE NASAL PASSAGE THROUGH A RESIDUAL ANTERIOR PALATAL DEFECT &IGURE  ! WIRE LOOP SET INTO THE POSTERIOR MARGIN OF A DENTURE

BASE TO WHICH BLACK GUTTA PERCHA 0 WILL BE BONDED .OTE THE WINDINGS OF SOFT WIRE TO INCREASE THE ANCHORAGE FOR THE 0 !S MENTIONED IN THE INTRODUCTION THE OUTCOME FOR A COMBINED DENTURE OBTURATOR PROSTHESIS IS USUALLY MORE SUCCESSFUL IF THE TWO ELEMENTS ARE BUILT INDEPENDENTLY 4HIS MEANS THAT FOR LARGER DEFECTS THE TRAY NEED ONLY BE LOADED TO RECORD THE MARGINS OF THE DEFECT WHEN THE DENTURE IMPRESSION IS TAKEN n JUST SUFFICIENT DETAIL FOR THE PALATE TO BE CORRECTLY CONTOURED AND WIRE LOOPS TO BE ADDED TO RETAIN THE FUNCTIONAL IMPRESSION OF THE DEFECT WHEN THE DENTURE HAS BEEN COMPLETED 3MALLER DEFECTS NEED TO BE PACKED WITH A RIBBON OF GAUZE IMPREGNATED WITH SOFT PARAFFIN TO PREVENT IMPRESSION MATERIALS WITH LOW VISCOSITY PASSING THROUGH AND FORMING A MUSHROOM IN THE NASAL PASSAGES THAT CANNOT BE REMOVED WHEN SET &IGURE   4HE WIRE LOOPS TO RETAIN THE FUNCTIONAL MOULDING IN THE HARD PALATE REGION WILL BE OF AN APPROPRIATE HEIGHT TO AVOID INTERFERENCE WITH NASAL STRUCTURES

AND AS THESE MAY WELL NOT APPEAR IN THE ORIGINAL IMPRESSION THE TECHNICIAN WILL NEED WRITTEN GUIDANCE ON THE SIZE AND POSITIONING OF THE REQUIRED LOOP ! LOOP EXTENDING FROM THE POSTERIOR BORDER OF THE DENTURE BASE WILL BE NECESSARY TO SUPPORT A SPEECH BULB MOULDING &IGURE   4HE LATTER IS DIFFICULT TO ORIENTATE AND THE TENDENCY IS FOR IT TO BE MADE TO FOLLOW THE CONTOUR OF THE RESIDUAL SOFT PALATE &IGURE   4HIS IS WRONG AND THE BEST WAY TO GET ON THE RIGHT TRACK IS TO BANISH ANY CONCEPT THAT WHAT IS TO BE PRODUCED IS AN ARTIFICIAL SOFT PALATE THAT WILL BLEND INTO THE CLEFT AND REPLACE MISSING TISSUE 4HE OBTURATOR IS TO BE STRATEGICALLY PLACED AND MOULDED SO THAT THE RESIDUAL MUSCULATURE CAN CONTRACT DOWN TO IT PROVIDING A NASO PHARYNGEAL SEAL 4O RETURN TO THE FUNCTIONAL ANATOMY DETAILED ABOVE THE SUPPORTING LOOP NEEDS TO BE DIRECTED TOWARDS THE ANTERIOR TUBERCLE OF # 7HEN THE DENTURE BASE IS SEATED THE CORRECTLY POSITIONED LOOP AND SUBSEQUENTLY THE OBTURATOR WILL

APPEAR TO LIFT WELL INTO THE NASO PHARYNX ABOVE THE CLEFT SOFT PALATE &IGURE   -ATERIALS &IGURE  !N INCORRECTLY CONCEIVED OBTURATOR MOULDING FOLLOWING THE CONTOUR OF THE RESTING CLEFT SOFT PALATE  $ENTAL5PDATE "LACK GUTTA PERCHA 0 !SSOCIATED $ENTAL 0RODUCTS ,TD 3WINDON LACKS MANY PROPERTIES THAT WOULD APPEAR ON THE LIST OF &IGURE  ! CORRECTLY ORIENTATED OBTURATOR RESTING IN THE NASOPHARYNX IDEALS FOR A FUNCTIONAL IMPRESSION MATERIAL )T NEEDS TO BE INITIALLY SOFTENED IN WATER AT APPROXIMATELY ²# IT IS MALODOROUS PARTICULARLY WHEN TRIMMED WITH A HOT WAX KNIFE AND NOT A CLEAN MATERIAL WITH WHICH TO WORK 4HE PROPERTY THAT KEEPS IT IN USE AFTER A CENTURY AND A HALF S SERVICE TO DENTISTRY IS THAT EVEN THOUGH A RELATIVELY HIGH TEMPERATURE IS NEEDED FOR INITIAL FORMING IT WILL CONTINUE TO MOULD AT MOUTH TEMPERATURE FOR n HOURS AFTER PLACEMENT )T IS AN UNVULCANIZED RUBBER MATERIAL THAT WILL LOSE COHESION ON MOULDING ONCE THE SHELF LIFE HAS EXPIRED

/RANGE SOLVENT (ENRY 3CHEIN 5+ (OLDINGS ,TD 3OUTHALL IS A USEFUL MATERIAL WHEN CLEANING UP AFTER USING BLACK 0 -OULDING PROCEDURE Q 7IND FINE SOFT WIRE AROUND THE RETAINING LOOP TO ASSIST IN BONDING THE 0 &IGURE   Q 3OFTEN THE MATERIAL IN A WATER BATH AT ²# AND MOULD AN APPROPRIATE AMOUNT TO THE APPROXIMATE FORM REQUIRED REMEMBERING THAT CORRECTLY POSITIONED THE SPEECH BULB NEED BE NO MORE THAN n MM IN HEIGHT Q (EAT THE WIRE LOOP ON THE PROSTHESIS IN A FLAME AND SQUEEZE THE 0 ON TO IT Q 0LACE THE PROSTHESIS IN THE MOUTH WARNING THE PATIENT THAT THE MATERIAL WILL BE WARM AND INITIALLY SUPPORT THE 0 IN POSITION WITH THE INDEX FINGER 4HE PATIENT WILL PROBABLY WISH TO SWALLOW VOLUNTARILY IF NOT GIVE SOME WATER FOR SIPPING Q !FTER  MIN REMOVE THE PROSTHESIS FOR INSPECTION -OULDED SURFACES MAY BE DISTINGUISHED FROM DEFICIENT AREAS BY THE SMOOTH SURFACE &IGURE  AND THE FLOW OF EXCESS MATERIAL FROM THE -AY  0ROSTHETIC$ENTISTRY MOULDED ZONE !LTHOUGH MORE

0 CAN BE GRAFTED TO DEFICIENT AREAS USING A HOT WAX KNIFE RE SOFTENING AND RE DISTRIBUTING AVAILABLE MATERIAL WITH FINGER PRESSURE IS RECOMMENDED Q 5SE A HOT WAX KNIFE TO REMOVE EXCESS MATERIAL AFTER CHILLING THE MOULDING IN ICED WATER Q (AVING MADE ADJUSTMENTS AND RE SOFTENED THE 0 RETURN THE MOULDING TO THE MOUTH !S PHARYNGEAL SHAPE VARIES WITH HEAD POSITION AND MOVEMENT OF THE CERVICAL SPINE HAVE THE PATIENT TURN THE HEAD TO LEFT AND RIGHT AND DROP THE CHIN TO THE CHEST TO ENSURE THAT THERE IS NO OVERBUILDING &URTHER FORMING IS UNDERTAKEN BY ENGAGING THE PATIENT IN CONVERSATION 4HE PROCESS OF SOFTENING ADJUSTMENT AND RE MODELLING PROCEEDS UNTIL THE PATIENT IS CONFIDENT ENOUGH TO GO AWAY WEARING THE PROSTHESIS FOR CONTINUED FUNCTIONAL MOULDING AND THE OPERATOR IS CONFIDENT THAT NASAL ESCAPE SOUNDS HAVE BEEN ELIMINATED WITHOUT THE VOICE SOUNDING AS IF THE PATIENT HAS A COLD 4HIS BALANCE BETWEEN HYPO AND HYPERNASALITY CAN BE A DIFFICULT ONE TO ACHIEVE AND IF IT IS AT ALL

POSSIBLE TO WORK WITH A SPEECH AND LANGUAGE THERAPIST THE OPPORTUNITY SHOULD BE GRASPED %XPECT A SIGNIFICANT IMPROVEMENT RATHER THAN gNORMALg SPEECH QUALITY 4HE CHARACTERISTICS OF CLEFT PALATE SPEECH ARE NOT SIMPLY DUE TO THE LACK OF A PALATAL RESONATOR BUT TO THIS AND ALL THE SUBSTITUTION TRICKS OF MUSCULAR FUNCTION THAT THE PATIENT HAS LEARNED OVER THE YEARS IN AN ATTEMPT TO MODULATE NASAL AIRFLOW 4HEREIN LIES THE BIG DIFFERENCE IN WORKING WITH PEOPLE WHO HAVE CONGENITAL PALATAL DEFECTS AS OPPOSED TO THOSE WITH ACQUIRED DEFECTS 4HE PATIENT RETURNS WITH FEEDBACK IN A WEEK )F ADEQUATE TIME WAS SPENT WITH THE INITIAL MOULDING THERE SHOULDNgT BE ANY ADJUSTMENT OF A MAJOR NATURE REQUIRED &OR MINOR NIGGLES A COATING OF ONE OF THE MORE RAPIDLY GELLING TISSUE CONDITIONERS SUCH AS #OE #OMFORT # !MERICA )NC #HICAGO IS HELPFUL 4HIS IS APPLIED AND THE PATIENT AGAIN ENGAGED IN CONVERSATION 4HE CONDITIONER ACTS AS A PRESSURE INDICATOR BEING REMOVED FROM THE REMAINING OVERBUILT

REGIONS OF THE BULB WHILST ALSO FILLING MINOR DEFICIENCIES &IGURE   /N COMPLETION THE PROSTHESIS IS RETAINED FOR THE OBTURATOR TO BE PROCESSED IN ACRYLIC TO THE MOULDED FORM )SO #OMPOUND # #ORPORATION -AY  &IGURE  ! COATING OF TISSUE CONDITIONER OVER A GUTTA PERCHA CORE 4HE ORIGINAL MOULDING WAS SLIGHTLY SHORT IN LENGTH AND TOO FULL POSTERO LATERALLY MULTIPLE INTERVENTIONS AND THAT FURTHER SURGERY WOULD BE COUNTERnPRODUCTIVE Q 4HE SPEECH AND LANGUAGE THERAPIST WISHES TO UNDERTAKE A PROGRAMME OF OBTURATOR BULB REDUCTION AS AN AID TO ACTIVE THERAPY )N SUCH AN INSTANCE A LONG CONNECTOR IS REQUIRED OVER THE REPAIRED PALATE &IGURE   3OME PATIENTS MAY BE ABLE TO TOLERATE A FULL LENGTH SOFT PALATE IMPRESSION FOR THE CONNECTOR TO BE MADE BUT FOR MOST IT WILL BE NECESSARY TO SUPPLEMENT THE IMPRESSION WITH A MEASUREMENT USING A STRIP OF CARD SO THAT THE TECHNICIAN HAS FULL INFORMATION )F THERE IS SOME DOUBT AS TO THE LENGTH OR FORM REQUIRED IT IS POSSIBLE TO

EMBED PARALLEL COIL SPRINGS IN THE RETAINING ACRYLIC PLATE &IGURE   4HESE ARE WOUND AROUND A  MM WIRE STAPLE SO THAT A CONNECTOR OF SUCH WIRE MAY BE MOVED IN OR OUT OR EVEN REPLACED FOR ONE OF ALTERNATIVE FORM 0ALATAL TRAINING APPLIANCES AND SUPPORTS &IGURE  )SO COMPOUND USED TO RE ESTABLISH DENTURE DETAILS THAT HAD TO BE BLOCKED OUT IN THE MASTER IMPRESSION 4OKYO IS A USEFUL MATERIAL IN WHICH TO BUILD SMALL OBTURATORS FOR THOSE SURGICAL BREAKDOWN DEFICIENCIES THAT HAD TO BE PACKED OFF PRIOR TO IMPRESSION TAKING &IGURE   5NLIKE 0 AND TISSUE CONDITIONING MATERIAL FLOW AT MOUTH TEMPERATURE IS NOT SELF LIMITING AND SO THE PATIENT CANNOT LEAVE THE SURGERY WITH THE MATERIAL ON THE DENTURE 4HESE ITEMS HAVE A SUPERFICIAL RESEMBLANCE BUT FUNCTION IN DIFFERING WAYS 4HE LOOP OF THE TRAINING APPLIANCE 04! IS CONTOURED TO THE RESTING SOFT PALATE &IGURE   )T IS USED AS AN ADJUNCT TO SPEECH THERAPY IN SITUATIONS WHERE THERE IS HABITUAL LIFTING OF THE SOFT

PALATE BY THE TONGUE SO CALLED gTONGUE HUMPINGg 4HE 04! IS THOUGHT TO FUNCTION BY PLACING A BARRIER BETWEEN THE DORSUM OF THE TONGUE AND THE PALATE TO RE ENFORCE EXERCISES 4HE DEVICE HAS ALSO BEEN RECOMMENDED TO HELP PREVENT DROOLING WHEN A PATIENT HAS SUFFERED A STROKE BY CREATING AN AWARENESS OF THE PALATE AND STIMULATING SWALLOWING /BTURATORS TO SUPPLEMENT SHORT PALATAL REPAIRS 3MALL NASO PHARYNGEAL OBTURATORS MAY BE REQUESTED FOLLOWING SOFT PALATE REPAIR FOR A NUMBER OF REASONS Q !S A DIAGNOSTIC PROCEDURE TO TEST IF PHARYNGOPLASTY MIGHT SUBSEQUENTLY HELP WHEN INITIAL REPAIR HAS LEFT A SHORT SOFT PALATE Q 4HE PATIENT MAY DECLINE FURTHER SURGERY WHILE STILL ANXIOUS FOR SPEECH IMPROVEMENTS Q 4HE SURGEON FEELS THAT THE VASCULAR SUPPLY HAS BEEN COMPROMISED FOLLOWING PREVIOUS &IGURE  ! LONG CONNECTOR TRAVERSING A SHORTENED PALATAL REPAIR TO CARRY AN OBTURATOR WHICH ESTABLISHES PALATO PHARYNGEAL SEAL $ENTAL5PDATE  0ROSTHETIC$ENTISTRY &IGURE  4HE PARALLEL

COILS EMBEDDED IN THE RETAINING BASE ENABLE ADJUSTMENT OF THE OBTURATOR CONNECTOR POSITION AS NECESSARY A &IGURE  ! PALATAL TRAINING APPLIANCE 4HE LOOP LIES PASSIVELY AGAINST THE RESTING SOFT PALATE &IGURE  ! PALATAL SUPPORT APPLIANCE LIFTING THE SOFT PALATE 4HE WIRE LOOP IS PADDED WITH ACRYLIC TO PREVENT SOFT TISSUE TRAUMA IN THIS ARTICLE ARE NOT THE SOLE PROVINCE OF THE HOSPITAL PRACTITIONER AND OVER THE YEARS IT HAS BEEN POSSIBLE TO ASSIST AT A DISTANCE $0S IN THIS TYPE OF WORK 3OME FURTHER EXPERIENCE OF PROSTHETIC DENTISTRY IS NECESSARY PARTICULARLY FOR MORE RECENT GRADUATES BUT THERE IS REWARD IN THE TEAMWORK FREQUENTLY INVOLVED AND IN ACHIEVING SOMETHING A LITTLE OUT OF THE EVERYDAY RUN FOR THE PATIENT B 2EFERENCES &IGURE  A ! LATERAL SKULL RADIOGRAPH SHOWING THE INCREASED HORIZONTAL DIMENSION ACROSS THE NASO PHARNYX IN A PATIENT WITH A NEUROMUSCULARLY COMPROMISED SOFT PALATE B ! REPEAT VIEW WITH THE PALATAL SUPPORT APPLIANCE IN POSITION )N

CONTRAST THE LOOP OF THE PALATAL SUPPORT IS PADDED WITH HARD ACRYLIC AND IS USED AS A LIFT TO HOLD THE SOFT PALATE OF THE NEUROLOGICALLY COMPROMISED PATIENT HIGHER IN THE NASO PHARYNX &IGURES   A AND B  4HIS ASSISTS THE REDUCED PALATAL FUNCTION IN ATTEMPTED NASO PHARYNGEAL CLOSURE HELPING SWALLOWING AND REDUCING HYPERNASALITY IN SPEECH 4HE THEORY OF THE LIFT APPLIANCE IS STRAIGHTFORWARD BUT THE DOWNWARD LOADING FORCE OF A NEUROMUSCULARLY INCOMPETENT SOFT PALATE HAS TO BE EXPERIENCED TO BE APPRECIATED AND DEVELOPING SUFFICIENT RETENTION FOR THE PLATE CARRYING THE DEVICE CAN REPRESENT A REAL CHALLENGE #ONCLUSION 4HE TYPES OF APPLIANCE DESCRIBED  7ALTER *$ (ALE 6 ! STUDY OF THE LONG TERM RESULTS ACHIEVED BY THE ILLIES &RY PROCEDURE "R * 0LAST 3URG   n  7ALTER *$ 4HE DESIGN OF PROSTHESES USED IN THE TREATMENT OF VELOPHARYNGEAL INSUFFICIENCY "R $ENT *   n  -ULDER *7 6ELOPHARYNGEAL FUNCTION AND SPEECH $OCTORAL

DISSERTATION 5NIVERSITY OF RÚNINGEN   7ALTER *$ 0ALATOPHARYNGEAL ACTIVITY IN CLEFT PALATE SUBJECTS * 0ROSTHET $ENT   n  3ELLEY 7 /RAL AND PHARYNGEAL REHABILITATION )N 3TROKE #ARE !N )NTERDISCIPLINARY !PPROACH ,UBBOCK ED ,ONDON &ABER  &ABER  PPn !BSTRACTS (/7 $/ 9/5 !33%33 7)3$/- 4%%4( 4HE 0RESURGICAL 7ORKUP BEFORE 4HIRD -OLAR 3URGERY (OW MUCH IS ENOUGH ( "ETTER ) !BRAMOVITZ " 3CHLOMI ! +AHN ET AL *OURNAL OF /RAL AND -AXILLOFACIAL 3URGERY   n 4HE PURPOSE OF THIS PAPER IS TO ASSESS THE NEED FOR #4 SCANS IN THE SURGICAL WORKUP FOR WISDOM TEETH REMOVAL 0REVIOUS STUDIES HAVE SHOWN THAT UP TO  OF PATIENTS CAN HAVE A SENSORY DISTURBANCE  $ENTAL5PDATE OF THE INFERIOR ALVEOLAR NERVE FOLLOWING WISDOM TEETH REMOVAL 7HAT THIS PAPER ASKS IS WHETHER PLAIN RADIOGRAPHY IS ENOUGH OR SHOULD WE BE ROUTINELY #4 SCANNING OUR PATIENTS 3IXTY FIVE PATIENTS HAD #4 SCANNING TO ASSESS THE RELATIONSHIP OF THE APICES

TO THE MANDIBULAR CANAL AND THERE WAS A CONTROL GROUP OF  PATIENTS WHO HAD PLAIN RADIOGRAPHY &ORTUNATELY THE RESULTS SHOWED THAT THE #4 SCAN DID NOT CHANGE THE CLINICAL OUTCOME AND THE AUTHORS FELT THAT THE ROUTINE USE OF #4 SCANNING IN WISDOM TOOTH ASSESSMENT COULD NOT BE JUSTIFIED AS ONLY  ACCURACY OF THE RELATIONSHIP BETWEEN APICES AND CANAL WAS ACHIEVABLE BY THE SCAN )T IS GOOD TO SEE THAT PLAIN RADIOGRAPHY IS STILL THE INVESTIGATION OF CHOICE AS THE EXPENSE OF ROUTINELY #4 SCANNING OUR PATIENTS WOULD BE EXORBITANT !DRIAN #URTIS 3TOKE -ANDEVILLE (OSPITAL !YLESBURY -AY