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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 4  |  Issue : 2  |  Page : 164-167

Prosthodontic rehabilitation of velopharyngeal insufficiency with definitive obturator


1 Department of Maxillofacial Prosthodontics and Implantology, Peoples Dental Academy, Bhopal, Madhya Pradesh, India
2 Department of Maxillofacial Prosthodontics and Implantology, Peoples College of Dental Sciences and Research Centre, Bhopal, Madhya Pradesh, India

Date of Web Publication11-Aug-2017

Correspondence Address:
Sunil Kumar Mishra
Department of Maxillofacial Prosthodontics and Implantology, Peoples College of Dental Sciences and Research Centre, Bhopal, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_17_17

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  Abstract 


Velopharyngeal insufficiency resulted from the defect in soft palate due to acquired or congenital reasons, which cause incomplete closure of the palatopharyngeal sphincter. The individual with such defect faces problem in eating, speaking, breathing as well as faces psychological trauma in society. This article presents a case report of a patient with congenital velopharyngeal defect. A definitive cast partial prosthesis with a hollow acrylic bulb obturator was planned for the patient. This case report presents a modified impression technique for making definitive obturator along with cast partial denture for better retention and stabilization of the prosthesis. The prosthesis increases the acceptance as it prevents the hypernasality; improve mastication and speech of the patient.

Keywords: Cast partial denture, hollow obturator, speech aid prosthesis, velopharyngeal defect


How to cite this article:
Hazari P, Mishra SK, Khare A. Prosthodontic rehabilitation of velopharyngeal insufficiency with definitive obturator. J Cleft Lip Palate Craniofac Anomal 2017;4:164-7

How to cite this URL:
Hazari P, Mishra SK, Khare A. Prosthodontic rehabilitation of velopharyngeal insufficiency with definitive obturator. J Cleft Lip Palate Craniofac Anomal [serial online] 2017 [cited 2021 Oct 16];4:164-7. Available from: https://www.jclpca.org/text.asp?2017/4/2/164/212832




  Introduction Top


The hard and soft palatal defects are caused due to acquired, congenital, or developmental reasons. Incomplete embryonic development results in congenital defect of palate. Surgical resection of neoplastic disease leads to acquired defect of the palate.[1]

Cleft of the soft palate causes velopharyngeal insufficiency, a functional inability of the soft palate to form a seal with the posterior and/or lateral pharyngeal walls.[2] Unless the importance of soft palate in producing speech and forming valving action is not recognized, a socially acceptable speech cannot be obtained. In unoperated cases, a better treatment planning would eliminate many of these difficulties.[3]

Ideal age for repair of the cleft palate is 9–18 months for better speech of the child. In older children and adults, there is lesser degree of speech improvement with the repair. The main goal of surgery in adults is to prevent nasal regurgitation. Contraindications for surgical repair in cleft palate are hemoglobin <10 g/dl, untreated malaria, malnutrition, central neurologic disorder, upper respiratory infections, Pierre Robin syndrome, advanced age, valvular heart disease, etc.[4]

In patients where surgery is contraindicated, a maxillofacial prosthodontist can reestablish the palatopharyngeal integrity with the help of obturators to improve mastication, speech, deglutition, and aesthetics. Gravitational forces in the maxilla cause loss of retention of prosthesis.[2],[5],[6] This case report presents a patient treated for congenital velopharyngeal defect with a definitive cast partial prosthesis with a hollow acrylic bulb obturator for better retention and stabilization of the prosthesis.


  Case Report Top


A 32-year-old male patient reported to Maxillofacial Prosthodontics Department with chief complaint of difficulty in speech and defect in the palate. On intraoral examination, an isolated cleft palate extending posteriorly, involving the entire soft palate was seen [Figure 1]. The defect was present since birth. The patient was not willing for surgical correction to improve the nasal regurgitation. Speech improvement following surgery could not be guaranteed. The speech therapist suggested prosthesis to improve intraoral air pressure and speech intelligibility followed by speech therapy to eliminate compensatory articulation productions. A definitive cast partial prosthesis with a hollow acrylic bulb obturator was planned followed by speech therapy.
Figure 1: Intraoral view showing the palatal defect

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Preliminary impression was made in a stock tray with alginate (Zelgan, Dentsply, USA) extended posteriorly up to soft palate with the help of impression compound (DPI, Mumbai, India) [Figure 2]. The patient was instructed to move his head side to side in circular manner and extend as far forward as possible and to speak and swallow, so that remaining palatopharyngeal musculature is activated and would mould the impression. The diagnostic cast obtained was surveyed for designing of the framework. Special tray was fabricated with pharyngeal extension, and with low fusing compound and tissue conditioners; pharyngeal impression was recorded [Figure 3]. The above-mentioned movements were repeated several times until the patient was able to tolerate the tissue conditioner obturator and drink water and breathe comfortably. Mouth preparation was done, and special tray was modified and pharyngeal impression obtained earlier was removed and attached to another special tray for making dentulous impression [Figure 4]. The final impression was made with polyvinyl siloxane elastomers (Reprosil, Dentsply, USA) [Figure 5] and poured. The master cast obtained was surveyed, blocked out and duplicated with agar to obtain a refractory cast. The wax pattern was made over the refractory cast and casting procedure was done to obtain cast partial framework. Try-in of framework was done in the patient's mouth [Figure 6] followed by wax up on the cast for the obturator part. Flasking and dewaxing were done and mold was packed with heat cured resin (DPI, Mumbai, India) and cured. Lost salt technique was used to make the obturator hollow. The insertion of final prosthesis was done [Figure 7] and checked for speech, comfort, and retention. Sore spots present on tissues were checked with pressure indicating paste and relieved. The patient had good palatopharyngeal function with prosthesis as he swallowed water through a straw. A change in pronunciation of velar sounds with prosthesis was observed. Postinsertion instruction was given and the patient was referred to speech therapist. A noticeable improvement in the speech was found with prosthesis in situ. On a seven-point scale to access the speech intelligibility,[2] a pretreatment score 5 (isolated words understood) changed to score 4 (repetition) after 24 hand then to score 3 (occasional repetition of words required) after 1 month and finally to score 2 2 (listeners attention needed) after 6 months.
Figure 2: Primary impression of the defect

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Figure 3: Special tray

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Figure 4: Modified special tray

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Figure 5: Final impression of the defect

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Figure 6: Try in of the framework

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Figure 7: Final prosthesis in patient's oral cavity

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  Discussion Top


Velopharyneal sphincter is a mscular valve formed by soft palate, lateral walls and posterior pharyngeal wall which is responsible for controlling the passage of air during phonation. Lack of tissues causes impaired movement of this valve and leads to velopharyngeal insufficiency. Patients with velopharyngeal defect have oronasal communication, difficulty in speech, and deglutition. Different treatments are available, surgery can approximate the defect and other option is rehabilitation with obturator prosthesis along with speech therapy.[7],[8]

In this case, the definite closed hollow obturator was given to keep the weight to its minimum. Open-hollow obturators are commonly used than closed-hollow obturators, but its fabrication is difficult and there is accumulation of fluids at the internal surface of the bulb.[9]

The major concern with the temporary obturators is retention which was eliminated in this case by giving obturator retained with cast partial denture.[10] The acrylic obturator was given, as silicone obturator gets deformed during mastication and is prone to fungal infections.[11] Mazaheri and Millard found that voice quality was best when the speech bulb was positioned on the posterior pharyngeal and lateral pharyngeal wall activity.[12] In this case also the loop extended from the prosthesis posteriorly and laterally for the better palatal support to improve the function, swallowing and to reduce the hypernasality of speech.[13]


  Conclusion Top


The definitive obturator prosthesis as reported by the patient is very retentive compared to his previous temporary prosthesis. The modified impression technique provides a marked improvement in stability of the prosthesis. The hypernasality of speech was corrected up to patient's satisfaction with the help of speech therapist. The increased resistance of prosthesis improves the psychology of the patient and promises the success of the prosthesis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Yenisey M, Cengiz S, Sarikaya I. Prosthetic treatment of congenital hard and soft palate defects. Cleft Palate Craniofac J 2012;49:618-21.  Back to cited text no. 1
    
2.
Varghese K. Prosthetic rehabilitation of a congenital soft palate defect. J Indian Prosthodont Soc 2014;14 Suppl 1:181-6.  Back to cited text no. 2
    
3.
Mazaheri M. Indications and contraindications for prosthetic speech appliances in cleft palate. Plast Reconstr Surg Transplant Bull 1962;30:663-9.  Back to cited text no. 3
    
4.
Sitzman TJ, Marcus JR. Cleft lip and palate: Current surgical management. Clin Plast Surg 2014;41:xi-xii.  Back to cited text no. 4
    
5.
Neha D, Sunil D, Khetan J. Prosthetic rehabilitation of an edentulous Veau's class II – A case report. Bangladesh J Med Sci 2013;12:435-8.  Back to cited text no. 5
    
6.
Bhat V. A close-up on obturators using magnets: Part II. J Indian Prosthodont Soc 2006;6:148-53.  Back to cited text no. 6
  [Full text]  
7.
Banerjee S, Kumar S, Chakraborty N, Gupta T, Banerjee A. Prosthodontic rehabilitation of velopharyngeal disorders-A case series. J Indian Prosthodont Soc 2013;13:352-7.  Back to cited text no. 7
    
8.
Gonzalez JB, Aronson AE. Palatal lift prosthesis for treatment of anatomic and neurologic palatopharyngeal insufficiency. Cleft Palate J 1970;7:91-103.  Back to cited text no. 8
    
9.
Iramaneerat W, Seki F, Watanabe A, Mukohyama H, Iwasaki Y, Akiyoshi K, et al. Innovative gas injection technique for closed-hollow obturator. Int J Prosthodont 2004;17:345-9.  Back to cited text no. 9
    
10.
Kahlon SS, Kahlon M, Gupta S, Dhingra PS. The soft palate friendly speech bulb for velopharyngeal insufficiency. J Clin Diagn Res 2016;10:ZD01-2.  Back to cited text no. 10
    
11.
Wang RR. Sectional prosthesis for total maxillectomy patients: A clinical report. J Prosthet Dent 1997;78:241-4.  Back to cited text no. 11
    
12.
Mazaheri M, Millard RT. Changes in nasal resonance related to differences in location and dimension of speech bulbs. Cleft Palate J 1965;31:167-75.  Back to cited text no. 12
    
13.
Walter JD. Obturators for cleft palate and other speech appliances. Dent Update 2005;32:217-8, 220-2.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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