1. 20. Restoration of Soft Palate Defects
John Beumer III, DDS, MS
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2. Etiology of Soft Palate Defects
v Resection of tumors
of the soft palate
v Clefts
v Chemo-radiation

3. Prosthetic Restoration of Soft
Palate Defects

4. 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.

5. RPD Frameworks
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.

6. 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.

7. Border Molding the Obturator
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

8. Border Molding the Obturator
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.

9. Border Molding the Obturator
The obturator must enable the patient to develop sufficient oral
pressure for the oral components of speech and resonance.
However, balance between oral and nasal resonance
must be achieved if normal speech is to be achieved.
Adequate nasal airway is necessary for nasal phonemes,

10. Border Molding the Obturator
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.

11. Border Molding the Obturator
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.

12. Compound cutback
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.

13. Corrected Impression
Border molding is
completed by having the
A 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
B

14. Completed impressions
Characteristics of a good impression
10-15 mm

15. Soft Palate Obturators
Completed impressions
Characteristics of a good impression
10-15 mm
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

16. Correcting impressions
Note the exposure of compound
in this impression. This area of
the impression is overextended
and must be remolded.
This region was cut back
and remolded with
Completed impression
thermoplastic wax.

17. The impression is boxed in the usual manner

18. Processing
Altered cast The obturator portion of
the cast is filled with wax
before flasking.

19. Processing
Clear heat cure acrylic resin is preferred.

20. Delivery
Extensions are verified with:
a) Pressure indicating paste
b) Disclosing wax

21. Soft Palate Obturators
Completed Obturator
• Oral side is concave
• Nasal side is convex
• All surfaces are highly
polished

22. Soft Palate Obturators
Delivery
At rest, there is space around During contraction the
the obturator. This allows for obturator comes in contact
the production of nasal sounds with the velopharyngeal
and permits nasal breathing. musculature and enables the
production of normal oral
sounds and swallowing.

23. 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.

24. Obturator reduction and
compensatory movement
1988 1995
l 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.

25. The oral surfaces of the obturator
prosthesis must be concave
This obturator prosthesis
was made for a patient
with a partially repaired
cleft lip and palate. Note
the concave oral surface.
Flat or convex oral
surfaces may cause
gagging or difficulty
during swallowing

26. Oral surface must be concave
The oral surface of the initial prosthesis was convex and activated the
gag reflex. The remade prosthesis eliminated this problem.
Convex surfaces precipitate gagging and may
interfere with the oral phase of swallowing.

27. Implant retained soft palate obturators
In edentulous patients, the effectiveness of an obturator
restoring V-P function is dramatically improved.
Why?
Retention
Precision of placement of the obturator
prosthesis

28. Patient is status post partial palatectomy. In addition, about two thirds of
the soft palate had been removed. The defect was not lined with skin and
provided no retentive undercuts. Note the torus tubarius (arrow).
A lateral cephalometric x-
ray indicated sufficient
bone for placement of
several implants in the
premaxilla. Only four of
the six were uncovered.
Denture adhesive was used to
retain the complete denture and
obturator

29. Four implants of the six were
uncovered and a bar
fabricated. The maxillary
molar was retained and used
for posterior support. Note
that most of the palatal shelf
has been retained. An implant
support tissue bar was
An impression tray with
retentive clips is fabricated in
preparation for an altered cast
impression of the defect.

30. The retention provided by the bar
enables the making of accurate
altered cast impressions. The
velopharyngeal area was border
molded with dental compound and
corrected with a thermoplastic wax.

31. The completed altered cast impression

32. v Face bow and centric records were made and
transferred to the articulator is the usual fashion.
vThe completed complete denture and obturator
vThe completed prosthesis in position. It made a dramatic
impact on the patient’s psychologic outlook. Retention was
excellent and speech, mastication, and swallowing were
restored.

33. Tissue bar designs – Four Implants
Implant assisted designs are recommended to
minimize the risk of implant overload.

34. UCLA Design
v Anterior – Posterior spread should
be maximized
v The anterior two implants should be
12-20 mm apart
A-P spread
ERA attachments are positioned adjacent to the distal implants.
This attachment permits the overlay prosthesis to be compressed
into the mucoperiosteum in the extension areas still present. As a
result, the denture bearing tissues absorb the occlusal forces.

35. Soft palate defects secondary to
tumor resections
Alterations at surgical resection to
enhance the prosthetic prognosis
v Ifthe resection extend posteriorly to include
the middle third of the soft palate (the area
occupied by the levator), the resection should
be extended to include the remaining
posterior third.
v The residual portion of soft palate should not
be tethered to a flap. Otherwise, access to
the residual velopharyngeal musculature may
be impaired.

36. a
b
a: Squamous carcinoma of tonsil. b:
Low grade mucoepidermoid of the soft
palate. In both patients significant
portions of soft palate were removed.

37. Alterations at surgery
The residual soft palate is tethered to the lateral
pharyngeal wall. The prognosis for the obturator
prosthesis is guarded because:
vThe movement of the residual V-P mechanism is
impaired.
vAccess to the defect is difficult.

38. Alterations at surgery to improve
the prosthetic prognosis
Examples of inappropriate attempts to
reconstruct the soft palate

39. Surgical modifications (cont’d)
Soft palate resection
The posterior one third of the soft palate was retained in both
these patients. This strip of mucosa is nonfunctional and prevents
proper extension of an obturator prosthesis into the residual
velopharyngeal mechanism that is still functional.
Result: Speech will be hypernasal.

40. Alterations at surgery to improve the
prosthetic prognosis
a b
Key factor – Access to the residual V-P musculature
a: Soft palate defect. Lateral wall of pharynx has been
resurfaced with lateral forearm flap. b: Obturator prosthesis
extends around and behind the residual soft palate to engage
still functional right pharyngeal wall and residual portion of
soft palate. V-P function was restored to normal

41. Ideal Soft Palate Defects
The soft palate is not tethered to a flap or the lateral
pharyngeal wall. Therefore:
Its movement will not be impeded during V-P function.
Access to the area of V-P movement is not impaired
Result: Normal speech and swallowing can be predictably restored.

42. Tonsillar defects that extend onto
the soft palate
Use of free vascularized flaps
Should the flap be tied to the residual soft palate?
v If more than half of the levator palatini is resected (ie, if the
resection crosses the midline) the flap should not be
connected to the residual portion of the soft palate. Such a
defect is best restored with an obturator prosthesis
v If less than the above is resected the flap can be connected
to the soft palate with a reasonable expectation that the
residual levator will be able to pull the flap into such a
position so as to achieve velopharyngeal closure.

43. Surgical reconstruction of the soft palate
This resection falls short of the uvula. The soft palate defect
was effectively reconstructed with a free flap.
If the resection extends across the midline the defect should
be restored with an obturator prosthesis.

44. This resection extended beyond midline. The flap used to
reconstruct the defect was tied to the residual soft palate., The
mass of the residual levator veli palatini is insufficient to
elevate the soft palate superiorly and posteriorly to
achieve velopharyngeal closure.
Effective obturation is difficult because of limited
access to the residual velopharyngeal complex.

45. 1 week postoperative
Surgical Modifications
v This flap was not tied
to the soft palate.
Easy access to the
velopharyngeal defect
makes obturation
4 months postoperative easy and predictable.

46. Surgical Modifications
vAll of the below represent ill
conceived attempts to
reconstruct the soft palate.
Result: Patients with
V-P insufficiency but
which cannot be effectively
obturated prosthetically.

47. Myocutaneous flaps
A PMC flap was used to
restore this tonsillar defect.
The soft palate was not
tethered to the flap.
Therefore access to the
residual V-P area is
ensured and V-P
function is easily
restored with an
obturator (arrow).

48. Surgical Obturators - Soft Palate Tumors
The cast is altered. The
surgeon plans to remove
the entire soft palate and
the right posterior alveolar
ridge and hard palate.
Adenoid cystic carcinoma
of the junction of hard
and soft palate

49. Surgical Obturators - Soft Palate Tumors
Note the reduction
in the soft palate
area (arrows).
The cast should be
adjusted in order to
develop the soft palate
extension along the
palatal plane.

50. Surgical Obturators Soft Palate Tumors
Following resection the
obturator portion is
relined with a temporary
denture reliner.

51. Delayed Surgical Obturation
v Recommended for lateral defects of
the soft palate
v Impressions are made after surgery
v At delivery the obturator extension

52. Delayed surgical obturation
a c
b
a: Soft palate defect secondary
to surgical resection. b:
Obturator extension has been
developed with a temporary
denture reliner that can
adjusted and polished. This
prosthesis can serve as interim
obturator. c: Prosthesis in
position.

53. Interim obturators.
The obturator extension is border molded with a
temporary denture reliner (Rim Seal). We favor Rim
Seal because it is quite moldable and can be polished.

54. Posterior Border Defects
In these defects the obturator extends up and
behind the residual soft palate.
Velopharyngeal closure is obtained by engaging
the remnants of the levator veli palatini in lateral
pharyngeal walls with the obturator.

55. RPD framework. Note that
the retention loop for the
obturator does not extend
into the defect. This is a
mistake commonly made
by dental labs. It can be
corrected following the
molding of the obturator
extension.
v Initial molding is
made with modeling
compound.

56. Border molding is complete
vThe initial molding is
accomplished with modeling
compound.
vThe compound is cut back 1-2
mm before addition of the
thermoplastic wax.

57. v The pattern is refined with a thermoplastic wax
(Iowa wax)
v The excess (arrows) wax trimmed away and the
patient is asked to wear the pattern for another 90
minutes to complete the impression.

58. The completed pattern is boxed in the

59. A new retention loop that extends into the

60. Completed
prosthesis
• It is delivered in
the usual
fashion using
pressure
indicating paste
(PIP) and
disclosing wax.

61. Completed prosthesis in position
v During V-P closure the lateral extension of the obturator
engages the lateral pharyngeal walls.
v At rest there is space between the obturator and the lateral
walls permitting nasal breathing and normal nasal resonance
The oral side of the
obturator is concave.
Obturators that are
too low cause the
patient to gag during
swallowing.

62. Lateral border defects
a b c d e
f g h
a: RPD framework. b, c, d, e and f: Interim
obturator seated on master cast and with silicone
putty and used to make initial obturator extension.
g and h: Final border molding of obturator
prosthesis. i: Completed prosthesis in position

63. Prognosis for normal V-P function with and
obturator prosthesis
Access to the defect – Can you engage
the active V-P areas? If you cannot
engage these areas the prognosis is poor
Residual movement of the residual
velopharyngeal mechanism. In the
absence of movement, speech cannot be
restored to normal.

64. What is the prognosis for V-P
function in this patient?
Excellent:
v Good access to the active V-P areas
v Excellent movement of the V-P complex
v Excellent retention available for the prosthesis

65. What is the prognosis for V-P
Excellent:
Good access
Excellent movement of the V-P complex
Excellent retention for the prosthesis

66. Prognosis for V-P function?
The patient is S/P resection of the right tonsil and soft
palate for a squamous carcinoma. The patient received
a course of postoperative radiation therapy.
The tongue was
not affected by the
resection. The
premaxilla was not
in the field of
radiation.

67. Prognosis for V-P function?
Good
Excellent movement of the left pharyngeal wall
Good access to the left lateral wall of the defect
Retention suboptimal for the prosthesis (the patient was irradiated and the
posterior palatal seal area had been altered by the resection).
Retention can be significantly improved with the use of
osseointegrated implants changing the prognosis to excellent.

68. Prognosis for normal speech?
Patient is S/P resection of the entire soft palate and
the posterior portion of the hard palate for a large
pleomorphic adenoma
Clinical exam
Little or no movement of
the residual
velopharyngeal
mechanism
Little means of retention
Little support and stability

69. Prognosis for normal speech
Challenge:
a) Develop a secure means of retention so as to maximize the
efficiency of the obturator
b) Restore speech to normal
Solution:
a) Placement of
osseointegrated implants in
the premaxilla
b) Reduce the lateral extension
of the obturator so as to
allow for nasal airway and
reasonable nasal resonance
without making the speech
excessively hypernasal

70. Prognosis for normal speech
Will the speech be restored to normal in this patient
with the obturator prosthesis?
No!!! Why not?
In a patient with little or no
movement of the residual
velopharyngeal mechanism and
a properly extended obturator,
speech will be slightly
hypernasal during the
production of oral sounds and
slightly hyponasal during the
production of nasal sounds.

71. Prognosis for Normal Speech
Patient is S/P resection of the lateral third of the soft palate
for a recurrent squamous cell carcinoma. She has
received 6600 cGy via opposed lateral facial fields.
Clinical exam:
a) Residual soft palate and the
left pharyngeal wall moves
well
b) Retention will be
compromised because
patient is edentulous
c) Stability and support are
adequate for the maxillary
complete denture

72. Prognosis for Normal Speech
Challenge:
a) Develop a secure means of retention for the
complete denture and obturator
b) Restore speech to normal
Solution:
a) Place osseointegrated implants
into the premaxilla (this area
was out of the field of radiation).
b) Develop the contours and
extensions of the obturator in a
normal fashion.

73. Prognosis for Normal Speech
l Will the patient’s speech be restored to normal with
the complete denture and obturator prosthesis?
Why in this patient and not in the previous
.
Yes!!
patient?
a) Excellent movement of
the residual V-P
mechanism
b) Excellent access to the
area of residual V-P
mechanism

74. Prognosis for V-P function
Patient is S/P resection of a squamous carcinoma of
the tonsil extending onto the soft palate. The right base
of the tongue was included in the resection along with
hypoglossal and lingual nerves on that side.

75. Prognosis for V-P function
Excellent:
•Fair access to the left lateral wall of the defect
•Excellent movement of the left lateral pharyngeal wall
•Good retention for the prosthesis (post-palatal seal area was
not affected by the surgical resection and the patient was not
irradiated postoperatively).

76. Prognosis for V-P function
The quality of speech articulation, however was only fair
because of the loss of the base of the tongue and the loss
of motor and sensory innervation of tongue on the resected
side.

77. Prognosis for V-P function
A small tongue flap was used to resurface the tonsillar area.
The mobility of the tongue was only slightly affected. The soft
palate elevates but does not achieve closure. Access to the
defect is difficult. Sufficient dentition is available for retention.

78. Prognosis for V-P function
Although access is limited appropriate contours of the
obturator can be developed that will enable the patient to
achieve velopharyngeal closure. Prognosis is good.

79. a
Junction hard palate – soft palate defects
a b c
a: Schematic drawing of movement of
anterior margin of soft palate during
palatal elevation. b: Patient with defect
of hard and soft palates, with soft
palate at rest. c: Same patient during
elevation. Contact should be
maintained between soft palate and
obturator during elevation to minimize
leakage.

80. Junction hard palate – soft palate defects
To maintain seal, an
extension (arrow) must
be developed which
engages the nasal side
of the soft palate when
the soft palate elevates.

81. Junction hard-soft palate defects
The soft palate posterior to the defect did not elevate sufficiently
to achieve V-P closure and so the obturator was extended
through the defect to engage the lateral pharyngeal wall.
Fortunately, the defect was wide enough to permit this
extension.

82. Junction hard-soft palate defects
Speech was restored to normal. Note how the top
of the obturator extension has been reduced as
compared to the molded pattern.

83. Velopharyngeal insufficiency and
incompetence secondary to chemoRT
Secondary to muscle wasting and fibrosis
The soft palate is shortened and does not elevate sufficiently
well to achieve velopharyngeal closure.
v Treatment options
v Soft palate obturator
v Palatal lift prosthesis

84. Soft palate dysfunction secondary to chemoRT
v This patient’s soft palate was foreshortened and heavily scarred secondary
to chemoradiation. Elevation of the soft palate was minimal and it did not
achieve closure against the posterior pharyngeal wall
v Since the patient was edentulous an attempt was made to obturate the
defect as opposed to fabricating a palatal lift.
v The obturator prosthesis bridges the soft palate and engages the
velopharyngeal deficit.
v The extension crossing the soft palate slightly elevates the palate before
entering the defect area.

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