Palatal lift prosthesis/ orthodontic straight wire technique
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Palatal lift prosthesis/ orthodontic straight wire technique
- 2. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
- 3. Contents • Introduction • Anatomy of soft palate • Function of soft palate • Defect of soft palate • Classification of Palatopharyngeal deficiencies • Speech • Physiology and anatomy of Palatopharyngeal closure • Speech problem • Diagnostic assessment www.indiandentalacademy.com
- 5. • Clinical evaluation • Achieving acceptable speech • Prosthodontic procedure • Palatal lift prosthesis • Palatal lift prosthesis in complete denture • Speech bulb prosthesis • Results of palatal lift prosthesis and combination prosthesis • Speech therapy • Conclusion www.indiandentalacademy.com
- 6. INTRODUCTION • The palatal lift prosthesis is used to improve soft palate dysfunction. • It places the soft palate in contact with the lateral and posterior pharyngeal walls to prevent nasal air escape during speech • Prevents regurgitation of food and liquid during swallowing. www.indiandentalacademy.com
- 7. ANATOMY OF SOFT PALATE www.indiandentalacademy.com
- 8. MUSCLE OF SOFT PALATE www.indiandentalacademy.com
- 9. NERVE SUPPLY OF SOFT PALATE www.indiandentalacademy.com
- 10. FUNCTION OF SOFT PALATE www.indiandentalacademy.com
- 11. CLASSIFICATION OF SOFT PALATE DEFECT JPD 1978.vol 39 page 539www.indiandentalacademy.com
- 12. Surgically unrepaired JPD 1978 vol 39 .539www.indiandentalacademy.com
- 13. • Surgically repaired soft palate www.indiandentalacademy.com
- 14. • Soft palate paralysis www.indiandentalacademy.com
- 15. • Palatopharyngeal deficiencies may be classified on the basis of physiology and structural integrity www.indiandentalacademy.com
- 16. Palatal insufficiency Inadequate length of the soft palate to affect palatopharyngeal closure www.indiandentalacademy.com
- 17. Palatal incompetence adequate length of soft palate www.indiandentalacademy.com
- 18. Speech Speech is a learned process that makes use of anatomic structures designed primarily for respiration and deglutition. (Huntington1968) www.indiandentalacademy.com
- 19. Components of speech (Kantner and Westwww.indiandentalacademy.com
- 21. Speech begins with respiration Vibrate the vocal cords ,called phonation tone modified by the resonators the pharynx, oral and nasal cavity shaped by the movement of the tongue, soft palate, teeth and lips during articulation JPD 2000 VOL 83 PAGE 90www.indiandentalacademy.com
- 22. SPEECH AND MAXILLOFACIAL PROSTHETICS www.indiandentalacademy.com
- 23. PALATOPHARYNGEAL / VELOPHARYNGEAL FUNCTION This term relates to the coordinated movement of the soft palate and the lateral and posterior nasopharyngeal wall which is so important for speech and swallowing . DENTAL UPDATE 2005.32.217www.indiandentalacademy.com
- 24. Physiology and anatomy Palatopharyngeal mechanism is a precisely coordinated valve formed by several muscle groups. www.indiandentalacademy.com
- 26. • When Palatopharyngeal closure is required www.indiandentalacademy.com
- 27. The speech problem Hypernasality Nasal air loss on the plosives and affricate and the fricative sounds JPD AUG 1968 PAGE 182www.indiandentalacademy.com
- 29. ACHIEVING ACCEPTABLE SPEECH Speech and myofunctional therapy Surgical procedures to reduce the Palatopharyngeal gap Faradization and electrical vibration massage Prosthetic elevation and stimulation Combination of surgery and a prosthesis JPD 1976,MARCH ,PAGE 319 www.indiandentalacademy.com
- 30. PROSTHODONTIC PROCEDURE Palatal incompetency Palatal insufficiency www.indiandentalacademy.com
- 32. Palatal lift prosthesis was first advocated by GIBBONS and BLOOMER (1958) www.indiandentalacademy.com
- 33. Indication • Myasthenia gravis • Cerebrovascular accidents • Traumatic brain injuries • Bulbar poliomyelitis • Cerebral palsies • Injury to the soft palate www.indiandentalacademy.com
- 34. Contraindication • If adequate retention is not available for the prosthesis • If the soft palate is not displaceable • Uncooperative patients www.indiandentalacademy.com
- 35. Objectives hypernalality palatal disuse tissue Palatopharyngeal function neuromuscular response Repositioning of tongue JPD MARCH 1976 www.indiandentalacademy.com
- 36. Advantages • Gag response is minimized • Physiology of the tongue is not compromised • Access to the nasopharynx for the obturator is facilitated www.indiandentalacademy.com
- 37. • The lift portion may be developed sequentially to aid patient adaptation to the prosthesis • The lift principle has application to a diverse patient population that cannot be treated as effectively with palatal surgery. www.indiandentalacademy.com
- 40. Before PLP After PLP www.indiandentalacademy.com
- 42. Clinical evaluation JPD 1987.VOL 58 PAGE 206 www.indiandentalacademy.com
- 43. Palatal lift prosthesis in edentulous patients JPD 1987 VOL 58. NO 2.206www.indiandentalacademy.com
- 44. JPD 1987 VOL 58. NO 2.206www.indiandentalacademy.com
- 47. Removable palatal lift prosthesis QUINTESSENCE INT 2002;33;675www.indiandentalacademy.com
- 50. Speech bulb or combination prosthesis A conventional speech prosthesis may be divided into three specific components or stages The maxillary section The palatal extension Nasopharyngeal section JPD MAY 1978 VOL 39 PAGE 539www.indiandentalacademy.com
- 53. Moulding procedures for speech bulb The end of the loop should be at least 4mm short of posterior pharyngeal wall The head should be turned from left to right and the chin dropped to the chest The bulb should not interfere with the musculature or pharyngeal narrowing www.indiandentalacademy.com
- 55. • Speech bulb should be placed in the location of the greatest posterior and lateral pharyngeal wall activity • voice quality is best judged when speech bulb is at this position. www.indiandentalacademy.com
- 56. Palatal training aid Adisman has described an isometric palatal training prosthesis www.indiandentalacademy.com
- 57. • it is similar to the conventional speech prosthesis • include a cast metal rings circumscribing the uvula to permit free, unimpeded activity www.indiandentalacademy.com
- 58. • an acrylic extension retained by a cast metal loop in the nasal cavity • provides the antagonistic resistance to dorsal movement of the soft palate • it is attached superiorly to the uvula ring www.indiandentalacademy.com
- 60. Prerequisites of the palatal lift/pharyngeal section combination prosthesis Maxillary portion designed to achieve optimal retention and stability The lift portion should be placed so that palatal elevation occur Elevation of soft palate should be gradual www.indiandentalacademy.com
- 61. Pharyngeal section should be placed in the region where constriction of the posterolateral pharyngeal wall takes place The reduction of the pharyngeal section Speech therapy including lip, tongue, and palatal exercise JPD march 1976 www.indiandentalacademy.com
- 62. Results of palatal lift and combination prosthesis www.indiandentalacademy.com
- 63. Speech therapy JP 2010 ;19:397- 402 Bloomer mini test Palatal incompetence Palatal insufficiency www.indiandentalacademy.com
- 65. Conclusion The prosthodontist play a vital role in the management of Palatopharyngeal disorders . Palatal lift prosthesis serves to reduce hypernalality and thus improves the intelligibility of speech Above all it contributes to improving the patient self esteem. www.indiandentalacademy.com
- 66. The advantages of prosthodontic treatment is relatively simple, noninvasive and versatile . The speech prosthesis can eliminate hypernasality and produce stimulation of the soft palate and does not hinder growth and development. www.indiandentalacademy.com
- 67. • References • Maxillofacial rehabilitation, Beumer,Curtis and Fritell • Maxillofacial prosthetics. Chalian • BD Chaurasia – human anatomy 3rd edition • Australian dental journal 1988;33;6:491-495 • Brit Dent J.1981;151:338 www.indiandentalacademy.com
- 68. • JPD June 1967;page 620-626 • JPD May 1996;479-482 • JPD Aug 1987 vol 58 page 206 • JPD march 1976 • JPD 1978 vol 39 page 539-545 • JPD 1991;66:63-71 • JPD Aug 1968;page 182-188 www.indiandentalacademy.com
- 69. • JPD 2000;83:99-106 • JPD 2000;83: 90-98 • Quintessence Int 2002;33:675-678 • Dental update 2005;32:217-223 • JP 2010 ;19:397-402 www.indiandentalacademy.com
Editor's Notes
- Soft palate is movable muscular fold suspended from the posterior border of the hard palate it separates the nasopharynx from the oropharaynx and is looked upon as a traffic controller at the cross roads between the food and air.
- The palate controls two gates ,the pharyngeal isthmus and the oropharyngeal isthmus. It can completely close them or can regulate their size according to requirements .though these movements of the soft palate plays an important role in
- Palatal insufficiency refers to patients with inadequate length of palate to affect Palatopharyngeal closure with normal physiologic limits. Patients with congenital and developedmental aberrations and acquired soft palate defects would fall into this classification.
- Palatal incompetence refers to patients with essentially normal Palatopharyngeal structures but the intact mechanism is unable to affect Palatopharyngeal closure. The patients with neurological diseases such as bulbar poliomyelitis and myasthenia gravis or neurological defects secondary to cerebrovascular accidents are included in this category.
- Kantner and west in 1941 divided speech into five components
- Chierici and lawson added audition or the ability to hear sound in this lists, the successful performance of these functions is necessary for the production of acceptable speech
- Speech begins with respiration which provides the power or pressure during exhalation to vibrate the vocal cord s called phonation and producing a complex tone .this tone is modified by the resonators the pharyngeal, oral and nasal cavities. It is then shaped by the movement of the tongue ,soft palate ,teeth and lips during articulation to arrive at the end result which is fully formed speech .
- Of 6 components of speech, resonance and articulation are most readily influenced by maxillofacial prosthodontic rehabilitation. These two components are intimately related and difficult to separate into distinct entities for purposes of clinical evaluation
- When neurogenic impairment of the Palatopharyngeal port is present ,speech is typically characterized by excessive nasal resonance (hypernalality ),inappropriate audible nasal air emission and decrease in intraoral air pressure during the production of speech sounds. An understanding of normal Palatopharyngeal physiology for speech is a prerequites to adequately assess the Palatopharyngeal port ,which may or may not be functioning and subsequently may or may not be contributing to speech intelligibility.
- The muscle associated with this region are the superior constrictor muscle, Palatopharyngeal, salpingopharyngeus ,levator and tensor palati and palatoglossus.
- At rest soft palate drapes downward so that oropharaynx and nasopharynx are open and coupled to allow for normal breathing through the nasal passages ,when Palatopharyngeal closure is required the middle one third of the soft palate arcs upward and backward to contact the posterior pharyngeal wall at or above the level of the palatal plane.
- . Complete Palatopharyngeal closure is required for normal deglutition and the production of some speech sounds such as plosives .for other phonemes such as vowels and nasal consonants the Palatopharyngeal port will be open in varying degrees.
- Speech problems is common to persons with inadequate Palatopharyngeal closure and they resemble speech sounds heard in individuals with a congenital cleft palate. They include .hypernalality and nasal air loss on the plosive (p,b,t,d,k and g ) and affricative (ch,j),and the fricative (s, z, sh ,f, v, th sounds .these sounds which requires varying amounts of intraoral breath pressure for their articulation are weakly produced .nasality may range from mild to severe and may exist alone or in combination with disorders of articulation
- For patients who cannot receive surgical treatment prosthetic treatment combined with speech therapy is the treatment of choice. prosthetic management of vp insufficiency is carried out by means of speech aid prostheses whereas vp incompetency treated with palatal lift prosthesis. The functional components of the SAP is a nasopharyngeal section that is shaped to conform to the activity of the vp during speech and swallowing where as plp reduces the hypernalality by approximating the incompetent soft palate to the posterior pharyngeal wall.
- Palatal lift prosthesis are useful in selected situations. The palatal lift prosthesis as name implies displaces the soft palate superiorly and posteriorly to assists the soft palate to effect closure with the peripheral pharyngeal tissues.
- The objectives of a palatal lift prosthesis is to displace the soft palate to the level of normal palatal elevation enabling closure by pharyngeal wall action , if length of the soft palate is insufficient to feel closure after maximal displacement addition of an obturator may be necessary behind the displaced soft palate .to reduce hypernalality and escape of nasal air by palatal elevation ,to reduce the degree of palatal disuse atrophy, to increase Palatopharyngeal function by constant stimulation ,to increase neuromuscular response by gentle stimulation and speech exercise ,to assist in the repositioning of the tongue
- For dentulous patient, the palatal section of the plp is securely retained by the teeth while the Palatopharyngeal section physically raises the soft palate. In the edentulous patient retention of a complete denture necessitates good border seal .attachment of a fixed Palatopharyngeal section will interrupt the border seal and cause dislodgment of the prosthesis. a plp for the edentulous patient therefore must include a movable Palatopharyngeal section.
- 1) make priliminary impression with irreversible hydrocolloids .2) refering to the cef ,alter the soft palate section of the diagnostic cast to simulate the contour of the raised soft palate.3)make custom tray for the final impression 4) make final impression in usual manner 5)following jaw relation ,teeth arrangement ,wax the Palatopharyngeal section .
- Wax up of Palatopharyngeal section .process the palatomaxillary section and the Palatopharyngeal section separately. On the master cast embedded the niti wires in both the sections with autopolymersing acrylic resins to relate the section to each other . .note open to reduce weight .plp with niti orthodontic wires joining the section …palatal lift prosthesis in place .
- Denture were made accordance with the ordinary procedure. For final impression of the plp section the tray section was made with self curing acrylic resin at eh posterior border of the wax denture .after trying patients maximum intercuspation ,retention ,the degree of Palatopharyngeal closure and the inhibition in respiration were assessed the plp was constructed with soft wax and silicone .three stainless steel sprue pin tubes were embedded in the wax denture and resin were polymerized .cobalt chromium wire were inserted into each tube and the other end were bend for the retention of plp.the plp was waxed up and the maxillary denture with movable plp was completed .
- View of the patients mouth with the removable plp in place .view of the mouth with denture but without plp in mouth .
- Although it is possible for a skilled operator to construct speech prostheses from a one stage impression technique but it is prudent and more precise to follow a three stage sectional impression procedures.
- Scarred ,immobile soft palate with deviated uvula, maxillary section with the wrought metal extension ladder ,impression of the soft palate in thermo labile paste over the ladder extension,
- Ladder extension with thermo labile material recording soft palate. Adaptation of thermo labile paste to the pharyngeal wall ,anatomic detail registered in thermo labile impression
- Acrylic resin extension bar ,adaptation of acrylic resin palatal extension bar to pharyngeal wall and musculature,thermolabile paste impression of the nasophangeal section ,nasopharyngeal section processed in clear acrylic resin.
- Adisman has described an isometric palatal training prosthesis or palatal training device .it is similar to the conventional speech prosthesis but include a cast metal rings circumscribing the uvula to permit free, unimpeded activity of the uvula .an acrylic extension retained by a cast metal loop in the nasal cavity provides the antagonistic resistance to dorsal movement of the soft palate it is attached superiorly to the uvula ring .this type of prosthesis is indicated in those patients demonstrated congenital palatal incompetency where the soft palate appears anatomically normal but demonstrates little or no mobility.