Soft Palate Speech Bulb Prostheses

Defects of the soft palate usually require maxillofa-cial prosthetic intervention. Palatopharyngeal closure normally occurs when the soft palate elevates and contracts the lateral and posterior pharyngeal walls of the nasopharynx.27 When a portion of soft

Figure 20-8. A, Six months post-maxillectomy. B, Definitive obturator. C, Definitive obturator in occlusion.

palate is excised or when the soft palate is perforated, scarred, or neurologically impaired, complete palatopharyngeal closure cannot occur. Speech becomes hypernasal, and normal swallowing is compromised. With a pharyngeal speech bulb obturator, the patient may be able to reestablish palatopharyngeal closure. The speech bulb obturator must not interfere with breathing, impinge on soft tissue during postural movements, or interfere with the tongue during swallowing and speech. During the breathing and production of nasal sounds, the space around the speech bulb reflects a potential for muscular contraction. During the production of speech sounds, the sphincter muscular network moves into contact with the stationary acrylic resin speech bulb portion, establishing palatopharyngeal closure. A correctly constructed and positioned speech bulb can provide non-hypernasal and intelligible speech and functional swallowing for patients with acquired soft-palate defects.28

Optimally restoring the acquired soft-palate defect is probably one of the most difficult intraoral challenges for a maxillofacial prosthodontist. One must consider approaches for restoration of a soft-palate resection in conjunction with newer surgical interventions for head and neck cancer. Many tumors can originate from the retromolar trigone, oropharynx, base of the tongue, posterior buccal mucosa, palatal minor salivary glands, extension of paranasal sinus tumors posteriorly, and not the soft palate alone. Many resections of the soft palate include a segmental mandibulectomy, a base-of-tongue resection, or a partial glossectomy, pharyn-gectomy, cheek mucosa resection, palatectomy and maxillectomy (partial, subtotal, or total).29

Similar to the interim hard palate obturator prosthesis, an interim soft palate speech bulb obturator uses acrylic resin and 18-gauge wrought-wire clasps (when appropriate) for retention. If a musculocuta-neous flap is used for reconstruction of the lateral border of the soft palate, only minimum contact of the speech bulb should be attained against the flap. Many of these flaps and grafts provide bulk and do not provide physiologic movement in any direction. If a defect is present posterior to this flap, a properly placed speech bulb component into the nasopharynx can extend laterally and come in close approxima

Figure 20-8. A, Six months post-maxillectomy. B, Definitive obturator. C, Definitive obturator in occlusion.

tion with the torus tubarius, thus improving speech intelligibility while not interfering with breathing. Impressions of the soft-palate defect usually take place approximately 10 days after surgery. An extended dental tray with dental compound and wax can be safely used at this time with an irreversible hydrocolloid impression material.

Reconstruction with regional or free flaps in this region will necessitate a variety of speech bulb shapes, each individually formed for functional results (Figure 20-10). Difficulty in obtaining speech phonemes is not necessarily related to the size of the speech bulb but rather to the location of the defect and reconstruction.

Before And After Smoking Teeth

For this patient population, separating or differentiating resonance, articulation, hypernasality, and hyponasality is sometimes difficult. Factors affecting speech and swallowing will vary, including location of the defect, surgical flap reconstruction, compromised or nonfunctional adjacent anatomic structures and assessment at different postoperative time intervals.

During the postoperative period, if the soft palate resection includes a neck dissection, gastric pull-up procedure or reconstructed flap to the residual base of the tongue or pharynx, edema of the tongue will ensue, thus adjacent buccal spaces can be compromised. During this period the patient can experience

Figure 20-9. A, Osteogenic sarcoma-maxillary anterior gingiva. B, Surgical specimen. C, Anterior defect at surgery (anterior maxillary resection). D, Anterior defect 2 months post surgery. E, Definitive obturator in occlusion—4 months after surgery.
Soft Palate Difficulty Swallowing

difficulty in obtaining maximum physiologic movement to complete the velopharyngeal complex.

In summary, rehabilitation of the soft-palate resection can have a variety of subjective successes. Modified barium swallow, cinefluoroscopy and nasal endoscopic studies can be used to show abnormal muscular movements in a wide range of functional activities.30 Defining objective measurements (length, width and height) for proper speech bulb prosthesis placement is difficult. Reduction and

Figure 20-10. A, Soft-palate defect with microvascular radial free-flap reconstruction of the lateral pharyngeal wall. B, Speech bulb extension on denture base extended into the nasopharynx. C, Speech bulb prosthesis in place.

elimination of hypernasality does not necessarily correlate with elimination of leakage of liquids or foods through the nasal cavity. Head position and tongue maneuvering can contribute to the effectiveness of the speech bulb. Variation in the healing of the surgical margins is the rule rather than the exception. A lateral cephalometric radiograph can demonstrate the appropriate extension of the speech bulb in the nasopharynx and its position with the anterior tubercle of the atlas.

Rehabilitation of the soft palate is an ongoing treatment consideration. Other factors will contribute to improvement of speech and swallowing over time; hence, multiple prosthetic modifications and continued evaluation are necessary to achieve long-term functional success. Objective measurement of speech is difficult for the patient who has palatal insufficiency after soft-palate resection in addition to resection of adjacent hard and soft oral and oropharyngeal tissues. Nasality thus remains a perceptual phenomenon, the definition of which is elusive. Thus, each patient must be analyzed on an individual basis via means of voice interpretation and reading ability. The speech bulb prosthesis is effective in rehabilitating soft-palate defects and should be considered and discussed with the patient prior to resection.

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