39.2 Palatal Lift Prostheses for the Treatment of Patients
39.2.6 Objectives in Making Prosthetic Lift
1. Reduce hypernasality and nasal air escape by velar elevation
2. Reduce the degree of disuse atrophy
3. Increase velopharyngeal function by constant and continuous stimulation
4. Increase neuromuscular response by gentle stimu- lation and speech exercises
39.2.6.1 Results of Using Lift
and Combination Prostheses Methods of Evaluation
1. Speech testing procedures 2. Nasal endoscopy
3. Radiographic evaluation (e.g., cineradiography, cephalometrics, sectional laminography, or tomo- graphy)
4. Oral nasal air pressure and air flow assessing de- vices
5. Electronic instrumentation such as Tonar and sonograph
The optimal result depends on the type of oral pha- ryngeal involvement. If the neurological disorder is more localized to the velopharyngeal region, and the patient has few or no speech articulatory disorders, the prosthetic result is optimal. Patients with muscle paralysis of the tongue, lips, larynx, and respiratory organs usually respond less favorably to prosthetic care. Their phonatory and articulatory disorders usu- ally remain after the prosthetic treatment. These pa- tients often require more intensive and coordinated myofunctional therapy.
Patients’ tolerance and acceptance of prosthetic treatment vary. Some patients have less difficulty than others, becoming accustomed to the palatal and velopharyngeal coverage and decreased oral pharyn- geal space and volume.
Fig. 39.1. a Patient with palatopharyngeal insufficiency. The treatment procedure is the stimulation of the soft palate by a palatal lift prosthesis followed by pharyngeal flap surgery.
bView of palatal lift prosthesis in position.cPalatal view of the lift prosthesis
a
c
b
a b
c
Fig. 39.2. a Lateral radiograph of patient in Fig. 18.1 demon- strates the palatopharyngeal relationship prior to elevation and stimulation.bHeight of velar elevation during the sound
“E.”cTracing of the cephalogram in a
Fig. 39.3. a Radiographic view of the palatal lift prosthesis of patient in Fig. 18.2 in position. Note the degree of palatal eleva- tion.bIncreased mobility of the soft palate after 1 year of pros- thetic stimulation. Pharyngeal flap surgery was done after
14 months of soft palatal stimulation, after which the lift pros- thesis could be discarded. c Cephalometric tracing of the palatal lift prosthesis and the degree of velar elevation accom- plished by the lift
a b c
Fig. 39.4. Top left:Patient with palatopharyngeal incompeten- cy in which the soft palate is paralyzed as a result of neurologic involvement after an accidental head injury.Top right:Palatal
lift in position.Bottom left:Increased soft palate elevation after 6 months of prosthetic velar stimulation.Bottom right:Oral and palatal view of the lift prosthesis
Fig. 39.5. a Lateral radiograph of the patient in Fig. 18.4 prior to stimulation saying “E.”bThe palatal lift prosthesis in posi- tion elevating the soft palate.cNote the increase in the degree
of palatal elevation. After 11 months of stimulation and speech therapy patient is saying “E.” Note the substantial increase in the velar elevation
a b c
Fig. 39.6. a Tracing of a lateral cephalogram of the patient in Fig. 18.5 prior to soft palate stimulation by a palatal lift prosthesis.
bTracing of the palatal lift prosthesis and elevated soft palate
b a
Fig. 39.7. a Patient with a palatopharyngeal insufficiency in which the soft palate is short and has limited mobility.bCom- bination palatal lift pharyngeal section in position. The uvula was displaced by the prosthesis without causing any irritation.
cPalatal view of the prosthesis a
c
b
We have also noted variations in muscle response to mechanical stimulation. The velum of the same patient, shortly after placement of the lift, becomes more active, and after 6 months to 1 year, prosthetic stimulation and support can be discarded. Whether the increased velar elevation is the result of prosthet- ic stimulation or neuromusculature recovery is diffi- cult to assess. However, we can state that, in our expe- rience, similar patients who received speech therapy as the only mode of velopharyngeal stimulation demonstrated less functional recovery over the same period of time than patients where the prostheses were employed (see Figs. 38.6 and 38.7).
In our series of patients, we have found more marked nasal pharyngeal than velar musculature re- sponse to the prosthetic stimulation. With the velopharyngeal bulb, the patient often develops com- pensatory muscular constriction, requiring frequent reduction in the size of the pharyngeal bulb. In some patients, complete elimination of the bulb was accom-
plished. We could safely state that the reason for the variation in the degree of response observed in pa- tients with velar incompetency and patients with velopharyngeal insufficiency is that we have two sep- arate phenomena to consider. For one patient, we are trying to stimulate muscle activity by prosthetic phys- ical therapy; for the other patient, we are attempting to create muscle build-up or constriction as a result of prosthetic placement.