1. SOFT CLEFT PALATE
Kunal parekh

2. In simpler terms, a palatal
obturator covers any fistulas
(or "holes") in the roof of the
mouth that lead to the nasal
cavity, providing the wearer
with a plastic/acrylic,
removable roof of the mouth,
which aids in speech, eating,
and proper air flow.

4. Palatal Obturator
 Closes or occludes opening caused by cleft or fistula
 Used to facilitate separation of oral & nasal cavities
for speech, feeding, & swallowing
 hypernasality
 suckling ability in babies

6. A palatal obturator may be used to compensate for hypernasality
and to aid in speech therapy targeting correction of
compensatory articulation caused by the cleft palate.
Speech bulbs and palatal lifts aid in velopharyngeal closure and do
not obturate a fistula.
A speech bulb, yet another type of prosthetic device often
confused with a palatal obturator, contains a pharyngeal section,
which goes behind the soft palate.

8. General rule for prosthodontist…
1. The obturator for an adult patient shold be located in
the nasopharynx at the level of normal palatal closure.
2. The inferior margin of the obturator should be placed at
the level of greatest muscular activity exhibited by the
residual palatophryngeal complex.
3. The inferior extension of the obturator will usually be an
extension of the palatal plane as extended to the
posterior pharyngeal wall.

9. PROSTHETIC TREATMENT OF SOFT
PALATE CLEFTS

10. TYPES OF OBTURATOR
three types
 Fixe pharyngeal.
 Hinged pharyngeal.
 Meatal.
Type----
 Immediate surgical obturation
 Delayed surgical obturation

11. Obturator Categories
 Modification Obturator Short term
 Interim Obturator  Post surgery
 Definitive Obturator Long term

12. TYPES OF OBTURATOR
 The fixed
is an extension of a denture projecting in to the
pharynx at about the level of the anterior arch of the
atlas and shaped so that it can be griped by the
pharyngeal walls.
 The hinged
is attached to the posterior border of a
denture by a hinge and its lateral borders are shaped
so that they may be griped by the remnants of the
soft palate and be raised and lowered with them .

13.  The meatal obturator
is an extension of the back of the
denture, upwards at right angles to It, so that it
occludes the opening of the posterior nares.
 The meatal obturator is only used in cases
presenting a very large cleft and is difficult to
adjust so that it prevents the nasal escape of air
when speaking the oral consonants and does
not help the patient when swallowing.

15. A meatus obturator is designed to close the posterior nasal
choanae through a vertical extension from the distal aspect of the
maxillary prosthesis.
Such a design will reduce leverage factors on the prosthesis but will
not permit function of the pharyngeal muscles against it.
The meatus oburator is often thought to be mechanical while the
fixed
pharyngeal obturator is thought to be more physiologic.
The hinged pharyngeal oburator is not often referred to in recent
times because of the mechanics involved in its fabrication.

16. Design of the prosthesis
•must apply the basic principles of support, retention and stability so as to
minimize the stress generated to the structures of the mouth.
• All of these entities need to be considered in detail before prosthetic
intervention is undertaken.
•The location of the fulcrum line, retentive undercuts and potential for indirect
retention will be important factors in determining the prognosis.
•In general, the prosthesis will have a fulcrum line near the defect area.

17. •If natural teeth or implants are present to provide retention and
support for the prosthesis, the fulcrum line will pass between the
most posterior occlusal rests on each side of the arch.
•Retentive clasps placed into undercuts adjacent to the defect will
resist the downward displacement of the prosthesis due to the
effects of gravity.
•Occlusal rests on the opposite side of the fulcrum line from the
defect will act as indirect retainers. Long guide planes on the
natural teeth will also assist in prevention of rotational
dislodgment of the prosthesis.

18. IMPRESSION MAKING Procedure
 Upper and lower perforated stock trays were
selected. Upper tray was modified with wax
extension into the defect to record the defect.
 Then upper and lower preliminary impressions were
made with irreversible hydrocolloid. The upper
impression also records the defect.
 Impressions were poured with dental stone to make
diagnostic casts.

21.  Next step is the fabrication of special tray for border molding.
 Lower special tray is fabricated in conventional manner using autopolymerising
acrylic resin.

22. But during the fabrication of upper tray following factors were
kept in mind.
 There should be a 5 mm gap between the bulb and posterior
pharyngeal wall.
 Angle of the bulb should be approximately 20° relative to the
palatal plane.
 Keeping in mind all these criteria upper special tray was
fabricated with autopolymerising acrylic resin having
pharyngeal extension.
Impression of the defect area was made with modeling
plastic wax.

24.  Border molding was accomplished by recording all the
functional movements of the soft palate, i.e., by asking
the patient to tilt her head side-to-side and front-back
when sitting upright.
 the patient is instructed to flex the neck fully to achieve
contact of the chin to the chest. This movement will
establish contact of the middle third of the soft palate
with the soft tissue covering the dorsal tubercle of the
atlas.
 Lateral aspects of the lift are formed by rotation and
flexion of the neck to achieve chin contact with the right
and left shoulder respectively.

25.  Check indentation made by the ant. And posterior
tonsillar pillars, the tori tubari , passavant’s pas, and the
anterior tubercule of the atlas.
 Shiny area will indicate the lack of tissue contact.
 Activated pharyngeal musculature will displaced the
excess modeling plastic superiorly and inferiorly and
these excess should be trimmed.

27.  If the position and contours of the obturators
are satisfactory , reduced all extension
approximately by 1mm.
 Add thermoplastic wax because this will ensure
the overextension of obturator.
 Contour modification are done if required.

28.  Oral surface should be concave to provide space
for tongue.
 Superior surface should be convex and well
polished to facilitate the deflection of nasal
secretion into oropharynx.
 Area of excessive pressure are relieved using
pressure indicating paste on lateral and posterior
wall.

29. Placement of thermoplastic corrective wax onto
oropharyngeal extension.

30. Recording of surgical defect with thermoplastic corrective
wax.

31. A. Thermoplastic corrective wax removed from base.
B, Autopolymerizing resin added to space provided by
thermoplastic corrective wax.

32. If hyponasal voice is still evident ..then postero-
lateral dimensions of the obturator is reduced
judiciously.

33. Size and position of obturator….factors to
be consider
1.The closure of soft palate against the posterior
pharyngeal wall extends approximately 5-7mm in
vertical height with closure at o above the level of the
palatal plane.
2.At pharyngeal wall activity ( middle position of
obturator) the speech is is best for patients.

34. Test for speech,,-- aids in assessing the perceived
resonance balance
1. Manometric air pressure recordings.
2.Comparatie oral and nasal airflow
measurements.
3. Sound spectrographic analyses

35.  Lower Border molding was done in conventional
manner.
 Boxing was done and impressions were poured
with die stone to fabricate master casts.

36. Procedure for edentulous patient
 Autopolymerising acrylic resin record bases were made. In case of
upper record base did not include the pharyngeal extension.
 Jaw relations and try in was done in accordance with for
conventional complete denture fabrication procedures.
 After try in was over, all the undercuts of the defect area were
blocked with wax.
 Flasking and dewaxing was done. Then dentures were processed
with heat cure acrylic resin.
 Lid for the bulb was processed separately with heat curing acrylic
resin and was attached to the completed denture with
autopolymerising acrylic resin.

37.  Patient found drastic improvement in speech
and nasal regurgitation was reduced. Patient
was advised to continue her referral to speech
therapist.
 . Once surgical care and speech therapy have
been completed, the need for follow-up care is
needed unless specific problems manifest.
Preventive care is imperative if long-term
preservation of the supporting structures is
desired.

38. SILICONE RETENTIVE OBTURATOR
 In congenital clefts of the hard palate , enclosed or
open- ended, and acquired clefts , a use fullform of
obturator is made of silicone ( or latex rubber )
which is attached to the denture by studs .
 The obturator is removable and adjustments can
be made . the design is useful in the edentulous
cleft patient and in large acquired defects of the
palate where retention is a major problem.

39. STAGES
 Cut a postdam 5mm from the edge of the
cleft on the master cast .
 Fill the cleft with wax and carve to the
contour of a normal palate .
 Add a sheet of wax .
 Embed two studs.
 Take an impression of the cast in elastomer .
 Add to studs to the impression and pour it to
produce a working cast.

40.  Use working cast to make a complete denture.
 Pour a plaster register to the master cast to hold the studs in relation to the
cleft.
 Fill the cleft with silicone rubber in produce the obturator which is retained
on the studs on the denture.
 The master cast serves as a permanent mould for replacement obturators
 If soft palate obturation is required then gutta-percha can be added to the
silicone obturator and, after moulding in the mouth , returned to the master
mould and studs prior to making a new , accurate mould.

41. A modification obturator may be used in the short-term
to block a palatal fistula, for augmentation of the seal
and to separate the oral and nasal cavities.
An interim palatal obturator is used post-palatal
surgery.
A definitive obturator is used when further
rehabilitation is not possible for the patient and is
intended for long-term use

42. This obturator aids in closing the remaining fistula and is
used when no further surgical procedures are planned.
It must be frequently revised.

43. Limitations of Prosthetic
Devices
• Require insertion and removal
 Have to redo periodically due to growth
 Can be lost or damaged
 May be very uncomfortable
 Compliance is often poor
 Don’t permanently correct the problem
 Many centers use only if surgery is not
possible

44. Speech Bulb

45. Speech Bulb
 Occludes nasopharynx when the velum is
short (velopharygeal indufficiency)
 Aids in velopharyngeal closure
 Contains pharyngeal section, goes behind
soft palate
 Can be combined with an obturator

47. One Researcher’s Results
 ‘Eighty-seven percent (39/45) of all
patients increased their functional
oral intake of food/liquid including
92% of stroke patients and 80% of
head/neck cancer patients.’

48. The Latham Device

49. Nasoalveolar Obturator

50. reference

51. American Speech-Language-Hearing Association. (2001). Roles
of Speech-Language Pathologists in Swallowing and Feeding
Disorders: Technical Report [Technical Report]. Retrieved from
www.asha.org/policy. doi:10.1044/policy.TR2001-00150
Mark S. Chambers, DMD, MS,a James C. Lemon, DDSb and
Jack W. Martin, DDS, MS,c
M.D. Anderson Cancer Center, The University of Texas, Houston,
Tex
Curtis TA, Beumer J. Speech, velopharyngeal function, and restoration of
soft palate defects. In: Beumer J, Curtis TA, Marunick MT, editors. Maxillofacial
rehabilitation: prosthodontic and surgical considerations.
St. Louis:
Isbiyaku EuroAmerica; 1996. p. 304-19
Taylor TD (2000) Clinical maxillofacial prosthetics.
Quintessence Pub Chicago, 129-131

52. Thank
you