speech bulb obturator reduction program for vpi

8/9/2019 Speech Bulb Obturator Reduction Program for VPI

1/61

m

OREGON

I-IEALTI-I

SCIENCES

UNIV RSIlY

CIIII..I) I)EVELOPMENT

& REHAUIfJTA Il0N CENTER

1 .0.

Box 5 7 i ~

Portland,

Oregon 97207-0574

Services

or

G1. ildre1l

u itb

Special J eallb Needs

l}1lfl

ersity

AjJUfatedPlugrllll

June

I,

1994

To Whom It

May

Concern:

RE:

Neil Gillespie

This

38

year old I1lan has a repaired unilateral cleft lip

and

palate. His primary surgery

was

done in Pennsylvania

and he

had SOITIe secondary work including a pharyngeal

flap

for

speech, in Florida.

Since speech treatlnent

for

serious hypernasality has been unsuccessful up to this point, the

patient came to Ine

for

consultation about a

speech

plan.

Examination shows objectionable hypernasality with moderate nasal emission

of

air which

markedly weakens all

16

air pressure phonemes.

Use

of

the

fiber-optic nasendoscope on

May

26th verified that the pharyngeal flap, done three years ago (for speech), has pulled loose.

The treatment plan is to utilize a telnporary speech prosthesis (for circa

two

years)

to

markedly obturate

all

sounds froln entering the nasal cavity. After normal oral resonance is

obtained

and

Inaintained for about

four

to

five ITIonths,

an

obturator reduction program would

begin whereby the throat and palate 111usculature would be "challenged" by slowly making the

obturator

sl11aller, in stages.

At the end

of approximately

two

years, it

is

expected that oral

nasal

resonance anti oral air pressure

would

be close to normal limits and that pharyngeal and·

palate 111usculalurc \vould

have

inlproved considerably. This

is

expected to nlake

the

patient's

velopharyngeal systenl nluch Inore anlenabie

to

a surgical procedure

to

substitute for the

speech prosthesis \vithout

c0l11promising

the

patient's nasal airway.

Respectfully sublnitted,

Robert W. Blakeley, Ph.D.

Professor of Speech Pathology,

Director, Craniofacial Disorders Progralll

b l a k b : g i l l e ~ p i


2/61

m

OR GON

HE LTH

SCIENCES UNIVERSITY

CHILD DEVELOPMENT

&

REHABILITATION CENTER

P.O. ox 574 Portland

Oregon

97207-0574

Seroices

for

Children with Special Health Needs

Universi V

ffiliated

Program

November 21, 1995

NEIL GILLESPIE

1001 COOPER PT RD SW 140-180

OL

YMPIA WA 90505

Dear

Mr

Gillespie:

I am enclosing a copy

of

your dental record. With any adult

prosthesis, you are encouraged to have routine dental care and

maintenance in order to optimize the usefulness of the device.

Sincerely,

l ~

Peter Lax,

M


3/61

April 1994, dinner at the Multnomah Athletic Club (MAC), Portland, Oregon

Upper right: Dr. Robert W. Blakeley, Ph.D, Speech Pathologist. (1924-2010)

Upper left: Neil Gillespie (age 38 in 1994)

Lower right: Dr. Ningyi Li, MD, DDS, Professor and Chairman Maxillofacial

Department, Affiliated Hospital of Qingdao Medical College, People's Republic of China

Dr. Li was at the time a visiting scholar at Oregon Health Science University (OHSU).

Lower left: Neil Gillespie


4/61

speech prosthesis a.k.a. speech bulb obturator

Speech bulb obturator made at Oregon Health Sciences University (OHSU)

under the direction of Dr. Robert Blakeley, PhD, Speech Pathologist.

To correct velopharyngeal incompetence (VPI) or hypernasal speech.


5/61

e _ I l 1 J ~ ? r? l _ ' : ~ l ~

. . c : . ~ _ ~ _ C ~ ~ _ ~ P J ~ ~ a n

CC.

A. s a : E . c i - l _ ~ _ m e l ~ . ~ . . 0 J ~

t ) , - ( l _ n _ J ~ o T _ } ~ r t ) _ i .

t.il.I:..

. . : l . n _ ~ ) . ' ~ l ~ ~ _ t

e s . ~ .

I ' :ob('r t 1.:. ILlakeJ ey.

I ' l l . n.

I"op

anll

btt:ral

views ot the

Slll.:C\:h p r o s t l t C ~ i ~ ; wilh its palatal

ponilH1

J

tai'

piece, obl.urato.' und

rCfcntiuo w'ircs.

.1I

:(1

;'

' .

10

Il '

l'

:'

.. 5

.....

'0 ._ .

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I

/.;

/

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-

.


6/61

Ii.

Nunnal

Palillul -P hurYIlJeul

b.

Ablluunill Palatal-Pharyngeal

ClotJul·e.

Clobure wJ[h P

llltll l InBut

f lc lcncy


7/61


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19/61

Cleft Craft, The Evolution of its Surgery

Volume III, Avelolar and Palatal Deformities

D. Ralph Millard, Jr. MD, F.A.C.S.

Chapter 53, Palatal Obturators


20/61

53

PALATAL

OBTURATORS

BEFORE

SURGERY

OF THE

PALATE

HAD BEEN

DEVELOPED

OBTURATORS WERE

IN

USE

ACCORDING

TO

HISTORICAL SCHOLAR

BLAIR

ROGERS

AS

NOTED IN

CLEFT

LIP

AND

PALATE

97

INTERESTINGLY

THE

EARLIEST

EVIDENCE OF

SIMPLE

RETENTIVE

DENTAL

PROSTHESIS

WAS

FOUND

AT

EL

GIZEH DATING

FIOM THE END OF

THE

OLD

EMPIRE CIRCA

25

BC

IT WAS

MADE OF

GOLD

WIRE

LINKED

TOGETHER

THE

LOWER LEFT SECOND

AND

THIRD

MOLARS

AND HAD

HEEN

WOVEN

AROUND

THEIR

GINGIVAL

MARGINS

THUS

HEGAN

MANS

EARLY ATTEMPTS

TO CONSTIUCT

THE INTRAOIAL

PROSTHESES

THAT

PLAYED

SUCH

AN

IMPORTANT

INLE IN

SUHSEQUENR

CENTURIES

IN

THE EVOLUTION OF

CLEFT

PALATE THERAPY

AND

SURGERY

DESPITE

THE

SUPPORTERS

OF AMATUS

LUSITANUS

AS

THE INVENTOR

OF THE OHTURAROR

WCINHUIGER

PARE

WAS

FAMILIAR

WITH

PALARAL

CHRURATORS

AS EARH AS 537 TO

5 39

SIN

HE

HAD OHSER

EL

THEIR

USE

MANS

TIMES

IN

THE

HARTLES

FOUGHT

HEYOND

THE

ALPS

IN 56 LUSITANUS PREVIOULY

OF

ANCONA

WAS

PROBABLY

THE FIRST

TO

DESCRIBE WHAT

IS

KNOWN

TODAY AS

PALATAL

OBTURATOR

GREEK

NOBLEMAN

PRESENTED

PERMANENT

LUETIC

FISRULA

OF THE

PALATE

TO

LUSITANUS

WHO

DESIGNED

PROSTHESIS

THESE ARE

HIS

WORDS

TRANS

LATED

BY JOSHUA

LEIBOWITZ OF

HEBREW

UNIVERSITY

IN ISRAEL

WHILE

AT

YALE

PAY

ATTENTION

TO

THE

WA

INVENTED THE

FOLLOWING EXTRAORDINATY

AITIFICE

WHICH

MADE

POSSIHLE

CORRECT

AND DISTINCT

SPEECH

AS

IF

HE

HAD

NEVER

HAD

ANY

ILLNESS

ORDERED

GOLDSMITH

TO

PREPARE

GOLDENHEADED

NAIL

THE HEAD OF

THE

NAIL

WAS

ROUND AND HROAD

ENOUGH

TO

CLOSE THE

TOTAL CIRCUMFERENCE OF

THE

FORAMEN

WHEREAS

THE

TIP

OF THE NAIL AS

NARROW

AND

ROUND AND

TO THIS

RIP

SMALL

SPONGE

WAS

FITTED

HIS THE

PATIENT

HAD

TO

INTRODUCE INTO

THE

FORAMEN WHERE IT

EXPANDED

WITH

MOISTURE AND

SO

REMAINED

FIXED IN

POSITION

87


21/61

THIS

OBTURATOR

WASREMOVED

TWICE

DAILY

FOR

CLEANING

WHILE IT

WAS

IN

THE

PATIENTS

SPEECH

WAS

ELEGANT

WHEN

IT

WAS

OUT

TOTALLY

DEFICIENT

JACQUES

HOULLIERS

MENTION

OF

THE

USE

OF

WAX OR

SPONGE

TO

PLUG PALATE PERFORATIONS

SUGGESTS

THAT

SUCH

PRIMITIVE

OBTURATORS

WERE

ALREADY

IN

USE

BY

THE

MIDDLE OF

THE SIXTEENTH

CENTULY

WHEN

BUCCOPHARYNGEAL SYPHILITIC

ULCERS AND

PALATAL

PERFORATIONS

WERE

PREVALENT

AND

RECOGNIZABLE

IN 56

PIERRE

FRANCO

HUGUENOT

SURGEON

OF

PARIS

WROTE

THOSE WHO

HAVE CLEFT

PALATES ARE MORE

DIFFICULT

TO CURE AND

THEY ALWAYS

SPEAK

THROUGH

THE

NOSE

IF

THE

PALATE

IS

ONLY

SLIGHTLY

CLEFT

AND IF

IT

CAN

HE

PLUGGED

WITH

COTTON

THE

PATIENT

WILL

SPEAK

MORE

CLEARLY

OR

PERHAPS

EVEN

AS

WELL

AS

IF

THERE

WERE

NO

CLEFT

OR

BETTER

PALATE

OF SILVER

OR LEAD

CAN BE

APPLIED

BY

SOME

MEANS AND

RETAINED

THERE

IN

564 AMBROISE

PAR CALLED

HIS

SMALL

OBTURATORS

COUVERCIES

AND

ONLY

IN

575

CHANGED

THE

NAME

TO

OBTURATEUR WHICH

ROGERS

CONJECTURED

WAS

PROBABLY

THE FIRST

TIME

IN

MEDICAL

HISTORY

THAT

THE

WORDOHIURATOR

WAS

USED

PAR

REFERRING

ONLY

TO

TRAUMATIC AND

LUETIC

PALATAL

DEFECTS

EXPLAINED

HIS

TECHNIQUE

OF

FILLING

THE

CAVITIE OF THE PALAT

WITH

PLATE

OF

GOLD

OR

SILVER

LITTLE

BIGGER

THAN

THE

CAVITIE IT SELF IS BUT

IT

MUST

BE

AS

THICK

AS

CROWN

AND

MADE

LIKE

UNTO DISH IN

FIGURE

AND

ON

THE

UPPER

SIDE

WHICH SHALL

BE

TOWARDS

THE

BRAIN

WILL

HECOM MORE SWOLN

AND

PUFFED

UP

SO THAT IT WILL

FILL

THE

CONCAVIRIE OF THE

PALAR

THAT

THE ARTIFICIAL

PALAT

CANNOT

FALL

DOWN

BUT

STAND

FAST AND

FIRM

AS IF IT STOOD OF IT

SELF

SINCE

SURGICAL

CORRECTION

OF

HARD

PALATE

DEFECT

OFFERED DIFFI

CULTIES

FOR

CENTURIES

AND

AS

ROGERS

HAS

NOTED

SURGEONS

OF

THE

MIDDLE

AGES

AVOIDED

SURGERY

OF

THE

PALATE

LIKE

THE

PLAGUE

THE

PROSTHETIC

AIDS

OF THE RENAISSANCE

DESERVED

PRAISE

AND

WERE

USED

FOR ABOUT

2

YEARS

THE

PRINCIPLE

WAS

IMPROVED

IN

728

BY

PIERRE

FAUCHARD

THE

FATHER OF MODERN

DENTISTRY

WHEN

HE INAUGURATED

FIXATION

OF

THE

OBTURATOR

TO

DENTAL

PROSTHESIS

HE

DESCRIBED

FIVE

DIFFERENT

OBTURATORS OF

SOPHISTICATED

DESIGN

SOME

WITH

MOVABLE

WINGS

OPERATED

BY

SCREWS

AND

EACH COVERED

WITH SOFT

SPONGES

WHICH

COULD FILL IN

MOST

PALATAL

PERFORATIONS NO

MATTER

HOW

IRREGULAR

THEIR

MARGINS

THESE

WERE ILLUSTRATED IN

PLATE

38

OF

FAUCHARDS LE

CARU

RGIEN DENTSTE

ON TRAT

AES

DENTS

746

878


22/61

J6

L26

IN

757

BOURDET

IRNPRUVCD

PALATAL

OBTURATORS

BY

FIXING

THEM

NOT

TO

THE

PALATE

ITSELF OR

INSIDE THE

NOSE

BUT

BY

MEANS

OF

LATERAL

CLASPS

TO

THE TEETH

IN

82

DELABARRE

CONSTRUCTED

RUBBER

PROSTHESIS

WITH BANDS

AND

CLASPS

THAT UTILIZED

THE

PALATAL

MUSCLES

TO

MOVE

THE VELAR

SECTION

OF

THE

PROSTHESIS

MINERAL TEETH WERE

ATTACHED TO THE

PALATE

BY

MEANS

OF

SPRINGS

MOVABLE

PART

MADE

OF

ELASTIC

GUM

WAS

ATTACHED TO

RESTORE

THE VELUM

AND UVULA

MOHAMED

ARAMANY

OF THE

UNIVERSITY

OF

PITTSBUIGH

STUDYING

THE

HISTORY

OF

PROSTHETIC

MANAGEMENT

OF CLEFT

PALATE

REPORTED

THAT

JAMES

SNELL WAS

BELIEVED TO

BE

THE

FIRST

TO

ATTEMPT

THE

TREATMENT

OF

CONGENITAL

CLEFTS

WITH

OBTURATORS

IN

828

ABOUT 3

YEARS

AFTER

PARE

WROTE

HIS

DESCRIBING

AN

OBTURATOR

FOR

LUETIC

AND

TRAUMATIC

CLEFTS

SNELLS

ATTEMPT

TO RESTORE

THE SOFT

PALATE

STOPPED

SHORT

OF

OCCUPYING

THE

PHARYNGEAL SPACE

IN 84

STEAM

WHO

HAD

CONGENITAL

CLEFT HIMSELF

WHICH

HAD

UNDERGONE

FEW

UNSUCCESSFUL

OPERATIONS

ATTEMPTED

TO CONSTRUCT

AN

APPLIANCE

OF

HIS

OWN

AND WAS

THE

FIRST

TO

EXTEND

THE

SPEECH

AID INTO

THE

PHARYNGEAL

AREA

IN

845

SIMON

HULLIHEN

OF

VHEELING

WEST

VIRGINIA

NOTEN

879


23/61

WHERE

THE

OSSEOUS

PALATE

IS

LIKEWISE

INVOLVED MORE OR LESS OF

AN

APERTURE

WILL OF

COURSE

REMAIN

WHICH

MUST BE CLOSED

EITHER

THROUGH

THE

MEDIUM

OF

GRANULATIONS

OR

BY GOLD

OBTURATOR

OR

ARTIFICIAL

PALATE

BEFORE

MUCH

BENEFIT

CAN BE DERIVED

IN 86

MCGRATH

INTRODUCED

FIXED

PROSTHESIS

AND

EXTENDED

THE VELAR SECTION

INTO THE

NASOPHARYNX

ALSO IN

86

NORMAN

KINGSLEY

WORKED

WITH

STEAM

TO CONSTRUCT

SPEECH

APPLIANCE

FOR

PF

SEVERE

BILATERAL

CLEFT

AND LATER

IMPROVED

STEAMS

DESIGN BY

SIMPLIFYING

IT

FOR THIS

ADVANCE HE

RECEIVED

GOLD

MEDAL

AT THE

AMERICAN DENTAL

CONVENTION

AT

SARATOGA

IN

863

IN

867

WILHELM

SUERSEN

GERMAN

DENTIST

ALSO

IMPROVED

STEAMS

APPLIANCE

CONSTRUCTING

FIXED

PROSTHESIS

AND

MPHA

SIZED

THE

IMPORTANCE

OF THE

MUSCLE

ACTIVITY

OF

THE

PHARYNX

RTICULARLY

IN

SECURING

CONTACT

OF

THE

PHARYNGEAL

SECTION OF

THE

PROSTHESIS

WITH

THE

HARYNGEAL

MUSCULATURE

TO

OCCLUDE

THE

NASO

PHARYNX

TEMPORARILY

IN

88

KINGSLEY

WAS

THE

FIRST

TO

ADVOCATE

SPEECH

THERAPY

FOLLOWING

THE

CONSTRUCTION

OF

AN OBTU

878 PASSAVANT

EMPLOYED

COLLARBUTTON

OBTURATOR

SIMILAR

TO

THAT

OF

GARIEL

TO MAINTAIN

POSTERIOR

DISPLACEMENT

OF THE

VELUM

AFTER

TRANSVERSE INCISION

IN

385 WOLFF OF BEILIN

ADVOCATED THE

USE

OF

SCHLITSKX SOFT

RUBBER

PHARYNGEAL

OBTURATOR

AFTER

SUCCESSFUL

CLEFT

PALATE

OPERA

SCBLITSK

OBTUR

RIONS

IN ALL

CASES IN

WHICH

THE VELUM

WAS

TOO SHORT

TO REACH THE

WALL

OF

THE

PHARYNX

IN

894 WOLFF

DISCARDED

THIS

OBTURATOR FOR

HAHNS

HOLLOW

HARD

RUBBER

PHARYNGEAL OBTURATOR

WHICH

EXCEPT

LFI

SCHITISKY

PHIRYN

OBTUSATOIS

FOR

THE

MATERIAL

WAS

CONSTRUCTED LIKE

THE

SCHLITSKY ONE

EARLY

COMBINED

USE

OF

PROSTHESIS

AFTER

SURGERY

IN

9 2 PICKERILL OF

NEW

ZEALAND

COMBINED

PROSTHESIS

WITH

PALATOPLASRY

IN

RATHER

UNUSUAL AND

UNPHYSIOLOGICAL

WAY

OBTURATIR


24/61

IN 92

CASE

DEVELOPED

THE VELAR OBTURATOR

DESIGNED

WITH

CAREFUL

ATTENTION TO

THE

PALATOPHARYNGEAL

MUSCLES

THAT

CONTACTED

THE

PROSTHESIS

ALSO IN

92

DENTAL

SURGEON

KELSEY FRY

INSINUATED

HIS

APPLIANCE

INTO THE COMBINED

HOLE

OF

THE ANTERIOR

HARD

PALATE

AND

THE DEFECT

BETWEEN

HARD AND SOFT

PALATES

CREATED

BY

HAROLD

GILLIES

TO

ACHIEVE

PUSHBACK

OF THE

VELUM

THIS

TECHNIQUE

IS

DESCRIBED IN

CHAPTER

25

COMBINED

PROSTHESIS

FOR

TEETH

FACIAL

CONTOUR

AND

PALATE

OBTURATOR

IN

932

IN THE

LANCET GILLIES

WITH

KILNER

REVEALED

HIS

EARLY

DECIPHERING

OF

ONE

OF THE

MAJOR

PROBLEMS

IN

SECONDARY

CLEFT

SURGERY

THE COMMONEST

CONTOUR

DEFORMITY

SEEN

IN OLD

HARELIP

AND CLEFT

PALATE

CASES

IS

PTODUCED

BY

FLATNESS

OF THE

LIP

AND

DEPRESSION

OF

THE

NOSE

IT

IS OBVIOUS

THAT THE

FLAT

LIP

IS

CAUSED

LACK OF FORWARD

PROJECTION

IN THE

UNDETIVING

MAXILLA

MOST

MARKED

WHEN

THE

PREMAXILLA

HAS BEEN

REMOVED

BUT

PRESENT

IN

LESSER

DEGREE

IN

LARGE

PROPORTION

OF

LIPS

EITHER HI OR

UNILATERAL

THE

TYPC

OF

DEPICMCD

NOSE

CNCOUNTEIED MAY

BE

DEFINED

AS

ONE AS

WHOLE

IS SIRUARCD NEATER

THE ETRICAL

AXIS OF

THE

BOD

THAN NOR

MA

THIS NASAL

DEFORMITY HAS MOIE

COMPLICATED

ORIGIN

THAN

THAT OF

THE

LIP

FACTORS

OBSEIVED INCLUDE

THE

BACKV

DISPLACEMENT

OF THE

INAXILLAC RESULTING

FIOM THE SCAR

TISSUE

PULL

WHICH

FOLLOWS

SUCCESSFUL CLOSURE

OF THE

PALATE

CLEFT

DEFINITE

UNDERDEVELOPMENT

OF

THE

NORMAL AMOUNT

OF BONE IN THOSE

PARTS

OF THE

MAXILLAE

WHICH BORDER ON

THE

PYRIFORM

OPENING

THE

BACKWARD

PRESSURE

OF

TIGHT

LIP

DEFINITE

FAILURE IN

THE

FORWARD

GROWTH

OF

THE NASAL

SEPTUM

THE

NATURAL

COROLLARY

TO

THE

BACKWARD

DISPLACEMENT

OF THE

MAXILLAE IS THAT

THE

UPPER

TEETH

COME

TO

LIE

WELL

INSIDE THOSE

OF THE

LOWER

JAW

CREATING

INEFFICIENT

MASTICATION

AND AN

ULTRAPROMINENT

LOWER

LIP

IN

932

GILLIES

AND KILNER

READVOCATED

THE BUCCAL

INLAY

AND

PROSTHETIC PRINCIPLE

FIRST

DEVELOPED

BY

GILLIES

AND

FRY

IN 92

FOR

THE

CLEFT

PALATE PATIENT

BUT

ADMIRABLE

TOO

IN

THE CONTRACTED

FACES

AND

NOSES

OF

THE

LUETIC

DEFORMITY

IN

FACT

INTRANASAL

PROSTHETIC

SUPPORT

ATTACHED TO THE

UPPER

PLATE

COULD BE

INTRODUCED

INTO THE

88


25/61

LUETIC

SKINGRAFTLINED

NOSE

SO

THAT IT IS

PERFECTLY POSSIBLE

FOR

PATIENT

TO

POCKET

SEVERAL

DIFFERENTSHAPED

BRIDGES

AND

CHANGE

HIS

RACIAL AND FACIAL

CHARACTERISTICS

BY

SIMPLE SLEIGHT

OF

SUNDAY

MONDAY

SATURDAY

PREOPERATIVELY

PREPARED

SIMPLE

METAL

CAP

SPLINT

WAS FIXED

TO

THE

EXISTING

TEETH IT

HELD SMALL

ADJUSTABLE

TRAY

IN FRONT

TO

SUPPORT

THE

MOLDING

MATERIAL USED

TO

BUILD

FORWARD

THE

CONTOUR

AND

CARRY

THIERSCH

GRAFT

TO

LINE THE

POCKET THROUGH

AN

UPPER

BUCCAL SULCUS

INCISION

THE SOFT TISSUES OF

THE

LIP

NOSE AND

CHEEKS

WERE FREED FROM THE

UNDERLYING

RETROPOSED

MAXILLAC

INTO

THIS

RAW

AREA

THIERSCH

GRAFT

WAS

FITTED

RAW

SURFACE

OUTWARD

TAKEN

FROM

THE HAIRLESS INNER

ASPECT

OF

THE

UPPER

ARM

AND

MOUNTED

ON THE

MOLDED

STENT OVER THE

TRAY

WHICH

WAS FIXED

TO

THE

CAP SPLINT

CE

THE

GRAFT

HAD

TAKEN

AND THE LINED

POCKET

HAD BEEN ESTAB

LISHED

PERMANENT

UPPER

DENTURE WAS

FITTED

TO

REPLACE

MISSING

TEETH

HIDE

MISPLACED

ONES

BLOCK

THE ORONASAL

COMMUNICATION

WHILE

LEAVING

THE NASAL

AIRWAY

FREE

AND

PUSH

FORWARD

THE

LIP

AND

NASAL BASE

AND

OCCLUDE ITS TEETH

NORMALLY

WITH THOSE OF THE

MANDIBLE

AS

NOTED

BY

GILLIES AND KILNER

THE HOLE CH OF

THE FACE IS ALTEICD

FOT HE HCTTCI

THE

DIASS HACK

ATE

FE

THE

PATIENT

IS

DOOMED TO

WEAR DENTUTE

HESS MAN

OF US

ESCAPE

ER

OCCASIONALLY

FESS

DROPS

OF

IMBIBED FLUID LEAK

THROUGH

THE

NOSE

AND

OCEASIONALL

AN

IRRITANT

IHINORRHEA

PELSISUS

FOR

TIME

THERE

ARE

TIMES EVEN

TODAY

WHTN

THIS

IPPROEH

IS USED

AND

ON RARE

CECASIONS IS THE METHOD OF

CHOICE

COOPER

HERBERT

COOPER

AN ORTHODONTIST OF

LANCASTER

PENNSYLVANIA

IN

THE

LATE

2 S

AND

EARLY

3 S

BEGAN

TO

SEE

MANY

CLEFT

PALATE

WRECKS GENERAL

SURGEONS

AFTER FULL

MORNING

OF

COLECTOMIES AND

THROIDECTOMIES

WOULD

TURN UVET

THE CLEFT

PALATES

TO THE

JUNIOR

SURGEON

AND

CONSEQUENTLY

MANY

CASES

WERE

BOTCHED

ENDING

UP

WITH FISTULAE

AND

SCAIRING COOPER

FELT THAT

NO

FURTHER

SURGERY

WAS

INDICATED

IN SUCH

DISASTERS

AND

DURING

HIS

DENTAL RESTORATION HE

ADDED BULB

TO

THE

PROSTHESIS

TO

HELP

THE

PALATE

IN THE LATE

3 S

DORRANCE

BECAME

AWARE

OF

COOPERS

STT CSS ITH OBTURATORS AND

MADE

TN

EFFORT

TO COMBINE FOTEES

8S2


26/61

ROBERT

IVY

FRIEND OF BOTH

COOPER

AND

DORRANCE

RECALLED

WITH

GLEE

AN

EPISODE

IN

CLEFT

PALATE

CLINIC ABOUT

938

THE

HEAVY

DOGMATIC

DOMINEERING

OVER

FOOT

DORRANCE

FINALLY

IRRITATED

THE

QUIET

UNASSUMING

FOOT INCH

COOPER

INTO

THROWING

DOWN

THE

GAUNTLET

TO

DORRANCE

BOAST

ABOUT

HIS

PUSHBACK

PROCEDURE

COOPER RESPONDED

CAN

BRING

CASES

THAT

HAVE

BEEN

RESTORED

DENTALLY

WHICH HAVE

GOOD

SPEECH

GEORGE

IF

YOULL BRING

HUNDRED

PALATE

CASES

WHICH

HAVE HAD

YOUR

PUSHBACK

OPELATION

TO THE

SAME

MEETING

WELL HAVE

SHOWDOWN

IVY

SAID

DORRANCE

NEVER

TOOK

COOPER

UP

ON

THIS

CHALLENGE

FIXED

BRIDGE

INITIAL

MODELS

EGIL

HARVOLD

NOW

OF

THE

UNIVERSITY

OF

CALIFORNIA

WHILE AT

THE

NORMAL ARCH

CLEFT PALATE ARCH

OF OSLO

IN

FIRST

BEGAN

ARYDEL

AFTER ORTHODONTIC

TOR

IN

THE

DEVELOPMENT

OF THE CLEFT

PALATE

MALOCCLUSION WAS AN

TREATMLNT

INWARD

ROTATION

OF THU

MAXILLARY SEGMENTS

AROUND FULCRUM

IN

LEFT

PALATC

ITCH

AFT

TT

THE

REGION

OF

THE

MAXILLARY

TUBEROSITY

RATHER

THAN

MERE

INDIVID

BEFOIT IUATNMNT

UAL TOOTH

MOVEMENT

FOR CORRECTION

OF

THIS

HARVOLD

DEMON

TMOD

IN

95I

AND

963

THAT

THE DISLOCATED

SEGMCNTS

COULD

BE

RITFNTION

RELOCATCD

BY

ORTHODONTIC

MEANS

AND THEN THE

POSITION

OF

THE

V

LINT

INDIVIDUAL TEETH

COULD BE

CORRECTED

BY

STANDARD

ORTHODONTICS

9

AND

967

BBHN

IN

COOPERATION

WITH HARVOLD

SOLVED THE

PROSTHODONTIC

PROBLEMS

BY

ESTABLISHING

THAT THE

POSTORTHODUNTIC

RESULTS COULD BE

PERMANENTLY

RETAINED

BY

MEANS

OF

RELATIVELY

SHORT

SPLINT

ACTOSS

THE CLEFT

BESIDES

RETENTION

THE

SPLINT

PROVIDED

MISSING

TEETH AND

CORRECTION

OF

MALFORMED TEETH

IN THE CLEFT

AREA

FOLLOWING

THIS

REGIMEN

RAMSTAD

OF

THE

UNIVERSITY

OF

OSLO

IN

THE

973

CLEFT

PAATE

JOURNAL PRESENTED

SEVERAL

IMPRESSIVE

CASES IN

WHICH THE

POSTORTHODONTIC

ARCH

FORM HAD BEEN

MAINTAINED

WHILE

THE DENTAL

ABNORMALITIES WERE

CORRECTED

HE

NOTED

THE FIXED

BRIDGE

IS

THE

PIOSTHODONTIC

TREATMENT

OF

CHOICE

SHOWN

HERE IS ONE

OF HIS BILATERAL CLEFTS

AFTER

ORTHODONTIC

TREATMENT

ITH

AN

EIGHTUNIT

RETENTION

BRIDGE

WITH

IEMOVABLC

FISLULA OBTURATOR IN

POSITION

AND INCISOR

RELATIONSHIP

SATISFACTORY

TREATMENT RESULLS

WITH

REFERENCE

TO

THE

POSRPROSTHODON

TIC

ADULT


27/61

OCCLUSION IN

63

UNILATERAL

AND

9

BILATERAL

COMPLETE

CLEFT

CASES

WERE

NOTED

NO

BUCCAL CROSSBITE OCCURRED IN

635

OF THE UNILATERAL AND IN

789

OF

THE

BILATERAL

CLEFT

CASES POSITIVE

OVERJER

AND

OVERBITE

OCCURRED IN

ALMOST

9

OF

THE UNILATERAL AND IN ALL

THE BILATERAL

CASES

MORE COMPLEX

APPLIANCES

IN

965

ROBERTS

PRESENTED COMPLEX

OBTURATORS ATTRIBUTED

TO

FAUCHARD AND

DESIGNED

TO

OPEN

IN

THE

CLEFT

TO

PROVIDE

RETENTION

MOVEMENT

OF THE

WINGS

IS

ACHIEVED

BY USING

THE

KEY

BEFORE

PALATAL

SURGERY

HAD BEEN

DEVELOPED

AND LATER

WHEN

LESS

SOPHISTICATED

AND

MORE

TRAUMATIC

SURGERY

HAD

SO SCARRED THE

PALATE

THAT

FUNCTION

WAS

IMPAIRED

AND

ALSO IN

CASES

OF

SEVERE

CONGENITAL

INSUMCIENCY

OF

PALATAL

TISSUE

THE OBTURATOR HAS

BEEN

OF

USE

AS

SURGERY

HAS

IMPROVED

THE OBTURATOR

HAS

GONE

ON THE

SHELF

BUT IN

SOME AREAS UNDER CERTAIN

CONDITIONS IT

MAY

BE OF

VALUE

MODERN

STAND

ON

PALATE

PROSTHESIS

ROBERT

MILLARD

DIRECTOR

OF

SPEECH

AND

HEARING

SERVICES

AT

THE

IP

LANCASTER CLEFT PALATE

CLINIC

ACKNOWLEDGED

THAT THE

MAJORITY

OF

CLEFTS

CAN BE

CLOSED

BY

OPERATIVE

PROCEDURES

IN

97

FOR

CLEFT

LZ

AND PAATE

HE

PRESENTED

SOME

INTERESTING GUIDELINES

FOR

CASES

IN

WHICH

PROSTHESIS

WAS

UNDER

CONSIDERATION

INDICATIONS

FOR

PROSTHESES

IN

UNOPERATECI

PALATES

WIDE

CLEFT OF THE SOFT

PALATE

WITH

INSUFFICIENT

LOCAL TISSUE AVAILABLE

TO

ACCOMPLISH

FUNCTIONAL

REPAIR

LOB

WIDE CLEFT

OF

THE

HARD

PALATE

WHICH CANNOT BE

CLOSED

WITH

VOMER

FLAP

OR

OTHER

LOCAL TISSUE

NEUROMUSCULAR DEFICIT OF THE SOFT

PALATE

AND

PHARYNX

CASES WITH

JUSTIFIED

MEDICAL

CONTRAINDICATION

TO

SURGERY

SUCH AS BLOOD

DYSCRASIA

OR WHEN

SURGERY

IS

DELA

ED

EXPANSION

PROSTHESIS

FOR

IMPRO

EMENT

OF

SPATIAL ICLATIONSHIPS

COMBINED

PROSTHESIS

AND

ORTHODONTIC

APPLIANCE

884


28/61

INDICATIONS FOR

PROSTHESIS

IN

OPERATED

PALATES

INCOMPETENT

VELOPHARYNGEAL

MECHANISM

WITH

DEEP PHARYNGEAL

SPACE

BEHIND

THE VELUM

SURGICAL

FAILURESFISTULAS

IN THE

ALVEOLUS

HARD

OR

SOFT

PALATE

CONTRAINDICATL

FOR

PRUI THUSIS

FEASIBILITY

OF

PRIMARY

OR

SECONDARY

SURGICAL REPAIR

BASED

ON

DEFINITIVE

DIAGNOSTIC

METHODS

SEVERE

MENTAL

RETARDATION

UNCOOPERATIVE

PATIENT

AND

PARENTS

UNCONTROLLED

DENTAL

CARIES

PARTIAL

OI

COMPLETE

ANODONRIA

DENTINOGENESIS

IMPERFECRA

AND

AMELOGENOSIS

IMPERFECTA

LACK

OF TRAINED

PROSTHODONTIST

KENNETH

ADISMAN OF NEW YORK

UNIVERSITY

DENTAL

CENTER

CHOSEN TO

WRITE THE

CHAPTER

ON

CLEFT PALATE PROSTHETICS FOR THE

97 CEFT

LIP

AND

PALATE WAS

TRAINED UNDER WALTER

WRIGHT

AND

SINCE

97

HAS

WORKED

WITH

JOHN

CONVERSE

AT

THE NEW YORK

UNIVERSITY

MEDICAL CENTER

TO

INTEGRATE

DENTAL

TREATMENT

WITH

RECONSTRUCTIVE

PLASTIC

SURGERY

AND

SPEECH

THERAPY ACCORDING

TO

ADISMAN

THERE

ARE

THREE

GENERAL

TYPES

OF

PROSTHESIS

JISMAN

THE FIXED

OR

IMMOBILE

PROSTHESIS

WHICH REMAINS

STATIONARY

PERMITTING

THE

PALATAL

AND

PLAN

NGCAL

MUSCULATURE

TO CONRACT

AND

FUNCTION

AGAINST

ITS

LATEIAL AND

POSTERIOR

STIRFACCS THIS

IS

THE

ACCEPTED PE

FOR

PIOSTLIETIC

THERAPY

THC

HINGE

NI

MOVEAHIC

PIOSTHESIS POPULAI

IN

THE NINCREENRH

CENRUIS

WHICH

ATTEMPRCD

TO

IMITATE THE SOFT

PALATE

HUT WAS TOO

COMPLICATED

AND

DIFFICULT

TO

MAKE AND

MAINTAIN

THE

MEARUS

TYPE

EXTENDED INTO THE NASAL

CASITY

INSTEAD OF THE

PHARYNX

WITH

AN

AIRWAY PROVIDED

BY

PEIFORATION

OF THE NASAL

EXTENSION THIS

TYPE

IS

INDICATED FOR

UNIEPAIRED

HARD AND SOFT

PALATE

CLEFTS

ADISMAN

CONSIDERS

PROSTHETIC

INRERVCNRION INDICATED

FOR FEED

ING

AIDS AND WHERE

SURGICAL

CLOSURE IS

NOT

DEEMED

ADVISABLE

OR

PRACTICAL

BECAUSE OF

POOR HEALTH

EXRENSIVC

CLEFTS

LACK OF

LOCAL

TISSUE

COLLAPSED

ARCHES

OR

FAILED

SURGERY

OR IN

CONJUNCTION

WITH

SURGERY

HE

FORWARDED

EXAMPLES

OF HIS CLEFT

PALATE PROSTHESIS

THE

MODERN

STANDARD

PROSTHESIS

IS

COMPOSED

OF

THREE

PARTS

THE MAXILLARS

SECTION SIMPLE

ACT

LIE

RESIN BASE

COS

ERING

THE

HARD

PALATE

AND

RCTAINCD

ON

THE TEETH

HN

ILEXILDIE

GOLD

WIRE

CLASPS

835


29/61

THE

PALATAL

EXTENSION

SECTION CAST METAL BAR

THAT

TRAVERSES THE

LENGTH

OF

THE SOFT

PALATE

AND ENDS IN

LOOP

FOR RETENTION OF

THE

NASOPHARYNGEAL

SECTION

THE

NASOPHARYNGEAL

SECTION WHICH ENDS IN BULB

OF THE

REQUIRED SIZE

DEPENDING

ON

THE

DEFORMITY

IT

IS

USUALLY

MADE

OF

CLEAR

METHYL

METHACRYLATC

RCSIN

SO THAT IRRITATION OF THE

PHARYNGEAL

MUCOSA

CAN BE

DETECTED

IT MUST BE

LARGE ENOUGH

TO

PROVIDE

VELOPHARYNGEAL

SEAL

DURING

PHONATION AND

SWALLOWING

BUT

NOT BLOCK THE NASAL

PASSAGES

FOR

RESPIRA

TION

IN

UNOPERATED

CASES

MOST

PHARYNGEAL

BULBS

ARE SITUATED

HIGH

IN

THE

NASOPHARYNX

WITH THE

LOWER

ATEA

OF THE BULB IN

LINE

WITH

THE

POSTERIOR

NASAL

SPINE

AND

PALATAL

PLANE

IN

POSTOPERATIVE CASES

THE BULB

IS

GENERALLY

PLACED

LOWER

IN THE

NASOPHAR

NX

BECAUSE

THE VELAR TISSUE

AIDS IN

PARTIALLY

CLOSING

THE

VELOPHARYNGEAL

PORT

BUT

NOT SO LOW

AS TO

BE

DISLODGED BY

THE

TONGUE DURING SWALLOWING

VITH

THE

SAME ATTISTIC

STIEIK THAT

ATTIACTS

HIM

TO

THE

BEICHES

FOR

SEASHELL

COLLCCTING

ACHS II

IN CONSTIUCTS CLEFT

PALATE PIOSTHESES

IS

SHO

TO

IMPIOVE

BOTH

FUNCTION

AND

APPEATANCE

TO

HELP

THE

PATIENT

IN

TAKING

USEFUL LE

IN

SOCIET

886


30/61

PROSTHESES

CAN

BE CONSTIUCTED AS

APPLIANCES

FOR

PALATAL

TRAINING

STIMULATION

OR

LIFTING

BERKOWITZ

OF THE

UNIVERSITY

OF

MIAMI

EXPRESSED

HIS

THOUGHTS

ABOUT

SPEECH

AID

PROSTHESIS

ARAM

AND

SUBTELNY REPORT

THAT WHEN THE

SYNERGISTIC

BEHAVIOR OF THE ELAR

AND

PHARYNGEAL

RNUSCULATUIE

IS

INADEQUATE

IN

CREATING

SPHINCTERIC TYPE

OF

LUMEN CLOSURE

VELOPHARYNGEAL

CLOSURE SPEECH

CAN

BE

ASSISTED

P 5

RHETIC

AID

THE

SPEECH

BULB

PHARVNGEAL

EXTENSION

USUALLY

CONSTRUCTED

OF

ACIYLIC

IESIN ROUST

CONFORM TO

THE

DIMENSION

SHAPE

AND

POSITION

OF THE

ELOPHARY OGEAL

OPENING

SX HICH

EXISTS

DURING

FUNCTION

THEREFORE

THE

PI

POSITIONING

OF

THE

PHARVNGEAL

SECTION IS

CIITICAL

TO

PROSTHETIC

SUCCESS

SPCECH

AID

APPLIANCE

THE THICE

II

TS

PECTH

BULB CONNECTED

PROSTHETIC

FAILURES THAT

IS THOSE

HICH

DO NOT

IMPROS SPEECH

IESULR

TO

DENTURE

SHANK

WHEN

PHARYNGEAL

SECTIONS ARE

INAPPROPRIATE

IN

SI7E

SHAPE

OR

PLACEMENT

OMPERCNR SPLTCLL

UD

IPPLI

IN

887


31/61

THEY

STATE

THAT

VELOPHARYNGEAL

CLOSURE IS

CLOSELY

RELATED

TO THE

PALATAL

PLANE

FROM

TO

YEARS

OF

AGE

IT IS

SLIGHTLY

BELOW

THE

PALATAL

PLANE

AFTER

YEATS

OF

AGE

CONTACT IS

SLIGHTLY

ABOVE

THE

PLANE

ALSO

THE

ANTERIOR TUBERCLE

OF

THE FIRST

CERVICAL

VERTEBRA IS

POOR

LANDMARK

FOR THE

PLACEMENT

OF

THE

PHARYNGEAL

SECTION THE

PHARYNGEAL

SECTION

MUST MAKE

CONTACT

WITH

THE

POSTERIOR

PHARYNGEAL

WALL

AND BE

CONTACTED

BY

THE

MUSCLES OF

THE

LATERAL

ASPECTS

OF

THE

NASOPHAIYNX AS

WELL

AS

THE

SOFT

PALATE

DURING

FUNCTION

REST

PHONATION

OF

UL

POOI

PROSTHESIS

PROPER

PROSRHCSI

ARARN

SUBTELNY

INCOMPETENT SPEECH

AID

APPLIANCE

THIS VELUM

WAS

HEAVILX SCARRED

AND

IMMOBILE IT FAILED

TO ELEVATE

ON

FUNCTION

THE MAXILLA

WAS

HYPOPLASTIC

THE

SPEECH

BULB

AS

PLACCD VERY

LOW

DUE

TO THE

NATURE

OF

THE ELUM AND

TBEICFORE

FAILCD

TO RCDUC NASAL

IESO

NANCE

ALTHOUGH

IT

MADC

CONTACT OH THE

POSTERSOS PM NGEAL

ALL

AND

XX

AS

OF

ADEQUATE WIDTH

IT STILL DID

NOT FUNCTION AND

DO

ALL IT

SHOULD

HAVE DONE

TO

IMPTOX SPECCH

HAD IT EXTENDED

MORE

SUPERIOIL

INTO RHC

PLMR

NX

IT

XX

OULD

HAVE

REDUCED

NASAL

RESONANCE

888


32/61

VARIATIONS

IN

COMBINED

USE

OF

OBTURATOR

AND

PHARYNGEAL

FLAP

IN

958

IN

THE

AMERICAN

JOURNAL

OF SURGERY

RICHARD

WEBSTER

WITH

QUIGLEY

COFFEY

QUERZE

AND

RUSSELL OF

BROOKLINE

PROPOSED

THE

EARLY

USE

OF

AN

OBTURATOR TO

CLOSE

THE CLEFT OF THE

HARD

PALATE

IN

ORDER

TO

AVOID

SURGERY

OF

THIS

AREA

UNTIL THE

AGE

OF

TO

YEARS

AS

EARLIER

SURGERY

WAS

COMING

UNDER

SCRUTINY

AS

POSSIBLE

CAUSE

OF

MAXILLARY GROWTH

RETARDATION

AT THE

SAME TIME

IN ORDER NOT TO

IMPEDE

SPEECH

DEVELOPMENT

WEBSTER

CLOSED THE

SOFT

PALATE

WITH

THE

AID

OF ONE

OF

HIS

WIDE

SUPERIORLY

BASED

PHARYNGEAL FLAPS

IN 973

TOMOHIRO

SHIGEMATSU

OF

TOKYO

DENTAL

COLLEGE

AFTER

AN

EXTENSIVE

STUDY

CONCLUDED

THE ABOVE

RESULTS

INDICATE

THAT

PHATYNGEAL FLAP

SURGEIY

AND

SPEECH

AID

IMPROVE

THE

HYPERNASALITY

AND

DYSARTHRIA

OF CLEFT

PALATE PATIENTS

WITH

NASOPHARYNGEAL

INCOMPETENCE SPEECH

AID IS

LESS EFFECTIVE THAN

PHARYNGEAL

FLAP SURGERY

FOR

IMPROVING SPEECH

BUT IT SEEMS TO

BE

USEFUL TO

SET

SPEECH

AID BEFORE

PHAR

NGEAL

FLAP

SURGERY

IN ORDER TO

IMPROVE

POSTOPERATIVE

SPEECH

RESULTS

TEMPORARY

OBTURATOR

AS

STOPGAP

PENDTNQ

POSSTBLE

LATER

SURG

ROBEIT BLAKELEY

TALL

LANKY

LAD

GROWINGUP

IN

THE

MICHIGAN

OUTDOORS

GOT

TO

COLLEGE

IA THE

HIGH

HURDLES

ITH

STRONG

CONTENTION FOR

THE

OLYMPIC

GAMES

AFTER

YEAR

AND HALF

OFLAW

SCHOOL

HE

DISCOVERED

THE EXCITEMENT

OF

SPEECH

PATHOLOGY

AND

ENDED

UP

WITH

THREE

DEGREES

IN THIS

SPECIALTY

AT THE

UNIVERSITY

OF

OREGON

HE

HAS

PIONEERED

SYSTEMATIC

REDUCTION

OF

TEMPORARY

ROBERT

BLAKELEY

SPEECH PROSTHESIS

FOR

CLEFT

PALATE PATIENTS

IN

WHOM

SURGERY

WAS

UNSUCCESSFUL

HERE IS

RESUM

OF HIS COMMENTS

IN

977

IT

IS

IMPORTANT

THAT WE

INTERRUPT

NASAL EMISSION

EARLY ENOUGH

FOR EACH

CHILD

IN ORDER THAT THIS

NASAL EMISSION

NOR

INTERFERE

WITH

DEVELOPMENT

OF

THC 6 AIR

PRESSURE

CONSONANTS

OR

THAT

WE

STOP

THE

NASAL AIR LEAK

EARLY ENOUGH

SO

THAT

ERRORS ALREADY OCCURRING

DO

NOT

BECOME

FLIMLY

HABITUATED EATH

COMPENSA

TORY

ERRORS ARE USUALLY RELATIVELY

EASILY

ALTERABLE

BY

THE

PATIENT

ANDOR

CLINICIAN

IF NORMAL

ORAL BREATH

PRESSURE

IS

PRM

IDED

EALLY

ENOUGH

AS

NOTED

IN

972

SUBSTANTIALLY

HABITUATED

COMPENSATORY

ERRORSARE

DIFHCULT TO

UNDO

8A9


33/61

EVEN

WITH

FORMAL

SPEECH

HABILITATION

PROCEDURES

THE

SPEECH

GOAL

FOR

CHILDREN

WITH

REPAIRED

CLEFT

PALATE

SHOULD BE

PREVENTION

DUTING

PRESCHOOL

YEARS

NOT CORRECTION IN

GIADE

SCHOOL AFTER

HABITUATION

THE

TEMPORARY SPEECH PROSTHESIS

CAN BE

CONSTRUCTED

PLACED

AND

THE CHILD

OBTURATED

WITHIN

PERIOD

OF

TWO TO

SEVEN

DAYS

DEPENDING

UPON

MANAGE

ABILITY

OF THE CHILD AND

COOPERATION

OF

THE

PARENTS

JBTURATION OF

COURSE

IS

THE

GOAL STOP

THE NASAL

EMISSION

OF AIR

EARLY

ENOUGH

AND

THE CHILD WILL

DEVELOP

NORMAL

ARTICULATION

ON HIS

OWN

OR WITH

MINIMAL

PARENTPROFESSIONAL

ASSISTANCE IN

VIRTUALLY

ALL INSTANCES

THE OBTURATOR

WILL

PROVIDE

NORMAL

VOICE

QUALITY

OR

SLIGHT

TEMPORARY

HYPONASALITY

WHEN IT

IS

PLACED

IN THE

CHILDS

MOUTH

THE

OREGON

CRIPPLED

CHILDRENS

PROGRAM

AT

THE

UNIVERSITY

OF

OREGON

PRESENTLY

HAS

25

CHILDREN

WHO

WEAR

TEMPORARY SPEECH

PROSTHESIS

IN

PROGRAM ENCOMPASSING

SOME

75

PATIENTS

OBTURATORS

HAVE BEEN

PROVIDED

FOR

CHILDREN

AS

YOUNG

AS

TWO

YEARS EIGHT

MONTHS

THE OBTURATOR

REDUCTION

PROGRAM

WORKS

SOMETHING

LIKE THIS

INITIALLY

AN

OBTURATOR

OF

NECESSITY

IS MADE

LARGE ENOUGH

TO ELIMINATE

HYPERNASALITY

AND

NASAL EMISSION

THIS

VITRUALLY ALWAYS

ENTAILS

OVERIMPINGEMENT

UPON

THE

MUSCULARUIE OF THE

AREA AT

ABOUT

THE

HORIZONTAL

PLANE

OF

THE HARD

PALATE

THE

PATIENT

TENDS

TO

DRAW

AWAY

FROM

THE

OBTURATOR

INITIALLY

OR MAY

HABITUALLY

RELAX THE

PHARYNX

TO

PRODUCE SOME

SOUNDS

BECAUSE THAT

HAS

BEEN

HISHER

LEARNED

RESPONSE

THUS

ONE MUST FORCE

ORAL EMISSION VIA

THE

OBTURATOR

RAKING

CAIC NOT

TO

IMPINGE

TOO

RML

UPON

SOFT

TISSUE

OVEILYING

THE

ATLAS

IN

ORDER

TO

GET

CONRI

OL OF

THE

HYPERNASALIRV

AND

NASAL EMISSION

THEREAFREI

THE RECOMMENDATIONS

ARE

SPECIFIC

TO

CONSONANT

RRTICULATION

ALONE

NO

OTHER

MANAGEMENT

OF

THE VOICE IS

REQUIRED

SAX

MANIPULATION

OF

THE

SIZE

OF THE OHTUI AROI

AFTER

THE

PATIENT

HAS

WORNAN OBTURATOR FOUR

TO

EIGHT

MONTHS

THAT

PATIENT

IS AN

HABITUAL

ORAL

SPEAKER WITH

TLIC OBTURATOR

IN

PLACE

AND IS

ALTERING

ARTICULATION

BY

MATURATION

ALONE

BY

PARENT

ASSISTANCE

OR

BY

FORMAL

HELP

FROM

SPEECH

PATHOLOGIST

IT IS

AT

THIS

RIME

THAT

SYSTEMATIC REDUCTION OF THE

OBTURATOR

CAN

BEGIN

THIS

IS CARRIED

OUR

BY

THE

SPEECH

PATHOLOGIST

AND

DENTIST

USING

COMBINATION

OF

SPEECH

RESTING UTILIZATION

OF

NASAL

LISTENING

TUBE AND

THE NASAL

FLUTTER

TEST

PRESSURE

INDICATOR

PASTE

ON

THE OBTURATOR

DURING

SPEECH

TESTING

AND ORAL

INSPECTION

THE

AMOUNT AND

PLACE

OF

REDUC

TION IS

THEREBY

DETERMINED

IN

GRADUAL

STEPS

AT EACH

APPOINTMENT

EG

TO

MM ON

EACH SIDE

OF THE OBTURATOR

AND

MM

FROM

THE

ANTERIOR

AND

CONTINUES

UNTIL THE

SPEECH PATHOLOGIST BEGINS TO

DETECT

SUBCLINICAL

SIGNS

OF

HYPERNASALIRY

ANDOR

NASAL

EMISSION

THE

REDUCTION

PROCESS

IS THEN

DISCON

TINUED

MODEL OF

THE OBTURATOR

PORTION

IS

REPRODUCED

IN DENTAL

STONE AS

PERMANENT ICCORD

AND THE

PATIENT

RETURNS

IN

APPROXIMAREL

FOUR

MONTHS FOR

THE

SAME

APPROACH

TO OBRURAROI

REDUCTION

BECAUSE HIS

PALAROPHARYNGEAL

MUSCULATURE HAS

USUALLY

MADE

UP

THE DIFFERENCE

THIS

RIME

IN

AN

89


34/61

APPARENT

PHYSIOLOGIC

MAINTENANCEOFTHESTATUS

QUO

FOR

COMPLETE

VP

CLOSURE

OBTURATOR

REDUCTION

CONTINUES IN

THIS FASHION

OVER SIX

NINE AND

TWELVE

MONTH

INTERVALS

UNTIL THE LIMITS OF

VP

COMPENSATION

ARE

APPROACHED

MOST

OF

THE

PATIENTS

AT

THIS

POINT

IN THEIR

MANAGEMENT

HAVE BOTH NORMAL

VOICE

AND

ARTICULATION

THUS

ANY

SURGICAL

PROCEDURE

USUALLY PHARYNGEAL

FLAP

BECOMES

SUBSTITUTE

FOR

THE

PROSTHESIS

IN CHILD

WITH NORMAL

SPEECH

IT IS

FELT

BY

THE

SURGEON

LINDGREN

DENTIST

ADAMS

AND

SPEECH

PATHOLOGIST

BLAKELEY

AS

PUBLISHED

IN

964

THAT THE

PATIENT

BECAUSE

OF

NORMAL

MONITORING

SYSTEM

FOR

SPEECH

AND

MAXIMALLY COMPEN

SATED

VP MUSCULATURE

IS

FAR

BETTER CANDIDATE

FOR

SECONDARY

VP

SURGERY

FOR

SPEECH

PURPOSES

THAN

HE WOULD HAVE BEEN

PRIOR

TO USE

OF THE

SPEECH

PROSTHESIS

IN ONE

STUDY BY

ME

IN 97

OF

6

OBTURATOR

PATIENTS

9

PERCENT

OF THE

OBRURATORS

WERE

REDUCED IN

SIZE

TO

THE

POINT

OF

REMOVAL

LEAVING

THOSE

PATIENTS

WITH NORMAL

VOICES

THIRTY

PERCENT

OF THE

6

WERE

REFERRED

FOR

SURGICAL

SUBSTITUTE

WITH

GOOD

RESULTS AFTER

IT

WAS

FELT THAT

THEIR OBTURATOIS

COULD

NOT

BE

ADDITIONALLY

REDUCED

IN SIZE THE

REMAINDER OF

THE

PATIENTS

CONTINUED

UNDER

THE OBTURATOR

REDUCTION

PROGRAM

ONE CANNOT

ACCOUNT

EXACTLY

FOR

THE

AMOUNT

OF

VP

COMPENSATION

MUSCLE

HYPERTROPHY

IN AN

OBRUIAROR REDUCTION

PROGRAM

FOR

ANY GIVEN PATIENT

SOME

PATIENTS

NO

DCMBR REQUIRE

NO

COMPENSATION

OF MUSCULATURE

BUT

ONLY

NEED

OBRURARION

AND

OBTURATOR

REDUCTION

WEANING

TO

REACH

THE

MUS

CULATURE

HOW

TO

FUNCTION

OPTIMALLY DURING SPEECH

HOWEVER

SOME

GENERAL

IZATIONS CAN

BE MADE

BASED

UPON

THE HISRORKAL DENTAL STONE

MODELS OF

OBTURATOIS

REDUCED

THE

GREATEST

COMPENSATION

OBVIOUSLY OCCURS

IN RHC LATERAL

PHAI

NGEAL

WALLS

AND

COMPENSATORY

HYPERRROPHY

OF

VP MUSCULATURE

DOES

TAKE

PLACE

IN SUBSTANTIAL

NUMBER

OF

PATIENTS

IN THE

6

PATIENT

SUUD

NOTED

THE MEAN LATERAL

REDUCTION WAS IT5

MM

WHILE

THE

MEAN

REDUCTION WAS

29

MM

IN

975

IN

THE

TRANSACTIONS OF

THE SIXTH INTERNATIONAL

CON

GRESS

OF

PLASTIC AND

RECONSTRUCTIVE

SURGERY

HIROSE

OF

MAT

SUMOTO

JAPAN

RECALLED THAT

YEARS

BEFORE

CASE

OF

PURPURA

IN

CLEFT

PALATE

HAD

PREVENTED

EARLY

SURGERY

THIS

PRECIPITATED

THE

EARLY FITTING

OF

AN

OBTURATOR

TO

FACILITATE

EATING

AND

SPEECH

UNTIL

SUCH TIME

AS

SURGICAL CLOSURE

WAS

INDICATED HIROSES

SUBSEQUENT

EXPERIENCE

WITH

THE

USE

OF

TEMPORARY

OBTURATORS

PROVED

THAT

THEY

WERE MOST

EFFECTIVE

WHEN

THEY

COVERED THE CLEFT

CORRECTLY

AND

EXTENDED TO

THE

POSTERIOR

PHARYNGEAL

WALL

WHEN

THE VELAR

PIECE

FITTED

SNUGLY

INTO THE

CLEFT AND

ITS

TIP

ALMOST TOUCHED

THE

POSTERIOR PHARYNGEAL

ALL

FIVE OUT

OF

EIGHT PATIENTS

OBTAINED

NORMAL

SPEECH

MNOIE

89


35/61

WHEN THE VELAR

PIECE

MADE

OF

SOFT ELASTIC

SILICONE

RUBBER

COVERED THE

CLEFT

THE

TIP

AGAIN

ALMOST

TOUCHING

THE

POSTERIOR

PHARYNGEAL

WALL

SEVEN

OF

NINE

PATIENTS

OBTAINED

NORMAL

SPEECH

HIIOSE NOTED

THE

PROPEI

AGE

TO

BEGIN

WEAIING

THE OBTURATOT

SEEMED

TO

BE

TWO

YEARS

BECAUSE

AT

THAT

TIME

THE DCNRITION

OF FIRST

MOLARS

IS

ALMOST

FINISHED

AND

WE

CAN

USE

THEM

TO HOLD THE

OBTUIATOT WITH

CLASPS

THE

CHILDREN

SOON

LIKED

TO

WEAI

THE

OBTUIATOIS AND

THEY

DID

NOT LIKE TO

SPEAK

OR

EAT

WITHOUT

THE

OBRURATORS IN

NINE

CASES OF WHICH THE

PUSHBACK

OPERATION

AS

PER

FORMED

AT

LARCI

DATE

ALL

OBTAINED NORMAL

SPEECH

BY

THIS

METHOD AND ALL

UISES EIAINCD

NORMAL

SPEEC

PI

FOR

FLOATING

PREMAXILLA

PROSTHESIS

CAN BE USED

TO

FIX

FLOATING PREMAXILLA

FIXED

PARTIAL

DENTURE IN

THE

TEENAGE

CHILD

CONSISTS OF

ACRYLIC

OR

VINYL

RESIN

OVER

CAST

GOLD

COPINGS

ON ABUTMENT

TEETH

AND

ACRYLIC

OR

VINYL

RESIN

PONTICS

FOR

THE

MISSING

TEETH

THE

RESULT

IS FIXATION

OF

THE

PREMAXILLA

TO THE

LATERAL

MAXILLARY

PROCESSES

FUNCTIONAL

OCCLUSION

AND

NORMAL COSMETIC

APPEARANCE

OVERLAY

DENTURE

SUPERIMPOSED

PROSTHESES

ARE

INDICATED FOR

PATIENTS

WITH

CLEFT

PALATE

WHO

RECLUIRE

OCCLUSAL AND

COSMETIC

IMPROVEMENT

BECAUSE OF

UNDERDEVELOPED

MAXILLA OT

OVERDEVELOPED

MANDIBLE

TO

CORRECT THE

DISHARMONY

AND

MAIRELATIONSHIP

BETWEEN

THE

TWO

WHERE FOR

892


36/61

SOME

REASON

CORRECTIVE

SURGERY

IS

CONTRAINDICATED

OVERLAY

DEN

TURES ARE

INDICATED

FOR

PATIENTS

WHO

HAD

PREMAXILLARY

RESECTION

EARLY

IN

LIFE

RESULTING

IN

MAXILLARY

CONTRACTION

LEAVING

FORESHORTENED

OCCLUSAL

RELATIONSHIP

IN

CONSEQUENCE

OF THE LACK OF

VERTICAL

LATERAL AND

ANTEROPOSTERIOR

GROWTH

PATIENTS

WITH

FLOATING

PREMAXILLAE

IN ABNORMAL

RELATIONSHIPS

SO

THAT

MAXILLAE ARE

CONTRACTED

PATIENTS

WITH

LIP

COLLAPSE

AND

TIGHTNESS

IN WHOM THE

SUPER

IMPOSED

PROSTHESIS SUPPORTS

AND

PLUMPS

THE

LIP

FOR

MORE

HARMONIOUS

FACIAL

CONTOUR

POSTOPERATIVE

CLEFT

PALATE PATIENTS

WITH FEW

OR

MINIMAL

NUM

BER

OF ABUTMENT

TEETH

EXHIBITING

COLLAPSED

OCCLUSAL

RELATION

SHIPS

DUE

TO INHIBITION

OF

MAXILLARY

GROWTH

AS

COMPARED

TO

MANDIBULAR

DEVELOPMENT

AS THE

PROSTHODONTIST

CUM

TO

THE AID OF THE

SURGEON

THE

SURGEON

CAN

BE OF

ASSISTANCE

TO

THE

PROSTHODONTIST

SCARRED

PALATE

MAY

BE

REDIVIDED

TO CREATE MORE

FAVORABLE

NASOPHARYNGEAL

AREA

FOR

PLACEMENT

OF

THIS

SECTION

OF LHE

PIOSUHESIS

RECONSTRUC

NON

OF LABIAL

SULCUS

OR EXCISION

OF

FIBROUS

BANDS AND ADHESIONS

CAN

FACILITATE

THE

PLACEMENT

OF PROSTHESIS

RESECTION

OF AN

OBSTRUCTING FLOATING

PREMAXILLA

MAY

CREATE

BETTER

ENVIRONMENT

TOT

PROSTHESIS

AND

IN

THE

ABSENCE

OF

TEETH

CREATION OF RETENTION

PERFORATIONS

IN THE MUCOSA

MAY

ALLOW MUCOSAL INSERTS TO

AID IN

RETAINING

THE

PROSTHESIS

ROBERT MILLARD

EMPHASIZED

THE

IMPORTANCE

OF

HAVING

THE

SPEECH PATHOLOGIST

AND THE

PROSTHODONTIST

WORK

TOGETHER

WITH

THE

PATIENT

AND

THE

PARENTS

TO

ACHIEVE THE

OPTIMAL

USE OF THE

PROSRHCRIC

SPEECH

APPLIANCE

PROSTHESES

CAN

BE

OF INESTIMABLE

VALUE

IN

MAINTAINING

FUNCTION

WHILE

ONE

IS

AWAITING

THE

OPTIMUM

RIME

IN

RESPECT

NO

GROWTH

FOR

SURGERY

FROM THE

SURGEONS

POINT

OF VIEW AFTER

THAN

THE

NEED

FOR

PROSTHESIS

SHOULD BE EXTREMELY

R2RE

AS

IN

INDICATES EITHER

FAILURE OF

SURGERY

OR

UNWILLINGNESS

OT

INABILITY

NO

CARRY

OUR

ADEQUATE

SECONDARY

SURGERY


37/61

LIBBY

WILSONMACKBY

OF

RANCHO

LOS

AMIGOS

HOSPITAL

CALIFORNIA

EMPHASIZED

THE VALUE

OF VARIOUS

PROSTHETICS

BEFORE AND

IMMEDIATELY

AFTER CLEFT

PALATE

SURGERY

IN

978

SHE NOTED

PROSTHETIC DEVICES

CAN

POSITIVELY

AFFECT THE

OUTCOME

OF

SURGICAL

PROCE

DURES

WHEN

PLACCD

IN

NEONATE

WITH

PALATAL DEFECT INTRAORAL

APPLIANCES

HELP

TO

OBTURATE

THE CLEFT

DURING

FEEDING

THE

APPLIANCE

PROVIDES

FIRM

SURFACE

AGAINST

WHICH

THE

INFANTS

TONGUE

WILL

TRAP

THE

NIPPLE

AND

FACILITATE

DELIVERY

OF FLUIDS IT

MAY

ALSO

AFFORD

SOME

PROTECTION

TO THE DELICATE

NASAL

BBY

WILSON

IVLACKBY MUCOSAWHICH WOULD

OTHERWISE BE

EXPOSED

TO

IRRITANTS FROM THE

ORAL

CAVITY

AFTER

LIP CLOSURE

THIS

SIMILAR DEVICES

HELP

ICTAIN

PU

OF THE

PALATAL

SHELVES

AND

PIOMOTE

MORE FAVOJ ABLE

MAXILLARYMANDIBULAI

RELATIONSHIPS

MAXILLARY

ARCH FORM

CAN BE

REGULATED

BY

MODIFYING

THE

APPLIANCES

AS

THE

CHILD

GROWS

WHEN

PALATAL

REPAIR

IS

PERFORMED

THE

SUTURE LINE

CAN BE

PROTECTED

FROM

THE

INFANTS

TONGUE

BY

CONTOURING PLASTIC

CONRAINCI LID

TO THE

ARCH

AND

SECURING

THIS WAFER

IN

POSITION

ITH

ABSOIBABLE

SUTURE

MATERIALS

894


38/61

•

• •

• •

415-13

Rev.

]-

MERIC N ONCOLOGIC

HOSPIT L

CHART COpy

ROGRESS REPORT

Notll prairllss of caslI. complications. chanilll n dlaposls

condition

on

dlscharill . Instructions

to

patlllnt

GILLESPIE, Neil

74123

7/22/85

The pa t i en t i s a 9 year old white male r e f e r r e d by Dr. Carver

who i s s t a t us

pos t

l e f t un i l a t e ra l 'Class IV l i p and pa la t e r e pa i r

a t approximate ly age two

years old .

e

i s unc lear

about the de ta i l s

o f the degree o f h i s de fec t s , the su rg ica l

procedures ,

who performed

th i s , or

exac t ly

where it was done.

Apparent ly ,

a f t e r

the

i n i t i a l

bout of su rger i es to repa i r

the

l i p and hard and so f t

pa l a t e , he

had

no fu r the r su rg ica l

in tervent ion . e

had no

ongoing fol low-up

for

t h i s problem. At approximate ly age

13

to 14 years o ld ,

he

underwent

or thodont ic

t rea tment

a t Temple Univers i ty

Ho spi ta l s

Dental

School

and t h i s u l t ima te ly resu l t ed in the placement

of

a

r e t a i n e r with

a

pros the t ic

l e f t l a t e r a l inc i sor . e has worn t h i s s ince t ha t t ime.

e no t ices dra inage of food i n to the l e f t nasal

f loor .

His l e f t and

· r igh t

n o s t r i l s

are opened, although the l e f t i s

somewhat

s t u f fy

and

occluded.

His

main concerns upon presen ta t ion

are re la ted to

the

pe r s i s t e n t

c l e f t in the l e f t alveolus , the dra in ing f i s tu la ,

and

the

poss i b i l i t y

of

foregoing

the

need

fOD a

pros the t i c

device.

In

add i t ion ,

however,

it i s

obvious on

confront ing

the

pa t ien t t ha t

he has

a moderate

amount

o f

nasal

deformi ty , f l a t t e n ing

o f

the l e f t

s ide in the

premaxi l la ry

region,

and

l i p d i s t o r t i on , pa r t i c u l a r ly

a t

the vermi l ion .

In

addi t ion ,

the

pa t i e n t has

a s ign i f i c a n t ly hypernasal

speech pa t t e rn

with ~ v o u s

velopharyngeal

incompetence.

On phys ical examinat ion beginning ex te rna l ly , the p a t i e n t has

a s l igh t ly

l a rge

nose with a small

dorsa l

hump. The

s i z e of the nose

i s s l i gh t ly l a rge r

than

propor t ional t o h i s face , a l though not

exaggera ted ly so.

The

r i gh t

a l a r

dome i s fu l l .

The

l e f t a la r

ca r t i l age

i s pos t e r io r ly and l a t e r a l ly displaced and somewhat

hypoplas t ic compared to the l e f t s ide .

The

l e f t a la r base

i s

a l so

l a t e r a l l y

d isp laced .

The nos t r i l

sill

i s

f l a t t e ne d ,

and

there

i s

an obvious

f i s t u l a between the

d i s t a l nasa l

f loo r and the ora l

cavi ty . The l e f t columella , l ikewise,

i s somewhat hypop las t i c and

twis ted .

The

upper

l i p

sca r

i s well

healed

and appears to be a

LeMesurier o r Tennison-Randal l

type

repa i r .

The upper

l i p

tuberc le

i s preserved, but the vermil ion border i s

somewhat

i r r egu la r .

Length appears , however, to

be

sa t i s fac tory .

There i s

a - l a t e r a l

orb i c u l a r i s

bulge o f the

l e f t upper l ip . In t e rna l ly , t he re

i s

a

wide

c l e f t of the l e f t a lveo la r r idge

a t

the l evel of the l a t e r a l i nc i so r

with

a f i s t u l a i n to the nasa l f loor . This runs

pos t e r i o r l y

and nearly

to

the end o f the secondary pa la te . The so f t

pa la te has

a l i nea r

scar .

it

i s

very

shor t , and there

i s l a t e r a l

movement

but no

cen t ra l movemen

of note .

cont inued •


39/61

GILLESPIE Nei l

Page

Two

7/22/85

y

impress ion

and recommendation to

the pa t i en t

genera ted

th ree

s pec i f i c areas of i n t e r e s t . One r e l a t e s to the s c a r r ev i s ion

of

h is

upper nose and

the

r e l a t i ons h i ps

of hi s

nasa l

t i p ,

nose

and

secondary

defo rmi t i e s

in

t h i s

area .

The

second

a rea o f

i n t e re s t

in importance i s the

a lveo la r

c l e f t with the

naso -o ra l f i s t u l a .

The t h i r d a rea i s

the

pa la t e with obvious ve lopharyngea l incompetence

and

a

foreshor t

and sca r red pa l a t e .

y i n i t i a l recommendations wi l l

be

t ha t the

pa t i en t undergo

or thodont ic evalua t ion .

I w i l l

ar range

for

him to

see

Dr. Rosario

Mayro fo r eva lua t ion

as

wel l as

x-rays

to assess

his occ lusa l

r e la t ionsh ips . t a l so

should

be

noted

t ha t he, i n gene ra l ,

had

a f a i r ly s a t i s f ac to ry

occ lusa l re l a t ionsh ip .wi th

some

l a t e r a l

col lapse

and

c ros s b i t e on

the minor segment

on

the l e f t

and eva lua te h i s

adequacy

as a

candida te for bone g r f t i n ~ w h i h

I

th ink he would

qua l i fy . Subsequent to

t h i s ,

I w i l l

have him see Dr. Harvey Rosen

concerning

the

ac tua l surg i ca l

procedure

and

a l s o

he

w i l l

be

seen

by

Miss Mari lyn Cohen

a speech pa tho log i s t

with

s pec i a l

i n t e r e s t

in

pa t i e n t s having c l e f t l i p and pa la t e for

an

eva lua t ion concerning

f ea s ib i l i t y of pos te ropharyngea l f l ap in

a pa t i en t

o f

t h i s age group.

Concerning the

ex te rna l

rev i s ions , t h i s can be accomplished concerning

the

upper l i p , possib ly a t the same t ime

as

the f i s t u l a c losu re with

orll lcularis

r ed i rec t ion , a rev i s ion

of

the

n o s t r i l

sill

and

the

l a t e r a l

a l a r base , and a l so poss ib ly t i p rh inop las ty o r t h i s can

be accomplished a t

a

l a t e r

da te with

a

formal rh inoplas ty

in concer t

with other procedures . In addi t i on , the

vermi l ion border

should be

repai red . This can be

done by

Z-plas ty

technique.

The pa t i en t , t he re fore , wi l l be seen by the consul t an t s and

a

genera l p lan

with

t im i ng fo r

surgery ,

e t c . ,

w i l l

be

made.

We

wi l l

arrange to make

these

arrangements and fo l low-up with the pa t i en t .

No l e t t e r .

M.D.

econs t ruc t ive Surgery

JK:bsm

T--8/1 /85

D--7/23/85

ep

s1ak


40/61

VANIA HOS AL

,

N l i . \ l a ~ ~ Hospital I Founded 1751

, -

AND

INJURED

HARVEY M, ROSEN.

M,D,

D

Head, Se,lion of Plastic

Surge

PENNSYLVANIA 19107

gti ie

3H,301.50uth Eighth s

(215)

829-5643

-

, ROBERT

CATHCART,

Pre

1?A . ; . 7 ~

August

12, 1985

I

e·tV

Lj-)-?7

/8

',.,

:. ,

Joseph Kusiak,

M.D.

American Oncologic Hospital

Central Shelmire Avenues

~ ~ ~ l ~ ~ e l p h i Pennsylvania

,.',

19111

.

RE: Neil

Gille .pie

Dear

Joei

,

This

lllorning

your

patient ,

t-lr.

Neil

Gillespie , was

seen

in

consultation regarding

his

secondary c le f t l i p

and

palate deformi

t i es . His

major concern a t

th is

point in time

i s the edentulous

space in the region

of

the l e f t l a te ra l incisor which

necess i ta tes

wearing

a

removable appliance.

This

area has never been bone grafted.

On physical examination there i s the obvious

stigmatA

of

an

unila tera l

l e f t

sided c le f t l i p and pala te . Examination of the l i p

reveals

poor

aligrunent

of

the vermilion border . There i s lack of muscle continui'ty

high in the l i p . Nasal examination

shows

a

deviated

septum with

the

body

of

the septum in the l e f t nasal airway

and

the

caudal

end pre

senting in the

r ight

nasal

airway.

There i s a

f l a ~ ~ Q ~ l a r

base. Tho

a la r

s i l l i ~ recessed. There

i s a

slumping of the l e f t alar rim.

Tht::

r ight

lower

l a te ra l

car t i lage

i s

hypertrophied

compared

to

the

l e f t

lower l a te ra l car t i l age . Intraora l examination reveals

an

edentulous

space in the region

of

the l e f t l i1teral inc isor . There

is

an

obvious oronasal f i s tu la .

There i ~ a s l ight poster ior cross

bi te in

the l e t t

poster ior

segment.

There i s

marked velopharyngeal

escape.

I

e x p ~ a n w d

to Mr. Gillespie

tha t

in

order

for nim

to have

a

i i x ~ d

bridge

appliance made 6 0 thathhe could be

r id

of his removable ap

pliance, an alveolar bone

graf t

would

be necGssary. Whether

or

not the poster ior cro86bite should be

corrected

prior to th i s

time

i s

up

to

Dr. Mayro. At

the

~ time tha t the bone

graf t

i s per

formed l ip revision could be

done

as well.

At

a secondary procedure

a

posterior

pharyngeal

f lap

And

naaal

reviaion

could

be

performed.

he

Institute.

III

North

49th

Street

I

Philadelphia, Pennsylvania 19139

I

Telephone

(215) 471.2000


41/61

•

Joa.ph

Kuaiak,

M.D.

-2-

Auguat 12, 1985

Thank you

for referring K • • G11leQpie.

I looK

forward to 41a

c u s ~ him

with

you.

Sest revarda.

Sincerely

youre,

Harvey M. Rosen, M.D. D.M.D.

i H a e ~

cel

Rosie

Mayro D.M.D. 1830 Rittenhouse Square,

Phila . ,

PA 19103

Ma. Marilyn

Cohen Facial Reconstruction

Center, Children .

Hoapital,

Philadelphia,

PA

191 4

u

10-

J ; 1 ~

\


42/61

~ U U U t

THE

CHILDREN S

HOSPITAL OF PHILADELPHIA

THE CLEFT PALATE PROGRAM

34th

and Civic Center Boulevard

Philadelphia. Pa 19104

(215)

596-9120

Don

LaRossa.

M.

D.,

Director

September 12,

1985

Joseph Kusiak, M.D.

American

Oncologic

Hosp i t a l

Dept . of Pl a s t i c Surgery

Dept. of Surgery

Cent ra l

and Shelmire Ave.

Phi l ade lph i a , PA

19111

RE:

Nei l G i l l e sp i e

B.D.

3/19/56

Dear

Joe :

Thank you for

r e f e r r i n g Nei l G i l l e sp i e fo r a

speech e v a l u a t i o n .

I

had the

oppor tun i ty of eva lua t ing t h i s

gent leman

on

August

1 ,

1985.

had

a h i s t o r y of a u n i l a t e r a l c l e f t

l i p and

p a l a t e

r epa i red

some

1me in ear ly chi ldhood. He i s p r e s e n t l y wear ing a den ta l

s h e l l

which

ob tu ra t i ng

to

some

degree an

a n t e r i o r p a r a l l e l

f i s t u l a . He

has

had a shor t course of speech therapy dur ing h i s e a r l y schoo l y e a r s .

Mr.

G i l le s p i e s

speech

i s

c h a r a c t e r i z e d

by

hypernasa l i t y

with

nasa l

escape. i ~

hypernasa l i t y i s

accen tu a t ed when he

removes

h is

p a l a t a l

app l iance

but I

do

not

f e e l

t h a t

the f i s t u l a i s the prime cause ~ f

the hype rnasa l i ty or the

nasa l

excape. Occlusion of h i s

na r i s with

the app l iance in

p lace

g r e a t l y improves the o v e r a l l q u a l i t y of h i s

speech and gene ra l ly

e l imina t es

the hypernasa l i t y . His a r t i c u l a t i o n

i s wel l with in the

normal

range .

On

d i r e c t phys ica l examinat ion , he appears

t o h a v e

a deep o r a l pharynx

wi th a

shor t but mobile s o f t pa l a t e .

He

has an a c t i v e gag

r e f l e x ,w i t h

f a i r l y

good

l a t e r a l

wal l motion. I would

suspec t

t h a t

he would do

f a i r l y

wel l

wi th a

p o s t e r i o r

p h r y n g ~ l f lap ~ u t

g iven

h is

age

the .

prognos i s

i s

guarded . I

discussed

t h i s recommendat ion

with

Mr.

Gi l l e s p i e

and

a l so

in formed

him

t h a t t he re

i s

the

p o s s i b i l i t y

even

with the

p o s t e r i o r pharyngeal f l ap tha t

t he re

may not be an improvement in h i s

speech

and

t h a t

he could poss ip ly r equ i re speech therapy fo l lowing

the

f l ap .

I do

not

f e e l

he would

b e n e f i t

from

a course

of

speech

t herapy a t t h i s po in t

in

t ime

as

t h i s appears to be an anatomic d e f e c t .

:

PlASTIC

SURGERY Peter Randall,

M.D.

Don LaRossa,

M.D.

Linton Whitaker, M.

D.,

Ralph Hamilton, M.

D.,

R:Barrett Noone,

M.D.,).

Brian Murphy, · M ~

,:" Arthur Brown,

M.D. SPEECH

PATHOLOGY Marilyn Cohen,

B.A.,

Marilyn Bernhard, M.A.; DENTIST. Rosario Mayro, D.M.D.,

'Imes

Schweipi;

D.D.S.;

QTORHINOLARYNGOLOGY

William Potsic, M.D., Steven Handler, M.D., Ralph Wetmore, M.D.; AUDIOLOGY: Richard Winchester,

Ph.D.;

PEDIATRICS Patrick Pasquariello, M.D.; SOCIAL

WORK

Susan Freimark,

A.C.S.W.


43/61

(2 )

RE:

Nei l Gi l l e sp ie

I f you would

l i k e f u r th e r co n f i rma t io n of t he problem

would

recommend

proceed ing wi th

n as a l

pharyngoscopy

r a th e r

than

l a t e r a l

s t a t i c x- rays .

Thank you fo r al lowing to

p a r t i c i p a t e

in Mr.

G i l le s p i e s

ca re .

With b es t r eg a rd s ,

S i n ce re l y yours ,

Mari lyn A.

Cohen

Speech Pa tho log i s t

MAC med

cc: Harvey Rosen M.D.

Rosie

Mayro M D. t -


44/61

Rosario Felizardo Mayro D.M.D.

Practice Limited to Orthodontics


45/61

Rosario

Felizardo Marro, D.M.D.

Practice Limited to Orthodontin

Harch 31, 1986

Dr. Harvey Rosen

Pennsylvania

~ o s p t l

Sui te

309

700 Spruce S t re e t

Phi l ade lph ia , PA., 19106

Re: Nei l Gil leso ie

Dear

Harvey:

Mr. Nei l Gil lesp ie

has

began

or thodon t i c

t rea tment

in

prepa ra t ion fo r

bone g ra f t i n g . I a n t i c i p a t e

t ha t

he w i l l be ready fo r surgery

in

the month o f August,

1986. Gil lesp ie w i l l

be

in touch

with

you s r ~ y

to

s e t up

a de f in i t e

da te

•

Please do not he s i t a t e

to c a l l me i

you have

any

ques t ions .

Best

regards ,

Sincere ly yours ,

Rosar io

F .

r:layro,

D.J.·LD.

RFi'1:er

cc : Dr.

Joseph

Kusiak

1830 Rittenhouse Square,

I-A,


215 735 5211

:


46/61

n l ( ) ( j C V 1 t i c _ ~ kld

ral li g . S/S

M I \ ~ f ~ '.f.JYI)1

f ,

I-)M 1),1\

~ I ; ~ ) J

II

I ,IX: f J I

ejml l

9.111 i J ( ~ ,

Pllli

1\11111'1111\, III r I I ~ W I

V;\NI/\

I')K)')

APRIL 22) 986

ROSARIO F.

MAYRO)

D.M.D.

1850

RITTENHOUSE

SQUARE

PHILADELPHIA)

PA

19103

RE:

N IL

GILL SPI

DEAR

ROSIE:

AT YOUR KIND

SUGGESTION

I EXAMINED

YOUR

PATTFNT NEIL GILLESPIE

TODAY TO EVALUATE THE EXTENT OF GINGIVAL

RECESSION

AND PLAN

CORRECTIVE

SURGICAL

PROCEDURES. THIS THRITY-YEAR OLD MAN IS IN GOOD

GENERAL

HEALTH.

HE IS CURRENTLY UNDERGOING ORTHODONTIC TREATMENT IN

YOUR

OFFICE

AND

A MAXILLARY

BONE

GRAFT

IS SCHEDULED

LATE NEXT

SUMMER

WITH DR. ROSEN.

THE PATIENT

HAS

SEVERE

GINr.IVAL

RECESSION IN THE LOWER ARCH EXTENDING

FROM

THE

LOWER LEFT· FJ

RST

PREMOLAR TO THE

LOWER RIGifT

FIRST PRfMOI_AR.

THERE

IS

ALSO

SEVERE

CERVICAL

EROSION WHICH APPEARS TO BE SECONDARY

TO OVERZEALOUS

TOOTHBRUSHING.

IN

THE UPPER ARCH THERE IS RECESSION

AND

MUCOSAL

MARGINAL

TISSUE

ON

THE

CANINES

AND

RIGHT

LATERAL

INCISOR.

THERE

IS ALSO

A

HIGH MAXILLARY FRENUM BETWEEN THE CENTRAL INCISORS.

THE PATIENT HAS MINOR

COMPLAINTS

OF

SENSITIVITY

WITH EXTREMES OF HOT

AND COLD IN AREAS OF RECESSION.

As

W

DISCUSSED I WILL BE PROCEEDING WITH

CORRECTIVE

MUCOGINGiVAl

PROCEDURES IN ORDER TO S T ~ I L I Z

THF. DENTOGINGIVAL JUNCTION

AND

PREVENT FURTHER

RECESSION

DURING ORTHODONTIC

TREATMENT. IN

AR E A

WHERE

SENSIVITITY IS

A PROBLEM

OR

THERE

ARE COSMETIC CONCERNS THE

PROCEDURES

WILL BE

DESIGNED

TO OBTAIN COVERAGE OF

EXPOSED

ROOT

SURFACES.


47/61

DR. ROSARIO MAYRO

APRIL

22J 986

PAGE wo

I SEE NO PROBLEM WITH CONTINUED TOOTH

MOVEMENT

IN THE UPPER ARCH. I

WOULDJ HOWEVERJ F ~

ACTIVE

ORTHODONTIC TREATMENT IN THE

LOWER

ARCH

UNTIL AFTER

I HAVE COMPLETED

THE MUCOGINGIVAL SURGERY.

I LOOK

FORWARD TO COLLABORATI

NG

WITH

YOU IN THE

TREATMENT

OF TH IS

VERY

CHALLENG

ING

CASE. I

WILL

KEEP YOU

POSTED

ON

Mi<

G

I

LLESP I E S

PROGRESS.

S I N C E R J ~ Y

,./

i

\ ,/

/ ;

MARK

SNYDERJ D.M.D.

MBS:MEB

CC: HARVEY ROSENJ D M D J M.D.

"

, : -

1 . t L: •


48/61

PeriodontI S and

Ora Diagnosis

MARK BSNYDER,

DMD,

PC

_.

---_

_ _ -

220-sc5J

TH

SIXTEENTH STREET SUITE 900

PHII.ADELPI

/lA,

PLNN5YIVANIA I JIOY

(21 :»

:>46 O ?9

JULY 3 1986

ROSARIO

F. MAYRO

D.M.D.

1850 RITTENHOUSE SQUARE

PHILADELPHIA"

PA 19103

RE: N IL GILLESPIE

DEAR ROSIE:

I

AM

PLEASED

TO

REPORT

THAT

I

HAVE

COMPLETED

PERIODONTAL

SURGERY

ON

YOUR PATIENT NEIL

GILLESPIE. A

BAND

OF

KERATINIZED

GINGIVAL

TISSUE

WAS PLACED

FROM

THE

LOWER

LEFT

SECOND

PREMOLAR

EXTENDING

ACROSS THE

ANTERIOR REGION

TO

THE LOWER

RIGHT

SECOND PREMOLAR. IN THE UPPER

ARCH THE MUCOSAL MARGINS ON THE ANTERIOR TEETH WERE ALSO REPLACED BY

KERATINIZED GINGIVA. NEIL TOLERATED THE PROCEDURES ~ X T R M Y

WELL

AND HEALING

HAS BEEN UNEVENTFUL.

INCIDENTIALLY"

THERE

HAS

ALSO BEEN

SIGNIFICANT

IMPROVEMENT

IN

HIS PLAQUE

CONTROL.

I

HAVE RECOMMENDED THAT NEIL BE

SEEN ON AN

ONGOING BASIS

FOR

PERIODONTAL

HEALTH MAINTENANCE

APPROXIMATELY

EVERY FOUR

TO

SIX WEEKS

DURING THE

ORTHODONTIC PHASE

OF

HIS

TREATMENT. I WILL

EE SEeING

HIM

AGAIN

SHORTLY

BEFORE HIS

SURGERY

WITH HARVEY ROSEN.

HIS

PERIODONTIUM

IS

CURRENTLY

HEALTHY

ENOUGH TO

WITHSTAND

THE

RIGORS

OF

ANY

ANTICIPATED TOOTH MOVEMENT.

i

THANK

YOU

FOR REFERRING

THIS MOST CHALLENGING

CASE TO

ME

FOR

TREATMENT. IF I CAN BE

OF

ANY

FURTHER

ASS I

STANCE"

PLEASE DON

T

HESITATE

TO

CALL.

JUL 0,,1986

CC:

HARVEY ROSEN" D.M.D. M.D.


49/61

~ N S Y L V A N I A H O S P J ~ ~ L

. N.tion's

Fint

HOIpit.11 FoundN 1751

/

SICK

AND

INJURED

HARVEY M. ROSEN. M.D

.•

He.d. Section of PI

. .

tic Surae

AND

SPRUCE STREETS

Suite 3H. 301 South Eiahth S

ADELPHIA, PENNSYLVANIA

19106

H.

ROBERT CATHCART, Pr

(215) 829-5643

May

18, 1987

P e t e ~ Randall , M.D.

University of Pennsylvania Hospital

Four

Silvers te in

3400 Spruce Stree t


RE:

Neil

Gil lespie

Dear Peter :

I

have

asked

Mr.

Neil

Gil lespie to

see

you

in

consul ta t ion

regarding

a secondary c l e f t

nasal deformity.

Mr. Gil lespie had

been

referred

to

me

by

Joseph

Kusiak

for a bone graf t ing

procedure to

his

res idual

alveolar

c le f t .

When f i r s t seen

by

me he had a very

large

nasal pal

ata l f i s tu la with a s ign i f ican t alveolar defect . In addi t ion,

speech bulb obturator reduction program for vpi

Documents