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FIGURE 7-7 A and B, Ectopic lateral incisors in two different
youngsters. The ectopic teeth could distort anterior sibilants
and/or contribute to backed placement of tip alveolar
consonants. (From Trost-Cardamone JE: Structural organic disorders of speech:
graduate course, California State University at Northridge, Northridge, CA.)
If you do not have a dentist working literally at your side, you may
have difficulty determining whether the child has extra teeth,
duplicated teeth, missing teeth, and even ectopically erupted teeth. It's
always good to make notes that make descriptive sense to you, such as
“crowded dentition,” “a lot of dental spacing,” or “teeth are not well
aligned.”
There is no one-to-one relationship between dental deviations and
speech articulation problems. Some youngsters may have multiple
missing or malaligned teeth and show lile to no effect on speech. The
key to determining whether any improvement can be made in distorted
or substituted productions of sibilants, for example, in the presence of
dental anomalies is stimulability. Do not assume that the presence of
dental spacing, teeth out of alignment, or other dental deviations
automatically means that the child has a structural barrier to beer
articulation. The other side of that coin is the number of years that
some children have had useless speech therapy in the presence of a
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dental anomaly or malocclusion that was indeed an obligatory barrier
to beer articulation.
2. If the youngster has extensive dental caries, draw this to the aention
of the parents and also notify the treatment team, or make a referral for
team care if that is not already in place. Parents often do not realize
what their children's intake of soda and candy is doing to their teeth.
Similarly, many parents do not brush their toddler's teeth or teach the
child to brush his or her own teeth.
Occlusion
1. Children with clefts are prone to having various types of
malocclusions, as discussed in detail in Chapter 6. The most common
ones are crossbites, meaning that the maxillary dental arches are inside
(rather than outside) the mandibular arch. Crossbites may be unilateral,
bilateral, anterior, or “complete,” meaning that the entire maxillary arch
is in crossbite. Figure 7-8 shows a child with a repaired bilateral cleft of
the lip and palate and an anterior crossbite. Figure 7-9 shows both
dental and occlusal deviations in a youngster with a repaired cleft.
Figure 7-10 shows the typical lateral crossbite and missing lateral
incisor often seen in children with clefts, but there is also a crossbite of
the central incisor on the noncleft side. Figure 7-11 shows a severe Class
III malocclusion (complete crossbite throughout the dental arch) in a
teenager. Other illustrations of malocclusions are found in Chapter 6.
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FIGURE 7-8 This youngster has a residual defect in the
repaired lip and also has an anterior crossbite that extends from
maxillary canine to canine. (From Trost-Cardamone JE: Cleft palate speech, a
comprehensive 2-part set. ASHA professional development course, 2013.)
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FIGURE 7-9 Both dental and occlusal deviations in a patient
with a right-sided cleft. Right central incisor is in crossbite and is
rotated. Right lateral incisor and canine are absent, leaving an
open bite space, and the next two teeth are in crossbite. There is
also malalignment of the mandibular teeth. (From Trost-Cardamone JE:
CDS 660: Structural organic disorders of speech: graduate course, California State
University at Northridge, Northridge, CA.)
FIGURE 7-10 Anterior and left crossbite malocclusion, missing
left lateral incisor contributing to lateral open bite space. (From
Trost-Cardamone JE: CDS 660: Structural organic disorders of speech: graduate
course, California State University at Northridge, Northridge, CA.)
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FIGURE 7-11 A youngster with a severe Class III malocclusion
and unavoidable reversed labiodentals /f, v/ or replacement with
bilabial fricatives; likely dentalization of alveolars /s, z, t, d, n, l/.
In reports from dentists, you may see the name “Angle” before the
classification of the occlusion (e.g., The child has an Angle Class II
malocclusion). Edward Angle was the American orthodontist who
developed the classification system that continues to be widely used in
orthodontic practice.
Alveolar clefts are often intentionally left open into the early years of
childhood because the maxilla is still growing forward, and both dental
and surgical service providers may fear that bone grafting of the
alveolar cleft will interfere with that growth. Thus, an opening through
the alveolus is not a “postsurgical fistula” although it may be a source
of air leakage into the nasal cavity associated with anterior pressure
consonants.
2. Remember that malocclusions, like the various dental deviations
discussed earlier, do not necessarily cause articulation problems.
Coexistence of two problems does not imply cause and effect: a
youngster can have an articulation problem and a malocclusion, but the
malocclusion is not necessarily the cause of the articulation problem.
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3. The important issue regarding speech, dental deviations, and
malocclusions is whether the speech errors are treatable, given the
current structural status, or whether physical management
(orthodontics, orthognathic surgery) is required before any speech
intervention is initiated and can be successful.
Palatal Vault and Velum: Anatomical Integrity
See Figure 7-12 for a schematic illustration of the palate.
1. Fistulas: In repaired cleft lips and palates, always look for fistulas and
note their location and apparent size, and (with the help of the dentist
or plastic surgeon) determine whether or not the fistula is actually
“patent,” that is, open all the way through to the nasal cavity. The
dentist or surgeon can help the SLP in determining the patency of a
fistula by temporarily covering the fistula with an adhesive material
that sticks to the mucosal surface of the palate. (Several types of such
materials are available from medical and dental suppliers.) The SLP can
determine whether nasal air loss is eliminated by this temporary
obturation. Postsurgical fistulas can occur anywhere in the repaired
hard or soft palate. Figure 7-13 shows an anterior oronasal fistula in a
child with a repaired cleft. Figure 7-14 shows another child with a larger
fistula in the posterior hard palate. Some fistulas that appear to be
patent are actually blind-ended and are therefore not a route for loss of
the oral air stream into the nasal cavity (Folk et al., 1997). Another place
that you may find a fistula is along the lines of the premaxillary sutures
(the anatomical junctures of the premaxilla with the rest of the alveolar
ridge as shown schematically in Fig. 7-12). Such fistulas may be
extensions of an unoperated alveolar cleft. If you find such a fistula in a
youngster and think it is problematic for speech, discuss it first with the
child's parents and then, with the parents' permission, discuss it with
the treatment team.
2. Submucous cleft palates are discussed at length in Chapter 1.
Additional examples are found in Figures 7-15, 7-16, 7-17, and 7-18.
Figure 7-17 demonstrates how a submucous cleft can be missed on a
quick intraoral view: if the examiner does not elicit phonation (and thus
elevation of the palate), the presence of a submucous defect can be
missed. Figure 7-18 shows a submucous cleft in which the mucosal
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layer was so thin that a prenatal “tear” resulted in a congenital fistula.
Figure 7-19 shows a repaired palate (not a submucous cleft) in which
the repair was not carried out all the way through the uvula, thus
leaving a residual bifid uvula. Although visually suspect, this does not
necessarily mean that the repaired palate is incapable of good VP
closure for speech.
Most of the illustrations of submucous clefts demonstrate the
importance of palpating the palatal vault with your finger, although
some are so obvious to the eye that such palpation may not be
necessary. However, it is good to get into the habit of palpating the
palate whenever a youngster has speech indicative of inadequate VP
closure so that you can identify a bony notch or midline area of thin
tissue in the velum. Previous examiners of the child (e.g., ENTs, plastic
surgeons) may have assumed that lack of easily seen signs of a
submucous cleft meant that the hypernasal speech had no physical
cause and should therefore be amenable to speech therapy. Both of
these assumptions are wrong. Remember the following: (1) one or more
of the three classic signs of a submucous cleft (palpable bony notch,
zona pellucida, bifid uvula) may be present—or even all three—in an
individual who does not manifest any sign of VPI in speech; and (2)
conversely, even severe VPI can be present in speech without any of the
classic three signs. When the child has a submucous cleft of the hard
palate, you may feel a V-shaped notch (with the point of the V pointing
toward you). As already pointed out, these defects vary in posterior-toanterior extent and in width. Usually, submucous defects of the hard
and soft palate occur together. However, a muscular deficiency may be
present in the soft palate without a defect in the hard palate. You may
feel a particularly soft area (without much muscular bulk) in the soft
palate. When you ask the youngster to say “ah,” you may see the soft
palate take on a V- or tent- shape. However, if you find evidence of an
asymptomatic submucous defect (meaning no effect on speech), advise
the parents to discuss this with the child's physician at their next visit
with that professional because such findings have genetic significance.
3. In postsurgical cases, you will also be looking for any signs that the
repaired palate may have come partially apart (“dehisced”).
4. The “ah” test is not a valid or reliable assessment of velopharyngeal
closure adequacy or physiology. It can inform us regarding any
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movement capability of the soft palate during phonation and whether
that movement is asymmetrical. But never think that you can see
velopharyngeal closure on the intraoral view. You cannot. VP closure takes
place in the nasopharynx, which is out of the line of intraoral view.
Even if the palate is short, you cannot judge VP closure from the
intraoral view. Imaging studies are required to determine functional
velar length, depth, and width of the nasopharynx, as well as
physiology of velopharyngeal closure for speech.
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FIGURE 7-12 Landmarks of the palate in an infant. The dotted
lines denote landmarks that cannot be seen on the intraoral
exam, although the posterior nasal spine is often visible as a
highlighted, white area on the actual examination. The same is
true of the median raphe, which may appear as a whitened area
on the intraoral view. Both the median raphe and the posterior
nasal spine should be easily palpable on a digital examination.
The same is not true of either the premaxillary sutures or the
incisive foramen, landmarks that demarcate the triangle-shaped
premaxilla. (From Peterson-Falzone SJ, Hardin-Jones MA, Karnell MP: Cleft palate
speech [4th ed]. St. Louis: Mosby, 2010.)
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FIGURE 7-13 Repaired cleft lip and palate with a small fistula in
the region of the incisive foramen; potential source of nasal air
emission (NAE) accompanying anterior pressure
consonants. (From Trost-Cardamone JE: CDS 660: Structural organic disorders of
speech: graduate course, California State University at Northridge, Northridge, CA.)
FIGURE 7-14 Repaired cleft lip and palate with a larger fistula
in the posterior hard palate; potential source of NAE on posterior
pressure consonants. (From Trost-Cardamone JE: CDS 660: Structural organic
disorders of speech: graduate course, California State University at Northridge,
Northridge, CA.)
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