Maxillofacial prosthetics is a sub-specialty or often called as super-specialty of prosthodontics. All Maxillofacial Prosthodontists are prosthodontists first and then attain a fellowship training (1 year) exclusively in Maxillofacial Prosthetics. Maxillofacial prosthodontists treat patients who have acquired and congenital defects of the head and neck (maxillofacial) region due to cancer, surgery, trauma, and/or birth defects. Maxillary obturators, Speech-aid prosthesis (formerly called as Pharyngeal/Soft Palate Obturators) and Mandibular-Resection prostheses are the most common prostheses planned and fabricated by Maxillofacial Prosthodontists. Other types of prostheses include artificial eyes, nose and other facial prostheses fabricated in conjunction with an anaplastologist.Treatment is multidisciplinary involving oral and maxillofacial surgeons, plastic surgeons, head and neck surgeons, ENT doctors, oncologists, speech therapists, occupational therapists, physiotherapists, and other healthcare professionals.
It is the role of the speech-language pathologist to determine the specific aspects of speech and swallowing that may best be facilitated by a prosthesis and to actively participate in designing an appliance that best fulfills the intended objectives. The speech-language pathologist assesses the effectiveness of the appliance for speech and swallowing functions and provides direction for modifications in prosthesis size, shape, or other design characteristics that may result in further speech and swallowing improvement. Following construction and fitting of the prosthesis, the speech-language pathologist provides treatment to help the patient reach optimum levels of speech and swallowing function.
Palatal LiftTo raise the velum when velar mobility is poorUsed for velopharyngeal incompetence, as in dysarthria
short-term prosthetics used to close defects of the hard/soft palate that may affect speech production or cause nasal regurgitation during feeding. Following surgery, there may remain a residual oronasal opening on the palate, alveolar ridge, or labial vestibule. 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. 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.Palatal obturators are not to be confused with palatal lifts or other prosthetic devices. A palatal obturator may be used in cases of a deficiency in tissue, when a remaining opening in the palate occurs. In some cases it may be downsized gradually so that tissue can strengthen over time and compensate for the decreasing size of the obturator. The palatal lift however, is used when there is not enough palatal movement. It raises the palate and reduces the range of movement necessary to provide adequate closure to separate the nasal cavity from the oral cavity. 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.Palatal obturators are needed by individuals with cleft palate, those who have had tumors removed or have had traumatic injuries to their palate.
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. This obturator aids in closing the remaining fistula and is used when no further surgical procedures are planned. It must be frequently revised. A definitive obturator is used when further rehabilitation is not possible for the patient and is intended for long-term use
A typical prosthetic tongue for speech is flat with wide anterior elevation, which aids in articulation of anterior lingual alveolar sounds (eg, /t/, /d/). The typical prosthetic tongue also has a posterior elevation, which aids in production of posterior lingual alveolar sounds (eg, /k/, /g/) and helps shape the oral cavity for improved vowel productions The tongue prosthesis for swallowing is made with a trough in its posterior slope to guide the food bolus into the oropharynx. A speech pathologist and, when necessary, a nutritionist should monitor all patients who have a glossectomy.
Intra-Oral Prosthetics Taylor Harris & Brittany Janowski
What are intra-oral prosthetics?• Artificial substitutes for missing, altered, or deformed oral structures• Placed in vocal tract• Primarily used to improve speech & swallowing
Role & Responsibilities of the SLP • Determine specific needs • Actively participate in design of appliance • Assess effectiveness • Provide direction for modifications • i.e. size, shape • Provide follow-up treatment & monitor • Swallowing, speech, voice, resonance • Teach patient about care & cleaning
Palatal Lift• Designed to augment or replace hard and soft palate tissue defects• Aids in restoration of soft palate functions• Improves velopharyngeal closure• Commonly used for dysarthria; velopharyngeal incompetence
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• Not to be confused with palatal lift
Obturator Categories• Modification ObturatorShort term• Interim Obturator Post surgery• Definitive Obturator Long term
Speech Bulb• Occludes nasopharynx when the velum is short (velopharygealindufficiency)• Aids in velopharyngeal closure• Contains pharyngeal section, goes behind soft palate• Can be combined with an obturator
Tongue Prosthetic• Sometimes used following total glossectomy• Steel clasps attach to lower teeth• Facilitates speech & swallowing
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
Assessment• Prosthetic assessment is provided to: • evaluate, select, and/or dispense a prosthetic device to improve functional communication • including associated activities and participation
Who Can Assess• Prosthetic assessments are conducted by appropriately credentialed and trained SLPs• SLPs perform assessments as members of collaborative teams that include • Individual • family/caregivers • Educators • medical personnel
Why Assess?To identify:• underlying strengths and weaknesses related to the use of prosthetic as it affects communication and swallowing• effects of prosthetic on activities such as capacity and performance in everyday communication and participation• factors that serve as barriers or facilitators for successful communication/swallowing
What Process Includes• Review of status• Case history info• Standardized and/or nonstandardized methods• Follow-up services• Cost considerations & safety and health implications• Dispensing practices
Setting of Assessment• Clinical, educational or other natural environment setting conducive to eliciting a representative sample of the clients communication using a prosthetic device.• Identifying the influence of related factors on functioning (activity and participation) requires assessment data from multiple settings.
Documentation of Assessment• Results, interpretation, prognosis, and recommendations.• Provide a rationale for the preferred prosthetic; a description of device; procedures involved in the assessment of the device; counseling provided to the patient; and the patient„s response.
Prosthetic Intervention Intervention services are conducted to assist individuals to understand,use, adjust, and restore their customized prosthetic device.
Who Provides InterventionServices?• conducted by appropriately credentialed and trained SLPs, possibly supported by SLP assistants under appropriate supervision.• SLPs as members of interdisciplinary teams
Expected Outcomes of Treatment• Strengths & weaknesses related to communication /swallowing• Acquire new skills and strategies using the device• Aid for successful communication/swallowing• Provide appropriate accommodations and train how to use them• Improve abilities, functioning, participation, and contextual facilitators• May result in recommendations for reassessment or follow-up, or referral for other services
Goal(s) Associated WithProsthetics• Painless, efficient swallowing of secretions• Unrestricted head movement• Elimination or reduction of nasal emission• Decrease respiratory effort/long breath groups• Increased subglottal pressures; increased loudness• Improved articulatory precision• improved speech intelligibility• normalized nasality
Clinical ProcessDepending on assessment results, intervention addresses the following:• Provide info, course of intervention and duration, effective communication/swallowing• Education and maintenance, info about safety and instrument warranty• How repair, maintain, and modify• Intervention accomplishes objectives• Meets the abilities, needs, and wants of patient and who they communicates with, considering the environment it will be used
Setting of Treatment• clinical or educational settings• other natural environments that are selected on the basis of intervention goals and in consideration for the social, academic, and/or vocational activities that are relevant to the individual.
sEMG• As muscles contract, microvolt level electrical signals are created within the muscle that may be measured from the surface of the body. A procedure that measures muscle activity from the skin is referred to as surface electromyography (SEMG).
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.‟
Cultural/Ethical Considerations It is important to be culturally sensitive in assessment and treatment of individuals needing dysphagia management.
Things to Consider aboutDiversity• Foods to use in dysphagia assessment and treatment• Who is it appropriate to talk with about therapy?• Choosing assessments that are culturally considerate
Counseling• Counseling is important for individuals pre and post surgery• Being a part of society and communicating with others is something humans need, and the need for prosthetics can alter this from happening.
References• 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• American Speech-Language-Hearing Association. (2004). Preferred Practice Patterns for the Profession of Speech-Language Pathology [Preferred Practice Patterns]. Available from www.asha.org/policy.• Crary, M. A., Carnaby, G. D., Groher, M. E., &Helseth, E. (2004). Functional benefits of dysphagia therapy using adjunctive sEMG biofeedback [Abstract]. Dysphagia, 19, 160-164.doi:10.1007/s00455-004- 0003-8• Grames, L.M., Jones, D.L., Kummer, A.W., Kurnell, M.P., Ruscello, D. (2006). Response to “Velopharyngeal dysfunction:Speech characteristics, variable etiologies, evaluation techniques, and differential treatments” by Dworkin, Marunick, &Krouse . Language, Speech, and Hearing Services in Schools. 36, 236-238.• Light. J. (1995). A review of oral and oropharyngeal prosthesis to faciliatate speech and swallowing. American Journal of Speech-Language Pathology, 4, 15-21.• Likes, C. P., McCarthy, E. S., Zwilling, C., Dingman, C. A coordinated, multidisciplinary approach tocaring for the patient with head and neck cancer [PPT document]. Retrieved from South Carolina Speech Language Hearing Association Web site: http://www.scsha.com/handouts/session42.pdf