• Users Online: 2071
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 32  |  Issue : 1  |  Page : 61-66

The speech outcome of definitive obturators constructed using two different impression techniques


1 Department of Phoniatrics, Faculty of Medicine, Alexandria University, Alexandria, Egypt
2 Unit of Phoniatrics, Otorhinolaryngology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
3 Department of Prosthodontics, Faculty of Dentistry, Alexandria University, Alexandria, Egypt

Date of Submission31-Dec-2014
Date of Acceptance28-Feb-2015
Date of Web Publication5-Feb-2016

Correspondence Address:
M El-Maghraby Reham
Lecturer of Phoniatrics, 12 Street El Nahda Roushdy, Alexandria
Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1012-5574.175862

Rights and Permissions
  Abstract 

Objectives
The aim of this study was to evaluate the accuracy of two different impression techniques through the assessment of the performance of the two definitive obturators fabricated by each technique.
Patients
A total of six partially edentulous patients with unilateral maxillary surgical defects were selected from those admitted at the Prosthodontic Department, Faculty of Dentistry, Alexandria University.
Methods
For every patient, two hollow bulb obturators were constructed, each using a different impression technique. Three patients started with the open face tray impression technique and the other three started with the altered cast impression technique. Each patient was given one obturator at a time and was instructed to use it for 2 months. All patients were subjected to the following: (a) a preprosthetic evaluation, (b) an evaluation 2 months after the insertion of the first obturator, and (c) an evaluation 2 months after the insertion of the second obturator. During each session, speech and swallowing were evaluated.
Results
Regarding the three formant frequencies of the vowel /a/, there was a statistically significant improvement only in F1 between the altered cast and the preprosthetic phase and between the altered cast and the open face impression techniques, whereas concerning vowel /e/, there was a statistically significant improvement in F2 in favor of the altered cast impression technique. The degree of nasality in the vowels and the plosives were significantly improved in the altered cast technique. However, there was no significant improvement in the nasality between the two techniques with regard to oral and nasal sentences. There was an observed improvement in the competence and the shape of the velopharyngeal valve with the obturator than without the obturator.
Conclusion
The altered cast technique caused statistical improvement in the nasality of vowels and plosives as compared with the open face impression technique. Both treatment modalities caused general improvement in the patient's satisfaction and in swallowing with no statistically significant difference between them.

Keywords: maxillectomy, obturators, speech prosthesis


How to cite this article:
Reham M E, Lobna M E, Ahmed M A, Mohamed M A. The speech outcome of definitive obturators constructed using two different impression techniques. Egypt J Otolaryngol 2016;32:61-6

How to cite this URL:
Reham M E, Lobna M E, Ahmed M A, Mohamed M A. The speech outcome of definitive obturators constructed using two different impression techniques. Egypt J Otolaryngol [serial online] 2016 [cited 2019 Dec 16];32:61-6. Available from: http://www.ejo.eg.net/text.asp?2016/32/1/61/175862


  Introduction Top


Maxillectomy is a treatment option for maxillary cancer. This very often leaves an oronasal and/or an oroantral defect, resulting in severe functional problems concerning mastication, deglutition, and speech, and of equal importance produces a feeling of social insecurity with unfavorable psychological and economic consequences [1] . Although microvascular tissue transfer is regarded as a safe and adequate treatment option, there are certain indications to use prosthetic devices for maxillectomy reconstruction. Particularly, in older patients, in patients with a morbidity rate, and in patients with an unfavorable life expectancy, quick and sufficient prosthetic rehabilitation is of significant importance to preserve and restore the quality of life [2] . The primary goal of prosthetic obturation is the closure of the maxillectomy defect and separation of the oral cavity from the sinocaval cavities. A pressure-resistant seal of the obturator bulb against the mucosal lining and skin graft, if placed, restores speech and swallowing functions [3] . A successful prosthetic design for functional restoration of the maxillectomy defect utilizes the remaining palate and dentition to maximize the support, the stability, and the retention of an obturator bulb. Fabricating a successful obturator prosthesis used for the prosthetic rehabilitation of congenital or acquired defects in the maxilla depends on making a detailed impression and constructing the prosthetic parts compatible with the oral tissues [4] . Different impression techniques for fabricating obturators have been used in various studies. The impression material and the technique varied according to the type of palatal defect and its requirements [5] . The accuracy, the dependability, and the competence of the final impression have not been compared or evaluated sufficiently. Selection of the impression technique has always been delegated to the operator's preference [6] .


  Patients Top


A total of six partially edentulous patients with unilateral maxillary surgical defects were selected from those admitted at the Prosthodontic Department, Faculty of Dentistry, Alexandria University.


  Methods Top


For every patient, two hollow bulb obturators were constructed, each using different impression techniques. Three patients started with the first technique and the other three started with the second technique. The first technique was the open face tray impression technique. A preliminary impression using a stock tray and an irreversible hydrocolloid impression material was made for both the upper and the lower arches. The framework was tried inside the patient's mouth and checked for stability, retention, adaptation, and interferences with occlusion and articulation. The second technique was the altered cast impression technique. A study cast was poured in stone. The impression was then separated from the cast and surveyed for the location of undercuts, the location and the contour of guide planes, and the selection of the path of insertion. Each patient was given an obturator at a time and was instructed to use it for 2 months. Auditory perceptual analysis of the patient's speech was performed to assess the degree of hypernasality, audible nasal air escape, and the overall intelligibility score. The speech of the patients was evaluated using the Arabic articulation test [7] . Spectrographic analysis of the patients' speech using a Computerized Speech Lab (CSL) was performed to assess the first three format frequencies of the three vowels. Nasometric evaluation using a nasometer was performed to measure the nasal and the oral energy. The speech intelligibility was assessed through voice recording of the patient. Swallowing was assessed using flexible nasopharyngoscopic examination to assess the movements of the velum, the lateral and the posterior pharyngeal walls, and the shape of the velopharyngeal valve. Patients' satisfaction was evaluated by a modified Obturator Functioning Scale [8] of the Memorial Sloan-Kettering Cancer Centre.


  Results Top


Assessment of speech

Speech tests were conducted for each patient using the CSL, a nasometer, the speech intelligibility test, and an Arabic articulation test.

Assessment of the first three formant frequencies of the vowels /a/,/e/,/o/ using the Computerized Speech Lab preprosthetically and at different periods of treatment.

When the mean values of F1, F2, and F3 of the altered cast impression technique and the open face technique were compared with each other and with the preprosthetic phase, the observed mean values in the altered cast impression technique were slightly higher [Table 1]. However, the Mann-Whitney analysis showed that there was a statistically significant increase only in F1 between the altered cast impression technique and the preprosthetic phase (P2 = 0.021; P 0≤ 0.05), and between the altered cast impression technique and the open face impression technique (P3 = 0.035; P ≤ 0.05). For the vowel /e/, the Mann-Whitney analysis showed that there was a statistically significant increase in F2 between the open face impression technique and the preprosthetic phase (P1 = 0.041; P 0≤ 0.05) and between the altered cast impression technique and the preprosthetic phase (P2 = 0.022; P ≤ 0.05). Also, there was a significant increase in the F2 between the altered cast impression technique and the open face impression technique (P3 = 0.047; P ≤ 0.05). For the vowel /o/, the Mann-Whitney analysis showed that there was a statistically significant increase in the mean values of F1 between the altered cast impression technique and the preprosthetic phase (P2 = 0.0105; P ≤ 0.05) and between the altered cast and the open face impression technique (P3 = 0.014; P ≤ 0.05). There was also a statistically significant increase in the mean values of F2 between the altered cast impression technique and the preprosthetic phase (P2 = 0.014; P ≤ 0.05) and between the altered cast and the open face impression techniques (P3 = 0.021; P ≤ 0.05) [Table 2].
Table 1 Comparison of the mean values of the fi rst three formant frequencies (F1, F2, and F3) of the vowels /a/,/e/,/o/ between the preprosthetic phase, the open face impression technique, and the altered cast impression technique

Click here to view
Table 2 P values for the fi rst three formant frequencies (F1, F2, and F3) of the vowels /a/,/e/,/o/

Click here to view


An analysis of the degree of nasality in vowels, plosives, and oral and nasal sentences using a nasometer preprosthetically and at different periods of treatment was performed.

There was a statistically significant decrease in the mean values of nasality between the open face impression technique and the preprosthetic phase in the vowels /a/,/e/,/o/ (P1 = 0.023, 0.001, 0.035, respectively) [Table 3]. There was a statistically significant decrease in the mean values of nasality between the altered cast impression technique and the preprosthetic phase in the vowels /a/,/e/,/o/ (P2 = 0.001, 0.001, 0.001, respectively). When the mean values of nasality in the plosives /p/,/t/,/k/ in the altered cast technique were compared with the preprosthetic phase and with the open face impression technique, the observed mean values in the altered cast technique were lower. Also, when the mean values of nasality of oral sentences in the altered cast technique were compared with the preprosthetic phase and with the open face impression technique, the observed mean values of the altered cast technique were slightly higher. However, the Mann-Whitney analysis showed that there was no statistically significant difference in the degree of nasality of both oral and nasal sentences when the mean values of the two techniques were compared with each other and when each technique was compared with the preprosthetic phase [Table 4].
Table 3 Comparison of the mean values of the degree of nasality in the vowels /a/,/e/,/o/,/p/,/t/,/k/ nasal sentence and oral sentence between the preprosthetic phase, the open face impression technique, and the altered cast impression technique

Click here to view
Table 4 P values of the degree of nasality in the vowels /a/,/e/,/o/,/p/,/t/,/k/ nasal sentence and oral sentence

Click here to view


Assessment of speech intelligibility was performed from a 15 s sequence of spontaneous conversation, and from the 1 to 10 counting recordings preprosthetically and at different periods of treatment using a four-point scale.

At the preprosthetic phase, it was found that five patients had score 3 (83.3%), which represents a severe condition, and one patient had score 2 (16.7%), which represents a moderate condition. In the open face impression technique, it was found that five patients had score 0 (83.3%), which represents normal condition of speech, and one patient had score 1 (16.7%), which represents mild condition. In the altered cast impression technique, it was found that four patients had score 0 (66.7%), which represents normal condition of speech, one patient had score 1 (16.7%), which represents mild condition, and one patient had score 2 (16.7%), which represents moderate condition.

Arabic articulation test

In the preprosthetic assessment, the test showed hypernasality of the vowels, the presence of consonant imprecision, and nasal escape of air during speech. These findings were improved with obturator prosthesis.

Assessment of swallowing

The presence of impaired mobility of the soft palate with normal mobility of both lateral pharyngeal walls leading to mild velopharyngeal valve incompetence of sagittal shape were noted in the preprosthetic phase. There was an observed improvement in the competence and the shape of the velopharyngeal valve with the obturator than without the obturator. The mobility of the soft palate was also improved with the obturator. However, there was no observed difference between the two obturators constructed using the two impression techniques.

Patient satisfaction

Regarding patient satisfaction, no statistical significance was noted, although the mean scores in the open face impression technique were higher than that in the altered cast impression technique in those who found difficulty in wearing the obturator, felt heaviness in the mouth, had difficulty in taking off the obturator, and had discomfort when chewing with the obturator . The mean scores were in favor of the altered cast impression technique with regard to the difficulty in wearing the obturator, feeling heaviness in the mouth, difficulty in taking off the obturator, and discomfort when chewing. In both methods, there was equal improvement in speech [Table 5].
Table 5 Comparison between the open face impression technique and the altered cast impression technique with regard to patient satisfaction

Click here to view



  Discussion Top


Intraoral impression techniques for maxillectomy patients are well documented in the literature. The most commonly used impression techniques were the altered cast and the open face impression techniques [9] . According to Zaki and Aramany [10] the use of an open face impression tray facilitates proper extension at the site of the defect. Regarding the altered cast technique used, advantages included simplified tray manipulation, decreased patient trauma, the ability to use a custom-fabricated tray for optimal impression material thickness, precise intraoral positioning, and stability of the tray [11] . Regarding CSL, the results also demonstrated that maxillectomy patients had significantly low values of F2 for all vowels without the obturator than with the obturator. As maxillectomy creates a large space in the superior frontal portions of the vocal tract by connecting the oral and the nasal cavities, maxillectomy patients have difficulty in creating a proper front cavity constriction through the tongue position. This difficulty decreases the F2 value, especially for front vowels such as /e/. The effect of the defect on /a/ is less significant than that on the other vowels, because /a/ is a back and low vowel [12] . This coincides with the results in this study in which there was a statistically significant improvement in the values of F2 in the vowels /e/ and /o/ and in favor of the altered cast technique. Although statistically insignificant, the mean values of F3 were higher in both impression techniques when compared with the preprosthetic phase and in favor of the altered cast technique. This agrees with the findings of Xing et al. [13] who studied the evaluation of the speech outcomes in patients with unilateral maxillary defect rehabilitated with maxillary obturator prosthesis using the CSL and found that there was an increase in F3 values after treatment with the obturator.

By assessing the results obtained from the nasometer, it seemed obvious that the use of both obturators constructed using the two different impression techniques provided an apparent general improvement in the degree of nasality in the vowels /a/,/e/,/o/ and in the plosives /p/,/t/,/k/. These results agree with Eckardt et al. [14] who found that after sufficient rehabilitation, nasalance can be as low as in normal individuals. This also corresponds with Rieger et al. [15] who reported significant improvement in the nasality with obturators. There was a statistically significant improvement in the degree of nasality of both vowels and plosives in the altered cast technique when compared with the open face impression technique, which indicates a better seal obtained by the obturator constructed by the altered cast impression technique. The probable explanation for this slight improvement in the degree of nasality may be due to the stability of the metal framework, which allows good peripheral molding of the defect. This agrees with the findings of Tripathi et al. [11] who noted a reduced hypernasality in speech with the use of the altered cast impression technique. However, no statistically significant difference was obtained between the preprosthetic phase, the open face impression technique, and the altered cast impression technique in the degree of nasality in oral and nasal sentences. This was in accordance to De Krom [16] , who stated that the use of isolated vowels has been preferred to the connected speech fragments, because the production of isolated vowels can be more easily controlled and standardized than that of connected speech, and because isolated vowels are less affected by confounding articulatory information than are connected speech fragments. In the present study, perceptual assessment of the speech intelligibility demonstrated a statistical improvement in the speech produced with the use of obturators (constructed by both techniques) compared with that produced without an obturator, which is in agreement with results reported in the literature [17] . These results also agree with Aramany and Drane [18] who published the results of a study assessing the voice quality of the maxillary prosthesis in six patients. The listeners preferred the voice quality of the speech produced with prosthetic obturation to that produced without obturation. Furthermore, Kipfmueller and Lang [19] evaluated changes in the intelligibility occurring in six patients as a function of the treatment stage. This study showed no statistically significant difference in the speech intelligibility between obturators fabricated using the open face impression technique and those fabricated using the altered cast impression technique. This may be due to the fact that when the maxillectomy is confined to the bony palate, the speech after the placement of a prosthesis is usually within normal limits [20] . In the preprosthetic assessment for this study, the Arabic articulation test showed hypernasality of the vowels, the presence of consonant imprecision, and nasal escape of air during speech. These findings were improved with obturator prosthesis because of the closure of the velopharyngeal valve. Flexible nasopharyngoscopic examination revealed more improvement in the competence and the shape of the velopharyngeal valve with the obturator than without the obturator. However, there was no observed difference between the two obturators constructed using the two impression techniques. This may be because the velopharyngeal incompetence was mild due to the fact that all patients had defects in the hard palate only. The Obturator Functioning Scale showed that patients had a clearly low level of problems in speech when using both obturators constructed by different impression techniques. However, difficulty in swallowing was significantly improved in the altered cast impression technique as compared with the open face impression technique.


  Conclusion Top


The altered cast technique caused statistical improvement in the nasality of vowels and plosives as compared with the open face impression technique. Both treatment modalities caused general improvement in patients' satisfaction and in swallowing with no statistically significant difference between them.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Devlin H, Barker GR. Prosthetic rehabilitation of the edentulous patient requiring a partial maxillectomy. J Prosthet Dent 1992; 67:223-227.  Back to cited text no. 1
    
2.
Curtis TA, Beumer J. Restoration of acquired hard palate defects. In: Beumer J, Curtis TA, Marunick MT, eds Maxillofacial rehabilitation: prosthodontic and surgical considerations. St Louis, MO: Ishiyaku EuroAmerica; 1996: p. 122-8.  Back to cited text no. 2
    
3.
Martin JW, King GE, Kramer DC, Rambach SC. Use of an interim obturator for definitive prosthesis fabrication. J Prosthet Dent 1984; 51:527-528.  Back to cited text no. 3
[PUBMED]    
4.
Srinivasan M, Padmanabhan TV. Rehabilitation of an acquired maxillary defect. J Indian Prosthet Society 2005; 5:155-157.  Back to cited text no. 4
    
5.
Arcuri MR, Taylor TD. Clinical management of the dentate maxillectomy patient. In: Taylor TD ed. Clinical maxillofacial prosthetics. Chicago, IL: Quitessence; 2000: 116-118.  Back to cited text no. 5
    
6.
Chandra TS, Sholapurkar A, Joseph RM, Aparna IN, Pai KM. Prosthetic rehabilitation of a complete bilateral maxillectomy patient using a simple magnetically connected hollow obturator: a case report. J Contemp Dent Pract 2008; 9:70-76.  Back to cited text no. 6
    
7.
Kotby MN, Bassiony S,El-Zomar M, Mohsen E, Standardization of an articulation test. Proceedings of the 9th Annual Ain Shams Medical Congress; 1986; Cairo, Egypt.  Back to cited text no. 7
    
8.
Anasane N, Chitnis D. Rehabilitation of a maxillectomy defect with definitive hollow bulb obturator: a case report. J Indian Dent Assoc 2010; 4:429-431.  Back to cited text no. 8
    
9.
Oh WS, Roumanas E. Alternate technique for fabrication of a custom impression tray for definitive obturator construction. J Prosthet Dent 2006; 95:473-475.  Back to cited text no. 9
    
10.
Zaki HS, Aramany MA. Open-face custom tray for edentulous obturator impression. J Prosthet Dent 1981; 45:639-642.  Back to cited text no. 10
[PUBMED]    
11.
Tripathi S, Chand P, et al. A noval approach of altered cast technique in bilateral partial maxillectomy patient with severly restricted mouth opening. ISRN Dentistry 2011; 5:34-39.  Back to cited text no. 11
    
12.
Sumita YI, Ozawa S, Mukohyama H, Ueno T, Ohyama T, Taniguchi H. Digital acoustic analysis of five vowels in maxillectomy patients. J Oral Rehabil 2002; 29:649-656.  Back to cited text no. 12
    
13.
Xing GF, Jiao T, Sun J, Jiang YL. Evaluation of the speech outcomes in patients with unilateral maxillary defect rehabilitated with maxillary obturator prosthesis. Shanghai Kou Qiang Yi Xue 2005; 14:352-354.  Back to cited text no. 13
    
14.
Eckardt A, Teltzrow T, Schulze A, Hoppe M, Kuettner C. Nasalance in patients with maxillary defects - reconstruction versus obturation. J Craniomaxillofac Surg 2007; 35:241-245.  Back to cited text no. 14
    
15.
Rieger J, Wolfaardt J, Seikaly H, Jha N. Speech outcomes in patients rehabilitated with maxillary obturator prostheses after maxillectomy: a prospective study. Int J Prosthodont 2002; 15:139-144.  Back to cited text no. 15
    
16.
De Krom G. Consistency and reliability of voice quality ratings for different types of speech fragments. J Speech Hear Res 1994; 37:985-1000.  Back to cited text no. 16
    
17.
De Carvalho-Teles V, Pegoraro-Krook MI, Lauris JR. Speech evaluation with and without palatal obturator in patients submitted to maxillectomy. J Appl Oral Sci 2006; 14:421-426.  Back to cited text no. 17
    
18.
Aramany MA, Drane JB. Effect of nasal extension section on the voice quality of acquired cleft palate patients. J Prosthet Dent 1972; 27: 194-201.  Back to cited text no. 18
[PUBMED]    
19.
Kipfmueller LJ, Lang BR. Presurgical maxillary prosthesis: an analysis of speech intelligibility. J Prosthet Dent 1972; 28:620-625.  Back to cited text no. 19
[PUBMED]    
20.
Runte C, Tawana D, et al. Spectral analysis of /s/ sound with changing angulation of the maxillary central incisors. Int J Prosthet Dent 2002; 15:254-258.  Back to cited text no. 20
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


This article has been cited by
1 Passavantís ridge during speech production with and without pharyngeal bulb
Beatriz K. de Almeida,Gabriela Z. Ferreira,Homero C. Aferri,Viviane C.C. Marino,Jeniffer de C.R. Dutka,Maria InÍs Pegoraro-Krook
Journal of Communication Disorders. 2019; : 105939
[Pubmed] | [DOI]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Patients
Methods
Results
Discussion
Conclusion
References
Article Tables

 Article Access Statistics
    Viewed957    
    Printed6    
    Emailed1    
    PDF Downloaded119    
    Comments [Add]    
    Cited by others 1    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]