Main Ideas and Concepts

💀 Clefts of the Lip and Palate

Clefts (1)

1. What is a cleft?

An abnormal opening in an anatomical structure due to failed fusion during fetal development.

2. Difference between cleft lip and cleft palate?

Cleft lip = opening of lip/alveolus.
Cleft palate = opening between oral and nasal cavities.

3. Types of clefts by palate formation?

Primary palate: anterior to incisive foramen (lip & alveolus, 7 weeks).

Secondary palate: posterior to incisive foramen (hard palate, velum, uvula, 9 weeks).

4. Causes of clefts?

Multifactorial — genetic (3–5% recurrence risk) + environmental (teratogens, infections, poor nutrition, obesity/diabetes).

5. Examples of teratogens?

Phenytoin, valium, corticosteroids, smoking, alcohol, lead, radiation.

6. Structural effects of cleft lip?

Wide, flat nose, short columella, abnormal dentition.

7. Functional effects of cleft lip?

Articulation errors and altered resonance.

8. Effects of cleft palate? VNFE

VP insufficiency, nasal regurgitation, feeding issues, ET dysfunction.

9. What are cleft muscles of Veau? AILM

Abnormally inserted levator muscles along cleft margins in secondary palate.

The cleft muscles of Veau refer to the abnormally inserted levator veli palatini muscles found in individuals with cleft palate.

10. What is a submucous cleft?

Defect beneath intact mucosa; may include muscle or bone separation.

a hidden cleft where the muscles and/or bones of the soft or hard palate didn’t fuse normally, but the mucosal covering looks intact — so the cleft isn’t visibly open like a typical cleft palate.

11. Classic triad of a submucous cleft?

Bifid uvula, zona pellucida (bluish midline), and notch in posterior hard palate.

12. Overt vs occult submucous cleft?

Overt = visible orally.
Occult = hidden, visible only nasopharyngoscopically.

13. Submucous cleft speech effects?

VP insufficiency, hypernasality, nasal emission, ET dysfunction.

🧠 Speech, Resonance, and VP Dysfunction

Speech deficits copy (1)

14. What is resonance for speech?

Modification of sound by oral, nasal, and pharyngeal cavities.

15. What determines resonance quality?

VP valve function + cavity size and shape.

16. What is a resonance disorder?

Abnormal transmission of sound through oral/nasal/pharyngeal cavities.

17. Types of resonance disorders? HHCM

Hypernasality, hyponasality, cul-de-sac resonance, mixed resonance.

18. Hypernasality — cause and perception?

Too much nasal sound from VP leak; most evident on vowels.

19. Obligatory distortions vs compensatory errors?

Obligatory: normal placement, distorted from structure → surgery only.

Compensatory: abnormal placement to improve intelligibility → needs therapy.

20. Causes of hypernasality? VSFM

VP opening, submucous cleft, large fistula, or mislearning.

21. Hyponasality/denasality — definition?

Reduced or absent nasal resonance on nasal sounds (“stuffy” voice).

22. Common causes of hyponasality? NO

Nasal obstruction (cold, allergies, adenoids, deviated septum, over-correction).

23. Cul-de-sac resonance — description?

Sound trapped in a cavity with blocked exit → muffled, low-volume voice.

24. Mixed resonance — description?

Combination of hypernasality and hyponasality on different sounds; often due to VPI + obstruction.

25. Nasal emission — definition?

Air escape through nose on pressure sounds due to VP leak or fistula.

26. Types of nasal emission? Hint: there are 4

Nasal rustle: small VP gap

Audible emission: medium gap

Inaudible: large gap

Phoneme-specific: misarticulation only

27. Secondary signs of nasal emission? WSNC

Weak consonants, short utterances, nasal grimace, compensatory articulations.

🦷 Prosthetic Management

Prosthetics

28. Prosthetic device — definition?

Artificial replacement for missing/malformed part to improve speech, mastication, aesthetics.

(A custom-made artificial device that restores normal speech, eating, or facial structure when surgery isn’t possible or complete.)

29. Who fabricates prostheses?

Prosthodontist (dental specialist).

30. Main prosthetic categories?

Facial, dental, and speech appliances.

31. What is a palatal obturator?

Removable device that covers open palate/fistula to reduce nasal air escape.

A dental retainer with a solid section that covers or plugs an opening in the palate (like a hole or fistula). like a cork for the palate

32. Palatal lift — function?

Raises passive velum for VP incompetence or mild insufficiency.

A retainer-like base that extends backward with a tail that lifts the soft palate upward and backward toward the pharyngeal wall.

33. Speech bulb obturator — function?

Fills VP gap for structural insufficiency.

A retainer with a bulb-shaped extension that fills the velopharyngeal gap in the nasopharynx.

The bulb blocks the air leak between the naso- and oropharynx during speech.

34. Advantages of prosthetics?

Used when surgery is delayed, risky, or declined; helps post-op or with neuro disorders.

35. Disadvantages of prosthetics?

Frequent refitting, poor retention, expensive, uncomfortable, not permanent.

📊 Objective / Instrumental Assessment

Objective assessment

36. What is nasometry?

Measures oral vs nasal acoustic energy to assess resonance.

37. Nasometer function?

Two mics record nasal and oral sound through a separator plate.

38. Formula for nasalance?

N ÷ (N + O) × 100 (% nasal energy).

39. Nasometry passages?

Adults: Zoo, Rainbow, Nasal.
Children: SNAP-R.

40. Direct instrumental procedures? VNM

Videofluoroscopy, nasopharyngoscopy, MRI.

41. Videofluoroscopy (VF)?

Real-time x-ray showing VP movement during speech.

42. Nasopharyngoscopy (NP)?

Endoscopic visualization of VP closure through nasal cavity.

43. MRI for VP?

Shows levator and VP structure in detail; static and costly.

🩺 Surgical Management / VPI

Surgery_VPI

44. Palatoplasty — goal?

Repair cleft palate to restore feeding, middle ear, and VP function.

45. “Rule of 10” for lip repair?

≥10 lbs, ≥10 g hemoglobin, <10,000 WBC, ≥10 weeks old.

46. Complications of lip repair? WD SL NS A GR

Whistle deformity, short lip, nasal stenosis, asymmetry, growth restriction.

47. VPI — definition and cause?

Structural inability for complete VP closure; requires surgery or prosthesis.

48. VP incompetence — definition? N PVM

Neurogenic poor velar movement; may respond to therapy or prosthetic lift.

49. Surgical options for VPI? FSAV

Pharyngoplasty (flap/sphincter/augmentation) and veloplasty.

1⃣ Flap – bridge the gap
2⃣ Sphincter – squeeze it closed
3⃣ Augmentation – fill the space
4⃣ Veloplasty – lengthen the palate

50. Contraindications for VPI surgery? ABB

Airway obstruction, progressive neuro issues, severe cognitive/hearing limits, radiation, bleeding risk.

“No Surgery if Air, Brain, or Blood at Risk.”

• Air = airway obstruction

• Brain = neuro or cognitive disorder

• Blood = bleeding disorder or radiation history

51. What is a pharyngeal flap?

Tissue bridge from PPW to velum with side ports for breathing/nasal sounds.

52. Optimal surgical placement for VPI correction?

High in nasopharynx near maximal velar and LPW movement.

53. Complications of VPI surgery?

Overcorrection → hyponasality/apnea; undercorrection → hypernasality/nasal emission.

54. What is maxillary advancement?

Moves maxilla forward for Class III malocclusion; improves aesthetics but can worsen VPI.

Maxillary advancement is a surgical procedure performed to move the upper jaw (maxilla) forward so it aligns properly with the lower jaw (mandible) and improves both facial balance and speech function

55. Effect of maxillary advancement on speech?

Reduces distortions; may increase VPI risk due to velar displacement.