CC BY
15
УДК 616.31
http://dx.doi.org/10.26787/nydha-2686-6838-2019-21-10-105-110
ОРТОДОНТИЧЕСКАЯ КОРРЕКЦИЯ У ДЕТЕЙ С РАСЩЕЛИНОЙ ГУБЫ И НЕБА С ПОМОЩЬЮ РЕЧЕВЫХ
ОБТУРАТОРОВ
Дудник О.В., Мамедов Ад.А., Зубков А.В.
ФГБОУ ВО Первый Московский государственный медицинский университет им. И.М. Сеченова,
г. Москва, Российская Федерация
ORTHODONTIC CORRECTION IN CHILDREN WITH CLEFT LIP AND PALATE USING SPEECH OBTURATORS
Dudnik O. V., Mamedov Ad.A., Zubkov A. V.
I.M. Sechenov First Moscow State Medical University, (Sechenov University), Moscow, Russian Federation
Аннотация: Целью исследования было повышение эффективности хирургического лечения у детей с расщелиной губы и неба, с помощью пре-ортодонтической коррекции с использованием речевого обтуратора. Обследовано 80 детей с врожденной челюстно-лицевой патологией. Из них 40 человек были отобраны для консервативного ортодонтического лечения с использованием речевого аппарата. Контрольную группу (35 человек) составили дети с расщелиной губы и неба после первичной уранопластики с нарушениями речи, у которых речевой аппарат не использовался. Наши исследования показывают, что использование речевого аппарата совместно с логопедом позволило улучшить каче-створечи практически сразу после фиксациире-чевого аппарата. Однако в дальнейшем обучение у логопеда проводилось под наблюдением смежных специалистов - ортодонта, эндоскописта и рентгенолога.
Ключевые слова: расщелина губы, расщелина нёба, речевые обтураторы, небно-глоточная недостаточность, ортодонтическое лечение, уранопластика
БИБЛИОГРАФИЧЕСКИЙ СПИСОК
Annotation: The aim of the study was to increase the effectiveness of surgical treatment in children with cleft lip and palate, affordable pre-orthodontic correction with the use of speech aid appliance. 80 children with congenital maxillofacial pathology were examined. Of these, 40 people were selected for conservative orthodontic treatment using a speech aid appliance. The control group (35 people) consisted of children with cleft lip and palate after primary urano-plasty, having speech disorders, in which the speech aid appliance was not used. Our studies show that the use of speech aid appliance together with a speech therapist allowed to improve the quality of speech almost immediately after the fixation of the speech aid appliance. However, in the future, speech therapy training was held under the supervision of related specialists - orthodontist, endoscopist and radiologist.
Keywords: cleft lip, cleft palate, speech obturators, velopharyngeal insufficiency, orthodontic treatment, uranoplasty
REFERENCES
[1] Fontoura C. et al. Association of WNT9B gene polymorphisms with nonsyndromic cleft lip with or without cleft palate in Brazilian nuclear families // The Cleft Palate-Craniofacial Journal. - 2015. - T. 52. - №. 1. - [p.44-48].
[2] Fomenko I.V. The Effectiveness of modern methods of diagnosis and treatment in the complex rehabilitation of patients with congenital unilateral complete cleft of the upper lip and palate : dis. - Volgograd: autoref. Dis. ... doctor of medical science, 2011, -[p.24].
[3] Gibbon F. E., Lee A., Yuen I. Tongue-palate contact during selected vowels in normal speech // The Cleft Palate-Craniofacial Journal. - 2010. - T. 47. - №. 4. - [p.405-412].
[4] Kang S.H., Lee J.W., Lim S.H., Kim Y.H., Kim M.K. Dental image replacement on cone beam computed tomography with three-dimensional optical scanning of a dental cast, occlusal bite, or bite tray impression. Int J Oral Maxillofac Surg., 2014; [p.1293-3014].
[5] Kummer A.W. et al. Current practice in assessing and reporting speech outcomes of cleft palate and velopharyngeal surgery: a survey of cleft palate/craniofacial professionals //The Cleft Palate-Craniofa-cial Journal. - 2012. - T. 49. - №. 2. - [p.146-152].
[6] Pet M.A. et al. The Furlow palatoplasty for velopharyngeal dysfunction: Velopharyngeal changes, speech improvements, and where they intersect //The Cleft Palate-Craniofacial Journal. - 2015. - T. 52. - №. 1. - [p.12-22].
[7] Yuh-Jia Hsieh, Yu-Fang Liao, Akshai Shetty. Predictors of poor dental arch relationship in young chil-drenwith unilateral cleft lip and palate. Clin Oral Invest 2012; [p.1261-1266].
[8] Reiser E., Skoog V., Gerdin B., Andlin-Sobocki A. Association Between Cleft Size and Crossbite in Children With Cleft Palate and Unilateral Cleft Lip and Palate. Cleft Palate J., 2010; [p.175-181].
After the primary uranoplasty on children with cleft lips and palate (CLP), complications in the form of partial or complete divergence of the tissues of the palatopharyngeal ring occur. According to some clinics - this happen in up to 25% of all cases. This has a big impact on the further development of the speech, sometimes the therapy by speech therapists is unavoidable. This depends on many reasons, including the remoteness of accommodation, the absence of a speech therapist on places, irregular classes with a speech therapist. In some cases, this is because of the impossibility of carrying out repeated operations due to the patient's chronic diseases, diseases of the central nervous system, and the limited possibility of general anesthesia.
Oral dentures for the velopharyngeal insufficiency (VPI) treatment in children with cleft palate began to be applied 30 years ago. They were used in cases when surgery was undesirable or impossible, and also when it was impossible to accurately predict the improvement in speech quality after surgery [1]. From sources of literature it is known that the purpose of temporary speech obturators is to increase the air pressure in the oral cavity for the fastest development of a correct articulation. After the articulation is normalized, or becomes close to normal according to the patient's age, the obturator can be reduced in size every 3 or 4 months with the hope that they can be successfully removed later [2], or at least ensure the smallest amount of surgery [3]. An appliance for the VPI treatment may to some extent be an alternative to surgery for obtaining palatopharyngeal competence [4].
Operations to eliminate VPI in patients who were wearing obturators have some advantages over surgery in patients who were not wearing them [5].
The use of speech obturators is a conservative treatment, with which the speech of children after the uranoplasty with VPI it can be normalized [6].
Children with the operated cleft palate wear an obturator for an average of 2-4 years. They quickly and easily learn to put on and take off their dentures (as well as orthodontic appliances) to maintain oral hygiene. Successful use of speech appliance should be carried out under the constant control and correction of the surgeon, dental therapist, orthodontist, speech therapist, otolaryngolo-gist, and all specialists who are ready to work with parents and children.
Nowadays, the results of speech prosthetics are much better than 30-40 years ago, because experts used to be afraid to make obturators "too big" or "too small", suggesting that the device "irritates the tissues of the palatopharyngeal complex" [7].
Gibbon F. E., [3] used speech appliance in 100% of cases in children after primary uranoplasty to obtain a normal or acceptable voice and oral exhalation of air. Kummer A.W., [5], reported a success rate of 95% by VPI treatment with a speech appliance.
Pet M. A. et al. [8] conducted a research on the results of treatment with appliance. They found that up to 9% of patients could not undergo repeated surgical treatment, and 35% of the researched patients who received VPI appliance treatment had to continue surgical treatment.
Yuh-Jia Hsieh et al. [7] reported a 95% success rate in VPI treatment using a speech appliance. Over 35 years, approximately 400 patients with transient speech prostheses were observed at the University of Oregon (USA). Patients wore applicators from 1 to 10 years (on average 3-5 years). In 25-45% of cases, after removing the obturators, there was no need for an operation.
Gibbon F. E., [3] combined the use of the speech appliance with the velopharyngeal flap; Reiser E. [8] combined the plastic of the soft palate with the method of moving the leg of the pharyngeal flap.
In our opinion, all options for the surgical elimination of VPI supported by a speech obturator [6] can be effective as well as an interdisciplinary approach.
Purpose. Improving the effectiveness of surgical treatment in children with cleft lip and palate due to preliminary orthodontic correction with the use of speech obturators.
Material and methods. Based on our research we present the results of clinical observations of orthodontic conservative care for 80 children from four to sixteen years old with various forms of CLP (complete cleft lip and palate, cleft palate) with subsequent study and generalization of direct and immediate results of treatment.
Clinical examination was conducted according to the standard scheme. 80 children with congenital maxillofacial pathology were examined. 40 people from them were selected for conservative orthodontic treatment using a speech obturator.
The control group (35 people) was made up of children with CLP after primary uranoplasty who have speech disorders in work with whom the speech appliance was not used. The patients were distributed according to the clinical-anatomical classification of congenital CLP adopted in the clinic [7].
Research results. Our studies show that the use of speech appliance, together with a speech therapist, made it possible to improve the quality of speech almost immediately after fixing the speech appliance. However, in the future speech therapy training was carried out under the control and supervision of related specialists - an orthodontist, an endoscopist and a radiation diagnostics doctor. It was necessary for the correction of the speech appliance.
This can be seen in the example of speech appliance and their modifications, which we use in the clinic (Fig. 1, 2a, 2b, 3, 4).
Fig. 1. Speech appliance for eliminating velopharyngeal insufficiency
Fig. 2. A patient with velopharyngeal insufficiency(a), an appliance in the oral cavity(b)
Fig. 3. Speech appliance with a screw to correct speech disorder in a patient with a cleft lip
and palate after velopharingoplasty
Fig. 4. Speech appliance to correct speech disorder in a patient with a cleft lip and palate
Successful use of speech appliance should be carried out under the constant supervision and correction of the surgeon, dental therapist, orthodontist, speech therapist, and specialists who are ready to work with parents and children. The final goal of the interdisciplinary approach is to free patients with VPI from their obturators, or at least to ensure the smallest amount of surgical intervention.
The fibrofaringoscope perfectly helps to determine the need for correction of the distal end of the obturator if the patient is tolerant. Thanks to the endoscope, you can see and correct the speech appliance, observe air leaks and palatine-pharyngeal closure.
For the functional recovery of the speech disorder it was recommended to use palatopharyn-geal prosthetics using a speech appliance [[2]].
Unfortunately, such prosthetics aren't spread in our country did not. Apparently, we have to develop this perspective direction. In our opinion, prolonged use of the speech appliance may not always lead to recovery of the speech, especially on patients at the age of 12 years and upon. However, the size, shape, position and duration of wearing the obturator should be determined during the constant comprehensive examination of a patient with VPI according to an individual program. The data of logopedic, endoscopic, electrodiagnostic and other types of studies of the function of velopharyngeal ring (VPR) should be interpreted by the expert assessment. However, it should be noted that the obturator is an alien object of the oral cavity, which fulfilled its function, it must be removed (!), and the tissues of the VPR structures are recovered in the anatomical and functional sphincter by surgery.
Obviously, any combination of the above methods is possible as the choice of optimal treatment. The only question arises: is it possible to use more simple ways to eliminate VPI? How to achieve good results of speech recovery, strengthen the patient's health and ensure the reliability of rehabilitation outcomes? It seems to us that there should always be an alternative and variation of treatment methods, especially on older patients with severe extensive defects of the soft palate with velopharyngeal insufficiency. It is important to correctly and constructively make a choice of surgical and rehabilitation appliance to offer the patient in a comprehensive way of taking it into account of modern standards in this care and the quality of their execution.
Conclusions. Based on the available data, it can be concluded that a systematic approach to the problem of speech recovery allows:
- differentially choose the optimal methods of treatment using new technological methods;
- to solve the problem of rehabilitation based on the use of data of endoscopic diagnostics, which allows to determine which of the VPR structures is the least mobile and to what extent it participates in the clamping mechanism, which is the main component of speech recovery;
- to determine the indications for the use of one or another method depending on the degree of participation in the mechanism of closing of each of the structures and the entire VPR as a whole. The use of surgical methods should be based on an interdisciplinary approach in the methods of
examining the function of VPR (spectral analysis of speech, electrodiagnostics of muscular structures of VPR, etc.), allowing to choose with the greatest accuracy the method of eliminating VPI taking into account the localization of the pathological process (in NC , all NGK structures), which, finally, allows to solve the problem of rehabilitation and to achieve the restoration of normal speech. When it is impossible to provide surgical care, a method is proposed to use orthodontic speech appliance,
aimed at developing the muscles of the structures of the velopharyngeal ring and preventing air leakage through the nose during spontaneous speech.
Conflict of interest: The authors of this article confirmed the lack of conflict of interest andfinancial support, which should be reported.
