Presurgical maxillary prosthesis: An analysis of speech intelligibility

Maxillof a&al prosthetics

Presurgical speech

maxillary

prosthesis:

An analysis

of

intelligibility

Leo J. Kipfmueller,

Ph.D.,* and Brien R. Lang, D.D.S., M.S.**

Central Michigan University, Mt. Pleasant, University of Michigan, Ann Arbor, Mich.

Mich.,

and The

P

resurgical maxillary prosthesesfor patients undergoing maxillectomy procedures for cancer serve primarily as aids to healing during the recovery period and secondarily in improving speech, esthetics, and the general emotional well-being of the patient. Detailed speech analysis and quantitated supporting data of speech improvement are essential for an objective evaluation of patient treatment. Therefore, a study was initiated to evaluate changes in intelligibility of speech within a patient by paired comparisons of the patient’s speech prior to and following surgery with and without the maxillary prosthesisin place in the mouth. REVIEW OF THE LITERATURE Several author+ have reported the use of a prosthesisas a method of maxillary closure following surgical resection. The importance of the maxillary prosthesishas been related to a shortened hospital stay and the over-all recovery and restoration of the patient’s mora.le.6p’ Acceptable quality of speech and oral function can be attained by using a presurgical maxillary prosthesis in most patients .6 However, the intelligibility of speech attained by the patient needs to be quantitated to effectively judge clinical improvement. PROCEDURES Six patients ranging from 24 to 59 years of age were referred prior to surgery for prosthesisconstruction and speech recordings. Three of the patients were edentulous. The other three patients had sufficient maxillary teeth following surgery to provide abutment support.

tation,

Supported in part by a Research Fellowship from the Department Department of Health, Education and Welfare. *Associate Professor, Department of Speech and Dramatic Arts. **Associate

620

Professor

and Chairman,

Department

of Complete

of Vocational

Dentures.

Rehabili-

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Presurgical

maxillary

prosthesis

621

Table I. The total number of errors before surgery and after surgery, with and without the prosthesisas indicated by Fairbanks’ rhyme test tabulations -.. Condition

Patient No.

Date of recordings

1

10-09-65 1 l-02-65 1 Z-20-65

9

01-25-66 04-l 9-66 06-15-66

83

03-15-66 07-l l-66 12-07-67

29

06-15-66 08-01-66

18

11-01-66 12-06-66 01-l 1-67 07-18-67

68

01-16-67 02-16-67 04-16-67 12-20-67

84

2

3

4 5

6

Presurgery

and No. With

prosthesis

of errors

-Without

_._.“..

p7osthesi.r

64 7

333 8.53

265 302

588 380

435 302

1058 1073

154

1054

131 124 52

1152 1170 1070

389 287 167

666 552 447

-..-

Impressions of the maxillary dental arch were made with an elastic (rubberbase) impression material. Anterior teeth removed with the surgical specimen were replaced by the prosthesis. Posterior occlusion was avoided at the site of the surgical defect when possible.The prosthesiswas processedin heat-cured acrylic resin and inserted immediately following the operation. Ten days after the operation, or as soon as the patient could tolerate the impression procedures, the restoration was modified by the addition of an hollow elastic extension. This modification improved voice resonanceand helped to obliterate the defect. Each patient recorded a different word list from Fairbanks’ Test of Phonemic Differentiations.8 This test has been shown to be of value in studying pathologic speakers9-11 and it permits a definitive evaluation of specific consonant change in speakers.121 I3 These recordings were made in a sound-treated room before and after surgery with and without the restoration in the mouth. Each patient recorded the original word list he or she usedbefore surgery. These recordings were randomly dubbed to a master tape and were played back to a group of 30 untrained listeners. Score sheets developed by Fairbanks8 using the word stem, such as -en, ---ot, _un, and the like, were used by the listeners for the entire 50 words. The listeners’ task was to write the first letter or letters as they heard the word spoken. This procedure permitted a means of assessingloss of intelhgibility in the initial production of consonants. Since these words were recorded prior to surgery and following surgery with and without

622

Kipfmueller

0

J. Prosthet. December,

and Lang

RECORDINGS

Fig. 1. Per cent of intelligibility and date as evaluated by 30 untrained listeners: 99 surgery without dentures (11-2-65); 96 44 per cent, postsurgery without dentures

Dent. 1972

RECORDINGS

0

of testing for patient No. 1 based on 1,500 words per cent, presurgery (10-g-65); 52 per cent, postper cent, postsurgery with dentures (1 l-2-65); (12-20-65); 99 per cent, postsurgery with dentures

( 12-20-65). Fig. 2. Per cent of intelligibility and date of testing for patient No. 2 based on 1,500 words as evaluated by 30 untrained listeners: 95 per cent, presurgery (l-25-66); 61 per cent, postsurgery without dentures (4-19-66); 83 per cent, postsurgery with dentures (4-19-66); 75 per cent, postsurgery without dentures (6-15-66); 80 per cent, postsurgery with dentures (6-15-66).

100

JO0 !z 2cer 75 E 50 4 5- 25

75 50 g- 25 0

0

0 RECORDINGS

0

RECORDI N6S

Fig. 3. Per cent of intelligibility and date of testing for patient No. 3 based on 1,500 words as evaluated by 30 untrained listeners: 98 per cent, presurgery (1-16-66); 30 per cent, postsurgery without dentures (2-16-66); 71 per cent, postsurgery with dentures (2-16-66); 29 per cent, postsurgery without dentures (12-7-67); 80 per cent, postsurgery with dentures (12-7-67). Fig. 4. Per cent of intelligibility and date of testing for patient No. 4 based on 1,500 words as evalaated by 30 untrained listeners: 98 per cent, presurgery (6-15-66); 30 per cent, postsurgery without dentures (8-l-66); 90 per cent, postsurgery with dentures (8-l-66). the prosthesis in the mouth, this provided presurgery speech and postsurgery speech.

a technique

of matching

each subject’s

RESULTS Each subject recorded a 50 item word list which was played back through headsets to 30 untrained listeners. Thus, each subject was evaluated on the basis

of 1,500 words. The results of the untrained listeners responding to initial consonants are presented in Table I.

Presurgical

maxillary

prosthesis

623

5 75 “3 50 z s 25 =0 RECORDI N6S Fig. 5. Per cent of intelligibility

and date of testing for patient No. 5 based on 1,500 words as evaluated by 30 untrained listeners: 96 per cent, presurgery (1 l-l-66); 23 per cent, postsurgery without dentures (12-6-66); 91 per cent, postsurgery with dentures (12-6-66); 22 per cent, postsurgery without dentures (l-11-67); 92 per cent, postsurgery with dentures (l-11-67); 29 per cent, postsurgery without dentures (7-18-67); 97 per cent, postsurgery with dentures (7-18-67).

> 5-

100 75

:--1 50 i 25 0 RECORDINGS Fig. 6. Per cent of intelligibility

and date of testing for patient No. 6 based on 1,500 words as evaluated by 30 untrained listeners: 94 per cent, presurgery (1-16-67); 56 per cent, postsurgery without dentures (2-16-67); 74 per cent, postsurgery with dentures (2-16-67); 64 per cent, postsurgery without dentures (4-16-67); 81 per cent, postsurgery with dentures (4-16-67); 71 per cent, postsurgery without dentures (12-20-67); 89 per cent, pestsurgery with dentures ( 12-20-67).

DISCUSSION Table I and Figs. 1 to 6 indicate the effects of the maxillary prosthesison initial intelligibility of consonants as scored by 30 untrained listeners. In every patient, the prosthesishelped to decreasethe number of errors. The greatest improvement was found for patient No. 5 with 1,046 initial consonants showing sound improvements. In two patients ( 1 and 5)) fewer errors occurred following surgery than occurred during presurgery speech. Both of these patients had teeth remaining for retention of the prosthesis. This was a possible contributing factor. With the exception of patient No. 2, continual improvement was observed with each recording following surgery. The improvement may be the result of scar contrarture about the hollow elastic extension or patient adaptability. In patient No. 2. a large part of the soft palate was surgically removed. This patient was edentulous. In an earlier study comparing graduate students with velopharyngeal inade-

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and Lang

J. Prosthet. Dent. December, 1972

quacy and patients wearing supportive-type speech aids, the range of errors for graduate student speakerswas 1 to 1811: The Fairbanks’ Rhyme Test was used in this study. Two of these patients scored 18 or lesserrors in their presurgical speech. Subtelny, Koepp-Baker, and Subtelnyi4 reported that, “Cleft palate subjects with complete velopharyngeal closure were able to produce words or syllables with approximately a 10 per cent lossof intelligibility.” Four patients (Nos. 1, 4, 5, and 6) scored 0.4 to 11 per cent lossof intelligibility with the prosthesisduring their last postsurgical recording. None of the 6 patients received speech therapy before or after surgery. The results of this study indicate that the prostheseswere of definite assistance in speech improvement. In two patients (1 and 5), intelligibility of speech with the prosthesisat the last recording was better than that of presurgery speech results. In patients 2, 3, 4, and 6, the differences in presurgery and postsurgery speech intelligibility at the last recording with the restoration in the mouth were 14.5, 18.1, 8.8, and 5.4, respectively. Comparison of the percentage differences between presurgery and postsurgery speech intelligibility at the last recording without the restoration in the mouth reveals that the differences were 19.5, 70.1, 69.8, and 23.4 for patients 2, 3, 4, and 6, respectively. When these differences are considered as indices for future employement and habilitation, the condition is more conducive for successwith the prosthesisin the mouth than without it. Repair of a maxillary surgical defect with a split-thickness graft generally requires a delay of 6 months to 1 year. I51I6 If a maxillary prosthesis is not used, the patient becomes retiring and introspective and eventually withdraws into his own “shell.” Difficulty in eating, speaking, and continuous drooling of saliva are especially damaging to the ego. This discomfort to the patient is avoided by the use of a maxillary prosthesisconstructed presurgically, which greatly decreasesthe general morbidity. Failure to intelligently communicate should not be a postsurgical complication of maxillectomies for cancer. SUMMARY

Studies on speech intelligibility were conducted on six patients undergoing maxillectomy procedures for cancer. Each patient recorded a different word list from the Fairbanks’ Test of Phonemic Differentiations for a presurgical and postsurgical speech analysis. Speech improvement as a result of wearing a maxillary prosthesis was measured by the paired comparison technique, and the percentage of improvement in intelligibility was reported. References 1. 2. 3. 4. 5.

Prosthesis and Its Role as a Healing Art, Miglani, D. C., and Drane, J. B.: Maxillofacial J. PROSTHET. DENT. 9: 159-164, 1959. A.: Management of Surgical Defects of the Gutman, D., Malberger, E., and Neder, Maxilla, J. Oral Surg. 22: 244-248, 1964. Pettit, L. S., Williams, B. H., and Ryan, R. M.: Prosthesis After Maxillectomy, J. PROSTHET. DENT. 10: 938-986, 1960. Robinson, J. E.: Prosthetic Treatment After Surgical Removal of the Maxilla and Floor of the Orbit, J. PROSTHET. DENT. 13: 178-184, 1963. Sala, H. L., and Spear, J.: Restoration of the Upper Jaw and Its Immediate Restoration, Oral Surg. 13: 1033-1037, 1960.

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6. Lang, B. R., and Bruce, R. A.: Presurgical Maxillectomy Prosthesis, J. PKOSTHE’T. DENY. 17: 613-619, 1967. 7. Scannell, J. B.: Practical Considerations in the Dental Treatment of Patients With Head and Neck Cancer, J. PROSTHET. DENT. 15: 764-769, 1965. 8. Fairbanks, G.: Test of Phonemic Differentiations: The Rhyme Test, J. Acoust. SW. Am 30: 596-600, 1958. 9. Prim, D., and Bloomer, H. H.: A Word Intelligibility Approach lo the Stlltly of Sp?cc‘!t Change in Oral Cleft Patients, Cleft Palate J. 2: 357-368, 1965. 10. Prim, D., and Bloomer, H. H.: A Preliminary Study of Methods for Evaluating Speech and Related Behavior Changes in Oral Cleft Patients, The University of Michigan, ORA Project, Ann Arbor, Mich., 1966. 11. Kipfmueller, L. J.: The Effects of Palatal Lift and Modified Palatal Lift Appliances on Speech and Velopharyngeal Function, Doctoral dissertation, The University of Michiyan, Ann Arbor, Mich., 1969. Unpublished. 12. Clarke, F. R., Nixon, J. C., and Stuntz, S. E.: Technique for Evaluation of Speech Systems, Stanford Research Institute, Project 5090, Menlo Park, Calif., 1964. 13. Hirsh, I. J. Information Processing in Input Channels for Speech and Language: The Significance of Serial Order of Stimuli, in Millikan, C. L., and Darley, F. L., editors: Brain Mechanisms Underlying Speech and Language, New York, 1967, Grune & Stratton, Inc., pp. 21-38. 14. Subtelny, J. D., Koepp-Baker, H., and Subtelny, J. D.: Palatal Function and Cleft Palate Speech, J. Speech Hear. Disord. 26: 213-224, 1961. 15. Longacre, J. J., DeStefano, G. A., Holmstrand, K., Leichliter, J. W., and Jolly, P.: The Immediate Versus the Late Reconstruction in Cancer Surgery, Plast. Reconstr. Surg. 28: 549-561, 1961. 16. Shirokov, E. P.: Carcinoma of the Palate, Am. J. Surg. 100: 530-533, 1960. DR. KIPFMUELLER DEPARTMENT OF SPEECH AND DRAMATIC CENTRAL MICHIGAN UNIVERSITY MT. PLEASANT, MICH. 48858 DR. LANG UNIVERSITY DENTAL SCHOOL THE UNIVERSITY OF MICHIGAN ANN ARBOR, MICH. 48104

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