1. 19. Speech, Velopharyngeal Function
Sal Esposito DMD, FICD
Jana Rieger, PhD
John Beumer III, DDS, MS
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2. Speech Mechanism
No organs in the human
body are solely
responsible for the
production of speech. It
is a combination of the
upper digestive and
respiratory tracts working
in harmony.

3. The static structures are important in establishing
the route the air takes during connected speech
The dynamic structures control and direct the
exhaled air to form the appropriate speech sound.

4. Components of speech
vRespiration
vPhonation
vResonation
vArticulation
vNeural integration
vAudition

5. Respiration
During speech inhalation is accomplished very rapidly and
accounts for only 10% of total respiratory time. Exhalation is
regulated by muscle forces according to the air supply
necessary for the desired sentence length during connected
speech.

6. Phonation
Phonation occurs when the exhaled air reaches the level of
the larynx, the first physiologic valve and a sound vibration is
produced. The true vocal folds are two strips of voluntary
muscle which produce that sound.

7. Phonation
Abduction Adduction
When voice is desired, the vocal folds are (adducted) by muscle
contraction and air is pushed against them from below with sufficient force
to blow the edges apart. The folds close again for each vibration due to
the elasticity of the edges. This cycle is repeated very rapidly, as
phonation is maintained for speech.

8. Resonation
v The sounds produced at the level of the vocal
folds is not the final acoustic signal which is
perceived as speech. This sound is modified
by the chambers and structures above the level
of the glottis. The pharynx, oral cavity, and
nasal cavity act as resonating chambers by
amplifying some frequencies and muting others,
thus refining tonal quality.

9. Resonators
v Nasal Cavity
v Pharynx
v Oral Cavity

10. Nasal Cavity
Primary resonating
chamber for consonants
m, n, ng
Pharyngeal and Oral Cavities
Resonating chamber for all other
English sounds.

11. Compromised Oral Structures
v Balance between oral – nasal resonance is lost

12. Articulation
Amplified, resonated sound is formulated
into meaningful speech by the articulators,
namely, the lips, tongue, cheeks, teeth,
and palate, by changing the relative
spatial relationship of these structures.

13. Articulation occurs when the resonated sound reaches the oral
cavity, another physiologic valve. There, it is formed into
meaningful speech by the action of the mandible, tongue, lips,
soft palate, hard palate, alveolar ridge and teeth.
Fricative Sounds

14. Anatomic Components of Speech
Static Dynamic
Teeth Tongue
Palate Soft Palate
Alveolar ridge Lips
Palmer, 1974

15. Neural integration
v Speech is integrated by the central nervous
at the peripheral and central levels.
v Neurologicimpairments may compromise a
specific component of the speech
mechanism, such as the vocal folds, the soft
palate or the tongue.

16. The static structures are important in establishing
the route the air takes during connected speech
The dynamic structures control and direct the
exhaled air to form the appropriate speech sound.

17. Audition
v Audition, or the ability to receive acoustic
signals, is vital for normal speech. Hearing
permits reception and interpretation of
acoustic signals and allows the speaker to
monitor and control speech output.
v Speech development is hampered in

18. Speech Phonemes
Vowels
Voiceless consonants
v “p”, “t”, ”f ”
Voiced consonants
v “b”, “d”, “g”
All vowels and most consonants use the oral pharynx and the
oral cavity as the primary resonating chambers. However, there
are 3 nasal consonants (“m”, “n”, and “ng”), that use the nasal
cavity as the primary resonating chamber.
Almost all speech sounds require at least a modicum of nasal
resonance, as evidenced by the distortions in voice quality
exhibited by individuals with severe nasal congestion.

19. Speech and Maxillofacial Prosthetics
The components most effected by
maxillofacial rehabilitation efforts
Resonance
vSoftpalate defects
vHard palate defects
Articulation
vTongue mandible defects

20. Velopharyngeal Closure
v Velopharyngeal
(V-P) closure is sphincteric.
Movement of the posterior pharyngeal wall
blends with movements of the lateral
pharyngeal walls and elevation of the soft
palate.
v Thelevel of closure is slightly below the
level of the torus tubaris bilaterally and
slightly above the level of the palatal plane.
v Closure patterns are variable.

21. Two physiologic mechanisms seem
logical for velopharyngeal closure.
1) The angle of entrance of the Levator Veli
Palatini into the soft palate in the adult is
consistent with the posterior-superior
movement of the velum during closure for
speech.
2) The passage of the levator, lateral to
the torus tubaris most likely results
in the medial-posterior-superior
displacement of the torus during

22. Velopharyngeal Closure
Regulates the flow of air into the oral
or nasal chambers according to the
characteristics of the desired speech.

23. Velopharyngeal Closure
.
This valving is accomplished by the
sphincteric muscle action resulting from
medial movement of the lateral pharynx
and superior-posterior elevation of the
middle one-third of the soft palate against
the posterior pharyngeal wall to seal the
velopharyngeal port.

24. Sphinteric muscle activity viewed
through videonasoendoscope
Posterior
Pharyngeal Wall
Lateral Pharyngeal Wall Soft Palate

25. Normal velopharyngeal closure pattern
Soft palate
Lateral
pharyngeal wall
Posterior
vSoft palate elevates and thickens pharyngeal wall
vLateral pharyngeal walls are displaced medially
vPosterior pharyngeal wall is pulled anteriorly
From Sphrintzen et al, 1974

26. Velopharyngeal Closure
Videofluoroscopy of the soft palate in the rest and
elevated positions. Closure is achieved with the
middle one-third of the soft palate.

27. Velopharyngeal closure patterns:
Varies depending on function
Lateral
Lateral
wall
wall
movement
movement
Soft palate
Soft
palate
elevation
From Sphrintzen et al, 1974

28. Patterns of closure also vary from
patient to patient
v Coronal pattern
v Sagittal pattern
v Circular pattern
v Circular pattern with Passavant’s ridge
From Siegel-Sadewitz et al, 1982

29. Velopharyngeal closure patterns
Coronal
Sagittal
Circular
Circular with
Passavant’s ridge
From Siegel-Sadewitz et al, 1982

30. .
Various closure patterns in base projection. The left column
represents contour of the velopharyngeal portal at rest, middle
column shows partial closure, and the right column shows full
closure.
A- Normal subject
B - Repaired cleft palate subject. Note
the absence of the uvular bulge.
C – Repaired cleft palate subject
with a circular closure pattern.
D – Repaired cleft palate with
circular closure pattern and
Passavants’s pad (Shaded area).
E – Repaired cleft palate with a
sagittal closure pattern.
From Skolnick et al, 1973

31. Velopharyngeal closure
Patient with a repaired cleft achieving
velopharyngeal closure in upright position but
not in extension. Note that the nasopharynx is
deepened in the extended position
From McWilliams et al, 1968

32. A B
In a 5 year old closure is obtained with an inferior-superior
movement of the soft palate at a level below the palatal plane
(A). At 18, closure is characteristically above the palatal plane
and accomplished by an anterior-posterior movement of the
soft palate (B). from Aram A. et al., 1959)
From Aram et al., 1959

33. The pattern of soft palate movement
varies between men and women.
Men Women
l In men the soft palate is longer, the elevation greater,
the amount of contact with the posterior pharyngeal
wall is less and the inferior point of contact is higher
than in women. From McKerns et al, 1970

34. Velopharyngeal Function
v Velopharyngeal insufficiency – The length of
the hard and/or soft palate is insufficient to affect
velopharyngeal closure, but with movement of
the remaining tissues within physiologic limits.
The defect is secondary to a structural limitation
v Velopharyneal incompetence - The
velopharyngeal structures are normal
anatomically, but the intact mechanism is unable
Prosthetic rehabilitation is effective in both
palatopharyngeal incompetence and insufficiency

35. Velopharyngeal Incompetence
There is an adequate amount of tissue present but it
is functionally impaired by neuromuscular disease.

36. Velopharyngeal Insufficiency
The soft palate is
short and unable to
create closure as
seen in congenital
or acquired defects
of the soft palate.

37. Velopharyngeal Insufficiency
These soft palate clefts have been repaired but they are
short and cannot reach the posterior pharyngeal wall
during elevation. Hence they are insufficient.

38. Velopharyngeal Insufficiency
v This patient is unable to achieve closure during the
production of the “e” sound because the soft palate has

39. Methods of evaluation
Multiview videofluoroscopy
Nasal endoscopy

40. Video Naso-endoscopy
Direct visualization of palatopharyngeal space.
Aids in impression making.
An effective tool in determining whether the
prosthesis is achieving maximum palatopharyngeal
closure during connected speech.

41. Velopharyngeal Closure
Videofluoroscopy of the soft palate in the rest and
elevated positions. Closure is achieved with the middle
one-third of the soft palate.

42. Nasoendoscoptic view of attempted velopharyngeal closure
of patient with myasthenia gravis without and with a palatal
lift. Veopharyngeal closure at rest (A). Best attempt at
closure without lift (B). Partial velopharyngeal closure is
accomplished when the patient is fitted with a palatal lift (C).

43. Velopharyngeal closure
Velopharyngeal orifice size
• This opening should be less than 0.2
cm 2 during the production of plosive
and fricative sounds. If the opening is
greater than the above, the
respiratory effort must be increased to
compensate (Warren, 1965).
• However, there is not a direct linear
relationship between velopharyngeal
orifice size and the level of perceived

44. Nasality appears to be noticeable to the listener
at a velopharyngeal orifice size above 20 mm2
(Warren)
With congenital or
acquired defects of
the soft palate the
palatopharyngeal
space is greater than
this dimension.

45. Nasal Resistance
Resistance to nasal airflow may contribute to
increased oral pressure and improve the
effectiveness of speech of patients with larger
velopharyngeal orifices
It is the sum of the resistance of the
velopharyngeal mechanism, nasal resistance,
and the increase in respiratory effort that
determines the oral pressure available for
Nasal resistance is increased by enlarged
turbinates, repaired clefts, deviated septums,
atresia of the nostrils, neoplasms and other factors

46. Nasal Valve
v The area between the upper and lower lateral
cartilages, the pyriform aperture and the anterior
terminus of the inferior turbinates
v Dilates
during inspiration and both active and
passive flattening occurs during expiration
The nasal valve may explain the reason for the facial
grimacing exhibited by patients with velopharyngeal
incompetence or insufficiency during speech articulation

47. Oral vs Nasal Breathing
v Restrictionswithin the nasal cavity in
patients with soft palate defects may lead
to oral rather than nasal breathing. This
factor must be taken into consideration
when fabricating soft palate obturators,
particularly in patients with little or no
movement of the residual velopharyngeal

48. Timing of velopharyngeal closure
Timing errors compound the
problems associated with
velopharyngeal inadequacy

49. Anatomy of the
Velopharyngeal Complex

50. Anatomy and physiology of V-P complex
v Levator veli palatini - Elevates the soft palate and brings the
lateral pharyngeal wall medially.*
v Uvulus muscle - Thickens and lengthens the soft palate (velar
eminence). The velum can stretch anywhere from 13 to 28 %.*
v Superior constrictor - Brings the posterior pharyngeal wall
anteriorly.*
v Tensor veli palatini – Dilates the Eustachian tubes.
v Salpingo pharyngeus – A remnant in most patients.
v Palatoglossus – Positions the tongue during speech by exerting a
downward pull on the soft palate.
v Palatopharyngeus – Contracts to narrow the pharynx.
*Muscles directly involved in velopharyngeal closure.

51. Innervation of the velopharyngeal
mechanism:
Pharyngeal plexus –
This plexus is supplied by the
glossopharyngeal and vagus nerves.
Some studies have indicated that perhaps
Note: The tensor veli palatini is
innervated by the trigeminal nerve.

52. Anatomy and physiology
Levator veli palatini
Elevates the soft palate and brings the lateral
pharyngeal wall medially
Uvulus muscle
Thickens and lengthens the soft palate (velar
eminence). The velum can stretch anywhere
from 13 to 28 %.
Superior constrictor

53. Of these the levator veli palatini and
musculus uvulus muscles are most
important
• EMG studies have indicated that these two muscles
are synchronous during speech.
• The levator elevates the soft palate and at the same
time the uvulus contracts to fill the gap between
the lateral and posterior pharyngeal walls.

54. Dickson (1975) and Honjo et.al. (1976)
using both radiographic and motion
picture film concluded that lateral
pharyngeal wall movement which is
essential for palatopharyngeal closure
is a result of the displacement of the
Torus Tuberis due to the contraction of
the Levator muscle sling.

55. Soft Palate
Soft palate runs continuously from the end of the
hard palate and ends posterior inferiorly in a free
margin, which forms an arch with the palatoglossal
and palatopharyngeal folds on each side.
Tensor aponeurosis
Pterygoid hamulus
Levator
veli palatini Palatppharyngeus
Palatoglossus
Musculus uvulae

56. Levator Veli Palatini
Origin - Posterolateral side of the auditory tube and
lower surface of the petrous portion of the
temporal bone.
Insertion - Middle one-third of palatal aponeurosis.
Levator
Veli
Palatini
View from behind

57. Levator Veli Palatini
Primary muscle responsible for velopharyngeal closure.
During contraction, it elevates the soft palate posterolaterally
to contact posterior and lateral pharyngeal walls.
Levator veli palatini
Hard palate

58. Levator veli palatini
Levator veli
palatini

59. Uvular muscle
Origin - anterior to the Levator
Insertion - palatine uvula
Innervation - pharyngeal plexus
Levator
Eminence
Uvular Muscle

60. Uvular muscle is most cohesive at the Levator eminence
thickening, in the middle one-third of the soft palate. The
Levator eminence is caused by the contraction of the Levator
and Uvular muscles functioning at right angles.
Levator Eminence
Uvular Muscle

61. Uvular Muscle
When contracting – it thickens
and lengthens the soft palate
anywhere from 13 to 28%.

62. Uvular Muscle
A paired intrinsic muscle of the soft palate
Uvular Muscle

63. Posterior Pharyngeal Wall

64. Superior Constrictor
Origin - medial pterygoid plate, hamulus,
pterygomandibular raphe, lingular
Insertion - pharyngeal tubercle of occipital base
Innervation - pharyngeal plexus
Superior
Constrictor
Superior
Constrictor
after Frank H. Netter, M.D.

65. Superior constrictor
During speech the level of EMG activity of
the superior constrictor is inconsistent and
not in harmony with the levator or the uvulus
muscles.
The fibers of the superior constrictor insert
into the soft palate. Kuehn (1990)
speculated that these muscle fibers may
assist the musculus uvulae to draw or

66. Posterior wall movement and compensatory
adaptations - Does Passavants pad contribute
to V-P closure?
a) The importance of forward movement and its
contribution to V-P closure is debatable.
b) Most normal speakers demonstrate little or
no forward
movement of the posterior pharyngeal wall
during V-P closure.
c) About 1/3 to ½ of patients with V-P
incompetence or insufficiency develop
Passavant’s pad.
d) It is not clear that Passavant’s pad contracts
in perfect harmony with the residual levator
or uvulus muscle elements.
This debate remains unresolved.

67. Associated Musculature
Tensor veli palatini
Palatoglossus
Salpingo pharyngeus

68. Tensor Veli Palatini
Origin – Anterolateral side of the auditory tube and the
angular spine and scaphoid process of the sphenoid
Insertion – Extends by tendon around the hamulus and
inserrts and forms the palatine aponeurosis.
Tensor Veli Palatini
Levator Veli Palatini
Tensor Tendon
after Frank H. Netter, M.D.

69. Tensor Veli Palatini
While there is some question as to its role in palatal
pharyngeal closure; when it contracts, the aponeurosis
becomes taut because the hamulus is below the level of
the hard palate and the aponeurosis is lowered causing a
downward movement of the anterior soft allowing for the
upward movement by the Levator.
Tensor Tendon
after Frank H. Netter, M.D.

70. Tensor Veli Palatini
At the level of the soft palate the Tensor is not
actually a muscle, but rather an aponeurosis.
Tensor Tendon
after Frank H. Netter, M.D.

71. Palatoglossus
Origin – Middle one–third of the soft palate
Insertion – Dorsolateral surface of the tongue
Innervation – Pharyngeal plexus
Palatoglossus

72. Palatoglossus
When contracting it helps raise the soft palate and
tongue during swallowing and lower the soft palate
during speech.
Palatoglossus
after Frank H. Netter, M.D.

73. Palatopharnygeus
Origin - Palatine aponeurosis
Insertion – Lateral wall of pharynx and forms posterior
tonsillar pillars
Innervation – Pharyngeal plexus
Palatopharyngeus
View from behind

74. Palatopharyngeus
Narrows the lateral pharyngeal wall.
Palatopharyngeus

75. Salpingo pharyngeus
This muscle does not contribute to
velopharyngeal closure. It is
frequently absent or when present,
rarely of substantial size.
The salpingo pharyngeal fold is
primarily glandular in nature, not

76. Compensatory actions
Passavants pad
Elevation of the tongue
Nasal resistance

77. Superior Constrictor and Passavant’s Pad
In some patients with velopharyngeal dysfunction a
muscular bulge is seen during speech and swallowing.
It is referred to as
Passavant’s pad.
•Passavant’s pad occurs in about one third to one half of patients with
velopharyngeal dysfunction
•Probably composed of fibers of the superior constrictor
•Associated with a circular pattern of V-P closure

78. Tongue position and velopharyngeal
closure
Patients with V-P insufficiency or
incompetence often have a more posterior
and superior tongue position during speech,
presemably as a means of reducing the size
of the V-P orifice during function.
This high tongue position increases oral
resistance but contributes to faulty
articulation.

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