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OREGON
I-IEALTI-I SCIENCES UNIVERSIlY
CIIII..I) I)EVELOPMENT & REHAUIfJTA'Il0N CENTER
1'.0. Box 57/i~ Portland, Oregon 97207-0574

Services for G1., ildre1l u,itb Special J/eallb Needs


l}1lfl..ersity AjJUfated Plugrllll1

June I, 1994

To Whom It May Concern:


RE: Neil Gillespie

This 38 year old I1lan has a repaired unilateral cleft lip and palate. His primary surgery was

done in Pennsylvania and he had SOITIe secondary work including a pharyngeal flap for

speech, in Florida.

Since speech treatlnent for serious hypernasality has been unsuccessful up to this point, the

patient came to Ine for consultation about a speech plan.

Examination shows objectionable hypernasality with moderate nasal emission of air which

markedly weakens all 16 air pressure phonemes. Use of the fiber-optic nasendoscope on May

26th verified that the pharyngeal flap, done three years ago (for speech), has pulled loose.

The treatment plan is to utilize a telnporary speech prosthesis (for circa two years) to

markedly obturate all sounds froln entering the nasal cavity. After normal oral resonance is

obtained and Inaintained for about four to five ITIonths, an obturator reduction program would

begin whereby the throat and palate 111usculature would be "challenged" by slowly making the

obturator sl11aller, in stages. At the end of approximately two years, it is expected that oral

nasal resonance anti oral air pressure would be close to normal limits and that pharyngeal and

palate 111usculalurc \vould have inlproved considerably. This is expected to nlake the patient's

velopharyngeal systenl nluch Inore anlenabie to a surgical procedure to substitute for the

speech prosthesis \vithout c0l11promising the patient's nasal airway.

Respectfully sublnitted,

Robert W. Blakeley, Ph.D.

Professor of Speech Pathology,

Director, Craniofacial Disorders Progralll

blak/b:gille~pi.

OREGON

HEALTH SCIENCES UNIVERSITY


CHILD DEVELOPMENT & REHABILITATION CENTER
P.O. Box 574, Portland, Oregon 97207-0574

Seroices for Children with Special Health Needs


Universi(V Affiliated Program

November 21, 1995

NEIL GILLESPIE
1001 COOPER PT RD SW #140-180
OLYMPIA WA 90505
Dear Mr. Gillespie:
I am enclosing a copy of your dental record. With any adult
prosthesis, you are encouraged to have routine dental care and
maintenance in order to optimize the usefulness of the device.

Sincerely,

\l-~

Peter Lax, DMD

April 1994, dinner at the Multnomah Athletic Club (MAC), Portland, Oregon

Upper right: Dr. Robert W. Blakeley, Ph.D, Speech Pathologist. (1924-2010)


Upper left: Neil Gillespie (age 38 in 1994)
Lower right: Dr. Ningyi Li, MD, DDS, Professor and Chairman Maxillofacial
Department, Affiliated Hospital of Qingdao Medical College, People's Republic of China
Dr. Li was at the time a visiting scholar at Oregon Health Science University (OHSU).
Lower left: Neil Gillespie

speech prosthesis a.k.a. speech bulb obturator


Speech bulb obturator made at Oregon Health Sciences University (OHSU)
under the direction of Dr. Robert Blakeley, PhD, Speech Pathologist.
To correct velopharyngeal incompetence (VPI) or hypernasal speech.

!e_Il1J~? r? ql_':~l~...c:.~_~_C~~_~PJ~~an CC.


A. s a ":E.ci-l_~_mel~.~ . .0J~t),-(l_n_J~oT_}~rt)_i!. t.il.I:.. ..:l.n_~)!."'~l~~_t e ns.~.

1.:.

I':ob('rt

I"op anll btt:ral views ot the Slll.:C\:h

..

.....-"

.,

.....

.1I

;' ~J

.<.)
III

\.,:

(:.1

ILlakeJ

n.

ey. I'll.

prostltC~i~;

wilh its palatal ponilH1 J tai' piece, obl.urato.' und


rCfcntiuo w'ircs.

'

.'"

:(1

10

.)

\,.

..

Il'

~.\

. . >.

~.

;,/- {jJ

:J

I"

;,.J

l'

.. 5

:'

.....
J.J
/.;

'0

._.

-I

/2 -/(J 6)

t{;

,,~

Stone rnodds of a series of obturalOr reductions nLlm;wulng, after' nine


Inonllls, in removal
the appliance with completely compensated pabto
pharyngC:1I1 muscles lind 110"11<,1 voice will lIrticullltion. The child wa.
live years, lour months of age when he ohtained the ohtur;lIor and 1111<.1. l!
n,pair.cd uniJa!.eral ddt tip and palMe.

or

II ~

"'Ill

III

')

'"

(~ht"l;llor

.,/

I!

6.'

...

t ,':,

/
,;./

II"

/0',

'f

.I()

1' . '>

llliIlIIlH..:IUS lillerally al\lJ '"~ 111dllllll'ICrS alllt..:rjn'l'n~ilt..:.. iorlYJ (H.':l."UlTing


Thn~arl<T, IlO addllHHwl pal'Il,\'pharyng~all1lllsciccompe",;alinll
1poll.. pl:IIT
'J:lving "c~nltaJ t:nic.."e and :1.rl;l"tdalit11)1 lilt.: cllild 1Iu. lI UI1c..krwt:1I1 a ph~H'yng(::lI 1Llf~
111(I(.('111IT(: ;I~" ;\ ~.III)Slil'I(.c (Clf Ihe I In):if11'.::;is. N,lrrllill ~pCl"\.:h \\'a~; .lnaintaincd.
J-rc had a n::pnin~d
1IIlilall:'"al l:kl1 lip ,,,ttl palal.l: "thot sl.ant:d \VC;llln,~ rite speed, prllst.ht'si~~ 1.11 age..' lhr(~c yt';.lI~, H!lle
rtUJluh~;
-rtle gn:.lIe:.-'l lrlll~;(k uHTlIH.:n:;atinn illv;lri;\hk {h.:~:lIrs ill the li.lfCral pharyngeal \IIJalh.

"Vel ,I

n~dUc.(HIIlSI

6.!

.U}~ij

'"~

'''<'Illy

,"'V"

11.

111""111

perind.

Ii.

Nunnal Palillul -P'hurYIlJeul


ClotJule.

b.

Ablluunill Palatal-Pharyngeal
Clobure wJ[h P.... llltll.l InBut
flclcncy.

Cleft Craft, The Evolution of its Surgery


Volume III, Avelolar and Palatal Deformities
D. Ralph Millard, Jr. MD, F.A.C.S.
Chapter 53, Palatal Obturators

53

OBTURATORS

PALATAL

BEFORE

WERE

ROGERS

NOTED IN

INTERESTINGLY

WAS FOUND

AT

BC

2500

THE

EARLIEST

EVIDENCE

EL

GIZEH

DATING

OF

SIMPLE

FIOM

END

THE

WAS MADE OF GOLD WIRE LINKED

IT

BEEN

1971
DENTAL

RETENTIVE

MANS EARLY

INLE

SUCH AN IMPORTANT

THE INVENTOR

AS

EARH

MANS

TIMES

IN

THE

IN

1560

TO

LUSITANUS

WHAT

DESCRIBE

IS

AS

1537

TO 15

39

SIN

PREVIOULY

OF

KNOWN TODAY

PRESENTED

LUSITANUS

WHO DESIGNED
LEIBOWITZ

PROSTHESIS

OF

AMATUS

LUSITANUS

THE

WAS PROBABLY

USE

OF THE

IN

PALATE

TO

WORDS TRANS

ARE HIS

OF HEBREW UNIVERSITY

FIRST

GREEK

OBTURATOR

FISRULA

THESE

WITH

THEIR

ALPS

THE

PALATAL

LUETIC

PERMANENT

OF CLEFT

EVOLUTION

HE HAD OHSER EL

ANCONA

AS

THAT PLAYED

PARE WAS FAMILIAR

WCINHUIGER

HARTLES FOUGHT HEYOND

NOBLEMAN

LATED BY JOSHUA

THE SUPPORTERS

DESPITE

OF THE OHTURAROR

PALARAL CHRURATORS

THE

THUS

MARGINS

PROSTHESES

IN

SUHSEQUENR CENTURIES

AND SURGERY

PALATE THERAPY
AS

IN

CIRCA

THE LOWER LEFT SECOND

TOGETHER

THE INTRAOIAL

TO CONSTIUCT

ATTEMPTS

PROSTHESIS

OLD EMPIRE

THE

OF

AND THIRD MOLARS AND HAD HEEN WOVEN AROUND THEIR GINGIVAL
HEGAN

DEVELOPED

SCHOLAR BLAIR

TO HISTORICAL

AND PALATE

LIP

CLEFT

HAD

PALATE

USE ACCORDING

IN

OBTURATORS
AS

OF THE

SURGERY

WHILE

ISRAEL

AT

YALE
PAY ATTENTION

TO THE

WA

WHICH MADE POSSIHLE

INVENTED

THE FOLLOWING

CORRECT AND DISTINCT

SPEECH

AS IF

EXTRAORDINATY

AITIFICE

HE HAD NEVER HAD ANY

ILLNESS
ORDERED
NAIL

SMALL

WHEREAS THE
SPONGE WAS

FORAMEN WHERE

871

TO PREPARE

GOLDENHEADED

NAIL

THE

HEAD OF THE

WAS ROUND AND HROAD ENOUGH TO CLOSE THE TOTAL CIRCUMFERENCE

FORAMEN
RIP

GOLDSMITH

IT

TIP

OF THE NAIL

FITTED

AS

NARROW AND ROUND

HIS THE PATIENT

OF THE

AND TO THIS

HAD TO INTRODUCE

INTO

THE

MOISTURE AND SO REMAINED FIXED IN POSITION


EXPANDED WITH

THIS

WAS REMOVED TWICE

OBTURATOR

WAS IN

THE

HOULLIERS

JACQUES
PLUG PALATE

IN

1561

WHO HAVE

IN

CLEFT

PALATES
IF

ARE

OBTURATORS

ONLY SLIGHTLY

IS

AMBROISE PAR

HIS

CALLED

WORD OHIURATOR WAS USED


PALATAL

EXPLAINED

OF THE

PALAT WITH

THE CAVITIE
LIKE

SELF

IT

UNTO

BUT

IS

DISH

IT

SMALL

AND

CLEFT

IF

AND FIRM

FAST

SINCE
CULTIES

OF THE

WHICH ROGERS

MEDICAL

HIS

TECHNIQUE

OF

PLATE OF GOLD OR SILVER


BE AS THICK

LITTLE

SURGICAL

IF

AND

MIDDLE AGES AVOIDED

FAUCHARD
FIXATION

WINGS

PRINCIPLE

MODERN

FAUCHARDS

878

THEIR

FILL

IN

FILL

CANNOT

FALL

HARD PALATE

DEFECT

OFFERED DIFFI

DOWN

BUT

SELF

TO

PLAGUE

AND WERE USED

PRAISE

WAS IMPROVED IN 1728


DENTISTRY

DENTAL

WHEN HE

PROSTHESIS

SOPHISTICATED

DESIGN

HE

MOST

PALATAL

MARGINS THESE

PERFORATIONS

WERE

LE CARU RGIEN DENTSTE

ON

ILLUSTRATED

TRAT

BY PIERRE

INAUGURATED
DESCRIBED

FIVE

SOME WITH MOVABLE

BY SCREWS AND EACH COVERED WITH

OPERATED

WHICH COULD

OF

WILL

PALAT

IT

PALATE

THE FATHER OF

YEARS

IT

BE

AS

THE

OBTURATORS

IRREGULAR

OF

SHALL

ROGERS HAS NOTED SURGEONS OF THE


OF THE
LIKE
THE
SURGERY
THE

OF THE OBTURATOR

DIFFERENT

OF

OF THE RENAISSANCE DESERVED

AIDS

FOR ABOUT 200

THE ARTIFICIAL

STOOD

CORRECTION

FOR CENTURIES

PROSTHETIC

IT

BIGGER

CROWN AND

AS

IN

PALAR

AS

THAT

HISTORY

REFERRING ONLY TO TRAUMATIC AND

MUST

THAT

CAN BE

COUVERCIES

AND ON THE
FIGURE
WHICH
UPPER SIDE
TOWARDS THE BRAIN WILL HECOM MORE SWOLN AND
PUFFED UP SO THAT
CONCAVIRIE

CAN HE

IT

OR LEAD

OBTURATORS

IN

ALWAYS

OR PERHAPS EVEN AS

TO OBTURATEUR

TIME

FIRST

PAR

DEFECTS

THE CAVITIE

NAME

CHANGED THE

AND THEY

OF SILVER

PALATE

THERE

WAS PROBABLY THE

STAND

WERE

PERFORATIONS

MORE CLEARLY

WERE NO CLEFT OR BETTER

CONJECTURED

THE

WHEN

CENTULY

TO CURE

DIFFICULT

WILL SPEAK

1575

MADE

MORE

THE PALATE

AND ONLY IN

THAN

AND PALATAL

BY SOME MEANS AND RETAINED

1564

LUETIC

SUCH PRIMITIVE

TO

HUGUENOT SURGEON OF PARIS WROTE

COTTON THE PATIENT

THERE

IF

APPLIED

FILLING

WAS OUT

IT

OF WAX OR
SPONGE

USE

OF THE SIXTEENTH

ULCERS

FRANCO

THROUGH THE NOSE

AS

SUGGESTS

SYPHILITIC

PIERRE

PLUGGED WITH

THE

IT

AND RECOGNIZABLE

PREVALENT

THOSE

THE
THAT

USE BY THE MIDDLE

BUCCOPHARYNGEAL

IN

MENTION OF

PERFORATIONS

WERE ALREADY

SPEAK

WHEN

ELEGANT

WHILE

DEFICIENT

TOTALLY

WELL

SPEECH WAS

PATIENTS

FOR CLEANING

DAILY

AES

SOFT

SPONGES

NO MATTER HOW
IN

PLATE

DENTS

38

1746

OF

J6

L26

IN

BOURDET IRNPRUVCD

1757

THE

TO

CLASPS

MOVE

TEETH

THE

VELAR SECTION

TO THE PALATE

ATTACHED
OF ELASTIC

GUM

MOHAMED ARAMANY
THE
THAT

SNELL

JAMES

YEARS AFTER

CLEFTS

TO

SNELLS

AND

PALATE

OF OCCUPYING
STOPPED SHORT

STEAM WHO HAD


FEW UNSUCCESSFUL
OF

HIS

OWN

OF PITTSBUIGH
CLEFT

THE

FIRST

IN

DESCRIBING

LUETIC

CLEFTS

CONGENITAL

CLEFT

ATTEMPT
THE

FIRST

MADE

TO

STUDYING
REPORTED

PALATE
TO

ATTEMPT

1828

THE

ABOUT 300

AN OBTURATOR FOR
RESTORE

THE

PHARYNGEAL SPACE IN

SOFT

1841

HIMSELF WHICH HAD UNDERGONE

OPERATIONS ATTEMPTED TO CONSTRUCT

AND WAS THE

PART

VELUM AND UVULA

THE

WITH OBTURATORS

PARE WROTE HIS


TRAUMATIC

BE

WERE

TEETH

MOVABLE

MANAGEMENT OF

WAS BELIEVED

TREATMENT OF CONGENITAL

RESTORE

OF THE UNIVERSITY

OF PROSTHETIC

HISTORY

MINERAL

BY MEANS OF SPRINGS
TO

MUSCLES

THE PALATAL

OF THE PROSTHESIS

LATERAL

RUBBER

CONSTRUCTED

DELABARRE

WAS ATTACHED

THEM

BY FIXING

NOSE BUT BY MEANS OF

THE

1820

IN

OBTURATORS

WITH BANDS AND CLASPS THAT UTILIZED

PROSTHESIS
TO

OR INSIDE

ITSELF

NOT TO THE PALATE

PALATAL

TO EXTEND

THE

SPEECH

AN APPLIANCE
AID

INTO

THE

PHARYNGEAL AREA
IN

NOTEN

879

1845

SIMON

HULLIHEN

OF VHEELING

WEST VIRGINIA

WHERE THE

OSSEOUS

GRANULATIONS OR BY
CAN

THE

MUST

1860
VELAR

BE CLOSED

GOLD OBTURATOR

INTO

THE

WORKED WITH
BILATERAL

SEVERE

AND

WILHELM

1867

THE

IN

PHARYNX

THE

THAT

VELUM

IN

1385

TO

WALL

OLFI

SCHITISKY

PHIRYN

IN

ALL

CASES

ALSO

DENTIST

OF THE

ACTIVITY

WAS

POSTERIOR

1912

THE

1894

AFTER

SUCCESSFUL

VELUM WAS
WOLFF

WAS CONSTRUCTED

PALATOPLASRY

IN

AFTER
OF

NEW

RATHER

OF THE

THE

FIRST

TO

OF AN OBTU

OF THE

ADVOCATED THE USE OF SCHLITSKX

COMBINED
PICKERILL

PHARYNX

DISPLACEMENT

CLEFT

DISCARDED

LIKE

USE

THE

OPERA
THE

OBTURATOR FOR

THIS

WHICH

SCHLITSKY

EXCEPT

ONE

OF

SURGERY

ZEALAND

COMBINED

PROSTHESIS

UNUSUAL AND UNPHYSIOLOGICAL

OBTURATIR

PALATE

SOFT

TOO SHORT TO REACH

MATERIAL

IN

MPHA

COLLARBUTTON OBTURATOR SIMILAR

FOR THE

PROSTHESIS

THE

IMPROVED

AND

PROSTHESIS

HOLLOW HARD RUBBER


PHARYNGEAL OBTURATOR

EARLY

BY

1863

IN

HAHNS
OBTUSATOIS

AT

FOR

INCISION

WHICH

OF THE PHARYNX IN

DESIGN

GOLD MEDAL

KINGSLEY

MAINTAIN

OF BEILIN

IN

SPEECH APPLIANCE

FOLLOWING THE CONSTRUCTION

RUBBER PHARYNGEAL OBTURATOR


RIONS

NORMAN

1860

MUSCULATURE TO OCCLUDE THE NASO

1880

TRANSVERSE

WOLFF

IN

OF THE PHARYNGEAL SECTION

EMPLOYED

OF GARIEL
AFTER

MUSCLE

HARYNGEAL

PASSAVANT

ALSO

SARATOGA

FIXED

CONTACT

ADVOCATE SPEECH THERAPY

OBTUR

OF

BENEFIT

AND EXTENDED

PROSTHESIS

GERMAN

OF THE

TEMPORARILY

1878

AT

CONSTRUCTING

SECURING

WITH

PROSTHESIS

SCBLITSK

MUCH

IMPROVED STEAMS

LATER

SUERSEN

IMPORTANCE

RTICULARLY

FIXED

ADVANCE HE RECEIVED

THIS

STEAMS APPLIANCE

IN

OF AN
APERTURE

THROUGH THE MEDIUM

TO CONSTRUCT

AMERICAN DENTAL CONVENTION

TO

OR LESS

PALATE BEFORE

NASOPHARYNX

STEAM

CLEFT

FOR

IT

SIMPLIFYING

SIZED

EITHER

OR ARTIFICIAL

MCGRATH INTRODUCED
SECTION

KINGSLEY

IN

MORE

INVOLVED

DERIVED

BE

IN

PF

LIKEWISE

IS

PALATE

OF COURSE REMAIN WHICH

WILL

WAY

WITH

IN

ATTENTION

CAREFUL

WITH

HIS

INSINUATED

AND

BY HAROLD

GILLIES

THE

MUSCLES

SURGEON KELSEY FRY

COMBINED HOLE OF

THE

THAT

BETWEEN HARD AND

SOFT

CREATED

PALATES

VELUM

OF THE

PUSHBACK

THE ANTERIOR

THIS

25

CHAPTER

TEETH

FOR

PROSTHESIS

CONTOUR AND

FACIAL
PALATE

OBTURATOR
THE LANCET

IN

WITH

GILLIES

REVEALED HIS

KILNER

OF ONE OF THE MAJOR PROBLEMS IN SECONDARY CLEFT

DECIPHERING

EARLY

IN

DENTAL

1921

ACHIEVE

TO

COMBINED

1932

DEFECT

DESCRIBED

IS

TECHNIQUE

INTO

OBTURATOR DESIGNED

VELAR

PALATOPHARYNGEAL

ALSO IN

APPLIANCE

HARD PALATE

THE

TO

THE PROSTHESIS

CONTACTED

IN

THE

CASE DEVELOPED

1921

SURGERY
THE COMMONEST CONTOUR DEFORMITY
IS

OF THE
PTODUCED BY FLATNESS

SEEN IN

FLAT LIP

MAXILLA

MOST MARKED WHEN THE PREMAXILLA

LESSER

THE

TYPC

WHOLE

MA
THE

SIRUARCD

IS

OF THE

OBSEIVED

OPENING

THOSE

PARTS

OF

PULL WHICH

THE BACKWARD PRESSURE OF

THOSE

ULTRAPROMINENT

IN

1932

PROSTHETIC

TIGHT

NOSES

AND KILNER

PRINCIPLE

FIRST

PATIENT

OF THE

SUPPORT ATTACHED

881

JAW

IS

CREATING

ONE

AS

NOR

THAN
THAN

ORIGIN

THAT

OF

OF THE

DISPLACEMENT

CLOSURE

OF THE NORMAL AMOUNT


BORDER ON THE
DEFINITE

LIP

THAT

AS

FOLLOWS SUCCESSFUL

THE

SEPTUM

IN

NATURAL

THE

UPPER

INEFFICIENT

PYRIFORM

FAILURE IN

THE

TO

THE

COROLLARY
TEETH

COME

TO LIE

AND AN

MASTICATION

LOWER LIP

GILLIES

THE CLEFT PALATE

AND

OF THE LOWER

WHICH

MAXILLAE

BACKWARD DISPLACEMENT OF THE MAXILLAE


INSIDE

BACKV

PRESENT

BOD

THE

OF

UNDERDEVELOPMENT

THE

NASAL

AXIS

THE

INCLUDE

FORWARD GROWTH OF THE

WELL

HI

MOIE COMPLICATED

HAS

DEFINITE

PALATE CLEFT
IN

EITHER

ETRICAL

THE SCAR TISSUE

FIOM

RESULTING

BONE

THE

NEATER

THE UNDETIVING

OR UNILATERAL

NOSE CNCOUNTEIED MAY BE DEFINED

NASAL DEFORMITY

FACTORS

LIP

IN

OBVIOUS

IS

IT

REMOVED BUT

HAS BEEN

OF LIPS

LARGE PROPORTION

OF DEPICMCD

THIS

INAXILLAC

OF

IN

DEGREE

PALATE CASES

CLEFT

NOSE

LACK OF FORWARD PROJECTION

CAUSED

THAT THE

IS

OF THE

AND DEPRESSION

LIP

AND

OLD HARELIP

LUETIC

TO THE

READVOCATED THE BUCCAL

DEVELOPED BY GILLIES
BUT ADMIRABLE
DEFORMITY

IN

TOO

IN

FACT

AND

FRY

INLAY
IN

1921

THE CONTRACTED
INTRANASAL

AND
FOR
FACES

PROSTHETIC

INTRODUCED INTO
UPPER PLATE COULD BE

THE

LUETIC

SUNDAY

MONDAY

NOSE

SKINGRAFTLINED

SO THAT

IT

BRIDGES

AND CHANGE HIS

IS

PERFECTLY

FOR

POSSIBLE

AND

RACIAL

TO POCKET SEVERAL
DIFFERENTSHAPED

PATIENT
FACIAL

CHARACTERISTICS

BY

SIMPLE

SLEIGHT

OF

SATURDAY

PREPARED SIMPLE METAL CAP SPLINT WAS FIXED

PREOPERATIVELY
THE

TEETH

EXISTING

IT

HELD

SMALL

SUPPORT THE MOLDING MATERIAL


AND CARRY
BUCCAL

THIERSCH

USED TO BUILD
THE

GRAFT TO LINE

SULCUS INCISION

ADJUSTABLE

THE SOFT

THIERSCH

THE

INNER

HAIRLESS

MOLDED

OF THE LIP

NOSE AND CHEEKS

GRAFT HAD

CE THE

HIDE

WHICH WAS

TRAY

TAKEN

WHILE LEAVING
NASAL

AND THE LINED

THE NASAL AIRWAY

AND

BASE

FIXED

OCCLUDE

FROM

CAP

SPLINT

POCKET HAD BEEN ESTAB


FITTED

TO REPLACE

MISSING

COMMUNICATION

FREE AND PUSH FORWARD THE LIP


TEETH

ITS

THE

TO

ONES BLOCK THE ORONASAL

MISPLACED

RAW

THIS

RAW SURFACE OUTWARD TAKEN

PERMANENT UPPER DENTURE WAS

TEETH

INTO

OF THE UPPER ARM AND MOUNTED ON THE

ASPECT

OVER THE

STENT

LISHED

GRAFT WAS FITTED

TO

THROUGH AN UPPER

WERE FREED FROM THE UNDERLYING RETROPOSED MAXILLAC


AREA

FRONT

FORWARD THE CONTOUR

POCKET

TISSUES

IN

TRAY

TO

NORMALLY

WITH

THOSE

AND

OF THE

MANDIBLE
AS NOTED BY
THE

FE

ATE

CH

HOLE

THE

OCEASIONALL

THERE

DOOMED

FESS
IRRITANT

THE

IS

IS

TIMES

ARE

CECASIONS

OF THE FACE

PATIENT

ER OCCASIONALLY
AN

AND KILNER

GILLIES

ALTEICD

IS

EVEN TODAY

METHOD

THE

HCTTCI

DENTUTE HESS

DROPS OF IMBIBED
IHINORRHEA

HE

FOT

TO WEAR

FOR

PELSISUS

WHTN

THIS

MAN

HACK

ESCAPE

OF US

LEAK THROUGH THE

FLUID

DIASS

NOSE AND

TIME

IPPROEH

IS

USED

AND ON

RARE

OF CHOICE

COOPER
HERBERT
IN

THE

COOPER AN
LATE

20S

AND

30S BEGAN

EARLY

WRECKS GENERAL SURGEONS

THROIDECTOMIES

WOULD

AFTER

FULL

FISTULAE

INDICATED

ADDED

IN

AND SCAIRING

MADE

8S2

TN

EFFORT

TO

COMBINE

FOTEES

PALATE

HIS

DENTAL

THE PALATE

STT

CSS

ITH

AND

TO THE JUNIOR

PALATES

THAT NO FURTHER
SURGERY

TO HELP

DORRANCE BECAME AWARE OF COOPERS

CLEFT

WERE BOTCHED ENDING

CASES

AND DURING

BULB TO THE
PROSTHESIS

MANY

MORNING OF COLECTOMIES

COOPER FELT

SUCH DISASTERS

TO SEE

THE CLEFT

TURN UVET

SURGEON AND CONSEQUENTLY MANY


WITH

OF LANCASTER PENNSYLVANIA

ORTHODONTIST

RESTORATION
IN

UP
WAS
HE

THE LATE 30S

OBTURATORS

AND

WITH

THE

IRRITATED

THROWING

DOWN

PUSHBACK

PROCEDURE

CAN

SPEECH GEORGE

HAVE BEEN RESTORED

HIS

HUNDRED PALATE CASES WHICH

THE

HAVE HAD YOUR

SHOWDOWN

MEETING WELL HAVE

SAME

HAVE GOOD

THIS

CHALLENGE

BRIDGE

FIXED

INITIAL

HARVOLD NOW OF

EGIL

INTO

ABOUT

WHICH

DENTALLY

NEVER TOOK COOPER UP ON

DORRANCE

SAID

IVY

TO

OPELATION

PUSHBACK

FINALLY

COOPER

BOAST

DORRANCE

THE

COOPER RESPONDED

YOULL BRING

IF

TO

GAUNTLET

CASES THAT

100

BRING

THE

INCH

FOOT

UNASSUMING

QUIET

DORRANCE

FOOT

OVER

RECALLED

1938

ABOUT

CLINIC

PALATE

DOMINEERING

DOGMATIC

HEAVY

CLEFT

IN

AN EPISODE

GLEE

COOPER AND DORRANCE

OF BOTH

FRIEND

ROBERT IVY

OF OSLO

OF CALIFORNIA

THE UNIVERSITY

WHILE

MODELS
NORMAL

AT THE

CLEFT
FIRST

IN

ARCH

PALATE

ARCH

ARYDEL

BEGAN

AFTER ORTHODONTIC
THE

TOR IN

INWARD

RELOCATCD

ORTHODONTIC

BY

INDIVIDUAL

BBHN

OF THIS

DISLOCATED

MEANS AND

THEN

1973

WHICH

DENTAL

THE

FIXED

ABNORMALITIES

BRIDGE

SHOWN
TREATMENT

HERE

THE

IS

IS

ITH

OBTURATOR

TREATMENT

00

ORTHODONTICS

BY

MEANS OF

RELATIVELY

OF THE UNIVERSITY

CLEFT

SEVERAL IMPRESSIVE

RESULLS

WERE CORRECTED

PIOSTHODONTIC

ONE OF

HIS

AN EIGHTUNIT
IN

POSITION

IN

CASES IN

WHILE

HE NOTED

TREATMENT OF CHOICE

BILATERAL

RETENTION

AND INCISOR

WITH REFERENCE

AREA

OF OSLO

THE POSTORTHODONTIC ARCH FORM HAD BEEN MAINTAINED

THE

FISLULA

OF THE

POSITION

OF MALFORMED TEETH IN THE

PAATE JOURNAL PRESENTED

CLEFT

BE
SEGMCNTS COULD

RETENTION THE SPLINT PROVIDED

RAM STAD

REGIMEN

THIS

FOLLOWING
THE

ACTOSS THE CLEFT BESIDES

TEETH AND CORRECTION

MISSING

BEFOIT

TO

THE

CLEFTS

BRIDGE

AFTER

WITH

RELATIONSHIP

ORTHODONTIC
IEMOVABLC
SATISFACTORY

POSRPROSTHODON TIC

ADULT

RITFNTION

1V

ITCH

IUATNMNT

DEMON

HARVOLD

THE

TT

PALATC

AFT

THAT THE POSTORTHODUNTIC

RETAINED

COULD BE PERMANENTLY

SHORT SPLINT

LEFT

FULCRUM IN

COOPERATION WITH HARVOLD SOLVED THE

IN

PROSTHODONTIC PROBLEMS BY ESTABLISHING


RESULTS

TREATMLNT

TUBEROSITY RATHER THAN MERE INDIVID

COULD BE CORRECTED BY STANDARD

TEETH

AND 1967

191

AROUND

SEGMENTS

THAT THE

AND 1963

195I

MALOCCLUSION WAS AN

PALATE

FOR CORRECTION

MOVEMENT

IN

CLEFT

MAXILLARY

OF THE MAXILLARY

TOOTH

TMOD

OF THU

ROTATION

THE REGION
UAL

OF THE

DEVELOPMENT

LINT

OCCLUSION

63

IN

AND

UNILATERAL

BILATERAL

19

CLEFT

COMPLETE

CASES

WERE NOTED

NO

BUCCAL

BILATERAL
THE

CROSSBITE

CLEFT

OCCURRED

CASES

POSITIVE

AND IN

UNILATERAL

ALL

635

IN

OF THE UNILATERAL

OVERJER AND OVERBITE


THE

BILATERAL

789

AND IN

OCCURRED IN

ALMOST

OF THE

90

OF

CASES

MORE COMPLEX APPLIANCES


IN

ROBERTS PRESENTED

1965

COMPLEX

FAUCHARD AND DESIGNED TO OPEN

MOVEMENT

OF THE WINGS

THE

IN

ACHIEVED

IS

OBTURATORS

CLEFT

TO PROVIDE

BY USING

BEFORE PALATAL SURGERY HAD BEEN DEVELOPED


AND

SOPHISTICATED
THAT

PALATE

MORE TRAUMATIC

FUNCTION

OF

INSUMCIENCY

CONGENITAL

BUT

SHELF

SOME

IN

TISSUE

THE

TO

RETENTION

KEY

WHEN LESS

LATER

SO SCARRED

THE

CASES

OF SEVERE

OBTURATOR

HAS BEEN

OBTURATOR HAS GONE ON THE

THE

UNDER CERTAIN

AREAS

HAD

AND ALSO IN

PALATAL

OF USE AS SURGERY HAS IMPROVED

THE

AND

SURGERY

WAS IMPAIRED

ATTRIBUTED

CONDITIONS

MAY

IT

BE OF

VALUE

MODERN STAND
PALATE

PROSTHESIS

ROBERT
IP

MILLARD

LANCASTER

CLEFT

OF SPEECH

DIRECTOR

PALATE

CLINIC

AND PAATE

HE PRESENTED

WHICH

PROSTHESIS

INDICATIONS

FOR PROSTHESES IN

WIDE

CLEFT

WIDE

UNOPERATECI

NEUROMUSCULAR
CASES WITH

GUIDELINES

INSUFFICIENT

FOR

CASES

LZ
IN

LOCAL TISSUE

AVAILABLE

TO

REPAIR

CANNOT BE CLOSED WITH

DEFICIT

WHEN

OF THE

SOFT

PALATE

VOMER

FLAP

AND PHARYNX

MEDICAL CONTRAINDICATION
SURGERY

IS

TO SURGERY SUCH AS

DELA ED

EXPANSION

PROSTHESIS

FOR

COMBINED

PROSTHESIS

AND ORTHODONTIC
APPLIANCE

884

FOR CLEFT

OF

TISSUE

JUSTIFIED

OR

MAJORITY

THE

PALATES

OF THE HARD PALATE WHICH

LOCAL

DYSCRASIA

INTERESTING

1971

AT

WAS UNDER CONSIDERATION

FUNCTIONAL

CLEFT

OR OTHER

SOME

SERVICES

THAT THE

PROCEDURES IN

OF THE SOFT PALATE WITH

ACCOMPLISH

AND HEARING

ACKNOWLEDGED

CAN BE CLOSED BY OPERATIVE

CLEFTS

LOB

ON

IMPRO EMENT

OF SPATIAL

ICLATIONSHIPS

BLOOD

IN

FOR PROSTHESIS

INDICATIONS

IN

FAILURESFISTULAS

SURGICAL

DEEP PHARYNGEAL SPACE

VELUM

THE

BEHIND

MECHANISM WITH

VELOPHARYNGEAL

INCOMPETENT

PALATES

OPERATED

CONTRAINDICATL

THE

HARD OR SOFT PALATE

ALVEOLUS

PRUI THUSIS

FOR

FEASIBILITY

OF PRIMARY

DIAGNOSTIC

METHODS

OR SECONDARY SURGICAL

BASED ON DEFINITIVE

REPAIR

MENTAL RETARDATION

SEVERE

AND PARENTS

PATIENT

UNCOOPERATIVE

UNCONTROLLED DENTAL CARIES PARTIAL OI COMPLETE ANODONRIA


IMPERFECRA
LACK OF

TRAINED

PROSTHODONTIST

NEW YORK

KENNETH ADISMAN OF

1971

CEFT LIP

SINCE

1971

AND PALATE WAS

MEDICAL

RECONSTRUCTIVE

THE

ARE

THREE

OR IMMOBILE

FIXED

AND SPEECH
TYPES

WHICH

PROSTHESIS

NEW YORK

THE

AT

DENTAL

INTEGRATE

GENERAL

FOR THE

UNDER WALTER WRIGHT AND

TRAINED

TO

SURGERY

PLASTIC

THERE

ADISMAN

CENTER

CENTER

PROSTHETICS

WORKED WITH JOHN CONVERSE

HAS

DENTAL

UNIVERSITY

CHOSEN TO WRITE THE CHAPTER ON CLEFT PALATE

UNIVERSITY

DENTINOGENESIS

AND AMELOGENOSIS IMPERFECTA

THERAPY

ACCORDING

AND POSTERIOR STIRFACCS THIS

LATEIAL

REMAINS

THE

IS

TO

OF PROSTHESIS

JISMAN

STATIONARY

PERMITTING

THE PALATAL AND PLAN NGCAL MUSCULATURE TO CONRACT AND FUNCTION


ITS

WITH

TREATMENT

AGAINST

PE FOR PIOSTLIETIC

ACCEPTED

THERAPY

THC HINGE
WHICH

MOVEAHIC

NI

DIFFICULT

TYPE

WITH AN AIRWAY
INDICATED

ADISMAN

PROVIDED

TISSUE

FOR UNIEPAIRED

CONSIDERS

COLLAPSED

SURGERY

HE

MODERN

STANDARD

THE

IN

NINCREENRH

CENRUIS

HUT WAS TOO COMPLICATED AND

NASAL CASITY

HARD

AND SOFT PALATE

CLOSURE

SECTION

AND RCTAINCD

ON THE

IS

HN

CLEFT

CLEFTS
IN

LIE

ILEXILDIE

FOR

LACK

OF

CONJUNCTION

PALATE

COMPOSED OF

SIMPLE ACT
TEETH

INDICATED

EXRENSIVC

OF HIS

TYPE

FEED

NOT DEEMED ADVISABLE

SURGERY OR

FORWARDED EXAMPLES
PROSTHESIS

IS

THIS

CLEFTS

INRERVCNRION

PROSTHETIC

OF THE PHARYNX

INSTEAD

OF THE NASAL EXTENSION

PEIFORATION

ARCHES OR FAILED

MAXILLARS

835

BY

THE

BECAUSE OF POOR HEALTH

PRACTICAL

THE

POPULAI

SOFT PALATE

EXTENDED INTO

AND WHERE SURGICAL

AIDS

ING

THE

MAKE AND MAINTAIN

TO

THE MEARUS

IS

PIOSTHESIS

ATTEMPRCD TO IMITATE

PROSTHESIS

THREE

RESIN BASE COS ERING

GOLD WIRE CLASPS

OR
LOCAL

WITH

THE

PARTS
THE HARD PALATE

THE
THE

PALATAL EXTENSION
SOFT PALATE

CAST METAL BAR THAT TRAVERSES THE


LENGTH OF

SECTION

AND ENDS IN

LOOP FOR RETENTION

OF THE
NASOPHARYNGEAL

SECTION

THE NASOPHARYNGEAL
ON

DEPENDING

IT

TION

IN

SO THAT

MUST BE

LARGE

ENDS IN
IS

ENOUGH TO

BULB OF THE REQUIRED

MADE OF

USUALLY

OF THE

IRRITATION

AND SWALLOWING

PHONATION

IT

DEFORMITY

RCSIN

METHACRYLATC

DETECTED

THE

WHICH

SECTION

PROVIDE

CLEAR

NASOPHARYNX
NASAL SPINE

THE

VELOPHARYNGEAL

BUT NOT BLOCK THE NASAL


PASSAGES

LOWER ATEA OF THE BULB IN

AND PALATAL PLANE

PLACED LOWER IN

POSTOPERATIVE

THE NASOPHAR NX BECAUSE

THE VELOPHARYNGEAL

CLOSING

IN

METHYL

PHARYNGEAL MUCOSA CAN BE

WITH

LINE

DURING

HIGH IN THE
THE POSTERIOR

CASES THE BULB

THE VELAR TISSUE

SEAL

FOR RESPIRA

UNOPERATED CASES MOST PHARYNGEAL BULBS ARE SITUATED


WITH

SIZE

IS

GENERALLY

AIDS IN

BUT NOT SO LOW AS TO BE


PORT
DISLODGED

PARTIALLY

BY THE

TONGUE DURING SWALLOWING

VITH

THE

FOR SEASHELL
IS

SHO

PATIENT

886

SAME

ATTISTIC

COLLCCTING
TO IMPIOVE

IN

TAKING

STIEIK

ACHS

II

IN

THAT ATTIACTS
CONSTIUCTS

BOTH FUNCTION
USEFUL

LE

IN

HIM

CLEFT

TO THE BEICHES

PALATE

AND APPEATANCE
SOCIET

PIOSTHESES
TO

HELP

THE

CAN BE CONSTIUCTED

PROSTHESES

BERKOWITZ

OR LIFTING

STIMULATION

ARAM AND SUBTELNY

THAT

REPORT

AND PHARYNGEAL RNUSCULATUIE

LUMEN
RHETIC
ACIYLIC

CLOSURE

AID

VELOPHARYNGEAL

THE

SPEECH

ELOPHARY OGEAL

OPENING

OF THE

POSITIONING
PROSTHETIC

WHEN PHARYNGEAL

887

SPLTCLL

HICH

SX

PHARVNGEAL

FAILURES

THAT

SECTIONS

UD

WHEN

THE

CLOSURE

IPPLI

IN

IS

TO

THE
EXISTS

PROSTHESIS

SPEECH

SPHINCTERIC

TYPE

BE ASSISTED

CAN

EXTENSION

OF THE ELAR

BEHAVIOR

CREATING

DIMENSION

USUALLY

SHAPE

IS

CIITICAL

AND POSITION

HICH

ARE INAPPROPRIATE

TO PROSTHETIC

DO NOT IMPROS
IN

SI7E

SHAPE

OF

P105

CONSTRUCTED

THE
DURING FUNCTION THEREFORE

SECTION
THOSE

IN

TRAINING
OF MIAMI

UNIVERSITY

SYNERGISTIC

INADEQUATE

BULB PHARVNGEAL

ROUST CONFORM

IESIN

OMPERCNR

IS

OF THE

SPEECH AID

THOUGHTS ABOUT

HIS

EXPRESSED

FOR PALATAL

AS APPLIANCES

OF

OF THE

PI

SUCCESS

SPEECH

IESULR

OR PLACEMENT

THE THICE
SPCECH AID APPLIANCE
BULB
CONNECTED
II TS
PECTH
TO

DENTURE

SHANK

STATE THAT

THEY

PLANE FROM

VELOPHARYNGEAL CLOSURE
YEARS OF

TO

YEATS OF AGE CONTACT


THE

FIRST

CERVICAL

SLIGHTLY

VERTEBRA

IT

IS

SLIGHTLY

POOR LANDMARK

IS

OF THE NASOPHAIYNX

WELL

AS

REST

TO THE

PALATAL

BELOW THE PALATAL


PLANE

SECTION

THE

AS

PHONATION

FOR

THE

AFTER

BY THE
SOFT

OF THE

PLACEMENT

MAKE

MUST

PHARYNGEAL WALL AND BE CONTACTED

POSTERIOR

RELATED

CLOSELY

ABOVE THE PLANE ALSO THE ANTERIOR TUBERCLE OF

THE PHARYNGEAL

PHARYNGEAL SECTION

ASPECTS

IS

AGE

IS

CONTACT

WITH

MUSCLES OF THE

THE

LATERAL

DURING FUNCTION

PALATE

OF UL

POOI PROSTHESIS
PROPER PROSRHCSI
ARARN

SUBTELNY

INCOMPETENT

THIS

AID

SPEECH

VELUM

FUNCTION THE MAXILLA


DUE TO THE

NATURE

NANCE ALTHOUGH
OF ADEQUATE

IMPTOX

APPLIANCE
SCARRED AND

WAS HEAVILX

IT

WIDTH

WAS HYPOPLASTIC

OF THE

ELUM

MADC

CONTACT

IT

SPECCH HAD

STILL

IT

DID

THE

SPEECH

AND TBEICFORE

OH

NOT FUNCTION

IT

FAILED

BULB

AS

FAILCD

THE POSTERSOS

AND DO

EXTENDED MORE SUPERIOIL

HAVE REDUCED NASAL RESONANCE

888

IMMOBILE

ALL

INTO

IT

ON

PLACCD VERY LOW

RCDUC

TO

PM

TO ELEVATE

NGEAL

NASAL
ALL

AND

IESO
XX

AS

SHOULD HAVE DONE TO


RHC

PLMR NX

IT

XX

OULD

COMBINED USE
AND PHARYNGEAL

OBTURATOR

RUSSELL

AND
QUIGLEY COFFEY QUERZE

ORDER TO AVOID

SURGERY WAS

EARLIER

AREA UNTIL

OF THIS

SURGERY

COMING UNDER
AT

GROWTH RETARDATION

MAXILLARY

PROPOSED THE

OF BROOKLINE

THE AGE OF
AS

SCRUTINY

TO

AS

YEARS

CAUSE OF

POSSIBLE

SAME TIME

THE

IN

OF THE HARD PALATE

TO CLOSE THE CLEFT

USE OF AN OBTURATOR

EARLY

WEBSTER WITH

THE AMERICAN JOURNAL OF SURGERY RICHARD

IN

1958

IN

OF
FLAP

IN

VARIATIONS

ORDER NOT TO

IN

WEBSTER CLOSED THE SOFT PALATE WITH


SPEECH DEVELOPMENT
BASED PHARYNGEAL FLAPS
SUPERIORLY
AID OF ONE OF HIS WIDE

IMPEDE
THE

AN EXTENSIVE
THE ABOVE
IMPROVE

THE

INDICATE

HYPERNASALITY

THAT

AID

SURGERY FOR IMPROVING


BEFORE

PHAR

NGEAL FLAP

PHATYNGEAL

AND

SPEECH BUT
SURGERY

IS

CLEFT

PALATE

WITH

PATIENTS

SEEMS TO BE USEFUL

IT

AID

SPEECH

THAN PHARYNGEAL

EFFECTIVE

LESS

ORDER TO IMPROVE

IN

AND

SURGEIY

FLAP

OF

DYSARTHRIA

SPEECH AID

NASOPHARYNGEAL INCOMPETENCE
FLAP

AFTER

CONCLUDED

STUDY

RESULTS

TOKYO DENTAL COLLEGE

OF

TOMOHIRO SHIGEMATSU

1973

IN

TO SET

SPEECH
SPEECH

POSTOPERATIVE

RESULTS

TEMPORARY OBTURATOR
PENDTNQ POSSTBLE LATER
ROBEIT

BLAKELEY

IA

GOT TO COLLEGE

OUTDOORS
CONTENTION

FOR THE

SPEECH

PROSTHESIS

PIONEERED
FOR CLEFT

UNSUCCESSFUL HERE

IT

IS

RESUM

IS

IMPORTANT THAT WE INTERRUPT

OR

ERRORS ALREADY OCCURRING


TORY

ERRORS ARE

CLINICIAN
IN

1972

8A9

IF

USUALLY

THAT

AT

HALF OF LAW

HIS

COMMENTS
EARLY

THE

1977

IN

ENOUGH FOR

HABITUATED

PRESSURE

HABITUATED

ALTERABLE

EASILY
IS

WAS

EACH CHILD

OF THC 16

AIR

NASAL AIR LEAK EARLY ENOUGH SO THAT

DO NOT BECOME FLIMLY


RELATIVELY

OF

OF TEMPORARY

WHOM SURGERY

IN

AND

THE UNIVERSITY

REDUCTION

PATIENTS

NASAL EMISSION

WE STOP

NORMAL ORAL BREATH

SUBSTANTIALLY

STRONG

NOR INTERFERE WITH DEVELOPMENT

IN ORDER THAT THIS NASAL EMISSION


PRESSURE CONSONANTS

ITH

OF SPEECH PATHOLOGY

SPECIALTY

OF

THE MICHIGAN

YEAR AND

AFTER

SYSTEMATIC
PALATE

IN

HURDLES

HIGH

THIS

SURG

GROWING UP

EXCITEMENT

THE

ENDED UP WITH THREE DEGREES IN


HE HAS

THE

OLYMPIC GAMES

SCHOOL HE DISCOVERED

OREGON

LAD

LANKY

TALL

STOPGAP

AS

PRM IDED

BY
EALLY

THE

EATH

COMPENSA

PATIENT

ENOUGH

DIFHCULT
COMPENSATORY ERRORS ARE

ANDOR

AS

NOTED

TO

UNDO

ROBERT BLAKELEY

WITH

EVEN

CHILDREN

FORMAL

WITH REPAIRED

THE TEMPORARY

NASAL

ASSISTANCE

IN

OR

QUALITY

TWO

TO SEVEN

SLIGHT

OF

DEPENDING

PRESCHOOL

UPON MANAGE
OF COURSE

EARLY ENOUGH AND THE

AIR

ON HIS OWN OR WITH MINIMAL


INSTANCES

ALL

VIRTUALLY

DAYS

OF THE PARENTS JBTURATION

EMISSION

DEVELOP NORMAL ARTICULATION

DUTING

CAN BE CONSTRUCTED
PLACED AND THE CHILD

PROSTHESIS

AND COOPERATION

GOAL STOP THE

FOR

SPEECH GOAL

AFTER HABITUATION

SCHOOL

OF

THE

PROCEDURES

SHOULD BE PREVENTION

PALATE

GIADE

PERIOD

OF THE CHILD

ABILITY

IN

SPEECH

OBTURATED WITHIN

THE

CLEFT

NOT CORRECTION

YEARS

HABILITATION

SPEECH

THE OBTURATOR

WILL

PARENTPROFESSIONAL

WILL PROVIDE NORMAL VOICE

WHEN

TEMPORARY HYPONASALITY

CHILD

IS

IT

IS

IN

PLACED

THE

CHILDS

MOUTH
THE OREGON
HAS

PRESENTLY

CHILDRENS

CRIPPLED

THE

AS

YOUNG

OBTURATOR

MUSCULARUIE

THE

REDUCTION

THIS

TENDS

RELAX THE

HABITUALLY

OBTURATOR RAKING
THE

IN

ATLAS

THEREAFREI

ALONE
THE

AFTER

ARTICULATION
SPEECH

DENTIST

NOT TO IMPINGE

IS

HAS

IT

TESTING

THIS

EACH

HYPERNASALIRY

THE

SAME

890

IS

EMISSION

SOFT

VIA

TISSUE

THE

OVEILYING

AND NASAL EMISSION

TO CONSONANT
SAX

REQUIRED

FOUR TO EIGHT

RRTICULATION

OF

MANIPULATION

SIDE

IS

CARRIED

RIME

TEST

THAT

OUR BY
RESTING

IN

OF THE

OBTURATOR

THE

PORTION

OF

PASTE

ALTERING

IS

THE

FROM

OF THE

AND

NASAL LISTENING

ON THE OBTURATOR
PLACE

THE

OF REDUC

EG

APPOINTMENT

PROCESS

IS

BECAUSE
DIFFERENCE

HIS

OF

SIGNS

THEN DISCON

REPRODUCED IN DENTAL
APPROXIMAREL

TO

AND

ANTERIOR

TO DETECT SUBCLINICAL

REDUCTION

REDUCTION

MADE UP

PATIENT

SPEECH PATHOLOGIST

MM FROM

BEGINS

APPROACH TO OBRURAROI
USUALLY

THE

UTILIZATION

AND

PATHOLOGIST

NASAL EMISSION

IS

REDUCTION

THE AMOUNT AND

RETURNS IN

HAS

SYSTEMATIC

STEPS AT EACH

GRADUAL

AND

PLACE

PRESSURE INDICATOR

AND ORAL INSPECTION

THE SPEECH

ANDOR

THIS

IN

MONTHS THAT

ASSISTANCE OR BY FORMAL HELP

ICCORD AND THE PATIENT

MUSCULATURE

UPON

OBTURATOR

TLIC

AT

MODEL OF THE OBTURATOR

PERMANENT

MAY

OR

INITIALLY

ORAL

HYPERNASALIRV
SPECIFIC

OBTURATOR

OF SPEECH

DETERMINED

CONTINUES UNTIL

TINUED

ARE

WITH

IS

COMBINATION

THEREBY

OBTURATOR

RML

TOO

OF THE VOICE

WORN AN

SPEAKER

CAN BEGIN

MM ON

THE

UPON

OHTUI AROI

TUBE AND THE NASAL FLUTTER

TION

AND

HYPERNASALITY

PLANE OF THE HARD PALATE

FORCE

ONE MUST

BY MATURATION ALONE BY
PARENT

DURING SPEECH

AN

INITIALLY

OVERIMPINGEMENT

FROM THE

TO GET CONRI OL OF THE

ORAL

USING

THIS

PHARYNX TO PRODUCE SOME SOUNDS BECAUSE THAT HAS BEEN

PATHOLOGIST

OBTURATOR

DRAW AWAY

MANAGEMENT

THE PATIENT

HABITUAL

AN

IS

OTHER

OF THE

SIZE

ENTAILS

LIKE

TO ELIMINATE

AREA AT ABOUT THE HORIZONTAL


TO

IN

MONTHS

ENOUGH

ALWAYS

OF OREGON

UNIVERSITY

OBTURATORS HAVE BEEN PROVIDED

EIGHT

LARGE

RECOMMENDATIONS

THE

NO

VITRUALLY

CAIC

ORDER

THE

PROGRAM WORKS SOMETHING

RESPONSE THUS

LEARNED

HISHER

AT

TEMPORARY SPEECH PROSTHESIS

PATIENTS

YEARS

MADE

IS

OF THE

PATIENT

TWO

AS

OBTURATOR OF NECESSITY
NASAL EMISSION

WEAR

SOME 750

PROGRAM ENCOMPASSING
FOR CHILDREN

WHO

CHILDREN

125

PROGRAM

FOUR

STONE

AS

MONTHS FOR

PALAROPHARYNGEAL
THIS

RIME

IN

AN

CONTINUES

OBTURATOR REDUCTION

CLOSURE

TWELVE MONTH INTERVALS UNTIL THE LIMITS

MOST OF THE

BY THE

FELT

IS

VP

SATED

MUSCULATURE

PHARYNGEAL

NORMAL SPEECH

ADAMS AND

DENTIST

THAT THE PATIENT

1964

IN

AND MAXIMALLY

VP

FOR SECONDARY

HE WOULD HAVE BEEN PRIOR

THAN

PURPOSES

SPEECH

WITH

CHILD

BETTER CANDIDATE

FAR

IS

IN

SYSTEM FOR SPEECH

NORMAL MONITORING

OF

BECAUSE

AND

ARE APPROACHED

PROCEDURE USUALLY

PUBLISHED

AS

NINE

OVER SIX

MANAGEMENT HAVE BOTH NORMAL

THEIR

PROSTHESIS

BLAKELEY

FASHION

VP

COMPLETE

COMPENSATION

LINDGREN

SURGEON

PATHOLOGIST

SPEECH

VP

SURGICAL

FOR THE

SUBSTITUTE

BECOMES

FLAP

OF

THIS POINT IN

AT

THUS ANY

AND ARTICULATION

VOICE

IT

PATIENTS

THIS

IN

FOR

QUO

MAINTENANCEOFTHESTATUS

PHYSIOLOGIC

APPARENT

SURGERY

OF

TO

USE

PATIENTS

19

COMPEN

THE

FOR

SPEECH

PROSTHESIS

IN

ONE STUDY

WITH

REDUCED IN

WAS

IT

REDUCTION

CULATURE

HOW TO

IZATIONS

CAN

NGEAL

WALLS AND

29

MM
IN

THE

IN

SUMOTOJAPAN
CLEFT

THE

UPON

SUCH TIME

DENTAL

SOME

MUS

THE

IN

THE

OF THE

SIXTH

RECALLED THAT 10

SUUD NOTED
WAS

REDUCTION

CON

INTERNATIONAL

HIROSE

SURGERY

OF

MAT

CASE OF PURPURA IN

SURGERY THIS

TO FACILITATE

RHC LATERAL

MUSCULATURE DOES

MEAN

YEARS BEFORE

EARLY

CLOSURE

VP

THE 60 PATIENT

MMWHILE

MODELS OF

STONE

OCCURS IN

OBVIOUSLY

PATIENTS

TRANSACTIONS

AS SURGICAL

EATING

WAS INDICATED

PRECIPITATED

THE

AND SPEECH UNTIL

HIROSES

SUBSEQUENT

WITH THE USE OF TEMPORARY OBTURATORS PROVED THAT THEY

EXPERIENCE

WERE MOST
TO

WHEN

EFFECTIVE

THE POSTERIOR

SNUGLY

POSTERIOR

WAS IT5

OF AN OBTURATOR

FITTING

EXTENDED

NUMBER OF

HAD PREVENTED

PALATE

MUSCLE

PATIENT

REACH

TO

HISRORKAL

AND RECONSTRUCTIVE

OF PLASTIC

PATIENTS

VP COMPENSATION

OF
COMPENSATORY HYPERRROPHY

REDUCTION

LATERAL

1975

GRESS

BASED

OF THE

DURING SPEECH HOWEVER SOME GENERAL

OPTIMALLY

SUBSTANTIAL

TAKE PLACE IN

MEAN

MADE

BE

OBTURATOIS

OF MUSCULATURE BUT ONLY NEED

REDUCED THE GREATEST COMPENSATION

OBTURATOIS

THE

FUNCTION

FOR

PROGRAM

WEANING

REDUCTION

AND OBTURATOR

OBRURARION

THEIR

THAT

FELT

PROGRAM FOR ANY GIVEN

REDUCTION

THOSE

WERE REFERRED

THE REMAINDER

SIZE

NO DCMBR REQUIRE NO COMPENSATION

PATIENTS

60

OF THE

PERCENT

OF THE

PERCENT

REMOVAL LEAVING

OF

POINT

WITH GOOD RESULTS AFTER

AN OBRUIAROR

IN

HYPERTROPHY

INTO

THE

PHARYNGEAL

NORMAL SPEECH

891

THE

TO

CANNOT ACCOUNT EXACTLY FOR THE AMOUNT OF

ONE

FITTED

OBTURATOR

THIRTY

UNDER THE OBTURATOR

CONTINUED

EARLY

SIZE

VOICES

COULD NOT BE ADDITIONALLY

PHAI

OF 60

1970

IN

NORMAL

SUBSTITUTE

SURGICAL

ME

WERE REDUCED IN

OBRURATORS
PATIENTS

BY

THEY

COVERED THE

PHARYNGEAL WALL
CLEFT

ALL

AND

FIVE

ITS

OUT

TIP

OF

CLEFT

CORRECTLY AND

WHENTHE
ALMOST

EIGHT

VELAR

TOUCHED

PATIENTS

PIECE
THE

OBTAINED
MNOIE

WHEN

THE

COVERED THE

VELAR

PIECE
THE

CLEFT

TIP

THE

AT

TO BEGIN

AGE

THAT TIME

CAN USE

THEM

TO WEAI

THE

UISES

IN
LARCI

PARTIAL

DATE

OVER

VINYL

RESIN

CAST

IN

OCCLUSION

RUBBER
POSTERIOR

NORMAL

SPEECH

MOLARS

ALMOST FINISHED

IS

NOT LIKE
THE

THE
TO SPEAK

PUSHBACK

NORMAL SPEECH

CHILDREN

THE

WE

SOON LIKED

OR EAT WITHOUT

THE

AS

PER

OPERATION

METHOD AND

BY THIS

ALL

PI

PREMAXILLA
TO

FIX

MISSING

CONSISTS

LATERAL

TEETH

MAXILLARY

FIXED

PREMAXILLA

FLOATING

CHILD

TEENAGE

FOR THE

TO

AND

OF ACRYLIC

THE

RESULT

IS

OR VINYL
ACRYLIC

OR

FIXATION

OF

FUNCTIONAL

PROCESSES

AND NORMAL COSMETIC


APPEARANCE

SUPERIMPOSED

DENTURE
PROSTHESES

WHO RECLUIRE

AND

ARE

INDICATED

OCCLUSAL AND COSMETIC

UNDERDEVELOPED MAXILLA
DISHARMONY

FIRST

SEEMED TO BE TWO
YEARS

WITH CLASPS

OBTAINED

SPEEC

THE

PONTICS

OVERLAY

892

THE

GOLD COPINGS ON ABUTMENT TEETH AND

PREMAXILLA

PALATE

ALL

CAN BE USED

DENTURE

RESIN

THE

OBTAINED

OBTURATOT

CASES OF WHICH

FLOATING

PROSTHESIS

OF

AND THEY DID

NINE

NORMAL

EIAINCD

THE

WEAIING

THE DCNRITION

OBTUIATOIS

AT

FOR

SILICONE

ALMOST TOUCHING

AGAIN

TO HOLD THE OBTUIATOT

OBRURATORS

FORMED

ELASTIC

NOTED

PROPEI

BECAUSE

SOFT

OF NINE PATIENTS

PHARYNGEAL WALL SEVEN

HIIOSE

MADE OF

OT

FOR PATIENTS

CLEFT

IMPROVEMENT BECAUSE OF

OVERDEVELOPED MANDIBLE

MAIRELATIONSHIP

WITH

BETWEEN

THE

TO CORRECT THE

TWO WHERE

FOR

SOME

CORRECTIVE

REASON

IN

WHO HAD

WITH

IMPOSED

THE

PALATE PATIENTS

ABUTMENT TEETH

THE

ROBERT
SPEECH
THE

IN

THE

AID

OF

THE

FAILURE

THE

SURGEON

SCARRED

RECONSTRUC

OF LHE PIOSUHESIS

OF FIBROUS BANDS AND ADHESIONS


RESECTION

PROSTHESIS

MAY

OF

AN

BETTER ENVIRONMENT

CREATE

THE ABSENCE OF TEETH CREATION

OF RETENTION

INSERTS

TO

AID

IN

PROSTHESIS

EMPHASIZED
AND

AND THE

THE

PARENTS

THE

WORK

PROSTHODONTIST
TO ACHIEVE

THE

THE

OF HAVING

IMPORTANCE

WITH

TOGETHER

OPTIMAL

USE

OF THE

SPEECH APPLIANCE

IS

CAN BE OF INESTIMABLE

AWAITING

PROSTHESIS
OF

TO

FAVORABLE NASOPHARYNGEAL

THE

VALUE

IN

OPTIMUM RIME

IN

SHOULD BE EXTREMELY R2RE

SURGERY

OR

UNWILLINGNESS

ADEQUATE SECONDARY SURGERY

OT

FUNCTION

MAINTAINING

OF VIEW
SURGERY FROM THE SURGEONS POINT

FOR

RELATION

PROSTHODONTIST

MUCOSA MAY ALLOW MUCOSAL

MILLARD

PROSTHESES

WHILE ONE

OCCLUSAL

GROWTH AS COMPARED

THE

OF

PREMAXILLA

PATHOLOGIST

PROSRHCRIC

FOR

THE

IN

PATIENT

NUM

MORE

SECTION

PLACEMENT

AND

PROSTHESIS

THE

TO

TO CREATE

OF THIS

OBSTRUCTING FLOATING

RETAINING

TO

SULCUS OR EXCISION

LABIAL

PERFORATIONS

WITH FEW OR MINIMAL

OF MAXILLARY

CUM

REDIVIDED

MAY BE

FACILITATE

TOT

MORE

LIP

DEVELOPMENT

AREA FOR PLACEMENT

CAN

SUPER

FOR

THE

COLLAPSED

EXHIBITING

DUE TO INHIBITION

PROSTHODONTIST

NON OF

SO

CONTOUR

ASSISTANCE
SURGEON CAN BE OF
PALATE

WHOM THE

IN

SUPPORTS AND PLUMPS

CLEFT

MANDIBULAR

AS

AND

LATERAL

ABNORMAL RELATIONSHIPS

IN

AND TIGHTNESS

COLLAPSE

LIP

FACIAL

POSTOPERATIVE

SHIPS

OCCLUSAL

GROWTH

PROSTHESIS

HARMONIOUS

BER OF

RESULTING

ARE CONTRACTED

MAXILLAE

PATIENTS

LIFE

FORESHORTENED

LEAVING

WITH FLOATING PREMAXILLAE

PATIENTS

IN

EARLY

CONSEQUENCE OF THE LACK OF VERTICAL

IN

ANTEROPOSTERIOR

THAT

RESECTION

PREMAXILLARY

CONTRACTION

MAXILLARY

RELATIONSHIP

DEN

OVERLAY

FOR

TURES ARE INDICATED

PATIENTS

CONTRAINDICATED

IS

SURGERY

AS

RESPECT NO

GROWTH

AFTER THAN THE NEED


IN

INABILITY

INDICATES
NO

EITHER

CARRY

OUR

CALIFORNIA

AFTER

PROSTHETIC

SURFACE AGAINST
DELIVERY
BBY WILSON

IVLACKBY

CLEFT

DEVICES

WHEN PLACCD

TO OBTURATE

HELP

THE VALUE

EMPHASIZED

IMMEDIATELY

DURES

THE

IT

AFTER LIP

AND

MAY

ALSO AFFORD

BE

SOME

OUTCOME OF

THE

DEVICES

HELP

SURGICAL

PROCE

APPLIANCES
FIRM

PROVIDES

TRAP THE NIPPLE


TO THE

AND

FACILITATE

DELICATE

NASAL

FROM THE ORAL CAVITY

IRRITANTS

ICTAIN

NOTED

INTRAORAL

APPLIANCE

PROTECTION

BE EXPOSED TO

SHE

AND

PU

FAVOJ ABLE

MAXILLARYMANDIBULAI

REGULATED

BY MODIFYING

THE

OF THE PALATAL
RELATIONSHIPS

APPLIANCES

AS

THE

GROWS

INFANTS

SECURING

894

MORE

1978

HOSPITAL
BEFORE

PROSTHETICS

PALATAL DEFECT

TONGUE WILL

SIMILAR

FORM CAN

WHEN PALATAL
THE

THIS

THE

DURING FEEDING

THE INFANTS

PIOMOTE

ARCH

MAXILLARY
CHILD

CLOSURE

AFFECT

NEONATE WITH
CLEFT

WHICH

OF FLUIDS

OF VARIOUS

CAN POSITIVELY
IN

LOS AMIGOS

SURGERY IN

PALATE

MUCOSA WHICH WOULD OTHERWISE

SHELVES

OF RANCHO

WILSONMACKBY

LIBBY

THIS

REPAIR

IS

PERFORMED THE SUTURE LINE

TONGUE BY CONTOURING
WAFER IN

POSITION

ITH

PLASTIC

CAN BE PROTECTED

CONRAINCI

ABSOIBABLE

SUTURE

LID

TO THE

MATERIALS

ARCH

FROM
AND

AMERICAN ONCOLOGIC HOSPITAL

PROGRESS REPORT
Notll prairllss of caslI. complications. chanilll In dlaposls

condition on dlscharill. Instructions to patlllnt

415-13

Rev. ]-8]

CHART COpy

GILLESPIE, Neil

#74123

7/22/85

The patient is a 29 year old white male referred by Dr. Carver


who is status post left unilateral 'Class IV lip and palate repair
at approximately age two years old. He is unclear about the details
of the degree of his defects, the surgical procedures, who performed
this, or exactly where it was done. Apparently, after the initial
bout of surgeries to repair the lip and hard and soft palate, he had
no further surgical intervention. He had no ongoing follow-up for
this problem. At approximately age 13 to 14 years old, he underwent
orthodontic treatment at Temple University Hospital's Dental School
and this ultimately resulted in the placement of a retainer with a
prosthetic left lateral incisor. He has worn this since that time.
He notices drainage of food into the left nasal floor.
His left and
right nostrils are opened, although the left is somewhat stuffy and
occluded.
His main concerns upon presentation are related to the persistent
cleft in the left alveolus, the draining fistula, and the possibility
of foregoing the need fOD a prosthetic device.
In addition, however,
it is obvious on confronting the patient that he has a moderate amount
of nasal deformity, flattening of the left side in the premaxillary
region, and lip distortion, particularly at the vermilion.
In
addition, the patient has a significantly hypernasal speech pattern
with ~bvious velopharyngeal incompetence.
On physical examination beginning externally, the patient has
a slightly large nose with a small dorsal hump. The size of the nose
is slightly larger than proportional to his face, although not
exaggeratedly so. The right alar dome is full.
The left alar
cartilage is posteriorly and laterally displaced and somewhat
hypoplastic compared to the left side. The left alar base is
also laterally displaced. The nostril sill is flattened, and there
is an obvious fistula between the distal nasal floor and the oral
cavity. The left columella, likewise, is somewhat hypoplastic and
twisted. The upper lip scar is well healed and appears to be a
LeMesurier or
Tennison-Randall type repair. The upper lip tubercle
is preserved, but the vermilion border is somewhat irregular.
Length appears, however, to be satisfactory. There is a-lateral
orbicularis bulge of the left upper lip.
Internally, there is a wide
cleft of the left alveolar ridge at the level of the lateral incisor
with a fistula into the nasal floor. This runs posteriorly and nearly
to the end of the secondary palate. The soft palate has a linear scar.
it is very short, and there is lateral movement but no central movement
of note.
continued ...

GILLESPIE, Neil
Page Two .
7/22/85
My impression and recommendation to the patient generated
three specific areas of interest. One relates to the scar revision
of his upper nose and the relationships of his nasal tip, nose,
and secondary deformities in this area. The second area of interest
in importance is the alveolar cleft with the naso-oral fistula.
The third area is the palate with obvious velopharyngeal incompetence
and a foreshort and scarred palate.
My initial recommendations will be that the patient undergo
orthodontic evaluation.
I will arrange for him to see Dr. Rosario
Mayro for evaluation as well as x-rays to assess his occlusal
relationships.
It also should be noted that he, in general, had
a fairly satisfactory occlusal relationship.with some lateral collapse
and crossbite on the minor segment on the left and evaluate his
adequacy as a candidate for bone graftin~which I think he would
qualify. Subsequent to this, I will have him see Dr. Harvey Rosen
concerning the actual surgical procedure and also he will be seen by
Miss Marilyn Cohen, a speech pathologist with special interest in
patients having cleft lip and palate for an evaluation concerning
feasibility of posteropharyngeal flap in a patient of this age group.
Concerning the external revisions, this can be accomplished concerning
the upper lip, possibly at the same time as the fistula closure with
orlllcularis redirection, a revision of the nostril sill and the
lateral alar base, and also possibly tip rhinoplasty or this can
be accomplished at a later date with a formal rhinoplasty in concert
with other procedures.
In addition, the vermilion border should be
repaired.
This can be done by Z-plasty technique.
The patient, therefore, will be seen by the consultants and a
general plan with timing'for surgery, etc., will be made. We will
arrange to make these arrangements and follow-up with the patient.
No letter.

ep
s1ak, M.D.
econstructive Surgery
JK:bsm
T--8/1/85
D--7/23/85

PENNSYLVANIA HOS- TTAL


~

The Nl!!,i.\la~~ Hospital I Founded 1751

'',

DEPARTMENT FOR SICK AND INJURED


EIGHTH AND.SPKUCF; STREETS
P.ADELPHIA, PENNSYLVANIA 19107
.
PHONE (215) 829-5643

HARVEY M, ROSEN. M,D, D,M,D,


Head, Se,lion of Plastic Surgery

gtiTie 3H,301.50uth Eighth sr

H, ROBERT CATHCART, President

1?A ~,.;.7~

I etV1

August 12, 1985

Lj-)-?7
',.,

:.",

Joseph Kusiak, M.D.


American Oncologic Hospital
Central " Shelmire Avenues
,.',
~~~l~~elphia, Pennsylvania
19111

RE:

/8&

".
Neil Gille.pie

Dear Joei"" ,
This lllorning your patient, t-lr. Neil Gillespie, was seen in
consultation regarding his secondary cleft lip and palate deformi
ties. His major concern at this point in time is the edentulous
space in the region of the left lateral incisor which necessitates
wearing a removable appliance. This area has never been bone grafted.
On physical examination there is the obvious stigmatA of an unilateral
left sided cleft lip and palate. Examination of the lip reveals poor
aligrunent of the vermilion border. There is lack of muscle continui'ty
high in the lip. Nasal examination shows a deviated septum with the
body of the septum in the left nasal airway and the caudal end pre
senting in the right nasal airway. There is a fla~~Q,~lar base. Tho
alar sill i~ recessed. There is a slumping of the left alar rim.
Tht:: right lower lateral cartilage is hypertrophied compared to the
left lower lateral cartilage. Intraoral examination reveals an
edentulous space in the region of the left li1teral incisor. There
is an obvious oronasal fistula. There i~ a slight posterior cross
bite in the lett posterior segment. There is marked velopharyngeal
escape.
I exp~a1nwd to Mr. Gillespie that in order for nim to have a iix~d
bridge appliance made 60 thathhe could be rid of his removable ap
pliance, an alveolar bone graft would be necGssary. Whether or
not the posterior cro86bite should be corrected prior to this time
is up to Dr. Mayro. At the &~e time that the bone graft is per
formed lip revision could be done as well. At a secondary procedure
a posterior pharyngeal flap And naaal reviaion could be performed.

and The Institute. III North 49th Street I Philadelphia, Pennsylvania 19139 I Telephone (215) 471.2000

Joa.ph Kuaiak, M.D.

Auguat 12, 1985

-2-

Thank you for referring K% G11leQpie.


cuas~9 him with you.

I looK forward to 41a

Sest revarda.
Sincerely youre,

Harvey M. Rosen, M.D., D.M.D.


1iHa/e~

cel

u:

Rosie Mayro, D.M.D., 1830 Rittenhouse Square, Phila., PA 19103


Ma. Marilyn Cohen, Facial Reconstruction Center, Children'.
Hoapital, Philadelphia, PA 19104

10-,,, ~ .~ J;.1/..~

\.

~UUNUtD

11155

THE CHILDREN'S HOSPITAL OF PHILADELPHIA


THE CLEFT PALATE PROGRAM
34th and Civic Center Boulevard

Philadelphia. Pa 19104

(215) 596-9120

Don LaRossa. M. D., Director

September 12, 1985

Joseph Kusiak, M.D.


American Oncologic Hospital
Dept. of Plastic Surgery
Dept. of Surgery

Central and Shelmire Ave.

Philadelphia, PA 19111
RE:

Neil Gillespie
B.D. 3/19/56

Dear Joe:

>"

Thank you for referring Neil Gillespie for a speech evaluation.


I
had the opportunity of evaluating this gentleman on August 1, 1985.
~e had a history of a unilateral cleft lip and palate repaired some
1me in early childhood.
He is presently wearing a dental shell which
l ' l s obturating to some degree an anterior parallel fistula.
He has
had a short course of speech therapy during his early school years.
Mr. Gillespie's speech is characterized by hypernasality with nasal
escape.
Hi~ hypernasality is accentuated when he removes his palatal
appliance but I do not feel that the fistula is the prime cause ~f
the hypernasality or the nasal excape.
Occlusion of his naris with
the appliance in place greatly improves the overall quality of his
speech and generally eliminates the hypernasality.
His articulation
is well within the normal range.
On direct physical examination, he appears to'have a deep oral pharynx'
with a short but mobile soft palate.
He has an active gag reflex,with
fairly good lateral wall motion.
I would suspect that he would do
- fairly well with a posterior pharyng~al flap ~ut given his age the
.
prognosis is guarded.
I discussed this recommendation with Mr. Gillespie
and also informed him that there is the possibility even with the
posterior pharyngeal flap that there may not be an improvement in his
speech and that he could possiply require speech therapy following
the flap.
I do not feel he would benefit from a course of speech
therapy at this point in time as this appears to be an anatomic defect.
>.' :

1:,,:,:9

M.D~.

PlASTIC SURGERY: Peter Randall, M.D., Don LaRossa, M.D., Linton Whitaker, M. D., Ralph Hamilton, M. D., R:Barrett Noone, M.D.,). Brian Murphy,
, ,:" Arthur Brown, M.D.
SPEECH PATHOLOGY: Marilyn Cohen, B.A., Marilyn Bernhard, M.A.; DENTIST."" Rosario Mayro, D.M.D., 'Imes Schweipi;
D.D.S.;
QTORHINOLARYNGOLOGY: William Potsic, M.D., Steven Handler, M.D., Ralph Wetmore, M.D.; AUDIOLOGY: Richard Winchester,
Ph.D.;
PEDIATRICS: Patrick Pasquariello, M.D.; SOCIAL WORK: Susan Freimark, A.C.S.W.

l'

,
0'

RE: Neil Gillespie

(2)

If you would like further confirmation of the problem, I would


recommend proceeding with nasal pharyngoscopy rather than lateral
static x-rays.
Thank you for allowing m~ to participate in Mr. Gillespie's care.
With best regards,
Sincerely yours,

Marilyn A. Cohen
Speech Pathologist

MAC/med
cc:

Harvey Rosen, M.D.


Rosie Mayro, M. D. t..""

Rosario Felizardo Mayro, D.M.D.


Practice Limited to Orthodontics

<tober 10, 1985


~1r. ~1eil

Gillespie
2020 t~lalnut Street
Philadelphia, Penna., 19103

rear

~1r.

Gillespie:

I have received infonnation fran Dr. Harvey Ibsen that he is


going to wait lll1til we finish the presurgical orthodontic
alignment of your teeth. The sequence of events will be as
follows:

1. Presurgical orthodontic alignment


as soon as possible - orthodontic
braces are placed.
2. Bone grafting surgery in ~ r
if expansion is accanplished by then.
3. Finishing orthodontic treatn:ent (at
least 3 to 6 rronths after the surgery)
4. Prosthetic replacerent of the missing
teeth by Dr Dennis Sanfason
:Pest regards,
Sincerely yours,

{L :;/t~
Rosario F. r4:lyro,

D.~-1.D.

RFl-1:er

1830 Rittenhouse Square, li-r\., PhilAdelphia,

P~nnsylvania

19103

215-735-5211

Rosario Felizardo Marro, D.M.D.


Practice Limited to Orthodontin

Harch 31, 1986

Dr. Harvey Rosen

Pennsylvania ~ospital

Suite 309

700 Spruce Street

Philadelphia, PA., 19106

Re:

Neil Gillesoie

Dear Harvey:
Mr. Neil Gillespie has began orthodontic treatment

in preparation for bone grafting.


I anticipate that

he will be ready for surgery in the month of August,

1986. ~tr. Gillespie will be in touch with you shor~y

to set up a definite date


Please do not hesitate to call me if you have any questions.
i

Best regards,
Sincerely yours,

,~
Rosario F. r:layro, D.J.LD.

RFi'1:er

cc:

Dr. Joseph Kusiak

1830 Rittenhouse Square, I-A, Philadelphia, Pennsylvania 19103

215-735-5211
,: ....

-- n"l()(jCV1tic_~ ;kld
Oral Dli/g .'S/S

MI\~!f~ I~

'.f.JYI)1 f!, I-)M 1),1\

I ',IX: III f'J III ejmll 9.111 i 'J(~,

Pllli 1\11111'1111\, III r'II'~WI V;\NI/\ I')K)')

~I!;~)' III J II

APRIL

22) 986

ROSARIO

F.

MAYRO) D.M.D.

1850 RITTENHOUSE SQUARE


PHILADELPHIA) PA 19103

RE: NEIL GILLESPIE


DEAR ROSIE:
AT YOUR KIND SUGGESTION I EXAMINED YOUR PATTFNT" NEIL GILLESPIE"
TODAY TO EVALUATE THE EXTENT OF GINGIVAL RECESSION AND PLAN
CORRECTIVE SURGICAL PROCEDURES. THIS THRITY-YEAR OLD MAN IS IN GOOD
GENERAL HEALTH. HE IS CURRENTLY UNDERGOING ORTHODONTIC TREATMENT IN
YOUR OFFICE AND A MAXILLARY BONE GRAFT IS SCHEDULED LATE NEXT SUMMER
WITH DR. ROSEN.
THE PATIENT HAS SEVERE GINr.IVAL RECESSION IN THE LOWER ARCH EXTENDING
FROM THE LOWER LEFT FJ RST PREMOLAR TO THE LOWER RIGifT FIRST PRfMOI_AR.
THERE IS ALSO SEVERE CERVICAL EROSION WHICH APPEARS TO BE SECONDARY
TO OVERZEALOUS TOOTHBRUSHING. IN THE UPPER ARCH THERE IS RECESSION
AND MUCOSAL MARGINAL TISSUE ON THE CANINES AND RIGHT LATERAL INCISOR.
THERE IS ALSO A HIGH MAXILLARY FRENUM BETWEEN THE CENTRAL INCISORS.
THE PATIENT HAS MINOR COMPLAINTS OF SENSITIVITY WITH EXTREMES OF HOT
AND COLD IN AREAS OF RECESSION.

As WE DISCUSSED" I WILL BE PROCEEDING WITH CORRECTIVE MUCOGINGiVAl


PROCEDURES IN ORDER TO ST~BILIZE THF. DENTOGINGIVAL JUNCTION AND
PREVENT FURTHER RECESSION DURING ORTHODONTIC TREATMENT.
IN AR E A 5
WHERE SENSIVITITY IS A PROBLEM OR THERE ARE COSMETIC CONCERNS" THE
PROCEDURES WILL BE DESIGNED TO OBTAIN COVERAGE OF EXPOSED ROOT
SURFACES.

DR. ROSARIO MAYRO


APRIL 22J 1986
PAGE Two

I SEE NO PROBLEM WITH CONTINUED TOOTH MOVEMENT IN THE UPPER ARCH. I


WOULDJ HOWEVERJ DEFE~ ACTIVE ORTHODONTIC TREATMENT IN THE LOWER ARCH
UNTIL AFTER I HAVE COMPLETED THE MUCOGINGIVAL SURGERY.
I LOOK FORWARD TO COLLABORATI NG WITH YOU IN THE TREATMENT OF TH IS
VERY CHALLENG ING CASE.
I WILL KEEP YOU POSTED ON Mi<. GILLESP I E S
PROGRESS.
I

SINCERJ~Y,/,
Ii

MARK

~.

\1

,./'
/';

,/

SNYDERJ D.M.D.

MBS:MEB
CC:

HARVEY ROSENJ

D.M.D.J

M.D.

,:-'

"

1".

t..

L:, ...

PeriodontICS and
Ora/Diagnosis

MARK BSNYDER, DMD, PC

_. ---_.. _._----

220-sc5JTH SIXTEENTH STREET SUITE 900


PHII.ADELPI /lA, PLNN5YIVANIA

I(JIOY

(21': ':>46 O/?9

JULY

3" 1986

ROSARIO F. MAYRO" D.M.D.


RITTENHOUSE SQUARE
PHILADELPHIA" PA 19103

1850

RE:

NEIL GILLESPIE

DEAR ROSIE:

I AM PLEASED TO REPORT THAT I HAVE COMPLETED PERIODONTAL SURGERY ON


YOUR PATIENT NEIL GILLESPIE. A BAND OF KERATINIZED GINGIVAL TISSUE
WAS PLACED FROM THE LOWER LEFT SECOND PREMOLAR EXTENDING ACROSS THE
ANTERIOR REGION TO THE LOWER RIGHT SECOND PREMOLAR.
IN THE UPPER
ARCH THE MUCOSAL MARGINS ON THE ANTERIOR TEETH WERE ALSO REPLACED BY
KERATINIZED GINGIVA. NEIL TOLERATED THE PROCEDURES ~XTREMELY WELL
AND HEALING HAS BEEN UNEVENTFUL. INCIDENTIALLY" THERE HAS ALSO BEEN
SIGNIFICANT IMPROVEMENT IN HIS PLAQUE CONTROL.
I HAVE RECOMMENDED THAT NEIL BE SEEN ON AN ONGOING BASIS FOR
PERIODONTAL HEALTH MAINTENANCE APPROXIMATELY EVERY FOUR TO SIX WEEKS
DURING THE ORTHODONTIC PHASE OF HIS TREATMENT. I WILL EE SEeING HIM
AGAIN SHORTLY BEFORE HIS SURGERY WITH HARVEY ROSEN. HIS PERIODONTIUM
IS CURRENTLY HEALTHY ENOUGH TO WITHSTAND THE RIGORS OF ANY
ANTICIPATED TOOTH MOVEMENT.
i

THANK YOU FOR REFERRING THIS MOST CHALLENGING CASE TO ME FOR


TREATMENT.
IF I CAN BE OF ANY FURTHER ASS ISTANCE" PLEASE DON 'T
HESITATE TO CALL.

CC:

HARVEY ROSEN" D.M.D." M.D.

JUL 0,,1986

.._._ ...._,

I ...

.~NSYLVANIA HOSPJ~ ~L
. N.tion's Fint HOIpit.11 FoundN 1751

DEPARTMENT FOR SICK AND INJURED


EIGHTH AND SPRUCE STREETS
....ADELPHIA, PENNSYLVANIA 19106

HARVEY M. ROSEN. M.D. D.M.D


He.d. Section of PI..tic Suraery
Suite 3H. 301 South Eiahth Street

~EPHONE (215) 829-5643

H. ROBERT CATHCART, Pruidenl

May 18, 1987

Pete~ Randall, M.D.

University of Pennsylvania Hospital

Four Silverstein

3400 Spruce Street

Philadelphia, Pennsylvania 19104

RE:

Neil Gillespie

Dear Peter:
I have asked Mr. Neil Gillespie to see you in consultation regarding
a secondary cleft nasal deformity. Mr. Gillespie had been referred
to me by Joseph Kusiak for a bone grafting procedure to his residual
alveolar cleft. When first seen by me he had a very large nasal pal
atal fistula with a significant alveolar defect. In addition, he had
a rather severe cleft nasal deformity with a large amount of velopharyn
geal insufficiency. A pharyngeal flap was discussed, but he declined
this and wanted to concentrate on the bone grafting of his alveolar
cleft as well as some secondary nasal surgery. He was operated upon
last spring, at which time he underwent bone grafting of his rather
,..-extensive alveolar cleft and, at the same time, repositioning of the
nasal septum and nasal' spine in the midline. He did wel~ followinq
~ these procedures, and approximately six months
later he underwent
a rhinoplasty procedure involving further work on his septum with
only minimal resection, reduction of a dorsal nasal hump, and reduc
tion of his left alar flaring. As a Desult of the last mentioned
maneuver, he has developed some blockage of the left nasal airway due
to excessive buckling of the lower lateral cartilage. It is-significant
to note that prior to his nasal surgery he denied having anY}di,fficul
ties wi t~ nas';ll br 7athing.. For thi~ reason. no extensi.Y,~.~~9r:kwa~~~ne
to the r~ght ~nfer~or turb~nate, wh~ch is s~.'.~~;J~
".t'IY'hypertrop~~ed,
and the nasal septum was not more ~~--.e:i.el~'~rese'6ted.
.' .
',' '., ~'i'r,:~~;'f:::'.'"

I would appreciate your thouqhts on his residual problem. If you


think further significant improvement can be obtained, and if he is
agreeable, please do not hesitate to proceed with any surgery that you
think advisable.
..
Thank you in advance for seeinq Mr. Gillespie.

Best regards.

Sincerely yours,

Harvey M. Rosen, M.D., D.M.D.


hrnr/eg
.nd The Institute. 111 North 49th Street I Phil.delphi., Pennsylv.ni. 19139 I Telephone (215) 4712000
, ,,-:t:. I )f~

'1 '

.:;~ .

'. I,,):,

HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA


4TH FLeOR - SILVERSTEIN PAVILION
3400 SPRUCE STREET
PHILADELPHIA, PA. 19104
(215) 662-2000

JONATHAN E. RHOADS, M.D.


CLETUS W. SCHWEGMAN, M.D.
BROOKE ROBERTS, M.D.
PETER RANDALL, M.D.
JULIUS A. MACKIE, M.D.
L. HENRY EDMUNDS, JR., M.D.
LEONARD D. MILLER, M.D.
CLYDE F. BARKER, M.D.
RALPH HAMILTON, M.D.
HENRY D. BERKOWITZ, M.D.
HAZEL I. HOLST, M.D.
LINTON A. WHITAKER, M.D.
ERNEST F. ROSATO, M.D.
LEONARD J. PERLOFF, M.D.
JAMES L. MULLEN, M.D.

June 17, 1987

DON LA ROSSA, M.D.

RICHARD N. EDIE, M.D.

LARRY W. STEPHENSON, M.D.

JOHN L. ROM BEAU, M.D.

GORDON P. BUZBY, M.D.

ALI NAJI, M.D.

W. CLARK HARGROVE, III, M.D.

V. PAUL ADDONIZIO, M.D.

CLIFFORD W. DEVENEY, M.D.

KAREN E. DEVENEY, M.D.

IRA J. FOX, M.D.

JOHN M. DALY, M.D.

MICHAEL H. TOROSIAN, M.D.

scon P. BARTLEn, M.D.

Harvey M. Rosen, M.D., D.M.D.

Suite 3H

301 S. Eighth Street

Phi1ade1phLa, PA 19106

RE:

Neil Gillespie

Dear Harvey:
Thank you so much for your letter concerning Mr. Neil Gillespie.
This certainly sounds like an interesting and rather difficult
situation. I would be very pleased to see him. I will
certainly keep you in touch with any plans, and do appreciate so
much information.
Thanks again.

Peter Randall, M.D.


PR:spd
cc:

~oseph

Kusiak, M.D.

~Mr. Neil Gillespie

UNIVERSITY OF PENNSYLVANIA
DIVISION OF PLASTIC SURGERY

Hospital of the University of Pennsylvania


Tenth Floor/Penn Tower
3400 Spruce Street
Philadelphia, Pennsylvania 19104
Don LaRossa, M.D.
Associate Professor of Surgery

(215) 662-2044

March 14, 1989


Mr. Neil J. Gillespie
1801 Buttonwood St., 1109
Philadelphia, PA 19130
Dear Mr. Gillespie:
I enjoyed meeting wi th you in my office on March 6, 1989 to discuss
your interest in further reconstructi ve surgery of the nose and lip area.
You are 32 years old and were born with a cleft of your lip and palate. You
brought along with you a recorded history of the surgeries that you have
had in the past both to repair the cleft of the lip and palate and
reconstructive procedures since then.
Your latest operations were done
by Dr. Harvey Rosen at Pennsyl vania Hospi tal.
The last operation was a
rhinoplasty done on December 15, 1986.
Prior to tha t you had a bone graft
done as well. Since your last surgery you have had trouble breathing through
the left nostril.
Otherwise you were happy with the results of your
surgeries. Al though the breathing is your main concern you would entertain
the idea of addi tional surgery on the external nose if the proposals were
appealing to you.
You are an otherwise healthy person, you don't take any medications
on a regular basis and have no known medical allergies. The only additional
surgery that you have had was for a fractured ankle in the past.
On my physical examination I found some flattening of the nasal tip
on the left side.
Addi tionally, there is a depression of the crease just
above the nostril so that the amount of support in that region is reduced.
Therefore when you inspire through your nose, there is a collapse that reduces
the air flow.
Internally, the base of the septum is deviated to the left
side. In most cleft cases it is deviated to the opposite side. Additionally,
you have an enlarged inferior turbinate.
The combination of these two
features reduces the nasal airway by approximately fifty to sixty percent.
Even when I hold your left nostril open somewhat wi th a speculum, there
is a degree of obstruction on the left that I feel is related to the deviation
of the septum and the turbinate.
The turbinate is one of the fins that
protrudes from the outer wall of the nose into the nasal cavi ty.
These
warm and humidfy the air as it passes through the nasal passages.
I additionally found your palate to be very short and noted some
nasali ty in your speech. The area of the bone grafting appears to be very
nicely healed.
I think overall you have a very nice result from the surgeries that
you have had thus far.
Your breathing may be improved by reducing some
of the obstruction in the left nasal passage. This would require a partial
removal of the turbinate and septum in order to enlarge the amount of space
in the left nasal airway.
I also fel t that a cartilage graft taken from
either the septum or the ear might be helpful in supporting the left nostril.
This may help keep it from collapsing inward when you inspire through the
nose.

Mr. Neil J. Gillespie


Page 2 of 2

Externally, some addi tional grafting could be done on the tip of the
nose on the left side.
The purpose would be to try to elevate the tip of
the nose to make it more even wi th the opposi te side.
For both of these
grafting procedures cartilage can be taken from ei ther the septum, if there
is a sufficient amount, or from the cupped portion of the ear.
This is
done through an incision behind the ear and usually leaves very Ii ttle in
any noticeable deformi ty.
There is of course a scar present behind the
ear where the incision is made, but in most people this is not conspicuous
because of its location.
The shortness of your palate is contributing to some nasality of your
speech.
I pointed out that if you were to improve the left nasal airway,
your speech might deteriorate since the reduced air flow on the left side
is actually helping to control the loss of air through the nose during speech.
If this obstruction is relieved air .may flow more freely through your nose
making your speech more nasal sounding.
If this were to occur addi tional
surgery might be needed. This would consist of a posterior pharyngeal flap
where a piece of tissue from the back of the throat is connected into the
palate to help to reduce the air flow into the nose.
An obturator could
also be used to accomplish the same thing.
As you know, obtura tors are
like extended upper dentures with a part that helps to lift the palate or
to reduce the amount of air space coming up into the nose.
Although there are some possible benefits to be derived from the surgery
we discussed, you should consider the possible complications and the risk
that things might not work out the way ei ther you or I expected them to.
If you feel that the possible benefits as I outlined them to you would
outweigh the risk of complications for disappointment and feel that you
would like to have the surgery done, please let me know so that appropriate
letters can be wri tten to your insurance company for a pre-authorization
for the surgery. If you would like to discuss this at greater length, please
make another appointment to see me.
Thank you for asking my opinion and
for the privilege of sharing in your medical care.
Sincerely yours,

{k~

Don LaRossa, M.D.

DLR:dg
cc:

Rosario Mayro, D.M.D.

FOUNDED 1855

THE CHILDREN'S HOSPITAL OF PHILADELPHIA


THE CLEFT LIP AND PALATE PROGRAM
34th and Civic Center Boulevard

Philadelphia, PA 19104

(215) 596-9120

Don LaRossa, M.D., Director

Pam Onyx, Coordinator

March 30, 1989

Don LaRossa, M.D.


HUP
RE: Neil Gillespie
DOB: 3/19/56
Dear Don:
I had the opportunity of reevaluating Neil Gillespie on March 30, 1989. The
speech evaluation is essentially unchanged since his last evaluation in 1985.
Mr. Gillespie's speech is characterized by hypernasality with consistent
nasal escape. On direct physical examination the palate appears to be short
and slightly immobile. Articulation is within the normal range.
I would recommend nasoendoscopy to confirm velopharyngeal incompetence and
to evaluate the degree of lateral wall motion. Mr. Gillespie was counseled
regarding the options for correction of his hypernasal voice quality, includ
ing the use of dental prosthetics and posterior pharyngeal flap. I also ex
plained to Mr. Gillespie that the prognosis after placing a posterior pharyn
geal flap are somewhat guarded in an adult and that he may continue to have
some persistent hypernasality requiring additional speech therapy. I believe
Mr. Gillespie is interested in proceeding with a nasoendoscopy and will be
contacting you after he receives notification from your office.
Thank you for the opportunity of participating in this patient's care.

'

Sincerely yours,
, / ' ,/-'

'.,

/'

_-:;rh ~rC/

Marilyn E. Cohen
Speech Pathologist
MEC:sam
cc:

Mr. Neil Gillespie

PLASTIC SURGERY: Peter Randall, M.D., Don LaRossa, M.D., linton Whitaker, M.D., Ralph Hamilton, M.D., Harvey M. Rosen, M.D., Joseph F. Kusiak, M.D., R. Barrett Noone,
M.D., ). Brien Murphy, M.D. SPEECH PATHOLOGY: Marilyn Cohen, B.A., Marilyn Bernhard, M.Ed. DENTISTRY: Rosario F. Mayro, D.M.D., Dennis G. Sanfacon, D.M.D., Barry
S. Kayne, D.D.S., Stanley Horwitz, D.D.S., Howard M. Rosenberg, D.D.S.
OTORHININOLARYGOLOGY: William Potsic, M.D., Steven Handler, M.D., Ralph Wetmore, M.D.,
AUDIOLOGY: Dan F. Konkle, Ph.D.
PEDIATRICS: Patrick Pasquariello, M.D.
SOCIAL WORK: David ). Beele, M.S.W., A.C.S.W.
Lawrence W. C. Tom, M.D.
GROWTH/ANTHROPOLOGY: Nancy Minugh-Purvis, Ph.D. GENETICS: Elaine H. Zackai, M.D., Donna M. McDonald, M.s. PATIENT EDUCATION: Pamela H. Onyx, B.A.
NURSING: Kelly Gould, R.N.

li. 'Ralph Millard, Jr., M.D., F.A.C.S.

thony

Wolfe, M.D., F.A.C.S.

Walter R. Mullin, M.D., F.A.C.S.

December 3, 1990

Mr. Neil J. Gillespie


23 Sweetgum Road
Levittown, PA 19056
Dear Mr. Gillespie:
Arrangements have been made for your admission to Jackson Memorial Hospital,
East Tower, on Thursday, December 13th, 1990 between the hours of 12:00 and
2:00 p.m., for surgery the following day. Please be prepared to pay the
hospital a deposit of $4400 toward payment of your final bill. However, they
may accept insurance forms in lieu of payment. Please let us know at once if
you prefer to be admitted on the morning of surgery, as we would have to arrange
for your lab work to be done prior to the day of surgery.
Also, we've arranged for Dr. Millard and his Resident, Dr. LaTourette, to see
you in our office on Wednesday, December 12th at 10:00 a.m. for medical workup.
Please send us your insurance forms with "insured section" completed and signed.
This will help expedite the processing of your claim. Be sure to find out and
let us know if your insurance company requires pre certification for planned
surgery. Contact Marisol in our office as soon as possible regarding this
matter.
Kindly confirm these arrangements upon receipt of this letter. If we do not
hear from you by December 12th, we will assume that you are unable to go ahead
at this time and we will find it necessary to remove you from the schedule
until we hear from you again.
Enclosed is a list of special instructions which should help answer some of
your questions. If we can be of further assistance, please feel free to call
upon us.

~urs.
Chris Montoto
Secretary to Dr. Millard

D. Ralph Millard, Jr., M.D., F.A.C.S.

Anthony Wolfe, .M.D., F.A.C.S.


Walter R. Mullin, M.D., F.A.C.S.

'The Plastic Surgery Centre


Plutic and Re.:onsl:ruc:tivc Surgery Tel. (305) 325144.
1444 N.W. 14th Avenue

Miami. Florida 33125

December 6, 1990

Christy Barcelona
Pennsylvania Blue Shield
Pre-authorization Request
P. O. Box 890041
Camp ~ill, PA 1708900041

Re: Neil Gillespie


ID: D5ll5395
Group: 20l63C

TO WHO-I IT HAY CONCERi'J

The above natmed patient was seen in consultation by D. Ralph


Hillard, Jr., M.D. on May 26, 1989 at which time reconstructive.
surgery was scheduled.
The patient \Vas born with a tmilateral cleft of the lip and palate
including nasal distortion lvith difficulty breat~~g and nasal
escape, secondary to tIle cleft. TIle proposed surgical procedure
lvill be cleft rhinoplasty lvith submucous resection, possible pharyngeal
flap and cleft lip correction, procedure codes: 30520, 40720 and 42226.
Dr. Hillard's fee for these procedures lvill be approximately $3,900.00.
Dr. ~lillard feels very strongly that this surgery is functional i."1
nature.
We will greatly appreciate receiving pre-authorization for this surgical
procedure. We will also appreciate your expeditious attention to this
request as Hr. Gillespie's surgery is scheduled for Dece.'nber 14, 1990.

S)7Z:t:~r:L

Marisol Pardo,
Insurance Secretary

~1P/a

JUN 29 1993
MUTAZ B. HABAL., M.D., F.R.C.S.C., FAC.S.
PLASTIC AND RECONSTRUCTNE SURGERY
801 W. Dr. ".rtin L ICing, Jr. BIwI.

Tampa, FL 33603-3301

Telephone: 813/231HH09
FacsOnBe: 813/.238-1119

May 5, 1993

RE:

NEIL GILLESPIE

To Whom It May Concern:


Neil Gillespie is a pleasant 37 year old white male patient
seen 'today for the first time at the Tampa Bay Craniofacial
Center. He brings with him today an organized synopsis of the
multiple operative procedures that he has undergone, initially
in Philadelphia and the last in Miami.
The patient presents with velopharyngeal incompetency and is
leaking air both posteriorly and interiorly.
The palate is
short and does not appear to have much activity.
Prior to
preparing Mr. Gillespie for a surgical procedure, I would like
to do a complete visualization of his problem to see if the
pharyngeal flap needs to be removed and enough time allowed
for the tethered flap to adjust, or if a complete flap with
two small posts on each side is appropriate in order to allow
him to communicate and be understood despite his hypernasal
speech which at the present time cannot be comprehended.
These operative procedures will be discussed with the patient
following the visualization procedure which has been scheduled
at st. Joseph's Hospital on 6/1/93 and again in consultation
with Dr. Scheuerle. I will see him prior to the procedure on
5/26/93 at 1:45 p.m.
Should you have any questions, please do not hesitate 'to com
municate with us.
Sincerely,

/U V/ G.-i~- fr~{t:-L--l
Mutaz B. Habal, M.D.
(dictated but not read)

MBH/bbd/5-8

June 2, 1993
Robert E. Williams, Ed.D.
certified Rehabilitation Counselor
Department of Labor and Employment Security
Divisional of vocational Rehabilitation
11213 B North Nebraska Avenue
Tampa, Florida 33612

Department of Communication Sciences


and Disorders
College of Arts and Sciences
University of South Florida
4202 East Fowler Avenue, BEH 255
Tampa, Florida 33620-8100
(813) 974-2006
FAX (813) 974-2668

Re.: Neil J. Gillespie


Dear Dr.

Willia~s,

Thank you for your letter of inquiry concerning Mr.


Neil Gillespie's health and employment status and
potential. Each of your five questions concerning Mr.
Gillespie's diagnosis and treatment plan is listed and
addressed below.
1. What is Mr. Gillespie's disability (ies) and what
is the level of severity?
-.,.
Mr. Gillespie has sustained the surgical results
of mUltiple treatments for a congenital cleft lip and
palate. While he is facially intact, he retains several
incomplete elements of the sequelae of this congenital
dysmorphology.
Because of the oro-nasal fistula and
velar limits, Mr. Gillespie is utilizing extreme measures
to make his speech intelligible. He is applying undue
stress to the laryngeal and pharyngeal musculature a
control the normal air stream. Because of his extra
effort in striving to meet the demands of society, he is
at risk for damaging his larynx. Also, the unnatural
openings between the nose and mouth invite incidence of
infection and irritation to sensitive tissues that were
never meant to associate in this way.
Exchange of food
stuffs and secretions between the two cavities must be
stopped to promote complete healing and maximal function.
2. What is Mr. Gillespie's functional level? What
physical limitations (e.g., speaking, hearing,
communicating, etc.) are imposed by the disabilities?
Because of his present oro-facial-pharyngeal
status, Mr. Gillespie is not advised to use his full voice
in long-term verbalization. That is, prior to closure of
the fistulae, and correction of the palate, he would be
ill advised to lecture, or undertake pUblic speaking. He
can communicate intelligibly on a one-to-one basis and as
such he displays an astute mind with considerable
.~
experience with interpersonal communication. This level
of communication is possible due to Mr. Gillespie's
conscientious and accurate speech articulation. When he
attempts to use a stronger (louder) voice, the increased

'<\MPA

ST. PETERSBURG

SARASOTA

UNIVERSITY OF SOUTH FlORIOA IS

FORT MYERS

LAKELAND

m AFFIRMATIVE ACTION I EOUAL OPPORTUNITY INSTITUTION

air pressure increases the hypernasal resonance and


thereby decreases the effectiveness of his speech. He
looses intelligibility and fatigues rapidly.
Because I have no objective data on his hearing
status, I can only be suspicious that it is currently
within normal range, but also that he has sustained the
effects of early, untreated middle ear effusions that
usually result in conductive hearing loss during infancy.
effort was seen yesterday at the Tampa Bay Craniofacial
Center for assessment of the current status of his
congenital orofacial cleft condition.
Mr Gillespie is
experiencing severe speech expression problems due to
inadequate intra-oral and oronasal structures. Although
he has had several surgeries in an earnest attempt to
resolve this problem, none of the procedures have
completed the treatment he requires in order to produce
clear verbal communication ..
3. What is the probable future course of the
disability (ies)?
If untreated, Mr. Gillespie rjsks irritation and
abuse with abrasion to the laryngeal tfssues, continued
irritation to the upper airway and mutual irritation and
possible infection to the oral and nasal mucosa due to the
uncontrolled exchange of cavity contents during every day
living activities.
4. Are there any work environments that must be
avoided?
If untreated, Mr. Gillespie must work in settings
that provide minimal irritants to the nasal, oral and
pharyngeal mucosa. He must avoid excessive drying of
those tissues and the linings of the larynx. He must not
shout, use his speaking voice in excess, or be exposed to
excessive or continual loud noise because of both the
hearing factor and the need to override the noise with use
of a loud voice.
5. will treatment ease, alleviate, or remove the
disability (ies)? If so, what treatment is recommended?
Treatments are available to alleviate the current
problems and remaining dysmorphologies that underlie the
problems cited above. However, the exact mode of
treatment requires an objective examination of Mr.
Gillespie's intra-oral, oro-nasal, and oro-pharyngeal
structures.
The approach that has been suggested by the
Craniofacial Team at the Tampa Bay Craniofacial Center
includes the following steps.
A.
- out patient hospitalization for nasendoscopy to
determine the present cause of immobility in the soft
tissue of the soft palate and to visualize the extent of
the nasopharyngeal gap.
If the last surgical result has
modified over time, it mqy be desirable to surgically

modify the present condition by severing any tethering


tissue that is limiting palatal function. Prior or
sUbsequent to the hospital experience, a complete
aUdiological assessment would be helpful to rule out any
middle ear dysmorphologies connected with the congenital
problem.
.
B. - Clini9al observation indicates that following
this careful, objective examination, Mr. Gillespie will
need surgical correction of (a) the anterior oronasal
fistula; (b) bone graft to complete the maxillary alveolar
arch; and (c) 'secondary palatoplasty to form a pharyngeal
flap to reduce the hypernasality. [Please note that the
order in which these are listed assure that the separation
of cavities, the continuation of the airway and the
skeletal support of soft tissue modification will prevent
any' future deterioration of these same tissues.] ,. ".,'
, . c.' :.-Following surgeries to correct all the current
interfering dysmorphologies, Mr. Gillespie will need to
'.' have sixmontlls of speech therapy to 'assure' that he no
.'c longer over-activates his larynx and' learns to utilize
;. fully 'th.e're-confiqilred oral and oro";;pharyngeal
,,"
: structures.
' " ," '
. ,;':::;Due to his current physical disability Mr. Gillespie
is ':experiencing rejection in job applications . It is the
opinion of the Craniofacial Team that correction of the
'identified sequelae of the congenital dysmorphology, this
young may will be able to find employment in any current
or emerging job site that requires his type of skills. He
is competent in matters of business, and has a keen
interest in dealing with people~ He may seek employment
in human service areas, personnel management, or
counseling whether in business or in some specialized area.,
of human communication. As a student at the University of
South Florida and a promising contributor to our
community, this young man needs support to pursue
. appropriate treatment for the remaining dysmorphologies of
his mouth, throat and face.
'
.
Please let me know if I can be of further assistance
. to you in your efforts to provide the needed assistance to
Mr Gillespie.

fLe~:l~y~,~'t.G-<A.,c...'l/t.."',

~/i6

euerle,
CCC-SLP

Professor

co-Director, Tampa Bay Craniofacial Center

Craniofacial Center
Health Science Center

PO Box 100424
Gainesville, FL 32610-0424
Telephone: (352) 846-0801
Fax: (352) 846-1539
e-mail: Wiliiams@dentaLufLedu

Clinic Report: Videofluoroscopic assessment of the velopharyngeal port during


function for speech

Re:
Dental No.:
Medical No.:

Neil Gillespie
18-80-41
10-44-032

This forty year old white male was seen on November 25, 1996 for a videofluoroscopic
assessment of his velopharyngeal port during function for speech. Mr. Gillespie is currently
wearing a speech bulb obturator, and his speech resonance frequently alternates between
hyponasality and hypernasality. The purpose oftoday's filming was to determine the size,
configuration and placement of the bulb in the nasal pharynx to determine if alteration of
these factors can improve his overall resonance quality. The nasal pharyngeal structures
were coated with a thin barium sulfate solution to aid in defining soft tissue contrast.
Records were obtained in the lateral and frontal (A-P) planes with and without the speech
bulb obturator.
Detailed analysis of the film revealed the following conditions:
1. Without the obturator the soft palate is mobile, demonstrating a movement pattern
appropriate to the several speech samples Jared produced. Although there is good velar
mobility, contact with the posterior pharyngeal wall is not achieved. That is!, a consistent gap
of 10 - 12 mm exists between the elevated velum and the posterior pharyngeal wall during
speech.
2. The depth of the nasopharynx, as measured along the palatal plane from the posterior
nasal spine to the posterior pharyngeal wall is 25 mm. This compares to the norm of 24 mm
2 mm/SD revealing Mr. Gillespie's nasopharyngeal depth to be well within normal limits
for his age.
3. The configuration of the posterior pharyngeal wall is nearly vertical above and below the
palatal plane, a pattern well within normal limits.
4. An A-P view revealed symmetrical mesial movement of the lateral pharyngeal walls
approximately 25 - 50% of the distance from rest to midline.

Neil Gillespie
Fluoroscopic assessment of VP Function for Speech
November 25, 1996

In summary, Mr. Gillespie presents with a speech pattern characterized by near normal
resonance but which frequently alternates between hyponasality and hypernasality. He is
currently wearing a speech bulb obturator and today's assessment revealed placement and
configuration to be near optimal.' Without the obturator, Mr. Gillespie's speech is
significantly hypernasal and although the velum elevates appropriately there remains a
consistent gap of 10 - 12 mm during speech. In order to further define whether any
improvement can be made to the speech bulb obturator or if a secondary surgical technique
might be a viable consideration, a nasendoscopic assessment should be conducted.
If I can be of any further assistance in the interpretation of this film please call me at (352)

8:;~~

W. N. Williams, Ph.D.

Speech-language Pathologist

cc:

Mr. Neil Gillespie

1121 Beach Drive, N.E.

Apt. C-2

81. Petersburg, FL 33701-1434


Mr. Glenn Turner
P.O. Box 100435 JHMHC
Dr. Brent Seagle
P.O.Box 100286 JHMHC
Medical, Dental, Center Records

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