Phonetic in complete denture

phonetics play an important role in planning and preparing complete denture for the complete edentulous patients.design of the prosthetic denture affects speech in a number of ways.

1. PHONETICS IN COMPLETE DENTURE Dr. SHANNON FERNANDES II MDS Dept. PROSTHODONTICS

2. CONTENTS Introduction Definition History Types of speech Classification of speech S sound and their prosthodontic considerations Phonetics in recording jaw relation Phonetics during trial insertion Prosthodontic implications in denture designs affecting speech Speech tests Speech analysis Conclusion

3. DEFINITION SPEECH:- the act of expressing or describing thoughts, feelings, perceptions by articulation of words. PHONETICS:- the branch of linguistics that deals with the sounds and their production, combination , description and representation by written symbols .

4. HISTORY 1949 SEARS recommended grooving the palate just above the median sulcus of the patient. LANDA suggested the use of S sound to determine the free way space and M sound to establish desirable rest position . Landa uses labiodentals ( f and V) as an adjunct to the arrangement of maxillary anterior teeth. He believes that teeth should be arranged so that fricatives can be pronounced properly and naturally. He also maintains that proper vertical dimension is the key to proper pronunciation of s and sh Allen: improved phonetics in denture construction. J Pros dent. 8 753-763.1958

5. Allen: improved phonetics in denture construction. J Pros dent. 8 753-763.1958 1951 POUND was successful in improving phonetics by contouring the entire palatal aspect of maxillary denture to simulate normal palate . 1953 & 1956 SILVERMAN used speaking methods to measure patients vertical dimension with and without denture. MORRISON suggested the use of sixty six and mississippi to determine closest speaking space .

6. Normal speech depends upon the proper functioning of five essential mechanisms: (1) The Motor , consisting of the lungs and associated musculature of larynx and muscles which supply the air, (2) The vibrator , consisting of the vocal cords which gives pitch to the tone, (3) The Resonator , consisting of oral, nasal, and pharyngeal cavities and paranasal sinuses which create overtones peculiar to each individual, .

7. (4) The enunciators or aticuIators , consisting of the lips, tongue, soft palate, hard palate and teeth, which form musculoskeletal valves to obstruct the passage of air, breaking up the tones and producing the individual speech sounds, and (5) The initiator , consisting of the motor speech area of the brain and the nerve pathways which convey the motor speech impulses to the speech organs.

8. The primary concern in phonetics is with the changes in the stream of air as it passes through the oral cavity. Therefore, the enunciators or articulators are of greatest interest to us. Of these, the tongue plays a major role. The tongue is the principal articulator of the consonants and it changes position and shape for the pronunciation of each of the vowels.

9. NEUROLOGIC INTEGRATION Factors for speech production are highly coordinated, some sequentially and some simultaneously by the CNS. Speech is a learned function and requires adequate hearing, vision, and normal nervous system for its full development.

10. RESPIRATION The movement of air in the respiratory and expiratory phase is important in the production of our speech

11. PHONATION Air from the lungs courses through the trachea Sound is produced in the larynx AND Vibration of vocal cord takes place

12. RESONANCE Sound that is produced by the vocal cord is modified by various chambers. Resonators are Pharynx Oral cavity Nasal cavity Paranasal sinuses

13. SPEECH ARTICULATION Sound that is produced is formed into very meaningful words Tongue, lips, palate, teeth and mandible play a very important role in speech articulation.

14. TYPES OF SPEECH VOWELS : a e i o u they are called voiced sounds. CONSONANTS: may be either voiced or produced without vocal cord vibration, in which case they are called breathed sounds. eg . p, b, m, s, t, r, z COMBINATION : is blend of consonant and vowels , articulated in quick succession and identified as one. Eg . WORD

15. CLASSIFICATION OF SPEECH According to Boucher Vowels Consonants Plosives /stops : these sound are produced when overpressure of air has been built up by consonants between the soft palate and pharyngeal wall and released in an explosive way. ex. P (pay) B (bay) T (to) D (dot) Fricatives: also called sibilant sounds characterized by their sharp and whistling sounds when air is squeezed through the nearly obstructed articulators. Eg . S (so) Z (zoo)

16. Afficatives : mix of plosives and fricatives Eg . Ch (Chin) J (jar) Nasal consonants: produced without oral exit of air. Eg . M (man) N (name) NG (bang) Liquid consonants: also called semi vowels. As the name suggests they are produced without friction. Eg . R (rose) L (lily) Glides: they are sounds characterized by a gradually changing articulator types . Eg . W (witch) Y (you)

17. Classification of CONSONANTS based on place of their production Palatolingual sounds Linguodental sounds Labiodental sounds Bilabial sounds

18. PALATAL SOUNDS PRODUCED BY TONGUE AND HARD PALATE S T D L N S – the sound ‘s’ as in sixty six is formed by a hiss of air escaping through the median groove of the tongue when the tongue is behind the upper incisor. Groove will not always coincide with the median palatal raphe . If groove is deep a whistling sounds when be heard when pronouncing s If groove is shallow s is softened towards sh ( lisping )

19. Clinical significance Thus we can say that sound ‘ s ’ can be used to check the proper placement of anterior teeth. Also thickness of denture base can be adjusted in case the sound S is not produced correctly Denture should be thickened in proper area when the depth of the groove is deep.

20. Silverman also use words with S to establish and check a proper vertical dimension of occlusion.

21. The sound ‘s’ may be distorted to a slushy ‘ sh ’. This results from leakage of air at the lateral borders of the tongue when the tongue is not sufficiently confined in the bicuspid region. This phenomenon, known as stigmatismus lateralis .

22. Rugae area is very Important for production of these sounds T D N L Tongue must be placed firmly against the anterior part of hard palate for production of these words. PALATOLINGUAL SOUNDS PRODUCED BY TONGUE AND RUGAE

23. Therefore…. Should rugae be duplicated in the denture or no is the question that arises…. Slaughter says .. The smoothness of the denture is disturbing and the tongue looses its capacity for local orientation Landa says that rugae is useless or even detrimental because it adds more bulk to the denture…

24. Clinical significance If teeth too lingual – T will sound like D If teeth too forward - D will sound like T

25. PALATOLINGUAL SOUNDS FORMED BY TONGUE AND SOFT PALATE Consonant k (committee) , ng and g (give) are representative of the palatolingual group of sounds . This Sound is formed by raising the back of the tongue to occlude with the soft palate and then suddenly depressing the middle portion of the back of the tongue and releasing the air in a puff.

26. Clinical significance If the posterior borders are over extended or if there is no tissue contact k becomes ch sound.

27. LINGUODENTAL SOUNDS Consonant Th is representative of the linguodental group of sounds Dental sounds are made with the tip of the tongue extending slightly between the upper and lower anterior teeth.

28. This Sound is actually made closer to the alveolus (the ridge) than to the tip of the teeth. Careful observation of the amount of tongue that can be seen with the words - this, that, these and those will provide information as to the labio -lingual position of the anterior teeth.

29. Clinical significance If about 3mm of the tip of the tongue is not visible, the anterior teeth are probably too far forward. If more than 6mm of the tongue extends out between the teeth when such sounds are made, the teeth are probably too lingual.

30. LINGUOALVEOLAR SOUNDS T, D, S, Z, are representative of the linguoalveolar group of sounds Formed by contact of the tip of the tongue with the most anterior part of the palate (the alveolus) or the lingual sides of the anterior teeth.

31. Sibilants (sharp sounds) s, z, sh , ch & j (with ch & j being affricatives) are alveolar sounds, because the tongue and alveolus forms the controlling valve. Important observations when these sounds are produced are the relationship of the anterior teeth to each other.

32. Clinical significance Upper and lower incisors should approach end to end but not touch. Failure indicates a possible error in the horizontal overlap of the anterior teeth

33. LABIODENTAL SOUNDS F and V are representatives of the labiodental group of sounds. Formed by raising the lower lip into contact with the incisal edge of the maxilliary anterior teeth.

34. Clinical significance Upper anterior teeth are too short (set too high up), V sound will be more like an F. If they are too long (set too far down), F will sound more like a V.

35. BILABIAL SOUNDS B,p and m are representatives of the bilabial group of sounds. Formed by the stream of air coming from the lungs which meets with no resistance along its entire path until it reaches the lip.

36. Clinical significance 1. Used to asses the correct interarch space 2. Correct labiolingual positioning of the anterior teeth 3. Labial fullness of the rims can also be checked

37. PHONETICS IN RECORDING JAW RELATION Also called as the speaking method Sibiliant sounds like S and M is used. S sound gives the approximate closest speaking space* M sound gives us the freeway space* Approximately 2mm of space must be there between the two occlusal rims

38. Clinical significance of ‘S’ sound Thickness of denture 2. Antero-posterior position of teeth 3. Vertical dimension of occlusion 4. Width of dental arch: 5. Relationship of upper teeth to the lower anterior teeth

39. PHONETICS DURING TRIAL INSERTION I t is difficult to locate speech problems at the try-in stage because the tongue and lips do not react the same with the wax as they do with the finished and polished denture base . But to accept the correct vertical dimension, the patient should be put through a series of phonetic tests. Tikrit University College of Dentistry 4 th class/ reem prosthetic lec-16

40. 1) Evaluation of the " closest speaking space ": Ask the patient to say s,s,s or count from 50 to 60 a -If the teeth make contact during speech, indicate that there is not enough interocclusal distance between the teeth (increase vertical dimension). b -If there is whistling during saying sss , so the vertical dimension of occlusion may need to be increased or the position of the anterior teeth changed. c -thickness of palatal area of upper denture may also affect …

41. 2) Instruct the patient to say " th ” as in 33. The tongue should protrude to occupy the interocclusal space If the interocclusal space is less than 2 – 4 mm the anterior teeth may be placed too far anteriorly or the vertical overlap may be so great that there is insufficient space for the tongue to protrude between the teeth.

42. 3)Instruct the patient to pronounce "m" rapidly The mandible should remain stationary while the lips contact each other to make sound. 4)Instruct the patient to say " f" or " v” or 55 To evaluate both the anterior – posterior and superior – inferior position of the maxillary teeth . a-If the incisal edges of the upper anterior teeth contact the lingual side of the lower lip, so the upper anterior teeth are set too far lingually or the lower anterior teeth are set too far labially .

43. b-Difficulty in making contact between the lower lip and upper teeth usually indicates that the maxillary anterior teeth must be moved downward . c-The upper teeth are placed too far inferiorly if the incisal edges depresses the lower lip when the "f" and "v" sounds are formed.

44. PROSTHODONTIC IMPLICATION IN DENTURE DESIGN AFFECTING SPEECH 1. Denture thickness and peripheral outline 2. Vertical dimension 3. Occlusal plane 4. Relationship of the upper and lower teeth 5. Post dam area 6. Anteriorposterior positioning of teeth 7. Width of dental arch

45. DENTURE THICKNESS AND PERIPHERAL OUTLINE If the denture bases are too thick. • Lisping will occur with the word like S C and Z • Palatolingual sounds most affected. (T,D)

46. VERTICAL DIMENSION Any change in VD, Bilabials are mostly affected like P B and M • If both rims touch prematurely it indicates excessive vertical dimension. • In try in stage teeth clicking will be heard.

47. OCCLUSAL PLANE Any changed in occlusal plane, Labioldental sounds like F and V are affected. • If occlusal plane is too high the correct positing of the lower lip is difficult • If the occlusal plane is too low there is overlap of the lower lip on the labial surface of upper teeth

48. ANTERIORPOSTERIOR POSITIONING OF TEETH F and V sounds are hampered. • labiopalatal positions of the teeth is very Important • Teeth if placed too palatally the lower lip will not meet the incisal edge of the upper teeth.

49. Post dam area Palatolingual consonants are affected ( K,NG and G) • Thick post dam areas will irritate the dorsum of the tongue

50. Patient feels nausea like effect while speaking • If inadequate the plosive sound of the word is hampered • This area is very important in singers who wear complete denture

51. Width of dental arch If teeth are set in an arch that is too narrow the tongue will be cramped • Consonants like T, D, N , K and S are affected

52. RELATIONSHIP OF THE UPPER AND LOWER INCISORS The chief concern is the S CH, J and Z sound. • These sounds need a near contact of the upper and lower teeth so that the air stream is allowed to pass.

53. SPEECH TEST The speech test should be made after (1) satisfactory esthetics, (2) correct centric relation, (3) proper vertical dimension and balanced occlusion have been attained and also after wax up for esthetics has been completed.

54. TEST 1:TEST OF RANDOM SPEECH • Engage the patient in a conversation and obtaining a subjective speech analysis by asking the patient say how he feels, how his speech sounds to him and what words seem most difficult to pronounce.

55. TEST 2: TEST OF SPECIFIC SPEECH SOUNDS This is best accomplished by having the patient say 6-8 words containing the sound and then combining these words into a sentence. The following is the list of sounds to be tested

56. S Sh Six, sixty, ships, sailed Mississippi, sure ,sign, sun, shine T D N L Locator, located, tornado, near, Toledo Ch J Joe, Joyce, joined, George, Charles, church F V Vivacious, Vivian, lived, five, fifty, five, fifth, avenue

57. Test 3: TEST OF READING A PARAGRAPH Make the patient read a paragraph containing abundance of S, Sh , Ch sounds.

58. PALATOGRAPHY Palatography is a group of techniques to record contact between the tongue and the roof of mouth to get articulatory records for the production of speech sounds. Palatography is used for speech analysis.

59. REQUIREMENT FOR MAKING PALATOGRAM Patient with severe gagging must not be used for making palatograms . A uniformly thin artificial palate is constructed of methyl methacrylate . Palate is inserted in mouth and tested for retention and adaptation. The subject has to practice speaking with this palate in mouth until speech becomes clear. The patient should be trained to open his mouth wide as soon as the desired sounds are pronounced without contacting the palate and tongue again.

60. The tracing material should permit easy application and must not be distasteful. The palate must be thoroughly dried before applying the material ( nonscented talcum powder) and must have a contrasting colour for visibility and identification.* Activated charcoal and chocolate powder can also be used.

61. A study of the palatograms showed that in pronouncing the consonants, the primary area of tongue contact is the alveolar area, and that only a small portion of the hard palate is involved. In a comparative analysis of the ‘s’ and ‘ sh ’ palatography ,it was interesting to note that the rugae area was contacted slightly in some cases and not at all in others , but that in all cases the entire posterior alveolar area was always contacted .* It was further noted that the rugae area was only slightly Involved in the pronunciation of the t, d,n,and l.

62. SOME PROSTHETIC CONSIDERATIONS Older complete denture wearers experience greater difficulties in adapting their speech to new prostheses and need longer time to regain their natural speech. A frequent cause is impaired auditory feedback, and therefore a simple auditory test might be useful in such patients to make a proper diagnosis. Speech adaptation to new complete dentures normally takes place within 2 to 4 weeks after insertion. If maladaptation persists, special measures should be taken by the dentist or by a speech pathologist. When new prostheses have to be made for these patients, certain difficulties in learning new motor acts may delay and obstruct the adaptation .

63. Consequently, a virtual duplication of the previous denture’s arch form and polished surfaces, especially the palate of maxillary denture, will frequently solve a problem that may arise due to speech and adaptation difficulties. Variation in thickness and or volume of denture and of the vertical and horizontal dimension of occlusion may result in unpredictable audible changes to the voice. Patient should be informed about possible effects of modified or new denture on their new voice.

64. CONCLUSION With the increased tendency to arrange anterior teeth in an irregular mode, dentist must be aware of the consequences to phonetic impairment. Therefore , appropriate measures must be taken to correct phonetic problems. Finally , if the speech problem persists in spite of providing the patient with phonetically correct dentures, then the dentist must consider the patient’s level of education.

65. REFERENCES Zarb and bolender : speech consideration with complete denture; prosthodontic treatment for edentulous patients. Robert Rothman; phonetic consideration in denture prosthesis, J Prosthet dent 1961;11:214-223 Allen: improved phonetics in denture construction. J Pros dent. 8 753-763.1958 Sharry . Complete denture prosthodontics 3 rd edi . Phonetics. Cheierici , lawson ; clinical speech consideration in prosthodontics . J postht dent; 1973; 29; 1:29-39. Meyer M Silverman: the speaking method in measuring vertical dimention ; J Prosthet dent 1953;3: 193-199 Tikrit University College of Dentistry 4 th class/ reem prosthetic lec-16 Middle-East Journal of Scientific Research 12 (1): 31-35, 2012 ISSN 1990-9233 A Abdullah Al Kheraif and R Ramakrishnaiah Indian Journal of Dental Sciences . Speech considerations with complete denture A Kalra , M Kinra R Fahim review article

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