PERSPECTIVES
SIG 5
Review Article
The Effect of Dental and Occlusal
Anomalies on Articulation in Individuals
With Cleft Lip and/or Cleft Palate
Kazlin N. Masona
Purpose: Dental and occlusal anomalies are common in
individuals with cleft lip and palate, placing them at risk for
speech sound distortions. Speech-language pathologists
and dental practitioners frequently interact when presented
with clinical problems secondary to dental and occlusal
anomalies. This is especially true when treating a child
with a cleft lip and palate. The speech sound error types
must be identified and their etiologies evaluated to develop
appropriate management plans. The purpose of this
review article is to describe the types of dental and occlusal
anomalies that are common in individuals with cleft lip
and/or palate and discuss the impact these anomalies
have on articulation.
Method: A review of the literature was completed with a
focus on prevalence, definitions, and descriptions of dental
and occlusal anomalies in individuals with cleft lip and
palate. The impact of dental/occlusal anomalies on speech
production is described.
Results and Conclusions: There is sufficient evidence that
dental and occlusal anomalies have an impact on articulation,
but the relationship of dental or occlusal status is not always
a direct one. The phonemes most affected by aberrant oral
conditions are sibilants, though other phonemes may be
impacted as well. These speech errors are considered to be
obligatory oral distortions in that they are made in response to
an oral structural defect. These speech errors are not typically
amenable to speech therapy, but rather require orthodontic
and/or surgical correction. Such treatment can be effective in
improving these errors, often spontaneously, however, speech
therapy may be necessary (and most effective) following
correction of the dental and/or occlusal anomalies if errors
persist.
C
with isolated cleft lip. In patients presenting with both
cleft lip and palate, Akcam et al. (2010) found that 96.7%
of patients demonstrated at least one dental anomaly.
Consequently, structural anomalies found in the anterior
oral cavity and skeletal malocclusion may present added
complications for speech development in patients with
cleft lip and palate, which can exacerbate speech production
difficulties (Courtney et al., 1996; Hardin-Jones & Jones,
2005; Leavy et al., 2016; Molsted & Dahl, 1990; Satoh et al.,
2004).
Speech disorders associated with cleft lip and palate
have been well documented in the literature (Hardin-Jones
& Jones, 2005; Kuehn & Moller, 2000; Kummer, 2014;
Marshs, 2009; Peterson, 1975; Sell, 2005; Trost, 1981).
Speech production errors in children with cleft lip and palate are often grouped into categories of error types. Zajac
and Vallino (2017) presented a framework for classification
of articulation errors seen in individuals with cleft lip and
palate. Within this context, compensatory errors are considered to be active articulatory substitutions that individuals
raniofacial anomalies, such as cleft lip and palate,
often result in anatomic differences that impact
both structure and function in the craniofacial
and dentofacial complex. Furthermore, anomalies that
impact the relationship between the maxilla and mandible,
such as cleft lip and/or palate, can alter speech production.
Due to this, children with cleft lip and palate are often at
risk for speech/articulation disorders.
A high prevalence of dental and occlusal anomalies
have been reported in individuals with cleft and craniofacial
differences and these occur with greater frequency than that
which occurs in the noncleft population. Vallino et al. (2008)
documented dental and occlusal anomalies in 62% of patients
a
Department of Human Services, University of Virginia,
Charlottesville
Correspondence to Kazlin N. Mason: kazlin.mason@virginia.edu
Editor-in-Chief: Brenda L. Beverly
Editor: Brenda Louw
Received March 1, 2020
Revision received May 19, 2020
Accepted September 3, 2020
https://doi.org/10.1044/2020_PERSP-20-00056
Publisher Note: This article is part of the Forum: Consideration of
Structural Anomalies Related to Cleft and Craniofacial Conditions.
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Disclosures
Financial: Kazlin N. Mason has no relevant financial interests to disclose.
Nonfinancial: Kazlin N. Mason is the Continuing Education Content Manager for
ASHA Special Interest Group 5: Craniofacial and Velopharyngeal Disorders and
a member of the Professional Development Committee.
Perspectives of the ASHA Special Interest Groups • Vol. 5 • 1492–1504 • December 2020 • Copyright © 2020 American Speech-Language-Hearing Association
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SIG 5 Craniofacial and Velopharyngeal Disorders
Table 1. Differences between compensatory and obligatory speech errors.
Compensatory speech errors
Placement is abnormal
Learned behaviors that are amenable to therapy
Errors typically persist after surgery to correct
velopharyngeal insufficiency
Treatment: Speech therapy addressing accurate
placement
Example:
Glottal stop sound substitution for /p/
Pharyngeal stops and pharyngeal fricatives
with velopharyngeal dysfunction may produce to bypass the
anatomical or velopharyngeal deficit (Vallino et al., 2019). In
contrast, obligatory errors have been defined as unavoidable
errors that occur as a consequence of structural conditions
such as dental and occlusal anomalies or velopharyngeal
dysfunction (Vallino et al., 2019). Thus, obligatory errors
are structurally based, whereas compensatory errors are
thought to be learned. Obligatory errors and compensatory
errors are also categorized as passive or active speech errors
(Harding & Grunwell, 1998; Hutters & Brøndsted, 1987)
with obligatory errors classified as passive and compensatory
errors active (Harding & Grunwell, 1996). Table 1 illustrates
key differences between compensatory speech errors and
obligatory oral distortions.
In passive or obligatory speech errors, the manner of
the articulatory target is typically maintained, but the place
of articulation is altered resulting in a distortion of the target sound. These errors or distortions occur within the oral
cavity (Vallino et al., 2019). In contrast, active speech errors
are produced posterior to the velopharyngeal valve and used
in substitution of individual sounds or sound classes (Vallino
et al., 2019). Obligatory errors arise secondary to oral structural deviations (e.g., dental/occlusal deviations and/or palatal fistulae) or physically based oral–nasal balance/resonance
disorders (Harding & Grunwell, 1996; D. L. Jones, 2000;
Riski, 1979; Riski & DeLong, 1984; Trost, 1981). Obligatory errors related to velopharyngeal dysfunction include
hypernasality, nasal air emission, and weak oral pressure
consonants. Obligatory errors secondary to dental and occlusal anomalies are termed obligatory oral distortions.
Unlike compensatory speech errors, obligatory errors
are not readily amenable to speech therapy. Therefore, management of cleft lip and palate requires multidisciplinary
care across specialties, typically within the context of a
cleft/craniofacial team. When patients with cleft lip and/or
palate present with obligatory oral distortions, it requires an
interdisciplinary partnership between the speech-language
pathologist (SLP) and dental practitioner. Depending on
the errors present and etiologies of errors, collaboration
with differing dental practitioners (e.g., dentists, orthodontists,
and/or oral-maxillofacial surgeons) may be warranted. The
purpose of this review article is to provide an introduction to
craniofacial development in children with cleft lip and/or
palate, describe the types of dental and occlusal anomalies
Obligatory oral distortions
Placement is typically preserved
Not amenable to correction with therapy
Speech distortion errors due to abnormal structure,
typically correct following orthodontics or surgery
Treatment: Correct structure
Example:
Lateral lisp as consequence of anterior crossbitte
Distortion of sibilant targets due to airflow interference
from dental/skeletal anomalies
that are commonly seen, and discuss the impact these anomalies have on articulation. Collaboration between the dental
practitioner and SLP will be emphasized.
Orofacial Development in Patients With Cleft
Lip and Palate
In a typically developing population, the growth of
the mandible follows Scammon’s curve for general body
structures and studies have reported that the mandible
has an accelerated prepubertal and pubertal growth spurt
(Bateman & Mason, 1984; Bloomer, 1971; R. Mason &
Proffit, 1974). The tongue is reported to reach adult size
by age 8 years, mirroring the growth of Scammon’s neural
tissues (R. Mason & Proffit, 1974). Similarly, the growth
of the maxilla closely mirrors the neural growth curve and
is reported to complete its growth between 8 and 12 years
of age (R. Mason & Proffit, 1974).
In individuals with nonsyndromic cleft lip and palate,
mandibular and lingual growth appear to follow similar
trends (R. Mason & Proffit, 1974). However, maxillary
growth is frequently restricted secondary to surgical interventions for cleft lip and palate (Jolleys, 1954; Liao & Mars,
2005; Meazzini et al., 2008, 2011). These interventions can
alter both the bony and muscular structures of the craniofacial complex. Due to this, the craniofacial complex undergoes many changes following surgical interventions for
cleft lip and palate as well as changes relating to typical
developmental stages and growth patterns that occur between infancy and adolescence (Bishara, 1973; da Silva
Filho et al., 1993; Doucet et al., 2019; Jackson et al., 2020;
Mars & Houston, 1990; Reddy et al., 2017; Ross, 1970;
Shibasaki & Ross, 1969).
Children with oral clefts are at a higher risk for disorders of speech production related to underlying oral and
nasopharyngeal anomalies resulting from the cleft (Kuehn
& Moller, 2000). Furthermore, tissue deficiencies and heterogeneous anomalies of the oral cavity are common in individuals with cleft lip and palate. For example, individuals
with bilateral cleft lip and palate often demonstrate a protrusive premaxilla prior to surgical repair, which may result
in more significant dental anomalies (Long et al., 2000).
Specifically, individuals presenting with bilateral cleft lip
and palate are more likely to demonstrate a greater degree
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SIG 5 Craniofacial and Velopharyngeal Disorders
of tissue deficiency and larger nasopharyngeal volume than
individuals with unilateral cleft lip and palate (Long et al.,
2000; K. Mason & Perry, 2016). Thus, individuals with cleft
lip and palate can exhibit cleft-specific differences in craniofacial anatomy and physiology depending on the type and
severity of the cleft (Reddy et al., 2017; Tome et al., 2016).
This heterogeneity of the mechanism impacts maturation
and growth of craniofacial and dentofacial structures (Honda
et al., 2002; Ross, 1970; Subtelny & Subtelny, 1959; Tan
et al., 2012).
The maxilla is the primary bony structure involved
in clefting, and a hypoplastic and/or retrusive maxilla is
commonly observed. The degree of maxillary hypoplasia
and/or retrusion is related to the cleft type as well as the
timing and type of surgical management received. In unilateral cases, medial collapse of the maxillary arch can create misalignment of the bony maxillary segments (Peat,
1974). This problem frequently results in the development
of dental and occlusal anomalies, such as an anterior crossbite on the side of the cleft. In contrast, the premaxilla is
often protrusive prior to repair for patients with bilateral
cleft lip and palate. Following repair, forward growth of
the maxilla and alveolar segments may be reduced due to
hypoplasia of the structures and the restrictive effects of
surgical intervention (Reiser et al., 2011, 2010). The mandible is not directly impacted by clefting; however, positioning of the mandible can be altered by the horizontal
and vertical alignment of the maxilla (Wolford & Stevao,
2002). Additionally, maxillary hypoplasia may give an appearance of a prognathic mandible in a child with a cleft
(Molina & Figueroa, 1999; Ogasawara et al., 2002). Therefore, the SLP needs to re-evaluate a child with a cleft lip
and palate at staged intervals with a focus on when changes
are likely to occur and how surgical, dental, and other
management procedures are likely to impact articulatory
development and velopharyngeal function.
Dental and Occlusal Anomalies Associated
With Cleft Lip and Palate
Dental deviations observed in individuals with cleft
lip and/or palate can also be seen in individuals without
cleft lip and/or palate. The differences, however, relate to
the severity, frequency, and location of dental anomalies.
Furthermore, this relationship is variable due to individual
subject differences. Studies have reported relationships between severity of clefting and number of dental anomalies
(Akcam et al., 2010; Qureshi et al., 2012; Tannure et al.,
2012). Dental deviations can arise secondary to the cleft lip
and/or palate or following surgical intervention for the cleft.
Occlusal anomalies, related to the relationship between the
maxillary and mandibular arches, can also occur in both
cleft and noncleft populations (Akcam et al., 2010; Vallino
& Tompson, 1993). For those with cleft lip and/or palate,
severity is often related to the type and location of the cleft.
These occlusal relationships may be related to dentition
and/or skeletal anomalies of the dental arches. Occlusal
defects and dental anomalies observed in individuals
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with cleft lip and/or palate will be defined and described
below.
Occlusal Defects Associated With Cleft Lip and Palate
Occlusal defects are problems related to the relationship between the upper and lower jaws. Occlusal defects
can be dental (related to the teeth alone) or skeletal (involving the relationship between the maxilla and/or
mandible). A classification system to define occlusion
and malocclusion was designed by Angle (1899), and, despite debate on how this system may best be applied and
adapted in modern clinical practice (Katz, 1992a, 1992b),
it continues to be referenced today. In normal occlusion,
the maxillary arch is larger and fits over the mandibular
arch. In the population of individuals with cleft lip and
palate, this is not often the case due to maxillary hypoplasia from the cleft itself as well as consequences of surgical
interventions (Vargervik, 1983).
In Angle’s system, the maxillary and mandibular first
molars serve as reference points to define the occlusal relationship. Furthermore, while Angle’s system references the
occlusal relationship of the maxillary and mandibular molars, it is additionally important to take into account how
the orientation of the skeletal maxillary and mandibular
arches impact both dentition and the overall dentofacial
complex. Accordingly, alignment/occlusion of the anterior
and posterior dentition (as seen in crossbite and open bite
relationships) is often directly related to alignment of the
cranium, maxilla, and the mandible (Bloomer, 1971; Leavy
et al., 2016).
Class I. This occlusal pattern is often referred to as a
“neutroclusion,” and the arch relationship is normal, but
misalignment of the anterior teeth may still be present. In
a Class I occlusal pattern, the mesial buccal cusp of the
maxillary first molar is typically positioned to the buccal
groove of the mandibular first molar (see Figure 1). When
anterior dentition is misaligned, but occlusal relationship is
appropriate, this pattern may be termed as “Class I malocclusion” (Christie, 1977; Katz, 1992b).
Class II. A Class II occlusal pattern has the mesial
buccal cusp of the maxillary first molar positioned anterior
to the buccal groove of the mandibular first molar. This may
be referred to as a “distoclusion.” This occlusal relationship is less common in individuals with cleft lip and palate;
however, children with Stickler syndrome, Pierre Robin
sequence, or mandibulofacial dysostosis (Treacher Collins syndrome) may demonstrate a Class II malocclusion (Kamioka
et al., 2007; Suri et al., 2010; Vallino-Napoli, 2002). If misalignment of the maxillary and mandibular arches is present, a patient may be labeled as having a “retrognathic”
mandible and/or “prognathic” maxilla, depending on the
overall craniofacial profile.
Class III. In a Class III occlusal pattern, or “mesioclusion,” the mesial buccal cusp of the maxillary first molar is
positioned posterior to the buccal groove of the mandibular
first molar. This can arise secondary to maxillary hypoplasia
and/or a prognathic mandible (Ellis & McNamara, 1984;
Guyer et al., 1986; Meyer-Marcotty et al., 2011). Class III
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SIG 5 Craniofacial and Velopharyngeal Disorders
Figure 1. A normal Class I occlusal relationship. Arrows identify the relationship between the maxillary and
mandibular molars.
malocclusions may be observed in individuals with cleft lip
and palate who demonstrate significant midface hypoplasia
(Vargervik, 1983). Garrahy et al. (2005) noted a Class III
occlusal relationship occurred in 31.3% of children with bilateral cleft lip and palate, compared to 9.1% of children
with unilateral cleft lip.
Crossbites. The overlap of the maxillary arch with
the mandibular arch is reversed when a crossbite is
present (Garrahy et al., 2005; Pruzansky & Aduss, 1964;
Wangsrimongkol & Jansawang, 2010), resulting in a maxillary tooth or teeth that rest inside the mandibular arch. This
arrangement is frequently seen in patients with Class III
malocclusion. Maxillary hypoplasia and restricted maxillary width often contribute to this configuration (Figueroa
& Polley, 2007). Anterior crossbites occur when the central incisors, lateral incisors, and/or canines rest inside the
mandibular incisors. A posterior crossbite occurs when
the teeth posterior to the canines rest inside the mandibular teeth. Crossbites can be right-sided, left-sided, or bilateral. A crossbite of one or more teeth on the side of the
cleft often occurs in the primary dentition of patients with
cleft lip and/or palate (Leavy et al., 2016). Figure 2 provides one example of a crossbite after alveolar bone grafting in an individual with unilateral cleft lip and palate.
Open bite. Subtelny and Sakuda (1964) defined an
open bite as an opening in the vertical dimension of the
maxillary and mandibular teeth (i.e., these teeth do not
make contact when in a centric occlusion). An open bite
can occur in the anterior and/or posterior dentition and
may be a result of dental etiologies (such as thumb sucking
or poor dental eruption) and/or skeletal etiologies (such
as poor facial growth). Class II and III occlusal anomalies
can coexist with an open bite relationship. Open bites can
have a significant impact on articulation. An anterior open
bite may be present in patients with Treacher Collins syndrome. Within this syndrome, the mandible is hypoplastic
with a downward curvature of the lower border of the
mandible. As a consequence, these individuals typically
develop a Class II skeletal open bite malocclusion (da Silva
Dalben et al., 2006; Martelli-Junior et al., 2009). Figure 3
demonstrates an example of a skeletal Class III malocclusion
with an open bite. The malocclusion is termed a “skeletal”
Class III malocclusion since the discrepancy between the upper
and lower dentition is related to either an overdevelopment
of the mandible or a retrusive position of the maxilla. In this
Figure 2. (A) The left lateral incisor has erupted in an anterior
crossbite and the canine is erupting in crossbite as well. (B) Left
sided view of the dental arch. Note the maxillary posterior and
canine crossbite. Image and caption courtesy of Robert Mason,
DMD, PhD.
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SIG 5 Craniofacial and Velopharyngeal Disorders
Figure 3. A skeletal Class III malocclusion (arrows) with an open
bite. Note the horizontal relationship of upper and lower canines
and first molars as well. Image and caption courtesy of Robert
Mason, PhD, DMD.
example, the mandible is overdeveloped, and thus, the open
bite and malocclusion involved is a product of the jaw
disparity.
Dental Anomalies Associated With Cleft Lip and Palate
Dental anomalies refer to abnormalities in a tooth or
several teeth that have deviated in form, number, or position.
Specific anomalies related to dentition play a role in the
potential for speech production difficulties for individuals
with cleft lip and palate. The severity of clefting and number
of dental anomalies present are typically correlated. Dental
anomalies were found to be 7 times more prevalent among
patients with cleft lip and palate than the general population
(Lopes et al., 1991). More than 93% of patients with unilateral cleft lip and palate and 96% of patients with bilateral
cleft lip and palate present with at least one dental anomaly
(Akcam et al., 2010; Qureshi et al., 2012; Tannure et al.,
2012). The congenital absence of the cleft-sided lateral incisor has been observed in 40%–50% of patients with both unilateral and bilateral cleft lip and palate (Lourenço Ribeiro
et al., 2003; Rullo et al., 2015). In a cohort of 201 patients
with unilateral cleft lip and palate and unilateral cleft lip
and alveolus, Jamilian et al. (2016) identified the upper left
lateral incisor as the most frequently missing tooth and this
corresponded with the location of the cleft. In a study of
patients with isolated cleft palate, Margareta, Rune, and
Olafur (1998) identified a higher frequency of agenesis of the
mandibular second premolar, followed by the maxillary lateral incisor, and the upper second premolar. Consequently,
dental anomalies are specific to the type and location of the
cleft or may arise as a result of surgical intervention. Cleftspecific relationships of the central and lateral incisors,
as well as missing, malpositioned, or malformed teeth have
additionally been reported (Akcam et al., 2010; Camporesi
et al., 2010). Anomalies of dentition frequently seen in
individuals with cleft lip and palate include missing teeth
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(hypodontia), supernumerary teeth, natal teeth, ectopic teeth,
malpositioned teeth, crossbites, and open bites (Shprintzen
et al., 1985). Fistulae in the anterior oral cavity may be present as well and must be assessed as these also demonstrate
the potential to impact speech production depending on the
severity and location.
Missing teeth (hypodontia). Hypoodontia, or congenitally missing teeth, are common in the primary dentition
of patients with cleft lip and palate (Lopes et al., 1991).
Missing teeth have been reported to be directly related to
severity and location of the cleft, with a higher likelihood
of hypodontia occurring in more severe forms of clefting
(Lopes et al., 1991). Most often, the lateral incisor neighboring the cleft is affected (Bishara et al., 1985).
Supernumerary teeth. Supernumerary teeth, or additional teeth that are present beyond the typical deciduous
or permanent dentition, have been reported to occur in approximately 16%–22% of patients with cleft lip and palate
(Lopes et al., 1991; Vichi & Franchi, 1995). Lourenço et al.
(2003) report this as the second most common anomaly
found in patients with cleft lip and palate. These teeth are
frequently located near the site of the cleft, but can also
be found posteriorly along the maxillary and mandibular
arches. Most commonly, these can be present in the maxilla,
distal to the cleft in the premaxillary area.
Natal teeth. Natal teeth occur in approximately 2%
of infants with unilateral cleft lip and palate and 10% of
infants with bilateral cleft lip and palate (Leung & Robson,
2006). Natal teeth represent the early eruption of primary
deciduous teeth and are reported to occur along the maxillary
incisal area of individuals with cleft lip and palate. These teeth
are present when the child is born, often demonstrate hypoplastic enamel, and are mobile in nature (Leung & Robson,
2006). Presence of natal teeth may impact successful use of
presurgical orthodontics, such as nasal alveolar molding,
and require careful extraction (Ziai et al., 2005).
Ectopic teeth. Ectopic teeth are those that erupt in an
abnormal location. In individuals with cleft lip and palate,
eruption adjacent to or within the cleft site is common.
Ectopic eruption has been reported to range between 2%
and 6% for the maxillary first molars and between 1% and
2% for the permanent canines (Barberia-Leache et al., 2005;
Fox et al., 1995). For individuals with cleft palate only,
ectopic eruption occurs more frequently in the premolar
region (Margareta et al., 1998).
Malpositioned teeth. Rotated eruption of the permanent central and lateral maxillary incisors typically occur
adjacent to the cleft as a result of altered development (i.e.,
clefting) along embryological suture lines (Braumann et al.,
2002; Letra et al., 2007). Malpositioned teeth are very common in children with cleft lip and palate. Approximately
16% of children with cleft lip and palate and 7% of children
with cleft palate only demonstrate malpositioned maxillary
teeth (Filho et al., 2015).
Positive or negative overjet. These terms are used to
describe the horizontal relationship between the anterior
dentition. An overjet can be related to the positioning of
the teeth alone (dental defect) or associated with occlusal
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SIG 5 Craniofacial and Velopharyngeal Disorders
misalignment. When associated with malocclusion, a positive
overjet is commonly present with a Class II malocclusion.
A negative overjet (or underjet) is commonly correlated
with a Class III malocclusion and an anterior crossbite.
Overbites and underbites. An overbite or underbite is
used to describe the vertical relationship between the anterior
dentition. When the maxillary incisors overlap more than
25% of the mandibular incisors, an overbite is present. An
underbite is present when the mandibular incisors overlap
the maxillary incisors. Underbites may be observed with
a Class III malocclusion while overbites may be seen with a
Class II malocclusion.
Other Contributors to Articulatory Distortions
in Cleft Lip and Palate
Appliances. Palatal expanders are often placed during
the mixed dentition stage (between 6 and 9 years of age) to
facilitate maxillary expansion in children with cleft lip and
palate. The quad helix device may impact articulatory placement for tongue tip alveolar consonants. However, a rapid
palatal expander (see Figure 4) does not typically interfere
with articulation given where it is positioned in the oral cavity. Any speech distortion that arises from dental appliances
typically resolves once the appliance is removed.
Palatal fistulae. Palatal fistulae can occur along embryological fusion lines or surgical suture sites post–palate
repair due to a breakdown or dehiscence of tissue (Cohen
et al., 1991; Parwaz et al., 2009; Stein et al., 2019). A palatal fistula may also occur as a result of palatal expansion.
The impact of a fistula on speech production is highly variable and dependent on size and location (Karling et al.,
1993). For example, a fistula located at the junction of the
hard and soft palate will result in more significant speech
production difficulties than a small pinhole fistula along
the alveolar ridge. These small fistulae in the alveolar ridge
may have absent or minimal impact on speech in individuals with cleft lip and palate (Karling et al., 1993).
Figure 4. Image of a palatal expander.
Importance of Identifying Dental and Occlusal
Status for SLPs
Identification and documentation of the dental and
occlusal status is important for SLPs to assess as it guides
recommendations and treatment (i.e., “Are the articulation
errors I’m detecting able to be remediated with therapeutic
measures or is their etiology related to a structural anomaly? Is a referral for an alternate orthodontic, prosthetic,
or surgical management route needed?”). Assessment of
dental and occlusal status can be completed during the oral
exam. To assess dentition, ask the child to “bite/close your
teeth and smile.” To visualize the occlusal relationship, clinicians can use a tongue blade to retract the cheek and visualize the posterior molar relationships. Figure 5 presents
an example of the multiple dental and occlusal anomalies
that could occur in a single patient. As will be discussed
below, when speech errors are obligatory to underlying
dental or occlusal defects, speech therapy is not typically
warranted.
Relationship Between Speech Production and Dental/
Occlusal Anomalies in Cleft Lip and Palate
According to Kummer (2020), “…when there is normal dental and occlusal relationships, the lips come together
easily at rest, the lower lips are able to approximate the maxillary teeth for labiodental sounds, and the jaws (both the
maxilla and mandible) are appropriately aligned so that the
tongue tip rests under the alveolar ridge and behind the maxillary incisors.” For individuals with cleft lip and palate, these
ideal relationships are not always achieved, resulting in
articulatory distortions, adaptations, and compensations.
Articulation of consonants is determined therefore, in part,
by the relationships of the dentition, maxillary and mandibular arches, and hard palate. The majority of speech sounds
are produced in the anterior oral cavity and the dental arch
Figure 5. Dental and occlusal anomalies in patient with repaired
unilateral complete cleft lip and palate demonstrating an anterior
and posterior crossbite, collapsed maxillary arch, rotated and
malpositioned incisors, congenitally absent lateral incisor on the
right, absent premolars, and suspected ectopic eruption of the
left lateral incisor along the cleft suture in the alveolar ridge.
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SIG 5 Craniofacial and Velopharyngeal Disorders
relationship is an important factor in articulatory placement
and intelligibility (Johnson & Sandy, 1999; Subtelny &
Subtelny, 1959; Vallino & Tompson, 1993). Consequently,
due to anatomical differences in the oral cavity arising from
a cleft, children with cleft lip and palate typically demonstrate poorer articulation skills than children without cleft
palate or with cleft lip only (Chanchareonsook et al., 2006;
Kuehn & Moller, 2000; Kummer, 2014; Riski & DeLong,
1984). For example, a cleft that includes the alveolus may
alter articulatory contacts for the tongue tip. In cases of
bilateral cleft lip and palate, the premaxilla may be significantly protrusive and the ability to achieve a bilabial seal
can be impacted for /p, b, m/. Maxillary collapse associated
with both unilateral and bilateral cleft lip and palate may
contribute to these difficulties as well as occlusal misalignment, missing or malpositioned teeth, ectopic eruption, and
the presence of supernumerary teeth in the palatal region.
Impact of Dental and Occlusal Anomalies
on Speech Production
Dental anomalies. Anomalies of the dentition, in the
absence of occlusal, velopharyngeal, or other craniofacial
differences are less likely to result in significant articulatory
deficits. However, when dental variations occur in conjunction with the craniofacial differences commonly seen in individuals with cleft lip and palate, such as arch malformations
or velopharyngeal insufficiency, the potential impact on
speech production is increased (Subtelny, 1964; Laine
et al., 1988).
The likelihood of dental anomalies being present
during critical periods of speech development is increased
for children with cleft lip and palate (Harding & Grunwell,
1996; Vallino et al., 2008). Ectopic eruption and supernumerary teeth can pose difficulties for speech production
depending on their location and severity. It is common
for the incisors of individuals with cleft lip and palate to
be displaced posteriorly or erupt in the palate, which may
impact the production of lingua-palatal phonemes (Gable
et al., 1995; Leavy et al., 2016). An anterior crossbite can
also impact placement of the tongue tip, secondary to interference from the maxillary incisors, which results in an
obligatory lateral distortion or frontal distortion. Rotated
and misaligned teeth can also impact production of centralized oral airflow resulting in obligatory speech errors.
The severity of speech production difficulty has been reported to increase when multiple dental anomalies occur
simultaneously (Akcam et al., 2010; Peterson-Falzone,
1988, 1995).
Occlusal anomalies. Malocclusion of the maxillary
and mandibular arches have the potential to impact articulation. However, the true influence on speech production
is often multifactorial, and many occlusal, dental, and/or
velopharyngeal anomalies may co-occur to alter the overall
function of the articulatory system and severity of the speech
deficit (Kummer, 2016; Vallino et al., 2008). Maxillary arch
width has been reported to contribute to errors in speech
production (Laitinen et al., 1998; Zajac et al., 2012). Poorer
articulatory accuracy has been documented in children with
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a narrower maxillary arch in comparison to the mandibular
arch (Vallino & Tompson, 1993). Severe maxillary protrusion, seen in Class II malocclusions, can impact bilabial closure needed to produce /p/, /b/, and /m/ phonemes, resulting
in a labiodental production for these targets. Mandibular
protrusion or maxillary retrusion, seen in Class III malocclusions, demonstrates similar speech consequences.
The palatal vault is often narrow in Class III malocclusions associated with both unilateral and bilateral cleft
lip and palate, and the restricted arch width may impact
tongue placement for sibilant and affricate phonemes (R.
Mason & Proffit, 1974). Articulatory distortions related
to dental open bites and crossbites can be exacerbated by
skeletal malocclusion as well. Anterior open bites, resulting
from significant arch anomalies, can result in interdental
distortions of sibilant targets. Posterior open bites may result in lateral or retroflex distortions (Yamashita & Michi,
1991). Furthermore, both a Class II and Class III malocclusion can reduce the vertical dimension of the anterior
oral cavity causing lingual crowding and the potential for
obligatory lateral distortion of sibilant phonemes (Kummer,
2020). See Table 2 for a summary of dental and occlusal
anomalies and the potential resulting articulation error(s).
Phonemes Frequently in Error
Fletcher (1978) examined the speech sound production skills of a group of children with cleft lip and palate
through the use of factor analysis. In these individuals, it
was reported that children with cleft palate produced sibilants
(/s, z, ʃ, ʒ/) in error 47% of the time. Nonsibilant fricatives
(/θ, ð, f, v/) were produced in error 24% of the time, and
plosive targets (/p, b, t, d, k, g/) were produced in error 17%
of the time. The speech sound /s/ was the most frequently
misarticulated target (Fletcher, 1978). Additional studies
have reported similar results related to articulation abilities
in children with cleft lip and palate (C. Jones et al., 2003;
Morris & Ozanne, 2003; Subtelny & Subtelny, 1959; Whitehill & Chau, 2004). Vallino and Tompson (1993) identified
consonant errors across four occlusal patterns. Individuals
demonstrating a Class II malocclusion, with and without
open bite, produced /s, z/ in error at a rate of 90% and /ʃ,
ʒ, tʃ, dʒ/ in error at a rate of 46%–48%, and /p, b, m/ in error at a rate of 9%–11%. Consequently, phonemes commonly impacted by malocclusion and dental anomalies
are those produced in the anterior area of the oral cavity
and typically include /t, d, f, v, s, z, ʃ, ʒ, tʃ, dʒ/ (C. Jones
et al., 2003; Lohmander & Olsson, 2004; Subtelny & Subtelny, 1959; Vallino & Tompson, 1993).
Obligatory Articulation Errors Secondary to Dental
Anomalies and Malocclusion
Obligatory articulation errors result in perceptual
distortions of speech sounds secondary to lateral direction
of airflow and interdental, retroflex, or lingual placement
(Yamashita & Michi, 1991). For example, production of
sibilant targets /s/ and /z/ may be produced with what appears as an anteriorly displaced tongue position (lingual
protrusion); however, the Class III malocclusal relationship
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SIG 5 Craniofacial and Velopharyngeal Disorders
Table 2. Impact of dental and occlusal anomalies on speech.
Dental or occlusal
anomaly
Missing teeth
Phonemes impacted
Resulting obligatory speech error(s)
/s, z/
Depending on location, lateralization, or interdentalization (frontal lisp) of sibilants
targets may occur (/s, z/).
Distortion of sibilants, lingual–alveolar, and lingual–palatal consonants may occur
when teeth are rotated. This can interfere with airflow and tongue placement for
alveolar targets (/s, z, ʃ, ʒ , t, d/).
If located in the premaxilla or anterior palate, may alter tongue placement of lingual–
alveolar consonant targets (/t, d, s, z, n, l/).
Malpositioned or
rotated teeth
/s, z, ʃ, ʒ, t, d/
Ectopic and
supernumerary
teeth
Crossbite
(anterior and/or
posterior)
Open bite
/t, d, s, z, n, l/
/f, v, s, z, ʃ, ʒ, tʃ, dʒ/
/m, p, b, t, d, s, z, n, l/
Overbite or Underbite
/s, z, ʃ, ʒ/
Class II malocclusion
/p, b, m/
Class III malocclusion
/p, b, m, f, v, s, z, ʃ, ʒ,
tʃ, dʒ/
Lateralization of sibilant and affricate targets (/s, z, ʃ, ʒ, tʃ, dʒ/) may occur. If severe,
labiodental phonemes (/f, v/) may be produced as a reverse labiodental.
Difficulty approximating lips for bilabial targets in severe Class II and Class III malocclusion.
May result in labiodental production of bilabial targets (/p, b/) and interdental distortion
of lingual–alveolar targets (/t, d, s, z, n, l/).
A shortened vertical dimension may result in lingual crowding or lateral distortion of
sibilant targets (/s, z, ʃ, ʒ).
May impact bilabial closure of /p, b/ due to inability of upper lip to approximate lower
lip. Approximation of these consonants may be obtained by approximating the lower
lip with the maxillary central and lateral incisors with a mild auditory and visual
distortion.
May demonstrate difficulty approximating lips for bilabial targets.
May result in labiodental production of bilabial targets (/p, b/), interdental production
of sibilants (/s, z/), and reverse labiodental production of fricatives /f, v/.
Affricates /ʃ, ʒ, tʃ, dʒ/ may be impacted by lateralized and retroflex distortions from
the maxillary dentition.
is the cause of the anterior tongue position. This results in
an obligatory interdental distortion. Given that the position
of the tongue is directly influenced by the oral cavity, this
obligatory error is unavoidable and a Class III malocclusion
causes the interdental positioning of the tongue for alveolar
targets. Obligatory distortions of affricate phonemes may
demonstrate similar interdental productions, as a result of a
Class III malocclusion, with lingual protrusion resulting in
lateralized productions of /tʃ, dʒ/. Class II malocclusions with
or without skeletal open bites can also result in interdentalized sibilants, and, in extreme cases, bilabial stops may
be produced labiodentally. Daniloff et al. (1980) found interdental productions such as this resulted in less acoustic
energy distributed across a broader frequency range, which
would explain perceptual differences heard in these obligatory productions. An anterior crossbite can impact sibilants
and lingual–alveolar targets as well, resulting in obligatory
lateral distortions. In this case, the dorsum of the tongue
may articulate with the maxillary incisors causing lateralization of airflow for sibilant and lingual–alveolar targets.
Vallino et al. (2019) also make an argument for classifying palatalized tongue tip alveolar stops (/t, d/), when
produced with the dorsum of the tongue and tongue tip
down, as an obligatory oral distortion, particularly when
other tongue tip alveolar targets are impacted (e.g., /l, n/).
The authors cite reduced maxillary arch width commonly
associated with a Class III malocclusion, eruption of teeth
in the anterior palate, and/or oronasal fistulae as potential
structural causes for this distortion. This error is often difficult to identify accurately, and SLPs should carefully inspect the articulatory contacts for these targets.
Visual distortions have been described by Vallino
and Tompson (1993). Visual distortions may also arise as
a result of dental and occlusal anomalies. When a visual
distortion is present, despite the abnormal appearance of
the obligatory articulatory production, the target generally
maintains many of the perceptual and acoustic features.
For example, an anterior crossbite with Class III malocclusion may obligate an individual to produce a bilabial
fricative or a reverse labiodental production for /f/ and /v/
phonemes (Harding & Grunwell, 1995). The lower lips
may also articulate with the upper teeth for bilabial stops
and nasals (/p, b, m/; Valling, 1990; Vallino & Tompson,
1993). Children with cleft lip and palate may additionally
demonstrate a lateral shift of the mandible when attempting sibilant productions (/s, ʃ, tʃ, dʒ/), as a result of anterior
dental and occlusal anomalies (Harding & Grunwell, 1996;
Vallino & Tompson, 1993). Visual errors of this nature
do not typically result in distortions of the acoustic signal.
These visual distortions are the result of attempting to produce appropriate oral speech sounds while meeting the
demands of rapid, conversational articulation, despite the
structural deficits presented by a skeletal or dental malocclusion related to the cleft lip and palate.
In a discussion of Vallino and Tompson’s study, Warren
(1993) elaborated on how the nature of visual distortions highlights the “highly regulated and precise process of coordination and integration” of the speech structures. He speculated
that, in the presence of malocclusion, the speech subsystem is
required to adapt to the structural deficit to maintain oral pressure at an appropriate level. He argued that “visual distortions
may in fact be successful adaptations in placement.” Others
Mason: Dental Anomalies and Obligatory Speech Errors
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SIG 5 Craniofacial and Velopharyngeal Disorders
have referred to these visual errors as adaptive compensations
(LeBlanc & Cisneros, 1995; Leblanc & Golding-Kushner,
1992; Peterson-Falzone et al., 2001). Golding-Kushner
(1995) noted that these errors are the “closest possible
approximation of a sound in the presence of an anatomic
deviation.” In many cases, however, these visual distortions are passive and not active articulatory changes. These
errors also differ from compensatory/maladaptive errors,
given that they remain in the oral cavity and perceptual/
acoustic characteristics are generally preserved. Obligatory
errors of this nature may or may not resolve once the
anatomic relationship between oral structures is corrected.
Additional research is needed for this unique class of errors
to more fully understand the articulatory response to these
anatomic differences.
Clinical Implications: To Treat or Not to Treat?
Generally, when structural deficits are the cause of a
speech error, the error will not respond to speech therapy.
Production of these targets are likely to improve with dental
and/or orthognathic management. For example, orthognathic surgery to improve a Class III malocclusion can result in improved articulation of sibilants without the need
for speech intervention. Palatal expansion by the orthodontist may cause a temporary increase in sibilant distortions,
but once the child adapts to the expander, speech generally
returns to baseline without direct intervention. However,
Peterson-Falzone et al. (2001) note that some individuals
“may benefit from traditional placement therapy techniques
to eliminate mild distortion errors despite the dental or occlusal anomalies that are present.” Generally, the majority
of patients will be unable to eliminate these errors until orthodontic or orthognathic management is completed. It remains
difficult to predict when this will be the case. Therefore,
a thorough assessment and/or diagnostic therapy may be
beneficial to facilitate this determination and make referrals
as needed.
Successful management relies heavily on the contributions of many professions. For obligatory oral distortions,
coordination between dental, orthodontic, and speechlanguage practitioners is necessary. Delineation of treatment goals, coordination and timing of treatment across
specialties, and maintenance of coordinated follow-up is
enhanced through this multidisciplinary process. For patients
who may be candidates for orthognathic surgery, pre- and
postoperative speech evaluations are necessary (American
Cleft Palate-Craniofacial Association, 2018). When articulation deficits are present in children with cleft lip and/or
palate, part of the SLP’s role is to identify if what is being
perceived during speech production tasks is truly an obligatory distortion or another type of speech error (compensatory
or developmental) and to determine appropriate intervention
plans (e.g., surgical, dental, speech-language therapy).
The oral exam and speech sample are key to making
this determination. Trost-Cardamone (2013) has developed a guide specifically related to obtaining speech samples in children with cleft lip and palate. The American
1500
Speech-Language-Hearing Association’s (ASHA) Practice
Portal provides an in-depth hierarchy for evaluating speech
and resonance in children with cleft lip and palate (ASHA,
n.d.). Vallino-Napoli (2004) has additionally developed a
process model and flow chart that outlines assessment tasks
for this population. The most recent edition of Kummer’s
textbook further provides a video library of resources and
speech samples to reference for self-study (Kummer, 2020).
These resources, in combination with informational sessions presented annually by ASHA’s Special Interest Group
(SIG) 5: Craniofacial and Velopharyngeal Disorders, provide a framework to facilitate these clinical decisions.
Conclusions
The majority of speech sounds in English are produced
in the anterior area of the oral cavity. Therefore, the presence of a cleft lip and palate has the potential to significantly
alter the anatomic relationships of structures within the oral
cavity, resulting in articulatory distortions secondary to
dental and occlusal anomalies. There is sufficient evidence
that dental and occlusal anomalies have an impact on articulation, but the relationship of dental or occlusal status
is not always a direct one (Leavy et al., 2016; PetersonFalzone & Graham, 1990; Vallino & Tompson, 1993).
The phonemes most affected by aberrant oral conditions
are sibilants, though other phonemes may be impacted
as well. These speech errors are considered to be obligatory oral distortions in that they are made in response to
an oral structural defect. These speech errors are not typically amenable to speech therapy, but rather require orthodontic and/or surgical correction. Such treatment can be
effective in improving these errors, often spontaneously
(Golding-Kushner, 2004; Harding & Grunwell, 1995, 1998;
Valling, 1990; Vallino et al., 2008). However, speech therapy may be necessary (and most effective) following correction of the oral defects if errors persist (Zajac & Vallino,
2017). Given that obligatory oral distortions frequently
co-occur with other articulation errors (e.g., compensatory
speech errors, developmental articulation disorders), as well
as resonance disorders, SLPs should carefully identify and
assess these errors. Collaboration with the craniofacial team
and dental professionals is necessary to coordinate care and
provide appropriate intervention for these patients.
Acknowledgments
The author would like to acknowledge Bob Mason for his
contributions to this review article.
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