Citation
An x-ray study of unrepaired, complete cleft palate oral- pharyngeal structures and their functioning during vowel phonation

Material Information

Title:
An x-ray study of unrepaired, complete cleft palate oral- pharyngeal structures and their functioning during vowel phonation
Creator:
Knobeloch, F. X. Calvin, 1925-
Publisher:
[s.n.]
Publication Date:
Language:
English
Physical Description:
v, 68 leaves. : illus. ; 28 cm.

Subjects

Subjects / Keywords:
Cleft palate ( lcsh )
Speech disorders ( lcsh )
Speech thesis Ph. D ( lcsh )
Dissertations, Academic -- Speech -- UF ( lcsh )
Genre:
bibliography ( marcgt )
non-fiction ( marcgt )

Notes

Thesis:
Thesis - University of Florida.
Bibliography:
Bibliography: leaves 64-67.
General Note:
Manuscript copy.
General Note:
Vita.

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18315681 ( OCLC )

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Full Text
An X-Ray Study of Unrepaired, Complete Cleft
Palate Oral-Pharyngeal Structures and Their
Functioning During Vowel Phonation
By
F. X. CALVIN KNOBELOCH
A DISSERTATION PRESENTED TO THE GRADUATE COUNCIL OF
THE UNIVERSITY OF FLORIDA
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE
DEGREE OF DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA August, 1959




ACKNOWLEDGMENTS
The writer wishes to express his gratitude and indebtedness to Dr. McKenzie Buck, chairman of his supervisory committee, who has been a constant source of encouragement and inspiration. As a member of the national research group which conducted the parent study, Dr. Buck arranged for the use of the X-ray plates and tape recordings utilized for purposes of analysis in this study.
The writer would also like to express his sincere
appreciation to Professor H. P. Constans who, as the original chairman of his supervisory committee, has been most helpful with his advice and cooperation in the planning of the writer's doctoral program.
Further expression of appreciation is extended to
Dr. J. M. MacLachlan and Dr. W. W. Ehrman~n of the Department of Sociology, and to Dr. L. L. Zimmerman and Dr. C. K. Thomas of the Department of Speech, for their cooperation as members of the writer's supervisory committee. In addition, the writer would like to extend his thanks to Dr. R. E. Tew and Dr. D. A. Harrington, who were original members of his supervisory committee.
Special expression of appreciation is extended to Frank E. Law, D.D.S., Chief, Operational Research Branch, Division of Dental Public Health, Washington, D.C., who organized the study team which collected the raw data for the present study. The writer would also like to express special appreciation to the citizens of Puerto Rico who participated in the study.
The acknowledgments for this study would be wholly inadequate without an expression of appreciation to the writer's wife for her devotion, encouragement, cooperation, ii




and understanding during his doctoral program. Although they are too young to realize, the writer is indebted to his children for the source of inspiration which they are.
iii




TABLE OF CONTENTS
Page
ACKNOWLEDGMENTS . . . . . . . . . ii
LIST OF TABLES . . . . . . . . . v
Chapter
1. INTRODUCTION . . . . . . . . 2.
II. DESCRIPTION OF PROCEDURE . . . . . 1.0
Selection and Matching of Subjects . . 10
Procedure for Recording and Analysis of
Speech Samples . . ... .. .. .. 12
Apparatus and Procedure for Obtaining
X-ray Plates .. .. .. ... .. .. 15
Measurements of the X-ray Plates . . . 18
III. RESULTS . . . . . . . . . 23
Facial and Oral Cavity Dimensions . . . 23
Measurements Related to Tongue Size and
the Horizontal Position of the High
Point ofthe Te gu. . .. .. .. 27
Vertical Tongue Position . .~ .. 31
Excursion of the Tongue from Rest to
Vowel Positions .. .. ... .. . 35
Measurements of the iNaso-pharyngeal
Structures . . . . . . 0 0 0 39
Lip and MhOpening pe... . . . .. 47
Analysis of Speech Samples .. .. . ... 51
IV. SUMMARY AND CONCLUSIONS .9.99.9..9999. 56
V. DISCUSSION .. .. .... .. ... 60
LIST OFREFERENCES .. .. .. .. .. .. . 64
iv




LIST OF TABLES
Table Page
1. MEASUREMENTS OF MAXILLA, MANDIBLE, ORAL
CAVITY, AND DISTANCE FROM TERMINATION OF HARD PALATE TO POSTERIOR PHARYNGEAL WALL
AT REST . 24
2. MEASUREMENTS RELATED TO TONGUE SIZE AND
HORIZONTAL POSITION OF HIGH POINT OF TONGUE
ON INCISAL REFERENCE LINE. . . . . . 28
3. MEASUREMENTS OF THE PHARYNGEAL OPENINGS ON
AND BELOW THE INCISAL REFERENCE LINE . . 30
4. VERTICAL MEASUREMENTS OF TONGUE HEIGHT . . 32
5. MEASUREMENTS OF MOVEMENT OF TONGUE FROM
REST TO VOWEL POSITIONS . ......... 36
6. MEASUREMENTS OF OPENING OF THE VELO-PHARYNGEAL
STRUCTURES AND AREA OF POSTERIOR PHARYNGEAL
WALL AT THE LEVEL OF THE TUBERCLE OF THE ATLAS 40
7. MEASUREMENTS OP MOVEMENT OF THE POSTERIOR
PHARYNGEAL WALL AT THE LEVEL OF THE TUBERCLE
OF THE ATLAS . . . . . . . . 43
8. MEASUREMENTS OF LIP AND MOUTH OPENING AT REST
AND PHONATION . . . . . . . . 48
9. COMPARISON OF ARTICULATION SCORES AND QUALITY
RATINGS OF INDIVIDUALS WITH UNREPAIRED CLEFT
PALATES . . . . . . . . . . 55
V/




CHAPTER I
INTRODUCTION
Various scholars have used the X ray in speech investigations since its discovery in 1895, according to Parmenter and Trevino (19). Of primary significance, at least in terms of stimulating thought and further investigation, were the studies of Russell (21, 22, 23). He utilized X-ray techniques in his studies of vowel and consonant production in normal subjects.
Parmenter and Trevino (19) criticized Russell principally for his presentation of evidence against a physiological basis for vowel differentiation. They felt that Russell's interpretation of his X-ray plates was correct, but they were of the opinion that his technique for maintaining a fixed posture during exposure was inadequate. For their X-ray investigation of normal subjects, they devised a head positioner which appeared to control the head adequately in a horizontal plane. There is some question as to the control afforded the head in the antero-posterior plane. The results of their study supported the hypotheses of a progression of tongue positions as the vowels are produced in traditional order, and of a fairly definite tongue position for each vowel for each individual studied.
The criterion of a fixed and constant head position during X-ray exposure continued to receive attention in subsequent studies conducted on normal subjects. In 1934, Norris
(18) utilized a head positioner developed by Higley in her study of vowel production in adults as it is related to voice. Norris' conclusions concerning nasality and denasality indicated a wide uvular opening or a thinning of velar tissue for
1




2
the former, and a complete uvular closure or a thickening of the velum for the latter.
Nurther investigation of naso-pharyngeal closure in adults was done by Wolfe (32) in 1942. Recognizing the limitations of lateral X-ray plates, he reported that his data seemed to reveal only a shortening of the antero-posterior diameter of the naso-pharynx. His data also indicated upward and backward movement of the velum, together with a slight forward movement of the posterior pharyngeal wall. This series of movements effected a naso-pharyngeal closure which was not complete for most of his subjects. He found that greater anterior movement of the posterior pharyngeal wall was accompanied by less posterior movement of the velum, and
vice versa.
Comparing oral and pharyngeal structures of adults with nasal voices and adults with superior voices, Hixon
(15) found that the over-all vertical and antero-posterior dimensions of the face were very similar for both groups. The measurements of the midsagittal diameter of the pharynx and the midsagittal measurements of the tongue indicated that the tongue was carried further posteriorly in the nasal group while at rest and for the vowelta] with a tendency in
this direction for[ae] Hixon also commented on his findings regarding naso-pharyngeal structures, but he reported that these structures were not clearly defined on his X-ray plates.
The study contained his recommendations to clarify this problem; i.e., the use of slower speed cassettes, the use of a lead focusing plate, and painting the entire inferior margin of the soft palate in order to differentiate the uvula from the soft palate proper.
While the study conducted by Brodie (2) was also
concerned with subjects with normal structures, it differed
from the preceding investigations in that it was longitudinal in aspect. Brodie indicated that the use of an X-ray




technique in growth studies had been predicted as early as 1922, but that its development was not perfected for this purpose until 1931. In that year Broadbent published the full details of a roentgenographic cephalometer and began a long range investigation of the head of the growing child. Brodie summarized his own investigation with the statement that a longitudinal study of growing children indicated that the morphogenetic pattern of the individual was established at a very early age. Once this pattern was attained, he found that it did not change. Herzberg and Holic (14) reported that their findings confirmed Brodie's results by anthropologic methods. Their findings were based on measures obtained from three hundred and twenty-six adult human skulls.
Growth studies have also been conducted using cleft palate subjects. Graber (8) reported his analysis of the developmental patterns and facial morphology in cleft palate. As a group, his subjects showed deficient patterns of maxillary growth, laterally, antero-posteriorly, and vertically. He indicated that patients whose palatal clefts had not been manipulated surgically showed a pattern of maxillary growth that was essentially normal. Mandibular growth on the whole appeared normal. The lack of development noted in mandibular growth in Graber's subjects was considered to be no more
than would be found in the same distribution of normal subjects. Graber's chief contention, it would seem, was a serious consideration of the propriety of early closure of cleft palates. Postponement of surgery until the end of the fourth year of life was indicated, at which time the majority of total maxillary width had been accomplished. A necessary further precaution was pointed out due to a continuation of downward and forward growth of the maxilla until twenty years of age.
Krogman (17) offered some support of Graber's (8) findings regarding the growth of unrepaired structures in




4
his report of cumulative X-ray studies done at the Philadelphia Center for Research in Child Growth. He stated that the postnatal growth patterns of unrepaired cleft palate and normal faces did not differ, except that growth in the former proceeded in keeping and in harmony with the basic deviation initially introduced by the cleft. He felt that an optimum time for surgical procedure would be somewhere between four and six years of age, and possibly as early as two to three years of age if the growth tempo of the individual child was such that there was evidence of advanced growth.
Harrington (13) confirmed Wolfe's (32) questioning of the nature of velo-pharyngeal closure with the results of his study of ten cadavers and the X rays of three living subjects. The various aspects of his investigation led him to the conclusion that mesial movement of the pharyngeal walls occurred over considerable vertical extent, rather than as a continuation of Passavant's cushion. Consequently, the mechanism acting to produce velo-pharyngeal closure was not of the nature of a simple sphincter. A similar phenomenon was suggested earlier by Townshend (30) in his critique of the formation of Passavant's bar.
Using X rays, plaster models, and photographs,
Slaughter and Brodie (25) concluded tneir study with statements that further supported Graber's (8) contention regarding the impropriety of early surgical repair of cleft palates. They also presented statements to support Graber
(8) and Krogman's (17) remarks on the essentially normal growth rate of congenitally deformed parts which were not
permanently damaged.
Buck (4, 5) conducted an X-ray study of oral and
pharyngeal structures in patients, ranging in age from seven to nineteen years, who had surgically repaired cleft palates. His findings regarding over-all vertical and antero-posterior dimensions of the face further substantiated Graber's (8)




premise of the interference of early surgical closure with growth. Buck found smaller midsagittal measurements of the tongue in his cleft palate subjects, as did Hixon (15) in his non-cleft nasal subjects. Concerning midsagittal pharyngeal diameter on and below the incisal reference line, Buck found measurements for his two groups to be very similar. Proportional measurements of the horizontal position of the high point of the tongue, which took into consideration the structural differences between the two groups, were also very similar. These measurements failed to support Hixon's conclusion on posterior tongue carriage. Lower tongue carriage in the oral cavity was indicated by Buck when he found a tendency for the cleft palate subjects to show a greater vertical distance between the hard palate and the tongue. Regarding velo-pharyngeal movement, Buck reported significantly larger openings for his cleft palate subjects, smaller horizontal and predominantly vertical movement of the velum in the cleft palate group, and very small posterior pharyngeal wall movement for both groups. He also found no significant differences between the two groups on measures of mouth and lip opening.
The error of Gustav Passavant was commented on by
Calnan (6), who based his contentions on clinical and radiological evidence. Passavant had observed his ridge in a normal subject, but he failed to explain why it was observed in only one in fifty patients. Calnan felt that Passavant's phenomenon could be seen in unrepaired cleft palates, but witn an occurrence in less than 25 per cent of cases. He explicitly denied that tae phenomenon was a factor in normal speech.
Hagerty and Hoffmeister (9) felt that the cleft palate was closed primarily to improve speech. They offered a quantitative measure of speech as an indicator of success in palatal closure, if no other damage was incident




6
to the closure. It was hypothesized that measurements of the minimal velo-pharyngeal distance taken during prolongation of
(s ) enabled them to predict nasality from the X ray with about 75 per cent accuracy.
Laminagraphy, a recent development in X-ray studies, has been utilized in some of the more recent cephalometric investigations. This is a technique for obtaining measurements of tissues which lie in planes from the surface to the midline. The tube and film of the laminagraph move during exposure, and the X ray penetrates deeper each time it passes over a body. Brader (1) pointed out that this technique permits projection of any selected plane of a body to the exclusion of all other planes. To illustrate, structures lying in the plane of the vertical process of the maxilla, in the plane of the nasal turbinates, and in the plane of the nasal septum could be viewed on successive laminagraphic plates. Static X-ray plates present a view only of the midsagittal plane. Brader further stated that laminagraphy made possible the visualization of certain anatomical structures or pathologic lesions which are not susceptible to clear projection by any other method. Brader conducted preliminary tests to determine the accuracy with which images in laminagraphic projection might be measured. These tests indicated that such measurements lay within the limits of scientific accuracy, i.e., within one-half millimeter of direct measurements.
In 1953, Subtelny (28) reported his findings of a
laminagraphic investigation of the width of the naso-pharynx and related structures in normal and pre-operated cleft palate children. The subjects were all under three years of age and ninety-one unoperated cleft palate patients were included in the study. Perhaps the most striking finding reported was the indication of an abnormally wide naso-pharynx in the cleft palate individuals. The bi-hamular measurement, which is the distance between the inferior terminations of the medial pterygoid plates of the spnenoid bone, was found to be




larger for this group. The outward flare of these medial plates was found to increase as they descended. Subtelny hypothesized that certain muscles pulled on the open embryonic suture to create this wider dimension. He introduced an element of doubt as to the validity of this hypothesis when he commented on certain of these muscles which could have the opposite effect on the suture. The lateral pressures on the open suture created by the tongue might augment the widening effect. In the case of a repaired lip, the buccinator musculature is such that it should have a restraining effect. Subtelny commented that there appeared to be a levelling off in naso-pharyngeal width growth during the second year of life.
Ricketts' (20) laminagraphic study stressed the
need for a more complete understanding of the basicranial structures. He cautioned that inferences from height and depth dimensions projected on lateral X-ray films were not conclusive. In view of Subtelny's (28) finding on nasopharyngeal dimensions and the findings of his own study, he concluded that the actual size of the adenoid was not as important in velo-pharyngeal closure as the available space that it filled in the naso-pharynx. He was in agreement with Graber (8) in stressing the importance of the descending growth of the hard palate in evaluating the individual condition. -Without an increased range of activity in the soft palate, this descent seemed to explain two circumstances: the frequently experienced increased nasal emission in postoperative cleft palate patients after the age of six to eight years, and the almost spontaneous disappearance of mouth breathing in some patients in this same age group.
A discussion of the significance of early orthodontia in cleft palate habilitative planning by Subtelny
(29) included references to a laminagraphic study he had




8
completed on repaired cleft lip and cleft palate children prior and subsequent to surgical reconstruction of the lip. He found that the molding action of the lip was not restricted to the alveolar border alone, but might cause an architectural rearrangement involving each maxilla. In many cases that demonstrated this movement, Subtelny found that the maxillary constriction was severe enough to bring about contact between the inferior nasal turbinate and the nasal septum. This condition he offered as a possible explanation for the distortion of nasal sounds in cleft palate speech, which has been described as a hyponasality superimposed on the hypernasal quality.
Hagerty, Hill, Pettit, and Kane (10) reported a
laminagraphic study concerned with posterior pharyngeal wall movement in normal adults. They concluded that it was doubtful whether the actual extent of excursion of the posterior pharyngeal wall was significant enough to make important differences in speech. Exception to this conclusion would occur when the individual possessed a Passavant's bar large and vigorous enough to participate actively in closure. These authors also reported on soft palate movement in normal adults (11). In the absence of a vigorous Passavant's bar, it seemed evident that the soft palate participated far more aggressively than the posterior pharyngeal wall in the regulation of the naso-pharyngeal aperture during speech.
Passavant's bar was seen in only nine of eighty subjects, and was functional in only three. These findings support those of Wolfe (32) on the participation of the velum in velopharyngeal closure.
The preceding discussion of static X-ray investigations forms the background for the present study. Graber
(8), Krogman (17), and Slaughter and Brodie (25) have suggested that the growth pattern of the structures of individuals with unrepaired cleft palates proceeded as in




9
normally structured individuals. Krogman offered the qual.ificat ion that such growth would be in keeping and in harmony with the deviation introduced by the anomaly. The study by Buck (3), using individuals with repaired cleft palates, offered support to their contentions. A special case in Buck's investigation revealed that the cleft palate individual whose speech was judged as having relatively little nasality differed chiefly from the other cleft palate subjects in only two respects: (1) the relatively normal size of his facial and oral structures, and (2) in his being able to achieve a fairly complete closure of the nasal port. It is of interest to note that Buck reports this individual to have undergone only lip repair prior to his seventeenth year. At the age of seventeen surgical repair was performed on the hard and soft palates.
Several questions, based on suggestions derived from the foregoing review of literature, constitute the basis for the present study;
1. How does a group of physically mature individuals
with complete, unrepaired cleft palates compare
with a similar group of normally structured
individuals of the same national origin?
2. How does a group of physically mature individuals
with complete, unrepaired cleft palates compare
with other cleft palate individuals who have
undergone surgical repair prior to maturation?
3. What effect does the presence of the unrepaired
anomaly have on the speech of the adult?




CHAPTER II
DESCRIPTION OF PROCEDURE
The experimental design of the present study is
similar to that used by Buck (3) in his X-ray investigation. He studied oral and pharyngeal structures and functioning in individuals with repaired cleft palates.
Two groups of adult Puerto Ricans were studied: (a)
an experimental. group with complete, unrepaired cleft palates, with or without repaired clefts of the lip; and (b) a control group with normal structures, speech, and hearing, selected at random. Tape recordings of both groups were judged for accuracy of articulation and excellence of voice quality.
Three lateral X-ray plates were available on each of the subjects: phonation of the vowels (i], (a], and (u]. A lateral X-ray plate and an antero-posterior plate, both at physiologic rest, were available on some of the subjects.
Each lateral X-ray plate was traced and the tracings
were measured to secure data related to the size, positioning, and movement of the oral and pharyngeal structures, and the cr0ss-sectional diameters of the oral and pharyngeal cavities. Lateral measurements of the skeletal structures of the face were obtained directly from the antero-posterior plates.
The data obtained from the measurements and the
judgments of the tape recordings were analyzed by various statistical techniques in order to permit comparison between the two groups of subjects.
Selection and M~atching of Subjects
The present study may be described as a detailed
'10




analytical aspect of a par*tt study sponsored by the U. S. Department of Health, Education, and Welfare. Tne motivating factor which led to the formulation of the parent study was a desire to accumulate data on physically mature individuals who had untreated cleft palates. The criterion for choosing a site for the study was the location of a suitable group of cases. Through the interest and cooperation of the Insular Department of Health, a sizable group of such cases was located on the Island of Puerto Rico. A study team of dentists and a speech pathologist visited the island in June, 1957, and June, 1958t to collect the raw datal. Dentists, social workers, and other personnel from the Insular Department of Health and Puerto Rican health centers augmented the study team while the investigation was in progress. Prior to the team's arrival on the island, case finding was accomplished by the Bureau of Crippled Children and the Bureau of Dental Health of the Puerto Rico Department of Health, assisted by the Puerto Rioan Office of Vocational Rehabilitation. Medical examinations were conducted on the 1957 study group but, as it was felt that the results were completely negative, they were not conducted on the 1958 study group.
To be included in the study group, cases had to meet the following qualifications; (1) must have reached maturation (fifteen years of age or over); and (2) must have a palatal cleft, which had never been treated surgically or prosthetically.
On the basis of descriptions that were available
for the individual subjects, the twenty individuals selected
lThe members of the study team included Frank E.
Law, D.D.S.; John T. Fulton, D.D.S.; McKenzie Buck, Ph.D.; and others. (The names of these individuals are available upon request.) This team is to return to Puerto Rico to collect more data. None of the results of the parent study are to be published until all aspects of the study are completed. A portion of the X rays and tape recordings gathered by the team were made available to the author to enable him to fulfill part of the requirements for his advanced degree in speech pathology.




12
for inclusion in the experimental group have been classified as having complete, unrepaired cleft palates, with or without a repaired lip. Actual verification of this classification is dependent on examination of palatal casts of the subjects, which did not arrive in time for the present study. Fifteen of these individuals had normal hearing. Two of the remaining five had mild hearing losses, which might be attributed to their cleft palates. The other three subjects had unilateral hearing lossesp, which probably were not related to their cleft conditions.
Thirty.-six normally structured adults were also examined. The criteria for selection of these individuals were that they had achieved normal structural growth and possessed the normal speech and hearing of Puerto Ricans. These individuals were selected at random at the various examination centers. Of the thirty-six, twenty were chosen for inclusion in the present. study as a control group.
The age range of the experimental group members was sixteen to fifty-seven years. This group was composed of fourteen males and six females. The age range of the control group was seventeen to forty-six years. There were eighteen females and two males in this group. No attempt was made to match individuals in the two groups as to age and sex, because all of thie subjects had met the criterion regarding physical maturation, and optimum growth had been accomplished.
Procedure for Recording and Analysis of Speech Samples
In the experimental group, a tape recording was made of each subject reading a list of Spanish words. The list, which follows, was constructed to contain the consonants and vowels of the language of the subjects in all of the intraword positions in which they occur.




13
Consonants: (p] polio, copa
(~t] taza, gato
(i] carro, vaca
_1 gato, guagua
(B] bote, libro
(d] diente, dedo
(f[ cafe, fund
(mI mesa, cama
(n] nene, mano, jabon
StS] china, leche
(N] nino, piea
(8] silla, taza, ojos
[1] leche, bola, arbol
(r] carne, dolar
[rr] rrosa, carro
[y] llave, pollo
(x] jarro, angel
Vowels: [a] agua, casa, pata
[e] eje, pesa, nene
(i] hilo, maguey, tina
[o] ojo, sopa, huevo
[u] uno, cuna
The following consonants are not the same as those used in English, and require explanation: (B], bilabial fricative; [d], voiced dental stop or fricative; (t], voiceless dental stop; [n], dental nasal; [N] palatal nasal; (1] dental lateral; Ir] single tap lingua-alveolar; rT trilled lingua-alveolar; ly], voiced palatal fricative; and (x], voiceless velar fricative. None of the vowels are the same as those used in English. They represent approximately the same vowels that appear in Latin, in that they are pure and not diphthongized. There is a tendency for all of the vowels except (a] to be diphthongized in English.
Each subject was instructed to read the words in the
order in which they appeared in the list. In several instances the subjects were unable to read and were asked to repeat the words after they were spoken to them by a Puerto Rican. The control group subjects were recorded in the same manner.




14
The recordings were made on a Wollensak tape recorder: Model T 15000 high fidelity, dual speed. The instrument's portability was an important consideration in its selection. Although the recording room conditions were far from ideal, ambient noise level was kept at a minimum.
Twenty recordings of the experimental group members
and twelve recordings of the normal subjects were arranged in random number order for analysis. The author and another speech pathologist acted as judges to determine phonetic accuracy of consonants and vowels, and quality differences as reflected in deviations from normal oral and nasal resonance. Resonance was rated on a five-point scale, with 1 representing normal resonance and 5 representing the greatest deviation from normal oral and nasal resonance. A numerical score of articulation was attained by assigning values to the articulated sounds: 0 indicated correct production; 1 indicated a distortion; and 2 indicated either a substitution or an omission. In addition, the judges compared their analysis sheets in order to determine which consonants and vowels were found to be most frequently defective. Several deviations in articulation were noticed which, on the basis of the speech samples of the normal subjects, were apparently due to dialect differences. Such deviations were not considered to be errors.
Ratings of vowel and consonant articulation by the
judges did nGt differ with statistical significance. A high positive coefficient of correlation, .98, was calculated for the two sets of ratings.
Spriestersbach (27) and Sherman (24) have suggested
that more valid ratings of quality can be achieved if recordings are played backwards. They both feel that irrelevant factors, which tend to influence quality judgments, are thus eliminated. Since neither of the present judges was conversant in Spanish, it did not appear necessary to use this




15
method of playback. After the recordings had been analyzed phonetically, quality judgments were made. The tapes were listened to continuously at several different times. No marked differences in numerical rating were noted. The final judgments yielded a positive coefficient of correlation of .77. The judgments did not reveal any statistically significant differences.
Apparatus and Procedure for Obtaining X-ray Plates
Control .f Head Position
In order to minimize movement of the head during the X-ray exposures, a head positioner was utilized. This device was designed by Howell (16) and was constructed at the University of Florida. One of the criteria used in the designing of the head positioner was that it should be portable without sacrificing sturdiness. This makes practicable the use of such a positioner in a field study. The head positioner utilizes ear rods, which insert into the external auditory meati, to control movement in the sagittal plane. An armature which rests against the nasion of the subject is used in an attempt to prevent rotation of the head position around the axis created by the ear rods.
In addition to minimizing head movement, the head positioner provides another advantage, that of aiding in the definition of the Frankfort line on the X-ray films. As in the studies by Buck (3) and Hixon (15), each subject was seated in a comfortable position in order not to disturb the habitual carriage of the oral and pharyngeal structures. The relative position of the chair with respect to the head positioner was adjusted to make possible this comfortable posture. Marking of Structures
None of the structures were marked in the present study. The rationale behind this lack of marking may be attributed in




16
part to Buck (3). The experimental group in his study had the midline of the tongue, the midline of the velum and hard palate, and the midline of the posterior pharyngeal wall covering Passavant's pad marked with a mixture of barium and gum acacia. Severe gagging on the part of the control group members prevented marking the midline of the posterior pharyngeal wall. With this exception, similar markings were applied to the control group members. In an effort to discover the possible error resulting from a lack of marking of structures, Buck conducted an additional experiment in connection with his study. Eight normally structured individuals, who did not present severe gag reflexes, were X-rayed with and without the marking of structures. A comparison of measurements obtained from these X rays revealed an average difference between the two sets of measurements of plus or minus 0.6 millimeters. X-ray Exposures Made
Four lateral cephalometric plates were acquired on both the experimental and control groups: one at physiologic rest and one each while phonating the vowels (i], [a], and [u]. These vowels were selected because they are representative of extremes of tongue positions used in phonation. The low front vowel (e) used in some X-ray studies, is not present in the language of the subjects of the present study. The fifth Xray exposure was an antero-posterior view used to obtain lateral measurements of the skeletal structures of the face.
Due to faulty exposure and/or developing techniques, thirty-one of the plates were not available. For the experimental group fifteen lateral rest exposures, twenty exposures each of the pnonation of the three vowels, and ten anteroposterior exposures were secured. Twelve lateral rest exposures, twenty exposures each of the phonation of the three vowels, and twelve antero-posterior exposures were obtained for the control group.
In addition, it must be remarked that of the one
hundred and sixty-nine plates available for this study, many




17
were unavoidably over-exposed or under-developed, obliterating much of the soft tissue. This condition was a result of variations in electronic output, and in some instances the equipment appeared to be faulty. Various colored gelatins were used to clarify the structures illustrated by the under-developed or over-exposed plates. Straw, amber, pink, and blue gelatins, or a combination of any two of these, were tried experimentally in viewing the plates. It was found that frequent changing of the gelatins was necessary in order to obtain the best results. This procedure tended to rectify the faulty exposure and/or development.
To check on the accuracy of the tracings, all of the
tracings for a single subject were re-examined at random intervals during the tracing process by the researcher and his supervisory chairman. In the event of a discrepancy, the tracings were corrected. This procedure indicated that there was a high degree of accuracy on the original tracings. Control of Vowel Phonations, Intensity, and Pitch
The subjects in each group were instructed to phonate the vowels indicated in the preceding section. Whenever possible, a practice period was held prior to the X-ray exposures, For the most part, the subjects had little difficulty producing good examples of these vowels.
Other variables which might possibly be related to the movements of the tongue and other oral structures during phonation include the pitch and intensity of the voice. Buck
(3) reported that these two variables produced relatively minor effects on -the positioning of the oral structures during vowel phonation, as long as the variations in pitch and intensity were not large. The subjects in the present study were instructed to maintain comfortable pitch and intensity levels during phonation when the X-ray exposures were being made. No instrumental control was available to determine maintenance of the criteria.




i8
Measurements of t~he X-ray Plates
The procedure for securing measurements from the X-ray plates was basically that used by Hixon (15) and Buck (3). Each plate was placed on an X-ray tracing table especially constructed for this study. Flashed-opal frosted glass and varying light intensities of fifteen, twenty-five, sixty, and one hundred watts were used. A clear acetate tracing paper and a hard-lead drawing pencil were used to record the outlines of the structures. The outline of the hard and soft palates, the central incisors (when present), the mandible, the posterior wall of the pharynx, the tubercle of the Atlas, the midline of the tongue, and the lips were traced. To construct the Frankfort line, the inferior margin of the bony orbit and the outline of the ear rod were traced. The anterior nasal spine was also traced, but this structure was frequently physiologically absent or the X-ray technique obliterated it.
The Frankfort line was used as a base line for the
construction of all perpendiculars and parallels constructed for the various measurements of the study. When the superior surface of the ear rod was obscured by the armature of the head positioner, it was necessary to reconstruct the actual dimension of the ear rod on the tracings. The incisal ref erence line was drawn tangent to the superior margin of the central incisors of the mandible. This reference line interseated the posterior pharyngeal wall and was parallel to the Frankfort line.
Hagerty, etal (10), used a series of lines on the
posterior pharyngeal wall to determine tissue movement at the level of the tubercle of the Atlas. A modification of this technique was utilized in the present study. A perpendicular line was constructed tangent to the most anterior projection of the tufberale of the Atlas. This line was extended to intersect the incisal reference line and served as the posterior border of the area. A horizontal line, level 4, passed




19
through the most anterior projection of the tubercle. At intervals of one-half centimeter, other horizontal lines were drawn superiorly and inferiorly to this level. The remaining lines were numbered in descending order, level 1 being the most superior line.
Figure I is a master tracing of an X-ray plate of a normal. subject. This figure shows the reference points and location of measurements used for all of the tracings in the study. The two reference lines already discussed are designated as follows: the Frankfort line, A'C', extending from the inferior margin of the bony orbit to the superior surface of the ear rod; and the incisal reference line, LP?, extending from the mandibular incisors to the posterior pharyngeal wall.
Measurements for the present study will be classified as follows: linear measurements, measurements of openings, area measurements, and measurements of movement from rest to phonation. They will be discussed in that order, with reference to Figure 1.
The linear measurements that were made along the various lines include the following distances: FG, the distance from the termination of the hard palate to the posterior pharyngeal wall; LP, the length of the oral cavity; MO, the length of the tongue on the incisal reference line; BI, the distance between the Frankfort line and the high point of the tongue; HI, the distance between the hard palate and the high point of the tongue; IN, tongue height above the incisal reference line; and IN, the horizontal position of the high point of the tongue in the oral cavity. Each linear measurement was made twice. In case of a discrepancy, the measurement was rechecked and recorded.
Measurements of openings are as follows: OP. pharyngeal opening on the incisal reference line; lip opening, the smallest opening between the lips; and the smallest




20
BONy
o eir a.... e e'
HADoA
PA LA 7"
)eLE
OF rHE
A4LA.5
8'. 0 e
#/
4*-S- Hyosho
8oE
Figure 1. Master tracing showing reference points and location
of measurements
A'C' Frankfort line LP Incisal reference line FO Termination of the hard palate to the posterior pharyngeal
wall
LP Oral cavity length HO Tongue length on the incisal reference line BI Frankfort line to the high point of the tongue HI Hard palate to the high point of the tongue IN Tongue height above the incisal reference line LN Horizontal position of the high point of the tongue OP Pharyngeal opening on the incisal reference line 1-6 Levels used for obtaining measurements of movement of
the posterior pharyngeal wall




21
pharyngeal opening, the smallest distance between the posterior border of the tongue and the posterior pharyngeal wall (above the body of the hyoid bone and below the incisal reference line). Velo-pharyngeal opening is the smallest distance between the posterior surface of the velum and the posterior pharyngeal wall. Mouth opening is considered to be the distance between the parallel lines drawn tangent to the maxillary and mandibular incisors. In an effort to substantiate this measurement, tile distance BN, extending from the Frankfort line to the incisal reference line, was also measured. The procedure used to check linear measurements was employed in the case of measurement of openings.
Area measurements for the study were made by means of a planimeter. The three areas measured were the total tongue area above the incisal reference line, the tongue area anterior to the high point of the tongue, and the area of the posterior pharyngeal wall. Each area was traced three times and the average of the three measurements was recorded. This precaution was taken in an effort to control variations occurring while the areas were measured. The planimeter is a sensitive instrument, and it was difficult to trace the outline of an area without varying from the lines.
Measurements of movement from rest to phonation were made along the parallel and horizontal lines constructed in reference to the tongue and the posterior pharyngeal wall. The vertical movement of the high point of the tongue was made on line BN, the distance IN being variable. Horizontal movement of the high point of the tongue was made on the incisal reference line, the variable distance being LN. Movement of the posterior pharyngeal wall was made on the lines constructed in the area of the tubercle of the Atlas. Unfortunately, the same area demarcated by the most superior and the most inferior of these lines was not visible on all of the lateral X-ray plates.




22
Skeletal Measurements of the Face
JK, the length of the maxilla was measured on the incisal reference line. This measurement is the distance between perpendicular lines dropped tangent to tile notch just inferior to the anterior nasal spine and to the termination of the hard palate. LP', the length of the mandible was also measured on the incisal reference line. This is the distance between the mandibular incisors and the perpendicular dropped tangent to the most anterior projection of the tubercle of the Atlas (line CP'), a measurement between stationary bony structures at rest.
The antero-posterior exposures at physiologic rest
were used to determine tne width of the maxilla and mandible. These plates were not traced, but were placed on the illuminated tracing table, and the measurements were taken directly from the plates. Tie width of the maxilla is the distance between the widest extents of its bony margin on the level of the horizontal plates of the maxilla. The width of the mandible is the distance from the angle of the ramus on the right side to the angle of the ramus on the left side.
As in the case of the linear measurements, each measurement of the face was made twice. The second measurement was compared with the first one and was recorded if the two were identical. In the event of a discrepancy, the measure was taken a third time and a comparison was made prior to recording.




CHAPTER III
RESULTS
Facial and Oral Cavity Dimensions
Graber (8), Krogman (17), Slaughter and Brodie (25), and Buck (4) have presented findings which indicate that early surgical repair of cleft palates tends to interfere with structural growth. In addition these authors have commented, directly and by inference, that the structures in unrepaired cleft palate patients follow a pattern of essentially normal growth. One of the first considerations of the present study, inasmuch as it deals with adults whose cleft palates have not been surgically manipulated, is a comparison of measurements of facial structures for the unrepaired cleft palate and normal groups. Measurements of tongue size, horizontal tongue carriage, pharyngeal openings, vertical tongue carriage, tongue movement, velo-pharyngeal opening, posterior pharyngeal wall measurements, and lip and mouth opening will be discussed in the order given. Facial Measurements
Table 1 presents the data dealing with the skeletal measurements of the maxilla and mandible. The statistical analysis used in this and all subsequent tables will be described in detail in the present section. An arithmetic mean, standard deviation, and standard error were computed for each set of measurements for each of the two groups of subjects. Also shown in the tables are the mean difference, the standard error of this difference, and the critical ratio or "t" statistic. Each table also shows the values for "t" which are required for statistical significance at the 1.0 per cent and 5.0 per cent levels of confidence.
23




24
TABLE 1
MEASUREMENTS OF MAXILLA, MANDIBLE, ORAL CAVITY, AND DISTANCE FROM
TERMINATION OF HARD PALATE TO POSTERIOR PHARYNGEAL WALL AT REST (All measurements in millimeters)
Normal Cleft Palate Differences
1. Maxilla length M 50.08 M 49.80 M .28
SD 4.80 SD 7.80 SE 2.55
SE 1.45 SE 2.08 t .109
t (df 25): 1.0% 2.787; 5.0% 2.060
2. Maxilla width M 64.00 m 68.90 m 4.90
SD 5.49 SD 4.30 SE 2.19
SE 1.66 SE 1.43 t 2.237
t (df 20)0 1.0% 2.845; 5.o0% 2.086
3. Mandible length M 80.92 M 80.73 M .19
SD 7.23 SD 6.20 SE 2.74
SE 2.18 SE 1.66 t .069
t (df 25): 1.0% 2.787; 5.0% 2.060
4. Mandible width M 96.66 M 99.20 x 2.54
SD 3.57 SD 5.20 SE 2.05
SE 1.08 SE 1.73 t 1.239
t (df 20): 1.0% 2.845; 5.o0% 2.086
5. Oral cavity M 83.66 M 80.46 M 3.20
length SD 6.80 SD 4.98 SE 2.44
SE 2.05 SE 1.33 t 1.311
6. Termination of M 27.83 M 25.40 M 2.43
hard palate to SD 3.74 SD 4.56 SE 1.66
posterior phar- SE 1.13 SE 1.22 t 1.463
yngeal wall
t (df 25)t 1.0% 2.787; 5.0% 2.060




25
The form,&t for this presentation is t (df 25): 1.0% 2.787; 5.0% 2.060, with df designating the degrees of freedom for a particular set of measurements. Anything less than the 5.0 per cent level of confidence would be largely due to chance and was not recorded.
iKaxiJla Lengzth and Width
A comparison of maxilla length measurements for the two groups revealed a mean difference of approximately onefourth millimeter, which is not statistically significant. Graber (8) and Buck (4) indicated that the retardation they found in maxilla length was possibly a result of early surgery. The present finding would seem to lend support to this contention. The members of the experimental group, who had undergone no palatal surgery, approximated the measurement found in the normal subjects. There was almost a five millimeter difference between the cleft and non-cleft groups on the measurement of maxi2lla width. This difference was significant at the 5.0 per cent level of confidence. Krogman (17) has indicated that cleft palate structures w ill follow normal growth patterns, but that these patterns will be influenced by the presence of the anomaly. This appears to be what has happened
in the present situation. No retardation in maxillary width was found. The measurement of maxilla. width of the experimental group was greater than that of the controls. MandibleLength and Width
As in the case of maxilla length, the two groups were
found to exhibit only a slight mean difference in the measurement of mandible length. This difference, less than onefourth millimeter, was not significant. Buck's (4) experimental group showed a shorter mandible length measurement which was statistically significant, and was apparently due to interference from the surgery performed on the lip. Graber (8) attributes the effect of this interference to the nature of




26
the construction of the orbicularis otis muscle, which encircles the mouth opening. Since the fibers of this muscle are continuous, a shortening of the fibers in surgery on the upper lip will exert pressure on the mandible as well as on the maxilla. Following the trend shown in maxilla width measurements, the cleft palate subjects had the greater mean mandible width, in the amount of 2.54 millimeters.
Oral Cavity Length
The measurement of oral cavity length is the distance from the mandibular incisors to the posterior pharyngeal wall, along the incisal reference line. The posterior termination of the oral cavity is the point of intersection of the reference line with the posterior pharyngeal wall. Since the antero-posterior dimensions of the maxilla and mandible revealed no statistically significant differences between the two groups, it is to be expected that similar results would be obtained for the measurement presently under consideration. The two groups were found not to differ with statistical significance in oral cavity length. Antero-posterior Width of the Naso-haryn
The distance from the termination of the hard palate to the posterior pharyngeal wall, which is the inferior antero-posterior diameter of the naso-pharynx, presented no statistically significant difference between the two groups. The normal subjects' measurement was found toexceed that of the cleft palate subjects in the amount of 2.43 millimeters. It is interesting to note that Ricketts (20) has reported that a study of the relation of the tubercle of the Atlas to the hard palate indicated that no one fixed relationship prevailed. It would seem, therefore, that a consideration of the antero-posterior width of the naso-pharynx does not necessarily reveal the influence of the area of the posterior pharyngeal wall at the level of the tubercle of the Atlas.




27
The measurement should apparently be evaluated solely as a structural dimension.
Measurements Related to Tongue Size and the
Horizontal Position of the High Point of the Tongue
No statistically significant differences were found between the two groups of this study on measurements related to tongue size and the horizontal position of the high point of the tongue. These measurements are set forth in Table 2.
Smaller midsagittal measurements of the tongue were reported by Hixon (15) for his normally structured nasal group. This group also showed a tendency toward a more posteriorly located horizontal tongue position. Buck's (4) repaired cleft palate subjects also had smaller midsagittal tongue measurements than his normal group. However, he found a tendency for the repaired cleft palate group to carry the tongue further forward in the oral cavity than the control group. Tendencies in tne present study were toward a more anterior tongue carriage at rest and for the vowel (i., and toward a more posterior carriage for the other two vowels. r ea ening
Midsagittal diameters of the pharynx are a further indication of tongue carriage in the oral cavity. The rationale behind this statement is readily discerned when measurements of pharyngeal opening are defined. Pharyngeal opening on the incisal reference line, item 1 of Table 3, is the measurement of the distance between the posterior surface of the tongue and the posterior pharyngeal wall. The smallest pharyngeal opening, item 2 of Table 3, is similar. It is the distance between the posterior surface of the tongue and the posterior pharyngeal wall, below the incisal reference line and above the body of the hyoid bone. These measurements should vary in direct relationship to the tongue carriage; a more anterior carriage will increase the measurement, and a




28
TABLE 2
MEASUREMENTS RELATED TO TONGUE SIZE AND HORIZONTAL POSITION OF
HIGH POINT OF TONGUE ON INCISAL REFERENCE LINE
Rest (i] (a] [u]
1. Total tongue Normal
area above M 11.02 9.28 10.78 9.26
incisal refer- SD 2.33 1.72 3.54 2.86
ence line; in SE .70 .39 .81 .66
square centi- Cleft Palate
meters M 9.81 8.52 11.60 10.22
SD 4.14 2.90 4.51 4.73
SE 1.11 .67 1.03 1.09
Differences
M 1.21 .76 .82 .96
SE 1.31 .77 1.32 1.27
t .923 .987 .621 .756
2. Tongue area Normal
anterior to M 6.34 4.52 6.02 4.94
high point of SD 1.67 1.03 2.16 1.64
tongue; in SE .50 .24 .50 .38
square centi- Cleft Palate
meters N 5.58 4.06 6.48 5.82
SD 2.30 1.35 2.59 3.17
SE .61 .31 .59 .73
Differences
1 .76 .46 .46 .88
SE .79 .39 .77 .82
t .962 1.179 .597 1.073
t (df 25): 1.0% 2.787; 5.0% 2.060 Rest t (df 38)t 1.0% 2.711; 5.0% 2.025 Phonation




29
TABLE 2 Continued
Rest (i] [a] (u]
3. Horizontal Normal
position of M 43.16 32.50 48.08 48.58
high point of SD 4.56 5.10 5.22 4.60
tongue; in SE 1.37 1.54 1.57 1.39
millimeters Cleft Palate
M 41.66 29.00 50.53 53.80
SD 5.30 3.97 6.03 8.19
SE 1.42 1.06 1.61 2.19
Differences
M 1.50 3.50 2.45 5.22
SE 1.98 1.87 2.25 2.60
t .758 1.872 1.089 2.008
t (df 25)t 1.0% 2.787; 5.0% 2.060
4e Tongue length Normal
on incisal M 66.25 52.90 59.20 49.50
reference SD 5.90 6.10 7.70 6.80
line; in SE 1.78 1.40 1.77 1.56
millimeters Cleft Palate
M 61.46 51.80 55.55 47.20
SD 9.00 9.10 6.00 6.00
SE 2.41 2.09 1.38 1.38
Differences
M 4.79 1.10 3.65 2.30
SE 2.99 2.52 2.25 2.08
t 1.602 .437 1.622 1.106
t (df 25), 1.0% 2.787; 5.0% 2.060 Rest t (df 38): 1.0% 2.711; 5.0% 2.025 Phonation




30
TABLE 3
MEASUREMENTS OF THE PHARYNGEAL OPENINGS ON AND BELOW THE INCISAL REFERENCE LINE (All measurements in millimeters)
Rest i] [a] [ u]
1. Pharyngeal open- Normal
ing between the M 11.33 22.10 8.35 12.20
tongue and the SD 3.57 4.40 3.00 4.10
posterior wall, SE 1.08 1.01 .69 .94
on the incisal Cleft Palate
reference line M 12.46 26.60 9.35 11.00
SD 4.33 7.70 3.50 7.60
SE 1.16 1.77 .80 1.74
Differences
M 1.13 4.50 1.00oo 1.20
SE 1.58 2.0o4 1.04 1.98
t .715 2.206 .962 .606
2. Smallest phar- Normal
yngeal opening M 8.41 19.90 7.15 12.05
below the SD 4.39 5.10 3.10 4.10
inoisal line SE 1.32 1.17 .71 .94
and above the Cleft Palate
body of the M 10.73 21.30 8.55 10.70
hyoid bone SD 3.04 7.10 3.20 7.30
SE .81 1.63 .73 1.67
Differences
M 2.32 1.40 1.40 1.35
SE 1.55 2.00 1.03 1.93
t 1.497 .70 1.359 .699
t (df 25)s 1.0% 2.787; 5.0% 2.060 Rest t (df 38): 1.0% 2.711; 5.0% 2.025 Phonation




31
more posterior carriage will decrease it.
The only statistically significant difference found in the measurements of pharyngeal opening was for the'vowel (i in the measurement of this opening on the incisal reference line. This difference was significant at the 5.0 per cent level of confidence, and the experimental group showed a measurement greater than that of the control group in the amount of 4.5 millimeters.
Mention has already been made of the obliteration
of some of the soft tissue on the X-ray plates. When this occurred in connection with the outline of the tongue, there appeared to be no other alternative than dropping a perpendicular to the incisal reference line from the most anterior or posterior termination of the outline of the tongue. For this reason, no definite conclusion should be drawn in regard to tongue carriage. Tentatively, however, it will be observed that the cleft palate subjects were consistently found to have a more anterior carriage of the tongue for the vowel (i]. This observation was made on both the measures of horizontal position of the tongue and pharyngeal opening measurements. Again tentatively, a tendency toward a more posterior tongue carriage for the vowel [a] was not supported when pharyngeal openings are considered. Speculating further, a tendency toward a more posterior tongue carriage for the vowel [u] is supported by the measures of horizontal tongue position and pharyngeal openings.
Vertical Tongue Position
Ta&e Height Above the Incisal Reference Line
The distance of the high point of the tongue above
the incisal reference line, item 1 of Table 4, was measured on the perpendicular line which passes through the most superior point of the tongue. This measurement revealed no statistically significant differences between the two groups.




32
TABLE 4
VERTICAL MEASUREMENTS OF TONGUE HEIGHT (All measurements in millimeters)
Rest [i) [ a] [I ul]
1. Distance of Normal
high point of M 23.00 24.00 25.16 25.16
tongue above SD 3.00 1.63 5.05 4.20
the incisal SE .90 .49 1.52 1.27
reference line Cleft Palate
M 21.20 22.41 29.13 27.73
SD 6.75 4.00 8.54 9.10
SE 1.80 1.07 2.28 2.43
Differences
M 1.80 1.59 3.97 2.57
SE 2.02 1.18 2.74 2.75
t .891 1.347 1.449 .935
t (df 25): 1.0% 2.787; 5.0% 2.060
2. Distance of Normal
high point of M 6.66 3.60 12.85 5.05
tongue below SD 2.66 1.50 3.10 2.80
the hard SE .80 .34 .71 .64
palate Cleft Palate
M 8.53 6.05 14.65 5.35
SD 5.70 5.o00 6.20 5.70
SE 1.52 1.15 1.42 1.31
Differences
M 1.87 2.45 1.80 .30
SE 1.72 1.20 1.59 1.45
t 1.087 2.042 1.132 .207
t (df 25): 1.0% 2.787; 5.0% 2.060 Rest t (df 38): 1.0% 2.711; 5.0% 2.025 Phonation




33
TABLE 4 Continued
Rest [i] [(a] [u]
3. Distance from Normal
Frankfort line M 30.08 31.45 41.05 33.40
to high point SD 3.25 3.90 5.50 5.00
of tongue SE .98 .89 1.26 1.15
Cleft Palate
M 34.46 33.30 40.25 31.70
SD 4.98 3.80 5.80 5.80
SE 1.33 .87 1.33 1.33
Differences
M 4.38 1.85 .80 1.70
SE 1.65 1.24 1.83 1.75
t 2.655 1.492 .437 .971
t (df 25): 1.0% 2.787; 5.0% 2.060 Rest t (df 38)t 1.0% 2.7111 5.0% 2.025 Phonation




34
There was a tendency for the cleft palate subjects to exhibit lower tongue carriage at rest and for the vowel [i]. For the vowels (a] and [u), this group had a tendency to carry the tongue higher in the oral cavity. Hixon (15) found a tendency for greater tongue height in his normally structured nasal group, while Buck's (4) repaired cleft palate subjects
showed a tongue height that was less than that found in his normal subjects. A possible explanation for greater tongue height on the vowels (a] and [u] in the cleft palate subjects of the present study is the existence of the open suture in this group. It might be speculated that the individuals with unrepaired clefts may show greater tongue height in an effort to fill the void in their structures.
Distance of tb_4& Pa of the Tongu-e
Be],o the ajt
____ Palate
A second measure of the vertical tongue carriage in
the oral cavity is the distance between the high point of the tongue and the hard palate, item 2 of Table 4. A measurement that revealed greater tongue height above the incisal reference line should show a smaller dimension between the tongue and the palate, and vice versa, since the two groups are similar on antero-posterior structural measurements. This hy. pothesis holds true for the rest position and for the vowel [i], as the cleft palate subjects show the greater dimension between the tongue and the palate. The difference is statistically significant only for the vowel, however. A discrepancy seems to appear in the case of the other two vowels, though, as the cleft palate subjects showed tendencies for greater tongue height and a greater measurement between the
tongue and the palate. There is a possible explanation for the discrepancy, due to the fact that the high point of the tongue frequently fell posterior to the termination of the hard palate for some of the subjects in both groups. It became necessary to approximate the measurement under consider-




35
ation by extending the hard palate and/or nasal septum by means of a line tangent to the highest point of the hard palate and parallel to the incisal reference line.
Dst2ae from the Frankfort ineh eAQ the A P the Tone
A third measure of tongue height, item 3 of Table 4, was employed in an effort to clarify vertical tongue carriage. This measurement is the distance between a relatively static plane, the Frankfort line, and the high point. of the tongue. When this distance is considered, the trend observed in the measurement of tongue height above the incisal reference line is continued. The smaller tongue height shown for the experimental group in item I of Table 4 is reflected in the greater dimension for this group in the measurement of the distance between the Prankfort line and the tongue. The distance at rest in the present instance is significant at the
5.0 per cent level of confidence. The greater tongue height shown for the experimental group in item 1 is reflected in a smaller distance between the Frankfort line and the tongue. The difference is not statistically significant for any of the three vowels.
In summary, measurements of vertical tongue carriage in the oral cavity do not reveal a consistent trend toward either a lower or a higher tongue position.
Excursion of the Tongue from
Rest to Vowel Positions
The measurements of tongue movement shown in Table
5 were obtained by computing the means of the actual movement from rest to phonation for each subject. These measurements were also computed by using the difference between the means at rest and the means for the vowel positions. The results were found to be identical in most instances and to vary only minutely where differences were found. Large




36
TABLE 5
MEASUREMENTS OF MOVEMENT OF TONGUE FROM REST TO VOWEL POSITIONS (All measurements in millimeters)
(i] Ca] Cu]
1. Linear Normal
measure- M 1.00 2.16 2.16
ments of SD 3.03 5.44 3.72
vertical Range -6.0 to 6.0 -5.0 to 13.0 -5.0 to 10.0
movement SE .91 1.64 1.12
of Cleft Palate
tongue M 1.13 7.93 6.53
SD 5.00 8.71 7.10
Range -10.0 to 9.0 -9.0 to 25.0 -12.0 to 15.0
SE 1.34 2.33 1.90
Differences
M .13 5.77 4.37
SE 1.63 2.85 2.20
t .080 2.025 1.986
2. Linear Normal
measure- M 10.66 -4.91 -5.41
ments of SD 3.77 5.10 4.10
horizon- Range 5.0 to 17.0 -15.0 to 7.0 -11.0 to 2.0
tal SE 1.14 1.54 1.24
movement Cleft Palate
of M 12.66 -8.86 -12.13
tongue SD 4.30 4.65 6.10
Range 7.0 to 20.0 -18.0 to 2.0 -22.0 to 3.0
SE 1.15 1.24 1.63
Differences
M 2.00 3.95 6.72
SE 1.62 1.99 2.03
t 1.235 1.985 3.310
t (df 25)t 1.0% 2.787; 5.0% 2.060
Negative numbers indicate a downward direction to vertical movement and a posterior direction to horizontal movement.




37
standard deviations were computed which, when compared with the means, would indicate a marked positive skewness. Although Buck (3) observed some positive skewness in his results on this measurement, he felt that it could be accounted for because of the fact that vertical tongue movement can vary in direction as well as in magnitude. The bases which he gives for this contention are variations in the position of the tongue at rest and variations in jaw positions for the vowels. The latter factor would tend to affect the tongue position relative to the incisal reference line. Similarly, horizontal movement can vary in direction as well as in magnitude for the various subjects.
Vertical TonPue Movement
Item 1 of Table 5 shows no statistically significant
differences between the two groups on the measure of vertical tongue movement. For the vowel [ii, the two groups exhibit a strikingly similar amount of-movement.* For the vowels [a) and [u], the cleft palate subjects show much greater amounts of movement. This may be due to tongue and jaw positions, or it may be due to the presence of the uxioperated cleft and the tendency toward a more posterior tongue carriage for the vowels ( a] and ( W].
An examination of the range of movements for the two
groups shows a consistently larger range for the experimental group. It might be hypothesized that this extreme range of movement is a further reflection of greater compensation because of the oral anomaly. Clinical observation has often borxie out the fact that some structural deviations of the oral
cavity provoke compensatory measures with surprisingly acceptable acoustic results.
The findings of the investigation of repaired cleft
palate subjects (3), while not statistically significant, revealed that they consistently demonstrated greater average upward movement of the tongue. As was previously indicated,




38
the same trend was observed in the Present study for the vowels
(a] and (u].
The linear measurement of the horizontal position of
the tongue from rest to phonation is shown in item 2 of Table
5. The differences for the vowels Li] and (a] are not statistically significant. In the case of the last vowel, the difference is significant beyond the 1.0 per cent level of confidence. For this vowel, the cleft palate subjects show a posterior movement that exceeds the measurement for the normal subjects by approximately 7.0 millimeters. Buck (3) found no statistically significant differences between his two groups on any of the measurements of horizontal tongue movement. He reported tendencies for his repaired cleft palate subjects to exhibit greater anterior movement for the vowel Li] than did the normal group. He found a tendency for the posterior shift of the high point of the tongue to be less for the cleft palate group for the back vowels, with both groups showing an average amount of movement posteriorly.
Any attempt to explain the greater posterior movement on the vowels (a] and (u] in the present study would have to give consideration once again to the unrepaired structures. It is suggested here that the amount of movement in this direction is due in part, at least, to the relative absence of structures which would serve to impede the movement. It is
also felt that, as was suggested in connection with vertical movement of the tongue, the factor of compensation might have an effect on the magnitude of the movement. However, the ranges of movement seen in the measures of vertical shift of the tongue differ from those for horizontal shift of the tongue. The cleft palate subjects show a considerably greater range of horizontal movement only for the vowel [u]. Their range is
less than the normals for the vowel (a], and very similar to the normals for the vowel (i].




39
Measurements of the Naso-pharyngeal Structures
No attempt was made to measure the vertical or horizontal shift of the velum during phonation, as little or no movement was observed in the experimental group. The exact nature of unrepaired velar movement, when it did occur, was difficult to ascertain, since the clefts of the experimental group subjects extended through the soft tissue. In addition, the soft tissues were frequently too obscured to be reliable for measurement and subsequent analysis. Velo-Pharyngeal 0peninq
In spite of the condition of the velar images on the X-ray plates, an attempt was made to demarcate the posterior surface of the velum. By employing various colored gelatins, tracings were made of the velum. The following discussion of measurements of velo-pharyngeal opening should be considered as yielding highly tentative findings.
Item 1 of Table 6 shows that the two groups did not
differ with statistical significance on velo-pharyngeal opening at rest. This measure showed a statistically significant difference beyond the 1.0 per cent level of confidence in the case of each of the three vowels, however. The greatest difference occurred in the case of the front vowel. For the
vowels (a] and (u], the velum appeared to be in contact with the superior surface of the tongue. This condition could have created an elevation of the velum in itself. While the
measurements regarding tongue carriage were not consistent in direction, the cleft palate subjects had a tendency to
carry the tongue further forward and lower in the oral cavity for the front vowel than did the control group. The tendency for the other vowels was toward retraction and greater height for the experimental group. These circumstances would seem to make the speculation of elevation of the unrepaired velum by the tongue at least partially plausible. In addition, disruption of muscular continuity by the oral anomaly, especially




40
TABLE 6
MEASUREMEN S OF OPENING OF THE VELO-PHARYNGEAL STRUCTURES AND AREA OF POSTERIOR PHARYNGEAL WALL AT THE LEVEL OF THE TUBERCLE OF THE ATLAS
Rest ([i) [(a] (u]
1. Smallest velo- Normal
pharyngeal M 9.83 .55 1.00 .15
opening SD 2.08 1.20 1.60 .40
SE .63 .28 .37 .09
Cleft Palate
M 8.86 9.50 7.90 7.50
SD 3.10 4.30 3.90 4.90
SE .83 .99 .89 1.12
Differences
M .97 8.95 6.90 7.35
SE 1.04 1.03 .97 1.13
t .933 8.689 7.113 6.504
2. Area of the Normal
posterior phar- M 1.36 1.28 1.43 1.32
yngeal wall at SD .85 .63 .69 .65
the level of SE .26 .14 .16 .15
the tubercle of Cleft Palate
the Atlas; in M 1.61 1.68 1.78 1.69
square centi- SD .58 .68 .64 .67
meters SE .15 .16 .15 .15
Differences
M .25 .40 .35 .37
SE .300 .214 .217 .215
t .833 1.869 1.613 1.721
t (df 25)t 1.0% 2.787; 5.0% 2.060 Rest t (df 38): 1.0% 2.7111 5.0% 2.025 Phonation




41
in the case of the levators veli palatini, would appear to render these muscles incapable of or inadequate in the execution of their normal action. It is conceivable, then, that the velum in the unrepaired cleft palate subjects would be little more than two pendant pieces of tissue, susceptible to movement caused by contact with the moving tongue. Another possible explanation of the narrowing of the velo-pharyngeal opening on the vowels (a] and C u]is that offered by Harrington
(12) and supported by Williams (31). These studies indicate a positive correlation between velar and lingual movements. That is, as the back of the tongue moves superiorly or inferiorly, the soft palate tends to follow. This explanation would apparently have to disregard muscle discontinuity in the unrepaired cleft palate subject. Area of the Posterior Pharyngeal Wall
The technique for measuring the area of the posterior pharyngeal wall at the level of the tubercle of the Atlas was adapted from the one employed by Hagerty, et a1. (10). The two techniques differ in the location of the posterior border of the area. The posterior margin for the present study was a perpendicular line dropped tangent to the most anterior projection of the tubercle of the Atlas. In the other study, the perpendicular line passed through the mid-point of the tubercle. The area of the posterior pharyngeal wall for the subjects of the present study should be smaller when compared to the results set forth by Hagerty, et al.
Examination of item 2 of Table 6 shows no statistically significant differences between the two groups in the measurement of the area. However, the differences are large during phonation. The cleft palate subjects showed consistently larger measures of the area for all of the vowels than for the rest position. The normal subjects showed a larger measure only for the vowel (a].
Hagerty, et al. (10) used the vowel (a] and the conso-




42
nant '.8i in their laminagraphic study. They reported a mean difference greater for [a] than rest of .176 square centimeters for their white subjects, and .270 square centimeters for their Negro subjects. The control group of the present study showed a mean difference greater for [a) than rest of .07 square centimeters, while the difference for the experimental group was .17 square centimeters. As has been suggested, the smaller area used in the present study would account for the difference seen between the results of the two studies. With this difference given consideration, it seems that the present control group measurement is comparable to the white group measurement. The present experimental group measurement does not appear to differ too greatly from the Negro group measurement.
Posterior Pharyngeal Wall Movement
As in the case of the area measurement, the technique for measuring posterior pharyngeal wall movement is an adaptation of that used by Hagerty, et,.al. (10). Their iJnes were constructed 1.0 centimeter apart, but actual points of greatest excursion were found frequently to fall between those lines. Consequently, the lines within the area just discussed were constructed one-half centimeter apart for the present study. Table 7 contains the measurements of movement of the posterior pharyn6geal wall on the lines constructed within the area. The negative numbers indicate a posterior movement. This type of movement was observed in both groups of subjects. Because the levels in the present study do not coincide with those in the study by Hagerty, eta. a level-by-level comparison will not be made. Furthermore, such a comparison does not seem practical in view of their finding that the greatest excursion frequently occurred between lines. All of the movements reported for their study were, however, in an anterior direction and were slight in magnitude.




43
TABLE 7
MEASUREMENTS OF MOVEMENT OF THE POSTERIOR PHARYNGEAL
WALL AT THE LEVEL OF THE TUBERCLE OF THE ATLAS (All measurements in millimeters)
[i] (a] (u]
1. Level 1 Normal
M .00 .33 .67
SD 3.56 3.54 3.94
Range -5.0 to 5.0 -5.0 to 6.0 -6.0 to 6.0
SE 1.59 1.58 1.76
Cleft Palate
M .57 1.14 1.43
SD 1.18 2.03 1.50
Range -1.0 to 3.0 -2.0 to 4.0 -1.0 to 4.0
SE .48 .83 .61
Differences
M .57 .81 .76
SE 1.66 1.79 1.87
t .343 .453 .406
t (df 11): 1.0% 3.1061 5.0% 2.201
2. Level 2 Normal
M -050 .83 .00
SD 2.47 3M30 2.31
Range -3.0 to 6.0 -5.0 to 7.0 -3.0 to 5.0
SE .74 .99 .70
Cleft Palate
M -.17 1.15 1.33
SD 2.34 2.71 2.95
Range -7.0 to 2.0 -2.0 to 7.0 -5.0 to 7.0
SE .71 .78 .89
Differences
H .33 .32 1.33
SE 1.02 1.26 1.13
t .324 .254 1.177
t (df 22)t 1.0% 2.819; 5.0% 2.074
Negative numbers indicate a posterior movement,




44
TABLE 7 Continued
(i] [a] [u]
3. Level 3 Normal
M -.42 .67 .00
SD 1.40 1.93 1.29
Range -3.0 to 2.0 -3.0 to 4.0 -2.0 to 2.0
SE .42 .58 .39
Cleft Palate
M -.47 .00 -.13
SD 3.18 2.22 2.22
Range -5.0 to 9.0 -4.0 to 4.0 -5.0 to 3.0
SE .85 .59 .59
Differences
M .05 .67 .13
SE .95 .83 .71
t .052 .807 .183
4. Level 4 Normal
M -.08 .83 .08
SD 1.80 1.60 1.80
Range -4.0 to 3.0 -3.0 to 3.0 -3.0 to 3.0
SE .54 .48 .54
Cleft Palate
M -.73 -.33 -.60
SD 1.84 1.62 1.45
Range -5.0 to 2.0 -4.0 to 2.0 -4.0 to 1.0
SE .49 .43 .39
Differences
M .65 1.16 .68
SE .74 .65 .68
t .878 1.784 1.000
t (df 25): 1.0% 2.787; 5.0% 2.060
Negative numbers indicate a posterior movement.




45
TABLE 7 Continued
Li] [a] (u]
5. Level 5 Normal
M .09 .82 .27
SD 1.08 1.75 1.60
Range -3.0 to 1.0 -3.0 to 4.0 -4.o to 2.0
SE .34 .55 .51
Cleft Palate
M -1.00 -.6o -1.07
SD 1.86 1.54 1.29
Range -4.0 to 2.0 -3.0 to 2.0 -4.0 to 1.0
sE .50 .41 .34
Differences
M 1.09 1.42 1.34
SE .60 .69 .61
t 1.817 2.058 2.197
t (df 24)t 1.0% 2.797; 5.0% 2.064
6. Level 6 Normal
M .14 .28 .00
SD 1.36 2.05 1.77
Range -3.0 to 1.0 -4.0 to 3.0 -4.0 to 2.0
SE .56 .84 .72
Cleft Palate
M -.82 -.82 -1.18
SD 1.80 1.64 1.59
Range -3.0 to 3.0 -3.0 to 3.0 -4.0 to 2.0
sE .57 .52 .50
Differences
M .96 1.10 1.18
SE .79 .98 .88
t 1.215 1.122 1.341
t (df 16)t 1.0% 2.921; 5.0% 2.120
Negative numbers indicate a posterior movement.




46
At level 1, no statistically significant differences were observed. The normal subjects showed no movement for the vowel (i). The remaining measurements, in both groups, were in an anterior direction. The range of movements was greater in each instance for the normal group.
Both groups showed a posterior movement for the
vowel (i] at level 2, and primarily anterior movement for the vowels (a] and (u]. None of the differences are statistically significant. The ranges of movement seem to be more compatible for the two groups at this level.
No statistically significant differences were found in movement at level 3. Both groups showed posterior movement for the vowel (i). For the vowel [a], the normal subjects showed an anterior movement, while the cleft palate subjects showed no movement. The normal subjects exhibited no movement on the vowel (u), but the cleft palate group showed a slight posterior movement. The ranges were larger for the cleft palate group in each instance, although the range for the two groups is similar for the vowel (a].
Consistent posterior movement was shown by the cleft palate group at level 4. Posterior movement was shown by the controls for the vowel [i], with anterior movement on the other vowels. The ranges of movement are almost identical at this level. No statistically significant differences were found.
At level 5, the experimental group again showed consistent posterior movement, while the normal subjects showed consistent anterior movement. The difference for the vowel (u] is significant at the 5.0 per cent level of confidence. The ranges do not appear to differ too greatly at this level.
No statistically significant differences were found at level 6. The cleft palate subjects continued to show consistent posterior movement. The control group showed




47
anterior movement for the vowels (i] and [a), but no movemenit for trie vowel [u]. Once again, thle ranges do not appear to differ too greatly.
In summary, the cleft palate subjects showed more posterior than anterior movement. The reverse was true for the normal subjects. The two groups showed some movement in both directions on several levels. The -reatest consistency of movement was shown at the most superior level and was anterior in direction, except for the lack of movement for the normal subjects on the front vowel. Consistency is also observable at the two lowest levels, where the experimental group showed consistent posterior movement. With the exception of the lack of movement for the vowel (u] at level 6, the normal subjects showed consistent anterior movement at the two lowest levels.
An examination of the tracings of the lateral X-ray
plates of the experimental group revealed no obvious bulging of the posterior pharyngeal wall which could be labelled Passavant's pad. The tracings of the control group plates revealed a strong possibility of the existence of this phenomenon in only two cases. In no instance was the phenomenon as marked as those pictured in the study by Hagerty, et al. (10). Small amounts of posterior pharyngeal wall movement were reported by Buck (5), Williams (31), Wolfe (32), and Hagerty, et al. The relatively slight amount of movement found in the present study appears to be consistent with their findings.
Lip and Mouth Opening
Lip Opening
Item 1 of Table 8 is the measurement of the smallest lip opening at rest and during phonation. At rest the difference is considerably larger, but not statistically significant, for the cleft palate group. The two groups show very similar openings for the vowel (Ii For the other two




48
TABLE 8
MEASUREMENTS OF LIP AND MOUTH OPENING AT REST AND PHONATION (All measurements in millimeters)
Rest (i] (a] (u]
1. Lip opening Normal
M 2.66 7.20 14.15 1.75
SD 1.43 2.70 4.70 1.20
SE .43 .62 1.08 .28
Cleft Palate
M 4.80 7.00 19.45 3.10
SD 4.50 5.30 9.40 2.60
SE 1.20 1.22 2.16 .60
Differences
M 2.14 .20 5.30 1.35
SE 1.28 1.37 2.41 .65
t 1.671 .146 2.199 2.077
2. Mouth opening Normal
M 1.00 2.15 12.50 4.65
SD 4.20 3.60 6.00 4.60
SE 1.27 .83 1.38 1.06
Cleft Palate
M 1.46 .15 12.40 2.25
SD 1.78 4.20 7.60 5.00
SE .48 .96 1.74 1.15
Differences
M .46 2.00 .10 2.40
SE 1.35 1.27 2.22 1.56
t .341 1.575 .045 1.538
t (df 25)t 1.0% 2.787; 5.0% 2.060 Rest t (df 38): 1.0% 2.711; 5.0% 2.025 Phonation




49
TABLE 8 Continued
Rest ( i] [ a] ( ]
3. Distance from Normal
Frankfort line M 53.08 55.30 65.85 58.10
to incisal SD 4.61 4.20 6.40 5.60
reference line SE 1.39 .96 1.47 1.28
Cleft Palate
M 55.66 55.25 67.85 58.15
SD 5.50 6.60 8.00 7.80
SE 1.47 1.51 1.84 1.79
Differences
M 2.58 .05 2.00 .05
SE 2.02 1.80 2.35 2.19
t 1.277 .028 .851 .023
t (df 25): 1.0% 2.787; 5.0% 2.060 Rest t (df 38)t 1.0% 2.711; 5.0% 2.025 Phonation




50
vowels the difference is significant at the 5.0 per cent level, with the cleft palate subjects showing the larger measurement. The majority of the experimental group subjects had unrepaired lips, which would have a bearing on the amount of lip opening. Mouth OpeninR
Two measurements were -utilized to establish mouth opening because of the irregularities in dentition introduced as a result of the oral anomaly. The first measurement, the distance between the maxillary and mandibular incisors, would apparently reflect this aberration to a considerable extent. In an effort to eliminate the error which should be inherent in intepicisal measurements, the distance between the Frankfort line and the incisal reference line was also used. No statistically significant differences wore found for either measurement, as shown in items 2 and 3 of Table 8.
A comparison of the two measurements shows some discrepancies, which might possibly be attributed to the irregular dentition of the experimental group subjects. Mouth opening between the incisors was very similar for the two groups at rest and for the vowel (a]. Considerably larger differences, which were very similar in magnitude, were observed for the vowels (ii and (u]. These results reflect those found in the study of repaired cleft palate subjects (4), who showed no statistically significant differences between the groups on mouth opening measurements.* The second measuremerit of mouth opening, the distance between the Frankcfort line and the incisal reference line, would appear to give a more accurate description of mouth opening. This measurement would not reflect dental irregularities as much as the distance between the incisors would. Again, no statistically significant differences were found. However, a complete reversal of the differences was shown. At rest and for the vowel (a], the largest differences were observed, while the differences on inter-incisal distance were very small for these two positions.
The measurement of the distance between the Frankfort line and




51
the incisal reference line showed very slight differences for the vowels (i] and (u]. The differences on the measurements of the distance between the incisors for these two vowels was much larger. It would be difficult to explain the reversal found in comparing the two measures of mouth opening, other than to attribute it to dentition irregularities.
Analysis of Speech Samples
Tape recordings were acquired of the members of the experimental and control groups. Twenty recordings of the experimental group subjects and twelve recordings of control group subjects were spliced in order of random number arrangement. The speech of the control group subjects provided the standard of articulatory correctness among these Spanishspeaking individuals. The tape recordings of the experimental group subjects were first analyzed to determine phonetic accuracy of articulation. The articulation was scored as: 0, correctly produced; 1, distorted; and 2, substituted or omitted. A total of these scores for each individual yielded the articulation score. The maximum score possible was 44. If the speech sound was not produced correctly initially, medially, and finally, an error was noted. The reason for selecting an either-or scoring procedure was that the judges, felt that the sounds would either be correct or incorrect because of the organic factor involved. Clinical evidence observed locally indicates a great deal of consistency in the misarticulations of individuals with repaired cleft palates.
The articulation scores of the experimental group
ranged from 10 to 36, with a mean score of 20. Some of the individual scores seemed to be too high when compared with over-all impressions of intelligibility. This could have
been due to the articulatory inconsistencies observed as the sounds appeared in different positions. If the errors had been noted in the specific positions in which they occurred, the articulation scores may not have been so high.




52
The following symbols were used to represent the sounds peculiar to Spanish: [B], bilabial fricative; d] voiced dental stop or fricative; (t], voiceless dental stop; [n], dental nasal; EN], palatal nasal; [i, dental lateral; (r], single tap lingua-alveolar; rr] trilled lingua-alveolar; [y], voiced palatal fricative; and [z], voiceless velar fricative. The Spanish vowels approximate those of Latin. They are pure vowels and are not diphthongized. There is a tendency to diphthongize all but (a] in English. An actual count of the number of times errors were noted yielded the following sequence, in decreasing order of frequency of occurrence:
Bound Frequency of
Consonants: (rz] 20
(k] 18
[g] 18
(tx] 18
(B] 17
(d] 17
(t] 16
[r] 15
[a] 14
[f] 13
(p] 12
(m] U
(N] 7
[n] 6
(1] 6
(x] 4
(y] 2
Vowels: [i] 10
Ce] 4
Eo] 2
The presence of the unrepaired cleft palates is reflected in the frequency of misarticulation of the two velar plosives, (W and [g. The trilled lingua-alveolar sound [ rr] heard in the speech of the control group subjects was absent in the speech of the experimental group members. The inconsistencies noted in the production of the other sounds possibly indicates the presence of a functional articulation problem. The errors




53
noted for the three vowels, Ci], e], and (o], were primarily distortions. The vowels La] and [u] were produced correctly by all of the subjects. These distortions could have resulted from the structural abnormalities of the oral and nasal resonating cavities.
The second analysis of the tape recordings was concerned with quality, as reflected in deviations from normal oral and nasal resonance. The recordings of the control group subjects were used as the standard for this judgment. A fivepoint scale was used, with a score of 1 representing normal resonance, and a score of 5 representing the greatest deviation from normal resonance. Excessive nasality, denasality, breathiness, harshness, and hoarseness were heard in the voices of the experimental group subjects. In addition, there was another quality observed which has not been appropriately described in any voice text of the author's acquaintance. This phenomenon may be described as a "wide open" quality, for lack of a more scientific designation. There seemed to be a certain hollowness in some of the voices, due perhaps to the presence of a single cavity resulting from the absence of palatal structures. This might be called an oral-nasal cavity. A tabulation of the quality ratings follows:
Rating Nuber of Subjects
1 0
2 2
3 5
4 10
5 3
The mean rating for the group was 3.7. None of the experimental group subjects were judged to have normal quality, and only two of this group approached a normal quality rating. A quality rating that was midway between the two extremes was assigned to five of the cleft palate subjects. More than half of the subjects in the experimental group were considered




54
to have extreme deviations from normal oral and nasal resonance. The relatively small number of cases at either extreme of the scale emphasizes the homogeneity of the quality ratings.
Spriestersbach (27) and Sherman (24) have suggested
that tape recordings of speech samples should be played backward to give more valid ratings of quality. They found that the judges were influenced by articulation in their quality judgments. The judges appeared to be judging articulation rather than qua.lity. Since neither of the judges in the present investigation was conversant with Spanish, it was felt that there was no need to play backward the tape recordings of the Spanish-speaking individuals. In order to insvestigate the influence of articulation on the judges' ratings of quality, a coefficient of correlation was computed between the ratings of articulation and quality. This correlation was -.08# which indicates that the articulation of the Spanish-speaking subjects had no apparent effect on the judgments of quality.
It is of interest to note a few of the actual scores of the individuals with unrepaired cleft palates who fell at the extremes of the distribution of the articulation scores. The subjects who had the largest number of articulation errors had ratings of quality of 3 and 4. The subjects with the smallest number of articulation errors had quality ratings of 3, 4, and 5. A complete tabulation of these combined data is presented in Table 9.
Further analyses of the speech of individuals with unrepaired cleft palates, which will be forthcoming as the parent study continues, should be of interest. Further comparison based on the analysis of the tape recordings of the present study was not considered necessary at this time. The presence of the oral anomaly in the experimental group undoubtedly
accounted for some of the deviation from the speech standard of the normal group. It is felt that much of the faulty
articulation of the individuals with unrepaired cleft palates is more than likely functional, and may be due only in part to the oral anomaly.




55
TABLE 9
COMPARISON OF ARTICULATION SCORES AND QUALITY RATINGS OF
INDIVIDUALS WITH UNREPAIRED CLEFT PALATES
Number of Articulation Quality
Subjects Scores Ratings
1 10 5
2 11 3, 4
3 14 39 4, 5
1 16 2
3 18 4, 4, 4
1 19 2
3 20 3, 4, 4
1 22 4
1 26 5
1 28 4
1 32 3
1 34 3
1 36 24
Articulation was scored as: 0, correctly produced; 1, distorted; and 2, substituted or omitted. The possible range of scores was 0 to 44. A mean articulation score of 20 was computed.
Quality was rated on a five-point scale, a continuum of 1 through 5. Number 1 represents normal oral and nasal resonance; 3 represents a moderate deviation from normal resonance; and 5 represents the most extreme deviation from normal resonance. A mean quality rating of
3.7 was computed.




CHAPTER IV
SUMMARY ANDI CONCLUSIONS
Twenty Puerto Rican adults with complete, 'unrepaired cleft palates formed the experimental group of the present study. The criteria for inclusion in this group were that the oral anomalies had had no surgical or prosthetic treatment, and that the individuals had reached physical maturity.
Cleft lips in these individuals could have been repaired or unrepaired. A control group was composed of twenty normally structured adult Puerto Ricans, who met the criteria of having achieved normal structural growth and of possessing the normal speech and hearing of Puerto Ricans. The age range covered by the groups was fifteen to fifty-seven years. Pleagle (7) has suggested that his findings confirm the generally accepted theory that individuals mature earlier in the tropics than they do in a temperate climate. Hence, the presence of the youngest members of the groups does not appear to be incompatible with the criteria imposed.
Three lateral X-ray plates were obtained on each of the forty subjects, during phonation of the vowels (i], (a], and (u]. Twenty-seven lateral X-ray plates at physiologic rest were also available for the two groups. Bach lateral plate was traced and measured. Measurements were taken directly from the twenty-two antero-posterior plates available for the two groups. All of the measurements were subjected to statistical analysis.
Tape recordings of all of the experimental group subjects and several of the control group subjects were analyzed to determine phonetic accuracy of consonants and vowels, and quality differenoes as reflected in deviations 56




57
from normal oral and nasal resonance.
The following conclusions may be drawn from the data:
1. Measurements of maxilla length, mandible length
and width, oral cavity length, and width of the naso-pharynx revealed no statistically significant differences between the two groups. The cleft palate subjects demonstrated a wider mean maxilla width, significant at the 5.0 per cent level of
confidence (Table 1).
2. The two groups did not differ with statistical
significance on measurements related to tongue size and the horizontal position of the tongue (Table 2).
3. Pharyngeal opening measurements on and below the incisal reference line did not differ with statistical significance, except for the vowel [i] when the measurement was made on the reference line (Table 3). It is suggested that differences in tongue shape may account for the apparent irregularity to be observed in the table.
4. No statistically significant differences were
found on measures of vertical tongue height above the incisal reference line. The two groups differed with statistical significance on the vertical distance between the tongue and the hard palate when phonating the vowel (A] The vertical distance between the Frankfort line and the tongue showed a statistically significant difference only at rest (Table 4). Discrepancies observed in a comparison of the last two measurements may be due to structural deviations.
5. The nature of the urirepaired anomaly seems to be reflected in the measurements of tongue movement (Table 5). While the differences in vertical tongue movement were not significant statistically, there was a marked tendency for greater upward movement in the cleft palate group on the vowels [a] and (u]. Differences in horizontal movement of thae tongue were statistically significant only for the vowel [ul. However, a marked tendency for greater posterior movement was observed for the vowel [a].




58
6. Measurements of velo-pharyngeal opening during phonation revealed very large differences between the two groups, which were statistically significant beyond the 1.0 per cent level. The range of mean differences was from 6.9 millimeters to 8.95 millimeters, with the cleft palate subjects having the larger opening on each vowel (Table 6).
7. Area measurements of the posterior pharyngeal wall at the level of the tubercle of the Atlas did not differ with statistical significance for the two groups (Table 6).
8. Measurements of movement on the lines constructed within the area of the posterior pharyngeal wall were very slight in magnitude, and differed significantly, at the
5.0 per cent level of confidence, only for the vowel Lu] at level 5 (Table 7). The cleft pal.- te subjects showed consist. ent posterior movement at this level, while the normal subjects showed consistent anterior movement. The same types of movement were observed in the two groups at the next lowest level, but no statistically significant differences were found.
9. A larger lip opening, which was statistically
significant, was found for the cleft palate group on the vowels [a] and Lu] (Table 8). The presence of unrepaired cleft lips in the experimental group might possibly account for these differences.
10. The two groups were found not to differ with statistical significance on measurement of mouth opening between the incisors or when measured from the Frankfort line to the incisal reference line (Table 8).
11. The articulation analysis of the speech of the experimental group subjects revealed many inconsistencies. It is felt that the oral anomaly accounts for some, but not all, of the articulation errors.
12. The quality analysis of the tape recordings of the experimental group subjects revealed marked deviations from the quality of the control group subjects. These




59
deviations are to be considered largely due to the unrepaired cleft palates and the virtual absence of palatal structures.




CHAPTER V
DISCUSSION
The two groups in the present study were found to be very similar on external, skeletal measurements. The only statistically significant difference observed on structural measurements was that regarding maxilla width. This difference may be due to the pull of muscles on the open suture, and would appear to be in agreement with 3ubtelny's
(28) indications in his study of pre-operated cleft palate children. Subtelny also suggested, as did Slaughter and Pruzaneky (26), that lip repair naas a tendency to narrow the palatal cleft. Although no definite conclusion can be reached in this respect in the present study, it is interesting to speculate on the available data. Six members of the
experimental group who nad lip repair at undisclosed ages showed a mean maxilla width of 68.33 millimeters. A mean maxilla width of 69.75 millimeters was found using the measurements of four experimental group subjects who had no lip repair. There is a difference between these two measurements of less than 1.5 millimeters. Some questions arise in view of these highly speculative findings. While the individuals with repaired lips showed a slightly narrower maxilla width, is it necessarily the lip closure which caused this? In view of the fact that the time of the lip repair is not known for these individuals, a second question arises. Need there be any concern as to when the lip is repaired? The answers to these questions by future investigations would be interesting and valuable.
The measurements of the smallest velo-pharyngeal
openings during phonat ion revealed wider openings in the cleft palate group, which were significant beyond the 1.0 per cent
6o




61
level of confidence. The exact nature of muscle movement in the unrepaired velum is difficult to ascertain. There appeared to be a complete lack of movement in these tissues. It is felt that the variations in the measurements at rest and for the vowels were due to movement of the velum as it came in contact with the posterior-superior surface of the tongue. However, in his study of individuals with repaired cleft palates, Buck (5) also found wider velo-pharyngeal openings during phonation for his experimental group.
In essence, a comparison of the measurements of a group of physically mature individuals witn complete, unrepaired cleft palates and a normally structured group of adults of the same national origin emphasizes the basic similarities between the two groups.
Buck's (3) repaired cleft palate subjects differed significantly from a matched control group on measures of over-all vertical and antero-posterior dimensions of the face, midsagittal measurements of the tongue, tongue height in the oral cavity, and velo-pharyngeal opening during phonation. When the experimental group of the present study was compared with the repaired cleft palate subjects, the only similarity found was in the wide velo-pharyngeal openirngs during phonation. Is it the surgery or the cleft itself which causes the aberrations in velar movement and size? It may be that muscle discontinuity in the cleft soft palate, repaired and unrepaired, is influential in producing similar phenomena in the two groups. The repaired cleft palate subjects also demonstrated smaller over-all antero-posterior facial dimensions, smaller midsagittal measurements of the tongue, and lower tongue height in the oral cavity. The unrepaired cleft palate group approximated normal facial dimensions. While the unrepaired cleft palate group showed some smaller midsagittal tongue measurements and some lower tongue height than their control group, there were no consistent tendencies on either measure.




62
A comparison of groups of individuals with repaired and unrepaired cleft palates indicates that the unrepaired group show more normal external, skeletal measurements on lateral X-ray plates. It should be remarked here, however, that the experimental group of the present study did show some minor structural and functional deviations which are evidently in harmony with the unrepaired anomaly. For example, no consistent trends were observed in measurements related to tongue carriage or tongue movement. However, the greater posterior movement and posterior and superior tongue carriage on the vowels (a] and (u] seemed to be due to an attempt to fill the void in the palatal structures. Another example of a minor structural and functional deviation is found in the measurement of wider lip opening on the vowels (a] and (u], which reflects the presence of the unrepaired lips in the experimental group.
There is much clinical evidence to support the frequent occurrence of hearing losses in individuals with repaired cleft palates. The vast majority of the individuals in the experimental group of the present study were found to have normal hearing. Only two of the experiental group subjects had hearing losses which might be attributed to their cleft conditions. These losses were bilateral, uniform, and mild in both ears. Is it possible that there is surgical interference with the growth process of the musculature around the orifices of the Eustachian tubes? This may be a partial explanation of the hearing problems so often seen in individuals with repaired cleft palates.
Analyses of the tape recordings of the experimental group subjects revealed that the unrepaired cleft palate did have an effect on their articulation and quality. It would be difficult, and perhaps unwise, to attempt to state the exact nature of this effect. Many inconsistencies in articulation were noticed in listening to the recordings.




63
Although the velar plosives were among the most frequently misarticulated sounds, they were observed to be produced adequately in some instances. As in the case of many individuals with repaired cleft palates, a number of the articulatory problems seemed to be functional rather than organic. It would seem that an early program of psychological counselling and speech training would have been of great value to these people. The occurrence of a correctly articulated sound in some intra-word positions supports the theory that speech training would have produced more consistently correct articulation as these individuals matured. The effect of the unrepaired anomaly on quality judgments was not as marked as might be expected. Even though none of the individuals in the experimental group were judged to have normal quality, they did not all present the same degree of deviation from normal. An examination of the palatal casts, which will be available on these subjects in the future, should shed some more light on the analyses of the recordings. It is possible that those individuals who had a complete and wide cleft were those who were more likely to be judged to have near normal quality.
In summary, the present study has presented results which lend support to the findings of Graber (8), Krogman
(17), Slaughter and Brodie (25), and Buck (4), among others. These studies stress the interference of early surgery with superior facial growth in individuals with cleft palates. The various measurements and the analyses of the tape recordings of the present study would seem to lend support to the desirability of prosthetic treatment in individuals such as those in the experimental group. It is gratifying to note that many cleft palate treatment t 'eams are considering the insertion of speech appliances as early as possible. This not only aids speech and psychological development, but allows time for more structural growth to assist in potential surgical consideration.




LIST OF REFERENCES
1. Brader, A.C., The application of the principles of cephalometrio laminagraphy to studies of the frontal planes of the human head. American Journal of Orthodontics, 35,
1949, 249-268.
2. Brodie, A.G., Some recent observations on the growth of the face and its implications to the orthodontist. American Journal of Orthodontics and Oral Surgery, 2",
1940, 741-757.
3. Buck, M.W., An X-ray study of cleft palate oral and pharyngeal structures and their functioning during vowel
phonation. Ph.D. Dissertation, State University of Iowa,
1951.
4. Buck, M., Facial skeletal measurements and tongue carriage in subjects with repaired cleft palates. Journal
of Speech and Hearing Disorders, 18, 1953, 121-132.
5. Buck, M., Post-operative velo-pharyngeal movements in cleft palate cases. Journal of Speech and Hearing Disorders, 19, 1954, 288-294.
6. Calnan, J., The error of Gustav Passavant. Plastic and Reconstructive Surgery, 13, 1954, 275-289.
7. Pleagle, P.K., Social Problems in Puert Rico. Boston, New York, and Chicago: D.C. Heath and o., 1917.
8. Graber, T.M., Cranoifacial morphology in cleft palate and cleft lip deformities. Surgery, Gynecology and
Obstetrics, 88, 1949, 359-369.
9. Hagerty, R., and Hoffmeister, P.S., Velo-pharyngeal closure; an index of speech. Plastic and Reconstructive
Surgery, 13, 1954, 290-298.
10. Hagerty, R.F., Hill, M.J., Pettit, H.S., and Kane, J.J.,
Posterior pharyngeal wall movement in normals. Journal
of Speech and Hearing Research, 1, 1958, 203-210.
11. Hagerty, R.F., Hill, M. J., Pettit, H.S., and Kane, J.J.,
Soft palate movement in normals. Journal of Speech and
Hearing Research, 1, 1958, 325-330.
64




65
12. Harrington, R., A note on a lingua-velar relationship.
Journal of Speech Disorders, 11, 1946, 25.
13. Harrington, R., A study of the mechanism of velopharyngeal closure. Journal of Speech Disorders, 9,
1944, 325-345.
14. Herzberg, F., and Holic, R., An anthropologic study of
face height. American Journal of Orthodontics and Oral
Surgery, 29, 1943, 90-100.
15. Hixon, E.H., An X-ray study comparing oral and pharyngeal
structures of individuals with nasal voices and individuals with superior voices. M.S. Thesis, State University of Iowa, 1949.
16. Howell, E.T., An investigation of cinefluorographic
techniques, procedures, and equipment pertinent to the
study of speech structures and their movement. M.A.
Thesis, University of Florida, 1955.
17. Krogman, W.M., The problem of the cleft palate face.
Plastic and Reconstructive Surgery, 14, 1954, 370-375.
18. Norris, M.A., X-ray studies of vowel production as it
is related to voice. M.A. Thesis, State University of
Iowa, 1934.
19. Parmenter, C.E., and Trevino, S.N., Vowel positions as
shown by X-ray. Quarterly Journal of Speech, 18, 1932,
351-369.
20. Ricketts, R.M., The cranial base and soft structures
in cleft palate speech and breathing. Plastic and Reconstructive Surgery, 14, 1954, 47-61.
21. Russell, G.O., First preliminary X-ray consonant study.
Journal of the Acoustical Society of America, 5, 1934,
T47-25 1.22. Russell, G.O., Speech and Voice. New York: MacMillan,
1931.
23. Russell, G.O., The mechanism of speech. Journal of the
Acoustical Society of America, 1, 1929, 83-109.
24. Sherman, D., The merits of backward playing of connected
speech in the scaling of voice quality disorders.
Journal of Speech and Hearing Disorders, 19, 1954, 312321.




66
25. Slaughter, W.B., and Brodie, A.G., Facial clefts and
their surgical management in view of recent research.
Plastic and Reconstructive Surgery, 4, 1949, 311-332.
26. Slaughter, W.B., and Pruzansky, S., The rationale for
velar closure as a primary procedure in the repair of
cleft palate defects. Plastic and Reconstructive
Surgery, 13, 1954, 341-357.
27. Spriestersbach, D.C., Assessing nasal quality in cleft
palate speech of children. Journal of Speech and Hearig Disorders, 20, 1955, 266-270.
28. Subtelny, J.D., An X-ray study of width of nasopharynx
and related anatomical structures in normal and preoperated cleft palate children. American Association for Cleft Palate Rehabilitation Newsletter, 3, 1953,
29. Subtelny, J.D., The significance of early orthodontia
in cleft palate habilitative planning. Journal of
Speech and Heariim Disorders, 20, 1955, 135-147.
30. Townshend, R. H., The formation of Passavant's bar.
The Journal of Laryngology and Otolouy, 55, 1940, 15431. Williams, R.L., A serial radiographic study of velopharyngeal closure and tongue position in certain vowels.
Northwestern University Bulletin, 52, 1952, 9-12.
32. Wolfe, W.G., X-ray study of certain structures and
movements involved in nasopharyngeal closure. M.A. Thesis,
State University of Iowa, 1942.
ADDITIONAL REFERENCES
1. Berry, M.P., Lingual anomalies associated with palatal clefts. Journal of Speech and Hearing Disorders, 14,
1949, 359-362.
2. Bloomer, H., Observations on palatopharyngeal movements in speech and deglutition. Journal of Speech and Hearing
Disorders 18, 1953, 230-246.
3. Brown, S.F., and Oliver, D., A qualitative study of the
organic speech mechanism abnormalities associated with
cleft palate. Speech Monographs, 6, 1939, 127-146.




67
4. Graber, T.M., Changing philosophies in cleft palate management. Journal of Pediatrics, 37, 1950, 400-415.
5. Johnson, W., Brown, S.P., Curtis, J.F., Edney, C.W., and Keaster, J., Speech Handicapped School Children.
New York: Harper, 1956.
6. Kaltenborn, A.F., An X-ray study of velo-pharyngeal closure in nasal and non-nasal speakers. M.A. Thesis,
Northwestern University, 1948.
7. Matthews, J., and Byrne, M.C., An experimental study of tongue flexibility in children with cleft palates.
Journal of Speech and Hearing Disorders, 18, 1953, 4347.
8. McDonald, E.T., and Koepp-Baker, H., Cleft palate speech: an integration of research and clinical observation. Journal of Speecn and Hearing Disorders,
16, 1951, 9-20.
9. Parmenter, C.E., and Bevans, C.A., Analysis of speech radiographs. American Speech, 8, 1933, 44-56.
10. Pruzansky, S., The role of the orthodontist in a cleft
palate team. Plastic and Reconstructive Surgery, 14,
1954, 10-29.
11. Travis, L.E. (Ed.), Handbook of Speech Pathology. New
York: Appleton-Century-Crofts, Inc., 1957.
12. Van Riper, C., and Irwin, J.V., Voice and Articulation.
Englewood Cliffs, N.J.: 1958.
13. Wardill, W.E.M., Cleft palate. The British Journal of
Surgery, 16, 1928, 127-148.




BIOGRAPHICAL NOTE
F. X. Calvin Knobeloch was born in Tell City,
Indiana, on August 5, 1925. He was graduated from Tell City Hign School in 1943, and received his Bachelor of Science in Education degree from Indiana University in 1949. A year of graduate study was completed at Indiana University from 1949 to 1950. He served in the United States Marine Corps from November, 1943, to May, 1946, and from September, 1950, to October, 1951. On July 5, 1953, he married Sheila Ann Richeson. Their daughter, Katherine, was born September 24, 1957, and their son, Timothy, was born April 25, 1959.
From September, 1958, to August of 1959, Mr. Knobeloch held the position of senior clinician in the Speech and HearingClinic at the University of Florida. Prior to this appointment, he held tne following positions: speech correctionist, Alachua County (Florida) Public Schools, 195758; graduate assistant in Speech and Hearing, University of Florida, 1956-57; graduate assistant in Theatre, University of Florida, Spring and Summer Semesters, 1956; remedial reading and English teacher, South Side Junior High School, St. Petersburg, Florida, 1954-55; speech teacher, New Albany (Indiana) Senior High School, 1951-54; and graduate assistant in Speech, Indiana University, 1949-50.
Mr. Knobeloch is a member of Sigma Alpha Eta, national honorary speech and hearing fraternity; Alpha Kappa Delta, national sociological honor society; Theta Alpha Phi, national dramatics honorary fraternity; and Chi Gamma Iota, veterans' scholastic honorary fraternity. He is also a member of the American Speech and Hearing Association and the Florida Speech and Hearing Association.
68




This dissertation was prepared under the direction of the chairman of the candidate's supervisory committee and has been approved by all members of that committee. It was submitted to the Dean of the College of Arts and Sciences and to the Graduate Council, and was approved as partial fulfillment of the requirements for the degree of Doctor of Philosophy. August 8, 1959
Dean, Coliege of Arffs ad Sciences
Dean, Graduate School
SUPERVISORY COMMITTEE: Chairman
L, A




Full Text

PAGE 1

An X-Ray Study of Unrepaired, Complete Cleft Palate Oral-Pharyngeal Structures and Their Functioning During Vowel Phonation By F. X CALVIN KNOBELOCH A DISSERTATION PR ESE NT E D TO TH E GRAD UATE C OUN C IL OF TH E U NIV E RSITY OF F L OR ID A IN PARTIAL FULFILLMENT OF THE REQUIREM E NTS FOR THE DEGR EE O F D O C T O R O F PHIL OSO PHY UNIVERSITY OF FLORIDA August, 1959

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ACKNOWLEDGMENTS The writer wishes to express his gratitude and in debtedness to Dr. McKenzie Buck, chairman of his supervisory committee, who has been a constant source of encouragement and inspiration. As a member of the national research group which conducted the parent study, Dr. Buck arranged for the use of the X-ray plates and tape recordings utilized for purposes of an a lysis in this study. The writer would also like to express his sincere appreciation to Professor H.P. Constans who, as the original chairman of his supervisory committee, has been most helpful with his advice and cooperation in the planning of the writer's doctoral program. Further expression of appreciation is extended to Dr. J.M. MacLachlan and Dr. W.W. Ehrmann of the Department of Sociology, and to Dr. L. L. Zimmerman and Dr. C. K. Thomas of the Depart m ent of Speech, for their of the writer's supervisory committee. writer would like to extend his thanks cooperation as members In addition, the to Dr. R. E. Tew and Dr. D. A. Harrington, who were original members of his super visory committee. Special expression of appreciation is extended to Frank E. Law, D.D.S., Chief, Operational Research Branch, Division of Dental Public Health, Washington, D.c., who organized the study team which collected the raw data for the present study. The writer would also like to express special appreciation to the citizens of Puerto Rico who participated in the study. The acknowledgments for this study would be wholly inadequate without an expression of appreciation to the writer's wife for her devotion, encouragement, cooperation, ii

PAGE 3

and understanding during his doctoral program. Although they are too young to realize, the writer is indebted to his chil dren for the source of inspiration which they are. iii

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TABLE OF CONT ENTS ACKNOWLEDG MEN TS . Page 11 LIST OF TABLES Chapter V I. INTRODUCTION . . . . II. DESCRI.PTION OF PROCEDURE . . 1 10 Selection and Matching of Subjects 10 Procedure for Recording and Analysis of Speech Samples 12 Apparatus and Procedure for Obtaining X-ray Plates 15 Measurements of the X-ray Plates 18 III. RESULTS . . 23 Facial and Oral Cavity Dimensions 23 Measurements Related to T ongue Size and the Horizontal Position of the High Point of the Tongue 27 Vertical Tongue Position 31 Excursion of the Tongu e from Rest to Vowel Positions 35 Measurements of the Naso-pharyngeal Structures 39 Lip and Mouth Opening. 47 Analysis of Speech Samples 51 IV. SUMMARY AND CONCLUSIONS . . V. DISCUSSION LIST OF REFERENCES . . . . 56 60 64 iv

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LIST OF TABLES Table l. MEASUREMENTS OF MAXILLA, MANDIBLE, ORAL CAVITY, AND DISTANCE FROM TERMINATION OF HARD PALATE TO POST E RIOR PHARYNGEAL WALL AT REST 2. MEA S UREMENTS RELATED TO TONGUE SIZE AND HORIZONT A L POSITION OF HIGH POINT OF TONGUE Page 24 ON INCISAL REFERENCE LINE. 28 3. MEASUREMENTS OF THE PHARYNGEAL OPENINGS ON AND BELOW THE INCISAL REFERENCE LINE 4. VERTICAL MEASUREMENTS OF TONGUE HEIGHT 5. MEASUREMENTS OF M OVEMENT OF TONGUE FROM REST TO VOWEL POSITIONS 6. MEASUREMENTS OF OPENING OF THE VELO-PHARYNGEAL STRUCTURES AND AREA OF POSTERIOR PHARYNGEAt 30 32 36 WALL AT THE LEVEL OF THE TUBERCLE OF THE ATLAS 40 7. MEASUR.EJ.Vi.ENTS OF MOVEMENT OF THE POSTERIOR PHARYNGEAL WALL AT THE LEVEL OF THE TUBERCLE OF THE ATLAS 43 8. MEASUREMENTS OF LIP AND MOUTH OPENING AT REST AI'f""'D PHONATION. 48 9. COMPARISO N OF ARTICULATION SCORES AND QUALITY RATINGS OF INDIVIDUALS W ITH UNREPAIRED CLEFT PA:LATES 55 V

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CHAPTER I INTRODUCTION Various scholars have used the X ray in speech inves tigations since its discovery in 1895, according to Parmenter and Trevino (19). Of primary significance, at least in terms of stimulating thought and further investigation, were the studies of Russell (21, 22, 23). He utilized X-ray techniques in his studies of vowel and consonant production in normal subjects. Parmenter and Trevino (19) criticized Russell princi pally for his presentation of evidence against a physiologi cal basis for vowel differentiation. They felt that Russell's interpretation of his X-ray plates was correct, but they were of the opinion that his technique for maintainin g a fixed posture during exposure was inadequate. For their X-ray investigation of normal subjects, they devised a head poai tioner which appeared to control the head adequately in a horizontal plane. There is some question as to the control afforded the head in the antero-posterior plane. The results of their study supported the hypotheses of a pro g ression of tongue positions as the vowels are produced in traditional order, and of a fairly definite tongue position for each vowel for each individual studied. The criterion of a fixed and constant head position during X-ray exposure continued to receive attention in sub sequent studies conducted on normal subjects. In 1934, Norris (18) utilized a head positioner developed by Higley in her study of vowel production in a dults as it is related to voice. Norris' conclusions concerning nasality and denasality indi cated a wide uvular opening or a thinning of velar tissue for l

PAGE 7

the former, and a complete uvular closure or a thickening of the velum for the latter. Further investigation of naeo-pharyngeaJ. closure in adults was done by Wolfe (32) in 1942. Recognizing the lim itations of lateral X-ray plates, he reported that his data seemed to reveal only a shortening of the antero-posterior diameter of the na.eo-pharynx. His data also indicated upward and backward movement o! the velum, together with a slight forward movement of the posterior pharyngeal wall. Thie series of movements effected a naso-pharyngeal closure which was not complete for most of his subjects. He found that greater anterior movement of the posterior pharyngeal wall was accompanied by less posterior movement of the velum, and vioe versa. Comparing oral and pharyngeal structures of adults with nasal voices and adults with superior voices, Hixon (15) found that the over-all vertical and antero-poeterior dimensions of the face were very similar for both groups. The measurements of the midsagittal diameter of the pharynx and the midsagittal measurements of the tongue indicated that the tongue was carried further posteriorly in the nasal group while at rest and for the vowel(a], with a tendency in this direction for[ae] Hixon also commented on his findings regarding naso-pharyngeal structures, but he reported that these structures were not clearly defined on his X-ray plates. The study contained his recommendations to clarify this problem;!.!, the use of slower speed cassettes, the use of a lead focusing plate, and painting the entire inferior margin of the soft palate in order to differenti a te the uvula from the soft palate proper. While the study conducted by Brodie (2) was also concerned with subjects with normal structures, it differed from the preceding investigations in that it was longitu dinal in aspect. Brodie indicated that the use of an X-ray

PAGE 8

technique in growth studies had been predicted as early as 1922, but that its development was not perfected for this purpose until 1931. In that year Broadbent published the full details of a roentgenographic cephalometer and began 3 a long range investigation of the head of the growing child. Brodie summarized his own investigation with the statement that a longitudinal study of growing children indicated that the morphogenetic pattern of the individual was es~abliahed at a very early age. Once this pattern was attained, he found that it did not change. Herzberg and Helie (14) reported that their findings confirmed Brodie's results by anthropologic methods. Their findings were based on measure obtained from three hundred and twenty-six adult human skulls. Growth studies have also been conducted using cleft palate subjects. Graber (8) reported his analysis of the developmental patterns and facial morphology in cleft palate. As a group, his subjects showed deficient patterns of maxil lary growth, laterally, antero-posteriorly, and vertically. He indicated that patients whose palatal clefts had not been manipulated surgically showed a pattern of maxillary growth that was essentially normal. Mandibular growth on the whole appeared normal. The lack of development noted in mandibu lar growth in Graber's subjects was considered to be no more than would be found in the same distribution of normal subjects. Graber's chief contention, it would seem, was a serious consideration of the propriety of early closure of cleft palates. Postponement of surgery until the end of the fourth year of life was indicated, at which time the majority of total maxillary width had been accomplished. A necessary further precaution was pointed out due to a continuation of downward and forward growth of the maxilla until twenty ye a rs of age. Krogman (17) offered some support of Graber's (8) findings regarding the g rowth of unrepaired structures in

PAGE 9

4 his report of cumul.ative X~ray studies done at the Philadel p h ia Center for Research in Child Growth. He stated that the postnatal growt h patterns of unrepaired cleft pala t e and normal faces did not differ, except that growth in the former proceeded in keeping an d in h armony wit h the basic deviation initially introduced by the cleft. He felt that an optimum time for surgical procedure would be somewhere between four and six years of age, and possibly as early as two to three ye a rs of age if the growth tempo of the individual child was such that there was evidence of advanced growth. Harrington (13) confirmed Wolfe's (32) questioning of the nature of velo-pharyngeal closure with the results of his study of ten cadavers and the X rays of three living subjects. T h e various aspects of his investig a tion led him to the conclusion th a t mesial movement of the pharyngeal w alls occurre d over considerable vertic a l extent, r a ther than as a continuation of Passavant's cushion. Conse q uently, the mech anism acting to produce velo-phary ng eal closure w a s not of the nature of a si m ple sphincter. A similar p he n omenon was sug g ested earlier by Townshend (30) in his critique of the formation of Passav a nt'e bar. Using X rays, pla s ter models, and photographs, Slaughter and Brodie (25) concluded t n eir study with state ments that further supported Graber's (8) contention re garding the impropriety of early surgical repair of cleft palates. They also presented statements to support Graber (8) and Krogman's (17) remarks on the essentially normal growth rate of congenitally deformed parts w hich were not permanently damaged. Buck (4, 5) conducted an X-r a y study of or a l and phar y ngeal structures in patients, ranging in age from seven to ninetee n years, wh o h a d surgically repaired cleft pal a tes. H i s f i ndings re g a rding over-all vertic a l and anterop osterior dimens ion s of the face further substantiated Graber's (8)

PAGE 10

premise of the interference of early surgical closure with growth. Buck found smaller midsagittal measurements of the tongue in his cleft palate subjects, as did Hixon (15) in his non-cleft nasal subjects. Concerning mids a gittal pha ryngeal diameter on and below the incisal reference line, Buck found measurements for his two groups to be very similar. Proportional measurements of the horizontal position of the high point of the tongue, which took into consideration the structural differences between the two groups, were also very similar. These measurements failed to support Hixon's conclusion on posterior tongue carriage. Lower tongue carriage in the oral cavity was indicated by Buck when he found a tendency for the cleft palate subjects to show a greater vertical distance between the hard palate and the tongue. Regar d ing vela-pharyngeal movement, Buck reported significantly larger openings for his cleft palate subjects, smaller horizontal and predominantly vertical movement of the velum in the cleft palate group, and very small posterior pharyngeal wall movement for both groups. He also found no significant differences between the two grou p s on measures of mouth and lip opening. The error of Gustav Passavant was commented on by Calnan (6), who based his contentions on clinical. and radi ologioa.l evidence. Pasaavant had observed his ridge in a \ normal subject, but he failed to explain why it was observed 1n only one in fifty patients. Calnan felt that Passavant'a phenomenon could b e a en in unre pa ired cleft palates, but with an occ u r rence 1n. less than 25 per cent of cases. He explicitly denied t hat tn e phenomenon was a factor in normal. speech. Hagerty and Hoff m eister (9) felt that the cleft pal a te was closed p rim a rily to im p rove speech. They o~ fered a quantitative mea s ure of speech as an indicator of success in palatal closure, if no other dam a ge was incident 5

PAGE 11

6 to the closure. It was hypothesized that measurements of the minimal velo-phary ngeal distance taken during p rolongation of ( s] e nabl ed t hem to pre dict nasa lity from the X ray with about 75 per ce nt accur a cy. Lamina g rap hy a recent development in X-r a y studies, has been utilized in some of the more recent cephalometric investi ga tions. This is a technique for obtai n ing m easure ments of tissues which lie in planes from t h e surface to the midline. The tube and film of the laminagraph move during exposure, and the X ray penetrates deeper each time it passes over a body. Brader (1) pointed out th a t this technique per mits projection of any selected plane of a body to the ex clusion of all other planes To illustr a te, structures l y ing 1n the plane of the vertical process of the maxilla, in the plane of the nasal turbinate s and in t h e p la ne of the nasal septum could be viewed on successive lami nag raphic plates. Static X-ray plates pre3ent a view only of the mid sagittal plane. Brader further st a ted th at l aminag raphy made possible the v isualization of certain anatomical structures or pathologic lesions which are not susce p tible to clear projec tion by any other method. Br a de r conducted p reliminary te sts to deter m ine the accuracy with which images in laminagraphic projection might be m e a s ured. These tests in dic a ted that such measurements lay within the limits of scientific accuracy, i._!., within one-half millimeter of direc t measl.lX e ments In 1953, Subtelny (28) reported his findings of a lamin a graphic investig a tion of the w idt h of t he naso-pharynx and rel ated structures in normal and pre -oper a ted cleft palate children. The subjects were all under t h ree years of age and ninety-one unoperated cleft palate pat ients were included in the s tu dy Perhaps the most striking finding re p orte d was the indic a tion of an abnor m ally w ide naso-pharynx in t h e cleft pal a te individuals. The bi-hamu.lar measurement, which is the distance between the inferior termin a tions o f the medial pterygoid plates of t he sphenoid bone, was f ound to be

PAGE 12

larger for this group. The outward flare of these medial plates was found to increase as they descended. Subtelny hypothesized th a t certain muscles pulled on the open embryonic su ture to cre~te this wider dime ns ion. He in troduced an element of doubt as to the validity of this hypot h esis when he commented on certain of these muscles which could have the opposite effect on the suture. The lateral pressures on the open suture cre a ted by the tongue might augment the widening effect. In the case of a re paired lip, the buccinator muscul a ture is such that it should have a restraining effect. Subtelny commented that there appeared to be a levelling off in naeo-pharyngeal. width growth during the second year of life. Ricketts (20) laminagraphic study stressed the need for a more complete understanding of the basicranial structures. He cautioned that inferences from height and depth dimensions projected on lateral X-r a y films were not conclusive. In view of Subtelny's (28) finding on naso pharyngeal dimensions and the findings of his own study, he concluded that the actual size of the adenoid was not as important in velo-pharyngeal closure as the available space that it filled in the naso-pharynx. He was 1n greement with Graber (8) in stressing the importance of the descending growth of the hard pal a te in evaluating the individual condition Without an increased range of ac tivity in the soft palate, this descent seemed to expl ai n two circumstances; the frequently experienced increased nasal emission 1n postoperative cleft palate patients after the age of six to eight years, and the almost spontaneous disappearance of mouth breathing in some patients in this same age group. A discussion of the significance of early ortho dontia in cleft palate habilitative planning by Subtelny (29) included references to a laminagraphic study he had 7

PAGE 13

completed on repaired cleft lip and cleft palate children prior and subsequent to surgical reconstruction of the lip. He found that the molding action of the lip was not re stricted to the alveolar border alone, but might cause an architectural rearrangement involving each maxilla. In many cases that demonstrated this movement, Subtelny found that the maxillary constriction was severe enough to bring about contact between the inferior nasal turbinate and the nasal septum. This condition he offered as a possible ex planation for the distortion of nasal sounds in cleft palate speech, which has been described as a hyponasality super imposed on the hypernasal quality. 8 Hagerty, Hill, Pettit, and Kane (10) reported a laminagraphic study concerned with posterior pharyngeal wall movement in normal adults. They concluded that it was doubt ful whether the actual extent of excursion of the posterior pharyngeal wall was significant enough to make important differences in speech. Exception to this conclusion would occur when the individual possessed a Passavant's bar large and vigorous enough to participate actively in closure. These authors also reported on soft palate movement in normal adults (11). In the absence of a vigorous Passavant's bar, it seemed evident that the soft palate participated far more aggressively than the posterior pharyngeal wall in the reg ulation of the naso-pharyngeal aperture during speech. Pass a vant's bar was seen in only nine of eighty subjects, and was functional in only three. These findings sup p ort those of Wolfe {32) on the participation of the velum in velo pharyngeal closure. The preceding discussion of static X-ray investiga tions forms the background for the present study. Graber (8), Krogman (17), and Slaughter and Brodie (25) have suggested that the growth pattern of the structures of individuals with unrepaired cleft palates proceeded as in

PAGE 14

9 normally structured individuals. Krogman offered the quaJ. ific a tion that such growth would be in keeping and in harmony with the deviation intro d uced by the anomaly. The study by Buck (3), using individuals with repaired cleft palates, offered support to their contentions. A special case in Buck's investigation revealed that the cleft pal a te individ ual whose speech was judged aa having relatively little nasality differed chiefly from the other cleft palate subjects in only two respects: (1) the relatively normal size of his f a cial and oral structures, and (2) in his being able to achieve a fairly com pl ete closure of the nasal port. It is of interest to note that Buck reports this individual to have undergone only lip repair prior to his seventeenth year. At the age of seventeen surgical repair was performed on the hard and soft pal a tes. Severai questions, based on sug g estions derived from the foregoing review of liter a ture, constitute the basis for the present study: l. How does a group of physically mature individuals with complete, unrapaired cleft palates compare wit h a similar group of normally structured individuals of the same national origin? 2. How does a group of physically mature individuals with complete, unrepaired cleft palates compare with other cleft pal a te individuals who have undergone surgical repair prior to maturation? 3. What effect does the presence of the unrepaired anomaly have on the speech of the adult?

PAGE 15

CHAPTER II DESCRIPrION OF PROCEDURE The experimental design of the present study is similar to that used by Buck (3) in his X-ray investigation. He studied oral. and pharyngeal structures and :functioning in individuals with repaired cleft pal.ates. Two groups of adult Puerto Ricans were studied: (a) an experimental group with complete, unrepaired cleft palates, with or without repaired clefts of the lip; and (b) a control group with normal structures, speech, and hearing, selected at random. Tape recordings of both groups were judged for accuracy of articulation and excellence of voice quality. Three l ateral X-ray plates were av a ilable on each of the subjects: phonation of the vowels [1], [a], and [u]. A lateral X-ray plate and an antero-posterior plate, both at physiologic rest, were available on some of the subjects. Each lateral X-ray plate was traced and the tracings were measured to secure data related to the size, positioning, and movement of the oral and pharyngeal structures, and the cross-sectional diameters of the oral and pharyn g eal cavities. Lateral measurements of the skeletal structures of the face were obtained directly from the antero-posterior pl a tes. The data obtained from the measurements and the judgments of the tape recordin gs were analyzed by various statistical techniques in order to permit comparison between the two gr oups of subjects. Selection and Matching of Subjects The present study may be described as a detailed 10

PAGE 16

ll analytical asp ect of a pa ren t stud y s p onso r ed by the U. s. Department o f Health, Ed u cation, and W el fare. T ne motivating !actor which led to the formulation of the parent study was a desire to accumul at e data o n physically mature individuals who had untreated cleft pal. a tes. T h e criterion for choosing a site for the study was the location of a suitable group of cases. Through the intere s t and cooperation of the Insular Department of Health, a sizable group of such cases was lo cated on the Island of Puerto Rico. A study team of dentists and a speech pathologist visited the island in June, 1957, and June, 1958, to collect the raw data 1 Dentists, social. wor-kers, and other personnel from the Insular Department of Health and Puerto Rican healtn centers augmented the study team while the investigation was in progress. Prior to the tea.m's arrival on the island, case finding was accomplished by the Bureau of Crippled Children and the Bureau of Dental Health of the Puerto Rico Department of Health, assisted by the Puerto Rican Office of Vocational Reha bil itation. Med ical examinations were conducted on the 1957 study group but, as it was felt that the results were completely neg ative, they were not conducted on the 1958 study group. To be included in the study grou p cases had to meet the following qualifications: (l) must have reached mat uration (fifteen years of age or over); and (2) mu.st have a palatal cleft, which had never been treated surgically or prosthetioally. On the basis of descriptions that were available for the individual subjects, the twenty individuals selected he members of the study team included Frank E. Law, D.D.S.; John T. Pul.ton, D.D.S.; McKenzie Buck, Ph.D.; an d others. (The n a mes of these individuals are available upon request.} This team is to return to Puerto Rico to collect more data. None of the results of the parent study are to be published until all aspects of the study are completed. A portion of the X rays and t ape recordin g s gathered by the team w ere made available to the a uthor to enable him to fulfill part of the requirements for his ad vanced degree in speech pathology.

PAGE 17

12 for inclusion in the experimental group have been classified as having complete, unrepaired cleft palates, with or without a repaired lip. Actual verification of this classification is dependent on examination of pal a tal casts of the subjects, which did not arrive in time for the present study. Fifteen of these individuals had normal hearing. Two of the remaining five had mild hearing losses, which might be attributed to their cleft palates. The other three subjects had unilateral hearing losses, which probably were not related to their cleft conditions. Thirty~six normally structured adults were also ex amined. The criteria for selection of these individuals were th a t they had achieved normal structural growth and possessed the nor m al speech and hearing of Puerto Ricans. These indi viduals were selected at random at the various examination centers. Of the thirty-six, twenty were chosen for inclusion in the present study as a control group. The age range of the experimental group members was sixteen to fifty-seven years. This group was composed of fourteen males and six females. The age range of the control group was seventeen to forty-six years. There were eighteen females and two males in this group. No attempt was made to match individuals in the two groups as to age and sex, be cause all of the subjects had met the criterion regarding physical maturation, and optimum growth had been accomplished. Procedure for Recordipg and Analysis of Speech Samples In ~he experimental group, a tape recording was made of each subject reading a list of Spanish words. The list, which follows, was constructed to contain the consonants and vowels of the language of the subjects in all of the intra word positions in which they occur.

PAGE 18

13 Sou.pd Words Consonants: ( P] pol.lo, copa ( t) taza, gato (lg carro, vaca (g) gato, gu.agua [BJ bote, libro (d] diente, dedo (f] cafe, fu.nda cm] mesa, cama [n] nene, mano, jabon c ts l china, leche [N] nino, pina. [ S) sill.a, taza, ojoa (l] leche, bola, arb.ol (r] carne, dol.ar [rr] rrosa, carro [Y] llave, pol.lo (X] jarro, angel Vowels: (a] agua, casa, pata [ e] eje, pesa, nene [ i] hilo, maguey, tina ( o] ojo, aopa, huevo (u] uno, cuna The following consonants are not the same as those used in English, and require explanation: [B], bilabial fricative; [d], voiced dental stop or fricative; [t], voice less dental stop; [ n] dent a l nasal; [N] palatal nasal; [ l] dental lateral; ( r1 single tap lingua-alveolar; ( rr) trilled lingua-alveolar; (y], voiced palatal fricative; and [x], voiceless velar fricative. None of the vowels are the same as those used in English. T h ey represent approximately the same vowels that appear in Latin, in that they are pure and not diphthongized. There is a tendency for all of the vowels except [a] to be dip hth ongized in English. Each subject was instructed to read the words in the order in which they appeare d in the list. In several instances the subjects were unable to read and were asked to repeat the words after they were spoken to them by a Puerto Rican. The control group subjects were recorded in the same manner

PAGE 19

14 The recordings were made on a Wollensak tape recorder: Model T 1500, high fidelity, dual speed. The instrument's portability was an important consideration in its selection. Although the recording room conditions were far from ideal, ambient noise level was kept at a minimum. Twenty recordings of the experiment a l group members and twelve recordings of the normal subjects were arranged in random number order for analysis. The author and another speech pathologist a cted as jud g es to determine phonetic accuracy of consonants and vowels, and qua lity differences as reflected in devi a tions from normal oral and nasal resonance. Resonance was rated on a five-point scale, with 1 represent ing normal resonance and 5 representing the greatest d eviation from normal oral an d nasal resonance. A numerical score of articul a tion was attained by assigning values to the artic ulated sounds: 0 indicated correct production; 1 indicated a distortion; and 2 indicated either a substitution or an o m ission. In addition, the judges compared their analysis sheets in order to determine which consonants and vowels were found to be most frequently defective. Several deviations in articulation were noticed which, on the basis of the speech samples of the normal subjects, were a p p arently due to dialect differences. Such deviations were not considered to be errors. Ratings of vowel and consonant articulation by the judges did n o t differ with statistical significance. A high positive coefficient of correlation, .98, was calculated for the two sets of ratings. Spriestersbach (27) and Sherman (24) have suggested th a t more valid ratings of qu a lity can be achieved if record ings a re played backwards. They both feel th a t irrelevant factors, which tend to influence q uality judgments, a re thus eliminated. Since neither of the present judges was conver sant in Spanish, it did not appear necessary to use this

PAGE 20

15 method of playback. After the recordings had been analyzed phonetically, quality judgments were made. The tapes were listened to continuously at several different ti m es. No marked differences in numerical rating were noted. The final judgments yielded a positive coefficient of correl a tion of .77. The judgments did not reveal any statistically signifi cant differences. Apparatus an d Procedure for Obtaining X-ray Plates Control of Head Position In order to minimize movement of the head during the X-ray exposures, a head positioner was utili z ed. This device was designed by Howell (16) and was constructed at the Uni versity of Florida. One of the criteria used in the design ing of the head positioner was that it s 11 ou l d be portable with out sacrificing sturdiness. This makes practicable the use of such a positioner in a field study. The head positioner uti lizes ear rods, which insert into the external auditory meati, to control movement in th e S a gittal plane. An a rm a ture which rests against the nasion of the subject is used in an attempt to prevent rotation of the head p osition a ro un d the axis creat ed by the ear rods. In addition to minimizing head move m ent, the head po sitioner provides another advantage, that of aiding in the definition of the E 1 rankfort line on the X-ray films. As in the studies by Buck (3) and Hixon (15), eac h subject was seated in a comfortable position in order not to di s turb the habitual carriage of the oral and pharyngeal structures. The relative position of the chair with respect to the head positioner was adjusted to make possible this comfortable posture. Marking .2f Structures None of the structure s were marked in the present study. The rationale behind this lack of marking may be attributed in

PAGE 21

16 part to Buck (3). The experimental group in his study had the midline of the tongue, the midline of the velum and hard palate, and the midline of the posterior pharyngeal wall covering Paa savant's pad marked with a mixture of barium and gum acacia. Severe gagging on the part of the control group members prevent ed marking the midline of the posterior pharyngeal wall. With this exception, simil a r markings were applied to the control group members. In an effort to discover the possible error re sulting from a lack of marking of structures, Buck conducted an additional experiment in connection with his study. Eight normally structured individuals, who did not present severe gag reflexes, were X-rayed with and without the marking of struc tures. A comparison of measurements obtained from these X rays revealed an average difference between the two sets of measure ments of plus or minus 0.6 millimeters. X-ray Exposures Made Four lateral cephalometric plates were acquired on both the experimental and control groups: one at physiologic rest and one each while pnonating the vowels [i] (a], and ( u ]. These vowels were selected because they are representative of extremes of tongue positions used in phonation. The low front vowel ( ee] used in some X-ray studies, is not present in the language of the subjects of the present study The fifth ray exposure was an antero-po aterior view used to obtain lateral measurements of the skeletal structures of the face. Due to faulty exposure and/or developing techniques, thirty-one of the plates were not available. For the experi ment~l group fifteen lateral rest exposures, twenty exposures each of the phonation of the three vowels, and ten antero posterior exposures were secured. Twelve lateral rest expo sures, twenty exposures each of the phonation of the three vowels, and twelve antero-posterior exposures were obtained for the control group. In addition, it must be remarked that of the one hundred and sixty-nine plates available for this study, many

PAGE 22

17 were unavoidably over-exposed or under-developed, obliterating much of the soft tissue. This condition was a result of vari ations in electronic output, and in some instances the equip ment appeared to be faulty. Various colored gelatins were used to clarify the structures illustrated by the under-developed or over-exposed plates. Straw, amber, pink, and blue gelatins, or a combination of any two ot these, were tried experimentally in viewing the plates. It was found that frequent changing of the gelatins was necessary in order to obtain the best results. This procedure tended to rectify the faulty exposure and/or development. To check on the accuracy of the tracings, all of the tracings for a single subject were re-examined at random inter vals during the tracing process by the researcher and his supervisory chairman. In the event of a discrepancy, the tracings were corrected. This procedure indicated that there was a high degree of accuracy on the original tracings. Control .Q.f Vowel Phonations, Intensity,~ Pitch The subjects in each ~roup were instructed to phonate the vowels indicated in the preceding section. Whenever pos sible, a practice period was -held prior to the X-ray exposures. For the most part, the subjects had little difficulty producing good examples of these vowels. Other variables which might possibly be related to the movements of the tongue and other oral structures during pho nation include the pitch and intensity of the voice. Buck (3) reported that these two variables produced relatively minor effects on the positioning of the oral structures during vowel phonation, as long as the variations in pitch and intensity were not large. The subjects in the present study were in structed to maintain comfortable pitch and intensity levels during phonation when the X-ray exposures were being made. No instrumental control was available to determine maintenance of the criteria.

PAGE 23

18 Me a surements of the X-ray Plates The procedure for securing measurements from the X-ray plates was basically that used by Hixon (15) and Buck (3). Each plate was placed on an X-ray tracing table especially constructed for this study. Flashed-opal frosted glass and varying light intensities of fifteen, tw enty-five, sixty, and one hundred watts were used. A clear acetate tracing pap er and a har d-lead drawing pencil were used to record t he outlines of the structures. The outline of the ha rd and soft palates, the central incisors (when present), the mandible, the posteri or wall of the pharynx, the tubercle of the Atlas, the m1dl1ne of the tongue, and t h e lips were traced. To construct the Frankfort line, the inferior margin of the bony orbit and the outline of the ear rod were traced. The anterior nasal spine was also traced, but this structure was frequently physio logically absent or the X-ray technique obliterated it. The Frankfort line was used as a base line for the construction of all perpendiculars and parallels constructed for the v a rious measurements of the study When the su p er ior surface of the ear rod was obscured by the armature of the head positioner, it was necessary to reconstruct the actual dimension of the ear rod on the tracings. The incisal refer ence line was drawn tangent to the superior margin of the central incisors of the mandible. This reference line inter sected the posterior pharyngeal wall and was parallel to the Frankfort line. Hagerty, et al. (10), used a series of lines on the posterior pharyngeal wall to determine tissue movement at the level of the tubercle of the Atlas. A modificatio n of this technique was utilized in the pr esent study. A perpendicular line was constructed tange nt to the m ost anterior p rojection of the tubercle of the Atlas. This line was extended to intersect the incisal reference line and served as the p o terior border of the area. A h orizontal line, level 4 p a ssed

PAGE 24

19 through the most anterior proj e ction of the tubercle. At intervals of one-half centimeter, ot h er horizontal lines were drawn superiorly and inferiorly to this level. The remaining lines were numbered in descendi n g order, level l being the most superior line. Figure l is a master tracing of an X-ray plate of a normal subject. Thia figure shows the reference points and location of measurements used for all of the tracings in the study. The two reference lines already discussed are des ignated as follows : the Fra.nk:fort line, A'C', extending from the inferior margin of the bony orbit to the superior surface of the ear rod; and the incisal reference line, LP, extending from the mandibular incisors to the posterior pharyngeal wall. Measurements for t h e present study will be classified as follows: linear measure m ents, measurements of openings, area measurements, and measurements of movement from rest to phonation. They will be d iscussed in that order, with ref erence to Figure 1. The linear measurements that were made along the various lines include the following distances: FG, the distance from the termination of the hard palate to the posterior ph a ryngeal wall; LP, the length of the oral cav ity; MO, the length of the tongue on th e incisal reference line; BI, the distance between the Frankfort line and the high point of the tongue; HI, the distance between the hard palate and the high point of the tongue; IN, tongue height above the incisal reference line; and LN, the horizont a l position of the high point of the tongue in the oral cavity. Eac h linear measurement was made twice. In case of a discrepancy, the measurement was rechecked and recorded. Measurements of openings are as follows: OP, pha ryngeal opening on the incisal reference line; lip opening, the smallest opening between the lips; and the smallest

PAGE 25

80Ny A oRe,r 8 8' e e' Figure 1. Master tracing showing reference pointa and location of measurements A'C' Frankfort line LP Incisal reference line FO Termination of the hard palate to the posterior pharyngeal wall LP Qral cavity length H) Tongue length on the incisal reference line BI Frankfort line to the high point of the tongue HI Hard palate to the high point of the t ongue IN Tongue height above the incisal reference line LN Horizontal position of the high p o int of the tongue OP Pharyngeal opening on the incisal reference line 1-6 Levels used for obtaining measurements of movement of the posterior pharyngeal wal l 20

PAGE 26

21 pharyngeal opening, the smallest distance between the posterior border of the tongue and the posterior pharyngeal wall (above the body of the hyoid bone and below the incisal reference line). Velo-pharyngeal opening is the smallest distance between the posterior surface of the velum and the posterior p h aryngeal wall. M outh opening is considered to be the distance between the pa r a llel lines drawn t ang ent to t he m axill a r y and m an dibul a r incisors. In an effort to substantiate this m easure ment, t h e distance BN, extending from the Frankfort line to the incisal reference line, was also measured. The procedure used to check li n ear measurements was employed in the case of measurement of openings. Area measurements for the study were made by means of a planimeter. The three areas measured were the total tongue area above the incisal reference line, the tongue area anterior to the high point of the tongue, and the area of the posterior pharyngeal wall. Each area was traced three times and the average of the three m easurements was r e corded. This precau tion was taken in an effort to contr ol variations occurring while the a reas were measured. The planimeter is a sensitive instrument, and it was difficult to trace the outline of an area without varying from the lines. Measurements of movement from rest to phonation were made along the p a rallel and hori~ontal lines constructed in reference to the tongue and the posterior pharyngeal wall. The vertical movement of the hign point of the tongue was made on line BN, the distance IN being variable. Horizontal movement of the high point of the tongue was made on the incisal reference line, the variable distance being LN. M ove ment of the posterior phary ng eal wall was made on the lines constructed in the area of the tubercle of the Atlas. Un fortunately, the same a rea demarcated by the most superior and t h e most inferior of these lines was not visible on all of the l a teral X-ray plates.

PAGE 27

Skeletal Measurements of~~ JK, the length of the maxilla was measured on the incisal reference line. This measurem ent is the distanc e between perpendicular lines dropped tangent to t11e notch 22 just inferior to the anterior nasal spine and to the ter mination of the hard palate. LP', the lengtn of the mandible vas al.so measured on the incisal reference line This is the distan ce between the mandibular incisors and the perpendicular dropped tangent to the most anterior projection of the tuber cle of the Atlas (line CP'), a measurement between stationary bony structures at rest. The antero-posterior exposures at physiolo g ic rest were used to determine tne width of the maxilla and mandible. These plates were not tr a ced, but were placed on the illumi nated tracing table, and the measurements were taken directly from the plates. '.1 1 .he width of the maxilla is the distance between the widest extents of its bony margin on the level of the horizontal plates of the maxilla. The width of the mandible is the distance from the angle of the ramus on the right side to the angle of the ramus on the left side. As in the case of the linear measurements, each meas urement of the face was made twice. The second measurement was compared with the first o ne and was recorded if the two were identical. In the event of a discrepancy, the measure was taken a third time and a comparison was made prior to recording.

PAGE 28

CHA.PrER III RESULTS Facial. and Oral. Cavity Dimensions Graber (8), .Krogman {17), Slaughter and Brodie (25), and Buck (4) have presented findings which indicate that early surgical repair of cleft palates tends to interfere with structural growth In addition these authors have commented, directly and by in:f'erence, that the structures in unrepaired cleft palate patients follow a pattern of essentially normal growth. One o f the first considerations of the present study, inasmuch as it deals with adults whose cleft palates have not been surgically manipulated, is a comparison of measurements of faoial structures for the un repaired cleft pal a te and normal groups. Measurements of tongue size, horizont a l tongue carriage, pharyngeal openings, vertical tongue carriage, tongue movement, velo-pharyngeal opening, posterior pharyng eal wall me asure ments, and lip and mouth openi ng will be discussed in the order given. Fa cial Mea sur ements Table l presents the data dealing with the skeletal. measurements of the maxilla and mandible The statistical analysis u sed in this and al.l subsequent tables will be described in detail in the present section. An arithmetic mean, standard deviati on, and standard error were computed for each set of measurements for each of the two groups of subjects. Also shown in the tables are the mean difference, the standard error of this difference, and the critical ratio or "t" statistic. Each table also shows the values for "t" which are required for statistical significance at the 1.0 per cent and 5.0 per cent levels of confidence. 23

PAGE 29

1. 2. 3 4o 5. 6. TABLE 1 MEASUREMEN'IS OF MAXILLA, MANDIBLE, ORAL CAVITY, AND DISTANCE FROM TERMINATION OF HARD PALATE TO POSTERIOR PHARYNGEAL WALL AT REST (All measurements in millimeters) 24 Normal Cleft Palate Differences Maxilla length M .50.08 M 49.80 M .28 SD 4o80 SD 7.80 SE 2o55 SE 1.45 SE 2.08 t .109 t (df' 25)1 1.()% 2.787; 5.()% 2.060 Maxilla width M 64.oo M 68.90 M 4.90 SD 5.49 SD 4.30 SE 2.19 SE 1066 SE 1.43 t 2.237 t (df' 20):: 1.()% 2.845; .5-0% 2.086 Mandible length M 80.92 M 80. 73 M ol9 SD 1.23 SD 6.20 SE 2.74 SE 2.18 SE 1.66 t .069 t (df' 25)t 1.0% 2.787; .5-0% 2.060 Mandible width M 96.66 M 99.20 M 2.54 SD 3.,57 SD 5.20 SE 2.0.5 SE 1.08 SE lo73 t 1.239 t (df' 20)t 1.0% 2084.5; 5-0% 2.086 oral cavity M 83.66 M 80.46 M 3.20 length SD 6.80 SD 4.98 SE 2.44 SE 2.05 SE 1.33 t 10311 Termination of M 27 .. 83 M 25.40 M 2.43 hard palate to SD J.74 SD 4.56 SE 1.66 pos ~ erior pharSE 1.13 SE 1.22 t 1.463 yngeal wall t (df 25)t 1.0% 20787; 5-0% 2.060

PAGE 30

25 The form.B.t for this presentation is t (df 25): 1.0% 2.787; 5.0% 2.060, with df designating the degrees of freedom for a particular set of measurements Anything less than the 5.0 per cent level of confidence would be largely due to chance and was not recorded. Maxilla Length~ Width A comparison of maxilla length measurements for the two groups revealed a mean difference of approximately one fourth millimeter, which is not statistically significant. Graber (8) and Buck (4) indicated that the retardation they found in maxilla length was possibly a result of early surgery. The present finding would seem to lend support to this conten tion. The members of the experimental group, who had under gone no palatal surgery, approximated the measurement found in the normal subjects. There was almost a five millimeter dif ference between the cleft and non-cleft groups on the measure ment of maxilla width. This difference was significant at the 5.0 per cent level of confidence .Krogman (17) has indi cated that cleft palate structures will follow normal growth patterns, but that these patterns will be influenced by the presence of the anomaly. This appears to be what has happened in the present situation. No retardation in maxillary width was found. The measurement of maxilla width of the exper imental group was greater than that of the controls. Mandible Length~ Width As in the case of maxilla length, the two groups were found to exhibit onJ.y a slight mean difference in the measure ment of mandible length. This difference, less than one fourth millimeter, was not significant. Buck's (4) experi mental group showed a shorter mandible length measurement which was statistically significant, and was apparently due to interference from the surgery pe+formed on the lip. Graber (8) attributes the effe c t of this interference to the nature of

PAGE 31

the construction of the orbicu.laris oris musc le, which en circles the mouth ope ning Since the fibers of this muscle are continuous, a shortening of the fibers in surgery on the upper lip will exert pressure on the mandible as well as on the maxilla. Follo w ing the trend shown in maxilla width measurements, the cleft palate subjects had the greater mean mandible width, in the amount of 2.54 millimeters. Cavity Le:n,gth 26 The measurement of oral cavity length is the distance from the mandibular incisors to the posterior pharyngeal wall, along the inoisal reference line. The posterior termination of the oral cavity is the point of intersection of the ref erence line with the p o sterior pharyngeal wall. Since the antero-poaterior dimensions of the maxilla and mandible r~ vealed no statistically si g nificant differences be tween the two groups, it is to be expected that similar results w ould be obtained for the measurement presently under consideration. The two groups were found not to differ w it a statistical signi ficance in oral c a vity length. Antero-posterior Width QI~ Naso-pharynx The distance from the termination of the hard palate to the poaterior pharyngeal wall, wh ich is t he inferior antero-posterior diameter of the naso-pharynx, presented no statistically significant difference between the two groups. The normal subjects' measurement wa s found to exceed that of the cleft palate subjects in the amount of 2.43 millimeters. It is interesting to note that Ricketts (20) has reported that a study of the relation of the tubercle of the Atlas to the hard palate indicated that no one fixed relationship prevail ed. It would seem, therefore, that a consideration of the antero-posterior width of the naeo-pharynx does not neces sarily reveal the influence of the area of the posterior pharyngeal wall at the level of the tubercle of t h e Atlas.

PAGE 32

The measurement should apparently be evaluated solely as a structural dimension. Measurements Related to Tongue Size and the Horizontal Position of the High Point of the Tongue No statistically significant differences were found between the two groups of this study on measurements related to tongue size and the horizontal position of the high point of the tongue. These measurements are set forth in Table 2. Smaller midsagittal measurements of the tongue were reported by H i xon (15) for his normally structured nasal group. This group also showed a tendency toward a more posteriorly located horizontal tongue position. Buck's (4) repaired cleft palate subjects also had smaller midsagittal tongue measurements than his normal group. However, he 27 found a tendency for the repaired cleft palate group to carry the tongue further forward in the oral cavity than the control group. Tendencies in tne present study were toward a more anterior tolloO-U.8 car r ia&e a t rest and for the vowel (i], and toward a more posterior carriage for the other two vowels. P~a;ry:g.geJ. Openings Midsagittal diam e t ers of the p harynx are a further indication of tongue carriage in the oral cavity. The ra tionale behind thia atatement is readily discerned when measurements of pharyngeal o p e n ing are defined. Pharyngeal opening on the incisal reference line, item l of Table 3, is the measurement of the distance between the posterior surface of the tongue and the posterior pharyngeal wall. The smallest pharyngeal opening, item 2 of Table 3, is similar. It is the distance between the posterior surface of the tongue and the posterior pharyngeal wall, below the incisal reference line and above the body of the hyoid bone. These measurements should vary in direct relationship to the tongue carriage; iJt, a more anterior carriage will increase the measurement, and a

PAGE 33

1. 2. TABLE 2 MEASUREMEN'IS RELATED TO TONGUE SIZE AND HORIZONTAL POSITION OF HIGH POINT OF TONGUE ON INCISAL REFERENCE LINE Rest [i] [a] Total tongue Normal area above M 11.02 9.28 10.78 incisal referSD 2.33 1.72 3.54 ence line; in SE .10 .39 .81 square centiCleft Palate meters M 9.81 8.52 11.60 SD 4.14 2.90 4.51 SE 1.11 .67 1.03 Differences M 1.21 .76 .82 SE 1.31 .77 1.32 t .923 .987 .621 Tongue area Normal anterior to M 6.34 4.52 6.02 high point of SD 1.67 1.03 2.16 tongue; in SE .,o .24 .so square centiCleft Palate meters M ,.58 4.o6 6.48 SD 2.30 1.35 2.59 SE .61 .31 .;9 Differences M .76 .46 .46 SE .79 .39 .11 t .962 1.179 .597 t (df 25): 1.0% 2.767; ,.()% 2.o60 Rest 2 8 (u] 9.26 2.86 .66 10.22 4.73 1.09 .96 1.27 .756 4.94 1.64 .J8 ,.62 3.17 .73 .88 .. 82 1 073 t (df 38h 1.()% 2.711; ,.()% 2.02, Phonation

PAGE 34

29 TABLE 2 Continued Rest [ i] [ a] [ u] J. Horizontal Normal position of M 43.16 .32.50 48.08 48.58 high point of SD 4.56 5.10 5.22 4.60 tongue; in SE 1.37 1.54 1.57 1 .39 millimeters Cleft Palate M 41.66 29.00 50.53 53.80 SD 5.30 3.97 6.03 8.19 SE 1.42 1 06 1.61 2.19 Differences M 1.50 3.50 2.45 5.22 SE 1.98 1.87 2.25 2.6o t -758 1.872 1.089 2.008 t (df 25)t 1.0% 2.787; 5-0% 2.060 46 Tongue length Normal on incisal M 66.25 52.90 .59.20 49.50 reference SD 5.90 6.10 1.10 6.80 line; in SE 1.78 1.40 1.77 1.56 millimeters Cleft Palate M 61.46 51.80 55.55 47.20 SD 9.00 9.10 6.oo 6.00 SE 2.41 2.09 1.38 1..38 Differences M 4.79 1.10 J.65 2.30 SE 2.99 2.,2 2.25 2.08 t 1.602 .437 1.622 1.106 t (df 25) I 1.0% 2.787; 5-0% 2.060 Rest t (d! 38): 1.0% 2.711; 5-0% 2.02, Phonation

PAGE 35

1. 2. TABLE 3 ME.ASUREMEN'IS OF mE PHARYNGEAL OPENINGS ON AND BELOW THE INClSAL REFERENCE LINE (All measurements in millimeters) 30 Rest [ 1] [ a] [ u) Pharyngeal openNormal ing between the M 11.33 22.10 8.35 12.20 tongue and the SD 3.57 4.40 J.00 4.10 posterior wall, SE 1.08 1.01 .69 .94 on the incisal Cleft Palate reference line M 12.46 26.60 9.35 11.00 SD 4.33 1.10 3.50 7.60 SE 1.16 1.77 .80 1.74 Differences M 1.13 4.50 1.00 1.20 SE 1.58 2.04 1.04 1.98 t .715 2.2o6 .962 .6o6 Smal lest pharNormal yngeal opening M 8.41 19.90 7.15 12.05 below the SD 4.39 5.10 3.10 4.10 incisal line SE 1.32 1.17 .71 .94 and above the Cleft Palate body of the M 10.73 21.JO 8.55 10.70 hyoid bone SD J.04 7.10 ).20 1.30 SE .Bl 1.63 073 1.67 Differences M 2.32 1.40 1.40 1.35 SE 1.55 2.00 1.03 1.93 t 1.497 .10 1.359 .699 t (df' 25) s 1.0% 2.787; 5.0% 2.060 Rest t (df' 38): 1.0% 2. 711; 5-0% 2.025 Phonation

PAGE 36

more posterior carriage will decrease it. The only statistically significant difference found in the measurem~nts of pharyngeal opening was for the vowel [1], in the measurement of this openin g on the incisal ref ere n ce line. This difference was significant at the 5.0 per cent level of confidence, and the experimental grou p showed a measurement greater than that of the control group in the amount of 4.5 mllJ.imeters. Mention has already been made of the obliteration 31 of so m e of the soft tissue on the X-ray plates. When this occurred in connection with the outline of the tongue, there a pp eared to be no other alternative than dropping a perpen dicular to the incisal reference line from the most anterior or posterior termination of the outline of t h e tongue. For this reason, no definite conclusion should be drawn in re g a rd to tongue carriage. Tentatively, however, it will be observed that the cleft pal.ate subjects were consistently found to have a more anterior carriage of the tongue for the vowel [i]. This observation was made on both the measures of horizontal position of the tongue and pharyngeal opening measurements. Again tentatively, a tendency toward a more posterior tongue carriage for the vowel [al was not supported when pharyngeal openings are considered. Spec ulating further, a tendency toward a more posterior tongue carriage for the vowel [u] is supported by the measures of horizontal tongue position and pharyngeal openings. Vertical Tongue Position Tongue Height Above _lli Incisal Reference~ The distance of the high point of the tongue above the incisal reference line, item l of Table 4, was measured on the perpendicular line which passes through the most superior point of the tongue. This measurement revealed no statistically significant differences between the two groups.

PAGE 37

1. 2. TABLE 4 VERTICAL MEASUREMEN'IS OF TONGUE HEIGHT (All measurements in millimeters) Rest [ i] [ al Distance of Normal high point or M 23.00 24.00 25.16 tongue above SD 3.00 1.63 5.05 the incisal SE .90 .49 1.52 reference line Cleft Palate M 21.20 22.41 29ol3 SD 6.75 4.,00 8.54 SE 1.80 1.07 2.28 Differences M 1.80 1.59 3 ) .97 SE 2.02 1.18 2.74 t .891 1.347 1.449 t (df 25) s 1.()% 2.787; 5-0% 2.060 Distance of Normal high point of M 6.66 3.60 12.85 tongue below SD 2.66 1.50 3.10 the hard SE .80 .34 .71 palate Cleft Palate M 8.5) 6.05 14.65 SD ,.10 5.00 6.20 SE 1.52 1.15 1.42 Differences M 1.87 2.45 1.80 SE 1.72 1.20 1.59 t 1.087 2.042 1.132 t (df 25)t 1.()% 2.787; 5.0% 2.060 Rest 32 [ u] 2,.16 4.20 1.27 27.73 9.10 2.43 2.57 2.75 .935 5.05 2.80 .64 5.35 5.70 1.31 .JO 1.45 .207 t (df 3 8 ): 1.0% 2.711; 5.0% 2.025 Phonation

PAGE 38

33 TABLE 4 Continued Rest [i] [a] [ u] 3. Distance from Normal Frankfort line M 30.08 31.45 41..05 33.40 to high point SD 3.25 3.90 5.50 5.00 of tongue SE .98 .89 1.26 1.15 Cleft Palate M 34.46 33.30 40.25 31.70 SD 4.98 3.80 5.80 5.80 SE l.33 .87 1.3.3 1.33 Differences M 4.38 1.85 .80 1.10 SE 1.65 1.24 1.83 1.75 t 2.655 1.492 .437 .971 t (df' 25): 1.0% 2.787; 5-0% 2.060 Rest t (df 38)t 1.0% 2.711; 5-0% 2.025 Phonation

PAGE 39

34 There was a tendency for the cleft palate subjects to exhibit lower tongue carriage at rest ana. for the vowel (i]. For the vowels ( a] and ( u], this group had a tendency to carry the tongue higher in the oral cavity. Hixon (15) found a tend ency for greater tongue height in his normally structured nasal group, while Buck's (4) repaired cleft palate subjects showed a tongue height that was less than that found in his normal subjects. A possible explanation for greater tongue height on the vowels (al and (u] in the cleft palate subjects of the present study is the existence of the open suture 1n this group. It might be speculated that the individuals with unrepaired clefts may show greater tongue height in an effort to fill the void in their structures. Ditance of ID:&! Point Qi !l:.! Tongue Below !ill! Palate A second measure of the vertical tongue carriage 1n the oral cavity is the distance between the high point of the tongue and the hard palate, item 2 of Table 4. A measurement that revealed greater tongue height above the incisal ref erence line should show a smaller dimension between the tongue and the palate, and vice versa, since the two groups are sim ilar on antero-posterior structural measuremen ts. This hy pothesis holds true for the rest position and for the vowel [1], as the cleft palate subjects show the greater dimension between the tongue and the palate. The difference is sta tistically significant only for the vowel, however. A dis crepancy seems to appear in the case of the other two vowels, though, as the cleft palate subjects showed tendencies for greater tongue height and a greater measurement between the tongue and the palate. There is a possible explanation for the discrepancy, due to the fact that the high point of the tongue frequently fell posterior to the te:nnination of the hard palate for some of the subjects in both groups. It be crune necessary to approximate the measurement under consider

PAGE 40

ation by extending the hard palate and/or nasaJ. se ptum by means of a line tangent to the highest point of the hard palat e and parallel to the i n cisal reference line. Distance from 1a,! Frankfoz:t .i2. _lli Point .Q.f lli Tongue A third measur e of tongue height, item 3 of Table 35 4, was employed in an effort to clarify vertical tongue carriage. This measurement is the distance between a relative ly static plane, the Frankfort line, and the high point of the tongue. When this distance is considered, the trend ob served in the measurement of tongue h eight above the incisal reference line is continued. The smaller tongue height shown for the experimental group in item l of Table 4 i s re fl ected in the greater dimension for this group in the measurement of the distance between the Frankfort lins and the tongue. The distance at rest in the present instance is significant at the 5.0 per cent level of confidence. The g re ate r tongue height shown for the experimental group in ite m l is reflected in a s m all.er dist ance between the Frankfort line and the tongue. The difference is not statistically significant for any of the three vowels. In summary, measurements of vertical tongue carriage in the oral c a vity do not reveal a consistent trend toward either a lower or a higher tongue position. Excursion of the Tongue from Rest to Vowel Positions The measurements of tongue movement shown in Table 5 were obtained by computing the means of the actual move ment from rest to phonation for each subject. These measure ments were also computed by using the difference between the means at rest and the means for the vowel positions. The results w ere found to be identical. in most instances and to vary only minutely where differences were found. Large

PAGE 41

1. 2. 3 6 TABLE 5 MEASUREMENm OF MJVEMENT OF TONGUE FROM REST TO VOWEL POSITIONS (All meaaurements in millimeters) [ i] [ a] [ u] Linear Normal measureM 1.00 2.16 2.16 ments of SD J.OJ 5.44 J 72 vertical Range -6.o to 6.o -5.o to 13.0 -5.0 to 10.0 movement SE .91 1.64 1.12 of Cleft Palate tongue M 1.13 7o9J 6.53 SD 5oOO 8.71 7.10 Range -10.0 to 9o0 -9.0 to 25.0 -12.0 to 15.o SE 1.34 2.33 1.90 Differences M .13 5.77 4.37 SE 1.63 2.85 2.20 t .080 2.025 1.986 Linear Normal measureM 10.66 -4.91 -5.41 ments of SD ). 77 5.10 4.10 horizonRange 5.0 to 17.0 -15.0 to 7.0 -11.0 to 2 0 tal SE 1.14 1.54 1.24 movement Cleft Palate of M 12.66 -8.86 -12.13 tongue SD 4.JO 4.65 6.10 Range 1 0 to 20.0 -18.o to 2.0 -22.0 to 3.0 SE 1.15 1.24 1.63 Differences M 2.00 J.95 6.72 SE 1.62 l.99 2.03 t 1.235 1.985 3.310 t (dt 25)t 1.0% 2.787; 5.0% 2.060 Negative numbers indicate a downward direction to vertical movement and a posterior direction to horizontal movement.

PAGE 42

37 standard deviations were computed which, when compared with the means, would indicate a marked positive skewness. Al though Buck (3) observed some positive skewness in hi s results on this m easurement, he felt that it could be accounted for because of the fact th a t vertical tongue movement can vary in direction as well as in magnitude. The bases w hich he g i v es for this contention are variations in the position of the tongue at rest and variations in jaw positions for t h e vowels The latter factor would tend to affect t he tongue p osition relative to the incisal reference line. Si m ilarly, horizontal movement can vary in direction as well as in magnitude for the various subjects Vertical Tongue Movement Item l of Table 5 shows no st a tistically signific a nt differences between the two groups on the m easure of vertical tongue movement. For the vowel [1], the two g rou p s exhibit a strikingly similar amount of movement. For the vowels [a) and [u], the cleft palate subjects show much greater amounts of movement. This may be due to tongue and jaw positions, or it m ay be due to the presence of the unoperated cleft and the tendency toward a more posterior tongue carriage for the vowels [ a] and [ uJ. An examination of the range of movements for the two g ro ups shows a consistently larger range for the experiment a l group It might be hypothesized th a t this extreme range of movement is a further reflection of greater compensation be cause of the oral anomaly. Clinical observation has often bor n e out the fact that some structural deviations of the oral cavity provoke compensatory measures with surprisingly accept able acoustic results. The findings of the inve~tigation of repaired cleft palate subjects (3), wh ile not statistically significant, re vealed that they consistently demonstrated greater average upward movement of the tongue. As was previously indic a ted,

PAGE 43

38 the same trend was observed in the present study for the vowels [a] and [ u]. Horizontal Tongue Movement The linear measurement of the horizontal position of the tongue from rest to phonation is shown in item 2 of Table 5. The differences for the vowels ( i] and [ a] are not sta tistically significant. In the case of the la s t vowel, the difference is significant beyond the l.O per cent level of confidence. For this vowel, the cleft palate subjects show a posterior movement that exceeds the measurement for the normal subjects by approximately 7.0 millimeters. Buck (3) found no statistically significant differences between his two groups on any of the measurements of horizontal tongue movement. He reported tendencies for his repaired cleft palate subjects to exhibit greater anterior movement for the vowel (1) than did the normal group. He found a tendency for the posterior shift of the high point of the tongue to be less for the cleft palate group for the back vowels, with both groups showing an average amount of movement posterio rly. Any attempt to explain the greater posterior movement on the vowels (a] and [u] in the present study would have to give consideration once again to the unrepaired structures. It is suggested here that the amount of movement in thie direction is due in part, at least, to the relative absence of structures which would serve to impede the movement. It is also felt that, as was suggested in connection with vertical movement of the tongue, the factor of compensation might have an effect on the magnitude of the movement. However, the ranges of movement seen in the measures of vertical shift of the tongue differ from those for horizontal shift of the tongue. The cleft palate subjects show a considerably greater range of horizont a l movement only for the vowel [u]. Their range is less than the normals for the vowel [ a] and very similar to the normals for the vowel [i].

PAGE 44

39 Measurements of the Naso-pharyngeal Structures No attempt was m a de to measure the vertical or hor izontal shift of the velum during phonation, as little or no movement wa s observed in the experimental group. The exact nature of unrep a ired velar movement, when it did occur, was difficult to ascertain, since the clefts of the experimental group subjects extended through the soft tissue. In addition, the soft tissues were frequently too obscured to be reli a ble for measurement and subsequent analysis. Velo-pharyngeal Opening In spite of the condition of the velar images on the X-r a y plate s an attempt was made to demarcate the posterior surface of the velum. By employing various colored gelatins, tracings were made of the velum. The following discussion of measurements of velo-pharyngeal opening should be considered as yielding highly tentative findings. Item l of Table 6 shows th a t the two groups did not differ with statistical significance on velo-pharyngeal open ing at rest. This measure showed a statistically significant difference beyond the 1.0 per cent level of confidence in the case of each of the three vowels however. The gre a test dif ference occurred in the case of the front vowel. For the vowels [a] and ( u), the velum appeared to be in contact with the superior surface of the tongue. This condition could have created an elevation of the velum 1n itself. While the measurements regarding tongue carriage were not consistent in direction, the cleft palate subjects had a tendency to carry the tongue further forward and lower in the oral cavity for the front vowel than did the control group. The tendency for the other vowels was toward retr a ction and greater height for the experimental group. These circumstances would seem to make the speculation of elevation of the unrepaired velum by the tongue at least partially plausible. In addition, dis ruption of muscular continuity by the oral anomaly, especially

PAGE 45

40 TABLE 6 MEASUREMEN'IS OF OPENING OF THE VELO--PHARYNOEAL STRUCTURES AND AREA OF PQ5 ff:RIOR PHARYNGEAL WALL AT nm LEVEL OF THE TUBERCLE OF THE ATLAS Rest [ 1) [ a] [ u] 1. Sma llest veloNormal pharyngeal M 9.83 .55 1.00 .1, opening SD 2.08 1.20 1.60 .40 SE .63 .28 .37 .09 Cleft Palate M 8.86 9.50 7.90 7.50 SD 3.10 4.30 3.90 4.90 SE .83 .99 .89 1.12 Differences M .97 8.95 6.90 7.35 SE lo04 1.03 .97 1.13 t .93.3 B.689 7.113 6.504 2. Area of the Normal posterior phar-M 1.36 1.28 1.43 1.32 yngeal wall at SD .8, .6J .69 .65 the level of SE .26 ol4 .16 .15 the tube rc le of Cleft Palate the Atlas; in M 1.61 1.68 1.78 1.69 square centiSD .58 .68 .64 .67 meters SE .15 .16 .15 .1, Differences M .25 .40 .35 .37 SE .JOO .214 .217 .21, t .8JJ 1.869 1.613 1.121 t (d.f' 25): 1.0% 2.787; 5.0% 2.06o Rest t (df )8) I 1.0% 2.711; 5-0% 2.025 Phonation

PAGE 46

in the case of the levators veli palatini, would appear to render these muscles incapable of or inadequate in the ex ecution of their normal action. It is conceivable, then, 41 that the velum in the unrepaired cleft palate subjects would be little more than two pendant pieces of tissue, susceptible to movement caused by contact with the moving tongue. Another possible explanation of the narrowing of the velo-pharyngeaJ. opening on the vowels [ a] and ( u) is that offered by Harrington (12) and supported by Willi~s (31). These studies indicate a positive correlation between velar and lingual movements. That is, as the back of the tongue moves superiorly or in feriorly, the soft palate tends to follow. This explanation would apparently have to disregard muscle discontinuity in the unrepaired cleft palate subject. .21.. the Posterior Pharyngeal Wall The technique for measuring the area of the posterior pharyngeal wall at the level of the tubercle of the Atlas was adapted from the one employed by Hagerty, et al. (10). The two techniques differ in the location of the posterior border of the area. The posterior margin for the present study was a perpendicular line dropped tangent to the most anterior projection of the tubercle of the Atlas. In the other study, the perpendicular line passed through the mid-point of the tubercle. The area of the posterior pharyngeal wall for the subjects of the present study should be smaller when compared to the results set forth by Hagerty, et al. Examination of item 2 of Table 6 shows no statistically significant differences between the two groups in the measure ment of the area. However, the differences are large during phonation. The cleft palate subjects showed consistently larger m easures of the area for all of the vowels than for the rest position. The normal subjects showed a larger measure only for the vowel [a]. Hagerty, et al. (10) used the vowel [G] and the conso

PAGE 47

42 nant a ] in their laminagraphic study. They reported a mean difference greater for (Q] than rest of .176 square centime ters for their white subjects, and .270 square centimeters for their Negro subjects. The control group of the present study showed a mean difference greater for [ al than rest of .07 square centimeters, while the difference for the exper imental g rou p was .17 square centD n eters. As has been sug gested, the smaller area u sed in the present study woul d ac count for the difference seen between the results of the two studies. W it h this difference given consideration, it seems that the present control group measurement is comparabl e to t h e white group measurement. T h e present experiment a l g roup measurement does not appear to differ too g re a tly from t h e Negro g rou p measurement. Posterior Pharyngeal Wall Movement As in the case of the are a measurement, the tecr:iuique for measuring posterior phary ng eal wall movement is an a aptation of th a t used by Hagerty, eLal. (10). Their lies were constructed 1.0 centimeter apart, but a ctual p oints of g reatest excursion were found frequently to fall between those lines. Consequently, the lines within the a rea juat discussed were constructed one-half centimeter apart for the present study. Table 7 contains the mea s urements of m ove ment of the posterior pharyngeal wall on the li n es construct ed within the area. The ne ga tive numbers indicate a pos terior movement. This ty p e of m ove m ent was observed in both groups of subjects. Because the level s in the present study do not coincide with those in the study by Hagerty, et al., a level-by-level comparison will not be made. Furthermore, s u ch a co m parison does not seem practical in view of their finding th a t the greatest excursion frequently occurred be t w een lines. All of the movements re p orted for their study were, h owever, in an anterior direction and were slight in magnitude.

PAGE 48

1. 2. 43 TABLE 7 MEAS UREMEN'IS OF M:>VEMENT OF THE POO TERIOR PHARYNGEAL WAU. AT THE LEVEL OF THE TUBERCLE OF THE ATLAS (All measurements in millimeters) [ i] ( a] [ u] Level 1 Normal M .oo .33 .61 SD 3.56 3.54 3.94 Range -5.o to ,.o -,.o to 6.o -6.o to 6.o SE 1.59 1.58 1.76 Cleft Palate M .,1 1.14 1.43 SD 1.18 2.03 1.,0 Range -1.0 to 3.0 -2.0 to 4.o -1.0 to 4.o SE .48 .83 .61 Differences M .,1 .81 .76 SE 1.66 1.79 1.87 t .343 .453 0406 t (df 1 1 ): 1.()% ),.106; ,.()% 2.201 Level 2 Normal M -.,,o .8.3 .oo SD 2.47 )oJO 2.31 Range -3.0 to 6.o -5.0 to 7.0 -.3.0 to ,.o SE .74 .99 070 Cleft Palate M ol7 1.15 1 .3.3 SD 2 34 2.71 2.95 Range -7.0 to 2.0 -2o0 to 7 .o -5.0 to 7o0 SE .71 .78 .89 Differences M .33 032 1.33 SE 1.02 1.26 l o l3 t .324 .254 1.177 t (df' 22)t 1.0% 2.819; 5.0% 2.074 Ne g at i ve numbers indicate a posterior movement.,

PAGE 49

44 TABLE 7 Contin u ed (i] [al [ u] J. Level 3 Normal M -.42 .67 .oo SD 1.40 1.93 1.29 Range -) ... 0 to 2.0 -3.0 to 4 o -2.0 to 2.0 SE .42 058 .39 Cleft Palate M -.47 .oo -.13 SD J.18 2.22 2.22 Range -5.o to 9.0 -4.0 to 4.0 -5.0 to 3o0 SE ~85 .59 .59 Differences M .05 .67 .13 SE .95 .83 .11 t .052 .807 .. 183 4. Level 4 Normal M -.08 .83 .08 SD 1.80 1.60 1.80 Range -4.0 to 3.0 -J.0 to 3.0 -J.0 to J.0 SE .54 .48 .54 Cleft Palate M -.73 ... 33 -.60 SD 1.84 1.62 1.45 Range .. 5 .. 0 to 2o0 -4.o to 2.0 -4.o to 1.0 SE .49 .43 .39 Differences M .65 1.16 .68 SE .74 65 68 t .878 1.784 1.000 t (df 25): 1.()% 2.787; 5-0% 2.060 Negative numbers indicate a posterior movemento

PAGE 50

45 TABLE 7 Continued [ i] [ a] [ u] ,. Level 5 Normal M .09 .82 .27 SD 1.08 1.75 1.60 Range -3.0 to 1.0 -3.0 to 4oO -4oO to 2.0 SE .34 055 .,1 Cleft Palate M -1.00 -.60 -l.07 SD 1.86 1.54 l.29 Range -4.o to 2.0 JoO to 2.0 -4 .. o to 1.0 SE .so .4). .34 Differences M 1.09 1.42 1.34 SE .60 .69 .61 t 1.817 2.058 2.197 t (df 24)1: 100% 2.797; ,.()% 2oo64 6. Level 6 Normal M .14 .28 .oo SD 1.36 2.0, 1.77 Range -3.0 to l.O -4.o to 3.0 -4.o to 2.0 SE .56 .84 72 Cle.ft Palate M -.82 -.82 -1.18 SD 1.80 1.64 1.59 Range ... 3.0 to J.O -3.0 to 3.0 -4 .. o to 2.0 SE .57 .,2 .. ,o Differences M .96 1.10 1.18 SE 079 .98 .88 t 1.215 1.122 1.341 t (df 16):1.0% 2.921; ,.()% 2.120 Negative numbers indicate a posterior movemento

PAGE 51

At level 1, no atatistically significant differences were observed. The normal subjects showed no movement for the vowel (1]. The remaining measurements, in both groups, were in an anterior direction. The range of movements was greater in each instance for the normal group. Both groups showed a posterior movement for the 46 vowel [ i ) at lev e l 2 and p r im a r il y an t e rior m o v e ment f or t h e vowels [al and [ u J N o n e o f the d iff ere n ce s ar e st a ti st ically significant. The range s of movement seem t o be mo re co mpat ible for the two groups at this level. No statistically significant differences were found in movement at level 3. Both groups showed posterior move ment for the vowel [i) For the vowel [ a] the normal subjects showed an anterior movement, while the cleft pal ate subjects showed no movement. The normal subjects ex hibited no movement on the vowel ( u], but the cleft pal ate group showed a slight posterior movement. The ranges were larger for the cleft pal a te group in each instance, although the range for the two groups is similar for the vowel (a]. C o nsistent posterior movement was shown by the cleft pal a te group at level 4. Posterior movement was shown by the controls for the vowel [1], with anterior movement on th e other vowels. The ranges of movement are almost iden tical at this level. No statistically significant differences were found. At level 5, the experimental group again showed con sistent posterior movement, while the normal subjects show ed consistent anterior movement. The difference for the vowel [u] is significant at the 5.0 per cent level of confidence. The ranges do not appear to differ too great ly at this level. No statistically significan t differences were found at level 6. The cleft palate subjects continued to show c on sistent posterior movement. The control group showed

PAGE 52

anterior movement for the vowels [1] and [a], but no move ment for the vowel [ u] Once again, the ranges do not appear to differ too g re a tly. In summary, the cleft pal at e subjects showed more posterior than anterior movement. The reverse was true 47 for the normal subjects. The two groups showed some move ment in both directions on several levels. The grea test consistency of movement was shown at the most superior level and w as anterior in direction, except for the lack of move ment for the normal subjects on the front vowel. Consist ency is also observable at the two lowest levels, where the experimental group showed consistent posterior movement. With the exception of the lack of movement for the vowel (u] at level 6, the normal subjects showed consistent anterior move ment at the two lowest levels. An examination of the tracings of the lateral X-ray plates of the experimental grou p revealed no obvious bulging of the posterior phar y ngeal wall which could be labelled Passavant's pad. The tracings of the control group plates revea1ed a strong possibility of the existence of this phenomenon in onl y two cases. In no instance was the phe nomenon as marked as those pictured in the study by Hagerty, et al. (10). Small amounts of posterior pharyngeal wall movement were reported by Buck (5), Williams (31), Wolfe (32), and Hagerty, et al. The relatively slight amount of move ment found in the present s tudy appears to be consistent with their findings. Lip and Mouth Opening Lip Openin,g Item l of Table 8 is the measurement of the smallest lip opening at rest and during phonation. At re s t the dif ference is considerably larger, but not statistically sig nificant, for the cleft palate group. The two g roups show very simil a r openings for the vowel [ iJ For the other two

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1. 2. TABLE 8 MEASUREMEN'IS OF LIP AND K>U'I'H OPENING AT REST AND PHON.ATION (All measurements in millimeters) Rest ( 1] [a] Lip opening Normal M 2.66 1.20 14.15 SD 1.43 2.10 4.70 SE .43 .62 1.08 Cleft Palate M 4.80 1.00 19.45 SD 4.50 5.30 9.40 SE 1.20 1.22 2.16 Differences M 2.14 .20 5.30 SE 1.28 1.37 2.41 t 1.671 .146 2.199 Mouth opening Normal M 1.00 2.15 12.50 SD 4o20 3.60 6.00 SE 1.27 .83 1.38 Cleft Palate M 1.46 .15 12.40 SD 1.78 4.20 7.60 SE .48 .96 1.74 Differences M .46 2.00 .10 SE 1.35 1.27 2.22 t .341 1.575 .045 t (df 25)t 1,0% 2.787; 5-0% 2.060 Rest 48 ( u] 1.75 1.20 .28 3.10 2.60 .60 1.35 .65 2.011 4.65 4.60 1.06 2.25 5.00 1.15 2.40 1.56 10538 t (df 38): 1.0% 2.711,; 5,0% 2.02, Phonation

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49 TABLE 8 Contin ued Rest [ 1) ( a] [ U] J. Distance from Normal Frankfort line M 53.08 55.JO 65.85 58.10 to incisal SD 4.61 4.20 6.40 5.60 reference line SE 1.39 .96 1.47 1.28 Cleft Palate M 55.66 55.25 67.85 58.15 SD 5.50 6.60 8000 1.80 SE 1.47 1.,1 1.e4 1.79 Differences M 2.58 .05 2.00 .05 SE 2.02 1.80 2.35 2.19 t 1.277 .028 .851 .02J t (df 25) i 1.0% 2.787; 5.0% 2.o60 Rest t (df J8)t 100% 2. 711; 5eQ% 2.025 Phonation

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5 0 vowels the difference is significant at the 5.0 per cent level, with the cleft palate subjects showing the l a rger measurement. The majority of the experimental group subjects had unrepaired lips, which would have a bearin g on the amount of lip opening. Mouth Opening Two measurements were utilized to establish m outh open ing because of the irregularities in dentition introduced as a result of the oral anomaly. The first measurement, the dis tance between the maxil1ary and mandibular incisors, would apparently reflect this aberration to a considerable extent. In an effort to eliminate the error which should be inherent in intel'-3..noisal measurements, the distance between the Frankfort line and the incisal reference line w as also used. No statis tically significant differenc e s were found for either m easure ment, as shown i n items 2 and 3 of Tabl e 8. A comparis o n of the tw o measurements shows some dis crepancies, which might possibly be attributed to t h eir regular dentition of the experimental g roup subjects. Mouth opening between the incisors was very similar for the two groups at rest and for the vowel (al. Considerably lar g er differences, which were very similar in m agnitude, were ob served for the vowels [1] and [u]. These results reflect those found in the study of repaired cleft palate subjects (4), who showed no statistically significant differences between the groups on mouth opening m easurements. T he second measure ment of mouth opening, t he distance between the Frankfort line and the incisal reference line, would appear to give a more accurate description of mou th opening. This measurement would not reflect dental irregularities a s much as the distance be tween the incisors would. A gain, no statistically significant differences were found. However, a complete reversa1 of the differences was shown. At rest and for the vowel [al the largest differences were observed, while the differences on inter-incisal d istance were very small for these two positions. The measurement of the distance between the Frankfort line and

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51 the incisal reference line showed very slight differences for t h e v owels [i] and [u]. The differences on the measurements of the distance bet w een the incisors for these two vo w els was much 1.arger. It would be difficult to explain the reversal found in comparin g the two measures of mouth ope n ing, other than to attribute it to dentition irregul a rities. Analysis of Speech Samples Tape recordings were acquired of t h e members of the experimental and control groups. Twenty recordings of the experimental group subjects and twelve recordings of control g roup subjects were spliced in order of random number arrange ment. The speech of the control group subjects provided the standard of articul a tor y correctness among these Spanish speaking individuals. The tape recordings of the experimental g roup subjects were first analyzed to dete rm ine phonetic accuracy o f articulation. The articulation was scored as: 0, correctly produced; l, distorted; and 2, substitut e d or omitted. A total of these scores for each individual yielded the articulation score. The maximum score possible was 44. If the speech sound was not produced correctly initially, medially, and finally, an error was noted. The reason for s electing an either-or scoring procedure was that the judges felt that the sounds would either be correct or incorrect be cause of the organic factor involved. Clinical evidence ob served locally indicates a great deal of consistency in the misarticulations of individuals with repaired cleft palates. The articulation scores of the experimental group ranged from 10 to 36, with a mean score of 20. Some o f the individual scores seemed to be too high when compared with over-all impressions of intelligibility. This could have been due to the articulatory inconaietencies observed as the sounds appe a red in different positions. If the errors had been noted in the specific positions in which they occurred, t h e articul a tion scores may not h ave been so high.

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52 The following symbols were used to represent the sound.a peculiar to Spanish: [B], bilabial fricative; [ d] voiced dental stop or fric a tive; ~), voiceless dent a l stop; [n), dental nasal; [N], palatal nasal; [11, dental lateral; (rl, single tap lingua-alveolar; [rr] i trilled lingua-alveolar; [Y) voiced palat a l fricative; and [ x] voiceless velar fric ative. The Spanish vowels approximate those of Latin. They are pure vowels and are not diphthongized. There is a tend ency to diphthong~ze all but [a] in English. An actual count of the number of times errors were noted yielded the follow ing sequence, 1n decreasing order of frequency of occurrence: Consonants: Vowels: Sound [rr] [k] [g] (ts] (B] (d) (t] [r] [a] [f] (p] [m] [N] [n] [l] [x] [Y] [i] (e] [o] Frequency of Error 20 18 18 18 17 17 16 15 14 13 12 ll 7 6 6 4 2 10 4 2 The presence of the unrepaired cleft palates is reflected in the frequency of miaarticuJ.ation of the two velar plosives, [k] and ( g] The trilled lingua-alveolar sound [ rrl heard 1n the speech of the control group subjects was absent in the speech of the experimental group members. The inconsistencies noted in the production of the other sounds possibly indicates the presence of a functional articulation problem. The errors

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5 3 noted for the three vow els, [i], (e], and [o], were primarily distortions. The vowels [a] and ( u] were produced correctly by all of the subjects. These distortions could have result ed from the structural abnormalities of the oral and nasal resonating cavities. The second analysis of the tape recordings was concern ed with quality, as reflected in deviations from normal oral and nasal resonance. The recordings of the control group subjects were used as the st a ndard for this judgment. A five point scale was used, with a score of l representing normal resonance, and a score of 5 representing the g re a test devi ation from normal resonance. Excessive nasality denasality, breathiness, harsh n ess, and h oarse n ess w ere h eard in the voices of the experiment a l group subjects. In addition, there was another quality observed which has not been a p propriately described in any voice text of the author's a cquaintance. This phenomenon may be described as a "wide open" q uality, for lack of a more scientific d esignation. There se_emed to be a certain hollo w ness in some of the voices, due perhaps to the presence of a single cavity resulting from the absence of palatal structures. This might be called an oral-nasal cavity. A tabulation of the quality ratings follows: Ratin,5 Number .21 Subjects l 0 2 2 3 5 4 10 5 The mean rating for the group was 3.7. Non e of the exper imental group subjects were judged to h a ve normal quality, an d only two of this group approached a normal q uality rating. A quality rating that was midway between t he t wo extremes was assigned to five of the cleft p al a te sub j ect s. Mor tha n half of the subjects in the experime n tal. gro up w e r e c onsider e d

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54 to h av e extreme deviation s from normal oral an d nas al resonance. Th e r elative ly sm all numb er of cases at either extreme of the scale emp ha sizes the homogeneity of the qual ity ratings. Spriestersbach (27) and Sherman (24) have suggested that tape recordings of speech samples should be played back ward to give more valid ratings of quality. They found that the judges were influenced by articulation in their quality judgments. The jud g es appeared to be judging articulation rat h er than q u a lity. Since n eit her of the judges in the present investi gati on was convers an t wi t h Spa nish, it wa s felt that there was no n eed to play backw ar d the tape record ings of the Spanish-speaking individuals. In order to in vestigate the influence of articulation on the judges' ratings of quality, a coefficient of correlation was computed between the ratings of articulation and quality. This correlation was -.08, which indicates that the articulation of the Spanish-speaking subjects had no apparent effect on the judgments of quality. It is of interest to note a few of the actual scores of the individuals with unrepaired cleft palates who fell at the extremes of the distribution of the articulation scores. The subjects who had the largest number of articulation errors had ratings of quality of 3 and 4. The subjects with the smallest number of articulation errors had quality ratings of 3, 4, and 5. A complete tabulation of these combined data is presented in Table 9. Further analyses of the speech of individual s with un repaired cleft palates, which will be forthcoming as the parent study continues, should be of interest. Further comparison based on the analysis of the tape recordings of the present study was not considered necessary at this time. The presence of the oral anomaly in the experime n t a l g roup undoubtedly accounted for some of the deviation from the speech standard of the normal group. It is felt th a t much of the faulty articulation of the individuals with unrepaired cleft palates is more than li k ely functional., and may be due only in part to the oral anomaly.

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TABLE 9 COMPARISON OF ARTICULATION SCORES AND ~UALITY RATINGS OF INDIVIDUALS WITH UNREPAIRED CLEFT PALATES Number of ATticulation Quality Subjects Scores Ratings 1 10 5 2 11 3, 4 3 14 3, 4, 1 16 2 3 18 4, 4, 4 1 19 2 3 20 3, 4, 4 1 22 4 1 26 1 28 4 1 32 3 1 34 3 1 36 4 Articulation was scored as: o, correctly produced; 1, distorted; and 2, substituted or omitted. The possible range of scores was Oto 44. A mean articulation score of 20 was computed. Quality was rated on a five-point scale, a continuum of 1 through 5o Number 1 represents normal oral and nasal resonance; 3 represents a moderate deviation from normal resonance; and 5 represents the most extreme deviation from normal resonanceo A mean quality rating of J.7 was computed. 55

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CHAPI'ER IV SUMMARY AND CONCLUSIONS Twenty Puerto Rican adults with complete, unrepaired cleft palates fonned the experimental group of the present study. The criteria for inclusion in this group were that the oral anomalies had had no surgical or p rosthetic treat ment, and that the individuals had reached physical maturity. Cleft lips in these individuals could have been repaired or unrepaired. A control group was composed of twenty normal ly structured adult Puerto Ricans, who met the criteria of having achieved normal. structural growt h and of possessing the normal speech and hearing of Puerto Ricans. The age range covered b y the groups was fifteen to fifty-seven years. Fleagle (7) has sug g ested that his findings confirm th e generally accepted theory that individuals mature ear lier in the tropics than they do in a temperate climate. Hence, the presence of the youngest members of the groups does not appear to be incompatible with the criteria im posed. Three lateral X-ray pl a tes were obtained on e a ch of the forty subjects, during phonation of the vowels [1], (a], and (u]. Twenty-seven lateral X-ray plates at phys iologic rest were a lso available for the two groups. Each lateral plate was traced and measured. Measurements were taken directly from the twenty-two antero-posterior plates available for the two groups. All of the mea s urements were subj ected to statistical analysis. Tape recordings of all of the experimental group subjects and several of t h e control grou p subjects were analyzed to determine phonetic accuracy of consonants and vowels, and quality differences as reflected in deviations 56

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57 from normal oral and nasal resonance. The following conclusions may be drawn from the data: 1. Measurements of maxilla length, mandible length and width, oral cavity length, and width of the naso-pharynx revealed no statistically signif'icant differences between the two groups. The cleft palate subjects demonstrated a wider mean maxilla width, significant at the 5.0 per cent level of confidence (Table 1). 2. The two groups did not differ with statistical significance on measurements related to tongue size and the horizontal position of the tongue (Table 2). 3. Pharyngeal opening measurements on and below the inciaal reference line did not differ with statistical sig nificance, except for the vowel (i] when the measurement was made on the reference line (Table 3). It is suggested that differences 1n tongue shape may account for the apparent ir regularity to be observed in the table. 4. No statistically significant differences were found on measures of vertical tongue height above the incisal reference line. The two groups differed with statistical significance on the vertical distance between the tongue and the hard palate when phonating the vowel (.1) The vertical distance between the Frankfort line and the tongue showed a statistically significant difference only at rest (Table 4). Discrepancies observed 1n a comparison of the last two measurements may be due to structural deviations. 5. The nature of the unrepaired anomaly seems to be reflected in the measurements of tongue movement (Table 5). While the differences in vertical. tongue movement were not significant statist1cal1y, there was a marked tendency for greater upward movement in the cleft palate group on the vowels (a] and Cul. Differences in horizontal movement of the tongue were statistically significant only for the vowel [u]. However, a marked tendency for greater posterior move ment was observed for the vowel (a].

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6. Measurements of velo-pharyngeal opening during phonation revealed very large differences between the two groups, which were statistically significant beyond the 1.0 per cent level. The range of mean differences was from 6.9 millimeters to 8.95 millimeters, with the cleft palate sub jects having the larger opening on each vowel (Table 6). 58 7. Area measurements of the posterior pharyngeal wall at the level of the tubercle of the Atlas did not differ with statistical significance for the two groups (Table 6). 8. Measurements of movement on the lines construct ed within the area of the posterior pharyngeal wall were very slight in magnitude, and differed significantly, at the 5.0 per cent level of confidence, only for the vowel [u] at level 5 (Table 7). The cleft paL :;, te subjects showed consist ent posterior movement at this level, while the normal subjects showed consistent anterior movement. The same types of movement were observed in the two g roups at the next lowest level, but no st a tistically significant dif ferences were found. 9. A l a r g er lip opening, which was statistically significant, was found for the cleft palate g roup on the vowels [a] a nd (u) (Table 8). The presence of u.nrepaired cleft li ps in the experimental group might possibl y account for these differences. 10. The two groups were found not to differ with statistical significance on measurement of mouth opening between the incisors or when measured from the Frankfort line to the incisal reference line (Table 8). 11. The articulation analysis of the speech of the experimental group subjects revealed many inconsistencies. It is felt that the oral anomaly account s for so me, but not all, of the articulation errors. 12. The quality analysis of the tape recordings of the experiment a l group subjects revealed marked deviations from the quaJ.ity of the control group subjects. These

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59 deviations are to be considered largely due to the unrepair ed cleft palates and the virtual a b sence of palatal struc tures.

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CHAPTER V DISCUSSION The two groups in the present study were found to be very similar on external, skeletal measurements. The only statistically significant difference observed on structural measurements was that regarding maxilla width. This dif ference may be due to the pull of muscles on the open suture, and would appear to be in agreement with Subtelny's (28) indications in his study of pre-operated cleft palate children. Subtelny also sug g ested, as did Slaughter and Pruzansky (26), that lip repair has a ten d ency to narrow the pal a tal cleft. Although no definite conclusion can be re a che d in this res p ect in the p resent study, it is interest ing to speculate on the available data. Six members ot th e experiment a l group who na d li p repair at undisclosed ages showed a mean maxilla width of 68.33 millimeters. A mean maxilla width of 69.75 millimeters was found using the measurements of four experimental group subject s who had no lip repair. There is a difference between these two measure ments of less than 1.5 millimeters. Some questions arise in view of these highly speculative findings. Wh ile the in dividuals with repaired lips showed a slightly narrower maxilla width, is it necessarily the lip closure which caus ed this? In view of the fact that the time of the li p re pair is not known for the s e individuals, a second question arises. Need there be any concern as to when the lip is repaired? The answers to these questions by future investi gations would be interesting a nd v a luable. The measurements of the smallest velo-pharyngeal openings during phonation revealed wider openings in the cleft palate g roup, which were significant beyond the 1.0 per cent 60

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61 level of confidence. The exact n a ture of muscle movement in the unrep a ired velum is difficult to ascertain. There ap peared to be a complete l a ck of movement in these tissues. It is felt that the variations in the measurements at rest and for t h e vowels were due to movement of the velum as it came in contact with the posterior-superior surface of the tongue. However, in his study of individuals with re p aired cleft palates, Buck (5) also found wider veloph aryn g eal o p enings during phonation for his experimental group. In es s ence, a co m parison of the measurements of a group of physically m a ture individual s wit h comp l ete, un repaired cleft palates and a norma l l y structured grou p of adults of t h e same national origin e m phasizes the b a sic similarities between the two groups. Buck's (3) repaired cleft pal a te subjects di f fered significantl y from a matched control group on mea s ures of over-all vertical an d antero-posterior dimensions of the f a ce, midsagittal m easure m ents of the tongue, tongue hei gh t in the or a l cavity, and velo-pharyn g e a l o p eni ng duri ng pho nation. When the experimental group of t h e present study was co m pared wit h the repaired cleft palate subjects, t h e onl y similarity found was in the wide velo-p h aryngeal open ings during phonation. Is it the surgery or the cleft itself which causes the aberrations in velar movement and si z e? It may be th a t muscle discontinuity in the cleft soft pal a te, repaired and unrep a ired, is influential in prod u cin g similar p h enomena in the two groups. The repaired cleft pal a te subje c ts also demonstr a ted smaller over-all antero-posterior facial dimensions, smaller mids a gitt a l measure m ents of the tongue, and lower tongue heig h t in the or a l cavity. The unrepaired cl e ft p al a te g roup ap p roximated normal facial d im e n sions. While the unre pa ired cle f t p al a te g roup sho w ed some s m aller midsagittal tongue measurem e n t s and some lower tongue h ei gh t t h an t h eir control group, t h ere w ere no con sistent te nd e n cies on eit h er measure.

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A comparison of groups of individuals with repaired and unrepaired cleft palate s indicates that the unrepaired group show more normal external, skeletal measurements on later a l X-ray plates. It should be remarked here, however, that the experimental group of the present study did show some minor structural and functional deviations which are evidently in harmony with the unrepaired anomaly. For example, no consistent trends were observed in measurements related to tongue carriage or tongue movement. However, the greater posterior movement and posterior and superior tongue carriage on the vowels [a] and (u] seemed to be due to an atte m pt to fill the void in the palatal structures. Another example of a minor structural and functional de viation is found in the measurement of wider lip opening on the vowels (al and [u], which reflects the presence of the unrepaired lips in the experimental group. There is much clinical evidence to support the fre quent occurrence of he a ring losses in individuals with re paired cleft palates. The vast majority of the individuals in the experi m ental group of the present study were found 62 to have normal hearing. Only two of the experi m ental group subjects h a d hearing losses which might be attributed to their cleft conditions. These losses were bilateral, uniform, and mild in both ears. Is it possible that there is sur gical interference with the growth process of the musculature around the orifices of the Eustachian tubes? This may be a partial explanation of the hearing problems so often seen in individuals with repaired cleft palates. Analyses of the tape recordings of the experimental group subjects revealed that the unrepaired cleft palate did have an effect on their articulation and quality. It would be difficult, and perhaps unwise, to attempt to state the exact nature of this effect. M a ny inconsistencies in articulation were noticed in listening to the recordings.

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63 Although the velar plosives were among the most frequently misarticulated sounds, they were observed to be produced adequately in some instances. As in the ca s e of many in dividuals with repaired cleft palates, a number of the articulatory problems seemed to be functional rather t h an organic. It would seem that an earl y program of psycho logical counselling and sp eech trainin g would ha ve been of great value to these people. The occurrence of a correctly articulated sound in some intra-word positions supports the theory that speech training would have p roduced more con sistently correct articulation as these individuals matured. The effect of the unrepaired anomaly on quality judgments was not as mar k ed as might be expected. E ven though none of the individuals in the experimental group were judged to h a ve normal quality, they did not all present the same de gree of deviation from normal. An examination of the pal atal casts, which will be availab le on these subjects in the future, should shed some more light on the analyses of the recordings. It is possible that those individuals who had a complete and wide cleft were those who were m ore likely to be judged to have near normal quality. \ In summary, the present study has presented results which lend support to the findings of Graber (8), Krogman (17), Slaughter and Brodie (25), and Buck (4), among others. These studies stress the interference of early sur g ery with sup erior facial growth 1n individuals with cleft palates. The various measurements and the analyses of the tape re cordings of the present study woUld seem to le~d sup p ort to the desirability of prost h etic tre a tment in i n dividuals such as those in the experiment a l group. It is gratifying to note that many cleft pal a te tre a t men t teams are consider ing the insertion of speech appli an ces as early as possible. This not only aids s peec h and psyc h olo g ical development, but allows time for more structural growth to assist in potential surgical consideration.

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1. 2. 4. 5. 6. 1. 8. 9. 10. 11. LIST OF REFERENCES Brader, A.C., The application of the principles of ceph alometric laminagraphy to studies of the frontal planes of the human head. American Journal of Orthodontics, 35, 1949, 249-268. Brodie, A.G., Some recent observations on the growth of t h e face and its implications to the orthodontist. merican Journal of Orthodontics~ Oral Surgery, 2b, 1940, 741-757. Buck, M.W., An X-ray study of cleft palate oral and pha ryngeal structures and their functioning during vowel phonation. Ph.D. Dissertation, State University of Iowa, 1951. Buck, M., Facial skeletal measurements and tongue car riage in subjects with repaired cleft palates. Journal .Q.f Speeoh Hearing Disorders, 18, 1953, 121-132. Buck, M., Post-operative velo-ph a ryngeal movements in cleft palate cases. Journal of Speech~ Hearing Dis orders, 19, 1954, 288-294. Calnan, J., The error of Gustav Passavant. Plastic~ Reconstructive Surgery, 13, 1954, 275-289. Fleagle, F.K., Social Problems in Puerto Rico. Boston, New York, and Chicago: D.C. Heath and Co., 1917. Graber, T.M., Cranoifacial morphology in cleft palate and cleft lip deformities. Surgery. Gynecology !Y!.9:_ Obstetrics, 88, 1949, 359-369. Hagerty, R., and Hoffmeister, F.S., Velo-pharyngeal closure; an index of speech. Plastic~ Reconstruct1ve Surgery. 13, 1954, 290-298. Hagerty, R.F., Hill, M.J., Pettit, H.S., and Kane, J.J., Posterior pharyngeal wall movement in normals. Journal of Speech and Hearing Research, 1, 1958, 203-210. Hagerty, R.F., Hill, M. J., Pettit, H.S., and Kane, J.J., Soft palate movement in normals. Journal .Qi: Speech fil!g, Hearing Research, 1, 1958, 325-330. 64

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12. Harrington, R., A note on a lingua-velar relationship. Journal of Speech Disorders, 11, 1946, 25. 13. Harrington, R., A study of the mechanism of velo pharyngeal closure. Journal ._ Speech Disorders, 9, 1944, 325-345. 14. Herzberg, F., and Holic, R., An anthropologic study of face height. American Journal .91.. Orthodontics~~ Surgery, 29, 1943, 90-100. 65 15. Hixon, E.H., An X-ray study comparing oral and pharyngeal structures of individuals with nasal voices and indi viduals with superior voices. M.S. Thesis, State Univer sity of Iowa, 1949. 16. Howell, E.T., An investigation of cinefluorographic techniques, procedures, and equipment pertinent to the study of speech structures and their movement. M.A. Thesis, University of Florida, 1955. 17. Krogman, W.M., The problem of the cleft palate face. Plastic and Reconstructive Surgery, 14, 1954, 370-375. 18. Norris, M.A., X-ray studies of vowel production as it is related to voice. M.A. Thesis, State University of Iowa, 1934. 19. Parmenter, C.E., and Trevino, S.N., Vowel positions as shown by X-ray. Quarterly Journal of Speech, 18, 1932, 351-369. 20. Ricketts, R.M., The cranial base and soft structures in cleft palate speech and breathing. Plastic .:.ill! .fut constructive Surgery, 14, 1954, 47-61. 21. Russell, G.O., First preliminary X-ray consonant study. Journal of the Acoustical Society of America, 5, 1934, 247-251.22. Russell, G.O., Speech~ Voice. New York: MacMillan, 1931. 23. Russell, G.O., The mechanism of speech. Journal .Q.f !ill! Acoustical. Society .91.. America, l, 1929, 83-109. 24. Sherman, D., The merits of backward playing of connected speech in the scaling of voice quality disorders. Journal of Speech and Hearing Disorders, 19, 1954, 312321.

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25. Slaughter, W.B., and Brodie, A.G., Facial cleft s and their surgical mana g ement in view of recent research. Plastic~ Reconstructive Surgery, 4, 1949, 3.lJ.-33 2 26. Slaughter, W.B., and Pruzansky, s., T h e rationale for velar closure as a primary procedure in the repair of cleft palate defects. Plastic and Reconstructive Surgery, 13, 1954, 341-357. 27. Spriestersbach, D.C., Assessin g nasal quality in cleft palate speech of children. Journal .21. Speech and Hear ing Disorders, 20, 1955, 266-270. 2 8 Subtelny, J.D., A n X-ray study of widt h of n a sopharynx a nd rel a ted anatomical structure s in normal and pre operated cleft p a late children. American Associ a tion for Cle f t Palate Rehabilitation New s letter, 3, 1953, ,.:11. 29. Subtelny, J.D., The si g nificance of early orthodontia in cleft palate habilitative planning. Journal of SReech Hearing Disorders, 20, 1955, 135-147. 30. Towns h end, R.H., T h e formation of Passavant's bar. The Journal of L a ryngology an d Otolo g .v, 55, 1940, 154165. 66 31. Williams, R.L., A serial radiograp h ic s t udy of velo ph a r y nge a l clos u re a nd tongue p o s ition in cert a in vowels. Northwestern University Bulletin, 52, 1952, 9-12. 32. Wolfe, W.G., X-ray study of certain structures and movements involved in naeopharyngeal closure. M .A. Thesis, State University of Iowa, 1942. ADDITIONAL REFERE NCE S l. Berry, M.F., Lingual anomalies associated wit h palatal clefts. Journal ,21. Speech fil2 Hearirw Disorders, 14, 1949, 359-362. 2. Bloomer, H., Observations on palatopharyngeal movements in speec h and deglutition. Journal .Qf Speech !1<.! Hearing Disorders, 18, 1953, 230-246. 3. Brown, S.F., and Oliver, D., A qualitative study of the organic speech mechanism abnormalities associ a ted wit h cleft palate. Speech Monographs, 6, 1939, 127-146.

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4. Graber, T.M., Changing philosophies in cleft palate management. Journal .Q;! Pediatrics, 37, 1950, 400-415. 5. Johnson, w., Brown, S.P., Curtis, J.F., Edney, c.w., and Keaster, J., Speech Handicapped School Children. New York: Harper, 1956. 6. Kaltenborn, A.F., An X-ray study of velo-pharyngeal closure in nasal and non-nasal speakers. M.A. Thesis, Northwestern University, 1948. 7. Matthews, J., and Byrne, M.C., An experimental study of tongue flexibility in children with cleft palates. Journal of Speech and Hearing Disorders, 18, 1953, 4347. 8. McDonald, E.T., and Koepp-Baker, H., Cleft p a l a te speech: an integration of research and clinical ob servation. Journal .Q! Speech~ H e aring Disorders, 16, 1951, 9-20. 9. Parmenter, C.E., and Bevans, C.A., Analysis of speech radiographs. American Speech 8, 1933, 44-56. 10. Pruzansky, s., The role of the orthodontist in a cleft palate team. Plastic~ Reconstructive Surgery, 14, 1954, 10-29. 11. Travis, L.E. ( Ed.), Handbook of Sp eech Pathology. New York: Appleton-Ce ntury-Crof ts, Inc., 1957. 12. Van Riper, c., and Irwin, J .V., Voice and Articulation. Englewood Cliffs, N. J .: 195 8 13. Wardill, W E.M., Cleft palate.~ British Journal of Surgery, 16, 1928, 127-148. 67

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BIOGRAPHICAL NOTE F. X. Calvin Knobeloch was born in Tell City, Indiana, on August 5, 1925. He was graduated from Tell City Hign School in 1943, and received his Bachelor of Science in Education degree from Indiana University in 1949. A year of graduate study was completed at Indiana University from 1949 to 1950. He served in the United States Marine Corps from November, 1943, to May, 1946, a nd from September, 1950, to October, 1951. On July 5, 1953, he married Sheila Ann Richeson. Their daughter, Katherine, was born Septem ber 24, 1957, and their son, Timothy, was born April 25, 1959. From September, 1958, to August of 1959, Mr. Knobeloch held the position of senior clinician in the Speech and Hear ing Clinic at the University of Florida. Prior to this appointment, he h el d the following positions: speech cor rectioniat, Alachua County (Florida) Public Schools, 195758; graduate assistant in Speech and Hearing, University of Florida, 1956-57; graduate assistant in Theatre, University of Flo rida, Spring and Summer Semesters, 1956; remedial reading and English teacher, South Side Junior High School, St. Petersburg, Fl orida, 1954-55; speech te~cher, New Albany (Indiana) Senior High School, 1951-54; and graduate assistant in Speech, Indiana University, 1949-50. Mr. Knobeloch is a member of Sigma Alpha Eta, na tional honorary speech and hearing fr a ternity; Alpha Kappa Delta, national sociological honor s ociety; Theta Alpha Phi, national dramatics honorary fraternity; and Chi Gamma Iota, veterans' scholastic honorary fraternity. He is also a member of the American Speech and Hearing Association and the Florida Speech and Hearing Association. 68

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This dissertation was prepared under the direction of the c h airman of the candi d ate's supervisory committee and has been approved by all members of that committee. It was sub mitted to the Dean of the College of A rts a nd S ciences and to the Gr a duate Council, and w as approved as parti a l fulfillment of the re q uirements for the degree of Doctor of Philosophy. August 8, 1959 Dean~ Sciences Dean, Graduate School


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